Orthoplastic Approach to Lower Extremity Reconstruction: An Update

Propeller flap's assisted recipient site closure after free SCIP flap coverage of medial ankle defect: A case report

Defects in the distal lower limbs are common in the field of orthoplastic reconstruction. The ankle area presents little subcutaneous tissue and is often affected by high-energy traumas and bone fractures. Wounds in this region are frequently associated with severe edema that might prevent primary closure. Due to its thinness and tension, the skin overlying both the medial and lateral malleoli is prone to necrosis, which can further lead to large soft tissue defects. Vessels, nerves, and tendons can easily become exposed. The reconstructive approach should aim to provide high-quality tissue that is durable enough to withstand the weight-bearing pressures and the friction from shoes, while remaining sufficiently elastic to conform to the shape of the ankle and to permit the foot movement. In this study, we describe the use of an additional propeller flap to reduce skin tension at the recipient site. A superficial circumflex iliac artery perforator (SCIP) flap was utilized to cover a defect below the medial malleolus. However, after flap inset, achieving a primary closure of the proximal wound without tension was not possible. During the dissection of the posterior tibial artery, perforator vessels were identified and preserved. The larger of these vessels was then used to vascularize a propeller flap, which was then rotated toward the defect to aid a tension-free closure. The postoperative course was uneventful. This case may provide a valuable insight into the challenges often faced during wound closure, even after flap inset. Since the flap itself may increase the width of the dissection area, the present case shows the importance of preserving perforator vessels during the proximal dissection since they can allow the harvest of an additional flap to achieve primary closure and further alleviate tension.

Exploring the Role of Free Tissue Transfers in the Preservation of Bone Length and Knee Joint Function after Lower Limb Trauma: A Retrospective Analysis

Lower limb trauma often results in mangled extremities, and in some cases, complete amputation may be necessary. However, limiting the extent of amputation and preserving the major knee joint are crucial to enhance mobility and overall functionality. By providing painless soft tissue coverage on the stump, early prosthesis use and the initiation of physiotherapy become more feasible. Soft tissue transfers hold the potential to benefit patients in two essential aspects: first, resolving soft tissue deficiencies without causing bone shortening, and second, preparing the stump to enhance overall functionality. A retrospective study conducted at Chang Gung Memorial Hospital (2009-2016) focused on lower limb amputation patients who underwent soft tissue transfers at different time periods compared to those without stump reconstruction. Out of the 2391 cases of lower limb injuries treated operatively, 117 amputations were performed in 110 patients (44 above the knee and 73 below the knee). Among them, 12 patients received soft tissue transfers for limb salvage and soft tissue deficiency after amputations. It was observed that patients in this group were typically younger, predominantly female, had longer hospital stays, and underwent a greater number of surgical procedures (p < 0.05). Through the use of soft tissue transfers, successfully preserved tibial bone length and functional knee joint in selected patients was achieved. This approach effectively resolved soft tissue deficiencies following lower limb amputations, optimizing physiotherapy and facilitating functional rehabilitation.

[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.

Telemedicine support aids lower limb reconstruction after combat injury in Ukraine

Since the destructive and illegal full-scale invasion of Ukraine in February 2022, caring for the victims of war trauma has been an essential function of Ukrainian clinicians [ 1, 2]. The authors present a case where using novel dynamic digital thermography (DDT), combined with international telemedicine support, contributed to saving the lower limb of an injured Ukrainian soldier. A male soldier in his 30s presented with a 'through and through' fragmentation wound to the right thigh from an artillery shell exploding nearby. After initial haemorrhage control and resuscitation, the patient was transferred to a tertiary hospital. Using telemedicine support, reconstructive surgery was planned and performed successfully using a perforating flap technique. DDT was used pre-operatively to identify a perforating vessel and post-operatively to ensure perfusion of the flap. The patient made a good recovery and was discharged 14 d post-operatively.

Scalp Reconstruction Using the Latissimus Dorsi Free Flap: A 12-Year Experience

BACKGROUND

Complex scalp defects are regularly reconstructed using microvascular tissue transfer. The latissimus dorsi free flap is one of the workhorse flaps used in scalp reconstruction. These cases necessitate, particularly in the elderly, a close cooperation between plastic surgeons and neurosurgeons. The purpose of this study was to evaluate the suitability of the latissimus dorsi free flap for complex scalp reconstructions and to analyze potential risk factors.

METHODS

A retrospective study identified 43 patients undergoing complex scalp reconstruction using a latissimus dorsi free flap at our department between 2010 and 2022.

RESULTS

The mean patient age was 61 ± 18 years. Defects were mostly caused by oncologic tumor resections (n = 23; 55%), exposure to a cranioplasty (n = 10; 23%) or infection (n = 4; 9%). The most frequent recipient vessels were the superficial temporal artery (n = 28; 65%), external carotid artery (n = 12; 28%) and the venae comitantes (n = 28; 65%), external jugular vein (n = 6; 14%). The reconstructive success rate was 97.7%. There was one total flap loss (2%). Partial flap loss occurred in five cases (12%). Follow-up was 8 ± 12 months. Major complications were seen in 13 cases, resulting in a revision rate of 26%. Multivariate logistic regression identified active tobacco use as the only risk factor for major complications (odds ratio 8.9; p = 0.04).

CONCLUSION

Reconstruction of complex scalp defects using the latissimus dorsi free flap yielded high success rates. Among the potential risk factors, active tobacco use seems to affect the outcome of complex scalp reconstructions.

Free versus Pedicled Flaps for Lower Limb Reconstruction: A Meta-Analysis of Comparative Studies

Background: Free and pedicled flaps are both valuable surgical strategies for lower limb reconstruction. Evidence that compares both techniques is scarce. Our aim is to synthetise all the comparative studies by conducting a meta-analysis to identify post-operative outcomes. Method: A systematic review of pubmed, EMBASE, Cochrane library, and Web of Science was conducted, aiming at articles comparing the outcomes of free versus pedicled flaps in lower limb reconstruction. A pooled analysis with the Mantel and Haenszel methods and random effect analysis provided results as a risk ratio with a 95% confidence interval. Results: 10 retrospective studies were selected. While the flap necrosis rate did not differ significantly between techniques (RR 1.35, 95%CI 0.76–2.39, p = 0.31), the partial flap necrosis rate was significantly lower in free flaps (RR 0.45, 95%CI 0.22–0.91, p = 0.03). The overall complication rate (RR 0.83, 95%CI 0.64–1.07, p = 0.16) and revision surgery rate (RR 1.38, 95%CI 0.55–3.50, p = 0.49) did not differ significantly. No significant difference was found in the high aesthetic satisfaction rate (RR 1.76, 95%CI 0.57–5.41, p = 0.32) and post-operative infection rate (RR 0.85, 95%CI 0.55–1.33, p = 0.48). Conclusion: Despite important variability in the choice of flaps and outcomes reported among studies, free and pedicled flaps appear to be reliable surgical strategies for lower limb reconstruction with similar surgical outcomes.

The triple conjoined scapular-latissimus dorsi-groin flap for reconstruction of long lower extremity degloving injury: A case report

Since the introduction of the angiosome concept, many attempts have been made to push the dimensional limits of free tissue transfers. While initially limited by the boundaries of random vascularization of adjacent angiosomes, wider flaps were transferred by combining contiguous source vessels. Combined flaps, either chimeric or conjoined, represent nowadays the largest reconstructive options in the human body. This is the first report of a triple conjoined free flap with two vascular anastomoses, able to cover the anterior surface of the entire lower limb, representing the longest flap ever reported in history. A 43-year-old woman sustained a car accident as a pedestrian and presented with a massive circumferential degloving injury of the right lower limb. Femoral displaced shaft fracture and Gustilo type IIIb tibial fracture were diagnosed with emergent CT scan. A myocutaneous latissimus dorsi flap was planned, conjoined with the scapular flap to obtain a thick and large cover for the knee, and with a groin flap, to cover for the foot. Descending branch of lateral circumflex femoral artery and anterior tibial artery at the dorsum of the foot were selected as recipient vessels. Donor site was closed primarily. All flaps survived and no immediate nor late complications were reported. Follow up was 3 months. The triple conjoined flap can be considered a safe and useful reconstructive tool in severe degloving injuries of the lower limb, allowing the coverage of a large surface of the lesion with a single operation and without increasing the donor site morbidity.