The spinal manifestations of neurofibromatosis include cervicothoracic kyphosis, in which scalloping of the vertebral body and erosion of the pedicles may render conventional techniques of fixation impossible. We describe a case of cervicothoracic kyphosis managed operatively with a vascularised fibular graft anteriorly across the apex of the kyphus, followed by a long posterior construct using translaminar screws, which allow segmental fixation in vertebral bodies where placement of the pedicle screws was impracticable.

Introduction: Some centres in the UK have recently seen a shift away from internal fixation and free tissue transfer (Fix and Flap), towards temporary monolateral external fixation, soft tissue coverage and definitive Ilizarov frame fixation (Flap and Frame).

Methods: Patients sustaining open fractures were identified prospectively and followed up beyond frame removal. After open wound debridement a monolateral ex-fix was applied. Soft tissue coverage was then achieved by our plastic surgeons. As the soft tissues settled, the temporary ex-fix was exchanged to an Ilizarov frame for definitive fixation. Open fractures with bone loss were similarly treated, with either acute shortening or bone transport, depending on the extent of bone loss and state of soft tissues.

Results: Between July 2002 and June 2004, 21 grade 3 open fractures in 18 patients were treated by Flap and Frame. There were 15 male and 3 female patients, with mean age 36. Segment involved was 19 tibias and 2 femurs. There was associated bone loss (mean 9cm) in 6 fractures. 8 had other associated injuries.

Gustilo grade, 3A/3B/3C = 6/13/2. Both 3C fractures required early amputation.

Wound closure, 5/6 fractures with bone loss required free tissue transfer (FTT); however only 3/15 fractures without bone loss required FTT to achieve soft tissue cover, most requiring fasciocutaneous flap or split skin graft only.

Median time in Ilizarov frame was 160 days for patients without bone loss. For those fractures with bone loss frame time ranged from 180–540 days, with some patients still requiring ongoing Ilizarov treatment.

All fractures without bone loss united. At mean 14 month follow up only one fracture of 21 had clinical evidence of deep sepsis. 1 tibial fracture showed a 12 degree malunion, while 7/18 patients had a superficial pinsite infection requiring a course of oral antibiotics. One free tissue transfer failed in a grade 3C fracture, leading to early amputation (in conjunction with the recognised vascular injury).

Conclusions: Grade 3 open fractures remain a significant treatment challenge. This was particularly true of those with associated bone loss, where without exception the treatment time in an Ilizarov frame was prolonged. A deep sepsis rate of 1/21 fractures treated by Flap and Frame compares favourably with other published series. In the 15 fractures without bone loss, times to union also compared very favourably. Unlike in previous series, many fractures did not require free tissue transfer, as there was no internal fixation device present at the fracture site requiring coverage.

Flap and Frame appears to be a very satisfactory method of treating grade 3 open fractures, with low deep sepsis rate, high union rate, satisfactory times to union, and reduced requirement for free tissue transfer to obtain soft tissue coverage.