Current concepts in microsurgical soft tissue reconstruction of lower extremity trauma in a single-vessel extremity

Abstract

Advancements in microsurgical techniques have allowed for the salvage of extremities that would otherwise be amputated. Despite these improvements, mangling injuries of the lower extremity with concomitant open fracture continue to present a challenge for reconstructive surgeons. These injuries are further complicated by circumstances in which a single vessel is perfusing the foot after trauma (Gustilo 3C injuries). Although the foot may remain perfused in this instance, free flap coverage of open fractures with concomitant vascular injury requires careful planning to maintain a viable foot. The surgeon must adapt surgical plans based on both preoperative and intraoperative findings. In this review, we discuss current concepts and reconstructive techniques for performing free flap reconstruction in single-vessel lower extremities.

Keywords

Lower extremity / reconstruction / microsurgery

References

[1] Janis JE,Attinger CE.The new reconstructive ladder: modifications to the traditional model.Plast Reconstr Surg2011;127 Suppl 1:205S-12S

[2] Scalea TM,Moore EE.Western trauma association critical decisions in trauma: management of the mangled extremity.J Trauma Acute Care Surg2012;72:86-93

[3] Bosse MJ,Kellam JF.An analysis of outcomes of reconstruction or amputation after leg-threatening injuries.N Engl J Med2002;347:1924-31

[4] Azoury SC,Kovach SJ.Principles of orthoplastic surgery for lower extremity reconstruction: why is this important?.J Reconstr Microsurg2021;37:42-50

[5] Boriani F,Baldini T.Orthoplastic surgical collaboration is required to optimise the treatment of severe limb injuries: a multi-centre, prospective cohort study.J Plast Reconstr Aesthet Surg2017;70:715-22

[6] Sommar P,Halle M.Effects of a formalized collaboration between plastic and orthopedic surgeons in severe extremity trauma patients; a retrospective study.J Trauma Manag Outcomes2015;9:3 PMCID:PMC4404286

[7] Gans I,Levin LS.A Lower Extremity Musculoskeletal and Vascular Trauma Protocol in a Children’s Hospital May Improve Treatment Response Times and Appropriate Microvascular Coverage.J Orthop Trauma2015;29:239-44

[8] Khouri RK.Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304 consecutive cases.J Trauma1989;29:1086-94

[9] Yazar S.Selection of recipient vessel in traumatic lower extremity.J Reconstr Microsurg2012;28:199-204

[10] Ducic I,Attinger CE.Outcomes of microvascular reconstruction of single-vessel lower extremities: limb salvage versus amputation.J Reconstr Microsurg2009;25:475-8

[11] Ricci JA,Stranix JT.Reconstruction of gustilo type IIIC Injuries of the lower extremity.Plast Reconstr Surg2019;144:982-7

[12] Arnež ZM,Ramella V.Limb and flap salvage in gustilo IIIC injuries treated by vascular repair and emergency free flap transfer.J Reconstr Microsurg2017;33:S03-7

[13] Stranix JT,Jacoby A.Not all gustilo type IIIB fractures are created equal: arterial injury impacts limb salvage outcomes.Plast Reconstr Surg2017;140:1033-41

[14] Harashina T.Analysis of 200 free flaps.Br J Plast Surg1988;41:33-6

[15] Anandasivam NS,Swallow MS.Tibial shaft fracture: a large-scale study defining the injured population and associated injuries.J Clin Orthop Trauma2017;8:225-31 PMCID:PMC5605888

[16] Court-Brown CM.“The epidemiology of tibial fractures,” J Bone Joint Surg Br 1995;77:417-2.

[17] Crowe CS,Lee GK.Hospital transfer of open tibial fractures requiring microsurgical reconstruction negatively impacts clinical outcomes.Ann Plast Surg2017;78:S180-4

[18] Hsu CS,Rubin GD.CT angiography in pediatric extremity trauma: preoperative evaluation prior to reconstructive surgery.Hand (N Y)2008;3:139-45 PMCID:PMC2529130

[19] Carney MJ,Momeni A,Weissler JM.Anastomotic technique and preoperative imaging in microsurgical lower-extremity reconstruction: A Single-Surgeon Experience.Ann Plast Surg2020;84:425-30

[20] Gottlieb LJ.From the reconstructive ladder to the reconstructive elevator.Plast Reconstr Surg1994;93:1503-4

[21] Park S,Lee TJ.Algorithm for recipient vessel selection in free tissue transfer to the lower extremity.Plast Reconstr Surg1999;103:1937-48

[22] Chen HC,Chen S,Wei FC.Selection of recipient vessels for free flaps to the distal leg and foot following trauma.Microsurgery1994;15:358-63

[23] Broer PN,Mayer JM.Comparison of outcomes of end-to-end versus end-to-side anastomoses in lower extremity free flap reconstructions.J Reconstr Microsurg2020;36:432-7

[24] Ahmadi I,Miller G.End-to-end versus end-to-side microvascular anastomosis: a meta-analysis of free flap outcomes.J Reconstr Microsurg2017;33:402-11

[25] Albertengo JB,Buncke HJ.A comparative study of flap survival rates in end-to-end and end-to-side microvascular anastomosis.Plast Reconstr Surg1981;67:194-9

[26] Hsieh Y,Kwon S.Chang’s technique of sequential end-to-side microvascular anastomosis.IMJ2017;

[27] Tan BK,Chew W.Use of the slit arteriotomy for end-to-side arterial anastomosis in free-tissue transfers to the extremities.J Plast Reconstr Aesthet Surg2009;62:1519-23

[28] Sen C,Iscen D.Simple and reliable procedure for end-to-side microvascular anastomosis: the diamond technique.Microsurgery2006;26:160-4

[29] Soutar D,Tanner N.The radial forearm flap: a versatile method for intra-oral reconstruction.Br J Plast Surg1983;36:1-8

[30] Foucher G,Merle DM.A compound radial artery forearm flap in hand surgery: an original modification of the Chinese forearm flap.Br J Plast Surg1984;37:139-48

[31] Lin CH,Lin YT.Sixty-five clinical cases of free tissue transfer using long arteriovenous fistulas or vein grafts.J Trauma2004;56:1107-17

[32] Knackstedt R,Gatherwright J.Single-stage versus two-stage arteriovenous loop microsurgical reconstruction: a meta-analysis of the literature.Microsurgery2018;38:706-17

[33] Cavadas PC.Arteriovenous vascular loops in free flap reconstruction of the extremities.Plast Reconstr Surg2008;121:514-20

[34] Momeni A,Levin LS.Does the use of arteriovenous loops increase complications rates in posttraumatic microsurgical lower extremity reconstruction?.Microsurgery2018;38:605-10

[35] Albäck A,Ihlberg L.Valvulotomy of non-reversed saphenous vein bypass grafts: a randomised, blinded, angioscopy-controlled study.Eur J Vasc Endovasc Surg1999;18:144-8

[36] Hong JP,Suh HP.Supermicrosurgery in lower extremity reconstruction.Clin Plast Surg2021;48:299-306

[37] Hong JPJ,Suh HSP.Supermicrosurgery: principles and applications.J Surg Oncol2018;118:832-9

[38] Hong JP.The use of supermicrosurgery in lower extremity reconstruction: the next step in evolution.Plast Reconstr Surg2009;123:230-5

[39] Hong JP.Using perforators as recipient vessels (supermicrosurgery) for free flap reconstruction of the knee region.Ann Plast Surg2010;64:291-3

[40] Manrique OJ,Ciudad P.Lower extremity limb salvage with cross leg pedicle flap, cross leg free flap, and cross leg vascular cable bridge flap.J Reconstr Microsurg2018;34:522-9

[41] Boerum MS, Wright T, McFarland M, Fiander M, Pannucci CJ. Cross-leg flaps for lower extremity salvage: a scoping review.J Reconstr Microsurg2019;35:505-15