Open tibia fractures have a high risk of infection.
It is well accepted that soft tissue injuries in open fractures should be debrided agressively, while bone should be preserved as much as possible. Is bone not a tissue or does it responds better to infection?
I am presenting a case of an open tibia fracture (high energy injury looking from the X-rays and CT scan) and the way we are managing it.
At the time of starting this blog we have completed or almost completed 20 patients with similar injuries. Results are encouraging and pending definitive review and publications.
25 August 2016
Initial X-rays after review in our A&E.
CT scan reconstructions - coronal
CT scan reconstructions - saggital
26 August 2016
Images below show the tibia after damage control surgery, skeletal stabilisation and wound dressing (VAC).
01 September 2016
Definitve debridement of bone and soft tissue, cement spacer with antibiotic beads and soft tissue cover.
26 September 2016
After successful soft tissue cover and infection prevention temporary external fixator was replaced by TSF fine wire frame. At the same time corticotomy for bone transport was done and cement spacer removed with another set of reabsorbable antibiotic beads put in the defect. Post op X-rays are below.
One month after the injury we have definitive soft tissue cover, definitive skeletal stability and infection free. There are certainly quicker ways to do it, but are they better and more reliable/predictable?
07 October 2016
Still significant pain, otherwise stable frame. Everything as planned. Bone transport started - gap in the proximal tibia is increasing.
18 October 2016
Good progress but there is still pain. No obvious infection around the wound - free flap (soft tissue cover).
01 November 2016
One of the wires in the transported fragment became infected and was very painful. As we already have 4 wires and two half pins (which we preserved from the initial surgery) in the transported fragment we can/may safely remove the infected wire under sedation. In my opinion it is too painful to do it in clinic or even under "gas and air".
Otherwise, X-rays show nice regenerate and the position of the distal fragment is improving. Hopefully we will dock it soon but the free flap is restricting us from doing it any faster. We will certainly need some time to accommodate.
06 November 2016
Lengthening progressing well. Good quality regenerate. Stiffness of the knee is not improving. CPM was organised. Pin sites still inflamed but overall improved.
13 November 2016
Good progress. Pin site infection under control. Knee flexion contracture still present but it is improving.
Excellent quality of regenerate. Further progress in transport - 7mm in last 14 days. As planned. Still 30mm to go before fibula disimpacted. At that point will dock it and fine tune the leg length.
03 January 2017
No major problem. Pin sites OK.The knee is still a bit stiff but improving.
X-rays show good progress and excellent regenerate. Fibula is slowly geting back to length.
07 February 2017
Further progress. Some swelling around the transported fragment which could represent an infection. But it does go down during the night. Antibiotics for a week.
Leg length more or less restored.
Next task is to dock the fragment using the frame. A new prescription was given to complete the job. Hopefully in second attempt.
14 February 2017
Old haemathoma bursted. Pain improved.
Prescription completed. Position acceptable. Will compress the docking site further.
28 February 2017
Improved soft tissues. Docking completed and docking site well compressed (bent olive wires). No further treatment for the docking site planned at the moment.
28 March 2017
No major issues. Pain is still present. No obvious sign of infection. Walking still restricted but I believe it is improving.
As you can see on the X-ray below the docking is completed and the site compressed - bent olive wires. All struts still very tight.
02 May 2017
Everything under control and progressing well. Docking was successful and position is maintained.
10 October 2017
CT scan confirmed union at the docking. Regenerate required further time to consolidate. 4 weeks ago the frame was removed.
Patient is walking with a stick, still limping. X-rays below confirm that the fracture and regenerate are healed. Whilst there is still some varus of the distal tibia, a large proportion of it is very likely due to the inadequate view (X-ray tibia does not give the same representation as X-ray ankle, at least not in every patient).
11 January 2018
Pain is still present and not improving. X-rays suggest that there is a bit of a tilt in the distal tibia. Just the view or actual tilt?
13 March 2018
Pain is not improving. Patient walking but not comfortable.
24 May 2018
Prominent distal fibula was resected and TSF applied.
On discharge TSF prescription started to apply some compression to the non-union site and correct the deformity.
19 June 2018
TSF prescription completed. Because of the new angle of the rings, the most distal ring was touching the heel area hence it was repositioned. It had no wires attached as it worked as a neutralisation ring to counteract the forces on the ring with wires attached (wires only on one side of the ring).
27 July 2018
Alignment restored. Will just need a bit of compression and hopefully we are done.
06 November 2018
Patient was seen 6 weeks ago where everything looked OK. 4 weeks ago patient dynamized his frame and was walking with one stick or unaided on shorter distances.
X-rays show that the non-union has united completely. Frame was removed on the same day under sedation.
07 December 2018
4 weeks post frame removal. Patient is walking unaided, no significant pain. A stick only for longer distances.
Mr Matija Krkovic, MD, PhD
I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.