Propeller Flaps of the Lower Extremity

Comparing the Clinical Effects of Free and Pedicled Flap in Repairing Small Area of Distal Lower Limb Soft Tissue Defects: A Retrospective Comparative Study

Background and Aims

The exposure of tendons, blood vessels, nerves, and bone due to soft tissue defects in the foot poses a significant challenge for microsurgeons. Free perforator flaps and pedicled perforator flaps are currently the most common methods used for repairing small areas of soft tissue defects in the distal lower limb.

Methods

A retrospective analysis was carried out on 124 patients with small soft tissue defects in the distal lower limb from January 2009 to December 2021. The evaluation criteria encompassed the patient's intraoperative condition, the occurrence of short-term and long-term postoperative complications, as well as the esthetic and functional outcomes.

Results

In this study, two groups of patients with similar soft tissue defects were included. However, the free perforator flap group showed more severe wound damage compared to the pedicled perforator group. Intraoperatively, the pedicled perforator group needed a larger flap area for wound repair, and the free perforator group had higher intraoperative blood loss and longer operation time. Postoperatively, the incidence of complications was significantly higher in the pedicled perforator group, while the esthetic outcomes were poorer, but the functional evaluation results were better.

Conclusion

For small soft tissue defects in the distal lower limb, both free perforator flap and pedicled perforator flap are effective in wound repair. The free perforator flap has the advantage of being able to handle more complex wounds with less limitation by location. In cases where the microsurgical expertise is relatively limited and the injuries are minor, pedicled perforator can be considered as the primary choice.

Level of Evidence

III, case-control study.

Anatomic study of propeller flaps based on perforators of the posterior tibial artery

Lower limb injuries resulting from sports activities, industrial accidents, and traffic incidents represent a significant global healthcare challenge. These injuries often entail a high risk of complications, especially when fractures are associated with substantial soft tissue damage. Open fractures classified as Gustilo type II or III are particularly susceptible to complications such as fistula and osteomyelitis. Globally, millions of lower limb injuries are reported annually, leading to considerable morbidity and escalating healthcare costs. The standard treatment for shin ulcers with bone exposure involves the debridement of necrotic tissue, followed by coverage of the defect with well-vascularized tissue. Classical flaps are employed in certain cases; however, their applicability, along with techniques such as pedicled muscle flaps from the rectus abdominis or tensor fasciae latae muscles, depends on the extent and location of the injury. Classical flaps are employed in certain cases, but their applicability depends on the extent and location of the injury. Given these limitations, propeller flaps have emerged as highly effective alternatives for microsurgical reconstruction in lower limb recovery. The objective of our study was to delineate the anatomy and demonstrate the utility of propeller flaps based on the perforators of the posterior tibial artery. By providing detailed anatomical insights, we aimed to highlight the strategic advantages of propeller flaps in complex lower limb reconstruction cases.

Perforator-Based Propeller Flap Application in Pressure Ulcer Reconstruction: A Comparative Analysis With Advancement Flaps

BACKGROUND

Pressure ulcers are a prevalent and debilitating condition, often necessitating surgical reconstruction. Various flap techniques, such as Advancement Flaps (AF) and Perforator-based Propeller Flaps (PBPF), are commonly used for pressure sore reconstruction. While both techniques have proven effective, there is limited research comparing their outcomes in different clinical scenarios. In recent years, PBPF has demonstrated favorable outcomes in various reconstruction fields. However, there remains a need to establish the optimal technique for specific clinical conditions and patient populations. Therefore, this study aims to compare the outcomes of PBPF and AF in patients undergoing pressure ulcer reconstruction.

METHODS

A retrospective analysis was performed on patients who underwent pressure sore reconstruction utilizing either AF or PBPF techniques between January 2020 and December 2023. Data on demographics, pressure ulcer details, operative time, hospital stay, recurrence rate, and complications were collected and analyzed.

RESULTS

In this study of 56 patients, 30 underwent AF, and 26 underwent PBPF. Demographic and clinical characteristics showed no significant differences. Clinical and surgical outcomes indicated no significant differences in defect size (p = 0.517), hospitalization period (p = 0.786), follow-up duration (p = 0.746), number of preoperative debridements (p = 0.781), time to recurrence (p = 0.224), or postoperative complications (p = 0.757). However, PBPF resulted in a smaller flap size (93.7 ± 29.5 cm2 for AF vs. 70.5 ± 19.7 cm2 for PBPF, p < 0.001), a longer operation time compared to AF (94.6 ± 39.1 min for AF vs. 161.0 ± 38.9 min for PBPF, p < 0.001), and lower recurrence rate in long-term follow-up (p = 0.036).

CONCLUSIONS

PBPF may have the drawback of prolonged surgical time due to the complexity of the surgical procedure. However, when applied appropriately, it can be a meaningful surgical approach for reducing the recurrence rate of pressure ulcers.

Innovative Synchronous Use of a Reverse Sural Flap and Reverse Hemisoleus Muscle Flap for Post-traumatic Lower Leg Reconstruction: A Case Report With a Long Term Follow-Up and a Quality of Life Assessment

We present a case report of a 47-year-old male with an extensive tissue deficiency of the right lower leg. The patient was hospitalized for approximately one month in the intensive care unit following a motorcycle accident that resulted in polytrauma. He suffered a fracture of frontal and parietal bones, traumatic brain injury, intracerebral hematoma with a subarachnoid hemorrhage and thoracic trauma. At first, lower leg wound was treated with a negative pressure wound therapy vacuum-assisted closure (VAC) dressing. Afterwards, he was qualified for a surgical wound closure with synchronous use of two reverse flow flaps: a reverse sural flap (RSF) and a reverse hemisoleus muscle flap (RHMF). Both flaps were dissected, and the RHMF was used to cover the exposed bone and the fracture site while the RSF closed the distal part of the wound. Split-thickness skin graft was meshed in scale of 1:1.5 and used to cover the RHMF and the remaining lower leg wounds. In the following days, uneventful wound healing was observed and the patient was discharged on day 34. The patient was invited for a follow-up examination two years after the procedure. His quality of life was assessed using SF-36 and Lower Extremity Functional Scale. It was determined to be satisfactory when compared to patients with identical injuries. Ultrasound examination of the gradient and blood flow velocity showed preserved graft perfusion and no structural abnormalities were detected. Adequate wound preparation and the choice of surgical technique allowed rapid healing and, above all, salvage of the limb that was at high risk of amputation.

Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study

BACKGROUND

The efficacy and safety of perforator-based propeller flaps (PPF) versus free flaps (FF) in traumatic lower leg and foot reconstructions are debated. PPFs are perceived as simpler due to advantages like avoiding microsurgery, but concerns about complications, such as flap congestion and necrosis, persist. This study aimed to compare outcomes of PPF and FF in trauma-related distal lower extremity soft tissue reconstruction.

METHODS

We retrospectively studied 38 flaps in 33 patients who underwent lower leg and foot soft tissue reconstruction due to trauma at our hospital from 2015 until 2022. Flap-related outcomes and complications were compared between the PPF group (18 flaps in 15 patients) and the FF group (20 flaps in 18 patients). These included complete and partial flap necrosis, venous congestion, delayed osteomyelitis, and the coverage failure rate, defined as the need for secondary flaps due to flap necrosis.

RESULTS

The coverage failure rate was 22% in the PPF group and 5% in the FF group, with complete necrosis observed in 11% of the PPF group and 5% of the FF group, and partial necrosis in 39% of the PPF group and 10% of the FF group, indicating no significant difference between the two groups. However, venous congestion was significantly higher in 72% of the PPF group compared to 10% of the FF group. Four PPFs and one FF required FF reconstruction due to implant/fracture exposure from necrosis. Additionally, four PPFs developed delayed osteomyelitis post-healing, requiring reconstruction using free vascularized bone graft in three out of four cases.

CONCLUSIONS

Flap necrosis in traumatic lower-leg defects can lead to reconstructive failure, exposing implants or fractures and potentially causing catastrophic outcomes like osteomyelitis, jeopardizing limb salvage. Surgeons should be cautious about deeming PPFs as straightforward and microsurgery-free procedures, given the increased complication rates compared to FFs in traumatic reconstruction.

DATA ACCESS STATEMENT

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Free peroneal artery perforator flap for reconstruction of traumatic limb soft tissue defects: A retrospective case series study

BACKGROUND

The free peroneal artery perforator (FPAP) flap is used for soft tissue defects after burns and trauma. However, the use of FPAP flaps to repair limb soft tissue defects for immediate reconstruction was rarely reported previously. Therefore, the purpose of this report is to evaluate free peroneal artery perforator flap to reconstruct traumatic limb soft tissue defects for immediate reconstruction.

PATIENTS AND METHODS

A total of 25 cases of limb soft tissue defects undergoing immediate reconstruction of FPAP flap transfer were retrospectively evaluated from January 2019 to June 2019 in our institute. The locations of defects included the palm (10 cases), finger (5 cases), foot (7 cases), ankle (2 cases) and wrist (1 case). The sizes of defect varied from 3 × 2 cm to 15 × 7 cm (54.1 cm2 in average). Flaps were harvested based on the peroneal perforator vessels, initially marked using hand-held Doppler.

RESULTS

Average size of harvested flap was 9.7 × 6.2 cm (ranging from 3.5 × 2 cm to 16 × 8 cm). All perforators were harvested from the peroneal artery and the arterial diameter ranged from 0.8 to 1.7 mm. The average pedicle length was 3.04 cm (range, 1.85-4.75 cm). Five vascular thrombosis were found including three cases of arterial thrombosis and two cases of venous thrombosis which were successfully salvaged by re-operation and vein graft. Satisfying functional outcome and acceptable appearance were achieved at 6 months or longer after surgery (range, 6-15 months, 12 months in average). All flaps survived at the end-point.

CONCLUSIONS

The FPAP flap is a reliable and thin fasciocutaneous flap, which can be used for repairing limb soft tissue defects. The FPAP flap can be used for covering defects with various appearances, locations, and sizes.