Repair of a large soft tissue defect in the leg with cross-leg bridge free transfer of a latissimus dorsi myocutaneous flap: a case report

A 48-year-old man sustained a traffic accident injury to his left leg. It was an open fracture of the left tibia and fibula accompanied by a large soft tissue defect (27 cm×7 cm). Doppler examination revealed the posterior tibial artery was occluded due to thrombosis. Three weeks after injury, the latissimus dors myocutaneous flap was elevated with a T-shaped vascular pedicle and was interposed between the two vascular ends of the posterior tibial vessel of the contralateral leg. Two end to end anastomoses were performed between the two vascular ends of the posterior tibial vessel of the contralateral leg and the latissimus dors myocutaneous flap’s T-shaped vascular pedicle. The latissimus dorsi myocutaneous flap was used for repair of a large soft tissue defect of the left leg. The vascular pedicle was cut off after 28 days and the flap survived completely. After 3-years’ follow-up postoperatively, a good contour was confirmed at the recipient area. The right tibia and fibula fractures were confirmed healing radiologically. The posterior tibial artery of contralateral leg was demonstrated patent by clinical and Doppler examinations.     

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 ...     

Salvage of a through-knee amputation level using a free fillet of sole flap

A young adult male sustained a compound crural fracture with a 15 cm defect of tibia and fibula, and an extensive soft-tissue loss of the lower leg and knee joint. A free fillet of sole flap was raised on the amputated foot and transferred to the soft-tissue defect around the femoral condyles in order to prevent an above-knee amputation. Intact vascularisation and sensation of the flap were secured by microsurgical anastomoses of the popliteal and posterior tibial vessels and the sciatic and tibial nerves. The patient was rehabilitated rapidly with a prosthesis. At the 12-month follow-up, he demonstrated excellent ?foot”? sensibility, stable soft-tissue coverage of the stump, and an optimal functional result. © 1993 Wiley-Liss Inc.     

Free vascularized osteocutaneous flap from scapula to the tibia

Summary Microvascular transfer of a free vascularized osteocutaneous flap from the scapula to the tibia is presented. The patient had a 10 cm tibial bone defect and also required overlying soft tissue reconstruction. A scapular osteocutaneous flap was successfully transferred to the proximal tibial defect. No complications were seen during an 18 month follow-up. Although the contralateral fibula is a popular choice for tibial reconstruction, if it is not available, the free vascularized scapular osteocutaneous flap may be an alternative choice of treatment.     

Reconstruction of an extensive tibial soft-tissue defect with multiple local muscle flaps for limb salvage when free-tissue transfer was not an option

The use of microvascular free-tissue transfer for stable soft-tissue coverage has all but replaced the use of local muscle flaps to provide for reliable soft-tissue coverage of an extensive tibial wound. However, free-tissue transfer may not be an option of choice for patients with an extensive tibial defect for various reasons. We present two cases of extensive tibial soft-tissue defect that were managed successfully by multiple local muscle flaps with skin grafts. Both patients had complete healing of their wounds with only minimal complications. These cases demonstrate that an extensive tibial soft-tissue defect can be reconstructed with innovative use of multiple local muscle flaps. This approach is a good alternative to free-tissue transfer for limb salvage, and should be offered to patients with an extensive tibial wound when free-tissue transfer is not an option.     

游离腓骨骨皮瓣加单臂外固定架治疗胫骨骨缺损

目的 探讨游离腓骨骨皮瓣治疗胫骨骨缺损的方法和临床疗效.方法 采用吻合血管的游腓骨骨皮瓣移植加单臂外固定架治疗12例因创伤、慢性骨髓炎导致的胫骨骨缺损患者.结果 患者腓骨骨皮瓣携带皮岛血运均良好,切口均一期愈合.12例均获随访,时间12~48个月.全部骨性愈合,患者恢复行走功能.结论 吻合血管的游离腓骨骨皮瓣移植加单臂外固定架治疗胫骨骨缺损临床疗效满意.     

开放性胫腓骨骨折合并胫骨骨缺损的手术治疗

目的探讨开放性胫腓骨骨折伴有大段骨缺损的手术治疗方法。方法自2003—09-2012—04对51例开放性胫腓骨骨折伴骨缺损者根据骨缺损长度进行分组,其中24例一期行外固定架结合腓骨钢板固定骨折端,二期骨缺损处行髂骨植骨;27例一期行Ihzamv骨搬移技术治疗胫骨大段骨缺损。结果骨缺损均得以重建,患者肢体长度完全恢复,患者肢体长度与健侧之差均〈2cm,无一例出现畸形,皮肤软组织得到修复。结论外固定架结合钢板固定是治疗合并胫骨骨缺损的开放性胫腓骨骨折的有效方法,骨缺损6em以内患者肢体功能及长度得以重建。IHzamv骨搬移技术也是治疗胫骨大段骨缺损合并软组织缺损的有效方法,尤其适用于骨缺损长度大于6cm的患者。     

The use of massive allograft with intramedullary fibular graft for intercalary reconstruction after resection of tibial malignancy

Reconstruction after intercalary excision of tibia malignancy is challenging. The combined use of a vascularized fibular flap and allograft can provide a reliable reconstructive option. Eight patients underwent reconstruction with an allograft and vascularized fibula following tibia malignancy resection. Patients were examined clinically and radiographically. The average age of patients was 16.5 years. The mean follow-up time was 38.4 months. Contralateral free fibula flap was used in three patients and ipsilateral pedicle fibula in five. The average length of defect was 11.8 cm and of fibula flap was 15.9 cm. Primary union was achieved in seven patients. The average time for bone union was 5.8 months at fibula-tibia junction and 14.1 months at allograft-tibia junction. Five patients had 10 complications. The Musculoskeletal Tumor Society average score was 90.8% at final follow-up. Intramedullary fibular flap in combination with massive allografts provide an excellent option for reconstruction of large bony defects after tibial malignancy extirpation. Ipsilateral pedicle fibula transportation had the advantages of short operation time and avoidance of donor site complications compared with the contralateral free fibula transfer.     

Double vascularized fibula growth plate transfer for the reconstruction of long segmental tibia in pediatric patients: Report of three cases

Osteosarcoma is a common bone tumor for pediatric patients that has a complex treatment including chemotherapy and radical surgical resection. There are few functional leg reconstruction possibilities described in the literature for pediatric patients due to limited growth potential. The aim of this report is to show long-term results using double vascularized growth plate flaps for the long segmental tibial reconstruction in growing children with satisfactory functionality and preserved limb growth without the use of permanent foreign materials. Three patients with sarcoma in the proximal part of the tibial bone were treated with complex therapy that included preoperative chemotherapy, radical resection of proximal metaepiphysis with tibial growth plate and half of the diaphysis and transplantation of double fibula growth plate flaps—the pedicled ipsilateral and the contralateral as a microvascular flap. The first patient, a male, 13 year with periosteal sarcoma, underwent 17 cm tibial resection with transplantation of the ipsilateral fibula 20 cm and contralateral fibula 20.1 cm, and continued follow-up for 6 years. The second patient, a male, 6 years of age with osteosarcoma, had 14 cm tibial resection with 16 cm ipsilateral and 16.1 cm contralateral fibular transplantation, continued follow-up for 5 years. The third patient, a female, 12 years of age with osteosarcoma, underwent 14 cm tibial resection with 15.4 cm ipsilateral and 15.9 cm contralateral fibular transplantation, and current follow-up of 1 year. Double fibular growth plate transfer is limb-sparing method for a proximal tibial reconstruction with natural growth potential for the pediatric patients.     

Fibula fracture stabilization with a guide wire as supplementary fixation in tibia fractures

The tibia is the most commonly fractured long bone. Although the goals of fracture management are straightforward, methods for achieving anatomical alignment and stable fixation are limited. Type of management depends on fracture pattern, local soft-tissue involvement, and systemic patient factors. Tibial shaft fractures with concomitant fibula fractures, particularly those at the same level, may be difficult to manage because of their inherent instability. Typically, management of lower extremity fractures is focused on the tibia fixation, and the associated fibula fracture is managed without fixation. In this article, we describe a novel technique for intramedullary fixation of the fibula, using a humeral guide wire as an adjunct to tibia fixation in the setting of tibial shaft fracture. This technique aids in determining length, alignment, and rotation of the tibia fracture and may help support the lower extremity as whole by stabilizing the lateral column. In addition, this technique can be used to help maintain reduction of the fibula when there is concern about the soft tissues of the lower extremity secondary to swelling or injury. Our clinical case series demonstrates the safety, effectiveness, and cost-sensitivity of this technique in managing select concurrent fractures of the tibia and fibula.     

Rekonstruktion oss?rer Defekte

In the armamentarium of microvascular bone transfers the free fibula has became a standard procedure in reconstructive surgery during recent decades. Because this bone graft can be harvested as a combined osteocutaneous or osteomyocutaneous flap, it has proven to be especially useful for reconstruction of combined bone and soft-tissue defects. Due to its long cylindrical shape, mechanical strength and potential to hypertrophy the microvascular fibula transfer is considered the most suitable autograft for the reconstruction of tibial, femoral or humeral defects. In this article different indications and surgical techniques of microvascular fibula bone grafts are discussed.     

Flow‐through fibula flap using soleus branch as distal runoff: A case report

The flow‐through fibula flap utilizing the soleus branch as a distal runoff has not yet been reported. We herein present a patient with left tibial adamantimoma in whom wide resection of the tumor resulted in a segmental tibial defect 22 cm in length. The defect was successfully reconstructed with a flow‐through free fibula osteocutaneous flap using the soleus branch of the peroneal artery as a distal runoff. The short T‐segment of the peroneal artery was interposed to the transected posterior tibial artery. The soleus branch has a constant anatomy and a larger diameter than the distal stump of the peroneal artery. Short interposed flow‐through anastomosis to the major vessels is much easier and more reliable than the conventional methods. We believe that our method represents a versatile option for vascularized fibula bone grafting for extremity reconstruction. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013     

Arthrodesis for ankle osteoarthritis after harvesting of free vascularized fibular bone: a case report

Introduction Although free vascularized fibular bone grafting is a good method for the reconstruction of large bone defects, it might cause morbidity of the donor leg. Progression of ankle osteoarthritis, valgus deformity and instability of the donor leg subsequently leading to arthrodesis has rarely been reported. Materials and methods A 53-year-old man suffered from a left tibial comminuted and Gustilo type IIIb open fracture. A folded free vascularized osteoseptocutaneous flap was harvested from the right fibula and transferred to the left tibial bone defect. After the reconstructive surgery, the patient obtained a solid union of the left tibial shaft uneventfully. Ten years later, he suffered intermittent pain on his right ankle. Plain radiographs revealed progressive tibiotalar osteoarthritis. Right ankle arthrodesis with crossed cannulated screws fixation and osteosynthesis of the fibula to the tibia and talus were performed. However, this procedure failed due to a deep infection and osteomyelitis. A revision of the failed ankle fusion was performed by using a vascularized iliac bone flap to strut the anterolateral aspect of the tibiotalar bone defect. A ventral plate fixation and supplementary onlay bone grafting were applied across the anterior aspect of the tibiotalar joint. At the 2-year follow-up, the patient had no pain and resumed his regular daily activities. Conclusions Harvesting of the fibula may cause longterm ankle osteoarthritis that requires ankle arthrodesis. In revision arthrodesis a ventral plate fixation and vascularized iliac bone flap may be the treatment of choice, neutralizing the large moment due to the long lever arms.     

Free vascularized osteocutaneous fibular graft to the tibia in 51 consecutive cases

The authors reviewed retrospectively the clinical results of 51 consecutive cases of vascularized osteocutaneous fibular graft to the tibia for the reconstruction of extensive tibial bone and soft-tissue defects. The mean duration of follow-up was 31 months (range: 13 to 76 months). In the 51 procedures of free vascularized osteocutaneous fibula graft from the contralateral side, bony union was achieved in 48 cases at an average of 3.74 months after the operation, except for two cases of non-union and two cases of delayed union. Forty-eight cutaneous flaps survived, and three cutaneous flaps failed due to deep infection and venous thrombosis. All united fibulae hypertrophied during the follow-up periods. Stress fracture of the grafted fibula was the most common complication (16 cases), and it was treated with above-the-knee cast immobilization or internal fixation with a conventional cancellous bone graft. The free vascularized osteocutaneous fibular graft is recommended as a useful treatment modality for the reconstruction of extensive tibial defects combined with soft tissue injury.     

小腿外侧腓骨皮瓣交腿修复合并血管损伤的大段胫骨骨感染及缺损

 目的 探讨小腿外侧腓骨皮瓣交腿修复合并血管损伤、大面积皮肤软组织缺损的大段胫骨骨感染及缺损的疗效。方法 回顾性分析2004 年9 月至2008 年9月治疗8 例合并血管损伤的大段胫骨骨感染及缺损患者资料, 男6 例, 女2 例;年龄19~55 岁, 平均36 岁;病史2 周至3 个月, 平均2 个月;胫骨缺损长度8~20 cm, 平均13 cm;皮肤缺损面积10 cm x 7 cm~22 cm x 12 cm。彻底清创, 根据皮肤软组织缺损面积及胫骨缺损长度在健侧小腿设计外侧腓骨皮瓣的切取范围、腓骨切取长度、切取位置。切取皮瓣及腓骨, 将双下肢交叉于蒂部松弛位置, 外固定支架固定, 腓骨修复胫骨骨缺损, 外固定支架一期重建胫骨稳定性, 皮瓣覆盖创面修复皮肤软组织缺损。术后4~6 周, 二次手术断蒂。结果 8 例患者全部获得随访, 随访时间6~36 个月, 平均24 个月。术后8 例移植组织全部成活, 无一例发生感染及骨髓炎, 皮瓣均在术后2 周顺利愈合;骨折愈合时间6~15 个月, 平均11 个月;移植皮瓣外形良好;患者基本恢复负重行走功能。末次随访时, 根据Edwards 胫骨骨折评定标准, 优4 例, 良2 例, 差2 例。结论 小腿外侧腓骨皮瓣交腿修复合并血管损伤、大面积皮肤软组织缺损的大段胫骨骨感染及缺损具有手术操作相对简单、成功率高、疗效好等优点, 可恢复患者下肢行走功能。     

Acute management of severe soft-tissue damage accompanying open fractures of the lower extremity

Open fractures of the lower extremity accompanied by extensive soft-tissue damage can be effectively managed by a collaborative approach between orthopedic and plastic surgeons. The fundamental concepts of this aggressive, systematic approach are adequate debridement and soft-tissue healing by delayed primary intention. The protocol that has evolved at the MIEMSS Shock Trauma Unit involves emergency radical debridement of all devitalized soft tissue and bone fragments together with external stabilization of the fractured extremity. The zone of injury, which is often not apparent at presentation, is determined by serial debridements performed in the operating room over several days. When the wound is defined, soft-tissue closure is obtained with local or free muscle transfer. In very high energy-induced trauma, local muscle flaps are often involved in the zone of injury or are inadequate to cover the resultant defects. Free muscle transfers that provide large amounts of undamaged, well-vascularized tissue are therefore the reconstructive alternative of choice for such injuries. Bone defects are bridged 4 to 6 weeks after soft-tissue closure with cancellous or vascularized fibula grafts depending on defect size. This regimen, which has virtually eliminated the problem of infection, has been successful in salvaging and rehabilitating these severely injured lower extremities.     

Reconstruction of large diaphyseal defects, without free fibular transfer, in Grade-IIIB tibial fractures

Eight Grade-IIIB tibial fractures that were associated with large soft-tissue and segmental diaphyseal defects, averaging ten centimeters in length, were successfully reconstructed without the use of a free fibular transfer. A free tissue flap was the preferred form of soft-tissue coverage. The osseous reconstruction was accomplished by using a massive amount of autogenous cancellous bone graft. Beads that were made from polymethylmethacrylate and impregnated with two antibiotics at the time of operation were used as soft-tissue spacers to preserve the volume of the diaphyseal defect for later receipt of the cancellous bone graft. The beads prevented the soft-tissue flap from collapsing into and adhering to the site of the tibial defect. The beads also served as vehicles for local delivery of the antibiotics that they contained. When the soft-tissue flap had healed, the beads were replaced with cancellous graft. All of the tibiae healed. The time to healing averaged nine months. The average duration of external fixation was 5.5 months. One deep infection developed, but resolved after debridement and antibiotic therapy. This conservative technique is safe and reliable for patients who have sustained a high-energy tibial fracture and a large segmental diaphyseal defect.     

Free fibula transfer in the treatment of difficult distal tibia fractures

Management of the high-grade open distal tibia fracture remains problematic. The authors reviewed the charts of 14 cases of distal tibia and tibial plafond fractures reconstructed with a free fibula transfer. Six cases involved a plafond defect, and the fibula was used to arthrodese the tibio-talar joint. Seven cases included a skin paddle. Three of the four patients with osteomyelitis cleared their infection. Twelve patients went on to osseous union, and two were ultimately treated with amputation. Patients who went on to union had an average of 1.1 subsequent procedures, began full weightbearing in an average of 5.8 months, and were weightbearing without any assistive devices by an average of 8.5 months. There was no significant correlation between the time to full weightbearing and either the presence of infection or the length of the original defect. In this series, 86 percent success was obtained when a free fibula transfer was used either to bridge a tibial non-union or to promote arthrodesis of the tibio-talar joint.     

Use of latissimus dorsi flap pedicle as a T-junction to facilitate simultaneous free fibular flap inset in lower extremity salvage

Marjolin's ulcer is a very aggressive form of squamous cell carcinoma arising from chronic wounds or unstable scars. A resection margin of at least 2 cm with clear deep margin is required on removal. A 79-year-old male presented with chronic osteomyelitis of the left anterior tibial region with chronic ulceration. Biopsy revealed squamous cell carcinoma. The tumour, measuring 8 cm, was resected with surrounding unstable scar tissue including en bloc resection of the involved tibial bone, leaving the posterior cortex. Reconstruction was done with a fibular free flap from the contralateral side, but the pedicle length was too short to reach the anterior tibial vessels. To bridge the vascular gap, and to cover the soft-tissue defect, a latissimus dorsi free flap was harvested using the muscle-sparing method. The thoracodorsal vessels were used as an interpositional graft to anastomose the peroneal vessels of the fibular flap. The patient was ambulatory by 4 months, and complete bone union was seen after 6 months. During the 18-month follow-up period, there was no evidence of recurrence.     

A simple treatment for a 15-cm tibia bone defect: a case report of an ipsilateral vascularized fibula transfer

Segmental defects of the tibia present a challenging problem. This report demonstrates the use of an ipsilateral vascularized fibula transfer (IVFT) in a patient with a 15 cm tibial bone defect following tumor resection. Bone union was achieved within 6 months, and 8 years after the surgery the patient has full knee flexion and extension and is still employed in the same vocation as he was prior to surgery. With current interest in reconstructive techniques such as vascularized fibular grafts, segmental allografts, and bone transportation, the technique of ipsilateral vascularized fibula transfer has become neglected. The purpose of this case report is to highlight its use and draw attention to its advantages and disadvantages.