Single-Stage "Fix-and-Flap" Orthoplastic Repair of Severe Open Tibial Fractures Leads to Improved Clinical Outcomes: A Systematic Review
Taylor I. Harris
UMass Chan School of Medicine, Worcester, MA
Background: Gustilo-Anderson grade III tibial fractures are exquisitely difficult to manage as they require extensive soft tissue repair in addition to fracture fixation. These injuries are best managed collaboratively by Orthopedic and Plastic surgeons. While this “Orthoplastics” approach has decreased the rates of adverse outcomes in these injuries, there is much variation in the Orthoplastic methodology. It has been recommended that definitive bone fixation and soft tissue coverage be completed simultaneously in a single-stage, but there is a paucity of large scale studies providing evidence to support this recommendation. This study aims to report the outcomes of a single-stage "fix-and-flap" approach through a systematic review of the available literature.
Methods: Systematic review of the literature was performed. Medline and Google Scholar were used and all English language studies published since 2000 were included. 103 studies were initially evaluated for inclusion. Reference lists of included studies were also examined for eligible studies. Gustilo grade III tibial shaft fractures in adults that were managed with a single-stage Orthoplastics approach were identified and evaluated with regard to outcomes of interest. Exclusion criteria included studies with patients <16 years old, case studies, and systematic reviews. Primary outcomes of interest included rates of deep infection and limb salvage. Secondary outcomes of interest included rates of non-union and re-operation, and time to bone union.
Results: 15 studies were eligible. 11 of these studies reported rates of deep infection as an outcome, with rates ranging from 0.98%-20%. The pooled rate between studies was 7.34%. Seven studies reported rates of limb salvage with a range of 96.25%-100%, with a pooled rate of 97.8%. Six reported rates of non-union with a range of 0%-14%, with a pooled rate of 6.6%. Six reported time to bone union with a range of 24-40.3 weeks and pooled average time of 34.2 weeks. Four reported rates of reoperation ranging from 7%-55%, with a pooled rate of 31.1%. Studies that compared a single-stage to a multi-stage approach side-by-side unanimously favored the single-stage approach.
Conclusions: Outcomes of Gustilo grade III open tibial fractures utilizing an Orthoplastics approach that is specifically done in a single-stage produce markedly reduced rates of adverse outcomes. Therefore, not only should Orthopedic surgeons and Plastic surgeons collaborate in the management of severe open tibial fractures, but evidence shows definitive fixation and coverage should be done in a single-stage for improved outcomes.
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