The Evidence for Plastic Surgery

Stone, Christopher

• Publisher: tfm Publishing Ltd
• Year: 2008
• ISBN:
  9781908986214
• Topic: Medicine
• Subtopic: Medical Theory, Practice & Reference

Evidence-based medicine is now firmly established in the lexicon of modern health care. In The Evidence for Plastic Surgery the diverse spectrum of plastic surgical practice is called to account by a cross-examination of the available evidence in support of many of the common treatment protocols and surgical procedures in everyday use. The result is a text that makes an important contribution to some of the contentious debates within the specialty and details the critical appraisal of new or developing techniques. The Evidence for Plastic Surgery is a unique and invaluable reference source for senior doctors and for those in training, not only in plastic surgery but also in a variety of other closely aligned specialties including general and orthopaedic surgery.

Chapter 1

Timing and method of soft tissue reconstruction in patients with IIIb tibial fractures

Andrew DH Wilson MRCS

Specialist Registrar, Plastic and Reconstructive Surgery

Christopher Stone FRCS (Plast.)

Consultant, Plastic and Reconstructive Surgery

ROYAL DEVON AND EXETER HOSPITAL, EXETER, UK

Introduction

Lower limb extremity injuries constitute a leading cause of hospital admissions among adolescents and young adults (18-54 years of age), accounting for almost 250,000 hospitalisations each year in the US ¹.

For many centuries limb amputation had been the only option for patients disabled by a grossly traumatised or chronically infected lower extremity, with prosthetics providing satisfactory ambulation and support. In this present era when reconstructive options are many and varied, recognising a non-salvageable limb is perhaps the greatest challenge to the orthopaedic and plastic surgeon alike. Advances in fracture management, asepsis and microsurgical techniques have provided the basis for the development of limb salvage procedures and functional reconstruction.

H. Winnett Orr’s method of plaster cast immobilisation of open extremity fractures, with wounds covered with dressings under a cast, largely ignored the principles of debridement of devitalised tissues as advocated by Pierre-Joseph Desault (1744-1795). Cases of osteomyelitis were all too frequent, prompting Joseph Trueta to undertake tissue debridement along with secondary wound closure, including the application of skin grafts to granulation tissue. This approach persisted between 1939-1942, but thereafter the importance of restoring the soft tissues over an open fracture within the first week of injury began to be appreciated, as evidenced by the incidence of post-fracture osteomyelitis following World War I (~80%), compared with that following World War II (~25%).

Within the last three decades the inception and development of free tissue transfer techniques for lower limb injuries ² has revolutionised the management of open fractures and the prevention of osteomyelitis. Whatever the timing and method of reconstruction advocated in the many suggested protocols ^{3, 4, 5-13}, the common aim remains the restoration or maintenance of limb function with expedient bony union and stable soft tissue coverage. More recently, attention has focused upon the additional goal of minimising flap donor-site morbidity ^{9, 13, 14} and a re-appraisal of the efficacy of free fasciocutaneous flaps as an alternative to muscle flaps for limb reconstruction ^{5, 6, 8-10, 14}.

Methodology

Medline, PubMed and Cochrane databases were used to gather publications on open tibial fractures using the medical subject headings ‘tibial fractures’, ‘open’, ‘reconstruction’, ‘lower extremity’, ‘timing’, ‘treatment outcome’. Further publications were sourced from cited manuscripts.

Classification of open fractures

As with all classifications, the aim in the classification of open tibial fractures is to guide treatment and predict prognosis. Various systems have been proposed in an attempt to offer useful prognostic indicators and guide the optimal management plan ^{2, 11, 15, 16}. The most widely used classification is that of Gustilo, first outlined in 1976 ² and modified in 1984 ¹⁵ (Table 1). The revised system divides Type III injuries into subgroups reflecting the state of the periosteum and adequacy of limb perfusion, but it has been criticised for inter-observer discordance ^{17, 18} and makes no allowance for nerve injury, crucial to treatment planning. Further attempts at classifying complex limb injuries have resulted in the Mangled Extremity Syndrome Index, Mangled Extremity Severity Score, Predictive Salvage Index and Limb Salvage Index. These indices are complicated and do not always accurately predict outcome ¹⁹.

Table 1. Gustilo’s revised classification of open fractures ^15.
Type I	Open fracture
	Clean wound <1cm in length
Type II	Open fracture
	Laceration >1cm long without extensive soft tissue damage, flaps or avulsions
Type III	Open fracture
	Extensive soft tissue laceration, damage or loss
	Open segmental fracture or traumatic amputation
	High velocity gunshot injuries
	Open fractures caused by farm injuries
	Open fractures requiring vascular repair
	Open fractures older than 8 hours
Type III subtype (1984)
A	Adequate periosteal cover of a fractured bone despite extensive soft tissue laceration or damage High energy trauma irrespective of size of wound
B	Extensive soft tissue loss with periosteal stripping and bone exposure Usually associated with massive contamination
C	Associated with arterial injury requiring repair

Epidemiology

The annual incidence of open long bone fractures in the UK...

Table of contents

• Cover Page
• Title Page
• Publisher
• Contents
• Foreword
• Introduction: Applying evidence-based medicine to plastic surgery
• Chapter 1: Timing and method of soft tissue reconstruction in patients with IIIb tibial fractures
• Chapter 2: Vacuum-assisted closure: basic science and clinical practice
• Chapter 3: The management of necrotising fasciitis
• Chapter 4: The relationship between increasing body mass index and complications in plastic surgery
• Chapter 5: Prophylaxis to prevent venous thrombo-embolic disease in plastic surgery patients
• Chapter 6: Physiological responses to burn injury and resuscitation protocols for adult major burns
• Chapter 7: Improving outcome in paediatric burns
• Chapter 8: Biological skin substitutes
• Chapter 9: Sentinel lymph node biopsy in melanoma
• Chapter 10: Management of inguinal and pelvic nodes in patients with stage III malignant melanoma
• Chapter 11: Prognostic indicators in adult soft tissue sarcoma
• Chapter 12: Evidence-based imaging of soft tissue sarcomas
• Chapter 13: Hypospadias correction: one or two stages?
• Chapter 14: Cleft palate closure: the timing and options for surgical repair
• Chapter 15: Post-traumatic wrist instability
• Chapter 16: Wrist arthroscopy: its role in diagnosis and treatment
• Chapter 17: The role of small joint arthroplasty in osteoarthritis of the hand
• Chapter 18: Monitoring of microvascular free tissue transfers
• Chapter 19: Use of the anterolateral thigh flap for intra-oral reconstruction
• Chapter 20: A comparison of TRAM and DIEP flaps for breast reconstruction
• Chapter 21: Immediate versus delayed breast reconstruction
• Chapter 22: Strategies for minimising palpable implant rippling in the augmented breast
• Chapter 23: Gynaecomastia: an algorithmic approach to surgical management (with special emphasis on liposuction)
• Chapter 24: Trends in aesthetic facial surgery: the role of endoscopic brow and minimal access facial lifts
• Chapter 25: Surgical rejuvenation of the aging neck
• Chapter 26: Trends in aesthetic facial surgery: the Hamra lower lid blepharoplasty
• Chapter 27: Fibrin sealant in plastic surgery
• Chapter 28: Ablative and non-ablative techniques for rejuvenation of photo-aged skin
• Chapter 29: Hand and facial composite tissue allotransplantation
• Chapter 30: Hyperbaric oxygen therapy in plastic surgery