ABSTRACT
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Introduction:
Grade 3B/C open
tibial fractures with grossly contaminated
degloving injuries have poor outcomes, with or without
vascular injuries.
Treatment decision oscillates between
limb salvage and
amputation. The standard protocol of repeated
debridement and delayed
wound cover is a challenge in
developing countries due to overcrowded
emergencies and limited
operating room availability. We present results of our modified protocol involving primary stabilisation with external fixation and immediate
wound cover as an aggressive modality of
treatment. Material and
Methods:
Thirty-three
patients with severe open tibial shaft fractures were managed using a standardised protocol of emergent
debridement, external fixation and immediate
wound cover with free distant/local rotational
muscle flaps and fasciocutaneous flaps, and with vascular repair in Grade 3C fractures.
Intra-articular fractures were excluded.
Patients were followed for a minimum of three years, with an assessment of clinical, radiological and functional outcomes.
Results:
Wound cover was achieved with 24 distant free
muscle flaps, four local rotational
muscle flaps and five fasciocutaneous flaps. All fractures united with an average
time to union of 40.3 weeks (16-88). Fifteen
patients (45.4%) underwent only a single major
surgery using primary definitive external fixation. Deep
infection was seen in four
patients (12.1%). Nineteen
patients had excellent to good outcomes, six were fair, and eight were poor.
Conclusion:
“Fix and Flap” in the same
sitting, using immediate
wound cover and external fixation, has given good results in our
hands despite the delayed presentation, the neurovascular deficit and the
degloving injury. This may be a better management strategy in overcrowded
tertiary care centres of
developing countries, with a single
surgical procedure in almost half the cases.