IP Journal of Surgery and Allied Sciences

Online ISSN: 2582-6387

IP Journal of Surgery and Allied Sciences (JSAS) open access, peer-reviewed quarterly journal publishing since 2019 and is published under the Khyati Education and Research Foundation (KERF), is registered as a non-profit society (under the society registration act, 1860), Government of India with the vision of various accredited vocational courses in healthcare, education, paramedical, yoga, publication, teaching and research activity, with the aim of faster and better dissemination of knowledge, we will be publishing the article ‘Ahead more...

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Get Permission Mudgal, Prasad, and Naik: Anterolateral thigh free flap surgery for medial malleoli fracture with extensive dorsal foot skin defect: A case report


Introduction

Lower extremity defects are associated with a lack of local soft tissue and blood supply. This presents difficult issues for surgeons. Reconstruction techniques for lower limb defects include skin grafting, direct closure, and local flaps such as the muscle flap, cross-leg flap, and free flap.1 One drawback of the local flap is that it restricts movement. In addition to causing patients discomfort as it limits their range of motion, the cross-leg flap has the drawback of necessitating a second procedure in order to isolate the pedicle.2

The free flap has the disadvantage of potentially increasing the amount of time needed for the treatment and requiring highly vascularized recipient locations and microsurgical methods. It is beneficial because the flap itself has good vascularity, it is simple to obtain identical tissue, the size of the defect sites essentially has no restrictions on its use, and it can produce satisfactory cosmetic results.3 According to Pollak et al, even in situations where the reconstruction could be adequately completed with a local flap, a better prognosis would be obtained in reconstruction surgery utilizing a free flap.4

Case Report

Here is a case of 48-year-old female who had alleged history of road traffic accident, sustained injury to right foot, presented with the wound over the dorsal aspect of foot (Figure 1). X-ray shows medial malleoli fracture with dislocation of fifth proximal interphalangeal joint (Figure 2, Figure 3). Ultrasound doppler study showed biphasic flow over dorsalis pedis artery, anterior tibial artery, posterior tibial artery.

Figure 1

Clinical picture at the time of presentation in emergency department

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Patient was posted for surgery for wound debridement (Figure 4) and K-wire application for medial malleoli fracture and dislocation of fifth metatarsophalangeal joint after reduction (Figure 5, Figure 6). Vacuum assisted Closure (VAC) was done intraoperatively after wound debridement.

Figure 2

Pre-op X-ray showing medial malleoli fracture

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Figure 3

Pre-op X-ray showing dislocation of fifth proximal metatarsophalangeal joint

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Figure 4

Clinical picture after wound debridement

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On postoperative day 3, patient was posted for anterolateral thigh free flap surgery for defect skin over dorsal aspect of foot (Figure 7, Figure 8).

Figure 5

Post-op X-ray showing K-wire application to medial malleoli fracture

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Figure 6

Post-op X-ray showing K-wire application to dislocation of fifth proximal metatarsophalangeal joint

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Figure 7

Anterolateral free flap donor site (i)

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Figure 8

Anterolateral free flap donor site (ii)

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Heparin sodium injection 5,000 units in sodium chloride 0.9% was used intra operatively to irrigate the vessels (Figure 9). Postoperatively foot was immobilized with below knee slab and measures were taken to keep body temperature at least 37.6°C (warming blanket, room temperature).         

Figure 9

Intraoperative clinical picture

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Figure 10

Post-op day 2 clinical picture

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After 6 months of follow-up, flap has taken very well, patient had a good functional outcome (Figure 11, Figure 12).

Discussion

The ALT flap usually yields adequate functional recovery and favourable surgical outcomes with high success rates.5 The flap's developed vascular architecture contributes to its endurance by facilitating effective integration and repair.

The success rate of anterolateral thigh flap transfer is higher than 95%, and the ALT flap has become a workhorse of reconstructive microsurgery with broad indications for reconstructing defects from head to foot. 6. The advantages of using the ALT flap include:

  1. Ease of harvest due to reliable anatomy.

  2. Long and large calibre vascular pedicle.7

  3. Versatility in flap modification like flap thinning or harvesting of chimeric flaps, depending on the donor site requirement.

  4. Little donor site morbidity.

While complications like infection or partial flap loss are possible, they may be controlled with proper surgical technique and postoperative care.8 The other complication includes venous and arterial insufficiency, thrombosis, venous congestion, twisting of pedicle, compression of pedicle, tension at flap edges leading to marginal skin necrosis.

Figure 11

6-month follow-up clinical picture (side view)

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Figure 12

6-month follow-up clinical picture (front view)

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Conclusion

We discovered that an appropriate treatment option for treating soft tissue abnormalities and forefoot skin damage is the Anterolateral thigh flap.9 This flap can be utilized to fill traumatic lesions that are small to medium in size and expose bone or tendons. In carefully chosen patients, there was little surgical morbidity at the donor and recipient sites. Long-term benefits in terms of appearance and functionality are also provided by this modified technique.10 Yet, there is a chance that this flap will result in a vascular crisis, particularly in individuals requiring emergency surgery.

Conflict of Interest

None.

References

1 

MC Ferreira JM Besteiro A A Monteiro Jr A Zumiotti Reconstruction of the foot with microvascular free flapsMicrosurgery1994151336

2 

YG Song GZ Chen YL Song The free thigh flap: A new free flap concept based on the septocutaneous arteryBr J Plast Surg198437214959

3 

JP Hong Reconstruction of the diabetic foot using the anterolateral thigh perforator flapPlast Reconstr Surg200611751599608

4 

YR Kuo J Seng-Feng FM Kuo YT Liu PW Lai Versatility of the free anterolateral thigh flap for reconstruction of soft-tissue defects: review of 140 casesAnn Plast Surg20024821616

5 

FC Wei V Jain N Celik HC Chen DC Chuang CH Lin Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flapsPlast Reconstr Surg20021097221926

6 

JG Löfstrand CH Lin Reconstruction of defects in the weight-bearing plantar area using the innervated free medial plantar (instep) flapAnn Plast Surg201880324551

7 

O Scheufler D Kalbermatten G Pierer Instep free flap for plantar soft tissue reconstruction: indications and optionsMicrosurg200727317480

8 

JP Hong EK Kim Sole reconstruction using anterolateral thigh perforator free flapsPlast Reconstr Surg2007119118693

9 

M Pappalardo SF Jeng PL Sadigh HS Shih Versatility of the free anterolateral thigh flap in the reconstruction of large defects of the weight-bearing foot: a single-center experience with 20 consecutive casesJ Reconstr Microsurg20163256270

10 

J Liebau A Berger N Pallua HJ Dordel Reconstruction of plantar defectsEur J Plast Surg1997203005



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Article type

Case Report


Article page

90-93


Authors Details

Chandrashekar V Mudgal, Krishna Prasad, Rajesh B Naik


Article History

Received : 27-07-2024

Accepted : 24-08-2024


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