The Effects of Timing of Soft Tissue Coverage on Outcomes After Reconstruction of Type IIIB Open Tibia Fractures

Abstract

High-energy open fractures of the tibia are frequently associated with tissue loss, wound contamination, and compromised vascularity that often result in amputation. The management of these severe injuries remains a challenge for orthopedic reconstructive surgeons. Studies have compared the timing of soft tissue coverage of Gustilo type IIIB open tibia fractures with associated outcomes such as rate of deep infection, primary union, length of hospitalization, flap failure, and eventual secondary amputation. These studies often highlight better outcomes with specific time domains that are not always attainable at a large tertiary hospital with multi-system trauma patients. Many studies do not account for delayed patient transfers after initial open fracture management elsewhere. This retrospective analysis of the limb salvage outcomes included 140 consecutive patients with Gustilo type IIIB open tibia fractures who presented to the authors' level I trauma center between 2001 and 2014. The authors included patients who required delayed coverage or who were transferred from outside institutions. The majority (77%) were male, and the mean age was 39.4 years. Motor vehicle accidents were the most common cause of injury, and 83% of patients obtained full weight-bearing status with successful limb salvage. Twenty patients had a secondary amputation, with the cause being refractory osteomyelitis in 52%. This study provides guidance on treating a heterogeneous patient population with severe open tibia fractures typically seen in a large tertiary hospital orthopedic trauma service. [ Orthopedics . 2019; 42(5):260–266.]

Timing of Flap Coverage With Respect to Definitive Fixation in Open Tibia Fractures

“…This is the first large study to directly compare the predictive ability of various time windows of delay with flap coverage on wound infection. [31][32][33][34][35][36][37][38][39][40] We determined with regression modeling that definitive fixation to flap coverage was more predictive than using traditional time origins to measure delay. 41 We validated the association by adjusting for confounding in a subsequent model.…”

Open tibial shaft fracture management in Argentina: an evaluation of treatment standards in diverse resource settings

“…Notably, the AATO Exterior Committee reported performing soft-tissue coverage less frequently within a 7 day post-injury standard than the Interior Committee surgeons. [21][22][23][24] The AATO Exterior Committee also reported having more access to plastic surgeons at their institutions, in contrast to the AATO and Non-AATO Interior Committee groups that cited a lack of available plastic surgeons to provide definitive coverage. This discrepancy in access to multidisciplinary management is welldocumented in LMICs worldwide.…”

The Continued Impact of Godina's Principles: Outcomes of Flap Coverage as a Function of Time After Definitive Fixation of Open Lower Extremity Fractures

“…4,[7][8][9][10] Previous studies have shown a wide array of coverage timelines, with many delaying coverage well into the "subacute period," and delays up to a month showing similar infection, flap loss, and nonunion rates as studies advocating for early soft tissue reconstruction. [11][12][13][14][15][16][17][18][19][20][21][22] Consensus among experts and the literature coalesced around Godina's previous 72-hour mark 4,7,15,19,21,[23][24][25] and the 7-day mark. 9,16,18,19,[25][26][27][28][29][30][31][32][33] Currently, the American College of Surgeons/Orthopedic Trauma Association guidelines recommend the treatment of open tibial wounds within 7 days.…”

“…[11][12][13][14][15][16][17][18][19][20][21][22] Consensus among experts and the literature coalesced around Godina's previous 72-hour mark 4,7,15,19,21,[23][24][25] and the 7-day mark. 9,16,18,19,[25][26][27][28][29][30][31][32][33] Currently, the American College of Surgeons/Orthopedic Trauma Association guidelines recommend the treatment of open tibial wounds within 7 days. 34 We sought to test Dr. Godina's original findings as well as these guidelines in patients who sustained open lower extremity fractures and underwent this growing paradigm of early and definitive open reduction and internal fixation (ORIF) of their injuries prior to soft tissue reconstruction.…”

“…11 12 13 14 15 16 17 18 19 20 21 22 Consensus among experts and the literature coalesced around Godina's previous 72-hour mark 4 7 15 19 21 23 24 25 and the 7-day mark. 9 16 18 19 25 26 27 28 29 30 31 32 33 Currently, the American College of Surgeons/Orthopedic Trauma Association guidelines recommend the treatment of open tibial wounds within 7 days. 34…”