Brmsh Jourd 0
o/‘Plasr~
1992 The Brltsh
Surgery (1992). 45. 571-577
Assoc~atmn of Plastic Surgeons
I
PLASTIC
SURGERY
Management of the soft tissues in open tibia1 fractures J. 0. Small and R. A. B. Mollan Department of Plastic Surgerv, The Ulster Hospital, Musgrave Park Hospital, Berfast
Dundonald,
and Department
of Orthopaedic
Surger~~.
SUMMARY. This paper reviews the treatment of 168 open tibia1 fractures referred to the Northern Ireland Plastic Surgery Service over a 15-year period. Flap reconstruction was carried out in 133 (79%) and split skin graft cover in 22 (13 %). There were 18 amputations (11%). There was a high incidence of complications among early post-injury fasciocutaneous flaps and late free flaps. Twenty-five primary free flaps were transferred without complication. The current management of open tibia1 fractures in this Unit is described.
Surgery Unit at the Ulster and Royal Victoria Hospitals, Belfast. The average patient age was 24 years (range 7-82) and the male to female ratio was 6.6: 1. Road traffic accidents were the commonest cause of injury (Table 2) and the majority of fractures occurred in the middle third of the leg (Table 3). There were 174 flap reconstructions carried out in 133 fractures (Table 4tin each of 41 fractures two flaps were transferred. Twenty-two fractures had split skin graft cover only and primary amputation was carried out in 13 fractures, soft tissue reconstruction not having been attempted.
The anteromedial surface of the tibia is mainly subcutaneous. It is not surprising therefore that fractures of the tibia1 shaft, particularly high energy injuries, frequently result in wide exposure of the fracture site. An open tibia1 fracture requiring flap cover corresponds to the Type IIIB open fracture classified by Gustilo et al. (1984) (Table 1). A Type IIIC open fracture is one which is complicated by vascular injury. Types I, II and IIIA open fractures are categories not complicated by exposure of the fracture site (Gustilo and Anderson, 1976). As little as two decades ago the choice of flap reconstruction for this injury was limited (Saad, 1970). However, a wide variety of flaps now exists for reconstruction in the leg, although not all possess the ability to cover open tibia1 fractures successfully and reliably. In many situations local flaps are not usable because of violation of the flap territory or its pedicle by the injuring force. While flap cover fulfils the basic surgical principle that an exposed fracture must be covered by viable soft tissue, the ability of the flap tissues (skin, subcutaneous fat, fascia or muscle) to influence fracture healing biologically has not been critically assessed. There is strong experimental evidence that muscle, in particular, is intimately involved in the biologic process of fracture healing (Wray and Lynch, 1959; Gothman, 196 1, 1962 ; Rhinelander and Baragry, 1962 ; Cavadias and Trueta, 1965 ; Rhinelander et al., 1968 ; Trueta, 1974) and, based on this experimental evidence, muscle would appear to be the tissue of choice for covering an open tibia1 fracture (Holden, 1972 ; McKibbin, 1978 ; Whiteside and Lesker, 1978). This paper reports a study of the management of this injury over a period of 15 years in this Unit. We have endeavoured to assess the effects and influence of evolving reconstructive ideas on the outcome of open tibia1 fractures, and discuss our current management.
Results
Prior to 1983 the majority of open tibia1 fractures were referred to a plastic surgeon at a relatively late stage. Soft tissue reconstruction was thus carried out many weeks to months following injury. More recently, as a result of greater liaison between orthopaedic and Table 1
Type I Type II
Type IIIA
Type IIIB Type IIIC
Table 2
Classification of open fractures (Gustilo) An open fracture with a wound of i I cm, and clean An open fracture with a wound of > 1 cm without extensive soft tissue damage, flaps or avulsions Adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high energy trauma irrespective of the size of the wound Extensive soft tissue injury and loss with periosteal stripping and bone exposure An open fracture associated with arterial injury requiring repair
Mechanism
of injury
Road traffic accident Civil disturbance Industrial/agricultural Leisure activities
Clinic& material
Over a 1%year period (1975-1989) 165 patients with 168 open tibia1 fractures were referred to the Plastic 571
115 ‘4 20 9
572
British Journal
Table 3
Level of fracture
~
Upper third
23 83 62
Middle third Lower third
Table 4
Open tibia1 fractures:
Table 5
Number of 50 free flaps
Flap reconstruction
1977-1988
97
1987-1989 Fig. 2
60 33 4
Figure 2--0ver 50% of free flaps were transferred injury during the last 3 years of the 15year period
within 72 h of reviewed.
70 7
Total
60
40
168 fractures.
Local flap Pedicled muscle flap Fasciocutaneous flap Random skin flap Free tissue transfer Cross-leg flap
Table 6
free flaps 72 h of injury)
13 (8%) 133 (174 flaps) 22
Flap reconstruction Split skin graft 165 patients.
(within
197551989
Primary amputation
Primary
of Plastic Surgerv
174
Free tissue transfer Latissimus dorsi Rectus abdominis Radial forearm DCIA Fibula Groin @CIA) TFL
31 18 8 7 3 2
Total
70
1
Number of fractures m
Primary
El
Local flap
amputation
m
Split skin graft
m
Free flap
Fig. 3
1975-7s
1980-84
1985-89
(32)
(38,
(98)
Fig. 1 Figure l--In brackets 5-year period.
are the number
Table 7
graft
Split
skin
cover
Adequate cover Long-term problems Unstable skin with ulceration Chronic bone infection Non-union Total
of fractures
treated
in each
in 22 patients 7 15 10 3 2
Fig. 4 22
Figure 3-A free rectus abdominis muscle flap inset by peripheral underlapping. Figure APart of the thick fibrous sheath has been dissected off the deep surface of the medial head of gastrocnemius.
Management
of the Soft Tissues in Onen Tibia1 Fractures
513
A.T.A
Fig. 5 Figure %-An on-table angiogram 3 h following injury, showing loss of vascular markings distal to the reduced fracture, and blockage of all three main arteries with contrast material leaking out of the posterior and anterior tibia1 arteries at the fracture site.
plastic surgeons, the soft tissue injury has been treated at a much earlier stage. The mean delay between injury and soft tissue reconstruction during the period 1975- 1982 was 2.8 months, compared with a mean delay of 4 days during the period 1983-1989. The variety of flaps used in this series is shown in Table 5 and the variety of free flaps in Table 6. All rectus abdominis flaps and all but two latissimus dorsi flaps consisted of muscle only. The length of iliac crest in the DCIA flaps ranged from 4-10 cm and the length of fibular transfers ranged from 14 to 20 cm. All fibular transfers and two DCIA transfers consisted of bone only. Figure 1 shows a number of interesting features. The 15-year period under review has been divided up into three 5-year periods and analysis of the cases treated between 1985 and 1989 compared with the previous decade shows :A three-fold increase in the number of open tibia1 fractures referred to this Unit. An absolute increase in the number of cases reconstructed using free tissue transfers and a corresponding decrease in the percentage of cases reconstructed by local flaps. An increase in the number of primary amputations. Figure 2 shows the trend towards early definitive reconstruction of this injury in this Unit. In the 3-year period 1987-1989 24 out of 46 free flaps (52%) were transferred within 72 h of injury, compared with only one out of 24 free flaps during the previous lo-year
Fig. 6 Figure &Selection of a saphenous vein graft. (A) Suitably large tributary entering in a distal direction is ideal. (B) However, the more usual proximally-directed tributary can be transposed so that when the graft is reversed the tributary can be anastomosed to the posterior tibia1 artery and the long saphenous vein to the popliteal artery proximally and the tibio-peroneal trunk distally. In this way, all three main arteries in the leg are reconstructed. Dilatation of the graft with heparinised saline overcomes spasm.
period. (The first free flap for cover of an open tibia1 fracture was carried out in this Unit in 1977.) It is also pertinent to point out that 13 out of 33 fasciocutaneous flaps were transposed within 1 month of injury. Complications
A total of 22 out of 174 flaps (12.6%) underwent necrosis (7 fasciocutaneous flaps, 7 free flaps and 8 local muscle flaps). This necessitated a second flap in 18 cases while four did not undergo further flap reconstruction. The highest complication rate occurred in fasciocutaneous flaps with 7 out of 33 developing problems. Five out of 13 fasciocutaneous flaps transferred within 1 month of injury suffered tip necrosis resulting in exposure of the fracture site in all. Two further “early” fasciocutaneous flaps were seen to be poorly perfused following dissection and were thus returned to their beds. Despite this, necrosis of the distal portion occurred in one such flap. Twenty fasciocutaneous flaps transferred more than 1 month following injury were all free of complications. Seven out of 70 free flaps failed. Five of the initial group of 10 free flaps failed but there have only been
British Journal of Plastic Surgerv
574
Fig. 7 Figure 7+A) The latissimus dorsi pedicle. The subscapular artery divides into the thoracodorsal artery and the circumflex scapular artery. (B) A latissimus dorsi muscle flap has been revascularised by end-to-end anastomoses of the subscapular artery and vein to the posterior tibia1 artery and a posterior tibia1 vena comitans. A damaged segment of the posterior tibia1 artery has been reconstructed by a reversed vein graft anastomosed proximally to the circumflex scapular artery and distally to the posterior tibia1 artery.
two failures among 60 free flaps (3.3 %) transferred subsequently. All failures, with one exception, occurred in flaps that were transferred to chronic wounds many weeks following injury. Twenty-five primary free flaps have all been free of complications. Of 22 patients who had split skin graft cover of their fractures, adequate long-term cover was achieved in only seven, with 15 suffering long-term problems (Table 7). Current management tibia1 fractures
of Type IIIB and IIIC open
Primary surgical management
Based on the experience gained and the lessons learned from this series, a clear management policy has now been agreed with our orthopaedic colleagues. In the vast majority of cases an external fixator is the method of choice for skeletal stabilisation and this is usually
applied prior to the debridement. A thorough exploration and radical debridement of the wound is then carried out, during the course of which it is frequently necessary to slacken the fixator in order to displace the fracture to expose and explore the deep flexor and peroneal compartments adequately. If a local flap is deemed appropriate, this is usually done at the primary procedure. When a free flap is considered necessary, and the required personnel available, it is carried out at the primary procedure. If this is not possible, the wound is covered with a moist dressing and arrangements made to carry out free tissue transfer within 72 h. When the primary treatment is carried out at another hospital, the patient is transferred to the Plastic Surgery Unit on the following day or as soon as is convenient. With very few exceptions a muscle flap covered with a split skin graft is used for coverage of an exposed tibia1 fracture in this Unit. A generous in-setting of the flap is ensured by underlapping at least 1 cm of muscle
Management
575
of the Soft Tissues in Open Tibia1 Fractures
under the skin margins and securing the muscle edge with tie-over bolus sutures (Fig. 3). Care is taken to make sure that bare muscle is in contact with the fracture site and, to this end, any aponeurotic or fascial sheath is dissected off the appropriate segment of the muscle flap (Fig. 4). Splitting a muscle flap in the line of its fibres is sometimes necessary to allow enclosure of fixator pins.
A high index of suspicion is the most vital factor in the early diagnosis of an associated major vascular injury. If a vascular injury is suspected, conventional angiography of the limb is carried out. Frequently, however, this may incur undue delay or the patient may already be anaesthetised. In such situations the surgeon performs an on-table angiogram. This is a rapid and straightforward procedure which gives immediate and vital information (Fig. 5). Repair of injuries to the popliteal artery. its trifurcation or the major arteries in the leg are well within the scope of surgeons with microvascular training. A bifurcated saphenous vein graft should be used to repair ;I trifurcation injury (Fig. 6). Following harvesting. the graft is dilated to its original in viz-0 size by gentle hydrostatic pressure. This reverses and prevents further spasm and allows much better size matching of the vessels. Injuries of the anterior or posterior tibia1 arteries distal to the trifurcation are repaired using standard vascular techniques. There are situations, however, where I degree of improvisation can facilitate such reconstruction (Fig. 7). Decompression of the leg compartments is carried out where considered necessary, bearing in mind that exploration, debridement and dissection of recipient vessels frequently results in adequate decompression of all compartments. If a nerve injury is diagnosed on clinical examination then the appropriate nerve trunk must be explored during the course of the debridement. It takes little time to do this and it establishes the gross nature of the nerve injury. In the vast majority of cases one is dealing with a direct crush or traction injury of the tibia1 nerve without disruption of its physical continuitj. An accurate prognosis at this point may therefore be difficult to make but the general principles governing nerve injury and repair must be considered for each individual case.
Physiotherapy is begun within a few days of injury, paying particular attention to the ankle and foot. Passive and active exercises of the ankle, subtalar and tarsal joints. as well as the toes, are carried out. Great emphasis is placed on this programme of rehabilitation and only exceptional circumstances are allowed to interfere with it. The aim is to transfer the patient to the Orrhopaedic Department within 2-3 weeks of injury with a healed wound, functioning joints and particularly a supple foot. As soon as the wound is healed a pressure stocking is applied to the limb to control swelling. Modification of the stocking is
Fig. 8 Figure
hospital
8-A pressure sewing room.
stocking
with
Velcro
required to allow it to fit snugly (Fig. 8).
stuns
around
made
in the
the fixator
Bone gtvfiing
This is carried out as a combined procedure with the orthopaedic surgeon 34 weeks following flap cover or as soon as soft tissue healing is complete. The fracture site is exposed by dissection around the flap margin. being aware of, and careful with regard to, the position of the vascular pedicle. There is little elasticity in the skin grafted muscle flap at this early stage which makes wound closure difficult if excess bone is packed into the defect. Therefore, a large pocket which readily accommodates the graft should be dissected and the quantity of graft inserted should not exceed that which will allow comfortable closure of the wound. The indication for bone grafting is bone loss either at the time of injury or subsequently by debridement (avascular bone). If there is contact. in part. of heulrl7~. cortical bone across the fracture gap. a cancellous bone graft is usually adequate regardless of the quantity of bone lost. If, however, there is a complete gap of > 3 cm a vascularised bone graft (DCIA or fibula) is used. 5-6 cm has been mentioned as the cutoff point between conventional and vascularised bone grafts. However, in our experience. the incidence of non-union is very high if defects > 3 cm are managed in a conventional fashion.
Discussion While it has been accepted that skin necrosis leads to major complications in tibia1 shaft fractures (Hicks. 1964) the precise role of the soft tissues in the healing of such fractures has not been widely appreciated. Therefore, trauma surgeons have tended to relegate soft tissue reconstruction to the secondary phase (Chacha. 1974; Freeland and Mutz. 1976: Clancey and Hansen, 1978). Until recently the choice of flap reconstruction in the leg remained limited and although the soft tissue problems associated with open
British
576
tibia1 fractures were appreciated among plastic surgeons, the solutions (Harrison, 1968) remained unattractive. The advent of local pedicled and particularly free muscle flaps has produced more elegant and biologically more effective techniques with which to reconstruct this injury. Fasciocutaneous flaps enjoyed a surge of popularity following their description by Pontln (1979). Their greater reliability. compared to the notoriously unreliable random-pattern skin flap, and their ease of dissection, made them a popular choice for covering defects in the leg. However, while a number of clinical series expounded their virtues (Ponten, 1979; Barclay rt al., 1982; McGregor and Palmer, 1985), their use was not described in the acute phase following severe injury. In the light of current knowledge on fracture healing, local flaps that cannot be safely transferred in the early stages following injury cannot be considered for the reconstruction of open tibia1 fractures. In our experience fasciocutaneous flaps are unreliable for up to 4 weeks following severe trauma to the leg. That this is the case is not surprising because the loose areolar layer, superficial to the deep fascia, which contains the fine vascular network of the fascial plexus, is frequently oedematous and haemorrhagic in the acute phase following injury. The shearing forces of injury transmitted through this delicate layer readily damage the network of fascial vessels. It is, after all, the “degloving layer” of the leg. There are two broad indications for free flap coverage in the leg-a defect in the lower third or an extensive defect at any level. Muscle would appear to be the flap of choice because of its beneficial biological influence on fracture healing (Wray and Lynch, 1959; Holden, 1972; McKibbin, 1978 ; Whiteside and Lesker, 1978). There does not appear to be any indication, that we are aware of, to use a musculocutaneous flap; they are excessively bulky and result in a greater donor defect. The two popular free muscle flaps in this series were the Iatissimus dorsi and the rectus abdominis. Both possess long pedicles with good vessel size. The rectus abdominis muscle is an ideal shape for covering linear defects over the tibia while the more expansive latissimus dorsi is indicated when the defect is more extensive. Furthermore, exposed anterior compartment and peroneal muscles alongside the fracture would appear to recover better gliding function if covered with a muscle flap than by a split skin graft directly onto the exposed muscle bellies. The rectus abdominis muscle flap is quicker and easier to dissect than the latissimus dorsi. However, patient positioning on the operating table with regard to the defect, recipient vessels and the presence of other injuries may dictate the use of one or other flap. Problems have not been encountered with the abdominal wall following unilateral removal of the rectus abdominis muscle. However, the fascial sheath must be carefully repaired to minimise the risk of herniation. In this Unit we are increasingly of the opinion that free tissue transfer provides by far the most appropriate reconstruction for the majority of Types IIIB and IIIC open tibia1 fractures. The practice of more thorough exploration and debridement of this injury
Journal of Plastic Surgery
invariably results in a defect that can only adequately be covered by a free flap. Potentially usable local flaps or their pedicles will frequently have been damaged and will therefore be unusable. The practice of compromising a severely injured leg further by sacrificing a local muscle or segment of intact skin should be considered with caution and the principle of avoiding this by importing a distant flap is indeed a sound one. In this series all primary free flaps were without complication. There is little doubt that the primary phase is the optimal time for free flap reconstruction and that any delay beyond this period increases the cumulative operating time and thus the hospitalisation time and cost of treatment (Godina, 1986). Most importantly, it increases the risk of flap failure (Byrd et al., 1985; Godina, 1986). Skin grafts are not usually adequate for covering open tibia1 fractures-only 5 % were successfully covered by this technique in this series. In 15 out of 22 cases the decision to use skin grafts was clearly erroneous. It is difficult to understand how some authors achieve cover by split skin grafting alone in the majority of severe open fractures reported in their series (Chapman and Mahoney, 1979 ; Edwards, 1983 ; Gustilo et al., 1984). There were five failures in the initial group of 10 free flaps in this series. However, there were only two failures in 60 free flaps transferred subsequently. There are a number of factors which may explain this:(a) The earlier free flaps were transferred without exception at a late stage to chronic wounds. (b) The significance of perivascular fibrosis and other vascular changes in and around such wounds was not appreciated at that time. The choice of free flaps in the initial stages of this (c) series was limited. (d) The materials, instruments and microscopes available today are superior. It has been satisfying to observe the evolution of a rational and systematic approach to the reconstruction of this difficult injury in this Unit. We now have a well established pecking order of flaps for reconstructing this injury, but this is not a substitute for the thorough assessment of each individual case by an experienced surgeon and selection of the mode of reconstruction most appropriate for each case. The temptation to select the quick and easier option when it comes to soft tissue reconstruction must be avoided. On the other hand, free tissue transfer must be seen to be an attractive reconstructive technique in terms of operating time and success rate. Acknowledgement The authors sincerely wish to thank their colleagues in Orthopaedic and Plastic Surgery, who have participated in the reconstruction of the cases reported in this series.
References Barclay, T. L., Cardoso, E., Sharpe, D. T. and Crockett, (1982). Repair of lower leg injuries with fasciocutaneous British Journal qf Plastic Surgery. 35. 127.
D. J. Raps.
Management
of the Soft Tissues
in Open
Byrd, H. S., Spicer, T. E. and Cierney,
G.
Tibia1
Fractures
( 1985). Management
517
of
open tibia1 fractures.
PIustic md Reconslructive Surger?, 76. 7 19 Cavadias, A. X. and Trueta, J. ( 1965). An experimental study of the vascular contribution to the callus of fracture. Surger?. G>wecolog~~ mc/ Ohsrc~rrics. 120. 73 I. Chacha. P. B. (1974). Salvage of severe open fractures
of the tibia l@trx, 6. 154. Chapman, M. W. and Mahoney, .!%I.(1979). The role ofearly internal tixatlon in rhc management of open fractures. Clinicd Orthothat might have required
amputation.
pedics (md Reluted Resrowh. 138. IX. Clancey. C. J. and Hansen, S. T. ( 1978). Open fractures of the tibia. A revlcw of one hundred and two cases. Journd q/‘Bonr crnJJoinr Suryrry. 60A. I 18. Edwaids, C. E. (1983). Staged reconstruction of complex open tibia1 fractures usmg Hoffmann external fixation. Clinical 0r~hopaetlic.t and Reiuted Research. 178. 130. Freeland, A. E. and Mutz, S. B. ( 1976). Posterior bone grafting for infected un-united fractures of the tibia. Journal of‘ Bone & Join/ Surgery,. 58A. 653. Godina, M. ( 1986). Early microsurgical reconstruction of complex trauma of the extremities. P/[r.\ric untl Reconstructiw Suyer!. 78. 2x5. Gothman. L. ( 1961). Vascular reactions in experimental fractures. Microangiographic and radioisotope studies. Arta Chirurgitr Scundinuricu Supplwnmtum. 284. 3. Gothman. L. (1961). Local arterial changes associated with ex-
perimental fractures of the rabbit’s tibia treated with encircling wires (Cerclage). A microangiographic study. Acta Chirurgia Scandirwicu. 123, 17. Gustilo, R. B. and Anderson, J. T. ( 1976). Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. Journal qf Bone & Joint Surger~~, 58A. 453. Gustilo, R. B., Mendoza, R. M. and Williams, D. N. (1984). Problems in the management of Type III (severe) open fractures: a new classification of Type 111 open fractures. The Journal o/‘Trauma. 24. 74’. Harrison, S. H. (1968).Fractures of the tibia complicated by skin loss. Briti.sh Jmrrnul o/ Plusrrc~ Surgery, 21, 261. Hicks, J. H. (I 964). Amputation in fractures of the tibia. Jo~nul of Bone & Join/ Surger~~. 46B. 3x8.
Holden, C. E. A. (1972). The role of blood supply to soft tissue in the healing of diaphyseal fractures. Jmrrnd r>/ &VW md./nin, .%tr,ccr1,. 54A. 993. McGregor, J. C. and Palmer, J. H.
( 19x5). A critical rev& of llap repairs in the lower limbone unit’s experience over the past live years. Chirtrrgia f’ltrsrka. 8. 95. McKibbin, B. (I 97X). The biology of fracture-healing in long hone. Journul qf Bone & Joinr Surgery. 608. 150. Pontkn, B. (1981). The fasciocutaneous fap: ita uw in soft tissue defects of the lower leg. Bri~idz Journtrl o/‘P/tr.vtr~~ .Surgcry. 34. 2 15. Rhinelander, F. W. and Baragry, R. A. (I 961). Microanpiograph) in bone healing. I. Undisplaced closed fractures. ./~rj~i ,I/ Bone [ml/ Join/ Surger!. 44A. 1273. Rhinelander. F. W., Phillips, R. S., Steel, b. %I. and Beer, J. C‘.
(1968). Microangiography
in bone healing
.I~~rrrcl/ t>f Bonr &
Joint .Sur,q+~~. 50A. 643. Saad, M. N. (1970). The problems
limbs.
especially
when
oftraumatIc hkin 10~3of the lower associated with sheletal Inlury. Briri.sh
Jound c$Surgery. 57, 601. Trueta, J. (1974). Blood supply and the rate ot‘ heahng of tibia1 fractures. Cl~nicul Orthopedics uml Relurrcl Rescwrc~h, 105. I I Whiteside, 1.. A. and Lesker, P. A. 1197X). Thr elYect.\ of extr:l-
psriosteal
and subperiosteal
dissection:
II. On fractul-e
healing.
Journal q/ Bone untl Join! Surger~~. 6OA. 76 Wray, J. B. and Lynch, C. J. (1959). Th e vascular response to fracture of the tibia in the rat. Jorrrnd !I/ R~IW md Jrrinr ,Srrr,yert’. 4lA. 1143.
The Authors J. 0. Small, FRCSI, Consultant in Plastic Surgery. The Ulster Hospital. Dundonald, Belfast, BT16 ORH R. A. B. Mollan, MD, FRCS. FRCSI, Professor in Orthopaedic Surgery. Musgrave Park Hospital. Belfast Requests
for reprints
to: Mr J. 0. Small.
Paper received 27 December I99 I, Accepted 20 May 1992. after revision.
‘O-2
o/‘Plasr~
1992 The Brltsh
Surgery (1992). 45. 571-577
Assoc~atmn of Plastic Surgeons
I
PLASTIC
SURGERY
Management of the soft tissues in open tibia1 fractures J. 0. Small and R. A. B. Mollan Department of Plastic Surgerv, The Ulster Hospital, Musgrave Park Hospital, Berfast
Dundonald,
and Department
of Orthopaedic
Surger~~.
SUMMARY. This paper reviews the treatment of 168 open tibia1 fractures referred to the Northern Ireland Plastic Surgery Service over a 15-year period. Flap reconstruction was carried out in 133 (79%) and split skin graft cover in 22 (13 %). There were 18 amputations (11%). There was a high incidence of complications among early post-injury fasciocutaneous flaps and late free flaps. Twenty-five primary free flaps were transferred without complication. The current management of open tibia1 fractures in this Unit is described.
Surgery Unit at the Ulster and Royal Victoria Hospitals, Belfast. The average patient age was 24 years (range 7-82) and the male to female ratio was 6.6: 1. Road traffic accidents were the commonest cause of injury (Table 2) and the majority of fractures occurred in the middle third of the leg (Table 3). There were 174 flap reconstructions carried out in 133 fractures (Table 4tin each of 41 fractures two flaps were transferred. Twenty-two fractures had split skin graft cover only and primary amputation was carried out in 13 fractures, soft tissue reconstruction not having been attempted.
The anteromedial surface of the tibia is mainly subcutaneous. It is not surprising therefore that fractures of the tibia1 shaft, particularly high energy injuries, frequently result in wide exposure of the fracture site. An open tibia1 fracture requiring flap cover corresponds to the Type IIIB open fracture classified by Gustilo et al. (1984) (Table 1). A Type IIIC open fracture is one which is complicated by vascular injury. Types I, II and IIIA open fractures are categories not complicated by exposure of the fracture site (Gustilo and Anderson, 1976). As little as two decades ago the choice of flap reconstruction for this injury was limited (Saad, 1970). However, a wide variety of flaps now exists for reconstruction in the leg, although not all possess the ability to cover open tibia1 fractures successfully and reliably. In many situations local flaps are not usable because of violation of the flap territory or its pedicle by the injuring force. While flap cover fulfils the basic surgical principle that an exposed fracture must be covered by viable soft tissue, the ability of the flap tissues (skin, subcutaneous fat, fascia or muscle) to influence fracture healing biologically has not been critically assessed. There is strong experimental evidence that muscle, in particular, is intimately involved in the biologic process of fracture healing (Wray and Lynch, 1959; Gothman, 196 1, 1962 ; Rhinelander and Baragry, 1962 ; Cavadias and Trueta, 1965 ; Rhinelander et al., 1968 ; Trueta, 1974) and, based on this experimental evidence, muscle would appear to be the tissue of choice for covering an open tibia1 fracture (Holden, 1972 ; McKibbin, 1978 ; Whiteside and Lesker, 1978). This paper reports a study of the management of this injury over a period of 15 years in this Unit. We have endeavoured to assess the effects and influence of evolving reconstructive ideas on the outcome of open tibia1 fractures, and discuss our current management.
Results
Prior to 1983 the majority of open tibia1 fractures were referred to a plastic surgeon at a relatively late stage. Soft tissue reconstruction was thus carried out many weeks to months following injury. More recently, as a result of greater liaison between orthopaedic and Table 1
Type I Type II
Type IIIA
Type IIIB Type IIIC
Table 2
Classification of open fractures (Gustilo) An open fracture with a wound of i I cm, and clean An open fracture with a wound of > 1 cm without extensive soft tissue damage, flaps or avulsions Adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high energy trauma irrespective of the size of the wound Extensive soft tissue injury and loss with periosteal stripping and bone exposure An open fracture associated with arterial injury requiring repair
Mechanism
of injury
Road traffic accident Civil disturbance Industrial/agricultural Leisure activities
Clinic& material
Over a 1%year period (1975-1989) 165 patients with 168 open tibia1 fractures were referred to the Plastic 571
115 ‘4 20 9
572
British Journal
Table 3
Level of fracture
~
Upper third
23 83 62
Middle third Lower third
Table 4
Open tibia1 fractures:
Table 5
Number of 50 free flaps
Flap reconstruction
1977-1988
97
1987-1989 Fig. 2
60 33 4
Figure 2--0ver 50% of free flaps were transferred injury during the last 3 years of the 15year period
within 72 h of reviewed.
70 7
Total
60
40
168 fractures.
Local flap Pedicled muscle flap Fasciocutaneous flap Random skin flap Free tissue transfer Cross-leg flap
Table 6
free flaps 72 h of injury)
13 (8%) 133 (174 flaps) 22
Flap reconstruction Split skin graft 165 patients.
(within
197551989
Primary amputation
Primary
of Plastic Surgerv
174
Free tissue transfer Latissimus dorsi Rectus abdominis Radial forearm DCIA Fibula Groin @CIA) TFL
31 18 8 7 3 2
Total
70
1
Number of fractures m
Primary
El
Local flap
amputation
m
Split skin graft
m
Free flap
Fig. 3
1975-7s
1980-84
1985-89
(32)
(38,
(98)
Fig. 1 Figure l--In brackets 5-year period.
are the number
Table 7
graft
Split
skin
cover
Adequate cover Long-term problems Unstable skin with ulceration Chronic bone infection Non-union Total
of fractures
treated
in each
in 22 patients 7 15 10 3 2
Fig. 4 22
Figure 3-A free rectus abdominis muscle flap inset by peripheral underlapping. Figure APart of the thick fibrous sheath has been dissected off the deep surface of the medial head of gastrocnemius.
Management
of the Soft Tissues in Onen Tibia1 Fractures
513
A.T.A
Fig. 5 Figure %-An on-table angiogram 3 h following injury, showing loss of vascular markings distal to the reduced fracture, and blockage of all three main arteries with contrast material leaking out of the posterior and anterior tibia1 arteries at the fracture site.
plastic surgeons, the soft tissue injury has been treated at a much earlier stage. The mean delay between injury and soft tissue reconstruction during the period 1975- 1982 was 2.8 months, compared with a mean delay of 4 days during the period 1983-1989. The variety of flaps used in this series is shown in Table 5 and the variety of free flaps in Table 6. All rectus abdominis flaps and all but two latissimus dorsi flaps consisted of muscle only. The length of iliac crest in the DCIA flaps ranged from 4-10 cm and the length of fibular transfers ranged from 14 to 20 cm. All fibular transfers and two DCIA transfers consisted of bone only. Figure 1 shows a number of interesting features. The 15-year period under review has been divided up into three 5-year periods and analysis of the cases treated between 1985 and 1989 compared with the previous decade shows :A three-fold increase in the number of open tibia1 fractures referred to this Unit. An absolute increase in the number of cases reconstructed using free tissue transfers and a corresponding decrease in the percentage of cases reconstructed by local flaps. An increase in the number of primary amputations. Figure 2 shows the trend towards early definitive reconstruction of this injury in this Unit. In the 3-year period 1987-1989 24 out of 46 free flaps (52%) were transferred within 72 h of injury, compared with only one out of 24 free flaps during the previous lo-year
Fig. 6 Figure &Selection of a saphenous vein graft. (A) Suitably large tributary entering in a distal direction is ideal. (B) However, the more usual proximally-directed tributary can be transposed so that when the graft is reversed the tributary can be anastomosed to the posterior tibia1 artery and the long saphenous vein to the popliteal artery proximally and the tibio-peroneal trunk distally. In this way, all three main arteries in the leg are reconstructed. Dilatation of the graft with heparinised saline overcomes spasm.
period. (The first free flap for cover of an open tibia1 fracture was carried out in this Unit in 1977.) It is also pertinent to point out that 13 out of 33 fasciocutaneous flaps were transposed within 1 month of injury. Complications
A total of 22 out of 174 flaps (12.6%) underwent necrosis (7 fasciocutaneous flaps, 7 free flaps and 8 local muscle flaps). This necessitated a second flap in 18 cases while four did not undergo further flap reconstruction. The highest complication rate occurred in fasciocutaneous flaps with 7 out of 33 developing problems. Five out of 13 fasciocutaneous flaps transferred within 1 month of injury suffered tip necrosis resulting in exposure of the fracture site in all. Two further “early” fasciocutaneous flaps were seen to be poorly perfused following dissection and were thus returned to their beds. Despite this, necrosis of the distal portion occurred in one such flap. Twenty fasciocutaneous flaps transferred more than 1 month following injury were all free of complications. Seven out of 70 free flaps failed. Five of the initial group of 10 free flaps failed but there have only been
British Journal of Plastic Surgerv
574
Fig. 7 Figure 7+A) The latissimus dorsi pedicle. The subscapular artery divides into the thoracodorsal artery and the circumflex scapular artery. (B) A latissimus dorsi muscle flap has been revascularised by end-to-end anastomoses of the subscapular artery and vein to the posterior tibia1 artery and a posterior tibia1 vena comitans. A damaged segment of the posterior tibia1 artery has been reconstructed by a reversed vein graft anastomosed proximally to the circumflex scapular artery and distally to the posterior tibia1 artery.
two failures among 60 free flaps (3.3 %) transferred subsequently. All failures, with one exception, occurred in flaps that were transferred to chronic wounds many weeks following injury. Twenty-five primary free flaps have all been free of complications. Of 22 patients who had split skin graft cover of their fractures, adequate long-term cover was achieved in only seven, with 15 suffering long-term problems (Table 7). Current management tibia1 fractures
of Type IIIB and IIIC open
Primary surgical management
Based on the experience gained and the lessons learned from this series, a clear management policy has now been agreed with our orthopaedic colleagues. In the vast majority of cases an external fixator is the method of choice for skeletal stabilisation and this is usually
applied prior to the debridement. A thorough exploration and radical debridement of the wound is then carried out, during the course of which it is frequently necessary to slacken the fixator in order to displace the fracture to expose and explore the deep flexor and peroneal compartments adequately. If a local flap is deemed appropriate, this is usually done at the primary procedure. When a free flap is considered necessary, and the required personnel available, it is carried out at the primary procedure. If this is not possible, the wound is covered with a moist dressing and arrangements made to carry out free tissue transfer within 72 h. When the primary treatment is carried out at another hospital, the patient is transferred to the Plastic Surgery Unit on the following day or as soon as is convenient. With very few exceptions a muscle flap covered with a split skin graft is used for coverage of an exposed tibia1 fracture in this Unit. A generous in-setting of the flap is ensured by underlapping at least 1 cm of muscle
Management
575
of the Soft Tissues in Open Tibia1 Fractures
under the skin margins and securing the muscle edge with tie-over bolus sutures (Fig. 3). Care is taken to make sure that bare muscle is in contact with the fracture site and, to this end, any aponeurotic or fascial sheath is dissected off the appropriate segment of the muscle flap (Fig. 4). Splitting a muscle flap in the line of its fibres is sometimes necessary to allow enclosure of fixator pins.
A high index of suspicion is the most vital factor in the early diagnosis of an associated major vascular injury. If a vascular injury is suspected, conventional angiography of the limb is carried out. Frequently, however, this may incur undue delay or the patient may already be anaesthetised. In such situations the surgeon performs an on-table angiogram. This is a rapid and straightforward procedure which gives immediate and vital information (Fig. 5). Repair of injuries to the popliteal artery. its trifurcation or the major arteries in the leg are well within the scope of surgeons with microvascular training. A bifurcated saphenous vein graft should be used to repair ;I trifurcation injury (Fig. 6). Following harvesting. the graft is dilated to its original in viz-0 size by gentle hydrostatic pressure. This reverses and prevents further spasm and allows much better size matching of the vessels. Injuries of the anterior or posterior tibia1 arteries distal to the trifurcation are repaired using standard vascular techniques. There are situations, however, where I degree of improvisation can facilitate such reconstruction (Fig. 7). Decompression of the leg compartments is carried out where considered necessary, bearing in mind that exploration, debridement and dissection of recipient vessels frequently results in adequate decompression of all compartments. If a nerve injury is diagnosed on clinical examination then the appropriate nerve trunk must be explored during the course of the debridement. It takes little time to do this and it establishes the gross nature of the nerve injury. In the vast majority of cases one is dealing with a direct crush or traction injury of the tibia1 nerve without disruption of its physical continuitj. An accurate prognosis at this point may therefore be difficult to make but the general principles governing nerve injury and repair must be considered for each individual case.
Physiotherapy is begun within a few days of injury, paying particular attention to the ankle and foot. Passive and active exercises of the ankle, subtalar and tarsal joints. as well as the toes, are carried out. Great emphasis is placed on this programme of rehabilitation and only exceptional circumstances are allowed to interfere with it. The aim is to transfer the patient to the Orrhopaedic Department within 2-3 weeks of injury with a healed wound, functioning joints and particularly a supple foot. As soon as the wound is healed a pressure stocking is applied to the limb to control swelling. Modification of the stocking is
Fig. 8 Figure
hospital
8-A pressure sewing room.
stocking
with
Velcro
required to allow it to fit snugly (Fig. 8).
stuns
around
made
in the
the fixator
Bone gtvfiing
This is carried out as a combined procedure with the orthopaedic surgeon 34 weeks following flap cover or as soon as soft tissue healing is complete. The fracture site is exposed by dissection around the flap margin. being aware of, and careful with regard to, the position of the vascular pedicle. There is little elasticity in the skin grafted muscle flap at this early stage which makes wound closure difficult if excess bone is packed into the defect. Therefore, a large pocket which readily accommodates the graft should be dissected and the quantity of graft inserted should not exceed that which will allow comfortable closure of the wound. The indication for bone grafting is bone loss either at the time of injury or subsequently by debridement (avascular bone). If there is contact. in part. of heulrl7~. cortical bone across the fracture gap. a cancellous bone graft is usually adequate regardless of the quantity of bone lost. If, however, there is a complete gap of > 3 cm a vascularised bone graft (DCIA or fibula) is used. 5-6 cm has been mentioned as the cutoff point between conventional and vascularised bone grafts. However, in our experience. the incidence of non-union is very high if defects > 3 cm are managed in a conventional fashion.
Discussion While it has been accepted that skin necrosis leads to major complications in tibia1 shaft fractures (Hicks. 1964) the precise role of the soft tissues in the healing of such fractures has not been widely appreciated. Therefore, trauma surgeons have tended to relegate soft tissue reconstruction to the secondary phase (Chacha. 1974; Freeland and Mutz. 1976: Clancey and Hansen, 1978). Until recently the choice of flap reconstruction in the leg remained limited and although the soft tissue problems associated with open
British
576
tibia1 fractures were appreciated among plastic surgeons, the solutions (Harrison, 1968) remained unattractive. The advent of local pedicled and particularly free muscle flaps has produced more elegant and biologically more effective techniques with which to reconstruct this injury. Fasciocutaneous flaps enjoyed a surge of popularity following their description by Pontln (1979). Their greater reliability. compared to the notoriously unreliable random-pattern skin flap, and their ease of dissection, made them a popular choice for covering defects in the leg. However, while a number of clinical series expounded their virtues (Ponten, 1979; Barclay rt al., 1982; McGregor and Palmer, 1985), their use was not described in the acute phase following severe injury. In the light of current knowledge on fracture healing, local flaps that cannot be safely transferred in the early stages following injury cannot be considered for the reconstruction of open tibia1 fractures. In our experience fasciocutaneous flaps are unreliable for up to 4 weeks following severe trauma to the leg. That this is the case is not surprising because the loose areolar layer, superficial to the deep fascia, which contains the fine vascular network of the fascial plexus, is frequently oedematous and haemorrhagic in the acute phase following injury. The shearing forces of injury transmitted through this delicate layer readily damage the network of fascial vessels. It is, after all, the “degloving layer” of the leg. There are two broad indications for free flap coverage in the leg-a defect in the lower third or an extensive defect at any level. Muscle would appear to be the flap of choice because of its beneficial biological influence on fracture healing (Wray and Lynch, 1959; Holden, 1972; McKibbin, 1978 ; Whiteside and Lesker, 1978). There does not appear to be any indication, that we are aware of, to use a musculocutaneous flap; they are excessively bulky and result in a greater donor defect. The two popular free muscle flaps in this series were the Iatissimus dorsi and the rectus abdominis. Both possess long pedicles with good vessel size. The rectus abdominis muscle is an ideal shape for covering linear defects over the tibia while the more expansive latissimus dorsi is indicated when the defect is more extensive. Furthermore, exposed anterior compartment and peroneal muscles alongside the fracture would appear to recover better gliding function if covered with a muscle flap than by a split skin graft directly onto the exposed muscle bellies. The rectus abdominis muscle flap is quicker and easier to dissect than the latissimus dorsi. However, patient positioning on the operating table with regard to the defect, recipient vessels and the presence of other injuries may dictate the use of one or other flap. Problems have not been encountered with the abdominal wall following unilateral removal of the rectus abdominis muscle. However, the fascial sheath must be carefully repaired to minimise the risk of herniation. In this Unit we are increasingly of the opinion that free tissue transfer provides by far the most appropriate reconstruction for the majority of Types IIIB and IIIC open tibia1 fractures. The practice of more thorough exploration and debridement of this injury
Journal of Plastic Surgery
invariably results in a defect that can only adequately be covered by a free flap. Potentially usable local flaps or their pedicles will frequently have been damaged and will therefore be unusable. The practice of compromising a severely injured leg further by sacrificing a local muscle or segment of intact skin should be considered with caution and the principle of avoiding this by importing a distant flap is indeed a sound one. In this series all primary free flaps were without complication. There is little doubt that the primary phase is the optimal time for free flap reconstruction and that any delay beyond this period increases the cumulative operating time and thus the hospitalisation time and cost of treatment (Godina, 1986). Most importantly, it increases the risk of flap failure (Byrd et al., 1985; Godina, 1986). Skin grafts are not usually adequate for covering open tibia1 fractures-only 5 % were successfully covered by this technique in this series. In 15 out of 22 cases the decision to use skin grafts was clearly erroneous. It is difficult to understand how some authors achieve cover by split skin grafting alone in the majority of severe open fractures reported in their series (Chapman and Mahoney, 1979 ; Edwards, 1983 ; Gustilo et al., 1984). There were five failures in the initial group of 10 free flaps in this series. However, there were only two failures in 60 free flaps transferred subsequently. There are a number of factors which may explain this:(a) The earlier free flaps were transferred without exception at a late stage to chronic wounds. (b) The significance of perivascular fibrosis and other vascular changes in and around such wounds was not appreciated at that time. The choice of free flaps in the initial stages of this (c) series was limited. (d) The materials, instruments and microscopes available today are superior. It has been satisfying to observe the evolution of a rational and systematic approach to the reconstruction of this difficult injury in this Unit. We now have a well established pecking order of flaps for reconstructing this injury, but this is not a substitute for the thorough assessment of each individual case by an experienced surgeon and selection of the mode of reconstruction most appropriate for each case. The temptation to select the quick and easier option when it comes to soft tissue reconstruction must be avoided. On the other hand, free tissue transfer must be seen to be an attractive reconstructive technique in terms of operating time and success rate. Acknowledgement The authors sincerely wish to thank their colleagues in Orthopaedic and Plastic Surgery, who have participated in the reconstruction of the cases reported in this series.
References Barclay, T. L., Cardoso, E., Sharpe, D. T. and Crockett, (1982). Repair of lower leg injuries with fasciocutaneous British Journal qf Plastic Surgery. 35. 127.
D. J. Raps.
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in Open
Byrd, H. S., Spicer, T. E. and Cierney,
G.
Tibia1
Fractures
( 1985). Management
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of
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PIustic md Reconslructive Surger?, 76. 7 19 Cavadias, A. X. and Trueta, J. ( 1965). An experimental study of the vascular contribution to the callus of fracture. Surger?. G>wecolog~~ mc/ Ohsrc~rrics. 120. 73 I. Chacha. P. B. (1974). Salvage of severe open fractures
of the tibia l@trx, 6. 154. Chapman, M. W. and Mahoney, .!%I.(1979). The role ofearly internal tixatlon in rhc management of open fractures. Clinicd Orthothat might have required
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pedics (md Reluted Resrowh. 138. IX. Clancey. C. J. and Hansen, S. T. ( 1978). Open fractures of the tibia. A revlcw of one hundred and two cases. Journd q/‘Bonr crnJJoinr Suryrry. 60A. I 18. Edwaids, C. E. (1983). Staged reconstruction of complex open tibia1 fractures usmg Hoffmann external fixation. Clinical 0r~hopaetlic.t and Reiuted Research. 178. 130. Freeland, A. E. and Mutz, S. B. ( 1976). Posterior bone grafting for infected un-united fractures of the tibia. Journal of‘ Bone & Join/ Surgery,. 58A. 653. Godina, M. ( 1986). Early microsurgical reconstruction of complex trauma of the extremities. P/[r.\ric untl Reconstructiw Suyer!. 78. 2x5. Gothman. L. ( 1961). Vascular reactions in experimental fractures. Microangiographic and radioisotope studies. Arta Chirurgitr Scundinuricu Supplwnmtum. 284. 3. Gothman. L. (1961). Local arterial changes associated with ex-
perimental fractures of the rabbit’s tibia treated with encircling wires (Cerclage). A microangiographic study. Acta Chirurgia Scandirwicu. 123, 17. Gustilo, R. B. and Anderson, J. T. ( 1976). Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. Journal qf Bone & Joint Surger~~, 58A. 453. Gustilo, R. B., Mendoza, R. M. and Williams, D. N. (1984). Problems in the management of Type III (severe) open fractures: a new classification of Type 111 open fractures. The Journal o/‘Trauma. 24. 74’. Harrison, S. H. (1968).Fractures of the tibia complicated by skin loss. Briti.sh Jmrrnul o/ Plusrrc~ Surgery, 21, 261. Hicks, J. H. (I 964). Amputation in fractures of the tibia. Jo~nul of Bone & Join/ Surger~~. 46B. 3x8.
Holden, C. E. A. (1972). The role of blood supply to soft tissue in the healing of diaphyseal fractures. Jmrrnd r>/ &VW md./nin, .%tr,ccr1,. 54A. 993. McGregor, J. C. and Palmer, J. H.
( 19x5). A critical rev& of llap repairs in the lower limbone unit’s experience over the past live years. Chirtrrgia f’ltrsrka. 8. 95. McKibbin, B. (I 97X). The biology of fracture-healing in long hone. Journul qf Bone & Joinr Surgery. 608. 150. Pontkn, B. (1981). The fasciocutaneous fap: ita uw in soft tissue defects of the lower leg. Bri~idz Journtrl o/‘P/tr.vtr~~ .Surgcry. 34. 2 15. Rhinelander, F. W. and Baragry, R. A. (I 961). Microanpiograph) in bone healing. I. Undisplaced closed fractures. ./~rj~i ,I/ Bone [ml/ Join/ Surger!. 44A. 1273. Rhinelander. F. W., Phillips, R. S., Steel, b. %I. and Beer, J. C‘.
(1968). Microangiography
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Joint .Sur,q+~~. 50A. 643. Saad, M. N. (1970). The problems
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Jound c$Surgery. 57, 601. Trueta, J. (1974). Blood supply and the rate ot‘ heahng of tibia1 fractures. Cl~nicul Orthopedics uml Relurrcl Rescwrc~h, 105. I I Whiteside, 1.. A. and Lesker, P. A. 1197X). Thr elYect.\ of extr:l-
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The Authors J. 0. Small, FRCSI, Consultant in Plastic Surgery. The Ulster Hospital. Dundonald, Belfast, BT16 ORH R. A. B. Mollan, MD, FRCS. FRCSI, Professor in Orthopaedic Surgery. Musgrave Park Hospital. Belfast Requests
for reprints
to: Mr J. 0. Small.
Paper received 27 December I99 I, Accepted 20 May 1992. after revision.
‘O-2
