Foot and ankle reconstruction using the radial forearm flap: a review of 25 cases

Bone exposure in the leg: is a free muscle flap mandatory?

BACKGROUND

In lower leg defects with bone, hardware, or articular exposure, a free tissue transfer is often the only valuable option. However, in well-selected clinical cases, pedicled flaps are still indicated because they provide an alternative for the more demanding and risky microsurgical procedure. The medial adipose-fascial flap of the leg represents an ideal local regional fascial flap.

METHODS

Twenty-two medial adipose-fascial flaps (performed in 21 patients) were reviewed retrospectively and compared with a series of 22 free gracilis flaps (22 patients) selected out of 150 muscular free flaps for lower leg reconstruction. All patients with defects larger than 40 cm, peripheral vascular disease, deep defects, and osteomyelitis were excluded in order to obtain the same surgical indications in which the local medial adipose-fascial flap could have been used.

RESULTS

The overall surgical results were comparable, but more medical complications, a longer operative time, and a longer hospital stay were seen in the free muscle group. Moreover, patients reconstructed with a medial adipose-fascial flap appeared to be more satisfied with the aesthetic result of their reconstruction.

CONCLUSIONS

Muscle coverage is not mandatory to cover bone in the lower leg. The medial adipose-fascial flap can provide a good alternative for free flap coverage. This flap seems to have fewer medical complications, requires a shorter operative time and hospital stay, and can provide better aesthetic results than a free muscle flap.

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.

Reconstruction of foot defects with free lateral arm fasciocutaneous flaps: Analysis of fifty patients

In this article, long-term outcomes of foot reconstruction with free lateral arm fasciocutaneous flaps were retrospectively analyzed in 50 patients. The patients, 38 men and 12 women, ranged in age from 7-73 years (mean, 43.5 years). Indications for surgery included trauma (32 patients), diabetes mellitus (7 patients), burns (7 patients), chronic ulcers (3 patients), and tumor (1 patient). The locations of defects were the dorsum (n=21), ankle (n=12), medial (n=6), lateral (n=6), posterior heel (n=2), and distal sole (n=3) Concomitant bone injury occurred in 5 cases, and the weight-bearing surface of the foot was involved in 5 patients. Defects ranged in size from 27-76 cm(2) (mean, 36.4 cm(2)). Successful reconstructions were accomplished in 46 cases (92%). Flap complications included total flap loss and below-knee amputation (1 patient) and partial flap loss (3 patients); 75% (3/4) of these cases had diabetes as a comorbid factor, and 25% (1/4) had a concomitant bone injury. Six patients with dorsum defects required debulking of the flap (11.1%). None of the patients required modified shoes. In the majority of cases, flaps provided stable coverage and a gain in protective deep-pressure sensation. In long-term follow-up (up to 4 years), patients regained their ambulation, free of pain. Even in weight-bearing areas, none of the cases experienced ulceration or skin breakdown. Free lateral arm flaps provided excellent durability, with solid bony union and successful restoration of the contour of the foot in moderate-sized foot defects.

Heel Reconstruction With an Iliac Osteocutaneous Free Flap

During the Homeland War in Croatia, many civilians suffered from war wounds of the extremities. Explosive war wounds create composite and devastating injuries mainly by high-energy transfer to the tissue. We present an early reconstruction of explosive heel wound with an iliac osteocutaneous free flap with late follow-up result.

Reconstruction for lower extremity limb salvage in soft tissue carcinoma

Limb salvage procedures for the lower extremity have a 95% success rate and have essentially supplanted primary amputation as the primary treatment for limb-threatening malignancies. En bloc tumor resection involving major neural and vascular structures that once led to amputation are now successfully reconstructed using free-tissue transfer in combination with neoadjuvant and adjuvant chemoradiation therapies and brachytherapy. Planning for reconstruction of complex lower extremity wounds begins at the time of diagnosis and extends to postoperative rehabilitation. Developing a successful reconstructive plan requires a team approach with accurate assessment of the anticipated loss of critical structures, wound location, defect size, and an understanding of the local and distant tissues available for reconstruction. Comprehensive assessment of the anticipated wound combined with an understanding of the distant and local tissues available for reconstruction allows the reconstructive surgeon to select tissues from the entire body that have improved functional and aesthetic outcomes for patients.

Radial forearm free flap for coverage of postoperative lateral heel wounds after open reduction and internal fixation of the calcaneus

For intraarticular calcaneus fractures, open reduction and internal fixation has become commonplace for the reduction of morbidity of postinjury arthritis. Despite adequate surgical results, there are often associated postoperative wound complications. The purpose of this study was to describe a unique application of the radial forearm free flap for coverage of lateral postoperative heel defects seen after calcaneal fixation. Seven lateral heel wounds after open reduction of calcaneal fractures in 6 patients were covered with radial forearm free flaps. The technique used involved passage of the pedicle of the laterally placed flap anteriorly to the Achilles tendon so that it can be anastomosed to the posterior tibial artery. Flap application was 100% successful, with good functional and cosmetic results in all patients. The radial forearm free flap provides a quick, reliable, and easily harvested source of coverage for lateral heel wounds seen after open reduction and internal fixation of the calcaneus. Tunneling of the flap pedicle anterior to the Achilles tendon is simple and provides the additional advantages of access to reliable vessels, reduced scarring, and avoidance of further wound problems often seen with incisions used to access the anterior tibial artery.

Reconstruction of the weight-bearing surface of the foot with nonneurosensory free flaps

Neurotized fasciocutaneous flaps and split-skin grafted muscle flaps are the most frequently used free flap alternatives for the reconstruction of weight-bearing surfaces of the foot. An objective comparison of the innate characteristics of these two flap types, with respect to long-term stability, has not been possible because sensory reinnervation in the fasciocutaneous flaps has been a confounding factor. This study compares nonsensate fasciocutaneous flaps (n = 9) with nonsensate split-skin grafted muscle flaps (n = 11), with mean follow-up periods of 34.3 and 31.3 months, respectively. Patients completed a form that included questions regarding degree of pain at the operative site, presence of ulcers, ability to wear normal shoes, employment status, and time spent standing on foot. Touch and deep sensation were evaluated with Semmes-Weinstein and vibration tests, respectively. Significantly less pain and less ulceration (p < 0.05) were observed in the fasciocutaneous group. Semmes-Weinstein monofilament tests revealed poorer results with split-skin grafted muscle flaps, compared with fasciocutaneous flaps. These results indicate that even if the sensory protection of fasciocutaneous flaps is not considered, these flaps have superior properties, compared with split-skin grafted muscle flaps.

Reconstruction of through-and-through gunshot wounds to the feet with free gracilis muscle flaps

Reconstruction of a through-and-through gunshot wound (GSW) to the foot remains a challenging problem for plastic and orthopedic surgeons, because it is difficult to achieve reliable soft tissue coverage of the foot while at the same time optimizing foot contour and weightbearing. In the past year, four patients with such an injury were treated with initial wound debridement and stabilization of the metatarsals, followed by a free gracilis muscle transfer with a split-thickness skin graft. One patient also had a secondary iliac bone graft to the first metatarsal. All patients have completely healed wounds, are free of osteomyelitis, and have achieved an excellent contour and good ambulation of the foot without donor site problems. Thus, a free gracilis muscle transfer should be considered first for reconstruction of a through-and-through GSW to the foot, because it can provide reliable soft tissue coverage with excellent contour and minimal donor site morbidity.

Management of chronic critical limb ischemia

The patient with CLI is challenging and requires a multi-disciplinary approach to effective management that involves a team of individuals proficient in various aspects of vascular disease. Fig. 4 details the approach at the University of Michigan's comprehensive vascular medicine program.

Limb salvage for soft-tissue malignancies of the foot: an evaluation of free-tissue transfer

Free flaps may safely allow meaningful ambulation, durable limb preservation, and better quality of life in patients undergoing resections of soft-tissue cancers of the foot. To prove this, the records of a series of patients at The University of Texas M. D. Anderson Cancer Center (n = 67) who underwent limb salvage following tumor-related resection (n = 71 procedures) from 1989 to 1999 were retrospectively reviewed. Eighteen patients who were not candidates for local flaps or skin grafts received a total of 20 free flaps to preserve their limbs. Most defects (mean size, 78 cm2; range, 20 to 150 cm2) were on a weight-bearing surface of the foot (nine on a weight-bearing heel, three on a plantar foot); the remainder were on a non-weight-bearing surface (six on dorsum, two on a non-weight-bearing heel). Melanoma was diagnosed in nine cases (50 percent); soft-tissue sarcoma, in seven (39 percent); and squamous cell carcinoma, in two (11 percent). Fasciocutaneous and skin-grafted muscle flaps were used on both weight-bearing and non-weight-bearing surfaces. Free-tissue transfer was successful in 17 of 20 cases (85 percent); the three flap losses occurred in two patients. Minor complications (i.e., small hematoma, partial skin graft loss, and delayed wound healing) occurred in five patients. In all cases of successful free-tissue transfer, patients began partial weight bearing at a mean of 7.4 weeks (range, 2 to 12 weeks), and all ultimately achieved full weight bearing. Sixty-seven percent still required special footwear. In one patient, an ulceration on the weight-bearing portion of the flap resolved after a footwear adjustment. Only one patient was lost to follow-up (mean, 23 months). In the 17 remaining patients, limb salvage succeeded in 15 (88 percent). Of these, nine (60 percent) were alive without evidence of disease, three (20 percent) were alive with disease, and three (20 percent) had died of disease. Local recurrence developed in two patients but was successfully treated by excision and closure. No late amputations were required for local control. Thus, it seems that free flaps help facilitate limb salvage and that they may preserve meaningful limb function in patients who undergo resection of soft-tissue malignancies of the foot.

Soft tissue coverage options for dorsal foot wounds

The soft tissue of dorsum of the foot consists of a thin pliable surface that allows for significant excursion and tendon gliding. Reconstructive options must preserve these important functions and allow for reasonable contour so the patient may wear a shoe postoperatively. Special attention must be given to the mechanism of injury and overlying pathophysiology involved with each wound. Local flaps can provide adequate wound coverage in settings in which the vasculature and subcutaneous structures have been preserved. In wounds in which the regional vascularity is compromised or in which tendon and bone have been lost, a free-tissue transfer can provide for more substantial coverage. The multiple options available with free-tissue transfer allows for the possibility of composite tissue transfer, including vascularized bone or tendon, and the ability to create a sensate flap with excellent contour.

Creating two independent fasciocutaneous free flaps from a single radial forearm donor site

The authors describe the creation of two independent fasciocutaneous free flap units from a single radial forearm donor site. After the radial forearm flap is elevated in the standard manner, based on the entire length of the radial artery, the individual flap units are developed as island flaps based on the proximal and the distal radial artery respectively by transecting the radial artery, its accompanying veins, and the cephalic vein. Thus, two independent radial forearm free flaps are created from a single donor site: The proximal one has antegrade flow and the distal one has retrograde flow. The individual free flap units were transferred, and microvascular anastomoses were performed simultaneously by two surgical teams. This technique was used in 2 patients presenting with bilateral foot defects that required reconstruction with a thin, reliable flap such as the radial forearm flap.