title: Short-term outcomes of severe open wartime tibial fractures treated with ring external fixation.
abstract: 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.
authors.affiliation: Department of Orthopaedic Surgery, National Naval Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889, USA. john.keeling@med.navy.mil
authors.forename: John J
authors.initials: JJ
authors.lastname: Keeling
authors.forename: David E
authors.initials: DE
authors.lastname: Gwinn
authors.forename: Scott M
authors.initials: SM
authors.lastname: Tintle
authors.forename: Romney C
authors.initials: RC
authors.lastname: Andersen
authors.forename: Francis X
authors.initials: FX
authors.lastname: McGuigan
mesh_terms: D003646:Debridement; D016267:External Fixators; D005500:Follow-Up Studies; D005592:Fracture Fixation / Q000295:instrumentation*; D017102:Fracture Healing; D005597:Fractures, Open / Q000601:surgery*; D006801:Humans; D008297:Male; D012086:Reoperation; D012189:Retrospective Studies; D016038:Skin Transplantation; D013978:Tibial Fractures / Q000209:etiology / Q000473:pathology / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D014481:United States; D014857:Warfare