CHALLENGING THE DOGMA OF THE SEVEN CENTIMETRE RULE: A PROSPECTIVE STUDY EVALUATING INCISION PLACEMENT AND WOUND HEALING FOR TIBIAL PLAFOND FRACTURES

Abstract

This prospective observational study was designed to report the soft tissue complications after fixation of tibial plafond fractures in an effort to challenge the current recommendation that a seven centimeter skin bridge represents the minimum safe distance between surgical incisions. Our hypothesis was that many of the skin bridges would be less than seven centimeters and that this would not result in an increased incidence of wound complications.

All injuries received surgical treatment using a minimum of two surgical approaches for the tibial plafond and the associated fibula fracture (if applicable). Forty-two adult patients with forty-six tibial plafond fractures were enrolled in the study between July 1, 2004 and Dec 30, 2005. There were 1 A1, 3 B1, 2 B3, 6 C1, 6 C2 and 28 C3 fractures. Forty-four plafond fractures had an associated fibular fracture. There were thirty-six closed and ten open fractures. High energy injuries were managed using a two staged approach consisting of fibular ORIF through a posterolateral approach combined with spanning external fixation, followed by tibial ORIF when soft tissue swelling subsided (forty-four fractures). The surgical approaches used, the length of the incisions, the distance between the incisions (size of the skin bridge), and the overlap between the incisions was recorded. The surgical wounds were followed until healing and for a minimum of three months.

Two surgical approaches were used in thirty-two fractures and three approaches were used in fourteen. These one hundred and six surgical incisions produced sixty skin bridges. The approaches used included pos-terolateral (forty-four), anterolateral (thirty-nine), medial (eleven), anteromedial (eight), and posteromedial (four). The mean skin bridge size was 5.9 cm. Only 15% of the skin bridges were > 7 cm, while 70% were 5–7 cm, and 15% were < 5 cm. The mean overlap between incisions in the study was 7.9 cm. One hundred two incisions healed uneventfully. Healing of two anterolateral incisions was complicated by eschars that resolved with local wound care. One posterolateral fibular incision failed to heal until the fibular plate was removed. One patient required subsequent surgical procedures for infection.

Despite a measured skin bridge of less than seven centimeters in 85% of instances, the soft tissue complication rate was low in this group of patients. With careful attention to soft tissue management and surgical timing, incisions for plafond fractures may be placed less than seven centimeters apart, allowing the surgeon to optimise exposures based on the pattern of the injury.