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Abstract

Original Article Journal of Bone and Joint Diseases| Jan-April 2020 | 35(1): 29-34

© 2020 by Journal of Bone and Joint Diseases | Available on www.jbjdonline.com | DOI- 10.13107/jbjd.2020.v35i01.008 This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which

permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

IntroductionIncidence of fractures of long bones is increasing day by day due to increased road traffic accidents and other domestic accidents. The shaft of the tibia is one of the most common sites of an open fracture as one third of its surface is subcutaneous [1, 2]. Open fractures of the tibia are associated massive soft tissue injury and bone loss with high rates of infection and non union resulting in poor treatment outcome [1, 2]. The treatment goals include prevention of infection, soft tissue coverage and fracture stabilization leading to union with simultaneous mobilisation of nearby joints enabling early return to function [3, 4]. The specific method of skeletal fixation and soft tissue management in open fractures continues to be a topic of debate in orthopaedic traumatology

with the treatment options ranging from external fixators, Ilizarov fixators, nailing, plating, tibial synostosis, free or vascularized bone grafting along with allografts or bone substitutes, all having their own set of complications [1, 3, 4, 5]. Treatment protocol of compound fractures involves thorough initial debridement and external fixation followed by closure of the wound either by flap rotation or skin grafting. Then intramedullary interlocking nailing or plating with or without bone grafting is done as a secondary procedure [6] .The disadvantages of this technique are higher incidence of infection than closed fractures treated with intramedullary nailing alone; need for several operative procedures, longer period of hospitalization and increased economic burden to the already poor patients [7, 8, 9]. Stabilization of compound

1Department of Orthopedics, K. D. Medical College, Hospital & Research Center, Mathura, U.P, India2Department of Orthopedics, Uttar Pradesh University of Medical Sciences Saifai, Etawah, U.P, India

Address of Correspondence:Dr. Pulkesh Singh,Kanti Devi Medical College, Hospital & Research Center, NH-2, Post Akbarpur, Chhatta, Mathura, U.P, IndiaE-mail: [email protected]

Dr. Pulkesh Singh Dr. Santosh Kumar Singh

Background: Surgical management of compound fractures of tibia either or without bone loss are full of complications. These injuries are complicated both for patient and the treating surgeon. Many operative procedures are needed for treating such patients. Along with providing a stable fixation it employs the principal of distraction osteogenesis to fill the bone gap. It is a less invasive surgery with minimal blood loss. Immediate weight bearing prevents disuse osteoporosis and muscle atrophy with consequent preservation of limb function. There is no need of bone grafting. Compared to ilizarov this construct is less bulky, it is easier to apply, post op dressing is easier and it is less cumbersome for the patient. Hence LRS fixator can be used as a good treatment option in such patients. This study was conducted to analyze the efficacy, functional and radiological outcome of Limb Reconstruction System (LRS) in management of open fractures of tibia with or without bone loss as a primary and definitive tool.Methods: We treated 20 patients with compound injuries of tibia between December 2014 and November 2018 with Limb Reconstruction System (LRS) as a primary and definitive tool. 15 males & 05 females were included in this study with age ranging from 20 – 50 years. All the patients had compound fractures of tibia (except Type III C) with or without bone loss.Results: Average follow up period was 36.45±4.7 weeks ranging from 06 – 18 months. There was sound bony union in all of the cases with resolution of infection. The mean time of full weight bearing was 10.45±2.25 weeks and bone union time was 23.26±6.33 weeks. ASAMI score (Association for the Study and Application of the Method of Ilizarov) for bony outcome was Excellent in 13 (65%) patients, Good in 5 (25%) patients, Fair in 1 (5%) patient and Poor in 1 (5%) patient. ASAMI score for functional outcome was Excellent in 14 (70%) patients, Good in 4 (20%) patients, Fair in 1 (5%) patient and Poor in 1 (5%) patient. Rail external fixator was sufficient enough for wound healing & bony union.Conclusion: Limb Reconstruction System (LRS) offers an alternative option to treat compound fractures of tibia because of simplicity of application, its good fracture stability, adjustable geometry, light weight, affordable cost, patient friendly and can induce/enhance fracture healing by compression and distraction osteogenesis.Keywords: Limb Reconstruction System (LRS), Compound Fractures, Ilizarov.

1 2 2Pulkesh Singh , Santosh Kumar Singh , Simrat Pal Singh Gill

Management of Compound fractures of tibia by Limb Reconstruction System (LRS)

29| | | | | Journal of Bone and Joint Diseases Volume 35 Issue 1 Jan-April 2020 Page 29-34

Dr. Simrat Pal Singh Gill

fractures of tibia by external fixators promotes soft tissue healing, preserves the bone vascularity, accessibility to wound and causes less blood loss [8, 9]. Traditionally complex nonunions and open fractures are managed by the Ilizarov ring fixators but it is heavy and complicated to manage, both for the surgeon and the patient [10].Limb Reconstructive System (LRS) is a modular unilateral frame consisting of Shanz pins, rail rods and sliding clamps [11, 12]. It is simple, effective, adjustable, light weight and offers rigid stabilization of fracture fragments along with access to wound dressing [11, 12]. The management of open fractures with the LRS fixator allows immediate functional stabilization of fractures,

weight bearing and axial f r a c t u r e s i t e m o v e m e n t promoting an early callus response and fracture union [13, 14]. It can induce and enhance fracture healing by compression and distraction osteogenesis as well as bone transport can also be done easily in cases of bone loss [15, 16]. Our aim was to use external fixation as primary a n d d e f i n i t i v e l i n e o f m a n a g e m e n t f o r o p e n fractures of long bones of the lower limb and return the patient to full function as soon as possible thus avoiding the need to undergo several operative procedures and economic burden on the poor p a t i e n t s . T h i s s t u d y investigated the role of external fixation by Limb reconstruction system (LRS)

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“n” Percentage

20 – 30 6 30%

31 – 40 7 35%

41 – 50 7 35%

Male 15 75%

Female 5 25%

RTA 16 80%

Gunshot Injury 4 20%

I 2 10%

II 7 35%

III A 8 40%

III B 3 15%

< 12 hrs 0 0

12 – 24 hrs 14 70%

> 24 hrs 6 30%

Characteristics

Gender

Mode of Injury

Time to Surgery

Table 1: Patient variables

Age

(Mean = 35.5 yrs)

Type of Fracture

(Gustilo Anderson

Classification)

Mean

Time of Full weight

bearing10.45±2.25 weeks

Time for Union 23.26±6.33 weeks

Follow up Period 36.45±4.7 weeks

Amount of bone

transport3.5 cm

Secondary soft tissue

procedures3 (15%) Patients

Table 2: Outcome measures

Preoperative X-ray 1 month followup

Final union Post operative X-ray

2 month followup

4 month followup 6 month followup

fixator on the principles of ilizarov techniques in the management of open tibia fractures with well supervised follow up.

Material and MethodsWe performed this prospective study to analyze the efficacy, functional and radiological outcome of Limb Reconstruction System (LRS) in management of open fractures of tibia with or without bone loss as a primary and definitive tool. The 20 patients for the study were selected from the patients attending the outpatient and emergency department of a tertiary care centre in North India from December 2014 to November 2018. Clearance from the institutional ethical committee was taken.

Inclusion criteria:1. Age between 20 – 50 years2. Patients with compound fractures tibia type I, II, IIIA and III B.3. Patients willing to give written informed consent

Exclusion criteria:1. Patients with closed fractures.2. Patients with compound type III C fractures.3. Pathological fractures4. Those with inability to walk (recumbent position).5. Very poor anaesthetic and general risk patients.

Each patient was subjected to thorough clinical and radiological examination along with routine pathological investigations to rule out associated injuries and other co morbid conditions. Prophylactic administration of cephalosporins along with aminoglycosides, tetanus toxoid and tetanus immunoglobulins was done to combat infection [17]. Once the patients were haemodynamically stabilized; primary wound debridement and thorough lavage with copious amount of normal saline was done. Primary splintage of the fracture was done by either Plaster of Paris slab or Bohler Braun Splint. Open fractures were classified according to Gustilo Anderson’s classification as Type I, II, III with further classification of type III into three groups as III A, III B and III C [ 18].After anaesthetic fitness Limb reconstructive system was applied under spinal anesthesia and image intensifier in the supine position away from the site of wound preferably on the anteromedial surface of tibia such as to leave enough area for the intended soft tissue procedure if required. Surgical debridement with removal of all dead necrotic tissues and free loose bone pieces was done simultaneously. Acute docking was done in case of transverse and oblique fractures while it was used just as a neutralisation device in case of comminuted and segmental fractures. Corticotomy was done at the metaphyseal region with the intention of bone transport in cases of bone loss. Wound management involved regular dressing, delayed primary closure, secondary closure, flap rotations and split skin grafting. In some cases wound was left to heal by secondary intention. Post-operatively I/V antibiotics and analgesics were given till the wound became healthy and then oral antibiotics were given. Quadriceps drill, hamstring exercises and range of motion exercises of knee and ankle were encouraged from the second postoperative day in all the cases. Immediate weight bearing was advised in cases of fractures without bone loss and according to fracture anatomy. In cases of bone loss; bone transport was started 2 weeks after corticotomy at the rate of 0.25 mm four times a day with the help of compression distraction unit resulting in a total bone transport of 1 mm/day. The same was taught to the patient. This bone transport was continued till the fracture end approximated. Then distraction was stopped and dynamization of the LRS system done, which was followed by weight bearing mobilization by the patient as per his tolerance. Full weight with help of walker was started once there were clinical and radiological signs of union. Follow up was done at regular intervals of one month for first six months and then at 3 monthly intervals till the union was achieved clinically and radiologically.Clinical assessment included (a) Presence or absence of pain (b) Joint stiffness (c) Limb length discrepancy (d) Deformity



“n” Percentage

Pin tract infection 4 20%

Pin loosening 3 15%

Joint stiffness 3 15%

Delayed union 2 10%

Non union 1 5%

Shortening > 2 cm 0 0

Chronic osteomyelitis 0 0

Table 3: Complications

Bony outcome “n” Percentage

Excellent 13 65%

Good 5 25%

Fair 1 5%

poor 1 5%

Functional outcome

Excellent 14 70%

Good 4 20%

Fair 1 5%

Poor 1 5%

Table 4: Bony and Functional results as per ASAMI

Score

(e) Gait and Weight bearing (f) Shortening (g) Status of wound (h) Signs of osteomyelitis (i) Pin loosesing. Radiological assessment was based on (a) Union at fracture site (b) Signs of osteomyelitis (c) Loosening of pins (d) Quality of bone in cases of bone transport. Final assessment for bone results and functional results were done using ASAMI score (Association for the Study and Application of the Method of Ilizarov).

Results In the present study 20 cases of compound fractures of tibia were treated by Limb reconstructive system as a definitive form of treatment. Epidemiological, clinical and functional evaluation of these patients was done with emphasis on rehabilitative outcomes and complications. There were 15 male (75%) and 5 (25%) female patients ranging from 20 – 50 years of age with mean age of 35.5 years (Table 1). Higher incidence of compound fractures in male is due to their more active outdoor working. Road traffic accidents (80%) were the most common mode of injury followed by gunshot injury (20%). These fractures are usually related to high energy trauma associated with road traffic accidents. In our series duration between injury and operation was between 12–24 hours in 14 (70%) cases and > 24 hours in 6 (30%) cases (Table 1). The delay in operation was due to either late reporting to the hospital or because of other associated injuries or medical problem.Among the 20 patients 2 (10%) had Grade I Compound fracture, 7 (35%) had Grade II fracture, 8 (40%) had Grade III A fracture and 3 (15%) had Grade III B fracture (Table 1). In 12 (60%) patients right leg was injured while 8 (40%) patient had left leg involvement. In 16 (80%) cases operation time was 45 minutes while in the rest 4 (20%) cases duration of surgery was about 1 hour due to difficulty in achieving proper reduction and placement of implant.Partial weight bearing with walker was allowed in 15 (75%) cases on 3rd-4th post operative day. Partial weight bearing could not be done in 5 (25%) cases because of severely communition, other fracture in same limb or in contralateral limb. Satisfactory fracture union occurred in all the cases in 4 – 7 months after which full weight bearing was allowed. The mean time of full weight bearing was 10.45±2.25 weeks and bone union time was 23.26±6.33 weeks (Table 2). 3 patients with type III A fracture and 2 patients of type III B fracture with bone loss required corticotomy and bone transport, which was done at the rate of 0.25mm four times a day each day based on the principles of distraction osteogenesis. Average bone loss in these 5 patients was 3.5 cm. Acute docking of fracture fragments was done in rest 15 cases.The postoperative hospital stay in our series was less than 10

days in 17 (85%) cases. Hospital stay extended for more than 10 day in 3 (15%) cases requiring soft tissue procedures. Adequate soft tissue coverage was done with split skin grafts for 2 and local flaps for 1 patient after 3-4 weeks and took up well. All the primarily and secondarily sutured wounds healed well. Out of total 20 patients, 2 patients (10%) were followed for 6 months. 10 patients (50%) for 6 to 12 month. 8 patients (40%) for 12 to 18 months. The average follow up period was 36.45±4.7 weeks ranging from 06–18 months (Table 2).In our study pin tract infection was found in 04 (20%) cases which healed by pin tract dressing. Delayed union was observed 02 (10%) cases (Table 3). Joint (knee or ankle) stiffness was observed in 03 (15%) cases. Loosening of pin was observed in 03 (15%) cases. Shortening and chronic osteomyelitis were not observed in any of the cases (Table 3). One of the patients of type III B fracture ended up with infected non union. This patient was treated by debridement, sequestrectromy and refixation with LRS fixator. Corticotomy and bone transport was done to replace the excised portion of the bone.ASAMI score (Association for the Study and Application of the Method of Ilizarov) for bony outcome was Excellent in 13 (65%) patients, Good in 5 (25%) patients, Fair in 1 (5%) patient and Poor in 1 (5%) patient (Table 4). ASAMI score for functional outcome was Excellent in 14 (70%) patients, Good in 4 (20%) patients, Fair in 1 (5%) patient and Poor in 1 (5%) patient (Table 4).Discussion This study attempted to evaluate the results of LRS external fixation in open fractures of tibia as a definitive form of treatment in terms of fracture union and early functional rehabilitation without the use of several operative procedures. LRS fixator provides easy accessibility for the management of soft tissue injuries and early bony and soft tissue reconstruction significantly reducing the risk of infection, non union and amputation [19].In our study the mean age group of the patients in was 35.5 years with males accounting to 75% cases. This was in accordance with the study conducted by Thakur et al in 79 patients with mean age group of 38 years in males predominanance (83.5%) [20]. Present study is also comparable to Mehtab et al [22], Beltsios et al [22] and Shikari et al [23] where mean age were 34.75 years, 36 years and 35.5 years respectively.n this study, road traffic accidents were the major cause of injury in 80% patients. While in the study conducted by Adrover et al [24], road traffic accident was the major cause of injury in 81.9% of patients where as in Thakur et al [20] series, 87.3% of patients with open fractures were caused by road traffic accidents.





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References

In our study 7 (35%) patients had Grade II fracture and 8 (40%) patients had Grade III A fractures. It is comparable to study by Tekan et al [25] and Fredrico Neto et al [26] where maximum patients were also of type IIIA.The mean bone union time in our study was 23.26±6.33 weeks which is comparable to studies by Ajmera et al [27], Thakur et al [20], Chandraprakash et al [28] where mean bony union time was 24 weeks, 20 weeks and 22 weeks respectively. In our study the mean bone transport was 3.5 cm which is less compared to the other series like Robert et al (6 cm) [29], Sen et al (5 cm) [30], Mekhail et al (5.7 cm) [31].Results of bony and functional outcomes assessed by ASAMI score in our study were comparable to studies by Ajmera et al [27], Patil et al [32] and Pal et al [28]where they found excellent results in 76%,67% and 68.75% respectively; good results in 12%, 25% and 18.75% respectively; fair result in 4%, 4% and 10% respectively; poor results in 8%, 4% and 2.5% respectively. In our study bony outcome was Excellent in 65% patients, Good in 25% patients, Fair in 5% patient and Poor in 5% patients. Functional results were also comparable with the above studies.Illizarov remains the gold standard treatment in such type of

fractures but our study shows the effectiveness of LRS also in these fractures with bone loss to achieve union and limb length simultaneously. The method of application of this monolateral fixator is simple with better patient compliance as compared to Ilizarov [33].

ConclusionLimb reconstruction system is a simple and easy system which can be used for all open fractures. Fixation with LRS is a single definitive surgery allowing early mobilization and full weight bearing. It is a cost-effective mode of treatment. It is a simple technique with short learning curve compared to Illizarov ring fixator. Patient compliance is excellent. It can also be used for bone lengthening/transportation, deformity correction, in patients with infective non-union and osteomyelitis. Implant can be reused which brings down the cost of surgery considerably.



Conflict of Interest: Nil. Source of Support: None

How to Cite this ArticleSingh P, Singh S K, Gill S P S. Management of Compound fractures of tibia by Limb |

Reconstruction System (LRS) Journal of Bone and Joint Diseases Jan-April 2020; | |

35(1): 29-34.

18. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of TypeIII open fractures. New classification of Type III open fractures. J Trauma 1984;24:742.

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20. Thakur AJ, Patankar J. Open tibial fractures. Treatment by uniplanar external fixation and early bone grafting. J Bone Joint Surg.1991;73(3):448-51.

21. Piwani M, Bhutto IA, Ahmed I. Evaluation of AO external fixator in the management of open diaphysial fracture of tibia gustilo type IIIA and IIIB. Gomal J Med Sci. 2015;13(1):66-9.

22. Beltsios M, Savvidou O, Kovanis J, Alexandropoulos P, Papagelopoulos P. External fixation as a primary and definitive treatment for tibial diaphyseal fractures Strategies Trauma Limb Reconstr. 2009;4(2):81–7.

23. Shikari A, Wani A, Padha K, Bhatti M, Dang H. Fixation Of Compound Fractures Of Distal Tibia Using A Delta External Fixator As A Definite Modality Of Treatment With Or Without Fibular Plating/ Limited Internal Fixation With K- Wires. Int J Orthopedic Surg. 2010;18(2):1-7.

24. Antich-Adrover P, Marti Garin D, Maurias-Alvarez J, Puente-Alfonso C. External fixation and secondary intramedullary nailing of open tibial fracture-A randomized prospective trial. JBJS. 1997;79(3):433-7.

25. Tekin AC, Saygılı MS, Adaş M, Çabuk H, Arslan SM, Dedeoğlu SS, et al. Outcome of type 3 open tibial diaphyseal fractures managed with a Limb reconstruction system: analysis of a 49- patient cohort.

Med Princ Pract. 2016;25:270-5. 26. Neto FCJ, Canal MP, Alves BAF, Ferreira PM, Ayres JC, Alves R.

Analysis of the characteristics of patients with open tibial fractures of Gustilo and Anderson type III. Rev Bras Ortop. 2016;51(2):143-9.

27. Ajmera A, Verma A, Agrawal M, Jain S, Mukherjee A. Outcome of limb reconstruction system in open tibial diaphyseal fractures. Indian J Orthop.2015;49(4):429-35.

28. Chandra Prakash Pal et al. Comparative study of the results of compound tibial shaft fractures treated by Ilizarov ring fixators and limb reconstruction system fixators. Chinese J Traumatol. 2015;18:347-51.

29. Robert Rozbruch S, Weitzman AM, Tracey Watson J, Freudigman P, Katz HV, Ilizarov S. Simultaneous treatment of tibial bone and soft-tissue defects with the Ilizarov method. J Orthop Trauma. 2006;20:197–205. [PubMed: 16648701]

30. Sen C, Kocaoglu M, Eralp L, Gulsen M, Cinar M. Bifocal compression-distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: A report of 24 cases. J Orthop Trauma. 2004;18:150–7. [PubMed: 15091269]

31. Mekhail AO, Abraham E, Gruber B, Gonzalez M. Bone transport in the management of posttraumatic bone defects in the lower extremity. J Trauma. 2004;56:368–78. [PubMed: 14960982]

32. Patil M. Definitive Management of Open Tibia Fractures Using Limb Reconstruction System. J Clin Diagnos Res. 2016;10(7):1-4.

33. El-Rosasy MA. Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia. J Bone Joint Surg Br 2007; 89:80-8

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8 Article 1025 JBJD 2020jbjdonline.com/wp-content/uploads/2020/01/8-Article_1025_JBJD-20… · 08/01/2020 · Then intramedullary interlocking nailing or plating with or ... management