title: 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.
abstract: 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Plastic Surgery Department, Università degli Studi di Milano, IRCCS Policlinico San Donato, Piazza Malan, 20097 San Donato Milanese, Milan, Italy. luca.vaienti@unimi.it
authors.forename: Luca
authors.initials: L
authors.lastname: Vaienti
authors.forename: Adriano
authors.initials: A
authors.lastname: Di Matteo
authors.forename: Riccardo
authors.initials: R
authors.lastname: Gazzola
authors.forename: Luca
authors.initials: L
authors.lastname: Pierannunzii
authors.forename: Giovanni
authors.initials: G
authors.lastname: Palitta
authors.forename: Andrea
authors.initials: A
authors.lastname: Marchesi
mesh_terms: D000328:Adult; D000368:Aged; D005260:Female; D005593:Fracture Fixation, Internal / Q000009:adverse effects / Q000295:instrumentation*; D050723:Fractures, Bone / Q000382:microbiology / Q000601:surgery; D005599:Fractures, Ununited / Q000453:epidemiology / Q000382:microbiology / Q000601:surgery*; D006801:Humans; D007869:Leg Injuries / Q000453:epidemiology / Q000382:microbiology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D019651:Plastic Surgery Procedures / Q000379:methods*; D012189:Retrospective Studies; D013524:Surgical Flaps / Q000382:microbiology; D016896:Treatment Outcome; D014946:Wound Infection / Q000453:epidemiology / Q000601:surgery*; D055815:Young Adult