Complications and Outcomes Associated with Combat-Related Grade III Periarticular Tibia Fractures

BACKGROUND: Open periarticular tibia fractures due to war-related trauma present difficult reconstruction challenges and options. These complex fracture cases are frequently coupled with other concomitant injuries in our patient population, confounding the timing and options for reconstruction.  This study outlines risk factors contributing to complications, reoperations, and amputation in patients suffering combat-related periarticular tibia fractures.

METHODS: After obtaining IRB approval, a retrospective review of patients who sustained a periarticular tibia (plafond and/or plateau) fracture during war conflicts from 2003-2011 was reviewed. Collated data included injury patterns, reconstruction methods, reoperation rates, complications, and outcomes. A logistic regression analysis with amputation as our outcome variable against injury and treatment characteristics was performed to determine significant predictors of delayed amputation.

RESULTS: A total of 146 patients sustained combat-related periarticular tibia fractures(Table 1). Mean age was 26.7±6.8 years, with the majority of cases(86%) suffering blast injuries. In 111 patients(76%) provisional spanning external fixation within the battlefield setting was performed.   Flap coverage was required in 12% of fracture cases(18:9 pedicle;9 free). 

Table 1: Breakdown of combat periarticular tibial fracture cases

Total combat periarticular tibial fractures	N=146
Open	92 (63%)
Grade 3a	65
Grade 3b	20
Grade 3c	7
Closed	54 (37%)
Orthopedic Treatments
Open Reduction & Internal Fixation	115 (79%)
Ring External Fixation	27 (18%)
Nonoperative	4 (3%)

Fifty percent of cases underwent reoperation for complications, most commonly due to post-traumatic osteoarthritis and/or infection.  The overall infection rate was 21.9%(32/146), while 25% of open fractures(23/92) had associated infectious complications. Gram-negative bacteria were associated with 78%(18/23) of open fracture infections, with Acinetobacter and E-Coli the most frequent pathogens. While 16%(24/146) of all cases underwent delayed amputation, a much higher percentage, 31%(10/32) of patients with fractures complicated by infection required amputation. Based on logistic regression analysis, patients having ipsilateral fractures, open fractures, and infections were found to sustain significant increases in late amputation rates.

Conclusion:  Open Periarticular tibia fractures suffered from combat-related trauma are associated with high complication rates and higher than expected delayed amputation rates. These findings are substantially higher than that observed within the reported civilian literature. Based on our study, careful counseling and expectation management must be had in those war trauma patients suffering open periarticular fractures undergoing attempts at limb salvage.