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Doshi A, Borle F, Bhola N. Unveiling the Extraordinary: A Rare Type IIIA Infra-Popliteal Arterial Variation in a Free Fibula Osteocutaneous Flap for Mandibular Reconstruction. Cureus 2024; 16:e59984. [PMID: 38854181 PMCID: PMC11162288 DOI: 10.7759/cureus.59984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Accepted: 05/09/2024] [Indexed: 06/11/2024] Open
Abstract
The free fibula flap (FFF), based on the peroneal artery (PA) system, is the gold standard for mandibular reconstruction. Various anatomical variations in the infra-popliteal lower limb vascular system exist. These variations present as an intraoperative surprise to surgeons even after an unremarkable clinical vascular examination of the leg. Here, we report one such case, where we performed successful mandibular reconstruction after encountering a Type IIIA variation of infra-popliteal arterial vasculature.
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Affiliation(s)
- Akash Doshi
- Oral and Maxillofacial Surgery, Sharad Pawar Dental College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Firoz Borle
- Plastic and Reconstructive Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Nitin Bhola
- Oral and Maxillofacial Surgery, Sharad Pawar Dental College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Kim KB, Ryu J, Lee JY. Fibular free flap with proximal perforator skin paddle due to aberrant anatomy - a case report. Maxillofac Plast Reconstr Surg 2024; 46:5. [PMID: 38376599 PMCID: PMC10879059 DOI: 10.1186/s40902-024-00416-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/29/2024] [Indexed: 02/21/2024] Open
Abstract
BACKGROUND The fibular free flap is considered one of the most valuable options for mandible reconstruction. A perforator flap has gained widespread acceptance in oral and maxillofacial reconstruction. Typically, the fibula flap is obtained primarily with the distal perforator due to its reliable blood supply, with less attention given to the proximal perforators during the harvesting process. Normally, the distal perforator of the fibula exhibits stability and shows limited anatomical variations. However, there have been reported cases in which the distal perforator is absent. At times, these vascular abnormalities remain undetectable through Doppler examination or preoperative angiography evaluation. Therefore, this case details the experience of encountering the rare event of vascular abnormality in oral cancer surgery. CASE PRESENTATION This article reports the case of a patient who presented with a congenital absence of the distal perforator in the peroneal artery, attributed to a vascular abnormality. Additionally, we provide a review of the concept of utilizing the proximal perforator as an alternative approach in the flap harvesting process. CONCLUSIONS While the distal perforator of the peroneal artery is typically utilized for fibula free flap procedures, surgeons must remain cognizant of the potential for its absence due to aberrant anatomy. Recognizing an alternative approach in such cases can be pivotal for precise surgical planning and favorable outcomes in oral and maxillofacial reconstruction.
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Affiliation(s)
- Kyu-Bum Kim
- Department of Oral & Maxillofacial Surgery, School of Dentistry, Pusan National University, Yangsan, Korea
| | - Jihye Ryu
- Department of Oral & Maxillofacial Surgery, School of Dentistry, Pusan National University, Yangsan, Korea
| | - Jae-Yeol Lee
- Department of Oral & Maxillofacial Surgery, School of Dentistry, Pusan National University, Yangsan, Korea.
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Kumar V, Gupta PK, Bindu A, Mantri M, Mathews S, Jaiswal D, Kant Shankhdhar V. Safety of free fibula flap harvest in IIIA and IIIB tibio-peroneal trunk variations. J Plast Reconstr Aesthet Surg 2023; 85:326-333. [PMID: 37541049 DOI: 10.1016/j.bjps.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 07/03/2023] [Accepted: 07/04/2023] [Indexed: 08/06/2023]
Abstract
INTRODUCTION In head and neck cancer malignancies, free fibula flap is the gold standard for reconstruction of segmental bone defects owing to its predictable anatomy, long bone length, and feasibility for multiple osteotomies. However, sometimes because of variations in anatomy of tibio-peroneal trunk, it is a dilemma for the surgeons to use free fibula flap for reconstruction. This case series aimed to evaluate the safety of harvest of fibula in such cases in terms of acute and chronic donor-site complications. MATERIAL AND METHODS A retrospective study was conducted from January 2018 to May 2021. All the patients with tibio-peroneal trunk anomaly, diagnosed during surgery, who underwent successful harvest of the free fibula were included in the study and analyzed for the early major and minor donor wound complications, long-term donor complications, and late functional deficit using the Foot and Ankle Disability Index (FADI). RESULTS Out of 714 free fibulae operated, 26 patients (3.6%) had such tibio-peroneal trunk variations: 22 (2.9%) cases of type III A and B anomalies and 4 (0.56%) cases of type III C anomalies. The average FADI score was 95.3%. No one had any difficulty in personal care and activity of daily living. CONCLUSIONS The free fibula flap can be safely harvested in patients with type III A and B anomalies if vascularity of foot after clamping of peroneal vessels is good and anterior tibial vessels are normal.
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Affiliation(s)
- Vineet Kumar
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
| | - Prince Kumar Gupta
- Department of Plastic and Reconstructive Surgery, HBCH and MPMMCC, Tata Memorial Centre, Varanasi and Homi Bhabha National Institute, Mumbai, India.
| | - Ameya Bindu
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
| | - Mayur Mantri
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
| | - Saumya Mathews
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
| | - Dushyant Jaiswal
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
| | - Vinay Kant Shankhdhar
- Department of Plastic and Reconstructive Surgery, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
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Lee CR, Kim SH, Kwon HJ, Ahn MY, Nam YS, Moon SH. Proximal peroneal perforator flap, cadaveric study, and clinical applications for shallow defect reconstructions. Microsurgery 2023. [PMID: 36756700 DOI: 10.1002/micr.31018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 12/02/2022] [Accepted: 01/19/2023] [Indexed: 02/10/2023]
Abstract
PURPOSE Peroneal artery perforator offers a versatile range of microvascular tissue transfer methods from local flaps to vascularized osteocutaneous fibula flaps. It is one of the few flaps that can cover shallow defects that require thin and pliable skin paddles, such as in hands and feet (Han et al., 2018). The proximal region of the lower leg offers such flexible and thin flap compared to the middle and distal lower leg (Winters & de Jongh, 1999). However, the anatomy of the proximal peroneal artery perforator is relatively unknown in literature and its proximity to the common peroneal nerve (CPN) has not yet been studied. This study conducted a cadaveric study and put it in application into clinical settings. METHODS Twenty lower leg specimens were dissected according to the methods of clinical proximal peroneal artery perforator flap harvest. Perforators arising in the proximal lower leg area of between 20 and 40 percentile of fibular length were inspected. Perforator length, location from fibular head, course, and location of CPN were recorded. Clinical reconstruction cases using the proximal lateral lower leg were analyzed. Six patients between the ages of thirty and seventy were included. Five cases were due to trauma, and one from mass excision, but all required thin and pliable flaps for reconstructions in hands or feet. Flaps were designed concentrical oval shapes, and harvest was done similarly to cadaveric perforator dissection, but perforator dissection was done only up to the required pedicle length. Perforator length, flap size, thickness, and long-term complications were recorded. RESULTS Among 20 specimens, a total of 20 perforators were found in 18 cadavers (90%). Two specimens showed no perforators while two specimens showed multiple perforators. The perforators were located at an average of 101 mm from fibular head, with an average length of 55 mm ranging from 20 to 153 mm. The average size of perforator at origin was 2.0 mm, ranging from 1.0 to 3.6 mm. 45% showed septocutaneous course and 55% intramuscular course. Two out of 20 perforators were shown to arise from source vessels other than the peroneal artery. All clinical cases were successful without complications or debulking for contour shaping. Flap sizes ranged from 15 to 40 cm2 . Largest flap width was 5 cm, and all donor sites were primarily closed without complications. One year of follow-up showed no complications. CONCLUSION Proximal peroneal artery perforator flap provides a reliable pedicle for a versatile tissue transfer. This study shows that the perforators of the proximal lateral lower leg often arise from vessels other than the peroneal artery, such as the anterior tibial artery or popliteal artery, as had been previously reported (Winters & de Jongh, 1999). Although the source vessel varies, perforator anatomy is at a safe distance from CPN. This variation of source vessels suggests a change in nomenclature to "proximal peroneal perforator flap." The clinical applications of this flap showed that it can be effectively used for reconstructions of shallow defects, such as in the hands and feet without secondary procedures for debulking.
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Affiliation(s)
- Chae Rim Lee
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Sang Hyun Kim
- Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hyo Jeong Kwon
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
| | - Min Young Ahn
- Catholic Institute for Applied Anatomy, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Yong Seok Nam
- Department of Anatomy, College of Korean Medicine, Dongshin University, Chonnam, Republic of Korea
| | - Suk-Ho Moon
- Department of Plastic and Reconstructive Surgery, Seoul St. Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea
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Chappell AG, Ramsey MD, Dabestani PJ, Ko JH. Vascularized Bone Graft Reconstruction for Upper Extremity Defects: A Review. Arch Plast Surg 2023; 50:82-95. [PMID: 36755653 PMCID: PMC9902088 DOI: 10.1055/s-0042-1758639] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 08/04/2022] [Indexed: 02/09/2023] Open
Abstract
Upper extremity reconstruction may pose clinical challenges for surgeons due to the often-critical, complex functional demands of the damaged and/or missing structures. The advent of vascularized bone grafts (VBGs) has aided in reconstruction of upper extremity (UE) defects due to their superior regenerative properties compared with nonvascularized bone grafts, ability to reconstruct large bony defects, and multiple donor site options. VBGs may be pedicled or free transfers and have the potential for composite tissue transfers when bone and soft tissue are needed. This article provides a comprehensive up-to-date review of VBGs, the commonly reported donor sites, and their indications for the treatment of specific UE defects.
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Affiliation(s)
- Ava G. Chappell
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Matthew D. Ramsey
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Parinaz J. Dabestani
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Loyola University Medical Center, Maywood, Illinois
| | - Jason H. Ko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois,Address for correspondence Jason H. Ko, MD, MBA, Associate Professor, Program Director Plastic Surgery Residency, Division of Plastic and Reconstructive SurgeryDepartment of Orthopedic Surgery, Northwestern University Feinberg School of MedicineChicago, IL 60611
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The Versatility of Atherosclerotic Cardiovascular Disease Risk Score in Determination of Popliteal Artery Branches Patency in Computed Tomography Angiography. Plast Reconstr Surg Glob Open 2023; 11:e4791. [PMID: 36733947 PMCID: PMC9886511 DOI: 10.1097/gox.0000000000004791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 12/07/2022] [Indexed: 01/29/2023]
Abstract
The atherosclerotic cardiovascular disease (ASCVD) risk score is used to estimate coronary artery disease and stroke risk. Atherosclerosis affects arteries throughout the body, including the legs, causing peripheral arterial disease. Atherosclerosis causes luminal stenosis in popliteal artery branches, which affects operative decisions such as intravascular surgery, and lower limb reconstruction. The objective was to investigate the relationship between the ASCVD risk score and degree of stenosis among the popliteal artery and its branches. Methods The data regarding all patients who underwent computed tomography angiography (CTA) of the legs during 2016-2021 with complete data for ASCVD risk score assessment were recruited. The association between luminal stenosis from CTA and calculated ASCVD risk score was analyzed. Results A total of 383 limbs of 117 men and 81 women, averaged 66.5 years old, were studied. Common comorbidities included hypertension (84.3%), diabetes mellitus (61.1%), and chronic kidney disease (34.3%). Average 10-year ASCVD risks in the greater than or equal to 50% stenosis group of popliteal, anterior tibial, and posterior tibial arteries were significantly higher than the less than 50% stenosis group (P < 0.01). The peroneal artery had no significant difference between stenosis groups. The popliteal artery had significantly higher lifetime ASCVD risks than in the greater than or equal to 50% stenosis group (P < 0.01), but the other arteries showed no statistically significant difference. Conclusions The 10-year ASCVD risks showed significant higher values in the greater than or equal to 50% stenosis group of popliteal, anterior tibial, and posterior tibial arteries. These findings can establish the further study on how ASCVD risks can be applied to predict the stenosis of these arteries and guide the rationale of preoperative leg CTA for FFF harvest.
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Morton ZE, Davis PL, Brown RO, Thomas WW. Adjustment of radial forearm free flap design around self-inflicted wrist wounds. Arch Clin Cases 2022; 9:94-99. [PMID: 36176491 PMCID: PMC9512133 DOI: 10.22551/2022.36.0903.10210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
The radial forearm free flap (RFFF) is one option of many free-tissue flaps that is frequently selected to reconstruct defects of the head and neck. It is popular due to its relatively thin and pliable associated soft tissue, reliable supplying vasculature, and appropriate diameter and length of the supplying vessels to perform microvascular anastomosis. This case report describes the use of the RFFF to reconstruct an oral cavity defect following tumor resection in a patient who required adjustment of the typical RFFF design. This patient has a significant psychiatric history leading to self-induced forearm lacerations that resulted in substantial scarring of her bilateral forearms in the anatomical area typically included in the RFFF. Since the RFFF was the optimal reconstructive option for this patient, the design of the RFFF was able to be moved proximally up her forearm to avoid inclusion of the scars in the flap. Adequate blood flow of the ulnar artery was confirmed with an Allen's test preoperatively to ensure the radial artery could be taken as part of the RFFF without causing ischemia of the hand. Following surgical resection of the patient's tumor, the RFFF was harvested and inset to reconstruct the resulting oral cavity defect. The patient has had no complications following her resection and reconstruction to date. This report highlights the adaptability of the RFFF, allowing adjustments to typical flap design to optimize outcomes for each individualized patient.
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Affiliation(s)
- Zoey E. Morton
- University of South Carolina School of Medicine Greenville, Greenville, SC, United States.,Corresponding author. Zoey Morton, University of South Carolina School of Medicine Greenville, 607 Grove Rd, Greenville, SC 29605, USA.
| | - Paul L. Davis
- Greenville ENT and Allergy Associates, Greenville, SC, United States
| | - Robert O. Brown
- Greenville ENT and Allergy Associates, Greenville, SC, United States
| | - W. Walsh Thomas
- Greenville ENT and Allergy Associates, Greenville, SC, United States
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Talwar A, Bai J, Wester JR, Attar S, Peabody TD, Ko JH. Vascularized Medial Femoral Condyle Periosteal Flaps With Allograft Bone for Distal Radius Giant Cell Tumors: A Case Report. JBJS Case Connect 2022; 12:01709767-202209000-00033. [PMID: 36049023 DOI: 10.2106/jbjs.cc.21.00652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CASE Distal radius reconstruction after giant cell tumor (GCT) resection is typically performed with free fibular flaps when a vascularized bone is needed. However, vascularized fibular flaps are contraindicated in patients with peroneal artery variants. We present 2 patients with GCTs of the radius and bilateral peronea arteria magna who underwent resection with wrist fusion using an allograft bone and vascularized free medial femoral condyle periosteal flaps. Both patients had excellent outcomes with minimal postoperative morbidity. CONCLUSION Allograft bone with vascularized medial femoral condyle periosteal flaps is an effective option for reconstructing distal radius defects after GCT resection when conventional methods fail.
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Affiliation(s)
- Abhinav Talwar
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jennifer Bai
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - James R Wester
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Samer Attar
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Terrance D Peabody
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Jason H Ko
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
- Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Rosli MA, Wan Sulaiman WA, Halim AS. A Lucky Case of Successful Free Fibula Osteocutaneous Flap Harvest in Peronea Arteria Magna. Arch Plast Surg 2022; 49:253-257. [PMID: 35832676 PMCID: PMC9045525 DOI: 10.1055/s-0042-1744411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
The free fibula flap (FFF) is based on the peroneal artery (PA) system, and it is well known that several anatomical variations of the lower limb vascular system exist, including peronea arteria magna (PAM). PAM is a rare congenital variation in which both anterior tibial artery and posterior tibial artery are either aplastic or hypoplastic, and as a result, PA will be the dominant blood supply to the foot. This variation was described as type III-C in Kim-Lippert's Classification of the Infra-Popliteal Arterial Branching Variations. The awareness of its existence is crucial as it often precludes FFF from being harvested due to the risk of significant limb ischemia and limb loss. Despite some literature reporting donor site complications and impending limb loss following FFF harvest in PAM, preoperative vascular mapping before FFF transfer remains controversial among the microsurgeons. We present a case with an incidental intraoperative finding of PAM that had a successful FFF harvest by luck, without preoperative vascular mapping.
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Affiliation(s)
- Mohamad Aizat Rosli
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
- Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
| | - Wan Azman Wan Sulaiman
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
- Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
| | - Ahmad Sukari Halim
- Hospital Universiti Sains Malaysia, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
- Reconstructive Sciences Unit, School of Medical Sciences, Universiti Sains Malaysia, Kota Bharu, Kelantan, Malaysia
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Knitschke M, Baumgart AK, Bäcker C, Adelung C, Roller F, Schmermund D, Böttger S, Streckbein P, Howaldt HP, Attia S. Impact of Periosteal Branches and Septo-Cutaneous Perforators on Free Fibula Flap Outcome: A Retrospective Analysis of Computed Tomography Angiography Scans in Virtual Surgical Planning. Front Oncol 2022; 11:821851. [PMID: 35127535 PMCID: PMC8807634 DOI: 10.3389/fonc.2021.821851] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 12/24/2021] [Indexed: 11/13/2022] Open
Abstract
BackgroundVirtual surgical planning (VSP) for jaw reconstruction with free fibula flap (FFF) became a routine procedure and requires computed tomography angiography (CTA) for preoperative evaluation of the lower limbs vascular system and the bone. The aim of the study was to assess whether the distribution and density of periosteal branches (PB) and septo-cutaneous perforators (SCP) of the fibular artery have an impact on flap success.MethodThis retrospective clinical study assessed preoperative CTA of the infra-popliteal vasculature and the small vessel system of 72 patients who underwent FFF surgery. Surgical outcome of flap transfer includes wound healing, subtotal, and total flap loss were matched with the segmental vascular supply.ResultA total of 72 patients (28 females, 38.9 %; 44 males, 61.1 %) fulfilled the study inclusion criteria. The mean age was 58.5 (± 15.3 years). Stenoses of the lower limbs’ vessel (n = 14) were mostly detected in the fibular artery (n = 11). Flap success was recorded in n = 59 (82.0%), partial flap failure in n = 4 (5.5%) and total flap loss in n = 9 (12.5%). The study found a mean number (± SD) of 2.53 ± 1.60 PBs and 1.39 ± 1.03 SCPs of the FA at the donor-site. The proximal FFF segment of poly-segmental jaw reconstruction showed a higher rate of PB per flap segment than in the distal segments. Based on the total number of prepared segments (n = 121), 46.7% (n = 7) of mono-, 40.4% (n = 21) of bi-, and 31.5 % (n = 17) of tri-segmental fibula flaps were at least supplied by one PB in the success group. Overall, this corresponds to 37.2% (45 out of 121) of all successful FFF. For total flap loss (n = 14), a relative number of 42.9% (n = 6) of distinct supplied segments was recorded. Wound healing disorder of the donor site was not statistically significant influenced by the detected rate of SCP.ConclusionIn general, a correlation between higher rates of PB and SCP and the flap success could not be statistically proved by the study sample. We conclude, that preoperative PB and SCP mapping based on routine CTA imaging is not suitable for prediction of flap outcome.
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Affiliation(s)
- Michael Knitschke
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
- *Correspondence: Michael Knitschke,
| | - Anna Katrin Baumgart
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
| | - Christina Bäcker
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
| | - Christian Adelung
- Department of Diagnostic and Interventional Radiology and Pediatric Radiology, Justus-Liebig-University, Giessen, Germany
| | - Fritz Roller
- Department of Diagnostic and Interventional Radiology and Pediatric Radiology, Justus-Liebig-University, Giessen, Germany
| | - Daniel Schmermund
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
| | - Sebastian Böttger
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
| | - Philipp Streckbein
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
| | - Hans-Peter Howaldt
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
| | - Sameh Attia
- Department of Oral and Maxillofacial Surgery, Justus-Liebig-University, Giessen, Germany
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Marttila E, Salli M, Mesimäki K, Kainulainen S, Snäll J, Wilkman T. The combined anterolateral thigh-Partial iliac crest minihybrid free flap for mandibular reconstruction. Microsurgery 2021; 42:312-318. [PMID: 34967042 DOI: 10.1002/micr.30854] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 09/29/2021] [Accepted: 11/29/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND AND AIMS Tumors of the oral cavity often require extensive resections leading to significant hard and soft tissue defects. Microvascular free flaps, consisting of both hard and soft tissue, are often required in reconstructions. Hybrid flaps, composed of two different joint free flaps, offer potential alternatives for head and neck reconstruction. This report presents our results with a modified hybrid ALT/DCIA, that is, minihybrid free flap (MH-flap) composed of the anterolateral thigh (ALT) and a partial inner lamina iliac crest only (partial DCIA) for reconstruction of the mandibular region. PATIENTS AND METHODS Eight patients underwent oral cancer reconstruction of the mandible with the MH-flap. The MH-flap was harvested sparing the outer crest and lamina of crista, and its pedicle was combined to the distal pedicle of ALT. Clinical data and postoperative complications were analyzed. RESULTS The mean length of the osseous graft was 64 mm (range 54-78 mm). None of the patients had complications requiring surgical intervention. No donor site complications were observed. The overall survival rate was 100%. The mean length of follow-up was 16 months (range 7-30 months). CONCLUSIONS According to our results, the ALT-partial DCIA MH-flap has postoperative outcomes comparable to those of the fibular flap. The flap is a good option with excellent bone properties for reconstruction of limited mandibular defects not suitable for fibular or scapular reconstruction.
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Affiliation(s)
- Emilia Marttila
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Malla Salli
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Karri Mesimäki
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Satu Kainulainen
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Johanna Snäll
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
| | - Tommy Wilkman
- Department of Oral and Maxillofacial Diseases, Helsinki University Hospital, Helsinki, Finland
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Dargan D, Lakshminarayan R, Chuo CB. Free gracilis end-to-side microanastomosis to a peronea arteria magna: a case report. J Med Case Rep 2021; 15:601. [PMID: 34903282 PMCID: PMC8667773 DOI: 10.1186/s13256-021-03133-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 09/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Complex orthoplastic lower limb trauma in individuals with multiple injuries requires considerable resources and interdisciplinary collaboration for good outcomes. We present the first reported end-to-side free flap microanastomosis for lower limb trauma reconstruction involving a peronea arteria magna without radiographic collaterals. CASE PRESENTATION A 55-year-old Caucasian gentleman involved in road traffic collision sustained an open tibial fracture on the anteromedial distal third of the left lower leg with local degloving and a subtotal right foot and ankle degloving. Both injuries were reconstructed with free tissue transfer. A left lower limb peronea arteria magna successfully received a free gracilis muscle flap by end-to-side microanastomosis and perfusion of the foot was preserved. This rare anatomical variant and its anatomy is reviewed, as well as a description of the suggested preoperative planning and technique for reconstruction. CONCLUSIONS Successful free flap reconstruction may be performed to a lower limb with a peronea arteria magna recipient as the lone vessel supplying the foot in trauma, although preoperative counseling of the risks, benefits, and options are essential. LEVEL OF EVIDENCE Level V, case report.
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Affiliation(s)
- Dallan Dargan
- Department of Plastic Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK.
| | | | - Cher Bing Chuo
- Department of Plastic Surgery, Hull University Teaching Hospitals NHS Trust, Hull, UK
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13
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Ma C, Wang L, Tian Z, Qin X, Zhu D, Qin J, Shen Y. Standardize routine angiography assessment of leg vasculatures before fibular flap harvest: lessons of congenital and acquired vascular anomalies undetected by color Doppler and physical examinations. Acta Radiol 2021; 62:1716-1725. [PMID: 33455413 DOI: 10.1177/0284185120980001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Fibular flaps have been widely used for mandibular and maxillary reconstructions. On occasion, anatomical variants of fibular arteries (FA) will be encountered. PURPOSE Although anatomical variants of FA during fibular harvest have been reported, controversy exists regarding whether simple color Doppler ultrasonography (CDU) and physical examinations (PE) are sufficient for early preoperative detection. MATERIAL AND METHODS A 10-year retrospective analysis in our department was performed to find the patients with various FA anomalies confirmed by computed tomography angiography (CTA) or intraoperative findings. RESULTS A total number of 19 FA anomalies were found either pre- or intraoperatively in 16 patients, in whom three cases were with bilateral FA variants. Type IIIC variants, also called arteria peronea magna (great peroneal artery), were confirmed in two legs, while the majority (13 legs) had type IIIA hypoplastic/aplastic posterior tibialis arteries (PTA). Four legs had new type IIID (low FA and PTA bifurcations). Preoperative CDU and PE only suspected anomalies in two legs. Six cases proceeded with using the affected fibulas, within whom vascular grafts were used in half of them for lengthening the FA pedicle. Local ischemia, partial soleus muscle necrosis, and claudication were reported in one. CONCLUSIONS Routine CTA before every fibular harvest, rather than simple PE and CDU, should be added for screening contraindications and ensuring safety for fibular flap harvest.
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Affiliation(s)
- Chunyue Ma
- Department of Oral & Maxillofacial – Head & Neck Oncology, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, PR China
| | - Lei Wang
- Department of Oral & Maxillofacial – Head & Neck Oncology, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, PR China
| | - Zhuowei Tian
- Department of Oral & Maxillofacial – Head & Neck Oncology, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, PR China
| | - Xingjun Qin
- Department of Oral & Maxillofacial – Head & Neck Oncology, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, PR China
| | - Dan Zhu
- Department of Radiology, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Jinbao Qin
- Department of Vascular Surgery, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, PR China
| | - Yi Shen
- Department of Oral & Maxillofacial – Head & Neck Oncology, 9th People’s Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai Key Laboratory of Stomatology, Shanghai, PR China
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14
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Abdel Razek AAK, Saleh GA, Denever AT, Mukherji SK. Preimaging and Postimaging of Graft and Flap in Head and Neck Reconstruction. Magn Reson Imaging Clin N Am 2021; 30:121-133. [PMID: 34802575 DOI: 10.1016/j.mric.2021.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Head and neck reconstructive surgical techniques are complex; now the microvascular free tissue transfer is the most frequently used. The postreconstruction imaging interpretation is challenging due to the altered anatomy and flap variability. We aim to improve radiologists' knowledge with diverse methods of flap reconstruction for an accurate appreciation of their expected cross-sectional imaging appearance and early detection of tumor recurrence and other complication.
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Affiliation(s)
| | - Gehad A Saleh
- Faculty of Medicine, Department of Diagnostic Radiology, Mansoura University, Elgomhoria Street, Mansoura 35512, Egypt
| | - Adel T Denever
- Faculty of Medicine, Department of Surgery, Mansoura University, Elgomhoria Street, Mansoura 35512, Egypt
| | - Suresh K Mukherji
- Marian University, Head and Neck Radiology, ProScan Imaging, Carmel, IN, USA.
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15
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Computed Tomography Angiography (CTA) before Reconstructive Jaw Surgery Using Fibula Free Flap: Retrospective Analysis of Vascular Architecture. Diagnostics (Basel) 2021; 11:diagnostics11101865. [PMID: 34679563 PMCID: PMC8534841 DOI: 10.3390/diagnostics11101865] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 10/06/2021] [Accepted: 10/08/2021] [Indexed: 11/16/2022] Open
Abstract
Computed tomography angiography (CTA) is widely used in preoperative evaluation of the lower limbs' vascular system for virtual surgical planning (VSP) of fibula free flap (FFF) for jaw reconstruction. The present retrospective clinical study analysed n = 72 computed tomography angiographies (CTA) of lower limbs for virtual surgical planning (VSP) for jaw reconstruction. The purpose of the investigation was to evaluate the morphology of the fibular bone and its vascular supply in CTA imaging, and further, the amount and distribution of periosteal branches (PB) and septo-cutaneous perforators (SCPs) of the fibular artery. A total of 144 lower limbs was assessed (mean age: 58.5 ± 15.3 years; 28 females, 38.9%; 44 males, 61.1%). The vascular system was categorized as regular (type I-A to II-C) in 140 cases (97.2%) regarding the classification by Kim. Absent anterior tibial artery (type III-A, n = 2) and posterior tibial artery (type III-B, n = 2) were detected in the left leg. Stenoses were observed mostly in the fibular artery (n = 11), once in the anterior tibial artery, and twice in the posterior tibial artery. In total, n = 361 periosteal branches (PBs) and n = 231 septo-cutaneous perforators (SCPs) were recorded. While a distribution pattern for PBs was separated into two clusters, a more tripartite distribution pattern for SCPs was found. We conclude that conventional CTA for VSP of free fibula flap (FFF) is capable of imaging and distinguishing SCPs and PBs.
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16
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The congenital popliteal vasculature patterns in fibular free flap reconstruction by means of surgical anatomy in cadavers. Sci Rep 2021; 11:19584. [PMID: 34599273 PMCID: PMC8486740 DOI: 10.1038/s41598-021-99203-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Accepted: 09/22/2021] [Indexed: 11/17/2022] Open
Abstract
Fibular free flap (FFF) is frequently used for reconstruction requiring vascularized bone. Thus, understanding its vasculature variation is crucial. This study investigates the popliteal artery branching variations in Thai cadavers and compares them with previous studies. One hundred and sixty-two legs from 81 formalin-embalmed cadavers were dissected. The popliteal artery branching patterns were classified. The previous data retrieved from cadaveric and angiographic studies were also collected and compared with the current study. The most common pattern is type I-A (90.7%). For the variants, type III-A was the majority among variants (6.2%). Type IV-A, hypoplastic peroneal artery, was found in one limb. A symmetrical branching pattern was found in 74 cadavers. Compared with cadaveric studies, type III-B and III-C are significantly common in angiographic studies (p = 0.015 and p = 0.009, respectively). Type I-A is most common according to previous studies. Apart from this, the prevalence of type III-A variant was higher than in previous studies. Furthermore, type III-B and III-C are more frequent in angiographic studies which might be from atherosclerosis. Thus, if the pre-operative CTA policy is not mandatory, the patients at risk for atherosclerosis and population with high variants prevalence should undergo pre-operative CTA with cost-effectiveness consideration.
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17
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FFF Utilizing an Arteriovenous Vascular Loop of Two Peroneal Venae Comitantes for a PAM. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3790. [PMID: 34522567 PMCID: PMC8432636 DOI: 10.1097/gox.0000000000003790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 06/30/2021] [Indexed: 11/29/2022]
Abstract
Vascularized bone grafting is widely used for reconstruction of osseous defects of the forearm. Fibular free flap (FFF) is one option, which relies on harvesting the peroneal artery. This procedure is subject to lower extremity anatomic variants; therefore, some recommend preoperative angiography. However, high quality evidence for this approach and its cost-effectiveness are lacking and instead one can diligently assess the vascular anatomy intraoperatively. Here, we describe a case of a 73-year-old man who was found to have a peronea arteria magna intraoperatively during an FFF for a left radius reconstruction secondary to an infectious nonunion. We describe an approach to performing an FFF using an arteriovenous vascular loop through the fibula employing the two accompanying peroneal venae comitantes. The patient had no complications and was found to have appropriate healing of the upper extremity without lower extremity compromise at 3-month follow-up. This report illustrates an alternative to using an interpositional venous graft for peronea arteria magna found intraoperatively during FFFs.
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18
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Impact of Planning Method (Conventional versus Virtual) on Time to Therapy Initiation and Resection Margins: A Retrospective Analysis of 104 Immediate Jaw Reconstructions. Cancers (Basel) 2021; 13:cancers13123013. [PMID: 34208555 PMCID: PMC8235255 DOI: 10.3390/cancers13123013] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/11/2021] [Accepted: 06/13/2021] [Indexed: 12/24/2022] Open
Abstract
Simple Summary Computer-aided design and manufacturing of osseous reconstructions are currently widely used in jaw reconstructive surgery, providing an improved surgical outcome and decreased procedural stumbling block. However, data on the influence of planning time on the time-to-surgery initiation and resection margin are missing in the literature. This retrospective, monocentric study compares process times from the first patient contact in hospital, time of in-house or out-of-house biopsy for tumor diagnosis and surgical therapy of tumor resection, and immediate reconstruction of the jaw with free fibula flaps (FFF). Two techniques for reconstruction are used: Virtual surgical planning (VSP) and non-VSP. A total of 104 patients who underwent FFF surgery for immediate jaw reconstruction from 2002 to 2020 are included. The study findings fill the gaps in the literature and obtain clear insights based on the investigated study subjects. Abstract Virtual surgical planning (VSP) and patient-specific implants are currently increasing for immediate jaw reconstruction after ablative oncologic surgery. This technique contributes to more accurate and efficient preoperative planning and shorter operation time. The present retrospective, single-center study analyzes the influence of time delay caused by VSP vs. conventional (non-VSP) reconstruction planning on the soft and hard tissue resection margins for necessary oncologic safety. A total number of 104 cases of immediate jaw reconstruction with free fibula flap are included in the present study. The selected method of reconstruction (conventionally, non-VSP: n = 63; digitally, VSP: n = 41) are analyzed in detail. The study reveals a statistically significant (p = 0.008) prolonged time to therapy initiation with a median of 42 days when the VSP method compared with non-VSP (31.0 days) is used. VSP did not significantly affect bony or soft tissue resection margin status. Apart from this observation, no significant differences concerning local tumor recurrence, lymph node, and distant metastases rates are found according to the reconstruction method, and affect soft or bone tissue resection margins. Thus, we conclude that VSP for immediate jaw reconstruction is safe for oncological purposes.
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19
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Qazi E, Wilting J, Patel NR, Alenezi AO, Kennedy SA, Tan KT, Jaberi A, Mafeld S. Arteries of the Lower Limb-Embryology, Variations, and Clinical Significance. Can Assoc Radiol J 2021; 73:259-270. [PMID: 33886403 DOI: 10.1177/08465371211003860] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES The purpose of this article is to review the embryology of the lower limb arterial anatomy along with common variants and their clinical relevance. DESIGN Embryologic variations of the lower limb arterial system may be explained by i.) persistence of primordial arterial segments, ii.) abnormal fusion, iii.) segmental hypoplasia/absence, or a combination of both. Persistent sciatic artery, corona mortis, and popliteal entrapment syndrome will also be discussed with associated symptoms, and potential complications. CONCLUSION Knowledge of these variations is essential for surgical and endovascular management as failure to recognize them can result in complications.
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Affiliation(s)
- Emmad Qazi
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Joerg Wilting
- Department of Anatomy and Cell Biology, Georg-August-University Goettingen, Kreuzbergring, Germany
| | - Neeral R Patel
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Abdullah O Alenezi
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sean A Kennedy
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kong T Tan
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Arash Jaberi
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Sebastian Mafeld
- Department of Medical Imaging, University Health Network, University of Toronto, Toronto, Ontario, Canada
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20
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Betar NM, Subramaniam SS, Borgna SC. Fibula free flap with type IIIB popliteal artery branching: a case report and recommendations. EUROPEAN JOURNAL OF PLASTIC SURGERY 2021. [DOI: 10.1007/s00238-020-01673-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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21
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Abstract
Reconstruction of critical size bone defects in the lower extremity poses a significant risk to not only limb malfunction but also amputation. The reconstructive goal of free bone flaps is to provide vascularized bone that restores length and stability. This applies to the native limb and also in amputations when a vascularized length of bone is required to maintain level of amputation. Multiple anatomic regions of the lower extremity may be successfully reconstructed with the fibula free flap.
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Affiliation(s)
- Christopher Bibbo
- Foot & Ankle Surgery, Plastic Reconstructive & Microsurgery, Orthopaedic Trauma and MSK Infection Services, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, 2401 West Belvedere Avenue, Baltimore, MD 21215, USA.
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22
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Vieira L, Isacson D, Dimovska EOF, Rodriguez-Lorenzo A. Four Lessons Learned from Complications in Head and Neck Microvascular Reconstructions and Prevention Strategies. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3329. [PMID: 33564573 PMCID: PMC7858199 DOI: 10.1097/gox.0000000000003329] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 10/28/2020] [Indexed: 12/29/2022]
Abstract
Free flap reconstruction in the head and neck region is a complex field in which patient comorbidities, radiation therapy, tumor recurrence, and variability of clinical scenarios make some cases particularly challenging and prone to devastating complications. Despite low free flap failure rates, the impact of flap failure has enormous consequences for the patients. METHODS Acknowledging and predicting high risk intra- and postoperative situations and having planned strategies on how to deal with them can decrease their rate and improve the patient's reconstructive journey. RESULTS Herein, the authors present 4 examples of significant complications in complex microvascular head and neck cancer reconstruction, encountered for the last 10 years: compression and kinking of the vascular pedicle, lack of planning of external skin coverage in osteoradionecrosis, management of the vessel-depleted neck, and vascular donor site morbidity after fibula harvest. CONCLUSION The authors reflect on the causes and propose preventative strategies in each peri-operative stage.
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Affiliation(s)
- Luís Vieira
- *From the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Daniel Isacson
- *From the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Eleonora O. F. Dimovska
- *From the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Andres Rodriguez-Lorenzo
- *From the Department of Plastic and Maxillofacial Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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23
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Venkatesh MS, Kumaraswamy MK, Shivalingappa SK, Waiker VP. Fibula Musculo-Osteocutaneous Flap with Full Thickness of Flexor Hallucis Longus Muscle. World J Plast Surg 2021; 10:22-29. [PMID: 33833950 PMCID: PMC8016380 DOI: 10.29252/wjps.10.1.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Fibula flap has been a gold standard method for reconstruction of the mandible. It has been used for reconstruction of maxilla as well as long bones, effectively. Fibula flap in selected cases has been used as a pedicled flap. The flexor hallucis longus muscle has been used to obliterate the dead space during the reconstruction. With a wide range of indications, the use of flexor hallucis muscle has studied for the reconstruction. METHODS In a retrospective case record analysis study, 38 subjects were enrolled, included 32 patients with reconstruction of mandible, 1 patient with reconstruction of maxilla, 4 patients with 3 free flaps and 1 pedicled flap with reconstruction of the tibia. RESULTS The success rate was 89%, with 4 flap failures. The muscle was used for reconstruction of the tongue, floor of the mouth, antrum, and to cover the fibula graft. CONCLUSION Flexor hallucis longus muscle harvested with the flap could decrease the operative time, ease the harvest, and fill the dead space during reconstruction.
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Affiliation(s)
- Mysore Srinivas Venkatesh
- Department of Plastic Surgery, Ramaiah Medical College and Hospital, Bengaluru, 560040, Bangalore, India
| | - Mohan Kumar Kumaraswamy
- Department of Plastic Surgery, Ramaiah Medical College and Hospital, Bengaluru, 560040, Bangalore, India
| | | | - Veena Prabhakar Waiker
- Department of Plastic Surgery, Ramaiah Medical College and Hospital, Bengaluru, 560040, Bangalore, India
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24
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Schuderer JG, Meier JK, Klingelhöffer C, Gottsauner M, Reichert TE, Wendl CM, Ettl T. Magnetic resonance angiography for free fibula harvest: anatomy and perforator mapping. Int J Oral Maxillofac Surg 2019; 49:176-182. [PMID: 31564478 DOI: 10.1016/j.ijom.2019.09.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 07/17/2019] [Accepted: 09/10/2019] [Indexed: 01/21/2023]
Abstract
The purpose of this study was to outline lower leg vessel anatomy and to investigate reliability and limitations of magnetic resonance angiography (MRA) in patients proposed for microvascular fibula transplantation (free fibula flap (FFF)). We retrospectively investigated MRAs of 99 patients considered for FFF. Frontal MRA planes and maximal intensity projections (MIPs) were evaluated for fibula lengths, anatomical branching pattern, arterial stenoses and fibular perforator positions in both legs (n=198). Normal branching patterns were observed in 168 (85.3%) legs. Twenty-nine (14.7%) legs presented abnormal branching patterns. Once (0.5%) the anterior, 19 times (9.6%) the posterior tibial artery were absent or hypoplastic. Nine (4.6%) lower legs presented an arteria peronea magna. Average length of the tibiofibular trunk (TFT) was 3.3±0.15cm. A total of 492 perforators were found with an average of 2.5 (±0.82±0.99) perforators per leg. A mapping of perforator run-offs was illustrated true to scale. Lower limb stenoses were distributed in the anterior tibial artery (14.1%), in the posterior tibial artery (11.1%) and in the fibular artery (8.1%). Smoking (P=0.828), diabetes (P=0.727) and peripheral arterial occlusive disease (P=0.172) did not correlate with presence of stenoses. Preoperative lower limb angiography avoids postoperative complications. MRA reliably and non-invasively identifies anatomical variants and arterial stenoses without radiation. Illustration of perforator run-offs enhances incision planning for fibula harvest.
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Affiliation(s)
- J G Schuderer
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany.
| | - J K Meier
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - C Klingelhöffer
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M Gottsauner
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - T E Reichert
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - C M Wendl
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - T Ettl
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
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25
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Pedicled Peroneal Artery Perforator Flap for Knee Defect Reconstruction: Case Presentation and Literature Discussion. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2018; 6:e2034. [PMID: 30881814 PMCID: PMC6414094 DOI: 10.1097/gox.0000000000002034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 09/24/2018] [Indexed: 11/25/2022]
Abstract
There have been very limited data on the use of pedicled peroneal artery perforator flaps in knee soft-tissue reconstruction, especially for anterior and medial defects. Here, we present a case of proximally based peroneal artery perforator flap for knee soft-tissue reconstruction in a defect that included lateral, anterior, and medial surfaces of the knee presenting the technical challenges associated with this flap. A 15-year-old girl presented with extruded knee implant after osteosarcoma resection of femur. The defect involved the whole knee with the anterior and mostly the lateral knee surfaces. Her medical condition precluded the use of free tissue transfer. During her previous surgery, gastrocnemius muscles were detached with injured vascular pedicled and posterior tibial artery. Successful single-stage coverage was achieved using a large proximally based pedicled peroneal artery perforator flap. There are only few reports that described the use of peroneal artery flaps for knee soft-tissue coverage. The reach of a proximally based flap can be increased when it is raised on a distal perforator or when peroneal artery has a proximal takeoff. Furthermore, removing the fibula can facilitate the dissection and the reach of the flap till the most medial aspect of the knee. Pedicled peroneal artery perforator flap provides superior soft-tissue coverage with limited morbidity for knee soft-tissue reconstruction; however, flap reach is usually affected by anatomic variation. Preoperative planning can help to determine the reach of the flap and ease the dissection.
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26
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Chang EI, Chu CK, Chang EI. Advancements in imaging technology for microvascular free tissue transfer. J Surg Oncol 2018; 118:729-735. [DOI: 10.1002/jso.25194] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 07/10/2018] [Indexed: 11/06/2022]
Affiliation(s)
| | - Carrie K. Chu
- Department of Plastic SurgeryThe University of Texas MD Anderson Cancer CenterHouston Texas
| | - Edward I. Chang
- Department of Plastic SurgeryThe University of Texas MD Anderson Cancer CenterHouston Texas
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27
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Verhelst PJ, Dons F, Van Bever PJ, Schoenaers J, Nanhekhan L, Politis C. Fibula Free Flap in Head and Neck Reconstruction: Identifying Risk Factors for Flap Failure and Analysis of Postoperative Complications in a Low Volume Setting. Craniomaxillofac Trauma Reconstr 2018; 12:183-192. [PMID: 31428242 DOI: 10.1055/s-0038-1651515] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 01/05/2018] [Indexed: 10/14/2022] Open
Abstract
The fibula free flap (FFF) has been a workhorse in maxillofacial reconstruction. High success rates of this technique are reported. However, identifying risk factors for flap failure and analyzing complications can open the way to better patient care. A retrospective analysis was conducted of all FFFs performed over a 20-year period at a low-volume single tertiary center to identify risk factors and postoperative complications. A total of 129 FFFs were included (122 mandible, 7 maxilla). Complete flap failure occurred in 12.4% and partial flap failure in 7.8% of patients. A significant relation was found between younger age and flap failure, and most failures were associated with venous thrombosis. In-hospital surgical complications occurred in 60.5%, in-hospital medical complications in 49.6%, and out-of-hospital complications in 77.5% of patients. The in-hospital reintervention rate was 27.1%, and including salvaged flaps, flap survival rate was 87.6%. Osteomyocutaneous FFF failure (complete 12.4%; partial 7.8%) is an important clinical reality in a low-volume head and neck reconstruction center resulting in an in-hospital reintervention rate of 27.1%. Postoperative complications are frequent, both surgical and out-hospital complications. These results provide a better understanding of the limitations of the FFF in a low-volume center and can be used to optimize care in this kind of setting.
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Affiliation(s)
- Pieter-Jan Verhelst
- Department of Oral and Maxillofacial Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Flore Dons
- Department of Oral and Maxillofacial Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Pieter-Jan Van Bever
- Department of Oral and Maxillofacial Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Joseph Schoenaers
- Department of Oral and Maxillofacial Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Lloyd Nanhekhan
- Department of Oral and Maxillofacial Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Constantinus Politis
- Department of Oral and Maxillofacial Surgery, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
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28
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Wilkman T, Husso A, Lassus P. Clinical Comparison of Scapular, Fibular, and Iliac Crest Osseal Free Flaps in Maxillofacial Reconstructions. Scand J Surg 2018; 108:76-82. [DOI: 10.1177/1457496918772365] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and Aims: This study compared the three most used composite flaps in maxillofacial reconstructions in our institute. Patients and Methods: Between 2000 and 2012, a total of 163 patients with mandibular, maxillary, and orbital defects received either scapular, fibular, or iliac crest osseal reconstructions in Helsinki University Hospital, Departments of Plastic Surgery and Maxillofacial Surgery. Data regarding the patient demographics, complications, and outcomes were analyzed. Results: There were 92 deep circumflex iliac artery flaps (56%), followed by 42 scapular (26%) and 29 fibular flaps (18%). The rate of flap loss was the highest in the deep circumflex iliac artery group (p = 0.001). Reconstructions using fibula were fastest (p = 0.001) and had lowest perioperative blood loss (p = 0.013). There were no significant differences in the number of early or late complications between the flaps, but donor site complications were more severe in deep circumflex iliac artery. Osteotomies as well as dental implants were safely performed in all flaps with equal results. Conclusion: All three flaps of this study can be performed with awareness of the deep circumflex iliac artery flap being the least reliable alternative. The knowledge of the advantages and disadvantages of several osseal-free flap alternatives is beneficial in selecting the best suitable method for each individual patient requiring maxillofacial osseal reconstruction.
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Affiliation(s)
- T. Wilkman
- Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
- Department of Oral and Maxillofacial Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - A. Husso
- Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - P. Lassus
- Department of Plastic Surgery, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
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Smit JM, Negenborn VL, Jansen SM, Jaspers MEH, de Vries R, Heymans MW, Winters HAH, van Leeuwen TG, Mullender MG, Krekel NMA. Intraoperative evaluation of perfusion in free flap surgery: A systematic review and meta-analysis. Microsurgery 2018; 38:804-818. [DOI: 10.1002/micr.30320] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 02/03/2018] [Accepted: 03/02/2018] [Indexed: 12/21/2022]
Affiliation(s)
- Jan Maerten Smit
- Department of Plastic, Reconstructive & Hand Surgery; VU University Medical Centre; Amsterdam The Netherlands
| | - Vera L. Negenborn
- Department of Plastic, Reconstructive & Hand Surgery; VU University Medical Centre; Amsterdam The Netherlands
- Amsterdam Public Health research institute; VU University Medical Center; Amsterdam The Netherlands
| | - Sanne M. Jansen
- Department of Plastic, Reconstructive & Hand Surgery; Academical Medical Center; Amsterdam The Netherlands
| | - Mariëlle E. H. Jaspers
- Department of Plastic, Reconstructive & Hand Surgery; VU University Medical Centre; Amsterdam The Netherlands
- Association of Dutch Burn Centers; Beverwijk The Netherlands
| | - Ralph de Vries
- Medical Library, Vrije Universiteit; Amsterdam The Netherlands
| | - Martijn W. Heymans
- Department of Epidemiology & Biostatistics; VU University Medical Centre; Amsterdam The Netherlands
| | - Hay A. H. Winters
- Department of Plastic, Reconstructive & Hand Surgery; VU University Medical Centre; Amsterdam The Netherlands
| | - Ton G. van Leeuwen
- Department of. Biomedical Engineering & Physics; Academical Medical Center; Amsterdam The Netherlands
| | - Margriet G. Mullender
- Department of Plastic, Reconstructive & Hand Surgery; VU University Medical Centre; Amsterdam The Netherlands
- Amsterdam Movement Sciences; VU University Medical Center; Amsterdam The Netherlands
| | - Nicole M. A. Krekel
- Department of Plastic, Reconstructive & Hand Surgery; VU University Medical Centre; Amsterdam The Netherlands
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30
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Anatomy of the vasculature of the lower leg and harvest of a fibular flap: a systematic review. Br J Oral Maxillofac Surg 2017; 55:904-910. [DOI: 10.1016/j.bjoms.2017.08.363] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 08/25/2017] [Indexed: 11/23/2022]
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Sandelin H, Tukiainen E, Ovaska M. Amputation following internal fixation of an ankle fracture via the posterolateral approach - a case report. Acta Orthop 2017; 88:358-360. [PMID: 27892754 PMCID: PMC5434610 DOI: 10.1080/17453674.2016.1262679] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Henrik Sandelin
- Department of Orthopaedics and Traumatology and;,Correspondence:
| | - Erkki Tukiainen
- Department of Plastic and Reconstructive Surgery, Helsinki University Central Hospital, Helsinki,Finland
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Tremp M, Kappos EA, Oranges CM, di Summa PG, Schaefer DJ, Zhang YX, Wettstein R, Kalbermatten DF. Extending the limits of the anterior tibial artery as the recipient vessel for around the knee and proximal lower extremity defect reconstruction using the free anterolateral thigh and gracilis flap. Microsurgery 2017; 38:60-65. [PMID: 28233928 DOI: 10.1002/micr.30163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Revised: 01/04/2017] [Accepted: 02/02/2017] [Indexed: 11/06/2022]
Abstract
PURPOSE The aim is to describe a technique with orthograde dissection of the anterior tibial artery (ATA) used as the recipient vessel for the end-to-end (ETE) anastomosis in defect reconstruction around the knee and for proximal/middle third leg defects with free anterolateral thigh (ALT) and gracilis flaps. PATIENTS AND METHODS Between March 2009 and May 2014, 22 patients undergoing lower extremity reconstruction were evaluated. Of those, 4 patients were included. The locations of injury were 3 defects around the knee and 1 defect at the proximal and middle third of the lower leg (mean defect size 18 x 8.5 cm and a range of 17-20 x 5-10 cm). There were 2 cases after trauma and 2 cases with infection. Two free gracilis and 2 free ALT flaps were performed of equal size to the defects. The mean flap pedicle length was 11 cm (range of 7-16 cm) and the mean length of the mobilized recipient vessels was 10.5 cm (range of 6-14 cm). RESULTS One flap loss (ALT) occurred, requiring a salvage procedure with a latissimus dorsi flap, whereas wound dehiscence at the donor site and a hematoma below the ALT flap was observed in 2 cases, requiring small revision. After a mean follow-up of 52 months (range of 38-87 months), there was stable soft tissue coverage in all patients. CONCLUSION By orthograde dissection of the ATA, an adequate vessel length and size may be achieved, improving arc of rotation to successfully cover more distant defects.
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Affiliation(s)
- Mathias Tremp
- Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Elisabeth A Kappos
- Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Carlo M Oranges
- Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Pietro G di Summa
- Department of Plastic, Reconstructive, and Hand Surgery, University Hospital of Lausanne, Lausanne, Switzerland
| | - Dirk J Schaefer
- Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Yi Xin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai, China
| | - Reto Wettstein
- Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Basel, Basel, 4031, Switzerland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive, Aesthetic, and Hand Surgery, University Hospital Basel, Basel, 4031, Switzerland
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A solution to the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur: Bridging with vein transplantation. Injury 2017; 48:486-494. [PMID: 27876350 DOI: 10.1016/j.injury.2016.10.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2016] [Accepted: 10/16/2016] [Indexed: 02/02/2023]
Abstract
PURPOSE The present study aimed to evaluate the feasibility and clinical efficacy of bridging vein transplantation to deal with the vessel shortage during free vascularized fibular grafting for reconstructing infected bone defects of the femur. METHODS Twelve patients (aged 15-58 years) with infected bone defects of the femur (between 6.0 and 18.0cm) were recruited in this study. Vacuum sealing drainage were applied after extensive debridement of the infected bone defects and irrigated with 0.9% sodium chloride solution for 1-2 weeks. After the drainage was clear and the focal infections were controlled, the free vascularized fibula was harvested for reconstructing the femoral bone defects. The vascularized fibula was grafted and fixated appropriately at the recipient site. The autogenous great saphenous vein was harvested, one end was anastomosed and bridged the vascular pedicles of the fibular grafts, and the other end anastomosed the artery and/or the vein in the recipient healthy site. RESULTS Mean length of vein transplantation with vascularized fibular graft was 10.2 cm (range 7-15cm). All patients had good radiological healing without recorded nonunion or malunion. No patient developed deep infection or implant failure. Primary bone healing was achieved in 10 patients; however, 2 grafted fibular formed pseudarthrosis with the recipient femoral and then healed after a secondary surgery. One patient suffered from graft stress fracture after bone healing and healed after external fixation. After the mean follow-up of 30 months (9-72 months), according to the Enneking scoring system, clinical outcomes were excellent in 7 patients, good in 4 and fair in one. The functional recovery rate of the lesion limb was 89.4%. CONCLUSIONS Free vascularized fibular graft with vein transplantation bridged vascular pedicle can effectively repair the infected bone, improve blood supply to the bone defect site, and help control infection. It is a feasible and effective treatment for infected bone defects of the femur with poor soft tissue conditions, or blood supply vessel shortage.
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Portilho PO, Leite TFDO, Cardoso R, Pires LAS, Silva JG, Chagas CAA. Clinical features of a rare anatomical variation of the posterior tibial and fibular arteries. J Vasc Bras 2016; 15:234-238. [PMID: 29930595 PMCID: PMC5829761 DOI: 10.1590/1677-5449.003416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
The posterior tibial artery normally arises from tibial-fibular trunk at the popliteal fossa, together with the fibular artery. The classic course of the posterior tibial artery is to run between the triceps surae muscle and muscles of the posterior compartment of the leg before continuing its course posteriorly to the medial malleolus, while the fibular artery runs through the lateral margin of the leg. Studies of both arteries are relevant to the fields of angiology, vascular surgery and plastic surgery. To the best of our knowledge, we report the first case of an anastomosis between the posterior tibial artery and the fibular artery in their distal course. The two arteries joined in an unusual “X” format, before division of the posterior tibial artery into plantar branches. We also provide a literature review of unusual variations and assess the clinical and embryological aspects of both arteries in order to contribute to further investigations regarding these vessels.
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