SLR - November 2021 - Gilberto A. Vila-Arroyo

Radical Treatment of Severe Open Fractures of Extremities by Orthoplastic Surgery: A 10-Year Retrospective Study

Reference: Yang Z, Xu C, Zhu YG, Li J, Wu ZX, Zou JW, Xue BB, Miao DM, Shang L, Zhao GY. Radical Treatment of Severe Open Fractures of Extremities by Orthoplastic Surgery: A 10-year Retrospective Study. J Orthop Surg Res. 2021 May 27;16(1):340. doi: 10.1186/s13018-021-02479-2. PMID: 34044870; PMCID: PMC8157635.

Level of Evidence: III

Scientific Literature Review

Reviewed By: Gilberto A. Vila-Arroyo, DPM
Residency Program: Tower Health Phoenixville Hospital – Phoenixville, PA

Podiatric Relevance: Lower extremity LE open fractures can range from simple to complex. It would behoove the podiatric surgeon to be familiar with novel orthoplastic techniques and their associated benefits/complications in order to better serve their patients. Although this article studies both UE and LE injuries, the vast majority are LE.

Methods: This study aimed to prove that an orthoplastic approach was effective in the treatment of severe open fractures. The authors conducted a retrospective single-center study of 41 patients who presented with severe open fractures (Gustilo-Anderson IIIb or greater) in an upper and/or lower extremity between January 2008 and January 2019 that had undergone radical orthoplastic surgery (debridement, fixation, and soft-tissue reconstruction) to stabilize the fracture and close the wound by 72h. Immediate osseous stability was achieved with temporary internal fixation, external fixation, or a combination. Soft-tissue defect was covered using a vascularized muscle flap (gastrocnemius or soleus) or a free flap from the thigh. Final fixation was implemented later between 7-29w S/P injury (average 13w). Patients were followed for 2y after the end of their clinical course. Data extracted included AO classification, MESS score, stabilization technique, flap type, initial antibiotic timing, infection rate, and time to fracture union.

Results:
1. Total Patients/Accidents=41 (Traffic Accidents=28 (68.3 percent), Blunt Trauma=9 (22.0 percent), Drifting-Down Injuries=3 (7.3 percent) (drifting-down was not defined), Twist Trauma=1 (2.4 percent)

2. Patients with Lower Extremity Fractures=37 (0 patients had both UE and LE fractures): Male=29 (78.4 percent), female=8 (21.6 percent), Average Age=38.4 (8-77), Gustilo-Anderson IIIb=37 (100 percent), MESS <6=9 (24.3 percent), MESS >7=28 (75.7 percent), External Fixation=10 (27.0 percent), Internal Fixation=3 (8.1 percent), Combination=24 (64.9 percent), Thigh Free Flap=15 (40.6 percent), Gastrocnemius Flap=10 (27.0 percent), Soleus Flap=12 (32.4 percent), Average Initial Antibiotic Timing=14.5h (3-30), Infected Fractures=5 (13.5 percent), Amputation=1 (2.7 percent), Average Fracture Union Time=34.6w (12-84).

Conclusions: The authors define the orthoplastic technique as aggressively achieving soft-tissue coverage and osseous stability almost immediately. They attempt to prove its superiority when compared to the traditional orthopedic technique, which they define as focusing on fracture stabilization while wound closure is delayed until after 72h. A great quality about this article is that it provides substantial information about each patient. It also showcases orthoplastics well. However, they unfortunately didn’t perform a direct comparison to the orthopedic approach. Additionally, the data, though plenty, is not well organized. Methodology-wise, it is beneficial that they did concentrate on severe open fractures since they’re the most difficult to treat. In the results, they focused on infection rates and found a rate of 14.6 percent (13.5 percent in LEs). They state it’s comparable to other orthoplastic studies, specifically citing Gopal with a rate of 15.9 percentand also citing a prospective multicenter cohort study with a rate of 14.5 percent. However, they don’t directly cite any papers demonstrating the infection rate of the orthopedic approach, which would’ve been beneficial to better assess if the orthoplastic is truly superior. Overall, this article is interesting for those currently diving into orthoplastics, but should not be utilized to solidify its position over the orthopedic approach until a control group has been studied as well.

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