DELAYED LOCAL LEG FLAPS

By JOHN BOWEN, F.R.C.S., and ALLAN MEARES, F.R.C.S., F.R.A.C.S.

The Queen Victoria Hospital, East Grinstead, Sussex

THE use of local flaps on the lower limb is generally considered hazardous, but 3 cases are presented to show that with delay such flaps can be used to repair defects in the lower limb where a cross-leg flap or other method is considered undesirable.

Case I. A lad of 17 sustained a compound fracture of the right tibia and fibula in a motor-cycle accident. Elsewhere an unsuccessful attempt was made to cover the fracture by means of a local rotation flap. He was seen a year later, his fracture now united but with exposed tibia. He was heavily built with thick bulky Iegs which influenced the decision in favour of a further local flap instead of a cross-leg flap.

A proximally based flap medial to the defect was delayed and 2 weeks later transposed after excision of the ulcer and dead bone. The secondary defect was split-skin grafted. He was discharged from hospital soundly healed 8 weeks after admission (Fig. I).

FIG. I. Case I-Post-operative result showing outline of flap and grafted secondary defecr.

FIG. z. Case II-Ulcer upper third of tibia with exposed bone.

FIG. 3. Case II-Delayed distally based lateral flap.

FIG. 4. Case II-Delayed proximally based medial flap.

Case II. A S3-year-old man whose leg was crushed by a falling wall sustained a compound fracture of the right tibia. This was treated elsewhere, the leg being immobilised in a long leg plaster. A month later the skin overlying the fracture was found to have necrosed exposing the fracture site. He was seen 3 months after his injury with an ulcer over the upper third

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FIG. 5. Case II-Early post-operative result (medial side). FIG. 6. Case III-Proposed extent of excision with flaps outlined.

FIG. 7. Case III-Plan of distally based lateral flap. FIG. 8. Case III-Plan of proximally based medial flap.

FIG. 9 FIG. IO

FIG. II

DELAYED LOCAL LEG FLAPS 169

,of the tibia and a clinically un-united fracture in the base of the ulcer (Fig. 2). Because of his age and already established joint stiffness due to immobilisation it was decided to repair the defect with local flaps rather than with a cross-leg flap.

FIG. 12. Case III-Post-operative (medial aspect).

FIG. 13. Case III-Post-operative (lateral aspect).

Radical debridement of the wound including removal of dead bone was performed and lateral and medial flaps were delayed (Figs. 3 and 4). Two weeks later a further delay was carried out and the following week the flaps were raised and transposed to close the defect. He was discharged 8 weeks after admission (Fig. 5) the fracture still ununited but with good skin cover.

Case III. A 5t-year-old airline pilot presented with an ulcer on the anterior aspect of the right tibia due to chronic osteomyelitis. At the age of 15 an acute osteomyelitis of the

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right tibia had been decompressed. He was then trouble free until an air crash during the war when the right tibia was fractured. This reactivated the osteomyelitis and, while the fracture united, he was left with a discharging wound which has required daily dressing.

On examination there was an ulcer at the lower third of the anterior tibia1 border measuring 4 x 3 cm. with exposed underlying bone. Five centimetres below this was a further discharging sinus (Fig. 6). Because of his symptoms and the risk of malignant change it was decided that the area should be excised and the resulting defect covered with medial and lateral local flaps (Figs. 7 and 8). Two weeks later they were transposed to cover the defect created by excising the ulcer and exposed cortical bone (Figs. 9-11). The secondary defects were split-skin grafted. Six weeks after admission he was discharged soundly healed (Figs. 12 and 13).

DISCUSSION

The cross-leg flap is the most commonly used method of repairing full thickness defects over bare bone in the lower limb. It is not, however, without its drawbacks. It is difficult for each surgeon to decide for himself the indications for and the compli- cations resulting from any one procedure. For example, it has been shown by various workers that age may cause joint stiffness after a cross-leg flap, while others have shown that age is not a contra-indication. (Hayes, 1962; Stark and Kaplan, 1972). The same may be said of thrombo-embolic complications (Letterman, 1961; Hayes, 1962).

The advantages of local flaps over distant flaps are numerous and obvious, and while they have a bad reputation in the lower third of the leg we feel this to be a useful technique as a result of our recent experience with these 3 cases. Small defects can be covered with one proximally based flap whereas larger defects may require an additional distally based flap. In our experience the distally based flap is as safe as the proximally based flap.

The key to success is of course adequate delay. Our method is to raise the flap in a bipedicle fashion. If a further delay is thought necessary the flap is again raised and the distal end divided. A drain has always been placed under the delayed flap to prevent haematoma. It has been our practice to raise deep fascia with the flap at the time of delay. Due to the inherent lack of elasticity in the lower leg skin the flap should be of generous dimensions to cover adequately the defect without tension at the time of transposition. Though we have not lost any part of a flap it would seem important that the junctions of 2 flaps should not overlie a critical area such as an ununited fracture site.

Since the procedure is multi-staged, there is no reduction in the total time spent in hospital compared with other procedures.

SUMMARY

Three cases of delayed local flaps are presented as a method of repair for full thickness defects of the lower limb. This method has some advantages over other available techniques.

Our thanks are due to Mr John Watson, F.R.C.S., who suggested this surgical approach and allowed us to operate on his patients. We are indebted to the Department of Medical Photography at the Queen Victoria Hospital.

REFERENCES

HAYES, H. (1962). Cross leg flaps after the age of 50. Plastic and Reconstructive Surgery, 30, 646-650.

LETTERMAN, G. S. and SCHURTERM, P. A. (1961). Prophylactic anticoagulation in the cross leg flap procedure. Plastic and Reconstructive Surgery, 27, 520-526.

STARK, R. B. and KAPLAN, J. M. (1972). Cross leg flaps in patients over 50 years of age. British Journal of Plastic Surgery, 25, 20-21.