Document Type: TECHNICAL NOTE

Authors

Infection, Open tibial fracture, Polymethylmethacrylate, Soft tissue defect

Abstract

 
The management of soft tissue defects in tibial fractures is essential for limb preservation. Current techniques are not without complications and may lead to poor functional outcomes. A salvage method is described using three illustrative cases whereby a combination of flaps and antibiotic-impregnated polymethylmethacrylate beads are employed to fill the bony defect, fight the infection, and provide a surface for epithelial regeneration and secondary wound closure. This was performed after the partial failure of all other options. All patients were fully ambulatory with no clinical, radiographic or laboratory sign of infection at their most recent follow-up. Although our findings are encouraging, this is the first report of epithelialization of the skin on a polymethylmethacrylate scaffold. Further studies investigating the use of this technique are warranted.

Keywords

Main Subjects

1. Gustilo RB, Anderson JT. Prevention of infection
in the treatment of one thousand and twenty-five
open fractures of long bones: retrospective and
prospective analyses. J Bone Joint Surg Am. 1976;
58(4):453-8.
2. Templeman DC, Gulli B, Tsukayama DT, Gustilo RB.
Update on the management of open fractures of the
tibial shaft. Clin Orthop Relat Res. 1998; 350:18-25.
3. Caudle RJ, Stern PJ. Severe open fractures of the tibia.
J Bone Joint Surg Am. 1987; 69(6):801-7.
4. Shepherd LE, Costigan WM, Gardocki RJ, Ghiassi AD,
Patzakis MJ, Stevanovic MV. Local or free muscle
flaps and unreamed interlocked nails for open tibial
fractures. Clin Orthop Relat Res. 1998; 350:90-6.
5. Gopal S, Majumder S, Batchelor AG, Knight SL, De
Boer P, Smith RM. Fix and flap: the radical orthopaedic
and plastic treatment of severe open fractures of the
tibia. J Bone Joint Surg Br. 2000; 82(7):959-66.
6. Paley D, Maar DC. Ilizarov bone transport treatment
for tibial defects. J Orthop Trauma. 2000; 14(2):76-85.

7. Tulner SA, Schaap GR, Strackee SD, Besselaar PP,
Luitse JS, Marti RK. Long-term results of multiplestage
treatment for posttraumatic osteomyelitis of
the tibia. J Trauma. 2004; 56(3):633-42.
8. Arnold PG, Yugueros P, Hanssen AD. Muscle flaps
in osteomyelitis of the lower extremity: a 20-year
account. Plast Reconstr Surg. 1999; 104(1):107-10.
9. Ring D, Jupiter JB, Gan BS, Israeli R, Yaremchuk MJ.
Infected nonunion of the tibia. Clin Orthop Relat Res.
1999; 369:302-11.
10. Musharrafieh R, Osmani O, Saghieh S, Elhassan B,
Atiyeh B. Microvascular composite tissue transfer for
the management of type IIIB and IIIC fractures of the
distal leg and compound foot fractures. J Reconstr
Microsurg. 1999; 15(7):501-7.
11. Rozbruch SR, Pugsley JS, Fragomen AT, Ilizarov S.
Repair of tibial nonunions and bone defects with
the Taylor Spatial Frame. J Orthop Trauma. 2008;
22(2):88-95.
12. Khanna SC, Speiser P. In vitro release of
chloramphenicol from polymer beads of alphamethacrylic
acid and methylmethacrylate. J Pharm
Sci. 1970; 59(10):1398-401.
13. Adams K, Couch L, Cierny G, Calhoun J, Mader JT. In
vitro and in vivo evaluation of antibiotic diffusion from
antibiotic-impregnated polymethylmethacrylate
beads. Clin Orthop Relat Res. 1992; 278:244-52.
14. Wenke JC, Owens BD, Svoboda SJ, Brooks DE.
Effectiveness of commercially-available antibioticimpregnated
implants. J Bone Joint Surg Br. 2006;
88(8):1102-4.
15. Penn-Barwell JG, Murray CK, Wenke JC. Local
antibiotic delivery by a bioabsorbable gel is superior
to PMMA bead depot in reducing infection in an open
fracture model. J Orthop Trauma. 2014; 28(6):370-5.
16. Kretlow JD, Shi M, Young S, Spicer PP, Demian N,
Jansen JA, et al. Evaluation of soft tissue coverage over
porous polymethylmethacrylate space maintainers
within nonhealing alveolar bone defects. Tissue Eng
Part C Methods. 2010; 16(6):1427-38.
17. Nguyen C, Young S, Kretlow JD, Mikos AG, Wong M.
Surface characteristics of biomaterials used for space
maintenance in a mandibular defect: a pilot animal
study. J Oral Maxillofac Surg. 2011; 69(1):11-8.
18. Masquelet AC, Fitoussi F, Begue T, Muller GP.
Reconstruction of the long bones by the induced
membrane and spongy autograft. Ann Chir Plast
Esthet. 2000; 45(3):346-53.
19. Gouron R, Petit L, Boudot C, Six I, Brazier M, Kamel S, et
al. Osteoclasts and their precursors are present in the
induced-membrane during bone reconstruction using
the Masquelet technique. J Tissue Eng Regen Med. 2014.
20. Gruber HE, Riley FE, Hoelscher GL, Bayoumi
EM, Ingram JA, Ramp WK, et al. Osteogenic and
chondrogenic potential of biomembrane cells from
the PMMA-segmental defect rat model. J Orthop Res.
2012; 30(8):1198-212.
21. Pelissier P, Masquelet AC, Bareille R, Pelissier SM,
Amedee J. Induced membranes secrete growth
factors including vascular and osteoinductive factors
and could stimulate bone regeneration. J Orthop Res.
2004; 22(1):73-9.