Wound coverage considerations for defects of the lower third of the leg

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1 Review Article Wound coverge considertions for defects of the lower third of the leg Bu Bjntri, R. Rvindr Bhrthi, S. Rj Spthy Deprtment of Plstic, Hnd nd Reconstructive Microsurgery nd Burns, Gng Hospitl, Mettuplym Rod, Coimtore, Tmil Ndu, Indi Address for correspondence: Dr. S. Rj Spthy, Deprtment of Plstic, Hnd nd Reconstructive Microsurgery nd Burns, Gng Hospitl, Mettuplym Rod, Coimtore, Tmil Ndu, Indi. Emil: ABSTRACT Antomicl fetures of the lower third of the leg like sucutneous one surrounded y tendons with no muscles, vessels in isolted comprtments with little intercommuniction etween them mke the coverge of the wounds in the region chllenging prolem. Free flps continue to e the gold stndrd for the coverge of lower third leg wounds ecuse of their ility to cover lrge defects with high success rtes nd fesiility of using it in cute situtions y choosing distnt recipient vessels. Reverse flow flps re more useful for the coverge of the nkle nd foot defects thn lower third leg defects. The perfortors in the lower third leg on which these flps re sed re often dmged during the injury. In medium-sized defects of less thn 50 cm 2 size, locl trnsposition flps, perfortor flps, or propeller flps cn e used. Preopertive identifiction y the Doppler is essentil efore emrking on these flps. Of the muscle flps, the peroneus revis flp cn e used in selected cses with smll defects. In spite of ll recent developments, cross-leg flps continue to remin s useful technique. In rre occsions when other flps re not possile or when other options fil it cn e life ot. In the uthor s prctice free flps continue to e the first choice for coverge of wounds in the lower third leg with grcilis muscle flp for smll nd medium defects, ltissimus dorsi muscle flp for lrge defects nd nterolterl thigh flp when skin flp is preferred. KEY WORDS Free fl ps; perfortor fl ps; lower leg defects INTRODUCTION The ntomicl fetures of the lower third of the leg mke the wound coverge of the soft tissue loss into chllenging prolem. The ones of the lower third re vulnerle to injury. Due to the pucity 283 Quick Response Code: Access this rticle online Wesite: DOI: / of soft tissues round them, the frctures tht occur re often open. Most muscles ecome tendons t tht level nd in the cse of soft tissue loss, skin grft my not suffice nd flp cover ecomes mndtory. The three mjor rteries to the leg, nterior nd posterior tiil, nd peronel re in closed comprtments nd they do not hve significnt communictions etween them. Recently lot of work hs een done on the perfortors rising from these vessels in the lower third of the leg. The ones from the posterior tiil nd the peronel re significnt nd could e used for flps in the region. These perfortors my e lost in degloving injuries nd such flps my not e possile. Indin Journl of Plstic Surgery My-August 2012 Vol 45 Issue 2

2 Conventionl teching recommends gstrocnemius muscle nd myocutneous flps nd fsciocutneous flps for the upper third leg defects, soleus flps for the middle third defects nd free flps for the lower third defects. Understnding of the vsculr supply of muscles nd the mpping of the perfortors hs widened the resources ville for the plstic surgeon for the coverge of the lower third of the leg. In this rticle, we hve tken the commonly used flps nd detil the technicl spects which we feel re importnt for otining good outcome. FREE FLAPS FOR THE LOWER THIRD OF LEG WOUNDS In spite of the dvent nd usge of other options like reverse flow flps nd perfortor flps, free flps continue to e the gold stndrd for coverge of lower third leg defects [Figure 2]. Free flps hve the following dvntges. 1. The size or the geometry of the defect is not n issue when plnning free flps. 2. It cn sfely e used in cute trum y sourcing DEBRIDEMENT Qulity deridement is the key to success for the heling of the wounds in the lower third of the leg. This hs to follow the well lid out guidelines of deridement. [1,2] In the lower leg, it is prticulrly importnt when the nkle joint is open. In such situtions, the mximum displcement seen t the time of initil exmintion is not the mximum displcement tht hppened t the time of injury. [Figure 1] The wound is usully on one side nd it is quite possile tht the tissues on the other side of the nkle re contminted due to their direct contct with the injuring surfce. This re hs to e derided well efore reduction of the frcture disloction to prevent infection. After frcture fixtion it is not possile to rech this re nd it is one of the commonest cuse of infection nd non-heling of the wounds in the region. Figure 1: () A wound t the lower third of the leg, showing the frcture disloction of the nkle joint. () The rel extent of displcement tht would hve occurred t the time of the ccident, in which even the lterl side of the nkle would hve een directly exposed to the contminnts. This my escpe the scrutiny of deridement predisposing to infection c d Figure 2: ( nd ) A ptient with ilterl lower third leg open frcture with soft tissue loss, (c) oth sides covered y grcilis free fl p nd (d) the result t 5 weeks with complete heling of the wounds Indin Journl of Plstic Surgery My-August 2012 Vol 45 Issue 2 284

3 recipient vessels wy from the zone of injury. 3. It does not involve dditionl scrring in the surrounding re, s would hppen when locl flps re used nd their size does not llow primry closure. 4. When well plnned, the success rte could e s high s 98%. 5. Choice of free flp could e mde ccording to the need of the defect - muscle flps when cvities need to e filled nd skin flps when surfce defects re to e covered or ccess is needed for secondry procedures like one grfting. TECHNICAL TIPS The success of free flps to the lower third of the leg so much depends upon choosing good recipient vessels, it hs een sid tht the surgery of free flps to the lower third of the leg is the surgery of choosing the recipient vessels. The vessels must e chosen wy from the zone of injury. This could e done y extending the wound to source the vessels. Usully the posterior tiil rtery is chosen, ecuse the nterior tiil vessels ecome deeper s we go proximlly into the middle third of the leg. Godin who propgted the concept of erly free flp cover for open frctures suggested the technique of exposing the vessels from the poplitel foss in the midline nd continuing distlly until the extent where good vessels re present in proximity to the wound. [3] The vessels re pproched etween the two heds of gstrocnemius nd spitting the soleus in the midline. The vessels re esily ccessile. He dvocted this technique even to the wounds of the lower third of the leg, since it ensured tht there ws no proximl level injury to the veins. While this technique my not e prcticed in ll situtions, it is sfe method to follow when there is segmentl frcture of the oth ones of the leg or proximl injury nd there is possiility of dmge to the vene commitntes t proximl level. Routinely done, it does not tke extr time nd the effort is worth the confidence it provides during the procedure. Sometimes nterior or posterior tiil vessels my e injured nd the injured vessel could e used s the recipient vessel. Though it ppers to e the nturl sequence of decision, it hs to e done with cre. This prctice is sfer to use in the cute sitution. Even within h of injury, the rtery needs to e exmined closely 285 to remove ll thromus in the end. In ligted or divided vessel, clot fills up the vessel t lest up to the first rnch, proximl to the injury nd the vessel needs to e excised proximl to tht level. Good pulstile flow must e otined efore the vessel is ccepted s the recipient vessel. In single vessel lim, it is sfer to choose the single vessel (mostly the posterior tiil rtery) nd ttch the flp y performing n end to side nstomosis. [4] We feel this is sfer nd esier lterntive thn choosing the nterior tiil rtery t proximl level. Surgeons routinely performing free flps to the lower third of the leg must ecome proficient in end to side nstomosis. Angiogrms re rrely needed to know the vessel sttus nd we hve never done one. In prospective study of 36 ptients, Lutz et l. found tht in none of the cses with t lest one plple pulse did preopertive ngiogrphy dd relevnt informtion which led to pln chnge in free flp trnsfer. [5] Authors concluded tht preopertive ngiogrphy is indicted only when other pedl pulses re not plple, nd tht norml preopertive ngiogrphy does not gurntee the presence of vessels suitle for nstomosis. Most prolems occur due to the veins nd no investigtion would revel their sttus for microvsculr nstomosis. Useful informtion cn e otined y creful clinicl exmintion. Both dorslis pedes nd posterior tiil pulses must e felt efore deciding the choice of vessel. It is good prctice to do n Allen s test. Simultneously oth pulstions re felt nd compression of the posterior tiil rtery will mke the dorslis pedes pulse to dispper if the lim is supplied y the posterior tiil rtery only. In such situtions, end to side nstomosis with posterior tiil rtery is mndtory. Vene commitntes re the preferred choice of veins for free flps. They re dequte enough nd re esily ville ner the site of rteril nstomosis. Sometimes the long sphenous vein is used. The superficil veins in the lower third of the leg re quite musculr nd they re more prone to spsm thn the deeper veins. The vessel ends need to e well dilted efore using them. When high flow flps like the ltissimus dorsi flps re used, venous dringe is criticl nd good clire vein needs to e chosen. When free flps re done secondrily or for chronic wound more cre needs to e exercised in choosing the vessels, ecuse filures re higher thn when free Indin Journl of Plstic Surgery My-August 2012 Vol 45 Issue 2

4 flps re done to the lower third of the leg defects for cute wounds. Chronicity nd infection mke the vessel dissection difficult. The edem tht occurs during the initil insult, infection or chronicity leds to firosis long the neurovsculr plne. This mkes the dissection of the veins difficult nd they rupture with every ttempt t isoltion. Good qulity veins nd rteries hve good plne of tissue to dissect round them nd this is used s guideline in choosing the vessel for nstomosis. A nice plne must e ville round the vein t the level of nstomosis. This is the singulr dvntge of the Godin pproch in choosing the recipient vessels for the free flp. Cn vessels distl to the injury e used for ttching the free flp? Sometimes the division of the rtery, which hs een pulsting, revels tht the flow is retrogrde thn ntegrde. In such situtions, the rtery cn e ttched to the distl segment, ut the veins hve to e ttched in the regulr mnner. This is more possile in middle third defects thn in the lower third leg defects. In ll suspected situtions, it is etter to go for n end to side nstomosis. Complictions Flp monitoring nd nstomosis prolems re delt the sme wy s when performing free flps in other res nd hence not discussed in detil. A compliction specific to the reconstruction of the lower third of the leg defects is lone discussed. In single vessel lim, indvertently if n end to end nstomosis is done, the mount of distl lood flow due to collterl circultion my not e sufficient in some cses. This my declre itself y the foot ecoming ple t the end of the nstomosis. If it is very ple, it my e etter to re-estlish the circultion nd then perform n end to side nstomosis for the flp t different level. A vein grft my e needed. This is sfer lterntive when distl vsculrity is very poor. When llowed to declre itself, it tkes few dys nd it strts with the toes losing turgidity followed y shrinking nd colour chnge. At tht stge, nothing ctive cn e done nd one must wit to decide on the level of secondry mputtion. This stel phenomenon cn occur prticulrly in elderly people who hve peripherl vsculr disese. [6] REVERSE FLOW FLAPS Reverse flow flps sed on the nterior tiil nd posterior tiil rtery re known ut re seldom used to cover defects of the lower leg since they scrifice mjor vsculr supply to the foot. Reverse flow flps which do not scrifice mjor vessel re populr in institutions where microsurgicl fcilities re not ville. They re sed on the vessels tht ccompny the surl nerve nd lesser sphenous vein. [7] These vessels re linked with septocutneous perfortors rising from the peronel rtery in the lower third of the leg. A constnt perfortor ville t 5-8 cm proximl to the lterl mlleolus is good one to se the flp. [Figure 3] When used for lower third leg defects, one hs to e sure tht the link etween the perfortors nd the rteries ccompnying the surl nerve nd the lesser sphenous vein re intct. In cute trum situtions, one hs to e creful. Reverse flow flps re sfer for nkle nd foot defects thn lower third defects. Good udile Doppler signls re importnt efore emrking on this flp. Most of the posterior spect of the skin in the middle third of the leg cn e tken s reverse flow flp nd used to cover the lower leg defects. The surl nerve is deeper to deep fsci proximl to the middle of the leg nd lies etween the two heds of the gstrocnemius. When elevting the flp, the proximl incision is mde first nd the surl nerve nd the lesser sphenous vein re first identified eneth the fsci nd included in the flp. As dissection proceeds distlly, the se of the flp could e c Figure 3: () The defect in the lower third leg exposing the frcture site, () covered y reverse fl ow surl rtery fl p nd (c) shows the ovious donor site Indin Journl of Plstic Surgery My-August 2012 Vol 45 Issue 2 286

5 nrrowed to just include the nerve nd the vein nd is centred on the posterior peronel intermusculr septum to include the perfortors rising from the peronel vessels. In this wy, the flp is mde relile. Flps of smller dimeter (up to 5 cm) cn e directly closed. These flps shre the disdvntge of estheticlly uncceptle donor sites common to ll lrge flps rised from the leg when they hve to e covered with the skin grft. In this spect, the free flps hve definite dvntge. LOCAL AND PERFORATOR FLAPS IN THE LOWER THIRD OF THE LEG Locl trnsposition flps cn e used to cover smll defects in the lower third of the leg nd their gretest limittion is the size of the defect they could cover in this region [Figure 4]. Incresed understnding of the lood flow dynmics hs shown us tht vessels of smll dimeter when isolted cn supply lrge territory of the skin. Flps sed on these smll vessels clled s perfortors could e used to cover even ig defects. The flp could e islnded nd sed only on the perfortors nd it increses the moility of the flp. When turned over 180, it is clled s propeller flp [Figure 5]. Dissection requires skill nd it cn e clled s microsurgery without nstomosis. Figure 4: () An open frcture disloction of the nkle which fter reduction left trnsverse defect which could not e primrily closed, () covered y locl trnsposition fl p 287 These flps re prticulrly useful for smll- to mediumsized defects round the nkle up to 50 cm 2 in size. For the defects on the medil nd nterior leg, propeller flps sed on the perfortors of the posterior tiil rtery, which seems to hve constnt perfortor t round 10 ± 2 cm could e sfely done. For nrrow criticl defects V Y dvncement cn e done wherein one or multiple perfortors supplying the skin islnd cn e sfely dvnced to cover the defect. On the lterl spect distlly, the peronel perfortors re smller in size nd numer nd re not tht constnt in position. In such sitution throw over flp sed on the posterior tiil rtery perfortor cn e sfely done. [8] It is good to do preopertive Doppler to mrk the perfortors on which the flp cn e plnned. However, there is high percentge of flse-positive signls. The perfortors re est identified on the tle y using n explortory incision. Depending on the numer nd size of the perfortors, one hs to e redy to lter the pln. For posterior tiil rtery, the explortory incision is usully mde posteriorly tking cre to plce it over the musculr prt nd preserve the fsci over the tendochilles. We hve noted constnt significnt perfortor t the level 10 ± 2 cm from the medil mlleolus. If we see perfortor going to the muscle, we expect cutneous perfortor t the sme level. After hving identified the perfortor of dequte size, the flp is plnned sing it s pivotl point. Adding n dditionl 1 cm length of the flp llows esy inset. It hs een oserved tht the clockwise rottion of the flp kinks the pedicle less nd hence the flp should e plnned ccordingly. The flp is islnded retining ll the significnt perfortors to it. After relesing the tourniquet, the flp viility is checked sed on the perfortor on which it hs een plnned y temporrily clmping the other perfortors with microclmps. If it is dequte, the other perfortors re divided. If not, it requires n ltertion in the pln. All the firous strnds round the pedicle re crefully removed with microforceps nd scissors to void kinking of the vein on rottion. Now the flp cn e rotted to the defect. The flp is inset with few loose sutures. The donor defect cn e closed primrily only in nrrow longitudinl defects. In cute trum, skin grfting of the donor site is preferred ecuse the edem mkes closure tight nd difficult. While doing this flp, we cnnot commit till the perfortor is identified. In the sence of the idel perfortor, one hs to e prepred to do free flp. Indin Journl of Plstic Surgery My-August 2012 Vol 45 Issue 2

6 c d Figure 5: () A mjor crush injury of the lower third of the leg, () the defect fter deridement nd the Doppler exmintion showed good udile signls t X, nd fl p mrked, (c) the proposed fl p elevted on one side nd the perfortor visulized efore the whole fl p is rised, (d) the fl p rised nd rotted through 180 degrees to cover the criticl re nd (e) well-settled flp nd the heled donor re e MUSCLE FLAPS In the distl third of the leg, ll the muscles ecome tendinous nd hence there is not enough of muscle ulk to provide flp cover. However distlly sed peroneus revis muscle flp hs een descried which cn relily cover the defects in the lower leg nd round the mlleolr regions. [9,10] This is sed on the distl perfortor which is found within 6 cm from the tip of lterl mlleolus [Figure 6]. This is the lst of the series of perfortors supplying the muscle. CROSS LEG FLAPS Cross leg flps, in spite of the inherent moridity ssocited with the procedure, continue to remin s useful technique for the coverge of wounds in the lower third of the leg. They re prticulrly useful when the lower third of the defect is ssocited with proximl injury. In such cses though the rteries my e ptent, suitle veins for the free flp my not e ville. Cross leg flp when plnned for the lower third leg defects hs to e distlly sed flp [Figure 7]. The se is to e plned to include perfortors not only from the posterior tiil rtery ut lso from the peronel rtery nd the surl nerves. While plnning, the length of the proximl edge of the flp will e equl to the length of the defect. If long ridge segment is needed nd if the flp extends to the proximl third of the leg, prior dely is dvised. Since cross leg flps re resorted to in situtions where other options re not fesile, it is sfer to dely the flp. Flps division is done t 3 weeks. If the inset of the flp exceeds more thn 70% of the outline of the defect, dely prior to division my not e needed. ROLE OF VAC VAC or vcuum-ssisted closure, otherwise clled NPWT (negtive pressure wound therpy) hs een used extensively in complex wounds of the lower lim either s n interim mesure efore the definitive cover or s definitive therpy to chieve wound cover y forming grnultion tissue over the implnts nd exposed ones over which skin grft cn e pplied. In retrospective study pulished in 2006 y Prrett et l., [11] they found chnging trend in the use of free flps in period of 12 yers. Free flps decresed from 42% over the first period to 11% in the lst 4 yers when VAC ws extensively used. They hve sid tht there is no sttisticlly significnt difference in infection, mputtion nd mlunion/nonunion rtes. Bhttrchryy [12] studied the infection rte in 38 ptients with Grde III B open frctures treted with NPWT to see if the definitive time for wound closure cn e extended eyond the conventionlly held view of 7 dys. There ws n increse of infection rte from 12% to 57% despite the Indin Journl of Plstic Surgery My-August 2012 Vol 45 Issue 2 288

7 c Figure 6: () A defect on the lterl side of the lower third of the leg nd () the distlly sed peroneus revis muscle rised retining the lst perfortor. The clmp is on the proximl perfortor to confirm the viility of the muscle with the distl perfortor, (c) the muscle turned over to cover the defect nd (d) the heled wound with primrily closed donor defect d Figure 7: () Exposed one in the lower third leg with grft ll round in mjor crush injury leg with no good proximl recipient vessels. () Distlly sed cross leg fl p, where the proximl edge ttches to the length of the defect (c) fter completion of reconstruction c use of negtive pressure. Although the study is smll, this does suggest degree of cution in using NPWT s delying tctic in lower extremity trum nd suggests tht the strtegy of trying to close these wounds within 7 dys is still essentil in the er of negtive pressure wound therpy. DISCUSSION We now hve set of vile lterntives to cover the vrious defects in the lower third of the leg. Wht would one use depends upon the fmilirity nd the comfort levels of the surgeon with the technique s much s the vrious circumstnces. This is sometimes good since y repetedly doing the procedure one msters the technique which helps to keep the complictions down. But however good the surgicl skills my e, ech flp nd technique hs its own inherent limittions. Hence, it is good tht plstic 289 surgeon is fmilir with ll techniques so tht he hs wide choice to choose from to the enefit of the ptient prticulrly in demnding sitution s when covering defect in the lower third of the leg. Of ll the ville options, free flps still remin the gold stndrd for the coverge of soft tissue defects of the lower third of the leg. Skin or muscle free flps could e chosen s per the need, nd the size nd shpe of the defect re not fctor nd estheticlly lso it is the most desirle since it does not leve donor defect in the vicinity. When microsurgicl fcilities re not ville, other options my e chosen eing fully wre tht locl pedicled flps nd perfortor flps re eqully techniclly demnding procedures. Negtive pressure wound therpy is populr ut there re no studies which del exclusively with lower third Indin Journl of Plstic Surgery My-August 2012 Vol 45 Issue 2

8 leg defects. It is good temporry mesure to cover the wound ut not e used s delying tctic to performing flp cover when needed. While in other prts of the lower lim it my reduce the incidence of the need for flp cover, it is questionle s to how much it will reduce the need in the lower leg nd nkle region. If there would e need for secondry procedures like one grft or one trnsport to e done, then erly skin flp cover is etter option. With the knowledge of perfortors supplying the lower third leg, locl flps nd perfortor flps re eing done with incresing frequency. They re limited y size tht they could cover nd re to e done with equl cre s though performing microvsculr procedure. Helthcre delivery is currently very much influenced y the cost of cre nd the surgeon s choice of vrious procedures is lso influenced y the reimursement levels. Hence, studies of the vrious procedures should lso e evluted y the socil system in which the study hs een performed. Ultimtely the surgeon should choose the procedure which in his hnds would give the est result keeping the est interest of the ptient in mind. REFERENCES 1. Gupt A, Shtford RA, Wolff TW, Tsi TM. Scheker LR. Vevin LS. Tretment of the severely injured upper extremity. J Bone Joint Surg 1999;81: Spthy SR. Deridement prepring the wound ed for cover. In: Srhi S, Tiwri VK, editors. Principles nd Prctice of Wound Cre. New Delhi: Jypee Puishers; p Godin M. A thesis on the mngement of injuries to the lower extremity. PresernovDruz. Ljuljn: Godin M. Preferentil use of end-to-side rteril nstomoses in free fl p trnsfers. Plst Reconstr Surg 1979;64: Lutz BS, Wei FC, Mchens HG, Rhode U, Berger A. Indictions nd limittions of ngiogrphy efore free fl p trnsplnttion to the distl lower leg fter trum: Prospective study in 36 ptients. J Reconstr Microsurg 2000;16: Sonntg BV, Murphy RX, Chernofsky MA, Chowdry RP. Microvsculr stel phenomenon in lower extremity reconstruction. Ann Plst Surg 1995;34: Msquelet AC, Romn MC, Wolf G. Skin islnd fl ps supplied y the vsculr xis of the sensitive superfi cil nerves: Antomic study nd clinicl experience in the leg. Plst Reconstr Surg 1992;89: Bjntri B, Spthy SR, Burgess TM. The throw over fl p; modifi ction of the propeller fl p for reconstruction of nondjcent soft tissue defects. Indin J Plst Surg 2011;44: Ng YH, Chong KW, Tn GM, Ro M. Distlly pedicled peroneus revis muscle fl p: A verstile lower leg nd foot fl p. Singpore Med J 2010;51: Lorenzetti F, Lzzeri D, Bonini L, Ginnotti G, Piolnti N, Lisnti M, et l. Distlly sed peroneus revis muscle fl p in reconstructive surgery of the lower leg: Postopertive nkle function nd stility evlution. J Plst Reconstr Aesthet Surg 2010;63: Prrett BM, Mtros E, Priz JJ, Orgill DP. Lower extremity trum: Trends in the mngement of soft-tissue reconstruction of open tii-fi ul frctures. Plst Reconstr Surg 2006;117: ; discussion Bhttchryy T, Meht P, Smith RM, Pomhc B. Routine use of wound vcuum- ssisted closure does not llow coverge dely in open tiil frctures. Plst Reconstr Surg 2008;121: How to cite this rticle: Bjntri B, Bhrthi RR, Spthy RS. Wound coverge considertions for defects of the lower third of the leg. Indin J Plst Surg 2012;45: Source of Support: Nil, Conflict of Interest: None declred. Indin Journl of Plstic Surgery My-August 2012 Vol 45 Issue 2 290