Limb salvage surgery

Abstract

The threat of lower limb loss is seen commonly in severe crush injury, cancer ablation, diabetes, peripheral vascular disease and neuropathy. The primary goal of limb salvage is to restore and maintain stability and ambulation. Reconstructive strategies differ in each condition such as: Meticulous debridement and early coverage in trauma, replacing lost functional units in cancer ablation, improving vascularity in ischaemic leg and providing stable walking surface for trophic ulcer. The decision to salvage the critically injured limb is multifactorial and should be individualised along with laid down definitive indications. Early cover remains the standard of care, delayed wound coverage not necessarily affect the final outcome. Limb salvage is more cost-effective than amputations in a long run. Limb salvage is the choice of procedure over amputation in 95% of limb sarcoma without affecting the survival. Compound flaps with different tissue components, skeletal reconstruction; tendon transfer/reconstruction helps to restore function. Adjuvant radiation alters tissue characters and calls for modification in reconstructive plan. Neuropathic ulcers are wide and deep often complicated by osteomyelitis. Free flap reconstruction aids in faster healing and provides superior surface for offloading. Diabetic wounds are primarily due to neuropathy and leads to six-fold increase in ulcerations. Control of infections, aggressive debridement and vascular cover are the mainstay of management. Endovascular procedures are gaining importance and have reduced extent of surgery and increased amputation free survival period. Though the standard approach remains utilising best option in the reconstruction ladder, the recent trend shows running down the ladder of reconstruction with newer reliable local flaps and negative wound pressure therapy.

Keywords: Limb salvage; foot ulcers; limb trauma; lower limb reconstruction.

Figure 1

(a) A 24-year-old lady with Gustilo IIIB injury with circumferential soft-tissue loss and avascular tibial segment. Referred after failed attempts of both gastrocnemius flap. (b) Harvesting of fibula 12 cm with skin paddle. (c) Reconstructed tibial defect and soft-tissue following 1 year. (d) Osseous union of vascularised fibula

Figure 2

(a) Crush injury leg, Gustilo-IIIB type with circumferential skin loss and loss of lower third of tibia and fibula in a 55-year-old lady. Circumferential raw area was skin grafted and reconstruction planned with osteocutaneous free fibula flap. Posterior tibial artery was the only perfusing vessel. (b) Anastomosis end to side in the zone of injury to the posterior tibial vessels. (c) Anastomotic site covered with skin paddle. (d) Well healed flap with normal ambulation and weigh bearing without support at 22 months post surgery.(e) Stable osseous union at 38 months post reconstruction

Figure 3

(a) A young lady with soft-tissue sarcoma resection defect of left groin. Tumour infiltrating the femoral artery was resected. Femoral artery reconstructed with saphenous vein graft. (b) Reconstruction planned with vertical rectus abdominus flap based on inferior epigastric artery. (c) Prior to inset of flap, brachytherapy ports inserted for radiotherapy. (d) Early post-operative with well settled flap

Figure 4

(a) A 58-year-old lady with insensate foot with trophic ulcer of 8 years duration due to Hansen's disease. (b) Reconstruction planned with radial artery forearm free flap with posterior tibial as end to side recipient vessel. (c) 2 years post-reconstruction with well-settled flap. (d) Flap without excessive bulk, contoured to the foot