Reverse-flow Anterolateral Thigh Research Articles

Application of Staged Negative Pressure Wound Therapy and Flap Surgery for Infection Control After Patellar Internal Fixation Surgery.

The anatomic position of the patella is superficial, making it vulnerable to injuries. Treatment of patella infection after internal fixation surgery remains a big challenge due to minimal soft tissue coverage and vital tissue exposure. Forty-two patients aged 10 to 59 years were admitted to the institution's burn unit between January 2010 and December 2019. Each presented with infection after patellar fracture surgery. Twenty-seven infections were superficial, whereas 15 were deep with pyogenous arthritis of the knee. Negative pressure wound therapy (NPWT) was applied after radical debridement to remove necrotic subcutaneous tissues and internal fixation devices. In addition, cases with septic arthritis were irrigated continuously with normal saline. After 5 to 10 days of NPWT treatment and irrigation, wound infection was well controlled. Afterward, 42 wounds were resurfaced with pedicled flaps, the 42 patients received 17 reverse-flow anterolateral thigh (ALT) perforator flap, 12 medial sural artery perforator flaps, 7 gastrocnemius musculocutaneous flaps, as well as 6 saphenous artery flaps. Thirty-seven flaps survived uneventfully. However, 3 flaps developed venous congestion in the distal end. Two flaps developed tip necrosis. All patients were followed up between 3 and 48 months. Infection beneath the flap occurred in 3 patients and healed after an additional debridement surgery. The staged NPWT and flap surgery strategy focus on thorough debridement and immediate internal fixation devices removal, effective fracture fixation, efficient NPWT application, targeted administration of antibiotics, and adequate soft tissue coverage. This study established that the procedure was effective in infection control after patellar internal fixation surgery.

Unusual Venous Drainage of A Reverse-Flow Anterolateral Thigh Flap: A Case Report

Unusual Venous Drainage of A Reverse-Flow Anterolateral Thigh Flap: A Case Report

Unusual Venous Drainage of A reverse-flow Anterolateral Thigh Flap. A Case Report

Unusual Venous Drainage of A reverse-flow Anterolateral Thigh Flap. A Case Report

Reconstruction of Soft-Tissue Defect Around the Knee Using a Pedicled Reverse-Flow Anterolateral Thigh Flap: A Case Report

Coverage of traumatic soft-tissue defects around the knee is a challenging problem for reconstructive surgeons though many reconstructive options are available. We planned to use a pedicled reverse-flow anterolateral thigh (ALT) flap using the distal branch of the descending branch of the lateral circumflex femoral artery (LCFA) for pedicle length extension in a patient with the ALT perforator branch originating from the proximal portion of the descending branch of LCFA. We present the successful use of a pedicled reverse-flow ALT flap to cover a soft tissue defect around the knee.

Distally based anterolateral thigh flap: an underutilized option for peri-patellar wound coverage

Wound coverage in the supra-patellar area presents a significant challenge for orthopaedic and reconstructive surgeons due to the need for preservation of knee joint function but the paucity of regional soft tissue flaps available. While many orthopaedic and reconstructive surgeons make use of the rotational gastrocnemius flap for coverage of peri-patellar defects, this flap has certain limitations. The goal of this study was to report a single-centre experience with the use of the distally based anterolateral thigh flap (ALT) and review the current literature on the use of the ALT for peri-patellar defects. In this report, both a single-centre experience using distally based anterolateral thigh (ALT) island flaps for supra-patellar wound coverage and the existing literature on this topic were reviewed. A systematic literature review was performed to assess the use of the ALT for peri-patellar wounds. Five patients with a mean age of 69 underwent a distally based ALT flap for coverage of peri-patellar defects. Four out of 5 flaps survived at the end of their respective follow-up. Based on this combined experience, the distally based reverse-flow anterolateral thigh island flap represents a useful but relatively underutilized option for appropriately selected supra-patellar wounds due to minimal donor site morbidity, multiple flap components, and predictable pedicle anatomy. The flap’s major weakness is its potentially unreliable venous drainage, requiring delay or secondary venous outflow anastomosis. Given the ALT flap’s favourable profile, the authors recommend consideration for its use when managing a peri-patellar coverage wound issue.

Knee reconstruction using a distally based anterolateral thigh flap: an anatomical cadaveric study.

To study the vascular territory of the descending branch of the lateral circumflex femoral artery and its anastomosis around the knee and to identify the cutaneous perforator supply to the distally-based or reverse flow anterolateral thigh (dbALT) flap. In particular, the distance of the first perforator branch arising from the knee and above region, as well as the number of branches and position of each perforator, beneficial for effective flap design, are also examined. Fresh cadaveric lower limbs were dissected and the distance of the first perforator branch arising from the knee and above regions, which are vascular supplies for flaps, as well as the number of branches and position of each perforator are described. A total of 54 thigh cadavers had at least two cutaneous perforator branches above the knee 10cm from the superior border of the lateral patella. The mean (± standard deviation) of the first perforator distance was 2.57±0.93cm above the superior-lateral border of the patella. All perforating branches were 4±2cm, 93% were 10±2cm from the superior lateral border of patella, and 100% were at 20±3cm (mid-thigh length) which were the traditional anterolateral thigh flap. The dbALT flap technique resulted in constant and reliable references about perforator sites. Thus, this type of flap is a viable option in patients who present with soft tissue defects around the knee and upper third of the leg.

膝前面皮膚軟部組織欠損に対して逆行性前外側大腿皮弁を用いて治療した 1 例

膝前面皮膚軟部組織欠損に対して逆行性前外側大腿皮弁を用いて治療した 1 例

Versatility and “flap efficiency” of pedicled perforator flaps in lower extremity reconstruction

The use of pedicled perforator flaps provides an alternative to free tissue transfer for lower limb reconstruction. We use computer-aided image analysis to investigate the versatility of pedicled perforator flaps for the reconstruction of lower limb defects. Between April 2007 and April 2011, a case series of 61 patients with wounds of the lower extremity from knee to ankle were reconstructed with pedicled perforator flaps. We performed 16 pedicled reverse-flow anterolateral thigh (RF-ALT) flaps, 8pedicled medial sural artery perforator (MSAP) flaps, 26 pedicled peroneal artery perforator (PAP) flaps, and 11 pedicled posterior tibial artery perforator (PTAP) flaps. Digital planimetry of defects covered was analyzed and the "efficiency" of each flap was calculated, which allowed the assessment of the merits of each flap in the management of lower limb defects. Flaps healed primarily in 82% of cases (50/61). Approximately 50% of the secondary donor sites required skin grafting. Complications requiring secondary surgery occurred in 18% (11/61) of the cases. Six required secondary skin grafting (10%). One RF-ALT flap was converted into a free flap, one PAP required arterial supercharging, and three pedicled RF-ALT flaps required venous supercharging. Image analysis showed that these pedicled perforator flaps could cover 75% of the surface area of the lower leg. The higher length of perforator allowed for greater "flap efficiency" and better versatility of tissue cover. Image analysis can be used as a modality to assess the versatility of individual flaps in the reconstruction of lower limb defects.

Reverse-flow anterolateral thigh flap without antegrade venous reconstruction for knee soft-tissue reconstruction

Summary For soft-tissue defects around the knee area, the pedicled gastrocnemius flap is classically the first choice for reconstruction. However, the gastrocnemius flap is not always sufficient, and it carries certain donor site morbidity. When local lower limb flaps are insufficient or unavailable, free-tissue transfer is considered. Because few recipient vessels are located around the knee, free-tissue reconstruction remains challenging. In addition, the optimal donor site for large soft-tissue defects has not been clearly established. The anterolateral thigh (ALT) flap is easily accessible and has minor donor site morbidity. We evaluated the reverse-flow ALT pedicled flap as a candidate for the reconstruction of large soft-tissue defects around the knee. We performed a retrospective review of charts between 2005 and 2008. A total of four patients underwent reverse-flow ALT flap for reconstructing large soft-tissue defects around the knee. None of the flaps were augmented in venous drainage with a venous supercharge. We reviewed the defect characteristics, flap size, patient factors, and reconstructive outcomes. The soft-tissue defects were successfully reconstructed for all patients intraoperatively. However, venous congestion of varying degrees developed postoperatively in all patients. Two of the patients had partial flap necrosis but were successfully treated with debridement and skin grafting or local flap repair. The reverse-flow ALT flap can be used to reconstruct large soft-tissue defects around the knee successfully. However, venous congestion remains the main cause of flap complication. In such clinical scenarios, we suggest either using a smaller flap or performing venous supercharge to enhance venous return and improve the survival ratio of the flap.

The Clinical Course of Reverse-flow Anterolateral Thigh Flap: Need to Prepare for Venous Congestion and Salvage Operation

The Clinical Course of Reverse-flow Anterolateral Thigh Flap: Need to Prepare for Venous Congestion and Salvage Operation

Clinical experience with a reverse-flow anterolateral thigh perforator flap for the reconstruction of soft-tissue defects of the knee and proximal lower leg

Soft-tissue defects in the knee region are usually complex and require adequate reconstruction with flaps. The aim of this article is to present the authors' experience using the reverse-flow anterolateral thigh perforator flap for the reconstruction of a variety of soft-tissue defects around the knee including the upper third of the leg. A total of 17 reverse-flow anterolateral thigh perforator flaps were used for reconstruction of soft-tissue defects around the knee and the upper third of the leg between December 2006 and December 2010. The ages of patients ranged from 26 to 82 years (mean, 64.3). Defect sizes ranged from 6×8 to 10×14 cm. The application of the reverse-flow anterolateral thigh perforator flaps in relation to the variable arterial anatomy was described. The dimensions of the largest flap used for reconstruction were 10×16 cm. The perforators were musculocutaneous in 14 patients and septocutaneous in three patients. The maximal pedicle length was 28 cm. All of the flaps survived. Only two flaps developed partial skin necrosis at the distal end. Good aesthetic and functional results with adequate range of motion were achieved in all cases. Despite a variable vascular anatomy that can be challenging for the surgeon, reverse-flow anterolateral thigh perforator flap is a safe and reliable method for reconstruction of the defects around the knee and even the upper third of the leg.

Antegrade Venous Drainage in a Reverse-Flow Anterolateral Thigh Flap

Sir: The distally based, reverse-flow anterolateral thigh flap variant was described by Zhang in 1990.1 The flow pattern in this flap is well understood and involves communication between the descending branch of the lateral circumflex femoral artery and the lateral superior genicular artery or profunda femoris artery,2 providing pedicled flap coverage of the knee and a satisfactory donor defect. However, venous congestion and edema may compromise the flap (Fig. 1).3,4 We present an innovative method for antegrade augmentation of venous outflow in the reverse-flow anterolateral thigh flap, to improve reliability.Fig. 1.: Although venous congestion subsided within days, the viability of the flap was jeopardized, and it was felt that partial flap loss might occur in the reverse-flow anterolateral thigh flap. Appearance (left) 2 days after flap transfer and (right) 9 days later.The cutaneous perforators are located by means of a Doppler probe and marked. The skin paddle is based over the distal perforator. The medial incision continues down to deep fascia. The perforators are identified in the subfascial plane, lateral to the incision, and are traced to the descending branch of the lateral circumflex femoral artery. If the perforators arise from the transverse branch of the lateral circumflex femoral artery, the flap must be raised as a free flap. The final flap design is then marked and the lateral portion of the flap is elevated. A vascular clamp is applied temporarily to the proximal descending branch of the lateral circumflex femoral artery to confirm adequate flap circulation. The descending branch is then divided proximally, at the junction of descending and transverse branches. The descending branch is dissected distally until an adequate pivot point is reached. The flap is transposed into the recipient site. The great saphenous vein is then transposed anteriorly by open incision or subcutaneous tunnel. The proximal flap pedicle is swung anteriorly and the major concomitant pedicle vein is anastomosed to the great saphenous vein (Fig. 2). The vascular pedicle of the flap is sufficient to reach the great saphenous vein easily. Thus, the flap is drained by the great saphenous vein in an antegrade manner.Fig. 2.: Before anastomosing the major concomitant vein of the proximal flap pedicle to the great saphenous vein, the flap appeared bluish and dusky, and bleeding of dark blood was found at the flap margin.The abundant vasculature around the knee enables various local flap possibilities.5 However, donor-site cosmesis may limit the use of local cutaneous flaps, and regional muscle flaps may produce unacceptable functional and aesthetic deficits. Also, free flap techniques may entail long procedures and changes of patient position. The reverse-flow anterolateral thigh flap provides good wound coverage around the knee. Even in defects involving patellar tendon loss, this flap can also provide fascia lata for one-stage reconstruction.2 However, reports describing the use of the reverse-flow anterolateral thigh flap are scant.1–4 Venous congestion would seem to be the main complication limiting its appeal. In our first three conventional reverse-flow anterolateral thigh flaps, venous congestion occurred in every case and, although subsiding within days, it did jeopardize flap viability, with one episode of partial flap necrosis. In the subsequent case, venous drainage was augmented by anastomosis to the great saphenous vein, as described, allowing physiologic venous drainage from the flap. In this case, congestion did not arise. This technique added approximately 30 minutes to the operating time. Antegrade augmentation of venous drainage in the reverse-flow anterolateral thigh flap by anastomosis of one concomitant vein to the great saphenous vein may improve the reliability of this useful flap. ACKNOWLEDGMENT The authors thank C. P. O'Boyle, M.D., for assistance with the preparation of this article. DISCLOSURE None of the authors has a financial interest to declare in relation to the content of this article. Cheng-Hung Lin, M.D. Chung-Chen Hsu, M.D. Chih-Hung Lin, M.D. Yi-Chieh Chen, M.D. Fu-Chan Wei, M.D. Department of Plastic and Reconstructive Surgery Chang Gung Memorial Hospital Chang Gung Medical College and Chang Gung University Taipei, Taiwan

Are Reverse Flow Fasciocutaneous Flaps an Appropriate Option for the Reconstruction of Severe Postburn Lower Extremity Contractures?

Full thickness burns involving the lower extremity can result in severe contractures, which impair extremity functions if they are not managed with proper treatment and rehabilitation. After release of postburn contracture of the knee, ankle, and metatarsophalangeal joints, defects often require coverage by flaps. Twelve distally based reverse flow flaps were performed for lower-extremity reconstruction after release of postburn flexion contractures. All of the patients were male and their age ranged from 20 to 23 years, with a mean age of 21. After the release of the contractures, 3 flaps were used based on the location of the contractures. The reverse flow anterolateral thigh flap was used for knee reconstruction (n = 4, 33%). The reverse flow sural flap was used for ankle reconstruction (n = 4, 33%), and the reverse flow medial plantar flap was used for metatarsophalangeal reconstruction (n = 4, 33%). The sizes of the flap varied from 2 to 17 cm wide and 3 to 18 cm in length. All defects were covered successfully. Reverse fasciocutaneous tissue transfer to reconstruct the soft tissue defects provide early motion. Sufficient contracture release is achieved without displacement of anatomic landmarks. The reverse-flow flap is a reasonable and reliable choice for each joint level in the lower extremity.

The earlier clinic experience of the reverse-flow anterolateral thigh island flap

Since Song first reported the anterolateral thigh flap in 1984, this flap has been applied widely in clinical practice. In 1997, we found that the proximal end of the vascular pedicle of the anterolateral thigh flap showed active bleeding. We therefore believed that this flap could form the reverse-flow flap, which can be used clinically. From 1997 to 2002, two patients who suffered from soft tissue defects in their lower extremities have been repaired successfully with the reversed flow anterolateral thigh island flaps. The reverse-flow anterolateral thigh island flap with reliable blood supply and long vascular pedicle can be designed to repair soft tissue defects around ipsilateral knee joint or contralateral distal rejoins of the leg, especially in the difficulty cases.