Fasciocutaneous flaps in reconstruction of the lower extremity

The fasciocutaneous flap, when correctly chosen, can supply an expedient solution for some of the challenging soft-tissue problems in the leg. The fasciocutaneous flap should be included in the list of reconstructive options for the lower extremity, particularly in the distal tibia. The improved knowledge of blood supply to the fasciocutaneous flaps allows the design of a safer, longer, more useful flap.     

应用穿支皮瓣治疗下肢远端慢性骨髓炎并皮肤缺损

目的 探讨游离或带蒂穿支皮瓣在治疗下肢远端慢性骨髓炎并皮肤缺损创面修复中的应用价值.方法 应用穿支皮瓣游离或带蒂移位修复胫前及足踝部慢性骨髓炎并皮肤缺损28例.游离移植13例:采用股前外侧穿支皮瓣修复胫前2例,踝前3例,足背2例,足跟2例;小腿外侧腓动脉穿支皮瓣修复足背4例.带蒂移位15例:胫后动脉穿支皮瓣修复胫前4例,修复内踝2例;腓动脉外踝后上穿支皮瓣修复足跟6例,外踝及足背各1例;第1跖背动脉穿支皮瓣修复近节(足母)趾背侧1例.抗生素液灌流伤口7例,万古霉素明胶海绵残腔填塞8例.结果 1例胫后动脉穿支皮瓣出现静脉回流不足,表浅坏死,自行愈合,其余皮瓣无坏死.随访6个月～2年,2例复发,分别经1次和2次手术后愈合,其余均一期愈合,皮瓣外形满意.3例行二期骨移植.最后一次随访时,患者可行走,患肢完全负重,按足部疾患治疗效果标准评定平均为84.5分.结论 游离或带蒂穿支皮瓣血供良好,可用于治疗残腔不大的慢性骨髓炎并皮肤缺损.     

Bipedicled fasciocutaneous flaps in the lower extremity.

It is well known that a bipedicled skin flap permits survival of longer flaps due to the secondary recruitment of vascularity. Inclusion of the deep fascia with such a flap, obeying the principles of the single-pedicled fasciocutaneous flap, provides even greater security for the immediate transposition of yet larger or riskier flaps without the need for delay maneuvers. This variation is especially valuable for the management of difficult wounds encountered in the lower extremity when no other local options may be available. Thirteen local bipedicled fasciocutaneous flaps including both vertical and horizontal orientations, without isolation of any discrete fascial perforators, have been successfully used for soft tissue coverage in the distal leg and ankle with only three (23%) minor complications as untoward sequelae. Another major advantage of this bipedicled version of the fasciocutaneous flap was that the inclusion of a distal pedicle simultaneously may be designed to prevent bone or tendon exposure at the donor site that otherwise frequently is a concern with a unipedicled flap.     

Fasciocutaneous flaps for lower extremity wounds

The use of fasciocutaneous flaps to cover soft tissue defects of the lower leg following trauma, is discussed in this article. Our experience with 15 cases is presented. There have been no complications. We feel that fasciocutaneous flaps are a safe and reliable method for the management of difficult wounds of the lower leg.     

Comparative evaluation in the treatment of chronic post-traumatic osteomyelitis of the lower leg: free flaps compared with local flaps

Forty-nine out of 101 patients treated for post-traumatic chronic osteomyelitis of the lower leg at the Innsbruck University Hospital for Plastic and Reconstructive Surgery in Austria between 1979 and 1996 were included in this retrospective study. The following parameters were covered in the statistic evaluation: postoperative complications, rates of flap survival, recurrence and revision, nosocomial infections, duration of hospitalisation, chronic oedema of the lower leg, and patient satisfaction. Postoperative complications, recurrence, and flap loss rates were significantly lower in the free-flap group. These low rates are most likely responsible for the significantly shorter hospitalisation of patients treated with free flaps. For these reasons, their use may be considered first-choice therapy in the treatment of chronic post-traumatic osteomyelitis of the lower leg.     

Free and pedicle flaps in lower extremity trauma

Improvements in microsurgical techniques and perioperative management have led to more attempts at limb salvage surgery after severe extremity trauma. Although some microsurgery-trained orthopedic surgeons will perform extremity soft tissue reconstruction, many rely on plastic surgeons or hand surgeons. However, the orthopedic trauma surgeon often remains the principle decision maker in the follow-up of these patients. Therefore, orthopedic surgeons should have a clear understanding of the planning and execution of flap reconstruction of the traumatized extremities. Collaboration with the microsurgery team will also improve planning of orthopedic procedures and facilitate a better understanding of the expected outcomes after tissue transfer. This becomes especially important when considering, debridement, early amputation versus extensive soft tissue reconstruction and when discussing these alternatives with patients and family as well as postoperative course. The goals of this article are to provide orthopedic trauma surgeons with an understanding of the selection, planning, and execution of tissue transfers for posttraumatic extremity reconstruction and to review their successes and outcomes in the literature. Communication between teams involved in reconstruction of the traumatized extremity and an understanding of limitations are paramount to successful outcomes after reconstruction.Level of Evidence: Not ratable.     

Muscle flap coverage for the lower extremity

The use of local transposition muscle flaps for coverage of the lower extremity has been overshadowed in recent years by the development of microsurgical techniques for tissue transfer. There are still definite indications for local muscle flaps in reconstruction of the lower extremity. An outline of criteria of selectivity as it applies to specific wounds and practical pitfalls of their use is presented.     

Role of vascularized bone grafts in lower extremity osteomyelitis

Vascularized bone grafting seems to be a valuable reconstructive technique for the treatment of osteomyelitis with skeletal defects greater than 6 cm in length. Fibular osteocutaneous, composite rib, and iliac osteocutaneous flaps are the most commonly used vascularized bone grafts clinically. Vascularized bone can obliterate dead space, bridge large bone defects, enhance bone healing, resist infection by ensuring blood supply, allow early rehabilitation, and ensure better clinical outcomes in the treatment of lower extremity osteomyelitis. Success rates range from 80% to 95%. Complications of surgery include anastomosis failure, donor site problems, and fracture of the grafted bone.     

Muscle and myocutaneous flaps on the lower limb

Defects of the lower limb can be repaired in several ways and a very satisfactory closure can be obtained using muscular and myocutaneous flaps. The soleus muscle, both heads of the gastrocnemius muscle, the peroneus brevis muscle and the flexor hallucis longus muscle can all be used, the choice depending on the site of the defect.     

Perforator-based flaps in distal upper and lower extremity defects

The reconstruction of complex distal extremity defects is challenging with both cosmetic and functional considerations. This case series reviews our experience of using perforator-based flaps in 28 patients requiring reconstruction of 30 distal extremity defects. Hand held Doppler localisation of the perforators was carried out preoperatively in all cases. Flaps used were either fasciocutaneous or adipofascial and 90% of the defects were post-traumatic. Uncomplicated closure was achieved in 22 cases, with the majority of complications being minor. Complete failure was encountered in only two cases and as such was comparable with our experience of free tissue transfer. We propose consideration of perforator based flaps as an acceptable alternative to free tissue transfer in many extremity defects and find the hand held Doppler probe to be an invaluable tool in flap planning.     

Local muscle flaps in the treatment of chronic osteomyelitis

When large soft-tissue and osseous defects remain after débridement of a chronic osteomyelitic lesion, application of a local muscle flap can be an effective way to achieve wound closure. Utilizing this surgical technique and specific antimicrobial therapy for the causal microorganisms, the infectious process was eradicated in thirty-nine of forty-two patients with osteomyelitis who were followed for at least two years after treatment. The osteomyelitic process was post-traumatic in origin--that is, a complication of a fracture or its treatment--in twenty-eight patients, the result of soft-tissue trauma without a fracture in eight, a complication of elective surgery in three, and the result of hematogenous seeding in three patients. Nine of the forty-two patients had an infected non-union. The infectious process involved the tibia in 62 per cent of the patients. Pseudomonas aeruginosa was the most frequently isolated causal organism. A soleus or gastrocnemius muscle flap was most frequently utilized to achieve closure. In five patients, a combination of two muscle flaps was utilized. Although this technique successfully eradicated the infectious process in 93 per cent of the patients, twenty-two patients required additional surgical treatment. Six required such treatment for a persistent non-union and two, for weakened diaphyseal bone after eradication of the septic process. A cancellous bone-grafting procedure was performed in all eight patients after the muscle flap had healed, and union was achieved in six of them. One patient eventually requested an amputation for a persistent non-union, and the remaining patient had a fibular synostosis performed for a persistent tibial non-union. A local muscle flap can be used in patients with a large defect of soft tissue and bone after débridement of an osteomyelitic lesion if the flap can be elevated and transposed into the defect without compromising its vascular supply. Although they are not applicable to the treatment of all patients with osteomyelitis, local muscle flaps can be extremely useful in the treatment of this lesion. When combined with thorough débridement and specific antimicrobial therapy, it has become a successful technique in the management of chronic osteomyelitis.     

De-epithelialised "turn over" axial-pattern flaps in the lower extremity

Leonard (1981) has reported the successful use of a de-epithelialised "turn over" deltopectoral flap for a chest wall defect. This paper presents the application of the principle of a de-epithelialised " turn over" type of flap to the fasciocutaneous flap described by Pontén (1981) and the dorsalis pedis flap described by O'Brien and Shanmugam (1973) and McCraw and Furlow (1975) for defects of skin and subcutaneous tissue in the lower extremity. The reason for their choice and the alternatives are briefly discussed and some general comments are added on the use of de-epithelialised "turn over" flaps.     

Local fasciocutaneous flaps for cutaneous coverage of lower extremity wounds

Severe lower extremity trauma frequently results in a soft-tissue deficit that mandates wound coverage using some form of vascularized flap. The recent rediscovery of inclusion of the deep fascia during elevation of random skin flaps has enhanced the viability of large local flaps as a reconstructive option in the lower leg. In selected cases of relatively uncontaminated, moderate-sized defects, the choice of this maneuver has permitted closure of many defects which previously might have required a complex microsurgical tissue transfer. This series of 41 random-based local fasciocutaneous flaps in the lower leg in 38 patients has in all cases except two been successful in achieving preferred wound healing. Flap necrosis occurred only in these two cases presumably due to peripheral vascular insufficiency necessitating limb amputation in one patient. Eight (19%) had some form of complication, most occurring in the subset of flaps used for distal third lower leg wounds. The fasciocutaneous flap is conceptually simple, rapidly elevated and inset, and minimizes the region of surgical insult for many multitrauma patients who otherwise might have to forego any attempt for limb salvage.