title: Delayed flap reconstruction with vacuum-assisted closure management of the open IIIB tibial fracture.
abstract: OBJECTIVE
  Vacuum-assisted closure (VAC) therapy has been shown to be effective at reducing bacterial counts in wounds until definitive bony coverage. However, there is continued debate over timing and type of definitive wound coverage even with VAC therapy application.
  
  
  METHODS
  From 2004 to 2009, 32 patients with Gustilo type IIIB open tibia fractures were initially treated with VAC therapy were included. The number of debridements, length of treatment with VAC dressing, definitive wound coverage management, and length of hospital stay, flap-related complications, and time to radiographic fracture healing were recorded.
  
  
  RESULTS
  The mean Injury Severity Score was 17.3 ± 2.0. All wounds closed after being treated with the primary VAC closure. The mean interval between the initial injury and definitive intervention was 10.9 days ± 0.3 days. Twenty of 27 patients (74%) underwent rotational muscle flaps; four received free muscle flaps and three only with split-thickness skin grafts for definitive wound coverage. Nine of 32 patients (28%) underwent below knee amputation, five without flap coverage after several VAC sessions and four after definitive flap coverage. The average time to union was 10.0 months ± 2.0 months. Eight patients developed nonunion and 11 patients developed infections. The average follow-up time is 2.4 years ± 0.2 years. Patients were divided into two groups for analysis according to the interval time. The rate of infection was significantly increased in patients who had an interval of more than 7 days from the time of injury to flap coverage.
  
  
  CONCLUSIONS
  The VAC therapy may help to reduce the flap size and need for a flap transfer for type IIIB open tibial fractures. However, prolonged periods of VAC usage, greater than 7 days, should be avoided to reduce higher infection and amputation risks.
authors.affiliation: Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China. hzy707@yahoo.com.cn
authors.forename: Zhiyong
authors.initials: Z
authors.lastname: Hou
authors.forename: Kaan
authors.initials: K
authors.lastname: Irgit
authors.forename: Kent A
authors.initials: KA
authors.lastname: Strohecker
authors.forename: Michelle E
authors.initials: ME
authors.lastname: Matzko
authors.forename: Nathaniel C
authors.initials: NC
authors.lastname: Wingert
authors.forename: Joseph G
authors.initials: JG
authors.lastname: DeSantis
authors.forename: Wade R
authors.initials: WR
authors.lastname: Smith
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D003131:Combined Modality Therapy; D005260:Female; D005500:Follow-Up Studies; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000379:methods*; D017102:Fracture Healing / Q000502:physiology; D005597:Fractures, Open / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D006084:Graft Rejection; D006085:Graft Survival; D006801:Humans; D015601:Injury Severity Score; D008297:Male; D008875:Middle Aged; D054843:Negative-Pressure Wound Therapy; D011859:Radiography; D019651:Plastic Surgery Procedures / Q000379:methods; D012189:Retrospective Studies; D017695:Soft Tissue Injuries / Q000150:complications / Q000601:surgery*; D013524:Surgical Flaps; D013530:Surgical Wound Infection / Q000175:diagnosis / Q000628:therapy; D013978:Tibial Fractures / Q000150:complications / Q000000981:diagnostic imaging / Q000601:surgery*; D013997:Time Factors; D016896:Treatment Outcome; D014945:Wound Healing / Q000502:physiology; D055815:Young Adult