Lower Limb Soft Tissue Defects Research Articles

Cross-leg flaps: A nonmicrosurgical alternative treatment method in complex lower extremity trauma reconstruction.

This study aimed to present our experiences with cross-leg flap surgery, which demonstrates successful outcomes in lower limb soft tissue defects without the necessity of microsurgical intervention. The retrospective study included 26 patients (18 males, 8 females; mean age: 35.6±12.2 years; range, 18 to 65 years) between January 2015 and September 2019. A fasciocutaneous cross-leg flap was applied to the recipient extremity, and the extremities were immobilized by a tubular external fixator. Flap divisions were performed on the 21st postoperative day. At least two years of clinical outcomes were presented. Twenty-five flaps survived and recovered completely without any complication at the donor site, flaps, or the recipient area. In one diabetic patient, partial flap loss was encountered, which granulated with secondary healing. All patients demonstrated stable wound coverage, with none demanding additional soft tissue surgeries. All patients resumed normal ambulation and physical activity without any residual joint stiffness. Cross-leg flap method is an effective and respectable option for extremity salvage as a good alternative to free flaps for the management of traumatic complex lower limb defects. This method is simple, provides abundant blood supply to the wound, and does not require microsurgical experience or a good working recipient artery.

Muscle vs. Fasciocutaneous Microvascular Free Flaps for Lower Limb Reconstruction: A Meta-Analysis of Comparative Studies.

(1) Background: Lower extremity microvascular reconstruction aims at restoring function and preventing infection while ensuring optimal cosmetic outcomes. Muscle (M) or fasciocutaneous (FC) free flaps are alternatively used to treat similar conditions. However, it is unclear whether one option might be considered superior in terms of clinical outcomes. We performed a meta-analysis of studies comparing M and FC flaps to evaluate this issue. (2) Methods: The PRISMA guidelines were followed to perform a systematic search of the English literature. We included all articles comparing M and FC flap reconstructions for lower limb soft tissue defects following trauma, infection, or tumor resection. We considered flap loss, postoperative infection, and donor site morbidity as primary outcomes. Secondary outcomes included minor recipient site complications and the need for revision surgery. (3) Results: A total of 10 articles involving 1340 patients receiving 1346 flaps were retrieved, corresponding to 782 M flaps and 564 FC flaps. The sizes of the studies ranged from 39 to 518 patients. We observed statistically significant differences (p < 0.05) in terms of donor site morbidity and total flap loss with better outcomes for FC free flaps. Moreover, the majority of authors preferred FC flaps because of the greater aesthetic satisfaction and lesser rates of postoperative infection. (4) Conclusion: Our data suggest that both M and FC free flaps are safe and effective options for lower limb reconstruction following trauma, infection, or tumor resection, although FC flaps tend to provide stronger clinical benefits. Further research should include larger randomized studies to confirm these data.

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

MODIFIED SURAL FLAP TO COVER DISTAL LOWER LIMB SOFT TISSUE DEFECTS

The purpose of this study was to evaluate the outcomes of coverage of soft tissue defects of leg and foot by sural flap with preserving a lane of skin over the pedicle (cutaneous pedicle) with open passage between donor and recipient sites. A proscriptive study including thirty-six patients with distal lower limb soft tissue defects was carried out in the period between June 2018 and June 2019 at Sohag University Hospital. All these 36 patients underwent modified sural flap with preserved lane of skin over the pedicle with open passage for the pedicle between donor and recipient sites. Evaluation of viability of the flap, resistance against infection, healing of the flap, donor site healing and weight bearing, postoperative follow up to nine months. Group of patients including thirty-six patients with distal lower limb soft tissue defects underwent modified sural flap, the indication for flap cover was Motor car accident in 26 cases (72.2%) and exposed plate was in 6 cases (16.7%) crushing trauma was in 4 cases (11.1%). Infection were the common complications encountered Six cases (16.7%) three cases (8.35%) complicated by distal ischemia and One case (2.8%) was totally lost with increase in the flap viability with modified sural flap. Modified sural flap by preserving alane of skin over the pedicle and open passage between donor and recipient site increase venous return of the flap and increase flap viability.

Anatomic Study and Clinic Application of Transverse Circumflex Scapular Artery Perforator Flap Repair of Lower Limb Soft Tissue Defects in Children.

The aim of this study was to demonstrate the viability of the transverse circumflex scapular artery perforator flap (TCSAPF) in children with soft tissue defects of the lower limb. In an anatomic study, 25 fresh cadavers were injected with lead oxide-gelatin for spiral computed tomography and 3-dimensional image reconstruction. In a 3-year clinical application study, children with soft tissue defects and exposed tendons and/or bones in the lower limb underwent free-TCSAPF repair of the defect. Perforators from the transverse branch of the circumflex scapular artery were identified in both anatomical and clinical studies. The average external diameter was 0.9 ± 0.3 mm. Each perforator supplied an average area of 63.5 ± 16.8 cm in anatomical. Twenty-one children were included in this group (9 boys, 12 girls, mean age, 6.6 ± 2.7 years). The size of the flaps ranged from 6 to 17 cm × 4.5 to 7 cm (average, 65.3 ± 22.6 cm). The average flap harvesting time was 30.1 ± 8.5 minutes, average operation time was 138.6 ± 31.5 minutes, and average blood loss was 89.5 ± 21.9 mL. The average length of the vessel pedicle was 8.2 ± 2.4 cm. Arterial congestion occurred in one child, 18 hours postoperatively; subsequent re-exploration and great saphenous vein transplantation were successful. Of the 3 children who had bulky flaps, 1 patient underwent defatting. Satisfactory outcomes included good appearance and function of the recipient and donor areas. The TCSAPF provides high-quality skin and vessel flexibility, providing a reliable blood supply in children. The flap has potential benefits over existing perforator flaps.

Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases

PurposeThe aim of this report is to compare free perforator flaps and propeller flaps in the coverage of lower limb soft tissue defects. Patients and methods179 patients (age between 5 and 92 years old), underwent soft tissue reconstruction of the lower limb between January 2009 and January 2015, either by free flap or propeller flap. The two groups were retrospectively evaluated in order to assess the outcome, complications and potential risk factors. Correlations between risk factors and presence/absence of failure or complications have been evaluated with descriptive statistical analysis and a set of logistic regression models. Finally, an economic analysis was conducted to evaluate the different tecniques. ResultsIn a simple descriptive statistical analysis, the overall failure rate is 6% for free flaps and 3.7% for propeller flaps; the complication rates are 14% vs 21.5% and it increases as dimension increases. The logistic models relating failure and complications with potential risk factors do not show significant differences, whereas the economic analysis show that the average expense of free flaps is 5077.5€ per patient, 1595.6€ per patient for propeller flaps. ConclusionsOur results do not demonstrate significant differences between the two groups about correlation of risk factors or flap size with complication or failure. The surgical option choice should be taken only after accurate evaluation of the soft tissue surrounding the defect. Propeller flaps should be preferred in case of small/medium size defects in otherwise healthy extremities. Free perforator flaps should be the choice in large defects due to trauma or vascular diseases. The economic analysis suggests that propeller flap should be considered when possible.

Experience of one-stage repair of the wounds after excision of soft tissue malignant tumor in lower limb by deep inferior epigastric perforator flap in 11 cases

Objective To investigate the clinical efficacy of one-stage repairing the wounds after excision of soft tissue malignant tumor in lower limb with deep inferior epigastric perforator (DIEP) flaps. Methods From August, 2016 to July, 2018, 11 patients(8 males and 3 females; aged 35-76 years) with the soft tissue defects in the lower limb underwent immediate reconstructive operations with DIEP flap after their tumor resection. The defects ranged in area from 11 cm×7 cm to 25 cm×10 cm after extended resection, including 5 cases of bone exposure. The DIEP flap area ranged from 11 cm×8 cm to 26 cm×18 cm. Among them, 9 cases were treated with free transplantation and 2 cases with pedicle transplantation. The donor sites were closed directly. The patients’ limb function, tumor recurrence and the healing of surgical incision had been followed-up. Results Eleven flaps survived and the donor sites healed directly. One flap had skin pigmentation due to postoperative vascular crisis, and the other flaps had satisfied texture and appearance. All patients were followed-up from 6 to 30 months. The lower limb movement was normal. All the donor sites had a good healing with no pain and abdominal complications. No tumor recurrence was observed during the followed-up period. Conclusion DIEP flap have many advantages, such as large cutting area, which is suitable for large-area wound repair after extended excision of soft tissue malignant tumor in lower limb. At the same time, the perforator vessel is constant and the caliber are thick, also the donor area is concealed and can be sutured directly. This kind of the technique for reconstruction of lower limb soft tissue defects after malignant tumor resection is well acceptable. Key words: Deep inferior epigastric perforator flap; Lower limb; Soft tissue malignant tumor; Wounds after excision; Repair

ANTEROLATERAL THIGH FLAP IN LOWER LIMB RECONSTRUCTION

Introduction: Anterolateral thigh flap is one of the most researched and widely used perforator flaps in the recent decades in plastic surgery as a whole and in limb reconstruction, especially in cases with complex deflects, in particular. This report aimed to evaluate anterolateral thigh flap in reconstruction of complex lower limb soft tissue defects. Subjects and methods: From August 2014 to August 2015, at Hue University of Medicine and Pharmacy Hospital, 12 cases with complex soft tissue defects in lower limb were reconstructed and covered with ALT flaps: two distal based pedicle ALT flaps for popliteal and around knee joint defects and 10 composite ALT free flaps for lower leg reconstruction. Results: Twelve flaps used included: two peripheral pedicled fasciocutaneous flaps, ten complex free flaps (01 complex myo-fasciocutaneous flap providing muscle for deep space filled, fascial for tendon reconstruction and surface covering of the defect; 05 vastus lareralis myocutaneous flaps providing muscle for dead space filling and covering; 04 fasciocutaneous flaps involving the fascia lata for fascial reconstruction and covering). The size of flaps ranged from 8 to 27cm in length and from 6 to 13cm in width. The largest flap was 240cm2,the smallest was 50cm2. All 12 flaps survived. Short-term results at one month after surgery were consideredas good in eleven patients and fair in one patient. There were no special complications at donor sites. Paresthesia at the donor site was noted in two cases. Conclusion: ALT flap with its versatility as peripheral pedicled flap or free flap can be used in lower limb reconstruction with high success rate of 100% (12/12). Preoperative skin perforator mapping by Doppler was highly accurate (12/12) compared with intraoperative findings. Complex free ALT flap is suitable for reconstruction of major defects involving different type of tissue in lower limb with satisfied results. Key words: Anterolateral thigh flap, limb, ower limb

ANTEROLATERAL THIGH FLAP IN LOWER LIMB RECONSTRUCTION

Introduction: Anterolateral thigh flap is one of the most researched and widely used perforator flaps in the recent decades in plastic surgery as a whole and in limb reconstruction, especially in cases with complex deflects, in particular. This report aimed to evaluate anterolateral thigh flap in reconstruction of complex lower limb soft tissue defects. Subjects and methods: From August 2014 to August 2015, at Hue University of Medicine and Pharmacy Hospital, 12 cases with complex soft tissue defects in lower limb were reconstructed and covered with ALT flaps: two distal based pedicle ALT flaps for popliteal and around knee joint defects and 10 composite ALT free flaps for lower leg reconstruction. Results: Twelve flaps used included: two peripheral pedicled fasciocutaneous flaps, ten complex free flaps (01 complex myo-fasciocutaneous flap providing muscle for deep space filled, fascial for tendon reconstruction and surface covering of the defect; 05 vastus lareralis myocutaneous flaps providing muscle for dead space filling and covering; 04 fasciocutaneous flaps involving the fascia lata for fascial reconstruction and covering). The size of flaps ranged from 8 to 27cm in length and from 6 to 13cm in width. The largest flap was 240cm2,the smallest was 50cm2. All 12 flaps survived. Short-term results at one month after surgery were consideredas good in eleven patients and fair in one patient. There were no special complications at donor sites. Paresthesia at the donor site was noted in two cases. Conclusion: ALT flap with its versatility as peripheral pedicled flap or free flap can be used in lower limb reconstruction with high success rate of 100% (12/12). Preoperative skin perforator mapping by Doppler was highly accurate (12/12) compared with intraoperative findings. Complex free ALT flap is suitable for reconstruction of major defects involving different type of tissue in lower limb with satisfied results. Key words: Anterolateral thigh flap, limb, ower limb

Reconstruction of lower limb traumatic soft tissue defects in Togo

Background: The management of lower limb soft tissue defects is still a challenge in our setting. Aims: This study aimed to review the clinical and socio-demographic characteristics of the patients with traumatic lower limbs defect and evaluate the results of surgical management in our setting. Settings and Design: Retrospective descriptive study. Materials and Methods: The charts of 30 adults patients treated surgically for lower limb soft tissue defects in the period from 1 January to 31 December 2014 were reviewed. Socio-demographic, clinical and therapeutic characteristics were documented. Statistical Analysis Used: The results were as general descriptive statistics, presented as medians, percentages and ranges. Results: The mean age was 34 years (range 18–60 years). The sex ratio was 3.28 for men. In 83% of the cases (20/30), injuries were due to collision between motorcycle and other vehicles. Soft tissue defects were type III B (50%, 15/30) and III A (47%, 14/30) of Gustilo-Anderson classification. The mean time between injury and reconstructive surgery was 48 days (range 14–118 days). Reconstruction techniques were mostly split skin graft (53%, 16/30) and neuro-sural distal pedicled flaps (20%, 6/30). Five cases of persistent osteomyelitis were observed. Conclusion: The non-availability of microsurgery limited our practice to regional and local flaps that gave good results and protected bone fractures that mainly healed in acceptable time.

Reverse sural fasciocutaneous flap with a cutaneous pedicle to cover distal lower limb soft tissue defects: experience of 109 clinical cases.

BackgroundSoft tissue defects over the mid- and distal third tibia, heel, dorsum and plantar aspect of the foot and over the medial, lateral and posterior aspect of the ankle are a common scenario in clinical orthopaedic practice. In this article, we describe the utility of the reverse sural fasciocutaneous flap with a cutaneous pedicle in 109 clinical cases with distal lower limb soft tissue defects.Materials and methodsA total of 109 patients were operated on for moderate (5–15 cm) and large (more than 15 cm) soft tissue defects at various sites along the lower limb including foot, heel and sole with the reverse sural fasciocutaneous flap. The defects were secondary to trauma (61 cases), diabetic ulcers (12 cases), post-traumatic scar contracture (8 cases), venous ulcer (4 cases), wound dehiscence (10 cases), leprotic non-healing ulcer (1 case), post-infective wound (1 case), radiation-induced ulcer following radiotherapy for synovial cell sarcoma (1 case), post-fibromatosis excision (1 case), post-dermatofibrosarcoma excision (1 case), post-heel melanoma excision (1 case) and actinomycosis foot (1 case). Patients were assessed for flap uptake and healing of defects.ResultsAmong the 102 cases analysed, 81 were male and 21 female with an average age of 32.7 years. The average size of the flaps was 148.10 ± 59.54 cm2. The flap healed uneventfully in 89.21 % of patients. Edge necrosis occurred in 9 cases. Donor site regrafting was required in 7 patients.ConclusionThe reverse sural fasciocutaneous flap with a cutaneous pedicle is a quick, versatile, easy and safe soft tissue defect coverage technique to cover most of the soft tissue defects of the lower limb in common orthopaedic practice and does not require any microvascular repair, though it may be cosmetically unappealing in a few cases.Level of evidenceIV (Case series)

Versatility of reverse sural fasciocutaneous flap for reconstruction of distal lower limb soft tissue defects.

In this study we present our experiences with the reverse sural fasciocutaneous flap to reconstruct the distal lower limb soft tissue defects caused by traumatic injuries. These flap graftings were carried out from Oct. 2010 to Dec. 2012 in our department. The series consisted of 36 patients, including 21 men and 15 women with an average age of 46.2 years (14-83 years) and with a medium follow-up period of 18 months (12-24 months). Of all the cases of acute trauma, there were 10 cases of trauma of distal tibia, 9 cases of trauma of perimalleolus, and 17 cases of trauma of midfoot and forefoot. Related risk factors in the patients were diabetes (2 cases), advanced age (>65 years, 3 cases) and cigarette smoking (6 cases). The reverse flow sural island flap irrigation depended on lower perforators of the peroneal artery. The fasciocutaneous pedicle was 3-4 cm in width and the anatomical structures consisted of the superficial and deep fascia, the sural nerve, short saphenous vein, superficial sural artery together with an islet of subcutaneous cellular tissue and skin. The most proximal border of the flap was only 1.5 cm away from the popliteal skin crease and the pivot point was 5-7 cm above the tip of the lateral malleolus. All the flaps survived. No arterial crisis occurred in any case. The venous congestion occurred in 2 cases and got better after raising the limbs and bloodletting. Only in an old man, 1.5 cm necrosis of distal margin of his flap occurred and finally healed after continuous dressing change. One-stage skin grafting was performed, and all the donor sites were sutured and successfully healed. It was concluded that the reverse sural fasciocutaneous flap is safe and reliable to extend to the proximal third even near the popliteal skin crease. We also concluded this flap can be safely and efficiently used to treat patients with large and far soft-tissue defects from the distal leg to the forefoot with more versatility and it is easier to reach the recipient sites.

External Fixator Kickstands for Free Soft Tissue Flap Protection

Protected elevation represents a critical component of postoperative care, particularly in posteriorly located flaps, to prevent pressure on the flap's vascular pedicle and ensure a successful skin graft. Although several short case series and technique papers have described kickstand placement to prevent heel ulcers as an adjuvant to fixator placement for fracture management, there remains a paucity of reports describing external fixator placement solely for extremity elevation and pressure alleviation in the postoperative care of flap coverage procedures. Patients who underwent lower extremity free flap coverage procedures requiring temporary elevation were included. Age, diagnosis, soft tissue procedures performed, type of external fixator placed, duration of frame placement, mode of removal, and complications related to external fixator placement were documented. Patients requiring external fixator placement for fracture management were excluded. Twelve patients with 13 lower limb soft tissue defects were included in our case series. A thin-wire ring external fixator kickstand was applied in 5 limbs while the rest underwent placement of a uniplanar carbon fiber bar type external fixator kickstands. The average time for removal of the frames was 4 weeks. No complications were reported from kickstand placement. The use of external fixator kickstands is an effective and safe adjuvant to soft tissue flap procedures for the lower extremity. Our case series is the largest in the literature and first to address the technical considerations for frame placement, positioning, and removal for external fixator kickstands placed solely for flap coverage procedures. Level IV, retrospective case series.

Propeller Flaps in Lower Limb Reconstruction: Case Series

Introduction: Traditionally in reconstruction of lower limb soft tissue defects, muscle flaps have been the ‘Gold Standard’ for Gustillo Anderson Grade III B fracture involving upper and middle third defects. Lower third defects were usually reconstructed with free flaps. Evolution in flap surgery has enabled fasciocutaneous, adipofascial and superthin flaps to be harvested for the purpose of reconstruction thereby minimizing morbidity from muscle inclusion into the flap. We present our experience with perforator (propeller) flaps for reconstruction of soft tissue defects in the lower limb. Materials and methods: Between February 2010 and April 2010, 6 consecutive patients, 34 years (18-50 years old), were referred to our services post trauma to the lower extremity. This case series consists of patients from two separate centers in Malaysia. All wounds were classified as Gustillo Anderson Grade IIIB. All patients were operated under spinal anaesthesia. Perforators were identified and traced to major limb vessel and skin paddle was designed around the perforator. Skin paddle was then rotated into the defect in the lower third of the leg. Results: All the patients tolerated the procedure well. There was one case of epidermolysis, however the remainder of the flap survived and wound healed completely. Two flaps based on the peroneal artery initially underwent distal congestion but however improved on day three post-operatively. All six flaps survived 100% post inset for middle and distal third leg reconstruction. Conclusion: Propeller flaps in our experience is a versatile option for reconstruction of lower leg soft tissue defects with associated Grade IIIB open fractures.

Increasing Versatility of the Distally Based Sural Flap

Repairing distal lower limb soft tissue defects remains challenging for reconstructive surgeons. Relatively few procedures have real efficiency and low morbidity. Since its initial description, the distally based sural flap has been used increasingly for this indication. However, controversy exists about the upper limit of the skin paddle of the sural flap. In the present series, 11 patients underwent surgery with distally based sural flaps. In 6 patients, the flap skin paddle was partially or totally placed beyond this controversial limit on the proximal calf region. To increase the skin irrigation of this region, whole mesenteric tissue under the deep fascia of the leg was included in the flap. Venous congestion and distal tip necrosis can impair the success of flap surgery. To overcome these problems, the flap pedicle was not passed through the subcutaneous tunnel. All flaps survived completely, and no cases of venous congestion developed. Thus, extending the donor area to the upper part of the leg is a reliable maneuver to repair more distal defects of the leg and foot, and abstaining from passing the pedicle through a subcutaneous tunnel could contribute to a decreased risk of venous congestion.

Intraoperative Hemodynamic Evaluation of the Latissimus Dorsi Muscle Flap: A Prospective Study

The aim of this study was to assess intraoperatively the hemodynamic changes in the donor vessel of free latissimus dorsi (LD) flap before and after denervation and to analyze flow changes after flap transfer. Twenty-seven patients underwent LD muscle microvascular reconstruction for lower-limb soft tissue defects. Measurements of blood flow were performed intraoperatively by using a 2- to 5-mm probe ultrasonic transit-time flowmeter around the dissected vessels. Registrations were made in the thoracodorsal artery before and after harvesting the flap, after compressing and cutting the motor nerve, and after anastomosis. Mean blood flow of in situ harvested thoracodorsal artery as measured intraoperatively by transit-time flowmeter was (mean ± standard deviation) 16.6 ± 11 mL/min and was significantly increased after raising the flap to 24.0 ± 22 mL/min (p <0.05); it was 25.6 ± 23 mL/min after compressing the motor nerve and was significantly increased after cutting the motor nerve to 32.5 ± 26 mL/min (p <0.05). A significant increase of blood flow to 28.1 ± 19 mL/min was also detected in the thoracodorsal artery after flap transplantation with end-to-side anastomosis (p <0.05). Vascular resistance in the thoracodorsal artery significantly decreased after flap raising and anastomosis (from 7.5 ± 3.4 to 4.0 ± 1.9 and to 4.5 ± 2.4, respectively, p <0.05). LD flap harvesting increases blood flow and decreases resistance in the thoracodorsal artery, especially after denervation.

Lower limb soft tissue reconstruction using microsurgical techniques.

Trauma is the main cause of lower limb soft tissue defects followed by tumor resection, vascular disease and osteomyelitis. 17 patients were operated on using microsurgical techniques during the last 10 years. 9 of the patients had traumatic defects, 5 had various malignant tumors, 2 patients had arterial insufficiency and finally 1 patient had chronic osteomyelitis. The latissimus dorsi either as muscle flap with a split thickness skin graft or as a musculocutaneous flap was used the most frequently in our series. Other flaps, including the radial forearm neurovascular flap, the rectus abdominis flap, the scapular flap, the groin and the dorsalis pedis flaps were used less often. Delayed primary cover was used, except in 1 case with an opened knee joint trauma, where emergency repair was performed. Complications included: 2 partial skin graft necroses which required revision and 2 flap necroses caused by venous thrombosis. With follow-up more than 4 years in all but 2 patients, functional results were found satisfactory. Cosmetic results, however, were less satisfactory.