Treatment of acute bone defects in severe lower limb Trauma
Introduction
Lower limbs diaphyseal fractures with segmental bone defect due to comminution, bone pieces loss in open fractures or removal of highly contaminated fragments represent an important challenge for trauma surgeons. We can find such bone defects in the presence of good soft tissues conditions, or in presence of a poor or absent skin coverage, these latter conditions generally classified according to Gustilo [1]. Since these fractures often occur after high energy trauma, we always tend to consider these as open fractures, even if without real skin lesions, then better classifying them according to Tscherne [2] (Table 1.); this led us to treat them applying the DCO (damage control orthopedics) approach. The first step in the management of these injuries is the accurate evaluation of the lesion, especially looking at the surrounding soft tissues. A closed “envelope” is not necessarily a good “envelope”. In a high energy trauma, the bruise of soft tissues could lead to severe complications (higher rates of infection, soft tissue necrosis). In our Unit, in case of open injuries, the protocol consists of the debridement of the necrotic tissues, irrigation and immediate external fixation as first steps, accompanied by a broad-spectrum antibiotic therapy (amoxicillin + clavulanate). On the other hand, if a closed but damaged envelope is present, only external temporary stabilization and antibiotic therapy are performed. Subsequently, a period of full rest is mandatory for the soft tissue to get in the best conditions for the definitive surgical treatment: the duration of this period depends on the type and intensity of the trauma and the general conditions of the patient, but it is usually between 7 and 21 days.
Winquist [3] defined the entity of the bone gap in a fracture with a classification that we modified extending it also to tibial shaft fractures and dividing small gaps (less than 5 cm) from large ones (more than 5 cm), (Table 2).
In the case of a partial bone loss (grade 1 or 2) autologous/homologous cancellous bone grafts with or without osteoinductive materials and a definitive osteosynthesis are generally used.
For more extensive bone problems with real defects (grade 3 and 4) the fractures are treated by means of more sophisticated methods. In these cases, an accurate planning of the surgical approaches and of the fixation device for the definitive treatment is mandatory to obtain the best results. Non-unions may be the consequence of a poor primary stability or a violated biology. In our experience, after a further careful debridement, we often choose an Ilizarov frame. The bone reconstruction is obtained by means of bone transport. In cases where skin problems are minor, massive bone grafts and locking plates may also play a role [4,5]. The choice between external and internal fixation is based on the quality of the soft tissues and the presence of length discrepancy. In fact, external frames may normalize the length inequality during the treatment.
The use of vascular fibular grafts is also a good option for severe bone gaps in acute cases (>10–15 cm) [6,7]. These grafts may be stabilized with simple K-wires and plasters or with long plates. Our experience in the last years lead us to routinely stabilize these reconstructions with the Ilizarov frames (eventually assembled for compression or distraction) which may give several advantages: perfect stability allowing early weight bearing, versatility (possibility to change reduction or to compress or distract), less invasively with lesser risks of infections, absence of internal devices at the end of the treatment.
Section snippets
Patients and methods
During a period of 6 years (from 2007 to 2013) 8 (6 males) patients with acute large bone defects were treated at our institution by means of vascularized bone grafts.
Two of them presented with femoral shaft bone defects and 6 with tibial shaft defects. The mean age was 39.57 years (29–79). All of them received temporary stabilization and eventual debridement and/or plastic reconstruction of soft tissues in case of bony exposure before the definitive treatment with the microvascular graft. The
Results
The mean treatment time, which is often connected to the mean consolidation time, was 61 weeks. It is important to be noted that 6 patients had infection at the lesion site prior to the intervention, thus justifying the long period of treatment (Staphylococcus Aureus, Epidermidis, Pseudomonas Aeruginosa, Staphylococcus Capitis were the main involved pathogens). One of these patients, who was drug addicted, underwent amputation for massive infection during the hospitalization after the
Discussion
Many methods of bone defects reconstruction are reported in the literature: vascularised/non vascularised – autologous/homologous bone grafts, (massive) cancellous bone grafts using Papineau or Masquelet techniques and distraction osteogenesis supported by circular external fixators [4,5,[7], [8], [9], [10], [11], [12], [13], [14], [15], [16], [17], [18], [19]. Numerous are also the described systems of stabilization of the grafts: cast, k-wires, screws only, plates, nails.
All these techniques
Declaration of Competing Interest
All authors declare no conflict of interest.
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This paper is part of a Supplement supported by the European Federation of Societies of Microsurgery (EFSM) and the Serbian Society for Reconstructive Microsurgery (SSRM).