Definitive management of significant soft tissue loss

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Mar 23, 2014 - lengthening with restoration of deformity combined with distraction tissue ... or local tissue transfer is time consuming and costly [11, 12]. The risks inherent with .... paid to vascularity of the distal limb becomes even more important. .... frequent, usually minor and requires only short-course antibiotic treatment ...

Definitive management of significant soft tissue loss associated with open diaphyseal fractures utilising circular external fixation without free tissue transfer, a comprehensive review of the literature and illustrative case Matt D. A. Fletcher & Leonid N. Solomin

European Journal of Orthopaedic Surgery & Traumatology ISSN 1633-8065 Volume 25 Number 1 Eur J Orthop Surg Traumatol (2015) 25:65-75 DOI 10.1007/s00590-014-1441-0

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Author's personal copy Eur J Orthop Surg Traumatol (2015) 25:65–75 DOI 10.1007/s00590-014-1441-0

GENERAL REVIEW

Definitive management of significant soft tissue loss associated with open diaphyseal fractures utilising circular external fixation without free tissue transfer, a comprehensive review of the literature and illustrative case Matt D. A. Fletcher • Leonid N. Solomin

Received: 30 January 2014 / Accepted: 12 March 2014 / Published online: 23 March 2014 Ó Springer-Verlag France 2014

Abstract Accepted management of diaphyseal fractures associated with significant tissue loss is rigid intramedullary stabilisation with free or rotational musculocutaneous flap coverage. Circular external fixation is a powerful tool in the management of limb trauma and with recent advances has been developed to provide multiple techniques for which even massive tissue loss can be addressed without the need for free tissue transfer. Gradual and acute shortening, acute fracture deformation and gradual lengthening with restoration of deformity combined with distraction tissue histiogenesis can provide the surgeon with an array of options which can be precisely tailored to the particular personality of a severe open diaphyseal fracture. Keywords Open fracture  External fixation  Ilizarov method  Tissue transfer  Acute shortening  Distraction histiogenesis Introduction Open fractures are serious injuries. According to the Gustilo and Anderson classification, type IIIb injuries represent an M. D. A. Fletcher (&) NE Department of Surgical Services, Dawson Creek and District Hospital, 11100-13th Street, Dawson Creek, BC V1G 3W8, Canada e-mail: [email protected] L. N. Solomin Vreden Russian Research Institute of Traumatology and Orthopedics, 8 Baykova 8 Str., Saint Petersburg 195427, Russia L. N. Solomin St. Petersburg State University, 7–9 Universitetskaja Str., Saint Petersburg 199034, Russia

associated soft tissue defect which cannot be closed directly and require soft tissue reconstruction with a flap to achieve coverage [1]. Complication rates of open fractures increase proportionally to the size of the defect, the degree of tissue devitalisation, involvement of neurovascular structures and degree of comminution [2]. Open tibial diaphyseal fractures preponderate, at least partly due to the limited soft tissue coverage of this limb segment [3]. Traditionally, primary wound closure was not recommended, but recently this belief has been challenged and early closure appears to reduce infection [4–7]. The ‘fix and flap’ concept has been accepted as a gold standard for the management of defects which cannot be primarily closed [7–10]. Access to plastic surgery and in particular microsurgical skills may be difficult in more remote or less developed areas [7], and addressing significant open wounds with free or local tissue transfer is time consuming and costly [11, 12]. The risks inherent with free flap coverage are well recognised, and patient factors can frequently preclude the use of such treatment [7]. Free tissue transfer, local rotational musculocutaneous flaps and cross-limb flaps suffer the risks of flap failure and donor site morbidity which are not insignificant [9, 13]. Internal fixation of fractures with associated free flaps can be associated with a significant delay before weight-bearing, which is less desirable [14, 15]. Vacuum-assisted closure (VAC) devices are a useful method to address deep tissue loss either in the short term or definitively [16, 17]. VAC therapy generates granulation tissue over viable soft tissues and bone and can obliterate a defect whilst simultaneously reducing bacterial colonisation and increasing microcirculation [19]. VAC application can, however, be problematic or impossible with circular fixation in place, and the cost is not insignificant [18]. Skin cover is still a necessary further step, and subsequent flap coverage is associated with a risk of failure [20].

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Circular external fixation according to the work pioneered by Gavril Ilizarov is a very powerful tool in the management of limb trauma [15, 21]. The most recent iteration of the Ilizarov frame is the hexapod circular fixator, of which the most well-known and utilised examples are the Taylor spatial frame (TSF; Smith & Nephew, Memphis TN, USA) and the ortho-SUV frame (OSF; Pitkar, Pune, India). These devices build upon the success of the original Ilizarov frame by increasing the ability of the fixator to correct deformity in six degrees of freedom simultaneously [15, 22]. Furthermore, they have the unique ability to control and manipulate bone segments and rapidly adjust conformation of the frame to suit the purpose of the intervention. The debate regarding intramedullary versus external fixation of diaphyseal tibial fractures remains; however, there is evidence that external fixation is associated with statistically significant shorter healing periods, time to weight-bearing and reduction in complications [23]. Ilizarov’ principles of distraction osteogenesis and histiogenesis have revolutionised the management of limb segment deformity and shortening [21, 24]. In other surgical disciplines, the principle of progressive distraction to increase the surface area of skin and soft tissue for coverage or reconstruction through the use of tissue expanders has also been successfully applied [25, 26].

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Fig. 1 Ilizarov tissue distraction (according to Solomin)

Acute shortening Review The unique abilities of circular fixators to manipulate bone segments have been innovatively described by a number of authors to definitively address the problems associated with significant open limb injuries and tissue defects without recourse to free tissue transfer in the definitive management of tissue loss. The following represent the techniques presently devised. Tissue distraction The initial application of distraction histiogenesis to obtain coverage of a wound was described by Ilizarov [15, 21]. A wound margin is attached by plate or wires to traction apparatus connected to an external frame, and progressive distraction applied, with gradual coverage of bone and soft tissues [27] (Fig. 1). Once sufficient skin has been generated, and suture closure can be performed [15, 28]. This has particular benefit in superficial tissue loss with underlying viable muscle and fascial support, e.g. gunshot wounds with only superficial devitalisation [15, 27, 29]. A similar mechanical technique, utilising a ‘shoelace’ device within the margins of the wound alone, has been likewise described with encouraging results [30].

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Open fractures may be amenable to acute primary closure if intercalary comminuted fragments are removed, or perpendicular squaring osteotomies of the fragment ends are performed, and the limb segment shortened by apposition of the fragment ends. This technique can be seen to be of particular use with multiple comminuted devitalised fragments at the fracture site. In this manner, tissue defects, transversely biased especially, may be obliterated and tension-free skin closure performed. In the case of humeral fractures, minor limb shortening is functionally often well tolerated, so length restoration may not be necessary [31]. In the lower limb, however, length inequality is poorly tolerated, and so restoration of length is an all but obligatory step. This can be performed concomitantly with or remote to the initial fracture management. Bifocal/bilocal acute shortening and subsequent lengthening The paradigm for this concept is the multifocal compression– distraction technique [15, 27] (Fig. 2a–f). Acute fracture shortening and compression are performed as previously described whilst simultaneously performing distraction osteogenesis at a separate locus (or several loci in the case of massive bone loss) within the limb segment, most commonly

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Fig. 2 Acute shortening and gradual lengthening. a acute injury, b, c acute shortening and closure, d bifocal lengthening, e united fracture and consolidated regenerate, f clinical appearance

within the same frame construct. This has been proven to be highly efficacious in addressing the open fracture, whilst simultaneously restoring length as rapidly as possible to permit mobilisation and so reducing frame time maximally. Both Sen et al. [32] and Rozbruch et al. [33] described excellent results in a total of 49 patients with a mean frame time of 31–43 weeks and salvage of all limbs with this technique. Other authors have reported similar outcomes [34, 35]. The quality of bone regenerate achieved with multifocal lengthening appears greater than unifocal lengthening in patients with large bone defects [36]. Yokoyama [37], however, reported less acceptable functional outcomes and residual limb segment shortening. In the special case of Gustilo type IIIC fractures, acute shortening can also permit direct anastomosis of the arterial injury, avoiding the need for vascular graft reconstruction following debridement [27]. A variant technique is to perform acute shortening as described, and lengthening of the limb segment at a subsequent juncture, often utilising a new frame. This has been reported with mixed results [35, 38].

Monofocal/monolocal acute shortening and subsequent lengthening Acute fracture shortening is commenced with 14–18-day compression, and subsequently distraction osteogenesis is performed through the fracture site (Fig. 3a–f). This has been described by Solomin [15] and Lerner [27] and reported in the Russian literature with good results [39–43]. Martel and Shved [42] reported that monolocal consecutive compression–distraction osteosynthesis was used in tibial open fractures with bone defects of 2–4 cm (23 patients) and femoral bone defects of 4–6 cm (4 cases). In 70 % of cases, the defect was located in the metaphysis, 10 % of these were children with diaphyseal and metaphyseal defects and 20 % of patients had triangular defects. Progressive distraction was commenced after wound healing. The duration of distraction depended on the size of the defect and ranged from 21 to 45 days. Fixation period ranged from 65 to 113 days. Average osteosynthesis index was 28.7 days per 1-cm lengthening.

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Fig. 3 a Initial injury, b acute shortening and compression, c commencement of distraction, d completion of distraction, e consolidated regenerate, f clinical result

Fig. 4 a Gradual shortening (according to Mullen et al. [44]). b Gradual shortening and bifocal lengthening

Gradual shortening Some defects associated with open fractures are not amenable to acute axial reduction. These include situations where the soft tissue deformation may kink vasculature leading to distal ischaemia, where the stiffness and bulk of the soft tissues prevent axially aligned shortening and when the wound morphology is vertically orientated and shortening leads to increased divergence of the skin margins [27]. In some cases, the wound can be approximated, but bone apposition cannot be achieved immediately and must be performed gradually [15]. Mullen et al. [44] described a technique whereby gradual compression of a significant osteocutaneous defect was performed at a rate of 1–2 mm per day (Fig. 4a), enabling primary healing of the wound and union of the tibial defect with a residual one-inch limb length inequality which was subsequently addressed by ipsilateral femoral lengthening.

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Gradual shortening can be combined with contemporaneous bifocal lengthening to minimise frame time (Fig. 4b). This can be of more use in chronic and scarred open wounds and infected non-unions where stiff soft tissues do not permit acute shortening across a significant defect. Acute malreduction with delayed correction The defect in the soft tissue envelope is frequently more severe than the bone defect in many tibial fractures; the variety of mechanisms of injury applied to the lower limb in particular may result in serpiginous or circular defects following primary wound excision. Relatively small areas of tissue loss can result in the inability to achieve primary closure due to circular or rectangular morphology. These defects are typically unilateral [27]. In this situation, particularly with minimal bone loss, it is possible to perform

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Fig. 5 Acute malreduction. a Clinical picture. b, c AP views showing intentional deformity (according to Sharma and Nunn [46])

angular manipulation of the limb to permit apposition of wound edges for primary closure, despite adequate wound excision (Fig. 5). This results in malreduction of the osseous injury. Subsequent controlled correction of deformity can be performed, either immediately following wound healing [45] (vide infra) or following a 4–6-week period [46]. Both methods produce new integumentary growth by distraction histiogenesis, the former predominantly at the wound site. Lerner [36] reported good outcomes in three patients of a series of 12 with defects requiring significant angulation to achieve closure. Sharma [46] reported excellent outcomes in two patients using this technique and described a series of parameters for decision-making. Lahoti [47] described closure of defects ranging from 3 to 10 cm in seven patients with good outcome and no requirement for tissue transfer. Alternatively, a bilocal technique can be performed with length restored at the separate osteotomy site [48]. Combinations of the above can be performed with initial shortening, progressive deformation to achieve closure, delayed correction and bilocal lengthening [49]. A critical observation during this procedure is the status of the perfusion of the distal limb segment; any evidence of ischaemia during angulation, shortening and rotation should be carefully assessed and deformation reduced if present [27, 48]. In this case, conversion to a different technique is indicated. Acute malreduction with malrotation and delayed correction A further variant technique on the concept of acute malreduction is to add malrotation of the limb segment in order to achieve tissue closure (Fig. 6). This can achieve further ease of wound apposition where acute shortening or angulation may require a severe deformity to achieve closure of the

wound, whereby the magnitude of deformity parameters is shared over multiple axes of deformation. These limb segment manipulations are ideally served by the use of hexapod fixators as the deformity can be described as a single integrated vector and corrected simultaneously. This has been described with success by Lerner and Solomin [15, 27]. When rotation is included in limb deformation, the attention paid to vascularity of the distal limb becomes even more important. Illustrative example of acute malreduction and delayed restoration A 53-year-old restrained female passenger was involved in a frontal high-speed motor vehicle collision sustaining multiple limb injuries including a segmental fracture of the left tibia (Fig. 7), the upper comminuted intra-articular metaphyseal fracture was grade IIIA with a 2 by 3 mm wound and the lower diaphyseal fracture grade IIIB with a 5 by 4 cm wound. Following primary wound excision and irrigation, the upper open wound was closed without tension, and the lower was deemed primarily irreparable. A stacked TSF was constructed around the limb with a rings first technique, and the fractures deliberately shortened and angulated (Fig. 8) to allow apposition of wound ends for tension-free repair, which was achieved with interrupted mattress sutures. Two weeks postoperatively, the wounds had healed well. Correction of deformity was commenced, utilising software-driven correction protocol that limited correction through the lower wound to 1-mm distraction per day. At 6 weeks, correction was achieved and the lower healed wound had grown significantly with a healthy appearance (Fig. 9). Note was made of occasional hair follicles within the scar confirming tissue histiogenesis rather than healing by secondary intention, i.e. the presence

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Fig. 6 a–d Use of the Ortho-SUV Frame in the treatment of an open fracture of the lower leg. a, b Acute rotation ? angulation ? translation provide optimal conditions for wound closure and healing. c,

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d All components of the deformity are eliminated using an ‘‘integrated’’ trajectory/vector

four when limb alignment was sufficient for ambulation. Scar condition was excellent, with marked hypopigmentation apparent (Fig. 10b, c). Function was reported as excellent by the patient with residual symptoms confined to the intra-articular portion of the upper tibial fracture.

Discussion

Fig. 7 Segmental left tibial fracture

of skin appendages confirmed that this was not simply due to scar stretching [21]. Full union of the upper fracture was achieved at 16 weeks and of the lower fracture at 38 weeks following index injury (Fig. 10a). Weight-bearing had been permitted since week

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Severe open tibial fractures pose a significant risk to the patient and the limb, and have a high likelihood of lengthy treatment, re-operation and are associated with a definite risk of amputation. Conventional techniques using intramedullary fixation and tissue transfer provide a multidisciplinary approach to their management. Circular external fixation offers another option. The techniques developed during the evolution of distraction histiogenesis, facilitated in part by the innovation of hexapod fixators, offer the orthopaedic surgeon an almost limitless series of options to address salvageable major diaphyseal injuries. Free tissue transfer has an enduring role in the management of grade IIIB fractures; it can be combined with

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Fig. 8 Deformed fracture sites to permit closure of wound

Fig. 9 Appearance of wound at end of distraction histiogenesis

distraction osteogenesis to provide immediate coverage of a defect and permit a healthy environment for the subsequent management of bone loss with excellent results. Lowenburg [50] reported long-term results of bone transport in combination with free flap coverage in 34 patients with combined osteocutaneous defects, with excellent final outcome; however, this was associated with an average frame time of 10.8 months and a reoperation rate of 29 %. The cost, risks and morbidity of free tissue transfer may not be appropriate or possible in every situation and require a high level of coordination between surgical disciplines. A

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single solution in the form of circular external fixation to address combined osteocutaneous pathology appears an attractive alternative. The traditional Ilizarov fixator is a powerful tool [15, 21]; however, it is limited inasmuch as that only a single parameter (or two parameters in the case of angular lengthening) can be addressed within a single frame construct, and thus, adjustments to the frame need to be performed for complex situations. Multiple issues often must be treated in series, rather than parallel. Treatment therefore can be lengthy and require multiple frame adjustments. Correction cannot always rapidly be achieved and adjusted to suit the particular personality of the injury, and deliberate deformation of a limb, whilst possible, is technically difficult. The TSF and OSF are computer-navigated hexapod fixators whose suite of software allows precise correction of multiple deformity parameters. The ability to unlock the struts to adjust the frame permutation to maximally adjust limb position permits rapid reduction or deformation of deformity and soft tissue tension. One particularly useful feature is the ability to define a precise point on the limb whereby speed of correction or lengthening can be defined. This permits a very precise lengthening schedule to be applied to a specific locus through skin and nerves in particular, to avoid lengthening at a rate greater than that maximal for distraction histiogenesis, which according to Ilizarov is ideally 1 mm per day [15, 21]. Early weight-bearing is most useful in the management of lower limb fractures treated with external fixation [15, 21]. In addition to the mobility achieved by ease of ambulation, functional management of the limb, avoidance of joint contractures and muscle atrophy and reduction in the generalised disuse atrophy or ‘cast disease’ are also achievable and hasten return to active function and independence during the treatment period [15]. Early weightbearing can speed fracture union and regenerate consolidation through dynamic and controlled axial compression. A highly unstable or comminuted fracture treated with rigid internal fixation cannot be permitted unrestricted weight-bearing, and regions of bone loss treated with grafts must be especially protected. Circular external fixation obviates this situation as weight-bearing can be performed even with significant regions of bone loss [15, 27]. Bifocal acute shortening and delayed lengthening is a most valuable technique in addressing significant bone loss associated with soft tissue defects. However, time to final consolidation of the lengthened bone is variable and can be prolonged [33, 51]. Fracture of regenerate is not uncommon, which has been reported as occurring in up to 30 % of cases of lengthening [52, 53]. Other complications are not infrequent, and outcomes may be variable [32, 51]. This option has particular use in the management of very significant bone loss.

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Fig. 10 a Radiologic union, b appearance prior to frame removal, c final appearance

Acute shortening with intentional deformation to achieve wound closure is a safe and effective management for dealing with tissue loss in the tibia. The technique of acute deformation has been nicely described as conversion of a IIIB fracture to a IIIA, allowing primary healing of the wound with subsequent correction [46]. The major role of the skeletal system is to support the soft tissues; these options can uniquely and definitively address combined injuries initially concentrating on the soft tissue injuries with excellent outcome and minimal intervention compared with internal fixation and tissue transfer. By applying the recognised principles of distraction histiogenesis to a healing wound, restoration of tissue integrity over the prior defect can be achieved more rapidly without the need for scar consolidation and subsequent limb realignment or bifocal lengthening and thus can achieve axial alignment for commencement of weightbearing at the earliest possible juncture, particularly when bone loss is minimal and tissue loss more severe. This has particular value when access to plastic surgery is limited or contraindications to free musculocutaneous flaps exist. Comparing the outcomes and complications of these techniques with those of the ‘fix and flap’ methodology is difficult inasmuch as the options here described are frequently uniquely tailored to the specific injury patterns and do not necessarily follow a standard application or surgical

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approach. This is further compounded by a preponderance of small series and case reports in the literature. Likewise, the use of free tissue transfer also can vary significantly based on the donor site and manipulation of the graft. In terms of free tissue treatment with internal fixation, the success of treatment is variable and is strongly affected by the delay in obtaining flap coverage; Caudle [54] reported a 23 % tibial non-union rate which rose to 77 % if cover was delayed more than 1 week, with a corresponding increase in infection from 8 to 59 %. In the subgroup of type IIIB and IIIC fractures treated with early flap coverage, there was a subsequent amputation rate of 29 %. Gopal [8] reported a 100 % union rate in the tibia; however, this was associated with 9.5 % infection rate and 62 % delayed union if an immediate ‘fix and flap’ technique was used. Yazar [9] reported on 61 patients treated with free tissue transfer and noted an 11 % complete and 8 % partial flap failure rate, 10 % donor site morbidity and 8 % infection rate. In a series of 36 patients treated with soft tissue coverage, Cierny [6] reported 5 (14 %) amputations, 7 (19 %) deep infections and 3 (8 %) non-unions. In 24 patients treated with tibial bifocal compression distraction, Sen [32] reported a 10.7 % pin site infection rate and 52 complications of which half were deemed minor, with a significant complication rate of 13.4 % which included knee contracture, loss of range of motion in

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the ankle and knee, malalignment and osteomyelitis, which required further intervention to address. Rozbruch [33] described a series of 25 patients deemed unsuitable for free tissue transfer treated with both monofocal and bifocal transport in the tibia, and reported no amputations, no deep infection and no failure of treatment. El-Rosasy [34] described 21 patients treated with acute shortening and gradual lengthening and noted three complications; a transient peroneal nerve palsy, one regenerate fracture, and a 10° ankle equinus contracture. Lerner [36] likewise noted no major complications with this technique and a 42 % pin track infection rate. Yokoyama [38] conversely noted a higher rate of complications with two cases of equinovarus deformity, a regenerate fracture, two cases of significant limb length inequality, a deep infection and two frame failures in six patients treated with acute shortening and gradual lengthening. This, however, does not appear to match other investigators results. The case reports and small series of deformation and restoration do not describe any significant complications to these methods of treatment. Generally speaking, the complications of fine wire external fixation include (1) pin tract infection which is frequent, usually minor and requires only short-course antibiotic treatment, (2) joint stiffness/contracture due to either juxta-articular pin site placement or significant lengthening and tension on muscles, which can often be prevented with meticulous detail to wire placement, avoidance of large muscle transfixion and regular physiotherapy, although can persist and require further intervention (3) frame element/pin breakage, which necessitates replacement of the broken element, (4) deep infection due to neglect of pin tract infections, (5) neurovascular injuries due to pin placement or traction, (6) delayed union at docking sites and (7) fracture of bone regenerate. In the landmark paper on complications encountered with the Ilizarov technique, Paley [52] describes a stratification of adverse outcomes from minor to severe. In 60 limb segment lengthenings, there were 27 true complications, of which 17 were minor. Three complications interfered with treatment and required re-operation. The original goals were achieved in 56 (93 %) of the cases. When comparing the complications between these techniques, it is apparent that the majority seen with circular external fixation are minor, do not interfere with the aims of treatment and do not result in catastrophic failure of the treatment goal, with a 0 % amputation rate following frame management of severe trauma in the published literature, as compared to up to 29 % in the free tissue transfer groups. This is further encouragement that the techniques described are not only as least as efficacious as the ‘fix and flap’ concept, but also have much lower significant complication and failure rates.

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The development of these techniques permits a customised and unique treatment plan to be created relative to the particular osteocutaneous injury, and provides the orthopaedic surgeon skilled in circular external fixation and distraction histiogenesis to manage an exceptionally wide range of pathology without the requirement for tissue transfer. Conflict of interest

None.

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