Soft tissue coverage in open fractures of tibia

Abstract

Background:The treatment of Gustilo Anderson type 3B open fracture tibia is a major challenge and it needs aggressive debridement, adequate fixation, and early flap coverage of soft tissue defect. The flaps could be either nonmicrovascular which are technically less demanding or microvascular which has steep learning curve and available only in few centers. An orthopedic surgeon with basic knowledge of the local vascular anatomy required to harvest an appropriate local or regional flap will be able to manage a vast majority of open fracture tibia, leaving the very few complicated cases needing a free microvascular flap to be referred to specialized tertiary center. This logical approach to the common problem will also lessen the burden on the higher tertiary centers. We report a retrospective study of open fractures of leg treated by nonmicrovascular flaps to analyze (1) the role of nonmicrovascular flap coverage in type 3B open tibial fractures; (2) to suggest a simple algorithm of different nonmicrovascular flaps in different zones and compartment of the leg, and to (3) analyze the final outcome with regards to time taken for union and complications.Materials and Methods:One hundered and fifty one cases of Gustilo Anderson type 3B open fracture tibia which needed flap cover for soft tissue injury were included in the study. Ninety four cases were treated in acute stage by debridement; fracture fixation and early flap cover within 10 days. Thirty-eight cases were treated between 10 days to 6 weeks in subacute stage. The rest 19 cases were treated in chronic stage after 6 weeks. The soft tissue defect was treated by various nonmicrovascular flaps depending on the location of the defect.Results:All 151 cases were followed till the raw areas were covered. In seven cases secondary flaps were required when the primary flaps failed either totally or partially. Ten patients underwent amputation. Twenty-two patients were lost to followup after the wound coverage. Out of the remaining 119 patients, 76 achieved primary acceptable union and 43 patients went into delayed or nonunion. These 43 patients needed secondary reconstructive surgery for fracture union.Conclusion:open fracture of the tibia which needs flap coverage should be treated with high priority of radical early debridement, rigid fixation, and early flap coverage. A majority of these wounds can be satisfactorily covered with local or regional nonmicrovascular flaps.

Emergency Soft Tissue Reconstruction Algorithm in Patients With Open Tibia Fractures

“…Using the algorithm developed in our clinic (the algorithm of emergency leg soft tissue reconstruction in patients with severe open tibia fractures), we obtain results which are consistent with the results of other studies in frequency flap necrosis and frequency of wound infection (see Table 5 ) [ 3 , 4 , 8 , 12 , 23 ]. The stated above proves the standardized approach (algorithm) of treatment patients with severe open tibia fractures to be effective and allow to decrease significantly the complication rate and to improve the treatment results.…”

“…In our clinic, we attempt to standardize the most foolproof flap choosing depending on a square and a localization of a soft tissue defect. Such attempts took place earlier, but the schemes were very complicated or only one type of flap was used (fasciocutaneous) [ 12 ], or they required calculating the square of defect additionally, that is not possible in emergency care [ 9 ]. Being a part of the algorithm, our scheme allows to make decisions concerning a local usage of free flaps depending on a square and a localization of a soft tissue defect.…”

“…A wide application of emergency soft tissues reconstruction after severe open fractures is obstructed by different opinions about wound closing time and necessity of graduated debridement, especially if necrosis develops in several days after a trauma [ 6 - 8 ]. Early closing of soft tissue defects is obstructed by selecting the the flap with particular type of blood circulation and type of tissue which are not exact and these published recommendations are hard to follow in emergency surgery [ 9 - 12 ]. Other complicated questions of emergency soft tissue reconstruction in patients with open tibia fractures are general conditions and presence of polytrauma in 30% of these patients, complicating the implementation of emergency reconstructive operations and in some cases rendering it dangerous for patient’s life [ 13 , 14 ].…”

Management of Gustilo Anderson III B open tibial fractures by primary fascio-septo-cutaneous local flap and primary fixation

“…Although fasciocutaneous, 17 sural, 20 propeller, 16 21 and adipofascial 22 flaps have been commonly employed for the closure of skin defects, 15 16 Hallock 25 reported 30% complications with fasciocutaneous flaps and Almedia 20 reported 25% complications and 4.5% failure with sural artery flaps, whereas the current article reports only 19% complications and 2.7% failure with septocutaneous shift. Panse et al .…”

“…Soft tissue injuries have been managed by different methods. The list includes primary suturing, 14 fasciocutaneous flaps, 15 16 17 18 19 sural flaps, 20 propeller flaps, 16 21 adipofascial flaps, 22 pedicled muscle flaps, 17 18 19 23 24 free perforator, 25 26 and free muscle flaps. 23 25 26 Various other techniques that are rarely used are bipedicled fasciocutaneous flaps, 27 multiple relaxing incisions; 28 Taylor spatial frame for acute deformation to close open wound and delayed correction; 29 30 negative pressure wounds therapy 31 in the 1 st week followed by flap or Split Skin Graft (SSG), tissue expanders for converting III B to III A open fractures, and free fibular osteoseptocutaneous flap graft.…”