Safety evaluation of secondary conversion from external fixation to internal fixation for open tibia fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

LIU Xi ,  CEN Shiqiang , XIANG Zhou , ZHONG Gang , YI Min , FANG Yue , LIU Lei , HUANG Fuguo

Department of Othopedics, West China Hospital, Sichuan University, Chengdu Sichuan, 610041, P.R.China;

Corresponding author：

CEN Shiqiang, Email: ahsir7201@126.com

Keywords：

Open tibial fracture; infection; erythrocyte sedimentation rate; C reactive protein; external fixator; internal fixation

DOI：

10.7507/1002-1892.201611127

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Objective To evaluate the safety of conversion from external fixation to internal fixation for open tibia fractures. Methods Between January 2010 and December 2014, 94 patients (98 limbs) with open tibia fractures were initially treated with external fixators at the first stage, and the clinical data were retrospectively analyzed. In 29 cases (31 limbs), the external fixators were changed to internal fixation for discomfort, pin tract response, Schantz pin loosening, delayed union or non-union after complete wound healing and normal or close to normal levels of erythrocyte sedimentation rate (ESR), C reactive protein (CRP), and the leucocyte count as well as the neutrophil ratio (trial group); in 65 cases (67 limbs), the external fixators were used as the ultimate treatment in the control group. There was no significant difference in gender, age, side of the limbs, interval from injury to the first debridement, initial pathogenic bacteria, the limbs that skin grafting or flap transferring for skin and soft tissue defect between the two groups ( P>0.05). The incidence of Gustilo type III fractures in the control group was significantly higher than that in the trial group (P=0.000). The overall incidence of infection was calculated respectively in the two groups. The incidence of infection according to different fracture types and whether skin grafting or flap transferring was compared between the two groups. The information of the pathogenic bacteria was recorded in the infected patients, and it was compared with the results of the initial culture. The incidence of infection in the patients of the trial group using different internal fixation instruments was recorded. Results The overall incidences of infection for the trial and control groups were 9.7% (3/31) and 9.0% (6/67) respectively, showing no significant difference (χ²=0.013, P=0.909). No infection occurred in Gustilo type I and type II patients. The incidence of infection for Gustilo type IIIA patients in the trial group and the control group were 14.3% (1/7) and 6.3% (2/32) respectively, showing no significant difference (χ²=0.509, P=0.476); the incidence of infection for type IIIB patients in the two groups were 50.0% (2/4) and 14.3% (2/14) respectively, showing no significant difference (χ²=2.168, P=0.141); and the incidence of infection for type IIIC patients in the two groups were 0 and 16.7% (2/12) respectively, showing no significant difference (χ²=0.361, P=0.548). Of all the infected limbs, only 1 limb in the trial group had the same Staphylococcus Aureus as the result of the initial culture. In the patients who underwent skin grafting or flap transferring, the incidence of infection in the trial and control groups were 33.3% (2/6) and 13.3% (2/15) respectively, showing no significant difference (χ²=1.059, P=0.303). After conversion to internal fixation, no infection occurred in the cases that fixed with nails (11 limbs), and infection occurred in 4 of 20 limbs that fixed with plates, with an incidence of infection of 20%. Conclusion Conversion from external fixation to internal fixation for open tibia fractures is safe in most cases. However, for open tibia fractures with extensive and severe soft tissue injury, especially Gustilo type III patients who achieved wound heal after flap transfer or skin grafting, the choice of secondary conversion to internal fixation should carried out cautiously. Careful pre-operative evaluation of soft tissue status, cautious choice of fixation instrument and meticulous intra-operative soft tissue protection are essential for its safety.

Citation： LIU Xi, CEN Shiqiang, XIANG Zhou, ZHONG Gang, YI Min, FANG Yue, LIU Lei, HUANG Fuguo. Safety evaluation of secondary conversion from external fixation to internal fixation for open tibia fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2017, 31(6): 665-669. doi: 10.7507/1002-1892.201611127 Copy

1.	Ktistakis I, Giannoudi M, Giannoudis PV. Infection rates after open tibial fractures: are they decreasing? Injury, 2014, 45(7): 1025-1027.
2.	Xu X, Li X, Liu L, et al. A meta-analysis of external fixator versus intramedullary nails for open tibial fracture fixation. J Orthop Surg Res, 2014, 9: 75.
3.	Li Y, Jiang X, Guo Q, et al. Treatment of distal tibial shaft fractures by three different surgical methods: a randomized, prospective study. Int Orthop, 2014, 38(6): 1261-1267.
4.	Feng W, Fu L, Liu J, et al. Biomechanical evaluation of various fixation methods for proximal extra-articular tibial fractures. J Surg Res, 2012, 178(2): 722-727.
5.	Fang X, Jiang L, Wang Y, et al. Treatment of Gustilo grade III tibial fractures with unreamed intramedullary nailing versus external fixator: A meta-analysis. Med Sci Monit, 2012, 18(4): RA49-RA56.
6.	Joveniaux P, Ohl X, Harisboure A, et al. Distal tibia fractures: management and complications of 101 cases. Int Orthop, 2010, 34(4): 583-588.
7.	Monni T, Birkholtz FF, de Lange P, et al. Conversion of external fixation to internal fixation in a non-acute, reconstructive setting: a case series. Strategies Trauma Limb Reconstr, 2013, 8(1): 25-30.
8.	Roussignol X, Sigonney G, Potage D, et al. Secondary nailing after external fixation for tibial shaft fracture: risk factors for union and infection. A 55 case series. Orthop Traumatol Surg Res, 2015, 101(1): 89-92.
9.	Kurylo JC, Axelrad TW, Tornetta P 3rd, et al. Open fractures of the distal radius: the effects of delayed debridement and immediate internal fixation on infection rates and the need for secondary procedures. J Hand Surg Am. 2011, 36(7): 1131-1134.
10.	Thakore RV, Francois EL, Nwosu SK, et al. The Gustilo-Anderson classification system as predictor of nonunion and infection in open tibia fractures. Eur J Trauma Emerg Surg, 2016. [Epub ahead of print].
11.	Horan TC, Gaynes RP, Martone WJ, et al. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol, 1992, 13(10): 606-608.
12.	Recknagel S, Bindl R, Wehner T, et al. Conversion from external fixator to intramedullary nail causes a second hit and impairs fracture healing in a severe trauma model. J Orthop Res, 2013, 31(3): 465-471.
13.	Foni NO, Batista FA, Rossato LH, et al. Postoperative infection in patients undergoing inspection of orthopedic damage due to external fixation. Rev Bras Ortop, 2015, 50(6): 625-630.
14.	Battistelli S, Fortina M, Carta S, et al. Serum C-reactive protein and procalcitonin kinetics in patients undergoing elective total hip arthroplasty. Biomed Res Int, 2014, 2014: 565080.
15.	Yuan K, Li WD, Qiang Y, et al. Comparison of procalcitonin and C-reactive protein for the diagnosis of periprosthetic joint infection before revision total hip arthroplasty. Surg Infect (Larchmt), 2015, 16(2): 146-150.
16.	Neumaier M, Scherer MA. C-reactive protein levels for early detection of postoperative infection after fracture surgery in 787 patients. Acta Orthop, 2008, 79(3): 428-432.
17.	Wright EH, Khan U. Serum complement-reactive protein (CRP) trends following local and free-tissue reconstructions for traumatic injuries or chronic wounds of the lower limb. J Plast Reconstr Aesthet Surg, 2010, 63(9): 1519-1522.
18.	Ettinger M, Calliess T, Kielstein JT, et al. Circulating Biomarkers for Discrimination Between Aseptic Joint Failure, Low-Grade Infection, and High-Grade Septic Failure. Clin Infect Dis, 2015, 61(3): 332-341.
19.	Parekh AA, Smith WR, Silva S, et al. Treatment of distal femur and proximal tibia fractures with external fixation followed by planned conversion to internal fixation. J Trauma, 2008, 64(3): 736-739.
20.	Avilucea FR, Sathiyakumar V, Greenberg SE, et al. Open distal tibial shaft fractures: a retrospective comparison of medial plate versus nail fixation. Eur J Trauma Emerg Surg, 2016, 42(1): 101-106.

1. Ktistakis I, Giannoudi M, Giannoudis PV. Infection rates after open tibial fractures: are they decreasing? Injury, 2014, 45(7): 1025-1027.
2. Xu X, Li X, Liu L, et al. A meta-analysis of external fixator versus intramedullary nails for open tibial fracture fixation. J Orthop Surg Res, 2014, 9: 75.
3. Li Y, Jiang X, Guo Q, et al. Treatment of distal tibial shaft fractures by three different surgical methods: a randomized, prospective study. Int Orthop, 2014, 38(6): 1261-1267.
4. Feng W, Fu L, Liu J, et al. Biomechanical evaluation of various fixation methods for proximal extra-articular tibial fractures. J Surg Res, 2012, 178(2): 722-727.
5. Fang X, Jiang L, Wang Y, et al. Treatment of Gustilo grade III tibial fractures with unreamed intramedullary nailing versus external fixator: A meta-analysis. Med Sci Monit, 2012, 18(4): RA49-RA56.
6. Joveniaux P, Ohl X, Harisboure A, et al. Distal tibia fractures: management and complications of 101 cases. Int Orthop, 2010, 34(4): 583-588.
7. Monni T, Birkholtz FF, de Lange P, et al. Conversion of external fixation to internal fixation in a non-acute, reconstructive setting: a case series. Strategies Trauma Limb Reconstr, 2013, 8(1): 25-30.
8. Roussignol X, Sigonney G, Potage D, et al. Secondary nailing after external fixation for tibial shaft fracture: risk factors for union and infection. A 55 case series. Orthop Traumatol Surg Res, 2015, 101(1): 89-92.
9. Kurylo JC, Axelrad TW, Tornetta P 3rd, et al. Open fractures of the distal radius: the effects of delayed debridement and immediate internal fixation on infection rates and the need for secondary procedures. J Hand Surg Am. 2011, 36(7): 1131-1134.
10. Thakore RV, Francois EL, Nwosu SK, et al. The Gustilo-Anderson classification system as predictor of nonunion and infection in open tibia fractures. Eur J Trauma Emerg Surg, 2016. [Epub ahead of print].
11. Horan TC, Gaynes RP, Martone WJ, et al. CDC definitions of nosocomial surgical site infections, 1992: a modification of CDC definitions of surgical wound infections. Infect Control Hosp Epidemiol, 1992, 13(10): 606-608.
12. Recknagel S, Bindl R, Wehner T, et al. Conversion from external fixator to intramedullary nail causes a second hit and impairs fracture healing in a severe trauma model. J Orthop Res, 2013, 31(3): 465-471.
13. Foni NO, Batista FA, Rossato LH, et al. Postoperative infection in patients undergoing inspection of orthopedic damage due to external fixation. Rev Bras Ortop, 2015, 50(6): 625-630.
14. Battistelli S, Fortina M, Carta S, et al. Serum C-reactive protein and procalcitonin kinetics in patients undergoing elective total hip arthroplasty. Biomed Res Int, 2014, 2014: 565080.
15. Yuan K, Li WD, Qiang Y, et al. Comparison of procalcitonin and C-reactive protein for the diagnosis of periprosthetic joint infection before revision total hip arthroplasty. Surg Infect (Larchmt), 2015, 16(2): 146-150.
16. Neumaier M, Scherer MA. C-reactive protein levels for early detection of postoperative infection after fracture surgery in 787 patients. Acta Orthop, 2008, 79(3): 428-432.
17. Wright EH, Khan U. Serum complement-reactive protein (CRP) trends following local and free-tissue reconstructions for traumatic injuries or chronic wounds of the lower limb. J Plast Reconstr Aesthet Surg, 2010, 63(9): 1519-1522.
18. Ettinger M, Calliess T, Kielstein JT, et al. Circulating Biomarkers for Discrimination Between Aseptic Joint Failure, Low-Grade Infection, and High-Grade Septic Failure. Clin Infect Dis, 2015, 61(3): 332-341.
19. Parekh AA, Smith WR, Silva S, et al. Treatment of distal femur and proximal tibia fractures with external fixation followed by planned conversion to internal fixation. J Trauma, 2008, 64(3): 736-739.
20. Avilucea FR, Sathiyakumar V, Greenberg SE, et al. Open distal tibial shaft fractures: a retrospective comparison of medial plate versus nail fixation. Eur J Trauma Emerg Surg, 2016, 42(1): 101-106.

Chinese Journal of Reparative and Reconstructive Surgery

Safety evaluation of secondary conversion from external fixation to internal fixation for open tibia fractures

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