Reconstruction of complex soft tissue defects including tendons with anterolateral thigh flap extended to fascia lata: Long term recovery and functional outcomes

Abstract

Background We evaluated composite anterolateral thigh (ALT) flaps including vascularized fascia lata (FL), for stable soft tissue coverage and tendons restoration at various joint levels in a one‐stage procedure. Methods We performed a retrospective investigation including 21 “functional” ALT flaps between November 2006 and December 2016. In all patients included, FL was shaped to anatomical reproduce a tendon structure. Functional analysis included range of motion and force assessment. Functional scores were established according to Chen classification, DASH, and LEFS score. Defects resulted from tumor excision, trauma, burn, or infection‐debridement and were distributed in four main anatomical districts: knee (seven cases), ankle (six cases), forearm‐elbow (four cases), and hand‐wrist level (three cases). Results Nineteen flaps were raised as free flaps, while two as distally‐based propeller flaps. Average follow‐up was 38 months. Major complication requiring the harvest of a second flap was seen in two patients, whereas three flaps presented superficial necrosis and was treated in an outpatient regimen. We observed 81% of total ROM recovery compared to contralateral sides with 89% recovered articular stability. Best articulation outcomes were present in elbow reconstruction, while ankle reconstructions showed less articularity. Hospital stay was significantly reduced in hand and wrist functional reconstruction when compared with reconstruction at the ankle level (P < 0.05). Conclusion The ALT flap extended to vascularized FL provides a particularly effective and resistant tissue that can be folded to reconstruct and support tendinous structures. This can restore functional and structural integrity after complex defects in a single stage procedure.

Orthoplastics in Periprosthetic Joint Infection of the Knee: Treatment Concept for Composite Soft-tissue Defect with Extensor Apparatus Deficiency

“…Three different reconstructive techniques were described: (i) a pedicled lateral gastrocnemius muscle with an attached lateral Achilles tendon, (ii) a pedicled MSAP gastrocnemius flap with a distally pedicled gracilis and semitendinosus tendon, and (iii) a free composite ALT flap that included vastus lateralis and FL [10,16,20,21]. The functional outcome reported was good at 12 and 18 months, and no other complications [16] apart from knee pain [20] were seen; instead, rather favourable outcomes [10,21] were observed. In particular, recurrence of infection was denied, which in our series led to arthrodesis 1.8 and 2 years after plastic surgical reconstruction.…”

“…This resulted in seven articles [10,[16][17][18][19][20][21] of which three [17][18][19] were excluded, as they elaborated on cases with PJI after TKA and extensor apparatus deficiencies but failed to include concomitant soft-tissue envelope defects. The remaining four articles [10,16,20,21] included a total of four patients. It appeared likely that the described orthoplastic techniques were performed by a team of orthopaedic and plastic surgeons together, although this was not explicitly stated.…”

“…Sapino et al published two cases of defect reconstruction with a free composite ALT flap, including the vastus lateralis and FL [10]. Di Summa et al performed a retrospective functional investigation of 21 ALT flaps [21], investigating the same two patients in different contexts. The fasciocutaneous part of the flap reconstructed the skin and hypodermis defect, and the vascularized fascia lata was used to reconstruct the patellar tendon defect.…”

“…The curative orthopaedic treatment concept for chronic PJI of the knee frequently differentiates between a one-stage and a two-stage approach. For the combined orthoplastic approach, Chiou et al, di Summa et al, and Sapino et al described a one-stage approach [10,20,21], whereas Pérez-García et al reconstructed the soft-tissue envelope and extensor apparatus at the first stage of a two-stage approach [16]. Despite these differences in stages, all institutions reported that they aimed to reconstruct the soft-tissue defect as early as possible.…”

Microsurgical salvage of complex dorsal shearing injuries of the hand and wrist

“…More recently, several authors have described single-stage reconstruction of dorsal hand defects with composite cutaneotendinous flaps, including the dorsalis pedis cutaneotendinous flap [18] and the composite anterolateral thigh flap taken with fascia lata [19][20][21] . Composite flaps including bone have also been described, such as the free serratus anterior fascial flap with vascularized scapula for combined soft tissue and bony defects of the dorsal hand [22] .…”