Free tissue transfer for lower extremity trauma in the pediatric patient

Aim:The utilization of free-tissue transfer secondary to traumatic lower extremity defects in the pediatric population is scarcely described.Factors include microsurgeon inexperience,inadequate center resources,and fear of historically described poor surgical outcomes.The aim of this study is to investigate more recent articles describing free-flap microsurgical reconstruction for these defects.Methods:A systematic review of the literature was conducted through the online databases PubMed,Embase,and Web of Science,examining for articles with at least 20 subjects utilizing free-tissue transfer for soft-tissue defects of the pediatric(aged 18 and younger)lower extremity following traumatic etiology since 2005.Outcomes included flap failure,return to the operating room,and functional status,where available.Results:Seven studies were deemed appropriate for inclusion,with a total of 243 flaps included.Motor vehicle and motorcycle accidents were greater than 75%of total etiology.Most defects involved the foot or ankle(65.1%).In total,perforator flaps compromised the majority of flaps(54%),with the most common being the anterolateral thigh,the scapular/parascapular,and deep inferior epigastric flaps.Less common perforators included the groin flap,tensor fascia lata,radial forearm,lateral arm,and thoracodorsal perforator flap.Muscle-based flaps were less common(46%),with the latissimus dorsi and rectus muscle flaps composing the majority.The most commonly used recipient vessel was the anterior tibialis(49.5%)and posterior tibialis vessels(45.3%).Most studies performed reconstruction within 7-10 days of presentation.There was a cumulative 6.5%flap failure rate.Conclusion:Free tissue transfer for pediatric lower extremity trauma is an important tool that likely leads to powerful outcomes.Recent trends indicate increasing usage of perforator flaps.This study shows that based on existing data,free flap utilization for pediatric patients is an adequate modality for repair,and may warrant greater consideration moving forward.

Soft-tissue management and reconstruction of lower-extremity trauma

Soft-tissue management and subsequent salvage of the lower extremity following trauma has long presented difficult challenges to the plastic surgeon.Trauma to the lower extremity can produce long-term sequelae consisting of psychological trauma,functional deficits,and increased costs to the healthcare system.Avoiding incorrect management is important,and is compounded by the fact that few guidelines exist on appropriate treatment and patient counseling.This study aims to describe the authors’experience at a large limb salvage center in order to further delineate management strategies.

Expanding the top rungs of the extremity reconstructive ladder:targeted muscle reinnervation,osseointegration,and vascularized composite allotransplantation

Osseointegration(OI),targeted muscle reinnervation(TMR),and vascularized composite allotransplantation(VCA)are just a few ways by which our reconstructive ladder is evolving.It is important to recognize that amputation does not necessarily denote failure,but surgeons should strive to find ways to provide these patients with means for obtaining better satisfaction and quality of life postoperatively.TMR and OI have added options for mutilating lower extremity injuries that necessitate amputation.More recently,the senior author(Levin LS)described the"penthouse"floor of the reconstructive ladder being VCA.Despite the advances in VCA over the last 20 years,there are many challenges that face this discipline including indications for patient selection,minimizing immunosuppressive regimens,standardizing outcome measures,establishing reliable protocols for monitoring,and diagnosing and managing rejection.Herein,the authors review TMR,OI,and VCA as additional higher rungs of the reconstructive ladder.