Developing Orthoplastic Capacity for Soft-tissue Defects via Short-term Training: A Case Series in Samburu County, Kenya

Abstract

Background:

Orthopedic surgeons frequently encounter soft-tissue defects in the management of extremity trauma. Timely soft-tissue coverage is essential to minimize infection, avoid osteomyelitis, and reduce the risk of amputation. In many low- and middle-income countries, the collaborative effort between orthopedic and plastic surgeons is impractical due to a shortage of plastic and reconstructive surgeons. This study presents a retrospective case series of lower extremity soft-tissue flap reconstruction in an austere environment.

Methods:

The case series included 15 consecutive cases of 13 patients who underwent lower extremity soft-tissue flap procedures between 2018 and 2024. These flaps were performed by a single orthopedic surgeon following participation in a short-term soft-tissue coverage training course. Demographics, injury mechanism, Gustilo-Anderson classification, wound size, flap type, fixation method, follow-up duration, time to wound healing and bony union, functional outcomes, and postoperative complications were collected.

Results:

The most frequent indication for flap coverage was Gustilo-Anderson type IIIB open tibia fractures, which accounted for 43.8% of cases, followed by postoperative wound breakdown with exposed orthopedic hardware. The reverse sural artery flap was the most common flap type, performed on 37.5% of cases, followed by transposition flaps (25%) and gastrocnemius muscle flaps (18.6%). The overall flap success rate was 86.7%.

Conclusions:

The results demonstrate the importance of hands-on surgical training courses and reinforce the value of orthoplastic skill-building as a scalable and sustainable approach to addressing the gap in reconstructive care in austere environments.

Takeaways

Question: Can critical soft-tissue defects be successfully managed in low-resource settings where there is a shortage of plastic and reconstructive surgeons?

Findings: This study evaluated outcomes of soft-tissue flap reconstruction in an austere environment by a single orthopedic surgeon trained through a university-led soft-tissue reconstruction course and reinforces the value of orthoplastic skills in successfully performing limb-salvaging soft-tissue reconstruction.

Meaning: Building orthoplastic capacity in low-resource settings is crucial for managing critical soft-tissue defects and limb salvage.

INTRODUCTION

Orthopedic surgeons frequently encounter soft-tissue defects in the management of extremity trauma, particularly in the context of Gustilo-Anderson (GA) type III open fractures of the distal leg. These injuries are especially prone to complications due to the inherently limited muscular coverage of the distal third of the tibia and the extensive soft-tissue damage often caused by high-energy trauma.¹ The biological potential for healing is further compromised by necessary surgical interventions, such as open reduction and internal fixation. When defects expose bone, ligaments, tendons, or orthopedic hardware, timely soft-tissue coverage—preferably within 7 days—is essential to minimize infection, avoid osteomyelitis or chronic disability, and reduce the risk of amputation.^2,3

In high-income countries (HICs), the standard of care involves a multidisciplinary effort between orthopedic and plastic surgeons to jointly address the bony and soft-tissue components of these injuries, a collaborative effort that has been termed “orthoplastic” management. However, in many low- and middle-income countries (LMICs), such multidisciplinary approaches are impractical due to the critical shortage of plastic and reconstructive surgeons, particularly in rural and underserved areas. Orthopedic surgeons in these settings are often the only providers capable of managing both fracture stabilization and complex wound reconstruction. Furthermore, the absence of wound care specialists and limited access to timely intervention frequently transform initially manageable wounds into critical soft-tissue defects, often involving exposed implants or joint structures.

Soft-tissue flap reconstruction remains the cornerstone of management for these complex wounds. The available options include free tissue transfer, local fasciocutaneous flaps such as rotation or transposition flaps, regional flaps such as the reverse sural artery flap (RSAF) or cross-leg flap, and muscle flaps, including the gastrocnemius and soleus.⁴ Most orthopedic surgeons, however, lack formal training in these techniques, as flap reconstruction has traditionally fallen under the domain of plastic and reconstructive surgery. Although free flaps require microsurgical expertise and specialized equipment, multiple studies have shown that local and regional pedicled (nonmicrovascular) flaps can be effectively performed by orthopedic surgeons with appropriate training.^5,6 Mastery of these techniques enables orthopedic surgeons to manage critical wounds independently, thereby expanding the surgical capacity of health systems in resource-limited settings.

This study presents a retrospective review of 15 consecutive cases of lower extremity soft-tissue flap reconstruction performed by an orthopedic surgeon practicing in rural Kenya following participation in the Surgical Management and Reconstructive Training (SMART) course, a university-led soft-tissue coverage training program. This case series illustrates how hands-on training in reconstructive techniques implemented in austere environments can serve as a sustainable and impactful strategy for building orthoplastic capacity in LMICs.

MATERIALS AND METHODS

Study Setting

This retrospective case series was conducted at Samburu County Teaching and Referral Hospital (SCTRH), located in the North Rift Valley region of Kenya. Samburu County is predominantly rural, with more than 80% of its population residing in remote or pastoralist communities. The hospital serves a catchment area of approximately 1 million people but is staffed by 1 orthopedic trauma surgeon (D.S.) and equipped with only 1 operating theater. Open fractures and complex soft-tissue injuries are commonly seen at the facility, with most cases resulting from motorbike collisions or high-velocity firearm injuries (Fig. 1). The latter has become increasingly prevalent during the past 5 years, primarily due to tribal conflicts and land disputes related to climate change–induced resource scarcity. In this setting, the management of complex orthopedic trauma frequently demands more advanced surgical skills and the ability to apply foundational principles to fill the gap of limited resources available.

Fig. 1.

Critical soft-tissue defect in AK-47–related high-velocity gunshot injury.

Study Design and Inclusion Criteria

The study included 13 patients treated at SCTRH between 2018 and 2024 who underwent 15 lower extremity soft-tissue flaps. Inclusion criteria were the presence of one or more critical soft-tissue defects that were deemed to require flap coverage for successful healing. These included GA type III open tibia fractures, postoperative wounds with hardware exposure, wounds with exposed denuded bone or tendon, chronic osteomyelitis/infected nonunion, and open joints unlikely to heal by secondary intention or skin graft alone. Judgement of wounds that met these criteria was made by the primary treating surgeon. Patients were excluded if their injuries were deemed unsalvageable due to overwhelming soft-tissue destruction. Due to strong cultural preferences, amputations were not performed during the initial operative exploration regardless of the limb condition. This study was approved by the local institutional review board at SCTRH, and written informed consent for publication of clinical images was obtained.

Data Collection and Outcomes

Data collected included demographic variables (eg, age, sex, comorbidities), injury mechanism, GA classification, wound size (measured after completion of debridement and before flap closure), flap type, fixation method, follow-up duration, time to wound healing and bony union, functional outcomes, and postoperative complications (Table 1). Follow-up timepoints included in the study were at 6 weeks, 6 months, and 12 months. The median follow-up duration was 24 months (interquartile range: 12–36 mo). In this setting, hospital funds were allocated toward patient transport, ensuring that no patients in the study missed their follow-up appointments.

Table 1.

Patient Information and Outcomes

Patient	Case	Age, y	Sex	Comorbidities	Wound Type	Injury Mechanism	Wound Size, cm2	Flap Performed	Associated Orthopedic Injury	Follow-up Duration, mo	Time From Flap to Complete Soft-tissue Healing, wk	Radiographic Healing at 6 mo From Fixation or Completion of Transport	S&S, Degrees	Postoperative Complications
1	1	35	M	N/A	PTI	RTA	36	Gastrocnemius	Infected tibia midshaft	36	10	Yes	>90	N/A
2	2	13	M	N/A	ATW	Fall	90	Gastrocnemius	Proximal tibia	36	8	Yes	>90°	Skin graft necrosis
3	3	45	M	N/A	ATW	RTA	35	RSAF	Distal tibia	36	20	Yes	>90	Skin graft necrosis
4	4	20	M	N/A	ATW	RTA	72	RSAF	Distal tibia	24	10	Yes	>90	Skin graft necrosis
5	5	60	F	Hypertension	SSI	RTA	35	RSAF	Distal tibia	20	16	Yes	>90	Skin graft necrosis
6	6	25	F	N/A	IWB	RTA	30	Transpositional	Midshaft tibia	24	N/A	N/A	>90	Flap necrosis
	7	25	F	N/A	IWB	RTA	35	RSAF	Midshaft tibia	24	6	Yes	>90°	Skin graft necrosis
7	8	55	M	Diabetes	IWB	RTA	40	RSAF	Tibia transport	24	12	Yes	>90	Skin graft necrosis
8	9	30	M	HIV	ATW	RTA	35	RSAF	Midshaft tibia	12	5	Yes	>90	Skin graft necrosis
9	10	18	M	N/A	ATW	RTA	18	Rotational	Distal tibia	24	6	Yes	>90	N/A
10	11	16	M	N/A	IWB	RTA	10	Transpositional	Bimalleolar	24	10	Yes	>90	N/A
11	12	50	F	N/A	IWB	RTA	12	Transpositional	Trimalleolar	12	4	Yes	>90	N/A
12	13	40	M	N/A	IWB	RTA	24	Transpositional	Tibia transport	24	6	Yes	>90	N/A
13	14	65	M	N/A	ATW	RTA	90	Soleus	Distal tibia	36	N/A	N/A	>90	Flap necrosis
	15	65	M	N/A	ATW	RTA	60	Cross-leg	Distal tibia	36	6	Yes	>90	N/A

ATW, acute traumatic wound; IWB, incision wound breakdown; PTI, posttraumatic infection; RTA, road traffic accident; SSI, surgical site infection.

The primary outcome was the flap success rate, which was defined as soft-tissue healing with a viable flap without the requirement for reoperation. Flap viability was measured at each follow-up by clinical assessment of capillary refill, color, and skin turgor. Major complications were failure of the flap to provide adequate soft-tissue coverage, resulting in reoperation; deep surgical site infection (defined as a clinically diagnosed infection requiring reoperation or antibiotic therapy); or nonunion (defined as failure to demonstrate radiographic union at final follow-up). Minor complications included wound healing issues that resolved without reoperation, such as partial skin graft loss. Functional status was assessed using ambulation and the squat and smile (S&S) functional test. The S&S test involves the patient performing a standardized deep squat in the lateral and frontal planes to assess strength and mobility. This test has been shown to be highly sensitive in predicting lower limb fracture healing. A satisfactory S&S test was defined as the ability to perform a squat with knee flexion greater than 90 degrees.⁷

Three general types of flaps were performed for soft-tissue reconstruction: muscle flaps, local fasciocutaneous flaps (predominantly transposition flaps), and nonmicrovascular island flaps (eg, RSAF). Skin grafts were used to cover flap donor-site wounds, exposed flap adipofascial pedicle tissue, or to complete wound coverage.

Surgeon Training

The operating surgeon (D.S.) had no prior formal training in soft-tissue reconstruction at the beginning of the study period. In 2018, the surgeon participated in the SMART course, offered by the Institute for Global Orthopaedics and Traumatology at the University of California, San Francisco. The SMART course is a 4-day surgical training program that integrates didactic instruction, surgical video demonstration, and hands-on cadaveric laboratory training on fundamental flap techniques for orthopedic trauma reconstruction.^8,9 The first 2 days focus on lower extremity soft-tissue reconstruction techniques, specifically the medial gastrocnemius muscle flap, soleus muscle flap, reverse sural fasciocutaneous flap, cross-leg flap, and 3 local fasciocutaneous flap techniques (transposition, rotation, and bipedicle flaps). The third day focuses on flap techniques for upper extremity coverage, including radial forearm, reverse radial forearm, latissimus dorsi, and groin flaps. The fourth day focuses on the design and development of clinical research projects relevant to participants’ patient populations. No formal postcourse mentorship is provided to attendees.

RESULTS

Thirteen patients underwent lower extremity soft-tissue flap reconstructions during the 6-year study period. The median age was 27.5 years (interquartile range, 13–65 y), and 75% of patients were male. Most patients had no history of diabetes (92.3%) or smoking (92.3%) and abstained from alcohol (84.6%).

The most frequent indication for flap coverage was GA type IIIB open tibia fractures, which accounted for 43.8% of cases. Postoperative wound breakdown with exposed orthopedic hardware was the second most common indication (Fig. 2), representing 37.5% of cases. Two patients presented with critical defects related to chronic osteomyelitis secondary to neglected open fractures, one of them particularly from a severe skin breakdown during a tibia transport procedure (Fig. 3), whereas 1 patient developed a critical defect from an infected regenerate during distraction osteogenesis using the Ilizarov method (Fig. 4). The soft-tissue defects were located in the proximal third of the leg for 2 cases, the middle third for 5 cases, and the distal third for 8 cases.

Fig. 2.

Critical soft-tissue defect with exposed hardware, patient 5.

Fig. 3.

Critical soft-tissue defect in tibial transport–related skin breakdown treated with RSAF, patient 7. A, Soft-tissue defect. B, Flap inset. C, Four-month follow-up.

Fig. 4.

Transposition flap, patient 12. A, Soft-tissue defect. B, Flap inset with skin graft. C, First-year follow-up.

The RSAF was the most commonly used procedure, applied in 37.5% of cases (Fig. 5). Among these, 2 patients older than 50 years of age underwent a delayed procedure to enhance flap survival. Transposition flaps were used in 25% of cases, followed by gastrocnemius muscle flaps (18.6%). A soleus muscle flap and a cross-leg flap were each used once. All soft-tissue reconstructive procedures were performed at the time of definitive skeletal stabilization, with intramedullary nailing used in half of the cases, external fixation in 5 cases, and plating in 3 cases. Skin grafts were used in all patients to complete wound coverage or address flap donor-site defects.

Fig. 5.

RSAF surgical technique highlights, patient 4. A, Lateral ankle defect. B, Flap elevation. C, Flap inset. D, Flap inset with skin graft. E, Four-week postoperative follow-up demonstrating partial skin graft necrosis. F, One-year follow-up.

The overall flap success rate was 86.7%, with 13 of 15 flaps achieving complete healing. Partial skin graft necrosis occurred in 74% of patients, typically involving 30% of the grafted area at the flap donor-site wounds and exposed flap adipofascial pedicle tissue. All cases were managed nonoperatively with wet-to-dry dressings and progressed to successful healing by secondary intention. Notably, 2 flaps failed and required reoperation: 1 located in the middle third of the limb and 1 in the distal third. There was no trend in flap survival based on the location of the defect. The first failure involved a 25-year-old woman with a fasciocutaneous transposition flap that developed 70% necrosis. A salvage RSAF was subsequently performed with successful healing (Fig. 6). The second failure occurred in a 65-year-old man with a GA type IIIB fracture treated with a soleus muscle flap, which failed and was salvaged by a cross-leg flap (Fig. 7). All included patients were ambulatory and able to perform a successful S&S functional test at final follow-up, with no pain and knee flexion greater than 90 degrees.

Fig. 6.

Transposition flap failure, patient 6. A, Initial flap inset with skin graft. B, Partial necrosis of transposition flap. C, Revision with RSAF inset with skin graft. D, One-year follow-up.

Fig. 7.

Cross-leg flap, patient 13. A, Immediate postoperative with external fixator. B, Six-month follow-up.

DISCUSSION

This study evaluated outcomes of soft-tissue flap reconstruction performed in an austere environment by an orthopedic surgeon trained through a university-led soft-tissue reconstruction course. An overall flap success rate of 87% was reported in this retrospective case series. Limb preservation with complete soft-tissue healing, bony union, and acceptable function was achieved in all patients.

Complication rates were comparable to other flap reports from surgeons in LMICs.^10,11 Flap failure occurred in 2 cases, both involving open fractures. These failures likely resulted from difficulty assessing soft-tissue viability, which has been cited in the literature as the “gray zone”—an indeterminate area where the extent of tissue devitalization is unclear.¹² In 1 case, soleus flap necrosis was attributed to trauma-induced injury of the muscle’s segmental pedicles. This highlights the importance of avoiding muscle flaps where vascular supply may be compromised in high-energy trauma zones, particularly in the middle third of the leg, as well as the difficulty in making this determination in austere environments that lack access to computed tomography angiography and handheld Doppler ultrasound.¹³ The other failure was a fasciocutaneous transposition flap, which could have been related to suboptimal flap design. A proximal-to-distal approach may have improved the outcome. These cases underscore the learning curve associated with flap design and planning, particularly in the context of delayed reconstruction and suboptimal local tissue.

The most common complication reported was partial loss of skin grafts from the flap donor-site wounds and adipofascial pedicles. This can be attributed to 2 factors: (1) the lack of skin graft harvest equipment and (2) the lack of adequate postoperative wound care and supplies. Regarding the former, skin grafts were harvested with a manual dermatome. Although usable, the thickness and quality of grafts harvested with this instrument are not as consistent as those obtained with a standard power dermatome. Regarding postoperative wound care, nurses in austere settings are often understaffed and lack basic supplies such as petroleum gauze. Despite these challenges, all patients achieved flap healing and were ambulatory at final follow-up, with no cosmetic complaints.

The RSAF was the most frequently used flap in this case series. Although technically more challenging, its versatility and suitability for a wide range of distal-third tibial defects make it a valuable tool in LMIC settings. The RSAF has been shown in multiple studies to be prone to venous congestion due to its retrograde flow and reliance on delicate venous drainage¹⁴; although none of the RSAF in this study failed. This can likely be attributed to the use of surgical refinements, including delayed procedures, large adipofascial pedicles, and grafting at pivot points. When properly executed, RSAF outcomes have been shown to have similar outcomes to free flaps.^14,15 Despite the success of RSAFs in our cohort, their use remains limited in many lower resourced environments. Several barriers likely contribute to this. At the institutional level, lack of operating theater availability, trained personnel, and local mentorship may restrict the ability to perform such flap procedures. Physician-level barriers may also exist, including limited exposure to flap-based reconstruction during training and reduced confidence in performing these procedures independently. Finally, patient-level factors can further influence treatment decisions, including financial constraints related to implant procurement, limited access to reliable postoperative follow-up, and challenges in maintaining the level of wound and flap care required after surgery.^16,17 These structural, provider, and patient factors may discourage the use of flap-based limb-salvage procedures, even in circumstances where techniques such as the RSAF may provide a viable reconstructive option.

In cases where fasciocutaneous flaps fail, cross-leg flaps remain a viable option. Although their use has declined in HICs due to concerns over patient morbidity and prolonged immobilization, they remain valuable in austere settings. In the current study, a cross-leg flap successfully salvaged a failed reconstruction, in contrast to another LMIC study that avoided cross-leg flaps due to logistical challenges, often opting for amputation.¹⁸

In HICs, microvascular flap coverage is considered an indispensable component in the treatment of large wounds in the middle or distal third of the lower extremity. In many LMICs, however, microsurgical free tissue transfer is not feasible due to a lack of specialized training and equipment, and soft-tissue coverage with nonmicrovascular flaps remains the only viable option. Many studies have demonstrated equivalent outcomes between microvascular and nonmicrovascular flap coverage,^10,11,19 with some demonstrating superior outcomes with the latter.^18,20 Unfortunately, surgical expertise even with nonmicrovascular flaps is extremely scarce in LMICs, and vastly more so in rural areas. To increase the surgical capacity for soft-tissue coverage in these areas, surgical training courses have been developed to provide training in these techniques to local, primarily orthopedic-trained surgeons.²¹

In studies originating from higher resourced countries, it has been demonstrated that orthopedic surgeons who have undergone focused training in nonmicrovascular flap reconstruction techniques are able to provide soft-tissue coverage for a large majority of traumatic lower extremity wounds, with results equivalent to microvascular coverage, including similar complication rates and improved time to flap coverage.^15,22 In contrast, there are few publications on orthopedic surgeons performing flaps in LMICs. Dorji¹⁴ described a series of 48 patients treated with nonmicrovascular flaps for a wide range of traumatic and nontraumatic wounds at a regional hospital in Bhutan, with a 98% reported success rate. Mathieu et al²² reported a series of 55 patients who underwent a total of 62 pedicled flaps at a joint French/Senegalese military hospital in Senegal, with an 89% success rate. Finally, Kamath et al¹² reported on 151 patients who underwent nonmicrovascular flap coverage during an 18-year period. These studies demonstrated not only the feasibility of treating the majority of GA type IIIB fractures successfully with nonmicrovascular flaps, but also that these procedures can be performed successfully by non–plastic and reconstructive surgeons in resource-limited settings.

Achieving timely coverage of exposed bone or implants to prevent infection and reduce the risk of septic nonunion and chronic osteomyelitis^2,18 requires immediate access to reconstructive expertise, which is rare in most LMICs, and even in some regional hospitals in HICs.²⁰ As orthopedic fixation strategies evolve toward internal fixation, even in GA type IIIB injuries,^12,23 delays in soft-tissue coverage represent a major obstacle to optimal outcomes. In this review, all applicable cases were treated with single-stage internal fixation and soft-tissue coverage, with no deep infections, supporting the “fix and flap” paradigm.²³

Hands-on training through the SMART course provided a sufficient technical foundation for a general orthopedic surgeon to perform diverse flap reconstructive techniques with reproducible results.⁹ This case series provided real-world evidence of that success in a rural environment with a high volume of trauma. Although long-term solutions include increasing the plastic and reconstructive surgery workforce in LMICs, short-term strategies involve equipping local orthopedic providers with foundational soft-tissue coverage skills. Structured, practical training courses are a cost-effective and scalable solution to meet this need.^24,25

There were limitations to this study. First, as a single-surgeon, single-institution retrospective case series, the findings may reflect surgeon-specific techniques and patient selection bias, which may limit generalizability to other surgeons, institutions, or settings. Second, this study had a relatively small sample size; however, the 15 flaps described in this review represent consecutive cases over a limited timeframe and reflect the realities of a rural referral setting, where the volume of complex limb injuries requiring flap coverage is substantially lower than that of urban hospitals. Nevertheless, the ability to successfully perform limb-salvage procedures in this context remains clinically meaningful and provides valuable insight into the feasibility and outcomes of flap reconstruction performed by an orthopedic surgeon. Third, the wide age range of patients treated may introduce heterogeneity, but all procedures were performed using the same decision framework and surgical technique. Finally, this study cannot isolate which elements of training contributed most to the surgeon’s successful skill acquisition.

CONCLUSIONS

This retrospective case series demonstrated that hands-on surgical training courses can equip orthopedic surgeons in low-resource settings with the capacity to perform limb-salvaging soft-tissue reconstruction. The success rate demonstrated after a 4-day surgical training course with technically complex flaps such as the RSAF lends support to the effectiveness of this type of capacity-building effort. With formal instruction and practical exposure, non–plastic and reconstructive surgeons can achieve reliable outcomes in managing critical extremity wounds. These findings reinforce the value of building orthoplastic capacity as a scalable and sustainable approach to addressing the reconstructive care gap in austere environments.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

Patients provided written consent for the use of their images.

ETHICAL APPROVAL

This study received approval from our local institutional review board in accordance with the Declaration of the World Medical Association on March 11, 2018 (SCRH/IRB/11/3/18).