title: Combined rib-latissimus flap; the "picket fence" concept for reconstruction of upper tibia defects.
abstract: BACKGROUND
  Upper tibia defects ,type3b Gustilo, due to huge size and volume are very difficult to reconstruct; usually several operations are needed for bone and soft tissue defects and the definite one stage reconstruction is yet to be found.
  
  
  OBJECTIVE
  In this article we reintroduce the rib- latissimus flap as an acceptable method to reconstruct tibia defects in selected cases.
  
  
  METHODS
  The latissimus muscle with one or two ribs revascualrized by reverse flow from perforators is harvested; the ribs are bisected after harvest yielding four to six struts of vascularized bone to fill the huge upper tibia defect. Internal fixation is very important and we favor LCP plates for long bone fixation and the rib struts are fixed in place by small titanium screws to maintain the "picket fence" design. The muscle is then wrapped around the ribs and the defect is completely reconstructed.
  
  
  RESULTS
  During the past 9 years we have used the rib-latissimus dorsi (RLD) muscle flap, without serratus muscle, in 7 patients with combined bone and soft tissue defects of the upper tibia. All the flaps healed without any major complications and only one stress fracture was seen and treated. The ribs healed and in a median of 14 months hypertrophied to the size of the upper tibia. Nonunion was not observed and patients with lower extremity defects were able to bear full weight within an average of seven months.
  
  
  CONCLUSIONS
  The fractures of tibia type 3a and 3b Gustilo are devastating injuries requiring several operations. Several combinations of RLD-Serratus have already been reported but a rib-LD muscle with "picket fence" design has not been reported .The RLD transfer with two ribs divided into four struts for bone coverage and muscle to cover all the upper tibia soft tissue defect can be a useful tool in the armamentarium of the surgeon treating combined defects in a single stage.
authors.affiliation: Department of Surgery, Tehran University of Medical Sciences, Tehran, IR Iran.
authors.forename: Shahram
authors.initials: S
authors.lastname: Nazerani
authors.affiliation: Trauma Research Center, Baqiyatallah University of Medical Sciences, and Attending Faculty , Azad University of Medical Sciences, Tehran, IR Iran.
authors.forename: Mohammad Hosein
authors.initials: MH
authors.lastname: Kalantar Motamedi
authors.affiliation: Asia Medical Center, Tehran, IR Iran.
authors.forename: Mohamad Reza
authors.initials: MR
authors.lastname: Ebadi
authors.affiliation: Shahid Beheshti University of Medical Sciences, Tehran, IR Iran.
authors.forename: Adel
authors.initials: A
authors.lastname: Ebrahimpoor
authors.affiliation: Tehran University of Medical sciences, Tehran, IR Iran.
authors.forename: Tara
authors.initials: T
authors.lastname: Nazerani
authors.affiliation: Tehran University of Medical sciences, Tehran, IR Iran.
authors.forename: Bardia
authors.initials: B
authors.lastname: Bidarmaghz
keywords: Reconstructive Surgical Procedures; Ribs; Tibia
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