Sie können Operatoren mit Ihrer Suchanfrage kombinieren, um diese noch präziser einzugrenzen. Klicken Sie auf den Suchoperator, um eine Erklärung seiner Funktionsweise anzuzeigen.
Findet Dokumente, in denen beide Begriffe in beliebiger Reihenfolge innerhalb von maximal n Worten zueinander stehen. Empfehlung: Wählen Sie zwischen 15 und 30 als maximale Wortanzahl (z.B. NEAR(hybrid, antrieb, 20)).
Findet Dokumente, in denen der Begriff in Wortvarianten vorkommt, wobei diese VOR, HINTER oder VOR und HINTER dem Suchbegriff anschließen können (z.B., leichtbau*, *leichtbau, *leichtbau*).
Indications for reconstruction of the lower extremity range from posttraumatic defects to infections and tumors. Despite advancements in plastic surgery, flap surgery still poses a challenge. In this retrospective study local flap surgeries and microsurgical free flaps were assessed. Postoperative complications and limb preservation were analyzed.
Methods
This retrospective study included 187 patients who were treated at a university-affiliated tertiary care hospital. Defects were of traumatic (29.4%) and nontraumatic (70.6%) etiology. Limb preservation was determined during a 12-month follow-up period. Patient characteristics, flap selection and postoperative flap-associated complications were collected.
Results
The patient population included 107 men (57.2%) and 80 women (42.8%), 104 (55.6%) free flaps and 83 (44.4%) local flaps were performed. In the free flap group latissimus dorsi and gracilis flaps were most commonly performed. The most common surgeries in the local flap group were gastrocnemius, soleus and plantaris medialis muscle flaps. The overall limb preservation rate was 92.5% with no significant difference between the two groups.
Conclusion
Both methods enable reconstruction of complex lower extremity wounds and enable limb preservation in many cases. The type of flap is selected based on the anatomical location of the defect, defect size and patient factors.
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Introduction
Plastic surgery plays a pivotal role in the field of lower limb reconstruction, encompassing a wide array of techniques aimed at restoring function, esthetics and quality of life for patients with various lower limb deformities and injuries [1, 2].
The feet play a crucial role in supporting the body’s weight and are essential for basic activities like walking, standing and running. Individuals with soft tissue deficiencies encounter difficulties in their daily tasks, while extremity amputations significantly impair function [3]. Reconstructive surgeons face unique challenges when dealing with tissue defects in the lower extremities. Success in reconstructive procedures hinges on a thorough understanding of anatomy, including muscle function and positioning in relation to surrounding structures. Planning for defect coverage relies on considerations, such as muscle size, vascular supply and skin area [4].
Anzeige
When discussing potential causes for lower extremity reconstruction, several factors come into play. Local issues such as pressure, infections and radiotherapy are common culprits. Metabolic factors, such as malnutrition and diabetes mellitus can also contribute [5]. Vascular problems, including peripheral artery occlusive disease, venous insufficiency and ulcers, may necessitate reconstruction. Dermatological conditions, such as squamous cell carcinoma, basal cell carcinoma and pyoderma gangrenosum can also require intervention. Iatrogenic causes, such as wounds resulting from steroid therapy or cytostatic therapy, are another consideration. Systemic factors, such as malignant processes, immunosuppression and hemodynamic disturbances may also play a role. Additionally, nicotine abuse, alcoholism, obesity, immobility, advanced age and trauma are potential contributing factors [6, 7].
Local flaps
Understanding the vascular anatomy of flaps enables the relocation of local flaps to the required site, enabling the creation of the desired form and function [8]. For local flaps, lower extremity defect reconstruction should replace similar tissues and minimize donor site complications. Achieving a satisfactory esthetic appearance and functional outcome is important [3]. Local flap reconstructions, when applicable and appropriate for the size of the defect, have been linked to fewer reoperations and shorter hospital stays compared to free flap reconstruction [9]. Local flaps present a dependable choice for addressing defects in the middle and distal regions of the lower extremities. This reconstruction method is suitable for small to medium-sized defects and can be safely utilized even in patients with comorbidities, such as diabetes mellitus and peripheral arterial occlusive disease, which can hinder wound healing [10]. Figure 1 illustrates a dorsalis pedis local flap of a male patient with a diabetic ulcer.
Fig. 1
a Preoperative markings of the dorsalis pedis flap, b preoperative picture of the ulcer, c intraoperative flap plasty and d final operation situs
In the lower extremity, the scarcity of soft tissues and compromised blood flow can pose challenges for reconstructive surgery, often necessitating microsurgical free flap reconstruction as the sole recourse for preserving the limb [2, 11]. Preserving the lower extremities enhances survival rates among multimorbid patients afflicted with nontraumatic defects [12]. Performing limb-sparing procedures alongside soft tissue reconstruction following oncological surgery should not be restricted solely to patients with curative intentions. Even patients in a palliative stage of the disease can experience pain relief and enhancements in quality of life through such surgical interventions [13]. An indicator for the likelihood of requiring secondary wound closure surgery is the presence of diabetes as a comorbidity [14].
The selection of the suitable flap considers factors such as the size of the defect, the patient’s overall health condition and the required tissue characteristics. Additionally, it is essential to confirm the presence of an appropriate connecting vessel in the vicinity of the defect. Particularly in extremities, angiography should be performed beforehand to assess the condition of the connecting vessels prior to surgery [15].
Anzeige
Drawing from Godina’s research, in cases of traumatic defects, early free tissue transfer has been linked to fewer complications compared to delayed reconstruction and is the optimal approach. The safe window for early soft tissue coverage can be extended to within 10 days of the injury. Various factors determine the time of reconstruction, such as the patient’s overall health and the contamination level of the defect [16].
The aim of this retrospective study was to assess the differences in reconstruction of the lower extremity by local flaps or free tissue transfer in traumatic and nontraumatic defects regarding limb preservation 12 months postoperatively. Postoperative morbidity and flap-associated complications were analyzed.
Material and methods
This retrospective investigation examined differences in lower extremity reconstruction using either local flaps or free tissue transfer for traumatic and nontraumatic defects, focusing on limb preservation and postoperative morbidity as well as flap-related complications, based on the chosen reconstructive treatment approach.
Approval for the study protocol was obtained from the Ethics Committee of the Medical University of Vienna (EK-number 1726/2019). Data for the study were extracted from patients’ medical records and operative notes.
Patients aged 18 years and above were included in this study, while pediatric patients were excluded. Patients with incomplete records or those who underwent extremity reconstructions at a different hospital were also excluded from the analysis.
A total of 187 patients with distal lower extremity defects underwent surgical reconstruction using either local or free flaps and were included in this retrospective study. Of the patients 104 received treatment involving free flap procedures, while 83 patients underwent local flap reconstruction.
The patient groups were divided by surgical reconstruction method. Patient demographics, the etiology and anatomical location of the defect requiring reconstruction and comorbidities were assessed. Postoperative follow-up times were analyzed. The main endpoint in both groups was limb preservation and complications during the follow-up period of 12 months.
To assess the outcome of the flap after surgery, flap-related complications were identified. Postoperative complications were categorized into minor and severe complications. Severe complications required surgical revision, whereas minor complications were resolved through conservative measures.
Anzeige
Statistical analysis
Statistical analysis was conducted using SPSS software (version 24.0 for Windows, IBM SPSS Statistics, Inc, Chicago, IL, USA). Categorical data were presented as absolute frequencies and percentages, both for the entire study population and for each treatment group (local flaps and free flaps) separately. Bar charts were utilized to illustrate the findings. For metric variables, tables were used to display the mean, standard deviation, median, minimum and maximum values, along with the number of valid observations for each variable. Normality was assessed using the Shapiro–Wilk test prior to analysis. Parametric and nonparametric tests were used for group comparisons.
Results
The 187 patients included in this study were categorized into 2 groups based on the surgical treatment. One group received treatment with a free tissue transfer (n = 104), while the other group underwent local flap surgery (n = 83).
Overall, 104 free tissue transfers were performed, involving 62 (59.6%) male and 42 (40.4%) female patients. The local flap group consisted of 84 patients, comprising 46 (54.7%) men and 38 (45.2%) women.
The average age of all patients was 52.27 years (SD ±17.68 years), ranging from 19–87 years. In the free tissue transfer group, the average age was 49.0 years (SD ±16.6 years), with a range of 19–87 years. The local flap group had an average age of 56.4 years (SD ±18.1 years; range: 20–87 years). A significant age difference was observed between the two groups (p = 0.004), as the average age of patients treated with free flap reconstruction was significantly younger.
Anzeige
The distribution of local flap types can be found in Table 1. The most commonly used local flaps were the gastrocnemius medialis flap (13.9%), the soleus flap (7.5%) and the gastrocnemius lateralis flap (5.9%).
Table 1
Local flap used to reconstruct lower extremity defects (n = 83)
Local flap type
n
Percentage
Gastrocnemius medialis
26
13.9
Soleus
14
7.5
Gastrocnemius lateralis
11
5.9
Plantaris medialis
7
3.7
Suralis
6
3.2
Random pattern local flap
5
2.7
Hemisoleus
4
2.1
Limberg flap
3
1.6
Dorsalis pedis
3
1.6
Extensor hallucis longus
2
1.1
Plantar
2
1.1
In the free tissue transfer group, the most performed flap was the latissimus dorsi (28.9%) followed by the gracilis flap (19.8%), shown in Table 2.
Table 2
Free flaps used for reconstruction of lower extremity defects (n = 104) TRAM transverse rectus abdominis muscle flap
Free flap type
n
Percentage
Latissimus dorsi
54
28.9
Gracilis
37
19.8
Fibula
9
4.8
Serratus anterior
2
1.1
TRAM
1
0.5
Random pattern flap
1
0.5
The most common etiologies of the lower extremity defects were trauma (29.3%), tumor genesis (25.0%) and postoperative defects (14.6%). This study included patients with defects in different anatomical regions of the distal lower extremity. Among these, the most common site was the knee (19%), followed by the middle third of the lower leg (17%) and the distal third of the lower leg (14%). Table 3 provides a detailed overview of the anatomical locations where free tissue transfers were performed.
Table 3
Anatomical location and performed free flap. (n = 104). TRAM transverse rectus abdominis muscle flap
Location
Free flap
n
Knee
Latissimus dorsi
16
Proximal 1/3 of the lower leg
Fibula
2
Latissimus dorsi
2
Gracilis
1
Serratus anterior
1
Distal 1/3 of the lower leg
Fibula
3
Latissimus dorsi
8
Gracilis
10
Heel
Latissimus dorsi
4
Gracilis
5
Serratus anterior
1
Random pattern flap
1
Lateral foot
Gracilis
6
Latissimus dorsi
3
Achilles tendon
Latissimus dorsi
1
Lower 2/3 of the lower leg
Latissimus dorsi
1
Gracilis
2
Lateral malleolus
Latissimus dorsi
2
Gracilis
5
Dorsum of the foot
Fibula
4
Latissimus dorsi
6
Gracilis
6
TRAM
1
Middle 1/3 of the lower leg
Latissimus dorsi
10
Gracilis
1
Malleolus medialis
Latissimus dorsi
1
Gracilis
1
Postoperative morbidity and flap-associated complications were analyzed by a reconstructive treatment concept. In the local flap group, the extremity could be preserved in 98.8%. In the group undergoing free tissue transfer, the rate of lower limb loss was 9.6%. Postoperatively, the overall survival rate of extremities was 97.2%. There was no statistically significant difference between the local and the free flap group.
Anzeige
Group comparisons showed no significant variation in flap loss rates based on the patients’ ages. Complications related to flaps in the local flap group requiring surgical revisions included 8 cases of complete flap loss and 3 hematoma evacuations. Partial flap necrosis occurred in 4 patients. The majority of patients (86.7%) experienced no severe complications.
In the free flap group, complications related to flaps included 19 cases of flap loss, 10 hematoma evacuations, 3 instances of venous thrombosis, and 3 instances of arterial thrombosis (21.9%).
The age of the patients did not significantly affect the lower leg amputation rate after 1 month or 12 months postoperative follow-up. Additionally, data on comorbidities were collected for patients in the local flap group. Of the patients 17 (20.5%) reported having comorbidities, such as peripheral artery occlusive disease (47.1%), diabetes (23.5%) and obesity (23.5%).
In the free flap group, 14 patients presented with comorbidities. The most common comorbidities were diabetes (64.3%), peripheral artery occlusive disease (21.4%), and obesity (14.3%). The Pearson χ2-test indicated no significant difference in the comorbidity rates between the two groups.
There was no significant difference in lower extremity reconstruction outcomes between local flaps and free flaps, whether for traumatic or nontraumatic defects, with respect to limb preservation at 12 months postoperatively. Additionally, morbidity and complications associated with the flaps were not significantly different between the two groups. Overall, our findings suggest that using either a free flap or a local flap yields similar outcomes in terms of limb preservation at 12 months postsurgery. Similarly, postoperative morbidity and complications were comparable across both groups.
Discussion
This study provides a comprehensive analysis of reconstructive outcomes for lower extremity defects using local flaps and free tissue transfers. The findings highlight that both surgical approaches achieve comparable rates of limb preservation and postoperative morbidity at 12 months. While free tissue transfers were predominantly used for larger more distal defects, local flaps remained effective for smaller and proximal defects, reflecting the tailored application of each technique based on defect characteristics and patient factors. The literature indicates that similar causes are reported for defects in the lower extremities [17‐20].
Flap selection for the distal lower extremity is determined by the size and anatomical location of the tissue defect. The choice of flap also considers donor site morbidity and aims to optimize the functionality of the lower extremity [18, 21, 22].
In many cases lower extremity defects go hand in hand with multiple comorbidities of the patients that can impact healing outcomes. Therefore, careful consideration of reconstructive options tailored to functional goals and risk factors is essential [23, 24].
The most frequently treated defect locations in this study were the knee region, the lateral malleolus and the proximal tibia.
The dimensions of the defect, vascular status of the lower extremity and patients’ comorbidities were described to determine treatment algorithms similar to those found in our study [22]. Consistent reconstructive results in larger defects can be achieved with latissimus and gracilis flaps as reported in previous studies [25]. One of the most common local flaps for the knee region and the proximal third of the lower leg was the gastrocnemius muscle flaps, which was consistent with the literature [26].
The progressive understanding of flap perfusion and design has elevated the reconstructive options in local and free flap applications and at the same time minimizing donor site morbidity [27, 28].
Free flap reconstruction was particularly advantageous for covering larger wounds in the distal lower extremity without additional trauma to local donor sites. It has become a pivotal step in the reconstructive ladder, with improved safety and efficacy supported by advancements in microsurgery [29, 30].
In this study the most commonly used free flaps were the latissimus dorsi and gracilis muscle flaps, recognized for their reliability in microsurgical practice and both often described as the ”workhorse“ of plastic and reconstructive surgery [31]. Free tissue transfer has demonstrated effectiveness in both traumatic and nontraumatic cases of lower extremity reconstruction, with flap selection influenced by patient-specific factors, timing of reconstruction, leg vascularity and defect characteristics [32, 33].
While both local and free flap reconstructions can contribute to extremity preservation, distal lower extremity cases are still associated with higher rates of postoperative complications [1, 34]. Postoperative complications are manageable with a high flap survival rate [6].
Limitations in this study are given through the retrospective character, the limited patient numbers and the limited types of flaps included in the analysis. Perforator flaps were not analyzed in this study due to the earlier period of some surgeries in our dataset, when the technique was less commonly employed.
Future studies should address the functional outcomes after lower extremity reconstruction, patient satisfaction and effects on quality of life. Furthermore, the postoperative setting should be analyzed in greater detail, like the self-efficacy of the patient.
Additionally, as these data were collected from a single institution with multiple reconstructive surgeons, variations in our patient population and surgical skills may limit the findings.
Conclusion
This study provides valuable insights into the outcomes of free tissue transfers and local flap surgeries in a cohort of 187 patients. The findings highlight significant differences in the age distribution between the two groups, with younger patients predominantly undergoing free tissue transfers. Despite this, age did not significantly impact critical postoperative outcomes, including flap loss rates or limb preservation rates.
Overall, both surgical techniques demonstrated efficacy in reconstructive plastic surgery, with outcomes largely independent of patient age and comorbidity rates. These findings underline the importance of individualized treatment planning, taking patient-specific factors and the complexity of the surgical needs into consideration. Further longitudinal studies may help clarify the long-term implications of these surgical approaches and optimize patient outcomes.
Acknowledgements
We thank the multidisciplinary team involved in patient care and for their contribution to this study.
Declarations
Conflict of interest
A. Fast, E. Placheta-Györi, T. Rath and C. Radtke declare that they have no competing interests. This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Ethical standards
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975. Approval for the study protocol was obtained from the Ethics Committee of the Medical University of Vienna (EK-number 1726/2019). Informed consent was obtained from all patients for being included in the study.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Baumeister SP, Spierer R, Erdmann D, et al. A realistic complication analysis of 70 Sural artery flaps in a multimorbid patient group. Plast Reconstr Surg. 2003;112(1):129–40.CrossRefPubMed
2.
Fischer J, Wink J, Nelson J, et al. A retrospective review of outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg. 2013;29(06):407–16.CrossRefPubMed
3.
AlMugaren FM, Pak CJ, Suh HP, et al. Best local flaps for lower extremity reconstruction. Plast Reconstr Surg Glob Open. 2020;8(4):e2774.CrossRefPubMedPubMedCentral
4.
Berger A, Liebau J. Defektdeckung im fußbereich. In: Berger A, Hierner R, editors. Plastische chirurgie. Berlin, Heidelberg: Springer Berlin Heidelberg; 2009. pp. 617–44. https://doi.org/10.1007/978-3-540-68814-3_17.CrossRef
5.
Singh N. Preventing foot ulcers in patients with diabetes. JAMA. 2005;293(2):217.CrossRefPubMed
6.
Xiong L, Gazyakan E, Wähmann M, et al. Microsurgical reconstruction for post—traumatic defects of lower leg in the elderly: a comparative study. Injury. 2016;47(11):2558–64.CrossRefPubMed
7.
Song P, Pu LLQ. The Soleus muscle flap: an overview of its clinical applications for lower extremity reconstruction. Ann Plast Surg. 2018;81(6S):S109–S16.CrossRefPubMed
8.
Hirtler L, Lübbers A, Rath C. Vascular coverage of the anterior knee region—an anatomical study. Kaibogaku Zasshi. 2019;235(2):289–98.
9.
Kozak GM, Hsu JY, Broach RB, et al. Comparative effectiveness analysis of complex lower extremity reconstruction: outcomes and costs for biologically based, local tissue rearrangement, and free flap reconstruction. Plast Reconstr Surg. 2020;145(3):608e–16e.CrossRefPubMedPubMedCentral
10.
Uyar İ. Reconstruction option in complex lower extremity defects where microsurgical repair is not possible: randomized bipedicled flaps. Ulus travma acil cerrahi derg. 2023. https://jag.journalagent.com/travma/pdfs/UTD_29_8_877_882.pdf. Accessed 26 Apr 2024.
11.
Culliford AT, Spector J, Blank A, et al. The fate of lower extremities with failed free flaps: a single institution’s experience over 25 years. Ann Plast Surg. 2007;59(1):18–22.CrossRefPubMed
12.
Kristensen MT, Holm G, Kirketerp-Moller K, et al. Very low survival rates after non-traumatic lower limb amputation in a consecutive series: what to do? Interact CardioVasc Thorac Surg. 2012;14(5):543–7.CrossRefPubMedPubMedCentral
Wong FK, Christensen JM, Meulendijks MZ, et al. Secondary surgery after lower extremity free flap reconstruction. Plast Reconstr Surg. 2023;152(5):1118–24.CrossRefPubMed
15.
Saint-Cyr M, Schaverien M, Arbique G, et al. Three- and four-dimensional computed tomographic angiography and venography for the investigation of the vascular anatomy and perfusion of perforator flaps. Plast Reconstr Surg. 2008;121(3):772–80.CrossRefPubMed
16.
Lee ZH, Stranix JT, Rifkin WJ, et al. Timing of microsurgical reconstruction in lower extremity trauma: an update of the godina paradigm. Plast Reconstr Surg. 2019;144(3):759–67.CrossRefPubMed
17.
Angelini A, Tiengo C, Cerchiaro MC, et al. Ortho-oncoplastic surgery in foot and ankle: a narrative overview on reconstruction of soft-tissue defects after oncologic resections. Microsurgery. 2024;44(4):e31168.CrossRefPubMed
18.
Soltanian H, Garcia RM, Hollenbeck ST. Current concepts in lower extremity reconstruction. Plast Reconstr Surg. 2015;136(6):815e–29e.CrossRefPubMed
19.
Hollenbeck ST, Woo S, Komatsu I, et al. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg. 2010;125(3):924–34.CrossRefPubMed
20.
Bekara F, Herlin C, Somda S, et al. Free versus perforator-pedicled propeller flaps in lower extremity reconstruction: what is the safest coverage? A meta-analysis. Microsurgery. 2018;38(1):109–19.CrossRefPubMed
21.
Chi D, Raman S, Tawaklna K, et al. Free functional muscle transfer for lower extremity reconstruction. J Plast Reconstr Aesthetic Surg. 2023;86:288–99.CrossRef
22.
Goldsmith T, Ford B, Marsden N, et al. Soft tissue coverage of the ankle: an algorithm for appropriate flap selection and the experiences of a newly established major trauma network. Injury. 2023;54(10):110920.CrossRefPubMed
23.
Qian Y, Li G, Zang H, et al. A systematic review and meta-analysis of free-style flaps: risk analysis of complications. Plast Reconstr Surgery—global Open. 2018;6(2):e1651.CrossRef
24.
Györi E, Fast A, Resch A, et al. Reconstruction of traumatic and non-traumatic lower extremity defects with local or free flaps. Eur Surg. 2022;54(1):44–9.CrossRef
25.
Eom JS, Sun SH, Hong JP. Use of the upper medial thigh perforator flap (gracilis perforator flap) for lower extremity reconstruction. Plast Reconstr Surg. 2011;127(2):731–7.CrossRefPubMed
26.
Daigeler A, Drücke D, Tatar K, et al. The pedicled gastrocnemius muscle flap: a review of 218 cases. Plast Reconstr Surg. 2009;123(1):250–7.CrossRefPubMed
27.
Saint-Cyr M, Schaverien MV, Rohrich RJ. Perforator flaps: history, controversies, physiology, anatomy, and use in reconstruction. Plast Reconstr Surg. 2009;123(4):132e–45e.CrossRefPubMed
28.
Mohan AT, Sur YJ, Zhu L, et al. The concepts of propeller, perforator, keystone, and other local flaps and their role in the evolution of reconstruction. Plast Reconstr Surg. 2016;138(4):710e–29e.CrossRefPubMed
29.
Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg. 1981;67(2):177–87.CrossRefPubMed
30.
Mifsud M, Ferguson JY, Stubbs DA, et al. Simultaneous debridement, Ilizarov reconstruction and free muscle flaps in the management of complex tibial infection. J Bone Jt Infect. 2020;6(3):63–72.CrossRefPubMedPubMedCentral
31.
Godina M. Preferential use of end-to-side arterial anastomoses in free flap transfers. Plast Reconstr Surg. 1979;64(5):673–82.CrossRefPubMed
