[Concept for the management of combined bone-soft tissue defects of the lower extremity]

Severe crush injuries of lower limbs with loss of bone and soft-tissue need a clear concept of treatment. After resuscitation the examination and restitution of the injured limbs blood supply has absolute priority. Function of the tibialis posterior nerve plays an important role in the decision-making between amputation or reconstructive procedure. Long term healing is strongly influenced by the correct debridement. After stabilisation crushed soft-tissue and disintegrated bone fragments are removed. Second look operations are performed every 24-48 hours until a clean and good vascularized wound can be guaranteed. The coverage with a local or free muscle flap should be performed within 96 hours. The reconstruction of desteroid nerves is done secondary by nerve transplantation, except in case of primary replantation. Immediately after coverage of the soft-tissue defects the reconstruction of the bone defect is started. The method depends on the degree of bone loss and includes bone grafting, callus distraction or bone segment transports with unilateral fixators. The patients qualification for a reconstructive procedure has to be examined seriously.