One-stage treatment and reconstruction of Gustilo Type III open tibial shaft fractures with a vascularized fibular osteoseptocutaneous flap graft.
OBJECTIVE
This study evaluated the usefulness of a single-stage, free-fibular vascularized osteoseptocutaneous flap transfer for Type III open tibial shaft fractures with segmental bone loss for the reconstruction of combined bone and soft tissue defects.


METHODS
Nonrandomized retrospective study.


METHODS
University Level I trauma center.


METHODS
All Gustilo Type III open tibial shaft fractures with segmental bone loss that were treated at one institution between 2000 and 2007 were identified from a trauma registry. The study group consisted of 28 patients with Type III open tibial fractures: 27 were Gustilo-Anderson Type IIIB and one was Grade IIIC. The cause of tibial injury included eight industrial accidents, seven motor vehicle accidents, five crushing injuries caused by heavy objects, five falls from a height, and three motorcycle crashes. The lengths of the preoperative segmental tibial bone loss ranged from 9 to 17 cm and the size of the associated soft tissue defects ranged from 8 × 6 cm to 15 × 7 cm.


METHODS
The free fibular vascularized osteoseptocutaneous flap was used to graft and reconstruct combined bone and soft tissue defects. The radical wound débridement, soft tissue and bone revision, fracture stabilization, and early soft tissue coverage were achieved by this technique in a one-stage procedure. The average duration from injury to one-stage reconstruction was 15.8 hours (range, 5.3 hours to 6.5 days).


METHODS
Radiographic and functional evaluation of the lower extremity.


RESULTS
All free fibular osteoseptocutaneous flaps survived completely. The average time to overall union for the entire group was 32 weeks after surgery (range, 26-41 weeks). None of the patients in this series had a nonunion. Acceptable radiographic alignment, defined as 5° of angulation in any plane, was obtained in 22 patients (78.6%). Malunion affected six (21.4%) fractures. According to the lower extremity functional assessment, excellent and good results were achieved for 82.1% (23 of 28), fair results were seen in 14.3 % (four of 28), and a poor result occurred in one case (3.5%).


CONCLUSIONS
The free fibular vascularized osteoseptocutaneous flap grafting is an effective alternative in management of Type III open tibial fractures using a one-stage procedure. The grafted fibula offers good fracture stabilization plus a vascularized bone graft, and the fibular flap can also provide a large piece of mobile skin to cover the soft tissue defect in Type III open tibial fractures. The free osteoseptocutaneous flap also serves as a visible monitor of the adequacy of the circulation of the grafted fibula.
Department of Orthopaedics, Xijing Institute of Clinical Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shannxi Province, People's Republic of China. zhenpingok@163.com
Ping
P
Zhen
Yun-Yu
YY
Hu
Zhuo-Jing
ZJ
Luo
Xing-Yan
XY
Liu
Hao
H
Lu
Xu-Sheng
XS
Li
D000293:Adolescent; D000328:Adult; D003646:Debridement / Q000379:methods; D005260:Female; D005592:Fracture Fixation / Q000379:methods; D005597:Fractures, Open / Q000000981:diagnostic imaging / Q000601:surgery*; D006801:Humans; D008297:Male; D008875:Middle Aged; D019637:Orthopedic Procedures / Q000379:methods*; D011859:Radiography; D012189:Retrospective Studies; D013524:Surgical Flaps; D013978:Tibial Fractures / Q000000981:diagnostic imaging / Q000601:surgery*; D016896:Treatment Outcome; D055815:Young Adult