First results with the immediate reconstructive strategy for internal hardware exposure in non-united fractures of the distal third of the leg: case series and literature review

Abstract

BackgroundFractures of the distal third of the leg are increasingly common and are often handled by open reduction and internal fixation. Exposure and infection of internal hardware could occur, especially after high energy traumas, requiring hardware removal and delayed soft tissue reconstruction. Nevertheless immediate soft tissue reconstruction without internal hardware removal is still possible in selected patients.In this study the effectiveness and the complications of immediate soft tissue reconstruction without internal hardware removal is analyzed.Methods13 patients, affected by internal hardware exposure in the distal leg, treated with immediate soft tissue reconstruction with pedicled flaps and hardware retention, are retrospectively analyzed, with special regard to flap survival and wound infection.ResultsWound infection was observed in 10 cases before surgery and in 5 cases surgical debridement was necessary before reconstruction which was performed in a separate operative session.After reconstruction, wound dehiscence and infection occurred in 5 cases, and in 3 cases removal of internal hardware was necessary in order to achieve the complete healing of dehiscence. In one case the previous flap failed but prompt reconstruction with a sural fasciocutaneous flap was performed without hardware removal and without complications. Pre-operative infection and late reconstructive surgery are predictive for higher rates of post-operative complications (respectively p 0.018 and p 0.028).ConclusionOur approach achieved full recovery in 53.8% of the treated cases after one-step surgery, therefore reducing hospitalization and allowing early mobilization. Controlled trials are needed to confirm the effectiveness of this strategy, although the present case series shows encouraging results.

Complications in ankle fracture surgery

“…Of note, even though all patients in Study IV had a deep infection prior to flap reconstruction, the number of complications was less than in a previous study assessing post-flap complications in nonunited fractures of the distal leg (Vaienti et al 2012a). Flap failure rates as high as 23% have been reported in patients with pre-flap infection (Gonzalez et al 2002).…”

“…Since removal of infected hardware prior to fracture union may result in disastrous complications (Calvert et al 2006), wound closure without hardware removal using techniques of soft-tissue reconstruction has been proposed. (Calvert et al 2006, Cavadas and Landin 2006, Cyrochristos et al 2009, Viol et al 2009, Tan et al 2010, Vaienti 2012a, Viaenti 2012b.…”

“…Soft-tissue defects around ankle are demanding to treat due to a fragile subcutaneous vascular network, thin soft-tissue coverage, and limited elasticity of the local skin (Kneser et al 2011, Vaienti et al 2012a). When planning a flap reconstruction for wounds around ankle, the patient's vascular status must be carefully determined with palpation of pulses, doppler ultrasound, and sometimes even with angiography (Levin 2001).…”

“…2012, Vaienti et al 2012a). There is a strong correlation between the pre-flap bacterial cultures and the outcome (Vaienti et al 2012a, Liu et al 2012, and flap failure rates as high as 23% have been reported in patients with pre-flap infection (Gonzalez et al 2002, Gonzalez andWinzweig 2005). Microvascular free flaps have been recommended for the coverage of infected hardware exposure of the distal leg, since the use of a well-vascularized tissue has shown to increase the rate of The present study had the following aims:…”

Complications in ankle fracture surgery

“…The following parameters have been identified as impor-tant for the potential salvage of the exposed hardware with soft-tissue coverage: 1) a proper patient selection; 2) hardware location; 3) duration of exposure; 4) presence and duration of infection; and; 5) presence of hardware loosening (Gonzalez et al 2002, Gonzalez and Weinzweig 2005, Cavadas and Landin 2007, Cyrochristos et al 2009, Viol et al 2009, Liu et al 2012, Vaienti et al 2012a.…”