Free tissue transfer for lower extremity reconstruction: a study of the role of computed angiography in the planning of free tissue transfer in the posttraumatic setting

Rate of Free Flap Failure and Return to the Operating Room in Lower Limb Reconstruction: A Systematic Review

Background: Soft tissue defects of the lower limbs pose significant challenges in reconstructive surgery, accounting for approximately 10% of all reconstructive free flaps performed. These reconstructions often encounter higher complication rates due to various factors such as inflammation, infection, impaired blood flow, and nerve injuries. Methods: A systematic review was conducted following PRISMA guidelines, reviewing literature from 2017 to 2024. Eligible studies included those on free flap reconstruction of lower limb defects in living human subjects, with more than three cases and reported rates of flap failure and return to the operating room. Systematic reviews and metanalysis were excluded. Results: A total of 17 studies comprising 5061 patients and 5133 free flap reconstructions were included. The most common defects were in the lower leg (52.19%) due to trauma (79.40%). The total flap necrosis rate was 7.78%, the partial necrosis rate was 9.15%, and the rate of return to the operating room for suspected vascular compromise was 13.79%. Discussion: Lower limb reconstruction presents challenges due to diverse etiologies and variable tissue requirements. Factors such as recipient vessel availability, flap selection, and multidisciplinary approaches influence outcomes. Muscle and fasciocutaneous flaps remain common choices, each with advantages and limitations. This systematic review underscores the importance of individualized treatment planning. Conclusions: Microsurgical reconstruction of lower limb defects demonstrates safety and reliability, with overall favorable outcomes. Flap selection should be tailored to specific patient needs and defect characteristics, emphasizing meticulous surgical techniques and multidisciplinary collaboration. This systematic review provides valuable insights into current standards and encourages adherence to best practices in lower limb reconstruction.

Comparison of Postoperative Complications in Patients Undergoing Limb Salvage Reconstructive Surgery Based on Estimated Prevalence of Preexisting Peripheral Arterial Disease

BACKGROUND

Limb salvage after lower extremity (LE) trauma requires optimal blood flow for successful microsurgical reconstruction. Peripheral arterial disease (PAD) decreases LE perfusion, affecting wound healing. Patients who present with LE trauma may have undiagnosed PAD, particularly those with atherosclerotic risk factors. This study assesses outcomes after LE salvage in patients at risk for PAD.

METHODS

This retrospective review evaluated patients who underwent LE reconstruction at a level 1 trauma center between 2007 and 2022. Patients with a nontraumatic mechanism of injury, missing postoperative records, and unspecified race were excluded. Demographics, flap characteristics, and postoperative complications were abstracted. The prevalence of LE PAD was calculated using a validated risk assessment tool.

RESULTS

At our institution, 285 LE flaps performed on 254 patients were included in the study. Patients were categorized by prevalence of PAD, including 12 (4.7%) with high risk, 45 (17.7%) with intermediate risk, and 197 (77.6%) patients with low risk. The high-risk cohort had higher rates of partial flap necrosis ( P = 0.037), flap loss ( P = 0.006), and amputation ( P < 0.001) compared with the low-risk group. Fewer high-risk patients achieved full ambulation compared with the low-risk ( P = 0.005) cohort. Overall flap survival and limb salvage rates were 94.5% and 96.5%, respectively. Among the intermediate- and high-risk cohorts, only 50.9% of patients received a preoperative vascular assessment, and 3.8% received a vascular surgery consultation.

CONCLUSIONS

Peripheral arterial disease represents a reconstructive challenge to microvascular surgeons. Patients with high-risk for PAD had higher rates of partial flap necrosis, flap loss, and amputation. In the setting of trauma, emphasis should be placed on preoperative vascular assessment for patients at risk of having undiagnosed PAD. Prospective studies collecting ankle-brachial index assessments and/or angiography will help validate this study's findings.

Usefulness of indocyanine green angiography in the intraoperative evaluation of recipient vessels for microsurgical lower extremity reconstruction in ischemic vasculopathy: Report of three cases

Choosing reliable recipient vessels is crucial for successful free flap reconstruction of lower extremity defects, especially in patients with ischemic vasculopathy. This report describes our experience with the intraoperative use of indocyanine green angiography (ICGA) for selecting recipient vessels in lower extremity free flap reconstruction cases. Three patients with lower extremity defects and ischemic vasculopathy underwent free flap reconstruction. Intraoperatively, the candidate vessels were evaluated using ICGA. In the first case, a 10 × 6 cm defect on the anterior side of the lower third of the leg caused by minor trauma and associated with peripheral arterial occlusive disease was reconstructed using a super-thin anterolateral thigh flap based on one perforator. In the second case, a 12 × 8 cm defect on the posterior side of the right lower leg caused by a dog bite and associated with severe atherosclerosis throughout all three major vessels in the lower leg was reconstructed using a muscle-sparing latissimus dorsi myocutaneous flap. In the third case, a 13.5 × 5.5 cm defect on the right lateral malleolar region, where the peroneus longus tendon was exposed due to Buerger's disease, was reconstructed using a one perforator-based super-thin anterolateral thigh flap. In all cases, ICGA was used to evaluate the functionality of the candidate recipient vessels. In two cases, the candidate vessels showed acceptable blood flow, and the operations proceeded as planned. In the third case, the planned vessels of posterior tibial vessels were not identified to have sufficient blood flow, and one of their branches showing enhancement in ICGA was selected and used as a recipient vessel. All flaps survived completely. No adverse events occurred during the follow-up period of postoperative 3 months. Our results suggest that ICGA may be a valuable diagnostic tool for evaluating the quality of candidate recipient vessels in cases where their functionality cannot be guaranteed with conventional imaging modalities.

The Effect of Free versus Local Flaps on Time to Union in Open Tibia Fractures

BACKGROUND

Early soft-tissue reconstruction of open fractures has been shown to decrease infection rates and improve rates of bony union. The purpose of this study was to compare the rates and time to union of open tibia fractures that underwent soft-tissue coverage.

METHODS

A retrospective chart review of 118 patients with open tibia fractures requiring soft-tissue reconstruction treated at a single level 1 trauma center was performed. Demographic data as well as flap type were collected. Union status was determined using modified Radiographic Union Scale in Tibia Fractures score greater than 11.

RESULTS

Limb salvage was achieved in 90% of patients. The overall rate of nonunion was 33%. Flap type significantly affected time to union, with local fasciocutaneous and keystone flaps having significantly longer time to union [202 days (SD 120.3)] than all other flap groups ( P = 0.01). Free flaps had significantly shorter time to union than local flaps [115 days (SD 49.6) versus 149 days (SD 75.4); P = 0.02]. Muscle flaps had significantly shorter time to union than fasciocutaneous flaps [123 days (SD 52.4) versus 165 days (SD 104.1); P = 0.04]. This remained true after controlling for fracture location, patient age, need for second flap, and fixation method ( P = 0.037). Patients who underwent an initial soft-tissue reconstruction with a local muscle flap were more likely to require a second flap to achieve wound closure (OR, 3.7; P = 0.008) and needing a second flap significantly increased time to union [162 days (SD 95.9) versus 122 days (SD 51.9); P = 0.03].

CONCLUSION

Flap type affects time to union but not nonunion rate in open tibia fractures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Arterial Injury Portends Worse Soft Tissue Outcomes and Delayed Coverage in Open Tibial Fractures

OBJECTIVES

To investigate if any injury to the three primary branches of the popliteal artery in open tibia fractures lead to increased soft-tissue complications, particularly in the area of the affected angiosome.

DESIGN

Retrospective cohort comparative study.

SETTING

Two academic level one trauma centers.

PATIENTS/PARTICIPANTS

Sixty-eight adult patients with open tibia fractures with a minimum one-year follow up.

INTERVENTION

N/A.

MAIN OUTCOME MEASUREMENTS

Soft-tissue outcomes as measured by wound healing (delayed healing, dehiscence, or skin breakdown) and fracture related infection (FRI) at time of final follow-up.

RESULTS

Eleven (15.1%) tibia fractures had confirmed arterial injuries via CTA (7), direct intraoperative visualization (3), intraoperative angiogram (3). Ten (91.0%) were treated with ligation and 1 (9.1%) was directly repaired by vascular surgery. Ultimately, 6 (54.5%) achieved radiographic union and 4 (36.4%) required amputation performed at a mean of 2.62 ± 2.04 months, with one patient going on to nonunion diagnosed at 10 months. Patients with arterial injury had significantly higher rates of wound healing complications, FRI, nonunion, amputation rates, return to the OR, and increased time to coverage or closure. After multivariate regression, arterial injury was associated with higher odds of wound complications, FRI, and nonunion. Ten (90.9%) patients with arterial injury had open wounds in the region of the compromised angiosome, with 7 (70%) experiencing wound complications, 6 (60%) FRIs, and 3 (30%) undergoing amputation.

CONCLUSIONS

Arterial injuries in open tibia fractures with or without repair, have significantly higher rates of wound healing complications, FRI, delayed time to final closure, and need for amputation. Arterial injuries appear to effect wound healing in the affected angiosome.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Using Duplex Ultrasound for Recipient Vessel Selection

INTRODUCTION

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

MATERIAL AND METHOD

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

RESULT

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

CONCLUSION

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

Impact of Periosteal Branches and Septo-Cutaneous Perforators on Free Fibula Flap Outcome: A Retrospective Analysis of Computed Tomography Angiography Scans in Virtual Surgical Planning

BACKGROUND

Virtual surgical planning (VSP) for jaw reconstruction with free fibula flap (FFF) became a routine procedure and requires computed tomography angiography (CTA) for preoperative evaluation of the lower limbs vascular system and the bone. The aim of the study was to assess whether the distribution and density of periosteal branches (PB) and septo-cutaneous perforators (SCP) of the fibular artery have an impact on flap success.

METHOD

This retrospective clinical study assessed preoperative CTA of the infra-popliteal vasculature and the small vessel system of 72 patients who underwent FFF surgery. Surgical outcome of flap transfer includes wound healing, subtotal, and total flap loss were matched with the segmental vascular supply.

RESULT

A total of 72 patients (28 females, 38.9 %; 44 males, 61.1 %) fulfilled the study inclusion criteria. The mean age was 58.5 (± 15.3 years). Stenoses of the lower limbs' vessel (n = 14) were mostly detected in the fibular artery (n = 11). Flap success was recorded in n = 59 (82.0%), partial flap failure in n = 4 (5.5%) and total flap loss in n = 9 (12.5%). The study found a mean number (± SD) of 2.53 ± 1.60 PBs and 1.39 ± 1.03 SCPs of the FA at the donor-site. The proximal FFF segment of poly-segmental jaw reconstruction showed a higher rate of PB per flap segment than in the distal segments. Based on the total number of prepared segments (n = 121), 46.7% (n = 7) of mono-, 40.4% (n = 21) of bi-, and 31.5 % (n = 17) of tri-segmental fibula flaps were at least supplied by one PB in the success group. Overall, this corresponds to 37.2% (45 out of 121) of all successful FFF. For total flap loss (n = 14), a relative number of 42.9% (n = 6) of distinct supplied segments was recorded. Wound healing disorder of the donor site was not statistically significant influenced by the detected rate of SCP.

CONCLUSION

In general, a correlation between higher rates of PB and SCP and the flap success could not be statistically proved by the study sample. We conclude, that preoperative PB and SCP mapping based on routine CTA imaging is not suitable for prediction of flap outcome.

Free Flap Coverage for Complex Primary and Revision Total Knee Arthroplasty

BACKGROUND

Free flap coverage in the setting of a total knee arthroplasty is rare. The purpose of the current study was to evaluate the outcome of patients who underwent a free flap to assist with soft-tissue coverage following a complex total knee arthroplasty.

METHODS

The authors used their institutional total joint registry to retrospectively review patients undergoing a free soft-tissue flap in the setting of complex primary and revision total knee arthroplasty. Among 29,069 primary and 6433 revision total knee arthroplasties from 1994 to 2017, eight (0.02 percent) required a free flap for wound coverage. This included three primary total knee arthroplasties (0.01 percent) for posttraumatic arthritis and five revision total knee arthroplasties (0.07 percent) in the setting of infection. Median follow-up was 4 years.

RESULTS

Free flaps included vertical rectus abdominis (n = 3), anterior lateral thigh (n = 2), latissimus (n = 2), and transverse rectus abdominis (n = 1). There were no total flap losses; however, one patient required additional skin grafting. Reoperation occurred in six patients, of which four were revisions of the total knee arthroplasty for infection (n = 2) and tibial component loosening (n = 2). One patient ultimately underwent transfemoral amputation for persistent infection. Following reconstruction, there was improvement in the median Knee Society Score (49 versus 82; p = 0.03) and total range of motion between preoperative and postoperative assessments (70 degrees versus 85 degrees; p = 0.14).

CONCLUSION

Free flap coverage in the setting of total knee arthroplasty was associated with a high rate of reoperation; however, the limb was able to be preserved in the majority of patients, with a reasonable functional outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Computed Tomography Angiography (CTA) before Reconstructive Jaw Surgery Using Fibula Free Flap: Retrospective Analysis of Vascular Architecture

Computed tomography angiography (CTA) is widely used in preoperative evaluation of the lower limbs' vascular system for virtual surgical planning (VSP) of fibula free flap (FFF) for jaw reconstruction. The present retrospective clinical study analysed n = 72 computed tomography angiographies (CTA) of lower limbs for virtual surgical planning (VSP) for jaw reconstruction. The purpose of the investigation was to evaluate the morphology of the fibular bone and its vascular supply in CTA imaging, and further, the amount and distribution of periosteal branches (PB) and septo-cutaneous perforators (SCPs) of the fibular artery. A total of 144 lower limbs was assessed (mean age: 58.5 ± 15.3 years; 28 females, 38.9%; 44 males, 61.1%). The vascular system was categorized as regular (type I-A to II-C) in 140 cases (97.2%) regarding the classification by Kim. Absent anterior tibial artery (type III-A, n = 2) and posterior tibial artery (type III-B, n = 2) were detected in the left leg. Stenoses were observed mostly in the fibular artery (n = 11), once in the anterior tibial artery, and twice in the posterior tibial artery. In total, n = 361 periosteal branches (PBs) and n = 231 septo-cutaneous perforators (SCPs) were recorded. While a distribution pattern for PBs was separated into two clusters, a more tripartite distribution pattern for SCPs was found. We conclude that conventional CTA for VSP of free fibula flap (FFF) is capable of imaging and distinguishing SCPs and PBs.

Computed tomography angiography and microsurgical flaps for traumatic wounds: What is the added value?

BACKGROUND

Microsurgical flaps are widely used to treat complex traumatic wounds of upper and lower limbs. Few studies have evaluated whether the vascular changes in preoperative computed tomography angiography (CTA) influence the selection of recipient vessel and type of anastomosis and the microsurgical flaps outcomes including complications.

OBJECTIVE

The aim of this study was to evaluate if preoperative CTA reduces the occurrence of major complications (revision of the anastomosis, partial or total flap failure, and amputation) of the flaps in upper and lower limb trauma, and to describe and analyze the vascular lesions of the group with CTA and its relationship with complications.

METHODS

A retrospective cohort study was undertaken with all 121 consecutive patients submitted to microsurgical flaps for traumatic lower and upper limb, from 2014 to 2020. Patients were divided into two groups: patients with preoperative CTA (CTA+) and patients not submitted to CTA (CTA-). The presence of postoperative complications was assessed and, within CTA+, we also analyzed the number of patent arteries on CTA and described the arterial lesions.

RESULTS

Of the 121 flaps evaluated (84 in the lower limb and 37 in the upper limb), 64 patients underwent preoperative CTA. In the CTA+ group, 56% of patients with free flaps for lower limb had complete occlusion of one artery. CTA+ patients had a higher rate of complications (p = 0.031), which may represent a selection bias as the most complex limb injuries and may have CTA indicated more frequently. The highest rate of complications was observed in chronic cases (p = 0.034). There was no statistically significant difference in complications in patients with preoperative vascular injury or the number of patent arteries.

CONCLUSIONS

CTA should not be performed routinely, however, CTA may help in surgical planning, especially in complex cases of high-energy and chronic cases, since it provides information on the best recipient artery and the adequate level to perform the microanastomosis, outside the lesion area.

Supermicrosurgery in Lower Extremity Reconstruction

Supermicrosurgery is defined as microsurgery working on vessels less than 0.8 mm, allowing applications in smaller-dimension microsurgery, such as lymphedema, minimal invasive reconstruction, small parts replantation, and application of perforator as recipient. To accommodate this technique, developments and use of finer instruments, smaller sutures, new diagnostic tools, and higher-magnification microscopes have been made. Although supermicrosurgery has evolved naturally from microsurgery, it has developed into a unique field based on different thinking and tools to solve problems that once were difficult to solve.

Three-dimensional CT angiography for surgical planning in congenital hand malformations: a case series presentation

Between January 2000 and December 2019, three-dimensional computer tomographic (CT) angiography was used in a total of 140 hands (116 patients, mean age 6.8 years) with congenital hand malformation to assess the vascular and bony structures. Analysis showed overall satisfactory three-dimensional CT images for operative planning, including detailed abnormal vascular patterns and bony malformations. Among the 116 patients, six patients with typical findings of a few malformations are reported in detail. Pitfalls in interpretation of the images and the use of three-dimensional CT angiography in surgical planning are discussed. We conclude that three-dimensional CT angiography is useful for preoperative planning of complex congenital hand malformations.Level of evidence: IV.

Single Artery Upper Extremity Salvage with Two Free Flap End-to-Side Brachial Artery Anastomoses

Background A 36-year-old male was involved in a motor vehicle accident, presenting with a Guistillo's IIIB crush injury to the upper extremity. A severely comminuted ulnar fracture resulted in a 10-cm bone defect with significant overlying soft tissue injury.

Methods The injury resulted in a wide zone of injury with inadequate collateral vascularity at the level of the elbow and distal viability dependent on the brachial artery. An osteocutaneous free fibular flap and fasciocutaneous anterolateral thigh flap were used to reconstruct the defect with both flaps anastomosed in an end-to-side fashion to the brachial artery.

Results The upper extremity was successfully salvaged, and the patient discharged from hospital at postoperative day 10. Both free flaps survived with no donor or recipient site complications at a follow-up period of 2 years.

Conclusion The case illustrates the challenges inherent to significant Guistillo's IIIB injuries with insufficient recipient vessels over a large zone of injury. While performing anastomoses outside the zone of injury is preferred, this case demonstrates the success of performing multiple anastomoses to the brachial artery in an end-to-side fashion within the zone of injury.

Perforator Variability of the Anterolateral Thigh Flap Identified on Computed Tomographic Angiography: Anatomic and Clinical Implications

BACKGROUND

 The anterolateral thigh (ALT) flap is a useful flap with minimal donor site morbidity. Preoperative computed tomographic angiography (CTA) for lower extremity reconstruction can determine vessel integrity and plan for recipient vascular targets. This study reviews lower extremity CTAs to further characterize ALT vascular anatomy and associated clinical implications thereof.

PATIENTS AND METHODS

 Lower extremity CTA studies were retrospectively reviewed, and information on ALT cutaneous perforator location, origin, and course was collected.

RESULTS

 A total of 58 lateral circumflex femoral artery (LCFA) systems in 31 patients were included. Average age was 38.8 ± 15.9 years with mean body mass index of 27.2 ± 5.7 kg/m². The majority of patients were females (23, 74.2%). The LCFA most commonly originated from the profunda femoris artery (87.3%), followed by the distal common femoral artery (9.1%). On average, there were 1.66 ± 0.69 cm perforators per extremity, with an average of 5.38 cm between adjacent perforators. Perforators originated from the descending branch of the LCFA in 89.6% of studies. Perforator caliber was <1 mm (29, 30.2%), 1 to 2 mm (55, 57.3%), or >2 mm (12, 12.5%). Mean distance from the most proximal perforator to the anterior superior iliac spine was 20.4 ± 4.82 cm. Perforators were musculocutaneous (46.9%), septocutaneous (34.4%), or septomyocutaneous (18.8%). In 58.1% of patients, only one thigh had easily dissectable septocutaneous and/or septomyocutaneous perforators, in which case preoperative CTA aided in donor thigh selection.

CONCLUSION

 ALT flap cutaneous perforator anatomy varies considerably. Using CTA, we report on rates of septocutaneous, myocutaneous, and septomyocutaneous perforators and underscore its utility in perforator selection.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Anastomotic Technique and Preoperative Imaging in Microsurgical Lower-Extremity Reconstruction: A Single-Surgeon Experience

BACKGROUND

The need for preoperative imaging as well as anastomotic technique (ie, end-to-side [ETS] vs end-to-end [ETE]) are areas of controversy in microsurgical lower-extremity reconstruction. The objective of this study was to (1) investigate whether preoperative imaging is mandatory and (2) to elicit if the type of anastomosis impacts clinical outcomes.

METHODS

A retrospective review of all patients who underwent microvascular lower-extremity reconstruction between 2007 and 2015 by a single surgeon was performed. Patients were categorized into groups based on anastomotic technique, that is, ETE versus ETS anastomosis. Patients in the ETE group were further subclassified into those who had preoperative imaging (computed tomography angiography [CTA]+) versus those who did not (CTA-). Parameters of interest included flap type, thrombosis rate, flap loss, length of stay (LOS), return to ambulation, and rate of secondary amputation. Two-sided statistical analysis was performed using Kruskal-Wallis rank-sum test and Fisher exact test.

RESULTS

One hundred twenty-eight patients were analyzed: ETE (n = 40) and ETS (n = 88). Mean follow-up for both groups was 20 ± 19 months. Anterolateral thigh flaps were most commonly performed (71%). Overall flap loss rate was 3.1% without any significant differences noted with respect to thrombosis (arterial, P = 0.09; venous, P = 0.56), flap loss (P = 0.33), LOS (P = 0.28), amputation (P = 1.00), or return to ambulation (P = 0.77). Furthermore, the availability of preoperative imaging (CTA+: N = 11 vs CTA-: N = 29) did not impact rates of thrombosis (arterial, P = 0.29; venous, P = 0.31), flap loss (P = 1.00), LOS (P = 0.26), or return to mobility (P = 0.62).

CONCLUSIONS

In light of similar reconstructive outcomes, we prefer to preserve distal extremity perfusion via ETS anastomoses whenever possible. Furthermore, preoperative vascular imaging angiography might not be necessary in patients with palpable pedal pulses on preoperative examination. An actionable algorithm for determining ETS versus ETE anastomosis in lower-extremity reconstruction is presented.

Medial approach to the peroneal vessels as recipients for free flap reconstruction of the leg

The anatomic variation in the branching pattern of the popliteal vessel has been well-established. Little has been written in the literature regarding recipient vessel selection for microvascular reconstruction in the lower extremity as it pertains to aberrant vascular anatomy. We present the case of a 57-year-old male patient who sustained a closed right lower extremity pilon fracture in a motor vehicle accident. The patient was initially treated with external fixation, which was followed by definitive open reduction and internal fixation 3 weeks later. Over the next 2 weeks, the patient developed skin ischemia of the anterior ankle. A free-tissue transfer was planned. A digital subtraction angiogram revealed absence of the posterior tibial (PT) vessels and an aberrant course of the peroneal (PR) artery. In the operating room, the medial distal leg was explored for the PT vessels, which were severely hypoplastic. Given the close proximity of the PR vessels, the dissection was extended proximally to assess these vessels for microvascular anastomosis. They were found to be suitable. A parascapular flap was harvested and transferred to the right leg wound without any significant stretch on the vessels for soft tissue coverage. The flap demonstrated excellent inflow and outflow, and the leg and foot remained well perfused. The patient's postoperative course was uncomplicated. The technique of exposing the peroneal vessels for microvascular anastomosis via a medial approach is described. This technique is an excellent option to have available when aberrant anatomy precludes the use more commonly utilized vessels.

Functional Outcomes After Heel Pad Reconstruction: A Review of 7 Cases

Sensate, durable heel pad reconstruction is challenging. The present study assessed the functional outcomes after heel pad reconstruction using various flap techniques at our institution. From June 2011 to June 2016 (5-year period), 7 consecutive patients underwent heel pad reconstruction for various etiologies, with 3 microvascular free flaps (42.9%; 2 musculocutaneous flaps [66.7%] and 1 contralateral medial plantar flap [33.3%]) and 4 local pedicle flaps (57.1%; 3 instep medial plantar artery flaps [75.0%] and 1 distally based reverse sural flap [25.0%]). The patient records and demographic data were reviewed, and surgically related information was obtained and analyzed. The subjective components of the American Orthopaedic Foot and Ankle Society hindfoot clinical ratings scale were used to evaluate the pain and functional outcomes. Sensation was assessed using Semmes-Weinstein monofilaments, and ulcer recurrence was recorded. The mean age of the patients was 41.7 (range 11 to 70) years, the mean defect size was 59 (range 12 to 270) cm², and the mean follow-up duration was 22 (range 15 to 43) months. Complete flap survival was achieved without significant complications in all 7 patients. Patients treated with the sensate medial plantar artery flap recorded the highest mean American Orthopaedic Foot and Ankle Society score of 57.3 (maximum score of 60) and experienced a return of deep sensation at 6 (range 6 to 24) months and protective sensation at 1 year. This was followed by the reverse sural flap and the musculocutaneous flap. No recurrent heel ulceration was observed in our series of patients. In conclusion, the sensate medial plantar flap is a satisfactory method for coverage of small- to moderate-size heel defects.

Preoperative Angiographic Criteria for Predicting Free-Flap Transfer Outcomes in Patients With Lower-Extremity Peripheral Arterial Disease

Patients scheduled for microsurgical reconstruction of the lower leg often receive preoperative assessment of recipient vessels using angiography. However, no clear standard is available for evaluating angiographic results to predict free-flap survival outcomes. We developed angiographic criteria for predicting surgical outcome in patients with lower-extremity peripheral arterial disease based on abnormality of the anterior tibial and posterior tibial arteries. We applied the criteria to a small number of patients scheduled for microsurgical reconstruction of the lower leg. Angiographies with arterial abnormalities were classified into 3 groups: favorable free-flap survival, compromised free-flap survival, and postsurgical pedal ischemia. The study enrolled 50 patients between 2005 and 2013. In 42% of patients, arterial abnormalities were observed by angiography. Age >65 years was the strongest risk factor for development of lower-leg arterial abnormality ( P < .001). The anterior tibial and peroneal arteries were significantly more stenotic than other vessels. In the favorable free-flap survival and compromised free-flap survival groups, free-flap transfers were attempted in 7 patients but intraoperatively abandoned in 2 patients, with postoperative failure in 1 patient. In the postsurgical pedal ischemia group, free-flap transfers were attempted in 10 patients but intraoperatively abandoned in 6 patients, with postoperative failure in 3.

Use of fibula flaps to treat persistent talonavicular nonunion: A report of three cases

Owing to the limited blood supply in the midfoot, multiple arthrodesis attempts in midfood joints may result in severe osteonecrosis, leading to a difficult scenario for bone reconstruction. This article describes the use of fibula flaps (two free and one pedicled flap) to reconstruct bone defects in three cases of persistent nonunion in midfoot joints. Before admission, all patients (aged 32-56 years old) had undergone multiple arthrodesis attempts (range 3-4) aimed at treating joint diseases associated with flatfoot or Müller-Weiss syndrome. All inserted flaps were stable, and bone fusion was confirmed by X-ray examination at month 4. After the follow-up period (range 1-4 years), all patients showed normal, painless gait. No foot deformities or further complications were observed. Our report suggests that fibula flap transfer may be a good alternative for treating persistent nonunion in midfoot joints involving bone loss, and may prevent the osteonecrosis associated with limited blood supply. © 2016 Wiley Periodicals, Inc. Microsurgery 36:430-434, 2016.

Vascular considerations in foot and ankle free tissue transfer: Analysis of 231 free flaps

OBJECTIVE

Successful foot and ankle soft tissue reconstruction is dependent on a clear understanding of the vascular supply to the foot. The aim of this study was to identify risk factors for reconstructive failure following foot and ankle free tissue transfer.

METHODS

The authors retrospectively reviewed their 17-year institutional experience with 231 foot and ankle free flaps performed in 225 patients to determine predictors of postoperative foot ischemia and flap failure. Postoperative foot ischemia was defined as ischemia resulting in tissue necrosis, separate from the reconstruction site.

RESULTS

Six (3%) patients developed postoperative foot ischemia, and 28 (12%) patients experienced flap failure. Chronic ulceration (P = 0.02) and an elevated preoperative platelet count (P = 0.04) were independent predictors of foot ischemia. The presence of diabetes was predictive of flap failure (P = 0.05). Flap failure rates were higher in the setting of an abnormal preoperative angiogram (P = 0.04), although the type and number of occluded arteries did not influence outcome. Foot ischemia was more frequent following surgical revascularization in conjunction with free tissue transfer and the use of the distal arterial bypass graft for flap anastomosis (P < 0.01). Overall, no differences were observed in foot ischemia (P = 0.17) and flap failure (P = 0.75) rates when the flap anastomosis was performed to the diseased artery noted on angiography, compared with an unobstructed native tibial artery.

CONCLUSIONS

Foot and ankle free tissue transfer may be performed with a low incidence of foot ischemia. Patients with diabetes, chronic ulceration, and an elevated preoperative platelet count are at higher risk for reconstructive failure. © 2015 Wiley Periodicals, Inc. Microsurgery 36:276-283, 2016.

Free flap transfer to preserve main arterial flow in early reconstruction of open fracture in the lower extremity

The selection of recipient vessels is crucial when reconstructing traumatized lower extremities using a free flap. When the dorsalis pedis artery and/or posterior tibial artery cannot be palpated, we utilize computed tomography angiography to verify the site of vascular injury prior to performing free flap transfer. For vascular anastomosis, we fundamentally perform end-to-side anastomosis or flow-through anastomosis to preserve the main arterial flow. In addition, in open fracture of the lower extremity, we utilize the anterolateral thigh flap for moderate soft tissue defects and the latissimus dorsi musculocutaneous flap for extensive soft tissue defects. The free flaps used in these two techniques are long and include a large-caliber pedicle, and reconstruction can be performed with either the anterior or posterior tibial artery. The preparation of recipient vessels is easier during the acute phase early after injury, when there is no influence of scarring. A free flap allows flow-through anastomosis and is thus optimal for open fracture of the lower extremity that requires simultaneous reconstruction of main vessel injury and soft tissue defect from the middle to distal thirds of the lower extremity.

The role of non-enhanced angiography in toe tip transfer with small diameter pedicle

BACKGROUND

Toe tip transfer allows functional and esthetic reconstruction of the lost fingertip, but it is still uncommon because identification and dissection of donor and recipient veins can be challenging. Nonenhanced angiography (NEA) is a device that emits infrared light at a wavelength of 850 nm, which is exclusively absorbed by hemoglobin. The light penetrates the bones and other soft tissues, effectively visualizing veins in real time. The aim of this report is to present the experience on the preoperative use of nonenhanced angiography for visualization of donor and recipient veins in toe tip transfers in a series of patients.

PATIENTS AND METHODS

Four cases of toe tip transfer and one case of free nail flap were performed for reconstruction of the tips of thumb and finger with preoperative examination using NEA. Patients' age ranged from 29 to 52 years old (average, 29.2 years old). Before the operation, the veins in the donor and recipient sites were marked using NEA, and the blood flow of the veins in the recipient site was confirmed.

RESULTS

Pedicles in all transferred toe tips were less than 2 cm in length, with diameters smaller than 0.8 mm. The postoperative courses were uneventful, and all transferred toe tips survived completely, with satisfying functional and aesthetic results.

CONCLUSIONS

NEA may facilitate venous dissection of the donor and the recipient sites, allowing safe and efficient toe tip transfer with a small pedicle.

Delineating the vascular territory (perforasome) of a perforator in the lower extremity of the rabbit with four-dimensional computed tomographic angiography

BACKGROUND

The anatomy of any particular vascular perforator relative to its vascular territory (perforasome) and flow characteristics is unique and complex. This arterial perforasome study with laboratory rabbits was conducted to assess four-dimensional computed tomographic angiography as an imaging tool for the design of individualized tissue transfers. This study offers clinically relevant information that should improve flap survival.

METHODS

Six New Zealand White rabbits weighing 3.0 to 3.25 kg underwent contrast-enhanced four-dimensional computed tomographic angiography in a 128-slice scanner after intraarterial injection of iopromide iodinated contrast material. Based on the image data, the perforasome of the posterior thigh perforator was marked onto the posterior thigh skin. The perforasome size was confirmed by microangiography. Data from four-dimensional computed tomographic angiography and microangiography were statistically compared.

RESULTS

Four-dimensional computed tomographic angiography clearly and accurately delineated the perfusion and vascular territories of the perforators. The area of the perforator flap as measured with four-dimensional computed tomographic angiography compared favorably to that obtained by means of microangiography; there was no statistically significant difference in the results from the two methods.

CONCLUSIONS

This study demonstrated that four-dimensional computed tomographic angiography was capable of accurately characterizing the vascular territory and flow characteristics of the arterial perforator in live rabbits. This technique for determining perforator location, axiality, and optimal perfusion territory will potentially benefit human patients.

Determination of lower limb microvasculature by intrafemoral arterial injection using computed tomography-assisted angiography

BACKGROUND

Computed tomography-assisted angiography (CTA) for lower limb vasculature can identify perforators only as small as 1 mm in diameter. The technique does not clearly show the microvascularity in subdermal layers of the skin. This study investigated a novel method of CTA using intrafemoral injection of contrast medium instead of intravenous injection to display the vascular anatomy of small perforators with a diameter less than 1 mm in the lower extremities of rabbits.

METHODS

Posterior thigh perforator surgery was performed for 15 New Zealand rabbits weighing 2.5 to 3.5 kg. Five rabbits underwent anatomic dissection to determine the vascular anatomy of the posterior thigh perforator and its location relative to adjacent structures. Of the remaining 10 rabbits, 5 were subjected to CTA scanning after injection of iodine contrast through a microcatheter inserted into the femoral artery, and 5 were subjected to CTA scanning through venous injection of contrast media. The latter group was designated as the control group (10 extremities). Images were viewed using a dedicated workstation. Postoperative outcomes and complications were monitored for 7 days after the procedure.

RESULTS

All the CTA images of intraartery administration clearly showed that the posterior thigh perforators originated from the popliteal artery. Injection of contrast agent through the femoral artery improved resolution of the CTA, enabling visualization of perforator arteries with diameters in the range of 0.3 to 0.4 mm. The images of the control group indicated the course of the perforator in the muscle of only six legs. The images of the remaining four legs did not display the perforator. The CTA-treated animals recovered without any complications. The anatomic dissection matched the CTA mapping.

CONCLUSIONS

Computed tomography-assisted angiography using intraarterial injection of contrast media enables visualization of vessels smaller than 1 mm in diameter. The described animal model also showed the presence of vascular branches in the subdermis. This imaging technique may help in the preoperative design of perforator flaps for use in clinical practice.

LEVEL OF EVIDENCE III

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Facial soft tissue trauma

Traumatic facial soft tissue injuries are commonly encountered in the emergency department by plastic surgeons and other providers. Although rarely life-threatening, the treatment of these injuries can be complex and may have significant impact on the patient's facial function and aesthetics. This article provides a review of the relevant literature related to this topic and describes the authors' approach to the evaluation and management of the patient with facial soft tissue injuries.