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Pierrie SN, Beltran MJ. Acute shortening and angulation for complex open fractures: an updated perspective. OTA Int 2023; 6:e245. [PMID: 37448568 PMCID: PMC10337845 DOI: 10.1097/oi9.0000000000000245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 12/22/2022] [Indexed: 07/15/2023]
Abstract
Reestablishing an intact, healthy soft tissue envelope is a critical step in managing lower extremity injuries, particularly high-grade open tibia fractures. Acute shortening and angulation can be used independently or together to address complex soft tissue injuries, particularly when bone loss is present. These techniques facilitate management of difficult wounds and can be combined with local soft tissue rearrangement or pedicled flaps as needed, avoiding the need for free tissue transfer. After angular deformity correction, adjacent bone loss can be addressed with bone grafting or distraction histogenesis. This article discusses the indications for, surgical technique for, and limitations of acute shortening and angulation for management of open lower extremity fractures.
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Affiliation(s)
- Sarah N. Pierrie
- Corresponding author. Address: Sarah N. Pierrie, MD, Department of Orthopaedic Surgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Room 5553, Cincinnati, OH 45267-0212. E-mail:
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Halsey JN, Iobst CA, Pearson GD. Acute Intentional Deformation of Open Tibial Fractures for Complex Soft Tissue Closure in the Pediatric Patient. EPLASTY 2022; 22:e35. [PMID: 36072058 PMCID: PMC9412025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Background. Lower extremity injuries in the pediatric population that are associated with Gustillo 3B/3C fractures require special consideration. Limb salvage should be attempted in the pediatric patient if at all possible, and oftentimes the soft tissue defect that is present over the bony fracture is substantial. The traditional algorithm used in the management of Gustillo 3B/3C fractures in plastic surgery, referred to as the reconstructive ladder, would recommend flap reconstruction with free tissue transfer in most cases because regional options are often unavailable or do not provide adequate coverage. Free tissue transfer procedures are extensive and necessitate a donor site; they often require multiple procedures and subsequent revisions. Furthermore, when concomitant injuries or medical conditions are present, a patient may not be an appropriate candidate for a free flap. Another option, however, does exist for the pediatric patient with a significant lower extremity injury that is often overlooked by the plastic surgeon. Several articles in the orthopedic literature describe the utility of temporary limb deformation to allow for soft tissue closure, with gradual correction of the bony deformity over time. Although the healing process for these procedures take several months, there is no need for extensive soft tissue reconstruction and the ultimate result is a leg that is functional with adequate coverage. This article reports a case where this type of bone and soft tissue reconstruction was performed in a patient with an excellent overall outcome. This technique could be useful in select cases as an option in pediatric lower extremity reconstruction.
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Affiliation(s)
- Jordan N Halsey
- Division of Pediatric Plastic Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Christopher A Iobst
- Department of Orthopedic Surgery, Nationwide Children's Hospital, Columbus, OH
| | - Gregory D Pearson
- Division of Pediatric Plastic Surgery, Nationwide Children's Hospital, Columbus, OH
- Department of Plastic Surgery, The Ohio State University College of Medicine, Columbus, OH
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Plotnikovs K, Movcans J, Solomin L. Acute Shortening for Open Tibial Fractures with Bone and Soft Tissue Defects: Systematic Review of Literature. Strategies Trauma Limb Reconstr 2022; 17:44-54. [PMID: 35734040 PMCID: PMC9166261 DOI: 10.5005/jp-journals-10080-1551] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
Introduction The presence of massive soft tissue loss in open tibial fractures is a challenging problem. Acute limb shortening is an alternative solution in situations where the use of flaps is limited. Materials and methods A review was conducted following the Preferred Reported Items for Systematic Reviews and Meta-analyses checklist (PRISMA) guidelines. A complete search of PubMed, EMBASE and MEDLINE was undertaken. Twenty-four articles related to closure of soft tissue defects through acute limb shortening were identified and included in this review. Results All report on restoration of limb function without or with minimal residual shortening. The authors note a decrease in the need for microsurgery. The external fixation devices used for deformity correction after closure of the soft tissue defect by acute shortening, angulation and rotation were the Ilizarov apparatus and circular fixator hexapods mainly. Conclusion Acute shortening is an alternative to microsurgical techniques. A ring external fixator is useful for restoring limb alignment after closing the soft tissue defect through creating a temporary deformity. The use of circular fixator hexapods can enable accurate correction of complex multicomponent deformities without the need to reassembly of individual correction units. How to cite this article Plotnikovs K, Movcans J, Solomin L. Acute Shortening for Open Tibial Fractures with Bone and Soft Tissue Defects: Systematic Review of Literature. Strategies Trauma Limb Reconstr 2022;17(1):44–54.
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Affiliation(s)
- Konstantins Plotnikovs
- Department of Orthopedic Surgeon, Traumatology and Orthopedics, Riga East University Hospital, Rīga Stradiņš University, Riga, Latvia
- Konstantins Plotnikovs, Department of Orthopedic Surgeon, Traumatology and Orthopedics, Riga East University Hospital, Rīga Stradiņš University, Riga, Latvia, e-mail:
| | - Jevgenijs Movcans
- Department of Traumatology and Orthopaedics, Riga East Clinical University Hospital, Riga, Latvia
| | - Leonid Solomin
- Russian Scientific Research Institute of Traumatology and Orthopedics named after RR Vreden, Saint Petersburg, Russia
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Acute limb shortening or creation of an intentional deformity to aid in soft tissue closure for IIIB/IIIC open tibia fractures. J Plast Reconstr Aesthet Surg 2021; 74:2933-2940. [PMID: 34049839 DOI: 10.1016/j.bjps.2021.03.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/26/2021] [Accepted: 03/13/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ring fixator techniques can precisely correct complex long bone deformities. In select patients, controlled shortening or intentional fracture deformation with delayed correction can also aid in complex wound coverage and limb salvage. METHODS This retrospective cohort study analyzed all patients who underwent acute limb shortening or intentional temporary fracture deformation between 2005 and 2020. Patients were divided into three groups based on reason for acute shortening or intentional deformity: (1) skeletal indications alone, with traditional flap coverage; (2) skeletal and soft tissue indications, to augment traditional reconstructive measures; and (3) skeletal and soft tissue indications, to avoid microsurgery altogether. Comorbidities, orthopedic and reconstructive methods, and functional outcomes were recorded. RESULTS Eighteen patients were identified: six in Group 1, five in Group 2, and seven in Group 3. Fractures were primarily in the distal third of the tibia. On initial assessment, all wounds would have required free tissue transfer. Group 1 patients were reconstructed with free flaps. Among Group 2, closure was accomplished by skin grafting (N = 1), local flaps (N = 1), pedicled muscle flaps (N = 1), and free flaps (N = 2). In Group 3, five wounds were closed primarily and two were skin grafted. All limbs were shortened, averaging 25.1 mm; seven were intentionally deformed, most commonly varus (10-20°). After skeletal correction, residual leg length discrepancy averaged 5.7 mm. No patients required amputation. CONCLUSIONS Acute skeletal shortening with or without intentional temporary deformation in select IIIB/IIIC open tibial fractures can facilitate soft tissue coverage and limb salvage in patients who might otherwise require amputation.
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Ma H, Yao H, Zhang T, Wan C. [A comparative study of Taylor spatial frame and unilateral external fixator in treatment of tibiofibular open fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2020; 34:447-451. [PMID: 32291979 DOI: 10.7507/1002-1892.201909120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To compare the effectiveness of Taylor spatial frame (TSF) and unilateral external fixator in the treatment of tibiofibular open fractures. Methods Between January 2016 and July 2018, 74 patients with tibiofibular open fracture who met the selection criteria were divided into TSF group (43 cases, fixed with TSF) and unilateral group (31 cases, fixed with unilateral external fixator) according to the principle of entering the group every other day. There was no significant difference in gender, age, affected side, cause of injury, type of fracture between the two groups ( P>0.05). The operation time, fracture healing time, removal time of external fixator, and complications were recorded and compared between the two groups. The limb function was evaluated according to Johner-Wruhs criteria for evaluating the final effectiveness of tibial shaft fracture treatment. The recovery of lower limb force line was ecaluated by LUO Congfeng et al. criteria. Results All patients were followed up 8-22 months, with a median of 12 months. All fractures healed, and no complication such as delayed union, nonunion, or osteomyelitis occurred. The operation time, fracture healing time, and removal time of external fixator in TSF group were significantly shorter than those in unilateral group ( P<0.05). At 3 months after the removal of the external fixator, the limb function was evaluated according to the Johner-Wruhs standard. In TSF group, 41 cases were excellent, 1 case was good, and 1 case was fair, and the excellent and good rate was 97.67%; in unilateral group, 30 cases were excellent and 1 case was fair, and the excellent and good rate was 96.77%; there was no significant difference between the two groups ( P=0.666). At 4 months after operation, the recovery of lower limb force line was ecaluated by LUO Congfeng et al. criterion. In TSF group, 41 cases were excellent, 2 cases were good, and 1 case was fair, and the excellent and good rate was 97.67%; in unilateral group, 29 cases were excellent, 1 case was good, 1 case was fair, and the excellent and good rate was 96.77%; there was no significant difference between the two groups ( P=0.666). Conclusion For tibiofibular open fracture, on the premise of fracture healing, TSF technology is superior to unilateral external fixation in terms of shortening operation time, fracture healing time, and removal time of external fixator.
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Affiliation(s)
- He Ma
- Department of Limb Orthopedics, Tianjin Hospital, Tianjin, 300211, P.R.China
| | - Hui Yao
- Department of Limb Orthopedics, Tianjin Hospital, Tianjin, 300211, P.R.China
| | - Tao Zhang
- Department of Limb Orthopedics, Tianjin Hospital, Tianjin, 300211, P.R.China
| | - Chunyou Wan
- Department of Limb Orthopedics, Tianjin Hospital, Tianjin, 300211, P.R.China
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Zhang N, Wan C, Zhang T, Ma J, Liu Z, Wang M, Ge Q. [The assessment of the application of Taylor spatial frame in treatment of intermediate or distal tibiofibula fractures]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2018; 32:1012-1017. [PMID: 30238728 PMCID: PMC8429999 DOI: 10.7507/1002-1892.201712095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 07/18/2018] [Indexed: 01/23/2023]
Abstract
Objective To determine the effectiveness and the safety of the Taylor spatial frame in treatment of intermediate or distal tibiofibula fractures. Methods The clinical data of 74 patients with intermediate or distal tibiofibular fractures treated between January 2015 and January 2017 were retrospectively analyzed. According to fixation methods, they were divided into internal fixation group (26 cases) and external fixation group (48 cases). There was no significant difference in the age, gender, cause of injury, type of fracture, time from injury to operation between 2 groups ( P>0.05). The intraoperative blood loss, fracture healing time, fixator removal time, and complications were recorded and compared. The final function evaluation criteria of Johner-Wruhs humeral shaft fracture were used to evaluate the function of the affected limb. The lower limb force line recovery after operation was evaluated according to the standard evaluation of LUO Congfeng et al. Results Both groups were followed up 6-22 months (median, 14 months). All patients obtained the fracture healing. The intraoperative blood loss, fracture healing time, and fixator removal time were significantly higher in the internal fixation group than those in the external fixation group ( P<0.05). There were 1 case of plate exposure, 1 case of delayed fracture healing, and 1 case of plate fracture in the internal fixation group; and there were 2 cases of delayed fracture healing and 4 cases of soft tissue defect in the external fixation group; no significant difference was found in the incidence of complications between 2 groups ( χ2=0.015, P=0.904). The function of the affected limb was evaluated by Johner-Wruhs standard at 10 months after operation, the results was excellent in 19 cases, good in 5 cases, and fair in 2 cases in the internal fixation group, with an excellent and good rate of 92.3%; the results was excellent in 42 cases, good in 3 cases, and fair in 2 cases in the external fixation group, with an excellent and good rate of 95.7%; showing no significant difference between 2 groups ( χ2=0.392, P=0.531). The lower limb force line recovery after operation was evaluated according to the standard evaluation of LUO Congfeng et al.at 4 months after operation, the results was excellent in 24 cases, fair in 1 case, poor in 1 case in the internal fixation group, with an excellent and good rate of 92.3%; the results was excellent in 46 cases, fair in 1 case, poor in 1 case in the external fixation group, with an excellent and good rate of 95.8%; showing no significant difference between 2 groups ( χ2=0.520, P=0.471). Conclusion The use of Taylor spatial frame in the treatment of the intermediate or distal tibiofibular fractures can obviously reduce the healing time and complications than the internal fixation of the plate. It can reduce the fracture treatment cycle and is beneficial to the fracture healing and limb function recovery, which is relatively safe and reliable.
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Affiliation(s)
- Ningning Zhang
- Graduate School of Tianjin Medical University, Tianjin, 300070, P.R.China
| | - Chunyou Wan
- No.1 Ward of Limb Orthopaedic and Reconstruction, Tianjin Hospital, Tianjin, 300211,
| | - Tao Zhang
- No.1 Ward of Limb Orthopaedic and Reconstruction, Tianjin Hospital, Tianjin, 300211, P.R.China
| | - Jihai Ma
- Tianjin University of Traditional Chinese Medicine, Tianjin, 300193, P.R.China
| | - Zhao Liu
- Graduate School of Tianjin Medical University, Tianjin, 300070, P.R.China
| | - Mingjie Wang
- No.1 Ward of Limb Orthopaedic and Reconstruction, Tianjin Hospital, Tianjin, 300211, P.R.China
| | - Qihang Ge
- Tianjin University of Traditional Chinese Medicine, Tianjin, 300193, P.R.China
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Abstract
In 16 years of conflict, primarily in Iraq and Afghanistan, wounded warriors have primarily been subjected to blast type of injuries. Evacuation strategies have led to unprecedented survival rates in blast-injured soldiers, resulting in large numbers of wounded warriors with complex limb trauma. Bone and soft tissue defects have resulted in increased use of complex reconstructive algorithms to restore limbs and function. In addition, in failed salvage attempts, advances in amputation options are being developed. In this review, we summarize state-of-the-art limb-salvage methods for both soft tissue and bone. In addition, we discuss advances in diagnostic methods with development of personalized clinical decision support tools designed to optimize outcomes after severe blast injuries. Finally, we present new advances in osteointegrated prostheses for above-knee amputations.
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Ramasamy PR. Management of Gustilo Anderson III B open tibial fractures by primary fascio-septo-cutaneous local flap and primary fixation: The 'fix and shift' technique. Indian J Orthop 2017; 51:55-68. [PMID: 28216752 PMCID: PMC5296850 DOI: 10.4103/0019-5413.197532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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 Open fractures of tibia have posed great difficulty in managing both the soft tissue and the skeletal components of the injured limb. Gustilo Anderson III B open tibial fractures are more difficult to manage than I, II, and III A fractures. Stable skeletal fixation with immediate soft tissue cover has been the key to the successful outcome in treating open tibial fractures, in particular, Gustilo Anderson III B types. If the length of the open wound is larger and if the exposed surface of tibial fracture and tibial shaft is greater, then the management becomes still more difficult. MATERIALS AND METHODS Thirty six Gustilo Anderson III B open tibial fractures managed between June 2002 and December 2013 with "fix and shift" technique were retrospectively reviewed. All the 36 patients managed by this technique had open wounds measuring >5 cm (post debridement). Under fix and shift technique, stable fixation involved primary external fixator application or primary intramedullary nailing of the tibial fracture and immediate soft tissue cover involved septocutaneous shift, i.e., shifting of fasciocutaneous segments based on septocutaneous perforators. RESULTS Primary fracture union rate was 50% and reoperation rate (bone stimulating procedures) was 50%. Overall fracture union rate was 100%. The rate of malunion was 14% and deep infection was 16%. Failure of septocutaneous shift was 2.7%. There was no incidence of amputation. CONCLUSION Management of Gustilo Anderson III B open tibial fractures with "fix and shift" technique has resulted in better outcome in terms of skeletal factors (primary fracture union, overall union, and time for union and malunion) and soft tissue factors (wound healing, flap failure, access to secondary procedures, and esthetic appearance) when compared to standard methods adopted earlier. Hence, "fix and shift" could be recommended as one of the treatment modalities for open III B tibial fractures.
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Affiliation(s)
- P R Ramasamy
- Department of Orthopaedics, Kauvery Hospitals, Trichy, Tamil Nadu, India,Address for correspondence: Dr. P R Ramasamy, H.O.D, Department of Orthopaedics, Kauvery Hospitals, 16, Vishwanathapuram, Tennur, Trichy - 620 017, Tamil Nadu, India. E-mail:
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Abstract
Most tibia fractures in children can be treated nonoperatively. For fractures that do require surgery, however, the most common methods of management include plating or flexible nail insertion. Some fracture patterns, such as periphyseal fractures, fractures with bone and/or soft tissue loss, or fractures with delayed presentation, are not easily amenable to these techniques. Hexapod external fixators are especially helpful in these difficult cases. The purpose of this review is to discuss the principles of performing hexapod circular external fixation applied to pediatric tibia fractures. Some of the additional capabilities of the hexapod external fixator will also be highlighted.
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Fletcher MDA, Solomin LN. Definitive management of significant soft tissue loss associated with open diaphyseal fractures utilising circular external fixation without free tissue transfer, a comprehensive review of the literature and illustrative case. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2015; 25:65-75. [PMID: 24659455 DOI: 10.1007/s00590-014-1441-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Accepted: 03/12/2014] [Indexed: 11/24/2022]
Abstract
Accepted management of diaphyseal fractures associated with significant tissue loss is rigid intramedullary stabilisation with free or rotational musculocutaneous flap coverage. Circular external fixation is a powerful tool in the management of limb trauma and with recent advances has been developed to provide multiple techniques for which even massive tissue loss can be addressed without the need for free tissue transfer. Gradual and acute shortening, acute fracture deformation and gradual lengthening with restoration of deformity combined with distraction tissue histiogenesis can provide the surgeon with an array of options which can be precisely tailored to the particular personality of a severe open diaphyseal fracture.
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Sabharwal S, Louie KW, Reid JS. What's new in limb-lengthening and deformity correction. J Bone Joint Surg Am 2014; 96:1399-406. [PMID: 25143503 DOI: 10.2106/jbjs.n.00369] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Sanjeev Sabharwal
- Department of Orthopedics, Rutgers-New Jersey Medical School, 90 Bergen Street, Doctor's Office Center, Suite 7300, Newark, NJ 07103. E-mail address for S. Sabharwal:
| | - Kevin W Louie
- Department of Orthopedics, Rutgers-New Jersey Medical School, 90 Bergen Street, Doctor's Office Center, Suite 7300, Newark, NJ 07103. E-mail address for S. Sabharwal:
| | - J Spence Reid
- Department of Orthopedics, Rutgers-New Jersey Medical School, 90 Bergen Street, Doctor's Office Center, Suite 7300, Newark, NJ 07103. E-mail address for S. Sabharwal:
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