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Pedicled fibular flap for reconstruction of composite defects in foot
Injury, Int. J. Care Injured 46 (2015) 405–410
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Pedicled fibular flap for reconstruction of composite defects in foot Chun-Yang Wang, Pei Han, Yi-Min Chai *, Sheng-Di Lu, Wan-Run Zhong Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 13 October 2014
Introduction: Reconstruction of complex injuries involving bone and soft-tissue in foot remains a tough challenge for surgeons. The free fibular flap is a popular flap for treating these composite defects. However, complications caused by microvascular anastomoses are not uncommon. Herein, we designed a pedicled fibular flap elevated in the ipsilateral leg for reconstruction of multiple defects in foot. Methods: From July 2005 to April 2013, four patients with composite defects in foot were treated by pedicled fibular flaps. The defects were located in the first metatarsal bone and medial cuneiform bone in two patients, in the fourth metatarsal bone in one patient, and in the second to fourth metatarsal bones in one patient. The size of soft-tissue defects ranged from 10 7 cm to 15 7 cm, and the length of bone defects ranged from 6 to 8 cm. Results: The length of fibular grafts ranged from 7 to 8.5 cm, and the size of skin flaps ranged from 11 8 cm to 16 8 cm. All flaps survived completely. Complications occurred in two patients. One suffered moderate venous congestion and the flap survived without intervention. The other one sustained re-infection. Debridement was performed and the wound healed uneventfully. Follow-up ranged from 8 to 32 months. Bone union occurred at an average of 12 weeks, and the skin flaps showed good cosmetic results. No serous donor-site complications occurred. Conclusion: The pedicled fibular flap transfer could avoid anastomosis complications and preserve healthy limb. It is a good option for reconstruction of complex defects in foot. ß 2014 Published by Elsevier Ltd.
Keywords: Fibular flap Foot injury Reconstruction Pedicled flap Microsurgery
Introduction High-energy foot trauma frequently causes open fractures or comminution of the metatarsal bones and compromise of dorsal soft tissue. The inherent paucity of local skin and muscle renders the violated foot easily susceptible to infection, resulting in complex tissue defects. Although amputation is a viable selection, a reconstructive procedure that provides a functional foot would be recommended [1]. With the advance in microsurgery, numerous surgical options have been developed for salvage of the lower extremity [2–5]. For manage composite tissue loss in extremity, the optimum method is one-stage reconstruction with an osteocutaneous flap tailored to individual defects [1,6–13]. The free fibular osteocutaneous flap is a revolutionized method for repairing complex defects in extremity and head and neck, due to its distinct advantages of appropriate length of vascularized
* Corresponding author at: Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600 YiShan Road, 200233 Shanghai, China. Tel.: +86 18930177558. E-mail address: [email protected] (Y.-M. Chai). http://dx.doi.org/10.1016/j.injury.2014.10.042 0020–1383/ß 2014 Published by Elsevier Ltd.
bone graft, reliable skin paddle and acceptable donor-site morbidity [14–16]. Satisfied results of complex foot injuries treated by free fibular flap have been reported by cases [6,8,11–13]. However, certain complications related to microvascular free tissue transfer have been reported [4,5]. Among them, flap loss caused by thrombosis or disruption of microvascular anastomoses is most serious, which could lead to amputation of the violated limb. Considering both the outcome and the safety of operations for patients, a procedure with lesser risk and more manageable is generally preferred by surgeons [17]. Thus, in this report, we tend to report our experiences of a pedicled fibular flap elevated in the ipsilateral leg for reconstruction of composite foot defects. Patients and methods Patients From July 2005 to April 2013, four patients with composite softtissue and bone defects in foot were treated by pedicled fibular flap transfers. All patients were male with an average age of 37 years (range from 29 to 43 years). The causes of injury include two motor vehicle accidents, and two crush injuries.
C.-Y. Wang et al. / Injury, Int. J. Care Injured 46 (2015) 405–410
406
improve drainage. Special medications included antibiotics, analgesics, and anticoagulant medication such as low-molecular-weight heparin. Flap monitoring was conducted to exclude tension and perfusion failure secondary to haematoma, swelling or external compression.
The composite defects were located in the first metatarsal bone and medial cuneiform bone in two patients, in the fourth metatarsal bone in one patient, and in the second to fourth metatarsal bones in one patient. The size of soft-tissue defects ranged from 10 7 cm to 15 7 cm, and the length of bone defects ranged from 6 to 8 cm. Details of these patients are shown in Table 1.
Results Surgical technique All four flaps survived completely, though two of them sustained complications postoperatively. One patient suffered moderate venous congestion and the flap survived without intervention. Re-infection occurred in the other patient. A secondary surgery of debridement was performed and the wound healed uneventfully (See Section case report). The length of fibular grafts ranged from 7 to 8.5 cm, and the size of skin flaps ranged from 11 8 cm to 16 8 cm. Follow-up ranged from 8 to 32 months. The skin flap showed good texture match and contour. Bone union occurred at an average of 12 weeks, when Kirchner wires were removed and the patients were allowed to partial weight bearing. Full weight bearing was permitted 6 months postoperatively by verifying radiographically. Donor-site morbidities in related to composite flap elevation were not noted by any of our patients.
Before definitive reconstruction, radical debridement was performed to remove all grossly contaminated or nonviable, necrotic tissue, followed by wound conditioning of negativepressure wound therapy. When a clean and stable wound was obtained (Fig. 1A), the definitive treatment was carried out. The procedure was performed with the patient supine and with the ipsilateral leg flexed approximately 45 degrees at the knee. A pedicled fibular flap matching the composite defects was outlined in the ipsilateral lower leg. The pivot point of the flap was usually set at 6 cm proximal to the lateral malleolus, where the peroneal artery gives off communicating branch to anterior or posterior tibial vessels [18]. The distance from the bone defect to the pivot point and the length of the bone defect were measured, which were used to determine the location and length of the pedicled bone graft, respectively. The position of skin paddle was determined by the presence and size of peroneal artery perforators that were detected with a hand-held Doppler preoperatively. The location and shape of soft-tissue defect should also be taken into consideration in flap design (Fig. 1B). Raising the pedicled fibular flap was similar to that of free flap. Briefly, the anterior border of the outlined skin paddle was incised, and carried down to the deep fascia. The flap was then raised in the subfascial plane to the posterior septum. Carefully identify the septocutaneous perforators supplying the skin paddle. Incising along the posterior border of the skin island, and tracing the perforator used for nourish the skin paddle back to its origin. Then the peroneus longus muscle was sharply dissected off the fibula, and ostotomies were performed with wire saws distally and proximally. The bone graft was retracted and rotated to facilitate dissection. All muscles were detached from the bone, and pedicle of peroneal artery was delicately dissected towards the pivot point (Fig. 1C). Finally, the pedicled composite flap was transferred to the recipient site without tension. The bone graft was shaped to fit the defect and fixed by Kirchner wires appropriately (Fig. 1D), followed by wound coverage with the skin paddle (Fig. 1E). The donor-site of the leg was closed primarily or with split-thickness skin grafts.
Case reports Case 1 A 34-year-old male was referred to us with open comminuted foot fractures due to a crush injury one month after initial injury. After debridement, composite defects occurred including the first metatarsal bone, medial cuneiform bone, and their soft-tissue coverage (Fig. 1A). To salvage the foot, a pedicled fibular flap was designed on the ipsilateral leg with the bone graft measured 7 cm in length and the skin paddle measured 12 5 cm in area (Fig. 1B and C). The bone graft bridged between the first proximal phalanx and navicular bone, and fixed with Kirchner wires (Fig. 1D and E). The donor site was closed primarily. The pedicled composite flap survived uneventfully. Kirchner wires were removed 10 weeks after operation, and the patient was allowed to partial weight bearing. The patient was satisfied with both the appearance and function of the restored foot at 15 months’ follow-up (Fig. 1F and G). Case 2 A 43-year-old male sustained a crush injury to the dorsum of his right foot, resulting in open fractures of the first to third metatarsal bones and vascular compromise to the third to fifth toes. Initially, the patient was treated at another institution with provisional stabilization and active dress changing. After 1 week, the wound was aggravated by infection and necrosis of regional soft-tissue
Postoperative care Immobilization and bed rest were usually maintained for 5 days, and the foot was elevated above the level of the heart to
Table 1 Patients’ demographic data. Patient
Age (years)/ gender
Aetiology
Location of bone defect
Size of soft-tissue defect (cm2)
Length of bone defect (cm)
Size of skin paddle (cm2)
Length of fibular graft (cm)
Flap survival
Complication
1
41/M
Motor vehicle accident
First metatarsal bone and
15 7
8
16 8
8.5
Complete
None
8
2
34/M
Crush injury
11 4
6
12 5
7
Complete
None
15
3
43/M
Crush injury
10 7
7
11 8
8
Complete
Re-infection
32
4
29/M
Motor vehicle accident
11 6
8
12 7
8.5
Complete
Moderate venous congestion
medial cuneiform bone First metatarsal bone and medial cuneiform bone Second to fourth metatarsal bone Fourth metatarsal bone
Follow-up (months)
8
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Fig. 1. A 34-year-old male patient suffered from composite defects in foot involving the first metatarsal bone, medical cuneiform bone and their soft-tissue coverage. (A) Preoperative view of injured foot. (B) After debridement, a pedicled fibular flap was designed on the ipsilateral leg. (C) The pedicle of the fibular flap was dissected towards the pivot point. (D) The fibular bone graft was tailored to match the defect and fixed appropriately. (E) The skin paddle of the fibular flap was used to cover the wound. (F) Appearance of the composite flap 15 months postoperatively. (G) Radiograph of the transferred fibular graft 15 months postoperatively.
(Fig. 2A). The patient was referred to our department for reconstruction. Serial debridement was performed to remove the necrotic tissue and control local infection. On completion of debridement, third to fifth toes were amputated, and composite defects occurred involving soft-tissue defect on the dorsal foot measuring 10 7 cm and bone defects including the second to fourth
metatarsal bones (Fig. 2B). The definitive reconstruction with a pedicled fibular flap was performed three weeks after injury (Fig. 2C). The bone segment measured 8 cm in length was fixed between the second toes and cuboid bone. The skin paddle measured 11 8 cm was used to cover the wound (Fig. 2D and E). The donor site was closed primarily. The flap circulation was well, but re-infection of the fifth metatarsal bone was noted
408
C.-Y. Wang et al. / Injury, Int. J. Care Injured 46 (2015) 405–410
Fig. 2. A 43-year-old male sustained a crush injury resulting in an open comminuted foot fractures. (A) Preoperative view of the injured foot. (B) After debridement, a relatively clean wound was obtained. (C) A pedicled fibular flap was designed on the ipsilateral leg from reconstruction of the complex injured foot. (D) The pedicle of the fibular flap was dissected towards the pivot point. (E) The composite flap was transferred to repair the defects. (F) Radiograph of the transferred fibular graft 19 months postoperatively. (G) Appearance of the composite flap 32 months postoperatively.
postoperatively, which required an additional debridement. Nevertheless, the flap was survived completely, and the wound healed uneventfully after the debridement. Bone union was noted at 14 weeks after surgery. Results of 3D gait analysis performed
one year postoperative implied that the function of the injured foot was similar to that of the normal foot (Table 2). The patient was satisfied with the outcome at 32 months’ follow-up (Fig. 2F and G).
C.-Y. Wang et al. / Injury, Int. J. Care Injured 46 (2015) 405–410 Table 2 Results of 3D gait analysis performed one year postoperative.
Cadence Double support Foot off Limp index Opposite foot contact Opposite foot off Single support Step time Stride time
Left (normal foot)
Right (injured foot)
92.9 steps/min 0.45 s 67.7% 1.01 48.4% 15.5% 0.43 s 0.67 s 1.29 s
96 steps/min 0.46 s 70.0% 1.05 53.3% 20.0% 0.42 s 0.58 s 1.25 s
Discussion The foot consisting of 28 bones plays an important role in standing and gait [2]. These well organized bones support daily biomechanics loads of up to three to seven times body weight [19]. In the stance phase of gait, the pressure is shared approximately equally by the heel and the five metatarsal bones. Composite defects involving metatarsal bones and their soft-tissue coverage can cause a devastating impact on the function of the entire lower extremity. Preferable treatment of those complex foot injuries should not simply aim at closure of the defects by amputation, but at the restoration of normal shape and function [1]. The advance of free osteocutaneous flap transfer has dramatically altered the management of composite defects involving bone and soft-tissue in foot. The vascularized bone graft could fill the bone defect, and the skin paddle could provide definitive soft-tissue coverage simultaneously. Yazar [4] presented two cases of metatarsal reconstruction with iliac osteocutaneous flap. Complete flap survival and bone union obtained in all cases. Kurokawa [9] reported a case of four metatarsal bone and soft-tissue defects reconstructed by a serratus anterior muscle rib osteomyocutaneous flap. The 9-year follow-up showed a good shape of the salvaged foot, and the arch structure was well. The patient could walk and run without support and pain. Lykoudis [1] introduced a multiple segmented free fibular flap for reconstruction of large complex midfoot defects in one-stage. Salgado [13] reported two cases of forefoot salvage after loss of the first and second metatarsal bones with free fibular flaps. At an average of 14 months’ follow-up, both the two patients regained independent ambulation. There is no doubt that the free osteocutaneous flaps, especially the fibular flap, represent excellent options for one-stage reconstruction of complex defects in extremities [3]. However, complications associated with tissue transfer surgery can never be underestimated [4,5]. Yazar [4] reported 63 cases of free osteocutaneous flap transfers for one-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Total flap lost was noted in two patients because of arterial thrombosis. One patient was treated by another composite flap transfer, and the other one by amputation. Eight patients suffered re-exploration due to compromised flap circulation, and five patients sustained partial necrosis. Tu [5] performed 267 cases of free vascular bone graft with or without skin paddle transfer for treatment of lower extremity osteomyelitis. Re-exploration occurred in 17 patients due to venous thrombosis. 12 cases survived, and the other 5 underwent lower limb secondary amputation. Partial flap loss was noted in 6 cases. To decrease the incidence associated with microvascular anastomoses, pedicled fibular flaps were designed to salvage serious injured foot in four cases in this report. All flaps survived completely, and none of them required early revision microsurgery. Compared with free fibular flap transfer, the pedicled transfer has distinct advantages for reconstruction of composite foot defects. First of all, microvascular anastomoses is avoided, which
409
could prevent re-exploration or total flap loss caused by circulatory compromise. In our cases, all flaps completely, and bone union occurred with long-term follow-up. Even re-infection occurred in case 3, the circulation of the flap was not compromised. Second, because no vessels are needed for anastomoses, the anterior or posterior tibial vessels in the injured foot are preserved, which could further reduce the foot morbidity. Third, as a pedicled flap, postoperative care and flap monitoring are less strict than those of free flaps. We usually monitor the flap every 4–6 h for the first three days, and thereafter every 8 h until discharge. Last but not least, the pedicled fibular flap is harvested in the ipsilateral leg, which prevents an extra morbidity in the healthy side. The main disadvantage of pedicled fibular flap is venous congestion, the common problem of a reflow–flow flap. Every effort should be made to prevent flap congestion into flap necrosis. The most important measure is to inset the pedicle of the composite flap and that of the componential flap without tension. Any torsion, kinking or compression of the pedicles may aggravate congestion postoperatively. A relative disadvantage is the requirement for detailed flap planning and experience of pedicle dissection. The main contraindication of this pedicle flap is accompanying injuries to the ipsilateral lower leg, such as fibular fracture. In addition, if the peroneal artery is the only artery supplying the foot, a free fibular flap is preferred. Conclusion The pedicled fibular flap transfer does not need microvascular anastomoses, and can largely reduce complications caused by circulatory compromise. It is an excellent choice for one-stage reconstruction of composite bone and soft tissue defects in foot. Author contributions Preparation of the manuscript, participator of the surgery and patients’ follow-up: Chun-Yang Wang; Participator of the operations: Pei Han and Sheng-Di Lu; Designer of the chimeric flap involved in the manuscript and the main operator of the surgery: Yi-Min Chai; Participator of patients’ follow-up: Wan-Run Zhong. Conflict of interest We declaimed that there are no disclosures or conflicts of interest for any authors. Acknowledgements This work was supported by grants from the National Natural Science Foundation of China (no. 81171728), the Science and Technology Commission of the Shanghai Municipality Program (no. 11JC1409400), and Ministry of Health’s Special Funds for Scientific Research on Public Causes (201402016). Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.injury. 2014.10.042. References [1] Lykoudis EG, Dimitrios P, Alexandros BE. One-stage reconstruction of the complex midfoot defect with a multiple osteotomized free fibular osteocutaneous flap: case report and literature review. Microsurgery 2010;30: 64–9.
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[2] Baumeister S, Germann G. Soft tissue coverage of the extremely traumatized foot and ankle. Foot Ankle Clin 2001;6:867–903. ix. [3] Huang WC, Chen HC, Wei FC, Cheng MH, Schnur DP. Chimeric flap in clinical use. Clin Plast Surg 2003;30:457. [4] Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004;114:1457–66. [5] Tu YK, Yen CY. Role of vascularized bone grafts in lower extremity osteomyelitis. Orthop Clin N Am 2007;38:37–49. vi. [6] Rajacic N, Ebrahim MK, Grgurinovic S, Starovic B. Foot reconstruction using vascularised fibula. Br J Plast Surg 1993;46:317–21. [7] Kurokawa M, Muneuchi G, Hamagami H, Fujita H. Reconstruction of four metatarsal bone and soft-tissue defects using a serratus anterior muscle rib osteomyocutaneous free flap. Plast Reconstr Surg 1998;101:1616–9. [8] Chung YK, Hong JP, Kang SY, Kim SW, Tark KC. A vascularized osteocutaneous fibular free flap for reconstruction of a complex injury of the foot. Ann Plast Surg 2000;45:541–3. [9] Kurokawa M, Yamada N, Suzuki S, Muneuchi G. Long-term follow-up of reconstruction of four metatarsal bone and soft-tissue defects using a serratus anterior muscle rib osteomyocutaneous free flap. Plast Reconstr Surg 2004;114:1553–5. [10] Toma CD, Dominkus M, Pfeiffer M, Giovanoli P, Assadian O, Kotz R. Metatarsal reconstruction with use of free vascularized osteomyocutaneous fibular grafts following resection of malignant tumors of the midfoot. A series of six cases. J Bone Joint Surg Am Vol 2007;89:1553–64.
[11] Tan O, Atik B, Ergen D. Management of a composite foot defect due to mine explosion using the free fibula osteocutaneous flap. J Reconstr Microsurg 2008;24:53–6. [12] Toriyama K, Kamei Y, Yagi S, Uchibori M, Nishida Y, Torii S. Reconstruction of the first and second metatarsals with free vascularised double-barrelled fibular graft after resection of a chondrosarcoma. J Plast Reconstr Aesthet Surg: JPRAS 2009;62:e580–3. [13] Salgado CJ, Lin CH, Fuller DA, Duncan AN, Camison L, Mardini S. Foot salvage after loss of the first and second metatarsal rays with a free fibular osteocutaneous flap. J Am Podiatr Med Assoc 2011;101:531–6. [14] Wei FC, Chen HC, Chuang CC, Noordhoff MS. Fibular osteoseptocutaneous flap: anatomic study and clinical application. Plast Reconstr Surg 1986;78:191–200. [15] Wei FC, Seah CS, Tsai YC, Liu SJ, Tsai MS. Fibula osteoseptocutaneous flap for reconstruction of composite mandibular defects. Plast Reconstr Surg 1994;93:294–304. discussion 5–6. [16] Chai YM, Wang CY, Zeng BF, Chen ZG, Cai PH, Kang QL, et al. Peroneal artery perforator chimeric flap for reconstruction of composite defects in extremities. Microsurgery 2010;30:199–206. [17] Wong CJ, Niranjan N. Reconstructive stages as an alternative to the reconstructive ladder. Plast Reconstr Surg 2008;121:362e–3e. [18] Yoshimura M, Shimada T, Hosokawa M. The vasculature of the peroneal tissue transfer. Plast Reconstr Surg 1990;85:917–21. [19] DiGiovanni CW, Benirschke SK, Hansen ST. Foot injuries. In: Browner BD, Jupiter JB, Levine AM, Trafton PG, editors. Skeletal trauma basic science management and reconstruction, Philadelphia: Saunders; 2003. p. 2375–492.
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Pedicled fibular flap for reconstruction of composite defects in foot Chun-Yang Wang, Pei Han, Yi-Min Chai *, Sheng-Di Lu, Wan-Run Zhong Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, Shanghai, China
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 13 October 2014
Introduction: Reconstruction of complex injuries involving bone and soft-tissue in foot remains a tough challenge for surgeons. The free fibular flap is a popular flap for treating these composite defects. However, complications caused by microvascular anastomoses are not uncommon. Herein, we designed a pedicled fibular flap elevated in the ipsilateral leg for reconstruction of multiple defects in foot. Methods: From July 2005 to April 2013, four patients with composite defects in foot were treated by pedicled fibular flaps. The defects were located in the first metatarsal bone and medial cuneiform bone in two patients, in the fourth metatarsal bone in one patient, and in the second to fourth metatarsal bones in one patient. The size of soft-tissue defects ranged from 10 7 cm to 15 7 cm, and the length of bone defects ranged from 6 to 8 cm. Results: The length of fibular grafts ranged from 7 to 8.5 cm, and the size of skin flaps ranged from 11 8 cm to 16 8 cm. All flaps survived completely. Complications occurred in two patients. One suffered moderate venous congestion and the flap survived without intervention. The other one sustained re-infection. Debridement was performed and the wound healed uneventfully. Follow-up ranged from 8 to 32 months. Bone union occurred at an average of 12 weeks, and the skin flaps showed good cosmetic results. No serous donor-site complications occurred. Conclusion: The pedicled fibular flap transfer could avoid anastomosis complications and preserve healthy limb. It is a good option for reconstruction of complex defects in foot. ß 2014 Published by Elsevier Ltd.
Keywords: Fibular flap Foot injury Reconstruction Pedicled flap Microsurgery
Introduction High-energy foot trauma frequently causes open fractures or comminution of the metatarsal bones and compromise of dorsal soft tissue. The inherent paucity of local skin and muscle renders the violated foot easily susceptible to infection, resulting in complex tissue defects. Although amputation is a viable selection, a reconstructive procedure that provides a functional foot would be recommended [1]. With the advance in microsurgery, numerous surgical options have been developed for salvage of the lower extremity [2–5]. For manage composite tissue loss in extremity, the optimum method is one-stage reconstruction with an osteocutaneous flap tailored to individual defects [1,6–13]. The free fibular osteocutaneous flap is a revolutionized method for repairing complex defects in extremity and head and neck, due to its distinct advantages of appropriate length of vascularized
* Corresponding author at: Department of Orthopedic Surgery, Shanghai Jiao Tong University Affiliated Sixth People’s Hospital, No. 600 YiShan Road, 200233 Shanghai, China. Tel.: +86 18930177558. E-mail address: [email protected] (Y.-M. Chai). http://dx.doi.org/10.1016/j.injury.2014.10.042 0020–1383/ß 2014 Published by Elsevier Ltd.
bone graft, reliable skin paddle and acceptable donor-site morbidity [14–16]. Satisfied results of complex foot injuries treated by free fibular flap have been reported by cases [6,8,11–13]. However, certain complications related to microvascular free tissue transfer have been reported [4,5]. Among them, flap loss caused by thrombosis or disruption of microvascular anastomoses is most serious, which could lead to amputation of the violated limb. Considering both the outcome and the safety of operations for patients, a procedure with lesser risk and more manageable is generally preferred by surgeons [17]. Thus, in this report, we tend to report our experiences of a pedicled fibular flap elevated in the ipsilateral leg for reconstruction of composite foot defects. Patients and methods Patients From July 2005 to April 2013, four patients with composite softtissue and bone defects in foot were treated by pedicled fibular flap transfers. All patients were male with an average age of 37 years (range from 29 to 43 years). The causes of injury include two motor vehicle accidents, and two crush injuries.
C.-Y. Wang et al. / Injury, Int. J. Care Injured 46 (2015) 405–410
406
improve drainage. Special medications included antibiotics, analgesics, and anticoagulant medication such as low-molecular-weight heparin. Flap monitoring was conducted to exclude tension and perfusion failure secondary to haematoma, swelling or external compression.
The composite defects were located in the first metatarsal bone and medial cuneiform bone in two patients, in the fourth metatarsal bone in one patient, and in the second to fourth metatarsal bones in one patient. The size of soft-tissue defects ranged from 10 7 cm to 15 7 cm, and the length of bone defects ranged from 6 to 8 cm. Details of these patients are shown in Table 1.
Results Surgical technique All four flaps survived completely, though two of them sustained complications postoperatively. One patient suffered moderate venous congestion and the flap survived without intervention. Re-infection occurred in the other patient. A secondary surgery of debridement was performed and the wound healed uneventfully (See Section case report). The length of fibular grafts ranged from 7 to 8.5 cm, and the size of skin flaps ranged from 11 8 cm to 16 8 cm. Follow-up ranged from 8 to 32 months. The skin flap showed good texture match and contour. Bone union occurred at an average of 12 weeks, when Kirchner wires were removed and the patients were allowed to partial weight bearing. Full weight bearing was permitted 6 months postoperatively by verifying radiographically. Donor-site morbidities in related to composite flap elevation were not noted by any of our patients.
Before definitive reconstruction, radical debridement was performed to remove all grossly contaminated or nonviable, necrotic tissue, followed by wound conditioning of negativepressure wound therapy. When a clean and stable wound was obtained (Fig. 1A), the definitive treatment was carried out. The procedure was performed with the patient supine and with the ipsilateral leg flexed approximately 45 degrees at the knee. A pedicled fibular flap matching the composite defects was outlined in the ipsilateral lower leg. The pivot point of the flap was usually set at 6 cm proximal to the lateral malleolus, where the peroneal artery gives off communicating branch to anterior or posterior tibial vessels [18]. The distance from the bone defect to the pivot point and the length of the bone defect were measured, which were used to determine the location and length of the pedicled bone graft, respectively. The position of skin paddle was determined by the presence and size of peroneal artery perforators that were detected with a hand-held Doppler preoperatively. The location and shape of soft-tissue defect should also be taken into consideration in flap design (Fig. 1B). Raising the pedicled fibular flap was similar to that of free flap. Briefly, the anterior border of the outlined skin paddle was incised, and carried down to the deep fascia. The flap was then raised in the subfascial plane to the posterior septum. Carefully identify the septocutaneous perforators supplying the skin paddle. Incising along the posterior border of the skin island, and tracing the perforator used for nourish the skin paddle back to its origin. Then the peroneus longus muscle was sharply dissected off the fibula, and ostotomies were performed with wire saws distally and proximally. The bone graft was retracted and rotated to facilitate dissection. All muscles were detached from the bone, and pedicle of peroneal artery was delicately dissected towards the pivot point (Fig. 1C). Finally, the pedicled composite flap was transferred to the recipient site without tension. The bone graft was shaped to fit the defect and fixed by Kirchner wires appropriately (Fig. 1D), followed by wound coverage with the skin paddle (Fig. 1E). The donor-site of the leg was closed primarily or with split-thickness skin grafts.
Case reports Case 1 A 34-year-old male was referred to us with open comminuted foot fractures due to a crush injury one month after initial injury. After debridement, composite defects occurred including the first metatarsal bone, medial cuneiform bone, and their soft-tissue coverage (Fig. 1A). To salvage the foot, a pedicled fibular flap was designed on the ipsilateral leg with the bone graft measured 7 cm in length and the skin paddle measured 12 5 cm in area (Fig. 1B and C). The bone graft bridged between the first proximal phalanx and navicular bone, and fixed with Kirchner wires (Fig. 1D and E). The donor site was closed primarily. The pedicled composite flap survived uneventfully. Kirchner wires were removed 10 weeks after operation, and the patient was allowed to partial weight bearing. The patient was satisfied with both the appearance and function of the restored foot at 15 months’ follow-up (Fig. 1F and G). Case 2 A 43-year-old male sustained a crush injury to the dorsum of his right foot, resulting in open fractures of the first to third metatarsal bones and vascular compromise to the third to fifth toes. Initially, the patient was treated at another institution with provisional stabilization and active dress changing. After 1 week, the wound was aggravated by infection and necrosis of regional soft-tissue
Postoperative care Immobilization and bed rest were usually maintained for 5 days, and the foot was elevated above the level of the heart to
Table 1 Patients’ demographic data. Patient
Age (years)/ gender
Aetiology
Location of bone defect
Size of soft-tissue defect (cm2)
Length of bone defect (cm)
Size of skin paddle (cm2)
Length of fibular graft (cm)
Flap survival
Complication
1
41/M
Motor vehicle accident
First metatarsal bone and
15 7
8
16 8
8.5
Complete
None
8
2
34/M
Crush injury
11 4
6
12 5
7
Complete
None
15
3
43/M
Crush injury
10 7
7
11 8
8
Complete
Re-infection
32
4
29/M
Motor vehicle accident
11 6
8
12 7
8.5
Complete
Moderate venous congestion
medial cuneiform bone First metatarsal bone and medial cuneiform bone Second to fourth metatarsal bone Fourth metatarsal bone
Follow-up (months)
8
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Fig. 1. A 34-year-old male patient suffered from composite defects in foot involving the first metatarsal bone, medical cuneiform bone and their soft-tissue coverage. (A) Preoperative view of injured foot. (B) After debridement, a pedicled fibular flap was designed on the ipsilateral leg. (C) The pedicle of the fibular flap was dissected towards the pivot point. (D) The fibular bone graft was tailored to match the defect and fixed appropriately. (E) The skin paddle of the fibular flap was used to cover the wound. (F) Appearance of the composite flap 15 months postoperatively. (G) Radiograph of the transferred fibular graft 15 months postoperatively.
(Fig. 2A). The patient was referred to our department for reconstruction. Serial debridement was performed to remove the necrotic tissue and control local infection. On completion of debridement, third to fifth toes were amputated, and composite defects occurred involving soft-tissue defect on the dorsal foot measuring 10 7 cm and bone defects including the second to fourth
metatarsal bones (Fig. 2B). The definitive reconstruction with a pedicled fibular flap was performed three weeks after injury (Fig. 2C). The bone segment measured 8 cm in length was fixed between the second toes and cuboid bone. The skin paddle measured 11 8 cm was used to cover the wound (Fig. 2D and E). The donor site was closed primarily. The flap circulation was well, but re-infection of the fifth metatarsal bone was noted
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Fig. 2. A 43-year-old male sustained a crush injury resulting in an open comminuted foot fractures. (A) Preoperative view of the injured foot. (B) After debridement, a relatively clean wound was obtained. (C) A pedicled fibular flap was designed on the ipsilateral leg from reconstruction of the complex injured foot. (D) The pedicle of the fibular flap was dissected towards the pivot point. (E) The composite flap was transferred to repair the defects. (F) Radiograph of the transferred fibular graft 19 months postoperatively. (G) Appearance of the composite flap 32 months postoperatively.
postoperatively, which required an additional debridement. Nevertheless, the flap was survived completely, and the wound healed uneventfully after the debridement. Bone union was noted at 14 weeks after surgery. Results of 3D gait analysis performed
one year postoperative implied that the function of the injured foot was similar to that of the normal foot (Table 2). The patient was satisfied with the outcome at 32 months’ follow-up (Fig. 2F and G).
C.-Y. Wang et al. / Injury, Int. J. Care Injured 46 (2015) 405–410 Table 2 Results of 3D gait analysis performed one year postoperative.
Cadence Double support Foot off Limp index Opposite foot contact Opposite foot off Single support Step time Stride time
Left (normal foot)
Right (injured foot)
92.9 steps/min 0.45 s 67.7% 1.01 48.4% 15.5% 0.43 s 0.67 s 1.29 s
96 steps/min 0.46 s 70.0% 1.05 53.3% 20.0% 0.42 s 0.58 s 1.25 s
Discussion The foot consisting of 28 bones plays an important role in standing and gait [2]. These well organized bones support daily biomechanics loads of up to three to seven times body weight [19]. In the stance phase of gait, the pressure is shared approximately equally by the heel and the five metatarsal bones. Composite defects involving metatarsal bones and their soft-tissue coverage can cause a devastating impact on the function of the entire lower extremity. Preferable treatment of those complex foot injuries should not simply aim at closure of the defects by amputation, but at the restoration of normal shape and function [1]. The advance of free osteocutaneous flap transfer has dramatically altered the management of composite defects involving bone and soft-tissue in foot. The vascularized bone graft could fill the bone defect, and the skin paddle could provide definitive soft-tissue coverage simultaneously. Yazar [4] presented two cases of metatarsal reconstruction with iliac osteocutaneous flap. Complete flap survival and bone union obtained in all cases. Kurokawa [9] reported a case of four metatarsal bone and soft-tissue defects reconstructed by a serratus anterior muscle rib osteomyocutaneous flap. The 9-year follow-up showed a good shape of the salvaged foot, and the arch structure was well. The patient could walk and run without support and pain. Lykoudis [1] introduced a multiple segmented free fibular flap for reconstruction of large complex midfoot defects in one-stage. Salgado [13] reported two cases of forefoot salvage after loss of the first and second metatarsal bones with free fibular flaps. At an average of 14 months’ follow-up, both the two patients regained independent ambulation. There is no doubt that the free osteocutaneous flaps, especially the fibular flap, represent excellent options for one-stage reconstruction of complex defects in extremities [3]. However, complications associated with tissue transfer surgery can never be underestimated [4,5]. Yazar [4] reported 63 cases of free osteocutaneous flap transfers for one-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Total flap lost was noted in two patients because of arterial thrombosis. One patient was treated by another composite flap transfer, and the other one by amputation. Eight patients suffered re-exploration due to compromised flap circulation, and five patients sustained partial necrosis. Tu [5] performed 267 cases of free vascular bone graft with or without skin paddle transfer for treatment of lower extremity osteomyelitis. Re-exploration occurred in 17 patients due to venous thrombosis. 12 cases survived, and the other 5 underwent lower limb secondary amputation. Partial flap loss was noted in 6 cases. To decrease the incidence associated with microvascular anastomoses, pedicled fibular flaps were designed to salvage serious injured foot in four cases in this report. All flaps survived completely, and none of them required early revision microsurgery. Compared with free fibular flap transfer, the pedicled transfer has distinct advantages for reconstruction of composite foot defects. First of all, microvascular anastomoses is avoided, which
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could prevent re-exploration or total flap loss caused by circulatory compromise. In our cases, all flaps completely, and bone union occurred with long-term follow-up. Even re-infection occurred in case 3, the circulation of the flap was not compromised. Second, because no vessels are needed for anastomoses, the anterior or posterior tibial vessels in the injured foot are preserved, which could further reduce the foot morbidity. Third, as a pedicled flap, postoperative care and flap monitoring are less strict than those of free flaps. We usually monitor the flap every 4–6 h for the first three days, and thereafter every 8 h until discharge. Last but not least, the pedicled fibular flap is harvested in the ipsilateral leg, which prevents an extra morbidity in the healthy side. The main disadvantage of pedicled fibular flap is venous congestion, the common problem of a reflow–flow flap. Every effort should be made to prevent flap congestion into flap necrosis. The most important measure is to inset the pedicle of the composite flap and that of the componential flap without tension. Any torsion, kinking or compression of the pedicles may aggravate congestion postoperatively. A relative disadvantage is the requirement for detailed flap planning and experience of pedicle dissection. The main contraindication of this pedicle flap is accompanying injuries to the ipsilateral lower leg, such as fibular fracture. In addition, if the peroneal artery is the only artery supplying the foot, a free fibular flap is preferred. Conclusion The pedicled fibular flap transfer does not need microvascular anastomoses, and can largely reduce complications caused by circulatory compromise. It is an excellent choice for one-stage reconstruction of composite bone and soft tissue defects in foot. Author contributions Preparation of the manuscript, participator of the surgery and patients’ follow-up: Chun-Yang Wang; Participator of the operations: Pei Han and Sheng-Di Lu; Designer of the chimeric flap involved in the manuscript and the main operator of the surgery: Yi-Min Chai; Participator of patients’ follow-up: Wan-Run Zhong. Conflict of interest We declaimed that there are no disclosures or conflicts of interest for any authors. Acknowledgements This work was supported by grants from the National Natural Science Foundation of China (no. 81171728), the Science and Technology Commission of the Shanghai Municipality Program (no. 11JC1409400), and Ministry of Health’s Special Funds for Scientific Research on Public Causes (201402016). Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/ j.injury. 2014.10.042. References [1] Lykoudis EG, Dimitrios P, Alexandros BE. One-stage reconstruction of the complex midfoot defect with a multiple osteotomized free fibular osteocutaneous flap: case report and literature review. Microsurgery 2010;30: 64–9.
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[2] Baumeister S, Germann G. Soft tissue coverage of the extremely traumatized foot and ankle. Foot Ankle Clin 2001;6:867–903. ix. [3] Huang WC, Chen HC, Wei FC, Cheng MH, Schnur DP. Chimeric flap in clinical use. Clin Plast Surg 2003;30:457. [4] Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004;114:1457–66. [5] Tu YK, Yen CY. Role of vascularized bone grafts in lower extremity osteomyelitis. Orthop Clin N Am 2007;38:37–49. vi. [6] Rajacic N, Ebrahim MK, Grgurinovic S, Starovic B. Foot reconstruction using vascularised fibula. Br J Plast Surg 1993;46:317–21. [7] Kurokawa M, Muneuchi G, Hamagami H, Fujita H. Reconstruction of four metatarsal bone and soft-tissue defects using a serratus anterior muscle rib osteomyocutaneous free flap. Plast Reconstr Surg 1998;101:1616–9. [8] Chung YK, Hong JP, Kang SY, Kim SW, Tark KC. A vascularized osteocutaneous fibular free flap for reconstruction of a complex injury of the foot. Ann Plast Surg 2000;45:541–3. [9] Kurokawa M, Yamada N, Suzuki S, Muneuchi G. Long-term follow-up of reconstruction of four metatarsal bone and soft-tissue defects using a serratus anterior muscle rib osteomyocutaneous free flap. Plast Reconstr Surg 2004;114:1553–5. [10] Toma CD, Dominkus M, Pfeiffer M, Giovanoli P, Assadian O, Kotz R. Metatarsal reconstruction with use of free vascularized osteomyocutaneous fibular grafts following resection of malignant tumors of the midfoot. A series of six cases. J Bone Joint Surg Am Vol 2007;89:1553–64.
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