Principles of Reconstruction for Complex Lower Extremity Wounds

Masquelet combined with free-flap technique versus the Ilizarov bone transport technique for severe composite tibial and soft-tissue defects

BACKGROUND

The treatment of bone and soft-tissue defects after open fractures remains challenging. This study aimed to evaluate the clinical efficacy of the Masquelet technique combined with the free-flap technique (MFFT) versus the Ilizarov bone transport technique (IBTT) for the treatment of severe composite tibial and soft-tissue defects.

METHODS

We retrospectively analysed the data of 65 patients with tibial and soft-tissue defects and Gustilo type IIIB/C open fractures treated at our hospital between April 2015 and December 2021. The patients were divided into two groups based on the treatment method: group A (n = 35) was treated with the MFFT and internal fixation, and group B (n = 30) was treated with the IBTT.

RESULTS

The mean follow-up period was 28 months (range 13-133 months). Complete union of both soft-tissue and bone defects was achieved in all cases. The mean bone-union times were 6 months (range 3-12 months) in group A and 11 months (range 6-23 month) in group B, with a significant difference between the two groups (Z = -4.11, P = 0.001). The mean hospital stay was 28 days (range 14-67 d) in group A which was significantly longer than the mean stay of 18 days (range 10-43 d) in group B (Z = -2.608, P = 0.009). There were no significant differences in the infection rate between group A (17.1 %) and group B (26.7%) (χ2 = 0.867, P = 0.352). The Total Physical Health Scores were 81.51 ± 6.86 (range 67-90) in group A and 75.83±16.14 (range 44-98) in group B, with no significant difference between the two groups (t = 1.894, P = 0.063). The Total Mental Health Scores were significantly higher in group A (90.49 ± 6.37; range 78-98) than in group B (84.70 ± 13.72; range 60-98) (t = 2.232, P = 0.029).

CONCLUSION

Compared with IBTT, MFFT is a better choice of treatment for open tibial and soft-tissue defects with Gustilo IIIB/C fractures. IBTT is the preferred option when the tibial bone defect is large or if the surgeon's expertise in microsurgery is limited.

[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.

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.

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.

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.

"Primary free-flap tibial open fracture reconstruction with the Masquelet technique" and internal fixation

BACKGROUND

Grade III open fractures of the lower extremity are serious injuries and are difficult to reconstruct. The optimal treatment for such injuries is unclear. We aimed to determine the safety and efficacy of orthoplastic reconstruction, using a primary free anterolateral thigh flap combined with the Masquelet technique and internal fixation for Gustilo grade IIIB/C open tibial fractures.

METHODS

From April 2018 to April 2019, 15 patients, ranging from 19 to 72 years old, with Gustilo grade IIIB/C open fractures were treated using a primary free anterolateral thigh flap combined with the Masquelet technique and internal fixation. This involved wound debridement and removal of free bone fragments, followed by bone cement packing of the defect, external fixation, and vacuum sealing drainage treatment. The final stage involved switching from external to internal fixation and wound repair using a free anterolateral thigh flap. Repair time ranged from 2 to 7 days. Flap size ranged from 25 × 15 cm² to 13 × 7cm². Hospital stay ranged from 11 to 50 days (mean, approximately 33.3 days). Bone cement was removed after 6-19 weeks and replaced with autogenic cancellous bone.

RESULTS

All flaps survived without incident. One patient experienced a wound infection, but there were no deep infections. For all patients, bone union was achieved after 4 to 7 months.

CONCLUSION

The use of a primary free anterolateral thigh flap combined with the Masquelet technique and internal fixation is a safe and effective procedure for reconstruction of Gustilo grade IIIB/C open fractures.

The Soleus Muscle Flap: An Overview of Its Clinical Applications for Lower Extremity Reconstruction

Lower extremity reconstruction often poses several challenges for the reconstructive surgeon. Because of limited local tissue options, patients who sustain extensive middle to distal third tibia fractures used to be at higher risk of limb loss without adequate soft tissue coverage. The traditional principle of reconstructing middle and distal third leg wounds with free tissue transfer is being challenged by advances in understanding of local muscle flap anatomy and surgical techniques to improve the efficacy of local flaps. In this article, we examine contemporary considerations, developed by the authors, for the appropriate indications of free tissue transfer versus use of local flaps such as the soleus muscle flap. We review the versatility and reliability of the soleus muscle as a local muscle option once the technique is mastered on how to safely and effectively design and execute this flap. We highlight the importance of an algorithmic approach to soft-tissue reconstruction of the lower extremity based on the best surgical option for the patient. This includes factors such as medical history, appropriate surgical candidacy, as well as the size and mechanism of injury to decide the most viable option for lower extremity reconstruction. We show that the medial hemisoleus muscle flap is a reliable local option, both by itself or in conjunction with other local flaps, to reconstruct less extensive wounds in the middle to distal third of the leg. Ultimately, such a local muscle flap must be mastered by the reconstructive surgeon to augment his or her armamentarium to provide a well-rounded reconstructive plan in managing the soft-tissue wound, while minimizing donor-site morbidity and potentially be more cost-effective in nature.

A Comprehensive Approach to Lower Extremity Free-tissue Transfer

Background:

The purpose of this study was to introduce a comprehensive approach to lower extremity free-tissue transfer and report the clinical outcome that has been achieved with this approach.

Methods:

The comprehensive approach developed by the author 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 part of this approach has its own special considerations. In an 8-year period, 28 consecutive lower extremity free-tissue transfers were performed in 28 patients by the author. The clinical outcomes were recorded based on the success of free-tissue transfer, any reoperations related to the revision of microvascular anastomosis, and any partial or total flap loss during an 8-year follow-up.

Results:

All 28 lower extremity free-tissue transfers were performed successfully. All patients were discharged home once they tolerated dangling. No reoperations were needed for revision of microvascular anastomosis. No total or partial flap loss was encountered. Overall success of free-tissue transfer to the lower extremity in this series was 100%.

Conclusions:

An ideal outcome of free-tissue transfer to the lower extremity can be accomplished with this comprehensive approach developed by the author. With good surgical judgment, adequate microsurgical skill, step-by-step intraoperative execution, and a protocol-driven clinical practice, the reconstructive surgeon should be able to improve his or her success for free-tissue transfer to the lower extremity.