Is the Ankle Fusion the Single Salvage Procedure and the Best Result for the Massive Distal Tibial Loss: Surgical Techniques and Clinical Results

Background: Management of high-energy injuries with extensive soft tissue damage and massive distal tibial loss is challenging and often lead to severe dysfunction. In these complex situations ankle fusion procedure is the most commonly performed surgery. Publications devoted to treatment options and outcomes in these surgical challenging conditions are relatively rare. Objective: The purpose of this work is to present our clinical experience in using staged external fixation protocol in the treatment of six patients who suffered from complex open fractures of the distal tibial segment with severe bone and soft tissue loss due to high-energy trauma. Methods: The retrospective analysis of six patients (Gustilo-Anderson III B and III C fractures) with massive distal tibial loss and treated using a staged protocol of external fixation between 1998 and 2010, was carried out. Mean bone loss was 11.5 cm (range, 9 – 15 cm). Results: All patients had reconstructive surgery using circular external fixation frames. The outcome in three of them was solid ankle fusion – two patients had acute distal shortening and proximal tibial elongation by distraction osteogenesis and one had acute fibular transfer to replace distal tibial loss with fixation using Ilizarov circular frame. In other three patients, the functional and the radiological outcome was pain-free ankle joint pseudoarthrosis – one had proximal tibial elongation, one had a combination of bone transport with distal fibular transfer and one had acute limb shortening without tibial elongation. All six patients were pain-free and satisfied with functional outcomes, regardless of the final solid bone fusion or pseudoarthrosis. Conclusions: The method of circular external fixation combined with proximal tibial elongation by distraction histogenesis is recommended for limb reconstruction in high-energy injuries with massive distal tibial loss including articular surface.