Cell Biochem Biophys DOI 10.1007/s12013-014-9954-z
ORIGINAL PAPER
Free Flap Combined with External Fixator in the Treatment of Open Fractures of the Calf Yuan Song • Xiaodong Qi • Jun Shen
Ó Springer Science+Business Media New York 2014
Abstract The objective of this study was to investigate the clinical effect of the treatment of open fractures of the leg using free flap in combination with external fixation, in order to improve the therapeutic outcomes. A retrospective analysis including 70 cases of leg open fracture patients between May 2010 and February 2013 was conducted. The patients were categorized into two groups: the control group of 35 patients, treated with the use of external fixation; and the observational group of 35 patients in the control group treated on the basis of the addition of free flap. Clinical effects were compared between the two groups after treatment. From the viewpoint of clinical effects, the number of cases in the control group with excellent, good, fair, and poor outcomes were found to be 6, 13, 11, and 5, respectively, and the respective ratios were 17.14, 37.14, 31.43, and 14.29 %; the number of cases in the observational group with excellent, good, fair, and poor outcomes were 15, 10, 8, and 2, respectively, with the respective ratios being 42.86, 28.57, 22.86, and 5.71 %, respectively; there were significant differences (p \ 0.05); two groups in the use of antibiotics in the number of days, number of dressing changes, debridement to terminal operation time, the number of operations, length of stay, time of pain had more significant differences (p \ 0.05); term complication of the control group was 45.71 %, and the long-term complication rate was 54.29 %; in the observational group, recent complication rate was 17.14 %, and the long-term complication was 20 %—with the two groups being significantly different (p \ 0.05), and the above being statistically significant. The long-term effect Y. Song (&) X. Qi J. Shen Department of Orthopedics, 8th Hospital of Shanghai, No. 8 Caobao Road, Shanghai 200235, China e-mail: [email protected]
for the group treated with the free flap in combination with external fixation for leg open fractures is good. Keywords Free flap External fixator The calf open fractures Clinical effect
Introduction The particular anatomic feature of the front of calf, the absence of muscle coverage, results in susceptibility to fracture under pressure. In most cases, open fracture occurs. The prognosis of open fracture in calf remains suboptimal, with high prevalence of nonunion and osteomyelitis caused by unhealed skin [1]. Therefore, a therapeutic strategy which can promote fracture healing and skin healing at the same time is of clinical importance. In this study, we retrospectively analyzed the application of free flap combined with external fixator in the treatment of open fractures of the calf. Our results showed that the treatment of calf open fractures with free flap combined with external fixator can offer optimal clinical benefits to patients.
Materials and Methods Patient Characteristics A total number of 70 cases with open fracture in calf were retrospectively analyzed in this study. All the subjects were categorized into two groups: control group (35 cases) and observational group (35 cases). 19 male and 16 female cases—aged 21–69 years with a mean age of 36.9 ± 3.5— were included in the control group. Course of disease
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varied from 1 h to 2 days with the average of 4.2 ± 3.1 h. The causes of injury included car accident (13 cases), pressure roller injury (9 cases), falling injury (8 cases), and machine injury (5 cases). 15 subjects had fracture in the left calf and 20 in the right. According to Gustilo classification, 19 cases were categorized as type II, 10 cases as type IIIA, and 6 cases as type IIIB. 20 male and 15 female cases— aged 20–70 years with the mean age of 36.2 ± 3.1—were included in the control group. Course of disease varied from 1.2 h to 2.5 days with the average of 4.5 ± 3.3 h. The causes of injury included car accident (15 cases), pressure roller injury (10 cases), falling injury (7 cases), and machine injury (3 cases). 13 subjects had fracture in the left calf and 22 in the right. According to Gustilo classification, 20 cases were categorized as type II, 9 cases as type IIIA, and 6 cases as type IIIB. No significant difference was found in the baseline characteristics between the control group and observational group (P [ 0.05). The diagnosis of open fracture in the calf included the following criteria [2]: (1) clear history of trauma and (2) fracture and significant translocation of tibiofibula confirmed by X-ray. Methods The control group was treated using external fixator, which could be single-arm external fixator, semicircular external fixator, and Ilizarav’s external fixator. Prolonged incision was performed at the open fracture site before reduction. Then external fixator was used after fracture reduction. The results were visualized using C-arm before complementing the surgery. In the case of comminuted fracture, Kirschner wire or screw was used to connect relatively big fractured blocks. Bone defect was treated with implantation of autograft such as hipbone. Relaxation suture was used to treat skin injury, while skin graft treatment was used in the subjects where skin injury cannot be treated with suture. All subjects in the observational group were treated with free flap combined with external fixator. Before surgery, color Doppler flow imaging (CDFI) was used to mark the spending point of skin. Cloth sample was designed according to point-line-plane principles and area and shape of trauma surface. Free flap should be 1–2 cm larger than the cloth sample. Lateral cutaneous nerve branch was separated with the flap. Realignment methods were used to separate the arterial branch. The arterial branch was well protected. Vessel pedicle was cut off after the reliable blood supply was confirmed in flap. After the cut-off of vessel pedicle, the recipient and trauma margin were temporarily fixed, and accompanying vein, arteriole, and nerve were matched. The trauma surface was closed after the reliable blood supply was confirmed, and drainage tube
123
was placed under flap. Medium-thickness flap was chosen for graft. Evaluation of Therapeutic Outcomes The therapeutic outcomes were evaluated according to the following standards [3]: cases with flap survival [95 %, no infection in needle site or in hospital, complete fracture healing without any impairment in walking function were graded as A; cases with flap survival [85 %, controlled infection, complete fracture healing with slight impairment in walking function were graded as B; cases with flap survival between 75 and 85 %, occurrence of infection, delayed fracture healing with need of mechanic aid for walking were graded as C; cases with flap survival \85 %, occurrence of infection or hematoma [5 cm2, difficulties in walking with swollen flap were graded as D. In addition, the early- and late-stage complications were compared. Statistical Analysis All data were analyzed with SPSS 13.0. Quantitative data were compared using t test, while enumeration data were compared using Chi-square test. P \ 0.05 was considered as statistically significant.
Results The Cleaning Time and Clinical Therapeutic Outcomes of Two Groups The results of the clinical therapeutic outcomes of two groups are shown in Table 1. The control group had A ? B rate of 54.28 % with an overall effective rate of 85.71 %. The observational group had A ? B rate of 71.43 % with an overall effective rate of 94.29 %. Significant difference existed in for A ? B rate and overall effective rate between groups (P \ 0.05). General Condition after Treatment in Two Groups Results of general conditions after treatment in two groups are shown in Table 2. Significant difference was found in duration of antibiotic treatment, dressing change, intervals between debridement and final surgery, times of surgery, duration of hospitalization, and duration of pain. Early and Late Complications of Two Groups The results of early- and late-stage complications are shown in Table 3. Significant difference was found in both
Cell Biochem Biophys Table 1 Comparison of clinical therapeutic outcomes (cases) Group
Cases
A
B
Cases
C
D
%
Cases
%
Cases
%
Cases
%
A ? B (%)
Overall effective rate(%)
Control group
35
6
17.14
13
37.14
11
31.43
5
14.29
54.28
85.71
Observation group
35
15
42.86
10
28.57
8
22.86
2
5.71
71.43
94.29
X2 P value
6.96
5.52
5.15
4.37
5.84
4.83
\0.05
\0.05
\0.05
\0.05
\0.05
\0.05
Table 2 Comparison of general conditions between groups (x ± s) Items
Control group (35)
Duration of antibiotic therapy (d)
15.1 ± 6.4
Dressing change (times) Intervals between debridement and final surgery (d) Surgery (times) Duration of hospitalization (d) Duration of pain compliant (d)
Table 3 Comparisons complications
between
Items
early-
and
T value
P value
8.9 ± 3.2
4.373
\0.05
26.5 ± 13.3
17.3 ± 7.4
4.253
\0.05
27.1 ± 11.4 3.1 ± 1.9
14.4 ± 7.2 1.9 ± 1.2
5.025 5.152
\0.05 \0.05
35.8 ± 13.6
24.4 ± 8.9
5.057
\0.05
9.5 ± 5.2
6.2 ± 3.3
4.962
\0.05
late-stage
Control group (35)
Observational group (35)
Cases
Cases
%
%
Early-stage complications Hemorrhage
3
8.57
1
2.86
Infection
4
11.43
1
2.86
Hematoma
2
5.71
2
5.71
Wound margin tension bubble Total
7
20.0
2
5.71
16
45.71
6
17.14
Late-stage complications Repair surface swollen
2
5.71
4
11.43
Chronic ulcer
6
17.14
0
0
Chronic pain
8
22.86
2
5.71
Function impairment Total
3
8.57
1
2.86
19
54.29
7
20.0
early- and late-stage complications between groups (P \ 0.05).
Discussion Open fracture in calf is quite common, which is always caused by high-energy injury. Open fracture is often associated with contusion of skin soft tissue with different extents of skin necrosis, which raises many concerns for internal fixation. Based on the previous studies by David et al., which showed that free flap could provide more clinical benefits to
Observational group (35)
patients with Gustilo type II and type III fractures, we used free flap combined with fixator in the treatment of calf open fracture. External fixator will not damage the blood supply at the fracture site. Therefore, external fixator could fix the fracture without worsening bone trauma [4]. Previous studies [5] have shown that nutritious blood vessels surrounding skin nerves play an important role in skin blood supply, leading to the introduction of concept of neuroskin. Zhang et al. [6] suggested that ipsilateral local rotational flap, sural nerve nutrition myocutaneous flap, and saphenous neurocutaneous flap are quite useful in the repair of trauma surface, because hallow neurocutaneous fascia vascular axis supplies blood through vessel traffic support to nutrition gastrocnemius, and nutritional vessels of sural nerve and small saphenous vein are homologous with nutritional vessels of muscle, fascia, and skin. The following are the main advantages of free flap [7]: (1) no compromise to major blood supply system of the trunk, good blood supply of flap, high resistance to infection, and satisfactory healing of tissues; (2) high-safety profile compared to other grafts, which makes suitable for use in clinical setting; (3) less pain for patients and no need for secondary pedicle compared to cross-leg skin flap; and (4) the large area of flap enables rotation with good amplitude without restriction of cutting range. From the experiences we got, the following points were noteworthy: (1) Complete debriding should be performed before surgery, skin tissue with bad blood supply and contusion should be removed [8]. (2) The defected surface should be measured before surgery, and color ultrasound should be performed to verify the condition of blood vessels.
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Cell Biochem Biophys
The choice of flap should be flexible with good understanding of the patient. (3) The length of the flap should be controlled during the surgery to avoid the impact of width of flap on the blood supply. The damage to surrounding tissue should be avoided with gentle operation. Sterile condition should be strictly maintained, and negative-pressure drainage should be used to prevent hematoma and exudate retention [9, 10]. (4) Post-surgery intensive care should be given to prevent osteofascial compartment syndrome. Dressing should be changed at regular intervals. For necrosis area less than 5 cm2, conservative dressing strategy should be employed. Exudate outflow should be ensured every time dressing is changed. (5) Two weeks after surgery, lifted position should be taken by the patients, and regular X-ray should be taken to avoid translocation. Passive function training could start 3 days post-surgery, and external fixator could be removed 8–12 weeks after surgery depending on the patient’s condition. Early function recovery training should be encouraged. This study suggested that free flap combined with external fixator provided clinical benefits, shortened hospitalization, and decreased the occurrence of complications, especially the late-stage chronic pain, chronic ulcer, and dysfunction. Therefore, it should be widely used in clinics.
References 1. Guichun, P., Songlin, Y., Hailiang, L., et al. (2011). Two-arm external fixator combination with internal fixator for calf open fracture. Trauma Surgery, 13(4), 333–336.
123
2. Dawei, Z., Guangyue, Z., Jun, L., et al. (2011). Use of anterolateral thigh flap in Gustilo III open fracture of calf with sift tissue defect. Chinese Journal of Microsurgery, 34(2), 116–118. 3. Jin, C., Xinke, Y., Yang, W., et al. (2008). Monolateral dynamic compression fixator for Severe open fractures with soft tissue crush injuries of the lower leg. Journal of Practical Orthopaedics, 14(3), 143–145. 4. Luo, Z., Lou, H., & Jiang, J. (2008). Pedicle flap transfer combined with external fixator to treat leg open fracture with soft tissue defect. Chinese Journal of Reparative and Reconstructive Surgery, 22(8), 956–958. 5. Wang, Y., Huang, J., Hu, S., et al. (2013). Close negative drainage combined with external fixator and flap in the treatment of severe calf open fracture. Youjiang Medical Journal, 41(1), 53–55. 6. Daofeng, Z., Li, F., Zhishan, Z., et al. (2010). Clinical outcome of different methods in management of open fracture of legs. Modern Chinese Doctor, 48(30), 117–119. 7. Jia, Hongwei, Cheng, Chunsheng, & Songfeng, L. V. (2007). Clinical applications of tibial bone-skin flaps in treatment of infective bone-skin defects of leg. Chinese Journal of Reparative and Reconstructive Surgery, 21(1), 30–33. 8. Lin, L., Geng, J., Yang, C., et al. (2011). VSD combination with island flap in treatment of open calf fracture with skin defects. Journal of Practical Orthopaedics, 17(3), 269–271. 9. Mingqing, X., & Xinli, Z. (2010). Combined application of external fixator in open fractures of the tibia. Jilin Medical Journal, 31(1), 85–86. 10. Zhen, L., Li-ming, L., & Yan-qing, C. (2009). Repair of soft tissue defect in the upper two-thirds of the leg with exposed bone by using medial head of gastrocnemius muscle flap. Hebei Medical Journal, 15(2), 153–154.
ORIGINAL PAPER
Free Flap Combined with External Fixator in the Treatment of Open Fractures of the Calf Yuan Song • Xiaodong Qi • Jun Shen
Ó Springer Science+Business Media New York 2014
Abstract The objective of this study was to investigate the clinical effect of the treatment of open fractures of the leg using free flap in combination with external fixation, in order to improve the therapeutic outcomes. A retrospective analysis including 70 cases of leg open fracture patients between May 2010 and February 2013 was conducted. The patients were categorized into two groups: the control group of 35 patients, treated with the use of external fixation; and the observational group of 35 patients in the control group treated on the basis of the addition of free flap. Clinical effects were compared between the two groups after treatment. From the viewpoint of clinical effects, the number of cases in the control group with excellent, good, fair, and poor outcomes were found to be 6, 13, 11, and 5, respectively, and the respective ratios were 17.14, 37.14, 31.43, and 14.29 %; the number of cases in the observational group with excellent, good, fair, and poor outcomes were 15, 10, 8, and 2, respectively, with the respective ratios being 42.86, 28.57, 22.86, and 5.71 %, respectively; there were significant differences (p \ 0.05); two groups in the use of antibiotics in the number of days, number of dressing changes, debridement to terminal operation time, the number of operations, length of stay, time of pain had more significant differences (p \ 0.05); term complication of the control group was 45.71 %, and the long-term complication rate was 54.29 %; in the observational group, recent complication rate was 17.14 %, and the long-term complication was 20 %—with the two groups being significantly different (p \ 0.05), and the above being statistically significant. The long-term effect Y. Song (&) X. Qi J. Shen Department of Orthopedics, 8th Hospital of Shanghai, No. 8 Caobao Road, Shanghai 200235, China e-mail: [email protected]
for the group treated with the free flap in combination with external fixation for leg open fractures is good. Keywords Free flap External fixator The calf open fractures Clinical effect
Introduction The particular anatomic feature of the front of calf, the absence of muscle coverage, results in susceptibility to fracture under pressure. In most cases, open fracture occurs. The prognosis of open fracture in calf remains suboptimal, with high prevalence of nonunion and osteomyelitis caused by unhealed skin [1]. Therefore, a therapeutic strategy which can promote fracture healing and skin healing at the same time is of clinical importance. In this study, we retrospectively analyzed the application of free flap combined with external fixator in the treatment of open fractures of the calf. Our results showed that the treatment of calf open fractures with free flap combined with external fixator can offer optimal clinical benefits to patients.
Materials and Methods Patient Characteristics A total number of 70 cases with open fracture in calf were retrospectively analyzed in this study. All the subjects were categorized into two groups: control group (35 cases) and observational group (35 cases). 19 male and 16 female cases—aged 21–69 years with a mean age of 36.9 ± 3.5— were included in the control group. Course of disease
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Cell Biochem Biophys
varied from 1 h to 2 days with the average of 4.2 ± 3.1 h. The causes of injury included car accident (13 cases), pressure roller injury (9 cases), falling injury (8 cases), and machine injury (5 cases). 15 subjects had fracture in the left calf and 20 in the right. According to Gustilo classification, 19 cases were categorized as type II, 10 cases as type IIIA, and 6 cases as type IIIB. 20 male and 15 female cases— aged 20–70 years with the mean age of 36.2 ± 3.1—were included in the control group. Course of disease varied from 1.2 h to 2.5 days with the average of 4.5 ± 3.3 h. The causes of injury included car accident (15 cases), pressure roller injury (10 cases), falling injury (7 cases), and machine injury (3 cases). 13 subjects had fracture in the left calf and 22 in the right. According to Gustilo classification, 20 cases were categorized as type II, 9 cases as type IIIA, and 6 cases as type IIIB. No significant difference was found in the baseline characteristics between the control group and observational group (P [ 0.05). The diagnosis of open fracture in the calf included the following criteria [2]: (1) clear history of trauma and (2) fracture and significant translocation of tibiofibula confirmed by X-ray. Methods The control group was treated using external fixator, which could be single-arm external fixator, semicircular external fixator, and Ilizarav’s external fixator. Prolonged incision was performed at the open fracture site before reduction. Then external fixator was used after fracture reduction. The results were visualized using C-arm before complementing the surgery. In the case of comminuted fracture, Kirschner wire or screw was used to connect relatively big fractured blocks. Bone defect was treated with implantation of autograft such as hipbone. Relaxation suture was used to treat skin injury, while skin graft treatment was used in the subjects where skin injury cannot be treated with suture. All subjects in the observational group were treated with free flap combined with external fixator. Before surgery, color Doppler flow imaging (CDFI) was used to mark the spending point of skin. Cloth sample was designed according to point-line-plane principles and area and shape of trauma surface. Free flap should be 1–2 cm larger than the cloth sample. Lateral cutaneous nerve branch was separated with the flap. Realignment methods were used to separate the arterial branch. The arterial branch was well protected. Vessel pedicle was cut off after the reliable blood supply was confirmed in flap. After the cut-off of vessel pedicle, the recipient and trauma margin were temporarily fixed, and accompanying vein, arteriole, and nerve were matched. The trauma surface was closed after the reliable blood supply was confirmed, and drainage tube
123
was placed under flap. Medium-thickness flap was chosen for graft. Evaluation of Therapeutic Outcomes The therapeutic outcomes were evaluated according to the following standards [3]: cases with flap survival [95 %, no infection in needle site or in hospital, complete fracture healing without any impairment in walking function were graded as A; cases with flap survival [85 %, controlled infection, complete fracture healing with slight impairment in walking function were graded as B; cases with flap survival between 75 and 85 %, occurrence of infection, delayed fracture healing with need of mechanic aid for walking were graded as C; cases with flap survival \85 %, occurrence of infection or hematoma [5 cm2, difficulties in walking with swollen flap were graded as D. In addition, the early- and late-stage complications were compared. Statistical Analysis All data were analyzed with SPSS 13.0. Quantitative data were compared using t test, while enumeration data were compared using Chi-square test. P \ 0.05 was considered as statistically significant.
Results The Cleaning Time and Clinical Therapeutic Outcomes of Two Groups The results of the clinical therapeutic outcomes of two groups are shown in Table 1. The control group had A ? B rate of 54.28 % with an overall effective rate of 85.71 %. The observational group had A ? B rate of 71.43 % with an overall effective rate of 94.29 %. Significant difference existed in for A ? B rate and overall effective rate between groups (P \ 0.05). General Condition after Treatment in Two Groups Results of general conditions after treatment in two groups are shown in Table 2. Significant difference was found in duration of antibiotic treatment, dressing change, intervals between debridement and final surgery, times of surgery, duration of hospitalization, and duration of pain. Early and Late Complications of Two Groups The results of early- and late-stage complications are shown in Table 3. Significant difference was found in both
Cell Biochem Biophys Table 1 Comparison of clinical therapeutic outcomes (cases) Group
Cases
A
B
Cases
C
D
%
Cases
%
Cases
%
Cases
%
A ? B (%)
Overall effective rate(%)
Control group
35
6
17.14
13
37.14
11
31.43
5
14.29
54.28
85.71
Observation group
35
15
42.86
10
28.57
8
22.86
2
5.71
71.43
94.29
X2 P value
6.96
5.52
5.15
4.37
5.84
4.83
\0.05
\0.05
\0.05
\0.05
\0.05
\0.05
Table 2 Comparison of general conditions between groups (x ± s) Items
Control group (35)
Duration of antibiotic therapy (d)
15.1 ± 6.4
Dressing change (times) Intervals between debridement and final surgery (d) Surgery (times) Duration of hospitalization (d) Duration of pain compliant (d)
Table 3 Comparisons complications
between
Items
early-
and
T value
P value
8.9 ± 3.2
4.373
\0.05
26.5 ± 13.3
17.3 ± 7.4
4.253
\0.05
27.1 ± 11.4 3.1 ± 1.9
14.4 ± 7.2 1.9 ± 1.2
5.025 5.152
\0.05 \0.05
35.8 ± 13.6
24.4 ± 8.9
5.057
\0.05
9.5 ± 5.2
6.2 ± 3.3
4.962
\0.05
late-stage
Control group (35)
Observational group (35)
Cases
Cases
%
%
Early-stage complications Hemorrhage
3
8.57
1
2.86
Infection
4
11.43
1
2.86
Hematoma
2
5.71
2
5.71
Wound margin tension bubble Total
7
20.0
2
5.71
16
45.71
6
17.14
Late-stage complications Repair surface swollen
2
5.71
4
11.43
Chronic ulcer
6
17.14
0
0
Chronic pain
8
22.86
2
5.71
Function impairment Total
3
8.57
1
2.86
19
54.29
7
20.0
early- and late-stage complications between groups (P \ 0.05).
Discussion Open fracture in calf is quite common, which is always caused by high-energy injury. Open fracture is often associated with contusion of skin soft tissue with different extents of skin necrosis, which raises many concerns for internal fixation. Based on the previous studies by David et al., which showed that free flap could provide more clinical benefits to
Observational group (35)
patients with Gustilo type II and type III fractures, we used free flap combined with fixator in the treatment of calf open fracture. External fixator will not damage the blood supply at the fracture site. Therefore, external fixator could fix the fracture without worsening bone trauma [4]. Previous studies [5] have shown that nutritious blood vessels surrounding skin nerves play an important role in skin blood supply, leading to the introduction of concept of neuroskin. Zhang et al. [6] suggested that ipsilateral local rotational flap, sural nerve nutrition myocutaneous flap, and saphenous neurocutaneous flap are quite useful in the repair of trauma surface, because hallow neurocutaneous fascia vascular axis supplies blood through vessel traffic support to nutrition gastrocnemius, and nutritional vessels of sural nerve and small saphenous vein are homologous with nutritional vessels of muscle, fascia, and skin. The following are the main advantages of free flap [7]: (1) no compromise to major blood supply system of the trunk, good blood supply of flap, high resistance to infection, and satisfactory healing of tissues; (2) high-safety profile compared to other grafts, which makes suitable for use in clinical setting; (3) less pain for patients and no need for secondary pedicle compared to cross-leg skin flap; and (4) the large area of flap enables rotation with good amplitude without restriction of cutting range. From the experiences we got, the following points were noteworthy: (1) Complete debriding should be performed before surgery, skin tissue with bad blood supply and contusion should be removed [8]. (2) The defected surface should be measured before surgery, and color ultrasound should be performed to verify the condition of blood vessels.
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The choice of flap should be flexible with good understanding of the patient. (3) The length of the flap should be controlled during the surgery to avoid the impact of width of flap on the blood supply. The damage to surrounding tissue should be avoided with gentle operation. Sterile condition should be strictly maintained, and negative-pressure drainage should be used to prevent hematoma and exudate retention [9, 10]. (4) Post-surgery intensive care should be given to prevent osteofascial compartment syndrome. Dressing should be changed at regular intervals. For necrosis area less than 5 cm2, conservative dressing strategy should be employed. Exudate outflow should be ensured every time dressing is changed. (5) Two weeks after surgery, lifted position should be taken by the patients, and regular X-ray should be taken to avoid translocation. Passive function training could start 3 days post-surgery, and external fixator could be removed 8–12 weeks after surgery depending on the patient’s condition. Early function recovery training should be encouraged. This study suggested that free flap combined with external fixator provided clinical benefits, shortened hospitalization, and decreased the occurrence of complications, especially the late-stage chronic pain, chronic ulcer, and dysfunction. Therefore, it should be widely used in clinics.
References 1. Guichun, P., Songlin, Y., Hailiang, L., et al. (2011). Two-arm external fixator combination with internal fixator for calf open fracture. Trauma Surgery, 13(4), 333–336.
123
2. Dawei, Z., Guangyue, Z., Jun, L., et al. (2011). Use of anterolateral thigh flap in Gustilo III open fracture of calf with sift tissue defect. Chinese Journal of Microsurgery, 34(2), 116–118. 3. Jin, C., Xinke, Y., Yang, W., et al. (2008). Monolateral dynamic compression fixator for Severe open fractures with soft tissue crush injuries of the lower leg. Journal of Practical Orthopaedics, 14(3), 143–145. 4. Luo, Z., Lou, H., & Jiang, J. (2008). Pedicle flap transfer combined with external fixator to treat leg open fracture with soft tissue defect. Chinese Journal of Reparative and Reconstructive Surgery, 22(8), 956–958. 5. Wang, Y., Huang, J., Hu, S., et al. (2013). Close negative drainage combined with external fixator and flap in the treatment of severe calf open fracture. Youjiang Medical Journal, 41(1), 53–55. 6. Daofeng, Z., Li, F., Zhishan, Z., et al. (2010). Clinical outcome of different methods in management of open fracture of legs. Modern Chinese Doctor, 48(30), 117–119. 7. Jia, Hongwei, Cheng, Chunsheng, & Songfeng, L. V. (2007). Clinical applications of tibial bone-skin flaps in treatment of infective bone-skin defects of leg. Chinese Journal of Reparative and Reconstructive Surgery, 21(1), 30–33. 8. Lin, L., Geng, J., Yang, C., et al. (2011). VSD combination with island flap in treatment of open calf fracture with skin defects. Journal of Practical Orthopaedics, 17(3), 269–271. 9. Mingqing, X., & Xinli, Z. (2010). Combined application of external fixator in open fractures of the tibia. Jilin Medical Journal, 31(1), 85–86. 10. Zhen, L., Li-ming, L., & Yan-qing, C. (2009). Repair of soft tissue defect in the upper two-thirds of the leg with exposed bone by using medial head of gastrocnemius muscle flap. Hebei Medical Journal, 15(2), 153–154.
