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Short-Term Outcomes of Severe Open Wartime Tibial Fractures Treated with Ring External Fixation

Keeling, John J. MD; Gwinn, David E. MD; Tintle, Scott M. MD; Andersen, Romney C. MD; McGuigan, Francis X. MD

Journal of Bone & Joint Surgery - American Volume: 01 December 2008 - Volume 90 - Issue 12 - p 2643–2651
doi: 10.2106/JBJS.G.01326
Scientific Articles
Supplementary Content

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.

1Department 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

2Department of Orthopaedic Surgery, Walter Reed Army Medical Center, 6900 Georgia Avenue, Washington, DC 20307

3Department of Orthopaedics, Georgetown University Hospital, 3800 Reservoir Road N.W. (G-PHC), Washington, DC 20007

Copyright 2008 by The Journal of Bone and Joint Surgery, Incorporated
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