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Plastic and Reconstructive Surgery - Global Open:
doi: 10.1097/GOX.0b013e31828c3215
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Suspension of Leg via a Single Tibial Pin Provides Postoperative Elevation and Pressure Off-loading for Lower Extremity Free Flaps

Kapadia, Sameer M. BS; Gust, Madeleine J. MD; Alghoul, Mohammed S. MD; Dumanian, Gregory A. MD

Open Access
United States
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Division of Plastic and Reconstructive SurgeryNorthwestern UniversityFeinberg School of MedicineChicago, Ill.

Correspondence to Dr. Dumanian, Division of Plastic and Reconstructive Surgery, Northwestern University, Feinberg School of Medicine, 675 North St. Clair Street, Suite 19-250, Chicago, IL 60611-2923, gdumania@nmh.org

This is an open-access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 3.0 License, where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. http://creativecommons.org/licenses/by-nc-nd/3.0. American Society of Plastic Surgeons

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Sir:

Postoperative positioning of patients undergoing reconstruction of posterior leg and foot defects remains a significant challenge. Considerations include the necessity to elevate the lower extremity, relieve pressure, perform local wound care, and ensure patient comfort. Many solutions have been proposed in the literature including the maintenance of a prone position and the use of splints with bulky dressings to relieve pressure. In recent years, external fixation has become a popular option. Much of the literature describes modifications of the Hoffman apparatus and other external fixation devices utilizing multiple pins.1–4 We present a method of lower extremity elevation utilizing a single tibial pin outside the zone of injury.

A 30-year-old male patient suffered a degloving injury in his heel in an industrial accident. He was initially managed with debridement, replacement of the degloved tissue, and placement of a subatmospheric pressure dressing. During the same operation, a midshaft tibial unicortical pin was placed to facilitate patient management. The pin was placed approximately midshaft through the tibia (Fig. 1), with particular attention paid in balancing the leg. A pin placed too distally will cause a locked knee, and conversely a pin placed too proximally will not provide an adequate elevation and relief from venous congestion.5 The pin was tethered to a bed box frame with an adjustable kerlix gauze (Fig. 2). The leg was then placed in a removable splint to ensure dorsiflexion of the ankle joint. The patient eventually underwent definitive closure with a vastus lateralis free flap. Strict leg elevation using this system was well tolerated by the patient, and he asked to keep the pin for several extra weeks after discharge because of the ease of using it to maneuver and elevate the leg during his rehabilitation.

Fig 1
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Fig 2
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As reported in the literature, there are many benefits to suspending the reconstructed leg including eliminating pressure on the reconstruction and decreasing venous congestion through reliable and constant elevation. This method also allowed for easy access during dressing changes and flap checks and required very little manipulation of the leg. We believe that our approach is unique from that of others in that it requires only placement of a single pin, and this pin is outside the zone of injury. Because a removable tether hangs the leg, physical therapists are easily able to remove the leg from suspension and help the patient perform dangling and other exercises.

In summary, we recommend that this method of lower extremity suspension be considered in the postoperative management of patients undergoing complex reconstruction of the posterior calf and heel. The tibial traction pin achieves the goals of pressure relief, consistent elevation, improved access for flap monitoring and care, and enhanced patient comfort as exhibited in this case.

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DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article and also to the products, devices, or drugs mentioned in this article. The Article Processing Charge was paid for by the authors.

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PATIENT CONSENT

The patient provided written consent for the use of his image.

Sameer M. Kapadia, BS

Madeleine J. Gust, MD

Mohammed S. Alghoul, MD

Gregory A. Dumanian, MD

Division of Plastic and Reconstructive Surgery

Northwestern University

Feinberg School of Medicine

Chicago, Ill.

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REFERENCES

1. Nappi JF, Drabyn GA. External fixation for pedicle-flap immobilization: a new method providing limited motion. Plast Reconstr Surg. 1983;72:243–245

2. Rosenfeld SR, Anzel SH. Use of the Hoffmann apparatus in myocutaneous pedicle flap. J Trauma. 1981;21:1045–1047

3. Roukis TS, Landsman AS, Weinberg SA, et al. Use of a hybrid “kickstand” external fixator for pressure relief after soft-tissue reconstruction of heel defects. J Foot Ankle Surg. 2003;42:240–243

4. Shmueli G, Nahlieli O, Baruchin A, et al. External fixation for fractures and pedicle flap immobilization: a convenient and inexpensive substitute. Plast Reconstr Surg. 1985;75:594–595

5. Kershaw CJ, Cunningham JL, Kenwright J. Tibial external fixation, weight bearing, and fracture movement. Clin Orthop Relat Res. 1993;Aug:28–36

© 2013 American Society of Plastic Surgeons

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