Leg Flap Research Articles

English

Compound fractures are common following road traffic accidents. It leads to open wound which needs treatment by plastic repairs such as rotation flaps, cross leg flaps, and skin grafting. Similarly, raw wounds and non-healing ulcers especially in osteomyelitis is a challenge to Orthopaedicians. Wounds with infection heal slowly and this often results in prolonged hospitalization. Standard treatment includes dressing and use of antibiotics which leads to financial burden on poor patients. Irrational use of antibiotics has lead to increasing resistance of bacteria to antibiotics. So far, sunlight has been utilized in treatment of rickets and osteomalacia. We have tried to utilize this mode of ecological treatment in an alternate way. Infected, non-healing wounds and ulcers were treated with exposure to sunlight which lead to scab formation and epithelisation leading to healing of wound due to UV rays. The purpose of this study was to determine the effects of ultraviolet radiation (UVR) on the healing of ulcers. METHODS: Our patients having non healing ulcers were subjected to this type of treatment. RESULTS: In selected patients having non- healing ulcers on extremities of various sizes were treated previously with routine line of treatment such as dressing and oral or parenteral antibiotics. Patients were explained mode of treatment and underwent solar therapy after receiving informed consent. Epithelisation on ulcer took place following UV therapy within average duration of 23 days. CONCLUSION: It was concluded that ultraviolet radiation had significant effects in destroying bacteria and also promoting wound healing.

The localization of the distal perforators of posterior tibial artery: a cadaveric study for the correct planning of medial adipofascial flaps

The adipofascial flap, introduced by Lin in 1994, has many advantages compared to fasciocutaneous or free flaps. Its dissection is relatively easy and fast with low donor-site morbidity, and it does not alter the shape of the leg. The aim of this dissection study is to evaluate the anatomic localization of the most distal perforator of the posterior tibial vessels to provide an anatomical rationale for the safe harvesting of distally based medial adipofascial flaps of the leg. 30 Lower limbs from 15 cadavers were used for this study. The most distal perforator from posterior tibial perforator artery, accompanied by at least one vein, was identified and its distance from the medial malleolus was noted. A distal perforator was found in all specimens; the mean caliber was 0.77 mm. In all cases, the perforator artery passed in the septum between flexor hallucis longus m. and flexor digitorum longus m. and was accompanied by two veins. In our series, the distance between the lowest perforator and the medial malleolus ranged from 3.5 to 8.2 cm. The median was 6.75 cm, the 5th percentile 4 cm and the 95th percentile 8.1 cm. The mean distance of the perforator from the medial tibial border was 1.23 cm. The mean ratio between the distance of perforator from the medial malleolus and the total leg length was 21%. Compared to all previous researches, our study has found more distal perforators from posterior tibial perforator artery. This fact may have important clinical consequences, because the anteromedial adipofascial flap would cover more distal soft tissue defects. Moreover, our data suggest some safety parameters to make the rising of a medial adipofascial leg flap safer in surgical practice.

Human The Distal Perforators Of Posterior Tibial Artery. A Study For The Correct Planning Of Medial Lower Leg Flaps

The adipofascial flap, introduced by Lin in 1994 (1), has many advantages compared to fasciocutaneous or free flaps for lower limb reconstruction. Its dissection is relatively easy and fast with low donor site morbidity and it doesn’t alter the shape of the leg. The aim of this dissection study is to evaluate the anatomic localization of the most distal perforator of the posterior tibial vessels to provide an anatomical rationale for the safe harvesting of distally based medial adipofascial flaps of the leg. Thirty lower limbs from 15 cadavers were used for this study. In all the limbs, the femoral artery was cannulated. Different techniques of injection were employed. 26 specimens were injected with latex to fill the entire vascular network and ease dissection. 3 specimens were injected with a mixture of barium sulphate and gelatin and underwent a CT scan. CT scan dataset were used to make 3D reconstruction. They underwent anatomical dissection after the scan. 1 Specimen was injected with red epoxy resin mixed with barium sulphate (2). This technique is aimed to perform comparative anatomical vascular studies between CT three-dimensional reconstructions and traditional dissection techniques. A distal perforator was found in all specimens; the mean caliber was 0.77 mm. In all cases, the perforator artery passed in the septum between flexor hallucis longus m. and flexor digitorum longus m. and was accompanied by two veins. In our series, the distance between the lowest perforator and the medial malleolus ranged from 3.5 to 8.2 cm. The median was 6.75 cm, the 5th percentile 4 cm and the 95th percentile 8.1 cm. The mean distance of the perforator from the medial tibial border was 1.23 cm. The mean ratio between the distance of perforator from the medial malleolus and the total leg length was 21%. Compared to all previous researches (3), our study has found more distal perforators from posterior tibial perforator artery. This fact may have important clinical consequences because the anteromedial adipofascial flap would cover more distal soft tissue defects. Moreover, our data suggest some safety parameters to make the rising of a medial adipofascial leg flap safer in surgical practice.

Combined reconstruction using cross leg flap and cross-Ilizarov external fixator in treatment of distal third tibial post-traumatic bone and soft time injuries

Background: Combined trauma of the lower third legofGustilo grade (GIII) B-C open tibia shaft fractures have a wide spectrum of injury to the bone and soft tissues. Objective: To evaluate the outcome of using Ilizarov external fixator and cross leg flap in patients with combined traumatic (GIII) B-C open lower thirrf tibial fractures. Patients and methods: This prospective study was conducted between 2008 and 2012 on 9 male patients of age between 18 to 42 years {average 37years). 4 patients were of Gustilo type !JIB with extensive periosteal stripping and 5patients of Gustilo type IIIC. 2patients were acute trauma (6-12) hours and 6 presented late (2-5months after injury). Exposure of bone and/or hardware was the mcyor problem in these patients. Nerve injury was negative in all patients. A protocol for sequential staged reconstruction and preoperative planning was arranged by the orthopedic and plastic surgeon in all cases. We used random pattern fasciocutaneous cross leg flap as soft tissue cover along with modified 3/8 Ilzarov frame (modified by orthopedic author) for tibial fracture with or without bone defect. Total treatment time till removal offixate ranged from 5 to 11 months. Follow up was at least 3 years after Ilizarov fixator removal. Results: Most flaps survived, two had marginal necrosis and one superficial epidermal necrosis. No complications were related to the donor site, flap, or by immobilization. Each patient resumed essentially normal gait and activity without stiffness ofjoints related to the flap or Ilizarov fixator. Complete failure occurred in one patient due to persistent severe infection and single vessel limb and underwent amputation. Conclusion: This study showed how the cross leg fasciocutaneous flap can be easily raised through an Ilizarov ring and can be transposed anteriorly to cover soft tissue defects in the lower thirrf of the leg without losing the stability of the construct

A Comparison Between Proximal Lateral Leg Flap and Radial Forearm Flap for Intraoral Reconstruction

Free flaps have become a popular option for the reconstruction of intraoral defects. The radial forearm flap used to be the workhorse flap for small and thin defects, but was associated with numerous donor-site morbidities. The proximal lateral leg flap can provide a thin and pliable tissue similar to the radial forearm flap but without the related donor-site morbidities. We compared the differences between these 2 flaps. Thirty-four patients with intraoral defects from September 2005 to October 2011 were reconstructed, using the radial forearm flap in 23 cases, and the proximal lateral leg flap in 11 cases. The radial forearm flap group had a success rate of 95.6%. The flap survival rate was 100% in the proximal lateral leg flap group. However, the difference was statistically insignificant. Skin graft was required in 22 of the 23 cases for the donor site of the radial forearm flap. Partial loss of the skin graft occurred in 5/22 (23%) of the patients, with exposure of tendons in 3/22 (14%). Delay in healing of the donor sites occurred in 6/23 (26%) of the patients. The donor sites of the proximal lateral leg flap were all closed primarily. One case developed wound dehiscence and this healed by conservative treatment. Long-term follow-up showed functional impairment of the donor forearm (reduced extension or grip strength) in 17% of the patients. Thirty percent of the patients developed sensory disturbance and 48% complained of poor outcome of the donor forearms. In the proximal lateral leg flap group, no motor or sensory functional deficits were seen. No patients complained of poor outcome of the donor legs. Primary closure of the donor site of the proximal lateral leg flap could be performed if the flap width was less than 6 cm. This flap is useful for patients with small and thin intraoral defects and is associated with minimal donor-site morbidity when compared to the radial forearm flap.

Ipsilateral Dorsalis Pedis Vascularized Pedicle Flap in the Distal Leg and Foot

Ipsilateral Dorsalis Pedis Vascularized Pedicle Flap in the Distal Leg and Foot

The pedicle modification of grafting in free flap which use medial-lower-leg-flap with a healthy limb cross-leg bridging thoracic umbilical flap

Objective To investigate the methods and effects of the pedicle modification in free flap which use medial-lower-leg-flap with a healthy limb cross-leg bridging thoracic umbilical flap.Methods From June 2006 to June 2010,twenty-eight cases with a large area of soft tissue defects caused by severe trauma were included in this study.We used The flap was used to repair the wound,the pedicle of the flap was improved which was designed by medial lower leg flap with a healthy limb cross-leg bridging thoracic umbilical flap:thoracic umbilical flap carrying the cross midline side flap.Medial lower leg flap in tongue cutting out and carrying on the medial malleolus perforator.In the processing of bridge-pedicled,we rolled the proximal porting of cross-leg flap,used medial malleolus perforator flap as a posterior wall and used thoracic umbilical flap carrying the cross midline lateral flap as anterior wall.Two portions formed a combined percutaneous tube.The two tile formmed a combined percutaneous tube.Fixing method for operation adopted external fixator which two legs were paralleling.Observation of postoperative flap survival situation,shape,color,elastic,scar contracture,and dysfunction.Results Twenty-eight cases of postoperative all flaps survived.Vascular crisis was appeared in 2 cases after 8 hours.Upon examination that was low blood pressure,low hematocrit.In treatment of transfusion and infusion,crisis mitigated.In 1 case after 12 hours with pain occurred arterial crisis,which was reliefed with analgesia.There were no vascular crisis in other 26 cases.Followed up for 2-20 months,flap had good blood supply,color and good elasticity.The appearance was not bloated and sensory recoverred partly.There was no apparent stiffness in double knee,ankle joint.Conclusion Medial lower leg flap with a healthy limb cross-leg bridging thoracic free flap transplantation for repairing serious soft tissue defects of the leg is clinically proven good means.Based on the improvement of pedicle,it can reduce the risk and complications.At the same time,it can improve the postoperative nursing care effects.It is worthy of popularization and application. Key words: Medial lower leg flap ; Thoracic umbilical flap ; Transplantation ; Vascular crisis ; Microsurgical operation

RECONSTRUCTION OF HIND FOOT DEFECTS;

BACKGROUND: Reconstruction of traumatic as well as non-traumatic hind foot defects is always a challenging task. Weshare here a simple and practical protocol (working solution) to select the most suitable method for soft tissue coverage of hind footdefects, customizable for every patient. METHODS: We carried out this study, in our department on 75 cases from March 2009 to May2012. All cases with wound/defect in hind foot area were included. Majority of cases were traumatic rest included cases of malignancy,Trophic ulcers, infection. Patient's data including age, sex, site of injury, mode of injury, extent of injury (isolated or combined), ifcombined structures involved, type of wound, management of wound, wound healing time and complications were noted. Once optimalwound conditions were achieved the best possible reconstructive option was selected. The various reconstructive options include VACtherapy, Skin graft, local transposition flap, perforator based flapspedicled faciocutaneous/ muscle flaps, intrinsic foot muscles, Medialplantar artery flap and distant flaps like cross leg flap and micro vascular free flaps. RESULTS: All patients had satisfactory and stablereconstruction. They were ambulating freely by 4-6 weeks post operatively. There were few complications like patchy graft loss,peripheral flap necrosis, flap congestion, but none was serious and did not require repeat surgery. CONCLUSION: The simplified protocolfollowed by us is a practical customizable solution for difficult task of hind foot reconstruction. The choice of one or multiple techniqueswill vary from time to time from one surgeon to another depending upon his or her experience and liking.

Femur–fibula–fillet of leg chimeric free flap for sacral-pelvic reconstruction

We describe the first case of a femur free flap in which we utilized the femur to restore pelvic ring continuity following a combined external hemipelvectomy-sacrectomy for cancer. We feel that the femur flap can be an important reconstructive tool for load-bearing bony reconstruction of the pelvis and spine when lower extremity amputation is required. We also utilized a fibula flap to stabilize the spine and a fillet of leg flap to provide soft tissue coverage as part of a chimeric femur-fibula-fillet of leg free flap from the same limb, allowing us to reconstruct a large, complex defect with "spare parts" from the discarded lower extremity, thereby totally eliminating any donor site morbidity.

Hemidiaphragmatic paralysis and hemohydrothorax following right internal jugular vein catheterization

Hemidiaphragmatic paralysis and hemohydrothorax following right internal jugular vein catheterization

The curative strategy of Gustilo type III fracture with soft tissue defect of leg in children

Objective To observe the curative effect of Gustilo typeⅢ fracture with soft tissue defect of leg in children.Methods Of the 15 patients,the area of the soft tissue defect varied from 5 cm × 6 cm to 8 cm × 12 cm.With regard to the location of soft tissue defect,two were situated at the upper third of the leg,eight were middle part of the leg,four were lower portion of the leg and dorsum of foot,one was lower portion of the leg and heel.The fracture was fixed by external fixation device and raw surface was closed by negative pressure drainage in the first stage.The raw surface was eventually covered by the transposition of regional flap or cross leg flap in the second stage.Among them,three patients underwent transposition of saphenous neuro-veno-fasciocutaneous flap, three patients underwent sural neuro-veno-fasciocutaneous flap transposition,one case of medial head of gastrocnemius muscle flap and 7 cases of cross leg flap were performed,while only 1 patient underwent free lateral anterior thigh flap transposition. Results One patient who underwent transposition of saphenous neuro-veno-fasciocutaneous flap present with necrosis of the distal end of the flap 5 days after operation,which was then cured by cross leg saphenous neuro-veno-fasciocutaneous flap.Dark crust in distal end of flap occurred in 1 patient who underwent sural neuro-veno-fasciocutaneous flap,which was cured by changing dressings.Bone fracture of 14 patients were all healed.One patient who was classified as Gustilo Ⅲ c underwent cross leg flap, but bone defect was produced 18 months later.Through 3 months to 2 years follow-up,the texture,colour and shape of flap is good. Conclusion With regard to Gustilo type Ⅲ fracture combined with soft tissue defect of leg in children,external fixation coupled with flap transposition can cure effectively. Key words: Fracture of leg; Gustilo type Ⅲ ; Flap of leg; Transplantation; Children; Microsurgery

The application of the horn shaped fasciocutaneous flap in lower leg

To explore the application of the horn shaped fasciocutaneous flap for the middle or small defect of low leg. Between April 2008 and November 2010,12 cases were covered the defects with horn flap in the leg, in which 4 cases were male, and 8 cases were female, such as squamous cell carcinoma, basal cell carcinoma, angioneoplasm, trauma and so on. Surgical repair of tissue defect size of about 3 cm x 3 cm-5 cm x 5 cm. Twelve cases were treated. Vascular deficiency happened at the distal end of one flap. All the other 11 flaps survived. The appearance and functional results were satisfactory with following up for 6 to 24 months. The horn shaped fasciocutaneous flap is simple, reliable, easy to perform, has a low complication rate, is cosmetically acceptable

Treatment of plantar cutaneous deficiency with retrograde medial pedicled skin flap of the leg

Objective To introduce clinical application of retrograde medial pedicled skin flap of the leg to repair the plantar cutaneous deficiency. Methods From January 2002 to May 2008, in our hospital we adopted retrograde medial pedicled skin flap to renovate 12 cases of plantar cutaneous deficiency. The size of the skin flaps ranged from 10 cm× 7 cm to 13 cm × 12 cm. Results Ten cases of retrograde medial pedicled skin flap were survived, the rest had partial necrosis because of distal blood flow obstacle. One was cured by changing dressings; the other was repaired by secondary operation. Morphology and function of soft tissue defects were renovated well with 6-18 months follow-up. Conclusion This operation is an effective and reliable technique for plantar cutaneous deficiency. Key words: Planta; Medial leg flap; Transplantation; Microsurgery

Repair of Soft-Tissue Defect Close to the Distal Perforating Artery Using the Modified Distally Based Medial Fasciocutaneous Flap in the Distal Lower Leg

In this study, we modified distally based posterior tibial artery perforator flaps for repair of soft-tissue defects close to the distal perforating artery in the distal lower leg. The flap was designed along the axial network around the saphenous nerve. Flap transfer was performed in 45 cases. The size of the defects after debridement ranged from 4 × 3 cm to 20 × 8 cm (mean, 13 × 5.5 cm). Flap size ranged from 9 × 3 cm to 25 × 10 cm (mean, 16 × 7 cm). In this series, 41 flaps survived completely. Venous congestion was not observed. At a mean follow-up of 16.5 months, all flaps matched the recipient sites in color, texture, and thickness. Donor site morbidity was minimal. The modified distally based posterior tibial artery perforator flap is a reliable and useful option for coverage of the soft-tissue defect close to the distal perforating artery in the distal lower leg.

Medial plantar artery combined flaps with saphenous nerve in repairing opposite side ventri-planta soft tissue defects

Objective To explore the feasibility of repairing opposite side ventri-planta soft tissue defects with the medial plantar artery combined flaps with saphenous nerve.Methods From Jan.2007 to Apr.2009,12 patients with opposite side ventri-planta soft tissue defects were repaired using the medial plantar artery combined flaps with saphenous nerve.Five cases used cross leg flaps,and 7 cases used free skin flaps.All the cases were men,with an age range of 6-40 years(only one child case).The sizes of flaps were 12 cm × 7 cm-13 cm × 8 cm for adults and 8.5 cm × 6 cm for child.The pedicles of cross leg flaps were cut off after 3-4 weeks.Results All the 12 flaps survived.The patients were followed up for 6 months to 1 year.The color,texture and appearance of the flaps were satisfactory.The flaps of the two point discrimination were 6-9 mm on ventri-planta of reconstruction,and the affected limb could exercise freely,without ulcer on the flap.Conclusion The medial plantar artery combined flaps with saphenous nerve can be used to repair opposite side ventri-planta vast soft tissue defects,with large flap and good texture,appearance.It can effectively recover the two point discrimination,but it has a complicated protocal.

COVERAGE OF EXPOSED TIBIA

The alarming rise in road traffic accident has resulted in increased incidence of degloving lower limb injuries requiring some sortof cover for exposed bones e.g tibia. Objective: To study and compare the rate of wound infection & decreased morbidity in degloving injuriesof lower limb following early bone coverage by various surgical methods of bone coverage. Design: Comparative, prospective study, Place& duration of study. Allied Hospital SU II Faisalabad. Period: From January 2002 to October 2004. Material & Methods: Thirty (30) patientsdivided into four groups, muscle & musculocutaneous flaps for 15 patients, local rotational flaps for 05 patients, cross leg flaps & decorticationfor 05 patients. The patients in each group were divided unequally because of unavailability of patients. Patients were also examinedpostoperatively for 06 weeks. Results: The patients underwent surgery for degloving injury of leg. Most of them were young malesbetween 5-45 years of age resulting mainly from different types of accidents. 2 out of 15(13.3%) patients having, musculocutaneous flapsdeveloped wound infection. 1 out of 5(20%) with local rotational flaps, 2 out of 5 (40%) with cross leg flaps & 3 out of 5(60%) with decorticationdeveloped wound infection. 14 out of 15(93.3%) patients with muscle & musculocutaneous flaps while 4 out of 5(80%) with local rotational flapsrecovered within 3 weeks. Patients with cross leg flaps recovered after one month while patients with decortication recovered after forty fivedays. 13 out of 15 regained full function (86%) with muscle & musculocutaneous flaps while patients having local rotational flaps regained 100%full function. 4 out of 5(80%) regained full function with cross leg flaps & 1 out of 5(20%) regained full function with decortication. Conclusions:Muscle & musculocutaneous flaps for exposed tibia is safe and effective method of treatment having low rate of wound infection with widercoverage & decreased morbidity.

Reconstruction of an External Hemipelvectomy Defect with a Two-stage Fillet of Leg-Free Flap

The defect created by external hemipelvectomy for bone and soft tissue tumor resection is a challenge to reconstruct because of the exposure of bone, neurovascular structures, and peritoneal contents, particularly in the setting of previous radiotherapy. In a nonsalvageable limb with extensive tumor involvement and radiation damage, a free fillet of leg flap can be used to provide the necessary large volume of tissue for reconstruction without donor site morbidity. Because of the lengthy operative time for the hemipelvectomy procedure, the fillet of leg flap may be subject to long ischemia time and a subsequently compromised outcome. A two-stage fillet of leg flap for a hemipelvectomy defect was performed with two goals: to decrease ischemia time and to allow the necessary resuscitation of the patient between operative stages. Stage one was dissection of a lower fillet of leg flap, transfer and anastomosis to the contralateral femoral vessels, and temporary inset in the groin. The patient and flap were observed in the intensive care unit for several days. The patient returned to the operating room 3 days later for staged external hemipelvectomy and inset of the viable fillet of leg flap. Throughout follow-up, the reconstructive results and functional outcome were excellent.

Clinical application of the modified medial fascia pedicel flap of the lower leg and the research of the zonation of the fascia pedicel's location

Objective To investigate the design and clinical result of the modified medial fasciocutaneous flap of lower leg in the different zonation. Methods The length of lower leg was divided into three zonations equally.According to the different zonation of the fasciocutaneous flap,the 45 patients were divided into three groups from Jan.2005 to Feb.2008.The defects of the patients were repaired with the flaps.The sizes of the flaps ranged from 5 cm×3 cm to 25 cm×10 cm.Results The flaps survived completely in 43 cases.The distal sides of flaps necrosed partially in 2 cases in the upper third of the lower leg.The necrosed part of the flap was repaired after the change dressings.The colour and texture of flaps were excellent,the appearance and function were satisfactory after a follow up of 4-20 months.Conclusion The modified medial fasciocutaneous flap of the lower leg is easy to design and dissect,blood supply is reliable without sacrifice of the major arteries.The flap can be used according to the different location of the fascia pedicel.It is the idea flap to repair the soft tissue defects of the front of knee joint,the leg,the ankle and the foot. Key words: Lower leg; Surgical flap; Transplantation; Microsurgery

Application of reversed perforator-plus sural neurofasciocutaneous flap in lower leg

Objective To report the operative technique and clinical results of reversed perforator-plus sural neurofasciocutaneous flap in lower leg. Methods Perforator-plus sural neurofasciocutaneous flaps, which designed along the axis of the sural nerve and based on the dual-pedicle of fasciocutaneous and per-oneal perforator, were used to reconstruct soft-tissue defect in lower extremities. Results Twenfy-four flaps, ranged from 25 cm×12 cm - 8 cm ×7 cm in size, survived completely without venous congestion and distal ischemia and necrosis. The color and texture of the flaps were good. The appearance and functional re-suits were satisfactory with following up for 6 to 12 months. Conclusion The modified technique in pediclehave minimized the complication, enlarged the size of the flap and improved the survive rates. It is a goodmethod in repairing large soft-tissue defects of extremities. Key words: Peroneal perforator; Sural nerve; Surgical flap; Foot; Microsurgery

Clinical study of the treatment of leg fracture combined with skin defect by using external fixator of bone and flap transplantation

Objective To explore the advantage of the treatment of leg fracture combined with skin defect by using external fixator of bone and flap transplantation. Methods Eight cases of leg fracture combined with skin defect were treated, the fractures were stabilized with versatile external fixation and the skin defect were repaired by transfering of saphenous neurocutaneous vascular cross leg flaps or medial head of gastrocnemias musculocutaneous flap. Results All flaps of 8 cases survived, the fracture healed without pressure sores, infection or necrosis. Conclusions It is a simple and effective way to treat patients with leg fracture and skin defect by using external fixator of bone and flap transplantation. Key words: External fixator; Flap; Skin defect