Neurotized sural flap: An alternative in sensory reconstruction of the foot and ankle defects

How to measure success in lower extremity reconstruction, which outcome measurements do we use a systematic review and metanalysis

Different factors have to be considered and weighted in the treatment algorithm of lower extremity reconstruction. A combination of both clinicians' and patients' perspectives is necessary to provide a conclusive picture. Currently, there aren't any standardized and validated measurement data sets for lower extremity reconstructions. This makes it necessary to identify the relevant domains. We, therefore, performed a systematic review and metanalysis of outcome measurements and evaluated their ability to measure outcomes after lower extremity reconstruction. A systematic review and metanalysis according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' protocol were performed for studies reporting at least one structured outcome measurement of lower extremity reconstruction. Both Patient (PROMs)- and Clinician reported outcome measurements (CROMs)were analyzed. Of the 2827 identified articles, 102 were included in the final analysis. In total 86 outcome measurements were identified, 34 CROMs, 44 PROMs and 8 (9.3%) outcome measurements that have elements of both. Twenty-four measure functional outcome, 3 pain, 10 sensations and proprioception, 9 quality of life, 8 satisfaction with the result, 5 measure the aesthetic outcome, 6 contours and flap stability and 21 contain multidomain elements. A multitude of different outcome measurements is currently used in lower extremity reconstruction So far, no consensus has been reached on what to measure and how. Validation and standardization of both PROMs and CROMs in plastic surgery is needed to improve the outcome of our patients, better meet their needs and expectations and eventually optimize extremity reconstruction by enabling a direct comparison of studies' results.

How Safe Is Reverse Sural Flap?: A Systematic Review

BACKGROUND

Soft tissue reconstruction of the lower third of the leg, the ankle, and the foot is challenging for reconstructive surgeons. The options for reconstruction are limited. Reverse sural flap is relatively easy to perform and considered a good option for reconstruction. The complication rates are variable in studies. This study aims to systemically review all available articles based on reverse sural flap focusing on complications of the flap. The overall complication of the flap helps to better understand the reliability of the flap.

METHODS

A comprehensive literature search was performed using MEDLINE, EMBASE, and Google Scholar to identify cases of reverse sural artery flap.

RESULTS

A pooled analysis of 89 articles was performed, which yielded 2575 patients (2592 flaps) over a period of 19 years. Most of the cases were performed in Asian countries (1540 flaps, 59.4%) with the majority being performed in China (746 flaps, 28.8%). The most common cause for reverse sural flap surgery was trauma/postsurgical (1785/2592) followed by burn/scarring. Flap complications were recorded in 653 of 2592 flaps (25.20%). The most common complication was partial flap loss, which was recorded in 204 flaps (7.85%) followed by venous congestion (79 flaps, 3.05%). Complete flap loss was observed only in 66 participants (2.5% of all the flaps performed).

CONCLUSIONS

Reverse sural flap is reliable flap for the reconstruction of lower leg, ankle, and foot. It can give a comparable outcome as free flap when meticulously performed and, in many cases, a better result.

Pedicled sural flaps versus free anterolateral thigh flaps in reconstruction of dorsal foot and ankle defects in children: a systematic review

BACKGROUND

This systematic review compared free anterolateral thigh (ALT) flaps versus pedicled distally based sural artery (DBSA) flaps for reconstruction of soft tissue defects of dorsal foot and ankle in children.

METHODS

A systematic literature search was performed to identify cases where an ALT or DBSA was used to reconstruct the dorsal foot in children. A total of 19 articles were included in the systematic review.

RESULTS

Eighty-three patients underwent an ALT reconstruction and 138 patients underwent a DBSA reconstruction. Patients who had a DBSA were more likely to require grafting of the donor site (P<0.001). The size of ALT flaps was significantly larger than DBSA flaps (P=0.002). Subsequent flap thinning was required in 30% of patients after ALT and 12% of patients after DBSA reconstruction (P<0.001). Complications occurred in 11.6% of DBSA and 8.4% of ALT flaps (8.4%).

CONCLUSIONS

Both flaps are valid options in reconstructing pediatric foot and ankle defects. Each flap has advantages and disadvantages as discussed in this review article. In general for larger defects, an ALT flap was used. Flap choice should be based on the size of the defect.

Reconstruction of the weight-bearing heel with nonsensate reverse sural artery flaps

BACKGROUND

The reverse sural artery flap (RSAF) is widely used to reconstruct foot and ankle defects. Although it is commonly used in a nonsensate type, there has been controversy as to whether it provides sufficient stability and durability when applied to weight-bearing heels. The aim of this study was to evaluate patient outcomes after weight-bearing heel coverage using a nonsensate RSAF.

METHODS

Twenty-three patients who underwent reconstruction surgery of the weight-bearing heel with RSAF from 2004 to 2018 in a tertiary hospital were retrospectively reviewed. All surgeries were performed without a sensate procedure. The patients' experience of pressure sore on the flap area and the ability to use normal footwear were investigated. Light touch, Semmes-Weinstein test (SWT), and two-point discrimination tests were assessed, along with postoperative wound complications.

RESULTS

Heel damage etiologies included malignant tumors in 14 (61%), trauma-related in 7 (30%) and diabetic ulcers in 2 (9%) patients. Patient mean age was 58 years (range, 18-93 years) and the mean follow-up period was 57 months (range, 12-185 months). The mean size of the flap was 64.1 cm2 (range, 20-169 cm²). All flaps healed without major complications. All returned to daily living activities and 20 (86%) patients were able to use normal footwear. Of the 11 patients who had available measurement records, 8 (73%) showed a light touch sense. The mean SWT value was 4.31 (range, 3.61- 4.56). Two-point discrimination was not observed in any of the patients. Two patients had experienced superficial ulcers on the flap within a one-year postoperative period, which spontaneously healed and did not recur. No full-thickness ulcers were observed during the follow-up period.

CONCLUSIONS

The results of this study suggest that patients who underwent nonsensate RSAF for the reconstruction of the heel could expect to maintain the property for stable weight-bearing without pressure sore.

Sihler's staining of the cutaneous nerves of the leg and its implications for sensory reconstruction

INTRODUCTION

This study aimed to reveal the entire cutaneous nerve distribution pattern of the leg and provide a morphological basis for sensory reconstruction during skin flap transplantation.

MATERIALS AND METHODS

Twelve adult cadavers were fixed with formalin, and the whole leg skin with subcutaneous fat was removed close to the muscle surface. The cutaneous nerves were visualized using modified Sihler's staining to reveal the distribution and innervation density of the cutaneous nerves.

RESULTS

The saphenous nerve innervated the anterior part, 82.2% of the upper-middle region of the lateral part of the anterolateral leg, and the upper 63.4% of the medial posterior leg. The superficial peroneal nerve innervated 90.1% of the lateral lower one-third of the anterolateral leg. The medial sural cutaneous nerve covered 26.4% of the posterior leg. The lateral sural cutaneous nerve covered 42.3% (approximately 28.6% overlap with the saphenous nerve) of the upper-middle region of the anterolateral and posterolateral leg. The number of branches differed between certain cutaneous nerves in the leg. Communications were observed between the arborizations of the four cutaneous nerves mentioned above. The highest density of primary and secondary nerve branches was observed in the upper one-third of the lateral posterior leg. The upper one-third of the posteromedial leg contained the highest density of intracutaneous nerve branches and highest number of total nerve branches.

CONCLUSIONS

These results may be used to map sensory regions when designing leg skin flaps for reconstruction surgery to obtain improved sensory recovery.

Use of free sensate SCIA flap for reconstruction of distal limb defects of moderate size

Recent attempts have been made to direct the sensory neurotisation of free superficial circumflex iliac artery (SCIA) flaps. However, donor nerves enabling sensory recovery are limited. We report our findings in fifteen patients who underwent distal limb defect reconstruction using a sensate SCIA flap, including the lateral cutaneous branch of the subcostal nerve (LCSN), between August 2017 and September 2018. The distance from the anterosuperior iliac spine to the point where the LCSN crossed the iliac crest ranged between 6.5 and 10 cm. The diameter ranged between 1.5 and 4.0 mm. The flap size ranged between 8 × 4 and 13 × 10 cm². All of the flaps survived uneventfully. Tests of sensory modalities, including the Semmes-Weinstein (SW) touch, vibration, pinprick, temperature and static two-point discrimination (s2PD) tests were applied in nine regions of each flap post-operatively. One or more modalities were present in at least one region at 6 months post-operatively, and the recovery of vibration perception was more consistent than that of SW touch and pinprick perception. The recovery of s2PD was noted in 4 cases over a follow-up period of more than 12 months. A reliable sensate flap with the LCSN can be considered as an attractive option for the sensory reconstruction of distal limb defects of moderate size.

Reconstruction of moderate-sized soft tissue defects in foot and ankle in children: Free deep inferior epigastric artery perforator flap versus circumflex scapular artery perforator flap

BACKGROUND

This retrospective study was conducted to compare the outcomes between the free deep inferior epigastric artery perforator (DIEP) flap and the circumflex scapular artery perforator (CSAP) flap in reconstruction of moderate-sized soft tissue defects in the foot and ankle of pediatric patients.

PATIENTS AND METHODS

From January 2004 to December 2016, 42 patients, ranging from 2 to 13 years old, underwent foot and ankle reconstruction, with a free DIEP flap in 21 cases and a free CSAP flap in the other 21cases.

RESULTS

All the flaps survived. No marked differences were observed in the demographics, flap size, recipient vessels, and overall early or late complication rate (p > 0.05). The CSAP group had a shorter operation time (134.3 ± 25 min vs. 202.4 ± 24.3 min, p < 0.05) and flap harvest time (29.7 ± 8.1 min vs. 52.2 ± 9.8 min, p < 0.05) than the DIEP group had. In long-term follow-up, the CSAP group showed a lower fat hyperplasia rate (14% vs. 52%, p < 0.05) and better cosmetic outcomes than the DIEP group did (p < 0.05). The functional outcomes had no marked differences (p > 0.05).

CONCLUSIONS

The DIEP flap and the CSAP flap are both good options for foot and ankle reconstruction of moderate-sized defects in pediatric patients. The CSAP flap has a shorter operation time and flap harvest time, a lower fat hyperplasia rate, and better long-term cosmetic outcomes than the DIEP flap does.

Reconstruction of Soft-Tissue Defects at the Foot and Ankle after Oncological Resection

Introduction

Solid malignancies at the foot and ankle region are rare and include mainly soft-tissue sarcomas, bone sarcomas, and skin malignancies. Complete surgical resection with clear margins still remains the mainstay of therapy in these malignancies. However, attainment of negative surgical margins in patients with locally advanced tumors of the foot and ankle region may require extensive surgery and could result in loss of extremity function. In these circumstances, plastic surgical techniques can frequently reduce functional impairment and cover soft-tissue defects, particularly in cases of large tumor size or localization adjacent to critical anatomic structures, thereby improving the quality of life for these patients. The aim of this article is to illustrate the various treatment options of plastic surgery in the multimodal therapy of patients with malignant tumors of the foot and ankle region.

Materials and methods

This article is based on the review of the current literature and the evaluation of the author’s own patient database.

Results

The local treatment of malignant extremity tumors has undergone major changes over the last few decades. Primary amputations have been increasingly replaced by limb-sparing techniques, preserving extremity function as much as possible. Although defect coverage at the foot and ankle region is demanding due to complex anatomical features and functional requirements, several plastic surgical treatment options can be implemented in the curative treatment of patients with malignant solid tumors in this area. Soft-tissue defects after tumor resection can be covered by a variety of local flaps. If local flaps are not applicable, free flap transfers, such as the anterolateral thigh flap, parascapular flap, or latissimus dorsi flap, can be utilized to cover nearly all kinds of defects in the foot and ankle region.

Conclusion

Soft-tissue reconstruction in the foot and ankle region is a vital component of limb-sparing surgery. It enables complete resection of locally advanced tumors and subsequent adjuvant radiotherapy. Modern plastic surgical techniques should, therefore, be integrated in the multimodal treatment concept of malignancies in the foot and ankle region.

The vastus lateralis free flap for lower extremity gustilo grade III reconstruction

BACKGROUND

Orthopedic trauma patients with Gustilo grade III injuries to the distal third of lower extremity present challenges to optimum reconstructive management. There is no consensus on the ideal autologous tissue for transfer in large lower extremity defect reconstruction. We present a large case series utilizing the vastus lateralis (VL) free flap for lower extremity Gustilo grade III reconstruction.

PATIENTS AND METHODS

This is a case series of patients who underwent VL free tissue transfer for Gustilo grade III injuries. A total of 38 free tissue transfers were performed for lower extremity reconstruction, 19 of which were VL flaps. Mean interval between injury and reconstruction was 46 days (range 7-240 days).

RESULTS

The mean wound size was 11.37 cm x 11.42 cm and all cases underwent delayed reconstruction. Seven day flap viability was 100% and 30-day flap viability was 17/19 (89%). There were six complications: two hematomas requiring drainage, one flap dehiscence, one distal flap loss requiring a reverse saphenous vein graft extension, and two complete flap losses. Of the two failed flaps, one was attributed to heparin-induced thrombocytopenia and the other to venous congestion complicated by methicillin-resistant Staphylococcus aureus infection.

CONCLUSIONS

The VL free flap is a reliable and versatile flap that can be tailored and tangentially thinned to match the shape and size of a defect, and the long pedicle allows the surgeon to stay away from the zone of injury. This flap should be strongly considered for lower extremity reconstruction, especially in salvage operations for large defects. © 2015 Wiley Periodicals, Inc. Microsurgery 37:212-217, 2017.