Composite neuromusculo-fasciocutaneous triceps brachii free flap for complex foot reconstructive surgery

Since it was first described by Song in 1982, then by Katsaros in 1984, the lateral arm flap has become a workhorse technique for upper limb reconstruction. Herein we describe a clinical case of complex foot defect and bring up the possibility of using a composite neuromusculo-fasciocutaneous lateral arm/triceps free flap for its reconstruction. A 19-year-old male nonsmoker suffered ballistic trauma to his right foot with open multifragment Gustilo-IIIb fractures of the first to fifth metatarsal bones. Two weeks after debridement and V.A.C.™ therapy performed in another hospital, we decided to reconstruct the remaining defect with a neuromusculo-fasciocutaneous medial triceps/lateral arm free flap anastomosed with the anterior tibial pedicle. The posterior brachial cutaneous nerve was sutured to a sensory branch of the superficial fibular nerve. The advantages and drawbacks of this technique are discussed and other options for this type of complex foot reconstruction are reviewed. After 3 years' follow-up, the metatarsal bones were consolidated without residual defect or chronic infection. The foot had sensation with full mobility and no pain. At the donor site, there was no complaint of scarring. Elbow extension/flexion was 0-0-130. Wrist extension/flexion was 60-0-60 and there was no extension deficit of the metacarpophalangeal joints. The composite neuromusculo-fasciocutaneous triceps brachii free flap was an excellent option for this complex foot defect. The choice of this reconstructive procedure among other options was made during our reconstruction board meeting while taking the patient's specific condition and our own experiences into account.

[Functional reconstruction of the forearm by composite free flap of fibula and soleus reinnervated. About a clinical case]

SUBJECT

We present the case of a forearm functional reconstruction of composite fibula free flap. This is a complex forearm trauma by crushing in a 24-year-old patient. The assessment of the lesions showed a bone defect of 15cm radial and ulnar diaphysis, a muscular defect of the posterior compartment of the forearm and a large skin defect next. The radial pedicle was also injured.

METHODS

At 48hours, we conducted a reconstruction by free fibular flap and soleus muscle. The fibula osteosynthesys was performed between the proximal ulna and radius distally. The nerve of the soleus muscle was anastomosed to a branch of the posterior interosseous nerve and tendons of the extensor muscles of the wrist and fingers were sutured to the distal portion of the transferred muscle.

RESULTS

At 6 months, bone healing is achieved. Soleus muscle contracts and the strength of the extensor muscles of the fingers and wrist has been listed 4. Joint amplitudes of -20°/75° for the wrist, complete for the long fingers and the elbow. The aftermath of the donor site is minimal.

CONCLUSION

Reconstruction by free fibular flap and reinnervated soleus muscle is often cited in the literature but few cases are described. It is for us, the best therapeutic solution for this type of injury. It restores muscle function satisfactorily all ensuring high quality coverage defect of the forearm.