This presentation atalks about the various reconstructive options in upper and middle third leg defects.

1. Dr Raghav Shrotriya
Department of Plastic Surgery
KEM Hospital, Mumbai
Reconstruction of Upper and
Middle 1/3rd Leg Defects

2. Heads
■ Introduction
■ Patient evaluation
■ Criteria for amputation
■ Reconstructive Ladder
■ Algorithm for management
■ Options for wound cover

3. Introduction
■ Most major limb injuries were historically treated with
amputations and the patient was destined to die of infection
■ Pierre Joseph coined the term- “Debridement”.
■ Ollier introduced concept of immobilisation and developed
plaster cast
■ Till the second world war, amputation was still the primary
treatment
■ Refinements and improved knowledge of plastic surgery has
since then helped limb salvage

4. Types of wounds in the upper
third of the leg
■ Loss of skin/ skin and subcutaneous
tissue with no exposure of bone or
tendon.
■ Loss of skin and subcut with exposure
of periosteum.
■ Loss of skin and soft tissue with
exposure of bone/tendon/nerves
■ Loss of skin and soft tissue with bone
defect

5. Gustilo and Anderson
Classification

6. Amputation vs Salvage
■ Mangled Extremity Severity Score (MESS)
criteria
■ score relied on four criteria:
(1) skeletal/soft-tissue injury
■
(2) limb ischemia
(3) shock
(4) patient age

8. Risk factors for amputation
■ Gustilo IIIC tibial injuries
■ sciatic or tibial nerve injury
■ prolonged ischemia (>4–6 hours)/muscle
necrosis
■ crush or destructive soft-tissue injury

9. ■ significant wound contamination
■ multiple/severely comminuted fractures;
segmental bone loss
■ old age or severe comorbidity
■ apparent futility of revascularization or failed
revascularization.

10. Goal of Reconstruction
➢ To restore or maintain function
➢ Coverage of defects and open wounds of
leg to give patients a healed wound
➢ To let them resume their life, ambulate, and
go back to work while preventing
amputation

11. ■ The focus in recent times has been –
ideal tissue selection to achieve
optimal functional and cosmetic results
as well as reduced donor site morbidity

12. Anatomy

14. Anterior TA, EDL,
EHL, PT
Deep
peroneal
nerve
Ant. tibial
artery
Dorsal Flex,
ext. toes &
invert
lateral PL, PB Superficial
peroneal n.
Peroneal
artery
Flex, eversion
Superficial
posterior
Gast, Plant,
Soleus
Posterior
tibial N.
posterior
Tibial artery
Plant. flex
Deep
posterior
Popletius,
flexors ,
tibialis post.
Posterior
Tibial N.
posterior
Tibial artery
Plantar.
Flexion,
inversion
compartment muscles Nerve artery function

15. Indications for reconstruction
■ Trauma
■ Osteomyelitis
■ Post cellulitis debridement wound
■ Exposed hard wares
■ Tumors

16. Patient Evaluation
■ Primary Survey – A B C of trauma
■ Triage
■ Secondary Survey- limb trauma

17. Assessment of injury
■ History or mechanism of injury
■ Vascular status of the extremity
■ Size of the skin wound
■ Muscle crush or loss
■ Periosteal stripping or bone necrosis
■ Fracture pattern, fragmentation, bone loss
■ Contamination
■ Compartment syndrome
■ Coexisting co-morbid conditions

18. The Reconstructive Ladder

19. Concept of Reconstructive
Elevator

20. Primary management
■ Hemodynamic stability is ensured
■ Vascular status is assessed
■ All the devitalised area and dead bone is
debrided
■ If wound is suitable for cover, it should be
covered with a muscle or fasciocutaneous
flap
■ If there is a lot of contamination and
osteomyelitis is a distinct possibility, then
antibiotic impregnated beads are packed into
the dead space

21. Primary management
■ X rays to evaluate any fractures or
osteomyelitis
■ Presence of any implants
■ Orientation and position of external
fixators if any
■ Doppler examination if any suspected
arterial trauma

22. ■ Further dressings are done till the
wound is healthy
■ In case of severe contamination,
hyperbaric oxygen therapy which
causes release of nascent oxygen in
the wound thereby killing microbes can
be commenced

24. Skin and subcutaneous tissue loss
only with no exposure of vital
structures
■ These wounds are usually simple and can
be covered with STSG once they are
ready
■ VAC therapy can be applied to hasten the
granulation and also to reduce the size of
the wound
■ Such wounds are predominantly seen on
the posterior aspect of the leg

25. Loss of skin and subcut with
exposure of paratenon/ periosteum
■ Such wounds occur on the anterior aspect
of the leg and are not very common
■ If the exposed paratenon or periosteum is
viable and unbreached, interim cover can
be given with STSG
■ However, STSG take may not be very
sound and a muscle flap cover may be
required subsequently

26. Value of autologous tissue
■ The skin harvested from the degloved or
amputated part can be utilized as biologic
dressings to permanent skin grafts.
■ The leg length can be preserved using soft tissue
distal from the zone of injury as fillet pedicled or
free flaps.
■ Amputated bones can be banked or used as a
flap to reconstruct the leg.

27. Primary Limb Amputation
■ Absolute indications:
○ anatomically complete disruption of the posterior
tibial nerve in adults
○ crush injuries with warm ischemia time greater than
6 h.
■ Relative indications:
○ serious associated polytrauma,
○ severe ipsilateral foot trauma
○ anticipated protracted course to obtain soft tissue
coverage and tibial reconstruction.

28. Soft tissue coverage timing
Timing Failure rate Infection rate Bone healing
time
Hospital time
<72 hours 1% 2% 6.8 months 27 days
72 hours-3
weeks
12% 18% 12.3 months 130 days
> 3 weeks 10% 6% 29 months 256 days
How timing of free flap coverage affects outcome in treatment of open fractures, from
Godina

29. Timing of Reconstruction
■ Early intervention:Lowest complication
rate and highest success rate
associated with closure within the first
72 hrs
■ Minimizes the risk for increasing
bacterial colonization and inflammation
leading to complications.

30. Factors affecting wound cover timing
■ General condition of the patient and
vascular status of extremity
■ Condition of the wound
■ Bacterial status of the wound
■ Type of fracture, different types of tissues
involved in the injury
■ Presence of exposed structures

31. Direct Closure
■ Direct closure is simplest and often most effective
means of achieving viable coverage
■ May need to “recruit” more skin to achieve a tension
free closure
■ Decreasing wound tension can be
accomplished by:
○ Relaxing skin incisions
○ Application of negative pressure wound therapy

32. Soft Tissue Management: Split
Thickness Skin Grafts
■ Exposed muscle or soft tissue
■ Bone or tendon with healthy periosteum /
paratenon
■ IIIA fractures, without exposure of
vessels, nerves or bone
❖ Inadequate for IIIB and IIIC injuries

33. Indications for Flap Coverage
■ Skin graft cannot be used
○ Exposed cartilage, tendon (without paratenon),
bone, open joints, metal implants
■ Flap coverage is preferable
○ Secondary reconstruction anticipated, flexor joint
surfaces, exposed nerves and vessels, durablitiy
required, multiple tissues required, dead space
present

34. Flaps used for coverage of
defects over upper and middle
1/3rd leg
■ Transposition flaps
■ Perforator based flaps
■ Local and regional flaps
■ Microvascular free flaps
■ Cross leg flaps
■ Management of bone defects

35. Local flap – upper and middle third
■ Skin flaps: transposition
■ Fasciocutaneous flap
■ Medial gastrocnemius musculoctaneous
flap
■ Soleus
■ Tibialis anterior
■ Flexor digitorum longus
■ Flexor hallucis longus
■ Extensor digitorum longus
■ Extensor hallucis longus

36. Sliding Transposition Flap
■ Lateral movement of standard transposition
flap or “bipedicle flap”: transverse tension
across pedicle and embarrassment of its
blood supply
■ Use of sliding transposition flap obviates
transverse tension by insetting distal
oblique edge of flap in to contralateral side
of defect-draping long axis of flap loosely
across convex surface

37. Flap Design
■ Suitable donor site selected medial or
lateral to defect
■ From lower end of defect , oblique line
is drawn which is the distal edge of
flap (equal in length to contralateral
side of defect)

38. ■ From end of this line , lateral edge of
flap drawn towards the base
■ Width of base should be adequate to
sustain circulation
■ Length to width ratio of 3:2 is usually
adequate

40. Perforator based flaps
■ Medial and lateral superior genicular arteries supply
the region around the knee, and are a source of
local perforator flaps in knee reconstruction
■ Musculocutaneous perforators from the femoral
artery, as well as several septocutaneous branches
including the descending genicular artery, medial/
lateral superior genicular arteries, medial/lateral
inferior genicular arteries, anterior tibial recurrent
artery, and popliteal artery cutaneous branch

41. ■ The saphenous artery is a superficial branch of
the descending genicular artery, arising medially
with the saphenous nerve and vein
■ Sural arteries (medial/lateral) arise from the
popliteal trunk
■ PTA perforators (4–5 on average) arise in the
intermuscular septum between the soleus and
flexor digitorum longus.

42. ■ ATA perforators that occur in two rows – one
from the tibialis anterior muscle or between the
TA and EHL and the second from the
anteromedial septum between the peroneus
tertius and peroneus brevis
■ The peroneal artery perforator flap is based on
perforators that emerge distally in the
posterolateral septum between the peroneus
longus and soleus muscles

47. Propeller Flap Concept
■ Local island fasciocutaneous flap
based on a single dissected perforator
which can rotate up to 180
■ Better contour by avoiding dogear and
bulk

49. Muscle/ Musculocutaneous
flaps
■ Gastrocnemius muscle flap
■ Hemisoleus flap
■ Sural A flap
■ Lateral Genicular A flap
■ Saphenous Venous flap
■ Free Tissue Transfer

50. Gastrocnemius flaps
Anatomy : Superficial muscle
■ 2 heads arise separately
from lower femur , femoral
condyles and posterior
knee capsule
■ Achilles tendon
■ Action : plantarflexion of
foot and flexion of knee
joint
Vascular Anatomy:
■ Type I
■ Medial sural artery
■ Lateral sural artery
■ L=6cm
■ D=2mm

51. Operative Technique
■ Incision : Posterior midline or
longitudinal between muscle and
defect
■ Sural N. and Saphenous V. : 2 key
landmarks in midline preserved :
help to locate natural cleavage
between 2 muscle bellies
■ Muscle fascia incised and blunt
dissection used to create plane
between it and underlying soleus
■ Muscle transected distally with a
cuff of tendon which can then be
brought anterior to the tibia through
a subcutaneous tunnel and
insetted

52. Sural Artery Flap

53. Saphenous Venous Flap
■ First described by Dr.Thatte and Dr. Wagh
■ Unipedicled venous flap based on the long
saphenous vein
■ Survival of the flap is attributed to perivenous
or perineural capillary network
■ Flap can be used to cover defects of :
➢ Upper third of the leg including posterior surface
➢ Popliteal fossa

54. Flap Design
■ Rectangular fasciocutaneous
island,designed as a 1:3 proportioned
rectangle with LSV in middle
■ Base of flap : midpoint of leg
■ Lowermost limit : above lower 3rd of leg
■ Medial extension : stops around area
of subcutaneous portion of tibia-3-5cm
from LSV
■ Equal breadth available on
posteromedial surface
■ Base of island consists of LSV with its
adventitia and surrounding areolar
tissue
■ Narrow base : flap mobility in arc from
0 to 170 degrees

55. Saphenous venous flap

56. Soleus
■ Muscle or
myocutaneous flap
■ Can be carried 5 cm
proximal to its
insertion
■ Important in venous
pumping mechanism
■ Long term effects on
venous flow not
documented

57. Anatomy
■ Deep to gastrocnemius muscle
■ Origin: posterior head and body of fibula
■ Insertion: calcaneus through achilles tendon
■ Motor nerve: posterior tibial and medial popliteal nerves
■ Size : 8 x 28 cm

58. Vascular anatomy
■ Type II 8 x 28 cm
■ Dominant pedicle:
■ Popliteal artery
■ Posterior tibial
artery (Proximal 2
branches)
■ Peroneal artery
(proximal 2
branches )
■ Minor pedicle
3 or 4 segmental
branches of posterior
tibial artery

59. Arc of rotation
■ Distally based flap
■ Based on minor
pedicles
■ Reverse transposition
■ Covers lower 1/3 of
tibia

60. Soft Tissue Coverage for the
Middle 1/3 Tibia
▶ Soleus flap
▶ Narrower muscle belly
compared to gastrocs
and a somewhat less
robust vascular supply
▶ Less tolerant of tension
compared to gastrocs
flap so harvesting and
mobilization of muscle
belly can be technically
demanding

61. Distally based Gracilis flap

62. Microvascular free tissue transfer
■ Revolutionized the treatment of high-energy
lower extremity injuries
■ Provides excellent vascularised tissue and
most helpful in cases of osteomyelitis
■ Adequate tissue for large defects
■ Well vascularized tissue controls local
bacterial innoculum
■ Delivers oxygen and antibiotic to tissues
■ Promotes soft tissue healing
■ Anterolateral thigh flap and gracilis for
smaller defects are favoured.

63. Considerations
■ Length of pedicle
■ Contour
■ Easy of harvest without leaving a noticeable
donor deficit (lattisimus dorsi muscle, gracilis
muscle, anterolateral thigh flap)
■ The type of tissue deficiency and volume
■ Donor-site morbidity
■ Recipient-site requirements
■ Vascular pedicle length
■ The anticipated aesthetic result

64. ■ Free Anterolateral Thigh Flap
■ Free Gracilis Muscle Flap

65. Free ALT flap

67. Free Gracilis Muscle Flap

68. Bone defect- options
■ Tibial bone gaps up to 4 cm are ideal for
autogenous cancellous grafting
■ Defects ≥6 cm warrant consideration of
either Ilizarov bone transport or vascularized
bone transfer
■ Bone gaps ≥12 cm :
○ indication for free or pedicled vascularized bone
flaps

69. Distraction osteogenesis (Ilizarov)
■ Used for bone defects upto 10 cm (ideally upto
6cm)
■ Fracture ends debrided, cortical osteotomy
done away from zone of trauma and distractor
rings placed
■ Distraction begins after 7 days and proceeds at
1 mm per day till defect covered. Frame kept for
1 year
■ Provides strong and anatomically correct bone.
The soft tissue defect can be covered with a
flap

70. Distraction osteogenesis (Ilizarov)

71. Free vascularised bone grafts
■ Free fibula flap (segmental and
nutrient supply from peroneal artery)
■ iliac crest vascularized bone flap (deep
circumflex iliac artery)
■ the vascularized scapular flap
(circumflex scapular artery).

72. Vascularised free fibula graft
■ Used for defects 6cm and above
■ Based on peroneal artery, which supplies
nutrient artery to the fibula
■ Fibula has an excellent capacity for
remoulding and hypertrophy
■ Can be raised along with a soft tissue and
skin pedicle
■ An average of 5 months for partial weight
bearing and 15 months for full weight
bearing required

73. Cross leg flaps
■ Usually the last resort
■ Axial blood supply by posterior descending
subfascial cutaneous branch of the
popliteal artery
■ Indications:
○ Major lower extremity injury with axial vessels damage
○ History of previous trauma and thrombosis
○ Bone tumour resection with chemotherapy &/or radiotherapy.

74. ■ Contraindications of free flap
○ A single vessel run off, scarcity of local tissue, damaged
recipient vessels and poor general condition.
○ No access to microsurgery
■ Disadvantage: Requires immobilization
of both extremities for extended
periods of time

75. Compound Flaps
■ Consists of multiple tissue components
linked together in a manner that allows
their simultaneous transfer.
■ These separate components can be
maneuvered and placed in a three-
dimensional manner to achieve an ideal
one-stage reconstruction

76. Hallock’s classification

77. Supermicrosurgery
■ Microsurgical anastomosis of vessels, with
a diameter <0.8 mm.
■ Lymphaticovenous shunting to treat
lymphedema
■ relatively a new concept for lower extremity
reconstruction.
■ perforator-to-perforator anastomoses
approach

78. ■ allow an increase in the selection of recipient
pedicles.
■ less time is consumed to secure the recipient
vessel
■ to elevate the flap by taking just a short segment
of the perforator pedicle
■ minimizes any risk for major vessel injury or can
utilize collateral circulation without apparent flow
of major vessels while having acceptable flap
survival

79. Summary
■ Upper and middle third leg defects are common
problems post traumatic injury
■ Early cover gives best long term results
■ Gastrocnemius flap is the first choice for cover
■ Bone defects are managed either by cancellous
grafts, free fibula flaps or Ilizarow’s technique
■ Osteomyelitis remains the most important
complication

80. Thank You