A New Reconstructive Technique for Below-Knee Amputation Coverage; Utilizing the Neurovascularized Lateral Compartment Flap, TMR, and RPNI
Corey Bascone1, Reena Sulkar2, Stephen Kovach3
University of Pennsylvania, Department of Surgery Division of Plastic Surgery, Philadelphia, PA USA
Background: The Below-Knee amputation (BKA) remains a viable surgical option in contexts such as trauma, oncology, and vascular disease. However, the current procedural gold standard of simple osteotomy and traction neurectomy, with a long posterior myocutanoeus flap can lead to less-than-optimal outcomes. Traction neurectomy is often associated with disorganized nerve growth, resulting in both residual limb pain (RLP) and phantom limb pain (PLP). The long posterior flap may result in residual limb widening, edema, muscle atrophy, and need for revisions. With recent literature advocating for the use of both targeted muscle reinnervation (TMR) and/or regenerative peripheral nerve interfaces (RPNI) at the time of amputation, we describe a new, effective, and incision protective reconstruction method for below-knee amputation coverage, via the utilization of these peripheral nerve techniques and a lateral compartment rotational muscle flap, neurotized by the superficial peroneal nerve.
Methods: Survey data from 25 consecutive patients who had below-knee amputation from October 2019 through October 2021, with peripheral nerve preparation using TMR or RPNI, and new flap technique closure with the neurotized lateral compartment flap were retrospectively analyzed.
Results: Satisfactory results were achieved with this combination of lateral rotational flap and peripheral nerve techniques in all 21 patients. 67% (n=14) of the patients were completely pain free, with only 33% (n=7) reporting RLP, and only 14.3% (n=5) reporting PLP. Only two patients reported an associated residual limb wound that inhibited them from achieving optimal prosthetic use. The residual limb region that correlated with the underlying superficial peroneal nerve was only indicated as a cause of RLP in two patients (9.52%).
Conclusion: The presented reconstruction technique provides increased residual muscle bulk, relocation of the residual limb incision, and decreased neuropathic pain. Performing the BKA with a neurotized lateral compartment flap provides reliable soft tissue coverage, resulting in a low chance of wound dehiscence, residual limb revision, and latency to prosthetic fitment.
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