Long-term follow-up of a severely traumatized leg treated with ipsilateral fracture-united fibular transfer in a patient with amputation of the contralateral leg: a case report

Extensive bone loss associated with severe vascular injury remains a challenge for lower extremity reconstruction. The fibular free flap has been utilized for many decades to reconstruct long-segment tibial defects. We present an unusual scenario of unilateral weight-bearing, wherein we salvaged the sole lower extremity by transfer of the fractured ipsilateral fibula and a bipedicled skin flap. A 38-year-old man sustained a severe crush injury in the right leg with loss of circulation. His left lower leg had a soft tissue defect measuring 20×15 cm with an exposed comminuted fracture and a 17-cm tibial defect, along with a segmental fracture of the fibula. Subsequently, we reconstructed the tibial defect by transferring a 17-cm-long section of the ipsilateral fibula. We covered the soft tissue defect with a bipedicled skin flap. The patient eventually began to ambulate independently after surgery.

2-Octyl Cyanoacrylate Glue Application on Split-Thickness Skin Graft for Lower Extremity Reconstruction

A split-thickness skin graft (STSG) is a very effective method for reconstructing skin defects in the lower extremities; however, suturing all graft margins during surgery is time-consuming. As an alternative, 2-octyl cyanoacrylate glue attaches the epidermal layer of an STSG to normal skin and functions like a suture. In this study, we assessed 2-octyl cyanoacrylate glue as a time-saving step in STSG procedures. We reviewed the charts of 87 patients who underwent STSG between May 2018 and August 2020. For the 10 patients who consented to the STSG procedure with 2-octyl cyanoacrylate glue, we evaluated the treatment site for complications and engraftment every 2 days for 14 days. The STSGs were successfully engrafted in all cases. Seroma, hematoma, wound dehiscence, or infection were not documented. No additional revision surgery was required. The use of 2-octyl cyanoacrylate glue in STSG margin fixation was safe, effective, convenient, and time-saving. This study found 2-octyl cyanoacrylate glue a good option for lower extremity skin defect reconstruction.

Reconstruction of Lower Extremity Necrotizing Fasciitis with Tibialis Anterior Musculofascial Flap and Skin Graft: A Case Report

Necrotizing fasciitis of the lower extremities results in large tissue defects, and most cases require reconstruction using skin grafts or flaps. We describe a 61-year-old man who developed necrotizing fasciitis of the right lower leg and septic shock, following a traumatic injury to his leg. Wound culture yielded methicillin-resistant Staphylococcus aureus. Extensive debridement was performed four times along with the use of appropriate antibiotics. After 2 weeks, physical examination showed an open wound (approximately 30×20 cm in size) with partial tibial bone exposure. Subsequently, the patient underwent successful reconstruction using a tibialis anterior musculofascial flap and split-thickness skin grafting. The tibialis anterior muscle was bihalved and pivoted to cover the exposed bone surface. The patient was without pain and was able to successfully perform daily activities at the 15-month follow-up. This case report highlights the utility of a bihalved tibialis anterior musculofascial flap for lower extremity reconstruction, particularly in patients for whom free flap transfers are unviable.

The Assessment of Postoperative Patency and Flow Pattern of Twisted Vascular Pedicle in Propeller Perforator Flaps in Lower Extremities Reconstruction

Background The propeller perforator flap is a variant of perforator flaps in which complete skeletonization of the perforator with venae commitantes is done to transfer the islanded flap on its pedicle with up to 180 degrees of twisting that predispose to its gradual occlusion by time. These flaps have been recently advocated for lower extremity reconstruction. However, reconstruction of the lower extremity especially in the distal third of the leg quite often involves multistage procedures that might necessitate flap re-elevation and little knowledge is available about postoperative patency of these flaps. Aim of the work The aim of this study is to assess the postoperative patency and flow pattern in twisted vascular pedicle of propeller perforator flaps used in lower extremity reconstruction. Materials and methods A Prospective study was conducted on 15 patients 18 years or older of both genders undergoing lower extremity soft tissue reconstruction by propeller perforator flaps rotated from 90 to 180 degrees at Ain Shams University Hospitals and Nasser Institute between 1st February and 31th December 2019. With exclusion of smoking, peripheral vascular diseases and diabetes mellitus, each patient was evaluated preoperatively in regards to age, gender, comorbidities, bacterial contamination or infection, cause of tissue loss. The flap size, source vessel, arc of rotation, donor site closure was analyzed. The flow pattern was evaluated by handheld Doppler device and used as a control for the study. Postoperatively, the same handheld Doppler device was used to localize the vascular pedicle, evaluate its patency and assess the flow pattern at a minimum follow up period of 3 months postoperatively in all patients. Results The mean age of the fifteen patients included was 35.3 years old. Six patients lost tissue was caused by unstable scar, while post-traumatic in the remaining. Preoperatively, four patients had osteomyelitis and four had wound infection. The rest of patients did not report any infection. Eight out of fifteen patients used perforators from peroneal vessel source, while seven patients used posterior tibial artery source. Forty percent of included participants had a 180 degrees arc of rotation, while 26.7% of participants had an arc rotation angle of 120 degrees, and 33.3% had 90 degrees. Five patients had early post-operative congestion that improved by conservative methods without de-rotation of the flap, one patient had skin graft loss over the donor site of the flap, and another patient suffered in addition to skin graft loss distal congestion leading to superficial skin necrosis. Eight patients had no complications. All patients had patent vessels with biphasic flow pattern postoperatively at a minimum of 3 months postoperatively. Conclusion The perforator propeller flaps are safe, reliable procedures and are considered as an ideal option in reconstructing small-medium defects of the middle and distal third of the leg providing similar skin texture with low rate of vascular obstruction. The present study documented patent vascular pedicle of propeller perforator flaps at three months postoperatively.

3-D generated anatomic custom talar cement spacers: case reports, technical tips and literature review

Background With today’s expanding use of total ankle arthroplasty, the ever-present trauma patient, and patients with uncontrolled comorbid conditions, surgeons face significant challenges for lower extremity reconstruction. These patients highlight some of those who may present with unique anatomy, bone loss, infection, and various other local and systemic factors that affect treatment options for successful outcomes. Three dimensional (3-D) printing for medical devices is allowing for new and customized ways to meet patient and surgeon goals of limb salvage and reconstruction. Case presentations While the majority of 3-D printing is done for the purpose of implantation, we present a technical tip for designing a 3-D printed mold from which to create an antibiotic cement spacer for implantation. With two case illustrations including a talus fracture nonunion and infected subtalar arthrodesis nonunion, we describe the process of patient selection, implant design, fabrication, and implantation of a custom molded antibiotic cement talus. Discussion Case illustrations present two successful limb salvage patients while giving a thorough explanation of our technique, learned tips and tricks. This applied technology builds on prior use of antibiotic cement in limb salvage of the lower extremity, most of which are joint sacrificing. 3-D printing the mold for an anatomic talus cement spacer results in a joint sparing limb salvage solution. Innovative 3-D printing technology is merged with current, pertinent literature regarding antibiotic cement to offer surgeons expanded options for temporary or definitive reconstructive techniques in some of the most challenging patients.