Soft-tissue flap coverage maximizes limb salvage after allograft bone extremity reconstruction

Limb salvage after extremity tumor ablation may include the use of allograft bone. The primary complication of this method is infection of the allograft, which can lead to limb loss in up to 50 percent of cases. The purpose of this study is to evaluate the efficacy of primary muscle flap coverage in the setting of allograft bone limb salvage surgery. This study is a prospective review of all patients with flap coverage of extremity allografts over the 10-year period 1991 to 2001. There were 20 patients (11 male and nine female patients) with an average age of 28 years (range, 6 to 72 years). Flap coverage was primary in 16 patients and delayed in four. Delayed coverage was performed for failed wounds that did not have a primary soft-tissue flap. Pathologic findings included osteosarcoma in nine patients, Ewing sarcoma in five patients, malignant fibrohistiocytoma in two patients, chondrosarcoma in two patients, synovial sarcoma in one patient, and leiomyosarcoma in one patient. Allograft reconstruction was performed for the upper extremity in 12 patients and for the lower extremity in eight patients. Flap reconstruction was accomplished with 20 pedicle flaps in 17 patients (latissimus dorsi, 12; gastrocnemius, four; soleus, three; and fasciocutaneous flap, one) and four free flaps (rectus abdominis, three; latissimus dorsi, one) in four patients. All pedicled flaps survived. There was one flap failure in the entire series, which was a free rectus abdominis flap. This case resulted in the only limb loss noted. The follow-up period ranged from 1 to 50 months (average, 12.35 months). At the time of final follow-up, three patients were dead of disease and 17 were alive with intact extremities. The overall limb salvage rate in the setting of bone allograft and soft-tissue flap coverage was 95 percent (19 of 20). Reoperation for bone-related complications was required in 50 percent (two of four) of cases receiving delayed flap coverage compared with 19 percent (three of 16) of patients with primary flap coverage (statistically not significant). The results of this study support the use of soft-tissue flap coverage for allograft limb reconstruction. In this series, no limb was lost in the setting of a viable flap. Reoperation was markedly reduced in the setting of primary flap coverage. Pedicled or microvascular transfer of well-vascularized muscle can be used to wrap the allograft and minimize devastating wound complications potentially leading to loss of allograft and limb.     

Upper limb salvage using a free radial forearm flap

Microsurgical transfer of a skin flap salvaged from a nonreplantable upper extremity that would otherwise be discarded may provide essential soft-tissue coverage of the amputation stump, so maintaining a functional range of motion in the elbow joint. A radial forearm free flap measuring 24 cm long by 9 cm wide was salvaged from the degloved forearm skin of a patient who sustained a proximal forearm amputation that was considered unsuitable for replantation. This allowed coverage of the proximal radius and ulna, preservation of a functional elbow joint, and successful fitting of a below-elbow prosthesis.     

Importance of additional microvascular anastomosis in esophageal reconstruction after salvage esophagectomy

Esophageal reconstruction after salvage esophagectomy in patients who have undergone curative-intent chemoradiotherapy for esophageal cancer is associated with a significant risk of perioperative morbidity and mortality. In particular, anastomotic leakage can cause severe and potentially fatal complications, including mediastinitis and pneumonia. The authors performed esophageal reconstruction with a pedicled right colon graft after salvage esophagectomy in eight patients. To decrease the rate of anastomotic leakage, the authors performed an additional microvascular anastomosis at the distal end of the graft. The distal stumps of the ileocolic artery and vein were anastomosed to the cervical vessels. After surgery, aspiration pneumonia and localized wound infection were observed in two patients each, but slight anastomotic leakage was observed in only one patient. Postoperative swallowing function was satisfactory in all patients. Although the incidence of anastomotic leakage is reportedly high, the authors observed anastomotic leakage in only one of eight patients. The authors believe that additional microvascular anastomosis helps prevent anastomotic leakage, especially in patients who have undergone salvage esophagectomy after curative chemoradiotherapy.     

Electromyographic assessment of Gait function following limb salvage procedures for bone sarcoma

Bone sarcomas are the fourth most common cancer in individuals under 25 years of age. Limb salvage procedures have become increasingly popular for the treatment of osteosarcomas as they have functional and physiological benefits over traditional amputative procedures. The purpose of this study was to assess locomotor patterns post lower limb salvage surgery via electromyographic and energetic measurement techniques on a group of intra-articular knee osteosarcoma patients greater than one year post surgery. A retrospective outcome study was undertaken on 20 limb salvage patients (10♀, 10♂) recruited from the Queensland Bone Tumour Registry. Results showed prolonged activation of rectus femoris and prolonged co-contraction of the rectus femoris and hamstring muscles (p > 0.05) in the affected limb of the limb salvage group compared to a control group. Prolonged rectus femoris activation and co-contraction was also evident in the unaffected lower limb suggesting alterations in gait programming within higher neuronal centres. The results are important for the development of rehabilitation programs as they suggest an overall reprogramming of the gait pattern, thereby limiting the impact of conventional strength and stretching interventions.     

Difficult reconstruction of an extensive injury in the lower extremity with a large cross-leg microvascular composite-tissue flap containing fibula

In the absence of proper recipient vessels, a large microvascular composite-tissue flap was transferred successfully for reconstruction of a leg with an extensive crush injury. This was accomplished by using vessels of the normal leg. The microvascular flap containing skin, muscle, and 15 cm of fibula survived well after division of the pedicle. To achieve good bone healing, the leg was protected by a brace while gradually increasing weight bearing. The functional result is satisfactory.     

Intraoral reconstruction with a microvascular peritoneal flap

The microvascular peritoneal flap offers a new reconstructive option for closure of intraoral defects. The flap is easy to raise, and donor-site morbidity is low. Unlike fascial flaps, in which the raw surface may take weeks to "mucosalize," the peritoneal surface heals primarily. Finally, the rectus muscle effectively covers all forms of mandibular reconstruction, and the reliable skin paddle makes possible the closure of substantial cutaneous defects.     

Upper limb loadings of gait with crutches

Long-term crutch users and patients with arthritis are particularly susceptible to upper limb joint degeneration during aided gait. The function of the walking aid for stability, support, and restraint/propulsion must be optimized with the upper limb loadings caused by the aids. Post-operative total hip replacement (THR) patients, tibial fracture, and paraplegic subjects using sticks and elbow crutches were analyzed in this study. Elbow and shoulder joint centers and aid orientations were monitored simultaneously in three dimensions and combined with aid forces to determine upper limb moment loadings. Three loading effects were observed: tendency for the aids to cause 1) the elbow to flex and shoulder to extend, 2) the elbow and shoulder to extend, and 3) the shoulder to abduct. Moment values of up to 0.10 Nm per body weight (BW) causing the shoulder to extend were measured, i.e., of similar magnitude to the moments at the hip in unaided gait. A modification of the elbow crutch, designed to improve medial-lateral stability, was unsuccessful in use due to wrist instability. This reinforced the requirement that crutch designs integrate the aid's function in gait with the ability of the upper limb joints to balance the applied loads.     

Improved salvage of complicated microvascular transplants monitored with quantitative fluorometry.

Quantitative fluorometry has been used to monitor circulation in transplanted toes and cutaneous flaps in our unit since 1982. Analysis of 177 uncomplicated transplants monitored by quantitative fluorometry shows that this technique has low false indication rates for arterial occlusion (0.6 percent of patients) and venous occlusion (6.2 percent of patients). None of these patients was reexplored because of a false monitor reading, and except for single abnormal sequences, monitoring appropriately indicated intact circulation throughout the postoperative period. Quantitative fluorometry has correctly indicated vascular complications in 21 (91.3 percent) of 23 transplants over an 8-year period. The salvage rate (85.7 percent) of the fluorescein-monitored reexplored transplants was significantly higher than the salvage rates of similar reexplored transplants not monitored with fluorescein and of reexplored muscle flaps (which cannot be monitored with the fluorometer used at this unit). These clinical data indicate that quantitative fluorometry is a valid and useful postoperative monitor for transplanted toes and cutaneous flaps.     

Free-tissue transfer for limb salvage in Purpura fulminans

A series of 13 patients is described to demonstrate the experience of the authors with free-tissue transfer for limb salvage in patients with purpura fulminans. A total of seven free-flap procedures were performed, with a loss of flap in one patient. The flaps were used for lower-extremity salvage in six patients and for upper-extremity salvage in one. Purpura fulminans is a devastating illness caused by endotoxin-producing bacteria such as meningococcus and pneumococcus. Clotting derangements and systemic vasculitis often lead to widespread tissue necrosis in the extremities. Local tissue is usually not available to cover vital structures in these complex wounds. In these situations, free-tissue transfer is necessary to achieve limb salvage. Microsurgical reconstruction in patients with purpura fulminans is a formidable challenge. Because of high platelet counts and systemic vasculitis, successful microvascular anastomosis is difficult. Abnormally high platelet counts persist well into the subacute and chronic phases of the illness. Pretreatment with antiplatelet agents before microvascular surgery may be beneficial. The systemic nature of the vascular injury does not permit microvascular anastomosis to be performed outside the "zone of injury." Extensive vascular exposure, even at a great distance from the wound, does not reveal a disease-free vessel. The friable intima is difficult to manage with a standard end-to-side anastomosis, but conversion to end-to-end anastomosis may salvage free-tissue transfers in cases in which intimal damage is too severe to sustain a patent anastomosis. Patients often have peripheral neuropathies caused by the underlying disease; however, this resolves with time and is not a contraindication to limb salvage.