Goldsmith Thomas, Ford Bryony, Marsden Nicholas, Emam Ahmed
Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK.
Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK.
Injury. 2023 Oct;54(10):110920. doi: 10.1016/j.injury.2023.110920. Epub 2023 Jul 16.
Replication of the thin and pliable native skin around the ankle remains a challenge for plastic surgeons treating soft tissue defects in this region. Flap reconstruction constitutes the mainstay of management of such injuries. Subsequent management often entails revisional debulking surgery to permit normal footwear and an acceptable aesthetic outcome. In light of limited elective operating capacity throughout the covid-19 pandemic, we adopted an algorithm to inform reconstruction in such injuries and limit the need for revisional surgeries. This study presents this algorithm, which considers patient age, functional status, co-morbidities, body habitus and defect location.
Retrospective analysis of a prospectively maintained database of all patients undergoing lower limb soft tissue reconstruction over 21 months was performed. All flap-based reconstructions of ankle defects were included; direct closures and skin grafts were excluded. All trauma patients were managed via a combined orthoplastic approach as per BOA-BAPRAS standards. All patients had Computed Tomography Angiography prior to their definitive reconstruction. Lower Extremity Functional Scale (LEFS) scores were analysed for patients with over 12 months of postoperative follow up, where available.
71 flaps were performed in 69 patients. Open ankle fracture was the most common cause (86%); other indications included osteomyelitis and surgical wound dehiscence. Mean age was 50 (13-87 years) with a higher proportion of males to females (ratio 1.25:1). There were 26 pedicled flaps (18 Medial Plantar Artery and 8 Peroneus Brevis) and 45 free flaps (22 Anterolateral thigh, 11 Superficial Circumflex Iliac Artery Perforator, 11 Gracilis and 1 Medial Sural Artery Perforator). Mean follow-up is 13.6 months. There were three flap failures, and four patients subsequently underwent delayed below knee amputation despite successful soft tissue healing. For the patients with a minimum of 12 months follow up, LEFS scores with an average of 51% were achieved (range 15-88%). Four patients have been listed for revisional/debulking surgery.
Although soft tissue defects around the ankle can be difficult to manage, with careful planning and addressing each patient individually, supported by an algorithmic approach, good functional and aesthetic outcomes can be achieved with low rates of secondary revision surgery.
对于治疗踝关节周围软组织缺损的整形外科医生而言，复制该区域薄而柔韧的天然皮肤仍然是一项挑战。皮瓣重建是此类损伤治疗的主要手段。后续治疗通常需要进行整形减容手术，以确保能正常穿着鞋子并获得可接受的美学效果。鉴于在整个新冠疫情期间择期手术能力有限，我们采用了一种算法来指导此类损伤的重建，并减少整形手术的需求。本研究展示了该算法，其考虑了患者年龄、功能状态、合并症、身体形态和缺损位置。
对一个前瞻性维护的数据库进行回顾性分析，该数据库包含了21个月内所有接受下肢软组织重建的患者。纳入所有基于皮瓣的踝关节缺损重建；排除直接缝合和植皮。所有创伤患者均按照英国矫形外科协会 - 英国整形外科协会（BOA - BAPRAS）标准采用联合矫形整形方法进行治疗。所有患者在进行最终重建前均接受了计算机断层扫描血管造影。对术后随访超过12个月（如有）的患者分析下肢功能量表（LEFS）评分。
69例患者共进行了71例皮瓣手术。开放性踝关节骨折是最常见的原因（86%）；其他适应症包括骨髓炎和手术切口裂开。平均年龄为50岁（13 - 87岁），男性与女性比例更高（比例为1.25:1）。有26例带蒂皮瓣（18例足底内侧动脉皮瓣和8例腓骨短肌皮瓣）和45例游离皮瓣（22例股前外侧皮瓣、11例旋髂浅动脉穿支皮瓣、11例股薄肌皮瓣和1例腓肠内侧动脉穿支皮瓣）。平均随访时间为13.6个月。有3例皮瓣失败，4例患者尽管软组织愈合成功，但随后仍接受了膝下延迟截肢。对于至少随访12个月的患者，LEFS评分平均达到51%（范围15 - 88%）。有4例患者已被列入整形/减容手术名单。
尽管踝关节周围的软组织缺损可能难以处理，但通过精心规划并采用算法方法支持下的个体化治疗，可实现良好的功能和美学效果，二次整形手术率较低。
