Lower Limb Reconstruction

If you’re dealing with an infection, injury, or other condition that’s impacting your lower extremity, then lower limb reconstruction surgery may be an option for you. This type of reconstructive surgery can help to improve the function and appearance of your leg. Dr. Nilesh Satbhai has years of experience in performing lower limb reconstruction procedures. Dr. Nilesh will work with you to develop a treatment plan that meets your specific needs and helps you get back to living life to the fullest.

Who is an ideal candidate for Lower Limb Reconstruction?

Lower limb reconstruction is ideal for individuals who have open wounds or defects in a lower limb due to trauma, tumor, or congenital abnormalities. Some subjects for this treatment include:

• Those who have an extensive bone injury due to trauma
• Those who have bone infection or osteomyelitis
• Those who have chronic wounds due to diabetes or vascular disease
• Those who have exposed grafts after vascular surgery or exposed prosthetic joints after hip or knee replacement
• Those who have had a tumor removed by surgery

Other types of injuries that require reconstruction are:

• Open fractures
• Vascular injuries
• Crush injuries
• Traumatic amputations
• Severe nerve injuries

If you have any of the above wounds or defects, book an appointment with Dr. Nilesh Satbhai in Mumbai immediately.

Procedures involved in Lower Limb Reconstruction

Before determining that a limb is completely unconscious, such injuries should be managed with debridement, nerve repair (whether primary or with nerve grafts), tendon repair, tissue flaps, and orthopedic fixation when applicable. Let’s understand them one by one:

Debridement

Debridement involves cleaning the wound by removing all the dead, necrotic, or hyperkeratotic tissue. Common indications for sharp surgical debridement are:

• Removal of necrotic tissue or dead tissue
• Removal of local infection to reduce bacterial burden, minimize the probability of resistance from antibiotic treatment, and obtain accurate cultures
• Stimulation of the wound bed to prepare for a skin graft or flap and to support healing

Nerve repair

The nerves of the lower limb originate from L2 through S2 spinal levels, forming the lumbosacral plexus. The major nerves are:

• Femoral nerve
• Obturator nerves
• Sciatic nerve which is comprised of two nerves - the tibial and common peroneal nerve (CPN)

The techniques used for nerve repair include the following:

• End-to-end repair: End-to-end repair is the process of suturing the ends of a nerve together. This is typically used for small nerve gaps.

• Nerve grafting: With this procedure, the doctor transplants a healthy nerve from another area of the body to the damaged nerve site.

• Nerve transfers: In this surgery, the doctor attaches a nearby healthy nerve to the damaged one.

• Nerve decompression: Nerve decompression is a procedure to relieve pressure on a nerve.

• Neurolysis under magnification: This is a type of nerve decompression done to relieve nerve compression caused by adhesions, scar tissue, or callus.

Tendon repair

Tendon injury in the lower limb is a common occurrence. The most frequently injured tendons are:

• Achilles tendon
• Patellar tendon
• Quadriceps tendon
• Hamstring tendons
• Peroneal tendons

Tendon repair is done by suturing the torn ends of the tendon. In some cases, tendon reconstruction may be necessary. This is done by attaching the tendon to another healthy tendon or bone.

Tissue flaps

Tissue flaps are a type of reconstructive surgery where the surgeon moves healthy tissue from one area of the body to another. The following procedures can be done for lower limb reconstruction. The commonly used tissue flaps are:

Fasciocutaneous Flaps

Fasciocutaneous flaps are tissue flaps that include skin, subcutaneous tissue (bottom layer of the skin), and the underlying connective tissue.

The most popular fasciocutaneous flap for many reasons is the anterolateral thigh (ALT) flap. It provides a good coverage solution for most lower limb defects as it is a very large flap with a long pedicle.

The ALT flap could be raised from the contralateral leg without intraoperative repositioning. It can be taken as a thin flap (or can be thinned after being raised) to provide a low-profile solution to tissue defects around the ankle and foot.

Muscle flaps

Muscle flaps are tissue flaps that include muscle, tendons, and the overlying skin. Muscle flaps are used to cover large wounds or defects.

Based on the largest muscle in the body, the latissimus dorsi (LD) flap is used when a large area is required. It has a long pedicle and can be quick to raise.

Wounds around the knee may be covered by using the medial or lateral head of a gastrocnemius muscle flap.

Defects around the knee and lower thigh can also be reconstructed with a lateral genicular artery muscle flap. Although free flaps are not typically used in this region, they remain an option when additional flaps are unavailable.

Orthoplastic wound preparation

The following steps are performed to prepare the wound before the surgery:

• A radical necrectomy (removal of necrosed tissue) will be performed that treats the wound as a “pseudotumor” by removing all the devitalized bone, soft tissue, and the contaminated surface tissue sharply with a scalpel.
• If you are not happy with the wound’s appearance (i.e., continued bacterial colonization, necrotic or fibrinous debris purulent appearance), you will be taken back for a second or third look.
• Irrigation with normal saline at very low pressure will be done.
• By the use of a hydrosurgery device that helps in surface decontamination, debridement, or removal of granulation tissue will be done before skin grafting.
• Keep the wound moist at all times utilizing a “wet to wet” dressing with petrolatum gauze, which should be covered with saline moist gauze.
• Early coverage is desirable.
• Manage edema and prevent equinus contracture.

Bone stabilization

The basic principles of bone fixation are:

• Fracture reduction and fixation for the restoration of anatomical relationships.
• Fracture fixation will provide absolute or relative stability to the fracture.
• Maintenance of blood supply to soft tissues and bone by gentle reduction techniques and careful handling.
• Early mobilization and rehabilitation of the injured area and the patient.

Bone fixation can be done by:

• Internal fixation: Internal fixation is a type of surgery where metal screws, plates, or rods are placed internally to hold the bone in place while it heals.

• External fixation: External fixation is a type of surgery where metal pins are inserted into the bone and connected to a frame on the outside of the body.

• Plaster immobilization: This is a type of external fixation where the plaster cast is used to hold the bone in place while it heals.

If bone contamination is remarkable or there is a concern for ongoing infection, then fractures require external fixation as the definitive treatment until the bone heals properly. Some important soft tissue reconstruction principles that are considered with the placement of external fixation pins and bars are as follows:

• Pins are placed as far from the wound as possible while maintaining fracture stability.
• Bars should not block the soft tissue window around the zone of injury.
• In the leg, mid anterior pins are better than medial or lateral pins to allow for vascular access for rotational muscle and perforator flaps and free flaps.
• The frame must be easily loosened for any adjustments that may be needed during reconstruction.

After bone stabilization, tibial defects may be reconstructed using a variety of flaps. In general, the tibial region is divided into three parts:

• Defects in the proximal third are best reconstructed using a gastrocnemius muscle flap.
• Defects in the middle third are typically repaired using pedicled gastrocnemius or soleus muscle flaps; however, as high-energy wounds in this region typically manifest with extensive zones of injury, local flaps may not be dependable. Free flap reconstruction would then be preferred, such as rectus abdominis, scapula, anterior lateral thigh, gracilis, and latissimus muscle flaps. These are also preferred for any wounds at the distal third of the tibia because of limited local tissue availability.
• For those in whom free flap reconstruction is not an option, a reversed sural flap may be advised. Foot and ankle reconstruction overlap with reconstruction in the distal third of the leg. However, debulking of free flaps is often necessary to optimize form and function of the reconstructed limb.

What are the benefits of Lower Limb Reconstruction?

Lower limb reconstruction can improve the function and appearance of the affected extremity. It can also help to prevent further complications such as infection, joint contractures, and amputation.

Lower limb reconstruction can also help to improve the quality of life for patients by restoring their ability to walk, run, and participate in activities they enjoy.