Case 1
Clinical Presentation
A 28-year-old White male had a complex left foot open fracture wound as a result of a motor vehicle accident. He suffered an avulsion injury of the left medial ankle with underlying comminuted fractures. There was significate bone loss and lack of continuity of bony structures with an open wound measuring 15 × 8 cm ( Fig. 49.1 ). The plastic surgery service was consulted for soft tissue coverage because the limb salvage would depend on it. He was brought to the operating room by the orthopedic foot and ankle service for ankle orthopedic reconstruction with primary bony fusion followed by a free tissue transfer to this large medial ankle wound by the plastic surgery service.
Operative Plan and Special Considerations
For such a large and complex soft tissue wound in the medial ankle, the primary soft tissue reconstructive option would be a free tissue transfer because there was no local option available to provide the reliable soft tissue coverage critical for limb salvage. As a contemporary reconstructive option, an anterolateral thigh (ALT) perforator flap can be selected to provide a good and reliable soft tissue coverage for this large open fracture ankle wound. The flap has a long pedicle and can provide a relatively large amount of the fasciocutaneous tissue for reliable soft tissue coverage of such a wound. Because a preoperative CT angiogram showed that the patient had a normal three vessels’ leg, the distal posterior tibial artery could be selected as a recipient vessel for an end-to-side arterial microanastomosis near the ankle soft tissue defect. A preoperative duplex scan could be performed to determine which side of the thigh should be selected as a donor site for an ALT perforator flap based on the size and blood flow of the perforator identified and the amount of intramuscular perforator dissection required.
Operative Procedures
Under general anesthesia, with the patient in the supine position, the soft tissue reconstructive procedure started by debriding the wound located in the medial ankle. All unhealthy-looking skin edges were freshly debrided and the wound was then irrigated with Pulsavac.
The posterior tibial artery and vein were explored first. The skin incision was extended proximally from the medial ankle wound and both vessel dissections were performed between the medial soleus and flexor digitorum longus muscles. Both the posterior tibial artery and vena comitans were carefully prepared under loupe magnification and were ready for microvascular anastomoses.
Based on a preoperative duplex scan finding, the left ALT perforator flap was designed. A 20 × 8 cm skin paddle was marked ( Fig. 49.2 ). Two perforators were confirmed by an intraoperative Doppler scan. The incision was made around the skin paddle down to the fascia. Suprafascial dissection was performed toward the perforators. Around those two medially located perforators, the intramuscular dissection was performed through the rectus femoris muscle. After at least 7 cm of intramuscular dissection with proper traction of the pedicle and by splitting the muscles between the rectus femoris and vastus lateralis muscles, the perforator was found to join the descending branch of the lateral circumflex femoral vessels ( Fig. 49.3 ). The distal descending branch of the circumflex femoral vessels was divided and dissection was continued further along the pedicle toward the profunda vessels. A 12-cm pedicle of the flap was obtained and divided with medium-sized clips off the profunda ( Fig. 49.4 ). During dissection, motor nerves to the vastus lateralis muscle were completely spared. The pedicle of the flap was then prepared under loupe magnification and the artery was flushed with heparinized saline.
The flap was temporarily inset into the wound. The pedicle and recipient vessels were prepared for microvascular anastomoses under an operating microscope. The arterial microanastomosis was performed between the pedicle artery and the posterior tibial artery in an end-to-side fashion with interrupted 8-0 nylon sutures after the correct size of arteriotomy on the posterior tibial artery was well prepared. The venous microanastomosis was performed between the pedicle vein and the posterior tibial vein with a 2.5-mm coupler device in an end-to-end fashion ( Fig. 49.5 ). After releasing all clamps, the flap appeared well perfused with a strong Doppler signal.
A drain was placed under the flap and the entire flap was inset into the left medial ankle wound and sutured to the adjacent skin edges with several interrupted 3-0 Monocryl sutures in half-buried mattress fashion as a single-layer closure. The skin incision in the distal leg over both microvascular anastomoses was approximated with several interrupted 3-0 Monocryl sutures ( Fig. 49.6 ).
The left thigh flap donor site was closed primarily. The transected portion of the rectus femoris muscle was approximated with several interrupted 2-0 Vicryl sutures. A fascial layer opening was approximated with several interrupted 3-0 PDS sutures and the subcutaneous closure was performed with interrupted 3-0 Monocryl sutures. The skin closure was performed with 3-0 Monocryl in a running subcuticular fashion ( Fig. 49.7 ).
Follow-Up Results
The patient did well postoperatively without any complications related to the free ALT flap transfer. He was discharged from hospital on postoperative day 12 after tolerating dangling protocol. The drain was removed during a subsequent follow-up office visit. The flap reconstruction site over the left medial ankle healed well ( Fig. 49.8 ).
Final Outcome
The left medial ankle wound after a free ALT flap reconstruction healed well with good contour and minimal scarring ( Fig. 49.9 ). The patient underwent further autologous bone grafting for the ankle bony reconstruction. Eventually, the ankle fracture site also healed. No flap debulking procedure was needed ( Fig. 49.10 ). The left thigh ALT flap donor site also healed well with minimal scarring ( Fig. 49.11 ). He has resumed his normal activities and has routinely been followed by the orthopedic foot and ankle service.
