Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan, Taiwan, China.
Department of Orthopedic Surgery, Musculoskeletal Research Center, Chang Gung Memorial Hospital, Chang Gung University and Medical College, Taoyuan, Taiwan, China.
Orthop Surg. 2024 Jan;16(1):94-103. doi: 10.1111/os.13940. Epub 2023 Nov 28.
Open tibial fractures are frequently encountered in high-energy traumas and can result in significant complications such as nonunion, osteomyelitis, and even amputation. Among open tibial fractures, Gustilo type IIIC cases are particularly challenging due to the concomitant occurrence of neurovascular injuries and soft tissue defects. This study aimed to assess factors that affect union time and complications in Gustilo IIIC tibial fractures.
Patients who presented at our center with IIIC open tibial fractures from January 2000 to October 2020 were eligible for this retrospective analysis. Patient demographics, fracture characteristics, and the timing, number, and type of surgical intervention were documented. Outcomes of interest included union time, occurrence of osteomyelitis, and amputation. We performed univariate analyses including chi-squared test, Fischer's exact test, analysis of variance, and Kruskal-Wallis test based on the normality of the data and multivariate analyses including Cox proportional hazards model and logistic regression analyses.
Fifty-eight patients were enrolled and grouped by fracture healing time; eight had timely union (13.8%); 27 had late union (46.6%); eight had delayed union (13.8%); three had nonunion (5.2%); and 12 underwent amputation (20.7%). Nine fractures (15.5%) were complicated by osteomyelitis. Union time was prolonged in cases of triple arterial injury, distal third fractures, multiple trauma with injury severity score (ISS) ≥ 16 points, and increased bone defect length. Additionally, a bone gap >50 mm, diabetes mellitus, low body mass index, and triple arterial injury in the lower leg were significant risk factors for amputation. A time from injury to definitive soft tissue coverage of more than 22 days was the major risk factor for osteomyelitis. A scoring system to predict union time was devised and the predicted probability of union within 2 years was stratified based on this score.
IIIC tibial fractures involving the distal third of the tibia, fractures with bone defects, triple arterial injury, and multiple trauma with ISS ≥16 points demonstrated delayed union, and an effective prediction system for union time was introduced in this study. Early soft tissue coverage can reduce the risk of osteomyelitis. Finally, diabetes and severe bone and soft tissue defects pose a higher risk of amputation.
开放性胫骨骨折常见于高能创伤，可导致非愈合、骨髓炎甚至截肢等严重并发症。在开放性胫骨骨折中，Gustilo Ⅲ C 型骨折由于同时存在神经血管损伤和软组织缺损，因此极具挑战性。本研究旨在评估影响 Gustilo Ⅲ C 型胫骨骨折愈合时间和并发症的因素。
本回顾性分析纳入 2000 年 1 月至 2020 年 10 月在我院就诊的 Gustilo Ⅲ C 型开放性胫骨骨折患者。记录患者的人口统计学、骨折特征以及手术干预的时间、数量和类型。主要结局指标包括愈合时间、骨髓炎发生和截肢。根据数据的正态性，我们进行了单变量分析，包括卡方检验、Fisher 确切检验、方差分析和 Kruskal-Wallis 检验，以及多变量分析，包括 Cox 比例风险模型和 logistic 回归分析。
58 例患者纳入研究，根据骨折愈合时间分组；8 例患者获得及时愈合（13.8%）；27 例患者延迟愈合（46.6%）；8 例患者延迟愈合（13.8%）；3 例患者不愈合（5.2%）；12 例患者截肢（20.7%）。9 例（15.5%）骨折合并骨髓炎。动脉三联征损伤、胫骨远端骨折、ISS≥16 分的多发伤、骨缺损长度增加均导致愈合时间延长。此外，骨间隙＞50mm、糖尿病、低 BMI 和小腿动脉三联征是截肢的显著危险因素。受伤至确定性软组织覆盖的时间超过 22 天是骨髓炎的主要危险因素。我们制定了一种预测愈合时间的评分系统，并根据该评分对 2 年内愈合的预测概率进行了分层。
胫骨远端、骨缺损、动脉三联征损伤和 ISS≥16 分的多发伤的 Gustilo Ⅲ C 型胫骨骨折延迟愈合，本研究提出了一种预测愈合时间的有效系统。早期软组织覆盖可以降低骨髓炎的风险。最后，糖尿病和严重的骨和软组织缺损增加了截肢的风险。
