Traumatic injuries of the leg and foot represent a significant burden on individuals and healthcare systems worldwide. These injuries commonly result from road traffic accidents, falls from height, workplace accidents, gunshot wounds, and sports-related trauma (1). Due to the anatomical complexity and essential functional roles of the lower extremities, such injuries often involve both skeletal and soft tissue components, making their management particularly challenging. Among all the etiological factors, road traffic accidents remain the most prevalent cause of traumatic leg and foot injuries (2). The management of this kind of injury requires a coordinated multidisciplinary approach. The initial phase of management is done by an Orthopedic and trauma surgeon. This included stabilization of fractures, control of hemorrhage, and debridement of devitalized structures. In cases involving open fractures with soft tissue loss, the involvement of plastic and reconstructive surgeons is crucial. Their advice is valuable for planning definite coverage preserving vascular structures as well and ensuring optimal placement of orthopedic hardware to facilitate soft tissue reconstruction later [3]. Over the past few decades, there have been significant advancements in the management of lower extremity trauma [4]. In addition, soft tissue reconstruction has improved from a refined understanding of vascular anatomy especially the angiosome concept which allows precise use of local fasciocutaneous flaps [5]. These improvements have now enabled surgeons to salvage the limb which previously would have been amputated. An important advancement of open fracture management is early definitive coverage of exposed bone and tendons using vascularized tissue. These procedures reduce the risk of osteomyelitis promote fracture healing, restore function, and improve cosmetic appearance [6]. In extensive degloving injuries where the bone is exposed without fracture timely flap coverage can prevent chronic non-healing wounds which are associated with prolonged use of negative pressure therapy or skin substitutes. Gustilo-Anderson classification helps to assess the severity of open fracture injuries and guides treatment protocols to be adopted [7]. The Mangled Extremity Severity Score (MESS), which was introduced by Johansen et al., is a predictive tool for assessing the likelihood of successful limb salvage or amputation which considers factors such as ischemia, shock, skeletal and soft tissue injury and patient’s age [8].  Foot injuries can be difficult to manage because the soft tissue coverage is minimal. Even small defects in these structures can lead to significant functional impairment. Flap reconstruction is often needed in the lower third area of the leg because the surrounding soft tissue is restricted, tendons are visible and the blood flow is lacking [9]. New approaches with perforator flaps from the posterior tibial and peroneal arteries provide solutions in extensive degloving injuries. Based on this background the current study aimed to analyze the clinical outcomes of various treatment modalities available for managing leg and foot injuries at a tertiary care hospital.

This prospective observational study was done in the Department of Plastic and Reconstructive surgery, Gandhi Medical College and Hospital, Secunderabad, Telangana between September 2022 to September 2024. Institutional Ethical approval was obtained for the study. Written consent was obtained from all the participants of the study after explaining the nature of the study in vernacular language.

 Inclusion Criteria

1. Patients of either sex and all age groups with soft tissue injuries in the leg and foot.
2. Patients with bony injuries in association with soft tissue injuries of leg and foot.

Exclusion Criteria

1. Congenital deformity of involved leg and foot.
2. Patients with chronic injuries.
3. Burns and post-burn contractures.
4. Patients with isolated bony injuries.
5. Patients who did not give consent.
6. Patients with non-salvageable injuries.

Based on the inclusion and exclusion criteria a total of 100 cases were identified and included in the study during the duration of the study.

Initial management: Patients presenting to the Emergency Department with leg and foot injuries following trauma were thoroughly evaluated for head injury, penetrating and blunt thorax, and abdominal injuries and long bone fractures by the respective departments. Resuscitation and management of all associated life-threatening injuries take precedence over limb injuries. In these cases, treatment of extremity injury was limited only to stabilization of extremity and control of bleeding. Once the patient was hemodynamically stable, the limb was examined for vascularity and the extent of soft tissue and bony loss. Vascularity was assessed by looking for a capillary refill. Dorsalis pedis/anterior tibial and posterior tibial vessels were palpated. When not palpable, a handheld Doppler probe was used. A neurological examination was then performed. This study also included patients with leg and foot injuries referred by other departments as well as those presented to our Outpatient facility after initial management elsewhere. MESS was used to assess the severity of each case.

Surgical procedure: After obtaining clearance from the Anesthesiologist, these patients were taken up for the surgery. Bone stabilization, either temporarily or definitively, was the first step in lower extremity reconstruction and was done by the Orthopedician. In cases with severe soft-tissue loss, exposure of the tibia, or significant contamination, the temporary use of an external fixator was often considered until debridement was complete and definitive skeletal stabilization was performed later. The reconstructive modality selected was based on both the patient and wound factors. In case of only post-traumatic raw area surgical modality employed was STSG. Tendoachilles was repaired by Krackow’s technique and the other tendons by the modified Kessler’s technique. Epineurium repair was done in case of nerve injury. In compound defects in the upper1/3rd of the leg, we used gastrocnemius muscle flap, fasciocutaneous flaps Medial inferiorly based fasciocutaneous flap, medial superiorly based fasciocutaneous flap, lateral inferiorly based fasciocutaneous flap. Flaps done in the middle 1/3rd and lower 1/3rd of the leg included reverse sural artery flap, perforator-based fasciocutaneous flaps, and cross-leg flaps depending on the defect size, location, and vascular status.

Postoperative management: Following surgery, all patients were monitored in a high-dependency ward based on their clinical status. Limb elevation was maintained to reduce edema and promote venous return. Vitals, neurovascular status, and flap viability were checked regularly. Antibiotics were continued as per protocol. Analgesia was optimized for pain control. For cases involving external fixators or bone stabilization, pin site care was performed daily. STSG dressings were inspected by day 3 for graft take. Immobilization of the limb was maintained until wound healing was adequate. Physiotherapy for joint mobility and muscle strengthening was initiated gradually post-wound stabilization.

Statistical analysis: All the available data was refined, segregated, and uploaded to an MS Excel spreadsheet and analyzed by SPSS version 23 in Windows format. All the continuous variables were represented as mean, standard deviation, frequency, and percentages. The categorical data was calculated using the Chi-square test the values of p (<0.05) were considered significant.

Table 2 shows the distribution of cases based on the Mangled Extremity Severity Score (MESS); this score helps in evaluating the limb salvage versus amputation decision. A critical analysis of the table shows that most of the cases had MESS scores between 4 and 6, indicating moderate to severe limb trauma. The most frequently observed score was scores 4 (26%) and 5 (24%), followed by scores 6 (17%). The Scores of 7 and 8 were observed in 12% of cases which often suggest the need for amputation. Milder injuries with scores of 2 or 3 were found in 21% of cases indicating milder injuries.

Surgical interventions performed in this study are shown in Table 3. Most patients i.e., 68% underwent flap cover-alone procedures because of extensive soft-tissue defects requiring reconstruction. Tendon and/or nerve repair only was performed in 11% of cases. The combined approach of tendon and/or nerve repair along with flap cover was performed in 10% of the cases because of complex injuries involving both soft tissue and functional structures. The need for split-thickness skin grafting (STSG) was found in 11% of patients, mostly for superficial coverage. These results showed that reconstructive surgery with flap cover was the predominant procedure required, and the involvement of the plastic and reconstructive surgeon is essential for lower limb trauma management.

Table 4 describes the detailed information on the 78 flaps used in lower extremity reconstruction in the cohort of the study. Most of the flaps were from the ipsilateral limb (89.7%) owing to its ease and quicker surgical access. Pedicled flaps were commonly used in 97.4% of cases because of the preference for local tissue transfer over free flaps due to resource constraints and patient suitability. Fasciocutaneous flaps were used in 82% of our patients, followed by muscle flaps in 14%, and myocutaneous flaps (4%). Fasciocutaneous flaps were used because they are simpler, provide reliable coverage options, and have fewer donor site morbidities. The results showed that the flaps were based on an efficient selection strategy tailored to the injury location, wound bed condition, and need for durable vascularized tissue coverage.

Table 5 shows the anatomical distribution of the flaps used in the study. A critical analysis of the table shows that the foot and ankle regions were the most commonly reconstructed areas in 32 cases, all of which were covered with fasciocutaneous flaps because of their versatility and minimal bulk suitable for distal limb areas. In 9/17 cases, the upper third of the leg required predominantly muscle flaps due to exposure of the bone. The use of myocutaneous flaps was limited to more extensive or combined defects. The middle- and lower-third injuries were managed mostly by fasciocutaneous flaps.

Table 6 shows the postoperative complications following the reconstructive procedures. The results showed that in 90% of the cases, there were no postoperative complications, reflecting good surgical technique and wound management. Flap congestion occurred in 4% of cases because of venous insufficiency or tension in the flap. Complications of partial graft loss and marginal flap necrosis were found each in 3% of the cases, which were managed by conservative measures or small surgical revisions. The low overall complication rate is due to the effectiveness of the surgical approach and postoperative wound care protocol.

Table 7 shows the functional recovery assessment based on Lower Extremity Functional Scale (LEFS) scores at 3 and 6 months, along with the overall outcomes. The evaluation at 3 months revealed that most of the patients had moderate scores ranging from 41 to 70, indicating ongoing recovery. At the end of 6 months, a shift towards a high score of 71 – 80 was found in 37% of the patients, which occurred due to improved function with time and rehabilitation. The final score analysis showed good scores in 53%, fair scores in 41%, and poor scores in 6% of cases based on LEFS and clinical judgment. The results revealed that the majority of patients achieved satisfactory limb function, and there will be improvement beyond 6 months with continued physiotherapy.

High-energy lower-extremity trauma poses a complex challenge for management due to the concomitant involvement of bone and soft tissue injury. At our tertiary care hospital, the initial management of such trauma follows the protocol of Advanced Trauma Life Support (ATLS), including resuscitation, systemic evaluation, and detailed assessment of limb viability. The important factors influencing treatment outcomes include existing comorbidities, such as diabetes mellitus, cardiovascular disease, and peripheral arterial disease. Gustilo-Anderson classification was used for open fractures, with type IIIB being most frequent in (68%) of cases.  Early orthopedic intervention is critical for fracture stabilization and wound debridement. The results of our study showed that 91% cases were young males predominantly injured in road traffic accidents, consistent with reports of other similar studies [10-14]. Injury severity was assessed using the Mangled Extremity Severity Score (MESS) and it was found that most of the scores were between 4 and 6. However, limb was successfully salvaged in three patients with MESS 8, as supported by the findings of Abdo et al. that MESS alone does not determine limb viability [15]. The site of injury was considered when designing the reconstruction strategy. The common location of the defect was the ankle and foot region in 44% of cases, followed by the upper third of the leg in 21% of cases. These findings are in agreement with those reported by Court-Brown et al. [16, 17]. 

In this study, we found that 21% of cases had tendon injuries and commonly involved tendons were tendochilles (10%), which occurred due to accidental falls. Huttunen et al [18] also reported a similar finding in their study. Surgical debridement was performed in all cases, and infection prevention was based on the culture analysis reports. Soft-tissue reconstruction was performed based on the location of the injury. Split-thickness skin grafts (STSG) were utilized in 11% of the patients; flap coverage only was performed in 78%. Franken et al. [19] have also reported similar findings in their study. Tendons and nerves were repaired in appropriate cases using the technique described by Krackow or modified Kessler methods, followed by structured splinting and physiotherapy protocols. Local flaps were used in 89.7% of the cases, cross-leg flaps in 6%, and free flaps in 2.6%. We used cross-leg flaps when free flap was not feasible because of the complexity of the injury zone [20, 21] Most flaps were fasciocutaneous (82%), followed by muscle (14%) and myocutaneous flaps (4%). Locoregional fasciocutaneous flaps are useful for lower-third leg, ankle, and foot defects. Reverse sural artery (RSA)and reverse peroneal artery (RPA) flaps are used in most cases [10, 22]. Upper third leg defects were managed with gastrocnemius muscle flaps in 53% of cases, and Naik et al. [23] reported similar findings in a similar study. For junctional upper/middle-third defects, both fasciocutaneous and myocutaneous flaps offer good outcomes. Middle-third defects (91.6 %) were treated with fasciocutaneous flaps. Lower-third defects were found to be challenging. They responded well to reverse flow fasciocutaneous flaps such as RSA and RPA. The reconstruction of the foot and ankle required free flaps due to minimal local muscle coverage; however, RSA flaps proved to be highly reliable, as reported in other studies [10, 22]. In this study, we exclusively used fasciocutaneous flaps for foot and ankle defects. The overall results showed that 64% of the flaps were single-staged and 36% required multi-stage surgeries, including delay and division inset. These findings show the importance of planning tailored to the injury and multidisciplinary coordination for successful lower-limb reconstruction.

The current study found that leg and foot injuries are common in young adult males. Effective management of these complex injuries is critical for restoring functional and aesthetic outcomes. Early orthopedic intervention and timely reconstruction with smaller wounds and a broader range of viable options must be performed. Flap reconstruction plays a pivotal role in treating complex lower extremity defects. The current study found that perforator-based fasciocutaneous flaps were highly effective, offering reliable coverage while preserving muscle function and minimizing donor-site morbidity. These flaps are generally easier to prepare and associated with fewer complications. They can be useful when secondary procedures are anticipated, such as bone grafting or tendon reconstruction. Furthermore, the Reverse Sural Artery (RSA) flap has emerged as a dependable option for covering defects in the lower third of the leg, ankle, and foot, which are often unsuitable for local flaps because of the thin overlying skin. The RSA flap does not require microvascular anastomosis, which makes it an efficient choice.  Overall, the expertise of plastic and reconstructive surgeons is critical in restoring the function, mobility, and quality of life of patients with leg and foot injuries.

1. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006 Aug;37(8):691–7.
2. Mock C, Quansah R, Krishnan R, Arreola-Risa C, Rivara F. Strengthening the prevention and care of injuries worldwide. Lancet. 2004 Jun 26;363(9427):2172–9.
3. Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM. Fix and flap: The radical orthopedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br. 2000 Jul;82(7):959–66.
4. Giannoudis PV, Pape HC. Severe musculoskeletal injuries: pathophysiology, diagnosis, and management. Springer Science & Business Media; 2007.
5. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg. 1998 Oct;102(4):599–616.
6. Yaremchuk MJ, Brumback RJ, Manson PN, Burgess AR, Poka A, Weiland AJ. Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstr Surg. 1987 Nov;80(5):1–14.
7. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma. 1984 Aug;24(8):742–6.
8. Johansen K, Daines M, Howey T, Helfet D, Hansen ST. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990 May;30(5):568–72.
9. Wei FC, Mardini S. Free-style free flaps. Plast Reconstr Surg. 2004 Jul;114(1):74–80.
10. Hoyt BW, Wade SM, Harrington CJ, Potter BK, Tintle SM, Souza JM. Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes. Clin Orthop. 2021 Nov 1;479(11):2388–96.
11. Gopinathan NR, Santhanam SS, Saibaba B, Dhillon MS. Epidemiology of lower limb musculoskeletal trauma with associated vascular injuries in a tertiary care institute in India. Indian J Orthop. 2017;51(2):199–204.
12. Mumporeze L, Uwamahoro C, Uwamahoro D, Beeman A, Jensen D, Tang OY, et al. A Comparative Gender Analysis of Injury Characteristics, Treatments and Outcomes among Persons Seeking Emergency Care in Kigali, Rwanda. Trauma Care. 2024 Mar;4(1):1–9.
13. Organization WH. Global status report on road safety: time for action [Internet]. World Health Organization; 2023. Available from: https://www.who.int/teams/social-determinants-of-health/safety-and-mobility/global-status-report-on-road-safety-2023 [Accessed on 30th Jan 2025]
14. Ameratunga S, Hijar M, Norton R. Road-traffic injuries: confronting disparities to address a global-health problem. Lancet Lond Engl. 2006 May 6;367(9521):1533–40.
15. Abdo EM, Farouk N, EIimam SE, Elshinawy WE, Abdelhafez AA, Hamza M, et al. Mangled Extremity Severity Score in the Assessment of Extremity Injuries - Is it Reliable? Vasc Endovascular Surg. 2023 Jul;57(5):445–50.
16. Court-Brown CM, Caesar B. Epidemiology of adult fractures: A review. Injury. 2006 Aug 1;37(8):691–97.
17. Court-Brown CM, Bugler KE, Clement ND, Duckworth AD, McQueen MM. The epidemiology of open fractures in adults. A 15-year review. Injury. 2012 Jun 1;43(6):891–97.
18. Huttunen TT, Kannus P, Rolf C, Felländer-Tsai L, Mattila VM. Acute Achilles Tendon Ruptures: Incidence of Injury and Surgery in Sweden Between 2001 and 2012. Am J Sports Med. 2014 Oct 1;42(10):2419–23.
19. Franken JM, Hupkens P, Spauwen PHM. The treatment of soft-tissue defects of the lower leg after a traumatic open tibial fracture. Eur J Plast Surg. 2010 Jun;33(3):129–33.
20. Mahajan RK, Srinivasan K, Ghildiyal H, Singh M, Jain A, Kapadia T, et al. Review of CrossLeg Flaps in Reconstruction of Posttraumatic Lower Extremity Wounds in a Microsurgical Unit. Indian J Plast Surg. 2019 Jan;52(01):117–24.
21. Manrique O, Bishop S, Ciudad P, Adabi K, Martinez-Jorge J, Moran S, et al. Lower Extremity Limb Salvage with Cross Leg Pedicle Flap, Cross Leg Free Flap, and Cross Leg Vascular Cable Bridge Flap. J Reconstr Microsurg. 2018 Sep;34(07):522–29.
22. Johnson L, Liette MD, Green C, Rodriguez P, Masadeh S. The Reverse Sural Artery Flap. Clin Podiatr Med Surg. 2020 Oct;37(4):699–726.
23. Naik MM, Harish GP, Nagaprasad N, Kantilal A. Clinical study of upper one-third leg defects. Int J Health Sci. 2022 Mar 27;6(S2):803–14.