Surgical Flaps For Repairing Tibia Traumatic Osteomyelitis Complicated With Soft Tissue Defect

Objective:The purpose of this study is to examine our experience with using 9 sorts of flaps to repair tibial posttraumatic osteomyelitis complicated with skin and soft tissue defect. To investigate each sort of flap's characteristic and the favorable options of repair different wounds.Method:From August 2000 to March 2010,181 cases of tibia traumatic osteomyelitis complicated with soft tissue-skin defect were treated with flaps restoration. The clinical information has been retrospect and analysis. Flaps of all cases were performed based on radical debridement and antibiotic therapy. We extended the anterior border of modification of gastrocnemius myocutaneous flaps to crista anterior tibiae, and set defects'border as flap's anterior border. There were 20 modified and 26 no-modified of medial gastrocnemius myocutaneous flaps in 46 cases; 13 modified and 11 no-modified of lateral gastrocnemius myocutaneous flaps in 24 cases; The site of 70 defects comprised 61 mid-upper tibia and 9mid-inferior tibia; the size of the flap ranged from 18.0 cm×7.0 cm to 35.0 cm×12.0 cm.23 cases did distally based sural neurofasciocutaneous flaps transferring; the wounds located at the mid and inferior tibia in 2 cases, and the inferior tibia in 21 cases.11 cases were the posterior tibial artery island flaps, including 8 cross-leg cases; the wounds located at the mid and inferior tibia; the size of the flap ranged from 18.0 cm×8.0 cm to 22.0 cm×13.0 cm.26 posterior tibial artery perforator-based flap, the site of defects comprised 1 upper tibia and 25 mid-inferior tibia.21 free flaps, The dimension of flap ranged from 19.0 cm×7.0 cm to 22.0 cm×16.0 cm. Other cases including 14 bi-pedicled fasciocutaneous flaps,2 sapheneous artery flaps, 2 anterolateral island flaps of the lower leg, and 12 local fasciocutaneous flaps.Result:Among the 23 distally based sural neurofasciocutaneous flaps,21 cases complete survived; 1 distal superficial necrosis,1 distal partial necrosis and 1 recurrent.17 survived in the 20 modified medial gastrocnemius myocutaneous flaps; 3 partial necrosis and 1 recurrent. In 26 no-modified medial gastrocnemius myocutaneous flaps,22 survived completely; 4 partial necrosis and 1 recurrent.11 survived in the 13 modified lateral gastrocnemius myocutaneous flaps; 2 partial necrosis and 1 recurrent. In 11 no-modified medial gastrocnemius myocutaneous flaps, 9 survived completely; 2 partial necrosis and 1 recurrent. There are 10 complete survived and 1 superficial necrosis in 11 cases of posterior tibial artery reversed island flaps; 24 complete survived,2 superficial necrosis and 2 recurrent in 26 cases of posterior tibial artery perforator-based flaps; 18 complete survived,1 superficial necrosis,2 partial necrosis and 1 recurrent in 21 cases of free flaps; 13 complete survived,1 distal partial necrosis and 2 recurrent in 14 cases of bi-pedicled fasciocutaneous flaps; 2 sapheneous artery flaps,2 anterolateral island flaps of the lower leg and local fasciocutaneous flaps totally survived. All cases of distal partial necrosis was healed after skin-grafting or the second stage flaps restoration. The raw surface had been curing and the infection been controlled of all patients when they discharge; during time in hospital range from 12 to 127days (mean,39 days). After operation, all patients were followed up for 1 to 72 months (mean,13 months). Osteomyelitis recurred 1-24 months after operation in 10 cases (5.5%) and healed by nidus clearing. Free flaps'average area were larger than pedicled fasciocutaneous flaps (P<0.05). Compare the mean of area in lateral gastrocnemius myocutaneous flaps, the modified group was larger than the no-modified group(P<0.05). As the effect of infection control, internal fixation unload group was better than reservation group (P<0.05).Conclusion:(1) The improved gastrocnemius myocutaneous flap enlarge the circumscription of donor-site of gastrocnemius myocutaneous flap, so as to extend its indication; This flap is a feasible option for reconstructions of mid and upper tibial posttraumatic osteomyelitis. (2)Because of large areas and suffice tissues, free flaps has been shown to be a reliable and predictable tool in tibial posttraumatic osteomyelitis complicated with large soft tissue defect reconstruction. (3) The posterior tibial artery reverse island flap, distally based sural neurofasciocutaneous flap and posterior tibial artery perforator-based flap were versatile, reliable procedure, useful in reconstruction of lower third leg defects, especially for middling size defect. (4) The surgical flap technique is safe, of short duration and reliable therapy effect in the management of post-traumatic osteomyelitis. (5) Unload internal fixation have a beneficial effect in infection control of osteomyelitis.