Microsurgical Reconstruction of the Lower Extremity

Abstract

Reconstruction of bony and soft tissue defects of the lower extremity has been revolutionized by the advent of microsurgical tissue transfer. There are numerous options for reconstruction. Possibilities include transfer of soft tissue, composite (bone and soft tissue) tissue, and functional muscle. Many lower extremity reconstructions require staged procedures. Planning is of paramount importance especially in regard to vascular access when multiple free flaps are required. Soft tissue reconstruction of the lower extremity may be accomplished with muscle flaps such as the rectus femoris and latissimus dorsi covered with a skin graft. Fasciocutaneous flaps such as the anterolateral thigh flap may be more appropriate in a staged reconstruction which requires later elevation of the flap. Loss of a significant portion of bone, such as the tibia, can be difficult to manage. Any gap greater than 6 cm is considered a reasonable indication for vascularized bone transfer. The contralateral free fibula is the donor site of choice. Functional reconstruction of the anterior compartment of the leg may be performed with a gracilis muscle transfer, effectively eliminating foot drop and providing soft tissue coverage. Muscle tensioning is critical for effective excursion and dorsiflexion of the foot. Long-term results of microsurgical reconstruction of the lower extremity show good results and reasonable rates of limb salvage.

Keywords

lower extremity reconstruction - microsurgery - functional muscle transfer - free fibula - trauma

• References

• 1 Yazar S, Lin C-H, Wei F-C. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004; 114 (06) 1457-1466
• 2 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
• 3 Qiu E, Kurlander DE, Ghaznavi AM. Godina revisited: a systematic review of traumatic lower extremity wound reconstruction timing. J Plast Surg Hand Surg 2018; 52 (05) 259-264
• 4 Raju A, Ooi A, Ong YS, Tan BK. Traumatic lower limb injury and microsurgical free flap reconstruction with the use of negative pressure wound therapy: is timing crucial?. J Reconstr Microsurg 2014; 30 (06) 427-430
• 5 Isenberg JS, Sherman R. Zone of injury: a valid concept in microvascular reconstruction of the traumatized lower limb?. Ann Plast Surg 1996; 36 (03) 270-272
• 6 Momeni A, Lanni MA, Levin LS, Kovach SJ. Does the use of arteriovenous loops increase complications rates in posttraumatic microsurgical lower extremity reconstruction?-A matched-pair analysis. Microsurgery 2018; 38 (06) 605-610
• 7 Philandrianos C, Moullot P, Gay AM. , et al. Soft tissue coverage in distal lower extremity open fractures: comparison of free anterolateral thigh and free latissimus dorsi flaps. J Reconstr Microsurg 2018; 34 (02) 121-129
• 8 Cho EH, Shammas RL, Carney MJ. , et al. Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: a multicenter outcomes analysis. Plast Reconstr Surg 2018; 141 (01) 191-199
• 9 Stranix JT, Lee Z-H, Jacoby A. , et al. Forty years of lower extremity take-backs: flap type influences salvage outcomes. Plast Reconstr Surg 2018; 141 (05) 1282-1287
• 10 Pannunzio ME, Chhabra AB, Golish SR, Brown MR, Pederson WC. Free fibula transfer in the treatment of difficult distal tibia fractures. J Reconstr Microsurg 2007; 23 (01) 11-18
• 11 Henry SL, Frome BA, Pederson WC. Vascularized bone transfer for severe injury around the ankle. Microsurgery 2009; 29 (05) 353-360
• 12 Rigal S, Merloz P, Le Nen D, Mathevon H, Masquelet A-C. ; French Society of Orthopaedic Surgery and Traumatology (SoFCOT). Bone transport techniques in posttraumatic bone defects. Orthop Traumatol Surg Res 2012; 98 (01) 103-108
• 13 El-Gammal TA, Shiha AE, El-Deen MA. , et al. Management of traumatic tibial defects using free vascularized fibula or Ilizarov bone transport: a comparative study. Microsurgery 2008; 28 (05) 339-346
• 14 Pederson WC, Person DW. Long bone reconstruction with vascularized bone grafts. Orthop Clin North Am 2007; 38 (01) 23-35 , v
• 15 Rendenbach C, Rashad A, Hansen L. , et al. Functional donor site morbidity longer than one year after fibula free flap: a prospective biomechanical analysis. Microsurgery 2018; 38 (04) 395-401
• 16 Momoh AO, Yu P, Skoracki RJ, Liu S, Feng L, Hanasono MM. A prospective cohort study of fibula free flap donor-site morbidity in 157 consecutive patients. Plast Reconstr Surg 2011; 128 (03) 714-720
• 17 Mahajan RK, Srinivasan K, Bhamre A, Singh M, Kumar P, Tambotra A. A retrospective analysis of latissimus dorsi-serratus anterior chimeric flap reconstruction in 47 patients with extensive lower extremity trauma. Indian J Plast Surg 2018; 51 (01) 24-32
• 18 Bigdeli AK, Gazyakan E, Schmidt VJ. , et al. Long-term outcome after successful lower extremity free flap salvage. J Reconstr Microsurg 2018 ;(October): 10.1055/s-0038-1675146