Reconstruction of Gustilo type IIIC tibial open fracture caused by shotgun injury using combination Masquelet technique and cross-leg pedicle flap

INTRODUCTION: The shotgun injury may cause large-scale bone and soft tissue destruction especially when people get shot from a very close range. Here we present a case of Gustilo type IIIC open fractures of the proximal tibia with vascular injury, large bone and soft tissue defect treated with Masquelet technique in combination with cross-leg pedicle flap. PRESENTATION OF CASE: A 34-year-old man presented with open proximal tibial fracture of Gustilo type IIIC, AO/OTA (Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association) classification 41-C2.3, caused by a shotgun injury from very close range (2 m). The wound was complicated with anterior tibial artery injury and segmental bone loss. After radical debridement, the fracture was temporarily stabilized with external fixator, followed by double plate fixation with cement spacer filled into the bone defect in accordance with the Masquelet technique. The soft tissue defect was covered with a cross-leg pedicle flap. At 3 months after trauma, the cement spacer was replaced by mixed autologous and synthetic bone graft. The fracture had successfully healed by 12 months after trauma. DISCUSSION: When the integrity of lower leg vessels is doubtful, the Masquelet technique in combination with cross-leg pedicle flap is an effective and safe alternative treatment for this condition. CONCLUSION: We recommend to manage Gustilo type IIIC open fractures of the proximal tibia with bone defect with Masquelet technique in combination with cross-leg pedicle flap especially when the free flap technique is relatively contraindicated or trauma surgeon is not a highly-skilled microsurgeon.