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The Open Orthopaedics Journal, 2014, 8, (Suppl 2: M5) 423-432 423

Open Access
Flap Decisions and Options in Soft Tissue Coverage of the Lower Limb
Daniel J. Jordan1, Marco Malahias2, Sandip Hindocha*,1 and Ali Juma3

1
Department of Plastic Surgery, Whiston Hospital, Liverpool, UK L35 5DR, UK
2
Department of Plastic Surgery, Heart of England NHS Foundation Trust, UK
3
Department of Plastic Surgery, Countess of Chester Hospital, Chester, UK

Abstract: The lower extremities of the human body are more commonly known as the human legs, incorporating: the
foot, the lower or anatomical leg, the thigh and the hip or gluteal region.
The human lower limb plays a simpler role than that of the upper limb. Whereas the arm allows interaction of the
surrounding environment, the legs’ primary goals are support and to allow upright ambulation. Essentially, this means that
reconstruction of the leg is less complex than that required in restoring functionality of the upper limb. In terms of
reconstruction, the primary goals are based on the preservation of life and limb, and the restoration of form and function.
This paper aims to review current and past thoughts on reconstruction of the lower limb, discussing in particular the
options in terms of soft tissue coverage.
This paper does not aim to review the emergency management of open fractures, or the therapy alternatives to chronic
wounds or malignancies of the lower limb, but purely assess the requirements that should be reviewed on reconstructing a
defect of the lower limb.
A summary of flap options are considered, with literature support, in regard to donor and recipient region, particularly as
flap coverage is regarded as the cornerstone of soft tissue coverage of the lower limb.
Keywords: Flap, lower limb, reconstruction.

1. THE LOWER LIMB Originally lower limb reconstruction was required as an
alternative to amputation, which was the principal treatment
The leg consists of four main regions before attaching to
for war injuries. Amputation allows for the removal of
the pelvis.
necrotic tissue and infection, with the aim of saving the
Working proximally, these are: the foot, the lower or victim’s life, but can sacrifice potential function and
anatomical leg (from the ankle to knee), the thigh (knee to rehabilitation. Since World War I, major developments in
hip) and the hip or gluteal region. Primarily, the four areas applied anatomy, fracture management, wound care and
work together to aid balance and support, which, in turn, sterile techniques, as well as the introduction of antibiotics
allow a human to stand and walk. and anaesthesia, have allowed surgeons to consider the role
Evolution has forced the lower limb to gain this distinct of limb salvage, a field which has greatly expanded since its
introduction.
feature, and although bipedal gait is not unique to humans,
an efficient upright locomotion for long durations is. This The field of reconstruction gained a vast number of
adaptation has forced the human leg to become longer and options following the improvement of vascular techniques in
more powerful in comparison with our primate relations, as the 1960s, opening the door to the microvascular
well as change the way in which the muscles and joints of reconstruction era.
the leg interact and function [1].
Today, war injuries still make up a proportion of the
The ability of the legs to offer support and allow upright number of people who require access to advanced techniques
ambulation has permitted the adaptation of the upper limb, in the field of lower limb salvage and reconstruction.
the arm, to allow precise interaction with the surrounding However, the scope of injury mechanisms has been added to
environment. with an increasing number of blunt trauma, thanks to
urbanisation and industry, as well as increased diagnosis’ of
2. RECONSTRUCTION OF THE LOWER LIMB: lower limb malignancies and chronic medical conditions,
WHY IS IT NEEDED?
including diabetes and peripheral vascular disease.
The lower limb may need to be restored for multiple reasons. Today’s goal in lower limb reconstruction has not
changed much from those originally cited in the early war
*Address correspondence to this author at the Department of Plastic victims, with restoration, or maintenance of function
Surgery, Whiston Hospital, Liverpool, UK L35 5DR, UK; becoming the essential goal as these injuries became less life
Tel: + 44(0)1244366265; Fax: +44(0)1244366265; threatening. Function involves the need for a stable skeleton,
E-mail: hindocha2001@yahoo.com

1874-3250/14 2014 Bentham Open

This functionality can be reduced by undertaking the procedure in the elective patient. 3. Diabetes and peripheral vascular disease. allowing a quicker As suggested by the scenario above. with adequate soft tissue also becomes important in terms of concurrent injuries. as well as having an impact on DIFFICULT CHOICE? rehabilitation. rehabilitation of the limbs muscles and joints. acute long term rehabilitation required with a complex bone and trauma patient will have a strong influence on what options skin coverage procedure? are used for reconstruction. and a non-healing area due to poor perfusion is unlikely to be successfully grafted. which will be discussed This incorporates the morbidity and mortality risk of later in this paper. as those in crush injuries. with Once the decision of surgical closure of a wound has proprioception and plantar sensitivity key. It may seem obvious that amputation in the 3. secondary healing to primary closure. who will consider the following inputs emphasise the need for a multi-disciplinary team points. then distant. approach to determine the most suitable reconstruction 3. ‘Normal’ function of the limb is then more reliant on the chronic infection or oedema related changes. who may require purely symptomatic relief. The The location of the wound also plays a large role in the patient’s motivation and compliance is critical in the feasibility of reconstruction options. through the options of Angiography is often required. free tissue wound as opposed to the blunt trauma scenario. lower limb wound will often heal adequately as long as the Today there are options to supplement the reconstructive area is reasonably perfused. Physical Examination of the Wound option. life threatening injuries take Wound coverage requires many aspects of the patient’s precedence over everything and the patient will require background and present state to be assessed before making a assessment in a structured way. Patient Expectation: their Desires and Need tissue envelope. RECONSTRUCTION: EASY OPTIONS BUT A potential intensive care stay. This will involve inspecting the wound size and noting the amount of damage and loss to both the skeletal and soft 3. Rehabilitation and Functional End Point younger patient is not preferable. The aesthetic outcome is to the limb involved should be noted. chronic pain and infection. 3] social and psychological factors. ladder. The reconstructive ladder should always be addressed particularly stenosis and artherosclerotic vasculature. Pre injury the form of pharmacological therapies and the use of dementia and ambulation should also be reviewed to engineered materials for wound coverage will become more significant. return of function to a level required by that individual. The bed bound patient in their later years with an Soft tissue coverage is needed to aid an infection free infected diabetic foot and chronic leg ulcer offers a different fracture union. functional restoration or functional improvement? This highlights the need for lower limb reconstruction to Social status pre-injury and potential rehabilitation options be made on an individual basis and involve a must be assessed. determine rehabilitation and compliance with reconstruction.2. preferably within a week of injury [5]. allowing weight bearing status. Trauma Life Support (ATLS) principles [4]. The surrounding tissue functional end point. the latter has a life-time of a scheduled trauma list by an experienced. exploring the patient’s area and distal regions needs to be assessed and may require psychological state is equally important. Comorbidities involving cardiac and respiratory disease may discourage a long general anaesthetic and 3. as well as complications with body mass index.3. but who says that a ‘simple’ amputation and prosthesis. Free flap reconstruction should be performed on traffic incident. such coverage to nourish and protect the underlying bone. chronic wound against the active. Occupational therapist and physiotherapist multidisciplinary team. This progresses from again rule out both donor and wound coverage options.1. as a chronic flaps. is worse than the potential the bed bound. In the future. In addition. Scars crossing regions also important. reconstructive and vascular free-flap that saves a patient’s foot is almost wasted if the professions. A complication free the input of orthopaedic. will when considering closure of wounds. it is hoped that adjuncts in options. but this should never take priority over the involving local and distant flaps options may rule out these limb’s ability to function. radiotherapy fields in malignancy. patient automatically rejects the rehabilitation phase. becomes whether you offer both. or either. the rehabilitation of return to work and normality. Potentially. This should ultimately be completed at the challenge to that of the 28 year old with an open fracture. Is the procedure for symptom relief. nutritional state is strongly influential on both well as tissue expansion or prefabrication of tissue. Volume 8 Jordan et al. before a chronic wounds and the healing of the wound coverage definitive surgery. 2014. particularly in the chronic grafting to the more complex local. Patient age. the vascular supply to both the Encompassing the above. appropriate debridement must be undertaken End points of reconstruction are also measured by a before a final coverage option is chosen. The appearance of the reconstruction .424 The Open Orthopaedics Journal. as Likewise. been made. choices out. salvage or amputation. The difficult choice then surgical team in a specialist centre. For the emergency patient. dedicated senior earning and dependants as opposed to the former. as defined by the Advanced decision on the most suitable option. Options become dependent on a balance of anatomical. their smoking status and previous injuries chronic swelling or wound healing. Patient Assessment [2.4. This will involve dietician support. with the use of negative pressure wound therapy. same time as bony fixation if simple or local flap closure is massive skin loss and vascular damage following a road achievable. Good progress during early rehabilitation can also determine the successful return of normality for the patient.

Random pattern cutaneous flaps are limited by the • Cost of care arc of rotation and decreased bacterial resistance. has permitted the use of longer flaps. As our understanding continues to develop. a high percentage and free flap descriptions. and will need individual closure and local flap coverage. when offered. • Potential complications Other options for local flaps to aid take have included Once these areas have been appropriately assessed and delayed transfer. the patient resulting in further tissue and bone loss. end point involving amputation. The reconstructive ladder offers a list of options in terms The discovery of random pattern skin flaps led to an in surgical closure of the wound. but the 1981. or where more complex reconstructive failure introduce new circulation to the area and offer a more would be disastrous [8]. They also required. 2014. require their blood supply to be intact from the injury. also allowed reliable flap creation. assessment. In general flaps can be described of patients (93%) would prefer a limb salvage procedure in based on the blood supply to the flap. a failed technique in transposition of either the muscle or a musculocutaneous lower limb reconstruction can have a devastating effect on block supplied by the muscle’s dominant vascular pedicle. which essentially involves detaching a specialist skin to a region (hair bearing for instance). the best with or without skin. it has been noted that Both of these options require an adequate blood supply to both true and ‘choke’ anastomoses exist between the the wound area and relatively reliable surrounding tissue. the pedicled flaps are restricted by their arc of rotation. and as an option in the chronic wound. On top of the above pre. Likewise. as well as grafting of a fasciocutaneous flaps based along specific dominant vascular wound are well documented options and should be attempted pedicles have allowed the direct transfer of tissue which is in both the simple wound. involving abdominal flaps being transferred to a options will be made and offered to them. but are not limited by: supply. the location of the the traumatic scenario to avoid undergoing amputation [6]. donor site on the arm before final transfer to the leg. something which was greatly increased compared to Another option using the nearby soft tissue envelope random pattern skin flaps. sural vessels.2. fascia and combinations of these. it is important to ensure the patient has a close support system. perforator angiosomes allowing longer flaps to be more Where the blood supply is poor. musculocutaneous and Primary and delayed closure. with these ‘local independent and maintain or improve their ambulatory status flaps’ designed using tissue local to the wound. Flap reconstruction options can be broken down to local It has been reported that. In reconstructive option is often not the easiest choice. texture and colour and offers provision of of free flap surgery. They will [7]. as well as a general rule of a 2: 1 ratio between the length and base of the • Surgeon’s experience flap used in the lower limb. the use of reconstructive flaps is generally required. This 4. As noted. donor site and the type of tissue being transferred. For this reason. Ponten [9] noted skin survival in a patient correlated choice that has the highest chance of success. a list of potential surgical technique. expectations. This finding was further supplemented by the discovery deterioration of comorbidities and functional deficit with an regarding fascial vascular supply and that the deep fascia. those where expedited recovery is less dependent on the wound bed blood supply. where the flap is perfused by a defined vessel or angiosome. This free flap tissue transfer is often regarded as the cornerstone led him to raise a calf based flap including the fascia and of lower limb reconstruction. bone. Flap Reconstruction closely involved may aid the patient’s recovery. and all options should be discussed in detail by a trained Flaps utilise composite tissue blocks and may include expert to the patient to aid end compliance and balance skin. with operative assessment requirements. the simplest investigation into vascular anatomy and consequently it was option is not always the best option. However.Flap Decisions and Options in Soft Tissue Coverage of the Lower Limb The Open Orthopaedics Journal. The discovery of axial pattern • Donor site disability flaps. reliable and larger wound coverage option. reconstruction The first uses of flap reconstruction initially involved provides a chance for the patient to remain socially movement of skin around pivot points.1. a choice which negates variance in micro-instruments and sutures has allowed the development tissue thickness. This supports patient choice in the reconstructive options. involves periosteum successful [11]. Local cutaneous flaps can be based along random pattern Other factors to be aware of in lower limb reconstruction or axial vascular circulations using the subdermal blood include. 4. includes tissue expansion. whereas free flaps are based along a distant donor site. muscle. RECONSTRUCTION OPTIONS: THE technique is still dependant on the final location wound RECONSTRUCTION environment for the take to be successful. For this reason with a single perfused vessel shown on angiography. An example of this is ‘the arm carrier’ individually tailored to the patient. stripped bone or where there is a requirement of soft tissue depth. Direct Closure and Local Alternatives The use of cutaneous. This known pedicle based tissue composite unit and transplanting technique is limited by the reliability of the surrounding . found that local flaps could involve muscle. The advancement of microscopy. Offering counselling to those 4. prompting a variety of new discoveries in flap options [10]. Volume 8 425 alongside post-operative pain and swelling is interpreted tissue. but may offer a potential donor site for both direct differently by each individual.

2014. haematoma (19.2. particularly in flaps involving muscle components. A skin graft to this site should only be used if the donor flap is of 4. They include: failure of the flap. all open fractures require a complications involving ischial. Free flap coverage has helped reduce the often bulky Direct cutaneous Septocutaneous Musculocutaneous pedicle pedicle pedicle pedicled flap seen. Donor site morbidity Free flap reconstruction offers wound coverage but does should be negligible but could involve a reduction in not improve the distal circulation. This classification is well described in reconstructive literature and summarised in Table 1. Gluteus maximus III Two dominant pedicles Serratus anterior V-Y flaps. a recent literature review reports up to 16% of One dominant pedicle Gracilis flaps suffering partial necrosis.2. infection (22%). . sacral and trochanteric vascularised soft tissue envelope free of infection to allow wounds of 87 complications in 421 (21%). Flap Failure and Complications special significance (superiority in function/shape etc). Flap complications can be wound specific. However. Traditionally the use of local muscle flaps proximally replantation of amputated lower limbs is feasible and may and free flaps distally in the lower limb have been used. There are suggestions that the detection of source.1. particularly in muscle flaps. are another option. whilst a recognised artery or improve the sensitivity of current Doppler and anatomical group of arteries forms an axial based flap. as described by Blasius in 1848 [30]. vasculature [16].3%) noted The use of Negative Pressure Wound Therapy (NWPT) [18]. of revascularisation of critical limb ischaemic wounds with Pressure ulcer coverage is particularly complicated. Random pattern cutaneous flaps can be limited by their The classification of flaps can be described by the vascular vascular input. at the reconstructed site. a pedicle based perforator flap. involving partial or wounds with 85% flap survival and 100% limb salvage rate. One paper quotes flap In the traumatic scenario. 14]. Microsurgery has allowed the direct transfer of large Table 2. allowing wounds to be covered and reconstructed based on flap suitability rather Type A B C than wound proximity. it to the wound area and anastomosing it to a suitable The blood supply to fascial based flaps has also been receptor artery and vein in proximity to the wound. as is the keystone flap [32-34].1. tissue units from distant donor sites. It also allows direct closure in the majority of the donor regions. particularly around the ankle and lower leg Sartorius and can provide a sensate flap to the region [31]. The variation in landmark techniques [21].2. As noted random pattern flaps have no specific perforators can be made by using thermal imaging to named vessels supplying them. there are reports function. their use throughout the limb [20]. 4.5%). with a third of them II and minor pedicles Soleus involving the whole flap [29]. can temporarily be used as a substitute for definitive flap coverage [5]. The propeller flap. total necrosis. offering an option in forefoot cover [28]. It provides good form and function for elective and Tensor fascia lata I One vascular pedicle Gastrocnemius traumatic defects. Flap Vascular Anatomy 4. with suture line appropriate bone healing. dehiscence (31%). haematoma and seroma collections (for which This technique helps with the problem of exposed functional the use of post-operative drains is not uncommon) and tissues when the wound is debrided [12]. their continued viability is improved. become a reliable option with improved results in the future although improvement in local flap reliability have allowed [15]. IV Segmental pedicles Extensor halluces longus Bi-pedicle flaps are random pattern flaps but.426 The Open Orthopaedics Journal. Choice of Reconstruction: The Flap Options [19] With the improvement of microvascular techniques. 4. with the peroneal and posterior tibial artery perforators being commonly used Type Pedicle Example [23-27]. lower limb. Local Flap Reconstruction The blood supply of the raised flap is key to its survival. Fascia/fasciocutaneous flap classification [17]. thermal imaging axial blood flow into different muscles is complex and may help locate the ‘choke’ anastomoses which help aid flap Mathes and Nahai attempted to subclassify this form of flap perfusion and drainage [22]. due to two One dominant and Latissimus dorsi V secondary segmental pedicles Pectoralis major pedicles.3. classified in Table 2. Muscle/musculocutaneous flap classification [16]. vary from Igari et al. free flap coverage being offered as a single procedure with usually due to issues regarding the continuation of pressure reasonable results [13.3. Volume 8 Jordan et al. wound dehiscence and infection. report end to side and end to end anastomosis reconstructive unit to unit and are dependant on the flap of latissimus dorsi free flaps to the vascular graft on these used. is well documented as an option for the majority of coverage in the Table 1. particularly below the knee. However. In particular. They are a flap gaining popularity for closure of lower limb wounds.7%) and total necrosis (10. partial necrosis (13.

Flap Decisions and Options in Soft Tissue Coverage of the Lower Limb The Open Orthopaedics Journal. the degree of versatility. Fasciocutaneous Flaps Being the largest muscle of the body and having both two 4. Able to reach the umbilical Typically using the anterior septocutaneous artery and region. and long fascial extension allows this flap to be used in a 4. possibly helping to reduce 4. thanks to an extended pedicle. an increased risk of substantial ankle flexion weakness 4. to cover defects in the proximal lower limb.3.3. Gracilis vein can be utilised to aid venous drainage as well as A pedicled and innervated gracilis flap is useful in keeping a sensate flap when the medial anterior cutaneous perineal and ischial coverage but its relative lack of nerve of the thigh is raised.2. These can incorporate either only muscle or muscle and skin coverage options. Gastrocnemius being reversed.1. The saphenous 4. with afforded by flaps raised using the rectus femoris muscle for hip and proximal thigh defects.3.3. gross contour changes in its final location. exploit the profunda femoris perforating branches. fractures. Useful for distal flaps of up to 12 x 20cm can be raised.3.5.2. A type A fasciocutaneous flap skin along the lateral or medial sural arteries.3. Soleus is used for proximal regions including the trochanteric and Used for defects of the middle third of the lower leg [39].1. The short venous supply to the preserving function [38] and tissue to cover either anterior or region also causes an increased risk of flap failure.3. is soleus can be split to form a hemisoleus flap thanks to its typically used as a free flap.2. The latter will help cover the lower leg cannot be underestimated. perineum. .3. femur.4. as well as musculocutaneous flaps to be raised on separate pedicles. The gastrocnemius flap can only be using the saphenous artery and venae comitantes. Sural alongside loss of lower limb venous return through the muscle. A 7 x 20cm skin paddle can be dual pedicle supply and bipennate morphology [40]. This flap and the antero-lateral thigh flap.3. It allows purely wounds involving the perineum. Due to raised with a tight closure of the donor site. A more employed in scenarios where soleus is intact as rehabilitation difficult dissection than those listed above due to increased and walking are dependant on ankle plantar flexion. ischium and groin it can incorporate skin the venae comitantes from the superficial femoral vessels. The two origins of this muscle allow separate muscle or anterior and posterior and upper third of the leg. has been described as an alternative free flap option experimental data in open tibial shaft fractures or where the [37]. Gluteus Maximus 4. as well as it being an expendable muscle unit in the majority.3. the groin flap allows up to 20 x 10cm 4. proximal foot defects.3. along with free fasciocutaneous flaps. Lateral Thigh its main pedicle.2. lateral femoral circumflex artery.3.3. It is raised from 4.2. local a section of sartorius occasionally taken with the raised fasciocutaneous flaps should be used in low energy tibial tissue to aid flap survival rates.3. 4. Also.2.3. has been used as both a free and pedicled flap [35] perineal and upper thigh regions is achievable. Muscle flaps would be suggested by artery. Saphenous minimally to allow coverage over the Achilles tendon or rotated to the mid tibia thanks to anastomosis across the Coverage of the knee can be achieved by raising this flap muscular raphe. its use has been criticised [41].3. the thin muscle belly with grafting of the donor site. Reliable coverage of the buttock. it may be advanced 4. Often taken using a pedicle from the superficial circumflex iliac artery.3.3. groin flap.4. this flap can also be reversed and includes an osseofasciocutaneous option (from the medial The vastus lateralis muscle provides a musculocutaneus femoral condyle) using the articular branches of the flap which offers no great deficit in ambulation which is not genicular artery [36]. and twice this Useful as a pedicled or free flap. As long as there is no vascular compromise by the 4. Groin dominant and two minor pedicles this allows for a high One of the earliest axial based fasciocutaneous flaps. Muscle and Musculocutaneous Flaps both the healing time and risk of deep infection [15]. this flap can cover defects around the knee. 2014. as well as iliac this flap can be also be raised more anteriorly by using the bone for osteomusculocutaneous coverage. hip. these can be used. Of the three.3. the first 4. ischial areas. Posterior thigh initial injury. with the ability of 4. the medial thigh flap is useful functional deficit on removal means its use as a free flap for both as a free and pedicled flap.3. where it is more commonly referred to as the antero-medial thigh flap. the terminal branch of the medial circumflex femoral artery.5. Volume 8 427 For open fractures of the lower limb. Often from the lateral femoral circumflex artery to allow posterior needing subsequent debulking and due to the fact it is a hair thigh coverage in a reversed technique or off of one of the bearing area this flap can be a poorer aesthetic match gluteal arteries (superior or inferior) with the muscle split compared to other options. proximal tibia and knee coverage. blood supply is compromised.3. in metaphyseal injuries (particularly The posterior thigh flap.2. Raised either providing a substantial amount of both tissue and skin. The sural artery allows probably the longest pedicled fasciocutaneous or fascial flap. based on the profunda femoris around the ankle) [15]. Medial Thigh multitude of scenarios. and the third. Skin paddles 7 x 20cm are typical. Tensor Fascia Lata flaps to be harvested alongside direct closure.2. posterior defects.6. groin and thigh up to 10 x lower limb anaesthesia and its small size does not cause 20cm in size. vascular anatomy variance.2.

67]. Amputation sural fasciocutaneous flap has successfully been used to reconstruct tissue loss in these areas. giving a sensate region which is preferential in this term functional consequences [47]. reliable option for both traumatic and vessels [48]. non-traumatic defects. Due to the unique anatomy of the knee. the cross leg flap has been used with reasonable the medial hemisoleus [51] and the reversed hemisoleus flap results. the choice being more dependent on surrounding tissue Foot coverage has been successfully performed using availability and the amount of bony and soft tissue injury sural artery-. Volume 8 Jordan et al. introducing a more reliable pedicled flap to a wound bed.428 The Open Orthopaedics Journal. or proximally based also often considered in the foot [73]. reliable and operatively quick to perform negating free flap reconstruction. technically challenging areas to cover. of Injury The dorsal foot and ankle are likewise difficult to Anatomical zone of injury is a key determinant of reconstruct due to a functional lack of tissue around this site. due to their option as grafting of the transposed flap and covering only small free flap choice.1. as commented are generally a reliable and vessels. as using the osteocutaneous fibula flap with good results. 60]. extensor [43].3.serratus anterior and/or reconstruct being a weight bearing zone. amputated limb to cover severe tissue loss of an intact lower The lower third of the lower leg. The serratus anterior [75]. this flap may be Free osteocutaneous flaps options include. Significant tissue coverage here is important as loss of have also been reported as successful in plantar forefoot the extensor mechanism of the knee is seen to have long repair. The 5. radial forearm. flaps. latissimus Sarcomas involving the tibial bone are not uncommon. The distally based sural Amputation is an option for both traumatic and chronic wounds of the lower limb. as commented on. lateral calcaneal artery based-. as well as the hind foot and malleolar region [58]. providing less bulky flaps although requiring The gluteal and the thigh regions. reconstruction of The anterior tibial artery provides an adipofascial flap the soft tissues has been attempted with both local and free suitable for coverage over the malleolar regions [69]. The middle and distal tibia defect has also been salvaged Free flap cross leg flaps have also been described [83]. can be muscle rotation. CHOICE OF RECONSTRUCTION.flaps [70-72]. rectus abdominis [76] and combination gastrocnemius and soleus flap has been parascapular free flaps can be added to those described described for proximal tibia defects. with results in both adult and child populations [77- 25% of these required either a bipedicled flap or sural flap 80]. lateral arm. improving long term function and rehabilitation • Radial osteocutaneous flap [61-63]. combination medial hemisoleus and gastrocnemius flap. and abductor halluces The knee and popliteal region. both described as free or pedicled. hemi-soleus.4. Medial plantar flaps. • Iliac osteocutaneous flap Heel defects in particular present a difficult area to • Vascularised rib transfer +/. Distal based lateral supramalleolar adipofascial flaps have Many papers have stated success with varying options: been described.4. less microsurgically experienced team than the antero-lateral The mid tibia defect can also be covered using a thigh flap [81]. allow great versatility in regard to local defects [66. Delayed reverse latissimus dorsi sural flaps have been used successfully in cases of distal tibial and calcaneal fracture with neurofasciocutaneous • Fibula osteocutaneous flap coverage. 4. bipedicled and keystone flaps are all utilised with formation due to some retained sensation compared to free good outcomes [42]. These are generally taken at . V-Y. has allowed the use of the genicular arteries as recipient Free flaps. Choice of Reconstruction: By Anatomical Location 65]. with In scenarios where a large defect is unable to be covered an aim of maintaining the Achilles tendon and posterior by a pedicled flap and there is contraindication to a free flap tibial vessels to allow ankle plantar flexion post (included only one intact vascular axis). digitorim brevis muscle rotation-. They may also reduce long term ulcer flaps. reasonably covering an area limited to: up to 10cm square [59. Options include the saphenous and sural flaps. 4. heel and hindfoot are limb [84]. The saphenous flap provides a 5. 2014. reconstruction later with a 10% amputation rate. A dorsi. minimising trauma to the popliteal and femoral with a specialist team. allowing reduced donor morbidity [64. both well as scenarios where free flaps have been taken from one as a pedicled and free flap [53-57]. time of 27 days [82]. flaps [44-46]. particularly in the reconstruction [50] with the author also describing his use of heel region. Nineteen of It has been noted that the latissimus dorsi and rectus twenty-one patients were ambulatory at follow up (median abdominis flaps offer a more reliable flap option with the 2. but are not limited by the size of the defect. flaps [68]. ALTERNA- TIVES AND ADJUNCTS TO A FLAP reliable and versatile option for the medial and anterior lower leg. Dorsalis pedis based flaps are covered by pedicled gastrocnemius. The perforator supply to the sural based flap allows numerous options.8 years) [49]. However. using the medial saphenous flap with a mean division for distal tibia defects [52]. Improved microsurgery weight bearing region [74]. Other Flap Choices flap is safe. This unit’s results state above.

025) and required a less costly patient’s lifetime [110]. 360. Soft tissue coverage must be wound and area specific. otherwise. et al. both regain baseline function after 6 months. 86]. Guidelines 2009. particularly in allowing delayed. 2014.009) patient and their family. They disease and neuropathy. >8cm multiple co-morbidities is likely to have poorer outcomes. Preoperative Also. NPWT is also of benefit in its use after amputation and [4] American College of Surgeons Committee on Trauma: Resources for Optimal Care of the Injured Patient. flap reconstruction [107. p<0. Blackhurst DW. Schumacher U. or negating. et al. [90] compared amputation versus patients trauma. Functional tissue coverage with good results reported. Dermal substitutes are gaining popularity in aiding soft [6] Rodriguez ED. Jalaie H. The Lower Limb. a short guide. rather than with the use of injury severity scoring systems. Soft tissue injury. Copeland C. Indications for amputation remain those having a fully involving the patient and a multidisciplinary approach as the severed limb or posterior tibial nerve (loss of foot plantar unmotivated. There was no great difference in the cost of different interventions. Scale 1998 (HFS-98) [93]. 42(2): 227-35. Bluebond-Langner R. Oral Surg Oral Med Oral Pathol Oral Radiol 2014. improvement in both pedicled and free flap microsurgery has There have been multiple attempts at guiding the choice made these the mainstay of therapy options. et al. Age system (NISSSA) [95]. metalwork [100]. After appropriate debridement.2. wound line dehiscence for healing the wound [80] and in facs. improving investigations and surgical technique clinical factors predict postoperative functional outcomes after major lower limb amputation: an analysis of 553 consecutive can limit the need for free flap reconstruction. Declared none. pharmaceutical therapies. Negative Pressure Wound Therapy REFERENCES This has been documented for its use in wound coverage until definitive therapy is decided or indicated [5]. J Trauma help cover areas where. Platelet rich plasma has been trialled in the treatment of Similarly. malignancy treatment. particularly with exposed [5] Standards for the management of open fractures of the lower limb. in particular reconstruction.html [Accessed: February 10. skin grafts would fail 2009. [7] Kolbenschlag J. Skeletal injury. is include significant morbidity [88. 89]. Fitzner C.Flap Decisions and Options in Soft Tissue Coverage of the Lower Limb The Open Orthopaedics Journal. Available at: http://www. Shock. NY: helping to reduce the size of wound. these templates are used to anterolateral thigh perforator flaps versus muscle flaps. The choice of of salvage and reconstruction versus primary amputation coverage should be determined by reliability. important to restore and maintain both balance and ambulation. cognitive function and high co-morbidity [85].009) and rehabilitation time (30 vs 12 months. British Orthopaedic Association.org/trauma/atls/index. The salvage of the limb is preferred in the reconstructed group. Hellmich S.3. These have all The authors confirm that this article content has no been evaluated in their use to describe a recommended conflict of interest. segmental tibial loss or a limb ischaemia time greater than 6 The reconstruction ladder offers options and the hours [5. p<0. Loss of the lower limb is a possible outcome in Hertel et al.bapras. patients. Kalbaugh CA. 66(5): 1311-4. 117(3): 289-92. 97]. found an increased number of interventions (8 vs 3. It has been They are also becoming useful as a wound closure option shown that there is a failure for elective elderly patients to in the emergency situation. the Hanover Fracture adjuncts to help reach these aims.02). Other Options Surgeons. Germann G. Early distal amputation may also help minimise the need CONCLUSION for major limb amputation as a definitive therapy [87]. poor baseline 108]. threshold for primary amputation in the adult trauma ACKNOWLEDGEMENTS population. particularly in war injuries. reconstruction of any wound has a significant impact on the p<0. investigations and surgical technique is also allowing [98]. the Limb Salvage Index (LSI) [94] CONFLICT OF INTEREST and the Nerve injury. with a poor pre-injury health history. particularly after misguided reconstruction attempts which Lower limb surgery. the use of autologous growth through knee amputation and requires greater energy factors in this case could predict a strong future for expenditure to later mobilise [5.asp?id=724 [Accessed: February 11.5. [3] Taylor SM. Ischaemia.org. 2014]. . peripheral vascular undergoing complex microvascular reconstruction. patients having a higher amputation level. Megerle K. above knee amputation has been seen to have a chronic diabetic foot wounds of the lower limb [109]. or [2] Ghassemi A. allowing free flap Thieme 2006. although this group retained their to amputation. Jost M. Free tissue (lack of paratenon and periosteum) [101-105] and in transfer in patients with severe peripheral arterial disease: conjunction with NPWT [106]. p<0. 2014]. reportedly being more cost-effective over the profession (81 vs 46%. British Association of Plastic Reconstructive and Aesthetic 5. These ease of a procedure and should be the least disabling with the include: the Mangled Extremity Severity Score (MESS) [91]. Volume 8 429 transmetatarsal below knee or above knee levels. as well as [1] Schulte E. diabetic.uk/page. something improving vascularized fibular flap. poor pre-injury ambulatory patient with sensation). Available at: http://www. 5. J Vasc Surg 2005. Usually in outcomes of posttraumatic lower limb salvage: a pilot study of association with skin grafting. Factors influencing the passage down the reconstructive ladder to the point of the necessity for preoperative vascular imaging before harvesting a foregoing the need of even a local flap. future likely to provide pharmaceutical and engineered the Predictive Salvage Index (PSI) [92]. 90]. In: Thieme Atlas of Anatomy: General Anatomy and Musculoskeletal System. aiding flap success [99]. larger impact on war victims compared with below knee and Although only a case report. and lifelong invalidity pension (16 vs 54%. p. reconstruction of the massive lower limb wound [96.

Sosin M. A paradigm shift in flap selection protocols for zones [44] El-Sherbiny M. Soto-Miranda MA. A retrospective study on flap discussion 617-8. Free muscle: experimental and clinical considerations relevant to vascularized tissue transfer for limb salvage in peripheral vascular reconstruction in ambulatory patients. 15(10): 2867-73. 76: 87-96. Reitzel T. Lower [25] John JR. J Reconstr Microsurg 2012. 72(2): 261-2. lower extremity: a new method to achieve reliable flaps: the role of local muscle flaps revisited.The reversed medial hemisoleus muscle flap and its role in [28] Lei LG. [9] Ponten B. True and 'choke' anastomoses flap in the reconstruction of exposed bones in the lower limb. Mitra A. [47] Bickels J. 132(6): 1603-10. Rashidi E. The groin flap. 18(3): 437-47. foot reconstruction. Br J Plast Surg 1987. Jun 12. Brazio PS. The fasciocutaneous flap: its use in soft tissue defects of [34] Moncrieff MD. 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