Long-Term Treatment Outcome of a Patient with Extensive Circular Soft Tissue Defect of the Distal Third of the Lower Extremity: A Case Report

Abstract

Background. Open fractures of the lower leg bones associated with extensive soft tissue defects are among the most challenging in trauma surgery.
 Aim of the study is to demonstrate the possibilities of modern reconstructive surgery in the treatment of severe polystructural trauma of the lower limb using a unique clinical example.
 Case description. An 18-year-old patient sustained a polytrauma which included head and extremities injuries as a result of a fall under a moving train. Due to the signs of uncompensated ischemia of the left lower limb at the first stage of treatment the patient underwent emergency left tibial artery thrombectomy, repeated debridement of the left lower leg wound, remounting of the external fixator, and lumbar sympathectomy. The second stage of surgical treatment included free transplantation of a vascularized anterolateral flap of the right thigh. The third stage included staged necrectomies; replacement of the soft tissue defect of the posteromedial surface of the distal lower leg with a sural fasciocutaneous vascularized flap on the distal vascular pedicle from the contralateral tibia; the fourth stage included cutting off the fasciocutaneous cross flap. At the follow-up, 2 years after the end of the treatment the patient complained of persisting swelling of the foot, which occurred during prolonged standing in the upright position and required elastic compression of the ankle joint. The cause of the swelling was impaired lymphatic outflow due to the damage to all venous collaterals in the injury area. She walks with full load on the injured limb without additional support. There is no pain syndrome, foot sensitivity is fully preserved.
 Conclusion. Presented clinical case demonstrates the possibility of successful replacement of an extensive circular defect of the distal lower leg using sequentially free and non-free vascularized tissue complexes.