Keywords
soft tissue injuries - perforator flap - lower extremity
Introduction
The World Health Organization (WHO) estimates that about 50 million victims of traffic
accidents live with disabilities or sequelae.[1] In Brazil, data from the Unified Health System (Sistema Único de Saúde, SUS, in
Portuguese) indicate an estimated cost of R$ 2.9 billion (Brazilian currency) due
to traffic accidents.[2]
Pedestrians, cyclists, and motorcyclists are the groups most vulnerable to traffic
accidents. Most patients are victims of motorcycle accidents, and they are young (25
to 35 years old) and male.[3] Polytrauma resulting from a motorcycle accident causes more serious injuries to
the head and extremities, with the main causes of death being fractures of the limbs
and pelvis, followed by trauma, laceration or rupture of abdominal organs, and traumatic
brain injuries.[4]
Traffic accidents lead to orthopedic trauma. Advances in medicine stimulate the improvement
of surgical techniques.[5] The injuries include complex injuries to the lower limbs, which are a challenge
regarding which type of treatment is most appropriate.[6] Reconstructive surgeries are complex due to the anatomical characteristics that
lead to difficulty in treating soft-tissue injuries.[7]
The flaps consist of mobilized tissue that is kept attached to its vascular pedicle,
ensuring adequate irrigation.[8] The use of propeller flaps to cover soft-tissue injuries started in 1991 as a surgical
approach to the substantial loss caused by trauma. Its use in the clinical practice
has improved as knowledge about the cutaneous vascular system increased. The factors
involved in choosing the most appropriate surgical technique include the location,
the extent of the lesion, the exposure of noble structures, and the surgeon's experience
with reconstruction techniques.[9]
The use of the propeller flap to cover lesions is an option when the area to be treated
is small to medium in size, located in a well-vascularized region, and surrounded
by healthy tissues. In this technique, we should consider the quality and volume of
the transferred soft tissue, the orientation of the scar and the adequate planning
of the flap, to enable the direct closure of the donor site without tension in the
area. When these indications are respected, the propeller flap has a high success
rate, low morbidity, fast recovery, good esthetic results, and reduced cost.[10]
The aim of the present article was to evaluate the use of a propeller flap to cover
soft-tissue injuries in the lower limb, as well as to identify the main causes of
trauma and the complications resulting from the surgical technique.
Material and Methods
The present is a retrospective cross-sectional study, which was carried out by reviewing
medical records and using a convenience sample. Data were obtained from the electronic
records of the patients cared for and registered in the Conecte/w (Wareline do Brasil,
Goiânia, GO, Brazil) software at the orthopedics emergency room of Hospital de Urgências,
from July 2018 to June 2019, for surgical treatment of soft-tissue injuries in the
lower limbs. Data collection was carried out with the Medical Archive and Statistics
Sector (Setor de Arquivo Médico e Estatística, SAME, in Portuguese).
After selecting the medical records, the following clinical aspects were evaluated:
1) sex; 2) age group; 3) type of injury; 4) cause of the injury; 5) initial diagnosis;
6) affected site; 7) incision and identification technique; 8) surgical planning;
9) flap design; 10) postoperative period; 11) result of the propeller flap; and 12)
complications. The data were collected in a specific form, and for the purpose of
comparison, photographic records of the surgical and postsurgical procedures were
used, and the frequencies were estimated in relation to the variables.
Results
Within 1 year, 14 individuals with soft-tissue injuries in the lower limbs undergoing
the propeller-flap surgical technique were identified. Regarding gender, all patients
were male (n = 14; 100%). The mean age of the patients was 36.4 ± 8.48 years, ranging from 26
to 48 years, with the highest frequency being that of young adults (25 to 29 years;
n = 4; 28.6%) and adults between 45 and 49 years of age (n = 4; 28.6%). Regarding the type of injury, most patients presented soft-tissue injuries,
with exposure of noble structures such as tendons, and without associated open fractures
(n = 08; 57%); the right side was the most affected (n = 10; 71.4%).
Motorcycle accidents were the main cause of injury among patients undergoing the propeller-flap
surgical procedure (n = 13; 92.7%). Only 1 (7.1%) patient suffered an injury resulting from a car accident.
Among the affected areas ([Table 1]), the posterior aspect of the distal third of the right leg was the most frequently
affected (n = 5; 35.7%), followed by the medial distal third on the same side (n = 3; 21.5%).
Table 1
|
Case
|
Age (years)
|
Flap (cm)
|
Affected location
|
Complications
|
Additional procedures
|
|
1
|
42
|
10 × 2
|
Medial face of the distal third of the right leg
|
No Complications
|
Skin graft
|
|
2
|
37
|
7 × 7
|
Medial face of the distal third of the left leg
|
Bleeding
|
Flap slimming
|
|
3
|
48
|
10 × 7
|
Distal posterior face of the right leg
|
No Complications
|
Skin graft
|
|
4
|
46
|
8 × 3
|
Posterior face of the distal third of the left leg
|
Bleeding
|
None
|
|
5
|
48
|
11 × 4
|
Distal posterior face of the right leg
|
No Complications
|
Skin graft
|
|
6
|
48
|
7 × 5
|
Medial face of the distal third of the right leg
|
No Complications
|
None
|
|
7
|
35
|
9 × 4
|
Medial face of the distal third of the right leg
|
No Complications
|
None
|
|
8
|
35
|
5 × 3
|
Medial face of the middle third of the right leg
|
No Complications
|
None
|
|
9
|
26
|
6 × 4
|
Distal posterior face of the right leg
|
Partial flap necrosis
|
Skin graft
|
|
10
|
28
|
5 × 3
|
Distal posterior face of the right leg
|
Flap dehiscence
|
None
|
|
11
|
27
|
4 × 3
|
Medial face of the middle third of the right leg
|
No Complications
|
None
|
|
12
|
32
|
6 × 4
|
Lateral face of the distal third of the left leg
|
Partial flap necrosis
|
None
|
|
13
|
27
|
6 × 4
|
Lateral face of the distal third of the right leg
|
No Complications
|
Skin graft
|
|
14
|
31
|
8 × 3
|
Medial distal third of the left leg
|
No Complications
|
Skin graft
|
The design of the cover flap of the wound varied from 4 × 3 cm to 11 × 4 cm. The flap
dimensions ranged from 12 cm2 to 70 cm2, with a mean size of 29 cm2 and an interquartile range of 21 cm2 to 38 cm2. Immediate postsurgical complications were present in 35.7% (n = 5) of the cases, and they included excessive bleeding (n = 2; 14.3%), partial necrosis (n = 2; 14.3%), and flap dehiscence (n = 1; 7.1%). In 42.9% (n = 6) of the cases, skin grafting was necessary to cover the donor area ([Table 1]). Regarding the result of the surgical technique used, thirteen patients had excellent
coverage, and in only one there was loss of the flap.
As for the surgical planning, in all cases, the procedure summarized below was followed.
Perforator flaps were indicated to cover wounds in the distal third of the leg and
perimalleolar region in the ankle. The arterial axes were the posterior tibial artery
and the anterior tibial artery. For anteromedial and posterior wounds, the option
was for the posterior tibial artery and lateral anterior tibial artery. The choice
of the perforator flap followed the aforementioned criteria. The patient was anesthetized
in the operating room, and exsanguination of the lower limb was performed. Afterwards,
the flap design was made, and the probable point of location of the pedicle (perforating
artery) was marked, but it was impossible to use the Doppler to identify the pedicle
due to the unavailability of this equipment in the hospital.
For the surgical technique, the procedure used in the cases is summarized below. After
drawing the flap and marking the probable location of the perforating artery, a skin
and subcutaneous incision was made up to the fascia. The fascia was raised subfacially
to locate the perforating artery for the nutrition of the flap. The perforating artery
was identified, with confirmation of its origin in the main axis in the posterior
or anterior tibial artery and entry into the flap through the fascia. Afterwards,
a template was made with a compress cut to the size of the wound to be reconstructed
up to the pedicle. The flap was then dissected and raised close to the fascia. In
all procedures, we ensured that the fascia was part of the flap, since it would be
responsible for the perfusion of the flap. Afterwards, the flap was rotated 180°,
with a larger flap covering the wound. Subsequently, the tourniquet was released,
and the flap perfusion was verified, and the suture was performed. The failure in
the donor area was covered with skin graft when necessary.
The postoperative period described in the medical record consisted of daily changing
the non-compressive dressings and maintaining the limb elevated. After hospital discharge,
the outpatient follow-up was carried out. Between two and four weeks, good flap maintenance
and lesion coverage were already reported in the medical record. [Figures 1] and [2] present the photographic records available in the medical file referring to the
surgical procedure with propeller flap performed on patients in cases 1 and 5 respectively
([Table 1]).
Fig. 1 (A) Soft-tissue injury with tendon exposure; (B) location of the perforating artery;
(C) dissection of the flap; (D) flap rotation; (E) cover and graft; (F) postsurgical
outcome.
Fig. 2 (A) Soft-tissue injury with tendon exposure; (B) location of the perforating artery;
(C) dissection of the flap; (D) flap rotation; (E) postsurgical outcome.
Discussion
In the state of Goiás, Brazil, there was an average of 91 traffic accidents per day
in the first half of 2019. About 60% of the victims of traffic accidents in the capital
city of Goiânia, during this period, were on motorcycles. Male individuals aged between
20 and 29 years represent 42% of the total of people involved in motorcycle accidents
in our country,[11] data similar to those observed in the present study. Sado et al.[12] evaluated the characteristics of victims of motorcycle accidents admitted to the
Emergency Hospital from December 1st to 31, 2007, and observed that the majority were
male (91%), and the most frequent injuries and surgical interventions were located
in the lower limbs (53.3%).
Shen et al.,[13] when evaluating patients with soft-tissue injuries examined at a hospital in China,
observed that most were male (80.6%; n = 29), and the average age was 39.7 years. Mendieta et al.[14] evaluated the use of the propeller flap to cover soft-tissue injuries to the lower
limbs in individuals examined at a hospital in Nicaragua, in which the mean age of
the patients was 32 years, and the male gender accounted for 75% of the cases, numbers
that are lower than those observed in the present study.
Lesions in the lower limbs have a low ratio of fatal cases; however, they require
reparative, corrective surgery, and, in some cases, amputations, which can compromise
the patients' quality of life.[5] When assessing the profile of individuals involved in motorcycle accidents in the
city of São Paulo, Brazil, Debieux et al.[15] observed that most injuries occurred in the lower limbs (53.9%), and more frequently
in the age group between 21 and 24 years (45%). Rezende et al.,[9] when evaluating the epidemiological profile, surgical treatment and postoperative
results of patients with complex traumatic injuries to the lower limbs, observed that
the motorcycle accident was responsible for the majority of the injuries (37.8%),
and that the lower third of the leg was the region most affected by trauma (50.4%),
followed by the medial third (32%).
Exposure of noble areas is common when lesions occur in the distal third of the leg,
requiring that they be covered with good quality tissues and vascularity.[6] The use of flaps to cover injuries resulting from trauma in soft tissues offers
similarities in texture to the injured area, good appearance, and partial or complete
repair of the donor site. The size of the flaps depends on the extent of the area
to be covered.[13] Shen et al.[13] reported in their study flaps ranging from 10 × 5 cm to 34 × 18 cm, values higher
than those reported in the present study. Sasidaran et al.[16] performed reconstruction of soft-tissue defects in the lower limb in 6 patients
from a Malaysian hospital in which the flap dimensions ranged from 3 × 3 cm to 10 × 5 cm,
values closer to those observed in the present study.
Bajantri et al.[17] suggested the use of propeller flaps for defects of up to 50 cm2; however, D'Arpa et al.[18] stated that there are other factors that should be considered when establishing
a maximum flap size, since it depends on the patient's body and leg size, skin flaccidity,
flap volume, adequate closure of the donor site, and countless other factors. The
authors conclude that propeller flaps are still an attractive option for small and
medium defects, especially at the level of the leg and foot.
When evaluating the postsurgical results, Nelson et al.[19] found a partial loss rate of 11.6%, lower than that observed in the present study
(14.3%). Sisti et al.[10] conducted a literature review between 2005 and 2015 and estimated the rate of postsurgical
complications resulting from the propeller-flap technique at 22.6%, and the highest
frequency was observed in the lower limb (31.8%), with partial flap necrosis and venous
congestion being the most frequent complications. In the present study, the complication
rate was higher than the mean observed by Sisti et al.,[10] but with similarity in relation to the most frequent complications.
Conclusion
Despite the limited number of medical records of patients undergoing the propeller-flap
technique to cover lesions in the lower limb, the use of this type of flap proved
to be a good alternative in most of the evaluated cases, with good surgical results,
although complications were observed in some cases.
