Simultaneous treatment of tibial bone and soft-tissue defects with the Ilizarov method

OBJECTIVES: To evaluate the potential for limb salvage using the Ilizarov method to simultaneously treat bone and soft-tissue defects of the leg without flap coverage. DESIGN: Retrospective study. SETTING: Level I trauma centers at 4 academic university medical centers. PATIENTS/PARTICIPANTS: Twenty-five patients with bone and soft-tissue defects associated with tibial fractures and nonunions. The average soft-tissue and bone defect after debridement was 10.1 (range, 2-25) cm and 6 (range, 2-14) cm respectively. Patients were not candidates for flap coverage and the treatment was a preamputation limb salvage undertaking in all cases. INTERVENTION: Ilizarov and Taylor Spatial Frames used to gradually close the bone and soft-tissue defects simultaneously by using monofocal shortening or bifocal or trifocal bone transport. MAIN OUTCOME MEASUREMENTS: Bone union, soft-tissue closure, resolution or prevention of infection, restoration of leg length equality, alignment, limb salvage. RESULTS: The average time of compression and distraction was 19.7 (range, 5-70) weeks, and time to soft-tissue closure was 14.7 (range, 3-41) weeks. Bony union occurred in 24 patients (96%). The average time in the frame was 43.2 (range, 10-82) weeks. Lengthening at another site was performed in 15 patients. The average amount of bone lengthening was 5.6 (range, 2-11) cm. Final leg length discrepancy (LLD) averaged 1.2 (range, 0-5) cm. Use of the trifocal approach resulted in less time in the frame for treatment of large bone and soft-tissue defects. There were no recurrences of osteomyelitis at the nonunion site. All wounds were closed. There were no amputations. All limbs were salvaged. CONCLUSIONS: The Ilizarov method can be successfully used to reconstruct the leg with tibial bone loss and an accompanying soft-tissue defect. This limb salvage method can be used in patients who are not believed to be candidates for flap coverage. One also may consider using this technique to avoid the need for a flap. Gradual closure of the defect is accomplished resulting in bony union and soft-tissue closure. Lengthening can be performed at another site. A trifocal approach should be considered for large defects (>6 cm). Advances in technique and frame design should help prevent residual deformity.     

小腿严重开放性骨折伴软组织缺损的治疗

目的 探讨小腿严重开放性骨折伴软组织缺损(Gustilo ⅢB型或ⅢC型)的治疗方法.方法 1990年1月至2008年12月,收治开放性胫腓骨骨折53例,其中Gustilo ⅢB型45例,ⅢC型8例.软组织缺损面积为6 cm×4 cm～18 cm×8 cm,8例伴骨缺损.急诊行骨折复位同定和血管修复,二期对软组织或骨缺损采用13种53块组织瓣移位或移植修复.骨折外固定支架固定35例,内固定16例,骨牵引及石膏固定2例.皮瓣或肌皮瓣47例,骨皮瓣6例.结果 51例获得随访,时间8个月～9年(平均18个月).骨折顺利愈合44例,愈合时间3.5～9.5个月,平均6.5个月.骨延迟愈合4例,骨不愈合3例,经手术植骨(5例)或骨外固定支架加压同定治疗(2例)均治愈.组织瓣移植53块,成活51块,坏死2块,成活率为96.2%.无截肢病例.结论 Gustilo ⅢB型或ⅢC型小腿严重开放性骨折,初期清创并采用以骨外支架为主的方法固定骨折,二期采用适当组织瓣移植修复软组织或骨缺损,是安全有效的治疗策略.     

The treatment of infected nonunions and segmental defects of the tibia by the methods of Ilizarov.

Circular external fixation using the Ilizarov apparatus combined with internal bone transport or compression-distraction techniques were used to treat 28 patients with infected nonunions or segmental bone loss of the tibia. There were 22 males and six females with an average age of 34 years (range, 17-58 years). Six of 28 patients had infected tibial nonunions associated with hemicircumferential bone loss. These tibiae were treated by anterior hemicircumferential corticotomy and partial bone fragment internal transport. Fifteen of the remaining 22 patients had an average of 4 cm of segmental bone loss (range, 2-7 cm). Seven patients without shortening or defect had infected nonunions associated with extensive diaphyseal sequestrae. These nonunions were treated by en bloc resection of the diaphyseal shaft and internal bone transport. All patients healed their infected extremities without the addition of cancellous bone graft, microvascular fibular, or soft-tissue grafting. Preoperative shortening was present in 13 of 28 patients. Regenerate new bone formation averaged 6 cm (range, 1.5-22 cm). Postoperative antibiotics were not administered in 21 of 28 patients. In seven patients, antibiotics were given for ten days after en bloc resection of the diaphyseal sequestrae. Equal limb length was maintained in 21 extremities, within 1 cm in five tibiae and less than 3 cm in two tibiae. Functional results were good to excellent in 21, fair in six, and poor in one. The application of Ilizarov techniques to diaphyseal infected nonunions and segmental defects is very encouraging. It may prove to be an excellent technique for future management of resistant diaphyseal infections of bone.     

Primary shortening with secondary limb lengthening for Gustilo IIIB open tibial fractures: a report of six cases

BACKGROUND: The treatment of type IIIB open tibial fractures remains a challenge for orthopedic surgeons, particularly with respect to the soft-tissue and subsequent bony reconstruction. The primary shortening and limb lengthening (PSLL) simplifies wound closure for severe open injuries without requiring microsurgical procedures as a main advantage. This method is thought to be also useful for type IIIB patients with polytrauma and other life-threatening injuries because it helps to control both wound sepsis and their general state. In the present study, we attempted to assess the problems, long-term functional outcome, and quality of life (QOL) of patients who were treated by PSLL for Gustilo type IIIB open tibial fractures in our facility. METHODS: Six patients with type IIIB open tibial fractures treated with PSLL were retrospectively reviewed. The mean shortening length was 7.4 cm (range, 4.5-10.3 cm). The mean percent shortening of the entire bone was 18.7% (range, 12.3-29.7%). Limb lengthening started at a mean interval of 10.3 months (range, 3-18 months) after the original injury. The mean healing index was 56.5 days/cm (range, 31.3-86.7 days/cm). The complications, functional outcome, and quality of life were evaluated for all cases. RESULTS: One superficial infection at the initial corticotomy, one deep infection around the shortening site, one refracture at the healed docking site, several wire breaks in external frames in two cases, and two severe equinovarus deformities occurred as complications of these procedures. Regarding functional outcome, three patients showed good outcome, two showed fair outcome, and one showed poor outcome. The percent shortening of the entire bone in the two fair cases were more than 25%. The median scale of physical health summary, mental health summary, and total general health summary in Short Form-36 (QOL) were lower than the standard scale in age-matched individuals. CONCLUSION: This PSLL treatment was thought to be a useful option for severe open fracture of the tibia, which had bony defect in more than 4.5 cm in length after serial debridement, although several complications occurred in this regimen. However, it is difficult to achieve an excellent function and QOL using these techniques. In addition, it is difficult for patients who underwent limb lengthening after shortening more than 25% of the total length of bone to gain good function.     

Outcome of limb reconstruction system in open tibial diaphyseal fractures

Background:Management of open tibial diaphyseal fractures with bone loss is a matter of debate. The treatment options range from external fixators, nailing, ring fixators or grafting with or without plastic reconstruction. All the procedures have their own set of complications, like acute docking problems, shortening, difficulty in soft tissue management, chronic infection, increased morbidity, multiple surgeries, longer hospital stay, mal union, nonunion and higher patient dissatisfaction. We evaluated the outcome of the limb reconstruction system (LRS) in the treatment of open fractures of tibial diaphysis with bone loss as a definative mode of treatment to achieve union, as well as limb lengthening, simultaneously.Results:Mean followup period was 15 months. The mean bone loss was 5.5 cm (range 4-9 cm). The mean duration of bone transport was 13 weeks (range 8-30 weeks) with a mean time for LRS in place was 44 weeks (range 24-51 weeks). The mean implant index was 56.4 days/cm. Mean union time was 52 weeks (range 31-60 weeks) with mean union index of 74.5 days/cm. Bony results as per the ASAMI scoring were excellent in 76% (19/25), good in 12% (3/25) and fair in 4% (1/25) with union in all except 2 patients, which showed poor results (8%) with only 2 patients having leg length discrepancy more than 2.5 cm. Functional results were excellent in 84% (21/25), good in 8% (2/25), fair in 8% (2/25). Pin tract infection was seen in 5 cases, out of which 4 being superficial, which healed to dressings and antibiotics. One patient had a deep infection which required frame removal.Conclusion:Limb reconstruction system proved to be an effective modality of treatment in cases of open fractures of the tibia with bone loss as definite modality of treatment for damage control as well as for achieving union and lengthening, simultaneously, with the advantage of early union with attainment of limb length, simple surgical technique, minimal invasive, high patient compliance, easy wound management, lesser hospitalization and the lower rate of complications like infection, deformity or shortening.     

Elastic nailing of tibia shaft fractures in young children up to 10 years of age

IntroductionAlthough tibia shaft fractures in children usually have satisfactory results after closed reduction and casting, there are several surgical indications, including associated fractures and soft tissue injuries such as open fractures. Titanium elastic nails (TENs) are often used for pediatric tibia fractures, and have the advantage of preserving the open physis. However, complications such as delayed union or nonunion are not uncommon in older children or open fractures. In the present study, we evaluated children up to 10 years of age with closed or open tibial shaft fractures treated with elastic nailing technique.MethodsA total of 16 tibia shaft fractures treated by elastic nailing from 2001 to 2013 were reviewed. The mean patient age at operation was 7 years (range: 5–10 years). Thirteen of 16 cases were open fractures (grade I: 4, grade II: 6, grade IIIA: 3 cases); the other cases had associated fractures that necessitated operative treatments. Closed, antegrade intramedullary nailing was used to insert two nails through the proximal tibial metaphysis. All patients were followed up for at least one year after the injury. Outcomes were evaluated using modified Flynn's criteria, including union, alignment, leg length discrepancies, and complications.ResultsAll fractures achieved union a mean of 16.1 weeks after surgery (range: 11–26 weeks). No patient reported knee pain or experienced any loss of knee or ankle motion. There was a case of superficial infection in a patient with grade III open fracture. Three patients reported soft tissue discomfort due to prominent TEN tips at the proximal insertion site, which required cutting the tip before union or removing the nail after union. At the last follow-up, there were no angular or rotational deformities over 10° in either the sagittal or coronal planes. With the exception of one case with an overgrowth of 15 mm, no patient showed shortening or overgrowth exceeding 10 mm. Among final outcomes, 15 were excellent and 1 was satisfactory.SummaryEven with open fractures or soft tissue injuries, elastic nailing can achieve satisfactory results in young children, with minimal complications of delayed bone healing, or infection.     

Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol

OBJECTIVES: This study evaluated the use of a staged protocol involving temporary spanning external fixation and delayed formal definitive fixation in the management of high-energy proximal tibia fractures (OTA types 41) with regard to soft-tissue management, development of complications, and functional outcomes. SETTING: Two level-one trauma centers and a tertiary care orthopaedic center. PATIENTS: Fifty-three patients with 57 high-energy tibial plateau fractures. METHODS: The authors instituted a protocol of immediate placement of knee spanning external fixation with management of soft-tissue injuries for all high-energy proximal tibia fractures. Between August 1999 and May 2002, 62 consecutive patients with 67 high-energy proximal tibia fractures (OTA types 41A, B, C) underwent temporary knee spanning external fixation on the day of admission. Nine patients with 10 fractures who transferred care after initial stabilization or sustained an extraarticular fracture were excluded. The remaining 53 patients with 57 fractures underwent repair of articular fractures and meta-diaphyseal fracture repair with plates and screw constructs or conversion to a ring fixator. These patients had a mean age of 47 years (standard deviation (SD), 14). Of these 53 patients, 42 (79%) were men and 11 (21%) were women. Characteristics of the 57 fractures were: 42 Schatzker VI (74%), 12 Schatzker V (21%), 2 Schatzker IV (4%), and 1 Schatzker II (2%). There were 41 closed fractures and 16 open fractures. (One patient had bilateral fractures with 1 extremity open and 1 closed). Orthopaedic evaluation at latest follow-up included a clinical and radiographic examination and functional outcome measurement with the Western Ontario McMaster functional knee score (WOMAC). Eight patients with 8 fractures were lost to follow-up. This left 45 patients with 49 fractures with a mean follow-up of 15.7 (SD, 5.7; range, 8-40) months. RESULTS: Complications included 3 (5%) deep wound infections, 2 (4%) nonunions, and 2 patients (4%) with significant knee stiffness (<90 degrees). Nine patients (16%) underwent additional surgery after definitive skeletal stabilization related to their injury. Range of knee motion at final follow-up was 1 degrees (SD, 4) to 106 degrees (SD, 15). The mean WOMAC was 91 (SD, 55). Poor results did not correlate with demographic or injury characteristics. DISCUSSION: We had a relatively low rate of wound infection in these complex injuries (5% overall). There was only 1 wound problem in our subset of patients with closed fractures and 2 infections in those with open fractures. One downside of this technique may be residual knee stiffness. The benefits of temporizing spanning external fixation include osseous stabilization, access to soft tissues, and prevention of further articular damage. Our relatively low rates of complications in patients who sustain high-energy proximal tibia fractures and the access this technique affords in open fractures and those with compartment syndrome lead us to recommend this technique in all high-energy intra-articular and extra-articular fractures of the proximal tibia. CLINICAL RELEVANCE: This study supports the practice of delayed internal fixation until the soft-tissue envelope allows for definitive fixation.     

Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor spatial frame

Infected tibial nonunions with bone loss pose an extremely challenging problem for the orthopaedic surgeon. A comprehensive approach that addresses the infection, bone quality, and overlying soft-tissue integrity must be considered for a successful outcome. Acute shortening with an Ilizarov frame has been shown to be helpful in the treatment of open tibia fractures with simultaneous bone and soft-tissue loss. Cases in which the soft-tissue defect considerably exceeds bone loss may require an Ilizarov frame along with a concomitant soft-tissue procedure; however, there are a number of potential difficulties with vascularized pedicle flaps and free tissue flaps, including anastomotic complications, partial flap necrosis, and flap failure. The technique described in this report involves acute shortening and temporary bony deformation with the Ilizarov apparatus to facilitate wound closure and does not require a concomitant soft-tissue reconstructive procedure. Once the wound is healed, osseous deformity and length are gradually corrected by distraction osteogenesis with the Ilizarov/Taylor Spatial frame.     

Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia

We have managed 21 patients with a fracture of the tibia complicated by bone and soft-tissue loss as a result of an open fracture in 10, or following debridement of an infected nonunion in 11, by resection of all the devitalised tissues, acute limb shortening to close the defect, application of an external fixator and metaphyseal osteotomy for re-lengthening. The mean bone loss was 4.7 cm (3 to 11). The mean age of the patients was 28.8 years (12 to 54) and the mean follow-up was 34.8 months (24 to 75). All the fractures united with a well-aligned limb. The mean duration of treatment for the ten grade-III A+B open fractures (according to the Gustilo-Anderson classification) was 5.7 months (4.5 to 8) and for the nonunions, 7.6 months (5.5 to 12.5). Complications included one refracture, one transient palsy of the peroneal nerve and one equinus contracture of 10 degrees .     

Extreme bone lengthening using distraction osteogenesis after trauma: a case report

We are reporting herein the result of a 22 cm tibial lengthening after using an acute shortening technique with acute temporary angulation for salvage of a posttraumatic lower limb injury. The patient was referred to our center 2 weeks after a Gustilo IIIB open complex injury to the lower limb that included bone and soft-tissue loss. After surgical debridement, the tibial gap was 22 cm and the soft-tissue defect on the anterior aspect of the calf measured 12 x 20 cm. An acute shortening using a 50 degrees angulation (apex posteriorly) of the tibia in an Ilizarov frame was done after a full assessment of all reconstructive surgical options. After complete wound healing, a progressive correction of the angulation was done. Bilevel tibial distraction at a rate of 1.75 mm/day restored the original lower limb length. The 22 cm tibial elongation included 17 cm proximal lengthening and 5 cm distal lengthening. The fractures consolidated after 371 days, all wounds had closed, and no signs of osteomyelitis were present. Good aesthetic and functional results were obtained. The patient had no leg discrepancy compared to his normal limb and he returned to his previous occupation as a garage mechanic and to his favorite sport, boxing. To our knowledge, this is the first report in the English literature of tibial lengthening of this magnitude following acute trauma.     

应用胫骨Ⅰ期短缩加Ⅱ期延长治疗严重胫骨开放性骨折

目的 评价应用胫骨Ⅰ期短缩加Ⅱ期延长的方法治疗严重胫骨开放性骨折的临床效果.方法 自2006年5月至2009年8月应用胫骨Ⅰ期短缩加Ⅱ期延长治疗5例严重胫骨开放骨折患者,均为男性;年龄23～41岁,平均35岁.清创和胫骨短缩后用单边外固定支架临时固定,血管损伤者行动脉吻合.1例伤口Ⅰ期闭合,2例经植皮后愈合,2例分别通过腓肠神经营养支筋膜瓣和交腿皮瓣闭合伤口.伤口愈合后从胫骨近端做截骨,应用Ilizarov架行胫骨延长,恢复小腿的长度.胫骨短缩3～5 cm,平均4.2 cm.结果 所有患者术后获18～24个月(平均20个月)随访.患者骨折短缩处伤口均获愈合,无一例发生感染.全部患者骨折均获愈合,愈合时间为6～12.5个月,平均9.6个月,平均愈合指数1.7个月/cm,患肢长度均恢复,与健侧无差别.按Paley功能评价标准:优3例,良1例,可1例.结论 应用胫骨Ⅰ期短缩加Ⅱ期延长治疗严重胫骨开放性骨折,具有安全可靠、简化治疗过程及减少皮瓣应用等优点,是一种较好的方法.

Abstract：

Objective To evaluate clinical results of primary shortening plus secondary lengthening of the tibia for sever tibial fractures. Methods From May 2006 to August 2009, 5 men with severe open tibial fracture were treated with primary shortening plus secondary lengthening of the tibia in our center. They were aged from 23 to 41 years (average, 35 years) . Four cases were Gustilo type MB and one was Gustilo type M C. The primary procedure included debridement, shortening of the tibia and temporary fixation with a unilateral external fixator, and arterial anastomosis in cases of vessel injury. The wounds healed primarily in one case, after skin graft in 2 cases, and after flap transplantation in 2 cases. After wound healing, secondary lengthening of the tibia was performed following osteotomy of the proximal tibia with an Ilizarov fixator to restore the length of the injured leg. The average shortening was 4. 2 cm (range, 3 to 5 cm). Results The average follow-up period was 20 months (range, 18 to 24 months). All the wounds were healed without signs of osteomyelitis. All the fractures united. The mean bone healing time was 9. 6 months (range, 6 to 12. 5 months) . The average healing index was 1. 7 months/cm. A normal length was restored in all the affected lower limbs. By Paley functional assessment system, 3 cases were excellent, one was good and one was fair. Conclusion Primary shortening plus secondary lengthening of the tibia is a reliable and successful method for sever tibial fractures, because it can simplify management and minimize the need for flap coverage.     

Reconstruction of distal tibia fractures using a posterolateral approach and a blade plate

OBJECTIVE: The aim of this article is to report a technique for the management of distal tibia fractures with significant anteromedial soft-tissue injury. The patients were initially treated with a spanning external fixator, open reduction and internal fixation (ORIF) of the fibula at the discretion of the surgeon, and soft-tissue management or flap coverage. ORIF of the tibia was performed on a staged basis, using a 90-degree cannulated blade plate and autogenous iliac crest bone graft through a posterolateral approach. DESIGN: Retrospective analysis of a consecutive series of patients. SETTING: Two academic level-1 trauma centers. PATIENTS: Fifteen patients with 15 distal tibia fractures (13 open fractures), Orthopedic Trauma Association (OTA) type 43A3 and 43C1, were definitively treated and followed to union between July 2000 and July 2004. Five patients were referred from outside sources after initial stabilization. INTERVENTION: Initial stabilization in an external fixator and management of the open fracture and soft tissue. Staged ORIF of the tibia with bone graft was performed through a posterolateral approach when the soft tissues allowed. OUTCOME MEASUREMENTS: Radiographic union, American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and complications. RESULTS: All 15 fractures were followed to union. Average time to union was 20 (12 to 47) weeks from the time of fixation with blade plate and bone grafting. (AOFAS) ankle-hindfoot score was used to measure outcome. The average score was 81 (60 to 97) out of a possible 100. There were no deep infections. There was one nonunion; the fracture united after revision with a locked plate and bone graft. The average length of follow-up was 14 months (4 to 37). CONCLUSIONS: The staged treatment of high-energy distal tibia fractures with soft-tissue injury can lead to good outcomes and consistent bone union. Our results were obtained by the combination of the posterolateral approach, careful soft-tissue management, and stable internal fixation.     

Korrekturosteotomie bei lateraler Tibiakopfimpression und Valgusfehlstellung

OBJECTIVE: Improvement of joint congruency in malunited lateral tibial plateau fractures, reduction of pain, prevention of osteoarthritis. INDICATIONS: Valgus malalignment of the proximal tibia combined with intraarticular depression of the tibial plateau. CONTRAINDICATIONS: Patients in poor general condition. Severe loss of knee function Elderly patients (> 65 years). Chronic infection. Soft-tissue problems, Inability to perform non-weight bearing after the operation SURGICAL TECHNIQUE: Oblique osteotomy of the middle third of the fibula. Straight lateral or parapatellar approach to the lateral proximal tibia. Lateral arthrotomy of the knee joint. Proximal open wedge osteotomy of the tibia. Intraarticular correction of the depressed lateral tibial plateau through subchondral impaction of cancellous bone grafts. Evaluation of leg alignment. Interposition of bicorticocancellous bone grafts to maintain the open wedge osteotomy. Internal fixation, if necessary. POSTOPERATIVE MANAGEMENT: Continuous passive motion to 90 degrees of flexion from the 1st postoperative day. After application of a stabilizing brace, patients are allowed toe-touch weight bearing for 8 weeks. After radiologic bony healing has occurred, patients are allowed to increase weight bearing stepwise. RESULTS: Between 1977 and 1998, 23 patients were operated on. There were two failures resulting in one arthrodesis and one total knee arthroplasty. After an average of 14 years (5-26 years) 21 patients were followed up. Two patients suffered from severe progression of osteoarthritis after the osteotomy, four had some progression of cartilage degeneration, and 15 presented without changes in osteoarthritis. Mean difference in pre- and postoperative tibiofemoral angle was 8.6 degrees (range 13-4.4 degrees), mean difference in pre- and postoperative depression 6 mm (range 4-9 mm), and mean difference in pre- and postoperative range of motion 12 degrees (range 0-20 degrees). There were no nonunions.     

Open fractures of the tibia treated by immediate intramedullary tibial nail insertion without reaming: a prospective study

OBJECTIVE: Does immediate tibial nail insertion without reaming as part of protocol-driven management provide a safe and effective treatment for open tibia fractures? STUDY DESIGN: Prospective cohort. SETTING: Level 1 trauma center. PATIENTS: A consecutive series of 161 patients with Gustilo grade I-IIIb open tibia fractures. INTERVENTION: Emergent incision and debridement of the wound with immediate tibial nail insertion without reaming, repeat incision and debridement, and soft-tissue coverage within 14 days. MAIN OUTCOME MEASUREMENTS: Time to union, number of secondary procedures performed to obtain union, implant failures, and the type and incidence of complications. RESULTS: One hundred and forty-three fractures were followed to union. Follow up averaged 2.2 years (0.6-5.5 years). Seventy-six fractures united in less than 6 months, 35 took between 6 and 9 months, and 32 took longer than 9 months. Twenty-five additional procedures were needed to obtain union in 16 of the delayed unions (12 nail exchanges, 4 bone grafts, 9 dynamizations). Complications included 3 patients with cellulitis, 1 superficial infection, 4 deep infections (1 grade I, 2 grade II, 1 grade IIIb), 3 loose screws, 2 broken screws, 5 malunions greater than 5 degrees, and 30 patients with decreased ankle motion when compared with the uninjured side. Not counting the ankle loss of motion, 18 complications occurred in 143 fractures (13%). Twenty-nine patients (20%) had complaints of minor knee pain and 30 (21%) had occasional fracture site pain after activity despite clinical and radiographic evidence of union. Eleven patients (8%) considered themselves completely disabled. Five patients were not treated by the standard protocol and are not included in the previously listed statistics; 3 were grade IIIB that did not have adequate coverage by 14 days, and 2 were grade II injuries that did not have a second debridement. Four of these 5 patients developed a complication. CONCLUSIONS: Protocol-driven management emphasizing meticulous soft-tissue management and the use of immediate tibial nailing without reaming appears to be safe and effective in the treatment of open tibia fractures. The deep infection rate for the patients who were treated by protocol was 3% and the implant failure rate was lower than has been previously reported, most likely attributable to attempts to obtain cortical contact and avoid fracture gaps. Overall satisfaction was good, but approximately 41% of the patients had complaints of knee or fracture site pain or both well after union.     

Subacute reconstruction of lower leg and foot defects due to high velocity-high energy injuries caused by gunshots, missiles, and land mines

The present study reviews 215 male patients suffering high velocity-high energy injuries of the lower leg or foot caused by war weapons such as missiles, gunshots, and land mines. They were treated in the Department of Plastic and Reconstructive Surgery at Gulhane Military Medical Academy (Ankara, Turkey) between November 1993-January 2001. Severe soft-tissue defects requiring flap coverage and associated open bone fractures that were treated 7-21 days (mean, 9.6 days) after the injury were included in the study. Twenty-three of 226 extremities (10.2%) underwent primary below-knee amputation. The number of debridements prior to definitive treatment was between 1-3 (mean, 1.9). Gustilo type III open tibia fractures accompanied 104 of 126 soft-tissue defects of the lower leg. Sixty-four bone defects accompanied 83 soft-tissue defects of the feet. Eighteen local pedicled muscle flaps and 208 free muscle flaps (latissimus dorsi, rectus abdominis, and gracilis) were used in soft-tissue coverage of 209 defects. Overall, the free muscle flap success rate was 91.3%. Bone defects were restored with 106 bone grafts, 25 free fibula flaps, and 14 distraction osteogenesis procedures. Osseous and soft-tissue defects were reconstructed simultaneously at the first definitive treatment in 94% of cases. The mean follow-up after definitive treatment was 25 (range, 9-47) months. The average full weight-bearing times for lower leg and feet injuries were 8.4 months and 4 months, respectively. Early, aggressive, and serial debridement of osseous and soft tissue, early restoration of bone and soft-tissue defects at the same stage, intensive rehabilitation, and patient education were the key points in the management of high velocity-high energy injuries of the lower leg and foot.     

External fixation of femoral fractures. Indications and limitations

The role of external fixation in the management of femoral shaft fractures is reviewed based on a study of 24 femoral fractures managed by either an AO or a Wagner external fixator during 1983-1986. Indications included open fractures with soft-tissue injury (13 patients), comminuted shaft fractures (six patients), and unstable operative candidates (five patients). In 14 patients, external fixation was a temporary method (Group I), while in ten patients it was the definitive method of stabilization (Group II). Twenty-one patients achieved solid union, two developed a delayed union, and one had a nonunion. Three patients developed pin-tract infections, and one developed osteomyelitis after intramedullary fixation in Group I. Two patients in Group II developed shortening (2.1 cm and 3.2 cm). Loss of motion occurred in 11 patients, averaging 56 degrees. It is suggested that external fixation be considered in the following types of femoral fractures: open fractures for aggressive management of soft-tissue injuries; closed fractures in severely traumatized, burn, or head injury patients; fractures about the knee resulting in floating knees; and infected femoral nonunions and pseudarthroses.     

Treatment of open tibial fracture with fixateur externe

External fixation with a Hoffmann or an ASIF frame was used in the treatment of 50 severe open lower leg fractures from 1979 to 1987. In 7 cases consolidation was achieved by means of external fixation without changing to any other method. Plaster cast fixation was subsequently performed after soft-tissue healing in 35 patients. Further methods of treatment applied after external fixation were intramedullary nailing in 5 cases, internal stabilization with a plate in 1 case and provision of a surgical support in 1 case. In 1 patient early amputation was necessary. On average, fracture healing took 6.7 (4-15) months, significantly correlating with the severity of soft-tissue lesion. Compound fractures of the proximal tibial shaft turned out to be problem cases, requiring up to 15 months for bone union. Acute infections occurred in 6 cases (12%), despite primary antibiotic prophylaxis. Nonunion was noted in 2 patients. A follow-up examination of 33 patients after a median of 45 months (range 6-99) showed full weight-bearing in all cases. Persistent soft-tissue problems were found in 7 patients, chronic osteitis in 4, and shortening of the extremity by up to 2 cm in 11 cases. One-third of the patients were out of work or had had to change their jobs as a social effect of their severe injuries.     

Acute shortening and lengthening following vascular repair with a vein graft for Gustilo–Anderson type IIIC open fracture: A report of two cases

We present two cases of lower extremity open fractures with vascular injury, where acute shortening and early lengthening were performed, following vascular repair with a vein graft. The two patients sustained Gustilo–Anderson type IIIC open fractures (one patient in the tibia and the other patient in the femur) with disruption of the popliteal artery. Initially, they were treated with debridement and stabilization using an external fixator. The disruptions of the popliteal artery were repaired by interposition of a saphenous vein graft. As soon as possible after the injury, the bone segment was resected and shortening was initiated with careful monitoring of blood circulation. After the bone gap and soft-tissue defects were closed at the end of the shortening, distraction osteogenesis was carried out in the proximal part of the tibia and the femur, respectively.There is not study reporting acute shortening and early lengthening performed on patients who underwent vascular repair with a vein graft. The procedures did not affect blood circulation, and resulted in a good clinical outcome. We consider this method a safe and effective way to treat lower extremity open fractures with vascular injury and massive soft tissue defects.     

Ender nail fixation in long bone fractures: experience in a level I trauma center

Early fixation of extremity fractures in polytrauma patients is a well accepted and desirable treatment. In our patient population, the indications for immediate Ender nail fixation was for Grade I and Grade II open long bone fractures and closed long bone fractures in patients with small intramedullary canals. Ender nails were also used in patients in whom reaming was undesirable. This included patients with open physes for immediate fracture fixation and in those with Grade III open wounds in a delayed fashion. These flexible nails were also implemented for use to minimize anesthesia time as a life saving measure in the severely injured. This study is a retrospective review of a 30-month period in which 68 patients with 91 fractures underwent Ender intramedullary nailing. The mean Injury Severity Score (ISS) was 12.4. There were 16 humerus fractures, 26 femur fractures, and 49 tibia fractures. Thirty-three per cent (30 fractures) were open fractures. The average operating time per fracture was 70 minutes (range, 15 to 150 minutes). The estimated blood loss per fracture was 150 cc with a range of 25 to 500 cc. The average followup is currently 19 months (range was 8 to 29 months). This approach achieved an excellent result in 95% of the patients treated. There were no wound, soft-tissue, or bony infections experienced. Major complications were seen in five patients: three nonunions and two malunions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Complications associated with the posterolateral approach for pilon fractures

OBJECTIVE: To review the complication rates of open reduction and internal fixation (ORIF) of tibial pilon fractures using the posterolateral approach. DESIGN: Retrospective review. SETTING: Two level I trauma centers. PATIENTS: Nineteen consecutive pilon fractures at an average of 13 (range, 13-45) months follow-up. Average age 46 (range, 21-72) years. Four of 19 were open fractures. INTERVENTION: Because of the high incidence of wound complications associated with the anterior approach for pilon fractures, patients were treated with initial temporary external fixation followed by delayed ORIF through the posterolateral approach to the distal tibia. The hypothesis was that the abundant soft-tissue coverage of the posterior distal tibia would decrease the rate of wound complications. MAIN OUTCOME MEASUREMENTS: The incidence of wound complications, nonunion, and early posttraumatic arthritis. This was a chart and radiograph retrospective review. RESULTS: The mean time to definitive treatment was 13 (range 2-30) days. Nine of 19 patients (47%) developed complications. There were 6 patients with wound problems, 2 patients with aseptic nonunions, 2 patients with infected nonunions, 3 tibiotalar fusions, and 1 patient with a 3-mm step off. In total, there were 14 major complications in 9 patients. Ten of 19 patients did not have any complication. CONCLUSIONS: The posterolateral approach does not eliminate the complications common to other approaches, but does offer a potential alternative when soft tissue concerns prevent other approaches. We do not recommend the posterolateral approach for the routine treatment of tibial pilon fractures.