Revisiting Bipedicled Flaps for Lower Extremity Distal Third Defects

Abstract

Background: Lower extremity reconstruction of the distal third of the leg is challenging. Free tissue transfer is the criterion standard. The COVID-19 pandemic encouraged seeking alternatives for resource consuming procedures. Bipedicled flaps are flaps with a dual-source subdermal perfusion. The purpose of this study was to assess outcomes of patients who had bipedicled flaps primary or auxiliary local flap for distal third leg/foot reconstruction. Methods: A retrospective review of patients undergoing lower extremity reconstruction (2020-2021) was performed. Inclusion criteria were patients older than 18 years with lower extremity wounds secondary to traumatic injury for which bipedicled flaps were used in the reconstruction. Exclusion criteria included lower extremity wounds secondary to peripheral vascular disease or diabetes. Results: Fourteen patients were included in the study. All patients had distal third of the leg/foot wounds, and 12 patients (87.5%) had concurrent leg fractures. In 8 patients (57.1%), the bipedicled flap was used to decrease the wound size and facilitate another concurrent flap: hemisoleus (21.4%), anterior tibialis muscle turnover (14.3%), medial plantar artery (14.3%), and posterior tibial artery perforator (14.3%). Mean wound size for bipedicle flaps used alone was 42.0 ± 18.3 cm 2 , whereas wounds that required a bipedicled flap with an additional flap were 69.9 ± 80.8 cm 2 ( P = 0.187). Two patients had partial flap necrosis (14.3%) but healed their defect. One patient had nonunion (7.1%). Limb salvage rate was 100%. Conclusions: Bipedicled flaps can be used as an alternative to free flaps in distal third leg/foot defects in select patients. If distal extremity wounds cannot be covered with a bipedicled flap alone, the flap can be used an accessory flap to facilitate reconstruction with other local flaps.

Locoregional Flap Reconstruction of the Distal Third of the Leg – What Role Does it Have in a Modern Reconstructive Algorithm?

“…[5][6][7]9,11,12 Other less common options include bipedicled flaps, random adjacent tissue rearrangement, and other less-common muscle flaps such as peroneus brevis. 8,13 For the workhorse flaps, failure rates and overall complication rates have been reported as 1%-7%, and overall complication rates as 21%-25%, which is comparable to rates for free tissue transfer. 3,9,10 While subpopulations of patients with open fractures of the distal third with soft tissue defects vary, locoregional options have been demonstrated to be noninferior when appropriately utilized.…”

“…In addition, these techniques avoid the need for microsurgical expertise, utilize fewer resources, are associated with decreased operative time, and are easier to coordinate for immediate coverage after treatment of orthopedic injuries. 3,5,[8][9][10] Further, these techniques are applicable in a wider range of settings and may preserve capacity at referral centers for patients that cannot be cared for elsewhere.…”