Free Flap for traumatic raw area: A case report

Vimala1*, Cecily Ruba2, Mahalakshmi3

1Nursing Incharge, Kauvery Hospital, Cantonment

2Nurse Educator, Kauvery Hospital, Cantonment

3Nursing Superintendent, Kauvery Hospital, Cantonment

Abstract

Free flap is free autologous tissue transfer which is used to describe the transplantation of tissue from one site of the body to another in order to reconstruct an existing defect. Flaps may be composed of any combination of skin, fascia and muscle, and bone complexity may  range from a random pattern skin flap based on a sub dermal plexus to a fascio-osteocutaneous free flap supplied by a known arterial perforator (branches of the deep artery of the thigh, usually three in number, so named because they perforate the tendon of the adductor Magnus to reach the back of the thigh).

Many techniques have been developed for reconstruction of the hand; however, less attention has been paid to foot reconstruction techniques. In particular, reconstruction of the forefoot and big toe has been considered a minor procedure despite the importance of these body parts for standing and walking.

Most of the weight load on the foot is concentrated on the forefoot and big toe, whereas the other toes have a minor role in weight bearing. Moreover, the forefoot and big toe are important for maintaining balance and supporting the body when changing directions. Recently, attention has been focused on the aesthetic appearance and functional aspects of the body, which are important considerations in the field of reconstructive surgery.

In patients, for whom flap reconstruction in the forefoot and big toe is planned, clinicians should pay close attention to flap survival as well as functional and cosmetic outcomes of surgery. In particular, it is important to assess the ability of the flap to withstand functional weight bearing and maintain sufficient durability under shearing force. Recovery of protective sensation in the forefoot area can reduce the risk of flap loss and promote rapid rehabilitation and functional recovery.

Here, we report our experience with a case of successful reconstruction of the 3rd 4th 5th toes with a sensate antero-lateral thigh flap, with a review of the relevant literature.

Background

Injury of the foot are less frequent than those of the hand, and the appropriate reconstructive methods remain unclear and difficult to execute. Previous studies have recommended various functional and cosmetic reconstruction methods for hand injuries while foot injuries are often more severe and clinicians face the challenge of preserving the limb function. The forefoot is defined as the portion of the foot inferior to the tarso-metatarsal joints and is composed of tendons, ligaments, soft tissue, and 19 bones. Together with the mid foot and hind foot, the forefoot is one of the primary regions of the foot and is considered an important weight-bearing body part.

Severe damage to the forefoot is frequently associated with damage to the skin, soft tissue, as well as blood vessels, nerves, tendons, and bone. Moreover, inadequate reconstruction can lead to severe restrictions in standing and walking. Among the components of the forefoot area, the big toe is considered the most important part. However, active reconstruction of the big toe is rarely performed. Reconstruction of the forefoot and big toe remains a major challenge in surgical practice, especially in terms of appearance and function. In patients indicated for active reconstruction with flap surgery, clinicians should consider the survival of the flap and the improvement of cosmetic and functional outcomes of surgery.

The technique involves transplanting soft tissue from different parts of the body, The transplanted tissue will have an artery and vein intact so that it can be attached to the tissue in the area that heads to be reconstructed. This vascularised blood supply allows the surgeon to transplant large amount of tissue making more likely to survive the trauma of transplantation

we report on a case of reconstruction of the traumatic raw area of left foot on 3rd 4th 5th toe where vastus lateralis muscle along with its pedicle was harvested from right thigh with which satisfactory functional and cosmetic outcomes were achieved.

Case history

The 48 years aged female was admitted with a history of post infective raw area over left 3rd toe of her left foot since three months. Initially the wound was very small which was neglected by the patient. Later it extended up to 4th and 5th toe which had not healed for three months. Hence the patient got admitted and wound debridement was done on 03.03.2024 and raw area was not closed with muscle. So the surgeon advised for free flap.

Social History

No history of addiction to cigarette smoking and alcohol and no drug allergy.

Allergies

No known medicine or environmental allergies.

Past medical history

This patient had type 2 diabetes mellitus for 13 years and was on oral hypoglycaemic agent. Known systemic Hypertension for 1 year, not on treatment.

Past surgical history

Wound debridement left foot – 05.01.2024

Wound debridement and amputation of left third, fourth, fifth toe – 16.02.2024

Physical examinations

Vital signs,

  1. Temperature – 98.4
  2. Heart rate – 78,
  3. Pulse – 80,
  4. SPO2 – 100%,
  5. BP – 110/70mm of hg
  6. GCS – 15/15

Initial Evaluation,

  1. CBC: Hb – 12g
  2. Serology: HIV – negative, HbsAg – non reactive
  3. RFT – Normal
  4. BT-CT – Normal

She got admitted with complaints of ulcer, left third toe and her sugar level was not controlled. Her wound had extended upto fourth, fifth toe. So doctor advised her amputation of toe’s. The patient and her family accepted and amputation was done on 16.02.2024. She had multiple dressings and the patient was discharged.

She was admitted on 29.04.2024. The wound had not closed. Following findings were observed.

  1. 7×6 cm raw area present over dorsum of left foot
  2. Third, fourth, fifth toes amputated
  3. Healthy granulation present
  4. Distal pulses palpable

She was advised free flap. The patient and family accepted and wound wash was given on 02.05.2024. Free flap was done on 02.05.2024.

Operation Notes

  • Parts painted and draped
  • Wound bed prepared – anterior tibial vessels dissected.
  • ACT flap with cuff of vastus lateralis muscle along with its pedicle harvested from right thigh
  • Flap inset given
  • Flap artery – anterior tibial artery – end to end – 9-0 prolene
  • Flap vein – anterior tibial vein – end to end – 9-0 prolene
  • Other vessels clipped
  • Complete hemostasis achieved
  • Skin graft harvested from the right thigh and fixed over periphery of flap over the muscle
  • Donor site closed in layers with romo vac drain insitu used 1-vicryl and 2-0 ethilon
  • Dressing done
  • Posterior slab applied
  • Flap vascularity assessed on table after creating windows.

Post-op Antibiotics

DrugDoseFrequency
Injection Piptaz4.5 gmTDS
Injection Paracetamol1 gmTDS
Syp. Cremaffin10mlHS
Insulin Human mixtard30/7010-10-8 U

Post-operative nursing care

Checking circulation of flap

  1. Asses colour of flap – dusky, blue, pink, pale
  2. Free flaps were be marked and draped for every one hour for 48 hours including time spent on surgical intensive care unit.
  3. Assessed the flap for change in size and swelling – key indicators for possible hematoma or other complications- which included sutures over the flap pulling apart, and for palpable crepitus beneath the skin.
  4. Warmer: When caring for flap particularly, the immediate post op period is essential to maintain adequate blood flow and temperature to ensure flap viability and to prevent hypothermia for initial 24–48 hr as the flap stabilised, the vascular supply improves, the external warming can be decreased and can be removed.
  5. Monitoring Blood Sugar: Monitoring blood sugar level in patients with flap especially free flap is crucial because high blood sugar (hyperglycemia can negatively impact flap healing and overall outcomes). Blood sugar level was monitored regularly every four hourly/six hourly and kept within optimum range. Elevated blood sugar can impair micro vascular circulation and compromise flap perfusion.
  6. Heparin Infusion: Heparin infusion can prevent thrombosis and maintain the patency of micro vascular anastomosis. Heparin is a blood thinner that prevents blood clot formation and thereby reducing the risk of flap failure due to thrombosis. It can be administered intravenously. Dosage and rate of infusion is determined based on the patient weight and coagulation profile. Heparin places a critical role in management of flap by preventing thrombosis and supporting flap viability.
  7. Positioning: Proper positioning to avoid pressure on the flap and maintain adequate blood flow is essential. We avoided exercise movement or compression
  8. Wound care: We kept the surgical site clean and dry adhering aseptic technique during dressing changes and monitoring for sign of infection, which was critical.
  9. Fluid Management: Fluid were administered through IV at first due to dehydration. IVF NS/RL – 100 ml per hour administered to the patient till clearing NPO status. After clearance of patient’s NPO status, reduce the IVF NS/RL – 50 ml per hour
  10. Nutritional Support: For any patient to come out of their illness the nutrition part is very important. The nurses were focused on patient’s nutrition along with doctors and dieticians to avoid nutritional deficiency. We provided high protein and fibre diet with IV fluid support
  11. Pain Management: Managing pain was effectively promoted towards patient comfort and mobility without compromising flap integrity. On first POD, the patient had moderate pain (score:5). Patient was initially treated with epidural infusion. Inj. Fentanyl 100mcg – 2ml, Inj. Ropin 0.75 mg – 20 mm, NS – 28 ml total – 50 ml was given 3 ml per hour along with Inj. Para – 1gm IV TDS, Inj. Tramadol – 50mg SOS.
  12. Health Education: Educating patient and relatives on signs of complications, wound care. Instructions and the importance of follow up care is essential for their involvement in recovery.

Follow up treatment of free flap

The patient was discharged on 13.05.2024.

Discharge advice

DrugDoseFrequency
Tab. Doxy100mgtwice a day for 5 days
Sac. FosfomycinOD A/D for 3 dose
Tab. Para1gmthrice a day for 5 days

Review after 5 days in OPD.

The follow up treatment of free flap is crucial for ensuring optimal healing, monitoring for complaints and promoting long term success.

  1. Monitoring flap viability – regular assessment of flap colour and temperature
  2. Wound Care – proper changing of dressing in aseptic technique
  3. Physical therapy and rehabilitation – to optimise functional outcome and minimise complications such as contractures.
  4. Nutrition and hydration – for wound healing and flap viability
  5. Pain management for comfort and mobility
  6. Psychological support should include counselling support to the patient and the family.

During the follow-up period, complications such as flap infection, ulceration, and flap loss were not observed. The patient was very satisfied with the shape and function of the reconstructed foot.

Conclusion

In conclusion, the free flap is a useful and reliable reconstruction option for big toe and forefoot defects. Reconstruction of the forefoot and big toe should be performed with consideration of the important roles of these body parts in walking, standing, maintaining balance, and supporting the body when changing directions. Surgeons should attempt active reconstruction in appropriately indicated cases while considering the cultural specificities of daily living activities without wearing shoes.

Reference

Ms. Cecily Ruba
Nurse Educator

B. Mahalakshmi
Nursing Superintendent

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