1) The document discusses the decline in use of free flap surgery for lower limb reconstruction and presents alternatives such as local flaps. 2) It then presents a case study of a 43-year-old man with an open tibia fracture and skin loss on his lower leg treated with reverse soleus flap reconstruction. 3) Outcomes of the case study showed healthy wound healing with the reverse soleus flap providing soft tissue coverage and allowing for definitive fracture treatment.

1. The decline of free flap surgery in lower
limb reconstruction
Level D evidence
Dr Vaikunthan Rajaratnam
Senior Consultant Hand Surgeon
Department of Orthopaedic Surgery
KTPH Alexandra Health
Singapore
5th International Conference on Plastic Surgery 'PlastiCon 2017‘
Dhaka, 28 February 2017

2. Medicine used to be simple,
ineffective and relatively safe.
Now it is complex, effective and
potentially dangerous.
Chantler C ( 1999 ) The role and education of doctors
in the delivery of healthcare

3. Resources
Flaps and Reconstructive Surgery,
Fu-Chan Wei MD FACS , Samir Mardini MD
Surgery of the Injured Hand: Towards Functional Restoration
R Venkataswami
SEMINARS IN PLASTIC SURGERY/VOLUME 24, NUMBER 1 2010
The Reconstruction of the Mutilated Hand ,M Neumeister ,A Amalfi,
www.handsurgerymanual.com
www.handsurgeryedu.com – register courses soft tissue reconstruction
http://www.facebook.com/handsurgeryedu
https://twitter.com/handsurgeryedu
http://www.linkedin.com/groups/Hand-Surgery-International-3804094

4. Problem identification
• Clear and concise
description of the
problem
• Identification of the
needs
• Identify and list
constraints and
limits
• Aetiology
• Structural analysis
• Functional analysis
Right Leg – 10 X 3 cm
skin loss over the right
tibia, bone exposed

5. Reconstructive ladder
Rung 1: Secondary intention
Rung 2: Primary closure
Rung 3: Delayed closure
Rung 4: SSG
Rung 5: FTSG
Rung 6: Tissue expansion
Rung 7: Random flap
Rung 8: Axial flap
Rung 9: Free flap
Mathes SJ, Nahai F. Classification of the vascular
anatomy of muscles: experimental and clinical
correlation.Plast Reconstr Surg. Feb 1981;67(2):177-87

6. Constraint analysis
•Assessment – anatomy, patient, surgeon, therapist,
•Time and timing
•Resources – expertise, experience, equipment, energy
•Ethics
•Aesthetics

7. • Assessment of viability/reconstruction
• Best undertaken in theatre
• Obtain 2nd opinion
• Especially- amputation
• Senior/ more experienced surgeon

8. Generating options
• Begin with the end in mind
• Priorities
• Holistic consideration
• Keep the patient in the centre
• Go beyond anatomy
• Think outside the ladder!

9. Role of soft tissue
• Sensation
• Animation
• Efferent Execution
• Social
• Communication
• Aesthetics

10. Requirements- reconstruction
• Wound debridement
• Vascularity
• Adequate skin cover
• Stabilisation of bone
• Skin with good vascularity for
bone healing

11. • Control infections
• aggressive debridement and
• vascular cover
Endovascular procedures
• Utilising best option in the reconstruction ladder
• running down the ladder of reconstruction with newer reliable
• local flaps and
• negative wound pressure
Indian Journal of Plastic Surgery May-August 2013 Vol 46 Issue 2

12. • Amputation fell from 70% to 1.8%
• wound mortality fell from 20% to 1.8
• non-union rates between 5% and 45%.
ANZ J Surg 83 (2013) 348–
353

13. • 18/42 responded (43%)
• Median follow-up time of 14 years since reconstruction.
• Road traffic the most common cause of trauma (12/18).
• The majority of participants (13/18) had SIP physical and psychosocial
sub-scores equivalent to the general population (<5), and half the
participants reported normal function
• 2 participants sub-scores of ≥20, implying severe physical disability,
associated with higher pain and stiffness scores

14. Vol. 39 / No. 2 / March 2012
distally pedicled propeller
perforator flaps used in
the reconstruction of
defects in the distal third
of the lower leg and foot.

15. • early appearance of healthy
granulation tissue,
• reduction in wound area and
• allowed simpler soft tissue
procedures
• NPWT improved clinical survival
of muscle flaps
Injury, Int. J. Care Injured 41 (2010) 780–786

16. • Godina emergency free flaps or
the ‘fix and flap’ concept
• flap reconstructions performed
beyond the frequently quoted
critical interval yielded similar
results to those of immediate
reconstruction within the first 3
days

17. 532 microsurgical extremity
reconstructions
Delayed treatment >72 h,
• total flap necrosis in 20% and
• Postoperative infections in 29%
Emergency fix and flap
• total flap necrosis 1% and
• Postoperative infections 2%

18. • treatment of subacute wounds with
assisted healing and selective
delayed reconstruction
• achieved good results with low
osteomyelitis rates (5.6%)
• giving priority to ensuring
preoperative infection control, by
providing the wound with a healing
potential, and
• by using smaller flaps compared
with radical debridement—early
free flap approach

19. MDT approach - the traumatologist, vascular surgeons,
orthopaedic surgeons, nurses, PA’s, and plastic
surgeons.
who is available, when can they do it, are they willing to
do it, and if they do it, can they do it with a degree of
certainty that will assure complete and ‘‘living
coverage’’, once coverage is provided?
In those circumstances, it is better to delay coverage or
even transfer a patient to another centre, than have an
inexperienced team of personnel try to provide
coverage with an unsuccessful outcome.
The latter certainly creates terrible morbidity, increases
hospitalisation costs, and generates emotional trauma
to patients.
In the polytrauma patient with open fractures,
particularly in the extremities, coverage is just one part
of total care that includes haemodynamic stabilisation,
fracture stabilisation, definitive fixation, perhaps
provisional coverage, definitive coverage, and then
reconstruction down the line of missing bone segments,
motor tendon units, or peripheral nerves.

20. • 2 years - no significant difference in scores
for the Sickness Impact Profile between
amputation and reconstruction groups
(12.6 vs. 11.8, P=0.53)
Predictors of a poorer score
• rehospitalization -major complication,
• low educational level,
• Nonwhite race,
• poverty,
• lack of private health insurance,
• Poor social-support network,
• low self-efficacy (the patient’s confidence
in being able to resume life activities),
• smoking, and
• involvement in disability-compensation
litigation.Patients with limbs at high risk for amputation can be
advised that reconstruction typically results in two-
year outcomes equivalent to those of amputation.
(N Engl J Med 2002;347:1924-31.)

21. CASE PRESENTATION
• 43 yr male construction
worker
• Brick fell on the left shin at
work
• Open Tibia distal fracture .
• 4 cm Degloving wound on
the Antero medial aspect
of distal 1/3 of Tibia .
• No neuro vascular deficit
• No other injuries

23. Wound debridement and Spanning External fixation

25. 4cm x 3cm wound, bone fragments in
communication with wound: another 1cm wound
over posterior calf

26. Definitive treatment for fracture

27. skin defect of 6x4cm
exposed bone
comminuted #

28. Reverse hemi
Soleus flap with
SSG
http://www.woundsresearch.com/files/wounds/photos/huuangfigure1111.jpg
• medial part of the soleus
muscle
• for reconstruction of the
medial and distal parts of the
lower limb
• narrow tibial exposures and
irrigation
• based on the posterior tibial
artery perforators

32. Post op Day 4

33. Further readings
Soft-tissue coverage of an extensive mid-tibial wound with the combined medial gastrocnemius and medial
hemisoleus muscle flaps: The role of local muscle flaps revisited,Pu, Lee L.Q.,Journal of Plastic, Reconstructive &
Aesthetic Surgery , Volume 63 , Issue 8 , e605 - e610
Tobin, G.R. Hemisoleus and reversed hemisoleus flaps. Plast Reconstr Surg. 1985; 76: 87–96
Reddy, V. and Stevenson, T.R. Lower extremity reconstruction. Plast Reconstr Surg. 2008; 121: 1–7
Daigeler, A., Drucke, D., Tatar, K. et al. The pedicled gastrocnemius muscle flap: a review of 218 cases. Plast
Reconstr Surg. 2009; 123: 250–257
Heller, L. and Levin, L.S. Lower extremity microvascular reconstruction. Plast Reconstr Surg. 2002; 108: 1029–
1041