Management of bony defects in open grade III fractures

Early soft tissue reconstruction is recommended in treating open grade III fractures. Yet, there are still controversies regarding the way to handle bony defects when the soft tissue reconstruction is completed. This is a retrospective study to evaluate various methods of treating bony defects after soft tissue reconstruction in open fractures. From May 1985 to June 1988, we experienced 16 cases of open grade III fractures of the extremities with bony defects which received either local treatment with flap transfers (five cases) or free flap transfers (11 cases). The bony defects ranged from 3 cm to 10 cm in length. Cancellous bone grafting was performed in nine cases, and two of them received internal fixation at the same time. Seven cases received vascularized bone grafts (six fibulas and one iliac bone). Our results showed that bone grafting, with either a conventional cancellous bone graft or a vascularized bone graft, is useful in treating bony defects after soft tissue reconstruction. Internal fixation of the fractures after removing an extraskeletal fixator has the disadvantages of soft tissue breakdown and of possible infection. Early posterolateral bone grafting was beneficial if a cancellous bone graft was used on the tibia. Double free tissue transfers were quite useful, and we did not lose any free tissue transfers in our series. Vascularized bone grafts should be considered in cases where the osseous gap is greater than 6 cm, or where the recipient bed is bad.