Acute Shortening for Open Tibial Fractures with Bone and Soft Tissue Defects: Systematic Review of Literature

INTRODUCTION

A large number (up to 24%) of tibial fractures are open injuries.^1,2 A significant proportion of open fractures are associated with extensive soft tissue damage (Gustilo-Anderson type IIIB).^3,4

It is recommended that definitive soft tissue closure or coverage should be achieved within 72 hours of injury if it cannot be performed at the time of debridement.^5–7 The use of soft tissue flaps is the most common method⁸ but there are situations when this strategy is not feasible. These include the inadvisability of prolonged surgical procedures in patients with polytrauma, or in patients who retain only a single vessel in the limb where the reconstruction undertaking is more complex. Massive damage to local soft tissues as well as an uncertain demarcation of the zone of the damage complicate matters further. Diabetes mellitus, immunodeficiency, malnutrition or a high degree of obesity are cautionary factors for the use of. One of the commonest reasons for not using flaps is the lack of a qualified plastic surgeon.^9–14

An alternative solution in such situations is the method of acute limb shortening.^9,15–18 The subsequent restoration of the length, alignment and shape of the limb is based on the principles of distraction histogenesis by Ilizarov; this was predicated on the general biological property of tissues responding to the dosed tension-stresses applied for growth and regeneration.^19–21

The purpose of this study was to review the published literature on the acute shortening method for the treatment of open fractures associated with extensive soft tissue defects (Flowchart 1).

MATERIALS AND METHODS

This literature review was carried out with guidance from the Preferred Reported Items for Systematic Reviews and Meta-analyses checklist (PRISMA).

RESULTS

The suitable articles were divided into two groups.

The first group—the use of the acute shortening method in acute trauma (Group I—Table 1).

The second group—the use of the acute shortening method for consequences of trauma such as infection (Group II—Table 2).

Acute shortening was used by six authors for acute trauma (Table 1:1, 2, 7, 11, 16, 17). Two authors used both acute shortening and a combination of acute and gradual shortening (Table 1:4, 8). Acute shortening and angulation were used by six authors (Table 1: 5, 6, 9, 12, 13, 15). The combination of acute shortening, angulation and rotation is mentioned by two authors (Table 1:6, 18).

Two authors (Table 2:6, 8) used acute shortening for cases which were consequent to complications of trauma. Another two authors used both acute shortening and a combination of acute and gradual shortening (Table 2:3, 4). Acute shortening and angulation were used by four authors (Table 2:1, 2, 7, 9).

In acute trauma, 11 authors used the Ilizarov apparatus to correct the created deformity (lengthening or elimination of angulation or both) (Table 1:1, 2, 4, 5, 6, 7, 8, 10, 15, 16, 17). The hexapod Taylor Spatial Frame was used by four authors (Table 1:12, 13, 14, 18). Three authors performed correction using various types of monolateral external fixation devices (Table 1:7, 8, 11).

For cases which were consequent to complications of trauma, the Ilizarov apparatus was used by six authors (Table 2:1, 3, 4, 5, 6, 8). Four authors used a Taylor Spatial Frame (Table 2:2, 3, 7, 9). Monolateral external fixation devices for deformity correction were used by two authors (Table 2:4, 6).

The maximum acute shortening carried out in a single stage was 3 cm by four authors. Further shortening was carried out gradually.^15,22–24 One author has stated that the limit of acute shortening is determined by the state of the soft tissues and the vascular status of the injured limb.²⁵ Other authors have proposed to control the safety of acute shortening by using intraoperative Doppler sonography and by monitoring blood flow in the distal vessels (a. dorsalis pedis and a. tibialis posterior), or with pulse oximetry on the big toe.^26,27

The size of the soft tissue defect closed by the methods of acute shortening, angulation, rotation singly or in combination varies greatly. In acute trauma, this was found to be from 1 × 2 cm (Table 1:4) to 12 × 20 cm (Table 1:6). For cases which were consequent to complications of trauma, the defect was from 2.5 × 2.5 cm (Table 2:2) to 10 × 15 cm (Table 2:1, 5).

The size of the bone defect ranged from 1 cm (Table 1:17) to 22 cm (Table 1:6) in the acute injury group and from 1 cm (Table 2:8) to 14 cm (Table 2:3) in the group of trauma consequences. The total fixation time in the device (inclusive of primary fixation, deformity correction and consolidation) in acute trauma ranged from 2 to 3 months (Table 1:4, 5) to 53 months (Table 1:5). For those cases that were complications of trauma, this ranged from 3 months (Table 2:8) to 16 months (Table 2:6). In both groups, the authors noted a decrease in the need for microsurgical intervention, namely, free flaps when using the acute shortening method to close extensive soft tissue defects. However, quantitative indicators are not provided.

All authors write of “complete or almost complete restoration of limb function with minimal shortening”. Some (Table 1:3, 4, 10, 18; Table 2:3, 4, 5, 6, 8) used the Paley classification (ASAMI) to evaluate the result;^28,29 others (Table 1:2, 11, 16) used Chen criteria.³⁰ One author (Table 1:7) used the Puno rating scale.³¹ Some researchers (Table 2:1, 2) considered return to work as a criterion.

In both groups, the following complications were more common during the treatment:

• Fractures of the transosseous elements and inflammation of soft tissues in the region of transosseous elements ranged from 0 to 100% in the group of acute trauma and from 0 to 75% in the group from consequences of trauma.

• Contractures and deformities in the adjacent joints range from 0 to 33% for acute trauma and from 0 to 50% for the consequences of trauma.

• Refractures ranged from 0 to 31% in the group of acute trauma and from 0 to 6% in the group of consequences of trauma.

• Various infectious complications ranged from 0 to 33% for acute trauma and 0 to 13% in the group of trauma consequences.

DISCUSSION

An analysis of the literature has shown that the use of the acute limb shortening method for closing a soft tissue defect, with subsequent reconstruction of the shape of the limb with an external fixation device, allows for primary wound closure and reduces the need for microsurgical procedures significantly.^9,11–13,16 The review has shown that there are many different terms for the same or similar solution to the problem of closing a soft tissue defect. These include acute shortening, primary shortening, acute deformation, angular shortening, intentional temporary deformation, intentional deformation, intentional temporary shortening and deformation, shortening with angulation and rotation, etc.^{9,11,12,14,18,24,26,27,32–34} We propose the above-mentioned terms can be replaced by one term, “Artificial Deformity Creation” or ADCr, which can include techniques of shortening, angulation and rotation either separately or in combination.

There are aspects of this method that warrant further research. An important unresolved issue is the maximum size and shape of a soft tissue defect when effective use of ADCr is possible without the need for supplementary microsurgery in the form of free flaps. No author has stipulated what this should be apart from reporting on the maximum defect closed in their work. As important is the limit of acute shortening, angulation and rotation at which the soft tissue defect is closed in a single stage. Four authors^15,22–24 have suggested, for a one-step acute shortening, a specific value of 3 cm. Three authors^25–27 propose to base the decision on the state of soft tissues and the vascular status of the injured limb, as well as on the results of pulse oximetry and intraoperative Doppler sonography. According to Atbasi et al. and Hernández-Irizarry et al., the criterion for the limit of acute shortening is the beginning of changes in Doppler and pulse oximetry. For postoperative control, digital subtraction angiography was performed on the 7th day, and a computed tomography with angiography 2 years later.²⁶ The authors describe the ability of the arteries to adapt to the new length of the limb. Variants to this aspect with angulation, rotation or translation have not yet been studied.

The optimal components of the artificially created deformity in terms of type and size so as to match the location, shape and size of the soft tissue defect have not been determined. With the exception that angulation is performed towards the soft tissue defect especially for unilateral defects, none of the authors give specific values. Lahoti et al.¹² speaks about the absence of an algorithm for creating angulation which the lower leg can endure without consequences and complications. There are several factors affecting the degree of deformation created including the location of the fracture, soft tissue oedema, fracture geometry and other associated complications.

The need to determine the type and size of the components of the artificially created deformation depends on the localization, shape and size of the soft tissue defect. In turn, the mounting of the external fixation device so as to complement the creation of deformity will depend on where the pins and wires are inserted and the positioning of the reference and corresponding rings.

The proposal to supplement an acute shortening with chronic or gradual^15,22–24 deserves attention. In acute trauma, the gradual shortening is limited in time to 72 hours as definitive closure of the wound should be accomplished in that time in order to reduce the risk of deep infection.^5,7 The method of using this combination of methods may be considered for cases of the consequences of trauma and reconstructive interventions, for example, after necrosis of free flaps, or for chronic wounds with contraindications to traditional plastic methods, etc.

The best device for correcting deformities created by ADCr, according to most authors, is the Ilizarov apparatus.^{8,14–16,18,22–24,26,32,35–39} Acute shortening alone produces a simple one-plane deformity (the shortening) whereas additional angulation gives a two-plane two-component deformity, viz., shortening and angulation in two planes (oblique-plane angulation). To correct each component of the deformity using Ilizarov method, oblique plane hinges or sequential positioning of hinges in two separate planes with partial reassembly of the apparatus is needed. Each stage of the correction requires X-ray confirmation of its effectiveness.^40,41 If a rotational component is added to the axial shortening and angulation, then a complex multi-component multi-plane deformity is created. According to some reports, each additional component of the deformity can potentially reduce the simplicity and accuracy of correction by the Ilizarov apparatus; from 0% for complex (multi-plane multicomponent) deformities to 79% for simple deformities.^41,42 One of the solutions to the problem of correcting complex deformities which are created after closing a soft tissue defect using the ADCr method is the use of circular fixator hexapods. The Taylor spatial frame (TSF) was the only hexapod system described in the literature review.^{11–13,15,27,43,44} The uses of the TSF for the correction of temporary deformities created for closing soft tissue defects have the following disadvantages:

• TSF struts are not compatible with other types and manufacturer of the rings except that designed specifically for TSF struts.

• The difficulty of fixing struts to stabilizing and “dummy” rings.

• Some difficulty in using the software with a non-orthogonal position of the reference ring.

At the present time, there is a need to use both the Ilizarov apparatus and that of circular fixator hexapods, despite both operating on fundamentally different platforms, for the creation of temporary limb deformities such as to enable wound closure in open fractures, and for their use in resolving these deformities.

Further research into acute limb shortening will eventually produce an algorithm for the use of ADCr. This will include indications and contraindications, equipment type, the optimum technique for performing each of the stages, postoperative management and the prevention of errors and complications. Such an algorithm should improve the results of treatment of these patients.

CONCLUSION

The method of creating a temporary artificial deformity (ADCr) is an alternative for situations where closure of a soft tissue defect with a free or rotated soft tissue flap is not possible. A ring external fixator is the optimal device for correcting the limb deformity that is created. Further research and clinical use of the ADCr method will enable an algorithm to be developed to establish the optimum indications, devices, technique and after-care for this strategy.

ORCID

Konstantins Plotnikovs https://orcid.org/0000-0002-6631-9343
Jevgenijs Movcans https://orcid.org/0000-0003-0561-4696
Leonid Solomin https://orcid.org/0000-0003-3705-3280

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