Tag Archives: limb salvage

Charcot Foot Limb Salvage Procedure with External Fixation and Medial Column Lengthening: A Case Presentation

by Mario Cala, DPM1, Beau Willis, BS2, Brian Carbonell, BS3, Scott Boynton, BS4pdflrg

The Foot and Ankle Online Journal 6 (8): 1

Charcot neuroarthropathy is a debilitating disease, which affects nearly a third of diabetic patients with peripheral neuropathy. Many of these cases result in below knee amputation due to secondary complications associated with this condition such as chronic ulceration with subsequent soft tissue infection and osteomyelitis. Previous studies have shown the effectiveness of utilizing external fixation and medial column arthrodesis to achieve a stable plantar grade foot in patients with Charcot neuroarthropathy. In this case we present a patient who has a complex deformity due to a previously shortened and hyper-mobile 1st ray combined with an ankle and forefoot valgus deformity. Through the utilization of previous modalities combined with restoration of 1st ray length, a stable plantar grade foot was achieved preventing below knee amputation.

Key words: Charcot Foot, Limb Salvage, Medial Column Lengthening.

Accepted: July, 2013
Published: August, 2013

ISSN 1941-6806
doi: 10.3827/faoj.2013.0608.001


Address correspondence to: 1Barry University / Mercy Hospital, Miami, FL, Residency Director Jackson North Medical Center, Miami, FL

2,3,4 Submitted as 4th year student, Barry University School of podiatric Medicine, Miami, FL


Charcot neuroarthropathy is a progressive condition that results in the destruction of single or multiple joints characterized by subluxation, dislocation, and osseous destruction[1]. Eventually, the Charcot process proves to be self-limiting and enters a quiescent phase, leaving the patient with an irreversible condition, in addition to an increased risk for secondary ulceration[4]. Complicated by peripheral neuropathy, the syndrome historically left the affected individual with the loss of the affected limb[2]. Pathogenesis is related to stress induced repetitive micro-trauma or acute injury on the affected lower extremity that has a loss of protective sensation[3].

Because of a traditional understanding that management of Charcot neuroarthropathy often resulted in non-practical ambulation, in the past many surgeons would choose to perform an amputation[3]. Charcot affects only 1% of diabetics, however it has been reported in a staggering 29% of diabetic patients with peripheral neuropathy and loss of protective sensation[3]. Take into mind that the survival rates for diabetic amputations at 5 years is only 50%[3], and it becomes evident that a need for alternative treatment modalities is high in demand. Today, an increasing number of surgeons are advocating for earlier intervention of Charcot changes[5].

To reinforce the concept that increased surgical intervention is needed, we present a case in which below the knee amputation was prevented through the use of an autologous bone grafted 1st ray, external fixation and tri-planar deformity correction.

Case Study

A 56-year-old male with a history of diabetes and Charcot joint disease presented with a chief complaint of left foot deformity with severe pain on weight bearing due to pressure under the medial malleolus and medial plantar foot ulcer. The patient had a previous left 1st metatarsal head resection due to chronic osteomyelitis. When the patient initially presented to the Mercy Emergency Department on June 4, 2012, a malodorous, purulent draining ulcer was noted to the left 1st metatarsophalangeal joint with a total area measuring 2.5 cm. The patient was noted to be completely neuropathic. The left foot and ankle were noted to be in severe valgus position, and the 1st metatarsophalangeal joint (MPJ) was dislocated. Infectious disease consults recommended a below knee amputation due to the extent and chronic nature of the condition. However, following podiatry consult, serial incision and drainages (I&D’s) with IV antibiotics, and future limb salvage reconstructive surgery was recommended upon infection control. In the period between June 2012 through to November 2012, six successful I&D’s with bone debridements were performed, resulting in control of infection. At that time, a decision was made to attempt to reconstruct the patient’s left lower extremity utilizing an external fixation frame.

On November 18, 2012, the patient was brought to the Mercy Operating Room for surgical correction of left Charcot joint disease. After general anesthesia was induced, attention was directed to the medial malleolus where a sagittal saw and blade was used to shave down all hypertrophic bone. A transverse cut from posterior to anterior was made with an osteotome and mallet on the medial malleolus to create a varus wedge. The wedge on the medial malleolus was closed for the left tibial correctional osteotomy.

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Figure 1 Left: Postoperative lateral radiograph showing bone graft placement, as well as, 1st ray extended length Right: Preoperative lateral radiograph showing shortened 1st ray.

Next, all cartilage was removed from the ankle in preparation for fusion. Autograft and allograft (Trinity Evolution) was applied to the ankle fusion site and the ankle varus wedge. Attention was then directed to the first MPJ, where all chronicity of the joint was resected, and the bones were fenestrated for fusion of the first MPJ. Autograft measuring 12.8mm x 8.5mm. (Fig. 1) taken from the tibial varus wedge osteotomy was introduced into the site to facilitate fusion, and restore length to the 1st metatarsal. An Orthofix MiniRail was applied to the 1st MPJ.

Two pins were placed proximally on the 1st metatarsal shaft and two distal pins were placed on the proximal phalanx. An elliptical incision was made over the medial and plantar aspect of the 1st MPJ to excise the skin ulcer of this area. Under fluoroscopy, correction of the deformity was achieved and medial arch height of the foot was restored resulting in a better anatomic position. K-wires (.062) were used to fuse the joint, and kept to recreate a high medial arch. An Orthofix external ring fixator was applied to the extremity with 2 olive wires in the proximal tibia, two olive wires in the distal tibia, two olive wires in the calcaneus, and 3 olive wires placed in the forefoot for anatomic correction. (Fig. 2)

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Figure 2 Top: Dorso plantar intra-operative radiograph showing placement of external fixator and monorail. Bottom: Lateral intra-operative radiograph showing placement of external fixator.

The ring external fixator consisted of 2 circular rings and 2 foot plates. The case progressed successfully to wound healing and primary fusion after 10 weeks.

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Figure 3 Top: Postoperative radiographs showing removal of hypertrophic bone formation as well as fusion of ankle joint. Bottom: Preoperative radiographs showing hypertrophic bone formation.

In follow-up visits, the patient states he is able to ambulate pain free and without assistance. Post-operative x-rays reveal fusion of the ankle joint (Figure 3), and correction of valgus deformity (Fig. 4) as well as fusion of the 1st MPJ with achievement of a more accurate length of the 1st metatarsal.

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Figure 4 Left: Postoperative radiographs showing forefoot valgus correction. Right: Preoperative radiographs showing forefoot valgus deformity.

This case presents a patient with a complex deformity in which chronic ulceration is due to a hyper-mobile first ray combined with a previously shortened 1st metatarsal. Prior studies have shown the effectiveness of external fixator use1, as well as medial column arthrodesis[6], in the management of patients with Charcot neuroarthopathy. By combining these two previous treatment modalities with extension of the 1st metatarsal, through the usage of an autologous bone graft, a stable plantar grade foot can be achieved (Fig. 5).

Conclusion

Below knee amputation is often the recommend procedure in Charcot joint disease patients with chronic non-healing ulceration and significant deformity[3]. The successful utilization of acute tri-planar correction, external fixation and autologous bone graft provides an alternative treatment for those patients with complex Charcot foot deformities.

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Figure 5 Left: Postoperative stable plantar grade L-foot free of ulceration. Right: Preoperative unstable L-foot with ulceration.

References

1. Zgonis T, Roukis T, Lamm B. Charcot foot and ankle reconstruction: Current thinking and surgical approaches. Clin Podiatr Med Surg. 2007 24:505-517. [PubMed]
2. Najafi B, Crews RT, Armstrong DG, Rogers LC, Aminian K, Wrobel J. Can we predict outcome of surgical reconstruction of Charcot neuroarthropathy by dynamic plantar pressure assessment? – A proof of concept study. Gait Posture 2010 31: 87-92. [PubMed]
3. Zgonis T, Stapleton J, Roukis T. Charcot Foot and Ankle Deformity. McGlamry’s Comprehensive  Textbook of Foot and Ankle Surgery. 4th ed, Ch 70. 1008-1021.
4. Jeffcoate W. Charcot neuro-osteoarthropathy. Diabetes Metab Res Rev 2008; 24(Suppl 1): S62–S65. [PubMed]
5. Burns PR, Wukich DK. Surgical reconstruction of the Charcot foot and ankle. Clin Podiatr Med Surg 2008 25: 95-120. [PubMed]
6. Capobianco CM, Stapleton JJ, Zgonis T. The role of an extended medial column arthrodesis for charcot midfoot neuroarthropathy. Diabetic Foot & Ankle 2010 1: 5282. [PubMed]

Diabetic Limb Salvage in the Septic Ankle: Case Studies of Arthrodesis using the Ilizarov Methodology

by Sutpal Singh, DPM. FACFAS, Albert Kim, DPM2, Timothy Dailey, DPM,3
Long Truong, DPM4, Maria Mejia, DPM5

The Foot and Ankle Online Journal 4 (10): 1

Diabetic patients usually have multiple comorbidities resulting in higher complication rates after ankle fractures. In many cases, the patient, through diabetic complications of peripheral neuropathy, may mistakenly ambulate resulting in dislocation or hardware failure if only internal fixation is utilized. Also, impaired wound healing, infection, non-union, mal-union and development of Charcot foot and ankle arthropathy may ensue. This article will present several cases in which open reduction and internal fixation in diabetic ankle fractures failed which then lead to osteomyelitis. This infection with the presence of diabetic neuropathy results in an increased risk for loss of limb. These cases were ultimately salvaged with septic ankle arthrodesis using the Ilizarov Method.

Key words: Diabetic ankle fracture, osteomyelitis, Limb Salvage, Septic Ankle Arthrodesis, Ilizarov Methodology.

Accepted: September, 2011
Published: October, 2011

ISSN 1941-6806
doi: 10.3827/faoj.2011.0410.0001


Treating diabetic ankle fractures is a very complex task and many times lead to multiple complications. The majority of diabetic patients have comorbidities such as peripheral vascular disease, osteoporosis with poor bone stock that can lead to poor healing potential and complications. A few of the complications encountered are ulcerations and wound dehiscence.

It has been well documented in the literature that diabetic patients with ankle fractures who underwent open reduction and internal fixation developed complications of wound infections, below the knee amputations, Charcot arthropathy, malunions, wound necrosis requiring plastic surgery, and deep sepsis. [1,2] When complications are encountered, often, salvage is managed by ankle arthrodesis. Our treatment protocol is to fuse the ankle using the Ilizarov Method.

When performing an ankle fusion there are a variety of different open surgical approaches to exposing the ankle for fusion as well as arthroscopic ankle fusions.

The open surgical approaches are more commonly used than the arthroscopic option. Of the many different open approaches the more common ones are the medial transmalleolar, lateral transmalleolar, anterior, and posterior approaches. A discussion on the various types of ankle arthodesis will be presented followed by the Ilizarov Method in septic ankle joint arthrodesis.

The medial approach is performed by using an osteotome or oscillating saw to create a transverse medial malleolar osteotomy at the level of the distal tibial articular surface. Next, the medial malleolus is reflected distally on the deltoid hinge, exposing the ankle joint. A power saw is used to resect the tibial plafond perpendicular to long axis of the tibia. Temporary fixation with Steinmann pins can be utilized to maintain the plantigrade position. [3]

The medial approach provides better visualization of the tibiotalar articulation [3,4,5], the surgical exposure obtained is more subcutaneous and gives better access for preparation of the articular surfaces. Neurovascular complications are also decreased by this approach. Finally, the medial approach allows for visualization in placement of a posterior screw which has to be placed blindly when using the lateral approach. [3]

In the lateral approach of ankle arthrodesis, an osteotomy is performed approximately 2 cm proximal to the level of the ankle joint. In this approach care must be taken not to sever the sural nerve. [3,4,5,6] The lateral approach is preferred over an anterior approach in cases with moderate to severe deformity. Therefore in cases where a severe deformity of the ankle joint is not present, an anterior approach is indicated.

In regards with the anterior approach, care is taken to avoid any damage to the terminal branches of the superficial peroneal nerve, the intermediate and the medial dorsal cutaneous nerves due to the course of these nerves under the incision site. [7] The fixation indicated for the anterior approach is composed of at least 2 screws inserted at 30 degrees with respect to the long axis of the tibia. These screws should cross proximal to the fusion site to maximize stability. In certain cases a third screw can be placed to improve sagittal plane stability. [7] A major advantage of the anterior approach is that the osteotomy of the lateral and medial malleoli is avoided. The other approach which is used but is not discussed in the literature as frequently is the posterior approach.

For the posterior approach, Hanson et al., concluded that using a posterior approach with a 95 degree blade plate is effective in large patients with a mild to moderate hindfoot deformity. [8]

In addition to the open techniques, an ankle fusion can be performed with arthroscopy. In the arthroscopic technique various abraders, curettes and other arthroscopic instrument are used to remove the cartilage from the joint surfaces using a camera and small portals through the ankle joint. After removing the cartilage the ankle is reduced into proper position and finally fixated internally with two transmalleolar screws. With arthroscopic fusion it has been shown that the average time to fusion is significantly less, whereas this produces a faster recovery period. The shorter time to fusion is likely a result of the minimal soft tissue stripping that is performed during the procedure. [4,9]

Regardless of whether an open or an arthroscopic fusion is performed, the position of the foot for fusion is the same. In the literature the correct position for fusion is valgus of the posterior foot varying from 0 to 5 degrees with an external rotation of 5 to 10 degrees, sloping slightly posterior talus relative to tibia and neutral flexion position. [1,2,4,5,6] In order to prevent malposition, the foot should be compared to the rest of the leg and the contralateral limb before fusing it.

Once the proper position is found the next concern is fixation. There are various methods of fixation such as compression with an external fixator, internal fixation using plates and screws, intramedullary fixation, and arthroscopic ankle fusion. [1,2]

In difficult cases of ankle arthrodesis and limb salvage the preferred fixation methods are Intramedullary (IM) nail and external fixation. [1,4,5,10,11] Obtaining a solid fusion can be challenging in compromised bony interfaces, and standard techniques of tibiotalar fixation such as crossed lag screws are often inadequate. An advantage that the Ilizarov technique has over IM nailing and the other internal fixation options is it can be used in cases of infection. [3,4] The Ilizarov method also spares the subtalar joint.

Post operative care is comparably the same in almost all the surgical procedures with non weightbearing in a posterior splint followed with a cast for at least 6 weeks, removal of casts depends on healing noted and once healing progresses the patient is placed in a CAM boot. [4,5]

For patients that were treated using the Ilizarov Method, early weight bearing is permitted. When comparing open arthrodesis with arthroscopic fusions, the arthroscopic patients were hospitalized for an average of 1.6 (1-4 day range) days whereas the open group was hospitalized for average of 3.4 days (1-6 day range). [12]

As discussed earlier, complications include malposition, neurovascular complications. Nonunions and amputations can also occur as a complication depending on the surgical approach. Initially they can be treated with prolonged periods of immobilization and minimal weightbearing. In addition, an external bone stimulator can be used. [11] If prolonged immobilization does not help then bone grafting and external fixation are recommended. [1,4,5,11,13,14,15] In cases in which non unions are painful and they are not able to be resolved with repeated surgical options an amputation is many times the only option. [11,13] Also superficial infection of the surgical incision or the pin sites in external fixation methods has been reported as occurring in 40% to 50% in which local wound care is usually sufficient enough. In cases of deeper infections where osteomyelitis is involved the rate of amputation is as high as 50% which happens more so in the case of fusions performed in an existing septic process. [11] This article will present failed open reduction internal fixation (ORIF) in diabetic patients that were salvaged in case of septic ankle fusion using the Ilizarov method in which both medial and lateral incisions were used.

Case Report

Case # 1

The first case is that of a 70 year-old diabetic, neuropathic, cardiomyopathic, liver transplant patient on dialysis. He had a bimalleolar ankle fracture stabilized with internal fixation. (Figs. 1 and 2) He was referred to our service after undergoing multiple surgeries including wound care and skin graft. He had a large ulcer on the medial and lateral ankle on the left lower extremity. His fibular plate was severely bent and the tibia was exposed on the medial side due to noncompliance and ambulation. An external fixator with several tibial screws and one calcaneal transfixation screw was used to temporarily hold the deformity. This was done prior to being transferred to our service. Cultures revealed Methicillin-resistant Staphylococcus aureus (MRSA) with osteomyelitis at the ankle and the patient was on intravenous (IV) antibiotics. After consulting with infectious disease, internal medicine, cardiology and vascular surgery, the patient was given clearance for limb salvage. The patient had only two choices at the time: (1) below the knee amputation or (2) limb salvage. He chose the latter. The treatment plan included wound care, debridement of the ulcer and removal of the necrotic and infected bone and soft tissue. This was performed 1 week prior to surgery. The patient then underwent a septic ankle arthrodesis using the Ilizarov frame as well as rotational flap to close the ulcer. (Figs. 3-5)

Figure 1  Pre-operative radiograph of failed internal fixation in case #1.

Figure 2  Clinical photograph of the exposed distal tibia and calcaneus in case # 1.

Figure 3   Application of the external fixator, closure of the calcaneal ulcer with a Graft Jacket, and rotational flap to cover the tibial wound at the ankle in case #1.

Figure 4  Showing lateral approach in case #1 with the external fixator.  The anteroposterior radiograph (A),  Lateral radiograph (B) and lateral radiograph after removal of wires from the subtalar joint (C) in case # 1.   All radiographs showing complete consolidation of the tibial talar joint.

Figure 5   Clinical photographs 4 months after surgery showing limb salvage with all wound healed with solid bone consolidation in case #1.

Case # 2

This patient is a 380lb, diabetic, neuropathic, cardiomyopathic patient with a malunion. (Fig. 6) He had an unstable ankle fracture at the fibula with complete rupture of the deltoid ligament. (Fig. 7A and 7B) He was stabilized with open reduction and internal fixation. He ambulated several days after the surgery resulting in malunion and widening of the tibial talar joint. He was seen by our service several months after the initial surgery. He had a large open wound down to the medial tibia with purulent drainage coming from the ankle joint. He presented with osteomyelitis of the ankle. Again, he was cleared for limb salvage.

Figure 6   Clinical photographs of open distal tibia with osteomyelitis in case # 2. (Close-up in inset)

 

Figure 7A and 7B   Anteroposterior  (A)  and lateral (B) radiographic views of a failed internal fixation resulting in a diabetic septic ankle.  (Case # 2)

The treatment plan again included wound care, debridement of the ulcer and removal of the necrotic and infected tissue. One week later, he had a septic ankle arthrodesis and subtalar joint arthrodesis using the Ilizarov frame as well as a rotational flap to close the ulcer at the ankle. (Figs. 8A, 8B, 9A, 9B, 10A, 10B, 11 and 12)

 

Figure 8A and 8B   Clinical photographs of septic ankle arthrodesis using the Ilizarov frame.  Medial view: Note closure of the ankle using a rotational flap (A) and anterior view.  This is the second day after surgery for case #2.

 

Figure 9A and 9B   Lateral (A) and anteroposterior (B) radiographic views 2 days after surgery showing ankle and subtalar joint arthrodesis compressed with an Ilizarov circular external fixator in case # 2.

 

Figure 10A and 10B  Medial (A) and lateral (B) views 3 months after tibial-talar-calcaneal fusion with the Ilizarov frame.  The skin on the medial side has completely healed with the rotational flap in case # 2.

Figure 11   The ulcer has completely healed and the Ilizarov external fixator has been removed in case #2.  The foot is very stable and completely fused at the tibial-talar-calcaneal joint.

  

Figures 12  Post operative radiographs showing complete arthrodesis of the tibial-talar-calcaneal joint and stabilization using percutaneous 6.5 mm fusion Synthes bolts after the Ilizarov frame was removed in case #2.

Case # 3

This patient is a 70 year old diabetic, neuropathic who suffered a severe ankle and foot fracture. She is a chronic tobacco abuser smoking 2 packs per day. She had an ORIF of the right ankle and foot. The patient developed a postoperative infection. She was referred to our service for limb salvage. On initial presentation the patient had a tremendous amount of putrid smelling brown pus coming from the medial ankle. (Fig. 13, 14A and 14B) Culture and sensitivity revealed MRSA. She was on IV Vancomycin. She was taken to the OR and an incision and drainage was performed. The necrotic bone and tissue as well as the hardware at the ankle were removed. The wound was then packed with iodoform and she had daily wound care. One week later, when the infection was controlled, she had a septic ankle arthrodesis using the Ilizarov Method. (Figs. 15, 16A, 16B, 17A, 17B)

Figure 13  Clinical photograph showing the diabetic open septic ankle joint.  The toes are to the upper right and the knee is to the upper left.  (Case #3)

 

Figure 14A and 14B   Severe foot and ankle deformity with sepsis at the tibial talar joint and failed hardware. (A) Note the probe in the medial ankle. (B) Putrid smelling brown pus was noted coming from the medial ankle and tracking across the ankle to the lateral mid leg area in  case #3.

Figure 15  Lateral radiographic view of the septic ankle arthrodesis using the Ilizarov frame several weeks after surgery.  There is good alignment of the tibial talar complex.  There is placement of antibiotic beads in the ankle/lower leg area.  (Case #3)

 

Figure 16A and 16B   There is a valgus rotation of the calcaneus relative to the long axis of the tibia.  (A) The forefoot was in neutral position without any varus or valgus. (B) All incisions have healed.  (Case # 3)

 

Figure 17A and 17B  After removal of the external fixator, insertion of internal splinting with Synthes metaphyseal plate, and calcaneal osteotomy with medial translation.  This shows good alignment of the lower extremity.  The tibial talar joint is completely fused. (A)  Lower leg, ankle and hind foot are in good alignment after the medial calcaneal slide osteotomy. (B) (Case #3)

Surgical Technique and Result

Case # 1: Three tibial rings, each 180 mm with several smooth 1.8 mm wires were applied to the proximal tibial segment. Also two half pins were also inserted and attached to the tibial rings. Then a foot plate was applied using the 1.8 mm wires. Note that the tibial rings and foot plate were not connected at this time. An incision was made on the lateral side. The hardware and the distal fibula were removed. On the medial side, the hardware and distal medial tibia were removed. The ulcer on the medial side was debrided and all necrotic tissue was removed. Then the tibial talar joint was resected until there was good apposition and bleeding. The wound was copiously irrigated with 3 liters of normal saline and bacitracin. The foot plate was manipulated to hold the tibial talar joint in good apposition with the second toe in line with the tibial tuberosity. There was no varus, valgus, dorsiflexion or plantar flexion noted. The tibial talar joint was in neutral position. The foot plate is used to move the foot such that the talus is directly under the tibia and not forward or behind the tibia. Several 0.062 Kirschner wires were inserted to hold the tibial talar joint. (Figs. 3 and 4)

Rods were then applied to the foot plate and tibial rings. Compression was applied in an axial direction. There was good alignment and good compression. Another incision was made above the ulcer and a full thickness rotational flap was performed to close the ulcer where the tibia was exposed. There were also two other ulcers noted which were created by the prior transfixation screw through the calcaneus. These ulcers were debrided to good bleeding tissue and then covered with Graft Jacket and sutured with 3-0 ProleneTM. The rest of the surgical sites were closed using 3-0 VicrylTM for deep tissue and 3-0 ProleneTM for the skin as well as skin staples.

The external fixation was left on for three months until consolidation was seen on radiograph. Then the external fixation was removed and the wires going into the subtalar joint was removed. A CROW boot was then dispensed to the patient to protect the limb. The patient then began ambulating with a walker. At six month and one year follow-up, the patient is still ambulating and without any recurrence. (Fig. 5)

Case # 2: Three 200 mm tibial rings were applied to the patient proximal to the open wound on the lower leg. Then 1.8 mm smooth wires were inserted and tensioned appropriately. Then 4 tibial half pins were inserted into the tibia and attached to the tibial rings.

Then a foot plate was applied to the foot with wires and tensioned appropriately. The tibial rings and the foot plate were not connected. Then an incision was made on the medial and lateral ankle. All the necrotic bone, tissue and the hardware were then removed. The tibia and the talus were then resected to good bleeding tissue and good apposition. The lateral incision was also extended to the subtalar joint and the subtalar joint was then denuded of cartilage. The large ulcer on the medial side was debrided and all necrotic tissue was removed. There was an even larger opening on the medial side after the debridement. The surgical site was irrigated with 3 liters of normal saline with bacitracin. The foot plate with the foot was then manipulated in a manner in which the tibia and second toe was in line. The tibial talar joint was in neutral position without varus or valgus. There was no varus, valgus, dorsiflexion or plantar flexion noted. The tibial talar joint was in neutral position. The foot plate is used to move the foot such that the talus is directly under the tibia and not forward or behind the tibia. Then several 0.062 Kirschner wires were inserted from the calcaneus, through the talus and then into the tibia.

Rods were then used to connect the foot plate to the tibial rings and this was then compressed to fuse the tibial-talar-calcaneal joint. Attention was then directed to the medial large ulcer. Another incision was made at the ulcer and a rotational flap was performed so as to close the ulcer. The surgical site was closed with 3-0 vicryl for the deep tissue, and 3-0 ProleneTM and skin staples for the skin.

The external fixator was left in place for three months until good consolidation was noted. The K wires were removed. Because he was morbidly obese, internal splinting with percutaneous 6.5 bolt screws from Synthes were inserted from plantar calcaneus to the tibia. He was also given custom AFO. (Figs. 8A,8B, 9A, 9B, 10A, 10B, 11 and 12) At six month and one year follow-up, the patient is still ambulating and without any recurrence.

Case # 3: The patient had severe abscess at the medial left ankle with the pus tracking laterally up the leg. (Fig. 13) An incision and drainage was performed on the medial and lateral ankle. The infected tissue, bone and hardware were all removed as well at the distal fibula. The surgical site was irrigated copiously with three liters of normal saline and bacitracin using a pulse lavage system. The surgical site was loosely approximated with 3-0 ProleneTM and skin staples. She then had wound care every day including the use of Betadine® soaked iodoform as well as irrigation with one liter of normal saline and bacitracin for 5 days. Once the infection was controlled, she was then taken back to the OR for a septic ankle arthrodesis.

The patient was taken back to the OR and three 180 mm tibial rings were applied to the left lower leg proximal to the infected area. (Fig. 15) The wires were tensioned appropriately and then 2 half pins were applied. Then a foot plate was applied and tensioned appropriately. The tibial talar joint was then resected and then placed in a neutral position without any varus or valgus. There was no varus, valgus, dorsiflexion or plantar flexion noted at the tibial talar joint. Also note that the foot plate is used to move the foot such that the talus is directly under the tibia and not forward or behind the tibia. Her tibial talar joint was in neutral position. This was then stabilized with several 0.062 K wires. The foot plate with the foot was then connected to the tibial rings with several rods. These were then tightened to compress the tibial talar joint. She did have a valgus tilt of the subtalar joint with the heel being laterally located. (Figs. 16A and 16B) Because of the complexity of the deformity, it was decided to perform a medial calcaneal slide osteotomy at a different time until there was complete consolidation of the tibial talar joint. Antibiotic beads of 1 gm of Vancomycin were made and inserted into the lower leg ankle area.

The external fixator was left in place for four months until good consolidation was noted. The K wires were removed. At this time, because of the severe deformity and possibility of recurrence and BKA, internal splinting with a 10-hole 3.5 mm metaphyseal plate and screws spanning the tibial-talar-calcaneal complex was performed. Also, a medial calcaneal slide osteotomy was also performed to have a more rectus foot and in better alignment of the leg and hindfoot. This was performed by making an incision on the lateral calcaneal area. The incision was deepened to the subcutaneous tissue and then to bone. A sagittal saw was used to perform the osteotomy and the calcaneus was translated medially approximately 2 cm and stabilized with several crossing K wires. (Figs. 17A and 17B)

Two months later, the wires in the calcaneus were removed and a custom Arizona brace was dispensed and she was able to ambulate with a walker.

After six months, she developed an ulcer on the plantar right foot. She had a Charcot foot prior to the severe infection on the left foot. This ulcerated after six months but with proper wound care, this ulcer completely healed. She was also dispensed another Arizona brace for the right lower extremity. At two year follow-up, she is doing well and has both of her legs and feet. (Figs. 18,19)

 

Figures 18  Two years after surgery, the radiographs show good alignment and complete arthrodesis of the tibial-talar-calcaneal bones.   The wires in the posterior calcaneus have all been removed in case #3.

Figure 19   Complete healing of the calcaneal osteotomy in anatomic good position after removal of the internal fixation wires in case #3.

Discussion

Multiple studies have noted that open reduction internal fixation in acute diabetic ankles fracture can be devastating. [16,17,18,19,20] Patients with complications associated with diabetes are at an increased risk for higher rates of in hospital mortality, in hospital post operative complications, length of stay and non-routine discharges. [19] Previous studies has shown mortality rate as high as 8.5% and deep infection of 17% associated with complications of diabetic ankle fracture. [18] Even after anatomical reduction with stable internal fixation, the diabetic neuropathic patients may experience complications such as breaking or bending the fibular plate, malunion, nonunion, and charcot arthropathy. After repeat ORIF of the ankle with stacked one-third tubular plates and several syndesmotic screws, failure can occur. It is noted in previous studies that diabetic neuropathic patients are 5 times more likely to need revision surgery when comparing to patient with uncomplicated diabetes. [20] Salvage by tibiotalocalcaneal fusion with intramedullary rod in this population group also failed due to non compliance. This can ultimately resulted in a below the knee amputation. [2,21] In revisions surgery, the fusion rate is noted to be lower than in primary arthrodesis. [22]

Thus, in our case reports, our protocol is to perform ORIF and then to stabilize the lower extremity with an Ilizarov frame. If the patient has peripheral vascular disease, the Ilizarov frame was applied with
very minimal to no internal fixation. If the patient is severely medically compromised, the surgery was performed under IV sedation using a popliteal block, common peroneal block at the neck of the fibula and saphenous nerve block at the level of the tibial tuberosity.

Several surgical techniques are currently accepted for performing primary ankle arthrodesis. These techniques include compression with an external fixator, internal fixation using plates and screws, intramedullary fixation, and arthroscopic ankle fusion. [1,22]

The Ilizarov technique offers several advantages that “traditional” fusion does not offer in patients with complex ankle pathology such as infection, limb-length discrepancy, mal-union, Charcot joints, talar osteonecrosis, and talar absence. [22] Internal fixation and arthroscopic techniques are not suitable methods for infection, bone loss, severe deformities, or failed procedures. [1] Post-operatively, the Ilizarov method allows for adjustments in mechanical control throughout the treatment period that is otherwise impossible with nails, screws, or plates. [1,22]

Potential limitations that can be associated with this technique include pin track problem, the cumbersome frame, and complexity associated with application of the frame. [22]

Pin track infections do occur but usually are managed locally with pin site care and oral antibiotics. However, the advantages outweigh these downfalls. These advantages prove even more invaluable when application is planned for revisions and complex situations. [1]

The Ilizarov technique provides stable fixation and allows application of primary and continuous forces along any axis and direction. [1,22] The dynamic axial fixation maintains bone contact without additional bone grafting and allows excellent bending, shearing, and torsional stability that allows early weightbearing. [1,22] Most patients are bearing partial weight immediately, therefore earlier compression is noted across the surgical site, enhancing fusion rate. [22]

Additionally, due to early ambulation, there is noted improvement in proprioception and reduction in complications such as deep vein thrombosis and deconditioning. [22]

The Ilizarov technique also enables correction in a single plane or in multiple planes. [1,2,22] A well aligned fusion ensures a near normal gait. It is recommended that fusion be position with valgus of the posterior foot varying from 0 to 5 degrees with an external rotation of 5 to 10 degrees, sloping slightly posterior and neutral flexion position. [1,2]

Ankle arthrodesis can be divided by approach as anterior, transmalleolar, or posterior or by method of fixation as external or internal. [1] However, when planning the proper procedure for the high risk diabetic patient, many techniques become less appropriate with frequent complications and difficult to achieve fusion site. In our case reports in this article, we performed septic ankle arthrodesis using the Ilizarov Method for limb salvage. All patients were told that a BKA was eminent. We were able to salvage the limb by the Ilizarov Methodology. It has been noted by Gabriel Ilizarov that osteomyelitis burns in the fury of osteogenesis. Osteogenesis occurs by compression and immobilization of bone using the Ilizarov Methodology. In the presence of infection of the tibiotalar joint, arthrodesis is a reasonable treatment option and in some cases may be the way to prevent amputation at a more proximal level. [2]

Conclusion

The previous cases of diabetic ankle fractures which were fixed with open reduction and internal fixation went on to septic ankle joints. Septic ankle joint is a difficult condition to treat with two viable options limb salvage ankle arthrodesis or below knee amputation. Patients must be aware that ankle arthrodesis may still end up in a BKA. Many different ankle arthrodesis surgical techniques exist with the salvage option.

Each surgeon has his or her preference as to their procedure of choice with each having their advantages and disadvantages. The author’s systematic approach to diabetic ankle fractures is to cast if they are non-displaced, and ORIF with an Ilizarov frame if ankle fracture is displaced. If they go on to a septic ankle joint then the area is debrided and internal hardware is removed and an Ilizarov method is used for ankle arthrodesis. In the authors experience the biggest complication with the Ilizarov frame is pin tract irritations and or infections but these are easily treated by removing the pin and placing a new one. The Ilizarov method is a good option in providing adequate compression and in allowing the patient to bear weight. It is important to follow these patients frequently to make sure the arthrodesis site is healing well and free of infections to prevent a BKA.

References

1. Salem KH, Kinzl L, Schmelz A. Ankle arthrodesis using Ilizarov ring fixators: A review of 22 cases. Foot & Ankle International 2006 27:764-70.
2. Klouche S, El-Masri F, Graff W, Mamoudy P. Arthrodesis with internal fixation of the infected ankle. J Foot & Ankle Surgery 2011 50: 25-30.
3. Schuberth J, Cheung C, Rush S, Blitz N, Roling B. The medial malleolar approach for arthrodesis of the ankle: A report of 13 cases. J of Foot & Ankle Surgery 2005 44:125-132.
4. Easley M. Operative Techniques in Foot and Ankle Surgery. Philadelphia: Lippincott Williams & Wilkins 2011.
5. Coughlin M, Mann R, Saltzman C: Surgery of the Foot and Ankle. Philadelphia. Mosby 2007.
6. Grass R, Rammelt S, Biewener A, Zwipp H: Arthrodesis of the ankle Joint” Clinics Podiatric Medicine Surgery 2004 21:161-178.
7. Karl-Heinz K, Hans-Jörg T, Fusszentrum W. Ankle arthrodesis with an anterior approach. Techniques Foot Ankle Surgery 2007 6: 243-248.
8. Hanson TW, Cracchiolo A 3rd: The use of a 95 degree blade plate and a posterior approach to achieve tibiotalocalcaneal arthrodesis. Foot Ankle International 2002 23:704-710.
9. Glick J, Morgan C, Myerson M, Sampson T, Mann J. Ankle arthrodesis an arthroscopic method: Long-term follow-up of 34 Cases. Arthroscopy 1996 12: 428-434.
10. Fragomen AT, Fragomen AT, Meyers KN, Davis N, Shu H, Wright T, Rozbruch SR. A biomechanical comparison of micromotion after ankle fusion using 2 fixation techniques: Intramedullary arthrodesis nail or Ilizarov external fixator. Foot & Ankle International 2008 29: 334-341.
11. Raikin S, Venkat R. An approach to the failed ankle arthrodesis. Foot Ankle Clinics 2008 13:401-416.
12. O’Brien T, Hart T, Shereff M, Stone J, Johnson J. Open versus arthroscopic ankle arthrodesis A comparative study. Foot Ankle International 1999 20: 368-373.
13. Hagen RJ. Ankle arthrodesis: problems and pitfalls. Clinical Orthopaedics and Related Research. 1986 202: 152-162.
14. Katsenis D, Bhave A, Paley D. Treatment of malunion and nonunion at the site of an ankle fusion with the Ilizarov apparatus. JBJS 2005 87A: 302–309.
15. Morgan CD, Henke JA, Bailey RW, Kaufer H. Long-term results of tibiotalar arthrodesis. JBJS 1985 67A: 546–550.
16. Costigan W, Thordarson D, Debnath U. Operative management of ankle fractures in patients with diabetes mellitus. Foot & Ankle International 2007 28: 32-37.
17. Jones KB, Maiers-Yelden KA, Marsh JL, Zimmerman MB, Estin M, Saltzman CL. Ankle fractures in patients with diabetes mellitus. JBJS 2005 87B: 489-495.
18. McCormack R.G., Leith J.M.: Ankle fractures in diabetics: Complications of Surgical Management. JBJS1998 80B: 689-692.
19. Wukich D, Joseph A, Ryan M, Ramirez C, Irrgang JJ. Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot & Ankle International 2011 32:120-30.
20. Kline AJ, Gruen GS, Pape HC, Tarkin IS, Irrgang JJ, Wukich DK. Early complications following the operative treatment of pilon fractures with and without diabetes. Foot & Ankle International 2009 30:1042-1047.
21. Thordarson, D: Ankle fractures in diabetics. Techniques in Foot and Ankle Surgery. 2004 3: 192-197.
22. Eylon S, Porat S, Bor N, Leibner E. Outcome of Ilizarov ankle arthrodesis. Foot & Ankle International. 2007 28: 873-879.


Address correspondence to: Sutpal Singh, DPM. FACFAS, FAPWCA, Chief Ilizarov Surgical Instructor at Doctors Hospital, West Covina, California.

1  Chief Ilizarov Surgical Instructor at Doctors Hospital, West Covina, California. Private practice in Southern California.
 Resident, Doctors of Podiatric Medicine (R3),
 Resident, Doctors of Podiatric Medicine (R2),
4,5  Residents, Doctors of Podiatric Medicine (R1).
All residents : Doctors Hospital of West Covina (PM&S-36).

© The Foot and Ankle Online Journal, 2011

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