Gait asymmetries after fibular free flap harvest: A cross-sectional observational study

BACKGROUND

The ability to walk safely after head and neck reconstruction with fibular free flaps in tumor surgery is a high priority for patients. In addition, surgeons and patients require objective knowledge of the functional donor-site morbidity. However, the effects of fibular free flap surgery on gait asymmetries have only been studied for step length and stance duration. This study analyses whether patients who have undergone fibular free flap reconstruction have enduring gait asymmetries compared to age-matched controls.

METHODS

Patients who underwent head and neck reconstruction with fibular free flaps between 2019 and 2023 were recruited, as well as age-matched controls. Participants walked on an instrumented treadmill at 3 km/h. The primary outcome measures were 22 gait asymmetry metrics. Secondary outcome measures were the associations of gait asymmetry with the length of the harvested fibula, and with the time after surgery.

FINDINGS

Nine out of 13 recruited patients completed the full assessment without holding on to the handrail on the treadmill. In addition, nine age-matched controls were enrolled. Twenty out of the 22 gait asymmetry parameters of patients were similar to healthy controls, while push-off peak force (p = 0.008) and medial impulse differed (p = 0.003). Gait asymmetry did not correlate with the length of the fibula harvested. Seven gait asymmetry parameters had a strong correlation with the time after surgery.

INTERPRETATION

On the long-term, fibular free flap reconstruction has only a limited effect on the asymmetry of force-related and temporal gait parameters while walking on a treadmill.

Quality of life and subjective donor-site morbidity in patients after a free fibula flap

INTRODUCTION

We evaluated the subjective donor-site morbidity and quality of life in patients with a free fibula flap (FFF) reconstruction in terms of self-reported symptoms, function and quality of life, and we compared inclusion vs. exclusion of the flexor hallucis longus (FHL) muscle in the graft, primary wound closure vs. skin graft and the occurrence vs. absence of donor-site complications.

METHODS

In this cross-sectional study, patients who underwent a mandibula or maxilla reconstruction with a FFF between 2011 and 2021, were included. Symptoms and function were measured with the Foot and Ankle Outcome Score (FAOS) and quality of life with both FAOS and a Visual Analogue Scale (VAS).

RESULTS

Thirty-four patients were included in the analyses (mean age 59 years, 59% males). Most patients underwent a mandibular reconstruction for a malignancy. The median FAOS domain scores ranged between 92.9 (interquartile range (IQR) 77.7-100.0) and 100.0 (IQR 88.2-100.0) points, and the median VAS score was 86.5 points. No statistically significant differences were found between inclusion vs. exclusion of the FHL, primary wound closure vs. graft and occurrence vs. absence of donor-site complications. An unfavorable trend was seen for inclusion of the FHL in the flap on recreational functioning, and quality of life.

CONCLUSION

Patients who underwent a FFF experience little donor-site morbidity and high quality of life, as measured by FAOS and VAS.

Comparison of split thickness skin graft versus full thickness skin graft for radial forearm flap donor site closure: A systematic review and Meta-analysis

BACKGROUND

The radial forearm flap (RFF) is one of the most commonly used flaps in reconstructive surgery. Split-thickness skin grafting (STSG) has traditionally been used for closure of the forearm. However, full-thickness skin grafting (FTSG) has gained in popularity to achieve more satisfactory results. The aim of the study is to identify the best RFF donor site closure technique by comparing the functional and aesthetic outcomes of STSG and FTSG.

METHODS

PubMed and EMBASE databases were queried. Only studies comparing complications rate, functional and aesthetic outcomes between STSG and FTSG were included. The primary outcome was graft failure rate. Secondary outcomes included the aesthetic result and functionality of the forearm/wrist.

RESULTS

A total of 13 studies were included in this review, accounting for a total of 712 patients with mean age of 60.7 years. Overall, 348 patients underwent FTSG and 377 underwent STSG. The mean follow-up was 14.7 months. The rate of graft failure in FTSG was significantly higher compared to STSG (OR: 2.79, 95 % CI 1.38-5.65, p = 0.004). There was no significant difference in rate of tendon exposure (OR: 0.83, p = 0.65) and infection (OR: 1.37, p = 0.42). Regarding the aesthetic outcome, no significant difference between FTSG and STSG based on observer (SMD = -0.37, p = 0.17) and patient (SMD = -0.016, p = 0.93) assessment, respectively. Overall postoperative functional assessment showed a not severely impaired hand and arm function in both groups. Subjective evaluation of pain was similar between groups.

CONCLUSION

FTSG is associated with higher risk of graft failure than STSG in RFF donor site closure, without significant improvement in aesthetic results.

Long-term patient-reported donor-site morbidity after free peroneal fasciocutaneous flap in head and neck reconstruction

OBJECTIVE

Fasciocutaneous free flap based on the peroneal artery (boneless version) is an option in our practice for head and neck reconstruction. However, the associated donor-site morbidity has rarely been discussed. Thus, this study investigated the long-term patient-reported donor-site morbidity associated with peroneal flaps.

METHODS

In this single-center, retrospective, observational study, 39 patients who underwent a free peroneal flap were enrolled. We evaluated donor-site morbidity with a modified questionnaire from Enneking et al. and Bodde et al.

RESULTS

Patient-reported daily life limitation was relatively low (5/39; 12.9%). Donor-site morbidities, namely pain (4/39; 10.3%), sensory disturbance (9/39; 23.1%), and walking limitation (9/39; 23.1%) were reported; most were rated minimal in severity. Among patients with walking limitation, muscle weakness (3/39; 7.7%), ankle instability (6/39; 15.4%), and gait alternation (6/39; 15.4%) were reported. Six patients developed claw toe.

CONCLUSION

Balancing successful reconstruction and donor-site morbidity is challenging. This long-term patient-reported survey revealed that harvesting peroneal flaps resulted in minimal or minor donor-site morbidity with no obvious impacts on the patients' daily quality of life. Although free radial forearm flaps and anterolateral thigh flaps are standard, free peroneal flaps have been proven reliable, with acceptable donor-site morbidity.

Donor-site morbidity of free fibula flap in pediatric patients: A systematic review and meta-analysis

The morbidity of free fibula flap (FFF) in pediatric patients has gained attention. Thus, we aimed to evaluate donor-site morbidity after FFF harvesting in pediatric patients and its relationship with age. A systematic literature search of databases for cross-sectional studies related to pediatric donor-site morbidity after FFF harvesting was performed. Two independent reviewers evaluated relevant article titles and abstracts to extract data regarding donor-site morbidity from each article. Fifteen studies were included in the meta-analysis that evaluated the rate of complications. Individual cases of ankle instability were divided into the 0-13- and 13-17-year-old groups. The Chi-square test was used to compare ankle instability between both groups. A logistic regression model was created to analyze the relationships between age and ankle instability/claw toe. Sixteen English articles published between 2007 and 2021 were included in the systematic review. Information on morbidities of 294 cases in which FFF was used was collected. The mean incidence rate of complications, instability, claw toe, and nerve injury were 19.3%, 12.9%, 5.9%, and 5.1%, respectively. Bivariate analysis showed that age was significantly correlated with the incidence of ankle instability but not with the incidence of claw toe. The Chi-square test showed that the incidence rate of ankle instability between the age groups was significantly different. Therefore, we recommend 14 years of age as a new predictive factor for ankle instability. Nevertheless, there is limited evidence in this field, and more pediatric research is needed to clarify these findings.

Quadriceps tendon autograft for primary anterior cruciate ligament reconstruction show comparable clinical, functional, and patient-reported outcome measures, but lower donor-site morbidity compared with hamstring tendon autograft: A matched-pairs study with a mean follow-up of 6.5 ​years

OBJECTIVES

To compare clinical and functional outcomes of patients after primary anterior cruciate ligament reconstruction (ACLR) using quadriceps tendon- (QT-A) and hamstring tendon (HT-A) autograft with a minimum follow-up (FU) of 5 years.

METHODS

Between 2010 and 2014, all patients undergoing ACLR were recorded in a prospectively administered database. All patients with primary, isolated QT-A ACLR and without any concomitant injuries or high grade of osteoarthritis were extracted from the database and matched to patients treated with HT-A. Re-rupture rates, anterior-posterior (ap) knee laxity, single-leg hop test (SLHT) performance, distal thigh circumference (DTC) and patient-reported outcome measures (PROMs) were recorded. Between group comparisons were performed using chi-square-, independent-samples T- or Mann-Whitney-U tests.

RESULTS

45 QT-A patients were matched to 45 HT-A patients (n ​= ​90). The mean FU was 78.9 ​± ​13.6 months. 18 patients (20.0%/QT-A: N ​= ​8, 17.8%; HT-A: n ​= ​10, 22.2%; p ​= ​.60) sustained a graft rupture and 17 subjects (18.9%/QT-A: n ​= ​9, 20.0%; HT-A: n ​= ​8, 17.8%; p ​= ​.79) suffered a contralateral ACL injury. In high active patients (Tegner activity level ≥ 7) rerupture rates increased to 37.5% (HT-A) and 22.2% (QT-A; p ​= ​.32), respectively. Patients with graft failure did not differ between both groups in terms of mean age at surgery (QT-A: 26.5 ​± ​11.6 years, HT-A: 23.3 ​± ​9.5 years, p ​= ​.63) or graft thickness (mean graft square area: QT-A: 43.6 ​± ​4.7 mm², HT-A: 48.1 ​± ​7.9 mm², p ​= ​.27). No statistical between-group differences were found in ap knee laxity side-to-side (SSD) measurements (QT-A: 1.9 ​± ​1.2 ​mm, HT-A: 2.1 ​± ​1.5 ​mm; p ​= ​.60), subjective IKDC- (QT-A: 93.8 ​± ​6.8, HT-A: 91.2 ​± ​7.8, p ​= ​.17), Lysholm- (QT-A 91.9 ​± ​7.2, HT-A: 91.5 ​± ​9.7, p ​= ​.75) or any of the five subscales of the KOOS score (all p ​> ​.05). Furthermore, Tegner activity level (QT-A: 6(1.5), HT-A: 6(2), p ​= ​.62), VAS for pain (QT-A: 0.5 ​± ​0.9, HT-A: 0.6 ​± ​1.0, p ​= ​.64), Shelbourne-Trumper score (QT-A: 96.5 ​± ​5.6, HT-A: 95.2 ​± ​8.2, p ​= ​.50), Patient and Observer Scar -Assessment scale (POSAS) (QT-A: 9.4 ​± ​3.2, HT-A: 10.7 ​± ​4.9, p ​= ​.24), SSD-DTC (QT-A: 0.5 ​± ​0.5, HT.- A: 0.5 ​± ​0.6, p ​= ​.97), return to sports rates (QT-A: 82.1%, HT-A: 86.7%) and SLHT (QT -A: 95.9 ​± ​3.8%, HT-A: 93.7 ​± ​7.0%) did not differ between groups. Donor-site morbidity (HT-A n ​= ​14, 46.7%; QT-A n ​= ​3, 11.5%; p ​= ​.008) was statistically significantly lower in the QT-A group. Five patients (11.1%) of the HT-group and three patients (6.7%) in the QT-group required revision surgery (p ​= ​.29).

CONCLUSION

Patient-reported outcome measures, knee laxity, functional testing results and re-rupture rates are similar between patients treated with QT- and HT- autografts. However, patients with QT-autograft have a smaller tibial postoperative scar length and lower postoperative donor-site morbidity. There is a tendency towards higher graft rupture rates in highly active patients treated with HT autograft.

LEVEL OF EVIDENCE

II.

The Use of Semi-Absorbable Mesh and its Impact on Donor-Site Morbidity and Patient-Reported Outcomes in DIEP Flap Breast Reconstruction

BACKGROUND

This study aimed to evaluate the impact of semi-absorbable mesh on donor-site morbidity and patient-reported outcomes in deep inferior epigastric perforator (DIEP) flap breast reconstruction.

METHODS

We conducted a retrospective cohort study of all patients who had DIEP flap breast reconstruction in our department from July 2007 to March 2019. Patients were invited to a comparative follow-up visit and grouped according to donor-site closure: primary fascial closure (the no-mesh group) and fascial reinforcement with semi-absorbable mesh in a subfascial position (the mesh group). The primary outcome of interest was donor-site morbidity, including bulging, hernia formation and rectus abdominis muscle strength. We also surveyed, surgical site complications and patient-reported outcomes using Patient and Observer Scar Assessment Scale v2.0 and BREAST-Q^© version 2.0.

RESULTS

A total of 191 patients had received DIEP flap breast reconstruction. Eighty-five patients (44.5%) with 108 DIEP flaps (53 patients in the mesh group and 32 patients in the no-mesh group) were included in the study. The mean BMI of the patients was significantly higher in the mesh group (mesh group, 26.9 vs. no-mesh group, 25.0, with p = 0.03). The incidence of hernia was significantly reduced in the mesh group (mesh group, 2.8% vs. no-mesh group, 13.5%, with p = 0.03). The incidence of bulging and the extent of rectus abdominis muscle strength were similar for both groups. Operative surgical site complications were reduced in the mesh group (mesh group, 7.5% vs. no-mesh group, 18.8%). There was no difference in patients' physical well-being and satisfaction with the donor site between groups. Patient-reported scar outcome was significantly better in the no-mesh group (p < 0.001).

CONCLUSION

Our novel method of donor-site closure with semi-absorbable mesh in a subfascial position for reinforcement of the anterior rectus fascia on the DIEP donor site is safe. It has no negative impact on surgical site complications and patient-reported outcomes, while reducing the incidence of hernias on the donor-site in DIEP flap breast reconstruction.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Impact of wound closure on fibular donor-site morbidity: a meta-analysis

Background

Vascularized free fibular flaps have been the “workhorses” for reconstruction of many kinds of bone defects. Nevertheless, there is no consensus regarding the optimal wound closure method for fibular donor sites. This study aimed to compare prognostic outcomes of primarily closures (PC) and skin grafts (SG) for fibular donor sites.

Methods

Studies regarding donor-site outcomes of PC versus SG in patients undergoing free fibular flap procedures were included. Two authors individually searched PubMed, Web of Science, EMBASE, Cochrane Library and clinicaltrials.gov up to February 2019, extracted the data and assessed quality of each selected article. Ultimately, The incidences of donor-site morbidities were evaluated.

Results

Five studies with a total of 119 patients were included in our analysis. No significant differences were found with respect to the rates of donor-site problems between the PC and SG groups.

Conclusions

Fibular flap patients undergoing PC and SG wound closures may have similar donor-site outcomes. Additional large-scale studies are necessary to draw a solid conclusion.

Electronic supplementary material

The online version of this article (10.1186/s12893-019-0545-1) contains supplementary material, which is available to authorized users.

The impact of harvest length and detachment of the interosseous membrane on donor-site morbidity following free fibula flap surgery-a biomechanical experimental study

PURPOSE

The fibula flap has been established for orofacial reconstruction following ablative surgery. Donor-site morbidity of the lower leg may be explained by the harvest technique and particularly by detachment of the M. extensor halluces longus (EHL) and M. extensor digitorum longus (EDL).

MATERIAL AND METHODS

On cadaveric lower leg specimens, the tendons of the EHL and EDL were dissected at the proximal phalanges and loaded with corresponding weights. The average displacement of the muscle was evaluated during the harvesting procedure.

RESULTS

Cumulative detachment of the interosseous membrane caused considerable displacement of the EHL but less impairment of the EDL. Segmental and cumulative osteotomy of the fibula implicated significant displacement of both EHL and EDL.

CONCLUSION

A recommendation can be given for cautious selection of osteotomy site of the fibula and for limited sacrifice of the fibula and adjacent attachments of the extensors to keep local-site morbidity at a minimum.

Knee donor-site morbidity after mosaicplasty - a systematic review

BACKGROUND

Mosaicplasty has been associated with good short- to long-term results. Nevertheless, the osteochondral harvesting is restricted to the donor-site area available and it may lead to significant donor-site morbidity.

PURPOSE

Provide an overview of donor-site morbidity associated with harvesting of osteochondral plugs from the knee joint in mosaicplasty procedure.

METHODS

Comprehensive search using Pubmed, Cochrane Library, SPORTDiscus and CINAHL databases was carried out through 10th October of 2016. As inclusion criteria, all English-language studies that assessed the knee donor-site morbidity after mosaicplasty were accepted. The outcomes were the description and rate of knee donor-site morbidity, sample's and cartilage defect's characterization and mosaicplasty-related features. Correlation between mosaicplasty features and rate of morbidity was performed. The methodological and reporting quality were assessed according to Coleman's methodology score.

RESULTS

Twenty-one studies were included, comprising a total of 1726 patients, with 1473 and 268 knee and ankle cartilage defects were included. The defect size ranged from 0.85 cm2 to 4.9 cm2 and most commonly 3 or less plugs (averaging 2.9 to 9.4 mm) were used. Donor-site for osteochondral harvesting included margins of the femoral trochlea (condyles), intercondylar notch, patellofemoral joint and upper tibio-fibular joint. Mean donor-site morbidity was 5.9 % and 19.6 % for knee and ankle mosaicplasty procedures, respectively. Concerning knee-to-knee mosaicplasty procedures, the most common donor-site morbidity complaints were patellofemoral disturbances (22 %) and crepitation (31 %), and in knee-to-ankle procedures there was a clear tendency for pain or instability during daily living or sports activities (44 %), followed by patellofemoral disturbances, knee stiffness and persistent pain (13 % each). There was no significant correlation between rate of donor-site morbidity and size of the defect, number and size of the plugs (p > 0.05).

CONCLUSIONS

Osteochondral harvesting in mosaicplasty often results in considerable donor-site morbidity. The donor-site morbidity for knee-to-ankle (16.9 %) was greater than knee-to-knee (5.9 %) mosaicplasty procedures, without any significant correlation between rate of donor-site morbidity and size of the defect, number and size of the plugs. Lack or imcomplete of donor-site morbidity reporting within the mosaicplasty studies is a concern that should be addressed in future studies.

LEVEL OF EVIDENCE

Level IV, systematic review of Level I-IV studies.

Progressive valgus deformity of the donor-site ankle after extraperiosteal harvesting the fibular shaft in children. Treatment with osteotomy and synostosis at one session

After extraperiosteal harvesting of the fibular shaft in children, progressive valgus deformity of the donor-site ankle may pose a serious problem. We present three illustrative case-histories: three children became functionally impaired and required surgery. Pathogenesis, natural history and surgical options are discussed. A supramalleolar osteotomy combined with a distal fibular-tibial synostosis is a good option to correct valgus and eliminate instability in one surgical session.

Objective and subjective evaluation of donor-site morbidity after nipple sharing for nipple areola reconstruction

Nipple reconstruction is of importance in achieving the best possible aesthetic outcome after breast reconstruction. Nipple sharing is a common technique; this study focused on the potential morbidity at the donor nipple. Between 2008 and 2012, 26 patients underwent nipple sharing at our institution. The donor nipple was examined before and after the procedure (mean follow-up of 21 months). Sensitivity, projection, diameter, and patient satisfaction were evaluated. The sensitivity in the donor nipple decreased, albeit insignificantly, from 1.2 g/mm2 (0.8-1.6) to 1.8 g/mm2 (0.8-4.8) (p=0.054, n=26). The projection due to graft removal decreased from 8.0 mm (6.8-10.0) to 4.5 mm (4.0-5.0) (p=0.001). Of the patients, 88% were "very satisfied" or "somewhat satisfied" with the sensitivity and 89% with the symmetry between the donor and reconstructed nipple. At least 60% of the patients were "very satisfied" with all aesthetic outcome parameters (projection, appearance, naturalness, color, and shape). All patients would agree to undergo this procedure again, if necessary. Nipple sharing was associated with minimal morbidity at the donor nipple. The postoperative projection was adequate. Regardless of whether simultaneous mastopexy was performed, the loss of sensitivity was minimal and presumably imperceptible to the patient. By using no sutures after graft removal and letting the donor nipple heal spontaneously, scarring was minimized and the natural appearance and good sensitivity of the donor nipple were preserved.

Donor-site morbidity of the inferior gluteal artery perforator flap for breast reconstruction in teenagers

BACKGROUND/OBJECTIVE

Few options, apart from the buttock area, are available for autologous breast reconstruction in thin teenagers. The aim of the present study was to objectively evaluate and compare donor-site morbidity of the inferior gluteal artery perforator (IGAP) flap with that of the previously described inferior gluteal musculocutaneous flap.

METHOD

A retrospective review of all IGAP flaps for breast reconstruction performed in teenagers between June 2006 and April 2011 at the Centre Hospitalier Universitaire Sainte-Justine, Montreal, Quebec, was performed. Patients were invited to undergo a specific physical evaluation and complete a questionnaire on aesthetic and functional outcomes.

RESULTS

Thirteen records and 11 photographic charts were reviewed. Lateral buttock flattening was noticeable in nine of 11 cases. Three patients experienced some degree of inferior displacement of the gluteal crease. All six patients available for the appointment presented with a zone of dysesthesia or hypoesthesia in the territory of the operated buttock and/or posterior thigh. No motor impairment was found. The questionnaire, completed by eight patients, revealed that six were satisfied or very satisfied with the surgery. Appearance of the operated buttock was rated 3.4 on a scale from 1 to 5 (5 = normal) compared with the normal side.

CONCLUSIONS

The IGAP flap remains a suitable option for breast reconstruction in slim teenagers. Similar to the myocutaneous flap, the major donor-site morbidity of the IGAP flap remains sensory impairment involving the posterior femoral cutaneous nerve. There is, however, less visible lateral depression when it is harvested as a perforator flap.