Surgical treatment of complex wounds of the lower extremities has greatly evolved in the last years, leading to a higher percentage of limb salvage and good functional recovery.

Microsurgery surely is a good weapon when facing extensive tissue losses and infections.

From 1994 to 2004, 25 patients have been treated in our department for complex traumas of the lower limb.

These cases include 4 acute complex injuries with extensive soft tissue loss (Gustilo III open fractures) which were treated with 3 Latissimus Dorsi and 1 Gracilis Muscle Flaps; 10 delayed referrals with exposed bone or bony/soft tissue loss (1 Fibula Flap for the distal femur, 1 Fibula Flap for the lower leg, 3 cases of amputation stump coverage, 2 Parascapular Flaps, 2 Gracilis Flaps, 1 Latissimus Dorsi Flap, 1 Serratus Flap with a rib, 1 Iliac Crest Flap); and 11 late reconstructions of chronic osteomyelitis: 1 distal femur infection (Double-barrel Fibula Flap), 10 infections of the middle or distal third of the lower leg (3 Fibula Flaps, 4 Latissimus Dorsi Flaps, 3 Gracilis Muscle Flaps).

In the last few years, the approach to bony tissue losses has been changing: on one hand, elongation techniques for the lower extremity give good results; on the other, microsurgery may allow a single-stage reconstruction of bone, muscle and skin defects, leading to much shorter hospitalization time, and improvement of the patients’ quality of life because of a faster recovery.

Over 90% of the flaps survived, leading to a good recovery of the patients. The two failures were due to the necrosis of a Gracilis Flap in the coverage of an amputation stump and that of a Latissimus Dorsi Flap used for an extensive soft tissue loss in a leg which subsequently had to be amputated.

In 78.5% of the cases of osteomyelitis recovery was obtained after a single operation, and in only 12.3% of the cases the flaps had to be partially revised.

In 2 cases, after the bony resection and coverage by means of a Gracilis Muscle Flap, a homolateral fibular transfer with the Ilizarov technique was performed.

The length of bone resections treated by fibular flaps was 8–12 cm (mean 9).

For decades the treatment of chronic post-traumatic osteomyelitis associated with bone exposure has been one of the most serious problems in the field of orthopaedic surgery. “Sterilisation” of the osteomyelitic site, that is radical débridement of all infected tissue, is the basic requirement of the treatment; in the past, the remaining defect of the débrided area was closed with skin grafts, which were removed in a further stage when the infection had cleared; then the defect was filled with muscle flap and bone graft of various types. Both soft tissue and osseous reconstruction took a relatively long period of time, requiring several-stage treatment. Over the years, introduction of microsurgery led to free muscle flaps and skin graft in one reconstruction setting in the 1970s and thin fascio-cutaneous flap reconstruction in the 1980s, allowing a shorter period of hospitalisation and an improvement in patients’ lifestyle.

We performed a retrospective study of 22 patients treated for chronic osteomyelitis (middle or distal 1/3 of the leg, n=10; tarsus, n=6; forearm, n=6) by means of free vascularised bone graft or composite grafts between 1992 and 2003. In most of them a two-stage treatment was performed (resection and sterilisation in the first stage and bone transfer in the second one); in others a one-stage treatment was performed.

In 78.5% of cases the infection was cured without requiring secondary procedures; revision of the flap was carried out in 12.3% of cases. In only one case leg amputation under the knee was necessary.

In spite of advanced treatment protocols, persisting infection and residual functional deficit is not rare. Over the years the approach has changed. The application of microsurgical tissue transfers for reconstruction of the extremities allows repair of significant bone and soft-tissue defects. A wide variety of free flaps offers the potential to reconstruct nearly any defect of the limbs. The total array of flaps and their indications is beyond the scope of a single discussion, but this paper focuses on a few flaps that have found application for coverage and functional restoration of the limbs.

Microsurgical transfers allow more radical débridement of the area affected by osteomyelitis with low peri-operative morbidity, reducing the number of procedures required to obtain bony union and subsequently effect a quick “return to work”. In management of chronic, post-traumatic osteomyelitis with soft-tissue loss, we prefer a well-vascularised muscle flap rather than a fascio-cutaneous flap (its important vascular supply helps reduce bacterial contamination).

The aetiology, pathogenesis and clinical staging of osteonecrosis of the femoral head have been the subject of considerable discussion. The same is true regarding the treatment of such conditions, which could be non-operative (shockwaves, no traction, PEMFs) or operative (conservative methods or prosthetic substitution), depending on the age of the patient and the degree of compromise of the femoral head.

During the period between 1972 and 2003 at the CTO Hospital of Turin, Italy, 54 patients underwent surgery. We used core decompression (forage biopsy) in 39 cases and in the other 15 cases free vascularised fibular grafting (microsurgical techniques). All the patients were at the initial stages of the condition (Steinberg I–IIIa), stages in which subchondral collapse had not yet occurred. Follow up average 125.6 months.

The results were estimated according to the Harris Hip Score, which allows for a score in relation to pain upon motional, functional and clinical deformity.

In light of our data, we can confirm that the advantage of the result is secondary to the appropriate use of surgical techniques in relation to the clinical staging of the pathology. We have, in fact, established a treatment protocol that calls for core decompression at stage 0 – IA and free vascularised fibular grafting at the more advanced stages that go from IB to IIIA.