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Staged Reconstruction Strategy for Gustilo Type IIIB and IIIC Open Fractures: A Case Series of 23 Patients
Tatsuhiko Muraoka1, Tsuneari Takahashi2, Yoshinori Ueno1
1Trauma Reconstruction Center, Yonemori Hospital, Kagoshima, Japan.
Introduction:
Management of Gustilo Type IIIB and IIIC open fractures remains challenging, particularly with regard to the timing of definitive fixation and soft-tissue reconstruction. Although early combined orthoplastic management is widely recommended, it is not always feasible in patients with severe injuries, polytrauma, or complex fracture patterns.
Materials And Methods:
We retrospectively reviewed 23 consecutive patients with Gustilo Type IIIB or IIIC open fractures treated at our institution between April 2022 and October 2024. Five patients underwent a single-stage "fix and flap" strategy, whereas 18 patients underwent a staged "fix followed by flap" strategy. Treatment selection was based on injury severity, fracture complexity, soft-tissue condition, and the overall physiological status of the patient. Clinical outcomes, including deep infection, non-union, malunion, and amputation, were assessed, together with treatment timing and operative duration.
Results:
Patients treated with the staged strategy tended to have more severe overall injuries, with a higher mean injury severity score than those treated with the fix-and-flap strategy (13.8 ± 7.3 vs. 10.8 ± 4.0, P = 0.25). All patients requiring concurrent surgery for other anatomical sites were treated with the staged protocol. Deep infection occurred in two patients in each group. One patient in the staged group required additional surgery for an infected non-union. No cases of malunion or amputation were observed in either group. Importantly, no patients required additional flap procedures, indicating that adequate soft-tissue coverage was achieved in all cases.The interval from injury to osteosynthesis was similar between groups, whereas the interval to soft-tissue reconstruction was significantly longer in the staged group (9.2 ± 2.2 vs. 4.8 ± 0.8 days, P < 0.01). Operative time for osteosynthesis was also significantly longer in the staged group.
Conclusion:
A staged "fix followed by flap" strategy appears to be a practical and clinically useful option for managing complex Gustilo Type IIIB and IIIC open fractures when early combined reconstruction is not achievable. This approach may allow more accurate planning of soft-tissue coverage in severe injuries.
