The Free Latissimus Dorsi Flap as Primary Free Flap and Crane Flap with Secondary Pedicled Transfer

ABSTRACT

We are reporting a case of a 43-year-old woman, who developed a soft tissue defect of the knee region following complex lower limb trauma. The defect was covered with a microvascular latissimus dorsi (LD) flap. The patient required a total knee replacement and developed a defect at the anterior aspect of the knee. This defect was covered by a second free LD flap from the ipsilateral side with anastomosis to the superficial femoral artery. Thrombosis of the superficial femoral artery resulted in complete flap loss. The soft tissue defect was covered with a pedicled medial gastrocnemius flap. Further surgery was undertaken to reconstruct the extensor mechanism of the knee. The resulting soft tissue defect was covered with a free anterolateral thigh (ALT) flap, which failed. The resulting defect left the knee prosthesis exposed. We used the first free LD flap covering the medial aspect of the lower leg as a pedicled axial myocutaneous flap. The deep portion of the flap remained in situ, covering the original soft tissue defect of the lower leg, and the main bulk of the LD was rotated by 180 degrees to the anterior defect of the knee. The crane flap healed uneventfully with a good outcome.

KEYWORDS

Microvascular flap - crane flap - pedicled flap - total knee replacement - latissimus dorsi flap

REFERENCES

• 1 Casanova D, Hulard O, Zalta R, Bardot J, Magalon G. Management of wounds of exposed or infected knee prostheses.  Scand J Plast Reconstr Surg Hand Surg. 2001;  35 71-77
• 2 Hong J P, Lee H B, Chung Y K, Kim S W, Tark K C. Coverage of difficult wounds around the knee joint with prefabricated, distally based sartorius muscle flaps.  Ann Plast Surg. 2003;  50 484-490
• 3 Papp A, Kettunen J, Miettinen H. Pedicled gastrocnemius flap in complicated total knee arthroplasty.  Scand J Surg. 2003;  92 156-159
• 4 Gravvanis A I, Iconomou T G, Panayotou P N, Tsoutsos D A. Medial gastrocnemius muscle flap versus distally based anterolateral thigh flap: conservative or modern approach to the exposed knee joint?.  Plast Reconstr Surg. 2005;  116 932-934
• 5 Umemoto Y, Adachi Y, Ebisawa K. The sural artery perforator flap for coverage of defects of the knee and tibia.  Scand J Plast Reconstr Surg Hand Surg. 2005;  39 209-212
• 6 Yuen J C, Zhou A T. Free flap coverage for knee salvage.  Ann Plast Surg. 1996;  37 158-166
• 7 Feldman J J, Cohen B E, May Jr J W. The medial gastrocnemius myocutaneous flap.  Plast Reconstr Surg. 1978;  61 531-539
• 8 Hsieh C H, Yang C C, Kuo Y R, Tsai H H, Jeng S F. Free anterolateral thigh adipofascial perforator flap.  Plast Reconstr Surg. 2003;  112 976-982
• 9 Wei F C, Jain V, Celik N, Chen H C, Chuang D C, Lin C H. Have we found an ideal soft-tissue flap? An experience with 672 anterolateral thigh flaps.  Plast Reconstr Surg. 2002;  109 2219-2226 discussion 2227-2230
• 10 Verhelle N A, Heymans O. How to deal with difficult microsurgical end-to-side anastomoses.  Microsurgery. 2005;  25 203-208
• 11 Crockett D J. The Millard “crane flap” for acute hand injuries.  Hand. 1970;  2 156-159
• 12 Millard D R. The crane principle for the transport of subcutaneous tissue.  Plast Reconstr Surg. 1969;  43 451-462