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Free Composite Serratus Anterior-Latissimus-Rib Flaps for Acute One-Stage Reconstruction of Gustilo IIIB Tibia Fractures

June 20, 2018 | Surgery
Matthew T. Houdek, MD ; Eric R. Wagner, MD ; Chad D. Watts, MD ; Stephen A. Sems, MD ; Steven L. Moran, MD
Author and Disclosure Information

Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article.

Dr. Houdek and Dr. Sems are Assistant Professors of Orthopedics, Dr. Wagner is an Upper Extremity Fellow, Dr. Watts is an Orthopedic Surgery Resident; and Dr. Moran is a Professor of Plastic Surgery and Orthopedics, Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota. Dr. Houdek was a resident at the time the article was written.

Address correspondence to: Steven L. Moran, MD, Mayo Clinic, Division of Plastic and Reconstructive Surgery, 200 First St. SW, Rochester, MN 55905 (email, moran.steven@mayo.edu).

Am J Orthop. 2018;47(6). Copyright Frontline Medical Communications Inc. 2018. All rights reserved.

Matthew T. Houdek, MD Eric R. Wagner, MD Chad D. Watts, MD Stephen A. Sems, MD Steven L. Moran, MD . Free Composite Serratus Anterior-Latissimus-Rib Flaps for Acute One-Stage Reconstruction of Gustilo IIIB Tibia Fractures. Am J Orthop.

June 20, 2018

TAKE-HOME POINTS

  •  Gustilo IIIB injuries with segmental bone loss can be difficult to treat with conventional means.
  •  Vascularized bone grafts are beneficial for reconstructing bone defects >5 cm.
  •  The SALR composite flap consists of bone and muscle.
  •  This flap can provide soft tissue coverage and vascularized bone in a single surgical procedure.
  • In this study, the use of the SALR composite flap was capable of healing large segmental bony defects at an average of 7 months.

Free fibula grafts have been considered the gold standard for the reconstruction of large (>6 cm) bone defects.6 In cases of “mangled extremities,” bone defects are associated with large soft tissue defects, which require either single-stage surgery consisting of 2 separate free flaps (ie, free fibula and free latissimus) or a 2-stage procedure where the soft tissue reconstruction precedes the bone reconstruction.2,7-9 Unlike free fibula and latissimus flaps, composite SALR flaps provide both osseous reconstruction and soft tissue in 1 flap supplied by a single vascular pedicle; unfortunately, outcomes using this flap for large Gustilo IIIB injuries are limited.1-5 The purpose of this study is to examine the use of free composite SALR flaps for soft tissue coverage in cases of Gustilo IIIB injuries with large soft tissue and bony deficits. This study specifically examines time to union, need for reoperation, and graft failure following the use of these flaps.

MATERIALS AND METHODS

Following approval from our Institutional Review Board, we retrospectively reviewed the medical records of patients undergoing a free composite SALR flap (n = 5) for the treatment of a severe open tibia fracture within 1 month of injury. All patients sustained open injuries classified as IIIB on the Gustilo-Anderson scale.10 Medical records were examined for the mechanism of injury (MOI), injury severity score (ISS), time from injury to free tissue transfer, medical comorbidities, surgical complications, and time to radiographic and clinical union. Radiographic union was determined by the presence of bridging bone on 3 of 4 of cortices on plain film radiographs.

All patients were male (n = 5), with a mean age of 25 years (range, 19-30 years) at the time of injury (Table). 

Table. Demographics and Outcomes of Patients Undergoing Free Tissue Transfer

Free Serratus Anterior-Latissimus-Rib Flaps

Age (Mean ± SEM)

23 ± 2 years

Males

5

Females

0

Tobacco Use

2

Body Mass Index (Mean ± SEM)

26.2 ± 0.9 kg/m2

Injury Severity Score (Mean ± SEM)

18 ± 5

Time to Tissue Transfer (Mean ± SEM)

1 ± 0.3 weeks

Time to Boney Union (Mean ± SEM)

7 ± 0.7 months

Time Non-Weight-Bearing (Mean ± SEM)

5 ± 0.5 months

The MOI included motorcycle collisions (n = 2), pedestrian struck by car (n = 1), motor vehicle collisions (n = 1), and direct blow to the leg (n = 1). The mean ISS of the cohort was 18 (range, 10-34) (Table). On average, patients underwent free tissue transfer within 1 week (range, 3 days to 2 weeks) from the time of injury. Patients in this cohort were followed clinically for a mean of 4 years (range, 1-6 years) after surgery. Patients were non-weight-bearing for an average of 5 months (range, 4-6 months) following their reconstructions.

RESULTS

All flaps survived. The mean time to radiographic and clinical union was 7 months (range, 6-9 months). Two patients underwent reoperation. One patient underwent a bone grafting procedure for a delayed union at 6 months postoperative, and 1 patient underwent irrigation and débridement of superficial soft tissue infection. Donor site complications occurred in 2 patients, including chronic rib pain (n = 1) and a pleural effusion requiring drainage (n = 1). At the last follow-up, all ribs had incorporated, and all patients were weight-bearing as tolerated on the limb.

CASE EXAMPLE

A 22-year-old male smoker was transferred to our facility after a motor vehicle accident with bilateral tibia fractures, 1 closed and 1 open with significant bone loss (Figures 1A, 1B). 

He had initially been placed in an external fixator and transferred to our facility. A preoperative computed tomography angiogram was obtained to determine patency of recipient vessels.

Continue to: Surgical Technique...

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