Soft tissue reconstruction of Gustilo-Anderson grade 3B open tibia fractures at a tertiary hospital: a retrospective case series

Abstract

BackgroundThe management of Gustilo-Anderson grade 3B open tibia fractures are challenging due to the high complication rates, including infection, non-union and amputation. Despite developing treatment options for these injuries, the optimal soft tissue cover option and timing of definitive surgery remains unclear and is often dictated by local context and available surgical expertise rather than the gold standard of care. The authors aimed to review the surgical techniques and outcomes for the management and reconstruction of the soft tissues in Gustilo-Anderson grade 3B tibia fractures treated at a tertiary hospital in South Africa. MethodsA retrospective study was conducted on 22 patients who underwent soft tissue reconstruction for grade 3B tibia fractures from January 2014 to July 2017. Patient demographics, medical comorbidities, injury characteristics and management practices such as time to debridement, relook time, use of negative pressure wound therapy (NPWT), soft tissue coverage techniques and complications were recorded and analysed. ResultsMost patients were males (n = 18; 82%) with an average age of 39.3 years (range 15-69). Pedestrian vehicle accidents accounted for 45% (n = 10), followed by motor vehicle accidents (n = 6; 27%) and gunshot wounds (n = 2; 9%). Most patients (n = 18; 82%) were initially debrided within 24 hours. The mean time for NPWT usage prior to cover was 12.5 days. The mean time before soft tissue cover was attempted was 13.7 days (range 2-35). Fasciocutaneous flaps (n = 11; 50%) were the most common method used to achieve bony cover, followed by pedicled muscle flaps (n = 8; 36%), free flaps (n = 2; 9%) and skin grafts (n = 1; 5%). Most patients (n = 13; 59%) achieved satisfactory outcomes. Seven (32%) required soft tissue revisions. Additional complications included complete flap loss resulting in amputation, partial skin graft loss and soft tissue infection. Fewer complications were seen in patients who were first debrided within 24 hours from time of injury. ConclusionDue to a resource constraint in our working environment, it is not possible to accurately follow available treatment guidelines in our management of grade 3B open tibia fractures. Despite this, the outcomes seen in this small sample were in keeping with those seen in the literature.