Free Flaps in Lower Extremity Reconstruction

The Imageology Study and Clinical Application of Perforating Branch of Posterior Tibial Artery

BACKGROUND

It is necessary to precisely locate the branches for better result of flap transplantation for the high variability of perforating branches of posterior tibial artery (PTA). In the research, digital subtraction angiography (DSA) and high-frequency ultrasound are jointly used to study the distribution and exact location of PTA perforating branches to guide clinical practice.

METHODS

From January 2020 to December 2022, 16 patients underwent DSA examination and 5 of them accepted further high-frequency ultrasound examination. The authors analyzed the distribution, number, location, direction, and lengths of PTA branches and used PTA perforator flaps to repair middle and inferior lower leg defects according to the above imaging findings. The donor site was repaired with skin grafts or a sequential PTA perforator flap.

RESULTS

A total of 81 branches of PTA were identified in 16 patients. Most of the perforating branches were in the middle and distal thirds of tibia. There was a significant correlation between the length of perforating branches and their perforating sites. Cluster analysis showed that larger branches appeared most frequently in the range of 15 to 20 cm from the tip of the inner ankle. 5 cases of PTA perforator flaps survived well.

CONCLUSION

DSA can clearly show the distribution of PTA and its branches, especially the dominant ones. The imaging findings can effectively guide PTA perforator flap design and harvesting, and thus improve the result of flap transplantation.

Combined Use of the Hemi-Split Tibialis Anterior Muscle and Soleus Muscle Flap for Reconstruction After the Excision of a Recurrent Soft Tissue Sarcoma in the Lower Leg

Reconstruction of large tissue defects following soft tissue sarcoma (STS) resection in the lower extremity presents a significant challenge for plastic surgeons. The optimal method should be selected from a wide array of techniques, depending on the size and location of the defect. Both pedicled and free flaps have demonstrated favorable outcomes. However, due to the nature of STS, there is concern about recurrence and the potential complications for secondary reconstruction. A 78-year-old male with leiomyosarcoma in the proximal third of the leg underwent wide excision and reconstruction using a pedicled medial gastrocnemius muscle flap. Local recurrence occurred at six months postoperatively, necessitating a second extended resection. This was followed by reconstruction using a hemi-split tibialis anterior muscle and hemi-split soleus muscle flaps, combined with a split-thickness skin graft. The postoperative course was uneventful, with complete survival of both the muscle flap and skin graft and no functional limitations in the lower extremity. The hemi-split tibialis anterior and soleus muscle flaps are considered valuable methods for reconstruction, preserving lower extremity function.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Usefulness of Free Tissue Transfer for the Reconstruction of Extensive Thigh Defects

BACKGROUND

 Despite the increasing popularity of free tissue transfer, thigh defects have been alienated from their potential indication, owing to the abundance of regional reconstruction options. However, some challenging situations where locoregional modalities may lead to suboptimal outcomes often require free flap. Due to lacking studies regarding microvascular reconstruction of thigh defects, this study aimed to investigate the versatility of free tissue transfer for reconstruction of thigh defects.

METHODS

 A retrospective review was performed for patients who underwent microvascular reconstruction of thigh defects between 2003 and 2021. Their demographics and operation-related data were summarized and postoperative outcomes were evaluated.

RESULTS

 Sixty-five patients were analyzed, with a median follow-up period of 15.5 months. Most common situations requiring free tissue transfer were extensive defects, followed by large dead space with exposure of major neurovascular bundle and chronic wounds surrounded by unhealthy regional tissue. Defects were most frequently located in the anterior compartment horizontally and in the distal thigh vertically. The median surface area of the defects was 180.0 cm2. The latissimus dorsi musculocutaneous and thoracodorsal artery perforator flaps were the two most commonly used flaps. Reliable recipient vessels could generally be easily found in the vicinity of defects. Overall complications developed in 12 cases (18.5%), including two of partial flap necrosis. No total flap loss was encountered.

CONCLUSION

 Free tissue transfer could provide reliable outcomes and facilitate rapid recovery, and could be actively considered for reconstruction of thigh defects in situations unfavorable to the locoregional option.

[Emergency free flap in reconstruction of the lower limb: About 23 cases over 11 years]

OBJECTIVES

To study the coverage period influence and various parameters concerning the microsurgical act on the patient clinical outcomes.

METHODS

We report 23 cases of reconstruction of lower limb loss of substance by free flap operated from 2010 to 2021. Among them, 9 patients were operated on as an emergency versus 14 in the secondary or late phase of the trauma.

RESULTS

The average age of injured patients operated on emergency was 42 years (17-68 years) and 34 years for the patients who undergo deferred surgery (17-57 years). The sex ratio (female/male) was 22% in patients operated on urgently and 7% in patients operated on later. Regarding the type of free flap, it was Serratus anterior muscle flap in 10 cases, Latissismus dorsi flap in 9 cases, ALT flap in 3 cases and Gracilis muscle flap in 1 case. There were 2 failures of vascularized free transfer (8.7%) with complete necrosis of the flap and 3 revision surgeries on venous thrombosis which finally made it possible to obtain 3 flap successes. We analyze the results (complications/osteitis) according to the time to coverage.

CONCLUSIONS

In our study, we did not find any significant difference between the groups operated in emergency and at a distance concerning the rate of infection and failure of the flaps.

Revisiting Bipedicled Flaps for Lower Extremity Distal Third Defects

BACKGROUND

Lower extremity reconstruction of the distal third of the leg is challenging. Free tissue transfer is the criterion standard. The COVID-19 pandemic encouraged seeking alternatives for resource consuming procedures. Bipedicled flaps are flaps with a dual-source subdermal perfusion. The purpose of this study was to assess outcomes of patients who had bipedicled flaps primary or auxiliary local flap for distal third leg/foot reconstruction.

METHODS

A retrospective review of patients undergoing lower extremity reconstruction (2020-2021) was performed. Inclusion criteria were patients older than 18 years with lower extremity wounds secondary to traumatic injury for which bipedicled flaps were used in the reconstruction. Exclusion criteria included lower extremity wounds secondary to peripheral vascular disease or diabetes.

RESULTS

Fourteen patients were included in the study. All patients had distal third of the leg/foot wounds, and 12 patients (87.5%) had concurrent leg fractures. In 8 patients (57.1%), the bipedicled flap was used to decrease the wound size and facilitate another concurrent flap: hemisoleus (21.4%), anterior tibialis muscle turnover (14.3%), medial plantar artery (14.3%), and posterior tibial artery perforator (14.3%). Mean wound size for bipedicle flaps used alone was 42.0 ± 18.3 cm2, whereas wounds that required a bipedicled flap with an additional flap were 69.9 ± 80.8 cm2 (P = 0.187). Two patients had partial flap necrosis (14.3%) but healed their defect. One patient had nonunion (7.1%). Limb salvage rate was 100%.

CONCLUSIONS

Bipedicled flaps can be used as an alternative to free flaps in distal third leg/foot defects in select patients. If distal extremity wounds cannot be covered with a bipedicled flap alone, the flap can be used an accessory flap to facilitate reconstruction with other local flaps.

Mechanical Dilation of the Recipient Vessel with the DeBakey Vascular Dilator in Lower Extremity Reconstruction: A Report of Two Cases

In lower extremity reconstruction, the recipient vessel often requires long-range mechanical dilation because of extensive vasospasm or plaque formation induced by concomitant atherosclerosis. While a forceps dilator can be used to manipulate and dilate vessels approximately 1 cm from their end, a DeBakey vascular dilator can dilate long-range vessels. The authors successfully performed free flap reconstruction of the lower extremity using the DeBakey vascular dilator. Of the two patients who underwent lower extremity reconstruction, one had extensive vasospasm, and the other had plaques in the recipient arteries. Irrigation with 4% lidocaine and dilation of the lumen with a forceps dilator were insufficient to restore the normal arterial blood flow. Instead, a DeBakey vascular dilator with a 1-mm diameter tip was gently inserted into the lumen. Then, to overcome vessel resistance, the dilator gently advanced approximately 10 cm to dilate the recipient artery. Normal arterial blood flow was gushed out after dilating the vessel lumen using a DeBakey vascular dilator. The vascular anastomosis was performed, and intravenous heparin 5000 IU was administered immediately after anastomosis. Prophylactic low-molecular-weight-heparin (Clexane, 1 mg/kg) was administered subcutaneously to both patients for 14 days. The reconstructed flap survived without necrosis in either patient.

Outcomes of Local Versus Free Flaps for Reconstruction of the Proximal One-Third of the Leg

BACKGROUND

Reconstruction of the proximal one-third of the leg often requires soft tissue transfer to facilitate limb salvage. Tissue transfers are usually local or free flaps depending on wound dimensions, location, and surgeon preference. Historically, the proximal third of the leg was covered with pedicle flaps, but recently, we have used more free flaps in this position. Using data from a level 1 trauma center, we sought to evaluate outcomes of surgical management of proximal-third leg reconstruction across local and free flaps.

METHODS

This is an institutional review board-approved, retrospective chart review undertaken at LAC + USC Medical Center from 2007 to 2021. Patient history, demographics, flap characteristics, Gustilo-Anderson fracture classification, and outcomes were collected and analyzed in an internal database. Outcomes of interest included flap failure rates, postoperative complications, and long-term ambulatory status.

RESULTS

Among 394 lower extremity flaps placed, 122 flaps involved the proximal-third leg across 102 patients. Average age of patients was 42.8 ± 15.2 years; of note, the free flap cohort was significantly younger than the local flap cohort (P = 0.019). Ten local flaps suffered from infectious complications: osteomyelitis (n = 6) and hardware infection (n = 4), versus only 1 free flap that suffered from hardware infection; notably, these differences were not significant across cohorts. Free flaps had significantly more flap revisions (13.3%; P = 0.039) and overall flap complications (20.0%; P = 0.031) compared with local flaps; however, partial flap necrosis (4.9%) and flap loss (3.3%) were not significantly different across cohorts. Overall flap survival was 96.7%, and full ambulation was achieved in 42.2% of patients without significant differences across cohorts.

CONCLUSIONS

Our evaluation of proximal-third leg wounds demonstrates fewer infectious outcomes with free flaps compared with local flaps. There are multiple confounding variables; however, this finding may speak to the reliability of a robust free flap. Overall, there was no significant difference in patient comorbidities across flap cohorts with great overall flap survival. Ultimately, flap selection did not affect rates of flap necrosis, flap loss, or final ambulatory status.

Team Approach: Perioperative Management of Pilon Fractures

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Tibial pilon fractures are devastating injuries requiring complexsurgical management resulting in a challenging postoperativecourse.

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A multidisciplinary approach is required to manage these injuries in addition to patients' medical comorbidities and concomitant injuries to achieve optimal outcomes.

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The case presented here demonstrates the importance of communication and teamwork between specialties in the management of a patient with a tibial pilon fracture that was medically optimized for surgery using a team-based approach.

Technical details for inset of flaps in transfer of double-level gastroepiploic lymph node flaps for lower extremity lymphedema

BACKGROUND

In this study, the method that can be followed to ensure rapid and uncomplicated recovery of lymph node flap (LNF) applied in the medial of the ankle for lymphedema treatment was investigated.

METHODS

Thirty-seven patients with class II of lower limb lymphedema underwent transfer of gastroepiploic LNF to the medial ankle and popliteal fossa areas. At the popliteal fossa region, the wound could always be closed primarily by the advancement of neighboring skin. The wound closure could be classified into three types at the medial ankle area (A) The partially exposed LNF was covered with a split-thickness skin graft (STSG) (n = 9). (B) A larger local flap was elevated, and the donor site of the local flap was covered with STSG (n = 18). (C) The skin flap's donor site was treated with pre-tie sutures (n = 10).

RESULTS

In the popliteal region, there was no complication of wound healing. In the ankle region, the wound was coated by a thin layer of hematoma over the exposed LNF in 5 patients of group A. It healed secondarily except for one patient who needed a secondary skin graft. The healing was perfect in group B. In group C the healing was good, but there was a hypertrophic scar in 7 patients and required steroid injection later.

CONCLUSION

To avoid complications of the gastroepiploic LNF at the medial ankle, it should be entirely covered by an anteriorly-based local flap, and the donor site defect of the local flap can be treated with either pre-tie sutures or a skin graft.

Scaffold Guided Bone Regeneration for the Treatment of Large Segmental Defects in Long Bones

Bone generally displays a high intrinsic capacity to regenerate. Nonetheless, large osseous defects sometimes fail to heal. The treatment of such large segmental defects still represents a considerable clinical challenge. The regeneration of large bone defects often proves difficult, since it relies on the formation of large amounts of bone within an environment impedimental to osteogenesis, characterized by soft tissue damage and hampered vascularization. Consequently, research efforts have concentrated on tissue engineering and regenerative medical strategies to resolve this multifaceted challenge. In this review, we summarize, critically evaluate, and discuss present approaches in light of their clinical relevance; we also present future advanced techniques for bone tissue engineering, outlining the steps to realize for their translation from bench to bedside. The discussion includes the physiology of bone healing, requirements and properties of natural and synthetic biomaterials for bone reconstruction, their use in conjunction with cellular components and suitable growth factors, and strategies to improve vascularization and the translation of these regenerative concepts to in vivo applications. We conclude that the ideal all-purpose material for scaffold-guided bone regeneration is currently not available. It seems that a variety of different solutions will be employed, according to the clinical treatment necessary.

"Outcomes of Local versus Free Flaps for Lower Extremity Trauma"

BACKGROUND

Lower extremity reconstruction often requires soft tissue transfer for limb salvage. Flaps are allocated based on injury size, location, and shape coupled with surgeon expertise. Ideally, vascularized tissue should have similar outcomes across local and free tissue transfers. By evaluating outcomes from a Level 1 trauma center, we aim to provide recommendations regarding surgical management of leg reconstruction with respect to local versus free flap implementation.

METHODS

This retrospective review evaluated patient medical history, demographics, flap characteristics, and outcomes from LAC + USC between 2007-2021 using an internal database. Outcomes included failure rates, complications, and ambulation.

RESULTS

357 lower extremity flaps were placed on 322 patients; 187 (52.4%) were local and 170 (47.6.%) were free flaps. Twenty-one (11.2%) local flaps suffered significantly more postoperative hardware infections and/or osteomyelitis compared to nine (5.3%) free flaps. Eleven (5.9%) local flaps developed partial necrosis, four requiring revision; 12 (6.4%) total local flaps required revision. Comparatively, sixteen (9.4%) free flaps developed partial necrosis, seven requiring revision; 18 (10.6%) total free flaps required revision. Flap survival was 96.3% for local versus 93.5% for free flaps. Percentage of fully ambulatory patients and time to final ambulation was not significant across cohorts.

DISCUSSION

Local flaps may portent higher risk for infection; though the cause is not clear, the results may be confounded by comorbidities. Nevertheless, there were no significant differences in flap survival or number of fully ambulatory patients across cohorts. Future studies should evaluate aesthetic results and patient satisfaction across flap types.