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3 Table 1. Data for individual patients. ISS: injury severity score, MESS: mangled extremity severity score, Gustilo class.: Gustilo classification, AO class.: AO classification, p.o.: post operation, TFL: tensor fastia lata flap, FVFG: free vascularized fibular graft, SOL: soleus flap, LD: latissimus dorsi flap, RA: rectus abdominis flap, mon.: month Table 2. Data for individual patients (continued). MRSA: methicillin resistance Staphylococcus aureus, ope.: operation, mon.: month, ROM: range of motion
4 Fig. 1. Case 2, 22 y.o.-male, left tibia) open fracture (Gustilo III B). a: appearance at the time of injury b: X-ray at the time of injury
5 Fig. 2. Case 2, 22 y.o.-male, left tibial open fracture (Gustilo III B). a: He can walk with no crutch at 8 months after injury. b: X-ray at 8 months after injury
6 土田 芳彦,他 a b Fig. 3. Case 8, 36 y.o.-male, left tibial open fracture (Gustilo IIIB). a: appearance at the time of injury b: X-ray at the time of injury a b Fig. 4. Case 8, 36 y.o.-male, left tibial open fracture (Gustilo IIIB). a, b: His leg was reconstructed with latissimus dorsi musclocutaneous flap at 4 days after injury. However, his leg was infected acutely. 542 JJAAM 2004; 15:
7
8 Joint Surg Am 1987; 69: ) Court-Brown CM, Wheelwright EF, Christie J, et al: External fixation for type III open tibial fractures. J Bone Joint Surg Br 1990; 72: ) Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78: ) Gopal S, Majumder S, Batchelor AG, et al: Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 2000; 82: ) Johansen K, Dames M, Howey T, et al: Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990; 30: ) Braithwaite IJ, Boot DA, Patterson M, et al: Disability after severe injury: five year follow up of a large cohort. Injury 1998; 29: ) Hertel R, Lambert SM, Muller S, et al: On the timing of softtissue reconstruction for open fractures of the lower leg. Arch Orthop Trauma Surg 1999; 119: ) Gorman PW, Barnes CL, Fischer TJ, et al: Soft-tissue reconstruction in severe lower extremity trauma. A review. Clin Orthop 1989; 243: ) Byrd HS, Spicer TE, Cierney G 3rd: Management of open tibial fractures. Plast Reconstr Surg 1985; 76: ) Yaremchuk MJ, Brumback RJ, Manson PN, et al: Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstr Surg 1987; 80: ) Cierny G 3rd, Byrd HS, Jones RE: Primary versus delayed soft tissue coverage for severe open tibial fractures. A com- parison of results. Clin Orthop 1983; 178: ) Worlock P, Slack R, Harvey L: The prevention of infection in open fractures: an experimental study of the effect of fracture stability. Injury 1994; 25: ) Holden CE: The role of blood supply to soft tissue in the healing of diaphyseal fractures. An experimental study. J Bone Joint Surg Am 1972; 54: ) Macnab I, De Haas WG: The role of periosteal blood supply in the healing of fractures of the tibia. Clin Orthop 1974; 105: ) Gustilo RB, Merkow RL, Templeman D: The management of open fractures. J Bone Joint Surg Am 1990; 72: ) Byrd HS, Cierney G 3rd, Tebbetts JB: The management of open tibial fractures with associated soft-tissue loss: external pin fixation with early flap coverage. Plast Reconstr Surg 1981; 68: ) Francel TJ, Vander Kolk CA, Hoopes JE, et al: Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional 1) Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984; 24: ) Caudle RJ, Stern PJ: Severe open fractures of the tibia. J Bone results. Plast Reconstr Surg 1992; 89: ) Tscherne H, Regel G, Pape HC, et al: Internal fixation of multiple fractures in patients with polytrauma. Clin Orthop 1998; 347:
9 ABSTRACT A Study of Treatment of Severe Open Tibial Fractures by Flap Surgery Yoshihiko Tsuchida, Yasufumi Asai, and Johta Saitoh Department of Traumatology and Critical Care Medicine, Sapporo Medical University We investigated the usefulness of flap surgery for Gustilo type III B and C severe open fracture of the tibia, for which treatment is difficult. The subjects were 9 patients with severe open fracture of the tibia who received a treatment at our emergency department between April 2000 and October There were 8 males and 1 female, and the mean age at injury was 32.9 years. Radical debridement and temporal external fixation were performed on the day of injury, and soft tissue reconstruction and definitive osteosynthesis were performed within a few days after injury to the best. The affected limb was salvaged in 7 of the 9 patients, but amputation was performed later in 2 patients. Primary bone healing was obtained in 6 of the 7 patients with salvaged limbs, and the mean bone healing time was 5.5 months (3-7 months). The patient with delayed bone healing underwent additional bone grafting and achieved bone healing. No concomitant osteomyelitis occurred in any patient. Leg shortening was observed in 1 patient, but the shortening was only 2cm. No patient exhibited 10 or more degrees of angular deformity or malrotation. In addition, relatively good ranges of motion of the knee and ankle joints were maintained, and all patients became able to walk without a stick within 1 year after injury. Thus, early flap surgery was effective for severe open fracture of the tibia. (JJAAM 2004; 15: ) Keywords: severe open fracture, tibial fracture, flap surgery Accepted for publication on June 15, 2004 (04-041)
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