Introduction

Gustilo IIIB open tibiofibular fracture is a severe type of lower extremity injury that involves extensive soft tissue damage, periosteal stripping, and exposed bone1,2,3. It is usually caused by high-energy trauma and is often associated with infection, necrosis, and vascular impairment4. Managing this complex injury remains challenging for orthopedic and plastic surgeons5. Therefore, finding an effective treatment to provide adequate fracture stabilization, debridement, and soft tissue coverage is important.

The current treatment options for Gustilo IIIB open tibiofibular fracture include split-thickness skin grafts, local flaps, and free tissue transfer5,6,7. However, each of these methods has its limitations and drawbacks. Split-thickness skin grafts may not provide sufficient coverage for large defects and may result in poor aesthetic and functional outcomes8. Local flaps are limited by the availability and quality of the surrounding tissue and may compromise the blood supply of the donor site9. Although free tissue transfer provides the best coverage and versatility, it is technically demanding, time-consuming, and associated with higher complication rates10. Therefore, there is a need for a novel technique that can provide reliable and effective soft tissue reconstruction for Gustilo IIIB open tibiofibular fractures. One such technique is the local muscle or myocutaneous flap transfer, which involves the transfer of a muscle or a composite flap from the same extremity to the defect site. This technique has several advantages over the conventional methods, such as preserving the blood supply of the flap, reducing the operative time and morbidity, and improving the functional and aesthetic outcomes11. Therefore, this study aimed to evaluate the local muscle or myocutaneous flap transfer for emergent repair of Gustilo IIIB open tibiofibular fracture.

Methods

Study design and participants

This retrospective case series included patients who underwent surgical repair for Gustilo IIIB open tibiofibular fractures using local muscle or myocutaneous flap transfer at the Weifang People’s Hospital (China) between May 2016 and April 2021.

The inclusion criteria were (1) patients with Gustilo IIIB open tibiofibular fractures and (2) underwent repair using local muscle or myocutaneous flap transfer. The exclusion criteria were (1) patients with damaged muscles around the fracture and the impossibility of transferring the muscle myocutaneous flaps or (2) patients with incomplete medical records.

This study was approved by the Ethics Committee of Weifang People’s Hospital (No: KYLL20231031-3). Due to the retrospective nature of this study, written informed consent was waived.

Orthoplastic repair

The orthoplastic repair was conducted in two stages. In the initial stage, the patients underwent a thorough physical examination and received intravenous antibiotics upon admission to the emergency room. Orthoplastic repair was planned after ruling out contraindications. The wound was debrided to remove any dead or contaminated soft tissue and free bone fragments. The resulting bone defects were filled with bone cement. The exposed bone parts were appropriately covered with nearby muscle using one of three types of flap surgery: medial gastrocnemius myocutaneous flap, medial gastrocnemius muscle flap, or soleus muscle flap. The distal and proximal ends of the fractures were fixed externally to maintain satisfactory lower extremity alignment. The wound was covered by a soft hydrophilic fiber dressing. Patients were administered second-generation cephalosporin antibiotics for 72 h postoperatively. The granulation tissues in the wounds were evaluated 3–10 days later to determine when the second stage surgery should occur to complete the wound closure or free skin grafting.

In the second stage of surgery, bone cement was replaced with autologous cancellous bone, or bone repair was performed using the Ilizarov technique, depending on the extent of the bone defect.

Data collection

Age, sex, causes of fracture, location of defect (left and right), mangled extremity severity score (MESS), soft tissue cover, hospital stay, vacuum-assisted closure (VAC), definitive fixation method, bone defect length (cm)/volume (cm3), skin defect area, and surgical repairs were reviewed. After hospital discharge, the patients were followed up in the clinic for up to 24 months. The survival of the flaps, the time required for fracture and wound to heal, complications, and lower extremity functional assessment using the Johner-Wruhs scoring system were documented. During the follow-up evaluations, complete bone healing was determined when the patients had full weight bearing.

Statistical analysis

Categorical data were presented as numbers or percentages, and continuous data were presented as medians (range). Only descriptive statistics were used.

Results

Baseline characteristics of study participants

Fifteen patients (11 males aged 19 to 72 years) were enrolled. Six patients were injured by heavy objects, and nine were in traffic accidents. The areas of the soft tissue defects ranged from 3 × 6 cm to 21 × 10 cm. The length of the tibial defect was between 0 and 13 cm (mean length of 5.1 cm). The MESS value was between 4 and 7. The mean time elapsed from injury to debridement was 5.3 h (2–13 h). After thorough debridement, all patients received first-stage surgery, which included covering the fracture wound with a local muscle or myocutaneous flap transfer (or combined with the Masquelet technique). After the muscle or myocutaneous flap transfer, three patients received skin grafting, and 12 patients received simple sutures to close the wound during the second-stage surgery. All local flaps transferred were able to completely cover the exposed bone wounds. Three patients received a medial gastrocnemius myocutaneous flap, eight received a medial gastrocnemius muscle flap, and four received a soleus muscle flap. During the second stage of surgery, three patients received skin grafting, and 12 patients received simple suturing to close the wound (Table 1).

Table 1 Baseline characteristics of the patients.
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Surgical outcomes

The follow-up ranged from 8 to 24 months. All fractures and wounds healed. The range of bone healing time was 6–17 months, and the range of wound healing time was 1–3 weeks. The flaps were soft, although with varying degrees of pigmentation. The length of hospital stay was 11–30 days (mean 26 days). The Ilizarov technique initially failed in two patients, but treatment was successful after the fracture ends were debrided. All patients reported acceptable functional recoveries and satisfactory leg appearance, with Johner-Wruhs scores of excellent, good, and fair in 10, four, and one patients, respectively. The excellent-good rate was 93.3%. Complications were found in four of 15 patients, including one case of infection and one of nonunion. These complications were managed successfully by appropriate interventions, such as debridement, antibiotic therapy, bone grafting, and revision surgery. No cases of flap loss, deep vein thrombosis, or amputation were reported in this study.

Case 1

A 33-year-old male was injured by a heavy object, resulting in an open left tibiofibular comminuted fracture (42-C3.2, Gustilo type IIIB). He had no other injury. The distal extremity had normal blood circulation but mild nerve contusion. Physical examinations showed an open wound to the left lower leg (Fig. 1A). A large segment of the fractured tibia was exposed, with periosteal stripping. After debridement, the free bone fragments were without blood supply. The anteroposterior and lateral radiographs of the tibia and fibula revealed a comminuted fracture of the tibia with local bone loss. The fibula exhibited a multi-segmental comminuted fracture. The ankle joint was aligned and stable (Fig. 1B, C). The patient was diagnosed with Gustilo IIIB open tibiofibular fracture. Debridement, internal and external fixation, local muscle or myocutaneous flap transfer, and reconstruction of the bone defect with an autogenous bone graft from the iliac crest were performed.

Fig. 1
figure 1

A 33-year-old male sustained a comminuted fracture of the left tibia and fibula (classified as 42-C3.2, Gustilo IIIB type) after being struck by a heavy object. (A–C) A comminuted fracture of the left tibia and fibula (classified as 42-C3.2, Gustilo IIIB type); (D,E) After thorough debridement, an external fixation frame was applied temporarily to the tibia, with the exposed bone covered by a soleus muscle flap to protect the wound surface; meanwhile, free skin grafting was performed to cover the muscular tissue; (F,G) The external fixator was removed, the skin graft survived stably and the wound healed; (H–K) Plate fixation.

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During the first stage of surgery, the free devascularized bone fragments were removed after debridement. A memory alloy fixator was used for fixation. The bone defects were temporarily stabilized with an external fixator (Fig. 1D). The medial head of the soleus muscle was used to cover the defect area. The surrounding skin was closed using tension sutures (Fig. 1E). The area of the wound was 12 × 6 cm. The granulation tissue grew well before the skin grafting, and the skin graft survived. Three weeks after wound closure, an intramedullary plate was inserted for fixation, and a small amount of autogenous iliac bone was grafted. The fracture site was healed 6 months later, with soft tissue coverage (Fig. 1F, G) and good fixation (Fig. 1H–K). The patient was followed up in the clinic for 22 months with satisfactory functional recovery.

Case 2

A 60-year-old female had an open comminuted fracture of the lower tibiofibular region due to a traffic accident. An area of the tibial periosteum, approximately 20 cm long, was exposed, as was the anterior tibial muscle (Fig. 2A, B). The free bone fragments were removed during debridement (Fig. 2C). The preoperative X-ray showed a severe comminuted fracture of the lower tibiofibular segment. The anteroposterior X-ray revealed a separation of the upper tibiofibular joint (Fig. 2D). There was no fracture in the ankle joint. The patient was diagnosed with Gustilo IIIB open tibiofibular fracture. Debridement, external fixation, local muscle or mucocutaneous flap transfer, and the Ilizarov technique were performed.

Fig. 2
figure 2

(A,B) Post-injury appearance of the open wound, with a substantial portion of the tibia exposed; (C) Avulsed bone fragments without blood supply; (D) Post-fracture X-ray of the tibia and fibula, demonstrating comminuted fractures at the distal ends; (E–G) Following debridement, tibial shortening is observed, with the anterior tibialis muscle flap and soleus muscle flap utilized to cover the wound site; (H,I) Follow-up X-rays after debridement and external fixation, illustrating the status of the surgical site. (J–L) Illustrates the process of tibial lengthening using the Ilizarov technique following the shortening procedure. (M,N) Represents the condition of the external fixation frame after the completion of distraction. (O,P) Demonstrates the state of the wound healing with a dry appearance. (Q,R) Shows the X-ray image upon removal of the external fixation apparatus.

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During the first stage of surgery, the soleus muscle was debrided. The anterior tibial muscle was sutured to cover the exposed tibia. Then, the area of the exposed wound was 25 × 6 cm (Fig. 2E-G). The tibia and fibula were shortened and fixed externally across the ankle joint (Fig. 2h-i). Two weeks later, the wound was closed after the soft tissue swelling subsided. One month later, the Ilizarov procedure was performed to lengthen the shortened tibia, with traction applied to the displaced fibula. The tibia was finally restored to its original length, and the proximal fibula returned to its normal position. The knee joint was stable. Figure 2 depicts the tibia and fibula completely healed 11 months after the Ilizarov procedure, although there was still a linear soft tissue scar in the lower leg (Fig. 2J-N). During 3 years of follow-up, repeat X-rays revealed satisfactory bone healing with normal alignment (Fig. 2O-R).

Discussion

The results showed that this technique was effective in providing adequate soft tissue coverage and fracture healing, with low complication and infection rates. The patients also reported satisfactory functional and aesthetic outcomes, with a high excellent-good rate. This technique may offer a viable alternative to the conventional reconstruction methods for this complex injury.

This study is supported by previous reports on the local muscle or myocutaneous flap transfer for defect treatment12,13,14. The advantages of this technique include preserving the blood supply of the flap and improving the functional and aesthetic outcomes15,16,17. The local muscle or myocutaneous flap transfer can also avoid the potential complications of free tissue transfer, such as flap failure, donor site morbidity, and microvascular anastomosis problems17,18,19. In the present study, the exposed bone parts of the wound were covered by a medial gastrocnemius myocutaneous flap in three patients, a medial gastrocnemius muscle flap in eight patients, and a soleus muscle flap in four patients. The medial head of the gastrocnemius muscle and a soleus muscle flap were used to cover the exposed tibia so that the bone could be covered with good tissue in the early stage, avoiding bone necrosis and bone infection caused by long-term exposure and reducing the risk of skin flap in the second operation. Satisfactory early soft tissue coverage was achieved for all patients.

The mean length of hospital stay in this study was 26 days, comparable to the reported range of 18 to 35 days in previous studies using local flap transfer for open tibial fractures20,21. Still, some studies using free flap transfer reported shorter hospital stays of 10 to 15 days22, suggesting that free flap transfer may have some advantages over local flap transfer in terms of hospitalization time. The survival rate of local flaps in this study was 100%, consistent with the high success rates of 95–100% reported in previous studies using local flap transfer12,23. It indicates that local flap transfer is a reliable and simple method for soft tissue coverage of open tibial fractures, with minimal risk of flap failure or necrosis. The mean time for fracture healing in this study was 43.8 weeks, slightly longer than the reported range of 24 to 40 weeks in previous studies using local flap transfer12,24,25. It may be related to the size and location of the bone defects, the type of bone reconstruction technique used (Masquelet or Ilizarov), and the presence of infection or nonunion. The mean time for wound healing in this study was 1–3 weeks, similar to the reported range of 2 to 4 weeks in previous studies using local flap transfer12,26,27,28. The results suggest that local flap transfer can provide adequate and rapid wound closure without major complications such as infection or dehiscence. The complication rate in this study was 26.7%, which is in the low range of the reported 20-50% in previous studies12,29. The complications in this study included two cases of Ilizarov technique failure, one case of infection, and one case of nonunion. These complications were managed successfully by appropriate interventions, such as debridement, antibiotic therapy, bone grafting, and revision surgery. No cases of flap loss, deep vein thrombosis, or amputation were reported in this study, which is consistent with the low incidence of these complications in other studies using local flap transfer12,30. It indicates that local flap transfer combined with the Masquelet or Ilizarov technique can provide satisfactory functional recovery with minimal impairment of range of motion, strength, and stability. The Johner-Wruhs scoring system used in this study showed that 10 patients had excellent results, four had good results, and one had fair results, with an excellent-good rate of 93.3%. It is comparable to the reported 80–100% range in other studies using local flap transfer12,15. It suggests that local flap transfer can also provide satisfactory cosmetic outcomes, with acceptable leg appearance and minimal donor site morbidity.

This study supports using the Masquelet or Ilizarov technique as a bone reconstruction option for open tibial fractures with bone loss31. The Masquelet technique is a two-stage procedure that involves the insertion of an antibiotic cement spacer in the first stage, followed by removing the spacer and grafting autologous bone within the induced membrane in the second stage32. The Ilizarov technique is a method of external fixation that allows a gradual distraction and compression of the fracture site and the correction of deformities and length discrepancies31,33. Both techniques effectively promote bone healing and restore limb function in patients with segmental bone defects34. In this study, both techniques achieved satisfactory results.

Nevertheless, this study also has some limitations that should be acknowledged. First, this single-center study has a small sample size and a short follow-up period, which may limit the generalizability and reliability of the results. Second, the study design was retrospective and lacked a control group, which may introduce selection bias and confounding factors. Third, the study did not assess the objective measures of the flap viability, such as perfusion and oxygenation, which may affect flap survival and wound healing. Fourth, the study did not evaluate the long-term outcomes of the flap transfer, such as flap contracture, hypertrophy, or atrophy, which may affect the functional and aesthetic results.

In conclusion, local muscle or myocutaneous flap transfer may be useful for treating Gustilo IIIB open tibiofibular fractures. It can provide satisfactory soft tissue coverage and fracture healing with low complication and infection rates. It can also improve the functional and aesthetic outcomes of the patients with a high excellent-good rate. Further studies with larger sample sizes, longer follow-up periods, and randomized controlled design are needed to confirm the benefits of this technique and compare it with the conventional methods of reconstruction.