Treatment of Complex War Wounds of the Lower Leg with Free Flaps and Ilizarov Method - Our Experience

Introduction: Indications for free flaps and Ilizarov method were severe bone fractures with extensive soft tissue defects and segmental bone defects longer than 4cm. The tissue defects of lower leg were classified as Gustillo IIIB and Gustillo IIIC. Microvascular tissue transfer provides closure of extensive defects in one act, better perfusion of the wounded region, make conditions for the reconstruction of deep structures, especially in wounds with complex tissue defects. Ilizarov method is a useful method of bone reconstruction, especially for lower leg. For defects longer than 4 cm, Ilizarov method provides better quality of bone replacement compared with free fibular graft

Methodology and Material: We used free flaps and Ilizarov method in treating 27 wounded subjects with vast tissue defects of lower leg at the Clinic of Plastic Surgery and Burns and Clinic of Traumatology and Orthopedic Surgery, with the aim of closing war wounds, covering deep structures and making the preconditions for later reconstruction of bone structures. Three months after the free flap transfer, we performed corticotomy and distraction of the longer (proximal or distal) bone segment of tibia.

Results: We analyzed types and time of free flaps applied, duration of the bone transport with Ilizarov apparatus, as well as the quality of reconstructed bone during the five-year follow-up. All of 27 patients that we treated with free flaps and Ilizarov procedure are able to walk independently without orthopedic devices, while the maximal shortening of the leg was 3 cm in 2 (7,4%) patients.

Conclusions: The knees and ankles are free for physical therapy in spite of Ilizarov device. In spite of the facts that the surgery is very time-consuming, that there is a need for microsurgical equipment and trained surgical team, in spite of technical complexity of the method and high proportion of unsuccessful unions of bone fragments at the joining site (which surely indicates the need for second procedure and sometimes calls for the modification of Ilizarov procedure), The experience of surgeons with Ilizarov method is of utmost importance because of the long-lasting treatment and frequent check-ups of bone regeneration and sanation of the joining site. The combination of two revolutionary methods in plastic and orthopedic surgery, free flap and Ilizarov methods, is a useful and reliable approach which finds place in the treatment of war wounds with extensive tissue defects of the lower leg.