Reoperative Aesthetic & Reconstructive Plastic Surgery

1976
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
In less-severe contractures, release can
be completed using a five-flap or
“jumping man” Z-plasty. A four-flap
Z-plasty can also be used. Typically, a
simple Z-plasty is not used because it
produces too deep a web space. After
the release, if there is signi cant carpal
or metacarpal exposure, flap recon-
struction is needed.This photo shows
a rst web space release with a four-
ap Z-plasty.
Another option for rst web release and reconstruction is to do a release with the
aid of an external skeletal distractor.The scar is released as much as possible and the
web is reconstructed using a full-thickness graft. An external skeletal distractor is
then placed at the time of surgery and distracted maximally. The tourniquet is re-
leased,and if there is a problem with blood ow,the distractor is relaxed.The distrac-
tor is left in position and gradually expanded 1 to 2 mm a day until optimal position-
ing between rst and second metacarpal heads is achieved. The external distractor
can then either remain in place or be replaced by a methylmethacrylate bar.This pa-
tient demonstrates thumb contracture before surgery.The contracture was released
and an external xator was placed to the thumb and index metacarpals. After graft-
ing, the rst web space was maintained with the external xator.

1977
Chapter 48
Reoperative Surgery After Excision and Grafting of Upper Extremity Burns
The patient is shown after the xator has been removed, with the ngers open and
closed.
Active and passive therapy to improve hand function can continue during the heal-
ing phase. The external xator can be removed 2 to 4 weeks after release follow-
ing adequate healing.
BOUTONNIÈRE DEFORMITY
Boutonnière deformity involving the PIP joint is the most common bone and joint
defect in the postburn hand. It results from destruction of the central slip of the ex-
tensor tendon.The lateral bands on the extensor hood then slips past the volar axis
of the PIP joint.Therefore they become exors at the PIP joint but remain exten-
sors at the DIP joint, as seen in the photo above.
Much has been written in the hand literature on the reconstruction of bouton-
nière deformities. Typically, reconstruction is performed by reconstruction of the
central slip, either by taking portions from the distal central slip and rotating them
backward or taking portions of the lateral bands and interweaving them to con-
struct a stable central segment. Repair in the burn patient often fails because of
poor soft tissue coverage over the PIP joint.

1978
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
An alternative is an extensor tenotomy at the level of the middle phalanx.The tenot-
omy is done as a step-cut lengthening, and the tendinous attachment at the DIP
joint is elevated completely. The DIP joint is opened to release the capsule, allow-
ing distal displacement of the distal phalanx. If the skin is tight, a skin graft must be
used to ll in the distal dorsal defect.After the lateral bands are loosened and the DIP
joint is exed, it is usually possible to extend the PIP joint to a full 180 degrees. Pin
xation is used to hold the DIP in exion and the PIP joint in extension, allowing
a rm base for the application of a split-thickness skin graft to be placed over the PIP
joint.This converts the deformity to that of a mallet nger, allowing greater exion
and extension of the PIP joint and greatly increasing nger function.
In patients with long-standing boutonnière deformities, capsular contractures can
occur and even bony changes within the joint itself.
In complicated boutonnière deformities, PIP fusion at 25 to 50 degrees
may be the best surgical treatment increasing the degree of exion
toward ulnar digits.
BURNS AFFECTING SOFT TISSUES, BONES, AND JOINTS
In severe burns that result in destruction of skin, tendons, periarticular ligaments,
and articular surfaces, it may be dif cult or even impossible to prevent contractures.
In most instances they preclude the possibility of mobilization of joints, and usually
they require arthrodesis, amputation, or partial or complete joint excision. When
fusion of the digital joints is necessary, it is best to fuse the PIP joint at approxi-
mately 50 degrees of exion and the DIP joint at approximately 15 degrees of ex-
ion.This stabilizes both areas and allows a satisfactory digit for grasping and hold-
ing. When performing these IP joint functions, it is mandatory to ensure proper
alignment and avoid rotation of the digits.
In the rarer condition of extension deformity, it is dif cult to create a exed pos-
ture.This is caused by the pull of the intrinsic tendons on the PIP joint that try to
hold it in hyperextension. To ensure stability, it is frequently necessary to place a
mortis bone graft into the arthrodesis site to better stabilize the joint and keep it
xated at the proper angle of exion.
In extreme cases of marked MP joint hyperextension, it is sometimes necessary to
resect the metacarpal head to improve function. Resection of the metacarpal head
allows the phalanges to be taken to neutral or slight exion, and this increases the
patient’s grasp ef ciency. This is often accompanied by other procedures to im-
prove grasp. Arthrodesis of the MP joints is rarely done, and the decision to do this
depends on the range of motion at the IP joints. If the latter is limited, arthrodesis
of the larger joint should never be done.
Amputation of part of a digit or an entire ray may be the best way to improve the
general use of the hand in these severe deformities. Fingertip removal, amputation

1979
Chapter 48
Reoperative Surgery After Excision and Grafting of Upper Extremity Burns
to the IP joints, or ray deletion may eliminate a useless segment and allow im-
provement in the same or adjacent digits.
COMPLEX THUMB R ECONSTRUCTION
Options for thumb reconstruction include metacarpal stacking (“on-top” plasty),
distraction osteogenesis and pedicle aps, pollicization (pedicle or free), and toe-to-
hand transfers. The goal in all of these is to provide for pinch or at least key grip.
All are useful and workable but need to be adapted according to the patient’s de-
sires and the state of the postburn hand at the time of reconstruction.
A postoperative radiograph is shown along with the hand with the skin graft in
place and the functional result.
This patient underwent “on-top” plasty in which the digital remnant was placed on
the thumb metacarpal to re-create the thumb and first web space. Preoperative
markings on the palm and a preoperative radiograph are shown. The index ap
was transferred and K-wire was placed.

1980
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
The donor digit, its dissection, and the free digit ap are shown, as well as the closed
donor site.
This case demonstrates the use of a nger-to-thumb free ap. Preoperative photos
of the patient’s palm and angiogram are shown.

1981
Chapter 48
Reoperative Surgery After Excision and Grafting of Upper Extremity Burns
The recipient site of the patient’s left hand was dissected and the free digit-to-
thumb procedure was performed. The implanted digit is shown along with a pal-
mar view of the neo-thumb.
Partial thumb reconstruction can be completed using island pedicle flaps taken
from other digits to provide for a sensate stable pad. However, this is done with
loss of sensation to the donor digit. Free tissue transfer options for simple soft tis-
sue reconstruction of the thumb include wrap-around aps, rst web space aps
taken from the foot for base reconstruction, and toe pulp aps to rebuild a sensate
digital tip. All of these are useful for coverage of nger defects as neurosensory aps
and are based on the rst dorsal metatarsal artery and plantar digital nerves.
Metacarpal stacking has shown great utility in reconstruction by providing a viable,
accomplishable pinch grip in even some of the most severely injured hands with
amputation of multiple digits. It was rst used by Littler3 in multiple digital recon-
struction and subsequently repeated in burn patients. It provides for a stable vascu-
larized osteocutaneous transfer with concomitant deepening of the rst web space.
Distraction osteogenesis and pedicled aps do provide for a stable thumb post with
coverage. However, their usefulness is limited because of poor sensation and less
mobility than with either pollicization or toe-to-hand transfers.

1982
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Pollicization is most commonly done for congenital absence of the thumb where
forearm musculature is deficient and nerve and functional retraining occur at a
younger age. Digital transfer in the hand allows for reestablishment of a function-
ing sensate thumb and provides an opportunity for maximum recovery of thumb
function. However, it requires an intelligent cooperative patient for retraining and
the availability of an experienced microvascular team.
CONCLUSION
Reconstruction of the burned hand begins with acute care. Early excision and graft-
ing, control of edema and adequate positioning are integral to the successful out-
come of the burned hand. In the acute setting, the positioning of the MP joint
helps determine the position of the hand. Acute soft tissue coverage is chosen on
limitations versus needs. Successful outcomes require cooperation of patient, sur-
geon and therapist in formulating an acceptable plan for maximum rehabilitation
and recovery of the burned person. Despite adequate care in the initial period, a
number of postburn sequelae and contractures still occur.
Digital and hand reconstruction requires formulation of a well thought out plan.
Microvascular transfer of thin pliable aps or digits and the use of soft-tissue sub-
stitutes blends variety into the traditional options for postburn reconstruction. Out-
come of burned hand treatment is related to function and appearance as deter-
mined by return to work, quality of daily living and patient self-acceptance.
References—With Key Annotated References
1. Pensler JM, Stewart R, Louis SR, et al. Reconstruction of the burn home:Full-thickness versus
split thickness skin grafts long-term follow-up. Plastic Reconstr Surg 81:46, 1988.
2. Hunt J, Moisidis E, Haertsch P. Initial experience of Integra in the treatment of post-burn an-
terior cervical neck contracture. Br J Plast Surg 53:652, 2000.
3. Littler JW. The neurovascular pedicle method of digital transposition for reconstruction of the
thumb. Plast Reconstr Surg 12:203, 1953.

1983
Chapter 48
Reoperative Surgery After Excision and Grafting of Upper Extremity Burns
Suggested Readings
Achauer BM. Burns of the upper extremity in burn reconstruction. New York:Thieme Medical
Publishers, 1991, p 100.
Authoritative text on burn reconstruction, with excellent illustrations.
Luce E.The acute and subacute management of the burned hand. Clin Plast Surg 27:49, 2000.
This article discusses the components of treatment plans that yield the most consistently favorable re-
sults for patients with upper extremity burns.
Mlakar JJ, Dougherty WR. Reconstruction of the burned hand. In Herndon DN, ed. Total Burn
Care, 2nd ed. Philadelphia:WB Saunders, 2002, p 628.
Extensively referenced chapter on the acute and reconstructive care of the burned hand.
Salisbury RE. Reconstruction of the burned hand. Clin Plast Surg 27:65, 2000.
This article discusses the importance of a sound surgical plan, set forth in conjunction with the burn
team with time goals to provide patients with burned hands the best chances for success.
Salisbury RE, Bevin AG. Atlas of Reconstructive Burn Surgery: Upper Extremity. Philadelphia:
WB Saunders 1981, p 108.
Groundbreaking text with many examples of dif cult burn reconstructive cases.
Salisbury RE, Dingeldein GP. The burned hand and upper extremity. In Green DP, ed. Operative
Hand Surgery, 4th ed. New York: Churchill Livingstone, 1993, p 2007.

1984
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
1. The procedure of choice for management of painful interphalangeal joints after
burn injury is:
a. Steroid injection
b. Capsulotomy
c. Arthrodesis
d. Resection arthroplasty
e. Alloplastic arthroplasty
2. In patients with burn injury involving all three levels of the upper extremity
that result in burn scar contracture, the rst contracture released should be the:
a. Axilla
b. Elbow
c. Wrist
d. Metacarpophalangeal joints
e. Interphalangeal joints
3. The most common adverse soft tissue sequela of deep second-degree or third-
degree burns involving the hand is:
a. Extension contracture of the metacarpophalangeal joint
b. Flexion contracture of the proximal interphalangeal joint
c. Burn scar syndactyly
d. Cold intolerance
e. Chronic pain
4. The most common bone and joint defect after severe burn injury to the hand is:
a. Boutonnière deformity of the proximal interphalangeal joint
b. Volar plate contracture of the proximal interphalangeal joint
c. Swann neck digital deformity
d. Mallet deformity of the distal interphalangeal joint
e. Collateral ligament contracture of the proximal interphalangeal joints
5. In cases of total thumb loss after burn injury, the best option for thumb recon-
struction is:
a. Metacarpal stacking
b. Distracting osteogenesis
c. Bone graft and local aps
d. Pollicization
e. Toe-to-thumb transfer
R EVIEW QUESTIONS

1985
R eoperation in peripheral nerve surgery is particularly complex. All surgery
creates trauma and scar tissue, and the same reoperative surgery intended to repair
peripheral nerve pathology inherently creates new incisions and scars that might
serve as the nidus for future nerve pathology. Therefore reoperation in peripheral
nerve surgery requires understanding of (1) anatomic nerve variations, (2) patterns
of nerve damage and entrapment that follow common operative procedures, and (3)
specialized surgical techniques for manipulation of the damaged peripheral nerve.
Peripheral nerve pathology results from any process that interferes with neuronal
conduction outside of the central nervous system;processes amenable to surgical in-
tervention include nerve damage caused by physical compression or trauma (for ex-
Reoperative Peripheral
Nerve Surgery
Ivica Ducic, A. Lee Dellon, and Ali Al-Attar
C ha pter 4 9
Reoperative Problems
Persistent paresthesia
Altered sensation or numbness
Recurrent nerve entrapment
Adhesions and scarring
Muscle weakness or loss
Chronic pain
Painful neuroma
Timing and choice of the treatment
Oh the nerves! The nerves!
The mysteries of this machine called man!
Charles Dickens

1986
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
ample, the trauma of surgery). Unlike other branches of plastic surgery, the goal of
a large number of peripheral nerve surgeries is to repair neuropathy in a patient
who has previously undergone surgery.Therefore these procedures are reoperative
in nature.
Reoperative peripheral nerve surgery encompasses repair of three pathophysiologic
entities. First, nerve transection (intentional or accidental) during any surgical pro-
cedure leads to dysfunction and possible neuroma formation and, if symptomatic,
might be amenable to reoperative intervention. Second, scar formation from any
surgery can surround a peripheral nerve and compress it;symptoms can be relieved
with surgical decompression of the peripheral nerve. Finally, patients who have
previously undergone peripheral nerve surgery (for example, carpal tunnel release)
might have recurrent symptoms, for which reoperation could be considered.
PRINCIPLES OF REOPERATIVE PERIPHERAL
NERVE SURGERY
Peripheral nerve injury becomes symptomatic either when a critical function is
lost or when paresthesia and pain replace normal sensory signaling. Proper nerve
function requires nerve continuity with adequate blood supply. Partial or complete
nerve transection will cause loss of sensory or motor function;the nerve’s regener-
ative capacity will then either reestablish neuronal continuity or will form a disor-
ganized scar within a mature end-bulb neuroma. Similarly, compression on a pe-
ripheral nerve causes ischemia and neuroma formation.1 A neuroma contains
bundled, disorganized nerve endings within a collagenous mass, and is an anatomic
source of localized pain and paresthesia that occurs after peripheral nerve damage.
Lundborg and Rydevik have1 extensively studied the anatomy of the blood supply
to peripheral nerves. The critical aspect for reoperative surgery is that there is a
signi cant intrinsic blood supply to the peripheral nerve that allows the surgeon to
lift the nerve from its anatomic bed, open the epineurium, and operate between the
fascicles.

.
The endoneurial and perineurial microvessels maintain an excellent vascularity to
the peripheral nerve. Segmental blood vessels enter the peripheral nerve through
the mesoneurium. In addition, an extensive number of longitudinal vessels in the
epineurium, perineurium, and endoneurium supply the nerve.2 However, pressures
above 20 mm Hg will decrease blood ow. Maki et al3 have demonstrated that the
“safe” length a nerve can be elevated from its bed (that is, its segmental vascular sup-
ply) is a distance of about 60 times the diameter of the nerve.Therefore the surgeon
should be more concerned with the need to move the nerve into an area that is free
from external compressive forces than with the length to which the nerve has been
neurolysed. Extreme caution should be exercised in repeat neurolysis of a periph-
eral nerve.
Management of a damaged peripheral nerve begins with accurately determining
the site of injury followed by medical and/or surgical intervention to restore func-
tion and eliminate pain.The history and physical examination will often suggest the
diagnosis;further imaging and electrodiagnostic testing is necessary, mainly to eval-
uate other causes of the symptoms.2,4 Central nervous system disease, particularly
spinal root impingement, can cause many of the same symptoms as peripheral nerve
damage and needs to be excluded.
1987
Chapter 49
Reoperative Peripheral Nerve Surgery
Patient With Chronic
Peripheral Nerve Pain
Peripheral nerve
surgery consult
Con rm diagnosis
Treatment surgery
Exclude:
Local pathology
(infection, nerve tumors, etc.)
Systemic neuropathy
Duration
(consider effect of previous
surgery or trauma)
Treat pathologic condition
Observation
Conservative measures:
— Removing the cause
— Optimizing medical status
— Targeted medical treatment
— Symptomatic pain relief
— Physical therapy
— Diagnostic nerve blocks
Medical management of paresthesia and pain caused by injured peripheral nerves
centers on symptom management and includes the administration of narcotic and
nonnarcotic analgesics, antidepressant medication, and centrally-acting agents such
as gabapentin. Although medical management may offer temporary relief for the
majority of patients, it can be complicated by increasing dosage requirements and
narcotic dependence as the acute insult develops into a chronic pain syndrome.5



6 months
6 months

1988
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Surgical relief is offered to a patient who is not relieved with medical therapy or
whose duration of symptoms exceeds 6 months. An algorithm for management of
a patient with chronic peripheral nerve pain is shown on p. 1986.
Reoperative peripheral nerve surgery should generally be performed by surgeons
who are experienced with these techniques. Symptomatic neuromas are excised,
and the two ends of the peripheral nerve can be reconnected. Alternatively, the
proximal end can be implanted into an altered neurotrophic environment (for ex-
ample, muscle), to prevent neuroma recurrence.6 Severed peripheral nerves need to
be debrided back to unscarred tissue, and then reconnected.
Peripheral nerve repair can be performed with direct end-to-end
reanastomosis, using nerve grafts or arti cial nerve conduits.
The surgeon must be prepared to perform a nerve graft instead of a nerve repair if,
during reoperation to restore nerve function, the nerve has been either divided in-
advertently at the rst operation or left for secondary repair because of some un-
favorable condition present during the rst operation. Preferred nerve graft donor
sites are listed in the box above. When the scarred proximal and distal ends of the
nerve are resected at reoperation, there will be a gap if the injury was anything but
a glass or knife laceration. In most instances, this gap cannot be closed using second-
ary sutures without placing an unacceptable degree of tension on the repair site.
Tension on the repair, without grafting, is likely to occur with digital nerve and
common volar digital nerve injuries. In the forearm, where nerves can be mobilized
more easily, a nerve defect of l or 2 cm may be overcome without grafting. How-
ever, when in doubt, perform a nerve graft.
UPPER EXTREMITY
BRACHIAL PLEXUS
Injury to the brachial plexus is frequently the result of trauma, including obstetric
trauma, and can warrant surgical repair. Depending on the sites of nerve transection,
initial surgical repair involves nerve reattachment or grafting. Despite excellent sur-
Medial antebrachial cutaneous nerve
Lateral antebrachial cutaneous nerve
Sural nerve (lateral sural nerve from common peroneal nerve can provide an extra 20 to
30 cm of donor graft when present)
Terminal posterior interosseous nerve (suitable for distal digital nerve grafts only)
Radial sensory nerve (suitable when grafting radial nerve for motor function)
Super cial peroneal nerve (suitable when grafting deep peroneal nerve for tibialis ante-
rior muscle function)
Preferred Nerve Graft Donor Sites

gical technique, functional recovery still eludes a large number of patients. Reop-
erative strategies include nerve transfer and muscle or tendon transfer.7,8 Nerve
transfers can involve neurotization of affected motor nerves using other nerves ei-
ther within or outside of the brachial plexus.
ULNAR NERVE AT ELBOW
Cubital tunnel syndrome refers to entrapment of the ulnar nerve in the postcondy-
lar groove.This description implies that at least the roof of the tunnel and the band
(described by Osborne) between the two heads of the exor carpi ulnaris muscle
have been released at the rst operation. Reoperation then is indicated for ulnar
nerve entrapment at the elbow regardless of where the ulnar nerve is located; it
may be in situ or it may be transposed anteriorly and lie subcutaneously, intramus-
cularly, or submuscularly. If the rst operation was a medial epicondylectomy, the
ulnar nerve may be adherent to the medial humeral epicondyle. Reoperation for ul-
nar nerve entrapment must be a true exploration of the ulnar nerve because, unfor-
tunately, the operative notes from previous surgeries are not always an accurate
guide as to the present location of the nerve.
1989
Chapter 49
Reoperative Peripheral Nerve Surgery
Medial intermuscular septum
Fascia from medial head of triceps brachii muscle to medial intermuscular septum
Thickened brachialis fascia
High origin of pronator teres muscle, super cial head
Common exor tendon
Periosteal origin of ulnar head of exor carpi ulnaris muscle
Tethering by motor branch of exor carpi ulnaris muscle
Unreleased Osborne’s band or roof of tunnel
Overgrowth of medial humeral epicondyle after medial epicondylectomy
Adherence of ulnar nerve in acceptable location resulting from prolonged splinting
Anatomic Structures Related to Recurrent or Persistent
Ulnar Nerve Entrapment at the Elbow
Successful ulnar nerve surgery at the elbow requires an understanding of the
anatomic structures that may be responsible for recurrent compression or persis-
tence of symptoms.9 These structures are listed in the box on p. 1990.
One procedure for ulnar nerve release at the elbow involves a musculofascial step-
type lengthening of the exor-pronator muscle mass.10 When this elongated muscle
mass is used to cover the ulnar nerve,enough slack should be allowed so that the sur-
geon’s nger can t between the muscle above and the nerve below; in this way
postoperative pressure from the reattached muscle mass is minimized.In addition,the
periosteal origin of the ulnar head of the exor carpi ulnaris muscle forms a sharp
edge at the point where the transposed ulnar nerve will cross; thus this structure
must be divided or excised, as was the medial intermuscular septum proximally.

1990
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
The need for reoperation for recurrent or persistent ulnar nerve entrapment at the
elbow is signi cant, as suggested by the review of worldwide results for ulnar nerve
surgery at the elbow.11 Results after the initial procedure to decompress the ulnar
nerve are excellent in most cases, if the degree of compression is minimal;however,
if the degree of compression is moderate or severe, regardless of which decompres-
sion technique is used, most techniques are associated with a failure or recurrence
rate of approximately 33%.
To arrive at a differential diagnosis for a patient who has persistent or recurrent
numbness and weakness in the little nger, the surgeon must determine whether
there is an additional compression site of the ulnar nerve.This compression may be
present distally in Guyon’s canal, or there may be a double-crush that includes
brachial compression in the thoracic inlet, the so-called thoracic outlet syndrome.
This double-crush injury is common after automobile trauma, and can be bilateral.
Furthermore, patients who have been in automobile accidents, and who present
about 2 years after the injury, often have associated carpal tunnel syndrome. In this
circumstance, when a patient presents with multiple bilateral peripheral nerve en-
trapments, diagnostic testing is necessary for cervical disc disease as well as any
medically treatable disease such as diabetes, hyperthyroidism or hypothyroidism,
collagen vascular disease, and alcoholism. Outside the United States, the possibility
of leprosy must also be considered, and referral to a neurologist or rheumatologist
for workup is appropriate.
R ADIAL NERVE IN THE FOREARM
Scarring in the spiral groove (status post humeral fracture)
Fibrotic bands from humerus to lateral humeral epicondyle
Anomalous muscular origins of brachioradialis muscle
Pathologic condition affecting radial head (rheumatoid arthritis, fracture callus)
Fibrous edge of extensor carpi radialis brevis muscle
Fibrous edge of supinator muscle (arcade of Frohse)
Fibrous surface of entire super cial head of supinator muscle
Vascular leashes crossing posterior interosseous nerve
Thickened fascia between brachioradialis tendon and extensor carpi radialis brevis
muscle distally
Radial sensory nerve exiting between slips of brachioradialis tendon
Anatomic Structures Related to Recurrent or Persistent
Radial Nerve Compression
Once radial sensory nerve entrapment in the forearm has been released, reoperation
is rarely necessary.12 Occasionally, a patient with de Quervain’s disease who was
treated with rst dorsal extensor compartment release may not have recovered; in
this situation the differential diagnoses include unreleased compression in the sec-
ond compartment (containing the extensor pollicis brevis muscle), radial sensory

nerve entrapment in the forearm, and injury to a branch of the radial sensory nerve
during the rst operation.13 For this last condition, the surgeon must consider the
need to resect the radial sensory nerve, and possibly the lateral antebrachial cuta-
neous nerve. Compression of the radial nerve in the radial tunnel and a C6 radicu-
lopathy must be considered as differential diagnoses for patients with recurrent or
persistent numbness in the distribution of the radial sensory nerve. A physical ex-
amination and electrodiagnostic evaluation are both necessary for a correct diagno-
sis. On rare occasions, the palmar cutaneous branch of the median nerve and the
posterior cutaneous nerve of the forearm can anomalously innervate the dorsora-
dial aspect of the forearm, resulting in persistent pain despite adequate surgical de-
compression of the radial sensory nerve and of the lateral antebrachial cutaneous
nerve. Anatomic structures related to recurrent or persistent radial nerve compres-
sion are listed in the box on p. 1990.
The need for reoperation for radial nerve compression in the proximal forearm
and elbow region suggests that one or more structures in that region may not have
been released at the rst operation.The concept underlying reoperation is that the
radial nerve, from the spiral groove of the humerus to the midforearm, must be
considered as coursing through a “multiple-crush” region that is analogous to the
median nerve in the forearm.14
The differential diagnoses also include entrapment at the more distal site of the ra-
dial sensory nerve in the forearm and C6 radiculopathy.Tendon transfers should be
considered for a patient with a failed posterior interosseous nerve release who has
had denervation for a signi cant period of time (greater than 1 year).When a pa-
tient has coexisting lateral humeral epicondylitis, this condition should be thor-
oughly treated before reoperation on the radial nerve is considered.
1991
Chapter 49
Reoperative Peripheral Nerve Surgery
Furthermore, the surgeon must ensure that the patient is not wearing any type of
counterforce brace. Such a device, as shown above, may cause compression of the
radial nerve in the radial tunnel as it attempts to transfer the force of the musculo-
tendinous unit from the lateral humeral epicondyle to the brace.

1992
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
R ECURRENT CARPAL TUNNEL SYNDROME
An extensive review of the results of carpal tunnel decompression performed to
treat carpal tunnel syndrome has been reported and suggests that at least 10% to
20% of patients do not achieve an excellent result.15 Thus there are many patients
who could potentially present for reoperation. Furthermore, approximately 2% of
patients who undergo carpal tunnel decompression will experience a complica-
tion other than failure before a good result is achieved.
The indications for reoperation in a patient who has already undergone carpal tun-
nel decompression are (1) the patient has not obtained relief of numbness and tin-
gling and (2) there is pain in and/or around the scar. Rarely, a patient with severe
thenar atrophy may have a functional problem with thumb apposition; in this case
tendon transfer may be considered. Nonetheless, suf cient ulnar nerve innervation
usually exists to ensure thenar muscle function.
Determining the correct diagnosis for a patient with persistent numbness after
carpal tunnel decompression is critical to the success of reoperative surgery. Prox-
imal sources of compression that need to be excluded include a brous sublimis
arch, the deep head of the pronator teres muscle in the forearm, the laceratus bro-
sus, or the ligament of Struthers at the elbow.
Furthermore, evaluation of more central sites of compression is mandatory. The
differential diagnosis includes brachial plexus compression at the thoracic outlet
and cervical disc disease. Finally, a patient with numbness in the index nger and
thumb after carpal tunnel decompression must be asked if the numbness is present
on the dorsum of those ngers. Radial sensory nerve compression16 can present as
failed carpal tunnel syndrome, and the radial nerve can innervate a signi cant por-
tion of the thumb pulp.17
Reoperation on the median nerve in the carpal tunnel after previous carpal tunnel
decompression requires a number of modi cations.18,19 A new incision is made to
the ulnar side of the rst incision.This access avoids the risk of incising the median
nerve, which is usually densely adherent to the undersurface of the palmar skin
and is encased between the divided edges of the deep transverse carpal ligament.
Using Guyon’s canal as a “vantage point,” neurolysis of the median nerve can be-
gin distal to the adherent site, and the incision can be extended into the forearm to
begin dissection distally from another unscarred area. A nerve stimulator can be
used to help identify the motor branch. In 25% of patients there is a separate tun-
nel for this branch as it courses between layers of transverse carpal ligament instead
of directly entering thenar muscles.20
Next, microsurgical intraneural neurolysis of the median nerve is performed. A
exor synovectomy is always executed as well, and the specimen is sent for patho-
logic examination; ndings consistent with rheumatoid arthritis or another colla-
gen vascular disease may be present. A small rim of the transverse carpal ligament

should also be sent with a request for amyloid staining if amyloidosis is being con-
sidered, or if the patient has some chronic disease for which secondary amyloido-
sis is a possibility (for example, renal disease).
The wrist is splinted in the neutral position for 7 to 8 days; the patient is then al-
lowed to move the wrist in the full range of motion. Finger movement begins on
the rst postoperative day. In 30 patients with 35 reoperated hands treated with
this approach, improvement was achieved in 32 patients (91.4%).19
At reoperation, one of several congenital anomalies may be noted, including (1)
lumbricales manus muscles within the carpal canal, (2) a high division of the me-
dian nerve so that it occupies a greater than expected volume within the tunnel, (3)
or a persistent median artery, which is often found in conjunction with a high di-
vision of the median nerve. If present, the persistent median artery should be pre-
served, but it should be separated from the median nerve via microsurgical dissec-
tion to prevent any vascular compression of the nerve. The blood supplied by the
persistent median artery may be needed for an incomplete vascular arch. If there is
a history of a wrist fracture, especially a distal radius fracture, it is critical to extend
the incision proximally and release the distal antebrachial fascia to well above the
fracture site.The median neurolysis may also need to be extended to this level.
MEDIAN NERVE IN FOREARM
1993
Chapter 49
Reoperative Peripheral Nerve Surgery
Ligament of Struthers
Lacertus brosus
High origin of super cial head of pronator teres muscle24
Deep ( brous) head of pronator teres muscle
Deep ( brous) head of exor sublimus muscle
Vascular leash crossing nerve
Anatomic Structures Related to Recurrent or Persistent
Median Nerve Entrapment in the Forearm
Reoperation for recurrent or persistent median nerve compression in
the forearm is not common; by far the more common situation is me-
dian nerve entrapment in the forearm after carpal decompression.
When reoperation is necessary for recurrent median nerve compression in the fore-
arm, the situation is analogous to that of the radial nerve in this same region:there
is potential for a multiple-crush injury of many anatomic structures in a short
length of the arm. Anatomic structures related to recurrent persistent median nerve
entrapment in the forearm are listed in the box above.

1994
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
The structure most commonly requiring release at reoperation is a second brous
arch resulting from the exor digitorum sublimus muscle originating from the in-
terosseous membrane.21 One structure not described extensively is the high origin
of the super cial head of the pronator teres muscle, which has been found in 20%
of cadaver dissections.22 This muscle origin can compress the median nerve against
the trochlear process of the humerus.
ELBOW PAIN
Recurrent chronic ulnar nerve entrapment at the elbow does not cause
elbow pain.
Acute degeneration of the ulnar nerve might cause this type of referred pain, al-
though this situation is exceedingly rare. Associated elbow pain is most likely the re-
sult of a neuroma of the medial antebrachial cutaneous nerve.23 Typically, there is an
area within the scar, usually anterior and distal, from which pain radiates to the el-
bow or just distal and anterior or posterior to the scar, but not to the little nger.
This pattern represents the distribution of the medial antebrachial cutaneous nerve,
usually its posterior branch.
The diagnosis can be con rmed by a diagnostic nerve block proximal to the ante-
cubital crease that relieves this pain while preserving sensibility in the little nger.
The preferred treatment is to resect the neuroma and implant the proximal end of
usually only the posterior branch into the triceps brachii muscle lateral to (deep
to) the ulnar nerve. In addition to the medial antebrachial cutaneous nerve, recur-
rent pain around the elbow can also be caused by neuroma of the medial brachial
cutaneous nerve, which arises from the medial cord of the brachial plexus just prox-
imal to the origin of the medial antebrachial cutaneous nerve.
FOREARM PAIN
Reoperation for painful neuroma is most commonly performed for problems over
the dorsoradial aspect of the forearm and wrist. As discussed previously, the most
common situation in terms of radial sensory nerve entrapment, is that the patient
will have had dorsal ganglion excision or rst dorsal extensor tendon release for de
Quervain’s disease, with iatrogenic injury to what is believed to be a branch of the
radial sensory nerve.Thus the nerve is usually resected to a more proximal level in
the rst operation for the painful neuroma of the radial sensory nerve (RSN).Typ-
ically the pain is either not improved, worse, or recurs within a few weeks, and
sensation is lost in the painful area.
As mentioned previously, the most common cause for reoperation is the lateral an-
tebrachial cutaneous (LABC) nerve overlapping the RSN to some degree.This sit-
uation occurs in 75% of patients.24

The approach to this problem begins with searching for a positive Tinel’s sign over
the proximal course of cutaneous nerves.These nerves may contribute to the pain,
similar to the RSN.The cutaneous nerve that most commonly generates pain is the
LABC nerve. In patients with some residual pain after resection of the RSN and the
LABC nerve, the involved nerves with anomalous distributions can be the palmar
cutaneous branch of the median (PCBM) nerve and the posterior cutaneous nerve
of the forearm.Therefore diagnostic nerve blocks are performed rst to the LABC
nerve at the antecubital crease and then 15 minutes later to the RSN over the dor-
soradial forearm. If the pain remains, then nerve blocks are performed to the
PCBM nerve and the posterior cutaneous nerve of the forearm, just anterior to the
radial head, to search for a possible anomalous overlap of these nerves. The dorsal
cutaneous branch of the ulnar nerve rarely enters this area.
It has been shown in a series of anatomic dissections that the PCBM nerve can
extend into the dorsoradial wrist area, and can even form a neuroma causing in-
volvement of this nerve in a pain syndrome.25,26 The treatment for this unusual sit-
uation is the same as that described for treatment when the PCBM nerve compli-
cates carpal tunnel decompression—resect the nerve and implant the PCBM nerve
into the pronator quadratus muscle.
If performed as a primary operation for pain relief, this treatment regimen involv-
ing (1) diagnostic nerve blocks, (2) resection of both the RSN and the LABC nerve,
and (3) implantation of the nerves into the proximal thick portion of the brachio-
radialis muscle has a success rate for pain relief and return-to-work approaching
90%. The success rate still approaches 50% even if the patient has had more than
three previous operations.27
W RIST PAIN
Intractable wrist pain can occur after orthopedic surgery on the wrist, or radial
nerve decompression. Recurrent radial nerve entrapment at the wrist is rare. The
differential diagnosis should include thrombosis of the ulnar artery and pisiotri-
quetral arthritis, both of which can cause symptoms similar to those of ulnar nerve
compression in Guyon’s canal. Alternative diagnoses, including wrist ganglia and
lipomas, should also be considered. Appropriate vascular testing and imaging stud-
ies are required.
The anterior interosseous nerve and the terminal branch of the posterior in-
terosseous nerve can serve as sources of intractable postoperative pain arising from
the dorsal wrist capsule.28-30 Interruption of the function of these nerves is indicated
for (1) wrist pain after sprain that is not relieved by appropriate splinting and anti-
in ammatory medication; (2) wrist pain after distal radius fracture when, radio-
1995
Chapter 49
Reoperative Peripheral Nerve Surgery

1996
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Iliohypogastric nerve
Genitofemoral nerve


Ilioinguinal nerve
Lateral femoral nerve
Genital branch
Femoral branch
Torso and groin pain can occur in a patient who has undergone open surgery on
the anterior abdominal wall, including appendectomy, inguinal hernia repair, ab-
dominoplasty, cesarean delivery, and hysterectomy.31-35 Pain generally follows either
inadvertent nerve transection or entrapment of the peripheral nerve within adja-
graphically, the radius is in the best position and the pain is not radiating from the
distal radiaoulnar joint and is not caused by a positive ulnar variance; and (3) pain
resulting from a triangular brocartilaginous tear for which arthroscopy has not
relieved pain, and a more extensive surgical intervention is not acceptable to the pa-
tient or the surgeon. Partial wrist denervations are generally contraindicated in pa-
tients with carpal instabilities because, even though the pain may be relieved, pro-
gressive collapse patterns occur and fusion of some type will most certainly be
required anyway.
TORSO AND GROIN PAIN

cent scar tissue, causing painful neuroma formation. The involved nerves on the
anterior abdominal wall are the ilioinguinal, iliohypogastric, and the genital branch
of the genitofemoral nerve;unfortunately considerable anatomic variability in these
nerves precludes avoiding them in planning surgical incisions.36,37 The illustration
above presents cutaneous nerves of the thigh and groin regions.
Postoperative pain in the torso and groin after a surgical incision on the anterior ab-
dominal wall needs to be evaluated for a several causes. First, the disease that initially
required surgery must be addressed to ensure that it has not recurred (for example,
recurrent hernia after inguinal hernia repair). Second, a careful history must be
taken and a physical examination performed to evaluate for novel, concurrent ab-
dominal or pelvic disease, particularly age- and sex-speci c causes, such as divertic-
ulitis in the elderly patient and endometriosis in the young adult female patient.
Third, imaging of the abdomen and pelvis, including imaging of the spine, is
mandatory to search for occult causes and spinal root entrapment. Finally, after the
exclusion of other causes, and with appropriate exam ndings that are suggestive of
peripheral neuropathy, surgical neurectomy can be performed. In the appropriate
setting, this procedure is generally successful.32,34,35 Patients in whom other causes
are excluded, and whose postoperative torso or groin pain is in the distribution of
a peripheral nerve, are frequently found to have a neuroma of the peripheral nerve.
Its removal and implantation into muscle is curative.
Patient Example
1997
Chapter 49
Reoperative Peripheral Nerve Surgery
This patient had chronic hip pain and thigh paresthesia in the distribution of the
lateral femoral cutaneous nerve. The nerve was surgically decompressed, resulting
in complete pain relief.

1998
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
LOWER EXTREMITY
FEMORAL NERVE
Femoral neuropathy has been documented in the postoperative setting as a conse-
quence of inadvertent damage after inguinal, orthopedic (hip), and urologic surger-
ies, as well as after femoral vessel catheterization.38-41 The mechanism of injury to
the femoral nerve is believed to be the result of compression of the nerve and the
psoas muscle during aggressive retraction; in certain abdominal procedures such as
renal transplantation and open aortic aneurysm repair, rates of femoral nerve dam-
age have been reported to be as high as 2% to 3%.42,43 An alternative mechanism of
perioperative femoral nerve damage results from compression of the inguinal liga-
ment on the femoral nerve in patients who undergoe a prolonged lithotomy.44
If femoral neuropathy after surgery is suspected, the patient should be evaluated
with a thorough neurologic examination, followed by imaging and electrodiagnos-
tic studies. Surgical intervention is warranted in patients for whom a trial of con-
servative treatment that includes physical therapy is unsuccessful. Optimal surgical
intervention should include neurolysis of the femoral nerve, followed by resection
and grafting at a later time if neurolysis does not prove to be bene cial.41
SUPERFICIAL PERONEAL NERVE
Variations in the anatomic course of the super cial peroneal nerve make this struc-
ture quite vulnerable to injury during operative procedures on the lower extrem-
ity.The common peroneal nerve classically winds around the bular neck and then
branches off its super cial branch into the lateral compartment of the leg;however,
it can also course into the anterior compartment or within the intermuscular sep-
tum that separates these two compartments.45 The location of the super cial pe-
roneal nerve is critical, given the number of surgical procedures performed in its
vicinity (for example, arthroscopy, open tibial reduction, fasciotomy, and fasciocu-
taneous aps) and the resultant risk of inadvertent operative injury.
Patients who have undergone surgery in the vicinity of this nerve and who have
postoperative signs and symptoms suggestive of neuropathy require careful exami-
nation to document ndings in the nerve’s distribution. After imaging and electro-
diagnostic studies are performed to con rm the diagnosis, surgical decompression
of the super cial peroneal nerve can be performed with resection and grafting if
complete nerve discontinuity is found. If a neuroma is encountered intraopera-
tively, it needs to be resected and the nerve primarily reanastomosed or grafted.
Surgical decompression of the common, deep, and super cial peroneal nerves rarely
fails in releasing compression;therefore reoperation after decompression is rare. Re-
current symptoms suggestive of nerve compression that develop after surgical de-
compression should prompt the search for alternative diagnoses, and particularly
for compression at other levels of the nerve pathways.

KNEE PAIN
1999
Chapter 49
Reoperative Peripheral Nerve Surgery
Medial cutaneous
nerve of the thigh
Medial retinacular nerve
Infrapatellar branch
of the saphenous nerve
Anterior cutaneous
nerve of the thigh
Distal branch of the
lateral cutaneous
nerve of the thigh
Common peroneal nerve
Lateral retinacular nerve
Arthroscopic knee surgery and knee arthroplasty will occasionally result in neu-
ropathy after inadvertent damage to the common peroneal nerve (CPN). Although
neither of these common procedures directly exposes the CPN, the nerve can be
damaged during the surgery itself or can become surrounded by scar tissue that
develops postoperatively, with resulting nerve transection or neuroma formation.46-48
The diagnostic workup must include evaluation and exclusion of other causes of
postoperative pain, particularly infection, loosened hardware, mechanical misalign-
ment, and neoplasm. Surgical management involves early and direct repair of the
transected nerve, with excision of any neuroma and reimplantation into muscle.49,50
Nerves that may serve as sources of chronic knee pain are illustrated above.
Although the CPN is the major peripheral nerve affected after knee surgery, neu-
romas of sensory nerves supplying the knee and its surroundings may develop when
they are severed or encased in scar tissue.These smaller peripheral nerves can be the
source of chronic postoperative knee pain, and examination ndings might be lim-
ited to deep or super cial paresthesia of the knee. The most commonly affected
sensory nerves are the lateral retinacular nerve (LRN), which causes deep knee

2000
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
pain, and the infrapatellar branch of the saphenous nerve (IPBSN), which causes su-
per cial knee pain. Excision of the involved neuroma followed by implantation of
the proximal stump into muscle results in durable pain relief. Other sensory nerves
that can also contribute to chronic pain through neuroma formation include the
medial retinacular nerve (MRN), the articular branch of the common peroneal
nerve, and the medial (MCNT) and anterior (ACNT) cutaneous nerves of the
thigh. Other sources of chronic knee pain in the lateral knee are the lateral femoral
cutaneous nerve (LCFN) and the deep anterior femoral nerve (DAFN).
AMPUTATION STUMP PAIN
Below-the-knee or above-the-knee amputations cut across major nerve bers, and
the delayed development of chronic stump pain in an amputee raises strong suspi-
cion for neuroma formation. Unfortunately, these patients are sometimes managed
based on a diagnosis of chronic pain, and are medicated with narcotics that aggra-
vate functional recovery and ambulation with prosthetics.
Patient Example
In the amputee whose stump does not have soft tissue infection, and whose imag-
ing studies do not suggest bone spurs or osteomyelitis, the diagnosis of neuroma
needs to be considered.51 Medical management with analgesia, narcotics, and anti-
depressant medication can ameliorate symptoms temporarily;however, surgical re-
moval of the neuroma with implantation of the proximal nerve stump into muscle
is therapeutic, often with rapid and dramatic pain relief.This patient had debilitat-
ing chronic stump pain, with exquisite point tenderness at the circled areas. The
lines indicate the path of the peripheral nerves. Neuromas of the saphenous and
sural nerves were later found immediately below the shaded areas. They were re-
sected and the proximal ends were implanted into muscle.

R ECURRENT TARSAL TUNNEL SYNDROME
Tarsal tunnel syndrome—the compression of the posterior tibial nerve in the tarsal
tunnel—is the most common chronic peripheral nerve compression syndrome of
the lower extremity. Unfortunately, reoperation is not rare.The original descriptions
of tarsal tunnel syndrome suggested that the area of compression was limited to
the region of the nerve beneath the exor retinaculum. However, it is clear based
on anatomic dissections that there is also a separate medial plantar tunnel and a
separate lateral plantar tunnel. When correlated to the anatomic structures of the
upper extremity, the tarsal tunnel represents the distal forearm, the medial plantar
tunnel is analogous to the carpal tunnel, and the lateral plantar tunnel represents
Guyon’s canal.52
Reoperation for recurrent or persistent complaints of numbness in the toes, or
burning beneath the metatarsal head, is most often required because these distal
two tunnels were not released at the rst operation. Signs of this condition on phys-
ical examination are (1) the incision will not extend much distal to the medial
malleolus and (2) there may be a Tinel sign over the medial plantar nerve just be-
neath the tubercle of the navicular bone, or over the lateral plantar tunnel with ap-
propriate radiation of sensation into the big or the little toe. Heel numbness or
pain may be caused by compression of the calcaneal nerve in its own separate tun-
nel beneath the fascia from the calcaneus to the abductor hallucis brevis muscle.
The indicated surgical treatment is to reexplore the entire posterior tibial nerve,
identify the calcaneal branch or branches, retract the abductor hallucis brevis mus-
cle, and release each of the distal tunnels separately. Excision of the interfascicular
septum that separates the two tunnels should be performed, thereby creating one
large tunnel for both nerves.This maneuver is similar to excision of the hook of the
hamate in the hand.The surgeon’s nger should pass easily to the plantar aspect of
the foot.The epineurium should be opened; internal neurolysis for intraneural -
brosis is required, especially at the junction of the medial and lateral plantar nerves
and the posterior tibial nerve.
When pain is one of the indications for reoperation in a patient with previous tarsal
tunnel release, the surgeon must check for the presence of neuromas. One poten-
tial site is the saphenous distal branch, which lies close to the medial malleolus;if the
original incision was near this site, then it is likely that the saphenous nerve is part
of the problem. If a neuroma is identi ed at this location, then the saphenous nerve
should be resected proximal to the ankle and the nerve implanted into muscle in
the distal anterolateral compartment.The nerve can be found adjacent to the saphe-
nous vein lying on top of the fascia.
A second potential neuroma site is the calcaneal nerve.This nerve may be a branch
arising from the posterior tibial nerve and/or the lateral plantar nerve. A small
2001
Chapter 49
Reoperative Peripheral Nerve Surgery

2002
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
branch arising from the medial plantar nerve and crossing anterior to the posterior
tibial vessels has also been noted;at this location the nerve is vulnerable to transec-
tion during the initial division of the flexor retinaculum. Neuromas of the cal-
caneal nerve often develop after surgery for plantar fasciitis or a calcaneal bone
spur. Treatment involves resection of the neuroma and then implantation of the
nerve into a muscle. The choice of muscle depends on the origin of the calcaneal
nerve—soleus muscle or exor hallucis longus muscle for a calcaneal branch aris-
ing from the posterior tibial nerve, or abductor hallucis brevis muscle for a branch
arising from the medial or lateral plantar nerve.
POSTERIOR TIBIAL NERVE
Ankle trauma suf cient to require ankle fusion can result in compression of the
posterior tibial nerve. Attempts at neurolysis of this nerve may lead to severe pain
relieved only by anesthetic block of this nerve. Amputation is frequently suggested
to these patients. Because an anesthetic plantar aspect to the foot is likely to cause
future problems related to infection and soft tissue ulceration, resection of the pos-
terior tibial nerve and muscle implantation is not recommended. Alternatively, ex-
cellent results can be obtained with the excision of the damaged nerve and inter-
fascicular nerve grafting of the posterior tibial nerve.53 This procedure results in
pain relief and recovery of better than protective sensation in the plantar aspect of
the foot.The patient must be informed before surgery that during neural regener-
ation postoperatively there may be 3 to 6 months of dysesthesias. If there is severe
scarring posterior to the medial malleolus, an extraanatomic route (anterior to the
medial malleolus) may be chosen for the nerve grafting.
DORSUM OF FOOT
Many surgeons have recognized that pain after surgery for Morton’s neuroma,
metatarsal fracture, and ganglia is the result of injury to the small cutaneous nerves
over the dorsum of the foot. Unfortunately, treatment has often involved resecting
the neuroma to a more proximal level (to the ankle) or implanting the nerve into
a metatarsal bone. With plantar exion and extensor tendon activation, recurrent
pain is predictable.
One alternative approach is to determine, using diagnostic nerve blocks, whether
both the deep and super cial peroneal nerves are involved. If, as is often the case,
both nerves must be resected, the patient must fully understand that with this sur-
gery the dorsum of the foot will then be completely and permanently anesthetic.
The surgeon must ensure, using appropriate blocks, that neither the sural nerve nor
the saphenous nerve is related to the pain syndrome.The peroneal nerves marked for
resection must be divided over the anterior ankle to be properly identi ed.Then an
incision is made over the anterolateral compartment, and the peroneal nerves are
pulled up into the leg from the ankle.The deep and super cial peroneal nerves are
individually implanted into different muscles of the anterolateral compartment. Al-
though this procedure will successfully relieve pain, it does not guarantee that when

the patient resumes extensive ambulation,the disuse atrophy sustained by these mus-
cles will not cause compartment syndrome-like symptoms in 6 months.To avoid this
problem, a fasciotomy of the anterolateral compartment must be performed.
Patient Example
2003
Chapter 49
Reoperative Peripheral Nerve Surgery
POSTOPERATIVE CONCERNS
Wound healing concepts can and should be applied to the peripheral nerve. Dur-
ing the rst week after surgery, the nerve will lie in an environment that is predom-
inantly inflammatory. Collagen is deposited into the wound during the second
postoperative week and undergoes cross-linking beginning in the third postoper-
ative week.The nerve will become adherent to the surrounding tissues if it is kept
immobile during the second and third postoperative weeks. Movement of the nerve
within its bed is necessary after the rst 7 to 8 days of splinting if it is to be loose
and able to slide through the surrounding tissues. The fact that a nerve will not
adhere to a bed of cut muscle and brous tissue if it is allowed to glide early in the
postoperative period was demonstrated for the ulnar nerve at the elbow in a ba-
boon model.54 An intramuscular transposition was performed on one arm and a
submuscular transposition (without musculofascial lengthening) was performed on
the other. No splints were placed. After 3 months, nerves had not adhered to the
muscle, and a good neuromysial plane had developed histologically.Therefore, in re-
operation on the peripheral nerve, the postoperative regimen must include some
movement of the joints during the first week and the removal of all splints at
8 days. If a nerve graft has been performed, continued protective splinting to pre-
vent extension may be continued into the second or third postoperative week, but
the patient should begin active exion during the second week.
This patient had numbness on the top of the
foot (dotted area) and pain at the site of the
arrow after undergoing treatment for an
open ankle fracture. A superficial peroneal
nerve neuroma was diagnosed. Exposed su-
perficial peroneal nerve at the level of the
anterolateral calf indicated the appropriate
site for excision and implantation of the
nerve to the muscle. If needed and when ap-
plicable, deep peroneal nerve can be ac-
cessed in the anterior compartment via the
same exposure.

2004
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
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34. Nahabedian MY, Dellon AL. Outcome of the operative management of nerve injuries in the
ilioinguinal region. J Amer Coll Surg 184:265-268, 1997.
This study evaluates various surgical etiologies for postoperative groin pain, demonstrating how inci-
sions and intraoperative stretching can result in nerve damage that manifests as chronic pain. Char-
acteristic symptoms and treatment options are discussed for these postoperative pain conditions.
35. Kim DH, Murovic JA,Tiel RL, et al. Surgical management of 33 ilioinguinal and iliohypogas-
tric neuralgias at Louisiana State University Health Sciences Center. Neurosurg 56:1013-1020,
2005.
36. Rab M, Ebmer J, Dellon AL. Anatomic variability of the ilioinguinal and genitofemoral nerve:
Implications for the treatment of groin pain. Plast Reconstr Surg 108:1618-1623, 2001.
37. Whiteside JL, Barber MD,Walters MD, et al. Anatomy of ilioinguinal and iliohypogastric nerves
in relation to trocar placement and low transverse incisions. Am J Obstet Gynecol 189:1574-
1578, 2003.
38. Keating JP,Morgan A.Femoral nerve palsy following laparoscopic inguinal herniorrhaphy. J Lap-
aroendosc Surg 3:557-559, 1993.
39. Unwin A, Scott J. Nerve palsy after hip replacement: Medico-legal implications. Int Orthop
23:133-137, 1999.
40. Warfel BS, Marini SG, Lachmann EA, et al. Delayed femoral nerve palsy following femoral
vessel catheterization. Arch Phys Med Rehabil 74:1211-1215, 1993.
41. Ducic I, Dellon AL, Larson EE.The treatment concepts for idiopathic and iatrogenic femoral
nerve mononeuropathy. Ann Plast Surg 55:397-401, 2005.
Femoral nerve injury results in signi cant patient morbidity; many causes of femoral nerve damage
are iatrogenic and are amenable to reoperative repair.This article reviews the multiple causes of injury
to this nerve, and describes surgical interventions based on the underlying pathophysiology. As a ma-
jor peripheral nerve in the lower extremity, femoral nerve injury and its surgical treatment serve as a
paradigm for reoperative peripheral nerve surgery.
2005
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Reoperative Peripheral Nerve Surgery

2006
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R EOPERATIVE SURGERY OF THE EXTREMITIES
42. Sharma KR, Cross J, Santiago F, et al. Incidence of acute femoral neuropathy following renal
transplantation. Arch Neurol 59:541-545, 2002.
43. Brasch RC, Bufo AJ, Kreienberg PF, et al. Femoral neuropathy secondary to the use of a self-
retaining retractor. Dis Colon Rectum 38:1115-1118, 1995.
44. Hsieh LF, Liaw ES, Cheng HY, et al. Bilateral femoral neuropathy after vaginal hysterectomy.
Arch Phys Med Rehabil 79:1018-1021, 1998.
45. Aigner F, Longato S, Gardetto A, et al. Anatomic survey of the common bular nerve and its
branching pattern with regard to the intermuscular septa of the leg. Clin Anat 17:503-512,
2004.
46. Krivic A, Stanec S, Zic R, et al. Lesion of the common peroneal nerve during arthroscopy.
Arthroscopy 19:1015-1018, 2003.
47. Esselman PC,Tomski MA, Robinson LR, et al. Selective deep peroneal nerve injury associated
with arthroscopic knee surgery. Muscle Nerve 16:1188-1192, 1993.
48. Agarwal M, Syed AA, Singh R, et al. Common peroneal nerve palsy after lateral unicompart-
mental knee arthroplasty. J Arthroplasty 18:92-95, 2003.
49. Kim TK, Savino RM, McFarland EG, et al. Neurovascular complications of knee arthroscopy.
Am J Sports Med 30:619-629, 2002.
Peripheral nerve damage after arthroscopy of the knee is increasingly recognized as this procedure has
become more common.The authors review the peripheral nerve, as well as vascular complications af-
ter knee arthroscopy.They outline safe clinical practices that minimize such complications and then de-
scribe how to recognize and treat them.
50. Dellon AL, Mont MA, Mullick T, et al. Partial denervation for persistent neuroma pain around
the knee. Clin Orthop Relat Res 329:216-222, 1996.
51. Murphey MD, Smith WS, Smith SE, et al. From the archives of the AFIP. Imaging of muscu-
loskeletal neurogenic tumors: Radiologic-pathologic correlation. Radiograph 19:1253-1280,
1999.
52. Dellon AL, Mackinnon SE. Homologies between the tarsal and carpal tunnels:Implications for
surgical treatment in the tarsal tunnel syndrome. Contemp Orthop 14:75-78, 1987.
53. Dellon AL, Mackinnon SE. Results of posterior tibial nerve grafting at the ankle. J Reconstr
Microsurg 7:81-83, 1991.
54. Dellon AL, Mackinnon SE, Hudson AR, et al. Effect of submuscular versus intramuscular
placement of ulnar nerve: Experimental model in the primate. J Hand Surg Br 11:117-119,
1986.

2007
Chapter 49
Reoperative Peripheral Nerve Surgery
1. The differential diagnosis for recurrent numbness in the radial nerve distribution
after decompression of the radial nerve in the forearm can include all of the fol-
lowing except:
a. Entrapment resulting from use of a counterforce brace around the elbow
b. Congestive heart failure
c. Cervical (C6) radiculopathy
d. Incomplete initial decompression
e. Hypothyroidism
2. Super cial neuropathic pain in the medial knee can result from involvement of
which of the following nerves?
a. Infrapatellar branch of the saphenous nerve
b. Anterior cutaneous nerve of the thigh
c. Lateral retinacular nerve
d. Deep peroneal nerve
e. Common peroneal nerve
3. In reoperation for failed carpal tunnel surgery, median nerve entrapment should
be assessed at all of the following sites except:
a. Laceratus brosus
b. Fibrous sublimis arch between the heads of the exor digitorum sublimes
c. Ligament of Struthers at the elbow
d. Deep (ulnar) head of the pronator teres muscle
e. Arcade of Struthers
4. A 32-year-old, otherwise healthy woman develops chronic groin pain extend-
ing to her left inguinal region after undergoing a cesarean section 7 months ago.
The most likely cause of this pain is:
a. Incisional hernia
b. Neuroma of the ilioinguinal nerve
c. Uterine contraction
d. Traction on the lateral femoral cutaneous nerve
e. Postoperative seroma
5. Principles of operative repair of peripheral nerves include all of the following
except:
a. Magni ed (loupe or microscope) visualization for internal neurolysis
b. Reapproximation of sensory nerve stumps to their target site
c. Debridement of injured peripheral nerve all the way to unscarred region,
despite sacri ce of “living” nerve
d. Tension-free repair with nerve graft or conduit, rather than slight tension
on direct end-to-end repair
e. Referral to a “high-volume” surgeon
R EVIEW QUESTIONS

(Trang không có chữ)

2009
Reoperative Surgery
Following Tissue Transplantation
in Extremity Reconstruction
Randy Sherman
C ha pter 50
Reoperative Problems
Persistent infection
Inability to wear preinjury footwear
Contour deformity
Flap failure
Dif cult ambulation
Refracture or bone grafting
Hypertrophic nonunion
Tendon adhesions
Nerve reconstruction
Tendon reconstruction or transfer
There is something beautiful
about all scars of whatever nature.
A scar means the hurt is over,
the wound is closed and healed, done with.
Harry Crews

2010
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R EOPERATIVE SURGERY OF THE EXTREMITIES
Extraordinary progress has been made in reconstructive extremity surgery since
the advent of vascularized tissue transfer for either wound coverage or functional
restoration.1,2 Tissue transplantation has allowed a spectrum of successive reopera-
tive procedures to be performed in grievously wounded, previously unsalvageable
extremities, whether the problem is addressed by local ap rotation or microsurgi-
cal free tissue transfer. Whereas a blast injury to the hand previously meant entire
loss of function of that extremity, composite tissue transfer can now restore essen-
tially all missing structures, leading to potentially signi cant functional rehabilita-
tion. Similarly, a malignant brous histiocytoma of the proximal tibia previously
required amputation and prosthesis;today wide en bloc excision with simultaneous
ap reconstruction currently results in limb salvage in a majority of cases. Although
a chronic nonunion of the tibia with subsequent infection and sinus tract formation
previously led to chronic osteomyelitis, today radical pseudotumor excision of the
infected tissue followed by obliteration of dead space with free tissue transfer can ar-
rest the infection and result in subsequent long bone healing in most affected pa-
tients.3 The frequency with which new and more comprehensive reconstructive
procedures are being described mandates a close assessment of how and when sub-
sequent surgical procedures should be performed in these previously injured but
initially reconstructed regions.
Unfortunately, in many circumstances, reoperative surgery after tissue transplanta-
tion to the extremity is required because of residual infection, recurrence of cancer,
partial or total loss of the initial ap, or residual aesthetic deformities. In patients
who present with infection, it is probable that the initial wound was never com-
pletely debrided. This problem would lead to the inevitable retention of a bony
sequestrum, further complicated by the placement of plates, screws, wires, or other
allografted material. Because a near anatomic reduction of any extremity fracture is
the primary goal of the orthopedic surgeon, there will be a consistent desire to
preserve and stabilize fragments of bone to achieve the most ideal reduction. As
lofty a goal as this may be, critical decisions to retain ischemic or devascularized tis-
sue combined with the placement of internal xation in the contaminated wound
environment can severely compromise the reconstructive outcome. Consequently,
collaboration between the orthopedic and plastic surgeons must begin as soon as
possible after the injury.This type of relationship should not be assumed a priori—
it must be built through continuous communication and experience. Inadequate re-
section of a tumorous mass with immediate ap coverage can result in contamina-
tion of a much larger eld requiring a more radical resection, more complicated
tissue transplant, or sadly, extremity amputation. This situation is further compli-
cated in patients who undergo postoperative irradiation.The selection of the wrong
ap, or more often, a reasonable but inadequate ap may lead to breakdown over a
critical portion of the initial reconstruction. Classic examples of this problem in-
clude the overzealous use of the soleus ap for large, midthird tibial defects. Al-
though routinely described for coverage problems in this area, the soleus muscle has
a short arc of rotation and may vary greatly as to the amount of its distal muscle
mass that is available for closure. Several seemingly straightforward type IIIb,

midthird tibial fractures are too large or laterally displaced. In these situations, free
tissue transfer alternatives are the wiser choice. More recently described local aps
arising from the distal third of the leg must be approached with great caution be-
cause their design, elevation, and overall reliability can be problematic. For the pa-
tient who has these conditions and who wants reoperative surgery, the unacceptable
long-term aesthetic result is a great concern. Surgeons who perform extremity re-
construction have ignored the integration of aesthetic principles in the procedural
domain for too long. Paying attention to contour as well as color and tissue con-
sistency match is more central than ever in providing an ultimately satisfactory out-
come. Although transferring large blocks of muscle may seem necessary, this ma-
neuver will almost always lead to contour irregularities further compounded by
color mismatches when using overlying skin grafts. Resurfacing procedures using
fasciocutaneous constructs such as the groin, parascapular, radial forearm, or anero-
lateral thigh ap provide better tissue match in many respects.
A local muscle ap will often be turned or a free muscle ap transferred with the
intention of returning to the operative site within 2 to 6 months to perform fur-
ther reconstructive surgery. Common examples include (1) elevating a previously
placed muscle ap after coverage of a type IIIb tibial fracture for the placement of
a cancellous bone graft;(2) elevating a local muscle ap or free tissue transfer about
the knee to replace a previously removed arti cial joint complex; or (3) perform-
ing a tendon transfer under a recently placed ap to restore nger exion, exten-
sion, and/or pinch. Given the initial strategies for multistaged reconstructive proce-
dures using the augmented tissue bed provided by the primary flap transfer,
secondary procedures should proceed in concert with originally planned goals.
Conversely, transfers should be chosen, designed, and transplanted with full consid-
eration given to possible subsequent elevation, reorientation, or revision.
Because of the nature of most complex extremity injuries, there may often be more
than one practitioner involved in the patient’s reconstruction and rehabilitation. It
is crucial for the plastic surgeon to develop an active and harmonious relationship
with colleagues involved in resolving these dif cult problems.The quality of this re-
lationship can be directly proportional to the timing and success of the patient’s
outcome. The value of a team approach is most noticeable when treating patients
who have complex open fractures of the lower extremity. Nearly all patients who
undergo muscle or musculocutaneous transfer for the reconstruction of compound
lower extremity fractures will eventually require bone grafting. The timing of the
bone grafting will be affected by the ability to achieve reliable and complete wound
closure, which in turn will depend on timely stabilization and debridement of the
initial fracture site. In type III fractures about the ankle or foot, these problems
might be compounded by a need to further revise the soft tissue envelope to
achieve a comfortable shoe t. Prolonged intervals between these numerous surger-
ies can be minimized by developing and maintaining constant communication with
orthopedic and rehabilitation medicine colleagues. It is crucial that the plastic sur-
geon responsible for initial wound coverage be present for all subsequent proce-
dures involving the local ap or free tissue transfer. Elevation, transposition, or other
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revision procedures involving the tissue transfer should not be left to anyone who
is unfamiliar with the original operative procedure. Consideration should be given
to pedicle orientation, probable sources of collateral revascularization, and ap con-
guration before any decisions can be made regarding ap elevation.
In reoperative surgery of the hand and upper extremity, the same principles apply
but must be directed toward an open and honest relationship with the hand ther-
apist. Inevitably, after major tissue transfers for reconstruction of the hand or pha-
langes, occupational therapy will be central to restoration of function. Reoperation
for tenolysis, tendon transfer, web space deepening, or ap debulking must be un-
dertaken as soon as the patient reaches a plateau in the rehabilitation progress.The
timing of these procedures depends entirely on a clear understanding of the ther-
apist’s perception of the presence or absence of progress in the rehabilitation envi-
ronment.
One of the greatest challenges presented to the reconstructive plastic surgeon in
these cases involves patient understanding, acceptance, and compliance. A patient
with a complex extremity injury may not inherently understand why tissue trans-
fer is required and, what is more important, why reoperative surgery—sometimes
in multiple stages—may be the safest and most reliable option for an ultimately
successful outcome. Extra time spent educating and empathizing with the patient
and family is key to ensuring their support in achieving ultimate rehabilitative goals.
Surprisingly, patient acceptance is quite high when basic wound healing principles
are explained and illustrated.This approach also applies to the description and dis-
cussion of plans for subsequent reoperative surgical procedures.The surgeon should
give the patient a clear outline regarding the expected number and timing of sec-
ondary procedures to provide a clear understanding of the length and complexity
of the healing process. By following this plan, the patient may look forward to the
reoperative surgical procedure as a milestone in the restorative process.
The surgeon must proceed very cautiously when pain is the primary problem for
the patient who is to undergo a reoperative procedure. Patients who present with
a symptom complex consistent with re ex sympathetic dystrophy are most chal-
lenging. Every attempt to diagnose and treat pain nonoperatively should be made
before planning subsequent staged reconstructions. Special attention should be
given to patients who build increasingly unrealistic expectations for nal aesthetic
or functional outcomes. It is important to remind them of their starting point so
that they can realistically measure their progress and understand their outcomes. Re-
viewing pictures and radiographs of the initial injury is often instructive and very
insightful for the patient.This process can help normalize the relationship between
the surgeon and the patient when inevitable plateaus or setbacks occur.
Spectacular progress is being made in the eld of high-demand prosthetics. As a re-
sult of these advances, knowing when to abandon lengthy, painful, and questionable
functional extremity reconstructions is increasingly important. The Walter Reed
Army National Medical Center Amputee Rehabilitation Program involves soldiers

and marines who have undergone amputations. Experience with these patients has
clearly demonstrated the bene ts of early amputation and prosthetic rehabilitation
to maximize function in quali ed patients. The decision to terminate an ongoing
reconstructive program in favor of amputation requires a great deal of discussion
and trust among the patient, family, and physician. It is crucial to involve therapists,
prosthetists, and others who have gone through the procedure to engender maxi-
mum support for and acceptance by the patient.
TIMING
The use of the wound vacuum-assisted closure (VAC), as originally described by
Argenta and Morykwas and subsequently popularized by numerous other authors,
cannot be underestimated. This procedure has been applied for a wide variety of
wound management problems across the surgical subspecialty spectrum. The un-
derlying premise of using this device is to apply negative pressure to an open
wound space where tissue edema is thought to be the primary cause of cellular is-
chemia.In creating a relative vacuum,the environmental hydrodynamics are changed
to allow intracellular uid to egress and be drained off, thus decreasing the size of
each cell.This bene cial architectural change then allows for the relief of pressure
against small capillaries and venules that open and reintegrate into the vascular sys-
tem to deliver hematologic constituents to the wound space. Overall, tissue oxy-
genation is thought to increase. Another advantage of this system is a more ef cient
delivery of immunocompetent cells and cellular building blocks. The use of the
wound VAC device has fundamentally altered our care of extremity wounds before
closure and has helped immeasurably in preparing wounds for closure or in avoid-
ing operative intervention altogether. However, the role of the wound VAC in re-
operative surgery of the extremities is unclear, especially for the surgeon who is
planning a serial reconstructive program for a patient with an inadequate soft tis-
sue envelope. More time and prospective trials using wound VAC for patients with
increasingly complex injuries are required before revised procedural recommenda-
tions can be made.
Subsequent elective reoperative surgery can be performed beginning at several days
to several years after ap transfer in the upper and lower extremity. The ultimate
functional and aesthetic goals of the particular reconstruction will in uence the
timeliness of subsequent intervention.There are very few hard and fast rules regard-
ing how long after a successful transfer a subsequent reconstructive or reoperative
procedure may be undertaken. Relative contraindications include residual or persis-
tent extremity edema, signs and symptoms of infection, or unusual pain patterns. If
the surgeon is forced to proceed with surgery under these circumstances,the patient
must be counseled as to the increased possibility of an ultimately poor outcome.
Surgical preferences vary widely for many reoperative issues, including elevation for
nerve grafting, tendon transfer, iliac crest bone grafting, ap reorientation, and de-
bulking. Some surgeons would argue that accomplishing as much as possible at the
time of transfer has the advantage of earlier incorporation and quicker return of
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function. Other surgeons, however, believe that the healed musculocutaneous ap
or completed epithelialization of the skin graft over a muscle ap are important
physiologic markers for successful wound closure, as well as prerequisites for sub-
sequent attempts to reconstruct other component structures such as bone, tendon,
or nerve.Teleologically, there should be no strict contraindication to reelevating a
pedicled or free transferred ap shortly after a successful transfer. Conversely, there
are no apparent disadvantages to lifting a ap years after its initial application. So
much is dependent on the particular goals of the restorative strategy.
PLANNING
INITIAL CONSIDERATIONS
Once a ap has been transferred, possible secondary surgery should be considered
as part of the initial planning process. Muscle aps are the preferred choice for the
obliteration of dead space in osteomyelitic defects, but may present problems for de-
bulking at a later date. Fasciocutaneous aps often provide a superior cosmetic re-
sult initially, but over time may require debulking when used in the hand or ankle
and foot regions because of their tendency to swell or develop segmental trapdoor
deformities. Pedicle length and position in relation to the ap inset must be con-
sidered at the initial tissue transfer if there is any possibility of subsequent ap ele-
vation. In an overwhelming majority of lower extremity compound fractures, the
open wounds are anteriorly oriented. Most high-energy impact fractures of the
tibia are the result of a direct and oncoming blow to the patient (for example, the
patient who is hit by the automobile bumper). Because of the lack of cushioning
soft tissue along the anterior crest of the tibia, forces that result in highly commi-
nuted fractures of the diaphysis of the tibia can decimate overlying skin, subcuta-
neous tissue, and anterior compartment musculature.With this predominant pattern
of injury, the anterior tibial vessels are rarely, if ever, chosen for recipient anasto-
moses.The box above lists considerations for reoperative surgery of the extremities.
Vascular anastomoses in free tissue transfer should be consistently performed out-
side the zone of injury whenever possible.This practice not only ensures the high-
est rate of anastomotic patency at the time of inset but also helps to separate the vas-
cular supply of the ap from the target area of the initial injury and subsequent
reconstructive site. We preferentially choose muscle aps with long pedicles that
can be anastomosed well-proximal to the zone of injury. When available, the pos-
Maintenance of vascular supply
Limited elevation of aps to meet the speci c needs of the reoperative problem
Liberal use of tourniquet control for ap reelevation and resuture
Early and prolonged use of compressive garments in reoperated lower extremities
Development of comprehensive surgical strategy including possible reoperative events
before choosing initial ap
Considerations in Reoperative Surgery of the Extremities

terior circulation is preferential because of its ease of exposure and relative lack of
side branches in the middle and distal thirds of the leg. Release of the soleus mus-
cle bers from the medial tibial diaphysis is all that is required to gain clear expo-
sure to the posterior tibial artery and concomitant veins in this area. Godina4 has
suggested a posterior approach to the trifurcation. Anastomosis of the donor ves-
sels is performed with the patient in a prone position after initial tacking of the
tissue transfer anteriorly. We have not had much experience with this alternative;
however, it clearly has the distinct advantage of ultimate separation of the injury site
from the vascular pedicle.
At the time of initial ap transfer, subdivision or partial reorientation of ap sub-
units can positively affect reoperative surgical outcomes. Muscle aps can be par-
tially divided along lines of vascular axes for simultaneous wound coverage and
deep space obliteration.We favor using the rectus abdominis muscle with a longi-
tudinal split for simultaneous osseous defect obliteration and cutaneous coverage.
Feibel et al5 have had favorable experience using the serratus anterior muscle.They
subdivide this transplant into its multiple slips, which in turn can be reoriented in
several planes.The latissimus dorsi muscle, with its two predominant subunits, can
be used in a similar fashion. Another option is to take the entire latissimus dorsi
muscle with the contiguous serratus anterior muscle on a common subscapular
pedicle. Although some orthopedists still use antibiotic beads, silicone block, or
methyl methacrylate spacers, subdivided vascularized muscle units have predomi-
nantly replaced these previously popular alloplastic implants because they provide
more physiologic dead space obliteration. At the time of revision surgery, eleva-
tion of the muscle transfer can then be con ned to excision of the deep dead space
subunit with replacement using cancellous bone, vascularized cortical bone, or en-
doprosthesis implantation or replacement.
When a ap is chosen for the reconstruction of composite defects of the hand,
muscle transplants are less favorable for injuries requiring subsequent tendon trans-
fers or nerve grafting procedures.Thin fasciocutaneous aps such as the lateral arm
or radial forearm aps tend to provide the ideal bed for secondary procedures in this
area. Parascapular aps have the advantage of being able to cover large defects, but
may bring with them an excess of fatty tissue and may require secondary debulk-
ing. Temporoparietal fascia transferred as a bilaminar ap is advantageous for sub-
sequent tendon transfer because of its exquisite vascularity and lack of bulk.
FLAP DEBULKING
Primary inset of muscle aps, either pedicled or freely transferred, often results in
objectionable contour deformity. However, muscle atrophy will usually occur be-
ginning as early as 8 to 12 weeks after surgery and will stabilize at approximately
1 year. With thorough preoperative counseling and periodic patient reeducation,
our experience has shown that if a complete progression of muscle atrophy is al-
lowed to occur, patients rarely request further debulking of the muscle ap. In cases
in which reduction of muscle volume is requested because of a persistent aesthetic
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contour deformity, two methods may be used.6 The rst method involves elevation
of the entire muscle on its pedicle with advancement and partial excision under-
taken in limited situations.This approach is often dif cult because of the progres-
sive lack of pliability of the muscle as it becomes increasingly brotic. Once the ap
has conformed to the wound size and shape, it may be more dif cult to reorient or
reduce the ap in a segmental fashion. The second method is the tangential exci-
sion of the muscle ap’s most super cial layers.This approach requires rst remov-
ing a previously placed skin graft followed by planar excision of the protruding
parts of the muscle ap itself. Other authors have described harvesting the mature,
previously placed skin graft and reapplying it as a mesh graft. In our experience
this leads to a markedly inferior aesthetic result and negates any advantage of im-
provement of contour deformity. In such cases we have applied a new sheet graft to
further improve the desired aesthetic appearance. Because the transferred pedicle
and vascular anastomoses are usually deep and proximal to the main body of the
muscle ap, this planing technique is quite safe in terms of maintaining vascularity
throughout the muscle transfer.
Alternatively, fasciocutaneous flaps may be inset at the time of primary transfer
with greater attention toward contour considerations. However, more often than
not, these flaps will eventually require debulking or defatting because of subse-
quent enlargement. Fasciocutaneous aps applied in the lower extremity, particu-
larly about the lower third of the tibia, ankle, or foot, tend to become increasingly
bulky with time, dependency, and ambulation.This condition is probably the result
of a less than ef cient out ow system for lymphatic and other extracellular uid
within the most super cial elements of the ap. Patients should be educated as to
the probability that one and sometimes up to three subsequent ap debulking and
defatting procedures in the distally placed fasciocutaneous ap will be necessary to
achieve maximal aesthetic restoration. When the fasciocutaneous ap is elevated
for the removal of skin and for wedge excision of fat, the primary vascular pedicle
should be maintained, if feasible. In addition, as much of the cutaneous marginal
scar as possible should be left undisturbed.7 Closure under moderate tension with
subsequent compression wrapping is usually very well tolerated.
Liposuction is another option to achieve volume removal in the fasciocutaneous
ap. As with free tissue transfer, the application of liposuction in this setting should
not vary signi cantly from other, more classic applications.
DIRECT FLAP MANIPULATION
In addition to debulking, segmental reelevation, and ap reorientation, direct lim-
ited manipulation may be required with certain procedures. These procedures in-
clude tunneling for the placement of tendon grafts or tendon transfers; placement
of ne-wire stabilizing devices for Ilizarov distraction or compression; and place-
ment of osteointegrated implants for prosthetic mounting. In addition, staged sep-
aration of previously inset aps can be performed.

In patients requiring tendon transfer or tendon grafting through the bed of a pre-
viously transferred ap, we have performed classic tunneling techniques using a
blunt-nosed tendon passer with excellent results. If a tendon suture is required un-
der the region of the transferred ap, small but adequate incisions can be made di-
rectly in the ap to avoid large-plane disruption, which occurs with ap elevation.
The classically described principles of tendon transfers and tendon grafting apply in
this situation—tissue equilibrium and maximal passive range of motion of the in-
volved joints must be obtained. These goals should be obtained in tissues affected
by the free ap transfer as well as in the surrounding soft tissues and joints.
Fine-wire pin xation of the fractured and comminuted tibia, in conjunction with
the application of the Ilizarov device, can be performed within the substance of a
free ap.8,9 Several authors have described successful outcomes with the application
of an Ilizarov device used simultaneously with (or sometime after) ap transfer for
wound coverage in the extremities. Once initial take of the muscle transfer is
achieved, distraction or compression osteosynthesis using the Ilizarov device presents
no signi cant problem to transplant viability. Feibel et al5 believe that certain mus-
cles including the latissimus dorsi, rectus abdominis, and gracilis allow easier ne-
wire movement than other muscles because of the parallel nature of the muscle
bers. In certain circumstances in which the muscle ap is initially applied for both
cutaneous wound coverage and obliteration of deep osseous dead space, secondary
limited elevation and removal of that interposed muscle segment may be required
to successfully allow nal bony docking.
When AO-type, half-frame external xators are used, primary pin xation in or
around the ap is discouraged. Conversely, wrapping a ap around an external pin
that is not placed through intact nontraumatized skin can also lead to sinus tract for-
mation and subsequent problematic wound closure. Once the defect is closed and
the ap is well-healed, placement of external pin xation through the substance of
the ap, although rarely indicated, can be safely performed.
Osteointegrated implant insertion is more appropriate for free aps used in the
head and neck and oromandibular region than to aps placed in the extremities. In
infrequent circumstances in which a partial prosthesis might be mounted in the
extremity, osteointegrated implants can be placed once primary wound coverage is
complete and tissue equilibrium is achieved.
In cases in which the geometry of the wound prevents a tailored inset of the trans-
ferred ap, an umbrella-type transplant may be performed with secondary ap sub-
division.This problem usually occurs in patients with composite degloving injuries
to the dorsum of the hand and phalanges. A planned syndactylization of the digits
may be performed with subsequent separation after 4 to 6 weeks, depending on the
condition of the recipient wound beds. As with congenital syndactyly release, ad-
ditional skin grafting in the web spaces is required. If there is concern about the un-
derlying vascularity, releases can be performed in a staged fashion.
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VASCULAR CONSIDERATIONS
When reoperative surgery is considered in the eld of a previously transferred ap,it
is wise to elevate the ap via its previously inset margins. This approach helps to
maintain blood ow through the natural axes of the speci c ap as it was originally
designed and transferred. Although there are anecdotal reports of pedicle division as
soon as 2 weeks after transfer without complication, there are also occasional reports
of delayed ap loss up to 12 months postoperatively as a result of acute division at the
anastomotic site.10,11 It is logical that maintenance of the pedicle, if possible, is the
most advantageous option when reelevating a transferred ap.The larger the surface
area that can be left undivided at any reoperative event, the more reliable the blood
supply to the ap. In most cases, the underlying blood supply need not be deemed
critical because an overwhelming majority of transfers is initially performed as a re-
sult of a lack of recipient site vascularity at the base of the wound. Examples include
osseous dead space caused by a comminuted fracture, exposure of a total knee or to-
tal hip arthroplasty, and exposure of the Achilles tendon with loss of paratenon.
GOALS OF TREATMENT
Because the problems that require ap transfer in the upper and lower extremities
are multiple and varied, the goals and strategies of reoperative surgery for these
various conditions are numerous. Clearly, each procedure has a common end point:
the restoration of function or form to the previously traumatized, congenitally de-
formed, or iatrogenically ablated extremity. Principal procedures performed for
these purposes include tendon transfers, tendon grafting, nerve grafting, bone graft-
ing, ap reorientation or division, ap debulking, recontouring, defatting, and sim-
ple elevation for revisions on underlying devices such as endoprostheses. In all of
these circumstances, the goal of the initial surgery is to provide an anatomic and
physiologic environment in which reoperative procedures have the best chance of
success in transforming the diseased extremity into a useful one.
REOPERATIVE PROCEDURES
As stated above, an overwhelming majority of reoperative surgery procedures in
the extremities after ap transfer is the result of a continuing need for functional
restoration. A representative spectrum of clinical examples illustrating speci c sec-
ondary reconstructive problems and their solutions after successful ap transfer is
presented.
STAGED TENDON R ECONSTRUCTION AND
R ELEASE OF FLAP SYNDACTYLIZATION
With complex composite injuries of the dorsum of the hand and nger in which
both soft tissues and extensor tendons have been lost, multicomponent reconstruc-
tion using the temporoparietal fascial ap in a bilaminar fashion can be accompa-
nied by staged extensor tendon reconstruction using temporary Silastic implants.

Patient Example
2019
Chapter 50
Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction
Soft tissue reconstruction was accomplished using a bilaminar temporoparietal fas-
cial ap with simultaneous placement of Hunter rod Silastic implants. The digits
were purposely syndactylized to allow simultaneous coverage of both the dorsum
of the hand and phalanges with one ap.
A 7-year-old child presented with an avulsive injury to the dorsum of the hand and
digits resulting from a lawn mower accident.There was a loss of skin, subcutaneous
tissue, and extrinsic extensor tendons on all four ngers to the level of the middle
phalanx. Stripping of the periosteum and cortices of the metacarpal bones and pha-
langes, with some loss of the dorsal hood complex over the metacarpophalangeal
joints, was also noted.

2020
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
Three months postoperatively, secondary tendon reconstruction was performed on
the rest of the ngers. Interpositional tendon grafts were applied to the extensor
digitorum communis muscle proximally and inserted into the middle phalanx dis-
tally. Simultaneous syndactyly release with additional split-thickness skin grafting in
the web spaces was accomplished. The hand was held in an extension splint for
4 weeks, after which controlled passive range-of-motion and then active-assisted
range-of-motion therapy was undertaken.The postoperative result is shown.
SECONDARY TENDON R ECONSTRUCTION
In composite injuries that disrupt tendon function with substantive loss of tendon
structure,priorities are stabilization of the underlying bony architecture,anatomic re-
duction of the joint surfaces,and wound closure with vascularized tissue.Once these
goals have been achieved, planning may proceed for the restoration of active joint
function using either tendon grafts or tendon transfers. Classic principles of tendon
transfer must be followed to their fullest extent to achieve maximal possible func-
After initial ap healing, the child received progressive occupational therapy for
joint mobilization. During the postoperative course one of the Silastic implants
became exposed on the distal surface and required removal.

tional return. Solid union of bony fractures must be achieved both clinically and ra-
diographically. Passive joint motion must be maintained and preferably maximized
using frequent and,often,daily occupational therapy for stretching, passive range-of-
motion exercises,and modality therapy.Tissue equilibrium as rst described by Bun-
nell must be achieved to provide the most favorable recipient bed. Classic transfers
for particular nerve or musculotendinous unit de cits may then be safely carried
out. In cases in which a soft tissue ap makes up a majority of the interposing tis-
sue between originating muscle and the end affector joint, subcutaneous tunnels are
developed within the ap using tendon passers just as might be performed on na-
tive uninjured tissues. According to the classic description, the reorientation of the
transferred musculocutaneous unit must achieve a straightline pull to the transferred
joint complex. Ultimate success of the functional restorative surgery demands that
the ap transfer address these ultimate needs at the initial inset.
Patient Examples
2021
Chapter 50
Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction
This 27-year-old, right-hand–dominant patient presented after a close-range shot-
gun injury to the radial side of the left hand. Tissues lost included the first
metacarpal, trapezium, and trapezoid bones;extensor pollicis longus, extensor pol-
licis brevis, and abductor pollicis longus muscles; portions of the rst interossoeus
dorsalis manus muscle; super cial branch of the radial nerve; and overlying skin
and subcutaneous tissue on the radial dorsum of the hand extending around the
palmar surface to include portions of the thenar eminence. Surprisingly, the distal
aspect of the thumb from the metacarpophalangeal joint onward remained viable,
with a vascularized base including the digital vessels, both digital nerves, and a
bridging soft tissue base within the palmar web space. Fortunately the exor pol-
licis longus muscle was uninjured. After initial debridement, stabilization was
achieved with external mini xation.

2022
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
The rst stage of reconstruction addressed bony stability and soft tissue coverage
with the transfer of a lateral arm osteocutaneous ap. The cutaneous nerve to the
forearm was carried with the osteocutaneous ap and used as a ow-through vas-
cularized nerve graft to repair the super cial branch of the radial nerve defect. Ex-
ternal xation was maintained and the humeral bone was further stabilized with in-
ternal pin xation to allow thumb-interphalangeal range of motion exercises during
osseous healing.
Once bony stabilization had been achieved 4
months postoperatively, the residual inability to
extend the thumb-interphalangeal joint was ad-
dressed with a tendon transfer using the extensor
indicis proprius muscle to reconstruct the lost ex-
tensor pollicis longus muscle.

As classically described, the extensor indicis proprius muscle was harvested through
a small longitudinal incision over the index nger metacarpophalangeal bone and
proximal phalanx. The muscle was further freed proximally using a small incision
over the distal forearm dorsally. After the tendon was rerouted out of its compart-
ment, it was passed through a tunnel made in the cutaneous portion of the lateral
arm osteocutaneous ap.The tunnel was developed from distal to proximal, retriev-
ing the extensor indicis proprius tendon for subsequent tendon juncture over the
thumb–proximal phalangeal area.Although classic extensor indicis proprius–extensor
pollicis longus muscle transfers are coapted more proximally than in this situation,
no option was available for a more proximal juncture because of the nature of the
segmental defect over the dorsum of the metacarpal bone. A modi ed Kessler ten-
don juncture was accomplished, and the thumb was held in extension with a spica
splint for 4 weeks. A spica-type brace replaced the initial immobilizer and con-
trolled-motion exercises were initiated.
2023
Chapter 50
Reoperative Surgery Following Tissue Transplantation in Extremity Reconstruction
After a complete course of therapy, virtually
complete thumb-interphalangeal extension
was restored.

2024
PART VI
R EOPERATIVE SURGERY OF THE EXTREMITIES
This right-hand–dominant man in his mid-thirties presented with a crushing de-
gloving injury of the left palm.This trauma resulted in the destruction of the thenar
intrinsics and the motor branch of the median nerve, as well as the exposure and
denuding of the entire exor tendon apparatus and zone III. The patient was ini-
tially treated with debridement and the wound was covered using temporoparietal
fascia supplemented with a full-thickness skin graft.
Periodic reports in the literature have described simultaneous tendon transfers or
tendon grafts placed under or accompanying free aps. We have used this tech-
nique with limited success in cases in which osseous stability or joint destruction
was not in question. In situations, however, in which bony union must be achieved,
simultaneous tendon transfer or tendon grafting has not led to a more rapid return
to functional restoration and has required tenolysis or revision tendon surgery.
Despite achieving wound closure and tissue equilibrium, the patient had no resid-
ual opposition of the thumb and ngers. Thus an extensor indicis proprius mus-
cle–opponensplasty (Zancolli-Burkhalter) was performed.The extensor indicis pro-
prius muscle was harvested through an incision over the index metacarpophalangeal
joint, and through a more proximal incision dorsally over the wrist and ulnarly at
the origin of the muscle.