SLR - June 2017 - Meaghan C. Stoinski

Microsurgical Reconstruction of Traumatic Lower Extremity Defects in the Pediatric Population

Reference: Momeni A, Lanni M, Levin LS, Kovach SJ. Microsurgical Reconstruction of Traumatic Lower Extremity Defects in the Pediatric Population. Plast Reconstr Surg. 2017 Apr; 139(4): 998-1004.
 
Scientific Literature Review

Reviewed By: Meaghan C. Stoinski, DPM
Residency Program: St. John Providence, Southfield, MI

Podiatric Relevance: Pediatric cases are some of the most sensitive patients podiatrists treat. Parents are set on high alert when their child is injured; naturally treating a child becomes a family affair. The authors hypothesized that reconstructive success for pediatric patients undergoing microsurgical reconstruction of traumatic lower extremity defects would be comparable to success rates reported in adults, and that young age or concerns regarding vessel size or behavior do not negatively impact surgical outcome.

Methods: This study was a retrospective analysis of traumatic pediatric lower extremity injuries requiring microsurgical reconstruction and the outcomes reported. It was performed at Duke and University of Pennsylvania from 1997-2012, including 40 total patients. Outcome measures used to answer the hypothesis included: patient age, sex, body mass index, medical history, defect location, flap type, recipient vessels, use of vein grafts, operative time, estimated blood loss, length of hospital stay after reconstruction, return to full weight-bearing and complication rate.

Results: 40 flaps were transferred in 40 patients with mean age of 11.4 years (1 to 17 years). The most common recipient vessel and paired vein was the posterior tibial artery in 27 patients, which is more anatomically protected in cases of trauma. Muscle flaps were predominant in 57.5 % as opposed to fasciocutaneous flaps used in 40% of the patients. Postoperative complications occurred in a quarter of these patients with 5% total flap loss rate. There were no donor-site complications. Mean postoperative hospital stay was 12.9 days (4 to 41 days). Patients returned to full weight bearing within a mean of 2.6 months (1 to 8 months).

Conclusions: Microsurgical reconstruction of traumatic pediatric lower extremity defects was concluded to be a safe and reliable intervention. Within the podiatric scope of practice, these techniques must be done in conjunction with a plastic surgeon. Acquiring the skills to be able to offer these types of flaps to our pediatric patients is truly priceless. The cosmetic result is enhanced by coverage when fascia is transferred. More importantly, the functional result is optimized by equal local pressure distribution in transferring similar size and thickness of tissue to cover large defects. The alternative would be secondary intention healing with negative pressure therapy, with or without hyperbaric oxygen therapy, resulting in a large cosmetic and functional defect. This study offered the most patients to date within the topic, demonstrating a low complication rate for flap coverage of these defects in children with no donor site morbidity. The flap success rate was 95%, offering a tool for children that would greatly benefit from flap coverage after lower extremity trauma. Flaps to treat traumatic defects may be considered in a similar way to adults, however the greatest difference is going to be considering short term functional outcome in the pediatric population in addition to, like adults, the long term functional outcomes. Fasciocutaneous flaps can decrease the development of functional contractures, which is important to consider especially in the pediatric population. For children, these reconstructive techniques can provide quite a rewarding outcome. 

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