Abstract
Open tibial fractures usually result from high-energy trauma. Severe soft-tissue injuries are often combined with open fractures of the distal tibia. A consecutive series of 42 patients with open extraarticular distal tibial fractures (Gustilo I–IIIc) operated on between July 2006 and February 2009 were included in the study reported here. We performed open reduction and internal fixation for the Gustilo I cases. Soft tissue was closed directly after antibiotic beads had been temporarily applied. For the Gustilo II and III cases, our treatment protocol included soft-tissue debridement of all devitalized soft tissue and bone fragments, pulsatile jet irrigation, and external stabilization. Soft tissue was temporarily closed with Epigard_ after the application of antibiotic beads. A second-look operation was scheduled after 3–5 days. Gustilo II patients needed an average of 1.1 (0–3) revisions until wound closure, compared to the average of 2.1 revisions necessary for the Gustilo III patients. It took 5.6 (0–16) days to obtain definitive wound closure in the Gustilo II patients and 9.9 (3–28) days in the Gustilo III patients. Skin grafting was sufficient for definitive softtissue closure in ten cases, local flaps in eight cases, and free musculocutaneous flaps were needed in six cases. Gustilo II patients with primary wound closure remained hospitalized for 11 days, while patients with secondary wound closure stayed in hospital for an average of 20 days. Our early results concerning infection rate, number of reoperations, and time to bony consolidation can be compared with other studies. Functional results will have to be evaluated at clinical follow-up.
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References
Court-Brown CM. The management of femoral and tibial diaphyseal fractures. J R Coll Surg Edinb 1998;43:374–380.
Court-Brown CM, Brydone A. Social deprivation and adult tibial diaphyseal fractures. Injury 2007;38:750–754.
Court-Brown CM, Rimmer S, Prakash U, McQueen MM. The epidemiology of open long bone fractures. Injury 1998;29:529–534.
Streicher G, Reilmann H. Distal tibial fractures. Unfallchirurg 2008;111:905–918.
Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 2006;117:2468–2475; discussion 2476–2467.
Levin LS, Condit DP. Combined injuries: soft tissue management. Clin Orthop Relat Res 1996;327:172–181.
Tu YK, On Tong G, Wu CH, Sananpanich K, Kakinoki R. Soft-tissue injury in orthopaedic trauma. Injury 2008;39[Suppl] 4:3–17.
Südkamp N, ed. Soft-tissue injury: pathophysiology and its influence on fracture management; AO principles of fracture management. New York: Thieme, 2000.
Rajasekaran S, Dheenadhayalan J, Babu JN, Sundararajan SR, Venkatramani H, Sabapathy SR. Immediate primary skin closure in type-III A and B open fractures: results after a minimum of five years. J Bone Joint Surg Br 2009;91:217–224.
Russell GG, Henderson R, Arnett G. Primary or delayed closure for open tibial fractures. J Bone Joint Surg Br 1990;72:125–128.
Byrd HS, Spicer TE, Cierney G, 3rd. Management of open tibial fractures. Plast Reconstr Surg 1985;76:719–730.
Hohmann E, Tetsworth K, Radziejowski MJ, Wiesniewski TF. Comparison of delayed and primary wound closure in the treatment of open tibial fractures. Arch Orthop Trauma Surg 2007;127:131–136.
Templeman DC, Gulli B, Tsukayama DT, Gustilo RB. Update on the management of open fractures of the tibial shaft. Clin Orthop Relat Res 1998;350:18–25.
Huang J, Yao YZ, Huang XK. Treatment of open fracture by vacuum sealing technique and internal fixation. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2003;17:456–458.
Bhattacharyya T, Mehta P, Smith M, Pomahac B. Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg 2008;121:1263–1266.
Ostermann PA, Henry SL, Seligson D. Timing of wound closure in severe compound fractures. Orthopedics 1994;17:397–399.
Heitmann C, Levin LS. The orthoplastic approach for management of the severely traumatized foot and ankle. J Trauma 2003;54:379–390.
Cierny G, 3rd, Byrd HS, Jones RE. Primary versus delayed soft tissue coverage for severe open tibial fractures: a comparison of results. Clin Orthop Relat Res 1983;178:54–63.
Caudle RJ, Stern PJ. Severe open fractures of the tibia. J Bone Joint Surg Am 1987;69:801–807.
Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984;24:742–746.
Weitz-Marshall AD, Bosse MJ. Timing of closure of open fractures. J Am Acad Orthop Surg 2002;10:379–384.
Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 2000;82:959–966.
Yaremchuk MJ. Acute management of severe soft-tissue damage accompanying open fractures of the lower extremity. Clin Plast Surg 1986;13:621–632.
Tu YK, Yen CY, Ma CH, Yu SW, Chou YC, Lee MS, Ueng SW. Softtissue injury management and flap reconstruction for mangled lower extremities. Injury 2008;39(Suppl 4):75–95.
Eggli S, Scholl E, Hertel R. Management of IIIB open tibial fractures by early osteosynthesis and local muscle flap. Unfallchirurg 1998;101:674–683.
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Faschingbauer, M., Meiners, J., Schulz, A.P. et al. Operative Treatment and Soft Tissue Management of Open Distal Tibial Fractures – Pitfalls and Results. Eur J Trauma 35, 527–531 (2009). https://doi.org/10.1007/s00068-009-9170-5
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DOI: https://doi.org/10.1007/s00068-009-9170-5