Background: A central reconstructive principle is the concept of replacement of like tissue with like tissue. Applying this concept to the lower extremity, we have been using the anterolateral thigh (ALT) fasciocutaneous (FC) or adipocutaneous (AC) free flap for coverage of traumatic open fractures. While free muscle flaps have been the mainstay of reconstruction for the distal lower extremity, we believe that replacement of like tissue with like tissue deserves investigation in this area. This study examines the rate of early postoperative complications associated with the anterolateral thigh (ALT) fasciocutaneous (FC) or adipocutaneous (AC) free flap for coverage of high-energy traumatic open fractures of the lower extremity.  These results are compared with the data available for outcomes associated with free muscle flaps for coverage of comparable lower extremity trauma.

Methods: 63 consecutive patients receiving ALT free tissue transfer for lower extremity limb coverage in the setting of trauma were studied. All patients were treated at a single institution (R. Adams Cowley Shock Trauma Center) and had at least six months of follow-up. Data analyzed included: age, gender, smoking status at the time of injury, medical risk factors for heart disease (diabetes, hypertension, hypercholesterolemia) and the ASIF/OTA classification of the fracture and soft tissue deficit, as documented at the time of injury. The treatment data consisted of the type of flap, time to reconstruction (TTR), and type of orthopedic fixation.  Early postoperative complications were defined as any one or more of the following having occurred within 6 months from surgical reconstruction: hematoma, wound infection, DVT, thromboembolism, partial flap loss, complete flap loss, continued osteomyelitis, and progression to amputation occurring within the first six months after the injury.

Results: All patients were similar with respect to age, gender, smoking status at the time of injury, and medical risk factors for heart disease.  Of the 63 patients evaluated, all had injuries classified as Gustilo IIIb. Complications were noted in 13 (20%) of the cases.  The most frequent complication was partial flap loss or superficial epidermolysis  4 (6.3%).  This was followed by hematoma 3 (4.7%) and continued osteomyelitis at 6 months 3 (4.7%).  One patient had complete flap loss and required a second free flap for limb salvage. Two patients had a documented DVT and required therapeutic anticoagulation (3.1%). No patient had a thromboembolic event. No patient progressed to amputation.Conclusions: The ALT free flap is a versatile and powerful tool for the reconstructive surgeon. The rates of early complications when this FC or AC flap is used in lower extremity reconstruction are comparable to those previously described in reports utilizing free muscle flaps for coverage of similar wounds. This retrospective analysis is a beginning investigation into the safety and efficacy of the ALT (FC) and (AC) flap when used to reconstruct high-energy open fractures of the lower extremity.