Original Research

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

Publish date: June 20, 2018

Matthew T. Houdek, MD

Eric R. Wagner, MD

Chad D. Watts, MD

Stephen A. Sems, MD

Steven L. Moran, MD

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.

References

1. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg. 2004;114(6):1457-1466. doi:10.1097/01.PRS.0000138811.88807.65.

2. Lin CH, Wei FC, Chen HC, Chuang DC. Outcome comparison in traumatic lower-extremity reconstruction by using various composite vascularized bone transplantation. Plast Reconstr Surg. 1999;104(4):984-992. doi:10.1097/00006534-199909040-00013.

3. Tu YK, Yen CY, Yeh WL, Wang IC, Wang KC, Ueng SW. Reconstruction of posttraumatic long bone defect with free vascularized bone graft: good outcome in 48 patients with 6 years' follow-up. Acta Orthopaedica Scandinavica. 2001;72(4):359-364. doi:10.1080/000164701753542014.

4. Lin CH, Wei FC, Levin LS, Su JI, Fan KF, Yeh WL, Hsu DT. Free composite serratus anterior and rib flaps for tibial composite bone and soft-tissue defect. Plast Reconstr Surg. 1997;99(6):1656-1665. Doi:10.1097/00006534-199705000-00028.

5. Georgescu AV, Ignatiadis I, Ileana M, Irina C, Filip A, Olariu R. Long-term results after muscle-rib flap transfer for reconstruction of composite limb defects. Microsurgery. 2011;31(3):218-222. doi:10.1002/micr.20857.

6. Moran CG, Wood MB. Vascularized bone autografts. Orthop Rev. 1993;22(2):187-197. doi:10.1097/01241398-199307000-00031.

7. Banic A, Hertel R. Double vascularized fibulas for reconstruction of large tibial defects. J Reconstr Microsurg. 1993;9(6):421-428. doi:10.1055/s-2007-1006751.

8. Malizos KN, Nunley JA, Goldner RD, Urbaniak JR, Harrelson JM. Free vascularized fibula in traumatic long bone defects and in limb salvaging following tumor resection: comparative study. Microsurgery. 1993;14(6):368-374. doi:10.1002/micr.1920140603.

9. Peat BG, Liggins DF. Microvascular soft tissue reconstruction for acute tibial fractures--late complications and the role of bone grafting. Ann Plast Surg. 1990;24(6):517-520.

10. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453-458.

11. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24(8):742-746. doi:10.1097/00005373-198408000-00009.

12. Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. NEJM. 2002;347(24):1924-1931. doi:10.1056/NEJMoa012604.

13. MacKenzie EJ, Bosse MJ, Pollak AN, et al. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. J Bone Joint Surg Am. 2005;87(8):1801-1809. doi:10.2106/JBJS.E.00032.

14. Bieber EJ, Wood MB. Bone reconstruction. Clin Plast Surg. 1986;13(4):645-655.

15. Melvin JS, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S. Open tibial shaft fractures: II. Definitive management and limb salvage. J Am Acad Orthop Surg. 2010;18(2):108-117. doi:10.5435/00124635-201002000-00005.

16. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78(3):285-292. doi:10.1055/s-2006-944324.

17. Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br. 2000;82(7):959-966. doi:10.1302/0301-620X.82B7.0820959.

18. Fischer MD, Gustilo RB, Varecka TF. The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. J Bone Joint Surg Am. 1991;73(9):1316-1322. doi:10.2106/00004623-199173090-00005.

19. Tielinen L, Lindahl JE, Tukiainen EJ. Acute unreamed intramedullary nailing and soft tissue reconstruction with muscle flaps for the treatment of severe open tibial shaft fractures. Injury. 2007;38(8):906-912. doi:10.1016/j.injury.2007.02.052.

20. Yaremchuk MJ, Brumback RJ, Manson PN, Burgess AR, Poka A, Weiland AJ. Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstr Surg. 1987;80(1):1-14. doi:10.1097/00006534-198707000-00002.

21. Ueng WN, Chuang CC, Shih CH. Double-rib composite free transfer to reconstruct a single-spared lower extremity defect. J Trauma. 1995;38(2):210-212.

22. Bruck JC, Bier J, Kistler D. The serratus anterior osteocutaneous free flap. J Reconstr Microsurg. 1990;6(3):209-213. doi:10.1055/s-2007-1006820.

23. Lin CH, Yazar S. Revisiting the serratus anterior rib flap for composite tibial defects. Plast Reconstr Surg. 2004;114(7):1871-1877. doi:10.1097/01.PRS.0000142767.13493.63.

24. Hui KC, Zhang F, Lineaweaver WC, Moon W, Buncke GM, Buncke HJ. Serratus anterior-rib composite flap: anatomic studies and clinical application to hand reconstruction. Ann Plast Surg. 1999;42(2):132-136. doi:10.1097/00000637-199902000-00004.

25. Buncke HJ, Furnas DW, Gordon L, Achauer BM. Free osteocutaneous flap from a rib to the tibia. Plast Reconstr Surg. 1977;59(6):799-804. doi:10.1097/00006534-197706000-00002.

26. Nusbickel FR, Dell PC, Mcandrew MP, Moore MM. Vascularized autografts for reconstruction of skeletal defects following lower extremity trauma. A review. Clin Orthop Relat Res. 1989;(243):65-70.

ABSTRACT

Gustilo IIIB injuries of the tibia with segmental bone loss continue to be a difficult reconstructive problem. The serratus anterior-latissimus-rib (SALR) composite flap consists of bone and muscle; this flap can provide soft tissue coverage and vascularized bone in a single surgical procedure. The purpose of this study is to describe the use of the SALR flap for the treatment of a large open tibia fracture with segmental bone loss, with a specific focus on postoperative complications, limb salvage, and time to union.

We reviewed the medical records of patients undergoing an SALR flap (n = 5) for the treatment of Gustilo Type IIIB tibia fractures within 1 month of injury. We compared the mechanism of injury, injury severity score, time from injury to free tissue transfer, complications, and time to radiographic and clinical union.

All patients were male, with a mean age of 25 years. On average, patients underwent free tissue transfer within 1 week of injury. The average time to radiographic union was 7 months. Two patients underwent reoperation. There were no graft failures.

Free SALR flaps can be a useful option for the treatment of high-energy tibia fractures with extensive soft tissue and bone loss. These flaps provide immediate osseous and soft tissue reconstruction with an acceptable complication profile.

Reconstruction of the lower extremity following Gustilo’s grade IIIB injuries is difficult due to loss of both combined soft tissue and segmental bone loss. Since these injuries necessitate the need for soft tissue flap coverage along with vascularized bone grafting, free fibula flaps have classically been used for reconstruction.^1-3 In the setting of bilateral lower extremity injury, the contralateral fibula is often not appropriate to harvest and transfer; therefore, other sources of vascularized bone grafts must be utilized including vascularized iliac crest and rib.^1-5 The vascularized iliac crest graft is insufficient to provide the bony reconstruction of bone defects >6 cm to 7 cm and does not have a reliable skin paddle.⁴ In contrast, free composite serratus anterior-latissimus-rib (SALR) flaps can provide both long segments of vascularized bone and abundant soft tissue coverage for large segmental defects.^1-5

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