[Treatment concept and results of grade 3 open fractures with arterial injuries requiring reconstruction]

Ninety-one open fractures associated with arterial injury requiring vascular repair (type IIIC injuries) were treated at the University of Louisville between May 1983 and January 1994. Involved anatomical areas were the humerus (6x), the forearm (11x), the femur (16x), the tibia (36x), the ankle (11x) and the foot (11x). Fracture management consisted of meticulous radical debridement, copious wound irrigation, fasciotomy and fracture stabilization. Additionally, 49 wounds (53.8%) were treated with the supplemental local use of antibiotics (tobramycin-PMMA-beads). Thirty-four patients underwent primary amputation whereas 57 repairs of the injured vessels were performed. There were 7 secondary amputations due to infection or poor revascularization resulting in an overall amputation rate of 45.1%. The wound infection rate was 12.1% (11/91) and the rate for osteomyelitis was 3.3% (3/91). The local use of the antibiotic beads was of significant benefit to lower infectious complications. Primary coverage of the soft tissue defect with free tissue transfer was associated with a high infection rate (2/3) and is not recommended for this type of injury. Temporary wound coverage with the "antibiotic bead pouch" technique until wound closure can be obtained in a sterile and viable environment leads to more satisfying results.