From July 2004 to March 2010, 13 patients underwent soft tissue reconstruction according to IRS due to internal hardware exposure and various-degree soft tissue damage. At the presentation c/o our departments of tissues infection was detected in 10 cases (76.9%) before surgery (mainly Enterococcus spp and Staphilococcus spp) and the wounds had an average measure of 38.2 ± 55.6 cm2.
The mean age at presentation was 46.4 years (ranging from 24 to 71) and the wound was present from an average of 5 months (9.89 months in cases affected by infection and 6.27 in patients without infection) In all cases the internal hardware was made by stainless steel.
In six patients the lesion was localized on the left lower limb, in seven patients on the right. In 15.4% of cases the wound lay at the lateral malleolus, in 23.1% on the medial malleolus and in eight cases (61.5%) along the distal third of tibia.
In all cases incomplete ossification at presentation was reported, in one case a soft tissue reconstruction was already attempted by local flaps.
In two cases, an eschar on more than 60% of the wound was observed.
Among infected patients, debridement of necrotic tissues was performed in five patients in order to achieve a sterile ground for the further soft tissue reconstruction. At the orthopedic follow-up, no signs of osteomyelitis have been reported (Additional file 2: Table S2 and Additional file 3: Table S3).
The following flaps were raised: sural fasciomiocutaneous in four cases, sural fasciocutaneous in three cases, three medial gastrocnemius muscle flaps, one soleus muscle flap, one perforator flap and one free anterolateral thigh flap. The mean time from internal hardware placement and soft tissue reconstruction was 13 months. After raising the flap, complications occurred in eight cases (61.5%). All of these cases were pre-operatively affected by soft tissues infection. No complications were observed in the other patients.
The observed complications include fistulization at flap‘s margin (five cases), necrosis (two cases) and dehiscence (one case). In those cases affected by fistulization (five patients), the coltures revealed the same of the infective agents observed before surgery.
In three cases the cutaneous dehiscence healed only after substitution of the internal hardware with an external fixator.
In two cases (15.4%), where the flap was affected by margin dehiscence and wound infection, the surgeon opted to perform debridement of necrotic and purulent tissues, 25 and 17 days after harvesting the flap.
In one case complete necrosis of the flap was observed six days after surgery (Additional file 4: Table S4 and Additional file 5: Table S5).
Assuming that no patients became infected after surgery, Mc Nemar test for paired samples showed no significative improvements in infection rate from the pre-operative period to the post-operative time (p = 0.125). Nevertheless a documented pre-operative infection is significantly associated with overall complications (p = 0.002), consisting in a predictive value of 0.89, while it is not associated with the necessity of further surgeries (p = 0.057), although this relationship is plausible.
When reconstruction was performed at more than six months from internal hardware application, higher rates of complications are observed (p = 0.028).
Apparently, wound size neither surgical debridement (performed in a previous surgery) have associations with the outcome variables, as much as the so-called “potentially predictive variables”. Surgical technique and complications have no statistically valuable nexus.
Full flap necrosis was observed in case two which was treated with a perforator flap. After flap failure, extensive debridement was performed and, in a further surgical time, a sural fasciocutaneous flap was harvested without hardware removal. The patient healed with no complications. Fracture fixation resulted stable in all cases and removal of internal hardware was generally unnecessary. In three cases internal hardware was removed for the application of external fixators in order to achieve complete healing of the wound where persistent wound infection and/or dehiscence was observed.
Among our case series, 10 patients came to our attention with exposed bone and infected wounds, belonging to stage 2 or superficial osteomyelitis according to Cierny-Mader classification . No signs of intramedullary, localized or diffuse osteomyelitis (stages 1, 3 and 4) have been reported. After the treatment with IRS, no signs of osteomyelitis were observed.