Session I - Tibia

The Functional Outcome of Severe Open Tibial Fractures Managed with a Radical Fix-and-Flap Protocol

Shiva Gopal, MS, FRCS; Alison Murray, BSc; Peter V. Giannoudis, MD; Stuart J.E. Matthews, FRCS; Malcolm R. Smith, FRCS, St. James's University Hospital, Leeds, U.K.

Purpose: We assessed the functional and health status outcomes after severe open tibial fractures (Gustilo grade IIIb and IIIc injuries) managed with a radical single-stage protocol with debridement, immediate skeletal stabilization, and muscle-flap cover (fix-and-flap protocol).

Methods: Thirty-three patients whose severe open tibial fractures had been treated with a radical procedure from 1992 to 1998 underwent formal functional assessment by an independent research physical therapist. All of the patients had previously been followed up until the union of their fractures. The following parameters were recorded: gait, use of walking aids or orthoses, limb-length discrepancy, knee and ankle-joint function, muscle wasting and strength, and the cosmetic appearance of the limb. The health outcomes were assessed using the Euroqol questionnaire and the SF-36. Personal comments and satisfaction or dissatisfaction with the limb salvage and an employment history were also recorded.

Results: The study group consisted of 29 adults and 4 children (27 male and 6 female patients) with 34 fractures. -0 Gustilo grade IIIb and 4 grade IIIc fractures. The mean age for the adult group was 48.3 years (19-79 years). 14 (48.27%) patients had other major limb fractures that affected their rehabilitation. Twenty nine patients had primary internal fixation and 4 had external fixation, overall 34% required an additional bone stimulating procedure; in two patients this involved bone transport to reconstruct large segmental defects. The mean time to bony union was 41 weeks (12-104 weeks). Only two patients developed deep infection (6.6%) that resolved with treatment.

Functional assessment: Knee stiffness was noted in 7 patients with a flexion deformity (5-10°) in 4 and flexion <100° in 3, the overall mean knee flexion was 115.6°. There was only1 patient with an equinus deformity of the ankle (5°) but plantar flexion of the ankle was decreased in 19 patients (mean loss 17°). All except one patient (Head injury with CVA) had at least MRC grade 4 power for all the thigh and leg muscles, 16 patients had thigh wasting (mean 1.5cm) and 14 calf wasting (mean 1.5cm). There were 20 patients with a limp, all had limb length discrepancy (mean shortening 1.35 cms; range 0.5-4 cms). Nine patients used a walking stick and 4 patients wore an Orthosis. 23 patients had an increase in girth of the affected leg that often included the free flap (mean 4.3 cm). Euroqol: the mean state of health score was 68/100. This appeared to be higher in those with an isolated tibial injury (71/100), as compared to those with associated injuries (64/100). SF-36: overall the mean physical score was 49, and the mean mental score 62. Patients with isolated injuries appeared to score better, on both physical (56 vs. 41), and mental scores (70 vs. 52), as compared to those where other injuries were present. Twelve (41%) of the adults returned to work, 7 to their original employment, 2 with minor modifications to their work and 3 changed to a lighter job.

Four children were assessed, at a mean age of 12.25 years, 2 had suffered IIIc injuries. All the children had normal joint function and were back to full time education and physically active. Two had some shortening (1.5 & 2 cm) but all had growing limbs with no increasing deformity.

Discussion and Conclusion: Our results compare favourably with previous outcome measures published for both limb salvage and amputations. All our patients expressed their satisfaction at retaining their own limbs, suggesting that this early, aggressive approach to limb salvage after severe open tibial fractures can produce a satisfactory outcome.