Soft Tissue Coverage of Open Tibia Fractures: A Regional Trauma Center’s Decade of Experience.
Erik A. Hoy, MD1, Christopher J. Got, MD2, Anthony Delsignore, BS3, Charles A. Adams, MD4, Scott T. Schmidt, MD1.
1Dept of Plastic Surgery, Brown University-Rhode Island Hospital, Providence, RI, USA, 2Dept of Orthopaedics, Brown University-Rhode Island Hospital, Providence, RI, USA, 3Warren G. Alpert School of Medicine at Brown University, Providence, RI, USA, 4Dept of Surgery, Brown University-Rhode Island Hospital, Providence, RI, USA.
PURPOSE - Since 1976, treatment of open tibia fractures has concentrated on definitive closure of these wounds within 7 days as outlined by Gustilo’s landmark article. We hypothesized that technological advances in wound care, may have rendered the “Soft-tissue coverage of open fractures in the first week” model obsolete.
METHODS - An IRB approved, retrospective review of the open tibia fractures treated at this facility from Jan 1997-July 2007 was performed. We surveyed our institution’s Trauma Registry Database for open fractures of the tibia, knee, and ankle. Inclusion was limited to males and non-pregnant females 18 years of age and older. Patient demographics, mechanism of trauma, type and number of surgical procedures performed, methods of local wound care, time to discharge, and complications were recorded and analyzed.
RESULTS - One-hundred and sixty patients were identified. After excluding 44 patients with incomplete data and 11 patients who expired from associated trauma,105 patients were included in the study. This accounted for a male:female ratio 2.2:1, and a mean age of 46 yrs. Fifty-eight percent of fractures were to the operators of motor vehicles, while 21% were in pedestrians struck by them. Falls accounted for 16% of fractures. These injuries were graded as Gustillo IIIA-IIIB fractures in 101 patients, and 4 patients with vascular injuries corresponding with Gustilo IIIC fractures. Fasciotomy was required in 87% of our patients: evidence of the severity of the injury patterns studied. Minor complications included infection (19% of patients, most commonly seen in external fixation pin tracts), exposed hardware (1.9%), and nonunion (8.6%). Major complications included death (6.9%) and amputation (early 1%, late 10.5%) wound dehiscence (3.8%), compartment syndrome (2%), flap loss (1 complete, 2 partial: requiring minor debridement). Average time to amputation (excluding outliers) was 15 days. Fourteen patients received pedicled muscle flaps, whereas 6 required microvascular free flap (MVFF). The pedicled flaps consisted of medial gastrocnemius, sural, reversed-sural, soleus, and fasciocutaneous flaps. Free flaps used were gracilis, rectus abdominis, and latissimus dorsi.
CONCLUSIONS - Since Gustilo’s initial description of these injuries, surgeons’ experience, advances in local wound care (VAC), and local drug delivery systems (antibiotic impregnated beads) have extended the window for coverage of these wounds beyond 1 week. This study represents the experience of a large regional trauma center over a ten-year period with several major advances in local wound care. Though complication rates were high, they are comparable to those previously reported in the literature despite fewer free flap reconstructions. In selected cases, these advances have obviated the need for microvascular free tissue transfer. However there is still a role for early soft-tissue coverage of severe IIIB-IIIC fractures.