Baldwin Keith D, Babatunde Oladapo M, Russell Huffman G, Hosalkar Harish S
Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 34th and Spruce, 2nd Floor, Silverstein Building, Philadelphia, PA, 19104, USA.
J Child Orthop. 2009 Jun;3(3):199-208. doi: 10.1007/s11832-009-0169-6. Epub 2009 Apr 3.
The management of open fractures of the tibia in a pediatric population represents a challenge to the clinician. Several case series over the course of many years have been performed describing the results of treating these injuries. It remains unclear, however, whether there is a preferred modality of treatment for these injuries, if a more severe injury confers a greater risk of infection, and if time to union is affected by Gustilo type, although trends seem to exist. The purpose of this study was to assemble the available data to determine (1) the risk of infection and time to union of various subtypes of open tibia fractures in children and (2) the changes in treatment pattern over the past three decades.
A systematic review of the available literature was performed. Frequency weighted mean union times were used to compare union times for different types of open fractures. Mantel Haentzel cumulative odds ratios were used to compare infection risk between different types of open fractures. Linear regression by year was used to determine treatment practices over time.
No significant change in practice patterns was found for type I and III fractures, although type II fractures were more likely to be treated closed in the later years of the study compared to the earlier years. Type III fractures conferred a 3.5- and 2.3-fold greater odds of infection than type I and type II fractures, respectively. There was no significant difference in odds of infection between type I and II fractures. There was a significant delay in mean time to union between type I and type II fractures, and between type II and type III fractures.
With the exception of type II fractures, the philosophy of treatment of open fractures of the tibia has not significantly changed over the past three decades. Closed treatment or internal fixation are both viable options for type II fractures based on their relatively low incidence of infection. This study also demonstrates a strong relationship between Gustillo sub-types and odds of infection in this population. Not surprisingly, union rates are also delayed with increasing injury severity.
小儿胫骨开放性骨折的处理对临床医生而言是一项挑战。多年来已有多个病例系列描述了此类损伤的治疗结果。然而，对于这些损伤是否存在首选治疗方式、更严重的损伤是否会带来更高的感染风险以及愈合时间是否受 Gustilo 分型影响（尽管似乎存在一些趋势）仍不明确。本研究的目的是汇总现有数据，以确定：（1）儿童开放性胫骨骨折各亚型的感染风险和愈合时间；（2）过去三十年治疗模式的变化。
对现有文献进行系统综述。使用频率加权平均愈合时间来比较不同类型开放性骨折的愈合时间。采用 Mantel Haentzel 累积比值比来比较不同类型开放性骨折之间的感染风险。通过逐年线性回归来确定随时间变化的治疗方法。
对于 I 型和 III 型骨折，治疗模式未发现显著变化，不过与研究早期相比，II 型骨折在研究后期更倾向于采用闭合治疗。III 型骨折发生感染的几率分别比 I 型和 II 型骨折高 3.5 倍和 2.3 倍。I 型和 II 型骨折之间的感染几率无显著差异。I 型和 II 型骨折之间以及 II 型和 III 型骨折之间的平均愈合时间存在显著延迟。
在过去三十年中，除 II 型骨折外，胫骨开放性骨折的治疗理念并未发生显著变化。基于 II 型骨折相对较低的感染发生率，闭合治疗或内固定都是可行的选择。本研究还表明 Gustilo 亚型与该人群的感染几率之间存在密切关系。不出所料，随着损伤严重程度的增加，愈合率也会延迟。
