Dorsal foot resurfacing using free anterolateral thigh (ALT) flap in children

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  • DORSAL FOOT RESURFACING USING FREE ANTEROLATERALTHIGH (ALT) FLAP IN CHILDREN

    TAREK A. EL-GAMMAL, M.D.,1* AMR EL-SAYED, M.D.,1 MOHAMED M. KOTB, M.D.,1 WALEED RIAD SALEH, M.D.,1

    YASSER FAROUK RAGHEB, M.D.,1 OMAR EL-REFAI, M.D.,1 and MOHAMMED HASSAN ALI EL FAHAR, M.D.2

    Very limited literature described the use of the free anterolateral thigh (ALT) among other flaps for pediatric lower limb reconstruction. Theaim of this study is to present our experience using the free ALT flap for reconstruction of soft tissue defects over the dorsum of the footand ankle in children. The study included 42 children aged 2.513 years with a mean of 6.18 years. Three children had crush injuries whilethe rest were victims of run over car accidents. All of the flaps were vascularized by at least two perforators; 88.23% were musculocutane-ous and 11.77 were septocutaneous perforators. All flaps were raised in a subfascial plane. Initial thinning was performed in five flaps and35% required subsequent debulking. Mean Flap surface area was 117.11 cm2. The recipient arteries were the anterior tibial artery in 38cases and posterior tibial artery in four cases. Venous anastomosis was performed to one vena commitant and in nine cases the longsaphenous vein was additionally used. Mean ischemia time of the flap was 2 hours while total operative time averaged 6.3 hours. About41% of donor sites were closed primarily while 59% required skin grafting. Primary flap survival rate was 92.8% (39/42 cases). Three flapsshowed venous congestion. After venous reanastomosis, two flaps showed partial loss and one flap was lost completely. Post-operativehospital stay averaged 7.5 days. The free ALT flap could be as safe, reliable, and aesthetically appealing option for foot/ankle resurfacingin children after traumatic soft tissue loss. VVC 2012 Wiley Periodicals, Inc. Microsurgery 33:259264, 2013.

    The anterolateral thigh (ALT) flap was first described bySong et al.1 In the last three decades, the ALT flap has

    gained popularity as a versatile and reliable option for

    soft tissue reconstruction. The possibilities of transferring

    large skin paddles and different tissue types on a large

    and long pedicle, potential for thinning, reinnervation,

    flow through revascularization and coverage of the

    extremities, with minimal donor-site morbidity are some

    of the reasons which have led to the success of this flap.2

    Microvascular free tissue transfer has been shown to

    be safe and reliable in adults and in children with success

    rates >90%.3 Free-flap reconstruction of post-traumatictissue defects in children need to be planned carefully

    with regards to the specific pediatric anatomy. Also, the

    evolution of childrens tissue and skeletal structures need

    to be taken into account. Apart from surgical considera-

    tions, psychosocial ramifications, and discomfort of pro-

    longed disability at a young age have to be kept in

    mind.4

    This article presents our clinical experience using the

    free ALT flap for reconstruction of soft tissue defects

    over the foot and around the ankle in children.

    PATIENTS AND METHODS

    From January 2005 to December 2010, 42 children

    received free ALT flap for coverage of large and exten-

    sive soft tissue defects over the dorsum of the foot and

    ankle exposing the extensor tendons and/or metatarsals

    with or without associated fractures of the metatarsals or

    ankle or open joints. Small defects eligible for local or

    pedicle skin flaps and defects associated with plantar loss

    or bone loss requiring bone grafts were excluded.

    Hospital records were reviewed and data were col-

    lected regarding patients demographics, type of trauma,

    timing of microsurgical reconstruction, flap dimensions,

    operative time, number, and type of perforators, donor-

    site closure, postoperative course and complications. The

    age of the children ranged between 2.5 and 13 years

    (mean age, 6.18 6 2.54 years). There were 10 femalesand 32 males. All children had post-traumatic skin and

    soft tissue loss over foot and around the ankle (Table 1).

    Three children had crush injuries while the rest were

    victims of run over car accidents. The left foot was

    involved in 55.9% of the cases and the right in 44.1%.

    All patients underwent reconstruction >72 hours aftertrauma within a mean of 15.8 6 2.54 days.

    Initial Management

    All wounds were debrided thoroughly. Bone fixation

    was done at the time of initial debridement. Additional

    reconstructive procedures were done at the time of ALT

    flap transfer. Bone fixation was done using k-wires andfoot was supported in a posterior slab. Daily closed

    wound dressing was done using conventional paraffin

    gauze and antibiotic ointment. No vacuum assisted

    closure VAC was used. All wounds were followed up by

    1Reconstructive Microsurgery Unit, Assiut University Hospitals and School ofMedicine, Assiut, Egypt2Plastic & Reconstructive Surgery, Mansoura University School of Medicine,Mansoura, Egypt

    *Correspondence to: Tarek Abdalla El-ammal, M.D.; ReconstructiveMicrosurgery Unit, Assiut University Hospitals and School of Medicine,Assiut 71526, Egypt . E-mail: tarek_elgammal@yahoo.com

    Received 24 June 2012; Revision accepted 3 November 2012; Accepted 5November 2012

    Published online 26 December 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/micr.22074

    VVC 2012 Wiley Periodicals, Inc.

  • serial wound culture. Patency of the anterior and poste-

    rior tibial vessels was evaluated using a hand held Dopp-

    ler and no angiographic studies as CTA or MRA were

    performed preoperatively.

    Surgical Technique

    A Two team approach was adopted, one for explora-

    tion/dissection of the recipient vessels and the other for

    harvesting the flap from the contralateral donor thigh.

    Normal skin edges were reached by excision of any

    tissues of doubtful viability to re-evaluate of the defect

    prior to determining final flap dimensions.

    Vessels exploration was done under tourniquet with-

    out exsanguination. The anterior tibial vessels outside the

    zone of injury were evaluated. If the flow was inadequate

    or there were signs of intimal injury on microscopic

    examination, the posterior tibial vessels were used for

    end to side anastomosis.

    A line was drawn between the anterior superior iliac

    spine and the midpoint of the lateral border on the patella

    on the donor thigh, with the child in the supine position.

    The location of the main perforators was detected with

    Doppler ultrasound and was centered primarily at the

    midpoint of the line. Additional perforators were located

    510 cm proximal and distal to the midpoint perforator.

    Perforators at these locations were designated from

    proximal to distal as vessels A, B, and C, respectively

    (Fig. 1). The design of the skin paddle was centered over

    two perforators using a patron tailored from the defect

    that included both of them. A pinch test was used to

    establish the amount of the skin that could be harvested

    allowing primary closure of the donor site if possible.

    The incision of the skin was started from the medial

    border at subfascial plane till the rectus femoris muscle

    was visualized and retracted exposing the intermuscular

    septum between it and the vastus latralis. Dissection of

    the perforators was carried out with the use of surgical

    loupes (3.5x or 4.5x). If a visible and pulsatile septocuta-

    neous perforator arising from the descending branch or

    originating directly from the LCFA was present, then the

    flap could be harvested as a septocutaneous flap. If not,

    the flap could be elevated as a musculocutaneous flap by

    including 2 cm cuff of vastus lateralis muscle.

    Venous anastomosis was done first followed by the

    arterial anastomosis using 10/0 interrupted monofilament

    nylon sutures. Heparinized saline (100 U/mL) was used

    as a local irrigant and intravenous bolus of 50100 U/kg

    was administrated just before releasing the clamps.

    The donor site was closed primarily after undermining

    if the defect was less than 10 cm wide, otherwise, a split

    thickness skin graft was used. Light dressing and non-

    adherent gauze impregnated with paraffin was used as a

    closed dressing for the grafted donor.

    Dextran 40 was usually run at 810 milliliters/kg/24

    hours approximately 5 days post-operatively. All children

    received post-operative sedation. Careful monitoring of

    the general condition of the patient and vital signs was

    done for the first 24 hours. All flaps were monitored ev-

    ery 1 hour for the first 24 hours then every 2 hours for 5

    days as regards color, temperature, and capillary refill to

    ensure patent microvascular anastomosis. Passive exer-

    cises were initiated 2 weeks postoperatively for 2 weeks

    then followed by active exercises for another 3 months.

    When required, flap debulking was done 6 months af-

    ter the initial surgery. The outline of the flap was marked

    and the proximal edge of the flap was incised along the

    scar for up to 50% of the flap circumference, the subcuta-

    neous fat was removed and the flap was advanced proxi-

    mally in order to reduce any redundant skin.

    Statistics were performed with IBM1 SPSS1 Statis-

    tics Version 19. Values are given as mean 6 standarddeviation.

    RESULTS

    All of the flaps were vascularized by at least 2 perfo-

    rators. A total of 88.23% of the perforators were muscu-

    locutaneous and 11.77% were septocutaneous perforators.

    All flaps were raised in a subfascial plane. Initial thinning

    was performed in five flaps and 35.7% required subse-

    quent debulking. Mean Flap dimensions were 15.5 62.72 cm 3 7.44 6 1.28 cm with a mean surface area of117.11 6 37.91 cm2. The recipient artery was theanterior tibial artery in 38 cases, and the posterior tibial

    Table 1. Associated Injuries of the Foot and Ankle

    Indication of coverage Number

    Exposed metatarsals and extensor tendons 18

    Exposed medial or lateral malleolus 4

    Open fracture one or more metatarsals 7

    Open fracture dislocation of the ankle joint 13

    Total 42

    Figure 1. Marking of the donor site : (A) proximal perforator, (B)

    main perforator, (C) distal perforator anterior superior iliac spine

    (ASIS). [Color figure can be viewed in the online issue, which is

    available at wileyonlinelibrary.com.]

    260 El-Gammal et al.

    Microsurgery DOI 10.1002/micr

  • artery in four cases. Venous anastomosis was performed

    to one vena commitant and in nine cases the long saphe-

    nous vein was additionally used. Mean ischemia time of

    the flap was 2.07 6 0.51 hours while the total operativetime was 6.33 6 1.05 hours. The average blood loss was453.29 6 104.11 cc. 41.18% of donor sites were closedprimarily while 59.52% needed skin grafting (Table 2).

    Post-operative hospital stay averaged 7.5 6 1.16days. Follow up averaged 42 months. All limbs survived.

    Primary flap survival rate was 92.86% (39/42 cases).

    Three flaps showed venous congestion. After venous

    reanastomosis, two flaps showed partial loss and one flap

    was lost completely. More than 70% of the cases were

    able to wear shoes even before debulking. Fifteen chil-

    dren complained that it was difficult to put on shoes

    because of the bulky flap and that the flap contour was

    not aesthetically pleasing. After the debulking satisfactory

    results were achieved in terms of contour and functional

    outcome (Table 3). Two representative cases are shown

    in Figures 23.

    DISCUSSION

    The unique architecture of the soft tissue of dorsum

    of the foot consists of a thin pliable surface that allows

    for significant excursion and tendon gliding. Reconstruc-

    tive options must preserve these important functions and

    allow for reasonable contour so the patient may wear a

    shoe postoperatively. There is often a paucity of local

    flap options in the setting of trauma, and free flap recon-

    struction is frequently indicated. The need for durable

    coverage of contaminated wounds or exposed joints, frac-

    tures, or hardware makes the free flap particularly well

    suited to trauma reconstruction.5

    In the last three decades, the advent and refinement

    of microsurgical techniques have brought about a revolu-

    tion in the treatment of distal lower extremity trauma. In

    the adult population, the principles of successful treat-

    ment of high-energy injuries of the ankle and foot are

    well defined.6 The use of free tissue transfer in children

    has demonstrated that it can be performed with accepta-

    ble morbidity.7,8 Although childrens anatomy may pres-

    ent unique technical challenges, the absence of diabetes,

    hypertension, atherosclerosis, and venous stasis in chil-

    dren makes free tissue transfer a particularly attractive

    option for complex reconstruction.5

    Namdar et al. reviewed several studies reporting the

    success of free latissimus dorsi muscle transfer in chil-

    dren for lower extremity reconstruction; he also reported

    that the hospital stay ranged from days to months due to

    seroma formation and conclude that because of the large

    volume and size of the transferred latissimus dorsi mus-

    cle, there was a common need for surgical revisions even

    if there are no clinical signs of malperfusion.4 In larger

    studies (512 children) a free latissimus dorsi muscle flap

    survival rate of 6780% has been reported.911 Haasbeek

    and collaeages described free gracilis muscle transfer for

    coverage after release of severe clubfoot deformity in

    children older than 4 years of age. The small vessel di-

    ameter often found in children younger than 4 years of

    age is not suitable for anastomosis.12 Recently, Tan et al.

    used nerve sparing latissimus dorsi flap to cover soft tis-

    sue defect with limited donor site morbidity.13 This study

    included one child with crush injury to the leg.

    Very limited literature described the use of the free

    ALT among other flaps for pediatric lower limb recon-

    struction. These previous studies did not address the

    peculiarities of the ALT flap in the pediatric population

    and held true the considerations based on experiences in

    an adult population.1418 The indication for use of ALT

    flap in our series was coverage of large and extensive

    soft tissue defects over the dorsum of the foot and ankle

    exposing the extensor tendons and/or metatarsals with or

    without associated fractures of the metatarsals or ankle or

    open joints. Small defects eligible for local or pedicle

    skin flaps were excluded. Defects associated with plantar

    loss or bone loss requiring bone grafts were treated with

    free muscle or osteocutaneous flap respectively. Our

    study is the largest in number regarding dorsal foot and

    ankle resurfacing using the free ALT for post traumatic

    soft tissue loss in children (Table 4).

    Road traffic accidents and crush injuries are the most

    frequently reported causes of extensive foot trauma in

    children, which require free-flap transfer for foot sal-

    vage.9,11,19 In the current study, 94.11% were victims of

    road traffic accidents and three cases suffered from crush

    injuries caused by heavy objects.

    All children underwent delayed reconstruction more

    than 3 days after trauma. This indicates that post-traumatic

    Table 2. Aesthetic Outcome

    Aesthetic outcome

    Donor site

    Primary closure 59.52%

    Skin graft 40.47%

    Hypertrophic scar 4.76%

    Keloid 7.14%

    Recipient site

    Flap Bulkiness 35.71%

    Table 3. Functional Scoring

    Functional scoring

    Walk normally for 10 m back and forth 3 times 90.47%

    Climb 10 stairs up 88.09%

    Wear normal shoes before debulking 71.42%

    Wear normal shoes after debulking 95.23%

    Dorsal Foot Resurfacing using Free ALT 261

    Microsurgery DOI 10.1002/micr

  • lower extremity reconstruction may be safely and reliably

    performed when the wound is adequately debrided and

    when other injuries have been stabilized. Karanas et al.

    adopted similar strategy in a series of 14 patients who

    underwent delayed microvascular reconstruction to lower

    limb injures.20 Recently, Arslan et al., have shown that the

    final results obtained after delayed definitive soft tissue

    reconstruction compared favorably with the results of early

    closure within 7 days of trauma.21

    Yildirim et al. suggested that there are several steps

    that should be followed when pediatric microsurgery is

    performed.16 Though lesser magnification is adequate

    for adults with reasonable vessel size, children usually

    require higher magnification (16x or 20x), and a better

    light source. Dissection should be performed with mi-

    croscopic magnification as well. Suture sizes of 11/0

    with 50 l needle are preferred for pediatric microsur-gery. In the presented cases we have used loop magnifi-

    cation (3.5x or 4.5x), as we have not performed

    intramuscular dissection to save time. Anastomosis was

    performed using 10/0 with 50 l needle. Vessel dissec-tion should be kept as minimal as possible to minimize

    vasospasm. It is reasonable to use a local vasodilator

    (papaverin, 2% lidocain).

    Figure 2. (A) A 5 year-old male child with extensive soft tissue loss over the dorsum of the foot with exposed metatarsals. (B) Immediately

    after free ALT transfer. (C) One year follow up. (D) donor site appearance following primary closure. [Color figure can be viewed in the

    online issue, which is available at wileyonlinelibrary.com.]

    262 El-Gammal et al.

    Microsurgery DOI 10.1002/micr

  • Chen et. al., in their report on 126 cases with lower

    extremity injuries, who had free tissue transfer have

    noticed that the anterior tibial artery had a much higher

    incidence of injury with more extensive damage than the

    posterior tibial artery.22 In our series, we have found that

    anastomosis to anterior tibial vessels was very safe

    in children so long trauma was confined to the foot. In

    addition, harvesting a long pedicle allowed doing the

    anastomosis outside the injury zone. We recommend

    adding one saphenous vein to help drainage of the flap.

    Post-operative analgesia is recommended to avoid postop-

    erative anxiety and vasospasm. Low molecular-weight

    dextran should be stopped at the 5th postoperative day to

    avoid bleeding complications.

    Five flaps were thinned at the time of inset in rela-

    tively obese children. It is safe doing limited primary

    thinning, as the subcutaneous fat in children is relatively

    higher than in adults. This has been confirmed by Demi-

    rtas et al. who successfully carried out primary thinning

    of the flaps and considered it an option especially for

    smaller flaps.17 Nearly one third of the successful flaps

    required debulking, which lead to improvement in con-

    tour with improving ability to wear normal shoes from

    71.42% to 95.23% without complications. Askouni et al.

    reported that delayed flap thinning using liposuction can

    lead to significant improvements in cosmetic outcomes in

    adult patient.23 Long follow up is recommended for those

    childrens donor site to evaluate any morphological

    growth changes.

    Garb et al., in their report on 20 children who under-

    went free ALT reconstruction, noticed that donor-site clo-

    sure required split-thickness skin grafts in six cases (30%).

    In the present study, with the larger mean surface area of

    the flap, 117.11 cm compared to that of 91.75 cm in Garb

    et al. series,18 nearly less than half (41.18%) of donor sites

    were closed primarily. This is related to elasticity of pedi-

    atric skin and aggressive undermining of skin edges with

    two-layer closure and fascia approximation. Donor-site

    grafting in children produces ugly scars and are at higher

    risk for hypertrophic scars, therefore it should be avoided

    if possible.24 Garb et al. recommended silicon sheeting

    and scar management.18 Gupota and Sharma recommended

    corticosteroid augmented by pressure garment and silicon

    sheeting to manage hypertrophic scars that might develop

    in children.25 We recommend the same protocol to prevent

    post-operative wound complications.

    Our vascular re-exploration rate was 7.2% (3 of 42

    cases), in the lower range of the 429% re-exploration

    rates reported in the literature for lower extremity free

    flaps in the pediatric population.3,7,26 Zhang et al.

    Figure 3. (A) A 5 year-old male child with extensive soft tissue loss

    over the right medial malleolus (B) Immediately after free ALT

    transfer. (C) One year follow up after flap debulking. [Color figure

    can be viewed in the online issue, which is available at wileyonline-

    library.com.]

    Table 4. Free ALT Flap for Pediatric Lower Limb Reconstruction-previous Reports

    Year Authors No Mean Age Defects Etiology Survival

    2007 Segev et al.14 2 10 LL Trauma, burn

    contracture

    100%

    2008 Upton and Guo15 4 UL/LL

    2008 Yildirim et al.16 2 9.5 UL/LL 100%

    2010 Demirtas et al.17 5 4.8 Foot Trauma 100%

    2011 Gharb et al.18 8 10.5 LL Trauma, burn,

    osteomyelitis

    2 partial flap

    necrosis

    2012 Current study 42 6.18 Dorsum of the

    foot and ankle

    Trauma 91.17%

    UL, Upper limb; LL, Lower limb.

    Dorsal Foot Resurfacing using Free ALT 263

    Microsurgery DOI 10.1002/micr

  • reported an average operative time of 7 hours with a

    range of 510 hours in adult.27 Our operative time was

Recommended

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