Salvage of a Below-the-Knee Amputation Level Following a Type-IIIB Open Tibial Fracture

Abstract

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. We report the case of a patient with an open Gustilo-Anderson type-IIIB tibial fracture with extensive soft-tissue loss and an associated bone loss of approximately 17 cm. The patient, not desiring limb salvage with free tissue transfer or bone transport and not wishing to undergo an above-the-knee amputation, elected to undergo a below-the-knee amputation with complex local and osseous soft-tissue reconstruction. An optimal-length residual limb with durable soft-tissue coverage was obtained through the creation of …