Limb salvage for soft-tissue malignancies of the foot: an evaluation of free-tissue transfer

Microvascular Muscle vs. Fascio-Cutaneous Free Flaps for Reconstruction of Plantar Load-Bearing Foot Defects-An International Survey

Background: The reconstruction of plantar load-bearing foot defects faces many plastic surgeons with a major challenge. The optimal patient- and defect-oriented reconstructive strategy must be selected. Methods: To analyze the current trends and recommendations in reconstruction of plantar load-bearing foot defects, we conducted an international survey among plastic surgeons querying them about their recommendations and experiences. Results: The survey revealed that the most common strategies for reconstruction of the foot sole are locoregional and microvascular free flaps, emphasizing the relevance of plastic surgery. Among microvascular free flaps, muscle and fascio-cutaneous free flaps are by far the most frequently used. The target qualities of the reconstructed tissue to be considered are manifold, with adherence being the most frequently mentioned. We observed a noteworthy correlation between the utilization of muscle flaps and a preference for adherence. In addition, we identified a substantial correlation between the usage of fascio-cutaneous free flaps and further target qualities, such as good skin quality and sensitivity. Conclusions: Our findings provide insights into the clinical reality and highlight important aspects that must be considered in reconstruction of the weight-bearing areas of the foot providing support in the selection of the appropriate therapy.

RB. Outcome Analysis Comparing Muscle and Fasciocutaneous Free Flaps for Heel Reconstruction: Meta-Analysis and Case Series

Background Choosing the components of free flap (fasciocutaneous or muscle) is one of the crucial but controversial decisions in heel reconstruction. This meta-analysis aims to provide an up-to-date comparison of fasciocutaneous flaps (FCFs) and muscle flaps (MFs) for heel reconstruction and to ascertain if one flap has an advantage over the other.

Methods Following the Preferred Reporting Item for Systematic Reviews and Meta-Analyses guidelines, a systematic literature review was performed identifying studies on heel reconstruction with FCF and MF. Primary outcomes were survival, time of ambulation, sensation, ulceration, gait, need for specialized footwear, revision procedures, and shear. Meta-analyses and Trial Sequential Analysis (TSA) were performed to estimate the pooled risk ratios (RRs) and standardized mean difference (SMD) with fixed effects and random effects models, respectively.

Results Of 757 publications identified, 20 were reviewed including 255 patients with 263 free flaps. The meta-analysis showed no statistically significant difference between MF and FCF in terms of survival (RR, 1; 95% confidence interval [CI], 0.83, 1.21), gait abnormality (RR, 0.55; 95% CI, 0.19, 1.59), ulcerations (RR, 0.65; 95% CI, 0.27, 1.54), footwear modification (RR, 0.52; 95% CI, 0.26, 1.09), and revision procedures (RR, 1.67; 95% CI, 0.84, 3.32). FCF had superior perception of deep pressure (RR, 1.99; 95% CI, 1.32, 3.00), light touch, and pain (RR, 5.17; 95% CI, 2.02, 13.22) compared with MF. Time to full weight-bearing (SMD, –3.03; 95% CI, –4.25, –1.80) was longer for MF compared with FCF. TSA showed inconclusive results for comparison of the survival of flaps, gait assessment, and rates of ulceration.

Conclusion Patients reconstructed with FCF had superior sensory recovery and early weight bearing on their reconstructed heels, hence faster return to daily activities compared with MFs. In terms of other outcomes such as footwear modification and revision procedure, both flaps had no statistically significant difference. The results were inconclusive regarding the survival of flaps, gait assessment, and rates of ulceration. Future studies are required to investigate the role of shear on the stability of the reconstructed heels.

Two-team-approached free flap reconstruction for plantar malignant melanoma: An observational (STROBE-compliant) trial

Reconstructive treatments of heel defects usually involve regional flap techniques such as medial plantar flap procedures due to the limited availability of adjacent soft tissues. Although free flaps have advantages in terms of function and aesthetics, they remain challenging due to the longer operation time required than for regional flaps. Thus, we introduce an appropriate 2-team surgical protocol to reconstruct plantar defects after wide excision of malignant melanoma using free flap coverage. From 2015 to 2020, a retrospective study was performed including 21 patients who underwent free flap surgeries to reconstruct defects due to plantar malignant melanoma. Lymphoscintigraphy was performed to localize sentinel lymph nodes, and the procedure was carried out by 2 teams working together, a tumor-ablative team and a reconstructive team. The present study is adhered to the STROBE guidelines for cohort studies. The average operation time was 241.4 minutes and was not significantly different even in cases with inguinal dissection (P value: 0.641). All flaps survived after 2 cases of venous insufficiency and 1 case of hematoma were resolved by immediate revision surgery. The 2-team approach to surgically reconstruct heel defects after wide excision of malignant melanoma using free flap coverage offers favorable results and lower morbidity than regional flap approaches.

Microsurgical Reconstruction of Foot Defects: A Case Series with Long-Term Follow-Up

(1) Background: Microsurgical reconstruction of foot defects with free flaps is rare as it is a challenging task for a surgeon. For extensive defects, advanced surgical procedures, such as free flap transfer with microsurgical anastomosis, may be the last chance to avoid major amputation. The aim of the study was to examine the opportunities and risks posed by free flap reconstruction of foot defects and to illustrate in which situations reconstruction is useful on the basis of case characteristics. (2) Methods: In this study, we retrospectively analyzed data of cases with free flap reconstruction of the foot from 2007 to 2022. Therefore, demographic data, comorbidities, information about the defect situation, data on the operational procedure, and complications were evaluated. (3) Results: A total of 27 cases with free flap coverage of foot defects could be included. In 24 of these cases (89%), defect coverage was successful. In 18 patients, some form of complication occurred in the postoperative stage. The most frequently used flap was the latissimus dorsi flap, with 13 procedures. (4) Conclusions: Foot reconstruction using free flaps is a proven procedure for the treatment of larger foot defects and can offer a predominantly good functional outcome. The lengthy process and possible complications should be thoroughly discussed in advance so as to provide criteria, suitably adjusted to the individual prerequisites of the patients, for deciding whether limb salvage using advanced surgical procedures should be attempted.

Free tissue transfers for reconstruction of weight-bearing heel defects: Flap selection, ulceration management, and contour revisions

BACKGROUND

Soft tissue defects in the weight-bearing heel represent a reconstructive challenge because of tissue complexity and lack of local/regional coverage. This study presents our reconstruction outcomes of different defect aetiologies, reconstruction timing, and flap selection.

METHODS

Patients with weight-bearing heel defects who underwent free tissue transfer from 2003 to 2014 and with at least 6 months of follow-up were retrospectively reviewed. Flap types (fasciocutaneous vs muscle/musculocutaneous), timing of reconstruction (early vs subacute vs delayed), and defect aetiology were compared in terms of flap failure, vascular complications, and ulceration.

RESULTS

Seventy-four flaps were used to reconstruct weight-bearing heel defects in 70 patients. Defect aetiology included trauma in 53 patients (75%), chronic wound in 12 patients (17%), and tumour resection in 6 patients (8%). Flap survival was 97% (72/74). There was no significant difference in flap failures between muscle and fasciocutaneous flaps. The timing of reconstruction showed no difference in flap survival. There was a significant difference in ulceration rate between the trauma and non-trauma groups (p = 0.001). Twenty-eight ulcers (39%) developed, 12 (43%) of which presented 3 years postoperatively, while only 6 cases (21%) presented within one year postoperatively.

CONCLUSION

Our experience represents one of the highest survival rates reported regarding free flap weight-bearing heel reconstruction. The anterolateral thigh flap was our first choice for extensive heel defects. Ulceration incidence was directly related to trauma and tends to develop 3 years after reconstruction. Delayed reconstruction was at least as safe as early or subacute reconstruction though with less need for debulking.

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.

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.

Total calcanectomy for metastasis of renal cell carcinoma in the calcaneus: A case report

We present a rare case of metastasis of renal cell carcinoma to the calcaneus in a 59-year-old man who presented with pain and inability to bear weight on the left foot 3 years after right nephrectomy for renal cell carcinoma. He successfully underwent en bloc resection of his right calcaneus with a limb salvage procedure, total calcanectomy without bony reconstruction. Histological findings identified the lesion as a metastasis originating from a renal cell carcinoma. Recent follow-up examination showed no recurrence. To the best of our knowledge, this is the first reported case to be treated with total calcanectomy for renal cell carcinoma metastasis.

Reconstruction Outcomes of Oncologic Foot Defect Using Well-Contoured Free Perforator Flaps

BACKGROUND

Reconstruction of foot defects following oncologic resection is a crucial element in the treatment of soft tissue malignancy of the foot.

OBJECTIVE

The present study aimed to comprehensively evaluate outcomes of oncologic foot reconstruction using free perforator flaps.

METHODS

Outcomes of patients with soft tissue malignancy of the foot who underwent reconstruction using a free perforator flap following ablative surgery were reviewed, and perioperative and delayed complications (secondary debulking operation and flap instability) were documented. The Foot Function Index (FFI) questionnaire was surveyed to assess functional status.

RESULTS

Overall, 72 patients were analyzed, with a median follow-up period of 28 months. Malignant melanoma was a predominant etiology. Three kinds of perforator flaps were used, with the thoracodorsal artery perforator flap being the most common. Flaps with skin dimensions matching the defect size were inset and the thickness of the flaps was controlled with primary defatting. Flap re-exploration was conducted in 11 (15.2%) cases and total flap loss occurred in 3 (4.2%) cases. Delayed complications developed in an additional 12 cases, therefore 23 (31.9%) cases required a return to the operating room. The average FFI score was 8.86 at postoperative month 36, on average (range 11-128 months). All respondents reported being independently ambulatory and had minimal difficulty in their daily lives. Reconstruction of defects on weight-bearing regions showed a significantly higher FFI score than that on nonweight-bearing regions (mean 11.96 vs. 4.79, p = 0.029), although the scores remained very low for both instances.

CONCLUSIONS

Oncologic foot defects can be reliably reconstructed using well-contoured free perforator flaps with minimal functional morbidity.

Limb salvage surgery following resection of a melanoma: Foot and ankle reconstruction using cutaneous flaps

Melanomas affect the foot and ankle region and are associated with a poor prognosis. The aim of the current study was to evaluate the functional and oncological outcomes of salvage surgery using cutaneous flaps for soft tissue reconstruction of the foot and ankle following the extended resection of a melanoma. A retrospective review was conducted to evaluate patients who presented with foot melanoma and underwent salvage surgery and defect reconstruction using three types of cutaneous flap (group S) or amputation (group A) between January 1999 and December 2010 at the First Hospital of Jilin University (Changchun, China). The postoperative mortality, surgical complications, functional outcomes and oncological outcomes were evaluated. Of the 21 patients, 11 were enrolled into group S and 10 were enrolled into group A. The median follow-up time of the patients was 58 months (range, 6–92 months). In group S, a reverse sural neurocutaneous island flap was used in six patients to perform the foot reconstruction, medial plantar flaps were used in four patients and lateral malleolus flaps were used in one patient. All 11 cutaneous flaps survived and provided satisfactory coverage. Only one cutaneous flap showed partial necrosis and required treatment comprising of debridement and regular changes to the wound dressing. The overall survival rate of patients was 65.0% and patients in the two groups experienced similar oncological outcomes. Salvage surgery with cutaneous flap reconstruction was found to be a reliable option for patients presenting with malignant melanoma of the foot and ankle.

The versatility of perforator-based propeller flap for reconstruction of distal leg and ankle defects

Introduction. Soft tissue coverage of distal leg and ankle region represents a challenge and such defect usually requires a free flap. However, this may lead to considerable donor site morbidity, is time consuming, and needs facility of microsurgery. With the introduction of perforator flap, management of small- and medium-size defects of distal leg and ankle region is convenient, less time consuming, and with minimal donor site morbidity. When local perforator flap is designed as propeller and rotated to 180 degree, donor site is closed primarily and increases reach of flap, thus increasing versatility. Material and Methods. From June 2008 to May 2011, 20 patients were treated with perforator-based propeller flap for distal leg and ankle defects. Flap was based on single perforator of posterior tibial and peroneal artery rotated to 180 degrees. Defect size was from 4 cm × 3.5 cm to 7 cm × 5 cm. Results. One patient developed partial flap necrosis, which was managed with skin grafting. Two patients developed venous congestion, which subsided spontaneously without complications. Small wound dehiscence was present in one patient. Donor site was closed primarily in all patients. Rest of the flaps survived well with good aesthetic results. Conclusion. The perforator-based propeller flap for distal leg and ankle defects is a good option. This flap design is safe and reliable in achieving goals of reconstruction. The technique is convenient, less time consuming, and with minimal donor site morbidity. It provides aesthetically good result.

Composite biological reconstruction following total calcanectomy of primary calcaneal tumors

BACKGROUND

Advances in oncologic treatment modalities and wide resection have made limb salvage procedures in calcaneal malignancy or aggressive benign tumor increasingly possible. However, reconstructions of the calcaneus remain a major surgical challenge because of the rarity and specific anatomy of this condition.

METHODS

we retrospectively reviewed 4 patients who had primary calcaneal tumors and underwent total calcanectomy and reconstructions with use of composite of allograft and vascularized osteocutaneous fibular grafts between 2007 and 2010. The diagnoses included chondrosarcoma in 1, fibrosarcoma in 1, aggressive osteoblastoma in 1, and giant-cell tumor in 1. Wide resection margins were achieved in all patients. The mean age at the time of the operation was 32.1 years. Patients were examined clinically and radiographically and were assessed functionally with Musculoskeletal Tumor Society (MSTS) score and American Orthopaedic Foot and Ankle Society (AOFAS) score.

RESULTS

The median duration of follow-up was 24.5 months. No local recurrence occurred in this series and all patients had no evidence of disease at the time of final follow-up. Limb salvage was achieved in all patients. Revision surgery was necessary in two patients because of complications (skin flap necrosis and infection). The average MSTS 93 score and AOFAS score were 91.7% and 87.5 at the final follow-up, respectively. All fibular flaps survived and bone unions achieved successfully. The overall mean time for bone union was 9.5 months. The mean time to full-weight bearing was 7 months.

CONCLUSIONS

Vascularized fibular flaps in combination with massive allografts provide an excellent option for biological reconstruction after total calcanectomy in tumor situation and have proven to be a successful limb salvage procedure, which result in earlier patient recovery and return of function.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Soft tissue reconstruction of the foot using the distally based island pedicle flap after resection of malignant melanoma

BACKGROUND

We report on our experience with using a distally based island flap for soft tissue reconstruction of the foot in limb salvage surgery for malignant melanoma patients.

METHODS

A distally based sural flap was used for 10 cases for the hindfoot reconstruction, and a lateral supramalleolar flap was used for 3 cases for the lateral arch reconstruction of the mid- and forefoot after wide excision of malignant melanomas.

RESULTS

The length of the flap varied from 7.5 cm to 12 cm (mean, 9.6 cm) and the width varied from 6.5 cm to 12 cm (mean, 8.8 cm). Superficial necrosis developed in four flaps, but this was successfully treated by debridement and suture or a skin graft. All thirteen flaps survived completely and they provided good contour, stable and durable coverage for normal weight bearing.

CONCLUSIONS

The distally based sural flap is considered to be useful for reconstructing the hindfoot, and the lateral supramalleolar flap is good for reconstructing the lateral archs of the mid- and forefoot after resection of malignant melanoma of the foot.

Oncosurgical and reconstructive concepts in the treatment of soft tissue sarcomas: a retrospective analysis

BACKGROUND

Patients with soft tissue sarcomas are initially treated in community hospitals and in the private practice setting in the majority of cases. Thus, this disease entity is initially treated by surgeons with limited experience and expertise regarding the complex and demanding therapeutic regimen necessary to address this distinct group of malignancies.

METHODS

A retrospective analysis was conducted with a particular focus on factors affecting patient outcome, oncosurgical intervention, and plastic surgical reconstruction.

RESULTS

A total of 75 patients were included in the study. Only 66% of all patients presented with a primary tumor. The remaining 34% presented with either local recurrence or distant metastasis. The oncosurgical procedure most commonly performed was wide excision (69%). However, amputation was unavoidable in 7% of cases. Single-step reconstruction included primary closure (19%), skin grafting (19%), local fascio- or myocutaneous flap transfer (31%), as well as free flap transfer (31%). 17 patients (20%) have deceased due to their underlying disease. Yet another 10% are alive with evidence of residual tumor. Kaplan-Meier analysis displayed significant differences in overall survival rate depending on disease stage upon initial presentation.

CONCLUSION

Based on our data favorable oncological outcomes with satisfactory functional results and limb preservation are achievable if oncological principles for resection are respected and reconstruction is performed according to plastic surgical principles.

Hemodynamic alterations in the transferred tissue to lower extremities

A higher incidence of failure has been reported for free flaps transplanted to the lower extremities. However, the physiological background of this phenomenon has not been elucidated. We reviewed the 3-day postoperative hemodynamic data for 103 free flaps, including the in situ venous pressure (N = 103), arterial pressure (N = 53), and surface blood flow (N = 42). The cases were divided into two groups based on the recipient site, i.e., lower extremity (the LE group: N = 29) and the other (non-LE group: N = 74). The venous pressure was significantly higher in the LE group (26.6 +/- 2.2 vs. 14.8 +/- 1.2 mmHg), whereas the arterial pressure immediately after surgery was lower than the non-LE group. The hemodynamic data within the transferred tissues demonstrated significant differences between groups, especially in the early postoperative period. There is a possibility that the high venous pressure may aggravate the poor perfusion in tissues transferred to the lower extremities.

Soft tissue sarcomas of the foot and ankle: impact of unplanned excision, limb salvage, and multimodality therapy

BACKGROUND

Foot and ankle sarcomas have historically been treated with amputation because of the difficulty in achieving local disease control and maintaining a functional foot. Potential opportunities for limb salvage may be further compromised by unplanned excisions.

MATERIALS AND METHODS

We reviewed 52 consecutive patients with soft tissue sarcomas of the foot and ankle and analyzed the impact of planned versus unplanned initial excision, limb salvage, and multimodality therapy on treatment and outcomes.

RESULTS

Unplanned excisions had been performed in 29 (55.8%) patients. Limb salvage was performed in 38 patients, with 14 requiring free soft tissue transfers. At an average followup of 99 (range, 24 to 216) months, the 5-year overall survival estimate was 76.3%. Although not statistically significant, we noted clinically relevant potential differences in local recurrence-free, disease-free, and oncologic survival between the planned and unplanned excision groups. Seven patients (13.5%) had a local recurrence, five of these following an unplanned excision. Functional scores averaged 83.2% for all patients which were similar between planned versus unplanned and amputation versus limb salvage groups. Significantly more patients with unplanned excisions required free flaps for limb salvage (p = 0.017) and received adjuvant radiotherapy (p = 0.0004).

CONCLUSION

Unplanned surgery for soft tissue sarcomas of the foot and ankle often results in the need for more aggressive surgery and/or adjuvant radiotherapy and may impact oncologic outcomes, but does not necessarily portend worse functional outcomes. Multimodal therapy and judicious use of soft tissue flap reconstruction allows limb salvage in most patients with favorable outcomes.

Subungual Melanoma

Melanoma management requires consideration of both oncologic and reconstructive principles to optimize both the likelihood of cure and quality of life. The plastic surgeon is encountering melanoma management that requires not only oncologic but also reconstructive surgery while considering both esthetic and functional results. Management of acrolentiginous melanoma typically involves the partial amputation of the thumb or the toe, with removal of the distal phalanx and the adjacent interphalangeal joint. The simple partial amputation of the second phalanx, preserving the pulp and the interphalangeal function (joints and tendinous insertions), and a made-to-measure ungual transfer provide excellent functional and esthetic results while maintaining similar oncologic outcomes. This report attempts to clarify the management of melanoma of the thumb.

Lower extremity reconstruction

The current recommendation for surgical treatment of tumors of the lower extremity is a limb-sparing resection. Limb-sparing resection coupled with complex reconstructive techniques and complemented by new chemotherapeutic agents and adjuvant radiation therapy has allowed us to achieve survival rates that are comparable to those of amputation with a better functional outcome. Recent advances in microsurgical techniques and the associated technologies and a better understanding of microvascular anatomy has allowed us to customize flaps to the specific needs of the patients and to achieve a lower donor site morbidity. Increased communication between the specialties of the multidisciplinary treatment team has also improved outcomes. The reconstructive component has become an integral part of the multidisciplinary care for patients with lower extremity tumors. It not only allows them to rapidly resume adjuvant therapies but also enables them to more easily resume their activities of daily living.

Retrospective review of free gracilis muscle flaps in the management of nonhealing diabetic foot ulceration

This study retrospectively examined data from 45 patients with diabetic foot ulcers who underwent free gracilis muscle reconstruction from January 1999 to December 2003. Twenty-five patients (55.6%) were men and 20 (44.4%) were women. The mean age was 60.2 years (range, 34-90 years). The mean follow-up was 27 months (range, 6-36 months). The lesions were located on the dorsum of the foot (38.5%), hallux (18.5%), and the fifth toe (12.3%). According to Wagner's classification, 28% of the ulcers were grade 2, 20% were grade 3, and 51.1% were grade 4. Initial management of these patients included control of blood sugar level, proper hydration, administration of antibiotics, treatment of coexisting diseases, and repeated debridements of wounds when necessary. A total of 48 gracilis muscle flaps were harvested for reconstruction. There were 35 (72.9%) patients with complete success when there was complete healing of the flap; 12 patients with partial success when there was some loss of the flap or skin graft, or draining wounds; and 1 patient (2.1%) with failure. There was no infection or hematoma of the flap donor site; only hypertrophic scarring occurred in 3 patients (6.6%). The free gracilis muscle flap is a safe, simple, and effective method for coverage of difficult diabetic foot ulcers. Its use results in good aesthetic and functional outcome and low donor site morbidity.

Model of radiation-impaired healing of a deep excisional wound

Despite many well-recognized benefits, administration of ionizing radiation before surgical resection of malignancies is associated with a high risk of wound-healing complications. Most animal models investigating techniques to improve wound healing use a superficial wound. The goal of this study was to develop a novel model of radiation-impaired healing using a deep excisional wound, which is closer to the clinical situation. In the first part of this study, female Lewis rats were exposed to 0, 12, 15, or 18 Gy single-fraction radiation to the buttocks. Three weeks later, deep wounds were created by excision of the gluteus maximus muscle. Irradiated wounds had a lower rate of healing of the surgically created defect than unirradiated wounds (p<0.001), but there was no significant difference between the different doses of radiation. Impaired healing was still evident at 12 weeks. The second part of this study investigated the ability of porcine small-intestinal submucosa (SIS) to improve healing in this animal model. At 6 weeks, wounds implanted with SIS showed improved healing at all doses of radiation compared with unimplanted irradiated wounds. However, higher doses of radiation were still associated with a lower rate of healing. SIS induced a cellular response that was not evident in defects that did not receive SIS, suggesting that SIS has the potential to stimulate repair. This reproducible model of radiation-impaired wound healing closely resembles the clinical setting. The results indicate that this model can be used to investigate new biomaterials as possible therapeutic agents to enhance wound healing.

Functional Evaluation After Reconstruction With Myocutaneous and Fasciocutaneous Flaps for Conservative Oncological Surgery of the Extremities

BACKGROUND

Limb-preservation surgery has evolved during the last two decades through application of pedicled and free flaps and has obtained oncological results similar to those with amputation for malignant neoplasms of the extremities. However, functional evaluation has not been performed comprehensively after these advanced reconstructive procedures. The aim of this study was to describe the oncological, surgical, and functional outcomes achieved in these patients.

METHODS

Patients had malignant neoplasms of the extremities and/or shoulder and hip girdle, underwent resective surgery and reconstruction with limb-preservation purposes, and were treated from 1997 to 2002. Survival analysis was performed, and functional evaluation after resection was performed with the Enneking system 1 year after surgery.

RESULTS

Thirty-two patients were included. The mean overall survival of the cohort was 5.6 years. Functional evaluation mean rating percentages for the upper and lower extremities were 86.5% and 75.2%. Functional outcomes were better for reconstruction with free flaps than with pedicled flaps in the lower extremities (rating percentages, 67% and 79.6%, respectively; P = .018).

CONCLUSIONS

Limb-preservation surgery is a safe treatment for malignant neoplasms. It can be performed with low morbidity and good oncological outcomes. Functional results in our series were good. Lower limb preservation has superior scores with free flap reconstructions because of their potential to cover extensive defects, and better results were obtained in walking, gait, and weight bearing.

The compound thoracodorsal perforator flap in the treatment of combined soft-tissue defects of sole and dorsum of the foot

Nine cases of massive soft-tissue loss of the foot were reconstructed by means of a compound (chimera) thoracodorsal artery perforator (TAP) flap, which reconstituted the different functional units (dorsum, heel, instep, weight-bearing surface). In each case, the flap consisted of a skin component isolated on its perforator in combination with a portion of latissimus dorsi muscle and/or serratus fascia, all pedicled on the thoracodorsal vessels. The pedicle length allows up to 4-6 cm of independent mobility of the skin island. The mobility of the various flap components allows the various functional units of the foot to be reconstructed without relying on multiple flaps or anastomoses. The pedicle length was sufficient to be able to perform the anastomosis out of the zone of injury. In some cases the skin island was harvested along with intercostal nerve branches, this gave us the potential to develop a sensate flap. The indications and advantages of this reconstructive method are discussed.

Free tissue transfer to a difficult wound of the lower extremity

Amputation is still recommended to patients with a difficult wound of the lower extremity because limb salvage after free tissue transfer in these patients remains uncertain. During the past 3 years, the authors studied 15 patients (11 men, 4 women; age range, 17-71 years) with difficult wounds of the lower extremities who had free tissue transfers for limb salvage. Eleven patients had an extensive soft-tissue defect (nearly the entire length) of the legs or feet, and 4 had a composite-tissue defect of the legs or feet that required bony reconstruction. A total of 16 free tissue transfers (13 free muscle flaps, 2 osteomusculocutaneous flaps, and 1 adipofascial flap) were performed in 15 patients (1 patient had bilateral transfers). A saphenous vein loop or graft was used in 3 patients and a subsequent bone graft was done in 2 patients. Free tissue transfer was accomplished successfully in 14 patients (93%). Limb salvage was achieved ultimately in 12 patients (80%) who were able to ambulate during a 36-month follow-up. The authors believe that free tissue transfer for limb salvage in any patient with a difficult wound of the lower extremity is still a worthwhile procedure and should be attempted if possible. Meticulous preoperative preparation and intraoperative execution combined with the use of innovative microsurgical techniques are the keys for success.

Reconstruction for lower extremity limb salvage in soft tissue carcinoma

Limb salvage procedures for the lower extremity have a 95% success rate and have essentially supplanted primary amputation as the primary treatment for limb-threatening malignancies. En bloc tumor resection involving major neural and vascular structures that once led to amputation are now successfully reconstructed using free-tissue transfer in combination with neoadjuvant and adjuvant chemoradiation therapies and brachytherapy. Planning for reconstruction of complex lower extremity wounds begins at the time of diagnosis and extends to postoperative rehabilitation. Developing a successful reconstructive plan requires a team approach with accurate assessment of the anticipated loss of critical structures, wound location, defect size, and an understanding of the local and distant tissues available for reconstruction. Comprehensive assessment of the anticipated wound combined with an understanding of the distant and local tissues available for reconstruction allows the reconstructive surgeon to select tissues from the entire body that have improved functional and aesthetic outcomes for patients.

Reconstruction of through-and-through gunshot wounds to the feet with free gracilis muscle flaps

Reconstruction of a through-and-through gunshot wound (GSW) to the foot remains a challenging problem for plastic and orthopedic surgeons, because it is difficult to achieve reliable soft tissue coverage of the foot while at the same time optimizing foot contour and weightbearing. In the past year, four patients with such an injury were treated with initial wound debridement and stabilization of the metatarsals, followed by a free gracilis muscle transfer with a split-thickness skin graft. One patient also had a secondary iliac bone graft to the first metatarsal. All patients have completely healed wounds, are free of osteomyelitis, and have achieved an excellent contour and good ambulation of the foot without donor site problems. Thus, a free gracilis muscle transfer should be considered first for reconstruction of a through-and-through GSW to the foot, because it can provide reliable soft tissue coverage with excellent contour and minimal donor site morbidity.