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Galarza L, Talbot HG, Bryant GC, Davis JM. Locoregional Flap Reconstruction of the Distal Third of the Leg - What Role Does it Have in a Modern Reconstructive Algorithm? Ann Plast Surg 2024; 92:S376-S378. [PMID: 38856998 DOI: 10.1097/sap.0000000000003961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
ABSTRACT Reconstruction of traumatic defects of the lower third of the leg poses a challenge due to limited locoregional options. Failed coverage can be associated with prolonged hospital stay, infection, loss of function, and unplanned return to surgery. Over the last few decades, free tissue transfer has dominated reconstructive algorithms for such defects; however, locoregional flaps may provide equally effective coverage in select patients. In the wake of the CODID-19 pandemic, locoregional flaps gained more consideration due to limited resources. We present a literature review and discussion of locoregional flaps, with emphasis on the quality and efficacy of these reconstructive modalities compared with free tissue transfer and surgical indications.Soleus flaps, reverse sural flaps, and cutaneous perforator-based flaps are workhorses for small to medium size defects of the distal third of the leg, even in the setting of concomitant orthopedic trauma and exposed vital structures. It is important to consider such alternatives an integral part of the reconstructive algorithm as they can provide durable coverage with a favorable complication profile with less resource utilization. Appropriate patient selection requires consideration of the character of the defect, smoking status, preexisting vascular disease, and the zone of injury.
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Affiliation(s)
- Laura Galarza
- From the Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, MS
| | | | - Gidarell C Bryant
- School of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Jared M Davis
- From the Division of Plastic and Reconstructive Surgery, University of Mississippi Medical Center, Jackson, MS
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2
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Lee JY, Lee HJ, Yang SH, Ryu JH, Kim HT, Lee BH, Kim SH, Kim HS, Lee YK. Treatment of Soft Tissue Defects after Minimally Invasive Plate Osteosynthesis in Fractures of the Distal Tibia: Clinical Results after Reverse Sural Artery Flap. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1751. [PMID: 37893469 PMCID: PMC10608781 DOI: 10.3390/medicina59101751] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/27/2023] [Accepted: 09/28/2023] [Indexed: 10/29/2023]
Abstract
Introduction: Distal tibial fractures make up approximately 3% to 10% of all tibial fractures or about 1% of lower extremity fractures. MIPO is an appropriate procedure and method to achieve stable metal plate fixation and osseointegration by minimizing soft tissue damage and vascular integrity at the fracture site. MIPO to the medial tibia during distal tibial fractures induces skin irritation due to the thickness of the metal plate, which causes discomfort and pain on the medial side of the distal leg, and if severe, complications such as infection and skin defect may occur. The reverse sural flap is a well-researched approach for covering defects in the lower third of the leg, ankle, and foot. Materials and Methods: Among 151 patients with distal tibia fractures who underwent minimally invasive metal plate fixation, soft tissue was injured due to postoperative complications. We treated 13 cases with necrosis and exposed metal plates by retrograde nasogastric artery flap surgery. For these patients, we collected obligatory patient records, radiological data, and wound photographs of the treatment results and complications of reconstructive surgery. Results: In all the cases, flap survival was confirmed at the final outpatient follow-up. The exposed area of the metal plate was well coated, and there was no plate failure due to complete necrosis. Three out of four women complained of aesthetic dissatisfaction because the volume of the tunnel through which the skin mirror passed and the skin plate itself were thick. In two cases, defatting was performed to reduce the thickness of the plate while removing the metal plate. Conclusions: Metal plate exposure after distal tibial fractures have been treated with minimally invasive metal plate fusion and can be successfully treated with retrograde nasogastric artery flaps, and several surgical techniques are used during flap surgery.
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Affiliation(s)
- Jun Young Lee
- Department of Orthopaedic Surgery, College of Medicine, Chosun University, 365 Pilmundae-ro, Dong-gu, Gwangju 61453, Republic of Korea; (J.Y.L.); (H.J.L.); (S.H.Y.); (J.H.R.); (H.T.K.)
| | - Hyo Jun Lee
- Department of Orthopaedic Surgery, College of Medicine, Chosun University, 365 Pilmundae-ro, Dong-gu, Gwangju 61453, Republic of Korea; (J.Y.L.); (H.J.L.); (S.H.Y.); (J.H.R.); (H.T.K.)
| | - Sung Hoon Yang
- Department of Orthopaedic Surgery, College of Medicine, Chosun University, 365 Pilmundae-ro, Dong-gu, Gwangju 61453, Republic of Korea; (J.Y.L.); (H.J.L.); (S.H.Y.); (J.H.R.); (H.T.K.)
| | - Je Hong Ryu
- Department of Orthopaedic Surgery, College of Medicine, Chosun University, 365 Pilmundae-ro, Dong-gu, Gwangju 61453, Republic of Korea; (J.Y.L.); (H.J.L.); (S.H.Y.); (J.H.R.); (H.T.K.)
| | - Hyoung Tae Kim
- Department of Orthopaedic Surgery, College of Medicine, Chosun University, 365 Pilmundae-ro, Dong-gu, Gwangju 61453, Republic of Korea; (J.Y.L.); (H.J.L.); (S.H.Y.); (J.H.R.); (H.T.K.)
| | - Byung Ho Lee
- Department of Orthopaedic Surgery, Daejung Hospital, 180 Daein-ro, Dong-gu, Gwangju 61473, Republic of Korea;
| | - Sung Hwan Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Bucheon, 170 Jomaru-ro, Wonmi-gu, Bucheon-si 14584, Republic of Korea; (S.H.K.); (H.S.K.)
| | - Ho Sung Kim
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Bucheon, 170 Jomaru-ro, Wonmi-gu, Bucheon-si 14584, Republic of Korea; (S.H.K.); (H.S.K.)
| | - Young Koo Lee
- Department of Orthopaedic Surgery, Soonchunhyang University Hospital Bucheon, 170 Jomaru-ro, Wonmi-gu, Bucheon-si 14584, Republic of Korea; (S.H.K.); (H.S.K.)
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Türker T, Hines E, Haddad D. Hemodynamics in Distally Based Sural Flaps for Lower Leg Reconstruction: A Literature Review. J Hand Microsurg 2023; 15:253-257. [PMID: 37701313 PMCID: PMC10495205 DOI: 10.1055/s-0042-1749445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
Coverage of posttraumatic and chronic wounds at the distal leg is a difficult problem due to limited soft tissue available for local flaps. The sural flap is a versatile and effective method for reconstruction in this area since it does not need a significant amount of time or assistance to complete. Improving the survival of these flaps is critically dependent on understanding the basics of flap circulation and why recent modifications were introduced. This review will serve as a much-needed comprehensive analysis of these topics for surgeons looking to increase the reliability of their sural flaps.
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Affiliation(s)
- Tolga Türker
- Department of Orthopaedic Surgery, The University of Arizona-Banner University Medical Center Tucson, Tucson, Arizona, United States
| | - Eric Hines
- Department of Plastic and Aesthetic Surgery, University of California-Irvine School of Medicine, Irvine, California, United States
| | - David Haddad
- The University of Arizona College of Medicine-Tucson, Tucson, Arizona, United States
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Puneky GA, Batchler KA, Kollapaneni SS, Blair JA, Davis JM. Simplified soft tissue coverage of the distal lower extremity: The reverse sural flap. OTA Int 2023; 6:e235. [PMID: 37448567 PMCID: PMC10337849 DOI: 10.1097/oi9.0000000000000235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/05/2022] [Indexed: 07/15/2023]
Abstract
Soft tissue defects involving the distal lower extremity present challenging problems for orthopaedic surgeons to manage. Historically, wounds not amenable to primary closure have necessitated assistance from multidisciplinary teams using plastic surgeons to obtain adequate soft tissue coverage through rotational flap or free tissue transfer procedures. Techniques related to soft tissue rearrangement and local rotational flap coverage have advanced over the years with a growing knowledge of local anatomy and vasculature. The reverse sural flap may be performed to cover soft tissue defects within 10 cm of the foot or ankle region, negating the need for microvascular intervention. The simplistic nature of the reverse sural flap is appealing to orthopaedic surgeons as a means to provide timely patient care without additional support because it does not require microvasculature work or the need for intraoperative microscopes and has been popularized among orthopaedic trauma surgeons as a necessary tool to possess. Here, we discuss the reverse sural flap to include history, relevant anatomy, clinical indications, and a description of the technique for application.
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Affiliation(s)
- George A. Puneky
- Department of Orthopedic Surgery, Medical College of Georgia, Augusta University, Augusta, GA
| | - Kathryn A. Batchler
- Medical Student, Medical College of Georgia at Augusta University, Augusta, GA
| | - Sai S. Kollapaneni
- Medical Student, Medical College of Georgia at Augusta University, Augusta, GA
| | - James A. Blair
- Department of Orthopedic Surgery, Medical College of Georgia, Augusta University, Augusta, GA
| | - Jana M. Davis
- Department of Orthopedic Surgery, Medical College of Georgia, Augusta University, Augusta, GA
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Tsunoda T, Yasuda T, Igaki R, Takagi S, Kawasaki K, Kanzaki K. Post-traumatic Aeromonas hydrophila Osteomyelitis caused by an Infected Gustilo-Anderson Grade 3B Tibial Fracture: A Case Report with a 7-year Follow-up. J Orthop Case Rep 2023; 13:41-46. [PMID: 37521386 PMCID: PMC10379255 DOI: 10.13107/jocr.2023.v13.i07.3746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/24/2023] [Indexed: 08/01/2023] Open
Abstract
Introduction Post-traumatic osteomyelitis (OM) is often caused by Staphylococcus aureus. However, occasionally, it is caused by an infection with a rare bacterium. A case of OM caused by Aeromonas hydrophila was first reported in 1975. Since then, only nine cases have been reported, making it a rare disease. Here, we report a case of rare A. hydrophila OM that developed following open tibial fracture (classified as Gustilo-Anderson 3B) caused by an injury in a river. Case Report The patient was a 50-year-old male who got injured in a river and was diagnosed with open tibial fracture. Debridement in the first surgery happened at a leisurely pace. Purulent discharge from the wound persisted despite external fixation; however, no bacterium was detected in the bacterial culture. The patient underwent multiple debridement procedures; A. hydrophila was detected in the bone marrow. Despite the appropriate administration of antibacterial drugs and debridement, infection persisted until radical bone resection and tissue reconstruction were performed. In the present case, OM following an open fracture caused by an injury in a river was suspected, which was caused by the rare bacterium A. hydrophila. Conclusion In cases of OM occurring after underwater trauma, A. hydrophila should be considered as a causative pathogen. In addition, in cases of post-traumatic OM accompanied by bone and soft-tissue defects, the orthoplastic approach is required.
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Affiliation(s)
- Tomoaki Tsunoda
- Department of Orthopaedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Tomohiro Yasuda
- Department of Orthopaedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Ryu Igaki
- Department of Orthopaedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Shinsuke Takagi
- Department of Plastic and Reconstructive Surg, Showa University School of Medicine, Tokyo, Japan
| | - Keikichi Kawasaki
- Department of Orthopaedic Surgery, Showa University Northern Yokohama Hospital, Yokohama, Japan
| | - Koji Kanzaki
- Department of Orthopaedic Surgery, Showa University Fujigaoka Hospital, Yokohama, Japan
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Tripathee S, Basnet SJ, Lamichhane A, Hariani L. How Safe Is Reverse Sural Flap?: A Systematic Review. EPLASTY 2022; 22:e18. [PMID: 35873071 PMCID: PMC9275416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Soft tissue reconstruction of the lower third of the leg, the ankle, and the foot is challenging for reconstructive surgeons. The options for reconstruction are limited. Reverse sural flap is relatively easy to perform and considered a good option for reconstruction. The complication rates are variable in studies. This study aims to systemically review all available articles based on reverse sural flap focusing on complications of the flap. The overall complication of the flap helps to better understand the reliability of the flap. METHODS A comprehensive literature search was performed using MEDLINE, EMBASE, and Google Scholar to identify cases of reverse sural artery flap. RESULTS A pooled analysis of 89 articles was performed, which yielded 2575 patients (2592 flaps) over a period of 19 years. Most of the cases were performed in Asian countries (1540 flaps, 59.4%) with the majority being performed in China (746 flaps, 28.8%). The most common cause for reverse sural flap surgery was trauma/postsurgical (1785/2592) followed by burn/scarring. Flap complications were recorded in 653 of 2592 flaps (25.20%). The most common complication was partial flap loss, which was recorded in 204 flaps (7.85%) followed by venous congestion (79 flaps, 3.05%). Complete flap loss was observed only in 66 participants (2.5% of all the flaps performed). CONCLUSIONS Reverse sural flap is reliable flap for the reconstruction of lower leg, ankle, and foot. It can give a comparable outcome as free flap when meticulously performed and, in many cases, a better result.
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Affiliation(s)
| | | | | | - Lynda Hariani
- Nepal Plastic Cosmetic and Laser Center, Lalitpur, Nepal
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Radhakrishnan GS, Anand S, Salim S, Boopathi K. Caveats of Local Fasciocutaneous Flaps for Distal Leg Defects-Anatomical Study and Clinical Application. J Foot Ankle Surg 2022; 61:497-502. [PMID: 34702680 DOI: 10.1053/j.jfas.2021.09.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 09/19/2021] [Accepted: 09/21/2021] [Indexed: 02/03/2023]
Abstract
The present trend for the management of distal leg defects is to opt for a free flap with local flaps being relegated to the backseat. We studied the perforator anatomy of the distal leg in the Indian population to see if there were any ethnic differences and then correlated it with a clinical study of local flaps used for the coverage of distal leg defects. A prospective observational study was carried out in 2 phases-anatomical study and clinical study from December 2018 to March 2020. In the anatomical study, 8 fresh cadavers, i.e., 16 lower limbs were dissected and the perforator anatomy in the distal leg was identified. In the clinical study, all patients undergoing local, pedicled fasciocutaneous flap cover for defects involving distal third leg were included with ages between 15 and 60 years. In the anatomical study, posterior tibial artery perforators in the distal-most part were found as a group of up to 3 perforators. In the clinical study, a total of 47 patients were included with a mean age of 38.0 ± 10.9 (range 17-55) years and female:male ratio being 1:2.6. The largest defect size was 120 cm2 (mean 28.2 ± 23.8 [range 6-120] cm2) and the most commonly used flap was the reverse sural artery flap in 20 (42.6%) cases. Overall, complications were seen in 7 (14.9%) cases and there was no case of flap failure. Thus, local flaps are an excellent option for coverage of distal leg defects and offer results comparable to free flaps.
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Affiliation(s)
- G S Radhakrishnan
- Associate Professor, Institute for Research and Rehabilitation of Hand & Department of Plastic Surgery, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
| | - Sunil Anand
- Senior Resident, Institute for Research and Rehabilitation of Hand & Department of Plastic Surgery, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India.
| | - Shalini Salim
- Senior Resident, Institute for Research and Rehabilitation of Hand & Department of Plastic Surgery, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
| | - K Boopathi
- Professor and Head of Department, Institute for Research and Rehabilitation of Hand & Department of Plastic Surgery, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India
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8
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Ferry AM, Gimenez AR, Abu-Ghname A, Xue EY, Pederson WC, Lazo DÁA, Maricevich M. Reconstruction of Complex Lower Extremity Defects. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00315-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Krishna D, Chaturvedi G, Khan MM, Cheruvu VPR, Laitonjam M, Minz R. Reconstruction of Heel Soft Tissue Defects: An Algorithm Based on Our Experience. World J Plast Surg 2021; 10:63-72. [PMID: 34912668 PMCID: PMC8662685 DOI: 10.29252/wjps.10.3.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 08/12/2021] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Sensory recovery and durability of the flap is the primary goal of heel soft tissue reconstruction. From the different options, the choice of the flap depends on the size of the defect, its location, and the availability of the donor area. METHODS In this retrospective study, 40 patients having heel defects were included from Jan 2016 to Dec 2018 in which different flaps were used for the reconstruction. The outcome was evaluated in terms of flap survival, recovery of sensation, the durability of coverage, and functional denouement. We also analysed the outcome between neuropathic and non-neuropathic ulcers of the heel. RESULTS Out of 40 patients’ medial plantar artery islanded flap was performed in eight cases, extended reverse sural flap in 16 cases, islanded reverse sural flap in six cases, local flaps in six cases, cross-leg flap in two cases, and free Latissimus Dorsi muscle flaps with Skin Graft cover in two cases. The patients were observed for a mean follow-up time of 15 months (12-20 months). Only two flaps showed marginal necrosis as an immediate complication. The majority of the flaps were tenacious in the follow-up period except for the six flaps that developed delayed ulceration. Return of protective sensation (P=0.006) and mean American Orthopaedic Foot and Ankle Society subjective score (P=0.025) was significantly higher in the non-neuropathic ulcer group. CONCLUSION Locoregional flaps can cover most of the heel defects with a satisfactory outcome. The functional outcome was lower in the reconstructed neuropathic heel ulcer group.
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Affiliation(s)
- Deepak Krishna
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, India
| | - Gaurav Chaturvedi
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, India
| | - Manal M Khan
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, India
| | - Ved Prakash Rao Cheruvu
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, India
| | - Michael Laitonjam
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, India
| | - Reena Minz
- Department of Burns and Plastic Surgery, All India Institute of Medical Sciences, Bhopal, India
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Msemwa JR, Mweya CN. A case report of a reverse sural flap for posterior ankle soft-tissue defect following an injury in a patient from Tanzania. SAGE Open Med Case Rep 2021; 9:2050313X211060685. [PMID: 34888053 PMCID: PMC8649446 DOI: 10.1177/2050313x211060685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 10/28/2021] [Indexed: 11/16/2022] Open
Abstract
In the treatment and management of severe wounds, microsurgical repair remains the gold
standard. However, it is difficult to transfer free tissue from a Tanzanian perspective
due to donor site morbidity, longer operational times, bulky forms, recipient vessel
stress, sophisticated surgical expertise, and high costs of the equipment. Meanwhile, the
reverse sural flap has been considered as the ultimate tissue restoration technique. This
study reviews a case of a 35-year-old man who was admitted at Mbeya Zonal Referral
Hospital in the Department of Orthopaedics, Trauma, and Neurosurgery in Mbeya, Tanzania.
The patient had a 9-day injury to the rear of his right ankle due to a cut he suffered
after tripping over a toilet seat in the washroom. After the diagnosis, the plan involved
surgical debridement, tendon repair, and reverse sural flap rotation. Despite the
difficult working environment requiring advanced learning experience, our patient fully
recovered after 3 weeks. Proving that reverse sural flap is one of the few available
possibilities in the protection of vital structures such as bone or tendons, in the distal
areas of the leg, ankle, and foot especially when the medical treatment facility lacks a
strong microsurgery team and equipment.
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Affiliation(s)
- Joseph R Msemwa
- Department of Orthopaedics, Trauma and Neurosurgery, Mbeya Zonal Referral Hospital, Mbeya, Tanzania.,Mbeya College of Health and Allied Sciences, University of Dar es Salaam, Mbeya, Tanzania
| | - Clement N Mweya
- Mbeya College of Health and Allied Sciences, University of Dar es Salaam, Mbeya, Tanzania.,Mbeya Medical Research Centre, National Institute for Medical Research, Mbeya, Tanzania
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Athanaselis ED, Fyllos A, Zibis AH, Karachalios T, Hantes M, Dailiana Z, Malizos K, Varitimidis S. A Single-Center Surgical Experience With the Reverse Sural Artery Flap as a Reliable Solution for Lower Leg Soft Tissue Defects, With Minimum Two-Year Follow-Up. Cureus 2021; 13:e16574. [PMID: 34434674 PMCID: PMC8380273 DOI: 10.7759/cureus.16574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/21/2021] [Indexed: 11/05/2022] Open
Abstract
AIM Small soft tissue defects of the distal tibia and hindfoot resulting from traumatic, operative, or neoplastic conditions and chronic ulcers can be successfully dealt with the use of the reverse sural artery flap (RSAF). This study aims to describe a single center's results and familiarity with this technique over a 15-year period of time. MATERIAL AND METHODS We retrospectively reviewed the clinical files of patients who were consecutively treated with RSAF and regularly followed up between January 1, 2004 and December 31, 2018, with a minimum postoperative follow-up period of two years. Patient demographics and comorbidities, location of the defect, performing surgeon, mean operation time, flap pedicle width, mean size of the defect, days of hospitalization following the operation, healing flap rate, and complications were recorded. RESULTS The sample consisted of 30 adult patients (25 men, 5 women), with a mean age of 51.07 years (16-80 years, SD 18.61). The mean operation time was 99.03 min (range 83-131, SD 10.57), and the mean size of the defect was 11.11 cm2 (range 6.1-19.4, SD 3.22). Successful flap rate (complete healing and coverage of the defect, with or without additional minor intervention) was 83.3% (25/30). Among successfully healed flaps, six patients with partial necrosis of the dermis were treated by an additional split-thickness skin graft. Five flaps failed to heal. Deep infection was present in two patients, leading to flap failure and reoperation. Serious venous congestion resulting in flap ischemia occurred in three cases. Circumferential keloid formation (not affecting successful outcome) was present in seven cases. Flap thickness approximated to normal within six months. All donor sites healed well (either by a split-thickness cutaneous flap or by immediate wound closure). Light paresthesia on the lateral border of the leg and foot disappeared within six months. CONCLUSIONS A single-center experience with the RSAF has yielded satisfactory clinical outcomes, and the long-term tackle with the difficult reconstruction conditions around the ankle, has led to valuable advice on surgical technique and postoperative protocol, based on an anatomical basis.
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Affiliation(s)
| | - Apostolos Fyllos
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Aristeidis H Zibis
- Anatomy, School of Health Sciences, University of Thessaly, Larissa, GRC
| | - Theofilos Karachalios
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Michael Hantes
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Zoe Dailiana
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Konstantinos Malizos
- Orthopedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
| | - Sokratis Varitimidis
- Orthopaedics and Musculoskeletal Trauma, University Hospital of Larissa, Larissa, GRC
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12
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Zeiderman MR, Pu LLQ. Contemporary approach to soft-tissue reconstruction of the lower extremity after trauma. BURNS & TRAUMA 2021; 9:tkab024. [PMID: 34345630 PMCID: PMC8324213 DOI: 10.1093/burnst/tkab024] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/22/2021] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Matthew R Zeiderman
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of California, Davis, Sacramento, CA, USA
| | - Lee L Q Pu
- Division of Plastic & Reconstructive Surgery, Department of Surgery, University of California, Davis, Sacramento, CA, USA
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13
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Reconstruction of Heel Soft Tissue Defects: An Algorithm Based on Our Experience. World J Plast Surg 2021. [DOI: 10.52547/wjps.10.3.63] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Emam A, Machhada A, Tilston T, Colavitti G, Katsanos D, Chapman T, Wright T, Khan U. Free tissue versus local tissue: A comparison of outcomes when managing open tibial diaphyseal fractures. Injury 2021; 52:1625-1628. [PMID: 33648742 DOI: 10.1016/j.injury.2021.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 02/04/2021] [Accepted: 02/06/2021] [Indexed: 02/02/2023]
Abstract
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).
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Affiliation(s)
- Ahmed Emam
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK
| | - Asif Machhada
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK
| | - Thomas Tilston
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK
| | - Giulia Colavitti
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK
| | | | - Thomas Chapman
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK
| | - Thomas Wright
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK
| | - Umraz Khan
- Southmead Hospital, North Bristol NHS Trust, City of Bristol, UK.
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15
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Muscle Cuff in Distal Pedicled Adipofascial Sural Artery Flaps: A Retrospective Case Control Study. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2021; 9:e3464. [PMID: 33786260 PMCID: PMC7997121 DOI: 10.1097/gox.0000000000003464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 01/07/2021] [Indexed: 11/26/2022]
Abstract
Background: Amputation after open tibial fracture occurs in 3% of cases. The rate increases when flap reconstruction is required. The standard care involves microsurgical tissue transfer although the pedicled reverse sural artery adipofascial flap (PRSAF) is a local alternative in patients endangered by a prolonged operative time. Incorporation of a gastrocnemius muscle cuff in this flap can be used to fill dead space and increase healing potential. Literature shows superior survival rates for both PRSAF and inclusion of a muscle cuff in comparison with the cutaneous version. The aim of the study was to compare the outcome of the PRSAF and the musculoadipofascial version (PRSMAF). We hypothesize that the PRSMAF provides similar lap viability and flap-related complication rates as does the adipofascial version. The muscle component may reduce the long-term osteomyelitis rate. Methods: Patients were evaluated retrospectively after reconstruction with either PRSAF or PRSMAF. Preoperative osteomyelitis, flap survival, complications and osteomyelitis clearance were analyzed. Results: The study shows preliminary results supporting the potential use of the PRSMAF. We compare either 23 PRSMAF or 20 PRSAF flaps. We found no statistically significant differences in flap survival or in complication rate. Conclusions: Although the anatomical situation may sometimes dictate the use of a free flap, a technically less-complicated option may in some cases offer a viable alternative. This study shows that the PRSMAF can serve as an alternative for complex bone defects in the limb, though it does not provide statistical improvement to the PRSAF.
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16
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Hasegawa H, Tsukamoto S, Honoki K, Shimizu T, Ferra L, Errani C, Sioutis S, Mavrogenis AF, Tanaka Y. Soft-tissue reconstruction after soft-tissue sarcoma resection: the clinical outcomes of 24 patients. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:1-10. [PMID: 33608754 DOI: 10.1007/s00590-021-02901-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/08/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE Pedicle or free-flap reconstruction is important in surgical sarcoma management. Free flaps are indicated only when pedicle flaps are considered inadequate; however, they are associated with a higher risk of flap failure, longer surgical times, and technical difficulty. To determine the skin defect size that can be covered by a pedicle flap, we investigated the clinical outcomes and complications of reconstruction using pedicle flaps vs. free flaps after sarcoma resection. METHODS We retrospectively studied the medical records of 24 patients with soft-tissue sarcomas who underwent reconstruction using a pedicle (n = 20) or free flap (n = 4) following wide tumour resection. RESULTS All skin defects of the knee, lower leg, and ankle were reconstructed using a pedicle flap. Skin defects of the knee, lower leg, and ankle were covered by up to 525 cm2, 325 cm2, and 234 cm2, respectively. The amount of blood loss was significantly greater in the free-flap group than in the pedicle flap group (p = 0.011). Surgical time was significantly shorter in the pedicle flap group than in the free-flap group (p = 0.006). Total necrosis was observed in one (25%) patient in the free-flap group; no case of total necrosis was observed in the pedicle flap group. CONCLUSION Less blood loss, shorter surgical time, and lower risk of total flap necrosis are notable advantages of pedicle flaps over free flaps. Most skin defects, even large ones, of the lower extremities following sarcoma resection can be covered using a single pedicle flap or multiple pedicle flaps.
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Affiliation(s)
- Hideo Hasegawa
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Shinji Tsukamoto
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan.
| | - Kanya Honoki
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Takamasa Shimizu
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
| | - Lorenzo Ferra
- Department of Orthopaedic Oncology, IRCCS Rizzoli Institute, Bologna, Italy
| | - Costantino Errani
- Department of Orthopaedic Oncology, IRCCS Rizzoli Institute, Bologna, Italy
| | - Spyros Sioutis
- Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Andreas F Mavrogenis
- Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Yasuhito Tanaka
- Department of Orthopaedic Surgery, Nara Medical University, 840 Shijo-cho, Kashihara, Nara, 634-8521, Japan
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17
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Abstract
Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.
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18
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Advancements in Reconstructive Surgery Broaden Opportunities for Salvage of the Injured Lower Extremity. Ann Plast Surg 2021; 84:238-245. [PMID: 31513085 DOI: 10.1097/sap.0000000000001977] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Advancements in microsurgery have made lower extremity reconstruction possible even after major soft tissue loss or tibial nerve disruption. There is an ongoing paradigm shift in the indications for amputation versus salvage and in flap selection protocols for different areas of the lower extremity. Initial evaluation, patient selection, triage, and timing of reconstruction are essential factors that can influence functional and aesthetic outcomes. The emergence of perforator flaps and the application of new concepts such as free-style flaps, propeller perforator flaps, thinning of free flaps, and supermicrosurgery have provided reconstructive surgeons with many techniques to decrease donor-site morbidity and improve outcomes. This includes options for reconstruction on extremities with single or no adequate runoff vessels. We present a review of the major advancements in reconstructive surgery for salvage of the traumatic lower extremity.
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19
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Bordianu A, Gheorghiu-Branaru M, Marinescu S. ALT flap and reverse sural flap for simultaneous soft tissue coverage of both medial and lateral calf wounds in a diabetic patient. Injury 2020; 51 Suppl 4:S31-S33. [PMID: 32151426 DOI: 10.1016/j.injury.2020.02.103] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2020] [Revised: 02/16/2020] [Accepted: 02/19/2020] [Indexed: 02/02/2023]
Abstract
Defects of the lower limb are generally difficult to correct, especially in patients with associated pathologies, and they represent a challenge for the reconstructive surgeon. The sural flap provides considerable versatility for lower limb reconstructions, successfully covering defects located between the knee and the ankle or the heel. Most frequently, this flap is used for defects located in the middle to distal third of the lower limb. The scope of reconstructing defects from the lower limb extremities must be concentrated both on covering the defect, and on functional recovery. When use of a local flap is insufficient, free flaps must be used, as they provide a wider coverage of defect. We report the successful surgical management of a case of a lower extremity injury consisting of a tibial pilon fracture, proximal fibula and lateral malleolus fractures, and a medium-to-large defect on both sides (internal and external) of the left ankle, on a 61 year-old patient, insulin dependent diabetic, heavy smoker, and with poor hygiene.
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Affiliation(s)
- Anca Bordianu
- "Bagdasar-Arseni" Emergency Hospital, Plastic and Reconstructive Department, University of Medicine and Pharmacy "Carol Davila", 10-12 Berceni Road, District 4, 41914 Bucharest, Romania.
| | - Matei Gheorghiu-Branaru
- "Bagdasar-Arseni" Emergency Hospital, Plastic and Reconstructive Department, Bucharest, Romania
| | - Silviu Marinescu
- "Bagdasar-Arseni" Emergency Hospital, Plastic and Reconstructive Department, University of Medicine and Pharmacy "Carol Davila", 10-12 Berceni Road, District 4, 41914 Bucharest, Romania
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20
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Johnson L, Liette MD, Green C, Rodriguez P, Masadeh S. The Reverse Sural Artery Flap: A Reliable and Versatile Flap for Wound Coverage of the Distal Lower Extremity and Hindfoot. Clin Podiatr Med Surg 2020; 37:699-726. [PMID: 32919599 DOI: 10.1016/j.cpm.2020.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
The reverse sural artery flap is a distally based fasciocutaneous or adipofascial flap used for wound coverage of the distal one-third of the lower extremity, ankle, and posterior heel. The flap harvest can be performed without sacrificing major arteries of the lower extremity. It can be elevated and mobilized with relative ease and a short operative time. It provides a good alternative to free tissue transfer in complex lower-extremity wounds with exposed bone, tendon, or hardware. The surgeon must be familiar with the management of venous congestion to improve the success of the flap.
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Affiliation(s)
- Lance Johnson
- University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Michael D Liette
- University of Cincinnati Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA
| | - Chris Green
- American College of Foot and Ankle Surgeons, Integris Limb Salvage Center, Oklahoma City, OK, USA
| | - Pedro Rodriguez
- Plastic and Reconstructive Surgery, OSF Saint Anthony Medical Center, University of Illinois, 698 Featherstone Road, Rockford, IL 61107, USA
| | - Suhail Masadeh
- University of Cincinnati Medical Center, Cincinnati Veteran Affairs Medical Center, 231 Albert Sabin Way, ML 0513, Cincinnati, OH 45276, USA.
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21
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The reverse sural artery flap- How do modifications boost its reliability? A systematic analysis of the literature. JPRAS Open 2020; 26:1-7. [PMID: 32875046 PMCID: PMC7451805 DOI: 10.1016/j.jpra.2020.07.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 07/19/2020] [Accepted: 07/23/2020] [Indexed: 11/20/2022] Open
Abstract
The reverse sural artery flap (RSAF) was first described approximately four decades ago and has since been used frequently for reconstruction of soft tissue defects in the distal part of the leg. Although the popularity of this flap never reached the extent of that of free perforator flaps, it still serves as a reliable alternative. This has been demonstrated by the increased rate of publication on the technique in recent years. The number of authors reporting data has risen up to 20 reports a year. During this time, several new modifications of the flap were inaugurated in order to boost the efficiency and reliability of the flap. The goal of this systematic analysis of the literature was to gain information on the influences of the modifications of the RSAF with regard to consistency and complication rates. An overall survival rate of 95% and a rate of complications of 14% were reported in all the analyzed cases. Some modifications were able to improve flap viability but not at a statistically significant extent. Venous supercharging and the adipofascial variant of the RSAF provided the best results. The RSAF is still a remarkable flap design, especially as a backup solution or in circumstances without a microsurgical skilled surgeon. Further investigation with controlled randomized prospective trials is vital to confirm this finding with more evidence.
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22
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Cajozzo M, Jiga LP, Jandali Z, Muradov M, Pignatti M, Cordova A, D'Arpa S. Complications and Solutions in Propeller Flap Surgery. Semin Plast Surg 2020; 34:210-220. [PMID: 33041693 PMCID: PMC7542210 DOI: 10.1055/s-0040-1714087] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Propeller perforator flaps (PPFs) have long been proven as valid reconstructive tools for a wide range of soft tissue defects in different body regions. During the last decade, despite their numerous advantages, many authors have thoroughly analyzed outcomes of these flaps, sometimes discouraging their use mainly because of a high failure rate. Accurate patient selection, adequate preoperative planning, and an appropriate dissection technique seem to potentially improve outcomes. Our study provides a review of the relevant literature related to PPF complications and of our experience, describing reasons for failure, measures for preventing them, and approaches for a prompt evaluation and management of complications.
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Affiliation(s)
- Marta Cajozzo
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncological and Oral Sciences (DICHIRONS), University of Palermo, Palermo, Italy
| | - Lucian P. Jiga
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Zaher Jandali
- Department of Plastic, Aesthetic, Reconstructive and Hand Surgery, Evangelisches Krankenhaus Oldenburg, University of Oldenburg, Oldenburg, Germany
| | - Mismil Muradov
- Department of Plastic Surgery, Syzganov National Scientific Center of Surgery, Almaty, Kazakhstan
| | - Marco Pignatti
- Department of Plastic Surgery, Policlinico di Sant'Orsola, DIMES, Bologna University, Bologna, Italy
| | - Adriana Cordova
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncological and Oral Sciences (DICHIRONS), University of Palermo, Palermo, Italy
| | - Salvatore D'Arpa
- Division of Plastic and Reconstructive Surgery, Department of Surgical Oncological and Oral Sciences (DICHIRONS), University of Palermo, Palermo, Italy
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23
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Bejinariu CG, Marinescu SA. Lower Limb Salvage Using the Medial Hemisoleus Flap Associated with the Reverse Sural Flap. J Med Life 2020; 12:461-465. [PMID: 32025268 PMCID: PMC6993290 DOI: 10.25122/jml-2019-0116] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The paper aims to present the reconstructive surgical approach in the case of a patient with complex soft tissue lesions of the calf. The patient was the victim of a road accident resulting in the fracture of the right tibia for which screw-plate osteosynthesis was performed. The chosen therapeutic solution was represented by covering the soft tissue defects using a complex algorithm that involved the use of a reverse sural flap associated with a medial hemisoleus muscle flap and a split-thickness skin graft. Considering functional recovery and the degree of patient satisfaction, the result of the therapeutic conduct was appreciated as very good. The association of the reverse sural flap with the medial hemisoleus flap can be a solution for solving complex cases with multiple soft tissue defects located in the middle and lower third of the calf.
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Affiliation(s)
- Catalin Gheorghe Bejinariu
- Department of Plastic and Reconstructive Surgery, "Bagdasar-Arseni" Emergency Clinical Hospital, Bucharest, Romania
| | - Silviu Adrian Marinescu
- Department of Plastic and Reconstructive Surgery, "Bagdasar-Arseni" Emergency Clinical Hospital, Bucharest, Romania
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24
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Innocenti M, Dell'Acqua I, Famiglietti M, Vignini L, Menichini G, Ghezzi S. Free perforator flaps vs propeller flaps in lower limb reconstruction: A cost/effectiveness analysis on a series of 179 cases. Injury 2019; 50 Suppl 5:S11-S16. [PMID: 31706586 DOI: 10.1016/j.injury.2019.10.039] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
PURPOSE The aim of this report is to compare free perforator flaps and propeller flaps in the coverage of lower limb soft tissue defects. PATIENTS AND METHODS 179 patients (age between 5 and 92 years old), underwent soft tissue reconstruction of the lower limb between January 2009 and January 2015, either by free flap or propeller flap. The two groups were retrospectively evaluated in order to assess the outcome, complications and potential risk factors. Correlations between risk factors and presence/absence of failure or complications have been evaluated with descriptive statistical analysis and a set of logistic regression models. Finally, an economic analysis was conducted to evaluate the different tecniques. RESULTS In a simple descriptive statistical analysis, the overall failure rate is 6% for free flaps and 3.7% for propeller flaps; the complication rates are 14% vs 21.5% and it increases as dimension increases. The logistic models relating failure and complications with potential risk factors do not show significant differences, whereas the economic analysis show that the average expense of free flaps is 5077.5€ per patient, 1595.6€ per patient for propeller flaps. CONCLUSIONS Our results do not demonstrate significant differences between the two groups about correlation of risk factors or flap size with complication or failure. The surgical option choice should be taken only after accurate evaluation of the soft tissue surrounding the defect. Propeller flaps should be preferred in case of small/medium size defects in otherwise healthy extremities. Free perforator flaps should be the choice in large defects due to trauma or vascular diseases. The economic analysis suggests that propeller flap should be considered when possible.
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Affiliation(s)
- Marco Innocenti
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy.
| | - Irene Dell'Acqua
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Matteo Famiglietti
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Livia Vignini
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Giulio Menichini
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy
| | - Serena Ghezzi
- Department of Plastic and Reconstructive Surgery and Microsurgery, Careggi University Hospital, Largo Palagi 1, 50139 Florence, Italy.
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25
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Assi C, Samaha C, Chamoun Moussa M, Hayek T, Yammine K. A Comparative Study of the Reverse Sural Fascio-Cutaneous Flap Outcomes in the Management of Foot and Ankle Soft Tissue Defects in Diabetic and Trauma Patients. Foot Ankle Spec 2019; 12:432-438. [PMID: 30526038 DOI: 10.1177/1938640018816378] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction. Soft tissue defects in the distal leg and foot are challenging conditions for reconstruction. The widely used reverse sural fascio-cutaneous flap (RSFCF) has been reported with large variation in complication frequency. Some authors reported higher complications in the diabetic population when compared with trauma patients. We compared the reliability of the RSFCF in treating such defects among both populations. Methods. This is a retrospective series with a prospective data collection of 24 patients (11 with type 2 diabetes and 13 in trauma settings) treated with an ipsilateral RSFCF for soft tissue defects of the distal leg and the rear foot. Healing events and complications were recorded and compared for both groups. The mean follow-up was 32 months. Results. Diabetic group versus trauma group showed the following results; mean flap healing time of 24 versus 22 days, donor site healing time of 14 versus 16 days, 1 total flap necrosis in both groups, 3 versus 2 cases of skin edge necrosis, 2 cases of temporary venous congestion in both groups, and 8 versus 10 cases of transient hypoesthesia of the lateral border of the foot. No infection was encountered in both groups and no recurrence of infection in the primary infected diabetic patients. Conclusions. We found the RSFCF to be useful, reproducible, and reliable in treating soft tissue defects with a very low frequency of serious complications. Diabetic patients were found to have similar outcomes when compared with trauma patients. Therefore, diabetes might not be a major factor of flap failure. Levels of Evidence: Level III: Therapeutic.
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Affiliation(s)
- Chahine Assi
- Department of Orthopedic Surgery, Lebanese American Hospital Medical Center-Rizk Hospital, Beirut, Lebanon (CA, CS, TH, KY), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,Hopital Libano-Francais, Zahle, Lebanon (MC), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
| | - Camille Samaha
- Department of Orthopedic Surgery, Lebanese American Hospital Medical Center-Rizk Hospital, Beirut, Lebanon (CA, CS, TH, KY), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,Hopital Libano-Francais, Zahle, Lebanon (MC), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
| | - Moussa Chamoun Moussa
- Department of Orthopedic Surgery, Lebanese American Hospital Medical Center-Rizk Hospital, Beirut, Lebanon (CA, CS, TH, KY), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,Hopital Libano-Francais, Zahle, Lebanon (MC), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
| | - Tony Hayek
- Department of Orthopedic Surgery, Lebanese American Hospital Medical Center-Rizk Hospital, Beirut, Lebanon (CA, CS, TH, KY), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,Hopital Libano-Francais, Zahle, Lebanon (MC), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
| | - Kaissar Yammine
- Department of Orthopedic Surgery, Lebanese American Hospital Medical Center-Rizk Hospital, Beirut, Lebanon (CA, CS, TH, KY), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon.,Hopital Libano-Francais, Zahle, Lebanon (MC), Center for Evidence-based Anatomy, Sports and Orthopedic Research, Beirut, Lebanon
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26
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Perumal R, Bhowmick K, Reka K, Livingston A, Boopalan PRJVC, Jepegnanam TS. Comparison of Reverse Sural Artery Flap Healing for Traumatic Injuries Above and Below the Ankle Joint. J Foot Ankle Surg 2019; 58:306-311. [PMID: 30850100 DOI: 10.1053/j.jfas.2018.08.057] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Indexed: 02/03/2023]
Abstract
The reverse sural artery (RSA) flap is popular among trauma surgeons to cover the distal third of the leg to the foot. However, flaps that inset in the foot seem to have a high necrosis rate. This study compared the healing of RSA flaps performed for defects proximal to the ankle versus defects distal to the ankle. Patient data were collected retrospectively between January 2005 and December 2009. Eighty-five patients with the lower leg, ankle, and traumatic foot injuries were divided into 2 groups. Group 1 (49 patients) had RSA flap cover for soft tissue and bony defect proximal and up to the ankle joint line, and group 2 (36 patients) had RSA flap cover distal to the ankle joint line. The time to healing and type of healing were compared between the groups. The demographics between the 2 groups were similar. The successful RSA flap healing rate was 65% in group 1 (32 of 49) and 42% in group 2 (15 of 36). The average time to flap healing between the groups was similar (p = .16). Group 1 had predominantly primary healing compared with group 2 (p = .03). Group 2 had a higher reoperation rate for wound necrosis, which was significant (p = .001). The success of the RSA flap is higher when used for proximal to ankle joint line defects. Surgeons should be aware of the chances of flap necrosis when undertaking RSA flap cover distal to the ankle joint line.
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Affiliation(s)
- Rajamani Perumal
- Assistant Professor, Department of Orthopaedics, Christian Medical College, Vellore, India
| | - Kaushik Bhowmick
- Assistant Professor, Department of Orthopaedics, Christian Medical College, Vellore, India.
| | - Karuppusami Reka
- Senior Demonstrator, Department of Biostatistics, Christian Medical College, Vellore, India
| | - Abel Livingston
- Assistant Professor, Department of Orthopaedics, Christian Medical College, Vellore, India
| | - P R J V C Boopalan
- Professor, Department of Orthopaedics, Christian Medical College, Vellore, India
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27
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Khundkar R. Lower extremity flap coverage following trauma. J Clin Orthop Trauma 2019; 10:839-844. [PMID: 31528054 PMCID: PMC6739290 DOI: 10.1016/j.jcot.2019.08.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 08/10/2019] [Indexed: 11/19/2022] Open
Abstract
Lower extremity injuries requiring soft tissue coverage comprises a significant proportion of these injuries worldwide. Reconstruction of the soft tissues overlying fractures is essential for bone union and reduction of infection thus improving function and reducing the rate of limb amputation. A systematic exploration and excision of the wound should be jointly performed by senior surgeons from Orthopaedic and Plastic Surgery. The grading of the injury and subsequent reconstruction of bone and soft tissue should only be planned once a thorough excision of all necrotic tissue has been performed. It is this thorough debridement and early flap coverage that contributes to infection-free bony union. This article explores the options for soft tissue flap coverage for the different zones in the lower limb.
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28
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Kawamoto N, Anayama T, Okada H, Hirohashi K, Miyazaki R, Yamamoto M, Kume M, Orihashi K. Indocyanine green fluorescence/thermography evaluation of intercostal muscle flap vascularization. Thorac Cancer 2018; 9:1631-1637. [PMID: 30264917 PMCID: PMC6275828 DOI: 10.1111/1759-7714.12871] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 08/17/2018] [Accepted: 08/18/2018] [Indexed: 11/28/2022] Open
Abstract
Background During anatomical lung resection in high‐risk patients, the bronchial stump is covered with tissue flaps (e.g. pericardial fat tissue and intercostal muscle) to prevent bronchopleural fistula development. This is vital for reliable reinforcement of the bronchial stump. We evaluated the blood supply of the flap using indocyanine green fluorescence (ICG‐FL) and thermography intraoperatively in 27 patients at high risk for developing a bronchopleural fistula. Methods Before reinforcing the stump with a flap, the fluorescence agent was intravenously injected and the blood supply was evaluated. The surface temperature of the flap was measured with thermography. The two modalities were then compared. Results ICG‐FL intensity and surface temperature on the distal compared to the proximal side of the flap decreased by 32.6 ± 29.4% (P < 0.0001) and 3.5 ± 2.0°C (P < 0.0001), respectively. In patients with a higher ICG‐FL intensity value at the tip than the median, the surface temperature at the tip decreased by 2.7 ± 1.7°C compared to the proximal side. In patients with a lower ICG‐FL value at the tip, the surface temperature decreased by 4.6 ± 1.7°C (P = 0.0574). The bronchial stump reinforced the part of the flap with adequate blood supply; none of the patients developed a bronchopleural fistula. Conclusions ICG‐FL confirmed variation in the blood supply of the intercostal muscle flap, even if prepared using the same surgical procedure. Thermography analysis tends to correlate with the fluorescence method, but may be influenced by the state of flap preservation during surgery.
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Affiliation(s)
- Nobutaka Kawamoto
- Department of Surgery II, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Takashi Anayama
- Department of Surgery II, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Hironobu Okada
- Department of Surgery II, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Kentaro Hirohashi
- Department of Surgery II, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Ryohei Miyazaki
- Department of Surgery II, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Marino Yamamoto
- Department of Surgery II, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Motohiko Kume
- Department of Surgery II, Kochi Medical School, Kochi University, Nankoku, Japan
| | - Kazumasa Orihashi
- Department of Surgery II, Kochi Medical School, Kochi University, Nankoku, Japan
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29
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Saad NH, Pontell ME, Winters BS, Daniel J, Saad A. The Periosteal Medial Femoral Condyle Free Flap: A New Option for Soft Tissue Reconstruction of the Distal Lower Extremity. Ann Plast Surg 2018; 79:372-376. [PMID: 28604551 DOI: 10.1097/sap.0000000000001104] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Small (<30 cm) soft tissue defects of the distal leg, foot, and ankle pose a complicated issue with regard to wound healing. Multiple flaps have been proposed for reconstruction of these wounds with varying levels of success. The medial femoral condyle flap is a free bone flap supplied by the descending geniculate artery. It is currently used in the treatment of fracture nonunion, infected bone defects, avascular necrosis, and osteoradionecrosis. This study proposes the use of the periosteal portion of the medial femoral condyle (PMFC) flap for soft tissue reconstruction of the distal leg, foot, and ankle. METHODS We performed a single-center, retrospective series of 6 patients with distal leg, foot, and ankle wounds. All patients underwent reconstruction using the PMFC flap. RESULTS Of the 6 patients, 5 had chronic wounds. There were no incidences of flap loss. Five patients healed without complication, four of which had undergone immediate skin grafting, whereas one had concomitant skin paddle reconstruction. The remaining patient required a second surgery with a rotation flap for recurrent osteomyelitis and wound infection 2 months after the initial surgery. Mean operative time decreased after a 2-case learning curve. CONCLUSIONS Small wounds of the distal extremity can be difficult to treat, with many requiring free or rotational flap coverage. We propose novel use of the PMFC flap for reconstruction of small soft tissue defects of the distal leg, foot, and ankle. In our series, we demonstrated no donor site morbidity, with excellent cosmetic and functional outcomes.
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Affiliation(s)
- Noah H Saad
- From the *University of Maryland Medical System, Baltimore, MD; †Department of Surgery, Drexel University College of Medicine, Philadelphia, PA; and ‡Rothman Institute of Orthopedics; and §The Plastic Surgery Center, The Institute for Advanced Reconstruction, Egg Harbor, NJ
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30
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Chi Z, Chen Y, Chu T, Gao W, Li Z, Yan H, Song Y. Distally based sural neuro-fasciocutaneous perforator flap for foot and ankle reconstruction: Surgical modifications for flap pedicle and donor site closure without skin graft. J Plast Reconstr Aesthet Surg 2018; 71:224-231. [DOI: 10.1016/j.bjps.2017.10.021] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 09/11/2017] [Accepted: 10/13/2017] [Indexed: 10/18/2022]
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31
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Hussain ON, Sabbagh MD, Carlsen BT. Complex Microsurgical Reconstruction After Tumor Resection in the Trunk and Extremities. Clin Plast Surg 2017; 44:299-311. [PMID: 28340664 DOI: 10.1016/j.cps.2016.11.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Reconstruction of soft tissue defects following tumor ablation procedures in the trunk and extremities can challenge the microsurgeon. The goal is not just to provide adequate soft tissue coverage but also to restore form and function and minimize donor site morbidity. Although the principles of the reconstructive ladder still apply in the trunk and extremities, free tissue transfer is used in many cases to optimally restore form and function. Microsurgery has changed the practice in soft tissue tumors, and amputation is less frequently necessary.
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Affiliation(s)
- Omar N Hussain
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - M Diya Sabbagh
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA
| | - Brian T Carlsen
- Division of Plastic and Reconstructive Surgery, Mayo Clinic, 200 First Street, Rochester, MN 55905, USA.
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32
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Abstract
Soft tissue wounds overlying the dorsum of the foot and ankle are difficult to treat, and historically have been treated with free tissue transfer. Advances in surgical technique have expanded the use of pedicle perforator flaps to avoid free tissue transfer in certain situations. The authors describe a technique for using an extensor digitorum brevis flap to provide soft tissue coverage for wounds of the ankle and foot. In the senior authors' experience, the use of this flap has achieved wound coverage in 100% of patients with smaller wounds (≤45 cm) of the ankle.
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