Microsurgical tissue transfers have become democratic after the 1980s (Wei et al., 2002).
With advances in surgical techniques and instrumentation, the failure rate in free flap has decreased and the importance has shifted from flap survival toward flap refinement. With the development of surgical techonology, surgeon’s concerns for the choice of wound coverage technique arouse controversy between free flap and local propeller flap on tibiofibular area.
However, there are nearly no studies that compare the outcome of local propeller flap and free flap after wound coverage of open tibiofibular fractures in the view point of bony union and rehabilitation of weight bearing and joint motion. There is a correlation between bony union and weight bearing meaning that the returning to regular values of weight bearing generally designate the occurrence of the clinical fracture union (Joslin et al., 2008).
Additionally to the study of outcomes we also endevored to set the indication of choice in wound coverage between local perforator flap and free flap case by case. According to our study, there was no significant difference between the two groups in perspective of total hospital days, rehabilitation of weight bearing and joint motion as well as bony union. This implies that free flap and local propeller flap deduct an almost equivalent consequence. Also, a control of infections was done for two weeks after wound coverage operation, showing the highest peak level in 3 days in the free flap group and in 4 days in the local propeller flap group after operation.
Infection control in flap coverage was applied on cases of osteomyelitis in each group with an appropriate anti-infective therapy which is necessary and sufficient for osteomyelitis treatment under consultation with the infectious disease departement (3 cases in free flap group, 2 cases in local propeller flap group) (Rao et al., 2011). There was a study that well-vascularized ALT free flap was successfully used to combat infection and bring stability to wounds with osteomyelitis (Hong et al., 2005). However in our study, even though there is a limitation due to few cases in each group, every patient with osteomyelitis was covered with free flap or local propeller flap operation without complications and within good infection control in regard to the stabilization of postoperative CRP trends.
Additionally to the results of our study regarding the bony union in both groups, there is a
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comparison with the bony union with another study available (Lee et al., 2012). The study was conducted with ALT free flap patients with open tibiofibular fractures. The mean
The free flap operation with microsurgical technique has its disadvantages due to a long operation time and prolonged ICU days after operation causing a decreasing treatment tolerance of patients even though the free flap can cover a larger size defect than a local perforator flap. This study showed statistical different results between both groups which were enumerated above. There was a great portion of patients in the local perforator flap group with morbidities like tabacco usage, end-stage renal disease and osteomyelitis.
However, the morbidity was not considered in the choice of wound coverage technique.
Especially a renal disease and diabetes can be a strong indicator for a possible reconstructive failure. Another study indicated an 1-year flap survival of 55% for patients with renal disease (Moran et al., 2002). Even though there is a limitation due to a small portion of patients with ESRD and diabetes, flaps with comorbidites and open tibial fractures together survived well in our study which shows a distinction to previous flap studies.
In our study, all flaps in the two groups were designed and elevated as fasciocutaneous flap. However, the controversy remains regarding which flap—muscle flaps or fasciocutaneous flaps—offers the optimal solution for a reconstructing of the lower extremity.
Muscle flaps have been advocated to be more stable than fasciocutaneous flaps because of the ease with which they can be contoured and their ability to be conformed into irregular contours (May et al., 1984, Harris et al., 1994). The muscle flaps were regarded as optimal choice for a soft tissue defect in lower extremity due to its superior vascularity that may promote fracture healing, enhance antibiotic delivery and decrease the incidence of infection (Arnold et al., 1999, Guzman-Stein et al., 1991). Also, more bulky muscle flaps have a superior ability to fill complex defects and dead space but muscle flaps remain pedicle-dependent and, as we all know, have the risk of treatment failure and it may arise after extended periords of time (Arnold et al., 1999). It must be monitored carefully, due to a
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tendency toward ischemia more than in fasciocutaneous flaps (Ulucay et al., 2006).
Instead, fasciocutaneous flaps have the benefit of superior aesthetics and contour and allow easier reexploration in subsequent procedures as they become pedicle-independent through dermal neuroangiogenesis (Yaremchuk et al., 1987). It allows skin flaps easily to be contoured with liposuction (Duffy et al., 2005). In addition, the color and texture of the ALT fasciocutaneous flap is more optimal for lower extremity reconstruction than muscle flaps with skin grafts. Also, fasciocutaneous flap may be a better alternative compared to muscle flap when avoiding donor site morbidity (Nasir et al., 2008). As for trauma patients, who may have other injuries and who need a long road of physical therapy, maximizing preservation of muscles would overall be a better choice (Park et al., 2007).
Also, there is controversy on time of the reconstruction of lower extremity. In a nonrandomized retrospective case series of open Gustilo IIIB fractures that the rate of infection and amputation risk was significantly increased in patients who had an interval of more than 7 days from the time of injury to flap coverage (Hou et al., 2011). However, in our study, all the cases underwent flap coverage after 10 days from trauma date by reasons of prior treatment of accompanying injury, wound preparation, local infection control, and stabilization of the patients’ vital sign. We assume that delayed wound coverage does not increase the infection or amputation risk with proper wound management and patients’ care.
The time of wound coverage should be selected carefully according to patients’ general condition and wound status.
However, there is another study which implies the conclusion that fasciocutaneous and musculocutaneous flap coverages resulting in an equal infection control on wound coverage of open fracture cases (Yazar et al., 2006). In our study, we deduced that fasciocutaneous flaps were a reliable wound coverage technique with controlling the infection of lower extremity which was indicated by CRP. Comparing the inflammation degree with CRP level, which was not attempted in previous studies, a considerable statistical difference was found that the CRP level results of the local propeller flap were lower until the 3rd postoperative than that of the free flap group. This may imply that a small wound size and the short operation time of local propeller flap operation lead to a lower inflammation rate until the 3rd day after operation. We reason out that an adequate choice of local propeller flap for wound coverage in open tibial fracture makes it more tolerable for patients due to a lower
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inflammation rate in the postoperative phase compared to free flap if soft tissue around defect site is safe from the zone of injury. Also, fasciocutaneous flap is reliable and as effective for covering the three-dimensional open tibial fractures as muscle flap and can better endure the subsequent secondary surgical procedures (Yazar et al., 2006).
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