Posterior tibial perforator-based flaps for leg and foot defects: Indications, limitations, and technical considerations

Treatment of two or more metatarsal fractures

INTRODUCTION

Metatarsal fractures are the most common type of foot fracture. When surgical treatment is needed, pinning is typically used, either percutaneous or open. However, this fixation method has been criticized by some authors who lament residual malunion and prefer to use plate and/or screws. The primary objective of our study was to compare the outcomes of K-wire versus plate and/or screw fixation for the surgical treatment of two or more metatarsal fractures. The secondary objective was to evaluate the factors that contribute to poor outcomes and complications. We hypothesized that plate and/or screw fixation will produce better functional outcomes than K-wire fixation.

MATERIALS AND METHODS

This was a prospective and retrospective multicenter study carried out between 1 January 2010 and 1 June 2018 with a minimum follow-up of 12 months. Three functional scores were determined (AOFAS, FAAM and SF12 physical and mental) preoperatively, postoperatively and at the final assessment. We evaluated the outcomes in the entire study population and in four injury type subgroups, including one with isolated metatarsal fractures to control analysis bias.

RESULTS

Our analysis compiled data from 165 patients (123 men, 42 women) who had a mean age of 38 years (16-82). The mean follow-up time was 27.9months (10-120). There were no complications in 130 patients (79%). Skin necrosis occurred in 25 patients (15%). The FAAM score was significantly higher in the plate and/or screw group 70.2 (17-84) versus 60.3 (31-84) in the K-wire group (P=0.033). The 78 (19-100) AOFAS was higher, but not significantly, in the plate and/or screw group versus 70 (12-100) in the K-wire group (P=0.144).

CONCLUSION

Trauma to the foot that causes a fracture in two or more metatarsals often occurs due to a crush injury (39%). The frequency of associated bone lesions means that a preoperative CT scan should be done routinely to analyze the injury pattern and determine the best treatment. The fixation method should be adapted to the local conditions; when possible, it is preferable to use rigid fixation with plates and/or screws as it yields better functional outcomes.

LEVEL OF EVIDENCE

IV; study with retrospective component.

Extensor digitorum brevis muscle flap for lower extremity coverage in a context of posttraumatic sepsis

INTRODUCTION

Traumatic injuries to the distal quarter of the leg present a significant risk of skin necrosis and exposure of the underlying fracture site or the osteosynthesis material that often result in bone and joint infection. In the case of small or medium-sized bone exposure, local muscles may be one of the best options for lower extremity coverage. We describe our experience using the extensor digitorum brevis muscle flap in a context of posttraumatic bone and joint infection in fourteen patients. Our main objective was to assess the outcomes and the donor-site morbidity of the extensor digitorum brevis muscle flap.

MATERIALS AND METHODS

A single-center retrospective study in a French reference center for bone and joint infection from 2014 to 2018 reviewed cases of traumatic injuries with skin complications and bone and joint infection that required an extensor digitorum brevis muscle flap coverage. Fourteen patients were evaluated for early and late complications, 11 men and three women with a mean age of 51.4±17.72 (19-71) years. Seven of these were open fractures and nine cases were pilon fractures. Donor-site morbidity was assessed in nine patients.

RESULTS

Early flap complications included two cases (14.2%) of hematoma, one case (7.1%) of partial necrosis and four cases (28.5%) of donor-site dehiscence. Late complications caused by persistent infection were found in two patients (14.2%), with one case (7.1%) of chronic osteoarthritis and one case (7.1%) of septic pseudarthrosis. From a functional and cosmetic point of view, eight patients (89%) were satisfied, to very satisfied.

CONCLUSION

Experience and a multidisciplinary approach are keys in providing an optimal treatment strategy for complex cases of bone and joint infection. The extensor digitorum brevis muscle is a reliable flap for small defects with underlying infection. Being made up of muscle tissue, this flap offers good resistance to infection and enables satisfactory distribution of antibiotics.

LEVEL OF EVIDENCE

IV.

Coverage of cutaneous substance loss in the leg: Techniques and indications

Cutaneous substance loss in the leg is frequent; more often than not, it is trauma-related. It calls for complex management and necessitates the application of all current reconstruction techniques, particularly microsurgery. As regards treatment, the available therapeutic arsenal is highly diversified, ranging from a simple free flap skin graft to local and locoregional flaps. During reconstruction, the surgeon is subjected to several constraints insofar as the objectives of the operation are esthetic as well as functional. Ideally, the fineness of the skin covering the anterior side of the leg will have been scrupulously respected. Reconstruction is aimed at producing a stable and reliable cutaneous envelope while limiting the morbidity of the donor site. The development of free perforator flaps corresponds to these two criteria by producing a fine flap adapted to the cutaneous thickness of the leg and limiting any functional and esthetic sequelae at the donor site.

Coverage of exposed bone and hardware of the medial malleolus with tibialis posterior artery perforator flap after ankle fracture surgery complications

Ankle fractures are among the most common orthopaedic surgical procedures. Skin-related complications of these surgeries are difficult to reconstruct due to the inadequacy of soft tissue in the region. Although free flaps are generally considered as the first choice in reconstruction of this area, free flaps may not be a suitable option especially in patients with advanced age and comorbidities. Perforator flaps offer a fast and safe alternative in lower extremity reconstruction. In the literature, there are a limited number of studies using perforator flaps in managing the postoperative complications of the lower extremity trauma surgeries. In our study, we report our experience with reconstruction of soft-tissue defects of medial malleolar region using posterior tibial artery perforator flap for postoperative complications of ankle fracture-related surgeries.