The distal superficial femoral arterial branch to the sartorius muscle as a recipient vessel for soft tissue defects around the knee: anatomic study and clinical applications

Sural Artery as a Recipient Vessel for Free Flaps

Introduction The axial vessels like the anterior and posterior tibial emerge as the first choice of recipient vessels, in free flaps for lower limb trauma. When the defects are located more proximally in the leg, the deeper course of the axial vessels makes the dissection more tedious. Alternative vessels like the descending genicular, medial genicular, and distal end of the descending branch of the lateral circumflex femoral can be used for an end-to-end anastomosis, well away from the zone of trauma.

The objective of this study was to define the indications and technique of the use of the sural vessels as the recipient pedicle for proximal and middle third leg defects.

Patients and Methods For the period 2006 to 2022, 18 leg defects following road traffic accidents were covered with latissimus dorsi muscle flap using sural vessels as the recipient pedicle.

Results Among 18 patients, 8 patients had defect in proximal third, 8 had a combined defect in proximal and middle third leg, and 2 had defect in middle third leg. Two patients developed arterial thrombosis and one patient had venous thrombosis for which re-exploration was performed. Two flaps were lost and sixteen had successful wound coverage.

Conclusion The sural vessels as recipient pedicle are easier to access and can be considered as a reliable option for free flaps in limb defects of proximal and middle third leg. Using the submuscular part of the vessel ensures a better distal reach of the flap.

An algorithmic approach to soft-tissue reconstruction around the knee using anterolateral thigh perforator flap in patients with post-traumatic knee osteomyelitis

Background

Free tissue transfer to the knee region in patients with chronic post-traumatic knee osteomyelitis (CTKOM) poses a great challenge to surgeons because the remaining soft tissues adjacent to defects, including vascular structures, are usually damaged by chronic inflammation and multiple debridements. Thus, we developed an algorithm to help select the optimal recipient vessels and appropriate anterolateral thigh perforator (ALTP) flap type. In addition, we performed surgery using this algorithm and achieved successful reconstructions. This study aims to review our experiences in algorithmic reconstruction and assess its efficacy.

Methods

According to the defect size and location, our algorithm suggested the use of various-shaped ALTP flaps with centrally located perforators (Cen-ALTP flap) or eccentrically located perforators (Ecc-ALTP flap). Besides, through the algorithm, one recipient vessel was selected among three candidates, including descending branch of the lateral circumflex femoral artery (DB-LCFA), anterior tibial artery (ATA), and posterior tibial artery (PTA). Based on this algorithmic decision, we performed individualized soft tissue reconstructions of the knee in 21 patients with CTKOM, between March 2013 and June 2021. The medical records of the patients were retrospectively reviewed.

Results

The Cen-ALTP flap (n = 15) and ATA (n = 9) were the most commonly used for reconstruction. The Cen-ALTP flap anastomosed to the ATA was most commonly selected (n = 7) using the algorithm, followed by the Cen-ALTP flap anastomosed to the DB-LCFA (n = 5), and the Cen-ALTP flap anastomosed to the PTA (n = 3). All transferred ALTP flaps survived the follow-up period. Postoperative venous congestion in two patients and hematoma in one patient were resolved by immediate treatment. The postoperative course was uneventful.

Conclusion

During free ALTP flap transfer to CTKOM-related knee defects, we could select the optimal recipient vessel and appropriate flap type using our algorithm and obtain excellent reconstructive outcomes. Therefore, we believe that our algorithm could provide helpful guidance to reconstructive surgeons on free ALTP flap transfer to reconstruct CTKOM-related soft tissue defects.

Flap reconstruction of the knee: A review of current concepts and a proposed algorithm

A literature search focusing on flap knee reconstruction revealed much controversy regarding the optimal management of around the knee defects. Muscle flaps are the preferred option, mainly in infected wounds. Perforator flaps have recently been introduced in knee coverage with significant advantages due to low donor morbidity and long pedicles with wide arc of rotation. In the case of free flap the choice of recipient vessels is the key point to the reconstruction. Taking the published experience into account, a reconstructive algorithm is proposed according to the size and location of the wound, the presence of infection and/or 3-dimensional defect.

Recipient vessels in the free flap reconstruction around the knee

Microsurgical free tissue transfer is playing a critical role in reconstruction of the soft tissue around the knee to salvage the limb, especially when the defects exist with a wide zone of injury or with a poor soft tissue condition, where local flaps are unavailable. For a successful free flap transfer, proper selection of a recipient vessel is essential and challenging. The survival and other outcomes of the transferred flaps were closely related to which recipient vessel was used and the location of anastomosis. In this article, we review most of the clinical reports about using free flaps to reconstruct the soft tissue around the knee, excluding the cases of postamputation, and discuss about the recipient vessels that can be used.