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Microsurgical Reconstruction of the Lower Extremity

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Microsurgical Reconstruction of the Lower Extremity 54 Microsurgical Reconstruction of the Lower Extremity William C. Pederson, MD, FACS1 Luke Grome, MD1 1 Division of Plastic Surgery, Baylor College of Medicine, Houston, Address for correspondence William C. Pederson, MD, FACS, Head, Texas Hand and Microsurgery, Texas Children’s Hospital, Sam Stal Endowed Professor of Plastic Surgery, Professor of Surgery, Orthopedic Surgery, Semin Plast Surg 2019;33:54–58. Neurosurgery, and Pediatrics, Baylor College of Medicine, Houston, TX (e-mail: [email protected]). Abstract Reconstruction of bony and soft tissue defects of the lower extremity has been revolutionized by the advent of microsurgical tissue transfer. There are numerous options for reconstruction. Possibilities include transfer of soft tissue, composite (bone and soft tissue) tissue, and functional muscle. Many lower extremity reconstructions require staged procedures. Planning is of paramount importance especially in regard to vascular access when multiple free flaps are required. Soft tissue reconstruction of the lower extremity may be accomplished with muscle flaps such as the rectus femoris and latissimus dorsi covered with a skin graft. Fasciocutaneous flaps such as the ante- rolateral thigh flap may be more appropriate in a staged reconstruction which requires Keywords later elevation of the flap. Loss of a significant portion of bone, such as the tibia, can be ► lower extremity difficult to manage. Any gap greater than 6 cm is considered a reasonable indication for reconstruction vascularized bone transfer. The contralateral free fibula is the donor site of choice. ► microsurgery Functional reconstruction of the anterior compartment of the leg may be performed ► functional muscle with a gracilis muscle transfer, effectively eliminating foot drop and providing soft transfer tissue coverage. Muscle tensioning is critical for effective excursion and dorsiflexion of ► free fibula the foot. Long-term results of microsurgical reconstruction of the lower extremity ► trauma show good results and reasonable rates of limb salvage. Reconstruction of bony and soft tissue defects of the lower tissue, bone, function, etc.), then proper planning is para- extremity has been revolutionized by the advent of micro- mount. It is not uncommon to have to perform a soft tissue surgical tissue transfer. We have the ability to repair and flap as a first stage to get the wound closed and to prepare the reconstruct significant tissue loss due to tumor extirpation bed for either bone transport or vascularized bone transfer. or trauma with microsurgical techniques. There are numer- Vascular access in terms of multiple free flaps (e.g., soft tissue ous options for soft tissue reconstruction, with the possibi- and then bone) is extremely important to avoid “burning lity of composite (bone and soft tissue) tissue transfer and bridges” for future flaps. At times, the same recipient vessels functional muscle transfer. This monograph will cover the can be utilized for more than one free flap, but this may and basics of lower extremity reconstruction with microsurgery. may not be wise. Frequently, the anterior tibial vessels are divided at the site of injury or fracture, and while these This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Planning vessels are sometimes not ideal, they can be utilized in an end-to-end fashion for the first flap. The second flap (usually Perhaps the most difficult aspect of performing complex the free fibula) can be anastomosed end to side to the lower extremity reconstruction is proper planning. Single- posterior tibial vessels to avoid compromise to the blood stage reconstruction of bone and soft tissue defects is often flow to the foot. Or this can be done in the opposite fashion, ideal1 but may not be practical depending on the situation. If with the original flap anastomosed to the posterior tibial the problem can be taken care of in one stage, planning is less vessels end to side and the fibula anastomosed to the anterior important, but if it is going to take multiple stages (soft tibial vessels. But keep in mind that the veins accompanying Issue Theme Free Tissue Transfer Copyright © 2019 by Thieme Medical DOI https://doi.org/ Reconstruction; Guest Editor: Yadranko Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0039-1677878. Ducic, MD, FRCS(C), FACS New York, NY 10001, USA. ISSN 1535-2188. Tel: +1(212) 584-4662. Microsurgical Reconstruction of the Lower Extremity Pederson, Grome 55 the anterior tibial artery are quite small, and may not be Anastomosis out of the zone of injury is ideal, but at times appropriate for anastomosis to the large peroneal veins difficult to do with extensive trauma. Experience has shown coming off the free fibula. In this case, venous anastomosis that microvascular anastomosis in the zone of trauma can be to the saphenous or even lesser saphenous veins might be successful if the vessels are not badly damaged.5 In our most appropriate. experience, the veins pose much more problems than the The choice of the initial soft tissue flap can be important as arteries, and the surgeon should have a backup plan for well. As we discuss later, muscle or fasciocutaneous flaps can be venous outflow if the chosen veins are damaged and/or utilized incoverage of lower extremity defects. If there issimply thrombosed. Vein grafting to proximal undamaged vessels a soft tissue defect, either flap can be entirely appropriate. If should always be a consideration in the lower extremity. there will definitely be a second procedure, whether it be bony Another option is to place an arteriovenous vascular loop or other reconstruction, it is usually easier to secondarily raise a prior to tissue transfer and utilize this for anastomosis to fasciocutaneous flap and/or operate through it than it is to do so vessels well out of the zone of injury.6 through a muscle flap covered with skin graft. There are a myriad of choices in terms of flaps for coverage Timing of reconstruction remains an area in which most of the lower extremity. Traditionally, muscle flaps (i.e., latissi- would agree with Godina that early coverage is the best,2 and mus dorsi, rectus femoris) have been utilized in the lower recent studies have confirmed that coverage within 72 hours extremity, but fasciocutaneous flaps (i.e., anterolateral thigh lowers rates of flap loss and long-term infection.3 Practically [ALT] flap) have become more popular recently.7 Muscle flaps speaking, however, this may not be possible in many cases. have the advantage that they atrophy over time and contour Negative pressure wound therapy as a temporizing measure very nicely (►Fig. 1). Even when covered with a split-thickness until wound coverage can be obtained is probably a reasonable skin graft, the overall appearance is not bad. Muscle flaps may approach in situations where early flap coverage is not be more difficult to raise again later for further reconstruction possible.4 (bone grafting, transport, etc.), however. Fasciocutaneous flaps can be too bulky when placed on thelower leg, and will thicken Soft Tissue if the patient gains weight. They are much easier to raise and operate through in the future, however.8 The best options for The lower leg tolerates major trauma poorly, as the skin the lower extremity in terms of soft tissue coverage are the coverage over the tibia is thin, particularly distally. Trauma latissimus dorsi and the ALT flap. Both have long pedicles, can here frequently leads to an open wound with exposed tibia, provide adequate tissue for large defects, and the ALT can be usually with an exposed fracture. Conversely, the thigh has a utilized with a portion of the fascia lata to reconstruct tendon tremendous amount of muscle surrounding the bone, and as well (i.e., the Achilles) (►Figs. 2, 3). The downside of the rarely is soft tissue reconstruction necessary in this area. The latissimus is that the patient must beturned to harvest it, and it upper tibial area can often be covered with local muscle flaps is generally taken without skin and covered with split-thick- (the soleus or gastrocnemius), but the middle to lower tibial ness skin graft. The downside of the ALT is that the pedicle area and the ankle usually will require microvascular tissue dissection can be tedious, and there are a few occasions where transfer for adequate soft tissue reconstruction. an adequate pedicle is not present. Recent work has shown For microvascular tissue transfer to the lower leg, con- that salvage rates of fasciocutaneous flaps and muscle flaps sideration of which recipient vessel to utilize is critical. With with a skin paddle are higher than muscle covered with split- significant trauma, the vessels to the lower leg can be injured, thickness skin grafts, probably due to easier monitoring of flow leading to issues of vascular access for microsurgical tissue to the flap.9 transfer. If the dorsalis pedis and posterior tibial pulse are palpable at the level of the ankle, we feel that vascular studies Bone are probably unnecessary. On the contrary, if both pulses are not palpable, we think it is prudent to obtain vascular Due to the poor skin coverage discussed earlier, tibial frac- studies. Arteriography is usually the best type of study to tures are frequently open, which can lead to devasculariza- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. obtain, computed tomography angiography and/or magnetic tion of the bone and potentially infection with loss of resonance angiography may be acceptable depending on the substance. High-energy fractures and those around the ankle expertise and skill of the local radiologists. In general, can be difficult to heal even in the best of circumstances. Loss however, we feel that the posterior tibial artery is the best of a significant portion of the tibia can be difficult to manage, choice for anastomosis in most cases.
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