Research Article

Severe Osteoarticular Trauma of the Knee: an Unusual Injury Assessment

Yassine Ben Bouzid*, Oualid Assouab and Mohamed Saleh Berrada

Department of Orthopaedic and Trauma Surgery, Ibn Sina University Hospital, Rabat, Morocco

Submission:April 11, 2023; Published:April 21, 2023

*Corresponding author: Yassine Ben Bouzid, Department of Orthopaedic and Trauma Surgery, Ibn Sina University Hospital, Rabat, Morocco, Email: yassine.benbouzid2@gmail.com

How to cite this article:Yassine Ben B, Oualid A, Mohamed Saleh B. Severe Osteoarticular Trauma of the Knee: an Unusual Injury Assessment. Ortho & Rheum Open Access J. 2023; 21(4): 556067. DOI: 10.19080/OROAJ.2023.21.556067

Abstract

We report the case of a 34-year-old man, who was involved in a traffic accident resulting in a type III open knee fracture. A large spectrum antibiotic therapy was administered (penicillin+gentamicin) with early surgical debridement. Bone stabilization was achieved with an external fixator bridging the knee and skin closure was possible. Postoperatively we did not observe any clinical infection. Consolidation was obtained after 6 months of surgery. After 12 months, the patient regained his autonomy but retained a frank stiffness of the knee.

Keywords:Osteoarticular; Open fracture; Infection; Antibiotics; Stabilization

Introduction

An open fracture is defined by the presence of a communication between a fracture site and the external environment. The skin opening may vary from a simple perforation to complete exposure of the bone. These fractures are the cause of significant morbidity because the risk of infection remains high due to the breakdown of all protective barriers [1]. Osteoarticular trauma of the knee exposes the patient to primary and secondary complications, which makes their management difficult. The esthetic and functional damage can be deleterious [2]. Hence the importance of a rapid and compliant management allowing the prevention of infection, bone consolidation and an improvement of the functional prognosis.

Visual case discussion

A 34 year old patient, victim of a road accident (pedestrian hit by a heavy vehicle), which resulted in a damaged knee. The clinical examination revealed a conscious patient (GCS 15/15); without signs of hemorrhagic shock. A skin opening of more than 30 cm, medial to the knee with exposure of the joint and all bone segments (Figure 1). The opening was classified as Gustilo III. Pelvic examination was normal; the rest of the musculoskeletal examination was unremarkable. The popliteal and posterior tibial pulses were perceived; the pedal pulse was abolished. Paralysis in the deep and superficial fibular territory was noted, without paralysis in the tibial nerve territory.

Radiological examination (Figure 1) revealed a simple line fracture of the lateral condyle, a comminuted fracture of the patella, and a comminuted fracture of the tibial plateau extended to the upper third of the shaft. A CT angiography was performed showing respect for the popliteal pedicle; the anterior tibial artery was sectioned with respect for the posterior tibial and fibular arteries. A large spectrum antibiotic therapy was introduced 4 hours after the trauma (penicillin and gentamicin) and the patient was taken to the operating room for surgical management. First, abundant irrigation (12L of saline) was performed with debridement and excision of all necrotic and necrotic tissue. An exploration of the knee found (Figure 2):
i.-A ruptured and frayed extensor apparatus.
ii.-Comminuted fracture of the patella.
iii.-Patellar fins were broken and shredded.
iv.-Rupture of the lateral and medial collateral ligaments, with respect to the central pivot.
v.-There was a bilateral meniscus tear.
vi.-A simple fracture of the lateral condyle.
vii.-A comminuted fracture of the tibial plateau with proximal extension on the tibial diaphysis.
viii. -The superficial and deep fibular nerves were transected with an average of 5 cm loss of substance.
ix. -The anterior tibial artery was ruptured and thrombosed. The posterior tibial and fibular axes were intact.

The patient underwent primary stabilization with an external fixator and tension-free skin closure (Figure 3).

Antibiotic therapy was maintained for 8 days with discontinuation of gentamicin after 5 days. Thromboprophylaxis was prescribed for 14 days. Partial weight-bearing was allowed only after 2 months of surgery and full weight-bearing after 3 months. Consolidation was achieved at 6 months. After 12 months, the patient regained his autonomy but with severe knee stiffness (30° flexion). In addition, no skin or infectious complications were observed (Figure 4).

Discussion

Open osteoarticular trauma represents a major problem in terms of both management and prognosis. Orthopaedic surgeons are constantly challenged by these injuries which, despite the development of surgical techniques, remain at high risk of infection and pseudarthrosis. The Gustilo classification is the most widely used system for classifying open fractures. It takes into account the energy of the fracture, the degree of soft tissue damage and contamination [3,4]. A second classification system is used to guide the surgeon in determining the indication for amputation in the context of major trauma to the limbs: the MESS score [5]. A score greater than or equal to 7 is predictive of amputation with an accuracy close to 100% [5-8].

All open fractures are contaminated by definition, with an infectious risk that differs according to the type of fracture. It is 0 to 2% for type I fractures, 2 to 10% for type II fractures and 10 to 50% for type III fractures [4,9]. Antibiotics should be administered systematically and early, ideally within 3 hours of the trauma [10]. This will reduce the risk of infection [11,12]. The duration of antimicrobial coverage remains debated and requires a multicenter randomized trial to determine the optimal duration that reduces the risk of infection without increasing the risk of antibiotic resistance [13]. Usually, surgical debridement is performed within 6 hours in an attempt to reduce the rate of infection and pseudarthrosis [14]. However, this approach remains controversial with respect to the risk of infection [15- 20], and there is no consensus. Skeletal stabilization protects soft tissue from further damage that may be caused by mobile fragments. Restoration of length and stabilization reduces dead space and allows for easier access to soft tissue while reducing the rate of infection [21-23]. Therapeutic means include external fixator, intramedullary nail, or plates depending on the type of injury and the risk of infection [24-29].

Conclusion

Open fractures are a challenging condition for orthopedic surgeons. Management is based on early administration of antibiotics, surgical debridement and effective stabilization of the bone, which decreases the risk of infection and allows for bone healing with an improved functional prognosis.

References

1. Cross WW 3^rd, Swiontkowski MF. Treatment principles in the management of open fractures. Indian J Orthop 42(4): 377-386.
2. C Le Rouzic-Dartoy, S Marleix, C Kokou-Senah, N Kerfant, R Audollent, et al. (2008) SOFOP-P0₂ – Traumatologie – Prise en charge d’un délabrement traumatique du membre inférieur chez un adolescent. Archives de Pédiatrie 15(5): 1027.
3. Gustilo RB, Mendoza RM, Williams DN (1984) Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 24(8): 742–746.
4. Gustilo RB, Gruninger RP, Davis T (1987) Classification of type III (severe) open fractures relative to treatment and results. Orthopedics 10(12): 1781–1788.
5. Johansen K, Daines M, Howey T, Helfet D, Hansen ST, et al. (1990) Jr Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 30(5): 568–572.
6. Helfet DL, Howey T, Sanders R, Johansen K (1990) Limb salvage versus amputation: Preliminary results of the Mangled Extremity Severity Score. Clin Orthop Relat Res 256: 80–86.
7. Slauterbeck JR, Britton C, Moneim MS, Clevenger FW (1994) Mangled extremity severity score: An accurate guide to treatment of the severely injured upper extremity. J Orthop Trauma 8(4): 282–285.
8. O'Sullivan ST, O'Sullivan M, Pasha N, O'Shaughnessy M, O'Connor TP (1997) Is it possible to predict limb viability in complex Gustilo IIIB and IIIC tibial fractures? A comparison of two predictive indices. Injury. 28(9-10): 639–642.
9. Zalavras CG, Marcus RE, Levin LS, Patzakis MJ (2007) Management of open fractures and subsequent complications. J Bone Joint Surg Am 89(4): 884–895.
10. Al-Arabi YB, Nader M, Hamidian-Jahromi AR, D A Woods (2007) The effect of the timing of antibiotics and surgical treatment on infection rates in open long-bone fractures: a 9-year prospective study from a district general hospital. Injury 38(8): 900–905.
11. Patzakis MJ, Wilkins J (1989) Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res 243: 36–40.
12. Patzakis MJ, Wilkins J, Moore TM (1983) Considerations in reducing the infection rate in open tibial fractures. Clin Orthop Relat Res 178: 36–41.
13. Isaac SM, Woods A, Danial IN, et al. (2016) Antibioprophylaxie chez l'adulte présentant une fracture ouverte du tibia : quelles sont les preuves de la durée d'administration? Une revue systé Chirurgie de la cheville du pied J 55: 146–150.
14. Bednar DA, Parikh J (1993) Effect of time delay from injury to primary management on the incidence of deep infection after open fractures of the lower extremities caused by blunt trauma in adults. J Orthop Trauma 7(6): 532–535.
15. Pollak AN, Jones AL, Castillo RC, Michael J Bosse, Ellen J MacKenzie, et al. (2010) The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma. J Bone Joint Surg Am 92(1): 7–15.
16. Prodromidis AD, Charalambous CP (2016) The 6-hour rule for surgical debridement of open tibial fractures: a systematic review and meta-analysis of infection and nonunion rates. J Orthop Trauma 30(7): 397–402.
17. Hendrickson SA, Wall RA, Manley O, William Gibson, Deirdre Toher, et al. (2018) Time to Initial Debridement and wound Excision (TIDE) in severe open tibial fractures and related clinical outcome: a multi-centre study. Injury 49(10): 1922–1926.
18. Weber D, Dulai SK, Bergman J, Richard Buckley, Lauren A Beaupre, et al. (2014) Time to initial operative treatment following open fracture does not impact development of deep infection: a prospective cohort study of 736 subjects. J Orthop Trauma 28(11): 613–619.
19. Westgeest J, Weber D, Dulai SK, Bergman Joseph, Buckley Richard, et al. (2016) Factors associated with development of nonunion or delayed healing after an open long bone fracture: a prospective cohort study of 736 subjects. J Orthop Trauma 30(3): 149–155.
20. Standards for the Management of Open Fractures of the Lower Limb (2009) British association of plastic raasb.
21. Merritt K (1988) Factors increasing the risk of infection in patients with open fractures. J Trauma 28(6): 823-827.
22. Worlock P, Slack R, Harvey L, Mawhinney R (1994) The prevention of infection in open fractures: An experimental study of the effect of fracture stability. Injury 25: 31–38.
23. Merritt K, Dowd JD (1987) Role of internal fixation in infection of open fractures: Studies with Staphylococcus aureus and Proteus mirabilis. J Orthop Res 5(1): 23–28.
24. Hildebrand F, Giannoudis P, Kretteck C, Pape HC (2004) Damage control: Extremities. Injury 35(7): 678–689.
25. Watson JT, Moed BR, Karges DE, Cramer KE (2000) Pilon fractures: Treatment protocol based on severity of soft tissue injury. Clin Orthop Relat Res 375: 78–90.
26. Cole PA, Zlowodzki M, Kregor PJ (2004) Treatment of proximal tibia fractures using the less invasive stabilization system: Surgical experience and early clinical results in 77 fractures. J Orthop Trauma 18: 528-535.
27. Bhandari M (2008) 75^th Annual Meeting of the American Academy of Orthopaedic Surgeons; 03/2008. San Francisco, California, USA San Francisco, CA: American Academy of Orthopaedic Surgeons; 2008. Reamed Versus Non-Reamed Tibial Intramedullary Nail Insertion on Re-operation Rates.
28. McGraw JM, Lim EV (1988) Treatment of open tibial-shaft fractures: External fixation and secondary intramedullary nailing. J Bone Joint Surg Am 70(6): 900–911.
29. Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM (2000) Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am 82(6): 781–788.