BACKGROUND: Since 1976, treatment of open tibia fractures has concentrated on definitive closure of these wounds within 7 days as outlined by Gustilos’s landmark article. We hypothesized that technological advances in wound care, may have rendered the “Soft-tissue coverage of open fractures in the first week” model obsolete.

METHODS: An IRB approved, retrospective review of the open tibia fractures treated at this facility from Jan 1997-July 2007 was performed. We surveyed the Rhode Island Hospital Trauma Registry Database for open fractures of the tibia, knee, and ankle. Inclusion was limited to males and non-pregnant females 18 years of age and older. Data of interest included injury mechanism and site, size of soft-tissue defect, type of bony fixation, type and timing of soft-tissue coverage, number of procedures, use of the VAC or antibitic-bead pouches, time to closure and length of hospital stay. Other points of of interest included complications such as infection, seroma, hematoma, nonunion, and need for revision procedures of soft-tissue or bony fixation. The keys outcomes studied were rate of limb salvage and rates of major complications.

RESULTS: One-hundred and sixty patients were identified, but 44 patients with incomplete data and 11 patients who expired from associated trauma were excluded. In total, 105 patients were included in the study with a male:female ratio 2.2:1, and a mean age of 46 yrs. Fifty-eight percent of fractures were to the operators of motor vehicles, while 21% were in pedestrians struck by them. Falls accounted for 16% of fractures. These injuries were graded as Gustillo IIIA-IIIB fractures in 101 patients, and 4 patients with vascular injuries corresponding with Gustilo IIIC fractures. Fasciotomy was required in 87% of our patients: evidence of the severity of the injury patterns studied. Minor complications included infection (19% of patients, most commonly seen in external fixation pin tracts), exposed hardware (1.9%), and nonunion (8.6%). Major complications included death (6.9%) and amputation (early 1%, late 10.5%) wound dehiscence (3.8%), compartment syndrome (2%), flap loss (1 complete, 2 partial: requiring minor debridement). Average time to amputation (excluding outliers) was 15 days. Fourteen patients received pedicled muscle flaps, whereas 6 required microvascular free flap (MVFF). The pedicled flaps consisted of medial gastrocnemius, sural, reversed sural, soleus, and fasciocutneous flaps. Free flaps used were gracilis, rectus abdominis, and latissimus dorsi. Though the rate of major and minor complications were high, they are comparable to those previously reported.

CONCLUSIONS: Since Gustillo’s initial description of these injuries, surgeons’ experience, advances in local wound care (VAC), and local drug delivery systems (antibiotic impregnated beads) have extended the window for coverage of these wounds beyond 1 week. In many cases, these advances have obviated the need for microvascular free tissue transfer. However early soft-tissue coverage of severe IIIB-IIIC fractures clearly plays a role despite the recent technical advances in wound care.