OTA 1999 Posters

Type III-B Open Tibial Fractures in the Elderly

Javad Parvizi, MD; M.E. Torchia; A. Bishop, Mayo Foundation, Rochester, MN

Aim: To evaluate the outcome of external fixation and local muscle flap coverage for open type III-B tibial fractures in the elderly

Methods and Materials: The clinical notes and radiographs of 12 consecutive patients over the age of 60, with Gustilo type III-B open tibial fractures, treated at our institution between 1979 to 1996 were reviewed. There were 7 males and 5 females, with an average age of 69 (range, 66 to 83). Mean follow-up was 6 years (range, 2 to 19 years) with no patient lost to follow-up.

Result: Five fractures occurred in patients with multiple injuries with a mean Injury Severity Score of 52 points (maximum 70 points). Seven were isolated tibial fractures. External fixation was used in all cases. Local muscle flaps in the form of soleus (7 cases) and gastrocnemius (6 cases) were performed at a mean of 8 days (range, 3 to 12 days) following the initial injury, for all except one patient. The latter patient due to medical reasons had a delayed soft tissue coverage of the fracture at 7 weeks. An average of 9 operative procedures was performed on each patient for treatment of the tibial fracture. One local flap was revised because of necrosis. The mean time to fracture union was 8.9 months (range, 2 to 28 months). Only one patient had uncomplicated fracture union. Healing was delayed in 4 patients. Seven other patients ultimately elected to proceed with below- knee amputation due to the presence of severe deep infection and nonunion. Infecting organism included Staphylococcus epidermidis (five cases), Pseudomonas aeruginosa (three cases), Enterobacter cloacae (three cases) and Staphylococcus aureus (one case).

Conclusion: In the elderly, an open type III-B tibial fracture can be a limb- threatening injury. In our practice over half of the elderly patients with open type III-B tibia fractures treated with external fixation and local muscle flap coverage have a protracted and complicated course leading to secondary amputation. In this setting alternative treatment methods should be considered.