|Year : 2013 | Volume
| Issue : 2 | Page : 100-105
Fasciocutaneous flap as a method of soft tissue reconstruction in open tibial fractures
Sachlang Debbarma, Nepram Sanjib Singh, Phuritshabam Iboiyama Singh, S Nongthon Singh, A Mahendra Singh, Raj Kumar Meena
Department of Orthopaedics, Regional Institute of Medical Sciences, Lamphelphat, Imphal, Manipur, India
|Date of Web Publication||19-Nov-2013|
S Nongthon Singh
Department of Orthopaedics, Regional Institute of Medical Sciences, Imphal, Manipur
Source of Support: None, Conflict of Interest: None
Objective: To study the role fasciocutaneous flap as a method of soft-tissue reconstruction in open tibial fractures soft-tissue defect and to compare their outcome when used as early coverage with that of delayed coverage. Materials and Methods: A total of 30 patients with open tibial fractures (type IIIB) were subjected to fasciocutaneous flap for the soft-tissue defect. Patients were divided into two groups based on the timing of soft-tissue reconstruction comprising of 15 patients in each group. Group I the early group (0-7 days) and group II delayed group (8-30 days). Results: Road traffic accidents accounted for the majority of fractures with 77.7% and 60% in group I and group II. The right leg was involved in 20 patients (66.7%) and left leg in 10 patients (33.33%). Middle one-third of the leg being the predominant site of wound defect 66.7% and 60% in group I and group II respectively. 66.7% of superficial infection was found with the delayed closure (group II) and 46% with early closure (group II). 26.7% of deep bony infection was found to be with the delayed closure and 20% with early closure. 80% of flap survived completely in group I while 73.3% flap survived in group II. In group I the time to union was between 13 weeks and 25 weeks accounting for 73.3% of the cases and in group II the time to union was between 26 weeks and 52 weeks, which accounted for 80% of the cases. The average hospital stay was 13.4 days in group I with 80% ranging in between 10 days and 20 days and in group II the average stay was 22.8 days with 53.3% ranging from 21 days to 30 days. Conclusion: The goals of soft tissue coverage in open fractures are to achieve a safe and early durable coverage, avoid nosocomial infection and optimize the healing and facilitate the future reconstruction. fasciocutaneous flap can reliably and effectively cover traumatic open tibial fractures soft tissue defect.Advantage of fasciocutaneous; they have their own blood supply producing a good durable cover and can be reopened for bony surgery.
Keywords: Delayed closure, Early closure, Fasciocutaneous flap, Open fracture
|How to cite this article:|
Debbarma S, Singh NS, Singh PI, Singh S N, Singh A M, Meena RK. Fasciocutaneous flap as a method of soft tissue reconstruction in open tibial fractures. J Med Soc 2013;27:100-5
|How to cite this URL:|
Debbarma S, Singh NS, Singh PI, Singh S N, Singh A M, Meena RK. Fasciocutaneous flap as a method of soft tissue reconstruction in open tibial fractures. J Med Soc [serial online] 2013 [cited 2020 Mar 28];27:100-5. Available from: http://www.jmedsoc.org/text.asp?2013/27/2/100/121574
| Introduction|| |
Open fractures are surgical emergencies, incidence of higher Gustilo's grades of open fractures are increasing with more high-energy road traffic accidents and in areas with more farm accidents, since soil contamination automatically changes the open fracture to grade III. Because of its location, the tibia is exposed to frequent injury; it is the most commonly fractured long bone. Because one third of the tibial surface is subcutaneous throughout most of its length, open fractures are more common in the tibia than in any other major long bone. The blood supply to the tibia is more precarious than that of bones enclosed by heavy muscles elsewhere. 
Infection doesn't loom large as hazard if the skin is not involved, but it has to be added to the list of possible complications when there is a break in the skin barrier, and this can be particularly serious when a fracture is part of injury. It is for this reason that the effective provision of skin cover becomes a matter of urgency; though, its provision has to be coordinated with the management of the other damaged structures, each of which carries its own imperative. Provision of an intact healthy soft-tissue envelope around fracture is beneficial for bone healing to occur and function to be restored. 
The loss of soft-tissue cover over a fracture, particularly when interrupted endosteal blood supply is combined with periosteal damage, demands coverage of exposed bone with vascularized tissue after through debridement of devitalized tissue. Soft-tissue coverage of severe type III open fractures of leg diminishes the rate of infection, non-union, and secondary amputation when it is performed early.  Various options for reconstruction of soft-tissue defect in open fractures, split skin graft (SSG), fascio-cutaneous flap, rotational muscle flap (with SSG), and free muscle flap (with SSG). the closure of traumatic lower extremity soft-tissue defects can be arranged in a hierarchy from direct closure to complex free tissue transfer. 
Fasciocutaneous flaps are those, which include skin, subcutaneous tissue, and the deep fascia. Ponten first described fasciocutaneous flaps in 1981. Previously, most lower limb flaps were based on the concept of random skin flap design, thus were limited by a certain length-to-width ratio (usually 1:1 in the lower extremity). Ponten flaps had length-to-width ratios as great as 3:1. These flaps have been referred to as Ponten superflaps. 
The timing of open wound closure has proponents in the immediate, early and delayed categories. T0 raditionally, immediate closure is defined as wound closure at the time of the initial surgical intervention, early closure is within 24-72 h window, and delayed closure extends beyond 3 days. 
Delayed closure of wound in open fractures, at any time after the initial debridement, was established as standard of care prior to the advent of current antibiotics, modern debridement methods, and improved fracture stabilization procedures.  t0 he standard of treating open wound fractures has become a combination of urgent aggressive debridement with excision of all dead and devitalized tissue, early stabilization of the fracture, and initiation of broad-spectrum antibiotics.  Subsequently, the wound is debrided every 48-72 h, with closure of the wound after final adequate debridement 1. , It has been shown that the optimal timing of wound closure or coverage is within 7 days of injury as delays more than 7 days are associated with higher infection rates. ,
The established management of severe open fractures is based on a philosophy of initial wound debridement and lavage, stabilization of fracture, and delayed wound closure.  Multiple reports have shown that infections of open wounds likely are not caused by the initial contamination, but instead by organisms acquired secondarily through nosocomial routes. ,,,
In accordance, Patzakis et al.  reported only 18% of infections related to open fractures are due to the initial organism. This has led to many authors suggesting that primary wound closure is safe and may actually reduce the rate of infection. ,,,,,
| Materials and Methods|| |
The study was conducted on 30 patients of open fracture (type IIIB) of the tibia admitted in the Orthopedics Department Regional Institute of Medical Sciences (RIMS), Imphal between 2010 and 2012. Initial resuscitation of all trauma patients was provided following advanced trauma life support guidelines. Patients were divided into two groups each comprising of 15 patients respectively. Initially, patients were assed to fit them in either of the group, based on the time since the injury at presentation and timing of soft tissue coverage. Group I early group, soft-tissue reconstruction was carried out on (0-7) days and whose time since the injury and had presented to the hospital with time lapse of <24 h. In group II late group, soft-tissue reconstruction was carried out on (8-30) days with patient presenting to the hospital with time lapse of >24 h and other unavoidable conditions. Patients were subjected to investigations of Complete blood count, liver function test, kidney function test Electrolyte, coagulation profile etc. for pre-anesthetic checkup. Plain radiograph of the side involved were taken in two planes.
Patients were resuscitated and associated injuries were taken care. The initial care consisted of analgesic, tetanus prophylaxis, betadine scrub and saline lavage, splint stabilization, and broad spectrum antibiotics. Soft-tissue injury and any bony loss was assessed using "Gustilo-Anderson classification of open leg wounds." Treatment of open fracture by immediate radical debridement outside the zone of injury with profuse lavage emergency irrigation and debridement, fracture stabilization, using the external fixation device was carried out in all patients irrespective of the groups, which is then followed by soft-tissue reconstruction according to the allocated group per se.
Soft-tissue defect with bone exposed at the fracture site were covered by using the fasciocutaneous flap [Figure 1], [Figure 2], [Figure 3], [Figure 4]. Fasciocutaneous flaps of the leg were planned based on septocutaneous vessel. For planning the fasciocutaneous flap, leg defect was divided into upper 1/3, middle 1/3 and lower 1/3. Based on the septocutaneous perforator of posterior and anterior tibial artery and peroneal artery skin with fascia as fasciocutaneous flap was raised as superiorly based (proximally), inferiorly based (distally) and transversally based fasciocutaneous flap from the same leg (ipsilateral). Donor site from where the flap was raised the secondary defect were covered with SSG harvested from thigh.
|Figure 1: (a) Soft tissue defect (medial aspect) (b) Soft tissue defect (anterior aspect)|
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|Figure 4: (a) Complete flap survival (b) After removal of external fixator (c) After removal of external fixator|
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The limb was immobilized with plaster of Paris slab. All patients received intravenous antibiotics for 5 days, which was changed to oral formulation from the 6 th day. Anti-inflammatory analgesics and other supportive measures were given as per individual requirement. Special instruction for the flap care with frequent monitoring, looking for hematomas and evacuation if detected, prevention of infection the distal part of the flap was inspected every day. Graft dressing was carried out on 5 th post-operative day and flap sutures were removed on the 10 th post-operative day.
Patient was taught on flap care and discharged and called on weekly basis to the OPD for initial 1 month for inspection of flap and all complication were recorded. All patients were followed clinically and radiologically until bony union or for 1 year. Post-operatively, external fixation was removed once union was confirmed radiologically. The extremities were protected with a brace and with crutch ambulation for 18-24 months to prevent stress fracture. Secondary procedure was carried out in case of non-union the procedure executed was bone grafting with plate fixation.
| Results|| |
In the study, the average age of patients in group I was 23 years while that of patients in group II was 28.4 years. Males were predominant in both the groups 87.7% in group I and 66.7% in group II.
Nearly, 60% of patients in group I attended our hospital with time elapsed of between 6 h and 12 h since the time of injury and in group II 80% of patient attended the hospital more than 12 h since the time of injury. Ipsilateral superiorly based flap predominated the most common type of flap being used with 80% and 73.3% in group I and group II.
Soft-tissue defect reconstruction was done by fasciocutaneous flap. In 53.3% soft-tissue cover was done within 4-7 days in group I and 66.7% of soft-tissue cover were carried out within 8-15 days with a maximum of 24 days in group II.
Superficial infection accounted for 46% (7/15) in group I, 4 were managed by local wound care and antibiotics and in group II it was 66.7% (10/15), 6 were managed with local wound care and antibiotics. Deep bony infection accounted for 20% (3/15) in group I, i.e., three superficial infection went on to develop deep bony infection and 26.7% (4/15) in group II, i.e., 4 superficial infection went on to develop deep bony infection. The difference was found to be statically significant (P value < 0.05).
In group I, the time to union was between 13 weeks and 25 weeks in 73.3% of the cases and in group II, the time to union was 26-52 weeks in 80% of the cases. The comparison was statically significant (P value < 0.005).
| Discussion|| |
The present study was conducted on patients with open tibial fracture type IIIB with soft-tissue defect, admitted in the Department of Orthopedics, RIMS Imphal with the aim of evaluating the role of soft-tissue reconstruction by fasciocutaneous flap and comparing the outcome between early closure and delayed closure of the wound defect.
Prospective study of 30 patients were carried out during the period between 2010 and 2012, patient were divided in two groups based on timing of soft tissue coverage and time since the injury into group I and group II respectively. Group I patients were treated with radical debridement, skeletal stabilization and soft-tissue reconstruction carried out between 1 day and 7 day whereas, as in group II patient were treated with radical debridement, skeletal stabilization and delayed wound closure carried out between 8 days and 30 days. Patients were followed clinically and radiologically to union or for 1 year.
The results were studied by comparing the two groups. The following variables of each patient recorded were analyzed: Age, sex, time since injury, mode of injury, side and site involved, size of wound defect, timing of flap coverage, type of flap, associated injuries, duration of hospital stay in days, complication (superficial infection and deep bony infection), partial flap survival, complete flap survival and total flap lost. The statistical analysis consisted of percentages, average and Chi-square test.
In the present study, the average age of patients in group I was 23 years while that of patients in group II was 28.4 years. 66.7% of patients in group I and 80% of patients in group II were between the age group of 21-30 years. Males were predominant in both groups with 88.7% in group I and 66.7% in group II. Thus, both groups were comparable in terms of age and sex (P value > 0.05).
60% of patients in group I attended our hospital with time lapsed of 6-12 h since the time of injury and in group II 80% of patient attended the hospital with more than 12 h since the time of injury [Table 1]. road traffic accident accounted for the most common mode of injury in our series with 77.3% in group I and 60% in group II.
|Table 1: Distribution of cases with aspect to time since the injury and other circumstances|
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Right leg was the predominant lower limb involved with incidence of 73.33% in group I and 60% in group II. Middle one third of the leg being the common site of the soft-tissue defect in both groups 66.7% and 60% in group I and group II respectively. Both groups were compare in terms of side involvement, site of wound defect (P value > 0.05).
The average size of the wound defect was 7.5 cm in group I and 8.3 cm in group II. Soft-tissue defect reconstruction by fasciocutaneous flap was carried out. In 53.3% of cases soft-tissue cover was carried out within the 4-7 days in group I and 66.7% of cases soft-tissue cover was carried out within the 8-15 days with a maximum of 24 days in group II [Table 2]. Ipsilateral superiorly based flap predominate the most common type of flap being used with 80% and 73.3% in group I and group II respectively. Both groups were compared (P value > 0.05).
Superfial infection accounted for 46% (7/15) in group I, 4 were managed by local wound care and antibiotics and in group II the superficial infection was 66.7% (10/15), six were managed with local wound care and antibiotics. Deep bony infection accounted for 20% (3/15) in group I i.e., three superficial infection went on to develop deep bony infection and 26.7% (4/15) in group II, i.e., four superficial infection went on to develop deep bony infection [Table 3]. The difference was found to be statically significant (P value < 0.05).In comparison with other series Haque et al.  (infection that accounted with early and delayed intervention were 12.5% and 75% respectively).
|Table 3: Distribution of cases with respect to the outcome of soft tissue coverage (fascio-cutaneous flap)|
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In group I complete flap survival was 80% and Partial flap lost was 20% (3/15) ultimately they went on to heal with secondary intention. In group II complete flap survival was 73.3% and partial flap lost was 26.7% (4/15) one was treated with SSG and other three healed by secondary intention. The difference was found to be statically significant (P value < 0.05). In comparison with other series, Yazar et al.  (Complete flap survival was 91.1% and partial flap failure was 7.6%) and Chittoria and Mishra  (partial flap loss was 5%).
External fixation was the method executed in all patients in the series. Among 15 patients in group I 53% (8/15) patients had union of fractures in a mean time 13.9 weeks and in 46.7% (7/15) patient they required secondary procedures, which ultimately united with a mean time of 19.7 weeks. In group II 40% (6/15) had the union of fractures in a mean time of 24.2 weeks and 60% (9/15) patient required secondary procedure, which ultimately united in a mean time of 48.5 weeks.
In group I, the time to union was between 13 weeks and 25 weeks in 73.3% of the cases and in group II the time to union was 26-52 weeks in 80% of the cases [Table 4]. The comparison was statically significant (P value < 0.005).
|Table 4: Distribution of cases with respect to time to union at the fracture site|
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The average hospital stay was 13.4 days in group I with 80% ranging from 10 days to 20 days and in group II the average stay was 22.8 days with 53.3% ranging from 21 days to 30 days. The comparison was significant (P value 0.005).
| Conclusion|| |
The management of type IIIB open tibial fractures involves appropriate initial evaluation, administration of antibiotics, urgent wound debridement, skeletal stabilization, coverage, and early rehabilitation. The goals of soft-tissue coverage in open fractures are to achieve a safe and early durable coverage, avoid nosocomial infection and optimize the healing and facilitate the future reconstruction. Fasciocutaneou flap can reliably and effectively cover traumatic open tibial fractures soft-tissue defect. Advantages of fasciocutaneous; they have their own blood supply produce good durable cover and can be reopened for bony surgery.
The timing of wound closure is debatable and that delayed primary closure at 5-7 days is probably optimal. This study has documented significantly better outcome with early local fasciocutaneous flap coverage with less hospital burden and stay, decreased infection and decreased time to union.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]