Session III Tibia

Prophylaxis of Infection in Open Tibial Shaft Fractures - An Analysis of 250 Consecutive Cases

Peter A.W. Ostermann, MD, PhD, Michael P. Hahn, MD, PhD, Axel Ekkernkamp, MD, PhD, Gunnar Möllenhoff, MD, Gert Muhr, MD, PhD

Department of Surgery, Trauma Center "Bergmannsheil", School of Medicine, University of Bochum, GERMANY

Purpose: This investigation should prove the results of modern principles in compound fracture care with primary regard to the treatment of the soft tissue.

Material and Methods: 250 compound tibial fractures were treated in an open prospective trial at our institution between January 1986 and June 1995. There were 53 grade I, 67 grade II and 130 grade III open fractures (Gustilo-Anderson classification). The grade III open fractures were subdivided by the Gustilo-Mendoza-Williams classification (IIIA: 86, IIIB: 28, IIIC: 16). All fractures were managed after a treatment protocol and the patients were followed in our clinic. Fracture management consisted of copious wound irrigation, serial meticulous radical debridements, the administration of i.v. antibiotics and fracture stabilization. Since May 1991, unreamed tibial nailing in type I throughout type IIIB open fractures was mainly performed. Previously, external fixation was the method of choice. In cases with extensive contamination (type IIIB) and uncertain vascularity (type IIIC) adjuvant local antibiotic therapy was used. All wounds were primarily left open. In wounds with exposed bone, the bone was covered with vital muscle (local or free flaps) within one week. In the last three years, 15 fractures with severe soft tissue injury and bone loss were primarily shortened to decrease the soft tissue defect and were secondary lengthened using the Ilisarov technique after soft tissue reconstruction ("accordion technique").

Results: 3 type IIIC open fractures underwent early amputation. All other fractures went on to bony union with an average healing time of 18.7 weeks. The deep bony infection rate was only 2.8% (7/250). There were no infections in grade I open fractures, 1.5% infections in grade II and 4.6% infections in grade III compound fractures. There was no infection associated with the accordion technique.

Discussion and Conclusion: This study shows that the major complication of open lower leg fractures, the deep bony infection, can be dramatically decreased following modern therapeutic principles. In our center we could decrease our infection rate from 13% before 1986 to 2.8% after 1986. The use of the accordion technique seems to be promising for severe open fractures of the tibia.