RECONSTRUCTION OF POSTERIOR COMPARTMENT OF LOWER EXTREMITY USING A FUNCTIONAL LATISSIMUS DORSI FREE FLAP: A CASE REPORT RUKMINI S. REDNAM, M.D. and BRIAN D. RINKER, M.D.*
We present an unusual case in an 8-year-old male that presented with a severe crushing injury to the right lower extremity with grade IIIB open tibia/fibula fracture and composite loss of the majority of the posterior muscle compartments and overlying skin and segmental loss of the tibial nerve. Composite reconstruction was performed with internal fixation, cable autografting of the tibial nerve, and a functional latissimus dorsi musculocutaneous flap. A motor branch of the tibial nerve to the soleus was used as the donor motor nerve. The patient achieved a bony union and began ambulating at 8 weeks postoperatively. At 24 months, the patient was running and jumping with plantar push-off. Recovery of plantar flexion was to the M5 level. Static and moving 2-point discrimination of the plantar foot was 8 mm and 6 mm, respectively. Functioning muscle transfer in a child with a severe lower extremity injury with composite tissue loss may provide soft C 2015 Wiley Periodicals, Inc. Microsurgery 36:77– tissue and motor-unit defect reconstruction with an acceptable functional restoration. V 80, 2016.
In the past, severe lower extremity injuries were either often treated with amputation or salvage without restoration of muscle function. Tendon transfer in the lower extremity is an acceptable reconstructive method; however, not all complex lower extremity injuries are amenable to this type of reconstruction.1–4 Free tissue transfer has become the standard of care for the salvage of large lower extremity wounds secondary to trauma or oncologic resection.5–8 Free functional tissue transfer may provide superior results over traditional tendon transfers and can be combined with local flaps, skin grafting, and primary closure. Over the past twenty years, advances in microsurgical composite tissue transfer have increased the rates of salvage of severe lower extremity injuries with partial or near-total restoration of lost functionality.9–12 Free functioning muscle transfers have been well described in both the face and upper extremity.13–16 In contrast, the literature on free functioning muscle transfer in the lower extremity consists of case reports and a few clinical series. The largest series of post-traumatic free functioning muscle transfers in the lower extremity was a series of 15 patients reported by Lin et al.12 of which only one was for posterior compartment reconstruction, utilizing the rectus femoris muscle in an adult patient. In the present report, we present a case of the use of a free functional latissimus dorsi muscle transfer to Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Kentucky, Lexington, KY Additional Supporting Information may be found in the online version of this article. *Correspondence to: Brian D. Rinker, M.D., Associate Professor of Surgery, Division of Plastic Surgery, University of Kentucky College of Medicine, 740 South Limestone, KY Clinic K446, Lexington, KY 40536-0284. E-mail: [email protected] Received 18 June 2014; Revision accepted 2 June 2015; Accepted 3 June 2015 Published online 24 June 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22443 Ó 2015 Wiley Periodicals, Inc.
reconstruct the posterior compartments of a pediatric patient who suffered a severe traumatic injury to his right lower extremity. CASE REPORT
An 8-year-old male sustained a severe crushing injury when he fell off a tractor during a hayride and was pinned beneath the wagon and a gate. He was airlifted from the scene to the University of Kentucky Children’s Hospital for initial evaluation and management. On initial examination, the patient was found to have a significant soft tissue injury to the posterior compartments of the right lower extremity as well as a grade IIIB open tibia and fibula fracture (Fig. 1A). The distal extremity was warm with evidence of perfusion. A dorsalis pedis pulse was present, but there was no pulse or Doppler signal over the posterior tibal artery. The patient was taken to the operating room emergently for wound debridement and stabilization of his open fractures. A uniplanar external fixator was placed and intraoperative exploration revealed an intact anterior tibial artery but severed posterior tibial and peroneal vessels, with segmental loss. The latter were ligated, as the single remaining vessel appeared to be adequately perfusing the extremity. There was a large deficit of soft tissues, including 150 cm2 of skin and nearly all of the muscles of the superficial and deep posterior compartments. In addition, the patient was noted to have segmental loss of the tibial nerve with a 6 cm nerve gap. The proximal and distal nerve ends were tagged with sutures, the wound was debrided, and a subatmospheric dressing was applied. On post-injury day 2, the patient was brought back to the operating room for further debridement. On postinjury day 4, the patient was brought back to the operating room for open reduction and internal fixation of the
78
Rednam and Rinker
Figure 2. Latissimus dorsi musculocutaneous flap with neurovascular pedicle.
Figure 1. A: Appearance on the day of injury, with traumatic loss of both deep and superficial posterior compartments, a 6 cm segment defect of the tibial nerve and Gustillo IIIB fracture. B: Appearance on post-injury day 4 after reduction and fixation of fractures.
tibia fracture, and at that time a composite reconstruction of the soft tissue was undertaken (Fig. 1B). The posterior muscle compartments and overlying skin were reconstructed with a free microvascular latissimus dorsi musculocutaneous flap (Figs. 2 and 3). The thoracodorsal artery was anastomosed to the tibioperoneal trunk in an end-toside fashion and the vein to the popliteal vein in an endto-side fashion. The tibial nerve was reconstructed with cable autografts. Five cables were used, each measuring 6 cm in length. Both sural nerves were used as donors, as well as a segment of the thoracodorsal nerve. To provide a functional muscle transfer, a branch of the tibial nerve to the absent soleus muscle was identified and coapted to the thoracodorsal nerve near its entry into the latissimus dorsi muscle. The muscle was inset proximally to the remaining stump of the medial and lateral gastrocnemius muscle and distally to the Achilles tendon at functional resting tension. The remaining 50 cm2 of open wound was reconstructed with a split thickness skin graft. The patient was brought back to the operating room two weeks later for debridement of a small residual medial leg wound and skin grafting. Physical therapy was initiated during the hospital admission and included range of motion and mobility training. Partial weightbearing was initiated at six weeks postoperatively. At three months there was radiologic evidence of bony union and full weight bearing was permitted. At 6 months post-injury, the patient was bearing weight fully and engaging in regular physical therapy for Microsurgery DOI 10.1002/micr
Figure 3. Appearance immediately following flap inset.
strengthening and motor retraining. His tibia was healed clinically and radiologically. On motor testing, recovery of plantar flexion was demonstrated to the M4 level, by the modified Medical Research Council (MRCC) grading system.17 The patient was able to ambulate, run lightly, and play basketball (Supporting Information Video). At 2 years postoperatively, the measured static and moving 2-pt discrimination on the plantar foot was 8 mm and 6 mm, respectively. Plantar flexion recovery was at the M5 level, and the patient was running and playing competitive basketball without difficulty (Figs. 4A–4C) DISCUSSION
The decision to amputate or attempt salvage of a mangled lower extremity is complex, and many factors must be considered to determine the patient’s overall limb prognosis.6 In pediatric patients, the traditional relative indications for amputation, such as large soft tissue loss and tibial nerve injury, must be reconsidered. In these cases, all options to restore a functional limb should be explored.
Composite Lower Extremity Reconstruction
Figure 4. A: Appearance at 2 years post-injury. B: Appearance at 2 years post-injury, demonstrating active plantar flexion. C: Appearance at 2 years post-injury, demonstrating active dorsiflexion.
In order to restore a normal gait, both plantar flexion and dorsiflexion should be preserved as well as plantar sensation. In the setting of large segmental loss of musculotendinous units, these functionalities can be restored through functional muscle transfer. The latissimus dorsi muscle is a large muscle that can be harvested along with a skin paddle in order to reconstruct composite deficits. It is one of the most commonly used free flaps, and its dissection is routine for most reconstructive surgeons.4,18–21 The thoracodorsal nerve innervates the entire latissimus dorsi muscle making it an ideal donor muscle for functional transfer.22 The latissimus dorsi flap was selected in this patient due to the large volumetric needs of the defect and the need for relatively larger vessels in a pediatric patient. However, functional donor site deficit was a significant concern. In a recent meta-analysis, Lee and Mun identified 22 articles which included data on functional donor morbidity following latissimus dorsi harvest.23 The DASH (Disabilities of the Arm, Shoulder, and Hand) Outcome Measure was performed in 163 patients. The DASH score for the disability/symptoms module and optional work module were 20 was reported for the sports/music module in two studies. This suggests that the latissimus donor site is well tolerated in the majority of patients and does not typically interfere with activities of daily living or work-related activities. However, it may result in permanent disabilities in some individuals who engage in upper level sporting or musical endeavors.23 After revascularization, the donor nerve should be coapted as close as possible to the recipient neuromuscular junction to minimize the distance of neuroregeneration.24 Attention should be paid toward insetting the
79
muscular portion of the flap at its normal resting tension to ensure the best muscle function. Immobilization is recommended for 4–6 weeks with gradual dangling of the extremity over time. Weight bearing status is dependent largely upon underlying orthopedic injuries. Long-term physical and occupational therapy play a key role in optimizing the functional free muscle transfer. Splinting and gentle passive range of motion is begun at 2 weeks postoperatively and continued throughout the recovery period to prevent joint contracture. Active motor retraining and strengthening are begun at 6 weeks postoperatively with gait training initiated with weightbearing restrictions are lifted. Free functioning muscle transfers for the lower extremity are based on techniques described for facial reanimation,13 restoration of upper extremity flexion and extension,14,15,25 and detrusor myoplasty for a contractile bladder.24 The goal of such a transfer is to provide a dynamic functioning muscle rather than a passive soft tissue reconstruction alone. In a landmark 1999 paper, Doi et al. presented a series of 17 patients who underwent reconstruction of extremity defects following resection of sarcomas with free functional muscle transfers, including 12 patients who received latissimus dorsi flaps for restoration of knee flexion or extension. In the discussion, the authors recommend this flap due to its excellent strength and excursion.26 In the last decade there have been several case reports and short clinical series further demonstrating the usefulness of the latissimus dorsi functional muscle transfer to restore knee extension following oncologic quadriceps resection.8,27–29 There are very few reports utilizing the latissimus dorsi functional muscle transfer in the setting of lower extremity trauma. Kobayashi et al. presented the use of the latissimus dorsi functional muscle transfer to restore ankle dorsiflexion in a case of tibial compartment syndrome.2 In 2005, Ozkan et al. presented a case of combined lower extremity revascularization and anterior compartment soft tissue restoration with a single flowthrough functioning latissimus dorsi flap in a child.30 In the present case, the patient had an intact anterior tibial artery and dorsalis pedis pulse in the foot, obviating the need for vascular reconstruction. Therefore, we elected to use a less technically demanding end-to-side anastomosis to the intact tibioperoneal trunk. However the flowthrough design is an option when simultaneous vascular reconstruction is necessary. Use of the lattisimus dorsi muscle as a functional muscle transfer for lower extremity posterior compartment reconstruction has not been reported previously. In addition, this is the first reported case of lower leg posterior compartment reconstruction with a free functioning muscle transfer in a child, and the first posterior compartment functioning reconstruction utilizing the latissimus dorsi muscle. Microsurgery DOI 10.1002/micr
80
Rednam and Rinker
Functional muscle transfer in a pediatric patient with a severe lower extremity injury with composite tissue loss may provide composite soft tissue reconstruction as well as motor-unit deficit reconstruction, and an acceptable return of functionality may be achieved. Due to the excellent capacity for functional recovery in pediatric patients, traditional contraindications to salvage, such as extensive segmental soft tissue loss and tibial nerve loss, should be reconsidered.
REFERENCES 1. Asirvatham R, Watts HG, Gillies H. Extensor hallucis longus coaptation to tibialis anterior: A treatment for paralytic drop foot. Foot Ankle 1993;14:343–346. 2. Kobayashi S, Sekiguchi J, Sakai Y, Ohmori KJ. Functioning free muscle transplantation to the lower leg. J Reconstr Microsurg 1995; 11:319–325. 3. Mont MA, Dellon AL, Chen F, Hungerford MW, Krackow KA, Hungerford DS. The operative treatment of peroneal nerve palsy. J Bone Joint Surg 1996;78:863–869. 4. Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg 2001;108:1029–1041. 5. 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;24:742–746. 6. Lange RH, Bach AW, Hansen ST Jr, Johansen KH. Open tibial fractures with associated vascular injuries: Prognosis for limb salvage. J Trauma 1985;25:203–208. 7. Carlson GW. The evolution of extremity reconstruction for soft tissue sarcoma. Ann Surg Oncol 2006;13:610–611. 8. Grinsel D, Di Bella C, Choong PF. Functional reconstruction of sarcoma defects utilizing innervated free flaps. Sarcoma 2012;2012: 315190. 9. Hallock GG. Simultaneous transposition of anterior thigh muscle and fascial flap: An introduction to the chimera flap principle. Ann Plast Surg 1991;27:126–131. 10. 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 defects. Plast Reconstr Surg 1997;99:1656–1665. 11. Lin CH, Wei FC, Lin YT, Yeh JT, Rodriguez Ede J, Chen CT. Lateral circumflex femoral artery system: Warehouse for functional composite free-tissue reconstruction of the lower leg. J Trauma 2006;60:1032–1036. 12. Lin CH, Lin YT, Yeh JT, Chen CT. Free functioning muscle transfer for lower extremity posttraumatic composite structure and functional defect. Plast Reconstr Surg 2007;119:2118–2126. 13. Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation, with microneurovascular anastomoses for the treatment of facial paralysis. A preliminary report. Plast Reconstr Surg 1976;57: 133–143.
Microsurgery DOI 10.1002/micr
14. Ikuta Y, Kubo T, Tsuge K. Free muscle transplantation by microsurgical technique to treat severe Volkmann’s contracture. Plast Reconstr Surg 1976;58:407–411. 15. Terzis JK, Sweet RC, Dykes RW, Williams HB. Recovery of function in free muscle transplants using microneurovascular anastomoses. J Hand Surg 1978;3:37–59. 16. Manktelow RT, McKee NH. Free muscle transplantation to provide active finger flexion. Hand Surg Am 1978;3:416–426. 17. Mackinnon SE, Dellon AL. Results of nerve repair and grafting. In: Mackinnon SE, Dellon AL, editors. Surgery of the Peripheral Nerve, 1st ed. New York; Thieme Medical; 1988. pp 89–129. 18. Pearl RM, Hentz VR. Irreplaceable free flaps in reconstructive surgery—Part I. Ann Plast Surg 1982;9:479–487. 19. Trignano E, Fallico N, Nitto A, Chen HC. The treatment of composite defect of bone and soft tissues with a combined latissimus dorsi and serratus anterior and rib free flap. Microsurgery 2013;33:173–183. 20. Zhu YL, Wang Y, He XQ, Zhu M, Li FB, Xu YQ. Foot and ankle reconstruction: An experience on the use of 14 different flaps in 226 cases. Microsurgery 2013;33:600–604. 21. Kim JT, Kim SW, Youn S, Kim YH. What is the ideal free flap for soft tissue reconstruction? A 10-year experience of microsurgical reconstruction using 334 latissimus dorsi flaps from a universal donor site. Ann Plast Surg 2015;75:49–54. 22. Taylor GI, Gianoutsos MP Morris SF. The neurovascular territories of the skin and muscles: Anatomic study and clinical implications. Plast Reconstr Surg 1994;94:1–36. 23. Lee KT, Mun GH. A systematic review of functional donor-site morbidity after latissimus dorsi muscle transfer. Plast Reconstr Surg 2014;134:303–314. 24. Ninkovic M, Stenzl A, Hess M, Feichtinger H, Schwabegger A, Colleselli K, Bartsch G, Anderl H. Functional urinary bladder wall substitute using a free innervated latissimus dorsi muscle flap. Plast Reconstr Surg 1997;100:402–411. 25. Manktelow RT. Functioning muscle transplantation to the arm. In: Brunelli G, editor. Textbook of Microsurgery. Milan: Masson SPA; 1988. pp 435–438. 26. Doi K, Kuwata N, Kawakami F, Hattori Y, Otsuka K, Ihara K. Limb-sparing surgery with reinnervated free-muscle transfer following radical excision of soft-tissue sarcoma in the extremity. Plast Reconstr Surg 1999;104:1679–1687. 27. Willcox TM, Smith AA, Beauchamp C, Meland NB. Functional free latissimus dorsi muscle flap to the proximal lower extremity. Clin Orthop Relat Res 2003;410:285–288. 28. Innocenti M, Abed YY, Beltrami G, Delcroix L, Balatri A, Capanna R. Quadriceps muscle reconstruction with free functioning latissimus dorsi muscle flap after oncological resection. Microsurgery 2009;29: 189–198. 29. Muramatsu K, Ihara K, Miyoshi T, Yoshida K, Hashimoto T, Taguchi T. Transfer of latissimus dorsi muscle for the functional reconstruction of quadriceps femoris muscle following oncological resection of sarcoma in the thigh. J Plast Reconstr Aesthet Surg 2011;64:1068–1074. 30. Ozkan O, Ozgentas¸ HE, Dikici MB. Flow-through, functioning, free musculocutaneous flap transfer for restoration of a mangled extremity. J Reconstr Microsurg 2005;21:167–172.
We present an unusual case in an 8-year-old male that presented with a severe crushing injury to the right lower extremity with grade IIIB open tibia/fibula fracture and composite loss of the majority of the posterior muscle compartments and overlying skin and segmental loss of the tibial nerve. Composite reconstruction was performed with internal fixation, cable autografting of the tibial nerve, and a functional latissimus dorsi musculocutaneous flap. A motor branch of the tibial nerve to the soleus was used as the donor motor nerve. The patient achieved a bony union and began ambulating at 8 weeks postoperatively. At 24 months, the patient was running and jumping with plantar push-off. Recovery of plantar flexion was to the M5 level. Static and moving 2-point discrimination of the plantar foot was 8 mm and 6 mm, respectively. Functioning muscle transfer in a child with a severe lower extremity injury with composite tissue loss may provide soft C 2015 Wiley Periodicals, Inc. Microsurgery 36:77– tissue and motor-unit defect reconstruction with an acceptable functional restoration. V 80, 2016.
In the past, severe lower extremity injuries were either often treated with amputation or salvage without restoration of muscle function. Tendon transfer in the lower extremity is an acceptable reconstructive method; however, not all complex lower extremity injuries are amenable to this type of reconstruction.1–4 Free tissue transfer has become the standard of care for the salvage of large lower extremity wounds secondary to trauma or oncologic resection.5–8 Free functional tissue transfer may provide superior results over traditional tendon transfers and can be combined with local flaps, skin grafting, and primary closure. Over the past twenty years, advances in microsurgical composite tissue transfer have increased the rates of salvage of severe lower extremity injuries with partial or near-total restoration of lost functionality.9–12 Free functioning muscle transfers have been well described in both the face and upper extremity.13–16 In contrast, the literature on free functioning muscle transfer in the lower extremity consists of case reports and a few clinical series. The largest series of post-traumatic free functioning muscle transfers in the lower extremity was a series of 15 patients reported by Lin et al.12 of which only one was for posterior compartment reconstruction, utilizing the rectus femoris muscle in an adult patient. In the present report, we present a case of the use of a free functional latissimus dorsi muscle transfer to Division of Plastic & Reconstructive Surgery, Department of Surgery, University of Kentucky, Lexington, KY Additional Supporting Information may be found in the online version of this article. *Correspondence to: Brian D. Rinker, M.D., Associate Professor of Surgery, Division of Plastic Surgery, University of Kentucky College of Medicine, 740 South Limestone, KY Clinic K446, Lexington, KY 40536-0284. E-mail: [email protected] Received 18 June 2014; Revision accepted 2 June 2015; Accepted 3 June 2015 Published online 24 June 2015 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/micr.22443 Ó 2015 Wiley Periodicals, Inc.
reconstruct the posterior compartments of a pediatric patient who suffered a severe traumatic injury to his right lower extremity. CASE REPORT
An 8-year-old male sustained a severe crushing injury when he fell off a tractor during a hayride and was pinned beneath the wagon and a gate. He was airlifted from the scene to the University of Kentucky Children’s Hospital for initial evaluation and management. On initial examination, the patient was found to have a significant soft tissue injury to the posterior compartments of the right lower extremity as well as a grade IIIB open tibia and fibula fracture (Fig. 1A). The distal extremity was warm with evidence of perfusion. A dorsalis pedis pulse was present, but there was no pulse or Doppler signal over the posterior tibal artery. The patient was taken to the operating room emergently for wound debridement and stabilization of his open fractures. A uniplanar external fixator was placed and intraoperative exploration revealed an intact anterior tibial artery but severed posterior tibial and peroneal vessels, with segmental loss. The latter were ligated, as the single remaining vessel appeared to be adequately perfusing the extremity. There was a large deficit of soft tissues, including 150 cm2 of skin and nearly all of the muscles of the superficial and deep posterior compartments. In addition, the patient was noted to have segmental loss of the tibial nerve with a 6 cm nerve gap. The proximal and distal nerve ends were tagged with sutures, the wound was debrided, and a subatmospheric dressing was applied. On post-injury day 2, the patient was brought back to the operating room for further debridement. On postinjury day 4, the patient was brought back to the operating room for open reduction and internal fixation of the
78
Rednam and Rinker
Figure 2. Latissimus dorsi musculocutaneous flap with neurovascular pedicle.
Figure 1. A: Appearance on the day of injury, with traumatic loss of both deep and superficial posterior compartments, a 6 cm segment defect of the tibial nerve and Gustillo IIIB fracture. B: Appearance on post-injury day 4 after reduction and fixation of fractures.
tibia fracture, and at that time a composite reconstruction of the soft tissue was undertaken (Fig. 1B). The posterior muscle compartments and overlying skin were reconstructed with a free microvascular latissimus dorsi musculocutaneous flap (Figs. 2 and 3). The thoracodorsal artery was anastomosed to the tibioperoneal trunk in an end-toside fashion and the vein to the popliteal vein in an endto-side fashion. The tibial nerve was reconstructed with cable autografts. Five cables were used, each measuring 6 cm in length. Both sural nerves were used as donors, as well as a segment of the thoracodorsal nerve. To provide a functional muscle transfer, a branch of the tibial nerve to the absent soleus muscle was identified and coapted to the thoracodorsal nerve near its entry into the latissimus dorsi muscle. The muscle was inset proximally to the remaining stump of the medial and lateral gastrocnemius muscle and distally to the Achilles tendon at functional resting tension. The remaining 50 cm2 of open wound was reconstructed with a split thickness skin graft. The patient was brought back to the operating room two weeks later for debridement of a small residual medial leg wound and skin grafting. Physical therapy was initiated during the hospital admission and included range of motion and mobility training. Partial weightbearing was initiated at six weeks postoperatively. At three months there was radiologic evidence of bony union and full weight bearing was permitted. At 6 months post-injury, the patient was bearing weight fully and engaging in regular physical therapy for Microsurgery DOI 10.1002/micr
Figure 3. Appearance immediately following flap inset.
strengthening and motor retraining. His tibia was healed clinically and radiologically. On motor testing, recovery of plantar flexion was demonstrated to the M4 level, by the modified Medical Research Council (MRCC) grading system.17 The patient was able to ambulate, run lightly, and play basketball (Supporting Information Video). At 2 years postoperatively, the measured static and moving 2-pt discrimination on the plantar foot was 8 mm and 6 mm, respectively. Plantar flexion recovery was at the M5 level, and the patient was running and playing competitive basketball without difficulty (Figs. 4A–4C) DISCUSSION
The decision to amputate or attempt salvage of a mangled lower extremity is complex, and many factors must be considered to determine the patient’s overall limb prognosis.6 In pediatric patients, the traditional relative indications for amputation, such as large soft tissue loss and tibial nerve injury, must be reconsidered. In these cases, all options to restore a functional limb should be explored.
Composite Lower Extremity Reconstruction
Figure 4. A: Appearance at 2 years post-injury. B: Appearance at 2 years post-injury, demonstrating active plantar flexion. C: Appearance at 2 years post-injury, demonstrating active dorsiflexion.
In order to restore a normal gait, both plantar flexion and dorsiflexion should be preserved as well as plantar sensation. In the setting of large segmental loss of musculotendinous units, these functionalities can be restored through functional muscle transfer. The latissimus dorsi muscle is a large muscle that can be harvested along with a skin paddle in order to reconstruct composite deficits. It is one of the most commonly used free flaps, and its dissection is routine for most reconstructive surgeons.4,18–21 The thoracodorsal nerve innervates the entire latissimus dorsi muscle making it an ideal donor muscle for functional transfer.22 The latissimus dorsi flap was selected in this patient due to the large volumetric needs of the defect and the need for relatively larger vessels in a pediatric patient. However, functional donor site deficit was a significant concern. In a recent meta-analysis, Lee and Mun identified 22 articles which included data on functional donor morbidity following latissimus dorsi harvest.23 The DASH (Disabilities of the Arm, Shoulder, and Hand) Outcome Measure was performed in 163 patients. The DASH score for the disability/symptoms module and optional work module were 20 was reported for the sports/music module in two studies. This suggests that the latissimus donor site is well tolerated in the majority of patients and does not typically interfere with activities of daily living or work-related activities. However, it may result in permanent disabilities in some individuals who engage in upper level sporting or musical endeavors.23 After revascularization, the donor nerve should be coapted as close as possible to the recipient neuromuscular junction to minimize the distance of neuroregeneration.24 Attention should be paid toward insetting the
79
muscular portion of the flap at its normal resting tension to ensure the best muscle function. Immobilization is recommended for 4–6 weeks with gradual dangling of the extremity over time. Weight bearing status is dependent largely upon underlying orthopedic injuries. Long-term physical and occupational therapy play a key role in optimizing the functional free muscle transfer. Splinting and gentle passive range of motion is begun at 2 weeks postoperatively and continued throughout the recovery period to prevent joint contracture. Active motor retraining and strengthening are begun at 6 weeks postoperatively with gait training initiated with weightbearing restrictions are lifted. Free functioning muscle transfers for the lower extremity are based on techniques described for facial reanimation,13 restoration of upper extremity flexion and extension,14,15,25 and detrusor myoplasty for a contractile bladder.24 The goal of such a transfer is to provide a dynamic functioning muscle rather than a passive soft tissue reconstruction alone. In a landmark 1999 paper, Doi et al. presented a series of 17 patients who underwent reconstruction of extremity defects following resection of sarcomas with free functional muscle transfers, including 12 patients who received latissimus dorsi flaps for restoration of knee flexion or extension. In the discussion, the authors recommend this flap due to its excellent strength and excursion.26 In the last decade there have been several case reports and short clinical series further demonstrating the usefulness of the latissimus dorsi functional muscle transfer to restore knee extension following oncologic quadriceps resection.8,27–29 There are very few reports utilizing the latissimus dorsi functional muscle transfer in the setting of lower extremity trauma. Kobayashi et al. presented the use of the latissimus dorsi functional muscle transfer to restore ankle dorsiflexion in a case of tibial compartment syndrome.2 In 2005, Ozkan et al. presented a case of combined lower extremity revascularization and anterior compartment soft tissue restoration with a single flowthrough functioning latissimus dorsi flap in a child.30 In the present case, the patient had an intact anterior tibial artery and dorsalis pedis pulse in the foot, obviating the need for vascular reconstruction. Therefore, we elected to use a less technically demanding end-to-side anastomosis to the intact tibioperoneal trunk. However the flowthrough design is an option when simultaneous vascular reconstruction is necessary. Use of the lattisimus dorsi muscle as a functional muscle transfer for lower extremity posterior compartment reconstruction has not been reported previously. In addition, this is the first reported case of lower leg posterior compartment reconstruction with a free functioning muscle transfer in a child, and the first posterior compartment functioning reconstruction utilizing the latissimus dorsi muscle. Microsurgery DOI 10.1002/micr
80
Rednam and Rinker
Functional muscle transfer in a pediatric patient with a severe lower extremity injury with composite tissue loss may provide composite soft tissue reconstruction as well as motor-unit deficit reconstruction, and an acceptable return of functionality may be achieved. Due to the excellent capacity for functional recovery in pediatric patients, traditional contraindications to salvage, such as extensive segmental soft tissue loss and tibial nerve loss, should be reconsidered.
REFERENCES 1. Asirvatham R, Watts HG, Gillies H. Extensor hallucis longus coaptation to tibialis anterior: A treatment for paralytic drop foot. Foot Ankle 1993;14:343–346. 2. Kobayashi S, Sekiguchi J, Sakai Y, Ohmori KJ. Functioning free muscle transplantation to the lower leg. J Reconstr Microsurg 1995; 11:319–325. 3. Mont MA, Dellon AL, Chen F, Hungerford MW, Krackow KA, Hungerford DS. The operative treatment of peroneal nerve palsy. J Bone Joint Surg 1996;78:863–869. 4. Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg 2001;108:1029–1041. 5. 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;24:742–746. 6. Lange RH, Bach AW, Hansen ST Jr, Johansen KH. Open tibial fractures with associated vascular injuries: Prognosis for limb salvage. J Trauma 1985;25:203–208. 7. Carlson GW. The evolution of extremity reconstruction for soft tissue sarcoma. Ann Surg Oncol 2006;13:610–611. 8. Grinsel D, Di Bella C, Choong PF. Functional reconstruction of sarcoma defects utilizing innervated free flaps. Sarcoma 2012;2012: 315190. 9. Hallock GG. Simultaneous transposition of anterior thigh muscle and fascial flap: An introduction to the chimera flap principle. Ann Plast Surg 1991;27:126–131. 10. 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 defects. Plast Reconstr Surg 1997;99:1656–1665. 11. Lin CH, Wei FC, Lin YT, Yeh JT, Rodriguez Ede J, Chen CT. Lateral circumflex femoral artery system: Warehouse for functional composite free-tissue reconstruction of the lower leg. J Trauma 2006;60:1032–1036. 12. Lin CH, Lin YT, Yeh JT, Chen CT. Free functioning muscle transfer for lower extremity posttraumatic composite structure and functional defect. Plast Reconstr Surg 2007;119:2118–2126. 13. Harii K, Ohmori K, Torii S. Free gracilis muscle transplantation, with microneurovascular anastomoses for the treatment of facial paralysis. A preliminary report. Plast Reconstr Surg 1976;57: 133–143.
Microsurgery DOI 10.1002/micr
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