Firearm reconstruction of the lower extremity. Multi-modal concept. A case report

Background: Repair of gunshot soft tissue defects of the lower extremity remains a complex and multifaceted task of reconstructive plastic surgery as a part of surgical care to injured warriors of the Armed Forces of Ukraine.

Given the proposed repair principle of "similar for similar" replacement, the best donor site for the reconstruction of gunshot defects of the soft tissues of the lower extremities should be considered the anatomical area within the damaged segment. At present, the reconstructive plastic surgery offers several types of island-, propeller flaps with retrograde perfusion for repairs of the shin wounds, but the region of anatomical "transition", including the ankle joint, the heel area, needs a special approach. We propose to consider a reverse sural flap as a bright alternative method of reconstruction of gunshot defects of the lower third of the shin, ankle joint and the posterior part of the foot (heel area).

In our clinical observation we demonstrate the convenience and utility of the multimodal concept and its practical implementation in the course of reconstruction of the penetrating gunshot defect of the foot IV^th  compartment: heel area of the right lower extremity (with the defect of soft tissues of the sole and foot, tangential gunshot fracture of the heel bone –11,0*10*8,0 cm. The defect was closed by means of a reverse sural flap. The multi-modal tactics of differential diagnosis in the pre-operative period, intra- and post-operative period allowed the choice of the donor zone with good perfusion at the expense of which the well-repaired anatomical structure of  the foot IV^th compartment was restored. This, in turn, provided an opportunity to restore the esthetic part of the defect well, to maintain a greater percentage of the loading (axial) function of the lower extremity and demonstrated positive dynamics during the restoration of the amplitude of active movements.

Key words: Perforated flaps, reverse sural flap, multi-modal concept