ABSTRACT
BACKGROUND: The treatment of Gustilo Anderson type 3B open fracture tibia is a major challenge and it needs aggressive debridement, adequate fixation, and early flap coverage of soft tissue defect. The flaps could be either nonmicrovascular which are technically less demanding or microvascular which has steep learning curve and available only in few centers. An orthopedic surgeon with basic knowledge of the local vascular anatomy required to harvest an appropriate local or regional flap will be able to manage a vast majority of open fracture tibia, leaving the very few complicated cases needing a free microvascular flap to be referred to specialized tertiary center. This logical approach to the common problem will also lessen the burden on the higher tertiary centers. We report a retrospective study of open fractures of leg treated by nonmicrovascular flaps to analyze (1) the role of nonmicrovascular flap coverage in type 3B open tibial fractures; (2) to suggest a simple algorithm of different nonmicrovascular flaps in different zones and compartment of the leg, and to (3) analyze the final outcome with regards to time taken for union and complications. MATERIALS AND METHODS: One hundered and fifty one cases of Gustilo Anderson type 3B open fracture tibia which needed flap cover for soft tissue injury were included in the study. Ninety four cases were treated in acute stage by debridement; fracture fixation and early flap cover within 10 days. Thirty-eight cases were treated between 10 days to 6 weeks in subacute stage. The rest 19 cases were treated in chronic stage after 6 weeks. The soft tissue defect was treated by various nonmicrovascular flaps depending on the location of the defect. RESULTS: All 151 cases were followed till the raw areas were covered. In seven cases secondary flaps were required when the primary flaps failed either totally or partially. Ten patients underwent amputation. Twenty-two patients were lost to followup after the wound coverage. Out of the remaining 119 patients, 76 achieved primary acceptable union and 43 patients went into delayed or nonunion. These 43 patients needed secondary reconstructive surgery for fracture union. CONCLUSION: open fracture of the tibia which needs flap coverage should be treated with high priority of radical early debridement, rigid fixation, and early flap coverage. A majority of these wounds can be satisfactorily covered with local or regional nonmicrovascular flaps.
ABSTRACT
Compound fractures involving the leg, exposing the tibia or other poorly vascularised tissues such as tendons still pose a big problem for a reconstructive surgeon and they need early plastic surgical intervention. A prospective study of 10 cases of moderate sized defects in the leg exposing the tibia due to trauma was undertaken between January 2003 and August 2004 with an average follow up of 12 months. Pre-operative identification of the perforator around the wound was meticulously performed using hand held Doppler equipment. Most of the wounds were covered within the first 3-5 days of the injury. All the flaps were raised from the anterior or the lateral compartment of the leg to cover the adjacent tibial bone. Five flaps were raised as proximally based and five flaps were raised as distally based flaps. No flap was raised and advanced in a V-Y fashion. Split skin grafting was required in all cases to cover the secondary raw area created following the flap elevation. All flaps survived and served the purpose. In one case we encountered a deep seated infection resulting in sinus formation needing further debridement in the form of sequestrectomy. In conclusion, the authors believe that the perforator based flap cover described here is simple, safe and a versatile procedure for a trauma surgeon to cover the moderate sized traumatic pre-tibial wounds exposing the bone and the tendons.
