Evaluation of the Suprafascial Thin ALT Flap in Foot and Ankle Reconstruction

Background Limb-threatening lower extremity injuries often require secondary bone grafting after soft tissue reconstruction. We hypothesized that there would be fewer wound complications when performing secondary bone grafting via a remote surgical approach rather than direct flap elevation. Methods A retrospective cohort study was performed at a single Level 1 trauma center comparing complications after secondary bone grafting in patients who had undergone previous soft tissue reconstruction after open tibia fractures between 2006 and 2020. Comparing bone grafting via a remote surgical incision versus direct flap elevation, we evaluated wound dehiscence requiring return to the operating room as the primary outcome. Secondary outcomes were deep infection and delayed amputation. Results We identified 129 patients (mean age: 40 years, 82% male) with 159 secondary bone grafting procedures. Secondary bone grafting was performed via a remote surgical approach in 54% (n = 86) and direct flap elevation in 46% (n = 73) of cases. Wound dehiscence requiring return to the operating room occurred in one patient in the flap elevation group (1%) and none of the patients in the remote surgical approach. The odds of deep wound infection (OR, 1.77; p = 0.31) or amputation (OR, 1.43; p = 0.73) did not significantly differ between surgical approaches. No significant differences were found in complications between the reconstructive surgeon elevating and re-insetting the flap and the orthopaedic trauma surgeon performing the flap elevation and re-inset. Conclusion Direct flap elevation for secondary bone grafting after soft tissue reconstruction for open tibia fractures did not result in more complications than bone grafting via a remote surgical approach. These findings should reassure surgeons to allow other clinical factors to influence the surgical approach for bone grafting.

Section: Discussionsupporting

confidence: 47%

Secondary Bony Defects after Soft Tissue Reconstruction in Limb-Threatening Lower Extremity Injuries: Does the Approach to Flap Elevation Matter?

Burke

Mundy

Gupta

et al. 2023

“…This may be the current ideal modality to map the distinctive planes of potential elevation as well as the vascular pathway in the same position as if in surgery. 25,[31][32][33][34] There was a 100% correlation between the preoperative perforator mapping using duplex color ultrasonography and intraoperative findings. 22 In addition to the vascular pathway and vessel diameter, peak velocity and flow volume can be calculated to evaluate the physiologic aspect of the proposed flap.…”

Section: Videomentioning

confidence: 87%

Planes for Perforator/Skin Flap Elevation—Definition, Classification, and Techniques

Kwon

Brown

Suh

et al. 2022

Introduction Elevation in different layers achieving thin flaps are becoming relatively common practice for perforator flaps. Although postreconstruction debulking achieves pleasing aesthetic results and is widely practiced, customized approach during elevation to achieve the ideal thickness will increase efficiency while achieving the best possible aesthetic outcome. Multiple planes for elevation have been reported along with different techniques but it is quite confusing and may lack correspondence to the innate anatomy of the skin and subcutaneous tissue. Methods This article reviews the different planes of elevation and aims to clarify the definition and classification in accordance to anatomy and present the pros and cons of elevation based on the different layers and provide technical tips for elevation. Results Five different planes of elevation for perforator flaps are identified: subfascial, suprafacial, superthin, ultrathin, and subdermal (pure skin) layers based on experience, literature, and anatomy. Conclusion These planes all have their unique properties and challenges. Understanding the benefits and limits along with the technical aspect will allow the surgeon to better apply the perforator flaps.

“…14 However, in this study most of these free flaps were applied for remote traumatic injury. 14 The incidence of unreliably small or absent perforators among ALT flap was reported to range from 2.7 to 4.8%. 10,15 In order to save the time during flap harvest, computed tomography angiography (CTA) and color duplex ultrasound (CDU) can be used for preoperative planning.…”

Section: Discussionmentioning

confidence: 98%

“…This theoretically leads to a thinner flap and precludes the need for secondary debulking procedures, which can decrease this cost. 14 However, in this study most of these free flaps were applied for remote traumatic injury. 14…”

Section: Discussionmentioning

confidence: 98%

Evaluating Resource Utilization with Free or Pedicled Perforator Flaps in Distal Leg Reconstruction

Hsiao

Zelenski

Tseng

et al. 2022

Background The decision between local and free tissue coverage for distal lower leg defects has long been dictated by the location and size of defects. Recent reports of distal defects treated successfully with pedicled perforator flaps demonstrate equivalent clinical outcomes; however, the complication rate can be high. The goal of this study was to evaluate the cost equivalence of free versus pedicled perforator flap to assist decision-making and guide clinical care. Methods The institutional database was searched for patients with acute injury over the distal lower extremity requiring free or pedicled perforator flap. Demographic, clinical, and total resource cost was gathered. Patients were matched to Gustilo–Anderson or Arbeitsgemeinschaft fur Osteosynthesefragen classification as well as size of defect and outcomes, and cost compared. Results We have included 108 free flaps and 22 pedicled perforator flaps in the study. There was no difference in complication rate between groups. Free flaps had significantly more reoperations, required longer operative time, and had longer intensive care unit (ICU) care with higher cost of surgery and overall cost than pedicled flaps. When controlling for size of defect, surgical cost remained significantly different between groups (p = 0.013), but overall cost did not. Multivariable regression analysis indicated flap type to be the primary driver of cost of surgery, while body mass index elevated the total cost. Conclusion Pedicled perforator flap coverage for small to medium-sized defects (< 70 cm2) is a viable and cost-effective option for distal lower leg soft tissue reconstruction after acute traumatic injury with similar clinical outcomes and shorter operative duration and ICU stay.