MANAGEMENT AND TIMING OF TREATMENT IN PATIENTS WITH OPEN LEG FRACTURES: THE ORTHOPLASTIC APPROACH

Background. Open fractures are among the most severe injuries observed in orthopedic patients and their treatment is always challenging, with urgency of surgical treatment and possible complication of local infection that may require multiple operations and even amputations. Soft tissue coverage and reconstruction in the leg is very complicated because the layer of soft tissue covering the bone is particularly thin. The main goal of open fractures treatment is to repair bone defects and perform adequate and functional soft tissue reconstruction. Objectives. The aims of our study were 1) to analyze the series of a referral center for Trauma needing an orthoplastic approach 2) to evaluate the timing of stabilization and debridement surgeries, VAC (Vacuum Assisted Closure) therapy and definitive flap coverage and 3) to analyze outcome and overall healing in relation to these parameters. Material & methods. We performed a retrospective analysis of patients who underwent surgical procedures for open fractures of the leg between 2016 and 2024. We enrolled 28 patients (21 males, 7 females) treated at a mean age of 50 years-old (range 15-82). According to Gustilo-Anderson classifications, there were 3 G–A type II fractures, 12 type IIIA, 11 type IIIB and 3 type IIIC. Data on timing of surgery, operative data and incidence of complications and postoperative checks were reported and statistically analyzed. We compared patients by assessing the following factors: timing from injury to debridement and eventual second look debridement, utilization and duration of VAC therapy, timing of flap coverage and timing and different techniques for bone definitive fixation. Results. The mean follow-up period was 20.9 months (range 2 - 57 months) and Kaplan – Meier overall survival to major complications was 60% at the 12-month follow-up with a mean healing time of 12.6 months. The rate of major complications was 55.2% (16 patients), of which the infection rate was 48.2% while the non-union rate was 27.6%. Conclusions. Bone fixation and soft tissue reconstruction integration into an orthoplastic approach provides better overall outcomes. The overall rate of major complications in patients with open-leg fractures treated with an orthoplastic approach was still quite high (55.2%), but there are clear surgical steps that if taken can lower this percentage. Proper initial wound cleaning and correct fixation treatment are fundamental and flap coverage should be performed between 10 and 14 days after or in junction with final bone fixation, if there are no contraindications. Negative pressure wound therapy is an excellent tool to bridge from first debridement and definitive wound coverage, but its lengthy use doesn’t translate to better outcomes.