Gustilo IIIB Open Fractures Research Articles

Immediate Soft Tissue Reconstruction in Lower Limb Traumas Using Propeller Perforator Flaps.

Open bone fractures represent a demanding clinical condition that can be life- or limb-threatening. For small- to medium-size soft tissue defects of the lower extremity, propeller perforator flaps are a viable option for reconstruction. We report our experience in Gustilo IIIB open fractures treatment with immediate coverage through propeller-based perforator flaps performed in acute setting. Between 2019 and 2022, 94 Gustilo III fractures were admitted to our trauma center, and 28 were Gustilo IIIB fractures. Five patients were eligible for an immediate perforator-based propeller flaps reconstruction. The mean age of the patients was 33.8 years. All of them were male. One of them was a heavy smoker (15 cigarettes per day). No other comorbidities were present. The mean operating time, including fracture reduction and fixation time, was 106 minutes. The length of the defect varied between 5 and 7 cm and the width between 3 and 4 cm. We reported no major complications, and none of the patients required a surgical revision of the flap. A patient with smoking habit reported a superficial flap necrosis. The mean follow-up was 5.5 months. No cases of nonunion or osteomyelitis have developed so far. The use of perforator-based propeller flaps, in acute trauma setting, has not been reported in literature so far. In our experience, propeller perforator flaps are a viable reconstructive option in immediate reconstruction during the acute management of open fractures.

Thin and superthin free flaps: An innovative approach to pediatric extremity reconstruction

IntroductionPublished standards for the management of open extremity fractures have improved limb salvage, fracture union, and deep infection rates, but the aesthetic and functional importance of our flap choices has been overlooked. Thin and superthin free flaps exhibit advantages over traditional free flaps in some situations but have seldom been reported in children. The aim of this paper is to present our experience of thin and superthin free flaps in pediatric extremity reconstruction. MethodsChildren (≤13 years) who underwent soft tissue reconstruction using a thin and superthin free flap following major extremity trauma are presented. ResultsFive patients (5 flaps) met the inclusion criteria. The median age was 9 (range 6–13). There were 3 Gustilo IIIB open fractures and 2 multiplanar degloving injuries. The median mangled extremity severity score (MESS) was 4 (range 2–6). The median time from injury to definitive soft tissue closure was 72 h (range 28–120 h). Four anterolateral thigh (ALT) flaps were raised as thin flaps, and 1 superficial circumflex iliac artery perforator (SCIP) was raised as a superthin flap. There was one re-exploration owing to venous congestion, and a second venous anastomosis was performed to enhance flap drainage. The same ALT flap exhibited necrosis at one margin, which was debrided and grafted before discharge. There were no other flap complications. No flap-related secondary surgeries were required. ConclusionThin and superthin free flaps are viable options in pediatric extremity reconstruction. They exhibit excellent aesthetic and functional contouring when a slender fasciocutaneous flap is needed, especially when body habitus renders traditional options unfavorable.

405 Radiological Analysis of Gentamicin Eluting Synthetic Bone Graft Substitute Used in The Management of Gustilo IIIB Open Fractures

Abstract Background Management of traumatic bone void associated with Gustilo IIIB open fractures is challenging. Gentamicin eluting synthetic bone graft substitute (Cerament-G) had been recently utilised for the management of patients with these injuries. This study aims to assess radiological signs of Cerament-G remodelling. Method Retrospective data analysis of all patients admitted to our unit with IIIB open fractures who had Cerament-G applied as avoid filler. Postoperative radiographic images of the fracture site at 6-weeks, 3-months, 6-months and at the last follow-up were reviewed. The radiological signs of Cerament-G integration, percent of void healing, and bone cortical thickness at the final follow-up were assessed. Results 34 patients met our inclusion criteria, mean age: 42 years. Mean follow-up time was 20 months. 59% of patients had excellent (>90%) void filling, 26.4% of patients had 50-90% void filling, and 14.6% had < 50% void filling. Normal bone cortical thickness was restored on AP and Lateral views in 55.8% of patients. No residual Cerement-G was seen on X-rays at the final follow-up in any of the patients. Conclusions Our results showed successful integration of Cerament-G with excellent void filling and normal cortical thickness achieved in more than half of the patients.

Concurrent internal fixation and soft tissue reconstruction by distally based sural flap: a practicable scheme for complex distal tibial fractures.

It is difficult to establish both fracture union and wound healing of open fractures complicated with soft tissue defects of the distal tibia. We describe the simultaneous use of internal fixation and soft tissue coverage by a distally based sural flap (DBSF) for these complex injuries. Seventeen patients with Gustilo IIIB open fractures of the distal tibia were operated on by internal fixation and DBSF coverage. Data were collected on the size of the defect, time to fixation and soft tissue coverage or 'fix & flap', types of implant, time to union, postoperative complications and objective clinical measurement. The average size of the soft tissue defect after debridement was 6.4 × 8.4 cm2 (range 4.0-9.0 × 6.0-12.0). The mean time to fix & flap was 8.1days (range 7-10). A medial precontoured plate was used in 8 patients and an anterolateral precontoured plate in 9. All fractures were united in a mean duration of 22.6weeks (range 20-28). One patient had partial flap necrosis. Using the Puno functional score, 2 patients had excellent functional outcomes and 15 patients had good functional outcomes. Concurrent Internal fixation and soft tissue reconstruction by DBSF is effective and reproducible for Gustilo type III open fractures of the distal tibia even in cases of more than 50 cm2 soft tissue defects.

Simultaneous internal fixation and soft tissue coverage by soleus muscle flap and variances: a reproducible strategy for managing open fractures of tibial shaft

The role of internal fixation and local muscle flaps for open tibial fractures is still not specifically determined. We describe the integration of internal fixation and soleus muscle flap for open fractures complicated with soft tissue loss of the tibial shaft. Twenty-seven patients with Gustilo IIIB open fractures of the tibial shaft were operated on by internal fixation and soft tissue coverage by soleus muscle flaps and variances. Data were collected on types of implants, types of flaps, union time, postoperative complications, and objective clinical measurement. Regarding implants for fixation, plates and screws were selected in 22 patients, and intramedullary nails in 5. Proximally based soleus flap was used in 17 patients, hemisoleus in 6, and reversed hemisoleus in 4. All flaps survived and all fractures were united with a mean union time of 21.8weeks (range 14-30). One patient had unplanned reoperations due to delayed union and equinus deformity of the ankle. All patients had good-to-excellent Puno functional score results. Internal fixation and soft tissue coverage, frequently referred to as 'fix and flap', by a local soleus muscle flap is safe and effective for open fractures accompanied with small-to-medium size soft tissue defect of the tibial shaft.

Combined medial gastrocnemius and hemisoleus flap: a reproducible alternative for open tibial fractures complicated with large or double soft tissue defects.

Utilization of combined local muscle flaps for Gustilo type IIIB open tibial fractures has not been clearly delineated. We describe a combination of medial gastrocnemius and hemisoleus flaps for managing open tibial fractures accompanying large or double soft tissue defects. Twelve patients with Gustilo IIIB open fractures of the tibial shaft with large (9) or double (3) defects were operated on by fracture stabilization and combined medial gastrocnemius and hemisoleus flap coverage. Data were collected on types of implants, types of flaps, union time, postoperative complications, and Puno functional scores. Regarding implants for fixation, an intramedullary nail was used in three patients, plate and screws in five, combined plate and intramedullary nail in one, and definitive external fixation was used in three. Regarding soft tissue coverage, combined medial gastrocnemius and hemisoleus flaps were used in ten patients, combined hemigastrocnemius and hemisoleus in one, and combined medial gastrocnemius and reversed hemisoleus in one. All flaps survived, and all fractures were united with a mean union time of 19.7weeks (range 16-24). Tip necrosis of the hemisoleus flap occurred in two patients. Regarding Puno functional score, one was determined to be excellent, nine was good and two was fair. Combined medial gastrocnemius and hemisoleus flaps are reliable and effective for open tibial fractures complicated with large or double soft tissue defects.

What is the ideal interval between dressing changes during negative pressure wound therapy for open traumatic fractures?

Negative pressure wound therapy (NPWT) is effective in infection control during treatment of severe open fractures. However frequent dressing changes during NPWT are costly and cause patient discomfort. If the interval between dressing changes could be extended, these problems would be reduced. In this article we compare the outcomes of open IIIB fractures with 3-day versus 7-day intervals between dressing changes. Patients who sustained Gustilo IIIB open fractures were included. All underwent conventional orthopaedic fixation with delayed latissimus dorsi flap coverage. Group 1 had 3-day intervals between dressing changes and group 2 had 7-day intervals. The final outcomes in the two groups were analysed. There were 38 patients in group 1 and 34 patients in group 2. Although the period between admission and final operation was similar in the two groups, the mean number of NPWT changes was 4.54 in 3 day in group 1 and 1.95 in group 2 (p<0.001). This led to a difference in NPWT-related costs; $341.26 in group 1 and $237.49 in group 2 (p<0.001). There was no difference in the frequency of complications such as infection or non-union of fractures. NPWT is useful treatment option for open fractures, to bridge between initial debridement and final microsurgical tissue transfer. Considering patient comfort, the costs related to the NPWT, and the final flap results, a 7-day interval between changes of the NPWT is acceptable.

Primary internal fixation combined with flap transfer to treat Gustilo-IIIB open fractures of lower extremity with severe soft tissue defect

Objective To investigate the clinical effect of primary internal fixation combined with flap transfer for Gustilo Ⅲ B open fracture of lower extremity with severe soft tissue defct.Methods From January,2008 to January,2013,15 patients with Gustilo Ⅲ B open fracture of lower extremity and severe soft tissue defect were treated with primary internal fixation combined with flap transfer.Among them,there were 2 cases of foot and ankle fracture,9 of lower-tibia and fibula,3 of upper-tibia and fibula and 1 of distal femur fracture.The areas of the flaps were 10 cm × 8 cm-28 cm × 16 cm.Three cases were treated by bone grafting because of bone defect.Results All patients were followed up for 6-24 months.All flaps were survived,and only small area of 2 cases with the distal necrosis were cured by changing the dressing; In 1 case,the wound was infection and healed after anti-infective and drainage treatment; 13 cases had bone union in primary stage,and the other 2 cases were achieved delayed union; the average healing time was 7.2 months,and no case of osteomyelitis was noted; the time of wound healing was 12-36 days,with an average of 18.1 days.According to lower extremity function evaluation form,the excellent and good rate was 86.6％.Conclusion It is a safe and effective strategy to treat the Gustilo Ⅲ B open fractures of lower extremity and severe soft tissue defect with primary internal fixation combined with flap transfer,which has advantages of reliable fixation,covering the wounds with satisfaction,recovering exercise early,shorten the treatment period,alleviating the suffering of patients and so on. Key words: Open fractures ; Gustilo ⅢB ; Lower extremity; Fixation ; Surgical flap

Internal fixation in the treatment of Gustilo IIIb open fractures of the leg

Gustilo type IIIb open fractures are most often associated with high energy trauma and cannot be closed by simple suture because of the high risk of infection and non-union. As an alternative to the external fixator, fixation by reamed locked intermedullary nailing was done according to the standard technique. The fixation allowed immediate partial or complete weightbearing and mobilisation of the neighbouring joints. In addition, it allows simple and rapid skin cover by flaps. This immediate skin cover allows one to diminish the risk of infection.