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 Table of Contents  
ORIGINAL RESEARCH REPORT
Year : 2016  |  Volume : 13  |  Issue : 1  |  Page : 2-5

Early outcomes of reconstructing complex distal leg defects in Lagos, Nigeria


1 Burns, Plastic Surgery and Hand Rehabilitation Unit, College of Medicine University of Lagos/Lagos University Teaching Hospital PMB 12003 Idiaraba, Nigeria
2 Trauma and Orthopaedic Surgery Unit, College of Medicine, University of Lagos, Lagos University Teaching Hospital, Lagos, Nigeria

Date of Web Publication2-Feb-2016

Correspondence Address:
Bolaji O Mofikoya
Burns, Plastic Surgery and Hand Rehabilitation Unit, College of Medicine, University of Lagos, Lagos University Teaching Hospital, PMB-12003, Idiaraba, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1595-9587.175482

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  Abstract 

Background: Complex defects in the distal third of the leg are often difficult problems for the reconstructive surgeon. Objective: This study aims to identify the early outcomes of reconstruction for complex defects of the distal leg. It explores basic demographics and presentation challenges associated with these defects. It further highlights various methods of reconstruction, complications, and outcomes. Materials and Methods: Between 2008 and 2013, all patients with lower leg and ankle defects that had definitive flap cover were prospectively studied. Age, sex, duration of defect, cause of defect, comorbidity, size of defects, and the reasons for delay in intervention were obtained for each patient. The type of flap used, complications, duration of hospital stay, early outcome, and ambulation status at 6 months were noted. Results: Twenty five patients were studied during the period with a male to female ratio of 3:2. Sixty eight percent (17) of the defects were trauma related. The inability to pay for treatment was the commonest cause of intervention delay. The mean size of the defects was 31 cm2. Diabetes and peripheral vascular disease were the commonest comorbidities. Perforator-based fasciocutaneous flaps were the most commonly used (48%;12), while muscle flaps (24%;6) and adipofascial turnover flaps (20%;5) were less utilized. Two patients died and one underwent a below-knee amputation. Late infection persisted in 16%(4) of the patients seen. Conclusion: Trauma-related defects predominated in this study, and financial issues delayed definitive intervention in many cases. Inspite of this, successful coverage was obtained in 84% of the patients. There was, however, a trend toward increasing infection and mortality among older patients.

Keywords: Complex, distal third leg defects in Lagos, Nigeria, reconstructing


How to cite this article:
Mofikoya BO, Ugburo AO, Enweluzo GO. Early outcomes of reconstructing complex distal leg defects in Lagos, Nigeria. J Clin Sci 2016;13:2-5

How to cite this URL:
Mofikoya BO, Ugburo AO, Enweluzo GO. Early outcomes of reconstructing complex distal leg defects in Lagos, Nigeria. J Clin Sci [serial online] 2016 [cited 2019 Oct 14];13:2-5. Available from: http://www.jcsjournal.org/text.asp?2016/13/1/2/175482


  Introduction Top


Complex injuries of the distal third of the leg region are usually of the Gustilo-AndersonIIIBtype and quite challenging for the plastic surgeon. The paucity of subcutaneous tissues, presence of bony prominences of the malleoli, greater risk of infection, and relatively poor blood supply of this region make reconstruction difficult. The current success in lower extremity reconstruction as measured by stable bony union, soft tissue healing, and normal ambulation has been achieved through a seamless, timely, and coordinated management of all injured structures in many centers. Early soft tissue coverage, usually within a week, is critical in preventing deep infection.

Sometimes there are delays in instituting definitive treatment for many of these patients in developing countries.[1] For many patients with complex defects from trauma, the exposure of underlying bone creates significant anxiety concerning ambulation and risks of amputation. While other parts of the leg present reliable local options of soft tissue coverage for complex defects, significant distal third leg defects have been the domain of free flaps.[2],[3],[4] Microvascular free flaps are not routine procedure in resource-constrained centers of many countries in our region. This procedure requires specialized equipment, training, and long operating times. However, with better understanding of the blood supply of the lower extremity, several clinical reports have confirmed the increasing reliability of local and regional perforator-based flaps in achieving the goal of distal third leg reconstruction. In this study, we seek to evaluate our early outcomes in the management of these defects at the Lagos University Teaching Hospital, Lagos, Nigeria.


  Materials and Methods Top


The Lagos University Teaching Hospital is a 875-bed tertiary health facility located within the city of Lagos, Nigeria. It is one of the three major government-owned tertiary hospitals that serve the estimated 15 million inhabitants of Lagos State, Nigeria. Data were prospectively collected from all patients that presented with complex soft tissue defects of the distal third of the leg and ankle between January 2008 and December 2013 at the Lagos University Teaching Hospital. All patients were jointly seen by the orthopedic and plastic surgery team at presentation as needed (usually within 24 h). Though the time of definitive orthopedic fixation (when required) was variable, all patients with distal leg defects needing a flap cover were subjects of this study.

The choice of flap was made based on the site, depth, and etiology of each defect. For the fasciocutaneous flaps the vascular territories of suitable perforators were explored with a handheld Doppler. Following preliminary exploratory incisions, the actual design was based on intraoperative findings. We designed the flaps after identifying the course of the perforator with a handheld pencil-tipped Doppler for reliability. This is our method of choice for large- and medium-sized defects. All other specific flaps were raised using the standard techniques. The patient demographics were recorded. The etiology and size of the defect (estimated with a simple ruler measuring the longest length in the head-to-toe direction and the breadth in a direction perpendicular to this), type of reconstruction, and associated comorbidities and complications were noted. Ambulation and late infections at 6 months were recorded during the follow-up period. All data were analyzed using SPSS version 15 (SPSS Inc. 233 South Wacker Drive, 11th Floor Chicago, IL). The continuous variables were presented as mean ± SD, the confidence interval was 95%, and the significance level was set at P ≤ 0.05. The results were illustrated with tables and figures.


  Results Top


Twenty five patients were recruited into the study: 15 males and 10 females. The mean age was 37.4 ± 16.7 years. Trauma was the majore tiological factor in 72% (n = 18), while 12% (n = 3) of patients had osteomyelitis with discharging sinuses that necessitated radical bone debridement and soft tissue cover. In addition, 8% (n = 2) of patients had implant exposure following open reduction and internal fixation (ORIF) for distal third fractures. In one patient, the cause of the defect was pressure sore and in another, necrotizing fascitis. The commonest comorbidities were diabetes (20%; n = 5) and peripheral vascular disease (12%; n = 3). Cerebrovascular accidents and sickle-cell disease occurred in one patient each (4%).

The largest defect measured 108 cm 2 in a patient with rollover crushing injury of the leg, while the smallest measured 2 cm 2 in an exposed lateral malleolar screw, which followed an ORIF of a fibular fracture. The mean size of all the defects was 31 ± 30 cm 2.

All patients studied had definitive cover done more than 5 days following injury or presentation.

The inability to make payments and the absence of health insurance delayed definitive treatment in 88% (n = 22) patients. Three (12%) patients did not initially consent to surgery due to the fear of amputation. Two x(6%) patients faced delayed referral within the hospital.

The commonest method of reconstruction done was inferiorly based fasciocutaneous flaps in 11 patients (48%). Eight patients had perforator-based fasciocutaneous flaps. The sural neurocutaneous flap was used in two patients, and one patient had a lateral supramalleolar flap, with muscle flaps (24%) and adipofascial turndown flaps (20%) being the next most frequently performed types of flap cover. There were three complete flap failures, one in a reverse suralflap in a diabetic patient with severe peripheral vascular disease, who eventually died. There was a failed distally based fasciocutaneous flap in a patient with peripheral vascular disease and a rollover injury that required a below-knee amputation. One adipofascial turndown flap patient suffered necrosis that required debridement and skin graft to complete the reconstruction [Table 1].
Table 1: Outcomes of complex distal leg defects

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The two mortalities were in patients with diabetes and peripheral vascular disease, and these were attributable to the comorbidities. All patients were followed up at the outpatient department for 6 months. During this period four patients were noted to develop infection (persistent purulent discharge at the flap margin from underlying osteomyelitis).


  Discussion Top


Complex defects of the distal third of leg region can present as difficult problems to the reconstructive surgeon. In our practice, the presentation is often delayed, commonly due to financial issues similar to other reports in similar settings.[5] As reported, male patients predominated this study probably because of the trauma-related defects in most of the patients, as extremity trauma is more frequent in the male population.

Diabetes mellitus (uncontrolled and previously undiagnosed) and peripheral vascular disease were the main comorbidities. Expectedly, our two mortalities were in these groups as both conditions have been associated with significant wound-healing problems in the lower extremity as well other comorbid events. Simple skin grafts play a limited role in complex defects, with slow take and graft loss making overall morbidity quite high. Fasciocutaneous flaps were introduced by Ponten [6] in 1981 and were the most commonly used in our series. With a better understanding of skin vascularity through the angiosome concept as a three-dimensional vascular territory, the sub fascial arborization of its cutaneous branches along with Doppler mapping of the direction has made it easier to raise more reliable flaps.[7],[8] On some large defects we had to use more than one flap [Figure 1]. Our experience mirrors that of other health care workers [9],[10],[11] with respect to the learning curve for perforator dissection. On account of significant reports of venous congestion and other complications, we use this option with caution in patients with high-energy injury and following a failed primary reconstruction when we occasionally employ a delay procedure [Figure 1].
Figure 1: (a) A 53-year-old with a medial ankle defect following plate fixation of an open fracture in distal articular tibia and fibula from a gunshot injury (b) Defect covered with combination of delayed supramalleolar flap and abductor hallucis muscle flap

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For medium- and small-sized defects we tend to favor adipofascial turndown flaps as they are versatile, easy to raise, and reliable particularly for exposed bone, exposed hardware, or complex defects with no cavities or dead space.[12],[13] One can also extend the traditional length-breadth ratio when outlined based on a perforator.

Despite the fact that there are few muscles available in this area, we found muscle flaps to be particularly useful for infected lesions such assaucerization for osteomyelitis and cavities-associated defects. The extensor digitorum brevis and the peroneus brevis have been known to be particularly useful for small distal third infected cavities.[14],[15] This was seen in our study as well. In this group none developed infection in the follow-up period.

A majority (84%) of the patients had stable soft tissue cover at discharge. In our study we observed that significant morbidity and mortality were higher in the older age group (over 55 years). This was probably attributable to the significant comorbidities (diabetes and peripheral vascular disease) in this group and it mirrors the experience of other health care workers in covering distal third defects.[16] We also noted that major complications were not significantly related to duration of defect, size, or sex of the patient (P > 0.05). In our study, the mean hospital stay was noted to be rather long (SD 34.2 ± 15.2 days post surgery). This is, however, not related directly to the procedures, as issues such as complications from the simultaneous orthopedic procedures, availability of rehabilitative care, willingness, and financial resources influence the time of final discharge.

As expected major complications caused a delay in ambulation for many patients however 87% of followed-up patients were ambulating at 6 months after surgery.

Four (16%) patients had persistent bone infection (for which they had appropriate antibiotic use and repeat bone debridement in one case). This was because of our mean duration of the defect of SD6.7 ± 10.1 days being rather long: It is known that infection rates are higher when reconstruction is delayed by longer than 1 week.[17]

Inspite of intervention delays and comorbidities, it appears that various soft tissue options can be successfully used to reconstruct most complex distal leg defects. As shown in our work, careful selection of appropriately tailored reconstructive techniques is needed to optimize outcomes.

 
  References Top

1.
Sharma BR. Road traffic injuries: A major global public health crisis. Public Health 2008;122:1399-406.  Back to cited text no. 1
    
2.
Thammannagowda RK, Ashish G, Mudukappa S, Pushkar D, Vijayakumar A. Comparison between peroneus brevis flap and reverse sural artery flap for coverage of lower one-third leg defects.ISRN Plastic Surgery 2014:10.doi:10.1155/2014/969420.  Back to cited text no. 2
    
3.
Rios-Luna A, Fahandezh-Saddi H, Villanueva-Martínez M, López AG. Pearls and tips in coverage of the tibia after a high energy trauma. Indian J Orthop 2008;42:387-94.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Parrett BM, Pribaz JJ. Lower extremity reconstruction. Rev Med ClinCondes 2010;21:66-75.  Back to cited text no. 4
    
5.
IfesanyaAO, Ogundele OJ, Ifesanya JU. Orthopaedic surgical treatment delays at a tertiary hospital in sub Saharan Africa: Communication gaps and implications for clinical outcomes. Niger Med J 2013;54:420-5.  Back to cited text no. 5
    
6.
Pontén B. The fasciocutaneous flap: Its use in soft tissue defects of the lower leg. Br J PlastSurg 1981;34:215-20.  Back to cited text no. 6
    
7.
Saint-Cyr M, Schaverien M, Arbique G, Hatef D, Brown SA, Rohrich RJ. Three- and four-dimensional computed tomographic angiography and venography for the investigation of the vascular anatomy and perfusion of perforator flaps. Plast Reconstr Surg 2008;121:772-80.  Back to cited text no. 7
    
8.
Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perforasome theory: Vascular anatomy and clinical implications. Plast Reconstr Surg 2009;124:1529-44.  Back to cited text no. 8
    
9.
Masia J, Moscatiello F, Pons G, Fernandez M, Lopez S, Serret P. Our experience in lower limb reconstruction with perforator flaps. Ann Plast Surg 2007;58:507-12.  Back to cited text no. 9
    
10.
Tos P, Innocenti M, Artiaco S, Antonini A, Delcroix L, Geuna S, et al. Perforator-based propeller flaps treating loss of substance in the lower limb. J Orthop Traumatol 2011;12:93-9.  Back to cited text no. 10
    
11.
Pignatti M, Pasqualini M, Governa M, Bruti M, Rigotti G. Propeller flaps for leg reconstruction. J PlastReconstrAesthetSurg 2008;61:777-83.  Back to cited text no. 11
    
12.
Lin SD, Lai CS, Chou CK, Tsai CW. The distally based posterior tibial arterialadipofascial flap. Br J Past Surg 1992;45:284-7.  Back to cited text no. 12
    
13.
Lin SD, Lai CS, Chiu YT, Lin TM, Chou CK. Adipofascial flap of the lower leg based on the saphenous artery. Br J PlastSurg 1996;49:390-5.  Back to cited text no. 13
    
14.
Bach AD, Leffler M, Knesser U, Kopp J, Horch RE. The versatility of distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg. Ann Plast Surg 2007;58:397-404.  Back to cited text no. 14
    
15.
Koul AR, Patill RK, Philip V. Extensor digitorumbrevis muscle flap: Modified approach preserving extensor retinaculum. J Trauma 2009;66:835-9.  Back to cited text no. 15
    
16.
Olawoye AO, Ademola SA, Iyun K, Michael A, Oluwatosin O. The reverse suralartery flap for the reconstruction of distal third of the leg and foot. Int Wound J 2014;11:210-4.  Back to cited text no. 16
    
17.
Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM. Fix and flap: The radical orthopaedic and plastic treatment ofsevere open fractures of the tibia. J Bone Joint Surg Br 2000;82:959-66.  Back to cited text no. 17
    


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