The Use of External Hardware for Lower Extremity Free Flap Elevation

Abstract

Sir: Lower extremity reconstruction can be a challenge because of limited local soft-tissue options and a propensity for dependent swelling. Microvascular surgery has enabled the coverage of more complex wounds and the salvage of severely traumatized extremities. Postoperative extremity elevation is vital to flap success, because it decreases edema and promotes venous return. The surgeon must also avoid an equinus deformity in the recipient leg. External fixation and orthopedic pins have been described for elevation and immobilization of cross-extremity flaps and pedicled flaps.1–4 They can also be used for cases of free flap reconstruction in which the patient has not sustained a fracture, such as in the microsurgical reconstruction of posterior heel defects.5 We present an effective method of ensuring adequate elevation and immobilization of the free flap–reconstructed lower extremity, which can also be adapted to prevent an equinus deformity. A 54-year-old woman sustained a crush injury of the right lower extremity with open calcaneal fractures that were treated with cortical screws. The wound was eventually reconstructed with a rectus abdominis free flap and application of an external fixator across the ankle joint to aid in elevation and to prevent an equinus deformity. The external fixator was removed in the office 3 weeks later. From 2000 to 2006, we applied an external fixator or pins to the lower extremity in seven patients during free flap placement who did not otherwise require hardware for fracture fixation. The extremity was then elevated by using rolls of gauze dressing at adjustable lengths to attach the hardware to a trapeze apparatus over the bed (Fig. 1).Fig. 1.: Elastic bandage–wrapped free flap covering a knee defect with an external fixator in place. The patient did not have a fracture that required external fixation. In this patient, the rehabilitation shoe was attached to the hardware to maintain ankle dorsiflexion. The leg was wrapped with an elastic bandage because the patient had started progressive dangling and elastic bandage wrapping as part of his postoperative rehabilitation.Four patients had external fixators placed and three patients had pins inserted. The free flaps included one anterolateral thigh flap, three rectus abdominis flaps, and three latissimus dorsi flaps. All flaps survived. One patient developed a pin-site infection 2 months postoperatively that necessitated removal of the hardware. The fixator had been left in place because of a popliteal wound next to the free flap. Otherwise, there were no other hardware-related complications. Although we regularly use a patient’s existing external hardware to aid in lower extremity elevation, electively applying an external fixator or orthopedic pins in lower extremity free flap reconstructions, when the hardware is not required for bony fixation, is a novel method with which to facilitate elevation of the extremity. The hardware should be placed by an orthopedic surgeon, with the plastic surgeon determining the optimal placement of pins. The reconstructive team should be intimately involved at this time, because injury to the flap by poor tissue handling can occur. The fixation allows for elevation of the lower extremity in a trapeze over the hospital bed, thereby limiting edema of the extremity and venous compromise of the free flap. A rehabilitation shoe can be strapped to the external fixator to prevent foot drop (Fig. 1), or an external fixator spanning the ankle joint can prevent the development of an equinus deformity. Monitoring of the free flap is facilitated because the flap does not have to be covered by bulky dressings. The hardware is easily removed in an outpatient setting. When performing lower extremity reconstructions, use of external hardware may assist in the ability to reduce swelling, ease dressing and wound care, limit risk of equinus deformity, improve patient compliance, and expedite advancement to rehabilitation therapy. Christine Rohde, M.D. Columbia University Medical Center New York-Presbyterian Hospital Brittny Williams Jamie P. Levine, M.D. Institute of Reconstructive Plastic Surgery New York University Medical Center New York, N.Y. DISCLOSURE None of the authors has a financial interest in any of the materials, products, or devices discussed in this article.