Lower Extremity Defects Research Articles

To Shrink or Not to Shrink? An Objective Assessment of Free Gracilis Muscle Volume Change in Lower-Extremity Defect Reconstruction.

Background: The use of free gracilis muscle flaps in reconstructive surgery of the lower leg is common practice to cover defects. However, there is still a lack of understanding of the morphometric changes that occur in the transferred muscle and area of interest over time, particularly the characteristic volume decrease that is observed over the course of the first year. This study aimed to assess volume changes in patients with free gracilis muscle flap reconstruction following infection, trauma, or malignancies of the lower extremity. Methods: Three-dimensional surface imaging was performed intraoperatively after 2 weeks, 6 months, and 12 months with the Vectra H2 system. A total of 31 patients were included in this study and analyzed. Results: There was an average volume increase of 146.67 ± 29.66% 2 weeks after reconstruction. Compared to this volume increase, there was a reduction of 108.44 ± 13.62% after 12 months (p < 0.05). Overall, we found a shrinkage to 85.53 ± 20.14% of the intraoperative baseline volume after 12 months. Conclusions: The use of non-invasive 3D surface imaging is a valuable tool for volume monitoring after free flap reconstruction of the lower extremity. The free gracilis muscle flap undergoes different phases of volume change over the first year, with the greatest influence on overall change being the development and decongestion of edema. Precise initial surgical tailoring is crucial for optimal long-term functional and cosmetic results.

Resurfacing of multiple adjacent defects with free multipaddle SCIAP flaps

BackgroundThe efficient resurfacing of multiple adjacent defects (MADs) requires precise reconstructive strategy. Various approaches (e.g., several flap transferring or prelamination of the recipient site) have been reported, but recipient-site impairments, pain, long hospitalization, and low cost-benefit results fatefully considered them as compromise approaches. This study aims to evaluate the feasibility of MADs reconstruction with free multipaddle superficial circumflex iliac artery perforator (SCIAP) flaps. MethodsFrom Dec 2015 to Dec 2020, we enrolled patients with upper and lower extremity defects treated with various multipaddle SCIAP flaps (2-paddle, 3-paddle, and 4-paddle). Patient demographics and outcomes of each group were collected. ResultsThirty-two, 21, and 6 patients underwent 2-paddle, 3-paddle, and 4-paddle SCIAP flaps transfers, respectively. All multipaddle SCIAP flaps survived without vascular problems, and the donor sites were closed directly. Except for 3 cases of 2-paddle SCIAP flaps drained by superficial circumflex iliac vein venous return, most cases (n = 56) were drained by venae comitans. Minor complications, including partial flap necrosis (4 cases) and lateral femoral cutaneous nerve palsies (11 cases), were treated conservatively. All patients were satisfied with the reconstructive outcome. ConclusionMultiple adjacent defects reconstruction is still a Gordian knot and lacks a golden standard. The free multipaddle SCIAP flap was demonstrated as a promising alternative, not only enriching its versatility but also initially highlighting the “replace need with need” reconstructive demand.

Analysis of Operation Duration in Thoracodorsal Artery Perforator Free-Flap Surgery of the Lower Extremities.

This retrospective study aimed to identify the factors that affect the duration of thoracodorsal artery perforator (TDAP) free-flap surgery and to offer strategies for optimizing the surgical procedure. We analyzed 80 TDAP flap surgeries performed by a single surgeon between January 2020 and December 2022, specifically focusing on free flaps used for lower-extremity defects with single-artery and single-vein anastomosis. The operation duration was defined as the time between the surgeon's initial incision and completion of reconstruction. Linear regression analyses were conducted to identify the factors affecting operation duration. The average operative duration was 149 minutes (range, 80-245 minutes). All flaps survived, although 8 patients experienced partial flap loss. The operative duration decreased with increasing patient age and when end-to-end arterial anastomosis was performed. However, the risk increased with larger flap sizes and in patients with end-stage renal disease. Our study identified several factors and methods that could accelerate TDAP free-flap procedures. These findings offer valuable insights for optimizing surgical processes and improving overall surgical outcomes. Although further research is needed to confirm and expand upon these findings, our study provides important guidance for surgeons in developing effective strategies for TDAP flap surgery.

Sensory and pain outcomes of neurotized skin-grafted free gracilis muscle flaps for lower extremity reconstruction

BackgroundSkin-grafted free gracilis muscle flaps are commonly used for lower extremity reconstruction. However, the loss of sensory function may lead to increased patient morbidity. This study prospectively analyzed the sensory and neuropathic pain outcomes of neurotized skin-grafted free gracilis muscle flaps used for the reconstruction of lower extremity defects. MethodsPatients undergoing lower extremity reconstructions between 2020 and 2022 with neurotized skin-grafted free gracilis muscle flaps were prospectively enrolled. Sensation was assessed at 3, 6 and 12 months postoperatively using monofilaments, two-point discrimination, a vibration device, and cold and warm metal rods. Sensations were tested in the center and periphery of the flaps, as well as in the surrounding skin. The contralateral side served as the control. Patients completed the McGill pain questionnaire to evaluate patient-reported neuropathic pain. ResultsTen patients were included. At 12 months postoperatively, monofilament values improved by 44.5% compared to that of the control site, two-point discrimination, cold detection, warmth detection, and vibration detection improved by 36.2%, 48%, 50%, and 88.2%, respectively, at the reconstructed site compared to those at the control site. All sensory tests were significantly better than 3 and 6 months values (p < 0.05), but remained significantly poorer than the control site (p < 0.05). Sensation in the central flap areas were similar to peripheral flap areas throughout the follow-up period (p > 0.05). The surrounding skin reached values similar to the control site at 12 months (p > 0.05). Moreover, 50% of patients reported neuropathic pain at 3 months postoperatively, 40% at 6 months, and 0% at 12 months (p < 0.05). ConclusionMechanical detection, vibration detection, temperature detection, and two-point discrimination significantly improved over time but without reaching normal sensory function at 12 months postoperatively. Neuropathic pain resolved at 12 months.

Stable Arterial Perforators Mapping in Lower Leg Using Color-Coded Doppler Sonography, Acoustic Doppler, and Thermal Imaging Camera in Patients Undergoing Digital Subtraction Angiography

Abstract Background Chronic defects in the lower leg present significant challenges in plastic surgery due to their diverse etiologies and association with impaired peripheral circulation. This study describes the localization of stable perforators and assesses their changing velocities after digital subtraction angiography (DSA) and alterations of flow characteristics. Methods Ten patients with lower extremity defects requiring DSA had undergone examinations by using standard methods. The localization of 40 stable perforators originating from the anterior tibial artery, posterior tibial artery, fibular artery, and medial sural artery was performed before and after angiography. Where stenoses or occlusions were observed, percutaneous transluminal angioplasty (PTA) was conducted, and velocity changes following reperfusion were measured. Results Angiographic abnormalities were observed in all of patients, thus necessitating PTA interventions. Prior to PTA, handheld acoustic Dopplers detected 37 out of 40 perforators (90%), whereas color-coded sonography detected 35 out of 40 perforators (87.5%). After PTA, these numbers increased to 38 out of 40 (95%) and 37 out of 40 (92.5%), respectively. The diameter of the perforators ranged between 1.14 and 1.16 mm. The mean flow characteristics included the peak systolic velocities (PSV) of 21.9 and 27.2, end-diastolic velocities (EDV) of 9.4 and 11.4, and resistance indexes (RI) of 0.63 and 0.71, respectively. In the postintervention period, 16 microvessels exhibited enlarged lumen diameters ranging from 1 to 3 mm, resulting in increased perfusion values for PSV in 85.2% (21.9/27.2) and EDV in 88.2% (9.4/11.4) of the patients. The RI increased from 0.63 to 0.71. However, two perforators showed decreases in flow velocity after PTA. Conclusion In most patients with chronic lower leg wounds and other comorbidities, adequate perforators for reconstruction can be identified by using conventional methods. PTA interventions positively impact blood flow in perforators, although they are not necessarily required prior to reconstruction.

Ilizarov method and its combined methods in the treatment of long bone defects of the lower extremity: systematic review and meta-analysis

BackgroundIlizarov method has become one of primary methods for treating bone defects. Currently, there is growing trend in the application of modified Ilizarov methods (e.g., applying unilateral external fixators or with flap tissue) and its combined methods (e.g., Ilizarov method with antibiotic spacer or internal fixation) to manage bone defects. However, there is a lack of studies with systematical evaluation of the clinical effects of these evolving methods. This study aimed to conduct a systematic review and meta-analysis for overall evaluating the clinical effects on long bone defects of lower extremity in Ilizarov methods and its combined methods.MethodsStudies were identified in three electronic databases (Pubmed, Embase and Cochrane Library) from the earliest indexing year through November 01, 2022, and relevant data were extracted subsequently. The total number of participants, number of participants with bone unions, bone result or functional result, and related complications including pin infection, pin loosening, pain, refracture, limb discrepancy, malalignment, joint stiffness, recurrent infection, and amputation were extracted in this study. Then, union rate (defined as the proportion of patients who achieved bone unions) and specific complication incidence rate (defined as the proportion of patients who experienced specific complication) were pooled estimated respectively. Relative risk (RR) was used for comparing the clinical effects among various Ilizarov technique.ResultsSixty-eight case series studies, 29 comparative studies, and 3 randomized clinical trials were finally included. The union rate of Ilizarov methods was 99.29% (95% CI: 98.67% ~ 99.86%) in tibial defects and 98.81% (95% CI: 98.81% ~ 100.00%) in femoral defects. The union rate of Ilizarov method with antibiotic spacer and intramedullary nail in tibial defects was 99.58% (95% CI: 98.05% ~ 100.00%) and 95.02% (95% CI: 87.28% ~ 100.00%), respectively. Compared to the Ilizarov methods, the union rate of the Ilizarov method with antibiotic spacer in tibial defects increased slightly (RR = 1.02, 95% CI: 1.01 ~ 1.04). Meanwhile, compared to Ilizarov methods, we found lower excellent rate in bone result in Ilizarov method with antibiotic spacer, with the moderate to high heterogeneity. Compared to the Ilizarov method, lower rate of pin infection, higher rate of recurrent infection and amputation were observed in Ilizarov method with intramedullary nail, however, the findings about the comparison of pin infection and recurrent infection between the two groups were presented with high degree of statistical heterogeneity.ConclusionOur study confirmed the reliable treatment of Ilizarov methods and its combined technique on long bone defects, and founded there were significant differences on some complications rate between Ilizarov methods and its combined technique. However, the findings need to be confirmed by further studies.

Soft Tissue Reconstruction After Revascularization.

Diabetic foot ulcer represents the primary cause of hospital admissions, amputations, and mortality in diabetic patients. The development of diabetic foot ulcers is influenced by peripheral neuropathy, infection, and ischemia, with diabetes contributing to peripheral artery disease. Free tissue transfer combined with revascularisation of the lower extremity provides the potential opportunity for limb salvage in individuals with lower extremity defects due to critical limb ischemia and diabetic foot.

Enhancing Lower Extremity Defect Coverage: High Viability Ultra-Thin Split-Thickness Skin Grafts Obtained from the Scalp.

Repairing lower extremity defects presents challenges due to the scarcity of available local tissue. Skin grafting is a widely employed technique for addressing non-healing ulcers, improving the quality of life of patients and minimizing discomfort. However, using traditional donor sites, such as the thigh, can hinder mobility and result in noticeable scarring and pigmentation changes. This study aims to assess the effectiveness of a novel approach utilizing autologous ultra-thin split-thickness skin grafts (STSGs) harvested from the scalp using a disposable, commercially available razor blade named DermaBlade. Fifteen patients (median age: 72 years, eight males and seven females) with diverse lower limb lesions, including carcinomas and ulcers of varying etiologies, were prospectively enrolled. Donor sites included the sideburn extending to the hairy temporal skin (nine cases) and hairy occipital skin (six cases). Ultra-thin skin strips (<0.2 mm thick) were obtained from the scalp through the use of the disposable flexible blade DermaBlade. The strips were positioned over the receptor area with no sutures in most cases and secured using dressings. A substantial majority of patients (90%) achieved successful graft take with no complications. Swift re-epithelialization occurred within a median of 12 days for the donor site and 24 days for the receptor site. No hair transfer or alopecic scars were noted. In contrast to traditional grafting methods, DermaBlade-assisted scalp grafting yields highly viable STSGs that adhere to wound beds without the need for sutures. Notable advantages of this technique encompass rapid wound healing, minimal complications, and superior cosmetic outcomes. Furthermore, it avoids scarring and alopecia, making it a promising approach for addressing lower extremity defects.

Surgical treatment of critical size bone defects with Masquelet technique versus bone transport: a systematic review and meta-analysis of comparative studies.

To date, the management of critical-sized bone defects lacks a universally accepted approach among orthopedic surgeons. Currently, the main options to treat severe bone loss include autologous grafting, free vascularized bone transfer, bone transport and induced-membrane technique. The purpose of this study is to critically compare the outcomes of Masquelet technique and bone transport to provide a higher level of evidence regarding the indexed techniques. The authors conducted a systematic search on several databases according to the PRISMA guidelines. English-written reports comparing outcomes of the Masquelet technique versus the bone transport technique in patients with critical-sized defects in lower extremities were included. Six observational studies involving 364 patients were included. The systematic review and meta-analysis of pooled data showed no significant difference in most outcomes, except for ASAMI bone outcomes and residual deformity, which showed better results in the bone transport group. The 64% of patients treated with Masquelet technique obtained excellent/good bone ASAMI results compared to 82.8% with bone transport (p = 0.01). Post-operative residual deformity was 1.9% with the bone transport method versus 9.7% with the Masquelet technique (p = 0.02). Both the Masquelet technique and bone transport showed comparable results for the management of critical-sized bone defects of the lower limb. However, these findings must be carefully interpreted due to the high risk of bias. Further prospective randomized controlled trials are necessary to better clarify the strengths and limitations of these two techniques and to identify the variables affecting the outcomes.

Reliability of reverse sural artery fasciocutaneous flap in older adult patients: Comparison study between older and younger patients

BackgroundThe reverse sural artery fasciocutaneous (RSAF) flap is a popular option for patients with soft tissue defects of the distal lower extremities. However, most studies have focused on young patients without comorbidities. This study aimed to report the clinical application of the RSAF flap and to evaluate its reliability in older adult patients. MethodsA retrospective study of fifty-one patients who underwent RSAF flap was included in this study between September 2016 and October 2021. Reconstruction outcomes and wound complications were compared between groups A (21 patients over 60 years of age) and B (30 patients under 60 years of age). ResultsOverall, 74.5% of the flaps healed primarily. The demographics of the two groups were similar, except for comorbidities (P = 0.01). The risk factors that affected the survival of RSAF flaps were not significantly different between the two groups (P > 0.05). The rate of wound complications in group A (42.85%) was significantly higher than that in group B (13.3%) (P = 0.04). However, all wound complications were treated using a simple procedure (skin grafting or simple suturing). ConclusionsThe RSAF flap can be a reliable salvage option to repair soft tissue defects of the lower extremities in older adult patients. It is safe and easy to harvest and transfer the flap; however, surgeons should be aware of the possibility of wound complications in older patients with comorbidities.

New Approach for Superthin Anterolateral Thigh Flap Elevation.

Anterolateral thigh (ALT) flaps are widely used for soft tissue reconstructions. They have several advantages, most notably a long pedicle, an appropriate pedicle caliber, low donor site morbidity, and the possibility of 2 teams working simultaneously. However, conventional, thick ALT flaps used for reconstructions of head and neck and lower extremity defects may cause postoperative range of motion limitations and cosmetic problems. The aim of this study was to develop and propose strategies to facilitate the harvest of superthin ALT flaps and minimize technical difficulties. This article provides step-by-step instructions for simple, quick, and reliable dissections of superthin ALT flaps. This study retrospectively analyzed data from 60 free superthin ALT flaps used for soft tissue reconstructions in 56 patients between January 2018 and February 2019. Superthin flaps were elevated just above the superficial Scarpa's fascia using a vertical approach. Thirty-eight of the patients were operated on for lower extremity wounds, 16 were for head and neck defects, and 6 were for upper extremity wounds. The mean follow-up period was 7 months. The median hospital stay was 10 days. Total flap loss was observed in 4 cases (6.6%), and partial flap loss was observed in another 4 cases (6.6%). The superthin elevated ALT flap is a reliable and effective option for the reconstruction of soft tissue defects. In our vertical approach, the wide field of view of the flap perforator provides easy dissection, making it easier to elevate the superthin ALT flap.

The Use of Conventional Lower-Frequency Color Doppler Ultrasound for Flap Planning in the Lower Extremity.

Handheld Doppler is often inaccurate in localization of perforators for pedicled and free flaps. Color Doppler ultrasound (CDU), in contrast, allows more accurate mapping and characterization of perforators to facilitate rapid flap harvest. Forty-seven flaps harvested from the lower extremity were evaluated preoperatively with CDU by a single surgeon with a conventional low-frequency ultrasound device (Philips Sparq, Cambridge, Mass). Flaps evaluated included profunda artery perforator flaps (n = 36), anterolateral thigh flaps (n = 2), pedicled propeller perforator flaps (n = 7), and toe transfers (n = 2). In all cases where a free profunda artery perforator or anterolateral thigh flap was used, the location of the dominant perforator visualized preoperatively correlated exactly with intraoperative findings. In cases where CDU was used preoperatively to locate a large perforator close to a lower extremity defect for reconstruction with a propeller perforator flap, all perforators could be used, and all flaps were successful. Preoperative CDU is particularly useful for flap planning where knowledge of the location of the dominant perforator is critical. This includes planning of thin and superthin free flaps, as well as freestyle perforator flaps. Our clinical experience suggests that this technology should be routinely adopted in certain aspects of reconstructive microsurgery.

Ovine Forestomach Matrix in the Surgical Management of Complex Lower-Extremity Soft-Tissue Defects.

Chronic lower-extremity defects may lead to major amputations and have severe consequences on patient quality of life and mortality. Dermal matrices have become part of the reconstructive ladder and are often deployed in these scenarios to quickly build neodermis, especially in volumetric defects over exposed bone and tendon initially, to allow for subsequent closure by means of split-thickness skin grafting (STSG) or secondary intention. Ovine forestomach matrix (OFM) is a decellularized extracellular matrix (ECM) bioscaffold available in both sheet and particulate forms that can be used as a dermal matrix in various soft-tissue reconstruction procedures. This retrospective case series evaluated the use of OFM products in the surgical reconstruction of 50 cases (n = 50) comprised of challenging lower-extremity defects from seven healthcare centers. Patient records were reviewed to identify comorbidities, defect cause, defect size, presence of exposed structures, Centers for Disease Control and Prevention contamination score, Wagner grade, OFM graft use, time to 100% granulation tissue, STSG use, overall time to heal, and postoperative complications. The primary study outcomes were time (days) to 100% granulation tissue formation, with secondary outcomes including overall time to wound closure (weeks), STSG take at 1 week, and complications. The results of this case series demonstrate OFM as a clinically effective treatment in the surgical management of complex lower-extremity soft-tissue defects with exposed structures in patients with multiple comorbidities. One application of OFM products was effective in regenerating well-vascularized neodermis, often in the presence of exposed structures, with a mean time to 100% granulation of 26.0 ± 22.2 days. These data support the use of OFM as a safe, cost-effective, and clinically effective treatment option for coverage in complex soft-tissue wounds, including exposed vital structures, and to shorten the time to definitive wound closure in complicated patient populations.

Influence of VAC Therapy on Perfusion and Edema of Gracilis Flaps: Prospective Case-control Study

In total, 26 patients with soft tissue defects of lower extremity underwent gracilis muscle flap reconstruction. The study group (VAC, n = 13) was supplied with postoperative negative pressure therapy as a dressing; the control group (NVAC, n = 13) was supplied with conventional fat gauze dressing. Postoperative measurements of micro- and macroperfusion were performed intraoperatively, on postoperative day (POD) 3 and POD 5. Flap edema measurement was performed intraoperatively, on POD 5 and 2 weeks after operation. The VAC group showed significantly better macroflow during intraoperative VAC treatment, as well on POD 3 and POD 5. Venous outflow was also better with lower hemoglobin levels. Microflow was better in the NVAC group with higher measured oxygen levels. All gracilis muscle flaps of the VAC group showed significantly less flap edema compared with the control group. VAC application on free gracilis muscle flaps leads to significantly less postoperative flap edema, improved arterial macroflow, and improved venous outflow. VAC therapy can be used without any danger for patient's safety, as flap survival is not endangered, and presents an easy to handle and pleasant dressing regimen for nursing staff and patients.

Bone-based versus soft-tissue free flaps in lower extremity reconstruction

BackgroundMost lower extremity defects and minor bone defect wounds requiring a free flap are treatable with soft-tissue flaps, whereas large bone defect wounds are treated with bone-based flaps. This study aimed to compare bone-based and soft-tissue-free flaps in terms of operative procedures and postoperative complications, including long-term outcomes of lower extremity reconstruction. MethodsThis two-center retrospective cohort study collected data from all lower-extremity reconstructions with free flaps performed between March 2014 and February 2022; the level of evidence is considered to be therapeutic level III. We investigated the operative procedure and postoperative complications classified as being related to either bone-based or soft-tissue flaps. The data were further classified into the trauma and non-trauma groups and the long-term postoperative outcomes of patients who were followed up for ≥12 months were analyzed. ResultsA total of 122 free flaps were included: 29 bone-based flaps (1 scapular and 28 fibular flaps) and 93 soft-tissue flaps (22 muscle-based and 71 fasciocutaneous flaps). There was no significant difference in postoperative complications, including long-term outcomes, between the free flap types, regardless of etiology. Vein grafts were used more often for bone-based flaps than for soft-tissue flaps (20.7% vs. 7.5%; p = 0.045). The donor veins of bone-based flaps were more often anastomosed to superficial veins than were those of soft-tissue flaps (37.9% vs. 10.8%; p < 0.001). ConclusionsUsing bone-based free flaps resulted in no significant differences in postoperative complications, including long-term outcomes, despite involving more complicated operative procedures than soft-tissue flaps. Thus, the use of vein grafts and anastomosis to the superficial venous system of the vascularized fibula graft may help avoid flap-related complications in bone-based free flaps.

Comparison of Complication Risks Following Lower Extremity Free Flap Reconstruction Based on Seven Pre-Operative Indications: Analysis of the ACS-NSQIP Database.

Background: Free tissue transfer is a valuable surgical option for the reconstruction of a myriad of complex lower extremity defects. Currently, there is a paucity of data that examines the risks of complications for each of these unique indications. Methods: Patients undergoing lower extremity free flap reconstruction from the ACS-NSQIP 2011-2019 database were stratified into groups based on the etiology and indication for reconstruction. Rates of major, surgical wound, and medical complications were compared over the first post-operative month. Multivariable logistic regression was used to identify complication predictors. Results: 425 lower extremity free flaps were analyzed. The most common indications for lower extremity free flap reconstruction were wound-related (29%), malignancy (21%), and trauma (17%). Seventeen percent of free flaps had a major post-operative complication, 9% had a surgical wound complication, and 16% had a medical complication. There were no significant differences in major complications between the indications. However, the independent risk factors for major complications varied widely. Those with an indication of malignancy and those who received a musculocutaneous free flap were significantly more likely to have a surgical wound complication compared to the remaining cohort (p < 0.05). Those requiring free flap reconstruction for orthopedic hardware related concerns as well as those with wound related indications were significantly more likely to have a post-operative medical complication (p < 0.05). Conclusion: Understanding the unique risk profiles between the various indications and populations of patients undergoing lower extremity free flap reconstruction is critical for providing accurate risk estimations and optimizing post-operative outcomes and monitoring. Keywords microsurgery, lower extremity free flap, free flap reconstruction.

Reconstruction option in complex lower extremity defects where microsurgical repair is not possible: Randomized bipedicled flaps.

Lower extremity defects may occur due to many etiological causes such as trauma, peripheral arterial disease, diabetic foot infections, tumor resection, gunshot injuries, and burns. Lower extremity defects show a wide clinical presentation ac-cording to the affected anatomical localization, amount of tissue, and tissue content. In this study, it is aimed to present the use of bipedicled flaps as a simple and reliable salvage method in cases where microsurgical repairs such as free flaps are not possible. Patients with soft-tissue defect in their lower extremities between March 2018 and September 2021 were scanned retrospectively over the file. Among these patients, patients who were repaired with a bipedicle flap were included in the study. The patients were followed up regularly for at least 12 months. During the follow-ups, the patients were photographed, a physical examination was performed in terms of flap viability, wound dehiscence, and soft-tissue infection, and the data were recorded. In this study, 23 patients with a defect in the lower extremity who were repaired with randomized bipedicled flap were retrospectively analyzed. In four patients, the location of the defect was located in the middle 1/3 of the leg, while in 19 patients, it was located in the distal 1/3 of the leg. The flap design was done vertically in 22 patients, and the flap design was done transversely in one patient. One bipedicled flap was used for defect repair in 14 patients, and two bipedicled flaps were used for defect repair in nine patients. While skin grafts were used for donor site repairs in 16 patients, the donor site was primarily repaired in seven patients. In the post-operative period, local soft-tissue infection was detected in five patients and dehiscence at the wound site in three patients, and uneventful healing was achieved with antibiotic therapy, resuturation, and appropriate wound care. No major complications such as flap or graft loss were experienced in any of the patients. Randomized bipediculated flaps are a very reliable option for the reconstruction of middle and distal lower extremity defects. We think that it is a reconstruction option that can be safely applied in small and medium-sized defects of the lower extremity, since it can be used even in patients with comorbidities such as diabetes mellitus and peripheral arterial disease that adversely affect wound healing.

Determination of the adequate vascular perfusion time of cross-leg free latissimus dorsi myocutaneous flaps in reconstruction of complex lower extremity defects.

Lower limb defects may be present due to various causes including infections, vascular diseases, tumor resections, and crush or avulsion injuries. Management of lower leg defects is acomplex problem, especially when they are large with deep soft tissue loss. These wounds are difficult to be covered with local skin flaps, distant skin flaps or even conventional free flaps because of the compromised recipient vessels. In such cases, the vascular pedicle of the free flap could be anastomosed to the recipient vessels of the contralateral healthy leg temporarily and then divided after adequate neo-vascularization of the flap from the wound bed. The ideal time to divide such pedicles should be investigated and accurately assessed to have the maximum success rate possible for these challenging conditions and procedures. Sixteen patients who did not have asuitable adjacent recipient vessel for free flap reconstruction had been operated with cross leg free latissimus dorsi flap between February 2017 and June 2021. The mean soft tissue defect dimension was 12 ×11 cm (the smallest 6 × 7 cm; the largest 20 × 14cm). Gustilo type 3B tibial fractures were present in 12 patients, while no fractures were present in the other 4 patients. Preoperatively, arterial angiography was performed on all patients. After the fourth week post-operatively, non-crushing clamp was applied around the pedicle for 15minutes. The clamping time was increased by 15 minutes on each consequent day (average 14 days). On the last 2 days, the pedicle was clamped for 2 hours, and bleeding was assessed by aneedle prick test. Clamping time was assessed in each case to reach ascientific calculation of the adequate vascular perfusion time needed for full flap nourishment. All flaps survived completely except two cases of distal flaps necrosis. Cross-leg free latissimus dorsi can provide asolution for large soft-tissue defects in lower extremities especially with absence of any suitable recipient vessels or when the use of vein grafts would not be feasible. However, ideal time before dividing the cross vascular pedicle should be identified to have the maximum success rate possible.

Commentary: Standardization of patient reported outcomes in lower extremity reconstruction

Lower extremity defects cause significant morbidity to patients, both in form and function.1 Fortunately, there exists a wide range of options for lower extremity reconstruction (LER), with donor sites including the anterolateral thigh, latissimus dorsi, and gracilis, as well as a choice for myocutaneous versus fasciocutaenous tissue.2 Although outcomes such as complications, flap survival, and function are well described in the literature3, patient reported outcomes (PRO) are underreported and should be taken into consideration for flap selection.

Simultaneous reconstruction of septic composite defects in lower extremities: Combination of fasciocutaneous perforator flap and Masquelet technique.

BackgroundManagement of composite defects with deep infection is a challenge to reconstructive surgeons. This study aimed to demonstrate the versatility, safety, and complications of simultaneous reconstruction of infectious composite defects with fasciocutaneous perforator flap combined with the Masquelet technique.MethodsThis study presents 10 patients in whom a fasciocutaneous perforator flap combined with the Masquelet technique was used to restore soft tissue and bone defects of the lower extremity, and were admitted in two level 1 trauma centers in Shanghai. The first stage included debridement of necrotic bone and infected tissues, implantation of a polymethylmethacrylate cement spacer to cover the void; bridging fixation of the osseous defect using external or internal fixators, and soft-tissue reconstruction with a fasciocutaneous perforator flap. The second stage included cement spacer removal with membrane preservation, refreshing bone edges, and grafting the cavity with bone morphogenetic proteins and autologous iliac bone graft.ResultsThe mean follow-up duration after autologous bone graft was 17.5 months. The average bony defects and average flap dimensions were 7.1 cm and 44.9 cm2, respectively. All flaps survived uneventfully. No recurrence of infection was detected in either the second stage of surgery or follow-up period. The mean duration of bone consolidation was 31.9 weeks. One patient had a 2 cm leg length discrepancy, and one patient had mild foot drop. No residual deformity requiring a secondary procedure occurred.ConclusionFasciocutaneous perforator flap combined with Masquelet technique provides a reliable and versatile alternative for patients with composite defects resulting from lower extremity infection.