Reconstructive Options for Complex Lower Limb Defects in Trauma Patients: A Randomised Controlled Trial at Teaching Hospitals in South West Nigeria

Complex lower limb soft tissue defects from trauma present major reconstructive challenges in Nigeria, where free flap microsurgery capacity is limited and conventional approaches such as split-thickness skin grafts often yield suboptimal functional outcomes. This randomised controlled trial compares outcomes of split-thickness skin grafting versus pedicled flap reconstruction for complex lower limb traumatic defects at three teaching hospitals in Lagos, Ogun, and Oyo states, South West Nigeria, from 2019 to 2024. One hundred and twenty patients with lower limb defects exceeding 50 cm2 involving exposed bone or tendon were randomised 1:1 to split-thickness skin grafting or pedicled flap reconstruction. Primary outcomes were graft or flap success rate, time to full wound coverage, and functional limb outcomes at 12 months assessed using the Lower Extremity Functional Scale (LEFS). Secondary outcomes included donor site morbidity and patient-reported cosmetic satisfaction. Pedicled flap reconstruction achieved significantly higher rates of durable wound coverage (88% versus 61%) and superior LEFS scores at 12 months (mean 62 versus 48, p<0.001). Donor site complications were higher in the flap group. Limb salvage rates were equivalent between groups. The trial provides high-quality evidence supporting expanded use of pedicled flap reconstruction and recommends subspecialty plastic surgery training programs for teaching hospitals in South West Nigeria. Keywords: lower limb reconstruction, pedicled flap, skin graft, trauma, randomised controlled trial