Venous-trapezium coupler anastomosis in a partially congested combined ALT/TFL-flap: A case report.

Background: Reconstruction of large soft tissue defects with extensive vascular trauma remains a challenge. Intraosseous cannulation, commonly used in emergency medicine, may offer a novel solution for venous outflow. We report the use of the trapezium bone for venous drainage in a combined anterolateral thigh and tensor fasciae latae (ALT/TFL) flap reconstruction. Case: A patient presented with an extensive volar forearm defect, multifragmentary distal radius fracture, and transection of the radial artery, several flexor tendons and the superficial radial nerve from a circular saw injury. Initial management at an outside facility included radial artery ligation, nerve repair, external fixation, and negative pressure wound therapy (NPWT). A large ALT/TFL flap was harvested for definitive reconstruction. End-to-end anastomoses were performed to the proximal radial artery, two concomitant veins, and the superficial palmar branch distally. Due to lack of suitable distal veins, venous outflow was augmented by intraosseous cannulation of the trapezium using a 3-0 coupler, resolving distal flap congestion. Flap: perfusion was successfully restored with no need for further revision. Flap debulking was performed with power-assisted liposuction. The patient recovered uneventfully. At one-year follow-up, recovery sufficient for daily activities and work was achieved. Conclusion: Intraosseous venous drainage may offer a viable salvage technique when conventional venous outflow is not feasible. This novel approach may expand the reconstructive microsurgeon's armamentarium in complex trauma cases.