Free Flaps in Complex Lower Limb Reconstruction - 2-Year Experience

Introduction: Complex lower limb reconstruction has always been a difficult area of knowledge with high complication rates, prolonged rehabilitation periods and radical solutions (amputation) ever present. Anatomical and vascular particularities of the lower limb frequently pose situations were local and regional tissues are insufficient for a satisfactory reconstruction.

Vascularized free tissue transfers enable a unique degree of freedom in dimension, tissue type and 3D morphology with the extra vascularisation input that is most likely to be needed. These characteristics are very important in the surgical principles for lower limb complex reconstruction. We present our department’s experience with free flaps for lower limb reconstruction.

Methodology and Material: From January 2012 to December 2013, a total of 30 free flaps for lower limb were performed. Epidemiologically, 25 male and 5 female patients were treated with a medium age of 48 years old (8-82 years old). The etiology of the defect was: acute trauma - 10 cases; orthopaedic surgery complication (skin necrosis, infection), iatrogenic - 7 cases; neoplastic - 8 cases; osteomyelitis - 4 cases; pseudartrosis - 1 case. The flaps used were: muscular gracillis - 10 cases; muscular latissimus dorsi - 7 cases; anterolateral thigh - 8 cases; muscular rectus abdominis - 2 cases; fibula - 2 cases; muscular latissimus dorsi + serratus anterior - 1 case.

Results: No complications were observed in 26 flaps. We had 3 microsurgical reexplorations for venous congestion (2) and ischemia (1) with 2 successful outcomes. There were 2 total flap necrosis (on the 3rd and 5th postoperative day) and 2 partial necrosis with subsequent need for debridement and skin grafting. 1 patient has a residual fistula related to a total knee prosthesis. 1 patient has an infected pseudarthrosis still in treatment. Functional results are considered good in 28 cases. 23 patients walk without additional weight support.

Conclusions: Lower limb defects frequently present as a serious challenge. Free flaps offer extra and incomparable possibilities for reconstruction and give solutions that can push an amputation scenery farer away.

Technical and logistical difficulties that are inherent to these techniques are contoured by specific training, experience and collaboration in specialized teams were a multidisciplinary Plastic Surgery - Orhtopedics approach is a must.