Complex Lower Extremity Limb Salvage After Open Tibial Fracture Utilizing Ovine Forestomach Matrix Graft for Rapid Granulation over Exposed Bone: A Case Report

Introduction: Open tibial fractures can lead to amputation, which affects patients physiologically and psychologically1 and increases the one-year mortality rate by 47.9%.2 Ovine forestomach matrix (OFM) has been utilized for limb salvage and reconstruction. This case details a pa- tient with a severe open tibial fracture complicated by peripheral arterial disease (PAD) whose limb was salvaged using OFM as part of a multidis- ciplinary treatment protocol. Methods: A 72-year-old female with severe PAD presented with a left proximal tibial fracture, large overlying laceration, and exposed bone after falling. Following initial external fixation then staged tibial open reduction and internal fixation, Orthopaedics consulted Plastic Surgery for soft tissue coverage of the open fracture. Non-palpable distal left lower extremity pulses prompted duplex ultrasonography, revealing se- verely diminished arterial velocities and total occlusion of the superficial femoral artery. Interventional cardiology was consulted and common femoral artery atherectomy was performed, greatly improving arterial in- flow. A partially adipose-replaced medial gastrocnemius flap was rotated over the fracture and exposed tibial hardware. Limited muscle flap size prevented a portion of the tibia from being covered. After complex partial wound closure, a central portion of the flap and periosteum-covered tibia remained exposed due to skin shortage. OFM morselized fine graft was applied over the uncovered central wound and tibia to encourage rapid granulation, followed by negative pressure wound therapy (NPWT). Results: Four days post-surgery, the patient returned to the operating room. The gastrocnemius flap remained viable and intact, and the OFM had achieved enough granulation to support split-thickness skin grafting. NPWT was applied. The patient was transferred to a long-term acute care hospital (LTACH) for ongoing NPWT and wound management and had full take of the graft and flap. Minor superficial wound dehiscence occurred but is healing well with conservative care. Discussion: Without a comprehensive, coordinated multidisciplinary team including Orthopaedic and Plastic Surgery, interventional cardiol- ogy, and LTACH practitioners, this patient likely would have undergone above-knee amputation. Avoiding free tissue transfer reduced procedure complexity and anesthetic risk. This case demonstrates OFM’s efficacy in limb salvage for complicated open fractures while highlighting the impor- tance of readily accessible, multidisciplinary care in such injuries.