Session IX - Tibia
Fix and Flap, the Radical Treatment of Severe Open Fractures of the Tibia
Siva Gopal, FRCS; Sanjib Majumder, FRCS; Andrew Batchelor, FRCS; Piet Deboer, FRCS; Malcolm Smith, MD, FRCS, St. James' University Hospital, Leeds, England; York District Hospital, York, England
Purpose: to determine the effectiveness of a radical approach to the treatment of 3B and 3C open fractures of the tibia with aggressive debridement, bony stabilisation and early muscle flap cover.
Methods: We retrospectively reviewed the records of 56 patients in whom we had treated a serious open fracture of the tibia over a five-year period 1991-1996. Full data in 12 additional patients was not available. All patients had received the acute care of a 3B or 3C open tibial fracture from our combined orthopaedic and plastic surgical service. Fracture treatment included radical wound debridement outside the zone of injury, skeletal stabilisation with an external fixator (principally before 1993) or an internal fixation device, depending on fracture anatomy and early soft tissue cover with a vascularised muscle flap (usually a free microvascular transfer with additional split-thickness skin grafting.) All patients were followed clinically and radiographically to fracture union (callus in two planes on x-ray and painless weightbearing) or 1 year.
Results: Fifty-six patients (57 fractures) were reviewed, 47 were male and 9 female, mean age 49 (3-89). There were 54, 3B injuries and 3, 3C; the OTA classification included 6 site 41, 23 site 42, 26 site 43 and 2 site 44. Twelve had bony stabilisation with an external fixation device and 45 with an internal fixation device (AO unreamed tibial nail or plates and screws according to the fracture anatomy). There were 6 pedicled flaps (gastrocnemius or soleus) and 51 free muscle flaps (41 latissimus dorsi, 5 gracilis and 5 rectus abdominis). On 22 occasions a single acute procedure was performed, in a further 11 the soft tissue cover was completed within 2 days, in a further 7 within 3 days and within a week in a further 11. In 6 patients the soft tissue cover was delayed after 1 week (max 18 days) because of extreme clinical circumstances. Two of the 3C injuries had an immediate vascular reconstruction and flap procedure; in the other the flap was delayed 48 hours after revascularisation. All were salvaged with excellent function. In the internal fixation group 34/45 united at a mean of 27.6 weeks. Eleven (25%) required an additional bone-stimulating procedure to achieve bony union. In the external fixation group 5/12 united at a mean of 14 weeks but 7/12 (58%) failed to unite and required an additional bony procedure. There were 4 subsequent amputations, two early, within 2 weeks (1 primary flap failure in a 89-year-old arteriopath and 1 serious acute infection) and 2 electively, over a year after injury, producing an overall functional limb salvage rate of 93%. The flap failure rate was 2/56 (3.6%) one requiring amputation and one rescued with a further successful flap. The superficial infection rate was 6/56 (11%), all resolving with antibiotics and local skin graft care. The deep (bony) infection rate was 5/56 (9%). One was amputated early, while three had received late flaps (after 1 week). Two bony infections were related to external fixator pins and 1 to a recognised inadequate, initial bony debridement.
Discussion and Conclusion: We believe that an aggressive combined orthopaedic and plastic surgical approach to these very severe injuries is the gold standard. Our figures suggest that immediate internal fixation and healthy soft tissue cover with a muscle flap is safe and that delayed cover and poorer skeletal stability with an external fixator provide the main source of problems. However, our combined service is unusual; we suggest that initial debridement, external fixation and referral is the safe procedure in the majority of situations.