Management of Gustilo type IIIB open tibial shaft fractures with limited resources: experience from an African trauma center.

PURPOSE: We sought to evaluate the management of Gustilo type IIIB open tibia diaphyseal fractures in an African trauma center with respect to soft tissue defect management and bone union achievement. Functional outcome assessment was the secondary objective. METHODS: A retrospective review was conducted including patients treated for open tibia fractures requiring flap coverage between 2007 and 2011. As plastic surgeons were lacking in availability, all procedures were performed by orthopedic surgeons trained in completing nonmicrosurgical flap transfers. RESULTS: Twenty-seven patients with a mean age of 36 years were included. Although the mean time to debridement was 11 h, early infection occurred in 16 (59%) patients. The mean time to flap coverage was 27 days. Among the 29 primary local flap transfers performed, only 4 failed. Secondary amputation was required in one patient after flap failure. Bone reconstruction procedures were required in nine patients and were performed after a mean period of 97 days. At the mean follow-up time of 13 months, 23 (88%) of the 26 remaining fractures had united. There were three septic nonunions and two cases of chronic osteomyelitis. Functional result was negatively influenced by the soft tissue defect area and low-quality flap coverage. CONCLUSIONS: To our knowledge, this is the first series reporting flap reconstructions performed by orthopedic surgeons for Gustilo type IIIB tibia fractures in an African hospital. Local pedicled flap transfers permitted the achievement of soft tissue coverage and bone union in most cases. Subsequent bone grafting was required in one-third of the cases.

Soft tissue reconstruction in the leg by orthopedic surgeons: Practices at an African trauma center.

INTRODUCTION: Soft-tissue coverage is a crucial step when treating open tibial fractures, which is often performed by orthopedic surgeons in a low resource setting. The objective of this study was to analyze the use of non-microsurgical flaps to treat such injuries in a West African trauma center. HYPOTHESIS: Pedicled flaps are reliable procedures that can be used by any orthopedic surgeon for soft-tissue coverage in the leg. METHODS: A retrospective study was conducted including patients treated between 2007 and 2011 for open tibial fractures or posttraumatic sequelae requiring flap coverage. Early flap necrosis and skin viability at the last follow-up were evaluated. RESULTS: Fifty-five patients with mean age 34 years were included. They had 57 soft-tissue defects requiring flap reconstruction, 36 of which were infected. In total, 62 pedicled flaps were performed: 12 muscular flaps and 50 fasciocutaneous flaps, including 40 rotational flaps and 10 island flaps. The short-term result was successful in 55 flaps (89%). Seven flaps had partial or complete necrosis, including three soleus flaps and three lateral supramalleolar rotational flaps. At the average follow-up of 9 months, skin viability was inferior in the posttraumatic sequelae group and seemed to be altered by primary bone infection. CONCLUSION: Soft-tissue coverage in the leg can be reliably achieved by orthopedic surgeons using simple and robust flaps that do not require pedicle dissection. Surgeon training in basic flap surgery is essential and still inadequate in emerging countries. LEVEL OF EVIDENCE: IV, Retrospective study.

Challenges of the induced-membrane technique in the reconstruction of traumatic tibial defect with limited resources : a cohort study.

This study sought foremost to evaluate the outcomes of applying the induced membrane technique (IMT) for tibia reconstruction within the context of a sub-Saharan Africa trauma center. Second, this study aimed to elucidate the conditions of IMT usage in a limited-resource setting. A retrospective study was performed among patients treated via IMT for posttraumatic tibial bone defects who had follow-up data available for at least 12 months. Eleven patients with a mean age of 36 years were included. All presented with an infected multi-tissue defect. The mean length of the tibia defect was 4.4 cm and the mean area of the soft-tissue loss was 32 cm2 . Pedicled flap coverage was required in all cases. At the mean follow-up time of 15 months bone union was achieved in nine of 11 cases, after additional inter-tibiofibular grafting was performed in four cases. Infection recurrence was noted in five of 11 cases. Most patients presented medium-quality soft-tissue coverage and suboptimal function. IMT may represent a valuable option for tibia reconstruction with limited surgical resources in cases where appropriate infection control and stable soft-tissue coverage can be ensured.