Emergency Soft Tissue Reconstruction Algorithm in Patients With Open Tibia Fractures

Lower Third Leg Trauma Management Algorithm; Kasr Alainy Protocol

Background

Soft tissue defects in the lower third of the leg present significant challenges for surgeons. Despite various options available for soft tissue coverage, selecting the most suitable option is limited by potential complications. In response to this challenge, some surgeons have sought to develop algorithms to guide decision-making in the management of lower leg trauma.

Methods

This prospective observational cross-sectional study included 53 patients with traumatic injuries to the lower third leg and ankle regions. Each patient underwent a management plan based on our proposed algorithm, which incorporated the utilization of negative pressure wound therapy and dermal substitutes. Outcomes were assessed in terms of the ability to achieve complete coverage, complication rates, duration of hospital stay, and return to normal daily activity.

Results

The proposed algorithm proved to be comprehensive and easily applicable, achieving complete coverage in 98.1% of cases. The mean duration for definitive coverage was 21.89 ± 12.84 days, and the majority of cases (81.1%) returned to normal daily activity within a mean duration of 60.69 ± 56.7 days. The use of dermal substitutes resulted in achieving coverage in wounds with exposed structures, with favorable outcomes in cases with a mean size of 11.39 ± 10.05 cm².

Conclusions

Our algorithm provides a safe and effective approach to manage traumatic defects of the lower third leg and ankle, considering the patient's general condition and the complexity of the wound. Proper utilization of dermal substitutes and negative pressure wound therapy is emphasized in the algorithm.

The Continued Impact of Godina's Principles: Outcomes of Flap Coverage as a Function of Time After Definitive Fixation of Open Lower Extremity Fractures

BACKGROUND

 Early soft tissue coverage of open lower extremity fractures within 72 hours of injury leads to improved outcomes. Little is known about outcomes when definitive fixation is completed first. The purpose of this study is to quantify postoperative outcomes when soft tissue reconstruction is delayed until after definitive open reduction and internal fixation (ORIF) is completed.

METHODS

 An insurance claims database was queried for all patients with open lower extremity fractures between 2010 and 2020 who underwent free or axial flap reconstruction after ORIF. This cohort was stratified into three groups: reconstruction performed 0 to 3, 3 to 7, and 7+ days after ORIF. The primary outcome was 90-day complication and reoperation rates. Bivariate and multivariable regression of all-cause complications and reoperations was evaluated for time to flap as a risk factor.

RESULTS

 A total of 863 patients with open lower extremity fractures underwent ORIF prior to flap soft tissue reconstruction. In total, 145 (16.8%), 162 (18.8%), and 556 (64.4%) patients underwent soft tissue reconstruction 0 to 3 days, 4 to 7 days, and 7+ days after ORIF, respectively. The 90-day complication rate of surgical site infections ( SSI; 16.6%, 16,7%, 28.8%; p = 0.001) and acute osteomyelitis (5.5%, 6.2%, 27.7%; p < 0.001) increased with delayed soft tissue reconstruction. Irrigation and debridement rates were directly related to time from ORIF to flap (33.8%, 51.9%, 61.9%; p < 0.001). Hardware removal rates were significantly higher with delayed treatment (10.3%, 9.3%, 39.3%; p < 0.001). The 0 to 3 day (odds ratio [OR] = 0.22; 95% confidence interval [CI]: 0.15, 0.32) and 4 to 7 day (OR = 0.26; 95% CI: 0.17, 0.40) groups showed protective factors against all-cause complications after bivariate and multivariate regression.

CONCLUSION

 Early soft tissue reconstruction of open lower extremity fractures performed within 7 days of ORIF reduces complication rates and reduces the variability of complication rates including SSIs, acute osteomyelitis, and hardware failure.

Management of Gustilo-Anderson IIIB open tibial fractures in adults-a systematic review

INTRODUCTION

Open tibial fractures are the most common open long bone fracture, despite this, the management of these complex injuries still remains a topic of discussion amongst orthopaedic surgeons.

SOURCES OF DATA

We searched the EMBASE, MEDLINE and Google Scholar and a systematic review of 7500 articles, leaving 23 after exclusion criteria were applied, in order to analyse the management of open tibial fractures.

AREAS OF AGREEMENT AND CONTROVERSY

Infection was noted to be the most significant concern amongst authors, with definitive external fixation having a high rate of superficial pin-site infection and internal fixation having a high deep infection rate.

GROWING POINTS

It is essential to have a combined ortho-plastic approach to the management of these fractures as muscle flaps were the most common form of soft tissue coverage.

AREAS TIMELY FOR DEVELOPING RESEARCH

A national pragmatic trial into the management of open tibial fractures is required looking at fixation methods and soft tissue coverage, with at least a 2-year follow-up in order to ascertain the most appropriate management of these fractures and patient-related outcomes.

Evaluation of pedicled flaps for type IIIB open fractures of the tibia at a tertiary care center

BACKGROUND

Soft tissue coverage plays a vital role in replacing the vascularity of the underlying bone in Gustilo type IIIB fractures. The aim of this article was to evaluate the feasibility of local pedicled flaps in type IIIB fractures at a tertiary care center.

METHODS

We included all cases of open Gustilo-Anderson type IIIB fractures of the tibia treated with local flap coverage from January 2017 to February 2019. We carried out a retrospective analysis to investigate the relationships of complications, hospital stay, and cost-effectiveness with the choice of flap, infective foci, site and size of the defect, and type of fixation.

RESULTS

Out of 138 Gustilo type IIIB fractures analyzed in our study, 27 cases had complications, of which 19 (13.76%) involved flap necrosis, four (2.89%) were infections, three (2.17%) involved partial necrosis, and one (0.72%) was related to bone spur development. Flap complications showed a statistically significant association with the perforator flap category (propeller flaps in particular) (P=0.001). Flap necrosis showed a significant positive correlation with cases treated within 3 weeks after trauma (P=0.046). A significant positive correlation was also found between defect size and the duration of hospital stay (P=0.03).

CONCLUSIONS

Although local flaps are harvested from the same leg that underwent trauma, their success rate is at least as high as microvascular flaps as reported from other centers. Amidst the local flaps, complications were predominantly associated with perforator flaps.

Degloving Soft Tissue Injuries of the Extremity: Characterization, Categorization, Outcomes, and Management

Background:

We aimed to identify degloving soft tissue injury (DSTI) patient characteristics, injury and reconstruction patterns, and factors affecting outcomes of DSTI injuries to propose a reconstructive protocol for these injuries.

Methods:

A retrospective analysis of consecutive patients with DSTIs of an extremity over a 22-year period has been done.

Results:

188 patients with 201 extremity DSTIs were included. Mean patient age was 37 years, with follow-up of 19.6 months. In total, 96% of injuries were related to motor vehicles or machinery, and 74.6% of DSTIs had injuries to structures deep to skin/subcutis. The avulsed tissue was utilized in reconstruction in 71.6% of cases and 86.8% of these experienced some loss of the used avulsed tissues. Of the total cases, 82% employed skin grafting in reconstruction. Dermal regeneration templates were used in 32% of patients. An estimated 86.5% of patients had negative pressure wound therapy utilized. Of the injured patients, 21% required flap reconstruction and 22% required some form of amputation. Age, body mass index, and tobacco use did not increase perioperative complications or amputation. DSTIs with injury to structures deep to skin/subcutis were associated with negative pressure wound therapy use (P = 0.02). DSTIs with underlying fractures required more procedures to reach reconstruction completion (P = 0.008), had more minor (P = 0.49) and major perioperative complications (P = 0.001), longer time to heal (P = 0.002), and increased need for amputation (P = 0.02).

Conclusions:

Factors affecting the reconstructive management and outcome of DSTIs include injury to structures deep to the skin/subcutis. We categorized DSTIs based on the level of injury and proposed a systematic approach to extremity DSTIs which may be utilized by plastic surgeons and other surgical services to manage these complex injuries.

Single-stage "Fix and Flap" gives Good Outcomes in Grade 3B/C Open Tibial Fractures: A Prospective Study

Introduction:

Grade 3B/C open tibial fractures with grossly contaminated degloving injuries have poor outcomes, with or without vascular injuries. Treatment decision oscillates between limb salvage and amputation. The standard protocol of repeated debridement and delayed wound cover is a challenge in developing countries due to overcrowded emergencies and limited operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate wound cover as an aggressive modality of treatment.

Material and Methods:

Thirty-three patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent debridement, external fixation and immediate wound cover with free distant/local rotational muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures. Intra-articular fractures were excluded. Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes.

Results:

Wound cover was achieved with 24 distant free muscle flaps, four local rotational muscle flaps and five fasciocutaneous flaps. All fractures united with an average time to union of 40.3 weeks (16-88). Fifteen patients (45.4%) underwent only a single major surgery using primary definitive external fixation. Deep infection was seen in four patients (12.1%). Nineteen patients had excellent to good outcomes, six were fair, and eight were poor.

Conclusion:

“Fix and Flap” in the same sitting, using immediate wound cover and external fixation, has given good results in our hands despite the delayed presentation, the neurovascular deficit and the degloving injury. This may be a better management strategy in overcrowded tertiary care centres of developing countries, with a single surgical procedure in almost half the cases.