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Tissue flaps and their use in open tibial fractures: a complex picture


In a review of treatment options for open tibial fractures, Chan et al. consider recent developments that may promote fracture healing and prevent nonunion. These fractures often occur in young men as a result of trauma, and achieving union takes, on average, 43 weeks, with 13% of cases developing nonunion despite care in the best centers.

Innovations in the patient care pathway, improved techniques for stabilizing the fracture, prompt debridement of nonviable tissue and the use of biological therapy to supply bone morphogenetic proteins have brought about improvements, but the type of tissue flap that is most effective remains unclear.

Using evidence from animal models, clinical studies, retrospective reviews and their own extensive experience, the authors conclude that fasciocutaneous flaps are preferable to muscle flaps in patients with a metaphyseal fracture close to the ankle, as this avoids the need for skin grafts. However, patients with diaphyseal fractures may benefit from a muscle flap as this promotes healing if the fracture is at higher risk of nonunion.

Editor’s comment: Using soft tissue flaps to cover the wound prevents infection and desiccation, but flaps also act as a source of vascularization and provide a local supply of stem cells, osteoprogenitor cells and growth factors. Early debridement and prompt use of a soft tissue flap is crucial, but the final choice of which soft tissue to use is dependent on the site and characteristics of the individual fracture.

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