INTRODUCTION
The main causes of tissue injuries around the knee include traumatic wounds, oncological
surgeries, invasive infections or burns1,2. Surgical reconstruction of these injuries represents a major challenge due to the
exposure of osteoarticular, tendinomuscular and neurovascular structures and has been
performed using different muscular and musculocutaneous flaps3,4. The use of a skin flap based on the pedicle of the superior lateral genicular artery
(SLGA) is less frequently reported in the scientific literature5.
OBJECTIVE
This article aimed to report the feasibility of using the SLGA-based flap to cover
injuries around the knee and proximal region of the leg in patients who were victims
of motorcycle accidents.
CASE REPORTS
The Ethics Committee approved this study under CAAE number: 52573721.3.0000.0033.
Five patients, four males (80%) and one female (20%), who were victims of motorcycle
accidents, were treated for injuries around the knee. Patient 1, male, 22 years old,
15 cm soft tissue lesion in the lateral region of the right knee. Patient 2, male,
19 years old, 16 cm soft tissue lesion in the lateral region of the right knee. Patient
3, male, 35 years old, 13 cm soft tissue lesion in the lateral region of the right
knee. Patient 4, male, 30 years old, 14 cm soft tissue lesion in the lateral region
of the left knee. Patient 5, female, 27 years old, 12 cm soft tissue lesion in the
lateral region of the right knee.
The flap designed to adjust to the defect resulting from the injury was based on the
SLGA vascular pedicle in all cases, and the donor areas were closed in the same surgical
procedure or supplemented with a skin graft. Figure 1 shows the schematic planning of the flap based on the SLGA.
Figure 1 - (A) Schematic planning of the flap based on the pedicle of the superior lateral genicular
artery. (B) Anatomical view of the pedicle. Illustration by Ernst Bock extracted from
the article by Wiedner et al.8 (GT: greater trochanter; M: midpoint; LC: lateral condyle).
Figure 1 - (A) Schematic planning of the flap based on the pedicle of the superior lateral genicular
artery. (B) Anatomical view of the pedicle. Illustration by Ernst Bock extracted from
the article by Wiedner et al.8 (GT: greater trochanter; M: midpoint; LC: lateral condyle).
Surgical technique
The patient was under spinal anesthesia and placed in lateral decubitus. After demarcation
of the anatomical parameters, which have as reference the projection of the greater
trochanter of the femur, the lateral condyle of the femur, the posterior border of
the vastus lateralis muscle and the anterior border of the biceps femoris. In this
previously designed area is found the SLGA. Next, exsanguination of the limb was performed
by gravity, followed by a tourniquet with a smarch band at the proximal level of the
thigh.
After making an incision on the skin and subcutaneous tissue following the line of
the lateral edge of the patella, the muscle fascia was incised after identifying the
edge of the vastus lateralis muscle, extending from the lateral projection of the
gluteal fold to the lateral topography of the knee. Careful dissection was then performed
in the subfascial region, delimited by the vastus lateralis muscle and posteriorly
by the biceps femoris muscle, continuing until it met the perforating branch of the
SLGA, increasing the dissection to deeper planes.
Subsequently, the necessary extension of the flap was defined, completing its dissection
towards the posterior aspect of the femur up to its origin in the popliteal artery.
The tourniquet was released to assess perfusion in the flap. After being perfused,
the flap was rotated towards the receiving area and fixed using simple stitches. Then,
in the donor area, the three tissues were brought together with a simple suture and,
when necessary, supplemented with a second skin graft.
RESULTS
Patients were discharged after five days of hospitalization with a prescription of
rivaroxaban 10mg, once a day, for 15 days and returned for dressing change twice a
week in the first two weeks and then twice every 15 days. In the periods of 5 and
14 days after hospital discharge, all patients showed good healing and good knee range
of motion. After the 15th postoperative day, the patients started physiotherapy to
recover joint range of motion, which occurred after 20 physiotherapy sessions.
The age group ranged from 19 to 35 years old, with an average of 26 years old. The
mean dimensions of the patients’ flaps were 13×7cm. There was complete flap survival
in all patients. Only patient 1 had necrosis of the skin graft three weeks after the
operation, which was resolved later with a new graft. The donor areas of all patients
healed well with no restriction in knee joint mobility. Hospitalization time was 14
days, and follow-up time was 12 months. Figures 2 to 5 show the photographic records of one of the cases (patient 5).
Figure 2 - Photographic record of the lesion (A) and details of the flap donor region (B) of
patient 5.
Figure 2 - Photographic record of the lesion (A) and details of the flap donor region (B) of
patient 5.
Figure 3 - Photographic records of the superior lateral genicular flap (A) and pedicle of the
superior lateral genicular artery (B) of patient 5.
Figure 3 - Photographic records of the superior lateral genicular flap (A) and pedicle of the
superior lateral genicular artery (B) of patient 5.
Figure 4 - Photographic record of the immediate postoperative period of the superior lateral
genicular flap of patient 5.
Figure 4 - Photographic record of the immediate postoperative period of the superior lateral
genicular flap of patient 5.
Figure 5 - Photographic record of the upper lateral genicular flap of patient 5 three weeks (A)
and four months (B) after the operation.
Figure 5 - Photographic record of the upper lateral genicular flap of patient 5 three weeks (A)
and four months (B) after the operation.
DISCUSSION
Most cases of lower limb soft tissue injuries occur in males young adults and result
from motorcycle accidents. Soft tissue defects around the knee are reconstructed with
pedicled perforator flaps, with the SLGA being a reliable flap option6.
Moktader et al.7 evaluated the reliability of the SLGA flap in 15 patients with injuries around the
knee, succeeding in 14 cases, and only one patient had necrosis at the distal margin
of the flap.
Wiedner et al.8 analyzed six cases of using the SLGA flap for soft tissue reconstruction around the
knee and observed flap survival in all patients, and only one patient had partial
necrosis at the distal tip of the flap without late complications.
Mahipathy et al.9 evaluated five patients with a mean age of 42 years, in whom the SLGA-based flap
was used for reconstruction of defects around the knee, and observed complete survival
of the flap in all patients, with distal necrosis in one patient who was treated conservatively.
The use of AGLS has aesthetic advantages, as the color and texture of the flap are
similar to those of the knee region and provide a better quality appearance compared
to muscle or musculocutaneous flaps, in addition to not causing problems in knee joint
mobility9.
CONCLUSION
The use of the SLGA-based flap is a viable technique and provides good coverage of
lesions around the knee and proximal region of the leg, with a high flap survival
rate and good clinical results consistent with those reported in the literature.
1. Hospital Estadual de Urgências de Goiás - Dr. Valdemiro Cruz, Goiânia, GO, Brazil
Corresponding author: Pedro Henrique Silva Benevides Avenida 31 de março esq. c/ 5ª Radial, Setor Pedro Ludovico, Goiânia, GO, Brazil.
Zip Code: 74820-300, E-mail: phsilvabenevides1@gmail.com
