Management of Gustilo Anderson III B open tibial fractures by primary fascio-septo-cutaneous local flap and primary fixation: The 'fix and shift' technique.

BACKGROUND: Open fractures of tibia have posed great difficulty in managing both the soft tissue and the skeletal components of the injured limb. Gustilo Anderson III B open tibial fractures are more difficult to manage than I, II, and III A fractures. Stable skeletal fixation with immediate soft tissue cover has been the key to the successful outcome in treating open tibial fractures, in particular, Gustilo Anderson III B types. If the length of the open wound is larger and if the exposed surface of tibial fracture and tibial shaft is greater, then the management becomes still more difficult. MATERIALS AND METHODS: Thirty six Gustilo Anderson III B open tibial fractures managed between June 2002 and December 2013 with "fix and shift" technique were retrospectively reviewed. All the 36 patients managed by this technique had open wounds measuring >5 cm (post debridement). Under fix and shift technique, stable fixation involved primary external fixator application or primary intramedullary nailing of the tibial fracture and immediate soft tissue cover involved septocutaneous shift, i.e., shifting of fasciocutaneous segments based on septocutaneous perforators. RESULTS: Primary fracture union rate was 50% and reoperation rate (bone stimulating procedures) was 50%. Overall fracture union rate was 100%. The rate of malunion was 14% and deep infection was 16%. Failure of septocutaneous shift was 2.7%. There was no incidence of amputation. CONCLUSION: Management of Gustilo Anderson III B open tibial fractures with "fix and shift" technique has resulted in better outcome in terms of skeletal factors (primary fracture union, overall union, and time for union and malunion) and soft tissue factors (wound healing, flap failure, access to secondary procedures, and esthetic appearance) when compared to standard methods adopted earlier. Hence, "fix and shift" could be recommended as one of the treatment modalities for open III B tibial fractures.

The significance of segmental fibular fractures in the management of associated tibial fractures.

One hundred seventy-six patients with 179 tibial shaft fractures (between March 2003 and August 2007) with a minimum of 4 months follow up were retrospectively reviewed by the author. Twenty-nine of these fractures were found to have segmental fibular fractures. These 29 fractures were analysed and compared with the total of 179 tibial fractures. Segmental tibial fractures with and without segmental tibial comminution were also analysed and compared. The segmental fibular fracture group had a greater incidence of associated injuries, associated fractures, open tibial fractures, Gustilo III B type fractures, major flap procedures, bony infection and bone grafting procedures which was statistically significant. The coincidence of segmental fibular fractures and segmental tibial fracture with segmental comminution indicated a bad prognosis. Segmental fibular fracture (associated with tibial fracture) appear more severe injury than segmental tibial fracture.

Chronic contained leak of abdominal aortic aneurysm presenting as lumbar neuropathy.

Chronic contained rupture of aortic aneurysm is a rare event which can cause diagnostic difficulties. It can present as high lumbar neuropathy, hence, chronic contained rupture should be borne in mind while examining patients with back pain. Delayed diagnosis and delayed surgical repair of the ruptured aneurysm can compromise the final results. The outcome of urgent repair of a chronic contained leak is equivalent to that of elective aneurysm repairs.

The role of a fibular nail in the management of Weber type B ankle fractures in elderly patients with osteoporotic bone--a preliminary report.

Fibular nailing was performed in 11 Weber type B ankle fractures in elderly patients (average 67.2 years) with osteoporotic bones between March 1996 and February 2000. All the fractures were displaced with significant talar shift. Nine patients remained under follow-up (average 25.9 months). Results were good and excellent in 88% of cases by the modified Olerud and Molander scoring system. One patient developed post-operative ankle subluxation and required ankle fusion. We feel that fibular nailing is an important tool in managing specific types of ankle fracture.