Comparison of delayed soft tissue coverage between anterolateral thigh free flap and local propeller flap on traumatic open tibial fracture Gustilo-Anderson grade IIIb

Comparison of delayed soft tissue coverage between

anterolateral thigh free flap and local propeller flap

on traumatic open tibial fracture Gustilo-Anderson

grade IIIb

by

Young Hoo Joh

Major in Medicine

Department of Medical Sciences

The Graduate School, Ajou University

Comparison of delayed soft tissue coverage between

anterolateral thigh free flap and local propeller flap

on traumatic open tibial fracture Gustilo-Anderson

grade IIIb

by

Young Hoo Joh

A Dissertation Submitted to The Graduate School of

Ajou University in Partial Fulfillment of The

Requirements for The Degree of Master of Medicine

Supervised by

Il Jae Lee, M.D., Ph.D.

Major in Medicine

Department of Medical Sciences

The Graduate School, Ajou University

This certifies that the dissertation

Of Young Hoo Joh is approved.

SUPERVISORY COMMITTEE

Il Jae Lee

Seung Hyun Yoon

Han Bum Joe

The Graduate School, Ajou University

December, 19

, 2014

i - ABSTRACT-

Comparison of delayed soft tissue coverage between anterolateral

thigh free flap and local propeller flap on traumatic open tibial

fracture Gustilo-Anderson grade IIIb

A reconstruction surgery is frequently needed in a lower limb trauma. It is a contentious issue which type of transfer technique and tissue should be used for wound coverage in lower limb, especially in tibial area. In this study, we tried to compare the utility of delayed reconstruction between free flaps and local propeller flaps for Gustilo type IIIB open tibial fractures with needed soft tissue coverage.

Patients were selected between February 2011 and June 2013.A total of 35 patients (32 males and 3 females) with traumatic open tibial fractures underwent reconstruction surgery and were retrospectively analyzed to compare anterolateral thigh free flap (17 males and 2 females) and local propeller flap (15 males and 1 female). In these series, all cases were treated by a delayed reconstruction because of the patients’ life threatening trauma and accompanying diseases. According to patients’ chart, the etiology and results were reviewed and statistically verified to find out a significant conclusion for both groups.

In t-test and rank sum test, there were significant statistical meanings in defect size, operation time, and ICU days after operation between two groups. Also, there was a meaningful statistical result that the inflammation marker was less elevated through 3 days after operation in the local propeller group than in the free flap group.

From this point of view, local propeller flap is useful method of reconstruction for patients with an open tibia fracture Gustilo type IIIb with a small size of defect in the mid-proximal tibia area and with an underlying medical disease who are vulnerable to a long operation time and inflammation after operation. It is possible to assume that an operation with local propeller flaps may be better tolerable for patients with medical comorbidities including tobacco usage, diabetes mellitus, hypertension, end stage renal disease and so on.

ii

Key words :Free Tissue Flaps; Perforater Flap; Fractures, Open/surgery; Tibial Fractures/surgery; Reconstructive Surgical Procedures/methods

iii

TABLE

OF

CONTENTS

ABSTRACT i

TABLE OF CONTENTS iii

LIST OF FIGURES iv

LIST OF TABLES v

I. INTRODUCTION 1

II. MATERIALS AND METHODS 2

III.RESULTS 4

IV.DISCUSSION 14

V.CONCLUSION 18

REFERENCES 19

iv

LIST

OF

FIGURES

v

LIST

OF

TABLES

Table 1

The results of comparisons between free flap and local propeller flap.7 Table 2

Coexisting condition and underlying disease of free flap and local propeller flap.8 Table3

Comparisons of complement reactive protein (CRP) between free flap and local propeller flap. 9

Table4

Summary data of ALT free flap group.10 Table5

１

I.

I

In these days, high energy and complex injuries are prevalent associated with extensive defects in soft tissue requiring reconstruction (Lee et al., 2012). It is of big concern for a plastic surgeon to select the wound coverage technique for the salvage of the lower limb. Local fascia or muscle flap is the preferable selection in soft tissue defect on thigh when gastrocnemius flap is preferable for the knee area, whereas free flap is the superior choice on foot reconstruction (Hallock et al., 2013). Though, there is controversy on reconstruction of tibial area according to the defect site (Hallock et al., 2013). Usually early coverage gives a better result but in special situation, for example, (1)accompanying severe trauma, (2)unstable vital sign, (3)cases which were transferred from another hospital, (4)failure of early reconstruction, delayed reconstruction cannot be avoidable. The purpose of our study was to compare the results of delayed wound coverage technique between anterolateral thigh (ALT) free flap and local perforator based propeller flap in an open tibia fracture.

Many surgical options for wound coverage are introduced for a defect in tibial area; vacuum assisted closure therapy, skin graft, local propeller flap and free flap. However, flap coverage is needed for a long run salvage of the lower limb because the use of local perforator flap and free flap allows a safe and reliable wound coverage in a soft tissue defect in open tibial fracture cases. Local propeller flap has its advantage compare to free flap in a short operation time and minimal donor site morbidity but has a limitation due to the donor which can be harvested from the zone of injury (Hallock et al., 2013). While free flap is superior to local propeller flap because the healthy tissue out of the zone of injury can be transferred to cover the defect it has its disadvantage due to a long operation time, necessity of the microsurgical technique and a minimal donor site morbidity (Kuo et al., 2001). In our department, we select kinds of flaps based on size and location of wound, severity, medical history and flap availability. We also compared the utility between free flaps and local propeller flaps based on treatment and clinical outcomes of the patients with Gustilo type IIIB open tibial fractures especially for delayed reconstruction.

2

II.

M

M

Between February 2011 and February 2014, 35 patients (32 males and 3 females) with traumatic open tibial fractures underwent reconstruction surgery. And all reconstruction of these series was performed at least 10 days after trauma due to patients’ trauma status and comorbidity. The surgeries were accomplished by a specialist of a multidisciplinary surgery team containing of plastic and orthopedic surgeons. The study subjects were assigned to the free flap group or the local propeller group. In the free flap group, we selected 19 patients with ALT free flap (17 males and 2 female) from all free flap cases. We limited to ALT free flap cases to reduce the bias. In the local propeller group, 16 patients (15 males and 1 female) were covered with local propeller flap for lower extremity salvage and reconstruction.

The causes of trauma type and other organ injury were evaluated by the patients’ chart. Following coexisting factors which can influence the flap survival was evaluated: tobacco usage, diabetes mellitus (DM), end-stage renal disease (ESRD), hypertension and osteomyelitis (Table 2). All patients in two groups were classified to Gustilo type IIIB open tibial fractures. Also, we reviewed wound location and size, flap outcome, postoperative complications, ICU days, hospital days, rehabilitation days after surgery and contour by photo to compare the differences of both groups. Perforators of flaps were confirmed in the preoperative period by medical images (lower extremity 3-dimensional computed tomography or lower extremity angiography) and hand-held Doppler before operation. The antibiotic treatments were established with consultation of the infectious disease department control inflammations and prevent an infection based on the results of wound cultures. The patient’s inflammatory status was appraised with inflammation lab marker (serum complement reactive protein [CRP]) which was periodically checked before and after the operation. We chose CRP level for indexing of inflammation and infection such as osteomyelitis due to its high sensitivity after surgery or trauma (Wright et al., 2010, Kallio et al, 1990, Neumaier et al, 2008). The bony union after operation was confirmed by an orthopedic surgeon with plain follow-up x-ray and clinical assessment that involved a subjective estimation of fracture site pain and fracture stability. Orthogonal plain radiographs were taken to assess fracture alignment and callus formation around the fracture (Smith et al,

3

2009).

We used t-test and rank sum test for the evaluation of statistical relationship between free flap and local propeller flap. Each parameter was selected and statistically compared between two groups.

The ALT fasciocutaneous free flaps were elevated in all free flap cases. In the local propeller flap group, there were 8 cases based on medial sural artery perforator, 3 cases based on peroneal artery 1 case based on lateral genicular artery perforator and 4 case based on posterior tibial artery perforator. When the open wound of tibia appeared prepared for wound coverage, the flap operation was planned with an orthopedic surgeon if combined operation was needed. During the operation, complete debridement was performed on the infected bone and soft tissues. Then flap elevation was performed and covered the defect site.

4

III.

R

The operation type was selected as free flap and propeller flap surgery according to fracture type, site and defect size. Each patient in this study presented with GustiloIIIb as fracture type. Two major complication cases were noted in the free flap group due to venous congestion. One case resulted in flap failure which was covered with a lateral genicular artery perforator based propeller flap after flap loss. The other case led to partial flap necrosis which was salvaged with conservative care. There were 7 minor complications in two groups.(5 in free flap group, 2 in local propeller flap group) In free flap group, there were 3 cases of wound dehiscence which needed suture and 2 cases of delayed healing which were healed after 3 weeks later after operation. One minor complication of delayed wound healing was noted in local propeller flap group and hematoma beneath the flap was noted in another case which was compromised with conservative care. All patients were allowed to ambulate in outpatient clinic after wound coverage surgery.

The majority of fracture sites were distal tibia on free flap cases (distal tibia 13, mid-tibia 3, proximal tibia 3). In local propeller flap cases it was middle and proximal tibia (mid-tibia 8, proximal tibia 8). The mean defect size was 95.9 cm2 (24–240 cm2_{) on free flap and 26.5}

cm2 (3–90 cm2_{) on propeller flap. The mean ages were 47.6 years (15–75 years) in free flap}

and 46.6 years (22–69 years) in local propeller flap. The mean time from injury to free flap coverage was 40.0 days and in propeller flap it was 29.1 days. Wound culture was done previous to flap coverage and bacterial or fungal identification was confirmed (Table 4, 5). In the free flap group, the highest mean level of inflammation lab marker (CRP) was 11.21 (mg/L) 3 days after operation but was stabilized to 1.04 (mg/L) during 2 weeks. In the propeller flap group, CRP showed the highest mean level with 6.2 (mg/L) 4 days after operation but was stabilized to 0.33 (mg/L) during 2 weeks. The mean operation time of free flap was 6.24 hours and of local propeller flap 3.40 hours (Fig. 1, Table 3). A passive rehabilitation of lower extremity and weight bearing were possible in 20.02 and 36.48 days each after free flap operation whereas 18.73 and 31.33 days each after propeller flap operation. All patients went to ICU in free flap group and ICU day was mean 6.21 days. Whereas in local propeller flap group, 3 patients went to ICU and ICU day was mean 1.12

5

days. Hospital days after operation was 61.43 days for the free flap group compared to 53.2 days for the perforator flap group. The bone union after operation was noted in 5.5 months in free flap group and 4.5 months in local propeller flap group.

In the statistical test of data, there were significant statistical meanings in defect size, operation time and ICU days after operation between both groups (Table 1). Whereas, there was no statistical relationship regarding trauma days at time point of operation, total hospital days, rehabilitation days after operation and bony union days after operation between both groups (Table 1). There was a statistical significant difference in the follow up results of CRP after operation in both groups. A lower CRP level was measured in the propeller flag group until 3 days after operation. However, after the third day of operation, CRP level was stabilized and there was no more statistical difference between both groups. It means there was a lower inflammation status in the local propeller group.

The morbidity of patients influencing the flap survival was checked retrospectively. The portion of the local propeller flap group regarding etiologies and underlying diseases (tobacco usage, DM, ESRD, and hypertension) was higher than that of the free flap group (Table 2). The number of patients with osteomyelitis in the review of patient charts was almost the same in both groups (Table 2).

6

Fig. 1.Peak serum CRP at each day in free flap group and local propeller group.

In the free flap group, the highest mean level of inflammation lab marker (CRP) was 11.21(mg/L) 3 days after operation but was stabilized to 1.04 (mg/L) during 2 weeks. In the propeller flap group, CRP showed the highest mean level with 6.2 (mg/L) 4 days after operation but was stabilized to 0.33 (mg/L) during 2 weeks. The mean operation time of free flap was 6.24 hours and of local propeller flap 3.40 hours

7 Table 1The results of comparisons between free flap and local propeller flap.

Free Flap Propeller Flap p-value Mean SD Mean SD

Defect Size (cm2) 95.9 5.50 26.5 3.88 0.0057*† Trauma days at operation 40.0 36.50 29.1 35.00 0.9067† Operation time (hours) 6.2 2.26 3.4 1.35 < 0.0001*†

ICU days 6.2 8.25 1.12 3.75 0.0322*†

Hospital days 61.4 22.95 53.2 24.52 0.4089 Rehabilitation days after

operation

1.Passive exercise (days) 20.0 16.75 18.7 2.75 0.4496 2.Weight bearing (days) 36.5 18.64 31.3 11.89 0.4809 Bone union (months) 5.5 4.25 4.5 2.38 0.6341† *: p-value < 0.05, †: p-value of rank sum test

8

Table 2Coexisting condition and underlying disease of free flap and local propeller flap.

Etiology Free flap(% from total 19) Propeller flap(% from total 16) Tobacco 3 (16%) 5 (31%)

DM 2 (11%) 2 (13%)

ESRD 0 (0%) 2 (13%)

HTN 2 (11%) 1 (6%)

OM 3 (16%) 2 (13%)

DM, diabetes mellitus; ESRD, end-stage renal disease; HTN, hypertension; OM, osteomyelitis

9

Table 3 Comparisons of complement reactive protein (CRP) between free flap and local

propeller flap.

Free Flap Propeller Flap p-value Mean SD Mean SD CRP (POD 0) 2.3 1.56 0.8 0.66 0.0040*† CRP (POD 1) 5.8 6.01 1.9 1.22 0.0095*† CRP (POD 2) 11.0 5.10 5.3 3.31 0.0201* CRP (POD 3) 11.2 5.52 5.9 3.42 0.0412* CRP (POD 4) 6.7 9.73 6.2 5.80 0.3440† CRP (POD 5) 7.3 6.96 2.9 3.67 0.1222† CRP (POD 6) 6.3 6.74 2.2 2.77 0.1025† CRP (POD 7) 5.5 3.64 3.0 3.51 0.1788 CRP (POD 14) 1.0 0.99 0.3 0.60 0.0805† *: p-value < 0.05, †: p-value of rank sum test

10 Table 4Summary data of ALT free flap group.

Case Gender Age Days to flap Soft tissue defect (cm2)

Size of flap (cm2)

Defect site Time to union (months)

Wound culture 1 M 54 12 10 x 8 11 x 9 distal 3 A.baumanni

2 M 51 47 14 x 7 16 x 8 distal loss A.baumanni 3 M 59 44 5 x 5 6 x 9 distal 7 S.maltophilia 4 M 75 85 10 x 5 11 x 6 distal expire Candida 5 M 40 16 8 x 7 9.5 x 8.5 proximal 3 A.baumanni 6 M 25 129 14 x 4 18 x 6 proximal 14 E.cloacae 7 M 63 12 15 x 9 16 x 10 distal 13 Candida 8 M 44 10 10 x 3.5 11 x 5 distal 5 E.faecalis 9 M 30 13 12 x 5 12 x 6 middle 5 no growth 10 M 22 15 20 x 11 20 x 11 proximal 2 MRCNS

11

12 M 70 51 6 x 3.5 8 x 5 distal 3 MRCNS 13 M 39 29 20 x 12 20 x 12 middle 5 CNS

14 F 15 63 12 x 8 14 x 10 distal 7 E. cloacae, MRSA 15 M 50 12 10 x 11 11 x 12 distal 5 MRCNS

16 M 35 15 9 x 10 10 x 12 distal 4 no growth 17 M 39 19 8 x 16 10 x 18 distal 4 no growth 18 M 73 22 9 x 12 11 x 14 distal 3 A.baumanni 19 F 29 41 10 x 9 12 x 10 distal 4 no growth

A.baumannii, Acinetobacterbaumannii; S.maltophilia,Stenotrophomonasmaltophilia; E.cloacae,Enterobactercloacae; MRCNS, Methicillin resistance coagulase-negative Staphylococcus; CNS, Coagulase-negative Staphylococcus; MRSA, Methicillin resistant staphylococcus aureus

12 Table 5Summary data of local propeller flap group.

Case Gender Age Days to flap Soft tissue defect (cm2)

Defect site Local flap perforator type Time to union (months)

Wound culture

1 F 66 42 4 x 1 middle medial sural artery perforator 5 MRSA 2 M 58 55 6 x 4 proximal peroneal artery perforator 11 A.baumannii 3 M 46 72 2 x 4 proximal medial sural artery perforator 5 no growth 4 M 29 15 2.5 x 2.5 middle medial sural artery perforator 3 no growth 5 M 22 36 15 x 6 proximal lateral genicular artery perforator 2 MRCNS 6 M 46 16 5 x 6 proximal peroneal artery perforator 3 no growth 7 M 48 36 2 x 1.5 proximal peroneal artery perforator 5 A.baumannii 8 M 63 20 7 x 5 middle medial sural artery perforator 5 no growth 9 M 69 12 5 x 5 middle medial sural artery perforator 5 no growth 10 M 42 10 8 x 6 middle posterior tibial artery perforator 5 CNS

13

11 M 50 15 6 x 6 middle posterior tibial artery perforator 4 CNS 12 M 61 30 3 x 2 middle medial sural artery perforator 6 no growth 13 M 28 10 6 x 4 proximal posterior tibial artery perforator 5 no growth 14 M 49 12 4 x 5 middle medial sural artery perforator 4 no growth 15 M 17 14 5 x 7 proximal posterior tibial artery perforator 4 MRCNS 16 M 50 12 5 x 6 proximal medial sural artery perforator 5 no growth

MRSA, Methicillin resistant staphylococcus aureus; MRCNS, Methicillin resistance coagulase-negative Staphylococcus; CNS, Coagulase-negative Staphylococcus; A.baumannii, Acinetobacterbaumannii

14

IV.

D

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.

15

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 average of bony union was 9.3 months in previous study and was 6.3 respectively 5.3 months in the free flap group and the local propeller flap group in our study. We used the median value of bony union for statistical evaluation to minimize the bias. There are limitations to compare both studies in depth due to different infectious rates and wound coverage times in both studies.

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

16

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

17

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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V.

C

Generally, local propeller flap has an advantage in lower extremity reconstruction due to rich vascular perforator in lower extremity, short operation time and minimal donor site morbidity if compared to free flap. In this study, even though they were reconstructed with delayed period, we proved the statistical superiority of local propeller flap in the view of ICU days and operation time. This result was possible due to a smaller soft tissue defect in the antetibial area which was statistically meaningful if compared to the free flap group. Also, this study demonstrates that local propeller flaps result in a statistical significant lower inflammatory rate until postoperative day 3 compared to the free flap group. But local propeller flap has its limitations due to transfer of tissue from zone of injury, requirement of small defect size and the confirmation of perforator on radiologic assessment. These limitations can be surmounted with an ALT flap. An ALT free flap is described with healthy tissue transfer, long pedicle length, large skin territory, flow-though and chimeric concept design, a two-team approach, and no need for changing the position (Yildirim et al., 2003, Wyber et al., 1990). In our conclusion, local propeller flap can be a superior choice than free flap for patients whose zone of injury is localized to the defect site with small size in mid-proximal tibia area and underlying medical disease which makes patients vulnerable for a long operation. In contrast, the cases with big trauma vector which makes defect size larger with extensive zone of injury on distal tibia are better to be covered with free flap. With more patients’ data, we would expect to produce a critical indication in wound coverage between free flap and local propeller flap for open tibia fracture Gustilo type IIIb.

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R

1.Lee JH, Chung DW, Han CS: Outcomes of anterolateral thigh-free flaps and conversion from external to internal fixation with bone grafting in gustilo type IIIB open tibial fractures. Microsurgery 32:431-437, 2012

2.Hallock GG: A paradigm shift in flap selection protocols for zones of the lower extremity

using perforator flaps. J ReconstrMicrosurg ;29:233-240, 2013

3.Kuo YR, Jeng SF, Kuo MH: Free anterolateral thigh flap for extremity reconstruction: clinical experience and functional assessment of donor site. PlastReconstrSurg 107:1766-1771, 2001

4. Wright EH, Khan U: Serum complement-reactive protein (CRP) trends following local and free-tissue reconstructions for traumatic injuries or chronic wounds of the lower limb.

J PlastReconstrAesthetSurg 63:1519-1522, 2010

5. Kallio P, Michelsson JE, Lalla M: C-reactive protein in tibial fractures. Natural response to the injury and operative treatment.J Bone Joint Surg Br 72:615-617, 1990

6. Neumaier M, Scherer MA: C-reactive protein levels for early detection of postoperative infection after fracture surgery in 787 patients. ActaOrthop 79:428-432, 2008

7. Smith TO, Hedges C, MacNair R: The clinical and radiological outcomes of the LISS plate for distal femoral fractures: a systematic review. Injury 40:1049-1063, 2009

8. Wei FC, Jain V, Celik N: Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps.PlastReconstrSurg 109:2219-2226; discussion 2227-2230, 2002 9.Joslin CC, Eastaugh-Waring SJ, Hardy JR:.Weight bearing after tibial fracture as a guide to

healing.ClinBiomech 23:329-333, 2008

10.Rao N, Ziran BH, Lipsky BA: Treating osteomyelitis: antibiotics and surgery.

PlastReconstrSurg 127 Suppl 1:177s-187s, 2011

11.Hong JP, Shin HW, Kim JJ: The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity. Plast Reconstr Surg 115:142-147, 2005

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12.Moran SL, Illig KA, Green RM:. Free-tissue transfer in patients with peripheral vascular disease: a 10-year experience. Plast Reconstr Surg 109:999-1006, 2002

13.May JW, Jr., Gallico GG, 3rd, Jupiter J: Free latissimus dorsi muscle flap with skin graft for treatment of traumatic chronic bony wounds. Plast Reconstr Surg 73:641-651, 1984 14.Harris PG, Letrosne E, Caouette-Laberge L: Long-term follow-up of coverage of weight

bearing surface of the foot with free muscular flap in a pediatric population.

Microsurgery 15:424-429, 1994

15.Arnold PG, Yugueros P, Hanssen AD: Muscle flaps in osteomyelitis of the lower extremity: a 20-year account. Plast Reconstr Surg 104:107-110, 1999

16.Guzman-Stein G, Fix RJ, Vasconez LO: Muscle flap coverage for the lower extremity.

Clin Plast Surg 18:545-552, 1991

17.Ulucay GE, Yildirim S, Aydogdu E: Reconstruction of crush injuries of the foot dorsum: is the latissimus dorsi muscle flap a reliable choice? J Reconstr Microsurg 22:157-166, 2006

18.Yaremchuk MJ, Brumback RJ, Manson PN: Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstr Surg 80:1-14, 1987

19.Duffy FJ, Jr., Brodsky JW, Royer CT: Preliminary experience with perforator flaps in reconstruction of soft-tissue defects of the foot and ankle. Foot Ankle Int 26:191-197, 2005

20.Nasir S, Aydin MA: Reconstruction of soft tissue defect of lower extremity with free SCIA/SIEA flap. Ann Plast Surg 61:622-626, 2008

21.Park JE, Rodriguez ED, Bluebond-Langer R: The anterolateral thigh flap is highly effective for reconstruction of complex lower extremity trauma. J Trauma 62:162-165, 2007

22.Hou Z, Irgit K, Strohecker KA: Delayed flap reconstruction with vacuum-assisted closure management of the open IIIB tibial fracture. J Trauma 71:1705–1708, 2011

23.Yazar S, Lin CH, Lin YT: Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 117:2468-2475; discussion 2476-2467, 2006

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extremity soft-tissue reconstruction. J Reconstr Microsurg 19:225-233, 2003

25.Wyble EJ, Yakuboff KP, Clark RG: Use of free fasciocutaneous and muscle flaps for reconstruction of the foot. Ann Plast Surg 24:101-108, 1990

22 - 국문요약 -

Comparison of delayed soft tissue coverage between anterolateral

thigh free flap and local propeller flap on traumatic open tibial

fracture Gustilo-Anderson grade IIIb

아주대학교 대학원의학과 조영후 (지도교수 :이일재) 외상으로 인한 하지의 골절 및 연부조직결손은 요즘 병원에서 많이 접할 수 있 는 환자군 이다. 특히 큰 외력으로 인한 외상의 종류가 많아짐에 따라, 하지로 연부조직의 재건을 요하는 경우가 있다. 이번 연구에서는 개방성 경비골 골절 환 자 Gustilo type IIIb에 대하여 연부조직 재건을 할 수 있는 방법인 전외측 허벅 지 유리피판술과 국소 플로펠러피판술에 대하여 비교 연구 하였다.

2011년 2월부터 2013년 6월까지 외상으로 인한 Gustilo type IIIb경비골 골 절 환자 총 35명을 대상으로 연구를 진행하였다. 전외측 허벅지 유리피판술을 사용한 환자수는 19명 (17명 남성, 2명 여성)이었으며, 국소 플로펠러피판술을 사용한 환자수는 16명 (15명 남성, 1명 여성) 이었다. 모든 환자들에 대하여 연 부조직 재건 수술은 다른 주요 부위의 외상으로 인한 전신상태로 감안하여 지연 성 수술로 진행하였다. 이번 논문의 연구를 통해서, 수술 전 연부조직 결손 크기, 수술 시간, 수술 후 중환자실 재원기간, 수술 후 3일까지의 혈청 CRP 수치 비교 등에 있어서 두 비 교군 간에 통계학적으로 유의미한 결과를 얻을 수 있었다. 이러한 결과를 통하여, 개방성 경비골 골절 Gustilo type IIIb 에서 연부조직 재건 수술을 결정하는 데 있어서, 여러 가지 지표를 참고하여 환자에게 적합한 수술적 방법을 선택하는 데 도움을 받을 수 있을 것으로 사료된다. 결론적으로, 연부조직의 결손의 크기가

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작고, 경비골 근위 부위의 결손일수록, 또한 외상의 정도가 크고 환자의 기저 질 환이 많아 긴 수술 시간 및 수술 후 염증 상태를 견디기 힘든 상황일수록 국소 프로펠러 피판술이 재건을 위한 좋은 선택으로 보여진다.

Key words :Free Tissue Flaps; Perforater Flap; Fractures, Open/surgery; Tibial Fractures/surgery; Reconstructive Surgical Procedures/methods