Y Tropet1, P Garbuio. 1. Service de Chirurgie Orthopédique - Traumatologique et Plastique, CHU Hôpital Jean-Minjoz, F-25030, Besançon Cedex, France.
Abstract
UNLABELLED: 126 records were studied retrospectively. The average age was 31.8 years (15-80 years) with 81% men which corresponds to other reports in the literature. Nearly half of the cases involved an accident of a two wheeled vehicle. The fractures were in the middle third in 50.1% of cases, the lower third in 33.6% and the upper third in 11.4%. 4.9% of fractures were bifocal. 46% had additional injuries (34% multiple injuries, 8% head injury). 4% were true polytrauma cases. The fracture was treated by external fixation in 103 cases and by intermedullary nailing in 23. Skin cover was by pedicle flap in 53, muscle flap 41 and fasciocutaneous flap in 12. 25 free flaps were done. Nineteen of these were muscular or musculocutaneous, 3 osteocutaneous and cutaneous alone in 3 cases. There was only one cross leg flap. Eventual skin cover occurred by secondary intention in 45 cases. Immediate bone grafting was done in 13.3% of cases between the 4th and 21st days, in 10% of cases and later in 15% of cases. RESULTS: Primary union occurred most often if skin cover had been achieved immediately at the same time as bony stabilisation. None of the free flaps done as an emergency failed. If skin cover was delayed superinfection was more frequent although the risk of non-union was the same whether the skin cover was done immediately or during the first 3 weeks. Intramedullary nailing did not increase the risk of infection. Bone grafts after the 21st day were frequent in this series. The number of operations and general anaesthetics increased significantly as a function of the delay in skin cover. The duration of hospitalisation was also shorter if the flap was done sooner. The average time to union was 10.2 months. It fell to 7.6 months if skin cover had been obtained immediately and to 6.5 months with intramedullary nailing as opposed to 10.3 months for external fixation which in general was associated with later skin cover. With external fixation and healing by secondary intention the delay in healing was greater than 12.9 months. These figures are statistically significant. Of the 46 patients reviewed ankle mobility was more than 50% normal in 61% of cases. Running was possible for 39% of cases. Prolonged immobilisation in an external fixator gave twice as many fair results as nailing. CONCLUSIONS: 1- The debridement was an important step. It should be completed straight away in one stage on admission. It is started under tourniquet and completed after release of the tourniquet to assess tissue vitality. 2- The fracture is best treated by locked nailing whenever possible. Skin cover manoeuvres are facilitated. The levels of the fractures limit the indications for nailing. Another limitation is delayed admission or severe contamination of the fracture site. 3- Coverage of the fracture site is best obtained a muscle flap which fills the dead space and whose trophic qualities offer the best barrier to infection. If the conditions are favourable a pedicle flap may be used. Any doubt about the integrity of a local flap is an indication for free muscle flap. Emergency cover os the most beneficial for the patient. It allows an osteocutaneous flap if necessary and protects the patient from superinfection with resistant hospital organisms. 4- When there is loss of bone substance or a butterfly fragment of doubtful viability the addition of cancellous or cortico-cancellous grafts may be done during cover of the fracture site as long as it is not infected. 5- Managing these serious open fractures is demanding but that is the price to pay to reduce the number of operations, the length of hospitalisation and the severity of the sequellae on which the return to work depends. Particular attention should be made to conserve the mobility of the ankle which in part has a bearing on the outcome.
UNLABELLED: 126 records were studied retrospectively. The average age was 31.8 years (15-80 years) with 81% men which corresponds to other reports in the literature. Nearly half of the cases involved an accident of a two wheeled vehicle. The fractures were in the middle third in 50.1% of cases, the lower third in 33.6% and the upper third in 11.4%. 4.9% of fractures were bifocal. 46% had additional injuries (34% multiple injuries, 8% head injury). 4% were true polytrauma cases. The fracture was treated by external fixation in 103 cases and by intermedullary nailing in 23. Skin cover was by pedicle flap in 53, muscle flap 41 and fasciocutaneous flap in 12. 25 free flaps were done. Nineteen of these were muscular or musculocutaneous, 3 osteocutaneous and cutaneous alone in 3 cases. There was only one cross leg flap. Eventual skin cover occurred by secondary intention in 45 cases. Immediate bone grafting was done in 13.3% of cases between the 4th and 21st days, in 10% of cases and later in 15% of cases. RESULTS: Primary union occurred most often if skin cover had been achieved immediately at the same time as bony stabilisation. None of the free flaps done as an emergency failed. If skin cover was delayed superinfection was more frequent although the risk of non-union was the same whether the skin cover was done immediately or during the first 3 weeks. Intramedullary nailing did not increase the risk of infection. Bone grafts after the 21st day were frequent in this series. The number of operations and general anaesthetics increased significantly as a function of the delay in skin cover. The duration of hospitalisation was also shorter if the flap was done sooner. The average time to union was 10.2 months. It fell to 7.6 months if skin cover had been obtained immediately and to 6.5 months with intramedullary nailing as opposed to 10.3 months for external fixation which in general was associated with later skin cover. With external fixation and healing by secondary intention the delay in healing was greater than 12.9 months. These figures are statistically significant. Of the 46 patients reviewed ankle mobility was more than 50% normal in 61% of cases. Running was possible for 39% of cases. Prolonged immobilisation in an external fixator gave twice as many fair results as nailing. CONCLUSIONS: 1- The debridement was an important step. It should be completed straight away in one stage on admission. It is started under tourniquet and completed after release of the tourniquet to assess tissue vitality. 2- The fracture is best treated by locked nailing whenever possible. Skin cover manoeuvres are facilitated. The levels of the fractures limit the indications for nailing. Another limitation is delayed admission or severe contamination of the fracture site. 3- Coverage of the fracture site is best obtained a muscle flap which fills the dead space and whose trophic qualities offer the best barrier to infection. If the conditions are favourable a pedicle flap may be used. Any doubt about the integrity of a local flap is an indication for free muscle flap. Emergency cover os the most beneficial for the patient. It allows an osteocutaneous flap if necessary and protects the patient from superinfection with resistant hospital organisms. 4- When there is loss of bone substance or a butterfly fragment of doubtful viability the addition of cancellous or cortico-cancellous grafts may be done during cover of the fracture site as long as it is not infected. 5- Managing these serious open fractures is demanding but that is the price to pay to reduce the number of operations, the length of hospitalisation and the severity of the sequellae on which the return to work depends. Particular attention should be made to conserve the mobility of the ankle which in part has a bearing on the outcome.