Gastrocnemius Myocutaneous Flaps for Knee Joint Coverage

Concurrent plate fixation and pedicled flap coverage for open fractures complicated by soft tissue loss of the tibia in pediatric cohort: a clinical series

BACKGROUND

The optimal treatment of open fractures complicated by soft tissue loss of pediatric tibial fractures remains inconclusive. The author described a protocol of concurrent plate fixation and pedicled flap coverage and retrospectively reviewed the outcomes of such injuries.

METHODS

A total of 25 pediatric cases with Gustilo lllB open tibial fracture were treated by single-stage plate fixation and pedicled flap reconstruction. The reviewed information consisted of time to fix and flap, type of plate, type of pedicled flap, fracture union time, postoperative complication and the clinical outcomes by objective scoring system.

RESULTS

Fix and flap was undergone between 7 and 12 days after injury with the average time of 8.2 days. Regarding the type of plate, narrow LCP was applied in 8, 3.5 mm precontoured LCP in 10, 5.0 mm precontoured in 2 and double LCP in 5. According to soft tissue reconstruction, the medial gastrocnemius flap was selected in 6 cases, myocutaneous medial gastrocnemius flap in 2, soleus flap in 3, hemisoleus flap in 5, reverse sural flap in 6 and combined medial gastrocnemius and hemisoleus flaps in 3. No flap-related complication was demonstrated. All cases established fracture union in between 12 and 24 weeks with an average time to union of 17.7 weeks. According to postoperative complications, infected plate occurred in 2 cases and implant irritation in 5. According to Puno functional score, excellent results were presented in 7 cases and good results in 18 cases.

CONCLUSION

Single-stage plate fixation and pedicled flap coverage are a reliable regimen for pediatric open fractures complicated by soft tissue loss of the tibia.

Utilization of the gastrocnemius flap for post-traumatic knee reconstruction: a systematic review

PURPOSE

High-energy injuries to the knee may lead to extensive soft tissue loss, fractures, and potential loss of extensor function. The gastrocnemius flap is a prominent reconstructive option for patients with injuries involving the knee and proximal third of the lower extremity. To the best of our knowledge, there has not been an informative review that has evaluated outcomes of patients who have undergone post-traumatic knee reconstruction with a pedicled medial or lateral gastrocnemius flap. The goal of this study is to assess outcomes in patients who have undergone gastrocnemius flap reconstruction after traumatic injuries to the knee.

METHODS

The review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) methodology. Four databases were utilized including PubMed, Cochrane Reviews, Embase, and CINAHL. Our search criteria consisted of the following keywords: gastrocnemius, flap, knee, and traum*.

RESULTS

A total of 204 studies were imported for screening, from which five papers met our final inclusion/exclusion criteria. The most common studies utilized in this review were case series followed by retrospective chart reviews. In total, 43 patients with traumatic soft tissue knee defects were included with an average patient age of 27.28 years. All patients had successful and clinical viable flaps post-operatively, and there were a total of five patients who had complications.

CONCLUSION

The gastrocnemius flap has demonstrated to be an effective option for individuals undergoing post-traumatic knee reconstruction. Infection rates, loss of mobility, and scarring represent a minority of complications that may be seen when this reconstructive technique is utilized. Still, additional randomized controlled trials and retrospective studies are required in order to further evaluate for other potential complications that may occur in this patient population.

Modified medial gastrocnemius myocutaneous flap with extended anterior, inferior and/or posterior boundaries: Anatomical observation and report of a clinical series of 33 flaps

INTRODUCTION

Reports on medial gastrocnemius myocutaneous (MGM) flaps with extended inferior and posterior boundaries are rare, and information about the MGM flaps with extended anterior boundaries is unavailable. Thus, this study aimed to investigate the vascular anatomical basis and clinical reliability of the modified MGM flap with extended anterior, inferior and/or posterior boundaries.

METHODS

Five fresh lower limb specimens from patients with recurrent tumours in the thigh were immediately irrigated and perfused. The stripped integuments were radiographed. The pretibial skin was equally divided into nine zones. The reconstruction outcomes of the modified MGM flaps were documented in 33 patients.

RESULTS

True anastomotic connections existed among the branches of the saphenous artery, the perforator from the inferior medial genicular artery and 3-5 (mean, 4.5) perforators from the posterior tibial artery in the upper two-thirds of the leg. A total of 33 modified MGM flaps were applied. The anterior margins of 26 modified flaps with extended anterior boundaries exceeded the medial edge of the tibia by 1.0-4.5 cm (mean, 2.1 cm). Fourteen modified MGM flaps were used to repair the defects involving the lower third leg, whose distal edges were located in the seventh (n = 8) or eighth (n = 6) zone. A 1-169-month (median, 9 months) follow-up was conducted for 33 patients. Of the 33 flaps, 29 (87.9 %) survived completely, partial necrosis occurred in four flaps with extended anterior (n = 2) or inferior (n = 2) boundaries.

CONCLUSIONS

Multiple source vessels are the vascular anatomical basis of the modified MGM flap with extended anterior, posterior and/or inferior boundaries. The modification of the MGM flap is feasible and reliable, broadening the applicable scope of the flap. The modified MGM flap can be applied to repair more distal, wider and larger-area defects with a simpler design and procedure.

Complex periprosthetic wound coverage in patients undergoing revision total knee arthroplasty: a single plastic surgeon study

INTRODUCTION

Options for soft tissue coverage in revision total knee arthroplasty (rTKA) range from primary wound closure to complex muscle flap reconstructions. The purpose of this study was to investigate the institutional experience of wound coverage options for complex soft tissue defects in rTKA.

MATERIALS AND METHODS

77 patients undergoing rTKA with complex wound closure by a single plastic surgeon were retrospectively reviewed. The average follow-up was 30.1 months. In 18 (23.4%) patients, an intraoperative decision for primary closure was made. Fifty-nine patients (76.6%) received either a local fasciocutaneous (N = 18), a medial gastrocnemius (N = 37), a free latissimus dorsi (N = 3) or a lateral gastrocnemius flap (N = 1). Revision-free survival and complication rates were assessed and risk factors were analyzed with Cox-regression analysis.

RESULTS

Medial gastrocnemius flaps had significant lower cumulative revision-free survival rates than local fasciocutaneous flaps (P = 0.021) and primary closures (P < 0.001) (42.5% vs. 71.5% vs. 100%,respectively). Comparing the most common complex closure procedures medial gastrocnemius flaps had the highest rate of prolonged wound healing (29.7%) and infection/reinfection (40.5%). Infection-associated flap procedures had significant lower cumulative revision-free survival rates (30.5%) than non-infection associated flap procedures (62.8%,P = 0.047). A history of more than two prior surgeries (HR = 6.11,P < 0.001) and an age ≥ 65 years (HR = 0.30,P = 0.018) significantly increased the risk of revision.

CONCLUSIONS

The results of this study indicate that primary closure -if possible- should be preferred to early proactive muscle flap coverage. Even in the hands of an experienced plastic surgeon muscle flaps have high revision and complication rates. The study highlights the need to clarify flap indications and to investigate alternative approaches.

Comparisons of the morbidities of a double gastrocnemius flap and a medial gastrocnemius flap in the orthoplastic reconstruction around the knee

BACKGROUND

The pedicled gastrocnemius flap is commonly used to treat lower limb defects. Either the medial, lateral, or both heads can be used. When extended soft tissue defects are present, a double gastrocnemius (DG) flap may be used. However, no data of the additional donor site morbidity compared to a medial gastrocnemius (MG) flap are available. The aim of this study was to compare the donor site morbidity of a DG with that of a MG.

METHODS

Patients with a soft tissue defect around the knee, treated with a gastrocnemius flap between 2018 and 2021 at the University Hospital of Lausanne and Bari, with a minimum follow-up of 12 months, were included. According to the size and the position of the defect, it was decided whether one (10 patients) or two (9 patients) heads of the gastrocnemius were necessary for the coverage. The mean age was 61 years (range 42-82) in DG, and 63 years (range 45-78) in MG. The average defect size was 89.8 cm2 in the DG group and 53.4 cm2 in the MG group. The etiologies were trauma (n = 10), infection (n = 7) and sarcoma (n = 2). A medial approach or a posterior midline approach was used for the harvesting of the gastrocnemius muscle. Once the flap was harvested, it was rotated and transposed anteriorly over the defect, either through a subcutaneous tunnel or by dividing the intervening skin bridge, depending on the soft tissue defect. A split-thickness skin graft was used to close the skin over the remaining exposed muscle flap. The active range of motion of the ankle and knee joints was measured. Muscle strength was assessed with a hand-held dynamometer and by the ability to stand on tiptoe. Physical function was evaluated through the Lower Extremity Functional Scale (LEFS).

RESULTS

The two groups were homogeneous, with no significant difference in age, sex, and BMI. All flaps survived in both groups. Both groups showed lower values in strength and range of motion of the operated leg, when compared to contralateral side. In plantar flexion, this accounted for a reduction in MG by 3.8 ± 1.0 kg of strength and 8 ± 3° of ROM, and in DG by 4.7 ± 1.7 kg and 16 ± 4°, respectively. For knee flexion, the reduction in MG was 4.4 ± 0.6 kg and 16 ± 7°, while in DG 5.6 ± 1.0 kg and 28 ± 6°. In the MG group, 60% were able to stand on the tiptoe of the operated leg, as opposed to 0% in DG. The average LEFS score in DG was lower by 10.9 points (p < .05). Questions concerning running and jumping had a lower score in DG (p < .01).

CONCLUSIONS

The harvesting of both gastrocnemii led to significant additional donor site morbidity compared to the harvesting of the medial gastrocnemius alone. However, the additional morbidity did not have an impact on activities of daily living and walking, even though it limited the ability to perform more demanding tasks such as running and jumping. Therefore, based on our study, the choice of a DG flap should be critically assessed in younger, more demanding patients.

Prophylactic Muscle Flaps Decrease Wound Complication Rates in Patients with Oncologic Spine Disease

BACKGROUND

Patients with oncologic spine disease face a high systemic illness burden and often require surgical intervention to alleviate pain and maintain spine stability. Wound healing complications are the most common reason for reoperation in this population and are known to impact quality of life and initiation of adjuvant therapy. Prophylactic muscle flap (MF) closure is known to reduce wound healing complications in high-risk patients; however, the efficacy in oncologic spine patients is not well established.

METHODS

A collaboration at our institution presented an opportunity to study the outcomes of prophylactic MF closure. The authors performed a retrospective cohort study of patients who underwent MF closure versus a cohort who underwent non-MF closure in the preceding time. Demographic and baseline health data were collected, as were postoperative wound complication data.

RESULTS

A total of 166 patients were enrolled, including 83 patients in the MF cohort and 83 control patients. Patients in the MF group were more likely to smoke ( P = 0.005) and had a higher incidence of prior spine irradiation ( P = 0.002). Postoperatively, five patients (6%) in the MF group developed wound complications, compared with 14 patients (17%) in the control group ( P = 0.028). The most common overall complication was wound dehiscence requiring conservative therapy, which occurred in six control patients (7%) and one MF patient (1%) ( P = 0.053).

CONCLUSIONS

Prophylactic MF closure during oncologic spine surgery significantly reduces the wound complication rate. Future studies should examine the precise patient population that stands to benefit most from this intervention.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

Application of Staged Negative Pressure Wound Therapy and Flap Surgery for Infection Control After Patellar Internal Fixation Surgery

The anatomic position of the patella is superficial, making it vulnerable to injuries. Treatment of patella infection after internal fixation surgery remains a big challenge due to minimal soft tissue coverage and vital tissue exposure. Forty-two patients aged 10 to 59 years were admitted to the institution's burn unit between January 2010 and December 2019. Each presented with infection after patellar fracture surgery. Twenty-seven infections were superficial, whereas 15 were deep with pyogenous arthritis of the knee. Negative pressure wound therapy (NPWT) was applied after radical debridement to remove necrotic subcutaneous tissues and internal fixation devices. In addition, cases with septic arthritis were irrigated continuously with normal saline. After 5 to 10 days of NPWT treatment and irrigation, wound infection was well controlled. Afterward, 42 wounds were resurfaced with pedicled flaps, the 42 patients received 17 reverse-flow anterolateral thigh (ALT) perforator flap, 12 medial sural artery perforator flaps, 7 gastrocnemius musculocutaneous flaps, as well as 6 saphenous artery flaps. Thirty-seven flaps survived uneventfully. However, 3 flaps developed venous congestion in the distal end. Two flaps developed tip necrosis. All patients were followed up between 3 and 48 months. Infection beneath the flap occurred in 3 patients and healed after an additional debridement surgery. The staged NPWT and flap surgery strategy focus on thorough debridement and immediate internal fixation devices removal, effective fracture fixation, efficient NPWT application, targeted administration of antibiotics, and adequate soft tissue coverage. This study established that the procedure was effective in infection control after patellar internal fixation surgery.

Role of the Gastrocnemius Musculocutaneous with a Propeller Style Skin Flap in Knee Region Reconstruction: Indications and Pitfalls

Background  Soft tissue reconstruction around the knee area is still an open question, particularly in persistent infections and multiple reoperations scenario. Flap coverage should guarantee joint mobility and protection, even when foreign materials are implanted. The chimeric harvesting of the musculocutaneous gastrocnemius flap, based on the sural artery perforators, can extend its applicability in soft tissue reconstruction of the upper leg, overcoming the drawbacks of the alternative pedicled flaps. Methods  A multicenter retrospective study was conducted enrolling patients who underwent to a pedicled, chimeric gastrocnemius musculocutaneous-medial sural artery perforator (GM-MSAP) or lateral sural artery perforator (GM-LSAP) flap for knee coverage in total knee arthroplasty (TKA) recurrent infections and oncological or traumatic defects of the upper leg from 2018 to 2021. Outcomes evaluated were the successful soft tissue reconstruction and flap complications. Surgical timing, reconstruction planning, technique, and rehabilitation protocols were discussed. Results  Twenty-one patients were included in the study. Nineteen GM-MSAPs and 2 GM-LSAPs were performed (soft tissue reconstruction in infected TKA [12], in infected hardware [4], and in oncological patients [5]). Donor site was closed primarily in 9 cases, whereas a skin graft was required in 12. Flap wound dehiscence (1), distal flap necrosis (1), distal necrosis of the skin paddle (1), and donor site infection (1) were the encountered complications. Flap reraise associated to implant exchange or extensive debridement was successful without requiring any further flap surgery. Conclusion  The propeller-perforator GM-MSAP offers qualitative defect coverage and easiness of multiple flap reraise due to skin availability and its laxity.

How to get the most out of your gastrocnemius and soleus flaps

Gastrocnemius and soleus flaps represent the workhorse local flaps to cover soft tissue defects of the proximal 1/3 and middle 1/3 of the leg, respectively. An important consideration before conducting a local flap is whether the flap can provide adequate coverage. The utility of the gastrocnemius flap can be increased using multiple techniques to increase the arc of rotation including the posterior midline approach, dissection at the pes anserinus and medial femoral condyle origin, scoring the fascia, and inclusion of a skin paddle. Concerning the soleus flap, the hemisoleus flap represents a technique to increase the arc of rotation. With a soleus flap, one must consider the soft tissue defect location, size, and perforator blood supply because these factors influence what soleus flap technique to use. This article discusses how to make the most out of gastrocnemius flaps and soleus flaps regarding maximizing coverage and ensuring successful flap outcome.

Muscle-only versus chimeric musculocutaneous gastrocnemius pedicled flap in complex orthoplastic reconstructions of the knee region: A retrospective study

BACKGROUND

The knee region represents a challenging area of soft tissue reconstruction. Specifically, in the context of total knee arthroplasty (TKA) or following high-energy trauma with fractures and hardware fixation, soft tissue defects can expose critical structures such as joint, bone or tendon, besides the implant/plates themselves, with dramatic consequences in terms of postoperative infection and hardware contamination.

METHODS

A retrospective study was conducted on a prospectively maintained database from January 2016 to February 2021. Inclusion criteria involved all patients who underwent an implant-associated infection of the knee and upper third of the leg coupled with a soft tissue reconstruction (STR) using the traditional gastrocnemius muscle (GM) pedicled flap or the chimeric GM-MSAP (medial sural artery perforator) flap.

RESULTS

Thirty-eight patients were included (group A, GM flap, 22 patients; group B, chimeric GM-MSAP flap, 16 patients). No statistically significant differences were detected in terms of age, comorbidities, defect size, follow-up, and flap complications. A statistically significant difference was seen among the groups in terms of successful flap re-raise (required because of a persistent infection of the implant or in a two-stage procedure setting, including the use of a cemented spacer) in favour of the GM-MSAP group.

CONCLUSION

The chimeric GM-MSAP, being safer to reraise if required, can be a significantly more powerful tool in those cases in which a two-stage procedure is planned or when there is a high probability for secondary intervention need, reducing the need to convert to either free flap coverage or amputation.

Knee Defect Reconstruction Using the Distally Based Anterolateral Thigh Flap Based on the Reverse Flow from the Oblique Branch of the Lateral Circumflex Femoral Artery

Reconstruction of soft tissue defects around the knee is challenging, and the most common solution is to use various locoregional flaps or, in some difficult cases, a free flap. The distally based anterolateral thigh (dALT) flap is a commonly used flap that relies on reverse blood flow from the descending branch of the lateral circumflex femoral artery (d-LCFA). Here, we present the case of an anteromedial knee reconstruction using a dALT flap after resection of a pleomorphic undifferentiated sarcoma. The tumor resection resulted in a 14 × 7 cm defect, and a dALT flap, measuring 20 × 8 cm was elevated. During the surgery, we found a robust oblique branch of the LCFA (o-LCFA) sending off two sizable perforators to the anterolateral thigh region, whereas the d-LCFA was relatively small with no usable perforators. Therefore, we harvested a dALT flap relying on reverse flow from the o-LCFA. The patient's postoperative course was uneventful, and the flap survived without complications. This report demonstrates that reverse flow from the o-LCFA may be an alternative to nourish a dALT flap in cases where the d-LCFA is hypoplastic or suitable perforators from the d-LCFA are unavailable.

Modified lateral gastrocnemius myocutaneous flap with extended anterior and/or inferior boundary

There is little information regarding the boundaries of the lateral gastrocnemius myocutaneous (LGM) flap. The aim of this study was to introduce the modified technique of the LGM flap with extended anterior and/or inferior boundaries and its anatomical basis. Five fresh lower limb specimens were perfused and radiographed. Between December 2003 and August 2018, 27 modified LGM flaps with extended anterior and/or inferior boundaries were raised in 27 patients to reconstruct the soft tissue defects over the middle and upper leg, knee, and lower thigh. Both the lateral popliteal cutaneous artery and musculocutaneous perforators from the lateral sural artery had rich linked arteries communicating with the chain-linked arterial network around both the posterolateral intermuscular septum and the sural nerve, and they also had rich transverse communicating arteries connecting with the perifascial arterial network overlying the anterior compartment in the upper and middle calf. Continuous fascial arterial networks were extended up to the level at the intermalleolar line. Twenty-three flaps survived uneventfully, 2 flaps displayed distal de-epithelialization, and 2 flaps (7.41%) developed partial necrosis. Osteomyelitis was cured successfully in all patients, and no relapse of infection was encountered during the follow-up period. Multiple feeder arteries are the arterial anatomic basis of the modified LGM flap. The modified LGM flap with extended anterior and/or inferior boundaries is feasible, and the modified flap with extended anterior boundaries is safe and reliable.

Gastrocnemius pedicled muscle flap for knee and upper tibia soft tissue reconstruction. A useful tool for the orthopaedic surgeon

Soft tissue defect coverage has always been a challenge for the orthopaedic surgeon. Over the last decades the surgery of flaps has completely changed the prognosis for large defects. The purpose of this study is to retrospectively review our experience with the gastrocnemius muscle as pedicled local flaps for reconstruction of knee and upper third of the tibia soft tissue defects. Twenty-seven patients underwent reconstruction of soft tissue defects around the knee using pedicled gastrocnemius muscle flaps. There were eighteen men and nine women ranged in with a mean age of 50.3 years. Medial gastrocnemius was used in 21 cases, and lateral gastrocnemius in 5 cases. In one patient, soleus and medial gastrocnemius were transferred simultaneously. All but one had at the same time split thickness skin graft for coverage of the muscle. All muscle flaps transferred were successful. There were no complications and all flaps survived completely without vascular compromise, satisfactory coverage of the defect, and good primary wound healing. There has been no recurrence of osteomyelitis. The donor sites healed perfectly with no remarkable resultant functional disability. A mean follow-up of 4.4 years revealed acceptable cosmetic results with high patient satisfaction. Our results indicate that the gastrocnemius muscle transfer is a useful technique for coverage of soft tissue defects in the upper tibia and around the knee in our orthopaedic practice. It is a reliable option for the coverage of exposed bone, the filling up of deep cavities and the treatment of bone infection. The principal advantage of a muscle flap is to bring a real blood supply to the recipient site and to improve the trophicity of the surrounding tissues. The pedicled muscle flap is our preference for the management of soft tissue defects around the knee, when no other procedure, apart from free flap is suitable. The pedicle flap is easier, quicker and with less complications than a free flap. Orthopaedic surgery has gained much from the use of island flap, however, it requires knowledge of the vascular anatomy and its variations promoted through cadaveric dissections and flap dissection courses.

Utilizing the various forms of the gastrocnemius muscle in fix & flap protocol: a reliable remedy for open proximal tibial fractures with accompanying soft tissue defect

BACKGROUND

Open proximal tibial fractures accompanied by soft tissue loss are substantially challenging to accomplish both bony consolidation and wound healing. The authors retrospectively delineated the utility of the various forms of the gastrocnemius muscle in fix & flap regimen for management of such complicated injuries.

METHODS

Thirty-one patients with open fracture accompanied by soft tissue loss of proximal tibia were managed by the protocol of fix & gastrocnemius flap. The collected data included implant for fixation, form of the gastrocnemius flap, postoperative complications, union time, and clinical assessment.

RESULTS

According to fixation devices, lateral anatomical locking compression plates were selected in 28 cases, dual plates in 1, and interlocking nails in 2. According to the forms of the gastrocnemius flap, medial gastrocnemius flap was utilized in 22 cases, medial hemigastrocnemius flap in 2, medial myocutaneous gastrocnemius flap in 2, lateral gastrocnemius flap in 3, and combined medial and lateral gastrocnemius flaps in 2. All flaps completely survived without any flap-related complications. Fracture consolidation was established in all patients with an average period of 19.9 weeks (range 16-26). Surgical site infection occurred in 3 cases, and delayed union in 1. By functional score of Puno, 3 cases were determined to be excellent, 27 to be good, and 1 to be fair.

CONCLUSION

Concurrent use of internal fixation and gastrocnemius flap reconstruction is a reliable and efficient protocol in managing open fractures with accompanying soft tissue defect of proximal tibia.

A triple-component deep inferior epigastric artery perforator chimeric free flap for three-dimensional reconstruction of a complex knee defect complicated with patella osteomyelitis

Reconstruction of a complex knee defect is challenging, especially when complicated with osteomyelitis. Complex knee defect requires multi-component three-dimensional reconstruction using a chimeric flap. Although anterolateral thigh (ALT) flap is the most workhorse chimeric flap, another chimeric flap is required when ALT flap is not available. In this report, we present a case of complex knee defect successfully treated with a free triple-component chimeric deep inferior epigastric artery perforator (DIEP) flap transfer. A 36 year-old male sustained right above-knee amputation and Gustilo IIIB open fracture of the left patella after being run over by a train. Stump formation was performed for the right limb amputation, and the left knee wound resulted in skin necrosis complicated with patella osteomyelitis. After debridement, the left knee wound showed a 3 × 2 cm articular capsule defect, 5 × 2 cm exposed patella stump, and a 16 × 9 cm skin defect. A triple-component chimeric DIEP flap, containing a 7 × 3 cm rectus abdominis muscle (RAM), a 3 × 2 cm RAM's fascia, and a 23 × 10 cm skin was transferred. The RAM's fascia was used to reconstruct the joint, the RAM to cover the exposed patella's stump and the reconstructed joint, and the skin paddle to cover the skin defect. Six months after the surgery, the patient could walk without osteomyelitis recurrence, and there was no limitation in the left knee joint's range of motion. Although indication is limited, a multi-component chimeric DIEP flap may be an option for three-dimensional reconstruction of a complex defect.

Coverage of cutaneous substance loss in the leg: Techniques and indications

Cutaneous substance loss in the leg is frequent; more often than not, it is trauma-related. It calls for complex management and necessitates the application of all current reconstruction techniques, particularly microsurgery. As regards treatment, the available therapeutic arsenal is highly diversified, ranging from a simple free flap skin graft to local and locoregional flaps. During reconstruction, the surgeon is subjected to several constraints insofar as the objectives of the operation are esthetic as well as functional. Ideally, the fineness of the skin covering the anterior side of the leg will have been scrupulously respected. Reconstruction is aimed at producing a stable and reliable cutaneous envelope while limiting the morbidity of the donor site. The development of free perforator flaps corresponds to these two criteria by producing a fine flap adapted to the cutaneous thickness of the leg and limiting any functional and esthetic sequelae at the donor site.

Lower limb perforator flaps: Current concept

Following a long period dominated by random fasciocutaneous flaps or muscle flaps, solutions to cover the lower limb have been largely diversified by the advent of so-called "perforator" flaps. Extended knowledge of vascular anatomy has propagated the development of this innovative procedure, in the objective of reducing morbidity. The existence of close to 400 perforator vessels in the body makes it possible to offer new flap perspectives for many defects, which were sometimes previously impossible to manage before except by free flap. For us, perforator flaps have become the current first-line solutions for small to medium size loss of substances. Understanding of vascular physiology and surgical experience are essential in choosing indications, detecting perforators, and modeling flaps to be optimally positioned in the reconstructive decisional algorithm. New skills are needed to master this type of reconstruction and limit failures, which implies a learning curve not only for flap design, perforator detection and surgical procedure, but also for monitoring and management of complications. In this manuscript, we outline the concepts and principles of the majority of the pedicled perforator flaps available for coverage of the lower limb, based on experience of more than 400 perforator flaps suitable for this localization.

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.