[Open fractures of the leg - Series from the University Hospital Hautepierre].

Nineteen cases were studied retrospectively between 1982 and 1993. All had been stabilised immediately by external fixators. Free or pedicle flap and early bone graft was carried out as required.Bone stability was obtained by Hoffmann or Orthofix fixators which allowed later manoeuvres for skin covers. The stabilisation by the fibula was attempted by intertibio-fibula grafting (ITF). Skin cover was obtained in 13 cases by pedicle flaps, in 4 by a free flap and 2 cases healed by secondary intention. The local flaps were 5 medial gastrocnemius or soleus flaps, 4 fasciocutaneous flaps, 3 medial gastrocnemius muscular cutaneous flaps and one cross-leg flap. These flaps were done on average at the 17th day (between 4th and 45th day). Four free flaps were done: 2 pure cutaneous flaps and 2 osteo-cutaneous flaps. A second flap was required in 3 cases because of infection or loss of soft tissue. A medial gastrocnemius flap and 2 free fibula flaps were done at the 105th and 210th day.Bony union was obtained primarily in 6 cases. Thirteen bone grafts were necessary of which 7 were done electively before three months (4 decortication grafts, 3 ITF). Additional bone graft was needed in 4 cases. Six non-unions were seen, 2 sterile which were treated by one decortication/graft and one ITF and 4 infected (21%) which were treated successfully by 2 ITF grafts and 2 free fibula flaps. Overall consolidation occurred by 9.9. months with good alignment in 15 cases. The complications were 2 varus and one 15° external rotation malunions and one shortening of 2 cm. Ankle movements were normal in 5 cases, reduced by 25% in 5 cases and by half in one case. There was one fixed equinus of 15° and one arhtrodesis. Five patients were able to run. The average number of general anaesthetics required was 5.7 and the average length of hospitalisation 120 days.In conclusion, the authors emphasise the beneficial role of early skin cover in the outcome of these fractures which is otherwise characterised by secondary contamination. They were extremely satisfied with the results of composite free grafts in cases of loss of substance of bone and soft tissue. At present, they tend towards locked nailing for these fractures preferably without reaming whenever possible. Skin cover can than be planned during the first 5 days after injury.