Composite Compound Free Flaps for Lateral Malleolar Reconstruction

Abstract

).Shortening or absence of the distal fibula may cause a clinically valgus hindfoot owing to the talar abduction and lateral rotation.1,2 A displacement of 1 mm or 30-degree lateral rotation could alter the load distribution and lead to an abnormal articular stress causing subsequent arthritis. 3-5In case of loss of both bone and soft tissue, a reconstructive treatment is mandatory in order to restore skin coverage and a functional ankle with long-term stability.We present two results of a one-stage reconstruction of the complex lateral malleolus traumatic defect with two different microsurgical composite compound flaps. Patients and Method Case 1A 25-year-old man with a subtotal defect of the left lateral malleolus and a 10 Â 6 cm skin defect because of a motorbike accident was treated with a combined iliac crest bone and iliacus muscle flap plus a split-thickness skin graft, revascularized in an end-to-end fashion on the peroneal vessels.Two screws were used to lock the iliac graft and reconstruct the tibiofibular syndesmosis (TFS). This decision was made intraoperatively because of impairment of ligamentous structures and instability of the ankle. Screws were removed 90 days after the procedure.At 5-month control, magnetic resonance imaging (MRI) showed good morphology of the articular surface of the ankle joint. At 13-year control, X-ray images showed a tibiofibular arthrodesis and no signs of arthritis with a flexo-extension of the tibiotalar joint comparable to the contralateral one (►Figs. 1 and 2). Case 2An 11-year-old girl presented a traumatic defect of partial left lateral malleolus with an associated 12 Â 22 cm skin defect, as a result of a car accident. We performed a free combined serratus muscle and ninth rib bone flap plus a split-thickness skin graft, revascularized in an end-to-end fashion on the anterior tibial vessels. Plate was employed to give stability and external support, thereby allowing an early mobilization.The plate and screws were removed on day 180. Clinical control showed good mobility and stability of the ankle. The flap was too bulky, and required secondary liposuction to improve the cosmetic result.At 7-year follow-up, X-ray images showed a well-integrated rib with a restored continuity of the bone and preservation of TFS. Plantar flexion of the ankle was 50 degrees and dorsal flexion 10 degrees (►Figs. 3 and 4). DiscussionLoss of tissue in the foot and ankle region represents a challenging problem because of the small number of local flaps available close to the structures involved in walking and load bearing.In case 1, as the tibiofibular ligaments were severely damaged, we fixed the bone with screws passing through three cortical structures for a tighter reconstruction to perform a tibiofibular arthrodesis leaving the tibiotalar joint free. The function and mobility of the ankle were good, and the patient did not experience any problems from the procedure in his daily life.In case 2, we proposed to perform bone synthesis with plate and screws, which would then be removed lat...