Operative Technique in Plastic Surgery – Kevin C.Chung

TECH FIG 1 • A. Axial T1 fat-suppressed contrast MRI
showing a tumor in the anterior compartment of the
lower leg between the tibialis anterior and extensor
digitorum longus. Biopsy confirmed benign
schwannoma. B. Coronal view demonstrating
craniocaudal extent of tumor. C. Intraoperative
photograph showing dissection through deep fascia
and separation of the tibialis anterior and extensor
digitorum. Simple dissection around the tumor capsule
was performed to deliver the tumor. D. Excised
specimen on the back table. E. Photograph showing
the defect after excision. Because the native muscles
were not excised, a primary closure was possible.
PEARLS AND PITFALLS
Wound
breakdown
■ Dead space after tumor removal should be managed with
drains, muscle flap, free tissue transfer, or a combination of

these techniques.
■ Have low threshold for aggressive soft tissue coverage.
Positive
margins
(sarcoma
excision)
■ Appropriate preoperative planning is important to minimize risk
of unplanned positive margins.
■ Inability to primarily close a wound should not interfere with
decision to remove a tumor with a clean margin. Plan on soft
tissue reconstruction.
■ Planned positive margins around critical structures such as
nerves and vessels may be appropriate in certain settings.
POSTOPERATIVE CARE
■ Mobilization and weight bearing depend on the extent of surgery. Activity
with no restriction may begin after simple tumor excision, whereas bed rest
may be desired after free tissue transfer.
■ Extremity elevation is recommended while the patient is in bed.
■ May administer antibiotics in the perioperative period.
OUTCOMES
■ Oncological outcomes include local recurrence and metastasis. Surveillance
for recurrence should be managed by a multidisciplinary sarcoma team. Local
recurrence is higher when margins are positive.
■ Functional outcomes depend on the extent of tissue resection and patient
overall health status. Most patients will experience some form of disability that
is proportional to the volume of muscle and bone resected.
COMPLICATIONS
■ Local recurrence occurs in a minority of patients with sarcoma and is more
common in patients with positive margins.
■ Deep infection can occur at any time after surgery and requires aggressive
therapy including surgical debridement and antibiotic therapy to achieve limb
salvage.
■ Weakness with ankle and foot motion is not uncommon given the proximity of
the nerves to most leg tumors and the need for extensive muscle excision.
REFERENCES
1. Christie-Large M, James SL, Tiessen L, et al. Imaging strategy for detecting
lung metastases at presentation in patients with soft tissue sarcomas. Eur J
Cancer. 2008;44(13):1841.

2. Johannesmeyer D, Smith V, Cole DJ, et al. The impact of lymph node disease
in extremity soft-tissue sarcomas: a population-based analysis. Am J Surg.
2013;206(3):289-295.
3. Mankin HJ, Mankin CJ, Simon MA. The hazards of the biopsy, revisited.
Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am.
1996;78(5):656-663.
4. O’Donnell PW, Griffin AM, Eward WC, et al. The effect of the setting of a
positive surgical margin in soft tissue sarcoma. Cancer. 2014;120(18):2866-
2875.

22
CHAPTER
Excision of Bone Tumors of
the Lower Leg
Raffi S. Avedian and Rohit Khosla
DEFINITION
■ Bone tumors of the tibia and fibula may be benign or malignant (bone
sarcoma) and exhibit a variable natural history ranging from latent to rapid
growth. Aggressive benign tumors and malignant tumors typically cause pain,
dysfunction, and fracture.
■ A bone tumor located in the tibia or fibula such that definitive treatment
requires excision of an intercalary segment of bone, sparing the ankle and knee
joints, is discussed in this chapter.
ANATOMY
■ The lower leg is made up of the tibia and fibula and four muscle
compartments: anterior, lateral, deep posterior, and superficial posterior (FIG
1).
■ Three principal arteries travel in the lower leg. The posterior tibial artery is
located in the deep posterior compartment on the surface of the tibialis
posterior. The anterior tibial artery is in the anterior compartment located deep
to the muscles on the surface of the interosseous membrane. The fibular artery
travels in the deep posterior compartment medial to the fibula under the flexor
hallucis longus; it sends branches to the lateral and anterior compartments and
a nutrient vessel to the fibula.
■ The deep peroneal nerve travels with the anterior tibial artery. The superficial
peroneal nerve is located in the lateral compartment; in the distal one-third of
the leg, it travels between the peroneus muscles and extensor digitorum longus
and pierces the deep fascia to become a cutaneous nerve.
PATHOGENESIS

■ The mechanism for bone tumor formation is not known.
■ Risk factors for sarcoma development include radiation exposure,
radiotherapy, pesticide exposure, and hereditary conditions including Li-
Fraumeni syndrome and retinoblastoma gene mutation.
NATURAL HISTORY
■ Active benign tumors such as giant cell tumor of bone, chondroblastoma, and
aneurysmal bone cyst will progress over time and may recur after excision but
are not lethal.
■ All bone sarcomas have the potential for local recurrence and metastasis.
■ Some bone sarcomas such as low-grade chondrosarcoma exhibit a slow rate of
growth and low risk of metastasis, whereas aggressive tumors like high-grade
osteosarcoma and dedifferentiated chondrosarcoma grow rapidly and have a
relatively high risk of metastasis.
■ Tumor variables that are associated with increased risk of metastasis include
high grade and large size (greater than 8 cm).
■ Lungs and other osseous sites are the most and second most common location
of metastasis, respectively.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Pain is a common presenting symptom for aggressive bone tumors.
■ A thorough history and examination are important to assess duration of
symptoms, comorbidities, physical dysfunction, organ involvement, overall
health, and patient expectations to best tailor treatment strategy for the
individual patient.
■ Neurovascular examination is mandatory for any extremity tumor.
IMAGING
■ Plain radiographs are used to formulate a differential diagnosis and a
preoperative plan.
■ Magnetic resonance imaging is routinely used to determine the extent of
intramedullary tumor involvement, presence of soft tissue extension, status of
the neurovascular structures, and preoperative planning.
DIFFERENTIAL DIAGNOSIS
■ The differential diagnosis for a bone tumor includes benign tumors, sarcomas,
lymphoma of bone, infection, and metabolic lesions (eg, hyperparathyroidism).

■ The most common bone sarcomas are osteosarcoma, chondrosarcoma, and
Ewing sarcoma.
FIG 1 • Cross-sectional anatomy of the lower leg
showing the contents of the anterior, lateral, superficial
posterior, and deep posterior compartments.
SURGICAL MANAGEMENT
■ The appropriate treatment for any musculoskeletal tumor is based on its
diagnosis and natural history.
■ Biopsy incisions are considered contaminated and must be resected at the time
of definitive surgery. Care should be taken to place the biopsy in a location that
does not interfere with the final surgical plan.
■ Intralesional curettage is the preferred treatment for benign tumors. Radical
resection with a clean margin is required for bone sarcomas.
■ Reconstruction depends on the extent of bone excision and may include simple
bone grafting, endoprosthetic implants, structural allografts, vascularized fibula
(ipsilateral centralized or contralateral free transplant), or combined allograft
and vascularized fibula.

■ The goal of surgery is to remove the tumor adequately to minimize recurrence
and restore the mechanical integrity of the bone and joints so that the patient
may have sufficient function to perform activities of daily living with minimal
pain.
Preoperative Planning
■ A patient is considered ready for surgery after completion of staging and
multidisciplinary review of pertinent imaging, pathology, and treatment
strategy.
■ The surgical plan is created by thorough study of the preoperative radiographs
and MR imaging.
■ Bone cuts are planned by measuring on preoperative imaging the distance
from an intraoperatively identifiable landmark (eg, medial malleolus or tibial
condyle) to the desired osteotomy site (FIG 2A,B).
■ The soft tissue margin depends on the size and location of a soft tissue
component to the tumor.
■ When tumor abuts, but does not encase blood vessels or nerves, they can be
dissected free by leaving the adventitia and epineurium on the tumor as the
margin.
FIG 2 • A. Anteroposterior radiograph of a 16-year-old
girl with a midtibia Ewing sarcoma. B. Sagittal T1-
weighted MRI demonstrating the intramedullary extent
of the tumor and measurements for bone resection.
Positioning

■ Patient positioning is based on the surgeon’s assessment of the critical
anatomy of the surgery and how best to visualize it during surgery.
■ Supine is the most common position for tumor excision of the lower leg. A hip
bump may be used to access more lateral tumors; conversely, frog legging the
extremity facilitates medial and posterior visualization.
■ If a flap is to be used, the harvest must be performed using a separate back
table and instruments and the surgical sites completely isolated to avoid
contamination.
Approach
■ The surgical approach varies based on location of the tumor.
■ Previous biopsy and surgical scars are considered contaminated and must be
excised en bloc with the tumor.
T E C H N I Q U E S
■ Diaphyseal Tibia Tumor Resection and
Reconstruction
■ Tourniquet is used at discretion of the surgeon by using gravity
exsanguination rather than Esmarch to avoid tumor dissemination.
■ A longitudinal incision is created that ellipses out the biopsy site. Skin flaps
are created as needed to ensure adequate visualization of the tumor and
critical anatomy (TECH FIG 1A,B).
■ Soft tissue dissection around the tumor is performed with the following
principles:
■ Adequate visualization must be achieved.
■ Margin of healthy tissue is kept on the tumor.
■ Nerves must be moved away from tumor. The epineurium may be used as
margin if tumor abuts the nerve.
■ Vessels must be moved away from tumor; the adventitia may be used as
margin if tumor abuts the vessels.
■ Single-vessel runoff to the foot may be acceptable depending on the extent
of soft tissue and collateral circulation excision.
■ Bone cuts are performed based on preoperative planning and measurements

to ensure complete tumor removal. Steinman pins may be inserted proximal
and distal to bone cuts prior to osteotomy for the purpose creating reference
points for leg length and rotation restoration (TECH FIG 1C,D).
■ Alternatively, an external fixator may be applied prior to osteotomy to
facilitate leg length and rotation restoration.
■ Fluoroscopy may be used at the discretion of the surgeon.
■ Hemicortical resection is an option if the tumor does not involve the entire
diameter of the bone.
■ Reconstruction is performed to restore mechanical stability of the extremity
using one of the following options:
■ Endoprosthetic implants may be cemented or press fit into native bone.1
■ Allografts are fashioned to fit the defect and secured in place with internal
fixation.
■ Vascularized fibula may be inserted end-to-end to the native tibia or
telescoped into the tibial canal to increase contact surface area (TECH FIG
2A–C).
■ A composite graft using vascularized fibula inserted into a structure
allograft (Capanna technique) has the theoretical advantage of combing the
structural support of a large allograft with the healing potential of a
vascularized graft.2
■ Ilizarov technique for bone lengthening.3
■ Allografts and endoprosthesis are at increased risk for infection; thus,
aggressive soft tissue reconstruction is recommended to minimize risk of
wound dehiscence resulting in exposed hardware.
■ Often, primary closure is not possible, and a local rotational flap or free
tissue transfer is used to reconstruct the soft tissues.

TECH FIG 1 • A. Intraoperative photograph of planned
incision incorporating biopsy site. B. Dissection
through skin and elevation of full-thickness flaps to
visualize the extent of tumor. Steinmann pins are
placed proximal and distal away from tumor as
references for leg length and rotation. C. Bone cuts
are made and muscle attachments released to allow
excision of the tumor in its entirety. D. The ipsilateral
fibula is dissected free keeping the flexor hallucis
longus muscle and associated nutrient vessels
attached. Notice that additional fibula length relative to
defect is harvested to allow for intramedullary
insertion.

TECH FIG 2 • A. Photograph showing fibula inserted
into the proximal and distal ends of the tibia. B. The
fibula is stabilized to the native tibia with internal
fixation, and allograft strut is placed for additional
support. C. Radiograph 14 months after surgery
showing incorporation of the fibula and allograft to the
native tibia.
PEARLS AND PITFALLS
Wound breakdown
■ Dead space after tumor removal should be managed
with drains, muscle flap, free tissue transfer, or a
combination of these techniques.
■ Have low threshold for aggressive soft tissue
coverage.
Positive margins
■ Appropriate preoperative planning is important to
minimize risk of unplanned positive margins.
■ Planned positive margins around critical structures
such as nerves and vessels may be appropriate in
certain settings
Allograft
nonunion/fracture
■ May be minimized by good cortical apposition of
graft to the native bone.
■ Restrict weight bearing until evidence of bone
healing is observed.
■ Counsel patients that reoperation for nonunion is
possible.
Malrotation/malalignment
■ Provisional placement of internal fixation, reference
pins, or external fixation away from tumor may be
used to maintain anatomic alignment.
POSTOPERATIVE CARE
■ Mobilization and weight bearing depend on the extent of surgery.
■ Extremity elevation is recommended while the patient is in bed.
■ Range of motion and therapy may begin after wound healing is sufficient.

■ May administer antibiotics while drains are in place.
OUTCOMES
■ Oncological outcomes include local recurrence and metastasis. Surveillance
for recurrence should be managed by a multidisciplinary sarcoma team. Local
recurrence is higher when margins are positive.
■ Functional outcomes depend on the extent of tissue resection and patient
overall health status. Most patients will experience some form of disability that
is proportional to the volume of muscle and bone resected.
■ Benevenia et al. showed an overall 27% nononcological complication rate for
intercalary prosthesis and average 77% Musculoskeletal Tumor Society
function score.4
COMPLICATIONS
■ Allograft nonunion and fracture, endoprosthesis loosening, and infection are
known complications and typically require additional surgery to achieve a limb
salvage.
■ Local recurrence occurs in a minority of patients and is more common in
patients with positive margins.
■ Malalignment of the reconstruction may occur and can be avoided by the use
of provisional fixation prior to making bone cuts and intraoperative
radiographs to ensure restoration of alignment and rotation.
■ Deep infection can occur at any time after surgery and requires aggressive
therapy including surgical debridement and antibiotic therapy to achieve limb
salvage. Removal of implants and allografts is often necessary to eradicate
infection.
REFERENCES
1. Ahlmann ER, Menendez LR. Intercalary endoprosthetic reconstruction for
diaphyseal bone tumours. J Bone Joint Surg Br. 2006;88(11):1487-1491.
2. Bakri K, Stans AA, Mardini S, Moran SL. Combined massive allograft and
intramedullary vascularized fibula transfer: the Capanna technique for lower-
limb reconstruction. Semin Plast Surg. 2008;22(3): 234-241.
3. McCoy TH Jr, Kim HJ, Cross MB, et al. Bone tumor reconstruction with the
Ilizarov method. J Surg Oncol. 2013;107(4):343-352.
4. Benevenia J, Kirchner R, Patterson F, et al. Outcomes of a modular intercalary
endoprosthesis as treatment for segmental defects of the femur, tibia, and

humerus. Clin Orthop Relat Res. 2016;474(2):539-548.

23
CHAPTER
Debridement of Soft Tissue
Infections of the Lower Leg
L. Scott Levin Paul Magnuson, and Paulo Piccolo
DEFINITION
■ The term debridement was coined by Joseph Pierre DeSault in the 18th
century. The French term implies the removal of soft tissues and bone that are
nonviable, with the goal of preventing infection. It is defined by the Oxford
medical dictionary as the process of cleaning an open wound by removal of
foreign material and nonviable tissue, so that healing may occur without
hindrance.1
■ By removing molecular, physical, and microbiologic barriers to healing,
debridement facilitates endogenous wound healing.
ANATOMY
■ The lower extremity consists of four major regions: the hip, thigh, leg, and
foot. It is specialized for support of body weight, adaptation to gravity, and
locomotion.
■ The thigh is divided in three compartments (anterior, posterior, and medial),
and the leg is divided in four compartments (anterior, deep, superficial
posterior, and lateral).
PATHOGENESIS
■ Wounds may originate through a variety of causes, such as soft tissue infection
(acute or chronic), trauma (thermal, electric, chemical, penetrating, or blunt),
vascular issues (arterial, venous, or lymphatic), neuropathic (eg, diabetes), or
malignancy.
■ The pathogenesis of the wound will play a key role in the treatment plan. A
wound from necrotizing fasciitis needs emergent attention and wide

debridement, as opposed to one caused by venous stasis, which can be dealt
with in an ambulatory setting and may be amenable to a more conservative
treatment approach.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A thorough history of present illness must be obtained. This is paramount in
establishing the cause, timing, and clinical implications of that wound, the
potential level of disability caused by it, and to plan further treatment.
■ Patient’s comorbidities such as obesity, diabetes, peripheral vascular disease,
surgical history, nutritional status, previous trauma and, nicotine use should all
be taken into account.
■ A thorough physical exam of the extremity in question must be performed
preoperatively, and many times, it should be completed in the operating room
under anesthesia to minimize patient’s discomfort and allow for a precise and
thorough analysis of the area.
■ Nerve integrity must be assessed before the patient is under anesthesia—both
motor and sensory aspects must be checked from the proximal thigh to the
distal toe.
■ Peripheral pulses are of extreme importance when treating lower extremity
wounds, as this will give vital information regarding limb perfusion, wound
pathogenesis, and options for future reconstruction.
■ Size and appearance of the wound, characteristics of the surrounding soft
tissue, and skeletal stability of the extremity should also not be overlooked.
The presence of exposed vital structures, including nerves, vessels, bones, and
joints, must be appreciated and well documented on the patient’s chart. The
presence of foreign body on the wound bed must be ruled out (eg, a chronic
wound caused by a retained piece of packing/dressing material).
IMAGING
■ Preoperative imaging studies are not always mandatory but often provide
valuable information to the reconstructive surgeon.
■ Plain films are important to assess proper bony alignment in the setting of
trauma or in acute infections to quickly assess for the presence of subcutaneous
gas.
■ Computed tomography (CT) with the aid of intravenous contrast (computed
tomography angiography [CTA]) may determine proper vascularization to the
extremity when there is any question regarding distal blood flow, be that acute

or chronic.
■ Bone scans and magnetic resonance imaging (MRI) to assess for bone viability
or osteomyelitis are important adjuncts when planning for debridement of a
lower extremity wound with exposed bone.
■ Other imaging modalities may aid the operating surgeon in evaluating
vascularity of the bone such as PET scans.2
SURGICAL MANAGEMENT
■ The decision to perform a surgical debridement of a lower extremity wound
lies in the hands of the reconstructive surgeon.
■ Before the era of free tissue transfer, debridement was often limited because
removing questionable tissue could lead to exposure of vital structures, such as
tendon devoid of paratenon, vessels, or nerves, and bone devoid of the
periosteum. Surgeons were reluctant to make the traumatic defects larger by
radical debridement. Subsequently, surgical techniques were more
conservative, and healing by secondary intention with wound contracture, scar,
and unstable soft tissues was the rule. Currently, free tissue transfer using large
well-perfused flaps facilitates radical debridement and necrectomy (removal of
dead tissue).
Preoperative Planning
■ General anesthesia is preferred. If patient is not a suitable candidate for
general anesthesia due to comorbidities, spinal anesthesia or regional block can
be considered.
FIG 1 • Left lower extremity wound following high-
energy trauma resulting in severe wound involving soft

tissue and bone. An external fixator was necessary for
skeletal support due to severe bony comminution.
■ As mentioned previously, a more thorough physical exam can be performed
with the patient under anesthesia.
■ Debridement should be performed with the use of the tourniquet. The
tourniquet is inflated to 350 mm Hg after an Esmarch bandage is used to
exsanguinate the limb. In cases of malignancy or infection, the use of the
tourniquet is contraindicated. In these cases, elevating the leg for 5 minutes
before inflating the tourniquet aids in limb exsanguination.
■ In an ischemic operative field, it is simpler to distinguish between healthy and
damaged tissues. The basic elements of this judgment are the appearance and
consistency of the tissues. Healthy tissue in the exsanguinated field is bright
and homogeneous in color. Subcutaneous tissue is yellow, muscles are bright
red, and the tendons and fascia have a white and shiny appearance.
■ Damaged tissues are recognized by the presence of foreign bodies, irregular
tissue consistency, and irregular distribution of dark red stains, caused by
hematomas or hemosiderin (FIG 1).
■ Evaluating muscle viability may propose a challenge in some cases.
Classically, the so-called 4 Cs—muscle color, consistency, contractility, and
capacity to bleed—are generally used to assess muscle viability and guide
debridement. Recent studies, however, show a potential tendency for normal
muscle resection3 as the surgeon’s impression of muscle viability does not
correlate with histological findings of the debrided muscle in the majority of
cases. Therefore, when large amounts of muscle appear of questionable
viability in the first stage of debridement, a second trip to the operating room
may be necessary to avoid over resection of viable muscle. This is in contrast
with clearly necrotic muscle, which will be discussed further.
■ Chronic wound
■ A: Chronic wounds present a different challenge to the surgeon. The presence
of scarring in the wound bed may impair the surgeon’s ability to appreciate
important aspects of the wound such as occult infection, its true area and
depth, and potential undermining and tunneling (FIG 2).
■ B: Due to the fact that these wounds remain open for a prolonged period of
time, in addition to other factors such as poor blood flow and hypoxia, they
are prone to become heavily colonized with bacterial or fungal organisms,

leading to biofilm formation (glycocalyx).
FIG 2 • Chronic right posterior ankle wound. One can
appreciate the surrounding scarring and the exposed
Achilles tendon with marked desiccation from prolonged
exposure. Undermining may not be immediately
appreciated, but further debridement may demonstrate
tissue undermining and small pockets of fluid and
nonviable tissue.
Positioning
■ The patient is positioned supine on the operating room table.
Approach
■ A “top-down” or “outside-in” approach to the debridement should be
undertaken, starting with the skin and subcutaneous tissue, followed by the
fascia and muscle, neurovascular structures, and bone.
T E C H N I Q U E S
■ Sharp Debridement of the Acute Wound
■ The patient is prepped with antiseptic solution and draped. The extremity is
elevated (as described above), and the tourniquet is inflated to 350 mm Hg.
■ Next, the wound is superficially washed gently with irrigating solution

usually attached to a cystoscopy tubing or through a bulb syringe to eliminate
blood clots or superficial debris. Pulsed irrigation systems are advocated by
some, but if used too vigorously with too high pressure or too close to tissue
planes, particularly around tendons, nerves, and vessels, it can insufflate
fascial planes, causing excessive tissue damage and increased edema.
Furthermore, it may not be productive in removing bacterial contamination.4
■ First, a no. 10 or no. 15 scalpel or sharp scissors are used to excise the skin
and dermis, particularly around the edge of the wound, back to the normal
tissue.
■ Next, the subcutaneous layer is inspected, debrided sharply with a no. 10 or
no. 15 scalpel to the level of the fascia. All fascia that is ripped, avulsed, or
contaminated is then removed.
■ The next layer encountered is the muscle. Necrotic muscle should be excised
and removed from the wound bed regardless of the volume. Leaving
unhealthy, necrotic muscle is most likely to result in subsequent infection.
This is often difficult to assess in a crush injury or gunshot blasts where the
zone of injury is less clearly defined (TECH FIG 1).
■ Denuded tendon, if not frayed, should be cleaned or fixed with a suture to
the surrounding tissue for later reconstruction.
■ Severed vessels are ligated, provided they are of no significance in the
viability of the injured extremity. If vessels are vital, they are excised to
normal-looking margins, and continuity is restored with interposition vein
grafts.
TECH FIG 1 • Left lower extremity wound caused by a
gunshot resulting in severe soft tissue and bony

trauma. There is a large amount of injured muscle
evidenced by the dark red stains, in contrast with likely
viable muscle superiorly.
■ The nerves are the only structures in which debridement is not radical. Those
parts that are destroyed without any doubt are removed, and nerve stumps are
tagged and anchored in the wound so as to avoid traction and allow later
reconstruction with nerve grafts. We prefer that a large cystoclip or hemoclip
be applied to the nerve stump so this can be seen on radiograph and
appropriate secondary planning can be done in terms of surgical approach
and location of the neuroma stump.
■ The periosteum that is elevated from the bone should be excised to the level
from which it is elevated. Small bone fragments devoid of the periosteum or
free-floating large segments, although they may be of structural significance,
should be removed for fear of colonization, contamination, and latent
infection.
■ At the conclusion of debridement, the wound is again irrigated and
tourniquet is let down, and then all tissue planes, particularly muscle, are
observed for bleeding as the arterial pressure increases in the limb.
■ Areas that are persistently nonviable, particularly the dermis, skin, and
muscle, are excised. Excision then can be done sequentially, watching for
punctate bleeding from either the dermis or the muscle. If large flaps have
been avulsed, excision is carried out through the skin to the level of bright
red blood coming from dermis on incision.
■ No attempt should be made to close the wound defect under any undue
tension for fear of further ischemic damage to already compromised tissues.
■ In cases of degloving injuries, the sequence of debridement remains the
same; however, in the end of the procedure, the portions of the avulsed skin
that appear viable may be used as a full-thickness graft after thorough in situ
defatting with sharp scissors or blade and bolstered to the wound. Special
attention is warranted in the postoperative period to ascertain skin graft take.5
■ Avulsed flaps with impaired venous outflow may be salvaged with
microsurgical venous anastomosis to more proximal veins.
■ Debridement of the Chronic Wound

■ Debridement of a chronic wound is also done with the limb exsanguinated
with aid of a tourniquet.
■ Superficial scar is excised completely so that the wound margins are in
healthy skin and subcutaneous tissue appears normal. The goals are to treat
the chronic wound like a tumor and excise it in its entirety down to normal
tissue planes. All scar in the wound should be removed in the same manner
as tumor surgeons operate; that is, the knife should always cut through
healthy tissues.
■ If a sinus tract is present or suspected, methylene blue dye may be injected to
identify its limits and its course. This way the entirety of the sinus tract can
be excised to its origin.
■ If functionally important structures are entrapped in the scar, the dissection
should commence in the healthy surrounding tissue, passing toward the scar
entrapment, where the structures such as nerves or tendons are carefully
dissected.
■ All areas of the bone not covered with the periosteum are removed, and
those that are exposed are burred with an iced saline bur. If punctate bleeding
is encountered from the cortical bone, the bone is left behind. If not, the bone
is removed until the so-called paprika sign, is identified. This is punctate
bleeding from the Haversian canals and indicates bone viability.
■ If there is sequestrum in the medullary canal, the anterior part of the bone
cortex, such as in the anterior tibia, should be removed even if it is well
perfused, to allow access to the medullary canal for placement of muscle
flaps that eliminate dead space and help control infection.
■ Hydrosurgery System
■ Recently, new modalities for wound debridement have emerged such as the
use of hydrosurgery systems (VERSAJET, Smith & Nephew, London, UK).
This novel modality allows accurate debridement of only unwanted tissue
while precisely conserving viable structures for eventual repair. It employs a
high-pressure water jet at 15 000 psi to create a Venturi effect, which
eliminates debrided tissues in the water stream, extricating it from the
underlying tissue (TECH FIG 2).6
■ The cost-effectiveness of such systems is still controversial, and it may not
be superior to conventional debridement so its use is left up to the surgeon’s

preference and the capabilities of the facility in which he/she operates.
TECH FIG 2 • VERSAJET system for wound
debridement.
■ Other Forms of Wound Debridement
■ Many other forms and mechanisms for debridement have been described but
are beyond the scope of this chapter such as biodebridement using maggots,
enzymatic debridement using topical products such as collagenase, newer
technologies such as ultrasound therapy, and plasma-mediated bipolar
radiofrequency ablation.7
■ These methods are measured against the current reference standard, which is
the sharp debridement technique described, and the method of choice for a
particular wound depends on various factors such as type, size and position
of wound, quantity and character of the exudate, patient tolerance, cost-
effectiveness and available equipment, and expertise of the treatment team.
PEARLS AND PITFALLS
Use of
tourniquet
■ The use of tourniquet decreases the amount of blood loss during
the procedure.
■ The use of Esmarch bandage is not necessary and sometimes
discouraged (eg, presence of infection or malignancy) as elevating

the extremity for approximately 5 minutes should exsanguinate the
extremity satisfactorily.
Hemostasis
■ Thorough hemostasis is performed after tourniquet is let down and
arterial pressure rises.
Necrotic
muscle
■ Muscle that appears clearly necrotic should be excised. Leaving
necrotic muscle behind is the surest way to acquire an infection.
Loupe
magnification
■ Use of loupe magnification helps the operating surgeon better
identify structures during the debridement. It also aids in
differentiating between viable and nonviable tissues.
Technique
■ The surgeon should approach the debridement as one would a
tumor, ie, excise its entirety down to healthy tissue.
POSTOPERATIVE CARE
■ An occlusive dressing is applied according to the surgeon’s preference.
Dressing changes should be performed on a daily or every-other-day basis.
■ Patient’s comfort is of paramount importance, so proper postoperative pain
control should be optimized and depending on size and location of the wound;
dressing changes have to be performed in the operating room under sedation or
general anesthesia.
■ Wound surfaces must be continually moistened and tissue desiccation must be
prevented.
■ The use of splints may aid in postoperative comfort and should be considered
for the postoperative period.
■ Elevation of the limb is of upmost importance to decrease the amount of
edema and aid in limb circulation.
■ Finally, one should take care of the “whole patient, not the hole in the
patient”—proper medical optimization, nutrition assessment, and physical
rehabilitation must be arranged as part of the postoperative regimen.
OUTCOMES
■ The primary outcome is wound healing. This may not be achieved by
debridement and closure alone.
■ Depending on the size and etiology of the wound, further treatment may be
warranted. Frequent dressing changes, application of biomaterials, or coverage
with a skin graft or flap may be necessary and are used at the discretion of the
treatment team.

COMPLICATIONS
■ Nonhealing wound. This may be caused by inadequate debridement of
necrotic tissues or foreign bodies, persistent contamination, underlying
metabolic disorder, noncompliance with postoperative care, or any other
number of factors.
■ Secondary infections. This is caused mainly by failure to debride necrotic
tissue or to remove colonized foreign body from the wound bed, which serves
as substrate for microorganism superinfection.
REFERENCES
1. “debridement”. In Concise Medical Dictionary. Oxford University Press,
2010.

9780199557141-e-2473
2. Dyke JP, Aaron RK. Noninvasive methods of measuring bone blood
perfusion. Ann N Y Acad Sci. 2010;1192:95-102.
3. Sassoon A, Riehl J, Rich A, et al. Muscle viability revisited: are we removing
normal muscle? A critical evaluation of dogmatic debridement. J Orthop
Trauma. 2016;30(1):17-21.
4. Owens BD, White DW, Wenke JC. Comparison of irrigation solutions and
devices in a contaminated musculoskeletal wound survival model. J Bone Joint
Surg Am. 2009;91(1):92-98.
5. Yan H, Gao W, Li Z, et al. The management of degloving injury of lower
extremities: technical refinement and classification. J Trauma Acute Care Surg.
2013;74(2):604-610.
6. Liu J, Ko JH, Secretov E, et al. Comparing the hydrosurgery system to
conventional debridement techniques for the treatment of delayed healing
wounds: a prospective, randomised clinical trial to investigate clinical efficacy
and cost-effectiveness. Int Wound J. 2015;12(4):456-461.
7. Madhok BM, Vowden K, Vowden P. New techniques for wound debridement.
Int Wound J. 2013;10(3):247-251.

24
CHAPTER
Tibial Reconstruction
Vishwanath R. Chegireddy, Michael J. A. Klebuc, and
Anthony Echo
DEFINITION
■ Trauma and neoplasia, requiring segmental bone resection, are the most
common causes for segmental defects of the tibia.
■ Radiation-induced bone necrosis and infection, namely osteomyelitis, is also
an indication for resection and possible reconstruction.
■ Reconstruction requires technical expertise, careful operative planning, and a
detailed understanding of the problem at hand.
■ Large commitment by both the patient and the physician is paramount due to
long complex rehabilitation period.
■ Options for reconstruction include either allograft or autograft material, most
commonly a vascularized fibular graft.
■ Allografts were initially used but were associated with considerably high rates
of complications and failures.
■ The concept of reconstruction of the tibial shaft with a vascularized fibular
graft was first suggested by Chacha and colleagues in 1981.1 They used the
ipsilateral fibula as a vascularized pedicle graft for nonunion of the tibia.
■ It has since been shown to be a viable and reliable technique for tibial
reconstruction.
■ The main advantage of using a vascularized autograft for tibial reconstruction
is the ability to use the normal biology of bone healing for incorporation rather
than relying on creeping substitution innate to prosthetic
material/nonvascularized graft use.
■ The vascularized fibular graft undergoes hypertrophy overtime in response to
continuous pressure load, which translates to remarkable long-term

durability.2–4
■ Factors that make the fibula an optimal source for a vascular graft are as
follows:
■ Anatomic accessibility
■ Independent blood supply
■ Relatively dispensable in lower extremity function
■ Capability to hypertrophy overtime in response to pressure
ANATOMY
■ The tibia is the second largest bone in the human body, after the femur.
■ Relevant leg anatomy includes four compartments (anterior, posterior,
superficial, and deep posterior) (FIG 1).
■ The tibia is the stronger of the two bones in the lower leg. It is found on the
medial side and is connected to the fibula by the interosseous membrane. It
forms a type of fibrous joint called syndesmosis with very little movement.
FIG 1 • Cross-sectional anatomy of four compartments
at the midtibial level.
■ The blood supply to the tibia is derived from a main nutrient artery and
periosteal branches derived from the anterior tibial artery.

■ The fibula is a long and thin cortical bone with a small medullary component.
In adults, the width of the fibula is 1.5 to 2 cm with a length of 35 cm of which
approximately 25 cm of the fibular diaphysis can be harvested for free grafting.
■ Vascular supply to the diaphysis of the fibula is via a dominant nutrient
endosteal artery and minor musculoperiosteal branches from the peroneal
artery and veins. These vessels run parallel to the fibula and course between
the flexor hallucis longus (FHL) and tibialis posterior muscle group.
■ The dominant nutrient artery branches 6 to 14 cm from the peroneal artery
bifurcation and enters the fibula posterior to the interosseous membrane. It then
courses into the nutrient foramen located in the middle third of the diaphysis
and further divides into an ascending and descending branch.
■ Musculoperiosteal vessels are derived from the peroneal artery and travel
within the posterolateral septum, through the flexor hallucis longus and tibialis
posterior muscle, giving segmental rise to four to eight branches that supply the
muscles in the anterior compartment, soleus muscle, and lateral leg skin
territory. The majority of the periosteal branches are located in the middle third
of the fibula.
■ Soft tissue defect coverage is achieved with a skin paddle supplied by
perforators traversing through the posterior crural septum with the majority
concentrating at the proximal and distal ends of the fibula. These
fasciocutaneous perforators supply a skin paddle up to 10 × 20 cm in size.5
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Detailed preoperative evaluation is required for patients undergoing extensive
long bone resection and intercalary bone defect reconstruction.
■ Determination should first be made as to whether reconstruction or salvage is a
viable option.
■ General health status should be carefully evaluated. An extensive
reconstructive effort should not be undertaken on a patient with an overall poor
health status.
■ The patient should have the ability to be compliant with both treatment and
rehabilitation.
■ Pertinent history includes the presence of significant comorbidities such as
deep venous thrombosis, peripheral vascular disease, lymphedema, trauma,
venous insufficiency, diabetes, or social history such as smoking.
■ Special attention should be to consider cardiovascular, surgical, or
hematologic diseases that may affect peripheral blood flow.

■ Physical exam should include a lower extremity and vascular examination.
This includes an evaluation of knee and ankle joints for range of motion and
laxity and a foot Allen test with a Doppler probe to assess dorsalis pedis and
posterior tibial arteries.
■ Peronea arteria magna is a congenital variant of the arterial inflow to the foot
that affects about 1% to 8% of the population, where both the anterior and
posterior tibial arteries are hypoplastic or absent with the peroneal artery
serving as the single arterial supply below the knee. The artery may need to be
reconstructed with a vein graft, or the other leg should be inspected.
■ Patients with an abnormal vascular exam or a history of trauma to the affected
extremity will need additional preoperative imaging such as computed
tomography angiogram (CTA), duplex ultrasound, or magnetic resonance
angiography (MRA) to identify atherosclerotic occlusive disease or congenital
anomalies.
IMAGING
■ Preoperative imaging of both the recipient and donor sites should include an
evaluation of:
■ Recipient site:
■ The extent of bone resection, length and diameter of the intercalary defect,
and potential soft tissue defect (FIG 2). This allows the surgeon to determine
the extent of the tumor burden, traumatic bone loss, or chronic osteomyelitis
and plan for reconstructive options.
■ Donor site:
■ Evaluate vascular supply with Doppler ultrasound (anterior tibial, posterior
tibial, and dorsalis pedis arteries), and exclude any fibular deformities.
■ Angiogram to look for vessel patency and flow to the foot
SURGICAL MANAGEMENT
Preoperative Planning
■ Determination must be made as to whether limb salvage is a viable option.
■ Taking into account patient factors and the extent of disease and/or resection is
imperative in determining the need for tibial reconstruction vs amputation.
■ Assessment of defect must include the need for bone, muscle, and skin; all of
which free fibular graft can provide.
■ Four centimeters of bone must be left proximally, whereas 6 cm must be left at

the distal portions of the fibula for knee and ankle stabilization, respectively.
Therefore, the maximum length of the graft obtainable will be the length of the
donor tibia less 10 cm.
■ Donor site should be the contralateral leg if used as a free flap. This allows for
simultaneous preparation of recipient site during fibula harvest and avoids the
use of potentially injured/involved donor site where the fibula may have been
fractured in the setting of trauma.
Positioning
■ Positioning depends mainly on the recipient site, as the fibula can be harvested
in both supine and lateral positions.
■ For contralateral free fibula flap harvest, the proper positioning facilitates two
teams to work together for recipient preparation and donor dissection
simultaneously (FIG 3).
■ In a supine position, a roll is placed under the ipsilateral hip, and the patient’s
knee is bent to 90 degrees.
FIG 2 • Preoperative MRI showing left proximal tibial
osteosarcoma.
■ A heel stop can be placed on the operative room table to help knee at 90
degrees when harvesting in the supine position.
■ If the patient is in a prone position, a roll is placed under the anterior ipsilateral
hip, and bending of the leg is not required.
■ All pressure points should be carefully padded and protected.

FIG 3 • If the contralateral fibula flap is desired, the
patient can be placed in a supine position, which allows
two teams to work simultaneously for recipient
preparation and donor site harvest.
Approach
■ Multidisciplinary team approach is taken involving both plastic surgeons and
orthopedic surgical teams to coordinate resection of the involved tibial bone
and reconstruction of the ensuing intercalary defect.
■ Careful planning of the incision for the exposure is necessary for flap harvest
and inset without compromising the skin envelope for coverage.
■ Tibial reconstruction can be achieved with free or pedicled fibula graft, in a
single- or double-barrelled fashion.
■ Reconstruction of smaller intercalary defects up to 13 cm can be achieved with
double-barrelled fibular flap, keeping the arterial blood supply intact while
performing an osteotomy in the fibula flap.
■ If a pedicled flap is desired, the ipsilateral leg will be used for both harvest and

inset. The advantages of pedicled flaps are that microvascular anastomosis is
unnecessary, and distant donor-site morbidity is avoided, which can occur with
free fibula graft.6
■ Intraoperative preparation of the fibula flap includes marking of anatomical
landmarks: head of the fibula, lateral malleolus, and anterior and posterior
fibular border (FIG 4).
■ If a skin deficit is present either in the setting of tumor/chronic osteomyelitis
resection or trauma, a skin paddle can be harvested with the fibular flap sharing
the same vascular pedicle, which facilitates early detection of flap compromise
and provides tension-free skin closure of recipient site.
■ A perforator is marked on the proposed skin paddle using intraoperative
Doppler localization along the posterior border of the fibula, corresponding to
the posterior intramuscular septum.
FIG 4 • Intraoperative marking of anatomical landmarks
for a contralateral fibula harvest: head of the fibula,
lateral malleolus, anteroposterior fibular border, and
skin paddle if needed.
T E C H N I Q U E S
■ Free Fibula Flap
■ After the tibial bone resection is completed by the orthopedic surgical team,
the dimensions of the intercalary bone defect are measured (TECH FIG 1A).

■ Prior to flap harvest, a sterile tourniquet is placed on the midthigh while
avoiding compression over the fibular head and common peroneal nerve.
■ Using marked anatomical landmarks, a midlateral vertical incision is made
over the fibula, and skin flaps are elevated at the level of the fascia.
■ Dissection is carried through the investing fascia of the lateral compartment,
anterior to the posterior intermuscular septum (TECH FIG 1B–D).
■ Care should be taken to preserve fasciocutaneous perforators traveling
through the posterior intermuscular septum if a skin island is needed for
osteocutaneous flap.
■ During proximal dissection, identify and preserve the common peroneal
nerve traversing around the head of the fibula to become the superficial
peroneal nerve.
■ The peroneal muscles are dissected off the anterior surface of the fibula and
reflected anteriorly to expose the anterior intermuscular septum. After
incising the septum to gain access to the anterior compartment, reflect the
extensor digitorum and hallucis muscles to identify and preserve anterior
tibial vessels and deep peroneal nerve.
■ The interosseous membrane is incised to enter the deep posterior
compartment, and the peroneal vessels are located between tibialis posterior
and flexor hallucis longus muscles.
■ Next, the peroneal vessels are identified proximally and distally, and
dissection is propagated circumferentially around the fibula and staying
medial to the vessels using a large right angle clamp. The vascular pedicle
should be maintained during dissection.
■ After adequate length of the fibula is marked for reconstruction, towel
clamps are used to apply lateral traction on the proximal and distal fibula
while osteotomizing with an oscillating saw or Gigli saw. A strip of
periosteum overlying the osteotomy site should be included to overlap the
osteotomy sites at the recipient site.
■ Prior to performing osteotomy, a microvascular clamp can be applied to the
peroneal artery distal to the osteotomy site to ensure adequate supply to the
foot and then divided (TECH FIG 1E).

TECH FIG 1 • A. Intraoperative photograph of the left
intercalary defect remaining after the tumor resection.
B. Exposure of peroneus longus and soleus at the
midtibial level. C. Dissection around the fibula and
lateral muscle compartment. Proceed dissection
proximally to identify and protect the superficial
peroneal nerve. D. Dissection proceeds anterior to the
fibula through the anterior intermuscular septum and
protects the deep peroneal nerve and anterior tibial
vessels. E. After the distal fibula osteotomy, the
peroneal vessels should be ligated distally, which are

located between FHL and tibialis posterior muscle
groups. F. Adequate fibula length is freed, and
proximal osteotomy is performed carefully while
protecting the pedicle vessels.
■ The vascular pedicle is dissected starting distally, carried proximally up to
the origin of tibioperoneal trunk, and ligated with approximately 2 to 6 cm
of pedicle length.
■ After the fibula graft is fully mobilized with the pedicle (TECH FIG 1F),
the tourniquet is released with robust arterial inflow and venous outflow and
healthy back bleeding from both the periosteum and intramedullary canal.
■ An osteomuscular flap can also be harvested in similar fashion to include
soleus and flexor hallucis longus muscles. This can aid in filling the dead
space in patients with extensive soft tissue defect.
■ If the distal osteotomy is close to the lateral malleolus, a screw fixation to
the tibia can be utilized to prevent valgus deformity and ankle instability,
which is more important in pedicle flap.
■ In a clean and well-vascularized recipient bed, the proximal and distal tibial
should be stabilized, and the medullary cavities should be prepared to receive
the free fibula graft.
■ The free fibula graft is then telescoped into the intercalary defect. Next, the
graft is anchored to the tibia proximally and distally with long compression
plates and screws spanning the bone defect. During this step, care is taken to
prevent any damage to the peroneal vessels.
■ Standard microvascular anastomosis is performed between the recipient
vessels and peroneal artery and accompanying venae comitantes.
Additionally, several fat grafts can be placed around the pedicle in an effort
to prevent compression.
■ After skin closure, a well-padded posterior leg splint is applied to keep the
foot in extension to prevent an equinus deformity.
■ Pedicled Fibula Graft
■ The recipient site defect is measured to estimate the length of the fibula
required for reconstruction (see TECH FIG 1A).

■ If the fibula flap is to remain pedicled (TECH FIG 2A), the flap is raised in
standard fashion, but the proximal vascular pedicle is not ligated (TECH FIG
2B).
■ The vascularized fibula flap is then transported through the space created
between the tibialis posterior muscle and the tibialis anterior muscle.
■ The distal-most segment of the bone will be used for the reconstruction. It
can either be transposed or reversed, but whichever way the flap is oriented,
it needs adequate pedicle length.
■ If the fibula is reversed and rotated 180 degrees, the pedicle will make a U-
turn, and care needs to be taken not to kink the pedicle on inset.
TECH FIG 2 • A. Illustration of pedicled fibula graft
with intact peroneal vessels. B. Intraoperative
photograph of an ipsilateral pedicled fibula graft. C.
Intraoperative photograph showing an allograft sp
anning the defect and an onlay fibula graft being
stabilized with long compression plates and screws.

■ Additionally, if the length of the vascular pedicle of the graft is expected to
be inadequate, it is necessary to harvest the graft as far from the base of the
pedicle as possible and separate the periosteum with the vascular pedicle to
make a longer vascular pedicle.
■ Once inset as an interposition graft, bone fixation of the fibula graft is
achieved with long compression plates and screws traversing the tibial defect.
■ Alternatively, an allograft can be used as an interposition graft spanning
the intercalary defect with an onlay fibula graft as a buttress, which can
provide greater stability (TECH FIG 2C).
■ Double-Barrelled Fibula Technique
■ Blood supply to the fibula is both endosteal and periosteal.
■ This technique is useful for proximal tibial reconstruction when the defect is
shorter than 13 cm.
■ Larger defects will not be able to be reconstructed with a single fibula in a
double-barrelled fashion; both fibulas would be required, and the second
fibula would need to be as a free fibula flap.
■ Additionally, this method provides two segments of bone, which doubles
the cross-sectional area of the flap but only requires one anastomosis.
■ Following the harvest, the graft is osteotomized at the midpoint, taking care
to avoid the peroneal vessels (TECH FIG 3).
■ At the site of the proposed osteotomy, the vascular pedicle is carefully
elevated off the bone flap in the subperiosteal plane with an elevator over a
segment of 2 to 3 cm, which will allow a malleable retractor to be placed to
protect the pedicle.
■ The graft is osteotomized at the midpoint and folded, with care taken to
preserve the peroneal vessels.

TECH FIG 3 • In the double-barrelled fibula repair, free
fibula is harvested with the peroneal vessels intact.
The graft is then osteotomized at the midpoint and
folded.
PEARLS AND PITFALLS
Peronea
arteria
magna
■ A congenital variant of the arterial inflow to the foot, where both the
anterior and posterior tibial arteries are hypoplastic or absent with
the peroneal artery serving as the single arterial supply below the
knee.
Injury to
common
peroneal
nerve
■ The nerve courses inferior to the head of the fibula and should be
identified during proximal dissection to prevent injury.
Careful
dissection
■ Preserve the posterior intermuscular septum, which carries
perforators to the skin paddle.

of skin
perforators
Joint
instability
■ At least 4 cm of fibula bone is preserved proximally to preserve the
stability of the knee.
■ At least 6 cm of fibula bone is preserved distally above lateral
malleolus to preserve stability of the ankle.
POSTOPERATIVE CARE
■ Recipient and donor sites should be monitored during the postoperative period
for vascular insufficiency and signs of free flap compromise, which can be
monitored if a skin island is harvested.
■ Flap function can be monitored with a combination of clinical exam and a
Doppler probe every hour during the first 24 hours. The flap patency should be
assessed until patient discharge.
■ Initially, patients should be advised no weight bearing on the surgical limb up
to 2 weeks. Afterward, partial weight bearing can be resumed with assistance
and progressed to full weight-bearing status after bone union.
OUTCOMES
■ Union time can range from 3 to 7 months.
■ Union rates upward of 75%.
■ Ambulation: all patients (100%) at an average 9.55 to 14.3 months7.
■ Joint stiffness (40%) and pain (18%) are frequent8.
■ Fibular hypertrophy occurs secondary to microfractures and callous formation.
COMPLICATIONS
■ Recipient site
■ Loss of flap primarily caused by vascular thrombosis
■ Nonunion
■ Infection
■ Hardware malfunction
■ Donor site
■ Inability to flex the great toe due to damage to flexor hallucis longus:
■ Knee or ankle joint instability with secondary pseudoarthrosis
■ Common peroneal nerve injury
ACKNOWLEDGMENTS

Thank you to Drs. C. Arroyo-Alonso and A.J. Steinberg, Institute for
Reconstructive Surgery, Houston Methodist Hospital and Weill Cornell
Medicine, Houston, Texas, for their contributions to the preparation of this
chapter.
REFERENCES
1. Chacha PB, Ahmed M, Daruwalla JS. Vascular pedicle graft of the ipsilateral
fibula for non-union of the tibia with a large defect: an experimental and
clinical study. J Bone Joint Surg. 1981;63B:244-253.
2. Capanna R, Campanacci DA, Belot N, et al. A new reconstructive technique
for intercalary defects of long bones: the association of massive allograft with
vascularized fibular autograft. Long-term results and comparison with
alternative techniques. Orthop Clin North Am. 2007;38(1):51-60, vi.
3. Malizos KN, Zalavras CG, Soucacos PN, et al. Free vascularized fibular grafts
for reconstruction of skeletal defects. J Am Acad Orthop Surg. 2004;12(5):360-
369.
4. Zaretski A, Amir A, Meller I, et al. Free fibula long bone reconstruction in
orthopedic oncology: a surgical algorithm for reconstructive options. Plast
Reconstr Surg. 2004;113(7):1989-2000.
5. Chen ZW, Yan W. The study and clinical application of the osteocutaneous
flap of fibula. Microsurgery. 1983;4(1):11-16.
6. Vail TP, Urbaniak JR. Donor-site morbidity with use of vascularized
autogenous fibular grafts. J Bone Joint Surg. 1996;78A:204-211.
7. Weichman KE, Dec W, Morris CD, et al. Lower extremity osseous oncologic
reconstruction with composite microsurgical free fibula inside massive bony
allograft. Plast Reconstr Surg. 2015;136(2):396-403.
8. Pelissier P, Boireau P, Martin D, Baudet J. Bone reconstruction of the lower
extremity: complications and outcomes. Plast Reconstr Surg.
2003;111(7):2223-2229.

25
CHAPTER
Soft Tissue Coverage of
Lower Leg—Free Flap
Goo-Hyun Mun and Kyong-Je Woo
DEFINITION
■ Microvascular free flap transfer is a reliable and often ideal option for soft
tissue reconstruction of a complex or large wound of the lower leg.
■ The goal of reconstruction is to provide durable soft tissue coverage to
maximize bony union in a traumatic wound and functional recovery and to
restore the aesthetic contour of the lower leg.
ANATOMY
■ Three main arteries branching from the popliteal artery are potential recipient
vessels for microvascular free flap transfer for soft tissue coverage of the lower
leg: the anterior tibial, posterior tibial, and peroneal arteries (FIG 1A–E).
■ Apart from the concomitant veins of the named arteries of the lower leg, the
two major superficial veins, which are the long (great) and short (small)
saphenous veins, may be used as recipient veins. The superficial veins run
superficial to the fascia cruris (deep fascia) of the lower leg (FIG 1F).
■ Sizable perforators to the overlying skin derived from any of the three major
vessels can also be recipient vessels when they are found near the defect.1,2
■ The specific recipient vessels are chosen according to the site of the defect.
■ Upper third of the lower leg: the upper third of the lower leg is technically
the most difficult zone for microvascular repairs because of the deep location
of major vessels. A long vein graft from the flap passing proximally to the
side of the femoral artery was commonly used in the past. However, sural
vessels (FIG 2) and the reversed descending branch of the lateral circumflex
femoral vessels can also be effective recipient options in this region.3
■ Middle third of the leg: the anterior tibial vessels are often used because the

vessels become more superficial as they descend (FIG 3). The posterior tibial
arterial and venous system may be easily exposed after retraction of the soleus
muscle when the defect is on the medial side of the leg (FIG 4).
■ Distal third of the leg: distal branches of all three major vessels are easily
accessible in this region because there is less overlying soft tissues, which
also makes them more susceptible to injury in traumatic defects. The
peroneal artery or its terminating calcaneal artery can also be used in the
lateral region of the leg (FIG 5). Perforators from the peroneal artery can be
used as recipient vessels in the lateral region (FIG 6).

FIG 1 • Main arteries and veins of the lower leg and
incisions for exposure of recipient vessels. A. Three
named arteries of the lower leg. B. Anterior tibial artery.
C. Incisions for exposure of the anterior tibial artery. D.
Incisions for exposure of the posterior tibial artery. E.
Incisions for exposure of the peroneal artery. F. Long
(A) and short (B) saphenous veins.
FIG 2 • A,B. Medial sural vessels as recipient vessel.

FIG 3 • A,B. Anterior tibial vessels for recipient vessel.
FIG 4 • Posterior tibial vessels for recipient vessel.
FIG 5 • Peroneal vessels for recipient vessel. A.
Peroneal vessels. B. Muscle chimeric TDAP perforator
flap. C. After inset of the flap.

FIG 6 • A,B. Peroneal artery perforators for recipient
vessel.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ A multidisciplinary approach with comprehensive communication between the
oncologist and/or orthopedic surgeon will allow better treatment outcomes.4
■ Preoperative planning should be carried out by considering anticipated defect
size, location, vascular anatomy, and comorbid conditions related to the
outcomes of reconstruction.
IMAGING
■ The authors routinely perform preoperative CT angiography to delineate the
vascular anatomy of the lower extremity except when it is contraindicated.
■ Detailed information of the vascular status helps determine proper
reconstruction options and recipient vessels, which ultimately decreases the
risk of reconstruction failure in the free flap transfer.5
SURGICAL MANAGEMENT
■ Soft tissue stability and long-term durability are of paramount concern in the
reconstruction of the lower leg.
■ The simple method is not always the best and often, a more complex method
of reconstruction, such as the free flap, is initially chosen to obtain better
functional and aesthetic outcomes.
■ Elaborate preoperative planning regarding recipient vessels, donor site, flap
composition (cutaneous, fasciocutaneous, musculocutaneous, chimeric,
composite flap), and positioning of the patient during the surgery is crucial for
successful soft tissue reconstruction of the lower leg. A muscle chimeric
perforator flap is useful for filling dead spaces created by soft tissue loss (FIG

5).6
■ Vascular complications are significantly higher if anastomoses are carried out
in the zone of injury, due to inflammation and trauma to recipient vessels. A
sufficiently longer pedicle or vessel graft may be necessary to reach normal
suitable vessels.
■ Donor site morbidity should also be considered in the preoperative planning.
The donor site that permits primary closure of the donor defect is always
favored over the ones that require skin grafting. The exact measurement of the
shape and size of the defect is valuable for donor tissue economy and
acceptable aesthetic results at the recipient site. A customized flap may be
effectively designed by using paper or transparent plastic template based on the
final defect shape.
■ The flap thickness can be controlled by defatting of the perforator flap at the
time of inset, which facilitates aesthetic reconstruction. On the other hand, flap
thickness can be controlled secondarily when tissue edema resolves
completely.
■ Fasciocutaneous flap vs muscle flap in contaminated wounds: A previous
animal study demonstrated that muscle flaps have advantages over the
fasciocutaneous flap for contaminated wounds.7 However, recent studies show
that there is no difference in bacterial eradication and quality of wound healing
between muscle and fasciocutaneous flap use.8,9
■ There is a controversy regarding how early a soft tissue defect should be
closed in lower extremity trauma. Early definitive soft tissue coverage may be
necessary where vital structures such as blood vessels and peripheral nerves or
hardware are exposed.10 The recent advent of negative pressure wound therapy
has helped provide additional time for better delineation of nonviable tissues
before final reconstruction in large, complex open wounds.11
Preoperative Planning
■ Vascular anatomy and degree of atherosclerosis are evaluated by preoperative
CT angiography (FIG 7).
■ Donor site and components of the flap are often decided preoperatively
according to predicted defect size, location, type of tissue requirement,
required pedicle length, surgeon’s expertise, and patient preference.
■ Rectus abdominis, latissimus dorsi, and the gracilis muscle flaps have been
commonly used for lower leg reconstruction. Popular cutaneous or

fasciocutaneous flaps for lower leg reconstruction are the radial forearm, sural,
anterolateral thigh, and thoracodorsal artery perforator (TDAP) flaps.8,12–14
Each flap has its advantages and disadvantages.
FIG 7 • CT angiography of the patient described in the
surgical technique in the text. All three main vessels of
lower legs are patent, and no atherosclerosis or
vascular occlusion exists in both lower legs.
FIG 8 • Positioning of the patient when the flap is to be
harvested from the ipsilateral back.
Positioning
■ Patient position is influenced by the donor site selection and planned recipient
vessel approach. The lateral decubitus position is convenient for harvesting
flaps from the back nourished by the subscapular vascular tree. When the

medial approach is used for the recipient vessel, such as the posterior tibial
vessel or medial sural vessel, the contralateral side of the back is the favored
donor site. When the anterior or lateral approach is to be used for the anterior
tibial artery or peroneal artery branches, it is better to harvest the flap from the
ipsilateral back, which helps to avoid patient repositioning during the free flap
surgery (FIG 8).
■ A tourniquet is usually applied on the thigh during defect preparation
including debridement and recipient vessel approach.
T E C H N I Q U E S
Video p7-c025
■ Wound Preparation
■ Recipient vessel decided on preoperative planning is checked for patency
using a handheld audible Doppler.
■ The ultimate defect is made by the complete debridement or excision of
pathologic, necrotic, or infected tissues under tourniquet control (TECH FIG
1).
■ Limited undermining of the skin flap around the wound margin is performed
to facilitate subsequent flap inset.
00:00 / 00:00

TECH FIG 1 • A,B. Wound preparation for free flap
reconstruction.
■ Recipient Vessel Preparation
■ Approach to recipient vessels
■ When the defect is extensive such as in oncologic resection or located in
the distal lower leg over the course of the major vessel, the recipient vessel
can be harvested directly inside the wound, which is advantageous for
avoiding added incisional scars.
■ An incision extending from the defect may be used when the adjacent
recipient vessel is to be utilized. A separate incision with subcutaneous
tunneling may be effectively employed for distant recipient vessel
approach.
■ Anterior tibial vessels are exposed through a dissection through the
intermuscular septum between the tibialis anterior and extensor digitorum
longus muscles (TECH FIG 2).
■ The deep peroneal nerve is carefully separated from the anterior tibial artery
and veins.

TECH FIG 2 • Recipient vessel preparation. Anterior
tibial vessels are exposed through a dissection
through the intermuscular septum between the tibialis
anterior and extensor digitorum longus muscles.
■ Assessment of the Defect
■ The tourniquet is deflated and meticulous hemostasis is performed. Irrigation
with saline solution is carried out.
■ Defect size along with its shape can be exactly measured using transparent
plastic or paper template, which will be used for flap design in the donor site.
■ Dead space that needs to be filled is also marked on the defect template.
■ Flap Harvest
■ Outline of relevant muscles and landmarks are marked on the skin (TECH
FIG 3A).
■ Perforators are located using handheld pencil Doppler and the flap is
designed using the template of the defect.
■ Once the targeted perforator is identified via a suprafascial dissection
through a limited incision on superior border of the flap, then the whole skin
paddle is elevated and meticulous intramuscular dissection of the pedicle
with bipolar forceps is commenced.
■ Motor nerve branches to the muscle are maximally preserved and the pedicle
is divided when sufficient length is obtained (TECH FIG 3B).
■ A closed suction drain is placed, and the donor wound is primarily closed in