Orthoplastic approach for the management of open tibial fractures: Should Orthopedic surgeons be trained to perform pedicled flaps?

Introduction: The management of open tibial fractures has greatly benefited from the development of the orthoplastic approach. Despite advances in soft tissue reconstruction techniques, the use of simple pedicled flaps performed by orthopedic surgeons remains a relevant option.

Hypothesis: In the context of orthoplastic reconstruction of tibial fractures, the use of pedicled flaps performed by orthopedic surgeons can optimize soft tissue coverage strategies.

Materials and methods: A retrospective study was conducted on 63 patients treated for open tibial fractures requiring soft tissue reconstruction between July 1, 2012, and July 1, 2021. Two groups were compared: Group 1 included patients operated on before July 1, 2018, when flaps were performed exclusively by plastic surgeons; Group 2 included patients operated on after July 1, 2018, when flaps were performed by either plastic or orthopedic surgeons. Demographic and injury-related data, type of flaps used, and the 1-month flap failure rate were analyzed. Time to coverage, time to soft tissue healing, and time to secondary internal fixation were recorded and compared between groups.

Results: In Group 1, 28 out of 45 patients (62%) underwent soft tissue coverage using flaps, of which 30 out of 31 flaps (97%) were performed by plastic surgeons. The free-to-pedicled flap ratio was 16:15. In Group 2, all 18 patients (100%) underwent flap coverage, of which 18 out of 20 flaps (90%) were performed by orthopedic surgeons. The free-to-pedicled flap ratio in this group was 2:18. The median time to coverage was significantly reduced in Group 2, from 28 days to 7 days (p < 0.05). Healing times were shortened. Flap failure rates were not significantly different between groups.

Conclusion: When the injury pattern allows, the use of pedicled flaps by orthopedic surgeons appears to reduce the time to coverage in open tibial fractures, thereby optimizing the orthoplastic reconstruction strategy. Training orthopedic surgeons in these simple, reliable, and reproducible reconstruction techniques is therefore recommended.

Level of evidence: IV.