A Case of Reconstruction of a Type IIIc Open Tibial Fracture with Bone Loss and Warm Ischemia Time of 13 Hours: Quality of Life and Review of the Literature

Abstract

BACKGROUND The management of open Gustilo IIIC fractures can be challenging even for experienced orthopedic surgeons. The decision between limb salvage and amputation is extremely difficult and the scoring systems do not seem to affect it significantly. Although ischemic time has been proven to be a major factor, attempts at reconstruction of limbs with ischemic time over 6 hours have been made in past decades. A simultaneous management of skeletal, soft-tissues, and vascular injury should be performed. This requires an orthoplastic surgeon who is capable of doing all the necessary operations by him/herself with hand-surgery and microsurgery expertise. CASE REPORT We present a case of a 49-year-old man with a type IIIC open tibial fracture with bone loss and warm ischemia time of 13 hours, who underwent revascularization and reconstruction with good radiological and functional results after a follow-up of 3 years. A few similar cases have been presented in the literature but none of them had a combination of bone loss, severe soft tissue injury, and complete vascular disruption after a crush injury. CONCLUSIONS The treatment of type IIIC open fractures of the tibia can be a demanding and time-consuming process. Detailed information about the necessity of multiple surgical interventions must be explained and fully understood by the patient in order to have realistic expectations.

Figure 1.

Images of the injured limb on admission. (A) The bone was exposed from the medial side, (B) Pale under the injury site and (C) Severe soft tissue injury of the lateral side.

Figure 2.

End-to-end bypass anastomosis of the posterior tibial artery using a 10-cm graft from the major saphenous vein of the ipsilateral thigh.

Figure 3.

A split-thickness skin graft was used 1 month after the first operation. (A) Subcutaneous tissue with adequate blood supply. (B) Split-thickness skin graft.

Figure 4.

(A) Anteroposterior and (B) lateral X-ray of the leg 3 years after the injury. Note the closure of the bone gap and the fine consolidation of the free lateral bone fragment. (C) Medial and (D) lateral images of the leg.