Pedicled sural flaps versus free anterolateral thigh flaps in reconstruction of dorsal foot and ankle defects in children: a systematic review

BACKGROUND

This systematic review compared free anterolateral thigh (ALT) flaps versus pedicled distally based sural artery (DBSA) flaps for reconstruction of soft tissue defects of dorsal foot and ankle in children.

METHODS

A systematic literature search was performed to identify cases where an ALT or DBSA was used to reconstruct the dorsal foot in children. A total of 19 articles were included in the systematic review.

RESULTS

Eighty-three patients underwent an ALT reconstruction and 138 patients underwent a DBSA reconstruction. Patients who had a DBSA were more likely to require grafting of the donor site (P<0.001). The size of ALT flaps was significantly larger than DBSA flaps (P=0.002). Subsequent flap thinning was required in 30% of patients after ALT and 12% of patients after DBSA reconstruction (P<0.001). Complications occurred in 11.6% of DBSA and 8.4% of ALT flaps (8.4%).

CONCLUSIONS

Both flaps are valid options in reconstructing pediatric foot and ankle defects. Each flap has advantages and disadvantages as discussed in this review article. In general for larger defects, an ALT flap was used. Flap choice should be based on the size of the defect.

Free flap and kickstand external fixator in foot and ankle soft tissue reconstruction. The versatility of a microsurgical-friendly application of an orthopedic device

INTRODUCTION

Foot and ankle are prone to injuries and often require free flap for complex soft tissue reconstruction due to the insufficiency of local soft tissue. Lower limb reconstruction can be commonly compromised by venous insufficiency, and the elevation of the limb represents a critical component of the postoperative care. This study aims to explore the versatility of combining free soft tissue flap reconstruction for complex foot and ankle defect with a temporary Kickstands External Fixator (KEF) placement.

MATERIALS AND METHODS

A retrospective analysis was performed on 14 patients with unilateral foot or ankle complex soft tissue defects (post-traumatic, soft tissue infection and osteomyelitis, chronic skin ulcer, sarcoma), treated with free flap and KEF placement. Patients' demographics, etiology of injury, type of reconstruction, duration of KEF, complications related to the flap and the KEF placement were recorded.

RESULTS

The mean age of patients was 52.57-year-old (range 35-68). The average follow up was 15.5 months (range: 3-25). An anterolateral thigh (ALT) flap was performed in 12 patients; 2 patients received composite forearm free flap plus flexor carpalis radial for Achilles tendon reconstruction. The average time for KEF removal was 378 weeks. All flaps survived, though partial necrosis was observed in 1 case. No complication at the flap donor site or related to the KEF placement was observed. No equinus deformity was reported.

CONCLUSION

The KEF placement when performing a complex soft tissue free flap reconstruction of foot and ankle could be an effective method to guarantee limb elevation, avoid pressure on the flap especially in posterior reconstructions, avoid heel pressure ulcer formation and equinus deformity.

The "nugget design": A modified segmental gracilis free flap for small-sized defect reconstruction on the lower extremity

BACKGROUND

Little attention has been given to the segmental free gracilis muscle flap supplied by secondary proximal pedicles. We introduce a technical refinement for small-sized three-dimensional defect reconstruction on the foot.

METHODS

Between November 2013 and August 2016, three patients with a mean age of 66 years (range 47-70 years) were included. A segmental gracilis free flap supplied by the most proximal secondary pedicle was harvested according to a modified "nugget design" to treat small-sized defects on the lower extremity requiring dead space reconstruction. Minor and major complications, sensitivity with Semmes-Weinstein monofilament test, soft tissue stability and patient satisfaction at final follow-up were recorded.

RESULTS

In one case, a segmental gracilis muscle was used for dorsal foot reconstruction after debridement of metatarsal phalanx I with osteomyelitis. In two cases, the segmental gracilis free muscle was harvested for defect reconstruction on the right plantar foot after excision of a melanoma. The first patient required revision after partial failure of the initial segmental gracilis free muscle flap. Overall, good results in foot function and a high degree of patient satisfaction was achieved (Likert scale 9.7, range 9-10) after a mean follow-up of 13 months (range 3-24 months).

CONCLUSIONS

Taken from the very proximal dorsal part of the gracilis muscle supplied by the most proximal secondary pedicle and leaving the vast majority of the muscle intact preserves the option to harvest a normal gracilis flap. This technique is especially suitable for small, three-dimensional defects on the lower extremity.

Orthobiologics in Pediatric Orthopedics

Orthobiologics are biologic devices or products used in orthopedic surgery to augment or enhance bone formation. The use of orthobiologics in pediatric orthopedics is less frequent than in other orthopedic subspecialties, mainly due to the naturally abundant healing potential and bone formation in children compared with adults. However, orthobiologics are used in certain situations in pediatric orthopedics, particularly in spine and foot surgery. Other uses have been reported in conjunction with specific procedures involving the tibia and pelvis. The use of bioabsorable implants to stabilize children's fractures is an emerging concept but has limited supporting data.

A comparison of axial circumference between superficial circumflex iliac artery perforator flap and other workhorse flaps in dorsal foot reconstruction

BACKGROUND

Management and reconstruction of dorsal foot defects present various difficulties and challenges. The main purpose of this article is to discuss experiences of using superficial circumflex iliac perforator (SCIP) flap in various defects of the dorsal foot region.

METHODS

From August 2012 to February 2015, a total of 13 patients - nine males and four females - received a reconstruction operation for dorsal foot defects using SCIP flaps (the SCIP group). The defects were caused by trauma (n = 9), diabetes (n = 3), and malignancy (n = 1). The mean age was 43.07 years, which ranged between 19-70 years. Additionally, 19 other patients, who underwent reconstruction operation of the foot dorsum using ALT and TDAP flaps during the same study period, were recruited for comparison. The axial circumference of the operated foot and unoperated contralateral foot was measured, and the difference were compared between all patients, as well as between the two groups.

RESULTS

All of the flaps survived after the operation, but secondary procedures were performed in two cases due to partial skin necrosis. The mean follow-up period was 13 months. The mean axial circumference discrepancy of the SCIP group (12.08 ± 2.96 mm) was significantly lower compared with ALT (25.21 ± 3.16 mm) and TDAP (29.88 ± 1.55 mm) groups (p < 0.01).

CONCLUSIONS

The authors experienced good results with using the SCIP flap in dorsal foot reconstruction. Reconstruction with the SCIP flap can be a good surgical option, with better postoperative symmetry and minimal donor sequelae, compared to conventional workhorse flaps.

Composite neuromusculo-fasciocutaneous triceps brachii free flap for complex foot reconstructive surgery

Since it was first described by Song in 1982, then by Katsaros in 1984, the lateral arm flap has become a workhorse technique for upper limb reconstruction. Herein we describe a clinical case of complex foot defect and bring up the possibility of using a composite neuromusculo-fasciocutaneous lateral arm/triceps free flap for its reconstruction. A 19-year-old male nonsmoker suffered ballistic trauma to his right foot with open multifragment Gustilo-IIIb fractures of the first to fifth metatarsal bones. Two weeks after debridement and V.A.C.™ therapy performed in another hospital, we decided to reconstruct the remaining defect with a neuromusculo-fasciocutaneous medial triceps/lateral arm free flap anastomosed with the anterior tibial pedicle. The posterior brachial cutaneous nerve was sutured to a sensory branch of the superficial fibular nerve. The advantages and drawbacks of this technique are discussed and other options for this type of complex foot reconstruction are reviewed. After 3 years' follow-up, the metatarsal bones were consolidated without residual defect or chronic infection. The foot had sensation with full mobility and no pain. At the donor site, there was no complaint of scarring. Elbow extension/flexion was 0-0-130. Wrist extension/flexion was 60-0-60 and there was no extension deficit of the metacarpophalangeal joints. The composite neuromusculo-fasciocutaneous triceps brachii free flap was an excellent option for this complex foot defect. The choice of this reconstructive procedure among other options was made during our reconstruction board meeting while taking the patient's specific condition and our own experiences into account.

Microvascular reconstruction of complex foot defects, a new anatomo-functional classification

Up until recently severe foot defects have been underestimated and amputation considered the treatment of choice. Inadequate treatment of foot defects is generally responsible for impaired deambulation resulting in physical and psychological handicap to the patient and producing a negative impact on social life. Foot reconstruction represents a recent advancement but is still a great challenge to the plastic surgeon; indeed the absence of a comprehensive anatomical classification of foot defects makes sharing clinical experiences difficult, slowing down the progress in this field. We report a single surgeon experience on a consecutive series of 47 complex foot reconstructions performed on 45 patients with microvascular free flaps over a 27-year period. A retrospective review of the cases was performed, a detailed analysis of the defects is presented and possible solutions debated so as to outline the key points in the diagnosis and treatment of foot defects. In the decision making process, soft tissue defect location, dimension, and functional relevance have proven to be as important as the exact definition of the bone defect. A new anatomical classification scheme for composite defects of the foot, involving both bone and soft tissue, is proposed in order to allow for a correct evaluation of the wound and an easier identification of the ideal treatment.

Perforator-based chimaeric thoracodorsal flap for foot reconstruction

The reconstruction of severe defects of the ankle and foot is a challenge. The ideal solution should combine a thin skin flap on the dorsum to allow shoe fitting and a muscle flap with a split-thickness skin graft on the weight-bearing area. Perforator-based thoracodorsal chimaeric flaps allow us to achieve these two goals with minimal donor-site morbidity. We present a reconstruction of an extended circumferential defect of the ankle with an exposed heel using a chimaeric thoracodorsal perforator flap with a serratus muscle flap. The skin flap was transferred on the dorsal foot, whereas the serratus anterior muscle was transferred on the exposed heel. Postoperative recovery was uneventful and the patient began full weight bearing after 3 months. Twelve months after reconstruction, natural shape and walking function were successfully achieved.