Vascularized composite tissue transfers or open fractures with massive soft‐tissue defects in the lower extremities

Abstract

From 1982 to 1998, we treated 39 patients with type IIIB and IIIC fractures in the lower extremities by vascularized composite tissue transfers. Thirty-four of the lesions affected the lower leg, and 5 the foot and ankle. The peroneal flap was used in 25 cases, the latissimus dorsi musculocutaneous flap in 12, the scapula flap in 1, and the gracilis muscle flap in 1. In cases with a peroneal flap transfer, 18 cases used osteocutaneous flap with a fibula. Postoperative circulatory disturbances resulted in revision surgery in 9 patients. Eventually, grafting was successful in 37 patients. In patients with a lower leg reconstruction, additional bone grafting was performed in 7 of 16 patients with cutaneous or musculocutaneous flap transfers. No patient with osteocutaneous flap transfers required an additional bone grafting. The mean periods between injury and time to bone union were 11.7 months in patients with cutaneous flap transfers, and 7.5 months in patients with osteocutaneous flap transfers.

Vascularized fibula transfer for lower limb reconstruction

“…When massive bone loss is associated with small or large skin defect, an osteoseptocutaneous fibular flap simultaneously or latissimus dorsi myocutaneous flap first and FVFG at a second stage are indicated, respectively. 42 Vascularized fibula maintains its own vascular supply and the osteoinductive osteoconductive and osteogenetic properties is associated with rapid incorporation, remodeling, and hypertrophy, so, the use of FVFG with or without a skin flap may hasten rehabilitation in patients with massive bone defects (Fig. 1).…”

Reconstruction of Large Defect of Foot with Extensive Bone Loss Exclusively Using a Latissimus Dorsi Muscle Free Flap: A Potential New Indication for This Flap

“…In these cases, functional reconnection between the rearfoot and the remainder of the midfoot and forefoot can be attempted with the use of foot orthoses, or, if these fail, with skeletal reconstruction techniques (8). These range from surgical arthrodeses (with or without autogenous or allogeneic bone grafts) to bone free flaps (3,7).…”

“…In this setting, several criteria determine the choice of the flap to be used in reconstruction, including donor site morbidity, length of the pedicle, and the extent and composition of the missing tissue (2,5). In particular, it is generally accepted that significant bone defects should be treated with bone flaps or grafts, either in the emergency department or subsequently (2,(4)(5)(6)(7)(8)(9). In the present report, we describe the unusual case of a young male patient who sustained extensive soft tissue and bone injury to his foot and who responded well to treatment using a single-stage latissimus dorsi free flap without the use of bone grafting.…”

Vascularized bone transfer for severe injury around the ankle

“…[6][7][8]11,[16][17][18][19]22,[24][25][26] Results in these series have also been good, with union rates exceeding 90% and infection rates of 0-16%. A common complication in these series is stress fracture of the transferred bone, occurring in roughly 10-30% of cases.…”

“…6 This can be an excruciatingly slow process. 7 It is practicable to transfer a soft tissue free flap to the wound as a first stage, followed by nonvascularized bone grafting, but this protracts the ultimate recovery even longer. In contrast, vascularized bone graft heals by a much faster osteoblast-mediated process, exactly as do routine fractures.…”