Date: Thu, 7 Oct 1999 15:15:47 +0100
Subject: Tibial fracture and large avascular butterfly
From: Chris Oliver
How many people place large fresh butterflies in closed wounds back into closed fractures to act as structural allografts? Is this heresy?
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Christopher Oliver FRCS (Tr & Orth) DM, Edinburgh Orthopaedic Trauma Unit,
Date: Thu, 7 Oct 1999 16:42:56 EDT
From: Tom DeCoster
I would incorporate cortical fragments without soft tissue attachment into the osteosynthesis of MOST fractures which were initially closed. I believe there are good reports on rapid revascularization of well reduced stable fragments treated in this manner, especially with plating. I believe the benefit to restoring bony anatomy outweights the risk of necrosis and infection in this setting and I believe the literature and most trauma surgeons supports this.
I consider it part of the the procedure and not a graft. If you do call it a graft then it would be an autograft not an allograft.
In open fractures I am much less likely to retain totally devascularized fragments. In this setting the risk of infection outweighs the benefits of retention in the vast majority of cases in my opinion. This is even more true now that we have much better techniques for treating post-traumatic segmental diaphyseal defects. I believe there is considerable variety of practice in this regards.
In your case of IM nailing of a closed comminuted tibia shaft fracture you performed an open reduction of a malreduced butterfly piece with supplemental cerclage fixation. I have seen quite a few problems from combined IM nail and cerclage and have heard the practice discouraged from the podium at OTA. I am not aware of specific literature addressing how much malreduction of tibial shaft comminution should be accepted with IM nailing or exactly what technique should be employed if considered unacceptable. My view of the images is a bit blurred in your case.