External fixation in open tibial fractures best evidence

EXTERNAL FIXATION IN OPEN TIBIAL FRACTURES-BEST EVIDENCE

Hitesh Gopalan UClinical Asst Professorwww.orthoevidence.comwww.orthopaedicprinciples.com

Extensive Research

Reamed Vs Unreamed External Fixation Vs Nailing Ex Fix followed by Delayed Nailing

SPRINT trial, Tornetta et al.,, Bhandari et al., Petrisor et al., Schemitsch et al., Swiontkowski et al..Giannoudis et al..

External Fixation

3B Bone loss Extensive periosteal stripping Contamination Delayed Presentation

Meta analysis 5 Randomised control trials comparing Ex Fix Vs

Nailing

Ex Fix Vs Nailing: no difference in deep infection rates

The no of patients with type 3B injuries was low(eg., SPRINT Trial)

Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH: Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br 2001;83:62-68 LEVEL 2.

High Quality RCT

Need for a high quality RCT that compares nailing Vs external fixation in 3B fractures

Infection after IM nailing Catastrophe

Multiple Surgeries

Prolonged treatment

Circular Fixator

Grading of Complications

Reoperation Dynamisation Bone Grafting Pin tract infections Treatment for an infected IM nail

Ciery and Mader

External Fixation

Deep infection rates: 4-6%

Loss of alignment

Pin Tract Infections

Union rates are similar with Nailing Vs Ex Fix

Giannoudis PV, Papakostidis C, Roberts C: A review of the management of open fractures of the tibia and femur. J Bone Joint Surg Br 2006;88:281-289. LEVEL -3

Surgeon Choice

Surgeons across North America

Surgeons across India

Delayed Conversion Loss of alignment

Shorter Duration of Ex fix

Safe Interval(10-14 days)

Bhandari M, Zlowodzki M, Tornetta P III, Schmidt A, Templeman DC: Intramedullary nailing following external fixation in femoral and tibial shaft fractures. J Orthop Trauma 2005;19:140-144.

LEVEL- 2

Reamed nailing Vs Ex Fix

Experimental data on thermal necrosis(Schemitsch et al..)

Inflammatory mediator release(Il-6 and HLA DR release)- correlates well with sepsis

Schemitsch EH, Kowalski MJ, Swiontkowski MF, Senft D: Cortical bone blood flow in reamed and unreamed locked intramedullary nailing: A fractured tibia model in sheep.

J Orthop Trauma 1994;8:373-382

Bone Loss

Delayed Presentation

Delays in Debridement

Delays in Antibiotic administration

External fixation: repeat debridements

Infection

External fixator

Antibiotic loaded cement

Conversion to a Ring fixator

Infection after IM nail

Removal of IM Nail

ALBC

Ring fixator: Excision and Bone transport

Evidence Cycle

Ask

Acquire

AppraiseApply

Act

“EBM Begins and Ends with the Patient”

Thank You