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Le ELH, McNamara CT, Constantine RS, Greyson MA, Iorio ML. The Continued Impact of Godina's Principles: Outcomes of Flap Coverage as a Function of Time After Definitive Fixation of Open Lower Extremity Fractures. J Reconstr Microsurg 2024. [PMID: 38382638 DOI: 10.1055/a-2273-4075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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. CONCLUSION 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.
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Affiliation(s)
- Elliot L H Le
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Colin T McNamara
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Ryan S Constantine
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Mark A Greyson
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado
| | - Matthew L Iorio
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, Colorado
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Futamura K, Sato R, Hasegawa M, Suzuki T, Tsuihiji K, Nishida M, Shirakawa T, Tsuchida Y. A gustilo IIIB open tibial fracture complicated by a huge bone defect and larger soft tissue defect: A case report. J Orthop Sci 2023; 28:1536-1542. [PMID: 34742618 DOI: 10.1016/j.jos.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 09/09/2021] [Accepted: 09/13/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Kentaro Futamura
- Department of Orthopaedic Trauma Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan.
| | - Ryo Sato
- Department of Orthopaedic Trauma Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Masayuki Hasegawa
- Department of Orthopaedic Trauma Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Takafumi Suzuki
- Department of Orthopaedic Trauma Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Kanako Tsuihiji
- Department of Orthopaedic Trauma Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Masahiro Nishida
- Department of Orthopaedic Trauma Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Tetsuya Shirakawa
- Department of Orthopaedic Trauma Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
| | - Yoshihiko Tsuchida
- Department of Orthopaedic Trauma Surgery, Shonan Kamakura General Hospital, 1370-1 Okamoto, Kamakura, Kanagawa, 247-8533, Japan
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Jitprapaikulsarn S, Patamamongkonchai C, Sukha K, Gromprasit A, Thremthakanpon W. Simultaneous internal fixation and latissimus dorsi pedicle flap coverage: A reliable regimen for open fractures with accompanying sizable soft tissue loss of the upper extremities. J Orthop Sci 2023:S0949-2658(23)00264-6. [PMID: 37833162 DOI: 10.1016/j.jos.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 02/15/2023] [Accepted: 09/15/2023] [Indexed: 10/15/2023]
Abstract
BACKGROUND The optimal treatment protocol for open fractures with accompanying sizable soft tissue defect of the upper extremities has not been specifically delineated. The authors described the concurrent use of internal fixation and latissimus dorsi (LD) pedicle flap coverage in managing such complex fractures. METHODS Twenty patients with open fractures accompanied by large soft tissue defect of the upper extremities (8 clavicle fractures and 12 humeral fractures) were treated by fix & LD pedicle flap. The dimension of the defect, time to fix & flap, post-operative complications, time to union and clinical measurements were recorded. RESULTS The mean size of the defect was 132.45 cm2 (range 6-12 x 2-20 cm2). The average time to fix & flap was 9.9 days (range 7-14). Fractures union was achieved in all patients with an average duration of 18.5 weeks (range 14-28). Regarding post-operative complications, distal flap necrosis occurred in 3 patients, retained seroma in 3 and heterotopic ossification in 1. By the Mayo Elbow Performance (MEP) score, 3 cases were considered to be excellent, 6 were good, 7 were fair and 4 were poor. By the University of California-Los Angeles (UCLA) shoulder score, 2 cases were considered to be excellent, 7 were good, 7 were fair and 4 were poor. The average Disabilities of Arm, Shoulder and Hand (DASH) score was 31.29 (range 12.5-58.3). CONCLUSION Fix & LD pedicle flap is a reliable regimen for open fractures with sizable soft tissue defect of the clavicle and humerus.
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Affiliation(s)
| | | | - Kritsada Sukha
- Department of Orthopedics, Buddhachinaraj Hospital, Phitsanulok, Thailand
| | - Arthit Gromprasit
- Department of Orthopedics, Buddhachinaraj Hospital, Phitsanulok, Thailand
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Dheenadhayalan J, Nagashree V, Devendra A, Velmurugesan PS, Rajasekaran S. Management of open fractures: A narrative review. J Clin Orthop Trauma 2023; 44:102246. [PMID: 37720489 PMCID: PMC10502353 DOI: 10.1016/j.jcot.2023.102246] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/22/2023] [Accepted: 08/31/2023] [Indexed: 09/19/2023] Open
Abstract
Open fractures are an emergency where the principal aim of the treatment is to maximise the restoration of limb function while preventing the dreaded consequences of infection and non-union. The decision-making process for open injuries is influenced by a variety of criteria, such as patient age, injury features, systemic response, activity level, comorbidities, and functional requirements. A collaborative orthoplastic approach to treating these injuries is essential for minimizing complications and need to be considered as a single specialty in early and long-term management. It has been shown that early prophylactic systemic antibiotics, wound irrigation, aggressive debridement of contaminated and devitalized tissue, and appropriate fracture fixation decreases the complications in all grades of open fractures. The advantages of Gram-negative antibiotics, the use of local antibiotics, intraoperative wound cultures, the "fix and flap" approach, and Negative Pressure Wound Therapy are few of the treatment options that are still controversial. The aim of this review is to provide a comprehensive review and practice guidelines regarding the management of open fractures.
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Affiliation(s)
- Jayaramaraju Dheenadhayalan
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Vasudeva Nagashree
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | - Agraharam Devendra
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
| | | | - Shanmuganathan Rajasekaran
- Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India
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5
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Othman S, Stranix JT, Piwnica-Worms W, Bauder A, Azoury SC, Elfanagely O, Klifto KM, Levin LS, Kovach SJ. Microvascular free tissue transfer for reconstruction of complex lower extremity trauma: Predictors of complications and flap failure. Microsurgery 2023; 43:5-12. [PMID: 34228378 DOI: 10.1002/micr.30785] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 01/12/2021] [Accepted: 06/25/2021] [Indexed: 01/12/2023]
Abstract
BACKGROUND Despite advanced wound care techniques, open fractures in the setting of lower extremity trauma remain a challenging pathology, particularly when free tissue transfer is required for coverage. We aimed to evaluate factors associated with flap failure in this setting using a large, heterogeneous patient population. METHODS Retrospective review of patients who underwent traumatic lower extremity free flap reconstruction (2002-2019). Demographics wound/vessel injury characteristics, pre and perioperative factors, and flap outcomes were analyzed. RESULTS One hundred eighty-eight free flaps met inclusion criteria, with 23 partial (12.2%) and 13 total (6.9%) flap failures. Angiography was performed in 87 patients, with arterial injury suffered in 43.1% of those evaluated. Time to flap coverage varied within 3 days (4.5%), 10 days (17.3%), or 30 days of injury (42.7%). In all, 41 (21.8%) subjects suffered from major flap complications, including failure and takebacks. Multivariate regression demonstrated the presence of posterior tibial (PT) artery injury predictive of both flap-failure (Odds ratio [OR] = 11.4, p < .015) and major flap complications (OR = 12.1, p < .012). Immunocompromised status was also predictive of flap failure (OR = 12.6, p < .004) and major complications (OR = 11.6, p < .007), while achieving flap coverage within 30 days was protective against flap complications (OR = 0.413, p < .049). Defect size, infection, and injury location were not associated with failure. CONCLUSIONS When examining a large, heterogeneous patient cohort, free flap outcomes in the setting of lower extremity open fractures can be influenced by multiple factors. This presence of PT artery injury, flap coverage beyond 30 days of injury, and immunocompromised status appear predictive of flap complications in this context.
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Affiliation(s)
- Sammy Othman
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - John T Stranix
- Department of Plastic Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - William Piwnica-Worms
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Andrew Bauder
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Omar Elfanagely
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Kevin M Klifto
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - L Scott Levin
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.,Department of Orthopedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA.,Department of Orthopedic Surgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
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Alrazak Mahmood MA, Mubarak Ali R, Salim N. SOFT TISSUE RECONSTRUCTION IN SEVERE OPEN LEG FRACTURE. INDIAN JOURNAL OF APPLIED RESEARCH 2022:47-49. [DOI: 10.36106/ijar/4014952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Methodology Eighteen patients who sustained severe open leg fractures (Gustilo’s III) were treated, average age of
25years.
Aims of study:The project is to evaluate: the benet of early over late soft tissue reconstruction in severe open leg fractures (Gustilo type III)
regarding the ap and bone healing.
All patients were treated by meticulous wound excision with stabilization of fracture and then wound cover, which is done early in 6 patients
(before 7 days) and late in 12 patients (after 7 days). local muscle ap was done in 9 patients (50%), local fasciocutanous ap in 6 patients (33/3%)
and free ap in 3 (16.7%).
CONCLUSION: primary reconstruction of Gustilo type III open tibial fractures had advantages compared with secondary reconstruction.
Smoking plays an important role in increasing complication.
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Management of soft-tissue coverage of open tibia fractures in Latin America: Techniques, timing, and resources. Injury 2022; 53:1422-1429. [PMID: 35101259 DOI: 10.1016/j.injury.2022.01.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 01/13/2022] [Accepted: 01/15/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE This study examined soft-tissue coverage techniques of open tibia fractures, described soft-tissue treatment patterns across income groups, and determined resource accessibility and availability in Latin America. METHODS A 36-question survey was distributed to orthopaedic surgeons in Latin America through two networks: national orthopaedic societies and the Asociación de Cirujanos Traumatólogos de las Américas (ACTUAR). Demographic information was collected, and responses were stratified by income groups: high-income countries (HICs) and middle-income countries (MICs). RESULTS The survey was completed by 469 orthopaedic surgeons, representing 19 countries in Latin America (2 HICs and 17 MICs). Most respondents were male (89%), completed residency training (96%), and were fellowship-trained (71%). Only 44% of the respondents had received soft-tissue training. Respondents (77%) reported a strong interest in attending a soft-tissue training course. Plastic surgeons were more commonly the primary providers for Gustilo Anderson (GA) Type IIIB injuries in HICs than in MICs (100% vs. 47%, p<0.01) and plastic surgeons were more available (<24 h of patient presentation to the hospital) in HICs than MICs (63% vs. 26%, p = 0.05), demonstrating statistically significant differences. In addition, respondents in HICs performed free flaps more commonly than in MICs for proximal third (55% vs. 10%, p<0.01), middle third (36% vs. 9%, p = 0.02), and distal third (55% vs. 10%, p<0.01) lower extremity wounds. Negative Pressure Wound Therapy (NPWT or Wound VAC) was the only resource available to more than half of the respondents. Though not statistically significant, surgeons reported having more access to plastic surgeons at their institutions in HICs than MICs (91% vs. 62%, p = 0.12) and performed microsurgical flaps more commonly at their respective institutions (73% vs. 42%, p = 0.06). CONCLUSIONS The study demonstrated that most orthopaedic surgeons in Latin America have received no soft-tissue training, HICs and MICs have differences in access to plastic surgeons and expectations for flap type and timing to definitive coverage, and most respondents had limited access to necessary soft-tissue surgical resources. Further investigation into differences in the clinical outcomes related to soft-tissue coverage methods and protocols can provide additional insight into the importance of timing and access to specialists.
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8
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Sakarya AH, Tsai KY, Hsu CC, Chen SH, Do NK, Anggelia MR, Lin CH, Lin CH. Free tissue transfers for reconstruction of weight-bearing heel defects: Flap selection, ulceration management, and contour revisions. J Plast Reconstr Aesthet Surg 2021; 75:1557-1566. [PMID: 34969626 DOI: 10.1016/j.bjps.2021.11.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 05/20/2021] [Accepted: 11/15/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Soft tissue defects in the weight-bearing heel represent a reconstructive challenge because of tissue complexity and lack of local/regional coverage. This study presents our reconstruction outcomes of different defect aetiologies, reconstruction timing, and flap selection. METHODS Patients with weight-bearing heel defects who underwent free tissue transfer from 2003 to 2014 and with at least 6 months of follow-up were retrospectively reviewed. Flap types (fasciocutaneous vs muscle/musculocutaneous), timing of reconstruction (early vs subacute vs delayed), and defect aetiology were compared in terms of flap failure, vascular complications, and ulceration. RESULTS Seventy-four flaps were used to reconstruct weight-bearing heel defects in 70 patients. Defect aetiology included trauma in 53 patients (75%), chronic wound in 12 patients (17%), and tumour resection in 6 patients (8%). Flap survival was 97% (72/74). There was no significant difference in flap failures between muscle and fasciocutaneous flaps. The timing of reconstruction showed no difference in flap survival. There was a significant difference in ulceration rate between the trauma and non-trauma groups (p = 0.001). Twenty-eight ulcers (39%) developed, 12 (43%) of which presented 3 years postoperatively, while only 6 cases (21%) presented within one year postoperatively. CONCLUSION Our experience represents one of the highest survival rates reported regarding free flap weight-bearing heel reconstruction. The anterolateral thigh flap was our first choice for extensive heel defects. Ulceration incidence was directly related to trauma and tends to develop 3 years after reconstruction. Delayed reconstruction was at least as safe as early or subacute reconstruction though with less need for debulking.
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Affiliation(s)
- Ahmet H Sakarya
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Kun-Yu Tsai
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Chung-Chen Hsu
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Nicholas K Do
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Madonna R Anggelia
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan
| | - Cheng-Hung Lin
- Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Chang Gung Medical College and Chang Gung University, Taoyuan, Taiwan.
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Al-Hourani K, Pearce O, Bott A, Riddick A, Trompeter A, Kelly MB. Three-vessel view debridement of the open tibial fracture: a surgical technique. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1435-1441. [PMID: 34505912 DOI: 10.1007/s00590-021-03110-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 08/25/2021] [Indexed: 11/26/2022]
Abstract
Adequate debridement of an open fracture is a key component of successful management. Despite having set debridement principles, there is no structured technique available in the literature to guide the surgeon in achieving this. We therefore present a technical note detailing the structured approach to the debridement of any open tibial fracture. Our unit has developed a novel stepwise technique termed locally as the "three-vessel view". Identifying all three primary vessels of the leg facilitates confirmation of inspection of all lower limb compartments thus minimising the risk of missed devitalised tissue or neglected areas of contamination and the potential for consequent disastrous outcomes as a result of inadequate exposure.
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Affiliation(s)
- K Al-Hourani
- Department of Trauma & Orthopaedic Surgery, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK
| | - O Pearce
- Department of Trauma & Orthopaedic Surgery, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK.
| | - A Bott
- Department of Trauma & Orthopaedic Surgery, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK
| | - A Riddick
- Department of Trauma & Orthopaedic Surgery, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK
| | - A Trompeter
- Department of Trauma & Orthopaedic Surgery, St George's University Hospitals NHS Foundation Trust, London, UK
| | - M B Kelly
- Department of Trauma & Orthopaedic Surgery, Southmead Hospital, Southmead Road, Bristol, BS10 5NB, UK
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10
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Zeiderman MR, Pu LLQ. Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma. BURNS & TRAUMA 2021; 9:tkab024. [PMID: 34345630 PMCID: PMC8324213 DOI: 10.1093/burnst/tkab024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/22/2021] [Indexed: 11/29/2022]
Abstract
The complex lower extremity wound is frequently encountered by orthopedic and plastic surgeons. Innovations in wound care, soft tissue coverage and surgical fixation techniques allow for improved functional outcomes in this patient population with highly morbid injuries. In this review, the principles of reconstruction of complex lower extremity traumatic wounds are outlined. These principles include appropriate initial evaluation of the patient and mangled extremity, as well as appropriate patient selection for limb salvage. The authors emphasize proper planning for reconstruction, timing of reconstruction and the importance of an understanding of the most appropriate reconstructive option. The role of different reconstructive and wound care modalities is discussed, notably negative pressure wound therapy and dermal substitutes. The role of pedicled flaps and microvascular free-tissue transfer are discussed, as are innovations in understanding of perforator anatomy and perforator flap surgery that have broadened the reconstruction surgeon’s armamentarium. Finally, the importance of a multidisciplinary team is highlighted via the principle of the orthoplastic approach to management of complex lower extremity wounds. Upon completion of this review, the reader should have a thorough understanding of the principles of contemporary lower extremity reconstruction.
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Affiliation(s)
- Matthew R Zeiderman
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Lee L Q Pu
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of California, Davis, Sacramento, CA, USA
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11
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Al-Zoubi NA, Shatnawi NJ, Khader Y, Heis M, Aleshawi AJ. Predictive Factors for Failure of Limb Salvage in Blunt Leg Trauma Associated with Vascular Injuries. J Emerg Trauma Shock 2021; 14:80-85. [PMID: 34321805 PMCID: PMC8312914 DOI: 10.4103/jets.jets_37_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Accepted: 02/02/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction: Blunt leg trauma is common; however, it is rarely associated with significant vascular injury. This study was undertaken to determine the risk factors attributed to failure of limb salvage in acute postoperative period in blunt leg trauma with vascular injuries after revascularization. Methods: A retrospective analysis was conducted of all patients with blunt leg trauma involving bone and soft tissue associated with vascular injuries. They were studied in terms of demographic data, associated comorbidities, mechanism of trauma, associated extra leg injuries, type and nature of bone fractures, soft-tissue injuries, nerve injuries, time of ischemia, Injury Severity Score (ISS), Mangled Extremity Severity Score (MESS), injured vascular segments, modality of vascular repair, modality of bone fixation, thrombosis at the site of vascular repair, complications, limb salvage failure, and mortality. Results: Vascular injuries were identified in 45 arterial segments and 9 popliteal veins among 31 patients. The patients were 93% male, with a mean age of 31 years. The MESS ranged from 6 to 11, and the ISS ranged from 9 to 41. The main pathology of the injured vessels was contusion/thrombosis in 28 legs, which were repaired by interposition-reversed long saphenous vein graft. Seven patients developed postoperative thrombosis and underwent thrombectomy/embolectomy. Failure of limb salvage occurred in seven limbs with no mortality. Conclusions: Severe multi-segmental bone fractures, prolong ischemic time of >10 h, and MESS of ≥9 are significant predictors of limb loss in patients with blunt leg trauma in association with vascular injuries.
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Affiliation(s)
- Nabil A Al-Zoubi
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Nawaf J Shatnawi
- Department of Surgery, Jordan University of Science and Technology, Irbid, Jordan
| | - Yousef Khader
- Department of Public Health, Jordan University of Science and Technology, Irbid, Jordan
| | - Mowafeq Heis
- Department of Radiology, Jordan University of Science and Technology, Irbid, Jordan
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12
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Lee ZH, Stranix JT, Levine JP. The Optimal Timing of Traumatic Lower Extremity Reconstruction: Current Consensus. Clin Plast Surg 2021; 48:259-266. [PMID: 33674047 DOI: 10.1016/j.cps.2021.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Marko Godina in his landmark paper in 1986 established the principle of early flap coverage for reconstruction of traumatic lower extremity injuries to minimize edema, fibrosis, and infection while optimizing outcomes. However, with the evolution of microsurgery and wound management, there is emerging evidence that timing of reconstruction is not as critical as once believed. Multidisciplinary care with a combined orthopedic and reconstructive approach is more critical for timely and appropriate definite treatment for severe lower extremity injuries.
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Affiliation(s)
- Z-Hye Lee
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John T Stranix
- Department of Plastic and Maxillofacial Surgery, University of Virginia Health, West Complex 4th Floor, 1300 Jefferson Park Avenue, Charlottesville, VA 22903, USA
| | - Jamie P Levine
- Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, NY, USA.
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Abstract
Open fractures of the lower limb remain a potentially devastating group of injuries that are challenging to manage. The primary aims of treatment are to optimise limb function and avoid serious complications such as infection and non-union, which are costly for both the patient and healthcare system. The management of these fractures has evolved significantly, and this is evident following the creation of national open fracture guidelines and a formal trauma system. These have served to standardise care for these injuries in the United Kingdom. The aim of this review is to update our colleagues on the current standard of lower limb open fracture care in the United Kingdom, and the impact this has had on patient outcomes.
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Affiliation(s)
- Khalid Al-Hourani
- Edinburgh Orthopaedics, The Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Oliver Pearce
- Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom.
| | - Michael Kelly
- Department of Orthopaedic Surgery, Southmead Hospital, Bristol, United Kingdom
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Yalcin NG, Bruscino-Raiola F, Ferris S. Proximal Trauma Increases Risk of Venous Thrombosis in Soft Tissue Reconstruction of Open Lower Limb Fractures. Front Surg 2021; 7:574498. [PMID: 33585543 PMCID: PMC7873860 DOI: 10.3389/fsurg.2020.574498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 12/14/2020] [Indexed: 11/13/2022] Open
Abstract
Lower limb salvage after major trauma is a complex undertaking. For patients who have suffered multi-level trauma to their lower limb we postulated that pelvic injury or ipsilateral lower limb injury proximal to the site of a free flap may increase the rate of post-operative complications. All patients who underwent lower limb free flap reconstruction as a result of acute trauma between January 2010 and December 2017 were included. The patients were divided into the study group (50 patients), who sustained a lower limb or pelvic injury proximal to the free flap site, and control group (91 patients) who did not sustain proximal lower limb or pelvic trauma. Complication rates were compared between the two groups. Overall, the proximal trauma group anastomotic thrombosis rate of 18.0% was significantly higher than the control group thrombosis rate of 2.2%. There was no statically significant difference in rates of hematoma, swelling or infection. Flap loss rate in the proximal trauma group was 4.0%, compared to the control group at 2.2%. All patients with a failed flap went onto have a successful reconstruction with a subsequent flap in the acute admission and there were no amputations. In the proximal injury study group despite the significantly increased rate of microvascular thrombosis requiring revision, the ultimate primary free flap survival rate was still 96%. Overall, severe coexisting proximal trauma predicted a higher venous microvascular complication rate but was not a contraindication to limb salvage.
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Affiliation(s)
- Nilay G Yalcin
- Plastic, Hand and Faciomaxillary Surgery Unit, Alfred Health, Melbourne, VIC, Australia
| | - Frank Bruscino-Raiola
- Plastic, Hand and Faciomaxillary Surgery Unit, Alfred Health, Melbourne, VIC, Australia
| | - Scott Ferris
- Plastic, Hand and Faciomaxillary Surgery Unit, Alfred Health, Melbourne, VIC, Australia
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Jaidev KD, Bhaskarwar A, Ghai A. Outcomes of fast-track primary internal fixation of open fractures in ballistic injuries – A single-center experience. JOURNAL OF ORTHOPEDICS, TRAUMATOLOGY AND REHABILITATION 2021. [DOI: 10.4103/jotr.jotr_46_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Jitprapaikulsarn S, Sukha K, Patamamongkonchai C, Gromprasit A, Thremthakanpon W. Concurrent internal fixation and soft tissue reconstruction by distally based sural flap: a practicable scheme for complex distal tibial fractures. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:711-718. [PMID: 33151483 DOI: 10.1007/s00590-020-02827-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Accepted: 10/30/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND 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. METHODS 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. RESULTS 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 8.1 days (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 22.6 weeks (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. CONCLUSION 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.
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Affiliation(s)
- Surasak Jitprapaikulsarn
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand.
| | - Kritsada Sukha
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Chawanan Patamamongkonchai
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Arthit Gromprasit
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Witoon Thremthakanpon
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
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Lee SY, Seong IH, Park BY. When is the Critical Time for Soft Tissue Reconstruction of Open Tibia Fracture Patients? J Reconstr Microsurg 2020; 37:249-255. [PMID: 33058097 DOI: 10.1055/s-0040-1717151] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND The timing of soft tissue reconstruction for soft-tissue defect in patients with open fractures in the lower extremity is known to be critical for successful outcomes. However, medical advances, including development of dressing materials and refinement in the microsurgical techniques, might have undergone modifications in this "critical period." There have been no studies on the role of timing on reconstructive outcomes. Thus, we have analyzed the effect of reconstruction timing on optimal surgical outcomes and complication rates in a single type of lower extremity injury. METHODS Data of patients who underwent microvascular free tissue transfer with an open fracture in the lower extremity from 2014 through 2016 were retrospectively reviewed (n = 103). Surgical outcomes, including flap complication rate, flap revision rate, and long-term bony complications, were analyzed serially in accordance with time interval until coverage using the receiver operating characteristic (ROC) curve analysis. Significant factors with a p < 0.05 in the univariate analysis were included in the multivariate logistic regression model to identify independent risk factors. RESULTS A total of 46 patients (33 males and 13 females) were finally included in the study. Based on the association between surgical timing and flap-related complication rate, the best cutoff period for surgery was 33 days, with an area under the curve of 0.658 (p = 0.040). Further, in the revision rate, the cutoff period was identified as 10 days (p = 0.016). Regarding the incidence of bony complications, ROC curve showed that the maximal period until operation was 91 days with no influence on the occurrence of bony complications (p = 0.029). CONCLUSION Although the best method is an early reconstruction, many modalities such as negative pressure wound therapy play a role as a temporary measure. Our study suggests that the acute or early period for successful reconstruction might be extended compared with previous studies.
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Affiliation(s)
- Seung Yeol Lee
- Department of Orthopaedic Surgery, Myongji Hospital, Hanyang University College of Medicine, Seoul, Republic of Korea
| | - Ik Hyun Seong
- Department of Plastic and Reconstructive Surgery, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
| | - Bo Young Park
- Department of Plastic and Reconstructive Surgery, School of Medicine, Ewha Womans University, Seoul, Republic of Korea
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18
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Jitprapaikulsarn S, Patamamongkonchai C, Gromprasit A, Thremthakanpon W. Simultaneous internal fixation and soft tissue coverage by soleus muscle flap and variances: a reproducible strategy for managing open fractures of tibial shaft. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:365-373. [DOI: 10.1007/s00590-020-02786-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 09/01/2020] [Indexed: 12/01/2022]
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19
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Jitprapaikulsarn S, Benjawongsathien K, Patamamongkonchai C, Gromprasit A, Thremthakanpon W. Combined medial gastrocnemius and hemisoleus flap: a reproducible alternative for open tibial fractures complicated with large or double soft tissue defects. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 31:413-420. [DOI: 10.1007/s00590-020-02772-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2020] [Accepted: 08/12/2020] [Indexed: 10/23/2022]
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20
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De Francesco F, Marchesini A, Campodonico A, Neuendorf AD, Pangrazi PP, Riccio M. A Multistep Iter for Functional Reconstruction in Mangled Upper Limb: A Retrospective Analysis of Integrated Surgical and Medical Approach. ACTA ACUST UNITED AC 2020; 56:medicina56080398. [PMID: 32784812 PMCID: PMC7466263 DOI: 10.3390/medicina56080398] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/16/2022]
Abstract
Background and objectives: Complex limb wounds with multiple tissue involvement are commonly due to high energy trauma. Tissue damage is a dynamic entity and the exact extent of the injury is rarely instantly perceptible. Hence, reconstruction frequently involves a multi-stage procedure concluding with tissue replacement. Materials and Methods: A retrospective study was conducted between 2006 and 2018 and included 179 patients with contaminated multi-tissue injuries treated with hyperbaric oxygen therapy, negative pressure therapy, physiotherapy and drug treatment associated with multiple surgical time in a multistep approach, focusing on pain levels and wound closure rates. Results: Despite the long-term response to traumatic events, a combined approach of delayed surgical reconstructive time in mangled upper limb yielded satisfactory functional outcomes. Conclusions: The complex upper limb wound with deep tissue exposure may be treated with a multi-stage procedure alternatively to immediate reconstruction. The integrated technique enables the preservation of existing healthy tissue and concurrent radical debridement, reducing the risk of infection, as well as avoiding the loss of free flaps and dehiscence due to incorrect wound estimation.
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Singh J, Dhillon MS, Dhatt SS. Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study. Malays Orthop J 2020; 14:61-73. [PMID: 32296484 PMCID: PMC7156180 DOI: 10.5704/moj.2003.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Introduction: Grade 3B/C open tibial fractures with grossly contaminated degloving injuries have poor outcomes, with or without vascular injuries. Treatment decision oscillates between limb salvage and amputation. The standard protocol of repeated debridement and delayed wound cover is a challenge in developing countries due to overcrowded emergencies and limited operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate wound cover as an aggressive modality of treatment. Material and Methods: Thirty-three patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent debridement, external fixation and immediate wound cover with free distant/local rotational muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures. Intra-articular fractures were excluded. Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes. Results: Wound cover was achieved with 24 distant free muscle flaps, four local rotational muscle flaps and five fasciocutaneous flaps. All fractures united with an average time to union of 40.3 weeks (16-88). Fifteen patients (45.4%) underwent only a single major surgery using primary definitive external fixation. Deep infection was seen in four patients (12.1%). Nineteen patients had excellent to good outcomes, six were fair, and eight were poor. Conclusion: “Fix and Flap” in the same sitting, using immediate wound cover and external fixation, has given good results in our hands despite the delayed presentation, the neurovascular deficit and the degloving injury. This may be a better management strategy in overcrowded tertiary care centres of developing countries, with a single surgical procedure in almost half the cases.
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Affiliation(s)
- J Singh
- Department of Orthopaedics, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
| | - M S Dhillon
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - S S Dhatt
- Department of Orthopaedics, Post Graduate Institute of Medical Education and Research, Chandigarh, India
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22
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Sagy M, Singh J, kalia A, Dahuja A, Garg S, Garg R. Wound healing of open fractures: comparison of vaccum assisted dressing versus traditonal dressing. Int J Orthop Trauma Nurs 2020; 36:100722. [DOI: 10.1016/j.ijotn.2019.100722] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Revised: 09/24/2019] [Accepted: 09/26/2019] [Indexed: 10/25/2022]
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Two-Stage Combined Ortho-Plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes? J Orthop Trauma 2019; 33:591-597. [PMID: 31211717 DOI: 10.1097/bot.0000000000001562] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To delineate whether timing to initial debridement and definitive treatment had an effect on patient outcomes in those undergoing 2-stage ortho-plastic management of Gustilo-Anderson type IIIB open tibial diaphyseal fractures. DESIGN Retrospective comparative cohort study over a 2-year period. SETTING Level 1 trauma center. PATIENTS/PARTICIPANTS A total of 148 patients were identified. After exclusion of ankle fractures, nondiaphyseal fractures and those who did not undergo 2-stage ortho-plastic management, 45 patients were eligible for final analysis. INTERVENTION Time to initial debridement and definitive management. MAIN OUTCOME MEASUREMENT Deep infection. Secondary outcomes being nonunion and flap failure. Multiple linear regression was used for outcomes. We assumed a priori that P values of less than 0.05 were significant. RESULTS Mean age was 54 years (SD 23.0), with 28 men and 17 women. Over a mean 2-year follow-up, there were 4 (4/45) deep infections, 2 infection-associated flap failures, and 1 vascular flap failure. All patients progressed to union. The mean time to initial debridement for the whole cohort was 19 hours (SD 12.3), and the mean time to definitive reconstruction was 65 hours (SD 51.7). Longer time to both initial debridement and definitive reconstruction was not found to be significantly associated with deep infection, infected flap failure, or nonunion. CONCLUSIONS Using a 2-stage ortho-plastic operative algorithm, timing to initial debridement and definitive fixation with soft-tissue coverage was not associated with negative outcomes. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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24
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Rikimaru H, Rikimaru-Nishi Y, Yamauchi D, Ino K, Kiyokawa K. New Alternative Therapeutic Strategy for Gustilo Type IIIB Open Fractures, Using an Intra-Wound Continuous Negative Pressure Irrigation Treatment System. Kurume Med J 2019; 65:177-183. [PMID: 31723082 DOI: 10.2739/kurumemedj.ms654009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
The treatment of Gustilo type IIIB and IIIC open fractures remains a challenging problem, because the infection rate is 15-45%. Infection can lead to serious complications such as osteomyelitis or amputation. The intra-wound continuous negative pressure and irrigation treatment (IW-CONPIT) was developed for infected wounds and intractable ulcers, and is very effective in suppressing infection and accelerating wound healing. Here the IW-CONPIT was applied to severe open fractures for the purpose of preventing infection. After thorough debridement and lavage of the wound, bony stabilization is performed by external fixation. Dermal matrix is grafted onto any areas where the bone or tendon is exposed. A sponge containing two tubes is placed over the entire surface of the wound including the dermal matrix. Then it is covered with a film dressing to make the wound completely airtight. A bottle of physiologic saline solution is attached to one tube, and a continuous aspirator is attached to the other. This system maintains negative pressure on the wound surface, which is continuously irrigated. Thirty-five patients were treated with this method. A superficial infection developed in two cases but was resolved by additional debridement and continued application of IW-CONPIT. Complete wound healing was obtained with split thickness skin graft in all cases. There were no complications such as osteomyelitis, delayed bone union or amputation. IW-CONPIT was able to definitively prevent wound infection in Gustilo type ⅢB open fractures. We believe this method will become a standard treatment option for this condition.
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Affiliation(s)
- Hideaki Rikimaru
- Department of Plastic and Reconstructive Surgery and Maxillofacial Surgery, Kurume University School of Medicine
| | - Yukiko Rikimaru-Nishi
- Department of Plastic and Reconstructive Surgery and Maxillofacial Surgery, Kurume University School of Medicine.,Division of Microscopic and Developmental Anatomy, Department of Anatomy, Kurume University School of Medicine
| | - Daisuke Yamauchi
- Department of Plastic and Reconstructive Surgery and Maxillofacial Surgery, Kurume University School of Medicine
| | - Koh Ino
- Department of Plastic and Reconstructive Surgery and Maxillofacial Surgery, Kurume University School of Medicine
| | - Kensuke Kiyokawa
- Department of Plastic and Reconstructive Surgery and Maxillofacial Surgery, Kurume University School of Medicine
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25
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26
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Tan YZ, Lu X, Luo J, Huang ZD, Deng QF, Shen XF, Zhang C, Guo GL. Enhanced Recovery After Surgery for Breast Reconstruction: Pooled Meta-Analysis of 10 Observational Studies Involving 1,838 Patients. Front Oncol 2019; 9:675. [PMID: 31417864 PMCID: PMC6682620 DOI: 10.3389/fonc.2019.00675] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Accepted: 07/10/2019] [Indexed: 12/13/2022] Open
Abstract
Purpose: This study aims to explore the effectiveness and safety of the enhanced recovery after surgery (ERAS) protocol vs. traditional perioperative care programs for breast reconstruction. Methods: Three electronic databases (PubMed, EMBASE, and Cochrane Library) were searched for observational studies comparing an ERAS program with a traditional perioperative care program from database inception to 5 May 2018. Two reviewers independently screened the literature according to the inclusion and exclusion criteria, extracted the data, and evaluated study quality using the Newcastle-Ottawa Scale. Subgroup and sensitivity analyses were performed. The outcomes included the length of hospital stay (LOS), complication rates, pain control, costs, emergency department visits, hospital readmission, and unplanned reoperation. Results: Ten studies were included in the meta-analysis. Compared with a conventional program, ERAS was associated with significantly decreased LOS, morphine administration (including postoperative patient-controlled analgesia usage rate and duration; intravenous morphine administration on postoperative day [POD] 0, 1, 2, and 4; total intravenous morphine administration on POD 0–3; oral morphine consumption on POD 0–4; and total postoperative oral morphine consumption), and pain scores (postoperative pain score on POD 0 and total pain score on POD 0–3). The other variables did not differ significantly. Conclusion: Our results suggest that ERAS protocols can decrease LOS and morphine equivalent dosing; therefore, further larger, and better-quality studies that report on bleeding amount and patient satisfaction are needed to validate our findings.
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Affiliation(s)
- Ya-Zhen Tan
- Center of Women's Health Sciences, Taihe Hospital, Hubei University of Medicine, Shiyan, China.,Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Xuan Lu
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Jie Luo
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Zhen-Dong Huang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Qi-Feng Deng
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Xian-Feng Shen
- Department of General Surgery, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Chao Zhang
- Center for Evidence-Based Medicine and Clinical Research, Taihe Hospital, Hubei University of Medicine, Shiyan, China
| | - Guang-Ling Guo
- Center of Women's Health Sciences, Taihe Hospital, Hubei University of Medicine, Shiyan, China
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27
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McMillan LJ, Parikh HR, Cunningham BP. Acute Treatment of Open Foot and Ankle Fractures Using a Bioartificial Dermal Regeneration Template and Split-Thickness Skin Grafting: A Report of 2 Cases. JBJS Case Connect 2019; 9:e0148. [PMID: 31140985 DOI: 10.2106/jbjs.cc.18.00148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CASE Two patients with open foot and ankle fractures were treated with aggressive irrigation and debridement and acute placement of a dermal regeneration template (DRT) followed by split-thickness skin grafting. Patient 1 was an 82-year-old female with a type IIIB open ankle fracture complexed with 2 significant regions of soft tissue loss. Patient 2 was a 54-year-old male with type IIIB open metatarsal fractures. Both patients healed without complication. CONCLUSIONS Complex open fractures in lower extremities can be managed with acute DRT application. This may be a more cost-effective solution compared to free flaps.
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Affiliation(s)
- Logan J McMillan
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.,Department of Orthopaedic Surgery, Regions Hospital, St Paul, Minnesota
| | - Harsh R Parikh
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.,Department of Orthopaedic Surgery, Regions Hospital, St Paul, Minnesota
| | - Brian P Cunningham
- Department of Orthopaedic Surgery, University of Minnesota Medical School, Minneapolis, Minnesota.,Department of Orthopaedic Surgery, Regions Hospital, St Paul, Minnesota
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28
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Lim J, Kwon H, Lee KM, Pak C. Immediate Lower Extremity Reconstruction Using an Anterolateral Thigh Free Flap With Simultaneous Interposition Graft of Descending Branches of Lateral Circumflex Femoral Vessels. INT J LOW EXTR WOUND 2019; 18:89-93. [PMID: 31064286 DOI: 10.1177/1534734618819932] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In a severely injured leg with acute limb ischemia, both immediate revascularization of an endangered part and coverage of soft tissue defect are crucial to limb salvage. In this article, we report a case of an anterolateral thigh free flap with interposition graft of descending branches of the lateral circumflex femoral vessels. A 18-cm-long graft was harvested and used to replace the injured anterior tibial vessels. One month later, a duplex sonogram revealed intact circulation to both the interposition graft and the flap. Despite anatomic inconstancy, the anterolateral thigh free flap is commonly utilized in reconstructive surgeries. When descending branches of the lateral femoral circumflex vessels were included sufficiently, its pedicle can be used to bridge a vascular defect in the extremity while covering soft tissue defect.
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Affiliation(s)
- Joonho Lim
- 1 Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.,2 Seoul National University, Seoul, Gyeonggi-do, Republic of Korea
| | - Heeyeon Kwon
- 1 Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.,2 Seoul National University, Seoul, Gyeonggi-do, Republic of Korea
| | - Kyoung Min Lee
- 1 Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.,2 Seoul National University, Seoul, Gyeonggi-do, Republic of Korea
| | - Changsik Pak
- 1 Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea.,2 Seoul National University, Seoul, Gyeonggi-do, Republic of Korea
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29
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Regional Variation and Trends in the Timing of Lower Extremity Reconstruction: A 10-Year Review of the Nationwide Inpatient Sample. Plast Reconstr Surg 2019; 142:1337-1347. [PMID: 30511989 DOI: 10.1097/prs.0000000000004885] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The ideal timing of soft-tissue coverage for open lower extremity fractures remains controversial. Using U.S. national data, this study aims to characterize secular trends and regional variation in the timing of soft-tissue coverage. METHODS Using discharge data from the Nationwide Inpatient Sample (2002 to 2011), the authors identified 888 encounters admitted from the emergency department with isolated open lower extremity fractures treated with pedicled or free tissue transfer. Soft-tissue coverage timing was assessed by patient factors, hospital characteristics, and fracture patterns. Statistical significance and secular trends were analyzed with generalized linear models. RESULTS The mean day of soft-tissue reconstruction was at 6.64 days. Over the 10-year period, the day of reconstruction increased significantly (from 6.12 days in 2002 to 12.50 days in 2011; coefficient, 0.09; 95 percent CI, 0.05 to 0.12; p < 0.001). Demographic and facility factors did not significantly impact timing. Elixhauser comorbidity scores greater than 2 were associated with later coverage (10.13 days versus 6.29 days; p = 0.001) along with multisite fractures (8.35 days; p = 0.022) and external fixators (8.78 days; p < 0.001). The U.S. Census division showed significant variation in timing ranging from 0.94 days (East North Central) to 9.84 days (Pacific). CONCLUSIONS A progressive delay in the timing of soft-tissue reconstruction was noted and may be attributed to negative-pressure wound therapy. The timing of soft-tissue coverage varied by region after adjusting for patient and hospital factors. Additional studies are needed to understand the impact of delayed soft-tissue coverage on patient outcomes and health services utilization.
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30
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Identifying Predictors of Time to Soft-Tissue Reconstruction following Open Tibia Fractures. Plast Reconstr Surg 2018; 142:1620-1628. [DOI: 10.1097/prs.0000000000005007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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31
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Abstract
Tendons connect muscle to bone and play an integral role in bone and joint alignment and loading. Tendons act as pulleys that provide anchorage of muscle forces for joint motion and stability, as well as for fracture reduction and realignment. Patients that experience complex fractures also have concomitant soft tissue injuries, such as tendon damage or rupture. Tendon injuries that occur at the time of bone fracture have long-term ramifications on musculoskeletal health, yet these injuries are often disregarded in clinical treatment and diagnosis for patients with bone fractures as well as in basic science approaches for understanding bone repair processes. Delayed assessment of soft tissue injuries during evaluation of trauma can lead to chronic pain, dysfunction, and delayed bone healing even following successful fracture repair, highlighting the importance of identifying and treating damaged tendons early. Treatment strategies for bone repair, such as mechanical stabilization and biological therapeutics, can impact tendon healing and function. Because poor tendon healing following complex fracture can significantly impact the function of tendon during bone fracture healing, a need exists to understand the healing process of complex fractures more broadly, beyond the healing of bone. In this review, we explored the mechanical and biological interaction of bone and tendon in the context of complex fracture, as well as the relevance and potential ramifications of tendon damage following bone fracture, which has particular impact on patients that experience complex fractures, such as from combat, automobile accidents, and other trauma.
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Affiliation(s)
- Elahe Ganji
- Department of Biomedical Engineering, University of Delaware, Newark, Delaware 19716
- Department of Mechanical Engineering, University of Delaware, Newark, Delaware 19716
| | - Megan L. Killian
- Department of Biomedical Engineering, University of Delaware, Newark, Delaware 19716
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32
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Qiu E, Kurlander DE, Ghaznavi AM. Godina revisited: a systematic review of traumatic lower extremity wound reconstruction timing. J Plast Surg Hand Surg 2018; 52:259-264. [DOI: 10.1080/2000656x.2018.1470979] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Emily Qiu
- Research Fellow, Plastic Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - David E. Kurlander
- Resident, Plastic Surgery, Case Western Reserve University, Cleveland, OH, USA
| | - Amir M. Ghaznavi
- Plastic Surgery, Case Western Reserve University, Cleveland, OH, USA
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Hospital Transfer of Open Tibial Fractures Requiring Microsurgical Reconstruction Negatively Impacts Clinical Outcomes. Ann Plast Surg 2018; 78:S180-S184. [PMID: 28118229 DOI: 10.1097/sap.0000000000000972] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Open tibial fractures are orthopedic emergencies that may present with severe soft tissue damage. Free tissue transfer is often required when local tissues are insufficient and patients may require hospital transfer to tertiary care centers for this purpose. Although the negative impact of inter-facility transfer has been well demonstrated in trauma patients, less is known regarding transfers for lower extremity injury patients. This study investigates differences in outcomes based on transfer status after open tibial fracture. METHODS Thirty-four consecutive open tibial fractures requiring free tissue transfer over a 13-year period (2001-2014) were retrospectively reviewed. Patients transferred from outside facilities were compared to non-transferred patients in regards to demographics, injury, surgical characteristics, and outcomes (mean follow-up of 2.5 years). Student t tests and chi square analysis were used to compare means and proportions, respectively. RESULTS One-half of patients were transferred from an outside hospital. Transferred and nontransferred patients were not significantly different in regard to age, sex, comorbidities, mechanism of injury, and Gustilo grade. There was no significant difference in the method of bony fixation or free flap used for soft tissue coverage. The time to wound vacuum-assisted closure placement was longer in transferred patients, though this difference was not found to be significant (2.4 vs 3.3 days, P = 0.55). Time to definitive bony fixation was delayed in the transfer group by 9 days (5.2 vs 14.1 days, P = 0.05) and to tissue coverage by 7 days (14.2 vs 20.9 days, P = 0.13). Rates of flap loss and amputation did not differ between the groups. However, transferred patients were more likely to develop osteomyelitis (risk ratio [RR], 3.0; P = 0.03), nonunion (RR, 5.0; P = 0.09), and require hardware removal (RR, 3.3; P = 0.01). CONCLUSIONS Transferred and nontransferred patients were not significantly different in their demographics or presentation. However, an analysis of clinical outcomes showed that transfer was associated with increased rates of osteomyelitis, nonunion, and hardware removal. Although likely multifactorial, this study suggests that a delay to definitive fixation and soft tissue coverage contributes to the increased rate of complications and poorer prognosis.
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Yasuda T, Arai M, Sato K, Kanzaki K. A Gustilo Type 3B Open Tibial Fracture Treated with a Proximal Flexor Hallucis Longus Flap: A Case Report. J Orthop Case Rep 2017; 7:70-73. [PMID: 28819607 PMCID: PMC5553842 DOI: 10.13107/jocr.2250-0685.756] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Introduction: In the treatment of Gustilo Type 3B open tibial fractures, it is important to perform soft tissue reconstruction and bone reconstruction simultaneously. Gastrocnemius muscle and soleus muscle flaps are generally used as rotational flaps for the tibia. The distal third of the tibia can often not be covered with the gastrocnemius muscle and soleus muscle flaps. Treatment distal to the distal third of the tibia is difficult because fewer flap options are available. In the present report, we describe our experience with a Gustilo Type 3B open tibial fracture treated by gastrocnemius muscle and soleus muscle flaps, along with an additional proximally based flexor hallucis longus flap, which is a rare procedure. Case Report: The participant was a 17-year-old male who injured his left tibia in a motorcycle traffic accident. Physical examination revealed a wound of 13 cm × 7 cm extending from the medial lower leg to the posterior aspect, with extensive skin loss. There was no nerve or vascular injury. The tibia was exposed, with detachment of the periosteum. The radiograph revealed a tibial shaft fracture. The AO/OTA classification was 42-A3.3, and it was classified as a Gustilo-Anderson Type 3B fracture. Gastrocnemius muscle and soleus muscle flaps were lifted in the area of the soft-tissue defect and then, placed over the tibia. Despite this, the distal portion of the tibia remained uncovered. Therefore, a flexor hallucis longus flap was lifted and placed over the distal portion of the tibia. On day 7 after the injury, the external fixation device was removed and the tibial shaft was fixated with two Ender nails (4.5 mm in diameter). The clinical course was satisfactory, and the skin graft and flap were successful. Bone union was achieved without infection, and the resulting range of motion was normal. Conclusion: For the treatment of Gustilo-Anderson Type 3B open tibial fractures, early treatment of the soft-tissue defect is vital. We surgically treated a Gustilo-Anderson Type 3B open tibial fracture with gastrocnemius muscle and soleus muscle flaps, along with an additional proximally based flexor hallucis longus flap, which is a rare procedure. In the event of a soft-tissue defect in the distal third of the tibia, the use of a proximally based flexor hallucis longus flap is an effective surgical approach.
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Affiliation(s)
- Tomohiro Yasuda
- Department of Orthopaedics, Fujigaoka Hospital, Showa University School of Medicine, Yokohama, Japan
| | - Masayuki Arai
- Department of Orthopaedics, Fujigaoka Hospital, Showa University School of Medicine, Yokohama, Japan
| | - Kaoru Sato
- Department of Orthopaedics, Fujigaoka Hospital, Showa University School of Medicine, Yokohama, Japan
| | - Koji Kanzaki
- Department of Orthopaedics, Fujigaoka Hospital, Showa University School of Medicine, Yokohama, Japan
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Open Tibia Shaft Fractures and Soft-Tissue Coverage: The Effects of Management by an Orthopaedic Microsurgical Team. J Orthop Trauma 2017; 31:339-344. [PMID: 28538454 PMCID: PMC5470841 DOI: 10.1097/bot.0000000000000815] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To compare the timing of soft-tissue (flap) coverage and occurrence of complications before and after the establishment of an integrated orthopaedic trauma/microsurgical team. DESIGN Retrospective cohort study. SETTING A single level 1 trauma center. PATIENTS Twenty-eight subjects (13 pre- and 15 post-integration) with open tibia shaft fractures (OTA/AO 42A, 42B, and 42C) treated with flap coverage between January 2009 and March 2015. INTERVENTION Flap coverage for open tibia shaft fractures treated before ("preintegration") and after ("postintegration") implementation of an integrated orthopaedic trauma/microsurgical team. MAIN OUTCOME MEASURE Time from index injury to flap coverage. RESULTS The unadjusted median time to coverage was 7 days (95% confidence interval, 5.9-8.1) preintegration, and 6 days (95% confidence interval, 4.6-7.4) postintegration (P = 0.48). For preintegration, 9 (69%) of the patients experienced complications, compared with 7 (47%) postintegration (P = 0.23). CONCLUSIONS After formation of an integrated orthopaedic trauma/microsurgery team, we observed a 1-day decrease in median days to coverage from index injury. Complications overall were lowered in the postintegration group, although statistically insignificant. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Yıldırım A, Kapukaya A, Mertsoy Y, Yiğit Ş, Çaçan MA, Atiç R. Management of open fractures using a noncontact locking plate as an internal fixator. Indian J Orthop 2017; 51:312-317. [PMID: 28566784 PMCID: PMC5439318 DOI: 10.4103/0019-5413.205686] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The treatment of open fractures leads to major problems which may be due to various reasons. It mainly causes soft tissue problems due to the absorption of a large amount of energy by the soft tissues and bone tissues. Although some recent treatment protocols have eliminated many problems regarding delayed soft tissue closure, it still remains a big challange. This study uses a method called the internal fixator technique with noncontact locking plate (NC-LP) which involves the use of a combination of advantages of open and closed fixation techniques. MATERIALS AND METHODS 42 patients (32 men and 10 women) having a mean age of 34.11 years (range 17-56 years) with open fractures operated using internal fixator technique between 2007 and 2012 were included in this study. A retrospective chart review was conducted to record the following: age, gender, anatomic region of fractures, fracture etiology, classification of open fractures by Gustilo-Anderson and AO classification, surgeries, length of hospitalization, location and pattern of fracture, length of followup, and complications. RESULTS The fractures were caused by traffic accidents, shotgun injuries, falls from heights, and industrial crush injuries. Based on the Gustilo-Anderson classification, 31 fractures were Type III and 11 were Type II, where 23 were localized in the tibia and 19 in the femur. Patients delay for a mean of 13.5 h (range 6-24 h) for operation and the mean followup interval was 27.8 months (range 16-44 months). The mean union time was 19.7 weeks (range 16-29 weeks). One patient had delayed union and implant failure, one patient had osteomyelitis, five suffered from surface skin necrosis, and one patient had an angulation of 17° in the sagittal plane, for which no additional intervention was performed. CONCLUSIONS This case series demonstrates that an "internal fixator technique" is an acceptable alternative to the management of open fractures of the femur or tibia in adult patients. The NC-LP method provided opportunities to achieve a stable fixation with noncontact between the implant and the bone tissues, and the fractures were sufficiently stabilized to allow union with a low complication rate.
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Affiliation(s)
- Azad Yıldırım
- Department of Orthopaedics and Traumatology, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey,Address for correspondence: Dr. Azad Yıldırım, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey. E-mail:
| | - Ahmet Kapukaya
- Department of Orthopaedics and Traumatology, Medical Faculty, Dicle University, Diyarbakır, Turkey
| | - Yılmaz Mertsoy
- Department of Orthopaedics and Traumatology, Gazi Yaşargil Training and Research Hospital, Diyarbakır, Turkey
| | | | - Mehmet Akif Çaçan
- Department of Orthopaedics and Traumatology, Medical Faculty, Dicle University, Diyarbakır, Turkey
| | - Ramazan Atiç
- Department of Orthopaedics and Traumatology, Medical Faculty, Dicle University, Diyarbakır, Turkey
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Abstract
The optimal treatment of open fractures continues to be an area of debate in the orthopedic literature. Recent research has challenged the dictum that open fractures should be debrided within 6 hours of injury. However, the expedient administration of intravenous antibiotics remains of paramount importance in infection prevention. Multiple factors, including fracture severity, thoroughness of debridement, time to initial treatment, and antibiotic administration, among other variables, contribute to the incidence of infection and complicate identifying an optimal time to debridement.
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Affiliation(s)
- Joshua C Rozell
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA; Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
| | - Keith P Connolly
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA; Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA
| | - Samir Mehta
- Department of Orthopaedic Surgery, University of Pennsylvania, 3737 Market Street, 6th Floor, Philadelphia, PA 19104, USA.
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Joshi A, Singh S, Jain S, Rohilla N, Trikha V, Yadav C. Outcome of application of primary versus secondary Illizarov's fixator in open tibial shaft fractures. World J Emerg Med 2016; 7:221-6. [PMID: 27547283 DOI: 10.5847/wjem.j.1920-8642.2016.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The present study aimed to compare outcome of primary and secondary Illizarov's fixator application as a treatment method for type III open tibial fractures in terms of non-union and wound infection. METHODS This prospective study was done in a tertiary care center. Forty-eight type III tibial fractures were treated with Illizarov's apparatus between 2008 and 2011. The patients were divided into two groups depending on the treatment protocol, timing of wound closure and Illizarov's application, primary (n=28) and secondary (n=20). RESULTS In the primary group, healing was achieved in all 28 patients. The median time to recovery was 24 weeks, and the median number of operations was 3. There were 6 patients with a bone defect. In the secondary group, complete recovery was achieved in 18 out of 20 patients. The median time to recovery was 30 weeks, and the median number of operations 5. There were 9 patients with a bone defect. The median time to recovery and the number of operations were significantly smaller in patients undergoing primary operation. Union was 100% in the primary group and more than 95% in the secondary group. Chronic osteomyelitis persisted in one patient and below amputation was done in one patient in the secondary group. CONCLUSION Primary wound closure and Illizarov's fixation required a smaller number of operations and shorter time to recovery than secondary wound closure and Illizarov's fixation, mostly due to a significantly less number of patients with a bone defect in the primary group.
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Affiliation(s)
- Anil Joshi
- Medical College, V.C.S.G. Government Medical Sciences and Research Institute, Srinagar, Pauri Garhwal, India; H.N.B. Base & Teaching Hospital, P.O.-Srikot, Srinagar, Srinagar Garhwal, Uttarakhand 246174, India
| | - Saurabh Singh
- Department of Orthopaedics, IMS BHU, Varanasi, India, Varanasi, Uttar Pradesh 221005, India
| | - Sudeep Jain
- Fortis Flt Lt Rajan Dhall Hospital, Ringgold Standard Institution, Safdarjung Enclave, New Delhi, Delhi 110070, India
| | - Narender Rohilla
- Fortis Hospital, Shalimar Bagh Ringgold Standard Institution, Safdarjung Enclave, New Delhi, Delhi 110033, India
| | - Vivek Trikha
- Department of Orthopaedics, All India Institute of Medical Sciences Ringgold Standard Institution, New Delhi, Delhi 110029, India
| | - Chandra Yadav
- Department of Orthopaedics, All India Institute of Medical Sciences Ringgold Standard Institution, New Delhi, Delhi 110029, India
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Hendrickson SA, Khan MA, Verjee LS, Rahman KMA, Simmons J, Hettiaratchy SP. Plastic surgical operative workload in major trauma patients following establishment of the major trauma network in England: A retrospective cohort study. J Plast Reconstr Aesthet Surg 2016; 69:881-7. [PMID: 27025358 DOI: 10.1016/j.bjps.2016.02.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2015] [Revised: 01/15/2016] [Accepted: 02/02/2016] [Indexed: 10/22/2022]
Abstract
INTRODUCTION The introduction of major trauma centres (MTCs) in England has led to 63% reduction in trauma mortality.(1) The role of plastic surgeons supporting these centres has not been quantified previously. This study aimed to quantify plastic surgical workload at an urban MTC to determine the contribution of plastic surgeons to major trauma care. METHODS All Trauma Audit and Research Network (TARN)-recorded major trauma patients who presented to an urban MTC in 2013 and underwent an operation were identified retrospectively. Patients who underwent plastic surgery were identified and the type and date of procedure(s) were recorded. The trauma operative workload data of another tertiary surgical specialty and local historical plastics workload data from pre-MTC go-live were collected for comparison. RESULTS Of the 416 major trauma patients who required surgical intervention, 29% (n = 122) underwent plastic surgery. Of these patients, 43% had open lower limb fractures, necessitating plastic surgical involvement according to British Orthopaedic Association Standards for Trauma (BOAST) 4 guidance. The overall plastic surgery operative workload increased sevenfold post-MTC go-live. A similar proportion of the same cohort required neurosurgery (n = 115; p = 0.589). DISCUSSION This study quantifies plastic surgery involvement in major trauma and demonstrates that plastic surgical operative workload is at least on par with other tertiary surgical specialties. It also reports one centre's experience of a significant change in plastic surgery activity following designation of MTC status. The quantity of plastic surgical operative workload in major trauma must be considered when planning major trauma service design and workforce provision, and for plastic surgical postgraduate training.
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Affiliation(s)
- S A Hendrickson
- Major Trauma Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W2 0NY, London, UK.
| | - M A Khan
- Major Trauma Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W2 0NY, London, UK
| | - L S Verjee
- Major Trauma Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W2 0NY, London, UK
| | - K M A Rahman
- Major Trauma Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W2 0NY, London, UK
| | - J Simmons
- Major Trauma Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W2 0NY, London, UK
| | - S P Hettiaratchy
- Major Trauma Centre, St. Mary's Hospital, Imperial College Healthcare NHS Trust, Praed Street, W2 0NY, London, UK
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Ali AM, McMaster JM, Noyes D, Brent AJ, Cogswell LK. Experience of managing open fractures of the lower limb at a major trauma centre. Ann R Coll Surg Engl 2015; 97:287-90. [PMID: 26263937 DOI: 10.1308/003588415x14181254789367] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION In April 2012 the John Radcliffe Hospital in Oxford became a major trauma centre (MTC). The British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4) require system-wide changes in referral practice that may be facilitated by the MTC and its associated major trauma network. METHODS From 2008 to 2013 a multistep audit of compliance with BOAST 4 was conducted to assess referral patterns, timing of surgery and outcomes (surgical site infection rates), to determine changes following local intervention and the establishment of the MTC. RESULTS Over the study period, 50 patients had soft tissue cover for an open lower limb fracture and there was a significant increase in the proportion of patients receiving definitive fixation in our centre (p=0.036). The median time from injury to soft tissue cover fell from 6.0 days to 3.5 days (p=0.051) and the median time from definitive fixation to soft tissue cover fell from 5.0 days to 2.0 days (p=0.003). The deep infection rate fell from 27% to 8% (p=0.247). However, in 2013 many patients still experienced a delay of >72 hours between injury and soft tissue cover, primarily owing to a lack of capacity for providing soft tissue cover. CONCLUSIONS Our experience may be relevant to other MTCs seeking to identify barriers to optimising the management of patients with these injuries.
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Affiliation(s)
- A M Ali
- Oxford University Hospitals NHS Trust , UK
| | | | - D Noyes
- Oxford University Hospitals NHS Trust , UK
| | - A J Brent
- Oxford University Hospitals NHS Trust , UK
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Olesen UK, Juul R, Bonde CT, Moser C, McNally M, Jensen LT, Elberg JJ, Eckardt H. A review of forty five open tibial fractures covered with free flaps. Analysis of complications, microbiology and prognostic factors. INTERNATIONAL ORTHOPAEDICS 2015; 39:1159-66. [PMID: 25750130 DOI: 10.1007/s00264-015-2712-z] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2014] [Accepted: 02/12/2015] [Indexed: 12/29/2022]
Abstract
PURPOSE Treatment of open fractures is complex and controversial. The purpose of the present study is to add evidence to the management of open tibial fractures, where tissue loss necessitates cover with a free flap. We identified factors that increase the risk of complications. We questioned whether early flap coverage improved the clinical outcome and whether we could improve our antibiotic treatment of open fractures. METHODS From 2002 to 2013 we treated 56 patients with an open tibial fracture covered with a free flap. We reviewed patient records and databases for type of trauma, smoking, time to tissue cover, infection, amputations, flap loss and union of fracture. We identified factors that increase the risk of complications. We analysed the organisms cultured from open fractures to propose the optimal antibiotic prophylaxis. Follow-up was a minimum of one year. Primary outcome was infection, bacterial sensitivity pattern, amputation, flap failure and union of the fracture. RESULTS When soft tissue cover was delayed beyond seven days, infection rate increased from 27 to 60 % (p < 0.04). High-energy trauma patients had a higher risk of amputation, infection, flap failure and non-union. Smokers had a higher risk of non-union and flap failure. The bacteria found were often resistant to Cefuroxime, aminoglycosides or amoxicillin, but sensitive to vancomycin or meropenem. CONCLUSION Flap cover within one week is essential to avoid infection. High-energy trauma and smoking are important predictors of complications. We suggest antibiotic prophylaxis with vancomycin and meropenem until the wound is covered in these complex injuries.
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Affiliation(s)
- Ulrik Kähler Olesen
- Department of Orthopaedic Surgery, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen Ø, Denmark,
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From battleside to stateside: the reconstructive journey of our wounded warriors. Ann Plast Surg 2014; 72 Suppl 1:S38-45. [PMID: 24740023 DOI: 10.1097/sap.0000000000000168] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Recent military operations in Iraq (Operation Iraqi Freedom) and Afghanistan (Operation Enduring Freedom) have led to further refinements of the military medical system's ability to provide advanced surgical care. The deployment of a global trauma care system has directly contributed to improved combat casualty survival rates. As a consequence of improved survivorship, a high-volume patient population of individuals having challenging multiple extremity injuries/amputations has presented to military treatment facilities. These patients present with unique mixed pattern blast injuries. Blast injuries incorporate multiple mechanisms of injury including penetrating fragmentary injury, blunt force trauma, flash burn, and overpressure wave damage. These complex injuries have furthered refinements in traditional reconstruction and facilitated early application of regenerative medicine therapies. This article summarizes information presented at the inaugural Garry Brody, MD Family Invited Lectureship presented at the 63rd California Society of Plastic Surgeons Annual.
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Abstract
In this article, we propose a methodology for the rational design of scaffold constructs in bone-tissue engineering. The construct under investigation is a sandwich structure with an Intramedullary rod (IM), a Biological Sponge (BS) and an External sleeve (ES). The IM rod provides axial resistance, BS facilitates the growth of new bone and ES provides stability to the construct by resisting torsion and bending. We demonstrate that only select combinations of stiffness between IM and ES facilitate the growth of new bone. Perren's interfragmentary strain theory is employed to clearly identify regions favoring bone growth from those favoring the formation of cartilage. Finally, design maps are constructed that clearly identify the combinations facilitating timely bone growth.
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Wei SJ, Cai XH, Wang HS, Qi BW, Yu AX. A comparison of primary and delayed wound closure in severe open tibial fractures initially treated with internal fixation and vacuum-assisted wound coverage: a case-controlled study. Int J Surg 2014; 12:688-94. [PMID: 24830686 DOI: 10.1016/j.ijsu.2014.04.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 03/20/2014] [Accepted: 04/20/2014] [Indexed: 12/19/2022]
Abstract
The ideal timing of wound closure for open tibial fractures is debatable. This study aimed to compare outcomes of primary and delayed wound closure in severe open tibial fractures initially treated with internal fixation and vacuum-assisted wound coverage (VAC). Data of 80 patients with Gustilo-Anderson type IIIA and IIIB open tibial fractures treated with primary internal fixation, VAC, either primary wound closure (PWC) or delayed wound closure (DWC), and external fixation were reviewed retrospectively, and outcomes and complications compared. Patients were divided into three groups, including a PWC group (n = 27), DWC group (n = 22), and a control group (n = 31) that had received external fixation. Among all patients, the median age was 38 years (IRQ 32-47 years), and 67.5% were male. Injuries included 33 Gustilo-Anderson type IIIA and 47 type IIIB. Among injuries, 83% (66/80) were high-energy trauma, 63.8% were contaminated and median injury severity score (ISS) was 14 points. Significant differences were found between groups in fixation methods (p < 0.001). No significant differences were observed between groups in rates of deep infection, osteomyelitis, amputation and nonunion at 6 and 12 months (all p > 0.05), although all rates were markedly lower in the PWC group. The outcomes of PWC performed in conjunction with primary internal fixation and VAC for the treatment of Gustilo-Andersen type IIIA and IIIB open tibial fractures are similar to or better than those of DWC with primary internal fixation and VAC.
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Affiliation(s)
- Shi-jun Wei
- Department of Microorthopaedics, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuchang Area, Wuhan 430071, China
| | - Xian-hua Cai
- Department of Orthopaedic Surgery, Wuhan General Hospital of Guangzhou Command, Wuhan 430070, China
| | - Hua-song Wang
- Department of Orthopaedic Surgery, Wuhan General Hospital of Guangzhou Command, Wuhan 430070, China
| | - Bai-wen Qi
- Department of Microorthopaedics, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuchang Area, Wuhan 430071, China
| | - Ai-xi Yu
- Department of Microorthopaedics, Zhongnan Hospital of Wuhan University, No. 169 Donghu Road, Wuchang Area, Wuhan 430071, China.
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Filobbos G, Salim F, Khan U. Is the Injury Severity Score Relevant in Complex Lower Limb Trauma? ACTA ACUST UNITED AC 2013. [DOI: 10.1308/147363513x13588739440816] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
First described by Baker et al in 1974, the injury severity score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. It was developed initially to evaluate motor vehicle victims with multiple injuries, with an original study group of 2,128 patients. The ISS is an established score to assess trauma severity and its application has extended beyond motor vehicle injuries to cover all aspects of trauma.
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Affiliation(s)
- G Filobbos
- Plastic Surgery Registrar, North Bristol NHS Trust
| | - F Salim
- Plastic Surgery Registrar, North Bristol NHS Trust
| | - U Khan
- Consultant Plastic Surgeon, North Bristol NHS Trust
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Evidence on prognosis. Plast Reconstr Surg 2013; 131:655-665. [PMID: 23446575 DOI: 10.1097/prs.0b013e31827c6f90] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
In the clinical decision-making process, prognostic information gives physicians guidance regarding disease and treatment that can be passed along to patients. Using the clinical scenario of a type IIIB open tibial fracture as an example, this article focuses on how to search prognostic literature effectively and how to critically appraise prognostic studies. A well-built clinical question using the Patients, Intervention, Comparison, and Outcomes methodology helps plastic surgeons derive information from the vast resources in an effective and time-efficient manner. Subsequent critical appraisal of the collected studies is the essential step for identifying the most relevant high-quality evidence to provide the best prognostic information to guide patient decision-making.
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Penn-Barwell JG, Bennett PM, Fries CA, Kendrew JM, Midwinter MJ, Rickard RF. Severe open tibial fractures in combat trauma. Bone Joint J 2013; 95-B:101-5. [DOI: 10.1302/0301-620x.95b1.30580] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The aim of this study was to report the pattern of severe open diaphyseal tibial fractures sustained by military personnel, and their orthopaedic–plastic surgical management.The United Kingdom Military Trauma Registry was searched for all such fractures sustained between 2006 and 2010. Data were gathered on demographics, injury, management and preliminary outcome, with 49 patients with 57 severe open tibial fractures identified for in-depth study. The median total number of orthopaedic and plastic surgical procedures per limb was three (2 to 8). Follow-up for 12 months was complete in 52 tibiae (91%), and half the fractures (n = 26) either had united or in the opinion of the treating surgeon were progressing towards union. The relationship between healing without further intervention was examined for multiple variables. Neither the New Injury Severity Score, the method of internal fixation, the requirement for vascularised soft-tissue cover nor the degree of bone loss was associated with poor bony healing. Infection occurred in 12 of 52 tibiae (23%) and was associated with poor bony healing (p = 0.008). This series characterises the complex orthopaedic–plastic surgical management of severe open tibial fractures sustained in combat and defines the importance of aggressive prevention of infection. Cite this article: Bone Joint J 2013;95-B:101–5.
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Affiliation(s)
- J. G. Penn-Barwell
- Royal Centre for Defence Medicine, National
Institute of Health Research, Surgical Reconstruction
and Microbiology Research Centre (NIHR SRMRC), Queen
Elizabeth Medical Centre, Edgbaston, Birmingham
B15 2TH, UK
| | - P. M. Bennett
- Royal Centre for Defence Medicine, Queen
Elizabeth Medical Centre, Edgbaston, Birmingham
B15 2TH, UK
| | - C. A. Fries
- Royal Centre for Defence Medicine, Plymouth
Hospitals NHS Trust, Derriford Road, Crownhill, Plymouth, Devon, PL6
8DH, UK
| | - J. M. Kendrew
- Royal Centre for Defence Medicine, Queen
Elizabeth Medical Centre, Edgbaston, Birmingham
B15 2TH, UK
| | - M. J. Midwinter
- Royal Centre for Defence Medicine, National
Institute of Health Research, Surgical Reconstruction
and Microbiology Research Centre (NIHR SRMRC), Queen
Elizabeth Medical Centre, Edgbaston, Birmingham
B15 2TH, UK
| | - R. F. Rickard
- Royal Centre for Defence Medicine, Plymouth
Hospitals NHS Trust, Derriford Road, Crownhill, Plymouth, Devon, PL6
8DH, UK
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49
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Griffin M, Malahias M, Khan W, Hindocha S. Update on the management of open lower limb fractures. Open Orthop J 2012; 6:571-7. [PMID: 23248730 PMCID: PMC3522114 DOI: 10.2174/1874325001206010571] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 08/31/2012] [Accepted: 09/19/2012] [Indexed: 01/29/2023] Open
Abstract
Open lower limb fractures pose a significant challenging pathology for orthopaedic and plastic surgeons to manage due to the combined soft tissue damage, bone loss and potential vascular compromise. These fracture require extensive team-work and expertise between several surgical specialties and the advice of non-surgical specialties to ensure good clinical outcomes. Extensive research has improved the outcomes of open lower limb fractures and current recommendation on the optimal management is always being updated to enhance patient outcomes. This review serves to provide an overview of the management of open tibial fractures using current evidence and recently updated UK guidelines. The optimal time for surgical debridement, surgical intervention, providing antibiotics and soft tissue coverage will be outlined as well as the indications for amputation.
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Affiliation(s)
- M Griffin
- Department of Surgery, St. Georges Hospital, Blackshaw Road, Tooting, London, SW17 0QT, UK
| | - M Malahias
- Department of Plastic Surgery, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham, B9 5SS, UK
| | - W Khan
- Royal National Orthopaedics Hospital, Stanmore, London, HA7 4LP, UK
| | - S Hindocha
- Department of Plastic Surgery, Whiston Hospital, Liverpool, L35 5DR, UK
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50
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Griffin M, Malahias M, Hindocha S, Khan W. Update on the management of compound lower limb fractures. Open Orthop J 2012; 6:518-24. [PMID: 23251301 PMCID: PMC3524792 DOI: 10.2174/1874325001206010518] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 08/31/2012] [Accepted: 09/04/2012] [Indexed: 02/08/2023] Open
Abstract
Compound lower limb fractures pose a significant challenging pathology for orthopaedic and plastic surgeons to manage due to the combined soft tissue damage, bone injury and potential vascular compromise. These fractures require extensive team-work and expertise between several surgical specialties and the advice of non-surgical specialties, to ensure good clinical outcomes. Extensive research has improved the outcomes of compound lower limb fractures and current recommendation on the optimal management is always being updated to enhance patient outcomes. This review serves to provide an overview of the management of compound tibial fractures using current evidence and recently updated UK guidelines. The optimal time for surgical debridement, surgical intervention, antibiotic regime and soft tissue coverage will be outlined as well as the indications for amputation.
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Affiliation(s)
| | - M Malahias
- Heart of England NHS Foundation Trust, Birmingham, UK
| | - S Hindocha
- Whiston Teaching Hospital, Liverpool, UK
| | - W Khan
- Royal National Orthopaedic Hospital, London, UK
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