[Gustilo type IIIb open fractures of the leg - Emergency treatment by internal fixation and simultaneous skin cover].

Sixteen patients were studied between 1986 and 1992. Fourteen patients were reviewed. One had died and one was lost to follow-up. The average was 35 years. There were 15 men and one woman. In 10 cases the fracture was isolated and in 6 there were multiple injuries. Two pre-operative arterial grafts were done. Four fractures were comminuted and in 3 there was a segmental loss of bone. Antibiotics were given for an average of 8 days using Penicillin and Metronidazole. Surgical treatment involved emergency debridement and fixation of the fracture by intramedullary nailing in 15 cases and by external fixation in one case. In 12 cases skin cover was done by local flaps (particularly gastrocnemius and soleus) and in 4 cases by free flaps (2 gracilis, 2 latissimus dorsi). There were no cases of amputation. There were no failures of the free flaps. Healing occurred by primary intention in 10 out of 16 cases (62.5%) at an average of 7.3 months with an average of 2.2 operations and an average hospitalisation of 36.8 days. Two local flap failures led to complications. There were 2 deep vein thromboses and one flap haematoma which required revision. There were 3 infections. Two early infections and one late infection with atrophic non-union were treated by removal of the nail and application of Ilizarov fixator which led to healing. Three non-infected non-unions required intertibial fibial grafting and exchange nailing. One delayed union healed after exchange nailing. The average time to secondary healing was an average of 16.5 months with an average of 5.6 operations and length of hospitalisation of 58.6 days. There were two cases of local flap necrosis, 2 cases of inadequate or absent locking and one case of lack of graft for a bony defect. In the late sequellae there were 5 rotatory or angulatory malunions and 4 shortenings from 1 to 3.5 cm. The inadequate locking and septic complications are the subject of litigation. From a functional viewpoint there was no loss of knee movement. In 9 out of 14 cases there was loss of ankle movement. In 9 out of 14 cases there was loss of ankle movement. Four cases had toe clawing and 3 cases of pes cavus. Eleven cases were able to work. Thirteen out of 14 complained of pain while one patient had a persistent limp and one required a walking stick.In conclusion, emergency stabilisation and skin cover are the imperatives. The results of nailing are encouraging in spite of a significant level of complications. The functional sequellae affected particularly the ankle and foot.