L09_OTA-Open-Tibia.ppt

Open Fractures of the
Tibial Diaphysis
Daniel N. Segina, MD
Robert V. Cantu, MD
David Templeman, MD
Created March 2004
Updated May 2010

Incidence
 Open fractures of the tibia
are more common than in
any other long bone
 Rate of tibial diaphysis
fractures reported from 2
per 1000 population to 2
per 10,000 and of these
approximately one fourth
are open tibia fractures*
*Court-Brown; McBirnie JBJS 1995

Mechanism of Injury
 Can occur in lower energy, torsional type
injury (e.g., skiing)
 More common with higher energy direct
force (e.g. car bumper)

Priorities
 ABC’S
 Assoc Injuries
 Tetanus
 Antibiotics
 Soft Tissue
Management
 Fixation
 Long term issues

Physical Examination
 Given subcutaneous
nature of tibia, deformity
and open wound usually
readily apparent
 Circumferential inspection
of soft tissue envelope,
noting any lacerations,
ecchymosis, swelling, and
tissue turgidity

Physical Exam
 Neurologic and vascular exam of extremity
including ABI’s if indicated Johansen K, J Trauma April 1991
 Wounds should be assessed once in ER, then
covered with sterile gauze dressing until treated in
OR- digital camera / cell phone
 True classification of wound best done after
surgical debridement completed

Radiographic Evaluation
 Full length AP and lateral
views from knee to ankle
required for all tibia
fractures
 Ankle views suggested to
examine mortise
 Arteriography indicated if
vascular compromise
present after reduction

Associated Injuries
 Approximately 30% of
patients have multiple
injuries
 Fibula commonly
fractured and its degree of
comminution correlates
with severity of injury
 Proximal or distal tib-fib
joints may be disrupted
 Ligamentous knee injury
and/or ipsilateral femur
(‘floating knee’) more
common in high energy
fractures

Associated Injuries
 Neurovascular structures
require repeated
assessment
 Foot fractures also
common
 Compartment syndrome
must be looked for

Antibiotics
Surgical Infection Society guideline: prophylactic antibiotic use in open
fractures: an evidence-based guideline. Hauser CJ, Surg Infect, Aug 2006
 First Generation Cephalosporin
 +/- Aminoglycoside
 +/- Pen G or Clindamycin if Pen allergic
 No Cipro alone Patzakis MJ, J Orthop Trauma Nov 2000
 24-72hr course

Classification of Open Tibia
Fractures
 Gustilo and Anderson open fracture classification first published
in 1976 and later modified in 1984
 In one study interobserver agreement on classification only 60%

Objectives of Surgical Treatment
 Prevent Sepsis
 Achieve Union
 Restore Function

Treatment of Soft Tissue Injury
 After initial evaluation
wound covered with
sterile dressing and leg
splinted
 Appropriate tetanus
prophylaxis and
antibiotics begun
 Thorough debridement
and irrigation undertaken
in OR within 6 hours if
possible
 Photo documentation

 Careful planning of skin incisions
 Longitudinal incisions / “Z” plasty
 Essential to fully explore wound as even
Type 1 fractures can pull dirt/debris back
into wound and on fracture ends
 All foreign material, necrotic muscle,
unattached bone fragments, exposed fat and
fascia are debrided

Irrigation
 Saline +/- surfactants (soap) Anglen J, Removal
of surface bacteria by irrigation. J Orthop Res 1996
 Pressure – avoid high pressure / pulse
lavage Polzin B, Removal of surface bacteria by irrigation. J
Orthop Res 1996
 Timing > 6 hrs Crowley DJ, Debridement and wound
closure of open fractures: The impact of the time factor on
infection rates. Injury 2007

 After debridement thorough irrigation with
Ringer’s lactate or normal saline
 Fasciotomies performed if indicated even in open
fractures
 After I+D new gowns, gloves, drapes and sterile
instruments used for fracture fixation

Bone Defects
 PMMA –aminoglycoside +/- vancomycin
 Bead pouch
 Solid spacer

Bone Defects: Bead Pouch
Ostermann PA, Local antibiotic therapy for severe open fractures: A
review of 1085 consecutive cases. J Bone Joint Surg Br 1995

Bone Defects: PMMA Spacer
Masquelet AC, Reconstruction of the long bones by the induced
membrane and spongy autograft [French]. Ann Chir Plast Esthet 2000

Large Fragments: What to do?
• Infection Rates with retained - 21%
• Infection Rates with removed- 9%
Edwards CC, Severe open tibial fractures. Results treating 202 injuries
with external fixation. CORR, 1998
• Use to assist in determining length, rotation
and alignment

Soft Tissue Coverage
 Definitive coverage should be performed within 7-
10 days if possible
 Most type 1 wounds will heal by secondary intent
or can be closed primarily Hohmann E, Comparison of delayed
and primary wound closure in the treatment of open tibial fractures. Arch
Orthop Trauma Surg 2007
 Delayed primary closure usually feasible for type
2 and type 3a fractures

 Type 3b fractures require either local
advancement or rotation flap, split-
thickness skin graft, or free flap
 STSG suitable for coverage of large
defects with underlying viable muscle

 Proximal third tibia
fractures can be covered
with gastrocnemius
rotation flap
 Middle third tibia
fractures can be covered
with soleus rotation flap
 Distal third fractures
usually require free flap
for coverage

Stabilization of Open Tibia
Fractures
 Multiple options depending on fracture
pattern and soft tissue injury:
IM nail- reamed vs. unreamed
External fixation
ORIF

IM Nail
 Excellent results with
type 1 open fractures

Unreamed IM Nail
 Time to union with
unreamed nails can be
prolonged- in one study of
143 open tibia fractures
53% were united at 6
months
 Vast majority of fractures
united, but 11% required
at least one secondary
procedure to achieve
union*
*Tornetta and McConnell 16th annual OTA 2000

Reamed Tibial Nailing
 In one study of type 2 and
type 3a fractures good
results- average time to
union 24 and 27 weeks
respectively; deep
infection rate 3.5%*
 Complications increased
with type 3b fractures-
average time to union was
50 weeks and infection
rate 23%*
*Court-Brown JBJS 1991

External Fixation
 Compared to IM nails,
increased rate of malunion
and need for secondary
procedures
 Most common
complication with ex-fix
is pin track infection
(21% in one study)*
*Tornetta JBJS 1994

Conversion from Ex-Fix to IM Nail
Bhandari M, Intramedullary nailing following external fixation in femoral and
tibial shaft fractures. J Orthop Trauma 2005
 Conversion between ex-fix and IM nail
 9% infection 90%union
 Infection rates decreased with shorter
duration of ex-fix time

Plate Fixation
 Traditional plating technique with extensive soft
tissue dissection and devitalization has generally
fallen out of favor for open tibia fractures
 Increased incidence of superficial and deep
infections compared to other techniques
 In one study 13% patients developed osteomyelitis
after plating compared to 3% of patients after ex-
fix*
*Bach and Handsen, Clin Orthop 1989

Percutaneous Plate Fixation
 Newer percutaneous
plating techniques
using indirect
reduction may be a
more beneficial
alternative
 Large prospective
studies yet to be
evaluated

Gunshot Wounds
 Tibia fractures due to low
energy missiles rarely
require debridement and
can often be treated like
closed injuries
 Fractures due to high
energy missiles (e.g.
assault rifle or close range
shot gun) treated as
standard open injuries

Amputation
 In general amputation
performed when limb
salvage poses significant
risk to patient survival,
when functional result
would be better with a
prosthesis, and when
duration and course of
treatment would cause
intolerable psychological
disturbance

Mangled Extremity Severity
Score
 An attempt to help
guide between primary
amputation vs. limb
salvage
 In one study a score of
7 or higher was
predictive of
amputation*
*Johansen et al. J Trauma 1991

Amputation
 Lange proposed two absolute indications for
amputation of tibia fractures with arterial
injury: crush injury with warm ischemia
greater than 6 hours, and anatomic division
of the tibial nerve*
*Lange et al. J Trauma 1985

LEAP Study
Bosse MJ, A prospective evaluation of the clinical utility of the lower-
extremity injury-severity scores. J Bone Joint Surg Am 2001

LEAP Study
 Plantar sensation not prognostic
 Scoring systems do not work
 Predictors of outcome
 Salvage vs Amputation about equal

Complications
 Nonunion
 Malunion
 Infection- deep and superficial
 Compartment syndrome
 Fatigue fractures
 Hardware failure

Nonunion
 Time limits vary from 6
months to one year
 Fracture shows no
radiologic progress toward
union over 3 month period
 Important to rule out
infection
 Treatment options for
uninfected nonunions
include onlay bone grafts,
free vascularized bone
grafts, reamed nailing,
compression plating, or
ring fixator

Malunion
 In general varus malunion
more of a problem than
valgus
 In one study deformity up
to 15 degrees did not
produce ankle
complications*
 For symptomatic patients
with significant deformity
treatment is osteotomy
*Kristensen et al. Acta Orthop Scand 1989

Deep Infection
 Often presents with
increasing pain, wound
drainage, or sinus
formation
 Treatment involves
debridement, stabilization
(often with ex-fix),
coverage with healthy
tissue including muscle
flap if needed, IV
antibiotics, delayed bone
graft of defect if needed

Deep Infection
 Not the Implant but the Management of the
Soft Tissues
 If IM nail already in place, reamed
exchange nail with appropriate antibiotics
may prove adequate treatment
 Staged reconstruction with the used of
PMMA + antibiotics

Superficial Infection
 Most superficial infections respond to elevation of
extremity and appropriate antibiotics (typically
gram + cocci coverage)
 If uncertain whether infection extends deeper
and/or it fails to respond to antibiotic treatment ,
then surgical debridement with tissue cultures
necessary

Compartment Syndrome
 Diagnosis same as in
closed tibial fractures
 Common with high
energy tibia fractures
 Release ALL 4
compartments

Reamed vs Unreamed: SPRINT Trial
Bhandari M, Randomized trial of reamed and unreamed intramedullary nailing
of tibial shaft fractures JBJS, 2008
 Possible benefit of reamed IM nails in
closed fractures
 No difference in open fractures
 Delaying reoperation for nonunion for at
least 6 months significantly lowers the need
for reoperation

Hardware Failure
 Usually due to delayed
union or nonunion
 Important to rule out
infection as cause of
delayed healing
 Treatment depends on
type of failure- plate or
nail breakage requires
revision, whereas
breakage of locking screw
in nail may not require
operative intervention

Negative Pressure Would
Therapy (NPWT)
 Can lower need for free flapsDedmond BT, The use of
negative-pressure wound therapy (NPWT) in the temporary treatment of soft-
tissue injuries associated with high-energy open tibial shaft fractures. J
Orthop Trauma 2007
 Cannot lower infection rates for Type IIIB
open fractures Bhattacharyya T, Routine use of wound vacuum-
assisted closure does not allow coverage delay for open tibia fractures. Plast
Reconstr Surg 2008

BMPs
 BMP-2 (Infuse) FDA approval in subset of
open tibia fractures BESTT study group JBJS 84, 2002
 Significant reduction in the incidence of
secondary procedures
 Accelerated healing
 Lower infections

Outcomes
 Outcome most affected by severity of soft tissue
and neurovascular injury
 Most studies show major change in results
between type 3a and 3b/c fractures
 In one study of reamed nailing, the deep infection
rate was 3.5% for type 2 and 3a fractures, but 23%
for type 3b fractures*
*Court-Brown JBJS 1991

Outcomes
 For type 3b and 3c fractures early soft tissue
coverage gives best results
 In one study of 84 type 3b and 3c fractures, results
with single stage procedure involving fixation
with immediate flap coverage better than when
coverage delayed more than 72 hours (deep
infection 3% vs. 19%)*
*Gopal et al. JBJS[Br] 2000

Suggested
treatment
algorithm
Melvin JS, Open Tibial
Shaft Fractures: I and
II, JAAOS, Jan-Feb 2010

Summary
 Different injury in young and old
 Important injury in both young and old
 Understand goals of treatment
 Maximize outcome with least iatrogenic
risk
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Lower Extremity
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L09_OTA-Open-Tibia.ppt

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