Gustilo IIIB Research Articles

The impact of cytokine responses in the intra- and extracellular signaling network of a traumatic injury

Investigations of cellular responses involved in injury and repair processes have generated valuable information contributing to the advancement of wound healing and treatments. Intra- and extracellular regulators of healing mechanisms, such as cytokines, signaling proteins, and growth factors, have been described to possess significant roles in facilitating optimal recovery. This study explored a collection of 30 spatiotemporal responses comprised of cytokines (IL-1α, IL-1ß, IL-2, IL-6, TNF-α, MIP-1α), intracellular proteins (Akt, c-Jun, CREB, ERK1/2, JNK, MEK1, p38, p53, p90RSK), phosphorylated proteins (p-Akt, p-c-Jun, p-CREB, p-ERK1/2, p-GSK-3α/ß, p-HSP27, p-IκBα, p-JNK, p-MEK1, p-p38, p-p70S6K, p-p90RSK, p-STAT2, p-STAT3), and a protease (Caspase-3), measured in skeletal muscle tissue following a traumatic injury (rodent Gustilo IIIB fracture). To optimize the analysis of context-specific data sets, a network centrality parameter approach was used to assess the impact of each response in relation to all other measured responses. This approach identified proteins that were substantially amplified and potentially central in the wound healing network by evaluation of their corresponding centrality parameter, radiality. Network analysis allowed us to distinguish the progression of healing that occurred at certain time points and regions of injury. Notably, new tissue formation was proposed to occur by 168 h post-injury in severely injured tissue, while tissue 1-cm away from the site of injury that experienced relatively minor injury appeared to exhibit signs of new tissue formation as early as 24 h post-injury. In particular, hallmarks of inflammation, cytokines IL-1ß, IL-6, and IL-2, appear to have a pronounced impact at earlier time points (0–24 h post-injury), while intracellular proteins involved in cell proliferation, differentiation, or proteolysis (c-Jun, CREB, JNK, p38, p-c-Jun; p-MEK1, p-p38, p-STAT3) are more significant at later times (24–168 h). Overall, this study demonstrates the feasibility of a network analysis approach to extract significant information and also offers a spatiotemporal visualization of the intra- and extracellular signaling responses that regulate healing mechanisms.

Treatment of open fracture of shaft of tibia-fibula Gustilo type III-B by SIGN interlocking nail and wound coverage by muscle flap within 72 hours of injury

<p class="abstract"><strong>Background:</strong> The open fracture of tibia-fibula Gustilo type III-B may threaten the survival of the injured leg. The objective of<strong> </strong>the study purpose was to see the effect of early coverage following fixation of open tibial shaft fracture<span lang="EN-IN">.</span></p><p class="abstract"><strong>Methods:</strong> This clinical trial was carried out in National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka from July 2004 to June 2006 for a period of two (2) years. Patients at age group of 18 years or above with both sexes presented with open fracture shaft of tibia-fibula Gustilo type III-B were selected as study population. The patients were surgically managed by SIGN Interlocking nail and wound coverage by muscle flap within 72 hours of injury. Bacteriological study of the wound was done in all cases.<strong> </strong>All fixation and coverage were performed within 72 hours of injury. Patients grading improved on subsequent follow up. Evaluation of results was done at every post-operative follow up.<strong></strong></p><p class="abstract"><strong>Results:</strong> A total number of<strong> </strong>12 young patients with open fracture tibia-fibula Gustilo III-B were recruited for this study. Their age varies from 18 years to 48 years. A total number of 83.33% cases wound debridement was done within 12 hours of injury. Most of the soft tissue healed (91.67%) within 0 to 20 days. There were no cases developed limb length discrepancy angulations or rotation. Superficial infections were occurred in 1(8.33%) case but no evidence of deep infection. In this study excellent result were obtained from 9 cases (75%), good results were found in 2 cases (16.67%), fair results from 1 case (8.33%)<span lang="EN-IN">. </span></p><p class="abstract"><strong>Conclusions:</strong> In conclusion early intramedullary fixation and exposed bone coverage by muscle flap is very important for prevention of infection, minimizing bone death simultaneously enhances bone healing<span lang="EN-IN">.</span></p>

Retrospective study of open tibial diaphyseal fractures type IIIA and IIIB by Ilizarov method

Background and objective: Open tibial fracture with or without bone loss in gustilo Anderson type IIIA and IIIB has been a challenge for most orthopaedic surgeons. Open tibial fracture is more prone for infection, non union and longer morbidity. In this study, we have evaluated the results of 34 patients with open tibial fracture GA type IIIA and IIIB by Ilizarov method in retrospective manner. An attempt has been made to review the literature for the results of Ilizarov external fixator for open diaphyseal fracture and compare our results with standard studies. Methods: In this retrospective study, 34 patients who are fulfilling our inclusion and exclusion criteria from Mumbai port trust hospital during the period of Dec 2012 to April 2016, treated for open tibial fracture by Ilizarov external fixator. Bone and functional results were evaluated using Tucker’s criteria and Johners and wruh’s criteria. Results: Results were assessed using Tucker score and Johner and wruh’s criteria and 91.1% had excellent to good result and 8.9% had fair to poor results using Tucker’s criterion and 30 (88.23%) cases had excellent to good results and 4 (11.77%) cases had poor results using Johner and Wruh’s criterion. Conclusion: Ilizarov method is one of the method to treat open tibial fractures, advantages being the early weight bearing and treating infection, bone loss, fracture union and wound problem at the same time.

Combined free anterolateral thigh flap and tibial bone transport for resurfacing large segmental bone and soft tissue defect of lower extremities

Objective To investigate the clinical efficacy of free anterolateral thigh flap transport combined with tibia bone transport in reconstruction of large segmental bone and soft tissue defect of lower extremities. Methods This retrospective case series review included 27 patients sustaining large segmental bone and soft tissue defect of lower extremities admitted between August 2006 and April 2016. There were 22 males and 5 females, with a mean age of 36 years (range, 16-56 years). Eleven patients were identified with Gustilo ⅢB type open injury, 14 Gustilo ⅢC type open injury, and 2 large bone and soft tissue defects after internal fixation of the closed lower extremity fractures. Size of soft tissue defect was 10.0 cm×5.5 cm-21.0 cm×10.0 cm. Size of the flaps was 13.0 cm×7.5 cm-23.0 cm×11.0 cm. Length of bone defect was 5.5~18 cm and length of bone transport was 6~21 cm. Anterolateral thigh flaps were employed for limb salvage. After wound healing, bone transport with the use of an Ilizarov ring external fixator was done to treat tibial bone defect. Flap survival, wound healing time, bone transport time, bone healing index and time of external fixator removal were recorded. Mineralization of regenerate bone was assessed using the bone healing index. Results were evaluated using the Paley scoring system. Results Mean follow-up period was 4 years (range, 1-8 years). All flaps survived and the wounds were healed without ulceration or infection. Mean time for wound healing was 4.5 months (range, 1-18 months). Time interval between wound healing and bone transport was 1-4 days (mean, 1.5 months). Mean bone healing index was 55 days (range, 45-65 days), demonstrating good bone mineralization. Mean time of external fixator removal was 24.5 months (range, 10-39 months). Shape of the tibia was satisfied. All patients were able to ambulate without use of an aid. According to the Paley scoring system, results were excellent in 21 patients and good in 6 patients. Conclusion Combined free anterolateral thigh flap and tibial bone transport provides enough bone and soft tissue and satisfactory recovery of limb function and morphology, indicating an effective treatment for large segmental bone and soft tissue defect of lower extremities. Key words: Surgical flaps; Ilizarov technique; Tibial fractures; Soft tissue injuries; Bone defect

Definitive Management of Open Tibia Fractures Using Limb Reconstruction System

Open fractures are treated as surgical emergency and early administration of intravenous antibiotic coupled with early irrigation and debridement decreases the infection rate dramatically. Limb Reconstruction System (LRS) is a unilateral rail system which consists of Shanz pins, rail rods and sliding clamps. It is specifically designed to enable the surgeon to perform simple and effective surgery as it offers rigid fixation of fracture fragments, allowing early weight bearing and reduces economic burden. To determine the efficacy of Limb Reconstruction System for treatment of compound tibia fractures. A prospective study was carried out where in 54 cases out of 412 compound tibia fractures having Modified Gustilo Anderson Type IIIA and IIIB with a mean age of 42±5 years were treated using LRS over a period of 26 months. Limb reconstruction system was used in acute docking mode or with corticotomy and bone transport was done depending upon the bone loss. The soft tissue condition was assessed and split thickness skin grafting and flap repairs were done as per the need. Clinical and radiological assessment was done at every follow-up. Bony and functional assessment was done by Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria. Among 54 patients, bony results as per ASAMI score were excellent in 36, good in 14, fair in 2 and poor in 2 patients. Functional results were excellent in 43, good in 7, fair in 4 patients. The average fracture union time was 8 months. Post-surgery patient satisfaction was excellent since fixation allowed weight bearing immediately. Average hospital stay was 7 days and financial burden was reduced by 40% as compared to multi staged surgery. The average time of return to work was 20 days. LRS is an easy, simple and definitive surgical procedure that allows immediate full weight bearing walking. It reduces hospital stay, is cost effective with excellent patient compliance and can also be used for bone lengthening/transportation.

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.

Tratamiento de fracturas abiertas de tibia grado IIIB-IIIC de Gustilo con colgajos libres microvascularizados

The purpose of this article is to report our clinical experienceof lower extremity microsurgical reconstruction insevere Gustilo IIIB or IIIC open tibial fra...

Secondary nailing after external fixation for tibial shaft fracture: Risk factors for union and infection. A 55 case series

IntroductionSecondary intramedullary nailing (SIN) following external fixation (EF) of tibial shaft fracture is controversial, notably due to the infection risk, which is not precisely known. The present study therefore analysed a continuous series of tibial shaft SIN, to determine (1) infection and union rates, and (2) whether 1-stage SIN associated to EF ablation increased the risk of infection. HypothesisFactors exist for union and onset of infection following tibial shaft SIN. Materials and methodsA retrospective series of SIN performed between 1998 and 2012 in over 16-year-old patients with non-pathologic tibial shaft fracture was analysed. EF pin site infection was an exclusion criterion. Fractures were graded according to AO and Gustilo classifications. Study parameters were: time to SIN, 1- versus 2-stage procedure, bacteriologic results on reaming product, post-nailing onset of infection, and time to union. ResultsFifty-five patients (55 fractures) were included. There were 16 closed and 39 open fractures: 7 Gustilo type I, 26 type II and 6 type IIIA; 33 AO type A, 14 type B and 8 type C. Mean time to SIN was 9±9.6 weeks (range, 4 days to 12 months). There were 23 1-stage procedures, and 32 two-stage procedures with a mean 12-day interval (range, 4–30 days). Twelve reaming samples were biologically positive without secondary infection. There were 4 septic complications (3 abscesses, 1 osteomyelitis), and 1 aseptic non-union required re-nailing. The union rate was 96%. The sole factor of poor prognosis was severity of fracture opening. One-stage SIN did not increase infection risk. DiscussionThe present results were better than reported in the literature, where the rates of Gustilo IIIA and IIIB fracture and pin site infection are, however, higher. Tibial shaft SIN is a reliable procedure, with infection risk correlating with Gustilo type and time to surgery. Surgery should be early, before onset of EF pin site infection. A 1-stage attitude appears feasible in early SIN. Level of evidenceLevel IV. Retrospective study type.

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

Masquelet technique for the treatment of a severe acute tibial bone loss

The “induced membrane” technique described by Masquelet has been used successfully for many years for posttraumatic bone defect reconstruction, non-unions and osteomyelitis. The main advantages are the two-step surgical procedure that in case of primary infection allows repeated debridement if necessary, in case of internal fixation early weight bearing with decreased malalignment risk and it has a short learning curve. A theoretical application of this procedure is the management of acute severe traumatic bone loss of the limbs despite the lack of this experience in literature. We report on a Gustilo IIIB meta-epiphyseal fracture (AO 43-C3) of the leg with a 6cm in length bone loss that was treated with the Masquelet technique.

Outcome of 28 open pilon fractures with injury severity-based fixation.

Open pilon fracture management and treatment poses a significant challenge to orthopedic surgeons. The purpose of this study was to determine patient outcomes for open pilon fractures based on wound complication and infection rates, as well as subjective outcome instruments. This was a retrospective consecutive case series of 28 fractures with Orthopaedic Trauma Association (OTA)-type 43-B and 43-C open pilon fractures. Mean length of follow-up was 36months and minimum of 1year. Ten fractures were Gustilo and Anderson grade IIIB, and the remaining fractures were grades I-IIIA. Patients were initially treated with spanning external fixation and staged wound debridement followed by osteosynthesis of the articular surface. Metaphyseal fixation was by either plate fixation or Ilizarov frame. The primary outcome was the incidence of deep tissue infection requiring surgery. Secondary outcomes included the incidence of other complications (nonunion, malunion, amputation) and functional outcomes (Short Musculoskeletal Functional Assessment Questionnaire and AAOS Foot and Ankle Questionnaire). Four patients developed deep tissue infections, three in the internal fixation group and one in the Ilizarov group, and all were treated successfully with staged debridement. There were two delayed unions required bone grafting, and infection-free union was ultimately achieved in all fractures. Two patients underwent arthrodesis secondary to post-traumatic arthritis, while no patients experienced malunions or amputations. The use of staged wound debridement in conjunction with either plate fixation or Ilizarov frame achieves low rates of wound infection and stable fixation after anatomic joint reconstruction for OTA-type 43-B and 43-C open pilon fractures.

Early Postoperative Outcomes Associated With the Anterolateral Thigh Flap in Gustilo IIIB Fractures of the Lower Extremity

A core concept in plastic surgery has been the replacement of "like-with-like" tissue. Applying this concept to the lower extremity, the anterolateral thigh (ALT) perforator flap has become a frequently used free flap for restoration of soft tissue defects involving the distal lower extremity. The objective of this study was to evaluate the rate of early postoperative complications associated with the ALT perforator free flap for coverage of high-energy traumatic open fractures of the lower extremity (Gustilo IIIB) and explore related patient risk factors. A retrospective chart review of 74 patients undergoing free tissue transfer for lower extremity limb coverage was performed. Early postoperative complications were defined as any 1 or more of the following having occurred within 6 months from surgical reconstruction: hematoma, wound infection, deep venous thrombosis, thromboembolism, partial flap loss, complete flap loss, continued osteomyelitis, and progression to amputation occurring within the first 6 months after the injury. Statistical analyses were performed using GraphPad software. Fisher exact test was performed to identify risk factors associated with greater morbidity. Of all patients, 26 (35%) were identified as those habitually using tobacco product and 48 (64%) were identified as nonusers of tobacco product. Moreover, 10 patients (14%) had other risk factors for atherosclerotic disease and 64 patients (86%) did not have other risk factors for atherosclerosis. Mean (SD) time to reconstruction was 4.74 (1.3) days (range, 3-8 days). Of all defects, 34 (46%) were reconstructed using adipocutaneous flaps and 40 (54%) were reconstructed using fasciocutaneous flaps. The most frequent complication was partial flap loss or superficial epidermolysis 4 (5.4%). Fisher exact test was performed, showing that patients who used tobacco product (cigarette smokers) and had other risk factors for atherosclerosis were significantly more at risk for complications (P < 0.001). In this retrospective review, those patients who had a positive history of tobacco use at the time of injury and those with risk factors for atherosclerosis had a significantly increased risk of flap complications. Although this is not surprising given the vasoconstrictive effects of nicotine and the impaired blood flow to the lower extremity in patients with atherosclerosis, this study will allow the surgeon to better counsel patients who have a history of tobacco use through complex reconstruction of the lower extremity. This analysis is a preliminary investigation into the safety and efficacy of the ALT fasciocutaneous or adipocutaneous flap to reconstruct high-energy open fractures of the lower extremity.

Intentional Deformation and Closure of Soft Tissue Defect in Open Tibial Fractures With a Taylor Spatial Frame—A Simple Technique

We describe a way of using Taylor spatial frames (TSFs) for acute deformation of Gustilo IIIB tibial fractures and infected tibial nonunions to close the soft tissue defects and to gradually restore anatomical alignment. We use the Direct Scheduler Utility module of the web-based software for TSFs to successfully restore the anatomical alignment. We report a case series of the above technique. Care was carried out at a tertiary referral center for limb reconstruction. Seven consecutive patients with significant soft tissue loss after tibial fractures were treated. Defects were closed with acute deformation of the fracture followed by gradual correction to anatomical alignment with a 2-ring TSF. Successful closure of the soft tissue defect was our primary outcome measure. Soft tissue defects ranged from 3 to 10 cm. All healed without additional plastic surgery to cover the exposed tibia. Only 1 patient required an additional TSF prescription to achieve anatomical alignment. The use of the Direct Scheduler module of the web-based TSF software allows the complete correction of complex deformities without the need for obtaining complex mounting and frame parameters. We achieved successful closure of soft tissue defects and restored the anatomical tibial alignment in all our cases.

Risk factors associated with infection in tibial open fractures

Background. The objective of the treatment of open fracture is to prevent infection, stabilize the bones, and restore function. However, infection is the most important step in achieving the latter aims. Objective. The objective of the current paper is to find risk factors associated with infection in a sample of tibial open fractures. Patients and Methods. A retrospective analysis was carried out. The study included all patients who underwent to tibial open fracture treatment in the Hospital Geral Roberto Santos-HGRS, Salvador, Bahia, Brasil, from March to October, 2009. Patients under the age of eight, with multiple fractures or suffering from systemic or bone disease were excluded. Clinical and demographic data were collected and Patient outcomes were divided into two groups: Group 1 comprises those without infection whereas group 2 comprises those with lesions which became infected. The two groups were evaluated in search for associated factors that could lead to infection. Results. We studied 50 patients. Our overall infection rate was 14 (28%; CI95%=15.5-40.5). Infection was significantly associated with place of trauma (OR 3.78; CI95%=1.4-5.5;p=0.02), and time delay superior to 24 hours (OR 3.4; CI95%=1.4-20.8; p=0.03). Fractures graded as Gustilo I, II and IIIA had a lower chance for infection compared to Gustilo IIIB and IIIC (OR 4.32; CI95%=1.3-19.1; p=0.01). Fractures graded Tscherne III and IV had a higher chance for infection, and it was the most significant isolated factor (OR 8.07; CI95%=2.4-47.1; p&lt;0.00).Conclusions. We confirmed the relationships between infection with Gustilo classification and as well as between infection and trauma from the countryside of Bahia State. We also presented a new relationship between soft tissue and infection, and another relating time delay of more than 12 hours with infection.

Never fear, a perforator will always appear: The use of a perforator flap based on the vasa nervosum of the anterior branch of the femoral cutaneous nerve

A 30 year old tree surgeon presented to our services with a Gustilo IIIB fracture to his right lower leg. An anterolateral thigh flap was planned for the reconstruction. Intraoperatively, there were no suitable perforators seen and a neurocutaneous perforator flap based on the vessels associated with the anterior branch of the femoral cutaneous nerve was used. The nerve was preserved in the flap harvest. He was discharged and later followed up in clinic with no complications.

Delayed amputation following trauma increases residual lower limb infection

Residual limb infection following amputation is a devastating complication, resulting in delayed rehabilitation, repeat surgery, prolonged hospitalisation and poor functional outcome. The aim of this study was to identify variables predicting residual limb infection following non-salvageable lower limb trauma. All cases of non-salvageable lower limb trauma presenting to a specialist centre over 5 years were evaluated from a prospective database and clinical and management variables correlated with the development of deep infection. Forty patients requiring 42 amputations were identified with a mean age of 49 years (±19.9, 1SD). Amputations were performed for 21 Gustilo IIIB injuries, 12 multi-planar degloving injuries, seven IIIC injuries and one open Schatzker 6 fracture. One limb was traumatically amputated at the scene and surgically revised. Amputation level was transtibial in 32, through-knee in one and transfemoral in nine. Median time from injury to amputation was 4 days (range 0-30 days). Amputation following only one debridement and within 5 days resulted in significantly fewer stump infections (p=0.026 and p=0.03, respectively, Fisher's exact test). The cumulative probability of infection-free residual limb closure declined steadily from day 5. Multivariate analyses revealed that neither the nature of the injury nor pre-injury patient morbidity independently influenced residual limb infection. Avoiding residual limb infection is critically dependent on prompt amputation of non-salvageable limbs.

Clinical study on the repairing of Gustilo III B and III C open tibia fractures by bone fixation and tissue flap

Objective To investigate the choice of methods and time on the treatment of Gustilo type 11I B and type m c open tibia fractures by bone fixation and tissue flap repairing. Methods The clinic data of 156 cases of Gustilo Ⅲ B and ⅢC open tibia fractures were retrospectively studied. There were 102 males and 34 females, with average age of 34 years（range 14 to 68 years）. Ninety-eight cases were classified as Gustilo type ⅢB and 38 cases were type Ⅲ C in degree. In all cases, one hundred and thirteen were treated with one- stage external fixation, ninteen cases were treated with secondary bone fixation. Sixty-seven cases of all wounds were repaired by one-stage vascular pedicle skin flap. Seven wounds were repaired by one-stage free flaps with vascular anastomosis. Sixty-two cases were secondary repaired by different flaps after defect tissue under VSD （vacuum-sealing-drainage） treatment by 1 to several weeks, which contains 9 free skin graft, eleven muscle flaps based on posterior tibial artery perforator, thirteen flaps based on fibial artery perforator, fourteen gastroc- nemius falps and 15 cross-leg flaps. Results Wound of all cases were healed wholly. Primary union oc- curred in 121 cases, twelve vases healed after bone grafting for segmental bone defect. Three cases with delayed union healed after reoperation for infection that caused osteomyelitis and sinus tract. The period of bone healing was form 5 to 12 months. Conclusion The treatment of Gustilo Ⅲ B and Ⅲ C open tibia fractures by one- stage or secondary bone fixation and tissue flap repairing get their advantages and disadvantages, but one-stage bone fixation and tissue flap repairing was better where appropriate. Key words: Tibia frartures ; Gustilo type; Bone fixation; Tissue flap

Operative stabilization of open long bone fractures: A tropical tertiary hospital experience

Background:Operative treatment of open fractures in our environment is fraught with problems of availability of theater space, appropriate hardware, and instrumentation such that high complication rates may be expected.Materials and Methods:We evaluated all open long bone fractures operatively stabilized at our center to determine the outcome of the various treatment modalities as well as the determinant factors.Result:A total of 160 patients with 171 fractures treated between December 1995 and December 2008 were studied. There were twice as many males; mean age was 35.0 years. About half were open tibia fractures. Gustilo IIIa and IIIb fractures each accounted for 56 cases (45.2%). Fifty-three percent were stabilized within the first week of injury. Interval between injury and operative fixation averaged 11.1 days. Anderson-Hutchin's technique was employed in 27 cases (21.8%), external fixation in 21 (16.9%), plate osteosynthesis in 50 (40.3%), and intramedullary nail 15 cases (12.1%). Mean time to union was 24.7 weeks. Fifty-two complications occurred in 50 fractures (40.3%) with joint stiffness and chronic osteomyelitis each accounting for a quarter of the complications. Union was delayed in grade IIIb open fractures and those fractures treated with external fixation.Conclusion:A significant proportion of open long bone fractures we operatively treated were severe. Severe open fractures (type IIIb) with concomitant stabilization using external fixation delayed fracture union. While we recommend intramedullary devices for open fractures, in our setting where locking nails are not readily available, external fixation remains the safest choice of skeletal stabilization particularly when contamination is high.

Long-Term Outcome of High-Energy Open Lisfranc Injuries: A Retrospective Study

The outcome of open Lisfranc injuries has been reported infrequently. Should these injuries be managed as closed injuries and is their outcome different? We undertook a retrospective study of high-energy, open Lisfranc injuries treated between 1999 and 2005. The types of dislocation, the associated injuries to the same foot, the radiologic and functional outcome, and the complications were studied. There were 22 patients. Five patients died. One had amputation. Of the remaining 16 patients, 13 men were followed up at a mean of 56 months (range, 29-88 months). The average age was 36 years (range, 7-55 years). According to the modified Hardcastle classification, type B2 injury was the commonest. Ten patients had additional forefoot or midfoot injury. All patients were treated with debridement, open reduction, and multiple Kirschner (K) wire fixation. All injuries were Gustilo Anderson type IIIa or IIIb. Nine patients had split skin graft for soft tissue cover. Mean time taken for wound healing was 16 days (range, 10-30 days). Ten patients (77%) had fracture comminution. Eight patients had anatomic reduction, whereas five had nonanatomic reduction. Ten of 13 (77%) patients had at least one spontaneous tarsometatarsal joint fusion. The mean American Orthopaedic Foot and Ankle Society score was 82 (range, 59-100). Nonanatomic reduction, osteomyelitis, deformity of toes, planus foot, and mild discomfort on prolonged walking were the unfavorable outcomes present. In open Lisfranc injuries, multiple K wire fixation should be considered especially in the presence of comminution and soft tissue loss. Although anatomic reduction is always not obtained, the treatment principles should include adequate debridement, maintaining alignment with multiple K wires, and obtaining early soft tissue cover. There is a high incidence of fusion across tarsometatarsal joints.

Treatment of Metachronous Lower Extremity Defects with Delay and Splitting of a Previously Advanced Reverse Sural Artery Flap

Sir: Soft-tissue reconstruction following distal third lower extremity trauma remains a challenging problem and is typically reconstructed using free tissue transfer. The reverse sural artery flap originally described by Masquelet et al. has gained popularity in reconstruction of these defects.1 Multiple modifications have been made to improve flap viability and venous drainage, convey sensibility, increase flap size, and augment arc of rotation.2 Splitting has been described in flaps with consistent segmental neurovascular supply including the latissimus dorsi, pectoral girdle muscles, and the radial forearm flap. Tobin described flap splitting for chest wall and intrathoracic reconstruction.3 However, delay and splitting of a previously advanced fasciocutaneous flap based on random-pattern blood supply has not yet been described. In this article, we present a case combining the concept of flap delay and splitting to maximize distal coverage of an adjacent area. A 44-year-old healthy man sustained a Gustilo grade IIIB open right tibia-fibula fracture with a 13 × 6-cm distal tibial soft-tissue defect and a partial-thickness loss at the heel. He underwent open reduction and internal fixation of the tibia with hardware exposure in the soft-tissue defect. Given the calf size, defect location, and vascular status, a 16 × 10-cm reverse sural artery rotation flap was elevated, including a small surrounding cuff of the gastrocnemius muscle.4 The flap was rotated and inset with minimal tension using an open tunnel approach. Over the course of the next 10 days, the flap demonstrated no evidence of ischemia or venous congestion. However, the heel ulcer progressed to full-thickness loss with exposed calcaneus after débridement. Additional coverage options were limited to free tissue transfer or advancement of a portion of the previously rotated reverse sural artery flap. The inferior portion of the flap that was not covering hardware or bone (defined fluoroscopically) was delayed with division through skin and subcutaneous tissue down to but not including fascia. One week later, the fascia was divided and the delayed segment was advanced and inset into the heel defect. The intervening area between split portions of the flap was skin grafted (Fig. 1). This maneuver provided durable, stable coverage of the exposed tibia and hardware and the subsequent heel defect (Fig. 2).Fig. 1.: Depiction of the flap delay and splitting. Stage 1, Rotation of the reverse sural artery flap to cover the medial malleolar defect. Stage 2, Delayed splitting of the reverse sural artery flap through subcutaneous tissue down to the fascia. Stage 3, Complete division of the split flap and rotation into the heel defect with a skin graft to the donor flap site.Fig. 2.: A reverse sural artery flap split and rotated to cover a heel defect. A split-thickness skin graft was placed over the donor flap site.Techniques of flap splitting have been described in dual blood supply situations. Splitting the reverse sural artery flap has not been described previously. The flap was initially delayed by dividing the skin and subcutaneous tissues. In a second stage, the fascia was divided and the flap was elevated and advanced to cover the heel defect. The concept of using flap engraftment and subsequent, staged transfer to a regional location was traditionally a main form of wound coverage before the development of axial and free flap transfer techniques. Tubed flaps were created and serially “waltzed” to different locations around the body. Although cumbersome and inefficient, many lessons about tissue transfer were learned. Engrafted tissue can be partially elevated in a new location and once again transferred to a contiguous location, thereby allowing engraftment. These techniques, combined with modern axial flap transfer, solved this patient's problem wounds. Jennifer M. Capla, M.D. Institute of Reconstructive Plastic Surgery New York University School of Medicine New York, N.Y. Joseph Michaels, IV, M.D. Baltimore, Md. Daniel J. Ceradini, M.D. Jamie P. Levine, M.D. Pierre B. Saadeh, M.D. Institute of Reconstructive Plastic Surgery New York University School of Medicine New York, N.Y.