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Short-Term Outcomes of Severe Open Wartime Tibial Fractures Treated with Ring External Fixation
John J. Keeling, MD1; David E. Gwinn, MD1; Scott M. Tintle, MD1; Romney C. Andersen, MD2; Francis X. McGuigan, MD3
1 Department of Orthopaedic Surgery, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889. E-mail address for J.J. Keeling: john.keeling@med.navy.mil
2 Department of Orthopaedic Surgery, Walter Reed Army Medical Center, 6900 Georgia Avenue, Washington, DC 20307
3 Department of Orthopaedics, Georgetown University Hospital, 3800 Reservoir Road N.W. (G-PHC), Washington, DC 20007
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. 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.
Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, the Department of Defense, or the United States Government.
Investigation performed at the Department of Orthopaedic Surgery, National Naval Medical Center, Bethesda, Maryland

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Dec 01;90(12):2643-2651. doi: 10.2106/JBJS.G.01326
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Abstract

Background: The treatment of complex open tibial fractures sustained in combat remains controversial. This study investigated the short-term outcomes of type-III tibial shaft fractures treated at our institution with ring external fixation.

Methods: A retrospective review identified sixty-seven type-III tibial shaft fractures in sixty-five consecutive patients treated between April 2004 and January 2007. Of these, forty-five tibiae in forty-three patients received fracture fixation with ring external fixation. The cases of thirty-six patients, who received treatment for thirty-eight tibial shaft fractures to completion with a standardized protocol, were reviewed.

Results: A blast mechanism accounted for thirty-five injuries, and three injuries were from high-velocity gunshot wounds. There were twenty-one type-IIIA, thirteen type-IIIB, and four type-IIIC fractures. Rotational or free soft-tissue flap coverage was performed on fifteen patients. Eighteen patients received planned delayed bone-grafting, and nine had only bone morphogenetic protein placed at the fracture site at the time of final wound closure. All fractures healed with <5° of malalignment. One patient underwent elective delayed amputation. The average time to union with frame removal was 221 days (range, 102 to 339 days).

Conclusions: Treatment of severe open wartime tibial fractures with a protocol-driven approach to wound management and placement of ring external fixation can result in a low rate of complications and a relatively high rate of fracture union. Most complications can be successfully managed without frame removal.

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

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    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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