Soft tissue coverage in open fractures of tibia

Sir,

We read the article by Kamath et al.¹ with great interest. The article primarily addresses management of open injuries of tibia in tertiary health centers of India, where facilities of advanced plastic reconstructive surgery do not exist. The article nicely covers all aspect of plastic reconstructive procedures for such injuries with orthoplastic approach, but we do not agree with authors in certain sections of article.

Authors describe that there is a shift in approach for treatment of soft tissue defects in open fractures favoring nonmicrovascular flaps. This cannot be considered as a generalized rule. Unfortunately, many surgeons still believe that pedicle flaps have advantage over free flaps owing to the potential for loss of free flaps. Mathes and Nahai² reviewed a large series of conventional flaps found approximately 10% loss of significant portion of flap; on the contrary, microsurgical free flap transfer has a well established overall failure rate of around 5%.³ Even series of lower extremity flaps in the presence of severe injury have a success rate of 90-98%.⁴ The authors have stated a flap loss of 25% has no basis. It is true that microsurgical flaps are more demanding and require more sophisticated setup with surgical skills, but we cannot label a procedure to be failure because it is more demanding.

Under Materials and Methods authors state that the flap was delayed in period 1. We want to know what was the period of delay? How they kept the bone covered during the period of delay? Because procedures of delay in flaps in particular reference to bone coverage will invite necrosis of the bone due to exposure during the period of delay.⁵

The crossed leg flap has its own advantages due to its simple application, but authors failed to comment on long periods of recumbence, awkward position of limbs, potential for venous thrombosis in leg and failure rates up to 20% associated with this flap.⁶