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OBJECTIVE To assess the risk factors associated with deep infection after operative treatment of peritalar fracture dislocations. DESIGN A retrospective study was performed to identify patients who had operative treatment of a peritalar fracture dislocation over an 11-year period (2008-2019). SETTING Level 1 trauma center. PARTICIPANTS Patients were identified by review of all surgical billing that included open reduction of peritalar dislocation. Minimum follow-up for inclusion was 3 months or the outcome of interest. A total of 178 patients were identified and 154 patients met inclusion criteria. MAIN OUTCOME The primary outcome was deep infection, defined as return to the operating room for debridement with positive cultures. RESULTS A total of 19 (12.3%) patients developed a post-operative deep infection. The most common associated fractures were talus (47%), calcaneus (33%), and fibula (9%). The infected group was significantly older (47.2 vs 39.5 years, p=0.03). Patients undergoing operative management for peritalar fracture dislocations with current smoking were found to have significantly higher odds of postoperative deep infection (74 vs 34%, aOR=7.4, 95% CI, 2.3-24.1, p=0.001). There was a significantly higher risk of infection in patients with a Gustilo-Anderson type 3 open fractures (32 vs 12%, aOR=5.7, 95% CI, 1.6-20.3, p=0.007). The infected group had high rates of below knee amputation when compared to the group without infection (47 vs 1%, p< 0.001). CONCLUSION In our retrospective study, risk factors for infection after peritalar fracture dislocation included older age, smoking, and Gustilo-Anderson type 3 open fracture. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Objective To determine the outcomes of pilon and tibial shaft fractures with syndesmotic injuries compared to similar fractures without syndesmotic injury. Design Retrospective Case-Control. Setting Level 1 Trauma CenterPatients/Participants: All patients over a 5-year period (2012-2017) with tibial shaft or pilon fractures with a concomitant syndesmotic injury and a control group without a syndesmotic injury matched for age, OTA/AO fracture classification and Gustilo-Anderson open fracture classification. Intervention Preoperative or intraoperative diagnosis of syndesmotic injury with reduction and fixation of both fracture and syndesmosis. Main outcome measurement Rates of deep infection, nonunion, unplanned reoperation and amputation in patients with a combined syndesmotic injury and tibial shaft/pilon fracture versus those without a syndesmotic injury. Results A total of 30 patients, including 15 tibial shaft and 15 pilon fractures were found to have associated syndesmotic injuries. The matched control group was comprised of 60 patients. The incidence of syndesmotic injury in all tibia shaft fractures was 2.3% and in all pilon fractures 3.4%.The syndesmotic injury group had more neurologic injuries (23.3% vs. 8.3% p=0.02), more vascular injuries not requiring repair (30% vs. 15%, p=0.13), and a higher rate compartment syndrome (6.7% vs. 0%, p=0.063). Segmental fibula fracture was significantly more common in patients with a syndesmotic injury (36.7% vs. 13.3%, p=0.04).Fifty percent of the syndesmotic injury group underwent an unplanned reoperation with significantly more unplanned reoperations (50% vs. 27.5%, p=0.04). The syndesmotic group had a significantly higher deep infection rate (26.7% vs. 8.3% p=0.047), and a significantly higher rate of amputation (26.7% vs. 3.3% p=0.002), while the nonunion rate was similar (17.4% vs. 16.7% p=0.85). Conclusion While syndesmotic injuries with tibial shaft or pilon fractures are rare; they are a marker of a potentially limb-threatening injury. Limbs with this combined injury are at increased risk of deep infection, unplanned reoperation and amputation. The presence of a segmental fibula fracture should raise clinical suspicion to evaluate for syndesmotic injury. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Open fractures about the elbow are an infrequent but complex injury with limited existing literature. The aims of the study were to review the treatment strategies of open elbows fractures, functional outcome and complication rates associated with the injury, and correlate the outcome with the topography of the fracture.Patients (n = 21) with open elbow fractures injuries over a 2-year period were analyzed. They were assessed regarding the orthoplastic characteristics of their injury as well any other associated injuries. Outcomes were assessed objectively (achievement of bony union, range of movement, infection status, need for further procedures) and subjectively (Oxford Elbow Score, EQ-5D, EQ-VAS).The commonest grade of open injury was grade 3 (43%). Associated orthopedic injuries were present in 62% and associated system injuries in 57%. Almost half of the patients were noted to have had a significantly increased presenting mortality risk as per Injury Severity Score assessment. Mean time to first wound débridement was 31 hours. There were no cases of deep or chronic infection. Complete bony union was noted in 85% of patients, and 48% of patients required removal of metalwork. Subgroup analysis of the cohort by fracture topography (single unipolar elbow bone injury vs. multiple elbow bony injuries) demonstrated no significant difference (P.05) regarding rate of complication or final Oxford Elbow Score, EQ-5D or EQ-VAS. Patients with injuries that involved the distal humerus had the highest rate for further procedures (P.05). The average Oxford Elbow Score, EQ-5D, and EQ-VAS scores for the whole cohort at final follow-up were 37.4, 0.54, and 62.18, respectively.Open elbow injuries are usually from high-energy trauma and often combined with other significant injuries. As a result, the timelines to elbow surgery were often delayed. However, this did not impact the local infection rates nor did it necessitate further surgery, but made achieving all British Orthopaedic Association Standards for Trauma targets difficult. Chronic infection was not an issue in this cohort. Subgroup analysis indicates open distal humerus fractures carry the highest risk for further procedures. This is most commonly in the form of removal of metalwork and fibrinolysis. End outcomes for patients with open elbow fractures can be positive, despite the notable presenting Injury Severity Score. A subspecialist elbow and orthoplastic approach whenever possible is advocated.

INTRODUCTION: Open ankle fractures in geriatric (age > 60 years) patients are a source of significant morbidity and mortality. Surgical management includes plate and screw fixation (ORIF), retrograde hindfoot nail (HFN), definitive external fixation (ex-fix) and below knee amputation. However, each modality poses unique challenges for this population. We sought to identify predictors of unplanned OR and short-term mortality after geriatric open ankle fractures managed by our service. MATERIALS AND METHODS: In an IRB-approved protocol, we evaluated patients over 60 years of age managed for a low energy open ankle/distal tibia pilon fracture by trauma fellowship-trained surgeons from a single academic department that covers two level I trauma centers. Our primary outcome was an unplanned return to the OR. Secondary outcomes were a 90-day “event”, defined as an all-cause hospital readmission or mortality, and 1-year mortality. Differences with a p-value < 0.1 measured on univariate analysis were evaluated using a multivariable logistic regression to identify independent outcome predictors. RESULTS: A total of 113 (60 ORIF, 36 HFN, 11 ex-fix, 6 amputations) were performed. Cohort mean age was 75.2 ± 9.8 years, and 31 patients (27.4%) were male. Mean age-adjusted charlson comorbidity index was 5.5 ± 2.0. Significant independent predictors of an unplanned return to the OR were male sex (OR 4.4, 95% CI 1.3 to 15.4), Gustilo Type III open fracture (OR 4.9, 95% CI 1.5 to 17.5) and ex-fix (OR 15.6, 95% CI 2.7 to 126.3). Independent predictors of a 90-day “event” were walker/minimal ambulation (OR 3.5, 95% CI 1.3 to 10.4), surgical site infection (OR 4.8, 95% CI 1.8 to 13.8) and reduced BMI (OR 0.9, 95% CI 0.9 – 0.99), while independent predictors of 1-year mortality were age (OR 1.1, 95% CI 1.003 to 1.2), ACCI (OR 1.4, 95% CI 1.02 to 2.0) and walker/minimal ambulator (OR 7.5, 95% CI 1.7 to 53) CONCLUSIONS: Host factors, particularly pre-operative mobility, were most predictive of 90-day event and 1-year mortality. Only definitive external fixation was found to influence patient morbidity as a significant predictor of unplanned OR. However, no surgical modality had any influence on short-term readmission or survival.

Background: Broad-spectrum antibiotic agents are sometimes utilized for prophylaxis of Gustilo grade III open fractures. However, this practice is not recommended by current guidelines, and it is unknown how patient outcomes are impacted. This study aimed to determine if prophylaxis with piperacillin-tazobactam (PT) results in different rates of infection versus guideline-concordant therapy (GCT). Patients and Methods: This was a single-center, retrospective cohort study of adult trauma patients with Gustilo grade III open long bone fractures admitted between January 2008 and August 2018. The primary outcome of infection (superficial or deep) at six weeks and secondary outcomes of delayed union, nonunion, Clostridioides difficile, and development of resistant organisms were abstracted from medical records. Guideline-concordant therapy was defined as a first-generation cephalosporin with or without an aminoglycoside. Univariable and multivariable analyses controlling for injury severity score (ISS) were performed. Results: One hundred twenty patients were included; 97 (81%) received PT, 23 (19%) received GCT. Common injury mechanisms were motor vehicle/motorcycle accident (57%) and falls (17%), and a majority involved a lower extremity (65%). Baseline characteristics were similar except higher median ISS in PT (14; interquartile range [IQR], 9-22) versus GCT (9; IQR, 9-14). Guideline-concordant therapy was given for a median of four (range, 2-8) days and PT for six (range, 3-11) days (p = 0.078). On univariable analysis, PT patients had more infections at six weeks (23.7% vs. 4.3%; p = 0.042), but multivariable analysis demonstrated no difference (odds ratio [OR], 5.81; 95% confidence interval [CI], 0.73-46.25; p = 0.096). Patients receiving prophylaxis with PT had a longer median length of stay at 16 days (range, 10-22) versus nine days (range, 4-16). No statistically significant differences in delayed union, non-union, Clostridioides difficile, or development of resistant organisms were observed. Conclusions: Broad-spectrum antibiotic prophylaxis with PT did not improve infection rates compared to GCT, suggesting it may not be warranted.

To compare deep infection rate and causative organisms in open fractures of the lower extremity from agricultural trauma with similar injuries in nonagricultural trauma.Retrospective.Two tertiary care institutions.Open lower extremity fractures sustained between 2003 and 2018 caused by agriculture-related trauma in adult patients were reviewed. A nonagriculture open fracture control group (NAG) was identified for comparison. Patient demographics and injury characteristics were assessed. Outcomes included occurrence of deep infection and causative organisms.One hundred seventy-eight patients were identified in the agriculture (AG) (n = 89) and control (NAG) (n = 89) groups. Among patients with agricultural injury, farm machinery was the most common mechanism in 69 (77.5%) of them. Open injuries of the foot (38.2%) and tibial shaft injuries (25.8%) were the most common in the AG and NAG groups, respectively. Deep infection was seen in 21% of patients in the AG group compared with 10% in the NAG group (P0.05). In the AG group, anaerobic infection occurred in 44% of patients with deep infection compared with 9.1% in the NAG group (P0.05). The most common anaerobic organisms included enterococci, Pseudomonas aeruginosa, and Clostridium perfringens.This study supports that open fractures due to agricultural trauma have a high infection rate, with anaerobic infection occurring at higher rates than in injuries due to nonagricultural trauma. Prophylactic treatment with antibiotics directed against anaerobes is indicated in these injuries.Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVE To identify the patient, injury and treatment factors associated with an acute infection during the treatment of open ankle fractures in a large multi-center retrospective review. To evaluate the effect of infectious complications on the rates of nonunion, malunion, and loss of reduction. DESIGN Multi-center Retrospective Review. SETTING Sixteen Trauma Centers. PATIENTS One thousand and three consecutive skeletally mature patients (514 men and 489 women) with open ankle fractures. MAIN OUTCOME MEASURES Fracture-related infection (FRI) in open ankle fractures. RESULTS The charts of 1,003 consecutive patients were reviewed and 712 patients (357 women and 355 men) had at least 12 weeks of clinical follow-up. Their average age was 50 years (range 16-96), and average BMI was 31; they sustained OTA/AO types 44A (12%), 44B (58%), and 44C (30%) open ankle fractures. The rate FRI rate was 15%. A multivariable regression analysis identified male sex, diabetes, smoking, immunosuppressant use, time to wound closure, and wound location as independent risk factors for infection. There were 77 cases of malunion, nonunion, loss of reduction and/or implant failure; FRI was associated with higher rates of these complications (p=0.01). CONCLUSION Several patient, injury and surgical factors were associated with fracture-related infection in the treatment of open ankle fractures. LEVEL OF EVIDENCE Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Introduction Current standards recommend antibiotic prophylaxis administered after open fracture injury. The purpose of this study was to assess culture results in patients with open fracture-associated infections, hypothesizing that cultures obtained do not vary by Gustilo-Anderson (GA) classification. Methods We examined cultured bacterial species from patients with open long bone fractures that underwent irrigation and debridement at a Level 1 trauma center (2008-2016), evaluating our current and two hypothetical antibiotic protocols to assess whether they provided appropriate coverage. The antibiotic protocols included protocols 1 (cefazolin, with gentamicin added for type III fractures), 2 (vancomycin and cefepime) and 3 (ceftriaxone). Results GA classification was not associated with bacterial gram stain (P = 0.161), nor was it predictive of mono- versus polymicrobial infection (P = 0.094). Of 42 culture-positive infections, 31 were type III and 11 were type I or II fractures. 27% of the infections for type I or II fractures were caused by organisms targeted by protocol 1 (OR 0.18, 95% CI 0.04-0.82; P = 0.027). There was no difference in coverage by fracture type among protocol 2 (P = 0.771) or protocol 3 (P = 0.891). For type III fractures, protocol 2 provided 94% appropriate coverage compared to 68% and 61% coverage by protocols 1 and 3, respectively. Conclusion For open fractures complicated by infection, isolated bacterial organisms do not correlate with GA open fracture classification, suggesting that hypothetical protocol 2 should be used for all fracture types. Protocol 2’s broad coverage, across all GA fracture types, may prevent infection by organisms not covered by current antibiotic prophylaxis.

Objective To determine the rate of acute compartment syndrome (ACS) in a series of patients with Gustilo-Anderson type IIIB open tibial shaft fractures that were treated using a specific two-stage orthoplastic protocol. Design Consecutive cohort study.Patients/Participants: Ninety-three (n =93) consecutive patients with a type IIIB open tibial shaft fracture (OTA/AO-42) treated utilizing a two-stage orthoplastic approach, between August 2015 and January 2018. Following exclusions, eighty-three (n=83) were eligible for analysis. Intervention Colloid resuscitation and two-stage orthoplastic reconstruction of type IIIB open tibial shaft fracture. Stage one consists of "three-vessel view" early debridement and temporary internal fixation, with stage two consisting of a single-stage fix and flap. Main outcome measurements Rate of ACS. Secondary outcomes included early/late sequelae of missed ACS, deep infection, arterial injury, nonunion and flap failure. Results Eighty-three (n = 83) patients were included for analysis. Median age was 45.4 years (Interquartile range (IQR) 35) with a median follow up of 1.6 years (IQR 0.8). Median number of operations was 2.0 (IQR 4). For the primary outcome, there were a total of zero (0/83) patients who required fasciotomy or developed early/late clinical sequelae of missed ACS. Six (6/83, 7.2%) patients developed deep infection, eighteen patients (18/83, 21.7%) experienced non-ischaemic arterial injury, five patients (5/83, 6.0%) experienced nonunion, with four patients (4/83, 4.8%) experiencing flap failure. Diabetes was the only variable associated with deep infection (p=0.025) and nonunion (p Conclusions Patients with type IIIB open tibial shaft fractures treated with colloid resuscitation and a two-stage orthoplastic protocol, which includes early "three-vessel view" exposure and debridement, do not appear to develop ACS. Furthermore, no sequelae of missed compartment syndrome was observed at final follow up. Level of evidence Therapeutic level III. See Instructions for Authors for a complete description of levels of evidence.

Objectives To identify factors associated with the need for reoperations in patients treated surgically for fracture nonunion. Design Retrospective cohort study. Setting One urban Level 1 trauma center and an orthopaedic specialty hospital. Patients/participants This study included 365 patients who did not and 95 patients who did undergo a reoperation after nonunion repair. Intervention All patients who underwent fracture nonunion repair were identified. Baseline demographic, injury, and surgical information were collected. These factors were compared between patients who did and did not require an unplanned reoperation. Main outcome measurements An unplanned reoperation after index fracture nonunion surgery. Results When compared with patients who did not undergo a reoperation after their index fracture nonunion surgery, patients who underwent at least 1 reoperation had a greater proportion of those who sustained an open fracture, a high-energy injury, initial neurologic or vascular injuries, the need for a flap or soft tissue graft at initial treatment, and lower extremity injuries with univariate analysis. Unplanned reoperation was also associated with diagnosis of "infected" nonunion at initial nonunion surgery. Multivariate analysis confirmed initial nerve or vascular injuries and positive infection status were statistically significant predictors of a reoperation. Conclusions Initial injury characteristics such as nerve or vascular injury at initial injury and positive infection status at the index nonunion surgery were associated with the need for a secondary surgery after nonunion repair. Appropriate care of these patients should be aimed at adjusting expectations of unplanned reoperation in the future and potentially enhanced treatment strategies. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Gustilo–Anderson type IIIB and IIIC open fractures of the lower extremities require reconstruction of extensively injured soft tissues using a free flap; however, impaired blood flow through the flap is an early postoperative complication. To detect flap congestion due to venous thrombosis, blood glucose and lactate level measurements within the flap are taken to determine variations in these levels. We aimed to detect early-stage venous congestion and to perform salvage operations. We included 22 limbs with lower leg and foot open fractures, with fracture sites covered using a free flap. A pinprick test was used to measure blood glucose and lactate levels. Of 7 and 15 congested and non-congested limbs, respectively, the 7 congested limbs had a mean flap blood glucose level immediately before salvage surgery of 3.8 ± 2.0 (7.4–1.8) mmol/L. The ratio to blood glucose levels in healthy fingertips was 0.6 ± 0.2 (0.8–0.3). Lactate levels increased to 13.3 ± 5.1 (9.4–22.8) mmol/L. The ratio of blood glucose levels in congested flaps and in healthy fingertips was significantly lower than that in non-congested flaps and in healthy fingertips (p = 0.0016). Lactate levels were significantly higher in patients with congestion (p = 0.0013). Salvage surgery was performed, thrombi were removed, and six limb flaps were viable. Flap blood glucose and lactate levels provide a quantitative method of evaluating blood flow and detecting flow abnormalities postoperatively, and are useful in detecting early congestion due to venous thrombosis.

BACKGROUND: Open tibial fracture research has traditionally focused on surgical techniques; however, despite technological advances, outcomes from these injuries remain poor, with patients facing a sustained reduced quality of life. Research has rarely asked patients what is important to them after an open tibial fracture, and this question could potentially offer great insight into how to support patients. A qualitative study may assist in our understanding of this subject. QUESTIONS/PURPOSES: We asked: (1) What common themes did patients who have experienced open tibial fractures share? (2) What stresses and coping strategies did those patients articulate? (3) What sources for acquiring coping strategies did patients say they benefited from? METHODS: Semistructured interviews were conducted with patients who had sustained an open tibial fracture between January 1, 2016 and January 1, 2019. All participants were recruited from a Level 1 trauma center in England, and 26 participants were included. The mean age was 44 ± 17 years, and 77% (20 of 26) were men. The patients’ injuries ranged in severity, and they had a range of treatments and complications. Transcripts were analyzed using framework analysis, with codes subsequently organized into themes and subthemes. RESULTS: Four themes were identified, which included recouping physical mobility, values around treatment, fears about poor recovery, and coping strategies to reduce psychological burden. Coping strategies were important in mitigating the psychological burden of injury. Task-focused coping strategies were preferred by patients and perceived as taking a proactive approach to recovery. Healthcare practitioners, and others with lived experience were able to educate patients on coping, but such resources were scant and therefore probably less accessible to those with the greatest need. CONCLUSION: Most individuals fail to return to previous activities, and it is unlikely that improvements in surgical techniques will make major improvements in patient outcomes in the near future. Investment in psychosocial support could potentially improve patient experience and outcomes. Digital information platforms and group rehabilitation clinics were identified as potential avenues for development that could offer individuals better psychosocial support with minimal additional burden for surgeons. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Summary Background Ring fixator techniques can precisely correct complex long bone deformities. In select patients, controlled shortening or intentional fracture deformation with delayed correction can also aid in complex wound coverage and limb salvage. Methods This retrospective cohort study analyzed all patients who underwent acute limb shortening or intentional temporary fracture deformation between 2005 and 2020. Patients were divided into three groups based on reason for acute shortening or intentional deformity: (1) skeletal indications alone, with traditional flap coverage; (2) skeletal and soft tissue indications, to augment traditional reconstructive measures; and (3) skeletal and soft tissue indications, to avoid microsurgery altogether. Comorbidities, orthopedic and reconstructive methods, and functional outcomes were recorded. Results Eighteen patients were identified: six in Group 1, five in Group 2, and seven in Group 3. Fractures were primarily in the distal third of the tibia. On initial assessment, all wounds would have required free tissue transfer. Group 1 patients were reconstructed with free flaps. Among Group 2, closure was accomplished by skin grafting (N = 1), local flaps (N = 1), pedicled muscle flaps (N = 1), and free flaps (N = 2). In Group 3, five wounds were closed primarily and two were skin grafted. All limbs were shortened, averaging 25.1 mm; seven were intentionally deformed, most commonly varus (10–20°). After skeletal correction, residual leg length discrepancy averaged 5.7 mm. No patients required amputation. Conclusions Acute skeletal shortening with or without intentional temporary deformation in select IIIB/IIIC open tibial fractures can facilitate soft tissue coverage and limb salvage in patients who might otherwise require amputation.

Objective To investigate the relationship between the infection rate and the timing of replacement of temporary external fixators with internal fixation, and the timing of immediate or delayed internal fixation after removal of temporary external fixation in the staging treatment modality of open fractures of extremities. Methods A retrospective analysis was performed on 122 cases of open fractures of extremities. External fixators were applied at the early stage and replaced with internal fixation when the condition of soft tissues improved and inflammatory indexes dropped to the normal range or showed a steady downward trend. Depending on the carrying time of external fixators after wound closure or healing, the patients were divided into three groups; the carrying time of groups A, B, and C was ≤ 14 days, 15–28 days, and > 28 days, respectively. Depending on the immediate or delayed internal fixation after removal of external fixator, patients were divided into group a (immediate internal fixation after removal of external fixator) and group b (delayed internal fixation after removal of external fixator, 5–7 days later). Results The infection rates of groups A, B, and C were 6.5%, 5.9%, and 23.3%, respectively. The differences among the three groups were statistically significant (P Conclusions The occurrence of infection of open fractures of extremities is associated with the fracture severity (Gustilo classification). For open fractures of Gustilo types I and II, the final internal fixation should be placed as soon as possible when the recovery of general and local conditions is good and the infection is controlled.

Purpose Aim of this study was to determine the rate of low-grade infection in patients with primarily as aseptic categorized tibial shaft nonunion and lack of clinical signs of infection. Methods In a retrospective study between 2006 and 2013, all patients who underwent revision surgery for treatment of tibial shaft nonunion without clinical evidence of infection were assessed. Bacterial cultures harvested during nonunion revision, C-reactive protein (CRP) and/or white blood cell (WBC) values at hospital admission, outcome, and epidemiological data were analyzed. Results In 88 patients with tibial shaft nonunion without any clinical signs of infection, bacterial samples remained negative in 51 patients. In 37 patients, microbiological diagnostic studies after long-term culturing demonstrated positive bacterial cultures whereas after short-term culturing for 2 days only 17 positive cultures were observed. In 12 cases a mixed culture with 2.3 different bacteria on average was detected. Among patients with negative bacterial cultures bone healing was achieved after 13.2 months. Nonunion with positive bacterial cultures required 19 (range 2-42) months until osseous healing (p = 0.009). Furthermore, nonunion with positive bacterial cultures require statistically more surgical revisions to achieve healing (2.9 ± 0.5 vs. 1.3 ± 0.1 additional procedure; (p = 0.003). Hematological studies carried out before surgical intervention did not demonstrate significant differences in CRP values (negative vs. positive cultures: 0.3 (range 0.3-2.8) mg/dl vs. 0.5 (range 0.3-5.7) mg/dl (p = 0.181) and in WBC values (negative vs. positive cultures: 7.4 (range 3.5-11.9) /nl vs. 7.3 (range 3.7-11.1) /nl (p = 0.723). Limitations of this study may include the varying amount of the at least four samples for microbiological diagnostics as well as the circumstance that for diagnosing low-grade infection swabs and tissue samples were included in this evaluation as being equivalent. Conclusion The pathogenesis of nonunion may originate from low-grade infection even in patients without clinical signs of infection. In addition, nonunion with positive bacterial cultures require statistically more surgical revisions to achieve healing. Therefore, during any revision surgery, multiple bacterial samples are intended to be harvested for long-term culturing. Particularly, in tibial shaft nonunion following Gustilo-Anderson type III open fractures, low-grade infection should be suspected. Trial registration number DRKS00014657. Date of registration 04/26/2018 retrospectively registered

Implant-associated infections remain one of the main problems in the treatment of open tibia fractures. The role of systemic antibiotic prophylaxis is now agreed and accepted; nevertheless, recent literature also seems to emphasize the importance of local antibiotic therapy at the fracture site. Several therapeutic strategies have been proposed to overcome this new need. Antibiotic-coated nails play crucial role in this, allowing both infection prevention and favoring the fracture stabilization. We describe the outcome of patients with open diaphyseal tibia fracture treated either with a standard uncoated nail or a gentamicin-coated nail from January 2016 to December 2018 at our second level emergency-urgency department. Primary outcomes were infection rate and bone union rate. Other outcomes reported are reoperation rate, time between injury and nailing, and safety of antibiotic nail. Numerical variables were tabulated using mean, standard deviation, minimum, maximum, and number of observations. Categorical variables were tabulated using number of observations. 23 patients treated with uncoated nail and 23 patients treated with antibiotic-coated tibia nail were included in the study and were evaluated for a minimum follow-up of 18 months. Among the 46 patients, 9 were Gustilo-Anderson type I, 21 type II, and 16 type III open fracture. Regarding the bone healing rate at 12 months, 16 fractures in the first group and 18 in the second were completely healed. 4 infections were found in the first group (3 superficial surgical site infection and 1 osteomyelitis) and 3 superficial infections in the second one. No adverse events have been recorded with antibiotic-coated nails. In this unicentric retrospective study observed no deep wound infections and good fracture healing in the use of antibiotic-coated nails. Antibiotic nails have been shown to play a role in the treatment of fractures in critically ill patients with severe soft tissue damage.

The medial plantar artery (MPA) is often sacrificed as the vascular pedicle of the medial plantar flap (MPF). However, for patients with ankle soft tissue defect caused by traffic accident, the anterior tibial artery (ATA) could be damaged and the blood supply of the distal foot would only come from the MPA and the lateral plantar artery (LPA). In this case, sacrificing the MPA for the MPF means that the LPA will become the mainly source of blood supply of the distal foot. Whether the blood supply of the distal foot is adequately guaranteed remains to be discussed. A total of seven patients with ankle soft tissue defect and ATA injury were enrolled in the study. The digital subtraction angiography (DSA) was performed to observe the hemodynamics of the ipsilateral foot. The MPF was harvested only when the foot arterial network consisting of the MPA, the LPA, the deep plantar arch, and the deep plantar artery of DPA, and the blood redistribution existed. DSA results showed the blood from the posterior tibial artery was redistributed to the ipsilateral foot and the MPA is not the dominant artery in the foot. Seven MPFs were harvested, and all flaps survived completely. No complications, such as pain, ulcer, and necrosis, occurred in the ipsilateral toes. The DSA could accurately and intuitively evaluate the hemodynamics of foot in patients with ATA injury. The DSA data and clinical practice proved that the ATA injury is not the contraindication of the MPF.

To compare the clinical outcomes of external fixator + elastic stable intramedullary nail (EF+ESIN) vs. external fixator (EF) in the treatment for open tibial shaft fracture in overweight adolescents.Patients of open tibial shaft fractures younger than 14 years old with body weight over 50 Kg treated with EF + ESIN or EF at our institute from 2010 to 2018 were reviewed. Patients with Gustilo Type III open fractures, pathological fractures, previous fracture or instrumentation in the operative leg were excluded. Baseline information and clinical data were collected from the hospital database and during out-patient visits.Forty-six patients, including 27 males and 19 females, were included in the EF group, whereas 35 patients, including 18 males and 17 females, were included in the EF + ESIN group (p = 0.527). The incidence of superficial infection was higher in the EF group (26/46, 56.5%) than the EF + ESIN group (12/35, 34.3%), p 0.001. The frontal and sagittal angulation was higher in the EF group (p 0.001), but the degrees in both groups were within the acceptable range. The union time was longer in the EF group (68.0 ± 12.7, d) than the EF + ESIN group (61.9 ± 11.9), p 0.001. The retaining of EF (11.9 ± 3.2, w) was longer in the EF group than the EF +ESIN group (5.7 ± 1.2, w), p 0.001.EF+ESIN is a safe and alternative choice for selected overweight adolescents with open tibial shaft fracture.

Background In complex injuries, external fixation device represents a challenge to maintain negative-pressure wound therapy (NPWT). In this trial, we compared a combination of bone wax and colostomy paste versus bone wax alone to seal NPWT around external fixation devices. Methods Debridement surgeries of limbs with open fracture and large soft tissue defect need NPWT to be applied around the external fixation devices were randomized into two groups. The seal between external fixation devices and the drape was established using either bone wax first and then reinforced with colostomy paste or bone wax alone. The primary outcome was seal failure within 3 days of debridement. Secondary outcomes included the number of seal failure per debridement surgery and the time spent in repairing the seal within 3 days. Results A total of 56 debridement surgeries were enrolled: 28 to the bone wax/colostomy paste group versus 28 to the bone wax control group. One patient in the control group died 1 day after the first debridement surgery. One patient in the bone wax/colostomy paste group was transferred to other hospitals within 3 days. The final analysis included 27 debridement surgeries in the bone wax/colostomy paste group and 27 debridement surgeries in the control group. The rate of seal failure (defined by loss of negative pressure at anytime within 3 days) was 81.5% (22/27) in the control group versus 11.1% (3/27) in the bone wax/colostomy paste group (p χ2 test). The bone wax/colostomy paste group also had significantly lower number of seal failures per debridement (median of 0 vs. 2; p = 0.004), and shorter time spent in repairing the seal (median of 0 vs. 18 min; p Conclusions Using bone wax followed by colostomy paste to seal NPWT around external fixation devices reduces seal failure.

Objectives To evaluate a large series of open fractures of the forearm following gunshot wounds in order to determine complication rates and factors that may lead to infection, nonunion, or compartment syndrome. Design Multi-center retrospective review. Setting Nine Level 1 Trauma CentersPatients/Participants: 168 patients had 198 radius and ulna fractures due to firearm injuries. All patients were adults, had a fracture due to a firearm injury and at least one year clinical follow-up or follow-up until union. Average follow-up was 831 days. Intervention Most patients (91%) received antibiotics. Formal irrigation and debridement in the operating room was performed in 75% of cases along with either internal fixation (75%), external fixation (6%), or I&D without fixation (19%). Main outcome measures Complications including neurovascular injuries, compartment syndrome, infection and nonunion. Results Twenty-one percent of patients had arterial injuries and 40% had nerve injuries. Nine patients (5%) developed compartment syndrome. Seventeen patients (10%) developed infections, all in comminuted or segmental fractures. Antibiotics were not associated with a decreased risk of infection. Infections in the ulna were more common in fractures with retained bullet fragments and bone loss. Twenty patients (12%) developed a nonunion. Nonunions were associated with high velocity firearms and bone defect size. Conclusions Open fractures of the forearm from gunshot wounds are serious injuries that carry high rates of nonunion and infection. Fractures with significant bone defects are at increased risk of nonunion and should be treated with stable fixation and proper soft tissue handling. Ulna fractures are at particularly high risk for deep infection and septic nonunion and should be treated aggressively. Forearm fractures from gunshot wounds should be followed until union to identify long term complications. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Adequate debridement of an open fracture is a key component of successful management. Despite having set debridement principles, there is no structured technique available in the literature to guide the surgeon in achieving this. We therefore present a technical note detailing the structured approach to the debridement of any open tibial fracture. Our unit has developed a novel stepwise technique termed locally as the "three-vessel view". Identifying all three primary vessels of the leg facilitates confirmation of inspection of all lower limb compartments thus minimising the risk of missed devitalised tissue or neglected areas of contamination and the potential for consequent disastrous outcomes as a result of inadequate exposure.

INTRODUCTION Despite decades of advancement in wound debridement, prophylactic antibiotic therapy, fracture stabilization, and soft tissue reconstruction, infection remains a serious complication after open fracture. Inconclusive historical data and new challenges with resistant organisms and antimicrobial stewardship having created a difficult environment within which to develop sound, evidence-based treatment protocols that can be applied universally. The first part of this 2-part series will synthesize the historical perspective along with the current concepts surrounding bacteriology and antibiotic use/stewardship. Part 2 will analyze and summarize the current literature regarding the management of open fracture and prevention of subsequent infection.Numerous authors from Hippocrates to Larrey noted that superior results were obtained with an early aggressive debridement of necrotic tissue after wounding.1-7 Historically, the usual outcome after open fracture was infection, sepsis, amputation, and death before the introduction of antibiotics.8-11 As recently as the first half of the 20th century, surgeons argued that if an appropriate debridement was performed, antibiotics were not necessary and advocated against their routine use over concern for resistant organisms.The current period of open fracture treatment (starting in the 1970s) heralded a more scientific era with critical evaluation of antibiotics, surgical debridement, and the development of standardized evidence-based protocols. This era began with 3 classic articles by Patzakis and Gustilo that, to this day, remain central to the discussion of infection prevention after open fractures.12-14. LEVEL OF EVIDENCE Therapeutic Level V. See Instructions for Authors for a Complete description of levels of evidence.

This study aimed to compare the clinical and radiological outcomes of conventional locked intramedullary nailing (IMN) and talon IMN in AO Type 42A tibial fractures.A total of 93 patients with AO Type 42A fracture were retrospectively analyzed. The patients were divided into two groups: Those treated with conventional IMN (Group 1), and those treated with talon distal locked nailing (Group 2). The patients were statistically compared in terms of age, sex, mechanism of injury, follow-up time, time to union, smoking status, presence of open fracture, presence of concomitant fibula fracture, development of malunion and nonunion, and the number of intraoperative fluoros-copy shots captured. All patients were evaluated with American Orthopaedic Foot and Ankle Society and Tegner Lysholm scores for clinical outcomes.A total of 93 patients (68 men and 35 women) participated in the study. Group 1 consisted of 35 (71.4%) men and 14 (28.6%) women, a total of 49 patients, while Group 2 consisted of 33 (75%) men and 11 (25%) women, a total of 44 patients. There were no significant differences between the two groups in terms of age, sex, mechanism of injury, follow-up times, smoking status, concomitant fibula fracture, presence of malunion, and presence of open fracture (p0.05). However, there were significant differences between both groups in terms of time to union, nonunion rate, and the number of fluoroscopy shots captured (p0.05). American Orthopaedic Foot and Ankle Society and Tegner Lysholm score were analyzed and compared, no statistically differences were found (p=0.786 and p=0.764).Although talon IMN reduces radiation exposure, locked conventional IMN has lower nonunion rates and achieves union faster.

Mycobacterium mucogenicum is a nontuberculous mycobacterium that is ubiquitous in nature. However, M. mucogenicum infection in patients with orthopedic trauma is rarely reported in the literature. Herein, we describe a 48 year old male Han Chinese patient whose right leg was squeezed by agricultural machinery, resulting in open tibial fractures. Postoperative antimicrobial treatment was administered because the wound had been contaminated by soil. However, no long-term wound closure occurred, and a culture of the wound exudation tested positive for M. mucogenicum. We established the clinical treatment plan according to the characteristics and drug sensitivity test results of M. mucogenicum, and the patient was discharged uneventfully. Increasingly, more reports of infection caused by nontuberculous mycobacteria are being published; however, to our knowledge, this is the first report of an orthopedic infection caused by M. mucogenicum. Because the treatment process of M. mucogenicum infection is long and complex, isolation and identification of M. mucogenicum are of great significance to effective clinical treatment.

Background Fracture-related infection (FRI) is a challenging complication in musculoskeletal trauma surgery and often complicates the management of open fractures. The CDC currently advocates a surveillance period of 90 days after fracture fixation, but it is unclear what duration of follow-up constitutes adequate surveillance for FRI. Inadequate follow-up will underestimate infections and, in clinical research, will make any interventions studied appear better than they really are, thereby resulting in misleading conclusions. Questions/purposes (1) What is the timing of FRI onset in patients with open fractures? (2) What is the proportion of FRIs captured when follow-up is limited to 90 days postoperatively versus when follow-up is extended to 1 year? Methods This is a secondary analysis of patient data from a previous retrospective cohort study that investigated whether the duration of perioperative antibiotic prophylaxis was independently associated with FRI in patients with open fractures. Of the 530 eligible patients in the source study, 3% (14) died. Of the remaining 516 patients, 97% (502) patients with 559 long-bone open fractures had 2 years of follow-up constituted the base cohort. Forty-seven fractures in 46 patients were complicated by FRI and were the focus of this secondary analysis. Medical records were reviewed in detail specifically for the current study. Seventy-eight percent (36 of 46) of patients were male, and the mean ± SD age was 42 ± 16 years. The most common mechanism of injury was a motor vehicle accident (63% [29 of 46] of patients), and the tibia was the most involved site (53% [25 of 47] of fractures). The median (interquartile range) time to debridement was 3.0 hours (IQR 2.0 to 4.0). FRIs developed in 3% (7 of 247) of Type I open fractures, 7% (11 of 164) of Type II, 17% (18 of 107) of Type IIIA, 29% (9 of 31) of Type IIIB, and 20% (2 of 10) of Type IIIC open fractures. Each clinic visit of each patient was reviewed, and data about the time of onset of any symptoms and signs suggesting or confirming an FRI, as reported by patients and/or determined by treating surgeons, were recorded. The proportions of FRIs with onset by specific time periods were determined. A Kaplan-Meier survival analysis was performed, and the FRI event rates with 95% confidence intervals were calculated. Results The median (IQR) time to the onset of FRI was 52 days (IQR 15 to 153). Follow-up of 90 days captured only 64% (30 of 47) of FRIs, whereas follow-up of 1 year captured 89% (42 of 47) of FRIs. The proportion of FRIs with onset within 1 year increased to 95% (42 of 44) in the presence of an already healed fracture. Conclusion Follow-up of 90 days after the management of an open long-bone fracture is inadequate for postoperative surveillance, especially for research purposes. Clinical research on interventions would report results appearing to be much better than they really are, potentially resulting in misleading conclusions. Follow-up of 1 year is preferable because most FRIs will develop before that time, especially when fracture union has occurred. A small percentage of patients may still develop infections beyond the first year after the management of an open fracture. The risk of missing these infections by not extending follow-up beyond 1 year must be balanced against the additional logistical burden. Future prospective multicenter studies and registries with long-term patient follow-up would help clarify this issue.Level of Evidence Level III, diagnostic study.

Introduction Antibiotics have been shown to be an essential component in the treatment of open extremity fractures. The American College of Surgeons' Trauma Quality Improvement Program, based on a committee of physician leaders including orthopedic trauma surgeons, publishes best-practice guidelines for the management of open fractures. Accordingly, it established the tracking of antibiotic timing as a metric with a plan to use that metric prior to trauma center site reviews. Our hypothesis was that this physician-led effort at the national level would provide the necessary incentive to effect change within our institution. Methods A retrospective review of all patients treated at our institution for open extremity fractures was performed over three time periods separated by two quality initiatives. The first initiative was an institution-driven effort to increase awareness and educate specific departments about the importance of prompt antibiotic administration. The second initiative was the tracking of antibiotic order and administration times with quarterly audits following newly published guidelines. Results Neither antibiotic order placement within one hour nor administration within one hour improved following our first institution-specific initiative. Both outcome measures significantly improved following the second quality initiative, as did median times from arrival to antibiotic order and administration. Conclusion Metrics developed and measured by a physician-led national organization led to practice changes at our hospital. Tracking of antibiotic timing for open fracture treatment was more effective than institutional education of healthcare providers alone. This study suggests that nationally published guidelines, developed and measured by physician leaders, will be found to be relevant by other physicians and can be a powerful tool to drive change. Level of evidence Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To evaluate the outcomes of patients who underwent soft tissue flap coverage during treatment of a tibia fracture nonunion. DESIGN Retrospective analysis on prospectively collected data. SETTING Academic medical center. PATIENTS/PARTICIPANTS One hundred fifty-seven patients were treated for a fracture nonunion after a tibia fracture over a 15-year period. Sixty-six patients had sustained an open tibial fracture initially and 25 of these patients underwent soft tissue flaps for their open tibia fracture nonunion. INTERVENTION Manipulation of soft tissue flaps, either placement or elevation for graft placement in ununited previously open tibial fractures. MAIN OUTCOME MEASUREMENTS Bony healing, time to union, ultimate soft tissue status, postoperative complications, and functional outcome scores using the Short Musculoskeletal Functional Assessment (SMFA). This group was compared with a group of open tibial fracture nonunions that did not undergo soft tissue transfer. RESULTS Bony healing was achieved in 24 of 25 patients (96.0%) who received flaps at a mean time to union of 8.7 ± 3.3 months compared with 39 of 41 patients (95.1%) at a mean 7.5 ± 3.2 months (P > 0.05) in the noncoverage group. Healing rate and time to union did not differ between groups. At latest follow-up, the flap coverage group reported a mean SMFA index of 17.1 compared with an SMFA index of 27.7 for the noncoverage group (P = 0.037). CONCLUSIONS Utilization of soft tissue flaps in the setting of open tibia shaft nonunion repair surgery are associated with a high union rate (>90%). Coverage with or manipulation of soft tissue flaps did not result in improved bony healing rate or time to union compared with those who did not require flaps. However, soft tissue flap coverage was associated with higher functional scores at long-term follow-up. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

BACKGROUND: This study sought to evaluate the effectiveness of locally developed external fixators (LDEF) as definitive treatment for open tibia diaphyseal fractures (OTDF) in Ivory Coast. METHODS: Gustilo I, II, and IIIA OTDFs of patients admitted within 24 hours of injury were prospectively included and treated with LDEF. The rates of union, mal-union, septic complications, as well as the functional results were assessed, in addition to the LDEF construct's integrity. Predictive factors of failure or poor results were assessed. RESULTS: Overall, 40 OTDF patients were admitted within 24 hours of injury. Gustilo I, II, and IIIA fractures were observed in three, 13, and 24 patients, respectively. Uneventful fracture healing was obtained in 29 cases, with an average union time of 8.47 months. Mal-union and non-union were registered in three and four cases, respectively. Pin-track infection (PTI) was observed in 13 cases and deep infection in seven. Infection resolved in all patients except four, who developed chronic osteomyelitis. None of the non-unions were associated with an infection. The overall functional result was satisfactory in 32 patients. PTI was the only predictive factor for chronic infection. Biplanar frames, when compared to monoplanar constructs, were associated with a significantly improved functional outcome. CONCLUSION: LDEF improved significantly the OTDF management, as it provided better stability and superior fracture healing rates than what is observed with the standard of care in the same environment. PTI remains an essential problem but with, hopefully, limited negative consequences.

Introduction Open tibial fractures are the most common open long bone fracture, despite this, the management of these complex injuries still remains a topic of discussion amongst orthopaedic surgeons. Sources of data We searched the EMBASE, MEDLINE and Google Scholar and a systematic review of 7500 articles, leaving 23 after exclusion criteria were applied, in order to analyse the management of open tibial fractures. Areas of agreement and controversy Infection was noted to be the most significant concern amongst authors, with definitive external fixation having a high rate of superficial pin-site infection and internal fixation having a high deep infection rate. Growing points It is essential to have a combined ortho-plastic approach to the management of these fractures as muscle flaps were the most common form of soft tissue coverage. Areas timely for developing research A national pragmatic trial into the management of open tibial fractures is required looking at fixation methods and soft tissue coverage, with at least a 2-year follow-up in order to ascertain the most appropriate management of these fractures and patient-related outcomes.

Floating knee injury is uncommon yet challenging problem. The situation is more complicated by presence of infection, open comminuted fractures, and late presentation. The aim of this study was to evaluate the closed reduction techniques by circular external fixation in a single stage to treat patients having infected neglected floating knee injuries. This retrospective study included 19 patients with a mean age of 34.4 years. The average duration from trauma to surgery was 51.1 days. All patients had at least one infected open fracture. According to Fraser’s classification, ten injuries were type I, one case was type IIa, four were type IIb, and four were type IIc. Patients were treated by closed reduction techniques using the Ilizarov principles. Orthoplastic procedures were done in four cases in the same surgical setting. Closed reduction and union were achieved in all cases with control of infection in 17 cases. The follow-up period averaged 41 months. The mean knee flexion was 97.4°. The complications included 5° extension lag (two cases), malunion (three cases), refracture (two cases), and DVT (four cases). The bone results were excellent (12 cases), good (5 cases), and poor (2 cases). The functional results were excellent (two cases), good (seven cases), acceptable (seven cases), and poor (three cases). Closed reduction techniques using a circular frame provided a valid treatment option for infected neglected floating knee injuries in one stage without bone grafting. However, the high rate of complications and the diminished knee range of motion should be considered.

Introduction Forearm shaft fracture is common in young adult patients and associated with soft tissue and organ injuries. In open fractures in polytrauma patients, damage control orthopaedics (DCO) is well indicated. The aim of this study is to describe intramedullary Steinmann pin fixation of the ulna as a DCO procedure for the forearm and present a case series. Description of the technique A 3.0 mm Steinmann pin is inserted retrograde in the ulna proximal fragment through the fracture site using the open wound as the approach. With direct visualization of the reduction, the pin is advanced into the distal fragment. The reduction of the longitudinal axis and shortening is thus achieved. Patients and methods This method was used for all open fractures of forearm both-bone fractures in polytrauma patients undergoing DCO from 2014 to 2019. The alignment and length of the ulna were evaluated radiographically after pin fixation and before and after definitive fixation. Differences in the need for secondary procedures and infection rate between DCO and definitive fixation were also evaluated. Results There were 30 males (85.7%) with an average age of 32.9 ± 12.0 years and a mean ISS (Injury Severity Score) of 29.4 (range, 18.0-41.0). The most common associated injuries were thoracic trauma (62.8%) and head trauma (45.7%). In the radius and ulna, 51.4% and 60.0% of fractures, respectively, were multifragmentary (types B and C). Gustilo type IIIA represented 77.1% of the injuries. Pin fixation achieved good alignment and length in all cases. The mean time between DCO and definitive fixation was 12.0 days, and no secondary procedure was needed, nor any case developed either superficial or deep infection. The conversion from DCO to definitive fixation was considered easy in all cases. Conclusion Intramedullary Steinmann pin fixation of the ulna is a viable option for DCO for forearm both-bone fractures in open fractures in polytrauma patients.

Introduction Several alternatives are now available when treating posttraumatic acute bone defects. Masquelet's technique represents a safe procedure to treat lower limb open fractures associated with significant bone defects and allows surgeons to try to reduce complications incidence. Material and Methods Retrospective study based on patients´ record files and images (2015-2017). Twelve patients suffering acute bone defect, treated using Masquelet technique, were evaluated. A total of ten patients were finally included after exclusion criteria were applied. Results Average time from injury to first stage surgery was 11 days. Free flaps were required in three cases (two latissimus dorsi and one anterolateral thigh flap). Time to second stage surgery was 115 days on average. As bone graft, reaming irrigation-aspiration system was associated to this technique. Consolidation was achieved in all patients but one after an average time of 8.4 months. There was only one case of limb shortening of 20 mm. There was no case of nonunion or infection, and patients could perform daily basic activities independently. VAS mean score was one point one year after final surgery. Conclusions Masquelet's technique achieves encouraging results when treating lower limb acute bone defects. Using this technique, surgeons could decrease infection incidence in open fractures with severe bone loss. On the other hand, it is a two-stage surgery process, which makes the process longer.

Introduction One of the complications of the surgical therapy for ankle fractures includes wound infection. This study aimed to evaluate postoperative function and clarify the risk factors associated with postoperative wound infection in patients receiving the open reduction and internal fixation for ankle fracture through a multicenter study. Subjects and method Among 1421 patients diagnosed as having closed ankle fracture and who were treated by surgical therapy in 11 institutions from 2014 through 2019, 1201 patients (men, n = 512, women, n = 689; the mean (SD) age, 50.9 (15.6) years; the mean body mass index [BMI] (SD), 24.3 (4.2) kg/m2) were included as subjects. Excluded were 220 patients due to self-termination of treatment, inability to follow up after discharge, open fracture, distal tibia shaft fracture, and pilon fracture. We extracted the following as risk factors of wound infection: age, sex, BMI, fracture type, injury energy and histories of smoking, diabetes, arteriosclerosis, heart failure and myocardial infarction. We conducted logistic regression analysis to investigate the risk factors of wound infection using these extracted items as explanatory variables and the presence or absence of wound infection as the response variable. Results Wound infection occurred after surgery for closed ankle fracture in 69 the 1201 patients (5.7%). The causative organism was methicillin-susceptible Staphylococcus aureus (MSSA) in 15 patients, methicillin-resistant S. aureus (MRSA) in 4 patients, Finegoldia magna in one patient, and S. haemolyticus in one patient. In the other patients, causative organisms were not detected, culture of the causative organisms was not conducted, or they were unknown. The univariate analysis showed significant differences in sex (p = 0.01) and for smoking (p = 0.002), fracture type (p = 0.02) and heart failure (p = 0.042). Logistic regression analysis showed that smoking and type of fracture (trimalleolar fracture) were significant explanatory factors for infection (odds ratio 1.83 and 1.98, p = 0 .040 and 0.042, respectively). Conclusions At 5.7%, the rate of postoperative wound infection in closed ankle fracture was not low. Staphylococcus was the most frequent causative organism. The surgeon should pay attention infection after surgery in the patients who had a trimalleolar fracture or smoking habits.

Supplemental Digital Content is Available in the Text., Objectives: (1) Evaluate intentional temporary limb deformation for closure of soft-tissue defects as a reconstruction strategy in open tibia fractures and (2) analyze the deformity parameters required for such reconstruction. Design: Multicenter retrospective cohort. Setting: Level I trauma center. Patients/Participants: Nineteen patients 18 years of age and older at the time of initial trauma, with a Gustilo–Anderson type IIIB or IIIC open tibia fracture treated with hexapod external fixation and intentional bony deformity created to facilitate soft-tissue closure. Intervention: Intentional limb deformation for soft-tissue closure, followed by gradual correction with a hexapod external fixator. Outcome Measurements: Radiographic healing, radiographic assessment of limb alignment, and functional and bony Application of the Method of Ilizarov Group score. Results: The average age was 45.3 (20–70), and 79% of patients were men. The most common mechanism of injury was motor vehicle accidents. The distal 1 of 5 of the tibia was the most common fracture location, with 37% of these involving the articular surface at the plafond. After wound closure, deformity correction was initiated after 30 days on average. Varus and apex posterior were the most common initial deformity required for primary soft-tissue closure. Bony and functional Application of the Method of Ilizarov Group outcomes were good or excellent in 94% of patients. Conclusion: Intentional deformation followed by a gradual correction can be an effective strategy to obtain bone union and soft-tissue coverage in certain open fractures. This technique, in essence, converts these injuries from type IIIB to IIIA. This strategy obviates the need for flap coverage and results in satisfactory outcomes. Level of Evidence: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

OBJECTIVES To correlate domains of the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) in open upper extremity injuries with type of definitive soft-tissue closure, complication rates, and unanticipated return to the operating room for complication. DESIGN Retrospective review of prospectively collected data. SETTING Level I trauma center. PATIENTS Two hundred thirty-four consecutive open upper extremity fractures. INTERVENTION Operative management of open upper extremity fractures. MAIN OUTCOME MEASUREMENTS Type of definitive closure, 90-day wound complication, and wound complication necessitating return to the operating room. RESULTS Two hundred eighty injuries were identified, and 234 had sufficient data for analysis. Eighty-four percent (196/234) of open wounds were closed primarily, 7% (16/234) required a skin graft, and 4% (9/234) required rotational or free flap. Thirteen percent (22/166) of those followed for 90 days had a wound complication, and 50% of those with complication required a return to the OR. All OTA-OFC classifications statistically significantly correlated with type of closure (P < 0.001), with skin having a high correlation (r = 0.79), muscle (r = 0.49) and contamination (r = 0.47) moderate correlations, and arterial (r = 0.32) and bone loss (r = 0.33) low correlations. OTA-OFC muscle classification was predictive of 90-day wound complication (OR 0.31, 95% confidence interval 0.07-0.21). OTA-OFC domains correlated variably with return to the OR. CONCLUSION OTA-OFC clinically correlates with definitive wound management and 90-day wound complication in open upper extremity fractures. OTA-OFC skin classification has a high correlation with the type of definitive wound closure. OTA-OFC muscle was the only domain that correlated with 90-day wound complication and was predictive of 90-day wound complication. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Introduction Open lower extremity fractures pose a challenge for treating surgeons. All surgical strategies have the common aim to facilitate fracture healing. Fracture union, however, should be critically considered in the context of functional recovery and not in isolation. Both local and free tissue transfer have benefits and drawbacks. Aim This study aims to compare the functional outcomes of open tibial diaphyseal fractures managed with internal fixation, comparing outcomes of those receiving free tissue transfer as opposed to local flaps Methods This study follows the STrengthening the Reporting of Observational studies in Epidemiology (STROBE) criteria. Data were collected retrospectively from a prospectively maintained database at our institution. Inclusion criteria included a non-comminuted Gustilo type-IIIB open tibial diaphyseal fracture requiring intramedullary nailing. Forty three patients with local flaps and 180 patients with free flaps were included Results and conclusion 233 patient underwent reconstruction for open fracture using local flaps (n=43) or free flaps (n=180). In the context of Gustilo type-IIIB non-comminuted, mid-tibial diaphyseal fractures treated with intramedullary nailing, free fasciocutaneous flap reconstructions leads to significantly improved functional outcomes in patients of all ages when compared to local fasciocutaenous flaps. (77 ± 19 v 50 ± 22 % for local flaps; P

Aims Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date. Methods Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score. Results The mean age of the patients was 9.9 years (2.8 to 15.8), and 28 were male (64%). A total of 30 fractures (68%) involved a motor vehicle collision, and 34 (77%) were classified as Gustilo Anderson (GA) grade 3B. There were 17 (50%) GA grade 3B fractures, which were treated with a definitive hexapod fixator, and 33 fractures (75%) were treated with a free flap, of which 30 (91%) were scapular/parascapular or anterolateral thigh (ALT) flaps. All fractures united at a median of 12.3 weeks (interquartile range (IQR) 9.6 to 18.1), with increasing age being significantly associated with a longer time to union (p = 0.005). There were no deep infections, one superficial wound infection, and the use of 20 fixators (20%) was associated with a pin site infection. The median Enneking score was 90% (IQR 87.5% to 95%). Three patients had a bony complication requiring further surgery. There were no flap failures, and eight patients underwent further plastic surgery. Conclusion The timely and comprehensive orthoplastic care of open tibial fractures in this series of patiemts aged < 16 years resulted in 100% union and 0% deep infection, with excellent patient-reported functional outcomes. Cite this article: Bone Joint J 2021;103-B(6):1160–1167.

Background:\ud Open tibia fractures are a common injury following road traffic collisions and place a large economic burden on patients and healthcare systems. Summarising their economic burden is key to inform policy and help prioritise treatment.\ud Methods:\ud All studies were identified from a systematic search of Medline, Embase and the Cochrane Central Register of Controlled Trials. We included any human with a diagnosed open tibia fracture, following any intervention. The primary outcome was any costs reported or patient return to work status. Secondary outcomes included average length of stay, wage loss, absenteeism and complications such as infection, amputation and nonunion. Data was extracted and we performed a descriptive narrative summary.\ud Results:\ud We reviewed 1,204 studies from our searches. A total of 34 studies were included from 14 different countries. The average age was 37.7 years old and 76% of the patients were male. 6.5% were Gustilo I, 12% Gustilo II and 82% Gustilo III. Initial direct hospitalisation costs were reported to be between £356 to £126,479 with an average length of stay of 56 days (3.1-244). 89% of participants were working pre-injury, 60% fully returned to work, 17% returned to work part time or changed profession and 22% did not return to work at one-year. The most common complications reported were 22% infection, 11% nonunion and 16% amputation. Mean follow-up duration for the studies was 25 months.\ud Conclusion:\ud The economic burden of open tibia fractures varies greatly, but it is costly for both hospitals and patients. The current evidence is predominantly from high-income countries (HICs), especially the USA. Further research is required to investigate the costs of open tibia fractures using validated costing tools, especially in low-income countries (LICs), to help inform and direct policy.

Open proximal tibial fractures accompanied by soft tissue loss are substantially challenging to accomplish both bony consolidation and wound healing. The authors retrospectively delineated the utility of the various forms of the gastrocnemius muscle in fix & flap regimen for management of such complicated injuries. Thirty-one patients with open fracture accompanied by soft tissue loss of proximal tibia were managed by the protocol of fix & gastrocnemius flap. The collected data included implant for fixation, form of the gastrocnemius flap, postoperative complications, union time, and clinical assessment. According to fixation devices, lateral anatomical locking compression plates were selected in 28 cases, dual plates in 1, and interlocking nails in 2. According to the forms of the gastrocnemius flap, medial gastrocnemius flap was utilized in 22 cases, medial hemigastrocnemius flap in 2, medial myocutaneous gastrocnemius flap in 2, lateral gastrocnemius flap in 3, and combined medial and lateral gastrocnemius flaps in 2. All flaps completely survived without any flap-related complications. Fracture consolidation was established in all patients with an average period of 19.9 weeks (range 16–26). Surgical site infection occurred in 3 cases, and delayed union in 1. By functional score of Puno, 3 cases were determined to be excellent, 27 to be good, and 1 to be fair. Concurrent use of internal fixation and gastrocnemius flap reconstruction is a reliable and efficient protocol in managing open fractures with accompanying soft tissue defect of proximal tibia.

The purpose of this study was to evaluate the radiological and clinical outcomes of treatment of comminuted open fractures of the metacarpal bone (MCB) with associated injuries to soft tissues, tendons, and neurovascular structures using antegrade intramedullary nailing (AIN) at least 2 years postoperatively. Between January 2008 and December 2017, a total of 27 patients who met the inclusion/exclusion criteria were included in this study. The inclusion criterion was open and comminuted fracture (with/without segmental bone defects). We evaluated simple radiograph and computed tomography (CT) findings and clinical conditions (visual analog scale [VAS] pain score and Disabilities of the Arm, Shoulder, and Hand [DASH] score), including active range of motion (ROM) at metacarpophalangeal joint (MP) and grip strength at final follow-up. The mean preoperative angulation was 29.63° ± 7.59° and the mean shortening was 9.30 ± 2.38 mm. Union was achieved at mean 12.3 weeks postoperatively, without any complications due to operative treatment. The dorsal angulation measured on the CT scans, shortening on simple radiographs was significantly improved (10.26 °± 3.19°, 0.52 ± 1.05 mm, respectively). The final VAS and DASH scores were 0.41 ± 0.64 and 3.6 ± 2.47, respectively, indicating satisfactory outcomes. The final ROM was 85.0° ± 3.67°. The mean final grip strength was 89.56 ± 5.69% relative to the normal side. A mean extension lag at the MP joint of 12° was noted in three patients; however, it was resolved by additional tenolysis. AIN is a simple method for fixation of open comminuted metacarpal fractures accompanied by soft tissue injury. The simplicity of the method is beneficial for repairing associated injured structures and healing soft tissue. Minimized additional damage around the MCB during surgery and good stability resulted in satisfactory bony union with minimal angulation, shortening, and rotation. Level IV, Retrospective case series.

High energy open midfoot injuries are uncommon but devastating injuries. A combination of complex fracture dislocations and soft tissue injury patterns render reconstruction challenging. The aim of this study was to assess the surgical and patient reported outcomes following orthoplastic management of open midfoot injuries in a Major Trauma Center. A retrospective review of all open midfoot fractures admitted to our unit between January 2015 and December 2016 was undertaken. Demographics, operative details, complications, additional surgeries, and patient reported outcomes in the form of EQ-5D and Enneking scores were collected. Fifteen patients were identified (13 male, mean age 39.2 years). One patient underwent amputation at initial debridement and 8 required additional debridement. Of these 8 patients, 3 had an amputation during their index admission. In the limb salvage group (11 patients), definitive soft tissue cover involved free flaps in 6 patients, split skin graft in 3 patients, and delayed primary closure in 2 patients. Definitive orthopedic treatment was internal fixation in 8 and external fixation in 3 patients. Two patients required a Masquelet procedure for bone loss. One patient had a toe amputation and 1 had a below knee amputation for deep infection. The median EQ-5D score was 66 (interquartile range 43), and the median Enneking score was 20.5 (interquartile range 9). Limb salvage following open midfoot fractures is technically possible in most cases, however this often involves multiple procedures and the outcomes are variable and difficult to predict. Patients should be carefully counseled, and amputation considered in all such cases.

Objective This study aimed to retrospectively analyze clinical data of a series of patients with severe open fractures of extremities (Gustilo IIIb or IIIc), who achieved a satisfactory outcome through radical orthoplastic surgery, so as to provide a reference for determining the treatment of severe open fractures of extremities. Methods The clinical data of 41 consecutive patients with severe open fracture (Gustilo IIIb or IIIc) of the limb, who underwent successful surgical debridement, fixation, and soft tissue reconstruction in one stage between January 2008 and January 2019, were retrospectively reviewed. Postoperative indicators, including infection rate and union time, were acquired by a regular follow-up and analyzed. Results The mean (±SD) age of the patients was 38 ± 16 years. A total of 90 open fractures and severe soft tissue damages were analyzed. The soft tissue cover was achieved within 72 h. The overall rate of infection was 14.6% (6/41). Sex and the Mangled Extremity Severity Score were associated with infection. The median union time of 40 patients (one amputation) was 32 weeks. Conclusion The overall rate of infection exhibited a lower tendency in this study compared with previous studies on high-grade open fractures following a two-stage orthopedic approach. The consequence of infection rate and union time was similar to that in previous studies. These results indicated that the single-stage radical orthoplastic treatment was an effective and reliable option for reconstructing severe open fractures.

BACKGROUND Although external fixator is standard for managing staged treatment of open tibial fracture, the main disadvantage of this device is too bulky to be tolerated by most patients for longtime use. The purposes of this pilot study were to compare the biomechanical properties of a novel low-profile external fixator (LP-ESF) with a traditional ESF and also to evaluate its performance in patients with Gustilo type IIIb tibial open fractures. METHODS A prospective clinical pilot study started from January 2015 to December 2017, and 18 patients with Gustilo type IIIb open tibial fractures underwent the fixation with a novel LP-ESF system. The biomechanical properties of the LP-ESF were compared with the Synthes External Fixation System according to the standard ASTM F1541-02. These patients were divided into two groups according to the size of bony defect. The postoperative clinical outcomes were subsequently collected. RESULTS The biomechanical properties of the LP-ESF were comparable with those of Synthes External Fixation System and had an improved the axial/torsional stiffness and ultimate strength. In the clinical study, all patients with LP-ESF had fracture union. The duration of application of LP-ESF was 3.5 to 18 months until fracture union. In 10 of 18 patients, their fractures were immobilized with the LP-ESF until bone union, and no pin tract infection and no chronic osteomyelitis were recorded. The 36-Item Short Form Health Survey life quality and health survey were good to excellent in these patients. Notably, the LP-ESF allowed a patient with severe bone and soft-tissue defects to preserve the leg and joints function. CONCLUSION In this study, we found that the novel LP-ESFs had improved clinical outcomes. The long-term LP-ESF application seems to be tolerable in our patients. This novel approach permits better controls in deep infection and faster healing of fractures, and thus may provide a viable alternative treatment for Gustilo type IIIb open tibial fractures.

Daily walking stance benefits the health, whereas lower extremity reconstruction aims to accomplish balanced walking and posture control. If local flap or tendon transfer cannot provide the basic function, microsurgical reconstruction is indicated for bony, soft tissue, and sensation restoration. Wound repair can use every modality and can achieve varying wound coverage results. However, all reconstruction should have functional goals using either local flap or free flap to restore the lost function. With less recipient site secondary damage, microsurgery can provide healthy composite tissue with like-replaces-like approach to create more stable long-term results.

This investigation develops a predictive model for loss of alignment (LOA) following fixation of open tibia fractures.An analysis was performed of adults with diaphyseal open tibia fractures randomized to intramedullary nailing (IMN) or external fixation (EF) followed at 6, 12, 24, and 52 weeks postoperatively. Demographic data were collected at baseline. Pre-injury and follow-up EuroQol 5-Dimensions (EQ-5D) and pain score were measured. Radiographs, taken postoperatively and in follow-up, were assessed for coronal and sagittal angulation, and used to calculate the modified Radiographic Union Scale for Tibia fractures (mRUST). LOA was defined as an increase in angulation5° by one year follow-up. Fracture comminution was defined using AO/OTA classification. Putative risk factors were assessed for association with LOA using bivariate logistic regression. Adjusted associations with LOA were estimated using multivariable logistic regression and marginal analysis.Analyses included 129 patients (70 IMN, 59 EF), majority male, of mean age 33 years (range 17.7-73) and body mass index (BMI) 25.2 (range 15.5-45.1), with 48% Type A, 41% Type B, and 11% Type C fractures (AO/OTA classification). The likelihood of LOA with EF increased with greater fracture comminution; 45.21% (p0.001), 77.50% (p0.001), and 100% LOA for Type A, B, and C fractures respectively. Relative risk of LOA for EF compared to IMN was 3.87 (95% CI 1.36, 11.02), 3.75 (95% CI 1.77, 7.92), and 5.76 for Type A, B, and C fractures, respectively. Compared to patients who lost alignment, patients without LOA had improved fracture healing (p = 0.003) and higher EQ-5D scores (p = 0.03) at one year.Increasing age and BMI are associated with LOA and segmental fracture amplifies the protective effect of IMN versus EF. The importance of LOA as a surrogate outcome after operative treatment of open tibial fractures is supported by its association with inferior radiographic and functional patient outcomes.

Objectives To determine the factors associated with successful union and eradication of infection in the setting of staged procedures to treat obviously infected nonunions of long bones. We hypothesize that patients with positive intraoperative cultures obtained at the time of definitive surgery for infected nonunions are more likely to have persistent nonunion than those with negative cultures. Design Multicenter retrospective review. Setting Eight academic Level 1 trauma centers. Patients/participants Patients who underwent staged management for obviously infected nonunion of a long bone. Main outcome measurements For each patient, initial fracture management, management of retained implants, number of debridements, grafting, bacteriology, antibiotic course, bone defect management, soft-tissue coverage, and definitive surgery performed were reviewed. Results A total of 134 patients were treated with staged procedures for obviously infected nonunion of a long bone (mean age 49 years, 60% open fractures, and mean follow-up 22 months). During definitive procedures, 120 patients had intraoperative cultures taken with 43% having positive cultures. For culture-positive patients, 41 patients achieved eventual union and 10 had persistent nonunion. Of 69 culture-negative patients, 66 achieved eventual union and 3 had persistent nonunion. The number of patients with union versus persistent nonunion was statistically significant between culture-positive and culture-negative groups (P = 0.015). Conclusions Management of infected nonunion in long bones with staged treatments before definitive fixation are beneficial but ultimately less effective when performed in the setting of positive bacterial cultures at the time of definitive management. Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: Management of open fractures remains a major clinical challenge because of the higher energy involved in the injury, the greater local trauma, tissue necrosis, and extensive contamination. Even though early surgical debridement was thought to be critical, limited available operative techniques have minimized surgery in favor of early antibiotic administration. No clear agreement on the surgical approach, debridement, or irrigation technique exists. Surgeons continue to argue about the use of various fluids, the appropriate pressure of irrigation, antiseptics, and other factors. The current work reviews the available data and summarizes the capabilities of modern orthopedic irrigation solutions. Methods: To delineate available research on the topic, the PubMed database was queried for the most common techniques, fluid variables, and chemical adjuvants utilized in current open fracture and wound irrigation methodologies. Modes of delivery, volume, pressure, temperature, timing, solution type, and additives are evaluated in the context of known outcomes to determine which solutions may be preferable. Results: Various methods have been described with their own advantages as well as limitations. Particular solutions may apply to specific clinical scenarios, presence of implants, and degree of tissue contamination. Desired irrigation solutions are isotonic, non-toxic, non-hemolytic, transparent, sterilizable, efficient in removing debris and pathogens, as well as affordable; however, no current irrigant achieves all these desired characteristics. Conclusions: Despite being crucial for the healing of open fractures, there is no clear gold standard for irrigation. Although there are some novel irrigation solutions, there has been a paucity of research on finding new, safer, and more effective irrigation solutions that will promote wound healing and reduce infection.

Background We sought to evaluate whether tourniquet use, with the resultant ischemia and reperfusion, during surgical treatment of an open lower-extremity fracture was associated with an increased risk of complications. Methods This is a retrospective cohort study of 1,351 patients who had an open lower-extremity fracture at or distal to the proximal aspect of the tibia and who participated in the FLOW (Fluid Lavage of Open Wounds) trial. The independent variable was intraoperative tourniquet use, and the primary outcome measures were adjudicated unplanned reoperation within 1 year of the injury and adjudicated nonoperative wound complications. Results Unplanned reoperation and nonoperative wound complications were roughly even between the no-tourniquet (18.7% and 19.1%, respectively) and tourniquet groups (17.8% and 20.8%) (p = 0.78 and p = 0.52). Following matching, as determined by model interactions, tourniquet use was a significant predictor of unplanned reoperation in Gustilo Type-IIIA (odds ratio, 3.60; 95% confidence interval, 1.16 to 11.78) and IIIB fractures (odds ratio, 16.61; 95% confidence interval, 2.15 to 355.40). Conclusions The present study showed that tourniquet use did not influence the likelihood of complications following surgical treatment of an open lower-extremity fracture. However, in cases of severe open fractures, tourniquet use was associated with increased odds of unplanned reoperation; surgeons should be cautious with regard to tourniquet use in this setting. Level of evidence Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Highlights • Despite a UK national lockdown, the incidence of open lower limb fractures presenting to our trauma centre was comparative to pre-pandemic levels. • Road traffic accidents continue to be the most common mechanism of injury, possibly related to an increase in speeding. • High energy injuries predominate in males. • Time to initial debridement and definitive wound coverage was not significantly affected. The average length of stay in hospital was reduced., Background: COVID-19 has created huge pressures on healthcare systems. The ongoing provision of major trauma services during this time has proved challenging. We report our experience of managing open lower limb fractures (oLLFs) during the pandemic in a London major trauma centre (MTC). Methods: This was a prospective study of all open lower limb fractures presenting to our unit over the initial 48 days of UK government lockdown - 24th March till 10th May 2020. Results were compared to the same time period in 2019 retrospectively. Epidemiological data, mechanism, Gustilo-Anderson (G-A) severity grading, time to initial debridement and definitive coverage were analysed. Results: There was a 64% reduction in emergency department (ED) attendances (25,264 vs 9042). There was an 18% reduction in oLLFs (22 vs 18). Approximately three-quarters of injuries were in males across both cohorts (77% vs 78%) and tended to occur in younger patients (median age, 37 vs 35). Road-traffic-accidents (RTAs) were the most common injury mechanism in both 2019 and lockdown, but a rise in jumpers from height was seen in the latter. A similar pattern of G-A severities were seen, however only 3 injuries during lockdown required major soft tissue reconstruction. There was no significant difference in times taken for initial debridement (p = 0.72786) or definitive wound coverage (p = 0.16152). A greater proportion of independent operating was seen during lockdown between orthopaedics and plastic surgery. Conclusions: Despite government lockdown measures, oLLFs still placed significant burden on our MTC. Notwithstanding significant staffing alterations and theatre pressures, we have been able to ensure these lower limb emergencies remain a surgical priority and have managed to utilise resources appropriately.