Delayed Reconstruction of the Perforator Pedicle Propeller Flap after the Induced Membrane Technique for Gustilo IIIB Open Distal Tibial Fracture

Abstract

Objective

This study aimed to evaluate the safety and efficacy of delayed reconstruction of the perforator pedicle propeller flap after the induced membrane technique in the treatment of Gustilo IIIB open distal tibial fracture, and to evaluate the clinical outcome and complications of two different perforator pedicle propeller flaps.

Methods

Thirty-four patients with Gustilo IIIB open distal tibial fractures treated by the induced membrane technique and delayed reconstruction of two different perforator pedicle propeller flaps from May 2017 to March 2022 were retrospectively analyzed. Patients were divided into two groups according to the different kinds of perforator pedicle propeller flaps covered. The operation required two stages. The Radiographic Union Score for Tibial fractures (RUST) was used to evaluate the healing of the tibial bone defect. The American Orthopaedic Foot and Ankle Society (AOFAS) score was used to evaluate ankle function. The complications associated with the technique were recorded.

Results

The number of serial debridements, excluding those performed during emergency and final operations, was a mean of 2.28 ± 0.83 in the PAPF group. The PAPF group had a mean bone defect length of 6.76 ± 0.69 cm, the median healing time of 13.11 ± 0.96 months, RUST score 12.68 ± 1.63, and AOFAS score of 84.12 ± 6.38. On the other hand the PTAPF group’s mean bone defect length was 6.73 ± 0.95 cm, the median healing time 12.63 ± 1.46 months, RUST score 13.73 ± 1.53 and AOFAS score 82.79 ± 5.49. There were no observed significant differences the two groups in the number of serial debridements, bone defect length, bone union time, RUST score, or AOFAS score (p > 0.05). Flap size ranged from 9 × 6 cm² to 14 × 7 cm² in the PAPF group and from 9 × 6 cm² to 13 × 7 cm² in the PTAPF group. There were no severe complications such as flap-related complications or amputation. The differences in complications in the two groups were not statistically significant.

Conclusion

In cases of severe open tibial fracture, the reconstructive method is important. When delayed reconstruction is inevitable, surgeons should first perform radical debridement, followed by vacuum sealing drainage as a bridging therapy; both PAPF and PTAPF can be considered for definitive soft tissue coverage.

Zusammenfassung

Ziele

Ziel dieser Studie war es, die Sicherheit und Wirksamkeit der verzögerten Rekonstruktion des Perforator-Pedikel-Propellerlappens nach der induzierten Membrantechnik bei der Behandlung der offenen distalen Tibiafraktur von Gustilo IIIB zu untersuchen. Des Weiteren wurden die klinischen Ergebnisse sowie die Komplikationen von 2 verschiedenen Perforator-Pedikel-Propellerklappen bewertet.

Methoden

Bei der Studie handelt es sich um eine retrospektive Analyse von 34 Patienten mit offenen distalen Tibiafrakturen nach Gustilo IIIB. Die Patienten wurden von Mai 2017 bis März 2022 mit der induzierten Membrantechnik und der verzögerten Rekonstruktion von 2 verschiedenen Perforator-Pedikel-Propellerklappen behandelt. Die Patienten wurden in 2 Gruppen eingeteilt, je nachdem, welche Art von Perforator-Pedikel-Propellerklappen für die Behandlung verwendet wurde. Die Operation umfasste 2 Phasen. 1. Stufe: Der Radiographic Union Score für Tibiafrakturen (RUST) wurde verwendet, um die Heilung des Tibiaknochendefekts zu beurteilen. 2. Stufe: Der Score der American Orthopaedic Foot and Ankle Society (AOFAS) wurde verwendet, um die Knöchelfunktion zu bewerten. Die mit der Technik verbundenen Komplikationen wurden entsprechend erfasst.

Ergebnisse

Die Anzahl der seriellen Debridements, mit Ausnahme derjenigen, die während der Notfall- und Abschlussoperationen durchgeführt wurden, betrug in der PAPF-Gruppe durchschnittlich 2,28 ± 0,83 und in der PTAPF-Gruppe 2,19 ± 0,83. Die PAPF-Gruppe hatte eine durchschnittliche Knochendefektlänge von 6,76 ± 0,69 cm, eine mediane Heilungszeit von 13,11 ± 0,96 Monaten, einen RUST-Score von 12,68 ± 1,63 und einen AOFAS-Score von 84,12 ± 6,38. Bei der PTAPF-Gruppe hingegen betrug die durchschnittliche Knochendefektlänge 6,73 ± 0,95 cm, die mediane Heilungszeit 12,63 ± 1,46 Monate, der RUST-Score 13,73 ± 1,53 und der AOFAS-Score 82,79 ± 5,49. Es wurden keine signifikanten Unterschiede zwischen den beiden Gruppen in Bezug auf die Anzahl der seriellen Débridements, die Länge des Knochendefekts, die Knochenaufbauzeit, den RUST-Score oder den AOFAS-Score beobachtet (p > 0,05). Die Klappengröße reichte von 9 × 6 cm² bis 14 × 7 cm² in der PAPF-Gruppe und von 9 × 6 cm² bis 13 × 7 cm² in der PTAPF-Gruppe. Es traten keine schwerwiegenden Komplikationen wie Lappenkomplikationen oder Amputationen auf. Die Unterschiede bei den Komplikationen in den beiden Gruppen waren statistisch nicht signifikant.

Schlussfolgerung

Die rekonstruktive Methode spielt bei schweren offenen Tibiafrakturen eine sehr wichtige Rolle. In Fällen, in denen eine verzögerte Rekonstruktion unumgänglich ist, sollte der Chirurg zunächst ein radikales Débridement durchführen, gefolgt von einer Vakuum-Drainage als Überbrückungstherapie. Schließlich können PAPF und PTAPF für eine definitive Weichteilabdeckung in Betracht gezogen werden.

Keywords

open fracture - bone defect - induced membrane - flap transplantation - vacuum sealing drainage

Schlüsselwörter

offene Fraktur - Knochendefekt - induzierte Membran - Lappentransplantation - Vakuum-Drainage

Publication History

Received: 19 March 2023

Accepted after revision: 01 August 2023

Article published online:
22 September 2023

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