Infection risk in Gustilo and Anderson type III tibia and fibular fractures treated with external fixation in a tertiary hospital of a developing country

David G. Mancha, Michael B. Ode, Idumagbodi Amupitan, Icha I. Onche


Background: Open fractures of the tibia and fibula present with multiple management challenges of wound care, bone stabilization, potential risk of infection and its control. Attempt to resolve this problem, stabilization of the fracture with external fixators was introduced. However, this procedure predisposes infection too. This was an overview of the disposition of infection in the course of managing type III fractures in our center.

Methods: This was a retrospective study of disposition of infection in Gustilo and Anderson type III open fractures of the tibia and fibula treated with external fixation device over ten years in Jos university teaching hospital. Data extracted from patients records and operation notes included age, sex, nature of open fracture with respect to Gustilo and Anderson classification in theater. Wound culture reports extracted early and weeks after commencement of treatment. The findings were analyzed using Epi info statistical software version 3.5.3.

Results: A total of 74 patients, 63 (85.1%) males and 11 (14.9%) females (M:F=5.7:1) with mean age of 37.97±13.57 years. The mean duration of injury-presentation time was 13.48±38.73 days, 41 (55.4%). Patients that present with clinical infection were 40 (54.1%) among which staphylococcus aureus was isolated in 21 (28.3%). While treatment was on, the flora became altered. Motor cycles were responsible for 25 (33.7%), gunshots 20 (27%), motor vehicle injuries 19 (25.6%) while pedestrians accounted for 9 (12.2%).

Conclusions: Type III fractures sustained from high energy risk of infections due to late presentation in our setting. Bacterial isolates tend to alter in course of hospitalization.


Infection, Type III fractures, Open fractures

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Johnson EN, Burns TC, Hayda RA, Hospenthal DR, Murray CK. Infectious complications of open type 111 tibial fractures among combat casualties. Clin Infect Dis. 2007;45(4):409-15.

Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand twenty five open fractures fractures of long bones: retrospecive and prospective analysis. J Bone Surg Am. 1976;58(4);453-8.

Cross WW, Swioinkoski MF. Treatment Principles in the management of open fractures. Indian J Orthop. 2008;42(4):377-86.

Ikem IC, Oginni LM, Bamgboye EA, Ako-Nai AK, Onipede AO. The bacteriology of open fractures in Ile-Ife, Nigeria. Niger J Med. 2004;13(4):359-65.

Khatod M, Botte MJ, Hoit DB, Meyer RS, Smith JM, Akeson WH. Outcomes of open tibia fractures: Relationship between delay in treatment and infection. J Trauma. 2003;55(5):949-54.

Rittmann WW, Schibli M, MItter P, Allgower M. Open fractures. Long term results in 200 consecutive cases. Clin Orthop Relat Res. 1979;(138):132-40.

Dellinger EP, Miller SD, Wertz MJ, Grypma M, Droppert B, Anderson PA. Risk of infection after open fracture of the arm or leg. Arch Surg. 1988;123(11):1320-7.

Johnson EN, Burns TC, Hayda RA, Hospenthal DR, Murray CK. Infectious complications of open type 111 tibial fractures among combat casualties. Clin Infect Dis. 2007;45(4):409-15.

Ikem IC, Ogini LM, Ogunlusi JD. Determinants of management outcome in open tibia fracture in Ile Ife. Nig J Medical Res. 2006;8(1-2):81-5.

Paul HK, Seth SL. Gustilo and Anderson classification. Clinc Othop Related Res. 2012;470(11):3270-4.

Kamat AS. Infection rates in the open fractures of the tibia: is the 6 hours rule fact or fiction? Adv Orthop. 2011;2011:943495.

Pollack AN. Timing of debridement of open fractures. J Am Acad Orthop Surg. 2006;14(10):48-51.

Nwadiaro HC, Nwadiaro PO, Kitmas RAT. Principles of traditional bone setting in middle belt of Nigeria: a critical appraisal. Niger J Surg Res. 2014;3( 4):114-8.

Hongli JO, Xiao E, Graves DT. Diabetics and its effect on bone and fracture healing. Curr Osteoporos Rep. 2015;13(5):327-35.

Griffin M, Malahias M, Khan W, Hindocha S. Update on the management of open lower limb fractures. The Open Orthop J. 2012;6(3):571-7.

Neubauer T, Bayer GS, Wagner M. Open fractures and infection. Acta Chir Orthop Traumatol Cech. 2006;73(5):301-12.

Palotti FL, Macmull S, Mustaq N, Mobasheri R. Current concepts and principles in open tibia fractures-part II management. MOJ Orthop Rheumatol. 2017;8(2):00305.

Penn-Barwel JG, Murray CK, Wenke JC. Early anibiotics and debridement independently reduced infection in an open fracture model. J Bone Joint Surg Br. 2012;94(1):107-12.

Berg RJ, Okoye O, Inaba K, Konstancetindis A, Misiel R, Bamparas G, et al. Extremity firearm trauma:the impact of injury pattern on clinical outcomes. Am Surg. 2012;78(12):1383-7.

Lowy FD. Staphylococcus aureus infections. N Engl J Med. 1998;339(8):520-32.

Lew DP, Waldvogel FA. Osteomyelitis. Lancet. 2004;364(9431):369-79.

Josse J, Velard F, Gangloft SC. Staphylococcus aureus vs. Osteoblast Relationship and consequencies in osteomyelitis. Front Cell Infect Microbiol. 2015;5:85.

Ikem IC, Oginni LM, Bamgboye EA. Open fractures of the lower limb in Nigeria. Int Orthop. 2001;25(6):386-8.

Odatuwa-Omagbemi DO, Adiki TO, Elachi CI, Bafor A. Complications of traditional bone setters treatment of musculoskeletal injuries: experience in private setting in Warri, South-South Nigeria. Pan African Med. J. 2018;30:189.

Birth MC, Anderson BW, Toby EB. Wang J. Osteomyelitis: Recent advances in pathophysiology and therapeutic strategies. J Orthop. 2016;14(1):45-52.

Joseph CM, Jepegnanam TS, Ramasamy B, Cherian BM, Nithyananth M, Sudarsanam TD, et al. Time of debridement in high grade lower limb open fractures and its effect on union and infections: A prospective study in tropical setting. J Orthop Surg (Hong Kong). 2020;28(1):2309499020907558.

Tornetta P, Bergman M, Watnik N, Berkowitz G, Steuer J. Treatment of grade 111B open tibial fracture. A prospective randomize comparison external fixation and non reamed locked nailing. J Bone Joint Surg Br. 1994;76(1):13-9.

Persad IJ, Reddy RS, Saunders MA, Patel J. Gunshot to extremities/experience of a UK trauma center. Injury. 2005;36(3):407-11.

Kantor AH, Gallagher SJ, Rosario LE, Abate ME, Zamorano DP. The effect of treatment delay on infection in open tibia fractures: a retrospective study in Ethiopia. Int J Orthop. 2019;6(2).

Padzakis MJ, Mer D. Antibiotic and Antimicrobial considerations in open fractures. South Med J. 1977;70(1):46-8.