Lower extremity microsurgical reconstruction

Does Side Matter? The Impact of Free Flap Harvest Laterality on Ambulatory Function in Lower Extremity Traumatic Reconstruction

BACKGROUND

 Free flaps are essential for limb salvage in patients with lower extremity (LE) trauma; however, significant donor-site morbidity could impact functional outcomes. This study compares postoperative ambulatory function between contralateral and ipsilateral free flap harvest in LE traumatic reconstruction.

METHODS

 A retrospective review was performed on patients who underwent LE reconstruction at a level 1 trauma center from 2009 to 2022. Flap characteristics, injury history, and ambulatory function were collected. Flap harvest laterality was determined in relation to the injured leg. The flaps were categorized as either fasciocutaneous or those that included a muscle component (muscle/myocutaneous). Chi-squared and Mann-Whitney tests were used for statistical analysis.

RESULTS

 Upon review, 173 LE free flaps were performed, of which 70 (65.4%) were harvested from the ipsilateral leg and 37 (34.6%) were from the contralateral leg. Among all LE free flaps, the limb salvage rate was 97.2%, and the flap survival rate was 94.4%. Full ambulation was achieved in 37 (52.9%) patients in the ipsilateral cohort and 18 (48.6%) in the contralateral cohort (p = 0.679). The average time to full ambulation did not vary between these cohorts (p = 0.071). However, upon subanalysis of the 61 muscle/myocutaneous flaps, the ipsilateral cohort had prolonged time to full ambulation (6.4 months, interquartile range [IQR]: 4.8-13.5) compared with the contralateral one (2.3 months, IQR: 2.3 [1.0-3.9]) p = 0.007. There was no significant difference in time to full ambulation between flap harvest laterality cohorts among the fasciocutaneous flaps (p = 0.733).

CONCLUSION

 Among free flaps harvested from the ipsilateral leg, fasciocutaneous flaps were associated with faster recovery to full ambulation relative to muscle/myocutaneous flaps. Since harvesting muscle or myocutaneous flaps from the ipsilateral leg may be associated with a slower recovery of ambulation, surgeons may consider harvesting from a donor site on the contralateral leg if reconstruction requires a muscle component.

Sensory and pain outcomes of neurotized skin-grafted free gracilis muscle flaps for lower extremity reconstruction

BACKGROUND

Skin-grafted free gracilis muscle flaps are commonly used for lower extremity reconstruction. However, the loss of sensory function may lead to increased patient morbidity. This study prospectively analyzed the sensory and neuropathic pain outcomes of neurotized skin-grafted free gracilis muscle flaps used for the reconstruction of lower extremity defects.

METHODS

Patients undergoing lower extremity reconstructions between 2020 and 2022 with neurotized skin-grafted free gracilis muscle flaps were prospectively enrolled. Sensation was assessed at 3, 6 and 12 months postoperatively using monofilaments, two-point discrimination, a vibration device, and cold and warm metal rods. Sensations were tested in the center and periphery of the flaps, as well as in the surrounding skin. The contralateral side served as the control. Patients completed the McGill pain questionnaire to evaluate patient-reported neuropathic pain.

RESULTS

Ten patients were included. At 12 months postoperatively, monofilament values improved by 44.5% compared to that of the control site, two-point discrimination, cold detection, warmth detection, and vibration detection improved by 36.2%, 48%, 50%, and 88.2%, respectively, at the reconstructed site compared to those at the control site. All sensory tests were significantly better than 3 and 6 months values (p < 0.05), but remained significantly poorer than the control site (p < 0.05). Sensation in the central flap areas were similar to peripheral flap areas throughout the follow-up period (p > 0.05). The surrounding skin reached values similar to the control site at 12 months (p > 0.05). Moreover, 50% of patients reported neuropathic pain at 3 months postoperatively, 40% at 6 months, and 0% at 12 months (p < 0.05).

CONCLUSION

Mechanical detection, vibration detection, temperature detection, and two-point discrimination significantly improved over time but without reaching normal sensory function at 12 months postoperatively. Neuropathic pain resolved at 12 months.

The Effect of Regional Anaesthesia on Free Flap Survival in Lower Extremity Reconstructions

Background

The effect of different modalities of anaesthesia in microvascular free flap surgery has been a topic of ongoing debate. Comparative data to study the effect of general anaesthesia and regional anaesthesia in the form of peripheral nerve blocks (PNBs) on lower extremity free flap survival is lacking to date. This study aims to elucidate the effect of regional anaesthesia on flap survival in lower extremity free flap reconstructions.

Methods

A retrospective cohort study of all patients who underwent free vascularised flap reconstruction of the lower extremities between 2012 and 2021 at the Amsterdam University Medical Centre (UMC), The Netherlands, and between 2019 and 2021 at the Radboud UMC, Nijmegen, The Netherlands. In this cohort, we analysed partial and total flap failures.

Results

In this cohort, 87 patients received a total of 102 microvascular free flap reconstructions of the lower extremity. In 20.5% of these operations, patients received a supplemental PNB. Total flap failure was 23.8% in the regional anaesthesia group compared to 21% in the group with general anaesthesia only (p = 0.779). Operation time was longer for patients with regional anaesthesia (p = 0.057). Length of stay was on average 2 days shorter for patients with supplemental regional anaesthesia (p = 0.716).

Discussion

This is the largest cohort comparing flap survival in patients receiving general anaesthesia to general anaesthesia with a PNB in lower extremity reconstructions to date. We cannot attribute a significant beneficial or detrimental effect of regional anaesthesia to flap survival. High failure rates stress the need for future studies.

How to cite this article

Koster ITS, den Os MM, Rutten MVH, et al. The Effect of Regional Anaesthesia on Free Flap Survival in Lower Extremity Reconstructions. Strategies Trauma Limb Reconstr 2024;19(1):15-20.

[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.

Timing of Unplanned Reoperation After Lower Extremity Free Flap Reconstruction: What Are the Roles of Procedure Indication and Defect Etiology?

BACKGROUND

Advancements in lower extremity (LE) microsurgery have allowed for the expansion of indications for LE reconstructions. This project aims to better understand the temporal pattern and risk factors associated with LE free flap failure based on the clinical indication.

MATERIALS AND METHODS

We analyzed all patients undergoing LE free flap reconstruction from the American College of Surgeons National Surgical Quality Improvement Program 2012-2019 prospectively collected data to determine rates and timing of reoperation. Free flaps were stratified by indication, type, and timing of reoperation. Weibull survival models were used to compare rates of takebacks among time intervals. Multivariable logistic regression was used to identify independent predictors for unplanned reoperation.

RESULTS

Four hundred seven of LE free flaps were analyzed. There was a 14.5% rate (59/407) of unplanned reoperation within the first 30 postoperative days (PODs) after surgery. When stratified by the indication necessitating reoperation, patients with an underlying vascular indication had the highest rate of reoperation (40.9%). The reoperation rates were significantly different between indications (P < 0.05) The mean daily proportion of patients experiencing reoperation was highest during POD 0 to 2 (1.47% reoperations per day), which dropped significantly during POD 3 to 10 (0.55% per day) and again during POD 11 to 30 (0.28% per day, P < 0.05). African American race as well as malignant, prosthetic/implant, and wound/infectious indications were significant independent predictors for unplanned reoperation.

CONCLUSIONS

Lower extremity reconstruction is an important reconstructive option for the coverage of a myriad of defects. Understanding the differences between postoperative reoperation timelines among indication subtypes is important for updated flap monitoring protocols, optimizing ERAS pathways, and beginning dangle protocols.

An algorithmic approach to soft-tissue reconstruction around the knee using anterolateral thigh perforator flap in patients with post-traumatic knee osteomyelitis

Background

Free tissue transfer to the knee region in patients with chronic post-traumatic knee osteomyelitis (CTKOM) poses a great challenge to surgeons because the remaining soft tissues adjacent to defects, including vascular structures, are usually damaged by chronic inflammation and multiple debridements. Thus, we developed an algorithm to help select the optimal recipient vessels and appropriate anterolateral thigh perforator (ALTP) flap type. In addition, we performed surgery using this algorithm and achieved successful reconstructions. This study aims to review our experiences in algorithmic reconstruction and assess its efficacy.

Methods

According to the defect size and location, our algorithm suggested the use of various-shaped ALTP flaps with centrally located perforators (Cen-ALTP flap) or eccentrically located perforators (Ecc-ALTP flap). Besides, through the algorithm, one recipient vessel was selected among three candidates, including descending branch of the lateral circumflex femoral artery (DB-LCFA), anterior tibial artery (ATA), and posterior tibial artery (PTA). Based on this algorithmic decision, we performed individualized soft tissue reconstructions of the knee in 21 patients with CTKOM, between March 2013 and June 2021. The medical records of the patients were retrospectively reviewed.

Results

The Cen-ALTP flap (n = 15) and ATA (n = 9) were the most commonly used for reconstruction. The Cen-ALTP flap anastomosed to the ATA was most commonly selected (n = 7) using the algorithm, followed by the Cen-ALTP flap anastomosed to the DB-LCFA (n = 5), and the Cen-ALTP flap anastomosed to the PTA (n = 3). All transferred ALTP flaps survived the follow-up period. Postoperative venous congestion in two patients and hematoma in one patient were resolved by immediate treatment. The postoperative course was uneventful.

Conclusion

During free ALTP flap transfer to CTKOM-related knee defects, we could select the optimal recipient vessel and appropriate flap type using our algorithm and obtain excellent reconstructive outcomes. Therefore, we believe that our algorithm could provide helpful guidance to reconstructive surgeons on free ALTP flap transfer to reconstruct CTKOM-related soft tissue defects.

End-to-side Anastomosis on Digital Arteries: Just a Technical Choice or a Real Benefit?

High-quality evidence is currently poor regarding the benefits of end-to-end (ETE) or end-to-side (ETS) anastomosis in arterial and venous anastomoses, despite being postulated as a potential influence on outcomes. A sufficient microvascular anastomosis is indispensable for the success of any free tissue transfer. ETS microvascular anastomoses have been becoming increasingly important as they allow reconstruction even in patients with impaired vascular status. To the authors’ knowledge, no studies have examined the choice of ETE or ETS anastomoses specifically for digital arteries.

Resurfacing of lower extremities: Versatility of thigh flap as pedicle extension graft with consecutive thoracodorsal artery perforator-based flap

BACKGROUND

For successful microsurgical reconstruction using free tissue transfer, healthy recipient vessels must be obtained from outside the zone of injury. Securing an appropriate length pedicle length is also essential, and various techniques for lengthening a vascular pedicle have been developed. Herein, we present our experience using the descending branch (DB) of the lateral circumflex femoral vessels (LCFVs) with a thigh flap as an extender graft for consecutive second flap.

METHODS

We reconstructed the complex and vessel-depleted defects of nine patients. The mean age was 47.6 years. The defects were located in the lower leg in four patients, in the perineum in two patients and in the forearm in three patients. The two patients who suffered from Fournier's gangrene underwent a pedicled anteromedial thigh (pAMT) flap with the DB of the LCFVs and seven patients, five who suffered high-energy trauma and two who had scar contracture, underwent a free anterolateral thigh (ALT) flap with the distal run-off DB of the LCFVs. In all patients, second consecutive free latissimus dorsi or thoracodorsal artery perforator flaps were prepared and the thoracodorsal vessels of the second flap were anastomosed to the distal DB of the LCFVs.

RESULTS

The total length of the thigh flap pedicles measured from both ends of the DB of the LCFVs varied from 15 to 20 cm, which was sufficient for use as a vascular conduit. Of the 18 flaps, 17 survived completely without any complications and 1 pAMT flap showed partial necrosis, which was covered with a perineal perforator-based island flap. The mean follow-up period was 16.7 months. Unfortunately, one patient, who suffered a total amputation below the knee and had replantation surgery, underwent amputation due to venous congestion in the distal leg. However, the previous two flaps survived and were used for coverage of the stump.

CONCLUSIONS

Using a thigh flap as a vascular extender graft for second flap may be an alternative option in vessel-depleted reconstructions.

Combined Orthoplastic Approach in Fracture-Related Infections of the Distal Tibia

This series reports on the treatment of distal tibia (DT) fracture-related infections (FRI) with a combined orthoplastic approach. Thirteen patients were included. In eight patients with extensive bone involvement and in those with a non-healed fracture, the DT was resected (“staged approach”). In five cases, the DT was preserved (“single-stage approach”). A wide debridement was performed, and the cavity was filled with antibiotic-loaded PerOssal beads. All patients had a soft-tissue defect covered by a free vascularized flap (anterolateral thigh perforator flap in eight cases, latissimus dorsi flap in five). At the final follow-up (mean 25 months, range, 13–37), no infection recurrence was observed. In one patient, the persistence of infection was observed, and the patient underwent a repeated debridement. In two cases, a voluminous hematoma was observed. However, none of these complications impacted the final outcome. The successful treatment of FRI depends on proper debridement and obliteration of dead spaces with a flap. Therefore, when dealing with DT FRI, debridement of infected bone and soft tissues must be as radical as required, with no fear of the need for massive reconstructions.

Lower Extremity Soft Tissue Reconstruction Review Article

Reconstruction plays a valuable role in the management of lower extremity wounds for limb salvage. The goals of reconstruction are to improve function and quality of life, return to work, and pain reduction while providing a long-lasting durable reconstruction. The plastics and reconstructive surgical approach in conjunction with the orthopedic or trauma team, referred often as the "orthoplastic" approach, can yield the best outcomes for patients. The following sections discuss reconstruction principles and techniques that can be applied broadly for lower extremity wounds secondary to trauma, infection, and tumor resection.

Modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure for complex lower extremity reconstruction

BACKGROUND

Complex lower limb reconstruction due to severe trauma remains a challenge for reconstructive surgeons. Here, we introduce a modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure and evaluate its clinical efficacy.

METHODS

Between January 2013 and December 2019, 22 patients (range 10 to 64 years old) with unilateral lower limb injury underwent modified donor blood flow-preserved cross-leg anterolateral thigh flap procedures. Among them, 16 cases were traffic accidents, 5 cases were persistent ulcers, and 1 case was a degloving injury. The arterial pedicle of the flap was prepared in a Y-shaped fashion and microanastomosed to the posterior tibial artery of intact leg in a flow-through style. A split-thickness skin graft was applied to wrap the vascular pedicle after anastomosis. The flap was designed in a single or bilobed fashion according to the shape of the tissue defect. The operation time, the intraoperative blood loss and the length of hospital stays were recorded. The vascular pedicle was divided 4 weeks after anastomosis. Doppler ultrasound was performed to evaluate the blood flow of the donor posterior tibial artery during postoperative follow-up.

RESULTS

All 22 flaps survived. The tissue defects ranged from 12 × 6 to 21 × 18 cm². The flap sizes ranged from 14 × 7.5 to 24 × 21 cm². The average operation time, intraoperative blood loss and length of hospital stays were 6.73 ± 1.49 h, 280.95 ± 59.25 ml and 30.55 ± 2.52 days, respectively. Eighteen flaps were designed in a single fashion, while four were in bilobed fashion. Twenty patients underwent fasciocutaneous flap transplantations, while two underwent musculocutaneous flap transplantations. Two cases developed local lysis of the flap which healed after further debridement. Direct suture of the incision after flap harvest was performed in 16 cases, while additional full-thickness skin grafting was performed in the remaining 6 cases. Further bone transport procedures were performed in 15 patients who had severe tibia bone defects. The blood flow of donor posterior tibial artery was confirmed in all patients during follow-ups. All patients recovered flap sensation at the final follow-up. The postoperative follow-ups ranged from 18 to 84 months, and no long-term complications were observed.

CONCLUSIONS

The modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure is an ideal method to repair severe lower limb trauma with tibial artery occlusion which avoids sacrificing the major artery of the uninjured lower limb.

Versatility of perforator flaps for lower extremity defect coverage: Technical highlights and single center experience with 87 consecutive cases

BACKGROUND

Lower extremity defects have been and remain one of the greatest challenges in reconstructive surgery. Perforator flaps have been accepted as a valid procedure to cover such a defect. Different techniques have been described and nowadays many options are available. However, there were not studies that comprehensively review the most modern techniques and clinical application of the use of perforator flaps in the lower extremity reconstruction. In the present report, we gathered most of them, presenting an updated and large case series where different pedicled and free perforators flaps were employed in simple and complex scenarios in a large series of cases.

PATIENTS AND METHODS

Eighty-seven patients presenting soft tissue defects of the lower extremities were treated by means of different perforator-based flaps, in either free or pedicled fashion. The flaps were based on different perforator vessels, namely deep lateral circumflex femoral artery, profunda femoris artery, superficial femoral artery, medial sural artery, peroneal artery, posterior tibial artery, anterior tibial artery, and medial plantar artery. Patients' mean age was 61.9 years old (range 21-87 years old), 58 were males and 29 females. The 12 patients received sequential flaps and 9 received double free flaps, for a total sum of 106 flaps. The causes of the defects were trauma in 41 patients and tumors in 46 patients, located throughout the lower limbs. Size of the defect ranged from 3 cm × 4 cm to 25 cm × 9 cm.

RESULTS

The dimensions of the flap skin paddles ranged from 3 cm × 4 cm to 16 cm × 5 cm for the pedicled flaps (42 cases) and from 6 cm × 4 cm to 25 cm × 8 cm for the free ones (45 cases). Mean flap's size was 48 cm² (range 12-80 cm² ) for the pedicle flaps and 104 cm² (range 24-200 cm² ) for free flaps. In two pedicled cases, a distal congestion was encountered, requiring a second surgery. Debulking procedures were performed in 2 patients. All the patients were successfully treated and no flaps were lost. Mean follow-up period was 8.4 months (range 3-12 months). No range of motion impairment was encountered after surgery and all the patients were able to return to habitual life.

CONCLUSIONS

The present case series highlights the reliability and versatility of perforator flaps for lower extremity defect coverage. Following careful consideration of the etiology, dimensions, location, patient comorbidities, and presence of adequate perforators, a pedicled or free perforator flap can be potentially successful in the most disparate circumstances.

Muscle vs. Fasciocutaneous Microvascular Free Flaps for Lower Limb Reconstruction: A Meta-Analysis of Comparative Studies

(1) Background: Lower extremity microvascular reconstruction aims at restoring function and preventing infection while ensuring optimal cosmetic outcomes. Muscle (M) or fasciocutaneous (FC) free flaps are alternatively used to treat similar conditions. However, it is unclear whether one option might be considered superior in terms of clinical outcomes. We performed a meta-analysis of studies comparing M and FC flaps to evaluate this issue. (2) Methods: The PRISMA guidelines were followed to perform a systematic search of the English literature. We included all articles comparing M and FC flap reconstructions for lower limb soft tissue defects following trauma, infection, or tumor resection. We considered flap loss, postoperative infection, and donor site morbidity as primary outcomes. Secondary outcomes included minor recipient site complications and the need for revision surgery. (3) Results: A total of 10 articles involving 1340 patients receiving 1346 flaps were retrieved, corresponding to 782 M flaps and 564 FC flaps. The sizes of the studies ranged from 39 to 518 patients. We observed statistically significant differences (p < 0.05) in terms of donor site morbidity and total flap loss with better outcomes for FC free flaps. Moreover, the majority of authors preferred FC flaps because of the greater aesthetic satisfaction and lesser rates of postoperative infection. (4) Conclusion: Our data suggest that both M and FC free flaps are safe and effective options for lower limb reconstruction following trauma, infection, or tumor resection, although FC flaps tend to provide stronger clinical benefits. Further research should include larger randomized studies to confirm these data.

Using Duplex Ultrasound for Recipient Vessel Selection

INTRODUCTION

 Among the many factors involved in reconstructive microsurgery, identifying a good recipient vessel is one of the key elements leading to a successful result.

MATERIAL AND METHOD

 Multiple modalities have been used to identify recipient vessels from simple palpation of axial arteries to hand-held Doppler, duplex ultrasound, computed tomography angiograms, and other advanced techniques. Although these various modalities bring their own unique advantages, using the duplex ultrasound can provide far superior and real-time information based on the anatomy and physiology of the recipient vessel.

RESULT

 Duplex ultrasound is a valuable and powerful tool for reconstructive surgeons who are interested in performing microsurgery or supermicrosurgery.

CONCLUSION

 As we enter the era of individualized/customized reconstruction using superthin flaps, perforator-to-perforator anastomosis, and supermicrosurgery, understanding and becoming versatile with duplex ultrasound will be critical especially in choosing recipient vessels.

Safety and Vascular Impact of Perforator Propeller Flaps during Distal Lower Limb Reconstruction

Background:

In distal lower limb defects, the paucity of local tissues dictates a free-flap (FF)-based reconstruction frequently. The propeller perforator flap (PPF) offers a good alternative when the patient or the limb or both are not fit for FF-based reconstruction. Also, in contexts of restricted healthcare resources, armed conflict scenarios, or during pandemics like the ongoing COVID-19 pandemic, PPF is considered a valuable alternative to free-flap-based reconstruction. Additionally, PPFs are less sacrificing in terms of major limb vessels and distal limb vascularity. Yet, the distal lower limb vascular impact for PPF-based reconstruction has not been studied before.

Methods:

In total, 23 patients with distal lower limb defects were reconstructed with PPFs. By using U/S arterial duplex, the peak arterial velocity (PA velocity) was measured pre and postoperatively in 15 (65.2%) out of the 23 patients. This measurement was done to the vessel segment distal to the used perforator.

Results:

An estimated 21 out of 23 flaps succeeded to reconstruct the patients’ defects safely and to give all patients stable coverage without further surgeries. Only two patients had flap failure, which was managed successfully through additional reconstruction sessions. The difference between pre- and postoperative PA velocity was not statistically significant.

Conclusions:

PPFs are a safe cost-effective reconstruction modality for distal lower limb defects. This advantage is very valuable in cases of restricted healthcare resources, wars, and during pandemics. In terms of distal limb vascularity, PPFs have no significant impact and can be used safely.

The free flap man: An heroic 50-year odyssey via multiple flaps

Most lower extremity challenges can be solved by a solitary free flap. Yet if multiple wounds exist in a single extremity, or if bilateral extremities are involved, then multiple free flaps by necessity may be required to preserve ambulatory capabilities. Even rarer is their need in a sequential fashion. Thus is the uniqueness of this steelworker who at the young age of 23 sustained bilateral foot and ankle molten steel immersion injuries, initially salvaged by skin grafts virtually directly on bone. Over the next 50 years there were repeated episodes of graft instability that required five different free flaps to provide stable soft tissue coverage. Amputation was avoided, allowing minimal interruption at work as a bus driver until retirement. This patient's long journey was only possible due to the virtue of persistence, proving the value of that trait inherent within the true microvascular surgeon. It should be no wonder that appropriately this is the "free flap man."

Reconstruction of Foot and Ankle Defects Using Free Lateral Arm Flap: A Retrospective Review of Its Versatile Application

Background

Successful reconstruction of the feet and ankles remains challenging due to limited quantities of soft tissue and laxity. The free lateral arm flap (LAF) is an alternative to conventional flaps and has been widely used due to advancements in its flap characteristics. This study is aimed at utilizing the advantages of this flap to validate its increased applications for foot and ankle defects.

Methods

Twenty patients with various LAF types between May 2011 and May 2020 were enrolled. Clinical data was retrospectively collected, and defect sites were classified according to the subunit principle. We utilized various LAF types, such as LAFs with sensate, extended, osteomyocutaneous, or myocutaneous flaps, as necessary. A two-point discrimination test was performed, and results were statistically compared between flaps.

Results

Among the diverse etiologies of skin defects, chronic inflammation was the most common cause of defects. Various LAF types, including LAFs with fasciocutaneous, extended fasciocutaneous, musculocutaneous, and osteomyocutaneous flaps, were used. The versatility of free LAF helped successfully cover various defects in all cases. Results of the two-point discrimination test were statistically significant between groups.

Conclusions

Free LAF is a unique soft tissue free flap that is more versatile than other flaps, allowing flaps to be continuously modified and applied to various foot and ankle defects under different clinical conditions.

Free ALT Perforator Flap in Nonobese Patients: The Recontouring of Soft Tissue Defects Around Foot

BACKGROUND

The anterolateral thigh (ALT) perforator flap is well-described and versatile option for reconstruction of soft tissue defects around foot and ankle. This retrospective review was performed for reconstruction of soft tissue defects around foot with ALT perforator flaps in patients with normal and overweight body mass index (BMI).

METHODS

Between January 2016 and November 2020, ALT flaps were used in 30 patients for foot defects.

RESULTS

Etiologic factors were trauma (18 patients), diabetic foot ulcer (6 patients), tumor (3 patients), infection (2 patients) and burn contracture (1 patient). Mean body mass index (BMI) value was 24.9 ± 4.1 (17-30). Mean flap dimension was 145 ± 86 (40-420) cm². Recipient vessels were anterior tibial artery in 17 patients (56%), posterior tibial artery in 12 patients (40%), reversed flow dorsalis pedis artery in 1 patient (3.3%). In 24 patients (80%), 2 vein anastomoses were done. Debulking were applied in two patients (6.6%). Donor area was grafted in four patients (13.3%). Mean flap score was 1.25 ± 0.5. Mean flap thickness was 10 ± 2 (7-14) mm. Visual Analogue Scale (VAS) score was 7.75 ± 1.04 (6-10). The patients were followed up for a mean of 14 ± 11 (1-30) months.

CONCLUSION

We think that ALT flap is still reliable and precious option because it provides ideal soft tissue reconstruction by means of recontouring of foot in nonobese patients.

Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma

The complex lower extremity wound is frequently encountered by orthopedic and plastic surgeons. Innovations in wound care, soft tissue coverage and surgical fixation techniques allow for improved functional outcomes in this patient population with highly morbid injuries. In this review, the principles of reconstruction of complex lower extremity traumatic wounds are outlined. These principles include appropriate initial evaluation of the patient and mangled extremity, as well as appropriate patient selection for limb salvage. The authors emphasize proper planning for reconstruction, timing of reconstruction and the importance of an understanding of the most appropriate reconstructive option. The role of different reconstructive and wound care modalities is discussed, notably negative pressure wound therapy and dermal substitutes. The role of pedicled flaps and microvascular free-tissue transfer are discussed, as are innovations in understanding of perforator anatomy and perforator flap surgery that have broadened the reconstruction surgeon’s armamentarium. Finally, the importance of a multidisciplinary team is highlighted via the principle of the orthoplastic approach to management of complex lower extremity wounds. Upon completion of this review, the reader should have a thorough understanding of the principles of contemporary lower extremity reconstruction.

The Cost of Care Associated with Microvascular Free Tissue Transfer by Anatomical Region: A Time-Driven Activity-Based Model

Background Microvascular free tissue transfer (FTT) is a reliable method for reconstruction of complex soft tissue defects. The goal of this study was to utilize time-driven activity-based cost (TDABC) accounting to measure the total cost of care of FTT and identify modifiable cost drivers.

Methods A retrospective review was performed on patients requiring FTT at a single, level-I academic trauma center from 2013 to 2019. Patient and surgical characteristics were collected, and six prospective FTT cases were observed via TDABC to collect direct and indirect costs of care.

Results When stratified by postoperative stay at intensive care units (ICUs), the average cost of care was $21,840.22, while cases without ICU stay averaged $6,646.61. The most costly category was ICU stay, averaging $8,310.99 (40.9% of nonstratified overall cost). Indirect costs were the second most costly category, averaging $4,388.07 (21.6% of nonstratified overall cost). Overall, 13 of 100 reviewed cases required some form of revision free-flap, increasing cumulative costs to $7,961.34 for cases with non-ICU stay and $22,233.85 for cases with ICU stay, averaging up to $44,074.07 for patients who stayed in the ICU for both procedures. An increase in cumulative cost was also observed within the timeframe of the investigation, with average costs of $8,484.00 in 2013 compared to $45,128 for 2019.

Conclusion Primary drivers for cost in this study were ICU stay and revision/reoperation. Better understanding the cost of FTT allows for cost reduction through the development of new protocols that drive intraoperative efficiency, reduce ICU stays, and optimize outcomes.

Free tissue versus local tissue: A comparison of outcomes when managing open tibial diaphyseal fractures

INTRODUCTION

Open lower extremity fractures pose a challenge for treating surgeons. All surgical strategies have the common aim to facilitate fracture healing. Fracture union, however, should be critically considered in the context of functional recovery and not in isolation. Both local and free tissue transfer have benefits and drawbacks.

AIM

This study aims to compare the functional outcomes of open tibial diaphyseal fractures managed with internal fixation, comparing outcomes of those receiving free tissue transfer as opposed to local flaps METHODS: This study follows the STrengthening the Reporting of Observational studies in Epidemiology (STROBE) criteria. Data were collected retrospectively from a prospectively maintained database at our institution. Inclusion criteria included a non-comminuted Gustilo type-IIIB open tibial diaphyseal fracture requiring intramedullary nailing. Forty three patients with local flaps and 180 patients with free flaps were included RESULTS AND CONCLUSION: 233 patient underwent reconstruction for open fracture using local flaps (n=43) or free flaps (n=180). In the context of Gustilo type-IIIB non-comminuted, mid-tibial diaphyseal fractures treated with intramedullary nailing, free fasciocutaneous flap reconstructions leads to significantly improved functional outcomes in patients of all ages when compared to local fasciocutaenous flaps. (77 ± 19 v 50 ± 22 % for local flaps; P < 0.001).

Perforator-Based Pedicled Cross-Leg Flaps in Pediatric Patients: A New Idea to Increase Flap Reach

BACKGROUND

Distal lower limb reconstruction is one of the most difficult and challenging tasks in plastic surgery. Despite the continuous advances in microsurgical techniques, pedicled cross-leg flaps still have a major role particularly in pediatric patients. Many techniques have been described to maximize the potential of the cross-leg flaps. The introduction of fasciocutaneous flaps has provided more potentials and made lower leg reconstruction easier and more successful. The description of perforator system in the leg has also made a revolution in the regional reconstruction. In this report, we present a new modification that increases the reach and facilitates the inset of the flaps.

METHODS

The flap is taken from the posteromedial skin of the middle third of the leg. The design is determined by the location, size, and shape of the defect. The base of the flap should contain at least 2 perforators located by Doppler device. After elevation of the fasciocutaneous flap, 2 back cuts are performed in the upper and lower edge of the flap base preserving the 2 previously located perforators.

RESULTS

Fifty patients, 32 males and 18 females, were reviewed and presented. Age of the patients ranged from 4 to 13 years and the defect size ranged from 20 to 130 cm. All flaps survived with 3 flaps had mild marginal ischemia, 2 flaps had mild infection, and 1 flap had partial dehiscence.

CONCLUSIONS

Back cuts made at the edges of the base of a cross-leg flap, preserving the feeding perforators, can increase the flap reach without jeopardizing its viability. It is also an easy to do technique and does not require any extra equipment or time.

Reconstruction of traumatic and non-traumatic lower extremity defects with local or free flaps

Background

Despite continuous surgical advances, reconstruction of complex lower extremity wounds remains challenging. The indication of local flaps or microsurgical free tissue transfer depends on the anatomical location and size of the defect, as well as the comorbidities and general condition of the patient. In this study, local and free flap reconstruction of distal lower extremity defects was assessed, and postoperative complications and limb salvage were analyzed.

Methods

A total of 34 patients were included in this retrospective study. Distal lower extremity defects were of traumatic (29%) and non-traumatic (71%) etiologies. Patient characteristics, flap selection, postoperative complications, and limb preservation within the first 12 months were assessed and compared by reconstructive treatment concept. Statistical analysis included parametric and non-parametric tests. The two-sided alpha was set at 5% for all statistical tests.

Results

While 21 patients were treated with local flaps, 13 patients underwent microsurgical free flap reconstruction. The most common comorbidities were peripheral vascular disease and diabetes. Local flaps included the gastrocnemius muscle flap, soleus flap, sural flap, and plantaris medialis flap. The most commonly used free flaps for soft tissue reconstruction were latissimus dorsi and gracilis muscle flaps. The overall lower extremity preservation rate was 94.1%. There was one case of below-knee amputation 1 month after free flap reconstruction, and one case of first-ray amputation of the foot after local flap coverage.

Conclusion

Reconstruction of lower extremity defects can be achieved by local or free flap reconstruction. Flap selection is influenced by anatomical location, defect size, and patient factors.

Free Flaps in Lower Extremity Reconstruction

Free tissue transfer to the lower extremity for limb salvage remains challenging. A comprehensive approach includes patient selection, flap selection, selection of the recipient vessels, flap dissection, flap preparation, microvascular anastomosis, flap inset, immediate postoperative care, intermediate postoperative care, and further follow-up care. Each step in this comprehensive approach has its unique considerations and should be executed equally to ensure an optimal outcome. Once acquired, some clinical experience along with adequate microsurgical skill, good surgical judgment, well instructed and step-by-step intraoperative execution, and a protocol-driven practice, successful free tissue transfer to the lower extremity can be accomplished.

Reconstruction of Quadriceps Muscle Function Using the Latissimus Dorsi Muscle Transfer in an Elderly Patient: A Case Report

CASE

We report a case of a 71-year-old man diagnosed with high-grade undifferentiated pleomorphic sarcoma in the left thigh. He underwent partial resection of the quadriceps and proximal femoral bone, followed by reconstruction with a latissimus dorsi free muscle flap through end-to-end vascular and nerve anastomosis with the femoral vessels and a branch of the femoral nerve, respectively. Recovery of 3/5 knee extension function was achieved 3 months postsurgery without complications.

CONCLUSION

Free neurotized latissimus dorsi muscle transfer is a successful reconstructive option to restore knee extension after quadriceps resection.

LEVEL OF EVIDENCE

Level IV.

Harvesting the anterolateral thigh flap with non-sizable perforators

BACKGROUND

The anterolateral thigh flap (ALT) has proven over time to be one of the best reconstructive workhorses due to its versatility and reliability. Without preoperative imaging, vascular anomalies such as having no sizable perforator are sometimes encountered during dissection. We propose a technique, based on a modified version of the traditional myocutaneous ALT to allow harvest of the flap based on non-sizable perforators. This technique can also enable the splitting of a flap when only one sizable perforator is present.

METHODS

A retrospective review of patients who received reconstruction with free ALT flap from 2013 to 2019 by the senior author HSS was performed and included all flaps in which non-sizable perforators were harvested. Data collected for analysis included patient demographics, flap size, defect location, inset type, and flap survival.

SURGICAL TECHNIQUE

Despite detachment of the majority of skin paddle from the muscle, the flap is harvested with a sleeve of areolar tissue containing preferably more than one non-sizable perforator attached to a small muscular segment of the vastus lateralis containing the pedicle.

RESULTS

A total of 349 ALT flaps were performed during the review period by senior author HSS, and 25 flaps were harvested with non-sizable perforator, 10 of which were to enable a split. There were no total losses and 6 partial losses; 2 were amenable to direct closure after debridement, 1 required skin graft, and 3 required a new flap for wound coverage. Incorporating more than one non-sizable perforator increases the reliability of the flap. This technique should be used with caution in patients with multiple underlying comorbidities and when a flow-through flap is required. We were able to achieve primary closure of all donor sites.

CONCLUSIONS

It is possible to harvest the anterolateral thigh flap without sizable perforators by conversion to a modified version of the myocutaneous flap. In well-selected patients, using our technique, several non-sizable perforators can reliably perfuse an ALT without the need to use an alternative donor site. This maximizes the number of harvestable ALTs and increases the reconstructive potential by splitting previously "un-splitable" flaps.

Treatment of traumatic losses of substance in the foot

Treatment of traumatic loss of bone and tissue substance in the foot necessitates special consideration of the anatomy and physiology of the segment. The causes of foot trauma are multiple and in many cases violent, leading to progressive tissue deterioration that may require multi-phased debridement. The therapeutic objective is to reconstruct a functional foot permitting painless pushing off, walking and footwear use by restoring a stable bone framework, with resistant covering satisfactorily adjusted to the different zones of the foot. While coverage of the back of the foot must be fine, coverage of the plantar zones will be padded. The reconstructive surgeon shall be particularly attentive to plantar sensitivity. To take up the surgical challenge, it is of paramount importance to fully master a wide-ranging therapeutic arsenal ranging from conventional grafts to composite free flaps in view of proposing the solution most suited to the type, size and location of the loss of substance, all the while striving to generate as few sequelae as possible at the donor site. In order for reconstruction to be successful, multidisciplinary collaboration between plastic surgeons, orthopedists and physician is highly recommended.

Comparison of the outcomes of adipofascial and two-staged fasciocutaneous reverse sural flap in patients with lower leg trauma

BACKGROUND

Distal one - third trauma of the lower limb is a complex condition to treat. The reverse sural flap is a time tested procedure for reconstruction of such defects especially in patients where free flaps are ruled out due to comorbidities. The purpose of this study is to compare the two modifications of the classical technique of reverse sural flap (adipofascial and fasciocutaneous) which is lacking in the literature.

MATERIAL & METHODS

In this study, the authors conducted a retrospective analysis of 67 patients with lower one-third leg defects reconstructed with either adipofascial reverse sural flap (Group A, n = 37) or two-staged fasciocutaneous reverse sural flap (Group B, n = 30) in a tertiary care hospital in North India between 2015 and 2019. An evaluation of the different flap characteristics of the two variants of the reverse sural flap was done and compared. Mean follow up period was 12 months.

RESULTS

The adipofascial group showed shorter operative time, was a single-stage and with better reach and aesthetic outcome. The complications did not differ except that for the adipofascial group was associated with unstable skin graft over the flap initially which did not require any treatment.

DISCUSSION

Lower one-third defect of the lower limb has been a challenge for reconstructive surgeons all over the world. The goal of reconstruction is a functional lower limb. Although free tissue transfer is the preferred modality of treatment of such cases but it may not be possible in all cases due to various reasons. Reverse sural flap is a very lucrative local option for such reconstructions as it is easy to perform, reliable, low profile and bulk, require minimal facilities with less operative time. Adipofascial flaps represent an extremely useful modification of the reverse sural flap which is quick to perform with minimal donor site morbidity.

CONCLUSION

Adipofascial reverse sural artery flap is a good option for patients with lower limb trauma with the added advantage of being single-stage and with better donor site cosmesis as compared to the fasciocutaneous reverse sural artery flap.

Importance of Vascularity and Selecting the Recipient Vessels of Lower Extremity Reconstruction

BACKGROUND

 Successful lower extremity reconstruction using free flaps begins by identifying a good recipient vessel and understanding the surrounding environment of the defect.

METHODS

 One should consider multiple factors when selecting the recipient vessel such as the status of the axial arteries, trying to preserve flow as much as possible, extent and severity of the defect, and ultimately what type of anastomosis will be ideal.

RESULTS

 Multiple factors of importance are reviewed and show the relevance in decision making and provide an algorithm.

CONCLUSION

 In addition to the multiple factors to be considered, the ultimate decision should be made on the table during surgery when the actual artery or vein is exposed and shows signs of good pulsation and flow.

[Soft tissue defects following tumor resection in the limbs and trunk : Plastic reconstructive soft tissue and revision concepts]

BACKGROUND

Tissue defects of the trunk and limbs after oncologic surgery and radiation require plastic reconstructive tissue coverage. Depending on the location and size of the wound as well as the interdisciplinary treatment concept, different reconstructive procedures are performed. These range from skin transplantation to local and pedicle flaps, to perforator flaps and free microsurgical tissue transfer.

METHODS

The modern "reconstructive ladder" can be regarded as an orientation for the sequence of the reconstructive options. Considering the patient's wishes and risk profile, an individual reconstructive concept must be devised. The best functional and simultaneously safest procedure with the smallest secondary defect is to be chosen. Wound preconditioning via vacuum-assisted closure can precede definitive tissue coverage in order to optimize local conditions.

CONCLUSION

Safe tissue coverage can be achieved even in advanced stages of oncologic disease and after extensive surgery by performing wound preconditioning and arteriovenous loop grafting to induce safe de novo recipient vessels for two-stage free tissue transfer. The choice between maximum plastic reconstructive options for a curative approach or limited palliative surgery is to be harmonized and balanced with therapeutic goals and the patient's biologic resources. Preservation and restoration of quality of life and functionality is the plastic surgeon's dictum.

Surgical defect reconstructions in knee, lower leg, and foot with flaps: a retrospective analysis

Background

The first description of local fascio-cutaneous flaps used for the coverage of soft tissue defects of the limbs originates from the 1980s. Over the years, this technique has advanced, and in the meantime, a sub-group of flaps named perforator-based propeller flaps has gained increased attention. In our study, we aimed to demonstrate our experience of operating surgeries with perforator-based propeller flaps and to compare this technique with other flap techniques, which are to reconstruct tissue defects of the knee, lower leg, and foot.

Methods

A systematic retrospective search for flap procedures for defect reconstructions in the knee, lower leg, and foot from our database was performed. All data between January 2010 and August 2018 were considered. We identified 56 procedures performed on 14 female and 42 male patients with the mean age of 54.13 years. Reconstruction procedures consisted of 34 free flaps, 14 perforator-based propeller flaps, and eight other perforator-based flaps. Compared to free flaps, the perforator-based propeller flaps had shorter surgery duration by 46.6% (p < 0.0001) and the complication rate in the cases of perforator-based propeller flaps was reduced by 31.14% (p = 0.0315). Furthermore, the operations carried out with perforator-based propeller flaps resulted in a significantly lower rate of revisions by 36.03% (p = 0.0204), compared to those with free flaps. The majority of the donor sites of free flaps were self-closing with the direct suture (p = 0.004).

Conclusions

Based on our findings, we can propose the applicability of perforator-based flaps in treating defects of the knee, lower leg, and foot. With a correct indication, perforator-based propeller flap represents a promising alternative to free flaps, with its significantly shorter surgery duration, lower complications rate, and lower revision rate. However, both techniques of the free flap transfer and the transfer of local pedicle-based flap possess their advantages and disadvantages. Therefore, it is hard to define which microsurgical technique is exclusive in treating lower leg defects.

Level of evidence: Level IV, therapeutic study.

Challenges of Setting up a Lower Extremity Reconstruction Practice in a Constrained Environment

BACKGROUND

 Microsurgical lower extremity reconstruction remains challenging, especially when resources are limited such as lack of proper equipment, human resources, administrative support, and located in a remote area far from tertiary care. Nevertheless, reconstructive solutions are required, especially when in urgent trauma situations. In this article, we evaluate ways of overcoming challenges and issues that should be considered in a newly established unit by sharing our initial lower extremity reconstruction experience.

METHODS

 We report a local hospital's initial lower extremity reconstruction experience in February 2017 to January 2018. Through a total of seven patients, we tried to enhance the environment, instruments, nurses' contribution, and perspective of the peers and community in terms of factors related to the surgeon, hardware, environment, supporting faculty, reimbursement, and patients.

RESULTS

 Four patients underwent reconstruction with a freestyle propeller flap and three with an anterolateral thigh flap; in one case, a superficial circumflex iliac artery perforator flap was chosen to salvage partial flap necrosis. Increased experience of the surgeon, new equipment, continuing nurse/patient education, and collaborating with other departments allowed us to choose more challenging flaps and be more meticulous while decreasing the operation time and hospital stay.

CONCLUSION

 To start a lower extremity reconstruction practice in a resource-poor environment, the surgeon needs to evaluate the relevant factors; moreover, he or she should continuously improve them until a working methodology is achieved. Despite all the challenges, the adaptations learned at this center can be applied to other local hospitals around the world to set up a lower extremity reconstruction practice and improve its outcomes.

Functional and oncological outcomes of limb-salvage surgery for foot and ankle tumors

BACKGROUND

Limb-salvage surgery has become the backbone treatment for musculoskeletal tumors in the last decades. However, limb-salvage with safe margins for tumors of the foot and ankle is challenging, due to the complex anatomy of this region. This study aimed to evaluate functional and oncological outcomes, complications, and local recurrence of limb-salvage procedures for tumors of the foot and ankle.

METHODS

This study was a retrospective review of 18 patients with primary tumors of the foot and ankle who underwent limb-salvage surgery between 1996 and 2015, with a minimum follow-up of 2 years. Clinical presentations, radiological and histopathological investigations, surgical procedures, functional and oncological outcomes, complications and local recurrences were analyzed. The Musculoskeletal Tumor Society (MSTS) scoring system was utilized for evaluation of the functional outcome.

RESULTS

With a mean follow-up period of 44.2 months, 7 males and 11 females with a mean age of 29.2 years were included. Nine patients were presented as recurrent cases. The most common location was forefoot in 7 patients. Synovial sarcoma was the histopathologic diagnosis in 7 patients. The final surgical margins were wide in 15 patients, wide-contaminated in one patient, and marginal in two patients. After resection, soft tissue reconstruction and wound coverage were done by soft tissue flaps in 4 patients. The mean MSTS score was 27.5. Four patients developed local recurrence, all of them were recurrent cases.

CONCLUSION

Limb-salvage surgery for foot and ankle tumors is an effective treatment option with good functional outcome.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Selecting a free flap for soft tissue coverage in lower extremity reconstruction

BACKGROUND

Goals of lower extremity microvascular reconstruction (LEMR) include the restoration of function, prevention of infection, and optimal cosmesis. Indications for LEMR include large defects that are not amenable to pedicled options, a large zone of injury, and large complex defects. The novice microsurgeon should first master a handful of free flaps to develop an armamentarium of options for addressing such defects. The scope of this review is to provide free flap options for LEMR in any of the thirds of the lower leg. After reading this article, the reader will understand variations, advantages, disadvantages, indications, and tips for raising each of these flaps.

METHODS

Six most commonly used free flaps for LEMR are described in this paper, including the anterolateral thigh flap (ALT) and its variations, the radial forearm flap (RFFF), the lateral arm flap (LAF), the gracilis muscle flap, the rectus abdominis flap (RAF) and the latissimus dorsi flap and its variations. Indications, advantages, disadvantages and technique tips are discussed for each flap. Moreover, selection of the recipient vessels, preoperative management along with an algorithm are also provided.

CONCLUSIONS

The ALT flap is a workhorse in covering defects of the leg, foot, and ankle. It's the flap of choice at our institution, especially given the number of traumatic wounds seen as a result of motor vehicles, all-terrain vehicles (ATV), lawnmowers, and gunshot wounds (GSW). At times, the lower extremity zone of injury requires a distant donor site. The RAF can also provide coverage for large soft tissue defects but donor-site morbidity remains its main drawback. The LAF and RFFF provide two pliable options, one that provides pliable soft tissue with minimal donor site morbidity and another that provides a long pedicle. The free gracilis flap is an excellent choice for crossing the ankle joint. Lastly, the free latissimus dorsi is indicated for large defects of the lower extremity independently of the location.

Amputations versus Salvage: Reconciling the Differences

BACKGROUND

 There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation.

METHODS

 In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population.

RESULTS

 The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease.

CONCLUSION

 Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population.

Don't Shoot Yourself in the Foot: Reconstruction of a Through-and-Through Gunshot Wound of the Foot

A 69-year-old man presented with an accidental, self-inflicted, through-and-through left foot gunshot wound. An entry wound on the dorsum of the foot was noted, with a larger exit wound on the plantar aspect. X-ray revealed comminuted fractures of the second, third, fourth, and fifth metatarsals with numerous foreign bodies. Immediate excisional debridement was performed, and negative-pressure wound therapy was applied. A second look was performed 48 hours later. Five days after initial debridement, a Kirschner wire was utilized for fixation of the second metatarsal fracture, and an external fixator applied to the fifth metatarsal due to extensive bone loss. A free gracilis muscle flap was used to fill the defect, with plans for a vascularized bone graft at a later date. The flap was tunneled through the wound to the plantar aspect of the foot, with an overlying split-thickness skin graft. The patient’s postoperative course was uncomplicated, and secondary bone grafting was not required. The gracilis flap was used to reconstruct the bony and soft tissue defects, and secondary muscle fibrosis appeared to provide adequate skeletal support. The patient was full weight-bearing by 4 months and has since returned to his preoperative activities, baseline gait, and regular footwear. The free gracilis muscle flap may serve as a valuable reconstructive option for through-and-through gunshot wounds to the foot, restoring both contour and function, while eliminating the need for secondary bone grafting.

Use of the subscapular system by maintaining unilateral decubitus placement without repositioning in microvascular free tissue transplantation

BACKGROUND

In microvascular free-tissue harvest and transfer, the need for repositioning from lateral decubitus position and the inability to use a two-team approach are major drawbacks of the subscapular system. We present our experience with the subscapular system for upper and lower extremity reconstruction using a two-team approach without need for repositioning.

METHODS

We conducted a retrospective chart review for all patients undergoing free flap transplant based on the subscapular system to the upper or lower extremity at our microsurgical facility from January 1, 2007 to December 31, 2011. Only cases not requiring intraoperative repositioning were included. Sixty-four patients underwent the two-team approach (37 upper extremity and 27 lower extremity transplants). Flap types included latissimus dorsi musculocutaneous, partial superior latissimus, dorsal thoracic fascia, serratus, scapular bone, and thoracodorsal artery perforator, either alone or as chimeric flaps. All patients were placed in the lateral decubitus position for the duration of the surgery.

RESULTS

The ipsilateral subscapular system was used in 16% of cases for lower extremity defects, where the anterior tibial vessels served as recipient vessels. The contralateral subscapular system was used in all remaining cases for upper extremity or the vast majority for lower extremity (84%) defects, where either the superficial femoral, genicular, popliteal, sural, or posterior tibial vessels served as recipient vessels. With the exception of one partial flap loss secondary to infection, all flaps survived.

CONCLUSIONS

Proper lateral decubitus positioning allows for a two-team approach without compromising safety or outcomes.

Acute Treatment of Open Foot and Ankle Fractures Using a Bioartificial Dermal Regeneration Template and Split-Thickness Skin Grafting: A Report of 2 Cases

CASE

Two patients with open foot and ankle fractures were treated with aggressive irrigation and debridement and acute placement of a dermal regeneration template (DRT) followed by split-thickness skin grafting. Patient 1 was an 82-year-old female with a type IIIB open ankle fracture complexed with 2 significant regions of soft tissue loss. Patient 2 was a 54-year-old male with type IIIB open metatarsal fractures. Both patients healed without complication.

CONCLUSIONS

Complex open fractures in lower extremities can be managed with acute DRT application. This may be a more cost-effective solution compared to free flaps.

Review of Cross-Leg Flaps in Reconstruction of Posttraumatic Lower Extremity Wounds in a Microsurgical Unit

Since the advent of microsurgery, and expanding expertise in the field, extensive traumatic wounds of leg have been managed successfully with free tissue transfer. Various patient-related factors may preclude the use of free flaps even in units with available expertise and infrastructure. It is in such situations that the "cross-leg flap" comes into play. In these cases, instead of attempting complicated anastomotic techniques or anastomosis in the zone of trauma, it is better to perform the simpler and more reliable cross-leg flap. In this study, we try to show the utility of a cross-leg flap based on a retrospective study of 198 patients who underwent cross-leg flap in our institute over a period of 15 years extending from November 2003 to March 2018.

MATERIALS AND METHODS

Case sheets of all patients who underwent cross-leg flap from November 2003 to March 2018 were reviewed. The location of defect in the leg, the indication for cross-leg flap, the pattern of cross-leg flap, and perioperative complications were noted.

RESULTS

A total of 198 patients underwent cross-leg flap for traumatic soft tissue injury of leg during this period. The most common reason for performing cross-leg flap was poor pulsatility of the recipient artery as seen intraoperatively, followed by the economics of the procedure wherein the initial cost of free flap was found significantly higher compared with cross-leg flap. All flaps survived with partial necrosis occurring in 23 patients. All flaps settled well by 2 years' time. Bony union/fracture healing evaluation was not a part of this study.

CONCLUSION

Cross-leg flap is still a useful tool for leg wound coverage even in microsurgical unit in situations precluding free flap coverage.

Management of Post-Traumatic Composite Bone and Soft Tissue Defect of Leg

Management of composite defects of leg following trauma requires a planned ortho-plastic approach right from the outset. Timely, planned intervention results in reduced amputation rates and improved limb salvage and function. Right from the time of presentation of the patient to the emergency with such injury, the process of decision making in terms of salvage or amputation, local flap cover/free flap cover, bone reconstruction first or soft tissue or both combined, come into play. Guidelines on management are unclear for such defects, a literature search yielding various methods being used by different authors.

This article is a review of current literature on management of composite leg defects.

A summary of the literature search in terms of various management options given by various authors including the rationale, advantages and disadvantages of each strategy has been provided in this article. The management protocol and method followed by the author in his institute for management of such composite defects have been described in detail. The article seeks to provide readers with an understanding of the management strategies so that appropriate method could be chosen to provide best result.

A Scientometric Analysis of the 50 Most Cited Articles for Reconstruction of the Lower Extremity

Background

Lower extremity reconstruction has always been a challenge. Some of the published articles had a major impact on the field but are often not considered as classics because they have fewer citations. We therefore conducted a scientometric analysis of the most cited articles with a focus solely on the lower limb.

Methods

A search was conducted on Medline, the Web of Science database, Google Scholar, and Scopus identifying articles relevant to reconstructive surgery of the lower limb. All journals were included with no time frames. Articles relating solely to orthopedics or vascular reconstruction were excluded. The number of citations obtained were then plotted and compared between the different search engines. The mean citation number was calculated by taking into consideration the total number of years since the article's first year of publication. Articles were then ranked and classified according to their authors, their years of publications, and their countries. They were furthermore categorized and analyzed.

Results

Highly cited articles were easily retrieved with Google Scholar, mostly published in Plastic and Reconstructive Surgery (n = 37) and were mainly authored by American Medical Centers (n = 22). Fifty-four percent (54%) of these classic articles discussed the design of new flaps or were anatomical studies.

Conclusions

We were not able to find a correlation between the year of citation and the number of citations. The citation pattern of a paper cannot be predicted, but a majority of highly cited article allowed the design of new reconstructive techniques.

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

BACKGROUND

Covering defects at the lower leg and foot is a common challenge in reconstructive surgery. A flap is often required, and free flaps are widely used. The posterior tibial perforator-based flap constitutes a valuable option in this situation. The objectives of this study were to evaluate the reliability of the posterior tibial perforator-based flap, report any complications, and describe the outcomes, with the goal of defining the indications of this flap in the treatment of lower limb defects.

HYPOTHESIS

The posterior tibial perforator-based flap is a useful and reliable option for soft-tissue defect reconstruction at the leg and foot.

MATERIAL AND METHOD

Patients managed using a posterior tibial perforator-based flap to cover soft-tissue defects of the leg and foot were reviewed retrospectively. A physical examination was performed and radiographs obtained at the last postoperative follow-up visit.

RESULTS

Thirteen patients with a mean age of 46.9 years (range: 25-73 years) were reviewed after a mean follow-up of 19.5 months (range: 16-63 months). The tissue defects were due to compound fractures in 10 patients and to postoperative complications in 3 patients. Mean flap size was 12.3cm by 6.2cm. The donor site was covered by a skin graft in 12 patients and closed primarily in 1 patient. The procedure was successful in 11 (85%) patients.

DISCUSSION

The posterior tibial perforator-based flap is a method of choice for covering soft-tissue defects at the leg and foot. Careful patient selection and flawless technique contribute to minimise the failure rate.

LEVEL OF EVIDENCE

IV, retrospective study.