Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?

Al-Hourani, Khalid; Fowler, Tim; Whitehouse, Michael R; Khan, Umraz; Kelly, Michael

doi:10.1097/bot.0000000000001562

Cited by 34 publications

(44 citation statements)

References 41 publications

(37 reference statements)

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“…All cases were managed with external fixation, wound coverage and vascular intervention, if needed, at the time of the initial surgical intervention using a single-stage standardised protocol by a multidisciplinary team of orthopaedic, plastic and vascular surgeons. Comparing the results of our fiveyear study with conventional standard protocols advocating serial debridement and delayed wound cover 11,12,14,48 ) and functional outcomes of joint stiffness, union rates and pain) were comparable to our study. A slightly higher initial flap failure rate requiring revision flap surgery in our study (9% vs 3.5%) could be due to gross contamination combined with a delayed presentation in many of our cases.…”

Section: Discussionsupporting

confidence: 77%

Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study

Singh¹,

Dhillon²,

Ss³

2020

Malays Orthop J

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Introduction:Grade 3B/C open tibial fractures with grossly contaminated degloving injuries have poor outcomes, with or without vascular injuries. Treatment decision oscillates between limb salvage and amputation. The standard protocol of repeated debridement and delayed wound cover is a challenge in developing countries due to overcrowded emergencies and limited operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate wound cover as an aggressive modality of treatment. Material and Methods: Thirty-three patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent debridement, external fixation and immediate wound cover with free distant/local rotational muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures. Intra-articular fractures were excluded. Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes. Results: Wound cover was achieved with 24 distant free muscle flaps, four local rotational muscle flaps and five fasciocutaneous flaps. All fractures united with an average time to union of 40.3 weeks (16-88). Fifteen patients (45.4%) underwent only a single major surgery using primary definitive external fixation. Deep infection was seen in four patients (12.1%). Nineteen patients had excellent to good outcomes, six were fair, and eight were poor. Conclusion: "Fix and Flap" in the same sitting, using immediate wound cover and external fixation, has given good results in our hands despite the delayed presentation, the neurovascular deficit and the degloving injury. This may be a better management strategy in overcrowded tertiary care centres of developing countries, with a single surgical procedure in almost half the cases.

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Section: Discussionsupporting

confidence: 77%

Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study

Singh¹,

Dhillon²,

Ss³

2020

Malays Orthop J

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“…Two studies reported mean time to debridement in groups with infection compared to groups without infection [31,35]. The overall effect was not statistically significant (standardised mean difference = −0.0135; 95% CI, −0.1065 to 0.0795; p = 0.32).…”

Section: Infectionmentioning

confidence: 95%

“…Of the 20 included studies, only 5 provided a description of the debridement carried out [26][27][28][29][30]. Only three studies specified that an Orthoplastic approach was used in the management of fractures [31][32][33]. Six studies did not specify the method of skeletal fixation [32,[34][35][36][37][38], whereas the rest used various methods for the management of the reported fractures.…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

“…Six studies did not specify the method of skeletal fixation [32,[34][35][36][37][38], whereas the rest used various methods for the management of the reported fractures. Furthermore, only two studies specified the method of soft tissue reconstruction [28,31]. All but one study [34] specified the use of antibiotic prophylaxis.…”

Section: Characteristics Of Included Studiesmentioning

confidence: 99%

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The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis

et al. 2021

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Introduction: Open tibial fractures are complex injuries with variable outcomes that significantly impact patients’ lives. Surgical debridement is paramount in preventing detrimental complications such as infection and non-union; however, the exact timing of debridement remains a topic of great controversy. The aim of this study is to evaluate the association between timing of surgical debridement and outcomes such as infection and non-union in open tibial fractures. Materials and Methods: We performed a systematic review and meta-analysis of the literature to capture studies evaluating the association between timing of initial surgical debridement and infection or non-union, or other reported outcomes. We searched the MEDLINE, PubMed Central, EMBASE, SCOPUS, Cochrane Central and Web of Science electronic databases. Our methodology was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane handbook for systematic reviews of interventions. Results: The systematic review included 20 studies with 10,032 open tibial fractures. The overall infection rate was 14.3% (314 out of 2193) and the overall non-union rate 14.2% (116 out of 817). We did not find any statistically significant association between delayed debridement and infection rate (OR = 0.87; 95% CI, 0.68 to 1.11; p = 0.23) or non-union rate (OR = 0.70; 95% CI, 0.42 to 1.15; p = 0.13). These findings did not change when we accounted for the effect of different time thresholds used for defining early and late debridement, nor with the Gustilo–Anderson classification or varying study characteristics. Conclusion: The findings of this meta-analysis support that delayed surgical debridement does not increase the infection or non-union rates in open tibial fracture injuries. Consequently, we propose that a reasonable delay in the initial debridement is acceptable to ensure that optimal management conditions are in place, such that the availability of surgical expertise, skilled staff and equipment are prioritised over getting to surgery rapidly. We recommend changing the standard guidance around timing for performing surgical debridement to ‘as soon as reasonably possible, once appropriate personnel and equipment are available; ideally within 24-h’.

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“…A new transcortical 3.5mm DCP is applied to the anterior tibial cortex, bridging any communition or butterfly fragments. This bridging plate allows the 'plateassisted' technique that facilitates the intramedullary nailing and is part of the unit's orthoplastic protocol (14). If it was felt the new plate was essential for stability of a…”

Section: Surgical Interventionsmentioning

confidence: 99%

Plate-Assisted Intramedullary Nailing of Gustilo Type IIIB Open Tibial Diaphyseal Fractures: Does Adjunctive Plate Retention Affect Complication Rate?

Stoddart

Al-Hourani

Fowler

et al. 2020

Journal of Orthopaedic Trauma

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Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?

Abstract: Two-stage combined ortho-plastic management of type IIIB open diaphyseal tibial fractures requiring flap coverage: Is the timing of debridement and coverage associated with outcomes?

Cited by 34 publications

References 41 publications

Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study

Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study

The Effect of Delayed Surgical Debridement in the Management of Open Tibial Fractures: A Systematic Review and Meta-Analysis

Plate-Assisted Intramedullary Nailing of Gustilo Type IIIB Open Tibial Diaphyseal Fractures: Does Adjunctive Plate Retention Affect Complication Rate?

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