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Lee YJ, Kim J, Lee CR, Kim JH, Oh DY, Jun YJ, Moon SH. Anterolateral Thigh Chimeric Flap: An Alternative Reconstructive Option to Free Flaps for Large Soft Tissue Defects. J Clin Med 2023; 12:6723. [PMID: 37959189 PMCID: PMC10648588 DOI: 10.3390/jcm12216723] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 10/13/2023] [Accepted: 10/18/2023] [Indexed: 11/15/2023] Open
Abstract
The anterolateral thigh (ALT) skin flap provides abundant, thin, pliable skin coverage with adequate pedicle length and calibre, and tolerable donor site morbidity. However, coverage of relatively large defects using the ALT flap alone is limited. We present our experience of using the ALT flap coupled with the vastus lateralis (VL) flap supplied by the same pedicle for large defect reconstruction. Between 2016 and 2020, ten patients with extensive lower-extremity or trunk defects were treated using the ALT/VL chimeric flap. The ALT portion was used to cover the cutaneous and joint defect while the VL part was used to resurface remnant defects, and a skin graft was performed. All flaps were based on the common descending pedicle, and branches to separate the components were individually dissected. All defects were successfully reconstructed using the ALT/VL chimeric flap. No surgery-related acute complications were observed, and the patients had no clinical issues with ambulation or running activities during the long-term follow-up period. With the separate components supplied by a common vascular pedicle, the ALT/VL chimeric flap allows us to reconstruct extensive defects with joint involvement or posterior trunk lesions. Thus, the ALT/VL chimeric flap may be a suitable alternative for extensive tissue defect reconstruction.
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Affiliation(s)
- Yoon Jae Lee
- Department of Plastic and Reconstructive Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 07345, Republic of Korea; (Y.J.L.); (J.H.K.)
| | - Junnyeon Kim
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.K.); (C.R.L.); (D.Y.O.); (Y.J.J.)
| | - Chae Rim Lee
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.K.); (C.R.L.); (D.Y.O.); (Y.J.J.)
| | - Jun Hyeok Kim
- Department of Plastic and Reconstructive Surgery, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 07345, Republic of Korea; (Y.J.L.); (J.H.K.)
| | - Deuk Young Oh
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.K.); (C.R.L.); (D.Y.O.); (Y.J.J.)
| | - Young Joon Jun
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.K.); (C.R.L.); (D.Y.O.); (Y.J.J.)
| | - Suk-Ho Moon
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea; (J.K.); (C.R.L.); (D.Y.O.); (Y.J.J.)
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Othman S, Colen DL, Azoury SC, Piwnica-Worms W, Fischer JP, Levin LS, Kovach SJ. Soft-Tissue Reconstruction of Complicated Total Ankle Arthroplasty. Foot Ankle Spec 2022; 15:464-471. [PMID: 33215522 DOI: 10.1177/1938640020969596] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Total ankle arthroplasty (TAA) is a popular modality to treat end-stage arthritis or internal ankle derangement. Unfortunately, failure rates remain undesirably high, with severe complications, including prosthesis failure, ankle fusion, and amputation. The importance of a stable soft-tissue envelope for coverage of implant compromise has been previously described, but the predictive factors for successful salvage of complicated TAA remain poorly understood. METHODS A retrospective review was conducted of patients requiring soft-tissue reconstruction following TAA wound complications. Patient demographics, history, microbiological data, reconstructive approach, and outcomes data were collected. Statistical analysis was used to abstract factors associated with unsuccessful prosthetic salvage. RESULTS In all, 13 patients met inclusion criteria: 8 (61.5%) achieved prosthetic salvage, and 5 (38.5%) failed. The majority (90.9%) of patients presented with infected joints. Reconstructive techniques included skin grafts, dermal substitutes, locoregional flaps, and free tissue transfer. Successful prosthetic salvage was associated with shorter time intervals between wound diagnosis and index reconstructive surgical intervention (median: 20 days for salvage vs 804 days for failure; P = .014). Additionally, salvage was associated with reduced time from the index orthopaedic/podiatric surgical intervention to the index reconstructive surgery procedure (12 vs 727 days; P = .027). CONCLUSION The prognosis of complicated TAA requiring soft-tissue reconstruction remains poor, especially in patients who present with infected joints. Several reconstructive techniques, ranging from simple skin grafts to complex free tissue transfers, can be used successfully. Early intervention to achieve soft-tissue coverage is crucial in maximizing salvage rates in the setting of complicated and infected TAA. LEVEL OF EVIDENCE Level IV.
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Affiliation(s)
- Sammy Othman
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - David L Colen
- Division of Plastic Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - William Piwnica-Worms
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - John P Fischer
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - L Scott Levin
- Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Orthopedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Addressing common orthopaedic calamities with microsurgical solutions. Injury 2021; 52:3561-3572. [PMID: 34030865 DOI: 10.1016/j.injury.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 05/04/2021] [Indexed: 02/02/2023]
Abstract
Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.
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Cunningham DJ, Ryan SP, Hong C, Mithani SK, Adams SB. Incidence and Risk Factors for Flap Coverage After Total Ankle Arthroplasty. Foot Ankle Int 2021; 42:744-749. [PMID: 33517785 DOI: 10.1177/1071100720982901] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Wound complications following total ankle arthroplasty (TAA) can have a significant impact on patient morbidity, particularly when they require flap coverage. We sought to determine the risk factors associated with the need for flap coverage after TAA and hypothesized that medical and operative risk factors such as diabetes and additional procedures would be associated with the need for flap coverage after TAA. METHODS We performed a single-center retrospective review of TAAs from April 2007 to February 2019. Patient demographics and medical comorbidities were collected, in addition to other procedures performed at the time of TAA. Patients were stratified by the need for flap coverage, and unadjusted inferential statistics were performed to evaluate the risk factors associated with subsequent need for flap coverage. RESULTS Among 2065 patients undergoing TAA, 28 (1.4%) patients required flap coverage after the index arthroplasty. Patients requiring flap coverage were older (P = .045), had higher Charlson comorbidity indices (P = .017), and had higher rates of diabetes and pulmonary disease (P = .038). Patients requiring flap coverage also had higher rates of additional procedures (P = .043, P = .007). The most common flap was a radial forearm free flap, which was performed in 14 (50%) patients. Twenty-one patients (75%) requiring flap coverage had a stable, plantigrade foot at median 1.5-year follow-up. CONCLUSION Patient and operative risk factors, including advanced age, increased comorbidity burden, diabetes, pulmonary disease, and increased number of simultaneous procedures, were significantly associated with need for subsequent flap coverage. This should be considered as the indications for TAA expand. LEVEL OF EVIDENCE Level III, retrospective, prognostic cohort study.
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Affiliation(s)
- Daniel J Cunningham
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Cierra Hong
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Suhail K Mithani
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
- Division of Plastic Surgery, Duke University Medical Center, Duke South, Durham, NC, USA
| | - Samuel B Adams
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, NC, USA
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Incidence of Major Arterial Abnormality in Patients with Wound Dehiscence after Lower Extremity Orthopedic Procedures. Plast Reconstr Surg 2020; 146:1382-1390. [PMID: 33234975 DOI: 10.1097/prs.0000000000007361] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Surgical dehiscence can occur after lower extremity orthopedic procedures. Underlying vascular aberrancy and localized ischemia contribute to chronic wound development requiring advanced techniques such as free tissue transfer. Localized vascular abnormality is an underrecognized contributing factor to such dehiscence. The authors reviewed their lower extremity free tissue transfer experience in this population to analyze the incidence of arterial abnormality and outcomes. METHODS The authors conducted a retrospective review of 64 lower extremity free tissue transfers performed for chronic wounds after orthopedic procedures from 2011 to 2018. The primary outcome was major arterial abnormality as identified on angiography. Secondary outcomes were flap success, limb salvage, and ambulation status. RESULTS The median age was 58 years, and 44 were men (69 percent). Comorbidities included osteomyelitis (77 percent), diabetes (39 percent), and peripheral vascular disease (17 percent). The incidence of arterial abnormality on angiography was 47 percent. Defect location correlated with angiosome of arterial abnormality in 53 percent. The flap success rate was 92 percent. Limb salvage and ambulation rates were 89 and 89 percent, respectively, at an average follow-up of 17.6 months. Men demonstrated an increased rate of limb salvage (p = 0.026). Diabetes (p = 0.012), arterial abnormality (p = 0.044), and arterial flap complication (p = 0.010) correlated with amputation. CONCLUSIONS The high incidence of arterial abnormality in this population highlights the importance of expedient multidisciplinary care, including vascular and plastic surgery. Diagnostic angiography is important for identifying major arterial abnormality and the need for free tissue transfer for definitive coverage.
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Barg A, Bettin CC, Burstein AH, Saltzman CL, Gililland J. Early Clinical and Radiographic Outcomes of Trabecular Metal Total Ankle Replacement Using a Transfibular Approach. J Bone Joint Surg Am 2018; 100:505-515. [PMID: 29557867 DOI: 10.2106/jbjs.17.00018] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In the last 2 decades, total ankle replacement has gained greater acceptance as a treatment option in patients with end-stage ankle osteoarthritis. However, there is a lack of literature on total ankle replacement using a lateral transfibular approach. Therefore, we sought to report early clinical and radiographic results for a patient cohort treated with total ankle replacement using a lateral transfibular approach, performed by a single surgeon. METHODS From October 2012 to December 2014, 55 primary total ankle arthroplasties using the Zimmer Trabecular Metal Total Ankle implant were performed in 54 patients (29 male and 25 female; mean age, 67.0 years). Clinical assessment, including pain evaluation and measurement of ankle range of motion, was conducted preoperatively and at the latest follow-up. Weight-bearing radiographs were used to determine angular alignment of the tibial and talar components and to analyze the bone-implant interface. Intraoperative and postoperative complications, revision surgeries, and survivorship were evaluated. RESULTS Implant survival was 93% at 24 months of follow-up. There were 3 revisions of a tibial component due to aseptic loosening. In 10 of the 55 cases, a secondary procedure was performed during follow-up. The mean follow-up duration was 26.6 ± 4.2 months. No delayed union or nonunion was observed for fibular healing. The average visual analog scale (VAS) pain score decreased significantly, from 7.9 ± 1.3 to 0.8 ± 1.2. The average total range of motion increased significantly, from 22.9° ± 12.7° to 40.2° ± 11.8°. CONCLUSIONS Early results of total ankle replacement using the Zimmer trabecular metal implant and the lateral transfibular approach demonstrated improved patient-reported outcomes and increased ankle motion at a minimum follow-up of 2 years. In the 55 consecutive cases, the fibular osteotomy required for access to the ankle healed without complications. Painful early loosening due to lack of osseous ingrowth required revision in 3 of 55 cases. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexej Barg
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
| | - Clayton C Bettin
- Department of Orthopaedics and Biomedical Engineering, University of Tennessee Health Science Center, Campbell Clinic, Memphis, Tennessee
| | - Albert H Burstein
- Department of Biomechanics and Biomaterials, Hospital for Special Surgery, New York, NY
| | | | - Jeremy Gililland
- Department of Orthopaedics, University of Utah, Salt Lake City, Utah
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Hallock GG. Soft Tissue Coverage After Revisional Foot and Ankle Surgery. Clin Podiatr Med Surg 2017; 34:389-398. [PMID: 28576197 DOI: 10.1016/j.cpm.2017.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Unlike the traumatic "mangled" foot and ankle in which amputation could be an acceptable if not preferred option, revisional foot and ankle surgery starts with a viable foot that is then injured by the surgeon hopefully to benefit the patient. Any untoward sequela, such as inadequate wound healing, instead always requires consideration of limb salvage. Unfortunately, this may not be so simple. A proactive approach to solve this problem in a timely fashion is important. The goal must always be to get a healed wound so the final result improves the ability for independent ambulation by the patient.
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Affiliation(s)
- Geoffrey G Hallock
- Division of Plastic Surgery, Sacred Heart Hospital, The Lehigh Valley Hospital, 1230 South Cedar Crest Boulevard, Suite 306, Allentown, PA 18103, USA.
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Avashia YJ, Shammas RL, Mithani SK, Parekh SG. Soft Tissue Reconstruction After Total Ankle Arthroplasty. Foot Ankle Clin 2017; 22:391-404. [PMID: 28502354 DOI: 10.1016/j.fcl.2017.01.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Wound complications following total ankle replacement are common. A team approach, including plastic surgeons, should be utilized to manage these wound issues. The handling of the wound, from the index procedure, to a variety of flaps, can be utilized to provide a successful outcome following an ankle replacement.
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Affiliation(s)
- Yash J Avashia
- Division of Plastic Surgery, Duke University, Room 135, Brown Zone, Duke South, Durham, NC 27710, USA
| | - Ronnie L Shammas
- Division of Plastic Surgery, Duke University, Room 135, Brown Zone, Duke South, Durham, NC 27710, USA
| | - Suhail K Mithani
- Division of Plastic Surgery, Department of Orthopaedic Surgery, Duke University, 3609 Southwest Durham Drive, Durham, NC 27707, USA
| | - Selene G Parekh
- North Carolina Orthopaedic Clinic, Department of Orthopaedic Surgery, Fuqua Business School, Duke University, 3609 Southwest Durham Drive, Durham, NC 27707, USA.
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Alrashidi Y, Galhoum AE, Wiewiorski M, Herrera-Pérez M, Hsu RY, Barg A, Valderrabano V. How To Diagnose and Treat Infection in Total Ankle Arthroplasty. Foot Ankle Clin 2017; 22:405-423. [PMID: 28502355 DOI: 10.1016/j.fcl.2017.01.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Periprosthetic infection after total ankle arthroplasty (TAA) is a serious complication, often requiring revision surgery, including revision arthroplasty, conversion to ankle arthrodesis, or even amputation. Risk factors for periprosthetic ankle infection include prior surgery at the site of infection, low functional preoperative score, diabetes, and wound healing problems. The clinical presentation of patients with periprosthetic ankle joint infection can be variable and dependent on infection manifestation: acute versus chronic. The initial evaluation in patients with suspected periprosthetic joint infections should include blood tests: C-reactive protein and erythrocyte sedimentation rate. Joint aspiration and synovial fluid analysis can help confirm suspected periprosthetic ankle infection.
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Affiliation(s)
- Yousef Alrashidi
- Orthopaedic Department, College of Medicine, Taibah University, P.O. Box 30001, Almadinah Almunawwarah 41411, Kingdom of Saudi Arabia
| | - Ahmed E Galhoum
- Nasser Institute for Research and Treatment, Cairo, Egypt; Department of Orthopaedics and Traumatology, Swiss Ortho Center, Schmerzklinik Basel, Hirschgässlein 15, Basel 4010, Switzerland
| | - Martin Wiewiorski
- Orthopaedic and Trauma Department, Kantonsspital Winterthur, Brauerstrasse 15, 8401 Winterthur, Switzerland
| | - Mario Herrera-Pérez
- Orthopaedic Department, University Hospital of Canary Islands, La Laguna, Calle El Pilar 50 4 piso, 38002 Tenerife, Spain
| | - Raymond Y Hsu
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Alexej Barg
- Department of Orthopaedics, University of Utah, 590 Wakara Way, Salt Lake City, UT 84108, USA
| | - Victor Valderrabano
- Orthopaedic Department, Swiss Ortho Center, Schmerzklinik Basel, Swiss Medical Network, Hirschgässlein 15, Basel 4010, Switzerland.
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