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| anterior tibial artery to flap artery anastomosis |
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| Flap insetted |
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| Flap insetting lateral view |
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| lateral skin graft and scar of previous surgery |
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| Exposed bone |
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| Sequestrum popping out |
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| Well settled flap |
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| good contour and color match |
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| Post op day 2 |
7 year old Iraqi boy had a fracture tibia following a fall, being undisplaced fracture a cast was applied in 2016 . Poorly applied cast resulted in skin break down and bone was exposed . This was discovered once cast was removed. Plastic surgeon was consulted and local rotation flap was done . Flap surgery was not very successful with total break down of flap . Loss of flaps are very difficult to fathom and morale hits new low. Family decided to seek treatment aboard once the the situation of wound stabilized , In november 2017 father and son travelled to India and I saw the patient in Metro hospital Faridabad . Orthopedic surgeon ( Dr Sujoy Bhattacharjee )opinion was taken in view of intact posterior cortex decision was taken to do flap only.
On 11/11/17 patient was taken up for surgery and necrotic dead bone was removed and through reaming of bone to remove any residual infection was taken. Multiple flaps options were in my mind. We dissected anterior tibial pedicle till ankle and kept it there . Long defect favoured gracillis ,so gracillis was harvested and transferred . After flap insetting excess muscle was placed into bony defect of anterior cortex. Flap was connected to anterior tibial vessels as shown in picture. A sheet of skin graft was placed on muscle with little left for monitoring .Patient was kept in ICU for three days for monitoring , I prefer to do warm lignocaine flushing of pedicle area it prevents hematoma and spasm . Flap went of well and patient was discharged on post op day 7 . Left over raw area was left to granulate and epithelise. After one month patient father send this photo which show well settled flap with good contour and color match.
Patient was young boy who had partially healed fracture and dead necrotic bone exposed for almost one year, After removal of sequestrum how much bone is going to be left whether that would good enough for weight bearing was issue to be deliberated. There was reconstructive attempt which failed and with scarring all around case was little daunting. Microvascular surgery is a tough job especially in upper one third of leg. Anterior tibial vessels are unpredictable in upper one third leg especially with trauma. I usually do end to side arterial anastomosis but this time I chose end to end. Because of small size of vessel pediatric microvascular is always challenging. Vessel spasm is a big issue in leg vessels and anterior tibial vessel no different. In this case also it went to spasm and took two hours to come out , hot saline ,lignocaine and papaverine were used. Muscle flaps are very good in filling up cavity cand combating bony infection,hence the choice. Donor site morbidity is negligible and scar is hidden. It is pertinent to share that doing cross leg flap was not a option father refused consent for it .
Micro vascular surgery sometimes solves difficult problems in a very easy way all you have to do is not to mess it up.
Dr Adhishwar Sharma +91 8860650846 adhishwar7@gmail.com
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