Purposive bone shortening––a technique which aided soft-tissue coverage in a Grade III Gustillo–Anderson Open Distal Third Leg Fracture: A case report and treatment strategy

Mohamed Nazir Ashik; JK Giriraj Harshavardhan; S Sundar Suriyakumar

doi:10.4103/ijors.ijors_28_21

CASE REPORT

Year : 2022 | Volume : 30 | Issue : 1 | Page : 19-23

Purposive bone shortening––a technique which aided soft-tissue coverage in a Grade III Gustillo–Anderson Open Distal Third Leg Fracture: A case report and treatment strategy

Mohamed Nazir Ashik, JK Giriraj Harshavardhan, S Sundar Suriyakumar
Department of Orthopaedics, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India

Date of Submission	25-Oct-2021
Date of Acceptance	05-Mar-2022
Date of Web Publication	30-Jun-2022

Correspondence Address:
Mohamed Nazir Ashik
Department of Orthopaedics, Sri Ramachandra Medical College and Research institute, Chennai, Tamil Nadu
India

Source of Support: None, Conflict of Interest: None

Check

DOI: 10.4103/ijors.ijors_28_21

Abstract

Problems faced in open fractures of the distal third tibia are usually associated with soft-tissue coverage, infection control, and union of the bone. Tibia is commonly associated with impaired healing if soft tissues are severely damaged. Not all cases can be treated with flaps due to its unavailability in acute settings, high learning curve, and cost. We present the outcomes of a case of an open Grade III-B Gustillo–Anderson distal tibia fracture treated with debridement and deliberate bony shortening which helped in primary closure of the wound. A 61-year-old gentleman, a known hypothyroid, had an alleged history of accidental cut injury over right lower limb by a machine used for cutting trees. He sustained a 7 cm × 4 cm laceration over the anteromedial aspect of the distal tibia with blown-out soft tissues and bone exposed. Wound debridement and stabilization with ankle spanning external fixation were immediately done. Wound could be primarily closed because the tibia and fibula were deliberately shortened during the external fixation. Many free bone fragments were removed during debridement leaving a bony void. One week later bone graft was used to fill the void after redebridement of the wound and wound could be primarily closed. Negative wound therapy was used as an adjuvant. One month later the external fixator was converted to Ilizarov fixator, which was removed at the end of 5 months, showing a fully healed fracture without soft-tissue complications at the end of 6 months follow-up. Debridement and shortening of the open tibia is a powerful technique to provide bony apposition and allow primary wound closure without tension, averting the need for any secondary reconstructive procedures.

Keywords: Acute bony shortening, ASAMI criteria, Ilizarov, purposive shortening

How to cite this article:
Nazir Ashik M, Giriraj Harshavardhan J K, Suriyakumar S S. Purposive bone shortening––a technique which aided soft-tissue coverage in a Grade III Gustillo–Anderson Open Distal Third Leg Fracture: A case report and treatment strategy. Int J Orthop Surg 2022;30:19-23

How to cite this URL:
Nazir Ashik M, Giriraj Harshavardhan J K, Suriyakumar S S. Purposive bone shortening––a technique which aided soft-tissue coverage in a Grade III Gustillo–Anderson Open Distal Third Leg Fracture: A case report and treatment strategy. Int J Orthop Surg [serial online] 2022 [cited 2023 Mar 25];30:19-23. Available from: https://www.ijos.in/text.asp?2022/30/1/19/348192

Key Message

Use of acute bone shortening to substitute use of flap or soft-tissue coverage in open fractures especially in patients at increased risk of flap failure such as the elderly, diabetic, smokers, peripheral vascular diseases, and those with medical comorbidities

Introduction

Distal leg fractures occur most frequently following high energy trauma, associated with severe soft-tissue loss precipitating an open fracture condition that requires both a stable fixation of fracture fragments and soft-tissue coverage.^[1] Attention is given toward closure of an open wound to prevent future infection which can progress to osteomyelitis. Gustillo–Anderson grade III open fracture with severe contamination and comminution is always a nightmare to surgeons when it comes to limb salvage. Difficulties with soft-tissue coverage, infection control, and bone union can result in serious disability.^[1] Invariably healing is poor in distal leg fractures due to precarious blood supply. Tibia being a subcutaneous bone, severely damaged surrounding soft structures leads to impaired healing and poor prognosis.^[2] Flaps are considered the mainstay treatment for soft-tissue coverage. Nonmicrovascular flaps are less demanding while microvascular flaps are technically demanding and a high learning curve is needed.^[3] Problems with flap procedures include infections, flap necrosis, cost, and a need of an expert plastic surgical team.^[3],[4],[5] We present the outcomes of a case of an open Grade III-B Gustillo–Anderson distal tibia fracture treated with debridement and deliberate bony shortening which helped in primary wound closure.

Case Report

A 61-year-old gentleman, a known hypothyroid, had an alleged history of accidental cut injury over right lower limb by a machine used for cutting trees while cutting trees sustaining a 7 cm × 4 cm laceration over the anteromedial aspect of the distal tibia with blown-out soft tissues and bone exposed [Figure 1]A. The wound was grossly contaminated with sand particles but luckily the vascular supply distal to the fracture was left intact. Radiographic imaging of his leg showed comminuted fracture of distal third tibia and fibula at the same level [Figure 1]B. No other musculoskeletal injury was present. After stabilizing his vital parameters, Tetanus toxoid as prophylaxis and cefazolin and empirical antibiotic was given and he underwent an emergency wound debridement and initial fracture stabilization. Thorough wound debridement and irrigation with 9 L of normal saline was done by the senior most trauma surgeon. All devitalized tissues especially skin were removed till the ends bled red. Nonviable bone was identified based on their color, desiccation, absence of bleeding on both ends or the fragments that failed the “Tug test,” where the bony fragments have hardly any muscle attachment and can be removed with much ease. There was no tendon or nerve injury as the wound was on the bare anteromedial aspect of the leg. The fracture was stabilized with an ankle spanning external fixator [Figure 2]A. Even though the wound looked intimidating [Figure 2]B, the wound could be closed primarily [Figure 2]C, accepting some degree of shortening of tibia. Shortening of tibia and fibula by removing the nonviable bone facilitated primary closure of the wound. Intramedullary nail was not used as there could be an infective environment. But there was a huge bone void in the tibia which needed to be filled. A week later, with the help of plastic surgery specialists, with a plan of a soft-tissue cover in mind, second look with irrigation of the wound was done. The bone void in the tibia was filled with large quantities of iliac crest autograft. The shortening of the fibula and tibia aided in the approximation of the wound without any flap coverage. Negative pressure wound therapy was also used over the sutured wound for 1 week to facilitate wound healing.

Figure 1: Grade IIIB lacerated wound (A). Distal one-third comminuted fracture of tibia and fibula at the metaphyseal diaphysis junction (B)

Click here to view

Figure 2: Initial stabilization of the fracture was done with ankle spanning external fixator with 2 pins proximal to the fracture and 2 pins distal to the fracture (A). The image in the left shows the wound picture after bony shortening and debridement. The image in the right is after primary closure of the wound after wound debridement with ETHILON suture (B)

Click here to view

Four weeks later, ankle spanning external fixator was removed and replaced with Ilizarov fixator without spanning the ankle joint [Figure 3]A. The external fixator was left intact for 4 weeks to let the wound heal. The patient was started on full weight-bearing mobilization as tolerated with walker support and was reviewed periodically every 2 weeks for pin tract care. Radiographs were taken monthly. Around 5 months with good callus formation in radiograph [Figure 3]B. The Ilizarov frame was removed and a patellar tendon bearing (PTB) cast was applied for the next 4 weeks. At the end of 6 months from the initial procedure, the cast was removed and the patient has an excellent radiological [Figure 3]C and functional outcome [Figure 4]A–F. He is walking without any form of support with excellent knee bending up to 100° of flexion and ankle range of movements of 45° plantar flexion and 10° dorsiflexion with no postoperative bone or soft-tissue complications and no visible soft-tissue loss or atrophy. Functional outcome and bone union as per radiograph were assessed as per the ASAMI criteria.^[1],[5],[6] As per ASAMI criteria [Table 1] and [Table 2] our case showed excellent bone union and good functional outcomes. Patient has a true shortening of 1.5 cm in tibia, compared to the opposite leg which was well compensated by pelvic tilt during walking.

Figure 3: Conversion from external fixator to Ilizarov ring fixator (A). After 4 months of injury using Ilizarov fixator (B). Radiography after 6 months post injury, showing good callus formation after PTB cast removal (C)

Click here to view

Figure 4: 6 months postop clinical pictures with excellent functional outcomes of knee flexion up to 100° and ankle plantar flexion of 45° and dorsiflexion of 10° (A–F)

Click here to view

Table 1: ASAMI––bone results using Ilizarov method

Click here to view

Table 2: ASAMI––functional results using Ilizarov methods

Click here to view

Discussion

Grade III Gustillo–Anderson open distal tibia fractures pose a challenge for the orthopedic surgeons, plastic team, and even for the postoperative rehabilitation team, to bring about a combined favorable outcome.^[3] The technique of intentional bone shortening to promote a primary wound closure is stressed in this case report to avert the complications that can be expected in using a soft-tissue cover in the form of a flap. Various series in works of literature have documented the potency of such an alternate technique.^[4],[7],[8]

Nho et al.^[7] also describe the technique of deliberate bone shortening to allow wound closure, followed by a circular frame fixation in open fractures. Sen et al.^[9] expressed the results of acute shortening in treatment of grade-III open tibia fractures with osteocutaneous loss in 24 patients. In this series the radiological results were excellent in 21 and good in 3. Functionally results were excellent in 19, good in 4, fair in just 1 and no skin grafts were used. It is recommended that the safe limit for acute leg shortening is 3 cm and the defect is to be closed gradually to avoid neurovascular compromise.^[8]

In some circumstances, a substitute to flap coverage may be profitable. Occasionally the treating plastic surgeon will declare a patient unfit for a flap due to deficient local soft-tissue, poor vascular supply for a free tissue transfer like atherosclerotic plaque diseases of vessels or single vessel extremity^[7] and other medical comorbidities contraindicated for flap surgeries or when facilities for free flap are not available. Some studies stress the fact that flaps will cause greater medical complications, longer procedure time with an increased hospital stay, work as a nidus for further superficial or deep infections, donor site morbidity of unaffected skin^{[3],[4],[10],[11]} and flaps cannot be used in the presence of underlying infections.^[8]

We used the negative pressure dressing over the wound to augment the healing. The use of negative pressure wound therapy has diminished the rate of free or local flap procedures.^[12],[13] The negative pressure wound therapy reduces edema, decrease bacterial loads, increase granulation tissue formation, and other pathways to promote wound healing. Ilizarov fixation can provide adequate stability for distal one-third tibia fractures without spanning the ankle joint as shown in this case report. Weight bearing can be allowed early in view of circumferential stability of this fixator. Micromotion at the fracture site stimulates secondary union.

Ilizarov fixator negates the complications of plating these fractures and does not damage the blood supply of the residual bone. The learning curve for this fixator is also narrow and hence accepted widely.^[11] Application of PTB cast after the removal of Ilizarov fixator in our case proved advantageous. PTB cast creates convenience to permit normal movements of knee joint, enabling patients to do their day-to-day activities. The rehabilitation process is also easy unlike the long leg cast with gait never being a problem. The patients can walk promptly after removal of PTB cast even in the absence of any external support.^[14]

Conclusion

Acute shortening of bone can facilitate wound closure in some open fractures, importantly in those contraindicated for flaps. This is a powerful tool in open distal tibia fractures which when combined with bone grafting and Ilizarov fixation can give excellent results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.	Makhdoom AU, Shaikh BJ, Baloch RA, Malah HR, Tunio ZH, Jokhio MF. Management of segmental fracture of tibia treated by Ilizarov external fixation. J Ayub Med Coll Abbottabad 2020;32:291-4.
2.	Teraa M, Blokhuis TJ, Tang L, Leenen LP. Segmental tibial fractures: An infrequent but demanding injury. Clin Orthop Relat Res 2013;471:2790-6.
3.	Kamath JB, Shetty MS, Joshua TV, Kumar A, Harshvardhan , Naik DM. Soft-tissue coverage in open fractures of tibia. Indian J Orthop 2012;46:462-9. [PUBMED] [Full text]
4.	Salih S, Mills E, McGregor-Riley J, Dennison M, Royston S. Transverse debridement and acute shortening followed by distraction histogenesis in the treatment of open tibial fractures with bone and soft-tissue loss. Strategies Trauma Limb Reconstr 2018;13:129-35.
5.	Aktuglu K, Erol K, Vahabi A. Ilizarov bone transport and treatment of critical-sized tibial bone defects: A narrative review. J Orthop Traumatol 2019;20:22.
6.	Paley D, Chaudray M, Pirone AM, Lentz P, Kautz D. Treatment of malunions and mal-nonunions of the femur and tibia by detailed preoperative planning and the Ilizarov techniques. Orthop Clin North Am 1990;21:667-91.
7.	Nho SJ, Helfet DL, Rozbruch SR. Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor spatial frame. J Orthop Trauma 2006;20: 419-24.
8.	El-Rosasy MA. Acute shortening and re-lengthening in the management of bone and soft-tissue loss in complicated fractures of the tibia. J Bone Joint Surg Br 2007;89:80-8.
9.	Sen C, Kocaoglu M, Eralp L, Gulsen M, Cinar M. Bifocal compression-distraction in the acute treatment of grade Iii open tibia fractures with bone and soft-tissue loss: A report of 24 cases. J Orthop Trauma 2004;18:150-7.
10.	Bundgaard KG, Christensen KS. Tibial bone loss and soft-tissue defect treated simultaneously with Ilizarov-technique: A case report. Acta Orthop Scand 2000;71:534-6.
11.	Lerner A, Fodor L, Soudry M, Peled IJ, Herer D, Ullmann Y. Acute shortening: Modular treatment modality for severe combined bone and soft-tissue loss of the extremities. J Trauma 2004;57:603-8.
12.	Schlatterer DR, Hirschfeld AG, Webb LX. Reply to the letter to the editor: Negative pressure wound therapy in grade Iiib tibial fractures: Fewer infections and fewer flap procedures? Clin Orthop Relat Res 2016;474:2317.
13.	Bhattacharyya T, Mehta P, Smith M, Pomahac B. Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg 2008;121:1263-6.
14.	Suman RK. The management of tibial shaft fractures by early weight bearing in a patella tendon bearing cast: A comparative study. J Trauma 1977;17:97-107.