Early internal fixation combined with free anterolateral thigh perforator flap transplantation to treat open ankle fracture-dislocation_Chinese Journal of Reparative and Reconstructive Surgery

Authors：

HU Xingfeng , WANG Xiang , JI Liang , LIANG Wei , LUO Qixin , PENG Yang ,  LI Qingsong

Department of Hand and Microsurgery, the Fourth People’s Hospital of Guiyang, Guiyang Guizhou, 550001, P. R. China;

Corresponding?author：

LI Qingsong, Email: 34451660@qq.com

Keywords：

Ankle fracture-dislocation; anterolateral thigh perforator flap; soft tissue defect; internal fixation

DOI：

10.7507/1002-1892.202505079

Video：

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Objective To evaluate the effectiveness of early internal fixation combined with free anterolateral thigh perforator flap (ALTPF) transplantation in the treatment of open ankle fracture-dislocation. Methods A retrospective analysis was performed on the clinical data of 13 patients with open ankle fracture-dislocation who were admitted and met the inclusion criteria between January 2021 and May 2024. Among them, there were 9 males and 4 females, with the ages ranging from 23 to 61 years (mean, 45.3 years). Fracture types included 5 cases of simple medial or lateral malleolar fracture-dislocation, 7 cases of bimalleolar (medial and lateral) fracture-dislocation, and 1 case of trimalleolar fracture-dislocation. Additionally, 3 cases were complicated with bone defects (1 medial malleolus defect and 2 lateral malleolus defects). All injuries were classified as type ⅢB according to the Gustilo-Anderson classification for open fractures. The size of wound defects ranged from 7 cm×5 cm to 18 cm×12 cm. The time from injury to surgery was 2-20 hours (mean, 4 hours). All patients underwent emergency thorough debridement upon admission. The fracture-dislocation was temporarily stabilized with an external fixator, and the wound was covered with antibiotic-impregnated bone cement sheets or vacuum sealing drainage. Definitive internal fixation of the fracture and free ALTPF transplantation were performed 5-7 days after the initial emergency procedure. Postoperatively, wound healing, flap survival, and fracture union were monitored. At last follow-up, clinical outcomes were assessed using the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score. Results All 13 patients were followed up 6-24 months (mean, 8.2 months). All flaps survived completely, and all fractures achieved union, with an union time of 3-11 months (mean, 5.5 months). One patient developed a superficial infection at the wound margin, which healed after regular dressing changes and drainage. No internal fixation-related complication (e.g., deep infection, implant loosening, or secondary ankle instability) were observed. At last follow-up, the total AOFAS ankle-hindfoot score was 78.6±13.5, with 3 excellent, 7 good, 2 fair, and 1 poor cases, yielding an excellent and good rate of 76.9%. Conclusion Early internal fixation combined with ALTPF transplantation for open ankle fracture-dislocation can shorten the treatment course and maximize the recovery of ankle joint function.

Citation： HU Xingfeng, WANG Xiang, JI Liang, LIANG Wei, LUO Qixin, PENG Yang, LI Qingsong. Early internal fixation combined with free anterolateral thigh perforator flap transplantation to treat open ankle fracture-dislocation. Chinese Journal of Reparative and Reconstructive Surgery, 2025, 39(9): 1175-1179. doi: 10.7507/1002-1892.202505079 Copy

1.	Cao MM, Zhang YW, Hu SY, et al. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg, 2022, 9: 965814. doi: 10.3389/fsurg.2022.965814.
2.	Lawson KA, Ayala AE, Morin ML, et al. Republication of “ankle fracture-dislocations: A review”. Foot Ankle Orthop, 2023, 8(3): 24730114231195058. doi: 10.1177/24730114231195058.
3.	朱慶棠, 李文軍, 朱磊, 等. 嚴重開放性肢體創傷早期救治專家共識. 中華顯微外科雜志, 2023, 46(1): 7-24.
4.	Xue X, Li N, Ren L. Effect of vacuum sealing drainage on healing time and inflammation-related indicators in patients with soft tissue wounds. Int Wound J, 2021, 18(5): 639-646.
5.	Burtt KE, Badash I, Leland HA, et al. The efficacy of negative pressure wound therapy and antibiotic beads in lower extremity salvage. J Surg Res, 2020, 247: 499-507.
6.	Rupp M, Walter N, Szymski D, et al. The antibiotic bead pouch-a useful technique for temporary soft tissue coverage, infection prevention and therapy in trauma surgery. J Bone Jt Infect, 2023, 8(3): 165-173.
7.	余斌, 王博煒. 外固定支架在創傷骨科中的應用. 中華創傷骨科雜志, 2020, 22(4): 282-285.
8.	Kamin K, Rammelt S, Kleber C, et al. External fixator: temporary fixation and soft tissue management of the ankle. Oper Orthop Traumatol, 2020, 32(5): 421-432.
9.	Wawrose RA, Grossman LS, Tagliaferro M, et al. Temporizing external fixation vs splinting following ankle fracture dislocation. Foot Ankle Int, 2020, 41(2): 177-182.
10.	Ye Z, Zhao S, Zeng C, et al. Study on the relationship between the timing of conversion from external fixation to internal fixation and infection in the treatment of open fractures of extremities. J Orthop Surg Res, 2021, 16(1): 662. doi: 10.1186/s13018-021-02814-7.
11.	Shen M, Tejwani N. Open tibial shaft fracture fixation strategies: intramedullary nailing, external fixation, and plating. OTA Int, 2024, 7(4 Suppl): e316. doi: 10.1186/s13018-021-02814-7.
12.	Abdelgawad A, Elabd A, Pisquiy JJ, et al. Early internal fixation of open ankle malleolar fractures is not associated with increased complications: case control study. Acta Orthop Belg, 2022, 88(4): 825-833.
13.	Pearce O, Al-Hourani K, Kelly M. Ankle fractures in the elderly: Current concepts. Injury, 2020, 51(12): 2740-2747.
14.	張磊, 李明慧, 張夢瑤, 等. 下脛腓聯合損傷重建術中螺釘植入角度的生物力學研究. 中國修復重建外科雜志, 2024, 38(12): 1480-1485.
15.	Mauffrey C, Barlow BT, Smith W. Management of segmental bone defects. J Am Acad Orthop Surg, 2015, 23(3): 143-153.
16.	Goldsmith T, Ford B, Marsden N, et al. Soft tissue coverage of the ankle: An algorithm for appropriate flap selection and the experiences of a newly established Major Trauma Network. Injury, 2023, 54(10): 110920. doi: 10.1016/j.injury.2023.110920.
17.	Laitonjam M, Khan MM, Krishna D, et al. Reconstruction of foot and ankle defects: A prospective analysis of functional and aesthetic outcomes. Cureus, 2023, 15(6): e40946. doi: 10.7759/cureus.40946.
18.	徐永清, 唐舉玉, 劉元波, 等. 股前外側皮瓣穿支解剖學特征與定位方法的專家共識 (2024版). 中國臨床解剖學雜志, 2024, 42(5): 489-499.
19.	周洪翔, 鐘林, 何亮, 等. Flow-through橋式股前外側皮瓣修復復雜小腿軟組織缺損. 中國修復重建外科雜志, 2023, 37(4): 482-487.
20.	王偉, 周征兵, 程冬冬, 等. 聯體股前外側穿支皮瓣修復足踝部大面積軟組織缺損. 中國修復重建外科雜志, 2022, 36(9): 1178-1180.

1. Cao MM, Zhang YW, Hu SY, et al. A systematic review of ankle fracture-dislocations: Recent update and future prospects. Front Surg, 2022, 9: 965814. doi: 10.3389/fsurg.2022.965814.
2. Lawson KA, Ayala AE, Morin ML, et al. Republication of “ankle fracture-dislocations: A review”. Foot Ankle Orthop, 2023, 8(3): 24730114231195058. doi: 10.1177/24730114231195058.
3. 朱慶棠, 李文軍, 朱磊, 等. 嚴重開放性肢體創傷早期救治專家共識. 中華顯微外科雜志, 2023, 46(1): 7-24.
4. Xue X, Li N, Ren L. Effect of vacuum sealing drainage on healing time and inflammation-related indicators in patients with soft tissue wounds. Int Wound J, 2021, 18(5): 639-646.
5. Burtt KE, Badash I, Leland HA, et al. The efficacy of negative pressure wound therapy and antibiotic beads in lower extremity salvage. J Surg Res, 2020, 247: 499-507.
6. Rupp M, Walter N, Szymski D, et al. The antibiotic bead pouch-a useful technique for temporary soft tissue coverage, infection prevention and therapy in trauma surgery. J Bone Jt Infect, 2023, 8(3): 165-173.
7. 余斌, 王博煒. 外固定支架在創傷骨科中的應用. 中華創傷骨科雜志, 2020, 22(4): 282-285.
8. Kamin K, Rammelt S, Kleber C, et al. External fixator: temporary fixation and soft tissue management of the ankle. Oper Orthop Traumatol, 2020, 32(5): 421-432.
9. Wawrose RA, Grossman LS, Tagliaferro M, et al. Temporizing external fixation vs splinting following ankle fracture dislocation. Foot Ankle Int, 2020, 41(2): 177-182.
10. Ye Z, Zhao S, Zeng C, et al. Study on the relationship between the timing of conversion from external fixation to internal fixation and infection in the treatment of open fractures of extremities. J Orthop Surg Res, 2021, 16(1): 662. doi: 10.1186/s13018-021-02814-7.
11. Shen M, Tejwani N. Open tibial shaft fracture fixation strategies: intramedullary nailing, external fixation, and plating. OTA Int, 2024, 7(4 Suppl): e316. doi: 10.1186/s13018-021-02814-7.
12. Abdelgawad A, Elabd A, Pisquiy JJ, et al. Early internal fixation of open ankle malleolar fractures is not associated with increased complications: case control study. Acta Orthop Belg, 2022, 88(4): 825-833.
13. Pearce O, Al-Hourani K, Kelly M. Ankle fractures in the elderly: Current concepts. Injury, 2020, 51(12): 2740-2747.
14. 張磊, 李明慧, 張夢瑤, 等. 下脛腓聯合損傷重建術中螺釘植入角度的生物力學研究. 中國修復重建外科雜志, 2024, 38(12): 1480-1485.
15. Mauffrey C, Barlow BT, Smith W. Management of segmental bone defects. J Am Acad Orthop Surg, 2015, 23(3): 143-153.
16. Goldsmith T, Ford B, Marsden N, et al. Soft tissue coverage of the ankle: An algorithm for appropriate flap selection and the experiences of a newly established Major Trauma Network. Injury, 2023, 54(10): 110920. doi: 10.1016/j.injury.2023.110920.
17. Laitonjam M, Khan MM, Krishna D, et al. Reconstruction of foot and ankle defects: A prospective analysis of functional and aesthetic outcomes. Cureus, 2023, 15(6): e40946. doi: 10.7759/cureus.40946.
18. 徐永清, 唐舉玉, 劉元波, 等. 股前外側皮瓣穿支解剖學特征與定位方法的專家共識 (2024版). 中國臨床解剖學雜志, 2024, 42(5): 489-499.
19. 周洪翔, 鐘林, 何亮, 等. Flow-through橋式股前外側皮瓣修復復雜小腿軟組織缺損. 中國修復重建外科雜志, 2023, 37(4): 482-487.
20. 王偉, 周征兵, 程冬冬, 等. 聯體股前外側穿支皮瓣修復足踝部大面積軟組織缺損. 中國修復重建外科雜志, 2022, 36(9): 1178-1180.

Chinese Journal of Reparative and Reconstructive Surgery

Early internal fixation combined with free anterolateral thigh perforator flap transplantation to treat open ankle fracture-dislocation

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