Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma

Abstract

The complex lower extremity wound is frequently encountered by orthopedic and plastic surgeons. Innovations in wound care, soft tissue coverage and surgical fixation techniques allow for improved functional outcomes in this patient population with highly morbid injuries. In this review, the principles of reconstruction of complex lower extremity traumatic wounds are outlined. These principles include appropriate initial evaluation of the patient and mangled extremity, as well as appropriate patient selection for limb salvage. The authors emphasize proper planning for reconstruction, timing of reconstruction and the importance of an understanding of the most appropriate reconstructive option. The role of different reconstructive and wound care modalities is discussed, notably negative pressure wound therapy and dermal substitutes. The role of pedicled flaps and microvascular free-tissue transfer are discussed, as are innovations in understanding of perforator anatomy and perforator flap surgery that have broadened the reconstruction surgeon’s armamentarium. Finally, the importance of a multidisciplinary team is highlighted via the principle of the orthoplastic approach to management of complex lower extremity wounds. Upon completion of this review, the reader should have a thorough understanding of the principles of contemporary lower extremity reconstruction.

Predictors of surgical site infection following reconstructive flap surgery: A multi-institutional analysis of 37,177 patients

“…Patient-related risk factors of SSI following UE&LE reconstruction have not been investigated previously. However, external protective factors against SSI have been reported and include early wound cleaning and reconstruction, the use of negative pressure wound therapy before reconstruction, and free flaps rather than local flaps ( 33 – 36 ). In patients who had RFS of the LE, the strongest predictor of SSI was disseminated cancer, a logical reason for RFS of the LE, and a surrogate for overall impaired systemic immunity ( 37 ), which potentially increases the risk of postoperative SSI.…”

Imaging for thinned perforator flap harvest: current status and future perspectives

“…One additional feature that makes indocyanine green angiography (ICGA) stand out is that it allows synchronized real-time perforator mapping and quantitative flap perfusion evaluation [ 17 ]. Such features can be invaluable, especially when larger flaps are involved [ 44 ]. A recent report on a successful unprecedented full-thickness skin graft-like thinned perforator flap with guidance further ascertained its significance in thinned flap harvesting [ 12 ].…”

Reconstruction of a knee defect in a morbidly obese patient with a pedicled reverse anterolateral thigh flap

“…Limited local tissue and exposed bone and ligaments often necessitate free tissue transfer. Microvascular reconstruction may be challenging due to pre-existing scarring and lack of reliable recipient vessels in the zone of injury 1–3. The result is often poor wound healing and prolonged recovery.…”