Single Centre Experience of Flap Reconstruction in Patients with Lower Limb Vascular Anatomical Variants: Case Series, Review of the Literature and Algorithm for Management

Author(s): Frances Bowerman, James Warbrick- Smith, Ahmed Emam, Nicholas Marsden

Introduction: Soft tissue reconstruction in the form of local and free tissue transfer provides the mainstay of treatment in open lower-limb fractures. Developments in pre-operative imaging have led to improved surgical planning, reduced operative times, and aid in identifying abnormal vascular anatomy. There is a paucity of literature regarding soft tissue reconstruction in patients with aberrant vascular anatomy, with no general consensus on management. We describe our experience managing a series of seven patients within the last two-years with anatomical vascular variations requiring soft tissue reconstruction for open lower limb fractures, review the current literature and propose a surgical algorithm to aid in managing these complex cases.

Materials and Method: Retrospective analysis of a departmental lower limb-flap database performed to identify all traumatic defects requiring flap reconstruction over a 24-month period (September 2020-Aug 2022) following the establishment of a Major Trauma Network. Patient demographics, injury details, surgical procedures and post-operative complications were recorded. All patients had a computed tomography angiography (CTA) prior to definitive surgery. Inclusion criteria included all patients identified to have a vascular anatomical variant following preoperative CTA.

Results: 7/188 patients undergoing flap reconstruction for lower-limb trauma were identified as meeting the inclusion criteria. Mean age 40 (28-81 years), female to male ratio of 4:3. There were four gracilis, two anterolateral thigh and one medial plantar artery flap performed, with two flaps requiring AV loops. There was one flap failure. There were five previous cases identified in the literature for review. Based on our experience and on reviewing the literature we propose a management algorithm for these complex cases.

Conclusion: This series demonstrates that free and pedicled flaps based on anatomical vascular variants can be successfully performed in limb salvage surgery. Pre-operative planning, informed by a surgeon-reviewed CTA, minimises the risk of distal ischaemia and allows thorough surgical planning to reduce technical difficulties that would otherwise be encountered intra-operatively.