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Role of Total Urinary Hydroxyproline for the Assessment of Fracture Union

Vol 32 | Issue 1 | Jan – June 2017 | page: 32-37 | Sabir Ali, Ajai Singh, Manish Yadav, Abbas Ali Mahdi, Rajeshwer Nath Srivastava


Authors: Sabir Ali [1], Ajai Singh [1], Manish Yadav [1], Abbas Ali Mahdi [2], Rajeshwer Nath Srivastava [1] 

[1] Department of Orthopaedic Surgery, K. G. Medical University, Lucknow, INDIA.
[2] Department of Biochemistry, K. G. Medical University, Lucknow, INDIA.

Address of Correspondence
Dr. Ajai Singh
Department of Orthopaedics Surgery,
K. G. Medical University, Lucknow, India.
Email: as29762@gmail.com


Abstact

Introduction: Predicting the fracture healing outcomes early is one of the most important and fundamental clinical determinations made in Orthopaedics. However, till date there are no methods yet.
Materials and methods: In this cohort study, after ethical clearance and informed consent formalities, total 107 patients were analysed. The serial estimation of total urine hydroxyproline was done at different follow-ups and further correlates it with the fracture healing progression measured using RUST score.
Results: As per 24th week of radiological follow-up, these patients were divided into two groups: Normal healing (n=91) and Impaired healing (n=16) groups. The total urinary hydroxyproline levels were measured at different follow-ups showed statistically significant difference between normal and impaired healing groups, except at baseline. A statistically significant positive correlation between total urinary hydroxyproline levels with fracture healing progression.
Conclusion: The serial monitoring of total urinary hydroxyproline levels can be used as an adjunct to clinical and radiological evidence of fracture healing to predict the outcomes early.
Keywords: Total Urinary Hydroxyproline, Fracture Healing, Impaired Healing.


Introduction
Fractures are common orthopaedic problem occurs most in long bones. Amongst all long bones, shaft of tibia is one of the commonest bones that are prone to fractures. Also due to lesser soft tissue coverage on anterior aspect, such fractures have relatively higher incidence of impaired healing amounting to 2 – 10% [1-2]. Non-union fracture is a dreaded complication with devastating outcomes for the patients that have required involving multiple surgical procedures, pain, morbidity, prolonged hospital stay and functional and psychosocial disability [3]. Ability in prompt identification of patients who are at high risk of non-union will enable early appropriate targeted treatment intervention leading to a successful outcome. Such approach would benefit not only the patient’s wellbeing but also the health care system in terms of the cost implications associated with long lasting treatment interventions and prolonged hospital stay.
Hydroxyproline is released by the breakdown of collagen in the tissues, especially during bone resorption, it degraded into free amino acid that circulates in plasma, and is almost entirely reabsorbed by the kidney. At last it completely oxidized in the liver and degraded to carbon dioxide and urea [4-5]. As the hydroxyproline released during degradation of collagen cannot be reutilized in collagen synthesis, these excreted in the urine and act as a definitive indicator of bone matrix turnover [6-8]. In the present study, we plan to analyzed the serial estimation of total urinary hydroxyproline throughout the initial phase of healing in patients with diaphyseal tibial fracture.

Materials and Methods
This is a prospective cohort study conducted between 2011 to 2015 at our institutional trauma center. After obtaining ethical clearance (Ref. Code: 55 E.C.M. IIB/P6) from institutional ethical review committee and informed consent formalities, the demographic data of all enrolled patients were collected.
As per inclusion-exclusion criteria, total 119 patients of both sexes of aged between 18 and 40 years with simple, fresh (less than 03 days) traumatic diaphyseal fractures of both bones leg managed conservatively were included in the study. Also the patients included in the study were suggested to avoid diets rich in collagen. All patients included in this study were managed conservatively (reduction -setting and above knee plaster cast under general/regional anesthesia). Prior to the management, the clinical and radiological examinations were done. They were admitted for next 24-48 hours and then discharged with a standard advice.
Total urinary hydroxyproline level were estimated from the 24 hours urinary samples according to the method of Bergman and Loxley, 1970 [9] at 04th day (baseline) and 06th & 10th weeks of post-fracture follow-ups.
The clinico-radiological examination was done at 06th, 10th, 16th, 20th, 24th post fracture weeks. The radiological progression of healing was evaluated using RUST scoring system [10-11]. The x-rays for RUST score were examined separately by two orthopaedic surgeons blindly and findings were noted separately. The average of scores was taken for final decision/analysis. The clinic-radiological evaluation at 24th week was used to label the healing as normal or impaired. Patients with normal bony healing were defined with RUST score ≥ 7 by the end of 24th week along with painless (no tenderness), motionless (no abnormal mobility) with presence of transmitted movements at fracture site. Otherwise they were labeled as impaired healing [10-11]. The clinical & radiological status (RUST Score) of union based on 24th week was then analysed against total urinary hydroxyproline level.

Statistical Analysis:
Statistical analysis was performed using SPSS software (SPSS Inc., Chicago, IL, USA) for Windows program (15.0 version). The continuous variables were evaluated by mean (±standard deviation) or range value when required. For comparison of the means between the two groups, analysis by Student’s t-test (unpaired) with 95% confidence interval. The correlation analysis was done using Spearman correlation coefficient. A P < 0.05 or 0.001 was regarded as significant.

Results
Out of 128 patients, 09 were excluded as per inclusion-exclusion criteria. Out of these 119 patients who were enrolled in our study, 12 patients were lost to follow-up. So, only 107 patients were analysed. The baseline characteristics of the patients showed in Table-1, which do not show any statistically significant difference.


As per clinico-radiological status of fracture healing at 24th week, these 107 patients were divided into: Normal Healing (n = 91) and Impaired Healing (n = 16) groups. Mean RUST score at 06th, 10th, 16th, 20th, and 24th weeks of post fracture follow-up were 6.32±0.49, 7.89±0.46, 8.41±0.60, 10.22±0.90 and 11.08±0.86 respectively in normal healing patients and 4.34±0.39, 4.65±0.43, 5.06±0.47, 5.62±0.46, 5.87±0.59 respectively in impaired healing patients. The mean time of healing in normal healing patients was 17.2 ± 3.7 weeks. Mean RUST score were significantly higher at each of the radiological follow-ups in normal healing as compare to impaired healing groups (p <0.0001) [Fig-1].


Total urinary hydroxyproline level at 04th day and 06th & 10th weeks after post-fracture follow-ups were 11.24±2.25, 13.62±3.11 and 10.63±2.79 respectively in normal healing patients and 10.89±2.08, 3.87±1.92 and 2.12±0.93 respectively in impaired healing patients.

The peak total urinary hydroxyproline level was obtained at 04th day (baseline) of post fracture. Significant positive correlation was found between the peak mean total urinary hydroxyproline level (at 04th day) with the fracture healing progression at all different follow up measured using RUST scoring [Table-3; Fig-2].

Discussion
Bone turnover is probably faster than in soft tissues, whereas nearly half of human collagen remains in bone. Excretion of hydroxyproline in urine is regarded as a marker of bone resorption. Approximately 50% of urinary hydroxyproline is derived from bone collagen breakdown [12]. Increased production of collagen is allied with increase in the hydroxyproline [13-14]. In the present study, we plan to analyzed the serial estimation of total urinary hydroxyproline throughout the initial phase of healing, hypothesizing that the total urinary hydroxyproline level might be altered and showed difference in level while compared between normal and impaired healing patients.
In the present study we observed that the total urinary hydroxyproline levels were measured at different follow-ups during the fracture healing progression showed statistically significant difference between normal and impaired healing groups, except at baseline value. Furthermore, statistically significant positive correlation between total urinary hydroxyproline levels with fracture healing progression (RUST score) were also observed.
Increase in the hydroxyproline also found soon after fracture that associated with an increased production of collagen. These modifications represent the changes in levels of total and free hydroxyproline excretion in urine [15-16]. In a recent study by Das., et al. [17], in patients with long bone fractures, significant differences were observed between normal union and nonunion groups in case of urinary hydroxyproline levels after treatment with a positive correlation between urinary hydroxyproline in normal united group. Mukhopadhyay., et al.[7] in their study also observed significant difference in total urinary hydroxyproline between normal union and nonunion groups, showed positive correlation with fracture healing. Our study observations relies on the results obtained by Das et al., [17] and Mukhopadhyay et al.,[7]. Thus, concluded that the serial monitoring of urinary hydroxyproline reflect the actual status of bone turnover in real time [18]. However, small sample size was the limitation of the present study.

Conclusion
Serial monitoring of biochemical marker of bone turnover like urinary hydroxyproline, reflect the actual status of fracture healing progression. Thus, quantification of total urinary hydroxyproline might be used as a complementary assessment tool to assess the fracture healing progression in parallel to clinic-radiological examination. By this, we can accurately assess the healing progression at real time and also may early predict the impaired healing, which could be helpful in performing early interventional procedures. Thus, this approach would benefit not only the patient’s wellbeing but also to the total health care system in terms of the substantial cost associated with long lasting treatment interventions and prolonged hospital stay. However, further multicentric studies were recommended.

Funding
This study was funded by Indian Council of Medical Research, New Delhi (No5/4-5/12/Trauma/2011-NCD-I).

Conflict of interest
The authors have no conflict of interests in this article.

Acknowledgements
This study was supported by Department of Biochemistry, King George’s Medical University, Lucknow, Uttar Pradesh, India and funded by funded by Indian Council of Medical Research, New Delhi.


References

1. Patel M., McCarthy J. J., Herzenberg J. Tibial Nonunion. Medscape Reference (2011).
2. Reed L. K., Mormino M. A. Distal tibia nonunions. Foot and Ankle Clinics 2008 13(4),725–735.
3. Marsh D. Concepts of fracture union, delayed union, and nonunion. Clinical Orthopaedics and Related Research 1998; (355, supplement),S22–S30.
4. Prockop DJ. Isotopic studies on collagen degradation and the urine excretion of hydroxyproline. Journal of Clinical Investigation 1964; 43(3): 453-460.
5. Lindstedt S and Prockop DJ. Isotopic studies on urinary hydroxyproline as evidence for rapidly catabolized forms of collagen in the young rat. Journal of Biological chemistry 1961; 236(5): 1399-1403.
6. Prockop DJ, Kivirikko KI, Tuderman L, Guzman NA. The biosynthesis of collagen and its disorders. New England Journal of Medicine 1979; 301(1): 77-85.
7. Mukhopadhyay M, Sinha R, Pal M, Bhattacharyya S, Dan A, Roy MM. Role of common biochemical markers for the assessment of fracture union. Indian Journal Clinical of Biochemistry 2011; 26(3): 274-278.
8. Jakob C, Zavrski I, Heider U, Brux B, Eucker J, Langelotz C, Sinha P, Possinger K, Sezer O Bone resorption parameters [carboxy-terminal telopeptide of type-I collagen (ICTP), amino-terminal collagen type-I telopeptide (NTx), and deoxypyridinoline (Dpd)] in MGUS and multiple myeloma. European Journal of Haematology 2002 69(1): 37-42.
9. Bergman I, Loxley R. The determination of hydroxyproline in urinary hydrolysates. Clin Chim Acta. 1979; 96:125–30.
10. Sabir Ali, Ajai Singh, Avinash Agarwal, Anit Parihar, A A Mahdi, R. N. Srivastava. Reliability of the RUST Score for the Assessment of Union in Simple Diaphyseal Tibial Fractures. Int J Biomed Res. 2014; 05 (05): 333-335.
11. Whelan DB, Bhandari M, Stephen D, Kreder H, McKee MD, Zdero R, Schemitsch EH. Development of the radiographic union score for tibial fractures for the assessment of tibial fracture healing after intramedullary fixation. Journal of Trauma and Acute Care Surgery 2010; 68(3):629–632.
12. Lowry M, Hall DE, Brosnan JT. Hydmxyproline metabolism by the rat kidney: distribution of renal enzymes of hydroxyproline catabolism and renal conversion of hydroxyproline to glycine and serine. Metabolism 1985; 34(10): 955-961.
13. Sjoerdsma A, Davidson J, Udenfriend S, Mitoma C. Increased excretion of hydroxyproline in Marfan’s syndrome. Lancet 1958; 2(7054): 994-994.
14. Block RJ, Weiss KW, Almquist HJ, Carroll DB, Gordon WG, Saperstein S. Amino Acid Handbook; Methods and Results of Protein Analysis. Springfield 1956; 3(record: 19571404492): 346.
15. Hodgkinson A and Thompson T. Measurement of the fasting urinary hydroxyproline: creatinine ratio in normal adults and its variation with age and sex. Journal of Clinical Pathology 1982; 35(8): 807-811.
16. Deacon AC, Hulme P, Hesp R, Green JR, Tellez M, Reeve J. Estimation of whole body bone resorption rate: a comparison of urinary total hydroxyproline excretion with two radioisotopic tracer methods in osteoporosis. Clinical Chemistry Acta 1987; 166(2-3): 297-306.
17. Soumi Das, Soumya Ghosh, Keya Pal, Arunima Chaudhuri, Soma Datta .Changes in biochemical markers in blood and urine in case of malunion and nonunion after fracture of long bones. Saudi Journal of Sports Medicine 2015; 15(3): 269-275.
18. Manish Yadav, Sabir Ali, Ajai Singh, Abbas Ali Mahdi. Hydroxyproline for the Assessment of Fracture Union. EC Orthopaedics 2016; 3(4): 368-376.


How to Cite this Article: Ali S, Singh A, Yadav M, Mahdi A A, Srivastava R N. Role of Total Urinary Hydroxyproline for the Assessment of Fracture Union. Journal of Bone and Joint Diseases  Jan – June 2017;32(1): 32-37.


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Comparative study of management of Gustillo Anderson Type I & II Fracture Tibia by Plaster of Paris Cast method and External Fixator Method

Vol 32 | Issue 1 | Jan – June 2017 | page: 25-31 | Jasveer Singh, Harish Kumar, Dinesh Kumar, S P S Gill, Pulkesh Singh, Manish Raj


Authors: Jasveer Singh [1], Harish Kumar [1], Dinesh Kumar [1], S P S Gill [1], Pulkesh Singh [1], Manish Raj [1]

[1] U P University of Medical Science Saifai Etawah UP, India.

Address of Correspondence
Dr. Jasveer Singh
Asst. Professor , Department of Orthopaedics , U P U M S , Saifai , Etawah, UP, India
Email: singhkgmc@gmail.com


Abstact

Background: Management of open fracture of leg are the subject of ongoing controversy and discussion despite newer innovation in implants and External Fixator devices. In spite of recent advances in implants choices, conservative management of fractures remain a viable option for surgeons in developing countries like India. The present study was to compare the effectiveness in terms of union of bone and wound healing between external fixator method management with conservative closed POP cast method management in Gustillo Anderson Type – I & Type – II open fracture of leg.
Material and Methods: Total forty patients were followed those having compound fracture tibia and fibula grade 1& 2, randomly selected for external fixator and conservative POP cast management. In these two groups i.e. closed plaster [CP]group and external fixator [EF] group 20 patients in each group followed on 3, 6, 12,and 24 weeks.
Results: Assessment was done based on different parameters and found that Gustillo Anderson Type – I & Type – II open fracture of Tibia and Fibula are better managed in CP group in term of better rate of healing and union of bone rather than external fixator group.
Conclusion: Considering all results conservative management (Cast Method) of open fractures grade 1 and 2 of tibia and fibula gives good results or even better than external fixator method. It is easy to apply in day to day practice and also cost effective in developing countries.
Key words: Tibia fracture, external fixator, cast methods.


Introduction
Tibial diaphyseal fractures are commonest open long bone fractures encountered by most orthopaedic surgeons (1). It is seen 23.5 % of these fractures are compound fractures (2). Guidelines to manage these compound fractures are Antibiotics as soon as possible to reduce the risk of infection , irrigation of open fracture wounds, early fracture stabilization after adequate debridement of wound, early closure of adequately debrided wounds(3). In past era three main techniques were used to prevent infection and treat open fractures (4,5,6).

1. The dressing were done by Dakin’s Solution.
2. The wound was merely exposed and allowed to granulated.
3. Conservative management like plaster to treat fractures

In developing counties like India where motor bikes are more common vehicle to use for transportation, Tibia bone fractures mostly compound fracture grade I and grade II. The management methods in these compound fracture of the Tibia by using External Fixator or Plating or Nailing which are costly so affordability of patients in developing counties is also a big concern. In modern era external fixator is main stay of treatment in open fractures but simultaneously conservative management with plaster cast method is also practiced by orthopaedic surgeons due to economic condition of patients and rush of patients in developing counties in grade 1 and grade 2 compound fractures.

Keeping mind all the facts in the developing country setting the present study has been done to see the effectiveness of POP cast method and External fixator method for management of compound fracture leg Gustilo Anderson type 1 and type 2.

Material and Methods
The aim of this comparative study to compare the effectiveness in the terms of union of bone and wound healing between External Fixator method and Plaster of Paris Casts Method. This trial was conducted from December 2014 to December 2015, in Hospital of Uttar Pradesh University of medical sciences Saifai Etawah after proper informed consent of each patient.
Inclusion criteria were female or male ≥18 years, with compound type 1&2 Gustilo-Anderson diaphyseal tibial and fibula (both bone leg fracture) fracture. Absence of any other bone fracture and any other organ injury in other parts of the body. No compartment syndrome or other pathology of bone so that avoiding the factors that could affect the fracture healing. The fibula intact with tibia fractures or both leg bones fracture with compounding grade 1 / 2 were included in this study. Compound fracture grade 3 were excluded from the study.
After wound debridement in the management of wounds of Gustilo Grade I and Gustilo Grade II of open fractures of tibia different parameters were as follows in terms of –

1. Wound healing which was defined as –
-Difference in the size of wound from the initial wound on 03 weeks, 06 weeks, 03 months, 06 months.
-Presence of healthy granulation tissue on 03 weeks, 06 weeks, 03 months, 06 months.
-Absence of purulent discharge on 03 weeks, 06 weeks, 03 months, 06 months.
2. Duration of Hospital Stay.
3. Direct costs borne by the patient
4. Bone healing by radiologically and finally at 6 month with radiology and clinically.

Forty consecutive patient with Gustilo Grade I and Gustilo Grade II open Fracture of Tibia/ both bone leg fractures were included in the study after informed consent. The patient were randomly allocated to one of the two groups namely Closed Plaster in (CP) group (group 1) and External Fixator (EF) group (group 2). After through wound debridment and reduction of Fracture CP group was treated with the application of above knee closed plaster as it is applied for any injury to the leg. In the EF group fracture were stabilized by external fixators.
In external fixator group patient’s skin was prepared and tourniquet applied. Washing and draping of the wound was done as for a normal surgical procedure but allowing for a wide exposure of the involved area. The debridement of tissue began at the skin. Devitalized skin was removed until bleeding was visible in the skin edge. In a similar fashion the subcutaneous tissue was removed, including all contaminated tissue. The wound was enlarged sufficiently to allow adequate debridement and exposure of the fracture. After all dead tissue had been removed; irrigation of the wound with normal saline, povidone-iodine and hydrogen peroxide solution and surgically created wound was closed first. Thereafter according to the comparative groups, the fracture was stabilized by the help of an above knee plaster of Paris cast of CP group while for the EF group external fixation was done.
External fixator was applied after sharply incising the skin with short longitudinal incisions along safe zones. Bone was reached along the subcutaneous border of the tibia. A drill sheath was used during low-speed power drilling tapping and pin insertion. Pins were inserted by hand through sheaths with a T-handle.
The follow-up was done every 03weeks, 06weeks, 03months, 06months and the condition of the wound was noted. The wound in the plaster cost was inspected through a window and a Check X-ray was done to ascertain the alignment of reduction and if needed (i.e. loosening, lost reduction) the cast was changed. If no manipulation was needed or if the cost was not loose then the window was closed after dressing the wound with normal saline. Povidone-iodine and sterile gauze. For the External Fixator group, the patient was to get dressing done as per the condition of the wound and dressing was done mostly by normal saline, povidone-iodine and hydrogen peroxide (if needed). All the dressing were done mostly on OPD basis. At every follow up Size of wound in square centimeters was taken by taking an impression of the wound on a sterile gauze piece and transferring the imprint into a graph paper and measuring the number of square centimeters covered.
Granulation tissue of the wound was graded as per the visual observation into 0= absent, pale = 1, pink = 2 and red = 3.
If the epithelization of the wound was completed before six weeks then that was noted, else condition of the wound was noted at each follow up and split skin grafting was done when the wound was fit for the same and that time was noted.
.When granulations tissue adequate and no discharge from wound skin grafting of wounds were done if required.
.Stop Rules:
The allocated treatment was to stopped if –
In a smaller sample one group proved to better clinically and statistically then the trial wound have been stopped and all recruited patients were to receive the better treatment.
In the closed plaster group if there was –
1.High grade fever above 1030 F associated with tachycardia.
2.Excessive swelling and tenderness of regional lymph nodes.
3.Edema of distal part of the extremity.
4.Features of impending compartment syndrome.
5.Odour which was intolerable to the patient.
6.Vascular insufficiency suspected.
7.Gas gangrene suspected.

Results
This study was done in our hospital that is tertiary center where mostly trauma patients were referred cases. In referred patient who received primary treatment before arriving in the hospital were received antibiotics, dressing and splintage of the fracture at primary center. The next amount of patient were receiving dressing and splintage followed by only splintage. Thus splintage was the most common first-aid which was given to the patient followed by dressing and then antibiotics. (Table1)

Injury of compound grade tibia fracture Gustilo type 2 was more compare to type 1 in our emergency department (Fig. 1 and 6). In both group Gustilo type 1 fracture patients were less. There were more patient of Gustilo grade II Fracture treated by both the methods (Table 2). Comminuted and oblique fracture accounted for nearly 80% patient in both the groups. (Table3) Majority of patients were victim of road traffic injury in both groups (Table4). Most injuries were sustained during either motor vehicular accident or during fall from heights accounting for nearly 90% of the fraction of both groups of study. In view of socioeconomic status of patient family majority patients were of young age in both groups. 60% in cast group and 70% in fixator group were the patient who were economically productive to the society. So earning members of the family were injured in 67.5% of total patients. (Table5)



Wound size difference between two groups were clinically in external fixator group wounds heals much faster than plaster group. In external fixator group within 3 months wounds healed completely while in plaster group wound healed more than 3 months but difference in healing of the wound by the two modalities was found to be statically non-significant. Implying that the rate of wound healing by the two treatment option is similar (Table 6)
From the point of view of the quality of wound healing it was seen that the absence of the purulent discharge was significantly higher in the cast group thus suggesting a better wound healing is cast group at three weeks of observation. After three weeks when the patient was again studied the two groups showed non-significant difference and at six weeks all the wound had not purulent discharge except one of fixator group. After three months all the wound had not purulent discharge. For the granulation tissue there was very high significance in the appearance of red granulation tissue in cast at three weeks thus there was faster healing of wound in the cast group at three weeks. At the follow up six weeks and three months and six months the significance was not appreciable on univariate analysis (Table7)
All the patients at each follow up in both groups were examined for bone healing through x-rays (Fig. 2 and 7). At first follow up no callus was visible on x-rays in both groups. At second follow up 9 patients in plaster group and 8 patients in external fixator group x rays showed callus formation. At 6 months follow up (figure 5 and 10). No abnormal mobility and pain at fracture site. All the fractures in both groups those are included in study were united well on radiologically and clinically up to 6 months of intervention but union was much earlier visible on radiologically in more patients in plaster group (table8)
Hospital stay in plaster group was significantly vary less compare to external fixator group. The mean of hospital stay in plaster group 2.1 days and in external fixator group was 7.05 days. More hospital stay directly proportional to cost of treatment. Including implant cost, operation cost and hospital stay cost make big difference in total cost of both treatment.

Discussion
Leg is most common extremity and tibia is most common bone to fracture (1). Exact treatment of stabilization of open fracture both bone leg is matter of debate in orthopedics (7). If we compare all open fractures 63% of open injuries occurs only in leg (8]. Due lack of blood supply in distal leg and soft tissue cover, distal leg fractures are more susceptible to infections and nonunion (9,10). To reduce these complications thorough repeated debridement, intravenous antibiotics, stabilization of fracture, and early soft tissue intervention is required (10,11). Gustilo and Anderson [12) reported a 2-16% incidence of infections, a majority of which were type III compound injuries. So the overall less chances of infection in grade 1 and grade 2 fractures.
Now days To stabilize these type of open fractures External fixators (Fig. 8 and 9) are most commonly used but disadvantages of external fixators are pin tract infections(16%), rigidity of construct leads to nonunion, OT cost, hospital stay cost and cost of implants [28]. In open grade 1 and 2 leg fractures pop cast method (Fig. 3 and 4) is easier, simple, OPD procedure so no cost of OT, hospital stay and no implant cost.. In our study we were able to achieve primary closure of the wound in most of cases (in all cases of grade 1 and half of cases of grade 2 fractures). Near about 30% of total cases skin grafting was done. Yokoyama et al., [13] showed primary closures in 70.2% cases and secondary closures with Split skin grafts/ flaps in 29.8% cases.
Sir Winnett Orr (14)for the treatment of these fractures both the wound and the fractures were managed by closed plasters giving good results in 259/268 patients. Prof Trueta also used the method during the Spanish civil war with 976/1073 successful results (15,16).

A similar rate of healing was proved in the observation that the rate the difference the size of the wound was found to be non-significantly different in the two groups seen by the p – values of the means between the two group . This is seen in our observation that there was healthy granulation tissue in 20 to 20 patients in cast group while in the fixator group, there was healthy granulation 17 patients. The duration of hospital stay was also seen to be significantly different because the patients in whom cast was applied were discharged next days after checking for neurovascular assessment with explained instructions to follow up immediately in case of any explained stop rules of the treatment because no further intervention was required for the next three weeks. While in the fixator group, the patient was retained for wound inspection after two days. Regular dressings were done and they were discharged when the wound became healthy. These two different managements resulted in a statistically different durations of hospital stay in cast group at 2 days and in the fixator group at 7 days. This is seen in the significant p-value observation of 0.0005. Thus in the study it was seen that wound in the Gustilo grade-I and Gustilo grade-II open fracture of Tibia are better managed in closed plaster treatment in terms of better rate of healing of wound and union of bone to the patient. The lower duration of hospital stay effectively can result in a better turnover of patients.
Limitations of this study is exclusion of Gustilo grade 3 tibia fractures from this study because in grade 3 external fixation is method of choice no place for plaster there.

Conclusion
This randomized analysis of open fractures leg Gustilo type 1&2 revealed that plaster method (conservative) is a feasible, cost effective , easy to apply, and effective method compare to external fixator method in developing country like India. In developing countries where more and more open fractures but less medical facility at right place, however it is old methods to treat but still its value now days. Most data that received from this study however are not significant statically but plater method seems better in this situation.


References

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2. Pan RH, Chang NT, Chu D, Hsu KF, Hsu YN, Hsu JC, et al. Epidemiology of orthopedic fractures and other injuries among inpatients admitted due to traffic accidents: A 10-year nationwide survey in Taiwan. Scientific World Journal 2014. 2014 637872.
3. Okike, Kanu, and Timothy Bhattacharyya. “Trends in the management of open fractures.” J Bone Joint Surg Am 88.12 (2006): 2739-2748
4. Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand twenty- five open fractures of long bones : retrospective and prospective analyses, Joint Bone Surg 58A:453,1976.
5. Prevention of Infection in the Treatment of One Thousand and Twenty-five Open Fractures of Long BonesRetrospective and Prospective Analyses ,Ramon B. Gustilo, MD; John T. Anderson, MD J Bone Joint Surg Am, 2002 Apr; 84 (4): 682 -682
6. Tscherne H: The management of open fractures. In Tscherne H, Gotzen L, Eds: Fractures With soft tissue injuries, Berlin, 1984 Springer-Verlag.
7. Anderson LD, Hutchins WC, Wright PE, Disney JM. Fractures of the tibia and fibula treated by casts and transfixing pins. Clin Orthop. 1974;105:179–91
8. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type 3 (Severe) open fractures: a new classification of type 3 open fractures. J Trauma. 1984;24:742–46
9. Esterhai JL, Queenan J. Management of soft tissue wounds associated with type III open fractures. Orthop Clin North Am. 1991;22:427–32
10. Fischer MD, Gustilo RB, Vareeka TF. The timing of flap coverage, bone grafting and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft tissue injury. J Bone Joint Surg Am. 1991;73:1316–22
11. Patzakis MJ, Wilkins J, Moore TM. Considerations in reducing the infection rate in open tibial fractures. Clin Orthop. 1983;178:36–4
12. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. J Bone Joint Surg Am. 1976;58:453–08
13. Yokoyama K, Shindo M, Itoman M, Yamamoto M, Sasamoto N. Immediate internal fixation for open fracture of the long bones of the upper and lower extremities. J Trauma. 1994;37:230–36.
14. Orr HW 1929: osteomyelitis and compound fractures. Henry Kempton, London
15. Trueta J 1939: Closed treatment of war fracture. Lancet I: 1452, ii: 351.Medicine and the Spanish Civil WarNicholas ConiJ R Soc Med. 2002 Mar; 95(3): 147–150.
16. The Treatment of War Fractures by the Closed Method: (Section of Surgery)J. TruetaProc R Soc Med. 1939 Nov; 33(1): 65–74.


How to Cite this Article: Singh J,  Kumar H, Kumar D, S P S Gill, Singh P, Raj M. Comparative Study of Management of Gustillo Anderson Type I & II Fracture Tibia By Plaster of Paris Cast Method and External Fixator Method. The Answer to Unstable Peritrochanteric Fractures. Journal of Bone and Joint Diseases  Jan – June 2017;32(1):25-31 .


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