Lower Limb Reconstruction Research Articles

The Versatility of Atherosclerotic Cardiovascular Disease Risk Score in Determination of Popliteal Artery Branches Patency in Computed Tomography Angiography.

The data regarding all patients who underwent computed tomography angiography (CTA) of the legs during 2016-2021 with complete data for ASCVD risk score assessment were recruited. The association between luminal stenosis from CTA and calculated ASCVD risk score was analyzed. A total of 383 limbs of 117 men and 81 women, averaged 66.5 years old, were studied. Common comorbidities included hypertension (84.3%), diabetes mellitus (61.1%), and chronic kidney disease (34.3%). Average 10-year ASCVD risks in the greater than or equal to 50% stenosis group of popliteal, anterior tibial, and posterior tibial arteries were significantly higher than the less than 50% stenosis group (P < 0.01). The peroneal artery had no significant difference between stenosis groups. The popliteal artery had significantly higher lifetime ASCVD risks than in the greater than or equal to 50% stenosis group (P < 0.01), but the other arteries showed no statistically significant difference. The 10-year ASCVD risks showed significant higher values in the greater than or equal to 50% stenosis group of popliteal, anterior tibial, and posterior tibial arteries. These findings can establish the further study on how ASCVD risks can be applied to predict the stenosis of these arteries and guide the rationale of preoperative leg CTA for FFF harvest.

What is important to adults after lower limb reconstruction surgery: a conceptual framework

PurposePatient-reported outcome measures (PROMs) are used to understand the impact of lower limb reconstruction on patient’s Health-Related Quality of Life (HRQL). Existing measures have not involved this group of patients and their experiences during development. This study aimed to develop a conceptual framework to reflect what is important to patients requiring, undergoing or after undergoing reconstructive surgery.MethodsOur population of interest was people requiring, undergoing or after undergoing reconstructive surgery due to trauma, malunion, nonunion, infection or congenital issues treated by internal or external fixation. We undertook semi-structured interviews with patients and orthopaedic healthcare professionals (surgeons, methodologists and patient contributors) in England.ResultsThirty-two patients and 22 orthopaedic healthcare professionals (surgeons, methodologists and patient contributors) were interviewed between November 2020 and June 2021. Eight domains from a previously developed preliminary conceptual framework were used as a framework around which to code the interviews using thematic analysis. Six domains important to patients (from the perspective of patients and orthopaedic healthcare professionals) were included in the final conceptual framework: pain, perception-of-self, work and finances, daily lifestyle and functioning, emotional well-being, and support. These findings, plus meetings with our advisory panel led to the refinement of the conceptual framework.ConclusionThe first five domains relate to important outcomes for patients; they are all inter-related and their importance to patients changed throughout recovery. The final domain—support (from work, the hospital, physiotherapists and family/friends)—was vital to patients and lessened the negative impact of the other domains on their HRQL. These new data strengthen our original findings and our understanding of the domains we identified in the QES. The next step in this research is to ascertain whether current PROMs used with this group of patients adequately capture these areas of importance.

New insights in lower limb reconstruction strategies.

High Energy Musculoskeletal Traumas (HEMTs) represent a relevant problem for healthcare systems, considering the high social costs, and both the high morbidity and mortality. The poor outcomes associated with HEMT are related to the high incidence of complications, including bone infection, fracture malunion and non-union. The treatment of each of these complications could be extremely difficult. Limb reconstruction often needs multiple procedures, rising some questions on the opportunity in perseverate to try to save the affected limb. In fact, theoretically, amputation may guarantee better function and lower complications. However, amputation is not free of complication, and a high long-term social cost has been reported. A comprehensive literature review was performed to suggest possible ways to optimize the limb preservation surgeries of HEMT's complications in order to ameliorate their management.

Pédiatrie - Internal lengthening nails: a novel method of lower limb reconstruction in children

Intramedullary lengthening nails for lower limb reconstruction in children are a rapidly growing field and represent an alternative to external fixators. Today, two types of intramedullary lengthening nails are used: motorized (FITBONE) and magnetically driven (PRECISE) bone lengthening nails. Indications for limb lengthening nails are: 1) Significant lower limb length discrepancy; 2) Short stature and deformities due to musculoskeletal or dysplastic syndromes; 3) Constitutional short stature. Intramedullary lengthening surgery is challenging and represents a safe and reliable mode of treatment in patients under 18 years of age with an excellent reported outcome.

The impact of pre-existing venous pathology on lower limb free flap reconstruction and the role of preoperative screening: a systematic review.

Lower limb reconstruction is performed to replace like with like and achieve tissue durability. Free flaps are a method of reconstruction commonly used to manage cases of lower limb deficits. However, the failure rate is 8.5%, with venous thrombosis and congestion playing a significant role. Despite this, preoperative venous mapping of recipient site before free flap reconstruction is not routinely practiced, often resulting in pathologies remaining unidentified until the intraoperative stage. The aim of the review was to evaluate the existing literature on the topic of lower limb preoperative venous assessment, screening, and its effect on lower limb free flap survival. Five different databases were searched from their inception to August 2021. The search terms and included studies were independently reviewed by two investigators for their eligibility. Eleven articles were eligible for inclusion, with a combined patient population of 99, and 107 flaps were identified to have lower limb pathology at the donor or recipient vein. Venous pathology was detected preoperatively in 69 veins using ultrasound duplex scanning and computed tomography angiography; of them, 3 (4.34%) resulted in failure. In comparison, 38 veins were diagnosed with venous pathology intraoperatively; of them, 5 (13.85%) failed. The studies evaluated in this review demonstrated that preoperative screening for venous pathology showed a higher flap survival rate. It can therefore be inferred that developing a standardized preoperative process for identifying venous issues in lower limb free flap reconstruction may improve outcomes. This can be explored in future research, with a focus on assessing the validity and efficacy of such screening tools, and their role in the management of patients identified with venous pathology.

Biodegradable Temporising Matrix for Lower Limb Reconstruction following the Resection of Giant Marjolin’s Ulcer

NovoSorb® Biodegradable Temporising Matrix (BTM) is a synthetic matrix used as an adjunct in the reconstruction of certain complex wounds. We present a gentleman who sustained severe full-thickness lower limb burns as a child which were treated with split-thickness skin grafts. In later life, he went on to develop bilateral non-healing ulcers, resulting in a left above-knee amputation and a giant circumferential right lower limb squamous cell carcinoma (SCC) encompassing the majority of the lower leg. Surgical resection and salvage of the single remaining limb was achieved with the successful application of a BTM. BTM has proven to be successful in reconstructing a small number of SCC wounds; however, to the best of our knowledge, we are the first authors to test its application in the reconstruction of a circumferential defect associated with a giant lower limb Marjolin’s ulcer.

10-Year single center experience in lower limb reconstruction with free muscle flaps – factors influencing complications in 266 consecutive cases

The anatomy and technique of free muscle flaps – in particular gracilis flap and latissimus dorsi flap – in lower extremity reconstruction have been well described. There is a paucity of data on potential risk factors in larger patient series that affect the outcome. The objective of this study was to address this lack of knowledge by reporting outcomes and complications of free muscle flaps as a primary option in lower extremity reconstruction. From 2009 to 2020, a total of 253 consecutive patients with soft tissue defects of the lower limb from trauma, infection or malignancies underwent lower extremity reconstructive surgery with 266 free muscle flaps. Complications requiring revision surgery were noted in 36.1% of cases. Total flap loss occurred in 10.5% of cases. Patients requiring revision surgery were older, more likely to be female, more likely to be active smokers, and more likely to have a higher ASA score. Lower extremity reconstruction with free muscle flaps has a relevant complication rate that both patient and reconstructive surgeon need to be aware of. Prospective studies should try to further assess the factors affecting the outcome.

Morphometric and biomechanical analysis of gracilis and semitendinosus tendons

Background: Semitendinosus and gracilis muscle tendons are among the most frequently used grafts in anterior cruciate ligament reconstructive surgery. Gracilis is also frequently used in breast reconstruction as well as in upper and lower limb reconstruction as a free graft. Materials and Methods: A total of 60 human cadaver lower limbs were studied of 30 adults (12 men and 18 women) who have been embalmed at a tertiary care institution. Those cadavers whose lower limb had undergone surgery in the past and those with concomitant pathology that would have affected the local anatomy were excluded. Gracilis and semitendinosus tendons were taken out of embalmed remains after the cutaneous and subcutaneous tissues had been carefully dissected. Results: It was observed that the maximum load of all the semitendinosus tendons studied had a mean value of 768.2 ± 130.4 N. The semitendinosus tendon’s maximal load in males ranged from 698.4 to 1133.9 N. However in females, the semitendinosus tendon’s maximal load ranged from 589.5 to 780.0 N. Conclusion: The topographical and morphometric data from this study can be utilized as a database of anthropological parameters for the Semitendinosus and Gracilis muscle tendons of a population in a south Indian setting,

Analysis on the characteristics of 837 patients with post-traumatic lower limb deformities from QIN Sihe Orthopaedic Surgery Database between May 25, 1978 and December 31, 2020

To summarize and analyze the characteristics and treatment strategies of post-traumatic lower limb deformity based on QIN Sihe Orthopaedic Surgery Database. A clinical data of 837 patients with post-traumatic lower limb deformities treated by orthopaedic surgery between May 25, 1978 and December 31, 2020 in QIN Sihe Orthopaedic Surgery Database were analyzed retrospectively. The information of the patient's gender, age at the time of surgery, region of origin, cause of trauma, deformity side, orthopedic surgery related information (operation time, location, type, and fixation method after operation) were summarized and analyzed. All patients came from 32 provinces, municipalities, autonomous regions, and Taiwan in China. Among them, 551 cases (65.83%) were male and 286 cases (34.17%) were female. The age of the patients at the time of surgery was 3-84 years old, with an average of 27.6 years old, and the most patients were 16-45 years old (559 cases, 66.78%). The main cause of trauma was traffic accident injury (639 cases, 76.34%). The deformity mainly involved unilateral limbs, including 394 cases (47.07%) on the left side and 376 cases (44.92%) on the right side. The most patients were admitted between 2008 and 2017, accounting for 53.05% (444/837). All patients were operated on one or more sites (1 048 sites), among which ankle and toe surgery were the most, accounting for 48.38% (507/1 048). The patients received 1204 surgeries including tendon lengthening and soft tissue contracture release, et al. Orthopedic surgery combined with bone external fixation was used in 624 cases (467 cases of Ilizarov external fixation and 157 cases of combined external fixation), and plaster or brace external fixation was used in 213 cases. Post-traumatic lower extremity deformity patients have a large proportion of males, with a wide geographical distribution, involving various parts of the lower extremities, and most commonly in the foot and ankle. Orthopedic surgery combined with bone external fixation (Ilizarov technique) is the main methods for correction and functional reconstruction of post-traumatic lower limb deformity.

Free versus Pedicled Flaps for Lower Limb Reconstruction: A Meta-Analysis of Comparative Studies.

Background: Free and pedicled flaps are both valuable surgical strategies for lower limb reconstruction. Evidence that compares both techniques is scarce. Our aim is to synthetise all the comparative studies by conducting a meta-analysis to identify post-operative outcomes. Method: A systematic review of pubmed, EMBASE, Cochrane library, and Web of Science was conducted, aiming at articles comparing the outcomes of free versus pedicled flaps in lower limb reconstruction. A pooled analysis with the Mantel and Haenszel methods and random effect analysis provided results as a risk ratio with a 95% confidence interval. Results: 10 retrospective studies were selected. While the flap necrosis rate did not differ significantly between techniques (RR 1.35, 95%CI 0.76–2.39, p = 0.31), the partial flap necrosis rate was significantly lower in free flaps (RR 0.45, 95%CI 0.22–0.91, p = 0.03). The overall complication rate (RR 0.83, 95%CI 0.64–1.07, p = 0.16) and revision surgery rate (RR 1.38, 95%CI 0.55–3.50, p = 0.49) did not differ significantly. No significant difference was found in the high aesthetic satisfaction rate (RR 1.76, 95%CI 0.57–5.41, p = 0.32) and post-operative infection rate (RR 0.85, 95%CI 0.55–1.33, p = 0.48). Conclusion: Despite important variability in the choice of flaps and outcomes reported among studies, free and pedicled flaps appear to be reliable surgical strategies for lower limb reconstruction with similar surgical outcomes.

One-Stage Coverage of Leg Region Defects with STSG Combined with VAC Dressing Improves Early Patient Mobilisation and Graft Take: A Comparative Study.

Lower limb skin defects are very common and can result from a wide range of aetiologies. Split thickness skin graft (STSG) is a widely used method to address these problems. The role of postoperative dressing is primary as it permits one to apply a uniform pressure over the grafted area and promote adherence. Focusing on lower limb reconstruction, our clinical study compares the application of V.A.C. (Vacuum Assisted Closure) Therapy vs. conventional dressing in the immediate postoperative period following skin grafting. We included in the study all patients who received skin grafts on the leg region between January 2015 and December 2018, despite the aetiology of the defect. Only reconstructions with complete preoperative and postoperative follow-up data were included in the study. Patients were divided into two groups depending on if they received a traditional compressive dressing or a VAC dressing in the immediate postoperative period. We could retain 92 patients, 23 in the No VAC group and 69 in the VAC group. The patients included in the VAC group showed a statistically significant higher rate of graft take together with a lower immobilisation time (p < 0.05). Moreover, a lower rate of postoperative infection was recorded in the VAC group. This study represents the largest in the literature to report in detail surgical outcomes comparing the use of VAC therapy vs. conventional dressing after STSG in the postoperative management of lower limb reconstruction using skin grafts. VAC therapy was used to secure the grafts in the leg region, increasing the early graft take rate while at the same time improving patient mobilisation.

ROLE OF CROSS LEG FLAPS IN LEG AND FOOT RECONSTRUCTION: OUR EXPERIENCE

Introduction: The management of compound trauma has always been challenging. Free aps are the rst choice when soft tissue cover cannot be provided by local aps. When facilities for microsurgery are not available or certain factors preclude the microsurgical anastomosis or in cases of free ap failure, the cross leg aps have a big role to play in lower limb reconstruction. We are presenting our retrospective study on 30 cases of distal leg and foot defects covered successfully by cross leg aps. The aim of this study is to highlight the usefulness of cross legAims and objectives: aps in lower limb reconstruction. A retrospective study was done on 30 patients from January 2015 toMaterial and methods: December 2021 who underwent perforator based fasciocutaneous cross leg ap for post traumatic soft tissue defects of distal leg and foot. The mechanism of injury, size and site of defect were recorded. All aps were planned in reverse and limbs were immobilised with external xator. Post-operative complications if any were noted. The patients were followed till the ap became stable. The mechanism of injury was road side accident in 26 cases, machine injury in 2 cases and fall fromResults: height in 2 cases. 19 patients had soft tissue defect of distal 1/3rd of leg and 11 patients had foot defects. 26(86.67%) patients underwent distally based fasciocutaneous cross leg ap and 4(13.33%) patients underwent conventional anteromedially based fasciocutaneous ap. All aps survived well. 2 patients had discharge and 1 had margin necrosis but were managed conservatively. The perforators based fasciocutaneous cross leg aps provide an easy, simple, reliable and viableConclusion: cover for distal leg and foot reconstruction.

Design and Implementation of Athlete’s Knee Health Monitoring System Based on Cloud Computing

To learn about the health care of athletes in the knee joint, real-time to monitor the health of the human knee joint according to the cloud. The system uses a depth camera to collect the data information of the human lower limb alignment and obtains the spatial coordinate position of the human lower limb alignment through deep learning; then analyzes and processes the video sequence of the human lower limb alignment, including the wavelet function decomposition of the lower limb alignment information and reconstruction, and finally, the monitoring results were obtained by the knee joint scoring method. The system has completed the design of software and hardware and realized the method of extracting the coordinate information of the main joint points of the human body based on neural network. The health monitoring algorithm finally obtained the knee joint health status of the subjects through the evaluation system. By comparing the real health status of the subjects, the reliability of this research work was verified. The experiment shows that the monitoring error of the system is less than 10%, and the overall error is only 6%. The KSS standard score of the subjects is consistent with the monitoring and evaluation of the system, and the score trend is basically the same. For the situation that the overall score of the system is lower than the KSS standard, after communication and analysis with orthopaedic experts. It is speculated that it may be due to the subjective estimation of the subjects when measuring KSS, and the system monitoring algorithm is relatively strict and more objective. It is proved that the system designed in this paper can effectively monitor the health of athletes’ knee joint.

Modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure for complex lower extremity reconstruction

BackgroundComplex lower limb reconstruction due to severe trauma remains a challenge for reconstructive surgeons. Here, we introduce a modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure and evaluate its clinical efficacy.MethodsBetween January 2013 and December 2019, 22 patients (range 10 to 64 years old) with unilateral lower limb injury underwent modified donor blood flow-preserved cross-leg anterolateral thigh flap procedures. Among them, 16 cases were traffic accidents, 5 cases were persistent ulcers, and 1 case was a degloving injury. The arterial pedicle of the flap was prepared in a Y-shaped fashion and microanastomosed to the posterior tibial artery of intact leg in a flow-through style. A split-thickness skin graft was applied to wrap the vascular pedicle after anastomosis. The flap was designed in a single or bilobed fashion according to the shape of the tissue defect. The operation time, the intraoperative blood loss and the length of hospital stays were recorded. The vascular pedicle was divided 4 weeks after anastomosis. Doppler ultrasound was performed to evaluate the blood flow of the donor posterior tibial artery during postoperative follow-up.ResultsAll 22 flaps survived. The tissue defects ranged from 12 × 6 to 21 × 18 cm2. The flap sizes ranged from 14 × 7.5 to 24 × 21 cm2. The average operation time, intraoperative blood loss and length of hospital stays were 6.73 ± 1.49 h, 280.95 ± 59.25 ml and 30.55 ± 2.52 days, respectively. Eighteen flaps were designed in a single fashion, while four were in bilobed fashion. Twenty patients underwent fasciocutaneous flap transplantations, while two underwent musculocutaneous flap transplantations. Two cases developed local lysis of the flap which healed after further debridement. Direct suture of the incision after flap harvest was performed in 16 cases, while additional full-thickness skin grafting was performed in the remaining 6 cases. Further bone transport procedures were performed in 15 patients who had severe tibia bone defects. The blood flow of donor posterior tibial artery was confirmed in all patients during follow-ups. All patients recovered flap sensation at the final follow-up. The postoperative follow-ups ranged from 18 to 84 months, and no long-term complications were observed.ConclusionsThe modified donor blood flow-preserved cross-leg anterolateral thigh flap procedure is an ideal method to repair severe lower limb trauma with tibial artery occlusion which avoids sacrificing the major artery of the uninjured lower limb.

Free flap transfer with supermicrosurgical technique for soft tissue reconstruction: A systematic review and meta-analysis.

Supermicrosurgery is a technique that allows microsurgeons to accomplish dissections and anastomoses of vessels and nerve fascicles with diameters of ≤0.8 mm. Considering the potential benefits of this technique and limited literature synthesizing the outcomes of supermicrosurgery, the aim of this study was to summarize the available evidence of reconstructive supermicrosurgery and to estimate the success rate. We conducted a comprehensive search across PubMed, Scopus, Embase, and Web of Science. We included patient-based studies reporting on procedures for soft-tissue reconstruction with free flaps specifying the use of supermicrosurgery. We excluded studies reporting on lymphatic surgery, solely peripheral nerve surgery, and tissue replantation. Our primary endpoint was to calculate the flap success rate. Pooled estimates were calculated using a random-effects meta-analytic model. Forty-seven studies reporting outcomes of 698 flaps were included for qualitative synthesis. Overall, 15.75% of flaps were used for head and neck, 4.4% for breast and trunk, 9.3% for upper limb, and 69.2% for lower limb reconstruction. The most used flap was the superficial circumflex iliac artery perforator flap (41.5%). The overall flap success rate was 96.6% (95%CI 95.2%-98.1%). The cumulative rate of partial flap loss was 3.84% (95%CI 1.8%-5.9%). The overall vascular complication rate resulting in complete or partial flap loss was 5.93% (95%CI 3.5%-8.3%). Supermicrosurgery displays a high success rate. Further studies are necessary to explore the true potential of supermicrosurgery. This technique reformulates the boundaries of reconstructive surgery due to its extensive application.

Locoregional anesthesia for post-operative pain management in microsurgical reconstruction of the lower extremities: A retrospective study

ObjectiveOpioid-based analgesia is often used in the management of postoperative pain in arthroplasty cases. This article analyses the safety of single-shot peripheral nerve block (PNB) and potential analgesic benefits in patients undergoing lower limb free flap reconstruction. MethodsA retrospective review including all patients undergoing lower limb reconstruction with free flaps between October 2017 and April 2020 was performed. Patients were divided into two groups based on PNB utilization. The use of oral opioids, post-operative pain scores, flap-related outcomes, patient morbidity, and length of hospital stay (LOS) were compared between groups. ResultsThirty-one patients who underwent lower limb reconstruction with free flaps, were finally included in the study. Preoperative PNB was performed on 14 patients, while 17 patients received general anesthesia (GA) alone. Pain at rest, measured using the visual analog scale (VAS) score, was significantly lower (2.2 ± 1.7 vs. 4.9 ± 1.7) in the PNB group on postoperative day 1 (POD). The mean [median]±SD amounts of opioids consumed in morphine milligram equivalent (MME) were significantly lower in the PNB group on both POD1 (33.5 [22.5] ± 33.9 vs. 61.6 [48.0] ± 39.0), POD2 (29.0 [15.0] ± 29.2 vs. 58.0 [52.5] ± 37.0) and cumulatively over 7 days (164.0 [197.0] ± 132.8 vs. 315.4 [225] ± 203.2). Complication rates and LOS were not statistically different between groups, although trending toward lower take-back procedures and major complications in the PNB group. ConclusionPreoperative single-shot PNB significantly reduced postoperative opioid use and patient-reported pain severity and was not associated with an increase in complication rates.

ARACAM: A RGB-D Multi-View Photogrammetry System for Lower Limb 3D Reconstruction Applications.

In the world, there is a growing need for lower limb prostheses due to a rising number of amputations caused primarily, by diabetic foot. Researchers enable functional and comfortable prostheses through prosthetic design by integrating new technologies applied to the traditional handcrafted method for prosthesis fabrication that is still current. That is why computer vision shows to be a promising tool for the integration of 3D reconstruction that may be useful for prosthetic design. This work has the objective to design, prototype, and test a functional system to scan plaster cast molds, which may serve as a platform for future technologies for lower limb reconstruction applications. The image capture system comprises 5 stereoscopic color and depth cameras, each with 4 DOF mountings on an enveloping frame, as well as algorithms for calibration, segmentation, registration, and surface reconstruction. The segmentation metrics of dice coefficient and Hausdorff distance (HD) show strong visual similarity with an average similarity of 87% and average error of 6.40 mm, respectively. Moving forward, the system was tested on a known 3D printed model obtained from a computer tomography scan to which comparison results via HD show an average error of ≤1.93 mm thereby making the system competitive against the systems reviewed from the state-of-the-art.

Muscle vs. Fasciocutaneous Microvascular Free Flaps for Lower Limb Reconstruction: A Meta-Analysis of Comparative Studies.

(1) Background: Lower extremity microvascular reconstruction aims at restoring function and preventing infection while ensuring optimal cosmetic outcomes. Muscle (M) or fasciocutaneous (FC) free flaps are alternatively used to treat similar conditions. However, it is unclear whether one option might be considered superior in terms of clinical outcomes. We performed a meta-analysis of studies comparing M and FC flaps to evaluate this issue. (2) Methods: The PRISMA guidelines were followed to perform a systematic search of the English literature. We included all articles comparing M and FC flap reconstructions for lower limb soft tissue defects following trauma, infection, or tumor resection. We considered flap loss, postoperative infection, and donor site morbidity as primary outcomes. Secondary outcomes included minor recipient site complications and the need for revision surgery. (3) Results: A total of 10 articles involving 1340 patients receiving 1346 flaps were retrieved, corresponding to 782 M flaps and 564 FC flaps. The sizes of the studies ranged from 39 to 518 patients. We observed statistically significant differences (p < 0.05) in terms of donor site morbidity and total flap loss with better outcomes for FC free flaps. Moreover, the majority of authors preferred FC flaps because of the greater aesthetic satisfaction and lesser rates of postoperative infection. (4) Conclusion: Our data suggest that both M and FC free flaps are safe and effective options for lower limb reconstruction following trauma, infection, or tumor resection, although FC flaps tend to provide stronger clinical benefits. Further research should include larger randomized studies to confirm these data.

Short- and Long-Term Complications of Free Anterolateral Thigh Flap Reconstructions: A Single-Centre Experience of 92 Consecutive Cases.

Background The anterolateral thigh (ALT) flap has been amongst the most versatile components of the reconstructive surgeon's armamentarium. The authors utilise these flaps for a variety of reconstructive procedures including lower limb reconstruction; postsarcoma excision; and open fractures. Few studies have discussed the extent of recipient site morbidity and subsequent revisional procedures. We will report our experience of the ALT flap in 92 consecutive reconstructions with focus on recipient site complications and revisional procedures. Methods Retrospective data collection was done from 92 patients who underwent ALT flap reconstruction—for various large soft tissue defects—at our unit at the Royal Free Hospital, London. We evaluated primary recipient site complications and the requirements for secondary operations after flap transfer. Results All flaps survived with the exception of 3 cases (97% survival rate) in which irreversible venous thrombosis was encountered. 16 of 92 patients (17%) required a second recipient site operation for the following: 7 patients experienced major recipient site complications that warranted early return to theatre and 9 patients required a secondary revision thinning procedure(s). 8 of the 16 patients (50%) requiring second operations had construction on their lower leg/ankle/feet (p value = 0.10). Conclusions Our data demonstrated effective use of the ALT flap in the management of soft tissue reconstructive surgery. Partial flap necrosis was the main complication at the recipient site. In future work, secondary thinning procedures, particularly at the ankle/foot, should be separated from flap-specific complications. Furthermore, we demonstrate tailoring ALT thickness can be performed safely without compromising flap viability.

Microsurgical anastomosis using anterior versus posterior tibial artery in lower limb free tissue transfer.

Soft tissue lower limb reconstruction often requires free tissue transfer. We investigated whether the target vessels used for micro-vascular anastomosis in the lower limb influences microsurgical outcomes. Data from Plastic Surgery Departments of a major tertiary hospital in the United Kingdom (Leeds General Infirmary, LGI) and Australia (Princess Alexandra Hospital, PAH) were retrospectively analysed. Patients who underwent lower limb free flap reconstruction using the posterior (PTA) or anterior tibial artery (ATA) were included. Patient demographics, free flap and microvascular anastomosis details were analysed. Primary outcome was flap failure. Secondary outcome was return to theatre. Two hundred and thirty-four free flaps were included (PAH 115; LGI 119). 60% were muscle flaps. Eighty-one percent of patients were male, with trauma the cause in 82%. PTA was used for microsurgical anastomosis in 70% of cases. Venae comitantes were preferred (96%) for venous anastomosis. PTA group showed a higher proportion of patients with trauma as the mechanism of injury. ATA group was more likely to have an end-to-end arterial anastomosis configuration. Total flap loss was 3.8%. There was no clinically significant difference in flap failure or return to theatre using ATA versus PTA. Incidence of lower limb free flap failure is low (<5%) and not influenced by use of ATA versus PTA for microsurgical anastomosis. The choice of target vessels for microsurgical reconstruction of the lower limb should be predicated upon factors other than aversion to one or another vessel. If all other microsurgical considerations are equal, the surgeon can exercise personal preference.