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High-energy open fractures of the tibia are frequently associated with tissue loss, wound contamination, and compromised vascularity that often result in amputation. The management of these severe injuries remains a challenge for orthopedic reconstructive surgeons. Studies have compared the timing of soft tissue coverage of Gustilo type IIIB open tibia fractures with associated outcomes such as rate of deep infection, primary union, length of hospitalization, flap failure, and eventual secondary amputation. These studies often highlight better outcomes with specific time domains that are not always attainable at a large tertiary hospital with multi-system trauma patients. Many studies do not account for delayed patient transfers after initial open fracture management elsewhere. This retrospective analysis of the limb salvage outcomes included 140 consecutive patients with Gustilo type IIIB open tibia fractures who presented to the authors' level I trauma center between 2001 and 2014. The authors included patients who required delayed coverage or who were transferred from outside institutions. The majority (77%) were male, and the mean age was 39.4 years. Motor vehicle accidents were the most common cause of injury, and 83% of patients obtained full weight-bearing status with successful limb salvage. Twenty patients had a secondary amputation, with the cause being refractory osteomyelitis in 52%. This study provides guidance on treating a heterogeneous patient population with severe open tibia fractures typically seen in a large tertiary hospital orthopedic trauma service. [ Orthopedics . 2019; 42(5):260–266.]

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Summary: We present the case of a 65-year-old woman with extensive osteoradionecrosis of the scalp and calvaria after external beam radiation therapy for follicular lymphoma. Due to the compromise of her adjacent vasculature including the superficial temporal vessels, she underwent two-stage reconstruction with the creation of an AVL (arteriovenous loop) graft utilizing her great saphenous vein. This was anastomosed to her right facial artery and vein, which was then matured. She underwent resection of the necrotic portions of calvaria and soft tissue of approximately 180 cm2, and a vascularized free latissimus dorsi muscle flap was harvested and anastomosed to her new conduit. This free muscle flap was then covered with a split-thickness skin graft harvested from her thigh. She achieved satisfactory functional and cosmetic results with minimal morbidity and without complication despite her age, multiple co-morbidities, and extensive and complex disease process.