Letter to the Editor
Posterior and anterior tibialis turn-over muscle flaps with primatrix for salvage of lower extremity after free-flap failure
Article first published online: 18 JUL 2012
Copyright © 2012 Wiley Periodicals, Inc.
Volume 33, Issue 1, pages 77–78, January 2013
How to Cite
Kosutic, D., Biraima, A.M., SEE, M. and James, M. (2013), Posterior and anterior tibialis turn-over muscle flaps with primatrix for salvage of lower extremity after free-flap failure. Microsurgery, 33: 77–78. doi: 10.1002/micr.22034
- Issue published online: 18 JAN 2013
- Article first published online: 18 JUL 2012
- Manuscript Accepted: 9 MAY 2012
- Manuscript Revised: 29 APR 2012
- Manuscript Received: 1 APR 2012
Large pretibial defects associated with exposed bone or an open fracture following high energy degloving injuries require reconstruction with microvascular-free tissue transfer. This is often the only option for limb salvage. Despite appropriate vessel selection and adherence to meticulous technique, flap failure rates continue to be much higher in lower extremity trauma than in other anatomical sites, reaching up to 10%, with more than 20% of amputations following a failed-free flap.1, 2 Increased rates of lower-extremity free-flap failures have been associated with high-energy trauma, thrombocytosis, and intimal damage, particularly for reconstructions performed between 3 days and 6 weeks after injury.3 Execution of a second-free flap to salvage the extremity following initial free-flap failure is beset by a particularly high-failure rate, reported as high as 42–50%.4 Under these circumstances, a viable alternative to salvage a lower extremity would be extremely useful.
In 1993, Lo et al.5 described the split anterior tibialis muscle flap for coverage of avulsion lower leg injuries with minor bony exposure. Since this first description, the anterior tibialis muscle flap has been reported to be a reliable reconstructive option for soft-tissue defects with exposed mid-shaft of tibia. However, to the best of our knowledge, there have been no reports on a combination of posterior and anterior tibialis muscle turn-over flaps. These flaps are based on both posterior and anterior tibial artery perforators for coverage of extensive soft tissue defects resulting in the full length and width of tibia exposed, to salvage a lower limb after primary free-flap failure.
We describe the case of a 42-year-old male with extensive degloving injury to his right-lower leg associated with a Gustillo IIIB undisplaced open ankle fracture and exposure of the entire length and width of the right tibia (Fig. 1a). This injury was sustained from a high-energy road traffic accident. The patient was transferred 6 days postinjury from another institution, and free-flap reconstruction using the latissimus dorsi muscle was performed 2 days later to provide coverage of his right-lower leg extensive defects. On the fourth postoperative day, venous thrombosis of the anastomosis occurred necessitating exploration in the operating theater. However, the flap was not salvageable and was completely debrided. Longitudinal split posterior tibialis and anterior tibialis muscle turn-over flaps were dissected in full length from the knee to the ankle joint, preserving all the perforators arising from the posterior and anterior tibial arteries. Both muscles were turned-over and sutured to each other over entire length and width of exposed tibia (Fig. 1b). The turn-over tibialis muscle flaps were covered with Primatrix™ Dermal Repair Scaffold (TEI Biosciences, Boston, MA) and a topical negative pressure dressing was applied for a week. Successful integration of the dermal scaffold into completely viable muscles was noted after a week (Fig. 1c) and split thickness skin grafting was performed. Healing was uneventful and the grafts were fully taken 5 days postoperatively. At the 4 month follow-up, the patient had stable and esthetically pleasing results with no functional impairment (Fig. 1d).
Posterior and anterior tibialis longitudinal split flaps can provide successful reconstruction of difficult large soft-tissue defects and should be considered as a valuable alternative for salvage of lower extremity after a free-flap failure.
- 1The fate of lower extremities with failed free flaps: A single institution's experience over 25 years. Ann Plast Surg 2007; 59: 18–22., , , , , .
- 2The fate of lower extremities with failed free flaps. Plast Reconstr Surg 1996t; 98: 834–840., , .
- 3Thrombocytosis after major lower extremity trauma: Mechanism and possible role in free flap failure. Ann Plast Surg 1996; 36: 489–494., , , , , , , , .
- 4The fate of the failed second-attempt free flap. Ann Plast Surg 2001; 47: 41–46..
- 5Use of split anterior tibial muscle flap in treating avulsion injury of leg associated with tibia exposure. Ann Plast Surg 1993; 31: 112–116., , , .
Damir Kosutic M.D., Ph.D.*, A.M. Biraima M.D.*, Marlene See M.R.C.S., M.Sc.*, Matt James F.R.C.S. (PLAST)*, * Department of Plastic Surgery, Guy's and St Thomas's Hospital London, UK.