Early internal fixation combined with free anterolateral thigh perforator flap transplantation to treat open ankle fracture-dislocation_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

HU Xingfeng , WANG Xiang , JI Liang , LIANG Wei , LUO Qixin , PENG Yang ,  LI Qingsong

Department of Hand and Microsurgery, the Fourth People’s Hospital of Guiyang, Guiyang Guizhou, 550001, P. R. China;

Corresponding author：

LI Qingsong, Email: 34451660@qq.com

Keywords：

Ankle fracture-dislocation; anterolateral thigh perforator flap; soft tissue defect; internal fixation

DOI：

10.7507/1002-1892.202505079

Video：

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Objective To evaluate the effectiveness of early internal fixation combined with free anterolateral thigh perforator flap (ALTPF) transplantation in the treatment of open ankle fracture-dislocation. Methods A retrospective analysis was performed on the clinical data of 13 patients with open ankle fracture-dislocation who were admitted and met the inclusion criteria between January 2021 and May 2024. Among them, there were 9 males and 4 females, with the ages ranging from 23 to 61 years (mean, 45.3 years). Fracture types included 5 cases of simple medial or lateral malleolar fracture-dislocation, 7 cases of bimalleolar (medial and lateral) fracture-dislocation, and 1 case of trimalleolar fracture-dislocation. Additionally, 3 cases were complicated with bone defects (1 medial malleolus defect and 2 lateral malleolus defects). All injuries were classified as type ⅢB according to the Gustilo-Anderson classification for open fractures. The size of wound defects ranged from 7 cm×5 cm to 18 cm×12 cm. The time from injury to surgery was 2-20 hours (mean, 4 hours). All patients underwent emergency thorough debridement upon admission. The fracture-dislocation was temporarily stabilized with an external fixator, and the wound was covered with antibiotic-impregnated bone cement sheets or vacuum sealing drainage. Definitive internal fixation of the fracture and free ALTPF transplantation were performed 5-7 days after the initial emergency procedure. Postoperatively, wound healing, flap survival, and fracture union were monitored. At last follow-up, clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. Results All 13 patients were followed up 6-24 months (mean, 8.2 months). All flaps survived completely, and all fractures achieved union, with an union time of 3-11 months (mean, 5.5 months). One patient developed a superficial infection at the wound margin, which healed after regular dressing changes and drainage. No internal fixation-related complications (e.g., deep infection, implant loosening, or secondary ankle instability) were observed. At last follow-up, the total AOFAS ankle-hindfoot score was 78.6±13.5, with 3 excellent, 7 good, 2 fair, and 1 poor cases, yielding an excellent and good rate of 76.9%. Conclusion Early internal fixation combined with ALTPF transplantation for open ankle fracture-dislocation can shorten the treatment course and maximize the recovery of ankle joint function.

1.	Cao MM, Zhang YW, Hu SY, et al. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg, 2022, 9: 965814. doi: 10.3389/fsurg.2022.965814.
2.	Lawson KA, Ayala AE, Morin ML, et al. Republication of “ankle fracture-dislocations: A review”. Foot Ankle Orthop, 2023, 8(3): 24730114231195058. doi: 10.1177/24730114231195058.
3.	朱庆棠, 李文军, 朱磊, 等. 严重开放性肢体创伤早期救治专家共识. 中华显微外科杂志, 2023, 46(1): 7-24.
4.	Xue X, Li N, Ren L. Effect of vacuum sealing drainage on healing time and inflammation-related indicators in patients with soft tissue wounds. Int Wound J, 2021, 18(5): 639-646.
5.	Burtt KE, Badash I, Leland HA, et al. The efficacy of negative pressure wound therapy and antibiotic beads in lower extremity salvage. J Surg Res, 2020, 247: 499-507.
6.	Rupp M, Walter N, Szymski D, et al. The antibiotic bead pouch-a useful technique for temporary soft tissue coverage, infection prevention and therapy in trauma surgery. J Bone Jt Infect, 2023, 8(3): 165-173.
7.	余斌, 王博炜. 外固定支架在创伤骨科中的应用. 中华创伤骨科杂志, 2020, 22(4): 282-285.
8.	Kamin K, Rammelt S, Kleber C, et al. External fixator: temporary fixation and soft tissue management of the ankle. Oper Orthop Traumatol, 2020, 32(5): 421-432.
9.	Wawrose RA, Grossman LS, Tagliaferro M, et al. Temporizing external fixation vs splinting following ankle fracture dislocation. Foot Ankle Int, 2020, 41(2): 177-182.
10.	Ye Z, Zhao S, Zeng C, et al. Study on the relationship between the timing of conversion from external fixation to internal fixation and infection in the treatment of open fractures of extremities. J Orthop Surg Res, 2021, 16(1): 662. doi: 10.1186/s13018-021-02814-7.
11.	Shen M, Tejwani N. Open tibial shaft fracture fixation strategies: intramedullary nailing, external fixation, and plating. OTA Int, 2024, 7(4 Suppl): e316. doi: 10.1186/s13018-021-02814-7.
12.	Abdelgawad A, Elabd A, Pisquiy JJ, et al. Early internal fixation of open ankle malleolar fractures is not associated with increased complications: case control study. Acta Orthop Belg, 2022, 88(4): 825-833.
13.	Pearce O, Al-Hourani K, Kelly M. Ankle fractures in the elderly: Current concepts. Injury, 2020, 51(12): 2740-2747.
14.	张磊, 李明慧, 张梦瑶, 等. 下胫腓联合损伤重建术中螺钉植入角度的生物力学研究. 中国修复重建外科杂志, 2024, 38(12): 1480-1485.
15.	Mauffrey C, Barlow BT, Smith W. Management of segmental bone defects. J Am Acad Orthop Surg, 2015, 23(3): 143-153.
16.	Goldsmith T, Ford B, Marsden N, et al. Soft tissue coverage of the ankle: An algorithm for appropriate flap selection and the experiences of a newly established Major Trauma Network. Injury, 2023, 54(10): 110920. doi: 10.1016/j.injury.2023.110920.
17.	Laitonjam M, Khan MM, Krishna D, et al. Reconstruction of foot and ankle defects: A prospective analysis of functional and aesthetic outcomes. Cureus, 2023, 15(6): e40946. doi: 10.7759/cureus.40946.
18.	徐永清, 唐举玉, 刘元波, 等. 股前外侧皮瓣穿支解剖学特征与定位方法的专家共识 (2024版). 中国临床解剖学杂志, 2024, 42(5): 489-499.
19.	周洪翔, 钟林, 何亮, 等. Flow-through桥式股前外侧皮瓣修复复杂小腿软组织缺损. 中国修复重建外科杂志, 2023, 37(4): 482-487.
20.	王伟, 周征兵, 程冬冬, 等. 联体股前外侧穿支皮瓣修复足踝部大面积软组织缺损. 中国修复重建外科杂志, 2022, 36(9): 1178-1180.

1. Cao MM, Zhang YW, Hu SY, et al. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg, 2022, 9: 965814. doi: 10.3389/fsurg.2022.965814.
2. Lawson KA, Ayala AE, Morin ML, et al. Republication of “ankle fracture-dislocations: A review”. Foot Ankle Orthop, 2023, 8(3): 24730114231195058. doi: 10.1177/24730114231195058.
3. 朱庆棠, 李文军, 朱磊, 等. 严重开放性肢体创伤早期救治专家共识. 中华显微外科杂志, 2023, 46(1): 7-24.
4. Xue X, Li N, Ren L. Effect of vacuum sealing drainage on healing time and inflammation-related indicators in patients with soft tissue wounds. Int Wound J, 2021, 18(5): 639-646.
5. Burtt KE, Badash I, Leland HA, et al. The efficacy of negative pressure wound therapy and antibiotic beads in lower extremity salvage. J Surg Res, 2020, 247: 499-507.
6. Rupp M, Walter N, Szymski D, et al. The antibiotic bead pouch-a useful technique for temporary soft tissue coverage, infection prevention and therapy in trauma surgery. J Bone Jt Infect, 2023, 8(3): 165-173.
7. 余斌, 王博炜. 外固定支架在创伤骨科中的应用. 中华创伤骨科杂志, 2020, 22(4): 282-285.
8. Kamin K, Rammelt S, Kleber C, et al. External fixator: temporary fixation and soft tissue management of the ankle. Oper Orthop Traumatol, 2020, 32(5): 421-432.
9. Wawrose RA, Grossman LS, Tagliaferro M, et al. Temporizing external fixation vs splinting following ankle fracture dislocation. Foot Ankle Int, 2020, 41(2): 177-182.
10. Ye Z, Zhao S, Zeng C, et al. Study on the relationship between the timing of conversion from external fixation to internal fixation and infection in the treatment of open fractures of extremities. J Orthop Surg Res, 2021, 16(1): 662. doi: 10.1186/s13018-021-02814-7.
11. Shen M, Tejwani N. Open tibial shaft fracture fixation strategies: intramedullary nailing, external fixation, and plating. OTA Int, 2024, 7(4 Suppl): e316. doi: 10.1186/s13018-021-02814-7.
12. Abdelgawad A, Elabd A, Pisquiy JJ, et al. Early internal fixation of open ankle malleolar fractures is not associated with increased complications: case control study. Acta Orthop Belg, 2022, 88(4): 825-833.
13. Pearce O, Al-Hourani K, Kelly M. Ankle fractures in the elderly: Current concepts. Injury, 2020, 51(12): 2740-2747.
14. 张磊, 李明慧, 张梦瑶, 等. 下胫腓联合损伤重建术中螺钉植入角度的生物力学研究. 中国修复重建外科杂志, 2024, 38(12): 1480-1485.
15. Mauffrey C, Barlow BT, Smith W. Management of segmental bone defects. J Am Acad Orthop Surg, 2015, 23(3): 143-153.
16. Goldsmith T, Ford B, Marsden N, et al. Soft tissue coverage of the ankle: An algorithm for appropriate flap selection and the experiences of a newly established Major Trauma Network. Injury, 2023, 54(10): 110920. doi: 10.1016/j.injury.2023.110920.
17. Laitonjam M, Khan MM, Krishna D, et al. Reconstruction of foot and ankle defects: A prospective analysis of functional and aesthetic outcomes. Cureus, 2023, 15(6): e40946. doi: 10.7759/cureus.40946.
18. 徐永清, 唐举玉, 刘元波, 等. 股前外侧皮瓣穿支解剖学特征与定位方法的专家共识 (2024版). 中国临床解剖学杂志, 2024, 42(5): 489-499.
19. 周洪翔, 钟林, 何亮, 等. Flow-through桥式股前外侧皮瓣修复复杂小腿软组织缺损. 中国修复重建外科杂志, 2023, 37(4): 482-487.
20. 王伟, 周征兵, 程冬冬, 等. 联体股前外侧穿支皮瓣修复足踝部大面积软组织缺损. 中国修复重建外科杂志, 2022, 36(9): 1178-1180.

Chinese Journal of Reparative and Reconstructive Surgery

Latest ArticlesEarly internal fixation combined with free anterolateral thigh perforator flap transplantation to treat open ankle fracture-dislocation

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