The reconstructive ladder guides selection of wound closure technique from simplest to most complex. A patient has a complex lower leg wound with exposed bone following road traffic injury. Split-skin grafting has failed. What is the MOST appropriate next step on the reconstructive ladder?

• A Repeat split-skin grafting with a thicker graft
• B Local random-pattern flap
• C Negative pressure wound therapy followed by direct closure
• D Free flap microvascular transfer ✓

Explanation

Exposed bone cannot be covered by split-skin graft (which requires a vascularised wound bed) and local flaps around the distal lower leg are limited by poor vascularity (watershed zone). When simpler options (primary closure, skin grafting, local flap) have failed or are unavailable due to tissue loss and exposed avascular structures, free flap microvascular transfer (e.g., free anterolateral thigh flap, gracilis free flap) is the appropriate reconstructive step. Negative pressure wound therapy can be used as a bridge but is not definitive for exposed bone.

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.