Reconstruction of Gustilo Type IIIC Injuries of the Lower Extremity

Ricci, Joseph A.; Abdou, Salma A.; Stranix, John T.; Lee, Z‐Hye; Anzai, Lavinia; Thanik, Vishal; Saadeh, Pierre B.; Levine, Jamie P.

doi:10.1097/prs.0000000000006063

Cited by 20 publications

(16 citation statements)

References 24 publications

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“…The frequency of loss of the lower extremity free flap remains high compared with other areas of microsurgical reconstruction. 8 Injured lower extremity flap loss rates increase further as patent vessel numbers decrease on the extremity. 8,9 In cases where no suitable recipient vessel was found near the defect in the extremity to be reconstructed, vein grafts, arteriovenous loupes, or cross-extremity flaps are used.…”

Section: Discussionmentioning

confidence: 99%

Preserving the Blood Flow of the Recipient Artery in Cross-Leg Free Flap Procedure for Lower Extremity Reconstruction

Bali

Karatan

Tuluy

et al. 2020

The International Journal of Lower Extremity Wounds

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When there is no suitable vessel in the injured leg for microsurgical transfer, cross-leg free flaps can be considered for lower extremity reconstruction. This report describes patients who experienced lower extremity trauma and underwent reconstruction with cross-leg free flaps with preserved blood flow in the recipient artery. Anterolateral thigh flap is preferred for small to moderate defects. The descending branch of the lateral femoral circumflex artery was dissected 2 cm proximally and distally and was prepared in a T-shape. The branches of the T were anastomosed to the recipient artery in the contralateral leg in the first session of the cross-leg free flap procedure. After 3 weeks, the flap artery was separated from the bifurcation. For large defects, the latissimus dorsi flap was chosen. The thoracodorsal artery was anastomosed to the contralateral posterior tibial artery in the first session. After 3 weeks, to provide recipient vessel integrity, the thoracodorsal artery was transected from the flap and anastomosed to the distal stump of the posterior tibial artery. Between January 2017 and January 2019, 8 defects were reconstructed using an anterolateral thigh flap; the remaining 4 defects were reconstructed using a latissimus dorsi flap. All flaps survived without complications. Anterograde flow distal to the anastomosis was confirmed in all recipient arteries via Doppler ultrasound. In cross-leg free flaps, the continuity of the recipient artery can be established to prevent diminished blood flow to the recipient extremity.

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Section: Discussionmentioning

confidence: 99%

Preserving the Blood Flow of the Recipient Artery in Cross-Leg Free Flap Procedure for Lower Extremity Reconstruction

Bali

Karatan

Tuluy

et al. 2020

The International Journal of Lower Extremity Wounds

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“…The overall flap success rate in this group was 71%, lower than the 80 to >95% rates reported in the literature for lower extremity reconstruction. 4,[17][18][19][20][21] In the group in which the thrombectomy protocol was employed, the flap survival increased to 90% and there were no anastomotic-related complications in that group. In a small, retrospective study of this nature, it is difficult to identify the specific factors contributing to increased flap survival in the thrombectomy group.…”

Section: Discussionmentioning

confidence: 99%

Recipient Vessel Thrombectomy and Anastomosis within the Zone of Injury in Microvascular Extremity Reconstruction

Powers

Choi

Kale

2020

Journal of Reconstructive Microsurgery Open

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Background In traumatic extremity reconstruction, it is preferable to perform microvascular anastomoses outside the zone of injury. Alternatively, a recipient-vessel thrombectomy can be performed to improve the arterial inflow, potentially avoiding further proximal dissection and the use of a vein graft. The objective of this study was to evaluate the outcomes of microvascular anastomosis after thrombectomy in the zone of injury. Methods A retrospective review of patients who underwent free tissue transfer for traumatic extremity reconstruction by the senior author from 2013 to 2017 was conducted. Patient demographic and clinical data were gathered as well as use of vein grafts, recipient-vessel thrombectomy, postoperative anticoagulation, and flap outcomes. Results A total of 23 patients underwent 24 free flap procedures for traumatic extremity reconstruction. Ten patients underwent recipient-vessel thrombectomy with 2-Fr Fogarty catheter and were placed on postoperative anticoagulation. In this group overall, there was one case of flap loss due to late wound infection resulting in a 90% success rate. A total of 13 patients underwent 14 free flaps without the use of thrombectomy and vein grafts were performed for 3/14 (21%) patients. In this group, there were four cases of flap loss, resulting in a 71% overall success rate. Conclusion In traumatic extremity reconstruction, if the artery appears to be visibly appropriate with weak inflow, one may consider attempting thrombectomy to restore pulsatile flow prior to harvesting a vein graft. This study suggests this may be effective and safe with no anastomosis-related flap loss in the thrombectomy group. Further research is required to confirm our results.

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“…Stranix et al [20] , compared Gustilo IIIB injuries with increasing arterial injury, finding that limbs with a single vessel uninjured had higher flap failure risk [20] . A recent work by Ricci et al [112] though, compared the reconstructive outcomes of patients with Gustilo type IIIC injuries after emergent revascularization in order to determine whether there was an optimal treatment algorithm. According to their results, the rates of complications in these patients were comparable with the routinely reconstructed type IIIB injuries, therefore worth considering for limb salvage.…”

Section: Devascularized Limbsmentioning

confidence: 99%

Advances in microsurgery for upper and lower extremity reconstruction and limb preservation

Bolletta¹,

Rubino²,

Chen³

2019

PAR

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In the recent decades, microsurgical reconstruction has evolved from simple survival of the affected extremity to the improvement of functional and aesthetic outcome. This review retraces the main contributions to the advances of microsurgery for reconstruction of upper and lower extremities and limb preservation. In the upper extremity, it is important to restore fine motility, together with allowing prompt mobilization. In the lower limb, care must be taken in the reconstruction of weight-bearing areas and the aim must be proper ambulation and shoe wearing. Local perforator flaps can be considered for medium size defects. They provide thin coverage and can be performed in short operating time. Their use, though, is often limited by tissue availability. Free flaps allow to overcome this problem and, thanks to the recent development in the study of perforator vessels, the microsurgeon can choose the flap with the most appropriate characteristics. Chimeric flaps can accomplish simultaneous reconstruction of different tissue components and large bone defects often require vascularized bone reconstruction. When dealing with limb preservation it is very important to consider residual functionality. Functioning muscle transfer and targeted muscle re-innervation can be performed in these cases. A useful reconstructive tool in severely damaged limbs with limited blood supply is the use of cross-leg free flaps. In conclusion, extremity reconstruction and limb preservation are reaching new heights thanks, not only to the work of plastic surgeons, but also to the new developments in other fields of study such as oncology, traumatology, radiology and medical engineering.

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Reconstruction of Gustilo Type IIIC Injuries of the Lower Extremity

Cited by 20 publications

References 24 publications

Preserving the Blood Flow of the Recipient Artery in Cross-Leg Free Flap Procedure for Lower Extremity Reconstruction

Preserving the Blood Flow of the Recipient Artery in Cross-Leg Free Flap Procedure for Lower Extremity Reconstruction

Recipient Vessel Thrombectomy and Anastomosis within the Zone of Injury in Microvascular Extremity Reconstruction

Advances in microsurgery for upper and lower extremity reconstruction and limb preservation

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