Management of Post-Traumatic Composite Bone and Soft Tissue Defect of Leg

Ravi K Mahajan, Krishnan Srinivasan, Mahipal Singh, Adish Jain, Taha Kapadia, Ankush Tambotra, Ravi K Mahajan, Krishnan Srinivasan, Mahipal Singh, Adish Jain, Taha Kapadia, Ankush Tambotra

Abstract

Management of composite defects of leg following trauma requires a planned ortho-plastic approach right from the outset. Timely, planned intervention results in reduced amputation rates and improved limb salvage and function. Right from the time of presentation of the patient to the emergency with such injury, the process of decision making in terms of salvage or amputation, local flap cover/free flap cover, bone reconstruction first or soft tissue or both combined, come into play. Guidelines on management are unclear for such defects, a literature search yielding various methods being used by different authors. This article is a review of current literature on management of composite leg defects. A summary of the literature search in terms of various management options given by various authors including the rationale, advantages and disadvantages of each strategy has been provided in this article. The management protocol and method followed by the author in his institute for management of such composite defects have been described in detail. The article seeks to provide readers with an understanding of the management strategies so that appropriate method could be chosen to provide best result.

Keywords: Ilizarov; bone defect; composite defect; distraction; free fibula; free flap; leg trauma; lower limb trauma.

Conflict of interest statement

Conflict of Interest None declared.

Figures

Fig. 1 (A)
Fig. 1 (A)
Contaminated compound fracture of both bones of leg.(B)Post-debridement status with external fixator in place and bone loss.(C)X-ray of same patient showing bone loss.(D)Latissimus dorsi free flap done.(E)Ilizarov fixator applied after 1 month of free flap.(F)X-ray showing good consolidation of regenerate.(G)Healed wounds with no limb length discrepancy.
Fig. 2 (A)
Fig. 2 (A)
Nonviable tibia, due to prolonged exposure.(B)Post-debridement bone loss as seen on X-ray.(C)Defect covered with latissimus dorsi + serratus anterior free flap in first stage.(D)Ilizarov fixator applied after 1 month of free flap and patient can ambulate immediately.(E)X-ray showing good consolidation of the regenerate.(F)Healed wound with no limb length discrepancy.
Fig. 3 (A)
Fig. 3 (A)
Post-traumatic defect with external fixator in place in a single vessel limb.(B)Cross-leg flap done and stabilized with external fixator.(C)Ilizarov ring fixator applied after division and insetting of cross leg flap (3 weeks after primary surgery).(D)Wounds healed well with no limb length discrepancy.(E)Good consolidation of regenerate seen on X-ray.
Fig. 4 (A)
Fig. 4 (A)
Compound fracture of both bones of legs with contamination.(B)Post-debridement wound with external fixator in place.(C)Free osteocutaneous fibula harvested—13 cm.(D)Flap inset done.(E)Ilizarov fixator applied after 3 weeks.(F)Good hypertrophy of fibula at 10 months post-surgery.(G)Wound healed.

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