The role of microsurgical free flaps in distal tibia, ankle and foot reconstruction

Transcription

1 223 EEXOT Volume 59, (4): , 2008 The role of microsurgical free flaps in distal tibia, ankle and foot reconstruction A 6 year experience N.I. KARMIRIS, S.Α. VOURTSIS, C.M. ASSIMOMITIS, P.K. SPYRIOUNIS Department of Plastic and Reconstructive Surgery, 417 NIMTS ABSTRACT Aim: Reconstruction of defects in lower third of tibia, ankle and foot is a difficult task. In such scenarios, it is widely approved that free flaps are the workhorses. In our clinic, nine patients were operated on for reconstruction on these particular anatomic areas among Τhe data has been reviewed and useful results are extracted. Methods: Nine patients with defects in lower third of tibia, ankle and foot were treated in our clinic from the same surgeon (P.K.S.) among October 2001 and August Six of them were males with an average age of 47 years old. The causative factors were different, including: two patients suffering from trauma (one high energy trauma and a woman with both a degloving trauma and fractures of metatarsals), four patients suffering from chronic osteomyelitis, one patient suffering from chronic osteitis and ulceration after incomplete healing, one patient with a squamous cell carcinoma (SCC) of his sole and one patient with a heel pressure sore. Nine free flaps were used, including two radial forearm, two rectus abdominis, three vastus lateralis, one anterolateral thigh perforator flap and a latissimus dorsi free flap. Results: Six patients went on to uneventful healing. One flap failure occurred and the patient was subsequently treated with the use of a sural flap. There was one case in which the patient was reoperated due to Mailing address: P.K Spyriounis, MD, PHD, EBOPRAS Department of Plastic and Reconstructive Surgery, 417 NIMITS Monis Petraki 10, , Athens Tel.: , Fax: spyriounis@ath.forthnet.gr partial loss of the split thickness skin graft of the muscle flap. One patient, finally, suffered from late wound breakdown that was treated conservatively. Conclusions: The major role that free flaps play in this difficult anatomic area is emphasized. Sometimes, such as in high energy traumas, free flaps are not only the most useful but possibly the only solution. The free flap is the most cost effective and stable solution to the problem, despite its position at the top range of the reconstructive ladder. Key words: free flaps, distal tibia, ankle and foot reconstruction. INTRODUCTION The reconstruction of the lower third of tibia, ankle and foot of variable etiology, often consists a challenge for the reconstructive surgeon. The anatomic variations of the area and the lack of local flaps, mostly when facing large defects or high energy trauma, make the reconstruction both necessary and demanding. In many cases, a free flap is the first and only solution, especially at problems that seemed unsolved in the past. With the success rate becoming more than 90% in the hands of experts in microsurgery, almost everybody, nowadays, admits the usefulness of free flaps 1. In this paper, the experience of our department the last six years will be presented and conclusions about the type of flap, the donor site, the surgical approach and the pharmaceutical treatment will be drawn 2. PATIENTS AND METHODS From October of 2001 to August of 2006, 9 patients (6 men and 3 women), aged 25 to 74 years old, with an average age of 47, were operated on, at the department

2 224 E.E.X.O.T., Volume 59, Number 4, 2008 Picture 2. Planning for the opposite partial vastus lateralis muscle. With the use of a Doppler, perforator arteries of the descending branch of lateral circumflex femoral artery are drawn. Picture 1. Chronic Osteitis of the lower 1/3 of tibia. The reconstruction had been done with a skin graft on the periosteum. RESULTS In eight out of nine cases, free flaps survived completely and successfully achieved their reconstructive goals (success rate 89%). One patient suffered loss of the flap at the second postoperative day because of venous obstruction. Causes of necrosis are under discussion. However, the fact that the patient did not remain in the intensive care union (ICU) because there was no bed availability, may played a critical role. The lack of close hemodynamic monitor and her primary disease (multiple sclerosis) resulting in uncontrolled tonic spasms of her foot may as well influenced the reconstruction. She was finally treated successfully with a reverse neurocutaneous sural flap 3,4. Another patient suffered partial loss (about 20%) of split thickness skin graft, four months post-operatively, which was treated with a new skin graft. Finally, one patient suffered from an ulcer at the weight-bearing surface. Simple dressings provided solution. of Plastic and Reconstructive Surgery of our hospital. Follow up ranged from 16 to 74 months, with a mean of 45 months. The area of reconstruction included the distal third of tibia, ankle and foot. The causes of the defects were trauma in two cases (one with a high energy open fracture and a woman with a degloving injury of lower third of tibia, ankle and foot), chronic osteomyelitis in four cases, a patient with chronic osteitis, a patient with a squamous cell carcinoma and a woman with a pressure sore at the heel. Five different free flaps were used to cover the defects: two radial forearm fasciocutaneous flaps, two rectus abdominis muscle flaps, an anterolateral thigh perforator flap and a latissimus dorsi muscle flap. Patients, mode of reconstruction and results can be seen at table 1. CLINICAL CASES 1st Case A 64 year old man came at the department of Plastic and Reconstructive Surgery at NIMTS, with a trauma at the distal part of tibia for over 25 years which had been treated with a split thickness skin graft. The defect was about 10x12 cm and it had ulceration with purulence at the centre. The skin graft was in touch with the periosteum of the tibia. Distally to the skin graft, there was a longitudinal scar at the dorsum of the foot of about 20 cm and only reverse flow of the dorsalis pedis artery (checked with the Doppler). Preoperative check included x-ray, CT and cultures. The final diagnosis was chronic osteitis of the tibia (picture 1). Because of the size of the defect and the exposed tibia after the surgical debridement, the decision

3 N.I. KARMIRIS et al. The role of microsurgical free flaps in distal tibia, ankle and foot reconstruction - A 6 year experience 225 Table 1. At cases 2,4,6 with Chronic Osteomyelitis, generous debridement of the scar and surrounding lipothystrophic tissue, debridement of the bone, local application of gentamycin and i.v antibiotics according to cultures for two weeks followed by definite coverage of the defect with a free flap. At case 8, a Lisfranc amputation was initially done followed by two surgical debridements. SEX / AGE CAUSES FLAPS RECEPIENTS AND DONOR VESSELS COMPLICATIONS RESULT / TYPE OF ANASTOMOSIS 1. Man/37 Chr. Osteomyelitis Free Rectus Abdominis End to End anastomosis (Distally Success. of the tibia (L) Muscle Flap and Ilizarov Based) to the tibialis anterior art. and its vena commitante 2. Man/25 Unstable stump after Free Radial Forearm Flap End to End anastomosis to the Success transmetatarsal dorsalis pedis artery and amputation cutaneous vein. 3. Man/48 Squamous Cell Free Radial Forearm Flap End to End anastomosis to the Success Carcinoma (SCC) internal plantar artery and 2 veins of the sole (internal plantar s vena commitante and one cutaneous vein of the dorsum of foot). 4. Man/61 Chr. Osteomyelitis Free Rectus Abdominis End to End anastomosis (distally Success of the tibia(r) Muscle Flap based) to the dorsalis pedis artery and its vena commitante. 5. Woman/32 Deficiency of the Free Anterolateral End to End anastomosis to the. Lost of the flap at Reverse Sural heel-pressure sore Thigh Perf. Flap tibialis posterior artery and its the 2nd day post-op. Flap-Success. 2 venae commitante 6. Man/36 Chr. Osteomyelitis Free Vastus Lateralis End to End anastomosis to 4/12 post-op, 20% Success of the heel (R) Muscle Flap the dorsalis pedis artery and skin breakdown. End to End anastomosis in a Resettlement of STSG superficial vein. 7. Man/64 Chr. osteitis of Free Vastus Lateralis End to End anastomosis to 6 months post-op the tibia Muscle Flap the tibialis anterior artery and thinning of the flap a vena commitante. 8. Woman/74 Degloving Injury- Free Latissimus Dorsi End to End anastomosis to Small ulcer at the Conservative Fractures of Muscle Flap the tibialis posterior artery and pressure point of Treatment tarsometatarsal the great saphenous vein. the prothesis joints 18/12 post-op. 9. Woman/50 Trauma Free Vastus Lateralis End to End anastomosis Success. Muscle Flap to the tibialis posterior artery and the great saphenous vein.

4 226 E.E.X.O.T., Volume 59, Number 4, 2008 Picture 3. Partial (40%) vastus lateralis is shown attached on its vascular pedicle (descending branch of lateral circumflex femoral artery and its venae commitante). Picture 4. Post-operative view at one year following a single thinning procedure. Nice aesthetic result. for the use of a free vastus lateralis free flap, with 10x12 cm dimensions, was taken (picture 2). The flap was based at the descending branch of the lateral circumflex femoral artery and vein. With the use of the Varioscope AF3 5, the vessels of the flap anastomosed end to end with the tibialis anterior artery and its vena commitante, proximal to the deficiency (picture 3). Afterwards, a messed skin graft covered the muscle flap and the patient was transferred at ICU where he stayed for 24 hours. The patient stayed at the hospital for ten days and went on uneventful healing. Six months postoperatively, the flap was thinned with a tangential removal of excess flap, especially at the lateral side of tibia. The aesthetic and functional result is very good (pictures 4,5). The patient did suffer no functional defect. 2nd Case A 74 year old woman came at our department, three weeks after an accident that caused her a degloving injury of lower third of tibia, ankle and foot, combined with severe fractures of tarsometatarsal joints. An attempt to correct the fractures with Kirschner s pins and resuturing the degloved skin was done elsewhere. The necrosis included the muscles of the lower third of tibia and distally (picture 6). Below knee amputation was offered to the patient due to the extent of injury and the age of the patient. However, she did not accept the proposed treatment and demanded an attempt to preserve as much length as possible. So, after clear pre-operative investigations, we first proceeded in a transmetatarsal amputation Lisfranc s type and surgical debridement (picture 7). The final rehabilitation followed Picture 5. Post-operative result of the donor site with a simple lazy S scar and no functional morbidity. Picture 6. Pre-operative photo of a degloving injury with combined fractures of tarsometatarsal joints fifteen days ago.

5 N.I. KARMIRIS et al. The role of microsurgical free flaps in distal tibia, ankle and foot reconstruction - A 6 year experience 227 Picture 7. Initially, Lisfranc amputation along with surgical debridement was performed. Picture 8. Ten days following surgical debridement. Plan for using a contralateral LD. Note the exposed heel and calcaneal bones. after two weeks (picture 8). Angiography clarified the extension of vascular injury. Because of the size of the defect, a decision was made in using a free latissimus dorsi muscle flap, based on the thoracodorsal artery and vein. The anastomoses were made with the tibialis posterior artery and great saphenous vein end to end, proximal to the zone of injury and finally, the flap was set as wrap-around flap, covering the whole defect and the exposed bones of heel and tarsus. The patient was transferred at the ICU, where she remained for 48 hours. One week postoperatively, split thickness skin graft covered the muscle. The patient left the hospital three weeks post-op. Apart from seroma of the donor site, which was treated with aspirations, the patient went on uneventful healing (picture 9). Discussion The lower third of tibia, the ankle and the foot are all areas that pose a specific challenge in the reconstructive surgeon. The lack of local flaps, the thin subcutaneous tissue results in easy exposure of underlying bone, tendonsand the fact that it is a weight bearing area, all constitute different reasons which complicate the situation. Local flaps as the dorsalis pedis flap 6, the extensor hallucis longus, the tibialis anterior, the long flexors, the peroneus longus and peroneus brevis and the adipofascial flaps are best indicated in small defects and their value is controversial in trauma 7. Exception is the use of soleus muscle or hemisoleus which cover defects up to 10x8 cm 8,9 and the reverse neurocutaneous sural flap 3,4. However, they are both unable to reach the foot. As a rule, in trauma cases, the prudent use of local flaps is suggested. The already compromised limb blood supply may worsen and the edema is exaggerated. The anterior tibia muscle compartment is supplied by a single angiosome, therefore care is needed 10. Furthermore, the soleus muscle is named as "the peripheral heart" of the lower limb 11. The value of free tissue transfers is undisputable since early 70 s 12. Although VAC 13 treatment and distraction lengthening are suggested as alternatives in some cases, the free flap solution offers faster treatment and recovery and quick mobilisation. Foot is a particular anatomic area, because of weight bearing. Not so long ago, there were supporters of below knee amputation in severe foot and ankle injuries. Today, free flap reconstruction of the weight bearing areas is the preferred choice. Whether using muscle or fasciocutaneous flap is preferable, is a controversial topic 14. Both have pros and cons. Thinning of flaps and lack of sensation are some of them 15. It is generally agreed that these patients need to have an open eye through their lifetime for early recognition of erythema, skin breakdown or ulcers and seek immediate treatment and avoidance of pressure. Chronic osteomyelitis is another problematic entity. It is widely accepted that the disease is beyond the bone boundaries well affecting the surrounding tissues by inducing scar and lipothystrophy 16. Nowadays, simple methods of treatment as repetitive surgical debridement and delayed secondary closure have been replaced by generous surgical debridement of both bone and surrounding tissues and coverage of defects with microvascular free flaps. Both fasciocutaneous and muscle flaps serve this purpose well. Our preference as others is muscle flaps. They adequately cover the exposed bone and they are pliable enough to fill bone cavities as well. Furthermore, they improve the antibiotic delivery to the diseased area by improving the blood supply and induce leukocyte and macrophage migration 17. Surely, chronic osteomyelitis might appear years later in an area considered treated, therefore long follow-up are essential 18. Our treat-

6 228 E.E.X.O.T., Volume 59, Number 4, 2008 In conclusion, free microvascular flaps consist the upto-date most innovative solution in these injuries that offer quick therapy and fast rehabilitation as well as less inpatient time and less cost. In our experience, it is the choice in this particular anatomic area especially for large traumatic defects and chronic osteomyelitis. Picture 9. Post-operative photo at one year following the wraparound free LD muscle flap for both plantar and dorsal foot reconstruction. ment protocol consisted of free flap coverage and pre and post-op antibiotics and so far no recurrence occurred. Another controversial topic is the patient s age when considering microvascular reconstruction. In one of our cases, we faced a 74 year old patient with a major traumatic degloving injury of lower third of tibia, ankle and foot, combined with severe fractures of tarsometatarsal joints. Below knee amputation was offered to the patient due to the extent of injury. The patient did not accept the proposed treatment and demanded an attempt to preserve as much length as possible. Age as a sole mean is not a contraindication for free flap surgery 19. Others even suggest that third age is not at all a contraindication for microsurgical procedures 20. So, we first proceeded in a transmetatarsal amputation 21. Afterwards, a free wrap-around latissimus dorsi muscle flap was transferred successfully. Microsurgical clinical applications are steadily increasing, while the same time new donor sites are found. According to area of trauma, degree of damage, functional and aesthetic result, many options are available. A wide range of flaps of different consistency, bulk, and dimensions are available. Radial forearm fasciocutaneous flap 22 and latissimus dorsi muscle flap 16,23 are workhorses. However, other flaps with different pedicle length as the gracilis flap or the new ones ALT perforator flap 24,25 and the free vastus lateralis muscle flap 23,26 are attractive choices as well. The necessity of using the microscope for the microvascular anastomoses is controversial. The senior author uses the Varioscope AF3 5 and the loupes 27 with equal success rates as when using the microscope. Furthermore, comfort and independence of heavy equipment is secured. Cost effectiveness is another asset, as having a microscope in each hospital is rather utopia. However, paediatric microsurgery and vessels less than 1,5mm in diameter are better dealt with microscope as a rule. REFERENCES 1. Chaivanischsiri, P. Influence of Recipient Vessels on Free Tissue Transplantation of the Extremities. Plast. Reconstr. Surg. 1999; 104(4): Khouri RK, Cooley BC, Kunselman AR, Landis JR, Yeramian P, Ingram D, Natarajan N, Benes CO, Wallemark C. A Prospective Study of Microvascular Free-Flap Surgery and Outcome. Plast. Reconstr. Surg. 1998; 102: Spyriounis PK. The use of the reverse sural neurovenocutaneous flap in distal tibia, ankle and heel reconstruction. Eur. J. Plast. Surg. 2005; 28: Ayyappan T, Chadha A. Super Sural Neurofasciocutaneous Flaps in Acute Traumatic Heel Reconstructions. Plast. Reconstr. Surg. 2002; 109: McCraw JB, Furlow LT. The dorsalis pedis arterialized flap. A clinical study. Plast. Reconstr. Surg. 1975; 55: Attinger CE. Foot and Ankle Preservation. In: Aston SJ, Beasley RW, Thorne CHM, editors. Grabb and Smith s Plastic Surgery, 5th Edition, Philadelphia, New York, Lippincott- Raven, Yajima H, Tamai S, Ishida H, Fukui A. Partial soleus muscle island flap transfer using minor pedicles from the posterior tibial vessels. Plast. Reconstr. Surg. 1995; 96: Townsend PLG. An inferiorly based soleus muscle flap. Br. J. Plast. Surg. 1978; 31: Taylor GI, Pan WR. Angiosomes of the Leg: Anatomic Study and Clinical Implications. Plast. Reconstr. Surg. 1998; 102: Taylor GI,Caddy CM, Watterson PA Crock JG. The venous territories (venosomes) of the human body: Experimental study and clinical implications. Plast. Reconstr. Surg. 1990; 86: Serafin D, Georgiade NG, Smith DH. Comparison of free flaps with pedicled flaps for coverage of defects of the leg or foot. Plast. Reconstr. Surg. 1977; 59: Argenta LC, Morykwas MJ. Vacuum-assisted closure. A new method for wound closure and treatment: Clinical experience. Ann Plast Surg. 1997; 38: Sommerlad BC, McGrouther DA. Resurfacing the sole: Longterm follow-up and comparison of techniques. Br. J. Plast. Surg. 1978; 31: Goldberg JA, Adkins P, Tsai TM. Microvascular Reconstruction of the Foot: Weight-Bearing Patterns, Gait Analysis, and Long-Term Follow-Up. Plast. Reconstr. Surg. 1993; 92(5): Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteomyelitis: Experimental and clinical correlations. Plast. Reconstr. Surg. 1982; 69:

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