Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers.
ABSTRACT Free tissue transfer to the lower extremity has become a well-established reconstructive modality. The purpose of this study was to develop a "subunit" approach to patients undergoing free tissue transfer for foot and ankle wounds to help further define subunit-specific functional and aesthetic operative goals.
The institutional review board approved this retrospective review of 161 patients who underwent free tissue transplantation for foot and ankle wounds between March 1, 1997, and February 28, 2007, at a single institution. Endpoints included flap-related complications, secondary surgery, time to ambulation, flap stability, and limb salvage.
The most common types of wounds treated were trauma-related [n = 120 (75 percent)], diabetes-related [n = 24 (15 percent)], and oncologic defects [n = 8 (5 percent)]. Ten different donor sites were used for reconstruction, with the latissimus dorsi flap being the most common. The mean follow-up time was 26.9 months (range, 0.5 to 130 months). Mean time to ambulation was 3.1 months (range, 0.75 to 14 months). Overall, 11 percent of patients required revision surgery for flap instability at a mean time of 25.3 months after flap surgery. Wounds located over the heel (subunit 5) were most likely to develop instability (Fisher's exact test, p < 0.05). The overall 5-year limb salvage rate as determined by Kaplan-Meier analysis was 89 percent.
The use of free tissue transplantation for treatment of foot and ankle wounds is associated with a high rate of limb salvage. Although a variety of flaps may be used, the application of the subunit principle can assist surgeons in designing flaps that will address subunit-specific functional and aesthetic concerns.
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ABSTRACT: Introduction Because of the unique characteristics of its integument, the affirmation "replacing like with like" becomes more than evident in the reconstruction of defects of the ultraspecialized plantar skin. But, the paucity of local resources, and especially in the forefoot, transforms this attempt in a very challenging problem. Many techniques, including skin grafts and various types of flaps were used in the management of defects in the forefoot. We present a new useful flap in the reconstruction of skin defects in the forefoot, based on small perforator vessels originating either from the plantar metatarsal arteries or plantar common digital arteries. Materials and Methods Starting with June 2011, this flap was performed, as plantar transposition perforator flap, plantar propeller flap, or plantar propeller perforator plus flap, in seven patients with ulcers over the plantar forefoot. During a follow-up of 7 to 17 months (mean, 9.8 months), the local evolution regarding flap integration, pain, relapse, sensitive recovery, donor site, and footwear quality was analyzed. Results We registered a 100% survival rate of the flaps, with delayed healing in only one case. The gait resumption was possible after 6 weeks in all cases. Conclusion This new flap, based on small perforator vessels from the plantar metatarsal or common digital arteries, and which provides a good, stable, and sensory recovery, seems to be a promising method in the reconstruction of plantar skin defects over the metatarsal heads.Journal of Reconstructive Microsurgery 08/2014; · 1.01 Impact Factor
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ABSTRACT: After studying this article, the participant should be able to: 1. Understand the steps for evaluation of a patient with a lower extremity wound before initiating medical or surgical intervention. 2. Acknowledge that limb amputation and salvage can both be appropriate definitive treatment options. 3. Select proper nonsurgical or surgical techniques for wound management. 4. Appreciate the difference in the expected outcome according to the perspective of the physician versus the patient. Lower extremity acute trauma is a common occurrence. Ultimate functional outcomes are similar whether amputation or salvage by limb reconstruction is the treatment pathway chosen. The reconstructive surgeon must be knowledgeable enough to assist in making the correct decision for either option. Débridement is the cornerstone of management before embarking on definitive wound closure. Nonsurgical devices have provided a transition to optimize the wound, sometimes even replacing or lessening the need for vascularized tissues to permit this coverage. Nevertheless, flaps will always have a role varying according to the involved region of the lower extremity. Traditional muscle flaps can often today be supplemented by the use of perforator flaps. The latter have great versatility as pedicled flaps for all zones of the lower limb, in addition to being a dependable free flap alternative. Horrendous injuries can now be expected to be salvaged, with a reasonable aesthetic result possible and with minimal donor-site morbidity. Preferences by both physicians and patients tend to favor the course to limb salvage, but it must be appreciated by the caregiver that it is always the patient who has to live with the residua of an altered limb and lifestyle.Plastic and Reconstructive Surgery 12/2013; 132(6):1733-41. · 3.33 Impact Factor
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ABSTRACT: Wound breakdown after orthopaedic foot and ankle surgery may necessitate secondary soft tissue coverage. The foot and ankle region is challenging to reconstruct for orthopaedic and plastic surgeons owing to its complex bony anatomy and unique functional demands. Therefore, identifying strategies for plastic surgery of these wounds may help guide surgeons in defining the best treatment plan. We evaluated our current algorithmic approach for managing orthopaedic surgical wounds of the foot and ankle with respect to whether (1) prophylactic or simultaneous soft tissue coverage affected wound-healing complications (secondary plastic surgery, orthopaedic hardware removal, malunion, further orthopaedic surgery, ultimate failure) and (2) postoperative referral for soft tissue management was associated with wound location, size, and orthopaedic procedure. We retrospectively reviewed 112 patients who underwent elective orthopaedic foot or ankle surgery and required concomitant plastic surgery at our institution. Study end points included secondary plastic surgery procedures, hardware removal for infection, foot or ankle malunion, further orthopaedic surgery, and wound-healing failure as defined by a chronic nonhealing wound or need for amputation. Minimum followup was 0.6 months (mean, 24.9 months; range, 0.6-197 months). Four patients were lost to complete followup. We developed an algorithm that centers on two critical points of care: preoperative evaluation by the orthopaedic surgeon and evaluation and treatment by the plastic surgeon after referral. Compared with postoperative intervention, prophylactic or simultaneous soft tissue coverage did not lead to differences in frequency of secondary plastic surgery procedures (p = 0.55), hardware removal procedures (p = 0.13), malunions (p = 0.47), further orthopaedic surgery (p = 0.48), and ultimate failure (p = 0.27). Patients referred postoperatively for soft tissue management most frequently had dorsal ankle wounds (p < 0.001) of smaller size (p = 0.03), most commonly associated with total ankle arthroplasty (p = 0.004). Using our algorithmic approach, prophylactic or simultaneous soft tissue coverage did not improve the study end points. In addition, unexpected postoperative wound breakdown necessitating a plastic surgery consultation most commonly occurred on the dorsal ankle after total ankle arthroplasty. Our algorithm facilitates early identification of skin instability and enables prompt soft tissue coverage before or concurrently with orthopaedic procedures. The effect of prophylactic or simultaneous soft tissue coverage on postoperative wound healing requires further investigation. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.Clinical Orthopaedics and Related Research 02/2014; 472(6). · 2.79 Impact Factor