Abstract
Background
High energy open tibial fractures are complex injuries with no consensus on the optimal
method of fixation. Treatment outcomes are often reported with union and re-operation
rates, often without specific definitions being provided. We sought to describe union,
reoperation rates, and patient reported outcomes, using the validated EQ-VAS and Disability
Rating Index (DRI) scores, following stabilisation with a Taylor Spatial Frame (TSF)
and a combined orthoplastic approach for the management of soft tissues. A literature
review is also provided.
Method
A prospective cross-sectional follow up of open tibial fractures, treated at a level
1 major trauma centre, managed with a TSF using a one ring per segment technique between
January 2014 and December 2019 were identified. Demographic, injury and operative
data were recorded, along with Patient Reported Outcome Measures (PROM) scores, specifically
the EQ-VAS and Disability Rating Index (DRI). Union rates, defined by radiographic
union scale in tibia (RUST) scores, and re-operation rates were recorded. Appropriate
statistical analyses were performed, with a p<0.05 considered statistically significant.
Results
Overall, 51 patients were included. Mean age was 51.2 ± 17.4 years, with a 4:1 male
preponderance. Diaphyseal and distal fractures accounted for 76% of cases. Mean time
in frame was 206.7 ± 149.4 days. Union was defined and was achieved in 41/51 (80.4%)
patients. Deep infection occurred in 6/51 (11.8%) patients. Amputation was performed
in 1 case (1.9%). Overall re-operation rate was 33%. Time to union were significantly
longer if re-operation was required for any reason (uncomplicated 204±189 vs complicated
304±155 days; p = 0.0017) . EQ-VAS and DRI scores significantly deteriorated at 1 year follow-up
(EQVAS 87.5 ± 11.7 vs 66.5 ± 20.4;p<0.0001 and DRI 11.9 ± 17.8 vs 39.3 ± 23.3;p<0.0001). At 1 year post op, 23/51(45.1%) required a walking aid, and 17/29 (58.6%)
of those working pre-injury had returned to work.
Conclusion
Open tibial fracture have significant morbidity and long recovery periods as determined
by EQVAS and DRI outcome measures. We report the largest series of open tibial feature
treated primarily with a TSF construct, which has similar outcomes to other techniques,
and should therefore be considered as a useful technique for managing these injuries.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to InjuryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Epidemiology of open tibia fractures in a population-based database: update on current risk factors and clinical implications.Eur J Trauma Emerg Surg. 2019; 45 (455-453)
- Open fractures of the lower extremity: current management and clinical outcomes.EFORT Open Rev. 2018; 3: 316-325
- Outcomes following treatment of complex tibial fractures with circular external fixation: a comparison between the Taylor spatial frame and Truelok-Hex.STLR. 2019; 14: 142-147
- Incidence and epidemiology of tibial shaft fractures.Injury. 2015; 46: 746-750
- Risk factors for infectious complications after open fractures: a systematic review and meta-analysis.Int Orthop. 2017; 41: 1965-1982
- The prevention of infection in open fractures: a experimental study of the effect of fracture stability.Injury. 1994; 25: 31-38
- Treatment principles in the management of open fractures.Indian J Orthop. 2008; 42: 377-386
- Dhatt: single-stage “Fix and Flap” gives good outcomes in grade 3B/C open tibial fractures: a prospective study.Malays Orthop J. 2020; 14: 61-73
- The functional outcome of severe, open tibial fractures managed with early fixation and coverage.JBJS(Br). 2005; 86: 861-867
- Grade 3 open tibial shaft fractures treated with a circular frame; Functional outcome and systematic review of literature.Injury. 2015; 46: 751-758
- A systematic review of patient-reported outcome measures used in circular frame fiation.STLR. 2019; 14: 34-44
- Functional outcomes after tibial shaft fractures treated using the Taylor Spatial Frame.J Orthop Trauma. 2015; 29: e54-e59
British Orthopaedic Association and British Association of Plastic Reconstructive and Aesthetic Surgeons audit stnadards for trauma: Open Fractures (2017). Available online at https://www.boa.ac.uk/uploads/assets/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf. [Last accessed 21 June 2021]
- Agreement between retrospectively and contemporaneously collected patient-reported outcome measures (PROMs) in hip and knee replacement patients.Qual Life Res. 2018; 27: 1845-1854
- EuroQol: the current state of play. 37. Health Policy, 1996: 53-72
- The Disability Rating Index: an instrument for the assessment of disability in clinical settings.J Clin Epidemiol. 1994; 47: 1423-1435
- The Orthopaedic Trauma Society classification of open fractures.BJJ. 2020; 102-B: 1469-1474
- Interobserver and intraobserver variation in the assessment of the healing of tibial fracture after intramedullary fixation.JBJS(Br). 2002; 84: 15-18
- The radiographic union scale in tibial (RUST) score.Bone Joint Res. 2016; 5: 116-121
- Complications of limb lengthening: a learning curve.Clin Orthop Relat Res. 1994; 301: 10-18
- Interpretation of changes in health-related quality of life: the remarkable universality of half a standard deviation.Med Care. 2003; 41: 582-592
- The epidemiology of open fractures in adults. A 15 year review.Injury. 2012; 43: 891-897
Sprague S., Nguyen E., Phillips M., Bhandari M., Watson J.:The Taylor spatial frame for external fixation: a systematic literature review following 20 years of clinical outcomes. Available at https://www.smith-nephew.com/global/assets/pdf/products/surgical/tsf-20year-whitepaper07037v1.pdf
- Taylor Spatial Frame of reamed intramedullary nailing for closed fracture of the tibial shaft: a randomised controlled trial.J Orthop Trauma. 2020; 34: 612-619
- Management of high-energy tibial shaft fractures using the hexapod circular external fixator.BMC Surg. 2021; 21: 95
- Complications associated with hexapod circular fixation for acute fracture of the tibia diaphysis: a retrospective descriptive study at a high volume trauma centre.Injury. 2020; 51: 516-521
- Intramedullary nailing versus external fixation in Gustilo type III open tibial shaft fracture: a meta-analysis of randmised controlled trial.Strat Trauma Limb Recon. 2016; 11: 1-4
- A review of the management of open fractures of the tibia and femur.JBJS(Br). 2006; 3: 281-289
- Taylor spatial frame fixation in patients with multiple traumatic injuries; Study on 57 long-bone fractures.J Orthop Trauma. 2013; 27: 442-450
- Fracture healing following high energy tibial trauma: ilizarov versus Taylor Spatial Frame.Ann R Coll Surg. 2014; 96: 106-110
- Single-stage orthoplastic reconstruction of Gustilo-Anderson grade III open tibial fracture greatly reduced infection rates.Injury. 2015; 46: 2263-2266
- Orthopastic surgical collaboration is required to optmise the treatment of severe limb injuries: a multi-centre, prospective cohort study.J Plast Reconstr Aesthet Surg. 2017; 70: 71522
- The relationship between time to surgical debridement and incidence of infection in grade III open fractures.Strat Trauma Limb Recon. 2012; 7: 33-37
- Gustilo IIIB open tibial fractures: an analysis of infection and nonunion rates.Indian J Orthop. 2018; 52: 406-410
- What are the biomechanical properties of the Taylor Spatial Frame?.CORR. 2017; 475: 1472-1482
- Marais LC: short-term results of grade III open tibia fractures treated with circular fixators.SA Orthop J. 2016; 15: 20-26
- The influence of a weight bearing platform on the mechanical behaviour of two Ilizarov ring fixators: tensioned wires vs half-pins.JOSR. 2011; 61: 5272
- A biomechanical comparison between Taylors spatial frame and Illizarov external fixator.Malays Orthop J. 2014; 8: 35-39
- What is a safe angle for struts in a hexapod frame? Defining the limitation of different hexapod frames and a potential novel solution to frame instability.Orthop Proceding. 2018; (-B): 95
- Improvement of the bone-screw interface strength with hydroxyapatite-coated and titanium-coated AO/ASIF screws.J Orthop Trauma. 2002; 16: 257-263
- State of the art review: techniques to avoid pin loosening and infection in external fixation.J Orthop Trauma. 2002; 16: 189-195
- Hydroxyapatite-coated orhtopaedic screws as infection resistant materials; In vitro study.Biomaterials. 1999; 20: 323-327
- Hydroxyapatie-coated Schanz pins in external fixators used for distraction osteogeneis: a randomised, controlled trial.JBJS(Am). 2002; 84 (-A): 1162-1166
- Prevention of pine site infection in external fixation:a review of the literature.Strat Trauma Limb Recon. 2016; 11: 75-85
- Systematic review of incidence of pin track infection associated with external fixation.J Limb Lenghtening and Reconstruct. 2016; 2: 6-16
- Complex tibial fractures are associated with lower social classes and predict early exit from employment and worse patient-reported QOL: a prospective observational study of 46 complex tibial fractures treated with a ring fixator.Strat Trauma Limb Recon. 2018; 13: 25-33
- The outcome following fixation of bicondylar tibial plateau fractures.Bone Joint J. 2014; (-B:956-62): 96
- A prospective observational study of 56 patients treated with a ring fixator after a complex tibial fracture.STLR. 2017; 12: 35-44
- Complications and functional outcome after fixation of distal tibia fractures with locking plate- A multicentre study.Injury. 2016; 47: 1514-1518
- Medium-erm results after surgical treatment of high energy tibial plateau fractures.J Knee Sur. 2020; 33: 394-398
- Intrameduallry nail fixation versus locking plate fixation for dults with a fracture of the distal tibia: the UK FixDT RCT.Health Tech Assess. 2018; 22
- Outcome of tissue reconstruction in distal lower leg fractures: a retrospective cohort study.BMC Musculoskelet Disord. 2020; 21: 799
- Determinants of patient satisfaction after severe lower-extremity injuries.JBJS(Am). 2008; 90: 1206-1211
Bosse M.J., MacKenzie E.K., Kellan J.F., Burgess A.R., Webb L.X., Swiontkowski M.F. et al.: An analysis of outcomes of reconstruction or amputation of leg threatening injuries. NEJM 2002l 347(24):1924–31
- Management of severe open tibial fractures.Am J orthop (Belle Mead NJ). 2007; 36: 215-220
- Problems in management of type III (severe) open fractures: a new classification of type III open fractures.J Trauma. 1984; 24: 742-746
- Trends in the management of open fractures. A critical analysis.JBJS(Am). 2006; 88: 2739-2748
- The influence of fracture etiology and type on fracture healing: a review of 104 consecutive tibial shaft fractures.Arch Orthop Trauma Surg. 2011; 121: 325-328
- Court-Brown CM: fractures of the tibia. Can their outcome be predicted.JBJS(Br). 1999; 81: 71-76
- The 6-hour rule for surgical debridement of open tibial fractures: a systematic review and meta-analysis of infection and non union rates.J Orthop Trauma. 2016; 30: 397-402
- Prevalence and influencing factors of nonunion in patients with tibial fracture: systematic review and meta-analysis.J Orthop Surg Res. 2020; 15: 377
- A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia.Plast Reconstr Surg. 2008; 122: 1796-1805
- Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation).Injury. 2009; 40: 213-219
- Factors influencing functional outcomes after distal tibial shaft fractures.J Orthop Trauma. 2012; 26: 178-183
- Factors associated with trauma clinic follow-up compliance after discharge: experience at an urban level I trauma centre.J Trauma Acute Care Surg. 2014; 76: 185-190
- The fallacy of follow-up:when orthopaedic trauma patients actually return to clinic.JBJS(Am). 2021; 103: 469-476
- Global overview of response rates in patient and health care professiona surveys in surgery: a systematic review.Ann Surg. 2020; 275: e75-e81
- Stirton: loss of follow-up in orthopaedic trauma: who is getting lost to follow up?.J Orthop Trauma. 2015; 29: 510-515
- Long-term health status and trajectories of seriously injured patients: a population-based longitudinal study.PLOS Med. 2017; 14e1002322
- Outcome at 12 to 22 years of 1502 tibial shaft fractures.Bone Joint Journal. 2014; 96-B: 1370-1377
- LEAP study group: impactof smoking on fracture healing and risk of complications in limb-threatneing open tibia fractures.J Orthop Trauma. 2005; 19: 151-157
- The effect of smoking on bone healing: a systematic review.Bone Joint Res. 2013; 2: 102-111
- Effect of smoking on tibial shaft fracture healing.Clin Orthop Relat Res. 1999; 365: 184-200
- Population norms for the EQ-5D-3l: a cross-country analysis of population surveys for 20 countries.Eur J Health Econom. 2019; 20: 205-216
- Taylor Spatial Frame in the treatment of open tibial shaft fractures.Indian J Orthop. 2008; 42: 431-438
- Treatment of open fracture with a computer-assisted external fixator system without the use of fluoroscopy.J Orthop Surg Res. 2016; 11: 51
Article info
Publication history
Published online: October 20, 2022
Accepted:
October 17,
2022
Identification
Copyright
© 2022 Elsevier Ltd. All rights reserved.
