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Open Fractures ot the Lower Limb : The Role of Plastic Surgery in Reconstructing Soft Tissue Defects & Improving The Patient's Quality of Life by (Efterpi C. DEMIRI)

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 Associate Professor in Plastic Surgery, Medical School, Aristotle University of Thessaloniki



Plastic Surgery is the medical specialty that deals with reconstruction of tissue defects and restoration of deformities and functional impairment, concerning the skin, myo-osseous and neurovascular structures, located over the face and neck, the torso, the breast, the upper and lower extremities and the genitalia. [1] Etiologies of those deformities include trauma, chronic diseases, cancer, congenital anomalies or tissue degeneration. Plastic surgeons use various therapeutic approaches and surgical techniques focusing on the restoration of function, form and aesthetic appearance of the involved areas, and also the prevention of post-traumatic and post-operative complications. Although cosmetic surgery is perhaps the most popular part of the specialty, it covers only a limited area of the whole spectrum of plastic surgery fields and subjects, namely reconstructive surgery, microsurgery, hand surgery, oncological surgery of the skin and soft tissues, treatment of burns and traumas, tissue replanation, tissue engineering, etc. [2]


Reconstructive techniques: the use of flaps

The use of autologous grafts and flaps is the work-horse in reconstructive surgical methodology; the term «flap» describes a tissue unit, which is harvested surgically from its original place (donor site) but left attached to it by its vascular pedicle which assures blood supply to the flap; after being elevated, the flap is transposed to another area (recipient site) in order to restore an impaired form or function. Flaps are classified according to their consistency (skin flaps, muscle flaps, bone flaps, etc), the type of their transposition to the defect (rotation, advancement flaps), their vascular pattern (random, axial flaps) and their proximity to the recipient site (local flaps, regional flaps, distant flaps). [3]

The so-called «free flaps» are a special group of flaps which are dissected and detached completely from their donor area and transferred to a recipient site, which is usually located at a distant area of the body. In order to assure the free flap’s viability, it is mandatory to idenify and prepare its nutrient vessels (artery and vein) before its transfer to the recipient site, and anastomose them to other vessels, located near the defect which will be reconstructed by the flap. This re-vascularisation procedure of the free flap is performed using magnification of the surgical field with the aid of an operating microscope and microsurgical techniques. 

Free flaps are being used by plastic surgeons the last four decades; common indications for a free flap transfer include extended or composite tissue losses following high-energy injuries or major cancerological excisions over the face, the breast and the extremities.


Soft tissue reconstruction of open fractures of the lower limb

One of the most frequent indications for using flaps, either regional pedicled or distant free flaps, is the presence of post-traumatic soft tissue defects over the distal areas of the lower limb, following open fractures of the leg. According to Gustilo, open tibia fractures are classified to three types (I, II and III), the third one including the most severe and complex injuries with associated soft tissue losses, exposed bones and periosteal stripping (Gustilo IIIB) and major artery injuries requiring vascular repair (Gustilo IIIC). [4,5] Other indications for using free flaps over the leg are chronic bone infections (osteomyelitis) and congenital dysplasias (tibial pseudarthrosis).

The first step in managing complex injuries of the lower extremity, after bone stabilization and vascular repair, is to prepare the wound properly; in all cases, the role of meticulous surgical debridement, excision of all devitalised soft tissues and eradication of infection -before flap reconstruction- has already been well established. [6] Then, the characteristics of the defect (size and location, exposed underlying structures, associated injuries) should be carefully evaluated and parameters related to the patient (age, profession, general condition, other co-morbidities) should also be considered. Before coverage of the defect, the plastic surgeon should prioritize the reconstruction, based on patient needs and most critical functional deficits, and also consider the tissues that are injured or missing, and those that are available to use for reconstruction. Thus, the whole reconstructive procedure may now be planned: selection of the best indicated flap, donor area, recipient vessels, and/or need of vein grafts. [7,8] According to the principles of Godina, final coverage of an open lower extremity fracture should be performed as soon as possible [9,10] and followed by the appropriate rehabilitation of the extremity.

In the recent decades, the use of free flaps in covering severe open tibia fractures has changed the prognosis of those complex injuries and increased the number of salvaged limbs. [6] Published data shows that ~60% of limb-salvaged patients return to their previous work even with a several-years’ delay [11]; although the whole reconstructive process may last long and patients may frequently need many re-operations, the vast majority of them is satisfied with the result and happy to have their legs instead of being amputated. However, discussion and detailed information of the patient about these demanding reconstructive procedures is of utmost importance, because secondary amputation in severe open fractures of the lower limb may be required. [12]



Management of third-degree open fractures of the lower limb still consists a challenge for the reconstructive surgeon; a combined initial therapeutic approach by both orthopaedic and plastic surgeons is fundamental for a successful treatment, as it improves prognosis and quality of life of patients. [13,14] Besides, a mutlidisciplinary management and close collaboration of all specialties involved in those trauma cases (general surgeon, orthopaedic surgeon, vascular surgeon, plastic surgeon, infectiologist, intensivist, physiotherapist) may shorten the hospitalisation length and decrease the total cost needed for completing these most demanding surgical treatments. [15,16] 

In conclusion, it is absolutely necessary for all Trauma Centers and Emergency Hospitals to have well-trained and experienced Plastic Reconstructive Surgeons as members of their surgical teams; a plastic surgeon may significantly contribute to an optimal planning of the reconstruction, minimize complications, reduce hospitalisation and facilitate rehabilitation of the patients.






[3]. Thornton JF, Gosman AA. Skin grafts and skin substitutes and principles of flaps. In Kenkel JM (ed) Selected Readings in Plastic Surgery, vol 10(1), Southwestern, University of Texas, Dallas, 2004.

[4]. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures.  J Trauma. 24 (8): 742-746, 1984.

[5]. Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics. 10(12): 1781-1788, 1987.

[6]. Yaremchuk MJ. Acute management of severe soft-tissue damage accompanying open fractures of the lower extremity. Clin Plast Surg. 13(4): 621-632, 1986.

[7]. Vlastou C, Earle AS, Jordan R. Vein grafts in reconstructive microsurgery of the lower extremity. Microsurgery. 13(5): 234-235, 1992.

[8]. Demiri EC, Hatzokos H, Dionyssiou D et al. Single stage arteriovenous short saphenous loops in microsurgical reconstruction of the lower extremity. Arch Orthop Trauma Surg. 129(4): 521-524, 2009.

[9]. Godina M. Early microsurgical reconstruction of complex trauma of extremities. Plast Reconstr Surg. 78(3): 285-292, 1986.

[10]. Arnez ZM. Immediate reconstruction of the lower extremity - an update. Clin Plast Surg. 18(3): 449-457, 1991.

[11]. Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases. J Trauma. 29(8) 1086-1094, 1989.

[12]. Fochtmann A, Mittlböck M, Binder H et al. Potential prognostic factors predicting secondary amputation in third-degree open lower limb fractures. J Trauma Acute Care Surg. 76(4): 1076-1081, 2014.

[13]. Yaremchuk MJ, Gan BS. Soft tissue management of open tibia fractures. Acta Orthop Belg. 62 (suppl 1): 188-192, 1996.

[14]. Tomaino M, Bowen V. Reconstructive surgery for lower limb salvage. Can J Surg. 38(3) : 221-228, 1995.

[15]. Townley WA, Nguyen DQ, Rooker JC et al. Management of open tibial fractures - a regional experience. Ann R Coll Surg Engl. 92(8): 693-696, 2010.

[16]. Sen A, Xiao Y, Lee SA, Hu P et al. Daily multidisciplinary discharge rounds in a trauma center: a little time, well spent. J Trauma. 66(3): 880-887, 2009.

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