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262 British Journal of Plastic Surgery British Journal of Plastic Surgery (2001), 54 2001 The British Association of Plastic Surgeons doi: 10.1054/bjps.2000.3535 Modified dorsalis pedis flap for coverage of a pretibial pressure sore after hip rotationplasty B. Reichert, B. D. Krapohl, W. P16tz* and P. Mail~inder Division of Plastic Surgery, and *Department of Orthopaedic Surgery, Medical University of Liibeck, Liibeck, Germany SUMMARY A pretibial pressure ulcer after hip rotationplasty was reconstructed with a modified dorsalis pedis island flap. Total femur resection and replantation of the lower leg to the hip joint had been previously performed for recurrent synovial sarcoma. A pretibial pressure sore developed during subsequent plaster-cast immobilisation. After excision of the ulcer, the defect measured 18 x 4cm. The anterior tibial vessels were dissected to serve as a vascular pedicle for the dorsalis pedis fasciocutaneous flap. The reconstructed skin covering the tibial bone enabled the patient to walk on a prosthesis. 2001 The British Association of Plastic Surgeons Keywords: femoral neoplasm, postoperative complications, leg ulcer, surgical flaps, reconstruction. Rotationplasty is a well-established procedure after total femur resection, especially in children. Rehabilitation is superior to disarticulation of the hip or hemipelvectomy because patients regain hip and knee function.1 A tight fit of the prosthetic shaft is essential. The pretibial area has a low physiological resistance to pressure and shear forces, and is thus at increased risk of developing pressure-related complications. Skin defects with exposure of skeletal elements require flap coverage. The dorsalis pedis flap is one of the surgi- cal options available for skin coverage of the proximal anterior leg. It can be rotated to cover almost any site on the anterior aspect of the leg if the pedicle is mobilised up to the anterior tibial artery. 2 Since donor site complica- tions are common, this flap has few indications) Case report A 54-year-old female was referred to our unit by the Orthopaedic Department in February 1999. Five years previously, a synovial sarcoma of the right thigh had been resected en bloc with a small part of the diaphysis of the right proximal femur. In 1996, a frac- ture of the femoral shaft occurred at the site of the operation, which was stabilised by intramedullary nailing. In March 1998, the patient complained of a tender mass in the lateral thigh. MRI scans revealed a recurrent tumour measuring 13 • 5 x 8 cm, pene- trating the rectus femoris muscle and encroaching upon the femoral neck. Inguinal lymph nodes were uninvolved and there was no evidence of distant metastases. To achieve a wide resec- tion margin around the tumour, and because the tissue was proba- bly contaminated by prior surgery and the fracture, resection of the thigh and the whole femur was required. Preoperatively the patient received four courses of chemotherapy with ifosfamide, etoposide and adriamycin in combination with hyperthermic iso- lated limb perfusion. In November 1998, the femur was totally resected and the thigh was replaced by a type BIlIb rotationplasty (according to Winkelmann, 4 which is a modification of the procedure initially described by Borggreve5 and Van Nes6). The lower leg, rotated through 180~ , replaces the thigh, with the ankle acting as the knee joint. In a type BIlIb rotafionplasty, a total hip prosthesis with the femoral component introduced into the medullary canal of the proximal tibia is used to reconstruct the hip joint (Fig. 1). Tension-free anastomosis of the large vessels was performed, and the sciatic nerve was positioned laterally and subcutaneously in loops. Classification of the tumour was pT2b, pNx, pMx, G2. 7 Postoperative plaster-cast immobilisation lead to skin necrosis of the pretibial area, which was anterior prior to rotationplasty, in the proximal third of the leg. After 3 months of conservative treatment the ulcer had not healed (Fig. 2) and the patient was admitted to our institution. We excised the ulcer and the adjacent scar tissue, which resulted in an 18 x 4 cm defect with exposure of the anterior tibia. Complete reconstruction of the defect was achieved using a modification of the dorsalis pedis flap. After incision of the extensor retinaculum, the anterior tibial artery and the concomi- tant veins were dissected to allow transposition of the flap to the proximal third of the leg (Figs 3 and 4). The skin between the donor and the recipient sites was incised and the vascular pedicle positioned subcutaneously. To enable tension-free closure of this incision, the anterior tibial tendon and the distal part of the muscle were removed. The donor area on the right foot was covered with an unmeshed split-thickness skin graft from the left thigh. The flap and the grafted foot healed uneventfully, mobilisation started 18 days postopera- tively. Six months postoperatively, the patient was mobilised on a conventional prosthesis, with stable coverage of the pretibial area and the foot (Fig. 5). Chemotherapy continued after our intervention. Cardiotoxicity is a side-effect of adriamycin. Our patient developed congestive heart failure and died as a result of complications of this treat- ment 8 months after our operation. Discussion Out of the 134 cases in Winkelmann's series, eight suf- fered from superficial skin necrosis. None of them required flap coverage, although skin grafts were used in two patients. 4 Only 16 patients had undergone total femur resection and the mean age was 14.4 years (range: 2.5-48 years). In that study, 25 patients died of metastatic dis- ease and one patient died of complications following

Modified dorsalis pedis flap for coverage of a pretibial pressure sore after hip rotationplasty

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Page 1: Modified dorsalis pedis flap for coverage of a pretibial pressure sore after hip rotationplasty

262 British Journal of Plastic Surgery

British Journal of Plastic Surgery (2001), 54 �9 2001 The British Association of Plastic Surgeons doi: 10.1054/bjps.2000.3535

Modified dorsalis pedis flap for coverage of a pretibial pressure sore after hip rotationplasty

B. Reichert, B. D. Krapohl, W. P16tz* and P. Mail~inder

Division of Plastic Surgery, and *Department of Orthopaedic Surgery, Medical University of Liibeck, Liibeck, Germany

SUMMARY A pretibial pressure ulcer after hip rotationplasty was reconstructed with a modified dorsalis pedis island flap. Total femur resection and replantation of the lower leg to the hip joint had been previously performed for recurrent synovial sarcoma. A pretibial pressure sore developed during subsequent plaster-cast immobilisation. After excision of the ulcer, the defect measured 18 x 4cm. The anterior tibial vessels were dissected to serve as a vascular pedicle for the dorsalis pedis fasciocutaneous flap. The reconstructed skin covering the tibial bone enabled the patient to walk on a prosthesis. �9 2001 The British Association of Plastic Surgeons

Keywords: femoral neoplasm, postoperative complications, leg ulcer, surgical flaps, reconstruction.

Rotationplasty is a well-established procedure after total femur resection, especially in children. Rehabilitation is superior to disarticulation of the hip or hemipelvectomy because patients regain hip and knee function.1 A tight fit of the prosthetic shaft is essential. The pretibial area has a low physiological resistance to pressure and shear forces, and is thus at increased risk of developing pressure-related complications.

Skin defects with exposure of skeletal elements require flap coverage. The dorsalis pedis flap is one of the surgi- cal options available for skin coverage of the proximal anterior leg. It can be rotated to cover almost any site on the anterior aspect of the leg if the pedicle is mobilised up to the anterior tibial artery. 2 Since donor site complica- tions are common, this flap has few indications)

Case report

A 54-year-old female was referred to our unit by the Orthopaedic Department in February 1999. Five years previously, a synovial sarcoma of the right thigh had been resected en bloc with a small part of the diaphysis of the right proximal femur. In 1996, a frac- ture of the femoral shaft occurred at the site of the operation, which was stabilised by intramedullary nailing. In March 1998, the patient complained of a tender mass in the lateral thigh. MRI scans revealed a recurrent tumour measuring 13 • 5 x 8 cm, pene- trating the rectus femoris muscle and encroaching upon the femoral neck. Inguinal lymph nodes were uninvolved and there was no evidence of distant metastases. To achieve a wide resec- tion margin around the tumour, and because the tissue was proba- bly contaminated by prior surgery and the fracture, resection of the thigh and the whole femur was required. Preoperatively the patient received four courses of chemotherapy with ifosfamide, etoposide and adriamycin in combination with hyperthermic iso- lated limb perfusion.

In November 1998, the femur was totally resected and the thigh was replaced by a type BIlIb rotationplasty (according to Winkelmann, 4 which is a modification of the procedure initially described by Borggreve 5 and Van Nes6). The lower leg, rotated through 180 ~ , replaces the thigh, with the ankle acting as the knee joint. In a type BIlIb rotafionplasty, a total hip prosthesis

with the femoral component introduced into the medullary canal of the proximal tibia is used to reconstruct the hip joint (Fig. 1). Tension-free anastomosis of the large vessels was performed, and the sciatic nerve was positioned laterally and subcutaneously in loops. Classification of the tumour was pT2b, pNx, pMx, G2. 7

Postoperative plaster-cast immobilisation lead to skin necrosis of the pretibial area, which was anterior prior to rotationplasty, in the proximal third of the leg. After 3 months of conservative treatment the ulcer had not healed (Fig. 2) and the patient was admitted to our institution.

We excised the ulcer and the adjacent scar tissue, which resulted in an 18 x 4 cm defect with exposure of the anterior tibia. Complete reconstruction of the defect was achieved using a modification of the dorsalis pedis flap. After incision of the extensor retinaculum, the anterior tibial artery and the concomi- tant veins were dissected to allow transposition of the flap to the proximal third of the leg (Figs 3 and 4).

The skin between the donor and the recipient sites was incised and the vascular pedicle positioned subcutaneously. To enable tension-free closure of this incision, the anterior tibial tendon and the distal part of the muscle were removed. The donor area on the right foot was covered with an unmeshed split-thickness skin graft from the left thigh. The flap and the grafted foot healed uneventfully, mobilisation started 18 days postopera- tively. Six months postoperatively, the patient was mobilised on a conventional prosthesis, with stable coverage of the pretibial area and the foot (Fig. 5).

Chemotherapy continued after our intervention. Cardiotoxicity is a side-effect of adriamycin. Our patient developed congestive heart failure and died as a result of complications of this treat- ment 8 months after our operation.

Discussion

Out of the 134 cases in Winkelmann's series, eight suf- fered from superficial skin necrosis. None of them required flap coverage, although skin grafts were used in two patients. 4 Only 16 patients had undergone total femur resection and the mean age was 14.4 years (range: 2.5-48 years). In that study, 25 patients died of metastatic dis- ease and one patient died of complications following

Page 2: Modified dorsalis pedis flap for coverage of a pretibial pressure sore after hip rotationplasty

Dorsalis pedis flap after hip rotationplasty 263

f

Figure 3-~21osure of proximal pretibial defect with a fasciocutaneous island flap harvested from the dorsum of the foot. The vascular pedicle was formed by the anterior tibial artery and the concomitant veins.

Figure 1--Type BIIIb rotationplasty according to Winkelmann. 4

Figure 2--Pretibial ulceration after plaster-cast immobilisation.

chemotherapy. The follow-up period ranged from 4 months to 17 years.

Our patient underwent rotationplasty at the age of 54 years. The indication was a large locally recurrent

Figure 4--Flap in place; donor site prepared for closure with a split- thickness skin graft.

synovial sarcoma, which otherwise would have required hemipelvectomy. The prognosis for this patient was poor from the beginning; therefore, she was all the more deter- mined to refuse amputation. In an attempt to achieve the best possible degree of mobilisation she agreed to

Page 3: Modified dorsalis pedis flap for coverage of a pretibial pressure sore after hip rotationplasty

264 British Journal of Plastic Surgery

Figure 5--Result 6 months after uneventful healing of the flap.

rotationplasty, knowing that this is a very unusual proce- dure in adults.

Insufficient padding in a plaster splint is a major cause of pressure sores in orthopaedic surgery. Resistance to pressure can be diminished by the effects of hyperther- mic l imb perfusion. Sensory recovery after rotationplasty can be incomplete, and lack of sensibility further increases the r isk of pressure-related skin damage.

Once there is significant loss of pretibial soft tissue, any attempt to close the defect primari ly under tension will eventually result in an even larger defect. The anterior margin of the tibia is covered with nothing but skin, leav- ing the bone without further protection. Complete loss of skin in this area will, therefore, require flap coverage. The options are local rotation flaps, muscle flaps, pedicled island flaps or free revascularised flaps. Skin expansion has also been p roposed )

As the entire surface of the rotated proximal leg acts as a weight-bearing area, flaps should not be harvested there. Muscle flaps are frequently selected, but they are too bulky if the patient is to use a prosthesis. Free tissue transfer and skin expansion should be restricted to patients in good general condition without significant comorbidi ty of the leg. A fasciocutaneous island flap was, therefore, selected for our patient.

Although we were very well aware of the drawbacks resulting from donor site morbidity, we nevertheless decided to apply a dorsalis pedis flap harvested in an extended fashion, e Since McCraw and Furlow introduced the dorsalis pedis flap as a local transposition flap in

1975 9 its advantages have become well known: there is a constant vascular pedicle, dissection is safe in predictable anatomy and there is a low risk of venous congestion. If palpation or Doppler ultrasound cannot reliably confirm adequate perfusion of the foot without the anterior tibial artery, angiography is required.

The dorsalis pedis flap offers an ideal pretibial soft- tissue reconstruction. Technically, the procedure is not too difficult and the flap is very reliable. The risk of com- plications is moderate. We believe that in this case the donor site morbidity of the flap could be tolerated.

References

1. Winkelmann WW. Hip rotationplasty for malignant tumors of the proximal part of the femur. J Bone Joint Surg 1986; 68A: 362-9.

2. Kamal MS, Azab AS, Talaat HA. Leg repairs with an island flap from the dorsum of the foot, based on the anterior tibial vessels. Plast Reconstr Surg 1979; 64: 498-504.

3. Samson MC, Morris SF, Tweed AEJ. Dorsalis pedis flap donor site: acceptable or not? Plast Reconstr Surg 1998; 102: 1549-54.

4. Winkelmann WW. Rotationplasty. Orthop Clin North Am 1996; 27: 503-23.

5. Borggreve J. Kniegelenksersatz durch das in der Beinl~ingsachse um 180 ~ gedrehte Fuggelenk. Arch Orthop Unf Chit 1930; 28: 175-8.

6. Van Nes CP. Rotation-plasty for congenital defects of the femur: making use of the ankle of the shortened limb to control the knee joint of a prosthesis. J Bone Joint Surg 1950; 32B: 12-16.

7. American Joint Committee on Cancer. Soft tissue sarcoma. In AJCC Cancer Staging Manual. 5th ed. Philadelphia: Lippincott-Raven, 1997: 149-56.

8. Masquelet AC, Gilbert A. An Atlas of Flaps in Limb Reconstruction. London: Martin Dunitz, 1995: 241-58.

9. McCraw JB, Furlow LT Jr. The dorsalis pedis arterialized flap: a clinical study. Plast Reconstr Surg 1975; 55: 177-85.

The Authors

Bert Reichert MD, Senior Physician and Deputy of the Director Bj~rn Dirk Krapohi MD, Resident House Physician Peter Mailiinder MD, Senior Physician and Director

Division of Plastic Surgery,

Werner Pl~tz MD, Senior Physician and Former Director

Department of Orthopaedic Surgery,

Medical University of Ltibeck, Ratzeburger Allee 160, D-23552 Litheck, Germany.

Correspondence to Dr Bert Reichert.

Paper received 28 April 2000. Accepted 20 November 2000, after revision.