Background: Free tissue transfer is an essential component to lower extremity limb reconstruction and has dramatically improved salvage attempts. The reconstructive goals are to provide soft tissue coverage with good contour and restoration of function with minimal donor site morbidity. Complex defects of the ankle and the distal third of the tibia with comminution, soft tissue deficiency, and/or residual dead space often require free muscle flaps. One underutilized flap with several advantages is the free vastus lateralis. The purpose of this study is to critically examine the use of the free vastus lateralis muscle flap for lower extremity limb salvage and to describe our treatment protocol which involves a novel application for the vacuum assisted closure device.
Methods: We performed a retrospective review of the senior author’s experience utilizing the free vastus lateralis muscle flap for lower extremity limb salvage between May 2007 and October 2008. Demographic, complication, and follow up information was recorded. An identical protocol was utilized for each patient, beginning with preoperative angiography to access the vascular integrity of the extremity. Following debridement, the flap was raised from the ipsilateral thigh and inset with subsequent split thickness skin grafting. We applied a vacuum-assisted-closure (VAC) device over the skin-grafted muscle to reduce the edema and congestion which can complicate lower extremity free flap reconstruction. An implantable Cook Doppler was utilized for free flap monitoring. The VAC dressing was removed on POD 5 and a dangle regimen was initiated on POD 7.
Results: Thirteen patients underwent reconstruction with 14 vastus lateralis muscle flaps. The mean patient age was 43.5. Reconstruction in all cases was indicated secondary to trauma. Nine cases involved distal leg defects and 5 cases involved defects of the ankle or foot. Closure was performed on average 35.2 days after injury with an average case length of 4:34. Follow up averaged 6 months. We report one flap failure, which necessitated debridement and a second flap using a rectus abdominis muscle. One patient developed a superficial abscess on POD 19 and one patient developed a donor site hematoma, both of which required operative intervention. Three patients underwent revisions for contour deformities. All patients had a small area of persistent numbness in the lateral thigh, but there were no complaints of leg weakness.
Conclusions: The vastus lateralis muscle flap is an excellent alternative for reconstruction of lower extremity defects. Its advantages include a consistent anatomy and large caliber pedicle which has a length that facilitates anastomosis outside of the zone of injury, an adequate volume which can be tailored to fit the defect, a location enabling a two team approach and a low donor site morbidity. Our early experience using the vastus lateralis free muscle flap demonstrates successful lower extremity reconstruction with few complications and good lower extremity function and contour. Given its advantages, this versatile flap should be included as an option in lower extremity limb salvage operations.