PMC8204669_01
Preoperative defect
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F1
Negative wound pressure therapy (NPWT) was used for coverage and preconditioning of the 8 x 18 cm soft tissue defect (Figure 1 (Fig. 1)).
Defect with AV loop in situ
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F2
Preceding the free LD flap an AV loop system (AV loop marked * in Figure 2 (Fig. 2)) was constructed by the vascular surgery department on the popliteal P3 segment.
LD flap plus split skin graft and monitor island
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F3
The patient was thus ready to have the defect covered by means of a free LD flap with microvascular connection to the AV loop and simultaneous split skin coverage plus a monitor island (marked *) for better flap observation (Figure 3 (Fig. 3)) after 7 days of Doppler monitoring the AV loop. The final examination verified excellent blood circulation of the flap and monitor island (Figure 3 (Fig. 3)).
Postoperative result after 2 weeks
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F4
The initial care was performed by the outpatient unit with weekly follow-up visits and short-term visits after 2 and 8 weeks (Figure 4 (Fig. 4) and Figure 5 (Fig. 5)), 6 months (Figure 6 (Fig. 6) and Figure 7 (Fig. 7)) and 1.5 years post-surgery (Figure 8 (Fig. 8) and Figure 9 (Fig. 9)).
Postoperative result after 2 weeks
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F5
The initial care was performed by the outpatient unit with weekly follow-up visits and short-term visits after 2 and 8 weeks (Figure 4 (Fig. 4) and Figure 5 (Fig. 5)), 6 months (Figure 6 (Fig. 6) and Figure 7 (Fig. 7)) and 1.5 years post-surgery (Figure 8 (Fig. 8) and Figure 9 (Fig. 9)). Figure 5 (Fig. 5), Figure 6 (Fig. 6), Figure 7 (Fig. 7) and Figure 8 (Fig. 8) show the patient standing and able to walk with no crutches.
Postoperative result after 6 months, frontal view
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F6
The initial care was performed by the outpatient unit with weekly follow-up visits and short-term visits after 2 and 8 weeks (Figure 4 (Fig. 4) and Figure 5 (Fig. 5)), 6 months (Figure 6 (Fig. 6) and Figure 7 (Fig. 7)) and 1.5 years post-surgery (Figure 8 (Fig. 8) and Figure 9 (Fig. 9)). Figure 5 (Fig. 5), Figure 6 (Fig. 6), Figure 7 (Fig. 7) and Figure 8 (Fig. 8) show the patient standing and able to walk with no crutches.
Postoperative result after 6 months, lateral view
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F7
The initial care was performed by the outpatient unit with weekly follow-up visits and short-term visits after 2 and 8 weeks (Figure 4 (Fig. 4) and Figure 5 (Fig. 5)), 6 months (Figure 6 (Fig. 6) and Figure 7 (Fig. 7)) and 1.5 years post-surgery (Figure 8 (Fig. 8) and Figure 9 (Fig. 9)). Figure 5 (Fig. 5), Figure 6 (Fig. 6), Figure 7 (Fig. 7) and Figure 8 (Fig. 8) show the patient standing and able to walk with no crutches.
Postoperative result after 1.5 years, frontal view
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F8
The initial care was performed by the outpatient unit with weekly follow-up visits and short-term visits after 2 and 8 weeks (Figure 4 (Fig. 4) and Figure 5 (Fig. 5)), 6 months (Figure 6 (Fig. 6) and Figure 7 (Fig. 7)) and 1.5 years post-surgery (Figure 8 (Fig. 8) and Figure 9 (Fig. 9)). Figure 5 (Fig. 5), Figure 6 (Fig. 6), Figure 7 (Fig. 7) and Figure 8 (Fig. 8) show the patient standing and able to walk with no crutches.
Postoperative result after 1.5 years, lateral view
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F9
The initial care was performed by the outpatient unit with weekly follow-up visits and short-term visits after 2 and 8 weeks (Figure 4 (Fig. 4) and Figure 5 (Fig. 5)), 6 months (Figure 6 (Fig. 6) and Figure 7 (Fig. 7)) and 1.5 years post-surgery (Figure 8 (Fig. 8) and Figure 9 (Fig. 9)).
Posteropative X-rays after 1 year
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F10
The X-rays (Figure 10 (Fig. 10)) one year after bone fixation showed no sign of bone infection or pseudarthrosis after removal of the external fixator.
Intraoperative patient positioning
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F11
The patient was placed in a right lateral position allowing a two-team approach (Figure 11 (Fig. 11)).
Harvested LD flap
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F12
Venous anastomosis perfomed with 3.0 mm coupler
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F13
Under the surgical microscope, the venous anastomosis was performed with a 3.0 mm venous coupler (Figure 13 (Fig. 13)) whereas the arterial anastomosis was carried out using 8/0 Prolene single-button sutures (Figure 14 (Fig. 14)).
Arterial anastomosis, single button 8.0 Prolene sutures
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F14
Under the surgical microscope, the venous anastomosis was performed with a 3.0 mm venous coupler (Figure 13 (Fig. 13)) whereas the arterial anastomosis was carried out using 8/0 Prolene single-button sutures (Figure 14 (Fig. 14)).
LD flap after anastomosis covering the defect
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F15
After an ischemic time of 56 min the anastomoses were released and an excellent blood flow through the entire latissimus dorsi flap with instant capillarization of the monitor island could be seen (Figure 15 (Fig. 15)).