SINGAPORE ASSOCIATION OF PLASTIC SURGEONS

Limb Reconstruction

LOWER LIMB RECONSTRUCTION

Author: Dr Terence Goh
Lower limb reconstruction is done with the aims of limb salvage and preserving function. As plastic surgeons, we work closely with the general surgeons and orthopaedic surgeons who are often the referring surgeons for conditions that may threaten limb loss. Here is a list of common conditions that may lead to a referral for lower limb reconstruction:
  • Trauma – open fractures or degloving injuries involving the lower limb
  • Cancer 
  • Infection – necrotising fasciitis or diabetic infections of the foot and lower limb
The lower limb can be broadly divided into 2 main areas: above knee and below knee. The below knee area can be futher sub-divided into 3 broad areas : upper 1/3, middle 1/3 and lower 1/3. 

  1. Above knee defects. In the area from the hip to the knee, there is often abundant soft tissue, hence most of the soft tissue defects in this area are amenable to reconstruction with direct closure or local and pedicle flaps.
  2. Upper third of the Leg – The upper third of the leg including the knee can be reconstructed with either pedicle flaps from the thigh or from the calf area. Some of the common conditions we treat in this area include 1. Infections after total knee reconstruction and 2. Open injuries or fractures to the knee. The gastrocnemius or hemisoleus flap (muscles from the calf) can be used to reconstruct distal knee defects and defects in the upper third of the leg, whilst the anteriorlateral thigh flap (from the thigh) can be used in the reconstruction of proximal knee defects.
  3. Middle third of the leg – The middle third of the leg injuries often present as open fractures of the tibia bone and reconstruction can be performed with the adjacent gastrocnemius or hemisoleus muscle flaps. In severe cases of open tibia fracture where there is a lot of collateral damage to the muscle, a free tissue transfer may be necessary. 
  4. Distal third of the leg – The distal third of the leg includes the ankle and the foot. The main distinction in this area is the absence of soft tissue around the ankle joint and the foot for local or pedicle flaps. Traditionally, injuries to this area or infections affecting this area often requires free tissue transfer for reconstruction. However, with advances in reconstruction, selected conditions may still be amenable to reconstruction using pedicled flaps. 
  5. Diabetic foot conditions – Patients with diabetic foot ulcers deserve a special mention here as this is becoming an increasingly common reason for lower limb amputation. Early medical attention can allow early intervention to improve diabetic control, improve blood supply to the foot and treatment of the infection to prevent further tissue loss. In the past, reconstruction and limb salvage for diabetic patients used to be unpopular due to the high failure rates. With improved understanding of flap physiology we are now able to provide reconstruction and limb salvage for patients with diabetic 

TREATMENT

Depending on the severity of the injuries to the lower limb, your reconstruction may involve primary closure of skin, skin grafting, use of vacuum assisted devices for delayed closure, local flaps and free tissue transfer. Speak to you plastic surgeon early to discuss options for limb salvage and reconstruction.
  • Preparing for Surgery

    The success of lower limb salvage starts with early referral to a plastic surgeon. Imaging studies may be required to assess the extent of injury and also to ascertain the vascular supply to the limb. Detailed planning of the reconstructive options will be made and discussed with both the patient and referring surgeon. Once the plans are finalised, the patient is prepared for surgery. Most of these operations will require general anaethesia and a review by the anaesthesia team will be done prior to the operation.

  • Surgery

    Depending on the severity of the injury, the reconstruction may involved simple closure of skin to more complex options of free tissue transfer. Occasionally, local tissue such as skin from the calf or muscle can be used to rotate in and cover the defect. However, if there is significant tissue loss with critical structures such as bones or nerves exposed, free tissue transfer from a distant site e.g. from the thigh to the foot, will need to be perform to reconstruct he missing tissue components and salvage the limb.

  • Post-Surgery Care

    In the immediate post-operative period, patients will usually be observed in a high-dependency ward with nurses who are specialised to look after flaps. Patients are usually kept faster for the first 24 hours and thereafter if the flap is stable, they are allowed feeds. Tubes and drains are usually removed after a few days. Patients are mobilised early if possible, and this will be done with supervision from the physiotherapist. Whilst they are unable to weight-bear on the affected limb, they are often started on wheelchair mobilisation and crutches. Once the flap is stable the patients can be discharged and followed up in the outpatient clinic. Depending on the severity of the injury, patients may take weeks to months for rehabiliation as they begin their road to recovery.

Complications and Management

Limb reconstruction and limb salvage can life-changing for patients as they regain or maintain the ability to ambulate. However the road to recovery can be long and it may take some time before they are rehabilitated to full recovery. 

There are also potential complications:
  • Infections at both the recipient (injured) site and the donor site 
  • Bleeding, bruising, swelling and hematoma which may require blood transfusions
  • Flap loss – partial flap failure or complete flap failure
  • May require revision of flap or secondary flap procedures
  • Scars
  • Loss of function
  • Complications from anaesthesia
  • Complications from prolonged bedrest

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