Reconstruction of Complex Ankle Joint Defects Using a Composite Free Anterolateral Thigh Musculocutaneous Flap with Vascularized Fascia Lata: A 20-Year Follow-Up

Abstract

Sir: The reconstruction of complicated composite defects around the ankle is always a challenge for the plastic surgeon. With recent advances in microsurgical techniques, the free anterolateral thigh flap has emerged as one of the major resources for lower extremity salvage.1 We have attempted several techniques and now favor single-stage reconstruction of lower limb defects after open trauma using an anterolateral thigh myocutaneous flap with vascularized fascia lata. We report the case of a 17-year-old boy who sustained a car tire injury to his left foot, resulting in crush avulsion of the soft tissues, talofibular and calcaneofibular ligaments, and peroneus tendons, and partial loss of the fibula and talus. A 20 × 11-cm composite anterolateral thigh musculocutaneous flap including a 10 × 7-cm strip of vascularized fascia lata along with a cuff of vastus lateralis was harvested from the right thigh. The exposed ankle joint where the malleolar sclerotin was lacking was obturated by the vastus lateralis muscle of the flap. The fascial strip was rolled and interwoven to connect the peroneus musculotendinous junction and the lateral ankle ligament. End-to-end microvascular anastomoses were performed between the anterior tibialis vessels and the descending branch of the lateral circumflex femoral vessels. Most of the donor site was closed, and the residual area was covered by a split-thickness skin graft harvested from the opposite thigh (Fig. 1). The patient's postoperative course was uneventful. Two months postoperatively, the patient resumed his daily ambulating without any support, although a slight varus deformity of the left ankle was exhibited on physical examination. Three years postoperatively, the varus deformity had disappeared, and the patient could take part in physical training. Twenty years after the initial procedure, the patient was recontacted, and the function of the left ankle was evaluated by clinical examination. Although there was some loss of ankle activity, the patient did not have any problems with the stability of the joint and was sufficiently competent for his job (Fig. 2).Fig. 1.: A 17-year-old boy sustained a car tire injury to his left foot resulting in extensive crush avulsion (above, left). After débridement, a 20 × 11-cm composite anterolateral thigh musculocutaneous flap including a 10 × 7-cm strip of vascularized fascia lata was used to salvage the foot (above, right and below).Fig. 2.: Follow-up at 20 years revealed a well-contoured foot with acceptable activity of the ankle joint (above) and a narrow joint space with trauma-arthritic changes on the radiographic images (below).The reconstruction of combined defects including a large, deep defect of bone and soft tissue around the ankle is always clinically challenging and technically demanding.2 The use of traditional local flaps for reconstruction is limited, as these flaps only supply coverage of soft-tissue defects rather than preserving the stability and function of ankle joints.3 In contrast, the one-stage reconstruction associated with the anterolateral thigh flap offers many advantages to reconstructive surgeons, such as suitability for a two-team approach, rapid healing, high resistance to infection, and minimal donor-site morbidity.4 We favored the composite anterolateral thigh flap in this case because it meets most reconstructive needs for total ankle reconstruction as described above and has some other special advantages. First, in the case of wound infection, a musculocutaneous flap is safe because well-vascularized muscle tissue under the skin island prevents exposure of the joint and decreases the rate of infection after single-stage reconstruction. Second, in this case, the fascia lata was anchored to the distal and proximal remnants of peroneus muscles, which recovered the integrity and function of the evertors. More importantly, through the application of this composite flap, we successfully restored the ankle stability without arthrodesis, which would probably have resulted in additional postoperative complications for the patient. Twenty years postoperatively, although the radiographic image showed a narrow joint space with trauma-arthritic changes, the patient has achieved acceptable ankle power strength and range of motion (Fig. 2). In conclusion, the composite anterolateral thigh musculocutaneous flap with vascularized fascia lata represents an excellent option for covering complex defects around the ankle joint. The long-term functional and aesthetic results are good. We believe that this flap should be used as an alternative for reconstruction of extensive defects around the ankle. Kai Huang, M.D. Xiao-wen Zhang, M.D. Li-feng Shen, M.D. Qiao-feng Guo, M.D. Chun Zhang, M.D. Department of Orthopedics Tongde Hospital of Zhejiang Province Health Bureau of Zhejiang Province Hangzhou, Zhejiang, People's Republic of China DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.