Home About Journal AHEAD OF PRINT Current Issue Back Issues Instructions Submission Search Subscribe Blog    

Users Online: 2067 
Print this page  Email this page Small font sizeDefault font sizeIncrease font size 

 Table of Contents    
Year : 2013  |  Volume : 47  |  Issue : 3  |  Page : 317-318
Author's reply

1 Department of Orthopedics, Kasturba Medical College, Manipal University, Mangalore, India
2 K S Hegde Medical Academy and Tejasvini Hospital, Mangalore, India
3 Department of Surgery, Kasturba Medical College, Manipal University, Mangalore, India
4 Department of Orthopaedic Surgery, Tejasvini Hospital, Mangalore, India

Click here for correspondence address and email

Date of Web Publication10-May-2013

How to cite this article:
Kamath JB, Shetty M S, Joshua T, Kumar A, Harshvardhan, Naik DM. Author's reply. Indian J Orthop 2013;47:317-8

How to cite this URL:
Kamath JB, Shetty M S, Joshua T, Kumar A, Harshvardhan, Naik DM. Author's reply. Indian J Orthop [serial online] 2013 [cited 2020 Feb 21];47:317-8. Available from:

We appreciate the concerns raised by Nema S and Vyas GS [1] on our article "soft tissue coverage in open fractures of tibia." [2] Further we want to clarify the points raised.

This article primarily addresses management of open injuries of tibia in tertiary health centers of India, where facilities of advanced plastic and reconstructive surgery do not exist. We have quoted the references, [2] which clearly state that when there are alternative loco regional flaps, the role of free flaps is questionable. The need of a team of expert surgeons, the infrastructure, and the logistics will always be important deciding factors in the decision making in tibial open fractures. It is also needless to stress that obtaining consistent good results in free flaps for lower limb reconstruction involves steep learning curve, even in specialized micro vascular centers.

  1. We share the same views as Bhatti et al., [3] who have clearly expressed the advantages of local flaps for compound fracture in the lower leg. The complication rates following local and free flaps in their series were 18 and 27%, respectively. They concluded that although free flap surgery is a versatile procedure, it remains a more demanding and risky procedure than local flap surgery. Moreover, the local fascial flap of the leg can provide a better alternative for free flap coverage with fewer medical complications, a shorter operative time and hospital stay, and better esthetic results. The authors have quoted Khouri et al. [4] of institute of reconstructive surgery, New York, who have presented 304 consecutive cases of free flaps for open fractures in the leg. This publication comes from a very large specialized microvascular unit and even they conclude that in their hands, the failure rates of free flaps in lower limb for traumatic problems is 8% compared with none in nontraumatic conditions. Their final word is that the experience of surgeon is most important in the final outcome of free flaps in open fractures of tibia. The authors have also quoted Harashina, [5] who clearly states the steep learning curve as indicated by their failure rate of free flaps in the "early period" of as much as 25%. They also mention that the survival of free flap is lowest in the lower limb reconstruction. The above said articles were published in an era, when there were very little alternatives for flap coverage in distal one third. In this context, when technically less demanding nonmicrovascular procedures with easy and favorable learning curve are available to cover small/medium sized raw area, free flaps should be reserved for large defects which are not amenable to be covered by simple and safer procedures. We believe that there is a need for consensus regarding the indications for free flaps in open fractures of tibia and such indicated cases should be referred to exclusive microvascular surgical centers as early as possible so that the selected team of surgeons overcomes the steep learning curve effectively. We discourage the occasional arm chair attitude in microvascular surgery for lower limb trauma. The free flaps for open fracture tibia must be reserved for exceptional cases and they should be undertaken by exclusive microsurgical team/centers.
  2. We delayed the flaps in period 1 of our study for 5-7 days in loco-regional flaps based either proximally or distally. Bone during this waiting period was covered with nonadherent antiseptic dressing. Biological dressings such as collagen dressing were not readily available during that period. Its only in the later part of our study, [2] when we were exposed to perforator based flaps, distally based sural artery flap did we stop delaying the flaps. Hand held Doppler equipment was quite handy in the later part of our study, when we had to raise flaps with length-breadth ratio more than 2 or 3.
  3. With the use of external fixator with crossed leg flap (CLF), positioning and maintenance of the position, ability of the patient to turn to complete left and right lateral positions have become relatively easy. In an already externally fixed fracture, additional two schanz pins on the donor site are not an extensive surgical insult. Our experience with CLF has been very encouraging, and we are yet to encounter a case of venous thrombosis, which can be attributable to the CLF and the inevitable position associated with CLF. We feel that the increased incidence of Deep vein thrombosis (DVT) related to CLF is a myth and more theoretical.

   References Top

1.Nema S, Vyas GS. Soft tissue coverage in open fractures of tibia. Indian J Orthop 2013;47:317.   Back to cited text no. 1
  Medknow Journal  
2.Kamath BJ, Shetty MS, Joshua TV, Kumar A, Harshvardhan, Naik DM. Soft tissue coverage in open fractures of tibia. Indian J Orthop 2012;46:462-9.  Back to cited text no. 2
[PUBMED]  Medknow Journal  
3.Bhatti AZ, Adeshola A, Ismael T, Harris N. Lower leg flaps comparison between free versus local flaps. The Internet Journal of Plastic Surgery. 2007 Volume 3 Number 2. DOI: 10.5580/35c.  Back to cited text no. 3
4.Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: A 10-year experience with 304 consecutive cases. J Trauma 1989;29:1086-94.  Back to cited text no. 4
5.Harashina T. Analysis of 200 free flaps. Br J Plast Surg 1988;41:33-6.  Back to cited text no. 5

Correspondence Address:
Department of Orthopedics, Kasturba Medical College, Manipal University, Mangalore
Login to access the Email id

Source of Support: None, Conflict of Interest: None

Rights and PermissionsRights and Permissions


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Email Alert *
    Add to My List *
* Registration required (free)  


 Article Access Statistics
    PDF Downloaded54    
    Comments [Add]    

Recommend this journal