31. CONTRIBUTION OF FLAP COVER OF FRACTURE FOCI FOR CONTROLLING FOCAL INFECTION: PROSPECTIVE STUDY IN SUB-SAHARA AFRICA

Abstract

Purpose of the study: In sub-Sahara Africa, classical directed wound healing followed by a skin graft remains an important part of the treatment of open fractures with tissue loss. The purpose of his prospective cohort study was to assess a continuous series of muscle and fasciocutanous flaps, focusing on their contribution to the reduction of post-trauma focal infection.

Material and method: From September 2007, patients with an open fracture of the leg were studied prospectively. After emergency debridement and stabilisation, open fracture foci were covered with a muscle or fasciocutaneous flap secondarily. Twenty-five patients received 29 flap covers of the lower limb (21 fasciocutaneous and 8 muscle) from October 26, 2007 to February 24, 2009. The Gustillo-Anderson and Catagni classification was noted. Evaluation criteria were successful cover of the bone and presence or not of focal osteitis at last follow-up.

Results: Delay to admission was less than 4 hours in eight patients (30%). Time to primary surgery was greater than 4 h in 90% of patients. Time to flap cover was 29 days for the 18 first-intention flaps; 60 days for three repeat flaps; 217 days for seven second intention flaps. Inaugural colonisation of the fracture site was confirmed in 20 of the 25 patients. Complete necrosis of the flap occurred in four patients (16%) (two muscle flaps revised with fasciocutaneous flaps) and partial necrosis in two others. Successful primary cover was achieved with 12 flaps, and secondary cover in ten others after a new flap (n=3), directed healing, or complementary skin graft. At eight months, two patients had residual focal infection.

Discussion: This series exhibited particularly long delay to primary surgical care and a high level of inaugural focal infections.

Conclusion: Superficial tissue infection around the exposed fracture site should ideally be controlled within six weeks to prevent progression to osteitis. After complete excision of the irremediably damaged tissue, early cover with a flap closes the exogenous infection portal and prepares the wound for secondary bone reconstruction.