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

Long-Term Efficacy and Surgical Outcomes of Sural Neurovascular Flap Applications in Distal Lower Limb Wound Reconstruction: A Single-Center Retrospective Study of Patients Treated in Jingzhou City From 2012 to 2018

Background and Aim

The sural neurovascular flap has been effectively used to reconstruct complex tibial and soft tissue defects caused by severe trauma, promoting successful wound repair and healing. Proactive management is essential in minimizing postoperative complications and achieving optimal outcomes. This study evaluates the efficacy and long-term outcomes of sural neurovascular flap applications in distal lower limb wound reconstruction.

Methods

Our institution's ethics committee approved this retrospective study numbered YJ202457 involving 47 participants. Informed consent was obtained from all subjects. Data collected included demographic details, injury mechanisms and sites, mode and size of soft tissue defects, complications, cosmetic outcomes, and functional outcomes of the lower limb and ankle. All flaps were performed by a single surgeon, with follow-up from January 2012 to February 2018.

Result

The study observed minor complications, primarily superficial necrosis. Over 95% (45) of flaps survived, and less than 5% (2) required reoperations due to superficial necrosis. Patient satisfaction was high, with over 50% (24) achieving excellent cosmetic results and over 40% (20) good cosmetic results. The study recorded improved Functional Recovery and Quality of life.

Conclusion

Sural neurovascular flap applications show significant promise in reconstructing distal lower limb wounds. Our findings highlight the procedure's efficacy, demonstrated by high patient satisfaction, excellent cosmetic outcomes, and favorable functional results. Critical factors for success include meticulous patient selection, thorough debridement, and careful planning to mitigate risks and optimize outcomes. The patients with diabetes and hypertension were not included to minimize factors that could interfere with the study's results.

Concurrent plate fixation and pedicled flap coverage for open fractures complicated by soft tissue loss of the tibia in pediatric cohort: a clinical series

BACKGROUND

The optimal treatment of open fractures complicated by soft tissue loss of pediatric tibial fractures remains inconclusive. The author described a protocol of concurrent plate fixation and pedicled flap coverage and retrospectively reviewed the outcomes of such injuries.

METHODS

A total of 25 pediatric cases with Gustilo lllB open tibial fracture were treated by single-stage plate fixation and pedicled flap reconstruction. The reviewed information consisted of time to fix and flap, type of plate, type of pedicled flap, fracture union time, postoperative complication and the clinical outcomes by objective scoring system.

RESULTS

Fix and flap was undergone between 7 and 12 days after injury with the average time of 8.2 days. Regarding the type of plate, narrow LCP was applied in 8, 3.5 mm precontoured LCP in 10, 5.0 mm precontoured in 2 and double LCP in 5. According to soft tissue reconstruction, the medial gastrocnemius flap was selected in 6 cases, myocutaneous medial gastrocnemius flap in 2, soleus flap in 3, hemisoleus flap in 5, reverse sural flap in 6 and combined medial gastrocnemius and hemisoleus flaps in 3. No flap-related complication was demonstrated. All cases established fracture union in between 12 and 24 weeks with an average time to union of 17.7 weeks. According to postoperative complications, infected plate occurred in 2 cases and implant irritation in 5. According to Puno functional score, excellent results were presented in 7 cases and good results in 18 cases.

CONCLUSION

Single-stage plate fixation and pedicled flap coverage are a reliable regimen for pediatric open fractures complicated by soft tissue loss of the tibia.

Usefulness of external fixation and reverse Sural fasciocutaneous flap: Treatment of grade III B open tibial fractures in resource-limited settings

PURPOSE

Sierra Leone is a low-income country located on the west coast of Africa where the majority of the population does not have free access to emergency medical and surgical services, the principal cause of open tibia fractures is motorcycle collision. Open fractures of the middle and distal third of the tibial segments, particularly those classified as type III B, represent a challenge for orthopedic surgeons because of the loss of soft tissue coverage. The Reverse Sural Fasciocutaneous Flap (RSFF) has been shown to be an ideal and reproducible option for the treatment of soft tissue defects. The main aim of this study was to demonstrate the experience in Resource Limited Settings (RLS) by means of a short series of the efficacy of using a combination of external fixation and RSFF in the treatment of grade III B open tibia fractures where plastic surgeons were not available.

METHODS

This retrospective, descriptive, and non-experimental study included 8 patients who underwent surgical intervention between September 2020 and September 2021.

RESULTS

The skin defects were of various sizes; the smallest size was 4 × 7 cm, and the biggest size of 12 × 18 cm. We obtained a success rate in seven of the eight cases.

CONCLUSIONS

External fixation and reverse sural fasciocutaneous sural flap are excellent therapeutic options for the treatment of open grade III B diaphyseal and metaphyseal distal tibial fractures.

A Case of Reconstruction of an Open Tibial Fracture (Gustilo-Anderson Type IIIB) With Severe Skin and Bone Loss Using Corticocancellous Bone Plugs From the Iliac Crest and an Ilizarov Frame

Gustilo-Anderson type IIIB fractures include open fractures with extensive soft tissue injury with periosteal stripping and bony exposure. They are usually associated with massive contamination and can be challenging even for experienced surgeons. A multidisciplinary approach among plastic and trauma surgeons is often required. We present a case of a 58-year-old man with a type IIIB open tibial fracture initially managed with a bridging external fixation and primary skin closure using a fasciocutaneous sural flap. Two months later, there was no evidence of fracture healing and an Ilizarov device was applied with corticotomy at the proximal tibial metaphysis, which was modified five months later without changing the frame, placing autogenous iliac bone plugs at the fracture site using the mosaicplasty harvesting technique. Seven months after its initial placement, the Ilizarov device was removed allowing full weight-bearing, with callus formation present at 10-month follow-up. Finally, the patient showed acceptable radiological and functional outcomes after a follow-up of two years. The Ilizarov method should be considered as a therapeutic option for complicated open fractures with severe bone and skin loss. The patient should be fully informed about the complexity of these fractures and the necessity of multiple surgical interventions in order to have realistic expectations.