RECONSTRUCTIVE Lower Extremity Trauma: Trends in the Management of Soft-Tissue Reconstruction of Open Tibia-Fibula Fractures Brian M. Parrett, M.D. Evan Matros, M.D. Julian J. Pribaz, M.D. Dennis P. Orgill, M.D., Ph.D. Boston, Mass. Background: Open lower leg fractures with exposed bone or tendon continue to be challenging for plastic surgeons. Microvascular free-tissue transfer increases the ability to close wounds, transfer vascularized bone, and prevent amputation, yet remains a complex, invasive procedure with significant complication rates, donor-site morbidity, and failure rates. This review documents the changing treatment protocol in the authors institution for these injuries. Methods: Two hundred ninety consecutive open tibia-fibula fractures over a 12-year period (1992 to 2003) were retrospectively reviewed and methods and outcomes were compared by grouping the fractures into 4-year intervals. Results: The number of open lower extremity fractures increased, whereas the distribution of Gustilo grade I to III fractures remained unchanged. Overall, free-tissue transfer was performed less frequently and constituted 20 percent of reconstructions in period 1 (1992 to 1995), 11 percent in period 2 (1996 to 1999), and 5 percent in period 3 (2000 to 2003). For the most severe fractures, Gustilo grade III, free-flap reconstruction has decreased significantly, constituting 42 percent, 26 percent, and 11 percent of procedures in periods 1, 2, and 3, respectively. Local flaps for grade III fractures have remained relatively constant throughout the study. In contrast, local wound care for grade III fractures, including skin grafts, delayed primary closures, and secondary intention closures has significantly increased from 22 percent to 49 percent of reconstructions from periods 1 through 3. In 1997, the authors began to use the vacuum-assisted closure device and now use it in nearly half of all open fractures. Despite this trend, there has been no change in infection, amputation, or malunion/nonunion rates and a decrease in reoperation rate with at least 1-year follow-up. Conclusions: These results demonstrate a change in practice, with a trend down the reconstructive ladder, currently using fewer free flaps and more delayed closures and skin grafts with frequent use of the vacuum-assisted closure sponge. Possible reasons for this change are a better understanding of lower leg vascular anatomy and better use of improved wound care technology. (Plast. Reconstr. Surg. 117: 1315, 2006.) Lower extremity trauma, with open highenergy soft-tissue injuries, is frequently encountered at trauma centers and often requires plastic surgery involvement. Open fractures have high incidences of malunion and From the Division of Plastic and Reconstructive Surgery, Brigham and Women s Hospital, Harvard Medical School. Received for publication September 23, 2004; revised December 31, 2004. Presented at the 21st Annual Meeting of the American Society for Reconstructive Microsurgery, in Fajardo, Puerto Rico, January 16, 2005. Copyright 2006 by the American Society of Plastic Surgeons DOI: 10.1097/01.prs.0000204959.18136.36 infection, especially when they involve the tibia, 1 4 and require emergent irrigation and debridement in the operating room to remove devitalized soft tissue and bone. 4,5 Wounds are frequently left open and require repeated debridements, resulting in large soft-tissue defects. 6 The most important determinants of outcome after open fractures are wound size, degree of soft-tissue damage, and amount of contamination. 4,7,8 The Gustilo classification, the most widely accepted method of categorizing open fractures, defines three grades. 7 Grade I open fractures are smaller than 1 cm. www.plasreconsurg.org 1315
Plastic and Reconstructive Surgery April 1, 2006 Grade II injuries are 1 to 10 cm, with moderate tissue damage. Grade III injuries are larger than 10 cm, with extensive tissue damage, making it difficult to cover exposed bone or hardware. Grade III injuries are further divided into types A, B, and C, depending on severity of tissue loss. 9 Grade IIIA injuries have sufficient soft tissue for bone coverage but, after serial debridements, such coverage may not exist. Grade IIIB and C injuries have extensive tissue damage with periosteal stripping, making local soft-tissue coverage not possible; grade IIIC injuries have vascular injuries requiring repair. Early coverage of exposed bone, tendons, and neurovascular structures is crucial. 6,10 12 If possible, the goal is to close wounds within 7 days to decrease the risk of infection, osteomyelitis, nonunion, and further tissue loss. 13 15 Grade I, and a majority of grade II fractures, can be closed primarily. However, larger grade II fractures and a majority of grade III fractures require more advanced reconstructive procedures. Because of wound care advances over the past two decades, soft-tissue coverage is less of a limiting factor in limb salvage. Before the development of microsurgical techniques, treatment of severe lower extremity wounds was often amputation or skin grafting. 16 In complex wounds, skin grafts gave inadequate results because of the difficulty of healing over exposed bone, leading to high rates of osteomyelitis and amputation. In the late 1980s to early 1990s, microvascular free-tissue transfer became routine for salvage of traumatized extremities, allowing surgeons to reconstruct severe Gustilo grade III open fractures. 17 19 Many centers began to reconstruct the majority of grade III fractures with free-tissue transfer. 17 22 However, free flaps represent the highest rung on the reconstructive ladder, requiring technically demanding, costly, and time-consuming operations, with significant complication rates, donor-site morbidity, and failure rates. 23 25 Over the past 5 years, new wound care technologies have proven useful in the treatment of traumatic lower extremity open wounds. The vacuum-assisted closure device (VAC; KCI, San Antonio, Texas) uses continuous subatmospheric pressure, causing decreased tissue edema, decreased wound circumference, and increased granulation tissue. DeFranzo et al. 26 in 2001 demonstrated that the VAC sponge successfully stimulated profuse granulation tissue over exposed bone, allowing open fractures to be closed primarily, with skin grafts or with regional flaps. No free-tissue transfers were required in any of the 75 patients enrolled. This has allowed surgeons to close many Gustilo grade III fractures without free flaps. 26,27 In addition, other wound care technologies, such as the dermal matrix Integra (Integra LifeSciences, Plainsboro, N.J.), are being used in selected patients. 28 A better understanding of local flap design has also contributed to extremity reconstruction. Greater experience with local lower extremity flaps, including the sural flap and soleus flap, has demonstrated their versatility for the reconstruction of lower leg defects. 29 33 The sural flap has become reliable and routine for treatment of large soft-tissue defects of the distal lower limb because of its wide arc of rotation and consistent anatomical features and blood supply. 29 31 Studies also demonstrate the efficacy of the posterior tibial perforator saphenous subcutaneous and lesser saphenous venofasciocutaneous flaps in lower limb reconstruction. 34,35 These local flaps decrease the need for free flaps in the distal one-third of the lower leg. Although free-tissue transfer is a vital component of limb salvage, advances in wound care technology and better understanding of local flap design have provided increasing options for soft-tissue reconstruction of the severely injured lower extremity. The purpose of this study was to determine whether these advances have changed our approach to lower extremity trauma reconstruction. PATIENTS AND METHODS The authors retrospectively reviewed 290 consecutive open tibia-fibula fractures dating from January 1, 1992, to January 1, 2004. All fractures were evaluated and treated at a single, urban, academic Level I trauma center. Patient charts and operative reports were reviewed to collect demographic information and evaluate the treatment for open fractures. To determine trends in management of these injuries over the past 12 years, cases were divided into three periods of 4 years each: period 1 (1992 to 1995), period 2 (1996 to 1999), and period 3 (2000 to 2003). The number of Gustilo grade I, II, and III fractures was tabulated to identify changes in frequency and distribution of such injuries at our institution. 1316
Volume 117, Number 4 Lower Extremity Reconstruction Plastic surgery involvement in reconstruction of these injuries was recorded for each case. The type of soft-tissue coverage, location of injury, and date between injury and definitive coverage were determined. Soft-tissue coverage was categorized into one of six types: free-tissue transfer, regional or local flaps, split-thickness skin grafting, delayed primary closure, primary closure, or closure by secondary intention. The specific type of free flap or local flap and use of the VAC device was recorded for each case. The number of amputations during initial presentation was also noted. Long-term follow-up was performed by review of ambulatory care charts, follow-up radiographs, and interval operative reports. Outcome was assessed according to the number of nonunions/malunions/delayed unions, infections (osteomyelitis or soft-tissue infections requiring debridement), soft-tissue revisions (scar revisions, debulking of flaps), need for secondary soft-tissue coverage, and future amputations. Statistical evaluations were based on the chisquare trend test. All tests were two-tailed, with a value of p 0.05 considered significant. RESULTS From 1992 to 2003, the authors treated 290 consecutive open tibia-fibula fractures, with the total number of fractures increasing in successive periods (Table 1). All cases underwent intraoperative irrigation and debridement within 12 hours of injury. The amputation rate for grade III fractures during the initial presentation was 8 percent, 0 percent, and 6 percent for periods 1, 2, and 3, respectively. All immediate amputations were performed for grade IIIC fractures with severe neurovascular injuries not amenable to repair. Plastic surgery was involved in 49 percent of all cases and in 67 percent of grade III fractures. Table 2 summarizes the types of soft-tissue reconstruction performed in each period over the past 12 years. A total of 34 free-tissue transfers were performed in 33 patients, including 16 rectus myocutaneous flaps, nine latissimus flaps, three gracilis flaps, three anterolateral thigh flaps, two osteomyocutaneous flaps, and one radial forearm flap. There were three free flap failures (9 percent) in the 12-year experience, with subsequent wound coverage achieved with skin grafting, a bipedicle fasciocutaneous flap, and a new free flap, respectively. Eight flaps (24 percent) required revisions or debulking, and there was one free flap infection that resolved with administration of antibiotics. Overall, there has been a decrease in the use of free flaps for reconstruction of open lower extremity fractures. Free-flaps were performed in 20 percent of all reconstructions in period 1, 11 percent in period 2, and 5 percent in period 3 (p 0.002). For the most severe fractures, Gustilo grade III, free-tissue reconstruction has decreased from 42 percent of reconstructions in period 1 to just 11 percent in period 3 (Fig. 1) (p 0.001). Gustilo grade II injuries rarely required free flaps in period 1 (two of 35), and none were used in period 2 or 3. The rate of reconstruction with local or regional flaps has not changed significantly over 12 years; these procedures were performed for 21 percent of period 1, 14 percent of period 2, and 15 percent of period 3 cases (p 0.306). For Gustilo grade III fractures, local flaps were performed in 25 percent, 26 percent, and 32 percent of period 1, 2, and 3 reconstructions, respectively (Fig. 1) (p 0.444). A total of 53 local flaps were used in 48 cases. The most common were the gastrocnemius, soleus, bipedicle fasciocutaneous, and sural flaps. There were two local flap infections (4 percent) that resolved with antibiotics, one flap partial tip necrosis (2 percent) requiring a split-thickness skin graft, and one donor-site partial breakdown requiring a split-thickness skin graft; two flaps (4 percent) underwent future debulking. The gastrocnemius flap was used for coverage of the exposed upper third of the tibia and the patella. Soleus flaps provided coverage for the middle third of the leg primarily and selected defects in the lower third of the leg when used in a reverse fashion. The sural neurofasciocutaneous flap was first used in 1996, and its use has steadily Table 1. Patient Demographics and Gustilo Injury Grading No. of Gustilo Grade Injuries Period Years Male Average Age (yr) I II III IIIA IIIB IIIC 1 1992 1995 68 37.6 14 35 36 10 20 6 2 1996 1999 57 43.8 18 37 39 16 21 2 3 2000 2003 69 41.2 18 40 53 16 28 9 1317
Plastic and Reconstructive Surgery April 1, 2006 Table 2. Soft-Tissue Reconstruction Profiles for Tibia-Fibula Fractures from 1992 to 2003 Period No. of Grade III Fractures Average Time to Definitive Closure* Lost to Follow-Up Nonunion/ Malunion/ Delayed Union Infection Amp Soft-Tissue Coverage Revision Secondary Soft-Tissue Coverage 1 36 6.9 5 2 (6) 9 (25) 5 (14) 2 (6) 7 (19) 2 (6) 2 39 7.0 6 1 (3) 10 (26) 6 (15) 2 (5) 4 (10) 1 (3) 3 53 6.8 6 3 (6) 9 (17) 8 (15) 2 (4) 2 (4) 1 (2) *Values as days SD. Amputations (after original hospital admission). increased for defects in the distal third of the leg, ankle, and heel. Split-thickness skin grafts, secondary intention closures, and delayed primary closures increased significantly over time and were performed in 28 percent of period 1, 38 percent of period 2, and 53 percent of period 3 cases (Table2)(p 0.0002). For grade III fractures, these three procedures together increased from 22 percent to 49 percent of reconstructions from periods 1 to 3 (Fig. 1) (p 0.013). Since its inception in 1997, use of the VAC device has risen significantly. VAC application increased from 0 percent to 47 percent for all open fractures from periods 1 to 3 (Table 2) and was used for 74 percent of grade III fractures in period 3. Patient outcome for Grade III fractures was assessed after definitive soft-tissue coverage with at least 1-year follow-up (Table 3). The mean time from injury to definitive wound coverage for all grade III fractures was 7 days and has not changed significantly over time (Table 3). The rate of wound infections, consisting of soft-tissue infections requiring debridements and osteomyelitis, has been stable over the past 12 years at 15 percent. Rates of malunion, nonunion, delayed unions, and delayed amputations (occurring after the patient s original presentation) did not change significantly. Operative revisions have decreased significantly, from 19 percent to 4 percent, over periods 1 to 3 (p 0.017). The need for secondary wound coverage did not change significantly. DISCUSSION Open lower leg fractures with exposed bone or tendon continue to be challenging for surgeons. The appropriate treatment of these wounds has been the subject of much research over time and the goals remain the same: early irrigation and Fig. 1. Percentage of types of soft-tissue coverage for Gustilo grade III open fractures from periods 1to3. Decreasingdependenceonfreeflapsandcompensatoryincreaseinuseofsplit-thicknessskin grafting, delayed closures, and secondary intention closures are demonstrated. 1318
Volume 117, Number 4 Lower Extremity Reconstruction Table 3. Patient Follow-Up for Gustilo Grade III Fractures Year No. of Open Fractures Plastic Involved Free Flap Local Flaps STSG Delayed Primary Primary Secondary Amp* VAC Period 1 1992 28 15 7 5 2 6 8 0 0 0 1993 19 10 4 5 1 4 5 0 0 0 1994 16 8 1 6 0 4 4 0 1 0 1995 22 8 5 2 1 6 6 0 2 0 Total 85 41 17 18 4 20 23 0 3 0 Period 2 1996 19 8 1 4 0 6 8 0 0 0 1997 28 15 5 3 2 6 11 1 0 1 1998 20 12 2 3 5 5 5 0 0 3 1999 27 11 2 3 2 8 11 1 0 3 Total 94 46 10 13 9 25 35 2 0 7 Period 3 2000 27 14 2 5 3 9 7 0 1 5 2001 23 12 0 4 4 8 5 2 0 11 2002 37 20 2 7 5 11 7 3 2 22 2003 24 10 2 1 6 6 7 2 0 16 Total 111 56 6 17 18 34 26 7 3 54 Total (1992 2003) 290 143 33 48 31 79 84 9 6 61 STSG, split-thickness skin grafting. *Amputations (after original hospital admission). debridement followed by early soft-tissue coverage. 4 6,9 16 This retrospective study demonstrates a significant shift in practice, with a decreasing trend in the use of free flaps for open tibia-fibula fractures and a compensatory increase in skin grafts, delayed primary closures, and secondary intention closures, with continued dependence on local flaps. This trend is not attributable to a change in the distribution or severity of open fractures over time (Table 1). Despite this change in treatment, the amputation rate has not increased and softtissue coverage is completed on average within 7 days for all grade III fractures. Long-term follow-up demonstrates that outcomes have not been negatively impacted and there is a significant decrease in soft-tissue revisions, partly attributable to fewer free flap revisions (Table 3). Based on these data, we have devised a basic algorithm (Fig. 2) for the treatment of soft-tissue defects in open lower extremity trauma. The use of less complicated reconstructive methods can be attributed to a variety of factors, including improvements in orthopedic fixation systems, early involvement of plastic surgeons, 36 a better understanding of lower extremity anatomy, introduction of new technology, and the inherent difficulties of free-tissue transfer. With greater use of local flaps and design variations, we have consistently used local flaps to close many large grade III wounds, which is consistent with the current literature. 30,32,33,37 The traditional gastrocnemius and soleus flaps provide wound coverage for the upper and middle thirds of the lower leg, respectively. Softtissue coverage for wounds over the distal leg and heel can be difficult, and have often been treated with free flaps in the past. We now frequently use reverse sural flaps, 29 31 fasciocutaneous flaps, 34 perforator flaps, 35 and bipedicle flaps for distal wounds. The sural flap was used in seven cases, with no flap failures and one donor-site breakdown requiring a split-thickness skin graft. The sural flap and the lesser saphenous fasciocutaneous flap 34 are indicated for defects in the distal leg, ankle, and heel, providing a single-stage, rapid, easy dissection and relatively bloodless procedure, making it suitable for the comorbid or seriously injured patient who cannot undergo the long operative time of a free-tissue transfer. These flaps sacrifice no major artery or mobilizing structure and are thus indicated in trauma cases where a major leg artery has been damaged. Contraindications include injury to the peroneal artery or its perforators, peripheral arterial disease without Doppler evidence of peroneal perforators, severe venous insufficiency, or absence of the lesser saphenous vein. 38 Newer flaps, such as the posterior tibial artery perforator flap, 35 are indicated for coverage of the ankle or heel in patients with perforators that can be assessed by means of Doppler imaging and an intact greater saphenous vein; this flap is an important option in a patient with damage to the peroneal artery or sural flap soft tissue. 1319
Plastic and Reconstructive Surgery April 1, 2006 Fig. 2. Flow chart showing our method of treating open tibia-fibula fractures. Initially, these are taken emergently to the operating room, where they are debrided, orthopedic fixation is applied, and vascular repair is performed if needed. Thewoundisthenassessedforcontamination, swelling, andnecrosisandadecisionismadeastothetiming of closure. Frequently, VAC sponges are placed until the swelling has resolved; often at that point, delayed primary closure, local flaps, and skin grafts can be used for wound closure. *Primary or delayed primary closure. Wound care advances, especially the VAC device, with or without dermal substitutes, 28 allow more treatment options for open fractures. VAC sponge application avoids the need for free flaps in many large grade III wounds because of rapid production of granulation tissue over exposed bone, tendon, and hardware. 26,27 Our center uses the VAC sponge in 50 percent of open fractures and most grade III fractures. Now, with a bed of granulation tissue, these wounds are closed with skin grafts, delayed primary closures, or secondary closures, leading to a significant decline in free flaps procedures. In addition, free-tissue transfer is expensive and time-consuming and requires specialized practitioners. 25,39 The cost of free-tissue transfer is high, resulting from long operative times, expensive equipment, and need for intensive care unit monitoring. 25,40 Also, there is an increasing gap between cost of free flaps and insurance reimbursement. 25 Complications such as partial flap necrosis, thrombosis, or cardiac events from long operative times are relatively common, occurring in 17 percent of free flap patients in some studies. 23 25,41 43 Studies demonstrate higher rates of free flap failure in lower extremity trauma than nontraumatic extremity cases and free flaps in other body areas. 17,43 Taking this into consideration, alternative, less-invasive treatments with equally efficacious results, as outlined in this article, are appealing. The results of this study demonstrate a significant shift in the practice of lower extremity trauma reconstruction to simpler reconstructive 1320
Volume 117, Number 4 Lower Extremity Reconstruction techniques. There is no doubt that free-tissue transfer will have a continued role in complicated lower extremity wounds, but these new approaches are likely to reduce the overall complexity of managing these difficult problems. A further comparison of functional status, aesthetic appearance, and patient satisfaction will prove useful in determining the overall effect of this shift in practice on patient outcome. Dennis P. Orgill, M.D., Ph.D. Brigham and Women s Hospital Harvard Medical School 75 Francis Street Boston, Mass. 02478 dorgill@partners.org ACKNOWLEDGMENTS The Vacuum Assisted Closure Device (VAC, KCI, San Antonio, Texas) was used in this study. Dr. Orgill is a clinical investigator for studies using VAC technology through grants to Brigham and Women s Hospital by KCI, San Antonio, Texas; however, no grant or financial assistance was received for this study. REFERENCES 1. Patzakis, M. J., Wilkins, J., and Moore, T. M. 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