Open tibial fractures: An overview

Abstract

Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. The close proximity of the tibia to the skin makes it prone to extensive soft tissue damage and subsequent detrimental complications, such as infection and non-union. Thus, they were historically associated with high rates of amputation, sepsis, or even death. The advancement of surgical instruments and techniques, along the emergence of evidence-based guidance, have resulted in a significant reduction in complications. Peculiarly though, modern management strategies have a strong foundation in practices described in the ancient times. Nevertheless, post-operative complications are still a challenge in the management of open tibial fractures. Efforts are actively being made to refine the surgical approaches used, while noteworthy is the emergence of the Orthoplastic approach. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.

1. Introduction

Open fractures can be defined as fractures which communicate with the outside environment through a soft tissue wound. The majority of open fractures are those of the long bones, while most occur in the lower extremity and particularly the tibia.¹ Open tibial fractures have always been a challenge to manage, as historically they often resulted in amputation, sepsis or even death. Their perplexity is caused by the wound itself, which predisposes the fracture site to detrimental complications, such as infection and non-union.

The publication of evidence-based guidelines by professional organisations globally, along the advancement of surgical instruments and techniques, have resulted in a significant reduction in amputation, mortality, and infectious complications. Noteworthy has also been the emergence of the Orthoplastic approach, where orthopaedic and plastic surgeons co-jointly manage cases both inside and outside the operating theatre. The aim of this review is to summarise and discuss the historical perspective of the management of open tibial fractures, their epidemiology and classification, up-to-date principles of surgical management and outcomes following injury.

2. Historical perspective: 3000BC to World War II

We have been differentiating between open and closed fractures for more than 4500 years now. The first reported open fracture dates back to 3000-2500 BC and is believed to be Case 37 in the Edwin Smith Papyrus (Fig. 1).^2,3 Thousands years later, Hippocrates suggested cleansing and sealing the open fracture wound, reducing the fracture after 7–10 days using iron levers and sawing off any protruding bones.³ This practice continued for centuries until the renowned French barber-surgeon Ambroise Paré introduced the concept of wound dilatation and removal of bone fragments (Fig. 1).⁴ Paré was the first to report that the risk of infection and non-union increased when devitalised bone was not appropriately removed.³ Moreover, noteworthily, the advancement of firearms forced surgeons to improve the art of amputation, as injuries with extensive soft tissue and neurovascular damage became more common.³ It was around that time when we started seeing a differentiation of treatment based on the severity of the fracture. The most iconic case of limb salvage versus amputation was that of Sir Percivall Pott, famous English surgeon and founder of orthopaedics (Fig. 1).^5,6

Fig. 1.

Timeline of the advancement of open fracture management until the 19th century.

The establishment of debridement did not come until the 18th century, when Joseph Desault and his student, Baron Dominique Jean Larrey, introduced and tested the concept through their work (Fig. 1).³ Baron Larrey reported: ‘I washed the wound, removed all foreign bodies, cut off all disorganized and ragged parts, and applied the ligature on the vessels I had opened’.⁷ About 100 years later, Joseph Lister introduced antiseptic principles and achieved a decrease in complication and mortality rates (Fig. 1).⁸ At around the same time, Frederic S. Dennis published a case series of compound fracture management without a death.⁹ Dennis' reports revolutionised the management of open fractures – he suggested absolute cleanliness, immediate fixation and provision for free drainage when necessary. The question remained though ‘How long can a wound remain contaminated without getting infected?’. In response, Paul Leopold Friedrich (1898) created open wounds on guinea pigs' triceps and contaminated them with dirt and manure; demonstrating that open fracture wounds reach infection threshold at about 6 h after the injury due to the incubation period of bacteria.¹⁰ He suggested that the best treatment is exact debridement with excision of damaged tissue and that antiseptic solutions are only useful when the wound cavity can be accessed during bacterial germination. Few decades later, during World War II, Mather Cleveland and John Grove reported a 93% success rate when managing open fractures with thorough debridement, free drainage, and delayed wound closure.¹¹ The use of boric acid was quickly replaced by the use of penicillin, which reduced infection rate and the incidence of gangrene. Interestingly, modern techniques in the management of open fractures have their roots in practices first described in the ancient times.¹²

3. Epidemiology

Open fractures are uncommon, making up only 2.6% of all fractures.¹³ Their sparsity makes documentation of cases challenging. One of the largest scale epidemiological studies reviewing 2386 open fractures over a 15-year period, reported that tibial are one of the commonest types (13.7% including fibular diaphysis).¹⁴ In addition, they found that they occur at an average age of 43.3 years and are twice as common in males than in females.¹⁴ Open fractures are usually the result of road traffic accidents (34–43%) and falls from standing height (22–25%).^14,15 Moreover, it has been reported that tibial fractures constitute up to 51.8% of open fractures caused by road traffic accidents.¹⁶

Open tibial fractures are complex injuries with multifactorial outcomes and variable prognosis. Patients with open fractures are hospitalised twice longer compared to patients with closed fractures (p < 0.001).¹⁵ Out of common open fractures, tibial are the most severe, with a reported mean Injury Severity Score (ISS) of 13.5.¹⁴ This is a result of the close proximity of the tibia to the skin, making it prone to extensive soft tissue damage – 44.6% of open tibial fractures are Gustilo-Anderson Type III, indicating a wound of at least 10 cm big which is contaminated.¹⁴

4. Classification of open fractures

The severity of an open fracture can influence both the management strategy and patient outcomes.¹⁷ This has driven the development of grading systems allowing systematic classification of fractures with similar characteristics.18, 19, 20, 21, 22, 23, 24, 25 The earliest example is the one by Veliskakis,¹⁹ which was later modified by Gustilo and Anderson in 1976,¹⁸ and refined by Gustilo et al., in 1984.²⁵ The Gustilo-Anderson classification system is simple and functional, and has been extensively used for all open fractures in the past 36 years, regardless of being originally designed for tibial fractures only.²⁶ Another noteworthy scoring system for open fractures is the Ganga Hospital Score, which is particularly useful for injuries with extensive soft tissue damage and inadequate coverage.²⁷ More recently, the Orthopaedic Trauma Association (OTA) developed a new classification system for open fractures in an attempt to improve its predecessor.²⁰ Although various classification systems have been validated in the literature, the Gustilo and Anderson system remains the most widespread in clinical practice.²⁶ Nevertheless, they all have as common purpose to aid clinical decision-making, guide management, facilitate communication between practitioners, standardise reporting methods in research, and act as education tools.^26,28

4.1. Gustilo and Anderson

Veliskakis initially proposed a classification system following analysis of 80 open fracture cases.¹⁹ This simple system categorises fractures into 3 grades based on the size of the wound, loss of skin and muscle damage. Gustilo and Anderson later refined it, to take into consideration the wound size, level of contamination, and osseous injury.¹⁸ Type I are defined by a wound <1 cm long and clean (Fig. 2); type II by a laceration >1 cm without extensive soft tissue damage, flaps, or avulsion (Fig. 3); and type III by either an open segmental fracture, an open fracture with extensive soft tissue damage, or a traumatic amputation (Fig. 4, Fig. 5). Although this classification system revolutionised reporting of open fractures, a large variation was noted in severity, aetiology, and prognosis of Type III fractures, suggesting low specificity.²⁶ Gustilo et al. later refined Type III into 3 sub-categories (Type IIIA, IIIB and IIIC) to reflect this variability. Since its inception in 1984, the Gustilo-Anderson classification system was widely accepted with its strengths and limitations. In its advantage, it has a robust ability to associate severity grades with the incidence of complications, such as infection, amputation, and fracture prognosis.^17,18,25,29, 30, 31, 32, 33, 34, 35 On the contrary, it has showed poor to moderate inter-observer reliability, an underestimation of damage to muscle and bone, and a considerable subjective nature.^27,36,37

Fig. 2.

Gustilo-Anderson Type I open tibial fracture.

Fig. 3.

Gustilo-Anderson Type II open tibial fracture – (A) Before management; (B) Immediate post-operative result after bone fixation and soft tissue reconstruction.

Fig. 4.

Gustilo-Anderson Type IIIA open tibial fracture – (A) Before management; (B) Immediate post-operative result after bone fixation and soft tissue reconstruction.

Fig. 5.

Gustilo-Anderson Type IIIB open tibial fracture – (A) Following surgical debridement and temporary spanning external fixation; (B) Immediate post-operative result (‘fix and flap’); (C) One-week post-operative result.

4.2. Ganga Hospital Open Injury Severity Score

The Ganga Hospital Open Injury Severity Score (GHOISS) was developed at the Ganga Hospital, India in 1994 to predict limb salvage and outcomes following open tibial fracture injuries.²⁷ It is based on four domains: (1) Covering tissues (S1 to S5); (2) Skeletal structures (B1 to B5); (3) Functional tissues (M1 to M5); and (4) Comorbid factors (Co0 to Co14). Thus, an open fracture can be scored from 3 to 29. A score of 14 or less suggests probable limb salvage, whereas a score of 17 or more suggests probable amputation. A score of 15–16 is considered a ‘grey zone’. Furthermore, the covering tissue score yields suggestions on the soft tissue closure approach, ranging from primary closure to delayed flap.^38,39 Finally, it generates estimates in 6 treatment outcomes: total length of treatment, number of surgeries required, number of hospital admissions, length of hospital stay, final functional outcomes, and bony union time. GHOISS has been described to be superior in assessing Gustilo-Anderson IIIb injuries, where other scoring systems have demonstrated poor intra- and inter-observer reliability and inability to predict limb salvage and functional outcomes.⁴⁰ Since its inception, GHOISS has demonstrated a high sensitivity and specificity for amputation and good predictability of surgical outcomes in type IIIb open tibial fractures in both adults and children.^39,41,42

4.3. OTA

A recent attempt of an objective classification system is that of the OTA.²⁰ It has 5 components: skin injury, muscle injury, arterial injury, contamination and bone loss. Each is rated on a scale of 1 (mild) to 2 (moderate) to 3 (severe) using predefined criteria. Recent studies have demonstrated moderate to excellent interobserver reliability and predictive abilities relative to how the open fracture is treated.^43,44 When compared to the Gustilo-Anderson classification system, no difference was found for the interobserver reliability,⁴⁵ however, the OTA scale is superior in predicting post-operative complications and outcomes in patients with open long bone fractures.⁴⁶

5. Principles of surgical management

In the past, open fractures were associated with high mortality and catastrophic outcomes, however, with the advancement of modern surgical approaches, the prognosis of such injuries has improved radically.⁴⁷ Standard principles in the management of open fractures, include initial assessment and resuscitation, antibiotic and tetanus prophylaxis, surgical debridement and copious irrigation, fracture stabilisation, soft tissue closure, thorough rehabilitation, and adequate follow-up.47, 48, 49 In addition, the surgeon can take advantage of adjunct therapies, such as local antibiotic therapy, vacuum-assisted therapy, free tissue transfer, or bone-grafting. The surgeon should always aim to prevent infection, promote healing, and restore function, however, when indicated, a delayed primary amputation should be performed within 72 h of injury.⁵⁰

5.1. Standards and recommendations in the UK

Open tibial fractures require timely multidisciplinary management. The BOA and BAPRAS met for the first time in 1991, coming to consensus that patients with open tibial fractures should be managed jointly.⁵⁰ They published their first evidence-based recommendations in 1993, and then again in 1997, however, their implementation was challenged by geographical constraints of resources, particularly on the feasibility for performing surgical debridement in all wounds within 6 h.⁵¹ In an effort to alleviate the encountered difficulties, the recommendations were later revised to require the transfer of patients with open fractures of the lower limb to specialist centres that can provide Orthoplastic care and also, to extend the timeframe for debridement for non-contaminated wounds and low-energy fractures.⁵⁰ The emergence of the new guidelines was also associated with a paradigm shift from initial emergency surgery, to urgent transfer to an Orthoplastic service to facilitate a stepwise and disciplined management approach.⁵²

The latest standards for the management of open fractures of the lower limb were published in 2009, however, evidence-based recommendations were released later in 2016 by the National Clinical Guideline Centre (NCGC) and the National Institute for Health and Care Excellence (NICE) (NICE Guideline NG37).⁵³ These were developed following literature searches performed between March and April of 2015. They addressed 10 research questions in total, including optimal timing for debridement, however, in most domains synthesised evidence was of low or very low quality. BAPRAS and BOA produced a 19-point short version based on these standards, the BOA Standard for Trauma and Orthopaedics (BOAST) for open fractures guidelines (BOAST4).⁵⁴

5.2. Orthoplastic approach

Orthoplastic service can be defined as ‘the principles and practices of both specialties applied to clinical problems simultaneously, either by a single provider, or team of providers, working in concert for the benefit of the patient’.⁵⁵ The Orthoplastic approach in limb salvage was first introduced by Professor L. Scott Levin in the early 1990s,⁵⁵ while concurrently BOA and BAPRAS in the UK agreed on a common management of open tibial fractures. BOA/BAPRAS have broken this service in various component parts: a combined service of Orthopaedic and Plastic Surgery Consultants; sufficient combined operating lists with consultants from both specialties to meet the standards for timely management of open fractures; scheduled, combined review clinics for severe open fractures; and specialist nursing teams able to care for both fractures and flaps.⁵⁴ In an ideal scenario, both orthopaedic and plastic surgery teams would work in unison at all patient management stages: preoperative planning, intraoperative decision-making, and post-operative care and follow-up.⁵⁵ This approach in limb salvage can improve outcomes such as pain, function, and reduce length of hospital stay, post-operative complications and secondary procedures.56, 57, 58, 59, 60

5.3. Primary management

Initial assessment and management should follow life support principles for stabilising the patient's airway, breathing and circulation, before trying to save the limb.⁴⁹ Any external haemorrhage should be stopped by applying direct pressure, or applying a tourniquet as a final resort. Thereafter, it is vital to recognise any neurovascular injury early by performing thorough peripheral nerve and vascular examinations. A high degree of suspicion must be maintained for compartment syndrome, which is easy to miss in such acute situations.⁵⁰ The limb should then be cleared off gross contaminants, photographed for record, and sealed with sterile, saline dressing and adhesive film dressing.⁵⁰ If not already done, the limb should be aligned and splinted. There is no evidence that a washout in the emergency room is associated with reduced infection rates; on the contrary it has been suggested that it pushes debris deeper into the wound.⁵⁰ Two simple radiographs (x-rays) should be taken at an orthogonal view and include the ankle and knee joint for tibial fractures (Fig. 6). Adequate analgesia, antibiotic and tetanus prophylaxis should be administered, and the Orthopaedic and Plastic Surgery team informed as soon as possible.⁵⁰ All open fracture injuries are considered to be tetanus-prone, and tetanus prophylaxis should be administered as follows: in non-immunised individuals and in individuals with unknown immunisation status, a dose of the appropriate tetanus-containing vaccine should be administered immediately plus a dose of tetanus immunoglobulin at a different site; in individuals with incomplete primary immunisation a reinforcing dose plus a dose of tetanus immunoglobulins at a different site should be administered; and in fully immunised individuals (total of 5 doses of tetanus vaccine at suggested intervals) a tetanus vaccine is not required, but administration of tetanus immunoglobulin is needed if the wound is heavily contaminated.⁶¹

Fig. 6.

Fracture of the lower one third of the left tibia – (A) X-ray on admission; (B) Skeletal fixation using an intramedullary nail, post-operative x-ray.

5.4. Antibiotic prophylaxis

Prevention of infection is essential to avoid tragic complications such as amputation or even death. It is widely accepted that antibiotic prophylaxis can decrease infection rates in any type of injury. Similarly, in open fractures, antibiotics have been shown to reduce the incidence of early infections in the limbs.^62,63 There is still a universal lack of evidence on the optimal regimen, when it should be administered and for how long.^47,64

The latest standards suggested administering intravenous antibiotics within 3 h of injury.⁵⁰ However, the timing was later revised in BOAST-4 guidelines to administering antibiotics as soon as possible, and ideally within 1 h following injury.⁵⁴ This change is supported by a study reporting no infections in the group which received cefazolin prophylaxis within 66 min following injury, compared to a 17% rate of infection in those receiving antibiotics after 66 min.⁶⁵ These findings are further supported by a meta-analysis of randomised controlled trials, concluding that antibiotic prophylaxis reduces subsequent infection in patients with open fractures of the extremities.⁶⁶ In regards to duration, numerous primary studies and systematic reviews have demonstrated that antibiotic therapy past 24 h is not associated with a decrease in infection rate of open fractures.66, 67, 68, 69, 70

5.5. Debridement

Debridement is derived from the French word ‘débrider’ – to ‘unbridle’; in surgical terms ‘to release constrictions and tension in a wound by incision’.⁷¹ In modern surgery, it is better understood as to cleanse the wound by excising dead and devitalised tissue and removing foreign material. Gustilo and Anderson stated that ‘adequate debridement is the single most important factor in the attainment of a good result in the treatment of an open fracture’.¹⁸ This has been thereafter supported by several reviews and professional organisations.^47,49,50

It is recommended to initiate debridement by cleaning the wound with a soft brush using a soap solution to remove superficial particular debris.^50,72 Subsequently, the surgeon performs thorough soft tissue debridement and excision, removing all devitalised tissue, including necrotic bone fragments and muscle, and any foreign material (Fig. 7). This is done to reduce the risk of infection.⁴⁸ Necrotic muscle is assessed using the four C's: colour, contraction, consistency and capacity to bleed.⁷³ The use of a tourniquet should be minimised as it can have a catastrophic effect on subsequent tissue transfer.⁷⁴ However, in cases of multiplanar degloving, it can allow for identification of viable tissues or neurovascular structures in a bloodless field. Another major step of debridement is extending the wound along the nearest fasciotomy lines to allow for thorough soft tissue injury evaluation and easier delivery of the bone ends.⁵⁰ The tissues are then assessed systematically, from superficial to deep and from peripheral to central. This is followed by wound irrigation, classification of the fracture and careful Orthoplastic planning for definitive reconstruction.⁵⁰

Fig. 7.

High-energy Gustilo-Anderson Type II distal tibial fracture – (A) showing necrotic eschar pre-debridement; (B) healthy, vascularised soft tissue and bone post-debridement.

NICE performed a systematic review in April 2015 on the optimal timing of surgical debridement of open fractures.⁵³ Of the 9 included studies, only one suggested that early debridement results in a lower deep infection rate compared to delayed debridement; however, this study was for all open fractures.⁷⁵ One study on open tibial fractures only, demonstrated lower secondary amputation rates in fractures debrided within 24 h.⁷⁶ Schenker et al. performed a systematic review of the literature and meta-analysis on the effect of delayed surgical debridement on infectious complications in 3539 open long-bone fractures.⁷⁷ They reported that the data were inconclusive and could not indicate any association between delayed surgical debridement and rate of infection. Similar findings were reported by recent meta-analyses in 2016 and 2021, suggesting that there is no robust evidence on the effect of delayed debridement on infection and non-union rates in open tibial fractures.78, 137 Systematic reviews of open fractures of the hand and of paediatric open fractures, performed in 2016 and 2014, respectively, found no association between late surgical debridement and higher infection rates.^79,80 There is currently one registered Cochrane systematic review protocol aiming to assess the effects (risks and benefits) of timing of surgical interventions, including debridement, in the management of open long bone fractures.⁸¹ Current recommendations for the management of open fractures in the United Kingdom (UK), suggest immediate surgical debridement for highly contaminated and vascular-compromised wounds, or debridement within 12 h for high-energy and 24 h for low-energy open fractures.⁵⁰

5.6. Irrigation

Following tissue excision, it has been recommended to lavage the wound by low-pressure irrigation using large volumes of warm saline.⁵⁰ This practice has been extensively questioned by emerging evidence on the type, volume and flow of irrigation.^48,82 Several studies have demonstrated that high-pressure pulsatile lavage is superior at removing bacteria and debris compared to low-pressure.⁴⁸ On the contrary, numerous animal and experimental studies have suggested that high-pressure pulsatile lavage can have deleterious effects by causing tissue damage in the wound.⁸³ More recently, the FLOW (Fluid Lavage of Open Wounds) randomised controlled trial emerged, reporting similar wound complications, non-union and reoperation rates at various irrigation pressures.^84,85 Although the above findings seem to support the use of non-pulsatile low pressure flow irrigation for most open fractures, the surgeon should consider the extent of contamination and decide for each case independently.⁸³ In regard to the irrigating agent used, the main four types are: antiseptics, surfactants, antibiotics, and normal saline solution.⁸³ The lion's share of evidence supports the use of normal saline, which is less cytotoxic to the tissues, more effective at removing bacteria, and leads to a lower rate of reoperation.^83,86 Finally, it is common practice to use 3,6 and 9 L for Gustilo-Anderson Type I, II and III open fractures, respectively.^87,88 It seems that this 3-6-9 practice is related to the fact that normal saline solutions are widely available in 3L bags, rather than robust scientific data.⁷² Nevertheless, as a rule of thumb, larger or highly contaminated wounds require a larger volume of irrigating solution.

5.7. Temporary wound dressings

Following thorough surgical debridement and irrigation, the surgeon should cover the wound. If this is not possible immediately after debridement, then a temporary wound dressing can be used.⁵⁰ Negative pressure wound therapy in the form of Vacuum Assisted Closure™ (VAC™) (Fig. 8) has gained increasing popularity over the past two decades. They are superior compared to conventional wound dressings in reducing the risk of infection, non-union, flap necrosis and revision, and accelerating the wound healing process.^89,90

Fig. 8.

Negative pressure dressings in the form of VAC™.

Another method of reducing infection, is the use of antibiotic-impregnated cement beads covered by a semipermeable membrane to deliver high doses of antibiotic agents.^50,91 A randomised prospective study that compared antibiotic impregnated beads to intravenous antibiotics demonstrated higher infection rates in the former group, however, this was not statistically significant.⁹² On the contrary, a large retrospective study of 704 open fractures and a retrospective study of 78 fractures that compared systemic antibiotic prophylaxis to combined systemic and local antibiotic bead prophylaxis, both demonstrated statistically significant lower infection rates when a combination of the two prophylactic modalities was used.^93,94 One should note that antibiotic beads are not be used in combination with negative pressure dressings, as it has been demonstrated that their locally available concentration is reduced.^95,96

5.8. Soft tissue reconstruction

5.8.1. Timing of definitive soft tissue closure

A delay in soft tissue closure has been associated with increased rates of infection and non-union,^32,34,97, 98, 99, 100 and extended hospital stay.³² The current recommendation is to achieve definitive soft tissue closure or coverage within 72 h of injury, or if possible during surgical debridement.⁵⁰ If local or free flaps are going to be used, then coverage should ideally be performed during definitive bone fixation – the ‘fix and flap’ approach – which has been shown to reduce risk of infection and lead to good surgical outcomes.^101,102 Furthermore, regardless of the method of soft tissue reconstruction, if internal fixation is used, then coverage should be accomplished at the same time.⁵⁰

5.8.2. Types of definitive soft tissue reconstruction

In open fractures without vascular compromise, but which require a flap for coverage, local fasciocutaneous flaps are preferred, as they do not require microvascular anastomoses to be performed which carry additional risks of flap failure.^48,50 For open tibial fractures, gastrocnemius and propeller pedicled flaps are generally used for the upper one third; soleus and propeller pedicles flaps for the middle one third; and distally based sural and propeller flaps for the lower one third (Fig. 9).¹⁰³ Propeller pedicled flaps are ‘island flaps that reach the recipient site through an axial rotation of up to 180°’.¹⁰⁴ For larger defects accompanied by extensive degloving, free tissue transfer is preferentially used.¹⁰⁵ Although there is no robust evidence favouring muscle or fasciocutaneous flaps for free tissue transfer, experimental studies conclude that muscle is superior in larger defects.^50,106,107 However, with the increasing popularity of the use of the free anterolateral thigh flaps with some muscle (Fig. 10), this division is blurred.

Fig. 9.

Recommendations for use of flaps in definitive soft tissue closure of small and medium defects in the lower extremity.

Fig. 10.

Fasciocutaneous-muscle anterolateral thigh flap used in free tissue transfer for definitive wound coverage of a large defect in a Gustilo-Anderson type IIIC open tibial fracture.

5.9. Bone fixation

Definitive skeletal stabilisation is carried out as soon as possible after debridement, however, if not feasible, then spanning temporary external fixation is recommended.⁵⁰ Available surgical techniques of bone fixation include intramedullary nailing, external fixation, and plate-and-screw fixation. The choice of technique should be made based on the location and nature of the fracture, and the extent of soft-tissue injury.⁴⁹ External fixators offer rapid fracture stabilisation and limit further soft-tissue interference, however, when used as definitive treatment they often result in pin loosening, pin tract infection, and malunion (Fig. 11).¹⁰⁶ Intramedullary nailing (Fig. 6B) is associated with lower rates of superficial infection and malunion compared to external fixation techniques.^108,109 Intramedullary nailing is safe and effective, whereas both reamed and unreamed techniques have demonstrated a union rate of more than 95%.¹¹⁰ Studies comparing the two techniques found no significant differences in operative outcomes, but the reamed approach allows for the insertion of larger diameter nails which can offer increased stability.111, 112, 113 Intramedullary nailing seems to be superior to external fixation, however, circular frames are a favourable option in open tibial fractures with significant bone loss, contamination, or multilevel fracture pattern.^50,106 Finally, the use of plating is associated with an increased risk of infection and damage to periosteal blood supply.¹⁰⁶ It is mainly used as an adjunct to intramedullary nailing, providing additional stability during reaming or when inserting the nail.^114,115

Fig. 11.

Circular external fixators are used for definitive skeletal stabilisation of open bone fractures – (A) Fixator on an artificial bone model; (B) Post-operative x-ray of a lower open tibial fracture managed with external fixation.

6. Limb salvage versus primary amputation

Severe open tibial fractures with extensive soft tissue injury often call for a decision between limb salvage (reconstruction) or primary amputation. This decision should take into consideration several patient and injury factors, involve clinicians of different specialties (i.e. multidisciplinary team) and be in line with the wishes of the patient and their family.¹⁰⁶ Numerous predictive scoring systems have been developed to guide this verdict, including the mangled extremity severity score; the predictive salvage index; the limb salvage index; the nerve injury, ischemia, soft tissue injury, skeletal injury, shock and age of patient score; the Ganga hospital open injury score; and the Hannover fracture scale-97.⁵ However, several studies have demonstrated that these scoring systems cannot predict successful limb salvage.116, 117, 118

The BOA/BAPRAS recommendations are to proceed with a primary amputation in case of: avascular limbs exceeding a 4–6 h threshold of warm ischemia; or segmental muscle loss affecting more than two compartments; or segmental bone loss greater than one-third of the length of the tibia.⁵⁰

7. Outcomes following open tibial fracture injuries

7.1. Functional outcomes

In Orthopaedics, it is of paramount importance for the patient to regain function as soon as possible. This becomes particularly problematic in severe injuries, such as open fractures of the lower extremity. Functional outcomes can be estimated by the ability of the patient to perform specific activities.¹¹⁹ There are various self-reported patient questionnaires and scoring systems published in the literature, however, their extensive variability deems difficult to make an accurate comparison.⁴⁸ BOA/BAPRAS recommended the Enneking Score for scoring limb function and several measures for patient health status: the Study Short Form 36 Item Questionnaire (SF-36); the Sickness Impact Profile (SIP); and time to union.⁵⁰ A recent meta-analysis on severe open tibial shaft fractures treated with a circular frame, reported that this skeletal fixation method provides good functional outcomes in the majority of cases.¹¹⁹

7.2. Complications

7.2.1. Infection

Infection is one of the most common complications following open tibial fracture injuries.¹²⁰ Surgical debridement along with antibiotic prophylaxis are paramount in preventing this catastrophic complication.⁴⁸ The consequences of infection are well-known and widely accepted; not only do they significantly impact clinical outcomes, but also burden the healthcare service financially.⁷⁷ A retrospective, multicentre study of 2692 patients with open fractures has reported a 18.6% overall incidence of surgical site infection, with 1.6% being deep infection.¹²¹ Furthermore, they identified several risk factors associated with wound infection, including fracture type, increased operative duration (>122 min), increased anaesthesia time (>130 min), reduced intra-operative body temperature (<36.4 °C), high blood glucose (>100 mg/dL), low blood platelets (<288 × 10⁹), and high white blood cells (9.4 × 10⁹).¹²¹

There are no universal definitions for superficial and deep infection following open fracture injuries, however, these can be adjusted from the Centre's for Disease Control original definitions for surgical site infections.¹²² A superficial infection can be defined as any infection which involves the skin and subcutaneous tissue (Fig. 12, Fig. 13), and causes infectious signs including, but not limited to, purulent discharge, pain or tenderness, swelling, redness local heat or fever. A deep infection can be defined as any infection which involves the deep soft tissue or bone (Figs. 12 and 13), and causes infectious signs including, but not limited to, purulent discharge, pain or tenderness, swelling, redness local heat or fever. Positive microbiology cultures are not typically needed for diagnosis and infection can be confirmed by the attending surgeon.

Fig. 12.

Infections of the soft tissue following management of open tibial fractures – (A) Superficial infection; (B) Deep infection.

Fig. 13.

Schematic for differentiating between superficial and deep infection.

7.2.2. Non-union

Non-union is another detrimental complication of open fracture healing. It is associated with chronic pain, opiate and alcohol misuse, and subsequent unemployment and psychological problems.^123,124 The risk of bony delayed union, or non-union, is higher in open tibial fractures due to their close proximity to the skin and poor blood supply.¹²³ Injury risk factors for non-union include the severity of soft tissue damage, bone loss, degree of contamination and presence of compartment syndrome; while patient factors include age, sex, nutritional status, obesity, presence of comorbidities, smoking, diabetes and alcohol misuse.^48,125 Noteworthily, infection can contribute to bone necrosis and skeletal fixation failure, and inevitably predispose the bones to non-union.¹²⁶

Diagnosis of non-union is a challenge in Orthopaedics.¹²⁷ Definitions of tibial non-union vary in the literature, however, it is generally accepted that a diagnosis can be made when there is no evidence of progression of the healing process for 3 months or no healing after 9 months of the injury.^128,129 There are several radiographic scores for predicting non-unions which have shown substantial inter- and intra-observer reliability, however, further refinement is needed to produce systems that are robust and applicable to various fixation methods and bones.¹³⁰ In addition to plain radiographs, which can sometimes be poor predictors of non-union, computer tomography (CT) scans have demonstrated an 89.9% accuracy in detecting tibial non-union.¹²⁷ Once a non-union is established, the Non-Union Scoring System (NUSS) uses several risk factors and patient related factors to assess the severity of the non-union and guide treatment. It has been extensively used since its inception and has demonstrated good validity and reliability.131, 132, 133, 134

7.2.3. Other complications

The indications for primary amputation were described above, however, secondary amputation might also be performed in cases of ongoing post-operative complications, such as infection and non-union.⁴⁸ Although secondary amputation is an adverse outcome, long-term functional outcomes are not necessarily inferior to those of limb reconstruction.⁵⁰ Other considerable complications of open tibial fractures include regional pain syndrome and flap failure.^135,136

Confidentiality and consent for clinical photography

All clinical photography of cases included in this work is the courtesy of Barts Health NHS Trust, UK. All clinical photographs were captured in compliance with the Barts Health NHS Trust consent process and confidentiality protocol.

Funding

None.

Declaration of competing interest

None.