|Year : 2018 | Volume
| Issue : 2 | Page : 69-74
A study of open tibia and fibula fractures in fifty patients
Priyank V Kalaria1, Chirag S Kapoor2, Paresh P Golwala2
1 Department of Orthopaedics, Sola Civil Hospital, Ahmedabad, Gujarat, India
2 Department of Orthopaedics, Smt. Bhikhiben Kanjibhai Shah Medical Institute and Research Centre, Vadodara, Gujarat, India
|Date of Web Publication||5-Jul-2018|
Chirag S Kapoor
541, Ramdarsh Bungalow, Bank of India Lane, Opposite Manusmruti Hospital, Adjacent Gayatri Flats, Subhanpura, Vadodara - 390 023, Gujarat
Source of Support: None, Conflict of Interest: None
Introduction: The incidence of high energy trauma is increasing with increase in traffic. Due to its subcutaneous anatomical location, tibia is vulnerable to direct blow in high energy trauma. Open tibial fractures are true surgical emergencies because of the risk of extensive infection to bone and devitalized soft tissue. The most serious consequence of open tibial fractures is amputation-which usually can be prevented by prompt early surgical intervention. Materials and Methods: Open tibial fractures often are the result of trauma from motor vehicle collisions, farm accidents, falls from heights, or fall of heavy objects. We studied 50 patients with compound tibia-fibula fractures for their mode and grade of injury, methods of stabilization, rate of union, rate of infection, method of soft tissue coverage used, requirement of change of implants, requirement of secondary procedures, amputation & postoperative rehabilitation. Result: Majority of the patients belonged to the age group of 41-50 years with a male preponderance and the commonest mode of injury was road traffic accidents. Bone grafting was required in 38% patients. The average time of union for the patients who required bone grating was 43 weeks and in those who didn't need was 26.12 weeks. Six patients required amputation and two patients died. Conclusion: As the Gustilo-Anderson grade increases, the chances of infection and non-union also increase and outcome is poorer. So we feel that more aggressive treatment has to be carried out for Grade III injury within first 48 hours to achieve optimum outcome.
Keywords: Amputation, bone graft, gustilo-anderson, open tibia fractures, rehabilitation
|How to cite this article:|
Kalaria PV, Kapoor CS, Golwala PP. A study of open tibia and fibula fractures in fifty patients. Apollo Med 2018;15:69-74
| Introduction|| |
As urbanization and industrialization are progressing year by year with rapid increase in traffic, incidence of high energy trauma is increasing with the same speed. Due to its subcutaneous anatomical location, tibia is vulnerable to direct blow in high energy trauma.
There are five main principle causes of tibia diaphyseal fracture which include road traffic accidents (RTAs), fall from height (FFH), direct blow or assaults, sports injury, and gunshot injury. Modalities of treatment vary according to the type of fracture, bone density, age group, associated bony and soft tissue injuries, and other comorbid conditions.
Prognosis in open tibia fractures depends on the amount of initial displacement, degree of comminution, severity of soft tissue injury, and severity of contamination. The decision to amputate or salvage the limb can often be difficult even for experienced surgeons.
The management of open shaft tibia fibula fractures remains major challenge due to high incidence of early and late infections, nonunion, high number of secondary procedure, prolonged period of treatment, poor functional outcome, and possibility of secondary amputations. Thus, it becomes necessary to have a proper method not only to predict limb salvage but also to have a proper guideline for treatment and desired outcome.
Three goals must be met for the successful treatment of open fractures of tibia which include prevention of infection, achievement of bony union, and restoration of preoperative function. These goals are interdependent and usually are achieved in the chronological order given. Failure to prevent infection promotes delayed union or nonunion and therefore delays functional recovery of limb.
The aim of our study is to know the outcome of open tibia fibula fractures treated by various modalities of treatment and its complications.
| Materials and Methods|| |
This hospital-based prospective study was carried out on patients treated by various modalities for compound fractures of tibia and fibula with the following aims:
- Statistical analysis of adult patients with open tibia and fibula fracture
- To classify different types of fracture patterns
- To analyze the outcome of different modalities of treatment in open tibia and fibula fractures
- To account for complications encountered during different modalities and its treatment.
Our study included patient aged 18 years and above with open Grade I, II, and III (Gustilo Anderson classification) diaphyseal tibia and fibula fractures.
The modalities of operative management were based on the type of fracture, the amount of displacement, the amount of open injury, and surrounding skin condition of the shaft tibia. Based on fracture pattern, surgical treatment was done for all types of fracture. The patients were taken for surgery at the earliest possible time depending on their medical condition, skin condition, and the amount of swelling.
In case of open Grade I and II injury with early presentation, definitive fixation was done in the form of interlocking nail (reamed/unreamed/solid) or plate with the debridement of the wound.
In case of open Grade II with late presentation and Grade III injuries, the fracture was stabilized with external fixator and wound debridement was performed. All devitalized tissue and debris were removed. Regular sterile dressing was done till the wounds became healthy. After that, definitive fixation was performed.
In few cases of open Grade II and IIIa injuries, tibia interlocking nail was performed with or without reaming. In some cases, solid tibia interlocking nail was performed, especially in Grade IIIa fractures. After all signs of infection subsided, wound closure was performed in the form of skin grafting and rotational or free flaps as per requirement. In case of proximal and distal one-third shaft tibia fibula fractures, anatomical locking plate was done. Bone grafting was done in some cases as per requirement. The graft was harvested either from anterior or posterior iliac crest or in few cases from fibula.
In some cases with comminution, severe infection, nonunion, and infected nonunion ilizarov ring fixator was applied with or without corticotomy.
Patients were reviewed on serial follow-ups at 1, 3, and 6 months and further as per requirement. Partial weight bearing was started based on clinical and radiological assessment followed by full weight-bearing walking. All the patients were evaluated with modified Johner and Wruh's criteria [Table 1].
| Results|| |
In our study of fifty patients, majority of the patients were from 3rd, 4th, and 5th decade. Out of whom 28% were between 31–40 and 51–60 each, whereas 30% were from 41 to 50 years while there were 18% patients between 20 and 30 years of age with only 6% between 60 and 70 years of age. This suggests that majority of the patients were active earning population [Table 2]. Out of fifty patients, 94% (47) patients were males whereas 6% (3) patients were females. Majority of our patients were farmers or laborers (44%) whereas 28% were businessmen, 20% were drivers, 6% were students, and 2% were homemakers.
Majority of the open tibia fractures were due to RTAs, i.e., 72%, out of which RTA due to two-wheelers were 44% whereas RTA due to four-wheelers were 28%. Whereas 20% of the patients had FFH and only 8% had fall of heavy object on the limb.
In the study, ten patients (20%) were admitted within 24 h of injury whereas 17 (34%) patients were admitted within 24–48 h of injury. One of the patients presented to us after 1 year and 10 months of injury [Table 3].
Out of fifty open tibia fractures, 17 (34%) were Grade I whereas 18 were Grade II and 15 (30%) were Grade III fractures according to Gustilo Anderson Classification. In Grade III, three (6%) patients were classified under Grade IIIA, ten (20%) under Grade IIIB, and two (4%) under Grade IIIC who had no circulation in distal limb [Table 4]. Out of fifty patients, 21 (42%) patients presented to us with the clean wound, whereas 20 (40%) patients presented to us with contaminated wound. Nine patients (18%) had infected wound at the time of admission. Most of them presented after 48 h of injury.
From fifty patients of open tibia fibula fractures, 19 (38%) patients were treated with external fixator for the primary stabilization of fractures. While 18 had undergone tibia interlock nailing and 11 were treated with plating as a definitive fixation [Table 5].
Out of 29 patients who had undergone nailing or plating as primary definitive procedure, three out of 29 (10%) required revision of implant. Two of these patients (6.9%) who had undergone primary nailing had to be submitted for ilizarov due to infected nonunion. The patient (3.45%) who had undergone primary plating underwent interlocking nail as a revision of implant.
Two patients died in the study. Both deaths were due to the cause which was not related to tibial fracture. One of them sustained open Grade III humerus fracture with Grade I distal tibia fibula fracture and had severe infection in left upper limb leading to septicemia and death. While the other patients who sustained Grade III injury of femur and tibia, immediately after the admission developed fat embolism leading to pulmonary embolism and death.
Out of fifty patients, six (12%) patients required amputation. Primary amputation was performed in one case of Grade IIIC injury as limb was not salvageable. In two patients, amputation was done after the external fixator as one of them sustained Grade IIIC injury and limb was not salvageable while other sustained Grade IIIB injury and had gross infection. In three patients, amputation was performed after definitive fixation. Two of these three patients sustained IIIB injury and had gross infection whereas other sustained Grade I tibia fibula fracture with Grade III femur fracture. Above knee amputation was done due to gross infection at femur fracture site.
Average number of debridement in all patients was 2.58 per patient. This number increased to 5.42 in the patients who required amputation in Grade IIIA and IIIB injuries. Patients who sustained Grade II fractures, the average number of debridement was 2.8, whereas in patients who sustained Grade III injury, the average number of debridement was 3.78.
In our study, we have found that out of 18 Grade II injury patients, ten (55.6%) patients required no further treatment whereas four (22.2%) patients required split thickness skin graft and four (22.2%) patients required flap surgery. In Grade III injury, primary closure was possible in one patient only (6.7%), 6 (40%) patients required skin graft, whereas 3 (20%) patients required flap surgery and five (33.3%) patients required amputation.
Bone grafting was required in 19 (38%) patients. The average time of union for the patients who required bone grating is 43 weeks and in those who did not need it was 26.12 weeks. Earliest time required for union was 19 weeks and longest time required for union was 181 weeks.
Out of 42 patients (as six patients required amputation and two died), union occurred between 16 and 20 weeks in five patients (11.9%), in 18 patients (42.8%) union occurred between 21 and 28 weeks, and in 11 patients (26.2%) between 29 and 36 weeks. In 8 patients, union took very long time to occur [Table 6]. The union rate was 41.36 weeks in patients who had presented after 48 h and 26.78 weeks in patients who presented within 48 h. After excluding the patients who died during treatment or required amputation, the union rate in Grade I open fractures was 24.2 weeks. While in Grade II open fractures, the union rate was 33.22 weeks. In Grade III open fractures, the union rate was 47.77 weeks [Table 7].
The average follow-up of 48 patients was 18.06 months. The longest follow-up was 37 months whereas two patients died during treatment.
In our study, we have evaluated our patients according to modified Johner and Wruh's criteria. We have found that 60% of the patients had excellent results, 12% of the patients had good results, 12% of the patients had fair results, and 16% of the patient had poor results [Table 8].
Out of 17 patients who sustained Grade I injury, 14 patients had excellent result, 1 patient had fair, and 2 patients had poor results. Out of 18 patients who sustained Grade II injury, 14 patients had excellent result, 2 patients had good result, and 2 patients had fair result. Out of 15 patients of Grade III injury, two patients had excellent result, four patients had good, three patients had fair results, and six patients had poor results [Table 9].
| Discussion|| |
Open tibia fractures are frequently encountered in modern urban society. RTA remains the leading cause for this fracture. Open fractures are one of the most challenging injuries in trauma care. Compared to closed fractures, they have a significantly higher risk of infection, nonunion, and wound healing complications and often require multiple surgeries for definitive care. Successful treatment of these fractures involves prevention of infection, achievement of bony union, and restoration of preoperative functional state.
Although there is no dispute that soft tissue management is the most important factor in determining the outcome of open tibial fractures, the optimal method of fixation is debated.
We have conducted the study of fifty patients with open tibia fibula fractures in a span of 3 years. If we take age into consideration, in our series, youngest patient is 22 years old and oldest is 66 years of age. Nearly 76% (28) of the patients fall into the 3rd, 4th, and 5th decade of their life, with average age of 41 years as they are active earning people. Similar study of 47 patients was conducted in 2001 by Behairy and Al-Balla, who found mean age of 27 years. In a study done by Tornetta et al., the majority of the patients were between 30 and 40 years.
RTA was the most common mode of injury (72%). Out of which 40% (20 patients) were due to two-wheelers whereas 32% (16 patients) were due to four-wheelers and produced different types of fractures. Other common mode of injury was FFH (20%) and 8% had open fracture by falling of heavy object. Similar results were found by Tornetta et al. that show 85% of RTA. Behairy and Al-Balla  also had similar result, which is 87% RTA, followed by 8.5% by FFH and 4% with sports injury.
As most of these injuries are high energy trauma, so chances of involvement of the other injuries also increases. In our study, we have found that 40% of the patients had associated other bone fractures, in which ipsilateral femur fractures were most common which accounted for 14 (28%) of the patients. Similarly, one patient had ipsilateral bimalleolar fracture and two patients had ipsilateral Lisfranc injury. While other associated fractures included radius ulna, clavicle, and humerus and compression fracture of L2 vertebra. Similar results were observed with Behairy and Al-Balla, whose observation was 20% of all open tibia fractures sustained femur fractures also.
In our study, out of fifty open tibia fractures, 17 (34%) were Grade I whereas 18 (36%) were Grade II and 15 (30%) were Grade III open fractures according to Gustilo Anderson Classification. In Grade III, three (6%) patients were classified under Grade IIIA, ten (20%) under Grade IIIB, and 2 (4%) under Grade IIIC. Similar observation was noted by Behairy and Al-Balla. He observed 30% patients fall into Grade I, 27% in Grade II, 23% in Grade IIIA, 18% in Grade IIIB, and 2% had Grade IIIC.
We have found that majority of the fractures (22) (44%) were middle one-third of the tibia, whereas 14 (28%) had upper one-third tibia fractures and 13 (26%) had lower one-third tibia fracture. One patient (2%) had segmental tibia fibula fracture. Behairy and Al-Balla  have 21% of proximal one-third, 30% of middle one-third, and 49% have distal one-third tibia fractures. Behairy and Al-Balla  have more of distal tibia fibula fractures (49%), whereas we had more of middle tibia fibula fractures (44%).
We observed that 42% of the patients reported to us after getting primary treatment elsewhere. Out of the other 58% of the patients who had been primarily treated by us, 18% of the patients presented within 24 h of injury. Although 48 h had passed, seven patients had not taken primary treatment anywhere for open fractures.
Early stabilization of open fractures provides many benefits to the injured patient. It protects the soft tissues around the zone of injury by preventing further damage from mobile fracture fragments. It also restores length, alignment, and rotation, all vital principles of fracture fixation. The restoration of length also helps decrease soft tissue dead spaces and has been shown in studies to decrease the rates of infection in open fractures. The primary fixation in open fractures is usually decided by the condition of the wound at the time of admission. Nowadays, if the wound is comparatively cleaner, more and more surgeons have started using interlocking nail as a choice of implant. However, in our series, we have restored the fracture with external fixator in 38% of the patients compared to 16% of the patients in Behairy and Al-Balla  series. They had undertaken nailing in 40%, whereas we had done nailing in 36% of the patients. They had done plating in 7% of the patients whereas we had done plating in 22% of the patients. Remaining patients were given splints. Two patients (4%) required amputation on admission. One of them had Grade IIIB open fracture and had been primarily treated outside with fasciotomy and presented with severe infection. Another patient presented after 48 h of injury with Grade IIIC fracture with vascular compromise.
In our study, we have compared the primary fracture stabilization with the Gustilo Anderson grade. We have found that out of 17 patients of Grade I injury, interlocking nail was done in 12 patients whereas 5 patients were submitted for plating. In Grade II injury, eight patients were submitted for external fixation whereas interlocking nail and plating were done in five each. Out of 11 patients of Grade III injury, 11 were submitted for external fixator while 1 was submitted for interlocking nail and 1 was submitted for plating. Two patients required amputation as mentioned above.
Early soft tissue coverage decreases chances of infection and minimizes the protein loss. This increases the chances of union and early recovery. In our study, we have found that, in open Grade II fractures, primary closure was possible in ten out of 18 patients whereas four required split thickness skin graft and four required flap surgery. In open Grade III fractures, primary closure was possible in only one out of 15 patients, six patients required skin grafting whereas three patients required flap surgery and five patients with Grade III fractures had to undergo amputation.
In our study, bone grafting was required in 19 patients (38%) and average time of union in these patients was 43 weeks. While in the patients who did not require bone grafting, the average union time was 26.12 weeks. Study done by Giannoudis et al. had found observed that 17% of the open tibia fractures required bone grafting and time of union was 38.5 weeks in his study. Hence, our rate of bong rafting is higher. This can be explained as our patients reported late.
We found that union time increased as severity of open injury increased. In Grade I open injury, the union time was 24.2 weeks. While in Grade II open injury, the union time was 33.22 weeks. In Grade III open fractures, the union time was 47.77 weeks. Study done by Drosos et al. had found that in Gustilo Anderson Grade I open fractures, the union rate was 20.78 weeks, where in Grade II open fractures, the union time was 29.01 weeks. In Grade III injuries, the union rate was 32.04 weeks. Our union time for all three types is more than Drosos et al.
We have compared the level of fracture with the final outcome. We have found that out of 14 upper one-third tibia fibula fractures, 5 (35.7%) failed to unite after 6 months of injury. While one required amputation as he had severe infected wound. Out of 22 (44%) fractures which includes middle one-third shaft tibia fibula, five (22.72%) patients required amputation and five (22.72%) fractures failed to unite after 6 months of injury. Out of the five amputation, two were due to Grade IIIC injury whereas other three had uncontrolled infected wound. Out of 13 patients who sustained lower one-third tibia fibula fractures, three (23.07%) had nonunion, whereas one patient who sustained segmental fracture had nonunion. Two deaths occurred during the treatment, both of them due to causes not related to tibia fracture, which was discussed earlier.
Out of fifty patients, two patients died during the course of treatment and six patients required amputation. Hence, the following findings are of 42 patients. In our study, 2 patients (5%) had occasional pain whereas five patients (11.9%) had abnormal limping gait at final follow-up. Clifford et al. have found that 20% of the patients had on and off pain and 13% patients had abnormal limping gait.
In our study, we have found knee stiffness in 12 (28.57%) patients with mild-to-moderate limitation of knee range of movement and 6 (14.28%) patients had ankle stiffness. Majority of them had no limitation in daily living activity. Twelve of them (28.57%) had difficulty in sitting cross legged and difficulty in squatting. Seven out of these 12 patients had ipsilateral femur fracture or foot and ankle fractures. We had higher incidence of knee and ankle stiffness compare to Clifford et al., who had 8.4% of knee stiffness and 20.6% with ankle stiffness.
Final outcome for fifty patients was evaluated according to modified Johner and Wruh's criteria. We have found that out of fifty patients, thirty (60%) had excellent outcome, six (12%) of them had good result, six (12%) patients had fair result, and eight (16%) patients had poor outcome as six of them required amputation and other two died.
| Conclusion|| |
As the Gustilo Anderson Grade increases, the chances of infection and nonunion also increase and outcome is poorer. Hence, we feel that more aggressive treatment has to be carried out for Grade III injury within first 48 h to achieve optimum outcome.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]