Original Article
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Reconstruction of Foot and Ankle Defects with a Free Anterolateral Thigh Flap in Pediatric Patients Mehmet Ali Acar, MD1 Ali Güleç, MD1 Bahattin Kerem Aydin, MD1 Güney Yilmaz, MD1 Hakan Şenaran, MD1
Selcuk University, Konya, Turkey J Reconstr Microsurg 2015;31:225–232.
Abstract
Keywords
► foot and ankle ► free anterolateral thigh flap ► pediatric reconstruction ► trauma
received July 21, 2014 accepted after revision October 8, 2014 published online January 28, 2015
Address for correspondence Mehmet Ali Acar, MD, Department of Orthopaedics and Traumatology, Medical School of Selcuk University, Konya, Turkey (e-mail: [email protected]; [email protected]).
Background There are a limited number of published studies describing reconstruction with an anterolateral thigh (ALT) flap following lower extremity injury in pediatric patients. The aim of this study was to present our experiences with the application of a free ALT flap not only in the reconstruction of soft tissue defects around the pediatric foot and ankle but also in patients with bone, tendon, and ligament injuries that require repair. Materials and Methods Reconstruction with a free ALT flap was performed in 11 pediatric patients (mean age, 8.9 years; range, 3–15 years) between November 2010 and February 2013. The modes of injury were as follows: six traffic accidents, three firearm accidents, one agricultural machinery accident, and one bicycle chain accident. A retrospective evaluation of the applied surgical procedures was performed: flap size, perforator type and number, placement area, site of anastomosis, closure of the donor site, complications, and flap survival. Results The mean size of the skin flap was 83.2 mm2 (range, 48–117 mm2). Except for two patients, there were two perforators in the obtained flaps, which were 75% musculocutaneous and 25% septocutaneous. To strengthen the Achilles tendon in one patient, the ALT, together with the fascia lata, was raised as a composite flap. This flap was used as a “sensate flap” in three patients with defects in the heel area and as a “perforator flap” in seven patients. Anastomosis was performed in the anterior tibial artery in five patients and in the posterior tibial artery in six patients. Primary closure was performed for the donor site in all patients. Due to venous thrombus after 24 hours in one patient, reexploration was performed, and blood flow was regained with a vein graft. In the same patient, partial necrosis developed on the lateral edge of the flap; after debridement of the necrotic areas, closure was performed with a split thickness skin graft. After the ALT flap procedure, the primary flap survival rate was 90.9%. Conclusion The free ALT flap could be a safe, reliable, and aesthetically appealing option for foot/ankle resurfacing in children after traumatic soft tissue loss. The ALT flap can cover a far greater area and provide the versatility needed to optimize soft-tissue coverage. Clinical Question/Level of Evidence Level IV.
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1395888. ISSN 0743-684X.
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1 Department of Orthopedics and Traumatology, Medical School of
Ömer Faruk Erkoçak, MD1
Free Anterolateral Thigh Flap for Pediatric Foot and Ankle Defects The treatment of defects caused by trauma in pediatric patients remains a significant problem for surgeons. Free tissue transfer can be safely used in these patients, as in adults.1–3 However, there are some important points to consider when planning free tissue transfer in posttraumatic pediatric patients, and these points differ from those in adults. Flap dissection is more difficult in pediatric patients; the diameters of perforators and pedicles are smaller than those in adults, and there is the possibility of growth problems with the development of limb length discrepancy or deformity caused by open epiphysis.4 It is also more difficult to obtain cooperation in pediatric patients than in adults. In the postoperative follow-up period, full compliance from the patient’s family is essential. If these points are considered when planning free flap procedures in pediatric patients, flap survival rates will improve. The use of anterolateral thigh (ALT) flap, which was first described in 1984 by Song et al,5 has increased in popularity because, in addition to providing soft tissue coverage as a “sensate flap,” the ALT flap can be safely used as “musculocutaneous” for deep defects and as “flow through” for injuries accompanied by vascular defects, as well as in cases requiring composite tissue.6 Because of these advantages, free ALT flap usage, as a flap choice, has increased dramatically in the complex defects of the lower extremity reconstruction with free tissue transfer.7 In the literature, there are a limited number of studies that describe free ALT flap in lower extremity traumatic injuries in pediatric patients.2,8–12 This study aimed to investigate the use of free ALT flap in soft tissue defects around the foot or ankle that are accompanied by injuries of the ligament, tendon, joint, bone, or nerve loss in the pediatric patient group.
A retrospective evaluation of pediatric trauma patients was performed between November 2010 and February 2013; these patients underwent reconstruction with a free ALT perforator flap for fractures, defects, or joint dislocations with accompanying tissue loss injuries at the level of the foot or ankle in the lower extremity. Patient data were obtained from the patients’ hospital records. The patient demographic data (i.e., age, gender, side, and follow-up period), trauma mechanism, presence of additional injuries, time since trauma, surgical procedures performed, perforator type and number, size of the obtained flap, placement area, anastomosis site, closure of the donor site, complications, and flap survival were evaluated. Eleven patients (9 males, 2 females) aged between 3 and 15 (mean: 8.9) were enrolled in the study. The mean follow-up period was ranging from 13 to 29 months (mean: 20.7 5.83). The modes of injury were as follows: six traffic accidents, three firearm accidents, one agricultural machinery accident, and one bicycle chain accident. In all patients, there was at least one accompanying injury of the tendon, ligament, vein, and nerve damage, and/or bone fracture, in addition to an open injury requiring repair or reconstruction. Flap surgery was performed in a single Vol. 31
session in one patient, and flap surgery was performed after debridement in the remaining patients. Statistical analysis was performed with SPSS for Windows software (version 21.00, Chicago, IL). Values were given as the mean standard deviation.
Surgical Technique The use of ALT flap has been described in detail in the literature. In the current study, Doppler analysis was used to determine the perforator sites. First, an incision was made from the medial side to define the perforator sites. During dissection, 3.5 loop magnification was used, and the dissection was completed with a cuff of muscle around the perforator. In artery anastomosis, “end-toside” anastomosis was used in three patients. In the eight patients, the “end-to-end” technique was applied. In four patients, venous coupler was used for venous anastomosis. Heparin (30 U/kg) was given to patients 10 minutes before cross-clamping of the blood supply to the flap. No postoperative anticoagulation was used routinely.
Case 1 A 6-year-old girl presented with a necrotic, infected wound on the right Achilles tendon, which had developed as a result of her heel being trapped in a bicycle chain. During soft tissue debridement, a two-thirds section of the Achilles tendon in the coronal plane was debrided because of infection. A composite ALT flap with the fascia lata was planned for the same session. The defect on the Achilles tendon was closed with a composite (8 8 cm) fascia lata ALT flap. At 6 months postoperatively, flap debulking surgery was performed (►Fig. 1).
Case 2
Materials and Methods
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A 9-year-old male patient was referred to our clinic with defective injuries on the medial side of the left ankle following a firearm injury. On radiographs, a defective injury was observed in the medial malleolus epiphysis, as well as an accompanying deltoid ligament injury. For bone and deltoid ligament reconstruction after two sessions of debridement, medial malleolus reconstruction was performed with iliac crest apophysis. A 14 9 cm ALT flap was applied to cover the area (►Fig. 2).
Case 3 A 9-year-old boy presented with a firearm injury at the level of the left ankle. At initial examination, subtotal amputation from ankle level appeared to be necessary. The patient was admitted for emergency surgery, and anterior tibial artery repair was performed with a vein graft. The fracture ends were debrided, acute shortening was applied, and fixation was performed with a monolateral external fixator. During the follow-up period, necrotic areas developed on the skin; after observing an infection, the infected tissues were removed, and the subsequent defect was filled by reconstruction with a 12 6 cm free ALT flap. In the same session, a segment shift of bone from the proximal was performed for the bone defect (►Fig. 3).
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Acar et al.
Fig. 1 (A) Preoperative view, (B) skin and Achilles tendon defect after the debridement, (C) Achilles tendon reconstruction with composite flap using suture anchors, (D) postoperative clinic view.
Fig. 2 (A) Skin, deltoid ligament and bone defect over the left medial malleolus, (B) preoperative X-ray, (C) late postoperative clinic view, (D) reconstruction of medial malleolus bone and deltoid ligament defect with composite chondro-osteo-ligamentous autograft from the iliac crest composite chondro-osteo-ligamentous autograft using anchor and screws seen last fallow-up X-ray.
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Free Anterolateral Thigh Flap for Pediatric Foot and Ankle Defects
Free Anterolateral Thigh Flap for Pediatric Foot and Ankle Defects
Fig. 3 (A) Gunshot injuries of left ankle with soft tissue, artery, tendon, and bone defects, debridement and acute shortening of the bone with unilateral external fixator, (B) preoperative X-rays, (C) postoperative clinic view, (D) tibial lengthening X-ray.
Results Perforator development was complete in all patients. With the exception of two patients, there were two perforators in the obtained flaps, which were 75% musculocutaneous and 25% septocutaneous. As in adult patients, the perforators could be easily found lateral to the intermuscular septum. All dissections were performed with 3.5 loop magnification, and a microscope for perforator dissection during the dissection was not needed. Data concerning the time to the raising of the flap were available for eight patients. The mean time was 132 minutes ( 18 minutes). To protect the perforators while raising the flap, it was raised in all patients, leaving a wide muscular cuff, and early flap thinning was not used for any patient. The mean size of the flaps was 83.2 mm2 (range, 48–117 mm2). The arteries and anastomosis techniques were anterior tibial artery (end-to-end) in five patients, posterior tibial artery (end-to-side) in three patients, and posterior tibial artery (end-to-end) in three patients. Vein anastomosis was performed to the concomitant vein in all patients. During vein anastomosis, a venous coupler was used in four patients (1 size 2, 3 size 2.5). Primary closure was performed in the flap donor site in all patients. A hypertrophic scar developed as a complication in the donor site in two patients (►Table 1). To strengthen the Achilles tendon in one patient, the ALT and fascia lata were raised together as a composite flap. The flap was used as a “sensate” flap in three patients for defects in the heel area and as a “perforator” flap in seven patients. Journal of Reconstructive Microsurgery
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Full flap survival was observed in all patients. Due to venous thrombus after 24 hours in one patient, reexploration was performed, and blood flow was regained with a vein graft. In the same patient, because partial necrosis developed on the lateral edge of the flap after debridement of the necrotic areas, closure was performed with a split thickness skin graft. After ALT flap, the primary flap survival rate was 90.9%. Case no. 9, from the three patients who had undergone reconstruction of plantar region of foot, had suffered from heel ulcer in the follow-up period which resolved with insoles. In case no. 1, chafing had occurred owing to reparative friction which resolved by restriction of sport in the period of complaints. No complications occurred in case no. 3 in the long term. In terms of range of motion (ROM), the following restrictions of dorsiflexion were observed: 30 degrees in case no. 5, 20 degrees in case no. 6, and 30 degrees in case no. 8. However, no ROM restriction was observed in the remaining cases. Because of the insufficient cooperation resulting from small age, the evaluation of major peripheral nerve reconstruction (case no. 10) could not have been performed properly. A flap thinning procedure was performed in four patients at mean of 8.7 months (range, 8–10 months) after flap surgery. As sequelae, distal epiphyseal arrest developed in one patient. In one patient, despite lengthening, a 3-cm leg length discrepancy developed and that patient is still undergoing follow-up with height compensation.
Discussion Because perforator flaps are versatile and the donor site morbidity is low, they have gained a great degree of popularity. Because of the properties of several structures in pediatric patients, the development of perforators has not been completed. This difficulty is the greatest for free perforator flaps that are applied in children.11 In addition, because the vein diameters of pediatric patients are smaller than those of adults, technical difficulties can occur during anastomosis. Because of these disadvantages, microsurgery procedures in pediatric patients have developed more slowly than in adults.2 However, the successful use of free tissue transfer has been applied in pediatric patients, and these results have been published. Success rates similar to those in adult patients have been observed for these microsurgery procedures, and they can be used safely and effectively in pediatric patients.1,3,6 Reconstruction of lower extremity defects in pediatric patients is difficult because the skin around the foot and ankle is thin, and there are several structures in this small area. To successfully treat complex tissue defects in this area, it is necessary to debride dead tissues as soon as possible, as well as effectively repair or reconstruct ligaments, tendons, bones, joints, nerves, and vascular structures, after which early tissue coverage can be achieved.13 The popularity of free perforator flaps used either as free-style approach or as pedicled in all zones of lower extremity injuries has increased
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228
6 y/F
4
15 y/M
6 y/M
3
6
10 y/F
2
9 y/M
11 y/M
1
5
Age/ Gender
Case number
MVA
Gunshot Injuries
Bicycle chain injuries
Agricultural Injuries
Gunshot Injuries
MVA
Mechanism of injury
Medial part of the right calcaneus þ tarsal bones Tibia fractures þ Lisfranc joint fracture dislocation, medial cuneiform bone defect
Journal of Reconstructive Microsurgery Delayed
Tibial intramedullary nail fixation þ Lisfranc joint reduction and K-wire fixation
Harvest of the composite chondro-osteo-ligamentous autograft from the iliac crest with modify Langenskiold procedure
Debridement of infected and necrotic soft tissue over the Achilles tendon Reconstruction with composite flap using suture anchors Tibialis anterior
Tibialis posterior (ES) VC
12 8 cm
Tibialis posterior (ES)
88 cm
13 9 cm
Tibialis posterior
Tibialis anterior VC
11 8 cm
K-wire fixation of metatarsal EHL reconstruction with tendon transfer
11 6 cm
Tibialis posterior (ES) VC
15 7 cm
Iliac crest bone graft fix with Acutrak screw Lindholm Technique Achilles tendon reconstruction with suture anchoring STSG
Joint reduction Deltoid ligament repair Stump closure of the 2, 3, 4, 5 toes STCG
Recipient vessels
Flap size
Operation
Primer
Primer
Primer
Primer
Primer
Primer
Donor site closure
2 mc
2 mc
1 mc,1 sc
1 mc,1 sc
1 mc
1 mc,1 sc
Type and no perforator
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Over the left medial malleolus Defect of tibial medial malleolus with type 6 physeal fracture Ankle instability þ deltoid ligament defect Skin-facia
Immediate
Skin-facia and fascia lata (composite)
Delayed
Delayed
Skin-facia (sensate)
Dorsal þ plantar of right foot and posterior part of the lag, Talonavicular joint dislocation þ deltoid ligament rupture þ 2, 3, 4, 5 toes amputation Full thickness skin loos þ expose the calcaneus bone and Achilles tendon
Skin-facia
Delayed
Skin-facia
Dorsum of the right foot First þ second metatarsal fractures First MP joint dorsal part defect EHL and 2–3-4 extensor tendon defect
Over the right Achilles tendon Infected necrotic tissue over the Achilles tendon Soft tissue and Achilles tendon defect
Delayed
Skin-facia (sensate)
Hell þ plantar of right foot Calcaneus bone defect Achilles tendon defect
Timing of reconstruction
Flap type
Localization Additional injuries
Table 1 Patients demographics and reconstruction outcomes
None
None
Donor site hypertrophic scar (FD)
None
None (FD)
None
Complication
None
None
None
First toe valgus contracture
None
Chafing on the plantar surface
Sequela
(Continued)
26
16
19
22
17
28
Follow-up (Months)
Free Anterolateral Thigh Flap for Pediatric Foot and Ankle Defects Acar et al.
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13 y/M
11
MVA
MVA
MVA
Gunshot Injuries
MVA
Mechanism of injury
Lateral aspect of left ankle Lateral collateral ligament rupture
Medial aspect of right foot – tibial nerve injury þ right knee septic arthritis þ bilateral crush injury of leg
Dorsal þ plantar surface of right foot and posterior First metatarsal fracture þ full thickness skin loos þ expose the calcaneus bone dorsal and plantar part of foot
Anteromedial aspect of right ankle Ankle subtotal amputation
Medial aspect of right foot and ankle Bimalleolar type 2 physeal fractures ankle instability Deltoid ligament defect
Localization Additional injuries
Skin-facia
Skin-facia
Skin-facia (sensate)
Delayed
Delayed
Delayed
Delayed
Delayed
Skin-facia
Skin-facia
Timing of reconstruction
Flap type
Lateral collateral ligament reconstruction with tendon graft
Nerve repair with sural nerve graft septic arthritis debridement STSG
K-wire fixation for metatarsal fractures STSG Tibialis posterior
Tibialis posterior
Tibialis anterior VC
14 8 cm
86 cm
12 7 cm
Tibialis anterior
12 6 cm
Acute shortening with unilateral external fixator, anterior tibial artery repair with vein graft, proximal tibial lengthening, osteotomy with Ilizarov external fixator
Tibialis anterior
9 7 cm
Lateral malleolus fixation with K-wire and Deltoid ligament reconstruction with tendon graft
Recipient vessels
Flap size
Operation
Primer
Primer
Primer
Primer
Primer
Donor site closure
1 mc,1 sc
1 sc
2 mc
2 mc
2 mc
Type and no perforator
Venous thrombosis (salvage with vein graft) lateral part partial necrosis treated with skin graft (FD)
Donor site hypertrophic scar
None
None
None
Complication
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None
None
Ulceration on the plantar surface
Limb length discrepancy and distal epiphyseal growth arrest
None
Sequela
13
19
26
13
29
Follow-up (Months)
Free Anterolateral Thigh Flap for Pediatric Foot and Ankle Defects
Abbreviations: ES, end to side; FD, flap debulking; mc, musculocutaneous; MVA, motor vehicle accident; sc, septocutaneous; STSG, split thickness skin graft; VC, venous coupler.
3 y/M
10
9 y/F
8
9 y/M
7 y/M
7
9
Age/ Gender
Case number
Table 1 (Continued)
230 Acar et al.
Free Anterolateral Thigh Flap for Pediatric Foot and Ankle Defects
Acar et al.
231
Authors
Patient series
Mean age
Defect localization
Etiology
Other
Segev et al
1
12
Lower limb
Trauma
100% survival
Upton and Guo
3
Lower limb
100% survival
Yildirim et al
1
7
Lower limb
100% survival
Demirtas et al
5
4.8
Foot
Trauma
1 partial flap necrosis
Gharb et al
4
10.25
Lower limb
Trauma
2 partial flap necrosis and 1 flap was loss
El-Gammal et al
42
6.18
Dorsum of the foot and ankle
Trauma
92.86% primer flap survival
Current study
11
8.9
Foot and ankle
Trauma
1 partial flap necrosis 90.9% primer flap survival
not only because of the safety and efficacy but also because of minimal donor site complication and functional impairment.13–15 In the literature, traffic accidents and crush injuries16–18 play the greatest roles in the etiology of tissue loss requiring reconstruction with free tissue transfer. In the current study, traffic accidents were observed at a rate of 54.5%, firearm injuries at 27.3%, bicycle chain injuries at 9.1%, and agricultural machinery injuries at 9.1%. Although traffic accidents are the main agent, close-range firearm injuries have also been observed in the etiology in our country. Few published studies have described the use of free ALT flaps in pediatric lower extremity reconstruction. Previous studies that have noted the peculiarities of the ALT flap in the pediatric population have been based on experiences with adult patients.2,8–11 In the current series, the results were investigated for soft tissue injuries, which accompanied vein, nerve, tendon, ligament, and bone defects and required primary repair in addition to metatarsal bone and ankle fractures and tendon injuries in the foot and ankle region. Defects that could be covered with local or pedicle skin grafts were not included in the study. To the best of our knowledge, this study has the second highest number of pediatric patients who underwent ALT flap surgery to repair lower extremity injuries (►Table 2). In the literature, reexploration after lower extremity free flap surgery in pediatric patients has been reported at rates ranging from 4 to 29%.1,19,20 In the current study, the reexploration rate was 9.1% (1/11 patients). After surgery, four patients required flap thinning. The high rate of flap thinning could be attributed to leaving more of a surrounding muscular cuff when taking the flap and failing to use primary thinning. Demirtas et al10 reported that initial thinning could be successfully applied when raising small flaps. Because using skin grafts to close the donor site in pediatric patients increases the risk of ugly and hypertrophic scars, primary skin closure is recommended wherever possible. Primary closure of the donor site was performed in all patients in the current study. In two (18.2%) patients, a hypertrophic scar developed, and it was effectively treated with massage. Economides et al21 have mentioned only flap survival rates and complications in the functional outcome assessment, and the aforementioned literature has not focused on assessing
patient-centered outcomes of these reconstructive procedures. They have emphasized that scoring systems such as Short Form Health Surveys (SF-8, SF-12, and SF-36), European Quality of Life-5 Dimension (EQ-5D), and visual analog scale will have a great contribution on functional evaluation after lower extremity reconstructive procedures. Lack of objective functional assessment criteria in the current study is the weakness of our study. This study has some limitations, including the relatively small number of patients, inhomogeneous traumatic injuries, lack of long-term follow-up (particularly for patients with accompanying epiphyseal injuries), and lack of gait analysis of the patients with covered heel defects. In conclusion, as in adult patients, a free ALT flap can be a safe choice for pediatric patients with minimal donor site morbidity to treat defects following trauma around the foot and ankles; it can also act as a perforator flap for covering soft tissue, a composite flap in tendon defects and a sensate flap in heel and sole defects.
Financial Disclosure None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.
References 1 Yücel A, Aydin Y, Yazar S, Altintaş F, Senyuva C. Elective free-tissue
2
3
4 5
6
transfer in pediatric patients. J Reconstr Microsurg 2001;17(1): 27–36 Yildirim S, Calikapan GT, Akoz T. Reconstructive microsurgery in pediatric population-a series of 25 patients. Microsurgery 2008; 28(2):99–107 Duteille F, Lim A, Dautel G. Free flap coverage of upper and lower limb tissue defects in children: a series of 22 patients. Ann Plast Surg 2003;50(4):344–349 Parry SW, Toth BA, Elliott LF. Microvascular free-tissue transfer in children. Plast Reconstr Surg 1988;81(6):838–840 Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984; 37(2):149–159 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109(7):2219–2226, discussion 2227–2230
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Table 2 Previously reported cases of ALT flap in pediatric lower limb reconstruction in literature patient series
Free Anterolateral Thigh Flap for Pediatric Foot and Ankle Defects
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7 Fischer JP, Wink JD, Nelson JA, et al. A retrospective review of
14 Nosrati N, Chao AH, Chang DW, Yu P. Lower extremity reconstruc-
outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013;29(6): 407–416 Segev E, Wientroub S, Kollender Y, Meller I, Amir A, Gur E. A combined use of a free vascularised flap and an external fixator for reconstruction of lower extremity defects in children. J Orthop Surg (Hong Kong) 2007;15(2):207–210 Upton J, Guo L. Pediatric free tissue transfer: a 29-year experience with 433 transfers. Plast Reconstr Surg 2008;121(5): 1725–1737 Demirtas Y, Neimetzade T, Kelahmetoglu O, Guneren E. Free anterolateral thigh flap for reconstruction of car tire injuries of children’s feet. Foot Ankle Int 2010;31(1):47–52 Gharb BB, Salgado CJ, Moran SL, et al. Free anterolateral thigh flap in pediatric patients. Ann Plast Surg 2011;66(2): 143–147 El-Gammal TA, El-Sayed A, Kotb MM, et al. Dorsal foot resurfacing using free anterolateral thigh (ALT) flap in children. Microsurgery 2013;33(4):259–264 Song JW, Ben-Nakhi M, Hong JP. Reconstruction of lower extremity with perforator free flaps by free style approach in pediatric patients. J Reconstr Microsurg 2012;28(9):589–594
tion with the anterolateral thigh flap. J Reconstr Microsurg 2012; 28(4):227–234 Hallock GG. A paradigm shift in flap selection protocols for zones of the lower extremity using perforator flaps. J Reconstr Microsurg 2013;29(4):233–240 Organek AJ, Klebuc MJ, Zuker RM. Indications and outcomes of free tissue transfer to the lower extremity in children: review. [Review] J Reconstr Microsurg 2006;22(3):173–181 Rinker B, Valerio IL, Stewart DH, Pu LL, Vasconez HC. Microvascular free flap reconstruction in pediatric lower extremity trauma: a 10year review. Plast Reconstr Surg 2005;115(6):1618–1624 Erdmann D, Lee B, Roberts CD, Levin LS. Management of lawnmower injuries to the lower extremity in children and adolescents. Ann Plast Surg 2000;45(6):595–600 Shenaq SM, Dinh TA. Pediatric microsurgery. Reconstruction by free tissue transfer. Clin Plast Surg 1990;17(1):85–94 Clarke HM, Upton J, Zuker RM, Manktelow RT. Pediatric free tissue transfer: an evaluation of 99 cases. Can J Surg 1993;36(6):525–528 Economides JM, Patel KM, Evans KK, Marshall E, Attinger CE. Systematic review of patient-centered outcomes following lower extremity flap reconstruction in comorbid patients. J Reconstr Microsurg 2013;29(5):307–316
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9
10
11
12
13
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18
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Reconstruction of Foot and Ankle Defects with a Free Anterolateral Thigh Flap in Pediatric Patients Mehmet Ali Acar, MD1 Ali Güleç, MD1 Bahattin Kerem Aydin, MD1 Güney Yilmaz, MD1 Hakan Şenaran, MD1
Selcuk University, Konya, Turkey J Reconstr Microsurg 2015;31:225–232.
Abstract
Keywords
► foot and ankle ► free anterolateral thigh flap ► pediatric reconstruction ► trauma
received July 21, 2014 accepted after revision October 8, 2014 published online January 28, 2015
Address for correspondence Mehmet Ali Acar, MD, Department of Orthopaedics and Traumatology, Medical School of Selcuk University, Konya, Turkey (e-mail: [email protected]; [email protected]).
Background There are a limited number of published studies describing reconstruction with an anterolateral thigh (ALT) flap following lower extremity injury in pediatric patients. The aim of this study was to present our experiences with the application of a free ALT flap not only in the reconstruction of soft tissue defects around the pediatric foot and ankle but also in patients with bone, tendon, and ligament injuries that require repair. Materials and Methods Reconstruction with a free ALT flap was performed in 11 pediatric patients (mean age, 8.9 years; range, 3–15 years) between November 2010 and February 2013. The modes of injury were as follows: six traffic accidents, three firearm accidents, one agricultural machinery accident, and one bicycle chain accident. A retrospective evaluation of the applied surgical procedures was performed: flap size, perforator type and number, placement area, site of anastomosis, closure of the donor site, complications, and flap survival. Results The mean size of the skin flap was 83.2 mm2 (range, 48–117 mm2). Except for two patients, there were two perforators in the obtained flaps, which were 75% musculocutaneous and 25% septocutaneous. To strengthen the Achilles tendon in one patient, the ALT, together with the fascia lata, was raised as a composite flap. This flap was used as a “sensate flap” in three patients with defects in the heel area and as a “perforator flap” in seven patients. Anastomosis was performed in the anterior tibial artery in five patients and in the posterior tibial artery in six patients. Primary closure was performed for the donor site in all patients. Due to venous thrombus after 24 hours in one patient, reexploration was performed, and blood flow was regained with a vein graft. In the same patient, partial necrosis developed on the lateral edge of the flap; after debridement of the necrotic areas, closure was performed with a split thickness skin graft. After the ALT flap procedure, the primary flap survival rate was 90.9%. Conclusion The free ALT flap could be a safe, reliable, and aesthetically appealing option for foot/ankle resurfacing in children after traumatic soft tissue loss. The ALT flap can cover a far greater area and provide the versatility needed to optimize soft-tissue coverage. Clinical Question/Level of Evidence Level IV.
Copyright © 2015 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA. Tel: +1(212) 584-4662.
DOI http://dx.doi.org/ 10.1055/s-0034-1395888. ISSN 0743-684X.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
1 Department of Orthopedics and Traumatology, Medical School of
Ömer Faruk Erkoçak, MD1
Free Anterolateral Thigh Flap for Pediatric Foot and Ankle Defects The treatment of defects caused by trauma in pediatric patients remains a significant problem for surgeons. Free tissue transfer can be safely used in these patients, as in adults.1–3 However, there are some important points to consider when planning free tissue transfer in posttraumatic pediatric patients, and these points differ from those in adults. Flap dissection is more difficult in pediatric patients; the diameters of perforators and pedicles are smaller than those in adults, and there is the possibility of growth problems with the development of limb length discrepancy or deformity caused by open epiphysis.4 It is also more difficult to obtain cooperation in pediatric patients than in adults. In the postoperative follow-up period, full compliance from the patient’s family is essential. If these points are considered when planning free flap procedures in pediatric patients, flap survival rates will improve. The use of anterolateral thigh (ALT) flap, which was first described in 1984 by Song et al,5 has increased in popularity because, in addition to providing soft tissue coverage as a “sensate flap,” the ALT flap can be safely used as “musculocutaneous” for deep defects and as “flow through” for injuries accompanied by vascular defects, as well as in cases requiring composite tissue.6 Because of these advantages, free ALT flap usage, as a flap choice, has increased dramatically in the complex defects of the lower extremity reconstruction with free tissue transfer.7 In the literature, there are a limited number of studies that describe free ALT flap in lower extremity traumatic injuries in pediatric patients.2,8–12 This study aimed to investigate the use of free ALT flap in soft tissue defects around the foot or ankle that are accompanied by injuries of the ligament, tendon, joint, bone, or nerve loss in the pediatric patient group.
A retrospective evaluation of pediatric trauma patients was performed between November 2010 and February 2013; these patients underwent reconstruction with a free ALT perforator flap for fractures, defects, or joint dislocations with accompanying tissue loss injuries at the level of the foot or ankle in the lower extremity. Patient data were obtained from the patients’ hospital records. The patient demographic data (i.e., age, gender, side, and follow-up period), trauma mechanism, presence of additional injuries, time since trauma, surgical procedures performed, perforator type and number, size of the obtained flap, placement area, anastomosis site, closure of the donor site, complications, and flap survival were evaluated. Eleven patients (9 males, 2 females) aged between 3 and 15 (mean: 8.9) were enrolled in the study. The mean follow-up period was ranging from 13 to 29 months (mean: 20.7 5.83). The modes of injury were as follows: six traffic accidents, three firearm accidents, one agricultural machinery accident, and one bicycle chain accident. In all patients, there was at least one accompanying injury of the tendon, ligament, vein, and nerve damage, and/or bone fracture, in addition to an open injury requiring repair or reconstruction. Flap surgery was performed in a single Vol. 31
session in one patient, and flap surgery was performed after debridement in the remaining patients. Statistical analysis was performed with SPSS for Windows software (version 21.00, Chicago, IL). Values were given as the mean standard deviation.
Surgical Technique The use of ALT flap has been described in detail in the literature. In the current study, Doppler analysis was used to determine the perforator sites. First, an incision was made from the medial side to define the perforator sites. During dissection, 3.5 loop magnification was used, and the dissection was completed with a cuff of muscle around the perforator. In artery anastomosis, “end-toside” anastomosis was used in three patients. In the eight patients, the “end-to-end” technique was applied. In four patients, venous coupler was used for venous anastomosis. Heparin (30 U/kg) was given to patients 10 minutes before cross-clamping of the blood supply to the flap. No postoperative anticoagulation was used routinely.
Case 1 A 6-year-old girl presented with a necrotic, infected wound on the right Achilles tendon, which had developed as a result of her heel being trapped in a bicycle chain. During soft tissue debridement, a two-thirds section of the Achilles tendon in the coronal plane was debrided because of infection. A composite ALT flap with the fascia lata was planned for the same session. The defect on the Achilles tendon was closed with a composite (8 8 cm) fascia lata ALT flap. At 6 months postoperatively, flap debulking surgery was performed (►Fig. 1).
Case 2
Materials and Methods
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A 9-year-old male patient was referred to our clinic with defective injuries on the medial side of the left ankle following a firearm injury. On radiographs, a defective injury was observed in the medial malleolus epiphysis, as well as an accompanying deltoid ligament injury. For bone and deltoid ligament reconstruction after two sessions of debridement, medial malleolus reconstruction was performed with iliac crest apophysis. A 14 9 cm ALT flap was applied to cover the area (►Fig. 2).
Case 3 A 9-year-old boy presented with a firearm injury at the level of the left ankle. At initial examination, subtotal amputation from ankle level appeared to be necessary. The patient was admitted for emergency surgery, and anterior tibial artery repair was performed with a vein graft. The fracture ends were debrided, acute shortening was applied, and fixation was performed with a monolateral external fixator. During the follow-up period, necrotic areas developed on the skin; after observing an infection, the infected tissues were removed, and the subsequent defect was filled by reconstruction with a 12 6 cm free ALT flap. In the same session, a segment shift of bone from the proximal was performed for the bone defect (►Fig. 3).
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Fig. 1 (A) Preoperative view, (B) skin and Achilles tendon defect after the debridement, (C) Achilles tendon reconstruction with composite flap using suture anchors, (D) postoperative clinic view.
Fig. 2 (A) Skin, deltoid ligament and bone defect over the left medial malleolus, (B) preoperative X-ray, (C) late postoperative clinic view, (D) reconstruction of medial malleolus bone and deltoid ligament defect with composite chondro-osteo-ligamentous autograft from the iliac crest composite chondro-osteo-ligamentous autograft using anchor and screws seen last fallow-up X-ray.
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Free Anterolateral Thigh Flap for Pediatric Foot and Ankle Defects
Free Anterolateral Thigh Flap for Pediatric Foot and Ankle Defects
Fig. 3 (A) Gunshot injuries of left ankle with soft tissue, artery, tendon, and bone defects, debridement and acute shortening of the bone with unilateral external fixator, (B) preoperative X-rays, (C) postoperative clinic view, (D) tibial lengthening X-ray.
Results Perforator development was complete in all patients. With the exception of two patients, there were two perforators in the obtained flaps, which were 75% musculocutaneous and 25% septocutaneous. As in adult patients, the perforators could be easily found lateral to the intermuscular septum. All dissections were performed with 3.5 loop magnification, and a microscope for perforator dissection during the dissection was not needed. Data concerning the time to the raising of the flap were available for eight patients. The mean time was 132 minutes ( 18 minutes). To protect the perforators while raising the flap, it was raised in all patients, leaving a wide muscular cuff, and early flap thinning was not used for any patient. The mean size of the flaps was 83.2 mm2 (range, 48–117 mm2). The arteries and anastomosis techniques were anterior tibial artery (end-to-end) in five patients, posterior tibial artery (end-to-side) in three patients, and posterior tibial artery (end-to-end) in three patients. Vein anastomosis was performed to the concomitant vein in all patients. During vein anastomosis, a venous coupler was used in four patients (1 size 2, 3 size 2.5). Primary closure was performed in the flap donor site in all patients. A hypertrophic scar developed as a complication in the donor site in two patients (►Table 1). To strengthen the Achilles tendon in one patient, the ALT and fascia lata were raised together as a composite flap. The flap was used as a “sensate” flap in three patients for defects in the heel area and as a “perforator” flap in seven patients. Journal of Reconstructive Microsurgery
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Full flap survival was observed in all patients. Due to venous thrombus after 24 hours in one patient, reexploration was performed, and blood flow was regained with a vein graft. In the same patient, because partial necrosis developed on the lateral edge of the flap after debridement of the necrotic areas, closure was performed with a split thickness skin graft. After ALT flap, the primary flap survival rate was 90.9%. Case no. 9, from the three patients who had undergone reconstruction of plantar region of foot, had suffered from heel ulcer in the follow-up period which resolved with insoles. In case no. 1, chafing had occurred owing to reparative friction which resolved by restriction of sport in the period of complaints. No complications occurred in case no. 3 in the long term. In terms of range of motion (ROM), the following restrictions of dorsiflexion were observed: 30 degrees in case no. 5, 20 degrees in case no. 6, and 30 degrees in case no. 8. However, no ROM restriction was observed in the remaining cases. Because of the insufficient cooperation resulting from small age, the evaluation of major peripheral nerve reconstruction (case no. 10) could not have been performed properly. A flap thinning procedure was performed in four patients at mean of 8.7 months (range, 8–10 months) after flap surgery. As sequelae, distal epiphyseal arrest developed in one patient. In one patient, despite lengthening, a 3-cm leg length discrepancy developed and that patient is still undergoing follow-up with height compensation.
Discussion Because perforator flaps are versatile and the donor site morbidity is low, they have gained a great degree of popularity. Because of the properties of several structures in pediatric patients, the development of perforators has not been completed. This difficulty is the greatest for free perforator flaps that are applied in children.11 In addition, because the vein diameters of pediatric patients are smaller than those of adults, technical difficulties can occur during anastomosis. Because of these disadvantages, microsurgery procedures in pediatric patients have developed more slowly than in adults.2 However, the successful use of free tissue transfer has been applied in pediatric patients, and these results have been published. Success rates similar to those in adult patients have been observed for these microsurgery procedures, and they can be used safely and effectively in pediatric patients.1,3,6 Reconstruction of lower extremity defects in pediatric patients is difficult because the skin around the foot and ankle is thin, and there are several structures in this small area. To successfully treat complex tissue defects in this area, it is necessary to debride dead tissues as soon as possible, as well as effectively repair or reconstruct ligaments, tendons, bones, joints, nerves, and vascular structures, after which early tissue coverage can be achieved.13 The popularity of free perforator flaps used either as free-style approach or as pedicled in all zones of lower extremity injuries has increased
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228
6 y/F
4
15 y/M
6 y/M
3
6
10 y/F
2
9 y/M
11 y/M
1
5
Age/ Gender
Case number
MVA
Gunshot Injuries
Bicycle chain injuries
Agricultural Injuries
Gunshot Injuries
MVA
Mechanism of injury
Medial part of the right calcaneus þ tarsal bones Tibia fractures þ Lisfranc joint fracture dislocation, medial cuneiform bone defect
Journal of Reconstructive Microsurgery Delayed
Tibial intramedullary nail fixation þ Lisfranc joint reduction and K-wire fixation
Harvest of the composite chondro-osteo-ligamentous autograft from the iliac crest with modify Langenskiold procedure
Debridement of infected and necrotic soft tissue over the Achilles tendon Reconstruction with composite flap using suture anchors Tibialis anterior
Tibialis posterior (ES) VC
12 8 cm
Tibialis posterior (ES)
88 cm
13 9 cm
Tibialis posterior
Tibialis anterior VC
11 8 cm
K-wire fixation of metatarsal EHL reconstruction with tendon transfer
11 6 cm
Tibialis posterior (ES) VC
15 7 cm
Iliac crest bone graft fix with Acutrak screw Lindholm Technique Achilles tendon reconstruction with suture anchoring STSG
Joint reduction Deltoid ligament repair Stump closure of the 2, 3, 4, 5 toes STCG
Recipient vessels
Flap size
Operation
Primer
Primer
Primer
Primer
Primer
Primer
Donor site closure
2 mc
2 mc
1 mc,1 sc
1 mc,1 sc
1 mc
1 mc,1 sc
Type and no perforator
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Over the left medial malleolus Defect of tibial medial malleolus with type 6 physeal fracture Ankle instability þ deltoid ligament defect Skin-facia
Immediate
Skin-facia and fascia lata (composite)
Delayed
Delayed
Skin-facia (sensate)
Dorsal þ plantar of right foot and posterior part of the lag, Talonavicular joint dislocation þ deltoid ligament rupture þ 2, 3, 4, 5 toes amputation Full thickness skin loos þ expose the calcaneus bone and Achilles tendon
Skin-facia
Delayed
Skin-facia
Dorsum of the right foot First þ second metatarsal fractures First MP joint dorsal part defect EHL and 2–3-4 extensor tendon defect
Over the right Achilles tendon Infected necrotic tissue over the Achilles tendon Soft tissue and Achilles tendon defect
Delayed
Skin-facia (sensate)
Hell þ plantar of right foot Calcaneus bone defect Achilles tendon defect
Timing of reconstruction
Flap type
Localization Additional injuries
Table 1 Patients demographics and reconstruction outcomes
None
None
Donor site hypertrophic scar (FD)
None
None (FD)
None
Complication
None
None
None
First toe valgus contracture
None
Chafing on the plantar surface
Sequela
(Continued)
26
16
19
22
17
28
Follow-up (Months)
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13 y/M
11
MVA
MVA
MVA
Gunshot Injuries
MVA
Mechanism of injury
Lateral aspect of left ankle Lateral collateral ligament rupture
Medial aspect of right foot – tibial nerve injury þ right knee septic arthritis þ bilateral crush injury of leg
Dorsal þ plantar surface of right foot and posterior First metatarsal fracture þ full thickness skin loos þ expose the calcaneus bone dorsal and plantar part of foot
Anteromedial aspect of right ankle Ankle subtotal amputation
Medial aspect of right foot and ankle Bimalleolar type 2 physeal fractures ankle instability Deltoid ligament defect
Localization Additional injuries
Skin-facia
Skin-facia
Skin-facia (sensate)
Delayed
Delayed
Delayed
Delayed
Delayed
Skin-facia
Skin-facia
Timing of reconstruction
Flap type
Lateral collateral ligament reconstruction with tendon graft
Nerve repair with sural nerve graft septic arthritis debridement STSG
K-wire fixation for metatarsal fractures STSG Tibialis posterior
Tibialis posterior
Tibialis anterior VC
14 8 cm
86 cm
12 7 cm
Tibialis anterior
12 6 cm
Acute shortening with unilateral external fixator, anterior tibial artery repair with vein graft, proximal tibial lengthening, osteotomy with Ilizarov external fixator
Tibialis anterior
9 7 cm
Lateral malleolus fixation with K-wire and Deltoid ligament reconstruction with tendon graft
Recipient vessels
Flap size
Operation
Primer
Primer
Primer
Primer
Primer
Donor site closure
1 mc,1 sc
1 sc
2 mc
2 mc
2 mc
Type and no perforator
Venous thrombosis (salvage with vein graft) lateral part partial necrosis treated with skin graft (FD)
Donor site hypertrophic scar
None
None
None
Complication
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None
None
Ulceration on the plantar surface
Limb length discrepancy and distal epiphyseal growth arrest
None
Sequela
13
19
26
13
29
Follow-up (Months)
Free Anterolateral Thigh Flap for Pediatric Foot and Ankle Defects
Abbreviations: ES, end to side; FD, flap debulking; mc, musculocutaneous; MVA, motor vehicle accident; sc, septocutaneous; STSG, split thickness skin graft; VC, venous coupler.
3 y/M
10
9 y/F
8
9 y/M
7 y/M
7
9
Age/ Gender
Case number
Table 1 (Continued)
230 Acar et al.
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231
Authors
Patient series
Mean age
Defect localization
Etiology
Other
Segev et al
1
12
Lower limb
Trauma
100% survival
Upton and Guo
3
Lower limb
100% survival
Yildirim et al
1
7
Lower limb
100% survival
Demirtas et al
5
4.8
Foot
Trauma
1 partial flap necrosis
Gharb et al
4
10.25
Lower limb
Trauma
2 partial flap necrosis and 1 flap was loss
El-Gammal et al
42
6.18
Dorsum of the foot and ankle
Trauma
92.86% primer flap survival
Current study
11
8.9
Foot and ankle
Trauma
1 partial flap necrosis 90.9% primer flap survival
not only because of the safety and efficacy but also because of minimal donor site complication and functional impairment.13–15 In the literature, traffic accidents and crush injuries16–18 play the greatest roles in the etiology of tissue loss requiring reconstruction with free tissue transfer. In the current study, traffic accidents were observed at a rate of 54.5%, firearm injuries at 27.3%, bicycle chain injuries at 9.1%, and agricultural machinery injuries at 9.1%. Although traffic accidents are the main agent, close-range firearm injuries have also been observed in the etiology in our country. Few published studies have described the use of free ALT flaps in pediatric lower extremity reconstruction. Previous studies that have noted the peculiarities of the ALT flap in the pediatric population have been based on experiences with adult patients.2,8–11 In the current series, the results were investigated for soft tissue injuries, which accompanied vein, nerve, tendon, ligament, and bone defects and required primary repair in addition to metatarsal bone and ankle fractures and tendon injuries in the foot and ankle region. Defects that could be covered with local or pedicle skin grafts were not included in the study. To the best of our knowledge, this study has the second highest number of pediatric patients who underwent ALT flap surgery to repair lower extremity injuries (►Table 2). In the literature, reexploration after lower extremity free flap surgery in pediatric patients has been reported at rates ranging from 4 to 29%.1,19,20 In the current study, the reexploration rate was 9.1% (1/11 patients). After surgery, four patients required flap thinning. The high rate of flap thinning could be attributed to leaving more of a surrounding muscular cuff when taking the flap and failing to use primary thinning. Demirtas et al10 reported that initial thinning could be successfully applied when raising small flaps. Because using skin grafts to close the donor site in pediatric patients increases the risk of ugly and hypertrophic scars, primary skin closure is recommended wherever possible. Primary closure of the donor site was performed in all patients in the current study. In two (18.2%) patients, a hypertrophic scar developed, and it was effectively treated with massage. Economides et al21 have mentioned only flap survival rates and complications in the functional outcome assessment, and the aforementioned literature has not focused on assessing
patient-centered outcomes of these reconstructive procedures. They have emphasized that scoring systems such as Short Form Health Surveys (SF-8, SF-12, and SF-36), European Quality of Life-5 Dimension (EQ-5D), and visual analog scale will have a great contribution on functional evaluation after lower extremity reconstructive procedures. Lack of objective functional assessment criteria in the current study is the weakness of our study. This study has some limitations, including the relatively small number of patients, inhomogeneous traumatic injuries, lack of long-term follow-up (particularly for patients with accompanying epiphyseal injuries), and lack of gait analysis of the patients with covered heel defects. In conclusion, as in adult patients, a free ALT flap can be a safe choice for pediatric patients with minimal donor site morbidity to treat defects following trauma around the foot and ankles; it can also act as a perforator flap for covering soft tissue, a composite flap in tendon defects and a sensate flap in heel and sole defects.
Financial Disclosure None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this manuscript.
References 1 Yücel A, Aydin Y, Yazar S, Altintaş F, Senyuva C. Elective free-tissue
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3
4 5
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transfer in pediatric patients. J Reconstr Microsurg 2001;17(1): 27–36 Yildirim S, Calikapan GT, Akoz T. Reconstructive microsurgery in pediatric population-a series of 25 patients. Microsurgery 2008; 28(2):99–107 Duteille F, Lim A, Dautel G. Free flap coverage of upper and lower limb tissue defects in children: a series of 22 patients. Ann Plast Surg 2003;50(4):344–349 Parry SW, Toth BA, Elliott LF. Microvascular free-tissue transfer in children. Plast Reconstr Surg 1988;81(6):838–840 Song YG, Chen GZ, Song YL. The free thigh flap: a new free flap concept based on the septocutaneous artery. Br J Plast Surg 1984; 37(2):149–159 Wei FC, Jain V, Celik N, Chen HC, Chuang DC, Lin CH. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps. Plast Reconstr Surg 2002;109(7):2219–2226, discussion 2227–2230
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Table 2 Previously reported cases of ALT flap in pediatric lower limb reconstruction in literature patient series
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7 Fischer JP, Wink JD, Nelson JA, et al. A retrospective review of
14 Nosrati N, Chao AH, Chang DW, Yu P. Lower extremity reconstruc-
outcomes and flap selection in free tissue transfers for complex lower extremity reconstruction. J Reconstr Microsurg 2013;29(6): 407–416 Segev E, Wientroub S, Kollender Y, Meller I, Amir A, Gur E. A combined use of a free vascularised flap and an external fixator for reconstruction of lower extremity defects in children. J Orthop Surg (Hong Kong) 2007;15(2):207–210 Upton J, Guo L. Pediatric free tissue transfer: a 29-year experience with 433 transfers. Plast Reconstr Surg 2008;121(5): 1725–1737 Demirtas Y, Neimetzade T, Kelahmetoglu O, Guneren E. Free anterolateral thigh flap for reconstruction of car tire injuries of children’s feet. Foot Ankle Int 2010;31(1):47–52 Gharb BB, Salgado CJ, Moran SL, et al. Free anterolateral thigh flap in pediatric patients. Ann Plast Surg 2011;66(2): 143–147 El-Gammal TA, El-Sayed A, Kotb MM, et al. Dorsal foot resurfacing using free anterolateral thigh (ALT) flap in children. Microsurgery 2013;33(4):259–264 Song JW, Ben-Nakhi M, Hong JP. Reconstruction of lower extremity with perforator free flaps by free style approach in pediatric patients. J Reconstr Microsurg 2012;28(9):589–594
tion with the anterolateral thigh flap. J Reconstr Microsurg 2012; 28(4):227–234 Hallock GG. A paradigm shift in flap selection protocols for zones of the lower extremity using perforator flaps. J Reconstr Microsurg 2013;29(4):233–240 Organek AJ, Klebuc MJ, Zuker RM. Indications and outcomes of free tissue transfer to the lower extremity in children: review. [Review] J Reconstr Microsurg 2006;22(3):173–181 Rinker B, Valerio IL, Stewart DH, Pu LL, Vasconez HC. Microvascular free flap reconstruction in pediatric lower extremity trauma: a 10year review. Plast Reconstr Surg 2005;115(6):1618–1624 Erdmann D, Lee B, Roberts CD, Levin LS. Management of lawnmower injuries to the lower extremity in children and adolescents. Ann Plast Surg 2000;45(6):595–600 Shenaq SM, Dinh TA. Pediatric microsurgery. Reconstruction by free tissue transfer. Clin Plast Surg 1990;17(1):85–94 Clarke HM, Upton J, Zuker RM, Manktelow RT. Pediatric free tissue transfer: an evaluation of 99 cases. Can J Surg 1993;36(6):525–528 Economides JM, Patel KM, Evans KK, Marshall E, Attinger CE. Systematic review of patient-centered outcomes following lower extremity flap reconstruction in comorbid patients. J Reconstr Microsurg 2013;29(5):307–316
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