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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_998_Библиотеки_им_академика_М_И_Перельмана
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35 Soft Tissue Reconstruction oftheLower Limb
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a
b
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c
d
Fig. 35.4
defect. This case highlights a large defect in the medial
groin of the left leg following excision of a fungating
tumor. (a) Defect medial thigh. (b) Left and right: pedicled ALT raised on same leg, surface markers for perforators is the middle third along a line drawn between the
anterior superior iliac spine and the lateral edge of the
Anterolateral thigh (ALT) ap for medial groin
patella. (c) Left: raised ALT ap showing perforator pedicle. Right: tunnel for ALT to be passed through to reach
medial thigh defect. (d) Left: lateral thigh donor site
defect. Right: this can generally be closed directly up to
8cm. (e) Left and right: sutured pedicled ALT ap with
donor site drain in situ. (f) Results at 4weeks
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e
f
Fig. 35.4 (continued)
Table 35.5 Sural ap
Sural
Flap
attributes
Artery Perforating branches of medial sural
Vein Similar size to artery
Pedicle 3mm, although reverse sural ap
Nerve Sural nerve can be harvested
Fasciocutaneous±muscle
artery as well as perforators from the
peroneal artery, 1–2mm diameter
10–15cm
latter ap gives a 5–10cm pedicle with an
artery diameter less than 2mm. The posterior cutaneous nerve of the thigh can be
harvested with the ap.
2. Tensor Fascia Lata (TFL)
Useful as a pedicled or free ap, the thin
muscle belly and long fascial extension allow
this ap to be used in a multitude of scenarios,
as well as it being an expendable muscle unit
in the majority (Table35.6). Able to reach the
umbilical region, perineum, ischium, and
groin, it can incorporate skin to cover defects
in the proximal lower limb, as well as iliac
bone for osteomusculocutaneous coverage.
When planning its dissection, the TFL ap is
designed along a line between the anterior
superior iliac spine and the lateral femoral
condyle. The lateral femoral cutaneous nerve
can be harvested to provide a sensate ap and
enters the region of the ap just above the
greater trochanter between the gluteus medius
and gluteus minimus muscles (Fig.35.6).
ab
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d e
f g
Fig. 35.5 (a) Cement burn to knee exposing patella and
extensor apparatus of knee. (b) Saphenous ap drawn. (c)
Saphenous ap dissected. (d) Transposed fasciocutaneous
ap over exposed knee structures. (e) Transposed ap. (f)
Three weeks postoperative. (g) Six months postoperative
showing healed ap and sheet skin graft to donor site
medially
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Table 35.6 TFL ap
Tensor fascia lata (TFL)
Flap
attributes
Artery Ascending, or Transverse, branch of
Vein Vein travels with artery draining into
Pedicle 5–10cm
Nerve Lateral cutaneous nerve of the thigh
Muscle ap but can be harvested with
skin paddle
Beware lateral knee instability in the
athletic patient
lateral femoral circumex artery
(profunda femoral trunk)
1–3mm
lateral femoral circumex
3. Gracilis
A pedicled and innervated gracilis ap is
useful in perineal and ischial coverage, but its
relative lack of functional decit on removal
means its use as a free ap for the lower leg
cannot be underestimated (Table 35.7). It
allows purely lower limb anesthesia, and its
small size does not cause gross contour
changes in its nal location. It is raised from
its main pedicle, the terminal branch of the
medial circumex femoral artery. Although a
consistent ap (the muscle lies posterior and
c
d
e
Fig. 35.6 (a) Ischial pressure sore. (b) Marking for ped-
icled tensor fascia lata muscle ap. Pedicle found at proximal and middle third junction along an axis drawn from
anterior superior iliac spine and the lateral femoral con-
f
dyle. (c) Raised pedicled TFL. (d) Transposition to defect
showing donor site wound. (e) Wound coverage by transposition of pedicled ap. (f) Closure of donor wound.
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Table 35.7
Gracilis
Flap
attributes
Artery Gracilis vessels from medial femoral circumex system (profunda femoral artery branch)
Vein Two venae, can be bigger than artery
Pedicle 6cm
Nerve Nerve to gracilis (branch of obturator nerve)
Table 35.8
Soleus
Flap
attributes
Artery Medial half has reliable medial perforators from posterior tibial artery
Vein Similar size to artery
Pedicle 5–15cm, generally used as a pedicled ap but can be proximally or distally based
Nerve N/A
Table 35.9 Gastrocnemius ap
Gastrocnemius
Flap attributes Muscle ap
Artery Medial sural artery (medial belly) from popliteal artery
Vein Two venae or medial sural vein draining into the popliteal vein (medial belly)
Pedicle 2–5cm (short) generally used as a local pedicled muscle ap but can be used free
Nerve Medial and lateral branches to muscle bellies from posterior tibial nerve
Gracilis ap
Muscle ap
Generally can cover 6×20cm wounds
Can be harvested as a transverse upper gracilis (TUG) ap to include a skin paddle of up to 11×25cm
1–2mm
Soleus ap
Muscle ap
Both muscle bellies can be utilized but generally medial belly is preferred as reliable blood supply, and
hemisoleus maintains foot plantar exion strength
1.5–2mm diameter
Both muscle bellies can be utilized but generally medial belly is used (larger)
1–4mm
parallel to a line drawn between the pubic
tubercle and the medial tibial epicondyle) it
can often be too small to cover more severe
defects of the lower limb, with any skin paddle unreliable when using the more distal skin
of the thigh. For this reason, it is often useful
to locate the distal insertion of the gracilis tendon before nalizing the design of a musculocutaneous ap if this is required.
4. Soleus
Used for defects of the middle third of the
lower leg, soleus can be split to form a hemisoleus ap, thanks to its dual pedicle supply
and bipennate morphology (Table35.8) [36].
Due to an increased risk of substantial ankle
exion weakness alongside loss of lower limb
venous return through the muscle, its use has
been criticized [37].
5. Gastrocnemius
The two origins of this muscle allow sepa-
rate muscle or musculocutaneous aps to be
raised on separate pedicles, along the lateral
or medial sural arteries (Table35.9). The cutaneous defect can be unsightly, so it is preferred to harvest as a muscle ap and cover
this with a skin graft. Useful for distal femur,
proximal tibia, and knee coverage, it may be
advanced minimally to allow coverage over
the Achilles tendon or rotated to the mid-tibia,
thanks to the anastomosis across the muscular
raphe. The gastrocnemius ap can only be
employed in scenarios where soleus is intact
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as rehabilitation and walking are dependent
on ankle plantar exion (Fig.35.7).
6. Vastus Lateralis
This muscle provides a musculocutaneous
ap which offers no great decit in ambulation which is not afforded by aps raised using
the rectus femoris muscle for hip and proximal thigh defects. The latter is now more utilized for abdominal defects, and the ALT ap
supersedes both, using the same pedicle without the donor site morbidity of taking the
muscles below.
35.5.5.4 Other Flap Choices
Free osteocutaneous ap options include, but are
not limited to:
1. Iliac osteocutaneous ap (Table35.10)
2. Vascularized rib transfer ± serratus anterior
and/or latissimus dorsi
3. Fibula osteocutaneous ap (Table35.11)
4. Radial osteocutaneous ap (Table35.12)
35.5.6 Choice ofReconstruction: By
Anatomical Location ofInjury
Anatomical zone of injury is a key determinant of
introducing a more reliable pedicled ap to a
wound bed. Many authors have stated success
with varying options, and different aps may be
more suitable in a particular surgeons’ expertise
and personal experience.
The gluteal and the thigh regions, due to their
option as free ap choice, allow great versatility
in regard to local aps. V-Y, bipedicled, and keystone aps are all utilized with good outcomes
(Fig.35.8) (Table35.13) [38].
The upper thigh and groin have a multitude of
options. Most of the thigh aps described before
will reach groin to knee as pedicled options, with
the sartorius being a further muscle or musculocutaneous option. The sartorius muscle is often
“switched” to reduce dead space and protect the
femoral vessels when performing groin or inguinal node-basin dissections.
Due to the unique anatomy of the knee,
reconstruction of the soft tissues has been
attempted with both local and free aps, the
choice being more dependent on surrounding
tissue availability and the amount of bony and
soft tissue injury [39].
The knee and popliteal region can be covered
by pedicled gastrocnemius, or proximally based
hemisoleus, aps [40, 41]. Signicant tissue coverage here is important as loss of the extensor
mechanism of the knee can have long-term functional consequences. Improved microsurgery has
allowed the use of the genicular arteries as recipient vessels, minimizing trauma to the popliteal
and femoral vessels [42].
The tibia provides a unique challenge as it not
sheathed in a muscle coat, for instance, the femur,
and consequently inhabits a poorly vascularized
environment predisposing it to nonunion and
infection. The tibialis anterior muscle, if not
involved in the zone of injury, can be split to
cover small defects over the bone. This can be
done in a bipedicled turn-over or “book ap”
design. As well as in traumatic injuries, it should
be noted that sarcomas involving the tibial bone
are not uncommon.
The proximal tibia is usually well placed to be
covered with local aps involving the gastrocnemius or soleus muscles.
The mid-tibia defect can also be covered using
a combination medial hemisoleus and gastrocnemius ap, with an aim of maintaining the Achilles
tendon and posterior tibial vessels to allow ankle
plantar exion post reconstruction [43] with the
author also describing his use of the medial hemisoleus [44] and the reversed hemisoleus ap for
distal tibia defects [45].
The middle and distal tibia defect has also
been salvaged using the osteocutaneous bula
ap with good results, both as a pedicled and free
ap [46–48]. The bula’s blood supply allows the
bone to be hinged using osteotomy sites as
needed, providing the periosteum is kept intact as
the source of blood supply. This can be doublebarreled for reconstruction of long-bone defects,
such as the femur. Another option is distraction
osteogenesis. After removing the dead or infected
bone of the tibia, achieving closure of the soft tissue, which is made easier with the shortened
limb, the bone can be then distracted, often by as
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e
Fig. 35.7 (a) Defect to anterior knee region following
chronic wound after total knee replacement. (b) Following
debridement of necrotic tissue. (c) Pedicled gastrocnemius muscle ap brought from donor to tunnel and pulled
f
through defect– anterior view. (d) Posterior ap view. (e)
Muscle ap in situ – graft required as only muscle ap
harvested. (f) Closure of donor site with donor site drain
in situ
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Table 35.10 Iliac osteocutaneous/DCIA ap
Iliac osteocutaneous/DCIA
Flap
attributes
Artery Deep circumex iliac artery, branch of
Vein Usually larger than artery, draining into
Pedicle 4–7cm, dependent on harvest technique
Nerve N/A
Table 35.11 Fibula osteocutaneous ap
Fibula osteocutaneous
Flap
attributes
Artery Peroneal artery
Vein Two venae, draining into posterior tibial
Pedicle Generally short length but can be
Nerve Lateral sural nerve can be harvested
Table 35.12 Radial (osteocutaneous) forearm ap
Radial (osteocutaneous) forearm
Flap
attributes
Artery Radial artery with perforators
Vein
Pedicle 12cm
Nerve Supercial radial nerve or antebrachial
Iliac crest bone with adjacent periosteum,
iliacus muscle±skin paddle
Useful if bula option is not viable
Skin ap can be bulky
the external iliac artery
1.5–3mm caliber vessel
the saphenous vein
of bone and or skin paddle and whether
common DCIA/SCIA trunk
Fibula none with adjacent periosteum and
muscle cuff±skin paddle Take with
muscle to improve skin ap reliability of
up to 5cm width to allow primary closure
Preserve lower 6cm of bula for ankle
function. Up to 25cm bone able to be
harvested
Peroneal nerve in close proximity to
proximal region of bone
Check intact vascular arch supply to
lower limb
1–4mm caliber vessel
veins
increased up to 12cm by using distal
bone and dissecting free of proximal
bula
Fasciocutaneous ± tendon (palmaris
longus) ± bone (radius)
Skin paddle up to 10×40cm
Check intact vascular arch supply to
hand
2–4mm
Subcutaneous venous system +/−
cephalic vein
Venae comitantes of the radial artery are
also harvested but can be too small
nerves (medial/lateral) can be harvested
Fig. 35.8 Arterial axis of the groin region showing arterial pedicles for the main pedicle and free ap options in
this region
Table 35.13 A variety of aps
Perforating
branch
Artery
Deep circumex
iliac artery
Supercial
circumex iliac
Artery
Medial femoral
circumex Artery
Lateral femoral
circumex Artery
(typically) Flap
Iliac osteocutaneous
ap
Groin ap
Gracilis and TUG
ap (Medial thigh/
groin ap)
Ascending Tensor fascia lata
Transverse
Descending Anterolateral thigh
ap
ap
Rectus femoris/
vastus lateralis
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Table 35.13
Artery
Profunda femoris
(deep femoral)
artery
Supercial
femoral artery
(continued)
Perforating
branch
(typically) Flap
1 Supplies adductor
magnus muscle and
overlying skin
2 Lateral thigh ap
3 Posterior thigh ap
(as described by
Song [
4 (terminal)
Supplies skin paddle
over region of
anterior thigh
Sartorius
37])
much as 1mm a day, using external xation. This
can help to re-lengthen the bone over time which
stretches the soft tissue envelope over it and
reducing long-term disability.
This region can also be reached by fasciocutaneous aps based on the peroneal and posterior
tibial artery perforators described previously
(Figs.35.9 and 35.10).
The lower third of the lower leg, heel, and
hind foot are technically challenging areas to
cover. Options include the reverse saphenous and
sural aps. The saphenous ap provides a reliable
and versatile option for the medial and anterior
lower leg, as well as the hind foot and malleolar
region [49]. The sural fasciocutaneous ap has
successfully been used to reconstruct tissue loss
in these areas. The distally based sural ap is
safe, reliable, and operatively quick to perform
negating free ap reconstruction [50]. However,
this ap may be limited by the size of the defect,
reasonably covering an area up to 10cm square.
Other aps utilized in this region include the lateral calcaneal artery ap which can be transposed
to cover the Achilles tendon which can be raised
as a fasciocutaneous ap to cover defects up to
4cm in size. Otherwise, local muscle coverage of
the Achilles and malleolar region is fairly
limited.
The plantar region of the foot has two distinct
zones in terms of function: the weight-bearing
and the non-weight-bearing. The former is made
up of the heel, the head of the metatarsals, and the
lateral strip adjoining them. The toe pulps to a
lesser degree are used in some positions of gait
for weight-bearing too. Evolution has allowed
these areas to become hyper-keratinized, and
there is increased strong brous attachments to
the skin to deal with the repeated trauma. This
needs to be taken into account when replacing
defects of this region as thin grafts may do well in
the non-weight-bearing zones but stand little
chance when reconstructing the heavier loaded
sites, and a repeatedly ulcerated reconstruction
may be of poorer use to a patient than an amputation if the heel and weight-bearing zones have
been degloved.
Heel defects in particular present a difcult
area to reconstruct, being the main weightbearing zone. Delayed reverse sural aps have
been used successfully in cases of distal tibial
and calcaneal fracture with neurofasciocutaneous
coverage, improving long-term function and
rehabilitation. The perforator supply to the suralbased ap allows numerous options, allowing
reduced donor morbidity [51].
The dorsal foot and ankle are likewise difcult
to reconstruct due to a functional lack of tissue
around this site. Distal-based lateral supramalleolar adipofascial aps have been described, providing less bulky aps although requiring grafting of
the transposed ap and covering only small defects
[52]. They may also reduce long-term ulcer formation due to some retained sensation compared to
the majority of free ap reconstructions.
The anterior tibial artery provides an adipofascial ap suitable for coverage over the malleolar
regions [53]. Generally, if the paratenon is
present, a skin graft is adequate, although there
can be long-term pain and wound issues similar
to those seen in dorsalis pedis donor site surgery.
The temporoparietal fascial ap is a particularly
unbulky ap which is ideal for this region.
Foot coverage has been successfully performed using sural artery, lateral calcaneal arterybased, extensor digitorum brevis muscle rotation,
and abductor hallucis muscle rotation aps
(Table 35.14) [54–56]. The latter is of use in
smaller defects of the medial foot, but does not
reach the medial malleolus. It is based on the
medial plantar artery and nerve. The lateral plan-
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b
Fig. 35.9
loss. (b) Peroneal (bular) artery fasciocutaneous perforator marked. (c) Pedicled perforator ap mobilized over
(a) Anterior open tibial fracture with tissue
open fracture and donor defect reconstructed with skin
graft. (d) Left and right: patient at 3months
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