Tissue Defects Of Lower Extremity Research Articles

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.

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.

Immediate Versus Late Flap Coverage for Traumatic Soft Tissue Defects of Lower Extremity: A Comparative Observational Study.

BackgroundThe lower extremity trauma in patients often gets operated on late for the wound coverage and is associated with more health costs and other resources. Therefore, this study has been conducted to compare the outcome in terms of flap survival, complication rates, and hospital stay between immediate and late flap coverage of lower extremity traumatic wounds.MethodsThe comparative analysis of outcome is done in terms of flap survival, complication rates, and hospital stay after immediate and late flap coverage of 25 (n = 25) patients of lower extremity traumatic wounds in each group. The patients were observed, and data obtained were tabulated in a Microsoft Excel spreadsheet. The statistical analysis was done using IBM SPSS (V26.0, IBM Corporation, Armonk, NY, USA) statistical software. The chi-square test was used for descriptive data and the student's unpaired t-test for discrete-continuous data analysis. The p-value of less than 0.05 is considered significant.ResultsThe mean defect size with SD in the immediate flap cover group is 54.5 ± 29.5 cm2, while in the late flap cover group, it is 85 ± 65 cm2 with a significant p-value of 0.0378. The mean flap size with SD in the immediate flap coverage group is 70.5 ± 34.5 cm2, while in the late flap coverage group, it is 117 ± 87.5 cm2, and the difference is statistically significant. The mean hospital stay with SD in the immediate flap coverage group is 7.5 ± 2.5 days. In contrast, in the late flap coverage group, it is 29.5 ± 8.5 days, and the difference is statistically very significant.ConclusionThere are equivalent results in patients undergoing immediate and late flap coverage for the traumatic soft tissue defects of the lower extremity. There is a significant decrease in the hospital stay after immediate flap reconstruction, which subsequently reduces both direct and indirect health costs. However, there is a larger size flap requirement in cases of immediate lower extremity wound coverage.

Single-stage microsurgical reconstruction of large complex tissue defects of the lower extremities with two vascularized flaps

The purpose of this study was to explore the effectiveness of combined one-stage reconstruction of extensive complex defects of lower limb tissues and to analyze postoperative complications.Material and methods. The research involved 25 patients with bone and soft tissue defects of lower extremities. The first group included 16 patients, where the replacement of bone and soft-tissue defects of the lower leg was carried out with one complex bone-skin graft. The second group consisted of 9 patients who, along with major defects of the tibia, had concomitant extensive damage of soft tissues. To replace bone and soft-tissue limb defects, the autotransplantation technique of 2 free flaps, bone and soft-tissue (combined) was used.Results and discussion. In our study, we analyzed early and late postoperative complications, as well as the average time of fusion of the graft with the recipient bed and restoration time of the lower limb supportability. In the second group of patients, we did not observe any critical complications in the early postoperative period that would affect the results of patient`s treatment. The increase in the incidence of vascular complications is not statistically significant. In the late postoperative period (30 days or more), stress fractures of the fibular graft, traumatic fracture of the fibular graft, delayed consolidation of the graft ends with the recipient bone lasting more than 6 months were observed in both groups of patients. The incidence of these complications was comparable in both groups, there were no statistically significant differences. The average time of fusion of the graft with the recipient bed and the time of restoration of the lower limb supportability did not have statistically significant differences.Conclusion. One-stage reconstruction of extensive deep limb tissue defects by using an appropriate combination of two vascularized complex grafts (bone and soft tissue) provides a complete reconstruction of complex limb tissue defects without increasing the time of bone consolidation and the frequency of occurrence of critical complications in the postoperative period (total necrosis of vascularized flaps and deep wound infection process).

Application of Keystone flap in the repair of soft tissue defect of lower extremity

To study the effectiveness of Keystone flap in the repair of soft tissue defect of lower extremity. The clinical data of 27 cases with soft tissue defects of lower extremity treated by Keystone flap between January 2018 and June 2020 were retrospectively analyzed. There were 18 males and 9 females, with an average age of 43.9 years (range, 8-63 years). The cause of soft tissue defects included skin tumor in 3 cases, ulcer in 2 cases, soft-tissue infection in 8 cases, trauma in 7 cases, and donor site defect after free or pedicled flap transplantation in 7 cases. Defect size ranged from 2.0 cm×1.5 cm to 15.0 cm×9.5 cm. The types of Keystone flaps included type Ⅰ in 2 cases, type Ⅱa in 16 cases, type Ⅱb in 1 case, type Ⅲ in 6 cases, and Moncrieff modified type in 2 cases. The area of flap ranged from 3.0 cm×1.5 cm to 20.0 cm×10.0 cm. The donor site was directly sutured (26 cases) or repaired with skin grafting (1 case). The operation time was 45-100 minutes, with an average of 67.5 minutes; the hospitalization stay was 3-12 days, with an average of 8.5 days. Postoperative incision dehiscence occurred in 1 case, and flap marginal necrosis occurred in 2 cases, all of which were completely healed after dressing change; 1 case of incision was swollen and congested with tension blisters, which resolved spontaneously at 7 days after operation. The other flaps and the skin grafting survived and healed successfully, the wounds of recipient and donor sites healed by first intention. The healing time was 2-3 weeks (mean, 2.2 weeks). No pain occurred in all patients. All 27 cases were followed up 3-26 months (mean, 11.5 months). No obvious scar contracture and bloated skin flap were found. The texture and color of the skin in the recipient area were similar to those of the surrounding tissues and feel existed. The Keystone flap is a feasible and efficient way to repair soft tissue defect of lower extremity. Furthermore, the skin color and texture is similar to the surrounding tissue after healing.

Reconstruction of Extensive Soft Tissue Defects of Lower Extremity With the Extended Anterolateral Thigh Flap.

The anterolateral thigh flap is a classic flap used for various reconstruction defects. However, the flap viability of extended large skin paddles (ie, 240 cm2) was doubted by many surgeons. This study reports successful experience of reconstructing extensive soft tissue defects of lower extremity using extended large skin paddles. Twelve consecutive patients who had undergone reconstruction of defects using an extended anterolateral thigh flap were identified. Patient characteristics (age, sex, defect location, injured structures, and type of flap) and outcome data were analyzed retrospectively. One artery and 2 accompanying veins were anastomosed to vascularize each flap. Follow-up periods ranged from 10 to 91 months postoperatively. The average size of the flaps was 268.75 cm2 (range = 220-391 cm2). All flaps were perforator flaps with one perforator except that 2 perforators were used in 3 patients. Two patients suffered partial flap necrosis of the distal portion with delayed healing. In conclusion, the extended anterolateral thigh flap is a considerable option for massive defects requiring composite tissue coverage. This flap is advantageous for reconstructing various complex defects in the lower extremities, providing a pliable and vascularized tissue to cover exposed extensive defects including tendons, nerves, and bones.

LONG-TERM DONOR-SITE MORBIDITY IN COMPOSITE ANTEROLATERAL THIGH FREE FLAP FOR COMPLEX DEFECT OF LOWER LEG AND FOOT RECONSTRUCTION

Background: In recent years, the composite anterolateral thigh free flap with tensor fasciae latae or vastus lateralis has been a new-applied type of flap that can provide very good reconstruction materials in complex defects of lower leg and foot. The study purpose is to evaluate the systematically complications of donor site, related factors to results of the donor area, in order to apply the result to improve the treatment, which have not been much reported in literature. Materials and Methods: Systematic donor site morbilidy evaluation in a prospective, uncontrolled clinical descriptive study of 33 composite anterolateral thigh free flaps in various forms to reconstruct anatomical structures or to resconstruct deep defects combined with covering the surfaces for complex soft tissue defects in lower extremities for 32 patients due to different causes in lower leg and foot area from 2014-2019 at Hue University of Medicine and Pharmacy. Examining and evaluating aesthetic and functional result of donor-site 3 months and 6 months up to 2 year after surgery; evaluating the correlation between the width and the type of the flaps and donor site closure methods. Result: In 33 composite flaps used, flap width to thigh circumference less than 20% in 27 cases (81.8%), more than 20% in 6 cases (18.20% ); There were 28 cases in which the donor site was directly closed, 5 cases required skin graft; All direct closed cases had flap width/ thigh circumference index below 20%; On the contrary, in cases having this index greater than 20%, the donor site required skin graft with p < 0.01. There are 11/33 (33.33%) of cases reported complications in donor site ; lateral thigh paresthesia is the most complicated complication with 8/33 cases (24.24%), followed by bad scarring 3/33 cases (9.09%). Conclusion: Long term follow up donor site morbility after composite anterior thigh free flap present 11/33 cases (33.33%): mostly complications of the donor site are thigh paresthesia with 8/33 cases (24.24%), and bad scarring 3/33 cases (9,09%), which improve time by time. Keywords: Composite anterior thigh free flap, lower extremities soft tissue defect, donor site morbidity

Comparative Study between Perforator Based Island Flaps and Fasciocutaneous Flaps in Reconstruction of Lower Extremities

Background: Open wound of the lower limb is one of the common health problems that have a significant economic and social burden. It has a risk of osteomyelitis of the underlying bone and even necrosis can occur. Objective: To evaluate the difference between the perforator-based island flaps and fasciocutaneous flaps in reconstruction of lower extremities regarding; functional, aesthetic outcome, size of the flap, degree of rotation, technical difficulties, percentage of flaps survival, flap loss, operative time and donor site morbidity. Patients and Methods: The study was conducted on 40 patients with soft tissue defects in lower extremities which were equally distributed into two groups. Group 1 consisted of 20 patients that were treated by perforator based island flap and group 2 that consisted of 20 patients treated by fasciocutaneous flap. Results: The two techniques had similar results when evaluated by the Likert scale. The results of both procedures had no significant statistical differences as regards any of the Likert score components namely, color, texture, appearance, and shape. The main finding of the current study was the comparable postoperative outcome for both techniques. The number of patients that had necrosis was 7 in perforate based island flap and 4 in fasciocutaneous flap which represented 35% and 20% respectively of each studied group and this was statistically insignificant. Conclusion: Any flap can be used as a perforator-based island flap in which the source vessel is completely preserved. Perforator flaps have multiple advantages over Fasciocutaneous flaps as allowing increased diversity and versatility in the design and composition of flaps.

Comparative Study between Perforator Based Island Flaps and Fasciocutaneous Flaps in Reconstruction of Lower Extremities

Background: Open wound of the lower limb is one of the common health problems that have a significant economic and social burden. It has a risk of osteomyelitis of the underlying bone and even necrosis can occur. Objective: To evaluate the difference between the perforator-based island flaps and fasciocutaneous flaps in reconstruction of lower extremities regarding; functional, aesthetic outcome, size of the flap, degree of rotation, technical difficulties, percentage of flaps survival, flap loss, operative time and donor site morbidity. Patients and Methods: The study was conducted on 40 patients with soft tissue defects in lower extremities which were equally distributed into two groups. Group 1 consisted of 20 patients that were treated by perforator based island flap and group 2 that consisted of 20 patients treated by fasciocutaneous flap. Results: The two techniques had similar results when evaluated by the Likert scale. The results of both procedures had no significant statistical differences as regards any of the Likert score components namely, color, texture, appearance, and shape. The main finding of the current study was the comparable postoperative outcome for both techniques. The number of patients that had necrosis was 7 in perforate based island flap and 4 in fasciocutaneous flap which represented 35% and 20% respectively of each studied group and this was statistically insignificant. Conclusion: Any flap can be used as a perforator-based island flap in which the source vessel is completely preserved. Perforator flaps have multiple advantages over Fasciocutaneous flaps as allowing increased diversity and versatility in the design and composition of flaps.

Repair of composite tissue defect of lower extremity with free fibula composite tissue flaps assisted by 3D-CT angiography

Objective To investigate the clinical efficacy of free fibula composite tissue flap transplantation for repair of composite tissue defects of lower extremity assisted by three-dimensional CT angiography (3D-CTA). Methods From May 2013 to February 2018, 16 patients with severe lower extremity trauma were treated with fibular composite tissue flaps. The course, distribution and vascular variation of peroneal artery were determined by preoperative 3D-CTA. The survival and appearance of the flaps were observed after the operation. X-ray examination was performed 6 weeks, 3 months, 6 months and 1 year after the operation to observe the healing of the fracture and evaluate the functional recovery of the affected limbs. Results The anatomical structure of composite tissue flaps can be clearly displayed by 3D-CTA. The findings during operation were basically consistent with the preoperative design. The follow-up period ranged from 6 to 24 months, with an average of 13 months. All the flaps survived and the fracture healed well. According to Enneking system score the average point was 22. The lower extremity function recovered to 73% of that of the normal side. Ankle joint activity was normal in donor area, and there was no abnormal sensation in common peroneal nerve innervation area. Conclusion At the same time of repairing bone defects with free composite tissue flaps, the combined skin flaps can repair soft tissue defects, which effectively solve the problem of wound coverage and restore the function of affected limbs. The patients are satisfied with the prognosis. Key words: Lower extremity; Treatment outcome; Three-dimensional CT angiography; Fibula composite tissue flap

Tissue flap combined with sequential bone lengthening technique for repairing severe soft tissue and bone defects of lower extremity after burn injury

To investigate the effectiveness of tissue flap grafting and sequential bone lengthening for repairing severe soft tissue and bone defects of the lower extremity after burn injury. Between January 2010 and December 2015, 11 cases of large segmental bone and soft tissue defects in the leg were treated. There were 10 males and 1 female, with a mean age of 28 years (range, 19-37 years). The causes included traffic accident in 8 cases, high voltage electric burn in 2 cases, CO poisoning burn in 1 case. The time from injury to admission was 3-14 days (mean, 6.5 days). The bone defect length was 8-18 cm (mean,14 cm); the skin soft tissue defect ranged from 13 cm × 8 cm to 25 cm × 19 cm. After complete removal of necrotic tissue and lesions of the femur or the tibia, the tissue flaps were used to repair soft tissue defect of the lower extremity in one-stage operation; bone defect was treated by Orthofix single side external fixation or Ilizarov ring external fixation in two-stage operation. Eleven flaps survived completely, primary healing of incision was obtained in the others except for 1 patient who had necrotic bone infection, which was cured after removing necrosed femoral bone and filling with antibiotic bone cement spacer. During bone lengthening, pin tract infection occurred in 1 patient, and infection was controlled after dressing change. Bone lengthening ranged from 8 to 18 cm, with an average of 14 cm. After prolonged extension, the external fixator was retained for 4-12 months (mean, 6.5 months). All bone defects were repaired with bone healing time of 12-22 months (mean, 17 months). All patients were followed up 8-24 months (mean, 15 months). No vascular and neurological complication occurred during operation; no osteomyelitis or re-fracture occurred after operation, and the recovery of the lower extremity function was good. Tissue flap grafting combined with bone lengthening is an effective method to repair severe bone and soft tissue defects of lower extremity.

Repair of soft tissue defects in lower extremities by latissimus dorsi myocutaneous flap with T type of vascular pedicle

To investigate the Application of latissimus dorsi myocutaneous flap with T type of vascular pedicle in repairing soft tissue defects at lower extremities. Between January 2003 and August 2013,16 patients with skin and soft tissue defects at lower extremities were treated with T type vascular pedicled latissimus dorsi myocutaneous flap through bridge transplantation. There were 13 male and 3 female patients with an average age of 36.2 years(range,17-54 years).Skin and soft tissue defects in the lower extremities ranged from 18 cm × 13 cm to 32 cm × 15 cm. The T-configuration vascular anastomosis was formed by anastomosing the subscapular and circumflex scapular vessels to the proximal and distal ends of the posterior tibial vessel broken in the normal leg respectively in an end-to-end manner. The latissimus dorsi myocutaneous flap was used to cover the defect at damaged leg where vascular pedicle was wrapped by tube flap from the normal leg. External fixators was used to immobilize the bilateral lower legs postoperatively. Vascular crisis occurred in 3 cases. Vascular crisis was relieved after exploring the vessel.2 cases developed infection at the distal end of flap and cured by debridement. Primary healing was obtained in 11 cases after 2 weeks,and the total survival rate was 100％.The follow-up period lasted for 6 months to 5 years with an average of 3.4 years. The flap appearance was satisfactory and extremity function was restored to normal. The application of the T type of vascular pedicled latissimus dorsi myocutaneous flap by bridge transplantation is an effective method for repair skin and soft tissue defects in lower extremity without damaging for main blood vessels at contralateral limb, when affected extremities have no available vessel for anastomosis.

Free flaps for reconstruction of soft tissue defects in lower extremity: A meta-analysis on microsurgical outcome and safety.

Microsurgical free flaps for reconstruction of soft tissue defects in lower extremity have evolved into a reliable procedure over last decades; however, there lacked high level of evidence. A systematic literature research was performed including studies between 2000 and 2014 in English, German, and Chinese (PubMed, EMBASE). Publications were selected applying inclusion/exclusion criteria. Postoperative complications were statistically analyzed with metaprop command of R GUI 3.0.1. Alltogether 30 articles overlooking 1,397 free flaps were included. The rate of total flap loss was 6.0% (95% confidence interval [CI] = 4.0%-8.0%, PQ (P values of Q statistics) = 0.03); the thrombosis rate was 6.0% (95% CI = 4.0%-9.0%, PQ = 0.01); the hematoma rate was 4.0% (95% CI = 3.0%-5.0%, PQ = 0.79); the partial necrosis rate was 6.0% (95% CI = 4.0%-10.0%, PQ < 0.01); the early infection rate was 4.0% (95% CI = 2.0%-6.0%, PQ = 0.03), and the dehiscence rate was 3.0% (95% CI = 2.0%-5.0%, PQ = 0.12). Reconstruction for diabetic foot may be not associated with a significant increase of procedural risk (Total flap loss rate = 6%, 95% CI = 3.0%-9.0%, PQ = 0.44). Microsurgical reconstruction of soft tissue defects in the lower extremity reconstruction could be regarded safe and reliable. A standardization of report of perioperative parameters and clinical outcomes is needed. © 2016 Wiley Periodicals, Inc. Microsurgery 36:511-524, 2016.

Comparative analysis of results of early and late microsurgical reconstructive operations in patients with extensive posttraumatic tissue defects of lower extremities

Comparative analysis of patient treatment results with extensive and deep posttraumatic defects of different segments of lower limbs has been done in this article. Early (n=71) and late (n=127) microsurgical reconstructive operations with using island flaps and free axial skin flaps have been performed to all these patients. According to authors, early microsurgical reconstructive operations have significant opportunities due to similar but later done operations. In particular, operative treatment makes necessary conditions for reliably more frequent using of less difficult operations with island flaps and creates statistically reliable reduce of additional operations demand. This treatment also provides the best long-term results and a more complete functional recovery of the damaged lower extremities in terms from two to six years.

Reconstruction of Soft Tissue Defect of Lower Extremity With Free SCIA/SIEA Flap

Free tissue transfer is the most important means of soft tissue reconstruction for the lower extremity. However, cosmetic results and donor site morbidity are only of secondary concern of lower extremity reconstruction. In our efforts to obtain the best possible outcome for patients, as our first priority we chose free superficial circumflex inferior artery (SCIA)/superficial inferior epigastric artery (SIEA) flap over other free flap options in the soft tissue reconstruction of lower extremity because of some advantages. Over the past 3 year, 25 patients underwent lower extremity reconstruction with free SCIA/SIEA flap (n = 27). Twenty-six of 27 flaps were successful (96%), 6 required emergent postoperative re-exploration of the anastomosis, and 1 failed. Although secondary debulking procedure was performed for some flaps (n = 3), most flaps had acceptable thickness for functional and esthetic outcomes especially in the pretibial, ankle, and foot defect reconstruction with an average of 1-year follow-up. Based on our results, free SCIA/SIEA flap has the following advantages in soft tissue reconstruction of lower extremity: (1) large flaps may be harvested for extensive defect and/or to reach recipient artery for passing zone of injury; (2) if necessary, final flap debulking may be performed by surgical procedure using local anesthesia; (3) the donor site is closed in a similar manner to abdominoplasty incision so that excellent cosmetic result may be achieved.

Vascularized pedicle iliac crest for the repair of bone and soft tissue defect of lower extremity

To study the role of transplantation of the vascularized pedicle iliac crest for the repair of bone and soft tissue defect of lower extremity. The vascularized pedicle iliac crest was designed for the repair of bone and soft tissue defect of lower extremity according to anatomic feature of leg and foot. Skin graft was used for coverage of the iliac flap. Skin survival could demonstrate the survival of the vascularized pedicle iliac crest indirectly one week postoperatively. Skin survived completely in 4 cases and partly in 3 cases. Callus was seen at the transplantation site one month postoperatively, and K-wires were removed 4 months later in the cases of metatarsal defect. The external fixators were removed in the cases of tibia defect 6 to 8 months postoperatively. The functions of lower extremities were restored in 2 to 4 months. The bone and soft tissue defects were repaired, and ultimate function and cosmetic effects were satisfied after the mean follow up of 10 months (ranged from 6 to 15 months). Transplantation of the vascularized pedicle iliac crest is an ideal method for the repair of bone and soft tissue defect of lower extremity. The operation can be performed in one stage. The functions and cosmetic effects are better than the traditional methods.