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Year : 2021  |  Volume : 29  |  Issue : 3  |  Page : 179-182

Reconstruction of mutilating injuries of the lower extremity – Surgical decision-making for the plastic surgeon

Acibadem Hospital Group, Bagdat Clinic and Dr Cigdem Unal Plastic Surgery Clinic, Istanbul, Turkey

Date of Submission19-Dec-2020
Date of Acceptance16-Jun-2021
Date of Web Publication29-Jul-2021

Correspondence Address:
Dr. Cigdem Unal Gulmeden
Acibadem Hospital Group, Bagdat Clinic and Dr Cigdem Unal Plastic Surgery Clinic, Poyracik Street, Pinar apt. 63/6, 34365, Nisantasi, Tesvikiye, Istanbul
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tjps.tjps_36_21

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High-energy traumas of the lower extremity caused by road accidents, gunshot injuries, or heavy construction equipment usually involve the bone and vascular structures as well as the soft tissues surrounding them. Reconstruction of these injuries may require teaming up with orthopedic and vascular surgeons to solve the dilemmas. Vascular evaluation and determination of the zone of injury is necessary to make the best possible reconstruction plan to achieve a functional and vascularized lower extremity. Although preoperative radiodiagnostic methods help in choosing the recipient vessels, flaps, and anastomotic technique, the ultimate decision is best made during surgery.

Keywords: Angiography, computed tomography angiography, free tissue transfer, lower extremity reconstruction, recipient vessel

How to cite this article:
Gulmeden CU. Reconstruction of mutilating injuries of the lower extremity – Surgical decision-making for the plastic surgeon. Turk J Plast Surg 2021;29:179-82

How to cite this URL:
Gulmeden CU. Reconstruction of mutilating injuries of the lower extremity – Surgical decision-making for the plastic surgeon. Turk J Plast Surg [serial online] 2021 [cited 2021 Sep 17];29:179-82. Available from: http://www.turkjplastsurg.org/text.asp?2021/29/3/179/322675

  Introduction Top

Mutilating injuries of the lower extremity usually involve the bone and vascular structures as well as the soft tissues surrounding them. The most common etiology of these high-energy traumas are road accidents, gunshot injuries, or heavy construction equipment. The plastic surgeons may need to team together with orthopedic surgeons, and sometimes, vascular surgeons to solve the dilemmas in the best possible way.[1] Local flaps are scarce compared to other regions of the body, therefore should be planned carefully. Free tissue transfers may be the preferred method of reconstruction in many cases due to the major arterial injuries which could have been used as recipient vessels. In lower extremity injuries, knowledge regarding the zone of injury and relationships of disrupted vascular, bone, and soft tissue structure anatomy is critical in the reconstruction.[2] Achieving the ambulatory function of the lower extremity is very important as well as salvage when dealing with these types of injuries. Today, microsurgical reconstruction of the lower extremity is accepted as a safe procedure even though flap failure rates may be higher compared to other regions of the body.[3]

  Important Factors to Consider Before Reconstruction Procedures in Mutilating Injuries Top

Vascular evaluation of the injured lower extremity

When faced with a lower extremity injury requiring reconstruction, vascular examination distal to the injured area should be done first. Capillary refill, color, palpable pulses, and turgor of the extremity will give information on the initial status of the extremity. The vessels travel in their compartments that are in close proximity to the bones in the lower extremity; therefore, any high impact injury may affect the vascularity of the foot, especially if there is a bone fracture of the leg.[4],[5] Concomitant vascular injury in open fractures as a result of trauma is reported to be as high as 29%.[4]

Plastic and reconstructive surgeons have climbed the reconstructive ladder starting from basic muscle flaps of the lower extremity to “chimera,” and “Orochi” flaps for repair of complex lower limb defects.[6] Knowledge of the fine anatomy, especially after mutilating injures, has helped the reconstructive surgeons for this incredible leap to happen. Surgeons and radiologists have advocated various diagnostic methods to avoid complications such as foot ischemia or to determine the magnitude of vascular injury in the recipient vessels. The identification of vessel injury can be determined by various methods such as handheld Doppler, digital subtraction angiography (DSA),[7] and computed tomography angiography (CTA).[8] When physical or Doppler examination is inconclusive, or if the patient has a chronic peripheral vascular disease, angiographic evaluation can be done to assess the vascular status of the injured extremity.[2] Angiographic evaluation is helpful in patients with neurological deficit, when a bone fracture accompanies the soft tissue trauma, in those patients with external or internal hardware, or in patients with one or more pulse loss.[2],[4],[5]

Handheld Doppler is a reliable and noninvasive method for evaluation of the presence of blood flow in the arteries, but it cannot provide clear information regarding the dynamics flow such as proximal occlusion and distal reconstitution.[9] In patients with a single artery vascularizing the distal part of the injured extremity, it is possible to obtain a positive Doppler signal of the dorsalis pedis artery through the connection of the posterior tibial and anterior tibial vessels in the first web space even though the only means of leg perfusion is through the posterior tibial artery.

Although color flow Doppler ultrasound is a noninvasive modality in evaluation of blood vessels, it is highly operator dependent, difficult to perform in patients with open wounds, and does not give information of the entire vascular anatomy of the limb.[9] DSA has been the standard evaluation modality in assessment of arterial blood flow in many centers. Although DSA is replaced by CTA because of its potential complications such as puncture site hematoma, bleeding, thrombosis, and the necessity to administer higher doses of radiation, Uyeda et al.[10] state that DSA still has indications in selected patients. Magnetic resonance angiography in some circumstances may uncover distal arterial targets not visualized on DSA. However, spatial resolution is inferior to DSA and erroneous interpretations due to acquisition artifacts are common.[11] It provides inferior visualization in patients with metallic implants and external fixation.[9]

Images obtained by CTA are performed by static acquisition, dynamic information of blood flow is not acquired.[12] Since images are static images, it may be difficult to interpret whether the flow in the examined vessel is truly from the noninjured proximal part of the same vessel or from the collaterals between the noninjured segments or the adjacent arterial system. Another diagnostic dilemma that CTA poses is that vascular spasm, dissection, external compression from injured soft tissues, and hematoma may all present in the fashion of arterial narrowing.[13] This precludes direct evaluation of collateral flow and vasospasm. In addition, in patients who have metallic fixation material which can cause substantial image degradation, DSA may be considered as the initial imaging study performed when there is a high probability of injury.[10]

As a minimally invasive technique, CTA provides three-dimensional imaging of the vascular anatomy and surrounding structures. In lower extremity reconstruction, it has been used in vascular mapping of the donor site prior to free fibula harvest where variations in vascular anatomy are common, planning of perforator flaps in lower extremity reconstruction, and in preoperative assessment of peripheral arterial disease.[10],[13],[14],[15]

Currently, preoperative radiodiagnostic evaluation gives us access to a closed disrupted vascular system, and this can be used as a rough plan for surgical decision-making. Final flap, recipient vessel, or anastomotic technique should be planned during surgery.

Zone of injury and recipient vessels

Most of the high-energy injury wounds have a larger zone of trauma than expected. Failure to recognize this zone of injury may result in flap or extremity loss. Perivascular damage within the zone of injury may extend beyond macroscopically evident areas, especially in high-energy injuries; therefore, this increases the likelihood of thrombosis of vessels and might alter both arterial and venous flow dynamics.[2] Perivascular changes cause difficult dissection of vessels that increase thrombosis incidence or spasm after anastomosis.[2] It is important to explore the flow in the stump of an injured artery [Figure 1]a, [Figure 1]b, [Figure 1]c, when the dissection length enables, triphasic flow can be achieved in some cases. Some surgeons advocate using bypass vein grafts or arteriovenous loops to supply vascularization to the flap or the distal part of the extremity when the stump of a recipient vessel runs too short for anastomosis.[16]
Figure 1: (a): Lower extremity injury with heavy construction equipment of a 40-year-old male. Femur, patella, and tibia fracture were fixed with external fixation by orthopedic surgeons. 10 cm × 10 cm open wound on the anterior aspect of left ankle exposing tendons, 8 cm × 6 cm open wound exposing patella on knee. (b) Anterolateral thigh free flap was used for reconstruction of anterior aspect of the ankle and lateral head of the gastrocnemius and a split-thickness skin graft was used for patellar wound reconstruction. (c) The patient is seen 5 months postoperatively

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Lower extremity salvage in Gustilo IIIC injuries requires understanding the recipient vascular anatomy after major trauma.[17] It has been reported that in Gustilo III injuries requiring free flap coverage, the anterior tibial artery injury is much higher in comparison with the posterior tibial. The major reason for this was stated as its proximity to the tibia.[17],[18] The conjecture was that the impact of trauma sufficient enough to injure the posterior tibial artery often required amputation.[16] Today, with the help of advances in microscopes, microsurgical instruments, radiodiagnostic, and microsurgical techniques, this understanding has changed.

When preoperative radiologic investigations reveal a single vessel extremity, any arterial anastomosis to this single vessel should be end-to-side to ensure the continuation of this flow. In our previous study, we emphasized that using the arteries distal to the zone of injury for arterial anastomosis is easier in the upper extremity.[19] Unfortunately, it may not be preferable in the lower. When the impact of injury is so high that all major vessels are injured, a flow-through flap to cover the defect and ensure vascularization distal to the zone of trauma can be necessary.[18] It may be necessary to work with vascular surgeons if thrombectomy is mandatory in crush injuries [video 1 and [Figure 2]a, [Figure 2]b, [Figure 2]c, [Figure 2]d].
Figure 2: (a) Fifty-year-old male after being run over by a truck tire. Popliteal artery total occlusion with a thrombus. Popliteal artery, sciatic nerve exposed. Posterior thigh and leg muscles avulsed. (b) The appearance of the leg after the vascular surgeons completes the thrombectomy, and the leg is reperfused. The debridement is complete, the tip of the pick-up is showing the pedicle of the avulsed gastrocnemius muscle medial head. (c) The popliteal artery and sciatic nerve are covered with the medial and viable parts of the lateral gastrocnemius muscle. (d) The patient is seen 3 months after surgery

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Type of anastomosis

It has been shown that flap success is not affected by end-to-end or end-to-side anastomosis.[20] The main advantage of end-to-side anastomosis in the lower extremity is the preservation of a major vessel which may be the only vascular supply of the distal extremity. Another advantage is being able to overcome a vessel size mismatch by making the anastomosis a perforator of a major vessel. Other than these two major types of anastomosis, T-shaped or flow-through anastomosis can also be done in selected cases where reconstructing distal flow to the extremity is vital or there is a gap between the segments of the recipient vessels.[2]

Use of perforators as recipient vessels

Vascular damage is frequent in the lower extremity traumas, and it is common to be faced with a single vessel extremity. Peripheral arterial disease and diabetes are commonly seen, especially in the elderly. Using major vessels as recipients in the ischemic lower extremity may cause serious problems postoperatively. Perforators, being able provide good enough perfusion to large flaps, preclude the need to obtain major vessels as a recipient. When a well-perfused, pulsating perforator is obtained, it provides even better flow to the flap compared to major atherosclerotic vessels of an ischemic limb.[21] Perforators have blood supplies from different sources unlike major arteries that can go atherosclerotic, so they are considered advantageous in patients with peripheral arterial disease.[21],[22] Then, the only means to find a recipient vessel is to use a hand Doppler.

  Discussion Top

Microsurgeons, especially those who are at the beginning of the training, try their best to prevent an inappropriate decision that may result in limb loss or flap failure in mutilating injuries of the lower extremity. The surgeon's indication concerning whether to use a free or a local flap for reconstruction may change according to the extent of vascular injury of the extremity. What may also change is the recipient vessel for free tissue transfer, the level of anastomosis, or even the type of anastomosis on a one-vessel leg.

In most cases with all major arteries injured or those vascularized with a single vessel, preoperative radiological assessment of the injured lower extremity can help us lessen the cloud of insecurity about the best possible recipient vessels. Complete knowledge of the pertinent anatomy, as well as awareness of potential recipient vessels, is necessary for salvage of the perplexity of the high injury traumas of the lower extremity.

In two- or three-vessel extremity, local flaps or perforator flaps can be used instead of sacrificing major arteries as free flap recipient vessels. In a single vessel extremity, a free flap arterial anastomosis should be done end-to-side to the only artery, to a perforator of that artery, or to the stump or perforator of the injured arteries. In these cases, preoperative imaging prevents time loss due to exploration of other vessels which have limited or reverse flow. Patients with all major arteries injured may need emergency vascular repair, or they may present late with soft tissue defects requiring coverage. Flow-through flaps can be used as native conduits for soft tissue coverage as well as vascularization of the injured lower extremity. For complex defects of the lower extremity, reliable vascularization can be performed by bypass, vein grafts as well as flow-through flaps. Vascularized nerve flaps and bone flaps can be used for reconstruction of nerve palsy or bone defects.[6]

  Conclusion Top

We, as reconstructive surgeons, should be able to use whatever options remain available in lower extremity traumas, consider multiple factors for each patient, such as status of major arteries that supply flow to the distal part of the extremity and any accompanying peripheral vascular disease. Preoperative assessment of the extent of vascular injury in the severely traumatized lower extremity can change flap selection, target donor vessel and level, and type of anastomosis and can help in surgical decision-making, especially for the microsurgeons who are in the phase of gaining experience. Ultimate decision-making in the lower extremity is best done on the surgical table after exploration.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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Xiong L, Gazyakan E, Kremer T, Hernekamp FJ, Harhaus L, Saint-Cyr M, et al. Free flaps for reconstruction of soft tissue defects in lower extremity: A metaanalysis on microsurgical outcome and safety. Microsurgery 2016; 36: 511-24.  Back to cited text no. 3
Spector JA, Levine S, Levine JP. Free tissue transfer to the lower extremity distal to the zone of injury: Indications and outcomes over a 25-year experience. Plast Reconstr Surg 2007;120:952-9.  Back to cited text no. 4
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Uyeda JW, Anderson SW, Sakai O, Soto JA. CT angiography in trauma. Radiol Clin North Am 2010;48:423-38, ix-x.  Back to cited text no. 10
Feng S, Min P, Grassetti L, Lazzeri D, Sadigh P, Nicoli F, et al. A prospective head-to-head comparison of color doppler ultrasound and computed tomographic angiography in the preoperative planning of lower extremity perforator flaps. Plast Reconstr Surg 2016;137:335-47.  Back to cited text no. 11
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Chow LC, Napoli A, Klein MB, Chang J, Rubin GD. Vascular mapping of the leg with multi-detector row CT angiography prior to free-flap transplantation. Radiology 2005;237:353-60.  Back to cited text no. 15
Freedman AM, Meland NB. Arteriovenous shunts in free vascularized tissue transfer for extremity reconstruction. Ann Plast Surg 1989;23:123-8.  Back to cited text no. 16
Haddock NT, Weichman KE, Reformat DD, Kligman BE, Levine JP, Saadeh PB. Lower extremity arterial injury patterns and reconstructive outcomes in patients with severe lower extremity trauma: A 26-year review. J Am Coll Surg 2010;210:66-72.  Back to cited text no. 17
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Unal C, Yasar EK, Sarisoy TH. The role of preoperative radiological assessment of vascular injury on surgical decision making in mutilating injuries of the upper extremity. Ann Plast Surg 2013;70:289-95.  Back to cited text no. 19
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Suh HS, Oh TS, Hong JP. Innovations in diabetic foot reconstruction using supermicrosurgery. Diabetes Metab Res Rev 2016;32 Suppl 1:275-80.  Back to cited text no. 21
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  [Figure 1], [Figure 2]


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