Anatomical reconstruction of the patellar tendon with coverage using a perforator LGAP flap in ballistic trauma: The...

Ballistic injuries to the knee present a complex reconstructive challenge due to associated bone, tendon, and soft tissue loss. Early coordinated management between orthopedic and plastic surgery teams is essential to optimize functional outcomes.

We report the case of a 22-year-old male who sustained a Gustilo IIIb open fracture of the proximal tibia following a gunshot wound, with avulsion of the tibial tuberosity and complete patellar tendon rupture. Initial debridement and negative pressure therapy were followed, 48hours later, by anatomical reconstruction of the extensor apparatus using an iliac cortico-cancellous graft in continuity with a gluteal fascia strip, reinforced with pedicled semitendinosus and synthetic tape. Skin coverage was achieved with a pedicled lateral genicular artery perforator (LGAP) flap. Rehabilitation included immobilization in extension and progressive physiotherapy-assisted knee flexion.

At 18months, the patient presented complete wound healing, no pain at rest, and partial recovery of function (extension deficit 10°, flexion limited to 80°). The Knee injury and Osteoarthritis Outcome Score (KOOS) was 47. Early pedicled perforator flap coverage provided reliable soft tissue reconstruction while avoiding the complexity of microsurgical free flaps in this anatomically challenging region. The composite reconstruction restored mechanical continuity of the extensor apparatus, enabling stable joint function.

This case illustrates the feasibility and functional benefit of early, coordinated orthopedic-plastic reconstruction for complex ballistic knee injuries, combining bone-tendon reconstruction with local perforator flap coverage. Pedicled perforator flaps are a valuable option for small to medium-sized skin defects in the knee region.