Reconstruction of soft tissue and bone defects in lower extremity with free flaps

This article reports our experiences treating soft tissue and bone defects in the lower extremity with free flaps. One of the most common causes for lower extremity wounds are high-energy injuries. These kinds of injuries contain soft tissue and bone defects beyond neurovascular complications. The rate of infection and nonunion is very high in these injuries. Between 1988 and 1996, we applied 33 flaps to 28 patients. The numbers and kinds of the free flaps are as follows: 12 latissimus dorsi, nine radial forearm, seven lateral arm, three vascularised fibula grafts with skin, one gracilis, and one medial plantar flap. Three free flaps were lost (12%). The success rate is 88%. The advantage of free flaps is that they allow the reconstruction of the large defects in one-session operations. Thus, they decrease the rate of infection and increase that of nonunion. The patient returns to his active life at an earlier stage. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:176–181 1998     

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.     

Comparison of muscle flaps and delayed secondary intention wound healing for infected lower extremity arterial grafts

Selective preservation of infected arterial grafts is an alternative to graft excision. The purpose of this study was to compare the outcome and cost of treating infected lower extremity arterial grafts with either muscle flaps (MFs) or delayed secondary intention (DSI) wound healing. Between 1985 and 1991 we treated 28 graft infections by graft preservation. All grafts (19 polytetrafluoroethylene, 8 autologous vein, and 1 Dacron) were patent with intact anastomoses and showed no signs of sepsis. Wounds in 18 patients were treated by repeated, aggressive operative debridement and allowed to heal by DSI. Wounds in 10 patients were treated with MFs (4 sartorius, 3 gracilis, 1 rectus abdominis, 1 semimembranous, and 1 gastrocnemius). Costs included anesthesiologists' and surgeons' fees, operating room charges, and daily semiprivate and ICU bed charges. Four (14%) patients died from cardiac complications (1 DSI and 1 MF), sepsis (1 MF), and anastomotic hemorrhage (1 DSI). Of the 24 survivors, 4 patients treated by DSI required graft excision for nonhealing wounds (2), graft thrombosis (1), and recurrent infection (1). However, 3 of these 4 patients were not candidates for MFs because the wounds were not considered acceptable for a flap. Twenty (83%) grafts in survivors were successfully preserved after long-term follow-up (mean 26 mo). No survivors required an amputation. Twenty patients who did not require graft removal were compared for treatment by MF (n=8) or DSI (n=12). Two MFs (both sartorius) in survivors necrosed and a new flap was required to successfully preserve the graft. Average hospital and intensive care stay as well as hospital costs were not significantly different for the two groups. The majority of infected, patent lower extremity grafts with intact anastomoses can be successfully preserved with either MFs or DSI wound healing. We found no significant difference in outcome or cost for the two methods of treatment.Supported by the John F. Connelly Foundation, the James Hilton Manning and Emma Austin Manning Foundation, the Anna S. Brown Trust, and New York Institute for Vascular Studies.Presented at the Eighteenth Peripheral Vascular Surgery Society, Washington, D.C., June 6, 1993.     

足跟部软组织缺损修复的皮瓣选择

足跟部是人体负重部位,皮肤要求耐磨损、有感觉;其损伤后常伴有跟腱缺损与跟骨外露;并且跟后局部血液循环较差,破溃感染创面常经久不愈,形成慢性溃疡.对足跟部软组织缺损的修复需要维持跟腱功能、恢复正常外观和感觉、重建软组织、选择合适的供区.我科自1995年8月至2006年4月共收治46例足跟部软组织缺损患者,分别采用7种不同类型的皮瓣或肌皮瓣修复,获得随访32例,共34个皮瓣,现报告如下.     

Versatility of the lateral circumflex femoral arterial (LCFA) system flaps for lower extremity soft tissue reconstruction

Background

Complex and extensive limb defects involve difficult reconstructive problems, and lateral circumflex femoral artery (LCFA) system flaps provide an adequate reconstructive answer for these challenging wounds.

Methods

A retrospective review on 50 patients treated with LCFA system flaps to cover lower extremity wounds was carried out. Data collected included age, gender, defect size, defect location, flap size, flap composition, anatomical findings, donor site closure, secondary procedures, and complications.

Results

The overall flap survival rate was 96 %. We performed three flap re-explorations with two subsequent failures. Four different combinations of tissues from LCFA system flaps were employed to restore defects produced by open fractures in tibia (16), severe crushing or avulsion injury (15), chronic posttraumatic osteomyelitis (13), and others (6). The mean size of the skin flap was 162.56 cm² (range 54–312 cm²) and the volume of the muscle flap was 160 cm³ (range 44–250 cm³). Debulking procedures were performed in seven patients. Donor sites were closed primarily in all but five patients who required a skin graft.

Conclusions

The LCFA system is efficient and its use, versatility, and reliability in lower limb reconstruction have been proven. No other donor site in the body offers such a large amount of tissue with minimal donor morbidity. Level of Evidence: Level IV, therapeutic study.     

Localized, operable soft tissue sarcoma of the lower extremity

Recent developments in adjuvant treatment of soft tissue sarcomas of the extremities have altered the surgical approach to this disease. To assess the effects of changing management on local recurrence rates and to examine factors governing local failure, we reviewed the records of 315 adults with operable, nonmetastatic soft tissue sarcoma of the lower extremity who were treated at one institution over a ten-year period. The median follow-up was 8.2 years. One third of our patients presented with locally recurrent tumors after initial treatment elsewhere. Sixty-six percent of the lesions were above the knee, and 60% were high grade. Two thirds of the patients underwent limb-sparing surgery (LSS), which in the latter half of the study period outnumbered amputations by four to one. Local recurrence was directly related to the adequacy of the surgical margins. Adjuvant radiotherapy and chemotherapy did not significantly decrease local recurrence in patients who underwent LSS, although favorable trends were observed. A significantly increased risk of local failure was associated with age greater than 53 years, presentation with local recurrence, high tumor grade, deep location, positive nodes, and less than adequate surgical margins. Local failure also varied significantly with histologic type and was highest in patients with embryonal rhabdomyosarcoma and neurofibrosarcoma. Improved local control, particularly in patients with high-grade tumors, was observed in the latter half of the study period despite the increased use of LSS. When the data were subjected to multivariate analysis, the following variables emerged as independent predictors of local failure: age greater than 53 years, presentation with local recurrence, high grade, less than adequate margins, embryonal rhabdomyosarcoma, and neurofibrosarcoma. The key to local control of sarcomas of the extremities is resection of the tumor with adequate margins. The role of adjuvant treatment, particularly following LSS, is still being evaluated. The risk factor profile should be considered when selecting a treatment program for patients with lower extremity sarcomas.     

Primary reattachment of avulsed skin flaps with negative pressure wound therapy in degloving injuries of the lower extremity

Large avulsed skin flaps of the lower extremity caused by degloving injuries eventually develop skin necrosis in most cases. The current treatment option involves excision of the degloved skin and reapplication as a full- or split-thickness skin graft. We considered that reattachment of avulsed skin flaps without excision would be theoretically beneficial, since some circulation may remain around the connected pedicle and thus facilitate graft take. Furthermore, securing the skin to the original anatomic position is much easier using retained landmarks. We treated a total of 12 patients (13 cases) with degloving injuries of the lower extremity. In all cases, the avulsed skin flap was defatted and sewn back to the original position, then negative-pressure wound therapy was applied over those grafts as a bolster for approximately 7 days. Most of the avulsed skin flap took excellently, particularly close to the connected pedicle. Nine cases did not need any additional surgical procedures. Four cases required secondary skin graft for a small area of open wound due to partial necrosis of the defatted skin, as well as the raw surface left by the primary skin defect in the initial operation. Primary reattachment of the avulsed skin flaps without excision is convenient and efficient to cover the open wound over the exposed fascia and periosteum in degloving injuries. This would potentially offer a better alternative to definitive wound closure.     

Principles and descriptions of design of skin flaps for use on the lower extremity

Distinction must be made between tissue movability and tissue elasticity when considering tissue movement with the hope of predicting good results. Tissue movability is either inherent, as on the back of the thigh, or is created by undermining, back-cutting, or cutting out Bürow's triangles. The elasticity of skin is inherent everywhere and is difficult to accurately predict. Elastic tissue will gape when cut, whereas inelastic tissue will not. Finally, elastic tissue will rotate with little puckering but inelastic tissue will form large dog-ears when rotated. For these reasons, as soon as the decision has been made to use a flap it is important to "prethink" the dynamics of flap movement and decide which type of flap to use and what is to be accomplished. If consideration is given to which flap will best allow proper transfer of tissue and at the same time give the best cosmetic result, the task is usually simpler. By further considering the secondary movement of surrounding tissues (as well as the primary movement), the number of potential techniques and designs are greatly increased.     

应用腓肠内侧动脉穿支皮瓣修复下肢软组织缺损

目的总结应用腓肠内侧动脉穿支皮瓣和肌瓣修复下肢软组织缺损的临床应用效果。方法用皮瓣修复胫前区软组织缺损5例,其中,上1/3软组织缺损3例,胫骨中1/3缺损2例,供区均选用同侧小腿。皮瓣切取大小4．0 cm×5．0 cm～5．5 cm×8．0 cm。用肌瓣修复髌前区软组织缺损5例,肌瓣切取大小3．5 cm×4．5 cm～5．5 cm×6．6 cm,肌瓣上行一期中厚网状游离植皮。结果2例术后发生表浅感染,经更换敷料逐渐愈合,皮瓣和肌瓣全部成活,所有病例随访10个月～2．8年(平均1年8个月),没有发现明显的供区功能障碍。受区的外形较好,取得了较满意的效果。结论该皮瓣以腓肠内侧动脉的肌皮穿支为血供,具有血供丰富、血管解剖恒定、血管蒂长以及皮瓣较薄的优点,带蒂移植适宜修复下肢软组织缺损。供区不隐蔽是其缺点。     

岛状皮瓣和肌皮瓣修复小腿及足部创伤性皮肤软组织缺损

目的探讨岛状皮瓣和肌皮瓣修复小腿及足部创伤性皮肤软组织缺损的疗效及适应证。方法1995年1月至2004年9月，对52例小腿及足部创伤性皮肤软组织缺损的患者，采用腓肠肌肌皮瓣。小腿前外侧皮瓣，小腿外侧皮瓣，小腿内侧皮瓣，内踝上皮瓣，腓肠神经营养血管皮瓣等6种皮瓣和肌皮瓣进行修复。结果52例患者皮瓣全部成活，1例术后皮瓣下脓肿经切开引流愈合，3例皮瓣远端小面积局部坏死．经换药或再次手术移植皮片后创面愈合。术后随访4个月至4年，皮瓣成活良好，所修复的小腿及足恢复良好功能。结论岛状皮瓣和肌皮瓣是修复小腿及足部创伤性软组织缺损的理想方法，应根据小腿及足部软组织情况、血管条件、创面部位，选择不同的皮瓣修复。     

岛状皮瓣和肌皮瓣修复小腿及足部创伤性皮肤软组织缺损

目的探讨岛状皮瓣和肌皮瓣修复小腿及足部创伤性皮肤软组织缺损的疗效及适应证.方法 1995年1月至2004年9月,对52例小腿及足部创伤性皮肤软组织缺损的患者,采用腓肠肌肌皮瓣,小腿前外侧皮瓣,小腿外侧皮瓣,小腿内侧皮瓣, 内踝上皮瓣,腓肠神经营养血管皮瓣等6种皮瓣和肌皮瓣进行修复.结果 52例患者皮瓣全部成活,1例术后皮瓣下脓肿经切开引流愈合,3例皮瓣远端小面积局部坏死,经换药或再次手术移植皮片后创面愈合.术后随访4个月至4年,皮瓣成活良好,所修复的小腿及足恢复良好功能.结论岛状皮瓣和肌皮瓣是修复小腿及足部创伤性软组织缺损的理想方法,应根据小腿及足部软组织情况、血管条件、创面部位,选择不同的皮瓣修复.     

足内侧皮瓣移位修复足部皮肤软组织缺损

目的报道足内侧皮瓣修复足部中、小面积皮肤缺损的效果.方法采用足内侧皮瓣多向转位修复足跟、前足底、足背及内踝处皮肤软组织缺损19例,皮瓣面积3 cm×2 cm～10 cm×8 cm.结果皮瓣全部成活,平均随访22个月,皮瓣色泽基本正常,弹性好,有感觉,无溃破.结论该皮瓣符合足部修复要求,修复中小面积皮肤软组织缺损可作为首选.     

Covering of soft tissue defects of the lower leg with adipo-facial flaps

AIM OF THE STUDY: Soft tissue covering on the lower leg is a difficult challenge. A plastic surgical method for covering of these soft tissue defects is presented. PATIENTS AND METHODS: From May 1997 until May 2003 36 patients were treated using neurovascular flaps. Above the sural or the saphenous nerve an adipo-facial flap is dissected, rotated into the defect and fixed without tension. Wound closure of the donor-site defect is done primarily or by mesh-graft. RESULTS: In 35 cases the flap healed without functional impairment. Primary healing was achieved in 30 patients. In 5 cases partial loss of the skin island was registered, whereby subcutaneous tissue remained vital. Revision by mesh-graft transplantation led to successful healing in these patients. In only one patient necrosis of the flap was seen. CONCLUSION: Neurovascular flaps usually result in reliable and complete healing of soft tissue defects of the lower extremity.     

Function of skin grafts in children following acquired amputation of the lower extremity

BACKGROUND: Investigators have recommended aggressive use of skin-grafting in order to preserve length and proximal joint function following an acquired amputation in children. However, there is little objective evidence to either support or refute that recommendation. METHODS: We performed a retrospective review of the cases of all children for whom a skin graft had been applied to the residual limb following an acquired lower-extremity amputation at our Limb Deficiency Clinic between 1984 and 2002. Skin graft dysfunction, defined as breakdown, contracture, and/or pain, was considered to be clinically relevant if it required the child to discontinue use of the prosthesis for any period of time or if it required revision surgery to facilitate continued prosthetic fitting. RESULTS: Twenty-three children (mean age at amputation, 4.4 years) with a total of thirty-one acquired lower-extremity amputations had been treated with skin-grafting. At a mean of 6.3 years after the operation, sixteen (52%) of the thirty-one extremities had had no episodes of skin graft dysfunction. The remaining fifteen extremities (48%) had had clinically relevant skin graft dysfunction (breakdown in thirteen and contracture and pain in one extremity each). Nine of the ten extensive skin grafts underwent clinically relevant breakdown, as did thirteen of the twenty-four grafts that were located distally on the residual limb. Subsequent surgical revision of the residual limb because of inadequate function of the skin graft was performed on seven extremities (23%), with revision to a more proximal limb-segment level required in five. CONCLUSIONS: Focal skin-grafting (involving < or = 25% of the surface area) of partial-thickness soft-tissue defects in order to optimize the length of the residual limb at the time of an amputation is an effective option for children with an acquired lower-extremity amputation. Limited skin-grafting (involving 26% to 50% of the surface area) is more likely to result in skin graft breakdown, particularly when it is done distally. Extensive skin-grafting, while technically possible, frequently requires revision and rarely results in an optimally functioning limb. Alternative treatment strategies should be considered for extremities that would require extensive, distal skin-grafting.