Reconstruction of Extensive Soft-Tissue Defects with Concomitant Bone Defects in the Lower Extremity with the Latissimus Dorsi-Serratus Anterior-Rib Free Flap

Abstract

Background The combined latissimus dorsi-serratus anterior-rib (LD-SA-rib) free flap provides a large soft-tissue flap with a vascularized bone flap through a solitary vascular pedicle in a one-stage reconstruction.

Methods Seven LD-SA-rib free flaps were performed in seven patients to reconstruct concomitant bone and extensive soft-tissue defects in the lower extremity (tibia, five; femur, one; foot, one). The patients were all male, with an average age of 34 years (range, 20–48 years). These defects were secondary to trauma in five patients and posttraumatic osteomyelitis in two patients.

Results All flaps survived and achieved bony union. The average time to bony union was 9.4 months. Bone hypertrophy of at least 20% occurred in all flaps. All patients achieved full weight-bearing ambulation without aid at an average duration of 23.7 months. Two patients developed stress fractures of the rib flap. There was no significant donor site morbidity, except for two patients who had pleural tears during harvesting of the flap.

Conclusion The LD-SA-rib flap provides a large soft-tissue component and a vascularized bone flap for reconstruction of composite large soft-tissue defects with concomitant bone defects of the lower extremity in a one-stage procedure.

Keywords

latissimus dorsi - vascularized rib - large soft tissue defect - lower extremity

• References

• 1 Harii K, Yamada A, Ishihara K, Miki Y, Itoh M. A free transfer of both latissimus dorsi and serratus anterior flaps with thoracodorsal vessel anastomoses. Plast Reconstr Surg 1982; 70 (5) 620-629
• 2 Takayanagi S, Ohtsuka M, Tsukie T. Use of the latissimus dorsi and the serratus anterior muscles as a combined flap. Ann Plast Surg 1988; 20 (4) 333-339
• 3 Penfold CN, Davies HT, Cole RP, Evans BTE, Hobby JAE. Combined latissimus dorsi-serratus anterior/rib composite free flap in mandibular reconstruction. Int J Oral Maxillofac Surg 1992; 21 (2) 92-96
• 4 Lin CH, Wei FC, Levin LS , et al. Free composite serratus anterior and rib flaps for tibial composite bone and soft-tissue defect. Plast Reconstr Surg 1997; 99 (6) 1656-1665
• 5 Lin CH, Yazar S. Revisiting the serratus anterior rib flap for composite tibial defects. Plast Reconstr Surg 2004; 114 (7) 1871-1877
• 6 Tu YK, Yen CY. Role of vascularized bone grafts in lower extremity osteomyelitis. Orthop Clin North Am 2007; 38 (1) 37-49 , vi
• 7 Tu YK, Yen CY, Yeh WL, Wang IC, Wang KC, Ueng WN. Reconstruction of posttraumatic long bone defect with free vascularized bone graft: good outcome in 48 patients with 6 years' follow-up. Acta Orthop Scand 2001; 72 (4) 359-364
• 8 Georgescu AV, Ignatiadis I, Ileana M, Irina C, Filip A, Olariu R. Long-term results after muscle-rib flap transfer for reconstruction of composite limb defects. Microsurgery 2011; 31 (3) 218-222
• 9 Rajasekaran S, Naresh Babu J, Dheenadhayalan J , et al. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures. J Bone Joint Surg Br 2006; 88 (10) 1351-1360
• 10 Russell WL, Sailors DM, Whittle TB, Fisher Jr DF, Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann Surg 1991; 213 (5) 473-480 , discussion 480–481
• 11 de Boer HH, Wood MB. Bone changes in the vascularised fibular graft. J Bone Joint Surg Br 1989; 71 (3) 374-378
• 12 Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004; 114 (6) 1457-1466
• 13 Yang YF, Xu ZH, Zhang GM , et al. Modified classification and single-stage microsurgical repair of posttraumatic infected massive bone defects in lower extremities. J Reconstr Microsurg 2013; 29 (9) 593-600
• 14 Bartlett SP, May Jr JW, Yaremchuk MJ. The latissimus dorsi muscle: a fresh cadaver study of the primary neurovascular pedicle. Plast Reconstr Surg 1981; 67 (5) 631-636
• 15 Rowsell AR, Davies DM, Eisenberg N, Taylor GI. The anatomy of the subscapular-thoracodorsal arterial system: study of 100 cadaver dissections. Br J Plast Surg 1984; 37 (4) 574-576
• 16 Maxwell GP, Manson PN, Hoopes JE. Experience with thirteen latissimus dorsi myocutaneous free flaps. Plast Reconstr Surg 1979; 64 (1) 1-8
• 17 Wei FC, Chen HC, Chuang CC, Noordhoff MS. Fibular osteoseptocutaneous flap: anatomic study and clinical application. Plast Reconstr Surg 1986; 78 (2) 191-200
• 18 Berggren A, Weiland AJ, Ostrup LT, Dorfman H. Microvascular free bone transfer with revascularization of the medullary and periosteal circulation or the periosteal circulation alone. A comparative experimental study. J Bone Joint Surg Am 1982; 64 (1) 73-87
• 19 Papanastasiou VW, Lalonde DH, Williams HB. The vascular pattern and viability of microvascularized rib grafts based on periosteal circulation—an experimental study. Ann Plast Surg 1984; 13 (5) 375-382
• 20 Kurokawa M, Muneuchi G, Hamagami H, Fujita H. Reconstruction of four metatarsal bone and soft-tissue defects using a serratus anterior muscle rib osteomyocutaneous free flap. Plast Reconstr Surg 1998; 101 (6) 1616-1619
• 21 Kurokawa M, Yamada N, Suzuki S, Muneuchi G. Long-term follow-up of reconstruction of four metatarsal bone and soft-tissue defects using a serratus anterior muscle rib osteomyocutaneous free flap. Plast Reconstr Surg 2004; 114 (6) 1553-1555
• 22 Haw CS, O'Brien BM, Kurata T. The microsurgical revascularisation of resected segments of tibia in the dog. J Bone Joint Surg Br 1978; 60-B (2) 266-269
• 23 Musharafieh R, Osmani O, Musharafieh U, Saghieh S, Atiyeh B. Efficacy of microsurgical free-tissue transfer in chronic osteomyelitis of the leg and foot: review of 22 cases. J Reconstr Microsurg 1999; 15 (4) 239-244
• 24 Doi K, Kawakami F, Hiura Y, Oda T, Sakai K, Kawai S. One-stage treatment of infected bone defects of the tibia with skin loss by free vascularized osteocutaneous grafts. Microsurgery 1995; 16 (10) 704-712
• 25 Minami A, Kasashima T, Iwasaki N, Kato H, Kaneda K. Vascularised fibular grafts. An experience of 102 patients. J Bone Joint Surg Br 2000; 82 (7) 1022-1025
• 26 Yajima H, Tamai S, Mizumoto S, Inada Y. Vascularized fibular grafts in the treatment of osteomyelitis and infected nonunion. Clin Orthop Relat Res 1993; (293) 256-264
• 27 Peat BG, Liggins DF. Microvascular soft tissue reconstruction for acute tibial fractures—late complications and the role of bone grafting. Ann Plast Surg 1990; 24 (6) 517-520
• 28 Shaffer JW, Field GA, Goldberg VM, Davy DT. Fate of vascularized and nonvascularized autografts. Clin Orthop Relat Res 1985; (197) 32-43
• 29 Lin CH, Wei FC, Chen HC, Chuang DCC. Outcome comparison in traumatic lower-extremity reconstruction by using various composite vascularized bone transplantation. Plast Reconstr Surg 1999; 104 (4) 984-992
• 30 Economides JM, Patel KM, Evans KK, Marshall E, Attinger CE. Systematic review of patient-centered outcomes following lower extremity flap reconstruction in comorbid patients. J Reconstr Microsurg 2013; 29 (5) 307-316