Subacute reconstruction of lower leg and foot defects due to high velocity‐high energy injuries caused by gunshots, missiles, and land mines

The present study reviews 215 male patients suffering high velocity‐high energy injuries of the lower leg or foot caused by war weapons such as missiles, gunshots, and land mines. They were treated in the Department of Plastic and Reconstructive Surgery at Gülhane Military Medical Academy (Ankara, Turkey) between November 1993–January 2001. Severe soft‐tissue defects requiring flap coverage and associated open bone fractures that were treated 7–21 days (mean, 9.6 days) after the injury were included in the study. Twenty‐three of 226 extremities (10.2%) underwent primary below‐knee amputation. The number of debridements prior to definitive treatment was between 1–3 (mean, 1.9). Gustilo type III open tibia fractures accompanied 104 of 126 soft‐tissue defects of the lower leg. Sixty‐four bone defects accompanied 83 soft‐tissue defects of the feet. Eighteen local pedicled muscle flaps and 208 free muscle flaps (latissimus dorsi, rectus abdominis, and gracilis) were used in soft‐tissue coverage of 209 defects. Overall, the free muscle flap success rate was 91.3%. Bone defects were restored with 106 bone grafts, 25 free fibula flaps, and 14 distraction osteogenesis procedures. Osseous and soft‐tissue defects were reconstructed simultaneously at the first definitive treatment in 94% of cases. The mean follow‐up after definitive treatment was 25 (range, 9–47) months. The average full weight‐bearing times for lower leg and feet injuries were 8.4 months and 4 months, respectively. Early, aggressive, and serial debridement of osseous and soft tissue, early restoration of bone and soft‐tissue defects at the same stage, intensive rehabilitation, and patient education were the key points in the management of high velocity‐high energy injuries of the lower leg and foot. © 2005 Wiley‐Liss, Inc. Microsurgery 25:3–15, 2005.

[1]  M. Bosse,et al.  Timing of closure of open fractures. , 2002, The Journal of the American Academy of Orthopaedic Surgeons.

[2]  C. A. Jones,et al.  The Effect of Time to Definitive Treatment on the Rate of Nonunion and Infection in Open Fractures , 2002, Journal of orthopaedic trauma.

[3]  Roy Sanders,et al.  Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. , 2002, The Journal of trauma.

[4]  Melissa L McCarthy,et al.  Using the SF-36 for characterizing outcome after multiple trauma involving head injury. , 2002, The Journal of trauma.

[5]  P. Tornetta,et al.  High-energy tibial shaft fractures. , 2002, The Orthopedic clinics of North America.

[6]  L. Levin,et al.  Lower extremity microsurgical reconstruction. , 2001, Plastic and reconstructive surgery.

[7]  Y. Tropet,et al.  One-Stage Emergency Treatment of Open Grade IIIB Tibial Shaft Fractures With Bone Loss , 2001, Annals of plastic surgery.

[8]  M F Swiontkowski,et al.  A Prospective Evaluation of the Clinical Utility of the Lower-Extremity Injury-Severity Scores , 2001, The Journal of bone and joint surgery. American volume.

[9]  J. Keating,et al.  Substitutes for autologous bone graft in orthopaedic trauma. , 2001, The Journal of bone and joint surgery. British volume.

[10]  R. M. Smith,et al.  Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. , 2000, The Journal of bone and joint surgery. British volume.

[11]  M. Bhandari,et al.  High and low pressure pulsatile lavage of contaminated tibial fractures: an in vitro study of bacterial adherence and bone damage. , 1999, Journal of orthopaedic trauma.

[12]  O. Osmani,et al.  Microvascular Composite Tissue Transfer for the Management of Type IIIB and IIIC Fractures of the Distal Leg and Compound Foot Fractures , 1999, Journal of reconstructive microsurgery.

[13]  S. Asko-Seljavaara,et al.  Free flap reconstructions of 100 tibial fractures. , 1999, The Journal of trauma.

[14]  M. Şengezer,et al.  Reconstruction of foot defects due to mine explosion using muscle flaps , 1998, Microsurgery.

[15]  J. Sinclair,et al.  Primary free-flap cover of open tibial fractures. , 1997, Injury.

[16]  D. Rowley.  The management of war wounds involving bone. , 1996, The Journal of bone and joint surgery. British volume.

[17]  G. Cooper,et al.  Pattern and mechanism of traumatic amputation by explosive blast. , 1996, The Journal of trauma.

[18]  J. Hull.  Management of gunshot fractures of the extremities. , 1996, The Journal of trauma.

[19]  R. Ganz,et al.  Amputation versus reconstruction in traumatic defects of the leg: outcome and costs. , 1996, Journal of orthopaedic trauma.

[20]  M. Ws,et al.  Debridement of bacterial and particulate-contaminated wounds. , 1994 .

[21]  W. Hoffman,et al.  A prospective study of early soft tissue coverage of grade IIIB tibial fractures. , 1994, The Journal of trauma.

[22]  P. Adkins,et al.  Microvascular reconstruction of the foot: weight-bearing patterns, gait analysis, and long-term follow-up. , 1993, Plastic and reconstructive surgery.

[23]  M. Monsher,et al.  Thyroid "storm" after cervical facial rhytidectomy. , 1993, Plastic and reconstructive surgery.

[24]  I. Prpić,et al.  High-Energy War Wounds: Flap Reconstruction , 1993, Annals of plastic surgery.

[25]  P. Manson,et al.  Microvascular Soft‐Tissue Transplantation for Reconstruction of Acute Open Tibial Fractures: Timing of Coverage and Long‐Term Functional Results , 1992, Plastic and reconstructive surgery.

[26]  R. Mollan,et al.  Management of the soft tissues in open tibial fractures. , 1992, British journal of plastic surgery.

[27]  M. McKee,et al.  A comparison of the effects of skin coverage and muscle flap coverage on the early strength of union at the site of osteotomy after devascularization of a segment of canine tibia. , 1991, The Journal of bone and joint surgery. American volume.

[28]  C. Zinman,et al.  A philosophy of limb salvage in war: use of the fixateur externe. , 1991, Military medicine.

[29]  D. Rothkopf,et al.  Judgment and approach for management of severe lower extremity injuries. , 1991, Clinics in plastic surgery.

[30]  R. J. Fix,et al.  Muscle flap coverage for the lower extremity. , 1991, Clinics in plastic surgery.

[31]  Z. Arnež.  Immediate reconstruction of the lower extremity--an update. , 1991, Clinics in plastic surgery.

[32]  K G Swan,et al.  Principles of ballistics applicable to the treatment of gunshot wounds. , 1991, The Surgical clinics of North America.

[33]  D. Skinner,et al.  ABC of major trauma. Blast and gunshot injuries. , 1990, BMJ.

[34]  J. Ryan,et al.  Interaction of penetrating missiles with tissues: Some common misapprehensions and implications for wound management , 1990, The British journal of surgery.

[35]  P. Stern,et al.  Technical successes and functional failures after free tissue transfer to the tibia , 1990, Microsurgery.

[36]  G. Seabrook,et al.  Blunt tibial artery trauma: predicting the irretrievable extremity. , 1989, The Journal of trauma.

[37]  W. Shaw,et al.  Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. , 1989, The Journal of trauma.

[38]  E. Schemitsch,et al.  Effect of muscle flap coverage on bone blood flow following devascularization of a segment of tibia: An experimental investigation in the dog , 1989, Journal of orthopaedic research : official publication of the Orthopaedic Research Society.

[39]  B. Browner,et al.  The medical and economic impact of severely injured lower extremities. , 1987, The Journal of trauma.

[40]  C. Schwab,et al.  Twenty-one-year experience with land mine injuries. , 1988, The Journal of trauma.

[41]  P. Manson,et al.  Acute and Definitive Management of Traumatic Osteocutaneous Defects of the Lower Extremity , 1987, Plastic and reconstructive surgery.

[42]  R. Richards,et al.  The influence of muscle flap coverage on the repair of devascularized tibial cortex: an experimental investigation in the dog. , 1987, Plastic and reconstructive surgery.

[43]  M. Godina.  Early microsurgical reconstruction of complex trauma of the extremities , 1986, Plastic and reconstructive surgery.

[44]  H S Byrd,et al.  Management of Open Tibial Fractures , 1985, Plastic and reconstructive surgery.

[45]  S. Simon,et al.  Free Microvascular Muscle Flaps with Skin Graft Reconstruction of Extensive Defects of the Foot: A Clinical and Gait Analysis Study , 1985, Plastic and reconstructive surgery.

[46]  K. Johansen,et al.  Open tibial fractures with associated vascular injuries: prognosis for limb salvage. , 1985, The Journal of trauma.

[47]  D. N. Williams,et al.  Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. , 1984, The Journal of trauma.

[48]  S. Mathes,et al.  Comparison of the effect of bacterial inoculation in musculocutaneous and random-pattern flaps. , 1982, Plastic and reconstructive surgery.

[49]  J. May,et al.  Microvascular transfer of free tissue for closure of bone wounds of the distal lower extremity. , 1982, The New England journal of medicine.

[50]  Hoopes Je,et al.  Management of compound injuries of the lower extremity. , 1979 .

[51]  R. Ger.  The management of open fracture of the tibia with skin loss. , 1970, The Journal of trauma.