Cross leg posterior tibial artery fasciocutaneous island flap for reconstruction of lower leg defects

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  • Brifish Journal ofPlastic Surgery (1992), 45,62-65

    Cross leg posterior tibia1 artery of lower leg defects

    R. K. Sharma and G. Kola

    fasciocutaneous island flap for reconstruction

    Department of Plastic Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India

    SUMMARY. We have utilised a posterior tibial artery flap from the opposite healthy limb for reconstruction of defects of middle and lower third of leg in 6 patients. The flap can be based either distally or proximally as the need be. The results have been quite encouraging.

    Skin defects of the lower and middle third of the leg are a challenging problem, and in the past have been reconstructed using avariety of methods, including local random flaps, cross leg flaps (Stark, 1952), proximally based fasciocutaneous flaps (PontCn, 1981; Barclay et al., 1982), distally based fasciocutaneous flaps (Donski and Fogdestam, 1983; Lagvankar, 1990a, b), turn over flaps (Thatte et al., 1983), muscle flaps (Ger, 1966; Vasconez et al., 1974; Mathes et al., 1982; Arnold and Mixter, 1983), free flaps (OBrien et al., 1973; Daniel and Taylor, 1973; Yoshimura et al., 1984). Recently Hong et al. (1989) have described reconstruction of lower leg and foot defects with a reverse pedicled posterior tibia1 artery flap. This appears to be a reliable and simpler alternative to the microvascular free tissue transfer. However, in certain situations, local flaps from the same leg may not be suitable. In such cases, we have utilised the posterior tibia1 artery flap from the opposite healthy limb. We have named this technique the Cross leg posterior tibia1 artery fasciocutaneous island flap.

    Materials and methods

    Since December, 1989, till the present date we have ,utilised this technique in 6 patients (5 males and 1 female). In 4 patients distally based, and in 2 patients proximally based flaps were used. For defects of the lower third of the leg, a distally based flap was used, whereas a proximally based flap was employed for defects of the middle third of the leg.

    Surgical technique

    The technique of raising the posterior tibial artery flap has been described in detail by Hong et al. (1989). Before using this flap, it is imperative to ascertain that the limb is not fully dependent upon the posterior tibia1 vessels only. The interruption of the posterior tibia1 artery necessary during surgery can be simulated to a large extent by a technique similar to Allens test in which the posterior tibia1 artery is compressed manually and the patient told to move his or her toes for a few minutes.

    Depending upon the need, either a distally or proximally based flap of suitable size is marked on the opposite healthy limb (Fig. 1). The skin and fascia are incised all around and skin-fascia sutures are taken to avoid a shearing effect. The flap is gradually detached from the soleus muscle till the posterior tibial vessels are seen in the septum between soleus and flexor hallucis longus. The vessels are separated as a unit from the posterior tibia1 nerve. It should be noted that the vessels are not split at all. All the loose areolar tissue around the vessels is taken along the pedicle. The vessels are divided proximally or distally as the need be, and the pedicle is developed for about 10 cm (Fig. 2). The exposed posterior tibia1 nerve is covered by suturing the adjacent flexor hallucis longus and soleus muscles over it, and the donor area is covered with split skin graft. The limbs are placed in a suitable position, and the flap is sutured into the defect (Fig. 3). Almost the whole of the flap can be inset except a small area at the site of entry of the pedicle. The limb is immobilised (vide infra). 10 days later a clamp is applied (Fig. 4) to compress the vessels gradually for the next 2-3 days. After this the pedicle is divided under local anaesthesia in the ward itself.

    Immobilisation

    The ankles are immobilised by a figure of 8 plaster of paris bandage after keeping enough padding between the medial malleoli (Fig. 5). If a proximally based flap is used, in addition to immobilisation of the ankle, the knees are also immobilised with elastic crepe bandage for initial 2-3 days only. The patient is encouraged to perform knee and hip movements after 24 hours (Fig. 6).

    Results

    Table 1 shows the details of the patients for whom this technique was used.

    The proximally based flaps (2) survived completely (Figs 7,8). Out of 4 distally based flaps 2 had complete survival. In one patient the pedicle was compressed because of faulty immobilisation, and about 3.5 cm of

    62

  • Cross Leg Posterior Tibia1 Artery Fasciocutaneous Island Flap for Reconstruction of Lower keg Defects 43

    Pig. 1

    Figure B-Designing the flap on the opposite healthy leg. Figme 2-Line diagram showing elevation of a distally based flap. Fi@re 5 Flap suture+ 1 into the defect. The pedicle has been covered with split thickness skin graft. Figure &The clamp has been applied to corn press

    FHL - FLEX I-IALLUCIS LONGUS SOL - SOLEUS

    PTV _ POST TlBlALVESSEL

    PTN _ POST TIBIAL NERVE

    IMP _ INTERMUSCULAR PERFORATORS

    SN - SAPNENOUS VEINS

    MM _ MEDIAL MALLEOLUS

    Big. 3

    Kg. 4

    the vessels.

  • 64 British Journal of Plastic Surgery

    Fig. 5 Fig. 6

    Figure STechnique of immobilisation of a distally based flap. Figure G-Movements of knee and hip joints can easily be performed.

    flap was lost. In another patient with a flap size of 23 x 11 cm, about 2.5 cm of flap was lost. In both these patients, the bone could still be covered by advancing the flap and use of locally available tissue.

    Discussion

    Extensive skin defects of the lower and middle third of the leg with exposed bones are very difficult to cover, especially if these are associated with crush avulsion injuries. On many occasions there is also associated vascular injury, which leads to circulatory insufficiency in the limb. In such patients use of local skin, fasciocutaneous or muscle flaps is not possible. Even a free flap may also not be suitable because of absence of good recipient vessels in the vicinity of the

    defect. In such situations, flaps taken from the opposite healthy leg are a good alternative. A conventional cross leg flap is not very reliable and positioning of the limbs is extremely uncomfortable. Although fasciocu- taneous cross leg flaps are much more reliable and allow a greater freedom of leg positioning, the length: breadth ratio limits the length of the pedicle. It is difficult to use these flaps if external pin fixation has been applied for treatment of fractures.

    A cross leg posterior tibia1 fascidcutaneous island flap is free from all these difficulties. The positioning of the leg is very comfortable as the flap has a long pedicle. The immobilisation is doneonly at the level of the ankles, so the patient can easily perform knee and hip joint movements, thus avoiding troublesome postoperative joint stiffness.mAlmost complete inset of the flap can be given at the first sitting, and the pedicle

    Table

    Sr. Size of Proximally or distally No. Cases Age/sex Location/size of defect Jrap (cm) based Comments

    1. MS. 30M Defect lower l/3 of leg with 17 x 9 distal Detached.2 weeks later; exposed tibia 100% flap survival

    2. KS. 18M Compound fracture lower 18x9 distal Detached 2 weeks later; l/3 of tibia 100% flap survival

    3. P.K. 25M Compound fracture lower 23x 11 distal l/3 of tibia

    2.5 cm of flap necrosed at the tip; detached~ 3 weeks later

    4. B.S. 35M Compound fracture middle 20 x 10 proximal 100% survival; detached2 l/3 of tibia weeks later

    5. MS. 30M Multiple fracture tibia with 16 x 10 distal 3.5 cm of flap necrosed at exposed tibia in lower l/3 the tip; detached 3 weeks

    later

    6. S.R. 40F Compound fracture tibia 14x8 proximal Detached 2 weeks later; with exposed bone in 100% flap survival middle l/3 of tibia

  • Cross Leg Posterior Tibia1 Artery Fasciocutaneous Island Flap for Reconstruction sf Lower Leg Defects

    ire 7-Exposed bones in middle third of the leg. Figure 8- -De :fec

    can be divided under local anaesthesia in the ward itself? thus virtually making the procedure one stage. The flap is taken from the inner side of the leg and hence no pedicle length is lost, which happens with the laterally placed peroneal artery island flap (Yoshi- mura et al., 1990). The quality of the skin transferred is quite suitable to the defect because we are borrowing skin from the like area of the opposite leg. There is minimal donor site morbidity.

    The cross leg posterior tibia1 fasciocutaneous island flap is a simple and fairly reliable method of treating defects of the middle and lower third of the leg. In our experience SQ far, this method has proved to be a promising technique and gives us good reason to continue using it.

    Amok& P. G. and Mixter, R. C. (1983). Making the most of the gastrocnemius muscles. Plastic and Reconstruct&e Surgery, 72,38.

    Barclav, T. L., Cardoso. E. E.. Sharue, D. T. and Crockett, 5.,(1982X Rep& of lower leg.defec& with kasciocutaneous fla& &it& Journalof Plastic Surgery, 35, 127.

    Daniel, W. K. and Taylor, G. I. (1973). Distant transfer of an island flap by microvascular anastomosis: a clinical technique. FZustic and Reconstructiue Surgery, 52, 111.

    Donski, P. K. and wogdestam, I, (1983). Distally based fasciocuta- neous dlap from sural region. Scandinavian Journal of Plastic and Reconstructive Surgery, 17,191,

    Ger, B. 61966). The operative treatment of the advanced stasis ulcer: i? preliminary communication. American Journalof Surgery, 111, 659.

    Hong, G., StetTens, K. and Wan, IF. B. (1989). Reconstruction of the lower leg and foot with reverse pedicled posterior tibia1 fasciocutaneous flaps. British Journal of Plastic Surgery, 42,512.

    Lagvaukar, S. B. (1990a). Distally based random fasciocutaneous flaps for one stage reconstruction of defects in the upper two thirds of the leg. British Journal of Plastic Surgery, 43,541.

    Fig. 8

    :overed with a proximally based hap from the opposite healthy leg.

    Lagvankar, S. P. (1990b). Distally based random fasciocutaneous flaps for multistaged reconstruction of defects in the lower third of leg ankle and heel. British Journal ofPlastic Surgery, 43,468.

    Mathes, S. J., Alpert, B. S. and Chang, N. (1982). Use of muscle flaps in chronic osteomyelitis : experimental and clinical correla- tion. Plastic and Reconstructive Surgery, 69,815.

    OBrien, B. M., Macleod, A. M., Mayhurst, J. W. and Morrison, W. A. (1973). Successful transfer of a large island flap from the groin to the foot by microvascular anastomosis. PIustic and Reconstrac- tive Surgery, 52,27 1.

    Pont&, B. (1981). The fasciocutaneous flap : use in soft tissue defects of the lower leg. British Journal of Plastic Surgery, 34,215.

    Stark, R. B. (1952). The cross leg procedure. Plastic and Reconstruc- tive Surgery, 9,173.

    Thatte, R. L., Pat& D. and Taiwar, P. (1983). Deepithelised turn over axial pattern flaps in the lower extremity. British Journal of Plastic Surgery, 36,327.

    Vasconez, L. 0., Bustwick, 9. III aud M&raw, J. (1974). Coverage of exposed bone by muscle transposition and skin grafting. Hastic and Reconstructive Surgery, 53,526.

    Yoshimura, M., Imura, S., Shimamura, K., Yamawchi, S. and Nomura, S. (1984). Peroneal flap for reconstruction in the extremity : preliminary report. Plastic and Reconstructive Surgery, 74, %02.

    Yoskimura, M., Skimada, T., Matsuda, M., IBos~kaiva, M. a& Imuka, S. (1990). A new method for repairing skin defects of the lower leg under unsatisfactory condition utilisation of peroneal island flap from the opposite sound leg. Plastic andReconstructit.e Surgery, $5,123.

    R. K. Sharma, MS, MCh, Dip. National Board, Assistant Professor. G. Kda, MS, MCh, Pool Ohicer.

    Department of Plastic Surgery, Postgraduate Pnstitute of Medical Education and Research, Chandigarh 160012, Endia.

    Requests for reprints to Dr R. K. Sharma.

    Paper received 24 April 1991. Accepted 23 July 1991 after revision.

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