The fate of comminuted extruded or devitalized fragments of bone in Gustilo type III open fractures and an innovative form of treating them

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Aims: This prospective study investigated an innovative approach to the management of extruded or devitalized fragments of bone in patients with a Gustilo type III open fracture of the tibia, which enabled the efficient reconstruction of the bony defect while minimizing the requirement for iliac bone harvesting. Methods: A total of 12 patients with a Gustilo type III open fracture were enrolled into the study between June 2019 and June 2022. During initial emergency management, all patients were treated with radical debridement, the introduction of an antibiotic-loaded spacer, and stabilization of the fracture. Extruded or devitalized fragments, including detached and potentially contaminated segments, were collected and processed into autologous demineralized bone matrix (ADBM). In the second stage, after removal of the spacer, ADBM combined with iliac bone graft was implanted into the induced membrane cavity for reconstruction of the bony defect. The sterility of the ADBM specimens was assessed using microbiological culture. Volumetric analysis of iliac graft requirements was performed. Primary outcome measures including time to healing of the fracture and complications were recorded. The recovery of function was assessed using the Lower Extremity Functional Scale (LEFS) at final follow-up. Results: The mean follow-up was 32.5 months (24 to 48). No bacteria were detected in any ADBM implants. Complete reconstruction of the defect was achieved in all patients. Quantitative volume analysis revealed an autogenous bone-to-ADBM ratio of 1.36:1, reducing the autologous bone requirements. Radiological union occurred at a mean of seven months (5 to 10) after the second surgical stage. There were no complications such as rejection, infection, nonunion, or refracture. At the last follow-up, all patients had regained satisfactory function of the lower limb as recorded by a mean LEFS score of 72.2 (68 to 76). Conclusion: The processing of comminuted extruded or devitalized fragments of bone into ADBM represents a safe and effective strategy for managing severe open fractures of the tibia. When synergistically integrated with an induced membrane technique, this innovative approach considerably reduced the incidence of infection, diminished the need for iliac bone graft, and substantially enhanced the efficiency of reconstruction of the bony defect.

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