Lower limb reconstruction consists of a plethora of entities ranging from simple fractures to ligament tears to complex injuries involving bone as well as soft tissues. Most of the times, lower limb reconstruction needs a team approach with involvement of Orthopedician, Plastic surgeon and a Physiotherapist, not necessarily in the same sequence. As Plastic surgeons, we will mainly be in charge of the soft tissue defects over the lower extremity.
In case of crush injuries or traumatic amputations or bone loss over the lower extremity, it is always better if the Plastic surgeon sees the patient on arrival along with the orthopedic surgeon, so that necessary decision of limb salvage and coverage of the wounds can be considered along with bony fixation.
The soft tissue coverage or the open wounds which require cover over the lower limbs are generally managed by either skin grafts or flaps. Skin grafts are very thin layers of skin which are used to cover the defect. They are usually harvested from the thighs. The areas from which the skin grafts are harvested, heal over a period of three weeks. Flaps are thick tissues which are used to cover the wounds. The deciding factor on which one should be used to cover the wounds depends on many factors, the most important of which is the depth of the wound. If bones, tendons or other important structures like vessels or nerves are exposed, the wound is always covered with a flap. If there are superficial raw areas without exposure of vital structures, a skin graft is generally preferred. The area from which the flap is harvested is covered with a skin graft almost always taken from the thigh.
It is not wise to keep an exposed wound open for a long time. As Plastic surgeons, we prefer to cover the wound as early as possible , If the local wound conditions and systemic conditions of the patients permit. Nevertheless, opinion of a Plastic surgeon must always be sought since the very beginning when an open wound is anticipated.
When there is a wound requiring flap coverage, two types of flaps are commonly used. First one are locoregional flaps, where tissues from adjoining areas are used to cover the defects. Second are the free flaps, where in tissues from distant areas are harvested along with their blood vessels and are used to cover the defects. The choice of the flap to be used depends on the general condition of the patient, local condition of the wound and associated trauma to the leg, experience and comfort of the operating surgeon as well as infrastructure and set up of the place where the patient is going to be operated. It is best to leave the decision to the operating surgeon after understanding the pros and cons of various procedures.
Whenever, a graft or flap is used for coverage of a wound, the patients must understand that the leg is not going to look like before. Scars are always going to remain. They never go, but they do fade with time if proper post operative care is taken. Additionally, in case of flaps, there is a bulge which is seen , which generally reduces in size over a couple of months by regular use of massage and pressure garments. However, it might need secondary thinning procedures, if the patient so desires for aesthetic reasons.
Sometimes, if the defect is extensive and composite, it might not be possible to do the entire reconstruction in a single surgery. In such cases, multiple procedures are needed to provide an optimal functional and aesthetic outcome to the patient. For example, if the defect consists of bone loss as well as soft tissue loss, a decision might be taken to cover the soft tissue first. The leg is kept in an external fixator during that time, and secondary bony reconstruction is considered after a couple of weeks. Similarly, if there is loss of muscles, tendons or nerves, the function of the limb is compromised. Some movements might be lost because of trauma to the neuromuscular structures. In such cases too secondary tendon transfers are considered for optimal functional outcome of the lower extremity.
Tendon transfers are surgical procedures where some of the lesser important muscles/tendons are used to replace the function of the more important muscles /tendons. This type of surgery needs a prolonged course of physiotherapy to reeducate and strengthen the musculotendinous units used for tendon transfer.
Another important aspect of lower limb reconstruction is to provide sensory innervations if is lost .This necessitates nerve reconstruction using primary suturing of nerve grafts. Handling of nerves like vessels needs delicate tissue handling and magnification,and is best done by a Plastic surgeon. It must be understood that even after nerve reconstruction, it takes a very long time for the patient to develop protective sensations. Due foot care must be taken during this period and even after that to avoid repeated trauma and ulcerations to the reconstructed foot.
To sum up, lower limb reconstruction is complicated and needs multidisciplinary management for best possible outcomes. Multiple procedures might be needed for optimal functional outcomes. Opinion of the plastic surgeon must be solicited early to expedite the recovery, and improve the outcomes.
