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Salvage of a Below-the-Knee Amputation Level Following a Type-IIIB Open Tibial FractureA Case Report
Steven J. Morgan, MD1; Justin Newman, BS1; Kagan Ozer, MD1; Wade Smith, MD1; Raffi Gurunluoglu, MD1
1 Denver Health Medical Center, 777 Bannock Street, MC 0188, Denver, CO 80204. E-mail address for S.J. Morgan: steven.morgan@dhha.org
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedics, Denver Health Medical Center, Denver, Colorado

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2007 Dec 01;89(12):2769-2778. doi: 10.2106/JBJS.G.00556
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Extract

Open tibial fractures present with a wide spectrum of soft-tissue injuries and associated bone loss. Reconstruction of a functional limb is often a complex process that may require soft-tissue reconstruction techniques, including free tissue transfer and its associated risks, to manage the soft-tissue injury. In addition, bone loss, if appreciable, may require massive bone-grafting, bone transport, or free vascularized bone transfer to obtain a durable union. In these cases, successful limb salvage is never guaranteed and an extended period of time may be required to achieve a functional extremity1. Amputation, in these cases, may result in an equally successful functional outcome2. When possible, a below-the-knee amputation is the preferred amputation level because it has recognized functional benefits and is associated with decreased energy requirements for the amputee during activity3. Durable soft-tissue coverage and maintenance of appropriate length of the residual limb are paramount in maintaining an optimal outcome4. Unfortunately, the often high-energy mechanism of injury results in an extensive zone of injury. In some instances, the attainment of adequate bone and soft-tissue coverage may require the use of the same techniques that are utilized for limb salvage, which may result in suboptimal coverage and length to afford functional use of a prosthesis. Faced with these reconstruction dilemmas, amputation at a higher level is often the surgical choice.
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    References

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Cedomir S Vucetic
    Posted on December 13, 2007
    Limb Shortening as an Initial Salvage Procedure in Severe Segmental Injuries
    Institute of Orthopaedic Surgery & Traumatology, Clinical Centre of Serbia, Belgrade Serbia.

    To The Editor:

    We read the case report “Salvage of a Below the Knee Amputation Level Following a Type – IIIB Open Tibial Fracture”(1) with great interest. The authors described the use of free tissue transfer, massive bone grafting, bone transport, or free vascularized bone transfer to treat an injury of this magnitude. Our comment concerns the possibility of treating similar injuries, i.e. large areas of segmental destruction but with the distal limb intact, with a method that requires less extensive reconstructive efforts.

    We have reported(2) the use of temporary leg shortening in the zone of bone and soft tissue destruction in such injuries. Shortening makes possible more complete debridement, a lesser extent of soft tissue and bone defect, better prevention of infection and faster wound healing. The limb shortening may be reversed by the Ilizarov technique of equalization (lengthening). When the Ilizarov device is fixed and corticotomy is carried out, the lengthening of the extremity with elongation of all structures, bones and soft tissue, may be completed by simple distraction. This technique does not require the employment of more complex reconstructive procedures. Most commonly, the patient wears the device for several months and may be active without restrictions. The patient is advised to fully weight bear on the extremity during the elongation process. This concept of management has been applied by us in selected cases with good functional and cosmetic results.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. Morgan SJ, Newman J, Ozer K, Smith W, Gurunluoglu R. Salvage of a below-the-knee amputation level following a type IIIB open tibial fracture. A Case Report. J Bone Joint Surg Am. 2007;89:2769-2778.

    2. Vucetic C. Forearm elongation after hand replantation. A case report. J Bone Joint Surg Am. 2005;87:181-186.

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