The Free Anterolateral Thigh (ALT) Flap for Microsurgical Reconstruction of Traumatic Defects in Pediatric Foot

Abstract

Objective: Microsurgery has found early application in pediatric population despite the initial concerns on the technically challenging microanastomosis. Complex injuries of lower extremities in children have not received the same attention in the international literature, but some specific accidental foot injuries seem to have a particularly high frequency in that age group. The muscle flaps were initially the choice for the coverage of distal lower limb deficits; however, the donor site morbidity and the bulky appearance attracted attention to more delicate flaps, with the fasciocutaneous anterolateral thigh (ALT) flap becoming a basic reconstructive option. The present study considered all journal abstracts and articles on the use of free flaps in children's extremities in order to evaluate the use of the free ALT flap in pediatric patients. The literature search was performed with "PubMed" and "MEDLINE" databases according to PRISMA guidelines with the systematic review clustering eventually the results of 12 different studies. We investigated the use of 102 free ALT flaps for the reconstruction of traumatic foot defects in children with 95.1% flap survival rate and only 2 complete flap losses noted due to venous thrombosis; 6 flaps went for urgent re-exploration resulting in the unavoidable loss of one flap and the partial necrosis of 3 others. In the vast majority of cases the reconstruction was delayed and the total complication rate was 21.57%. It is reaffirmed that hypertrophic scarring tends to be more common in pediatric patients and split thickness skin graft should be avoided whenever primary closure without extensive tension is possible. More than a quarter (27.27%) of the children necessitated a secondary revision surgery, as the child's growth and the additional fat tissue make secondary debulking procedures really common. Special perioperative care, atraumatic dissection technique, and well established microsurgical experience are absolutely required when performing a free flap reconstruction in children. Nevertheless, the good functional outcome and the high survival rate of our review highlight the reliability of the free ALT flap for traumatic defects in pediatric foot.

Free Tissue Transfer in Pediatric Lower Limb Trauma

“…Christopoulos documented 22% complications in 102 ALT flaps for the foot, and other authors have had rates between 17.5 and 32% 2 17 30 These nonanastomotic complication rates can be kept down by meticulous postoperative care that is not related to patient age.…”

“…In a meta-analysis study, Christopoulos identified 83 patients who had a delayed, and only 7 had immediate flap cover with a < 5% partial or total flap loss. 30…”

“…10 Christopoulos identified a 4.9% rate in 102 patients undergoing ALT flaps for foot and ankle injuries. 30…”

“…2 Other authors have documented a 25 to 30% need for secondary surgery. 17 30 An empirical observation has been that since children are more pliable to learn new gait patterns to offload insensate areas of the foot, they fare better than adults with a similar reconstruction ( Fig. 6A–F ).…”