Heel pad microsurgically reconstructed by 
Latissimus Dorsi Flap

 
 

The significant step that led to increased success rate in limb salvage was the introduction of the concept of radical debridement( cleaning up of the wounds) before skeletal fixation.  Conventionally debridement was done to remove the contaminants and remove what was obviously dead.  Doubtful tissues were left behind for the ‘second look’ operation that was carried 24 to 48 hours later.  It was just this available option, which made surgeons conservative in their approach in removing tissues that were doubtfully viable or hypo vascular.  Undoubtedly this approach frequently led to infection, delay in coverage of the wound and increased morbidity2.  Further surgeons were reluctant to be radical in their approach to debridement since it made the defect larger and the available techniques of soft tissue coverage were found wanting.

The advent of microsurgical free flaps , where in  a block of tissue is taken from a part of the body is taken and attached  to where it is needed  by joining its blood supply by microsurgical techniques,  changed the scenario.  A flap like latissimus dorsi (muscle in the back) can cover even the whole length of the tibia.  Large defects could be covered as easily as small ones and basically surgery involved the same effort. Micro surgeons started performing flaps to cover the wounds early and sometimes in emergency situations.  In such instances there was no opportunity for the ‘second look’ operation and debridement was done in a radical fashion.  The surgical philosophy shifted from ‘removing what looked non-viable’ to ‘retaining only what was surely viable’. It was that shift in philosophy, which really reduced the infection rates and increased limb salvage.

 Care of the wound in the already compromised individual like an uncontrolled diabetic or hypertensive or a person with heart disease improved.  These individuals needed early debridement, since they tolerated complications like hemorrhage or infection much worse than a normal individual.  Wounds in medically compromised persons have to be debrided as early as a normal individual.  Delay not only increases morbidity, but also in some situations may even lead to mortality. Advances in anaesthesia and monitoring techniques have  made this possible. 

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