Strategies in Trauma and Limb Reconstruction

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VOLUME 13 , ISSUE 3 ( November, 2018 ) > List of Articles

Original Article

Transverse debridement and acute shortening followed by distraction histogenesis in the treatment of open tibial fractures with bone and soft tissue loss

Saif Salih, Edward Mills, Jonathan McGregor-Riley, Mick Dennison, Simon Royston

Keywords : Open fractures, Tibia, Circular frame, Ilizarov frame, Soft tissue flap, Limb reconstruction, Distraction histogenesis, Deformity correction

Citation Information : Salih S, Mills E, McGregor-Riley J, Dennison M, Royston S. Transverse debridement and acute shortening followed by distraction histogenesis in the treatment of open tibial fractures with bone and soft tissue loss. 2018; 13 (3):129-135.

DOI: 10.1007/s11751-018-0316-z

License: CC BY-NC-SA 4.0

Published Online: 01-06-2016

Copyright Statement:  Copyright © 2018; The Author(s).


Abstract

This retrospective case series evaluates the technique of transverse debridement, acute shortening and subsequent distraction histogenesis in the management of open tibial fractures with bone and soft tissue loss, thereby avoiding the need for a soft tissue flap to cover the wound. Thirty-one patients with Gustilo grade III open tibial fractures between 2001 and 2011 were initially managed with transverse wound extensions, debridement and shortening to provide bony apposition and allowing primary wound closure without tension, or coverage with mobilization of soft tissue and split skin graft. Temporary monolateral external fixation was used to allow soft tissues resuscitation, followed by Ilizarov frame for definitive fracture stabilization. Leg length discrepancy was corrected by corticotomy and distraction histogenesis. Union was evaluated radiologically and clinically. Patients’ mean age was 37.3 years (18.3–59.3). Mean bone defect was 3.2 cm (1–8 cm). Mean time to union was 40.1 weeks (12.6–80.7 weeks), and median frame index was 75 days/cm. Median lengthening index (time in frame after corticotomy for lengthening) was 63 days/cm. Mean clinic follow-up was 79 weeks (23–174). Six patients had a total of seven complications. Four patients re-fractured after frame removal, one of whom required a second frame. Two patients required a second frame for correction of residual deformity, and one patient developed a stiff non-union which united following a second frame. There were no cases of deep infection. Acute shortening followed by distraction histogenesis is a safe method for the acute treatment of open tibial fractures with bone and soft tissue loss. This method also avoids the cost, logistical issues and morbidity associated with the use of local or free-tissue transfer flaps and has a low rate of serious complications despite the injury severity.


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  1. Papakostidis C, Kanakaris NK, Pretel J et al (2011) Prevalence of complications of open tibial shaft fractures stratified as per the Gustilo-Anderson classification. Injury 42:1408-1415. https://doi.org/10.1016/j.injury.2011.10.015
  2. Nanchahal J, Nayagam D et al (2009) The standards for the management of open fractures of the lower limb, 1st edn. Royal Society of Medicine Press Ltd, London
  3. Gopal S, Majumder S, Batchelor AG et al (2000) Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Jt Surg Br 82:959-966
  4. Townley WA, Nguyen DQA, Rooker JC et al (2010) Management of open tibial fractures: a regional experience. Ann R Coll Surg Engl 92:693-696. https://doi.org/10.1308/003588410X12699663904592
  5. Parrett BM, Matros E, Pribaz JJ, Orgill DP (2006) Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures. Plast Reconstr Surg 117:1315-1322. https://doi.org/10.1097/01.prs.0000204959.18136.36 (discussion 1323-1324)
  6. Schlatterer DR, Hirschfeld AG, Webb LX (2015) Negative pressure wound therapy in grade IIIB tibial fractures: fewer infections and fewer flap procedures? Clin Orthop Relat Res 473:1802-1811. https://doi.org/10.1007/s11999-015-4140-1
  7. Sen C, Kocaoglu M, Eralp L et al (2004) Bifocal compression- distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: a report of 24 cases. J Orthop Trauma 18:150-157
  8. Nho SJ, Helfet DL, Rozbruch SR (2006) Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor spatial frame. J Orthop Trauma 20:419-424
  9. El-Rosasy MA (2007) Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia. J Bone Jt Surg Br 89:80-88. https://doi.org/10.1302/0301-620X.89B1.17595
  10. Saleh M, Rees A (1995) Bifocal surgery for deformity and bone loss after lower-limb fractures. Comparison of bone-transport and compression-distraction methods. J Bone Jt Surg Br 77:429-434
  11. Saleh M, Yang L, Sims M (1999) Limb reconstruction after high energy trauma. Br Med Bull 55:870-884
  12. Parmaksizoglu F, Koprulu AS, Unal MB, Cansu E (2010) Early or delayed limb lengthening after acute shortening in the treatment of traumatic below-knee amputations and Gustilo and Anderson type IIIC open tibial fractures: the results of a case series. J Bone Jt Surg Br 92:1563-1567. https://doi.org/10.1302/0301-620X.92B11.23500
  13. (2014) BOA Standards for Trauma (BOASTs). In: British Orthopaedic Association. https://www.boa.ac.uk/publications/boa-standards-trauma-boasts/. Accessed 7 May 2018
  14. Paley D (1990) Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res 250:81-104
  15. Hallock GG (1991) Complications of 100 consecutive local fasciocutaneous flaps. Plast Reconstr Surg 88:264-268
  16. Burns TC, Stinner DJ, Possley DR et al (2010) Does the zone of injury in combat-related Type III open tibia fractures preclude the use of local soft tissue coverage? J Orthop Trauma 24:697-703. https://doi.org/10.1097/BOT.0b013e3181d048b8
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