Vol 10 | Issue 2 | July-December 2024 | page: 24-30 | Rajesh Gayakwad, Suhas S Shah

https://doi.org/10.13107/jmt.2024.v10.i02.227

Author: Rajesh Gayakwad [1], Suhas S Shah [1]

[1] Department of Orthopaedics, KB Bhabha Municipal General Hospital, Mumbai, Maharashtra, India.
[2] Department of Orthopaedics, GMC Healthcare, Mumbai, Maharashtra, India.

Address of Correspondence
Dr. Rajesh Gayakwad,
Consultant Orthopedic Surgeon,GMC Healthcare, Mumbai, Maharashtra, India.
Ex PG Resident, Department of Orthopaedics, KB Bhabha Municipal General Hospital, Mumbai, Maharashtra,
India.
Email: drrajeshgaekwad@gmail.com

Abstract

Introduction: The current rationale for the management of open fractures is based on the work of Gustilo, Mendoza and Williams (1984). Their classification of such fractures has been shown to be of prognostic value (Caudle and Stern 1987; Hansen 1987). The prolonged nature of the treatment for type IIIB fracture frequently results in disruption of all aspects of the patient's life for a prolonged period.

Materials & Methods: There were 25 patients, with mean age of 29 years. The injuries were caused by motor vehicle accidents. All had type IIIB compound fractures of tibia/fibula. Patients received this treatment average 10 day post trauma. Management protocol included debridement, excision of devascularised bone ends, acute docking, bone grafting, and Ilizarov fixator with corticotomy. Patients were allowed to weight bear on 5th postoperative day. Average period of follow up was 2.5 yrs.

Results: All but three united, average time to union was 22 weeks. Average accepted LLD was 3cm (3 patients). 7 required second procedure in form of debridement and recorticotomy. There were 18 excellent, 3 good, 2 fair, 2 poor results. Complications encountered in form of pin tract infection (18% of pins), wire breakage (7), premature consolidation (1), delayed consolidation (2) osteomyelitis (6).

Discussion: We recommend the usage of Ilizarov apparatus to provide primary definitive fixation for high-energy long bone fractures. Early weight bearing even in severely comminuted fractures is the key factor that separates it from other methods of fixation. It promotes early functional recovery, eliminating fracture disease. Dynamisation and correction of deformities in any plane is easily accomplished. Frame constructs could be modified to facilitate wound cover and access. Therefore it lends the much-needed flexibility in complex fractures. Corticotomy, acute docking and lengthening allows removing the dead necrotic bone ends and correction of LLD by distraction at corticotomy site. In current study an association between the high energy trauma due to road traffic accident and incidence of Grade IIIb compound fractures was seen.
Conclusion: It is a one step solution, as it addresses simultaneously soft tissue cover to exposed bone, infection, and bone loss and permits early rehabilitation, thus good functional outcome.

Keywords: Compound tibia fractures, Wound Debridement, External Ring Fixator, Distraction osteogenesis, Corticotomy, Gustillo-Anderson score, AO Classification, DCP-Dynamic Compression Plate

Introduction:

Open fractures are more frequent in the tibia than any other long bone because one third of its surface is subcutaneous through most of its length. Furthermore the blood supply to the tibia is more precarious than that of other bones enclosed by heavy muscles. Due to all these factors, compound fractures of tibia are commonly complicated with delayed union, non-union and infection. More ever the optimal treatment of the compound fracture of shaft tibia remains controversial [1,2].
Thus treatment of the tibial shaft fractures has evolved from the era of life preservation to era of limb preservation and infection avoidance to era of optimum functional preservation. The appliances and methods available to treat the fractures of shaft tibia show the complexity and confusion in decision making with respect to the best treatment options.
In pre-listerian era, the compound fractures of tibia were mostly addressed by leg amputation in attempt to preserve life. With his principles of antisepsis, Joseph Lister managed these open injures with some success [3]. This heralded the approach of limb preservation and infection avoidance.
Throughout the 80’s external fixator had been the treatment of choice in open fractures of tibia as they provided stabilization with adequate access for wound management and soft tissue care. They had their own drawbacks in the form of pin track infection, pin loosening, malunion, delayed union and non-union. Plating as form of treatment devised by AO group is associated with increased risk of infection and skin necrosis [4,5].
Literature suggests that unreamed nails are superior to external fixator or the reamed nail in the management of compound fracture of tibia, while others did not find any difference between reamed and unreamed intramedullary nailing. Yet controversy exists on either side and rate of non-union with these procedures is too high near to about 37% [6,7,8]
Over the years Illizarov External Ring Fixation technique has been considered the ultimate solution for the compound fracture of tibia, both as primary modality and in those cases where the simple external fixators, reamed/unreamed intramedullary nailing methods have failed and in cases of non-union/malunion, considering the stability of the ilizarov apparatus which can be used to mobilize the patient at the earliest even in the severely comminuted fractures [9]

Hence this study endeavors to study the surgical technique of ilizarov external ring fixator and to evaluate clinical, functional and radiological results in the management of compound fractures of tibia caused by high energy trauma.

Materials And Methods
A total of 25 cases of Grade IIIb compound fractures of tibial/fibula shaft with fractures at least 7.5 cms from proximal articular surface and 5 cms from distal articular surface of tibia were selected. Patients with grade IIIc compound fractures, patients below 18 years and above 65 years, and those patients who found the apparatus aesthetically unacceptable were excluded from the study.
The Soft tissue component of the open wounds were classified with the one described by GUSTILLO-ANDERSON and modified by Gustillo, Gruninger and Davis [10,11], while the skeletal Component for the fractures of shat tibia-fibula, an AO Classification method was used [12].
After identifying the life threatening conditions and stabilizing the patient on the principles of ATLS[13], the wound in the injured limb was managed by removal of superficial contaminants, wound was washed with hydrogen peroxide, betadine so as to flush out blood clots, grit, contaminants .The wound was closed with sterile dressing soaked in normal saline. The deep exploration was done only in operation theatre.
Bactericidal intravenous antibiotic were started as soon as possible generally a third generation cephalosporin for gram positive coverage, an aminoglycoside for gram negative coverage, metronidazole for anaerobic coverage. Active and passive immunization against tetanus and clostridial organisms was given immediately. (Inj. ATS 1500 IV, Inj.AGGS 20,000 IV for compound fracture were administered as and when indicated) [14,15].
WOUDN IRRIGATION AND DEBIRDEMENT was done in the operation theatre under suitable anesthesia where thorough wound wash given with normal saline, hydrogen peroxide, betadine solution through mechanical irrigators like pulsatile lavage. The procedure was carried out under control of tourniquet with intermittent inflation and deflation to recognize the viability of the muscle and other soft tissues in the wound for which the quartet of Gregory was used, which includes-COLOR, CONSISTENCY, CAPACITY TO BLEED & CONTRACTILITY [16,17,18].
Definite treatment was attempted as early as possible within 24 hrs. In 19 patients the frame was applied within 6 hrs. Of another 6 patients, 4 patients presented to hospital with Monolateral ex-fix applied somewhere else. In other 2 patients, associated injuries did not allow immediate frame application. In them above knee slab was given with regular wound care till definitive surgery. The limb segment was sized with the actual ring or template with at least 2-3 cms of clearance between the inner edge of the ring and skin to accommodate the changes in dimensions of the extremity due to the swelling and dependent edema. More clearance was given posteriorly especially in the head injured and poly-trauma patients who were forced to be bedridden for a longer period of time. In our study, generally a 1600 ring size has met above criteria. The number of rings used was decided on the fracture anatomy and the dimensions of the open wound. Generally two rings above and two rings below the fracture site were used. Additional rings were applied as required which was decided on table. Six ring construct was done in segmental fractures (n-4, 16%).In rest of cases four ring construct was used. Bone grafting was done in patients with segmental fractures (n-4, 16%), fractures with bone loss (n-5, 20%) & rest of cases to augment healing (n-6, 24%). In extensively comminuted diaphyseal fractures, frame stability was enhanced by drop wires/shanz pins [19].
During surgery our aim was to make fracture site as transverse as possible. Special attention was given to the bleeding from the cortex of the fracture site and in cases of doubt, docking was done. Portable color Doppler was used to confirm the distal vascular status after acute docking in all cases of our study. After acute docking, the fracture fragments were held reduced by temporary four holed 4.5 mm DCP plate and cortical screws.
In our study, pure Russian technique was employed for frame construction [19]. A four-ring construct was generally applied in single level fractures with general rule of two level fixations in the major fracture fragment, generally we used a six ring construct. The distance between the fracture line and ring was kept to an average of 3 cms so as to increase the stability of the frame construct and to give enough room for compression/distraction and correction of any mal-alignment.
All wires used in our study were of olive type to add the stability of the construct and aid in fracture reduction and correction of any mal-alignment. Initially wires were passed in the shortest bone fragment parallel to the nearest joint to that short bone fragment. In mid shaft fractures, we preferred passing initial wires parallel to knee joint. Other wire is passed parallel to the opposite joint. These wires were used as reference wires for other wires. The angle formed between two wires passed at any level, was attempted to be at 90 degrees within the limits of the limb anatomy at that level. While transfixing the wires, power drill with start-stop technique with constant irrigation with cold saline by an assistant was used to avoid excessive thermal necrosis of the bone. Once the wire crosses the far cortex, drilling was stopped and wire was further pushed through by hammering with mallet or pulling out with pliers. During trans-fixation of wires, the muscles were kept at their maximum functional length and the nearby joints positions were changed when the wires passed from the flexor compartment to extensor compartment.i.e foot was dorsiflexed when anterior compartment was transfixed,platarflexed when posterior compartment was transfixed and inverted when peroneal compartment was impaled. The tension at skin-wire interface was kept to minimum either by mobilizing the skin in appropriate direction or by incising the skin at the interface. This was necessary to avoid any hindrance in joint range of motion [19].
Since we had used all of transfixing wire of olive type, tensioning was done from the side opposite to the olive bead. We used tension of 130 kg in all of the cases which was sufficient enough for weight bearing in our patients [20,21]. Following the surgical application of the frame, the various segments were moved by appropriate motors until, ideally, all rings were parallel and superimposed axially, and restoring the mechanical axis.
In our study corticotomy was done in case with extensive bone loss (n-5, 20%) during trauma or extesive bone removal(n-13, 52%) necessiated during process of docking.The level of corticotomy was at proximal metaphysis at level of tibial tuberosity between the two proximal full rings.We preformed the classical corticotomy used for triangular bones like tibia [22,23,24,25,26].

In our study, technique of wound healing by secondary intention and later closure by SSG was employed in most of patients (n-17, 68%). In very few patients (n-8, 32%) wound was managed by primary intention considering the severity of grade IIIb injuries. Of 8 cases, in only 2 patients wound could be closed by sutures [27,28]. In 5 cases wound was closed after docking at fracture site. In both instances wound was healthy enough for primary closure. In one case primary closure by local rotation flap was done with successful outcome. In 1(4%) patient local fascio-cutaneous flap was used to close the wound primarily since the wound status was good enough to allow the closure. This wound healed without infection. In another 6(24%) patients local rotation flaps of medial gastrocnemius (n-4, 16%) and soleus (n-2, 8%) was used with excellent result in form of complete healing of wound [29].
In patients with bone loss due to initial trauma, acute docking of fracture site, distraction at corticotomy site was started on POD-5 after check radiographs (n-18, 72%), at the speed of 1 mm/day which equals 1 complete rotation of the nut on the threaded connecting rod [30,31,32]. To aid this, the initial positions of the nut to be rotated were marked with paint (Nail polish) relative to their rings.
In all patients (n-25,100%) active /passive knee and ankle range of motion exercises are started on POD-1 onwards under supervision of physiotherapist. The physiotherapy session was done by the patient for about 2-3 hrs a day. On POD5, 4 patients(16%) with segmental fractures were kept NWB,while 7 patients (28%) kept PWB because of docking , >5 cms(n-3,12%) & bone loss with shortening <5 cms(4,16%).They proceeded to FWB by POD10.2 patient were still NWB till POD10 due bone loss >5 cms(1, 4%) and associated systemic injuries(1,4%) .These proceeded to PWB on POD5 and FWB on POD10.Majority of patients (21, 84%) were FWB by POD10 [33,34,35].

Results
23/25 fractures united. Average time to union was 22 weeks. Average accepted LLD was 3 cms in 3 patients.8/25 required second procedures. Second debridement was done in 3 cases of infected compound wounds closed primararily with sutures [36]. 1 patient had a Varus angulation of 5 degree at the fracture site (required correction of malalignment by recorticotomy and frame adjustment) [37]. 1 patient developed Stiffness around the knee joint; however the Knee range of motion was satisfactory in almost all cases. 3 cases of EHL transfixation occurred in our series, which later recovered after frame removal. In 2 cases wires were retensioned. In 2 cases recorticotomy was done for premature consolidation.1 patient required correction of loss of reduction on POD5 due to FWB.Second stage bone grafting was done in 5(20%) patients for delayed union, aseptic non-union (n-1,4%) and septic non-union(n-2,8%). Pin tract infection was seen in 7 (31) pins. All were grade I type which resolved by daily dressing and 5 day oral antibiotic course.1 case of foot drop was noticed in this series due to common peroneal nerve palsy during insertion of wire near knee joint. Wire passed posterior to neck of fibula. Spontaneous recovery occurred over 4 weeks without much active intervention. No vascular complications were seen any of the patients.
This study shows high incidence of open injuries in male population in comparison to female population, suggesting a relationship between the incidence and activity of the affected population. Our findings were comparable to standard epidemiological study [38,39,40,41] Middle third (n-14, 56%) followed by distal third (n-8, 32%) was most common anatomical locations of tibia affected in this study. Right leg was most commonly affected in our series. (n=18, 72%). There was clustering of the fractures in complex category (n-13, 52%, 42-c2.3).
In our study, 21(84%) cases sustained injury secondary to road traffic accidents. Majority of the victims were two wheeler riders followed by pedestrians. Only 1 case was of railway accident and 4 patients were of fall from height. The observation suggest that RTA is major causative agent of grade IIIb open injury with p>1, with the two wheeler riders and pedestrians being more susceptible to such injury. These findings are comparable to the findings of other studies. [38,39,40,41]
Based on Johner and Wruhs criteria [42], the final results were rated as 18 excellent, 3 good and 2 fair & 2 poor results were seen.

Discussion
In this study, Ilizarov fixator was chosen to primarily fix those fractures that produced high rate of complications with most conventional methods of fixation. For over half a century the Ilizarov device has been used for treatment of acute fractures and non-unions. This series is unique with respect to the complexity of the fractures considered. The specific category of fractures subjected to Ilizarov fixation was with the view to clearly define the role of the fixator in primary management of tibial fractures [43]. Even though the circumstances were adverse with respect to the fracture pattern, the union time was not unduly prolonged. Ilizarov external fixator provided one step solution in the management of compound fractures of long bones.
The structure is stable and enables the patient to bear weight on the affected limb even in much comminuted fractures, not easily achievable by other methods of fixation. The procedure is minimally invasive with little interference in the biology of fracture [44]. Current debate concerns the use of reamed and unreamed intramedullary nailing in open fractures because both techniques, to varying degrees negatively affect the circulation of cortical bone [45,46]. In patients with an open fracture, this has significant implications. Many standard studies have concluded against internal fixation of Grade III open fractures when compared to results of such fixation in Grade I, II open fractures. [46,47,48,49]. Based on literature, unreamed intramedullary nailing has been associated with a significantly lower rate of malunion than the external fixator or reamed nailing [50,51,52,53,54,55,56,57], nevertheless, unreamed nailing does not provide adequate stability for severely comminuted fractures with malunion rate of 0–27%.
Though IEF provides opportunity for simultaneous wound care and fracture management, it’s not as superior to monolateral external fixator because of technicality and cumbersome nature of ilizarov frame. Today the external fixator is considered only as temporary mode of fixation in compound fractures, which was done in 7 patients in our studies who had extensive soft tissue loss and contamination where primary IEF could not applied due to the technical aspects of IEF
Ilizarov is generally credited for the introduction of word corticotomy for percutaneous cortical osteotomy performed with osteotome. The word denotes an osteotomy of the cortex without disturbing the medullary canal and periosteum. It’s performed at metaphyseal level which according to ilizarov favor bone regenerate formation and also the soft tissues around this region are teleologically better adapted to distraction [58]. Monticello and Spinelli [59] and other orthopedic surgeons hold that the metaphysis has a much greater osteogenic potential than the diaphysis. Steen and Field [60] examined the difference between the healing of metaphyseal and diaphyseal level corticotomies under distraction. No difference was found in the healing time however the metaphyseal corticotomy was more stable than diaphyseal corticotomy [59,60].
However cases that required corticotomy and distraction, necessitated prolongation of the time on the fixator. However, this is an additional option with the Ilizarov fixator that makes it so versatile, since it allows correction of malalignment in three dimensions simultaneously also corrects LLD by principles of bone transport [61].
The elasticity of the wires used in the apparatus allows compressive movements at fracture site favoring rapid consolidation of the fracture callus, hence this method of treatment has shown high union rates in such complex fractures of bone which is known for non-union especially under influence of wound and high energy trauma [62,63,64]. Though axial compression can be achieved in intramedullary locked nails and monolateral external fixators, this is not possible in this class of fractures where high energy trauma causes comminution at fracture site. Schatzker reported 32 open tibial fractures treated with Ilizarov fixator. Healing time was 21.9 weeks in patients with a single injury and 25.7 weeks with multiple traumas similar to the results reported by Schwartzman et al. [65]. These features make this method of treatment unique when compared to other methods of treatment of open tibial fractures.

Conclusion
We recommend the usage of Ilizarov apparatus to provide primary definitive fixation for high-energy long bone fractures. Early weight bearing even in severely comminuted fractures is the key factor that separates it from other methods of fixation. It promotes early functional recovery, eliminating fracture disease. Dynamisation and correction of deformities in any plane is easily accomplished. Frame constructs could be modified to facilitate wound cover and access. Therefore it lends the much-needed flexibility in complex fractures. Corticotomy, acute docking and lengthening allows removing the dead necrotic bone ends and correction of LLD by distraction at corticotomy site. In current study an association between the high energy trauma due to road traffic accident and incidence of Grade IIIb compound fractures was seen.

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