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Analysis of Surgeon-Controlled Variables in the Treatment of Limb-Threatening Type-III Open Tibial Diaphyseal Fractures
Lawrence X. Webb, MD1; Michael J. Bosse, MD2; Renan C. Castillo, MS3; Ellen J. MacKenzie, PhD3
1 Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem, NC 27157-1070
2 Department of Orthopaedic Surgery, Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232
3 Center for Injury Research and Policy, Johns Hopkins Bloomberg School of Hygiene and Public Health, 624 North Broadway, Room 554, Baltimore, MD 21205
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Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the National Institutes of Health and the National Institute of Arthritis and Musculoskeletal and Skin Diseases. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
A commentary is available with the electronic versions of this article, on our web site (www.jbjs.org) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).
Investigation performed at Wake Forest University School of Medicine, Winston-Salem, North Carolina; Carolinas Medical Center, Charlotte, North Carolina; and Johns Hopkins Bloomberg School of Hygiene and Public Health, Baltimore, Maryland

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 May 01;89(5):923-928. doi: 10.2106/JBJS.F.00776
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Abstract

Background: The open tibial diaphyseal fracture remains a treatment challenge. The purpose of the present analysis of the long-term follow-up data on a previously reported cohort of patients was to identify surgeon-controlled variables that affected fracture union, complications, and final outcome in patients who had sustained a severe open tibial shaft fracture.

Methods: A cohort of 156 patients with a limb-threatening open tibial diaphyseal fracture was identified from the Lower Extremity Assessment Project (LEAP) study group. The patients were prospectively followed for two to seven years. In addition to the Sickness Impact Profile, other outcome metrics included the time to fracture union as well as the occurrence of infection and other complications that required rehospitalization. Statistical differences between groups were calculated.

Results: Within the parameters of the present study, the timing of débridement, the timing of soft-tissue coverage, and the timing of bone-graft placement had no effect on outcome. Patients in whom the fracture was definitively treated with an external fixator had more surgical procedures, took longer to achieve full weight-bearing status, and had more readmissions to the hospital for the treatment of infection and nonunion than did those in whom the fracture was treated with an intramedullary nail. Patients undergoing external fixation who also had a muscle flap for wound coverage had more physical impairment and a worse functional outcome than did patients who had an amputation.

Conclusions: Surgeons should carefully consider alternative treatment options for patients who have a severe open tibial fracture when limb salvage is perceived to require the combination of external fixation for fracture fixation and a muscle flap for wound coverage.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Lawrence X Webb
    Posted on September 04, 2008
    Dr. Webb and colleagues respond to Dr. Om
    Wake Forest University Medical Center

    Dr. Om is correct in stating in his letter that details about the nature and type of fracture were not included in our publication. These and other details delineated in a number of tables would have resulted in a more lengthy manuscript and were withheld at the suggestion of the reviewers. These injury characteristics included fracture classification (AO/OTA), as well as soft tissue injury classification (AO and Tscherne) in addition to the Gustilo and Anderson open fracture classification, all prospectively gathered according to the LEAP protocol(1).

    As stated in the discussion section, "…the injury as well as the treatment characteristics of the two groups of limb salvage patients (those managed with intramedullary nails and those managed with an external fixator) were looked at. Although the external fixation group had a slightly more severe injury, largely because of a higher proportion of bone loss, this difference was not significant. The mean probability of amputation score (a score combining all injury characteristics into a single probability of amputation) was 0.080 for the intramedullary nail group and 0.105 for the external fixation group (p=0.23). In all cases, the differences between the groups remained after comparison across equivalent injury groups, with adjustment for injury characteristics in multivariate regression models…"

    The major point of our paper was to analyze the influence of surgeon controlled variables on outcomes. Since nearly all patients in the study cohort and all patients looked at in this analysis had a definitive treatment with an external fixator or an intramedullary nail, this comparison was statistically meaningful. Those definitively managed with an external fixator took a longer time to weight bear, and spent more time in the hospital (most commonly for infection or delayed union). For those with a muscle flap and external fixation the functional outcome, prevalence of major complications and level of physical impairment at two years were worse than for those with a muscle flap and an intramedullary nail.

    References:

    1. Bosse, MJ et al An analysis of outcomes of reconstruction or amputation following leg threatening injuries N Engl J Med 2002 Dec 12;347(24):1924-31.

    Lakhwani Prakash Om, MS, DNB (Orth.)
    Posted on February 14, 2008
    Outcomes Following Type III Open Tibial Diaphyseal Fractures
    S.S. Medical College, Rewa, INDIA

    To The Editor:

    In the article, “Surgeon–Controlled Variables in the Treatment of Type –III Open Tibial Diaphyseal Fractures"(1), the authors may indeed have come to the correct conclusions, but I would point out that the study was limited to a comparison of outcomes following certain procedures such as external fixater, and intramedullary nail and soft tissue coverage.

    However, the authors did not provide details about the nature and type of fracture which greatly influences the management of these injuries and the functional outcomes. It is not the particular procedure i.e. external fixater or intra-medullary nail that determines the liklihood of a successful outcome but, rather, the primary injury characteristics that lead the surgeon to choose the treatment options. Hence, comparison done only on the basis of the procedures may not give us valid results.

    Such outcome measures as infection, union, number of surgical interventions, weight bearing status, and days of hospitalization are more pertinent than the particular treatment option.

    In addition, the description of type III open fracture is too wide as described in the Ganga Hospital trauma severity score by Rajasekran et al.(2) and it is very difficult to obtain any valid conclusion for all type III fractures combined.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated .

    References:

    1. Webb LX, Bosse MJ, Castillo RC, MacKenzie EJ, and the LEAP Study Group. Analysis of surgeon-controlled variables in the treatment of limb-threatening type-III open tibial diaphyseal fractures. J Bone Joint Surg Am. 2007;89:923-928.

    2. Rajasekaran S, Babu JN, Dheenadhayalan J, Shetty AP, Sundararajan SR, Kumar M, Rajasabapathy S. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures. J Bone Joint Surg BR. Oct. 2006;88-B:1351-1360.

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