Objective To evaluate the safety of conversion from external fixation to internal fixation for open tibia fractures. Methods Between January 2010 and December 2014, 94 patients (98 limbs) with open tibia fractures were initially treated with external fixators at the first stage, and the clinical data were retrospectively analyzed. In 29 cases (31 limbs), the external fixators were changed to internal fixation for discomfort, pin tract response, Schantz pin loosening, delayed union or non-union after complete wound healing and normal or close to normal levels of erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and the leucocyte count as well as the neutrophil ratio (trial group); in 65 cases (67 limbs), the external fixators were used as the ultimate treatment in the control group. There was no significant difference in gender, age, side of the limbs, interval from injury to the first debridement, initial pathogenic bacteria, the limbs that skin grafting or flap transferring for skin and soft tissue defect between the two groups ( P>0.05). The incidence of Gustilo type III fractures in the control group was significantly higher than that in the trial group (P=0.000). The overall incidence of infection was calculated respectively in the two groups. The incidence of infection according to different fracture types and whether skin grafting or flap transferring was compared between the two groups. The information of the pathogenic bacteria was recorded in the infected patients, and it was compared with the results of the initial culture. The incidence of infection in the patients of the trial group using different internal fixation instruments was recorded. Results The overall incidences of infection for the trial and control groups were 9.7% (3/31) and 9.0% (6/67) respectively, showing no significant difference (χ2=0.013, P=0.909). No infection occurred in Gustilo type I and type II patients. The incidence of infection for Gustilo type IIIA patients in the trial group and the control group were 14.3% (1/7) and 6.3% (2/32) respectively, showing no significant difference (χ2=0.509, P=0.476); the incidence of infection for type IIIB patients in the two groups were 50.0% (2/4) and 14.3% (2/14) respectively, showing no significant difference (χ2=2.168, P=0.141); and the incidence of infection for type IIIC patients in the two groups were 0 and 16.7% (2/12) respectively, showing no significant difference (χ2=0.361, P=0.548). Of all the infected limbs, only 1 limb in the trial group had the same Staphylococcus Aureus as the result of the initial culture. In the patients who underwent skin grafting or flap transferring, the incidence of infection in the trial and control groups were 33.3% (2/6) and 13.3% (2/15) respectively, showing no significant difference (χ2=1.059, P=0.303). After conversion to internal fixation, no infection occurred in the cases that fixed with nails (11 limbs), and infection occurred in 4 of 20 limbs that fixed with plates, with an incidence of infection of 20%. Conclusion Conversion from external fixation to internal fixation for open tibia fractures is safe in most cases. However, for open tibia fractures with extensive and severe soft tissue injury, especially Gustilo type III patients who achieved wound heal after flap transfer or skin grafting, the choice of secondary conversion to internal fixation should carried out cautiously. Careful pre-operative evaluation of soft tissue status, cautious choice of fixation instrument and meticulous intra-operative soft tissue protection are essential for its safety.
Objective To investigate the feasibility of Drawtex hydroconductive dressing in treatment of early implantation-associated infection and soft tissue defect after internal fixation of tibial fracture. Methods Thirty-six New Zealand rabbits were used to prepare the model of early implantation-associated infection after internal fixation of tibial fracture, and randomly divided into 3 groups (n=12) . The infected wounds were covered with Drawtex hydroconductive dressing (group A), chitosan solution gauze (group B), and normal saline gauze (group C), respectively. The dressing was changed every 2 days. X-ray films were performed at 1, 14, and 21 days. The gross observation, microbiological evaluation, and histological observation were done at 21 days. Results There was no significant difference in the wound grading according to the Jamesʾ grading criteria between groups at 21 days (χ2=3.713, P=0.156). X-ray films showed no bone destruction in all groups at 1 day; and there was no significant difference in radiographic scores between groups (P>0.05). At 14 days, the mild osteolysis was observed in group B; the radiographic score was significantly lower in groups A and C than in group B (P<0.05), but there was no significant difference between groups A and C (P>0.05). At 21 days, the osteolysis and osteomyelitis were observed in groups B and C; the radiographic score was significantly lower in group A than in groups B and C (P<0.05), but there was no significant difference between groups B and C (P>0.05). Also, the microorganism in bone tissue of group A was less than that of groups B and C (P<0.05); and the difference between group B and group C was not significant (P>0.05). Histological observation showed the mild inflammatory cell infiltration in group A and many inflammatory cells in groups B and C. The Smeltzer histological score was significant lower in group A than in groups B and C (P<0.05); and there was no significant difference between groups B and C (P>0.05). Conclusion Drawtex hydroconductive dressing can be used for the implantation-associated infection after tibial fracture internal fixation. And the effectiveness of Drawtex hydroconductive dressing is better than that of chitosan solution gauze and normal saline gauze.
ObjectiveTo investigate the effectiveness difference between bone transport with a locking plate (BTLP) and conventional bone transport with Ilizarov/Orthofix fixators in treatment of tibial defect. MethodsThe clinical data of 60 patients with tibial fractures who met the selection criteria between January 2016 and September 2020 were retrospectively analyzed, and patients were treated with BTLP (BTLP group, n=20), Ilizarov fixator (Ilizarov group, n=23), or Orthofix fixator (Orthofix group, n=17) for bone transport. There was no significant difference in gender, age, cause of injury, time from injury to admission, length of bone defect, tibial fracture typing, and comorbidities between groups (P>0.05). The osteotomy time, the retention time of external fixator, the external fixation index, and the occurrence of postoperative complications were recorded and compared between groups. The bone healing and functional recovery were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) criteria. Results All patients of 3 groups were followed up 13-45 months, with a mean of 20.4 months. The osteotomy time was significantly shorter in the BTLP group than in the Ilizarov group, and the retention time of external fixator and the external fixation index were significantly lower in the BTLP group than in the Ilizarov and Orthofix groups (P<0.05). Twenty-two fractures healed in the Ilizarov group and 1 case of delayed healing; 16 fractures healed in the Orthofix group and 1 case of delayed healing; 18 fractures healed in the BTLP group and 2 cases of delayed healing. There was no significant difference between groups in fracture healing distribution (P=0.824). After completing bone reconstruction treatment according to ASAMI criteria, the BTLP group had better bone healing than the Orthofix group and better function than the Ilizarov groups, showing significant differences (P<0.05). Postoperative complications occurred in 4 cases (20%) in the BLTP group, 18 cases (78%) in the Ilizarov group, and 12 cases (70%) in the Orthofix group. The incidence of complication in the BTLP group was significantly lower than that in other groups (P<0.05). Conclusion BTLP is safe and effective in the treatment of tibial defects. BTLP has apparent advantages over the conventional bone transport technique in osteotomy time, external fixation index, and lower limb functional recovery.
ObjectiveTo discuss the efficacy of skin stretcher applied for repair of postoperative skin and soft tissue defects in tibial fractures.MethodsBetween April 2016 and March 2017, 15 cases with skin and soft tissue defects after tibial fractures fixation were treated with the skin stretcher. There were 11 males and 4 females with an age of 24-59 years (mean, 37.5 years). The causes of injury included traffic accident in 7 cases, bruise in 3 cases, falling from height in 3 cases, and falling in 2 cases; without nerve and vascular injury in all patients. These cases were followed up 1-3 months after their first surgery, consisting of 3 closed fractures treated with open reduction and plate and screw fixation, 12 open fractures treated with external fixation after debridement. The area of skin defects ranged from 14 cm×5 cm to 20 cm×7 cm, all of which were stripped or spindle shaped skin defects. First, the skin was penetrated by two Kirschner wires which were locked by skin stretchers on both sides of the skin defect longitudinally. Then, the tension of skin stretchers was timely adjusted according to the skin flap blood supply and muscle compression. Finally, Kirschner wires and skin stretchers were removed when the edge of skin contacted and been sutured.ResultsAll skin and soft tissue defects were covered after stretching for 6-13 days. The interrupted sutured wounds healed at 12 days. Clinical scores of wound healing decreased from 3.40±0.51 at immediate postoperatively to 1.27±0.46 at 12 days postoperatively, showing significant difference (t=12.911, P=0.000). All the patients were followed up 4-12 months (mean, 6.5 months). After stretching, the skin color, elasticity, and pain and touch feeling were similar with the normal skin, and the hair growth was normal. After operation, 1 case of nail tract infection and 2 cases of calf discomfort occurred, and all were relieved after treatment.ConclusionIt is an effective method for repairing postoperative skin and soft tissue defects in tibial fractures with the application of skin stretchers.
Objective To summarize the cl inical appl ication of minimally invasive percutaneous locking compression plate (LCP) internal fixation in the treatment of tibial fractures and to evaluate its cl inical effects. Methods From September 2005 to September 2007, 13 patients with tibial fractures were treated with indirect reduction and minimally invasive percutaneous LCP internal fixation, 8 males and 5 females, aged 18-35 years old (27 on average). Among them, the fractures were caused by traffic accidents in 3 cases, by fall ing in 5 cases, by fall ing from height in 4 cases and by bruise in 1 case. The fractures were located at 1/3 upper tibia in 2 cases, at 1/3 medium tibia in 6 cases and at 1/3 lower tibia in 5 cases. All fracture were closed ones. According to the AO classification, 4 cases were type A, 7 type B and 2 type C. The time between fractures and operation was from 3 hours to 5 days (2.5 days on average). Results All incisions obtained heal ing by first intention. All patients were followed up for 10-18 months (13 months on average). All fractures reached cl inical heal ing, and the heal ing time was 12-20 weeks (16 weeks on average). There was no delayed fracture heal ing, nonunion, infection and internal fixation failure. No compl ications such as rotation, crispatura deformity and internal fixation loosening were found. According to the HSS scoring, the function of the knee joint was graded 85-95 (90 on average), and the range of motion was 100-130° (120° on average). According to the AOFAS Ankie Hindfoot Scoring, the function of the ankle joint was graded 80-95 (92.4 on average). Nine cases were excellent, 4 good, and the choiceness rate was 100%. Conclusion Minimally invasive percutaneous LCP internal fixation is in accord with biological set principles and beneficial for tibial fracture heal ing and reconstruction of soft tissues.
Objective To compare the clinical effect of reamed and nonreamed intramedullary interlocking nails on treating open tibial fractures. Methods From February 2002 to February 2004, 92 cases of open tibial fractures (86 patients) were treated with intramedullary interlocking nails. Of the 86 patients, 65 were male and 21 were female. Their age ranged from 18 to 68 years (36.5 on average). Of the 92 cases, 54 were in the reamed group and 38 in the nonreamed group. Patients moved with the support of crutch after their wounds were healed. Results All patients were followed up regularly for 6 to 24months. Infection rate in the reamed group and nonreamed group was 20.3% and 5.3% respectively, and there was significant difference between them (Ｐlt;0.05). The averagehealing time of the fractures was 22.5 weeks in reamed group and 19 weeks in nonreamed group, and there was no significant difference between them (Ｐ＞0.05). Delayed unions occurred in 8 cases and 3 cases in reamed group and nonreamed group respectively. Conclusion Compared with reamed group, nonreamed intramedullary interlocking nails have lowerinfection rate and fewer delayed unions and ununions.
Objective To describe a surgical device for closed reduction of tibial fracture and investigate its clinical effectiveness. Methods Between June 2010 and December 2012, 24 cases of tibial fractures were treated with intramedullary nailing using a surgical device for closed reduction. There were 18 males and 6 females with an average age of 40 years (range, 20-64 years). All fractures were closed. There were 3 proximal third fractures, 12 middle third fractures, and 9 distal third fractures. According to AO classification, 12 cases were classified as type A, 8 cases as type B, and 4 cases as type C. The mean time between injury and operation was 3 days (range, 1-12 days). The intraoperative fluoroscopy frequency to confirm closed reduction and guide wire passing the fracture site, and the duration between fracture reduction and nail insertion were recorded. The injured limb alignment and fracture angular deformity were measured as described by Freedman et al. The fuction of affected limb was estimated by Johner-Wruhs criteria. Results Closed reduction was successfully performed in 24 patients. The mean fluoroscopy frequency to confirm closed reduction was 3 (range, 2-5). The fluoroscopy frequency to confirm guide wire passing the fracture site was 2. The mean duration between fracture reduction and nail insertion was 30 minutes (range, 20-42 minutes). No intraoperative or postoperative complication occurred, such as infection, vessel and nerve injuries. All incisions healed by first intention. Seventeen patients were followed up 6-16 months (mean, 10 months). Radiographic evidence showed that bridging callous was observed at 2-4 months (mean, 2.5 months). The injured limb alignment was normal on anteroposterial and lateral radiographs at 5 months postoperatively, no malalignment and obvious angular deformity was observed. The internal fixator had good position. According to Johner-Wruhs criteria for evaluation of the affected limb function, the results were excellent in 12 cases and good in 5 cases with an excellent and good rate of 100%. Conclusion The surgical device for closed reduction of tibial fracture is simple and easy to use, and has good effectiveness combined with intramedullary nailing.