title: The "Road to Union" protocol for the reconstruction of isolated complex high-energy tibial trauma.
abstract: BACKGROUND
  The purpose of this study was to describe a standardized staged approach, "The Road to Union", for the reconstruction of isolated complex tibial trauma, both acute and chronic in nature.
  
  
  METHODS
  This retrospective study included all patients treated for complex tibial trauma at a specialized limb reconstruction centre, including acute open fracture as well as infected and aseptic non-unions. This standardized approach includes eight specific steps, employed in sequence. The time in external fixation (EFT), the external fixation index (EFI), and the distraction consolidation index (DCI) were the primary outcome measures. The relationship between EFI and DCI was assessed using Pearson's moment correlations.
  
  
  RESULTS
  Thirty-two patients with a mean age of 34.7±14.2years were included; 12 were treated for complex open tibial fractures with bone loss, 13 for infected non-unions, and 6 for aseptic non-union. The mean bone defect was 66±32mm. The total EFT was 42.5±14.8 weeks; the EFI measured 51.9±25.3 days/cm, and the DCI measured 48.3±21.4 days/cm. Union was achieved in 29 out of 32 patients (91%), and there was a strong and significant relationship between EFI and DCI (r=0.92, p=0.0001) measurements. Pin site infections were observed in 11 patients, and 3 patients had persistent non-union. Three patients underwent delayed amputations when reconstructive procedures were unable to achieve union.
  
  
  CONCLUSIONS
  The findings of this study demonstrate that a standardized staged treatment protocol of debridement, circular external fixation, soft-tissue management, distraction osteogenesis, and functional rehabilitation can result in a high rate of union in cases of complex tibial trauma, both acute and chronic in nature.
  
  
  METHODS
  Level IV; case series.
authors.affiliation: School of Medicine, University of Pretoria, South Africa; Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates. Electronic address: ehohmann@hotmail.com.
authors.forename: Erik
authors.initials: E
authors.lastname: Hohmann
authors.affiliation: Walk-a-Mile Centre for Advanced Orthopaedics, Pretoria, South Africa; Department of Orthopaedic Surgery, University of Pretoria, Steve Biko Academic Hospital, South Africa.
authors.forename: Franz
authors.initials: F
authors.lastname: Birkholtz
authors.affiliation: Department of Orthopaedic Surgery, University of Texas Health Science Center, San Antonio, TX, USA.
authors.forename: Vaida
authors.initials: V
authors.lastname: Glatt
authors.affiliation: Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia; Department of Surgery, School of Medicine, University of Queensland, Australia; Queensland University of Technology, Orthopaedic Research Institute, Australia.
authors.forename: Kevin
authors.initials: K
authors.lastname: Tetsworth
mesh_terms: D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001843:Bone Cements; D002985:Clinical Protocols; D003646:Debridement / Q000379:methods; D016267:External Fixators; D005260:Female; D005592:Fracture Fixation / Q000295:instrumentation / Q000379:methods; D017102:Fracture Healing / Q000502:physiology*; D005597:Fractures, Open / Q000503:physiopathology / Q000534:rehabilitation / Q000601:surgery*; D005599:Fractures, Ununited / Q000503:physiopathology / Q000534:rehabilitation / Q000601:surgery*; D006801:Humans; D008297:Male; D019857:Osteogenesis, Distraction; D012189:Retrospective Studies; D017695:Soft Tissue Injuries / Q000601:surgery*; D013530:Surgical Wound Infection / Q000188:drug therapy*; D013978:Tibial Fractures / Q000503:physiopathology / Q000534:rehabilitation / Q000601:surgery*; D016896:Treatment Outcome
chemical_list: D000900:Anti-Bacterial Agents; D001843:Bone Cements
keywords: Bone loss; Bone transport; Complex trauma; Infection; Limb reconstruction; Nonunion; Tibial fractures