A 52-Year-Old Man with a Gustillo-Anderson IIIB Open Tibial Shaft Fracture with Extensive Soft-Tissue Defect Requiring Limb Salvage with Artificial Deformity-Creating Technique

Abstract

BACKGROUND In this case report, an alternative way of treating Gustillo-Anderson IIIB type fractures with severe soft-tissue damage is provided for cases where, for various reasons, it is not possible to close a soft-tissue defect with a flap. CASE REPORT An artificial deformity-creating technique was applied for a patient with a right distal tibial open fracture (Gustillo IIIB type) with complete tibial cartilage and bone loss of 10 cm and severe soft-tissue defect after high-energy trauma. This technique includes damaged limb shortening, translation, angulation, and rotation for closure of soft-tissue defects using orthopedic hexapod and bifocal bone transport without need for plastic surgery. Because of the timely planning and application of the orthopedic hexapod for the artificial deformity correction, the final alignment of the limb was close to the physiological standard and had good functional outcomes. Despite the extremely severe shortening and acute angles, the total treatment time was only 75 weeks. At the 1-year follow-up after treatment completion, the patient had good functional outcomes with the 36-Item Short Form Survey score: general health, 80%; physical functioning, 85%; and social functioning, 100%. CONCLUSIONS In conclusion, we show that the artificial deformity-creating with subsequent orthopedic hexapod application and lengthening of a limb is a robust method that can be applied even for the treatment of severe open fractures with significant soft-tissue damage and bone loss, which can be performed outside high-level trauma hospitals and has good clinical outcomes without significant complications.

Figure 1.

(A) Computed tomography scan (preoperative) of the 52-year-old man showing Gustilo-Anderson III B open distal third tibial fracture. (B) Clinical photograph (preoperative) presenting the damaged limb with severe soft-tissue defect. (C) Clinical photograph showing extensive soft-tissue and bone defect after wound revision and debridement. (D) Clinical photograph (postoperative) presenting the fracture stabilization using monolateral external fixation apparatus and the vacuum-assisted closure system for wound coverage.

Figure 2.

(A) Clinical photograph showing the wound closure of the damaged limb by artificial deformity-creating including shortening, translation, angulation, and rotation. (B) X-ray (anteroposterior and lateral) showing the damaged limb after artificial deformity-creation was performed. (C) Clinical photograph presenting the residual skin defect closure using auto-dermoplasty.

Figure 3.

(A) X-rays (anteroposterior and lateral) after orthopedic hexapod mounting, to perform the deformity correction calculations. (B) Clinical photograph showing the end of artificial deformity correction using orthopedic hexapod. (C) X-ray (anteroposterior and lateral) presenting talocrural arthrodesis as fixation method using the Ilizarov frame. (D) Clinical photograph showing the patient before discharging from the hospital using crutches with partial weight-bearing.

Figure 4.

(A) Clinical photograph showing the limb lengthening by the double-level osteotomy using Ilizarov frame. (B) X-rays (anteroposterior and lateral) presenting 2 hexapods applied for the secondary deformity correction. (C) Clinical photograph showing the leg length and anatomical alignment were fully restored.

Figure 5.

(A) X-rays (lateral and anteroposterior) showing anatomical axis after length restoration and good ossification of the regenerate. (B) Clinical photograph presenting final results with the patient fully weight-bearing with no concerns.