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The Journal of Foot & Ankle Surgery xxx (2013) 1–6

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The Journal of Foot & Ankle Surgery

journal homepage: www.j fas .org

Case Reports and Series

Bone Propeller FlapdA Staged Procedure

Mathias Tremp, MD1, Ren�e D. Largo, MD 1, Olivier Borens, MD 2, Dirk J. Schaefer, MD 1,Daniel F. Kalbermatten, MD, PhD 1

1Department of Plastic, Reconstructive Aesthetic and Hand Surgery, University Hospital Basel, Basel, Switzerland2Orthopedic and Traumatology Department, Septic Surgical Unit, University Hospital Center and University of Lausanne, Lausanne, Switzerland

a r t i c l e i n f o

Level of Clinical Evidence: 4

Keywords:free flaplatissimus dorsi flapMasqueletstaged reconstruction

Financial Disclosure: None reported.Conflict of Interest: None reported.Address correspondence to: Daniel F. Kalberma

Plastic, Reconstructive Aesthetic and Hand Surgery, Ustrasse 21, Basel 4031, Switzerland.

E-mail address: dkalbermatten@uhbs.ch (D.F. Kalb

1067-2516/$ - see front matter � 2013 by the Americhttp://dx.doi.org/10.1053/j.jfas.2013.06.009

a b s t r a c t

The ideal reconstruction technique for complex defects of the lower limb consists of replacing tissue withsimilar tissue in an attempt to achieve a good functional result. A 23-year-old white male sustained a crushinjury with a grade IIIB open ankle dislocation. After open reduction and fixation, the patient developed severeosteomyelitis at the tibiotalar joint requiring a staged and radical debridement with a substantial combinedsoft tissue and bony defect over the distal tibia, fibula, and talus area. The reconstructive approach consisted ofa modified model of the propeller flap, implementing the spare part concept in a 2-stage procedure usinga prefabricated and vascularized “double-barrel” fibular graft. At 17 months postoperatively, a plain radiographshowed bony union with complete and stable coverage of the soft tissue defect. The patient was fullyweightbearing. In conclusion, there is evidence to suggest that the established concept of a soft tissuepropeller flap can be implemented on bone.

� 2013 by the American College of Foot and Ankle Surgeons. All rights reserved.

Since the introduction of the reconstructive ladder in 1982 byMathes and Nahai (1), technology has dramatically altered the para-digms and doctrines in modern reconstructive surgery. Severalreports have aimed to refine the reconstructive ladder concept (2–4).

Propeller flaps were first introduced in 1991 by Hyakusoku et al (5)and featured the latest advance in the history of reconstructivesurgery (6). The method consisted of elevating and rotating a centralpedicled flap, with a length largely exceeding its width (5). The flapwas rotated 90� on the central pedicle to release a postburn skincontracture. In the past few decades, modifications have been addedto avoid its limitations, such as the pin-wheel flap (7), scar bandrotation flap (8), and multilobed propeller flap (8).

The propeller flap can be used as the first choice to cover small andmedium-size defects, presupposing sufficient vascularization of thesurrounding tissue (9). From every perforator vessel of adequate size,a reliable perforatorflap can be harvested. The ability to rotate this flapto any angle up to 180 degrees makes it attractive for reconstructivesurgery. It can be applied to multiple defects, such as posterior trunkdefects (10), ischial or trochanteric pressure sores (11), soft tissuedefects of the leg or knee prosthesis infection (12), and upper limbdefects (6).

tten, MD, PhD, Department ofniversity Hospital Basel, Spital-

ermatten).

an College of Foot and Ankle Surgeon

Complex wounds usually require complex closure with an inter-disciplinary decision process. Today, however, composite flaps are thestate-of-the-art in reconstructive microsurgery (13). For bone defectslarger than 6 cm, the use of vascularized bone grafts with or withoutaccompanying composite soft tissue transplants for bone recon-struction has been recommended (14–16). The ideal bone graft forparticularly difficult skeletal deficiency problems should provide itsown vascular supply, with osteoconductive, osteoprogenitor, andosteogenetic properties (17). It has been shown that the double-strutvascular fibular graft is an effective treatment of complicated longbone defects of the lower extremity (18). Furthermore, several newmethods have been described using the propeller flap to covercomplex soft tissue defects. In a recent prospective study by Pignattiet al (12), the perforator-based propeller flap was introduced asa “skeletonized perforator flap” for soft tissue defect coverage after legor knee prosthesis infection. Also, the use of the expanded reversesural flap or reverse sural artery neurocutaneous island flap has beenproposed for reconstruction of complex wounds of the lowerextremity (19,20).

We present a new modification of the propeller flap with the aimof covering a large segmental bone defect and complex soft tissuedefect at the lower extremity using a 2-stage chimera propeller flap.In the first stage, a free latissimus dorsi (LD) flap, including a shortscapular bone fragment, is anastomosed to the popliteal artery,and the scapular bone fragment is docked to the distal fibula. Inthe second stage, the ipsilateral and prefabricated fibula is usedas a vascularized “double-barrel” fibular graft to cover the bonedefect.

s. All rights reserved.

M. Tremp et al. / The Journal of Foot & Ankle Surgery xxx (2013) 1–62

Case Report

In September 2009, a 23-year-old, nonsmoker, white male wasinjured in a car accident. He was diagnosed with vertebral fractures atC2-C3, fractures of the 10th and 11th right posterior ribs, a non-displaced fracture of the sternum, intra-abdominal organ traumawithbleeding, and an open left-sided tibiotalar dislocation (Gustilo gradeIIIB) (21). The vertebral fractures were stabilized 3 days after theaccident, and the other injuries, except for the tibiotalar dislocation,were treated conservatively. After immediate open reduction andexternal fixation of the ankle dislocation, the patient developedsevere osteomyelitis at the tibiotalar joint. The subsequent bonebiopsy revealed 3 different bacterial species (Morganella, Citrobacter,and Pseudomonas) requiring intravenous antibiotics (tazobactam andobramycin). A staged and radical debridement with insertion of anantibiotic-impregnated cement block into the distal tibia (Masquelettechnique) was performed, with external fixation maintained untilthe distal bone cavity had been covered (22).

The reconstructive concept consisted of an initial interdisciplinaryradical debridement of the nonvital distal tibia, fibula, and part of thetalus and covering of the soft tissue defect (size 42 � 23 cm) withwell-vascularized tissue. Second, the bone defect (size 18 cm) wasreconstructed (Fig. 1). Preoperative Doppler ultrasonography andangioscanning showed a patent posterior tibial artery (Fig. 2). Forreconstruction, the patient refused tissue harvest from thenoninjured contralateral leg. One month after the accident, defectclosure was performed using a free LD flap with a scapular bonefragment (medial border of the scapula) docked to the distal fibulawith 2 Kirschner wires (Figs. 3 and 4). The free LD flap was anas-tomosed end-to-side to the popliteal artery and was then skingrafted (Figs. 1 and 4B). Four months later, the prefabricated fibulawas used as a vascularized double-strut fibular flap to cover thedistal bone cavity after ligation of the proximal (feeder) fibularartery. The fibula was rotated 180 degrees clockwise around the pivot

Fig. 1. Schematic image of the bone propeller flap (A) showing the latissimus dorsi (LD) flap awires. (B) Close-up view of the scapula fragment with its vascularization provided by the Lthe consolidated scapula fragment, was used as a vascularized “double-barrel” fibular graft, togof the proximal fibular artery (C and D).

point (transplanted scapula segment) and intercepted from themidpoint with the complete blood supply remaining (Fig. 1) (23). Thepatient underwent surgery in the supine position. First, iliac crestautogenous bone grafting was performed. Then the external fixationwas removed, the flap was raised, radical debridement of all non-viable tissues was performed, and the antibiotic impregnated cementwas removed. The proximal and well-vascularized fibula was thenharvested and rotated clockwise 180 degrees and stabilized distallywith a locking compression plate to the tibia and talus to optimizestabilization. The head of the fibula was fixed with 2 spongious bonescrews. In addition, a tibial-talar-calcaneal fusion was performedusing a retrograde intramedullary nail (Fig. 2B and C). Subsequently,the site was closed in layers, and 1 drain was inserted. Immobiliza-tion for 5 days was prescribed, and low-molecular-weight heparinwas administered. To prevent a stress fracture, the extremity wasprotected with a walker boot and crutch ambulation for 3 monthspostoperatively.

Results

During the treatment course, the patient developed a fistula32 days after the distal bone cavity had been covered. This requiredoperative revision that included wide debridement with insertion ofgentamycin-impregnated beads, followed by antibiotic therapy for3 months with Bactrim, Rimactan, Ciproxin, and Tiberal. Six monthslater, the gentamycin-impregnated beads were removed andreplaced with cancellous bone from the ipsilateral femur using thereamer irrigator aspirator (RIA) technique (24). However, this didnot affect the overall outcome. After 17 months, a plain radiographshowed hypertrophy of the fibula and a remaining asymptomaticsmall gap at the proximal junction between the tibia and the graft(Fig. 2D and E). No signs of recurrent infection were seen. A finalfollow-up examination after 28 months revealed complete andstable coverage of the soft tissue defect (Fig. 2F). No partial flap

nd the medial border of the scapula fragment docked to the distal fibula with 2 KirschnerD flap into the fibula. After 4 months, the proximal and prefabricated fibula, includingether with cancellous bone from the iliac crest, to cover the tibial bone cavity after ligation

Fig. 2. Angioscanning showed a patent posterior tibial artery (A). Radiograph 2 days postoperatively (B and C). The proximal fibula was harvested and rotated clockwise 180 degrees andstabilized distally with a locking compression plate to the remaining tibia and talus. Osseous integration on plain radiograph after 17 months (D and E) with complete and stable coverageof the soft tissue defect after 28 months (F).

M. Tremp et al. / The Journal of Foot & Ankle Surgery xxx (2013) 1–6 3

necrosis had been observed. The patient was fully weightbearing ona plantigrade foot with an inlay in his shoe and, occasionally, with 1crutch. His knee function was 100% with no mobility at the anklejoint. He was unemployed but searching for a sedentary job.

A search of the published data revealed several treatment optionsfor complex lower extremity reconstruction, depending on thelocation and length of the bone and the size of the soft tissue defects.An overview of the different approaches and indications for openlower extremity fractures with combined bone and composite softtissue defects is provided in the Table.

Discussion

Ideally, tissue reconstruction for a complex tissue defect in thelower limb should be performed with low morbidity and a goodfunctional and cosmetic result. In our case, we chose to use a uniqueand modified model of the propeller flap in a 2-stage procedure usinga prefabricated and vascularized “double-barrel” fibular graft. Thisconcept allowed us to implement the spare part concept using anotherwise nonfunctional upper fibula segment to reconstruct themissing distal tibia without harvesting the fibula on the noninjuredside. Furthermore, no additional microsurgical branching wasnecessary on the single vessel that nourished the leg. Because of the

revascularization of the transplanted scapula segment, this is an idealvascularized bone.

In a recent publication, the concept of the reconstructive matrixwas proposed (25). This paradigm emphasizes the need for an optimalreconstructive strategy for the patient, the reconstructive environ-ment, and the surgeon (25). Therefore, a delicate balance must befound between causing patients minimal harm and providing themwith the best benefit.

Determining whether to perform limb salvage or amputation ofthe traumatized lower extremity remains a subject of considerableinterest and controversy (26,27). Several classification systems andinjury severity scores have been established during the past fewdecades in an attempt to avoid, not only unnecessary amputations,but also protracted attempts at salvage that might eventually beconverted to delayed amputation (28,29). The success of limb salvagewas related to the warm ischemia time and the quantitative degree ofarterial, nerve, bone, muscle, skin, and venous injury. Thus, a limbsalvage index of less than 6 has been considered to be successful forlimb salvage but a limb salvage index of 6 or greater and Gustilo typeIII-C fracture have been considered to be absolute indications foramputation (30). Although these scores can be useful tools in thedecision-making process, they should not be used as the principalcriteria for reaching difficult conclusions (28).

Fig. 3. Postoperative view after free latissimus dorsi (LD) flap and medial border of thescapula fixed to the distal fibula (arrow) by 2 Kirschner wires.

Fig. 4. (A) Free latissimus dorsi (LD) flap with the scapula (SC) fragment (medial border ofscapula). (B) Result with complete coverage of the soft tissue loss with skin graft.(C) Intraoperative view 4 months later with the proximal fibula harvested and rotatedclockwise 180 degrees and stabilized distally with a locking compression plate to the tibiaand talus (D). *Antibiotic-impregnated cement in the distal tibia. Arrow indicates thescapula fragment.

M. Tremp et al. / The Journal of Foot & Ankle Surgery xxx (2013) 1–64

To date, a paucity of data is available about “chimera” propellerflaps. If the defect size is limited and it is not necessary to fill a deepbone cavity or dead space, the propeller flap can be used alone in thetreatment of bone defects (e.g., osteomyelitis) (31). In a case report byRubino et al (31), a 3 � 1.5 cm of nonunited segment of the fibula wasremoved, and the defect was covered with a propeller flap 16 � 6 cm,which was based on a single peroneal perforator (31). However, ifa larger bone cavity is present, a “chimera” flap with a bone substitutewould be preferred.

Bone reconstruction can be achieved with conventional bonegrafts using either local or free flaps (32). It has been shown thatvascularized bone struts generally resist infection, do not undergoresorption, are associated with rapid remodeling and hypertrophy,and have good mechanical strength (33–35). For small to moderatesegmental bony defects, the Ilizarov bone-lengthening procedureprovides an option (36–38). For defects less than 10 cm, the iliaccrest transfer has been shown to yield superior results comparedwith microvascular fibula transfer (39). The iliac crest appears to

TableTreatment options for complex lower extremity reconstruction

Flap Advantages Disadvantages Mean Flap Size

Anterolateral thigh flap (44) Long pedicleAcceptable donor site morbidityFlap can be harvested from ipsilateral leg

Thicker in the more obese Western population 20.7 � 8.4 cm

Gracilis flap (45) Reliable and predictableHigh flap success and limb salvage rate

Donor site morbidity (46)Reduced bulkLimited to smaller wounds

5 � 30 cm

Latissimus dorsi flap (43,47) Indicated in infectionsGood for massive skin defects

Donor site morbidityFlap failure risk in children

25 � 35 cm

Rectus abdominis (48,49) Reliable anatomyEase of dissectionLarger luminal diameter

Interference with convalescent crutch walkingIncreased bulk

25 � 6 cm

Peroneal flap (43) Flap can be harvested from ipsilateral leg Small bone and skin defects 9 � 6 cmScapular flap (50) Long pedicle (8–10 cm)

Large flapSmall bone and skin defects 25 � 15 cm

Peroneal osteocutaneous flaps (43) Large bone defectEarlier bone union

Donor site morbidityLack of bulk

25 � 5 cm

Vascularized fibular osteoseptocutaneous flap (17,33) Good mechanical strengthResist infectionRapid remodeling

Donor site morbidityLack of bulk

12 � 24 cm

Iliac osteocutaneous flap(17) Defects <10 cmAnkle reconstruction (39)

Lateral thigh numbnessTemporary flank painLimited area of coverageLess reliable skin flap

10–12 cm

Combined vascularized rib transfers (17,51) Fast rate of healingMore resistant to infectionReliable in bone defects associated with

large soft tissue defect

High complication rate 25 � 35 cm

Free osteocutaneous lateral arm flap (52) Stable and aesthetic coverageMinimal donor site morbidity

Small diameter of vesselsCortical bone only

10 � 20 cm

M. Tremp et al. / The Journal of Foot & Ankle Surgery xxx (2013) 1–6 5

be more optimal than the fibula for reconstruction about theankle, regardless of the etiology (39). However, donor-site morbidity(e.g., pain at the donor site, abnormal sensations, or infection) at thevascularized iliac bone flap (14,40,41) must be taken into accountalthough the fibula results in less donor-site morbidity (42).Furthermore, vascularized bone transfer with osteocutaneous groinflaps, soleus-fibula flaps, or osteocutaneous lateral arm flaps havebeen reported for bone reconstruction of the lower extremity withan average interval to union of 9.5 months (32). Other bonegraft techniques have included vascularized fibular osteoseptocuta-neous flaps and peroneal osteocutaneous flaps, leading to goodrestoration (17,43).

One-stage procedures with transfer of the appropriate combina-tion of vascularized bone and a soft tissue flap have been shown tolead to successful functional results that are almost equal to micro-surgical staged procedures and conventional techniques (17). Thiswas shown in a study by Yazar et al (17) of 61 traumatic lowerextremity patients. Of those, 50 patients had received vascularizedfibular osteoseptocutaneous flaps, 6 had received vascularized iliacosteocutaneous flaps, and 5 had received 7 combined vascularized ribtransfers with serratus anterior muscle and/or LD muscle transfers(17). In their study, the postoperative infection rate was 7.9% witha primary bony union rate after successful free vascularized bonegrafting of 88.5% and complete flap survival of 88.9%.

In summary, complex lesions often require complex reconstructivesurgery. The orthopedist should be charge of the patient in such cases,although in the operating theater, a multidisciplinary team approachshould be used. Functional expectations, medical comorbidities andsociocultural patient factors should be considered for individualizedand optimized treatment.

The modified and combined propeller flap with an initial free LDflap and a subsequent prefabricated and vascularized “double-barrel”fibular graft is feasible for the reconstruction of complex soft tissue andlarge bone defects of the lower leg. The present case has shown that itis very important to analyze the defect and to use the spare part

concept (in our case, a nonfunctional proximal fibula) for reconstruc-tion. In conclusion, evidence has suggested that the establishedconcept of a soft tissue propeller flap can be implemented on bone.

Acknowledgment

We thank Dirk Fenner for his contribution in the preparation ofthe figures.

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