title: Noncontiguous and open fractures of the lower extremity: Epidemiology, complications, and unplanned procedures.
abstract: BACKGROUND
  Isolated fractures of the lower extremity are relatively common injuries while multifocal injuries resulting from high-energy trauma are less frequently encountered. Our objectives are to characterise patients who sustained multiple noncontiguous fractures and open fractures of the lower extremity, report the incidence of major complications, and identify factors that may contribute to complications and unplanned re-operations.
  
  
  METHODS
  A retrospective review of patients was performed at a Level 1 trauma centre from 2000 to 2013. Patients who sustained two or more noncontiguous operative fractures in an ipsilateral lower extremity, with at least one open fracture were included. Noncontiguous was defined as fractures in the same lower limb that were not in continuity on preoperative radiographs or intra-operatively. Demographic, injury characteristics, and hospitalisation data were collected. Primary outcomes included non-union, deep infection, and the need for unplanned surgeries.
  
  
  RESULTS
  257 patients sustained a total of 876 lower extremity fractures with an average of 1.7 open and 2.7 operative fractures in the qualifying limb. Ninety-nine patients (38.5%) sustained bilateral lower extremity injuries. Following their initial stay, 22.6% of patients had planned procedures (definitive fixation, skin, or planned bone grafting). Nearly half (45.9%) required one or more unplanned re-operation. Complications included deep infections (19.5%), non-unions (19.5%), and mal-unions (2.7%). 17.5% of the patients had at least one procedure for removal of painful implants. A deep infection was predictive of having a non-union (odds ratio, OR 7.5). The presence of a Gustilo-type IIIB/IIIC (OR 24.6/16.0) fracture was predictive of having a deep infection. After excluding painful implant removal, a type IIIB fracture was associated with an unplanned procedure (OR 13.8).
  
  
  CONCLUSIONS
  Patients with multiple non-contiguous lower extremity injuries associated with open fractures can expect complications including non-unions, deep infections, and painful implants. Nearly half of the patients will need further operative treatment.
authors.affiliation: Resident Physician, Department of Orthopaedic Surgery, MetroHealth Medical Center, Affiliated with Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH 44109, United States. Electronic address: hvallier@metrohealth.org.
authors.forename: Andrew T
authors.initials: AT
authors.lastname: Chen
authors.affiliation: Professor of Orthopaedic, Surgery Department of Orthopaedic Surgery, MetroHealth Medical Center, Affiliated with Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, OH 44109, United States.
authors.forename: Heather A
authors.initials: HA
authors.lastname: Vallier
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016025:Bone Transplantation / Q000379:methods; D002648:Child; D002675:Child, Preschool; D003646:Debridement / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000379:methods*; D005597:Fractures, Open / Q000150:complications* / Q000453:epidemiology / Q000601:surgery*; D006801:Humans; D015601:Injury Severity Score; D007869:Leg Injuries / Q000150:complications / Q000453:epidemiology / Q000601:surgery; D008297:Male; D008875:Middle Aged; D009104:Multiple Trauma / Q000453:epidemiology / Q000601:surgery; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000209:etiology / Q000517:prevention & control / Q000628:therapy; D007507:Therapeutic Irrigation / Q000379:methods; D014193:Trauma Centers; D016896:Treatment Outcome; D014481:United States / Q000453:epidemiology; D014945:Wound Healing; D055815:Young Adult
keywords: Lower extremity trauma; Noncontiguous fractures