An Analysis in Reconstruction of Traumatic Defects of Leg and Foot

INTRODUCTION: Management of lower extremity trauma with bone and soft tissue injury remains a formidable problem. Road traffic accidents, fall from height, sporting injuries and Gun shot injuries are the common causes for traumatic defects of leg and foot. Treatment of lower extremity has evolved over the last two decades to the point that many extremities that would have required amputation are now routinely salvaged. Treatment requires a team approach with the orthopedic, vascular and plastic surgeon. Classification of the severity of wounds given by Gustilo have allowed us to make an appropriate plan for reconstruction and also to be aware of the eventual prognosis. Fracture management has improved over the recent years by external fixation, intra medullary rodding and Internal plating, bone lengthening, artificial bone matrix and bone growth factors. Soft tissue management has improved over the recent years with a better understanding of local fasciocutaneous flaps, local muscle flaps and micro vascular free tissue transfers and also, the technique of vascular and nerve repair has been further refined. Extremity salvage is a long complicated process. so patients must be made aware of the expected course and the anticipated functional outcome. The goal of the reconstructive surgeon must be to salvage an extremity that is more functional than an amputated leg with prosthesis. We plastic surgeons have helped to bring about a fundamental change in the management of severe lower extremity injuries through new advances in soft tissue reconstruction, micro vascular replantations, nerve repairs and comprehensive planning of reconstructive problems. AIM OF STUDY: ● To analyze various reconstructive options for traumatic defects of leg and foot. ● To analyze the incidence, age, sex and etiology of the traumatic defects of leg and foot. ● To study the versatility of various flaps used in the reconstruction of traumatic defects of leg and foot. MATERIALS AND METHODS: This study was conducted in the Department of Plastic Surgery, Govt. Kilpauk Medical College hospital and Govt. Royapettah hospital over a period of 24 months. (July 2003-June 2005) All the cases with traumatic defects of leg and foot were included in this study. No specific selection criterion was used. A total no of 294 patients were included in this study. A careful history was taken looking in to the etiological factor, type of treatment at the time of injury-by a general surgeon or an orthopaedician. Each patient was subjected to thorough clinical examination to asses the present status of the wound. All patients underwent baseline investigations like Blood Hb, urine albumin, sugar and deposits, Blood urea and sugar, X-ray chest and ECG. X-ray of local part was taken as and when necessary. Pus for culture and sensitivity was sent only for cases with signs of infection. An orthopedic consultation was taken for cases, which needed orthopedic intervention at the time of surgery. Vacuum assisted closure system was used in a few cases with gross infection and a nonhealing tendency. Defects of leg and foot were classified into knee defects, upper third leg defects, middle third leg defects, lower third leg defects, ankle defects and foot defects for ease of discussion and arriving at conclusions All the patients were kept under continuous follow up till the wound heals completely. Then follow up was done according to the needs of the individual patient. OBSERVATION AND RESULTS: A total number of 294 patients were included in this study and treated. there is uniformity in the number of cases coming to the department with these defects every year. Children account for only 10% of cases. Most of the cases with traumatic defects of leg and foot are seen in males who account for 73% of cases. Females present less frequently and account for only 17% of cases. Road traffic accidents are the commonest cause for traumatic defects of leg and foot followed by fall from height and others. Middle third defects are less common when compared to upper third and lower third leg defects. Lower third defects and ankle defects are almost equal in occurrence. Foot defects are half that of lower third leg and ankle defects. Ankle defects have presented in variety of ways: Anterior, Posterior, Medial and Lateral defects. Toilet injuries are almost equal in occurrence to traumatic defects in ankle. Foot defects have presented as dorsal defect, plantar defect or heel pad avulsions. CONCLUSION: ● 294 patients with traumatic defects of leg and foot were treated during the period of July 2003 – June 2005. ● Males account for majority of the patients and RTA was the commonest cause. ● The number of cases are almost the same ever year. So awareness should be created among the general public to reduce the incidence of RTA. ● Upper third and lower third defects of the leg and ankle defects account for most of the cases. ● Problems in reconstruction are mainly encountered in the ankle and lower third leg defects because, local tissue availability is very minimal in these areas. ● Vacuum assisted closure (VAC) system was used in 2 cases and good results were achieved. So in future, VAC can be used for more no of cases. ● Perforator flaps (i.e.) Island fascio cutaneous flaps have negated the need for cross leg and free flaps. Of course there is a necessity for cross leg flap in some extreme situations, but their numbers have been drastically reduced. ● The referral for reconstruction is not done early enough sometimes, and so the residual morbidity of the skeleton makes the reconstruction redundant. ● Antibiotic coverage and anti microbial needs are not standardized yet. ● Ilizarov fixation is still a bugbear for reconstruction. Restricted operative field makes the surgery difficult and sometimes it becomes necessary to redo the whole reconstruction. ● Free flaps have not been taken up in the right earnest, probably due to logistics, but in future we are trying to do free flaps, which will ultimately improve our armamentarium