A 30-year-old man with no underlying disease sustained a crush injury to his foot and ankle and lower legs in a car crash. He was brought to our hospital in an ambulance. He sustained open fractures to the left foot and ankle (Gustilo Anderson classification Type IIIB) and bilateral open tibial shaft fractures(the right was aTypeI and the other was a TypeII). The tarsal bones were crushed, and a part of the bone protruded from the wound (Fig. 1). There was no damage to important internal organs, such as the brain or heart, and his physical status was stable. The radiograph and computed tomography scan showed dislocation of the ankle joint; severe foot and ankle instability were seen (Fig. 2a and b). The mangled extremity severity score (MESS) was six and the limb salvage index (LSI) was five on arrival. Amputation is recommended when the MESS is >=7 and LSI is >=6. We opted to perform limb salvage, because the blood flow was maintained by the posterior tibial artery and the sensory nerve in the foot sole was intact. Table 1 summarizes the lesion characteristics.
The ankle and foot were stabilized using Kirschner wires (K-wire) on the day of injury. We maximally removed the necrotic tissue and bone. We also provided temporary fixation for both open tibial shaft fractures with external fixators and covered the soft tissue defect with artificial dermis. On the next day, we performed second-look surgery and started negative pressure wound therapy(NPWT). After several debridement procedures, a wide bone defect had developed in the midfoot (Fig. 3a and b).
Open reduction and internal fixation (ORIF) for both tibial shaft fractures was performed with intramedullary nails on the 6thday after the trauma. Two days postoperatively, we performed ORIF for the left foot and ankle fracture.
We corrected the alignment of the hallux and fixed it with a titanium plate. We also fixed the lateral arch with some K-wires (Fig. 4a). Simultaneously, plastic surgeons performed soft tissue coverage with a latissimus dorsi flap (Fig. 4b). Thoracodorsal blood vessels were anastomosed to the posterior tibial artery and vein. However, the flap necrosed quickly. Therefore, a second grafting was performed using an anterolateral thigh (ALT) flap on the 21st day from injury. Perforating branches of the descending lateral femoral circumflex artery were connected to the anterior tibial artery and vein. To reduce the risk of infection, we removed the plate. We also removed necrotic navicular bone and stabilized the foot with K-wires. Then, we placed cement blocks into the bone defect.
The final surgery was performed 12 weeks after the second flap was grafted. We grafted an autologous bone block (corticocancellous bone, 1 cm x 1 cm x 1.5 cm) from the iliac crest on the bone defect, according to the Masquelet technique, and inserted a cannulated cancellous screw (CCS) from the fifth metatarsal bone to the talus, which passed through the autologous bone. We also grafted cancellous bone chips around the other bone defect (Fig. 5a-c).
Eight weeks after the final fixation, we allowed the patient to walk, with partial weight-bearing, while wearing a rocker bottom shoe. Fullweightbearing gait was initiated 4 months post-surgery. Presently, he can walk independently withoutpain, and there are no callosities in either sole (Fig. 6a and b). He was able to return to work 1 year after the injury and 2 years after the final operation, all screws were removed. He reported a high level of satisfaction. Regarding his ankle range of motion, plantarflexion was 15 , dorsiflexion was 0 , and the lower extremity functional scale score was 51 points at the time of return to work. On the radiograph, the M1-M5 angle was 22 , and the calcaneal pitch angle was 0 .Three years after the final fixation, when we performed the final follow-up examination, the sole sense was maintained, ankle plantarflexion was 20 , and dorsiflexion was 0 . At the same time point, on the radiograph, bone fusion was complete and no notable complications were observed (Fig. 7).