A 50cm fillet flap permitted above-knee amputation in lieu of hip disarticulation in a 20-yearold woman who had sustained severe injuries in a motorcycle accident. Although the flap was unusually long, the principles followed were the same as those for posterior flaps used in below-knee amputations and fillet flaps of the digits. The flap allowed preservation of maximal length in the residual limb and fully sensible skin coverage, both of which facilitated prosthetic usage.Maximal residual limb length and protective sensibility of the residual limb are two factors that facilitate the ability of an amputee to be an independent community ambulator. In consideration of these factors, a 50-cm fillet flap vascularized by the superficial femoral artery was used in a young trauma victim, allowing above-knee amputation rather than hip disarticulation. The flap provided full sensibility, thereby facilitating the patient's use of a prosthesis.
CASE REPORTA 20-year-old woman was injured in a motorcycle-truck accident in August 198 1. She sustained multiple injuries to the left lower and left upper extremities. She had no injuries of the head, From the Limb Viability Service, Departments of Orthopaedin, Surgery and Nursing, Harborview Medical Center, Seattle; Washington. Reprint requests to Robert J. Foster, M.D., thorax, or abdomen. The left lower extremity injuries included a Grade 111 open crush fracture of the left foot that rendered the foot avascular, Grade 111 open oblique midshaft fractures of the tibia and fibula, and a Grade 111 open multiply comminuted fracture of the femoral midshaft with circumferential muscle necrosis and degloving of the anterior thigh skin from the inguinal crease to the knee (Fig. 1). The patient was taken to Harborview Medical Center, Seattle for emergency treatment. Fluorescein was administered intravenously (2 ampules), and two minutes after injection the lower extremity was examined with a Wood's lamp. The degloved area did not fluoresce. However, the posterior lower extremity skin fluoresced fully from the buttock to the level of the foot injury (Fig. 2).The foot was avascular, and the bony injuries were sufficiently severe that foot reconstruction was not considered possible. A through-ankle (Syme's) amputation with reconstruction of the tibia1 fracture was considered. However, the perifemoral muscle necrosis precluded amputation any lower than at midthigh. Even an above-knee, midthigh amputation initially appeared ill advised due to the lack of skin and muscle coverage for the entire anterior surface of the thigh. However, because the fluorescein study had demonstrated the vascularity of the posterior skin of the extremity, it was decided to create a long flap to cover the large anterior soft tissue deficit. Use of this flap would avoid hip disarticulation and allow preservation of maximal length in the upper thigh and fully sensible skin coverage, thereby enhancing function in this young patient.The entire remaining portion of the distal femur, all necrotic muscle, and the tibia and ...