The use of local muscle flaps in foot and ankle reconstruction

Pedicled muscle flaps always should be considered as a reconstructive option when evaluating possible options to filling a defect around the foot and ankle. To gain confidence in using this option, multiple anatomic dissections with special attention to the vascular anatomy are necessary. These dissections also should give the surgeon a feel for the reach of the various flaps and their applicability in various circumstances. For optimal results, the interoperative dissections should be performed with loupes and the Doppler. This allows the surgeon to identify and protect the dominant pedicle. When insetting the flap, special attention is directed to avoid placing excessive torsion or tension on the pedicle so that the blood flow is not compromised. The flow, both arterial and venous, should be assessed after insetting the muscle with a Doppler. Pedicled muscle flaps offer a rapid and easy solution to difficult soft tissue problems around the foot and ankle. The operation can be performed with a regional block in under two hours. The postoperative stay is short, and the donor defect is minimal. Pedicled muscle flaps offer a great alternative to microsurgical free flaps, especially in the sick patient. They should be considered more often when looking at how to fill small defects with exposed bone or osteomyelitis around the foot and ankle.     

Preliminary experience with perforator flaps in reconstruction of soft-tissue defects of the foot and ankle

BACKGROUND: Microsurgical reconstruction has improved limb salvage in patients who because of many etiologies have soft-tissue loss from the lower extremities. Free-tissue transfer to the foot and ankle often interferes with postoperative function and footwear because of the bulk of a muscle flap. The foot and ankle often are best treated using thin flaps that will not contract and fibrose, particularly if secondary procedures are required. We hypothesized that perforator flaps, which are thin free-tissue transfers consisting of skin and subcutaneous tissue, both diminish donor site morbidity and are ideally suited for soft-tissue reconstruction of the foot and ankle. METHODS: Ten patients had free- tissue transfers to the foot and ankle using perforator flaps during a 2-year period. Four had acute posttraumatic wounds, three had soft tissue defects with exposed hardware or bone graft after reconstructive surgery, and three had large soft-tissue defects after foot infection secondary to diabetes. Nine had reconstruction with anterolateral thigh perforator flaps and one had reconstruction with a deep inferior epigastric artery (DIEP) perforator flap. RESULTS: All flaps survived. There were no deep infections. Three flaps had minor tissue loss requiring subsequent small skin grafts, all of which healed. There were no donor site complications and no interference of muscle function at the donor sites. Custom shoewear was not required to accommodate the flaps. CONCLUSION: This series highlights the success and utility of perforator flaps in microsurgical reconstruction of the foot and ankle. The greatest advantage of perforator flaps is the diminished donor site morbidity, which was achieved while maintaining high microsurgical success rates. These skin and fat flaps remained pliable and contracted less than muscle flaps, allowing for smooth tendon gliding and easy flap elevation for secondary orthopaedic procedures.     

Foot and ankle experience in orthopaedic residency

BACKGROUND: Dedicated orthopaedic residency training in the musculoskeletal discipline of foot and ankle is an important contribution to the development of a well-rounded orthopaedic surgeon. Current residency training guidelines are vague and do not require specific experience or proficiency in this discipline. METHODS: A one-page questionnaire on commitment to foot and ankle education in American Orthopaedic Surgery residency training programs was completed by all 148 program directors. RESULTS: Eighty of the programs (54.1%) had a single faculty member dedicated to foot and ankle orthopaedics, while 21 (14.2%) did not have a faculty member with a specific interest or commitment to problems related to the foot and ankle. Fifteen programs (10.1%) did not have a committed faculty member, nor did their residents have a clinical rotation dedicated to foot and ankle. Ninety-six programs (64.9%) had at least one clinical rotation dedicated to foot and ankle. Fifty-two (35.1%) did not. Thirty-three (34.7%) of those programs with a dedicated foot and ankle experience assigned residents during at least two periods of their training. Of those programs with a single foot-specific rotation, the most common year for training was in the PGY3 year (27 of 63, 42.9%). Of the 60 months' duration of most orthopaedic residency programs, 39 of 96 (40.6%) programs with a dedicated clinical foot and ankle rotation allocated an average of 12 weeks to foot and ankle. Twenty-six (27.1%) allocated less than 3 total months, and 31 (32.3%) allocated 16 to 24 weeks of dedicated foot and ankle experience. CONCLUSIONS: Current residency training in the United States does not universally require a commitment to foot and ankle education. A large number of residency programs do not have a faculty member committed to foot and ankle education, and almost one-third have no time specifically allocated to foot and ankle education.     

Lower limb reconstruction with bone free flaps: experience of 25 cases

Bone structure is fundamental for the function of the lower limbs—orthostatism and locomotion. Before the technical evolution observed in the last two decades, many extremities that are saved now were amputated in the past. Lower limb bone defects are generally associated with complex traumatic lesions and constitute a permanent reconstructive challenge. The management of this kind of defect requires a multidisciplinary approach involving plastic and orthopedic surgeons. The bone free flaps are a very important and technically exacting tool for lower limb bone reconstruction. We present and analyze our experience in 25 traumatic cases where we used 17 fibula free flaps and 2 iliac crest free flaps for tibia and talus reconstruction; 5 fibula free flaps for femur reconstruction; and 1 antebrachial radial osteocutaneous free flap for first metatarsal reconstruction. We registered 88% of success (three flap necroses—12%) with good bone integration and good functional recovery. Lower limb bone reconstruction is a long and tortuous stair whose success depends not only on the multidisciplinary surgical team but also on the patient's cooperation and determination     

Two different flaps for reconstruction of gunshot wounds to the foot and ankle in a child

An 8-year-old boy was shot in his right foot and ankle, which resulted in soft tissue lesions of the medial malleolus and lateral calcaneus, fracture of the medial malleolus, and partial loss of the calcaneus. We designed a distally based sural flap and a posterior tibial perforator flap for reconstruction of soft tissue defects at the lateral aspect of the calcaneus and the medial malleolus, respectively. Both flaps survived successfully, and the boy had a normal gait during follow-up.     

Free flaps for head and neck reconstruction in non-oncological patients: experience of 200 cases

Two hundred free flaps for reconstructing the head and neck regions in 192 patients with non-oncological pathology were studied. Pathological entities included Romberg's disease, hemifacial microsomia, acquired facial palsy, trauma, and burn sequelae. Indications for selecting a specific free flap for reconstructing each case, details of anastomoses, reexploration, flap success, operative time, length of hospitalization, and complications were studied. The long-term results of cosmetic and function were also obtained. Patient age ranged from 6 to 40 years. The most common diagnosis was Romberg's disease 39% (n = 75), followed by hemifacial microsomia 20% (n = 40). The free flap most frequently used was the scapular 32% (n = 64), followed by the groin free flap 21% (n = 42). A total of 190 flaps (95%) were successful, whereas only 10 (5%) were lost. The mean operative time was 5:30 h and the average hospital stay was only 6 days. There were no major complications and no deaths in the study group. The patients were followed for at least 1 year in all cases. It is concluded that free flaps are safe and reliable procedures for reconstructing complex head and neck non-oncological defects.     

The coverage of skin defects over the foot and ankle using the distally based sural neurocutaneous flaps: experience of 21 cases.

Skin defects over the foot and ankle remain a challenge to plastic surgeons. The distally based sural neurocutaneous flap is a reliable and effective procedure. The authors have performed 21 cases (22 flaps) since 2000. Twenty-one flaps survived uneventfully. The recipient range included the dorsum of the foot, heel and forefoot. The texture, thickness and colour were satisfactory although pressure ulcers occurred on flaps over the weight-bearing region, such as sole. The factors that influence the survival of the flap are the width of the pedicle, ligation of the lesser saphenous vein and complete vascular network around the ankle.     

足踝部软组织缺损的皮瓣修复

[目的]探讨皮瓣修复足踝部软组织缺损的临床效果。[方法]对53例足踝部软组织缺损患者分别采用邻近皮瓣转移、带血管蒂或游离血管皮瓣进行修复。[结果]1例因缝合太紧皮缘部分坏死，2例感染，50例皮瓣全部成活。随访6个月～3a，4例皮瓣稍嫌臃肿，3例局部瘢痕形成，余外观及功能良好，感觉部分恢复。[结论]根据足踝部软组织缺损情况采用不同的皮瓣修复方法，可达到良好的外观及功能。     

The use of periosteal flaps in scalp and forehead reconstruction

In certain clinical situations, coverage of scalp and forehead soft-tissue defects is best accomplished by skin graft. When bone is also exposed, however, skin graft coverage may not be possible. Flaps of periosteum can be used in these cases as bony coverage, thus providing the vascularized bed necessary for skin graft "take." Advantages and disadvantages of these periosteal flaps are discussed.     

Versatile use of rectus abdominis muscle and musculocutaneous flaps for soft-tissue reconstruction: our clinical experiences in 25 cases

The rectus abdominis muscle and musculocutaneous flaps have contributed to the efficient reconstruction of tissue defects that require a large amount of cutaneous and muscular tissue. In this article, outcomes of soft-tissue defects after reconstruction with the rectus abdominis muscle and musculocutaneous flaps were retrospectively analyzed. From August 2003 to June 2009, 25 flaps were transferred to reconstruct a wide variety of soft-tissue defects in the breast, chest wall, groin, perineal, and head and neck regions, as well as the upper and lower extremities. The rectus abdominis muscle and musculocutaneous flaps were used as part of 11 different approaches in 25 cases. There were 13 male and 12 female patients; the mean patient age was 44.2 years. The mean follow-up period was 8 months (range, 4–15 months). The overall success rate was 100%, and all flaps healed uneventfully. All reconstructive procedures were completed without any major complications. Rectus sheets were repaired primarily, and no mesh application was used. Minor complications related to transferred flaps were wound infection and dehiscence in one case, wound dehiscence in two cases, and flap lymphedema in one case. Minor complications related to the donor site were seroma in one case and wound infection and dehiscence in another case. This study presents our experience with the rectus abdominis muscle and musculocutaneous flaps in a series of 25 cases. The indications for the use of this particular flap with other flaps are discussed.     

Foot and ankle imaging in the athlete

Foot and ankle injuries are among the most common of all sports-related injuries. Many injuries are simplistic from a diagnostic standpoint, whereas others require a high level of suspicion and the use of appropriate diagnostic imaging modalities. Whether a professional athlete or a weekend warrior, all athletes want minimal disruption to their sporting activity and a quick return to competition. An accurate diagnosis aids in the development of an appropriate rehabilitation program and in return to activity. This article reviews the more common foot and ankle injuries seen in the podiatrist's office and the preferred imaging modalities used to evaluate them.     

Adipo-fascio-cutaneous flaps in the treatment of pilonidal sinus: experience with 50 cases

OBJECTIVE: To retrospectively analyse the results of pilonidal sinus managed using wide excision with primary eccentric closure with various adipo-fascio-cutaneous flaps. METHODS: Data from 50 consecutive patients who had elective surgery for chronic pilonidal sinus with wide excision of all the sinuses and primary eccentric closure with various adipo-fascio-cutaneous flaps (40 lateral advancements, 4 Z-plasties, four rotations, 1 rhomboid and 1 V-Y advancement) were retrospectively analysed. Special emphasis was placed on partial obliteration of the natal cleft, duration of wound healing, postoperative morbidity and hospital stay, loss of work days, cosmetic outcome and recurrence. RESULTS: In all patients, partial obliteration of the natal cleft was achieved by eccentric primary wound closure, with good cosmesis. Superficial necrosis of the flaps occurred in five patients (3 Z-plasties, 2 rotation flaps). None had collection, haematoma, infection or recurrence. CONCLUSION: Complete eccentric excision and partial obliteration of the natal cleft using various adipo-fascio-cutaneous flaps ensured reliable wound healing with fewer dressings and morbidity, shortened hospital stay and early resumption of work, good cosmesis and prevention of early and late recurrence. The lateral advancement flap is a viable option in the treatment of chronic pilonidal sinus.     

Nasolabial flaps in oral reconstruction: an analysis of 224 cases.

The nasolabial flap is a simple option for the reconstruction of selected oral defects. Though its use in floor-of-mouth reconstruction has been described, other uses in the oral cavity have not been studied extensively. We present a series of 224 oral malignancies where the nasolabial flap was used for reconstruction after surgical excision.     

Combined use of medial thigh skin flaps and gracilis musculocutaneous flaps for the reconstruction of scrotum

Summary A case of combined use of bilateral medial thigh skin flaps and gracilis musculocutaneous flaps for the reconstruction of a scrotal defect resulting from Fournier's gangrene is presented. The procedure provided a sac-like scrotum, and the donor sites were successfully reconstructed using bilateral gracilis musculocutaneous V-Y advancement flaps.     

The use of nail enfolded flaps for reconstruction of full-thickness ala nasi defects: an early report of experience

The most common etiology of nasal defects that require reconstruction is basal cell carcinoma, as well as squamous cell carcinoma and melanoma. In reconstructing full-thickness ala nasi defects following excision of basal cell carcinomas, we present our technique of the nail enfolded local flaps which involves the harvesting of the nail plate and placing it to serve as a supporting component. In four patients, the nail plate grafts are inserted into various local flaps, and used for reconstruction of full-thickness ala nasi defects. Lining deficiencies of the alar lobule were resurfaced with skin grafts. None of the cases experienced skin graft loss or nail plate exposure. The nail graft prevented alar collapse by supporting the nasal airway. This technique discards the need for a second operation.     

Experience with peroneus brevis muscle flaps for reconstruction of distal leg and ankle defects

Objective:

Peroneus brevis is a muscle in the leg which is expendable without much functional deficit. The objective of this study was to find out its usefulness in coverage of the defects of the lower leg and ankle.

Patients and Methods:

A retrospective analysis of the use of 39 pedicled peroneus brevis muscle flaps used for coverage of defects of the lower leg and ankle between November 2010 and December 2012 was carried out. The flaps were proximally based for defects of the lower third of the leg in 12 patients and distally based for reconstruction of defects of the ankle in 26 patients, with one patient having flaps on both ankles.

Results:

Partial flap loss in critical areas was found in four patients requiring further flap cover and in non-critical areas in two patients, which were managed with a skin graft. Three of the four critical losses occurred when we used it for covering defects over the medial malleolus. There was no complete flap loss in any of the patients.

Conclusion:

This flap has a unique vascular pattern and fails to fit into the classification of the vasculature of muscles by Mathes and Nahai. The unusual feature is an axial vessel system running down the deep aspect of the muscle and linking the perforators from the peroneal artery and anterior tibial artery, which allows it to be raised proximally or distally on a single perforator. The flap is simple to raise and safe for the reconstruction of small-to moderate-sized skin defects of the distal third of the tibia and all parts of the ankle except the medial malleolus, which is too far from the pedicle of the distally based flap. The donor site can be closed primarily to provide a linear scar. The muscle flap thins with time to provide a good result aesthetically at the primary defect.KEY WORDS: Ankle defects, lateral malleolus defects, lower leg defect, muscle flap, peroneus brevis flap, pedicle flap, tendo achilles defects     

Foot and ankle fractures in the industrial setting

Fractures of the ankle and foot are common in the worker. Proper initial assessment and treatment can result in a functional recovery that is prompt and complete in many cases. Many fractures, however, have a poor long-term prognosis and prolonged recovery. Frank initial discussions with the patient and case manager can help the system better manage the patient's future.