Treatment of Infected Fractures and Post-traumatic Osteomyelitis

of the Tibia with Local Fascio-cutaneous Flaps

Ashraf Abou-Hussein

Lecturer of Orthopaedics, Menoufiya University, Egypt

Post-traumatic osteomyelitis

• The primary objective of open fracture to render it a closed one

• When open fracture becomes infected, aggressive treatment should be instituted

• Long term morbidity

Fasciocutaneous flaps

• If available….

• Depends on plexus of vessels running above the deep fascia

• Beware of traumatized skin

Material

• 24 patients with infected open fractures and established post-traumatic osteomyelitis were treated in Menoufiya University Hospital over 5 years (from 2000-2005).

• Their age ranged from 9 to 63 years (average 29 years)

Material

• Duration of infection (2 weeks- one year)

• 20 infected fractures

• 4 chronic osteomyelitis after fracture healing

Material• Cirney-Mader Classification

• Type I 0…………….(Medullary)• TypeII 10 cases… (Superficial)• TypeIII 12 cases…….(cavity)• Type IV 2 cases……(Segmental

loss)• 2 patients were diabetics, 60 and 63 years

old• 13 smokers

Material

• Site of lesion

• Upper third 6 cases

• Middle third 11cases

• Lower third 5 cases

• Whole leg 2 cases

Method

• All patients had multiple debridements except one case of upper third osteomylitis, had only one debridement

Method

• Removal of any loose bony fragment

• Multiple debridements

• Judged by the clinical judgement of the wound

• No. of debridements (1-14 times!!!) (average three times)

Method• If a cavity is left in the bone (type III):

• Bone cement beads

11 cases• Bone graft

one case

Method

• Fasciocutaneous flap coverage

• Immediate flap elevation and inset…(17 cases).

Method

• Flap Delay…………..7 apatients

MethodFlap Types

• Transposition fasciocutaneous flap (15 cases)

• Bipedicle fasciocutaneous flaps (5 cases)

• Cross leg fasciocutaneous flaps (2 cases)

• Reverse flow superficial sural artery flap (one case)

• Proximally based superficial sural artery flap (one case)

Method

• Bone graft…..after 6 weeks

• By elevating the already healed flap

Results

• Follow up period (8 months- 5 years); average 2.2 years.

• For union

• Flap survival

• Presence of discharge

Results

• Duration of hospital stay (10 days-4 months)

Results

• No flap failure

• All fracture had united

Results

• Failures:

• 2 cases had persitent discharge:

• 2/24 (0.83%)

• One case of persistent discharge ; it was upper third osteomyelitis treated by single debridemnet, and immediate bone graft (triple attack)!!

• Another case with failure to achieve closure and persistent discharge (TypeIV)

• This patient was subsequently treated by Ilizarov segment transport by

• Dr. Mahmoud Al Rosasy Tanta University.

Dr. Al Rosasy, Tanta Univ.

Results

• One patient died after 8 months post trauma……after having union by Ilizarov segment transport…………..Acute renal failure

Case presentations

Discussion

• Debridement…..How much ?…

• Multiple debridements

Discussion

• Stable soft tissue skin cover is of primary priority for good long-term results.

• Local fascio-cutaneous flaps if available can provide this stable coverage and will enable the use of future bone graft through the same route.