The Free Latissimus Dorsi Flap as Primary Free Flap and Crane Flap with Secondary Pedicled Transfer

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.

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.