Primary free-flap cover of open tibial fractures

Sinclair, Jennifer; McNally, Martin; Small, J.O.; Yeates, H. A.

doi:10.1016/s0020-1383(97)00093-4

Cited by 65 publications

(36 citation statements)

References 24 publications

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“…Coverage within a week, and considerably sooner in some studies, has been shown to produce fracture union sooner, have a lower infection rate and require fewer operative procedures [18][19][20]. The Guidelines of the British Association of Plastic, Reconstructive and Aesthetic Surgeons and British Orthopaedic Association support this in recommending soft-tissue reconstruction within seven days of injury [21].…”

Section: Principles Of Reconstruction (A) Timing Of Reconstructionmentioning

confidence: 99%

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine

Evriviades

Jeffery

Cubison³

et al. 2011

Phil. Trans. R. Soc. B

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The conflict in Afghanistan has produced injuries similar to those produced from military conflicts for generations. What distinguishes the modern casualty of the conflict in Afghanistan from those of other conflicts is the effectiveness of modern field medical care that has led to individuals surviving with injuries, which would have been immediately fatal even a few years ago. These patients present several challenges to the reconstructive surgeon. These injured individuals present early challenges of massive soft-tissue trauma, unstable physiology, complex bony and soft-tissue defects, unusual infections, limited reconstructive donor sites, peripheral nerve injuries and traumatic amputations. Late challenges to rehabilitation include the development of heterotopic ossification in amputation stumps. This paper outlines the approach taken by the reconstructive team at the Royal Centre for Defence Medicine in managing these most difficult of reconstructive challenges.

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Section: Principles Of Reconstruction (A) Timing Of Reconstructionmentioning

confidence: 99%

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine

Evriviades

Jeffery

Cubison³

et al. 2011

Phil. Trans. R. Soc. B

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“…14,15,21,22 The orthopaedic management of this injury has changed considerably in recent years. While there remain enthusiasts for external fixation, 20 the use of larger hollow nails inserted after reaming and thinner solid unreamed nails has also become more popular, and each has their advocates. 23,24 While there has been a progressive change from external to internal fixation as experience has increased, most reports of internal fixation or primary nailing describe the technique in grade-I to grade-IIIa fractures and very few grade-IIIb injuries are included.…”

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confidence: 99%

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

Gopal¹,

Majumder

Batchelor

et al. 2000

The Journal of Bone and Joint Surgery. British volume

283

133

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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.

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“…In another series, infection rates, flap failure rates and non-union rates exceed 30-50 %. Other authors, in line with the guidelines of the British Orthopaedic Association, have reached similar conclusions, albeit at various breakpoints [2][3][4][5][7][8][9][10][11].…”

Section: Discussionmentioning

confidence: 56%

“…Choudy et al also found a higher non-union rate and infection rate in patients with flap cover after day seven [20]. Gopal et al and Sinclair et al reported series of open tibial fractures with very early skin cover (before day three) and definitive stabilization; 90-95 % of these patients had successful flap cover, with no infection, union of the fracture and excellent outcome without pain or walking disability [4,5]. Such results are exceptional.…”

Section: Discussionmentioning

confidence: 99%

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A review of forty five open tibial fractures covered with free flaps. Analysis of complications, microbiology and prognostic factors

Olesen

Juul

Bonde

et al. 2015

International Orthopaedics (SICOT)

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Primary free-flap cover of open tibial fractures

Cited by 65 publications

References 24 publications

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine

Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine

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

A review of forty five open tibial fractures covered with free flaps. Analysis of complications, microbiology and prognostic factors

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