18 www.e-arms.org Open fracture of the lower leg caused by high energy
trauma has been treated by emergency surgery in the department of orthopedic surgery. Contaminated soft tissues should be removed and the bone fractures restored by skeletal stabilization. The incidence of the vascular injury among the lower extremity fractures is 0.1%.1 Treatment of the open fracture is performed by external fixation or internal fixation.2 In open tibia fracture, soft tissue and neurovascular injuries should be cautiously evaluated at the time of fracture stabilization. When necrosis of the soft tissue starts, the invasive angiography in the lower extremity is required to rule out the arterial injury, as the anterior or posterior artery in the lower extremity is essential for free flap transplantation.
CASE REPORT
Authors report two cases of open tibia fracture, one of whom had an open comminuted fracture of the distal one- third of the right tibia and another one had a comminuted fracture of the proximal tibia, caused by autobike accident, which were fixed by external fixator or a plate, and screws in the previous hospital. The two patients were referred to our hospital because the tibia were exposed out of the soft tissue with acute impending osteomyelitis. A 67-year-old male had a comminuted fracture that had been fixed with external fixator on plain leg films (Fig. 1A). The right exposed tibia was measured around 30×11 cm (Fig. 1B). Preoperative femoral angiography identified obstruction of the anterior tibial artery at the level of proximal interosseous membrane in the proximal leg (Fig. 1C; black arrow). At exploration, the
Free Flap Transplantation in Open Tibial Fracture with Vessel Injury in the Elderly
Chang Eun Yu, Myung-Jae Yoo*, Jun-Mo Lee*
Department of Orthopedic Surgery, Presbyterian Medical Center, *Department of Orthopedic Surgery, Chonbuk National University Medical School, Chonbuk National University and Research Institute of Clinical Medicine, Chonbuk National University, Jeonju, Korea
pISSN 1226-2706 eISSN 2288-6184 Arch Reconstr Microsurg 2014;23(1):18-20
CC This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright © 2014 by the Korean Society for Microsurgery. All Rights Reserved.
Two aged patients who had open tibial fractures with arterial injury caused by high energy accidents underwent emergency arterial reconstruction using a greater saphenous vein and soft tissue repair using free flaps. In the patients, soft tissue necrosis developed and tibias were exposed at postoperative third week. Follow-up angiography through the superficial femoral artery showed occlusion of the anterior tibial artery. The anterior tibial artery was reconstructed using the contralateral greater saphenous vein graft and the latissimus dorsi myocutaneous and rectus abdominis muscle free flaps were transplanted for repair of necrotic soft tissue. The reconstructed arteries showed good perfusion to the new free flaps until union of the tibias occurred. The patients were followed-up for 21 years and 17 years postoperatively, respectively. In management of open comminuted fracture of the tibia, injury of the arterial system must be ruled out by angiography in addition to evaluation of the degree of soft tissue injury.
Key Words: Open tibial fracture, Angiography, Latissimus dorsi myocutaneous free flap, Rectus abdominis muscle free flap
Received April 17, 2014 Revised May 5, 2014 Accepted May 9, 2014
Correspondence to: Jun-Mo Lee Department of Orthopedic Surgery, Chonbuk National University Medical School, 20 Geonji-ro, Deokjin-gu, Jeonju 561-712, Korea
Tel: +82-63-250-1769 Fax: +82-63-271-6538 E-mail: [email protected]
ARMS
Case ReportArchieves of Reconstructive Microsurgery
Chang Eun Yu, et al. Free Flap Transplantation in Open Tibial Fracture with Vessel Injury in the Elderly
19
www.e-arms.org occlusion site of the anterior tibial artery was identified (Fig.
1D). The proximal intact portion of the anterior tibial artery of about 7 cm long was pulled back from the deep portion to the popliteal area, and a greater saphenous vein graft was anastomosed to the distal end of the intact portion of
the anterior tibial artery. The grafted vein was anastomosed to the thoracodorsal artery in the latissimus dorsi flap (Fig.
1E) and the remaining in-situ greater saphenous vein was anastomosed to the bigger vena comitante in the latissimus dorsi flap (Fig. 1F). The tibia was well united without the
Fig. 1. (A) In 67-year-old male, the lower leg X-rays showed comminuted fracture and fi xated with external fi xator. (B) Bony exposure of right tibia midshaft measuring around 30×11 cm. (C) Preoperative femoral angiography identifi ed obstruction of the anterior tibial artery in the proximal leg (black arrow). (D) Th e obstructed anterior tibial artery was identifi ed. (E) Th e grafted vein was anastomosed to the thoracodorsal artery in the latissimus dorsi fl ap. (F) Th e remaining in situ greater saphenous vein was anastomosed to the bigger vena comitante in the latissimus dorsi fl ap.
Th e tibia was well united without the development of osteomyelitis (G) and the free fl ap was well attached and healed (H).
Fig. 2. (A) Another 67-year-old female, the proximal tibia was fixed with a plate and screws. (B) The proximal tibia was exposed measuring 8.0×2.5 cm.
(C) Preoperative femoral angiography identified obstruction of the anterior tibial artery (black arrow). Rectus abdominis muscle flap (D) was transplanted (E). (F) The tibia fracture was well united and the plate and screws were removed. (G) Th e transplanted fl ap was well healed.
Arch Reconstr Microsurg Vol. 23. No. 1. May 2014
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development of osteomyelitis (Fig. 1G) and the free flap was well attached and healed (Fig. 1H). In another 67-year-old female patient, the proximal tibia was fixed with a plate and screws (Fig. 2A), but the soft tissue was lost and the proximal shaft of the right proximal tibia was exposed around 8.0×
2.5 cm (Fig. 2B). Preoperatively the femoral angiography identified obstruction of the anterior tibial artery (Fig. 2C:
black arrow). Rectus abdominis muscle flap (Fig. 2D) was transplanted on the exposed bone (Fig. 2E). The tibia fracture was well united and the plate and screws were removed (Fig.
2F). The transplanted flap was well healed (Fig. 2G).
DISCUSSION
Open tibia fracture is an emergency injury to orthopedic surgeons. In the favorable healthy state of the patient and under anesthesia, the contaminated or infectious materials in the soft tissue are removed by saline irrigation and the open fracture itself is stabilized by external fixation or a plate and screws. In the open comminuted fracture, the fracture fragments may secondarily make injury to the vital arteries and nerves in the lower extremity. If the arterial intimal injury is severe and located in the deep portion which makes the primary repair impossible, the arterial perfusion to the distal part of the lower extremity will be insufficient and eventually resulted in below-knee amputaion.3 Femoral angiography has to be performed to confirm the arterial injury site and the extent of the arterial obstruction in the lower extremity.
The anterior tibial artery occluded by thrombosis is exposed and opened until the intact intima appears under the loupes magnification, and then a contralateral greater saphenous vein graft is anastomosed to the healthy portion of the injured artery. The vein graft anastomosed to the healthy anterior tibial artery has to be long enough for end-to-end anastomosis to the donor artery without any tension. In two cases of severe comminuted tibia fracture, transplantation of free flap was successfully performed by end-to-end anastomosis of the donor artery to the arterialized recipient arteries of the latissimus dorsi myocutaneous and rectus abdominis muscle flaps, and then the free flaps covered
effectively the exposed tibia.
In the history of the atissimus dorsi flap, Baudet et al.4 reported the successful transfer of two free axillary flaps based on the thoracodorsal vessels. Since then, it has become an excellent flap for covering and filling in the variable- shaped illness or defect. The flap is so reliable and large that it can cover the large recipient defect area of 10 to 12 cm wide and 25 to 30 cm long. The thoracodorsal artery, which is >15 cm in length and 1.5 to 3.0 mm in diameter, supplies blood to the long and wide vascular pedicle in the flap.5
Rectus abdominis flap is a long, strap-like muscle and its maximum size is around 30×10 cm. The vascular pedicle from the deep inferior epigastric artery is 6 to 8 cm in length and 2 to 4 mm in diameter and has venae comitantes.6
After anastomosis, the intima is healed in 7 days,7 but authors kept the lower extremity in the long leg splint for 21 days due to concern of secondary vascular spasm.
REFERENCES
1. Howard PW, Makin GS. Lower limb fractures with associated vascular injury. J Bone Joint Surg Br 1990;72:116-20.
2. Dunbar RP Jr, Gardner MJ. Initial management of open fractures.
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3. Connolly JF, Whittaker D, Williams E. Femoral and tibial fractures combined with injuries to the femoral or popliteal artery. A review of the literature and analysis of fourteen cases. J Bone Joint Surg Am 1971;53:56-68.
4. Baudet J, Guimberteau JC, Nascimento E. Successful clinical transfer of two free thoraco-dorsal axillary flaps. Plast Reconstr Surg 1976;58:680-8.
5. Maxwell GP, Manson PN, Hoopes JE. Experience with thirteen latissimus dorsi myocutaneous free flaps. Plast Reconstr Surg 1979;64:1-8.
6. Bunkis J, Walton RL, Mathes SJ. The rectus abdominis free flap for lower extremity reconstruction. Ann Plast Surg 1983;11:373- 80.
7. Walker LN, Ramsay MM, Bowyer DE. Endothelial healing following defined injury to rabbit aorta. Depth of injury and mode of repair. Atherosclerosis 1983;47:123-30.
