Gatto Arianna, Stucchi Sara, Brambilla Leonardo, Cavalli Erica, Giacomini Giorgio, De Rosa Laura, Leone Giulio, Belingheri Michael, Ribuffo Diego, Zatti Giovanni, Marchesi Andrea
From the Department of Plastic Surgery, Hand Surgery and Reconstructive Microsurgery, Fondazione IRCCS-San Gerardo dei Tintori, Monza.
Orthopedic Department, Fondazione IRCCS-San Gerardo dei Tintori, University of Milano-Bicocca.
Ann Plast Surg. 2024 Oct 1;93(4):496-500. doi: 10.1097/SAP.0000000000004091. Epub 2024 Sep 3.
Open fractures of the lower limb represent a common challenge for trauma centers. Even where national guidelines are available, these standards are frequently missing. Our study evaluates the influence of polytrauma on the adherence to the timing and management required in an orthoplastic approach.
A retrospective review was performed on 36 patients affected by a Gustilo-Anderson grade IIIA, IIIB, or IIIC fracture of the lower limb between 2018 and 2022. Data related to patient management were analyzed: time to the first evaluation by a plastic surgeon, time to soft tissue coverage, time to definitive osteosynthesis, days in intensive care unit (ICU), days of hospitalization, and total cost of hospital stay. Patient satisfaction was evaluated through the administration of 2 questionnaires: the Enneking and the Foot Function Index (FFI).
In 23 patients (63.9%), a soft tissue reconstruction was required. Of these, 13 were polytraumas (PT) (56.5%) and 10 were affected by an isolated lower limb fracture (ILLF) (43.5%). The median time to wound excision was 7.0 days (IQR, 0-16.0) in the PT group and 12.5 days (IQR, 1-41.0) in the ILLF group, whereas the mean time to soft tissue coverage was 15.0 days (IQR, 4.0-17.0) in the PT group and 38.0 days (IQR, 25.0-65.0) in the ILLF group. Mean time to definitive fixation was 33.0 days (IQR, 6.5-70.0) in the PT group and 16.5 days (IQR, 3.0-26.0) in the ILLF group. Statistically significant difference was reported on mean time to soft tissue coverage, whereas not relevant differences were reported on mean time to plastic surgeon involvement, first debridement, definitive fixation, days of hospitalization, costs, and Enneking and FFI score.
This is the first study comparing the effectiveness of the orthoplastic approach between isolated lower limb fractures and polytraumas. According to our study, open lower limb fracture management is paradoxically more effective in polytraumas rather than in isolated injuries because a multidisciplinary approach is mandatory in severely injured and compromised patients.
下肢开放性骨折是创伤中心常见的挑战。即使有国家指南，这些标准也常常缺失。我们的研究评估了多发伤对遵循整形手术方法所需的时间安排和管理的影响。
对2018年至2022年间36例 Gustilo-Anderson IIIA、IIIB或IIIC级下肢骨折患者进行回顾性研究。分析了与患者管理相关的数据：整形外科医生首次评估的时间、软组织覆盖的时间、确定性骨固定的时间、重症监护病房（ICU）的天数、住院天数以及住院总费用。通过发放两份问卷评估患者满意度：Enneking问卷和足部功能指数（FFI）。
23例患者（63.9%）需要进行软组织重建。其中，13例为多发伤（PT）（56.5%），10例为单纯下肢骨折（ILLF）（43.5%）。多发伤组伤口切除的中位时间为7.0天（四分位间距，IQR，0 - 16.0），单纯下肢骨折组为12.5天（IQR，1 - 41.0）；而多发伤组软组织覆盖的平均时间为15.0天（IQR，4.0 - 17.0），单纯下肢骨折组为38.0天（IQR，25.0 - 65.0）。多发伤组确定性固定的平均时间为33.0天（IQR，6.5 - 70.0），单纯下肢骨折组为16.5天（IQR，3.0 - 26.0）。在软组织覆盖的平均时间上报告了统计学显著差异，而在整形外科医生参与的平均时间、首次清创、确定性固定、住院天数、费用以及Enneking和FFI评分方面未报告相关差异。
这是第一项比较单纯下肢骨折和多发伤整形手术方法有效性的研究。根据我们的研究，开放性下肢骨折的治疗在多发伤中反而比单纯损伤更有效，因为对于重伤和情况复杂的患者，多学科方法是必不可少的。
