Early Soft Tissue Coverage Research Articles

Soft Tissue Cover Of Open Tibial Fractures In Enugu, Nigeria

OBJECTIVE: Open tibial fractures remain a big challenge. The problem is on the increase with ‘legalization' of motorbike as means of transportation. Early soft tissue cover will obviate attendant complications and ensure osseous union. This study is a review of soft tissue cover for patients presenting to our centre METHOD: A retrospective study between January and December 2001. Data collated from patients folders and operating register included age, sex, part(s) of the leg involved, type of open fractures, associated injuries, time before presentation, time between injury and surgery, method of surgical management, complications and follow up period. RESULT: There were 155 patients with open tibial fractures during the period, 117 were males and 38 were females. The mean age was 35.7years. Road traffic accident was the commonest cause. The injury pattern is follows: Type1 forty-five (29.1%) patients, type 11 sixty-two (40%) and type 111 forty-five (29.1%). Distal third of the leg was the most and worst affected. Soft tissue cover was achieved by debridement and dressing till wound healed by secondary intention in 71 patients, primary closure in 8 patients and 29 had delayed primary closure. Thirty-three patients had split thickness skin graft cover while 14 patients had flap cover. Osteomyelitis was the commonest complication. CONCLUSION: Open tibial fractures remain a problem to the patient and the attending surgeon. We suggest early cooperation between Orthopaedic and Plastic Surgeons in management of this problem. Nig Jnl Orthopaedics & Trauma Vol.2(2) 2003: 90-93

Early internal fixation and soft tissue cover of severe open tibial pilon fractures.

We studied 32 consecutive patients with open distal tibial pilon fractures. All patients had radical debridement with immediate skeletal stabilisation and early soft-tissue cover with a vascularized muscle flap. The minimum follow-up was 1 (range 1-8) year. There were four superficial infections, two deep infections and two amputations. There were no long-term problems with union and no patient required an ankle fusion. Patients were assessed using the SF-36 questionnaire. There were significant differences from the US norm in physical function score ( p<0.01), role physical score ( p<0.05) and physical component score ( p<0.01). Physical component score of 38.5 was significantly better ( p<0.01) when compared with amputees from severe lower-extremity trauma. Our protocol for management resulted in a good functional outcome with low infection and amputation rates.

Early soft tissue coverage after complex foot trauma.

Complex foot injuries require early and durable soft tissue coverage to reduce infection rates and fibrosis, thereby improving the functional outcome. Definitive wound closure with tissue transfer was achieved as an emergency procedure within 24 hours in 2 of 28 cases, as urgent revision within 72 hours in 9 of 28 cases, and as early revision within 120 hours in 15 of 28 patients. To evaluate the global foot function the Maryland Foot Score was applied to 17 of 28 patients at the 1-year follow-up. The mean score was 74.2 (of 100) points, indicating "good" to "sufficient" foot function. The outcome was superior compared with a series of 18 consecutive open calcaneus fractures with delayed soft tissue coverage (64.4 points). These results were confirmed with a modified Merle d'Aubigné Score. The overall infection rate could be lowered to 7.1% after complex foot injuries with early soft tissue coverage compared to 26 open calcaneus fractures (19.2%). Functional scores allow a reasonable overall assessment of the results, but they are centered on subjective criteria. Thus they must be viewed in conjunction with radiologic and biometric factors as well as criteria valuable for plastic reconstruction, such as two-point discrimination and durability. Unfortunately, emergency flap procedures are still rare in foot surgery, although they permit primary stable osteosynthesis even with complex foot trauma. The foot should gain the same functional rank as the hand with respect to acute or emergency flap procedures to avoid further complications.

Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia

We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year. After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection. The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (&gt; 72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure.

Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.

We performed a retrospective review of the case notes of 84 consecutive patients who had suffered a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998. All had been treated by a radical protocol which included early soft-tissue cover with a muscle flap by a combined orthopaedic and plastic surgery service. Our ideal management is a radical debridement of the wound outside the zone of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap. All patients were followed clinically and radiologically to union or for one year. After exclusion of four patients (one unrelated death and three patients lost to follow-up), we reviewed 80 patients with 84 fractures. There were 67 men and 13 women with a mean age of 37 years (3 to 89). Five injuries were grade IIIc and 79 grade IIIb; 12 were site 41, 43 were site 42 and 29 were site 43. Debridement and stabilisation of the fracture were invariably performed immediately. In 33 cases the soft-tissue reconstruction was also completed in a single stage, while in a further 30 it was achieved within 72 hours. In the remaining 21 there was a delay beyond 72 hours, often for critical reasons unrelated to the limb injury. All grade-IIIc injuries underwent immediate vascular reconstruction, with an immediate cover by a flap in two. All were salvaged. There were four amputations, one early, one mid-term and two late, giving a final rate of limb salvage of 95%. Overall, nine pedicled and 75 free muscle flaps were used; the rate of flap failure was 3.5%. Stabilisation of the fracture was achieved with 19 external and 65 internal fixation devices (nails or plates). Three patients had significant segmental defects and required bone-transport procedures to achieve bony union. Of the rest, 51 fractures (66%) progressed to primary bony union while 26 (34%) required a bone-stimulating procedure to achieve this outcome. Overall, there was a rate of superficial infection of the skin graft of 6%, of deep infection at the site of the fracture of 9.5%, and of serious pin-track infection of 37% in the external fixator group. At final review all patients were walking freely on united fractures with no evidence of infection. The treatment of these very severe injuries by an aggressive combined orthopaedic and plastic surgical approach provides good results; immediate internal fixation and healthy soft-tissue cover with a muscle flap is safe. Indeed, delay in cover (>72 hours) was associated with most of the problems. External fixation was associated with practical difficulties for the plastic surgeons, a number of chronic pin-track infections and our only cases of malunion. We prefer to use internal fixation. We recommend primary referral to a specialist centre whenever possible. If local factors prevent this we suggest that after discussion with the relevant centre, initial debridement and bridging external fixation, followed by transfer, is the safest procedure.

Management strategies for complex wounds following total knee arthroplasty

Complex wounds following total knee arthroplasty can result in loss of the prosthesis or limb. We report our experience with 32 patients (33 knees) with complex wounds following total knee arthroplasty. Wound assessment includes size, location, depth, presence of infection, quality of tissue, and exposure of bone or prosthetic components. Management options include debridement and closure, local wound care, skin graft, fasciocutaneous flap, local muscle flap, and free tissue transfer. Postoperative outcome is based on complications and clinical evaluation using the Knee Society Score. Successful salvage of the total knee prosthesis was obtained in 28 of 33 knees (85%). Secondary procedures were necessary in ten knees and consisted of soft tissue revision in six knees, removal of prosthetic components in three knees, and both soft tissue revision and removal of prosthetic components in one knee. Our algorithm for management includes early plastic surgery consultation, control of infection, aggressive debridement, and early soft tissue coverage.

Combined muscle flap and Ilizarov reconstruction for bone and soft tissue defects.

Thirty-six patients were treated by Ilizarov transport in conjunction with muscle and myocutaneous flaps coverage. Thirty-one free flaps and 5 rotation flaps were performed. In 13 patients the procedures were carried out in 1-stage or simultaneous manner. In 23 patients, soft tissue coverage proceeded as the initial step followed by Ilizarov reconstruction as a delayed procedure. All flaps survived the simultaneous and delayed procedures and there were no anastomotic complications, but partial flap necrosis occurred in 1 patient 3 months after the index procedure at the time of flap elevation for docking site bone graft placement. The mean segmental defects were 10 cm and 5.8 cm for the simultaneous and delayed groups, respectively. The followup interval from the time of free flap coverage ranged from 2 to 44 months in the simultaneous group with a mean and median of 22 and 24 months, respectively. Twelve patients completed treatment in the simultaneous group with the followup interval from frame removal ranging from 3 to 36 months with a mean and median of 18 and 14 months, respectively. In the delayed group this interval ranged from 1 to 36 months, with a mean and median of 16 and 12 months, respectively, and a mean and median of 24.5 and 21 months, respectively, from the time of the index procedure. Union and absence of infection were achieved in 35 of 36 patients presenting with an acute open fracture, infected nonunion, or aseptic nonunion without stable soft tissue coverage. The Ilizarov fixators remained in place for a median of 9.5 months for the simultaneous group and 8.5 months for the delayed group. When soft tissue defects accompany an infected nonunion or high grade open fracture, the traditional Ilizarov treatment approach of soft tissue recruitment into the wound from the distant corticotomy site is inconsistent with the proven benefit of early soft tissue coverage. The combined approach provides a more reliable soft tissue bed for early cancellous bone grafting of the docking site and permits the accurate restoration of limb length for these very difficult problems.

Morbidity After Crush Injuries to the Foot

By retrospective review of hospital records and by follow-up clinical examinations, we evaluated 58 patients with crush injuries to the foot treated at our institution between 1986 and 1990. All patients had received initial treatment according to a standardized protocol determined by the type and magnitude of the injury. Patients were examined at a mean interval of 3.3 years (range 2-4) after injury, and the functional outcome was determined according to a foot trauma rating scale. Based on this scoring system, 46% of the patients had good functional outcome, 29% had fair results, and 25% had poor results. There was a significant correlation between a good functional outcome and careful adherence to the treatment protocol; however, some patients fared poorly regardless of treatment. Poor results occurred if treatment was not immediately initiated, if soft-tissue coverage was delayed (in those who experienced severe, mangling-type injuries necessitating partial foot amputation), if patients subsequently had neuritis or reflex sympathetic dystrophy, or if patients were involved in ongoing workers' compensation and litigation. We conclude that because crush injuries of the foot may be associated with prolonged morbidity, initial management should be directed toward recognition and treatment of compartment syndromes, early soft-tissue coverage, and rigid skeletal stabilization to enhance soft-tissue healing.

Improving reemployment rates after limb salvage of acute severe tibial fractures by microvascular soft-tissue reconstruction.

Patients with severe open tibial fractures may have a low rate of reemployment after reconstruction. Sixty-five limb-salvage patients were followed for at least 2 years to determine the factors that influence future employment. The preinjury conditions found to influence reemployment included age less than 40, higher education, and white-collar employment. Early postinjury reconstruction and established bone continuity are advantageous to the patient, and the likelihood of reemployment is improved. Reconstructive surgeons may improve employment rates by early soft-tissue coverage, bone grafting (immediate cancellous or free bone transfers), and complete healing. Ambulation follows if bone continuity is established early, and the patient has gained an early advantage on the way to employment and a purposeful future. The reemployment rate has improved to 67 percent in the 15 limb-salvage patients reconstructed after the initiation of aggressive intervention by the reconstructive surgeon. This equals the reemployment rate of traumatic below-knee amputees previously reported.

Open fractures of the diaphysis of the lower extremity in children. Treatment, results, and complications.

We reviewed the results of treatment of forty open diaphyseal fractures of the lower extremity in thirty-five children. The patients were between three and sixteen years old, and they had been managed between 1980 and 1988. The minimum duration of follow-up was one year. Eighty-six per cent of the patients had been injured in a motor-vehicle accident, and 74 per cent had associated injuries. Thirty-one of the fractures were Grade-II open or Grade-III open and seven were Grade-I open, according to the classification of Gustilo and Anderson. Two patients who had initially had a closed fracture were treated with a fasciotomy for a compartment syndrome, so these two fractures were included as open. Four other patients who had a Grade-II or III open fracture also needed a fasciotomy. All wounds were treated with immediate and repeat débridement and early soft-tissue coverage. Twenty-two fractures healed primarily. There were three early amputations. Twelve fractures that healed after six months were classified as delayed unions and three fractures were classified as non-unions because of the absence or arrest of healing, as seen on serial roentgenograms. Additional intervention was used to achieve union of eight of the fifteen fractures that had been classified as a delayed union or a non-union. Ten of the forty fractures were associated with infection, but osteomyelitis developed in only one patient. No patient had a growth arrest. Only one patient had a limb-length discrepancy that was more than two centimeters. Three early amputations and one delayed amputation were performed in patients who had a Grade-IIIC open fracture.

Team approach to tibial fracture

During a 10-year period, we managed 35 patients with 37 cases of Type III open tibial fractures, 15 cases within 1 week and 22 as late referrals. In all cases, simultaneous assessment and management by a microvascular and an orthopedic surgeon were mandatory throughout the treatment period. 6 of the 15 acute cases had a primary amputation. Of the remaining 31 cases, limb salvage was possible in 27. 31 flaps, pedicle and microvascular free flaps were used. Major complications occurred in 6 cases, but in 27 cases infection-free solid union was obtained. At long-term follow-up, average 5 years, the function was good or acceptable in 23 cases. We conclude that: (1) patients with Type III tibial injuries should preferably be transferred within a week after injury to a hospital where major reconstructive procedures are commonly performed, (2) early soft tissue coverage is essential in the management of these injuries, (3) unilateral external fixation should be the preferred technique of stabilization, and, finally, (4) plastic surgery expertise is important in management of severe tibial fractures.

The Use of Quantitative Bacterial Counts in Open Fractures

Late infections remain a significant complication in the treatment of open fractures, occurring in 2% to 25% of all open fractures. Recently there has been a trend toward early soft-tissue coverage of open fracture wounds. Quantitative bacterial counts have been used primarily by plastic surgeons to assess the viability of primary versus delayed wound closures. Quantitative bacterial counts were obtained in 52 consecutive open fractures in 50 patients to assess the correlation between quantitative bacterial counts and subsequent sepsis, to determine the effect of time to debridement on the quantitative bacterial count, and finally to review the bacteriology of open fractures. Forty-one of the 52 fractures had positive quantitative bacterial counts. Four of eight (50%) fractures with quantitative bacterial counts greater than 10(5) developed late sepsis, while only two of 44 (5%) with quantitative bacterial counts less than 10(5) or negative quantitative counts became infected. There was no correlation between time to debridement and quantitative bacterial count levels. A significant percentage of the positive quantitative bacterial counts were gram-negative organisms.

Early Prophylactic Bone Grafting of High-Energy Tibial Fractures

Fifty-three high-energy tibial fractures treated with early prophylactic posterolateral bone grafting were retrospectively reviewed. The bone-grafting procedures were performed at a mean of ten weeks following injury and at a mean of eight weeks following soft-tissue coverage. Ninety-six percent of the fractures had associated injuries with a mean injury severity score of 20.9. Seventy-nine percent of the fractures were classified as Grade III open fractures, and 40% had bone loss greater than 50% of the cortical circumference. Ninety-six percent of the fractures healed at a mean time of 43 weeks after injury. Segmental bone loss and soft-tissue injury requiring flap coverage were the best predictors of prolonged time to union. Comparison with a matched historical control group of tibial fractures not receiving early bone grafts revealed a mean reduction in time to union of 11.7 weeks (p = 0.03). The incidence of chronic osteomyelitis was 1.9%. These results are attributed to early and repeated aggressive debridement, immediate rigid external fixation, early soft-tissue coverage, and early posterolateral bone grafting. Recommendations include posterolateral cancellous bone grafting two weeks following wound closure by delayed primary closure, split-thickness skin graft, or local rotational myoplasty. A six-week delay following freely vascularized soft-tissue coverage prior to bone grafting is suggested.

Blunt popliteal artery trauma: one hundred consecutive injuries.

An institutional experience with 100 consecutive blunt popliteal artery injuries over a 20-year period was reviewed. The overall amputation rate was 15%; however, during the past 7 years this has declined from 23% to 6%. Minimizing delay in the revascularization of ischemic limbs, routine systemic heparinization, primary arterial repair when possible, repair of popliteal venous injuries, aggressive wound debridement, and early soft tissue coverage have contributed to improved limb salvage during the 1980s.

Blunt popliteal artery trauma: One hundred consecutive injuries

An institutional experience with 100 consecutive blunt popliteal artery injuries over a 20-year period was reviewed. The overall amputation rate was 15%; however, during the past 7 years this has declined from 23% to 6%. Minimizing delay in the revascularization of ischemic limbs, routine systemic heparinization, primary arterial repair when possible, repair of popliteal venous injuries, aggressive wound debridement, and early soft tissue coverage have contributed to improved limb salvage during the 1980s.

Improved Results from a Standardized Approach in Treating Patients with Necrotizing Fasciitis

Necrotizing fasciitis has been associated with significant morbidity and mortality. Thirty-three patients were studied over a 3-year period. Predisposing factors included intravenous drug abuse (30%), diabetes (21%), and obesity (18%). Severe pain (94%) and abnormal temperature (88%) were present, whereas laboratory data and x-ray were nonspecific. Gram-positive organisms were most frequently recovered (B-hemolytic streptococcus 45%). Treatment consisted of antibiotics, surgical debridement, re-exploration 24 hours before surgery, nutritional support, and early soft tissue coverage as needed. Mean duration from admission to operation was 43 hours. The average number of operative debridements was three and the average length of hospitalization was 47 days. Patients operated on less than 12 hours from admission or greater than 48 hours had shorter hospital stays (36 and 38 days). The critical time period was 12-48 hours after admission; all deaths and amputations were in this group and the average hospital stay was 62 days (p less than 0.05). The number of operations did not correlate to hospital stay. Despite antibiotics and aggressive debridement, significant morbidity exists if operation is delayed more than 12 hours. Methods of early detection such as local bedside diagnostic incision and fascial inspection may be needed in high risk patients to further reduce the morbidity and mortality.