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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

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      References

        • 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.
        Br J Plast Surg. 1997; 50: 570-583
        • Hallock G.G.
        Evidence-based medicine: lower extremity acute trauma.
        Plast Reconstr Surg. 2013; 132: 1733-1741
        • Soltanian H.
        • Garcia R.M.
        • Hollenbeck S.T.
        Current concepts in lower extremity reconstruction.
        Plast Reconstr Surg. 2015; 136: 815e-829e
        • Reddy V.
        • Stevenson T.R.
        MOC-PS(SM) CME article: lower extremity reconstruction.
        Plast Reconstr Surg. 2008; 121: 1-7
        • Green S.A.
        Ilizarov method.
        Clin Orthop Relat Res. 1992; 280: 2-6
        • Aronson J.
        Limb-lengthening, skeletal reconstruction, and bone transport with the Ilizarov method.
        J Bone Joint Surg Am. 1997; 79: 1243-1258
        • Paley D.
        • Catagni M.A.
        • Argnani F.
        • Villa A.
        • Benedetti G.B.
        • Cattaneo R.
        Ilizarov treatment of tibial nonunions with bone loss.
        Clin Orthop Relat Res. 1989; : 146-165
        • 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.
        J Bone Joint Surg Am. 2008; 90: 2643-2651
        • 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.
        J Orthop Trauma. 2006; 20: 419-424
        • 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.
        J Orthop Trauma. 2013; 27: 451-456
        • Lerner A.
        • Fodor L.
        • Ullmann Y.
        Acute temporary malpositioning for dealing with extensive tissue loss after severe high-energy trauma to extremities.
        in: Kocaoglu M Tsuchiya H Eralp L Advanced Techniques in Limb Reconstruction Surgery. Springer, New York2015: 111-117
        • Pierrie S.N.
        • Hsu J.R.
        Shortening and angulation strategies to address composite bone and soft tissue defects.
        J Orthop Trauma. 2017; 31: S32-S35
        • 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.
        J Orthop Trauma. 2003; 17: 549-554
        • Al-Sayyad M.J.
        Taylor spatial frame in the treatment of open tibial shaft fractures.
        Indian J Orthop. 2008; 42: 431-438
        • Ganger R.
        • Radler C.
        • Speigner B.
        • Grill F.
        Correction of post-traumatic lower limb deformities using the Taylor spatial frame.
        Int Orthop. 2010; 34: 723-730
        • Lerner A.
        • Fodor L.
        • Soudry M.
        Is staged external fixation a valuable strategy for war injuries to the limbs?.
        Clin Orthop Relat Res. 2006; 448: 217-224
        • Hou Z.
        • Irgit K.
        • Strohecker K.A.
        • et al.
        Delayed flap reconstruction with vacuum-assisted closure management of the open IIIB tibial fracture.
        J Trauma. 2011; 71: 1705-1708
        • 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.
        J Orthop Trauma. 2004; 18: 150-157
        • El-Rosasy M.A.
        Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia.
        J Bone Jt Surg. 2007; 89: 80-88
        • Godina M.
        Early microsurgical reconstruction of complex trauma of the extremities.
        Plast Reconstr Surg. 1986; 78: 285-292
        • 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.
        J Bone Joint Surg Br. 2000; 82: 959-966
        • 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.
        J Bone Joint Surg Br. 2004; 86: 861-867
        • 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.
        J Orthop Trauma. 2006; 20: 197-205
        • 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.
        J Trauma. 2004; 57: 603-608
        • Sharma H.
        • Nunn T.
        Conversion of open tibial IIIb to IIIa fractures using intentional temporary deformation and the Taylor Spatial Frame.
        Strat Traum Limb Recon. 2013; 8: 133-140