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Dong KX, Zhou Y, Cheng YY, Luo HT, Duan JZ, Yang X, Xu YQ, Lu S, He XQ. Clinical application of digital technology in the use of anterolateral thigh lobulated perforator flaps to repair complex soft tissue defects of the limbs. BURNS & TRAUMA 2024; 12:tkae011. [PMID: 38737342 PMCID: PMC11087825 DOI: 10.1093/burnst/tkae011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 12/04/2023] [Accepted: 02/25/2024] [Indexed: 05/14/2024]
Abstract
Background It is challenging to repair wide or irregular defects with traditional skin flaps, and anterolateral thigh (ALT) lobulated perforator flaps are an ideal choice for such defects. However, there are many variations in perforators, so good preoperative planning is very important. This study attempted to explore the feasibility and clinical effect of digital technology in the use of ALT lobulated perforator flaps for repairing complex soft tissue defects in limbs. Methods Computed tomography angiography (CTA) was performed on 28 patients with complex soft tissue defects of the limbs, and the CTA data were imported into Mimics 20.0 software in DICOM format. According to the perforation condition of the lateral circumflex femoral artery and the size of the limb defect, one thigh that had two or more perforators from the same source vessel was selected for 3D reconstruction of the ALT lobulated perforator flap model. Mimics 20.0 software was used to visualize the vascular anatomy, virtual design and harvest of the flap before surgery. The intraoperative design and excision of the ALT lobulated perforator flap were guided by the preoperative digital design, and the actual anatomical observations and measurements were recorded. Results Digital reconstruction was successfully performed in all patients before surgery; this reconstruction dynamically displayed the anatomical structure of the flap vasculature and accurately guided the design and harvest of the flap during surgery. The parameters of the harvested flaps were consistent with the preoperative parameters. Postoperative complications occurred in 7 patients, but all flaps survived uneventfully. All of the donor sites were closed directly. All patients were followed up for 13-27 months (mean, 19.75 months). The color and texture of each flap were satisfactory and each donor site exhibited a linear scar. Conclusions Digital technology can effectively and precisely assist in the design and harvest of ALT lobulated perforator flaps, provide an effective approach for individualized evaluation and flap design and reduce the risk and difficulty of surgery.
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Affiliation(s)
- Kai-xuan Dong
- Department of Orthopedics, The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Key Laboratory of Digital Orthopedics of Yunnan Province, 157 Jinbi Road, Xishan District, Kunming, Yunnan 650032, China
| | - Ya Zhou
- School of Rehabilitation, Kunming Medical University, 1168 Chunrong west Road, Yuhua Street, Chenggong District, Kunming, Yunnan 650504, China
| | - Yao-yu Cheng
- Department of Orthopedics, The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Key Laboratory of Digital Orthopedics of Yunnan Province, 157 Jinbi Road, Xishan District, Kunming, Yunnan 650032, China
| | - Hao-tian Luo
- Department of Orthopedics, The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Key Laboratory of Digital Orthopedics of Yunnan Province, 157 Jinbi Road, Xishan District, Kunming, Yunnan 650032, China
| | - Jia-zhang Duan
- Affiliated Hospital of Yunnan University, 176 Qinnian Road, Wuhua District, Kunming, Yunnan 650032, China
| | - Xi Yang
- Department of Orthopedics, 920 Hospital of the Joint Logistic Support Force, People's Liberation Army of China, 212 Road, Daguan District, Kunming, Yunnan 650032, China
| | - Yong-qing Xu
- Department of Orthopedics, 920 Hospital of the Joint Logistic Support Force, People's Liberation Army of China, 212 Road, Daguan District, Kunming, Yunnan 650032, China
| | - Sheng Lu
- Department of Orthopedics, The First People’s Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Key Laboratory of Digital Orthopedics of Yunnan Province, 157 Jinbi Road, Xishan District, Kunming, Yunnan 650032, China
| | - Xiao-qing He
- Department of Orthopedics, 920 Hospital of the Joint Logistic Support Force, People's Liberation Army of China, 212 Road, Daguan District, Kunming, Yunnan 650032, China
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Hong QE, Kua JEH, Tay VK, Chan SL, Ho CWG, Sun JM. Utilizing the Subunit Concept to Achieve Better Outcomes in Lower Limb Reconstruction: A Clinical Experience in an Asian Population. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5752. [PMID: 38645632 PMCID: PMC11030020 DOI: 10.1097/gox.0000000000005752] [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: 08/13/2023] [Accepted: 03/06/2024] [Indexed: 04/23/2024]
Abstract
Background The goals of reconstruction have progressed from filling a defect to enhancing function and aesthetic appearance. We aimed to achieve better aesthetic and functional outcomes in terms of shoe fitting and mobility. This is accomplished via a classification of the subunits and aesthetic considerations of the lower limb. Methods Between April 2017 and December 2021, 66 cases of lower extremity free fasciocutaneous flap reconstruction cases were included in this retrospective study. Data parameters include age, sex, comorbidities, etiology of lower limb wounds, choice of free flap reconstruction, recipient arterial vessels, complications of flap reconstruction, and need for secondary debulking procedures. Physiotherapy records were also examined to determine the time to independent ambulation. Results In total, 66 subjects were identified. The mean age was 48.6. An estimated 74.2% (n = 49) were men, 50% (n = 33) had diabetes, and 16.6% (n = 11) had peripheral vascular disease. Of the total wounds, 65.1% (n = 43) were caused by infection, whereas the remaining 34.9% (n = 23) were due to trauma. Of the cases, 72.7% (n = 48) had free anterolateral thigh flap reconstruction, 25.8% (n = 17) were reconstructed with superficial circumflex iliac artery perforator flaps, and 1.5% (n = 1) was reconstructed with medial sural artery perforator flaps. Cases that required secondary debulking procedures comprised 7.6% (n = 5). Conclusions Free fasciocutaneous flaps are useful in lower extremity reconstruction. Based on the subunit principle and aesthetic considerations for lower limb reconstruction, it can aid in optimizing functional rehabilitation and decreasing secondary procedures.
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Affiliation(s)
- Qi En Hong
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Changi General Hospital, Singapore
| | | | | | - Stephanie L.S. Chan
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Changi General Hospital, Singapore
| | - Christopher Wei Guang Ho
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Changi General Hospital, Singapore
| | - Jeremy Mingfa Sun
- From the Department of Plastic, Reconstructive and Aesthetic Surgery, Changi General Hospital, Singapore
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Sosa-Vazquez AA, Suro Santos Y, Serrato-Ruiz JA, Herrera-Valenzuela JA, Becerril-Pazara AA, Hayakawa-Davila VC. Lower Limb Degloving Trauma Reconstruction: A Case Report. Cureus 2023; 15:e48904. [PMID: 38106715 PMCID: PMC10725276 DOI: 10.7759/cureus.48904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/16/2023] [Indexed: 12/19/2023] Open
Abstract
Degloving injuries are caused by trauma with shear mechanisms, usually secondary to being run over in traffic accidents. It is characterized by the avulsion of skin and subcutaneous tissue, generating coverage deficit, and in severe cases, loss of the affected limb. Herein, we discuss a case of a six-year-old male run over by a truck, receiving a direct impact on the left lower extremity with a rubber tire. Debridement and surgical cleaning were performed and a negative pressure system was placed. Subsequently, dermal matrix and partial-thickness skin grafts were placed as coverage after the creation of a viable grafting bed.
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Affiliation(s)
- Alan Armando Sosa-Vazquez
- Plastic and Reconstructive Surgery, Instituto Mexicano Del Seguro Social, Unidad Medica de Alta Especialidad 71, Universidad Autonoma de Coahuila, Torreon, MEX
| | - Yeudiel Suro Santos
- General Surgery, Instituto Mexicano del Seguro Social, Hospital General de Zona No. 33, Monterrey, MEX
| | - Jorge Alejandro Serrato-Ruiz
- Plastic and Reconstructive Surgery, Instituto Mexicano del Seguro Social, Unidad Medica de Alta Especialidad 71, Universidad Autonoma de Coahuila, Torreon, MEX
| | - Jaime Aaron Herrera-Valenzuela
- Plastic and Reconstructive Surgery, Instituto Mexicano del Seguro Social, Unidad Medica de Alta Especialidad 71, Universidad Autonoma de Coahuila, Torreon, MEX
| | - Agustin Arturo Becerril-Pazara
- Plastic and Reconstructive Surgery, Instituto Mexicano del Seguro Social, Unidad Medica de Alta Especialidad 71, Universidad Autonoma de Coahuila, Torreon, MEX
| | - Victor Carlos Hayakawa-Davila
- Plastic and Reconstructive Surgery, Instituto Mexicano del Seguro Social, Unidad Medica de Alta Especialidad 71, Universidad Autonoma de Coahuila, Torreon, MEX
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Giunta G, Kapila A, Brussaard C, Nistor A, De Baerdemaeker R, Zeltzer A, Hamdi M. Redefining the vascular anatomy of the medial gastrocnemius muscle: A computed tomography angiography study. J Plast Reconstr Aesthet Surg 2023; 83:165-171. [PMID: 37276735 DOI: 10.1016/j.bjps.2023.04.074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/11/2023] [Accepted: 04/19/2023] [Indexed: 06/07/2023]
Abstract
BACKGROUND The medial gastrocnemius (GN) muscle flap is a historical reconstructive option in lower limb reconstruction. The flap is proximally based on the medial sural artery, and it is assumed not possible to harvest a distally based flap because of the absence of other minor pedicles. The aim of this study is to investigate the presence and the anatomy of a distal secondary pedicle given off by the posterior tibial artery (PTA). METHODS A retrospective CTA study was performed of 120 limbs between April 2018 and June 2020. 3D reconstruction was performed to delineate the anatomy of the distal secondary pedicle, if present. The distance of the pedicle, if found, from the intermalleolar line to the patella was noted. The number of pedicles, if multiple, was documented, as well as branches to the soleus muscle and the skin. RESULTS A distal pedicle to the gastrocnemius muscle was found in 64% of limbs. The average location from the intermalleolar line is 168 mm. The branching pattern from the PTA showed an isolated vessel going to the distal medial gastrocnemius (32.8%), two branches to the medial gastrocnemius and skin (39.3%), two branches to the medial gastrocnemius and soleus (24.6%), and three branches to the medial gastrocnemius, soleus, and the skin (3.3%). CONCLUSIONS This study confirms the presence of the secondary axial distal pedicle of the GN muscle. Furthermore, this study confirms that there is a likely association between the distal medial gastrocnemius pedicle and the PTA skin perforators.
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Affiliation(s)
- Gabriele Giunta
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium.
| | - Ayush Kapila
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Carola Brussaard
- Department of Radiology, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Alexandru Nistor
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Randy De Baerdemaeker
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Assaf Zeltzer
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
| | - Moustapha Hamdi
- Department of Plastic, Reconstructive and Aesthetic Surgery, University Hospital (UZ) Brussels, Laarbeeklaan 101, 1090 Brussels, Belgium
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Behr B, Lotzien S, Flecke M, Wallner C, Wagner JM, Dadras M, Daigeler A, Schildhauer TA, Lehnhardt M, Geßmann J. Comparative analysis of clinical outcome and quality of life between amputations and combined bone and flap reconstructions at the lower leg. Disabil Rehabil 2022; 44:6744-6748. [PMID: 34546826 DOI: 10.1080/09638288.2021.1971309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE At the lower leg, soft tissue defects with exposed bones, tendons, or hardware require flap coverage. In this retrospective study, we analyzed combined bone and soft tissue reconstructions compared to amputations of the lower leg in a civilian setting. MATERIALS AND METHODS Patients who underwent combined bone and flap reconstruction (LR) or amputation (LA) of the lower leg were eligible for the study. Bone conditions included fractures and bony defects due to posttraumatic osteomyelitis and non-union. Besides the analysis of the medical history, the study included clinical examination including extremity functional scale (LEFS) and SF-36-questionnaire. RESULTS LEFS score was significantly higher in the LR group compared to the LA group. Importantly, 42% in the LR group as opposed to 80% in the LA group could not return to their occupation. Mean hospitalization was 119 in the LR and 49 days in the LA group. SF-36 body item scores were significantly higher in the LR group as compared to LA. CONCLUSIONS Patients undergoing complex extremity reconstructions, including flap transfer to the lower leg have better functionality and higher quality of life than amputated patients. These data emphasize the advantages of these procedures and justify reconstructive efforts for limb salvage. Level of Evidence III.Implications for RehabilitationAmputation and combined bone and flap reconstruction in severe injuries of the lower leg can imply functional disabilities even after successful treatment.Albeit longer hospitalizations, patients with complex reconstructions showed better functional outcomes and had a higher quality of life.Limb salvage showed better functional outcomes and a higher rate in reintegration to work as compared to limb amputation.These data emphasize the importance of complex bone and soft tissue reconstruction in this patient cohort.
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Affiliation(s)
- Björn Behr
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Sebastian Lotzien
- Department of General and Trauma surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Marcel Flecke
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Christoph Wallner
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - J Maximillian Wagner
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Mehran Dadras
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Adrien Daigeler
- Department of Hand, Plastic, Reconstructive and Burn Surgery, BG Hospital Tübingen, Eberhard Karls University, Tübingen, Germany
| | - Thomas A Schildhauer
- Department of General and Trauma surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Marcus Lehnhardt
- Department of Plastic Surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
| | - Jan Geßmann
- Department of General and Trauma surgery, BG University Hospital Bergmannsheil, Ruhr University Bochum, Bochum, Germany
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Campitiello F, Mancone M, Corte AD, Guerniero R, Canonico S. Expanded negative pressure wound therapy in healing diabetic foot ulcers: a prospective randomised study. J Wound Care 2021; 30:121-129. [PMID: 33573486 DOI: 10.12968/jowc.2021.30.2.121] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE This study aims to evaluate the benefits of treating diabetic foot ulcers (DFU) through a revised procedure using the mechanisms underlying negative pressure wound therapy (NPWT) in such a way as to achieve reduced and more evenly distributed lateral tension lines across the wound. METHOD Patients with type 2 diabetes were assessed for elegibility. Included patients were divided randomly into two groups: the NPWT control group and the NPWT+ group. Patients in the NPWT control group were treated in the traditional manner: wounds were covered with foams shaped to fit the wound precisely. In the NPWT+ group, foams were shaped to fit the wound precisely, and an additional foam was then wrapped around the foot. RESULTS Some 85 patients were assessed for eligibility; 59 were randomised into two groups: 29 patients in the NPWT+ group and 30 patients in the NPWT group. The primary objective was median healing time (NPWT+ 19 days, interquartile ratio (IQR) 7.5; NPWT 33 days, IQR 16; p<0.00001), and complete wound healing at three weeks (NPWT+ 55.20% NPWT 26.70% p=0.02). Secondary endpoints included number of major amputations (none in either group) and number of infections (NPWT+ 3.44% of patients, NPWT 6.66% of patients; p=0.57). CONCLUSION Our initial findings show that this treatment significantly reduced wound closure times and accelerated healing in DFUs. It also demonstrated promising improvements in healing rates, with no significant increase in wound complications.
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Affiliation(s)
- Ferdinando Campitiello
- Department of Advanced Medical and Surgical Sciences, University of Campania 'Luigi Vanvitelli', Piazza Miraglia 2, Napoli, Campania, Italy
| | - Manfredi Mancone
- Department of Advanced Medical and Surgical Sciences, University of Campania 'Luigi Vanvitelli', Piazza Miraglia 2, Napoli, Campania, Italy
| | - Angela Della Corte
- Department of Advanced Medical and Surgical Sciences, University of Campania 'Luigi Vanvitelli', Piazza Miraglia 2, Napoli, Campania, Italy
| | - Raffaella Guerniero
- Department of Advanced Medical and Surgical Sciences, University of Campania 'Luigi Vanvitelli', Piazza Miraglia 2, Napoli, Campania, Italy
| | - Silvestro Canonico
- Department of Advanced Medical and Surgical Sciences, University of Campania 'Luigi Vanvitelli', Piazza Miraglia 2, Napoli, Campania, Italy
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Acute limb shortening or creation of an intentional deformity to aid in soft tissue closure for IIIB/IIIC open tibia fractures. J Plast Reconstr Aesthet Surg 2021; 74:2933-2940. [PMID: 34049839 DOI: 10.1016/j.bjps.2021.03.105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/26/2021] [Accepted: 03/13/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Ring fixator techniques can precisely correct complex long bone deformities. In select patients, controlled shortening or intentional fracture deformation with delayed correction can also aid in complex wound coverage and limb salvage. METHODS This retrospective cohort study analyzed all patients who underwent acute limb shortening or intentional temporary fracture deformation between 2005 and 2020. Patients were divided into three groups based on reason for acute shortening or intentional deformity: (1) skeletal indications alone, with traditional flap coverage; (2) skeletal and soft tissue indications, to augment traditional reconstructive measures; and (3) skeletal and soft tissue indications, to avoid microsurgery altogether. Comorbidities, orthopedic and reconstructive methods, and functional outcomes were recorded. RESULTS Eighteen patients were identified: six in Group 1, five in Group 2, and seven in Group 3. Fractures were primarily in the distal third of the tibia. On initial assessment, all wounds would have required free tissue transfer. Group 1 patients were reconstructed with free flaps. Among Group 2, closure was accomplished by skin grafting (N = 1), local flaps (N = 1), pedicled muscle flaps (N = 1), and free flaps (N = 2). In Group 3, five wounds were closed primarily and two were skin grafted. All limbs were shortened, averaging 25.1 mm; seven were intentionally deformed, most commonly varus (10-20°). After skeletal correction, residual leg length discrepancy averaged 5.7 mm. No patients required amputation. CONCLUSIONS Acute skeletal shortening with or without intentional temporary deformation in select IIIB/IIIC open tibial fractures can facilitate soft tissue coverage and limb salvage in patients who might otherwise require amputation.
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Parikh RP, Ha A, Tung T. Free Flap Reconstruction of Traumatic Pediatric Foot and Ankle Defects: An Analysis of Clinical and Functional Outcomes. J Reconstr Microsurg 2021; 37:783-790. [PMID: 33853128 DOI: 10.1055/s-0041-1727187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Traumatic lower extremity injuries involving the foot and ankle can have devastating consequences and represent a complex reconstructive challenge. To date, there are limited reports on microsurgical reconstruction for foot and ankle defects in children. This study aims to evaluate clinical and functional outcomes of free flaps for pediatric foot and ankle injuries. METHODS This is a retrospective review of patients undergoing free flaps for traumatic foot and ankle defects at a pediatric trauma center between 2000 and 2015. Patients with less than 5-year follow-up were excluded. Demographics, clinical characteristics, and postoperative outcomes were evaluated. RESULTS Thirty patients undergoing 30 flaps were analyzed. The mean age was 11.9 years (range: 2 to 17 years). Muscle flaps (n = 21, 70%) were more common than fasciocutaneous flaps (n = 9, 30%). Limb salvage with functional ambulation was achieved in 96.7% of patients (n = 29). The complication rate was 33.3% (n = 10), with wound breakdown (n = 6, 20.0%) as most common feature. There were no significant differences in limb salvage, total or partial flap loss, fracture union, and donor-site complications based on flap type. Fasciocutaneous flaps were more likely to require revision procedures for contour compared with muscle flaps (55.6 vs. 9.5%, p = 0.013). Mean follow-up was 8.5 years. CONCLUSION Microsurgical reconstruction of pediatric foot and ankle defects results in high rates of limb salvage. A defect- and patient-centered approach to reconstruction, emphasizing durable coverage and contour, is critical to facilitating ambulation and ensuring favorable long-term functional outcomes.
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Affiliation(s)
- Rajiv P Parikh
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri.,Department of Plastic and Reconstructive Surgery, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, District of Columbia
| | - Austin Ha
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas Tung
- Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
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Abstract
The perforator-plus flap is a new concept for lower extremity reconstruction. It combines a perforator flap with a traditional skin rotation flap. It can be another option for lower extremity soft tissue defects since the flap has an augmented blood supply. The ability to detect cutaneous perforators has improved with the Duplex scan imaging technique. These advances have made the perforator-plus flap a viable option for soft tissue reconstruction. It can be versatile and reduces donor site morbidity; it is technically simple to perform and faster than traditional free flaps. It achieves durable soft tissue coverage for lower extremity wounds.
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Affiliation(s)
- Ping Song
- Division of Plastic Surgery, Department of Surgery, University of California Davis Medical Center, University of California at Davis, 2335 Stockton Boulevard, Room 6008, Sacramento, CA 95817, USA
| | - Lee L Q Pu
- Division of Plastic Surgery, Department of Surgery, University of California Davis Medical Center, University of California at Davis, 2335 Stockton Boulevard, Room 6008, Sacramento, CA 95817, USA.
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Zhou C, Al Tarah M, Lauwers TM, Van der Hulst RRWJ. Timing of Microsurgical Reconstruction in Lower Extremity Trauma: An Update of the Godina Paradigm. Plast Reconstr Surg 2020; 146:691e-692e. [PMID: 33136973 DOI: 10.1097/prs.0000000000007300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Chao Zhou
- Department of Plastic and Reconstructive Surgery, Maastricht UMC+, Maastricht, The Netherlands
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11
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Tian J, Chen ZB, Li J. Use of Muscle Feeding Arteries as Recipient Vessels for Soft Tissue Reconstruction in Lower Extremities. Curr Med Sci 2020; 40:739-744. [PMID: 32862385 DOI: 10.1007/s11596-020-2235-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Accepted: 08/04/2020] [Indexed: 10/23/2022]
Abstract
Microsurgical free tissue transfer is still playing an important role in lower extremity reconstruction. Finding a suitable recipient artery for anastomosis is critical in the microsurgical procedure, especially in an extensive wound, or in a complex trauma combined with vascular injury. From April 2014 to March 2018, we retrospectively reviewed patients with traumatic/post-traumatic, oncologic, and electrical wounds in the lower extremity. Those treated with muscle feeding artery as recipient vessels were included. The latissimus dorsi (LD) muscle free flap, anterior lateral thigh (ALT) perforator free flap, and deep inferior epigastric perforator (DIEP) free flap were raised. The muscle feeding arteries to vastus lateral muscle and to medial head of gastrocnemius muscle, concomitant veins, and great saphenous vein were used as recipient vessels. Injuries included in the study were caused by tumour in 2 cases, car accident in 3 cases, crushing in 3 cases, burns in one case, and electrical injury in one case. The wound size varied from 14 cm × 6 cm to 30 cm × 20 cm. LD, ALT, and DIEP free flaps were used in 6, 3, and 4 patients, respectively. The muscle feeding arteries to medial head of gastrocnemius muscle, to sartorius muscle, and to vastus lateral muscle were used as recipient arteries in 4, 5, and one patient, respectively. Concomitant and great saphenous veins were used as recipient veins in 10 and 4 patients, respectively. Using the muscle feeding artery is feasible to avoid injury to the main artery and facilitate dissection and anastomoses, particularly when the wound is located proximal to the mid-third of the lower leg.
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Affiliation(s)
- Jia Tian
- Department of Hand Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Zhen-Bing Chen
- Department of Hand Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China
| | - Jin Li
- Department of Hand Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, 430022, China.
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12
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Bulla A, Delgove A, De Luca L, Pelissier P, Casoli V. The esthetic outcome of lower limb reconstruction. ANN CHIR PLAST ESTH 2020; 65:655-666. [PMID: 32800462 DOI: 10.1016/j.anplas.2020.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Accepted: 07/17/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND In recent years, the progress of anatomical knowledge and microsurgical techniques, in particular the development of perforator flaps, has risen the number of flaps available for lower leg reconstruction. The esthetic consequences of flap choice and harvest do have an impact on patients' quality of life. Nowadays, more researchers evaluate the esthetic changes following lower limb reconstruction. OBJECTIVES This review aims to summarize the available evidence on the esthetic outcome of lower limb reconstruction. DATA SOURCES A systematic review was planned to identify the most relevant indexed articles on this subject. The search was performed on Pubmed database without date of publication limits. STUDY ELIGIBILITY CRITERIA All papers about reporting information about the esthetic outcome of lower limb reconstruction were selected. Case reports and the articles not including specific information about complications, secondary procedures, and outcomes were excluded. The articles were categorized according to their topic and date of publication. The full texts of all the articles were obtained and read thoroughly. The references for each article were screened to identify articles that were eventually left outside our database search. PARTICIPANTS, AND INTERVENTIONS One hundred and eight articles were retained for the definitive review. Eleven review articles were kept because they represented a good source of information. Thirty-three articles were added after reading the full texts. The articles appear highly heterogeneous and at, this stage, only a critical and qualitative analysis could be performed. RESULTS We found information about 7895 lower reconstructions, 1295 local flaps, 6546 free flaps. LIMITATIONS The esthetic evaluation is intrinsic subjective. Many psychological and cultural factors influence both the patient and the surgeon. There is not a validated assessment tool for the esthetic outcome of lower leg reconstruction. Therefore, no quantitative analysis was performed. CONCLUSIONS Some ancient techniques are today obsolete, like the rectus abdominis free muscle flaps and perhaps free forearm flap, others are always useful, like gracilis and latissimus dorsi free flap. ALT flap is the most versatile perforator flap today available, but the SCIP flap is gaining the favor of a growing number of surgeons. Local flaps will be always performed with success but their indications should not be pushed beyond the medium-size defects. The best cosmetic outcome for each patient cannot necessarily be obtained neither with the easiest techniques nor with the most technically demanding ones. It is necessary to develop validated tools to assess the cosmetic outcome of lower limb reconstruction.
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Affiliation(s)
- A Bulla
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France.
| | - A Delgove
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - L De Luca
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - P Pelissier
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
| | - V Casoli
- Department of Plastic and Reconstructive Surgery, Hand Surgery, Burns Unit, F.X.-Michelet Center, University Hospital Bordeaux, place Amélie-Raba-Léon, 33076 Bordeaux, France
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Free-Flap Reconstruction for Diabetic Lower Extremity Limb Salvage. J Surg Res 2020; 248:165-170. [DOI: 10.1016/j.jss.2019.12.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 11/06/2019] [Accepted: 12/03/2019] [Indexed: 11/22/2022]
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Clegg DJ, Rosenbaum PF, Harley BJ. The Effects of Timing of Soft Tissue Coverage on Outcomes After Reconstruction of Type IIIB Open Tibia Fractures. Orthopedics 2019; 42:260-266. [PMID: 31355903 DOI: 10.3928/01477447-20190723-01] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 07/02/2019] [Indexed: 02/03/2023]
Abstract
High-energy open fractures of the tibia are frequently associated with tissue loss, wound contamination, and compromised vascularity that often result in amputation. The management of these severe injuries remains a challenge for orthopedic reconstructive surgeons. Studies have compared the timing of soft tissue coverage of Gustilo type IIIB open tibia fractures with associated outcomes such as rate of deep infection, primary union, length of hospitalization, flap failure, and eventual secondary amputation. These studies often highlight better outcomes with specific time domains that are not always attainable at a large tertiary hospital with multi-system trauma patients. Many studies do not account for delayed patient transfers after initial open fracture management elsewhere. This retrospective analysis of the limb salvage outcomes included 140 consecutive patients with Gustilo type IIIB open tibia fractures who presented to the authors' level I trauma center between 2001 and 2014. The authors included patients who required delayed coverage or who were transferred from outside institutions. The majority (77%) were male, and the mean age was 39.4 years. Motor vehicle accidents were the most common cause of injury, and 83% of patients obtained full weight-bearing status with successful limb salvage. Twenty patients had a secondary amputation, with the cause being refractory osteomyelitis in 52%. This study provides guidance on treating a heterogeneous patient population with severe open tibia fractures typically seen in a large tertiary hospital orthopedic trauma service. [Orthopedics. 2019; 42(5):260-266.].
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Alnaif N, Lee J, Azzi AJ, Aldekhayel S, Zadeh T. Preservation of lower extremity spare parts using the University of Wisconsin solution. SAGE Open Med Case Rep 2019; 7:2050313X18823438. [PMID: 30728972 PMCID: PMC6350014 DOI: 10.1177/2050313x18823438] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 12/17/2018] [Indexed: 11/16/2022] Open
Abstract
The management of a mangled limb is a challenging endeavor. With the advancement in microsurgery, spare parts surgery (fillet flaps) has gained recent interest. In the context of lower extremity amputation secondary to trauma, viable spare parts can provide stump soft tissue coverage, potentially preserving critical length and obviating above-knee amputations. Commonly, spare parts surgery is performed in the acute setting but tissue preservation is sometimes necessary. The authors report their experience preserving a fillet flap of a mangled lower extremity for 48 h using the University of Wisconsin solution. A sole fillet flap and a split-thickness skin graft were harvested and preserved from the amputated lower extremity (based on the posterior tibial artery and vein). Stump coverage was achieved by anastomosing the fillet flap to the proximal posterior tibial artery and vein. This solution has not been previously described for preservation of fillet flaps.
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Affiliation(s)
- Nayif Alnaif
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - James Lee
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Alain Joe Azzi
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Salah Aldekhayel
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, QC, Canada
| | - Teanoosh Zadeh
- Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, QC, Canada
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Lee ZH, Daar DA, Stranix JT, Anzai L, Thanik VD, Saadeh PB, Levine JP. Risk factors for microvascular free flaps in pediatric lower extremity trauma. Microsurgery 2019; 40:44-50. [DOI: 10.1002/micr.30427] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 10/31/2018] [Accepted: 12/27/2018] [Indexed: 11/10/2022]
Affiliation(s)
- Z-Hye Lee
- Hansjörg Wyss Department of Plastic Surgery; New York University School of Medicine; New York New York
| | - David A. Daar
- Hansjörg Wyss Department of Plastic Surgery; New York University School of Medicine; New York New York
| | - John T. Stranix
- Department of Plastic Surgery; University of Virginia Health System; Charlottesville Virginia
| | - Lavinia Anzai
- Hansjörg Wyss Department of Plastic Surgery; New York University School of Medicine; New York New York
| | - Vishal D. Thanik
- Hansjörg Wyss Department of Plastic Surgery; New York University School of Medicine; New York New York
| | - Pierre B. Saadeh
- Hansjörg Wyss Department of Plastic Surgery; New York University School of Medicine; New York New York
| | - Jamie P. Levine
- Hansjörg Wyss Department of Plastic Surgery; New York University School of Medicine; New York New York
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Extracellular Matrix Applications in the Treatment of Open Fractures With Complex Wounds and Large Soft Tissue Defects. J Orthop Trauma 2018; 32:e76-e80. [PMID: 29240612 DOI: 10.1097/bot.0000000000001034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Use of biologic scaffolds such as extracellular matrix (ECM) is a promising trend in the treatment of complex wounds in orthopedic trauma patients. In this clinical series we describe the technique of the successful application of porcine urinary bladder ECM products in the treatment of open fractures of the extremities with complex wounds and large soft tissue defects. The clinical outcomes demonstrated that even in challenging cases where local flap coverage of bone or neurovascular structures is not possible, sequential xenograft implantation allowed us to achieve a stable soft tissue envelope. Different forms of ECM products are easy to apply in the presence of orthopedic hardware. In certain wounds, complete closure can be achieved even without subsequent skin grafting. We recommend relatively earlier application of xenograft.
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Lin YN, Chuang CH, Huang SH, Huang SH, Lin TM, Lin IW, Lin SD, Kuo YR. Fat grafting for resurfacing an exposed implant in lower extremity: A case report. Medicine (Baltimore) 2017; 96:e8901. [PMID: 29310377 PMCID: PMC5728778 DOI: 10.1097/md.0000000000008901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
RATIONALE Although numerous reconstruction protocols have been reported for lower leg trauma, those for distal leg trauma remain few. We present the case of a woman with an implant exposure wound, who was successfully treated through fat grafting, without major flap surgery. PATIENT CONCERNS An 83-year-old woman with an exposed implant in lower extremity received reconstruction surgery once and the surgery failed. She refused additional major surgery and negative pressure wound therapy. DIAGNOSES The diagnosis of a tibia and fibula shaft open fracture (type IIIA) complicated with an exposed implant was made. INTERVENTIONS The procedure was performed by deploying purified and emulsified fat with a Micro-Autologous Fat Transplantation gun. The required lipoaspirate amount was grossly estimated using a standard formula: 0.5 cc of a lipoaspirate per square centimeter of wound. We prepared the lipoaspirate simply through centrifugation followed by physical emulsification. The endpoint of fat grafting was when lipoaspirate began to flow out of the wound. The initial dressing after the procedure included the topical usage of biomycin ointment with AQUACEL Foam (ConvaTec Inc., NC, USA) coverage, which was later changed to INTRASITE gel (Smith & Nephew, London, UK) with a gauze dressing for 4 weeks. After 4 weeks, dressing components were changed to Mepilex (Mölnlycke Health Care, Gothenburg, Sweden) alone. OUTCOMES The wound healed completely without requiring major flap surgery by 18 weeks after surgery. LESSONS Fat grafting is one kind of cell therapy and potentially has regenerative effects during wound healing. Fat grafting is critical in the healing processes of complicated wounds and might be considered a step in reconstruction surgery.
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Affiliation(s)
- Yun-Nan Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University
- Department of Surgery
| | | | - Shih-Hao Huang
- Department of Orthopaedics Surgery, Kaohsiung Municipal Siaogang Hospital
| | - Shu-Hung Huang
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University
| | - Tsai-Ming Lin
- Charming Institute of Aesthetic and Regenerative Surgery
| | - I-Wen Lin
- Department of Nursing, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
| | - Sin-Daw Lin
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University
- Department of Surgery
| | - Yur-Ren Kuo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Kaohsiung Medical University Hospital, Kaohsiung Medical University
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Barbera F, Lorenzetti F, Marsili R, Ragoni M, Lisa A, Zampa V, Pantaloni M. MRI anatomical preoperative evaluation of distally based peroneus brevis muscle flap in reconstructive surgery of the lower limb. J Plast Reconstr Aesthet Surg 2017; 70:1563-1570. [PMID: 28720406 DOI: 10.1016/j.bjps.2017.06.018] [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] [Received: 11/30/2016] [Revised: 06/11/2017] [Accepted: 06/18/2017] [Indexed: 11/17/2022]
Abstract
BACKGROUND The distally based peroneus brevis muscle flap has proved to be a simple solution for small- to moderate-sized wounds of the lower limb. The length of the muscle belly suitable for coverage is a crucial parameter. In this study, we evaluated the capability of 3D MRI of the lower limb to measure it preoperatively. METHODS Between 2008 and 2017, 32 patients with lower limb defects underwent preoperative MRI to measure the peroneus brevis muscle length. All patients underwent reconstruction, and the muscle was measured again intraoperatively during surgical dissection. Surgical measurements were then compared to the MRI ones. RESULTS MRI measures of the peroneus brevis muscle belly ranged from 9 to 21 cm (μ = 14.44 ± 3.43 cm), and intraoperative measures ranged from 9 to 20 cm (μ = 14.2 ± 2.3 cm). Thirty of 32 intraoperative measures corresponded to the MRI ones (variation = ± 1 cm, r = 0.92, p = 0.002). One patient showed an intraoperative muscle length 3 cm shorter than the MRI measure, and another patient had intraoperative muscle length 3 cm longer than the MRI one. All flaps survived, and no secondary local flap coverage was required, with no flap-related complication, limited donor site morbidity, and acceptable patient discomfort. CONCLUSIONS The reverse peroneus brevis muscle flap is a versatile alternative to free flap reconstruction in small- to moderate-sized defects of the lower limb. Preoperative 3D MRI is accurate to evaluate the anatomy of the muscle when performed by an expert radiologist. In our experience, it should become part of preoperative workup before performing a peroneus brevis flap procedure.
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Affiliation(s)
- Federico Barbera
- Plastic and Reconstructive Surgery Unit, University of Pisa, Santa Chiara Hospital, Pisa, Italy; Scuola Superiore Sant'Anna di Studi Universitari e Perfezionamento, Pisa, Italy.
| | - Fulvio Lorenzetti
- Plastic and Reconstructive Surgery Unit, University of Pisa, Santa Chiara Hospital, Pisa, Italy
| | - Ricccardo Marsili
- Plastic and Reconstructive Surgery Unit, University of Pisa, Santa Chiara Hospital, Pisa, Italy
| | - Matteo Ragoni
- Plastic and Reconstructive Surgery Unit, University of Pisa, Santa Chiara Hospital, Pisa, Italy
| | - Andrea Lisa
- Humanitas Research Hospital, University of Milan, Italy
| | - Virna Zampa
- Diagnostic Radiology Department, University of Pisa, Italy
| | - Marcello Pantaloni
- Plastic and Reconstructive Surgery Unit, University of Pisa, Santa Chiara Hospital, Pisa, Italy
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Ramasamy PR. Management of Gustilo Anderson III B open tibial fractures by primary fascio-septo-cutaneous local flap and primary fixation: The 'fix and shift' technique. Indian J Orthop 2017; 51:55-68. [PMID: 28216752 PMCID: PMC5296850 DOI: 10.4103/0019-5413.197532] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Open fractures of tibia have posed great difficulty in managing both the soft tissue and the skeletal components of the injured limb. Gustilo Anderson III B open tibial fractures are more difficult to manage than I, II, and III A fractures. Stable skeletal fixation with immediate soft tissue cover has been the key to the successful outcome in treating open tibial fractures, in particular, Gustilo Anderson III B types. If the length of the open wound is larger and if the exposed surface of tibial fracture and tibial shaft is greater, then the management becomes still more difficult. MATERIALS AND METHODS Thirty six Gustilo Anderson III B open tibial fractures managed between June 2002 and December 2013 with "fix and shift" technique were retrospectively reviewed. All the 36 patients managed by this technique had open wounds measuring >5 cm (post debridement). Under fix and shift technique, stable fixation involved primary external fixator application or primary intramedullary nailing of the tibial fracture and immediate soft tissue cover involved septocutaneous shift, i.e., shifting of fasciocutaneous segments based on septocutaneous perforators. RESULTS Primary fracture union rate was 50% and reoperation rate (bone stimulating procedures) was 50%. Overall fracture union rate was 100%. The rate of malunion was 14% and deep infection was 16%. Failure of septocutaneous shift was 2.7%. There was no incidence of amputation. CONCLUSION Management of Gustilo Anderson III B open tibial fractures with "fix and shift" technique has resulted in better outcome in terms of skeletal factors (primary fracture union, overall union, and time for union and malunion) and soft tissue factors (wound healing, flap failure, access to secondary procedures, and esthetic appearance) when compared to standard methods adopted earlier. Hence, "fix and shift" could be recommended as one of the treatment modalities for open III B tibial fractures.
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Affiliation(s)
- P R Ramasamy
- Department of Orthopaedics, Kauvery Hospitals, Trichy, Tamil Nadu, India,Address for correspondence: Dr. P R Ramasamy, H.O.D, Department of Orthopaedics, Kauvery Hospitals, 16, Vishwanathapuram, Tennur, Trichy - 620 017, Tamil Nadu, India. E-mail:
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Marchesi A, Parodi PC, Brioschi M, Riccio M, Perrotta RE, Colombo M, Calori GM, Vaienti L. Soft-tissue defects of the Achilles tendon region: Management and reconstructive ladder. Review of the literature. Injury 2016; 47 Suppl 4:S147-S153. [PMID: 27492062 DOI: 10.1016/j.injury.2016.07.053] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Defects of the Achilles tendon region represent a challenge for reconstructive surgeons. Several options are available but there is still no reconstructive ladder for this specific and tricky area. An up-to-date reconstructive ladder according to local and general conditions is proposed based on our multicentre experience and an extensive review of the English literature on PubMed. MATERIALS AND METHODS An extensive review of the English literature was performed on PubMed using the following key-words: "Achilles region", "heel", "soft-tissue reconstruction", "flaps", "grafts" and "dermal substitutes". RESULTS A total of 69 complete papers were selected, covering the last thirty years' literature. Although most of the studies were based on limited case-series, local and general conditions were always reported. A comprehensive reconstructive ladder of all the available reconstructive techniques for the Achilles region has been created based on our personal multicentre experience and the results of the literature review. CONCLUSIONS The reconstructive ladder is a concept that is still a mainstay in plastic surgery and guides decisions in the repair strategy for soft tissue defects. The optimal solution, according to the experience of the surgeon and the wishes of the patient, is the one that implies less sacrifice of the donor site. Perforator flaps should be the first-line option for small-to-moderate defects; the distally-based sural flap is the most reported for moderate-to-large defects of the Achilles region, and free flaps should be reserved mainly for complex and wide reconstructions.
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Affiliation(s)
- A Marchesi
- Department of Plastic and Reconstructive Surgery, I.R.C.C.S. Policlinico San Donato, Università degli Studi di Milano, San Donato Milanese, Via Morandi, 30 - 20097, Milan, Italy.
| | - P C Parodi
- Department of Plastic and Reconstructive Surgery, University of Udine, Udine, Italy
| | - M Brioschi
- Department of Plastic and Reconstructive Surgery, I.R.C.C.S. Policlinico San Donato. Università degli Studi di Milano, San Donato Milanese, Milan, Italy
| | - M Riccio
- Department of Reconstructive Plastic Surgery-Hand Surgery, AOU "Ospedali Riuniti", Ancona, Italy
| | - R E Perrotta
- Department of Medical and Surgery Specialties, Section of Plastic Surgery, University of Catania, Catania, Italy
| | - M Colombo
- Orthopaedic Reparative Surgery Department, Orthopaedic Institute Gaetano Pini, University of Milan, Italy
| | - G M Calori
- Orthopaedic Reparative Surgery Department, Orthopaedic Institute Gaetano Pini, University of Milan, Italy
| | - L Vaienti
- Department of Plastic and Reconstructive Surgery. I.R.C.C.S. Policlinico San Donato, Università degli Studi di Milano, San Donato Milanese, Milan, Italy
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Chang EI, Nguyen AT, Hughes JK, Moeller J, Zhang H, Crosby MA, Skoracki RJ, Chang DW, Lewis VO, Hanasono MM. Optimization of Free-Flap Limb Salvage and Maximizing Function and Quality of Life Following Oncologic Resection: 12-Year Experience. Ann Surg Oncol 2015; 23:1036-43. [DOI: 10.1245/s10434-015-4905-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Indexed: 11/18/2022]
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Cho EH, Garcia RM, Pien I, Kuchibhatla M, Levinson H, Erdmann D, Levin LS, Hollenbeck ST. Vascular considerations in foot and ankle free tissue transfer: Analysis of 231 free flaps. Microsurgery 2015; 36:276-83. [PMID: 25808692 DOI: 10.1002/micr.22406] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Revised: 01/15/2015] [Accepted: 02/27/2015] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Eugenia H Cho
- Division of Plastic and Reconstructive Surgery, Duke University Health System, Durham, NC
| | - Ryan M Garcia
- Division of Plastic and Reconstructive Surgery, Duke University Health System, Durham, NC
| | - Irene Pien
- Division of Plastic and Reconstructive Surgery, Duke University Health System, Durham, NC
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University Health System, Durham, NC
| | - Howard Levinson
- Division of Plastic and Reconstructive Surgery, Duke University Health System, Durham, NC
| | - Detlev Erdmann
- Division of Plastic and Reconstructive Surgery, Duke University Health System, Durham, NC
| | - L Scott Levin
- Department of Orthopaedics, Hospital of the University of Pennsylvania, Philadelphia, PA
| | - Scott T Hollenbeck
- Division of Plastic and Reconstructive Surgery, Duke University Health System, Durham, NC
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Jordan DJ, Malahias M, Hindocha S, Juma A. Flap decisions and options in soft tissue coverage of the lower limb. Open Orthop J 2014; 8:423-32. [PMID: 25408784 PMCID: PMC4235066 DOI: 10.2174/1874325001408010423] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2014] [Revised: 05/03/2014] [Accepted: 05/27/2014] [Indexed: 12/18/2022] Open
Abstract
THE LOWER EXTREMITIES OF THE HUMAN BODY ARE MORE COMMONLY KNOWN AS THE HUMAN LEGS, INCORPORATING: the foot, the lower or anatomical leg, the thigh and the hip or gluteal region. The human lower limb plays a simpler role than that of the upper limb. Whereas the arm allows interaction of the surrounding environment, the legs' primary goals are support and to allow upright ambulation. Essentially, this means that reconstruction of the leg is less complex than that required in restoring functionality of the upper limb. In terms of reconstruction, the primary goals are based on the preservation of life and limb, and the restoration of form and function. This paper aims to review current and past thoughts on reconstruction of the lower limb, discussing in particular the options in terms of soft tissue coverage. This paper does not aim to review the emergency management of open fractures, or the therapy alternatives to chronic wounds or malignancies of the lower limb, but purely assess the requirements that should be reviewed on reconstructing a defect of the lower limb. A summary of flap options are considered, with literature support, in regard to donor and recipient region, particularly as flap coverage is regarded as the cornerstone of soft tissue coverage of the lower limb.
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Affiliation(s)
- Daniel J Jordan
- Department of Plastic Surgery, Whiston Hospital, Liverpool, UK L35 5DR, UK
| | - Marco Malahias
- Department of Plastic Surgery, Heart of England NHS Foundation Trust, UK
| | - Sandip Hindocha
- Department of Plastic Surgery, Whiston Hospital, Liverpool, UK L35 5DR, UK
| | - Ali Juma
- Department of Plastic Surgery, Countess of Chester Hospital, Chester, UK
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Abstract
The mangled foot and ankle can be defined as a severe injury to multiple organ systems of this appendage that can include bone, muscle, tendon, and neurovascular structures. The magnitude and often rate-limiting parameter most likely to affect the decision to attempt foot salvage is the degree of soft tissue destruction. If irreplaceable or if function cannot be restored, amputation should be considered. If reconstruction is attempted, all nonviable tissues regardless of intrinsic function must first be removed by meticulous débridement.
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Affiliation(s)
- Geoffrey G Hallock
- Division of Plastic Surgery, Sacred Heart Hospital and Lehigh Valley Hospital, 1230 South Cedar Crest Boulevard, Suite 306, Allentown, PA 18103, USA; St. Luke's Hospital, Bethlehem, PA, USA.
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An effective method to access recipient vessels outside the zone of injury in free flap reconstruction of the lower extremity. Ann Plast Surg 2014; 73 Suppl 2:S136-8. [PMID: 25046668 DOI: 10.1097/sap.0000000000000202] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION A principle of microvascular surgery in lower extremity reconstruction is to identify recipient vessels and perform the anastomosis outside the zone of injury. Microsurgeons will often create an incision that extends from the wound several centimeters proximally to access the recipient vessels through healthy tissue. This iatrogenic wound, however, traverses the zone of injury and is susceptible to delayed healing and wound breakdown. These complications can be avoided by creating a unique incision proximal to the zone of injury through which the recipient vessels are dissected and the anastomosis performed. METHODS In 13 consecutive patients with lower extremity wounds requiring free flap reconstruction, a remote incision was made in healthy tissue proximal to the defect to access the recipient vessels outside the zone of injury. The pedicle was tunneled in the subcutaneous plane from the wound to this site, and the anastomosis was performed. The flap was inset in the standard fashion, and the remote incision was closed in layers. RESULTS There were 3 female and 10 male patients, and the median age was 65 years (18-85 years). Etiology of the wounds was traumatic (3 acute, 7 chronic), oncologic (2), and ischemic (1). Defects varied in size and were primarily located on the distal third of the extremity. Free flaps included radial forearm (4), anterolateral thigh (4), gracilis (2), vastus (1), latissimus dorsi (1), and parascapular (1). Postoperatively, there were no major complications related to the flap or any flap losses. There was 1 donor site hematoma requiring operative evacuation. There were no complications associated with the anastomotic incision. CONCLUSIONS Accessing the recipient vessels via a separate proximal incision in lower extremity free flap reconstruction allows excellent exposure outside the zone of injury, avoids wound healing problems, and protects the pedicle from injury in the setting of multiple-staged procedures.
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