Early Soft Tissue Coverage Research Articles

The Continued Impact of Godina's Principles: Outcomes of Flap Coverage as a Function of Time After Definitive Fixation of Open Lower Extremity Fractures.

Early soft tissue coverage of open lower extremity fractures within 72 hours of injury leads to improved outcomes. Little is known about outcomes when definitive fixation is completed first. The purpose of this study is to quantify postoperative outcomes when soft tissue reconstruction is delayed until after definitive open reduction and internal fixation (ORIF) is completed. An insurance claims database was queried for all patients with open lower extremity fractures between 2010 and 2020 who underwent free or axial flap reconstruction after ORIF. This cohort was stratified into three groups: reconstruction performed 0 to 3, 3 to 7, and 7+ days after ORIF. The primary outcome was 90-day complication and reoperation rates. Bivariate and multivariable regression of all-cause complications and reoperations was evaluated for time to flap as a risk factor. A total of 863 patients with open lower extremity fractures underwent ORIF prior to flap soft tissue reconstruction. In total, 145 (16.8%), 162 (18.8%), and 556 (64.4%) patients underwent soft tissue reconstruction 0 to 3 days, 4 to 7 days, and 7+ days after ORIF, respectively. The 90-day complication rate of surgical site infections ( SSI; 16.6%, 16,7%, 28.8%; p = 0.001) and acute osteomyelitis (5.5%, 6.2%, 27.7%; p < 0.001) increased with delayed soft tissue reconstruction. Irrigation and debridement rates were directly related to time from ORIF to flap (33.8%, 51.9%, 61.9%; p < 0.001). Hardware removal rates were significantly higher with delayed treatment (10.3%, 9.3%, 39.3%; p < 0.001). The 0 to 3 day (odds ratio [OR] = 0.22; 95% confidence interval [CI]: 0.15, 0.32) and 4 to 7 day (OR = 0.26; 95% CI: 0.17, 0.40) groups showed protective factors against all-cause complications after bivariate and multivariate regression. Early soft tissue reconstruction of open lower extremity fractures performed within 7 days of ORIF reduces complication rates and reduces the variability of complication rates including SSIs, acute osteomyelitis, and hardware failure.

Salvaging mangled upper limbs with early soft tissue cover with flaps- A case series

Mutilating upper limb injuries present complex challenges to both patients and surgeons, necessitating prompt and effective management strategies to achieve favorable outcomes. This retrospective study examines the cases of five consecutive patients with mangled upper limbs resulting from blunt trauma, evaluating demographics, injury mechanisms, injury patterns, and 60-day limb salvage outcomes. Among 2128 admissions between January and December 2022, five patients were identified with mangled upper limbs and open fractures, with an average age of 40.2 years and a notable male predominance (80%). The dominant hand was affected in 60% of cases, primarily due to blunt high-velocity road traffic accidents. The mean Mangled Extremity Severity Score (MESS) was 7.2, and the Ganga Hospital Open Injury Score averaged 16, indicating substantial injury severity without limb ischemia or compartment syndrome. All patients underwent definitive surgery within 48 hours, with various soft tissue reconstruction techniques employed, including free flaps, pedicle flaps, and local muscle mobilization, along with nerve grafting procedures. At the 60-day follow-up, successful limb salvage was achieved in all cases, with no instances of surgical site infection and excellent acceptance of skin grafted areas exceeding 95%. The findings underscore the importance of timely surgical intervention and comprehensive soft tissue coverage in achieving successful limb salvage outcomes in patients with mutilating upper limb injuries, emphasizing the critical role of early intervention and multidisciplinary collaboration.

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.

NECROTIZING SOFT-TISSUE INFECTIONS: A RETROSPECTIVE CASE SERIES AT A DISTRICT HOSPITAL IN SOUTH AFRICA

Necrotizing soft tissue infection (NSTI) is a rapidly progressive infection that typically starts in the dermis and epidermis and spreads along soft tissue planes, penetrating subdermal layers and can lead to massive tissue necrosis resulting in severe morbidity and mortality. The aim of this case series was to describe the epidemiology and burden of NSTI's at a District Hospital servicing a South African urban settlement.This retrospective case series was performed at a single centre. Consecutive patients were identified following a clinical diagnosis for NSTI. Further laboratory pre-operative work up was standardized including: use of validated Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC scores) and Human Immunodeficiency Virus (HIV) status. All patients who underwent surgical debridement were captured on the Theatre Database (www.medwebtools.org™). All patients received standardized perioperative, intra-operative and post-operative protocols for antibiotics, debridement and soft tissue closure or cover based on the severity of disease. Medical records, theatre notes, National Health Laboratory Service (NHLS) results and radiological results were captured for every patient.28 patients (14 male, 14 female) presented with NSTI over a 3 year period (2021–2023). The mean age was 39.5 years. The most common organisms cultured were Streptococcus pyogenes (10 patients), Staphylococcus aureus (9 patients), Bacillus cereus (3 patients).This retrospective case series is an important study because it demonstrates some of the highest incidence of NSTI globally; however, the cause of this is yet to be determined. Our results show that having a high clinical index of suspicion; using the LRINEC score to assess severity and using a standardized antibiotic and peri-operative protocol with early soft tissue cover that NSTI's can be managed effectively with a reduction in patient morbidity and overall length of hospital stay.

Gentamicin[sbnd]coated tibial nail is an effective prevention method for fracture-related infections in open tibial fractures

Fracture-related infection (FRI) is a common complication following open tibia fracture (OTF), especially in patients with high-energy trauma or comorbidities. The use of gentamicin-coated nail (GCN) has been proposed as a local adjuvant to prevent FRI in high-risk patients.Hypothesis: The incidence of FRI is expected to be lower in OTF treated with a GCN, alongside with no detrimental effects on fracture healing time.Objectives: This study aimed to evaluate the effectiveness of GCNs as a definitive fixation method and prophylaxis for FRI in OTFs. Secondary outcomes included non-union rates and time to healing.Methods: The study design was a mixed cohort, including a prospective group of patients treated with GCN (Expert Tibial Nail PROtect™, Depuy Synthes, Johnson&Johnson Company Inc, New Jersey, USA) and a retrospectively evaluated group treated with non-gentamicin-coated nail (NGCN). Patients with at least 12 months of follow-up were included. The treatment protocol consisted of timely administration of antibiotics, surgical debridement, and early soft-tissue coverage. Exclusion criteria included protocol infringement, traumatic amputation, and loss of follow-up.Statistical analysis was performed using Stata v14.0, with a significance level of p < 0.05.Results: The study included 243 patients, 104 in GCN group and 139 NGCN group. External Fixator use was higher in the NGCN group, but this did not significantly affect the FRI rate.GCN use was associated with a significantly lower incidence of FRI (2.88% GCN group vs. 15.83% NGCN group, OR 0.16, p < 0.01). Furthermore, GCN use was found to be a protective factor against tibial non-union (OR 0.41, p = 0.03). There were no adverse effects attributed to locally administered gentamycin. The NGCN cohort had a higher incidence of polytrauma, although the difference was not statistically significant. A longer time to heal as well as more FRI and Non-union according to the progression in Gustilo-Anderson classification was observed in the GCN group.Conclusion: Our findings suggest that GCN is an effective prophylactic method to reduce the risk of FRI in open tibial fractures at 12-month follow-up, as well as, probably derived from this protective effect, leading to lower fracture consolidation times when compared with cases treated without GCN.

Early Bony Fixation and Soft Tissue Coverage in Type IIIB Open Proximal Tibia Fractures: A Cross-sectional Study

Introduction: The tibia, the second largest bone in the human body, is largely enveloped by subcutaneous fat and skin, rendering it vulnerable to fractures and soft tissue injuries. This unique anatomical configuration contributes to a heightened susceptibility to open fractures. Notably, an aggressive treatment protocol involving radical debridement, internal fixation, and immediate or early soft tissue coverage with muscle flaps has demonstrated improved rates of bony union and reduced incidences of infection. Aim: To assess the clinical outcomes of early bony fixation and soft tissue coverage in Type IIIB open proximal tibia fractures. Materials and Methods: This cross-sectional observational study was conducted at the Department of Orthopaedics, BRD Medical College, in Gorakhpur, Uttar Pradesh, India. Total of 30 cases were enrolled between August 2021 and November 2022. The parameters assessed in the study encompassed patient demographics, including age and gender distribution, the aetiology of fractures, soft tissue coverage outcomes, time to bone union, knee joint movement postsurgery, and the incidence of complications such as superficial infections and chronic osteomyelitis. The analysis was conducted using Statistical Package for Social Sciences (SPSS) version 26.0, primarily employing descriptive statistics to present the results, with percentages and frequencies serving as the primary modes of representation. Results: All cases of Gustilo-Anderson Type IIIB high-grade open tibial fractures were included in this study, with the majority of patients being males 26 (87%) aged between 20 to 40 years. Road traffic accidents accounted for 25 (83.3%), while falls from height were responsible in 5 (16.7%) cases. Assessment of soft tissue coverage revealed 73.33% with good healing, 20% with fair healing, and 6.67% with poor healing. The time to bone union varied, with 10% of cases showing non union. Postsurgery, most cases demonstrated knee joint movement of over 120° (86.67%) and a few cases with movement ranging between 90-120° (13.33%). The incidence of complications was relatively low, with 3 (10%) cases presenting superficial infections and 2 (6.7%) suffering from chronic osteomyelitis. Conclusion: Early bony fixation and soft tissue coverage utilising the medial gastrocnemius flap, along with Split-Thickness Skin Grafting (STSG), demonstrate efficacy in treating high-grade open proximal tibia fractures (Gustilo-Anderson Type IIIB). This approach facilitates expedited bony union and contributes to a reduction in postoperative complications.

Outcome of Soft Tissue Coverage in Open Tibia Fractures with Non-Microvascular Flap at a Tertiary Care Hospital

Background: Open tibia fractures are high energy injuries often associated with large soft defects, extensive soft tissue stripping and contamination requiring multiple debridement procedures. Collective ortho-plastic approach helps us achieve proper debridement, adequate fixation and early soft tissue coverage. Due to fairly high incidence of failure, steep learning curve, time consuming procedure and the cost of treatment for those tedious free flaps, non-microvascular flaps are being preferred to cover the soft tissue defects or exposed hardware in open tibia fractures.&#x0D; Materials and Methods: A prospective study was carried out in 19 patients to assess the outcome of soft tissue coverage in open tibia fractures with non-microvascular flap. Out of these patients, 6 patients were treated with medial gastrocnemius flap, 5 patients with medial hemi-soleus, 5 patients with reverse sural fasciocutaneous flap, and 3 patients with local rotational random flaps. Outcome measures included bony union, deep surgical infection and flap failure.&#x0D; Results: 84% patients were male whereas 16% patients were female. Road traffic accident was the major cause of the defect among the patients (74%). Complications in the form of deep infection (10%), non-union (21%), delayed union (10%) and marginal flap necrosis (21%) were observed.&#x0D; Conclusion: In our study, early soft tissue coverage with appropriate non-microvascular flaps in management of severe open fractures of tibia was associated with more favourable outcomes.

Does negative pressure wound therapy reduce the odds of infection and improve health-related quality of life in patients with open fractures?

AimsTo evaluate the impact of negative pressure wound therapy (NPWT) on the odds of having deep infections and health-related quality of life (HRQoL) following open fractures.MethodsPatients from the Fluid Lavage in Open Fracture Wounds (FLOW) trial with Gustilo-Anderson grade II or III open fractures within the lower limb were included in this secondary analysis. Using mixed effects logistic regression, we assessed the impact of NPWT on deep wound infection requiring surgical intervention within 12 months post-injury. Using multilevel model analyses, we evaluated the impact of NPWT on the Physical Component Summary (PCS) of the 12-Item Short-Form Health Survey (SF-12) at 12 months post-injury.ResultsAfter applying inverse probability treatment weighting to adjust for the influence of injury characteristics on type of dressing used, 1,322 participants were assessed. The odds of developing a deep infection requiring operative management within 12 months of initial surgery was 4.52-times higher in patients who received NPWT compared to those who received a standard wound dressing (95% confidence interval (CI) 1.84 to 11.12; p = 0.001). Overall, 1,040 participants were included in our HRQoL analysis, and those treated with NPWT had statistically significantly lower mean SF-12 PCS post-fracture (p < 0.001). These differences did not reach the minimally important difference for the SF-12 PCS.ConclusionOur analysis found that patients treated with NPWT had higher odds of developing a deep infection requiring operative management within 12 months post-fracture. Due to possible residual confounding with the worst cases being treated with NPWT, we are unable to determine if NPWT has a negative effect or is simply a marker of worse injuries or poor access to early soft-tissue coverage. Regardless, our results suggest that the use of this treatment requires further evaluation.Cite this article: Bone Jt Open 2022;3(3):189–195.

How Much Does an Infected Fracture Cost?

Though infection is a common and costly complication following fracture, there is a scarcity of literature focused on the additional cost of healthcare when a fracture becomes infected. This literature review compiles existing heterogenous data to evaluate the cost of infected fractures, yielding an estimate of a 1.2-fold to six-fold increase in healthcare costs associated with infection. The increases in cost were largely driven by an increased length of stay. Factors which affect this increase include the infectious agent, the depth of infection and the location of the fracture. In order to reduce healthcare costs, early soft tissue cover and prophylactic antibiotics are effective in that they reduce the infection rates. An alternative approach is to reduce the length of stay, the key driver of cost, for example by reducing the length of inpatient antibiotic therapy. Further cost-utility analyses which focus on the same aspects of the healthcare costs are required for a more accurate estimation of the cost.

Modern concepts of treating diaphyseal forearm fractures (literature review)

BACKGROUND: Treating patients with open forearm fractures is always a difficult task. The complexity of treating these patients is related to the anatomical and biomechanical specifics of the segment. In many cases, fragmented, unstable fractures have serious soft tissue damage due to high-energy trauma, blood supply failure, the risk of infectious complications, prolonged wound healing, compartment syndrome development, delayed union, and contracture formation.&#x0D; AIM: This article reviews the modern native and foreign literature regarding the treatment of patients with open diaphyseal forearm fractures and identifies the main problems in these injuries.&#x0D; MATERIALS AND METHODS: The analysis of modern Russian and foreign literature concerning the treatment of patients with open diaphyseal forearm fractures is presented. The analysis was performed using the medical publication databases of CyberLeninka, eLibrary, and PubMed without limiting the search depth.&#x0D; RESULTS: The high percentage of unsatisfactory results of open fractures, both anatomical and functional, especially of severe type III fractures, presents a problem. This requires the developing methods to achieve fusion to avoid infectious complications and obtain a good functional result.&#x0D; CONCLUSIONS: Surgical wound management, stabilization of the fracture in the external fixation apparatus, prevention of infection with antibiotics, and early soft tissue coverage are necessary treatment steps to reduce the infection risk. Conversion of the device to submerged fixation allows early functional treatment, including rotational movement restoration. The choice of fixation method, the timing of the conversion, and the type of internal fixation remain a matter of debate.

Comparative Study of Muscle and Fascio-cutaneous Flaps for Coverage of Exposed Tibia

Background- Trauma is a leading cause of tibial fractures. In salvageable lower limb trauma, morbiditycan be greatly reduced with early soft tissue coverage of exposed tibia. Muscle flaps have traditionallybeen preferred over fascio-cutaneous flaps for coverage. With better description of the vascular supplyof the lower limb, however, there is now a shift towards fascio-cutaneous flaps: pedicled or free softtissue transfer.Methods- 216 patients who underwent flap coverage for exposed tibia in our institute between January2015 and December 2020 were evaluated in this retrospective, comparative study. Parameters studiedwere surgical complications, such as partial or complete flap necrosis, minor wound complications,venous congestion, donor-site complications; development of wound infection and osteomyelitis;duration of hospital stay; functional outcome and final aesthetic outcomeConclusion- Fascio-cutaneous flaps were found superior to muscle flaps for coverage of exposed tibiain many respects especially for middle and lower third defects. For upper third of tibia, gastrocnemiusmuscle and musculocutaneous flaps provide adequate coverage. But in case of middle and lower thirds,adequate coverage can be provided by perforator-based, propeller or distal sural flaps. If adequatedonor vessels are available, micro-vascular free soft tissue transfer, should be the preferred choice forlarge defects.

The Role of Negative-Pressure Wound Therapy in Patients with Fracture-Related Infection: A Systematic Review and Critical Appraisal.

Introduction Fracture-related infection (FRI) is a severe musculoskeletal complication in orthopedic trauma surgery, causing challenges in bony and soft tissue management. Currently, negative-pressure wound therapy (NPWT) is often used as temporary coverage for traumatic and surgical wounds, also in cases of FRI. However, controversy exists about the impact of NPWT on the outcome in FRI, specifically on infection recurrence. Therefore, this systematic review qualitatively assesses the literature on the role of NPWT in the management of FRI. Methods A literature search of the PubMed, Embase, and Web of Science database was performed. Studies that reported on infection recurrence related to FRI management combined with NPWT were eligible for inclusion. Quality assessment was done using the PRISMA statement and the Newcastle-Ottawa Quality Assessment Scale. Results After screening and quality assessment of 775 unique identified records, eight articles could be included for qualitative synthesis. All eight studies reported on infection recurrence, which ranged from 2.8% to 34.9%. Six studies described wound healing time, varying from two to seven weeks. Four studies took repeated microbial swabs during subsequent vacuum dressing changes. One study reported newly detected pathogens in 23% of the included patients, and three studies did not find new pathogens. Conclusion This review provides an assessment of current literature on the role of NPWT in the management of soft tissue defects in patients with FRI. Due to the lack of uniformity in included studies, conclusions should be drawn with caution. Currently, there is no clear scientific evidence to support the use of NPWT as definitive treatment in FRI. At this stage, we can only recommend early soft tissue coverage (within days) with a local or free flap. NPWT may be safe for a few days as temporarily soft tissue coverage until definitive soft tissue management could be performed. However, comparative studies between NPWT and early wound closure in FRI patients are needed.

Management of a mutilated hand: the current trends.

Mutilated upper limbs suffer loss of substance of various tissues with loss of prehension. The most important factor in salvage of a mutilated hand is involvement of a senior surgeon at the time of initial assessment and debridement. A regional block given on arrival helps through assessment and investigations in a pain-free state. Infection still remains the important negative determinant to outcome and is prevented by emergent radical debridement and early soft tissue cover. Radical debridement and secure skeletal stabilization must be achieved on day one in all situations. Dermal substitutes and negative pressure wound therapy are increasingly used but have not substituted regular soft tissue cover techniques. Ability to perform secondary procedures and the increased use of the reconstructed hand with time keeps reconstruction a better option than prosthesis fitting. Toe transfers and free functioning muscle transfers are the two major secondary procedures that have influenced outcomes.

Complications and Soft-Tissue Coverage After Complete Articular, Open Tibial Plafond Fractures.

To evaluate the incidence of nonunion and wound complications after open, complete articular pilon fractures. Second, to study the effect that both timing of fixation and timing of flap coverage have on deep infection rates. Retrospective case series. Three Academic Level 1 Trauma Centers. One hundred sixty-one patients with open OTA/AO type 43C distal tibia fractures treated with open reduction internal fixation (ORIF) between 2002 and 2018. The mean (SD) age was 46 (14) years, 70% male, with median (interquartile range) follow-up of 2.1 (1.3-5.0) years (minimum 1 year). There were 133 (83%) type 3A and 28 (17%) type 3B open fractures. Fracture fixation: acute, primary (<24 hours) versus delayed, staged ORIF (>24 hours). Soft-tissue coverage: rotational or free flap. Primary outcomes included deep infection and nonunion. Secondary outcomes included rates of soft-tissue coverage and reoperation. Acute fixation (<24 hours) was performed in 36 (22%) patients; 125 (78%) underwent delayed, staged fixation. Deep infection occurred in 27% patients and was associated with men (33% vs. 16%, P = 0.029), smoking (38% vs. 23%, P = 0.047), and type 3B fractures (39% vs. 25%, P = 0.046). Acute fixation of type 3A fractures demonstrated a higher rate of infection (38% vs. 20% P = 0.036) than delayed, staged fixation. In type 3B fractures, early flap coverage (<1 week) demonstrated a lower rate of infection (18% vs. 53%, P = 0.066) and 20% (vs. 43%) with a single-staged "fix and flap" procedure (P = 0.408). Nonunion occurred in 36 (22%) and was associated with deep infection (43% vs. 15%, P < 0.001). Fifteen (42%) were septic nonunions. Twenty-nine of the 36 (81%) nonunions achieved radiographic union after median (interquartile range) 27 (20-41) weeks and median (range) 1 (1-3) revision ORIF procedures. There was no difference in the rate of secondary union between septic and aseptic nonunions (85% vs. 86%, P = 1.00). There was a high rate of secondary procedures (47%): revision ORIF (17%), irrigation and debridement (15%), and removal of implants (11%). Complete articular, open pilon fractures are associated with a high rate of complications after ORIF. Early fixation carries a high risk of deep infection; however, early flap coverage for 3B fractures seems to play a protective role. We advocate for aggressive management including urgent surgical debridement and very early soft-tissue cover combined with definitive fixation during single procedure if possible. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Evaluation of the comparative results of ender’s nailing and AO type external fixator in the management of open fractures of the tibial shaft. (Gustilo type II, type IIIA and type IIIB): A comparative study

Background: Open tibia fracture, due to high energy or low energy trauma classified according to Gustilo-Anderson classification system. There are five keys to successful treatment: antibiotic therapy, radical debridement and pulsed lavage irrigation, stabilization of fracture with minimal further devascularization, early soft tissue coverage and early bone-grafting. Methods: The study included a total 24 patients of open fracture of tibia shaft type II, IIIA and IIIB (Gustilo) managed in IMCHRC Indore from 01/09/2018 to 01/09/2019. In these study we include pt. of both sex (19 males & 5 females). Results: Open tibia fractures were mostly in males (79.2%) where 70% were young patients with a mean age of 37 yrs. Among these patients 75% sustained high velocity injury. Mean period of fracture union in ENDERS group were 24.05 weeks (range 22 to 28 weeks) while in external fixator group was 27.08 weeks (range 29 to 30 weeks). Among these 24 cases infection detected in 3 cases (all were treated by external fixator; 06 cases belong to Gustilo-Anderson III group). 33.33% mal-alignment in external fixator group in comparison to 16.6% in patients treated with ENDERS nail. Conclusion: Open tibia fracture treated with ENDERS nail united earlier than external fixator and total number of secondary surgeries to achieve union in ENDERS nail was significantly lesser than external fixator group. Infection and mal-alignment rate was also high in external fixation cases.

Study to evaluate the outcome of soft tissue reconstruction in case of open tibia fractures

Aim: to evaluate the outcome of soft tissue reconstruction in case of open tibia fractures.Materials and Methods: This is prospective study of minimum 30 patients admitted to East point College of Medical Sciences and Research Centre. Thorough local examination of injured limb was done and fracture graded according to Gustilos grading of fracture. Post debridement grading and radiological evaluation of fracture was recorded. Wound management was decided as per the condition of the patient and wound contamination-acute (6 weeks). Fracture management included external fixation, IM fixation, plate fixation (Internal fixation), limited internal fixation-pin/K-wire/Screws, and pin plaster. Type of coverage was planned-Split thickness skin grafting; fasciocutaneous flap, Muscle flap and SSG. Results: Majority of the patients were found in age group between 21-30 years and least was in the age group of below 10 years. It was observed that majority of patients in our study were male (86.66%). RTA was the main mode of injury with 27 cases (90%). Out of 15 patients, 4 had head injury (13.33%), 5 had blunt abdomen trauma (16.66%), 4 patients had both head injury and blunt abdomen trauma (13.33%) and 2 patients had urinary bladder rupture (6.66%). Oblique fracture was found in 15 patients (50%), spiral in 10 cases (33.33%) and comminuted fracture in 5 cases (16.66%). Majority of patients underwent external fixation i.e. 17 cases (56.66%) followed by Internal fixation i.e.11 cases (36.66%). In this study excellent results were observed in 23 cases (76.66%), good in 5 cases (16.66%) and poor in 2 cases (6.66%).Conclusion: Early soft tissue coverage in the acute phase (1-6 days) should be the priority in order to prevent bacterial colonisation especially hospital acquired; wound desiccation, sequestration of the exposed bone. External fixation should be contemplated in highly comminuted fractures with severe contamination and when wound closure is not possible.

Lower limb paediatric trauma with bone and soft tissue loss: Ortho-plastic management and outcome in a major trauma centre

AimWe examined the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss. MethodPatients were identified from our prospective trauma database (2013-2018). Inclusion criteria were age (<18 years) and open lower-limb trauma. We assessed severity of soft tissue and/or bone loss, fracture complexity, surgical techniques and time to surgery. Paediatric quality of life and psychological trauma impact scores (HRQOL and CRIES), Ganga Hospital Injury Severity score (GHISS), union and complication rates were measured. ResultsWe identified 32 patients aged between 4 and 17 years. Twenty-nine patients had open tibia fractures including 14 patients with bone loss, one patient had an open femur fracture, one patient an open talus fracture and one an open ankle fracture with dorsal degloving. Thirty injuries were classified intra-operatively as Gustilo IIIB (or equivalent) and two injuries as Gustilo IIIC. In 10 patients primary skin closure was achieved by acute shortening following segmental bone loss. Twenty-two patients required soft tissue coverage: 17 free vascularised flaps, two fascio-cutaneous flaps and three split skin grafts were used. Two patients required vascular repair. Soft tissue coverage was achieved within 72 hours in 26 patients (81%) and within a week in 30 patients (94%). The surgical techniques applied were: circular fine wire frame (19), monolateral external fixator (4) and open reduction internal fixation (8). Median follow up time was 18 (7-65) months. Paediatric quality of life scores were available in 30 patients (91%) with a median total score of 77.2 out of 100. The psychological trauma impact scores showed one in three patients was at risk of developing post-traumatic stress symptoms (PTSD). The GHISS scores ranged from 6-13. All fractures went on to unite over a median time of 3.8 (2-10) months. Three patients (9%) had major complications; two flap failures requiring revision, one femur non-union requiring revision fixation. ConclusionLimb salvage and timely fracture union is possible in children with complex lower limb trauma. Early intervention providing adequate debridement, skeletal stabilisation and early soft-tissue cover including the option of free microvascular reconstruction in small children when required, delivers acceptable outcomes. A multidisciplinary team approach including clinical psychologists to address the psychological impact of trauma provides optimal holistic care for these children and adolescents. Therefore, treatment for these patients should only be performed in paediatric major trauma centres.

Treatment of Fingertip Injuries.

The goal of care when treating fingertip injuries is to minimize the risk of infection while maximizing function, tactile sensation, digit length, pulp padding, and appearance. This outcome can be achieved with careful soft-tissue coverage and, if possible, nail-bed preservation. When replantation for a fingertip amputation is not possible for anatomic or logistical reasons, local or regional flap reconstruction can be a useful alternative to gain early soft-tissue coverage and allow more functional rehabilitation. Reviewing current fingertip soft-tissue coverage procedures and demonstrating key anatomic and technical points with cadaveric dissections provides a foundation for the incorporation of these techniques into practice.

Prevention of infection in open fractures: Where are the pendulums now?

Soft tissue management and fracture fixation including initial external fixation in Gustilo-Anderson type II and type III open fractures are cornerstones in the treatment but details on timing and type of wound closure, irrigation and debridement, systemic and local antibiotics, antimicrobial-coated implants and the use of Bone Morphogenetic Protein-2 remain controversial. This article looks at current clinical evidence of these items for the management of open fractures. Timing of debridement and wound closure remains critical. Early debridement by an experienced team within 24 h seems adequate while gross contamination, a devascularized limb, a multi-injured patient and compartment syndrome require immediate surgical intervention. Wound closure during the first surgery was shown to result in reduced rates for infections and nonunion. If soft-tissue reconstruction is needed, it should be performed within the first 7 days. Regarding types of irrigation fluid, antiseptic and antibacterial solutions did not prove to be superior to saline. High pressure irrigation has not been demonstrated to be beneficial whereas antibiotic administration as soon as possible has been proven to be favorable. Administration of more than 72 h was not superior to shorter systemic antibiotic intervals. For Gustilo-Anderson type I and II, broad spectrum antibiotic therapy is reasonable. Additional aminoglycosides for broader coverage are recommended in Gustilo-Anderson type III fractures. There is newer literature on the beneficial effects of the use of local antibiotics, e.g. by antibiotic beads. Coating of internal fixation devices is a modern approach to improve infection prophylaxis and gentamicin-coated implants have been demonstrated to be safe in clinical application. Vacuum assisted closure (VAC) could not evidence negative pressure wound therapy to reduce infection risk, improve self-rated disability or quality of life in open fractures, however, enhance treatment costs. Recombinant human bone morphogenetic proteins (rhBMP)-2 showed promising data in Gustilo-Anderson type III open tibial shaft fractures with lower rates of invasive secondary procedures. In conclusion, there is evidence for thorough debridement and irrigation with saline, early soft tissue coverage and the use of systemic and local antibiotics. Except for a short-term soft tissue coverage VAC seems not to be beneficial and rhBMP-2 is an additional tool in Gustilo-Anderson type III open fractures.