Abstract
Soft tissue reconstruction of the distal third of the lower limb with exposure of the internal hardware is a challenging problem with several potential complications, such as exposure of the fracture line, fracture instability and bacterial contamination. The treatment of these lesions usually consists of substitution of the internal hardware with external fixation devices and further flap coverage. We propose a different reconstructive approach, characterized by harvesting a sural fasciomusculocutaneous flap on the exposed internal hardware once a sterile ground has been obtained. Four patients were retrospectively analyzed. Soft tissue reconstruction was achieved in all cases. In one case hardware removal was necessary for complete healing. The sural fasciomusculocutaneous flap is a safe alternative to other pedicled and free flaps. Moreover, it allows direct coverage of internal fixators, thus completing the reconstruction in less time. This flap fits best to the morphology of the wound and internal hardware, leaving the main vascular trunk of the leg intact and at the same time providing a reliable vascular supply.
Highlights
Soft tissue necrosis after internal fixation with the conventional plate-screw system is quite common
Soft tissue reconstruction of the distal third of the lower limb with exposure of the internal hardware is a challenging problem with several potential complications, such as exposure of the fracture line, fracture instability and bacterial contamination
We propose a different reconstructive approach, characterized by harvesting a sural fasciomusculocutaneous flap on the exposed internal hardware once a sterile ground has been obtained
Summary
Soft tissue necrosis after internal fixation with the conventional plate-screw system is quite common. In subjects with fractures treated with the locking compression plate system, Namazi and Mozaffarian [1] observed severe soft tissue damage leading to exposure of internal fixation devices in 23.5% of cases. The exposed hardware implies an additional problem that is often approached by replacing the internal hardware with external fixators [3] and soft tissue reconstruction in a second surgical period. This strategy requires prolonged healing times (requiring at least two surgeries, one for hardware removal and one for reconstruction), long hospital stays and delayed rehabilitation. The following series shows that patients with soft tissue infection and internal hardware contamination might benefit from a one-stage debridement and soft tissue reconstruction with a musculocutaneous flap without internal hardware removal
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