[Management of soft tissue injury in III B open tibial fractures: are local muscle flaps still up-to-date?]

Changing the treatment to reduce complication rate in open tibial fractures

Complications of open tibial fractures have been found to be very frequent after application of monotherapies (external fixator, plate, intramedullary nailing). The use of combined therapy has improved our results. We treated 658 patients for open tibial fractures over a course of 15 years. Plating was the method of treatment in the initial phase, and then external fixators and unreamed tibial nails (UTN) were used as a monotherapy. In the last ten years the option of a combined therapy was at our disposal, namely, changing the method of treatment. Monotherapy was performed in 352 cases, and 270 patients were treated in a combined manner. The rate of septic complications could be reduced with the combined therapy from 15.5% to 6.6%, the rate of bone healing disorders from 31.6% to 8.7%, and that of amputations from 4.9% to 0.7%. Elaboration of therapeutic tactics and their consistent application increases the healing potential of open tibial fractures. During this 15 year period, our therapeutic concepts have changed, whereby gradual, combined therapy models were initiated, increasing the advantages and decreasing the disadvantages of the different methods.

Combined single-stage osseous and soft tissue reconstruction of the tibia with the Ilizarov method and tissue transfer

OBJECTIVE

To determine the outcome of single-stage soft tissue and osseous reconstruction using the Ilizarov method and soft-tissue transfer.

DESIGN

A retrospective review.

SETTING

: A university-affiliated, tertiary-care center.

PATIENTS/INTERVENTION

We identified 11 patients from a retrospective review from January 1994 to July 1999 who underwent single-stage soft tissue and osseous reconstruction using the Ilizarov method. All 11 patients had an initial traumatic mechanism to their tibia and had previous operative intervention before the combined procedure. The Ilizarov procedure was performed for infected tibial nonunion (8 cases), or complex fracture with soft-tissue loss (3 cases).

MAIN OUTCOME MEASUREMENTS

Soft tissue transplant survival, union, range of motion, leg length discrepancy, the Association for the Study and Application of the Method of Ilizarov (ASAMI) score, radiographic parameters.

RESULTS

There were 8 concomitant free tissue flaps and 3 local pedicled flaps. Two patients had primary bone grafting, and 5 others had addition of an antibiotic impregnated bone substitute. There were 8 cases of elective reconstructive surgery and 3 cases of acute traumatic fracture. The mean duration of Ilizarov application was 26 weeks (range, 7 to 42). Eight tibiae united primarily, and 3 healed after delayed bone grafting. There were 2 major flap complications. Both were successfully managed with repeat surgery. One patient sustained a repeat open fracture and subsequently received an amputation. According to the ASAMI score, there were 9 excellent results, 1 good result, and 1 poor result.

CONCLUSION

Our study suggests that concomitant osseous and soft-tissue reconstruction with the Ilizarov technique and free or pedicled flaps is a viable option for patients with composite tissue defects.