Hip Reconstruction

Clinical Presentation

A 68-year-old White male had a complicated postoperative course after an osteocutaneous flap harvest from his right hip by another surgical service. He had a significantly large open wound over the right hip, measuring 25 × 10 cm, with exposed pelvic structures ( Fig. 31.1 ). This patient had previous wound debridement and a wound vacuum-assisted closure (VAC) by the primary service. Some granulation tissue had developed within the wound. The primary service used acellular dermal matrix that appeared to be incorporated with the wound bed ( Fig. 31.2 ). The plastic surgery service was asked by our ENT microvascular team to carry out a definitive wound closure.

Operative Plan and Special Considerations for Reconstruction

For this large soft tissue wound with exposed pelvic structures in the lateral hip and pelvis, a distant muscle flap with a relatively large amount of well-vascularized tissue, such as a rectus femoris muscle flap, can be selected to provide a one-stage soft tissue coverage and obliterate the potential space. The flap, which receives a blood supply primarily from the descending branch of the lateral circumflex femoral artery, is a type II muscle flap but is fairly reliable if the patient is free of peripheral vascular disease in the profound artery. It is a large muscle flap that can be used to cover lower abdominal wall or pelvic soft tissue defect. Approximation of the vastus lateralis and vastus medialis after the rectus femoris muscle flap harvest may possibly reduce weakness of the knee extension. An adjacent abdominal skin rotation flap can be added to facilitate the entire wound closure in addition to a skin graft to the muscle flap in this case.

Operative Procedures

Under general anesthesia with the patient in a supine position, the right hip wound was debrided first. All floating acellular dermal matrix was also excised but incorporated acellular dermal matrix was left in place.

The design for the right rectus femoris muscle flap harvest was marked. The skin incision was made from the anterior iliac spine to the central part of the patella after infiltration with 1% lidocaine with 1:100,000 epinephrine. The skin, subcutaneous tissue, and fascia were incised and the rectus abdominis muscle was identified. The muscle was elevated and a Penrose drain was used to wrap around the muscle. The dissection was done to free its attachment to the vastus lateralis and vastus medialis muscles. The muscle flap was then divided more distally close to the patella. The muscle was elevated and the pedicle vessels were identified. One minor pedicle vessel was temporally clamped first and then divided with hemoclips. Further dissection was made around the major pedicle. ( Fig. 31.3 ). The proximal end of the muscle was divided and the flap was then tunneled to the right hip wound and secured using interrupted 3-0 Monocryl sutures.

Because of the area with the exposed acellular dermal matrix, an adjacent skin rotation flap was also elevated. This flap, measuring 12 × 3 cm, was rotated into the area to cover the exposed acellular dermal matrix. The skin flap donor site was approximated with several interrupted 3-0 Vicryl sutures and the skin closure was done with skin staples. A 10 flat JP was inserted under the muscle flap. The flap was inserted into the right hip wound and secured with multiple 3-0 Monocryl sutures to create a better contour and soft tissue coverage ( Fig. 31.4 ).

A split-thickness skin graft was harvested with a dermatome from the right lateral thigh. It was meshed to 1:1/2 ratio. The skin graft was placed over the muscle and the rest of the granulation wound and secured with multiple skin staples ( Fig. 31.5 ). A VAC dressing was placed over the skin grafted muscle flap and connected to a VAC machine ( Fig. 31.6 ).

The rectus femoris muscle flap donor site was closed after irrigation. A 10 flat JP was inserted into the donor site. Both vastus lateralis and vastus medialis muscles were approximated with interrupted 2-0 Prolene sutures. The deep dermal closure was performed with interrupted 3-0 Monocryl sutures and the skin was closed with skin staples.

Follow-Up Results

The patient did well postoperatively without any issues related to flap reconstruction and donor wound closure. He was discharged from the hospital on postoperative day 7. His right hip and pelvic wound healed uneventfully ( Fig. 31.7 ). He was followed by both the primary service and the plastic surgery service for subsequent care.