First results with the immediate reconstructive strategy for internal hardware exposure in non-united fractures of the distal third of the leg: case series and literature review

Journal of Orthopaedic Surgery and Research

Andrea Marchesi¹  Giovanni Palitta¹  Luca Pierannunzii²  Riccardo Gazzola¹  Adriano Di Matteo¹  Luca Vaienti¹ 

[1] Plastic Surgery Department, Università degli Studi di Milano, IRCCS Policlinico San Donato, Piazza Malan, 20097 San Donato Milanese, Milan, Italy;Istituto Ortopedico Gaetano Pini, P.zza C. Ferrari, 1, Milan, Italy

关键词: Lower limb;    Pedicled flaps;    Immediate reconstruction;    Infection;    Internal hardware exposure;    Fracture;    Leg;    Reconstruction;    Internal fixator;    Flap;    Exposure;   

Others  :  817877
DOI  :  10.1186/1749-799X-7-30

 received in 2011-07-05, accepted in 2012-06-01,  发布年份 2012

【 摘 要 】

Background

Fractures of the distal third of the leg are increasingly common and are often handled by open reduction and internal fixation. Exposure and infection of internal hardware could occur, especially after high energy traumas, requiring hardware removal and delayed soft tissue reconstruction. Nevertheless immediate soft tissue reconstruction without internal hardware removal is still possible in selected patients.

In this study the effectiveness and the complications of immediate soft tissue reconstruction without internal hardware removal is analyzed.

Methods

13 patients, affected by internal hardware exposure in the distal leg, treated with immediate soft tissue reconstruction with pedicled flaps and hardware retention, are retrospectively analyzed, with special regard to flap survival and wound infection.

Results

Wound infection was observed in 10 cases before surgery and in 5 cases surgical debridement was necessary before reconstruction which was performed in a separate operative session.

After reconstruction, wound dehiscence and infection occurred in 5 cases, and in 3 cases removal of internal hardware was necessary in order to achieve the complete healing of dehiscence. In one case the previous flap failed but prompt reconstruction with a sural fasciocutaneous flap was performed without hardware removal and without complications. Pre-operative infection and late reconstructive surgery are predictive for higher rates of post-operative complications (respectively p 0.018 and p 0.028).

Conclusion

Our approach achieved full recovery in 53.8% of the treated cases after one-step surgery, therefore reducing hospitalization and allowing early mobilization. Controlled trials are needed to confirm the effectiveness of this strategy, although the present case series shows encouraging results.

【 授权许可】

   
2012 Vaienti et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

Figure 2.

Figure 3.

Figure 4.

Figure 5.

【 参考文献 】

• [1]Calori GM, Tagliabue L, Mazza E, de Bellis U, Pierannunzii L, Marelli BM, Colombo M, Albisetti W: Tibial-pilon fractures: which method of treatment? Injury 2000, 41:1183-1190.
• [2]Ayeni JP: Pilon fractures of the tibia: a study based on 19 cases. Injury 1988, 19:109-114.
• [3]Bone LB: Fractures of the tibial plafond. The pilon fracture. Orthop Clin North Am 1987, 18:95-104.
• [4]Brennan MJ: Tibial pilon fractures. Instr Course Lect 1990, 39:167-170.
• [5]Teeny SM, Wiss DA: Open reduction and internal fixation of tibial plafond fractures. Variables contributing to poor results and complications. Clin Orthop Relat Res 1993, 292:108-117.
• [6]Pugh KJ, Wolinsky PR, McAndrew MP, Johnson KD: Tibial pilon fractures: a comparison of treatment methods. J Trauma 1999, 47:937-941.
• [7]Wyrsch B, McFerran MA, McAndrew M, Limbird TJ, Harper MC, Johnson KD, Schwartz HS: Operative treatment of fractures of the tibial plafond. A randomized, prospective study. J Bone Joint Surg Am 1996, 78:1646-1657.
• [8]McFerran MA, Smith SW, Boulas HJ, Schwartz HS: Complications encountered in the treatment of pilon fractures. J Orthop Trauma 1992, 6:195-200.
• [9]Ruedi TP, Allgower M: The operative treatment of intra-articular fractures of the lower end of the tibia. Clin Orthop Relat Res 1979, 138:105-110.
• [10]Ruedi T: Intraarticular fractures of distal tibia: results after 9 years (author's transl). Arch Orthop Unfallchir 1973, 76:248-254.
• [11]Ruedi T, Allgower M: Late results after operative treatment of fractures of the distal tibia (pilon tibial fractures) (author's transl). Unfallheilkunde 1978, 81:319-323.
• [12]Ruedi T: Fractures of the lower end of the tibia into the ankle joint: results 9 years after open reduction and internal fixation. Injury 1973, 5:130-134.
• [13]Nieminen H, Kuokkanen H, Tukiainen E, Asko-Seljavaara S: Free flap reconstructions of tibial fractures complicated after internal fixation. J Trauma 1995, 38:660-664.
• [14]Babis GC, Vayanos ED, Papaioannou N, Pantazopoulos T: Results of surgical treatment of tibial plafond fractures. Clin Orthop Relat Res 1997, 99-105.
• [15]Bourne RB, Rorabeck CH, Macnab J: Intra-articular fractures of the distal tibia: the pilon fracture. J Trauma 1983, 23:591-596.
• [16]Brumback RJ, McGarvey WC: Fractures of the tibial plafond. Evolving treatment concepts for the pilon fracture. Orthop Clin North Am 1995, 26:273-285.
• [17]Viol A, Pradka SP, Baumeister SP, Wang D, Moyer KE, Zura RD, Olson SA, Zenn MR, Levin SL, Erdmann D: Soft-tissue defects and exposed hardware: a review of indications for soft-tissue reconstruction and hardware preservation. Plast Reconstr Surg 2009, 123:1256-1263.
• [18]Mathes S, Alpert B, Chang N: Use of the muscle flap in chronic osteomyelitis: Experimental and clinical correlation. Plast Reconstr Surg 1982, 69:815-829.
• [19]Tan KJ, Lim CT, Lim AY: The use of muscle flaps in the salvage of infected exposed implants for internal fixation. J Bone Joint Surg Br 2010, 92:401-405.
• [20]Cierny G, Mader JTHP: A clinical staging system of adult osteomyelitis. Contemp Orthop 1985, 10:17-37.
• [21]Arnez ZM: Immediate reconstruction of the lower extremity–an update. Clin Plast Surg 1991, 18:449-457.
• [22]Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986, 78:285-292.
• [23]Ronga M, Longo UG, Maffulli N: Minimally invasive locked plating of distal tibia fractures is safe and effective. Clin Orthop Relat Res 2000, 468:975-982.
• [24]Namazi H, Mozaffarian K: Awful considerations with LCP instrumentation: a new pitfall. Arch Orthop Trauma Surg 2007, 127:573-575.
• [25]Lesavoy MA, Dubrow TJ, Wackym PA, Eckardt JJ: Muscle-flap coverage of exposed endoprostheses. Plast Reconstr Surg 1989, 83:90-99.