Lower Limb Reconstructive Surgery

Lower limb reconstruction is a surgical procedure that reconstructs and/or restores function to the lower limbs whose structure is made up of the hip, thigh, leg and foot. The damage to the lower limb may have been caused by trauma, disease (cancer), or infection. The goal of the procedure is to salvage and preserve function to the limb in question in order to circumvent any form of amputation either partial or complete, and as result restore quality of life.

The damaged tissue in the lower limbs are reconstructed using flaps of tissue, bone, prosthetics and skin. The reconstruction procedure is done to allow movement, function and cosmetic achievements of the injured limbs.

The reconstruction of the lower limb is performed by a team of multi-disciplinary experts who include an orthopedic surgeon, vascular surgeon, and a plastic and reconstructive surgeon. These three components work together to attain the best functional and aesthetic functions to the affected limb.

The Orthoplastics approach is the reconstructive surgery of the extremities, that is, the application of practice and principles of orthopedic and plastic soft tissue surgery specialties applied together to heighten the results in limb reconstruction. When these specialties and perspectives are applied, the results in the reconstruction and salvage of the limbs are heightened.

Conditions Treated with Lower Limb Reconstruction Surgery

Some of the conditions that may require a lower limb reconstruction procedure include:

• Cases where a fracture or broken bone fails to heal on its own, also known as fracture non-union
• Injury to the surrounding tissue on the limb, shearing or loss of muscle, fascia and Pericranium (outer surface of the bones)
• Bone infection (osteomyelitis)
• Compartment syndrome, whereby there is increasing pressure within a compartment of the limb, which leads to blood flo, and a result damages muscles and nerves
• Tendon exposure
• Restriction of natural movement of a limb as a result of scar tissue, also known as scar contracture
• Chronic phantom pain after amputation or injury

Techniques Used in Lower Limb Reconstruction

The technique used during a lower limb reconstruction is determined after a thorough examination of the patient’s medical history, risk factors and symptoms in order to define the complexity and the method of revascularization to undertake. The advantage of Orthoplastic surgery is the combination of microvascular surgery and the bone recovery principles which is essential in the coverage of large bone defects.

Free Fibula Flap

Free fibula bone grafting is used in cases of component defects of the upper and lower extremity and have a significant role in performing traumatic reconstruction. When a long strut of bone is required, free fibula graft is used to repair the extremity. Free fibula is harvested with a skin paddle and a soleus muscle (located in the superficial posterior compartment of the leg from back of the knee to the ankle), and transferred to the targeted area of treatment for reconstructing the composite tissue.

Medial Femoral Condyle Free Flap

This refers to the bones of the knee joint. The vascularized bone graft from the medial and the lateral femoral condyle are used as a source of vascularized bone transfer for large bone reconstruction. The flap is an adaptable flap with a reliable anatomy which supplies a well vascularized corticoperiosteum (adjacent to the joint line of the knee from femoral artery). This method treats the fracture that occur on areas such as the tibia, ankle, foot, and thigh which remained ununited (failed to unite) for more than 10 years after an injury occurred.

When the flap is harvested, fibrous tissue together with an absorbable gelatin sponge (Gelfoam), hyaluronic acid and thrombin (an enzyme which acts on fibrinogen in blood that causes clotting) are placed in the bone defect, and the leg is sealed over a drain.

Skin Grafts

During a skin grafting procedure, a healthy patch of skin is extracted from another part of the patients’ body to cover the treated area. The type of skin graft is chosen depending on the type of defect. This procedure is done in 3 different ways:

• Composite graft: This is where fat, layers of skin and underlying soft tissues are harvested to cover wounds that have a complex shape
• Split thickness skin graft: This is when skin layers that are close to the surface are used to treat injuries and burns
• Full thickness skin graft: This is when skin layers from the donor site are used in treating small defects that are on the limbs

Possible Risks That May Lead to Amputation

The Orthoplastic approach will escalate positive results but amputating the limb at times can be considered over salvaging. The risk of amputation can be brought on by factors such as:

• Severity of damaged muscle
• Pre-tibial laceration which could stop sensation on the foot even after reconstruction
• Degree of ischemia (lack of blood flow) and infection
• Accompanying medical conditions or injuries which may put the patient at risk

Postoperative Care

After the lower limb reconstructive surgery, the patient will have consecutive neurovascular checkup of the operated area on an hourly basis for the first 2 days of the surgery. Then after every 4 hours for the next 3 days.

The limb that is operated on remains elevated for the next 24 hours, but after 48 hours, depending on the condition, it is highly recommended to start attempting minimal movements. This is to encourage and ensure that there is blood supply to the area.

If a splint was put in place, then it is removed after the 4^th day post-surgery and the patient can use a wheelchair or crutches. A physical therapist will be allocated to the patient after 5 days postoperative. Medication to prevent clot formation and artery blockage is prescribed.

Possible Complications of Lower Limb Reconstruction Surgery

Just like every other surgical procedure, lower limb reconstruction has risks that may occur such as:

• Bleeding
• Scarring
• Infection on the treated area
• A need for the surgery to be revised
• Complications from the anesthesia
• Partial or complete amputation of the limb in question

Pre-Op Guidelines

Depending on the severity of defect or damage to the lower limb, the reconstruction surgery is best performed by a qualified and experienced plastic and reconstructive surgeon and Orthopedic surgeon. A detailed consultation with the experts in question is highly recommended, which can happen multiple times before the reconstructive procedure takes place. During the consultations, the reconstructive surgeon will evaluate the patient, discuss on what the patient aims to achieve, the different techniques and approaches, the benefits of the procedure, the risks involved, the outcome and finally the recommended approach for optimal results and recovery.

Post-Op Guidelines and Recovery

For safe, faster, and optimal recovery after lower limb reconstructive surgery, the patient should follow all the recommendations made by the reconstructive and orthopedic surgeons, from taking care of the wound, prescribed medications, follow up on the doctors’ appointments, the dos and don’ts, and what to watch out for in cases of emergencies.

Get in Touch

Reconstructive surgery at Kings College Hospital Dubai focuses on the safety and care of every patient in a compassionate environment with state-of-the-art facilities. To book an online or in-person consultation and a detailed evaluation by one of our world class plastic and reconstructive surgeons in Dubai, get in touch using the contact details given, and our patient-care staff will book an appointment for you.