Motor and sensory morbidity associated with the anterolateral thigh perforator free flap

Long Term Follow-up of Composite Flaps for Single-stage Reconstruction of Concomitant Tendon and Soft Tissue Defects

Tendon rupture in the setting of significant soft tissue loss poses a challenging reconstructive situation, which requires (1) recreating a stable gait cycle, (2) reducing shear forces and re-rupture risk, and (3) providing adequate soft tissue coverage. In this study, we outline our experience with composite flaps in single-step reconstruction of various lower extremity tendinous injuries with soft tissue loss.

Methods

A retrospective review of all patients requiring free tissue transfer at our tertiary wound care center between 2011 and 2020 was performed. Patients undergoing single-stage free tissue transfer for both soft tissue coverage and tendon reconstruction were selected. Variables of interest included demographics, comorbid conditions, baseline functionality, reconstructive details, and wound characteristics. Outcomes of interest were flap success, return to ambulation, time to ambulation, and postoperative complications.

Results

Nineteen patients were included in this study. Patients were on average 48.0 years old (SD 16.5), with a median Charlson Comorbidity Index of 1.00 (IQR: 0.0-2.5). Defects were most often on the ankle (n = 1 3, 68.4%), with extension to the foot or leg in six of these cases. Median wound size was 68.0 cm² (IQR: 48.0-120.0). The most common tendon requiring reconstruction was the Achilles (n = 13, 68.4%). An anterolateral thigh flap with attached fascia lata extension rolled into a neotendon was used in all 19 cases. At baseline, all patients were ambulatory. Only one patient (5.3%) required return to the operating room for suspected vascular compromise. At a median of 14.4 months (IQR: 8.5-40.5), all 19 patients were ambulatory.

Conclusions

Simultaneous reconstruction of tendinous injuries and soft tissue defects can be readily achieved via composite free flaps. Although other methods of reconstruction can be considered for smaller soft tissue and tendon loss, this approach has significant utility for patients with large defects and yields robust return to preinjury functionality.

Synergistic effect of nanofat and mouse nerve-growth factor for promotion of sensory recovery in anterolateral thigh free flaps

Anterolateral thigh (ALT) free flaps are widely used for reconstruction, but poor sensory recovery of the flap tissue can cause unsatisfactory outcomes and poor function. Adipose‐derived mesenchymal stem cells (ADSCs) promote neural regeneration, but the clinical use of stem‐cell therapy has been limited by lack of regulatory approval. Nanofat is an autologous product that is prepared mechanically from harvested fat. It is enriched in ADSCs and does not contain any exogenous substances. The developmental and adult neurobiology of nerve‐growth factor (NGF) are well investigated, and mouse (m)NGF has been used to promote recovery following peripheral nerve injury. We investigated the promotion of nanofat and mNGF as either mono‐ or combined therapy on the sensory recovery of ALT free flaps. We found that nanofat and mNGF had a synergistic effect on sensory recovery that was associated with stimulation of angiogenesis and neurogenesis. Nanofat combined with mNGF was better at promoting neural regeneration and improving sensory recovery than treatment with either agent alone. The results provide a theoretical rationale for further study of the clinical use of nanofat combined with mNGF to promote the sensory recovery of ALT free flaps.

Reconstructive surgery for foot and ankle defects in pediatric patients: Comparison between anterolateral thigh perforator flaps and deep inferior epigastric perforator flaps

BACKGROUNDS

Due to the delicate tissue, small blood vessels and incomplete development of interarticular ligaments, skin and soft-tissue defects of the foot and ankle in pediatric patients remain a challenge for orthopedic and plastic surgeons. Anterolateral thigh perforator (ALTP) flap and deep inferior epigastric perforator (DIEP) flap are the most commonly used flaps for the repair of lower-extremity soft-tissue defects. The literature contains a shortage of evidence involving the differences between ALTP and DIEP flaps in the reconstruction of young patients with complex foot and ankle defects. This study was designed to determine which type of flap is better for foot and ankle repair in pediatric patients.

METHODS

From January 2004 to January 2018, 79 children younger than 14 years treated with DIEP flap (41 cases) or ALTP flap (38 cases) for composite defects of the feet and ankles were retrospectively investigated. The two groups were homogeneous in terms of age, the location of the defect, etiology, and flap area. Complications, scarring, cosmetic appearance, flap sensory recovery, and functional outcome were analyzed, and statistical analysis was performed.

RESULTS

The ALTP group had shorter operation time (155.0 ± 12.0 min vs 212.2 ± 23.9 min), flap harvested time (39.6 ± 5.1 min vs 57.2 ± 10.4 min), and operative blood loss (143.4 ± 23.7 ml vs 170.7 ± 44.7 ml) than the DIEP group (P <  0.05). In short-term follow-up, ALTP group showed a lower flap necrosis rate (5.3% vs 24.4%) and vascular insufficiency rate (2.6% vs 19.5%) than DIEP group (P <  0.05). In long-term follow-up, ALTP group showed a lower late complication rate and better cosmetic, functional, scar outcomes than DIEP group (P <  0.05).

CONCLUSIONS

The study showed that an ALTP flap may brings better results than a DIEP flap in terms of short- and long-term complications, scarring, and morpho-functional outcomes for pediatric patients undergoing reconstruction of foot and ankle defects.