Lower Limb Defects Research Articles

Determination of the adequate vascular perfusion time of cross-leg free latissimus dorsi myocutaneous flaps in reconstruction of complex lower extremity defects.

Lower limb defects may be present due to various causes including infections, vascular diseases, tumor resections, and crush or avulsion injuries. Management of lower leg defects is acomplex problem, especially when they are large with deep soft tissue loss. These wounds are difficult to be covered with local skin flaps, distant skin flaps or even conventional free flaps because of the compromised recipient vessels. In such cases, the vascular pedicle of the free flap could be anastomosed to the recipient vessels of the contralateral healthy leg temporarily and then divided after adequate neo-vascularization of the flap from the wound bed. The ideal time to divide such pedicles should be investigated and accurately assessed to have the maximum success rate possible for these challenging conditions and procedures. Sixteen patients who did not have asuitable adjacent recipient vessel for free flap reconstruction had been operated with cross leg free latissimus dorsi flap between February 2017 and June 2021. The mean soft tissue defect dimension was 12 ×11 cm (the smallest 6 × 7 cm; the largest 20 × 14cm). Gustilo type 3B tibial fractures were present in 12 patients, while no fractures were present in the other 4 patients. Preoperatively, arterial angiography was performed on all patients. After the fourth week post-operatively, non-crushing clamp was applied around the pedicle for 15minutes. The clamping time was increased by 15 minutes on each consequent day (average 14 days). On the last 2 days, the pedicle was clamped for 2 hours, and bleeding was assessed by aneedle prick test. Clamping time was assessed in each case to reach ascientific calculation of the adequate vascular perfusion time needed for full flap nourishment. All flaps survived completely except two cases of distal flaps necrosis. Cross-leg free latissimus dorsi can provide asolution for large soft-tissue defects in lower extremities especially with absence of any suitable recipient vessels or when the use of vein grafts would not be feasible. However, ideal time before dividing the cross vascular pedicle should be identified to have the maximum success rate possible.

Significance of foetal autopsy in diagnosis of VACTERL association

VACTERL association occurs in 1 in 10000- 40000 live births and is associated with vertebral defects, anal atresia, cardiac malformations, tracheoesophageal fistula, renal dysplasia and limb defects. A 19-week-old male foetus with antenatal diagnosis of foetal hydronephrosis on antenatal ultrasound in the left kidney was medically terminated and brought for foetal autopsy. No other malformation was reported on antenatal scan. On autopsy, facial abnormalities, upper and lower limb defects, coronal vertebral clefts and imperforate anus with a two vesselumbilical cord were found. Both environmental and genetic factors are considered to be responsible for this association. The present case illustrates the importance of foetal autopsy for making a definitive diagnosis in the missed sonographic findings like anal atresia and absence of upper- and lower-limb bones.

The Reversed Flow Hemisoleus Propeller Muscle Flap.

Soleus muscle flap can be used in different modifications to reconstruct lower limb defects. It can be proximally based, distally based, island or reversed flow flap. The first description of the soleus muscle as an island flap supplied by one distal perforator was reported by Yajima et al (Plast Reconstr Surg. 1995;96:1162-1168). However, its use as a propeller flap supplied by the distal perforators and rotated for more than 90 degrees was not described yet. The aims of the study are to study the detailed vascular anatomy of the distal perforators of the soleus muscle flap and to demonstrate the applicability of using it as a propeller flap. A total number of 42 patients were included in this study. These patients had various distal leg and foot defects. All patients were assessed preoperatively by Doppler study and computed tomography angiography to define the vascular status of the leg. The muscle was raised as a reversed flow flap, based on 1 or more distal perforators and its feeding vessel (posterior tibial artery) after being dissected and divided proximally. The muscle was rotated for more than 90 degrees to reach distal leg defects and approximately 180 degrees to reach the foot defects. All flaps survived completely with good and durable coverage. The vascularity of the limb was not affected in all patients. There was no functional donor site morbidity. The reversed flow hemisoleus muscle flap supplied by the distal perforators and the posterior tibial artery has a great arc of rotation that can cover all distal leg, ankle, and foot defects. Therefore, it can be used as alternative to free flap in lower extremity reconstruction. A new nomenclature is suggested for this flap which is the propeller hemisoleus muscle flap.

Lower Extremity Malformations.

Lower Extremity Malformations.

Single centre experience with the superficial circumflex iliac artery perforator (SCIP) flap for traumatic limb defects: A case-series for first year as a regional major trauma network during a global pandemic

The free superficial circumflex iliac artery perforator (SCIP) flap evolved from the traditional groin flap, conferring numerous advantages. The thin nature of the flap avoids the need for secondary revisions and debulking procedures, particularly pertinent when theatre capacity was limited during the COVID-19 pandemic. We present a series reporting our centre's first year experiences undertaking SCIP flap reconstruction for traumatic limb injuries following the establishment of our regional major trauma network. A retrospective analysis of all patients treated for traumatic limb defects in our centre was undertaken between September 2020 to September 2021. Data was collected on patient demographics, injury, flap dimensions and flap survival. Ten patients (M:F 1:1, mean age 45 years) with traumatic limb defects were reconstructed with SCIP flaps performed by the senior authors. All had sustained open fractures. Nine had lower limb defects, most commonly at the medial ankle, one had a volar wrist defect with a devascularised hand. The mean flap dimension was 6.3 × 14.5 cm. All were anastomosed end-to-side to the recipient artery except one end-to-end anastomosis to a posterior tibial artery perforator using super-microsurgery. There was 100% flap survival. Complications consisted of one flap suffering <10% tip necrosis requiring debridement and small skin graft. The SCIP flap provides reliable, thin and pliable tissue without the need for secondary flap revisions and should be considered in the armamentarium of the reconstructive surgeon in extremity trauma reconstruction, particularly in the current environment surrounding the global pandemic. • The free superficial circumflex iliac artery perforator (SCIP) flap evolved from the traditional groin flap, conferring numerous advantages. • The thin nature of the flap avoids the need for secondary revisions and debulking procedures, particularly pertinent when theatre capacity was limited during the COVID-19 pandemic. • We demonstrate that SCIP flap provides reliable, thin and pliable tissue without the need for secondary flap revisions and should be considered in the armamentarium of the reconstructive surgeon in extremity trauma reconstruction, particularly in the current environment surrounding the pandemic.

Influence of different fixation modes on biomechanical conduction of 3D printed prostheses for treating critical diaphyseal defects of lower limbs: A finite element study.

BackgroundApplying 3D printed prostheses to repair diaphyseal defects of lower limbs has been clinically conducted in orthopedics. However, there is still no unified reference standard for which the prosthesis design and fixation mode are more conducive to appropriate biomechanical conduction.MethodsWe built five different types of prosthesis designs and fixation modes, from Mode I to Mode V. Finite element analysis (FEA) was used to study and compare the mechanical environments of overall bone-prosthesis structure, and the maximum stress concentration were recorded. Additionally, by comparing the maximum von Mises stress of bone, intramedullary (IM) nail, screw, and prosthesis with their intrinsic yield strength, the risk of fixation failure was further clarified.ResultsIn the modes in which the prosthesis was fixed by an interlocking IM nail (Mode I and Mode IV), the stress mainly concentrated at the distal bone-prosthesis interface and the middle-distal region of nail. When a prosthesis with integrally printed IM nail and lateral wings was implanted (Mode II), the stress mainly concentrated at the bone-prosthesis junctional region. For cases with partially lateral defects, the prosthesis with integrally printed wings mainly played a role in reconstructing the structural integrity of bone, but had a weak role in sharing the stress conduction (Mode V). The maximum von Mises stress of both the proximal and distal tibia appeared in Mode III, which were 18.5 and 47.1 MPa. The maximum peak stress shared by the prosthesis, screws and IM nails appeared in Mode II, III and I, which were 51.8, 87.2, and 101.8 MPa, respectively. These peak stresses were all lower than the yield strength of the materials themselves. Thus, the bending and breakage of both bone and implants were unlikely to happen.ConclusionFor the application of 3D printed prostheses to repair diaphyseal defects, different fixation modes will lead to the change of biomechanical environment. Interlocking IM nail fixation is beneficial to uniform stress conduction, and conducive to new bone regeneration in the view of biomechanical point. All five modes we established have reliable biomechanical safety.

Реконструкция дефектов покровных тканей методом транспозиции локо-регионарных перфорантных островковых лоскутов

Introduction Treatment of chronic non-healing wounds in the presence of deep post-traumatic soft tissue defects is a challenge for trauma reconstruction. The objective of the study was to improve healthcare quality for patients with chronic soft tissue defects of the limb. The goals included evaluation of the effectiveness of reconstruction of defects of the lower limb using local transposition perforant flaps, and rationale for a preferred choice for the keystone perforator flap. Material and methods The review included 48 patients with post-traumatic and osteomyelitic soft tissue defects of lower limbs. Patients were divided into 2 groups. Patients of the study group were treated with regional perforator fasciocutaneous flaps combined with osteonecrectomy that could be also performed later (n = 22). In the comparison group (n = 26), post-traumatic and osteomyelitic defects were treated with conventional methods of local wound treatment, staged osteonecrectomies followed by autodermoplasty. Results The use of the transposition loco-regional perforator flaps resulted in the incidence of secondary necrosis reduced by 33.7% and the two-fold reduction in the average number of staged operations. One-stage reconstruction was performed in 72.7 % patients of the study group. The length of inpatient treatment decreased by an average of 30 bed days. Discussion The reduced length of treatment in the study group could be caused by the absence or a significantly reduced stage of local wound treatment; there were fewer complications in the form of secondary necrosis of deep-lying tissues that would require additional treatment stages. Conclusions Reconstruction of osteomyelitic defects with the transposition of loco-regional perforant flaps allowed lower complication rate and improved functional outcomes for patients with posttraumatic and osteomyelitic defects of soft tissues of lower limbs.

Microsurgical Anterolateral Thigh Flap for Reconstruction of Extremity Soft Tissue Defects in Pediatric Patients.

The anterolateral thigh flap is one of the most widely used flaps because it has the advantages of less damage to the donor site, no sacrifice of main blood vessels, and abundant soft tissue. However, the application of anterolateral thigh flap in children is relatively rare because of small blood vessels and rapid physiological changes. The aim of this study was to explore the effectiveness and characteristics of free anterolateral thigh flaps for the reconstruction of extremity soft tissue defects in pediatric patients. This study included 26 pediatric patients, with an average age of 6.7 years (range, 2-13 years). There were 5 cases of upper limb defects and 21 cases of lower limb defects, all of which were accompanied by exposed bones or tendons. The causes of defects included traffic injury in 9 cases, mechanical injury in 7 cases, collision injury in 4 cases, spoke injury in 3 cases, cicatricial contracture in 2 cases, and fibroma in 1 case. All defects were reconstructed with free anterolateral thigh flaps. Twenty-six anterolateral thigh flaps were harvested, including 15 fasciocutaneous flaps and 11 musculocutaneous flaps. The mean size of the flap was 73.4 cm 2 (range, 4 × 3 to 24 × 8 cm). The donor sites were sutured directly in 19 cases and underwent split-thickness skin grafting in 7 cases. There were 3 cases of vascular crisis, 3 cases of flap edge necrosis, 3 cases of infection, 1 case of pressure ulcer, and 1 case of dehiscence after surgery. Eleven patients had scar hyperplasia in the donor site. A total of 34 reoperations were performed, including 14 flap debulking, 7 debridement, 4 skin graft, 3 vascular crisis re-exploration, and 6 other procedures. Free anterolateral thigh flap was a safe and reliable option for reconstructing soft tissue defects of extremities in pediatric patients. Notably, the incidence of scar hyperplasia in the donor site and the possibility of reoperation in pediatric patients were higher than those in adult patients.

Role Closed Incision Negative Pressure Therapy in the Management of Keystone Flap in Lower Limb Defect

The keystone flap is a new flap design that has been added to the arsenal of cosmetic surgeons. The keystone flap is a type of flap that can be used to close soft tissue abnormalities using the local skin. It can be employed in a variety of situations. In the care of a keystone flap to repair a deficiency over the lower limb defect following a road traffic accident, we used closed incision negative pressure therapy.

Posterior Tibial Artery Perforator V-Y Advancement Flap for Small-Medium Size Lower Limb Defects.

Background:The posterior tibial artery perforator flap has been described as a good option for small to moderate lower extremity defects with consistent anatomy and caliber. Different geometrical designs are found in the literature for posterior tibial artery perforator flaps and are mostly executed as propeller, peninsular, and island flaps. Upon literature review, V-Y advancement flaps were not commonly used, despite the clear design, persistent anatomy, and straight execution. Our aim was to report our case series to present the validity of such design and the success of reconstruction.Method:Over 1 year, three cases were reconstructed successfully with posterior tibial artery perforator flaps with V-Y advancement design. Clinical evaluation was done for all patients as well as follow-up in the outpatient clinic until complete healing of the wounds was achieved. Multiple modifications were done intraoperatively to enhance flap reach and minimize the complications, including designing V-Y advancement flaps larger than the defect, careful perforator dissection, and finally, strict postoperative course.Results:All three cases healed completely with no complications. The average follow-up time in the clinic was 3 months.Conclusions:Posterior tibial artery perforator flap with V-Y advancement design is a viable option for reconstructing medium sized lower limb defects, but requires careful design and execution. The suggested steps will increase the survival of the flap and reconstruct the defect successfully.

Bone transport combined with bone graft and internal fixation versus simple bone transport in the treatment of large bone defects of lower limbs after trauma

BackgroundBone transport has been successfully applied for the management of large segmental bone defects. However, its main shortcoming is the long-lasting consolidation period, which may cause lots of related complications. To overcome this shortcoming, we developed bone transport combined with bone graft and internal fixation technique. The purpose of this study was to compare the clinical effects of this modified technique with simple bone transport in the treatment of large segmental bone defects of lower limbs after trauma.MethodsEighty-four patients with large segmental bone defects treated in our institution from January 2014 to January 2017 were selected for retrospective study. A total of 77 cases were completely followed. Among them, 35 patients were treated by bone transport combined with bone graft and internal fixation technique (Group A), and 42 by simple bone transport technique (Group B). Patients with open injuries were classified according to Gustilo-Anderson (GA) classification. The general data of Group A and B were compared. The time in external fixator, total cure time and operation times of two groups were recorded. Ennecking score was used to evaluate the recovery of limb functions while self-rating anxiety scale (SAS) for the postoperative anxiety evaluation. In addition, the total complication incidence was compared between Group A and B.ResultsThere was no significant difference in demographic data between Group A and B (p > 0.05). The time in external fixator of Group A and B was (4.8 ± 1.6) and (18.2 ± 3.9) months, respectively (p < 0.05). The total cure time was (17.6 ± 2.2) and (20.4 ± 2.8) months in Group A and B (p < 0.05). The number of operations in Group A and B was (4.9 ± 1.2) and (4.8 ± 1.0) (p > 0.05). Ennecking score of Group A and B was 84.7 and 75.7% (p < 0.05). SAS score and total complication incidence in Group A were significantly lower than those in Group B (p < 0.05).ConclusionsThe clinical effects of bone transport combined with bone graft and internal fixation technique were better than that of simple bone transport technique, including shorter time in external fixator, shorter total cure time, lower anxiety score and better limb functions.

Repair of critical diaphyseal defects of lower limbs by 3D printed porous Ti6Al4V scaffolds without additional bone grafting: a prospective clinical study

The repair of critical diaphyseal defects of lower weight-bearing limbs is an intractable problem in clinical practice. From December 2017, we prospectively applied 3D printed porous Ti6Al4V scaffolds to reconstruct this kind of bone defect. All patients experienced a two-stage surgical process, including thorough debridement and scaffold implantation. With an average follow-up of 23.0 months, ten patients with 11 parts of bone defects were enrolled in this study. The case series included three females and seven males, their defect reasons included seven parts of osteomyelitis and four parts of aseptic nonunion. The bone defects located at femur (five parts) and tibia (six parts), with an average defect distance of 12.2 cm. Serial postoperative radiologic follow-ups displayed a continuous process of new bone growing and remodeling around the scaffold. One patient suffered tibial varus deformity, and he underwent a revision surgery. The other nine patients achieved scaffold stability. No scaffold breakage occurred. In conclusion, the implantation of 3D printed Ti6Al4V scaffold was feasible and effective to reconstruct critical bone defects of lower limbs without additional bone grafting.Graphical abstract

Safety and Vascular Impact of Perforator Propeller Flaps during Distal Lower Limb Reconstruction.

Background:In distal lower limb defects, the paucity of local tissues dictates a free-flap (FF)-based reconstruction frequently. The propeller perforator flap (PPF) offers a good alternative when the patient or the limb or both are not fit for FF-based reconstruction. Also, in contexts of restricted healthcare resources, armed conflict scenarios, or during pandemics like the ongoing COVID-19 pandemic, PPF is considered a valuable alternative to free-flap-based reconstruction. Additionally, PPFs are less sacrificing in terms of major limb vessels and distal limb vascularity. Yet, the distal lower limb vascular impact for PPF-based reconstruction has not been studied before.Methods:In total, 23 patients with distal lower limb defects were reconstructed with PPFs. By using U/S arterial duplex, the peak arterial velocity (PA velocity) was measured pre and postoperatively in 15 (65.2%) out of the 23 patients. This measurement was done to the vessel segment distal to the used perforator.Results:An estimated 21 out of 23 flaps succeeded to reconstruct the patients’ defects safely and to give all patients stable coverage without further surgeries. Only two patients had flap failure, which was managed successfully through additional reconstruction sessions. The difference between pre- and postoperative PA velocity was not statistically significant.Conclusions:PPFs are a safe cost-effective reconstruction modality for distal lower limb defects. This advantage is very valuable in cases of restricted healthcare resources, wars, and during pandemics. In terms of distal limb vascularity, PPFs have no significant impact and can be used safely.

The keystone flap and its simplified version for malignant skin tumor defects of the lower limbs: A review of 25 cases

BackgroundSkin tumors commonly occur on the legs and are treated in first line by surgery. Several techniques are available to repair lower limb defects: secondary-intention healing, partial closure, primary closure with or without an s-plasty, or a skin graft. The lack of tissue laxity of the surrounding skin does not allow several local flaps (advancement, rotation, or transposition). Closing large skin defects at this site may be challenging. Patients and methodsWe retrospectively reviewed a series of consecutive patients undergoing malignant tumor wide excision on lower limbs, with a keystone flap or its simplified technique (releasing incision) for closure of a skin defect. ResultsTwenty-five patients, 17 women and 8 men, ranging from 19 to 95 years old (mean age: 70 years) were included. Keystone flap reconstruction on the lower limbs was performed in 19 cases and the simplified technique in 6. The excised tumors were as follows: squamous cell carcinoma (n=6), basal cell carcinoma (n=9), melanoma (n=9) and Bowen's disease (n=1). Three local complications were observed. No cases of recurrence were observed. ConclusionKeystone flap is a reliable surgical method for reconstruction of lower limb skin defects. Aesthetic results are better than when a skin graft is used, complications are uncommon, and prolonged operative time is avoided.

Arteriovenous supercharging: A novel approach to improve reliability of the distally based sural flap.

Complex soft-tissue defects of the distal third of the leg, foot and ankle with exposed bones/joints, tendons and implants need a flap for their closure. Distally based sural flap is commonly used, but it has a high partial necrosis rate due to venous insufficiency. We addressed this issue with AV supercharging by dorsalis pedis artery with short saphenous vein. Eight patients (seven males, mean age 34.12 years) with post traumatic lower limb defects over heel and foot were included. All flaps survived and healed although four flaps developed superficial partial epidermolysis. Average healing time was 20.12 days. Closure of the AV fistula was not required in any of the patients. At mean follow-up of two months, all patients were ambulatory with well settled flap. Arteriovenous supercharging of distally based sural flap through short saphenous vein improves the distal arterial perfusion in the flap and prevents distal flap necrosis.

Reverse Sural Fascio-Cutaneous Flap for Management of Patients with Distal Third of Lower Limb Soft Tissue Defects Referring to the Emergency Department Following Traumatic Events; A Review of 13 Cases

Introduction: Soft tissue defects over the distal leg and/or heel are probable injuries that need a flap. Various coverage techniques have been described in this regard. It seems that applying Reverse Sural Fascio-Cutaneous Flap (RSFCF) for reconstructing soft tissue defects of lower limbs has superiorities over other techniques. Objective: We intend to present a case series with soft tissue defect over the distal third of lower limb, covered using RSFCF technique. Methods: This is a case series and longitudinal study in which patients with crush injuries who referred to the emergency department (Sina hospital, Tehran, Iran) from 2013 until 2020 and were treated with RSFCF technique were included. The data were collected using patients’ charts, by interviewing the patients, and from hospital records. The patients' wounds were prepared, examined, and the surgery was done. Tendon and bone defects were repaired, and wounds were closed using reverse sural Fascio-Cutaneous Flap. Results: A total of 13 patients were eligible during the 6-year study period. Men were more commonly affected with no conclusive gender trend. The posterolateral part of the foot of the right leg was the most frequently injured part (53.8%). Only 1 patient had mentioned complications after surgery including mild congestion and abnormal sensory and motor examination. Patients were followed by the surgeons until 3 months after the operation and all of them had been able to resume their daily life activities by then. Conclusion: According to our findings, almost all of the patients (except one) had received their flaps without any complications. All the patients had been able to resume their daily life activities three months after the surgery. This may show that RSFCF, which can be quickly performed and does not need microsurgical skills, could be a suitable option for the coverage of distal third of lower limb soft tissue defects caused mainly by trauma

Versatility of Reverse Sural Artery Flap (RSAF) in management of lower limb defects: Our experience

Background: Wounds around the lower 1/3rd of leg and foot are difficult to manage. Treatment options like skin grafting, healing by secondary intention can result in an unstable scar. Free tissue transfers and Regional flaps has its own disadvantages. To circumvent these difficulties a fasciocutaneous flap harvested from sural angiosome was proposed. In this study, we have made an attempt to find out different scenarios in which this flap can be used as a management option and ways to minimize the complications associated with this flap. Methods: A retrospective observational study was conducted over 2 years. 30 patients were studied. Patient details was obtained from the case record, operative notes and postoperative follow-up.Results: Patients between the age of 10 years to 65 years were studied. RSA flap with adipofascial pedicle and fasciocutaneous pedicle was done in 21 and 9 patients respectively. Delaying of flap was done in 9 patients, with most common indication as distal defect. Common site of defect which were reconstructed was on the Tendoachilles region, Heel region. Various complications were loss of graft used to cover adipofascial pedicle, Venous congestion, hematoma formation and partial skin necrosis of the flap. None of the patients complained of any effect on routine activity during postoperative follow up.Conclusion: It is a versatile flap and different scenario can be managed with customization in plan. With proper selection of patients, it can be judiciously used to manage different leg defects.

Complex reconstructive microsurgery cases: the role of arteriovenous loops

In free-flap reconstructive microsurgery, arteriovenous loops can be a useful tool when adequate recipient vessels are absent. We present a case series of 12 patients in which this technique was used. Between 2000 and 2019, 12 patients with complex defects had free-flap reconstruction with the use of arteriovenous loops. There was a total of 9 men and 3 women, ranging in age from 22 to 71 years old. Six patients had post-traumatic lower limb defects, and 5 of them were reconstructed with latissimus dorsi free-flaps. The other six patients had head and neck defects in a previously irradiated field, and 3 of them were reconstructed with free osteofasciocutaneous fibula flaps. All the procedures were performed in a single-stage approach. There were 2 cases of total flap failure both in patients with multiple risk factors and several previous surgeries. One of the patients died because of a carotid artery blow-out on the second postoperative day. No other major complications were recorded. The mean hospitalization time was 60 days. The mean follow-up time was 31.1 months. Overall flap survival was 75%. This case series illustrates how free-flap surgery can be even more challenging when the surgical conditions are especially unfavorable. Arteriovenous loops proved to be an excellent technical resource allowing reconstruction with anastomosis on healthy distant vessels. Despite the good results with single-stage interventions, our opinion is that decision between single- and two-stage approach should be made case-by-case. Level of evidence: Level IV, therapeutic study.

Plastic Surgical Procedures for Lower Limb Reconstruction at a Tertiary Hospital in Nepal.

This study assessed the lower limb reconstruction outcome so that it will provide a baseline evidence to enable data-driven decision making to improve outcome in the future. In this study, hospital records from 1st January to 31st December 2019 were collected retrospectively. Complete data of all patients' records treated for lower limb defects at Kirtipur Hospital were included and incomplete data were excluded. Univariate and Bivariate analyses were performed Results: In total 110 patients were included in this study with a male predominance of 66.4% (n=73). The mean age of the patients was 38.7 years (+/- 20). The majority of the patients were from outside Kathmandu valley 79.1% (n=87) and referred 55.5% (n=61). The commonest cause of lower limb defects was trauma 69.1% (n=76), the procedure performed was skin graft 48.5% (n=72), and complication was wound infections, 43% (n=13) of total complications. The hospital stay of more than two weeks was more common among the referred patients 63.9% (n=39) as compared to non-referred patients 30.6% (n=15) and trauma etiology 34.2% (n=26) had more complications than other etiology. The mean age of patients with complications (32.4 years) was lower than those without complications (41.1 years). More number of referred patients (n=43) required multiple surgeries than non-referred patients (n=21). Referred cases were more likely to have multiple surgeries and a longer hospital stay than non-referred cases. Infection was the commonest complication and the majority of complications were seen in trauma and younger age group.

Introducing Negative Pressure Wound Therapy for Lower Limb Defects: A Report of Three Cases of Open Fractures Fixed with Ilizarov External Fixator

The Ilizarov external fixator fixes the ring frame to the bone using steel wires and pins, then connects the plurality with rods. It enables stronger fixation and adjustment in various angles and directions than that by other modular external fixators. It is often used for damage control and reduction fixation of open fractures, but there are difficulties in handling necrotic skin and soft tissue over time. In particular, when the bone is exposed, it is recommended to cover it with a flap or skin graft as soon as possible. However, in cases of a wound surrounded by an Ilizarov external fixator, flap plasty would be challenging due to the large number of steel wires and pins inserted. Therefore, the wound needs to be carefully managed until it is closed.We report three cases of lower limb open fractures with tissue defect, in which negative pressure wound therapy was introduced simultaneously with fixation using the Ilizarov external fixator and proper wound management.