Repair of a soft tissue defect of medial malleolus with cross-leg bridge free transfer of anterolateral thigh muscle flap: a case report

A 38-year-old man sustained a traffic accident injury to his right medial malleolus and leg.It was an open fracture of the right tibia and fibula accompanied by a large soft tissue defect of the right ...     

前锯肌肌肉筋膜瓣桥式移植修复小腿软组织缺损

目的 总结游离前锯肌肌肉筋膜瓣桥式移植修复小腿软组织缺损的临床应用经验.方法 2006年9月至2009年1月应用游离前锯肌肌肉筋膜瓣桥式移植修复7例小腿软组织缺损.肌肉筋膜瓣切取连带肩胛下与旋肩胛血管,血管蒂呈T形,与健侧小腿胫后动脉两断端行端端吻合,肌肉筋膜瓣及其血管蒂用中厚皮片网状移植覆盖.结果 7例肌肉筋膜瓣全部成活.术后经过顺利,取得了较满意的效果.随访9～42个月,供区无明显功能障碍,且供、受区外形均较好.健侧小腿经临床观察与多普勒超声血流探测仪检查,胫后动脉通畅.结论 该术式适宜修复小腿软组织缺损仅有1条主要动脉者,不损伤健侧小腿胫后动脉,且对供区的损伤也较轻.

Abstract：

Objective To investigate the application of free anterior serratus musculo-fascial flap in bridge style for the soft tissue defect at leg.Methods From Sept.2006 to Jan.2009,the free anterior serratus musculo-fascial flaps were used in bridge style in 7 cases with soft tissue defects at legs.The anterior serratus musculo-fascial flaps were elevated with subscapular and circumflex scapular vessels forming a T-shaped vascular pedicles.The T-shaped pedicle was end-to-end anastomosed with the two ends of the posterior tibial artery at the healthy leg.The musculo-fascial flap and its pedicle were covered with skin graft.Results All the 7 flaps survived completely with satisfactory result.The patients were followed up for 9-42 months with good functional and esthetic result both in donor site and recipient site.The patency of posterior tibial artery was demonstrated by clinical and Doppler examination.Conclusions This technique is particularly useful in leg reconstructive surgery when only one vessel remains.The patency of the posterior tibial artery at the healthy leg is preserved and the morbidity in donor site is minimal.     

桥式交叉"T"形血管吻合游离背阔肌皮瓣移植修复小腿软组织缺损

目的 介绍改进桥式交叉游离皮瓣移植的手术方法并总结分析.方法 2003年9月至2007年5月,应用桥式交叉"T"形血管吻合游离背阔肌皮瓣移植方法修复小腿软组织缺损患者6例.男5例,女1例;年龄21～48岁(平均32岁).软组织缺损范围20 cm×9 cm～32 cm×11 cm.皮瓣血管蒂切取时携带肩胛下与旋肩胛血管,使蒂呈"T"形,将其与健侧小腿胫后动脉两断端行端端吻合,血管蒂行中厚网状游离植皮包裹,未用皮管,小腿供区切口直接缝合.结果 1例术后皮瓣远端发生小的表浅感染,换药2周后愈合,皮瓣全部成活,术后经过顺利,获得较满意的效果.随访6个月～4年(平均2.7年),未发现明显的供区功能障碍.供区与皮瓣外形较好,供区小腿经临床观察与多普勒检查证实胫后动脉通畅.结论 利用"T"形血管与胫后血管吻合,降低对侧小腿供区的损伤,只要血管吻合质量好,对皮瓣血供无影响.这种技术特别适用于小腿软组织缺损须行血管吻合的皮瓣修复、但肢体仅有一根主要血管的病例.     

游离胸背动脉穿支皮瓣桥式移植修复小腿软组织缺损

目的总结游离胸背动脉穿支皮瓣或肌瓣桥式移植修复小腿软组织缺损的临床应用效果。方法自2006年9月至2009年1月,应用游离胸背动脉穿支皮瓣或肌瓣桥式移植修复小腿软组织缺损11例,缺损范围4cm×8cm至8cm×22cm。皮瓣切取连带肩胛下与旋肩胛血管,血管蒂呈T形,与健侧小腿胫后动脉行端端吻合,血管蒂用中厚网状游离植皮覆盖。结果除1例术后皮瓣远端发生小的表浅感染,经换药后愈合外,本组皮瓣全部成活。术后随访9个月至3.6年(平均2.9年),没有发现明显的供区功能障碍,供区与受区外形较好,健侧小腿经临床观察与Doppler检查,胫后动脉通畅。结论本方法适用于修复四肢软组织缺损后,患者仅存1条主要动脉者;行桥式游离胸背动脉穿支皮瓣或肌瓣移植不损伤健侧小腿胫后动脉,降低了对供区的损伤。     

Reconstruction of a tibial defect with microvascular transfer of a previously fractured fibula

A 43-year-old man sustained severe injuries to his lower limbs with extensive soft-tissue damage and bilateral tibial-fibular fractures. Acutely, the patient underwent external fixation and a free latissimus dorsi flap for soft-tissue coverage of the left leg. However, the tibia had a nonviable butterfly fragment that left a 7-cm defect after debridement. Subsequently, the contralateral fractured fibula was used as a bridging vascularized graft for this tibial defect. The transfer of a fibula containing the zone of injury from a previous high-energy fracture has not been reported. This case demonstrates the successful microvascular transfer of a previously fractured fibula for the repair of a contralateral tibial bony defect.     

Reconstruction of a severely crushed leg with interpositional vessel grafts and latissimus dorsi flap

We present a case of a near total amputation at the distal tibial level, in which the patient emphatically wanted to save the leg. The anterior and posterior tibial nerves were intact, indicating a high possibility of sensory recovery after revascularization. The patient had open fractures at the tibia and fibula, but no bone shortening was performed. The posterior tibial vessels were reconstructed with an interposition saphenous vein graft from the contralateral side and a usable anterior tibial artery graft from the undamaged ipsilateral distal portions. The skin and soft tissue defects were covered using a subatmospheric pressure system for demarcating the wound, and a latissimus dorsi myocutaneous free flap for definite coverage of the wound. At 6 months after surgery, the patient was ambulatory without requiring additional procedures. Replantation without bone shortening, with use of vessel grafts and temporary coverage of the wound with subatmospheric pressure dressings before definite coverage, can shorten recovery time.     

Cross-leg latissimus dorsi free flap with chimeric serratus anterior bridge for lower extremity trauma: Case report and reconstructive algorithm

Gustilo Grade IIIB and IIIC open fractures of the lower extremity often involve complex wounds requiring bony fixation and soft tissue reconstruction. We present a case of a 32 year-old male who suffered a traumatic Gustilo Grade IIIB open fracture of the tibia and fibula with an extensive soft tissue defect. Reconstruction was first attempted with a turbocharged anterolateral thigh flap that failed due to venous thrombosis. Due to vascular injury, limited reconstructive options were available from the ipsilateral leg. Limb salvage was subsequently achieved with a chimeric cross-leg latissimus dorsi-serratus anterior (LD-SA) free flap based off the contralateral healthy leg, using the serratus for pedicle bridge coverage so that the latissimus could be fully used for defect coverage. Though not extensively described in the literature, this flap is a versatile reconstructive option for limb salvage in patients with Gustilo IIIB or IIIC injuries to the lower extremity.     

Technique to re-establish continuity of the recipient artery after end-to-end anastomoses in cross-leg free flap procedure

In this report, a simple technique is described to restore the continuity of the recipient artery in cross-leg free flap procedure after end-to-end anastomoses. In the first stage, the latissimus dorsi flap was revascularized by end-to-end anastomosis between the posterior tibial artery of the noninjured leg and the thoracodorsal artery of the flap. After 4 weeks of neovascularization period, in the second stage when the pedicle was to be divided, the thoracodorsal artery was dissected until its bifurcation in the muscle, transected, and rerouted to the distal ligated end of the posterior tibial artery, accomplishing a simple end-to-end anastomosis between these two vessel ends. Thus, the continuity of the recipient artery was re-accomplished by replacing the normally discarded segment of the flap's arterial pedicle as an arterial graft, the patency of which was demonstrated clinically and by Doppler examination. The authors believe that this technique provides further benefit to the patient by accomplishing vascular flow through a major lower limb artery when the reconstructive pathway involves an end-to-end anastomosis in a cross-leg free flap procedure.     

交腿比目鱼肌瓣带蒂移植修复对侧小腿软组织缺损

目的:报告比目鱼肌瓣带蒂移植修复对侧小腿软组织缺损临床应用结果。方法:自2008年1月至2013年1月,应用比目鱼肌瓣移植修复对侧小腿软组织缺损8例,男7例,女1例;年龄20～49岁,平均31.8岁。损伤至手术时间:2～8周,平均46 d.肌瓣表面行Ⅰ期中厚网状游离植皮,供区直接缝合。结果:8例肌瓣全部成活,其中1例,受区创缘去除引流条后每天从引流孔有少量渗出液流出,经2周换药处理自然愈合。8例患者均获随访,时间1.5～4年 (平均2.5年).胫腓骨骨折全部愈合,受区外形较好。下肢功能按LEM标准评定,优2例,良5例,尚可1例。结论:比目鱼肌瓣带蒂移植很适宜伤肢仅有1条主要血管伴有软组织缺损的修复,可以减轻对供区的损伤。     

小腿内侧脂肪筋膜瓣桥式带蒂移植修复对侧小腿软组织缺损简

目的报告小腿内侧脂肪筋膜瓣桥式带蒂移植修复对侧小腿软组织缺损临床应用结果。方法自2009年1月至2012年6月,应用小腿内侧脂肪筋膜瓣桥式带蒂移植修复对侧小腿软组织缺损7例（男5例,女2例）,年龄26～45岁,平均38岁。伤后时间：最短16d,最长36d,平均21d。筋膜瓣和血管蒂表面行一期中厚网状游离植皮,供区直接缝合。结果脂肪筋膜瓣全部成活。术后随访7个月-3．0年,平均2．6年。胫、腓骨骨折全部愈合,受区外形较好。结论这种技术很适宜修复伤肢仅有1条主要血管时伴有软组织缺损,减轻了对供区的损伤。     

健侧胫后血管皮瓣桥携带游离皮瓣临床应用

目的 探讨下肢大面积软组织缺损采用游离组织移植修复而受区载供血管可以供缝接时的解决办法,方法 在形态学观察及动脉压和血流量测定的实验基础上,设计以健侧胫后血管形成单一顺行皮瓣成桥及顺,逆行两皮瓣桥作为血管蒂而携带游离皮瓣移植修复。结果 采用健侧胫后血管形成顺行皮瓣桥携带游离皮瓣移植修复伤肢一处创面缺损８例,皮瓣全部成活,创面修复,采用健侧胫后血管形成顺－逆行两个皮瓣桥分别携带两个游离皮瓣同时修复伤     

Use of a cross-leg free muscle flap to reconstruct an extensive burn wound involving a lower extremity

A young patient sustained a high-voltage burn with extensive destruction of the soft tissue in his left lower extremity. Occlusion of the anterior and posterior tibial arteries, loss of toe extensors and the superficial and deep peroneal nerves were noted, besides the exposure of the lower end of the tibia and metatarsal bones. In the absence of proper recipient vessels, a cross-leg free latissimus dorsi muscle flap with overlying skin and depending on the vessels of the contralateral foot was used successfully for reconstruction of the defect. The pedicle was divided 3 weeks after microvascular anastomosis and the flap survived completely. This technique permits transfer of free flaps to compromised wounds without available recipient vessels, and the latissimus dorsi muscle flap, with its characteristics of large size and copious vascularity, could be split to cover exposed bones in different areas simultaneously.     

Lower‐limb reconstruction with chimeric flaps: The quad flap*

Early soft‐tissue coverage is critical for treating traumatic open lower‐extremity wounds. As free‐flap reconstruction evolves, injuries once thought to be nonreconstructable are being salvaged. Free‐tissue transfer is imperative when there is extensive dead space or exposure of vital structures such as bone, tendon, nerves, or blood vessels. We describe 2 cases of lower‐extremity crush injuries salvaged with the quad flap. This novel flap consists of parascapular, scapular, serratus, and latissimus dorsi free flaps in combination on one pedicle. This flap provides the large amount of soft‐tissue coverage necessary to cover substantial defects from skin degloving, tibia and fibula fractures, and soft‐tissue loss. In case 1, a 51‐year‐old woman was struck by an automobile and sustained bilateral tibia and fibula fractures, a crush degloving injury of the left leg, and a right forefoot traumatic amputation. She underwent reconstruction with a contralateral quad free flap. In case 2, a 53‐year‐old man sustained a right tibia plateau fracture with large soft‐tissue defects from a motorcycle accident. He had a crush degloving injury of the entire anterolateral compartment over the distal and lower third of the right leg. The large soft‐tissue defect was reconstructed with a contralateral quad flap. In both cases, the donor site was closed primarily and without early flap failures. There was one surgical complication, an abscess in case 2; the patient was taken back to the operating room for débridement of necrotic tissue. There have been no long‐term complications in either case. Both patients achieved adequate soft‐tissue coverage, avoided amputation, and had satisfactory aesthetic and functional outcomes. With appropriate surgical technique and patient selection, the quad‐flap technique is promising for reconstructing the lower extremity.     

腓肠神经营养血管逆行皮瓣修复小腿下段及足部组织缺损

目的 了解腓肠神经营养血管逆行皮瓣修复小腿下段及足部组织缺损的临床效果.方法 1997年6月-2007年8月,笔者对56例小腿下段及足部组织缺损患者(小腿下段软组织缺损10例;创面感染,胫、腓骨骨折外露,骨坏死38例;足部组织缺损、贴骨瘢痕、骨髓炎8例)的创面,采用腓动脉穿支供血的腓肠神经营养血管逆行岛状皮瓣(46例)或肌皮瓣(10例)进行修复.皮瓣面积5 cm ×4 cm～22 cm × 16 cm,供瓣区直接拉拢缝合或行游离植皮封闭.结果 其中55例患者术后皮瓣完全成活,创面愈合.随访3～6个月无任何并发症,皮瓣质地优良,外观满意,患者行走正常,但皮瓣感觉功能恢复欠佳.1例患者治疗时为保留下肢长度,未将部分坏死胫骨去除,术后1个月皮肤破溃,经再次手术后创面愈合.结论 腓肠神经营养血管逆行岛状皮瓣或肌皮瓣移植术,是修复小腿下段及足部软组织缺损的较佳方法.     

旋股外侧动脉横支为蒂的股前外侧皮瓣重建肘部复合组织缺损的临床应用

目的 探讨以旋股外侧动脉横支为蒂的股前外侧皮瓣,游离移植修复肘部肱动脉伴皮肤软组织缺损的临床疗效.方法 2000年3月-2008年2月,对8例肘部肱动脉损伤伴皮肤软组织缺损的患者,急诊一期采用旋股外侧动脉横支为蒂的股前外侧皮瓣游离移植修复,同时用横支血管桥接缺损的肱动脉(3～7cm),皮瓣切取面积为12cm×6cm～20cm×10 cm.结果 8例肢体及皮瓣均顺利存活,术后随访10～21个月,肘部皮瓣无明显臃肿及瘢痕挛缩现象,肘关节屈伸活动度平均为105°(95°～125°),8例患侧肢体前臂远端尺、桡动脉搏动强度与健侧相同,B超显示患侧肱动脉血流与健侧基本相同.结论 切取股前外侧皮瓣时,如发现旋股外侧动脉降支有变异,可切取以旋股外侧动脉横支为蒂的股前外侧皮瓣,重建肘部肱动脉损伤和软组织缺损.     

Cross-leg pedicled free scapular flap for neuropathic foot ulcer: case report

A case is reported of the treatment of a chronic neuropathic ulcer on the lateral aspect of the foot with osteomyelitis. Extensive debridement and free scapular flap transfer were performed. Because the leg had only one patent vessel, the anterior tibial artery, which was unsuitable for anastomosis, the vascular anastomosis of the flap was performed to the posterior tibial vessel of the contralateral leg, which was used as a termporary carrier. The vascular pedicle was divided after 3 weeks, and the flap survived completely. This case report extends the indications of the cross-leg free flap for complex defects on a single-vessel foot.     

逆行供血的胸脐皮瓣游离移植修复胫骨外露创面

目的观察逆行供血的吻合血管胸脐皮瓣修复胫骨外露创面的临床效果.方法对44侧小腿动脉铸型标本进行了观测的基础上,于1993年5月～2000年7月,对临床收治的25例小腿中上段大面积软组织缺损,胫骨外露,其中18例有胫前或胫后血管长段受损栓塞,创面最大为28 cm×11 cm,最小为11 cm×9 cm.采用小腿远端胫前或胫后血管远端与腹壁下血管吻合的胸脐皮瓣移植修复创面.结果胫前动脉、胫后动脉和腓动脉三组主干型血管,三者彼此间在足踝部交通吻合十分丰富,有很好的相互代偿能力.术后移植皮瓣全部成活,皮瓣色泽、质地良好,创面完全修复.结论只要小腿胫前或胫后主要血管之一正常,受损血管远端正常,逆行供血良好,即可采用吻合血管的胸脐皮瓣修复小腿中上段大面积软组织缺损.     

Bilobed monobloc transfer including parascapular and neurovascular latissimus dorsi muscle flap for functional lower leg repair following muscle group resection for synovial sarcoma

Summary A 34-year-old female presented with a recurrent synovial sarcoma of the heel region. This necessitated ablative surgery of the soft tissues of the flexor side of the distal lower leg including tibial nerve, and posterior tibial artery down to the crural interosseous membrane. A fasciocutaneous parascapular flap, together with an ipsilateral latissimus dorsi muscle flap, was harvested with a common pedicle. The vessels of the monobloc transfer served as segmental interposition to restore the arterial continuity: proximally, the subscapular artery and distally, the thoracodorsal artery were used to bridge the tibial artery defect. To achieve achilles tendon motor function, the latissimus dorsi muscle flap was reinnervated from the tibial nerve stump. This procedure permitted the conservation of the lower leg, in spite of the extensive resection to obtain tumorfree margins in three dimensions and a simultaneous functional repair in one stage. Following this, combined oncological therapy could be rapidly instituted.     

游离背阔肌肌皮瓣与腓骨移植修复皮肤和骨骼复合缺损

用背阔肌肌皮瓣与游离腓骨组合移植的方法一期修复合并软组织缺损的胫骨缺损12例,桡骨缺损2例。游离胖骨的血管蒂与背阔肌皮瓣的旋肩胛动静脉吻合,而肩胛下动静脉作为腓骨与肌皮瓣的共同血管蒂与受区供养血管吻合。13例用桥式交叉的方式吻合血管。移植组织均获成活。随访表明移植的肌皮瓣生长良好,移植腓骨与宿主骨牢固连接,肢体功能得到恢复。介绍手术指征与方法,并就修复的优点和桥式交叉吻合血管的可靠性进行了讨论。     

Fibula osteoseptocutaneous flap with a variant perforator and peroneal artery arising from the anterior tibial artery

Since the report of the first cases of vascularized free fibula graft for treatment of open fracture of the tibia and fibula in 1975, there have been many other reports of the use of vascularized free osteocutaneous fibula flaps for reconstruction of the mandible or lower leg. Usually, these flaps have a single pedicle composed of the peroneal artery, to supply the fibula with septocutaneous or musculocutaneous branches arising from the peroneal artery to supply the lateral skin of the leg. Although some authors have reported variant perforators, there have been no reports of the peroneal artery arising from the anterior tibial artery and perforator arising from the posterior tibial artery. This is the first report of a variant of the peroneal artery and perforator using a vascularized free osteocutaneous fibula flap.