New scoring system predicting the occurrence of deep infection in open upper and lower extremity fractures: efficacy in retrospective re-scoring.

BACKGROUND: It is important to predict the occurrence of deep infection in open fractures when treating such fractures. We tried to develop a new scoring system for predicting the occurrence of deep infection in open upper and lower extremity fractures on the basis of the Hannover Fracture Scale'98 (HFS-98). METHODS: A total of 394 open upper and lower extremity fractures (351 patients) were retrospectively reviewed in the initial analysis. The relationship between Gustilo's grade and the eight items on HFS-98 in the open extremity fractures was first investigated by multivariate analysis. By this analysis, we selected significant items that correlated with Gustilo's grade. Among these cases, 318 patients with 352 open extremity fractures (humerus = 27, forearm = 62, femur = 76, tibia = 187) were used for the following infection analyses. The relationships between the incidence of deep infection and sex (male or female), age (<30, 30-50, <50 years), grade of polytrauma (ISS < 18, 18 < or = ISS < or = 30, ISS > 30), site of fracture (humerus, forearm, femur, tibia), existence of fracture line around joint (+ or -) or some significant items in the above initial analysis were further analyzed by multivariate analysis after univariate analysis. We devised a new scoring system of open extremity fractures based on P values in the above analysis. The discrimination of the newly devised scoring system was evaluated with receiver operating characteristic (ROC) curves. RESULTS: The following factors: muscle injury (MI, P = 0.0001); wound contamination (WC, P = 0.0001); and local circulation (LC, P = 0.0001) were significant factors affecting the occurrence of deep infection on multivariate analysis. We devised a new scoring system for open extremity fractures (MI: 0-20 points, WC: 0-20 points, and LC: 0-20 points). The cut-off point for occurrence of deep infection in these fractures was 35 by ROC analysis. CONCLUSIONS: This new scoring system was thought to be useful for predicting the occurrence of deep infection in open extremity fractures. However, further prospective study or multicenter study would be needed to clarify the validity of this scale.

Long-term functional outcome after unstable pelvic ring fracture.

PURPOSE: In patients with unstable pelvic ring fractures, the factors related to poor outcome are still controversial. The purpose of our study was to evaluate the long-term functional outcome of patients with unstable pelvic ring fractures and correlate it with various other factors. METHODS: Fifty-seven patients who had a minimal follow-up of 2 years completed the three-view plain radiographs, physical examination, and functional assessment with questionnaire. There were 28 male and 29 female patients with an average age of 42.4 years and Injury Severity Score of 24.6 points. The mean time of follow-up was 47.2 months. Thirty-nine patients were Tile type B, and 18 were type C. Twenty-three patients were treated conservatively, 22 with external fixation, and 12 with internal fixation. The results were scored with the Majeed score, the Iowa Pelvic Score, and the Medical Outcomes Study Short-Form 36-item Health Survey (SF-36). Statistical analysis was performed by use of the Pearson correlation coefficient test and multiple regression analysis. RESULTS: The average Majeed score was 79.7, the average IPS was 80.7, and the average physical component summary of the SF-36 was 13.4 points worse than that of the population norm. These scores correlate significantly with each other. The average residual displacement was 7.3 mm anteriorly and 5.2 mm posteriorly. Multiple regression analysis revealed that the Majeed score and the physical component summary of the SF-36 correlated with the presence of neurologic injury, and the Iowa Pelvic Score correlated with the presence of a mental disorder, posterior displacement, and neurologic injury. CONCLUSIONS: The long-term functional outcome after unstable pelvic ring fracture was not associated with Injury Severity Score, fracture location or fracture type. We discovered a close correlation between neurologic injury and functional outcome.

Segmental bony defect of the proximal phalanx in the great toe reconstructed by free vascularized bone graft from the supracondylar region of the femur: a case report.

We report the case of a 24-year-old man with a segmental bone defect of the proximal phalanx of the great toe that was successfully reconstructed by free vascularized bone graft (FVBG) from the supracondylar region of the femur after initial stabilization with external fixation and temporary antibiotic-impregnated bone cement. His functional outcome at 22 months follow-up was excellent. On the basis of this experience, FVBG from the supracondylar region of the femur can be used as an option for treating segmental bone defects of the great toe.

New scoring system predicting the occurrence of deep infection in open tibial fractures: preliminary report.

BACKGROUND: It is important to predict the occurrence of deep infection in open fractures when treating such fractures. We tried to develop a new scoring system for predicting the occurrence of deep infection in open tibial fractures on the basis of the Hannover Fracture Scale '98 (HFS-98). MATERIALS: A total of 202 open tibial fractures (195 patients) were retrospectively reviewed in the initial analysis. The relationship between Gustilo's grade and the eight items on the HFS in the open tibial fractures was first investigated by multivariate analysis. By this analysis, we selected significant items that correlated with Gustilo's grade. Among these cases, 179 patients with 185 open tibial fractures were used for the following infection analyses. The relationships between the incidence of deep infection and age (<46 years, 46-60 years, <60 years), grade of trauma (ISS <18, 18 < or = ISS < or = 30, ISS > 30), fracture location, or some significant items in the above initial analysis were further analyzed by multivariate analysis after univariate analysis. We devised a new scoring system of open tibial fractures based on p values in the above analysis. The discrimination of the newly devised scoring system was evaluated with receiver operating characteristic curves. RESULTS: The following were significant factors affecting the occurrence of deep infection on multivariate analysis: bone loss (p = 0.012); muscle injury (p = 0.012); wound contamination (p = 0.0001); and local circulation (p = 0.0001). We devised a new scoring system for open tibial fractures (bone loss: 0-20 points, muscle injury: 0-20 points, wound contamination: 0-30 points, and local circulation: 0-30 points). The cut-off point for occurrence of deep infection in these fractures was 60 by receiver operating characteristic analysis. CONCLUSIONS: This new scoring system was thought to be useful for predicting the occurrence of deep infection in open tibial fractures. However, further prospective study or extension of this scale for other open fractures would be needed.

Primary shortening with secondary limb lengthening for Gustilo IIIB open tibial fractures: a report of six cases.

BACKGROUND: The treatment of type IIIB open tibial fractures remains a challenge for orthopedic surgeons, particularly with respect to the soft-tissue and subsequent bony reconstruction. The primary shortening and limb lengthening (PSLL) simplifies wound closure for severe open injuries without requiring microsurgical procedures as a main advantage. This method is thought to be also useful for type IIIB patients with polytrauma and other life-threatening injuries because it helps to control both wound sepsis and their general state. In the present study, we attempted to assess the problems, long-term functional outcome, and quality of life (QOL) of patients who were treated by PSLL for Gustilo type IIIB open tibial fractures in our facility. METHODS: Six patients with type IIIB open tibial fractures treated with PSLL were retrospectively reviewed. The mean shortening length was 7.4 cm (range, 4.5-10.3 cm). The mean percent shortening of the entire bone was 18.7% (range, 12.3-29.7%). Limb lengthening started at a mean interval of 10.3 months (range, 3-18 months) after the original injury. The mean healing index was 56.5 days/cm (range, 31.3-86.7 days/cm). The complications, functional outcome, and quality of life were evaluated for all cases. RESULTS: One superficial infection at the initial corticotomy, one deep infection around the shortening site, one refracture at the healed docking site, several wire breaks in external frames in two cases, and two severe equinovarus deformities occurred as complications of these procedures. Regarding functional outcome, three patients showed good outcome, two showed fair outcome, and one showed poor outcome. The percent shortening of the entire bone in the two fair cases were more than 25%. The median scale of physical health summary, mental health summary, and total general health summary in Short Form-36 (QOL) were lower than the standard scale in age-matched individuals. CONCLUSION: This PSLL treatment was thought to be a useful option for severe open fracture of the tibia, which had bony defect in more than 4.5 cm in length after serial debridement, although several complications occurred in this regimen. However, it is difficult to achieve an excellent function and QOL using these techniques. In addition, it is difficult for patients who underwent limb lengthening after shortening more than 25% of the total length of bone to gain good function.

Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures.

BACKGROUND: Risk factors for deep infection in secondary intramedullary nailing (IMN) after external fixation (EF) for open tibial fractures were investigated by multivariate analysis following univariate analyses. METHODS: Forty-two open tibial fractures were treated with secondary IMN after EF. The open tibial fractures were classified according to the criteria proposed by Gustilo et al.: type II, 11; type IIIA, 8; type IIIB, 22 and type IIIC, 1. Locked IMNs with limited reaming were performed in 27 patients, and locked IMNs without reaming in 15 patients. The following factors contributing to deep infection were selected for analysis: age, gender, Gustilo type (II or III), fracture grade by AO type (A or B+C), fracture site, existence of multiple trauma (Injury Severity Score, ISS<18 or ISS> or = 18), existence of floating knee injury, debridement time (< or = 6 h or > 6 h), reamed (R) versus unreamed (UR) nailing, duration of external fixation (< or = 3 weeks or >3 weeks), interval between removal of EF and IMN (< or = 2 weeks or >2 weeks), skin closure time (< or = 1 week or >1 week), existence of superficial infection (+ or -) and existence of pin tract infection (+ or -). The relationship between deep infection and the above factors was evaluated by univariate analyses. RESULTS: Seven (16.7%) of the 42 open tibia fractures developed deep infections. All deep infections occurred in Gustilo type III (22.6%, 7/31). Only the skin closure time was a significant factor affecting the occurrence of deep infection on the present analysis (p = 0.006). CONCLUSION: The present evaluation showed that early skin closure within 1 week is the most important factor in preventing deep infections when treating open tibial fractures with secondary IMN after EF.

Early unreamed intramedullary nailing without a safety interval and simultaneous flap coverage following external fixation in type IIIB open tibial fractures: a report of four successful cases.

The conversion method from external fixation (EF) to intramedullary nailing (IMN) for open tibia fractures, especially to Gustilo type IIIB open tibia fractures, have potentially high risk of infections. We document a report of a more progressive approach in four consecutive cases of type IIIB open tibial fractures successfully managed with early unreamed IMN without a safety interval and simultaneous flap coverage following EF. The mean patients age at the time of injury was 43.8 years (range 23-64 years), and three patients were male. The timing from EF to IMN without safety interval combined with well-vascularised flap (free latissimus dorsi flaps in two patients and pedicled soleus flaps in two patients) ranged 48 to 72 hours. Average time to union was 14 months (range 9-21 months). There was one nonunion patient whose fracture healing was gained by reamed IMN without bone grafting. However, there were no infections. The functions in all patients were satisfactory. This early unreamed IMN without a safety interval and with simultaneous flap coverage following EF is a useful and effective option for treating type IIIB open tibial fractures.

Functional outcome and quality of life of Gustilo IIIB open tibial fractures requiring free tissue transfers: a report of eight cases.

Eight patients with type IIIB open tibial fractures requiring free tissue transfers were retrospectively reviewed. The functional outcome was evaluated by using a scoring system developed by Puno et al. (Microsurgery 17:167-173, 1996). Short Form 36 (SF-36) was used as a measurement of individuals' quality-of-life (QOL) scores. The average total score of all cases was 77.6. An excellent or good functional outcome was achieved in 37.5% (3/8). Six patients were evaluated by SF-36. The average physical health summary (T-PH) score was 47.9, the average mental health summary (T-MH) score was 53.5, and the average total general health summary (T-GH) score was 50.7. The mean T-MH score was significantly higher than the mean T-PH score (P < 0.05). Treated cases showed an acceptable QOL, considering the results of the T-GH. The mental QOL was higher than the physical QOL. In severe open tibial fractures, it is difficult to obtain a good or excellent functional outcome, even with reconstruction using free tissue transfers.

Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis.

The purpose of this study was to use multivariate analysis to evaluate contributing factors affecting deep infection and nonunion of open femoral fractures treated with locked intramedullary nailing (IMN). We examined 89 open femoral fractures (88 patients) treated with immediate or delayed locked IMN in static fashion at the Kitasato University Hospital from 1988 to 2001. Multiple regression models were derived to determine predictors of deep infection and nonunion. The following predictive variables of deep infection were selected for analysis: age, sex, Gustilo type (I+II or III), fracture grade by AO type (A or B+C), fracture site (proximal site+distal site or middle site), timing or method of IMN, reamed or unreamed nailing (R versus UR), debridement time (< or =6 h or >6 h), existence of polytrauma (ISS<18 or ISS> or =18), and existence of floating knee injury (+ or -). The predictive variables of nonunion selected for analysis were the same as those for deep infection, with the addition of deep infection (+ or -). Five fractures (5.6%) developed deep infections: one Gustilo type II and four type III. Multivariate analysis revealed that only Gustilo type significantly correlated with occurrence of deep infection (p<0.05). Nonunion occurred in 12 fractures (14.1%). Multivariate analysis revealed that only fracture grade by AO type significantly correlated with occurrence of nonunion (p<0.02).

Tibial fractures associated with crush injuries to the soft tissues of the dorsal foot in children.

We retrospectively studied 15 children with tibial fractures associated with crush injuries to the soft tissues of the dorsal foot. The fractures, including six open fractures, were united with no complications within an average of 11.1 weeks. Wound closure to treat crush injuries of the dorsal foot was achieved using split- or full-thickness skin grafts in most patients. The outcomes of these grafts were acceptable, and all skin coverage was successful and remained viable with no breakdown. Extensor tendon injuries of the foot sustained by eight patients could not be sutured or repaired due to the nature of the injuries. However, the functional abilities of those injured tendons that could be sutured to surrounding tissues in a neutral position were acceptable, even though two patients had contracture of the toes that was problematic when wearing shoes. To manage crush skin injuries of the dorsal foot, split- or full-thickness skin grafts appear to provide a simple and convenient treatment strategy. In cases associated with extensor tendon injuries, suturing damaged extensor tendons to surrounding tissues represents another useful strategy with acceptable outcomes.