The selection of recipient vessels is crucial when reconstructing traumatized lower extremities using a free flap. When the dorsalis pedis artery and/or posterior tibial artery cannot be palpated, we utilize computed tomography angiography to verify the site of vascular injury prior to performing free flap transfer. For vascular anastomosis, we fundamentally perform end-to-side anastomosis or flow-through anastomosis to preserve the main arterial flow. In addition, in open fracture of the lower extremity, we utilize the anterolateral thigh flap for moderate soft tissue defects and the latissimus dorsi musculocutaneous flap for extensive soft tissue defects. The free flaps used in these two techniques are long and include a large-caliber pedicle, and reconstruction can be performed with either the anterior or posterior tibial artery. The preparation of recipient vessels is easier during the acute phase early after injury, when there is no influence of scarring. A free flap allows flow-through anastomosis and is thus optimal for open fracture of the lower extremity that requires simultaneous reconstruction of main vessel injury and soft tissue defect from the middle to distal thirds of the lower extremity.
Reconstruction of a traumatized lower extremity using a free flap carries a greater risk of developing complications compared to reconstruction of other sites [
This retrospective study examined recipient vessels and vascular anastomosis techniques in 18 consecutive patients who underwent free flap transfer at an early stage after suffering open fracture of the lower extremity.
We performed free flap transfer within 1 week after injury in 18 consecutive patients (15 men and 3 women) who suffered Gustilo type IIIB open fracture of the lower extremity between January 2002 and December 2008. Mean age at the time of surgery was 31.9 years (range, 18–58 years). The causes of injury were a traffic accident in 15 cases and an occupational accident in 3 cases. Data on fracture site, transferred flaps, vessels selected for anastomosis, anastomosis techniques, and postoperative complications were obtained from medical records. Mean duration of follow-up was 41 months (range, 7–86 months).
The fracture sites were the proximal third of the lower extremity in 2 cases, the middle third of the lower extremity in 7, and the distal third of the lower extremity in 9. The transferred free flaps were an anterolateral thigh flap in 13 cases and a latissimus dorsi musculocutaneous flap in 5. The anastomosed recipient arteries were the anterior tibial artery in 10 cases, the posterior tibial artery in 6, the popliteal artery in 1, and the superior medial genicular artery in 1.
The vascular anastomosis techniques used were flow-through anastomosis in 12 cases, end-to-side anastomosis in 5, and end-to-end anastomosis in 1. Postoperative complications were congestion due to thrombosis in 2 patients who subsequently underwent reexploration and deep infection that subsided with additional debridement in 1 patient. Free flaps survived in all patients, including the 3 patients who underwent reoperation (Table
Patients summary.
Number | Age | Sex | Fracture site | Free flap | Recipient artery | Anastomotic type | Complications | Result | Comments |
---|---|---|---|---|---|---|---|---|---|
1 | 51 | M | Distal | ALT | Anterior tibial a. | Flow-through | Successful | ||
2 | 53 | M | Distal | ALT | Posterior tibial a. | Flow-through | Successful | ||
3 | 31 | M | Middle | ALT | Anterior tibial a. | Flow-through | Successful | ||
4 | 21 | M | Distal | ALT | Anterior tibial a. | Flow-through | Successful | ||
5 | 18 | M | Proximal | ALT | Medial inferior genicular a. | End-to-end | Successful | ||
6 | 34 | F | Middle | ALT | Posterior tibial a. | End-to-side | Congestion | Reexploration | Survival |
7 | 25 | M | Middle | ALT | Anterior tibial a. | End-to-side | Successful | ||
8 | 58 | F | Middle | ALT | Anterior tibial a. | Flow-through | Successful | ||
9 | 50 | M | Middle | LD | Posterior tibial a. | End-to-side | Successful | ||
10 | 22 | M | Distal | ALT | Anterior tibial a. | Flow-through | Successful | ||
11 | 19 | M | Distal | ALT | Posterior tibial a. | Flow-through | Successful | ||
12 | 33 | M | Middle | LD | Anterior tibial a. | Flow-through | Successful | ||
13 | 24 | M | Middle | LD | Anterior tibial a. | Flow-through | Successful | ||
14 | 32 | M | Distal | ALT | Posterior tibial a. | End-to-side | Successful | ||
15 | 30 | M | Proximal | LD | Popliteal a. | End-to-side | Deep infection | Debridement | Survival |
16 | 22 | M | Distal | ALT | Posterior tibial a. | Flow-through | Congestion | Reexploration | Survival |
17 | 21 | M | Middle | ALT | Anterior tibial a. | Flow-through | Successful | ||
18 | 30 | F | Middle | LD | Anterior tibial a. | Flow-through | Successful |
ALT: anterolateral thigh flap, LD: latissimus dorsi musculocutaneous flap.
A 58-year-old woman suffered open fracture injury to the lower right extremity in a traffic accident. On the day of injury, debridement and external fixation of the open fracture of the lower extremity were performed. On day 6 after injury, reconstruction was performed using intramedullary fixation and a free anterolateral thigh flap. On preoperative medical examination, the dorsalis pedis artery and posterior tibial artery were palpable. In surgery, the anterior tibial artery was carefully dissected to confirm the absence of injury. End-to-side anastomoses of the lateral circumflex femoral artery and anterior tibial artery with the anterolateral thigh flap were performed to preserve arterial blood flow. The anterolateral thigh flap survived without postoperative complications (Figure
(a) Open fracture of the lower extremity is accompanied by an moderate soft tissue defect on the anterior lower extremity. (b) X-ray findings. (c) Anterolateral thigh flap harvested from the same side. (d) The anterior tibial artery was selected for end-to-side anastomosis. (e) Appearance at 7 months postoperatively. (f) X-ray findings at 7 months postoperatively, showing bone union.
A 21-year-old man suffered open fracture injury to the lower right extremity in an occupational accident at a construction site. At the initial surgery, debridement and external fixation were performed. Two days later, open fracture of the lower right extremity was reconstructed with intramedullary fixation and free anterolateral thigh flap. Since the anterior tibial artery had been injured in the open fracture of the lower right extremity, the anterior tibial artery was reconstructed by interposing the lateral circumflex femoral artery of the anterolateral thigh flap. Lateral circumflex femoral veins were anastomosed with the concomitant and great saphenous veins using end-to-end anastomosis. The anterolateral thigh flap survived without postoperative complications. Four months after injury, autologous bone grafting was performed for the bone defect in the open fracture of the lower extremity. Bone union was achieved by 18 months after injury, and the patient has since returned to his original occupation (Figure
(a) Open fracture is located in the distal third of the lower extremity, accompanied by injury to the anterior tibial artery. (b) X-ray findings. The open fracture is accompanied by a bone defect. (c) The flow-through type anterolateral thigh flap harvested from the same side. (d) The anterior tibial artery is reconstructed by flow-through anastomosis with the lateral circumflex femoral artery. (e) Appearance at 18 months postoperatively. (f) X-ray findings at 18 months postoperatively, showing that union of the bone defect occurred after autologous bone grafting.
The selection of recipient vessels is crucial when reconstructing traumatized lower extremities with free flap. Since the anterior tibial artery is prone to injury in lower extremity trauma, the posterior tibial artery is often selected as the recipient vessel [
The anterior lower extremity is often injured in open fracture of the lower extremity, and recipient vessels pass through a deeper layer in parts more proximal to the zone of injury, making vascular anastomosis increasingly difficult. For this reason, Stompro and Stevenson [
Godina et al. [
For vascular anastomosis, to preserve the main arterial flow, we fundamentally perform end-to-side anastomosis or flow-through anastomosis. Various outcomes of end-to-side anastomosis have been reported [
To preserve main arterial flow in open fracture of the lower extremity, we perform end-to-side anastomosis if no obvious injuries to the main artery are present and flow-through anastomosis whenever possible if the fracture is accompanied by injuries to the main artery. Koshima et al. [
With an open fracture of the lower extremity, we utilize an anterolateral thigh flap with the pedicle descending branch of the lateral femoral circumflex artery for the moderate soft tissue defect and the latissimus dorsi musculocutaneous flap with the pedicle thoracodorsal artery and the serratus branch for the extensive soft tissue defect. These two techniques are long and include a large-caliber pedicle, and reconstruction can be performed with either the anterior or posterior tibial artery. Preparation of recipient vessels is easier during the acute phase when the influences of scarring have not yet manifested. Free flap, which allows flow-through anastomosis, is thus optimal for simultaneous reconstruction of the main vessel injury and soft tissue defect from the middle to distal thirds of the lower extremity.
When injury to the anterior or posterior tibial artery is suspected in open fracture of the lower extremity, we perform computed tomography angiography to evaluate the arterial injury. In open fracture of the lower extremity without arterial injury, we perform free flap transfer with end-to-side anastomosis to preserve the main vessels. When the arterial injury is present from the middle to distal thirds of the lower extremity in open fracture of the lower extremity, we perform free flap transfer with flow-through anastomosis as much as possible. Free flap transfer with flow-through anastomosis is a useful method that can simultaneously reconstruct soft tissue defects and the main artery.
The authors declare that there is no conflict of interests regarding the publication of this paper.