A Novel Flap to Repair Medial and Lateral Malleolar Defects

Tissue Coverage and Functional Reconstruction Outcomes With Use of Serratus Osteomusculocutaneous Free Flap in Lateral Malleolar Reconstruction: A Case Report

Currently, there is no ideal method defined in the repair of complex lateral malleolar defects, and the existing methods (i.e., bone repair, soft tissue or free flap closure) are far from producing functional results in terms of the ultimate recovery of ankle movements. Herein, an operative technique for soft tissue, ligamentous, and osseous reconstruction of fibular defect, using a free vascularized serratus anterior osteomusculocutaneous flap for reconstruction of a fibular deficit and the sixth costa for soft tissue coverage, was described in relation to tissue coverage and functional reconstruction outcome in a 31-year-old male patient with soft tissue and distal fibula defects in the lateral malleolus region caused by a traffic accident. Ankle movement was regained to almost full extent. No complications requiring further intervention was encountered in the donor site or ankle. In conclusion, the described operative technique enabled the repair of functional ligaments of the ankle joint in addition to repair of the soft tissue, lateral malleolus bone and skin defects in one session without the need for further additional operative intervention. Hence, the use of serratus osteomusculocutaneous free flap as a lateral malleolar reconstruction method seems to enable not only the tissue coverage but also to assist with functional reconstruction.

Propeller Flaps of the Lower Extremity

Wounds of the lower extremity involving the distal third of the leg remain a significant challenge due to anatomic location and often poor host physiology. Perforator-based propeller flaps may provide rapid coverage of these wounds with a relatively low rate of major complications and often readily managed minor complications. A thorough vascular evaluation must be performed prior to the procedure to ensure adequate flap design and selection of the correct perforator is performed. They have the added advantage over their soft tissue free flap counterparts in that they have significantly less host morbidity with similar rates of total necrosis.

Perforator-Pedicled Propeller Flaps for Lower Extremity Reconstruction

Reconstruction of the lower extremity is considered a major challenge due to frequent bone exposure and the absence of local tissue redundancy, as well as often due to the presence of vascular insufficiency. Many surgeons have preferred free flaps especially for reconstructing the more distal lower limb defects until the evolution of pedicled perforator flaps and propeller flaps in particular provided a like-with-like reconstruction of the lower extremity without affecting the main vessels of the limb or the underlying muscles, and without the risk of any microanastomosis especially in patients with multiple comorbidities. Perforator-pedicled propeller flaps as local flaps in the lower extremity are best suited for small- and medium-sized defects with minimal donor-site morbidity, regardless of the cause of the defect. Any of the three source vessels of the leg can provide reliable perforators for propeller flap coverage of the distal leg and foot. The three main risk factors that are relative contraindications may be advanced age, diabetes mellitus, and atherosclerotic peripheral vascular disease.

Anatomical study of anterior supramalleolar artery and its potential application to design a bi-foliate fasciocutaneous flap

Purpose:

A further understanding of the anterior supramalleolar artery (ASMA) and its potential applications in reconstructive surgery.

Materials and Methods:

A total of 24 fresh lower limbs from fresh cadavers were injected with red latex for dissection. The type of origin, course, diameter of the pedicle, and the distance between the origin of the ASMA from the anterior tibial artery to the extensor retinaculum (O-R) were recorded. Bi-foliate fasciocutaneous flaps were harvested using the branches of the ASMA.

Results:

We found four types of origin of the ASMA, and we have accordingly classified them into four types. 10 of them were type A, 7 were type B, 6 were type C and 1 was type D. The mean O-R (origin of ASMA to retinaculum) distance was 2.0 ± 0.8 cm. The diameter of the medial branch (D1), the diameter of the lateral branch (D2), and the diameter of artery stem (D3) (only in type A) were 1.0 ± 0.2 mm, 0.8 ± 0.3 mm, 1.1 ± 0.2 mm, respectively. The mean pedicle length of the lateral flap (L1) and medial flap (L2) were 5.1 ± 1.0 cm and 3.7 ± 0.6 cm, respectively.

Conclusions:

The ASMA exists constantly with four different types of origin. Its sizable diameter and lengthy pedicle make it suitable for bi-foliate fasciocutaneous flap transfer.

Flap decisions and options in soft tissue coverage of the lower limb

THE LOWER EXTREMITIES OF THE HUMAN BODY ARE MORE COMMONLY KNOWN AS THE HUMAN LEGS, INCORPORATING: the foot, the lower or anatomical leg, the thigh and the hip or gluteal region. The human lower limb plays a simpler role than that of the upper limb. Whereas the arm allows interaction of the surrounding environment, the legs' primary goals are support and to allow upright ambulation. Essentially, this means that reconstruction of the leg is less complex than that required in restoring functionality of the upper limb. In terms of reconstruction, the primary goals are based on the preservation of life and limb, and the restoration of form and function. This paper aims to review current and past thoughts on reconstruction of the lower limb, discussing in particular the options in terms of soft tissue coverage. This paper does not aim to review the emergency management of open fractures, or the therapy alternatives to chronic wounds or malignancies of the lower limb, but purely assess the requirements that should be reviewed on reconstructing a defect of the lower limb. A summary of flap options are considered, with literature support, in regard to donor and recipient region, particularly as flap coverage is regarded as the cornerstone of soft tissue coverage of the lower limb.

Descending branch of the perforating branch of the peroneal artery perforator-based island flap for reconstruction of the lateral malleolus with minimal invasion

BACKGROUND

Reconstruction of intractable ulcers on the lateral malleolus is challenging because affected patients suffer various complications. A lateral supramalleolar flap, nourished by the superficial cutaneous branch of the perforating branch of the peroneal artery, has been described as one of the most reliable methods for reconstructing this difficult region. Although the deep descending branch of the perforating branch of the peroneal artery has a tiny cutaneous perforator, a flap based on this perforator has not been described.

METHODS

The vascular anatomy of an island flap based on the descending branch perforator of the perforating branch of the peroneal artery was investigated using 20 cadaver legs. Distances from the lateral malleolus and the external diameters were investigated. Based on the anatomical study results, a perforator-based island flap was developed for clinical use and implemented in five cases.

RESULTS

The anatomical study revealed the descending branch perforator diameter to be smaller than the superficial cutaneous branch diameter, and the location to be considerably closer to the lateral malleolus. All five island flaps used clinically survived without complications.

CONCLUSIONS

A new perforator-based island flap of the descending branch of the perforating branch of the peroneal artery for reconstruction of the lateral malleolus was designed. The territory covered by the flap could be enlarged by including the adjacent angiosome area of the superficial cutaneous branch. This flap elevation technique was uncomplicated and sufficiently straightforward to be used for patients at high risk for complications with extended surgical procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

The anterior tibialis artery perforator (ATAP) flap for traumatic knee and patella defects: clinical cases and anatomic study

Soft-tissue reconstruction of traumatic patella and proximal tibial defects is challenging. Pedicled perforator-based adipocutaneous rotation flaps are a versatile local option as they have axial perfusion and greater freedom of transposition compared with random-pattern flaps, and replace the ideal tissue properties of this anatomic region.

EXPERIMENTAL

Anatomic dissections were performed on 15 fresh cadaver legs and location of the dominant perforator measured. Clinical: A retrospective review was conducted at the University of Maryland/R Adams Cowley Shock Trauma Center evaluating patients over a 3-year period.

EXPERIMENTAL

Cadaver dissections confirmed a principal perforator at 11.4 +/- 1.6 cm inferior to the patella. This vessel is consistently suitable in length and caliber for large rotation flap design. Clinical: Anterior tibial artery perforator flaps were performed on 4 patients following Gustilo IIIB wounds to the patella and tibial plateau. Two patients had rotation flap reconstructions to salvage failed gastrocnemius muscle flaps. All flaps were successful, however, one patient had overwhelming hardware infection several months later despite successfully healed flap.Local anterior tibial artery perforator flaps based on predictable perforators provide reliable coverage of patella and knee defects, bestowing versatility and flexibility to the reconstructive surgeon's armamentarium.