Tibia Fractures Resulting in Amputation

- Discussion:
    - mangled extremity severity score:
    - main controversy is whether tibial defect reconstruction and soft tissue reconstruction are indicated;
    - indications:
          - high velocity open tibia frx, w/ concomitant nerve, artery, &/or massive soft tissue disruption;
          - types IIIB and IIIC tibial frx w/ assoc w/ insensate foot or major bony injuries;
          - open tibia fractures w/ severe comorbidity (elderly pt, renal failure ect);
          - infected non unions, skin necrosis, skin loss in elderly pt w/ comorbidity;

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- Management:
    - technique of below knee amputation:
    - prevent infection:
          - irrigation (w/ > 9 lit) and repeated debridment;
          - debridement of open tibia fractures
          - consider leaving the wound open, wound vac, w/ delayed closure at 3-5 days post-injury;
          - antibiotics
          - type II and III open frx repeat debridment is required to evaluate amount of devitalized & potentially necrotic soft tissue;
          - soft tissue coverage as soon as the wound is clean;
                  - skin grafting & free flaps are often required;
                  - STSG over bone is rarely successful;

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- BKA Prosthesis:

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Open Tibial Fractures with Severe Soft-Tissue Loss. Limb Salvage Compared with Below-the-Knee Amputation.

Postoperative course of patients treated with iliac osteocutaneous free flaps. A two- to five-year follow-up study.

The Severely Traumatized Lower Limb: Reconstruction versus Amp: Vascular Injury Associated With Fracture-Dislocations of the Lower Extremity.

The Severely Traumatized Lower Limb: Reconstruction versus Amp: Limb Reconstruction versus Amputation Decision Making in Massive Lower Extremity Trauma.

The function of below-knee amputee versus the patient with salvaged grade III tibial fracture.

Open Tibial Fractures with Severe Soft-Tissue Loss.   Limb Salvage Compared with Below-the-Knee Amputation.

Lower limb replantation. A report of nine cases.

The Insensate Foot Following Severe Lower Extremity Trauma: An Indication for Amputation?

To Reconstruct or Not to Reconstruct?

An Analysis of Outcomes of Reconstruction or Amputation after Leg-Threatening Injuries.

Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies.

Open tibia fracture: amputation versus limb salvage. OPINION: below-the-knee amputation.