Calcaneal fillet flap: a new osteocutaneous free tissue transfer for emergency salvage of traumatic below-knee amputation stumps

Current Concepts in Lower Extremity Amputation: A Primer for Plastic Surgeons

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Understand the goals of lower extremity reconstruction and identify clinical scenarios favoring amputation. 2. Understand lower extremity amputation physiology and biomechanics. 3. Review soft-tissue considerations to achieve durable coverage. 4. Appreciate the evolving management of transected nerves. 5. Highlight emerging applications of osseointegration and strategies to improve myoelectric prosthetic control.

SUMMARY

Plastic surgeons are well versed in lower extremity reconstruction for traumatic, oncologic, and ischemic causes. Limb amputation is an increasingly sophisticated component of the reconstructive algorithm and is indicated when the residual limb is predicted to be more functional than a salvaged limb. Although plastic surgeons have traditionally focused on limb salvage, they play an increasingly vital role in optimizing outcomes from amputation. This warrants a review of core concepts and an update on emerging reconstructive techniques in amputee care.

Update in combined musculoskeletal and vascular injuries of the extremities

Combined musculoskeletal and vascular injuries of the extremities are conditions in which a multidisciplinary approach is a sine qua non to ensure life initially and limb viability secondarily. Vascular injuries as part of musculoskeletal trauma are usually the result of the release of a high energy load in the wound site so that the prognosis is determined by the degree of soft-tissue damage, duration of limb ischemia, patient’s medical status and presence of associated injuries. The management of these injuries is challenging and requires a specific algorithm of action, because they are usually characterized by increased morbidity, amputation rate, infection, neurological and functional deficits, and they could be life threatening. Although vascular injuries are rare and occur either isolated or in the context of major combined musculoskeletal trauma, the high index of suspicion, imaging control, and timely referral of the patient to organized trauma centers ensure the best functional outcome of the extremity in such challenging cases. Even after a successful initial treatment of a combined trauma pattern, long-term follow-up is crucial to prevent and detect early possible complications. The purpose of this manuscript is to provide an update on diagnosis and treatment of combined musculoskeletal and vascular injuries of the extremities, from an orthopedic point of view.

Reinventing Extremity Amputation in the Era of Functional Limb Restoration

BACKGROUND

Recent progress in biomechatronics and vascularized composite allotransplantation have occurred in the absence of congruent advancements in the surgical approaches generally utilized for limb amputation. Consideration of these advances, as well as of both novel and time-honored reconstructive surgical techniques, argues for a fundamental reframing of the way in which amputation procedures should be performed.

METHODS

We review sentinel developments in external prosthetic limb technology and limb transplantation, in addition to standard and emerging reconstructive surgical techniques relevant to limb modification, and then propose a new paradigm for limb amputation.

RESULTS

An approach to limb amputation based on the availability of native tissues is proposed, with the intent of maximizing limb function, limiting neuropathic pain, restoring limb perception/proprioception and mitigating limb atrophy.

CONCLUSIONS

We propose a reinvention of the manner in which limb amputations are performed, framed in the context of time-tested reconstructive techniques, as well as novel, state-of-the-art surgical procedures. Implementation of the proposed techniques in the acute setting has the potential to elevate advanced limb replacement strategies to a clinical solution that perhaps exceeds what is possible through traditional surgical approaches to limb salvage. We therefore argue that amputation, performed with the intent of optimizing the residuum for interaction with either a bionic or a transplanted limb, should be viewed not as a surgical failure, but as an alternative form of limb reconstruction.

Avoiding Above-the-Knee Amputation with a Free Tibiofibular-Talocalcaneal Fillet Flap and Free Latissimus Dorsi Flap

Despite the advances achieved in reconstructive surgery, amputation is still the only option after some severe traumas. Preservation of the knee joint is considered a significant functional advantage. We present the case of a 39-year-old man with a comminuted Gustilo type IIIC open tibia fracture with massive bone loss. To achieve a well-fashioned amputation stump and preserve the knee joint, a free osteocutaneous fillet flap was performed, including the distal tibia and fibula, talus, and calcaneus bones. As a result, a sensate and long amputation stump covered with thick skin from the sole of the foot provided a stable coverage with an excellent functional result and adjustment to prosthesis.

[Forearm osteomusculocutaneous free filet flap for arm reconstruction after amputation as an alternative to shoulder disarticulation]

We report the case of a 55-year-old woman suffering from a type I neurofibromatosis (also known as Von Recklinghausen neurofibromatosis) who was diagnosed with a high-grade schwannosarcoma of the median nerve, between the upper third and the medium third of the arm, upon contact with the humerus, invading the humeral vessels. The oncologic treatment of this tumour consisted in the amputation of the arm through the surgical neck of the humerus. In order to create a laterothoracic claw, to bring a partial function of the upper limb back, we decided to realize a free fillet forearm flap. This composite flap was composed of the radius and the ulna, all the forearm muscles and the skin of the anterior side of the forearm. A humeroradial plate osteosynthesis was done and the flap was then harvested with the radial pedicle, and anastomosed to the axillar artery. This procedure gave our patient a functional stump, giving back the arm functionality, especially the claw movement.

Free-fillet flap harvested in 'severe, high-energy landmine explosion' injuries of lower extremity: a case report

Fillet flaps harvested from the non-replantable or unsalvageable amputated segment can be used to cover tissue defects. We discuss the case of a patient who had suffered a severe high-energy landmine injury, including severe leg damage, resulting in a below-knee amputation and soft-tissue defect around the forearm region. We successfully harvested the fillet from the amputated part of the extremity to the forearm region. We conclude that harvesting of a fillet flap from severely injured lower extremity, resulting from a high-energy landmine explosion, is technically feasible.

Free fillet foot flap for salvage of below-knee amputation stump

Management of extensive bone and soft tissue defects, which occur after severe trauma of lower extremities and always lead to an unacceptable amputation in some cases, continues to challenge reconstructive surgeons. When performing lower extremity amputation, preservation of the knee joint has been put into a higher priority. The benefit of below-knee amputation over above-knee ones concentrates on a more normal gait with less energy expenditure during ambulation when a functioning knee joint is present.

[Crossover extremity transfers. Limb salvage in amputations with segmental defects]

Clinical conditions in which crossover extremity transfer should be considered are rare. In the case of bilateral amputation associated with extensive proximal segmental injury, ectopic implantation could be an additional concept for two-stage limb salvage. If replantation is impossible due to segmental damage of the amputated part, at least uninvolved tissue should be harvested for stump lengthening or improving soft-tissue at the ends. The case of a 34-year-old man with segmental amputation of the left forearm and left lower leg and mutilated amputation of the right hand caused by a train accident is presented. Limb salvage was performed by cross-hand replantation and modified rotationplasty of the left foot as a stump lengthening procedure.

Crossover Replantation of the Foot After Bilateral Traumatic Lower Extremity Amputation

BACKGROUND

Bilateral traumatic amputation and limb-threatening injury of the lower extremities is more challenging than the unilateral amputation. Successful replantation of both lower extremities has been reported previously. However, orthotopic implantations may not be possible when amputation of both lower limbs with different levels of section and degrees of damage to surrounding tissues occurs. It was reported that the crossover replanted foot in combination with prosthetic limb is better than 2 artificial limbs. Hence, crossover replantation should be considered when anatomic replantation of both lower extremities is not possible as a result of bilateral total or subtotal amputation. To our knowledge, there are few reports about the crossover replantation of the lower extremity in the literature.

CASE REPORT

A 30-year-old engineer being run over by the train had crushed the bilateral lower limbs in different anatomic levels. We decided to perform the crossover replantation of the right foot to the stump of the left leg to provide the patient with at least 1 weight-bearing sensate extremity. At the latest follow-up examination, 30 months after the operation, he had mild pain, especially in toes of the replanted foot. There was no ulceration in both the replanted extremity and the right amputation stump. The sole has maintained complete protective sensation. The patient described the functional result of the reimplanted leg as satisfying and better than the prosthesis that has caused much more problems than the replanted extremity. He had no complaint about the cosmetic result. He stated that he would have the crossover replantation again under the same condition. He was able to return to his previous job. Moreover, he affirmed that he is able to carry on his all social activities as he had done before the accident except for playing football. In conclusion, the possibility of the crossover replantation should be considered while evaluating the patient with bilateral lower limb injuries to allow the patient to stand on their own foot and still touch ground.

Hindfoot containment orthosis for management of bone and soft-tissue defects of the heel

BACKGROUND

Bone, soft-tissue, and nerve deficits of the weightbearing surface of the foot are frequent sequelae from foot trauma or diabetes mellitus and present challenging treatment issues. Injury to the specialized, shock-absorbing, heel-pad tissue containing spirally arranged fat chambers is particularly difficult to manage. Appropriate footwear modifications and shoe inserts for protection of this skin are essential to the long-term management of bone and soft-tissue defects of the heel. This study evaluated the performance of a new custom total contact foot orthosis (Hindfoot Containment Orthosis, HCO) which was designed to contain the soft tissues of the heel, reduce shear forces, redistribute weightbearing load, and accommodate bone or soft-tissue deformity of the heel.

METHODS

Twenty-two patients treated with HCO were retrospectively reviewed. Followup averaged 26 months. The effectiveness of the orthosis was assessed by how well the integrity of the soft tissue was maintained (e.g. the number of ulcerations since dispensing the orthosis), the number of refabrications of the orthosis that were required, and whether or not revision surgery was required.

RESULTS

Ten patients had superficial ulcerations. No patient required revision surgery. A total of 62 refabrications of the orthoses in 22 patients were required over a 2-year period. Overall results were good in 17 (77%) patients, fair in four (18%), and poor in one.

CONCLUSIONS

The HCO is effective for preservation of soft-tissue integrity of the heel pad after bony or soft-tissue injury. Important factors in achieving success with the HCO are patient compliance and periodic monitoring for refabrication of the orthosis to accommodate skeletal growth, change in foot size or shape, and compression or wear of insert materials.

Microsurgical free flap transfer to amputation sites: indications and results

A series of microsurgical free flap reconstructions to amputation stumps of the upper as well as the lower extremities was reviewed in 7 male and 2 female patients. Indications included preservation of length after trauma in 6 patients and cure of local infection in 2 patients. In 1 patient an extensive defect after resection of a recurrent shoulder sarcoma required use of a complete arm fillet free flap for tumor reconstruction. Microvascular free flaps used included four scapular flaps, two fillet flaps from the amputated extremity, one anterolateral thigh flap, and one lateral arm flap. Seven of 9 patients were fitted with a prosthesis and underwent occupational therapy resulting in ambulatory and improved functional status. Microvascular reconstruction is indicated in emergency settings as well as for elective reconstruction of amputation sites. Using uninjured "spare parts" of the amputated extremity should be considered. Elective reconstruction is performed preferably with free flaps based on the subscapular vascular system.

The concept of fillet flaps: classification, indications, and analysis of their clinical value

Tissue of amputated or nonsalvageable limbs may be used for reconstruction of complex defects resulting from tumor and trauma. This is the "spare parts" concept. By definition, fillet flaps are axial-pattern flaps that can function as composite-tissue transfers. They can be used as pedicled or free flaps and are a beneficial reconstruction strategy for major defects, provided there is tissue available adjacent to these defects.From 1988 to 1999, 104 fillet flap procedures were performed on 94 patients (50 pedicled finger and toe fillets, 36 pedicled limb fillets, and 18 free microsurgical fillet flaps). Nineteen pedicled finger fillets were used for defects of the dorsum or volar aspect of the hand, and 14 digital defects and 11 defects of the forefoot were covered with pedicled fillets from adjacent toes and fingers. The average size of the defects was 23 cm2. Fourteen fingers were salvaged. Eleven ray amputations, two extended procedures for coverage of the hand, and nine forefoot amputations were prevented. In four cases, a partial or total necrosis of a fillet flap occurred (one patient with diabetic vascular disease, one with Dupuytren's contracture, and two with high-voltage electrical injuries).Thirty-six pedicled limb fillet flaps were used in 35 cases. In 12 cases, salvage of above-knee or below-knee amputated stumps was achieved with a plantar neurovascular island pedicled flap. In seven other cases, sacral, pelvic, groin, hip, abdominal wall, or lumbar defects were reconstructed with fillet-of-thigh or entire-limb fillet flaps. In five cases, defects of shoulder, head, neck, and thoracic wall were covered with upper-arm fillet flaps. In nine cases, defects of the forefoot were covered by adjacent dorsal or plantar fillet flaps. In two other cases, defects of the upper arm or the proximal forearm were reconstructed with a forearm fillet. The average size of these defects was 512 cm2. Thirteen major joints were salvaged, three stumps were lengthened, and nine foot or forefoot amputations were prevented. One partial flap necrosis occurred in a patient with a fillet-of-sole flap. In another case, wound infection required revision and above-knee amputation with removal of the flap.Nine free plantar fillet flaps were performed-five for coverage of amputation stumps and four for sacral pressure sores. Seven free forearm fillet flaps, one free flap of forearm and hand, and one forearm and distal upper-arm fillet flap were performed for defect coverage of the shoulder and neck area. The average size of these defects was 432 cm2. Four knee joints were salvaged and one above-knee stump was lengthened. No flap necrosis was observed. One patient died of acute respiratory distress syndrome 6 days after surgery. Major complications were predominantly encountered in small finger and toe fillet flaps. Overall complication rate, including wound dehiscence and secondary grafting, was 18 percent. This complication rate seems acceptable. Major complications such as flap loss, flap revision, or severe infection occurred in only 7.5 percent of cases. The majority of our cases resulted from severe trauma with infected and necrotic soft tissues, disseminated tumor disease, or ulcers in elderly, multimorbid patients. On the basis of these data, a classification was developed that facilitates multicenter comparison of procedures and their clinical success. Fillet flaps facilitate reconstruction in difficult and complex cases. The spare part concept should be integrated into each trauma algorithm to avoid additional donor-site morbidity and facilitate stump-length preservation or limb salvage.