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The choice between limb salvage and primary amputation in a severely injured limb is at time difficult. A case of severe Gustilo type-IIIB open fracture of the tibia with massive soft tissue loss is presented to highlight the immediate and definitive treatment undertaken to preserve the limb.
The use of antibiotic impregnated beads has been shown to be a valuable adjunct in the prevention of infection in open fractures. The bead pouch technique employs these beads within the wound, producing high local levels of antibiotic in a moist environment. This effectively inhibits bacterial colonisation and wound infection whilst preventing desiccation of structures such as bone and tendons. This technique can be used to manage wounds until soft tissue cover is obtained, whether by delayed primary suture or by plastic surgical means. The potential use in acute military surgery includes the management of wounds associated with fractures, damage to tendons or neuro-vascular injury. In such cases delay in soft tissue cover may be clinically necessary or dictated by casualty evacuation to rearward surgical facilities. The bead pouch technique offers a means of managing the wound between initial wound surgery and soft tissue cover.
In order to compare the effectiveness of the Hoffmann-Vidal external fixator and the Ilizarov compression extension apparatus, the authors compared two homogeneous groups of 25 patients, selected by the computer, with open fractures of the mid third of the tibia. Clinical and radiographic comparison provided the important data necessary for an evaluation of the reliability of the two methods.
An operation is described in which a free vascularized fibular graft with a peroneal cutaneous flap is used for tibio-talo-calcaneal fusion and simultaneous skin coverage in treatment of comminuted open fractures of the talus and the calcaneus involving large skin loss. Nine months postoperatively, the tibio-talo-calcaneal arthrodesis was successful, with good coverage of the skin defect on the medial aspect of the sole. One year 7 months postoperatively, the patient is free of pain and able to walk with full weightbearing on the foot.
OBJECTIVES: The aim of this study was to evaluate the functional and clinical outcome of patients with open calcaneus fractures and to determine what factors were associated with these outcomes. DESIGN: Retrospective review of 2 level 1 prospective databases. SETTING/PATIENTS/PARTICIPANTS: All patients admitted with an open calcaneal fracture to 2 level 1 trauma units between January 1, 1987 and April 1, 1996 were identified. Data regarding demographics, injury characteristics, and treatment and complications were documented using a standardized data abstraction form. Radiographs were reviewed to document the fracture type according to Essex-Lopresti. For those patients who had computed tomography scans available, the Sanders et al classification was applied and documented. Patients were contacted and asked to return for follow-up evaluation including the American Orthopaedic Foot and Ankle Society ankle/hindfoot score, the Maryland Foot Score, and the Short Form 36 (SF-36). For patients not willing to return for examination, the questionnaires were completed over the telephone, and the objective scoring components were assigned to lowest score possible. RESULTS: Of 177 calcaneal fractures in patients treated as inpatients during the study period, we identified 30 open fractures in 29 patients. Twenty-seven patients had associated injuries. Two patients underwent amputation within 24 hours due to severe crush injury. Following urgent debridement, soft tissues were closed primarily (22 fractures) or with split thickness skin grafting (4 fractures) and free flap coverage (2 fractures); temporary spanning external fixation was used in 3 patients. Definitive fracture care was at the discretion of the treating surgeon and consisted of closed reduction without fixation (10 fractures), open reduction and bone grafting (1 fracture), minimal Kirschner wire (K wire) fixation (12 fractures), and formal lateral open reduction and internal fixation (5 fractures). There were no late amputations. There were no deep infections. Twenty-one of the 28 patients with salvaged limbs returned for follow-up evaluation, and 3 additional patients agreed to be interviewed by telephone. The average time to follow-up was 49 months with a range of 25 to 106 months. The overall American Orthopaedic Foot and Ankle Society ankle/hindfoot scores and Maryland Foot Scores were fair to poor. The average SF-36 results were within 1 standard deviation of published Canadian norms. Worse function was observed in patients with plantar wounds. Severely comminuted fractures had the worst function, whereas single joint depression injuries had the best functional outcome. CONCLUSION: Infection is uncommon following open calcaneus fractures treated with aggressive soft tissue management. Patients with plantar wounds and comminuted fractures are expected to have particularly poor functional results.
Even though massive osteoarticular allografts have been reported to restore function successfully after tumor resection, little has been published about this procedure in post-traumatic joint reconstruction. We report two pediatric patients who sustained a grade III open fracture of the distal femur and were treated with osteoarticular allografts as a salvage procedure. In each patient, a femoral condyle was inserted to treat the bone and cartilage defect, and a 4.5 dynamic compressive plate was applied to fix the graft to the host bone. There were no complications after the reconstructive procedure. At 2 and 10 years of follow-up, both patients showed a favorable functional and radiographic outcome using the scoring instruments of the Musculo-skeletal Tumor Society and the International Symposium on Limb Salvage.
A consecutive series of 119 type III B compound fractures in 103 patients was treated at the University of Louisville from May 1983 to May 1989. All patients had timely irrigation of their wounds, serial wound debridements, external skeletal stabilization and parenteral systemic antibiotics (penicillin, cefazolin, tobramycin). 96 open fractures were managed with the supplemental local use of tobramycin-PMMA-beads. There were 13.5% wound infections and 10.1% osteomyelitis observed. The additional local antibiotic therapy was of significant (p less than 0.001, p less than 0.025) benefit to lower both infectious complications. The amputation rate was overall 5%, 9.7% for the lower leg. Four patients died due to multiple trauma.
We reviewed the results of treatment of forty open diaphyseal fractures of the lower extremity in thirty-five children. The patients were between three and sixteen years old, and they had been managed between 1980 and 1988. The minimum duration of follow-up was one year. Eighty-six per cent of the patients had been injured in a motor-vehicle accident, and 74 per cent had associated injuries. Thirty-one of the fractures were Grade-II open or Grade-III open and seven were Grade-I open, according to the classification of Gustilo and Anderson. Two patients who had initially had a closed fracture were treated with a fasciotomy for a compartment syndrome, so these two fractures were included as open. Four other patients who had a Grade-II or III open fracture also needed a fasciotomy. All wounds were treated with immediate and repeat débridement and early soft-tissue coverage. Twenty-two fractures healed primarily. There were three early amputations. Twelve fractures that healed after six months were classified as delayed unions and three fractures were classified as non-unions because of the absence or arrest of healing, as seen on serial roentgenograms. Additional intervention was used to achieve union of eight of the fifteen fractures that had been classified as a delayed union or a non-union. Ten of the forty fractures were associated with infection, but osteomyelitis developed in only one patient. No patient had a growth arrest. Only one patient had a limb-length discrepancy that was more than two centimeters. Three early amputations and one delayed amputation were performed in patients who had a Grade-IIIC open fracture.
Recent reports using the Mangled Extremity Severity Score (MESS) suggest that a score of > or = 7 is 100% accurate in predicting the need for amputation of severely injured lower extremities. To further evaluate the value of the MESS in predicting amputation, specifically with respect to type IIIB and type IIIC (Gustilo and Anderson) open fractures of the tibia, we retrospectively evaluated 24 patients with these injuries. A significant difference (p = 0.001) between MESS values of 13 salvaged (6.36 +/- 0.35 SEM) and 11 amputated limbs (6.36 +/- 0.54 SEM) was found. A MESS value of > or = 4 was most sensitive (100%); a MESS value of > or = 7 was most specific, and a MESS value of > or = 7 was found to have a positive predictive value of 100%. Subsequently, we addressed recent criticisms of the MESS by including nerve injury in the scoring system and by separating soft-tissue and skeletal injury components of the MESS. We modified the MESS with a score called the NISSSA and applied it retrospectively to our cases. After careful statistical comparison we found both the MESS and NISSSA to be highly accurate (p < 0.005) in predicting amputation. The NISSSA was found to be more sensitive (81.8% versus 63.6%) and more specific (92.3 versus 69.2%).
Results of healing in 477 cases of open leg fractures treated in the Central Institut of Traumatology in Budapest are analysed in the article. 47,2% of cases were treated by closed methods. The authors are convinced that careful conservative management leads to good results, if the type of the fracture is suitable. Conditions of operative treatment are outlined. In favourable circumstances a stable internal fixation should be performed, otherwise inramedullary wiring and plaster may hold the fragments until healing occurs. Soft tissues should be handled carefully and placing sutures under tension must be avoided, by all means.
The reverse sural artery flap is a fasciocutaneous flap based on the median superficial sural artery and its communication with the perforating branch of the peroneal artery situated in the region of the lateral malleolar gutter. Reverse flow is established after elevation of the flap and with division of the sural artery and the nerve proximally. The authors present resurfacing of acute open fractures of the lower third of the leg in 7 patients immediately after the acute phase of injury. Reconstruction was carried out within an average of 3 days after injury. All 7 patients sustained low-velocity injuries. Although 2 patients had partial necrosis of the distal tip of the flap, all patients had excellent recovery with minimal donor site morbidity.
Course and prognosis of open lower leg fractures are significantly influenced by the concomitant soft tissue injury. Selection and timing of therapeutic procedures determine the final outcome. Fracture stabilisation takes priority. Early soft tissue coverage should be achieved by local cutaneous or fasciocutaneous flaps. Exposed bone can be covered by transposed local musculature. Especially in the distal third as well as in extensive soft tissue loss the microsurgical transplantation of free flaps is advantageous. Tissue expansion can provide skin for secondary replacement of instable scars.
The authors studied a group of 215 comminuted or open (Grade 1) fractures of the tibial diaphysis in order to compare two methods successively adopted at the 1st Clinic and 3rd Division of the Rizzoli Orthopaedic Institute. We at first chose to delay nailing in these two types of fracture for 4 weeks (131 cases) and obtained good results in terms of consolidation, but only fair results in terms of functional recovery of ankle and subtalar movement and axial alignment of the tibia. Successively, we used immediate osteosynthesis with a screwed nail (84 cases), the results of which were better for all the parameters considered. The criteria for delaying intramedullary osteosynthesis in grade 1 open fractures are still valid, particularly when there are problems which necessarily delay operative treatment within 8 hours of injury. However, immediate treatment is essential in these fractures when they are associated with vascular lesions or in patients with multiple injuries. Finally, the authors express their preference for intramedullary nailing as compared with external fixation for the treatment of these open fractures with limited exposure.
The treatment modalities currently used in surgical débridement leave the traumatic wound with viable but tenuous tissue and a variable level of microcontaminants potentially laden with bacteria. In high-energy contaminated wounds, retention of these contaminants within the tenuous tissue of the so-called zone of stasis can result in further tissue necrosis and the development of infection. A novel protocol for managing the high-energy contaminated open fracture involves two new techniques. First, Bernoulli's principle is used to facilitate a systematic excision of contaminants, as well as the wound surface to which they are adsorbed, by means of a high-velocity fluid stream. Second, topical negative pressure is established as a means to resuscitate the remaining edema-laden wound tissue to help avoid embarrassment to microcirculatory blood flow.
On 22 April 1676, Admiral De Ruyter suffered a fatal open fracture of the right lower leg during the naval battle near the Etna. The fleet doctor, Jan Mannart, and the two ship's surgeons treated the wound with brandy and prescribed rest, but fatal gangrene developed a few days later. Before Lister first reported his technique of antiseptic treatment in 1876, the possibilities for the treatment of open wounds were limited to cauterisation and application of hot oil. Until the middle of the 19th century, amputation of the wounded limb was the most obvious solution. Why amputation was not performed in the case of De Ruyter is unknown. Actually, however, amputation would probably have increased his chances of survival only to a limited extent.
A 27-year-old man with a high-energy, open-fracture dislocation of the ankle underwent debridement and open reduction of his injuries. During surgery a disruption-laceration of the posterior tibial tendon at the level of the fracture of the medial malleolus was found. Repair required location of the proximal muscle and tendon and controlled traction of the musculotendinous unit from its retracted position. Common aspects in the nine previously reported instances of this lesion include relatively high energy of the injury and the fracture type, a transverse fracture in the medial malleolus. Unique to this case was the open injury.
In a prospective study 40 consecutive patients with open tibial fractures were treated by the Hoffmann external fixator; the follow-up period was 18 months. All fractures were irrigated, debrided, and fixed rigidly with the Vidal-Adrey modification of the Hoffmann device as soon as the patients' condition allowed. The wounds were left open, to be closed secondarily with skin grafts, muscle flaps, and other plastic surgical procedures. The 40 wounds were all classified as Gustilo's Type II or III in relation to soft tissue damage; 36 injuries were due to motor vehicle accidents and four to gunshot wounds. At the 18-month follow-up examination there had been five amputations and five nonunions had healed after bone grafting; in addition, five patients had persistent pin drainage. Pin site drainage (80%) was the most common problem, but most cleared after removal of the fixator and five after curettage of ring sequestra. There was a high number of associated surgical procedures (2.4% per patient) related to the open fracture. At the 18-month follow-up examination bony healing was noted in all patients.
Split-thickness skin excision can be used as a one-stage procedure for the accurate diagnosis of flap viability and the immediate treatment of friction-avulsion injuries in severe open fractures. After cleaning the wound, the avulsed flap is temporarily sutured back to its original bed and a split thickness graft is taken from it and meshed to a 1:3 ratio. Surface dermal capillary bleeding then serves as an indicator of viability, clearly displaying a line for the excision of devascularized skin and correlating well with a concomitant fluorescein test. The wounds are re-opened and, after fixation of the fracture, the viable part of the flap is returned to its original bed and the remaining defects are covered with the meshed graft. We have treated 16 patients with extensive degloving injuries in this way, 15 needing only the single surgical procedure. All retained flaps survived, no other donor sites were needed and the split-thickness grafts took with 90% to 100% success.