Microsurgery for lower extremity injuries

Anastasios V. Korompilias a,*, Marios G. Lykissas a,Marios D. Vekris a, Alexandros E. Beris a, Panayotis N. Soucacos b

aDepartment of Orthopaedic Surgery, University of Ioannina, School of Medicine, Ioannina 45110, GreecebDepartment of Orthopaedic Surgery, University of Athens, School of Medicine, Athens, Greece

Injury, Int. J. Care Injured (2008) 39S, S103—S108

www.elsevier.com/locate/injury

KEYWORDSMicrosurgery;Lower extremity;Trauma;Free flaps

Summary An entire generation of orthopaedic and plastic surgeons has beenindelibly and perhaps overwhelmingly influenced by the introduction of microvasculartechnology to the fields of limb salvage and musculoskeletal reconstruction. Free-tissue transfer using microsurgical techniques has become a valuable method for thesalvage of lower extremities after trauma. The goals of free flaps are both soft-tissuecoverage and improvement of the functional outcome. The flap selection criteria forlower extremity reconstruction are based on the wound surface area, the type oftissue deficiency, length of the pedicle, volume of deficient tissue components anddonor site morbidity. Composite flaps represent the state-of-the-art for reconstruc-tive microsurgery, providing more than one function. Although many differenttreatment protocols have been proposed, they all highlight the importance of earlytissue coverage with bone management performed in a later stage.# 2008 Elsevier Ltd. All rights reserved.

Introduction

Primary amputation was once the mainstay of treat-ment for massive lower extremity injuries. Withtoday’s advances in microsurgical techniques alongwith a better understanding of soft-tissue and boneanatomy and physiology, the surgeon has the abilityto salvage traumatised lower extremities after high-energy injuries. Indications for lower extremity reco-nstruction, although more select than upper limbreconstruction, also include osteomyelitis, tumourreconstruction, non-unions, and radiation wounds.19

* Corresponding author. Tel.: +30 26510 97472;fax: +30 26510 97018.

E-mail address: koroban@otenet.gr (A.V. Korompilias).

0020–1383/$ — see front matter # 2008 Elsevier Ltd. All rights resedoi:10.1016/j.injury.2008.06.004

Many protocols have been described to recon-struct severe lower extremity trauma, all includingthe same basic principles: wide debridement, pri-mary fracture stabilisation, early coverage with wellvascularised tissue, and skeletal reconstruction.14,22

The goal of free-tissue transfer using microsurgicaltechniques is both soft-tissue coverage and improve-ment of the functional outcome.

Selection criteria for free flapreconstruction

A great number of local or free-tissue transfers arenow available. Local rotation skin flaps are oftenindicated for smaller wounds in the foot.8,18,28,36

rved.

S104 A.V. Korompilias et al.

Muscle transposition flaps are also of great impor-tance.8,18,28,36 Gastrocnemius and soleus flaps areoften used for the proximal and middle one-third ofthe leg.16 However, more distal and extensive footand leg wounds require free flaps.16

Free flaps can be divided according to their com-position into an isolated transplant of tissues, suchas skin, muscle or bone, and composite free flaps.19

Composite tissue transfer can be further classifiedinto cutaneous, musculocutaneous, and osteocuta-neous flaps. The selection criteria of free flap forlower extremity reconstruction are based on thewound surface area, the type of tissue deficiency,length of the pedicle, volume of deficient tissuecomponents, and donor site morbidity.19

Swartz and Mears33 classified trauma of the lowerextremity into four groups in order to make morespecific recommendations for free flap reconstruc-tion. Patients in Group I, with soft-tissue defectonly, may be treated with musculocutaneous ormuscle flaps, such as latissimus dorsi, gracilis, andrectus abdominis muscles. Patients with less than 8-cm soft-tissue and bone defect (Group II) may bemanaged successfully with composite bone andmus-cle transfers. Patients with severe soft-tissue andbone involvement (Group III) should be treated intwo stages. A first stage of freemuscle flap coverageshould be followed by a second stage of skeletalreconstruction. If severely infected wounds are alsopresent (Group IIIB), radical debridement of allinfected tissues is mandatory. For patients with abone defect only (Group IV), a free vascularisedfibular graft is the treatment of choice.

According to Yajima et al.,38 for Gustilo Type IIIopen fractures, patients with small skin and bonedefects may be treated with peroneal or scapularflaps, and conventional autologous bone graft, suchas iliac bone graft. For patients with a large bonedefect and small skin loss, an osteocutaneous flap isindicated. Vascularised bone graft is usuallyobtained from the fibula, the lateral border of thescapula, the iliac crest, and the ribs. These bonescan be harvested along with a cutaneous, septocu-taneous or a musculocutaneous flap. Fibula can betaken with a peroneal flap, iliac crest with a groinflap, ribs with serratus anterior and latissimus dorsi,and scapula can be harvested with a scapular or aparascapular flap. The fibula is often preferred forthe reconstruction of long bone defects because ofthe straight shape, the mechanical strength, thelimited donor site morbidity, and the possibility offolding the graft into two or even threepieces.1,3,24,34 The free vascularised iliac bone graftmay also be used. However, it is associated withhigher rate of donor site morbidity and inability tocover defects longer than 10-cm.38 Ribs can be used

as an alternative if fibular and iliac bone graft arenot available with a high complication rate.24,25

Vascularised scapular graft is preferred in youngwomen because the donor site can be hidden byclothing.38

The Ilizarov technique may be used in combina-tion with microsurgical transplants and affect flapselection. Pin and ring placement may either pre-cede or follow soft-tissue coverage.19 In the firstcase, Ilizarov technique is used for bone stabilisa-tion in cases of open fractures with adequate bonestock. Once the Ilizarov frame has been placed, themicrovascular surgeon should define the need forfree-tissue transfer. In the second case, the Ilizarovtechnique may be used for acute or gradual defor-mity correction. A deformity, such as non-union ormalunion, may be the result of inadequate initialstabilisation which precede a flap coverage proce-dure.

Distraction osteogenesis is another possibility ofcombined microsurgery and Ilizarov procedure incases of severe bone and soft-tissue defects. Corti-cotomy is performed proximal, distal, or both prox-imal and distal to the defect and the osteotomisedsegment is transported toward the defect.19 In manycases, the volume and the surface area of free flapneeded may be diminished due to the simultaneoustransposition of bone and attached soft tissuestoward the defect.11 Furthermore, distractionlengthening may successfully follow free-tissuetransfer in children, as long bones of this patientpopulation exhibit a strong regenerative response todistraction.29 An important technical notice is thatthe transferred flap should contain the vascularpedicle and anastomosis site in order to avoid undueforces on it.19

When a free vascularised bone graft, such asosteoseptocutaneous fibula, is used for bone defectsthat exceed 6-cm, the Ilizarov technique mayreplace internal fixation. Moreover, in cases ofsevere bone loss an Ilizarov procedure may be usedto fill the bone defect by either acutely shorteningthe bone and subsequent gradual lengthening orbone transport.10,17 By acutely shortening, thesoft-tissue defect is decreased and an easier flapwith less morbidity is often required.19

In case of massive skin loss and small bonedefects, a musculocutaneous flap is indicated.38

Musculocutaneous flaps include latissimus dorsi,gracilis, gastrocnemius, rectus abdominalis, andtensor-fasciae latae flaps. The latissimus dorsi mus-culocutaneous flap has been widely used because itis the largest flap possible to harvest, is richlyvascularised which makes it effective against infec-tion, and has a vascular pedicle of sufficient calibre,even in very small children.29 Moreover, latissimus

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dorsi musculocutaneous flap can be harvested withserratus anterior muscle for extensive complexdefects. Finally, for patients with large bone andskin defects, the vascularised fibular graft combinedwith latissimus dorsi musculocutaneous flap shouldbe used.38

A posttraumatic composite structure and func-tional defect of the lower extremities can be man-aged with free functioning muscle transfer in asingle stage reconstruction. When composite soft-tissue loss is associated with flexor and/or extensordefect, gracilis, rectus femoris or latissimus dorsimuscle can be used as a source for the free func-tioning flap. The selection criteria for the donormuscle depend on the relationship between the sizeof the donor muscle, the donor vessel, and themotor nerve relative to the site of the defect.23 Agracilis myocutaneous flap is used for ankle dorsi-flexion restoration, whereas rectus femoris muscleis often preferred for a weight-bearing muscledefect reconstruction. In cases of extensive soft-tissue deficit, rectus femoris muscle can be har-vested with an accompanying anterolateral thighmyocutaneous perforator flap.23 Moreover, in casesof composite soft-tissue, bone, and motor unitreconstruction, rectus femoris muscle can betransferred along with a tensor-fascie latae muscleflap combined with vascularised iliac crest bonegraft.23

For themanagement of proximal andmiddle thirdopen tibial fracture defects, free muscle or muscu-locutaneous flaps are usually used.40 At this level ofinjury, the recipient vessels are located deep in themuscles.41 Therefore, the pedicle of the selectedmuscles should be long enough to allow anastomosiswithout tension.

For complex defects of the ankle and distal thirdopen tibial fractures, a free muscle flap is thetreatment of choice in a severely comminutedfracture, large volume of tissue deficiency, andpresence of a deep dead space.40 At this level ofinjury a muscle flap with a short pedicle, such as agracilis flap may be used for covering because therecipient vessels are usually located near thedefect.41 However, if the fracture is not commin-uted, the tissue defect is small, and the deep deadspace is absent, a fasciocutaneous flap may beused.40 Fasciocutaneous flaps, such as the scapu-lar, parascapular, radial forearm, lateral arm andgroin, and anterolateral groin flaps give a bettercosmetic appearance compared with muscle ormusculocutaneous flaps. Furthermore, becauseof a lack of bulk, fasciocutaneous flaps whenapplied to the distal third of the tibia, the ankle,and the dorsum of the foot may allow patients towear normal shoes.40

Indications

Severely damaged limbs with intact sensibilityare candidates for salvage procedures.19 Nerveinjuries should be primarily sensory and distalenough in order to allow return of some functionwithin a reasonable amount of time.19 Primaryamputation should be considered in complexlower limb injuries with nerve damage becauserecovery and rehabilitation is more rapid with agood prosthetic replacement.2 Moreover, a 50%cost reduction has been estimated for patientsreceiving primary amputation compared to pati-ents with lower extremity reconstruction aftersevere trauma.4

According to Hierner et al.,20 an amputated partshould be replanted if certain conditions are pre-sent. These include lack of deep contamination andextended soft-tissue damage, time of cold ischae-mia less than 4—6 h, and total segmental tissue lossless than 15-cm. Moreover, a single level injury andthe possibility of reconstructing the injured poster-ior tibial nerve are additional criteria for attemptinglimb replantation. A functional extremity should bethe goal of treatment.

Any severely damaged limb in a child constitutesan indication for microvascular limb procedures.Although published success rates in children varyfrom 67% to 100%,7,12,21,26,27,30,31,35 probably dueto smaller vessel size and the increased suscept-ibility to vascular spasm, good function shouldalways be expected.29 Complications after micro-surgical lower extremity salvage in limb threa-tening injuries in children include growthdisturbance and limb-length discrepancy. Thesecomplications can be avoided with meticulousapplication of microsurgical techniques in free-tissue transfer and application of distraction osteo-genesis.29

Additionally, microsurgical procedures may beperformed successfully in the elderly, if appropriatepreoperative evaluation and perioperative closemonitoring are followed.19 High rates of limb sal-vage with good function should be expected if theunique features and co-morbidities of this popula-tion are taken into consideration.

Indications for free-tissue transfers include largedefects, composite tissue defects, and impairedvascularity.16 In adults, the most common indicationfor free flaps is the Gustilo Type IIIB open fracture,accounting for more than 90% of cases.14,22 Relativeindications for free-tissue transfers include failureof local flaps, obliteration of deep dead space,coverage of large chronic traumatic wounds, andcreation of a well vascularised bed for skeletalreconstruction in a second stage.16

S106 A.V. Korompilias et al.

Timing for microsurgicalreconstruction

Timing of soft-tissue coverage may affect the finalresults.14 Both patient and wound status determinethe treatment algorithm. Wound parameters thatshould be considered before wound closure includeexposed vital structures, type of fracture, type ofsoft tissues involved, and the risk of infection.19

Although many different treatment protocolshave been proposed, they all highlight the impor-tance of early post tissue coverage with bone man-agement performed at a later stage.5,6,9,14,39 Inorder to define the relationship between the flaptiming and the final results, including bone union,postoperative infections, failure rate, and hospitalstay, Godina14 divided 532 free flaps into four groupsaccording to the time of surgery. He demonstratedthat patients who were operated earlier had betterresults. In a prospective analysis of 22 consecutiveGustilo Type IIIB open fractures, Yaremchuk et al.,39

recommended muscle flap transfer between 7 and14 days after injury and after serial debridements ofbone and soft-tissue. According to the same authors,bone defect reconstruction should be performed anaverage of 9 weeks after soft-tissue coverage. Byrdet al.5,6 and Cierny et al.9 emphasised that externalskeletal fixation, aggressive debridement, and soft-tissue coverage should be performed within 5—7days after injury, whilst bone grafting should beperformed at 2—4 weeks. This time sequence isrecommended to reduce postoperative and chronicinfection rates, bone non-union, and flap failure.19

In cases of delayed patient presentation, woundsmay be associated with devitalised tissue andchronic osteomyelitis. In a series of 38 patients withchronic wounds of greater than 1 month’s durationwho underwent 42 free flaps, the rate of completeflap loss was 19%.15 This high complication rate indelayed soft-tissue coverage was in accordance withseveral studies. According to Byrd et al.,6 the com-plication rate was as high as 33% when covering wasperformed in both between 1 and 6 weeks and over 6weeks. Godina also noted a 12% flap failure rate forflaps covering wounds that were open for aminimumof 3 months after injury.14 However, the failure ratewas limited to 0.75% when coverage was performedduring the first 3 days after injury.14

Before primary closure with a free flap, twocrucial factors that should be considered are therisk of infection and the presence of exposed vitalstructures, such as nerves, vessels, and tendons.19

Infection may affect both the flap survival rate andthe functional outcome. If the risk of infection ishigh or a radical debridement could not be per-formed, primary wound closure with a free flap is

contraindicated. On the other hand, when a vitalstructure is exposed, primary or delayed primarycoverage should be considered.

Reconstruction of composite bone and soft-tis-sue defects may be performed either in 1 or 2stages. Many authors support that wound controlshould be achieved in a first stage whilst vascu-larised bone transfer for bone defects larger than6-cm should take place in a second stage, 6—8weeks after soft-tissue coverage.5,6,9,14,39 How-ever, according to some authors, this two-stageprocedure results in increase scarring and lack ofavailable recipient vessels.41 They suggest that thetransfer of a combination of vascularised bonegraft and soft-tissue flap with a one-stage proce-dure has several advantages, including promotionof bone union and early stability, reduction ofhealing time, and decreased difficulty of repeatedmicrosurgical procedures.13,25,32,37,41 Moreover,they support that a one-stage procedure providescomparable functional results with staged recon-struction.41

Complications

Complications after free-tissue transfer may con-cern the flap viability or the donor site and they canbe either acute or late. Flap complications occurusually during the first two post operative days andinclude arterial thrombosis and venous thrombosis,haematoma formation, haemorrhage, and flapoedema.19 Postoperative evaluation should includeclose monitoring of vital signs and flap circulationwith inspection of colour, capillary refill, and Dop-pler flowmetry.

Arterial thrombosis should be suspected if the flaphaswhite colour, reduced temperature, low capillaryrefill, decreased pallor, and no bleeding after pin-prick. In such cases the patient should undergorevision of the anastomosis. Venous insufficiency,manifested by a cyanotic flap which produces darkcolour after pinprick, may be managed with medic-inal leeches. The leeches reduce venous congestionby increased bleeding due to hirudin, an enzyme thatinhibits coagulation cascade and platelet aggrega-tion. However, if venous compromise insists, thepatient must be returned to the operating room forrevision of the venous anastomosis. In some cases, afree flap fails due to vascular insufficiency. Non-viable flaps should be removed and a new free-tissuetransfer should be considered if the patient’s generalcondition and the extremity’s state can tolerate asecond demanding surgical procedure. Otherwise, atemporary wound dressing, such as a wound vacuum-assisted closure should be used.19 Finally, in severely

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compromised extremities amputation may be thetreatment of choice.

Donor site complications include dysaesthesias,scar, and haematoma formation. The severity andfrequency of complications of the donor site dependon the bulk and complexity of the flap used, which inturn reflects the severity of the injury. Late com-plications include bone non-union and neuroma for-mation.

Conclusion

Conventional management of high-energy injuriesof the lower extremity results in poor functionaloutcome and often a late amputation. Nowadays,free-tissue transfer using microsurgical techniqueshas become a valuable method for the salvage oflower extremities after trauma. Free vascularisedbone grafts, composite soft-tissue transfer, inner-vated flaps, and functional composite free flaps maybe applied in one- or two-stage procedure toachieve a functional limp. Adequate outcomesmay be achieved by both meticulous wound pre-paration before coverage and careful selection ofthe free flap with regard to recipient-site require-ments. The patient with a significantly compromisedextremity should be notified about the multistagedreconstruction and become familiar with the possi-bility of a late limb amputation.

Conflict of interest

None.

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