Efficacy of free-flap-transfer and plate-fixation for Gustilo IIIB fractures in type II diabetic patients: A retrospective study

Abstract

Background: Managing Gustilo type IIIB fractures in patients with type 2 diabetes is challenging due to delayed healing and elevated complication risks. This retrospective study highlights the successful use of free-flap transfer combined with plate fixation, contributing insights into effective management strategies for these complex cases.

Aim: To evaluate free-flap transfer with plate fixation for managing Gustilo IIIB fractures in diabetic patients, focusing on outcomes.

Methods: A retrospective analysis of six cases was conducted with a minimum follow-up period of three years. Patients underwent free-flap transfer and plate fixation for fracture management. Outcomes assessed included bone union, flap viability, and complications requiring intervention or plate removal. The follow-up period ranged from three to four years. Persistent infections beneath the flap developed in two patients, necessitating daily wound care.

Results: Bone healing occurred within 17 to 34 months, with plate removal required in three patients after fracture consolidation. Traumatic osteomyelitis was observed in at least one patient. Despite challenges such as sinus formation and variations in flap pedicle anatomy, successful bone union and flap viability were achieved in all cases. Free-flap transfer combined with plate fixation shows promise for treating Gustilo type IIIB fractures in patients with diabetes. While infection and the need for plate removal surgeries were observed, consistent success in bone healing and flap viability highlights the potential of this approach.

Conclusion: Free-flap transfer with plate fixation effectively manages Gustilo IIIB fractures in diabetics, achieving bone/flap healing despite infection risks. Careful patient selection and further validation are critical.

Keywords: Free flap; Gustilo IIIB fractures; Plate fixation; Soft tissue defect; Type II diabetes.

Figure 1

Surgical management of Gustilo IIIB open forearm fracture. A: Type IIIB open fractures of the forearm; B: Eighteen days after the initial debridement and vacuum-assisted closure; C: Plate fixation; D: Raising of a free lateral circumflex femoral artery perforator flap; E: Anteroposterior (AP) radiograph after surgery; F: Two years post-surgery: AP view; G: Contour of the reconstructed forearm; H and I: Rotation of the forearm compared with the contralateral side.

Figure 2

Reconstruction of metacarpal fractures with composite free flap. A: Open fractures and defects of the 2^nd and 3^rd metacarpals; B: Wound before definitive surgery; C: Initial design of the composite free flap transfer; D: Free flap and non-vascularized half fibula; E and F: Nine months post-surgery: Bone healing and successful flap integration; G: Re-union of the fibula, minimizing donor site morbidity.

Figure 3

Hand reconstruction with free peroneal artery perforator flap. A: Open fracture and wound of the hand after repeated debridements; B: Multi-fractured metacarpals; C: Dissected free peroneal artery perforator flap; D and E: Twenty-seven months post-surgery: Flap coverage of the defect and maximal preservation of hand function; F: Bone healing.

Figure 4

Diabetic lower limb reconstruction with free latissimus dorsi flap. A: Diabetic leg with open fractures and skin defect; B: Design of the free latissimus dorsi flap; C: Locked compression plate used for bone fixation; D: Appearance of the flap 10 months post-surgery; E: Incomplete bone healing 18 months post-surgery; F: Complete bone healing and removal of internal hardware 30 months post-surgery.

Figure 5

Reconstruction of Gustilo IIIB tibial fracture with free latissimus dorsi flap. A: Gustilo IIIB fracture of the left leg; B: Removal of external fixation (EF) and fixation with locking compression plates, with exposure of the posterior tibial vessels; C and D: Harvested free latissimus dorsi muscle flap covering both the bone and plate with rich blood circulation; E and F: Thirty months post-surgery: Successful flap integration; G: Bone not united 18 months after surgery; H: Bone healing 29 months post-surgery.

Figure 6

Complex radius reconstruction with composite peroneal flap and free fibula. A: Gustilo IIIB fracture of the left radius with severe wound infection; B: Dry wound with extensive granulation tissue; C: Design of a composite peroneal perforator flap; D and E: Anastomosis of the free fibula and flap to the recipient site; F: Plate fixation; G-I: Successful flap integration with maximal preservation of wrist function; J and K: Pre- and post-operative radiographs.