Management of infected tibial fractures and chronic tibial osteomyelitis by muscle flap transfer: a comparison of two series of patients.

OBJECTIVE: The goal of this work is to compare therapeutic results of two groups of patients with an infected fracture or chronic osteomyelitis of the lower leg and ankle joint treated by the method of radical debridement followed by free flap transfer or muscle transposition. PATIENTS: In the period between 1 January 2002 and 30 September 2007 the authors used this method in the treatment of 52 patients (10 females and 42 males) with the average age of 44 years (ages ranged from 10 to 67). The observed group of patients was divided into retrospective and prospective subgroups. METHODS: The difference between the retrospective and prospective parts of the study was how radical the debridement and necrectomy of the soft tissues was. A comparison of therapeutic results in both subgroups was made by evaluation of the amounts of postoperative complications, number of follow-up surgeries and the actual weight-bearing ability of the treated extremity. RESULTS: The difference in the number of postsurgical complications (7 versus 2) was not significant (p=0.123), and neither was the difference in the number of follow-up surgeries (20 versus 17, p=0.706). The difference in the number of patients with fully weightbearing extremities (21 versus 22) was also not significant (p=0.670). CONCLUSION: The authors feel that analysis of complications showed somewhat better results in the prospective part of the study, despite the lack of statistical proof. Therefore the authors regard the method of extensive debridement with the following coverage of the soft tissue defect by muscle flap as suitable for the treatment of infected fractures in the area of the lower leg and ankle joint and the treatment of osteomyelitis of the tibia.

[Muscle flap transfer of the treatment of infected tibial and malleolar fractures and chronic osteomyelitis of the tibia]. / Vyuzití muskulárního laloku pri lécení infikovaných zlomenin a chronické osteomyelitidy v oblasti bérce a hlezna.

PURPOSE OF THE STUDY: The aim of the study was to evaluate the results of treatment in patients with infected fractures or chronic osteomyelitis in the tibial and ankle regions by radical debridement of skeletal and soft tissues and coverage of the defect, using free flap transfer or muscle flap transposition. MATERIAL: Between January 1, 2002 and December 31, 2004, 26 patients were treated by this method; 13 had infected tibial or ankle fractures and 13 showed osteomyelitis of the tibia. All patients, in the case of failure, would have been indicated for below-knee amputation. The group comprised six women and 20 men at an average age of 46 years (range, 10 to 67 years). METHODS: In this retrospective study, the following data were recorded: type of injury (multiple trauma, combined trauma, single trauma), fracture type according to the AO classification, grade of injury in open fractures by the Gustillo and Anderson classification, number of previous operations in patients with infected fractures, microbiological findings in all patients before defect coverage with a flap, interval between the injury and flap coverage, number of post-operative complications, number of subsequent operations, period of relief for the treated limb, actual weight-bearing of the limb, patient's satisfaction with the therapy. RESULTS: Since one patient died of heart attack during follow-up, 25 patients (5 women and 20 men) were included in the final evaluation. The average follow-up was 27 months (range, 15 to 49 months). The healing of infection and union of bone were recorded in 21 patients (84 %). Healing with pseudoarthrosis development occurred in three patients (12 %). One patient (4 %) had to undergo leg amputation due to persistent secretion. The duration of treatment before coverage of the defect was on average 10 weeks (range, 4 weeks to 6 months) in the patients with infected fractures, and 9 years (range, 2 to 20 years) in the patients with osteomyelitis. Post-operative complications were recorded in seven patients (27 %). Impaired vascularization of the flap in the early post-operative period was found in two patients (8 %). In two patients (8 %) residual infected tissue under the flap resulted in purulent secretion. In three patients (12 %), at the time of evaluation, the lower extremity could not bear weight due to non-union of fractured bone. DISCUSSION: The use of free or transposition muscle is regarded as the optimal method for the treatment of extensive defects of soft tissues in limb traumatology. The advantages include: good quality coverage of the defect; ability of vascularized flap tissue to transport antibiotic to the defect area; long-term improved perfusion in the fracture region is important for fracture healing. CONCLUSIONS: The treatment of infected tibial and malleolar fractures by debridement and subsequent coverage of soft tissue defects, using muscle flap transfer, permits elimination of infection in most of the patients, but often requires subsequent surgery in order to provide biological stimulation for healing of defective fractures. Treatment of osteomyelitis of the tibia by this method is demanding, but has a good prospect of healing in a period shorter than is necessary for treatment without muscle flap transfer.

[Infectious complications of surgically treated musculoskeletal injuries: review of risk factors and etiological agents in years 2000-2005]. / Infekcní komplikace operacní lécby poranení pohybového aparátu: prehled rizikových faktoru a eiologických agens za roky 2000-2005.

PURPOSE: Infection is considered one of the most serious complications of the surgical treatment of musculoskeletal injuries. The aim of the study was to evaluate known risk factors and etiological agents of infectious complications in patients surgically treated for musculoskeletal injuries within 6 years. METHODS: In a group of 5 234 patients followed in 2000-2005 the early or delayed infectious complication developed in 65 patients (26 women, 39 men, age 22-83 years). In every patient with infectious complication the important risk factors related to personal history, type of the injury, surgery and other treatment were recorded and microbiological culture results were collected. RESULTS: In 60 patients (92.3%) at least one of the following risk factors was registered: diabetes mellitus, age above 75 years, abuse of alcohol and drugs, distant infectious focus or severe skin disease at the time of surgery, polytrauma requiring long-termed stay in intensive care unit, extensive soft tissue injury associated with closed or opened fracture. In 27 patients (41.5%) grampositive cocci and in 17 patients (26.2%) gramnegative bacteria were isolated, in 12 patients (18.5%) mixed bacterial flora was identified and 9 patients (13.8%) had negative cultures. The most severe findings from microbiological view occurred in patients with extensive soft tissue injury associated with fracture, diabetes or long-termed stay in intensive care unit. CONCLUSION: The infectious complications after the surgical treatment of musculoskeletal injuries occurred predominantly in patients with risk factors. The extensive soft tissue injury associated with fracture, diabetes and long-termed stay of the polytrauma patient in intensive care unit were identified as the most frequent risk factors. The patients of these risk groups also presented with the most serious microbiological findings.