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Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage

Is the Timing of Debridement and Coverage Associated With Outcomes?

Al-Hourani, Khalid MRCSEd*; Fowler, Tim MRCS*; Whitehouse, Michael R. FRCS*,†,‡; Khan, Umraz FRCS§; Kelly, Michael FRCS*

doi: 10.1097/BOT.0000000000001562
Original Article

Objective: To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo–Anderson type IIIB open tibial diaphyseal fractures.

Design: Retrospective comparative cohort study over a 2-year period.

Setting: Level 1 trauma center.

Patients/Participants: A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis.

Intervention: Time to initial debridement and definitive management.

Main Outcome Measurement: Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant.

Results: Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion.

Conclusions: Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes.

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

*Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom;

Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, United Kingdom;

National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol, NHS Foundations Trust, University of Bristol, Bristol, United Kingdom; and

§Department of Plastic Surgery, Southmead Hospital, Bristol, United Kingdom.

Reprints: Khalid Al-Hourani, MRCSEd, Department of Trauma and Orthopaedics, North Bristol NHS Trust, Southmead Rd, Bristol BS10 5NB, United Kingdom (e-mail:

Supported by the NIHR Biomedical Research Centre at the University Hospitals Bristol NHS Foundation Trust and the University of Bristol. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health.

The authors report no conflict of interest.

Accepted May 22, 2019

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.