Controversy continues to surround the management
of patients with an open fracture of the lower limb and an associated
vascular injury (Gustilo type IIIC). This study reports our 15-year
experience with these fractures and their outcome in 18 patients
(15 male and three female). Their mean age was 30.7 years (8 to
54) and mean Mangled Extremity Severity Score (MESS) at presentation
was 6.9 (3 to 10). A total of 15 lower limbs were salvaged and three underwent
amputation (two immediate and one delayed). Four patients underwent
stabilisation of the fracture by external fixation and 12 with an
internal device. A total of 11 patients had damage to multiple arteries
and eight had a vein graft. Wound cover was achieved with a pedicled
flap in three and a free flap in six. Seven patients developed a
wound infection and four developed nonunion requiring further surgery.
At a mean follow-up of five years (4.1 to 6.6) the mean visual analogue
scale for pain was 64 (10 to 90). Depression and anxiety were common.
Activities were limited mainly because of pain, and the MESS was
a valid predictor of the functional outcome. Distal tibial fractures
had an increased rate of nonunion when associated with posterior
tibial artery damage, and seven patients (39%) were not able to
return to their previous occupation.
Between 1990 and 2000, 15 patients with open 3C fractures of the lower extremity were treated at our institution. Demographic data such as age, sex, associated injuries and co-morbidities were recorded. The mechanism of injury, ISS [Injury Severity Score] and MESS [Mangled Extremity Severity Score] were ascertained. The minimum follow up was 2 years. All the fractures were classified according to the AO system. The patients received a combined treatment by the orthopaedic and plastic surgeons and when necessary by the vascular surgeons. Treatment options, were based on the extent of soft-tissue damage and the configuration of the fracture. Intra-operative details including arteries and nerves involved, type of flap cover, quality of fixation and need for fasciotomy were recorded and analysed. A final follow up was carried out at a special clinic and the outcome was analyzed using SF-36 and EUROCOL. MESS and ISS were analyzed for possible predictors of final functional outcome. The patients were predominantly males. The main mechanism of injury was due to a road traffic accident and 6 of the patients had associated injuries in other parts of the body. In two thirds of the patients the fracture site was in the tibia, and in 3 cases there was a combined fracture in femur and tibia. The posterior tibial artery was involved in the vast majority of the cases, which was either disrupted or avulsed. The Salvage and reconstruction was carried out in 13 patients, which accounted for 77% of the cases and 2 patients underwent immediate amputation. Both had a Mangled Extremity Severity Score of 10. The bone fixation was mainly achieved by plating, or nailing. Half of the patients underwent fasciotomy, in the rest the compartments were decompressed due to the nature and extent of the injury. All the patients required secondary procedures, the mean total number of operations was 2.6. Although only one-fifth of the patients had some problems with self care, half experienced some problems with mobility. Anxiety and depression was a problem in two thirds of the patients, and about the same proportion of patients experienced moderate to severe pain. The mobility was correlated to the MESS score.
