Free Flap Reconstruction of Traumatic Pediatric Foot and Ankle Defects: An Analysis of Clinical and Functional Outcomes

Rajiv P. Parikh; Austin Ha; Thomas Tung

doi:10.1055/s-0041-1727187

Journal of Reconstructive Microsurgery, Inhaltsverzeichnis

J Reconstr Microsurg 2021; 37(09): 783-790
DOI: 10.1055/s-0041-1727187

Original Article

Free Flap Reconstruction of Traumatic Pediatric Foot and Ankle Defects: An Analysis of Clinical and Functional Outcomes

Rajiv P. Parikh

¹Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri

²Department of Plastic and Reconstructive Surgery, MedStar Washington Hospital Center/Georgetown University School of Medicine, Washington, District of Columbia

,

Austin Ha

¹Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri

,

Thomas Tung

¹Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri

› Institutsangaben

Abstract

Background Traumatic lower extremity injuries involving the foot and ankle can have devastating consequences and represent a complex reconstructive challenge. To date, there are limited reports on microsurgical reconstruction for foot and ankle defects in children. This study aims to evaluate clinical and functional outcomes of free flaps for pediatric foot and ankle injuries.

Methods This is a retrospective review of patients undergoing free flaps for traumatic foot and ankle defects at a pediatric trauma center between 2000 and 2015. Patients with less than 5-year follow-up were excluded. Demographics, clinical characteristics, and postoperative outcomes were evaluated.

Results Thirty patients undergoing 30 flaps were analyzed. The mean age was 11.9 years (range: 2 to 17 years). Muscle flaps (n = 21, 70%) were more common than fasciocutaneous flaps (n = 9, 30%). Limb salvage with functional ambulation was achieved in 96.7% of patients (n = 29). The complication rate was 33.3% (n = 10), with wound breakdown (n = 6, 20.0%) as most common feature. There were no significant differences in limb salvage, total or partial flap loss, fracture union, and donor-site complications based on flap type. Fasciocutaneous flaps were more likely to require revision procedures for contour compared with muscle flaps (55.6 vs. 9.5%, p = 0.013). Mean follow-up was 8.5 years.

Conclusion Microsurgical reconstruction of pediatric foot and ankle defects results in high rates of limb salvage. A defect- and patient-centered approach to reconstruction, emphasizing durable coverage and contour, is critical to facilitating ambulation and ensuring favorable long-term functional outcomes.

Keywords

limb salvage - lower extremity reconstruction - pediatric microsurgery

Volltext

Referenzen

References
1 Azoury SC, Stranix JT, Kovach SJ, Levin LS. Principles of orthoplastic surgery for lower extremity reconstruction: why is this important?. J Reconstr Microsurg 2021; 37 (01) 42-50
2 Kuo AD, Donelan JM. Dynamic principles of gait and their clinical implications. Phys Ther 2010; 90 (02) 157-174
3 Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg 1994; 93 (07) 1503-1504
4 Hallock GG. Evidence-based medicine: lower extremity acute trauma. Plast Reconstr Surg 2013; 132 (06) 1733-1741
5 Hollenbeck ST, Woo S, Komatsu I, Erdmann D, Zenn MR, Levin LS. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg 2010; 125 (03) 924-934
6 Momeni A, Lanni M, Levin LS, Kovach SJ. Microsurgical reconstruction of traumatic lower extremity defects in the pediatric population. Plast Reconstr Surg 2017; 139 (04) 998-1004
7 Upton J, Guo L. Pediatric free tissue transfer: a 29-year experience with 433 transfers. Plast Reconstr Surg 2008; 121 (05) 1725-1737
8 Claes KE, Roche NA, Opsomer D, De Wolf EJ, Sommeling CE, Van Landuyt K. Free flaps for lower limb soft tissue reconstruction in children: systematic review. J Plast Reconstr Aesthet Surg 2019; 72 (05) 711-728
9 Lee ZH, Daar DA, Stranix JT. et al. Risk factors for microvascular free flaps in pediatric lower extremity trauma. Microsurgery 2020; 40 (01) 44-50
10 Lickstein LH, Bentz ML. Reconstruction of pediatric foot and ankle trauma. J Craniofac Surg 2003; 14 (04) 559-565
11 May Jr JW, Rohrich RJ. Foot reconstruction using free microvascular muscle flaps with skin grafts. Clin Plast Surg 1986; 13 (04) 681-689
12 Rinker B, Valerio IL, Stewart DH, Pu LL, Vasconez HC. Microvascular free flap reconstruction in pediatric lower extremity trauma: a 10-year review. Plast Reconstr Surg 2005; 115 (06) 1618-1624
13 Herlin C, Sinna R, Bekara F, Delpont M, Dast S, Chaput B. The use of perforator flaps in lower extremity traumatic defect reconstruction in the pediatric population. Plast Reconstr Surg 2017; 140 (04) 634e-636e
14 Chiang YC, Jeng SF, Yeh MC, Liu YT, Chen HT, Wei FC. Free tissue transfer for leg reconstruction in children. Br J Plast Surg 1997; 50 (05) 335-342
15 Canales F, Lineaweaver WC, Furnas H. et al. Microvascular tissue transfer in paediatric patients: analysis of 106 cases. Br J Plast Surg 1991; 44 (06) 423-427
16 Egeler SA, de Jong T, Luijsterburg AJM, Mureau MAM. Long-term patient-reported outcomes following free flap lower extremity reconstruction for traumatic injuries. Plast Reconstr Surg 2018; 141 (03) 773-783
17 Zhu YL, Wang Y, He XQ, Zhu M, Li FB, Xu YQ. Foot and ankle reconstruction: an experience on the use of 14 different flaps in 226 cases. Microsurgery 2013; 33 (08) 600-604
18 Waters RL, Mulroy S. The energy expenditure of normal and pathologic gait. Gait Posture 1999; 9 (03) 207-231
19 Lugade V, Kaufman K. Center of pressure trajectory during gait: a comparison of four foot positions. Gait Posture 2014; 40 (04) 719-722
20 Sangeorzan A, Sangeorzan B. Subtalar joint biomechanics: from normal to pathologic. Foot Ankle Clin 2018; 23 (03) 341-352
21 Buchanan KR, Davis I. The relationship between forefoot, midfoot, and rearfoot static alignment in pain-free individuals. J Orthop Sports Phys Ther 2005; 35 (09) 559-566
22 Katoh Y, Chao EY, Laughman RK, Schneider E, Morrey BF. Biomechanical analysis of foot function during gait and clinical applications. Clin Orthop Relat Res 1983; (177) 23-33
23 Cho EH, Shammas RL, Carney MJ. et al. Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: a multicenter outcomes analysis. Plast Reconstr Surg 2018; 141 (01) 191-199
24 Crowe CS, Cho DY, Kneib CJ, Morrison SD, Friedrich JB, Keys KA. Strategies for reconstruction of the plantar surface of the foot: a systematic review of the literature. Plast Reconstr Surg 2019; 143 (04) 1223-1244
25 Lin CH, Mardini S, Wei FC, Lin YT, Chen CT. Free flap reconstruction of foot and ankle defects in pediatric patients: long-term outcome in 91 cases. Plast Reconstr Surg 2006; 117 (07) 2478-2487
26 Lee ZH, Abdou SA, Daar DA. et al. Comparing outcomes for fasciocutaneous versus muscle flaps in foot and ankle free flap reconstruction. J Reconstr Microsurg 2019; 35 (09) 646-651
27 Fox CM, Beem HM, Wiper J, Rozen WM, Wagels M, Leong JC. Muscle versus fasciocutaneous free flaps in heel reconstruction: systematic review and meta-analysis. J Reconstr Microsurg 2015; 31 (01) 59-66
28 Calotta NA, Pedreira R, Deune EG. The gracilis free flap is a viable option for large extremity wounds. Ann Plast Surg 2018; 81 (03) 322-326
29 Franco MJ, Nicoson MC, Parikh RP, Tung TH. Lower extremity reconstruction with free gracilis flaps. J Reconstr Microsurg 2017; 33 (03) 218-224
30 Kurlander DE, Durand P, Couto RA. et al. The muscle-sparing descending branch latissimus dorsi free flap for lower extremity reconstruction. Plast Reconstr Surg 2020; 145 (02) 412e-420e
31 Hallock GG. Identical rectus abdominis donor-site morbidity in compromised and healthy patients. J Reconstr Microsurg 1994; 10 (05) 339-343
32 Acar MA, Güleç A, Aydin BK, Erkoçak OF, Yilmaz G, Şenaran H. Reconstruction of foot and ankle defects with a free anterolateral thigh flap in pediatric patients. J Reconstr Microsurg 2015; 31 (03) 225-232
33 Holman WL, Davies JE, Lin JY. et al; VA CSP 474 Investigators. Consequences of radial artery harvest: results of a prospective, randomized, multicenter trial. JAMA Surg 2013; 148 (11) 1020-1023
34 Suominen S, Ahovuo J, Asko-Seljavaara S. Donor site morbidity of radial forearm flaps. A clinical and ultrasonographic evaluation. Scand J Plast Reconstr Surg Hand Surg 1996; 30 (01) 57-61
35 Ahmadi I, Herle P, Miller G, Hunter-Smith DJ, Leong J, Rozen WM. End-to-end versus end-to-side microvascular anastomosis: a meta-analysis of free flap outcomes. J Reconstr Microsurg 2017; 33 (06) 402-411
36 Broer PN, Moellhoff N, Mayer JM, Heidekrueger PI, Ninkovic M, Ehrl D. Comparison of outcomes of end-to-end versus end-to-side anastomoses in lower extremity free flap reconstructions. J Reconstr Microsurg 2020; 36 (06) 432-437
37 Song JW, Ben-Nakhi M, Hong JP. Reconstruction of lower extremity with perforator free flaps by free style approach in pediatric patients. J Reconstr Microsurg 2012; 28 (09) 589-594