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초록
Purpose:
Hardware exposure after the lower extremity fractures operation is challenging to manage and requires long-term treatment. The traditional management of exposed hardware usually includes hardware removal. The purpose of this study was to evaluate the proper treatment for the cases with exposed hardware in patients with lower extremity fracture.
Methods:
Between October 2011 and October 2015, a total of 14 cases of hardware exposure who had previously been managed for lower extremity fractures required surgical debridement, revised surgery by the orthopedic surgical team and reconstruction with fasciocutaneous perforator flaps. A retrospective chart review was performed.
Results:
Of the 14 cases included, 5 were open fractures at the time of the initial injury, and 9 were closed. The management of the exposed hardware was determined after examining the bony union status and device loosening. Anterolateral thigh free flap, posterior tibial artery perforator-based propeller flap, and peroneal artery perforator-based propeller flap were performed. All flaps survived without major complications. There were three cases of persistent infections that required the removal of the hardware again and repeated debridement. All three cases involved hardware that had been ex-changed during the flap surgery because of loosening.
Conclusion:
We achieved positive results by treating exposed hardware with fasciocutaneous perforator flaps and main-taining the original hardware, except in the cases where it had loosened. In cases with device loosening, there is possibili-ty of progression to persistent infection and osteomyelitis even after properly treated with device exchange and soft tissue reconstruction.
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Fig.1.
A treatment algorithm of our hospital for treating hardware exposure after lower extremity fracture operation.
Fig.2.
(A, B) The hardware was exposed through a 1.5×1.5 cm skin and soft tissue defect on the medial malleolus. (C) After a meticulous debridement, we left the hardware intact and covered the defect with a posterior tibial artery perforator-based propeller flap. (D) The surgical site remained closed and asymptomatic 6 months after the surgery.
Fig.3.
(A) The hardware was exposed through a 3×3 cm skin and soft tissue defect on the dorsum of the foot. (B) We left the hardware intact and covered the defect with a free anterolateral thigh fasciocutaneous flap. (C) The surgical site remained closed and asymptomatic 6 months after surgery.
Fig.4.
(A) After removal of the hardware, a 14×4 cm sized skin and soft tissue defect was noted on the antetibial area of the patient's left leg. (B) After hardware removal and intramedullary nailing of the tibia fracture, the soft tissue defect was covered using an anterolateral thigh free flap. (C) The surgical site remained closed and asymptomatic 28 months after surgery.
Table1.
The clinical characteristics of eleven cases following the surgical treatment of a lower extremity fracture
| No. | Age (yr)/ Sex | Initial type of injury | Interval between trauma and flap surgery (wk) | Defect size (cm) | Treatment of prosthesis | Type of flap | Underlying disease | Osteomyelitis (before the flap surgery) | Cultured organism | Union time (wk) | Complication |
|---|---|---|---|---|---|---|---|---|---|---|---|
| 1 | 15/F | Lt. lower leg amputation | 8 | 12×8 | Leave intact | Free ALT flap | - | - | E. coli MRSA | 46 | - |
| 2 | 25/M | Lt. tibia fracture | 17 | 14×4 | Exchange of internal fixator | Free ALT flap | - | ○ | E. cloacae | 72 | Persistent infection |
| 3 | 24/M | Lt. open tibiofibular fracture | 8 | 5×25×5 | Exchange of internal fixator | Free ALT flap | - | - | E. cloacae A. baumanii K. pneumonia S. maltophilia E. faecalis | 62 | Partial flap necrosis Persistent infection |
| 4 | 28/F | Rt. Pilon fracture, ankle | 5 | 1.5×1.5 | Leave intact | PTA perforator based propeller flap | - | - | No growth | 30 | - |
| 5 | 77/F | Lt. tibiofibular fracture | 45 | 3×1 | Leave intact | PTA perforator based propeller flap | - | - | No growth | 63 | - |
| 6 | 19/M | Lt. calcaneal fracture | 6 | 6×3 | Leave intact | Free ALT flap | - | - | A. baumanii E. faecalis E. coli MRSA | 28 | - |
| 7 | 23/M | Rt. open calcaneal fracture | 8 | 5×5 | Exchange of internal fixator | Free ALT flap | - | ○ | MRSA A. baumanii | 35 | Persistent infection |
| 8 | 75/M | Lt. open calcaneal fracture | 4 | 2×3 | Leave intact | Free ALT flap | HTN CVA | - | E. faecalis | 11 | - |
| 9 | 46/M | Lt. 1st, 2nd, 3rd metatarsal bone and medial cuneiform bone, fracture | 7 | 3×3 | Leave intact | Free ALT flap | - | - | MRCNS | 25 | - |
| 10∗ | 30/M | Rt. calcaneal fracture | 9 | 4×1 | Leave intact | Peroneal artery perforator based propeller flap | - | - | A. baumanii MRCNS MRSA E. faecalis | 18 | - |
| 11∗ | 30/M | Lt. calcaneal fracture | 9 | 5×3 | Leave intact | Free ALT flap | - | - | A. baumanii MRCNS | 18 | - |
| 12 | 32/M | Lt. tibia fracture | 27 | 2×2.5 | Leave intact | Posterior tibial artery perforator based propeller flap | - | ○ | No growth | 46 | - |
| 13 | 52/M | Lt. open tibiofibular fracture | 5 | 26×5 | Leave intact | Free ALT flap | - | - | MRSA | 34 | - |
| 14 | 27/M | Lt. calcaneal fracture | 3 | 2×4 | Leave intact | Peroneal artery perforator based propeller flap | Hyper-thyroidism | - | No growth | 60 | - |
F: female, Lt.: left, ALT: anterolateral thigh, E. coli: Escherichia coli, MRSA: methicillin resistant Staphylococcus aureus, M: male, E. cloacase: Enterobacter cloacase, A. baumanii: Acinetobacter baumanii, K. pneumonia: Klebsiella pneumonia, S. maltophilia: Stenotrophomonas maltophilia, E. faecalis: Enterococcus faecalis, Rt.: right, PTA: posterior tibial artery, HTN: hypertension, CVA: cerebrovascular accident, MRCNS: methicillin resistant coagulase-negative Staphylococci.
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