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Acute limb shortening or creation of an intentional deformity to aid in soft tissue closure for IIIB/IIIC open tibia fractures

  • Christine M. Jones
    Affiliations
    Lewis Katz School of Medicine, Temple University, Department of Surgery, Division of Plastic and Reconstructive Surgery, Philadelphia, 3401 N. Broad St, Philadelphia, PA 19140, PA, United States
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  • John M. Roberts
    Affiliations
    Penn State Health Milton S. Hershey Medical Center, Department of Surgery, Division of Plastic and Reconstructive Surgery, Hershey, 500 University Drive, Hershey, PA, 17033 PA, United States
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  • Edward A. Sirlin
    Affiliations
    Penn State Health Milton S. Hershey Medical Center, Department of Orthopedic Surgery, Division of Orthopedic Trauma, 500 University Drive, Hershey 17033, PA, United States
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  • Garrett A. Cavanaugh
    Affiliations
    Penn State Health Milton S. Hershey Medical Center, Department of Orthopedic Surgery, Division of Orthopedic Trauma, 500 University Drive, Hershey 17033, PA, United States
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  • John P. Anagnostakos
    Affiliations
    Penn State Health Milton S. Hershey Medical Center, Department of Orthopedic Surgery, Division of Orthopedic Trauma, 500 University Drive, Hershey 17033, PA, United States
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  • Randy M. Hauck
    Affiliations
    Penn State Health Milton S. Hershey Medical Center, Department of Surgery, Division of Plastic and Reconstructive Surgery, Hershey, 500 University Drive, Hershey, PA, 17033 PA, United States
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  • J. Spence Reid
    Correspondence
    Corresponding author.
    Affiliations
    Penn State Health Milton S. Hershey Medical Center, Department of Orthopedic Surgery, Division of Orthopedic Trauma, 500 University Drive, Hershey 17033, PA, United States
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Published:April 19, 2021DOI:https://doi.org/10.1016/j.bjps.2021.03.105

      Summary

      Background

      Ring fixator techniques can precisely correct complex long bone deformities. In select patients, controlled shortening or intentional fracture deformation with delayed correction can also aid in complex wound coverage and limb salvage.

      Methods

      This retrospective cohort study analyzed all patients who underwent acute limb shortening or intentional temporary fracture deformation between 2005 and 2020. Patients were divided into three groups based on reason for acute shortening or intentional deformity: (1) skeletal indications alone, with traditional flap coverage; (2) skeletal and soft tissue indications, to augment traditional reconstructive measures; and (3) skeletal and soft tissue indications, to avoid microsurgery altogether. Comorbidities, orthopedic and reconstructive methods, and functional outcomes were recorded.

      Results

      Eighteen patients were identified: six in Group 1, five in Group 2, and seven in Group 3. Fractures were primarily in the distal third of the tibia. On initial assessment, all wounds would have required free tissue transfer. Group 1 patients were reconstructed with free flaps. Among Group 2, closure was accomplished by skin grafting (N = 1), local flaps (N = 1), pedicled muscle flaps (N = 1), and free flaps (N = 2). In Group 3, five wounds were closed primarily and two were skin grafted. All limbs were shortened, averaging 25.1 mm; seven were intentionally deformed, most commonly varus (10–20°). After skeletal correction, residual leg length discrepancy averaged 5.7 mm. No patients required amputation.

      Conclusions

      Acute skeletal shortening with or without intentional temporary deformation in select IIIB/IIIC open tibial fractures can facilitate soft tissue coverage and limb salvage in patients who might otherwise require amputation.

      Keywords

      Introduction

      Tibial fractures are among the most common open fractures, second only to phalangeal fractures.
      • Court-Brown C.M.
      • Cross A.T.
      • Hahn D.M.
      • et al.
      A report by the British Orthopaedic Association /British Association of Plastic Surgeons Working Party on the management of open tibial fractures.
      Accordingly, plastic surgeons should be properly equipped with a number of reconstructive tools in their armamentarium. In the classic algorithm, open fractures of the leg are managed with pedicled muscle flaps in the proximal and middle tibial thirds, and free flaps distally.
      • Hallock G.G.
      Evidence-based medicine: lower extremity acute trauma.
      • Soltanian H.
      • Garcia R.M.
      • Hollenbeck S.T.
      Current concepts in lower extremity reconstruction.
      • Reddy V.
      • Stevenson T.R.
      MOC-PS(SM) CME article: lower extremity reconstruction.
      With the sophistication of modern emergency care and trauma protocols, more patients with high-energy fractures and multiple traumatic injuries are surviving to hospital care. Accordingly, open lower extremity fractures must be treated in the context of the whole patient. When comorbid injuries, dysvascular extremities, or pre-traumatic disease states preclude long microsurgical cases, patients may be left with few reconstructive options and recommended for amputation.
      The technique of distraction osteogenesis has the power to modify conventional management. Russian surgeon Gavriil Ilizarov pioneered methods of distraction osteogenesis and complex deformity correction in the 1970s that have since revolutionized orthopedic trauma care.
      • Green S.A.
      Ilizarov method.
      His landmark techniques now allow for more advanced treatment of segmental bone loss, nonunion, osteomyelitis, and deformity.
      • Aronson J.
      Limb-lengthening, skeletal reconstruction, and bone transport with the Ilizarov method.
      • Paley D.
      • Catagni M.A.
      • Argnani F.
      • Villa A.
      • Benedetti G.B.
      • Cattaneo R.
      Ilizarov treatment of tibial nonunions with bone loss.
      • Keeling J.J.
      • Gwinn D.E.
      • Tintle S.M.
      • Andersen R.C.
      • McGuigan F.X.
      Short-term outcomes of severe open wartime tibial fractures treated with ring external fixation.
      More recently, the use of orthopedic hexapods with software-assisted movement of bone fragments has allowed the creation of an intentional deformity at the fracture site for the sole purpose of facilitating soft tissue closure. Lower extremities can be acutely shortened or intentionally deformed in multiple planes to simplify soft tissue defects, effectively moving open fractures down the reconstructive ladder. The extremity can subsequently be lengthened or the bony deformity gradually corrected after soft tissue healing, but prior to bone union to provide good anatomical and functional outcomes (Figure 1).
      • Nho S.J.
      • Helfet D.L.
      • Rozbruch S.R.
      Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor Spatial Frame.
      • Lahoti O.
      • Dip N.B.
      • Findlay I.
      • Shetty S.
      • Abhishetty N.
      Intentional deformation and closure of soft tissue defect in open tibial fractures with a Taylor Spatial Frame – a simple technique.
      • Lerner A.
      • Fodor L.
      • Ullmann Y.
      Acute temporary malpositioning for dealing with extensive tissue loss after severe high-energy trauma to extremities.
      • Pierrie S.N.
      • Hsu J.R.
      Shortening and angulation strategies to address composite bone and soft tissue defects.
      Figure 1
      Figure 1Acutely shortening or intentionally deforming an open tibial injury can simplify reconstruction of a type IIIB/C injury.
      This study was undertaken to examine reconstructive outcomes in patients who underwent treatment of open tibial fractures with acute shortening or intentional temporary fracture deformation using the Ilizarov method as a means of limb salvage.

      Methods

      After obtaining Institutional Review Board approval, all patients who underwent acute tibial shortening or intentional skeletal deformation between 2005 and 2020 were enrolled in this retrospective cohort study. The nature of this cohort selected for open tibial fractures that would traditionally require free tissue transfer, although that was not a specific inclusion criterion. The study adhered to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines for cohort studies.
      Patients were divided into three groups based on the reason for acutely shortening or deforming the limb (Table 1). Group 1 consisted of patients whose limbs were shortened or intentionally deformed due to bone loss, with no effect on the type of reconstruction needed. Group 2 comprising patients whose limbs were shortened or intentionally deformed for soft tissue reasons, either to simplify the type of flap needed or after free flap had failed. Group 3 was composed of patients whose limbs were acutely shortened or intentionally deformed to avoid the need for flap coverage altogether. In the initial years included in the study, the technique was typically selected when patients were poorly suited to microsurgical reconstruction due to medical comorbidities. A softening of indications was noted throughout the study period, as technical advances made the technique applicable to a larger range of deformities, and early outcomes were observed to be satisfactory. In addition, orthopedic hexapod techniques became more advanced, allowing more precise control and correction of the temporary deformity.
      • Feldman D.S.
      • Shin S.S.
      • Madan S.
      • Koval K.J.
      Correction of tibial malunion and nonunion with six-axis analysis deformity correction using the Taylor Spatial Frame.
      • Al-Sayyad M.J.
      Taylor spatial frame in the treatment of open tibial shaft fractures.
      • Ganger R.
      • Radler C.
      • Speigner B.
      • Grill F.
      Correction of post-traumatic lower limb deformities using the Taylor spatial frame.
      Patients whose legs were acutely shortened for infection or nonunion unrelated to a subsequent flap reconstruction were excluded.
      Table 1Study groups.
      Indication for Acute Shortening or Intentional DeformityN
      Group 1For bone loss only; no effect on need for free flap6
      Group 2For soft tissue + bone loss; to simplify traditional reconstruction5
      Group 3For soft tissue + bone loss; avoided the need for free flap7
      Demographic data, mechanisms of injury, smoking status, comorbidities, orthopedic variables, reconstructive data, and functional outcomes were compared among the groups. Orthopedic variables collected included magnitude of acute limb shortening, nature of intentional deformities created, subsequent limb lengthening, direction of transport, location and timing of corticotomy, residual leg length discrepancy, bone grafting, and progression to amputation. Reconstructive data included type and timing of reconstruction, complications, and need for further surgery. Signs of infection before and after surgery were recorded. Ambulatory status at the final follow-up was noted.

       Surgical technique

      Upon presentation to the hospital, patients with Gustilo type IIIB or IIIC fractures were routinely evaluated by both the orthopedic and plastic surgery teams. Multiple rounds of debridement, preliminary external skeletal fixation, and revascularization in indicated cases were performed according to standard protocols. Both bone and soft tissue were debrided back to healthy, bleeding tissue until the full zone of injury was identified. In the interim, a negative pressure dressing with or without the addition of antibiotic beads was used.
      • Lerner A.
      • Fodor L.
      • Soudry M.
      Is staged external fixation a valuable strategy for war injuries to the limbs?.
      ,
      • Hou Z.
      • Irgit K.
      • Strohecker K.A.
      • et al.
      Delayed flap reconstruction with vacuum-assisted closure management of the open IIIB tibial fracture.
      In patients who required acute limb shortening or intentional deformation for skeletal reasons alone, soft tissue reconstruction was typically performed with a damage control fixator in place. Once initial flap healing was stable, the external fixator was removed and a multiplanar Ilizarov or orthopedic hexapod was applied, commonly 3–10 days after flap coverage. Timing of frame application versus soft tissue reconstruction in patients undergoing acute limb shortening or intentional deformation to assist with wound closure varied, depending on case-specific considerations.
      Specific details of bone shortening or intentional temporary deformity creation were highly dependent on the clinical situation. Suitability for the technique was determined jointly between the plastic surgery and orthopedic teams, based on medical comorbidities, vascular inflow/outflow, and wound characteristics. For open fracture wounds to be suitable for the technique, the soft tissue defect should be near the same level as the skeletal injury. Geometric orientation matters; transverse and oblique soft tissue defects are the most favorable for this technique.
      The damage control fixator allowed immediate visualization of the impact of shortening and/or deformity creation on the soft tissue defect. In some situations, additional healthy bone was debrided to allow more shortening, if it would significantly simplify soft tissue coverage (i.e. free flap to local tissue flap). In some situations, fibular resection was also required.
      In the tibia, the most commonly created deformity was varus, apex posterior, and internal rotation. Bone ends were usually fashioned in a transverse orientation to facilitate compression of the fracture following realignment in the case of deformity creation, or to allow acute compression if only shortening was performed. Once the optimal bone position was selected, the damage control frame was locked into position and the wound was either closed primarily without tension, or a new negative pressure dressing was applied in preparation for skin grafting or flap coverage.
      After definitive soft tissue coverage, the damage control frame was converted to a ring fixator or an orthopedic hexapod for definitive fracture management. If the limb was shortened, a corticotomy distant from the zone of injury was performed at the time of ring fixator application to allow the lost length to be regained via distraction osteogenesis (∼0.75 mm/day).
      • Paley D.
      • Catagni M.A.
      • Argnani F.
      • Villa A.
      • Benedetti G.B.
      • Cattaneo R.
      Ilizarov treatment of tibial nonunions with bone loss.
      ,
      • Sen C.
      • Kocaoglu M.
      • Eralp L.
      • Gulsen M.
      • Cinar M.
      Bifocal compression-distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: a report of 24 cases.
      ,
      • El-Rosasy M.A.
      Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia.
      When an orthopedic hexapod (Taylor Spatial Frame) was placed, a radiographic analysis of the deformity was performed post-application and a specific “correction program” was created for the patient. Correction was not initiated until after soft tissue healing, usually 14–20 days. Deformity correction usually proceeded at about 1°/day afterwards. Because of the stability of the ring fixators, weight bearing as tolerated was usually encouraged.

      Results

      Eighteen patients meeting inclusion criteria were identified, including 12 males and six females; these were categorized into six patients in Group 1, five patients in Group 2, and seven patients in Group 3. Fractures occurred in the distal tibia in 16 cases, middle tibial third in one case, and the proximal tibia in one. Mechanisms of injury and smoking status were similar among the groups. Patients in Groups 2 and 3 were more likely to be diabetic, have peripheral vascular disease, or have experienced acute cardiac conditions or coagulopathy (Table 2). On initial assessment, each wound would have needed a free flap.
      Table 2Baseline characteristics of Groups 1, 2, and 3 (BMI: Body mass index; DVT: Deep vein thrombosis; MI: Myocardial infarction).
      Group 1(N = 6)Group 2(N = 5)Group 3(N = 7)
      Patient characteristicsAge (Years) [Mean (SD)]42.7 (14.4)50.3 (7.6)48.2 (10.8)
      Male444
      Female213
      BMI (kg/m2) [Mean (SD)]26.9 (3.2)36.1 (11.1)32.9 (9.0)
      Length of follow-up (Months) [Mean (SD)]27 (24.8)53 (58.8)16 (9.9)
      Fracture locationProximal 1/3 tibia010
      Middle 1/3 tibia100
      Distal 1/3 tibia547
      Fracture severityGustilo IIIB656
      Gustilo IIIC001
      ComorbiditiesActive smoking223
      Diabetes011
      Chronic peripheral vascular disease010
      Acute arterial occlusion231
      Acute DVT010
      Acute MI001
      Previously failed free flaps021
      Mechanism of injuryMotorcycle collision231
      Crush201
      Fall low height012
      Fall from height102
      Motor vehicle collision011
      Gunshot wound100
      Pre-existing infectionChronic osteomyelitis121
      All patients’ limbs were acutely shortened, averaging 35.1 mm (range 7–53 mm), with a greater degree of shortening in Groups 2 and 3. Seven limbs were intentionally deformed; this included one patient in Group 2 and six patients in Group 3 (Table 3).
      Table 3Orthopedic characteristics and interventions.
      TotalGroup 1Group 2Group 3
      Limbs acutely shortened18 (100%)6 (100%)5 (100%)7 (100%)
      Amount of acute shortening [Mean (SD)]25.1 mm (12.0 mm)18.3 mm (11.7 mm)27.6 mm (3.4 mm)29.1 mm (14.6 mm)
      Limbs intentionally deformed7 (39%)0 (0%)1 (20%)6 (86%)
      Limbs subsequently lengthened14 (78%)6 (100%)3 (60%)5 (71%)
      Group 1 patients were reconstructed with free flaps (Table 4). Among the five patients in Group 2, closure was accomplished by skin grafting (n = 1), local fasciocutaneous flap (n = 1), pedicled muscle flaps (n = 1), and free tissue transfer (n = 2). In Group 3, five wounds were closed primarily and two were skin grafted. Detailed case examples from each group are presented below.
      Table 4Wound closure methods.
      Group 1Group 2Group 3
      Free flap620
      Pedicled muscle flap010
      Local fasciocutaneous flap010
      STSG012
      Primary closure005
      Limbs were subsequently lengthened by distraction osteogenesis in seventy-seven percent of patients (Table 3). After healing of the soft tissue, but prior to bone union, intentional deformities were corrected gradually over a 10- to 14-day period, using the software-generated correction plan. Cases in which lengthening was performed through a healthy segment of bone were usually lengthened in the proximal third of the tibia. Frame movement was initiated about ten days after frame application, and proceeded at 0.75 mm per day. After correction, residual leg length discrepancy averaged 5.7 mm (Table 5 and Table, Supplemental Digital Content 1). Patients were followed for an average of 30 months postoperatively (Table 2). No patients went on to amputation. All patients were ambulatory at their final follow-up.
      Table 5Outcomes.
      OverallGroup 1Group 2Group 3
      Postoperative infection, managed nonoperatively0000
      Partial loss of flap or graft, managed nonoperatively4 (22%)2 (33%)2 (40%)0
      Flap loss or infection requiring further reconstruction (failure of method)2 (11%)1 (17%)0 (0%)1 (14%)

      Residual leg length discrepancy5.7 mm6.8 mm9.6 mm1.3 mm
      Ambulatory18 (100%)6 (100%)5 (100%)7 (100%)
      Amputation0000
      One patient in Group 1 experienced free gracilis flap loss and required contralateral free gracilis flap. Of the patients whose reconstruction was performed via nonconventional methods with use of distraction osteogenesis, no patients in Group 2 required further reconstructive surgery. One patient in Group 3 developed wound breakdown and superficial infection, requiring a free gracilis flap. Thus, failure of method occurred in 17% of Group 1, 0% of Group 2, and 14% of Group 3 patients (Table 5).
      Additional parameters of orthopedic and reconstructive care are available in Tables, Supplemental Digital Contents 1 and 2.

       Case 1

      A 24-year-old female suffered a forklift injury, resulting in an open distal tibial fracture with wounds medially and laterally. The wounds were washed out on multiple occasions and stabilized with an external fixator. Once the wounds were clean, a free latissimus flap was performed. Due to significant nonviable bone at the fracture site, the limb was shortened 10 mm to obtain bony contact.

       Case 2

      A 56-year-old female presented with bilateral lower extremity fractures, including a IIIB open right pilon fracture. After initial debridement and external fixation, she underwent a free lateral arm fasciocutaneous flap. The flap was lost to venous congestion. Twelve days later, the wound was reconstructed with a free muscle-sparing transverse rectus abdominis myocutaneous flap, which likewise failed due to congestion. She was found to have extensive bilateral lower extremity deep vein thromboses, and right below knee amputation was considered. In a salvage procedure, her right tibia was acutely shortened 25 mm, then another 30 mm over the following 2 weeks, achieving soft tissue coverage of the fracture. The remaining wound granulated, and 2 months later was amenable to final closure by split thickness skin grafting after ankle fusion.

       Case 3

      A 45-year-old male presented to an outside hospital with a IIIB distal tibial fracture following a motorcycle collision. After initial washout and debridement, an intramedullary nail was placed. One month after fixation, infection developed at the fracture site, which required bony and soft tissue debridement. The resulting wound was unable to be closed. He was transferred to a tertiary care hospital for soft tissue coverage. Because of his history of poor medical adherence and frequent tobacco use, a free flap was felt to be a suboptimal means of reconstruction. As a result, his limb was shortened 31 mm, and a 10-degree varus, 20-degree apex-posterior deformity was created. His wound was closed primarily, and the bone and soft tissue healed uneventfully (Figure 2, Figure 3, Figure 4, Figure 5, Figure 6).
      Figure 2
      Figure 2Case #3. Nonviable bone and full-thickness soft tissue loss over the anteromedial tibia at time of first debridement and removal of hardware.
      Figure 3
      Figure 3A) Radiographic appearance after resection of 4 cm infected non-viable bone. B) Manual deformation to test effectiveness of deformity and shortening to close soft tissue primarily.
      Figure 4
      Figure 4A–C) Primary wound closure after application of the Taylor spatial frame following bone resection and deformity creation. Deformity is varus and apex posterior angulation.
      Figure 5
      Figure 5A–B) Appearance after wound healing (3 weeks).
      Figure 6
      Figure 6A) Final appearance of extremity showing excellent wound healing. B) Final radiographic appearance showing well-aligned and healed tibial fracture site with restoration of bone length via distraction osteogenesis.

      Discussion

      Advances in microsurgical technique have provided satisfactory outcomes and a high rate of limb salvage, even with complex open fractures of the distal tibia.
      • Godina M.
      Early microsurgical reconstruction of complex trauma of the extremities.
      • Gopal S.
      • Majumder S.
      • Batchelor A.G.
      • Knight S.L.
      • De Boer P.
      • Smith R.M.
      Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.
      • Gopal S.
      • Giannoudis P.V.
      • Murray A.
      • Matthews S.J.
      • Smith R.M.
      The functional outcome of severe, open tibial fractures managed with early fixation and flap coverage.
      However, microsurgical reconstruction is associated with a lengthy operative time, enhanced in-hospital resource utilization, and the need for technical expertise. A subset of patients may not be well-suited for free tissue transfer due to medical comorbidities that impart a high risk of flap failure, perioperative morbidity, or mortality related to the long operative time. Patients may not be willing to undergo the prolonged recovery, with intense postoperative monitoring and positioning restrictions. Some hospitals lack microsurgical capacity. Contour can be a concern, with bulky, unnatural-appearing limbs and poor footwear fit despite stable soft tissue coverage. In these cases, acute limb shortening or deformation can provide an alternative management technique with acceptable skeletal, soft tissue, and functional outcomes.
      Increasingly, the orthopedic literature has demonstrated successful limb salvage and maintenance of function with these techniques. Sen et al
      • Sen C.
      • Kocaoglu M.
      • Eralp L.
      • Gulsen M.
      • Cinar M.
      Bifocal compression-distraction in the acute treatment of grade III open tibia fractures with bone and soft-tissue loss: a report of 24 cases.
      treated 24 patients with Gustilo–Anderson IIIA or IIIB tibial fractures with mean soft tissue defects of 8.7 cm2 (range 2–50 cm2) and mean bone defects of 5 cm (range 3–8.5 cm) with acute shortening. Wounds were closed primarily in three-quarters of patients, and the remaining 1/4 underwent delayed primary closure after additional gradual shortening. The authors noted bony union in all cases, with good to excellent functional results and no amputations. Fifty-two complications occurred in 18 patients, for an average complication rate of 2.08 per patient, with the most common complications being soft tissue inflammation and pin tract infections.
      Rozbruch et al
      • Rozbruch S.R.
      • Weitzman A.M.
      • Watson J.T.
      • Freudigman P.
      • Katz H.V.
      • Ilizarov S.
      Simultaneous treatment of tibial bone and soft-tissue defects with the Ilizarov method.
      reported 25 patients with grade II–IIIC open tibial fractures with composite bone and soft tissue defects averaging 6 cm (range 2–14 cm) and 10.1 cm2 (range 2–25 cm2), respectively. Patients underwent acute limb shortening as a pre-amputation limb salvage attempt after flap coverage was deemed not to be a viable option by plastic surgeons; two patients had a history of failed flaps. Wounds healed with wet-to-dry dressing changes (n = 17), VAC (n = 3), or skin graft (n = 5); 96% of limbs achieved bony union after acute shortening alone or acute shortening with simultaneous lengthening outside the zone of injury. No amputations were required.
      Similarly, 21 patients were treated with acute shortening by El-Rosasy et al
      • El-Rosasy M.A.
      Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia.
      either in the early posttraumatic period or after established atrophic nonunion had been present for 6 or more months. Z-plasty incisions of unhealthy soft tissue edges assisted with closure in some cases. Twenty wounds were able to be closed primarily, and one required skin grafting. One patient developed a draining sinus tract postoperatively, in the absence of nonunion or deep infection, which was treated with excision and a local fasciocutaneous rotation flap. All limbs were salvaged, with successful fracture union.
      Several reports have incorporated angulation or deformation of the bone segments to close wounds that were not approximated by acute shortening alone, collectively representing 13 patients.
      • Nho S.J.
      • Helfet D.L.
      • Rozbruch S.R.
      Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor Spatial Frame.
      ,
      • Lahoti O.
      • Dip N.B.
      • Findlay I.
      • Shetty S.
      • Abhishetty N.
      Intentional deformation and closure of soft tissue defect in open tibial fractures with a Taylor Spatial Frame – a simple technique.
      ,
      • Lerner A.
      • Fodor L.
      • Soudry M.
      • Peled I.J.
      • Herer D.
      • Ullman Y.
      Acute shortening: modular treatment modality for severe combined bone and soft tissue loss of the extremities.
      ,
      • Sharma H.
      • Nunn T.
      Conversion of open tibial IIIb to IIIa fractures using intentional temporary deformation and the Taylor Spatial Frame.
      The technique allowed all wounds to be closed with local measures, most frequently with primary closure, with patients typically returning to independent function near premorbid levels with appropriate soft tissue and skeletal healing.
      Results of this study demonstrate successful limb salvage, low infection rates, and maintenance of independent ambulation using distraction osteogenesis for skeletal and soft tissue management in open tibial fractures, consistent with that reported in previous case series. This report is the first to compare patients with Ilizarov skeletal treatment and traditional reconstruction (Group 1) with those treated with combined distraction techniques to address soft tissue and bone defects simultaneously (Groups 2 and 3).
      Despite the utility of the technique, several physiologic limitations of acute shortening and deformity creation exist. In the tibia, acute shortening of greater than 3–3.5 cm can be associated with significant lymphedema, as well as potential for reduced arterial perfusion, venous outflow, or nerve function. Doppler examination of distal pulses should be performed routinely following these maneuvers, with reduction in deformity/shortening if concerns arise. In addition, the motor exam, sensory exam, and venous return should be monitored regularly in the immediate post-operative period.
      Several other considerations are prudent. Time in the ring fixator can be prolonged. This time is directly proportional to the length of reconstructed bone, with a general guideline of 1.5–2.0 months in the frame for every 1 cm of new bone formed. Thus, a 4-cm distal shortening to close a defect and a 4 cm proximal lengthening will require the patient to be in the frame for about 8 months. Time in the ring fixator can be a significant burden to both patient and family, as patients may require assistance to clean the pins, adjust the frame, and modify their clothing. Pain can be considerable, particularly during the early period of distraction. Familiarity with advanced ring fixation techniques involves a notable learning curve for the orthopedic surgeon. Use of this technique may be best suited to centers whose orthopedic surgeons are comfortable with complex applications of the hexapod device.
      Our level I trauma center treats approximately 150 tibia fractures annually, of which about 30% are open fractures. Of these 45 open fractures, approximately 15 are type IIIB, usually in the distal third of the tibia, making them candidates for free flaps. Our microvascular team places 10–20 free flaps per year for open fractures. The techniques of acute shortening and the creation of an acute deformity are amenable to these IIIB cases but should also be considered in type IIIA and even selected type II fractures to allow for a simpler, tension-free closure. In many ways, these techniques blur the distinction between types IIIA and IIIB, since tissue tension and bone length are now variables under surgeon control.
      In the context of the whole patient, limb shortening and/or acute deformity creation are powerful tools that can augment traditional limb reconstruction algorithms. These techniques facilitate limb salvage and maintain functional use of the extremity in many settings in which amputation would otherwise be the only option. Thus, the familiarity of the plastic surgeon with these techniques extends the range of possibilities for limb salvage when caring for patients with limb-threatening injuries, while maintaining low morbidity, high rates of success, and good clinical function.

      Conclusion

      Acute limb shortening and/or intentional skeletal deformation to assist or solve soft tissue coverage problems are powerful and reliable techniques. These methods are very useful additions in the arsenal of limb salvage and may provide treatment options for patients who would otherwise be facing amputation.

      Declaration of Competing Interest

      None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript. No funding was used for the conduction of this study.

      Appendix. Supplementary materials

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