An Analysis of Fasciocutaneous Flaps at various stages of cover of Open Tibial Fractures

INTRODUCTION: Coverage of open tibial fractures presents unique defects requiring the ingenuity of the surgeon in devising flaps for stable coverage. In our country road traffic accidents are the most common cause of lower limb trauma, followed by fall from height. Though well established norms are in place regarding the time and nature of cover, it requires a team effort with involvement of the orthopaedic surgeon as a rule, and allied specialities like vascular surgeons, general surgeons. Despite stable fixation being obtained earlier, the timing of soft tissue cover varies owing to several factors like availability of reconstruction team, doubtful vascularity, skill of the attending surgeon, concomittant injuries to the lower limb, comorbid factors, prolonged anaesthesia time etc. Though Free tissue transfer has revolutionised coverage of leg defects it may not be feasible to have the personnel with the necessary skill at that time. Fasciocutaneous flaps and Muscle flaps still have well established roles to play in extremity reconstruction. Plastic surgery becomes not only important in covering a raw area, but also in providing a functional limb with an acceptable aesthetic result. AIM: 1. To analyze fasciocutaneous flap reliability in coverage of open tibial fractures. 2. To analyze the complication rates of fasciocutaneous flaps at various phases of wound; Acute, subacute and chronic. 3. To compare the complication rates and ultimate wound coverage rates of fasciocutaneous flaps with free flaps from other series. 4. To compare proximally versus distally based fasciocutaneous flaps complication rates. 5. To establish a definitive time based protocol for fasciocutaneous flaps at Government General Hospital for open tibial fractures. MATERIALS AND METHODS: This study was conducted in the Department of Plastic Surgery, Government General Hospital and Madras Medical College over a period of 30 months Aug 2004 to Jan 2007. Only cases with post-traumatic open tibial fractures were included. Only patients with fasciocutaneous flap covers were chosen .A total of 74 patients were included in the study. Timing of coverage was classified into Acute - within 72 hours, Subacute - 3 days to 6 weeks, Chronic - Greater than 6 weeks. All patients were assessed with a thorough history, clinical examination, type of orthopaedic intervention and co-morbid illnesses. All patients, in addition to routine investigations were submitted to X-ray of the local part and Doppler examination of the peripheral pulses and perforators. In infected cases, seen late, they were already on appropriate antibiotics after culture and sensitivity. In Acute situations where immediate cover was done, the wound was debrided by the Plastic surgeon prior to skeletal fixation. In other cases wounds were debrided initially by the orthopaedic team and again during the cover by the plastic surgeons. Defects were classified according to their site as per the usual norms of upperthird, midthird and lower third. All patients were retained in the plastic surgical ward till the flap had healed completely. Follow up periods varied with the individual's compliance. RESULTS: A total number of 74 patients were included in the study over a period of 30 months between August 2004 to Janurary 2007. There was a noticeable difference in the number of cases in the last year owing to a higher number of muscle flaps being done for upper 1/3 leg defects as part of a change in department protocol. Though this was for a series of fasciocutaneous flaps only, it reflected the overall incidence of traumatic leg defects in general, with the adult male population being the most at risk 78%. The etiological indications for fasciocutaneous flap cover in this study showed Road traffic incidents to be the most common cause at 84%. Thus fasciocutaneous flaps in this study were most commonly used for middle third leg defects 48%, followed by lower third 34% and upper third 18%. This fact co-relates well with the fact mentioned in table 1 that the overall incidence of usage of fasciocutaneous flaps for upper third defects has decreased at Government General Hospital. In this series maximum number of fasciocutaneous flaps were done in the subacute phase - 41% and the least in the acute phase 27%. Inferiorly based fasciocutaneous flaps were the most commonly used in this study accounting for 56% of all flaps and, dual superiorly and inferiorly based flaps were the least commonly needed. Complications were greatest in the subacute phase - 28% of all cases with the chronic cases surprisingly mirroring the early phase in contradistinction to other studies, perhaps owing to adequate preparation with repeat debridements, sequesttrectomies, antibiotic cover and wound homeostasis in the interim period with adequate skeletal stabilisation. CONCLUSION: 1. Fasciocutaneous flaps are reliable, safe, fast to learn flaps for leg defects. 2. Males continue to be at high risk for compound tibial fractures particularly from Road traffic accidents. Stricter road safety protocols, safer roads, strict licensing could perhaps decrease the incidence of open tibial fractures. 3. Fasciocutaneous flaps have shown a decrease in their use for upper third defects, but continue to be a bulwark for the middle third defects. 4. Though muscle flaps have taken priority in upper third defects, fasiocutaneous flaps were very useful still in lower third defects as free tissue transfer was not done in our hospital during the period of the study. 5. Most cases in this study were operated on in the subacute phase which had the highest complication rates also indicating the need for early referral by the orthopaedician, a combined team approach, and involvement of the plastic surgeon in the planning of the case from the trauma ward itself. 6. The fact that there was no difference between free flaps and fasciocutaneous flaps in terms of flap loss in the early and chronic phases indicate that the fascioutaneous flaps can be safely done in the emergency sitting, where facilities for microsurgical transfer are not available, with the added advantage of decreased operating time. No necessity for two teams and no alterations in the haematological parameters. 7. Successful wound coverage results were the same as for free tissue transfer in other studies. 8. Flap coverage is best done within 72 hours of injury