Upload
orthoprinciples
View
570
Download
3
Embed Size (px)
DESCRIPTION
Citation preview
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