[The distally based adipofascial sural artery flap for the reconstruction of distal lower extremity defects]

Muscle Cuff in Distal Pedicled Adipofascial Sural Artery Flaps: A Retrospective Case Control Study

Background:

Amputation after open tibial fracture occurs in 3% of cases. The rate increases when flap reconstruction is required. The standard care involves microsurgical tissue transfer although the pedicled reverse sural artery adipofascial flap (PRSAF) is a local alternative in patients endangered by a prolonged operative time. Incorporation of a gastrocnemius muscle cuff in this flap can be used to fill dead space and increase healing potential. Literature shows superior survival rates for both PRSAF and inclusion of a muscle cuff in comparison with the cutaneous version. The aim of the study was to compare the outcome of the PRSAF and the musculoadipofascial version (PRSMAF). We hypothesize that the PRSMAF provides similar lap viability and flap-related complication rates as does the adipofascial version. The muscle component may reduce the long-term osteomyelitis rate.

Methods:

Patients were evaluated retrospectively after reconstruction with either PRSAF or PRSMAF. Preoperative osteomyelitis, flap survival, complications and osteomyelitis clearance were analyzed.

Results:

The study shows preliminary results supporting the potential use of the PRSMAF. We compare either 23 PRSMAF or 20 PRSAF flaps. We found no statistically significant differences in flap survival or in complication rate.

Conclusions:

Although the anatomical situation may sometimes dictate the use of a free flap, a technically less-complicated option may in some cases offer a viable alternative. This study shows that the PRSMAF can serve as an alternative for complex bone defects in the limb, though it does not provide statistical improvement to the PRSAF.

[Local flaps as a last attempt to avoid lower extremity amputation: an overview]

BACKGROUND

Soft tissue reconstruction in aged patients is challenging. Free tissue transfer can be carried out in healthy patients with a high success rate despite old age. When free tissue transfer is contraindicated in multimorbid patients, local flaps are often chosen, which are associated with a high complication rate. Such salvage interventions must be selected so that an amputation is not disadvantageously influenced by the selection of the donor site or is even impossible.

METHODS

The three distally based local flaps the sural artery flap, peroneus brevis muscle flap and perforator-based propeller flaps are discussed with respect to placement of the donor site as well as wound healing disorders.

RESULTS

The sural artery flap is disadvantageous as the donor site because the proximal dorsal calf region is affected, which in the case of a below the knee amputation enables soft tissue covering of the stump.

CONCLUSION

If a local flap is to be used as a salvage surgery in an attempt to prevent a below the knee amputation in a patient who is not suitable for free tissue transfer, special emphasis must be placed on the donor site of this flap. The proximal dorsal aspects of the distal calf are required for covering a potential stump and should not be violated by harvesting a local flap.

Treatment of the Secondary Defect on the First Metatarsophalangeal Joint Using the Medial Plantar Hallucal Artery Dorsal Perforator Flap

Injuries or burns to the dorsum of the first metatarsophalangeal (MTP) joint may develop scar formation, resulting in hyperextension contracture. Surgical correction of the deformity often produces a secondary defect. The purpose of this study is to report on the use of the medial plantar hallucal artery dorsal perforator flap for the treatment of such defect. From February 2010 to June 2011, 16 patients were treated. The mean preoperative hyperextension of the first MTP joint was 48 degrees. The mean size of the defects was 3.6 × 6 cm. The mean flap size was 4 × 6.5 cm. The mean pedicle length was 4 cm. All flaps survived completely. Patient follow-up lasted a mean of 14 months. At the final follow-up, the mean hyperextension of the first MTP joint was 9 degrees. After surgery, the mean Foot Function Index improved from 62 to 7. Almost all patients were satisfied with the results. Transferring the medial plantar hallucal artery dorsal perforator flap is a useful and reliable technique for the reconstruction of the secondary defect on the first MTP joint.

Coverage of Exposed Bone of the Lateral Malleolus With a Proximally Based Lateral Malleolar Perforator Flap

The treatment of soft tissue defects of the ankle, combined with an implant-related infection, remains a challenge. The present case report illustrates the use of a pedicled perforator flap for soft tissue reconstruction to cover a postoperative defect at the lateral malleolus after an ankle fracture.