PMC5620398_01
Extensive soft-tissue defects of the right lower leg and foot before debridement, accompanied by comminuted fracture of the proximal tibia, spiral fracture of the proximal fibula, fracture of the talus, and dislocation of the ankle joint.(a:clinical photo, b:x-ray of the leg, c: x-ray of the ankle).
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F1a
Bone, tendon, vessels and nerves were exposed with extensive soft-tissue defects of the wounded leg (Fig. 1a). Radiographs showed tibial comminuted fracture, talar open fracture and subluxation of right ankle (Figs. 1b-c).
Extensive soft-tissue defects of the right lower leg and foot before debridement, accompanied by comminuted fracture of the proximal tibia, spiral fracture of the proximal fibula, fracture of the talus, and dislocation of the ankle joint.(a:clinical photo, b:x-ray of the leg, c: x-ray of the ankle).
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F1b
The comminuted proximal tibial fracture was immobilized by an external fixator and there was a dull-red coloured wound of 40cm x10cm, with deep tissue exposed, necrotic tissue and faint yellow purulent secretions (Fig. 2).
Extensive soft-tissue defects of the right lower leg and foot before debridement, accompanied by comminuted fracture of the proximal tibia, spiral fracture of the proximal fibula, fracture of the talus, and dislocation of the ankle joint.(a:clinical photo, b:x-ray of the leg, c: x-ray of the ankle).
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F1c
At this moment, fresh granulation tissue surrounded the soft-tissue defects (Fig. 3).
An external fixator was applied to stabilize the fractures. There was an extensive soft tissue defect with sluggish circulation.
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F2
A free anterolateral thigh perforator flap and a free thoracic umbilical flap were designed (Fig. 4a). The designed thoracic umbilical flap pedicled with inferior epigastric vessels was harvested (Fig. 4b). The anterolateral thigh perforator flap was sutured with thoracic umbilical flap to make a combined free-tissue flap (Fig. 4c), which was boarding into the donor area of anterolateral thigh perforator flap on the left leg temporarily (Fig. 4d).
Healthy granulation tissue surrounding the soft-tissue defects after repeated debridement and VSD.
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F3
Two days later, the combined free-tissue flap was designed to recover the affected area of skin defects (Fig. 5a). The blood stream of posterior tibial artery nourishing the designed cross-bridge pedicled flap of the contralateral leg was detected by Doppler ultrasound; whilst, the cross-bridge pedicled flap was harvested to provide blood supply to the combined free-tissue flap from the posterior tibial artery (Fig. 5b). The anastomosis between the stem vein of combined free-tissue flap and the great saphenous vein of cross-bridge flap and the anostomosis between the branch veins of combined free-tissue flap and accompanying veins of posterior tibial artery of cross-bridge flap were performed at the same time (Fig. 5c).
The design and harvest of combined flap consisted of anterolateral thigh perforator flap and thoracic umbilical flap (a: the design of the combined flap, b:the harvest of thoracic umbilical flap, c: the harvested combined flap, d:the combined flap was temporarily sutured to the donated area of anterolateral thigh perforator flap).
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F4a
At 3-month follow-up, both the lower legs had a nearly normal appearance with complete coverage and radiographs of the wounded lower leg showed tibia and talus healing (Figs. 6a-b, c).