Reconstruction of Compound Tibial and Soft Tissue Loss Using a Traction Histogenesis Technique

Abstract

We used simultaneous bone and soft tissue transport for reconstruction of large compound tissue loss in the lower leg. We report the results and complications of a 12-patient series. The average age of the patients was 31.2 years (range 20 to 48 years). Seven patients had grade IIIB open tibial fractures, three had complications after grade II or IIIA, and two had an en-bloc resection of bone, muscle, and skin for a malignant bone tumor. Arteriography was routinely performed, and demonstrated at least one patent tibial artery. Every patient had normal sensibility of the sole. The first stage of the reconstruction was an aggressive excision of the all necrotic skin, muscle, and bone. The Ilizarov external fixator was applied and wires were secured under a tension of 100 kg, using a dynamometric tensioner. Cutaneous tissue loss was not replaced in 10 patients, when the bone was not exposed. A medial gastrocnemius flap was performed in two patients and lengthened with the bone. Corticotomy was performed 15 days after the first stage with careful respect for the periosteum. Distraction was initiated 15 days after the corticotomy. The average bone defect was 12.5 cm after initial excision. An average of 9 operative procedures and 18 months of treatment were required before bony union. The mean duration of bone transport was 6.5 months, and the mean duration of external fixation was 12 months. The final functional results were fair and only two patients returned to work. One patient had a below-knee amputation after 10 months of treatment. Ilizarov bone and soft tissue transportation is a very demanding technique for the patient and the surgical team, and does not reduce the duration of treatment. It seems to be appropriate for large compound tissue loss in a lower leg with a single patent artery, but alternative treatments (e.g., free tissue transfer or amputation) should also be considered.