On the timing of soft-tissue reconstruction for open fractures of the lower leg

Abstract The timing of soft-tissue reconstruction for severe open fractures of the lower leg is considered crucial to the later outcome, and yet pertinent publications are few. The purpose of this study was to add some based on evidence arguments for the choice of the most adequate timing in the management of these injuries. Twenty-nine consecutive open fractures of the tibia, including 24 grade 3B and 5 grade 3C fractures, were treated using a protocol of immediate debridement, early definitive skeletal stabilisation and early soft-tissue reconstruction. Fifteen lower legs were reconstructed after a mean delay of 4.4 days (range 1–9 days), while 14 lower legs were reconstructed immediately, i.e. as an emergency procedure on the day of admission. Both groups were comparable for sex, age, type of trauma, associated general injuries, type of fracture, associated arterial lesion, associated tendon rupture, type of soft-tissue reconstruction and duration of follow-up. All patients were reviewed at a mean follow-up of 47 months (range 15–89 months). In the delayed reconstruction group the time to full, unprotected weight-bearing (P = 0.0021), the time to definitive union (P = 0.0049), the number of reoperations (P = 0.0001) and the infection rate (P = 0.0374) were significantly higher. The data suggest that immediate reconstruction is, the general condition of the patient permitting, the timing of choice for soft-tissue coverage.

[1]  Jones Re,et al.  Primary versus delayed soft tissue coverage for severe open tibial fractures. A comparison of results. , 1983 .

[2]  M. Godina.  Early Microsurgical Reconstruction of Complex Trauma of the Extremities , 1986, Plastic and reconstructive surgery.

[3]  Y. Tropet,et al.  [Emergency cover of open fractures of the leg. Apropos of a series of 24 clinical cases]. , 1994, Annales de chirurgie plastique et esthetique.

[4]  P. Worlock,et al.  The prevention of infection in open fractures: an experimental study of the effect of fracture stability. , 1994, Injury.

[5]  R. Ketterl,et al.  [Reducing the risk of infection by use of an unreamed intramedullary nail in open tibial fractures]. , 1994, Zentralblatt fur Chirurgie.

[6]  H S Byrd,et al.  Management of Open Tibial Fractures , 1985, Plastic and reconstructive surgery.

[7]  A. Moss,et al.  Severe open fractures of the tibia , 1988, British medical journal.

[8]  P. Tornetta,et al.  Treatment of grade-IIIb open tibial fractures. A prospective randomised comparison of external fixation and non-reamed locked nailing. , 1994, The Journal of bone and joint surgery. British volume.

[9]  R. Ganz,et al.  Amputation versus reconstruction in traumatic defects of the leg: outcome and costs. , 1996, Journal of orthopaedic trauma.

[10]  C Krettek,et al.  [Intramedullary nailing of open fractures]. , 1996, Der Orthopade.

[11]  M. Rettig,et al.  Interobserver Reliability in the Gustilo and Anderson Classification of Open Fractures , 1993, Journal of orthopaedic trauma.

[12]  R. Gustilo,et al.  OTD classic article review - Gustillo RB, Anderson JT (1976) Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses , 2002, The Journal of bone and joint surgery. American volume.

[13]  R. Gustilo,et al.  The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. , 1991, The Journal of bone and joint surgery. American volume.

[14]  J. Kellam,et al.  Plate Fixation of Open Fractures of the Tibia , 1988, The Journal of bone and joint surgery. British volume.

[15]  M. Itoman,et al.  Contributing factors influencing type III open tibial fractures. , 1995, The Journal of trauma.

[16]  R. Ger.  Muscle transposition for treatment and prevention of chronic post-traumatic osteomyelitis of the tibia. , 1977, The Journal of bone and joint surgery. American volume.

[17]  C. Krettek,et al.  A new solid unreamed tibial nail for shaft fractures with severe soft tissue injury. , 1993, Injury.

[18]  R. Gustilo.  Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. , 1995, The Journal of bone and joint surgery. American volume.

[19]  J. Webb,et al.  Complications of external fixation of open fractures of the tibia. , 1987, Injury.

[20]  T. Heinz,et al.  [Primary stabilization of open fractures of the lower extremity with the interlocking nail--the results of a study of 91 patients]. , 1990, Aktuelle Traumatologie.

[21]  R. Schwartzberg,et al.  A sequential protocol for management of severe open tibial fractures. , 1995, Clinical orthopaedics and related research.

[22]  R. Jones,et al.  Primary versus delayed soft tissue coverage for severe open tibial fractures. A comparison of results. , 1983, Clinical orthopaedics and related research.