Floor plan - 2013 Annual Meeting - American Association for Hand ...

The Distal Superficial Femoral Arterial (SFA) Branch to the Sartorius Muscle as Recipient
Vessels for Peri-Knee Soft Tissue Reconstruction: Anatomic Study and Clinical Applications
Institution where the work was prepared: University of California, San Francisco, San Francisco, CA, USA
Fernando Herrera, MD; University of California, San Diego; Charles K. Lee, MD; University of California, San Francisco
(UCSF); Mark W. Kiehn, MD; University of Wisconsin; Scott Lee Hansen, MD; University of California at San Francisco
(UCSF)
BACKGROUND:
Soft tissue defects around the peri-knee and upper-third open tibial wounds present a significant challenge, particularly for large defects
which frequently require free tissue transfer. Recipient vessels for this region include the femoral, popliteal, and other distal branches.
Often times, these vessels are not optimal because of location or zone of injury. We describe a consistent recipient vessel choice for
microsurgical anastomosis, the distal SFA branch to the sartorius muscle (saphenous artery).
MATERIALS/METHODS:
4 fresh cadaver legs were dissected to identify the SFA branch to the sartorius muscle. Anatomic landmarks and measurements were
taken to identify the takeoff point of the distal sartorius branch and caliber of vessel. A case series of peri-knee reconstruction is
described to demonstrate its clinical utility
RESULTS:
The distal SFA branch was identified in all 4 cadaver specimens. The vessel takes off at 13cm (mean) proximal to the medial epicondyle
of the femur. Mean diameter was 1.5mm. The vessel can be found through an incision over the adductor hiatus. Dissection is taken
down to the superior border of the sartorius muscle and then posterior to the muscle. The branch to the muscle can be seen originating
from the SFA and enters the muscle from its deep side, accompanying the saphenous nerve. 3 cases of successful lower extremity
reconstruction with free tissue transfer and use of the distal SFA branch to the sartorius as recipient vessels are described. Venous outflow
was established with the sartorius branch or saphenous vein.
DISCUSSION:
Vessel choices for free tissue transfer around the knee include the popliteal, the descending geniculate artery, the superior medial
geniculate artery, the superficial femoral artery, and others. Recently, we have preferentially used the descending genicular vessels. In a
number of cases these vessels were absent or inadequate and compelled us to search for another vessel option which gave similar
advantages: consistent anatomy, good caliber vessels (>1.5mm diameter), proximal to the zone of injury, and a nearby saphenous vein
for outflow. The distal SFA branch to the sartorius gives these advantages and appears to be more consistent.
Trends in the Treatment of Severe Open Tibial Fractures
Institution where the work was prepared: BG Trauma Center Ludwigshafen, Ludwigshafen, Germany
Christoph Czermak; Emilios Nalbantis; Guenter Germann; Christoph Heitmann; University of Heidelberg
INTRODUCTION:
Treatment of severe open tibial fractures (Gustilo IIIb, IIIc) represent the classic interface between orthopedic and plastic surgery. This
“orthoplastic” approach is currently considered the Standard of Care. “Fix and flap” within the first 72-96 hours has been postulated
as “golden window“ in the treatment of these type of injuries. This retrospective study addresses the following questions: 1. Is the postulated
“golden window” practicable in a Level III Trauma Center? 2. How does the interval between trauma and reconstruction influence
the final outcome with respect to limb salvage? 3. Is limb salvage correlated to the type of flap employed? 4. Patient satisfaction
with the functional and aesthetic result. 5. Options of secondary othopedic correction in correlation to the flap type.
PATIENTS/METHODS:
During a five year period, 92 patients with severe open tibial fractures underwent reconstruction using different types of free flaps.
Twenty-five patients were primarily treated in our institution, 67 were secondary referrals after bone-reconstruction on outlying orthopedic
units. There were 72 men and 20 women, mean age 46 years (10-79). Study parameters were: Interval between trauma and reconstruction,
type of free flap, Hannover Functional Ability Questionaire, patient satisfaction, VAS, complications, limb salvage, secondary
orthopedic approach, Cybex.
RESULTS:
The following free flaps were used for reconstruction: Latissimus dorsi (39), Gracilis muscle (16), Rectus abdominis muscle (2), ALT (32),
Parascapular (2), Radial forearm (1), Lateral arm (1). 66 patients could be evaluated postoperative (71%). Flap survival rate was 91,4%. 5
of 8 patients with total flap loss underwent reconstruction with a second free flap, three patients had lower leg amputation. Average
interval between trauma and definitive wound closure was 18,6 (4-59) days. Mean score of FFbH was 72 (0-100), meaning a normal result.
Regarding the functional results there were no significant differences between musculocutaneous and cutaneous free flaps. Aesthetical
results of cutaneous flaps were superior compared to myocutaneous flaps.
DISCUSSION:
In none of our cases we could stay within the “golden window”. However, our data show that this had no significant influence on the
rate of limb salvage. Complication rate in comparison to the literature is not significantly increased. This may partly due to the fact that
the use of A-V loops to perform the vascular anastomosis remote from the zone of injuy is liberal in our department. Cutaneous perforator
flaps proved to be superior with respect to aesthetics and simplification of secondary orthopedic procedures than myocutaneous
flaps.
167