Soft Tissue Coverage Procedures Research Articles

Subatmospheric Pressure Dressings in the Temporary Treatment of Soft Tissue Injuries Associated With Type III Open Tibial Shaft Fractures in Children

This study was designed to evaluate the use of subatmospheric pressure dressings on high-energy open tibial shaft fractures in children. We hypothesized that the use of a negative-pressure dressing in these fractures would result in a decreased incidence of infection and decreased need for pedicled muscle flaps and free tissue transfer. A retrospective case series of 15 consecutive pediatric patients with 16 type III open tibial shaft fractures (8 type IIIA, 7 type IIIB, and 1 type IIIC). The patients' age ranged from 2 to 17 years. All patients underwent a standard protocol of serial irrigation and debridement of the open wound with bony stabilization. Temporary coverage of the open wound was obtained with the use of a subatmospheric pressure dressing until definitive wound coverage or closure. Infection occurred in 5 of 16 fractures, 2 requiring antibiotics alone (1 type IIIA and 1 type IIIB) and 3 requiring surgical intervention (2 type IIIB and 1 type IIIC). Seven of 16 (3 type IIIA, 3 type IIIB, and 1 type IIIC) fractures required repeat surgical intervention to facilitate bony healing. Only 3 patients required free tissue transfers or rotational muscle flaps for coverage, a 50% decrease compared with the initial classification. Compared with other described methods, the use of subatmospheric pressure dressings in the temporary treatment of soft tissue wounds associated with high-energy open tibial shaft may reduce the need for major soft tissue coverage procedures. Its effect on infection and fracture healing rates requires further study. A reduction in the need for major soft tissue coverage procedures with the use of negative-pressure dressings in this setting should result in decreased morbidity for these patients and in decreased social and financial costs.

Tube pedicle flap in the management of a Grade III C lower limb injury

Salvage of a Grade III C lower limb injury is a challenging problem. Apart from microsurgical revascularisation, they frequently need soft tissue coverage procedures. Due to the magnitude of the injury, local flaps from adjacent tissues may not be available and microsurgical free flaps are the flaps of choice. We present an instance where the defect in the middle third of a revascularised leg was covered by a tube pedicle flap raised from the groin and transferred, with the wrist as the carrier. This was chosen because of the below knee amputation on the opposite side combined with long segment circumferential loss of skin in the affected extremity and paucity of vein graft sources. Thus the reconstruction of a limb which was saved by microsurgery was completed by tube pedicle flap. In exceptional circumstances 'old' techniques are still useful.

The Treatment of Chronic Open Osteomyelitis of the Tibia in Adults

The treatment of 30 consecutive adult patients with chronic draining osteomyelitis of the tibia was reviewed. There were four treatment patterns. Eight patients had local debridement with or without soft tissue coverage procedures or bone graft. Three patients had radical debridement and bone transport using a circular frame. Eight patients were treated by the Papineau grafting technique after debridement. Eleven patients had debridement and circular frame fixation to correct associated nonunion, malunion, or shortening. All patients received long-term antibiotic therapy. At an average of 6 years' followup (minimum, 2 years), two patients had persistent drainage and one patient had an aseptic nonunion. This experience affirms the value of the circular frame, of the Papineau graft, of bone transport, and of long-term antibiotics for treatment of chronic osteomyelitis of the tibia. There was successful limb salvage in all of the patients and successful treatment (fracture healing without drainage) in 27 of 30 patients. Therapeutic study, Level III-1 (case-control study). See the Guidelines for Authors for a complete description of levels of evidence.

Use of an Expandable Nail in the Treatment of Non-Union Fractures of the Femur, Tibia and Humerus

Non-union after diaphyseal fractures is an important and relevant clinical problem. Despite the availability of improved surgical techniques, antibiotics, and complex soft tissue coverage procedures, non-union occurs in many patients after diaphyseal fractures [10] [20] [23] [36]. Twenty-four patients with the diagnosis of pseudarthrosis of femur, tibia, or humerus were operated on at the University of Louisville Hospital using an expandable intramedullary nail. The patients were followed until clinical and radiological union was achieved. Twenty-three of the twenty-four patients obtained satisfactory results with this method of fixation. This preliminary study demonstrates that an expandable intramedullary nail can be used successfully in the treatment of selected long bone pseudarthrosis.

The anterior T-frame external fixator for high-energy proximal tibial fractures.

The authors' experience using anterior T-frame external fixation combined with percutaneous internal fixation for treatment of high-energy proximal tibial fractures is reported. Thirty-six patients (38 fractures) were reviewed who were treated during a consecutive 42-month period. Three patients died and one patient had an amputation for a Type IIIC open injury, leaving 20 males and 12 females with 21 closed and 13 open fractures (two Type II, seven Type IIIA, three Type IIIB, and one Type IIIC). The average followup was 26 months. Fractures united at a mean of 20 weeks. Ten secondary surgical procedures were planned, including seven antibiotic bead removals with autogenous bone grafting and three soft tissue coverage procedures. Nine (26%) complications were found, including one deep infection (septic arthritis) and three pin tract infections, and one each malunion, nonunion, refracture, knee stiffness requiring manipulation under anesthesia, and deep venous thrombosis. The average Knee Society score was 85 for pain and 83 for function. All patients achieved full knee extension and mean flexion was 125 degrees. The anterior T-frame external fixator with percutaneous internal fixation is a reliable method to stabilize these injuries. It is simple, inexpensive, and effective.

An Aggressive Surgical Approach to the Management of Chronic Osteomyelitis

This is a review of 13 patients with chronic osteomyelitis treated at the author's institution using techniques similar to the management of giant cell tumors of bone. This included aggressive serial debridements and appropriate antibiotic coverage and subsequent bone-grafting or soft-tissue coverage procedures. The number of surgical procedures ranged from three to eight (average 4.2) and were performed every two to three days. Empiric antibiotics were started after cultures were taken at operation, and were changed to organism-specific therapy when culture results were available. Parenteral antibiotics were continued for a mean of five weeks (range, two to eight weeks) and seven of 13 patients received oral antibiotics for an additional two to six weeks after parenteral therapy. Bone grafting or muscle flaps or both were used in those patients with compromised structural integrity, or to fill created dead space and allow wound closure. In postoperative follow-up evaluation, none of the patients have had evidence for recurrent osteomyelitis (mean duration, 58 months; range, 27-89 months). This technique of serial operations with proper antimicrobial therapy, followed by bone grafting and local muscle flaps when needed, has led to excellent end results in the treatment of chronic osteomyelitis.

Severe Open Tibial Fractures

A prospective randomized study of severe open tibial fractures (Type II and III) was performed. Individual fractures were randomized to treatment groups according to initial antibiotic therapy: One consisted of a first-generation cephalosporin, and the other consisted of a third-generation cephalosporin. Initial antibiotic therapy was given in all patients for 48 h and then specific antibiotic treatment was used as indicated by culture. The purpose of this study was to determine whether or not additional gram-negative coverage had an effect on the overall infection rate or the type of infection in severe open tibial fractures. Additional factors, such as the timing of bone grafts and soft tissue coverage, were evaluated in this study as well. Although there was no statistical difference in the rate of infection with the use of a first- versus a third-generation cephalosporin, there was a trend toward a decreased infection rate as well as toward less morbid infections with the use of a third-generation cephalosporin. The study also confirms that early bone graft should not be performed prior to 6 weeks post injury or after successful soft tissue coverage has been achieved. On the other hand, soft tissue coverage procedures should be performed at the earliest possible date to decrease the overall infection rate.

Vascularized Tissue Transfer in the Treatment of Osteomyelitis

In conclusion, the efficacy of free tissue transfer in the treatment of osteomyelitis is geared mainly at enabling the surgeon to perform a wide radical debridement of infected and nonviable soft tissue and bone. Definitive bony management does not have to be performed concurrently with the soft-tissue coverage procedure and may be effectively staged. The type of free tissue transfer employed will depend upon the size and location of the defect, the condition of the contiguous structures, and the experience of the surgeon. Free tissue transfer that is used judiciously after the eradication of all infected bone and soft tissue appears to be a useful technique for controlling osteomyelitis.