Type IIIB Open Fractures Research Articles

Cross-leg limb salvage solution: A case report regarding the management of a major defect in a patient with type IIIB open distal tibial fracture

Tissue coverage of lower limb defects after tibial fractures remain one of the hardest areas for a surgeon to deal with. The definitive management of Gustillo type IIIB fractures depends on a series of factors, which have a high impact in the multidisciplinary management of this severe trauma. Although free flaps have been used succesfully in the last two decades, there remains some cases where easier plasties using the contralateral limb tissue reserved could be indicated. We describe our experience with a cross-leg flap in a severe-smoking patient for the reconstruction of a difficult leg defect.

A study of clinical outcome and patient quality of life in timing of free flap cover in type IIIB open fractures

Background: Open fractures of leg classified under type IIIB, those requiring free flap cover could be done as emergency procedure. The ideal timing has still remained controversial. Although it appears imperative to operate early and reduce length of hospital stay, costs, disability adjusted life years and put the patient back on his feet, our study was necessitated in the context of differing views regarding ideal timing of free flap.Methods: The prospective observational study was conducted for duration of 4 years between October 2015 to September 2019. Patients were taken up for free flap cover after optimization for the major surgery. Details of flap complications and the procedures for salvage were noted. At the end of one year following the injury, patient quality of life (PQOL) was tabulated for all patients.Results: Most common mode of injury was road traffic accidents. Early flaps were done in 28 and primary flaps in 22 patients. One patient had partial flap necrosis while 7 others had sub flap collections and partial flap necrosis. Duration of hospitalization was significantly lower in early flap cover group. PQOL measured with EQ-5D (EuroQol 5D) was significantly higher in the early flap covers.Conclusions: From our study we concluded that timing of free flap cover positively influenced clinical outcome of reduced hospitalization, although there was no relation of timing of free flap to flap or bone complications. The functional outcome measured by PQOL was significantly higher in patients who had microvascular reconstruction early.

Management of Gustilo type IIIB open tibial shaft fractures with limited resources: experience from an African trauma center.

We sought to evaluate the management of Gustilo type IIIB open tibia diaphyseal fractures in an African trauma center with respect to soft tissue defect management and bone union achievement. Functional outcome assessment was the secondary objective. A retrospective review was conducted including patients treated for open tibia fractures requiring flap coverage between 2007 and 2011. As plastic surgeons were lacking in availability, all procedures were performed by orthopedic surgeons trained in completing nonmicrosurgical flap transfers. Twenty-seven patients with a mean age of 36years were included. Although the mean time to debridement was 11h, early infection occurred in 16 (59%) patients. The mean time to flap coverage was 27days. Among the 29 primary local flap transfers performed, only 4 failed. Secondary amputation was required in one patient after flap failure. Bone reconstruction procedures were required in nine patients and were performed after a mean period of 97days. At the mean follow-up time of 13months, 23 (88%) of the 26 remaining fractures had united. There were three septic nonunions and two cases of chronic osteomyelitis. Functional result was negatively influenced by the soft tissue defect area and low-quality flap coverage. To our knowledge, this is the first series reporting flap reconstructions performed by orthopedic surgeons for Gustilo type IIIB tibia fractures in an African hospital. Local pedicled flap transfers permitted the achievement of soft tissue coverage and bone union in most cases. Subsequent bone grafting was required in one-third of the cases.

The Effects of Timing of Soft Tissue Coverage on Outcomes After Reconstruction of Type IIIB Open Tibia Fractures.

High-energy open fractures of the tibia are frequently associated with tissue loss, wound contamination, and compromised vascularity that often result in amputation. The management of these severe injuries remains a challenge for orthopedic reconstructive surgeons. Studies have compared the timing of soft tissue coverage of Gustilo type IIIB open tibia fractures with associated outcomes such as rate of deep infection, primary union, length of hospitalization, flap failure, and eventual secondary amputation. These studies often highlight better outcomes with specific time domains that are not always attainable at a large tertiary hospital with multi-system trauma patients. Many studies do not account for delayed patient transfers after initial open fracture management elsewhere. This retrospective analysis of the limb salvage outcomes included 140 consecutive patients with Gustilo type IIIB open tibia fractures who presented to the authors' level I trauma center between 2001 and 2014. The authors included patients who required delayed coverage or who were transferred from outside institutions. The majority (77%) were male, and the mean age was 39.4 years. Motor vehicle accidents were the most common cause of injury, and 83% of patients obtained full weight-bearing status with successful limb salvage. Twenty patients had a secondary amputation, with the cause being refractory osteomyelitis in 52%. This study provides guidance on treating a heterogeneous patient population with severe open tibia fractures typically seen in a large tertiary hospital orthopedic trauma service. [Orthopedics. 2019; 42(5):260-266.].

A comparison between the Major Trauma Centre management of complex open lower limb fractures in children and the elderly

Introduction: Open lower limb fractures can be devastating with outcomes determined by tissue damage and adherence to strictly defined care pathways. Managing such injuries in paediatric and elderly populations presents logistical and technical challenges to achieve best outcomes. Orthoplastic principles were developed mainly in the young adult population whereas requirements for paediatric and elderly patients need further understanding.Methods: A retrospective analysis was performed on two groups of patients at the extremes of age, with type IIIb (severe) open lower limb fractures, presenting to a Major Trauma Centre (MTC) with orthoplastic services over a six-year period - the first group being under 16 years; the second group being over 65. The timelines of combined surgery to both fix the fracture and flap the soft-tissue defect were strictly observed. Each group were followed-up for a minimum of nine months. Data were analysed according to patient demographics, mechanism of trauma, time to wound excision, time to definitive surgery, fixation technique, soft-tissue reconstruction type, deep infection rate, flap survival, bony union, secondary amputation and functional outcome (Enneking score).Results: 33 paediatric patients and 99 elderly patients were identified.Paediatric: The median age was 12 years. All the children were ASA Grade I. Open tibial fractures were most common (76%) followed by ankle fracture dislocation (12%). The majority were high-energy injuries and were commonly managed with external fixators (or frames) and free flap coverage. Median hospital stay was 12 days, and time to union 114 days, with median Enneking scores of 85%. There was one flap failure and no deep infections.Elderly: The median age was 76 years. ASA grades varied and reflected multiple comorbidities. High-energy injuries required free flaps, while more common, low-energy fragility fractures were covered with loco-regional flaps. Internal fixation with intramedullary nails was most commonly used. Median hospital stay was 13 days, and time to union was 150 days, with median Enneking scores of 70%. There was one flap failure, one deep infection, and one delayed amputation.Discussion: These results reflect both similarities and important differences in managing open fractures in the extremes of age. The specific challenges of each group of patients are discussed, including surgical aspects, but also the importance of orthoplastics infrastructure within the MTC and input from allied professionals to facilitate patient pathways.

New Alternative Therapeutic Strategy for Gustilo Type IIIB Open Fractures, Using an Intra-Wound Continuous Negative Pressure Irrigation Treatment System.

The treatment of Gustilo type IIIB and IIIC open fractures remains a challenging problem, because the infection rate is 15-45%. Infection can lead to serious complications such as osteomyelitis or amputation. The intra-wound continuous negative pressure and irrigation treatment (IW-CONPIT) was developed for infected wounds and intractable ulcers, and is very effective in suppressing infection and accelerating wound healing. Here the IW-CONPIT was applied to severe open fractures for the purpose of preventing infection. After thorough debridement and lavage of the wound, bony stabilization is performed by external fixation. Dermal matrix is grafted onto any areas where the bone or tendon is exposed. A sponge containing two tubes is placed over the entire surface of the wound including the dermal matrix. Then it is covered with a film dressing to make the wound completely airtight. A bottle of physiologic saline solution is attached to one tube, and a continuous aspirator is attached to the other. This system maintains negative pressure on the wound surface, which is continuously irrigated. Thirty-five patients were treated with this method. A superficial infection developed in two cases but was resolved by additional debridement and continued application of IW-CONPIT. Complete wound healing was obtained with split thickness skin graft in all cases. There were no complications such as osteomyelitis, delayed bone union or amputation. IW-CONPIT was able to definitively prevent wound infection in Gustilo type ⅢB open fractures. We believe this method will become a standard treatment option for this condition.

Guided growth surgery for genu valgum in mucopolysaccharidosis type VI: Timing is everything

Open injuries in children are rare compared to adults. In children with major open injuries, there is no specific scoring system to guide when to amputate or salvage the limb. The use of available adult scoring systems may lead to errors in management. The role of Ganga Hospital Open Injury Severity Scoring (GHOISS) for open injuries in adults is well established and its applicability for pediatric open injuries has not been studied. This study was done to analyse the usefulness of GHOISS in pediatric open injuries and to compare it with MESS(Mangled Extremity Severity Score).All children (0–18 years) who were admitted with Open type IIIB injuries of lower limbs between January 2008 and March 2015 were included. MESS and GHOISS were calculated for all the patients. There were 50 children with 52 type IIIB Open injuries of which 39 had open tibial fractures and 13 had open femur fractures.Out of 52 type IIIB open injuries, 48 were salvaged and 4 were amputated. A MESS score of 7 and above had sensitivity of 25% for amputation while GHOISS of 17 and above was found to be more accurate for determining amputation with sensitivity of 75% and specificity of 93.75%.GHOISS is a reliable predictor of injury severity in type IIIB open fractures in children and can be used as a guide for decision-making. The use of MESS score in children has a lower predictive value compared to GHOISS in deciding amputation versus salvage. A GHOISS of 17 or more has the highest sensitivity and specificity to predict amputation.

Analysis of primary interlocking nailing for open fractures of tibial shaft

Background: The results of closed intramedullary nailing technique are excellent for treating fractures of the tibial shaft. Court Brown reported that the time to union and infection rates were similar when open tibial fractures were treated by reamed locked intramedullary nail or an external fixator. But references regarding the results, incidence of infection, nonunion related to the specific type of open injuryare limited. Hence we decided to analyse primary interlocking nailing for open tibial fractures. Materials & Methods: All patients with open tibial fractures treated with primary interlocking nail were evaluated. Wound debridement and nailing were performed with image intensifier guidance. Static or dynamic locking was done depending upon the fracture stability. Results: 44 patients with 44 fractures were included in the study. 15 (34%) type I, 19 (43%) type II, 9 (20%) type IIIA, 1 type IIIB open fractures were treated. Reaming was done in 41 (93%) patients. Nine (20%) of the nails were dynamically locked. 95% united uneventfully except two (5%). The average time to union was 26 weeks for type I fractures, 29 weeks for type II, 34 weeks for type IIIA, 38 weeks for the type IIIB. There were three deep infections (7%). Conclusions: Primary Interlocking nailing for tibial open fractures is an excellent mode of therapy. Interlocking nailing reduces the incidence of complications like infection (7%), nonunion (5%). It is more acceptable to patients than external fixators.

Use of Ganga Hospital Open Injury Severity Scoring for determination of salvage versus amputation in open type IIIB injuries of lower limbs in children—An analysis of 52 type IIIB open fractures

Introduction and aimsOpen injuries in children are rare compared to adults. In children with major open injuries, there is no specific scoring system to guide when to amputate or salvage the limb. The use of available adult scoring systems may lead to errors in management. The role of Ganga Hospital Open Injury Severity Scoring (GHOISS) for open injuries in adults is well established and its applicability for pediatric open injuries has not been studied. This study was done to analyse the usefulness of GHOISS in pediatric open injuries and to compare it with MESS(Mangled Extremity Severity Score). MethodsAll children (0–18 years) who were admitted with Open type IIIB injuries of lower limbs between January 2008 and March 2015 were included. MESS and GHOISS were calculated for all the patients. There were 50 children with 52 type IIIB Open injuries of which 39 had open tibial fractures and 13 had open femur fractures. ResultsOut of 52 type IIIB open injuries, 48 were salvaged and 4 were amputated. A MESS score of 7 and above had sensitivity of 25% for amputation while GHOISS of 17 and above was found to be more accurate for determining amputation with sensitivity of 75% and specificity of 93.75%. ConclusionGHOISS is a reliable predictor of injury severity in type IIIB open fractures in children and can be used as a guide for decision-making. The use of MESS score in children has a lower predictive value compared to GHOISS in deciding amputation versus salvage. A GHOISS of 17 or more has the highest sensitivity and specificity to predict amputation.

Treatment strategies and therapeutic effects in treatment of floating knee in children

Objective To investigate the treatment strategies and clinical effects in treatment of floating knee in children. Methods A retrospective case series study was made on 26 cases of floating knee treated from July 2005 to June 2015. There were 22 males and four females, aged from 2-14 years (mean, 7.6 years). According to the Letts classification of the floating knee, ten cases were with type A, four with type B, two with type C, eight with type D, and two with type E. Closed fractures were noted in 16 cases and open fractures in 10 cases. According to the Gustilo classification of open fractures, one was with type ⅢA, six with type ⅢB, and three with type ⅢC. One case was amputated from the distal of the femur, eight cases were treated by traction and plaster caster, and 17 cases were treated by reduction and fixation of both femoral and tibil fractures. Wound healing, fracture union, Karsstrom criteria for functional outcome and complications were detected. Results All patients were followed up for mean 2.8 years (range, 1-6 years). One case of Gustilo type ⅢA and six cases of Gustilo type ⅢB open fractures had wound healing after one-stage debridement. Two cases of Gustilo type ⅢC showed wound healing after second-stage skin grafting. One case of Gustilo type ⅢC had amputation wound infection and was cured after a second debridement and dress change. Two had delayed union and there was no nonunion. According to the Karlstrom criteria, the excellent and good rate of functional outcome was 25% and 83% respectively in nonoperative and operative population (P<0.05). Malunion was found in four cases, genu vagum in three and overgrowth of 10-20 mm in seven. There was no premature closure of epiphysis. Conclusion Femur and tibia immobilization of floating knee in children is effective for bone union and functional recovery. Key words: Knee joint; Femoral fractures; Tibial fractures; Child

Crush neck with bilateral clavicle fractures managed with negative-pressure wound therapy and supracutaneous locked plating

Bilateral and open fractures of the clavicle are rare injuries, with Gustilo-Anderson Type III open clavicle fractures rarely seen. We have reported a case of bilateral clavicle fractures in a young male with crush injury of the neck on the right side, multiple associated rib fractures, and brachial plexus injury. The crush neck was managed with extensive debridement and clavicle fractures were managed with external fixation with a supracutaneous locking compression plate on the right side, and internal fixation with a reconstruction plate on the left side. The wound healed with serial negative-pressure dressings without any secondary procedure. Both the fractures united well with a good outcome. This case demonstrates the effective use of negative-pressure wound therapy and supracutaneous locked plating for a Gustilo-Anderson Type IIIB open fracture of the clavicle.

Results of open tibial fracture treatment using external fixation

Open lower leg fractures are the most common open fractures of the locomotor system and their treatment is associated with a number of complications. The aim of the paper was to present the results of the treatment of 68 patients with open lower leg fractures, as well as the complications that accompany the treatment of these fractures. In the analyzed group, there were 45 (66.18%) men and 23 (33.82%) women. The majority of patients – 33 (48.53%) of them – were injured in motor vehicle accidents, whereas 24 (35.29%) patients sustained injuries due to falls from heights. In two (2.94%) patients the cause of open tibial fractures was gunshot injuries. In the analyzed group, there were 18 (26.47%) type I open fractures, 21 (30.88%) type II open fractures, 19 (27.94%) type IIIA open fractures, seven (10.29%) type IIIB open fractures, and three (4.41%) type IIIC open fractures. The tibial shaft fracture healed without serious complications in 50 (73.53%) patients, whereas in 18 (26.47%) patients we observed some complications. Nonunion was found in 10 (14.71%) patients, osteitis in four (5.88), malunion in two (2.94%) patients. Milder complications such as soft tissue pin tract infection developed in 13 (19.12%) patients, infection of the open fracture wound soft tissue was observed in four (5.88%) patients. Basic principles in the treatment of open lower leg fractures in this study are thorough primary open fracture wound treatment followed by the delayed wound closure, stable fracture fixation using unilateral external skeletal device, proper antibiotic treatment and tetanus prophylaxis. The results correlate with similar studies.

The Gradual Expansion Muscle Flap

High-energy open fractures of the tibia have traditionally been fraught with challenges to include bone comminution or loss, soft tissue loss, nonunion, and infection. A number of techniques have been implemented to treat the severe soft tissue loss typically involving the anteromedial surface of the tibia to include wet-to-dry dressings or Papineau techniques, negative pressure wound therapy, acellular dermal matrices, and rotational or free tissue transfer with Masquelet technique, primary shortening, and distraction osteogenesis to address bone loss. We present a novel technique and subsequent case series that obviates the need of free tissue transfer while treating high-energy type IIIB open tibia fractures by performing an acute shortening and angulation of the tibia and rotational muscle flap coverage and split-thickness skin grafting of the soft tissue defect. Distraction histiogenesis with circular external fixation is then used to correct the residual osseous deformity while stretching the rotational muscle flap.

Elbow Hemiarthroplasty for Late Reconstruction of a Traumatic Elbow Bone Defect in a Young Patient: A Case Report.

Hemiarthroplasty of the human elbow was first described in 1947 by Mellen and Phalen1. Encouraging follow-up results with good range of motion and substantial pain relief after elbow hemiarthoplasty were published in 19742. Nevertheless, in cases with severe bone loss and comminution, the semiconstrained total elbow arthroplasty has been a very reliable solution during the last decades3,4, especially in elderly patients. However, in active patients with an injured dominant arm, the major mid and long-term complication of these semi or totally linked polyethylene components is the risk of loosening5. In younger patients, the new anatomic elbow hemiarthroplasty offers the possibility of greater mobility, stability, and promising long-term results6. We present the case of a young patient with a comminuted type-IIIB open fracture of the elbow with bone loss of the humeral condyles. After elbow hemiarthroplasty, the final follow-up (4.5 years postoperatively) showed that the treatment had been successful. The patient was informed that data concerning the case would be submitted for publication, and he provided consent. A thirty-one-year-old obese man (body mass index [BMI] of 35) without any other medical comorbidities presented to the emergency department following a motorcycle accident. Clinical and radiographic evaluation demonstrated an open intercondylar fracture (type IIIB according to the Gustilo-Anderson classification7) of the right dominant elbow, with bone loss of the humeral condyles and fracture of the olecranon tip. Complete radial nerve palsy was also noted. Immediate wound irrigation and surgical debridement were performed in the operating room. During surgical exploration, the radial nerve was found to be intact, and no major vascular injury was apparent. Because of extensive soft-tissue damage, internal fixation was not an option. An elbow-bridging external fixator (Orthofix, Lewisville, Texas) was applied, and a local skin flap was …

Evidence on Prognosis

In the clinical decision-making process, prognostic information gives physicians guidance regarding disease and treatment that can be passed along to patients. Using the clinical scenario of a type IIIB open tibial fracture as an example, this article focuses on how to search prognostic literature effectively and how to critically appraise prognostic studies. A well-built clinical question using the Patients, Intervention, Comparison, and Outcomes methodology helps plastic surgeons derive information from the vast resources in an effective and time-efficient manner. Subsequent critical appraisal of the collected studies is the essential step for identifying the most relevant high-quality evidence to provide the best prognostic information to guide patient decision-making.

Use of a Continuous External Tissue Expander in the Conversion of a Type IIIB Fracture to a Type IIIA Fracture

Various methods have been used for soft tissue coverage of Gustilo-Anderson type IIIB open fractures. These injuries are often contaminated and, by definition, are associated with extensive periosteal stripping and inadequate soft tissue coverage. These characteristics predispose the patient to infection, delayed union, nonunion, and the likelihood of multiple surgeries to achieve durable soft tissue coverage. Although free tissue transfer and rotational flap coverage are the mainstay of treatment for Gustilo-Anderson type IIIB fractures, these procedures typically require additional modalities, such as local wound care, negative-pressure wound therapy, and skin grafting, to expedite wound coverage. Numerous undesirable aspects of these tissue coverage techniques exist, including the requirement for repeated application, potential anesthesia complications, near-constant surveillance, patient compliance, graft failure, and cost. External tissue expanders offer the surgeon a device that can rapidly facilitate closure of full-thickness soft tissue defects. This technique offers the benefit of a 1-time application that is easy to apply and cost-effective and can significantly improve fracture coverage options with a cosmetically acceptable result. Although this technique has been previously described for fasciotomy and ulcer coverage, to the authors' knowledge, continuous external expansion has never been reported in open fracture wound management, specifically in converting type IIIB to type IIIA open fractures. The authors' early success with this method indicates that it may be a valuable tool in the management of Gustilo-Anderson type IIIB open fractures.

In vivo efficacy of a silicone‒cationic steroid antimicrobial coating to prevent implant-related infection

Active release antimicrobial coatings for medical devices have been developed to prevent and treat biofilm implant-related infections. To date, only a handful of coatings have been put into clinical use, with limited success. In this study, a novel antimicrobial compound was incorporated into a silicone (polydimethylsiloxane or PDMS) polymer to develop a novel active release coating that addressed several limitations of current device coatings. The efficacy of this coating was optimized using an in vitro flow cells system, then translated to an animal model of a simulated Type IIIB open fracture wherein well-established biofilms were used as initial inocula. Results indicated that the novel coating was able to prevent infection in 100% (9/9) of animals that were treated with biofilms and the novel coating (treatment group). In contrast, 100% (9/9) of animals that were inoculated with biofilms and not treated with the coating (positive control), did develop infection. Nine animals were used as negative controls, i.e., those that were not treated with biofilms, and showed a rate of infection of 11% (1/9). Eight animals were treated with the novel coating only to determine its effect on host tissue. Results indicated that the novel active release coating may have significant promise for future application to prevent biofilm implant-related infections in patients.

Experimental model of biofilm implant‐related osteomyelitis to test combination biomaterials using biofilms as initial inocula

Currently, the majority of animal models that are used to study biofilm-related infections use planktonic bacterial cells as initial inocula to produce positive signals of infection in biomaterials studies. However, the use of planktonic cells has potentially led to inconsistent results in infection outcomes. In this study, well-established biofilms of methicillin-resistant Staphylococcus aureus were grown and used as initial inocula in an animal model of a Type IIIB open fracture. The goal of the work was to establish, for the first time, a repeatable model of biofilm implant-related osteomyelitis, wherein biofilms were used as initial inocula to test combination biomaterials. Results showed that 100% of animals that were treated with biofilms developed osteomyelitis, whereas 0% of animals not treated with biofilm developed infection. The development of this experimental model may lead to an important shift in biofilm and biomaterials research by showing that when biofilms are used as initial inocula, they may provide additional insights into how biofilm-related infections in the clinic develop and how they can be treated with combination biomaterials to eradicate and/or prevent biofilm formation.

The dangers of damage control orthopedics: a case report of vascular injury after femoral fracture external fixation

BackgroundPlacement of external fixation frames is an expedient and minimally invasive method of achieving bone and joint stability in the setting of severe trauma. Although anatomic safe zones are established for placement of external fixation pins, neurovascular structures may be at risk in the setting of severe trauma.Case reportWe present a case of a 21-year-old female involved in a high speed motorcycle accident who sustained a Type IIIB open segmental femur fracture with significant thigh soft tissue injury. Damage control orthopedic principals were applied and a spanning external fixator placed for provisional femoral stabilization. Intraoperative vascular examination noted absent distal pulses, however an intraoperative angiogram showed arterial flow distal to the trifurcation. Immediately postoperatively the dorsalis pedis pulse was detected using Doppler ultrasound but was then non-detectable over the preceding 12-hours. Femoral artery CT angiogram revealed iatrogenic superficial femoral artery occlusion due to kinking of the artery around an external fixator pin. Although the pin causing occlusion was placed under direct visualization, the degree of soft tissue injury altered the appearance of the local anatomy. The pin was subsequently revised allowing the artery to travel in its anatomic position, restoring perfusion.ConclusionThis case highlights the dangers associated with damage control orthopedics, especially when severe trauma alters normal local anatomy. Careful assessment of external fixator pin placement is crucial to avoiding iatrogenic injury. We recommend a thorough vascular examination pre-operatively and prior to leaving the operating room, which allows any abnormalities to be further evaluated while the patient remains in a controlled environment. When an unrecognized iatrogenic injury occurs, serial postoperative neurovascular examinations allow early recognition and corrective actions.

Osteocutaneous Pedicle Flap Transfer for Salvage of Transtibial Amputation After Severe Lower-Extremity Injury

A conventional transtibial amputation may not be possible when the zone of injury involves the proximal part of the tibia, or in cases of massive tibial bone and/or soft-tissue loss. The purpose of this study was to examine the outcomes of salvage of a transtibial amputation level with a rotational osteocutaneous pedicle flap from the ipsilateral hindfoot. Fourteen patients who had an osteocutaneous pedicle flap from the ipsilateral foot were included in the study. Twelve patients were followed for more than twenty-four months (mean, 60.2 months) and were evaluated with use of the Sickness Impact Profile (SIP), Musculoskeletal Function Assessment (MFA), and a 100-ft (30.48-m) timed walking test. There were ten men and four women with mean age of 43.2 years. Thirteen patients had a type-IIIB open tibial fracture, and one had extensive soft-tissue loss secondary to a burn. Four patients were treated for infection after the index procedure. There were no nonunions of the tibia to the calcaneus. Three patients underwent late reconstructive procedures to improve prosthetic fit. No patient required subsequent revision to a more proximal amputation level. Mean knee flexion was 139°. A novel technique has been developed to salvage a transtibial amputation level with use of a rotational osteocutaneous flap from the hindfoot. In the absence of adequate tibial length and/or soft-tissue coverage to salvage the entire limb or to perform a conventional-length transtibial amputation, this technique is a highly functional alternative that does not require microvascular free tissue transfer.