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Reconstructive: Lower Extremity: Original Article

Trends in the Surgical Management of Lower Extremity Gustilo Type IIIB/IIIC Injuries

Burns, Jack C. M.D., M.S.; DeCoster, Ryan C. M.D., Ph.D.; Dugan, Adam J. M.S.; Davenport, Daniel L. Ph.D.; Vasconez, Henry C. M.D.

Author Information
Plastic and Reconstructive Surgery: July 2020 - Volume 146 - Issue 1 - p 183-189
doi: 10.1097/PRS.0000000000006912
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Abstract

Severe lower extremity trauma can significantly affect a patient’s quality of life, ability to work, and functional status.1 According to the National Trauma Data Bank, the lower extremity was the most commonly injured body region in 2016.2 Treatment of lower extremity trauma may include reconstructive surgery (i.e., limb salvage) or amputation with subsequent fitting of a prosthetic device. Daniel and Taylor first described lower extremity free tissue reconstruction in 1973 using a skin island flap in a patient with a posterior tibial defect.3 Regarding limb salvage procedures, the orthopedist Sigvard Hansen stated, “…patients had to go through years of repeated surgeries, infections, and bone grafting only to end up with a compromised amputation on a delayed basis.”4 Hansen’s call for objective guidelines to direct the decisions regarding lower extremity trauma stimulated the initiation of a multicenter study that aimed to objectively answer this question. This ultimately led to the Lower Extremity Assessment Project, which began in the 1990s. Since that time, advancements in microsurgical technology and technique have revolutionized lower extremity reconstruction and patient outcomes driven by the Lower Extremity Assessment Project studies.

The Lower Extremity Assessment Project was a multicenter prospective longitudinal endeavor at eight Level I trauma centers in the United States. The Lower Extremity Assessment Project studies sought to create measures to guide surgeons in their decision-making when determining whether to pursue limb salvage or primary amputation in those with significant lower extremity trauma.5,6 These studies demonstrated clinical equipoise between functional scores and quality of life of those undergoing either amputation or limb salvage.7,8 As such, no formal scoring system or algorithm was uniformly accepted to guide those decisions. Although we are much better at recognizing positive and negative prognostic factors such as location and severity of injury, we are no better at predicting which limbs should be salvaged or amputated based on a reliable and objective scoring system. Given that outcomes are similar between the cohorts, one would expect that amputations and limb salvage would be performed at similar rates if the injuries sustained were similar.9 With this in mind, it has been our impression that less limb salvage operations and more amputations were being performed at our medical center over the past decade. We therefore decided to look at this apparent trend and thus conceived of this study.

PATIENTS AND METHODS

A retrospective cohort study was conducted at the University of Kentucky Medical Center, an urban Level I trauma center, from 2005 to 2014, to assess trends in the surgical management of lower extremity trauma. This study was approved by the Institutional Review Board at the University of Kentucky.

Data Sources

Inclusion was limited to adult patients, aged 18 to 75 years, with Gustilo type IIIB or IIIC injuries that underwent limb salvage or primary amputation following lower extremity trauma over the study period. Gustilo classification was used to determine injury severity because the the Lower Extremity Assessment Project studies used the same classification system in the inclusion criteria.10 The University of Kentucky Trauma Registry was used to generate the initial patient list and served as the primary data source for this study. The University of Kentucky Trauma Registry is composed of uniform data elements that describe an injury event from the time of injury to discharge. These elements include details of the injury, prehospital care, initial resuscitation, hospital care, and outcomes. The data from the trauma registry is then aggregated, analyzed, and sent to the National Trauma Data Bank. The University of Kentucky trauma program data is used by the National Trauma Data Bank as a benchmark comparison to other Level I trauma centers. The University of Kentucky Trauma Registry was queried using the following CPT, 2018Professional Edition codes: free flap reconstruction (15756, 15757, 15758, 20955, 20956, 20957, 20962, 20969, 20970, 20972, and 20973), local flap reconstruction (14020, 14021, 14300, 14040, 14041, 14300, 14350, and 15738), and amputation (27590 and 27880).11,12 Electronic medical charts and operative reports were further reviewed to determine patient demographics and clinical characteristics.

Outcomes

Outcome variables of interest were extracted from the electronic medical records at the authors’ institution. Data included patient age at the time of injury, smoking status, obesity, hyperlipidemia, peripheral vascular disease, Gustilo injury grade (IIIB/IIIC), Injury Severity Score, and Abbreviated Injury Scale score. During the study, a total of six plastic surgeons were involved in reconstructive cases performed on the limb salvage cohort. These same surgeons were also responsible for trauma evaluation in cases in which a plastic surgery consultation was requested for patients in the amputation cohort. The primary outcome of this study was to determine trends in the management of lower extremity trauma.

Statistical Analysis

Chi-square and Fisher’s exact tests were used for dichotomous variables as appropriate. The Spearman correlation was used to assess trends in amputation versus reconstruction over the study timeframe. Mann-Whitney U and t tests were used to analyze plastic surgery consultation data. Furthermore, Pearson correlation was used to analyze trends in consultation data. To account for differences in baseline characteristics, a multivariate logistic regression model was constructed, which considered age, Injury Severity Score, and Abbreviated Injury Scale score for the lower extremity. All statistical analyses were performed using R programming language Version 3.4.3 (R Core Team, Vienna, Austria) or Stata Version 15.1 (StataCorp, College Station, Texas). Statistical significance was set at a value of p < 0.05.

RESULTS

From January of 2005 to December of 2014, 158 patients were treated for Gustilo type IIIB/IIIC lower extremity traumatic injuries following trauma at the University of Kentucky Medical Center. Of those patients, 10 were excluded because of incomplete data sets. In total, 148 patients met inclusion criteria and were included in the final analysis.

Patient Demographics

Patient demographics and clinical characteristics are described in Table 1. Patients were subdivided into amputation [n = 69 (46.6 percent)] and limb salvage [n = 79 (53.4 percent)] groups. Briefly, the median patient age was 42 years (range, 32 to 52 years). Differences (p < 0.0001) in amputation [type IIIB (68.1 percent) versus type IIIC (31.9 percent)] and reconstruction [type IIIB (98.7 percent) versus type IIIC (1.7 percent)] were observed. The median Injury Severity Score was higher in the amputation cohort [14.0 (interquartile range, 9.0 to 25.0)] than the reconstruction group [9.0 (interquartile range, 9.0 to 19.00)] (p = 0.016). Statistical differences in Abbreviated Injury Scale score for the lower extremity were also found when comparing the amputation and reconstruction cohorts (p = 0.010). Similarities in age, smoking status, obesity, hyperlipidemia, and peripheral vascular disease were observed between the groups.

Table 1. - Patient Demographics and Injury Characteristics by Procedure Type
Overall (%) Surgical Management p
Amputation (%) Reconstruction (%)
Total no. of cases 148 (100) 69 (46.6) 79 (53.4) N/A
Age, yr 0.084
Median 42 39 45
IQR 32–52 30–48 34–54
Smoking status 65 (43.9) 29 (42.0) 36 (45.6) 0.790
Packs per day 0.329
0 83 (58.5) 38 (59.4) 45 (57.7)
0.5 19 (13.4) 9 (14.1) 10 (12.8)
1.0 30 (21.1) 14 (21.9) 16 (20.5)
1.5 5 (3.5) 0 (0.0) 5 (6.4)
2 5 (3.5) 3 (4.7) 2 (2.6)
Unknown 6 5 1
Obesity 2 (1.4) 2 (2.9) 0 (0.0) 0.216
Hyperlipidemia 8 (5.4) 5 (7.2) 3 (3.8) 0.473
PVD 1 (0.7) 1 (1.4) 0 (0.0) 0.466
Type of reconstruction N/A
Free 44 (55.7) N/A 44 (55.7)
Local 35 (44.3) N/A 35 (44.3)
Gustilo injury type <0.001
IIIB 125 (84.5) 47 (68.1) 78 (98.7)
IIIC 23 (15.5) 22 (31.9) 1 (1.3)
ISS 0.016
Median 10.0 14.0 9.0
IQR 9.0–19.8 9.0–25.0 9.0–19.0
AIS score for leg 0.010
0 4 (2.7) 0 (0.0) 4 (5.1)
1 0 (0.0) 0 (0.0) 0 (0.0)
2 18 (12.2) 8 (11.6) 10 (12.7)
3 116 (78.4) 52 (75.4) 64 (81.0)
4 6 (4.1) 6 (8.7) 0 (0.0)
5 4 (2.7) 3 (4.3) 1 (1.3)
IQR, interquartile range; PVD, peripheral vascular disease; ISS, Injury Severity Score; AIS, Abbreviated Injury Scale.

Trends in Gustilo Type IIIB/IIIC Management

Overall, 69 patients (46.6 percent) underwent primary amputation. An additional 11 patients (7.4 percent) underwent reconstruction with secondary amputation within 1 year of the initial trauma. Time period analysis showed that the rate of amputation increased from 20.0 percent in period 1 (2005 to 2007), to 67.4 percent in period 2 (2008 to 2010), to 54.5 percent in period 3 (2011 to 2014) (p < 0.001), which is shown in Table 2. Graphically, this is depicted in Figure 1. The rate of primary amputation for Gustilo type IIIB/IIIC lower extremity injuries was found to increase over the study timeframe (r = 0.292; p < 0.001). These data are shown in Table 3. An additional multivariate regression model adjusting for age, Abbreviated Injury Scale score, and Injury Severity Score was performed comparing the adjusted and unadjusted odds of amputation by year, with the reference period being 2005 to 2007. It shows that the adjusted odds ratio (8.29; p < 0.001) and unadjusted odds ratio (8.54; p < 0.001) for amputation in period 2 increased. The adjusted odds ratio (4.80; p < 0.001) and unadjusted odds ratio (4.52; p < 0.01) for amputation also increased for period 3 (Table 4).

Table 2. - Trends in Lower Extremity Management from 2005 to 2014 Subdivided into Three Distinct Periods
Surgical Management
Overall (%) Amputation (%) Reconstruction (%) p
Total no. of cases 148 (100) 69 (46.6) 79 (53.4) N/A
Year of surgery
2005–2007 50 (33.8) 10 (20.0) 40 (80.0) <0.001
2008–2010 43 (29.1) 29 (67.4) 14 (32.6)
2011–2014 55 (37.2) 30 (54.5) 25 (45.5)

Table 3. - Year of Surgery by Procedure Type *
Surgical Management Spearman Rho (p)
Overall (%) Amputation (%) Reconstruction (%)
Total no. of cases 148 (100) 69 (46.6) 79 (53.4) N/A
Year of surgery 0.292 (<0.001)
2005 28 (18.9) 4 (14.3) 24 (85.7)
2006 11 (7.4) 1 (9.1) 10 (90.9)
2007 11 (7.4) 5 (45.5) 6 (54.5)
2008 8 (5.4) 5 (62.5) 3 (37.5)
2009 11 (7.4) 9 (81.8) 2 (18.2)
2010 24 (16.2) 15 (62.5) 9 (37.5)
2011 10 (6.8) 5 (50.0) 5 (50.0)
2012 18 (12.2) 9 (50.0) 9 (50.0)
2013 12 (8.1) 7 (58.3) 5 (41.7)
2014 15 (10.1) 9 (60.0) 6 (40.0)
N/A, not applicable.
*Column percentages are reported in the “overall” column and row percentages are reported in the stratified columns.

Table 4. - Unadjusted and Adjusted Odds Ratio of Amputation by Year
Year of Surgery Unadjusted OR of Amputation Adjusted* OR of Amputation
2005–2007 N/A N/A
2008–2010
OR 8.29 8.54
95% CI 3.34–22.17 3.31–23.89
2011–2014
OR 4.80 4.52
95% CI 2.06–11.94 1.88–11.64
N/A, not applicable; ISS, Injury Severity Score; AIS, Abbreviated Injury Scale.
*Adjusted for age, ISS, and AIS score for leg.
p < 0.001.
p < 0.01.

Fig. 1.
Fig. 1.:
Case counts for the reconstruction and amputation cohorts depicted from 2005 to 2014.

Plastic Surgeon Consultation Rate

In total, plastic surgeons were involved in 67.5 percent of all cases. Although all reconstructive cases included a plastic surgeon, plastic surgeons were consulted in only 30 percent of amputation cases (p < 0.0001). The plastic surgery consultation data were then further analyzed to assess trends over time. Our data demonstrated that consultation occurred less frequently over time; however, the results did not reach statistical significance (r = −0.0558; p < 0.6491).

DISCUSSION

The Lower Extremity Assessment Project studies aimed to identify an algorithm to determine those that should undergo amputation or limb salvage after suffering lower extremity trauma.13 However, after many years and multiple studies, no formal guidelines were agreed on, and clinicians continue to use a gestalt to guide their clinical management.5,14,15 The lower extremity literature is constantly evolving, making evidence-based clinical decisions increasingly complex.16 Our data show a statistically significant trend toward amputation and away from limb salvage in the surgical management of lower extremity trauma over time. This may represent a shift in the previously published trends concerning the treatment of lower extremity trauma, which showed lower amputation rates of open tibia-fibula fractures and a preference for limb salvage procedures.9,17 In this study, 11 of the 79 patients (13.9 percent) undergoing limb salvage operations ultimately went on to undergo an amputation procedure within the next year. Our secondary amputation rate falls within the range quoted in the literature, which is anywhere from 4 to 40 percent.17,18

Parrett et al. showed a similar trend, with free flap reconstruction being performed less frequently over their study (1992 to 2003).9 Although our study did not specifically differentiate free flap limb salvage from local flap reconstruction, our data show similar trends with lower extremity reconstruction. In our study, the reconstruction cohort consisted of 44 patients undergoing free flap reconstruction and another 35 patients treated with local flap reconstruction. Parrett et al. further concluded that an increasing number of patients with Gustilo type III injuries are being treated with wound care, namely, vacuum-assisted closure devices.9 Vacuum-assisted closure devices were introduced in 1997, approximately halfway through the investigation period used in the Parrett et al. study. However, these same devices were used throughout the duration of the period analyzed in this study. Despite the advent and use of this technology, our results show an increasing rate of amputations.

To further investigate the amputation rate, we evaluated preoperative plastic surgeon consultation rates requested by orthopedic surgeons for open tibial fractures. At our institution, lower extremity trauma is commonly, although not uniformly, treated in a multidisciplinary fashion, with plastic, orthopedic, and trauma surgeons involved in the care of the affected individual.19,20 Although a multidisciplinary approach is used to manage those patients undergoing limb salvage operations, the management of those undergoing primary amputations differs from the orthoplastic approach at our institution. In the case of the amputation cohort, only 30 percent of cases involved the plastic surgery service in the evaluation of the injury. These data are in concordance with previously published studies. It is possible that the proportion of patients in which a plastic surgery consultation was obtained may have affected the ultimate treatment management. Other institutions have instituted protocols that involve plastic surgery, vascular surgery, and orthopedic surgery to assist in microsurgical coverage of appropriate lower extremity wounds.21 Currently, our standards for caring for those with Gustilo type III injuries are variable depending on the orthopedic and plastic surgery providers that are on trauma call. As a result of our findings, we are in the process of formulating a consultation protocol that would include a simultaneous, combined orthoplastic evaluation of all patients with Gustilo type IIIB/IIIC injuries.

Although each of our plastic surgeons had extensive microsurgery experience, none received fellowship training in microsurgery. It is possible that the lack of microsurgical training may have affected the clinical decision-making and willingness to perform reconstruction in dire circumstances. However, MacKenzie et al. found that years of experience or fellowship training had no effect on decision-making in the evaluation of lower extremity trauma.5 A gap in the literature exists on correlating fellowhip training experience with functional outcomes, and future studies should further investigate this relationship.

As previously mentioned, functional outcomes and pain scores have been thoroughly investigated for both cohorts. Although it has been suggested that perhaps the functional outcomes of those undergoing amputations may be superior, additional studies have shown this not to be the case.22 In a systematic review, Saddawi-Konefka et al. showed that pain scores, long-term quality of life, and limb function do not differ greatly between those undergoing amputation and limb salvage.23 In addition, MacKenzie et al. also showed that members of each cohort are not reentering the workforce at significantly different rates.24 However, these studies compared patients using prosthetics over a decade old. It is possible that newer prosthetic technology has led to improved functional outcomes in those undergoing lower extremity amputations.25 The trend illustrated in the data begs for a more recent comparison of the functional outcomes and pain scores between those undergoing limb salvage and amputation procedures. In addition, the promise of targeted muscle reinnervation, which has shown reduced phantom limb pain and the potential for improved bioprosthetic use, only further emphasizes the need for updated comparisons between cohorts.26,27

Limitations

Although this study has generated important data regarding trends in the surgical management of lower extremity trauma, there are several limitations that should be taken into consideration when interpreting study results. First, the study is retrospective in nature, the limitations of which have been previously described. Second, this is a single-institution study; as such, study results should be interpreted with caution, as they may not be generalizable to other study populations or reflective of national trends. This is especially important when considering geographic variation, as Mundy et al. have demonstrated differences in lower extremity reconstruction rates by geographic region.28 However, previous publications analyzing lower extremity reconstruction at the authors’ institution have yielded results consistent with those reported in the Lower Extremity Assessment Project studies.29–31 In addition, our long-term follow-up was poor and did not allow for outcomes data (e.g., ambulatory status, disability) comparisons between cohorts. Finally, the Gustilo type IIIC injuries were seen almost exclusively in the amputation cohort. Although this bias undoubtedly affects the overall trend, similar trends are seen when injury grade is controlled for between the two cohorts.

CONCLUSIONS

Our data show a significant trend toward amputation and away from limb salvage during the period studied. Performing an increasing number of amputations in the face of improved microsurgery technology, enhanced techniques, and evolving wound care may seem counterintuitive, but this may be a testament to a number of factors, including advances in prosthetic and bioprosthetic technology or the lack of strict protocols including the involvement of a plastic surgery evaluation in patients with severe lower extremity trauma. The authors strongly support the role of plastic surgery consultation in those suffering Gustilo type IIIB/IIIC injuries, as a combined orthoplastic approach may be a more effective way to manage these complex injuries. Future long-term work from our group will assess the impact of a combined orthoplastic approach on the surgical management and outcomes of open tibial fractures. Future research should also seek to identify potential institutional barriers to a combined orthoplastic approach and should also determine what factors orthopedic surgeons take into consideration when deciding whether or not to consult a plastic surgeon. Finally, more stringent functional comparisons analyzing those using advanced, modern prosthetics and those that have undergone limb salvage procedures should be performed to determine whether this trend toward amputation could yield benefits that outweigh the increased lifetime costs associated with this management strategy.

ACKNOWLEDGMENT

This research was supported in part by the William S. Farish Endowed Chair in Plastic Surgery.

REFERENCES

1. Egeler SA, de Jong T, Luijsterburg AJM, Mureau MAM. Long-term patient-reported outcomes following free flap lower extremity reconstruction for traumatic injuries. Plast Reconstr Surg. 2018;141:773–783.
2. American College of Surgeons. National Trauma Data Bank 2016 annual report. Available at: https://www.facs.org/~/media/files/quality%20programs/trauma/ntdb/ntdb%20annual%20report%202016.ashx. Accessed November 9, 2019.
3. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular anastomoses: A clinical technique. Plast Reconstr Surg. 1973;52:111–117.
4. Hansen ST Jr.. The type-IIIC tibial fracture: Salvage or amputation. J Bone Joint Surg Am. 1987;69:799–800.
5. MacKenzie EJ, Bosse MJ, Kellam JF, et al. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma 2002;52:641–649.
6. Chung KC, Shauver MJ, Saddawi-Konefka D, Haase SC. A decision analysis of amputation versus reconstruction for severe open tibial fracture from the physician and patient perspectives. Ann Plast Surg. 2011;66:185–191.
7. Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347:1924–1931.
8. Momoh AO, Chung KC. Measuring outcomes in lower limb surgery. Clin Plast Surg. 2013;40:323–329.
9. Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower extremity trauma: Trends in the management of soft-tissue reconstruction of open tibia-fibula fractures. Plast Reconstr Surg. 2006;117:1315–1322; discussion 1323–1324.
10. Stranix JT, Lee ZH, Jacoby A, et al. Not all Gustilo type IIIB fractures are created equal: Arterial injury impacts limb salvage outcomes. Plast Reconstr Surg. 2017;140:1033–1041.
11. Townley WA, Urbanska C, Dunn RL, Khan U. Costs and coding: Free-flap reconstruction in lower-limb trauma. Injury 2011;42:381–384.
12. Ahlman JT, Attale T, Bell J, et al. Current Procedural Terminology: CPT 2018 Professional Edition. 2018.Chicago: American Medical Association Press;
13. Higgins TF, Klatt JB, Beals TC. Lower Extremity Assessment Project (LEAP): The best available evidence on limb-threatening lower extremity trauma. Orthop Clin North Am. 2010;41:233–239.
14. Aravind M, Shauver MJ, Chung KC. A qualitative analysis of the decision-making process for patients with severe lower leg trauma. Plast Reconstr Surg. 2010;126:2019–2029.
15. Shammas RL, Mundy LR, Truong T, et al. Identifying predictors of time to soft-tissue reconstruction following open tibia fractures. Plast Reconstr Surg. 2018;142:1620–1628.
16. Wilson E. Landmark papers in reconstructive lower limb trauma surgery have raised more questions than they have answered. Internet J Surg. 2006;10:1–4.
17. Tampe U, Weiss RJ, Stark B, Sommar P, Al Dabbagh Z, Jansson KA. Lower extremity soft tissue reconstruction and amputation rates in patients with open tibial fractures in Sweden during 1998-2010. BMC Surg. 2014;14:1–7.
18. Culliford AT IV, Spector J, Blank A, Karp NS, Kasabian A, Levine JP. The fate of lower extremities with failed free flaps: A single institution’s experience over 25 years. Ann Plast Surg. 2007;59:18–21; discussion 21–22.
19. Lerman OZ, Kovach SJ, Levin LS. The respective roles of plastic and orthopedic surgery in limb salvage. Plast Reconstr Surg. 2011;127(Suppl 1):215S–227S.
20. Levin LS. Discussion: Long-term patient-reported outcomes following free flap lower extremity reconstruction for traumatic injuries. Plast Reconstr Surg. 2018;141:784–785.
21. Gans I, Baldwin KD, Levin LS, et al. A lower extremity musculoskeletal and vascular trauma protocol in a children’s hospital may improve treatment response times and appropriate microvascular coverage. J Orthop Trauma 2015;29:239–244.
22. MacKenzie EJ, Bosse MJ. Factors influencing outcome following limb-threatening lower limb trauma: Lessons learned from the Lower Extremity Assessment Project (LEAP). J Am Acad Orthop Surg. 2006;14:S205–S210.
23. Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg. 2008;122:1796–1805.
24. MacKenzie EJ, Bosse MJ, Kellam JF, et al. Early predictors of long-term work disability after major limb trauma. J Trauma 2006;61:688–694.
25. Laferrier JZ, Gailey R. Advances in lower-limb prosthetic technology. Phys Med Rehabil Clin N Am. 2010;21:87–110.
26. Valerio IL, Dumanian GA, Jordan SW, et al. Preemptive treatment of phantom and residual limb pain with targeted muscle reinnervation at the time of major limb amputation. J Am Coll Surg. 2019;228:217–226.
27. Bowen JB, Wee CE, Kalik J, Valerio IL. Targeted muscle reinnervation to improve pain, prosthetic tolerance, and bioprosthetic outcomes in the amputee. Adv Wound Care (New Rochelle) 2017;6:261–267.
28. Mundy LR, Truong T, Shammas RL, Gage MJ, Pomann GM, Hollenbeck ST. Acute treatment patterns for lower extremity trauma in the United States: Flaps versus amputation. J Reconstr Microsurg. 2017;33:563–570.
29. Rinker B, Amspacher JC, Wilson PC, Vasconez HC. Subatmospheric pressure dressing as a bridge to free tissue transfer in the treatment of open tibia fractures. Plast Reconstr Surg. 2008;121:1664–1673.
30. Rinker B, Valerio IL, Stewart DH, Pu LL, Vasconez HC. Microvascular free flap reconstruction in pediatric lower extremity trauma: A 10-year review. Plast Reconstr Surg. 2005;115:1618–1624.
31. Vasconez HC, Nicholls PJ. Management of extremity injuries with external fixator or Ilizarov devices: Cooperative effort between orthopedic and plastic surgeons. Clin Plast Surg. 1991;18:505–513.
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