Reconstructive Strategies in Soft Tissue Coverage of Leg: A Prospective Descriptive study

INTRODUCTION: Since the earliest of our ancestors started walking in the upright position and freed the upper extremity to develop dexterity and finesse, the leg has gained importance as an organ that supports the whole body weight and that allows humans to stand up, walk, run, jump, and climb. The lower extremity has borne the brunt of injuries which also accompanied man’s march towards the modern age ranging from the industrial accidents to road traffic injuries to warfare injuries to the present day problem of victims of mines and terrorist attacks. WHO estimates that 100% of severe, 50% of moderate and 10% of mildly injured persons need long term rehabilitation services.1 Hospital-based studies reveal that disabilities persist for a long time with mean time taken to return to work ranges from 42 months to 120 months.2,3 Census 2001 and the National Sample Survey Organization estimate that nearly 2% of the Indian population is disabled.4 Injuries are responsible for nearly one third of all disabilities and Road Traffic Injuries contribute nearly half of them.5,6 It is estimated that nearly 3.5 million people in India have a disability from injuries with about 2 million being due to Road Traffic related disability. Treatment of high energy lower extremity trauma with soft tissue and bone injury remains a formidable problem. Treatment requires a team approach with the orthopedic, vascular and plastic surgeon. The goal in treatment of open tibial fractures and lower extremity salvage is to preserve a limb that will be more functional than an amputation. AIMS AND OBJECTIVES: 1. The aim of the study is to evaluate the different reconstructive options for management of leg defects. 2. The study also aims to develop an algorithm for soft tissue coverage in different parts of the leg. MATERIALS AND METHODS The study was a prospective descriptive study conducted in the Department of Plastic and Reconstructive Surgery of Thanjavur Medical College from January 2009 to December 2010. The patients were assessed clinically and included in the study according to the inclusion and exclusion criteria mentioned below. Inclusion Criteria: All patients with post traumatic defects of the leg including the non weight bearing heel 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 were excluded from the study. Patients for whom skin graft was planned were also excluded from the study. CONCLUSION: Small defects of the upper third of leg can be successfully reconstructed using local random pattern flaps. For complex defects in the upper third of the leg, the gastrocnemius muscle flap is a reliable flap with a good range of movements allowing it to reach most aspects of the upper third of the leg. The next option that is available if gastrocnemius is not available is proximally based fasciocutaneous flaps. Regarding defects of the middle third of the leg, the proximally based fasciocutaneous flap is the flap of choice followed by the inferiorly based fasciocutaneous flap, Free flaps are ideal if local tissue is not available, however cross leg flap is another excellent choice for large defects in spite of its drawbacks like inconvenience, discomfort and hospitalization for four weeks which were relatively insignificant as compared with the benefits achieved. For the distal third of the leg, the distally based sural neurofascicutaneous and saphenous neurofascicutaneous island flap is an excellent choice for reconstruction of lateral and medial defects respectively. Inferiorly based fasciocutaneous flaps should also be considered. Larger defects in the distal third are an indication for free flap transfer or cross leg flaps. In conclusion we emphasize the importance early through debridement and involvement of the plastic surgeon from the day of injury will facilitate early reconstruction which will enable the patient to return to work early. As of co-operation at the time of primary surgery between orthopedic and plastic surgeon will preserve potential flap options by avoiding placement of pins at sites that would endanger a potential flap or restrict its movement. Finally, the following algorithm may be proposed as a protocol for the management of leg defects