ARE TYPE-IIIC LOWER-EXTREMITY INJURIES AN INDICATION FOR PRIMARY AMPUTATION

There are few large series of the long-term results of severe devascul arized, open fractures to the lower extremity, Therefore, we retrospec tively reviewed our experience with 35 consecutively admitted patients who sustained Gustilo Type IIIC injuries and who presented to our Rei mplantation Center between 1984 and 1987, To our knowledge, this group of patients represents the largest series of this injury reported to date. The review included 21 patients who required primary amputation and 14 patients who underwent vascular, orthopedic, and delayed soft t issue reconstruction, This report details the treatment protocol used to result in our 93% success rate in the 14 patients with Type IIIC in juries who were successfully revascularized. Our initial management ap proach to the devascularized lower limb includes immediate revasculari zation with temporary shunts to minimize ischemia time, followed by re vascularization with vein grafts beyond the zone of injury and externa l fixation, Subsequent management included liberal use of microsurgica l free transplantation to overcome soft tissue defects; bone grafting as soon as infection and soft tissue coverage permitted and delayed wo und closure, Our approach differs in that definitive wound closure is avoided for 4 to 6 weeks to allow resolution of myonecrosis secondary to initial ischemia and subsequent reperfusion injury, Contraindicatio ns to this aggressive revascularization approach are poor patient heal th before injury, completely severed limb, segmental tibial loss great er than 8 cm, ischemia time greater than 6 hours, and severance of the posterior tibial nerve.