Dr. Om is correct in stating in his letter that details about the nature and type of fracture were not included in our publication. These and other details delineated in a number of tables would have resulted in a more lengthy manuscript and were withheld at the suggestion of the reviewers. These injury characteristics included fracture classification (AO/OTA), as well as soft tissue injury classification (AO and Tscherne) in addition to the Gustilo and Anderson open fracture classification, all prospectively gathered according to the LEAP protocol(1).

As stated in the discussion section, "…the injury as well as the treatment characteristics of the two groups of limb salvage patients (those managed with intramedullary nails and those managed with an external fixator) were looked at. Although the external fixation group had a slightly more severe injury, largely because of a higher proportion of bone loss, this difference was not significant. The mean probability of amputation score (a score combining all injury characteristics into a single probability of amputation) was 0.080 for the intramedullary nail group and 0.105 for the external fixation group (p=0.23). In all cases, the differences between the groups remained after comparison across equivalent injury groups, with adjustment for injury characteristics in multivariate regression models…"

The major point of our paper was to analyze the influence of surgeon controlled variables on outcomes. Since nearly all patients in the study cohort and all patients looked at in this analysis had a definitive treatment with an external fixator or an intramedullary nail, this comparison was statistically meaningful. Those definitively managed with an external fixator took a longer time to weight bear, and spent more time in the hospital (most commonly for infection or delayed union). For those with a muscle flap and external fixation the functional outcome, prevalence of major complications and level of physical impairment at two years were worse than for those with a muscle flap and an intramedullary nail.

References:

1. Bosse, MJ et al An analysis of outcomes of reconstruction or amputation following leg threatening injuries N Engl J Med 2002 Dec 12;347(24):1924-31.

To The Editor:

In the article, “Surgeon–Controlled Variables in the Treatment of Type –III Open Tibial Diaphyseal Fractures"(1), the authors may indeed have come to the correct conclusions, but I would point out that the study was limited to a comparison of outcomes following certain procedures such as external fixater, and intramedullary nail and soft tissue coverage.

However, the authors did not provide details about the nature and type of fracture which greatly influences the management of these injuries and the functional outcomes. It is not the particular procedure i.e. external fixater or intra-medullary nail that determines the liklihood of a successful outcome but, rather, the primary injury characteristics that lead the surgeon to choose the treatment options. Hence, comparison done only on the basis of the procedures may not give us valid results.

Such outcome measures as infection, union, number of surgical interventions, weight bearing status, and days of hospitalization are more pertinent than the particular treatment option.

In addition, the description of type III open fracture is too wide as described in the Ganga Hospital trauma severity score by Rajasekran et al.(2) and it is very difficult to obtain any valid conclusion for all type III fractures combined.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated .

References:

1. Webb LX, Bosse MJ, Castillo RC, MacKenzie EJ, and the LEAP Study Group. Analysis of surgeon-controlled variables in the treatment of limb-threatening type-III open tibial diaphyseal fractures. J Bone Joint Surg Am. 2007;89:923-928.

2. Rajasekaran S, Babu JN, Dheenadhayalan J, Shetty AP, Sundararajan SR, Kumar M, Rajasabapathy S. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures. J Bone Joint Surg BR. Oct. 2006;88-B:1351-1360.