Case 24: Ilizarov Method Extremity Solution for Severe Damage. Obtain Bone and Soft Tissues Stability

Abstract

This case reports a 49 year old female who was involved in a high-speed motor vehicle accident. She suffered a limb threatening type IIIC open distal tibia fracture with circumferential skin and muscle loss. She had exposed neurovascular structures. She was managed with limb salvage of aggressive surgical debridement, bony stabilization with a circular fixator, and early soft tissue coverage. Residual limb length discrepancy was addressed with staged proximal tibial osteoplasty.

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1 Brief Clinical History

This case describes a 49 year old female who was involved in a motor vehicle accident. She suffered an open type IIIC distal tibia fracture with complete loss of the overlying skin. The neurovascular structures and tendons were circumferentially exposed. The patient did not want an amputation.

2 Preoperative Clinical Photos and Radiographs

See Figs. 1, 2, 3, 4, and 5.

Fig. 1

Clinical photograph of the patient after damage control external fixator has been placed. The patient had severe crush injury to the distal leg with nonviable skin and muscle

Fig. 2

Clinical photograph of the patient post-debridement. Extensive debridement was necessary to remove any nidus for future infection that would compromise limb viability

Fig. 3

Intra-operative photograph after identification of at-risk structures (neurovascular bundle)

Fig. 4

Damage control external fixator maintained for limb stability during initial reconstructive efforts

Fig. 5

Clinical photograph of the patient’s limb post-debridement. Note the circumferential skin, subcutaneous tissue, muscle, and bone loss

3 Preoperative Problem List

• 1. Severe trauma to the leg with circumferential skin, muscle, and bone loss

• 2. s/p type IIIC distal tibia fracture

• 3. Exposed neurovascular structures

• 4. Distal tibial bone loss

• 5. Loss of ankle joint

4 Treatment Strategy

• Aggressive damage control orthopedics. This involves limb stability with “trauma” external fixator, serial debridements, early soft tissue coverage, and dead space management.

• Acute shortening technique to decrease the bone and soft tissue defect.

• “Orthoplastic” approach. Early involvement with a plastic and reconstructive surgeon experienced in limb salvage is critical.

• Soft tissues stability and multiple muscular flaps.

5 Basic Principles

• Immediate antibiotic therapy

• Stabilization of bone and soft tissues at index surgery

• Staged use of circular external fixation , especially if free flaps are necessary (limits surgical exposure for plastic surgeons)

• Early bone coverage with muscular flaps

6 Images During Treatment

See Figs. 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 18.

Fig. 6

Acute shortening and segmental bone stability

Fig. 7

Muscular rotational soleus and gastrocnemius flaps

Fig. 8

Immediate bone coverage with muscular flaps

Fig. 9

Ilizarov method for soft tissue and bony stability

Fig. 10

Neutral foot stability and skin defect over muscular structures

Fig. 11

Normal vascularity and sensation of the plantar aspect of the foot

Fig. 12

Early bone, tendon, and neurovascular structures should be covered with free-tissue transfer

Fig. 13

Functional reconstruction, bifocal tibial lengthening with external fixator

Fig. 14

Skin stability with foot arthrodesis (Ilizarov method)

Fig. 15

Circumferential soft tissue coverage has been achieved

Fig. 16

Skin coverage and ankle arthrodesis

Fig. 17

AP and lateral X-ray of the tibial after ankle arthrodesis and regenerate stability with an intramedullary nail

Fig. 18

AP and lateral X-ray of the ankle after ankle arthrodesis has been stabilized with a retrograde IM nail

7 Technical Pearls

• Ankle arthrodesis and leg stabilization

• Early skin coverage

• Staged limb lengthening with Ilizarov method

8 Outcome Clinical Photos and Radiographs

See Figs. 19, 20, 21, and 22.

Fig. 19

Skin lateral total cover

Fig. 20

Skin medial total cover

Fig. 21

Clinical photograph of the patient demonstrating full range of motion of the knee

Fig. 22

Final clinical photograph of bilateral lower extremities. The patient had no residual limb length discrepancy. The patient was walking without aids

9 Avoiding and Managing Problems

• Identify structures at risk early in treatment.

• Immediate soft tissue stability with an external fixator.

• Multidisciplinary team approach.

• Ilizarov device to protect the skin defects and impart bony stability.

• Experienced surgeon who is versatile in soft tissue coverage of the distal leg.

10 Cross-References

• Case 28: Proximal Tibial Bone Defect Treated with Intentional Deformity and Bone Transport

• Case 31: GIII B Open Pilon Fracture. Spacer, Flap, and 13.5 Centimeter Bone Transport to Ankle Arthrodesis (Delayed Arthrodesis Secondary to Large Bone Loss Including Ankle Plafond)

• Case 32: GIII B Pilon Fracture with Segmental Bone Loss

• Case 36: Distal Tibial Bone Defect Treated with Bone Transport Using Two Proximal Osteotomy Sites