Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia

Abstract

We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year.After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection.The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (>72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure. J Bone Joint Surg [Br] 2000;82-B:959-66.

An Algorithmic Approach for Managing Orthopaedic Surgical Wounds of the Foot and Ankle

“…Concerted efforts of the plastic surgeon and orthopaedic surgeon have improved treatment of complex foot and ankle wound problems that once may have been considered unsalvageable, particularly in the case of open fractures [7,11,13,14]. The orthoplastic approach, which integrates the expertise and surgical techniques of the two specialties, also may permit improvements in the management of foot and ankle problems that are not related to trauma.…”

Negative Pressure Wound Therapy in Grade IIIB Tibial Fractures: Fewer Infections and Fewer Flap Procedures?

“…All six studies [6,15,16,29,35,45] with data regarding flap rates and extended negative pressure wound therapy use reported a decrease in flap procedures with extended negative pressure wound therapy. Two [15,16] of the studies reported infection complications similar to those of historic controls [1,11,13,20,26,28]. Dedmond et al [15,16] concluded the avoidance of flap procedures, particularly in the pediatric population, in the end outweighed the equivalent infection rates.…”

“…The question was whether use of negative pressure wound therapy beyond 72 hours would result in increased infection rates compared with historic controls [1,11,13,20,26,28]. Reported infection rates are highly variable for Grade IIIB tibia wounds with the upper end at 67% [10].…”

Fraturas da diáfise da tíbia

“…The classic studies by Godina (26) and Gopal et al (27) , who performed early closure of injury or early flap rotation, demonstrate significantly reduced infection rates, even in severe open fractures.…”