Recipient vessels in the free flap reconstruction around the knee. Ann Plast Surg. 2013;71:429-433. [PMID: 23407250 DOI: 10.1097/sap.0b013e31824e5e6e]

"Extra-anatomical Pedicle Rerouting" An alternative technique to obtain new recipient vessels for microsurgical reconstruction in unfavorable clinical situations

BACKGROUND

Lack of adequate recipient vessels in certain anatomically unfavorable locations or in complex clinical situations is still a limitation to successful microsurgical transfer. To address such complex cases, advanced microsurgical techniques should be applied. In this paper, the authors describe their experience with the Extra-anatomical Pedicle Rerouting (EPR) technique, an alternative approach that was used in selected cases throughout the body to obtain healthy recipient vessels for microsurgical reconstruction in unfavorable clinical situations where suitable recipient vessels were difficult to find.

PATIENTS AND METHODS

Fifteen patients with defects of variable etiology (oncological resection, trauma, previous surgeries) located in the trunk or upper and lower extremities received EPR free flap reconstruction at our Institution. Operative data, postoperative course, and complications were recorded. Clinical and photographic follow-ups were also documented.

RESULTS

A total of 15 flaps (6 antero-lateral thigh (ALT), 6 latissimus dorsi/thoracodorsal artery perforator flap (LD/TDAP), 3 deep inferior epigastric artery perforator flap (DIEP)) were transferred adopting the EPR technique for oncological (11) and post-traumatic (4) defects. According to the different clinical scenarios, the rerouted vessels were the thoraco-acromial, posterior circumflex humeral, thoracodorsal, deep inferior epigastric, lateral circumflex femoral, anterior tibial, and medial sural pedicles. Mean length of the rerouted vascular conduits was 6.53 cm. Mean operative time was 420 minutes. No major complications were registered. Minor wound dehiscence was observed and managed conservatively in 3 patients.

CONCLUSIONS

The EPR technique proved to be useful in a reliable and reproducible manner in different regions of the body as an alternative solution to obtain healthy recipient vessels in anatomically and surgically unfavorable clinical situations.

A Novel Vascular Anastomotic Coupling Device for End-to-End Anastomosis of Arteries and Veins

OBJECTIVE

Hand-sutured (HS) techniques remain the gold standard for most microvascular anastomoses in microsurgery. HS techniques can result in endothelial lacerations and back wall suturing, leading to complications such as thrombosis and free tissue loss. A novel force-interference-fit vascular coupling device (FIF-VCD) system can potentially reduce the need for HS and improve end-to-end anastomosis. This study aims to describe the development and testing of a novel FIF-VCD system for 1.5 to 4.0 mm outside diameter arteries and veins.

METHODS

Benchtop anastomoses were performed using porcine cadaver arteries and veins. Decoupling force and anastomotic leakage were tested under simulated worst-case intravital physiological conditions. The 1.5 mm FIF-VCD system was used to perform cadaver rat abdominal aorta anastomoses.

RESULTS

Benchtop testing showed that the vessels coupled with the FIF-VCD system could withstand simulated worst-case intravital physiological conditions with a 95% confidence interval for the average decoupling force safety factor of 8.2 ± 1.0 (5.2 ± 1.0 N) and a 95% confidence interval for the average leakage rate safety factor of 26 ± 3.6 (8.4 ± 0.14 and 95 ± 1.4 μL/s at 150 and 360 mmHg, respectively) when compared to HS anastomotic leakage rates (310 ± 14 and 2,100 ± 72 μL/s at 150 and 360 mmHg, respectively). The FIF-VCD system was successful in performing cadaver rat abdominal aorta anastomoses.

CONCLUSION

The FIF-VCD system can potentially replace HS in microsurgery, allowing the safe and effective connection of arteries and veins. Further studies are needed to confirm the clinical viability and effectiveness of the FIF-VCD system.

Technical Variables in Lower Extremity Free Flap Reconstruction

BACKGROUND

 Lower extremity free flap failure rates are higher than in other areas of the body. While prior studies assessed the effect of intraoperative technical variables, these generally investigated individual variables and did not examine relationships between the many individual technical decisions made during free tissue reconstruction. Our purpose was to investigate the effect of variation in intraoperative microsurgical techniques on flap outcomes in a diverse cohort of patients requiring lower extremity free flap coverage.

METHODS

 Consecutive patients undergoing free flap reconstruction of the lower extremity at two level 1 trauma centers from January 2002 to January 2020 were identified using Current Procedural Terminology codes, followed by a review of medical records. Information regarding demographics and comorbidities, indications, intraoperative technical details, and complications was collected. Outcomes of interest included an unplanned return to the operating room, arterial thrombosis, venous thrombosis, partial flap failure, and total flap failure. Bivariate analysis was performed.

RESULTS

 In total, 410 patients underwent 420 free tissue transfers. The median follow-up time was 17 months (interquartile ranges: 8.0-37). Total flap failure occurred in 4.9% (n = 20), partial flap failure in 5.9% (n = 24), and unplanned reoperation in 9.0% (n = 37), with arterial thrombosis in 3.2% (n = 13) and venous thrombosis in 5.4% (n = 22). Overall complications were significantly associated with recipient artery choice, with arteries other than PT and AT/DP having a higher rate (p = 0.033), and with arterial revisions (p = 0.010). Total flap failure was also associated with revision of the arterial anastomosis (p = 0.035), and partial flap failure was associated with recipient artery choice (p = 0.032).

CONCLUSION

 Many interoperative options and techniques are available when performing microvascular lower extremity reconstruction that leads to equally high success rates. However, the use of arterial inflow outside of the posterior tibial and anterior tibial arteries leads to a higher overall complication rate and partial flap failure rate. Intraoperative revision of the arterial anastomosis portends poorly for ultimate flap survival.

Combined use of lower medial thigh perforator (LMTP) flap and pedicled medial sural artery perforator flap (MSAP) for lateral knee defects coverage after sarcoma resection: A case report and literature review of soft tissue defect around knee reconstruction

Reconstruction of knee defects still represents a challenge for reconstructive surgeons. After an extensive resection, the primary aim is to reach a stable result, while maintaining a good range of motion and aesthetic unity. The use of pedicled perforator-based flaps makes it possible to achieve these goals. Many are the flaps that can be used in this region, and the pedicle medial sural artery perforator (mSAP) flap is considered among one of the first-choice techniques. The purpose of this case report is to describe for the first time the use of pedicled mSAP flap to cover a lateral knee defect. A 79-year-old patient underwent extensive excision of sarcoma on the lateral side of the left knee, with removal of distal portion of the vastus lateralis muscle and portion of the biceps femoris tendon. The resulting defect from the excision measured 10 cm × 10 cm. To cover the postero-inferior part of the defect we decided to use a mSAP flap, with a skin paddle 10 cm × 5 cm, which was tunneled posteriorly to the popliteal artery and vein in order to reach the affected site. We then used a lower medial thigh perforator (pLMT) flap with a 15 cm × 5 cm skin paddle, rotated by 90° in a propeller fashion to cover the antero-superior portion of the defect. The decision to use two flaps was justified by the fact we wanted to close the donor areas with direct suturing for a better aesthetic result. The post-operative course was regular with only a small wound dehiscence that had healed by secondary intention. At 6 months postoperatively, the patient showed a complete active range of motion of the knee joint and absolute aesthetic satisfaction with flaps donor site and knee shape. A review of literature is also provided, with a specific focus on the different procedures for soft tissue defects reconstruction around the knee. According to our experience, the pedicle of the MSAP flap may be safely used as an additional reconstructive option for lateral knee defects.

Reconstruction of soft tissue defect around knee with thoracodorsal artery perforator flap and muscle-sparing latissimus dorsi flap

INTRODUCTION

Around the knee reconstruction is challenging for reconstructive surgeons. Several methods have been proposed, including perforator and muscle flaps; however, all have advantages and disadvantages. As the success rate of free-flap surgery increases, reconstruction around the knee using this method is becoming increasingly popular. Nevertheless, there are no large-scale case reports in the previous literature using either a thoracodorsal artery perforator flap (latissimus dorsi (LD) perforator flap) or a muscle-sparing latissimus dorsi (msLD) flap for reconstruction around the knee. In this retrospective report, we describe our clinical experiences and present an algorithm regarding recipient vessel choice in free-flap reconstructive surgery of around the knee defects.

PATIENT AND METHODS

Fifty-six cases in which a flap from the lateral thoracic area was used to reconstruct an around the knee defect between January 2016 and March 2022 were reviewed. The patients were aged 18-87 years (mean, 52.13 years), and of the 56 patients, 36 were male and 20 were female. Injuries were caused by trauma, contracture, rheumatoid vasculitis, tumor, infection, burns, sunken deformity, and pressure sores. The 56 cases included 22 with a defect including the knee, 14 with a defect below the knee (7 of the primary below-knee amputation [BKA] and 7 of the secondary BKA), 9 involving the distal medial thigh, 8 involving the distal lateral thigh, 2 involving the popliteal area, and 1 involving the middle thigh. Most cases were reconstructed using a single LD perforator flap or msLD flap. Chimeric or supplementary flaps were used when extensive coverage or dead space obliteration was required. The average size of the defect area was 253.6 cm2 (range: 5 × 6-21 × 39 cm2 ).

RESULTS

In the cases, the recipient artery used included the following: descending genicular artery (23), superficial femoral artery (14), descending branch of the lateral circumflex femoral artery (14), anterior tibial artery (2), popliteal artery (2), and posterior tibial artery (1). The recipient vein included the greater saphenous vein (24), descending branch of the lateral circumflex femoral vein (14), superficial femoral vein (7), descending genicular vein (6), anterior tibial vein (2), popliteal vein (2), and posterior tibial vein (1). The average flap size was 281.8 cm2 (range: 4 × 8-35 × 19 cm2 ). All flaps survived; however, seven complications occurred, including 2 partial flap losses, 1 arterial insufficiency, 1 hematoma, 1 minor dehiscence, 1 donor-site graft loss, and 1 short BKA. Normal knee range of motion (121-140°) was observed in 34 patients and 16 showed varying degrees of limited range of motion. Motion was not observed in four patients who underwent knee fusion and could not be evaluated in two patients who underwent above-knee amputation. The mean follow-up duration was 24.6 months (range: 4-72 months).

CONCLUSION

The LD perforator flap is ideal for the reconstruction of around the knee defects because it enables a long pedicle, large flap, and chimeric design. The msLD flap is ideal because it enables strong stump support, dead-space obliteration, and infection control. Moreover, since the two flaps are distant from the knee, this method is advantageous in terms of postoperative rehabilitation and there is minimal donor-site morbidity due to the thin nature of the LD muscle. In addition, the flap can be elevated in three positions and the operation can be completed without positional changes in various recipient vessel locations. Based on our experience, we conclude that the LD flap has the potential to be used as widely as or in preference to the anterolateral thigh flap in the reconstruction of around the knee defects.

Reconstruction of complex knee wounds with a distally based gracilis flap and gastrocnemius myocutaneous flap: A case report

A gastrocnemius muscle flap is a versatile option for covering the proximal one-third of the lower leg and around the knee. On the other hand, it is of limited use in patients with short gastrocnemius muscle or insufficient volume. The authors present a case in which a knee soft tissue defect occurred in a very thin patient and was reconstructed using a gastrocnemius myocutaneous flap and a distally based gracilis flap as a supplementary flap.

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.

[Application of deep inferior epigastric perforator flap for repair of extreme defects around knee]

OBJECTIVE

To investigate the effectiveness of the deep inferior epigastric perforator (DIEP) flap for extreme defects around the knee.

METHODS

Between June 2017 and December 2018, 15 patients with the extreme defects around the knee were admitted. There were 9 males and 6 females with a median age of 36 years (range, 23-51 years). The etiology was the traffic accident in 7 cases, tumor in 5 cases, and burn in 3 cases. The injured location was left knee in 8 cases and right knee in 7 cases. The size of soft tissue defects ranged from 15 cm×10 cm to 30 cm×20 cm, and all defects complicated with exposure of blood vessels, nerves, tendons, and other tissues. Transverse DIEP flaps with 1-2 vascular pedicles were prepared according to the size of the defect, including 6 cases of single-pedicle flaps and 9 cases of double-pedicle conjoined flaps. According to the depth of the defect, 10 cases of skin flaps were thinned under microscope. The size of the DIEP flaps ranged from 16 cm×10 cm to 32 cm×20 cm; the average thickness was 1.5 cm (range, 0.8-1.8 cm); the average pedicle length was 7.5 cm (range, 5.0-9.0 cm). The donor site was directly sutured.

RESULTS

One single-pedicle flap developed distal necrosis after operation, and healed after skin grafting; the other skin flaps survived, and the wounds at the donor and recipient sites healed by first intention. All patients were followed up 16-28 months (mean, 24 months). The shape and texture of the flap were satisfactory, and there was no abnormal hair growth or obvious pigmentation. There was only linear scar at the donor site and no complication such as abdominal hernia. The appearance and function of the knee were satisfactory. No recurred tumor was observed, and the scar contracture was released. At last follow-up, 13 cases were excellent and 2 cases were good, according to the Knee Society Score (KSS) criteria.

CONCLUSION

The DIEP flap is an ideal alternative for repairing the extreme defects around knee, with a concealed donor site, easy dissection, flexible design, as well as less complication.

"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.

[Clinical application of superior lateral genicular artery perforator propeller flap in repair of soft-tissue defects around knee joint]

Objective

To explore the feasibility and effectiveness of using the superior lateral genicular artery (SLGA) perforator propeller flap to reconstruct soft-tissue defects around the knee joint.

Methods

Between October 2013 and May 2019, 10 patients underwent repairing of soft-tissue defects around the knee joint using the SLGA perforator propeller flap. There were 6 males and 4 males, with a median age of 34.5 years (range, 6-66 years). Etiologies included radical tumor resection in 4 cases, post-burn scar contracture in 3 cases, post-burn hypertrophic scar in 2 cases, and prothesis exposure after knee arthroplasty in 1 case. Defects located on the lateral knee in 6 cases, proximal lateral leg in 2 cases, popliteal fossa in 1 cases, and infrapatellar region in 1 case. The size of soft-tissue defects was from 6 cm×4 cm to 14 cm×8 cm. The extraction range of the flap was from 10.0 cm×5.5 cm to 23.0 cm×7.0 cm; the length of the perforator pedicle was 2.5-5.0 cm, with an average of 3.65 cm; the flaps were rotated 180°, the large paddle of the propeller flap was used to repair the defect, and the small paddle was used to assist the closure of donor site.

Results

Blister was observed in the distal 3-cm of one flap and the flap survived after conservative management. All the flaps survived, and the wounds in the donor and recipient areas healed by first intention. There was no vascular crisis, incision dehiscence, infection, or other complications. All 10 patients were followed up 4 to 48 months, with an average of 12.6 months. The color and texture of the flap were similar to those of the recipient area, and there was no need for secondary operation for degreasing and thinning. Scar contracture was corrected; no tumor recurrence was found in tumor patients; the artificial knee joint was preserved, the knee joint flexion and extension activities were good, and all the patient and family members were satisfied with the appearance and function of the lower limbs after operation.

Conclusion

The SLGA perforator propeller flap surgery is relatively simple without the need of microvascular anastomosis, has the minimal donor-site morbidities, and can provide a compound flap for the repairing of a complex wound. The SLGA perforator propeller flap is one of the optional methods to repair soft-tissue defects around the knee joint.

Addressing common orthopaedic calamities with microsurgical solutions

Reconstructive microsurgery has been an essential aspect of orthopaedic surgery and extremity reconstruction since the introduction of the operating microscope in the mid-20^th century. The reconstructive ladder ranges from simple healing by secondary intention to complex procedures such as free tissue transfer and vascularized composite allotransplantation. As orthopaedic surgery has evolved over the past 60 years, so too have the reconstructive microsurgical skills that are often needed to address common orthopaedic surgery problems. In this article, we will discuss a variety of complex orthopaedic surgery scenarios ranging from trauma to infection to tumor resection as well as the spectrum of microsurgical solutions that can aid in their management.

Use of Muscle Feeding Arteries as Recipient Vessels for Soft Tissue Reconstruction in Lower Extremities

Microsurgical free tissue transfer is still playing an important role in lower extremity reconstruction. Finding a suitable recipient artery for anastomosis is critical in the microsurgical procedure, especially in an extensive wound, or in a complex trauma combined with vascular injury. From April 2014 to March 2018, we retrospectively reviewed patients with traumatic/post-traumatic, oncologic, and electrical wounds in the lower extremity. Those treated with muscle feeding artery as recipient vessels were included. The latissimus dorsi (LD) muscle free flap, anterior lateral thigh (ALT) perforator free flap, and deep inferior epigastric perforator (DIEP) free flap were raised. The muscle feeding arteries to vastus lateral muscle and to medial head of gastrocnemius muscle, concomitant veins, and great saphenous vein were used as recipient vessels. Injuries included in the study were caused by tumour in 2 cases, car accident in 3 cases, crushing in 3 cases, burns in one case, and electrical injury in one case. The wound size varied from 14 cm × 6 cm to 30 cm × 20 cm. LD, ALT, and DIEP free flaps were used in 6, 3, and 4 patients, respectively. The muscle feeding arteries to medial head of gastrocnemius muscle, to sartorius muscle, and to vastus lateral muscle were used as recipient arteries in 4, 5, and one patient, respectively. Concomitant and great saphenous veins were used as recipient veins in 10 and 4 patients, respectively. Using the muscle feeding artery is feasible to avoid injury to the main artery and facilitate dissection and anastomoses, particularly when the wound is located proximal to the mid-third of the lower leg.

Classification of Obviously Asymmetric Palpebral Fissures and Correction Based on Double Eyelid Surgery of the Primary Type

Bilateral palpebral fissures (PF) are rarely symmetrical. Palpebral plastic surgery is common in the Chinese population. This study aimed to assess the classification of obviously asymmetric palpebral fissures (OAPF). In addition, double eyelid surgery-based correction for the primary subtype was examined. Various clinical signs and etiologies were examined, and OAPF were classified into 3 subtypes: primary, secondary, and aging. For the secondary and aging subtypes, curative surgeries target the relevant underlying conditions. Patients with the primary subtype underwent corrective surgery based on double eyelid operation. After 8 to 12 months of follow-up, the corrective effects of different surgeries were evaluated in patients (n = 48) with primary OAPF. Satisfying look was obtained in all 48 cases, with smooth double eyelid lines and shapes, and no overt asymmetry between the 2 eyes. Thirteen patients developed hypophasis after levator plication, which was resolved within 1 month. Preoperative and postoperative PF were significantly different (1.48 ± 0.24 versus 0.19 ± 0.09 mm; P < 0.05). Overall, patients with OAPF can be classified into the primary, secondary, and aging subtypes. The 48 cases with the primary subtype showed a satisfying look after double eyelid surgery-based correction.

Lower medial thigh perforator (LMTP) propeller flap for reconstruction of soft tissue defects around the knee

BACKGROUND

Skin and soft-tissue defects around the knee are common and their reconstruction is still challenging and argued. Thin, pliable and well-vascularized tissues are required in order to restore the aesthetic appearance of the knee and facilitate joint function. Historically local muscle flaps were employed for the upper third of the lower limb reconstruction; however, since their introduction, different perforator flaps have been proposed for this purpose. The aim of this report is to share our clinical experience with the pedicled lower medial thigh perforator (p-LMT) flap for the reconstruction of skin and soft tissue defects around the knee.

PATIENTS AND METHODS

Between August 2013 and July 20, 2018, patients underwent pedicled LMT propeller flap reconstruction for defects around the knee. The subunits of the defects were the suprapatellar, the infrapatellar and patellar area and in two cases a full around the knee defect was reported. Cause of defects included trauma (13), tumor (4) and infection after knee operation (3) and defect sizes ranged from 4 × 3 cm² to 7 × 8 cm² .

RESULTS

Flap sizes ranged from 4 × 9 cm² to 6 × 16 cm² . One to two perforators based on the superficial femoral artery or descending genicular artery were found between the septum of satorius and vastus medialis, or piercing the vastus medialis during dissection. All flaps were rotated 180° in propeller fashion. All the donor sites were primarily closed and no complication at the donor site was detected. In the two cases of the total knee soft tissue defect, a double pedicled flaps reconstruction was required. After a 6 months follow-up, all the patients in the series achieved a full range of motion.

CONCLUSIONS

Fasciocutaneous flaps are currently the first reconstructive option for the soft tissue defects around the knee. The p-LMT flap reconstruction in this case series achieved good aesthetic and functional outcomes and this flap may be a valuable option for the reconstruction of the small to medium soft tissue defects around the knee.

Complex Reconstruction of the Knee with a Free Vertical Rectus Abdominis Flap after Periprosthetic Soft Tissue Necrosis

Periprosthetic joint infection (PJI) is limb threatening and difficult to treat. Although a two-stage re-implantation is accepted as the standard of care for PJI, extensive debridement, numerous surgeries, or liquifactive necrosis from the infection can result in a tissue defect. With a large tissue defect, soft tissue coverage is required to protect the prosthesis, fill any dead space, and obtain a satisfactory wound closure. With defects too large for local or regional flap coverage, free tissue transfer is the best option. We present a case in which soft tissue coverage with both medial and lateral gastrocnemius muscle flaps was not sufficient; free tissue transfer was necessary for both wound closure and creation of an adequate soft tissue envelope for the future placement of a prosthesis. Regardless of the complicated surgical history and extensive soft tissue damage, limb function was restored and the patient regained his independence.

Anastomosis of Free Flap Pedicle to Great Vessels

BACKGROUND

Free Flaps are viable option to cover the tissue defect. Pedicle anastomosis to vessel branches has excellent result. In some situations which there is a possibility of flap failure like shortage of vessel branches, possibility of pedicle kinking or need to vein graft, anastomosis to great vessels is justified.

METHODS

Six patients were allocated to study. Five cases for free jejunal flap and one case for free latissimus flap. In free jejunal flap group, pedicle anastomosis was performed as an end-side fashion to common carotid artery and internal jugular vein and in free latissimus flap, pedicle was anastomosed as an end-side fashion to superficial femoral artery and superficial femoral vein. Follow up was regular up to 20 years.

RESULTS

In free jejunal flap group, there were three female and two male with age from 30 to 59 years. The sixth case was a thirteen years old male with flexion contracture of right knee who underwent free latissimus flap. Follow up was regular for 20 years. All flaps survived, and good functional result was obtained in all except one.

CONCLUSION

Choosing great vessels as one side of anastomosis is safe and can be done as a primary approach due to technical demand or as a final resort when there is shortage of side branches.

Two sequential free flaps for coverage of a total knee implant

Knee revision arthroplasty following peri-prosthetic joint infections is a formidable challenge. Patients are at a high risk of recurrent infection, and the soft tissue over the revised implant is often of questionable quality. Flap reconstruction has improved the salvage rates of infected arthroplasties, and should be considered in all cases of revision arthroplasty. We present a challenging case requiring staged reconstruction with two free latissimus dorsi flaps after the initial use of a medial gastrocnemius flap.

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.

Soft Tissue Reconstruction and Flap Coverage for Revision Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty is a successful operation for treatment of arthritis. However, devastating wound complications and infections can compromise the knee joint, particularly in revision situations.

METHODS

Soft tissue loss associated with poor wound healing and multiple operations can necessitate the need for reconstruction for wound closure and protection of the prosthesis.

RESULTS

Coverage options range from simple closure methods to complex reconstruction, including delayed primary closure, healing by secondary intention, vacuum-assisted closure, skin grafting, local flap coverage, and distant microsurgical tissue transfer.

CONCLUSION

Understanding the advantages and pitfalls of each reconstructive option helps to guide treatment and avoid repeated operations and potentially devastating consequences such as knee arthrodesis or amputation.

Lateral Approach to the Popliteal Artery for Free Tissue Transfer to the Lower Extremity

Free tissue transfer to the proximal leg and knee requires appropriate recipient vessel selection. The popliteal vessels have historically been unpopular choices, due to their remote location often necessitating vein grafts, and need for prone positioning. In this report, we describe a lateral approach to the above-knee popliteal vessels, which was utilized for 2 cases of free tissue transfer to the lower extremity. Neither prone positioning nor vein grafts were needed. The lateral approach to the above-knee popliteal vessels and their branches is a viable option for the otherwise recipient vessel-depleted lower extremity.

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

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

Accompanying artery of sciatic nerve as recipient vessel for free-flap transfer: a computed tomographic angiography study and case reports

Suitable recipient vessels for free-flap transfer are hard to find in the posterior thigh. To investigate the versatility of accompanying artery of sciatic nerve as a recipient vessel in this region, we performed computed tomographic angiographic study of 20 consecutive healthy thighs in 10 patients. The presence and internal diameter of the accompanying artery were studied. The accompanying artery of the sciatic nerve was present in 11 thighs (55%) and the internal diameter of the artery at the mid-thigh level ranged from 2.1 to 3.2 mm. We used this artery as a recipient vessel for free flaps transferred to reconstruct extensive thigh defects in three patients with sarcomas. In all patients the flaps survived without vascular compromise. No sensory or motor dysfunction in the sciatic nerve distribution occurred in any patients. We believe that the accompanying artery of the sciatic nerve may be a recipient vessel for free-flap transfer in selected patients.