Combined reconstruction using cross leg flap and cross-Ilizarov external fixator in treatment of distal third tibial post-traumatic bone and soft time injuries

Combined  reconstruction using cross leg flap and cross-Ilizarov external  fixator in treatment of distal third tibial post-traumatic bone and soft time injuries

Mahmoud M Fayed, MD(aJ; Sherien M Salama, MD(bJ

{a) Orthopedic Department, Ain Shams University, Egypt.

(a) Plastic Surgery Department, Ain Shams University, Egypt.

Background: Combined trauma of the lower third legofGustilo grade (GIII) B-C open tibia shaft fractures have a wide spectrum of injury to the bone and soft tissues.

Objective: To evaluate the outcome of using Ilizarov external fixator and cross leg flap in patients with combined traumatic (GIII) B-C open lower thirrf tibial  fractures.

Patients  and methods:  This prospective study was conducted between 2008 and 2012 on 9 male patients of age between 18 to 42 years {average 37years). 4 patients were of Gustilo type

!JIB with extensive periosteal stripping and 5patients of Gustilo type IIIC. 2patients were acute trauma (6-12) hours and 6 presented late  (2-5months after injury).  Exposure of bone and/or hardware was the mcyor problem in these patients. Nerve injury was negative in all patients. A protocol  for sequential staged reconstruction and preoperative planning was arranged by the orthopedic and plastic surgeon in all cases. We used random pattern  fasciocutaneous cross leg flap as soft tissue cover along with modified 3/8 Ilzarov frame (modified by orthopedic author) for tibial fracture with or without bone defect. Total treatment time till removal offixate  ranged from 5 to 11 months. Follow up was at least 3 years after Ilizarov fixator removal.

Results:  Most  flaps survived, two  had marginal necrosis and  one  superficial epidermal necrosis. No complications  were related to the donor  site, flap, or by immobilization.  Each patient resumed essentially normal gait and activity without stiffness ofjoints related to the flap or Ilizarov fixator. Complete failure occurred in one patient due to persistent severe infection and single vessel limb and underwent amputation.

Conclusion: This study showed how the cross leg fasciocutaneous  flap can be easily raised through an Ilizarov ring and can be transposed anteriorly  to cover soft tissue defects in the lower thirrf of the leg without losing the stability of the construct.

Key words: Cross leg flap, Ilizarov fixator, lower tibial defect.

Introduction:

The anatomical features of the lower third ofthe leg make the wound coverage ofthe soft tissue loss in a complex injury a challenging problem for orthopedic  and plastic surgeons. The bones of the  lower third are vulnerable to injury. Due to the paucity of soft tissues around them, the fractures that occur are often open. Most muscles  become tendons  at that level and in the case of soft tissue loss, skin graft may not suffice and flap cover becomes mandatory. The three major arteries to the leg, anterior and posterior tibial, and peroneal are

in closed compartments and they do not have significant  communications   between  them, the poor vascularization and subsequent poor healing  encountered  in these  regions  make the coverage of the wounds in lower third leg a challenging  problem, and demand detailed knowledge of the local anatomy to select the best surgical alternative for each patient. 1

The primary goal in limb salvage is definite

wound  closure  by  using  appropriate  flaps. Since the cross-leg flap was first described by Hamiltonin  1874,2 it was the optimal option for  covering defects  of the  leg and foot for

a long  time.3 During  World War II, this flap was widely used, with satisfying results. With the  advent  of  microsurgical techniques, the cross-leg flap was used less frequently. Since the 1990s,  microvascular surgery  has been regarded by many centers as the gold standard for salvaging severely traumatized lower extremities.4  However,  free  flap  operations are technically highly demanding, expensive, time  consuming and  are  not  applicable for all the patients.  First, free flaps cannot not be used in patients who suffer extensive lower extremity  injury   with  axial  vessel   damage and who have a history of previous trauma or vessel  thrombosis. In addition,  free flaps are not suitable for patients with severe peripheral vessel diseases and for those whose general conditions do  not  allow  surgical  procedures of   long   duration.   Third,   electrical  injury, single vessel extremities, and extremities receiving radiotherapy after  tumor  resection are relative contraindications for free flap.5 In these  conditions, the  cross-leg flap could  be a good  choice  for  reconstructing the  defects as local fasciocutaneous and myocutaneous flaps are often not available.6,7 Many refinements of  the  cross-leg procedure have been reported, such as the cross-leg tibial posterior  perforator flap,8 distally  based sural artery   fasciocutaneous  cross-leg  flap,9  and the  saphenous  neurofasciocutaneous flap.l o These  improvements profoundly increase flexibility of  the  cross-leg flap  and  make  it versatile for treating lower extremity wounds. The  inclusion   of  fascia   in  the  flap  makes length-to-width ratio 3:1 perfectly safe.

This allows much greater area of skin to be

transferred with much more freedom  of leg position.ll

Open fractures of the tibia, with associated vascular  injuries,   have   historically  had   a very  poor  outcome, this  poor  prognosis has prompted some to call for early amputation in select cases.l2 Ilizarov external fixation has proven  to be  a valuable method  for treating open tibial fractures. The ability ofthe frame to stabilize  a fracture, provide compression at the fracture site, and allow  access  to the soft tissues reconstruction makes it an integral tool in the  management of severe  tibia  fractures

with  or without  bone  loss.  Metaphyseal fractures with significant  shaft extension and fractures with  short  periarticular  fragments are   examples  of   situations  in   which    an Ilizarov    frame   is   frequently  employed.l3

Nowadays, the  Ilizarov  non-free  bone plasty

and free vascularised autografts have been universally acknowledged as two alternative

ways for bone defect management. 14 Ideally,

the Ilizarov bone plasty implies a gradual transport of a vascularised osteotomised bone autograft that  is  enveloped into soft  tissues and  induces  guided  tubular   bone  formation in the  defect  gap  both  in  length  and  shape. The  system   of  Ilizarov  bone  reconstruction for defect management is based on two main techniques; lengthening of a defect fragment through an osteotomy with  consolidation of the transported fragment at the docking  site, and gradual tibiofibular synostosis or gradual tibialisation ofthe fibula.l5

When   large  areas  of  bone   are  exposed soft  tissue  cover  of such  an area  will reduce the  amount   of  bone  to  be  lengthened  and also provide  adequate vascularity to the underlying   bone    and   decrease    incidence of   osteomyelitis.l6  Because   the   cross-leg flap,  which   is  located   in  a  lower  rung  of the reconstructive ladder  Figure(l), is less technically demanding, demonstrates greater safety   and   could   provide   stable   coverage for  different  defects  in lower  third  leg  with few  complications.l7 Even  should   the  flap fail,  no  significant bridges  have  been  burnt and   all  the   other   surgical   options   remain viable.   Traditionally,  cross-leg   flaps   have been   problematic   because    of   difficulties with immobilization and positioning of the extremities from  the time  of initial  coverage to detachment. The use of external fixator for immobilization circumvents many of these problems  and facilitates the  use of cross-leg flaps in patients  in whom free tissue  transfer may not be optima1.18

In this article  we used  cross-leg flap as a first choice instead of a free flap for soft tissue reconstruction in 9 patients  with  grade  IIIB, C  open  lower  third  tibial  fracture  Table(l), along  with  3/8 modified  Ilizarov  ring fixator that  had dual effects, first to act on bone and

second to maintain positioning of two legs till division ofthe flap.

Patients and methods:

This prospective study was conducted between  2008  and  2012  at Nasser  Institute and  El-Helal  hospital.   Nine  patients  with post-traumatic    combined    bone    and   soft tissue detects affecting distal third tibia were treated.  Informed  written consent  was taken from  all  patients.  High  energy trauma  was the mechanism in all injuries, 2 motor car accidents, 6 motor cycles and one patient was injured by a factory machine. All patients were males between 18 and 42 years old. Right side distal tibial third was affected  in  5 patients and left side in 4. Four patients were Gustilo type IIIB with extensive periosteal stripping and 5 patients Gustilo type IIIC with anterior tibial artery injured in 4 and posterior tibial in one. Bone defect was present in 6 patients, in 2 or them bone loss was primary at time of injury and in other 4 patients bone loss was iatrogenic after aggressive debridement to remove infected sequestrated and avascular bone  fragments.   The  size  of  bone  defect ranged from 4-7 em with overlie soft tissue defect . Late presentation (2-5 months after injury)  was  present  in  6  patients,  2 of  the soft tissue defect had been covered by local flaps  by  others  but  failed.  4  defects  could not be covered by local flaps because of the extensive soft tissue injury and were subjected to  frequent  dressing.  One  delayed  primary after one  week  and 2 patients  presented  as acute trauma within 6-12 hours with variable degrees of infection were present in 5 cases. Nerve injury was negative in all patients. Number of previous operations ranged from

2 to 4 in the form of debridement,  unilateral fixator  and plating  associated  injuries  were present in 5 patients in the form of ipsilateral facture  terms  in  one,  contralateral  fracture hummers in one and 2 fracture ribs and one abdominal injury to which spleenectomy was done. General  condition  was satisfactory  in all except for anemia in 2 patients that was corrected  by  fresh  blood  transfusion   pre­ operative.  2 patients  were virus C infected. Exposure  of bone  and/or  hardware  was the

major problem in these patients. Summary of patient's data Table(2).

Methods:

A protocol for sequential staged reconstruction    and   preoperative    planning was arranged by the orthopedic and plastic surgeon in all cases. First stage included aggressive   debridement  of  both  bone  and soft  tissue  to  remove  all  infected  necrotic soft tissue and bone fragments  and creation of healthy trimmed bone, then stability was achieved by application of 3/8 Ilizarov ring modified  by the  orthopedic  surgeon  author and applied away from the route of cross-leg flap as directed by the plastic surgeon (mostly antero-lateral position) Figure(2,3a).

In second stage, to design the cross-leg flaps,  we  took  3  issues  into  consideration. First, position  of the limbs  as it is essential to find an appropriate position to make the recipient site as close to the donor site as possible for reducing the bridge segmentofthe flap, to make the flap lie easily on the defects with minimal tension, least discomfort to the patient and to give way for Ilizarov rings and wires to be applied in proper level according to the pre-surgical plane. Second, is the size, location, and shape of the defects, all defects in the study were over lower third tibia with underlying bone fracture and, or defect. Third consideration was the choice of flap, in our study random-patterned  flap was the choice. The principal donor site of random-patterned cross-leg flaps was the posterior  area of the leg (from the lower edge of the popliteal fosse to the  upper  edge  of the  Achilles  tendon). A wide base, not less than one-half of the length, was necessary for random flaps. It was recommended to raise the underlying fascia together to improve the blood supply of the flaps. When the flap was ready for mounting to the site of combined defect the Ilizarov surgeon started to apply another 3/8 Ilizarov frame on the donor leg side. Then, the cross­ leg flap was harvested to cover the soft tissue defect and after reaching the desired tension on the flap, satisfactory vascularity with no kinking, the orthopedic surgeon was asked to inter-connect both Ilizarofframes by crossing

rods reaching between male posts connected with  nylon  nuts to  allow  micro-adjustment and momentary change until reaching desired position satisfactory to the plastic surgeon as regard tension on his flap then tightening  of nuts was done to achieve stable cross-ilizarov frames. The donor site was covered with split thickness  skin graft, this stage lasted for 2-3 weeks till the third stage Figure(3b, c).

The third stage began about 15 days postoperatively by training for flap division through  ligation of the proximal  part of the flap pedicle. If the pedicle could be legated more than 45 minutes without ischemia or congestion appearance, it could be safely divided  Figure(4). In general,  the  pedicles were divided at 18 ±2 days (range 15 to 21 days) postoperative. After flap division the Ilizarov frame was removed from the donor site, the 3/8 ring on the affected side with bone defect was converted into a complete Ilizarov ring then  to  and  proximal  corticotomy  was done to start segment  transfer  after 10 days to cover the bone defect and patient was allowed to weight bear 3 weeks after for skin graft and flap to be taken and start joint range physiotherapy Figure(5, 6).

Results:

Hospital stay duration ranged from 3-4 weeks.  Cross leg flap was divided at 18 ±2 days  (range 15 to 21 days).  Follow up was at least 3 years after Ilizarov fixator removal (with exception of one patient lost during follow  up).  Follow  up was  done at regular visits  in  out-patient  clinic  weekly  till  end of bone transport then every 3 weeks till removal  of frame.  Assessment  in each  visit was    done    clinically    and    radiologically by  plain  X  ray.  Total  treatment   time  till removal   of  fixate  ranged   from   5  to   11 months according to the size of bone defect and rate of consolidation. 2 patients needed further surgical interference, one of the flap recession  and  other  needed  freshening  and bone graft at docking site. 8 patients out of 9 achieved successful combined reconstruction with union and cross flap cover. 4 patients needed simple adjustment of connecting rods between cross Ilizarov frames to allow better

position for cross flap vascularity; this was carried on in the ward during routine regular flap assessment by plastic surgeon in presence of  Ilizarov  orthopedic  surgeon  ready  to  do any necessary adjustment. Complications included regular Ilizarov technique complications  such as superficial pin tract infection  in 6 patients that was managed by pin care and antibiotics.  Residual shortening occurred in 2 patients and was about 1.5 and

2.5 em and was accepted by both. Residential

infection  and  sinus  discharging  pus  in  one and non union at docking site in 2 and was treated by freshening and bone grafting done through  incision  at  flap  border  away  from pedicle  and  was  done  by  plastic  surgeon. Ankle stiffness occurred in one patient due to soft tissue contracture. Delayed consolidation at  distraction   gap  occurred  in  2  patients and  was  treated  by  BMAT (bone  marrow aspiration            transfer).          Residual           deformity occurred in two patients in the form of varus

7  and  9  degrees  and  was  accepted  by the

patients. Residual equinity occurred in one patients treated by physiotherapy. Most flaps have survived without complications. Flap necrosis occurred in 2 patients.  1 suffered partial flap necrosis and a skin graft was used for  wound  closure  after  sharp  debridement and regular dressing and the other patient suffered  marginal  necrosis  and  the  surface had epithelialized  within  1 week. 3 patients developed osteomyelitis  in spite of total flap survival. All ofthese 3 patients suffered from wound infection when admitted. Complete failure  occurred  in one patient  due to persistent severe infection and single vessel limb and underwent amputation.

Discussion

Worldwide scholars  have been  dedicated for decades to the foundation of optimal treatment protocols for complex lower extremity wounds and have made great contributions. Currently, wound lavage, thorough debridement, skeletal stabilization, and healthy soft tissue coverage have been widely recognized as the surgical principles. In the distal tibia, free flaps were the preferred flaps for  covering  large soft  tissue  defects.

Local fasciocutaneous flaps described by Ponten have decreased the need for muscular and fi:ee flaps in reconstruction. 19 However in the presence of a ring fixator it is difficult to perform free flaps and local fasciocutaneous flaps. Cross leg flaps, in spite of the inherent morbidity associated with the procedure, continue to remain as a useful technique for the coverage of wounds in the lower third of the leg. They are particularly useful when fi:ee

FREE FLAPS DISTANT FLAPS LOCAL FLAPS

SKIN GRAFT

PRIMARY CLOSURE

SECONDARY CLOSURE

Figure {1): Reconstructive ladder: the cross­ leg flap was categorized  in the distant.flaps, which is on a lower rung than free.flaps.

flap and local flap are not available, a condition that fi:equently happened in complex trauma of type IIIB, C Gustilo type.2o The cross-leg flap being less technically demanding and easily handled as compared with fi:ee flap helps the surgeon to close the traumatic wound as soon as possible, thereby decreasing the incidence of complications, especially infection. Timely wound closure could increase the possibility for    lower    extremity    salvage.    Aydin,21

Figure {2): 40 year patient with delayed non­ united infected combined lower third tibial fracture with failed local flap,  aggressive debridement  of both  bone  and  soft  tissue was done to remove all infected necrotic soft tissue, bone  fragment till creation of healthy trimmed bone and soft tissue.

Figure (3a): Stage II reconstruction; 3/8 Rizarov frame mounted and crosslegflap washarvested and limb position was acfjusted.

Figure {3b): Contra lateral  Ilizarov  frame mounted and cross-connecting rods were bridged then cross leg.flap covered soft tissue defect and sutured in optimum position then cross connection was tightened.

Figure {3c): Plain X ray after application of

Ilizarov frame

Figure (4): Stage III, 21 days after cross leg  Rizarov, the contrateral frame removed, flap separated and 3/8 Ilizarov frame to be completed to full ring.

repmted   expetience   of   distally   pedicled sural fasciocutaneous cross-leg in 6 children who  suffered  from  cmsh  injmies,  and  all the flaps smvived without complications. Bhattacharya and Reddy,22 repmted 12 cases

using cross-leg  flaps  for  wound  coverage, and marginal necrosis within 2 ern occmTed in 2 patients. No flap loss was repmted in this ruticle. In om study, we used random pattern cross leg flap to cover lower third

Figure {5): After  full-ring Ilizarov  frame and full weight bearing.

combined defect in conjunction with Ilizarov fi·arne, partial flap necrosis occUlTed only in

2 out of 9 patients (22%), and other 7 had satisfactmy results regarding flap, vasculruity and adequate coverage. As a matter of fact, the 2 patients suffeting flap necrosis both had vasculru·impairment (Gustilo type IIIC)

Contrru·y to other articles about the duration of flap division after 3 weeks.23 In om study, flap division was done at 18 ±2 days (range 15 to 21). Accordingly, we strongly recommend pedicle training before flap division because it can not only guarantee  flap survival, but it can shmten  the unnecessruy hospital stay for these patients  hence decrease  the incidence of  complications   fi·om immobilization  like knee  stiffness,  deep  venous  thrombosis.  In this ruticle there was only one reported case of knee stiffuess, and no repmt of deep vein thrombosis. In addition contrruy to other ruticles  about   the  traditional   plaster   cast for  limb  immobilization  till  flap  division. In om study 3/8 Ilizru·ov fi·arne was applied

Figure {6): 10 months after cross-leg Ilizarov full weight bearing and satisfactory flap.

on  the  donor  leg  and  was  inter-connected with main Ilizru·ov fi·arnes by crossing rods reaching between male posts connected with nylon nuts to allow micro-adjustment  and momentruy change until reaching desired satisfactory position. This modification overcame the disadvantage of the cast as regru·d infection, difficult dressing, loose or tight cast and difficult visualization of the viability of the flap and flap apperu·ance after pedicle training.

In  open  tibial  fractme,  eru-ly aggressive debtidement of nonviable tissues,stabilization with an Ilizru·ov external fixator, and either primru·y or delayed primru·y closme followed by  eru·ly mobilization   and  weight  beru·ing is a sound treatment method for complex injUiies.24 Acute  shortening,  using  the Ilizru·ov technique  followed  by  progressive lengthening,  is one of  the methods  used to deal with complex  fi·actmes combined  with severe soft tissue injuries.25 Despite technical difficulties   and   problems   associated   with

Table 1: Open fracture: Gustilo classification

Table 2: Clinical data of patients

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pin-tract  infections, the  Ilizarov  external fixator   may  be  the  preferred  technique  in open  tibial  fractures because  of  high  union rates, the use of thin K-wires with minimal traumatic    effect,     and    more     successful

functional   results.26    The    most    frequent

complication  was   pintract   infections.26   In this article complications included  regular Ilizarov  technique  complications  such   as

superficial pin tract infection  in 66% patients that was managed by pin care and antibiotics. Accepted residual shortening (1.5 and 2.5 em) occurred in 22%. Ankle stiffness  occurred  in

22% of patients  due to soft tissue contracture treated    by   physiotherapy.  Residential infection and sinus discharging pus occurred in  11%  and  non  union  at  docking   site  in

22% and was treated  by freshening and bone

grafting.  Delayed  consolidation at distraction gap  occurred  in  22%  of  patients   and  was treated by BMAT (bone marrow aspiration transfer) Residual  deformity occurred  in 22% patients  in the form  of varus 7 and 9 degrees and was accepted by patients.

Conclusion:

On the basis of our results, we suggest adopting   this   method   for   functional  limb salvage  after  extensive complex  lower  third leg injury. The cross-leg flap is a safe reliable alternative to free tissue  transfer in certain situations of lower-limb trauma, and  can  be handled  easily with modified 3/8 ring Ilizarov frame  which  is safe,  versatile and  effective in providing stability,  bone  lengthening and allowing  early rehabilitation

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