[Reconstructive microsurgery procedures in orthopaedic departments performed by plastic surgeon]

The author carried out 50 free flaps in 49 patients during 10 year consulting practice in orthopaedic departments in the regional hospital in Otwock. 43 flaps were transplanted to lower extremities and 7 to upper. Extensive bone defects (bd), requiring reconstruction of shafts especially in case of tibiae predominated. The recipient sites of free tissue flaps were as follows: the arm--3 (bd), forearm--2 (bd), hand--2 (thumb defects), thigh--6 (bd--5, aseptic necrosis of the femoral head--1), tibiae--33 (bd and nonunion of tibiae--29, soft tissue defects (std)--4), foot--4 (std). In the post-traumatic cases criteria for operations were determined on the basis of the arteriography in the impaired extremity. The operations were performed in the period from some weeks to several years after the trauma. The following free flaps were used: peroneal flap--28, iliac flap--13, radial forearm flap--2, latissimus dorsi flap--3, rectus abdominis muscle flap--1, groin flap with aponeurosis of the external oblique muscle of the abdomen--1, toe--1, composite great and second toe--1. The operating microscope was usually used during microsurgical anastomoses, and in two cases a magnifying glass was used. Standard Ethilon sutures 10-0 with the needle of 100 or 130 microns in diameter were used for anastomoses. End-to-side microanastomoses both for artery and comitant vein prevailed. Dextran 40,000 and Aspirin were administered postoperatively. There was a survival rate of 98 percent with 49 flaps surviving and 1 failing. Early vascular complications were observed in 3 patients (2 in radial flaps and 1 in latissimus dorsi flap). Revision of the arterial microanastomoses was carried out in 2 patients, of the venous in one, obtaining complete survival of one of the flaps. Partial loss of the flap tissue without essential effect on the final treatment was observed in two remaining flaps. One patient with the disturbances of outflow was successfully treated with Heparin administered subcutaneously to the island of the flap. Thrombosis resulting in complete loss of one of the fibular flaps due to the wound infection was observed on the seventh day after the operation. Soft tissue and periosteum around sequestrum were revascularized generating sufficient bone recovery. Different depth necrosis of the island tissue in its peripheral parts was observed in some patients because of difficulties of blood outflow from the flap. Necrectomy or excision of the whole skin island in cases of very fatty flaps and skin grafting were indicated as giving a better cosmesis. Secondary procedures modeling the flap were not performed. Complete rebuilding of tibiae was not obtained only in two children treated because of congenital pseudoarthrosis of tibiae. In one patient with femur defect and vascularized fibular bone reconstruction late result of treatment is unknown. Treatment of the remaining patients was successful (92 percent).