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First results with the immediate reconstructive strategy for internal hardware exposure in non-united fractures of the distal third of the leg: case series and literature review

Luca Vaienti1*, Adriano Di Matteo1, Riccardo Gazzola1, Luca Pierannunzii12, Giovanni Palitta1 and Andrea Marchesi1

Author Affiliations

1 Plastic Surgery Department, Università degli Studi di Milano, IRCCS Policlinico San Donato, Piazza Malan, 20097 San Donato Milanese, Milan, Italy

2 Istituto Ortopedico Gaetano Pini, P.zza C. Ferrari, 1, Milan, Italy

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Journal of Orthopaedic Surgery and Research 2012, 7:30  doi:10.1186/1749-799X-7-30

Published: 28 August 2012



Fractures of the distal third of the leg are increasingly common and are often handled by open reduction and internal fixation. Exposure and infection of internal hardware could occur, especially after high energy traumas, requiring hardware removal and delayed soft tissue reconstruction. Nevertheless immediate soft tissue reconstruction without internal hardware removal is still possible in selected patients.

In this study the effectiveness and the complications of immediate soft tissue reconstruction without internal hardware removal is analyzed.


13 patients, affected by internal hardware exposure in the distal leg, treated with immediate soft tissue reconstruction with pedicled flaps and hardware retention, are retrospectively analyzed, with special regard to flap survival and wound infection.


Wound infection was observed in 10 cases before surgery and in 5 cases surgical debridement was necessary before reconstruction which was performed in a separate operative session.

After reconstruction, wound dehiscence and infection occurred in 5 cases, and in 3 cases removal of internal hardware was necessary in order to achieve the complete healing of dehiscence. In one case the previous flap failed but prompt reconstruction with a sural fasciocutaneous flap was performed without hardware removal and without complications. Pre-operative infection and late reconstructive surgery are predictive for higher rates of post-operative complications (respectively p 0.018 and p 0.028).


Our approach achieved full recovery in 53.8% of the treated cases after one-step surgery, therefore reducing hospitalization and allowing early mobilization. Controlled trials are needed to confirm the effectiveness of this strategy, although the present case series shows encouraging results.

Exposure; Flap; Internal fixator; Reconstruction; Leg; Fracture; Internal hardware exposure; Infection; Immediate reconstruction; Pedicled flaps; Lower limb