Bone exposure in the leg: is a free muscle flap mandatory?

BACKGROUND: In lower leg defects with bone, hardware, or articular exposure, a free tissue transfer is often the only valuable option. However, in well-selected clinical cases, pedicled flaps are still indicated because they provide an alternative for the more demanding and risky microsurgical procedure. The medial adipose-fascial flap of the leg represents an ideal local regional fascial flap. METHODS: Twenty-two medial adipose-fascial flaps (performed in 21 patients) were reviewed retrospectively and compared with a series of 22 free gracilis flaps (22 patients) selected out of 150 muscular free flaps for lower leg reconstruction. All patients with defects larger than 40 cm, peripheral vascular disease, deep defects, and osteomyelitis were excluded in order to obtain the same surgical indications in which the local medial adipose-fascial flap could have been used. RESULTS: The overall surgical results were comparable, but more medical complications, a longer operative time, and a longer hospital stay were seen in the free muscle group. Moreover, patients reconstructed with a medial adipose-fascial flap appeared to be more satisfied with the aesthetic result of their reconstruction. CONCLUSIONS: Muscle coverage is not mandatory to cover bone in the lower leg. The medial adipose-fascial flap can provide a good alternative for free flap coverage. This flap seems to have fewer medical complications, requires a shorter operative time and hospital stay, and can provide better aesthetic results than a free muscle flap.

How to deal with difficult microsurgical end-to-side anastomoses.

Although unexplained thrombotic failures still exist, the majority of free-flap failures are due to identifiable technical failures, indicating that an excellent operative technique remains the key point. However, some clinical circumstances, such as damaged or deeply located vessels, are related to a higher thrombotic risks, demanding refinements of the microsurgical procedure to avoid higher failure rates. We reviewed 195 free flaps in the lower leg in order to quantify these situations and how we dealt with them. In total, six flaps were performed with a T-interposition to cope with difficult end-to-side anastomoses on damaged vessels. In two cases, the use of a funnel-shaped vein graft facilitated difficult end-to-side anastomoses in the popliteal area. The authors believe that these refinements of microsurgery should not be first-choice procedures, but they have proven to be a useful tool for certain microsurgical reconstructions.

The medial adiposofascial flap of the leg: anatomical basis and clinical applications.

Despite recent advances in microsurgical techniques, coverage of lower leg defects by locoregional flaps remains indicated in selected cases. The interest in these types of flaps has improved because recent clinical work advocates that fascial and fasciocutaneous flaps can be well indicated for bone coverage. The anatomical study of the medial adiposofascial flap is presented in this article. The flap is based on the rich vascular network supplied by the saphenous artery and the posterior tibial artery perforators. This flap can be harvested on the anteromedial aspect of the leg and can be mobilized to cover defects located between the patella and the heel. This multiple blood supply makes it possible to harvest this flap in various ways, so various defects can be covered. To confirm and prove the versatility and clinical value of this flap, the authors have studied a series of 22 cases in which this flap was used for coverage of lower leg defects. For these defects, especially when situated in the lower third or around the heel and ankle, coverage by a free flap is most often the only proposed solution. However, the authors have obtained excellent results in the majority of these cases, avoiding a free flap procedure. Moreover, in this way, the option of using a free flap remains possible if needed. There is minimal donor-site morbidity and a high functional and aesthetic outcome, making this flap a first-choice flap in selected cases of lower leg defects.

The gracilis free muscle flap is more than just a "graceful" flap for lower-leg reconstruction.

In 60 consecutive cases, a gracilis free muscle flap was used to reconstruct defects in the lower extremity. Although the harvest of the gracilis free flap is straightforward, the flap is not frequently considered as a valid option for reconstruction because of its "gracile" shape. Hence, it is not considered voluminous enough to cover defects of significant size in the lower leg. However, once the epimysium is separated, the muscle flap spreads out and covers a large surface area, large enough to reconstruct wide rectangular wounds or extended spindleshaped defects. Especially in young patients, the volume of the gracilis muscle is much larger than expected from its descriptive but misleading name. Often it is precisely this patient population that gets involved in motorcycle accidents or traumas caused by contact sports. For the treatment of Gustilo type III open tibia fractures with moderately large-sized soft-tissue defects and for chronic lower leg defects with osteomyelitis, the gracilis muscle flap is an excellent choice. Fifty-nine out of the 60 flaps in long-term follow-up (minimally 3 years) fully healed. The pedicle can be more than 7 cm in length when the final dissection under the long adductor muscle is carried up to the origin at the deep femoral vessels. The functional and aesthetic outcomes at the donor site at the inner thigh are minimal, compared to alternative transfers for such defects, while the reconstructive features of the gracilis muscle flap are excellent.

Irreducible dislocation of the interphalangeal joint of the thumb: a case report.

A case of open irreducible dislocation of the interphalangeal joint of the thumb with interposed flexor pollicis longus tendon and palmar plate with sesamoid bone is described.

Liposuction in benign symmetric lipomatosis: sense or senseless?

Benign symmetric lipomatosis is a rare form of typical fat distribution in the shoulders, the arms, and the neck that can compromise the respiratory, nutritional, and psychological status of the patient. Alcoholism, malignant tumors of the upper airways, endocrine tumors, hypothyroidism, diabetes, and hypertriglyceridemia are often associated with its occurrence. Surgical removal via lipectomy or liposuction can give good cosmetic results, although recurrences often occur. Liposuction has become the first choice to treat this disorder in patients with smaller masses. We have operated on four such cases in which liposuction failed and surgical excision had to be performed. We present a summary of the clinical characteristics of all four patients and discuss the different treatment options.

How to deal with bone exposure and osteomyelitis: an overview.

The authors present an overview of the various techniques which can be used to achieve coverage of exposed bone, particularly in cases of bone exposure associated with an underlying fracture or osteomyelitis. Adequate debridement, possibly in several stages, is necessary in all cases to prepare the receptor site for the next step which is soft tissue coverage, achieved using various types of surgical procedures. Adequate reconstruction can be achieved with pedicled flaps in some cases but in cases with exposure of bone, free flaps usually represent a better option in cases where the condition of the patient is not a limiting factor. Thin fascio-cutaneous free flaps may be used in some cases with small and simple soft tissue loss, so as to minimise donor site mobidity. Free muscle flaps, such as from the latissimus dorsi, are preferable in cases with bone loss in order to fill any dead space; in cases with major bone loss, a free vascularised bone graft can be used, or composite grafts including bone, muscle and/or skin (fibula or crista iliaca flaps). Some reconstructions require a functional approach, such as over an exposed joint, or for the weight-bearing area of the foot or the soft tissues over the Achilles tendon. Survival of a free flap requires perfect, permeable microsutures; thrombosis of the anastomosis is a major complication which jeopardizes flap survival; close surveillance of the flap is required during the first few days, with hourly Doppler monitoring of the pedicle on the first day. The success rate can be as high as 90 to 100% in simple cases; failures may be related to surgical technique, inadequate choice of the flap, or specific features of the patient. In cases with an underlying bone infection, recurrence of infection occurs in 5 to 20% of cases; this requires additional treatment, possibly with repeat debridement, prolonged antibiotic therapy and sometimes a second free flap.