Te. Quirke et al., ARE TYPE-IIIC LOWER-EXTREMITY INJURIES AN INDICATION FOR PRIMARY AMPUTATION, The journal of trauma, injury, infection, and critical care, 40(6), 1996, pp. 992-996
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.