Abstract
The reconstruction of complex soft tissue losses associated with underlying fractures remains a clinical challenge. Many different factors have to be considered in the treatment algorithm to achieve functional recovery of the limb. Timing between injury and the definitive reconstruction has become less important. Instead the focus needs to be on aggressive debridement combined with a targeted antibiotic therapy and negative pressure wound therapy treatment to bridge the time until the optimal setup both on patient and clinician site is available. Defect coverage can often be achieved with regional flaps in the upper part of the lower limb. The distal third of the lower limb often requires coverage with a free tissue transfer. The current literature offers no evidence to support superior outcomes of either limb salvage or primary amputation for type IIIB and IIIC tibial fractures. When outcomes are similar between two treatment strategies, economic analysis that incorporates cost and preference may define an optimal treatment strategy to guide physicians and patients.
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References
Aldea PA, Shaw WW. The evolution of the surgical management of severe lower extremity trauma. Clin Plast Surg. 1986;13(4):549–69.
Tomaino MM. Amputation or salvage of type 3B/3C tibial fractures: what the literature says about outcomes. Am J Orthop (Belle Mead NJ). 2001;30(5):380–5.
Fischer JP, Wink JD, Nelson JA, Cleveland E, Grover R, Wu LC, et al. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg. 2013;29(6):407–16.
Harley BJ, Beaupre LA, Jones CA, Dulai SK, Weber DW. The effect of time to definitive treatment on the rate of nonunion and infection in open fractures. J Orthop Trauma. 2002;16(7):484–90.
MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma. 2002;52(4):641–9.
Ger R. The management of open fracture of the tibia with skin loss. J Trauma. 1970;10(2):112–21.
Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg. 2001;108(4):1029–41; quiz 1042.
Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN, Yaremchuk MJ. Microvascular soft-tissue transplantation for reconstruction of acute open tibial fractures: timing of coverage and long-term functional results. Plast Reconstr Surg. 1992;89(3):478–87; discussion 488–9.
Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from operation Iraqi freedom: successful subacute reconstruction of complex lower extremity battle injuries. Plast Reconstr Surg. 2009;123(1):218–29.
Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery. 2008;28(8):632–4.
Steiert AE, Gohritz A, Schreiber TC, Krettek C, Vogt PM. Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy - worse or worth? J Plast Reconstr Aesthetic Surg. 2009;62(5):675–83.
Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38(6):563–76; discussion 577.
Rinker B, Amspacher JC, Wilson PC, Vasconez HC. Subatmospheric pressure dressing as a bridge to free tissue transfer in the treatment of open tibia fractures. Plast Reconstr Surg. 2008;121(5):1664–73.
Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower extremity trauma: trends in the management of soft-tissue reconstruction of open tibia-fibula fractures. Plast Reconstr Surg. 2006;117(4):1315–22; discussion 1323–4.
Park JJ, Campbell KA, Mercuri JJ, Tejwani NC. Updates in the management of orthopedic soft-tissue injuries associated with lower extremity trauma. Am J Orthop (Belle Mead NJ). 2012;41(2):E27–35.
Molnar JA, DeFranzo AJ, Hadaegh A, Morykwas MJ, Shen P, Argenta LC. Acceleration of Integra incorporation in complex tissue defects with subatmospheric pressure. Plast Reconstr Surg. 2004;113(5):1339–46.
Reddix RN, Tyler HK, Kulp B, Webb LX. Incisional vacuum-assisted wound closure in morbidly obese patients undergoing acetabular fracture surgery. Am J Orthop (Belle Mead NJ). 2009;38(9):446–9.
Jordan DJ, Malahias M, Hindocha S, Juma A. Flap decisions and options in soft tissue coverage of the lower limb. Open Orthop J. 2014;8:423–32.
Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: the impact of the time factor on infection rates. Injury. 2007;38(8):879–89.
Reddy V, Stevenson TR. MOC-PS(SM) CME article: lower extremity reconstruction. Plast Reconstr Surg. 2008;121(4 Suppl):1–7.
Lee P, Levine J, Wei F-C. Reconstructive surgery of the lower extremity. New York: Thieme Medical Publishers Inc.; 2013.
Kang MJ, Chung CH, Chang YJ, Kim KH. Reconstruction of the lower extremity using free flaps. Arch Plast Surg. 2013;40(5):575–83.
Serafin D, Voci VE. Reconstruction of the lower extremity. Microsurgical composite tissue transplantation. Clin Plast Surg. 1983;10(1):55–72.
Lorenzo AR, Lin C-H, Lin C-H, Lin Y-T, Nguyen A, Hsu C-C, et al. Selection of the recipient vein in microvascular flap reconstruction of the lower extremity: analysis of 362 free-tissue transfers. J Plast Reconstr Aesthetic Surg. 2011;64(5):649–55.
Haug V, Panayi AC, Kadakia N, Abdulrazzak O, Endo Y, Udeh K, et al. Use of venous couplers in microsurgical lower extremity reconstruction: a systematic review and meta-analysis. Microsurgery. 2020;41(1):50–60.
Mao H, Xu G. A retrospective study of end-to-side venous anastomosis for free flap in extremity reconstruction. Int J Surg. 2015;17:72–8.
Chang EI. My first 100 consecutive microvascular free flaps: pearls and lessons learned in first year of practice. Plast Reconstr Surg Glob Open. 2013;1(4):e27. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4173838/.
Hardy KL, Davis KE, Constantine RS, Chen M, Hein R, Jewell JL, et al. The impact of operative time on complications after plastic surgery: a multivariate regression analysis of 1753 cases. Aesthet Surg J. 2014;34(4):614–22.
Azoury SC, Stranix JT, Kovach SJ, Levin LS. Principles of orthoplastic surgery for lower extremity reconstruction: why is this important? J Reconstr Microsurg. 2021;37(1):42–50.
Pederson WC, Grome L. Microsurgical reconstruction of the lower extremity. Semin Plast Surg. 2019;33(1):54–8.
Calderon W, Chang N, Mathes SJ. Comparison of the effect of bacterial inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr Surg. 1986;77(5):785–94.
May JW, Rohrich RJ. Foot reconstruction using free microvascular muscle flaps with skin grafts. Clin Plast Surg. 1986;13(4):681–9.
Chan JK-K, Harry L, Williams G, Nanchahal J. Soft-tissue reconstruction of open fractures of the lower limb: muscle versus fasciocutaneous flaps. Plast Reconstr Surg. 2012;130(2):284e–95e.
Cho EH, Shammas RL, Carney MJ, Weissler JM, Bauder AR, Glener AD, et al. Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: a multicenter outcomes analysis. Plast Reconstr Surg. 2018;141(1):191–9.
Hong JP, Shin HW, Kim JJ, Wei F-C, Chung YK. The use of anterolateral thigh perforator flaps in chronic osteomyelitis of the lower extremity. Plast Reconstr Surg. 2005;115(1):142–7.
Couteau C, Rem K, Guillier D, Moris V, Revol M, Cristofari S. Improving free-flap survival using intra-operative heparin: ritualistic practice or evidence-base medicine? A systematic review. Ann Chir Plast Esthet. 2018;63(3):e1–5.
Awwad AM, White RJ, Webster MH, Vance JP. The effect of temperature on blood flow in island and free skin flaps: an experimental study. Br J Plast Surg. 1983;36(3):373–82.
Lunt MJ, Ragab S, Birch AA, Schley D, Jenkinson DF. Comparison of caffeine-induced changes in cerebral blood flow and middle cerebral artery blood velocity shows that caffeine reduces middle cerebral artery diameter. Physiol Meas. 2004;25(2):467–74.
Xipoleas G, Levine E, Silver L, Koch RM, Taub PJ. A survey of microvascular protocols for lower extremity free tissue transfer II: postoperative care. Ann Plast Surg. 2008;61(3):280–4.
Rohde C, Howell BW, Buncke GM, Gurtner GC, Levin LS, Pu LLQ, et al. A recommended protocol for the immediate postoperative care of lower extremity free-flap reconstructions. J Reconstr Microsurg. 2009;25(1):15–9.
Isenberg JS, Siegal A, Sherman R. Quantitative evaluation of the effects of gravity and dependency on microvascular tissue transfer to the lower limb, with clinical applications. J Reconstr Microsurg. 1997;13(1):25–9.
Akula M, Gella S, Shaw CJ, McShane P, Mohsen AM. A meta-analysis of amputation versus limb salvage in mangled lower limb injuries—the patient perspective. Injury. 2011;42(11):1194–7.
Busse JW, Jacobs CL, Swiontkowski MF, Bosse MJ, Bhandari M, Evidence-Based Orthopaedic Trauma Working Group. Complex limb salvage or early amputation for severe lower-limb injury: a meta-analysis of observational studies. J Orthop Trauma. 2007;21(1):70–6.
Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg. 2008;122(6):1796–805.
Chung KC, Saddawi-Konefka D, Haase SC, Kaul G. A cost-utility analysis of amputation versus salvage for Gustilo type IIIB and IIIC open tibial fractures. Plast Reconstr Surg. 2009;124(6):1965–73.
Bekarev M, Goch AM, Geller DS, Garfein ES. Distally based anterolateral thigh flap: an underutilized option for peri-patellar wound coverage. Strateg Trauma Limb Reconstr. 2018;13(3):151–62.
Ling BM, Wettstein R, Staub D, Schaefer DJ, Kalbermatten DF. The medial sural artery perforator flap: the first choice for soft-tissue reconstruction about the knee. J Bone Joint Surg Am. 2018;100(3):211–7.
Walton Z, Armstrong M, Traven S, Leddy L. Pedicled rotational medial and lateral gastrocnemius flaps: surgical technique. J Am Acad Orthop Surg. 2017;25(11):744–51.
Wright JK, Watkins RP. Use of the soleus muscle flap to cover part of the distal tibia. Plast Reconstr Surg. 1981;68(6):957–8.
Hallock GG. Sagittal split tibialis anterior muscle flap. Ann Plast Surg. 2002;49(1):39–43.
Durand S, Sita-Alb L, Ang S, Masquelet A-C. The flexor digitorum longus muscle flap for the reconstruction of soft-tissue defects in the distal third of the leg: anatomic considerations and clinical applications. Ann Plast Surg. 2013;71(5):595–9.
Arnold PG, Hodgkinson DJ. Extensor digitorum turn-down muscle flap. Plast Reconstr Surg. 1980;66(4):599–604.
Ramanujam CL, Stuto AC, Zgonis T. Use of local intrinsic muscle flaps for diabetic foot and ankle reconstruction: a systematic review. J Wound Care. 2018;27(Suppl 9):S22–8.
Jackson IT, Scheker L. Muscle and myocutaneous flaps on the lower limb. Injury. 1982;13(4):324–30.
Li B, Chang S-M, Du S-C, Zhuang L, Hu S-J. Distally based sural adipofascial turnover flap for coverage of complicated wound in the foot and ankle region. Ann Plast Surg. 2020;84(5):580–7.
Gu H, Xiong Z, Xu J, Li G, Wang C. Clinical and anatomical study of the distally based lesser saphenous veno-lateral sural neurocutaneous flap for lower extremity coverage. J Orthop Sci. 2013;18(5):740–8.
Rogers AD, Dos Passos G. Propeller flaps for lower-limb trauma. South Afr J Surg Suid-Afr Tydskr Vir Chir. 2014;52(4):105–7.
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Besmens, I.S., Calcagni, M. (2022). Rehabilitation: Soft Tissue Coverage. In: Pape, HC., Borrelli Jr., J., Moore, E.E., Pfeifer, R., Stahel, P.F. (eds) Textbook of Polytrauma Management . Springer, Cham. https://doi.org/10.1007/978-3-030-95906-7_43
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