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Controversial Management of Open Tibial Fractures

28/11/2016

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Picture
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.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
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).
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management

01 September 2016 
Definitve debridement of bone and soft tissue, cement spacer with antibiotic beads and soft tissue cover.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management

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.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
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.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management

18 October 2016 
Good progress but there is still pain. No obvious infection around the wound - free flap (soft tissue cover).
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management

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.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. Remove the infected wire
  2. Continue with lengthening
  3. Continue with docking
  4. Weight bearing as tolerated
  5. Continue with knee physio exercises to prevent knee stiffness due to the bone transport (usually we see stiffness starting at around this time - 2 cm of regenerate and more)

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.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. Continue with lengthening but temporarily stopping docking due to the fibula length
  2. Increase knee exercises despite wires cutting through the skin
  3. Regular use of CPM

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.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
PLan:
  1. Continue with physio to regain the knee movements
  2. Continue with bone transport
  3. Weightbearing as tolerated
  4. Follow in 3-4 weeks

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.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. Continue with the treatment as started
  2. Weightbearing as tolerated
  3. Follow up in 2 weeks

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.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. Continue with physio and weight bearing as tolerated
  2. Keep an eye on the "infection"
  3. Proceed with the docking
  4. Follow up in three weeks

14 February 2017 
Old haemathoma bursted. Pain improved.
​Prescription completed. Position acceptable. Will compress the docking site further.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. Compress the docking site with the TSF
  2. Start weight bearing as pain allows
  3. Continue physio for the knee and ankle
  4. Follow up in 3 weeks

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.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. Continue weight bearing as pain allows
  2. Continue physio for the knee and ankle
  3. Follow up in 3 weeks

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.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. Weight bearing as tolerated
  2. Compress the docking site further in next 2-3 weeks (bone reabsorption)
  3. Follow up in 4 weeks

02 May 2017 
Everything under control and progressing well. Docking was successful and position is maintained.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. Continue as started
  2. Organise a CT scan to confirm the docking and look for signs of union
  3. Follow up with the scan results

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).
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. Continue physio
  2. Follow up in 3 months

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?
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. Very likely non-union despite CT confirmation of union
  2. Wait and see

13 March 2018
Pain is not improving. Patient walking but not comfortable. 
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. ​Booked for non-union surgery using TSF

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.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. TSF prescription
  2. Weight bearing as tolerated 

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).
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. Further TSF prescription to correct the residual varus 
  2. Weightbearing as tolerated.

27 July 2018
Alignment restored. Will just need a bit of compression and hopefully we are done.
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
open tibia fracture, tibia open fracture, grade 3B open tibia fracture, aggressive bone debridement, soft tissue management
Plan:
  1. Compression with the TSF
  2. Walking
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.
Picture
Picture

Plan:
  1. Weight bearing as tolerated
  2. No external support
  3. Follow up in 4 weeks 

07 December 2018
4 weeks post frame removal. Patient is walking unaided, no significant pain. A stick only for longer distances.
Picture
Picture
Plan:
  1. Follow up in 3 months
  2. Can discuss with plastic surgeons to reduce the free flap

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    Mr Matija Krkovic, MD, PhD

    I am Consultant Orthopaedic Trauma Surgeon with special interest in Limb reconstructions and bone infections.

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  • Home
    • Knee Surgery >
      • Symptomatic Osteoarthritis of the Knee >
        • Primary Care >
          • Initial Management
          • Intermediate Care
          • Referral Treshold
        • Secondary Care >
          • Total Knee Replacement
          • High Tibial Osteotomy
          • Knee Arthroscopy
          • Complex Primary Total Knee Replacement
          • Postoperative Management
        • Procedures recommended by NICE
        • Procedures with limitations by NICE
        • Procedures not recommended by NICE
        • Viscosupplementation
      • Trauma to the Knee >
        • Meniscal Injuries
        • ACL Injury
      • Partial v Total Knee replacement
    • Limb Lengthening >
      • Femoral lengthening over the nail
  • Orthopaedic Trauma
    • Complex Trauma Impact
    • Principles of fine wire frame fixation >
      • Indications for fine wire frame
      • Complications >
        • Predictable complications
        • Unpredictable complications
      • Pin sites management
      • Activities >
        • Videos
        • Photos
    • Poller or Blocking screw >
      • Mechanic of Poller screw
      • Without and With a Poller Screw
      • Third Generation Poller Screws >
        • Epicentric poller screws in osteoporotic bone
        • Epicentric poller screws in comminuted spiral fracture
      • Use of Poller Screw(s) in Complex Cases >
        • Segmental Femoral Fracture
        • Low Supracondylar Femoral Fracture
        • Low Supracondylar Femoral Fracture 2nd case
        • Femoral Non-union - Antegrade Nail
        • Femoral Non-union - Retrograde nail
        • Distal Tibia Spiral Fracture
    • VAC irrigation
    • Complex Cases >
      • Femoral diaphysis defect
      • Capitellum Fractures
      • Distal Femoral Fractures
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