PMC7306524_01
(A) Preoperative radiograph, AP view (B) Lateral view (C) Initial soft tissue loss caused by gunshot injury. The direction of the scissors indicates the bullet trajectory.
gr1.jpg
PMC7306524_01_gr1.jpg
fig0005
Radiographs indicated comminuted fracture with bone loss about 7 cm and multiple shotgun pellets (Fig. 1).
Computed tomography angiography at right knee with the reduction of metallic artifact. (Red arrow: anterior tibia artery with contrast enhancement, Blue dash box: missing segment of anterior tibia artery with poor contrast enhancement).
gr2.jpg
PMC7306524_01_gr2.jpg
fig0010
Computed tomography angiography revealed poor contrast enhancement in the right anterior tibial artery (Fig. 2).
Large soft tissue defect (20 cm x 15 cm) of the anterior border of the tibia after primary wound debridement.
gr3.jpg
PMC7306524_01_gr3.jpg
fig0015
Initial wound debridement with fixation by external fixator were done 2 h after the trauma (Fig. 3).
Antibiotic-loaded PMMA spacer used to fill the bone defect and double locking plates used to fix the fracture.
gr4.jpg
PMC7306524_01_gr4.jpg
fig0020
We filled the bone defect with vancomycin and gentamicin loaded cement spacer (Fig. 4).
Cross-leg pedicle flap nourished by posterior tibial artery and three perforator vessels marked with yellow arrow signs.
gr5.jpg
PMC7306524_01_gr5.jpg
fig0025
The flap is nourished by the posterior tibial artery and three perforator vessels (Fig. 5).
Donor site covered with split thickness skin graft.
gr6.jpg
PMC7306524_01_gr6.jpg
fig0030
We immobilized the two legs with cross-leg external fixators (Fig. 6).
(A) Radiograph at 12-months-follow-up, AP view and (B) lateral view (C) Patient is able to stand without leg length discrepancy (D) Well-healed skin graft and flap on both lower extremities.
gr7.jpg
PMC7306524_01_gr7.jpg
fig0035
At 12 months, bone healing was observed on the radiograph (Fig. 7).