Acute shortening and angulation for complex open fractures: an updated perspective

Abstract

Reestablishing an intact, healthy soft tissue envelope is a critical step in managing lower extremity injuries, particularly high-grade open tibia fractures. Acute shortening and angulation can be used independently or together to address complex soft tissue injuries, particularly when bone loss is present. These techniques facilitate management of difficult wounds and can be combined with local soft tissue rearrangement or pedicled flaps as needed, avoiding the need for free tissue transfer. After angular deformity correction, adjacent bone loss can be addressed with bone grafting or distraction histogenesis. This article discusses the indications for, surgical technique for, and limitations of acute shortening and angulation for management of open lower extremity fractures.

Keywords: angulation; distraction histogenesis; distraction osteogenesis; hexapod frame; induced deformity; open fracture; shortening; tibia fracture.

Figure 1.

In this case, varus and recurvatum were introduced to facilitate primary closure of a complex oblique wound. Bayonet apposition of the fractured tibia and/or fibula is permissible as long as it does not put undue tension on the wound or vascular structures.

Figure 2.

A 21-year-old man was involved in a motor vehicle collision. A, The patient had a type III open left tibia fracture with an oblique laceration involving the anterior and medial soft tissues. B, He underwent irrigation and debridement with removal of a devitalized cortical fragment, creating a nonsegmental defect. C, A varus and recurvatum deformity was induced in a circular ring fixator to allow primary closure of his wound. After wound healing, he began deformity correction in the hexapod frame. In the absence of substantial bone loss, neither bone grafting nor bone transport was needed. D, Eight weeks after frame application, he was transitioned to a cast for a 2-week pin holiday and then to an intramedullary rod. E, Five months after intramedullary rodding, he had clinically healed.

Figure 3.

A 38-year-old man sustained a high caliber ballistics injury to the left leg. A, B, The patient had a type III open left tibia fracture with significant periosteal stripping and medial soft tissue loss. C, He underwent irrigation and debridement with removal of devitalized bone, placement of antibiotic-eluting cement beads, and application of external fixation. D, Portions of the wound were closed, but a large posteromedial soft tissue defect remained. E, One week later, he was transitioned to a circular ring fixator to manage the composite bone and soft tissue defect. Devitalized bone was excised, and the tibia was shortened an estimated 5 cm. A varus and recurvatum deformity was induced to minimize the wound dimensions. F, Periosteum was no longer exposed after shortening and angulation, and the wound was eventually managed with split-thickness skin grafting. Note that carbon fiber bars (arrowhead; Smith and Nephew JET-X, Memphis, TN) were initially used in lieu of struts near the wound to facilitate local wound care. G, Two months after frame application, the carbon fiber bars were replaced with struts to create a hexapod frame that could accommodate deformity correction. A metaphyseal corticotomy was performed proximally to facilitate simultaneous bone transport. H, After deformity correction and lengthening, the patient was scheduled for open bone grafting of the docking site nonunion. I, Once the docking site healed, the hexapod frame was removed while the regenerate consolidated. One year after his injury, the frame was removed. J, K, At the final follow-up 17 months after the initial injury, the patient was ambulating without assistive devices and had returned to recreational activities (Courtesy of John D. Wyrick, MD).