Orthoplastic soft tissue management in lower limb open tibial fractures based on the angiosome concept: a narrative review

The purpose of this article is to introduce the angiosome concept in the lower legs and its consideration in severe soft tissue injuries in open tibial fractures. The main aim is to focus on the vascularity and perforators in the crura and to emphasise step-by-step time management and proper debridement for securing the maximal viability of the soft tissue before the reconstruction phase. So far, many publications have presented optimal traumatological protocols and timing in lower leg injuries and many reviews have compared fracture stabilisation and flap reconstruction options; however, no consensus exists. Radical and immediate debridement is crucial for minimising infection complications, revision surgeries and total healthcare costs, early definitive reconstruction, limb salvage success, decreased hospitalisation stay and better long-term quality-of-life outcome for the patients. The fundamental orthoplastic approach has been an indisputably accepted strategy since its introduction in the 1990s by Levin. Unfortunately, not all centres are staffed with a plastic surgeon 24/7. Furthermore, transportation to the tertiary specialist centre is often delayed; hence, we believe that a correct primary soft tissue and antibiotics administration protocol can be provided in all medical centres by orthopaedists. So, the basic knowledge of the principles of lower leg vascularity is, therefore, essential. In the difficult cases of the Anderson-Gustilo IIIC fractures, we provide some of the latest recommendations for soft tissue viability verification and blood perfusion improvement, when considering limb salvage versus amputation. This narrative review was developed in accordance with PRISMA 2020 recommendations for transparency in study selection and reporting.