Lower third leg defects
Anurag Pandey
Moderator : Dr Deepak Nanda
Anatomy
Blood Supply of Bones
Compartments of leg
Muscles of the Leg and Ankle
• Anterior Compartment
– Borders
• Lateral Shaft of Tibia
• Medial Shaft of Fibula
• Interosseous membrane
Anterior Compartment
– Structures
• Tibialis Anterior
• Extensor Hallucis
Longus
• Extensor Digitorum
Longus
• Peroneus Tertius
• Deep Peroneal Nerve
• Anterior Tibial Artery
• Anterior Tibial Vein
Lateral Compartment
– Borders
• Lateral Fibula
• Intermuscular fascia
between anterior
compartment and
posterior compartment
Lateral Compartment
• Arterial supply to
the lateral
compartment is
via perforating
branches of the
anterior &
posterior tibial
arteries
proximally and
the fibular artery
perforators
distally.
Lateral Compartment
• Structures
• Peroneus Longus
• Peroneus Brevis
• Superficial Peroneal
Nerve
• Peroneal Artery
• Superior and Inferior
Peroneal Retinaculum
Superficial Posterior Compartment
– Borders
• Deep posterior
compartment
• Fascia
Superficial Posterior Compartment
– Structures
• Soleus
• Gastrocnemius
• Plantaris
• Tibial Nerve
• Posterior Tibial
Artery
Deep posterior compartment
• Borders
– Interosseus
Membrane
– Posterior Tibia
– Posterolateral Fibula
– Superficial Posterior
Compartment
Deep posterior compartment
• Structures
– Tibialis Posterior
– Flexor Digitorum
Longus
– Flexor Hallucis
Longus
– Tibial Nerve
– Posterior Tibial
Artery
Causes of Defects
• Trauma
• Tumor Resection
• Vascular diseases – e.g. varicose veins
• Infection
• Others - Burns
Trophic ulcers
Classification of Open Fractures
Gustilo 1984
• Type I Open Fracture with a wound <1cm
• Type II Open Fracture with a wound <1cm
• Type III Open Fracture with extensive soft
tissue damage
• IIIA Type III with adequate soft tissue
coverage
• IIIB III with soft tissue loss with periosteal
stripping and bone exposure
• IIIC III with arterial injury requiring repair
Other Scoring systems
• Mangled Extremity Syndrome Index
• Mangled Extremity Severity Score
• Predictive Salvage Index
• Limb Salvage Index
• Largely complex and not accurately
predictive
(Bonanni et al 1993)
Historical Perspective
• Amputation: ancient technique‐
Hippocrates (400BC)
• Desault (1744‐1795): debridement of
traumatic wounds
• Ollier (1825‐1900): POP immobilisation
• WW1: Closed Plaster technique (Orr)
• Spanish Civil War: Trueta‐
– radical debridement before casting
• WW2: Same techniques but better antisepsis/
antibiotics
• 1960’s: Advent of flap transfer
• 1970’s: Microvascular techniques refined
Injury Recognition
• May be obvious, but degree of tissue damage
can easily be underestimated
• Be aware of closed degloving or crush injury
(either from trauma or immobilisation)
• Look for signs of vessel and nerve injury
• Involve orthopaedic and plastic surgeon
early
Treatment Plan
• Consideration of other injuries
• Prevent contamination of wounds by hospital
organisms (photo and cover)
• Initial wound debridement and fracture
stabilisation within 6 hrs
• Definitive wound coverage within 5 days
– NB consideration of
treatment location and timing
Types of fixation
Internal fixation
– May be associated with better rates of malunion and non
union
– May be more technically challenging
– May not preserve endosteal blood supply,
– Plates may compromise periosteum further
External fixateurs
– Fewer bone infections
– Easier to apply
– Associated with rates of high non/malunion
– Can get in the way of micro team
– Avoids extensive periosteal dissection
Timing of Soft Tissue Coverage
• Balance between adequate debridement and
development of infection
– Infection usually hospital acquired organisms
• Several studies addressing timing of wound
closure :Godina (1986)/ Gopal (2000)/ LEAP
study group (2000)
• Generally accepted: 3‐7 days is optimal, ie at
2nd look operation
Problems in coverage of lower 1/3
of leg
• Paucity of skin and soft tissue as the leg is
narrow as it comes down
• Subcutaneous placement of bone
• Most extrinsic flexors and extensors
become tendinous
• Little muscle available for transfer
• Sacrifice of donor muscle may impair
locomotor function
Reconstructive Techniques
• Secondary Intention
• Direct Closure
• Skin Graft
• Local Flap
• Regional Flap
• Distant Flap
• Free Flap
• Tissue Expansion
Skin grafts
• Technically simple
• Can cover large soft tissue defects
• Need appropriate wound bed
– no bare bone, open joints or tendons devoid of
paratenon
• Infected wounds?
• Thin, non‐durable skin cover
• Difficult to re-operate through
Flap Coverage
• Flap : tissue transferred or transplanted
with intact circulation
• Skin only
• fascia + skin
• Muscle
• muscle + skin
• Local
• Distant
• free flaps
Loco regional Flaps
• Fasciocutaneous flaps
Proximally based
Distally based
De epithelised turnover flaps
• Muscle Flaps
Distally based EDL
Tibialis anterior (for proximal wounds)
Peronius brevis
• Island flaps
Sural flap (distally based)
Saphenous flap
• Flaps based on perforator
• Propeller flap
Distant Flaps
Fasciocutaneous flap
crossleg flap
Freeflaps
• Free muscle flaps
gracilis free flap
rectus abdominis flap
latissimus dorsi flap
• Free fasciocutaneous flap
lateral arm flap
parascapular flap / scapular flap
radial forearm flap
Local fasciocutaneous Flaps
• Can be proximally or distally based
• Based on septocutaneous perforators from ant. Tibial,
post. Tibial and peroneal arteries
• These are possible only when the surrounding skin is
good
• Degloving of the surrounding skin reduces the reliability
of these flaps
• Perforator condition should be noted with a Doppler if
possible
• Medial perforators- From post. Tibial a.
pierce fascia in 4 regions- b/w 4-6 cm, 9-12 cm,
17-19 cm and 22-24 cm from medial malleolus
• Posterolateral perforators- from peroneal a.
Cluster at proximal and distal end of fibula
• Anterolateral perforators- from ant. Tibial a.
Perforate fascia just lateral to tibia
Cluster proximally b/w tibialis ant. & EDL and
distally b/w EDL & peroneus brevis
Local fasciocutaneous Flaps….
Transposition flap
‘V-Y’ advancement flap
• Takes
advantage of the
mobility of the
skin once the
fascia is fully
incised
• Based on one or
more perforators
Sural
Neurocutaneous
Island Flap
Distally based superficial sural
artery flap
• Described by Hasegawa
• Very widely used in various forms – pedicled, islanded,
adipofascial
• Can reach upto heel and proximal foot
• Delay is necessary in case longer flaps are required i.e.
going on to the upper third of the leg
Drawing of the procedure
Saphanous
neurocutaneous
island flap
Drawing of the procedure
Free flaps
• Requires microsurgical expertise
• A variety of of flaps can be used according
to one's preference
• Gracilis is used in smaller defects
Free Latissimus Dorsi Flap
Cross leg flaps
• In case of single vessel limbs
In case where the donor vessels are not suitable
for free tissue transfer
Ipsilateral flaps are not available
When other bridges have been burnt
Propeller flaps
Emerging concept
Isolation of pedicle helps 180 degree
rotation of the flap
Dissection around the pedicle may be
facilitated by the use of microscope
Scapula Free Flap
Scapular/Parascapular Free
Flap
• Triangular space
• May include bone
• Venous Supply
– Vena commitantes
• Arterial supply
– Circumflex scapular
Scapular/Parascapular Free
Flap
• Advantages
– Large skin paddle •Disadvantages
– Easy to harvest – Thick skin
– Difficult
– Low donor site
positioning
morbidity (closes
primarily)
– Availability for
bone
Lateral Arm Free Flap
• Venous supply
– Vena
commitantes in
spiral groove of
humerus
• Arterial supply
– Posterior radial
collateral artery
from profunda
brachii artery
Lateral Arm Free Flap
• Advantages
– Low donor site
• Disadvantages
morbidity (vertical
– Short and smaller
scar) caliber artery
– Easy positioning (maximum 14 cm)
– Potential for sensory – Longer dissection
innervation via posterior than RFFF
cutaneous nerve – Thicker
subcutaneous tissue
Rectus Abdominus Free Flap
• Arterial supply
based on deep
inferior epigastric
artery
• Venous supply form
vena commitantes
joining external iliac
vein
Rectus Abdominus Free Flap
• Advantages
– Easy positioning and
• Disadvantages
harvest – Often bulky
– Long and large – No sensation
caliber vessel potential
– Donor site closed – Potential for
hernia formation if
primarily
dissection below
– Large flap obtained arcuate line
– Anterior rectus
sheath durable
Latissimus Dorsi Free Flap
• Arterial supply
based on
thoracodorsal artery
• Venous drainage
from thoracodorsal
vein
• Motor nerve
innervation potential
with thoracodorsal
• nerve
Latissimus Dorsi Free Flap
Advantages
– Large flap with long
pedicle Disadvantages
– Possibility for – Difficult
“axillary megaflap” positioning
– Low donor site and two team
morbidity harvest
– Possibility of muscle – Postoperative
reinnervation via seroma formation
thoracodorsal nerve – Bulky flap
Radial Forearm Free Flap
• Venous Source
– Deep venous
commitantes
and/or cephalic
vein
• Arterial source
– Radial artery
Radial Forearm Free Flap
Advantages
– Thin skin with long, large
pedicle Disadvantages
– Loss of hand
– Easy positioning
– Poorly aesthetic donor
– Potential for sensate flap site
– Potential for unusual – Requires skin graft
shapes – Potential for pathologic
– Potential for vascularized fractures
– Loss of hand function
bone
– Ease of preoperative
evaluation
Lateral Thigh Free Flap
• Arterial supply is
from third perforator
of profunda femoris
artery
• Venous output from
associated vena
commitantes
Lateral Thigh Free Flap
• Advantages
– Large amount of
thin, hairless skin
– Low donor site
morbidity (primary Disadvantages
closure)
– Difficult
dissection
– Easy positioning
– Small, variable
– Sensation potential
pedicle
with lateral femoral
cutaneous nerve
Fibula Free Flap
Arterial supply based
on peroneal artery
• Venous supply is
accompanying vena
commitantes
• Aberrations in blood
supply (10%)
• Peripheral vascular
disease
Fibula Free Flap
Advantages
– Longest and
strongest bone stock Disadvantages
– Low donor site – High incidence of
morbidity peripheral vascular
– Easy positioning disease
– Excellent periosteal – Small cutaneous
blood supply
paddle
(contouring)
– Decreased ankle
strength and toe
– Support
flexion
osseointegrated
– Small risk chronic
implants
ankle pain
Advantages
-allows for transfer of bone, soft tissue
and skin in a one-stage procedure using
only one donor site
-fibula flap allows the most bone (up to
25-30cm) vs. 10-15 for the other bone
flaps
-blood supply to fibula is both
intraosseous and segmental, therefore,
osteotomies can be made
-fibula allows for a skin paddle up to
25cm in length and 5cm in width
A: scapula B: iliac crest C: radius D: fibula
