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Staged Reconstruction of Complex Open Tibial Fractures Using Hoffmann External Fixation

1983; Lippincott Williams & Wilkins; Volume: 178; Linguagem: Inglês

10.1097/00003086-198309000-00017

1528-1132

Charles C. Edwards,

Orthopedic Infections and Treatments

Soft tissue survival and freedom from infection are key factors in salvaging a useful leg following open tibial injuries. Both are facilitated by primary rigid fixation. Current external fixators can provide the requisite fracture stability without further disruption of the injured tissues or blood supply about the fracture. From the prospective study of more than 240 open tibiae, the author reports that by using a versatile external fixation system, aggressive serial debridements, and staged reconstruction of soft tissue and then bone, 90% of severely injured Grade III tibiae can be restored to useful function without infection. The goal is to reduce complications, functional deficits, and recovery time. To this end, the author advocates specific frame configurations to match the biomechanical needs of each fracture pattern with flexible frames for compressible fractures and more rigid frames for high-energy unstable fractures, combination transfixion and half-pin techniques to minimize loosening and infection, tibiometatarsal fixation or splints to preserve foot posture, and primary lag screw restoration of articular congruity to maximize ultimate joint function. Late limb loss and excessive recovery time can be reduced by advance planning with emphasis on staged reconstruction and risk-factor avoidance. Accordingly, the author recommends complete debridement of all nonviable muscle and bone prior to wound coverage and then restoration of optimum local physiology for bone healing with myo- or myocutaneous flaps in patients with extensive tissue injury. Subsequent fixator removal and plaster-protected ambulation yield early union for most compressible fractures. However, unstable fractures or those with bone discontinuity require grafting, shortening, and/or fusion techniques with continued external fixation for the most predictable recovery. Despite improved results with these methods, nonunions of certain unstable Grade III tibial fractures remain a dilemma. Neither early conversion to plaster with likely loss of alignment nor risky secondary internal fixation is ideal. Preferable alternatives include early and, often, repeated bone grafting of unstable fractures while they remain stabilized by external fixators and staged frame disassembly or possibly the use of new components to permit gradated axial loading. Perhaps electrical stimulation will also speed conversion of callus fibrocartilage to bone. Further controlled studies are needed to determine which of these methods will most effectively shorten the long reconstructive pathway for the most severe Grade HI tibial injuries.