The functional outcome of severe, open tibial fractures managed with early fixation and flap coverage

We studied the outcome and functional status of 33 patients with 34 severe open tibial fractures (Gustilo grade IIIb and IIIc). The treatment regime consisted of radical debridement, immediate bony stabilisation and early soft-tissue cover using a muscle flap (free or rotational). The review included standardised assessments of health-related quality of life (SF-36 and Euroqol) and measurement of the following parameters: gait, the use of walking aids, limb-length discrepancy, knee and ankle joint function, muscle wasting and the cosmetic appearance of the limb. Personal comments and overall patient satisfaction were also recorded. The mean follow-up was 46 months (15 to 80). There were 30 Gustilo grade IIIb fractures and and four grade IIIc fractures. Of the 33 patients, 29 had primary internal fixation and four, external fixation; 11 (34%) later required further surgery to achieve union and two needed bone transport procedures to reconstruct large segmental defects. The mean time to union was 41 weeks (12 to 104). Two patients (6.1%) developed deep infection; both resolved with treatment. The mean SF-36 physical and mental scores were 49 and 62 respectively. The mean state of health score for the Euroqol was 68. Patients with isolated tibial fractures had a better outcome than those with other associated injuries on both scoring systems. Knee stiffness was noted in seven patients (21%) and ankle stiffness in 19 (56%); 12 patients (41%) returned to work. Our results compare favourably with previous outcome measurements published for both limb salvage and amputation. All patients were pleased to have retained their limbs.     

Early unreamed intramedullary nailing without a safety interval and simultaneous flap coverage following external fixation in type IIIB open tibial fractures: a report of four successful cases

The conversion method from external fixation (EF) to intramedullary nailing (IMN) for open tibia fractures, especially to Gustilo type IIIB open tibia fractures, have potentially high risk of infections. We document a report of a more progressive approach in four consecutive cases of type IIIB open tibial fractures successfully managed with early unreamed IMN without a safety interval and simultaneous flap coverage following EF. The mean patients age at the time of injury was 43.8 years (range 23-64 years), and three patients were male. The timing from EF to IMN without safety interval combined with well-vascularised flap (free latissimus dorsi flaps in two patients and pedicled soleus flaps in two patients) ranged 48 to 72 hours. Average time to union was 14 months (range 9-21 months). There was one nonunion patient whose fracture healing was gained by reamed IMN without bone grafting. However, there were no infections. The functions in all patients were satisfactory. This early unreamed IMN without a safety interval and with simultaneous flap coverage following EF is a useful and effective option for treating type IIIB open tibial fractures.     

早期软组织覆盖成形在重度开放性胫骨骨折治疗中的作用

目的　研究早期软组织覆盖成形在重度开放性胫骨骨折治疗中的作用。　方法　Ⅲb型开放性胫骨骨折 76侧按软组织覆盖成形的时间不同分为三组。早期 (0～ 7d) 31侧 ,中期 (8～ 30d)2 4侧 ,晚期 (>30d) 2 1侧。比较各组感染、骨不愈合等并发症的发病率和平均骨折愈合时间。　结果　早期软组织覆盖成形组深部感染、骨折不愈合等并发症的发生率 (6 5 % ,12 9% )明显低于中、晚期组 (5 0 0 %、47 6 %和 37 5 %、38 1% ) ,平均骨折愈合时间 (5 0周 )少于中、晚期组 (78周和 82周 )。　结论　早期软组织覆盖成形可明显减少重度开放性胫骨骨折的并发症 ,缩短骨愈合时间。“早期”应尽量限于 1周内 ,1周后医源性感染的机会将会增加。     

Posterolateral approach for tibial pilon fractures: a report of two cases

Open reduction and internal fixation (ORIF) of displaced tibial pilon fractures can lead to a high percentage of good and excellent functional results, but has also been associated with a meaningful incidence of wound breakdown and infection. The use of the posterolateral approach to the distal tibia for ORIF of tibial pilon fractures is presented. This may be used instead of the standard anteromedial incision in certain fracture configurations. The flexor hallucis longus muscle coverage overlying the plate fixation of the tibia and ability to fix both the tibia and fibula through the same incision may decrease the risk of deep infection and wound complications in these injuries frequently associated with marked soft tissue trauma.     

Iatrogenic fractures in ankylosing spondylitis—a report of two cases

Study design: Two cases of intraoperative, iatrogenic cervical spine fractures in patients with ankylosing spondylitis are reported. Objective: To describe the uncommon complication of iatrogenic cervical spine fractures occurring during spine surgery in patients with ankylosing spondylitis. Summary of background data: To our knowledge, this is the first report on this rare complication. Methods: A 39-year-old patient (1) with ankylosing spondylitis was operated on for cervical stenosis due to C1/2 anterolisthesis. Fifteen hours postoperatively, he developed acute quadriplegia. MRI revealed a fracture/dislocation of C6 on C7 and compression of the spinal cord at this level. Revision was performed with decompression and instrumentation from the occiput to T3. A 55-year-old patient (2) with ankylosing spondylitis and thoracic hyperkyphosis underwent a correction procedure consisting of costotransversectomy, anterior cage implantation at T8/9, and posterior instrumentation from T4 to L1. Halo traction was temporarily applied for correction. At the end of the operation, with the patient still under anesthesia, increased mobility of the cervical spine was noticed. Emergent MRI revealed a fracture of the anterior structures of C6/7. Posterior instrumentation from C5 to T1 was then performed. Results: Quadriplegia persisted in patient 1 until his death secondary to further complications. Patient 2 was mobilized without any neurologic deficits. The fracture healed in good alignment. Conclusions: Iatrogenic fractures of the cervical spine during surgery in ankylosing spondylitis patients are a rare but potentially severe complication. Early diagnosis and therapy are necessary before dislocation, cord compression, and subsequent neurologic impairment occur.     

Actinomycosis complicating fibula flap mandible reconstruction: a report of two cases.

Two patients undergoing fibula flap mandible reconstruction developed chronic intraoral wounds and salivary fistulae. After initial attempts at salvage, tissue biopsies demonstrated Actinomycosis infection. With antibiotic treatment and debridement, one reconstruction was salvaged while one was lost. Actinomycosis infection should be considered a possible agent in chronic wounds complicating mandible reconstructions with microsurgical flaps.     

重度开放性Pilon骨折的治疗

目的 探讨重度开放性Pilon骨折的手术时机、手术方法选择及其对治疗效果的影响.方法 2003年4月至2008年7月收治开放性Pilon骨折患者21例,骨折按AO/OTA分类,均为C型,C2型17例,C3型4例;软组织损伤程度按照Gustilo标准,Ⅱ度18例,Ⅲ A度2例,Ⅲ B度1例.根据骨折类型、软组织损伤程度及受伤时间的不同采用两种不同的治疗方法,GustiloⅡ度C2型16例,GustiloⅡ度C3型2例,Gustilo ⅢA度C2型l例,采用创面清创胫骨有限内固定结合支架外固定术;GustiloⅢA度C3型1例,Gustilo ⅢB度C3型1例,采用创面清创跟骨牵引、延期手术.结果 所有患者术后获得6～48个月的随访,平均24个月.骨折复位情况影像学评估结果(Burwell-Charnley标准):解剖复位6例,复位一般14例,复位差1例.骨折全部愈合,愈合时间2.5～11个月,平均4.7个月,其中骨折延迟愈合2例,延迟愈合率9.5%.创面皮肤浅表坏死2例,浅表感染2例,深部感染1例,感染率14.3%.早期出现踝关节创伤性关节炎8例,发生率38.1%.按美国骨科协会足踝外科分会(American Orthopedic Foot Ankle Society,AOFAS)评分标准:评分为66～94分,平均85.2分.主要并发症包括皮肤、软组织坏死、感染,骨折延迟愈合,创伤性关节炎等.结论 治疗开放性Pilon骨折要根据骨折类型、软组织损伤程度及受伤时间的不同选择适当的手术时机和手术方式,正确评估软组织损伤情况、骨与软组织血运的保护是治疗关键.严格的清创、合理应用抗生素、酌情植骨、适时的功能锻炼可以减少并发症的发生.     

重度开放性Pilon骨折的治疗

Objective To discuss the operative methods, timing and outcomes of severe open Pilon fractures. Methods From April 2003 to July 2008, 21 patients with open Pilon fractures were admitted. All the patients were type C fracture according to AO/OTA classification, including 17 cases of type C2 and 4 cases of type C3. According to Gustilo classification, there were 18 cases of type Ⅱ, 2 cases of type ⅢA, 1 case of type ⅢB. The patients were treated in two different ways: one-stage minimally invasive osteosynthesis for reconstruction of the articular surface with transarticular external fixation of the ankle (19 cases),which included 16 cases of Gustilo Ⅱ AO/OTA C2, 2 cases of type Gustilo Ⅱ AO/OTA C3 and 1 case of type Gustilo ⅢA AO/OTA C2. Formal open reconstruction of the articular surface by plating and external fixation was performed when the condition of soft tissue had improved (2 cases), which included 1 cases of type Gustilo ⅢA AO/OTA C3 and 1 cases of type Gustilo Ⅲ B AO/OTA C3. Results All the patients were followed up from 6 to 48 months, with the mean of 24 months. The outcome of reduction was evaluated by the Burwell-Charnley score. Anatomical reduction was found in 6 cases, function reduction was in 14 cases and poor reduction was 1 case. The heal-time ranged from 2.5 to 11 months, with the mean of 4.7 months. The delayed union occurred in 2 cases. The rate of delayed union was 9.5%. Two patients experienced skin superficial necrosis. There were superficial infection in 2 cases and deep infection in 1 case. The infection rate was 14.3%. Eight cases experienced early traumatic arthritis. The incidence of this complication was 38.1%.According to American Orthopedic Foot Ankle Society (AOFAS) scale for ankle joint, the result of the treatment was 66-94, with an average of 85.2. Conclusion It is important to have the optimal timing of surgery and reliable fixation according to fracture classification, the condition of soft tissue and time after injury. It is the key to evaluate the condition of soft tissue and protect the blood supply.     

Shunt surgery in growing skull fractures: report of two cases

Growing skull fractures indicate underlying brain damage which is an important aetiological factor in their development. Two cases of growing skull fractures managed successfully with shunt surgery are presented. In one, the growing skull fracture was associated with an underlying tense occipital porencephalic cyst and in the other with cystic encephalomalacia and hydrocephalus. Following shunt surgery, signs of raised intracranial pressure were relieved, improvement in neurological status was noted, regrowth of the bone edges was seen and major surgery including brain debridement was avoided. The role of shunt surgery in growing skull fractures in infants is discussed and relevant details highlighted.     

Soft tissue coverage in open fractures of tibia

Background:

The treatment of Gustilo Anderson type 3B open fracture tibia is a major challenge and it needs aggressive debridement, adequate fixation, and early flap coverage of soft tissue defect. The flaps could be either nonmicrovascular which are technically less demanding or microvascular which has steep learning curve and available only in few centers. An orthopedic surgeon with basic knowledge of the local vascular anatomy required to harvest an appropriate local or regional flap will be able to manage a vast majority of open fracture tibia, leaving the very few complicated cases needing a free microvascular flap to be referred to specialized tertiary center. This logical approach to the common problem will also lessen the burden on the higher tertiary centers. We report a retrospective study of open fractures of leg treated by nonmicrovascular flaps to analyze (1) the role of nonmicrovascular flap coverage in type 3B open tibial fractures; (2) to suggest a simple algorithm of different nonmicrovascular flaps in different zones and compartment of the leg, and to (3) analyze the final outcome with regards to time taken for union and complications.

Materials and Methods:

One hundered and fifty one cases of Gustilo Anderson type 3B open fracture tibia which needed flap cover for soft tissue injury were included in the study. Ninety four cases were treated in acute stage by debridement; fracture fixation and early flap cover within 10 days. Thirty-eight cases were treated between 10 days to 6 weeks in subacute stage. The rest 19 cases were treated in chronic stage after 6 weeks. The soft tissue defect was treated by various nonmicrovascular flaps depending on the location of the defect.

Results:

All 151 cases were followed till the raw areas were covered. In seven cases secondary flaps were required when the primary flaps failed either totally or partially. Ten patients underwent amputation. Twenty-two patients were lost to followup after the wound coverage. Out of the remaining 119 patients, 76 achieved primary acceptable union and 43 patients went into delayed or nonunion. These 43 patients needed secondary reconstructive surgery for fracture union.

Conclusion:

open fracture of the tibia which needs flap coverage should be treated with high priority of radical early debridement, rigid fixation, and early flap coverage. A majority of these wounds can be satisfactorily covered with local or regional nonmicrovascular flaps.     

外固定架在地震致重度胫腓骨开放性骨折早期处理中的应用

目的 评估外固定架应用于地震伤致重度胫腓骨开放性骨折的早期治疗效果.方法 2008年5月12至17日收治83例(116侧)地震伤致胫腓骨开放性骨折伤员(均为Gustilo Ⅲ度开放性骨折),均采用积极清创结合外固定架治疗,主要评估指标包括深部感染的发生、截肢及伤口愈合情况.结果 83例(116侧骨折)伤员获18-23d随访.9侧Ⅲc型骨折术后出现肢体缺血坏死而行截肢术,1侧Ⅲb型骨折因肢体感染坏死合并脓毒败血症而行截肢术.20侧肢体出现深部感染,经反复创口清创、扩创后感染得到控制.伤口一期愈合52侧,二期愈合54侧(包括使用皮瓣、肌瓣、肌皮瓣转移及植皮术等治疗).结论 地震伤致重度胫腓骨开放性骨折的早期治疗中,应用外固定架固定可作为一种有效的治疗手段.     

吻合血管腓骨复合组织皮瓣移植修复与重建胫骨重度开放性粉碎性骨折

目的 探讨吻合血管的腓骨复合组织皮瓣移植一期固定与重建胫骨重度开放性粉碎性骨折的效果.方法 2001年2月至2007年10月收治胫骨重度开放性粉碎性骨折伴软组织缺损患者23例,男16例,女7例;年龄16～52岁,平均26.8岁.按Gustilo分型均为Ⅲ型,其中胫骨骨折累及长度11～17 cm,平均15.6 cm;小腿皮肤软组织缺损范围6 cm×3 cm～20 cm×9 cm.均采用吻合血管的腓骨复合组织皮瓣一期同时修复与重建胫骨重度开放性粉碎性骨折及胫前软组织缺损.结果 术后移植组织全部成活,皮瓣弹性、色泽良好,所有患者获得5个月～7年(平均3.5年)随访.移植腓骨与胫骨平均在1.8个月时有骨愈合征象,术后3.5～4.5个月形成良好的骨性愈合并恢复行走功能.无骨不连及骨折不愈合病例.结论 采用吻合血管的腓骨复合组织皮瓣移植可有效地对胫骨重度开放性粉碎性骨折进行修复与重建,实现一期骨折固定与胫前皮肤软组织缺损的修复.     

Pregnancy complicated by severe osteogenesis imperfecta: a report of two cases

IMPLICATIONS: This case report discusses the anesthetic management of two parturients with severe osteogenesis imperfecta who presented for cesarean delivery. Although the anesthetic management for milder forms of the disease has been previously reported, anesthetic options for cases of this severity have not.