A study to assess the functional and aesthetic outcome of soft tissue reconstruction of leg and foot defects using conventional and microvascular free flap techniques

INTRODUCTION: High energy lower extremity trauma1 with extensive injury and associated multiple bony injuries remains formidable problem in management. In trauma with multiple injuries the management is even more difficult. Pedestrian motor vehicle accidents, fall from heights, and sports injuries result in open tibial fractures that require complex bone and soft tissue management. The management of lower- extremity trauma has evolved over the last two decades to the point that many extremities would have required amputation are now routinely salvaged. Treatment requires a team approach with the orthopedic, vascular and plastic surgeons as part of the team. Fracture management has improved techniques of external fixation, intramedullary rodding and internal plating, bone grafting. Soft tissue management includes grafts, local muscle flaps, fascio-cutaneous flaps and micro vascular free flaps. The goal in treatment of open tibial fractures and lower extremity salvage is to preserve a limb that will be more functional than if it is amputated. Patients must be made aware of the expected course and anticipated functional outcome. AIMS OF THE STUDY: 1. To analyze the various sites of leg and foot defects. 2. To study different age and sex distribution. 3. To study various types of flaps done under each category of conventional and microvascular techniques. 4. To analyze the functional assessment and esthesis of reconstruction in two methods. 5. To study the complications. MATERIALS AND METHODS: All the patients who reported to the plastic surgical department, Govt. Stanley Medical College Hospital, who were presented with soft tissue defects of leg and foot were included in the study. The period of study: September 2010 to August 2012. The patients were referred from orthopedic, general surgery or came directly to plastic surgery department. All soft tissue defects of leg and foot due to trauma reconstructed using conventional and microvascular free flap techniques are included. Injuries to leg and foot with bone / tendon / nerve loss needing composite reconstruction are excluded. All the patients were analyzed according to the nature of injury, age and sex distribution, sites of defects, investigations and treatment planning. On follow up they were analyzed for functional outcome by Gait analysis, Range of movements, sensibility and aesthesis. The duration of time for return to work after reconstruction was analyzed in both forms of reconstruction. CONCLUSION: Local flaps are the mainstay of reconstruction for leg and foot for smaller defects. Local flaps give good results in functional as well as aesthesis. The duration of hospital stay is less and return to work is early for local flaps when compared to distant and free flaps. Larger defects exposing vital structures for which local flaps unavailable, free flaps are the main modality of reconstructive option. Free temporoparietal fascial flaps and free latissimus dorsi muscle flaps give good functional outcome and aesthesis for dorsum foot defects compared to bulky free anterolateral thigh flaps. Early wound coverage within a week mitigates infection, less hospital stay and enhances productivity of individual. Achievement of bipedal gait is earlier in sensate and less bulky flaps. The use of Doppler comes handy as far as designing local flaps. The conventional flaps are mainly used for male patients with all age groups except distant flaps. The distant flaps are more suitable for paediatric age groups. The free flaps are more used in paediatric and as well as younger age male patients. The acceptance of foot wear is good in cases of local flaps, thin fascial and muscle flaps