The decline of free flap surgery in lower limb reconstruction

Level D evidence

Dr Vaikunthan RajaratnamSenior Consultant Hand Surgeon

Department of Orthopaedic SurgeryKTPH Alexandra Health

Singapore

5th International Conference on Plastic Surgery 'PlastiCon 2017‘Dhaka, 28 February 2017

Medicine used to be simple, ineffective and relatively safe.Now it is complex, effective and potentially dangerous. Chantler C ( 1999 ) The role and education of doctors in the delivery of healthcare

ResourcesFlaps and Reconstructive Surgery, Fu-Chan Wei MD FACS , Samir Mardini MD

Surgery of the Injured Hand: Towards Functional Restoration R Venkataswami

SEMINARS IN PLASTIC SURGERY/VOLUME 24, NUMBER 1 2010

The Reconstruction of the Mutilated Hand ,M Neumeister ,A Amalfi,

www.handsurgerymanual.comwww.handsurgeryedu.com – register courses soft tissue reconstructionhttp://www.facebook.com/handsurgeryedu https://twitter.com/handsurgeryeduhttp://www.linkedin.com/groups/Hand-Surgery-International-3804094

Problem identification

• Clear and concise description of the problem

• Identification of the needs

• Identify and list constraints and limits

• Aetiology• Structural analysis• Functional analysis

Right Leg – 10 X 3 cm skin loss over the right tibia, bone exposed

Reconstructive ladderRung 1: Secondary intentionRung 2: Primary closureRung 3: Delayed closureRung 4: SSGRung 5: FTSGRung 6: Tissue expansionRung 7: Random flapRung 8: Axial flapRung 9: Free flap

Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation.Plast Reconstr Surg. Feb 1981;67(2):177-87

Constraint analysis• Assessment – anatomy, patient, surgeon, therapist,• Time and timing • Resources – expertise, experience, equipment, energy

• Ethics• Aesthetics

• Assessment of viability/reconstruction• Best undertaken in theatre

• Obtain 2nd opinion • Especially- amputation• Senior/ more experienced surgeon

Generating options• Begin with the end in mind• Priorities• Holistic consideration• Keep the patient in the centre• Go beyond anatomy• Think outside the ladder!

Role of soft tissue• Sensation• Animation• Efferent Execution• Social• Communication• Aesthetics

Requirements- reconstruction• Wound debridement• Vascularity• Adequate skin cover• Stabilisation of bone • Skin with good vascularity for

bone healing

• Control infections• aggressive debridement and • vascular cover

Endovascular procedures • Utilising best option in the reconstruction ladder• running down the ladder of reconstruction with newer reliable

• local flaps and • negative wound pressure

Indian Journal of Plastic Surgery May-August 2013 Vol 46 Issue 2

• Amputation fell from 70% to 1.8%• wound mortality fell from 20% to 1.8 • non-union rates between 5% and 45%.

ANZ J Surg 83 (2013) 348–353

• 18/42 responded (43%)• Median follow-up time of 14 years since reconstruction. • Road traffic the most common cause of trauma (12/18).• The majority of participants (13/18) had SIP physical and psychosocial

sub-scores equivalent to the general population (<5), and half the participants reported normal function

• 2 participants sub-scores of ≥20, implying severe physical disability, associated with higher pain and stiffness scores

Vol. 39 / No. 2 / March 2012

distally pedicled propeller perforator flaps used in the reconstruction of defects in the distal third of the lower leg and foot.

• early appearance of healthy granulation tissue,

• reduction in wound area and • allowed simpler soft tissue

procedures • NPWT improved clinical survival

of muscle flaps

Injury, Int. J. Care Injured 41 (2010) 780–786

• Godina emergency free flaps or the ‘fix and flap’ concept

• flap reconstructions performed beyond the frequently quoted critical interval yielded similar results to those of immediate reconstruction within the first 3 days

532 microsurgical extremity reconstructionsDelayed treatment >72 h, • total flap necrosis in 20% and • Postoperative infections in 29% Emergency fix and flap• total flap necrosis 1% and • Postoperative infections 2%

• treatment of subacute wounds with assisted healing and selective delayed reconstruction

• achieved good results with low osteomyelitis rates (5.6%)

• giving priority to ensuring preoperative infection control, by providing the wound with a healing potential, and

• by using smaller flaps compared with radical debridement—early free flap approach

MDT approach - the traumatologist, vascular surgeons, orthopaedic surgeons, nurses, PA’s, and plastic surgeons.

who is available, when can they do it, are they willing to do it, and if they do it, can they do it with a degree of certainty that will assure complete and ‘‘living coverage’’, once coverage is provided?

In those circumstances, it is better to delay coverage or even transfer a patient to another centre, than have an inexperienced team of personnel try to provide coverage with an unsuccessful outcome.

The latter certainly creates terrible morbidity, increases hospitalisation costs, and generates emotional trauma to patients.

In the polytrauma patient with open fractures, particularly in the extremities, coverage is just one part of total care that includes haemodynamic stabilisation, fracture stabilisation, definitive fixation, perhaps provisional coverage, definitive coverage, and then reconstruction down the line of missing bone segments, motor tendon units, or peripheral nerves.

• 2 years - no significant difference in scores for the Sickness Impact Profile between amputation and reconstruction groups (12.6 vs. 11.8, P=0.53)

Predictors of a poorer score • rehospitalization -major complication, • low educational level, • Nonwhite race, • poverty, • lack of private health insurance, • Poor social-support network, • low self-efficacy (the patient’s confidence in

being able to resume life activities),• smoking, and • involvement in disability-compensation

litigation.Patients with limbs at high risk for amputation can be advised that reconstruction typically results in two-year outcomes equivalent to those of amputation. (N Engl J Med 2002;347:1924-31.)

CASE PRESENTATION • 43 yr male construction

worker • Brick fell on the left shin at

work • Open Tibia distal fracture .• 4 cm Degloving wound on

the Antero medial aspect of distal 1/3 of Tibia .

• No neuro vascular deficit • No other injuries

Wound debridement and Spanning External fixation

4cm x 3cm wound, bone fragments in communication with wound: another 1cm wound over posterior calf

Definitive treatment for fracture

skin defect of 6x4cmexposed bone comminuted #

Reverse hemi Soleus flap with SSG

http://www.woundsresearch.com/files/wounds/photos/huuangfigure1111.jpg

• medial part of the soleus muscle

• for reconstruction of the medial and distal parts of the lower limb

• narrow tibial exposures and irrigation

• based on the posterior tibial artery perforators

Post op Day 4

Further readingsSoft-tissue coverage of an extensive mid-tibial wound with the combined medial gastrocnemius and medial hemisoleus muscle flaps: The role of local muscle flaps revisited,Pu, Lee L.Q.,Journal of Plastic, Reconstructive & Aesthetic Surgery , Volume 63 , Issue 8 , e605 - e610

Tobin, G.R. Hemisoleus and reversed hemisoleus flaps. Plast Reconstr Surg. 1985; 76: 87–96

Reddy, V. and Stevenson, T.R. Lower extremity reconstruction. Plast Reconstr Surg. 2008; 121: 1–7

Daigeler, A., Drucke, D., Tatar, K. et al. The pedicled gastrocnemius muscle flap: a review of 218 cases. Plast Reconstr Surg. 2009; 123: 250–257

Heller, L. and Levin, L.S. Lower extremity microvascular reconstruction. Plast Reconstr Surg. 2002; 108: 1029–1041