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A gustilo IIIB open tibial fracture complicated by a huge bone defect and larger soft tissue defect: A case report

Published:November 03, 2021DOI:https://doi.org/10.1016/j.jos.2021.09.018
      Soft tissue damage is severe in Gustilo IIIB (GIIIB) open lower leg fractures, and this damage, comminuted fracture, and loss of the periosteum increase the risk of complications by deep infection and nonunion [
      • Gustilo R.B.
      • Anderson J.T.
      Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses.
      ,
      • Gustilo R.B.
      • Corpuz V.
      • Sherman R.E.
      Epidemiology, mortality and morbidity in multiple trauma patients.
      ,
      • Gustilo R.B.
      • Gruninger R.P.
      • Davis T.
      Classification of type III (severe) open fractures relative to treatment and results.
      ,
      • Gustilo R.B.
      • Mendoza R.M.
      • Williams D.N.
      Problems in the management of type III (severe) open fractures: a new classification of type III open fractures.
      ]. Godina [
      • Godina M.
      Early microsurgical reconstruction of complex trauma of the extremities.
      ] reported a favorable outcome with osteosynthesis and flap surgery performed within 72 h, and a “fix and flap” procedure, in which bone and soft tissue reconstruction is completed early after injury, is now recognized as an ideal treatment [
      • 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.
      ,
      • Hertel R.
      • Lambert S.M.
      • Müller S.
      • Ballmer F.T.
      • Ganz R.
      On the timing of soft-tissue reconstruction for open fractures of the lower leg.
      ,
      • Rajasekaran S.
      • Naresh Babu J.
      • Dheenadhayalan J.
      • Shetty A.P.
      • Sundararajan S.R.
      • Kumar M.
      • Rajasabapathy S.
      A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures.
      ,
      • Rajasekaran S.
      • Dheenadhayalan J.
      • Babu J.N.
      • Sundararajan S.R.
      • Venkatramani H.
      • Sabapathy S.R.
      Immediate primary skin closure in type-III A and B open fractures: results after a minimum of five years.
      ]. However, the reconstruction of GIIIB open tibial fractures with large bone defects is still challenging and treatment is difficult even with the “fix and flap” procedure [
      • Keating J.F.
      • Simpson A.H.
      • Robinson C.M.
      The management of fractures with bone loss.
      ,
      • Schemitsch E.H.
      Size matters: defining critical in bone defect size.
      ,
      • Konda S.R.
      • Gage M.
      • Fisher N.
      • Egol K.A.
      Segmental bone defect treated with the induced membrane technique.
      ] because of the simultaneous reconstruction of bone and soft tissue defects. We herein report a case of a GIIIB open tibial fracture complicated by a huge bone defect (18 cm) and larger soft tissue defect (28 cm in the major axis and 18 cm in the minor axis), for which reconstruction was achieved using a free latissimus dorsi muscle flap and an acute shortening and gradual lengthening procedure (ASGL) [
      • Yokoyama K.
      • Itoman M.
      • Nakamura K.
      • Uchino M.
      • Tsukamoto T.
      • Suzuki T.
      Primary shortening with secondary limb lengthening for Gustilo IIIB open tibial fractures: a report of six cases.
      ,
      • Yokoyama K.
      Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia.
      ,
      • Fletcher M.D.
      • Solomin L.N.
      Definitive management of significant soft tissue loss associated with open diaphyseal fractures utilising circular external fixation without free tissue transfer, a comprehensive review of the literature and illustrative case.
      ,
      • Tetsworth K.
      • Paley D.
      • Sen C.
      • Jaffe M.
      • Maar D.C.
      • Glatt V.
      • Hohmann E.
      • Herzenberg J.E.
      Bone transport versus acute shortening for the management of infected tibial non-unions with bone defects.
      ].
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      References

        • Gustilo R.B.
        • Anderson J.T.
        Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses.
        J Bone Jntt Surg Am. 1976 Jun; 58: 453-458
        • Gustilo R.B.
        • Corpuz V.
        • Sherman R.E.
        Epidemiology, mortality and morbidity in multiple trauma patients.
        Orthopedics. 1985 Dec; 8: 1523-1528
        • Gustilo R.B.
        • Gruninger R.P.
        • Davis T.
        Classification of type III (severe) open fractures relative to treatment and results.
        Orthopedics. 1987 Dec; 10: 1781-1788
        • Gustilo R.B.
        • Mendoza R.M.
        • Williams D.N.
        Problems in the management of type III (severe) open fractures: a new classification of type III open fractures.
        J Trauma. 1984 Aug; 24: 742-746
        • Godina M.
        Early microsurgical reconstruction of complex trauma of the extremities.
        Plast Reconstr Surg. 1986 Sep; 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 Jt Surg Br. 2000 Sep; 82: 959-966
        • Hertel R.
        • Lambert S.M.
        • Müller S.
        • Ballmer F.T.
        • Ganz R.
        On the timing of soft-tissue reconstruction for open fractures of the lower leg.
        Arch Orthop Trauma Surg. 1999; 119: 7-12
        • Rajasekaran S.
        • Naresh Babu J.
        • Dheenadhayalan J.
        • Shetty A.P.
        • Sundararajan S.R.
        • Kumar M.
        • Rajasabapathy S.
        A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures.
        J Bone Jt Surg Br. 2006 Oct; 88: 1351-1360
        • Rajasekaran S.
        • Dheenadhayalan J.
        • Babu J.N.
        • Sundararajan S.R.
        • Venkatramani H.
        • Sabapathy S.R.
        Immediate primary skin closure in type-III A and B open fractures: results after a minimum of five years.
        J Bone Jt Surg Br. 2009 Feb; 91: 217-224
        • Keating J.F.
        • Simpson A.H.
        • Robinson C.M.
        The management of fractures with bone loss.
        J Bone Jt Surg Br. 2005 Feb; 87: 142-150
        • Schemitsch E.H.
        Size matters: defining critical in bone defect size.
        J Orthop Trauma. 2017 Oct; 31: S20-S22
        • Konda S.R.
        • Gage M.
        • Fisher N.
        • Egol K.A.
        Segmental bone defect treated with the induced membrane technique.
        J Orthop Trauma. 2017 Aug; 31: S21-S22
        • Yokoyama K.
        • Itoman M.
        • Nakamura K.
        • Uchino M.
        • Tsukamoto T.
        • Suzuki T.
        Primary shortening with secondary limb lengthening for Gustilo IIIB open tibial fractures: a report of six cases.
        J Trauma. 2006 Jul; 61: 172-180
        • Yokoyama K.
        Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia.
        J Bone Jt Surg Br. 2007 Jun; 89: 846
        • Fletcher M.D.
        • Solomin L.N.
        Definitive management of significant soft tissue loss associated with open diaphyseal fractures utilising circular external fixation without free tissue transfer, a comprehensive review of the literature and illustrative case.
        Eur J Orthop Surg Traumatol. 2015 Jan; 25: 65-75
        • Tetsworth K.
        • Paley D.
        • Sen C.
        • Jaffe M.
        • Maar D.C.
        • Glatt V.
        • Hohmann E.
        • Herzenberg J.E.
        Bone transport versus acute shortening for the management of infected tibial non-unions with bone defects.
        Injury. 2017 Oct; 48: 2276-2284
        • 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 Br. 2007 Jan; 89: 80-88
        • Masquelet A.C.
        • Fitoussi F.
        • Begue T.
        • Muller G.P.
        Reconstruction of the long bones by the induced membrane and spongy autograft.
        Ann Chir Plast Esthetique. 2000 Jun; 45: 346-353
        • Masquelet A.C.
        • Begue T.
        The concept of induced membrane for reconstruction of long bone defects.
        Orthop Clin N Am. 2010 Jan; 41: 27-37
        • Giannoudis P.V.
        • Faour O.
        • Goff T.
        • Kanakaris N.
        • Dimitriou R.
        Masquelet technique for the treatment of bone defects: tips- tricks and future directions.
        Injury. 2011 Jun; 42: 591-598
        • 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 Mar; 20: 197-205
        • McNally M.
        • Ferguson J.
        • Kugan R.
        • Stubbs D.
        Ilizarov treatment protocols in the management of infected nonunion of the tibia.
        J Orthop Trauma. 2017 Oct; 31: S47-S54
        • Napora J.K.
        • Weinberg D.S.
        • Eagle B.A.
        • Kaufman B.R.
        • Sontich J.K.
        Hexapod stacked transport for tibial infected nonunions with bone loss: long-term functional outcomes.
        J Orthop Trauma. 2018 Jan; 32: e12-e18
        • Cormack G.C.
        • Lamberty B.G.
        A classification of fascio-cutaneous flaps according to their patterns of vascularisation.
        Br J Plast Surg. 1984 Jan; 37: 80-87
        • Hallock G.G.
        Simultaneous transposition of anterior thigh muscle and fascia flaps: an introduction to the chimera flap principle.
        Ann Plast Surg. 1991 Aug; 27: 126-131
        • Koshima I.
        A new classification of free combined or connected tissue transfers: introduction to the concept of bridge, siamese, chimeric, mosaic, and chain-circle flaps.
        Acta Med Okayama. 2001 Dec; 55: 329-332
        • Koshima I.
        • Imai H.
        • Yoshida S.
        • Harima T.
        • Mizuta H.
        • Yamashita S.
        • Nagamatsu S.
        • Yokota K.
        • Kannan R.
        The ‘Orochi’ flap concept: multi-stage combined flap using sequential flaps.
        Int J Microsurg. 2019; 3: 4
        • Qvick L.M.
        • Ritter C.A.
        • Mutty C.E.
        • Rohrbacher B.J.
        • Buyea C.M.
        • Anders M.J.
        Donor site morbidity with reamer-irrigator-aspirator (RIA) use for autogenous bone graft harvesting in a single centre 204 case series.
        Injury. 2013 Oct; 44: 1263-1269
        • Haubruck P.
        • Ober J.
        • Heller R.
        • Miska M.
        • Schmidmaier G.
        • Tanner M.C.
        Complications and risk management in the use of the reaming-irrigator-aspirator (RIA) system: RIA is a safe and reliable method in harvesting autologous bone graft.
        PLoS One. 2018 Apr; 13e0196051
        • El-Gammal T.A.
        • Shiha A.E.
        • El-Deen M.A.
        • El-Sayed A.
        • Kotb M.M.
        • Addosooki A.I.
        • Ragheb Y.F.
        • Saleh W.R.
        Management of traumatic tibial defects using free vascularized fibula or Ilizarov bone transport: a comparative study.
        Microsurgery. 2008; 28: 339-346