Three-stage surgical approach for chronically infected tibial injuries successfully salvages lower limb

Managing critical-sized tibial defects is one of the most complex challenges orthopedic surgeons face. This is even more problematic in the presence of infection and soft-tissue loss.

Pablo S. Corona et al published an article in 'Archives of Orthopaedic and Trauma Surgery' journal describing a comprehensive three-stage surgical protocol for the reconstruction of infected tibial injuries with combined bone defects and soft-tissue loss, and reports the clinical outcomes.

A retrospective study at a specialized limb reconstruction center identified all patients with infected tibial injuries with bone and soft-tissue loss for a period of 8years. 31 patients were included in the study. All cases were treated using a three-stage protocol:

(1) Infected limb damage control;

(2) Soft-tissue coverage with a vascularized or local flap;

(3) Definitive bone reconstruction using distraction osteogenesis principles with external fixation.

Primary outcome was limb salvage rate and infection eradication. Secondary outcomes were patient functional outcomes and satisfaction.

Key findings of the study were:

• Patients in this series of chronically infected tibias had been operated upon 3.4 times on average before starting our limb salvage protocol.

• The mean soft-tissue and bone defect sizes were 124 cm2 (6–600) and 5.4 cm (1–23), respectively.

• A free flap was performed in 67.7% (21/31) of the cases;

• Bone transport was the selected bone-reconstructive option in 51.7% (15/31).

• Local flap failure rate was 30% (3/10), with 9.5% for free flaps (2/21).

• Limb salvage rate was 93.5% (29/31), with infection eradicated in all salvaged limbs.

• ASAMI bone score: 100% good/excellent.

• Mean VAS score was 1.0, and ASAMI functional score was good/excellent in 86% of cases.

• Return-to-work rate was 83%.

• 86% were "very satisfied" with the treatment outcome.

The authors concluded that – "The proposed three-stage surgical approach for the management of complex infected tibial injuries, with combined bone and soft-tissue defects, yields high rates of both infection eradication and successful limb salvage. This protocol consistently delivers good functional outcomes and high levels of self-reported patient satisfaction, despite its demand for more resources than a one-step approach, and an inherent potential for complications."

Refer for further details of Three stage surgical treatment protocol (TSP):

Three stage limb salvage in tibial fracture related infection with composite bone and soft tissue defect Pablo S. Corona, Carla Carbonell Rosell et al Archives of Orthopaedic and Trauma Surgery (2022) 142:3877–3887 https://doi.org/10.1007/s00402-021-04299-9