Are Type IIIC Lower Extremity Injuries an Indication for Primary Amputation

There are few large series of the long-term results of severe devascularized, open fractures to the lower extremity. Therefore, we retrospectively reviewed our experience with 35 consecutively admitted patients who sustained Gustilo Type IIIC injuries and who presented to our Reimplantation 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 tissue reconstruction. This report details the treatment protocol used to result in our 93% success rate in the 14 patients with Type IIIC injuries who were successfully revascularized. Our initial management approach to the devascularized lower limb includes immediate revascularization with temporary shunts to minimize ischemia time, followed by revascularization with vein grafts beyond the zone of injury and external fixation. Subsequent management included liberal use of microsurgical free transplantation to overcome soft tissue defects ; bone grafting as soon as infection and soft tissue coverage permitted and delayed wound 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. Contraindications to this aggressive revascularization approach are poor patient health before injury, completely severed limb, segmental tibial loss greater than 8 cm, ischemia time greater than 6 hours, and severance of the posterior tibial nerve.