The Gustilo classification was first published in 19761 and was later modified in 1984.2 It describes three types of open tibial fractures: I, II, and III. The latter is further divided into types a, b, and c, depending on associated soft tissue damage. It is generally accepted that an accurate assessment of the fracture in relation to the Gustilo classification can only be performed intraoperatively. Plastic surgical input is required to reconstruct most IIIb and IIIc fractures as in this case. The usual standard of care for open tibial fractures is early operative debridement with a team comprising a senior orthopaedic surgeon and a senior plastic surgeon. The aim of this early intervention is to debride the limb and make a joint formal assessment of the bony and soft tissue injuries such that a suitable plan for stabilization and soft tissue cover can be made. Where possible this will be performed at the same time, but if more complex intervention is required the wound can be temporized with negative pressure and a temporary external fixation device or external splintage.
2. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classi- fication of type III open fractures. J Trauma 1984;24(8): 742–746 Measured wound size is the key discriminator between type I and II injuries. The degree of wound contamination and the presence of a vascular injury are considered in type III injuries. The location of soft tissue injury and the degree of comminution are not specifically considered in this classification. The description of types I through IIIc are as follows: Type I: An open fracture with a clean laceration less than 1 cm long Type II: An open fracture with a clean laceration greater than 1 cm long without extensive soft tissue injury, flaps, or avulsions Type IIIa: Open fractures with extensive soft tissue damage, involving muscle, skin, and neurovascular structures, but with adequate soft tissue coverage Type IIIb: As above, except a more extensive injury with periosteal stripping, exposed bone, and/or massive contamination Type IIIc: Similar to a type IIIb injury with an additional arterial injury that requires repair In-depth knowledge of this classification is useful for everyday practice and for clinical exams as it is often tested in both written and viva examinations.1–3
3. Byrd HS, Spicer TE, Cierney G III. Management of open tibial fractures. Plast Reconstr Surg 1985;76(5):719–730 The Byrd1 classification is primarily based on the energy level of injury, ranging from low through moderate to high. It also differs from the Gustilo classification2,3 in that the fracture pattern and mechanism of injury are considered for some of the gradings. For example, whether the fracture is displaced, comminuted, or a simple oblique or spiral pattern is considered. Similarity between the two systems is that the degree of the soft tissue injury, including defect size and vascular injury, is considered in both classifications. Chronicity is not specifically considered in either classification, as it is assumed that all are acute injuries as follows: Type I: Low-energy forces causing a spiral or oblique fracture pattern with a skin laceration less than 2 cm and a relatively clean wound. Type II: Moderate-energy forces causing a comminuted or displaced fracture pattern with a skin laceration greater than 2 cm and moderate adjacent skin and muscle contusion, but without devitalized muscle. Type III: High-energy forces causing a significantly displaced fracture pattern with severe comminution, segmental fracture, or bone defect with extensive associated skin loss and devitalized muscle. Type IV: Fracture pattern as in type III but with extreme energy forces as in high-velocity gunshot or shotgun wounds, a history of degloving, or associated vascular injury requiring repair.
In 1983 Keller1 reviewed 10,000 tibial shaft fractures. In this review, neither fracture location or concomitant fibular fracture showed prognostic significance. Complications did increase in the presence of comminution, displacement, bone loss, distraction, soft tissue injury, infection, and polytrauma. For this reason, management of open tibial fractures has become more formalized in recent years in order to prioritize their early management with an orthoplastic approach. If the bone and soft tissue injury is managed optimally, this should reduce the chances of infection and other complications such as nonunion and chronic wounds. It stands to reason that the greater the energy of the injury involved, the greater the tissue damage and increased risk of complications. Low-energy injuries even when open tend to have reasonable outcomes with only modest intervention unless the host has significant other comorbidities.1–5
5. Wordsworth M, Lawton G, Nathwani D, et al. Improving the care of patients with severe open fractures of the tibia: the effect of the introduction of Major Trauma Networks and national guidelines. Bone Joint J 2016;98-B(3):420–424 Each of the above factors is highly relevant to the acute management of lower limb open tibial fractures. In general, the wound is washed and fully assessed in the OR with joint orthopaedic and plastic surgical teams present; then bony stabilization is performed in order to provide a stable base for further management. This often entails application of an external fixation device. The bone ends must, of course, be debrided fully before reduction. Vascular inflow must be established early to ensure distal limb perfusion. Thorough debridement of soft tissues must be performed with removal of any devitalized tissue and fasciotomies undertaken as required. Recent evidence has shown that the most important factor affecting outcome after an open tibial fracture is a thorough debridement of devitalized tissues. This is because it optimizes healing and minimizes infection risk. Recent advances in both civilian and military experience indicate that an aggressive washout protocol, temporary fracture stabilization, and application of a negative pressure dressing can also buy some time before formal reconstruction is performed.1,2
Based on current evidence, definitive free tissue cover for open tibial fractures should ideally be performed within the first week. Many authorities now prefer to achieve a so-called “fix and flap” approach within 48 hours. Timing will, of course, be affected by factors such as the nature of the injury, the presence of infection, degree of contamination, and bone loss. It will also be affected by other injuries and the general condition of the patient. For example, when patients have other life-threatening injuries and are in the intensive care unit (ICU), it will generally be preferable to delay free tissue transfer until they are more stable. Evidence presented by Byrd1 in the 1980s supported early debridement and soft tissue cover within the first 5–6 days. The authors found that this approach resulted in fewest complications and the shortest length of hospital admission. Godina2 found that patients who had debridement and free flap cover within 3 days had very low flap failure rates (less than 1%) and postoperative infection rates (1.5%). They found that patients who received their flaps between 3 days and 3 months had an increased flap failure rate (12%) and infection rate (17.5%). It should be noted that this is a relatively wide timeframe as it crosses both the acute, subacute, and chronic biologic phases involved in open fracture wounds. Patients who received flaps beyond 3 months had complication rates that fell somewhere between those managed in the early and intermediate phases. Yaremchuk et al3 had infection rates of 14% in a cohort of patients who received flap coverage at a mean of 17 days. Recent military and civilian experiences suggest that soft tissue cover can be safely delayed for a few days providing that adequate debridement has been performed and the wound temporized with a negative pressure wound therapy (NPWT) device.4,5 Some of the military data relates to injuries sustained with improvised explosive devices that alter the timeframe because of the requirement for multiple debridement procedures.5 In the UK, guidelines have been published jointly by the British orthopaedic and plastic surgery associations based on current available evidence.6 They suggest that most open tibial fractures are initially debrided, stabilized, and scheduled for surgery within 24 hours with both senior plastic surgeons and orthopaedic surgeons present. Exceptions are those with vascular compromise or severe contamination, as these need immediate management. The guidelines also suggest that soft tissue free flap cover should ideally be performed within the first week, in part to ensure that the flap recipient vessels are still in a healthy condition.
The tibia has three types of blood supply: periosteal, metaphyseal, and nutrient artery supply. The periosteal circulation derives from the primary limb vessels (not the metaphyseal artery) to supply the outer third of the cortex. The endosteal circulation derives from the nutrient artery and supplies the inner two-thirds (not one-third) of the cortex. When a long bone is fractured, the distal blood supply is usually preserved because of the structure of the periosteal circulation in which the vessels are oriented transversely.1,2
Exploration in the operating room (OR) shows a segment of nonviable tibia measuring 8 cm, which is removed. Distraction osteogenesis was pioneered by Ilizarov and this is typically indicated in segmental long bone gaps of up to 12 cm. It involves placement of an external distraction device with a corticotomy performed outside the zone of injury. Bone distraction is slow (1 mm per day, not 3 mm), so this method does take an extended time to achieve required bone length but probably represents the benchmark for long segmental defects of the tibia. The amount of bone generated is anatomically correct for the size of the defect and soft tissues can be closed by the docking method during the same process. Intraoperative blood loss is low so transfusion is not generally required. Distraction begins a week after device application. In cases like this scenario where there is segmental bone loss and soft tissue loss, it is appropriate to achieve wound closure with a free tissue transfer such as a latissimus dorsi or anterolateral thigh flap in the subacute setting. Temporary fracture stabilization can be achieved with a simple external frame. Once the soft tissues have healed (2–3 weeks), the external frame can be exchanged for a circular frame. The benefit of such fixation is that weight bearing can begin, so general mobility is improved and where bone ends are together, healing is accelerated. Nonvascularized bone is traditionally used for reconstructing smaller defects but some authors state that they can be used beneath vascularized muscle flaps for defects of up to 10 cm.1 Free osseous flaps such as fibula, scapula, and iliac crest may reliably be used to reconstruct segmental bone gaps. Fibula flaps can be harvested at lengths of up to 20 cm in adult patients, if required. The use of free tissue flaps is generally indicated for segmental gaps larger than 6 cm. Free flaps are still less favorable than bone transport for segmental tibial defect reconstruction because of the difference in bone shape and quality compared with the native tibia. Their role in upper limb segmental defect reconstruction (e.g., humerus) is probably more significant.
running. The flexor hallucis longus flap can be used to reconstruct middle third soft tissue defects. However, this muscle is important in push off for the great toe; therefore, it should not be sacrificed in physically active patients. With the current focus on the availability of surgeons skilled in free tissue transfer, local flap reconstruction in the lower limb is less commonly used, particularly for higher energy injuries. However, there remain some robust flaps that are particularly useful such as the gastrocnemius for mid and upper third defects. The extensor digitorum longus flap is supplied by the anterior tibial vessels (not the peroneal vessels) and can be used to close small wounds of the middle third. It is important to preserve the peroneal nerve during dissection of this flap. If the entire muscle is harvested, then permanent loss of toe extension will occur. A flexor digitorum longus flap can be used for small defects of the lower portion of the middle third, without significant functional loss. The medial head of gastrocnemius is preferentially chosen over the lateral head for reconstruction purposes, as it is larger and not because the functional outcome differs between the two. A proximally based soleus flap can be reliably used to cover the middle third anterior leg defects without causing a functional deficit, particularly if it is harvested as a hemisoleus.1–5
This wound should be amenable to skin grafting with or without partial closure, because the wound bed is healthy and vascularized. Although it might be tempting to try and close the wound directly if tissue laxity appears to be adequate, this can be risky because of the underlying fracture and anticipated swelling. Direct closure would not be an option due to soft tissue loss and free tissue transfer would be unnecessary.1,2
This wound is best covered with a medial gastrocnemius local flap and split-thickness skin graft (STSG). This is preferable to a lateral gastrocnemius because of its greater size and reach. The medial gastrocnemius muscle flap has become a real workhorse flap for this sort of case. It has a reliable blood supply based on the medial sural artery and venae comitantes. It is quick to raise and has good reach to the anterior knee over the patella. Raising this flap is often best performed using a separate incision running longitudinally on the medial aspect of the leg relatively close to the midline or just medial to it. This allows a clear view of the muscle and the midline raphe such that it can be separated from the lateral gastrocnemius while causing minimal damage to the Achilles tendon. The muscle can then be passed underneath a skin bridge to the defect site. If more reach is required, additional measures include proximal release or scoring of the under-surface of the muscle. The flap harvest incision can be closed directly and the muscle covered with split-skin graft. Free tissue transfer is not generally required in such cases unless local flap options have failed, where the defect includes the proximal patella or above, or in areas where there has been previous radiotherapy.1–3
This defect can be covered with a range of different free flaps or with a local fasciocutaneous propeller flap. However, because of its small size and the logistics of harvesting a gracilis versus a latissimus dorsi flap, a gracilis free flap is a better option in this case. Other popular alternatives include fasciocutaneous flaps such as the anterolateral thigh (ALT), scapula, groin, or lateral arm flaps. The benefit of such flaps is avoidance of a skin graft. There are no local options that will so reliably reconstruct this defect, aside perhaps from a dorsalis pedis or extensor digitorum brevis flap, which are not mentioned as options in this scenario. The medial gastrocnemius is useful as a local flap for proximal third tibial defects or after complications of total knee replacement (TKR). A variant of this vascular supply that may be useful for a defect of this size is a medial sural artery perforator (MSAP) flap which can be harvested on one or two perforators without sacrifice of the gastrocnemius muscle. The proximally based soleus is another potential option for proximal third defects and can also be used in the middle third. However, it would not be able to cover this defect. Split graft alone is only useful in distal third leg injuries where there is healthy muscle at the wound base.1–3
A gastrocnemius flap is a very good source for soft tissue coverage in mid to upper anterior tibial defects after trauma or tumor resection. It is particularly useful for reconstruction of anterior knee defects with an exposed knee prosthesis. The gastrocnemius muscle has two heads (medial and lateral); the medial is the larger and is most commonly employed for reconstructions. It receives its blood supply from the medial sural artery, which arises from the popliteal artery. When a medial gastrocnemius flap is raised, an incision is typically made on the medial aspect of the leg, 2 cm posterior to the tibia at midcalf level, and is continued proximally to the popliteal fossa. During this part of the dissection, care is required to prevent injury to the long saphenous vein and saphenous nerve. The fascia and overlying skin are then elevated off the medial gastrocnemius to the midline, where the medial and lateral heads meet. During this part of the dissection, the sural nerve and small saphenous vein are identified and preserved. The medial raphe between the medial and lateral heads should be divided, and the plane is developed down to soleus muscle. Within this plane, the plantaris tendon is identified. Next, the distal tendon is transected so that the flap can be raised from distal to proximal. Visualization of the sural artery pedicle is not usually required for coverage of a lower defect, as in this case. Where the arc of rotation is greater than 100 degrees, it can be useful to continue the dissection proximally and identify the medial sural artery pedicle and medial sural motor nerve supplying the flap. The nerve can also be transected to stop subsequent muscle contractions. The proximal gastrocnemius attachment or hamstring tendons can also be divided to improve flap reach, although this is not usually required in most cases.1 The proximally based (not distally based) soleus flap is a reasonable alternative and can be carried to a point 5 cm above its tendinous insertion. The bipedicled tibialis anterior flap is more suitable for middle third coverage. The reverse sural artery flap is used for the distal third.
Sensation to the medial calf is preserved in compartment syndrome because this area is supplied by the saphenous nerve that is located outside the compartments of the lower leg. Compartment syndrome is a condition where the intracompartmental pressure exceeds perfusion pressure, leading to ischemia and subsequent necrosis of the muscle compartments. It occurs in approximately 1 in 10 tibial fractures and must be recognized and treated early in order to avoid irreversible tissue damage. It can occur with both open and closed injuries and the fact that a fracture can breach a given compartment does not mean that the compartment is adequately decompressed. The main signs of compartment syndrome are the six p’s: pain (out of proportion to the injury and with passive stretch), pressure from swollen compartments, paresthesia of the involved compartment, paralysis or decreased strength of the involved compartment, pallor, and pulselessness as a result of vascular compromise. Loss of distal pulses is a late sign of compartment syndrome and is more likely because of vascular injury. To supplement clinical examination, intracompartmental pressures can be measured using devices specifically made for this purpose. A difference of 30 mm Hg or less between the measured pressure and diastolic pressure is considered a justification for decompression. When decompression is performed, a number of approaches are available. One example is to use combined medial and lateral approaches where longitudinal incisions are made 1–2 cm medial and 1–2 cm lateral to the tibial borders overlying the soft tissue compartments. This facilitates decompression of all four (not three) compartments: anterior, lateral, superficial posterior, and deep posterior. This also preserves the medial perforating vessels in case a local fasciocutaneous flap is required.1,2
The most common pathogen in osteomyelitis is S. aureus. Prophylactic use of antibiotics can significantly reduce the infection rate in lower limb trauma wounds, but a single dose is not sufficient. Thorough debridement and removal of all devitalized tissue are required, but small viable bone fragments can remain in situ. Negative pressure dressings are appropriate for patients with debrided osteomyelitic wounds in conjunction with antibiotic therapy.1
ulcer? The clinical description above suggests a diagnosis of venous ulcer. These tend to be located in the gaiter region between the malleoli and the gastrocnemius myotendinous junction, sometimes termed “boot strap distribution.” The other findings include chronic edema, varicosities, lipodermatosclerosis, and a history of deep vein thrombosis. Either incision or excision biopsy is indicated in suspected skin cancers such as a Marjolin’s ulcer arising in a chronic wound. Referral to the vascular team may be warranted in patients with a suspected arterial ulcer. These present as punched-out, painful ulcers with a history of claudication and absent pulses. Hyperbaric oxygen therapy may be indicated in radiation ulcers before surgical resection and soft tissue cover. It is not indicated in venous ulcers and neither is negative pressure wound therapy.1,2