Experience of using local flaps to cover open lower limb injuries at an Indian trauma center.

BACKGROUND: Optimal care of open, high-velocity, lower limb injury requires surgical skills in debridement, skeletal stabilization, and in providing appropriate soft tissue cover. Timely coordination between orthopedic and plastic surgeons, though ideal, is often difficult. In our center, orthopedic surgeons undertake comprehensive treatment of open fractures including soft tissue cover. We reviewed the results of the local flaps of lower limb, done by orthopedic surgeons.
MATERIALS AND METHODS: We retrospectively reviewed the results of the lower limb flaps done between January 2005 and December 2006. All flaps done at and below the level of knee were included.
RESULTS: There were 105 patients with 120 flaps during this period. Two patients with two flaps were lost to follow-up. The average age was 32 years. Sixty-four patients had Type IIIB Gustilo and Anderson injuries. Thirty-nine patients had isolated soft tissue injuries. The indications for flaps were exposed bone, tendon, and joint in 45, 11, and 12, respectively, or a combination in 35 patients. The flaps done were 51 reverse sural artery, 35 gastrocnemius, 25 local fasciocutaneous, and seven foot flaps. The flap dimensions ranged from 2 × 2 to 30 × 15 cm. Ninety-three flaps (79%) healed primarily. Among 25 flaps (21%) with necrosis, 14 flaps required secondary split skin graft for healing, while the other nine flaps healed without further surgery.
CONCLUSION: Appropriate soft tissue cover provided by orthopedic surgeons can help in providing independent, composite care of lower limb injuries.

INTRODUCTION

The optimal care of open, high-velocity, lower limb injury requires surgical skills in debridement, different modes of skeletal stabilization, and in providing appropriate soft tissue cover. When faced with a near epidemic of these injuries in developing countries, existing approaches to this problem may have to be modified.

It has been shown that 90% of disability-adjusted life years lost from road traffic injury occurs in developing countries.[1] In India alone, it is expected that there will be three million hospitalizations due to road traffic accidents in 2010.[2] An orthopedic surgeon in the developing world sees at least 20 times the number of Gustilo III B open tibial fractures than his counterpart in developed world.[3] The numbers of open ankle and foot injuries are likely to be exponentially higher in a barefoot population. Despite these statistics, trauma care in the developing world tends to follow the developed world model with multiple teams caring for the different facets of open injuries. The financially poorer segment of society is affected.[4] This segment of society can scarce afford to pay for highly specialized services, which do exist in urban centers. Although the results of single-stage reconstruction are good, timely coordination between orthopedic and plastic surgeons is often difficult.[35-7]

The question of “who does soft tissue cover?” should have evolved from the philosophical to the practical by now. It is clear that the workforce and availability of flap surgeons has become a problem.[8] Furthermore, Levin hinted that the days of Godina[9] will never again be reached and to be more practical. This is in the developed world where “ideal” surgery is practiced. It is even more imperative in developing countries; with emerging economies and with greater magnitude of open injuries, a different solution is sought. Although attempts have been made toward this,[1011] there is reluctance by those who influence opinion, to address this problem, as it may be radically different to conventional thinking. We performed these flaps in our attempt to provide a cost-effective solution, keeping in mind the best interests of the patient. The same constraints are likely to be present in many parts of the developing world. In these parts of the world, the paradox remains that despite the increasing number of open injuries, they remain a low priority for resource managers. In this scenario, the orthopedic community is more aware than others of this problem, has more resources, and is also keen to treat these injuries, especially as they often present at untimely hours. This paper intends to promulgate the fact that some orthopedic surgeons have been able to accomplish soft tissue coverage in the lower limb.

In our center, soft tissue cover of this magnitude is provided by orthopedic surgeons only in the recent past, though there has been a tradition of involvement in performing soft tissue cover.[1213] There were no financial incentives for these additional surgeries. The senior author undertook a short fellowship in plastic surgery, and his encouragement and teaching has resulted in the other authors performing flap surgeries under supervision initially and then independently. We reviewed our results of the flaps performed for open limb injuries at and below the level of knee.

MATERIALS AND METHODS

We retrospectively reviewed the results of flaps at and below the level of knee done in the orthopedic department of our 2 200 bed, multispeciality institution in a developing country between January 2005 and December 2006. Flaps done for traumatic soft tissue loss were included. We excluded flaps done after tumor resection and after debridement of chronic osteomyelitic wounds. The assessment was done by one of the authors at final follow-up.

There were 105 patients with 120 flaps during this time period. Two patients with two flaps were lost to follow-up and hence excluded. Thus, 103 patients with 118 flaps were used for analysis. The average age was 32 years (3-75). There were 88 males (85%) and 15 females (15%). Flap cover was done in 64 patients (62%) for Type IIIB Gustilo and Anderson fractures of both bones of leg and in 39 patients (38%) for isolated soft tissue injuries resulting in exposure of bone or vital structures like tendons and neurovascular bundle. In 45 patients (44%), either tibia or fibula was exposed; in 11 patients (10%), major tendons were exposed; in 12 patients (12%), either knee or ankle joint was exposed; and in 35 patients (34%), a combination of the above three was exposed. The flap dimensions ranged from 2 × 2 to 30 × 15 cm.

The flaps done were 51 reverse sural artery, 35 gastrocnemius, 25 local fasciocutaneous, and 7 foot flaps (lateral calcaneal artery-based flap – 5, extensor digitorum brevis muscle rotation flap – 1, abductor hallucis muscle rotation flap – 1).

In our series, gastrocnemius flaps were used to cover defects in the knee and proximal third of tibia [Figures 1 and 2]. Both gastrocnemii were used, if the soft tissue defect was larger. We used the gastrocnemius myocutaneous flaps and fasciocutaneous flaps for middle third cover, since soleus is usually traumatized in middle third leg injuries [Figures 3–5]. The sural artery flap was the mainstay of cover for the distal leg and foot [Figures 6–8].

Figure 1

Photograph of patient with open tibial plateau fracture after plating and loss of soft tissue over proximal third of tibia

Figure 2

Photograph showing exposed plate covered by medial gastrocnemius flap and distally by fasciocutaneous flap

Figure 3

Photograph of 14-year-old girl with Type IIIb open fracture of mid leg

Figure 5

Follow-up at 2 weeks

Figure 6

Photograph of 14-year-old girl with open ankle and loss of soft tissue of dorsum of foot

Figure 8

Photograph at follow-up at 2 months

Photograph showing distally based fasciocutaneous flap cover and external fixation of fracture

Photograph after debridement, skeletal stabilization, and reverse sural flap cover

RESULTS

Ninety-three flaps (79%) healed primarily. Twenty-five flaps (21%) had delayed healing [Table 1]. There was complete necrosis of three reverse sural artery flaps. One patient had bilateral reverse sural artery flaps for bilateral heel pad injury, after a fall from a height of 15 feet. On the tenth postoperative day, he had necrosis of both flaps. This was managed by debridement and split skin graft. He ambulates with a molded footwear and silicone insoles. He occasionally has breakdown of heel split skin graft that heals with total contact cast.

Table 1

Outcome of flaps with delayed healing

Another 18-year-old boy presented with open fracture dislocation of talus. He underwent debridement, open reduction of talus, and reverse sural flap cover for the exposed ankle joint. He also had complete necrosis of the flap. He underwent delayed debridement of the necrosed flap and split skin grafting. He was also given pulsed magnetic field therapy for wound healing and bone healing. His wound healed after 60 days. At a follow-up of one year, the wound had completely healed [Figure 9]. He was ambulant and attends school.

Figure 9

Complete necrosis of reverse sural artery flap healed with secondary split skin graft at follow-up after 14 months

Nine (36%) of the 25 flaps which had necrosis healed without any surgical intervention [Table 2]. Fourteen flaps (56%) required split skin grafting for healing. One reverse sural artery flap (4%) required secondary suturing after debridement of the necrosed tip and another (4%) with 20% necrosis was managed with fasciocutaneous flap to cover the necrosed area. There were no donor site problems in any of our flap harvest.

Table 2

Secondary procedures for flaps with delayed healing

DISCUSSION

Treatment of soft tissue loss has always been difficult for the trauma surgeon. There are two options, the traditional approach being bony injuries treated by orthopedic surgeons and soft tissue by plastic surgeons. This approach, requiring excellent cooperation and coordination between two busy surgical specialties in a large institution, is difficult to achieve. In addition, in our situation, because of the absence of protective clothing in patients with these injuries, they invariably arrive with gross contamination. Frequently, there is established infection when patients present late. In this situation, the timing of the flap becomes almost as important as the cover itself.[1415] The other approach is to perform both procedures by a single team. Masquelet described this as a holistic approach to open fractures rather than subjecting the patient to multiple surgical procedures by different teams at different intervals.[7]

As far as we know, few centers in the world have near perfect understanding and coordination of three different disciplines, i.e., orthopedics, plastic surgery, and anesthesia.[3] This is possible only in centers with few specialties and in centers that treat only trauma.

The advantage in our set up is that a single surgical team is involved in all stages of treatment, from debridement, skeletal stabilization, to soft tissue cover and for secondary procedures to accelerate fracture healing. The whole treatment is planned at the time of presentation in Accident and Emergency department, taking into consideration the associated systemic injuries and the general condition of the patient. It is imperative that the orthopedic surgeons, who are involved in emergency debridement and who are already comfortable with limb anatomy, familiarize themselves with performing soft tissue cover also, to optimize treatment. In our region of practice, the orthopedic surgeon bears primary responsibility in treatment of limb injuries and hence it is vital that they be more involved in providing soft tissue cover.

Though these techniques may be new to an orthopedic surgeon, careful soft tissue handling and biological fixation have become an integral part of the orthopedic surgeon's work. Our results showed that the majority of these flaps, which were mainly in the difficult area of lower leg and foot, healed primarily. The ones which had necrosis too healed subsequently without any major revisions.

The results of this study are comparable with other large studies with the sural artery flap,[1617] though the failures are often the nature of the bed and the infected state at arrival rather than the flap itself, making strict comparison between studies difficult. The sural artery flap also remains a good alternative to free flaps in the lower third of the leg.[1819] The main limitation of this study is that it does not compare with the earlier results when more than one team of surgeons provided the same treatment.

Though plastic surgeons will always be involved in extensive reconstructions and free flaps, involvement of orthopedic surgeons in soft tissue cover of open limb injuries helps in improved and timely treatment of patients in developing countries.

CONCLUSION

Soft tissue cover of lower limb injuries by a single team involved in bony stabilization and reconstruction using local flaps is an alternate and simpler solution to a difficult problem, especially when resources are limited and cooperation between two different teams is not always possible.