OTA 2006 Posters
Scientific Poster #40 Foot and Ankle
Challenging the Dogma of the 7-cm Rule: A Prospective Study Evaluating
Incision Placement and Wound Healing for Tibial
Plafond Fractures
James L. Howard MD, MSc (n); Julie Agel, MA, ATC (n);
David Barei, MD (n); Stephen Benirschke, MD (n); Sean Nork, MD (n);
Harborview Medical Center, University of Washington,
Seattle, Washington, USA
Purpose: This prospective observational study was designed to report
the soft-tissue complications after fixation of tibial plafond fractures
in an effort to challenge the current overriding sentiment that a 7-cm skin
bridge represents the minimum safe distance between surgical incisions.
Our hypothesis was that many of the skin bridges in the study would be less
than 7 cm and that this would not result in an increased incidence of wound
complications compared to previously published values.
Methods: Inclusion criteria included surgical treatment using a minimum
of two surgical approaches for the tibial plafond and the associated fibula
fracture (if applicable). 42 adult patients with 46 tibial plafond fractures
were enrolled in the study between July 1, 2004 and December 30, 2005. There
were 1 A1, 3 B1, 2 B3, 6 C1, 6 C2, and 28 C3 fractures. 44 plafond fractures
had an associated fibular fracture. There were 36 closed and 10 open fractures.
High-energy injuries were managed using a two-staged approach consisting
of fibular open reduction and internal fixation (ORIF) through a posterolateral
approach combined with spanning external fixation, followed by tibial ORIF
when soft-tissue swelling subsided (44 fractures). The surgical approaches
used, the length of the incisions, the distance between the incisions (size
of the skin bridge), and the overlap between the incisions were recorded.
The surgical wounds were followed until healing and for a minimum of 3 months.
Results: Two surgical approaches were used in 32 fractures and three
approaches were used in 14. These 106 surgical incisions produced 60 skin
bridges. The approaches used included posterolateral (44), anterolateral
(39), medial (11), anteromedial (8), and posteromedial (4). The mean skin
bridge size was 5.9 cm. Only 16% of the skin bridges were >7 cm, while
70% were 5-7 cm, and 14% were <5 cm. The mean overlap between incisions
in the study was 7.9 cm. 104 wounds healed uneventfully, 1 anterolateral
wound formed an echar that healed with secondary intention, and one posterolateral
fibular incision failed to heal. There were no postoperative deep infections
and no compromise of any intervening skin bridge.
Conclusion/Significance: Despite a measured skin bridge of less than
7 cm in 84% of instances, the soft-tissue complication rate was low in this
group of patients with tibial plafond fractures. With careful attention
to soft-tissue management and surgical timing, incisions can be placed with
skin bridges less than 7 cm.
If noted, the author indicates something of value received.
The codes are identified as a-research or institutional support; b-miscellaneous
funding; c-royalties; d-stock options; e-consultant or employee; n-no conflicts
disclosed, and *disclosure not available at time of printing.
·
The FDA has not cleared this drug and/or medical device for the use
described in this presentation (i.e., the drug or medical device is being
discussed for an "off label" use). · · FDA
information not available at time of printing.