Case 1 - 2025: Lower back reconstruction with free ALT flap, free radial bridge flap and vein graft

Keywords: Double free flap, flap to flap, free radial bridge flap, radial conduit, vein graft, lower back defect. Authors: Andrea Donfrancesco, MD and Jenny Löfgren, MD, Karolinska University Hospital, Stockholm, Sweden Abstract A challenging case of midline mid-lower back defect is presented. The patient underwent previously vertebral chondrosarcoma resection, spine fixation and post-operative radiotherapy, and was re-operated 2 years after because of vertebral bone re-absorption and rupture of the previously done spinal fixation. The skin and soft tissue never healed and the patient had a 22 x 10 cm defect of the mid-lower back with exposed fixation material, exposed dura above the spinal cord, and radiotherapy damaged tissue around. No local reconstructive option was feasible. We reconstructed the defect with a free ALT, connected to a free radial bridge flap and a saphenous vein graft, hooked up to the thoracodorsal vessel, and a new spinal fixation was performed. Reconstruction was successful. Patient medical history The patient is previously healthy, has no past medical history. She developed a bulge on the back at T12 level. MRI and biopsy showed chondrosarkoma. She was operated at Karolinska University Hospital in May 2022 with sarkoma resection, spinal fixation T 10 to L3, primary skin closure, and post- operative radiotherapy. After 2 years the patient presented with osteoporotic reabsorption of bone, fusion/collapse of L1-L2, and rupture of a shaft of the previous fixation. The patient underwent again surgery by the spine surgeon at our hospital in July 2024 with extraction of the previously done fixation, and a new longer fixation was performed T5 to L5. Beacuse the soft tissues ware previously irradiated, a left pedicled muscle latissimus flap was performed to have better coverage of the upper potion of the defect. The wound ruptured and got infected, with expsure of the spinal fixation material; the patient received targeted IV antibiotics and the woun