The technique of distraction osteogenesis put forward by Ilizarov is a biological method to reconstruct segmental defects and has been universally performed for the management of non-union, osteomyelitis, deformity, traumatic bone loss, and leg-length discrepancy.
Both microvascular and local flaps can offer soft tissue envelope, increase blood supply, improve bone healing, and defend against infection . According to the basic surgical principles for the management of Gustilo III open fractures, early soft tissue coverage has been proven crucial and effective during the treatment [4-6,10].
Theoretically, combination of these two powerful techniques could probably be an ideal method for reconstruction of segmental bone defects complicated by massive loss of soft tissue. We carried out the combined surgical technique of artery pedicled neurotrophic flap and distraction osteogenesis to treat 25 patients with high-energy tibial fractures graded as Gustilo III. All the cases achieved successful limb salvage and satisfactory function recovery without recurrence of infection.
The united of free tissue transfer and distraction osteogenesis has also been reported as an effective method for limb salvage in composite injuries [5,12]. However, the drawbacks of this technique including long operation time, donor site morbidity, and high technical requirement should not be ignored. Also, distraction osteogenesis beneath a free flap would compromise the vascularized tissue [13,14]. Therefore, instead of a free flap, we performed perforator artery pedicled neurotrophic flap, which is simpler and more efficient, for covering massive soft tissue defects. In this study, all flaps survived completely without complications. In addition, the concern of jeopardy to the pedicle resulting from device placement or subsequent distraction was not observed in this study. We attribute this to careful planning, small diameter of the wires, good stabilization of the flap, tolerable distraction rate, and the technique of percutaneous placement.
Unlike other surgeons [15,16], we did not perform temporary acute shortening and subsequent distraction in any of our patients. Because this technique causes limb disfigurement and may also leads to twist of the vasculature, which may further jeopardize the circulation of the mangled fractured extremity.
In spite of the surgical technique we presented in this study, single-stage reconstruction with an osteocutaneous flap is also an alternative to treat such complicated injuries [12,17]. This technique immediately fills bone defect, provides soft tissue coverage, and establishes vascularity to the bony bed. However, there are several factors which hinder the technique to be popular in clinic. The bone grafts usually cannot match in in caliber with tibia, which makes a long non-weight-bearing period inevitable to achieve compensatory hypertrophy. On the other hand, performing a single operation to address the soft-tissue and bone defect using a single large composite flap or multiple free flaps was not advisable due to the high risk of infection in infected cases. Also, this process is associated with a high risk of refracture or nonunion and has an unpredictable outcome. Our staged approach offers a number of benefits over single-stage reconstruction. Firstly, we would wait at least 4 weeks after debridement and soft-tissue coverage before carrying out the Ilizarov technique of distraction osteogenesis, during which any residual infection may manifest itself before bone reconstruction. Secondly, it can be used in reconstructing defects of any length and diameter without the need for a bone bank or the risks of donor site morbidity. Thirdly, the quality of bone obtained by distraction osteogenesis is better than that in vascularized fibular.
However, disadvantages of this combined technique including cost of treatment, complexity of added surgery, requirement of multiple outpatient adjustments, and long duration of treatment should be considered. The shortcomings of this study are the small number of enrolled cases, the lack of control group, and the short-term following up. Another limitation is that the cohort of patients is very heteronomous when compared the time from injury to initial surgery due to the fact that patients were commonly not sent to our hospital immediately.