The Treatment of Gustilo Grade IIIB Tibia Fractures with Application of Antibiotic Spacer, Flap, and Sequential Distraction Osteogenesis

Floating the Flap: Suspension of Soft Tissue Free Flap Over External Fixation-Guided Bone Transport: A Novel Technique

CASE

Wide resection of a synovial sarcoma of the anteromedial distal leg involving the dimetaphyseal tibia and posterior tibial tendon produced an 8.5-cm osseous defect. To keep the free flap from invaginating into the defect and prevent kinking of the anastomosis, six 1.5-mm Ilizarov wires (held in place by the external fixator) were placed under the flap to suspend it over the defect. No problems resulted with the vascularity or healing of the flap or with consolidation of the defect.

CONCLUSION

Suspending the flap over the defect with Ilizarov wires can prevent tissue invagination while avoiding need for additional procedures.

Open tibial shaft fracture fixation strategies: intramedullary nailing, external fixation, and plating

Tibial shaft fractures are one of the most common orthopaedic injuries. Open tibial shaft fractures are relatively common because of the paucity of soft tissue surrounding the bone. Despite the prevalence of these injuries, the optimal fixation strategy is still a topic of debate. The purpose of this article was to review the current literature on open tibial shaft fracture fixation strategies including intramedullary nailing, external fixation, and plating.

Outcomes following surgical fixation of Gustilo-Anderson IIIb open tibial fractures

There is no consensus as to the optimal skeletal fixation method for Gustilo-Anderson IIIb fractures. External fixation methods have previously shown higher rates of superficial infection, whilst internal fixation has shown higher risk of deep infection, but lower risk of other complications. This paper investigates outcomes in open tibial fractures based on fixation method. A retrospective review was performed for patients presenting to an ortho-plastic unit with GA IIIb tibial fractures between June 2013 and October 2021. 85 patients were identified. The most common implant was an intramedullary nail (IMN), used in 29 patients (34.1%); open reduction and internal fixation (ORIF) was performed in 16 patients (18.8%). 18 patients (21.2%) were definitively managed with a frame alone. Mean follow-up from was 18 months (2-77). Patients with ORIF needed a mean of 3.37 operations; it was 2.48 for IMN which was significantly different from frames at 5.00 (p=0.000). The mean time to bony union after definitive fixation was 11.4 months. This differed depending on the implant used for fixation, with ORIF at 7.1 months, 10.1 for IMN, and frames at 17.2 months; ORIF significantly differed from frames (p=0.009). Superficial infection was common, seen in 38.8% of patients, and only 3 patients (4%) developed deep infections involving metalwork, with no difference in rates of either based on fixation method This study supports that ORIF has faster healing times, with less time to union compared to frames. It also shows that no implant was superior to another in terms of outcomes.

External fixation versus intramedullary nailing for the management of open tibial fracture: meta-analysis of randomized controlled trials

AIM

Tibial shaft fractures are the most common type of long-bone fractures. External fixation (EF) and intramedullary nailing (IMN) are widely used surgical techniques for the definitive fixation of open tibial shaft fractures. The aim of this systematic review and meta-analysis was to compare EF to IMN for the definitive fixation of open tibial fractures.

METHODS

Medline, Embase, and CENTRAL databases were searched for eligible studies. We included randomized controlled trials (RCTs) that compared EF to IMN for skeletally mature adults with open tibial fracture (Gustilo I, II, and III). We evaluated the following outcomes: superficial infection, pin-track infection, deep infection, malunion, nonunion, delayed union, and implant/hardware failure. The risk ratio (RR) was used to represent the desired outcomes. The statistical analysis was performed using the random-effects model.

RESULTS

A total of 12 RCTs that enrolled 1090 participants were deemed eligible for the analysis. EF showed a significantly higher rate of superficial infection, pin track infection, and malunion compared to IMN (RR = 2.30, 95% confidence interval (CI): 1.34 to 3.95; RR = 13.52, 95% CI: 6.16 to 29.66; RR = 2.29, 95% CI 1.41 to 3.73, respectively). No substantial difference was found between EF and IMN in terms of deep infection, nonunion, delayed union, or implant/hardware failure (RR = 1.15, 95% CI 0.67 to 1.98; RR = 0.92, 95% CI 0.77 to 1.10; RR = 1.50, 95% CI 0.98 to 3.33; RR = 0.96, 95% CI 0.36 to 2.60, respectively).

DISCUSSION

The findings of our meta-analysis are consistent with the previous systematic reviews excepts for the implant/hardware failure which was found to be significant in favour of IMN by one of the previous reviews.

CONCLUSION

This meta-analysis confirms that IMN is better than EF with respect to clinical outcomes and complication rate for the definitive fixation of open tibial fracture.

Preventing biological waste: Effective use of viable tissue in traumatized lower extremities

Severe open lower extremity trauma requires debridement to remove contamination and devitalized tissues. Aggressive debridement should be balanced with preservation of viable tissue. These often damaged but preserved viable tissues are "spare parts" that augment the options available for reconstruction. The long-term goal of reconstruction should be functional limb restoration and optimization. Injury patterns, levels, and patient factors will determine whether this endeavor is better accomplished with limb salvage or amputation. This article reviews the rationale and strategies for preserving spare parts throughout debridement and then incorporating them as opportunistic grafts in the ultimate reconstruction to facilitate healing and maximize extremity function.

Level of Evidence

5.

Antibacterial and Anti-Biofilm Properties of Diopside Powder Loaded with Lysostaphin

BACKGROUND

Diopside-based ceramic is a perspective biocompatible material with numerous potential applications in the field of bone prosthetics. Implantable devices and materials are often prone to colonization and biofilm formation by pathogens such as Staphylococcus aureus, which in the case of bone grafting leads to osteomyelitis, an infectious bone and bone marrow injury. To lower the risk of bacterial colonization, implanted materials can be impregnated with antimicrobials. In this work, we loaded the antibacterial enzyme lysostaphin on diopside powder and studied the antibacterial and antibiofilm properties of such material to probe the utility of this approach for diopside-based prosthetic materials.

METHODS

Diopside powder was synthesized by the solid-state method, lysostaphin was loaded on diopside by adsorption, the release of lysostaphin from diopside was monitored by ELISA, and antibacterial and anti-biofilm activity was assessed by standard microbiological procedures.

RESULTS AND CONCLUSIONS

Lysostaphin released from diopside powder showed high antibacterial activity against planktonic bacteria and effectively destroyed 24-h staphylococcal biofilms. Diopside-based materials possess a potential for the development of antibacterial bone grafting materials.

Comparative Outcome of Hybrid External Fixator Versus Primary Ilizarov Fixator in the Treatment of Open Distal Tibia Extra-Articular Fractures

Introduction

Because one-third of the tibia is subcutaneous throughout most of its length and its location, it is more prone to open fractures. Open distal tibia fractures are mostly due to RTA and sports injuries. The goal of treatment is to obtain a healed, well-aligned fracture; pain-free weight-bearing; and functional range of motion of the knee and ankle.

Materials and Methods

33 patients of the 18-60-year age group with open distal tibia extra-articular fractures (without vascular injury), less than 3 weeks old trauma were included in the prospective study for 1 year period (1st June 2019 to 31st May 2020). 17 cases were treated with the Hybrid external fixator (HEF) and 16 cases were treated with the Ilizarov fixator (IF).

Results

Significantly (P < 0.05), the mean duration of surgery was less in the HEF group (67.6 min), faster union of open type-II fractures in the HEF group (16.4 weeks), and also a higher AOFAS score at 6 months in open type-II fractures in the HEF group (84.4). There were two cases of equinus deformity in the IF group and one case of valgus deformity in the HEF group.

Conclusion

HEF and IF are both equally effective in the treatment of open distal tibia extra-articular fractures with the advantage of stable fracture fixation, early weight-bearing, preserving soft tissue, minimal periosteal stripping, and providing one-staged definitive intervention. However, HEF is preferred over IF in terms of less operating time, faster union, and a better functional outcome with minimal complications.

Modern External Ring Fixation Versus Internal Fixation for Treatment of Severe Open Tibial Fractures: A Randomized Clinical Trial (FIXIT Study)

BACKGROUND

Modern external ring fixation has been hypothesized to reduce complications requiring hospital readmission compared with internal fixation when treating patients with high-energy open tibial shaft fractures. In this study, the 1-year probability of a major limb complication was compared between external and internal fixation of severe open tibial fractures.

METHODS

This multicenter randomized clinical trial included patients 18 to 64 years of age with severe open tibial shaft fractures randomly assigned to either modern external ring fixation (n = 127) or internal fixation (n = 133). The primary outcome was a major limb complication within 365 days after randomization; these complications included amputation, infection, a soft-tissue problem, nonunion, malunion, and a loss of reduction/implant failure.

RESULTS

Of 260 randomized patients, 254 were included in the final analysis. Their mean age (standard deviation) was 39 (13) years; 214 (84%) were men. The probability of at least 1 major limb complication was higher for external fixation (62.1% [95% confidence interval (CI): 53.4% to 70.8%]) than internal fixation (43.7% [95% CI: 35.5% to 52.9%]), with a risk difference of 18.4% (95% CI: 5.8% to 30.4%); p = 0.005). The most notable difference was in loss of reduction/implant failure, the rate of which was higher for external fixation (risk difference: 14.4% [95% CI: 7.0% to 21.6%]; p = 0.002). There was no appreciable difference in the probability of deep infection between external fixation (26.1%) and internal fixation (29.7%) (risk difference: -3.5% [95% CI: -14.8% to 7.8%]; p = 0.54). There were also no appreciable differences in the probabilities of amputation, nonunion, soft-tissue problems, malunion, or fracture healing between the groups.

CONCLUSIONS

These results argue against routine use of modern external ring fixation for the treatment of these severe open tibial fractures.

LEVEL OF EVIDENCE

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Union, complication, reintervention and failure rates of surgical techniques for large diaphyseal defects: a systematic review and meta-analysis

To understand the potential and limitations of the different available surgical techniques used to treat large, long-bone diaphyseal defects by focusing on union, complication, re-intervention, and failure rates, summarizing the pros and cons of each technique. A literature search was performed on PubMed, Web of Science, and Cochrane databases up to March 16th, 2022; Inclusion criteria were clinical studies written in English, of any level of evidence, with more than five patients, describing the treatment of diaphyseal bone defects. The primary outcome was the analysis of results in terms of primary union, complication, reintervention, and failure rate of the four major groups of techniques: bone allograft and autograft, bone transport, vascularized and non-vascularized fibular graft, and endoprosthesis. The statistical analysis was carried out according to Neyeloff et al., and the Mantel–Haenszel method was used to provide pooled rates across the studies. The influence of the various techniques on union rates, complication rates, and reintervention rates was assessed by a z test on the pooled rates with their corresponding 95% CIs. Assessment of risk of bias and quality of evidence was based on Downs and Black’s “Checklist for Measuring Quality” and Rob 2.0 tool. Certainty of yielded evidence was evaluated with the GRADE system. Seventy-four articles were included on 1781 patients treated for the reconstruction of diaphyseal bone defects, 1496 cases in the inferior limb, and 285 in the upper limb, with trauma being the main cause of bone defect. The meta-analysis identified different outcomes in terms of results and risks. Primary union, complications, and reinterventions were 75%, 26% and 23% for bone allografts and autografts, 91%, 62% and 19% for the bone transport group, and 78%, 38% and 23% for fibular grafts; mean time to union was between 7.8 and 8.9 months in all these groups. Results varied according to the different aetiologies, endoprosthesis was the best solution for tumour, although with a 22% failure rate, while trauma presented a more composite outcome, with fibular grafts providing a faster time to union (6.9 months), while cancellous and cortical-cancellous grafts caused less complications, reinterventions, and failures. The literature about this topic has overall limited quality. However, important conclusions can be made: Many options are available to treat critical-size defects of the diaphysis, but no one appears to be an optimal solution in terms of a safe, satisfactory, and long-lasting outcome. Regardless of the bone defect cause, bone transport techniques showed a better primary union rate, but bone allograft and autograft had fewer complication, reintervention, and failure rates than the other techniques. The specific lesion aetiology represents a critical aspect influencing potential and limitations and therefore the choice of the most suitable technique to address the challenging large diaphyseal defects.

Combined treatment using cross-leg free flap and the Masquelet technique: a report of two cases

We introduce a treatment that combines the cross-leg free flap with the Masquelet technique and describe two cases using this method for bone and soft tissue reconstruction. Both patients were successfully treated and ambulatory. This novel method can be safely performed using the delay technique, indocyanine-green angiography and near-infrared spectroscopy.

Antibiotic calcium sulfate-loaded hybrid transport versus traditional Ilizarov bone transport in the treatment of large tibial defects after trauma

Background

The purpose of this study was to compare the clinical effects of antibiotic calcium sulfate-loaded hybrid transport (ACSLHT) and traditional Ilizarov bone transport (TIBT) in the treatment of large tibial defects after trauma.

Methods

Eighty-five patients with large tibial defects after trauma were selected for retrospective study. The range of tibial defects was 6–22 cm. After thorough debridement and infection controlled, bone transport technique was used to reconstruct tibial defects. Forty-four patients were treated with ACSLHT technique (the ACSLHT group), while the other 41 were treated with TIBT technique (the TIBT group). Time in external fixator was evaluated by EFI score. Enneking score was used to evaluate limb functions. SAS score was used to evaluate postoperative anxiety status. In addition, complication incidence was compared, including axis deviation, docking site nonunion, infection recurrence and so on.

Results

There was no significant difference in preoperative general data between ACSLHT and TIBT group. EFI score in ACSLHT and TIBT group was 0.6 ± 0.1 cm/month and 1.7 ± 0.3 cm/month, respectively (P < 0.05). Enneking score of ACSLHT and TIBT group was 86.5% and 75.1% (P < 0.05). SAS score of ACSLHT group was significantly lower than that of TIBT group (P < 0.05). Complication incidence in ACSLHT group was significantly lower than that in TIBT group (P < 0.05).

Conclusions

Compared with TIBT group, ACSLHT group had shorter time in external fixator, better limb functions, lower postoperative anxiety score and lower complication incidence which is worth of clinical promotion.

Tibial Nail Combined with Vacuum Sealing Drainage for Gustilo Grade IIIB Open Tibial Fractures: A Patient Series

Gustilo grade IIIB open tibial fractures are relatively difficult to treat. We investigated the treatment effects of tibial intramedullary nails combined with vacuum sealing drainage (VSD) for Gustilo grade IIIB open tibial fractures. From March 2015 to March 2017, 13 cases of Gustilo grade IIIB open tibial fractures were treated with Expert Tibial Nails combined with VSD. Causes of injury included falls from a height (n = 9, 69.2%) and road accidents (n = 4, 30.8%). The duration from time of injury to hospital intake was 7.3 hours (range 5 to 9.5), and the time between injury and operation was 6.7 days (range 3 to 11). Six months after the operation, overall patient general health was investigated via the American Orthopaedic Foot and Ankle Society (AOFAS) ankle score and the physical and mental health dimensions of the Short-Form Health Survey 36 (SF-36). Postoperative complications and infections also were recorded. The results indicated that the median AOFAS score was 93.7 (range 89 to 97), with all individuals having either excellent (90 to 100; n = 10, 76.9%) or good (80 to 89; n = 3, 23.1%) outcomes. The median physical SF-36 score was 83.1 (range 72.5 to 93.0), and the median mental SF-36 score was 80.6 (range 69.7 to 92.0). Moreover, there were no instances of tibial shortening, neurovascular injury, postoperative complications, implant failure, malunion, or serious infections. In conclusion, intramedullary tibial nail combined with VSD is a safe and effective method to treat type grade IIIB open tibial fractures.

Management of acute bone loss following high grade open tibia fractures

INTRODUCTION

Optimal treatment for acute post-traumatic bone loss in the tibia remains unclear. Distraction osteogenesis (DO) and induced membrane technique (IM) have been established as the mainstays of treatment. Aim of this article is to review the current evidence regarding the use of these two methods.

METHODS

A review of the MEDLINE database was performed with strict inclusion and exclusion criteria focusing on treatment of the acute bone loss after open tibia fractures with DO and IM. Bone union rate was taken as the primary outcome and infection rate as secondary outcome.

RESULTS

Four studies out of 78 on the use of the DO and three studies out of 18 on the use of the IM technique matched the inclusion criteria. Union rate in the DO group ranged between 92% and 100%, with infection rates between 0 and 4%. In the IM group, union was reached in 42% to 100% of cases, with septic complications occurring in 12% to 43%. Differences in union rate and infection rate reached statistical significance.

DISCUSSION

We found a considerable evidence gap regarding treatment of bone loss in high grade open tibia fractures. The limitations of our study prevented us from drawing clear causative conclusions on the results. Although our study points to higher union rates and lower infection rate with the use of the DO technique, the results remain preliminary and further high-level evidence is needed to establish the roles of DO and IM in treatment of acute bone loss in open tibia fractures.

Bone Transport for Treatment of Traumatic Composite Tibial Bone and Soft Tissue Defects: Any Specific Needs besides the Ilizarov Technique?

Objective

To evaluate the surgical efficacy of bone transport (Ilizarov technique) plus “shortening-lengthening,” “flap surgery,” and “open bone transport” as individualized treatments for traumatic composite tibial bone and soft tissue defects.

Methods

We retrospectively analyzed sixty-eight cases (mean age: 35.69 years, (range, 16–65)) treated from July 2014 to June 2017, including 29 middle, 18 distal, and 21 proximal tibial bone defects (4–18 cm, mean: 7.97 cm) with soft tissue defects (2.5 cm × 4.0 cm to 30.0 cm × 35.0 cm after debridement). We adopted the bone transport external fixator to fix the fracture after debriding the defect parts. In the meantime, we adopted the “shortening-lengthening technique,” “flap surgery,” and “open bone transport” as individualized treatment based on the location, range, and severity of the composite tibial bone and soft tissue defects. Postoperative follow-up was carried out. Surgical efficacy was assessed based on (1) wound healing; (2) bone defect healing rate; (3) external fixation time and index; (4) incidence/recurrence of deep infection; (5) postoperative complications; and (6) Association for the Study and Application of the Methods of Ilizarov (ASAMI) score.

Results

The mean duration from injury to reconstruction was 22 days (4–80 d), and the mean postoperative follow-up period was 30.8 months (18–54 m). After the repair and reconstruction, 2 open bone transport patients required infected bone removal first before continuing the bone transport treatment. No deep infection (osteomyelitis) occurred or recurred in the remaining patients, and no secondary debridement was required. Some patients had complications after surgery. All the postoperative complications, including flap venous crisis, nail channel reaction, bone nonunion, mechanical axis deviation, and refracture, were improved or alleviated. External fixation time was 12.5 ± 3.41 months, and the index was 1.63 ± 0.44. According to the ASAMI score, 76.47% of the outcomes were good/excellent.

Conclusion

The Ilizarov technique yields satisfactory efficacy for composite tibial bone and soft tissue defects when combined with “shortening-lengthening technique,” “flap surgery,” and “open bone transport” with appropriate individualized treatment strategies.

Measuring outcomes following tibial fracture

AIM

The aim of this study was to determine how outcome is measured following adult tibial fracture in the modern era of functional outcome measurement and patient reported outcomes.

METHODS

A systematic review of publications since 2009 was performed, looking specifically at acute, adult tibial shaft fractures. Ovid Medline, Embase, PubMed and PsycINFO databases were searched for relevant titles which were then screened by two authors with adjudication where necessary by a third. Relevant articles were reviewed in full and data was extracted concerning the study participants, study design and any measures that were used to quantify the results following fracture. The results were collated and patient reported outcome measures were assessed using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) standards.

RESULTS

A total of 943 titles and articles were reviewed, with 117 included for full analysis. A wide range of clinical and radiological "outcomes" were described, along with named clinician- and patient-reported outcome measures. There was considerable heterogeneity and lack of detail in the description of the simplest outcomes, such as union, infection or reoperation. Reported clinician and patient reported outcome measures are variably used. None of the identified patient reported outcome measures have been validated for use following tibial fracture.

CONCLUSION

We recommend definition of a core outcome set for use following tibial fracture. This will standardise outcome reporting following these injuries. Furthermore, there is need for a validated patient reported outcome measure to better assess patient important outcomes in this patient group.

Eradication of Acinetobacter baumannii/Enterobacter cloacae complex in an open proximal tibial fracture and closed drop foot correction with a multidisciplinary approach using the Taylor Spatial Frame®: a case report

Background

Multi-drug-resistant bacteria (e.g. Carbapenem-resistant Acinetobacter baumannii, extended-spectrum betalactamase or carbapenemase-producing enterobacteriaceae) are emerging in early-onset infections. So far, there is no report describing the eradication of these bacteria in a osseous infection of an open proximal tibial fracture in combination with the hexapod technology to address both osseous consolidation and closed drop foot correction.

Case presentation

After sustaining a proximal tibial fracture (Gustilo 3B), a 41-year-old man was primarily treated with open reduction and internal fixation by a locking plate and split-thickness skin graft in the home country. At the time of admission to our hospital there was a significant anterolateral soft tissue defect covered with an already-necrotic split-thickness graft and suspicious secretion. CAT and MRI scans revealed no signs of osseous healing, intramedullary distinctive osteomyelitis, as well as a large abscess zone in the dorsal compartment. Multiple wound smears showed multi-drug-resistant bacteria: Acinetobacter baumannii (Carbapenem resistant) as well as Enterobacter cloacae complex (AmpC overexpression). After implant removal, excessive osseous and intramedullary debridements using the Reamer Irrigator Aspirator (RIA^®) as well as initial negative pressure wound therapy were performed. Colistin hand-modelled chains and sticks were applied topically as well as an adjusted systemic antibiotic scheme was applied. After repetitive surgical interventions, the smears showed bacterial eradication and the patient underwent soft tissue reconstruction with a free vascularized latissimus dorsi muscle flap. External fixation was converted to a hexapod fixator (TSF^®) to correct primary varus displacement, axial assignment and secure osseous healing. A second ring was mounted to address the fixed drop foot in a closed fashion without further intervention. At final follow-up, 12 months after trauma, the patient showed good functional recovery with osseous healing, intact soft tissue with satisfactory cosmetics and no signs of reinfection.

Conclusions

A multidisciplinary approach with orthopaedic surgeons for debridement, planning and establishing osseous and joint correction and consolidation, plastic surgeons for microvascular muscle flaps for soft tissue defect coverage as well as clinical microbiologists for the optimized anti-infective treatment is essential in these challenging rare cases.

Level of evidence

Level IV.

A Successful Limb Salvage of an Electrical Burned Patient With Extensive Soft Tissue and Femoral Bone Necrosis

Severe electrical injury presents a formidable therapeutic challenge for surgeons because of the requirement for complex soft tissue and bony reconstruction to restore functionality of the injured area. The authors report on the limb salvage procedure for a patient with extensive soft tissue and femoral bone necrosis from a high-voltage electrical burn. The right thigh and knee were burned, resulting in large areas of muscle necrosis and a long segment of distal femur exposure and necrosis. Complete debridement of the area resulted in a 20 × 35 cm soft tissue defect and an 18-cm long distal femoral bone defect. The wound was repaired through latissimus dorsi muscle transplantation and bony reconstruction using the sequential Ilizarov osteogenesis method. The injured limb was retained, and the functional recovery of the patient's leg was satisfactory. This experience indicates that the combination of flap transplantation and the Ilizarov osteogenesis method are good options for the treatment of large soft tissue and huge segmental bony defects.

Management of Osteomyelitis-Induced Massive Tibial Bone Defect by Monolateral External Fixator Combined with Antibiotics-Impregnated Calcium Sulphate: A Retrospective Study

AIM

The present study is aimed at evaluating the effect of combined treatment on massive bone defect using radical debridement, antibiotic calcium sulphate, and monolateral external fixator.

METHODS

35 patients with tibial osteomyelitis received radical debridement, and during surgery antibiotics-impregnated calcium sulphate was used for filling the bone defect. Monolateral external fixator was used to manage the bone defect of average 95 (61-185) cm.

RESULTS

Bone union was achieved in 34 patients (97.1%) with no reinfection. One case was presented with reinfection and further debridement was conducted. The average time for the utility of external fixation was 17 (7-32) months, and external fixation index (EFI) was 1.79 mon/cm. The mean follow-up duration after surgery was 33.7 (21-41) months. 19, 13, and 3 patients got excellent, good, and fair bone results, respectively. Meanwhile, functional results were excellent, good, fair, and poor in 13, 15, 6, and 1 patient. The most common complication was pain (100%) and superficial pin-tract infection (22.8%). Delayed maturation was incurred in 2 patients.

CONCLUSION

Our study reveals that radical debridement combined with antibiotics-impregnated calcium sulphate can suppress infection, and distraction osteogenesis using monolateral external fixators plays an effective role in managing osteomyelitis-induced massive tibial bone defect.

The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis

Objectives

As well as debridement and irrigation, soft-tissue coverage, and osseous stabilization, systemic antibiotic prophylaxis is considered the benchmark in the management of open fractures and considerably reduces the risk of subsequent fracture-related infections (FRI). The direct application of antibiotics in the surgical field (local antibiotics) has been used for decades as additional prophylaxis in open fractures, although definitive evidence confirming a beneficial effect is scarce. The purpose of the present study was to review the clinical evidence regarding the effect of prophylactic application of local antibiotics in open limb fractures.

Methods

A comprehensive literature search was performed in PubMed, Web of Science, and Embase. Cohort studies investigating the effect of additional local antibiotic prophylaxis compared with systemic prophylaxis alone in the management of open fractures were included and the data were pooled in a meta-analysis.

Results

In total, eight studies which included 2738 patients were eligible for quantitative synthesis. The effect of antibiotic-loaded poly(methyl methacrylate) beads was investigated by six of these studies, and two studies evaluated the effect of local antibiotics applied without a carrier. Meta-analysis showed a significantly lower infection rate when local antibiotics were applied (4.6%; 91/1986) than in the control group receiving standard systemic prophylaxis alone (16.5%; 124/752) (p < 0.001) (odds ratio 0.30; 95% confidence interval 0.22 to 0.40).

Conclusion

This meta-analysis suggests a risk reduction in FRI of 11.9% if additional local antibiotics are given prophylactically for open limb fractures. However, due to limited quality, heterogeneity, and considerable risk of bias, the pooling of data from primary studies has to be interpreted with caution.

Cite this article: M. Morgenstern, A. Vallejo, M. A. McNally, T. F. Moriarty, J. Y. Ferguson, S. Nijs, WJ. Metsemakers. Bone Joint Res 2018;7:447–456. The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis. DOI: 10.1302/2046-3758.77.BJR-2018-0043.R1

Comparing Radiographic Progression of Bone Healing in Gustilo IIIB Open Tibia Fractures Treated With Muscle Versus Fasciocutaneous Flaps

OBJECTIVES

To investigate how muscle and fasciocutaneous flaps influence the progression of bone healing in acute Gustilo IIIB tibia fractures.

DESIGN

Retrospective Chart Review.

SETTING

Urban Academic Level I Trauma Center.

PATIENTS/PARTICIPANTS

Between 2006 and 2016, 39 patients from a database of operatively treated long bone fractures met the inclusion criteria, which consisted of adults with acute Gustilo IIIB tibia shaft fracture requiring flap coverage and having at least 6 months of radiographic follow-up.

INTERVENTION

Soft tissue coverage for patients with Gustilo IIIB open tibia fractures was performed with either a muscle flap or fasciocutaneous flap.

MAIN OUTCOME MEASUREMENTS

A radiographic union score for tibia (RUST) fractures, used to evaluate fracture healing, was assigned to patients' radiographs postoperatively, at 3, 6, and 12 months from the initial fracture date. Mean RUST scores at these time points were compared between those of patients with muscle flaps and fasciocutaneous flaps. Union was defined as a RUST score of 10 or higher.

RESULTS

There was a significant difference (P = 0.026) in the mean RUST score at 6 months between the muscle group (8.54 ± 1.81) and the fasciocutaneous group (6.92 ± 2.46). There was no significant difference in the mean RUST score at 3 months (P = 0.056) and at 12 months (P = 0.947) between the 2 groups. There was also significance in the number of fractures reaching union, favoring muscle flaps, at 6 months (P = 0.020).

CONCLUSIONS

Patients with acute Gustilo IIIB tibia fractures who received muscle flaps have significantly faster radiographic progression of bone healing in the first 6 months than do patients who received fasciocutaneous flaps. Furthermore, according to radiographic evaluation, more Gustilo IIIB tibia fractures receiving muscle flaps reach union by 6 months than those flapped with fasciocutaneous tissue.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The Combined Use of a Neurocutaneous Flap and the Ilizarov Technique for Reconstruction of Large Soft Tissue Defects and Bone Loss in the Tibia

BACKGROUND

Management of posttraumatic large soft tissue defects and bone loss remains a therapeutic and surgical challenge for orthopedic surgeons. We assessed the use of a neurocutaneous flap and the Ilizarov technique in the reconstruction of severe composite defects in the tibia.

METHODS

We retrospectively reviewed 18 consecutive patients with trauma-related soft tissue defects and bone loss. The size of the soft tissue defect ranges from 8 × 9 cm to 14 × 18 cm. The mean size of bone loss was 4.5 cm. A great saphenous neurocutaneous flap or sural neurocutaneous flap was created to reconstruct the soft tissue defect. The Ilizarov external fixator was applied to reconstruct bony loss by means of distraction osteogenesis.

RESULTS

The mean follow-up period was 38.8 months. All transferred flaps survived completely. The area covered ranged from 9 × 10 cm to 15 × 20 cm. The mean distraction length and duration of use of the external fixator were 6 cm and 11.4 months, respectively. All patients achieved final union. Complications of superficial pin-tract infections and mild Achilles tendon contracture were observed, but these were resolved over time. All patients were satisfied with the outcome of the surgery.

CONCLUSIONS

A well-vascularized neurocutaneous flap is a safe and effective option in lower extremity reconstruction under a stable mechanical environment, which can be created using the Ilizarov technique. It is a good option for reconstructing severe complex defects in the lower limb.

The "Road to Union" protocol for the reconstruction of isolated complex high-energy tibial trauma

INTRODUCTION

The purpose of this study was to describe a standardized staged approach, "The Road to Union", for the reconstruction of isolated complex tibial trauma, both acute and chronic in nature.

METHODS

This retrospective study included all patients treated for complex tibial trauma at a specialized limb reconstruction centre, including acute open fracture as well as infected and aseptic non-unions. This standardized approach includes eight specific steps, employed in sequence. The time in external fixation (EFT), the external fixation index (EFI), and the distraction consolidation index (DCI) were the primary outcome measures. The relationship between EFI and DCI was assessed using Pearson's moment correlations.

RESULTS

Thirty-two patients with a mean age of 34.7±14.2years were included; 12 were treated for complex open tibial fractures with bone loss, 13 for infected non-unions, and 6 for aseptic non-union. The mean bone defect was 66±32mm. The total EFT was 42.5±14.8 weeks; the EFI measured 51.9±25.3 days/cm, and the DCI measured 48.3±21.4 days/cm. Union was achieved in 29 out of 32 patients (91%), and there was a strong and significant relationship between EFI and DCI (r=0.92, p=0.0001) measurements. Pin site infections were observed in 11 patients, and 3 patients had persistent non-union. Three patients underwent delayed amputations when reconstructive procedures were unable to achieve union.

CONCLUSION

The findings of this study demonstrate that a standardized staged treatment protocol of debridement, circular external fixation, soft-tissue management, distraction osteogenesis, and functional rehabilitation can result in a high rate of union in cases of complex tibial trauma, both acute and chronic in nature.

LEVEL OF EVIDENCE

Level IV; case series.

Orthoplastic surgical collaboration is required to optimise the treatment of severe limb injuries: A multi-centre, prospective cohort study

Open fractures are severe, complex, limb-threatening and high-energy injuries, often involving lesions of both bone and soft tissues. Traditionally, treatment has been piecemeal by orthopaedic and plastic surgeons. This study aimed to prospectively investigate whether combining orthopaedic and plastic surgery in treating these injuries is more effective than the conventional orthopaedic care. A prospective multi-centre cohort study was conducted. Differences in the type of approach to severe limb trauma allowed a comparison between combined orthoplastic and traditional exclusively orthopaedic treatment. Time for fracture and soft tissue healing and the recovery of limb function were the main outcome measures studied. All patients suffering from a severe open tibial fracture were prospectively included between January 2012 and December 2013 and followed until December 2014. Recruiting units were as follows: (1) an established orthoplastic centre, (2) a unit without experience in the orthoplastic approach and (3) a unit where the orthoplastic approach has been recently introduced in a developing country (Pakistan). A total of 160 patients were included in the study. Of these, 70% were treated with an orthoplastic approach, whereas 30% were treated by an orthopaedic team. All outcome measures were statistically improved by the orthoplastic approach. A coordinated, combined pathway to both the bony and the soft tissue components of open tibial fractures through orthoplastic surgery can be successfully delivered with attention to important timelines to achieve better patient outcomes in different socio-economic settings.

Nerve Regeneration and Functional Recovery With Neurorrhaphy Performed at the Early Distraction Osteogenesis: An Experimental Study

Distraction osteogenesis is widely used in many clinical situations, but distraction in cases accompanying nerve injury has been avoided due to concern of unfavorable effect on nerve regeneration by traction. This study evaluated the feasibility of early distraction lengthening after neurorrhaphy. Thirty-six rats were evenly distributed into 3 groups (12 rats in each group); neurorrhaphy and distraction (group I), neurorrhaphy and osteotomy without distraction (group II), and only distraction without neurorrhaphy (group III), respectively. After osteotomy on the right tibia, distraction started after 1 week and was continued for 40 days with 0.25 mm per day. Histological evaluation was carried out to identify nerve regeneration at 4, 8, and 12 weeks after surgery. Walking tract analysis was performed to assess the functional recovery preoperatively and 1, 4, 8, and 12 weeks postoperatively. Histologically, axon number ratio was significantly impaired in group I (0.48 ± 0.14) and group II (0.53 ± 0.13) compared with group III (0.88 ± 0.04) at 4 weeks (P = 0.020). There was no significant difference at both 8 and 12 weeks. Walking tract analysis showed significant differences between groups I and III (-40.5 ± 4.3), and groups II and III (-35.5 ± 5.0) at 1 week (P = 0.001), but no difference was observed at 8 and 12 weeks. Distraction osteogenesis in early stage after nerve repair is safe and effective, when performed at a rate of 0.25 mm per day in rats.

A Prospective Randomized Trial to Assess Fixation Strategies for Severe Open Tibia Fractures: Modern Ring External Fixators Versus Internal Fixation (FIXIT Study)

The treatment of high-energy open tibia fractures is challenging in both the military and civilian environments. Treatment with modern ring external fixation may reduce complications common in these patients. However, no study has rigorously compared outcomes of modern ring external fixation with commonly used internal fixation approaches. The FIXIT study is a prospective, multicenter randomized trial comparing 1-year outcomes after treatment of severe open tibial shaft fractures with modern external ring fixation versus internal fixation among men and women of ages 18-64. The primary outcome is rehospitalization for major limb complications. Secondary outcomes include infection, fracture healing, limb function, and patient-reported outcomes including physical function and pain. One-year treatment costs and patient satisfaction will be compared between the 2 groups, and the percentage of Gustilo IIIB fractures that can be salvaged without soft tissue flap among patients receiving external fixation will be estimated.

[Tissue flap combined with sequential bone lengthening technique for repairing severe soft tissue and bone defects of lower extremity after burn injury]

Objective

To investigate the effectiveness of tissue flap grafting and sequential bone lengthening for repairing severe soft tissue and bone defects of the lower extremity after burn injury.

Methods

Between January 2010 and December 2015, 11 cases of large segmental bone and soft tissue defects in the leg were treated. There were 10 males and 1 female, with a mean age of 28 years (range, 19-37 years). The causes included traffic accident in 8 cases, high voltage electric burn in 2 cases, CO poisoning burn in 1 case. The time from injury to admission was 3-14 days (mean, 6.5 days). The bone defect length was 8-18 cm (mean,14 cm); the skin soft tissue defect ranged from 13 cm × 8 cm to 25 cm × 19 cm. After complete removal of necrotic tissue and lesions of the femur or the tibia, the tissue flaps were used to repair soft tissue defect of the lower extremity in one-stage operation; bone defect was treated by Orthofix single side external fixation or Ilizarov ring external fixation in two-stage operation.

Results

Eleven flaps survived completely, primary healing of incision was obtained in the others except for 1 patient who had necrotic bone infection, which was cured after removing necrosed femoral bone and filling with antibiotic bone cement spacer. During bone lengthening, pin tract infection occurred in 1 patient, and infection was controlled after dressing change. Bone lengthening ranged from 8 to 18 cm, with an average of 14 cm. After prolonged extension, the external fixator was retained for 4-12 months (mean, 6.5 months). All bone defects were repaired with bone healing time of 12-22 months (mean, 17 months). All patients were followed up 8-24 months (mean, 15 months). No vascular and neurological complication occurred during operation; no osteomyelitis or re-fracture occurred after operation, and the recovery of the lower extremity function was good.

Conclusion

Tissue flap grafting combined with bone lengthening is an effective method to repair severe bone and soft tissue defects of lower extremity.

Does Integrated Fixation Provide Benefit in the Reconstruction of Posttraumatic Tibial Bone Defects?

BACKGROUND

Limb salvage in the presence of posttraumatic tibial bone loss can be accomplished using the traditional Ilizarov method of distraction osteogenesis with circular external fixation. Internal fixation placed at the beginning of the consolidation phase, so-called integrated fixation, may allow for earlier removal of the external fixator but introduces concerns about cross-contamination from the additional open procedure and maintenance of bone regenerate stability.

QUESTIONS/PURPOSES

Among patients deemed eligible for integrated fixation, we sought to determine: (1) Does integrated fixation decrease the time in the external fixator? (2) Is there a difference in the rate of complications between the two groups? (3) Are there differences in functional and radiographic results between integrated fixation and the traditional Ilizarov approach of external fixation alone?

METHODS

Between January 2006 and December 2012, we treated 58 patients (58 tibiae) with posttraumatic tibial bone loss using the Ilizarov method. Of those, 30 patients (52%) were treated with the "classic technique" (external fixator alone) and 28 (48%) were treated with the "integrated technique" (a combination of an external fixator and plating or insertion of an intramedullary nail). During that period, the general indications for use of the integrated technique were closed physes, no active infection, and a healed soft tissue envelope located at the intended internal fixation site; the remainder of the patients were treated with the classic technique. Followup on 30 (100%) and 28 (100%) patients in the classic and integrated techniques, respectively, was achieved at a minimum of 1 year (mean, 3 years; range, 1-8 years). Adverse events were reported as problems, obstacles, and complications according to the publication by Paley. Problems and obstacles are managed by nonoperative and operative means, respectively; in addition, they resolve completely with treatment. Complications, according to the Paley classification, result in permanent sequelae. Functional and radiographic results were reported using the Association for the Study and Application of Methods of Ilizarov scoring system.

RESULTS

Overall, there was a mean of four (range, 2-5) surgical procedures to complete the tibial reconstruction with a similar incidence of unplanned surgical procedures (obstacles) between the two groups (p = 0.87). Patients treated with integrated fixation spent less time in the external fixator, 7 months (range, 5-20 months) versus 11 months (range, 1-15 months; p < 0.001). There were seven problems, 15 obstacles, and zero complications in the classic group. Ten problems, 15 obstacles, and one complication occurred in the integrated fixation group. There was no difference in the severity (p = 0.87) or number (p = 0.40) of complications between both groups. Good to excellent Association for the Study and Application of Methods of Ilizarov function and bone scores were obtained in 100% and 98% of patients, respectively.

CONCLUSIONS

The integrated fixation method allows for a more efficient limb salvage surgical reconstruction in patients carefully selected for that approach, whereas the frequency of adverse events and ability to restore limb lengths was not different between the groups with the numbers available. Careful placement of external fixation pins is critical to decrease cross-contamination with planned internal fixation constructs. In this study of posttraumatic tibial bone defect reconstruction, good/excellent results were found in all patients after a mean of four surgical procedures; however, a larger multicenter prospective study would allow for more robust and generalizable conclusions.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Grade 3 open tibial shaft fractures treated with a circular frame, functional outcome and systematic review of literature

We report on the surgical and functional outcome of 22 patients with Grade 3 open tibial fractures treated with circular frame. All cases united and there were no re-fractures or amputations. All patients were assessed at a minimum of 1-year post frame removal. Assessment included clinical examination, IOWA ankle and knee scores, Olerud and Molander ankle score and EuroQol EQ-5D. Clinical scores were either good or excellent in over half of the patients in all knee and ankle scores. There was a significant positive correlation between functional outcomes and the EQ-5D score. The EQ-5D mean health state visual analogue score was comparable to the general UK population despite patients scoring less than the average UK population in three of the five domains. 36% reported some difficulties in walking and 41% had problems with pain. 14% had difficulties with self-care and 46% had difficulties with their usual activities. 14% had problems with anxiety or depression. Systematic review of the literature suggests, in the management of open tibial fractures, circular frames provide equivalent or superior surgical outcomes in comparison with other techniques. Our study finds the application of a circular frame also results in a good functional outcome in the majority of cases.

"Ilizarov" external fixation: what the radiologist needs to know

Circular external fixation, including the Ilizarov method, is a complex and often long-term treatment used for various orthopedic conditions. Due to the complexity of the hardware, frequent postoperative complications, and the potential for significant radiographic changes between visits, it is important for the radiologist to have a basic understanding of ring fixators. This publication reviews indications for external fixation versus internal fixation and whether to use a circular or uniplanar construct if external fixation is elected. Indications for and characteristics of static circular frames, intercalary and non-intercalary transport frames, and deformity circular frames will also be discussed. While general similarities exist between frame types, each has unique components of which the radiologist must be aware. An emphasis is placed on the important features and complications that arise during treatment.

The mangled foot and ankle: soft tissue salvage techniques

The mangled foot and ankle can be defined as a severe injury to multiple organ systems of this appendage that can include bone, muscle, tendon, and neurovascular structures. The magnitude and often rate-limiting parameter most likely to affect the decision to attempt foot salvage is the degree of soft tissue destruction. If irreplaceable or if function cannot be restored, amputation should be considered. If reconstruction is attempted, all nonviable tissues regardless of intrinsic function must first be removed by meticulous débridement.

Open tibial fractures grade IIIC treated successfully with external fixation, negative-pressure wound therapy and recombinant human bone morphogenetic protein 7

The aim of the therapy in open tibial fractures grade III was to cover the bone with soft tissue and achieve healed fracture without persistent infection. Open tibial fractures grade IIIC with massive soft tissue damage require combined orthopaedic, vascular and plastic-reconstructive procedures. Negative-pressure wound therapy (NPWT), used in two consecutive cases with open fracture grade IIIC of the tibia diaphysis, healed extensive soft tissue defect with exposure of the bone. NPWT eventually allowed for wound closure by split skin graft within 21-25 days. Ilizarov external fixator combined with application of recombinant human bone morphogenetic protein-7 at the site of delayed union enhanced definitive bone healing within 16-18 months.

Early postoperative outcomes associated with the anterolateral thigh flap in Gustilo IIIB fractures of the lower extremity

PURPOSE

A core concept in plastic surgery has been the replacement of "like-with-like" tissue. Applying this concept to the lower extremity, the anterolateral thigh (ALT) perforator flap has become a frequently used free flap for restoration of soft tissue defects involving the distal lower extremity. The objective of this study was to evaluate the rate of early postoperative complications associated with the ALT perforator free flap for coverage of high-energy traumatic open fractures of the lower extremity (Gustilo IIIB) and explore related patient risk factors.

METHODS

A retrospective chart review of 74 patients undergoing free tissue transfer for lower extremity limb coverage was performed. Early postoperative complications were defined as any 1 or more of the following having occurred within 6 months from surgical reconstruction: hematoma, wound infection, deep venous thrombosis, thromboembolism, partial flap loss, complete flap loss, continued osteomyelitis, and progression to amputation occurring within the first 6 months after the injury. Statistical analyses were performed using GraphPad software. Fisher exact test was performed to identify risk factors associated with greater morbidity.

RESULTS

Of all patients, 26 (35%) were identified as those habitually using tobacco product and 48 (64%) were identified as nonusers of tobacco product. Moreover, 10 patients (14%) had other risk factors for atherosclerotic disease and 64 patients (86%) did not have other risk factors for atherosclerosis. Mean (SD) time to reconstruction was 4.74 (1.3) days (range, 3-8 days). Of all defects, 34 (46%) were reconstructed using adipocutaneous flaps and 40 (54%) were reconstructed using fasciocutaneous flaps. The most frequent complication was partial flap loss or superficial epidermolysis 4 (5.4%). Fisher exact test was performed, showing that patients who used tobacco product (cigarette smokers) and had other risk factors for atherosclerosis were significantly more at risk for complications (P < 0.001).

CONCLUSIONS

In this retrospective review, those patients who had a positive history of tobacco use at the time of injury and those with risk factors for atherosclerosis had a significantly increased risk of flap complications. Although this is not surprising given the vasoconstrictive effects of nicotine and the impaired blood flow to the lower extremity in patients with atherosclerosis, this study will allow the surgeon to better counsel patients who have a history of tobacco use through complex reconstruction of the lower extremity. This analysis is a preliminary investigation into the safety and efficacy of the ALT fasciocutaneous or adipocutaneous flap to reconstruct high-energy open fractures of the lower extremity.

Is time to flap coverage of open tibial fractures an independent predictor of flap-related complications?

OBJECTIVES

The importance of the timing of flap coverage of open tibial shaft fractures remains controversial. Many studies have shown increased complications and infection rates associated with delay in coverage but have not controlled for risk factors that might be associated with both delay in coverage and complications. We hypothesized that the timing of flap coverage of open tibial fractures is not predictive of complications after controlling for known risk factors.

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENTS

Sixty-nine patients treated for acute tibial fractures (45 tibial shaft, 17 plateau, and 12 pilon fractures) at our center from 2004 through 2009 required 74 flaps. Patients requiring flaps later for wound breakdown or infection were excluded.

INTERVENTION

Electronic records and prospective trauma database were reviewed. All fractures were AO classified by a trauma fellowship-trained orthopaedic surgeon.

MAIN OUTCOME MEASUREMENTS

Primary outcome was flap complication, defined as infection or other flap-related adverse outcome requiring surgical treatment. Logistic regression analysis was conducted.

RESULTS

A logistic regression model that separated the first 7 days after injury from subsequent days found no increased risk for days 1 through 7. The odds of complications, and of infection in particular, increased by 11% and 16%, respectively, for each day beyond day 7 (P < 0.04).

CONCLUSIONS

Even after controlling for known risk factors for complications, including injury severity, time to flap coverage was a significant predictor of complications.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Principles of tibial fracture management with circular external fixation

There is a growing mass of literature to suggest that circular external fixation for high-energy tibial fractures has advantages over traditional internal fixation, with potential improved rates of union, decreased incidence of posttraumatic osteomyelitis, and decreased soft tissue problems. To further advance our understanding of the role of circular external fixation in the management of these tibial fractures, randomized controlled trials should be implemented. In addition to complication rates and radiographic outcomes, validated functional outcome tools and cost analysis of this method should be compared with open reduction with internal fixation.

Distraction osteogenesis in the treatment of long bone defects of the lower limbs: effectiveness, complications and clinical results; a systematic review and meta-analysis

We carried out a systematic review of the literature to evaluate the evidence regarding the clinical results of the Ilizarov method in the treatment of long bone defects of the lower limbs. Only 37 reports (three non-randomised comparative studies, one prospective study and 33 case-series) met our inclusion criteria. Although several studies were unsatisfactory in terms of statistical heterogeneity, our analysis appears to show that the Ilizarov method of distraction osteogenesis significantly reduced the risk of deep infection in infected osseous lesions (risk ratio 0.14 (95% confidence interval (CI) 0.10 to 0.20), p < 0.001). However, there was a rate of re-fracture of 5% (95% CI 3 to 7), with a rate of neurovascular complications of 2.2% (95% CI 0.3 to 4) and an amputation rate of 2.9% (95% CI 1.4 to 4.4).The data was generally not statistically heterogeneous. Where tibial defects were > 8 cm, the risk of re-fracture increased (odds ratio 3.7 (95% CI 1.1 to 12.5), p = 0.036). The technique is demanding for patients, illustrated by the voluntary amputation rate of 1.6% (95% CI 0 to 3.1), which underlines the need for careful patient selection.

Evidence-based medicine: lower extremity acute trauma

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the steps for evaluation of a patient with a lower extremity wound before initiating medical or surgical intervention. 2. Acknowledge that limb amputation and salvage can both be appropriate definitive treatment options. 3. Select proper nonsurgical or surgical techniques for wound management. 4. Appreciate the difference in the expected outcome according to the perspective of the physician versus the patient.

SUMMARY

Lower extremity acute trauma is a common occurrence. Ultimate functional outcomes are similar whether amputation or salvage by limb reconstruction is the treatment pathway chosen. The reconstructive surgeon must be knowledgeable enough to assist in making the correct decision for either option. Débridement is the cornerstone of management before embarking on definitive wound closure. Nonsurgical devices have provided a transition to optimize the wound, sometimes even replacing or lessening the need for vascularized tissues to permit this coverage. Nevertheless, flaps will always have a role varying according to the involved region of the lower extremity. Traditional muscle flaps can often today be supplemented by the use of perforator flaps. The latter have great versatility as pedicled flaps for all zones of the lower limb, in addition to being a dependable free flap alternative. Horrendous injuries can now be expected to be salvaged, with a reasonable aesthetic result possible and with minimal donor-site morbidity. Preferences by both physicians and patients tend to favor the course to limb salvage, but it must be appreciated by the caregiver that it is always the patient who has to live with the residua of an altered limb and lifestyle.

Evaluation of an endoscopic procedure for the treatment of docking site nonunion

OBJECTIVE

To determine the effectiveness of an endoscopic docking site surgery during the use of a classic bone transport technique for dealing with bone loss.

DESIGN

Retrospective comparative study.

SETTING

Level I trauma center.

PATIENTS

Nine patients treated with endoscopic docking site surgery (group 1) were compared with 18 patients treated with standard open grafting of the docking site (group 2). All 27 bone transports with distraction osteogenesis were performed for the treatment of segmental tibial bone defects.

INTERVENTION

In group 1, 6 tibial and 3 tibiotalar docking sites were endoscopically treated. Anteromedial (instrumentation) and anterolateral (visualization) portals were used without a tourniquet, using a 30-degree arthroscope and a motorized 5-mm shaver/abrader. Fibrous tissue was removed, bone ends abraded, and the bone canal cleaned with bone grafting.

MAIN OUTCOME MEASURE

Clinical and radiographic.

RESULTS

Bone transport lengthening was 9.7 and 9.1 cm in groups 1 and 2, respectively. Consolidation at the docking site occurred in 8 patients (89%) in group 1. The docking site consolidation time and index lengthening were lower in group 1 (18 vs. 20 weeks for group 2 and 1.59 vs. 1.82 mo/cm in group 1 vs. group 2). Time in the external fixator was similar between the 2 groups (461 vs. 466 days in group 1 vs. group 2). Normal alignment was observed in both groups.

CONCLUSIONS

This study provides evidence that minimally invasive endoscopic docking site treatment during bone transport is a safe and viable technique using a common arthroscopic instrumentation.

Long-term results and costs of muscle flap coverage with Ilizarov bone transport in lower limb salvage

OBJECTIVES

To determine long-term outcomes and costs of Ilizarov bone transport and flap coverage for lower limb salvage.

DESIGN

Case series with retrospective review of outcomes with at least 6-year follow-up.

SETTING

Academic tertiary care medical center.

PATIENTS

Thirty-four consecutive patients with traumatic lower extremity wounds and tibial defects who were recommended amputation but instead underwent complex limb salvage from 1993 to 2005.

INTERVENTION

Flap reconstruction and Ilizarov bone transport.

MAIN OUTCOME MEASUREMENTS

Outcomes assessed were flap complications, infection, union, malunion, need for chronic narcotics, ambulation status, employment status, and need for reoperations. A cost analysis was performed comparing this treatment modality to amputation.

RESULTS

Thirty-four patients (mean age: 40 years) were included with 14 acute Gustilo IIIB/C defects and 20 chronic tibial defects (nonunion with osteomyelitis). Thirty-five muscle flaps were performed with 1 flap loss (2.9%). The mean tibial bone defect was 8.7 cm, mean duration of bone transport was 10.8 months, and mean follow-up was 11 years. Primary nonunion rate at the docking site was 8.8% and malunion rate was 5.9%. All patients achieved final union with no cases of recurrent osteomyelitis. No patients underwent future amputations, 29% required reoperations, 97% were ambulating without assistance, 85% were working full time, and only 5.9% required chronic narcotics. Mean lifetime cost per patient per year after limb salvage was significantly less than the published cost for amputation.

CONCLUSIONS

The long-term results and costs of bone transport and flap coverage strongly support complex limb salvage in this patient population.

Evolution of orthopaedic reconstructive care

The patterns and severity of injury sustained by service members have continuously evolved over the past 10 years of combat in Iraq and Afghanistan. The 2010 surge of combat troops into Afghanistan, combined with a transition to counterinsurgency tactics with an emphasis on dismounted operations, resulted in increased exposure of US service members to improvised explosive devices and a new pattern of injury termed dismounted complex blast injury. This constellation of injuries typically includes multiple extremity injuries, high bilateral transfemoral amputations, amputated or mangled upper extremities, open pelvis fractures, and injury to the perineal and/or genital regions. These polytraumatized patients frequently present with head, abdominal, and genitourinary injuries, as well. Traditional methods of reconstruction must be optimized because tissue availability may be limited.

Tissue engineering approaches for bone repair: concepts and evidence

Over the last decades, the medical world has advanced dramatically in the understanding of fracture repair. The three components needed for fracture healing are osteoconduction, osteoinduction and osteogenesis. With newly designed scaffolds, ex vivo produced growth factors and isolated stem cells, most of the challenges of critical size bone defects have been resolved in vitro, and in some cases in animal models as well. However, there are still challenges needed to be overcome before these technologies can be fully converted from the bench to the bedside. These technological and biological advancements need to be converted to mass production of affordable products that can be used in every part of the world. Vascularity, full substation of scaffolds by native bone, and bio-safety are the three most critical steps to be challenged before reaching the clinical setting.

Clinical reliability of closed techniques and comparison with open strategies to achieve union at the docking site

PURPOSE

This retrospective review follows 31 tibial nonunions to compare union at the docking site using closed versus open strategies. In this cohort of patients, all but five were infected nonunions.

METHODS

Thirteen patients initially treated with single compression were compared with 18 patients treated by open revision of the docking site. In the single compression group, an average of 6.5 cm of bone was resected and index lengthening was 2.04. In the open revision group, a mean of 9.4 cm was resected and the index lengthening was 1.73.

RESULTS

Consolidation at the docking site occurred in all subjects in both groups. There was no statistical difference between the two groups. Conclusive evidence of superiority of one modality of treatment over the other cannot be drawn from our data.

CONCLUSIONS

The simple compression procedure requires less invasive surgery and is probably less demanding and more cost-effective in short transports.