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Analysis of Surgeon-Controlled Variables in the Treatment of Limb-Threatening Type-III Open Tibial Diaphyseal Fractures

¹ Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1070
² Department of Orthopaedic Surgery, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232
³ Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Hygiene and Public Health, 624 North Broadway, Room 554, Baltimore, MD 21205

Investigation performed at Wake Forest University School of Medicine, Winston-Salem, North Carolina; Carolinas Medical Center, Charlotte, North Carolina; and Johns Hopkins Bloomberg School of Hygiene and Public Health, Baltimore, Maryland

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institutes of Health and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Methods: A cohort of 156 patients with a limb-threatening open tibial diaphyseal fracture was identified from the Lower Extremity Assessment Project (LEAP) study group. The patients were prospectively followed for two to seven years. In addition to the Sickness Impact Profile, other outcome metrics included the time to fracture union as well as the occurrence of infection and other complications that required rehospitalization. Statistical differences between groups were calculated.

Results: Within the parameters of the present study, the timing of débridement, the timing of soft-tissue coverage, and the timing of bone-graft placement had no effect on outcome. Patients in whom the fracture was definitively treated with an external fixator had more surgical procedures, took longer to achieve full weight-bearing status, and had more readmissions to the hospital for the treatment of infection and nonunion than did those in whom the fracture was treated with an intramedullary nail. Patients undergoing external fixation who also had a muscle flap for wound coverage had more physical impairment and a worse functional outcome than did patients who had an amputation.

Conclusions: Surgeons should carefully consider alternative treatment options for patients who have a severe open tibial fracture when limb salvage is perceived to require the combination of external fixation for fracture fixation and a muscle flap for wound coverage.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

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				J. J. Keeling, D. E. Gwinn, S. M. Tintle, R. C. Andersen, and F. X. McGuigan Short-Term Outcomes of Severe Open Wartime Tibial Fractures Treated with Ring External Fixation J. Bone Joint Surg. Am., December 1, 2008; 90(12): 2643 - 2651. [Abstract] [Full Text] [PDF]

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