Distally Based Anterolateral Thigh Flap: An Anatomic and Clinical Study

Reverse flow anterolateral thigh free flap in a case with significant atherosclerosis: A viable alternative for arterial microvascular anastomosis

BACKGROUND

The concept of reserve flow perfusion for free flap reconstruction has been demonstrated in various applications in the literature. As it relates to the anterolateral thigh (ALT) free flap, the reserve flow principle has been primarily described to either augment or "supercharge" a large ALT to optimize skin perforator supply or lengthen the vascular pedicle.

METHODS

We report a case of a 77-year old male with chronic renal failure who had extensive atherosclerosis of the proximal descending lateral circumflex femoral artery (LCFA) where arterial anastomosis was unable to be performed.

RESULTS

We were able to circumvent this limitation by establishing reserve flow perfusion solely through the distal end of the descending LCFA. We describe our technique within the context of current literature on the topic of reverse flow perfusion in free flap reconstruction.

CONCLUSION

This report uniquely describes applying the distally based, reverse arterial flow principle in an ALT flap to circumvent an atherosclerotic proximal pedicle.

The accessory vascularization of the tensor fasciae latae muscle: towards a new classification?

PURPOSE

The tensor fasciae latae (TFL) muscle is supplied by the lateral femoral circumflex artery (LCFA), arising from the deep femoral artery. However, it has been noted that there is also a consistent vascular anastomotic network. The aim of this study was to describe the accessory vascularization of the TFL muscle through a descriptive anatomical study, in order to hypothesize the feasibility of harvesting a TFL flap in the event of an injury to the main pedicle. In addition, we illustrate this hypothesis with a successful clinical case of Scarpa freconstruction following ligature of the deep femoral artery.

METHODS

The description of the accessory vascularization was obtained by injecting dye into seven lateral femoral circumflex arteries (LCFA), six superficial circumflex iliac arteries (SCIA), and three inferior gluteal arteries (IGA).

RESULTS

The TFL muscle was vascularized primarily by the LCFA. A vascular anastomotic network with the SCIA and the IGA was observed. After selective injection to the SCIAs and IGAs, the subsequent injection to the LCFA showed a diffusion of the TFL skin paddle with a perforasome overlapping between the different vascular territories.

CONCLUSION

The ascending branch of the lateral femoral circumflex plays a dominant role in the vascularization of the TFL muscle. As a result of a periarticular anastomotic network of the hip, this artery establishes several connections with the proximal arteries. Consequently, in cases where blood flow through the LCFA is interrupted, it should be equally possible to harvest the TFL flap through its accessory vascularization.

Distally Based Anterolateral Thigh Flap Algorithm for Unexpected Situations during Soft-Tissue Defect Reconstruction around the Knee

BACKGROUND

The distally based (d) anterolateral thigh (ALT) flap is an effective option for soft-tissue reconstruction around the knee; however, unexpected situations may occur intraoperatively, impeding flap harvest. The authors proposed an algorithm for surgical conversion for unexpected situations encountered intraoperatively.

METHODS

Between 2010 and 2021, 61 dALT flap harvests were attempted for soft-tissue defect reconstruction around the knee; 25 patients underwent surgical conversion for anomalies, including lack of a suitable perforator, hypoplasia of the descending branch, and compromised reverse flow from the descending branch. After excluding improper cases, 35 flaps were harvested as planned (group A) and 21 surgical conversion cases (group B) were finally enrolled for analysis. An algorithm was developed based on the cases in group B. Outcomes, including complication and flap loss rates, were compared between groups to verify the algorithm's rationality.

RESULTS

In group B, the dALT flap was converted to a distally based anteromedial thigh flap ( n = 8), bipedicled dALT flap ( n = 4), distally based rectus femoris muscle flap ( n = 3), free ALT flap ( n = 2), or other locoregional flap that required additional incision ( n = 4). No differences in outcomes were observed between the two groups.

CONCLUSION

The proposed contingency planning algorithm for dALT flap surgery proved rational, as surgical conversion could be made by means of the same incision in most cases, and outcomes generated by the algorithm were acceptable.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Improving the outcome of distally based anterolateral thigh flap reconstruction: New classification and surgical guidelines

BACKGROUND

The distally based anterolateral thigh (dALT) flap is associated with a high incidence of venous congestion. This study aimed to investigate factors associated with vascular compromise to improve the outcomes.

METHODS

We retrospectively analyzed 41 dALT flap reconstructions performed between November 2010 and February 2023. The dALT flap was classified into type I, II, or III based on the origin (the descending, oblique, or transverse branch) of the chosen perforator. The distance from the pivot point to the superolateral patella, pedicle length, flap reach, complications, and loss rates were analyzed to identify different dALT flap characteristics.

RESULTS

The type Ⅰ flap had a shorter pedicle length (type Ⅰ vs. type Ⅱ, p = 0.000; type Ⅰ vs. type Ⅲ, p = 0.000) that primarily reached closer regions (distal third of the thigh anterior/lateral knee). Pedicle lengths were similar between type Ⅱ and Ⅲ flaps (p = 1.000), most of which reached more distal regions (medial/posterior knee or proximal third of the leg). However, the type Ⅲ flaps had a higher complication rate and flap loss rate, although no significant differences were observed (complication rate, p = 0.094; flap loss rate, p = 0.071).

CONCLUSIONS

To achieve more desirable outcomes using the dALT flap, preoperative assessment of flap pedicle length and proper intraoperative maneuvers that avoid compromising the reverse blood circulation are necessary.

Cross-leg free flaps and cross-leg vascular cable bridge flaps for lower limb salvage: experience before and after COVID-19

Background

Previous reports have evidenced the disruptive effect of the COVID-19 in microsurgical and reconstructive departments. We report our experience with cross-leg free flaps and (CLFF) and cross-leg vascular cable bridge flaps (CLVCBF) for lower limb salvage, technical consideration to decrease morbidity, and some structural modifications to our protocols for standard of care adapted to the COVID-19.

Methods

We retrospectively included consecutive patients undergoing reconstruction with CLFFs and CLVCBFs for lower limb salvage from January 2003 to May 2022. We extracted data on baseline demographic characteristics, mechanism of trauma, and surgical outcomes.

Results

Twenty-four patients were included, 11 (45.8%) underwent reconstruction with CLFF while 13 had CLVCBFs (54.2%). Fifteen patients (62.5%) underwent lower limb reconstruction under general anesthesia while 9 (37.5%) had combined spinal-epidural anesthesia. During COVID-19 pandemic, six CLFF cases were performed under S-E (25%). The average time for pedicle transection of muscle CLFFs and muscle CLVCBFs was comparable between groups (60 days versus 62 days, p = 0.864). A significantly shorter average time was evidenced for pedicle division of fasciocutaneous flaps in the CLFF group when compared to CLVCBFs (45 days versus 59 days, p = 0.002).

Conclusions

In selected patients, CLFFs and CLVCBFs offer an optimal alternative for lower limb salvage using recipient vessels out of the zone of injury from the contralateral limb. Modification in the surgical protocols can decrease improve resource allocation in the setting of severely ill patients during COVID-19.Level of evidence: Level III, Therapeutic.

Reconstruction of a knee defect in a morbidly obese patient with a pedicled reverse anterolateral thigh flap

The anterolateral thigh (ALT) flap is widely used in the reconstruction of a variety of soft tissue defects. Descriptions of patients with severe obesity in the literature are scarce. We report a case where a reverse pedicled fasciocutaneous ALT flap was successfully used for resurfacing of a knee defect measuring 12×6 cm in a patient with a body mass index (BMI) of 47.3. The flap was supercharged to the greater saphenous vein to optimise flap survival. Reconstruction of the soft tissue of the knee was achieved as planned. There were no flap or donor site complications.

"Reverse tensor fascia latae perforator flap for reconstruction of knee defect: Anatomic study by computed tomographic angiography and a case report"

BACKGROUND

Reverse anterolateral thigh perforator (ALTp) pedicle flap can be used to reconstruct perigenicular defect thanks to the anastomoses between the descending branch of the lateral circumflex femoral artery (LCFA) and the perigenicular network. In a few cases, however, patients do not present any ALTp. We hypothesized that, in such cases, an adjacent perforator, the tensor fascia latae perforator (TFLp), emerging from the LCFA ascending branch, could be used instead. To assess the feasibility of this technique, a radiological study was conducted. A first patient was treated using this option.

METHODS

Sixty lower limb computed tomography were analyzed. The first treated patient was a 50-years-old man suffering from a 5-mm chronic bone exposure and osteomyelitis. Other reconstructive options were not indicated since he presented a multiscarry leg, severe arteriopathy, and no ALTp. A TFLp flap was raised, and the LCFA ascending and descending branches were dissected in continuity. After ligation of the LCFA, the blood flow reversed in the descending branch to irrigate the flap through the ascending branch.

RESULTS

A TFL perforator was observed in all the cases of the radiological study. The LCFA branching pattern was compatible with achieving a reverse TFL perforator flap in 43 cases (72%). The average pedicle length was 32 cm (22-38 cm). In the first clinical case, the flap covered the defect easily. After three months, the patient showed no evidence of infection recurrence and recovered a painless walk.

CONCLUSION

The reverse TFLp flap can be a suitable option for perigenicular reconstruction.

Improving Outcomes in Anterolateral Thigh Flap Donor-Site Reconstruction Using Propeller Flaps: A Retrospective Comparative Study with Skin Grafting

BACKGROUND

 After anterolateral thigh (ALT) flap harvesting, skin graft of the donor site is commonly performed. When the defect width exceeds 8 cm or 16% of thigh circumference, it can determine lower limb function impairment and poor aesthetic outcomes. In our comparative study, we assessed the functional and aesthetic outcomes related to ALT donor-site closure with split-thickness skin graft compared with thigh propeller flap.

METHODS

 We enrolled 60 patients with ALT flap donor sites. We considered two groups of ALT donor-site reconstructions: graft group (30 patients) with split-thickness skin graft and flap group (30 patients) with local perforator-based propeller flap. We assessed for each patient the range of motion (ROM) at the hip and knee, tension, numbness, paresthesia, tactile sensitivity, and gait. Regarding the impact on daily life activities, patients completed the lower extremity functional scale (LEFS) questionnaire. Patient satisfaction for aesthetic outcome was obtained with a 5-point Likert scale (from very poor to excellent).

RESULTS

 In the propeller flap group, the ROMs of hip and knee and the LEFS score were significantly higher. At 12-month follow-up, in the graft group, 23 patients reported tension, 19 numbness, 16 paresthesia, 22 reduction of tactile sensitivity, and 5 alteration of gait versus only 5 patients experienced paresthesia and 7 reduction of tactile sensitivity in the propeller flap group. The satisfaction for aesthetic outcome was significantly higher in the propeller flap group.

CONCLUSION

 In high-tension ALT donor-site closure, the propeller perforator flap should always be considered to avoid split-thickness skin graft with related functional and aesthetic poor results.

Defect Reconstruction Using the Propeller Flaps Based on the Perforators Derived From the Lateral Circumflex Femoral Artery System

BACKGROUND

Although propeller flaps are a useful option for soft tissue defect reconstruction, reports based on the perforators of the lateral circumflex femoral artery (LCFA) are rare. We aimed to present our experience in defect reconstruction using the propeller flaps based on perforators from different branches of LCFA and apply these flaps in soft tissue defect reconstruction of the lower extremities.

METHODS

Twenty nine patients (32 flaps) underwent defect reconstruction using propeller flaps based on the perforator of the LCFA. Defects were located from the groin to the proximal leg. According to the source vessels from which the perforator originated, flaps were categorized into types I, II, III and IV, which represented perforators from the transverse, descending, oblique, and rectus femoris branches, respectively. Type II flaps were subdivided into types IIa and IIb flaps based on antegrade and reverse flows of the descending branch.

RESULTS

Flap sizes ranged from 12 × 6 cm to 30 × 15 cm (average, 22.69 × 9.19 cm) with the length of the vascular pedicle ranging from 3 to 7 cm (average, 4.86 cm). Flaps were rotated from 60° to 180° (average, 144.06°). There were 3 type I, 10 type IIa, 4 type IIb, 13 type III and, and 2 type IV flaps. Twenty-nine flaps survived after surgery. Total flap necrosis and venous congestion of the distal flap portion occurred in 1 and 2 patients, respectively.

CONCLUSIONS

Reconstruction using propeller flaps based on perforators of the LCFA is a safe, reliable, and versatile option for defect reconstruction of the lower extremities; however, it requires meticulous surgical dissection and patience.

The Anterolateral Thigh Perforator Flap: Its Expanding Role in Lower Extremity Reconstruction

The anterolateral thigh (ALT) flap is a popular flap for lower extremity reconstruction despite its varied pedicle anatomy. Beyond its use for soft tissue coverage, using the chimeric flap concept, the ALT flap is useful for tendon and ligament reconstruction and the creation of a gliding surface with the fascia lata component. The vastus lateralis muscle can be included for dead-space obliteration. The main pedicle is long and is a similar size match for major artery reconstruction. If several perforators are available, a split flap could be fashioned into a multitude of shapes all arising from the same pedicle.

Soft tissue coverage options around the knee

Defects around the knee exhibit various etiologies and pose challenges to both orthopedists and plastic surgeons. While a number of reconstructive coverage options are available, flaps are almost always required for complex defects. Many local flaps are easily placed, including muscle and perforator flaps sourced from the thigh to the leg. As the recipient vessels lie deep, free tissue transfers are challenging. Good postoperative management and efficient collaboration between orthopedic and reconstructive surgeons are the keys to successful knee reconstruction, restoring an esthetic contour and preserving joint function.

Collateral circulation of the femoral and genicular systems in human lower limbs is highly uncommon

The descending branch of the lateral circumflex artery is a septocutaneous vessel that is vital for free and pedicle thigh flap transfer surgeries when repairing tissue defects. It also forms an anastomosis with the superior lateral genicular artery to create a collateral pathway for circumventing occlusions in the superficial femoral artery (SFA). Many anatomical texts and atlases imply the persistence of this anastomosis. However, previous studies indicate variability in the source of the arteries that form the anastomosis, and have reported cases where an anastomosis does not exist. We hypothesized that variations from the conventional accepted pattern can be predicted by comparisons of arterial diameters, and that unconventional anastomoses may be present to facilitate collateral circulation to the limb. Fifty-one limbs were dissected and analyzed to establish the source of the descending branch of the lateral circumflex artery, classify the types of anastomoses, and compare the diameters of the descending branch of the lateral circumflex artery, the SFA and the profunda femoris artery to the common femoral artery (CFA). Vessel diameters were normalized to the diameter of the CFA to allow comparison of limbs from both sexes and to minimize the effects of cadaver size on correlating vessel size to the presence or absence of collateral circuits. We report that 62.7% of limbs (32/51) had typical branching patterns; however, only 27.4% of limbs (14/51) had any anastomosis to connect the proximal and distal regions of the thigh. Importantly, the SFA had a wider relative diameter in limbs without anastomoses than in limbs that had normal anastomoses, perhaps precluding the formation of a collateral pathway. Overall, collateral circulation of the lower limb was highly uncommon, in contrast to information inferred from anatomical texts. This study suggests the need for more thorough procedures for determining viable anastomoses prior to thigh flap surgeries to ensure flap survival.

Knee reconstruction using a distally based anterolateral thigh flap: an anatomical cadaveric study

OBJECTIVE

To study the vascular territory of the descending branch of the lateral circumflex femoral artery and its anastomosis around the knee and to identify the cutaneous perforator supply to the distally-based or reverse flow anterolateral thigh (dbALT) flap. In particular, the distance of the first perforator branch arising from the knee and above region, as well as the number of branches and position of each perforator, beneficial for effective flap design, are also examined.

METHOD

Fresh cadaveric lower limbs were dissected and the distance of the first perforator branch arising from the knee and above regions, which are vascular supplies for flaps, as well as the number of branches and position of each perforator are described.

RESULTS

A total of 54 thigh cadavers had at least two cutaneous perforator branches above the knee 10cm from the superior border of the lateral patella. The mean (± standard deviation) of the first perforator distance was 2.57±0.93cm above the superior-lateral border of the patella. All perforating branches were 4±2cm, 93% were 10±2cm from the superior lateral border of patella, and 100% were at 20±3cm (mid-thigh length) which were the traditional anterolateral thigh flap.

CONCLUSION

The dbALT flap technique resulted in constant and reliable references about perforator sites. Thus, this type of flap is a viable option in patients who present with soft tissue defects around the knee and upper third of the leg.

Soft Tissue Coverage for Defects around the Knee Joint

Soft tissue injuries around the knee present a challenge for providing a cover when there is loss of tissue. Various flaps comprising of skin and muscles around the joint have been described. Understanding the anatomical basis and the design of these flaps can aid in choosing the right flap for a given situation. A prompt cover of the defects aids in quicker healing and quicker rehabilitation of the patient.

Vascular coverage of the anterior knee region - an anatomical study

Descriptions of vessel angiosomes or perforasomes throughout the human body are quite frequent, and led to the development of flaps nowadays commonly used to surgically cover skin and soft tissue defects. In these procedures, the surgeon requires a profound anatomical knowledge of the respective blood vessels and the extent of the perfused area to define the size of the graft. In the region of the knee joint, descriptions of flaps based on the superior lateral genicular artery and descending genicular artery are quite frequent. In contrast, information regarding other popliteal branches is scarce or non‐existent. The aim of this study was to provide a concise and complete overview on the extent and variability of the perforator angiosomes of the femoral and popliteal arteries in the anterior knee region. Twenty lower extremities were dissected, the respective perforators identified and perfused with dye. All resulting angiosomes were marked and documented. A total of 84 angiosomes were identified in all specimens, with an average of 4.2 (3–6) angiosomes per specimen. The average size of the angiosomes was 97.04 ± 72.30 cm² (8.61–360.41 cm²), their source vessels had an average diameter of 1.42 ± 0.54 mm (0.60–3.25 mm). The complex and highly variable distribution of perforator angiosomes of the anterior knee region and especially of its less frequently investigated distal part was demonstrated. Based on these results, the planning of existing perforator flaps in this region and the development of flaps including the inferior medial or inferior lateral genicular arteries may be facilitated.

Reconstruction of complex soft tissue defects including tendons with anterolateral thigh flap extended to fascia lata: Long term recovery and functional outcomes

BACKGROUND

We evaluated composite anterolateral thigh (ALT) flaps including vascularized fascia lata (FL), for stable soft tissue coverage and tendons restoration at various joint levels in a one-stage procedure.

METHODS

We performed a retrospective investigation including 21 "functional" ALT flaps between November 2006 and December 2016. In all patients included, FL was shaped to anatomical reproduce a tendon structure. Functional analysis included range of motion and force assessment. Functional scores were established according to Chen classification, DASH, and LEFS score. Defects resulted from tumor excision, trauma, burn, or infection-debridement and were distributed in four main anatomical districts: knee (seven cases), ankle (six cases), forearm-elbow (four cases), and hand-wrist level (three cases).

RESULTS

Nineteen flaps were raised as free flaps, while two as distally-based propeller flaps. Average follow-up was 38 months. Major complication requiring the harvest of a second flap was seen in two patients, whereas three flaps presented superficial necrosis and was treated in an outpatient regimen. We observed 81% of total ROM recovery compared to contralateral sides with 89% recovered articular stability. Best articulation outcomes were present in elbow reconstruction, while ankle reconstructions showed less articularity. Hospital stay was significantly reduced in hand and wrist functional reconstruction when compared with reconstruction at the ankle level (P < 0.05).

CONCLUSION

The ALT flap extended to vascularized FL provides a particularly effective and resistant tissue that can be folded to reconstruct and support tendinous structures. This can restore functional and structural integrity after complex defects in a single stage procedure.

Distally-based free anterolateral thigh flap with a modified vena comitans

With the recent development in microsurgery, the use of a perforator flap has been widely implemented. If the length of the ALT flap pedicle is insufficient despite adequate preoperative planning, pedicle length extension is necessary. We planned for a reverse ALT free flap using the distal vessel of the descending branch for pedicle length extension in the case of ALT perforator branch originating from the proximal portion of the descending branch. For the management of venous congestion, the distal venae comitantes were anastomosed to the proximal venous stump in an antegrade manner, successfully resolving the venous congestion. Modified reverse-flow ALT free flap, wherein the venae comitantes are anastomosed to the proximal vein stump, is a good option that allows for relatively simple pedicle extension within the same operative field when securing an adequate pedicle length is difficult because of the origin of the perforator from the proximal descending branch, unlike the initial surgical plan.

Distally based anterolateral thigh flap: an underutilized option for peri-patellar wound coverage

Wound coverage in the supra-patellar area presents a significant challenge for orthopaedic and reconstructive surgeons due to the need for preservation of knee joint function but the paucity of regional soft tissue flaps available. While many orthopaedic and reconstructive surgeons make use of the rotational gastrocnemius flap for coverage of peri-patellar defects, this flap has certain limitations. The goal of this study was to report a single-centre experience with the use of the distally based anterolateral thigh flap (ALT) and review the current literature on the use of the ALT for peri-patellar defects. In this report, both a single-centre experience using distally based anterolateral thigh (ALT) island flaps for supra-patellar wound coverage and the existing literature on this topic were reviewed. A systematic literature review was performed to assess the use of the ALT for peri-patellar wounds. Five patients with a mean age of 69 underwent a distally based ALT flap for coverage of peri-patellar defects. Four out of 5 flaps survived at the end of their respective follow-up. Based on this combined experience, the distally based reverse-flow anterolateral thigh island flap represents a useful but relatively underutilized option for appropriately selected supra-patellar wounds due to minimal donor site morbidity, multiple flap components, and predictable pedicle anatomy. The flap’s major weakness is its potentially unreliable venous drainage, requiring delay or secondary venous outflow anastomosis. Given the ALT flap’s favourable profile, the authors recommend consideration for its use when managing a peri-patellar coverage wound issue.

Distally based anteromedial thigh flaps pedicled on the rectus femoris branch of the lateral circumflex femoral artery for reconstruction of soft-tissue defect of the knee

BACKGROUND

Anteromedial thigh flaps are far less clinically appealing than their anterolateral counterparts, and are occasionally considered as an alternative to the anterolateral thigh flap. Herein, we report the study of soft-tissue defects reconstruction in the knee using a distally based anteromedial thigh flap pedicled on the rectus femoris branch of the descending branch of the lateral circumflex femoral artery.

PATIENTS AND METHODS

Between July 2008 and September 2016, a distally based anteromedial thigh flap was used to reconstruct soft-tissue defects of the knee in 5 patients (3 males, 2 females; age range at surgery 4-55 years old). The perforating vessels supplying anteromedial thigh were derived from the rectus femoris branch of the lateral circumflex femoral artery. The rectus femoris branch shared a common trunk with the descending branches of the lateral circumflex femoral artery. Defect etiologies included malignant neoplasms in 2 cases and post-burn scar contracture in the remaining 3 cases.

RESULTS

The average flap size was 19.6 × 9.2 cm (range: 15-24 × 6-12 cm). There was no flap loss. Postoperative muscle weakness occurred in one case. The average follow-up time was 17.8 months (range: 5-36 months). No recurrence of tumor or scar contracture was noted.

CONCLUSIONS

Distally based anteromedial thigh flaps pedicled on the rectus femoris branch of the descending branch of the lateral circumflex femoral artery may serve as an alternative option to the distally based anterolateral thigh flap for soft-tissue defect reconstruction of the knee.

Rectus femoris branch: An alternative blood supply for a distally based anterolateral thigh flap

Successful raising of a distally based anterolateral thigh (dALT) flap mainly depends on a well-developed lateral circumflex femoral artery (LCFA) descending branch and an intact vascular connection between the descending branch and the vascular network of the knee. However, in some clinical scenarios, the descending branch is hypoplastic or the vascular connection of the knee is compromised. We present six cases of using dALT flaps in soft tissue defect reconstruction of the knee with either of the above-mentioned conditions. In these cases, the flaps relied on the reverse blood flow through the rectus femoris branch and showed complete survival postoperatively. We believe that the reverse flow from the rectus femoris branch could be an alternative blood supply for the dALT flap in the presence of hypoplasia of the LCFA descending branch or compromise of the vascular connection between the descending branch and the articular geniculate network.

[Clinical applications of distally based anterolateral thigh flaps based on perforating vessels from lateral circumflex femoral artery oblique branch]

Objective

To explore the feasibility and technical points of soft tissue defect reconstruction of the lower extremity using the distally based anterolateral thigh (dALT) flap based on perforating vessels from the lateral circumflex femoral artery (LCFA) oblique branch.

Methods

Between July 2010 and July 2016, 7 patients underwent defect reconstruction of the lower extremities using the dALT flap based on perforating vessels from the LCFA oblique branch. There were 4 males and 3 females with an average age of 26.7 years (range, 3-58 years). The etiologies included angiofibrolipoma in 1 case, malignant fibrous sarcoma in 1 case, soft tissue sarcoma in 1 case, and post-burn scar contracture in 4 cases. The disease duration was 13 years, 1 year, and 8 months in 3 patients with tumors respectively, and was from 6 months to 35 years in 4 patients with post-burn scar contracture. After resection of lesion tissues, the defect size ranged from 8 cm×6 cm to 24 cm×8 cm. The flap size ranged from 9 cm×7 cm to 24 cm×8 cm. The length of the pedicle ranged from 12 to 22 cm (mean, 16.6 cm). The distance from the flap pivot point to the superolateral border of the patella ranged from 9.5 to 14.0 cm (mean, 11.8 cm). The donor sites were directly closed in 6 cases and covered with the split-thickness skin graft in 1 case.

Results

All flaps survived after surgery without any major complications. All wounds at the donor and the recipient sites healed primarily. The patients were followed up from 5 to 54 months (mean, 30.7 months). The color, texture, and thickness of the flaps were similar to those of the surrounding skin. No tumor recurrence was observed. The range of motion of flexion and extension of the knee joint were greatly improved in the patients with post-burn scar contracture.

Conclusion

For patients who have the oblique branch from the LCFA descending branch which sends out perforating vessels to the skin of the anterolateral thigh region, a dALT flap could be used to reconstruct soft tissue defects of the lower extremities.

Soft-tissue Defects After Total Knee Arthroplasty: Management and Reconstruction

Wound healing complications associated with total knee arthroplasty present a considerable challenge to the orthopaedic surgeon. To ensure preservation of a functional joint, the management of periprosthetic soft-tissue defects around the knee requires rapid assessment, early and aggressive débridement, and durable, contoured coverage. Several reconstructive options are available to tailor soft-tissue coverage to the location, size, and depth of the wound. Special consideration should be given to the timing of the intervention, management of infection, and prosthesis salvage. The merits of each reconstructive option, including perforator, fasciocutaneous, muscular, and free microvascular flaps, should be weighed to select the most appropriate option. The proposed approach can guide surgeons in treating patients with these complex soft-tissue defects.

Surgical implications of anatomical variation in anterolateral thigh flaps for the reconstruction of oral and maxillofacial soft tissue defects: focus on perforators and pedicles

OBJECTIVES

To gain information on anatomical variation in anterolateral thigh (ALT) flaps in a series of clinical cases, with special focus on perforators and pedicles, for potential use in reconstruction of oral and maxillofacial soft tissue defects.

MATERIALS AND METHODS

Eight patients who underwent microvascular reconstructive surgery with ALT free flaps after ablative surgery for oral cancer were included. The number of perforators included in cutaneous flaps, location of perforators (septocutaneous or musculocutaneous), and the course of vascular pedicles were intraoperatively investigated.

RESULTS

Four cases with a single perforator and four cases with multiple perforators were included in the ALT flap designed along the line from anterior superior iliac spine to patella. Three cases had perforators running the septum between the vastus lateralis and rectus femoris muscle (septocutaneous type), and five cases had perforators running in the vastus lateralis muscle (musculocutaneous type). Regarding the course of vascular pedicles, five cases were derived from the descending branch of the lateral circumflex femoral artery (type I), and three cases were from the transverse branch (type II).

CONCLUSION

Anatomical variation affecting the distribution of perforators and the course of pedicles might prevent use of an ALT free flap in various reconstruction cases. However, these issues can be overcome with an understanding of anatomical variation and meticulous surgical dissection. ALT free flaps are considered reliable options for reconstruction of soft tissue defects of the oral and maxillofacial area.

Knee and Ankle Reconstruction With Reverse Anterolateral Thigh and Free Anterolateral Thigh Flap From One Donor Site

Traditionally, the anterolateral thigh (ALT) free flap is used in distal lower extremity reconstruction. Reverse ALT flap has become one of the most popular choices for knee joint soft tissue defects. A 53-year-old man sustained a degloving injury in the right lateral side of the lower extremity from the lateral malleolar area to the knee joint area. The contamination was severe, necessitating serial debridement and negative pressure wound therapy. After 4 weeks, no more soft tissue necrosis was evident. No more microorganism growth was confirmed by swab culture. ALT free flap using proximal perforator was planned for lateral malleolar area reconstruction and reverse ALT flap using distal perforator was planned to cover knee joint after confirming the pedicle length was sufficient for simultaneous knee and lateral malleolar area reconstruction.

Distal anastomosis patterns of the descending branch of the lateral circumflex femoral artery

BACKGROUND

The reverse anterolateral thigh (ALT) flap has shown good results in the treatment of patients who have skin and soft tissue defects around the knee and shin. The objective of this study was to show the anastomotic patterns of the descending branch of lateral femoral circumflex artery (db-LCFA) and locate the appropriate pivot point for reverse ALT flap.

MATERIALS AND METHODS

Fifty thighs from 25 embalmed cadavers from the Anatomy Department, Khon Kaen University in 2012, were dissected. The patterns of distal anastomoses of db-LCFA were recorded and appropriate pivot points for the reverse ALT flap were measured.

RESULTS

Three patterns of distal anastomosis of the db-LCFA were identified, including the anastomoses to the superolateral genicular arteries (46%), anastomoses to the profunda femoral arteries (28%), and unidentified distal anastomoses (26%). The mean distance of the pivot point was 9.4 ± 3.7 cm from the lateral epicondyle. The mean pedicular length was 13.2 ± 5.4 cm (mean ± SD). Most cadavers, 76%, showed a single db-LCFA. In cases where there was more than one db-LCFA, the distal anastomoses were found to be originating from the most medial db-LCFA.

CONCLUSION

The reverse ALT flap technique showed good results in the treatment of patients with skin and soft tissue defects around the knee and shin. Variations of the anastomoses and branching patterns of the db-LCFA may influence flap survival. Additional preoperative vascular evaluations would be helpful in defining the most compatible area from which to harvest the flap.

Proximally Based Anterolateral-Thigh (ALT) Flap for Knee Reconstruction: An Advancement Propeller Perforator Flap

BACKGROUND

Adequate coverage of the knee region is often challenging for plastic and orthopedic surgeons. In the last decade, among several reconstructive techniques, local perforator flaps have become useful reconstructive units. After a wide resection for soft-tissue sarcoma, the knee vascular web may be reasonably damaged and, consequently, perforator flaps based on a local pedicle [such as the distally based anterolateral thigh (ALT) flap] are not reliable. Thus, we harvested a proximally based ALT for knee coverage.

METHODS

A 52-year-old man underwent local radiation therapy and a wide resection of a soft-tissue sarcoma on the anterior-lateral aspect of the left knee, which resulted in a 15 × 10 cm defect. The defect was covered with a proximally based ALT, through an advancement and propeller relocation of its skin paddle.

RESULTS

All margins were tumor free. After 5 days, the donor site was closed primarily because of edema. Neither necrosis of the flap nor dehiscence of the wound was detected. No local relapses were detected at 6-month follow-up.

CONCLUSIONS

In case of soft-tissue defects of the knee region, with likely involvement of the local vascular web, a local perforator solution is the advancement and propeller proximally based ALT flap.

LEVEL OF EVIDENCE V

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[Coverage of anterior knee defect by reverse flow anterolateral thigh flap: About two cases]

The coverage of soft-tissue defects concerning the front of the knee and the proximal lower leg is a complex procedure. The reverse flow anterolateral thigh flap represents a good solution for this defects, especially when the coverage surface is large-sized and a free flap is not appropriate regarding the difficulty of the process. Flap retrograde vascularization is based on the anastomosis between the descending branch of the circumflex femoral artery and lateral superior genicular artery. It is an easy solution with low morbidity. The authors have chosen this flap to cover soft-tissue defect of anterior knee from two patients with total knee prothesis.

Reconstruction of complex soft-tissue defects around the knee joint with distally based split vastus lateralis musculocutaneous flap: a new technique

AIMS

The aim of this study was to report our experience of using distally based spilt vastus lateralis musculocutaneous flaps for soft-tissue defects around the knee joint - a new technique.

MATERIAL AND METHODS

Cadaver dissection studies were conducted in three cadavers to demonstrate perforators entering the lower third of the vastus lateralis muscle arising from the superior lateral genicular artery. Its application in eight clinical cases for the reconstruction of soft-tissue defects around the knee joint is reported.

RESULTS

Seven out of eight flaps survived well without any flap loss. One flap with a skin island measuring 12 × 20 cm suffered a loss of 2 cm distally. This was later treated with skin grafting. Six out of eight donor sites were closed primarily. Six patients achieved full functional range of motion by 3 months. One patient had a 10° limitation of knee extension. One patient had foot drop due to primary injury and walks with a limping gait.

CONCLUSIONS

This flap is a new reconstructive option for knee defects. It can reach distally up to the tibial tuberosity and does not require an intraoperative change of position. The donor site can be closed primarily and is hidden inside the clothing. The function of the knee is not affected as the majority of the muscle is kept in continuity.

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.

Reverse Anterolateral Thigh Flap to Revise a Below-knee Amputation Stump at the Mid-tibial Level

Summary:

The reconstruction of defects around the knee often poses a challenge due to the limited availability of local soft tissues. Indeed, this same problem is encountered when attempting to revise a below-knee amputation stump. Moreover, due to a paucity of recipient vessels in those who have undergone previous amputation secondary to trauma, free-flap reconstruction is often challenging and not always successful. We report a case of a reverse anterolateral thigh (ALT) flap used to revise a long below-knee amputation stump. Previous reports in the literature attest to the versatility of the reverse ALT to cover defects around the knee and proximal tibia, but to our knowledge, this is the first report of a reverse ALT reaching to the mid-tibial level.

The composite anterolateral thigh flap for knee extensor and skin reconstruction

The simultaneous reconstruction of a skin defect and lost extensor mechanism of the knee joint is difficult. We present a 31-year-old male who lost the patella and had a 9 × 10 cm skin defect after a total patellectomy for an infected open patellar fracture. A composite anterolateral thigh (ALT) flap including vascularized skin and fascia lata (FL) was elevated. The FL was folded and sutured to the remaining patellar tendon. The skin flap covered the skin defect. The wound healed uneventfully. Thirty months later, the active range of motion of the knee joint was 0°-120° and the extension strength of the knee joint was normal. He could stand on his right leg and walk without assistance. The composite ALT flap is a valuable option in knee reconstruction after a total patellectomy.

The anterolateral thigh perforator flap for reconstruction of knee defects

INTRODUCTION

Large defects around the knee remain challenging reconstructive problems. We report our experience with the use of the anterolateral thigh perforator flap for various defects in this area, based on the anatomy seen intraoperatively.

METHODS AND MATERIALS

Eight knee defects were reconstructed with the anterolateral thigh flap in accordance with our algorithm. Of them, 6 were performed as pedicled flaps and 2 as free flaps. For the pedicled flaps, 1 patient was reconstructed with an anterolateral thigh rotation flap, 3 patients with a directly transposed distally based anterolateral thigh flap, 2 patients with a "propeller" distally based anterolateral thigh flap. In the 2 patients reconstructed with the free anterolateral thigh flaps, the intramuscular part of the descending branch of the lateral circumflex femoral artery was used as the recipient vessel.

RESULTS

Reconstruction was successfully performed in all patients. Defects limited to the patella and above can be covered by antegrade anterolateral thigh rotation flaps. For larger defects, the distally based flap is needed. This can be used in cases where the perforators arise from the descending branch of the lateral circumflex femoral artery, either as a direct advancement or propeller flaps. In cases where the perforators are not usable or arises from the oblique branch of the lateral circumflex femoral artery, reconstruction was completed as a free flap. In such instances, the distal descending branch provides a reliable recipient vessel.

CONCLUSION

The anterolateral thigh flap offers a versatile and reliable option for defects around the knee. Its use requires a certain degree of reconstructive flexibility as the anatomic variations of the flap may require the flap to be transferred as a free flap in some cases.

Perforator plus fasciocutaneous flaps in the reconstruction of post-burn flexion contractures of the knee joint

BACKGROUND

A post-burn flexion contracture of the knee joint is a disabling condition which interferes with an upright posture and a bipedal locomotion. Islanded perforator flaps have been used to resurface the tissue defect which is produced as a result of the contracture release. Despite their various advantages, they are limited by an increased tendency to undergo venous congestion. Perforator-plus flaps can be used to overcome this limitation, while retaining the merits of the islanded perforator flaps.

METHODS

Ninteen patients with post flame burn flexion contractures of the knee joints underwent surgical releases and coverages by various local fasciocutaneous perforator-plus flaps. The patients were followed up for 6 months and the various aspects of the functional and the aesthetic rehabilitations were assessed.

RESULTS

All the local fasciocutaneous perforator-plus flaps resurfaced the tissue defect over popliteal fossa with good colour and texture match and maintenance of the contour. None of the flaps had any significant early or delayed complications (which included venous congestions) which necessitated reoperations. All the patients were satisfied with the functional and aesthetic outcomes.

CONCLUSION

Local fasciocutaneous perforator-plus flaps can be considered as one of the primary treatment modalities for the surgical release and reconstruction of post burn flexion contractures of the knee.