GUSTILO 3C OPEN FRACTURES OF THE LOWER EXTREMITY: ANALYSIS OF EARLY AND LATE OUTCOMES

Abstract

Between 1990 and 2000, 15 patients with open 3C fractures of the lower extremity were treated at our institution. Demographic data such as age, sex, associated injuries and co-morbidities were recorded. The mechanism of injury, ISS [Injury Severity Score] and MESS [Mangled Extremity Severity Score] were ascertained. The minimum follow up was 2 years. All the fractures were classified according to the AO system. The patients received a combined treatment by the orthopaedic and plastic surgeons and when necessary by the vascular surgeons. Treatment options, were based on the extent of soft-tissue damage and the configuration of the fracture. Intra-operative details including arteries and nerves involved, type of flap cover, quality of fixation and need for fasciotomy were recorded and analysed. A final follow up was carried out at a special clinic and the outcome was analyzed using SF-36 and EUROCOL. MESS and ISS were analyzed for possible predictors of final functional outcome.

The patients were predominantly males. The main mechanism of injury was due to a road traffic accident and 6 of the patients had associated injuries in other parts of the body. In two thirds of the patients the fracture site was in the tibia, and in 3 cases there was a combined fracture in femur and tibia. The posterior tibial artery was involved in the vast majority of the cases, which was either disrupted or avulsed. The Salvage and reconstruction was carried out in 13 patients, which accounted for 77% of the cases and 2 patients underwent immediate amputation. Both had a Mangled Extremity Severity Score of 10. The bone fixation was mainly achieved by plating, or nailing. Half of the patients underwent fasciotomy, in the rest the compartments were decompressed due to the nature and extent of the injury. All the patients required secondary procedures, the mean total number of operations was 2.6.

Although only one-fifth of the patients had some problems with self care, half experienced some problems with mobility. Anxiety and depression was a problem in two thirds of the patients, and about the same proportion of patients experienced moderate to severe pain. The mobility was correlated to the MESS score.

Conclusion: the functional outcome was most closely related to the severity of injury and the injury-surgery interval. Our study showed that improved functional outcome is possible following surgical treatment of these challenging injuries especially when prompt response is instituted by combined ortho/plastic/vascular surgical teams.