Purpose of the study: The different conflicts in ex-You-goslavia left a health care desert. A few medicosurgical units attempted to reconstruct, but their capacities were limited and focused on emergencies. Many patients had to be abandoned. One was a 13-year-old Kosovar boy with active torpid osteomyelitis of the humerus whose family brought him to the French military field hospital in Mitrovica.

Case report: The patient’s general status was mediocre with a hanging left arm which was painful upon mobilization. The skin had a normal aspect. Plain x-rays showed a purulent disintegration of the proximal third of the humerus with 11 cm shortening and loss of bone continuity. The forearm and hand were free of vascular or nervous deficits. Joint testing of the elbow and should was not contributive. The infectious agent was identified (multiple susceptible staphylococcus) and treated. A sequential strategy was undertaken for bone healing. The focus was exposed and stabilized by external fixation with insertion of a spacer and cement. At day 45, an autologous graft was inserted into the induced membrane. The fixator was removed at bone healing (20 days).

Results: The gain was 8 cm. Postoperatively, the patient responded well to double antibiotic therapy. Recovery of joint motion was spectacular for the shoulder but difficult for the elbow. The autologous graft inserted on day 45 was composed of a non-vascularized fibular component completed with grafts harvested from the two anterior iliac crests. At one year follow-up, the infectious focus remains quiescent. The patient can use his arm with no problem. The shoulder motion is subnormal and there is a certain degree of persistent stiffness of the elbow but with no functional complaint.

Discussion: This is a unusual clinical case where the induced membrane technique proposed by Masquelet for osteomyelitis of the humerus was used in an adolescent. The surgical strategy was chosen in part because of the context where microsurgery was not available.

Conclusion: Therapeutic success was achieved with simple reliable techniques. The motivation of the young patient and the efforts of four medicosurgical teams overcame the technical limitations encountered in this field situation. The potential usefulness of the induced membrane technique proposed by Masquelet was demonstrated.

Purpose of the study: The difficulty of achieving successful reconstruction after tissue loss involving the lower third of the leg, particularly the malleolar region in septic cases, is well known. We report our experience with sequential surgery to treat open fractures of the lower leg and examine the contribution of the distally-based neurocutaneous sural flap.

Material and methods: The following protocol was used for the treatment of tissue defects involving the lower third of the leg and the ankle in 16 patients: repeated wound debridement, change in fixation system for 13 cases, rapid cover of the posterior segment of the leg with an island-dissected distally based neurocutaneous sural flap. Ten nonunions were treated later with a bone graft. Mean age in this series of 14 men and 2 women was 34 years (range 21–70 years). Thirteen patients were secondary hospitalization patients. The Gustilo classification after debridement was class IIIb. Time to cover ranged from one to eight months.

Results: Healing was achieved in three weeks. For three cases, revision was necessary due to re-activation of an infectious focus. All fractures healed (with tibiotalar fusion in two cases).

Discussion: The distally-based pediculated neurocutaneous sural flap is an interesting alternative to microanastomosis flaps for reconstruction of tissue defects of the lower third of the leg. Harvested from the posterior aspect of the calf which is generally spared, this flap must be carefully planned since there is no potential for augmenting the covering capacity. Great care must be taken to protect the pedicle; in our experience tunnelisation must be avoided. This flap also allows cover of a sterile osteosynthesis plate and resists local infection well. It can be raised easily if a bone graft is later necessary. In trauma victims, the esthetic and sensorial prejudice can be considered minor.

Conclusion: The distally-based neurocutaneous sural flap greatly contributes to our strategy for the management of tissue defects involving the lower third of the leg. Its main limitation is its size which can rarely exceed 80 cm2 in our experience.

Purpose: Prognosis of open leg fractures is better when cover flaps are used early to cover tissue loss. Beyond eight days after high-energy trauma (Byrd stage III and IV), the therapeutic strategy requires discussion. The purpose of this study was to analyse the influence of flap covers on these complex fractures.

Material and methods: We conducted a retrospective analysis of 26 patients operated on from 1996 to 201. The therapeutic sequence was debridement, external fixation, and flap cover. High-energy trauma predominated (n=21). We used homolateral leg flaps (n=24, ten muscle flaps and 14 fasciocutaneous flaps) and free latissimus dorsi flaps (n=2). Flap cover was performed on day 8 (n=13), between day 8 and day 45 (n=11), or after day 45 (n=2).

Results: Cover flaps failed in eight cases requiring revision surgery. Time to cover or type of flap was not statistically related with initial severity of the injury. Time to cover influenced the type of flap chosen by the surgeons: 8/13 muscle flaps performed before day 8 versus 10/13 fasciocutaneous flaps after day 8 (p< 0.05). Complementary bone grafts were used for 18 patients before the third month leading to bone healing before ten months. Serious infection occurred in 16.6% of patients in the group treated before day 8 and in 36.66% of patients in the group treated after day 8. The severity of the initial injury and time to cover were not predictive of functional outcome.

Discussion: Proper management of high-energy leg fractures (Byrd stage III and IV) remains controversial. Most authors prefer external fixation to achieve skeletal stability. The growing interest for plastic surgery techniques for the leg segment has led to using locoregional homolateral leg flaps even after day 8. At this phase, we prefer muscle flaps. This attitude has demonstrated its usefulness in terms of healing time and its limitations due to the high risk of infection. Complementary bone grafting is performed before three months if signs of correct bone healing are absent on the control x-rays.

Purpose: Inverted pediculated fasciocutaneous flap is an alternative to microanastomosed free flap for cover of tissue loss of the lower third of the leg in trauma victims. We report our experience in fourteen patients.

Material and methods: Fifteen fasciocutaneous inverted pediculated island flaps were performed in fourteen trauma victims with major tissue loss of the lower limbs. Mean age was 42 year (range 24 – 70). There were thirteen men and one woman. The fracture was located on the lower third of the leg and involved the diaphysome-taphyseal junction in thirteen patients (associated with loss of heal tissue on one), the fibular malleolus in one and the tibial column in one. The Gustilo classification was two grade 0, three grade I, eight grade IIIB, and one grade IIIC. Four patients were given first-intention treatment. For the referral patients treated secondarily, three had a dehiscent wound with an exposed fixation plate.

A supramalleolar lateral flap was used in six patients (40%), a sural neurocutaneous flap with a distal pedicle in seven (47%), and a sural neurocutaneous flap with a distal pedicle in two (13%). Seven patients (50%) had a bone graft.

Results: Wound healing was achieved in thirteen patients, with three infectious complications. The one failure involved a sural neurocutaneous flap (grade IIIC fracture). The fixation plate was preserved under the flap in one patient who developed secondary nonunion. Fracture healing was achieved in all cases.

Discussion: Use of island fasciocutaneous flaps with a distal pedicle for the treatment of tissue loss of the lower third of the leg has grown steadily since the introduction of the concept. The principal advantage, beyond the simplicity of the flap procedure, is to spare locoregional vessel and muscle stock. Our series confirmed that this method can give good results if the flaps are carefully planned. This method should not be recommended as an emergency procedure. Combining two fasciocutaneous flaps could be a salvage solution in certain cases where the trauma context implies less concentration in the aesthetic and sensorial result.

Conclusion: Use of fasciocutaneous flaps with a distal pedicle is a first choice solution for covering tissue loss of the lower third of the leg and foot. This method should not be proposed as an emergency procedure.