A thirty-five-year-old man was brought to the Mikaelian Surgical Center in Yerevan, Armenia, on February 5, 1988, four hours after being injured in a motor-vehicle accident that had occurred sixty kilometers away. He had sustained a traumatic amputation with severe crushing of the soft tissues at the level of the proximal third of the tibia. The leg had been placed in ice, and it accompanied the patient. He had received no intravenous resuscitation in the four hours before his arrival, and he had a blood pressure of 90/60 millimeters of mercury (12.00/8.00 kilopascals). A tourniquet had been placed at the mid-part of the thigh at the scene of the accident. There were no other injuries.
According to the criteria of the mangled extremity severity score3, the patient had a high-energy skeletal and soft-tissue injury (4 points), had had a completely ischemic limb for less than six hours (3 points), had had persistent hypotension with no fluid resuscitation for four hours (2 points), and was thirty-five years old (1 point). This gave the patient a score of 10 points.
After fluid resuscitation, the patient was taken to the operating room, where extensive débridement was performed. The limb was shortened approximately thirteen centimeters. A three-ring Ilizarov apparatus was applied with apposition of the ends of the shortened bone. One ring was fixed to the proximal fragment with three tensioned wires, and two rings were fixed to the distal fragment with two wires used for the middle ring and three wires used for the distal ring. This procedure took twenty minutes. The microsurgical team revascularized the limb. The arterial repair was accomplished by side-to-side anastomosis of the posterior tibial and anterior tibial arteries, which were then joined to the popliteal artery. The superficial and deep peroneal nerves were repaired with microsurgical technique. The gastrocnemius and anterior tibial muscles were repaired, but the remainder of the muscles were approximated as a group because the medical condition of the patient was not stable. The skin was loosely approximated, and the bone ends were compressed with use of the Ilizarov apparatus.
Ten days postoperatively, an infection of the skin and soft tissues developed at the site of the replantation. It was treated successfully with débridement, antibiotics, and a free-tissue transfer that was performed forty-five days after the operation.
Distraction was begun through the site of osseous approximation on the twentieth postoperative day. The callus was distracted at a rate of 0.25 millimeter three times a day. The rate of distraction was increased to four times a day on the thirtieth day. On the forty-fifth day, a ten-by-eighteen-centimeter thoracodorsal free-tissue transfer with use of the popliteal artery was used to cover the soft-tissue defect that had resulted from the infection and the incomplete revascularization of soft tissues. Sixty days after the operation, the patient was discharged with instructions to continue distraction at a rate of 0.25 millimeter four times a day. However, he was erratic in following the instructions for lengthening and in keeping follow-up appointments.
On the eighty-first day, half-rings were applied, with use of rods and hinges, to the forefoot and calcaneus and were then connected to the main frame. The forefoot was dorsiflexed gradually to correct an equinus deformity. A radiograph made at 130 days revealed that the regenerated bone tapered to a thin strand. Distraction was halted at that time, as it was apparent that this site would not provide the bone that was necessary to obtain the remaining five centimeters of length that was needed. The additional five centimeters of length was achieved by performing a corticotomy three centimeters proximal to the ankle at 190 days. This site was distracted at a rate of 0.25 millimeter four times a day (Fig. 1). By 332 days after the operation, the normal length of the limb had been restored. Both areas of regenerated bone had consolidated, and the apparatus was removed. The patient wore a posterior splint for twenty days. At one year after the injury, the proximal and distal areas of regenerated bone were remodeling, and the knee demonstrated full extension as well as flexion to 90 degrees.
At a follow-up examination two years after the accident (Fig. 2), the limb was warm with a palpable dorsalis pedis pulse. Sensation had been restored to the dorsum and sole of the foot, with patchy areas of dysesthesia. The ankle had a passive range of motion from 5 degrees of fixed plantar flexion to 35 degrees of further plantar flexion. The active range of motion of the knee was 0 degrees of extension and 110 degrees of flexion. The extensor muscles of the calf demonstrated fibrillation without contraction, and the plantar flexor muscles demonstrated a small amount of motion. The patient wore regular shoes, had a good gait, used a cane for walking long distances, and had returned to his previous occupation as a truck driver.
The case of this patient illustrates that a severely injured limb can be salvaged with extensive débridement, deliberate shortening, and subsequent restoration of length with the Ilizarov technique.
Several features of this case report are noteworthy. Distraction was performed through the site of the amputation as well as at the site of the metaphyseal corticotomy. Despite early distraction (on the twentieth day after the injury) through bone and soft tissues that had been severely injured, and although it was necessary to perform a corticotomy to obtain the desired length, regeneration of both ends of the bone was satisfactory. Also, distraction at the sites of the neural and vascular repairs occurred without any apparent adverse effect. Nerve regeneration proceeded to the point that it provided this patient with sensation on the sole of the foot.
This technique has been described previously, but it was associated with treatment of more than two years' duration1,5. Early lengthening after soft-tissue healing in my patient resulted in restoration of the length of the limb and the consolidation of bone in one year. Absolute prerequisites for the use of this technique are the availability of microsurgical expertise and experience in the use of the Ilizarov apparatus. Immediate amputation, fitting with a prosthesis, and early rehabilitation are the standard treatment for most such injuries2. However, the result in this patient, which was a sensate foot and satisfactory function of the limb, was thought to be superior to an amputation.
NOTE: The author thanks Dr. Rodney K. Beals for assistance in the preparation of this manuscript.