Principles of Free

Tissue Transfer in
Orthopaedic Practice

Richard Lawson, MBBS, FRACS

L. Scott Levin, MD, FACS

Dr. Lawson is Lecturer, Department of

Hand and Peripheral Nerve Surgery,
Royal North Shore Hospital, Sydney,
New South Wales, Australia. Dr. Levin is
Chief, Division of Plastic Reconstructive
Maxillofacial and Oral Surgery, and
Professor, Orthopedic and Plastic
Surgery, Duke University Medical
Center, Durham, NC.
None of the following authors or the
departments with which they are
affiliated has received anything of value
from or owns stock in a commercial
company or institution related directly or
indirectly to the subject of this article:
Dr. Lawson and Dr. Levin.
Reprint requests: Dr. Levin, Division of
Plastic and Reconstructive Surgery,
Duke South Hospital, Room 134, Baker
House, Trent Drive/Brown Zone,
Durham, NC 27710.
J Am Acad Orthop Surg 2007;15:290299
Copyright 2007 by the American
Academy of Orthopaedic Surgeons.

290

Abstract
Free tissue transfer is a vital adjunct to orthopaedic practice; it may
optimize the treatment of many emergency and elective conditions
that require soft-tissue or bone augmentation. Consultation with a
colleague trained in microsurgery is often necessary in undertaking
free tissue transfer techniques. A two-team approach frequently is
used to maximize efficiency and minimize fatigue. Flaps with reliable pedicle anatomy are preferred. Flaps typically are raised using
an open technique, but endoscopic techniques can be utilized to decrease donor-site scarring. Free tissue transfer is a demanding procedure; careful preoperative planning is essential to ensure optimal
results. Free tissue transfer inevitably results in some donor morbidity, and flaps are carefully chosen to minimize this. The most
serious complication is failure of the flap. Free muscle flaps used in
soft-tissue reconstruction today result in little loss of function.

Definitions and
Terminology

ree tissue transfer is a procedure

in which soft tissue and/or bone
is harvested with its vascular pedicle
and transferred to a recipient site,
where the pedicle is anastomosed to
local vessels, thus revascularizing
the tissue. The pedicle is the vascular axis of the transferred tissue; it
contains an artery and one or more
veins. Pedicles with large vessel lumens and reliable anatomy are preferred. A long pedicle makes it easier
to perform a tension-free anastomosis in an optimal position, increasing
the likelihood of anastomotic patency. Larger vessel lumens increase
the ease of anastomosis.
Free flap is a term used to describe a transfer of soft tissue. The
process of dissecting and preparing a

flap for transfer is known as raising

or harvesting a flap. The flap is inset
into its recipient bed.
Free tissue transfers in orthopaedic surgery may include skin,
fascia, muscle, nerve, tendon, bone,
and/or joint. A flap containing two
or more tissue types is known as a
composite flap. Such a flap is particularly useful when reconstruction
must address the loss of several tissue types (eg, skin, bone, and muscle
in a severe open tibial fracture)
or in toe-to-hand transplantation,
in which a neurosensory flap is
required.
A fascial flap, such as the temporoparietal flap, contains fascia
alone and can provide a thin layer of
vascularized tissue that supports a
skin graft and allows underlying tissues to glide. A fasciocutaneous flap,
such as the radial forearm flap or

Journal of the American Academy of Orthopaedic Surgeons

Richard Lawson, MBBS, FRACS, and L. Scott Levin, MD, FACS

lateral arm flap, contains skin and

fascia and is thus a composite flap.
The skin and fascia are nourished by
small vessels originating from the
pedicle that pass through a fascial
septum and ultimately reach the
skin (Figure 1).
A perforator flap consists of skin
or subcutaneous fat and is perfused
by small vessels from an underlying
vascular system. However, these
vessels do not run in a fascial septum but rather pass directly through
or perforate muscle and fascia to vascularize a discrete vascular territory,
or angiosome. Perforator flaps provide the surgeon with increased versatility because these flaps do not
need to be based on a named artery.
They may be based on any identifiable perforating vessel,1 which has
made them an increasingly popular
tool for reconstructive surgeons
(Figure 2).
Tendocutaneous flaps, such as the
free innervated dorsalis pedis tendocutaneous flap, contain tendons
overlying fascia and skin and can be
particularly useful in resurfacing the
dorsum of the hand when composite
loss of tissue has occurred.
Bone and periosteum can be
raised alone, as in a free vascularized
fibular graft, or can be raised along
with other tissues; an osteofasciocutaneous transfer contains bone, fascia, and skin. The bone is vascularized by the periosteum connected to
the pedicle and may receive additional inflow by a distinct nutrient
artery arising from the pedicle.
A muscle flap is often raised with
a paddle of overlying skin to serve
both as a source of skin for coverage
and as a visual gauge of the flaps perfusion. Such a flap is called a myocutaneous flap, and the skin paddle is
called a buoy.
Functioning muscle transfers
contain a motor nerve in addition to
the vascular pedicle. The nerve is sutured to a source of donor axons with
the goal of achieving reinnervation
and voluntary control of the muscle
(Figure 3).
Volume 15, Number 5, May 2007

Figure 1

Fasciocutaneous flap. This cross section of the distal humerus illustrates the plane
of dissection for the lateral arm flap. The pedicle runs along the base of a fascial
septum, with perforating branches running through the septum to supply the
overlying fascia and skin.

Figure 2

Perforator flaps. This cross section through the left midthigh illustrates the
difference between a septocutaneous flap, in which the feeding vessel runs along
an intermuscular septum, and a perforator flap, in which the feeding vessels run
through muscle and fascia to vascularize the overlying tissue. (Adapted with
permission from Wei FC, Jain V, Suominen S, Chen HC: Confusion among
perforator flaps: What is a true perforator flap? Plast Reconstr Surg 2001;
107:874-876.)
291

Principles of Free Tissue Transfer in Orthopaedic Practice

Figure 3

Free gracilis flap, illustrating its pedicle, motor nerve, and overlying skin flap.

A fillet flap is tissue harvested

from a damaged part that has been
amputated; this salvage of usable
material may obviate the need for
additional tissue from undamaged
areas of the body. An emergency free
tissue transfer is a transfer performed immediately after the first
wound dbridement or within 24
hours after this dbridement.2

History
A basic principle of reconstructive
surgery, espoused by Sir Harold Gillies, the father of modern plastic surgery, is to replace like with like.3
The tissues surrounding the area to
be reconstructed may not provide
the required type, quality, or volume
of tissue, but microsurgery provides
the means to import tissues with
discrete blood supplies to virtually
any part of the body in which circulation can be reestablished.
Encouraged by the work of Jacobson and Suarez,4 free tissue transfer
became possible in the late 1960s
and early 1970s with the refinement
of the operating microscope, microvascular instruments, and fine
suture material. The first free flap
292

was the free groin flap, but this is

now rarely used because of its short
pedicle length. The free groin flap
has been superseded by far more versatile flaps, such as the widely used
radial forearm fasciocutaneous flap
described by Song et al5 in 1982. The
first free fibula transfer was reported
by Taylor et al6 in 1975. Taylor and
Ham7 introduced vascularized nerve
grafts in 1976. The first toe transfer,
in a rhesus monkey, was reported by
Buncke et al8 in 1966.
In the early days of reconstructive microsurgery, the primary emphasis was on achieving flap survival. However, now that survival
rates of 95% to 98% have become
expected, the emphasis has shifted
toward optimizing function and
appearance and minimizing donor
site morbidity.9

Harvesting the Free

Tissue Transfer
Flaps with reliable pedicle anatomy
are preferred. In most commonly
used flaps, the surface anatomy provides a useful guide to the underlying pedicle. However, a handheld
Doppler probe may be used to accu-

rately localize the pedicle; this can

be particularly useful in perforator
flaps, such as the anterolateral thigh
flap.
Flaps typically are raised using an
open technique, but endoscopic
techniques can be utilized to decrease scarring in the donor site. The
gracilis flap lends itself to endoscopic
harvesting because a major disadvantage of harvesting this flap by open
methods is the long scar created
along the medial aspect of the thigh.
The rectus abdominus and latissimus dorsi muscles are also sometimes harvested using endoscopic
techniques. Although endoscopic
harvest is technically demanding
and initially time-consuming, local
donor site scarring can be significantly decreased. For example, an incision length of 20 to 30 cm resulting
from an open method can be decreased to 7 cm, on average, using
endoscopy for the latissimus dorsi.10
The endoscopic technique also has
been shown to result in increased patient satisfaction.11

Application of the Free

Tissue Transfer
Coverage of Tissue
Defects and Management
of Combined Injuries
Optimal surgical management of
complex open injuries commences
with rigorous, methodical dbridement of contaminated and devitalized tissue under tourniquet control.
Nerves and major vessels should be
cleaned and preserved; all other soft
tissues may be dbrided. Bony fragments lacking soft-tissue attachment should be removed. Secondand third-look operations may be
necessary to ensure complete removal of all contaminated tissue.
When dbridement has been completed, the surgeon is left with the
challenge of obtaining coverage of
the resultant defect.12-14 One tool for
analyzing the options for wound
coverage is the reconstructive ladder.15 The bottom rung of the ladder,

Journal of the American Academy of Orthopaedic Surgeons

Richard Lawson, MBBS, FRACS, and L. Scott Levin, MD, FACS

representing the simplest option, is

primary wound closure. If this is not
possible, the ladder is ascended to
more complex options, including delayed primary closure, healing by
secondary intention, and skin grafting. Next in increasing complexity
are local flaps (raised from tissues
immediately adjacent to the defect)
and regional flaps (raised from tissues in the same limb). The top rung
of the ladder is a free flap (Figure 4).
Although it is usually advisable
to start at the bottom rung of the reconstructive ladder and attempt
simple wound closure, in some scenarios it can be advantageous to proceed directly to the top of the ladder,
particularly when dbridement has
left an extensive soft-tissue defect or
has exposed hardware or vital structures, such as bone, vessels, nerves,
or tendons. A free tissue transfer
brings in healthy vascularized tissue,
fills dead space, can cover large defects, and can expedite rehabilitation
by allowing earlier joint movement.
Open Fractures
Godina16 demonstrated that early
coverage (within 72 hours) of open
fractures with muscle flaps results
in improved outcomes, including
higher rates of bone union and lower rates of wound infection. Muscle
flaps are therefore usually chosen to
cover open fractures; these in turn
are covered with split-thickness skin
grafts because myocutaneous flaps
are often too bulky and are prone to
shearing of the skin component.
An appropriately sized flap is chosen to eradicate dead space. Small
defects can be covered with slips of
the serratus anterior muscle or portions of the gracilis. Large defects
can be covered with a latissimus dorsi flap, which provides up to 25 40
cm of coverage. Initially the muscle
may have a bulky appearance, but
because the muscle is denervated in
the course of transfer and atrophies
with time, the contour of the recipient site improves.
Volume 15, Number 5, May 2007

Management of Deep
Infection
Chronic osteomyelitis is most
commonly seen after an open fracture. The soft tissues at the fracture
site are usually scarred and adherent
to the underlying bone, and the vascularity of the region is impaired. In
fractures of the distal tibia, no reliable local muscles are suitable for
coverage of wounds after dbridement of the infected tissue.
This situation can be managed
using the principles of Cierny and
Mader,17 which consist of aggressive
dbridement of devitalized bone and
scarred tissues and coverage with a
muscle flap. A muscle flap is preferable to a fasciocutaneous flap because the muscle flap can effectively fill and eradicate dead space,
increase the vascularity of the affected area, and increase leukocyte function in the immediate area. If the
underlying internal fixation is contaminated, the optimal approach is
to remove it, provided the fracture
has united. When internal fixation
must be retained, it should be exchanged with noncolonized metalwork or, preferably, stabilized by
another means, such as external fixation. Retention of infected metalwork beneath the flap increases the
rate of recurrence of infection.
Reconstruction of
Segmental Bone Defects
Severe trauma, extirpation of a tumor, nonunion, or congenital pseudarthrosis all may result in segmental
skeletal loss. When amputation is
inappropriate, nonvascularized bone
grafting can be used for defects <5 to
6 cm in length. Ilizarov techniques
or a free vascularized bone graft can
be used to manage larger defects.
Vascularized bone grafts retain viable osteocytes and do not require
creeping substitution; hence, long
intercalary defects can be spanned.
The fibula has characteristics that
make it ideal for reconstruction of
segmental defects in long bones. The
fibula is vascularized by the peroneal

Figure 4

The reconstructive ladder.

artery and receives a nutrient artery

from this vessel in its mid third portion. The fibula can be harvested
with minimal morbidity to the leg
and will hypertrophy when exposed
to progressively increasing loads. In
adults, the mid portion of the fibula
is usually preferred in order to minimize the risk of instability of the
knee or ankle. Up to 25 cm of fibula
may be obtained. At least 6 cm of fibula is left distally to minimize the
risk of ankle instability, while dissection proximally past the neck of the
fibula will put the common peroneal
nerve at risk. Donor-site complications associated with harvesting the
fibula include transitory or permanent damage to the superficial or
deep peroneal nerves, contracture of
the flexor hallucis longus muscle,
and, in the skeletally immature patient, valgus deformity of the ankle.
Valgus deformity is prevented by creating a synostosis between the residual distal fibula and the tibia in patients younger than age 8 years.
The free vascularized fibula lends
itself well to reconstruction of segmental bone defects of the tibia,
femur, spine, clavicle, and forearm. It
has also been used, although with a
higher complication rate, in reconstruction of the humerus.18 When
increased volume of bone is required,
the fibula may be divided in its
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Principles of Free Tissue Transfer in Orthopaedic Practice

Figure 5

Overview of sources of vascularized bone for reconstruction of segmental defects.

* = vascularized epiphyseal fibular transfer for distal radius reconstruction in
skeletally immature patients, = double-barreled fibula option for femoral shaft
reconstruction

midsection while preserving the attachments of the peroneal artery,

thereby providing two segments that
are placed side by side in a doublebarreled arrangement.
It is possible to harvest the proximal fibula and proximal fibular physis to provide longitudinal growth of
the transplanted fibula. This procedure is technically demanding, however, because the proximal fibular
epiphysis receives its dominant vascular supply from the genicular arteries and branches of the anterior
tibial artery, whereas the shaft of the
fibula is nourished by a nutrient
branch from the peroneal artery. To
maximize the chances of epiphyseal
growth, both vascular territories
must be preserved19 (Figure 5).
Other sources of vascularized bone
for reconstruction include the lateral
border of the scapula as part of a scapular flap, the lateral distal radius as
part of an osteofasciocutaneous radial
forearm flap, and the lateral distal humerus as part of an osteofasciocutaneous lateral arm flap. Caution must
294

be exercised with the latter two donor sources because iatrogenic fracture is a recognized complication.
The ends of the osteotomy site should
be beveled to minimize stress risers,
and the defect should be prophylactically plated. The iliac crest, ribs, and
second metatarsal are also available
as sources of bone.
Functioning Free Muscle
Transfer
Brachial Plexus Surgery

Among the surgical options for

management of brachial plexus injuries are direct nerve repair and nerve
transfers. Both rely on reinnervation
of denervated muscles before the development of irreversible fibrofatty
degeneration. After degeneration has
occurred, a functioning free muscle
transfer, such as an innervated gracilis, rectus femoris, or latissimus dorsi, can be used to bring a healthy
muscle into the arm. The muscle is
harvested along with its nerve,
which is sutured to a healthy intraplexal or extraplexal nerve.

The gracilis muscle is often chosen for functioning free muscle

transfer because it is expendable, has
long muscle fiber length (providing
good excursion), and has a reliable
vascular pedicle from the medial circumflex femoral artery. Following a
successful gracilis transfer for deficient brachialis and biceps muscle
function, approximately 75% of patients have grade 3 or 4 elbow flexion; the typical patient can lift approximately 5 kg.20
An alternative approach to complete brachial plexus injury is to proceed to functioning free muscle transfer soon after the injury rather than
after muscle degeneration has occurred. Doi et al21 have advocated this
approach, which is designed to provide Prehensile function through the
use of two free muscle transfers. The
first free gracilis crosses the flexor side
of the elbow joint, using the brachioradialis and radial wrist extensors as
a pulley; the muscle is then sutured
to the wrist extensors. The second
free gracilis transfer is performed approximately 3 months later to provide
motors for the finger flexors. The
muscles are innervated by extraplexal
donorsthe first transfer by the spinal accessory nerve, the second by intercostal nerves. Intercostal nerves
are also used to motor the triceps
muscle and to provide sensory fibers
to the median nerve. Using this sequence of procedures, Doi et al22 obtained satisfactory elbow flexion in
96% of patients and prehension of at
least 30 of total active finger motion
in 65% of patients.
Volkmanns Ischemic
Contracture in the Forearm

In mild or moderate Volkmanns

contracture, sufficient muscle may
survive to allow tendon transfers to
replace lost functions. In severe
Volkmanns contracture, most of the
flexor mass and much of the extensor muscle mass of the forearm undergoes ischemic necrosis, leaving
insufficient muscle for tendon transfer. A solution to this problem is free

Journal of the American Academy of Orthopaedic Surgeons

Richard Lawson, MBBS, FRACS, and L. Scott Levin, MD, FACS

muscle transfer. One innervated gracilis free muscle can be used to provide finger (or wrist) flexor muscle,
and a second one can be used to provide finger (or wrist) extension.
Hand Reconstruction:
Toe-to-Thumb Transfer
Toe-to-hand transfer can provide
pinch grasp in the child with congenital absence of the digits, particularly in the setting of constriction
band syndrome, and can restore
function in the patient with traumatic digital loss. Options available
for toe-to-thumb transfer include using all or part of the great toe or using the second or third toes. The
great toe can be transferred en bloc
or, for reconstruction of a more distal defect, a segment can be obtained
in the form of a wraparound or a
trimmed toe transfer. The great toe
is approximately 30% larger than
the thumb, and a trimmed toe transfer has superior cosmetic results
compared with a standard great toe
transfer. Second toe transfer offers a
more pleasing donor site but has an
inferior appearance on the hand as
well as poorer functional results.23
Osteonecrosis
Osteonecrosis of the Femoral
Head

Urbaniak developed the use of the

vascularized fibula for management
of osteonecrosis of the femoral head,
in lieu of joint replacement with arthroplasty.24 The fibula acts as a
structural support for the subchondral bone and as a source of mesenchymal stem cells, which encourage
revascularization of the osteonecrotic bone. Comparison of patients
who underwent vascularized fibular
grafting with a cohort of patients in
whom osteonecrosis was treated
with core decompression demonstrated improved survival of the free
fibula group. Conversion to total hip
arthroplasty was the end point. At
50 months, 81% of the free vascularized fibula group had not required
conversion to a total hip arthroplasVolume 15, Number 5, May 2007

ty compared with 21% of the core

decompression group.24
Osteonecrosis and Nonunion
of Carpal Bones

Many pedicled grafts have been

described for the treatment of
scaphoid nonunion and Kienbcks
disease. Free vascularized bone grafts
may offer some advantages to local
pedicled grafts in the form of stronger, more easily shaped grafts and in
increased flexibility of placement of
the graft. Doi et al25 reported on the
successful treatment of 10 patients
with scaphoid nonunion, each of
whom received a free vascularized
graft from the medial supracondylar
aspect of the femur that was nourished by the descending medial genicular artery and fixed on the volar
aspect of the scaphoid.
Vascularized Joint
The options for reconstruction of
damaged or congenitally deficient
thumb or finger joints include primary repair of the joint surfaces and
fusion. Another solution, when the
requirement for motion of the joint
justifies the increased complexity
and donor morbidity, is a vascularized toe joint.26 The metatarsophalangeal joints of the second and third
toes can be used to reconstruct the
metacarpophalangeal (MCP) joints,
and the toe proximal interphalangeal
(PIP) joints can be used to reconstruct either the MCP joints or the
finger PIP joints. The vascular pedicle for the toe joints is based on the
dorsalis pedis arterial system.
Toe joint transfers have greater
ranges of motion when used to manage posttraumatic defects compared
with congenital lesions; approximately 30 of motion is typically obtained. An extensor lag of 20 to 30
usually occurs. This procedure is
very technically demanding.
Vascularized Nerve
Vascularized nerves may be preferable to nonvascularized grafts
when they will be placed in a scarred

bed or if a particularly large segmental defect must be spanned.

Adult patients with complete brachial plexus palsy will not achieve
return of function of the muscles innervated by the ulnar nerve. The ulnar nerve can therefore be harvested
along with the ulnar collateral arteries as a source of vascularized nerve
graft for reconstruction of the brachial plexus. This option is commonly used when the contralateral
C7 nerve root is chosen as a source
of axons for reconstruction of severe
brachial plexus palsy (Table 1).

Patient Selection
When assessing patients for elective
free tissue transfer, the treating surgeon must seek to optimize all medical parameters. Smoking has been
shown to affect blood flow and
wound healing, although it may not
affect the overall rate of anastomotic patency or flap survival.27
Simpler options, including amputation, may be preferable in the presence of complex pathophysiologic
states, such as chronic renal failure
or severe diabetes. Diminished mental capacity or psychiatric illness
may prevent compliance with postoperative care and rehabilitation.
Patient age does not appear to be
a major factor in patient selection.9,28

Perioperative and
Postoperative
Management of Free
Tissue Transfer
A free tissue transfer is a demanding
surgical procedure; careful preoperative planning is essential to ensure
optimal results. A two-team approach is often used to maximize efficiency and minimize fatigue, with
one team raising the tissue to be
transferred while the other team prepares the recipient site. Even the
most accomplished surgeon will
have a failure rate of 2% to 5%, and
part of the surgical plan is to have an
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Principles of Free Tissue Transfer in Orthopaedic Practice

Table 1
Overview of Donor Options for Free Tissue Transfer
Tissue
Type
Skin

Muscle

296

Donor Site

Size of Flap

Comments

Disadvantages

Radial forearm

Up to 10 30 cm

Workhorse flap
Reliable pedicle, pliable
skin, can be combined
with transfers of
tendon and bone

Healing of donor site may

be suboptimal, with poor
aesthetic appearance
Compromises arterial inflow
to hand

Groin

10 25 cm

Easily disguised donor

site

Short pedicle, aesthetic

implications of pubic hair
at medial aspect of flap,
complex vascular anatomy

Anterolateral thigh

Up to 25 18 cm

Large area of skin and

fascia available

May be aesthetic objections

in females
Less reliable pedicle
Can have very thick layer of
adipose tissue, particularly
in white patients

Lateral arm

Up to 8 15 cm (no
more than 6 cm width
if primary closure
desired)

Can have very small pedicle

Allows harvest from
If harvested over lateral
same arm as affected
epicondyle, can cause
limb
problems in healing of
Can be innervated with
graft used to cover donor
posterior cutaneous
defect
nerve of arm and
harvested with a
portion of the humerus

Scapular and
parascapular flaps

Up to 20 7 cm

Simple, reliable anatomy, Spreading of scar common,

hairless
and skin can be
Can be harvested with
particularly thick
strip of scapula if bone Not innervated
also required

Dorsalis pedis

Up to 14 12 cm

Can harvest with

extensor tendons, can
be innervated with
superficial or deep
peroneal nerves
Very thin, pliable flap
Good for extensor
surface of hand

Latissimus dorsi

Up to 25 40 cm

Workhorse muscle flap

Seroma formation at donor
Largest available muscle, site relatively common
thin and pliable, long
reliable pedicle

Gracilis

Up to 6 24 cm
Skin paddle up to
16 18 cm

Distal skin paddle unreliable

Full length of muscle
often used for free
muscle transfer; small
portion can be used for
smaller defects
Disguised donor scar, no
deficit

Serratus anterior

10 15 cm

Used for small defects

Thin pliable muscle,
easily contoured

Requires skin graft to cover

donor defect, which often
has poor take; thus, there
is significant donor-site
morbidity

Winging of scapula when

more than four slips are
removed

Journal of the American Academy of Orthopaedic Surgeons

Richard Lawson, MBBS, FRACS, and L. Scott Levin, MD, FACS

Table 1 (continued)
Overview of Donor Options for Free Tissue Transfer
Tissue
Type

Donor Site

Size of Flap

Comments

Disadvantages

Muscle Rectus abdominis

(contd)

Up to 25 6 cm
Skin paddle up to
21 14 cm

Easily harvested, good

pedicle diameter

Hernia possible unless

careful closure of rectus
sheath

Fascia

Radial forearm

8 20 cm

Can take fascia alone

with improved donor
cosmesis

Loss of radial artery

Temporoparietal

8 15 cm

Thin, pliable bilayered

Possible damage to frontal
flap applicable for
branch of facial nerve
coverage of exposed
May cause alopecia if
tendons
dissection plane too
Inconspicuous donor site superficial

Fibula

Up to 25 cm

Long, strong strut of

bone that can be used
to reconstruct defects
of all long bones
Can be combined with
vascularized
epiphyseal transfer to
allow growth

Uncommon peroneal nerve

palsy, flexor hallucis
longus contracture, ankle
instability
Relatively short pedicle
length

Radius

8 to 10 11.5 cm

Lateral aspect of distal

radius can be
harvested with radial
forearm flap

Radial fracture common

unless defect well
contoured and plated

Scapula

Up to 3 11 cm

Can be harvested with

scapular or
parascapular flap

Bone is thin and not easily

worked

Humerus

Up to 1 10 cm

Distal lateral humerus

can be harvested with
lateral arm flap

Bone is thin and not easily

worked

Iliac crest

Up to 12 4 cm
Skin paddle 8 18 cm

Curved bone can be

Inguinal hernia possible if
used to match curved
inadequate closure; curved
defects; rapidly healing bone infrequently required
cancellous bone
in orthopaedic
reconstruction

Bone

Toe

Great toe

Best thumb substitute

Larger than thumb by 30%;

significant donor
morbidity

Trimmed great toe (great

toe is harvested but
trimmed to better
match thumb)

Improved aesthetics
compared with great
toe transfer

Donor morbidity of loss of

great toe

Wrap-around

Best aesthetic
appearance of all toe
transfers
Preserves function of
great toe

Only applicable to thumb

loss where there is some
proximal phalanx available

Second toe

Less significant donor

defect

Inferior aesthetic appearance

on hand; looks like a toe

Volume 15, Number 5, May 2007

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Principles of Free Tissue Transfer in Orthopaedic Practice

alternative procedure to achieve

wound closure, should the first procedure fail.
Perioperative strategies are directed toward maximizing flap perfusion. Before surgery, the patient is
vasodilated; this is achieved by keeping the patient hot, happy, and hydrated. Some surgeons prefer to admit the patient the night before
surgery to allow intravenous hydration and to ensure that a warm environment is maintained.
Once in the operating room, the
ambient temperature should be kept
high (around 24C) and the patient
kept normothermic through the application of hot air blankets, heating
pads, and warmed intravenous fluids.
The optimal hematocrit level is
30, which provides the best compromise between low viscosity (promoting blood flow) and acceptable oxygen delivery to the tissues. Adequate
blood pressure is maintained primarily through use of fluid volume
rather than pressor agents. A urine
output of at least 1 mL/kg/hr is desirable. Poor flow through the vascular pedicle is often directly related to
low blood pressure or hypothermia;
correction of these variables typically results in a marked improvement
in blood flow.
The use of agents to alter viscosity and clotting, both during and after the operation, is controversial;
there is no high-quality scientific evidence to guide the surgeon. Aspirin,
heparin, and dextran are used frequently. Conrad and Adams29 have
published a useful review of pharmacology in microsurgery.
Postoperatively, the patient often
is kept intubated and sedated overnight to minimize fluctuations in
blood pressure and to allow an expeditious return to the operating room
should reexploration of the flap be
necessary.
Adequate perfusion of the free
tissue transfer can be monitored
through clinical observation or
through adjuncts such as laser or
implantable Doppler probes, which
298

may give an early indication of flap

perfusion problems and enhance the
flap salvage rate. Arterial insufficiency is indicated by a pale, cool flap
with delayed capillary refill and failure to bleed upon pin prick. Venous
insufficiency leads to a blue, mottled
color with immediate capillary refill
and swelling of the flap. Arterial insufficiency is an indication for immediate return to the operating
room, as is venous insufficiency in
most cases. Flap congestion may be
relieved by the removal of selected
sutures, changes in position, or the
loosening of constricting dressings;
however, when immediate improvement is not noted, emergency exploration is mandatory.
On return to the operating room,
the pedicle is inspected for kinking,
torsion, or compression, and any
large hematomas are removed. Patency of the pedicle is checked by visual inspection, aided by a sterile
Doppler probe. When there is no
other obvious reversible problem,
the anastomosis may need to be redone. As a last resort, a thrombolytic agent, such as streptokinase, may
be injected into the artery of the
pedicle to break down any thrombi
in the vascular bed. However, it is
important to disconnect the venous
outflow before doing this in order to
prevent systemic administration of
the agent.
Early return to the operating
room allows the salvage of >50% of
compromised flaps.9

Complications of Free
Tissue Transfer
The most serious complication is
failure of the flap (ie, ischemic necrosis of the tissue). Flap failure occurs
more frequently early in the surgeons experience. Different tissues
have varying tolerance for ischemia.
Muscle flaps are the least tolerant,
and failure to reestablish effective
perfusion by 2 hours usually results
in irreversible insult to the muscle.
Skin, fascia, and bone have greater

tolerance to ischemia, but ischemic

time should always be minimized.
Free tissue transfer inevitably results in some donor morbidity, and
flaps are carefully chosen to minimize this. For example, an anterolateral thigh flap leaves a large defect
that may be cosmetically unacceptable in a young female but would
have little aesthetic consequence in
a male. Endoscopic harvesting of
tissue can decrease donor-site scarring.
The muscle flaps that are routinely used typically result in little loss
of function. The gracilis is entirely
expendable. Loss of the latissimus
dorsi is compensated for by the remaining shoulder girdle muscles.
Harvest of a large flap and creation of a large raw surface may result in seroma formation, which is
most commonly seen with the latissimus dorsi flap. The seroma may be
treated with repeated aspirations or
excision if encapsulated.
The most common serious complication of a vascularized bone
transfer is nonunion. Bishop30 found
a primary union rate of 68% for vascularized fibular grafts, which increased to 82% with supplementary
bone graft.

Future Directions
The ultimate example of matching
like with like is allograft hand
transplantation. This provides the
only means of replacing the multiple
complex structures within the hand.
The main obstruction to use of this
technique, outside the experimental
setting, is the need for ongoing immunosuppression to prevent rejection of the allograft. Presently there
is intense research interest in the
field of immunomodulation to overcome this problem.31

Summary
Free tissue transfer can provide superior functional and aesthetic results
in a variety of posttraumatic and

Journal of the American Academy of Orthopaedic Surgeons

Richard Lawson, MBBS, FRACS, and L. Scott Levin, MD, FACS

elective settings. Refinements in indications and technique have resulted in higher rates of flap survival and
improved results.
The primary indication for free
tissue transfer in the emergency setting is to cover exposed vital structures. In the elective setting, free
tissue transfer can be used to
reconstruct segmental defects, treat
chronic deep-seated infection, replace lost function with free muscle
transfer, and replace lost or absent
digits.
Free tissue transfer is a demanding surgical procedure; careful attention to detail from both the surgeon
and anesthesiologist is necessary to
maximize flap survival. Physiologic
parameters must be closely monitored, hydration and temperature optimized, and pain controlled. In the
setting of a failing flap, urgent exploration in the operating room offers
the best chance to salvage the flap.

7.

8.

9.

10.

11.

12.

Acknowledgment
We thank Mr. Stan Coffman for
preparation of the figures accompanying the manuscript.

13.

References
Citation numbers printed in bold
type indicate references published
within the past 5 years.

14.

15.
1.

2.

3.

4.

5.

6.

Wei FC, Jain V, Suominen S, Chen

HC: Confusion among perforator
flaps: What is a true perforator flap?
Plast Reconstr Surg 2001;107:874876.
Lister G, Scheker L: Emergency free
flaps to the upper extremity. J Hand
Surg [Am] 1988;13:22-28.
Gillies H, Millard DR: The Principles
and Art of Plastic Surgery. Boston,
MA: Little & Brown, 1957.
Jacobson JH, Suarez EL: Microsurgery
in anastomosis of small vessels. Surg
Forum 1960;11:243-245.
Song R, Gao Y, Song Y, Yu Y, Song Y:
The forearm flap. Clin Plast Surg
1982;9:21-26.
Taylor GI, Miller GD, Ham FJ: The
free vascularized bone graft: A clinical

Volume 15, Number 5, May 2007

16.

17.

18.

19.

extension of microvascular techniques. Plast Reconstr Surg 1975;55:

533-544.
Taylor GI, Ham FJ: The free vascularized nerve graft: A further experimental and clinical application of microsurgical techniques. Plast Reconstr
Surg 1976;57:413-426.
Buncke HJ Jr, Buncke CM, Schulz WP:
Immediate Nicoladoni procedure in
the Rhesus monkey, for hallux-tohand transplantation, utilising microminiature vascular anastomoses. Br J
Plast Surg 1966;19:332-337.
Khouri RK, Cooley BC, Kunselman
AR, et al: A prospective study of microvascular free flap surgery and outcome. Plast Reconstr Surg 1998;102:
711-721.
Van Buskirk ER, Rehnke RD, Montgomery RL, Eubanks S, Ferraro FJ,
Levin LS: Endoscopic harvest of the
latissimus dorsi muscle using the
balloon dissection technique. Plast
Reconstr Surg 1997;99:899-905.
Lin CH, Wei FC, Levin LS, Chen MC:
Donor-site morbidity comparison between endoscopically assisted and
traditional harvest of free latissimus
dorsi muscle flap. Plast Reconstr
Surg 1999;104:1070-1078.
Heller L, Levin LS: Bone and soft tissue reconstruction, in Bucholz R,
Heckman JD (eds): Rockwood and
Greens Fractures in Adults, ed 5.
Philadelphia, PA: Lippincott Williams & Wilkins, 2001, pp 415-462.
Heller L, Levin LS: Lower extremity
microsurgical reconstruction. Plast
Reconstr Surg 2001;108:1029-1042.
Heitmann C, Levin LS: The orthoplastic approach for management of the
severely traumatized foot and ankle.
J Trauma 2003;54:379-390.
Levin LS: The reconstructive ladder:
An orthoplastic approach. Orthop
Clin North Am 1993;24:393-409.
Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;
78:285-292.
Cierny G III, Mader JT: Approach to
adult osteomyelitis. Orthop Rev
1987;16:259-270.
Heitmann C, Erdmann D, Levin LS:
Treatment of segmental defects of the
humerus with an osteoseptocutaneous fibular transplant. J Bone Joint
Surg Am 2002;84:2216-2223.
Serafin D: The fibular flap, in Serafin
D (ed): Atlas of Microsurgical Composite Tissue Transplantation. Philadelphia, PA: WB Saunders, 1996, pp
547-573.

20.

21.

22.

23.

24.

25.

26.

27.

28.

29.

30.

31.

Manktelow RT, Anastakis DJ: Functioning free muscle transfers, in

Green DP, Hotchkiss RN, Pederson
WC (eds): Greens Operative Hand
Surgery, ed 4. Philadelphia, PA:
Churchill Livingstone, 1999, vol 2, pp
1201-1219.
Doi K, Sakai K, Kuwata N, Ihara K,
Kawai S: Double free muscle transfer to restore prehension following
complete brachial plexus avulsion.
J Hand Surg [Am] 1995;20:408-414.
Doi K, Muramatsu K, Hattori Y, et al:
Restoration of prehension with the
double free muscle technique following complete avulsion of the brachial
plexus: Indications and long-term results. J Bone Joint Surg Am 2000;82:
652-666.
Wei FC: Thumb reconstruction, in
Berger RA, Weiss APC (eds): Hand
Surgery. Philadelphia, PA: Lippincott
Williams & Wilkins, 2004, pp 16631676.
Scully SP, Aaron RK, Urbaniak JR:
Survival analysis of hips treated with
core decompression or vascularized
fibular grafting because of avascular
necrosis. J Bone Joint Surg Am 1998;
80:1270-1275.
Doi K, Oda T, Soo-Heong T, Nanda V:
Free vascularized bone graft for nonunion of the scaphoid. J Hand Surg
[Am] 2000;25:507-519.
Foucher G: Vascularized joint transfer, in Green DP, Hotchkiss RN, Pederson WC, Wolfe SW (eds): Greens
Operative Hand Surgery, ed 5. Philadelphia, PA: Elsevier, 2005, vol 2, pp
1813-1834.
Krueger JK, Rohrich RJ: Clearing the
smoke: The scientific rationale for tobacco abstention with plastic surgery.
Plast Reconstr Surg 2001;108:10631077.
Coskunfirat OK, Chen H, Spanio S,
Tang YB: The safety of microvascular
free tissue transfer in the elderly population. Plast Reconstr Surg 2005;
115:771-775.
Conrad MH, Adams WP Jr: Pharmacologic optimization of microsurgery in
the new millennium. Plast Reconstr
Surg 2001;108:2088-2097.
Bishop AT: Vascularized bone grafting, in Green DP, Hotchkiss RN, Pederson WC (eds): Greens Operative
Hand Surgery, ed 4. Philadephia, PA:
Churchill Livingstone, 1999, vol 2, pp
1229-1250.
Amadio PC: Whats new in hand surgery. J Bone Joint Surg Am 2005;87:
468-474.

299