Muscle versus Fasciocutaneous Free Flaps in Lower Extremity Traumatic Reconstruction: A Multicenter Outcomes Analysis

Efficacy of superficial femoral artery as a recipient in free flap reconstruction around the knee: Four case reports and a literature review

Purpose

Reconstructing soft tissue defects around the knee with free flaps presents challenges in recipient vessel selection. Although the superficial femoral artery (SFA) offers exposure ease and anatomical stability, concerns arise regarding its distance from the defect site, difficulty in performing anastomosis and potential peripheral ischaemia. This study aimed to reassess the suitability of SFA as a recipient vessel for knee reconstructions by examining our cases and those from previous reports.

Methods

We reviewed four cases of knee soft tissue defects reconstructed with free flaps using the SFA, detailing surgical techniques and outcomes. Additionally, a comprehensive literature search was conducted for articles on using SFA as a recipient vessel for knee free flaps, using PubMed, Web of Science and EBSCOhost databases.

Results

In all four cases, latissimus dorsi (LD) flaps were used, with end-to-side anastomosis performed using a large slit-shaped arteriotomy. All flaps demonstrated successful survival without complications. Our analysis included 85 cases, comprising four of our cases and 81 cases from 16 articles. Sarcoma resection was the most common aetiology, followed by total knee prosthesis-related defects, trauma and osteomyelitis. Complete flap necrosis occurred in 5% of cases. The LD flap was the predominant choice, alongside other long-pedicle flaps. The SFA provided coverage for all knee areas except the distal lateral patellar region.

Conclusion

Despite the limited evidence, the SFA appears to be a reliable recipient vessel for knee soft tissue reconstruction. Comprehensive understanding of the characteristics of the SFA and flaps used enhances the safety and efficacy of soft tissue defect reconstruction around the knee.

Comparison of Complication Risks Following Lower Extremity Free Flap Reconstruction Based on Seven Pre-Operative Indications: Analysis of the ACS-NSQIP Database

Background: Free tissue transfer is a valuable surgical option for the reconstruction of a myriad of complex lower extremity defects. Currently, there is a paucity of data that examines the risks of complications for each of these unique indications. Methods: Patients undergoing lower extremity free flap reconstruction from the ACS-NSQIP 2011-2019 database were stratified into groups based on the etiology and indication for reconstruction. Rates of major, surgical wound, and medical complications were compared over the first post-operative month. Multivariable logistic regression was used to identify complication predictors. Results: 425 lower extremity free flaps were analyzed. The most common indications for lower extremity free flap reconstruction were wound-related (29%), malignancy (21%), and trauma (17%). Seventeen percent of free flaps had a major post-operative complication, 9% had a surgical wound complication, and 16% had a medical complication. There were no significant differences in major complications between the indications. However, the independent risk factors for major complications varied widely. Those with an indication of malignancy and those who received a musculocutaneous free flap were significantly more likely to have a surgical wound complication compared to the remaining cohort (p < 0.05). Those requiring free flap reconstruction for orthopedic hardware related concerns as well as those with wound related indications were significantly more likely to have a post-operative medical complication (p < 0.05). Conclusion: Understanding the unique risk profiles between the various indications and populations of patients undergoing lower extremity free flap reconstruction is critical for providing accurate risk estimations and optimizing post-operative outcomes and monitoring. Keywords microsurgery, lower extremity free flap, free flap reconstruction.

The Continued Impact of Godina's Principles: Outcomes of Flap Coverage as a Function of Time After Definitive Fixation of Open Lower Extremity Fractures

BACKGROUND

 Early soft tissue coverage of open lower extremity fractures within 72 hours of injury leads to improved outcomes. Little is known about outcomes when definitive fixation is completed first. The purpose of this study is to quantify postoperative outcomes when soft tissue reconstruction is delayed until after definitive open reduction and internal fixation (ORIF) is completed.

METHODS

 An insurance claims database was queried for all patients with open lower extremity fractures between 2010 and 2020 who underwent free or axial flap reconstruction after ORIF. This cohort was stratified into three groups: reconstruction performed 0 to 3, 3 to 7, and 7+ days after ORIF. The primary outcome was 90-day complication and reoperation rates. Bivariate and multivariable regression of all-cause complications and reoperations was evaluated for time to flap as a risk factor.

RESULTS

 A total of 863 patients with open lower extremity fractures underwent ORIF prior to flap soft tissue reconstruction. In total, 145 (16.8%), 162 (18.8%), and 556 (64.4%) patients underwent soft tissue reconstruction 0 to 3 days, 4 to 7 days, and 7+ days after ORIF, respectively. The 90-day complication rate of surgical site infections ( SSI; 16.6%, 16,7%, 28.8%; p = 0.001) and acute osteomyelitis (5.5%, 6.2%, 27.7%; p < 0.001) increased with delayed soft tissue reconstruction. Irrigation and debridement rates were directly related to time from ORIF to flap (33.8%, 51.9%, 61.9%; p < 0.001). Hardware removal rates were significantly higher with delayed treatment (10.3%, 9.3%, 39.3%; p < 0.001). The 0 to 3 day (odds ratio [OR] = 0.22; 95% confidence interval [CI]: 0.15, 0.32) and 4 to 7 day (OR = 0.26; 95% CI: 0.17, 0.40) groups showed protective factors against all-cause complications after bivariate and multivariate regression.

CONCLUSION

 Early soft tissue reconstruction of open lower extremity fractures performed within 7 days of ORIF reduces complication rates and reduces the variability of complication rates including SSIs, acute osteomyelitis, and hardware failure.

A single-center retrospective comparison of muscle versus cutaneous free flaps for posterior elbow defect reconstruction

INTRODUCTION

Comparative data on free flap outcomes for elbow defect reconstruction are still lacking. This study aimed to compare complication rates of free muscle flaps (MFs) versus cutaneous flaps (CFs) for posterior elbow reconstruction.

METHODS

In a single-center retrospective analysis, patients who underwent posterior elbow reconstruction with free MFs and CFs from 2000 to 2021 were analyzed. Retrospective chart review included patient demographics, operative details, and post-operative complications. Outcomes of interest that were compared included microvascular complications, partial or total flap necroses, wound dehiscence, hematoma or flap infection, and donor-site complications.

RESULTS

Sixty-six free flaps (CFs: n = 42; MFs: n = 24) were included, with a trend over time toward using CFs (64%). MFs were used for larger defects (CF: 175 ± 82 vs. MF: 212 ± 146 cm2; p = 0.13). Outcome analysis revealed an equal distribution of microvascular complications (10% vs. 13%; p = 0.7), partial flap necrosis (7% vs. 8%; p > 0.9), wound dehiscence (7% vs. 4%; p > 0.9), evacuation of hematoma (10% vs. 4%; p = 0.7), and infection (0% vs. 4%; p = 0.4). Total flap necrosis requiring additional flap surgery was necessary in one CF (2%) and in no MF (0%) (p > 0.9).

CONCLUSION

Surgical outcomes, flap necrosis rates, and microsurgical complications did not differ between CFs and MFs. Both flap types are safe and effective options. The free anterolateral thigh and latissimus dorsi flaps represent indispensable workhorses for the reconstruction of extensive elbow defects.

Elevating Lower Extremity Reconstruction: An Algorithmic Approach to Free Flap Re-elevation

BACKGROUND

 Free flap (FF) reconstruction is frequently required for soft-tissue coverage after significant orthopaedic trauma of the lower extremity (LE). While usually the final step in limb salvage, re-elevation of the previously inset FF may be necessary to restore a functional limb. In this study, we present our algorithm for LE FF re-elevation and review our experience to identify factors associated with successful limb salvage and return to ambulation.

METHODS

 A retrospective, single-institution review was conducted of adult patients with LE wounds who required FF reconstruction from 2016 to 2021. From this cohort, patients who required re-elevation of their LE FF were identified. Successful FF re-elevation was defined by limb salvage and return to ambulation.

RESULTS

 During the study period, 412 patients with LE wounds required flap reconstruction. Of these patients, 205 (49.8%) underwent free tissue transfer, and 39 (9.5%) met our inclusion criteria. From this cohort, 34 had successful FF re-elevation, while 1 was non-weight bearing and 4 were elected for amputation due to chronic complications unrelated to their FF. Univariate analysis revealed the total number of FF re-elevations (p < 0.001), the frequency of re-elevation indicated for orthopaedic access (p < 0.001), and infections necessitating return to the operating room (p = 0.001) were each negatively associated with limb salvage and return to ambulation.

CONCLUSION

 The described algorithm highlights the preoperative planning and meticulous flap preservation necessary for the successful coverage of critical structures following FF re-elevation. Our data demonstrate that LE FFs can be safely re-elevated for hardware access or flap revision. In these complex cases of LE trauma, management by a multidisciplinary team is essential for successful limb salvage.

[Versatility of the free serratus flap in microsurgical reconstruction: Evaluation of a series of 100 cases]

In the era of microsurgery and with the more recent advent of flaps, it is interesting to highlight the value of the serratus muscle flap in microsurgical reconstruction. A total of 100 flaps were performed in our department between 2001 and 2022, with 85% of cases in a post-traumatic context (acute or septic). There were 83 male and 17 female patients. The mean age was 40.5years, with extremes ranging from 11 to 76years. The origin of the tissue loss was as follows: acute trauma 73 cases; chronic/septic wound 19 cases; purpura fulminans 2 cases; tumour 6 cases. The size of the loss of substance varied from 15 to 200cm2, with an average of 90cm2. Four different types of flap were used: muscle flap ( 78 cases), musculocutaneous flap (5 cases), costo-osteomuscular flap (13 cases), costo-osteomusculocutaneous flap (4 cases). In all cases where the rib was taken, it was the 8th rib and sometimes the 7th. These vascularised rib flaps were performed for bone loss ranging from 5 to 12cm. In our series, there was a 6% complication rate at the recipient site (3 haematomas, 2 pneumothoraxes and one case of chronic pain). The overall success rate in our series was 82.8%, with only 20% of general complications and 6% of donor site complications, with very little aesthetic scarring or functional damage to the donor site. This flap, which is rarely used, is particularly interesting for limb reconstruction, as all its parameters can be adjusted according to the defect, and the length of its pedicle means that it can also be used to perform anastomoses at a distance from the traumatised area. It also offers the possibility of reconstructing a bony defect with a composite costal harvest.

Application of antibiotic bone cement combined with lobulated perforator flap based on descending branch of the lateral circumflex femoral artery in treatment of infected traumatic tissue defects of foot

OBJECTIVE

To evaluate the clinical effectiveness of antibiotic bone cement combined with the lobulated perforator flap based on the descending branch of the lateral circumflex femoral artery (d-LCFA) in the treatment of infected traumatic tissue defects in the foot, in accordance with the Enhanced Recovery after Surgery (ERAS) concept.

METHODS

From December 2019 to November 2022, 10 patients with infected traumatic tissue defects of the foot were treated with antibiotic bone cement combined with the d-LCFA lobulated perforator flap. The cohort comprised 6 males and 4 females, aged 21 to 67 years. Initial infection control was achieved through debridement and coverage with antibiotic bone cement, requiring one debridement in nine cases and two debridements in one case. Following infection control, the tissue defects were reconstructed utilizing the d-LCFA lobulated perforator flap, with the donor site closed primarily. The flap area ranged from 12 cm×6 cm to 31 cm×7 cm. Postoperative follow-up included evaluation of flap survival, donor site healing, and ambulatory function of the foot.

RESULTS

The follow-up period ranged from 7 to 24 months, averaging 14 months. Infection control was achieved successfully in all cases. The flaps exhibited excellent survival rates and the donor site healed by first intention. Based on the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scale, pain and function were evaluated as excellent in 3 cases, good in 5 cases, and moderate in 2 cases.

CONCLUSION

The application of antibiotic bone cement combined with the d-LCFA lobulated perforator flap is an effective treatment for infected traumatic tissue defects of the foot with the advantages of simplicity, high repeatability, and precise curative effects. The application of the d-LCFA lobulated perforator flap in wound repair causes minimal damage to the donor site, shortens hospital stays, lowers medical expenses, and accelerates patient rehabilitation, aligning with the ERAS concept. Therefore, it is a practice worth promoting in clinical use.

Outcomes of Muscle versus Fasciocutaneous Free Flap Reconstruction in Acute Burns: A Systematic Review and Meta-analysis

Background

Free flap reconstruction in acute burns is high risk but often required for limb salvage and coverage of vital structures. Prior studies have shown a flap loss rate up to 44%. This study aimed to compare the complications associated with muscle and fasciocutaneous free flaps in acute burn reconstruction.

Methods

A systematic review and meta-analysis was conducted according to PRISMA guidelines and registered on the PROSPERO database (CDR42023471088). The databases accessed were Embase, PubMed, Web of Science, and Cochrane Library. The primary outcome was free flap failure rate based on flap type. Secondary outcomes included venous congestion, arterial thrombosis, amputation, and need for reintervention.

Results

Twelve studies with 181 free flaps were included: 87 muscle flaps and 94 fasciocutaneous flaps. Muscle flaps had a higher risk ratio (RR) for total flap loss [RR: 2.32, 95% confidence interval (CI): 1.01-5.32, P = 0.04], arterial thrombosis (RR: 3.13, 95% CI: 1.17-8.42, P = 0.02), and amputations (RR: 8.89, 95% CI: 1.27-70.13, P = 0.03) compared with fasciocutaneous flaps. No significant differences were found in venous thrombosis (RR: 1.33, 95% CI: 0.37-4.78, P = 0.65) or need for reinterventions (RR: 1.34, 95% CI: 0.77-2.32, P = 0.29).

Conclusions

Muscle flaps in burn injuries are associated with higher risks of flap failure, arterial thrombosis, and amputations. Fasciocutaneous free flaps in acute burns seem to be safer with better outcomes, though further research is needed to confirm these findings.

[Acute and post-acute soft tissue reconstruction]

BACKGROUND

The precise analysis of the injured structures requiring reconstruction in complex wound defects is a prerequisite for successful restoration.

OBJECTIVE

The fundamental reconstructive strategies for soft tissue defects of the extremities including injuries to vessels, nerves and burn wounds in the context of the acute and post-acute trauma phases are presented.

MATERIAL AND METHODS

The different phases of soft tissue reconstruction are described. Recommendations for action with respect to the reconstruction of the functional structures are described. Two clinical case examples illustrate the approach.

RESULTS

The acute reconstruction phase is defined as the period 0-72 h after the traumatic event and includes surgical debridement, primary reconstruction of nerves and vessels using interpositional grafts if necessary and temporary soft tissue reconstruction. Combined thermomechanical trauma requires early debridement combined with internal fixation of open fractures. In the post-acute reconstruction phase, which is generally defined as a period of up to 6 weeks after the traumatic event, definitive soft tissue reconstruction is performed. In the case of long reinnervation distances, nerve transfer or motor replacement plastic surgery is performed in the post-acute phase.

CONCLUSION

The reconstruction of soft tissue after trauma necessitates a stage-dependent approach. In the acute phase procedures aim at the immediate preservation of the limb. In the post-acute phase, definitive soft tissue reconstruction is performed to enable maximum functional preservation. Combined thermomechanical injuries require early surgical treatment in order to prevent infections.

Rate of Free Flap Failure and Return to the Operating Room in Lower Limb Reconstruction: A Systematic Review

Background: Soft tissue defects of the lower limbs pose significant challenges in reconstructive surgery, accounting for approximately 10% of all reconstructive free flaps performed. These reconstructions often encounter higher complication rates due to various factors such as inflammation, infection, impaired blood flow, and nerve injuries. Methods: A systematic review was conducted following PRISMA guidelines, reviewing literature from 2017 to 2024. Eligible studies included those on free flap reconstruction of lower limb defects in living human subjects, with more than three cases and reported rates of flap failure and return to the operating room. Systematic reviews and metanalysis were excluded. Results: A total of 17 studies comprising 5061 patients and 5133 free flap reconstructions were included. The most common defects were in the lower leg (52.19%) due to trauma (79.40%). The total flap necrosis rate was 7.78%, the partial necrosis rate was 9.15%, and the rate of return to the operating room for suspected vascular compromise was 13.79%. Discussion: Lower limb reconstruction presents challenges due to diverse etiologies and variable tissue requirements. Factors such as recipient vessel availability, flap selection, and multidisciplinary approaches influence outcomes. Muscle and fasciocutaneous flaps remain common choices, each with advantages and limitations. This systematic review underscores the importance of individualized treatment planning. Conclusions: Microsurgical reconstruction of lower limb defects demonstrates safety and reliability, with overall favorable outcomes. Flap selection should be tailored to specific patient needs and defect characteristics, emphasizing meticulous surgical techniques and multidisciplinary collaboration. This systematic review provides valuable insights into current standards and encourages adherence to best practices in lower limb reconstruction.

Patient-reported esthetic outcomes following lower extremity free flap reconstruction: A cross-sectional multicenter study

INTRODUCTION

The goal of lower-extremity reconstructions is primarily to salvage the leg; however, esthetic outcomes are also important. This study aimed to assess the impact of a lower extremity free tissue transfer regarding social functioning, patient-reported esthetic outcomes, and possible differences between fasciocutaneous vs. muscle flaps.

MATERIAL AND METHODS

For this cross-sectional multicenter study, patients operated between 2003 and 2021, with a minimum follow-up of 12 months, were identified. Outcomes were obtained from 89 patients. Patient-reported outcomes were assessed using a questionnaire containing 5-point Likert scale questions grouped in three groups: aspect of the reconstructed leg, the aspect of the donor site, and the negative impact on social functioning. Physical functioning and mental health were assessed with the Short-Form-36.

RESULTS

The overall score for negative impact on social functioning was 22.2. This was 46.7 for the esthetic satisfaction of the reconstructed leg and 57.1 for the donor site. No significant differences were seen between patients who underwent a reconstruction with a fasciocutaneous flap compared to a muscle flap. Secondary surgical procedures for improving the esthetic aspect were performed in 12% of the patients in the fasciocutaneous group and 0% in the muscle group.

CONCLUSION

Our results show that the most optimal esthetic outcome is not defined by the type of flap. We found a strong correlation between physical functioning and the negative impact on social functioning that a reconstructed lower extremity may have. The result of this study can be taken into consideration during the shared decision-making process of choosing the most optimal reconstruction.

Soft tissue coverage for IIIB fractures: from timing to coverage options

Open tibia fractures are the most common open long bone injury. Most of these injuries involve a high-energy mechanism. Many standards for management have been created to provide guidance and a baseline for quality. There are several factors that must be considered when determining the timing of coverage for an open fracture with soft tissue compromise. Understanding the available options for soft tissue coverage, including local/rotational flaps and free tissue transfer, will allow for a tailored approach based on the personality of the injury. The aim of this review was to characterize the critical window of treatment based on the current literature and to provide a review of the available soft tissue coverage options.

Implications of Single-Vessel Runoff on Long-Term Outcomes of Free Tissue Transfer for Lower Extremity Reconstruction

BACKGROUND

 Patients with complex lower extremity (LE) wounds and single-vessel LE runoff (1-VRO) are often considered for amputation. While more challenging, free tissue transfer (FTT) is a means for limb salvage. This study aims to demonstrate the feasibility of limb salvage with FTT in patients with 1-VRO.

METHODS

 Patients undergoing FTT by a single surgeon between 2011 and 2021 were retrospectively reviewed. Data collected included demographics, wound characteristics, vascular status, and operative details. Patients were divided into cohorts based on 1- versus 3-VRO of tibial vessel inflow. Outcomes of interest included postoperative complications such as flap necrosis, flap success, limb salvage, and ambulatory status.

RESULTS

 A total of 188 patients underwent FTT to LE, with 25 patients (13.3%) having 1-VRO. Patients with 1-VRO had a comparable prevalence of diabetes (56.0% vs. 50.0%, p = 0.569) and end-stage renal disease (8.0% vs. 3.7%, p = 0.319). Osteomyelitis was more common in the 1-VRO group (80.0% vs. 60.1%, p = 0.056). FTT donor sites and flap composition were similar between cohorts. At mean follow-up of 21.2 months (interquartile range 24.5:5.6, 30.1 months), limb salvage rates were similar between cohorts (84.0% vs. 91.4%, p = 0.241), with no significant differences in ambulatory status or mortality. Higher complication rates occurred in the 1-VRO cohort (48.0% vs. 21.5%, p = 0.004), of which partial flap necrosis was more prevalent in the 1-VRO group (8.0% vs. 1.2%, p = 0.029). There was no difference in flap success rates between groups (p = 0.805). More postflap angiograms were performed in the 1-VRO group (32.0% vs. 9.2%, p = 0.001), but there was no difference in need for repeat percutaneous endovascular intervention between groups.

CONCLUSION

 This study demonstrates that FTT reconstruction to the LE remains a reliable reconstruction option for limb salvage in patients with single-vessel supply to the LE. Reliance on advanced perioperative management and patient optimization is effective at reducing negative outcomes.

Does Side Matter? The Impact of Free Flap Harvest Laterality on Ambulatory Function in Lower Extremity Traumatic Reconstruction

BACKGROUND

 Free flaps are essential for limb salvage in patients with lower extremity (LE) trauma; however, significant donor-site morbidity could impact functional outcomes. This study compares postoperative ambulatory function between contralateral and ipsilateral free flap harvest in LE traumatic reconstruction.

METHODS

 A retrospective review was performed on patients who underwent LE reconstruction at a level 1 trauma center from 2009 to 2022. Flap characteristics, injury history, and ambulatory function were collected. Flap harvest laterality was determined in relation to the injured leg. The flaps were categorized as either fasciocutaneous or those that included a muscle component (muscle/myocutaneous). Chi-squared and Mann-Whitney tests were used for statistical analysis.

RESULTS

 Upon review, 173 LE free flaps were performed, of which 70 (65.4%) were harvested from the ipsilateral leg and 37 (34.6%) were from the contralateral leg. Among all LE free flaps, the limb salvage rate was 97.2%, and the flap survival rate was 94.4%. Full ambulation was achieved in 37 (52.9%) patients in the ipsilateral cohort and 18 (48.6%) in the contralateral cohort (p = 0.679). The average time to full ambulation did not vary between these cohorts (p = 0.071). However, upon subanalysis of the 61 muscle/myocutaneous flaps, the ipsilateral cohort had prolonged time to full ambulation (6.4 months, interquartile range [IQR]: 4.8-13.5) compared with the contralateral one (2.3 months, IQR: 2.3 [1.0-3.9]) p = 0.007. There was no significant difference in time to full ambulation between flap harvest laterality cohorts among the fasciocutaneous flaps (p = 0.733).

CONCLUSION

 Among free flaps harvested from the ipsilateral leg, fasciocutaneous flaps were associated with faster recovery to full ambulation relative to muscle/myocutaneous flaps. Since harvesting muscle or myocutaneous flaps from the ipsilateral leg may be associated with a slower recovery of ambulation, surgeons may consider harvesting from a donor site on the contralateral leg if reconstruction requires a muscle component.

Muscle versus Fascia Free Tissue Transfer for Treatment of Chronic Osteomyelitis in the Comorbid Population

BACKGROUND

 In patients with chronic lower extremity (LE) wounds, chronic osteomyelitis confers additional complexity to achieving adequate treatment. Previous reviews demonstrate increased rates of osteomyelitis recurrence in patients who receive muscle flaps compared with fasciocutaneous flaps for LE limb salvage; however, these studies were not limited to atraumatic populations who receive exclusively free flaps. Thus, this study compared rates of recurrence in chronic osteomyelitis patients undergoing LE reconstruction with fasciocutaneous versus muscle free flaps.

METHODS

 Patients undergoing free tissue transfer (FTT) between July 2011 and July 2021 were retrospectively reviewed. Patients were stratified into fasciocutaneous and muscle free flap groups. Primary outcomes included osteomyelitis recurrence, flap complications, limb salvage, and ambulatory status.

RESULTS

 Forty-eight patients with pathologic diagnosis of chronic osteomyelitis of the wound bed were identified, of which 58.3% received fasciocutaneous (n = 28) and 41.7% received muscle flaps (n = 20). The most common comorbidities included diabetes mellitus (n = 29, 60.4%), peripheral neuropathy (n = 27, 56.3%) and peripheral vascular disease (n = 24, 50.0%). Methicillin-resistant or methicillin -sensitive Staphylococcus aureus were the most common pathogen in 18.7% (n = 9) of procedures. The majority of patients underwent a median of three debridements followed by negative pressure wound therapy prior to receiving FTT. At a median follow-up of 16.6 months, the limb salvage and ambulatory rates were 79.2 (n = 38) and 83.3% (n = 40), respectively. The overall rate of microsurgical flap success was 93.8% (n = 45). Osteomyelitis recurred in 25% of patients (n = 12) at a median duration of 4.0 months. There were no significant differences in rates of osteomyelitis recurrence, flap complications, limb salvage, ambulation, and mortality. On multivariate analysis, flap composition remained a nonsignificant predictor of osteomyelitis recurrence (odds ratio: 0.975, p = 0.973).

CONCLUSION

 This study demonstrates that flap composition may not influence recurrence of osteomyelitis following free flap reconstruction of chronic LE wounds, suggesting that optimal flap selection should be based on wound characteristics and patient goals.

Sensory and pain outcomes of neurotized skin-grafted free gracilis muscle flaps for lower extremity reconstruction

BACKGROUND

Skin-grafted free gracilis muscle flaps are commonly used for lower extremity reconstruction. However, the loss of sensory function may lead to increased patient morbidity. This study prospectively analyzed the sensory and neuropathic pain outcomes of neurotized skin-grafted free gracilis muscle flaps used for the reconstruction of lower extremity defects.

METHODS

Patients undergoing lower extremity reconstructions between 2020 and 2022 with neurotized skin-grafted free gracilis muscle flaps were prospectively enrolled. Sensation was assessed at 3, 6 and 12 months postoperatively using monofilaments, two-point discrimination, a vibration device, and cold and warm metal rods. Sensations were tested in the center and periphery of the flaps, as well as in the surrounding skin. The contralateral side served as the control. Patients completed the McGill pain questionnaire to evaluate patient-reported neuropathic pain.

RESULTS

Ten patients were included. At 12 months postoperatively, monofilament values improved by 44.5% compared to that of the control site, two-point discrimination, cold detection, warmth detection, and vibration detection improved by 36.2%, 48%, 50%, and 88.2%, respectively, at the reconstructed site compared to those at the control site. All sensory tests were significantly better than 3 and 6 months values (p < 0.05), but remained significantly poorer than the control site (p < 0.05). Sensation in the central flap areas were similar to peripheral flap areas throughout the follow-up period (p > 0.05). The surrounding skin reached values similar to the control site at 12 months (p > 0.05). Moreover, 50% of patients reported neuropathic pain at 3 months postoperatively, 40% at 6 months, and 0% at 12 months (p < 0.05).

CONCLUSION

Mechanical detection, vibration detection, temperature detection, and two-point discrimination significantly improved over time but without reaching normal sensory function at 12 months postoperatively. Neuropathic pain resolved at 12 months.

[Current role of the latissimus dorsi flap in traumatology: Analysis of the activity of a plastic surgery department in a military hospital]

Reconstructive surgery's workhorse, the latissimus dorsi flap is increasingly abandoned in favour of fasciocutaneous flaps. The purpose of this study was to analyse the methods used to perform this flap and the evolution of its indications in order to define its current place in traumatology. Forty-four cases were recorded retrospectively from January 2000 to December 2020 at HIA Percy, including 37 cases of free flaps, mainly performed for reconstruction of extensive loss of substance with bone and/or joint exposure. It was also performed in 10.8% of cases for salvage after failure of an alternative reconstruction solution. This analysis confirms the value of the latissimus dorsi flap in cases of significant substance loss in the lower limb, but also in burn patients for functional rehabilitation or to allow early rehabilitation.

Utilizing the Subunit Concept to Achieve Better Outcomes in Lower Limb Reconstruction: A Clinical Experience in an Asian Population

Background

The goals of reconstruction have progressed from filling a defect to enhancing function and aesthetic appearance. We aimed to achieve better aesthetic and functional outcomes in terms of shoe fitting and mobility. This is accomplished via a classification of the subunits and aesthetic considerations of the lower limb.

Methods

Between April 2017 and December 2021, 66 cases of lower extremity free fasciocutaneous flap reconstruction cases were included in this retrospective study. Data parameters include age, sex, comorbidities, etiology of lower limb wounds, choice of free flap reconstruction, recipient arterial vessels, complications of flap reconstruction, and need for secondary debulking procedures. Physiotherapy records were also examined to determine the time to independent ambulation.

Results

In total, 66 subjects were identified. The mean age was 48.6. An estimated 74.2% (n = 49) were men, 50% (n = 33) had diabetes, and 16.6% (n = 11) had peripheral vascular disease. Of the total wounds, 65.1% (n = 43) were caused by infection, whereas the remaining 34.9% (n = 23) were due to trauma. Of the cases, 72.7% (n = 48) had free anterolateral thigh flap reconstruction, 25.8% (n = 17) were reconstructed with superficial circumflex iliac artery perforator flaps, and 1.5% (n = 1) was reconstructed with medial sural artery perforator flaps. Cases that required secondary debulking procedures comprised 7.6% (n = 5).

Conclusions

Free fasciocutaneous flaps are useful in lower extremity reconstruction. Based on the subunit principle and aesthetic considerations for lower limb reconstruction, it can aid in optimizing functional rehabilitation and decreasing secondary procedures.

The Role of the Fascia-Only Anterolateral Thigh Flap in Extremity Reconstruction: The Fascia-Only Anterolateral Thigh Flap

BACKGROUND

Free flap selection in extremity reconstruction can be challenging. The ideal flap has to be thin and pliable to achieve optimal contour and function. We explore the role of the fascia-only anterolateral thigh (fALT) flap in extremity reconstruction.

METHODS

We conducted a retrospective review of our experience using fALT-free flap for extremity reconstruction over a 2-year period. Patient demographics, mechanism of injury, flap characteristics, complications- and follow-up were recorded. Descriptive statistics were calculated.

RESULTS

Twelve patients were included. The median (interquartile range [IQR]) age was 34 (28-52) years. One fALT flap was used for upper extremity reconstruction, while 11 flaps were used for lower extremity reconstruction (4 for lower third of the leg, 4 for dorsum of foot, and 3 for heel). The median (IQR) flap surface area was 90 (63-120) cm2 and time from injury to reconstruction was 10 (6-16) days. The postoperative course was uneventful for all flaps except for 1 flap failure and 1 delayed healing. The median (IQR) follow-up was 2 (1-4) months. In all cases, durable soft tissue reconstruction was achieved with no need for revisions.

CONCLUSIONS

The fALT-free flap can be successfully used in extremity reconstruction. The ALT fascia has robust perfusion that allows for the harvest of a large flap that can be surfaced with a split thickness skin graft. Its thin pliable tissue provides excellent contour for the hand, distal leg, and foot that does not require future thinning, optimizing the cosmetic and functional result.

Pedicled Peroneus Brevis Muscle Flaps as an Alternative to Fasciocutaneous Rotational Flaps for Lower-Extremity Soft Tissue Defects

OBJECTIVES

To report our experience using a peroneus brevis flap (PBF) for soft tissue defects of the distal third of the tibia, ankle, and hindfoot in resource-challenged environments.

METHODS

DESIGN

Retrospective review.

SETTING

Rural outpatient surgical facility in Honduras.

PATIENT SELECTION CRITERIA

Patients who sustained tibia, ankle, or hindfoot fractures or traumatic degloving, with critical-sized soft tissue defects treated with either a proximally based or distally based pedicled PBF to achieve coverage of the middle and distal third of the leg, ankle, and/or hindfoot.

OUTCOME MEASURES AND COMPARISONS

Flap healing, complications, and reoperations.

RESULTS

Twenty-three patients, 4 with proximally based and 19 with distally based PBF flaps were included. The mean patient age was 37.3 (SD = 18.3; range 18-75 years). Duration of follow-up averaged 14.7 months (SD = 11.4; range 4-46). The PBF successfully covered the defect without the need for additional unplanned surgical flap coverage in all but 2 patients. Thirty percent of the PBFs received a split thickness skin graft, while the remainder granulated successfully without skin graft. Four flaps were partially debrided without additional flap mobilization, while 1 flap was lost completely. Ten patients had successful re-elevation of their flaps for secondary procedures such as implant removal, spacer exchange, deep debridements, and bone grafting. All donor site incisions healed without complication.

CONCLUSIONS

The pedicled PBF allows coverage of distal leg, ankle, and hindfoot wounds using muscle in patients who may otherwise require free tissue flaps or transfer to another institution for coverage. PBFs can be learned and implemented without the use of microvascular techniques.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Secondary Bony Defects after Soft Tissue Reconstruction in Limb-Threatening Lower Extremity Injuries: Does the Approach to Flap Elevation Matter?

BACKGROUND

 Limb-threatening lower extremity injuries often require secondary bone grafting after soft tissue reconstruction. We hypothesized that there would be fewer wound complications when performing secondary bone grafting via a remote surgical approach rather than direct flap elevation.

METHODS

 A retrospective cohort study was performed at a single Level 1 trauma center comparing complications after secondary bone grafting in patients who had undergone previous soft tissue reconstruction after open tibia fractures between 2006 and 2020. Comparing bone grafting via a remote surgical incision versus direct flap elevation, we evaluated wound dehiscence requiring return to the operating room as the primary outcome. Secondary outcomes were deep infection and delayed amputation.

RESULTS

 We identified 129 patients (mean age: 40 years, 82% male) with 159 secondary bone grafting procedures. Secondary bone grafting was performed via a remote surgical approach in 54% (n = 86) and direct flap elevation in 46% (n = 73) of cases. Wound dehiscence requiring return to the operating room occurred in one patient in the flap elevation group (1%) and none of the patients in the remote surgical approach. The odds of deep wound infection (OR, 1.77; p = 0.31) or amputation (OR, 1.43; p = 0.73) did not significantly differ between surgical approaches. No significant differences were found in complications between the reconstructive surgeon elevating and re-insetting the flap and the orthopaedic trauma surgeon performing the flap elevation and re-inset.

CONCLUSION

 Direct flap elevation for secondary bone grafting after soft tissue reconstruction for open tibia fractures did not result in more complications than bone grafting via a remote surgical approach. These findings should reassure surgeons to allow other clinical factors to influence the surgical approach for bone grafting.

Key aspects of soft tissue management in fracture-related infection: recommendations from an international expert group

A judicious, well-planned bone and soft tissue debridement remains one of the cornerstones of state-of-the-art treatment of fracture-related infection (FRI). Meticulous surgical excision of all non-viable tissue can, however, lead to the creation of large soft tissue defects. The management of these defects is complex and numerous factors need to be considered when selecting the most appropriate approach. This narrative review summarizes the current evidence with respect to soft tissue management in patients diagnosed with FRI. Specifically we discuss the optimal timing for tissue closure following debridement in cases of FRI, the need for negative microbiological culture results from the surgical site as a prerequisite for definitive wound closure, the optimal type of flap in case of large soft tissue defects caused by FRI and the role of negative pressure wound therapy (NPWT) in FRI. Finally, recommendations are made with regard to soft tissue management in FRI that should be useful for clinicians in daily clinical practice.Level of evidence Level V.

Cross-leg flaps: Case series, review, and proposed classification

Background

Cross-leg (CL) flap procedures have a long history in reconstructive surgery, having been described for the first time in 1854. The application of these flaps can potentially solve many reconstructive issues with satisfactory outcomes.

Patients and methods

During our research into the history and development of CL flaps, we identified a variety of flaps for which a classification system can be proposed based on blood supply and flap modifications. In this study, 10 patients with different complaints were managed using posterior tibial artery (PTA) perforator CL flap and superiorly based sural CL flap with satisfactory outcomes.

Results

All flaps survived and healed smoothly; consequently, the flaps provided stable coverage, and the donor sites were reconstructed using skin grafts, which provided satisfactory results to the patients and/or their guardians.

Conclusion

To our knowledge, this is the first study to propose a simple classification and group different types of flaps mentioned in the literature under one category. CL flaps are a common reconstructive option for patients with injuries that limit their mobility.

Secondary Surgery after Lower Extremity Free Flap Reconstruction

BACKGROUND

Microsurgical free tissue transfer may be the only reconstructive option for lower extremity limb salvage. However, the functional and aesthetic results following free tissue transfer after initial salvage may be suboptimal, thus requiring secondary operations to facilitate definitive wound healing and/or refinement.

METHODS

A multi-institutional retrospective cohort study was performed including patients who underwent lower extremity free tissue transfer from January of 2002 to December of 2020. The authors' primary outcome variable was the presence of secondary surgery after free tissue transfer for lower extremity reconstruction. Independent variables (eg, wound cause, flap, donor type, recipient, comorbidities) were collected. Secondary surgery was categorized as (1) procedures for definitive wound closure and (2) refinement procedures. Multivariable logistic regression was performed to determine which variables were independently associated with the outcome.

RESULTS

A total of 420 free tissue transfers for lower extremity reconstruction were identified. Secondary surgery was performed in over half (57%) of the patients. Presence of diabetes (OR, 2.0; P = 0.01; 95% CI, 1.2 to 3.5) and use of a latissimus dorsi donor (OR, 2.4; P = 0.037; 95% CI, 1.1 to 5.4) were predictors of wound closure procedures. Fasciocutaneous (OR, 3.6; P < 0.001; 95% CI, 1.8 to 7.2) and myocutaneous (OR, 3.0; P = 0.005; 95% CI, 1.5 to 9.9) flaps were predictors of refinement procedures when compared with muscle-only flaps with skin grafts.

CONCLUSIONS

The majority of lower extremity free tissue reconstructions required secondary procedures to provide definitive wound closure and/or refinement. Overall, this study provides predictors of secondary surgery that will help formulate patients' expectations of lower extremity limb salvage.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, III.

Reconstruction of a Severe Open Tibiofibular Fracture using an Ipsilateral Vascularized Fractured Fibula with a Thoracodorsal Artery Perforator Free Flap

The Gustilo IIIB tibiofibular fractures often result in long bone loss and extensive soft tissue defects. Reconstruction of these complex wounds is very challenging, especially when it includes long bone grafts, because the donor site is limited. We describe our experience using a set of chimeric ipsilateral vascularized fibula grafts with a thoracodorsal artery perforator free flap to reconstruct the traumatic tibia defects. A 66-year-old male suffered a severe comminuted tibia fracture and segmented fibula fracture with large soft tissue defects as a result of a traffic accident. He also had an open calcaneal fracture with soft tissue defects on the ipsilateral side. All the main vessels of the lower extremity were intact, and the cortical bone defect of the tibia was almost as large as the fractured fibula segment. We used an ipsilateral vascularized fibula graft to reconstruct the tibia and a thoracodorsal artery perforator flap to resurface the soft tissue, using the distal ends of peroneal vessels as named into sequential chimeric flaps. After 3 weeks, the calcaneal defect was reconstructed with second thoracodorsal artery perforator free flap. Reconstruction was successful and allowed rapid rehabilitation because of reduced donor site morbidity.

The Preferred Reconstructive Choice for a Lower Third Tibial Exposure Defect: An Online Survey of 356 Microsurgeons

BACKGROUND

 One of the most challenging yet common areas in reconstructive surgery is the closure of defects in the lower leg. Surgeons can choose from several reconstructive options including local and free flaps. The aim of this study was to understand the reconstructive strategy for lower leg defects of different microsurgeons around the world by harnessing the power of social media and online questionnaires.

METHODS

 A case of a patient with an exposed plate over distal tibial fracture was presented via an online questionnaire distributed on various social media platforms. A total of 369 international microsurgeons replied with their preferred treatment choice. The data were analyzed according to geographic area, microsurgical training, seniority, and subspecialty.

RESULTS

 Among all the respondents (n = 369), 64% would have opted for a free flap reconstruction, while the remaining 36% would have opted for a local/pedicle flap. In the group that would have opted for a free flap, 63% would reconstruct the defect using a free fasciocutaneous flap, while the remaining 37% would have used a free muscle flap. In the local flap group, 60% would have used a local perforator while 30% would have chosen a conventional local flap. While North American and European microsurgeons had a clear preference toward free flaps, Asian, Middle Eastern, African, and South American surgeons were evenly divided between local and free flaps.

CONCLUSION

 In this study, we provide a current global overview of the reconstructive strategies for a lower limb with skin defect and bone or prosthesis exposure. We hope that this will be able to help global microsurgeons and patients worldwide.

Outcomes of Free Muscle Flaps versus Free Fasciocutaneous Flaps for Lower Limb Reconstruction following Trauma: A Systematic Review and Meta-Analysis

BACKGROUND

 Free flap reconstruction of the lower limb following trauma often suffers higher complication rates than other areas of the body. The choice of muscle or fasciocutaneous free flap is an area of active debate.

METHODS

 A systematic review of EMBASE, MEDLINE, PubMed, and Cochrane Register from inception to April 1, 2022 was performed. Articles were assessed using the methodological index for non-randomized studies instrument. The primary outcome was to assess and compare the major surgical outcomes of partial or total flap failure, reoperation, and amputation rates.

RESULTS

 Seventeen studies were included. All studies were retrospective in nature, of level three evidence, and published between 1986 and 2021. The most common muscle and fasciocutaneous free flaps used were latissimus dorsi flap (38.1%) and anterolateral thigh (ALT) flap (64.8%), respectively. Meta-analysis found no significance difference in rates of total flap failure, takeback operations, or limb salvage, whereas partial flap failure rate was significantly lower for fasciocutaneous flaps. The majority of studies found no significant difference in complication rates, osteomyelitis, time to fracture union, or time to functional recovery. Most, 82.4% (14/17), of the included studies were of high methodological quality.

CONCLUSION

 The rate of total flap failure, reoperation, or limb salvage is not significantly different between muscle and fasciocutaneous free flaps after lower limb reconstruction following trauma. Partial flap failure rates appear to be lower with fasciocutaneous free flaps. Outcomes traditionally thought to be managed better with muscle free flaps, such as osteomyelitis and rates of fracture union, were comparable.

Hardware Salvage in the Lower Extremity after Flap Coverage: 10-Year Single Center Outcomes Analysis

An unanswered question with open tibial fractures is whether the type of flap used affects hardware retention. Flap survival may not equate hardware retention or limb salvage. In this study, we performed a 10-year single institution review and analysis of all patients who had placement of hardware for open tibial fractures followed by flap coverage.

Methods

Inclusion criteria consisted of patients who underwent pedicled or free flap coverage of Gustilo IIIB or IIIC tibial fractures requiring open reduction and internal fixation. Outcomes and complications were statistically analyzed based on flap type. Flap type was stratified into free versus pedicled flaps and muscle versus fasciocutaneous flaps. Primary outcome measures included hardware failure and infection requiring hardware removal. Secondary outcome measures included limb salvage, flap success, and fracture union.

Results

Overall primary outcome measures were better for pedicled flaps (n = 31), with lower rates of hardware failure and infection (25.8%; 9.7%) compared with free flaps (n = 27) (51.9%; 37.0%). Limb salvage and flap success was not different comparing pedicled and free flaps. There was no significant difference in outcomes between muscle and fasciocutaneous flaps. Multivariable analysis showed that patients who had free versus pedicled flaps or muscle versus fasciocutaneous flaps had a higher chance of hardware failure. A formal orthoplastic team was established in the period from 2017 to 2022, after which flap numbers were higher and hardware failure less for pedicled and fasciocutaneous flaps.

Conclusions

Pedicled flaps were associated with lower rates of hardware failure and infection requiring hardware removal. A formal orthoplastic team improves hardware-related outcomes.

Reconstruction of Hand and Foot Defects with Free Serratus Carpaccio Flap and Free Serratus Fascia Flap: A Comparative Retrospective Study of Surgical Outcomes

BACKGROUND

Defects of the hand and foot often require an individualized reconstructive approach, due to their unique functional and aesthetic characteristics. Transferred tissues should be thin, pliable, and durable, with free fascial flaps meeting these requirements. This study aimed to evaluate the serratus fascia flap and the serratus carpaccio flap, which is a modification of the fascia flap, by including a thin muscle layer, with the goal of enhancing flap resilience and lowering morbidity rates.

METHODS

Between January 2000 and December 2017, 31 patients underwent microsurgical reconstruction of the hand or foot either by serratus fascia flap (fascia group) or serratus carpaccio flap (carpaccio group). The serratus fascia flaps were mainly harvested between 2000 and 2012, and the serratus carpaccio flaps between 2013 and 2017. Patient records were reviewed retrospectively, regarding demographics, complications, overall flap survival, additional revision surgeries, and surgical outcome. Categorical variables were compared using Fisher's exact test and continuous data with the Mann-Whitney tests. Logistic regression was used to examine the correlation between comorbidities and postoperative complication rates. Differences were considered significant when p < 0.05.

RESULTS

The fascia group consisted of 17 patients and the carpaccio group of 14 patients. The average patient age in the fascia group was 39.2 ± 10.5 years, and it was 39.1 ± 14.7 years in the carpaccio group. Overall complication rates were significantly lower in the carpaccio group than in the fascia group (28.6% vs. 70.6%, p = 0.03). The rates of overall flap survival (85.7% in the carpaccio group vs. 74.5% in the fascia group, p = 0.66) and partial flap loss (14.3% in the carpaccio group vs. 47.1% in the fascia group, p = 0.07) did not differ significantly among both groups. One postoperative hematoma of the donor site requiring revision surgery was reported in the carpaccio group (7.1%, p = 0.45) while no donor-site morbidity was reported in the fascia group.

CONCLUSIONS

Our findings indicate that the serratus carpaccio flap presents a promising alternative to the serratus fascia flap. This modification has proven to be effective in substantially reducing postoperative complications requiring additional surgical interventions. Therefore, the serratus carpaccio flap can be considered a dependable reconstructive option for addressing complex soft tissue defects of the hand and foot, with complication rates that are within an acceptable range.

Free flaps for lower limb soft tissue reconstruction - A systematic review of complications in 'Silver Trauma' patients

BACKGROUND

There are 12.5 million people aged 65 years and older living in the UK. The annual incidence of open fracture is 30.7 per 10,000 person-years. In females, 42.9% of all open fractures occur in patients ≥ 65 years.

METHODS AND MATERIALS

Preferred Reporting for Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study is registered with PROSPERO (CRD42020209149). The aim was to compare the complication profiles of free fasciocutaneous flaps and free muscular flaps in patients aged over 60 years undergoing lower limb soft tissue reconstruction following an open lower limb fracture. The search strategy based on strict inclusion criteria included PubMed, Embase and Google Scholar.

RESULTS

15 papers were identified, including 46 patients with 10 free fasciocutaneous flaps and 41 free muscle flaps. There were 3 complications in the fasciocutaneous group (30%) and 9 complications in the muscle group (22%). There was a total of 1 secondary procedure in the fasciocutaneous group and 4 in the muscle group.

DISCUSSION

There is insufficient data to provide statistical comparison between free fasciocutaneous versus free muscle flaps for lower limb reconstruction performed in those aged over 60 years. This systematic review highlights evidence for the successful use of free tissue transfer in the older population following an open fracture injury and requiring lower limb reconstruction. There is no evidence to suggest the superiority of one tissue type over the other, with the inference that well vascularised tissue is the most significant factor impacting outcome.

Beyond Limb Salvage: Limb Restoration Efforts Following Remote Combat-Related Extremity Injuries Optimize Outcomes and Support Sustained Surgical Readiness

INTRODUCTION

As the combat operational tempo of the military conflicts in Iraq and Afghanistan has declined over the last decade, there has been a decrease in the number of patients requiring acute limb salvage. In their place, a growing population of patients with persistent functional deficits, pain, and inadequate soft tissue coverage stemming from prior limb salvage strategies have returned to our institution seeking revision surgery. Herein, we examine our institution's evolving surgical approach to extremity reconstruction from 2011 through 2019, culminating in the development of our limb restoration concept. We also discuss the impact of this orthoplastic approach on the acute management of complex extremity trauma and its role in providing sustained surgical readiness during interwar years.

MATERIALS AND METHODS

We retrospectively reviewed all limb reconstructive procedures performed at our tertiary care military treatment facility between September 1, 2011 to December 31, 2019 to characterize the trends in extremity reconstruction procedures performed at our institution. Cases were identified as limb restoration procedures if they involved secondary/revision reconstructive procedures designed to optimize function, treat pain, or improve the durability of the injured extremity following initial reconstruction efforts.

RESULTS

Nearly 500 limb restoration procedures were performed during the study period. These procedures steadily increased since 2011, reaching a maximum of 120 in 2018. Orthoplastic procedures such as osseointegration, targeted muscle reinnervation, regenerative peripheral nerve interface, agonist-antagonist myoneural interface, and soft tissue resurfacing flap reconstruction accounted for the rise in secondary/revision reconstruction performed during this time period.

CONCLUSION

Limb restoration is a collaborative orthoplastic approach that utilizes state-of-the-art surgical techniques for treating complex extremity trauma. Although limb restoration originally developed in response to managing the long-term sequelae of combat extremity trauma, the concept can be adapted to the acute management setting. Moreover, limb restoration provides military surgeons with a means for maintaining critical war-time surgical skills during the current low casualty rate era. Level of Evidence: V, therapeutic.

The Effect of Free versus Local Flaps on Time to Union in Open Tibia Fractures

BACKGROUND

Early soft-tissue reconstruction of open fractures has been shown to decrease infection rates and improve rates of bony union. The purpose of this study was to compare the rates and time to union of open tibia fractures that underwent soft-tissue coverage.

METHODS

A retrospective chart review of 118 patients with open tibia fractures requiring soft-tissue reconstruction treated at a single level 1 trauma center was performed. Demographic data as well as flap type were collected. Union status was determined using modified Radiographic Union Scale in Tibia Fractures score greater than 11.

RESULTS

Limb salvage was achieved in 90% of patients. The overall rate of nonunion was 33%. Flap type significantly affected time to union, with local fasciocutaneous and keystone flaps having significantly longer time to union [202 days (SD 120.3)] than all other flap groups ( P = 0.01). Free flaps had significantly shorter time to union than local flaps [115 days (SD 49.6) versus 149 days (SD 75.4); P = 0.02]. Muscle flaps had significantly shorter time to union than fasciocutaneous flaps [123 days (SD 52.4) versus 165 days (SD 104.1); P = 0.04]. This remained true after controlling for fracture location, patient age, need for second flap, and fixation method ( P = 0.037). Patients who underwent an initial soft-tissue reconstruction with a local muscle flap were more likely to require a second flap to achieve wound closure (OR, 3.7; P = 0.008) and needing a second flap significantly increased time to union [162 days (SD 95.9) versus 122 days (SD 51.9); P = 0.03].

CONCLUSION

Flap type affects time to union but not nonunion rate in open tibia fractures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

10-Year single center experience in lower limb reconstruction with free muscle flaps - factors influencing complications in 266 consecutive cases

The anatomy and technique of free muscle flaps - in particular gracilis flap and latissimus dorsi flap - in lower extremity reconstruction have been well described. There is a paucity of data on potential risk factors in larger patient series that affect the outcome. The objective of this study was to address this lack of knowledge by reporting outcomes and complications of free muscle flaps as a primary option in lower extremity reconstruction. From 2009 to 2020, a total of 253 consecutive patients with soft tissue defects of the lower limb from trauma, infection or malignancies underwent lower extremity reconstructive surgery with 266 free muscle flaps. Complications requiring revision surgery were noted in 36.1% of cases. Total flap loss occurred in 10.5% of cases. Patients requiring revision surgery were older, more likely to be female, more likely to be active smokers, and more likely to have a higher ASA score. Lower extremity reconstruction with free muscle flaps has a relevant complication rate that both patient and reconstructive surgeon need to be aware of. Prospective studies should try to further assess the factors affecting the outcome.

Outcome comparison between muscle and fasciocutaneous flaps after secondary orthopedic procedures

Lower extremity wounds associated with fractures and bony defects often require secondary orthopedic procedures after flap coverage has been performed. In this study, we compare complications between muscle and fasciocutaneous flaps after secondary orthopedic procedures. A retrospective chart review study of all lower extremity soft tissue reconstructions by a single surgeon over seven years yielded a subgroup of patients who underwent secondary orthopedic procedures, including hardware removal, hardware revision, and bone grafting after flap reconstruction. Of 355 lower extremity, soft tissue reconstructions for orthopedic coverage performed in the time period studied, 102 patients underwent secondary orthopedic procedures after flap reconstruction. Of these, 54 received muscle flaps (52.94%), and 48 received fasciocutaneous flaps (47.06%). Using this subgroup of 102 patients, we compared muscle and fasciocutaneous flaps using three categories of wound complications following these secondary procedures: There were no superficial wounds requiring local wound care only in the muscle flap group (0%, n = 0) versus 4.17% (n = 2; p = 0.130) in the fasciocutaneous flap group. There were 2 lost flaps requiring surgical debridement and additional skin grafting in the muscle flaps group (3.70%) versus 2 (4.17%; p = 0.904) in the fasciocutaneous flap group. In the third category, flap loss requiring additional soft tissue reconstruction was 18.52% (n = 10) in the muscle group versus 2.08% (n = 1; p = 0.008) in the fasciocutaneous flap group. Our data support the existing literature indicating that fasciocutaneous flaps can tolerate secondary procedures better than muscle flaps and should initially be considered in patients with higher probability of needing additional orthopedic procedures after reconstruction.

Comparison of Lymphatic Drainage of the Lower Limbs After Soft Tissue Reconstruction by Microvascular Muscle Flap Versus Fasciocutaneous Flaps

INTRODUCTION

Complex traumatic injuries of the lower limb are increasingly being salvaged. The common long-term morbidity includes secondary lymphedema. The role of microvascular flaps is often discussed for lymph flow restoration. However, the differential effect of using muscle flap versus fasciocutaneous flap in the lower-limb trauma to avoid secondary lymphedema is not studied.

METHODS

Forty patients who underwent microvascular flap reconstruction were reviewed retrospectively to obtain data regarding clinical demographics and surgical procedure. Assessment for presence of clinical lymphedema was done. The lymphatic drainage in all these patients was assessed by 99mTc lymphoscintigraphy.

RESULTS

Of the 40 patients included in the study, group A (n = 23) underwent muscle-based free flap reconstruction, and group B (n = 17) had fasciocutaneous flaps. Clinical lymphedema was present in 21 patients, of which 18 were of group A and 3 of group B. On lymphoscintigraphy, 14 patients had either partial or complete obstruction in the reconstructed lower limb, 11 in group A and 3 in group B. All of them (n = 14) were found to have associated clinical lymphedema. The association of clinical lymphedema (P < 0.001) and obstructive pattern on lymphoscintigraphy (P < 0.05) with muscle flaps was found to be statistically significant.

CONCLUSIONS

With the advancement in surgery and techniques, not only salvageability but also stable and morbidity free outcomes are the goals. Fasciocutaneous flaps may have better lymphatic outcomes than the muscle-based flaps, and the criteria for lower-limb reconstruction can be reformed to include simultaneous soft tissue and lymphatic reconstruction.

Modified fourth lumbar artery local perforator flap: an alternative for reconstruction of nonhealing lumbosacral spinal defects

BACKGROUND

The reconstruction of nonhealing lumbosacral spinal defects remains a challenge, with limited options. The aim of this article was to review the authors' technique and experience with the modified fourth lumbar artery local perforator (MFLALP) flap for the coverage of nonhealing lumbosacral defects after spinal surgery.

METHODS

Between August 2012 and May 2021, we reviewed all MFLALP flaps performed for lumbosacral spinal defects. Patient demographics, wound aetiologies, surgical characteristics, and outcomes were reviewed retrospectively.

RESULTS

A total of 31 MFLALP flaps were performed on 24 patients during the research period. The median flap size was 152 cm² (range, 84-441 cm²). All flaps survived successfully, although there were two cases of minor complications. One patient had a haematoma and required additional debridement and skin grafting at 1 week postoperatively. The other patient suffered wound dehiscence at the donor site at 2 weeks postoperatively and required reclosure. The follow-up time ranged from 6 months to 5 years.

CONCLUSIONS

The MFLALP flap has the advantages of a reliable blood supply, sufficient tissue bulk and low complication rate. This technique is an alternative option for the reconstruction of nonhealing lumbosacral spinal defects.

Microvascular free tissue transfer for reconstruction of complex lower extremity trauma: Predictors of complications and flap failure

BACKGROUND

Despite advanced wound care techniques, open fractures in the setting of lower extremity trauma remain a challenging pathology, particularly when free tissue transfer is required for coverage. We aimed to evaluate factors associated with flap failure in this setting using a large, heterogeneous patient population.

METHODS

Retrospective review of patients who underwent traumatic lower extremity free flap reconstruction (2002-2019). Demographics wound/vessel injury characteristics, pre and perioperative factors, and flap outcomes were analyzed.

RESULTS

One hundred eighty-eight free flaps met inclusion criteria, with 23 partial (12.2%) and 13 total (6.9%) flap failures. Angiography was performed in 87 patients, with arterial injury suffered in 43.1% of those evaluated. Time to flap coverage varied within 3 days (4.5%), 10 days (17.3%), or 30 days of injury (42.7%). In all, 41 (21.8%) subjects suffered from major flap complications, including failure and takebacks. Multivariate regression demonstrated the presence of posterior tibial (PT) artery injury predictive of both flap-failure (Odds ratio [OR] = 11.4, p < .015) and major flap complications (OR = 12.1, p < .012). Immunocompromised status was also predictive of flap failure (OR = 12.6, p < .004) and major complications (OR = 11.6, p < .007), while achieving flap coverage within 30 days was protective against flap complications (OR = 0.413, p < .049). Defect size, infection, and injury location were not associated with failure.

CONCLUSIONS

When examining a large, heterogeneous patient cohort, free flap outcomes in the setting of lower extremity open fractures can be influenced by multiple factors. This presence of PT artery injury, flap coverage beyond 30 days of injury, and immunocompromised status appear predictive of flap complications in this context.

Patient-reported outcomes following free flap lower extremity reconstruction: A systematic review and meta-analysis

PURPOSE

Free flap reconstruction in the lower extremity has shown success for the management of large and complex defects, restoration of function, and favorable aesthetic outcomes. Patient-reported outcomes (PROs) have not been well explored in previous literature. This meta-analysis aimed to provide a comprehensive summary of PROs after free flap reconstruction in the lower extremity.

METHODS

We searched MEDLINE and Embase from 1946 to 2021 for studies reporting on PROs following free flap reconstruction in the lower extremity.

RESULTS

Overall, 53 studies were included, and 11 studies reported validated PRO measures for meta-analysis. A total of 1953 patients underwent reconstruction with 1958 free flaps for lower limb defects with a mean follow-up of 3.26 (0.25-7.83) months. The mean postoperative Lower Extremity Functional Scale (LEFS) scores were 60.3 (±12) out of 80 points (4 studies, 85 patients). The mean postoperative AOFAS scores were 75.1 (±15) out of 100 points (4 studies, 68 patients). The mean postoperative SF-36 scores were 88.1 (±8.0) out of 100 points; mental health component was 48.7 (±8.9), and physical component was 38.4 (±8.2), out of 50 points (4 studies, 88 patients).

CONCLUSION

Our findings demonstrated that patients report improved physical health, mental health, and function following lower extremity reconstruction with free flaps. Patients reported similar improvements in functional scores following lower extremity reconstruction regardless of their free flap type. Furthermore, patients with myocutaneous flaps may have improved mental health and worse physical health scores when compared to perforator flaps. The evidence profiles presented in this review indicate that additional research is needed to help guide future decision-making.

Surgical and demographic predictors of free flap salvage after takeback: A systematic review

BACKGROUND

Microsurgical free tissue transfer (FTT) is a widely employed surgical modality utilized for reconstruction of a broad range of defects, including head and neck, extremity, and breast. Flap survival is reported to be 90%-95%. When FTT fails, salvage procedures aim at establishing reperfusion while limiting ischemia time-with salvage rates between 22% and 67%. There are limited data-driven predictors of successful salvage present in the literature. This systematic review aims to identify predictors of flap salvage.

METHODS

A systematic literature review was conducted per PRISMA guidelines. Articles included in the final analysis were limited to those investigating FTT salvage procedures and included factors impacting outcomes. Cohort and case series (>5 flaps) studies up until March 2021 were included. Chi-square tests and linear regression modeling was completed for analysis.

RESULTS

The patient-specific factors significantly associated with salvage included the absence of hypercoagulability (p < .00001) and no previous salvage attempts (p < .00001). Case-specific factors significantly associated with salvage included trunk/breast flaps (p < .00001), fasciocutaneous/osteocutaneous flaps (p = .006), venous compromise (p < .00001), and shorter time from index procedure to salvage attempt (R = .746). Radiation in the head and neck population was significantly associated with flap salvage failure.

CONCLUSIONS

Given the complexity and challenges surrounding free flap salvage procedures, the goal of this manuscript was to present data helping guide surgical decision-making. Based on our findings, patients without documented hypercoagulability, no previous salvage attempts, fasciocutaneous/osteocutaneous flaps, trunk/breast flaps, and a shorter time interval post-index operation are the best candidates for a salvage attempt.

A comparison of healing and complication rates between common flaps utilized in total knee arthroplasty: a review of the literature

Background

Flap reconstruction with perforator, fasciocutaneous, muscular, and/or free microvascular flaps is utilized to cover wound defects and improve vascularization and antibiotic/nutrient delivery. Flap use in revision procedures for total knee arthroplasty has been explored previously; however, current data are limited and studies comparing healing and complication rates between different flap types are lacking.

Methods

A literature review was performed using PubMed on 13 January 2022. Studies were included if they reported healing and complication rates for either gastrocnemius, rectus abdominis, latissimus dorsi, fasciocutaneous, chimeric, or gracilis flaps in the setting of revision total knee arthroplasty (TKA).

Results

The final cohort included gastrocnemius (n = 421, healing rate 73.8%, complication rate 59.9%), gracilis (n = 9, healing rate 93%, complication rate 55.6%), latissimus dorsi (n = 41, healing rate 67%, complication rate 46.3%), rectus abdominis (n = 3, healing rate 100%, complication rate 0%), fasciocutaneous (n = 78, healing rate 70%, complication rate 19.2%), and chimeric flaps (n = 4, healing rate 100%, complication rate 25%). There was no significant difference when comparing healing rates across flap types (p = 0.39). There was a significant difference when comparing complication rates across flap types (p < 0.0001), with a significant difference being noted between gastrocnemius and fasciocutaneous complication rates (p < 0.0001). All other comparisons between flap types by complication rate were not significantly different.

Conclusions

Gastrocnemius flaps are the workhorse flap in the setting of revision TKA, as evidenced by this review. Healing rates did not vary significantly across flap types, which suggests that determining the appropriate flap for coverage of soft-tissue defects in revision TKA should be driven by defect size and location as well as physician experience and patient tolerance.

From replantation to transplantation: The evolution of orthoplastic extremity reconstruction

For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopedic trauma, tumors, infections, and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as a digital artery or nerve repair to more complex procedures such as autologous tissue transplantation. Functional muscle transfers, toe-to-hand transfers, and recently vascularized composite allotransplantation are the highest rungs on this ladder that help restore extremity function. The development of the orthoplastic approach over the last three decades simultaneously integrates the principles and practices of both orthopedic surgery and plastic surgery for optimal care and salvage of extremities. Clinical, anatomic, and basic science research in reconstructive microsurgery has resulted in significant improvements in extremity salvage, reconstruction, and restoration.

Approach to Complex Lower Extremity Reconstruction

Composite injuries to the lower extremity from etiologies including trauma and infection present a complex dilemma for the reconstructive surgeon, and require multidisciplinary collaboration amongst plastic, vascular, and orthopaedic surgical specialties. Here we present our algorithm for lower-extremity reconstructive management, refined over the last decades to provide an optimized outcome for our patients. Reconstruction is predicated on the establishment of a clean and living wound, where quality of the wound-bed is prioritized over timing to soft-tissue coverage. Once established, soft-tissues and fractures are provisionally stabilized; our preference for definitive coverage is for microvascular free-tissue, due to the paucity of healthy soft-tissue available at the injury, and ability to avoid the zone of injury for microvascular anastomosis. Finally, definitive bony reconstruction is dictated by the length and location of long-bone defect, with a preference to utilize bone transport for defects longer than 5 cm.

Urinary Bladder Matrix Grafting Versus Flap Coverage for Acute or Infected Wound Defects in Patients With Orthopaedic Trauma

OBJECTIVES

Urinary bladder matrix (UBM) grafting of acute or infected wound defects has been reported to be successful in small case series. The purpose of this study was to compare the outcomes of UBM grafting with flap coverage.

DESIGN

This is a retrospective comparative study.

SETTING

Level-1 trauma center.

PATIENTS

Orthopaedic trauma patients with wound defects not amenable to primary closure or skin grafting.

INTERVENTION

Wound coverage with UBM grafting (n = 26) by orthopaedic trauma surgeons versus flap coverage (n = 26) by microvascular-trained plastic surgeons.

MAIN OUTCOME MEASUREMENTS

Primary wound coverage success, complications, returns to the operating room, hospital length of stay, and time to wound healing.

RESULTS

The UBM group was more likely to have an American Society of Anesthesiologist class ≥3 (58% vs. 23%, P = 0.02), a foot/ankle wound (77% vs. 12%, P &lt; 0.001), an infected wound defect (81% vs. 50%, P = 0.03), and smaller defects (21 vs. 100 cm 2 , P = 0.02). UBM grafting resulted in a longer time to wound healing (6 vs. 2 months, P = 0.002) and a shorter hospital length of stay (2 vs. 14 days, P &lt; 0.0001). UBM and flap groups had similarly high rates of failure of primary wound coverage (31% vs. 31%; P = 1.0), complications (46% vs. 62%, P = 0.4), and returns to the operating room (46% vs. 65%; P = 0.2). All 3 acute traumatic wounds undergoing UBM grafting concurrently with fracture fixation experienced graft failure and osteomyelitis.

CONCLUSION

UBM grafting is an effective alternative to flap coverage for small traumatic or infected wounds but should be avoided in acute traumatic wounds undergoing fracture fixation.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

The durability of thin superficial circumflex iliac artery perforator flap in sole reconstruction: Clinical experience with 18 cases

BACKGROUND

The superficial circumflex iliac artery perforator flap's overall success in the reconstruction of the lower limb has been acceptable, but the sole of the foot remains more challenging. The purpose of this article is to report our experience employing the SCIP flap and evaluate its durability in reconstructing different units of the foot's sole, heel, middle, and forefoot.

PATIENTS AND METHODS

This retrospective study reviewed 18 patients with sole defect reconstructed with free SCIP flap from 2017 to 2019. 18 free SCIP flaps were harvested depending on the superficial branch of SCIA (n = 16) or deep branch (n = 2). All flaps were thin and elevated above the scrapa's fascia. The heel (n = 10), middle foot sole (n = 5), forefoot sole (n = 2), and combined heel and midfoot in one patient were among the defect locations. Sole defects were caused by trauma in 10 patients (55.5%), while the rest of the causes were melanoma (three patients, 16.7%), diabetic ulcer (three patients, 16.7%), and unstable scar (one patient), and calcaneal osteomyelitis (one patient). The defect size ranged from 24 to 230 cm² .

RESULTS

The flap dimensions ranged from 6 × 4 to 18 × 11 cm. Mean follow-up observations were 42.5 months. 72.2% of our patients developed protective sensation between 12-18 months. No ulcerations were observed, and all of the patients had successful functional recoveries with satisfying cosmetic outcomes.

CONCLUSION

The SCIP flap can be an optimal durable skin flap for weight-bearing sole reconstruction. SCIP flap has the advantage of being thin minimizing the problem of shearing, the need for secondary procedures, and the faster recovery of protective sensation that could prevent ulceration.

Microsurgical Strategies after Free Flap Failure in Soft Tissue Reconstruction of the Lower Extremity: A 17-Year Single-Center Experience

Background: There is no clear consensus on the optimal surgical strategy for providing safe coverage in salvage free flap surgery after total free flap failure. Methods: A retrospective study was conducted to evaluate patients with total failure of the primary free flap in lower extremity reconstruction between 2000 and 2017. Results: In a cohort of 1.016 patients, we identified 43 cases of total flap failure (4.2%). A total of 30 patients received a salvage free flap with a success rate of 83.3% (25/30). One patient received a secondary salvage free flap. Overall limb salvage after primary free flap loss was 83.7% (36/43). Conclusions: Microsurgical management of free flap loss in the lower extremity is challenging and requires a decisive re-evaluation of risk factors and alternative strategies. This should include reconsidering the flap choice with a tendency towards traditional and safe workhorse flaps, a low-threshold switch to different recipient vessels, including arteriovenous (AV) loops, bypasses (especially in case of venous insufficiency) and back-up procedures, such as negative pressure wound therapy or dermal regeneration templates with skin grafting in cases of lower demand and critically ill patients. We derived one suggestion from our previous practice: replacing perforator flaps with axial pattern flaps (“safe workhorses”).

Muscle/musculocutaneous versus fasciocutaneous free flap reconstruction in the lower extremity: A systematic review and meta-analysis

BACKGROUND

Free flaps for soft tissue coverage of the lower extremity can be broadly divided into muscle/musculocutaneous and fasciocutaneous flaps. The purpose of this systematic review and meta-analysis was to assess their different post-operative outcomes.

METHODS

A systematic search was performed in PubMed, Scopus, and the Web of Science from their inception to February 2022. Non-randomized comparative studies, which describe any post-operative outcome of muscle/musculocutaneous and fasciocutaneous free flaps reconstruction in the lower extremity were included. Articles with duplicate titles, editorials, review articles, case series, case reports, and publications lacking an abstract, those reporting pediatric patients, those describing only muscle/musculocutaneous or fasciocutaneous free flaps, those with incomplete or incomparable post-operative outcomes, and studies involving <10 muscle/musculocutaneous or fasciocutaneous free flaps were excluded. A comparative meta-analysis was conducted on muscle/musculocutaneous and fasciocutaneous free flaps outcomes, comprising vascular thrombosis, partial or complete flap necrosis, infection, donor-site complications, non-union, and primary or recurrent osteomyelitis. The fixed-effects meta-analysis model was used when low heterogeneity (I²  < 50%) was identified.

RESULTS

Twenty-two articles with a total of 2711 flaps (1584 muscle/musculocutaneous flaps and 1127 fasciocutaneous flaps) were included in the qualitative and quantitative assessment. The rates of any flap necrosis (12.0% vs. 7.4%; p = 0.007) and donor-site complications (16.7% vs. 6.7%; p < 0.0001) were significantly higher for muscle/musculocutaneous flaps than for fasciocutaneous flaps. There were no significant differences in the rates of vascular thrombosis (10.5% vs. 10.7%; p = 0.98), complete flap necrosis (6.2% vs. 4.7%; p = 0.30), infection (19.4% vs. 14.7%; p = 0.18), non-union (18.9% vs. 14.8%; p = 0.33), and primary or recurrent osteomyelitis (14.7% vs. 12.4%; p = 0.69).

CONCLUSION

This meta-analysis revealed no significant difference in long-term post-operative outcomes, but suggested that fasciocutaneous flaps should be preferred to avoid flap necrosis and donor-site complications.

Reconstruction Options for Lower Extremity Traumatic Wounds

The senior author first coined the "orthoplastic" approach to traumatic lower extremity reconstruction, by which multidisciplinary surgeons and specialists work together for optimal patient success. The goals of lower extremity salvage are to optimize limb appearance, restore unrestricted pain-free ambulation, and improve quality of life. Composite traumatic defects require an organized approach, and the reconstructive ladder is used for strategies of varying complexity for repair of soft-tissue wounds. The lower rungs of the ladder include simpler reconstructive options such as the use of skin grafts and local flaps, and the higher rungs represent complex techniques such as free tissue transfer. Although there is no notable difference between muscle and fasciocutaneous/perforator flaps in reconstructive outcomes, there has been a trend toward perforator flaps to minimize donor site morbidity.

Development of a mathematical formula and online tool to calculate the potential maximum flap width to allow for primary anterolateral thigh donor-site closure in Caucasians

BACKGROUND

Primary anterolateral thigh (ALT) flap donor-site closure is crucial to achieve patient satisfaction, avoid burdensome secondary surgeries, and avert poor outcomes. Only vague maximum flap width recommendations have been suggested, which fall short of acknowledging individual patient habitus and thigh morphology. Therefore, we aimed at identifying a user-friendly preoperative calculation of maximum flap width for primary closure.

METHODS

A total of 429 ALT free flaps performed between 2009 and 2020 were analyzed. A total of 350 donor-sites were closed primarily (82%) and 79 (18%) were split-thickness skin-grafted (STSG). Patient demographics including sex, age, and BMI, operative details, and flap characteristics were compared to assess their impact on the outcome variable. Receiver operating characteristic (ROC) curves were plotted for all significant predictors discriminating between closure and STSG. Areas under the curve (AUCs) were calculated for each parameter combination and optimal cutoffs were determined using Youden's Index.

RESULTS

Sex, age, BMI, and flap width alone were poor discriminators. Dividing flap width by BMI and logarithmized BMI yielded AUCs of 0.91 and 0.94, respectively. Including patient sex yielded the best fitting regression model (χ²  = 251.939, p < .0001) increasing the AUC to 0.96 (95% CI: 0.93-0.98, p < .0001). The optimal cutoff value discriminated between primary closure and STSG with 90% sensitivity and 89% specificity. An online calculator of patient-individual maximum ALT width was then programmed.

CONCLUSIONS

Sex and BMI are reliable predictors of successful primary ALT donor-site closure in Caucasians. We devised a novel formula for calculating patient-individual maximum ALT widths preoperatively, predicting failure of primary closure with 90% sensitivity in our cohort, available at: https://kitteltaschenbuch.com/altwidth/calculate.htm.