THE COMBINED ORTHOPLASTIC APPROACH TO THE MANAGEMENT OF SEVERE OPEN GRADE IIIB FRACTURES OF THE LOWER LIMB: FUNCTIONAL AND RADIOLOGICAL OUTCOME OF 100 CONSECUTIVE PATIENTS FROM A SPECIALIST CENTRE

To assess the efficacy of a combined orthoplastic approach to the management of severe grade III fractures of the lower limb, we looked at the functional and radiological outcome of 100 consecutive fractures from a specialist centre. A prospective analysis was performed on 100 consecutive open tibial fractures (98 patients). An early decision was made by a specialist multidisciplinary team as to whether the injured limb was reconstructable. In the reconstruction group there were 84 Gustilo grade IIIB/C injuries. Definitive skeletal stabilisation was most commonly with a circular frame (60%) or intramedullary nail (20%). The mean time to union was 26 weeks for diaphyseal fractures, 20 weeks for metaphyseal fractures and 10 weeks for ankle fractures. There was one aseptic non-union which is still undergoing treatment. The anterolateral thigh free flap was the most common soft tissue reconstruction used (42%). There were minimal surgical complications and only one free flap failure. Mean time to follow-up was 24 months. The mean limb functional score (modified enneking) was 83% of that of the normal limb and was not influenced by the site of fracture or type of fixation. The mean SF-36 score was 75 and there was a high return to employment (70%). In the primary amputation group there were 16 grade IIIB/C injuries. Mean time to follow-up was 38 months. The mean SF-36 score for the below knee amputees was 58 and there was again a high return to employment (58%). In the reconstruction group there is a 99% limb salvage rate with infection-free union to date and no delayed amputations. A higher return to functional activity/employment was achieved in the reconstruction group compared to the primary amputation group. Our results demonstrate that by using a combined orthoplastic approach in a specialist centre excellent results can be achieved for all patients presenting with severe open lower limb injuries.