43 - Lower Limb Reconstruction

Abstract

Lower extremity trauma is common and associated with significant morbidity and mortality. Initial management begins with Advanced Trauma Life Support as many patients have concomitant traumas. Secondary survey of the lower extremity consists of evaluation of skin, nerve function, vascular status, and musculoskeletal injuries. The patient’s Gustilo classification should be determined. It is imperative to identify vascular and nerve injuries. An ischemic limb should have circulation restored, ideally within 3–4 hours. Free flap reconstructive options can be limited by the availability of native recipient arteries and veins in the traumatized lower extremity. The standard of care of open tibial fractures involves early debridement and irrigation. Skeletal fixation may involve external fixation, plates/screws, and intramedullary nailing. Early definitive soft tissue reconstruction is preferred. Each patient’s reconstruction is tailored to the defect, available donor sites, and overall health status. Locoregional muscle flaps, like pedicled gastrocnemius and soleus flaps, are excellent for certain proximal third and middle third defects, respectively. Local fasciocutaneous flaps, like perforator flaps, can be designed throughout the leg due to a rich density of perforators present. Large defects or lower third defects are often best served with free flap reconstruction. Free muscle flaps and free fasciocutaneous flaps have been demonstrated to have similar outcomes. In cases of severe bone defects, skeletal reconstruction may consist of bone graft, free vascularized bone graft, or distraction osteogenesis. In very severe lower extremity trauma, limb salvage and reconstructive efforts must be compared to functional outcomes of transtibial amputation, as functional outcomes are ultimately similar. Management of lower extremity trauma requires a multidisciplinary approach and a personalized treatment plan for every patient.