Short-term outcomes of severe open wartime tibial fractures treated with ring external fixation

J Bone Joint Surg Am. 2008 Dec;90(12):2643-51. doi: 10.2106/JBJS.G.01326.


Background: The treatment of complex open tibial fractures sustained in combat remains controversial. This study investigated the short-term outcomes of type-III tibial shaft fractures treated at our institution with ring external fixation.

Methods: A retrospective review identified sixty-seven type-III tibial shaft fractures in sixty-five consecutive patients treated between April 2004 and January 2007. Of these, forty-five tibiae in forty-three patients received fracture fixation with ring external fixation. The cases of thirty-six patients, who received treatment for thirty-eight tibial shaft fractures to completion with a standardized protocol, were reviewed.

Results: A blast mechanism accounted for thirty-five injuries, and three injuries were from high-velocity gunshot wounds. There were twenty-one type-IIIA, thirteen type-IIIB, and four type-IIIC fractures. Rotational or free soft-tissue flap coverage was performed on fifteen patients. Eighteen patients received planned delayed bone-grafting, and nine had only bone morphogenetic protein placed at the fracture site at the time of final wound closure. All fractures healed with <5 degrees of malalignment. One patient underwent elective delayed amputation. The average time to union with frame removal was 221 days (range, 102 to 339 days).

Conclusions: Treatment of severe open wartime tibial fractures with a protocol-driven approach to wound management and placement of ring external fixation can result in a low rate of complications and a relatively high rate of fracture union. Most complications can be successfully managed without frame removal.

MeSH terms

  • Debridement
  • External Fixators*
  • Follow-Up Studies
  • Fracture Fixation / instrumentation*
  • Fracture Healing
  • Fractures, Open / surgery*
  • Humans
  • Male
  • Reoperation
  • Retrospective Studies
  • Skin Transplantation
  • Tibial Fractures / etiology
  • Tibial Fractures / pathology
  • Tibial Fractures / surgery*
  • Time Factors
  • Treatment Outcome
  • United States
  • Warfare*