Treatment of tibial wound consequences: further development of the Ilizarov technology

Introduction Severe open injuries and wounds of the tibia refer to the topical problem of traumatology due to the difficulties in the functional restoration of the segment when there is a bone and soft tissues defect. Material and method The treatment of 11 patients with soft tissue and tibial defects was analyzed. At the time of reconstruction, the age of male patients ranged from 20 to 52 years (mean age 34.2 ± 3.2 years). Gunshot wounds of tibia occurred in 7 injured and tibial injury was observed in 4 cases. Segmental defects of the tibia ranged from 6 cm to 18 cm, mean 12.6 ± 4.4 cm, myocutaneous defects ranged from 20 cm2 to 112 cm2, mean 74.4 ± 22.4 cm2. Results In seven cases, the wounds healed by primary intention, the signs of infection and marginal necrosis of the soft tissue component of the flap were observed in 4 (36.4 %) cases and were addressed conservatively (dressings and debridement), but in one case, necrosis was excised (on day 21) and autodermoplasty was performed using split skin graft. We had no problems with the transport (distraction) of bone regenerates, since the rib cage of the flaps protected the soft tissues and the vascular pedicle of the flap, despite the early start of distraction (mean period 7.3 ± 2.1 days) and the length of treatment, when averaged, was 163.2 ± 8.7 days. Support function was restored in all patients and the functional results were satisfactory. Discussion The combination of Ilizarov distraction osteogenesisand soft tissue reconstruction using free vascularized flap grafting makes it possible to invalidate the short-comings of both, i.e. to lighten up the bone transfer, to avoid damage to the scarred skin of the anterio-medial surface of tibia and to preserve the axial circulation of the graft. The inclusion of a rib fragment provided the required conditions for application the Ilizarov distraction method. The rib, not being a supportive bone tissue, protected the soft tissue component of the flap and its vascular pedicle from deformity and participated in the formation of callus. Conclusions Plastic filling in the extensive tibial defects using free vascularized myocutaneous flap with rib fragments and Ilizarov distraction osteogenesis provides favorable conditions for acute surgical intervention allowing to save the limb, restore the support ability and return the patients to work.