Optimum timing of conversion from DCO to definitive fixation in closed fractures of the lower limb: When and how?

Published:September 15, 2020DOI:


      • In DCO, Ex-fix stabilization is normally followed by a conversion to internal fixation, the optimum timing and method of which are still debated.
      • We wanted to determine whether the timing and the method of conversion one-stage influence the development of infection and non-union.
      • We analysed a series of 94 lower limb closed fractures who underwent DCO then converted to plate or nail, comparing them by timing of conversion.
      • The comparison did not show a significant correlation between timing of conversion within 22 days from DCO and infection or non-union.
      • These findings tell us that lower limb closed fractures can be safely converted to definitive fixation within 22 days from DCO in 1-stage procedure.



      In damage control orthopaedics (DCO), fractures are initially stabilised with external fixation followed by delayed conversion to definitive internal fixation. The aim of this study is to determine whether the timing of the conversion influences the development of deep infection and fracture healing in a cohort of patients treated by DCO after a closed fracture of the lower limb. Furthermore, we wanted to evaluate whether the one-stage conversion procedure is always safe.

      Materials and methods

      A retrospective cohort study was conducted at a single level 1 trauma centre. Ninety-four cases of closed fractures of lower limb treated by DCO subsequently converted to internal fixation from 2012 to 2019 were included. Development of deep infection, superficial infection, non-union and time to union were recorded. Patients were then divided into three groups according to the timing of conversion: Group A (<7 days), Group B (7-13 days), Group C (> 14 days). Comparison between groups was performed to assess intergroup variabilty.


      The mean number of days between DCO and conversion was 6.7±4.52 (range 1-22). We observed one case of deep infection (1.1%), one case of non-union (1.1%), four cases of superficial infection (4.3%) and mean time to union was ±1.38 months. Comparison between groups demonstrated no significant correlation between timing of conversion and development of superficial or deep infection and non-union, while it highlighted that complexity of the fracture and longer surgical time of conversion procedure were significantly higher in Group C.


      One-stage conversion to definitive internal fixation within 22 days from DCO is a safe and feasible procedure, which does not influence the incidence of infection or non-union.


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        • Scalea TM
        • Boswell SA
        • Scott JD
        • Mitchell KA
        • Kramer ME
        • Pollak AN
        External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics.
        J Trauma. 2000; 48 (discussion 21-3): 613-621
        • Jansen JO
        • Thomas R
        • Loudon MA
        • Brooks A
        Damage control resuscitation for patients with major trauma.
        BMJ (Clin Res ed). 2009; (b1778): 338
        • Brohi K
        • Cohen MJ
        • Ganter MT
        • Matthay MA
        • Mackersie RC
        • Pittet JF
        Acute traumatic coagulopathy: initiated by hypoperfusion: modulated through the protein C pathway?.
        Ann Surg. 2007; 245: 812-818
        • Pape HC
        • Giannoudis P
        • Krettek C
        The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery.
        Am J Surg. 2002; 183: 622-629
        • Encinas-Ullán CA
        • Martínez-Diez JM
        • Rodríguez-Merchán EC
        The use of external fixation in the emergency department: applications, common errors, complications and their treatment.
        EFORT Open Rev. 2020; 5: 204-214
        • Pairon P
        • Ossendorf C
        • Kuhn S
        • Hofmann A
        • Rommens PM
        Intramedullary nailing after external fixation of the femur and tibia: a review of advantages and limits.
        Eur J Trauma Emerg Surg. 2015; 41: 25-38
        • Cimbanassi S
        • OʼToole R
        • Maegele M
        • Henry S
        • Scalea TM
        • Bove F
        • et al.
        Orthopedic injuries in patients with multiple injuries: results of the 11th trauma update international consensus conference Milan, December 11, 2017.
        J Trauma Acute Care Surg. 2020; 88: e53-e76
        • Lavini F
        • Dall'Oca C
        • Mezzari S
        • Maluta T
        • Luminari E
        • Perusi F
        • et al.
        Temporary bridging external fixation in distal tibial fracture.
        Injury. 2014; 45: S58-S63
        • Hosny G
        • Fadel M.
        Ilizarov external fixator for open fractures of the tibial shaft.
        Int Orthop. 2003; 27: 303-306
        • Hadeed MM
        • Evans CL
        • Werner BC
        • Novicoff WM
        • Weiss DB
        Does external fixator pin site distance from definitive implant affect infection rate in pilon fractures?.
        Injury. 2019; 50: 503-507
        • Antich-Adrover P
        • Martí-Garin D
        • Murias-Alvarez J
        • Puente-Alonso C
        External fixation and secondary intramedullary nailing of open tibial fractures. A randomised, prospective trial.
        J Bone Joint Surg Br. 1997; 79: 433-437
        • Bhandari M
        • Zlowodzki M
        • Tornetta P
        • 3rd Schmidt A
        • Templeman DC
        Intramedullary nailing following external fixation in femoral and tibial shaft fractures.
        J Orthop Trauma. 2005; 19: 140-144
        • Harwood PJ
        • Giannoudis PV
        • Probst C
        • Krettek C
        • Pape HC
        The risk of local infective complications after damage control procedures for femoral shaft fracture.
        J Orthop Trauma. 2006; 20: 181-189
        • Parekh AA
        • Smith WR
        • Silva S
        • Agudelo JF
        • Williams AE
        • Hak D
        • et al.
        Treatment of distal femur and proximal tibia fractures with external fixation followed by planned conversion to internal fixation.
        J Trauma. 2008; 64: 736-739
        • Gill SP
        • Raj M
        • Kumar S
        • Singh P
        • Kumar D
        • Singh J
        • et al.
        Early conversion of external fixation to interlocked nailing in open fractures of both bone leg assisted with vacuum closure (VAC) - final outcome.
        J Clin Diagn Res. 2016; (Rc10-4): 10
        • Nieto H
        • Baroan C.
        Limits of internal fixation in long-bone fracture.
        Orthop Traumatol Surg Res. 2017; 103: S61-Ss6
        • Nanchahal J
        • Nayagam S
        • Khan U
        • Moran C
        • Barrett S
        Standards for the management of open fractures of the lower limb.
        Royal Society of Medicine Press Limited, 2009
        • Laible C
        • Earl-Royal E
        • Davidovitch R
        • Walsh M
        • Egol KA
        Infection after spanning external fixation for high-energy tibial plateau fractures: is pin site-plate overlap a problem?.
        J Orthop Trauma. 2012; 26: 92-97
        • Coester LM
        • Nepola JV
        • Allen J
        • Marsh JL
        The effects of silver coated external fixation pins.
        Iowa Orthop J. 2006; 26: 48-53
        • Haidukewych GJ.
        Temporary external fixation for the management of complex intra- and periarticular fractures of the lower extremity.
        J Orthop Trauma. 2002; 16: 678-685
        • Mahan J
        • Seligson D
        • Henry SL
        • Hynes P
        • Dobbins J
        Factors in pin tract infections.
        Orthopedics. 1991; 14: 305-308
        • Rigal S
        • Mathieu L
        • de l'Escalopier N
        Temporary fixation of limbs and pelvis.
        Orthop Traumatol Surg Res. 2018; 104: S81-Ss8
        • Horst K
        • Andruszkow H
        • Weber C
        • Dienstknecht T
        • Hildebrand F
        • Tarkin I
        • et al.
        Standards of external fixation in prolonged applications to allow safe conversion to definitive extremity surgery: the Aachen algorithm for acute ex fix conversion.
        Injury. 2015; 46: S13-S18
        • Demitri S
        • Vicenti G
        • Carrozzo M
        • Bizzoca D
        • De Franceschi D
        • Moretti B
        The Masquelet technique in the treatment of a non-infected open complex fracture of the distal tibia with severe bone and soft tissue loss: a case report.
        Injury. 2018; 49: S58-s62
        • Della Rocca GJ
        • Crist BD
        External fixation versus conversion to intramedullary nailing for definitive management of closed fractures of the femoral and tibial shaft.
        J Am Acad Orthop Surg. 2006; 14: S131-S135
        • Meinberg EG
        • Agel J
        • Roberts CS
        • Karam MD
        • Kellam JF
        Fracture and dislocation classification compendium—2018.
        J Orthop Trauma. 2018; 32: S1-S10
      1. National Healthcare Safety Network CDC. Surgical site infection (SSI) event. Procedure-associated module.; 2017. p. 9-1 -9-31.

        • Giannoudis PV.
        Surgical priorities in damage control in polytrauma.
        J Bone Joint Surg Br. 2003; 85: 478-483
        • Nowotarski PJ
        • Turen CH
        • Brumback RJ
        • Scarboro JM
        Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients.
        J Bone Joint Surg Am. 2000; 82: 781-788
        • Vicenti G
        • Bizzoca D
        • Nappi VS
        • Carrozzo M
        • Delmedico M
        • Solarino G
        • et al.
        The impact of lag screw in the healing time of distal tibia fractures treated with minimally invasive plate osteosynthesis: a randomized clinical trial.
        Injury. 2020;
        • Matsumura T
        • Takahashi T
        • Miyamoto O
        • Saito T
        • Kimura A
        • Takeshita K
        Clinical outcome of conversion from external fixation to definitive internal fixation for open fracture of the lower limb.
        J Orthop Sci. 2019; 24: 888-893
        • Mody RM
        • Zapor M
        • Hartzell JD
        • Robben PM
        • Waterman P
        • Wood-Morris R
        • et al.
        Infectious complications of damage control orthopedics in war trauma.
        J Trauma. 2009; 67: 758-761
        • Guerado E
        • Cano JR
        • Fernandez-Sanchez F
        Pin tract infection prophylaxis and treatment.
        Injury. 2019; 50: S45-Ss9
        • Suzuki T
        • Hak DJ
        • Stahel PF
        • Morgan SJ
        • Smith WR
        Safety and efficacy of conversion from external fixation to plate fixation in humeral shaft fractures.
        J Orthop Trauma. 2010; 24: 414-419
        • Yokoyama K
        • Uchino M
        • Nakamura K
        • Ohtsuka H
        • Suzuki T
        • Boku T
        • et al.
        Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures.
        Injury. 2006; 37: 554-560
        • Roussignol X
        • Sigonney G
        • Potage D
        • Etienne M
        • Duparc F
        • Dujardin F
        Secondary nailing after external fixation for tibial shaft fracture: risk factors for union and infection. A 55 case series.
        Orthop Traumatol Surg Res. 2015; 101: 89-92
        • Metsemakers WJ
        • Handojo K
        • Reynders P
        • Sermon A
        • Vanderschot P
        • Nijs S
        Individual risk factors for deep infection and compromised fracture healing after intramedullary nailing of tibial shaft fractures: a single centre experience of 480 patients.
        Injury. 2015; 46: 740-745
        • Tzioupis C
        • Giannoudis PV.
        Prevalence of long-bone non-unions.
        Injury. 2007; 38: S3-S9
        • Vicenti G
        • Bizzoca D
        • Cotugno D
        • Carrozzo M
        • Riefoli F
        • Rifino F
        • et al.
        The use of a gentamicin-coated titanium nail, combined with RIA system, in the management of non-unions of open tibial fractures: a single centre prospective study.
        Injury. 2019;
        • Large TM
        • Alton TB
        • Patton DJ
        • Beingessner D
        Does perioperative systemic infection or fever increase surgical infection risks after internal fixation of femur and tibia fractures in an intensive care polytrauma unit?.
        J Trauma Acute Care Surg. 2013; 75: 664-668
        • Blachut PA
        • Meek RN
        • O'Brien PJ
        External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. A sequential protocol.
        J Bone Joint Surg Am. 1990; 72: 729-735
        • Walker JA
        • Scammell BE
        • Bayston R
        A web-based survey to identify current practice in skeletal pin site management.
        Int Wound J. 2018; 15: 250-257
        • Hodel S
        • Link BC
        • Babst R
        • Mallee WH
        • Posso P
        • Beeres FJP
        Perioperative management of external fixation in staged protocols: an international survey.
        Eur J Orthop Surg Traumatol. 2018; 28: 565-572