Early internal fixation combined with perforator flap for treatment of forearm open fractures with soft tissue defects of Gustilo types IIIB & IIIC

Objective To investigate the clinical therapy of early internal fixation combined with perforator flap for forearm open fractures of Gustilo types ⅢB & ⅢC. Methods A retrospective study was conducted of the 45 patients with forearm open fracture of Gustilo type ⅢB or ⅢC who had been treated from July 2012 to October 2016 at Department of Traumatic Orthopaedics, The Ninth People’s Hospital of Wuxi. They were 26 men and 19 women, aged from 20 to 61 years (average, 41 years). Twenty cases were Gustilo type ⅢB and 25 Gustilo type ⅢC. By AO classification, 8 cases were type A, 21 ones type B, and 16 ones type C. The wound size ranged from 4 cm×3 cm to 36 cm×8 cm. Thirty-three patients were treated by primary internal fixation plus secondary transfer with a perforator flap, 12 ones by secondary internal fixation plus transfer with a perforator flap. The period from injury to secondary flap transfer ranged from 5 to 20 days (average, 12 days). In this series, 36 anterolateral thigh perforator flaps, 5 latissimus dorsal muscular flaps and 4 lateral arm flaps were transferred. Results All the 45 free flaps survived with no deep infection or osteomyelitis. Partial necrosis happened at the distal ends of 2 latissimus dorsal muscular flaps which were cured by skin graft. Postoperative circulatory crisis happened after transfer of an anterolateral thigh perforator flap which survived with 5 cm skin necrosis at the distal end after successful surgical exploration. Superficial wound infection happened in 12 patients with no deep or bone infection. All the patients were followed up for 12 to 36 months (average, 18.5 months). All the flaps were soft in texture, with varying degrees of pigmentation. The sensory recovery was S2 in 8 flaps, S3 in 29 flaps, and S4 in 8 flaps. Obvious scar hyperplasis was observed at the donor site in 5 cases while no obvious scar hyperplasis was observed in the other 40 ones. All the fractures got united after 4 to 14 months (average, 8.6 months). Nonunion happened in 2 patients who were treated with autologous iliac graft 8 months after operation. By Anderson criteria, the curative efficacy was assessed as excellent in 15 cases, as good in 21, as fair in 7 and as poor in 2, yielding an excellent to good rate of 80.0%. Conclusion Early internal fixation combined with perforator flap transfe is an effective strategy for treatment of forearm open fractures with soft tissue defects of Gustilo types ⅢB & ⅢC, due to its advantages of shortened treatment period, possibility for early rehabilitation, decreased complications and satisfactory functional recovery. Key words: Forearm injuries; Fractures, open; Fracture fixation, internal; Surgical flaps; Reconstructive surgical procedures