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Gunshot Wound: Reconstruction of an ankle defect in a five-year-old

Posted on August 1, 2011 | Comments Off on Gunshot Wound: Reconstruction of an ankle defect in a five-year-old

by Volkan Tanaydin, MD, PharmD1, Henri A.H. Winters, MD, PhD1, Wim R. Hogeboom, MD, PhD2, Elgun A.V.C.M. Zeegers, MD, PhD3, Oliver T. Zöphel, MD, PhD4

The Foot and Ankle Online Journal 4 (8): 2

Reconstruction of a severe traumatic bone and soft tissue defect of the ankle region is a great challenge for the reconstructive surgeon. We report a case where we used a pedicled vascularized fibular transfer in combination with the transposition of a local fasciocutaneous flap to reconstruct a gunshot injury in a child. We achieved a successful repair without the use of free flaps. We believe that this approach provided a safe and relatively simple solution with minimal donor site morbidity.

Key words: Gunshot wound, Gustilo classification, growing child, limb salvage, pedicled vascularized fibular transfer

Accepted: July, 2011
Published: August, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0408.0002

Reconstruction of a severe traumatic bone and soft tissue defect of the ankle region in a growing child is a great challenge for the reconstructive surgeon. In traumatic limb injuries, limb salvage and tissue replacement are important to obtain a functional result. In children especially, the consideration for future growth needs to be addressed. Historically, various reconstructive techniques have been described for the treatment of bony defects.

The use of non-vascularized cancellous bone grafts [1,2] and Ilizarov bone lengthening [3,4] have been advocated for defects measuring up to 5cm. Larger defects usually require a more complex reconstruction. More specifically, in the case of a large tibial defect, reconstructions using various vascularized bone autografts have been described in the literature. Since the introduction by Taylor, et al [5]., the free vascularized fibular graft6-8 has become a standard practice.

However, the required microsurgical anastomosis and the risk of donor site morbidity make this procedure unpredictable and not always feasible. In these cases, the pedicled vascularized fibula transfer8-11 could be an alternative approach. We report a unique case in which a pedicled vascularized fibular transfer in combination with the transposition of a local fasciocutaneous flap was used to reconstruct a severe Gustilo IIIC grade gunshot injury in a growing child. The parents of our patient gave informed consent for publication of the report and any accompanying images.

Case report

A five year-old girl sustained an accidental shotgun injury to her left lower extremity. The shotgun shell, loaded with 3mm diameter steel pellets, was fired from a very short distance, causing extensive bone and soft-tissue loss of the ankle region. (Fig. 1) On examination, there was complete destruction of the talocrural joint, the anterior tibial artery and the tendon of the anterior tibial muscle. The extensor hallucis longus, extensor digitorum longus and flexor hallucis longus muscles, as well as the posterior tibial artery seemed to be intact and the circulation of the foot was adequate. There was diminished sensation in the sole of the foot, but it was not possible to tell whether this was due to neuropraxia or more serious damage of the tibial nerve.

Figure 1 Radiograph of the left lower extremity. There is a large defect of the tibia and a fracture of the distal fibula. Note the many pellets in the ankle region.

Debridement of bone and soft tissue was performed under general anesthesia followed by fixation with a Hoffman external fixator, leaving a 10 cm defect of the distal tibia and soft-tissue loss, measuring 6x8cm ventrally and 5x6cm posterolaterally. (Fig.2)

Figure 2 The defect of the tibia is measuring approximately 10 centimeter after debridement and placement of the Hoffman external fixator.

During a second and third-look operation, the wound was again debrided and gentamicin beads were implanted within the wound. Most of the pellets from the gun shot were removed successfully during these procedures. An angiography was also performed during the third debridement. (Fig.3) This showed a retrograde blood flow from the posterior tibial artery to the dorsalis pedis artery with an interruption in the anterior tibial artery.

Figure 3 Angiography of the affected leg. There is retrograde filling of the dorsalis pedis by the posterior tibial artery. The distal third of the anterior tibial artery is not filled. Note the pseudoaneurysm in the posterior tibial artery.

The communicating branch between the peroneal and posterior tibial artery was not seen. It also revealed a pseudoaneurysm in the posterior tibial artery, just above the medial malleolus.

As the child’s parents requested no operations but to the affected leg – thereby precluding the use of free flaps – we opted for a pedicled ipsilateral vascularized fibula transfer, combined with a local soft tissue transfer and a split-thickness skin graft.

The patient was transferred to the VUMC hospital, where an ipsilateral vascularized fibula transfer was performed to reconstruct the distal tibia. The fibula, including the distal portion with the growth plate, was harvested through the posterolateral wound and transposed on its vascular pedicle to the tibial defect.

The distal portion was wedged into the remains of the talar bone and the proximal end was inserted into a slot in the tibial shaft. (Fig. 4) An external ring fixator (Orthofix) was placed. The pseudoaneurysm in the posterior tibial artery was resected and replaced with a vein graft from the right greater saphenous vein. (Fig. 5)

Figure 4 Ipsilateral Vascularized Fibular Transfer performed. Note the incision made as an extension of the existing posterolateral wound.

Figure 5 The pseudoaneurysm is resected and replaced by a vein graft of the right greater saphenous vein.

The tibial nerve was inspected and appeared to be completely intact. The anterior defect was closed with a transposition of a fasciocutaneous flap from the anterolateral side of the leg, leaving a posterolateral defect only instead of an anterior and posterior defect. (Figs. 6 and 7)

Figure 6 Local transposition of the fasciocutaneous flap to close the anteromedial defect.

Figure 7 Postoperative radiograph show the fibula, including the growth plate.  The fibula is transferred to the tibial defect and is wedged into the talar bone.

This remaining defect was treated with Negative Pressure Wound Therapy (NPWT) and after three weeks this defect was covered by a split-thickness skin graft and again treated with NPWT. (Figs. 8A and 8B). Complete clinical wound healing was obtained a few weeks later. Six months after surgery the patient developed a pin-tract infection. This was successfully treated by four weeks of intravenous antibiotics and replacement of the external ring fixator by a walking cast.

Figure 8 Wound healing after Negative Pressure Wound Therapy (a) and after Split-skin grafting. (b)

One year after surgery the radiographs show good consolidation and hypertrophy of the fibula graft. (Figs. 9 and 10) The walking cast will be replaced by a removable patellabearing walking boot.

Figure 9 Radiograph of leg one year after reconstruction. Good bone consolidation and hypertrophy of the fibular graft is seen. Note also the pin-tracts in the proximal tibia.

Figure 10  Three clinical views of the leg one year after reconstruction.

The patient is up to full weightbearing and still receiving physical therapy. Her footsole sensation is recovering slowly, but gradually. She functions well with minimal disability and can perform normal activities of daily life such as walking, swimming and playing, without any pain or discomfort.

Discussion

Presently, reconstruction of large tibial defects using free6-8 or pedicled [8-11] vascularized fibular grafts is common. A disadvantage of using the fibula as a graft for tibial defects is that the fibula does not have the same strength as the tibia.

In time, however, the fibula hypertrophies under load and has the potential to achieve the weightbearing capacity of the tibia. Weiland, et al., [12] describe an average time of 15 months to full weightbearing.

The decision to use either an ipsilateral pedicled fibula graft or a contralateral free vascularized fibula graft must be carefully considered for each individual case. A free vascularized fibula graft has the advantage of creating a great freedom of placement with no additional trauma caused to the injured leg. On the other hand, a free vascularized fibula graft calls for microsurgical anastomosis, with the risk of flap failure and creation of a separate donor site. An ipsilateral pedicled fibula graft may not always be feasible, but when it is utilized there is no need for microanastomosis and no separate donor site morbidity.

The donor site morbidity of a contralateral free fibula graft may be small [13,14], but in a child, progressive valgus deformity of the donor ankle has been described. [15,16] In this particular case, there was a destruction of the talocrural joint. Therefore the affected distal fibula was not needed for ankle stability in the future, enabling use of the ipsilateral distal fibula –including the growth plate- for reconstruction of the tibia.

The advantages and the disadvantages of both techniques are shown in Table 1. In our case, the decision was simplified by the fact that the child’s parents wanted no operations outside of the affected leg. Depending on the angiographic findings in the lower leg, we used the antegrade-flow pedicled flap based on the peroneal vessels. The arterial circulation of the foot of our patient was and is only supplied by the posterior tibial artery. However, we do not expect long-term complications in this field. Oxford, et al. [17] reported no complications in using a fibula-free flap in extremities with 100% obstructive vascular disease in the anterior or posterior tibial artery.

Table 1  Advantages and disadvantages of the pedicled vascularized fibular transfer.

The wound was treated with Negative Pressure Wound Therapy to promote granulation and wound contracture and to decrease the bacterial count. This approach is also described by Greer, et al. [18]

He suggests the role of subatmospheric dressing as an alternative to free flap for providing tissue coverage for certain small Gustilo grade IIIB or IIIC open tibial fractures. In the present case, we achieved a successful repair of a severe traumatic bone defect, without the use of free flaps. We believe that this approach provided a safe and relatively simple solution with minimal donor site morbidity.

References

1. Enneking WF, Eady JL, Burchardt H. Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects. JBJS 1980 62A: 1039-1058.
2. Green SA. Skeletal defects. A comparison of bone grafting and bone transport for segmental skeletal defects. Clin Orthop Relat Res 1994 301: 111-117.
3. Paley D, Maar DC. Ilizarov bone transport treatment for tibial defects. J Orthop Trauma 2000 14: 76-85.
4. Cierny G 3rd, Zorn KE. Segmental tibial defects. Comparing conventional and Ilizarov methodologies. Clin Orthop Relat Res 1994 301: 118-123.
5. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft. A clinical extension of microvascular techniques. Plast Reconstr Surg 1975 55: 533-544.
6. Hsieh CH, Jeng SF, Chen SH, Wei FC. Folded free vascularized fibular grafts for the reconstruction of combined segmental bone defects of distal tibia and fibula. J Trauma 2004: 56: 437-439.
7. Sharma S, Tiwari P, Kasabian AK, Longaker MT. Reconstruction of a tibial defect with microvascular transfer of a previously fractured fibula. Ann Plast Surg 2000 45: 202-206.
8. Chung DW, Han CS, Lee, JH. Reconstruction of composite tibial defect with free flaps and ipsilateral vascularized fibular transposition. Microsurgery 2011 31: 340-346.
9. Atkins RM, Madhavan P, Sudhakarb J, Whitwell D. Ipsilateral vascularised fibular transport for massive defects of the tibia. 1999 JBJS 81B: 1035-1040.
10. Hertel R, Pisan M, Jakob RP. Use of the ipsilateral vascularised fibula for tibial reconstruction. JBJS 1995 77B: 914-919.
11. Goren D, Sapir O, Stern A, Nyska M. Ipsilateral fibular transfer for a large tibial defect caused by a gunshot injury: case report. Mil Med 2005 170, 418-421.
12. Weiland AJ, Moore JR, Daniel RK. Vascularized bone autografts. Experience with 41 cases. Clin Orthop Relat Res 1983 174: 87-95.
13. Lee EH, Goh JC, Helm R, Pho RW. Donor site morbidity following resection of the fibula. JBJS 1990 72B: 129-131.
14. Goodacre TE, Walker CJ, Jawad AS, Jackson AM, Brough MD. Donor site morbidity following osteocutaneous free fibula transfer. Br J Plast Surg 1990 43: 410-412.
15. Wiltse LL. Valgus deformity of the ankle: a sequel to acquired or congenital abnormalities of the fibula. JBJS 1942 54A: 595-606.
16. Hsu LC, Yau AC, O’Brien JP, Hodgson AR. Valgus deformity of the ankle resulting from fibular resection for a graft in subtalar fusion in children. JBJS 1972 54A: 585-594.
17. Oxford L, Ducic Y. Use of fibula-free tissue transfer with preoperative 2-vessel runoff to the lower extremity. Arch Facial Plast Surg 2005 7: 261-264; discussion 265.
18. Greer S, Greer S, Kasabian A, Thorne C, Borud L, Sims CD, Hsu M. The use of a subatmospheric pressure dressing to salvage a Gustilo grade IIIB open tibial fracture with concomitant osteomyelitis to avert a free flap. Ann Plast Surg 1998 41: 687.

Address correspondence to: Henri A.H. Winters, MD, PhD
VU Medical Center, 4D128, P.O. Box 7057, 1007MB Amsterdam
Email: h.winters@vumc.nl

1  VU Medical Center, Department of Plastic, Reconstructive and Hand Surgery , Amsterdam.
2  Medisch Spectrum Twente, Department of Traumatology, Enschede.
3  Medisch Spectrum Twente, Department of Orthopedics, Enschede.
4  Medisch Spectrum Twente, Department of Plastic, Reconstructive and Hand Surgery, Enschede.

© The Foot and Ankle Online Journal, 2011

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Open Dislocated Bi-Malleolar Ankle Fracture in a Diabetic Treated with the Illizorov Apparatus: A case report in early ambulation and stabilization

Posted on February 1, 2010 | Comments Off on Open Dislocated Bi-Malleolar Ankle Fracture in a Diabetic Treated with the Illizorov Apparatus: A case report in early ambulation and stabilization

by Sutpal Singh, DPM. FACFAS1 , Chih-Hui (Jimmy) Tsai, DPM2, Albert Kim, DPM3,
Timothy Dailey, DPM4

The Foot and Ankle Online Journal 3 (2): 2

The authors describe a case report of a diabetic patient with an open bi-malleolar ankle fracture sustained after a motor vehicle accident that was treated immediately after injury. Treatment included extensive pulse lavage with antibiotic impregnated saline solution and reduction of the fractures using external fixation. Recovery lasted several months, followed by usage of a Pneumatic CAM walker. The external fixator allowed the patient to ambulate throughout the healing process. No internal fixation was utilized. After months of follow-up, there was good healing of the fractures with no infection of the tibia, fibula, and talus. The authors recommend reduction of tibial and/or fibular fracture(s) using the Ilizarov methodology especially in diabetic patients with open fractures and/or contaminated wound.

Key words: Open Ankle Fracture, Gustilo System, Bi-Malleolar ankle fracture, Ilizarov method.

Accepted: January, 2010
Published: February, 2010

ISSN 1941-6806
doi: 10.3827/faoj.2010.0302.0002

Historically, an open ankle fracture commonly equated with much morbidity and mortality. However with more modern therapy, the expected outcome has improved significantly. [1] The purpose of this article will be to describe a report of a diabetic patient with an open dislocated ankle fracture and the significance of treatment with the use of an Illizarov apparatus. In this article, discussion will focus on the classification, complications, and treatment protocols of open fractures to the ankle joint.

The Illizarov apparatus in our case allowed the patient ambulate during the recovery period in attempt to decrease other risks such as infection and osteomyelitis by use of open internal fixation and morbidity associated with prolonged immobility of a limb.

A fracture is considered to be open when there is a disruption of the skin and underlying soft tissues resulting in a communication between the fracture and the outside environment. Open fractures are most commonly classified according to the system developed by Gustilo and Anderson. [1,2]

The classification of open fractures is based on the size of the wound, the amount of soft tissue injury, fracture pattern and correlates with both infection and amputation rates. Type I open fractures are characterized by a clean wound smaller than 1 cm in diameter, appears clean with a simple fracture pattern and no skin crushing. The fracture can be short, oblique, or transverse. Type II presents with a laceration larger than 1 cm without significant soft tissue crushing or skin flaps, with minimal periosteal stripping; however, a more complex fracture pattern may result. Type III features a large crush component with comminution. It is larger than 5 cm, highly contaminated with extensive soft tissue injury. These injuries may also be older than six hours. Type III injuries are subdivided into three types: type IIIA which presents with adequate soft tissue coverage of the fracture despite high energy trauma or extensive laceration or skin flaps; type IIIB featuring inadequate soft tissue coverage with extensive periosteal stripping, and finally type IIIC which displays with any open fracture that is associated with vascular injury that requires repair. [2,3]

Patients with open fractures are at risk of complications of acute wound infection and osteomyelitis. The risk of a clinical infection depends on the severity of the injury and ranges from 0% to 2% for type-I open fractures, 2% to 10% for type-II, and 10% to 50% for type-III. [4] The rate of infection of open fractures is associated with the fracture characteristics, antibiotic therapy variables, and host parameters.

Another variable is the location of the open fracture with tibial open fractures resulting in twice the rates of infection than other areas of the body. [4] Other possible complications include inadequate soft tissue coverage or extensive soft tissue damage resulting in the failure to heal or even close. This may be exasperated by a compromised neurovascular status of the injured extremity or the development of a compartment syndrome. [5] Open fractures may also succumb to osseous mal-union or non-union, the loss of function, and even amputation.

Management of the open fracture is dependent upon the following principles: careful and thorough assessment of the patient; initial stabilization; classification of the injury; tetanus prophylaxis; antibiotic therapy; prompt surgical debridement and wound management; fracture stabilization through internal fixation, external fixation, or casting; early bone grafting; timely wound closure; supplemental procedures to achieve healing; and adequate follow-up. [6] In any given situation, the best option for fixation depends on a number of factors, including the bone involved, the fracture site, the wound location, and the condition of the patient. The available evidence supports the current trend toward earlier coverage and closure of open fracture wounds. [7] The ultimate goal of a surgeon when dealing with open fractures is to prevent infection, promote fracture healing, and restore alignment and function.

Case Report

A 33 year-old female who had a motor vehicle accident presents with an acute, open, dislocated, bi-malleolar fracture of the right ankle. She was immediately transferred to the emergency room. Her past medical history was significant for Type II Diabetes, diagnosed over 10 years ago. She has peripheral neuropathy, with numbness up to the mid-leg. The rest of the history and review of systems was unremarkable. The right ankle fracture presents to our service wrapped in gauze which is soaked in blood. She did not have a splint on, and the foot is severely dislocated. There is tremendous swelling, but no fracture blisters. Despite the extent of this high impact open fracture, a hand-held Doppler showed that she has good vascular status to the dorsalis pedis and posterior tibial arteries. Her capillary refill is immediate. The open ankle fracture is on the lateral side with the wound measuring approximately 9 cm x 5 cm. Even though the fibula, talus and distal tibia were exposed, there is enough skin to close the wound. Uniquely, there is no dirt or any gross contamination noted despite the nature of this accident. X-rays of the ankle indicated that she has a severely dislocated bi-malleolar ankle fracture. (Figs. 1A, B and C).

  

Figure 1A, B and C Variable views of the open ankle fracture.

The medial malleolus is comminuted. Since the open fracture is less than 6 hours old, she is taken to the operating room immediately in order to reduce the fracture using the Ilizarov frame. The patient is then allowed to ambulate directly after surgery when indicated.

Surgical Technique

Under general anesthesia, the open wound is cultured for bacterial organism. Afterwards, nine liters of bacitracin and Ancef impregnated saline is used to irrigate the wound. Two tibial rings are applied to the distal tibia and a foot plate is then applied. Both are tensioned appropriately. The foot plate is then manipulated so the fibular fracture and medial malleolar fracture are reduced in anatomical alignment. The foot plate and the tibial rings are then joined together with appropriate rods. Distraction of the foot plate is performed in order to pull the fibula and medial malleolus fractures into better alignment. The fibula is then stabilized using two K-wires while the comminuted medial malleolus is reduced using an olive wire at the largest fragment. The olive wire is inserted from distal-inferior-posterior-medial to proximal-superior-anterior-lateral, attached to the proximal tibial ring and tensioned for compression (Figs. 2A and B). The open wound is then very loosely approximated and packed with iodoform. Several days later, the culture results revealed no bacterial growth. The wound is again irrigated with normal saline and Bacitracin® and then completely closed using 3-0 prolene (Figs. 3A,3B,4,5A and 5B).

 

Figure 2  External fixation at the ankle.  Note the olive wire reducing the comminuted medial malleolar fracture. (A)  Lateral view of the ankle with an External Fixator in place. (B)

 

Figure 3  Ilizaorov Frame medial view (A) and lateral view. (B)

Figure 4  Loose approximation of the open fracture.  The iodoform packing has been removed from the open wound.

 

Figure 5  Medial View of the Ilizarov frame several months later. (A)  The Ilizarov frame several months later. (B)

Discussion

The complexity of open ankle fractures pose a challenge to many foot and ankle surgeons. By definition, an open fracture is considered contaminated or infected after six hours of no treatment. Very often in a high speed motor vehicular accident, there can be fracture of the tibia, fibula, and/or other part of the foot are present along with an open wound. In this report, we have a patient with a large open wound, bi-malleolar ankle fracture, and exposed tibial, fibular, and talus. The case is further complicated by the patient’s diabetes mellitus. However because surgery is performed immediately and the wound is clean with no gross contamination during examination, we were able to utilize the Illizarov apparatus immediately after the accident to fixate and stabilize the open ankle fracture.

An external fixator is recommended when a patient has poor bone stock, poor healing potential, open fractures, or fractures with contaminated wounds. [8] With a high level of morbidity and risk of osteomyelitis, application of internal fixation by itself followed by primary closure of the wound is not indicated. In addition, a larger wound would require a split-thickness skin graft or benefit from healing by secondary intention. Using an external fixator is not only minimally invasive, but it also allows the surgeon to stage the treatment appropriately. The patient can also benefit from being able to bear weight. Any wounds after surgery can easily be viewed and treated with an external fixator. This is of course, contraindicated when using a cast.

The complications associated with the use of an external fixator include pin tract infection and wire failure. These can be mitigated and appropriately treated with antibiotics and pin care to help prevent infection at these sites. The above patient is classified as having a Gustillo type IIIA. She has a large open wound with adequate soft tissue for coverage. She also has a severe ankle dislocation, bi-malleolar ankle fracture, and exposed tibia, fibula and talus. The external fixator was removed after 3 months. She then had a pneumatic cam walker applied. A two year follow-up showed that her ankle healed in an anatomical position with good range of motion (Figs. 6A and B).

 

Figure 6  Anteroposterior (A) and lateral view (B) two years after injury.

Conclusion

This case report shows the advantages to using external fixation for an open ankle fracture secondary to a motor vehicle accident. Use of external fixation has many advantages, as explained previously. The goals of open fracture surgery are to prevent infection, promote fracture healing, and restore function. A detailed history and physical is essential in these type of complicated cases. The surgeon must decide which surgical option is going to meet specific goals.

References

1.Patrick JH, Smelt GJ: Surgical progress-100 years ago. An assessment of Listerism at St. Thomas’s Hospital, London. Ann R Coll Surg Engl 59: 456 – 462, 1977.
2. Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg 58A: 453 – 458, 1976.
3. Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 24: 742 -746, 1984.
4. Patzakis MJ, Wilkins J: Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res 243: 36 – 40, 1989.
5. Blick SS, Brumback RJ, Poka A, Burgess AR, Ebraheim NA: Compartment syndrome in open tibial fractures. J Bone Joint Surg 68A: 1348 – 1353, 1986.
6. Zalavras CG, Marcus RE, Levin S, Patzakis MJ: Management of Open fractures and subsequent complications. J Bone Joint Surg Am 89A: 883 – 895, 2007.
7. Okike K, Bhattacharyya T: Current concepts review: Trends in the management of open fractures. J Bone Joint Surg 88A: 2739 – 2747, 2006.
8. Molloy A, Roche A, Narayan B: Treatment of nonunion and malunion of trauma of the foot and ankle using external fixation. Foot and Ankle Clinics Sept: 563 – 587, 2009.

Address correspondence to: Sutpal Singh, DPM. FACFAS. Private practice in Southern California. Email: spsingh@aol.com

1  Chief Ilizarov Surgical Instructor at Doctors Hospital West Covina. Fellow of the American College of Foot and Ankle Surgeons, Private practice in Southern California.
2  Chih-Hui (Jimmy) Tsai, DPM, Doctor of Podiatric Medicine (R3). Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina , (PM&S-36).
3  Albert Kim, DPM, Doctor of Podiatric Medicine (R2), Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36).
4  Timothy Dailey, DPM, Doctor of Podiatric Medicine (R1), Foot and Ankle Medicine and Surgery, Doctors Hospital of West Covina (PM&S-36).

© The Foot and Ankle Online Journal, 2010

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