Management of infected fractures of the tibia with associated soft tissue loss: experience with external fixation, bone grafting and soft tissue reconstruction using pedicle muscle flaps or microvascular composite tissue grafts.

The aim of this study was to assess the results of treatment given by a team of orthopaedic and plastic surgeons in a series of infected unhealed fractures of the tibia associated with loss of adjacent soft tissues. Twenty-five lower leg fractures, treated during a 10 year period, entered the study and were grouped according to the principles of treatment followed. In the earlier Group A (nine patients), the osteosynthesis implants were retained or changed to more stable internal fixation devices, the soft tissue defects were closed by conventional muscle or musculocutaneous flaps and bone grafting procedures were performed late in the treatment scheme. In the later Group B (16 patients) the implants were removed and the fracture stabilised by external fixation; the defects were covered with pedicle muscle flaps or with microvascular composite tissue grafts and cancellous bone grafting was performed at the same operation. Twenty-three fractures healed. One fracture developed non-union and in one patient infection necessitated below-knee amputation. The time of union after surgical reconstruction was significantly shorter in Group B (24 +/- 3 weeks) than in Group A (47 +/- 11 weeks). The results suggested that: in severe infected fractures of the tibia surgical implants used previously for fracture treatment should be removed and replaced with an external frame using firm axial compression, microvascular composite grafts seem to improve greatly the rate of healing, early bone grafting should be included in the reconstruction and late infections can be largely avoided even after extensive one-stage reconstructive procedures.