Reconstructive strategies for lower one third leg soft tissue defect

INTRODUCTION; Increasingly, urban trauma is becoming a major health care issue. Large emergency departments are inundated with patients with multiple injuries, requiring state-of-the-art care. Most of these complex injuries involve trauma to the extremities, often due to motor vehicle accidents. In a study by MacKenzie et al. It was shown that lower extremity injuries accounted for about 40% of the charges for motor vehicle trauma treatment in a given year. Hospital-based studies reveal that disabilities persist for a long time with mean time taken to return to work ranges from 42 months to120 months. Coverage of soft tissue defect of the leg presents unique defects requiring the ingenuity of the surgeon in planning flaps for stable coverage. Though well established norms are in place regarding the time and nature of cover, it requires a team effort, practicing it with involvement of the orthopaedic surgeon and allied specialities like vascular surgeons, general surgeons. The relatively unprotected antero-medial portion of tibia results in exposed bone after trauma, which requires specialized soft tissue cover. Most muscles become tendons at this level hence flap cover becomes mandatory in case of soft tissue loss. We must periodically reassess our own work, chart our future developments, and summarize them for the benefit of all involved in patient care. It was with these concepts in mind that this study was conceived and planned. AIM: 1. To evaluate various reconstructive options for management of lower 1/3rd leg soft tissue defect and to highlight their merits and demerits. 2. To establish a definitive time based protocol in managing these patients. 3. To formulate an algorithm for treating patients requiring flap coverage for lower 1/3rd leg soft tissue defect at Government Rajaji Hospital, Madurai. MATERIALS AND METHODS: This study was conducted in the Department of Plastic Surgery, Government Rajaji Hospital, Madurai over a period of 30 months from Aug 2010 to Jan 2013. Only cases with soft tissue defect of lower 1/3rd leg requiring flap cover i.e defects with tendon, bone or implant exposed or in patients undergoing staged procedures were included in this study. A total of 73 patients were included in the study. Timing of coverage was classified into Acute - within 72 hours, Subacute - 3 days to 6 weeks, Chronic - Greater than 6 weeks. Defects were classified according to their site as per the usual norms of upper third, mid third and lower third. Inclusion criteria: All patients with post traumatic soft tissue defects of the lower 1/3rd leg who required a soft tissue cover were included in the study Exclusion criteria: Patients with degloving injuries, arterial injury, head injury, abdominal injury, thoracic injury, bony injuries elsewhere, brachial plexus injuries and patients who were not willing to participate in the study and for whom skin graft was planned were excluded from the study. Methodology: All the patients included in the study were admitted to the trauma ward under the care of the attending orthopedician and received first aid. They were then resuscitated to minimize bleeding, restore airway and correct shock. OBSERVATIONS AND RESULTS: The age of patients ranged from 10 to 70 years in this study. Common age group affected is between 21 to 30 years and 41 to 50 years, 19% each, n=14. Male to female ratio is 7: 1 (M = 64, F = 9). The most common indication for flap cover was exposed tibia (71%), followed by exposed tendon 21% and exposed Implant 8%. The most common size of defect was small i.e, less than 30 cms2 (51%), followed by medium sized defects 30 to 90 cms2 (40%) & Large defects greater than 90 cms2 (9%). The most commonly performed procedure is the inferiorly based fasciocutaneous flaps (45%), followed by reverse fasciocutaneous flaps (32%). Inferiorly based fasciocutaneous flap from lateral side(79%) was the most commonly performed fasciocutaneous flap because of the presence of reliable and constant perforator. Inferiorly based Fasciocutaneous flaps is the most common procedure performed for small to medium sized defect. Neurofasciocutaneous flaps are excellent choice for medium to large size defect. We have done a muscle flap for smaller defect Propeller flap was done in one patient with small defect. Free flaps were done in three patients with large sized defects. The average duration of hospitalization was least for fasciocutaneous flaps – (57% of patients were discharged within 10 days) and longest for pedicled Neurofaciocutaneous flaps and free flaps (2 to 5 weeks). Of the 46 patients who rated the reconstruction as Good, 26 (57%) had underwent distally based fasciocutaneous flap from lateral side, 12 (26%) had underwent distally based reverse neurofasciocutaneous flap of them rated the reconstruction as good, 2 islanded RSA, 1 muscle flap, 1 propellar flap, 1 ALT and 1 LD. Of the 5 patients who had rated the reconstruction as poor 3(60%) had underwent distally based reverse neurofasciocutaneous flap and 2 (40%) distally based fasciocutaneous flap. 70% of patients graded the reconstruction as Good, 23% as Fair and 7% as poor. CONCLUSION: Though Free flaps are the gold standard for coverage of lower 1/3 leg soft tissue defects, distally based fasciocutaneous flaps and distally based reverse neurofaciocutaneous flaps are still very useful in a set up like ours where sophisticated instruments, prolonged theatre time, back-up anesthesia team for re-exploration is not available all the time , and also because of the long wait list of trauma patients for surgery as ours is a tertiary care centre. Fasciocutaneous flaps are reliable, safe, and fast to learn