The Treatment of Gustilo Grade IIIB Tibia Fractures with Application of Antibiotic Spacer, Flap, and Sequential Distraction Osteogenesis

Abstract

Gustilo grade III (GIII) B-C open tibia shaft fractures have a wide spectrum of injury to the bone and soft tissues. At the severe end of the spectrum are GIII B tibia fractures that combine segmental bone loss with soft tissue injuries which require flap reconstruction. These complex injuries can be treated combining circular tensioned wire fixation and distraction histiogenesis with flap reconstruction. GIII B tibia shaft fractures were retrospectively reviewed at an urban Level One Trauma Center from 1992 to 2008 which were treated with the Ilizarov method. Seventy-six patients with 78 fractures were treated. Thirty-eight fractures were treated with flaps. Out of this cohort, a subset of 19 fractures were treated using the protocol of initial multiple debridements, half pin resuscitation external fixation, soft tissue reconstruction over antibiotic spacers and delayed Ilizarov reconstruction after stabilization of the soft tissue envelope. The fractures had multiple aggressive debridements removing nonviable bone. Thirteen free flaps and 6 rotation flaps were applied. Flaps were applied a mean time of 34 days (12-77) after initial injury. Two free flaps failed and had a second successful application. Flap survival was 17 of 19 (89%). There was one partial necrosis and one flap hematoma. There was no flap complication from delayed elevation and spacer removal. Mean tibial bone defect was 9.4 cm (5-17). Reconstruction time was 26.5 months (12-73). Eighteen of 19 fractures were reconstructed with union and no deep infection or osteomyelitis. One fracture had a hypertrophic nonunion in a noncompliant patient. The use of antibiotic spacers and flaps to construct a soft tissue tunnel combined with distraction histiogenesis is an effective technique to salvage complex GIII B tibia fractures with segmental bone loss.

Clinical reliability of closed techniques and comparison with open strategies to achieve union at the docking site

“…Group B: the mean consolidation time was 323 days (range 187-559 days). Soft tissue interposition at the docking site was seen three times before surgical docking [11,18,24] (Fig. 2), and a false aneurism of the peroneal artery was seen after one of the surgical docking site procedures (this was treated by embolisation).…”

Evaluation of an Endoscopic Procedure for the Treatment of Docking Site Nonunion

“…6 In patients who sustain a docking site nonunion, revision surgery can be complicated by other reconstructive procedures performed with the original surgery, such as split thickness skin grafts and free flaps, as well as the implant itself, which makes access difficult. 7,8 Noninvasive techniques such as electrical stimulation, electromagnetic field, ultrasound, and bone marrow injection have been used for long bone nonunion, but these methods are not suitable in docking sites with an external fixator around the limb. Endoscopic procedures could allow a minimally invasive tissue-sparing approach to the docking site.…”

Does Integrated Fixation Provide Benefit in the Reconstruction of Posttraumatic Tibial Bone Defects?

“…The Ilizarov method of complex extremity reconstruction is accepted in the literature; however, the prolonged treatment time and patient-centered outcomes have questioned its use because patient-requested amputation has been documented as a result of intolerance of the treatment [14,17,24,29,36,37]. In the present study, no patient in either group requested an amputation; however, the impact on patients' impression of the treatment algorithm was not directly assessed in this study and should be an outcome measure to be analyzed in future studies.…”