Differences between the Upper Extremity and the Lower Extremity in Reconstruction Using an Anterolateral Thigh Perforator Flap

Lee, Sang Hyun; Suh, Jeung Tak; Ahn, Tae Young; Hong, Sung Min; Lee, Hyo Yeol

doi:10.4055/cios.2017.9.3.348

Cited by 6 publications

(6 citation statements)

References 20 publications

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“…Some surgeons have suggested that the ALT flap should not be harvested from the ipsilateral thigh if it is associated with traumatic injury, including femur fracture, pelvic fracture, or soft tissue injury, which requires simultaneous orthopedic intervention. 4 However, few reports have analyzed the relationships among concomitant injury from the initial trauma, surgery, and the vasculature of the ALT flap. Existing evidence suggests that perforators supplying ALT flaps are most likely to be located in the central third of the thigh, 6 and the majority of thighs have at least one perforator within the hot zone, namely a 5-cm radius around the midpoint of the thigh.…”

Section: Discussionmentioning

confidence: 99%

Ipsilateral distal third femoral shaft fracture and retrograde intramedullary fixation are not absolute contraindications to anterolateral thigh flap harvest: A case report

et al. 2022

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Despite the advantages of anterolateral thigh (ALT) flaps, many surgeons are hesitant to choose a thigh with ipsilateral femoral fracture and internal fixation as the flap donor site. To cover the right mid-upper leg wound, a free ALT flap was harvested from the left thigh of a 55-year-old man who initially underwent closed retrograde intramedullary fixation for a left distal third femoral shaft fracture. The flap was based on a musculocutaneous perforator located in the mid-thigh, which was approximately 10 cm above the proximal fracture level. No adhesion or scar formation between the fascia and adipose tissue was noted when the flap was raised suprafascially, and the adipose tissue surrounding the trunk of the descending branch of the lateral circumflex femoral artery was found to have mild edema. The patient regained good aesthetic outcomes and a complete range of active motion in both lower extremities. Based on current evidence of the vascular anatomy of the ALT flap in the literature and our experience, an ipsilateral thigh with distal third femoral shaft fracture and closed retrograde intramedullary fixation should not be considered an absolute contraindication to ALT flap harvesting.

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Section: Discussionmentioning

confidence: 99%

Ipsilateral distal third femoral shaft fracture and retrograde intramedullary fixation are not absolute contraindications to anterolateral thigh flap harvest: A case report

et al. 2022

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“…Increased collaboration between orthopaedic-and microvascular-trained surgeons in the management of soft tissue coverage after major extremity trauma has demonstrated promising results with shorter time to definitive soft tissue coverage, increased fracture union rates, and decreased infection rates [12][13][14]. However, more widespread adoption of these orthoplastic models has been slow, secondary to centers lacking the case volume to support similar programs as well as limited long-term data surrounding outcomes in collaborative flap-based limb salvage efforts.…”

Section: Discussionmentioning

confidence: 99%

Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes

Hoyt

Wade

Harrington

et al. 2021

Clin Orthop Relat Res

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Background Flap-based limb salvage surgery balances the morbidity and complexity of soft tissue transfer against the potential benefit of preserving a functional limb when faced with a traumatized extremity with composite tissue injury. These composite tissue injuries are well suited for multidisciplinary management between orthopaedic and plastic surgeons. Thus, it makes intuitive sense that a collaborative, orthoplastic approach to flap-based limb salvage surgery can result in improved outcomes with decreased risk of flap failure and other complications, raising the question of whether this orthoplastic team approach should be the new standard of care in limb salvage surgery. Questions/purposes (1) Is there an association between increased annual institutional volume and perioperative complications to include free and local flap failure (substantial flap viability loss necessitating return to the operating room for debridement of a major portion or all of the flap or amputation)? (2) Is an integrated orthoplastic collaborative approach to managing combat-related traumatic injuries of the extremities individually associated with a decreased risk of flap failure and overall flap-related complications? (3) What other factors, such as location of injury, injury severity score, and initial inpatient length of stay, were associated with flap necrosis and flap-related complications? Methods We performed a retrospective review of the electronic medical records of all patients who underwent flap-based limb salvage for combat-related extremity trauma in the United States Military Health System’s National Capital Region between January 1, 2003 and December 31, 2012. In total, 307 patients underwent 330 flap procedures. Of the 330 flaps, 59% (195) were local or pedicled flaps and 41% (135) were free flaps. Patients were primarily male (99% [303]), with a median (interquartile range) age of 24 years old (IQR 21 to 29), and 87% (267 of 307) of injuries were sustained from a blast mechanism. We collected data on patient demographics, annual case volume involving flap coverage of extremities, mechanism of injury, flap characteristics, perioperative complications, flap failure, flap revision, isolated orthopaedic management versus an integrated orthoplastic approach, and other salvage procedures. For the purposes of this study, orthoplastic management refers to operative management of flap coverage with microvascular surgeons present for soft tissue transfer after initial debridement and fixation by orthopaedic surgery. The orthoplastic management was implemented on a case-by-case basis based on individual injury characteristics and the surgeon’s discretion with no formal starting point. When implemented, the orthoplastic team consisted of an orthopaedic surgeon and microvascular-trained hand surgeons and/or plastic surgeons. In all, 77% (254 of 330) of flaps were performed using this model. We considered perioperative flap complications as any complication (such as infection, hematoma, dehiscence, congestion, or necrosis) resulting in return to the operating room for re-evaluation, correction, or partial debridement of the flap. We defined flap failure as a return to the operating room for debridement of a major portion of the flap or amputation secondary to complete or near-complete loss of flap viability. Of the flap procedures, 12% (40 of 330) were classified as a failure and 14% (46 of 330) experienced complications necessitating return to the operating room. Over the study period, free flaps were not more likely to fail than pedicled flaps (11% versus 13%; p = 0.52) or have complications necessitating additional procedures (14% versus 16%; p = 0.65). Results Our multiple linear regression model demonstrated that an increased number of free flaps performed in our institution annually in any given year was associated with a lower likelihood of failure per case (r = -0.17; p = 0.03) and lower likelihood of reoperation for each flap (r = -0.34; p < 0.001), after adjusting for injury severity and team type (orthoplastic or orthopaedic only). We observed a similar relationship for pedicled flaps, with increased annual case volume associated with a decreased risk of flap failure and reoperation per case after adjusting for injury severity and team type (r = -0.21; p = 0.003 and r = -0.22; p < 0.001, respectively). Employment of a collaborative orthoplastic team approach was associated with decreased flap failures (odds ratio 0.4 [95% confidence interval 0.2 to 0.9]; p = 0.02). Factors associated with flap failure included a lower extremity flap (OR 2.7 [95% CI 1.3 to 6.2]; p = 0.01) and use of muscle flaps (OR 2.3 [95% CI 1.1 to 5.3]; p = 0.02). Conclusion Although prior reports of combat-related extremity trauma have described greater salvage success with the use of pedicled flaps, these reports are biased by institutional inexperience with free tissue transfer, the lack of a coordinated multiservice effort, and severity of injury bias (the most severe injuries often result in free tissue transfer). Our institutional experience, alongside a growing body of literature regarding complex extremity trauma in the civilian setting, suggest a benefit to free tissue coverage to treat complex extremity trauma with adequate practice volume and collaboration. We demonstrated that flap failure and flap-related complications are inversely associated with institutional experience regardless of flap type. Additionally, a collaborative orthoplastic approach was associated with decreased flap failures. However, these results must be interpreted with consideration for potential confounding between the increased case volume coinciding with more frequent collaboration between orthopaedic and plastic surgeons. Given these findings, consideration of an orthoplastic approach at high-volume institutions to address soft tissue coverage in complex extremity trauma may lead to decreased flap failure rates. Level of Evidence Level III, therapeutic study.

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“…First, containing morbidity to one extremity by restricting all surgeries to the injured leg is ideal and as Demirtas et al have suggested, lower extremity nerve blocks for a single leg can be utilized in cases where general anesthesia is contraindicated. 13,14 In addition, Lee et al revealed faster return to ambulation citing the ability use of the unaffected limb for crutch use while operating on the contralateral leg affects both limbs, requiring a wheelchair for mobility. 14 This can be explained by limiting morbidity to just one extremity as opposed to extending morbidity to both extremities.…”

Section: Discussionmentioning

confidence: 99%

“…19,[22][23][24] Finally, several studies have shown higher patient satisfaction scores with ipsilateral donor sites compared with contralateral donor sites. 13,14 There were several limitations to this study due to its retrospective design. Given that this free flap registry spanned a wide time period of nearly four decades, we were unable to include a significant number of patients due to incomplete or unavailable charting.…”

Section: Discussionmentioning

confidence: 99%

Does Laterality of Lower Extremity Donor Site Affect Outcomes in Microvascular Soft Tissue Lower Extremity Reconstruction?

Rifkin

Lee

et al. 2020

J Reconstr Microsurg

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Background There are many different variables to consider in lower extremity microvascular soft tissue reconstruction including flap choice. Our aim is to objectively evaluate recipient complications related to lower extremity donor flap laterality. Methods A total of 77 lower extremity soft tissue reconstructions utilizing microvascular free tissue transfers for Gustilo type III between 1979 and 2016 were collected. We compared complication rates between ipsilateral and contralateral donor sites relative to the injured leg. The following parameters were analyzed: overall complications, total flap failure, partial flap failure, major complications, operative takebacks, and salvage rates. Results In this study, 25 ipsilateral reconstructions were performed, while 52 cases utilized the contralateral leg. Overall complication rates were higher in the ipsilateral group (40.0%) compared with the contralateral side (23.1%) but were not statistically significant (p = 0.12). The ipsilateral group was four times as likely to experience vascular compromise (24.0 vs. 5.8%; p = 0.05). However, there were no significant differences in complications, flap failures or flap survival. Mean operative time was significantly greater in the same side group as compared with the contralateral group (11.3 vs. 7.5 hours; p = 0.006). Conclusion Although there is a higher risk of anastomotic thrombosis, particularly venous thrombosis, associated with ipsilateral donor-site group, there were no significant differences in complications or flap survival. Flaps can be harvested from a traumatized leg with acceptable complication rates while avoiding the morbidity of operating on an uninjured limb.

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Differences between the Upper Extremity and the Lower Extremity in Reconstruction Using an Anterolateral Thigh Perforator Flap

Cited by 6 publications

References 20 publications

Ipsilateral distal third femoral shaft fracture and retrograde intramedullary fixation are not absolute contraindications to anterolateral thigh flap harvest: A case report

Ipsilateral distal third femoral shaft fracture and retrograde intramedullary fixation are not absolute contraindications to anterolateral thigh flap harvest: A case report

Institutional Experience and Orthoplastic Collaboration Associated with Improved Flap-based Limb Salvage Outcomes

Does Laterality of Lower Extremity Donor Site Affect Outcomes in Microvascular Soft Tissue Lower Extremity Reconstruction?

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