Tibial bone loss and soft-tissue defect treated simultaneously with Ilizarov-technique--a case report

Copyright © Taylor & Francis 2000. ISSN 0001–6470. Printed in Sweden – all rights reserved. A 36-year-old active fisherman had the lower anterior part of his leg blown off by a signal flare. The soft-tissue defect measured 10 ́ 15 cm with a large defect in the peroneal muscles. All extensor tendons to the foot were blown off. The tibial bone loss was 9 cm and the fibula defect 3 cm (Figure 1). The anterior tibial artery and vein as well as the superficial branch of the peroneal nerve were destroyed and there was dysesthesia along the dorsal part of the foot and on the first toe. The posterior tibial artery and nerve were intact, including the sural nerve. The patient was immediately admitted to the nearest hospital, where the devitalized tissue was removed. An external fixation was applied by Hoffman’s method (Figures 1 and 2) and antibiotic treatment was initiated. 17 days after the injury, the patient was sent to us. The open fracture, infected with staphylococcus aureus, was classified as Gustilo IIIB (Gustilo et al. 1984). The devitalized bone was curetted to firm, bleeding bone, and surrounding scar tissue was excised. The Hoffman apparatus was removed, and external fixation was applied using Ilizarov’s technique (Figure 3), this day is referred to as day 0 (Figure 6). The apparatus was applied with the hinges placed on the frame medially and laterally on each side of the leg in the frontal plane, on a level with the center of the defect. The bone defect was reduced by 3 cm in one step, to reduce the soft-tissue lesion (Figure 3). On day 6, an anterior angulation (Figure 4) was carried out, with a bending point at the center of the bony defect, at a rate of 4 degrees per day (1 degree ́ 4 per day). Compression was performed along with angulation in the segment defect, at a rate of 1/2 mm ́ 4 a day. After angulating for 16 days (day 22), the proximal and distal ends of the soft-tissue defect were brought into contact. The final angulation was about 64 degrees. Due to the angula-