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Soft Tissue Coverage for the Leg

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         - Arteriography 
         - Foot Reconstuctive Surgery 
         - Microanastomosis 
         - Pharmocological Agents in Vascular Surgery 

Initial Wound Care of Open Tibia Fractures

- Soft Tissue Coverage Following Tibial Frx: (Tibia Frx)
    - STSG;
          - split thickness skin grafts require a tissue bed such as periosteum that is capable of granulating;
          - skin graft will not take exposed bone stripped of its periosteum;
    - mechanical closure techniques:
          - references:
                 - The shoelace technique for wound closure in open fractures: report of early experience.
                 - The "rubber band technique": a simple method for closing large skin defects. 
                 - A simple solution for wound coverage by skin stretching
    - multiple relaxing incisions:
          - technique involves creation of multiple 5-10 mm incisions (made w/ 15 blade scapel) thru the dermis made in 1 cm wide rows parallel to
                 wound (w/ the initial MRI made 1 cm from the wound);
                 - the number of rows of relaxing incisions depends on the tightness of soft tissue;
                 - w/ in 3 weeks the relaxing incisions heal by contraction;
          - this technique was demonstrated to be effective in 22 patients w/ lower extremity orthopaedic trauma (there were no skin sloughs or wound infections);
          - technique can also be used to close fasciotomy incisions;
          - relative contra-indication: degloving injuries and possible tranverse wounds;
          - references:
                 - Multiple Relaxing Skin Incisions in Orthopaedic Lower Extremity Trauma.   
                 - Rockwood and Green's fractures in adults
                 - How to Reduce the Morbidity of Wound Closure following Extensive and Complicated Laminectomy and Tethered Cord Surgery
                 - Local-Advancement Soft-Tissue Coverage in a Child with Ipsilateral Grade IIIB Open Tibial and Ankle Fractures 

    - wound VAC;
                 - The use of a subatmospheric pressure dressing to salvage a Gustilo grade IIIB open tibial fracture with concomitant osteomyelitis to avert a free flap. 
    - fasciocutaneous flaps: 
                   - Distally-based random fasciocutaneous flaps for multi-staged reconstruction of defects in the lower third of the leg, ankle and heel.
                   - Distally-based random fasciocutaneous flaps for one-stage reconstruction of defects in the upper two-thirds of the leg.
                   - Distal lower leg local random fasciocutaneous flaps.
                   - Local fasciocutaneous flaps for cutaneous coverage of lower extremity wounds
                   - Perforator based flap coverage from anterior and lateral compartment of leg for medium sized traumatic pretibial soft tissue defects. 
                   - Muscle flap transposition for traumatic soft tissue defects of the lower extremity.  
                   - The reversed fasciosubcutaneous flap in the leg 
                   - Muscle transposition in lesions of the ischemic leg.
                   - Skin Island Flaps Supplied by the Vascular Axis of the Sensitive Superficial Nerves: Clinical Experience in the Leg
                   - Muscle transposition for treatment and prevention of chronic post-traumatic osteomyelitis of the tibia
                   - Peroneal island flap for skin defects in the lower extremity
                   - Early microsurgical reconstruction of complex trauma of the extremities
                   - The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury
                   - Anatomic Basis of Local Muscle Flaps in the Distal Third of the Leg.  
                   - Rotation fasciocutaneous flap repair of lower limb defects. 
                   - Sural Versus Perforator Flaps for Distal Medial Leg Wounds

    - local muscle flaps;
         - wounds located over the proximal third of tibia can usually be covered with local muscle flaps;
         - gastrocnemius Flap
                 - anterior and medial surfaces of tibia usually can be covered w/ medial head of the gastrocnemius muscle;
                 - lateral defects are best covered with a lateral gastrocnemius muscle.
         - soleus flap:
                 - reserved for defects in the middle third of leg; 
                 - Use of the soleus muscle flap to cover part of the distal tibia.  
         - dorsalis pedis fasciocutaneous flap:
         - tibialis anterior flap:
                 - ref: The tibialis anterior used as a local muscle flap over the tibia after soft tissue loss. 
         - tibial shortening to enhance local muscle flaps:
                 - The Gradual Expansion Muscle (GEM) Flap 

         - in the report by Ögün TC, et al., the authors report on a distally based superficial sural artery flap, first described as a distally based
                 neuroskin flap by Masquelet et al., is a skin island flap supplied by the vascular axis of the sural nerve;
                 - it has the largest arc of rotation of all flaps that have been described in this region;
                 - most important advantage is that it does not compromise a major artery;
                 - it is simple to dissect and has a low donor morbidity;
                 - new indication for patients with neglected ruptures of Achilles tendon;
                 - in 13 patients, the flap was successfully transferred;
                 - in two cases, partial necrosis of the flap ensued, which healed with secondary intention;
                 - references:
                          - An Easy and Versatile Method of Coverage for Distal Tibial Soft Tissue Defects.  
                          - Skin island flaps supplied by the vascular axis of the sensitive superficial nerves: anatomic study and clinical experience in the leg.
    - free tissue transfer:
         - used for massive defects that cannot be covered by local muscle in middle and proximal thirds of leg or enlarged defects in distal third of leg;
         - in the report by Pollak AN, et al. (2000), 190 patients (195 limbs) required flap coverage and had six months of follow-up;
               - authors found that use of a free flap to treat limbs with a severe underlying osseous injury was significantly less likely to lead to
                         a wound complication requiring operative intervention than was use of a rotational flap.  
         - common choices:
               - epigastric and rectus abdominis flap:
               - latissimus dorsi
               - gracilis
               - dorsalis pedis fasciocutaneous flap
         - early coverage of soft-tissue deficits of the extremity is indicated in order to minimize infection risk, promote vascularization of underlying
                    bone, and prevent dessication of exposed tissues; 
          - ref: Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia.
    - prognosis: (following free flap coverage);
         - long term free flap survival can be expected in about 85% of patients;
         - ultimate result depends on obtaining frx union and a non-draining wound; 
         - about 20% will end up undergoin BKA;
         - when infection deep infection is present, drainage may persist for over 1 year;
         - references:
                 Late Functional Outcome in Patients with Tibial Fractures Covered with Free Muscle Flaps.  
                 Microvascular Soft-Tissue Transplantation for Reconstruction of Acute Open Tibial Fractures: Timing of Coverage and Long-Term Functional Results.
                 Use of the Osteocutaneous Free Scapular Flap on the Lower Extremities.
                 The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury.
                 Efficacy of epidural anesthesia in free flaps to the lower extremity.
                 Free tissue transfer for type III tibial fractures. Microsurgery in 19 cases.
                 The management of open tibial fractures with associated soft-tissue loss: external pin fixation with early flap coverage.
                 Postoperative course of patients treated with iliac osteocutaneous free flaps. A two- to five-year follow-up study.
                 Free tissue transfer to the lower extremity.  
                 Free tissue transfer for type III tibial fractures. Microsurgery in 19 cases


 Primary vs Secondary Wound Reconstruction in Gustilo Type III Open Tibial Shaft Fractures: Follow-up Study of 35 Cases 

 Soft-tissue principles for orthopaedic surgeons