Critical assessment of the anterolateral thigh flap donor site.

BACKGROUND: The free anterolateral thigh flap (ALT) is now used as a 'workhorse flap'. The donor site morbidity is thought to be minimal, although most evidence derives from questionnaire-based studies rather than rigorous objective clinical assessment. In particular, robust quantitative data on thigh sensibility and quadriceps function is lacking. The aim of this study was to provide a comprehensive clinical assessment of donor site morbidity. METHODS: We performed a prospective study of consecutive free ALT perforator flaps performed at Salisbury Foundation Trust between March 2008 and April 2010. The donor site was assessed at six months including a questionnaire (symptoms, function), scar analysis (Vancouver Scar Scale, VSS), and evaluation of quadriceps power and lateral thigh sensibility (compared with the contralateral unoperated thigh). RESULTS: One hundred ALT flaps were performed on 97 patients (mean age 46.8 years). The donor site was closed directly in 88 cases and using a split skin graft in 12 cases. At follow-up (n=68), tingling was the most common reported symptom (59%), whereas pain, itching and muscle herniation were reported infrequently. Donor site scars were mostly flat, pale and soft but widened. Pathological scarring was rare. Sensibility was reduced in donor thighs (p<0.001) and correlated with flap width but peak quadriceps contraction was similar between donor and unoperated thighs. CONCLUSIONS: There was a high throughput and diverse application of ALT flap reconstructions during the study period. Reduced sensibility was common around the scar but rarely troublesome. Quadriceps function was not affected even when dissection of intramuscular perforators was required. The ALT is a versatile flap that can deliver a large skin paddle with minimal impact on thigh function.

Costs and coding--free-flap reconstruction in lower-limb trauma.

INTRODUCTION: The provision of a complex lower-limb trauma service has significant resource implications. This financial burden is not recognised by the current fixed price tariff system (Payment by Results). The aim of this study was to compare the actual costs of treatment with reimbursement. METHODS: We conducted a prospective study in two large regional plastic surgery centres in the UK, Salisbury Foundation Trust (SFT) and the Frenchay Hospital, Bristol (FH). The total cost of treatment for consecutive patients with complex lower limb trauma requiring free tissue transfer was calculated and compared with the Health Resource Group (HRG) tariff. RESULTS: A cost analysis was performed on 20 patients (10 Salisbury, 10 Frenchay) with open tibial fractures (all grade IIIb Gustillo & Anderson) requiring free-flap reconstruction (15 anterolateral thigh (ALT) flaps, one serratus, one latissimus dorsi (LD), one scapular and two gracilis). The mean treatment cost of performing a free flap was £12792 ± £970 SEM (SFT) and £10953 ± £650 (FH). In both centres, the cost was more than double the HRG tariff (£4220 SFT, £4892 FH, p < 0.05). CONCLUSIONS: Our study highlights the considerable disparity between the cost of managing patients with severe lower-limb trauma and the remuneration by Primary Care Trusts (PCTs). Accurate cost analysis of these cases will allow hospital trusts to negotiate appropriate tariffs with PCTs and develop services, which are cost neutral.

Congenital absence of flexor digitorum superficialis: implications for assessment of little finger lacerations.

Absence of flexor digitorum superficialis function in the little finger is a relatively common congenital anomaly that can complicate assessment of little finger injuries. We reviewed the prevalence of unilateral and bilateral absence of superficialis function in the published literature. In appropriate studies identified (1352 people), the anomaly was unilateral in 92 individuals (6.8%) and bilateral in 81 (6.0%). If superficialis function is absent in one little finger, the probability of absence in the opposite hand is 0.64. If superficialis function is present, the probability of absence in the other little finger is 0.02 (1 in 50). Absence of little finger superficialis function in one hand is therefore not a reliable indicator of this function in the opposite hand.