Definitive Soft Tissue Coverage Research Articles

The Role of Negative Pressure Wound Therapy in Temporizing Traumatic Wounds before Lower Limb Soft Tissue Reconstruction: A Systematic Review.

In practice, there is often a delay from initial debridement and temporary fixation to definitive soft tissue coverage of traumatic leg wounds. Without clear evidence, conservative negative pressure wound therapy (NPWT) is increasingly used to temporize these wounds. This systematic review summarizes and synthesizes the literature on using NPWT to temporize traumatic leg wounds before surgery in adult surgical patients. A comprehensive search of Medline, Embase, and Cochrane Library was performed from inception until July 2022, inclusively. Two independent reviewers performed screening, data extraction, and risk of bias assessment. Primary English studies, including adult patients (≥16 years old) with a fracture below the knee up to and including the ankle that received NPWT to temporize wounds before definitive soft tissue reconstruction with a flap and/or graft, were included. Thirty-four studies, including 804 patients who received NPWT, were included. The partial/total flap loss rate was 6.95% (n = 9 studies), the infection rate was 19.5% (n = 25 studies), the nonunion rate was 18% (n = 15 studies), the delayed union rate was 9.31% (n = 3 studies), and the amputation rate was 15.4% (n = 6 studies). The mean late stay was 43.1 days (n = 9 studies), and the follow-up length was 23.7 months (n = 9 studies). The mean time to wound healing was 5.63 months (n = 2 studies), and the time to soft tissue coverage was 40.8 days (n = 12 studies). The mean time to achieve bone union was 7.26 months (n = 6 studies). NPWT can be used to temporize traumatic wounds while awaiting soft tissue reconstruction.

Immediate versus early soft tissue coverage for severe open grade III B tibia fractures: a comparative clinical study

Controversy remains regarding timing in the management of grade III-B open tibia fractures. Many authors recommend an immediate definitive soft tissue coverage within a critical period of 12 hours, yet in many patients, this may be impossible due to concomitant injuries or delayed referral. The present case series aims to compare the role of immediate versus early soft tissue coverage for severe open grade III-B tibial fractures. 20 cases of tibial fractures of were divided into two groups; 10 cases each. Immediate group (within 12 hours) and early group (3-7 days), according to the soft tissue coverage time. Strict criteria for inclusion in the first group included debridement within 12 hours of injury, no sewage or organic contamination, the presence of bleeding skin margins, and the absence of systemic illness. All 20 cases had been treated by a debridement and soft-tissue cover with a muscle pedicle or fasio-cutanous flap. Functional outcome measures included deep infection rate, stable soft tissue coverage, number of inpatient’s stays, number of surgical procedures, and union time. The mean follow-up period was 24 months. Mean inpatient time was 30 and 41 days respectively. Mean surgical procedures were 2.2 and 3.4 respectively and union time was 26 versus 34 weeks. Mean inpatient time, mean surgical procedures per time and union time were pointedly less in the immediate flap coverage group which significantly improves results concerning early union, healing time, and cost of hospitalization and rehabilitation.

Predicting Union, Osteomyelitis, and Amputation Outcomes of Gustilo IIIC Open Tibial Fractures: A Retrospective Study.

Open tibial fractures are frequently encountered in high-energy traumas and can result in significant complications such as nonunion, osteomyelitis, and even amputation. Among open tibial fractures, Gustilo type IIIC cases are particularly challenging due to the concomitant occurrence of neurovascular injuries and soft tissue defects. This study aimed to assess factors that affect union time and complications in Gustilo IIIC tibial fractures. Patients who presented at our center with IIIC open tibial fractures from January 2000 to October 2020 were eligible for this retrospective analysis. Patient demographics, fracture characteristics, and the timing, number, and type of surgical intervention were documented. Outcomes of interest included union time, occurrence of osteomyelitis, and amputation. We performed univariate analyses including chi-squared test, Fischer's exact test, analysis of variance, and Kruskal-Wallis test based on the normality of the data and multivariate analyses including Cox proportional hazards model and logistic regression analyses. Fifty-eight patients were enrolled and grouped by fracture healing time; eight had timely union (13.8%); 27 had late union (46.6%); eight had delayed union (13.8%); three had nonunion (5.2%); and 12 underwent amputation (20.7%). Nine fractures (15.5%) were complicated by osteomyelitis. Union time was prolonged in cases of triple arterial injury, distal third fractures, multiple trauma with injury severity score (ISS) ≥ 16 points, and increased bone defect length. Additionally, a bone gap >50 mm, diabetes mellitus, low body mass index, and triple arterial injury in the lower leg were significant risk factors for amputation. A time from injury to definitive soft tissue coverage of more than 22 days was the major risk factor for osteomyelitis. A scoring system to predict union time was devised and the predicted probability of union within 2 years was stratified based on this score. IIIC tibial fractures involving the distal third of the tibia, fractures with bone defects, triple arterial injury, and multiple trauma with ISS ≥16 points demonstrated delayed union, and an effective prediction system for union time was introduced in this study. Early soft tissue coverage can reduce the risk of osteomyelitis. Finally, diabetes and severe bone and soft tissue defects pose a higher risk of amputation.

Delayed Reconstruction of the Perforator Pedicle Propeller Flap after the Induced Membrane Technique for Gustilo IIIB Open Distal Tibial Fracture.

This study aimed to evaluate the safety and efficacy of delayed reconstruction of the perforator pedicle propeller flap after the induced membrane technique in the treatment of Gustilo IIIB open distal tibial fracture, and to evaluate the clinical outcome and complications of two different perforator pedicle propeller flaps.Thirty-four patients with Gustilo IIIB open distal tibial fractures treated by the induced membrane technique and delayed reconstruction of two different perforator pedicle propeller flaps from May 2017 to March 2022 were retrospectively analyzed. Patients were divided into two groups according to the different kinds of perforator pedicle propeller flaps covered. The operation required two stages. The Radiographic Union Score for Tibial fractures (RUST) was used to evaluate the healing of the tibial bone defect. The American Orthopaedic Foot and Ankle Society (AOFAS) score was used to evaluate ankle function. The complications associated with the technique were recorded.The number of serial debridements, excluding those performed during emergency and final operations, was a mean of 2.28±0.83 in the PAPF group. The PAPF group had a mean bone defect length of 6.76 ± 0.69 cm, the median healing time of 13.11 ± 0.96 months, RUST score 12.68 ± 1.63, and AOFAS score of 84.12 ± 6.38. On the other hand the PTAPF group's mean bone defect length was 6.73 ± 0.95 cm, the median healing time 12.63 ± 1.46 months, RUST score 13.73 ± 1.53 and AOFAS score 82.79 ± 5.49. There were no observed significant differences the two groups in the number of serial debridements, bone defect length, bone union time, RUST score, or AOFAS score (p>0.05). Flap size ranged from 9×6cm2 to 14×7cm2 in the PAPF group and from 9×6cm2 to 13×7cm2 in the PTAPF group. There were no severe complications such as flap-related complications or amputation. The differences in complications in the two groups were not statistically significant.In cases of severe open tibial fracture, the reconstructive method is important. When delayed reconstruction is inevitable, surgeons should first perform radical debridement, followed by vacuum sealing drainage as a bridging therapy; both PAPF and PTAPF can be considered for definitive soft tissue coverage.

Revisiting the Role of Amniotic Membrane Dressing in Acute Large Traumatic Wounds: A Randomized Feasibility Study at a Level 1 Trauma Centre.

Acute large traumatic wounds require temporary dressing prior to the definitive soft tissue reconstruction, as the physiological derangement during the immediate postinjury period delays the definitive surgical intervention. Selecting an ideal dressing material from numerous available synthetic dressings and skin substitutes poses a challenge. Although amniotic membrane (AM) scaffold has a definitive role in promoting wound healing in burns and chronic wounds, however, its efficacy in acute large traumatic wound is lacking. The present trial aimed to evaluate the safety and efficacy of AM in wound bed preparation before the definitive soft-tissue reconstruction in acute large traumatic wounds. Sixty patients with acute large traumatic wounds (>10 cm × 10 cm) were divided into two groups (conventional dressing and AM dressing) using simple mixed block randomization. Wounds were assessed using the Bates Jensen Score at various timelines for the signs of early wound healing. The primary outcome was to evaluate the time taken for the wound bed preparation for definitive soft-tissue reconstruction. The secondary outcome was the pain assessment and complications, if any. There was significant reduction in the wound exudate as well as peripheral tissue edema in the intervention group (P = 0.01). AM dressing was significantly less painful (P = 0.01). The incidence of wound infection and need for debridement was decreased in the intervention group. However, the time interval to definitive soft-tissue coverage was statistically insignificant and comparable in both the groups. No adverse reactions were seen in either group. AM dressings are safe and efficacious with significant reduction in wound exudates and peripheral edema. However, these dressings do not hasten the wound maturation as compared to conventional dressings. AM dressings can be used as a less painful alternative to conventional dressing in the management of large acute posttraumatic wounds.

Complications and timing of soft tissue coverage after complete articular, open tibial plateau fractures

PurposeComplete articular tibial plateau fractures are typically high-energy injuries associated with significant soft tissue trauma. The primary aim of this study was to evaluate the incidence of wound complications and need for soft tissue coverage after open, complete articular tibial plateau fractures. The secondary aim was to study the effect of timing of fixation and timing of flap coverage on deep infection rates in these injuries. MethodsThis was a retrospective cohort study of consecutive patients > 18 years undergoing ORIF of a Bicondylar Tibial Plateau (BTP) fracture between 2001 and 2018. Surgical data were recorded for open fractures including number of debridements, timing of definitive ORIF and soft tissue coverage relative to injury. Primary outcomes included rates of deep infection and unplanned reoperation. Results508 AO/OTA 41C BTP fractures were identified, with 51 open fractures included in 50 patients with a mean (SD) age 45.7 (12.3) years and a mean (SD) follow up of 4.3 (3.8) years. There were 20 cases of deep infection, unplanned reoperation occurred in 26 cases. The majority of cases (28 fractures) had initial external fixation placed, while 24 had ORIF at the initial debridement. Twelve patients had a planned flap for definitive closure on average of 6.4 days (SD 3.9) after injury, 14 required a flap for wound complications. Among patients with IIB and C injuries, rates of deep infection (5/6 vs 1/6, p = 0.02) and reoperation (5/7 vs 2/6, p = 0.08) were higher in patients treated with flap coverage >7 days from injury compared to early flap coverage. There were no differences in complication rates between early (<24hrs) and delayed fixation. ConclusionsComplete articular, open tibial plateau fractures are associated with high rates of complications. Time to flap coverage of seven days or more was a significant predictor of deep infection and unplanned reoperation in this cohort. Patients should be counseled about the high rate of unplanned reoperation and definitive soft tissue coverage should be accomplished within a week of injury whenever possible.

Orthoplastic Treatment of Open Lower-Limb Fractures Improves Outcomes: A 12-Year Review.

The British Orthopaedic Association Standards for Orthopaedics and Trauma 4 (BOAST 4) inform the management of open lower-limb fractures. The authors conducted repeated reviews of performance against these standards over a 12-year period. This latest iteration has shown further improvements in outcomes concomitant with changes in service delivery. Data on Gustilo-Anderson grade IIIB or IIIC open lower-limb fractures were collected from a prospectively constructed departmental database and analyzed using Excel. Outcomes assessed included time to stabilization, time to definitive soft-tissue coverage, and deep infection rates. A total of 69% of patients in our cohort received care that aligned with BOAST 4 guidelines. Median time to stabilization was 14.2 hours and to soft-tissue coverage was 47 hours, with 71% of cases compliant with BOAST 4 guidelines. The overall deep infection rate was 6.5% in our cohort. There was a significantly lower deep infection rate in BOAST 4-compliant cases (2%) versus noncompliant cases (16%), respectively (P = 0.05). A total of 41 of 61 patients had fixation and soft-tissue coverage in a single operation (fix and flap), eight had staged operations, and 12 required local flap closure. There was no significant difference in deep infection rates among these approaches. Compliance with the BOAST 4 guidelines and time to definitive soft-tissue coverage have improved at our center since the last review. Deep infection rates were significantly lower in BOAST 4-compliant cases, further validating this approach. The fix and flap technique was introduced during the study period and reduces operative burden for patients. These results support a joint orthoplastic approach as the optimal management for these complex injuries. Therapeutic, IV.

Incidence and quality of care for open fractures in England between 2008 and 2019 : a cohort study using data collected by the Trauma Audit and Research Network.

This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England. Longitudinal data collected by the Trauma Audit and Research Network were used to identify 38,347 patients with open fractures, and a subgroup of 12,170 with severe open fractures of the tibia, between 2008 and 2019 in England. Incidence rates per 100,000 person-years and 95% confidence intervals were calculated. Clinical care was compared with the British Orthopaedic Association Standards for Trauma and National Major Trauma Centre audit standards. In total, 60% of all open fractures occurred in males; the median age was 48 years (interquartile range (IQR) 29 to 68). Between 2012 and 2019, the overall incidence in England was 6.94 per 100,000 person-years. In males, the highest incidence observed was in those aged 20 to 29 years (11.50 per 100,000 person-years); in females, incidence increased with age, peaking at 32.11/100,000 person-years at 90 years of age and over. Among those with severe open fractures of the tibia, there was a bimodal distribution in males, peaking at 20 to 29 years (3.71/100,000 person-years) and greater than 90 years of age (2.84/100,000 person-years) respectively; among females, incidence increased with age to a peak of 9.91/100,000 person years at 90 years of age and over. There has been variable improvement with time in the clinical care standards for patients with severe open fractures of the tibia. The median time to debridement was 13.0 hours (IQR 6.4 to 20.9); almost two-thirds of patients underwent definitive soft-tissue coverage within 72 hours from 2016 to 2019. This is the first time the incidence of all open fractures has been studied using data from a national audit in England. While most open fractures occurred in young males, the incidence increased with age in females to a much greater level than observed in older males. The degree of missing data in the national audit is startling, and limits the certainty of inferences drawn concerning open fracture care. Cite this article: Bone Joint J2022;104-B(6):736-746.

Free fibula flap thumb salvage after a gunshot wound: Case report emphasizing the orthoplastic approach

High-energy hand trauma damaging bone and soft tissue often leads to amputation. Thumb loss leads to significant disability and decreased quality of life. A variety of options exist to preserve or restore thumb function, but many are not viable when significant bone and overlying soft tissue are lost. In this case report, we present a case of a 30-year-old warehouse worker who suffered a gunshot blast injury to the hand, destroying his metacarpophalangeal joint and overlying soft tissue. Initially this was repaired at an outside hospital with a nonvascularized bone graft and no definitive soft tissue coverage that subsequently became infected. Free fibula osteocutaneous flap reconstruction prevented amputation and restored form and function to the thumb. Implementing an orthoplastic approach resulted in thumb salvage and restoration of this patient's quality of life. • Gunshot wounds to the upper extremity often cause impairment and disability. • Reconstruction with a free fibula osteocutaneous flap to the thumb prevented amputation. • The orthoplastic approach is the preferred method for reconstruction following limb trauma.

Perioperative management of open fractures in the lower limb.

An open fracture is a fracture which communicates with the external environment through a wound in the skin. Severe open fractures are managed by both orthopaedic and plastic surgeons to address injuries in both the bone and soft tissue. This review outlines the management of open fractures in the lower limb from the initial patient presentation to operative management (including debridement, skeletal fixation, definitive soft tissue coverage) according to the standards jointly published by the British Orthopaedic Association (BOA) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Additionally, the decision-making between limb salvage or amputation will be explored. Finally, this review will discuss the patient’s postoperative care including wound care and management of potential complications that may arise such as infection, flap failure and fracture non-union.

Wartime Soft Tissue Coverage Techniques for the Deployed Surgeon.

Since the start of the conflict in the Middle East in 2001, military orthopedic surgeons have faced complex orthopedic injuries including high-energy soft tissue wounds, traumatic amputations, and open fractures. Although orthopedic surgeons are well trained in the management of osseous injuries, the treatment of soft tissue injuries can be technically challenging and unfamiliar. Early washout, debridement of devitalized tissue, external fixation of bony injuries, and antibiotic therapy remain the foundation of early wound management. However, these unique extremity injuries have no standard plan of care, and definitive treatment options continue to evolve. The following report highlights the typical cases seen in the wartime setting and offers possible solutions for the associated soft tissue injuries. A single orthopedic surgeon at a Role 3 combat support hospital performed all cases in this series. This study is a report of the cases that the orthopedic surgeon encountered while deployed and the various techniques that can be used to manage the complex wounds seen in a deployed setting. Twelve patients were included in this report and the data are shown. Of the 12 patients, 6 were injured by an improvised explosive device (IED), 4 were injured by a high-velocity gunshot wound (HVGSW), 1 was injured by a gunshot wound (GSW), and 1 was injured in an auto versus pedestrian motor vehicle crash. The wound sizes ranged from 10 to 300 cm2. All patients required more than one irrigation and debridement before wound closure. There was a successful outcome in 11 of the 12 patients. The only patient without a known successful outcome was lost to follow up. Six patients were treated with split thickness skin graft (STSG) alone. Four patients were treated with STSG plus an additional means of coverage. One patient was treated with a random flap and one patient was treated with a full thickness skin graft. Integra was used in two of the patients. Each of the patients in whom integra was used had exposed bone and had a successful outcome with respect to tissue coverage. This study details different soft tissue coverage techniques that must be learned and possibly employed by the deployed surgeon. Limitations of this study include its retrospective nature and the selected sampling of cases. At initial presentation, the management of war wounds secondary to high-velocity gunshot wounds and improvised explosive devices can be quite daunting. Adhering to firm surgical principles of thorough and meticulous debridement is the foundation of later soft tissue reconstructive options. Once the tissue is deemed clear of infection and contamination, there are myriad treatment options utilizing flaps, synthetic materials, and skin grafting. These are relatively straightforward techniques that the general orthopedic surgeon can utilize while deployed in a combat setting. In the end, it is critical for deployed surgeons to learn multiple techniques to provide definitive soft tissue coverage in a wartime theater.

Duration of Administration of Antibiotic Agents for Open Fractures: Meta-Analysis of the Existing Evidence.

Surgical site infection remains a significant concern in treating patients with open fractures. In prevention of such, current guidelines support the immediate administration of antibiotic agents. The duration of antibiotic treatment is still controversial. A maximum of 72 hours, even in the absence of definitive soft tissue coverage, is recommended in a number of recent guidelines and consensus reports. The aim of this meta-analysis was to review and analyze all published literature evidence with regard to antibiotic duration in open fracture treatment. We conducted a comprehensive review of the available literature from the 1970s until the present, including five comparative (1284 open fractures) and 27 observational (5408 open fractures) studies. A subgroup analysis was further performed, based on the Gustilo type of open injury and the anatomic location of the fracture. In addition, we investigated the effect of antibiotic regimes shorter than 72 hours on infection rates. In the comparative studies, the summarized estimate of infection rate favored less than a 72-hour duration of antibiotic treatment, because prolongation of antibiotic treatment more than 72 hours did not seem to offer any protective effect against septic complications of open fractures (odds ratio: 0.85, 95% confidence interval [CI]: 0.60-1.21). The same trend was also documented in the observational studies, where the overall pooled estimate of infection rate was 10% (95% CI: 6.8%-14%) when antibiotic treatment did not exceed 72 hours and 9.2% (95% CI: 6.6%-12.2%) for more than 72 hours of antibiotic treatment (p = 0.53). In Gustilo I and II open fractures, the calculated pooled estimate of infection rate did not differ significantly when antibiotic treatment exceeded 72 hours (6%, 95% CI: 3.3%-9%) compared with shorter (up to 72 h) antibiotic protocols (4%, 95% CI: 1.8%-7%) (p = 0.52). In Gustilo III open fractures also, the calculated pooled estimate of infection rate (21.3%, 95% CI: 13%-31%) when duration of antibiotic treatment was more than 72 hours did not differ significantly compared with a shorter (less than 72 h) antibiotic treatment (17.7%, 95% CI: 12.5%-23.5%) (p = 0.39). A further subgroup analysis indicated that even shorter antibiotic regimes (24-48 h) were also equivalent to prolonged regimes of more than 72 hours in terms of infection rates. The results of the present systematic review and meta-analysis could not substantiate any benefit against septic complications of a prolonged duration of antibiotic treatment of open fractures, irrespective of their severity.

Abstract: The Efficacy of Negative Pressure Wound Therapy and Antibiotic Beads as Infection Prophylaxis in Post-Traumatic Lower Extremity Salvage

INTRODUCTION: This study compares outcomes in trauma patients receiving negative pressure wound therapy (NPWT), antibiotic beads, or both treatments prior to soft tissue reconstruction of the lower extremity. METHODS: This is retrospective review of patients requiring soft tissue reconstruction following traumatic lower extremity open fractures in an urban Level 1 trauma center between August 2007 and March 2015. Patients with infection prior to NPWT and/or antibiotic bead application were excluded. RESULTS: In 72 trauma patients with 73 extremities having open fractures and subsequent lower limb vascularized soft tissue reconstruction, 26 received only NPWT, 24 only antibiotic beads, 2 neither treatment and 23 both treatments. There was no significant difference in time from injury to definitive soft tissue coverage, time from injury to NPWT/bead placement, or length of NPWT/beads use between groups. Infection rate was 26.9% with NPWT only, 0.0% with antibiotic beads only, 50.0% with neither treatment, and 8.7% with antibiotic beads and NPWT in combination. Patients receiving antibiotic beads alone were significantly less likely to develop an infection or complication as those receiving NPWT alone (p<0.01, p<0.01) or combined NPWT/beads (p<0.01, p<0.01). Development of infection was associated with longer periods from initiation of NPWT use to definitive soft tissue coverage (p<0.01); this finding was independent of time from injury to soft tissue coverage but correlated with number of operations. Limb salvage rate was 95.9% and 50.0% of patient could ambulate without an assistance device 3 or more months out of surgery. CONCLUSION: Antibiotic beads may be more effective than negative pressure wound therapy in preventing infections in patients awaiting soft tissue coverage of wounds. Utilizing these treatments together does not improve infection rates. Limb salvage was successful in most cases regardless of treatment.

Fasciocutaneous Flaps for Open Fractures of the Tibia

The soft tissue envelope is crucial for proper healing in open tibia fractures. Fasciocutaneous flaps are effective in providing soft tissue coverage in open fractures with severe bone exposure, allowing for healing of the fracture and prevention of infection. Optimal flap selection and timing for definitive soft tissue coverage are controversial. With recent technological advances and surgical technique refinements, the options for flap selection have increased, with greater reliability of complex limb reconstruction procedures. Depending on the injury needs and patient characteristics, different levels of flap complexity can be used to achieve favorable functional and aesthetic outcomes. It is important to keep updated on the newly available technologies and to be aware of the existing surgical options to ensure the best patient care.

Complete major amputation of the upper extremity: Early results and initial treatment algorithm.

Traumatic major amputations of the upper extremity are devastating injuries. These injuries have a profound impact on patient's quality of life and pose a burden on social economy. The aims of the current study were to report about the initial management of isolated traumatic major upper limb amputation from the time of admission to definitive soft tissue closure and to establish a distinct initial management algorithm. We recorded data concerning the initial management of the patient and the amputated body part in the emergency department (ED) (time from admission to the operation, Injury Severity Score [ISS], cold ischemia time from injury to ED, and total cold ischemia time). The duration, amount of surgical procedures, the time to definitive soft tissue coverage, and the choice of flap were part of the documentation. All intraoperative and postoperative complications were recorded. All patients were successfully replanted (time from injury to ED, 59 ± 4 minutes; ISS16; time from admission to operating room 57 ± 10 minutes; total cold ischemia time 203 ± 20 minutes; total number of procedures 7.3 ± 2.5); definitive soft tissue coverage could be achieved 23 ± 14 days after injury. Two thromboembolic complications occurred, which could be treated by embolectomy during revision surgery, and we saw one early infection, which could be successfully managed by serial debridements in our series. The management of complete major amputations of the upper extremity should be reserved for large trauma centers with enough resources concerning technical, structural, and personnel infrastructure to meet the demands of surgical reconstruction as well as the postoperative care. Following a distinct treatment algorithm is mandatory to increase the rate of successful major replantations, thus laying the foundation for promising secondary functional reconstructive efforts. Therapeutic study, level V.

Management of open lower limb injuries in South West England and Wales.

The joint British Association of Plastic, Reconstructive and Aesthetic Surgeons/British Orthopaedic Association standards define best practice management in open diaphyseal fractures of the lower limb. The aim of our study was to review the regional approach and experience in South West England and Wales. A further objective was to evaluate service provision with regard to the standards' key recommendations. A prospective audit was undertaken of open diaphyseal fracture patients. Compliance with published standards within all orthoplastic services in South West England and Wales was assessed, and facilities were evaluated. A total of 86 patients were managed between October 2012 and March 2013. This was a 56% increase from 2008. Over half (56%) presented directly to the orthoplastic services with all patients undergoing debridement within 24 hours. Two-thirds (66%) of procedures were in daylight hours excluding those requiring immediate surgical intervention. Adherence to correct antibiotic therapy was 88% at admission, 50% at primary surgery and 62% at definitive surgery. Almost two-thirds (60%) of primary procedures were performed with combined senior orthoplastic teams, with 81% achieving definitive soft tissue coverage and fixation within seven days. Compliance improved in units with larger patient caseloads and where there was an early combined approach during daylight hours. Increased open lower limb fracture workload was demonstrated across South West England and Wales, probably owing to centralisation of trauma services. An improvement in early transfer of this patient group to orthoplastic facilities has allowed all patients to be assessed and debrided within the recommended timeframe. Standards were most likely to be met in those centres seeing higher numbers of injuries and when there was a daylight hours procedure by combined orthoplastic teams.

Low Complication Rate Associated With Raising Mature Flap for Tibial Nonunion Reconstruction

Tibia fractures may require soft tissue coverage with transposed tissue and can develop nonunions. Tibial defects can be approached with a posterolateral approach or by elevating the previously transposed tissue. No literature has previously reported the efficacy or safety of the latter approach. The purpose of this study was to report the flap survival rate and complications from delayed elevation of transposed soft tissue as part of a protocol for the treatment of tibia nonunions. In a retrospective review of patients having local, regional, or free soft tissue transposition for the management of open type III B high-energy tibial fractures and also requiring secondary procedures on the same tibia for treatment of tibial nonunion and/or osteomyelitis that required flap elevation, 23 patients with 24 flaps were identified and studied. The 24 flaps were elevated a total of 72 times as part of a staged protocol for nonunion reconstruction by a single surgeon. Primary end point was flap survival. Mean follow-up after definitive soft tissue coverage was 23.7 months. Mean follow-up after injury was 28.9 months. One flap failed after elevation. On a per elevation surgery basis, the flap survival rate was 98.6% (71 of 72). On a per flap basis, the flap survival rate was 95.8% (23 of 24). This is the first report of the survival and complication rates for delayed elevation of soft tissue flaps for tibial nonunion reconstruction. A total of 95.8% of flaps survived elevation. Flap elevation seems to be an alternative to posterolateral tibial approaches for treatment of tibial nonunions.

Delayed presentation of IIIB tibial fractures: outcome following management in a specialist centre

The aim of this study was to assess whether the outcome of delayed presentation of open tibial fractures from neighbouring orthopaedic units can be salvaged in a specialist ortho-plastic centre. All grade IIIB tibial fractures treated in a specialist unit over an 18-month period were retrospectively reviewed. Time to definitive soft tissue coverage, complications, number of operations and method of skeletal and soft tissue reconstruction were also reviewed. The functional outcome was assessed using the Enneking score. Forty-five consecutive patients (27 male and 18 female; mean age, 42.3 years) were treated using strict surgical protocols. Seventeen patients were referred locally, and 28 from seven neighbouring orthopaedic units. The mean time from injury to definitive surgery was 3.9 and 7.7 days for patients referred locally and those referred from neighbouring units, respectively. Definitive surgery, from the time of initial plastic surgery assessment, was performed at a mean of 2.4 days for patients referred locally and 2.8 days for patients referred from neighbouring units. One patient developed a deep soft tissue wound infection. There were no delayed amputations or any cases of infected non-union. Patients from neighbouring units underwent, on average, one extra operation. There was a delay from the time of injury in achieving soft tissue coverage in these patients (7.7 vs. 3.9 days). No significant difference in return of limb function between the two groups was detected. Referral to a specialist centre may produce equivalent functional return even if there is a delay in definitive treatment, at the expense of further risky surgery.

Principles of Definitive Soft Tissue Coverage With Flaps

Despite the emergence of negative pressure wound therapy with reticulated open cell foam (NPWT/ROCF) as delivered by V.A.C.(R) Therapy (KCI, San Antonio, TX) for orthopaedic trauma, vascularized tissue transfer whether it be pedicle, free, or tissue transfer using the operating microscope or as an island, remains the mainstay of soft tissue reconstruction for orthopaedic traumatology. The critisism of microvascular procedures has been that they are lengthy, costly, and required technical expertise to perform. While technical skills are required, microsurgical care has evolved into a routine operation with high degrees of success in experienced hand. The problem that still remains is access to surgeons who are interested in soft tissue reconstruction and can perform definitive coverage with flaps. There is a need in the orthopaedic community to solve the problem of lack of flap surgeons and as a result, NPWT/ROCF has been touted as the answer to flap reconstruction. NPWT/ROCF is an important addition to soft tissue reconstruction but it serves as a bridge rather than definitive coverage in many hands. Just as wound technology is evolving with tissue substitutes, growth factors and NPWT/ROCF flaps technology continues to advance with new perforator flaps and local regional flaps, particularly the sural flap, coming on line as mainstays of soft tissue reconstruction.

Free Flap Choice for Soft Tissue Reconstruction of the Severely Damaged Upper Extremity

Reconstruction of complex wounds of the hand associated with severe bone, tendon, nerve and soft-tissue injuries has been a major problem in hand surgery. Early definitive soft-tissue coverage of this kind of extensive wound with well-vascularized tissue is one of the most important stages of reconstruction for salvage of the extremity and restoration of function. Although multiple free flap donor sites have been described for complex upper extremity wounds, the authors think that anterolateral thigh (ALT) and lateral arm (LA) flaps are good choices for soft-tissue reconstruction in the upper extremity because of their reconstructive characteristics. These flaps can be used as flow-through and also sensate flaps. There is no need for position change intraoperatively and two teams may work simultaneously. Donor sites can be hidden and there is no required sacrifice of major artery or muscle.