Ankle fractures malreduction rate and its causes in two Brazilian tertiary training hospitals.

INTRODUCTION: Ankle fractures are one of the most frequent injuries managed by any trauma surgeon. Literature has shown that adequate reduction is of utmost importance to achieve satisfactory functional outcomes. However, malreduction rates remain high worldwide. The objective of the present study is to evaluate the quality of ankle fracture reduction in two major trauma centers in a large Brazilian city and to analyze the factors associated with malreduction METHODS: Epidemiologic data of 382 patients (189 men; 193 women) aged between 7 and 87 years who underwent osteosynthesis of the ankle in two trauma centers in a large Brazilian city. Electronic clinical records, preoperative and immediate postoperative radiographs in anteroposterior (AP), lateral and mortise views were evaluated. Pettrone's criteria were used to evaluate the quality of ankle fractures reduction. All radiographs were independently evaluated by two foot and ankle senior surgeons RESULTS: Overall, malreduction rate was 22.2%. Forty-seven (55.2%) fractures classified as malreduced had medial malleolar displacement The results showed three factors that significantly affected the quality of reduction (p<0.05), patients over 60 years, open fractures and fracture-dislocations. Patients aged over 60 years were twice more likely to have poor reduction of ankle fractures than younger ones. The risk of poor fracture reduction among those individuals with open fractures is 2.15 times greater than among patients with closed injuries. Fracture-dislocation imposed a 2.7 higher risk for malreduction DISCUSSION: We found a malreduction rate below most series previously published. Further results agree with the literature. Elderly people aged over 60 years, fracture dislocations and open fractures are associated with worse results, influencing the quality of the reduction, clinical outcomes, and the development of post-traumatic arthrosis CONCLUSION: Ankle fractures malreduction are associated with higher age, open fractures, and fracture-dislocations.

Osteosynthesis of a patellar fracture with repair of the knee extensor mechanism: Case report.

Patella fractures correspond to 1 % of all fractures. In recent decades, the role of the patella in increasing the lever arm of the quadriceps has been well defined. Surgical treatment is indicated for open fractures, those that compromise the function of the extensor mechanism, those with a joint gap >5 mm and/or joint incongruity >3 mm, a group that corresponds to around 30 % of the total. Anatomical reduction and stabilization with various types of modified tension bands is the most frequently used procedure. Biomechanical studies have shown that stabilization through the use of a tension band replacing the Kirchner wires with cannulated screws presents adequate resistance to fracture displacement and provides greater stability than the classic configuration, maintaining the theoretical principle of converting the forces of anterior tension of the patella generated by the quadriceps in compression at the level of the articular surface. A case of a patient who required reduction and osteosynthesis of an exposed patella fracture, associated with an extensor mechanism lesion, is presented. Clinical and radiographic characteristics of the patient and the resolution of the case are described.

Type of antibiotic but not the duration of prophylaxis correlates with rates of fracture-related infection.

PURPOSE: The issue of optimal prophylactic antibiotic administration for closed and open fracture surgeries remains controversial. The purpose of this study was to assess the role of type and duration longer than 48 h of antibiotic prophylaxis on the rates of fracture-related infection (FRI). METHODS: This is a single-center, prospective observational cohort study carried out with patients undergoing surgery for implants insertion to fracture stability. Risk estimates were calculated on the variables associated with factors for FRI and reported as a prevalence ratio (PR) with respect to the 95% confidence interval (CI). RESULTS: Overall, 132 patients were analyzed. The global rate of FRI was 15.9% (21/132), with open and closed fractures accounting for 30.5% (11/36) and 10.4% (10/96), respectively. The FRI rates in patients undergoing orthopedic surgery for fracture stabilization who received prophylactic antibiotic for up to and longer than 48 h were 8.9% and 26.4%, respectively. This difference did not reach statistical significance (prevalence ratio [PR] = 2.6, 95% confidence interval [95% CI]: 0.9-7.3. p = 0.063). CONCLUSIONS: Duration of antibiotic prophylaxis for surgical orthopedic fractures was not correlated with rates of FRI.

Aplicación clínica de la Impresión 3D en el manejo de fracturas abiertas de tibia: Nuevas fronteras en Traumatología. Estudio experimental / Clinical application of 3D Printing in open tibial fractures management: New frontiers of Orthopaedics. An experimental study

La Impresión 3D es una tecnología emergente utilizada cada vez más en medicina. En los países en vías de desarrollo, donde las fracturas por motocicletas y automóviles se encuentran en aumento, la disponibilidad de fijadores externos para el manejo de fracturas abiertas es un problema frecuente. La impresión 3D puede ser una alternativa económica e igualmente confiable a los dispositivos tradicionales elaborados con acero o titanio. El objetivo de este trabajo es mostrar la experiencia con el uso de Impresión 3D y su aplicación en el manejo clínico de fracturas abiertas diafisiarias de tibia. Se realizó un estudio pre-experimental y prospectivo. Se incluyeron 14 pacientes con fracturas de tibia AO/ASIF 42A, 42B y 42C tratados con un fijador externo con rótulas elaboradas con Impresión 3D como medida de Control de Daños en Ortopedia desde su ingreso hasta su resolución definitiva. Todos los pacientes fueron de sexo masculino, con un promedio de edad 23,16 años con 50% entre 20-23 años. Las fracturas fueron 42,85% tipo 42A, 37,71% 42B y 21,42% 42C. El 78,57% de las fracturas fueron ocasionadas por motocicletas: 57,14% grado II según Gustilo y Anderson, un 28,57% grado III y 14,28% grado I. El 37,71% eran politraumatizados. Ninguno de los pacientes presentó complicaciones como pérdida de la reducción, aflojamiento de las rótulas, ruptura o fatiga de las rótulas ni fatiga de la barra. La impresión 3D demostró ser una herramienta y alternativa útil en el manejo agudo de fracturas abiertas diafisiarias de tibia(AU)

3D Printing is an emerging technology used more and more in medicine. In developing countries, where motorcycle and automobile fractures are on the rise, the availability of external fixators for the management of open fractures is a frequent problem. 3D printing can be a cheap and equally reliable alternative to traditional devices made of steel or titanium. The objective of this work is to show the experience with the use of 3D Printing and its application in the clinical management of open diaphyseal fractures of the tibia. A pre-experimental and prospective study was made. 14 patients with AO/ASIF tibia fractures 42A, 42B and 42C treated with an external fixator with 3D-printed ball-caps as a Damage Control measure in Orthopedics from admission to final resolution were included. All patients were male, with an average age of 23,16 years, 50% between 20-23 years. The fractures were 42,85% type 42A, 37,71% 42B and 21,42% 42C. 78,57% of the fractures were caused by motorcycles: 57,14% grade II according to Gustilo and Anderson, 28,57% grade III and 14.28% grade I. 37,71% were polytraumatized. None of the patients had complications such as loss of reduction, loosening of the patellas, rupture or fatigue of the patellas, or rod fatigue. 3D printing proved to be a useful tool and alternative in the acute management of open diaphyseal fractures of the tibia(AU)

Manejo de fracturas abiertas de tibia en Cuba / Management of Open Tibial Fractures in Cuba

Introducción: Las fracturas abiertas de tibia son un subconjunto de la carga de traumatismos en América Latina. Se examinaron cuestiones relacionadas con el tratamiento potencialmente críticas en Cuba, país con recursos limitados, pero con un programa nacional de salud estandarizado, coherencia en educación y similitudes de programas de posgrado. Objetivos: Describir los patrones de tratamiento de la fractura abierta de tibia en Cuba, y comparar las características del manejo agudo y tardío en siete provincias del país. Métodos: Se encuestaron 67 cirujanos ortopédicos para evaluar cuatro aspectos en el tratamiento de la fractura abierta: profilaxis antibiótica, irrigación y desbridamiento, estabilización y tratamiento de heridas. Se utilizó el método de muestreo por conveniencia para identificar a los cirujanos y el análisis se realizó mediante la prueba exacta de Fisher (p < 0,05). Resultados: Se administraron antibióticos posoperatorios durante más de 72 horas para las fracturas GA-I/II (49 por ciento) y las fracturas GA-III (70 por ciento). Los cirujanos de La Habana (n= 32) utilizaron con más frecuencia la fijación interna primaria para las fracturas GA-I/II, que los cirujanos en las restantes provincias (n= 35) (64,3 porciento vs. 30,3 por ciento, p= 0,008). Los cirujanos de otras provincias realizaron cierre primario en el momento de la fijación definitiva de fracturas GA-I /II con más frecuencia que los de La Habana (62,9 por ciento vs. 32,3 por ciento, p= 0,013). Para fracturas GA-III, la mayoría de los cirujanos habaneros (88,6 %), al igual que los de las restantes provincias (96,8 por ciento) prefirieron realizar cierre diferido.Conclusiones: El tratamiento de fracturas abiertas de tibia en Cuba es generalmente consistente con otros países de América Latina. Se describen las características del manejo de fracturas abiertas de tibia en Cuba y se comparan las diferencias en los métodos de estabilización y tratamiento de heridas entre provincias, lo cual resulta útil para evaluar si son resultado de diferencias en la práctica quirúrgica, o en la disponibilidad de recursos. Esto representa una ayuda al abordar las formas de optimizar la atención al paciente, a través de la capacitación especializada y la asignación de los recursos(AU)

Introduction: Open tibia fractures are a significant subset of the overall trauma burden in Latin America. Latin American countries vary in their access to orthopaedic care resources, and country-specific orthopaedic recommendations are necessary. Cuba, a country with limited resources, has a standardized national health program, consistencies in education, and similarities across post-graduate training programs. This study aimed to identify management preferences for open tibia factures in Cuba. Objectives: To describe the treatment of open tibial fractures in Cuba, and to compare the characteristics of acute and delayed management across seven Cuban provinces. Methods: Sixty-seven orthopaedic surgeons were surveyed to evaluate four aspects of open fracture management, regarding antibiotic prophylaxis, irrigation and debridement, stabilization, and wound management. The convenience sampling method was used to identify surgeons and the analysis was performed using Fisher's exact test (p <0.05). Results: Postoperative antibiotics were administered for more than 72 hours for GA-I / II fractures (49 pecent) and GA-III fractures (70 percent). Surgeons in Havana (n = 32) used primary internal fixation for GA-I / II fractures more frequently than surgeons in the remaining provinces (n = 35) (64.3 pecent vs. 30.3 percent p = 0.008). Surgeons from other provinces performed primary closure at the time of definitive fixation of GA-I / II fractures more frequently than those from Havana (62.9 percent vs. 32.3 percent, p = 0.013). For GA-III fractures, the majority of Havana surgeons (88.6 percent), as well as those of the remaining provinces (96.8 percent) preferred to perform deferred closure. Conclusions: The treatment of open tibial fractures in Cuba is generally consistent with other Latin American countries. The characteristics of the management of open tibial fractures in Cuba are described and differences in wound stabilization and treatment methods between provinces are compared, which is useful to assess whether they are the result of differences in surgical practice, or in availability of resources. This is helpful in addressing ways to optimize patient care through specialized training and resource allocation(AU)

Comportamiento de pacientes con fracturas del pilón tibial tratados mediante fijación externa / Behavior of patients with tibial pilon fractures treated by external fixation

Resumen: Introducción: Las fracturas del pilón tibial constituyen lesiones de difícil manejo por su situación anatómica, mecanismo de producción y daño de las partes blandas que la rodean. El tratamiento quirúrgico es el más empleado, la fijación externa puede utilizarse de forma transitoria o definitiva. Objetivo: Evaluar el uso de la fijación externa en pacientes con fracturas del pilón tibial. Material y métodos: Se realizó un estudio con un nivel de evidencia IV, grado de recomendación B, en 34 pacientes con fractura del pilón tibial, atendidos de Enero de 2014 a Febrero de 2020. Desde el punto de vista estadístico se utilizó la distribución de frecuencias absolutas y relativas para variables cualitativas y para las cuantitativas la prueba de t Student. Resultados: El promedio de edad general fue de 45.8 años, predominó el sexo masculino con una razón de 1.4 a 1 y la fractura cerrada-abierta 1.8 a 1. Predominaron las fracturas tipo A según la clasificación del grupo AO. En relación a las fracturas abiertas predominaron las de tipo 3A. Se detectó significación entre un antes y un después al aplicar las escalas Olreud C y Molander H de la Sociedad Americana del Tobillo y Pie y el Ankle Scoring System. Las complicaciones del procedimiento quirúrgico fueron mínimas. Conclusiones: La fijación externa en pacientes con fracturas del pilón tibial es un método efectivo que puede emplearse de forma inmediata y definitiva en pacientes con fracturas abiertas y cerradas.

Abstract: Introduction: Tibial pylon fractures are difficult to manage injuries due to their anatomical situation, mechanism of production, and damage to the surrounding soft tissue. Surgical treatment is the most widely used, including external fixation that can be used temporarily or permanently. Objective: To evaluate the use of external fixation in patients with tibial pylon fractures. Material and methods: A pre-experimental study with a level of evidence II, recommendation grade B, was carried out in 34 patients with tibial pylon fracture, treated from January 2014 to February 2020. From the statistical point of view, the distribution of absolute and relative frequencies was used for qualitative variables and for quantitative variables, the Student's t test. Results: The general average age was 45.8 years, the male sex predominated with a ratio of 1.4 to 1 and the closed-open fractures 1.8 to 1. Type A fractures predominated according to the classification of the AO group. In relation to open fractures, 3A types predominated. Significance between a before and after was detected when applying the Olreud C and Molander H scales, from the American Ankle and Foot Society, and the Ankle Scoring System. The complications of the surgical procedure were minimal. Conclusions: External fixation in patients with tibial pylon fractures is an effective method that can be used immediately and definitively in patients with both open and closed fractures with few complications.

[Behavior of patients with tibial pilon fractures treated by external fixation]. / Comportamiento de pacientes con fracturas del pilón tibial tratados mediante fijación externa.

INTRODUCTION: Tibial pylon fractures are difficult to manage injuries due to their anatomical situation, mechanism of production, and damage to the surrounding soft tissue. Surgical treatment is the most widely used, including external fixation that can be used temporarily or permanently. OBJECTIVE: To evaluate the use of external fixation in patients with tibial pylon fractures. MATERIAL AND METHODS: A pre-experimental study with a level of evidence II, recommendation grade B, was carried out in 34 patients with tibial pylon fracture, treated from January 2014 to February 2020. From the statistical point of view, the distribution of absolute and relative frequencies was used for qualitative variables and for quantitative variables, the Student's t test. RESULTS: The general average age was 45.8 years, the male sex predominated with a ratio of 1.4 to 1 and the closed-open fractures 1.8 to 1. Type A fractures predominated according to the classification of the AO group. In relation to open fractures, 3A types predominated. Significance between a before and after was detected when applying the Olreud C and Molander H scales, from the American Ankle and Foot Society, and the Ankle Scoring System. The complications of the surgical procedure were minimal. CONCLUSIONS: External fixation in patients with tibial pylon fractures is an effective method that can be used immediately and definitively in patients with both open and closed fractures with few complications.

INTRODUCCIÓN: Las fracturas del pilón tibial constituyen lesiones de difícil manejo por su situación anatómica, mecanismo de producción y daño de las partes blandas que la rodean. El tratamiento quirúrgico es el más empleado, la fijación externa puede utilizarse de forma transitoria o definitiva. OBJETIVO: Evaluar el uso de la fijación externa en pacientes con fracturas del pilón tibial. MATERIAL Y MÉTODOS: Se realizó un estudio con un nivel de evidencia IV, grado de recomendación B, en 34 pacientes con fractura del pilón tibial, atendidos de Enero de 2014 a Febrero de 2020. Desde el punto de vista estadístico se utilizó la distribución de frecuencias absolutas y relativas para variables cualitativas y para las cuantitativas la prueba de t Student. RESULTADOS: El promedio de edad general fue de 45.8 años, predominó el sexo masculino con una razón de 1.4 a 1 y la fractura cerrada-abierta 1.8 a 1. Predominaron las fracturas tipo A según la clasificación del grupo AO. En relación a las fracturas abiertas predominaron las de tipo 3A. Se detectó significación entre un antes y un después al aplicar las escalas Olreud C y Molander H de la Sociedad Americana del Tobillo y Pie y el Ankle Scoring System. Las complicaciones del procedimiento quirúrgico fueron mínimas. CONCLUSIONES: La fijación externa en pacientes con fracturas del pilón tibial es un método efectivo que puede emplearse de forma inmediata y definitiva en pacientes con fracturas abiertas y cerradas.

Comparative accuracy assessment of the Gustilo and Tscherne classification systems as predictors of infection in open fractures.

OBJECTIVE: The aim of this study is to analyze the accuracy of the two classification systems for open fractures most commonly used in current medical practice, Gustilo and Tscherne, as predictors of infection. METHODS: A retrospective observational study was performed, including 121 patients suffering from open fracture of the appendicular skeleton treated at an emergency hospital. The fractures were classified according to Gustilo and Tscherne systems during the initial treatment, and ratings were subsequently confirmed or rectified during hospitalization. Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated according to each classification adopted. RESULTS: The results of this study demonstrated that both classifications of Gustilo and Tscherne are associated with the clinical outcome of infection in open fractures. The Gustilo classification achieved sensitivity of 76.7%, specificity of 53.8%, and accuracy of 59.5%. Tscherne's classification had a sensitivity of 56.7%, specificity 82.4%, and accuracy of 76.1%. CONCLUSION: The Tscherne system showed better accuracy, including specificity as a predictor of infection in open fractures, when compared with the Gustilo system.

OBJETIVO: Analisar comparativamente a acurácia dos dois sistemas para classificação de fraturas expostas mais usados na prática médica atual, Gustilo e Tscherne, como preditores de infecção nas fraturas expostas. MÉTODOS: Foi feito um estudo observacional retrospectivo com 121 indivíduos acometidos por fratura exposta do esqueleto apendicular atendidos em uma unidade de emergência hospitalar. As fraturas expostas foram classificadas segundo os dois sistemas durante o atendimento inicial; as classificações eram posteriormente confirmadas ou retificadas durante o internamento. Foram calculados sensibilidade, especificidade, valores preditivos positivos e negativos e acurácia, segundo cada classificação adotada. RESULTADOS: Os resultados demonstraram que ambas as classificações, de Gustilo e de Tscherne, apresentam associação com o desfecho clínico infecção em fraturas expostas. A classificação de Gustilo obteve sensibilidade de 76,7%, especificidade de 53,8% e acurácia de 59,5%. A classificação de Tscherne obteve sensibilidade de 56,7%, especificidade de 82,4% e acurácia de 76,1%. CONCLUSÃO: O sistema de classificação de Tscherne demonstrou maior acurácia, apresentou melhor especificidade como preditor de infecção em fraturas expostas quando comparado com o sistema de Gustilo.

Comparative accuracy assessment of the Gustilo and Tscherne classification systems as predictors of infection in open fractures / Análise comparativa da acurácia das classificações de Gustilo e Tscherne como preditoras de infecção em fraturas expostas

ABSTRACT Objective The aim of this study is to analyze the accuracy of the two classification systems for open fractures most commonly used in current medical practice, Gustilo and Tscherne, as predictors of infection. Methods A retrospective observational study was performed, including 121 patients suffering from open fracture of the appendicular skeleton treated at an emergency hospital. The fractures were classified according to Gustilo and Tscherne systems during the initial treatment, and ratings were subsequently confirmed or rectified during hospitalization. Sensitivity, specificity, positive and negative predictive values, and accuracy were calculated according to each classification adopted. Results The results of this study demonstrated that both classifications of Gustilo and Tscherne are associated with the clinical outcome of infection in open fractures. The Gustilo classification achieved sensitivity of 76.7%, specificity of 53.8%, and accuracy of 59.5%. Tscherne's classification had a sensitivity of 56.7%, specificity 82.4%, and accuracy of 76.1%. Conclusion The Tscherne system showed better accuracy, including specificity as a predictor of infection in open fractures, when compared with the Gustilo system.

RESUMO Objetivo Analisar comparativamente a acurácia dos dois sistemas para classificação de fraturas expostas mais usados na prática médica atual, Gustilo e Tscherne, como preditores de infecção nas fraturas expostas. Métodos Foi feito um estudo observacional retrospectivo com 121 indivíduos acometidos por fratura exposta do esqueleto apendicular atendidos em uma unidade de emergência hospitalar. As fraturas expostas foram classificadas segundo os dois sistemas durante o atendimento inicial; as classificações eram posteriormente confirmadas ou retificadas durante o internamento. Foram calculados sensibilidade, especificidade, valores preditivos positivos e negativos e acurácia, segundo cada classificação adotada. Resultados Os resultados demonstraram que ambas as classificações, de Gustilo e de Tscherne, apresentam associação com o desfecho clínico infecção em fraturas expostas. A classificação de Gustilo obteve sensibilidade de 76,7%, especificidade de 53,8% e acurácia de 59,5%. A classificação de Tscherne obteve sensibilidade de 56,7%, especificidade de 82,4% e acurácia de 76,1%. Conclusão O sistema de classificação de Tscherne demonstrou maior acurácia, apresentou melhor especificidade como preditor de infecção em fraturas expostas quando comparado com o sistema de Gustilo.

Infection rate in adult patients with open fractures treated at the emergency hospital and at the ULBRA university hospital in Canoas, Rio Grande do Sul, Brazil.

OBJECTIVE: To identify the infection rate in adult patients with open fractures treated at two tertiary hospitals in the city of Canoas, Rio Grande do Sul, Brazil. METHODS: This quantitative descriptive study was conducted at Hospital de Pronto Socorro de Canoas. Eligible participants were adults aged 18-60 years with open fractures who were admitted to the orthopedic trauma service from January to May 2014 and followed-up for one year. RESULTS: A total of 133 patients with open fractures were included; most were men (92.48%), with a mean age of 36 years. There was a predominance of Gustilo-Anderson type III fractures. The infection rate was 18.80%, being more frequent in Gustilo-Anderson type III fractures (72.00%). The most commonly observed bacteria were Staphylococcus aureus and Enterobacter aerogenes. CONCLUSION: The infection rate in open fractures of patients initially treated at the emergency department of HPSC was 18.8%. The infections occurred predominantly in Gustilo-Anderson type III fractures. The bacteria with the highest incidence in infections were Staphylococcus aureus and Enterobacter aerogenes.

OBJETIVO: Identificar a taxa de infecção em pacientes adultos com fratura exposta atendidos em dois hospitais terciários no município de Canoas, Rio Grande do Sul. MÉTODOS: Estudo quantitativo descritivo feito no Hospital de Pronto Socorro de Canoas (HPSC). Foram elegíveis os pacientes entre 18 e 60 anos internados com fratura exposta no setor de traumatologia e ortopedia da emergência do HPSC, de janeiro a maio de 2014, e que foram acompanhados por um ano. RESULTADOS: Foram incluídos 133 pacientes com fratura exposta, a maioria do sexo masculino (92,48%), com média de 36 anos. Houve predomínio de fraturas do tipo III de Gustilo e Anderson. A taxa de infecção foi de 18,80%, mais frequente em fraturas do tipo III de Gustilo e Anderson (72%). As bactérias mais frequentemente identificadas nas infecções foram Staphylococcus aureus e Enterobacter aerogenes. CONCLUSÃO: A taxa de infecção em fraturas expostas de pacientes atendidos inicialmente na emergência do HPSC foi de 18,80%. As infecções ocorreram predominantemente em fraturas do tipo III de Gustilo e Anderson. As bactérias com maior incidência nas infecções foram Staphylococcus aureus e Enterobacter aerogenes.

Fractura segmentaria abierta IIIa de húmero en paciente lactante: reporte de un caso / IIIa open segmental fracture of the humerus in an infant patient: a case report

Las fracturas diafisiarias de húmero constituyen solo el 3% de todas las fracturas en niños. Las fracturas abiertas de este segmento son poco frecuentes con muy pocos reportes en la literatura. Son el resultado de traumatismos de alta energía ocasionados por accidentes automovilísticos o precipitaciones de gran altura. Las fracturas abiertas en niños menores de 3 años, representa un verdadero reto y requieren un enfoque único y multidisciplinario. Las fracturas abiertas en los niños presentan desafíos especiales, donde deben considerarse las características especiales del hueso del niño que lo diferencian del hueso del adulto. La aplicación de los principios adecuados en el manejo de las fracturas abiertas, así como el establecimiento de protocolos específicos de tratamiento, son necesarios para garantizar una evolución adecuada de esas lesiones. Presentamos el caso de paciente lactante menor masculino, quien fue eyectado del asiento delantero de un vehículo rustico al volcarse éste por una pendiente, posterior a lo cual presenta fractura segmentaria abierta IIIa del húmero derecho. El paciente es llevado a quirófano de emergencia donde se realiza limpieza quirúrgica y la estabilización de la fractura con un mini fijador externo utilizado para el tratamiento de fracturas de muñeca en adultos. Presentamos su tratamiento, complicaciones y evolución a corto plazo.

The humeral shaft fractures accounts for only 3% of all fractures in children. Open fractures of this segment are rare with few reports in the literature. They result from high energy trauma caused by car accidents or precipitation from high altitude. Open fractures in children under 3 years represents a real challenge and requires a unique and multidisciplinary approach. We present male infant patient, who was ejected from the front seat of a rustic vehicle that overturned down a slope and presented an open segmental type IIIa fracture of the right humerus. The patient was taken to the operating room where an emergency surgical cleaning and stabilization of the fracture was performed using a mini external fixator currently utilized for treating adult wrist fractures. We present the treatment, complications and outcomes in the short term.

Infection rate in adult patients with open fractures treated at the emergency hospital and at the ULBRA university hospital in Canoas, Rio Grande do Sul, Brazil / Taxa de infecção em pacientes adultos com fratura exposta atendidos no hospital de pronto socorro e no hospital universitário Ulbra do município de Canoas, Rio Grande do Sul

ABSTRACT Objective: To identify the infection rate in adult patients with open fractures treated at two tertiary hospitals in the city of Canoas, Rio Grande do Sul, Brazil.. Methods: This quantitative descriptive study was conducted at Hospital de Pronto Socorro de Canoas. Eligible participants were adults aged 18-60 years with open fractures who were admitted to the orthopedic trauma service from January to May 2014 and followed-up for one year.. Results: A total of 133 patients with open fractures were included; most were men (92.48%), with a mean age of 36 years. There was a predominance of Gustilo-Anderson type III fractures. The infection rate was 18.80%, being more frequent in Gustilo-Anderson type III fractures (72.00%). The most commonly observed bacteria were Staphylococcus aureus, and Enterobacter aerogenes., . Conclusion: The infection rate in open fractures of patients initially treated at the emergency department of HPSC was 18.8%. The infections occurred predominantly in Gustilo-Anderson type III fractures. The bacteria with the highest incidence in infections were Staphylococcus aureus and Enterobacter aerogenes.

RESUMO Objetivo: Identificar a taxa de infecção em pacientes adultos com fratura exposta atendidos em dois hospitais terciários no município de Canoas, Rio Grande do Sul. Métodos: Estudo quantitativo descritivo feito no Hospital de Pronto Socorro de Canoas (HPSC). Foram elegíveis os pacientes entre 18 e 60 anos internados com fratura exposta no setor de traumatologia e ortopedia da emergência do HPSC, de janeiro a maio de 2014, e que foram acompanhados por um ano. Resultados: Foram incluídos 133 pacientes com fratura exposta, a maioria do sexo masculino (92,48%), com média de 36 anos. Houve predomínio de fraturas do tipo III, de Gustilo e Anderson. A taxa de infecção foi de 18,80%, mais frequente em fraturas do tipo III, de Gustilo e Anderson (72%). As bactérias mais frequentemente identificadas nas infecções foramStaphylococcus aureuseEnterobacter aerogenes. Conclusão: A taxa de infecção em fraturas expostas de pacientes atendidos inicialmente na emergência do HPSC foi de 18,80%. As infecções ocorreram predominantemente em fraturas do tipo III, de Gustilo e Anderson. As bactérias com maior incidência nas infecções foramStaphylococcus aureuseEnterobacter aerogenes.

The incidence and microbiological profile of surgical site infections following internal fixation of closed and open fractures.

OBJECTIVE: To evaluate the incidence and microbiological profile of surgical site infections (SSIs) associated with internal fixation of fractures and to compare differences in the SSIs observed among patients with closed and open fractures. METHODS: Retrospective study. Analyzed data included information from all patients who underwent surgery for fixation of closed or open fractures from January 2005 to December 2012 and remained outpatients for at least one year following surgery. Incidence of surgical site infection (SSI) was compared between patients with closed and open infection, as well as polymicrobial infection and infection related to Gram-negative bacilli (GNB). Cumulative antibiograms were performed to describe microbiological profiles. RESULTS: Overall incidence of SSI was 6%. This incidence was significantly higher among patients with open fractures (14.7%) than among patients with closed fractures (4.2%). The proportions of patients with polymicrobial infections and infections due to GNB were also significantly higher among patients with open fractures. Staphylococcus aureus and coagulase-negative Staphylococcus (CoNS) species were the primary infectious agents isolated from both groups. The overall incidence of MRSA (methicillin-resistant S. aureus) was 72%. A. baumannii was the predominant GNB isolate recovered from patients with open fractures and P. aeruginosa was the most frequent isolate recovered from patients with closed fractures, both exhibited low rates of susceptibility to carbapenems. CONCLUSIONS: Incidence of SSIs related to the internal fixation of fractures was significantly higher among patients with open fractures, indicating that an open fracture can be a risk factor for infection. Among the bacterial isolates, S. aureus (with a high prevalence of MRSA) and CoNS species were most prevalent. A. baumannii and P. aeruginosa isolates underscored the low rate of susceptibility to carbapenems that was observed in the present study.

OBJETIVO: Avaliar a incidência e o perfil microbiológico das ISC relacionadas a procedimentos de fixação de fraturas num hospital acadêmico ortopédico terciário em São Paulo, Brasil, e comparar as diferenças observadas entre os pacientes com fraturas fechadas e expostas. MÉTODOS: Estudo retrospectivo. Foram incluídos na análise os dados relativos a todos os pacientes que passaram por procedimento cirúrgico para fixação de fraturas fechadas ou expostas de janeiro de 2005 a dezembro de 2012 e que mantiveram seguimento por pelo menos um ano. Foi verificada a presença de associação entre o tipo de fratura, a incidência de ISC e as incidências de infecções polimicrobianas e por bacilos Gram-negativos. O perfil microbiológico foi estabelecido por meio da elaboração de antibiogramas cumulativos. RESULTADOS: A incidência geral de infecção de 6%. Essa incidência foi maior no grupo de pacientes com fraturas expostas (14,7%) do que naqueles com fraturas fechadas (4,2%), com diferença estatisticamente significante. O número de pacientes com infecções polimicrobianas e com infecções relacionadas a BGN também foi significativamente maior no grupo de casos relacionados a fraturas expostas. Staphylococcus aureus e espécies de Staphylococcus coagulase-negativo (CoNS) foram os principais agentes isolados nos dois grupos. A incidência de MRSA (S. aureus resistente a meticilina) dentre todos os isolados de S. aureus foi de 72%. A. baumannii foi o principal BGN isolado entre os pacientes com fraturas expostas e P. aeruginosa entre os pacientes com fraturas fechadas. Em ambos os casos, observaram-se baixos índices de sensibilidade a carbapenêmicos. CONCLUSÕES: A incidência de ISC relacionada à fixação interna de fraturas foi significantemente maior nos pacientes com fraturas expostas, o que indica que esse tipo de fratura pode ser um fator de risco para a ocorrência desse tipo de infecção. Dentre os isolados bacterianos, predominaram no geral S. aureus (com elevada prevalência de MRSA) e S. coagulase-negativo. Dentre os BGN, houve predomínio de A. baumanni também entre os isolados de pacientes com fraturas expostas e P. aeruginosa entre os isolados daqueles com fraturas fechadas.

The incidence and microbiological profile of surgical site infections following internal fixation of closed and open fractures / Infecção de sítio cirúrgico após fixação de fraturas fechadas e expostas - Incidência e perfil microbiológico

ABSTRACT OBJECTIVE: To evaluate the incidence and microbiological profile of surgical site infections (SSIs) associated with internal fixation of fractures and to compare differences in the SSIs observed among patients with closed and open fractures. METHODS: Retrospective study. Analyzed data included information from all patients who underwent surgery for fixation of closed or open fractures from January 2005 to December 2012 and remained outpatients for at least one year following surgery. Incidence of surgical site infection (SSI) was compared between patients with closed and open infection, as well as polymicrobial infection and infection related to Gram-negative bacilli (GNB). Cumulative antibiograms were performed to describe microbiological profiles. RESULTS: Overall incidence of SSI was 6%. This incidence was significantly higher among patients with open fractures (14.7%) than among patients with closed fractures (4.2%). The proportions of patients with polymicrobial infections and infections due to GNB were also significantly higher among patients with open fractures. Staphylococcus aureus and coagulase-negative Staphylococcus (CoNS) species were the primary infectious agents isolated from both groups. The overall incidence of MRSA (methicillin-resistant S. aureus) was 72%. A. baumannii was the predominant GNB isolate recovered from patients with open fractures and P. aeruginosa was the most frequent isolate recovered from patients with closed fractures, both exhibited low rates of susceptibility to carbapenems. CONCLUSIONS: Incidence of SSIs related to the internal fixation of fractures was significantly higher among patients with open fractures, indicating that an open fracture can be a risk factor for infection. Among the bacterial isolates, S. aureus (with a high prevalence of MRSA) and CoNS species were most prevalent. A. baumannii and P. aeruginosa isolates underscored the low rate of susceptibility to carbapenems that was observed in the present study.

RESUMO OBJETIVO: Avaliar a incidência e o perfil microbiológico das ISC relacionadas a procedimentos de fixação de fraturas num hospital acadêmico ortopédico terciário em São Paulo, Brasil, e comparar as diferenças observadas entre os pacientes com fraturas fechadas e expostas. MÉTODOS: Estudo retrospectivo. Foram incluídos na análise os dados relativos a todos os pacientes que passaram por procedimento cirúrgico para fixação de fraturas fechadas ou expostas de janeiro de 2005 a dezembro de 2012 e que mantiveram seguimento por pelo menos um ano. Foi verificada a presença de associação entre o tipo de fratura, a incidência de ISC e as incidências de infecções polimicrobianas e por bacilos Gram-negativos. O perfil microbiológico foi estabelecido por meio da elaboração de antibiogramas cumulativos. RESULTADOS: A incidência geral de infecção de 6%. Essa incidência foi maior no grupo de pacientes com fraturas expostas (14,7%) do que naqueles com fraturas fechadas (4,2%), com diferença estatisticamente significante. O número de pacientes com infecções polimicrobianas e com infecções relacionadas a BGN também foi significativamente maior no grupo de casos relacionados a fraturas expostas. Staphylococcus aureus e espécies de Staphylococcus coagulase-negativo (CoNS) foram os principais agentes isolados nos dois grupos. A incidência de MRSA (S. aureus resistente a meticilina) dentre todos os isolados de S. aureus foi de 72%. A. baumannii foi o principal BGN isolado entre os pacientes com fraturas expostas e P. aeruginosa entre os pacientes com fraturas fechadas. Em ambos os casos, observaram-se baixos índices de sensibilidade a carbapenêmicos. CONCLUSÕES: A incidência de ISC relacionada à fixação interna de fraturas foi significantemente maior nos pacientes com fraturas expostas, o que indica que esse tipo de fratura pode ser um fator de risco para a ocorrência desse tipo de infecção. Dentre os isolados bacterianos, predominaram no geral S. aureus (com elevada prevalência de MRSA) e S. coagulase-negativo. Dentre os BGN, houve predomínio de A. baumanni também entre os isolados de pacientes com fraturas expostas e P. aeruginosa entre os isolados daqueles com fraturas fechadas.

Resultados de la utilización de aloinjerto criopreservado en fracturas y consolidaciones fallidas de huesos largos / Outcomes of cryopreserved allograft in long bones fractures and nonunions

Introducción: El objetivo de este trabajo es evaluar las indicaciones y la incorporación del aloinjerto criopreservado en fracturas y consolidaciones fallidas de huesos largos. Materiales y Métodos: Estudio retrospectivo, 20 pacientes tratados entre 2005 y 2011, 7 fracturas y 14 consolidaciones fallidas de huesos largos en los que se utilizó aloinjerto óseo criopreservado (un paciente con compromiso bilateral de fémur), 11 asociados a autoinjerto. Edad promedio: 45.2 años (rango 19-74). Diez mujeres y 10 hombres. Defectos óseos clasificados en circunferenciales y no circunferenciales. Resultados: La consolidación luego del uso de aloinjerto molido de Banco se logró en 14 casos tras un promedio de 8 meses (rango 4-18); de los 7 restantes, se logró la consolidación luego de cirugías de revisión en 5 casos, uno permaneció sin consolidación y, en otro, se amputó el miembro. Conclusiones: El autoinjerto sigue siendo el patrón de referencia en la reconstrucción de defectos óseos. Los nuevos sistemas de extracción de autoinjertos, como el fresado con irrigación/aspiración (RIA, Synthes) han llevado a que el uso de aloinjerto en fracturas sea poco frecuente. Pero, en los pacientes de nuestra serie, con múltiples cirugías, defectos óseos o trastornos psiquiátricos graves, el aloinjerto óseo crioconservado aislado o asociado a autoinjerto permitió obtener buenos resultados (18 casos consolidaron), aunque 5 casos requirieron cirugías de revisión.

Background: The aim of this study was to evaluate the indications and incorporation of cryopreserved allograft in long bone fractures and nonunions. Methods: Retrospective study of 20 patients treated between 2005 and 2011, with 7 fractures and 14 long bones nonunions in which cryopreserved allograft bone was used (one patient had bilateral femoral involvement), associated with autograft in 11 cases. Average age 45.2 years (range 19 to 74). Ten women and ten men. Bone defects were classified according to whether they were circumferential or not. Results: Bony union after using morcellized allograft was achieved in 14 cases, after an average of 8 months (range 4 to 18), among the remaining 7 cases union was achieved after revision surgery in 5 cases, another case did not achieve consolidation, and an amputation was performed in another patient. Conclusions: Bone autograft remains the gold standard in bone defect reconstructions. Using new extraction systems for autografts, such as reamed irrigation/aspiration (RIA, Synthes) has made the use of allograft in fractures infrequent. In our patients with multiple surgeries, bone defects or severe psychiatric disorders, the use of isolated cryopreserved allograft or associated with bone autograft obtained good results (18 cases with consolidation), although 5 patients required revision surgeries.

Resultados de la utilización de aloinjerto criopreservado en fracturas y consolidaciones fallidas de huesos largos

Introducción: El objetivo de este trabajo es evaluar las indicaciones y la incorporación del aloinjerto criopreservado en fracturas y consolidaciones fallidas de huesos largos. Materiales y Métodos: Estudio retrospectivo, 20 pacientes tratados entre 2005 y 2011, 7 fracturas y 14 consolidaciones fallidas de huesos largos en los que se utilizó aloinjerto óseo criopreservado (un paciente con compromiso bilateral de fémur), 11 asociados a autoinjerto. Edad promedio: 45.2 años (rango 19-74). Diez mujeres y 10 hombres. Defectos óseos clasificados en circunferenciales y no circunferenciales. Resultados: La consolidación luego del uso de aloinjerto molido de Banco se logró en 14 casos tras un promedio de 8 meses (rango 4-18); de los 7 restantes, se logró la consolidación luego de cirugías de revisión en 5 casos, uno permaneció sin consolidación y, en otro, se amputó el miembro. Conclusiones: El autoinjerto sigue siendo el patrón de referencia en la reconstrucción de defectos óseos. Los nuevos sistemas de extracción de autoinjertos, como el fresado con irrigación/aspiración (RIA, Synthes) han llevado a que el uso de aloinjerto en fracturas sea poco frecuente. Pero, en los pacientes de nuestra serie, con múltiples cirugías, defectos óseos o trastornos psiquiátricos graves, el aloinjerto óseo crioconservado aislado o asociado a autoinjerto permitió obtener buenos resultados (18 casos consolidaron), aunque 5 casos requirieron cirugías de revisión.(AU)

Background: The aim of this study was to evaluate the indications and incorporation of cryopreserved allograft in long bone fractures and nonunions. Methods: Retrospective study of 20 patients treated between 2005 and 2011, with 7 fractures and 14 long bones nonunions in which cryopreserved allograft bone was used (one patient had bilateral femoral involvement), associated with autograft in 11 cases. Average age 45.2 years (range 19 to 74). Ten women and ten men. Bone defects were classified according to whether they were circumferential or not. Results: Bony union after using morcellized allograft was achieved in 14 cases, after an average of 8 months (range 4 to 18), among the remaining 7 cases union was achieved after revision surgery in 5 cases, another case did not achieve consolidation, and an amputation was performed in another patient. Conclusions: Bone autograft remains the gold standard in bone defect reconstructions. Using new extraction systems for autografts, such as reamed irrigation/aspiration (RIA, Synthes) has made the use of allograft in fractures infrequent. In our patients with multiple surgeries, bone defects or severe psychiatric disorders, the use of isolated cryopreserved allograft or associated with bone autograft obtained good results (18 cases with consolidation), although 5 patients required revision surgeries.(AU)

Vertical open patella fracture, treatment, rehabilitation and the moment to fixation.

Patella fracture is relatively uncommon and the vertical trace fracture represents almost 12-17%. The open patella fracture expresses 6-30%. The association of these two uncommon conditions was the aim of this case report even as the treatment and the moment of fixation (definitive surgical treatment). A 27-year-old man after a motorcycle accident showed an open patella fracture classified as a Gustilo and Anderson type IIIA lesion. The patient was immediately treated with precocious surgery fixation with a modified tension band which consists of two parallel K-wires positioned orthogonal to the fracture line and a cerclage wire shaped anteriorly at patella as an eight. The premature fixation benefited the infection prevention and provided earlier joint motion, which increased the nutrition of articular cartilage. Six months postoperatively, the patient had a satisfactory joint motion with full extension and 116° of joint flexion and returned to his daily life activities without restriction. Twelve months postoperatively, the patient had full extension and 120° of knee flexion without pain, joint effusion and instability. Muscle strength force was considered normal at grade V. In conclusion, early chirurgic treatment and precocious articular mobilization improve prognosis, suggesting that the employment of these practices should be adopted whenever possible in most of the open fractures.

Open anterior dislocation of the hip in an adult: a case report and review of literature.

Open anterior hip dislocation is a rare condition and results from high-energy trauma. Ten cases of open anterior dislocation have been described in the literature so far. Its rarity is due to the inherent stability of the joint, its deep position in the pelvis, with strong ligaments and bulky muscles around the articulation. Several factors influence the prognosis, such as the degree of compounding, the associated soft tissue injuries, the age of the patient and, mainly, the delay in reduction. The main complications are: arthrosis of the hip, with incidence of 50% of cases, when associated with fractures of the femoral head; and osteonecrosis of the femoral head, with incidence between 1.7 and 40% (in closed anterior dislocation). Because of the rarity and the potential disability of this lesion, we report a case in a 46-year-old man, involved in an automobile accident. The hip was reduced (anterior superior dislocation) in the first three hours of the trauma. The patient was kept non-weight bearing until sixth week, with complete weight bearing after 10th week. After one year follow-up, the functional result was poor (Harris Hip Score: 52), probably because of the associated labral tear, but without signs of osteonecrosis of the femoral head in magnetic resonance imaging.

A luxação anterior exposta do quadril é condição rara e resulta de trauma de alta energia. Até o momento, foram descritos na literatura 10 casos. Sua raridade deve­se à estabilidade inerente da articulação e à posição profunda na pelve, com fortes ligamentos e musculatura volumosa ao seu redor. Influenciam o prognóstico dessa lesão diversos fatores, tais como grau de contaminação, lesões de partes moles, idade do paciente e, principalmente, atraso na redução. As principais complicações são: artrose do quadril, com incidência que pode chegar a 50% dos casos, quando associada a fraturas da cabeça femoral; e osteonecrose da cabeça do fêmur, com incidência entre 1,7% e 40% (nos casos de luxação anterior fechada). Por causa da raridade e da potencial incapacidade funcional decorrente dessa lesão, relatamos o caso de um homem de 46 anos vítima de acidente automobilístico. Foi feita redução do quadril (luxação do tipo anterior alta) nas primeiras três horas pós­trauma. O paciente foi mantido sem carga até a sexta semana, com carga total após a 10ª semana. Após um ano de seguimento, observou­se resultado funcional pobre (Harris Hip Score: 52), provavelmente por causa de lesão labral associada, porém sem sinais na ressonância nuclear magnética de osteonecrose da cabeça femoral.

Tratamiento de las fracturas diafisarias del húmero con fijación externa ósea monolateral / Traitement des fractures diaphysaires de l'humérus par fixation externe unilatérale / Treatment of diaphyseal humerous fractures with mono-lateral external fixation

Introducción: la fractura del húmero ha sido siempre difícil de tratar, tanto de forma incruenta como por cirugía, debido a la anatomía de la región que dificulta su acceso quirúrgico y una inmovilización efectiva. Objetivo: exponer las ventajas del sistema de fijación externa ósea monopolar en su tratamiento, mostrar y difundir los resultados e incentivar su utilización. Métodos: se estudiaron 41 expedientes clínicos; se reunieron los datos requeridos y se colocaron en tablas utilizando un patrón pre-establecido. Los resultados se dividieron en buenos, regulares y malos. Resultados: en las 9 fracturas expuestas y en 9 de las 32 cerradas, el tratamiento fue de urgencia y en el resto de forma diferida. Dentro de los problemas predominó la infección en el sitio de inserción del alambre (58 por ciento); como complicaciones hubo un paciente con seudoartrosis infectada; 3 consolidaciones viciosas; 2 pacientes con parálisis radial uno por lesión nerviosa y otro por neuropraxia en la manipulación del nervio y un paciente hizo intolerancia al equipo; el tratamiento se concluyó con la conducta inicial en 91,6 por ciento de los casos, con un tiempo de consolidación promedio de 13,2 semanas. Aplicando el patrón mencionado se demostró que 75,6 por ciento de los pacientes tuvo buenos resultados, 12,2 por cierto regulares y también 12,2 por ciento resultados catalogados como malos. Conclusión: esta terapéutica tiene gran utilidad en el tratamiento de las fracturas del húmero y puede afirmarse que las ventajas superan con creces a las desventajas a presentarse(AU)

Introduction: humerous fracture has always been difficult to treat both by bloodless form or surgery due to the anatomy of the region that makes its surgical access and an effective immobilization difficult. Objective: to present the advantages of the mono-lateral external fixation, to show and spread the results and encourage its use. Methods: 41 clinical records were studied and required data were collected, placing them in tables using a determined pattern. The results were divided into good, regular and bad. Results: in 9 open fractures and 9 of the 32 closed ones, there was an emergency treatment and the rest underwent deferred treatments. Among the problems, the one that predominated was the infection in the wire insertion site (58 percent) As complications, a patient presented infected pseudoarthrosis, there were three malunions, two patients had radial paralysis (one by nervous lesion and the other due to neuropraxia caused by manipulation of the nerve) and a patient presented intolerance to the equipment. The treatment concluded with the initial behaviour in the 91.6 percent of the cases and an average healing time of 13.2 weeks. The application of the mentioned pattern showed that the 75.6 percent of patients had good results, the 12.2 percent had regular results and the 12.2 percent had results that were classified as bad. Conclusion: this therapy is very useful in the treatment of humerous factures and we can ascertain that its advantages far outweigh the disadvantages that can occur(AU)

Introduction: les fractures de l'humérus ont été toujours difficiles à traiter en raison de leur anatomie topographique empêchant l'accès chirurgical et l'immobilisation effective. Buts: exposer les bénéfices du système de fixation externe unilatérale pour le traitement de cette lésion, montrer et diffuser les résultats, et stimuler son utilisation. Méthodes: quarante-et-un dossiers médicaux ont été étudiés; des données nécessaires ont été recueillies et rangées en table, en utilisant un modèle préétabli. Les résultats sont classés de bons, passables et mauvais. Résultats: le traitement a été urgent dans 9 cas de fractures exposées et 9 cas de fractures fermées sur 32. L'infection du site d'insertion de la tige (58 pourcent) a été fréquente. Parmi les complications, on a trouvé une pseudo-arthrose infectée, trois consolidations vicieuses, deux paralysies radiales, une lésion nerveuse, une neurapraxie au moment de la manipulation du nerf, et un rejet. Suivant la conduite initiale, le traitement est mené à bien dans 91,6 pourcent des cas, avec un temps de consolidation de 13,2 pourcent semaines en moyenne. En appliquant la classification mentionnée ci-dessus, il y a eu de bons résultats (75,6 pourcent ), des résultats passables (12,2 pourcent), et de mauvais résultats (12,2 pourcent). Conclusion: cette technique est d'une grande utilité dans le traitement des fractures de l'humérus, et on peut affirmer que les bénéfices surpassent largement les possibles inconvénients(AU)

El uso de colgajos en la reconstrucción de defectos de cobertura en la pierna distal y dorso de pie / The use of flaps in the reconstruction of defects of coverage in the distal leg and dorsum of the foots

Resumen Objetivo: Mostrar las posibilidades quirúrgicas que existen en el tercio distal de la pierna y presentar la experiencia en los últimos 15 años con estos colgajos. Materiales y métodos: Se revisó durante 15 años los colgajos de sóleo directo e invertido, fasciocutáneos, de sural invertido y algunos colgajos libres para cubrir defectos en el tercio distal de la pierna y pie. Resultados: Se revisó a 112 pacientes con seguimiento mínimo de 3 meses; 18 tenían compromiso del tobillo y pie y el resto tenía exposiciones de tendones y/o de elementos neurovasculares. Los colgajos más usados fueron el sóleo, el sural invertido y el fasciocutáneo invertido. Se presentaron complicaciones menores, como necrosis distal de bordes, en cuatro colgajos, sin afectar la cobertura final. Un colgajo libre sufrió necrosis total. Discusión: Fracturas abiertas de tibia requieren cobertura rápida para disminuir los índices de infección y favorecer la curación. El sóleo sigue siendo de los más usados entre los colgajos locales para los defectos del tercio medio de la tibia. En esta serie se muestra que es apto para muchas reconstrucciones en la pierna distal, ya que se evita muchas veces el uso de un colgajo libre. El colgajo sural invertido es de gran seguridad y versatilidad, y llega a cubrir muchas veces defectos grandes en el dorso del pie y en el talón. Los colgajos libres son de mayor complejidad, debido a que se requiere personal especializado, así que es recomendable solucionar estos problemas con colgajos locales musculares, fasciocutáneos o neurocutáneos.

Abstract Objectives: report the surgical possibilities that exist in the distal third of the leg and present the experience in the past 15 years with these flaps Materials and methods: During 15 years we performed different flaps like soleus flaps, reversed fasciocutaneous flaps, reversed sural flaps and some microsurgical free flaps to cover defects in the distal third of the leg and the foot Results: We reviewed 112 patients followed at least 3 months, 18 had ankle joint or foot exposure and the other had exposure tendons and / or neurovascular elements. The most used flaps were the soleus, the reversed sural and the reversed fasciocutaneous. Distal necrosis was observed in the edge of the four flaps, but not affecting the final coverage. One of the free flaps suffered a total necrosis. Discussion: Open tibial fracture required fast coverage to reduce infection and promote healing.The soleus muscle is still the main flap to cover the defects of the middle third of the tibia. This series shows that this flap is suitable for many distal leg reconstructions, often avoiding the use of a free flap. The reverse sural flap is very safe and versatile, and is a good option to cover defects on the dorsum of the foot and heel. Free flaps are of greater complexity requiring specialized staff. It is recommended to solve these problems with local flaps, muscle flaps, fasciocutaneous or neurocutaneous flaps.