Application of Nice knot technique in wound closure of Gustilo type <b>Ⅲ</b>A and <b>Ⅲ</b>B open tibial fractures_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

YAO Zhipeng ¹ , WANG Minxing ² , ZHU Wenxiong ¹ , WANG Shanyi ¹ , HUANG Hongxuan ¹ ,  CHEN Zequn ¹

1. Department of Orthopedics, Dongguan Key Laboratory of Basic, Clinical and Digital Research on Common Orthopedic Diseases, the Tenth Affiliated Hospital of Southern Medical University (Dongguan People’s Hospital), Dongguan Guangdong, 523059, P. R. China;
2. Hospital Infection-Control Department, Dongguan Maternal and Child Health Care Hospital, Dongguan Guangdong, 523059, P. R. China;

Corresponding?author：

CHEN Zequn, Email: 365896237@qq.com

Keywords：

Nice knot technique; open tibial fracture; wound closure

DOI：

10.7507/1002-1892.202310090

Video：

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Objective To explore the effectiveness of Nice knot technique for wound closure in Gustilo type ⅢA and ⅢB open tibial fractures. Methods A retrospective study was performed on 22 patients with Gustilo type ⅢA and ⅢB open tibial fractures, who underwent wound closure using the Nice knot technique and were admitted between June 2021 and June 2022. There were 15 males and 7 females. The age ranged from 18 to 67 years, with an average of 41.9 years. The causes of injury included traffic accident in 11 cases, falling from height in 7 cases, and heavy object injuries in 4 cases. Fractures were located on the left side in 9 cases and on the right side in 13 cases. And 9 cases were type ⅢA fractures and 13 were type ⅢB fractures according to Gustilo classification. All patients had extensive soft tissue injuries, and no vascular or neurological damage was observed. The time from injury to debridement was 3-8 hours (mean, 6.5 hours). The sizes of wounds before operation and at 2 weeks after operation were measured and wound healing rate at 2 weeks after operation were calculated. The wound healing time and wound healing grading were recorded. The Vancouver Scar Scale (VSS) score was used to assess the wound scar after wound healed and the excellent and good rate was calculated. Results The wound area was 21.0-180.0 cm² (mean, 57.82 cm²) before operation, and it was 1.2-27.0 cm² (mean, 6.57 cm²) at 2 weeks after operation. The wound healing rate at 2 weeks after operation was 76%-98% (mean, 88.6%). After operation, 2 cases needed to adjust Nice knot due to skin cutting and 1 case occurred soft tissue infection on the wound. The other patient’s wounds healed. The average wound healing time was 27.8 days (range, 18-44 days). And the wound healing were grade A in 13 cases and grade B in 9 cases. VSS score was 2-9, with an average of 4.1; 10 cases were rated as excellent, 10 as good, and 2 as poor, with an excellent and good rate of 90.9%. All patients were followed up 9-24 months (mean, 14.6 months). During follow-up, no deep infection or osteomyelitis occurred. Two cases experienced fracture non-union, and were treated with compression fixation and bone grafting. The fractures of the other patients all healed, with a healing time of 85-190 days (mean, 148.2 days). Conclusion Nice knot technique can be used in wound closure of Gustilo type ⅢA and ⅢB open tibial fractures effectively, which is easy to operate.

Citation： YAO Zhipeng, WANG Minxing, ZHU Wenxiong, WANG Shanyi, HUANG Hongxuan, CHEN Zequn. Application of Nice knot technique in wound closure of Gustilo type ⅢA and ⅢB open tibial fractures. Chinese Journal of Reparative and Reconstructive Surgery, 2024, 38(1): 46-50. doi: 10.7507/1002-1892.202310090 Copy

1.	Court-Brown CM, Bugler KE, Clement ND, et al. The epidemiology of open fractures in adults. A 15-year review. Injury, 2012, 43(6): 891-897.
2.	Joosten PGF, Borgdorff MP, Botman M, et al. Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis. Eur J Trauma Emerg Surg, 2023. https://doi.org/10.1007/s00068-023-02366-x.
3.	Lua J, Tan VH, Sivasubramanian H, et al. Complications of open tibial fracture management: risk factors and treatment. Malays Orthop J, 2017, 11(1): 18-22.
4.	Hoekstra H, Smeets B, Metsemakers WJ, et al. Economics of open tibial fractures: the pivotal role of length-of-stay and infection. Health Econ Rev, 2017, 7(1): 32.
5.	Gopal S, Majumder S, Batchelor AG, et al. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg (Br), 2000, 82(7): 959-966.
6.	曾文波, 李姣, 郝東陽, 等. 三種固定方式治療GustiloⅢA-B型開放性脛骨骨折的對比. 中國矯形外科雜志, 2018, 26(24): 2209-2214.
7.	阮默, 徐永清, 沙勇, 等. 外固定支架治療GustiloⅡ、Ⅲ型脛腓骨開放性骨折. 中華創傷骨科雜志, 2014, 16(11): 965-970.
8.	Xu J, Chang R, Zhang W, et al. Skin stretch suturing with Nice knots in the treatment of small- or medium-sized wounds. J Orthop Surg Res, 2020, 15(1): 488.
9.	Sun C, Zhao J, Liu Z, et al. Comparing conventional flap-less immediate implantation and socket-shield technique for esthetic and clinical outcomes: A randomized clinical study. Clin Oral Implants Res, 2020, 31(2): 181-191.
10.	Malik SS, Hart D, Parashin S, et al. Does the Nice knot offer less elongation than the modified Prusik knot? An in vitro study in cadaver quadriceps tendons. Clin Orthop Relat Res, 2022, 480(7): 1403-1410.
11.	Yin Z, Yan J, Ge D, et al. Comparison of double-strand braided polyester sutures tension band (Nice knot) with cable tension band in transverse patellar fractures. Injury, 2021, 52(10): 3085-3090.
12.	Hill SW, Chapman CR, Adeeb S, et al. Biomechanical evaluation of the Nice knot. Int J Shoulder Surg, 2016, 10(1): 15-20.
13.	Collin P, Laubster E, Denard PJ, et al. The Nice knot as an improvement on current knot options: A mechanical analysis. Orthop Traumatol Surg Res, 2016, 102(3): 293-296.
14.	Zhong Q, Zhan J, Yang H, et al. A new method of Nice knot elastic fixation for distal tibiofibular syndesmosis injury. Orthop Surg, 2023, 15(3): 785-792.
15.	Hu F, Han S, Liu F, et al. A modified single-endobutton technique combined with nice knot for treatment of Rockwood type Ⅲ or Ⅴ acromioclavicular joint dislocation. BMC Musculoskelet Disord, 2022, 23(1): 15.
16.	Wu G, Chen YQ, Chen CY, et al. Clinical outcomes of doubled-suture Nice knot augmented plate fixation in the treatment of comminuted midshaft clavicle fracture. BMC Surg, 2021, 21(1): 270.
17.	張偉, 王海霞, 常銳. Nice自鎖滑線結牽張技術延遲閉合創面. 中國矯形外科雜志, 2022, 30(17): 1626-1629.
18.	陳濤, 馬信龍, 馬劍雄, 等. 雙股絲線縫合Nice結固定聯合彈性敷貼牽張治療皮膚軟組織缺損. 中華骨科雜志, 2020, 40(3): 154-159.
19.	Zhao C, Hsu CC, Moriya T, et al. Beyond the square knot: a novel knotting technique for surgical use. J Bone Joint Surg (Am), 2013, 95(11): 1020-1027.
20.	張延齡, 吳肇漢. 實用外科學. 3版. 北京: 人民衛生出版社, 2012: 166.
21.	Baryza MJ, Baryza GA. The Vancouver Scar Scale: an administration tool and its interrater reliability. J Burn Care Rehabil, 1995, 16(5): 535-538.
22.	倪國驊, 吳學建, 張德洪, 等. 皮膚彈性牽張法治療小腿皮膚缺損骨外露. 中華創傷骨科雜志, 2015, 17(7): 629-631.
23.	Boileau P, Alami G, Rumian A, et al. The doubled-suture Nice knot. Orthopedics, 2017, 40(2): e382-e386.
24.	陳濤, 劉莉茵, 馬信龍, 等. Nice結與皮膚牽張器用于中小型皮膚軟組織缺損治療的臨床研究. 天津醫藥, 2021, 49(7): 765-768.

1. Court-Brown CM, Bugler KE, Clement ND, et al. The epidemiology of open fractures in adults. A 15-year review. Injury, 2012, 43(6): 891-897.
2. Joosten PGF, Borgdorff MP, Botman M, et al. Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis. Eur J Trauma Emerg Surg, 2023. https://doi.org/10.1007/s00068-023-02366-x.
3. Lua J, Tan VH, Sivasubramanian H, et al. Complications of open tibial fracture management: risk factors and treatment. Malays Orthop J, 2017, 11(1): 18-22.
4. Hoekstra H, Smeets B, Metsemakers WJ, et al. Economics of open tibial fractures: the pivotal role of length-of-stay and infection. Health Econ Rev, 2017, 7(1): 32.
5. Gopal S, Majumder S, Batchelor AG, et al. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg (Br), 2000, 82(7): 959-966.
6. 曾文波, 李姣, 郝東陽, 等. 三種固定方式治療GustiloⅢA-B型開放性脛骨骨折的對比. 中國矯形外科雜志, 2018, 26(24): 2209-2214.
7. 阮默, 徐永清, 沙勇, 等. 外固定支架治療GustiloⅡ、Ⅲ型脛腓骨開放性骨折. 中華創傷骨科雜志, 2014, 16(11): 965-970.
8. Xu J, Chang R, Zhang W, et al. Skin stretch suturing with Nice knots in the treatment of small- or medium-sized wounds. J Orthop Surg Res, 2020, 15(1): 488.
9. Sun C, Zhao J, Liu Z, et al. Comparing conventional flap-less immediate implantation and socket-shield technique for esthetic and clinical outcomes: A randomized clinical study. Clin Oral Implants Res, 2020, 31(2): 181-191.
10. Malik SS, Hart D, Parashin S, et al. Does the Nice knot offer less elongation than the modified Prusik knot? An in vitro study in cadaver quadriceps tendons. Clin Orthop Relat Res, 2022, 480(7): 1403-1410.
11. Yin Z, Yan J, Ge D, et al. Comparison of double-strand braided polyester sutures tension band (Nice knot) with cable tension band in transverse patellar fractures. Injury, 2021, 52(10): 3085-3090.
12. Hill SW, Chapman CR, Adeeb S, et al. Biomechanical evaluation of the Nice knot. Int J Shoulder Surg, 2016, 10(1): 15-20.
13. Collin P, Laubster E, Denard PJ, et al. The Nice knot as an improvement on current knot options: A mechanical analysis. Orthop Traumatol Surg Res, 2016, 102(3): 293-296.
14. Zhong Q, Zhan J, Yang H, et al. A new method of Nice knot elastic fixation for distal tibiofibular syndesmosis injury. Orthop Surg, 2023, 15(3): 785-792.
15. Hu F, Han S, Liu F, et al. A modified single-endobutton technique combined with nice knot for treatment of Rockwood type Ⅲ or Ⅴ acromioclavicular joint dislocation. BMC Musculoskelet Disord, 2022, 23(1): 15.
16. Wu G, Chen YQ, Chen CY, et al. Clinical outcomes of doubled-suture Nice knot augmented plate fixation in the treatment of comminuted midshaft clavicle fracture. BMC Surg, 2021, 21(1): 270.
17. 張偉, 王海霞, 常銳. Nice自鎖滑線結牽張技術延遲閉合創面. 中國矯形外科雜志, 2022, 30(17): 1626-1629.
18. 陳濤, 馬信龍, 馬劍雄, 等. 雙股絲線縫合Nice結固定聯合彈性敷貼牽張治療皮膚軟組織缺損. 中華骨科雜志, 2020, 40(3): 154-159.
19. Zhao C, Hsu CC, Moriya T, et al. Beyond the square knot: a novel knotting technique for surgical use. J Bone Joint Surg (Am), 2013, 95(11): 1020-1027.
20. 張延齡, 吳肇漢. 實用外科學. 3版. 北京: 人民衛生出版社, 2012: 166.
21. Baryza MJ, Baryza GA. The Vancouver Scar Scale: an administration tool and its interrater reliability. J Burn Care Rehabil, 1995, 16(5): 535-538.
22. 倪國驊, 吳學建, 張德洪, 等. 皮膚彈性牽張法治療小腿皮膚缺損骨外露. 中華創傷骨科雜志, 2015, 17(7): 629-631.
23. Boileau P, Alami G, Rumian A, et al. The doubled-suture Nice knot. Orthopedics, 2017, 40(2): e382-e386.
24. 陳濤, 劉莉茵, 馬信龍, 等. Nice結與皮膚牽張器用于中小型皮膚軟組織缺損治療的臨床研究. 天津醫藥, 2021, 49(7): 765-768.

Chinese Journal of Reparative and Reconstructive Surgery

Application of Nice knot technique in wound closure of Gustilo type ⅢA and ⅢB open tibial fractures

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