{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,25]],"date-time":"2026-09-25T16:50:58Z","timestamp":1790355058659,"version":"4.1.0"},"reference-count":23,"publisher":"MDPI AG","issue":"19","license":[{"start":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T00:00:00Z","timestamp":1758844800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["www.mdpi.com"],"crossmark-restriction":true},"short-container-title":["JCM"],"abstract":"<jats:p>Background: Reconstruction of distal forearm and hand soft tissue defects remains a complex surgical challenge due to the functional and aesthetic significance of the region. Several flap options have been established such as the posterior interosseous artery flap (PIA) or temporalis fascia flap (TFF), yet the anterolateral thigh flap (ALT) has gained increasing attention for its versatility and favorable risk profile. Methods: We retrospectively analyzed 12 patients (7 males, 5 females; mean age 51.8 years) who underwent free microvascular ALT reconstruction for distal forearm and hand defects between May 2020 and May 2025. Etiologies included infection, chemical burns, explosion injuries, and traffic accidents. The mean defect size was 75.4 cm2, and the average operative time was 217 min. Secondary flap thinning was performed in eight cases. In one patient without available recipient veins, a pedicle vein was anastomosed using a coupler device anchored into a cortical window of the distal radius to establish venous outflow via the bone marrow. Results: All flaps demonstrated complete survival with successful integration. Minor complications included transient venous congestion in one case and superficial wound dehiscence in four cases. Functional outcomes were favorable, with postoperative hand function rated as very good in 10 of 12 patients at follow-up. The bone-anchored venous anastomosis provided effective venous drainage in the salvage case. Conclusions: The free microvascular ALT is a reliable and highly adaptable method for distal forearm and hand reconstruction. It provides excellent soft tissue coverage, allows for secondary contouring, and achieves both functional and aesthetic goals. Furthermore, intraosseous venous anastomosis using a coupler device might represent a novel adjunct that may expand reconstructive options in cases with absent or unusable recipient veins.<\/jats:p>","DOI":"10.3390\/jcm14196807","type":"journal-article","created":{"date-parts":[[2025,9,26]],"date-time":"2025-09-26T08:31:28Z","timestamp":1758875488000},"page":"6807","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":2,"title":["Microvascular ALT-Flap Reconstruction for Distal Forearm and Hand Defects: Outcomes and Single-Case Application of a Bone-Anchored Venous Anastomosis"],"prefix":"10.3390","volume":"14","author":[{"given":"Adrian Matthias","family":"Vater","sequence":"first","affiliation":[{"name":"Department of Plastic, Aestethic, Hand and Reconstructive Surgery, Medizincampus Niederbayern, University of Regensburg, General Hospital Passau, Innstra\u00dfe 76, 94032 Passau, Germany"},{"name":"Department of Trauma-, Hand-, Plastic and Reconstructive Surgery, University Hospital W\u00fcrzburg, Oberd\u00fcrrbacher Stra\u00dfe 6, 97080 W\u00fcrzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthias Michael","family":"Aitzetm\u00fcller-Klietz","sequence":"additional","affiliation":[{"name":"Department of Plastic, Aestethic, Hand and Reconstructive Surgery, Medizincampus Niederbayern, University of Regensburg, General Hospital Passau, Innstra\u00dfe 76, 94032 Passau, Germany"},{"name":"Department of Trauma, Hand and Reconstructive Surgery, Division of Plastic Surgery, University Hospital Muenster, 48149 Muenster, Germany"},{"name":"Division of Plastic Surgery, Institute of Musculoskeletal Medicine, University Hospital Muenster, 48149 Muenster, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Philipp Edmund","family":"Lamby","sequence":"additional","affiliation":[{"name":"Department of Plastic, Aestethic, Hand and Reconstructive Surgery, Medizincampus Niederbayern, University of Regensburg, General Hospital Passau, Innstra\u00dfe 76, 94032 Passau, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Julia","family":"Stanger","sequence":"additional","affiliation":[{"name":"Department of Plastic, Aestethic, Hand and Reconstructive Surgery, Medizincampus Niederbayern, University of Regensburg, General Hospital Passau, Innstra\u00dfe 76, 94032 Passau, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rainer","family":"Meffert","sequence":"additional","affiliation":[{"name":"Department of Trauma-, Hand-, Plastic and Reconstructive Surgery, University Hospital W\u00fcrzburg, Oberd\u00fcrrbacher Stra\u00dfe 6, 97080 W\u00fcrzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Karsten","family":"Schmidt","sequence":"additional","affiliation":[{"name":"Department of Trauma-, Hand-, Plastic and Reconstructive Surgery, University Hospital W\u00fcrzburg, Oberd\u00fcrrbacher Stra\u00dfe 6, 97080 W\u00fcrzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Michael Georg","family":"Jakubietz","sequence":"additional","affiliation":[{"name":"Department of Trauma-, Hand-, Plastic and Reconstructive Surgery, University Hospital W\u00fcrzburg, Oberd\u00fcrrbacher Stra\u00dfe 6, 97080 W\u00fcrzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Rafael Gregor","family":"Jakubietz","sequence":"additional","affiliation":[{"name":"Department of Trauma-, Hand-, Plastic and Reconstructive Surgery, University Hospital W\u00fcrzburg, Oberd\u00fcrrbacher Stra\u00dfe 6, 97080 W\u00fcrzburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2025,9,26]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1016\/j.hcl.2014.08.002","article-title":"Soft tissue coverage of the upper extremity: An overview","volume":"30","author":"Chim","year":"2014","journal-title":"Hand Clin."},{"key":"ref_2","first-page":"82","article-title":"Der Interossea posterior-Lappen--Ubersichtsarbeit und eigene Erfahrungen [The posterior interosseous flap--review and personal experience]","volume":"30","author":"Moshammer","year":"1998","journal-title":"Handchir. Mikrochir. Plast. Chir."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"272","DOI":"10.1177\/15589447211028925","article-title":"Versatility of the Posterior Interosseous Artery Flap: Emphasis on Powering Up the Toe Transfer","volume":"18","author":"Lee","year":"2023","journal-title":"Hand"},{"key":"ref_4","first-page":"498","article-title":"The posterior interosseus artery flap (piaf) in reconstructive surgery of the hand: Strategies of use and medico-legal implications","volume":"174","author":"Amadei","year":"2023","journal-title":"Clin. Ter."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"2088","DOI":"10.1016\/j.jhsa.2012.07.014","article-title":"The effectiveness of pedicled groin flaps in the treatment of hand defects: Results of 49 patients","volume":"37","author":"Goertz","year":"2012","journal-title":"J. Hand Surg. Am."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"745","DOI":"10.1097\/SAP.0000000000003702","article-title":"The Pedicled Sensate Osteocutaneous Groin Flap for Reconstruction of the Forearm and Hand","volume":"91","author":"Turan","year":"2023","journal-title":"Ann. Plast. Surg."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"475","DOI":"10.1016\/S0363-5023(86)80180-0","article-title":"Clinical applications of free temporoparietal flaps in hand reconstruction","volume":"11","author":"Upton","year":"1986","journal-title":"J. Hand Surg. Am."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"467","DOI":"10.1097\/01.prs.0000173059.73982.50","article-title":"Hand reconstruction using the thin anterolateral thigh flap","volume":"116","author":"Adani","year":"2005","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_9","doi-asserted-by":"crossref","unstructured":"Cheng, L., Dai, Q., Du, W.L., Che, K.X., Cao, T.Y., and Shen, Y.M. (Ann. Plast. Surg., 2025). Clinical Efficacy of Double Skin Paddle Anterolateral Thigh Flap in High-Voltage Electrical Burns of the Wrist and Hand, Ann. Plast. Surg., epub ahead of print.","DOI":"10.1097\/SAP.0000000000004370"},{"key":"ref_10","first-page":"2279","article-title":"Sensory reinnervation of free flaps in reconstruction of the breast and the upper and lower extremities","volume":"7","author":"Sinis","year":"2012","journal-title":"Neural Regen. Res."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"e38763","DOI":"10.1097\/MD.0000000000038763","article-title":"Surgical refinements and sensory and functional outcomes of using thinned sensate anterolateral thigh perforator flaps for foot and ankle reconstruction: A retrospective study","volume":"103","author":"Pan","year":"2024","journal-title":"Medicine"},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"49","DOI":"10.1007\/s12593-014-0167-x","article-title":"Neural Anatomy of the Anterolateral Thigh Flap","volume":"7","author":"Luenam","year":"2015","journal-title":"J. Hand Microsurg."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"e26517","DOI":"10.1097\/MD.0000000000026517","article-title":"The use of the posterior interosseous artery flap and anterolateral thigh flap for post-traumatic soft tissue reconstruction of the hand","volume":"100","author":"Ren","year":"2021","journal-title":"Medicine"},{"key":"ref_14","first-page":"719726","article-title":"Free anterolateral thigh flap in hand and upper extremity reconstruction: A retrospective study","volume":"45","author":"Adani","year":"2020","journal-title":"J. Hand Surg. Am."},{"key":"ref_15","first-page":"367","article-title":"Free tissue transfer in the hand: Review of 33 years ofexperience","volume":"32","author":"Wei","year":"2016","journal-title":"Hand Clin."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"165","DOI":"10.1007\/s00402-020-03635-9","article-title":"Retrospective analysis of free temporoparietal fascial flap for defect reconstruction of the hand and the distal upper extremity","volume":"141","author":"Horch","year":"2021","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"ref_17","first-page":"780","article-title":"Comparing the posterior interosseous artery flap and anterolateral thigh flap for hand reconstruction: A systematic review and meta-analysis","volume":"142","author":"Zhou","year":"2018","journal-title":"Plast. Reconstr. Surg."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"463","DOI":"10.1002\/micr.30460","article-title":"Soft tissue free flap for reconstruction of upper extremities: A meta-analysis on outcome and safety","volume":"39","author":"Zhang","year":"2019","journal-title":"Microsurgery"},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1055\/s-0039-3400515","article-title":"Long-Term Quality of Life after Free Flap Upper Extremity Reconstruction for Traumatic Injuries","volume":"36","author":"Zuidam","year":"2020","journal-title":"J. Reconstr. Microsurg."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"755","DOI":"10.1016\/j.bjps.2020.10.065","article-title":"Reconstruction of upper limb soft-tissue defects after sarcoma resection with free flaps: A systematic review","volume":"74","author":"Lucattelli","year":"2021","journal-title":"J. Plast. Reconstr. Aesthetic Surg."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"269","DOI":"10.3233\/CH-180467","article-title":"Do two venous anastomoses decrease venous thrombosis during limb reconstruction?","volume":"72","author":"Iamaguchi","year":"2019","journal-title":"Clin. Hemorheol. Microcirc."},{"key":"ref_22","first-page":"203","article-title":"Value of high resolution ultrasound and contrast enhanced US pulse inversion imaging for the evaluation of the vascular integrity of free-flap grafts","volume":"36","author":"Prantl","year":"2007","journal-title":"Clin. Hemorheol. Microcirc."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"13","DOI":"10.52547\/wjps.11.3.13","article-title":"Functional and Aesthetic Outcomes of the Anterolateral Thigh Flap in Reconstruction of Upper Limb Defects: A Systematic Review","volume":"11","author":"Hagiga","year":"2022","journal-title":"World J. Plast. 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