Pediatric Microsurgery

A free anterolateral thigh flap and iliotibial band for reconstruction of soft tissue defects at children's feet and ankles

BACKGROUND AND PURPOSE

High-energy injury to children caused by a traffic accident is usually characterised by extensive soft tissue defects with exposure or loss of tendons and bone at the foot. Segmental loss of the Achilles tendon along with soft tissue defects is a great challenge for microsurgical reconstruction. Free anterolateral thigh (ALT) flap is indicated for reconstruction of such defects because limited local tissues are available. Additionally, iliotibial band in the donor area can be used to reconstruct the damaged tendon.

MATERIALS AND METHODS

Here we described our successful management of 25 paediatric patients with such high-energy injury at feet and ankles in one-stage transplantation of a free ALT flap and an iliotibial band from January 2008 to January 2013. The tendon defect, ranging from 3 to 16cm in length, was reconstructed with an iliotibial band. The flaps ranged from 5 to 12cm in width and 8 to 18cm in length.

RESULTS

All the flaps survived completely and no donor site complications were observed. In two flaps there was a small area of distal necrosis which was healed by dressing changes. The mean follow-up time was 14.2 months (from 6 to 24 months). Limb function was assessed using the Maryland Foot Score. The excellent and good rate was 92%.

CONCLUSIONS

We believe a free ALT flap is ideal for reconstruction of massive soft tissue defects at the foot and ankle in children and an iliotibial band from the same donor site can be used for reconstruction of a damaged tendon.

Reconstruction of pediatric foot and ankle trauma

Although reconstruction of complex distal lower extremity trauma has been studied extensively, the subject has rarely been evaluated in the pediatric population. The authors review their experience with 18 patients ranging from 2 to 18 years of age, who were admitted to the trauma service of the Children's Hospital of the University of Pittsburgh between 1991 and 1999 and required plastic surgery evaluation for the management of foot and ankle injuries. The mechanism of injury included motor vehicle accidents (6), lawnmower injuries (6), gunshot wounds (2), crush injuries (2), burns (1), and complex soft tissue injuries (1). The average hospitalization was 14.3 days, and, on average, 3.1 surgical procedures were required per patient. Most of the cohort required microvascular free tissue transfer (11). One patient was managed conservatively, whereas the remainder underwent surgical reconstruction by primary wound closure (1), skin graft (2), or local flap (3). No patient has required treatment of growth disturbance or late functional problems, and the entire population was ambulatory by their 3-month postoperative evaluation. Despite the severity of these injuries, with reliance on microvascular free tissue transfer, an acceptable outcome can be achieved with preservation of the ability to ambulate.

Microvascular tissue transfer in paediatric patients: analysis of 106 cases

We report a series of 106 microvascular transplants performed in paediatric patients between 1973 and 1989. Eighty-eight percent of these flaps were successful. Two of the 13 failed flaps (1.9%) in this series were lost because of small vessel size. Otherwise, success rates (93% in the last 5 years) and complications were comparable to our adult cases. No growth-related complications were noted either in recipient or donor sites. We conclude that microvascular transplantation is a reliable procedure in children.