Title: Free Functioning Muscle Transfer for Lower Extremity Posttraumatic Composite Structure and Functional Defect
Authors: Chih-Hung Lin, MD, Yu-Te Lin, MD, Jiun-Ting Yeh, MD and Chien-Tzung Chen, MD
Source: Journal of Plastic and Reconstructive Surgery. 2007; 119(7): 2118-2126.
PODIATRIC RELEVANCE:
Lower extremity mutilation injuries pose a unique challenge to reconstructive surgeons especially in the setting of flexor and extensor loss. Local tendon transfers during the sub-acute phase of injury have been the mainstay of therapy to re-align and balance the foot and ankle following composite injuries to the lower extremity. Instead, the authors recommend functional muscle flaps to acutely improve function and reduce long-term limb morbidity. The objective of this study was to investigate the efficacy of free functioning muscle transfers in providing both functional and structural restoration in traumatized limbs.
METHODS:
This article retrospectively examined nineteen patients who sustained composite soft-tissue damage, with or without boney defect between 1996 and 2004. Patients were divided into three groups according to the Gustillo-Anderson Classification of open fractures. Group I sustained Type IIIB fractures (n=10), group II consisted of patients with neglected compartment syndromes (n=5) following Type IIIB and IIIC injuries while Group III participants sustained crush injury (n=4) to the lower extremity. Fifteen patients received free functioning rectus femoris or gracilis muscles transfers; gracilis was preferred in cases where ankle dorsiflexion had been compromised. The remaining four patients underwent composite rectus femoris transfers including vascular iliac crests (n=2) and antrolateral thigh flaps (n=2) for extensive segmental reconstruction of the soft tissue defects to the tibia and quadriceps respectively.
RESULTS:
Of the nineteen patients examined, two required re-exploration as a result of arterial occlusion one of which resulted in a BKA. Five patients required skin grafts to address skin paddle necrosis (n=3) and/or residual soft tissue defect (n=2). Re-innervation was attained at 5.2 months post-reconstruction in all but four patients who lacked demonstrable muscle contraction. Eighteen patients regained ambulatory function with only two patients requiring biomechanical control with ankle-foot orthoses. This study employed the Stanmore System to assess functional outcomes (0-100); Groups I and III had superior functional scores of 80.8 and 90.5 respectively compared to Group II participants (47.0) without significance to the type of flap utilized.
COMMENTS:
Local tendon transfers are still the mainstay of functional loss to the lower extremity however, in patients with composite tissue loss, their usefulness is limited. Advancements in microsurgical technique now enable acute-care physicians to harvest reliable primary free functioning muscle flaps to improve limb salvage in otherwise functionally devastating injuries.
________________________________________________________________________________________
Disclaimer:
Scientific Abstract Monthly postings are submitted by podiatric surgical residents. The ideas presented are not the opinions of the American College of Foot and Ankle Surgeons (ACFAS), nor are they presented as facts. ACFAS presents this information without any warranty of any kind, expressed or implied, and is not liable for its accuracy nor for any loss or damage caused by the user's reliance on information obtained in these areas.