Phẫu Thuật Tạo Hình Grabb & Smith’s (Bản Cập Nhật – Kevin C. Chung)

Interphalangeal/Metacarpal Phalangeal Joint Osteoarthritis
The anatomy of the DIP and PIP joints is relatively similar, with a bicondylar hinge joint surface
stabilized by strong collateral ligaments. In PIP joints, an extra degree of stability is added by the volar
plate. 4 Nearly all arthritic DIP joints demonstrate abnormalities in the collateral ligaments, but further
research is needed to determine the inciting cause. MCP joints differ from the interphalangeal (IP) joints
in that they are condyloid type; this allows for a greater range of motion that includes abduction,
adduction, and circumduction in addition to the flexion seen at the IPs. The MCP collateral ligaments and
sagittal bands are tight in flexion but lax in extension, allowing for the additional degrees of freedom.
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Examination
On physical examination, it is important to assess and document the range of motion at each affected joint
using a goniometer. Severe OA can lead to joint ankylosis and total loss of motion. Angulation in the
coronal plane should be assessed to detect significant deviation. Herberden nodules may be seen at the
DIP and may be lateral or dorsal midline swellings; they are related to osteophyte growth and extensor
mechanism swelling, respectively. 12 Bouchard nodules are similar swellings found at the PIP. Mucous
cysts are often present at the DIP and are unrelated to osteophytes but instead influenced by the
synovium and tendon sheath and are amenable to treatment with excision. 3
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Imaging
Imaging should be ordered of the entire hand as well as the specific fingers in question. Osteophytes seen
on radiographs are the first sign of IP OA. 3 Joint space narrowing coupled with lateral osteophyte
proliferation may cause the classic “gull wing” appearance at the IP joints or a “sawtooth deformity” may
be seen if there is erosion throughout the entire joint (Figure 93.1). 4 There are several grading systems
regarding IP OA, most notably the Kellgren-Lawrence and the Ghent University Scoring System;
however, they do not typically drive treatment recommendations.
FIGURE 93.1 Pan IP arthritis with diffuse joint space narrowing. Red circle demonstrates an early gull-wing sign. Red arrow
highlights a large subchondral cyst. The white lines accentuate coronal angulation. Blue arrow is representative of sclerosis.
Green arrow demonstrates one instance of fusion.
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Treatment
The patient’s goals and occupation are considered when determining the treatment for IP and MCP
arthritis as options must balance pain relief, stability, strength, and motion preservation. In general terms,
surgical treatment of DIP degeneration consists solely of arthrodesis, and there are no commercially
available arthroplasties for DIP joints. Implant arthroplasty is available for PIP and MCP joints, although
they are not typically used for the index finger because of stresses from thumb-index pinch, and
arthrodesis is usually recommended for this finger.
Fusion of the DIP joint is well tolerated, as only 15% of total digit motion occurs at the DIP. Grip strength
has been found to decrease by 20% to 25% because of the effects of quadrigia; removing the excursion of
the flexor digitorum profundus (FDP) tendon in the fused joint tethers the common FDP muscle belly.
The angle of fusion that provides the most dexterity with least loss of grip strength is from 10 to
20 degrees and has been studied in several simulated fusion models. 13 The procedure is performed
through a dorsal approach—the joint is excised and the bones fused with either 90-90 wiring or a
compression screw. Recent retrospective reviews showed a decreased nonunion rate (0%–11%) with
compression screws. 14 With any fusion, caution should be used in patients who consume nicotine
products, as this will slow bony healing.
The PIP joint contributes more to the range of motion of the digit, but it may also be fused in patients
with high demand. Although each surgeon has his/her preference for fusion angle, a fusion simulation
study demonstrated an angle of 40 degrees was well tolerated with the least loss of power grasp. 15 The
MCP is able to compensate for finger motion in the setting of DIP and PIP fusions; however, the converse
does not hold true because MCP fusion severely limits hand function and is not routinely recommended.
Fortunately, OA is more common in the IP joints and rarely seen in the MCP as opposed to rheumatoid
arthritis, which has widespread MCP involvement. 16
Arthroplasty can be used to treat the PIP or MCP with good to excellent outcomes in proper candidates.
Implant choice for OA is an important question that must be discussed with the patient and functional
goals in mind as they demonstrate similar pain relief, range of motion, and patient satisfaction. 16,17
Silicone implants are constrained, designed to hinge in the sagittal plane for they act primarily as a spacer
for the joint. They are held in place by the capsule formed around them, thus complications of synovitis
and angulation are seen on top of the baseline risks of infection and implant fracture. Pyrocarbon
implants are nonconstrained to allow greater motion but carry a higher reoperation rate and may
dislocate, loosen, or squeak. 4,17 Srnec et al. recommend silicone use for the PIP and pyrocarbon at the
MCP. 16 Patients should be counseled that joint range of motion is similar pre- and postoperatively
regardless of implant choice. The risk of implant failure is real; in laborers or young active patients, an
implant may not withstand the demands asked of it. Guidelines by joint for implant choice are seen in
Table 93.3.
TABLE 93.3
Treatment Options and Recommendations for Finger Arthritis
Joint
Options
Considerations
DIP
Arthrodesis
Fusion in 10–20 degrees of flexion
PIP
Arthrodesis
Fusion in 30–40 degrees of flexion
Arthroplasty (not recommended for index)
Silicone implant preferred given 
 constraint
MCP
Arthroplasty
Pyrocarbon implant preferred as 

nonconstrained
DIP, Distal interphalangeal; MCP, Metacarpal phalangeal; PIP, proximal interphalangeal.
An isolated arthritic PIP joint is often posttraumatic and related to incongruity at the articular surface and
additional options exist for treatment—volar plate arthroplasty, hemihamate arthroplasty, and
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vascularized toe joint transfer have all been described. In generalized OA of the hand, however, these
techniques are less useful both for the lack of adequate donors (for example, each hand only has one
hamate) as well as the soft tissue and synovial changes that make these options less reliable.
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Carpometacarpal Joint Arthritis
Basal joint or thumb CMC arthritis is one of the most widely studied and controversial topics in hand
surgery. The anatomy of the thumb CMC is unique, permitting three degrees of freedom to precisely
position the thumb tip in space. The joint comprises two saddles positioned perpendicularly to each
other, allowing an average of 50 degree flexion/extension and 40 degrees adduction/abduction.
Circumduction and opposition of 20 degrees are achieved with a twisting between the saddles and
requires strong capsular and ligamentous support to prevent subluxation. 18 Ligament laxity of even 1 to
2 mm can disrupt the balance of the forces and predispose to cartilage injury. 18,19 In power grip, the CMC
routinely experiences 120 kg of force, and in pinch the lever arm of the thumb multiples the force seen at
the tip by 12 when translated to the CMC. 20 Given the demands placed on the thumb in routine activities,
the high prevalence of OA in the CMC is not surprising.
Biomechanic knowledge is essential to understanding the pathology of CMC arthritis. Pinching the
thumb against the fingers in a wide grip translates the force dorsally at the metacarpal base, and a
restraint is needed to prevent dorsal subluxation. Many investigations have attempted to elucidate the
ligamentous anatomy of the thumb. Early studies cited the anterior oblique or “beak” ligament as the
primary stabilizer against dorsal translation and aimed treatment accordingly. 19,21 Recent landmark
work, however, has demonstrated that the anterior oblique ligament is not the critical ligament to
establish stability and it is laxed throughout motion. 22–24 Furthermore, these authors demonstrated the
importance of the three dorsal ligaments in stabilization of the thumb. Although controversy still exists
and recent reports describe between 3 and 16 different ligamentous contributions to the thumb CMC,
most agree that the dorsal structures are of key importance. 20,22
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Examination
Inspection of the thumb assesses for resting position; in end-stage disease, the webspace is contracted and
the metacarpal is adducted. This adduction is compensation for dorsal subluxation of the metacarpal
base. A palpable step-off from the metacarpal to the trapezium may be present, termed a “shoulder sign”
or “squaring.” Pain on palpation over the volar metacarpal base is frequently present; however, the
hallmark examination finding for CMC arthritis is a positive grind test, which is done with axial loading
and rotation of the thumb. 9 It is important to note any MCP hyperextension on examination. Patients
with a painful CMC will avoid thumb tip to index tip pinch and will instead use index tip to thumb pad,
leading to chronic MCP hyperextension that should be addressed if greater than 30 degrees (Figure 93.2).
25,26 Range of motion and key and tip pinch strength should be documented as well.
FIGURE 93.2 Additional pathology to watch for in patients with carpometacarpal arthritis. A. Concurrent metacarpal phalangeal
hyperextension of 45 degrees (circle). B. Radiograph demonstrating severe STT arthritis with complete collapse of the
scaphotrapezial joint space (arrow).
Other pathologies to rule out during differential diagnosis are De Quervain tenosynovitis, intersection
syndrome, flexor carpi radialis (FCR) tendonitis, and ulnar collateral ligament injury.
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Imaging
Radiographs should include lateral, oblique, and anteroposterior (AP) views of the thumb. Obtaining a
true AP view of the thumb, known as the Robert’s view, is achieved with the forearm in maximal
pronation with the dorsum of the thumb on the imaging table. 9 The Eaton stress view may be used as an
adjunct to assess dorsal subluxation and compare to the contralateral hand. This is an AP view with the
patient pushing the radial aspects of the thumb together. 19
In addition to assessment of the CMC, the scapho-trapezial-
 trapezoid (STT) joint should be examined in
every patient. As arthritis progresses, all surfaces of the trapezium become involved and failure to
diagnose and address degenerative changes at the scaphotrapezoid articulation may result in treatment
failure. Eaton proposed a radiographic classification of basal joint arthritis in 1973 that is still used today
with minor modifications (Table 93.4; Figure 93.3). 9,19
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FIGURE 93.3 Radiographs demonstrated Eaton stages of carpometacarpal (CMC) arthritis. A. Stage I: Slight CMC subluxation
with joint space widening, no osteophytes seen. B. Stage II: CMC subluxation of one-third with small osteophytes along the
ulnar aspect of the trapezium, joint space narrowing. C. Stage III: Complete loss of joint space and large osteophytes seen
throughout the trapezium. D. Stage IV: Demonstration of pantrapezial arthritis.
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TABLE 93.4
Eaton Stages of Thumb Carpometacarpal Arthritis 9,19
Stage
Joint 
 Space
Osteophytes
Scapho-
 trapezial-
 trapezoid Joint
Other
I
Slightly widened
Absent
Preserved
<1/3 dorsal 
 subluxation 
 of metacarpal
II
Slightly narrowed
<=2 mm
Preserved
III
Significantly narrowed
>2 mm
Preserved
Sclerotic 
 of cystic 
 changes in 
 subchondral 

bone
IV
Significantly narrowed
>2 mm
Involved
Pantrapezial involvement
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Treatment
Conservative treatment is typically the first step in basal joint arthritis. Splinting, hand therapy, activity
modification, antiinflammatories, and hyaluronate or steroid injections all have short-term benefit. 6
When and if these measures fail to provide adequate pain relief, there are a variety of surgical options.
Despite a multitude of studies, there has not been a method of treatment that demonstrates significantly
improved outcomes. Metacarpal base osteotomy may be used as it is effective in early stage (I or II)
disease by distributing the load of the metacarpal on the CMC joint. Studies have definitively shown that
use of prosthetic material—silicone, Marlex, or Gortex—provides inferior results, and we recommend
that if a spacer is used, it should be biologic. 27 Three main options exist: ligament reconstruction, fusion,
and trapeziectomy.
Ligament reconstruction is the first described treatment method by Eaton and Littler in 1973, and there
have been reports of using multiple different tendons (extensor carpi radialis longus, extensor pollicis
brevis, extensor pollicis longus, abductor pollicis longus, and flexor carpi radialis) in an attempt to
stabilize the CMC and prevent progression of arthritis. Ligament reconstruction has shown equivalent
outcomes to other methods when used for stage I or II disease; in Eaton’s 10 to 23 year follow-up series
71% of patients still reported mild pain despite all being satisfied with the procedure. 28
Arthrodesis of the CMC was pioneered by Muller in 1949, 25 and it is still recommended today for
younger patients or laborers who rely on grip strength. Motion is well preserved in both subjective and
objective measures; however, fusion carries a higher risk of complications than other procedures treating
CMC. The only randomized control trial comparing arthrodesis to trapeziectomy and ligament
reconstruction was halted as complications of delayed union, nonunion, complex regional pain syndrome
and neuroma were significantly higher in the arthrodesis group despite functional outcomes being
similar. 29 It is still a viable option, but the complications must be discussed with the patient and cessation
of nicotine-containing products preoperatively until union is recommended.
Trapeziectomy is the common component of modern treatment of CMC arthritis. There are many
variations of this treatment. Each option follows the principle of removal of the arthritic trapezium and
prevention of metacarpal subluxation both dorsally and proximally onto the scaphoid. The simplest
option is “hematoma distraction” where axial Kirschner wires are placed temporarily to maintain the
space. The ligamentous reconstruction tendon interposition pioneered in 1986 30 is the most widely used
in the United States with over 90% reporting this as the preferred method in 2010. 31 With the ligamentous
reconstruction tendon interposition, the FCR is harvested proximally while the distal attachment to the
index metacarpal base is maintained and tunneled through a drill hole in the base of the thumb
metacarpal to prevent dorsal subluxation. The remainder of the tendon is interposed in the space
formerly occupied by the trapezium to prevent proximal migration of the metacarpal. 30 Variations of this
method include interposition only, suspension only, and use of abductor pollicis longus or half of FCR; a
well-designed randomized trial as well as several systematic reviews have not been able to demonstrate
superiority of any of these procedures. 27,32 A newer procedure is the “suspensionplasty” or tight-rope
where a purpose-built permanent suture construct is passed through the index metacarpal to the thumb
metacarpal base and back then tied over a button to help prevent proximal migration and decrease
complications associated with the FCR donor site. These procedures are summarized in Table 93.5.
TABLE 93.5
Summary of Carpometacarpal Surgical Treatments
Procedure
Considerations
Ligament reconstruction
Used in Eaton Stage I or II
Metacarpal base osteotomy
Used in Eaton Stage I or II
Trapeziometacarpal arthrodesis
Higher complications reported than excision procedures (nonunion)
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Trapeziectomy variations
Hematoma distraction
Metacarpal pinned to prevent proximal migration
Tendon interposition
Frequently palmaris longus used
Ligament reconstruction tendon interposition
May be performed with FCR or abductor pollicis longus
Tight-rope suspension
Uses purpose-built suture suspension device
Complications specific to trapeziectomy procedures are primarily neuropathic: superficial radial or
palmar cutaneous nerve dysfunction and complex regional pain syndrome. 32 Failure to identify and
address concomitant thumb MCP hyperextension or STT arthritis can lead to persistent pain and poor
outcome. STT arthritis may be managed surgically by excision of the proximal trapezoid at the time of
trapeziectomy, as exposure is excellent. MCP hyperextension greater than 30 degrees should be treated.
Although many surgeons temporarily pin the joint, there is a high rate of relapse, so MCP arthrodesis
should be considered and is recommended if the MCP deformity exceeds 50 degrees. 26
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Wrist Arthritis
Understanding of the anatomy of the articular surface of the distal radius is key to diagnosis and
treatment of wrist arthritis. The wrist supplies the hand three degrees of motion: flexion/extension,
radial/ulnar deviation, and rotation. Historically it was believed 
 the majority of the load bearing was
through the scaphoid fossa of the radius; however, recent in vivo pressure transduction determined the
majority of the load passes through the lunate facet in all positions of the wrist, using a wide point of
contact to transmit force through the triangular fibrocartilage complex to the ulna as well as down the
intermediate column of the radius. 33 In contrast, greater motion occurs at the radioscaphoid articulation
as the scaphoid flexes during radial deviation and extends with ulnar deviation, passing through a 40%
range of motion arc. 34 The scaphoid drives the motion of the lunate and in turn the entire proximal carpal
row; differential motion between the scaphoid and lunate or within the scaphoid, thus alters normal wrist
kinematics and creates abnormal loading that predisposes to articular wear and injury. This process
explains why 95% of wrist arthritis seen is periscaphoid. 35 Although Kienbock disease or idiopathic
osteonecrosis of the lunate may lead to arthritic changes, it is a distinct process beyond the scope of this
chapter.
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Examination
A history of wrist trauma is common in wrist arthritis. Patients may have tenderness dorsally over the
scapholunate (SL) interval. In those with a scaphoid nonunion triggering arthritis, a positive Watson’s
test may be present—a painful clunk when the wrist is brought from ulnar to radial deviation with volar
pressure on the scaphoid. Range of motion is reduced and should be documented. Important conditions
to rule out on examination are carpal tunnel syndrome, trigger finger, rheumatoid arthritis, basal joint
arthritis, and pseudogout (the latter discussed below).
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Imaging
Bilateral AP wrist views should be obtained in all patients with concern for radiocarpal arthritis. SL
widening is an indicator of SL ligament compromise and may be seen only on a grip or clenched-fist
radiograph view. A “ring sign” may be seen on an AP view with excessive flexion of the scaphoid (Figure
93.4A). Lateral views should be examined for SL angle. An angle greater than 60 degrees is abnormal and
indicates scaphoid flexion with lunate extension (Figure 93.4B). This rotatory subluxation between the
scaphoid and lunate causes abnormal wear and arthritis. Scapholunate advanced collapse (SLAC) is used
to describe this spectrum of pathology (Figure 93.5), which constitutes 55% of radiocarpal arthritis 35,36
and is divided into three stages:
FIGURE 93.4 Radiographic findings in scapholunate advanced collapse. A. Scaphoid ring sign (arrow). B. Lateral view of a
wrist with SL dissociation demonstrating dorsal tilt of the lunate and volar tilt of the scaphoid leading to an increased SL angle
over 60 degrees. The lunate is highlighted in purple and the scaphoid in blue; the red lines allow visualization of the angle at
almost 90 degrees.
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FIGURE 93.5 Radiographic progression of radiocarpal arthritis. A. The inciting injury in scapholunate advanced collapse
(SLAC) wrist is a tear in the SL ligament that causes SL interval widening and proximal capitate migration; this image depicts a
fairly acute injury prior to the onset of arthritis. B. SLAC stage I: Arthritic changes limited to the radial styloid. C. SLAC stage II:
Severe arthritic changes in the scaphoid fossa with near complete loss of joint space. Note the preserved lunate fossa. D.
SLAC stage III: Arthritis of the entire distal radius.
Stage I: Arthritis limited to the radial styloid.
Stage II: Radioscaphoid arthritis with preservation of the lunate facet.
Stage III: Progression to capitolunate arthritis.
Scaphoid nonunion advanced collapse (SNAC) is arthritis arising from a nonunited scaphoid fracture and
demonstrates parallel stages to SLAC wrist. Similarly, there is abnormal rotation in the proximal row;
however, the axis of this rotation is intrascaphoid instead of between the scaphoid and lunate (Figure
93.6). 37
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FIGURE 93.6 Scaphoid nonunion advanced collapse wrist in the anteroposterior (A) and lateral (B) radiographic views.
It is important to carefully assess the position of the scaphoid to rule out pseudogout. Scaphoid
chondrocalcinosis advanced collapse due to pseudogout may be seen radiographically and is distinct
from SLAC wrist in that the scaphoid extends and both the scaphoid and lunate facets are involved.
Distinguishing scaphoid chondrocalcinosis advanced collapse is essential, as surgical treatment without
addressing the underlying pseudogout will likely lead to failure. 11
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Treatment
The most conservative surgical option for wrist arthritis is denervation—this may be selective with
excision of the posterior interosseous nerve only, or a wrist denervation accomplished by excising both
the anterior interosseous nerve and posterior interosseous nerve. It may be accomplished through a single
incision and does not compromise any future reconstructive options. There have been variable results
reported in the literature regarding success of this procedure, and it is accepted that more than 50% of
patients experience some degree of improvement in pain score. 38 In early SNAC wrist, distal pole
excision may be utilized if the fragment is less than half the scaphoid length. There is limited role for
radial styloidectomy alone in wrist arthritis.
Later stage wrist arthritis with a preserved lunate fossa has two primary surgical treatment options. In
reality, these are both considered salvage procedures and both lead to diminished range of motion that is
hopefully pain-free. There is ongoing debate on the relative indications for PRC versus 4CF. PRC uses
removal of the scaphoid, lunate, and triquetrum to convert the complex interactions between carpal
bones into a simple hinge joint with the capitate articulating in the lunate fossa. As a result of the
differential curvature radius of the capitate head and lunate, radiographic progression of arthritic change
is frequently seen in the lunate fossa; however, this has not been clinically correlated with a return of
pain. 39 Long-term results of PRC are acceptable, with a 14% to 35% conversion to wrist fusion. A capsular
interposition flap has been suggested to improve pain scores. 38 When examining risk factors for failure,
age less than 40 at the time of wrist fusion is strongly correlated and considered a relative
contraindication for PRC. 39-41
In the short term, 4CF has a higher complication profile, with increased risk of nonunion, infection, and
hardware removal. 42 Nicotine cessation in the immediate pre- and postoperative periods should be
advised. Performed by excising the scaphoid then removing the intercarpal articular surfaces of the
lunate, capitate, hamate and triquetrum to allow fixation of these bones into a carpal fusion mass, this
operation relies on an intact articular surface of the lunate to articulate with the distal radius.
The initial description uses Kirschner wires to hold the fusion; now fusion plates, compression screws
and staples are all available. Fusing the lunate in slight flexion has been suggested to provide improved
wrist extension as it prevents the fusion mass from impinging on the dorsal side of the radius. 43
Historically, PRC was thought to decrease grip strength by shortening the wrist but provide a greater arc
of motion, but multiple metaanalyses and a well-designed cohort study have demonstrated equivalence
of the PRC and 4CF in range of motion, grip strength, and multiple subjective performance variables
(Table 93.6). 38,42-44 When compared to the contralateral wrist, both procedures impart a 50% to 60%
decrease in range of motion and maintain 80% of grip strength. The only significant difference is a greater
arc of motion in radial-ulnar deviation with 4CF. 43 The insignificant difference in subjective measures
may be explained by the fact that activities of daily living require an arc of 35 degrees flexion to
80 degrees of extension, and both 4CF and PRC typically provide this degree of motion. 41,42
TABLE 93.6
Comparison of Proximal Row Carpectomy (PRC) and Four-Corner Fusion (4CF) a
Flexion Extension
Arc
Radial-Ulnar
Arc
Grip Strength
Functional
Outcome
Pain Relief
Failure (Progression to Wrist
Fusion)
4CF
64–76 degrees
13–30 degrees
70%–90% of
contralateral
Minimal
limitation
Significant
Rare
PRC
75–76 degrees
9–32 degrees
70%–90% of
contralateral
Minimal
limitation
Significant
Potentially increased in patients
<40
aRanges from 2009 metaanalysis by Mulford et al. 40 provided for patient counseling.
Small studies in the literature exist regarding limited intercarpal fusions—capitolunate fusion for
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example. These demonstrate similar outcomes to 4CF in range of motion and pain relief. A large
metaanalysis of the available data indicates a greater propensity for nonunion when the fusion mass is
smaller. 42 Because wrist fusion imparts an impairment on extremity function of 5% to 26%, total wrist
arthrodesis is considered the ultimate salvage procedure. Once other options are exhausted, it can be
effective. Despite overall acceptable outcomes, rates of pain relief vary widely, from 25% to 100% in the
multitude of studies. 45
Total wrist arthroplasty is typically used in older, low-demand patients and historically has played little
role in the management of OA. These implants require a strict lifting restriction often less than ten
pounds, and there has been scant investigation into the limits of this stipulation for the implants. There is
a real risk of dislocation if the prosthesis is overstressed, and hardware loosening and infection are
known complications. Recent retrospective reviews have demonstrated increasing success, ranging from
75% to 99% implant survival at 5 years, 46 and technological advances may make arthroplasty a more
viable option in young, high-demand patients in the coming years.
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Conclusions
OA affects the different joints of the hand and wrist in a variety of ways and treatment options vary
accordingly. Common first-line treatment is nonoperative management, with splinting, hand therapy,
antiinflammatories, and injections. Any surgical treatment of arthritis involves a tradeoff: in exchange for
pain, patients lose either motion (in the case of arthrodesis) or strength (in the case of arthroplasty).
Patient occupation and goals must be carefully considered before intervention, as many of our
interventions have equivalent outcomes.
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Questions
1. A 60-year-old woman comes into the office complaining of 6 weeks of pain at the base of the
thumb of the dominant right hand. It interferes with her leisure activities of knitting and cooking. On
examination, she has a positive grind test and weak grip strength. There is mild MCP hyperextension
of 15 degrees. Her X-rays demonstrate decreased trapeziometacarpal joint space and a 1 mm
osteophyte. No cystic changes are noted. What is the next step in management?
a. CMC arthrodesis
b. Trapezium excision and ligament reconstruction/tendon interposition
c. Spica cast immobilization for 2 months
d. Pinning of the MCP in neutral for 6 weeks
e. Splinting, NSAIDs, and steroid injection
2. A 40-year-old carpenter is seen in clinic complaining of base of thumb pain and difficult with grip
strength in his right, dominant hand. His thumb ray is adducted, and there is a palpable step-off over
the dorsum of the thumb MCP and pain with axial loading. Imaging demonstrates 50% subluxation
of the metacarpal and a 4-mm osteophyte with severe subchondral sclerosis. He has previously seen
two other surgeons and received different recommendations from each. Which of the following
options along with trapeziectomy is not recommended?
a. Tight-rope reconstruction
b. Hematoma distraction pinning
c. Palmaris longus interposition
d. Silicone spacer placement
e. FCR ligament reconstruction tendon interposition
3. A 66-year-old accountant returns to your office 1 year after undergoing trapeziectomy and
ligament reconstruction tendon interposition for severe CMC arthritis. She complains of ongoing
dull, aching pain in the wrist in a similar position to her presurgical pain. There is no thumb MCP
hyperextension, Tinel sign is absent, and range of motion and grip strength are symmetric when
compared to the contralateral side. X-rays of the wrist are obtained and do not demonstrate proximal
migration of the first metacarpal. What is the most likely cause of her continued pain?
a. Untreated scaphotrapezoid arthritis
b. Injury to the superficial branch of the radial nerve intraoperatively
c. Noncompliance with hand therapy postoperatively
d. Undiagnosed scaphoid injury
e. Long duration of symptoms prior to surgery predisposing to chronic pain
4. A 72-year-old man presents to clinic with a pain and a nodule over the lateral aspect of the index
DIP on the nondominant hand. Active range of motion is absent at the DIP. Gull-wing sign and
complete loss of the joint space are present on imaging. What is the best treatment option for a
functional outcome?
a. Excision of the Heberden nodule to control pain
b. Fusion of the DIP in 15 degrees of flexion
c. Repair of the FDP tendon to improve range of motion
d. Joint excision and pyrocarbon arthroplasty
e. Arthrodesis in full extension
5. A 42-year-old smoker is diagnosed with SLAC wrist. During the informed consent process, you
review his treatment options and discuss the risks of both PRC and 4CF. Which statement is correct
regarding the outcomes of the two procedures?
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a. In his age group, PRC has a higher likelihood of conversion to wrist fusion.
b. 4CF will provide him a greater arc of flexion and extension than PRC.
c. His grip strength will be markedly decreased in 4CF when compared to PRC.
d. PRC will more effectively relieve his pain than 4CF.
e. He is at higher risk for nonunion with 4CF.
1. Answer: e. In this patient with fairly early CMC arthritis, conservative management is the first-line
treatment. Her pain has been of relatively short duration and her X-rays demonstrate mild disease—
Eaton stage II is described. Rest, splinting, antiinflammatory use and steroids are all described as
first-line treatment. Splinting may be hand based and does not need to be rigid; it may take up to
12 months to resolve symptoms. Steroids have been demonstrated to provide short-term pain relief
in 40% of patients with early CMC arthritis.
2. Answer: d. Over 90% of the CMC arthroplasties performed in the United States use the ligament
reconstruction tendon interposition method despite four other well-described options. Multiple
studies have attempted unsuccessfully to quantify the “best” procedure for basal joint arthritis. Both
metaanalyses and randomized control trials have failed to find a difference in objective or subjective
outcomes with various reconstructions after trapeziectomy with the exception of prosthetic spacer
placement. Use of silicone, Marlex, or Gore-tex increases short- and long-term complications and
does not provide any functional benefit. Any of the above-listed options are viable treatments for
CMC arthritis with the exception of silicone spacer placement, which is not recommended.
3. Answer: a. Failure to diagnose and treat arthritis at the STT joint at the time of CMC arthroplasty
may lead to persistent pain in the base of the thumb. This is preventable if specifically assessed on
preoperative radiographs and should be part of the routine workup when planning basal joint
surgery. Patients complain of pain in a similar location to their CMC pain with the same dull, aching
quality. Temporary relief may be achieved with steroid injections.
4. Answer: b. This patient has a preoperative ankylosis of his DIP joint with severe OA and should
receive a fusion. Although some patients may prefer the cosmetic appearance of a finger fused in
extension, the index finger DIP is more functional with a 10- to 20-degree bend during routine
activities of daily living. Fusion as more than 20 degrees would be bothersome to the patient.
Although arthroplasty may be considered in specific patients, pyrocarbon is not designed for DIP
joints. A silicone implant acts primarily as a spacer, and the pre- and postoperative motion is usually
unchanged. With this patient’s inability to flex the fingertip at baseline, he has significant
inflammation of his synovium and surrounding structures that joint replacement would not solve; so
implant replacement would not improve his result. Heberden nodules have not been shown to
contribute to pain and excision is not recommended. There is no evidence of FDP injury in this
patient—his absent range of motion is due to severe arthritis and ankylosis of the joint—thus repair
of the FDP tendon is not indicated.
5. Answer: e. In this smoker, nonunion is the greatest risk during 4CF. It is well accepted that
nicotine is a risk factor for delayed and nonunions. As PRC does not have any bony healing to
complete, this risk is not present if the other procedure is chosen. The remaining outcomes of PRC
and 4CF are equivalent. Multiple retrospective studies, metaanalyses, and a well-designed cohort
study have demonstrated the same range of motion, grip strength, pain relief, and patient
satisfaction. 4CF does have a consistently greater arc of radial-ulnar deviation; however, this has not
been proven significant in day-to-day activities. There have been concerns raised about the
progression of arthritis in PRC given the different radii of curvature in the capitate and lunate;
however, this has only been found to be clinically significant in patients under the age of 40.
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References
Mobasheri, A, Batt, M. An update on the pathophysiology of osteoarthritis. Ann Phys Rehabil Med. 2016;59(5-6):333-339.
Martel-Pelletier, J. Pathophysiology of osteoarthritis. Osteoarthritis Cartilage. 2004;12:31-33.
Kaufmann, RA, Lögters, TT, Verbruggen, G, et al. Osteoarthritis of the distal interphalangeal joint. J Hand Surg. 2010;35(12):2117-2125.
Jacobs, BJ, Verbruggen, G, Kaufmann, RA. Proximal interphalangeal joint arthritis. J Hand Surg. 2010;35(12):2107-2116.
Wilder, FV, Barrett, JP, Farina, EJ. Joint-specific prevalence of osteoarthritis of the hand. Osteoarthritis Cartilage. 2006;14(9):953-957.
Spaans, AJ, van Minnen, LP, Kon, M, et al. Conservative treatment of thumb 
 base osteoarthritis: a systematic review. J Hand Surg.
2015;40(1):16-21, 
 e1-6.
Day, CS, Gelberman, R, Patel, AA, et al. Basal joint osteoarthritis of the thumb: a prospective trial of steroid injection and splinting. J Hand
Surg. 2004;29(2):247-251.
Heyworth, BE, Lee, JH, Kim, PD, et al. Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective,
randomized, double-blinded clinical trial. J Hand Surg. 2008;33(1):40-48.
Tsai, P, Beredjiklian, PK. Physical diagnosis and radiographic examination of the thumb. Hand Clin. 2008;24(3):231-237.
Kallman, DA, Wigley, FM, Scott, WW, et al. New radiographic grading scales for osteoarthritis of the hand: reliability for determining
prevalence and progression. Arthritis Rheum. 1989;32(12):1584-1591.
Trehan, SK, Lee, SK, Wolfe, SW. Scapholunate advanced collapse: nomenclature and differential diagnosis. J Hand Surg. 2015;40(10):2085-
2089.
Alexander, CJ. Heberden’s and Bouchard’s nodes. Ann Rheum Dis. 1999;58(11):675-678.
Melamed, E, Polatsch, DB, Beldner, S, Melone, CP. Simulated distal interphalangeal joint fusion of the index and middle fingers in 0° and 20°
of flexion: a comparison of grip strength and dexterity. J Hand Surg. 2014;39(10):1986-1991.In this study of healthy volunteers, orthoses were
used to simulate the degree of DIP fusion and effect of ADLs; 0 to 20 degrees was found to be acceptable, with the index providing the most limitation.
Villani, F, Uribe-Echevarria, B, Vaienti, L. Distal interphalangeal joint arthrodesis for degenerative osteoarthritis with compression screw:
results in 102 digits. J Hand Surg. 2012;37(7):1330-1334.
Woodworth, JA, McCullough, MB, Grosland, NM, Adams, BD. Impact of simulated proximal interphalangeal arthrodeses of all fingers on
hand function. J Hand Surg. 2006;31(6):940-946.
Srnec, JJ, Wagner, ER, Rizzo, M. Implant arthroplasty for proximal interphalangeal, metacarpophalangeal, and trapeziometacarpal joint
degeneration. J Hand Surg. 2017;42(10):817-825.
Daecke, W, Kaszap, B, Martini, AK, et al. A prospective, randomized comparison of 3 types of proximal interphalangeal joint arthroplasty. J
Hand Surg. 2012;37(9):1770-1779, e1-3.
Cooney, WP, Lucca, MJ, Chao, EY, Linscheid, RL. The kinesiology of the thumb trapeziometacarpal joint. J Bone Jt Surg Am. 1981;63A:1371-
1381.
Eaton, RG, Littler, JW. Ligament reconstruction for the painful thumb carpometacarpal joint. J Bone Jt Surg Am. 1973;55A:1655-1666.Eaton and
Littler first defined the classification of thumb CMC arthritis used today. Additionally, they describe their method of ligament reconstruction which is
the basis of today’s LRTI procedure.
Komatsu, I, Lubahn, JD. Anatomy and biomechanics of the thumb carpometacarpal joint. Oper Techn Orthop. 2018;28(1):1-5.
Napier, JR. The form and function of the carpo-metacarpal joint of the thumb. J Anat. 1955;89(3):362-369.
Ladd, AL, Lee, J, Hagert, E. Macroscopic and microscopic analysis of the thumb carpometacarpal ligaments: a cadaveric study of ligament
anatomy and histology. J Bone Jt Surg Am. 2012;94A:1468-1477.This anatomical study of the ligamentous stabilization of the thumb CMC
overturned 50 years of dogma that the anterior oblique (aka beak) ligament is the primary stabilizer of the joint and instead demonstrated the
importance of the dorsal ligaments as the key structural support at the CMC.
Pellegrini, VD. Osteoarthritis of the trapeziometacarpal joint: the pathophysiology of articular cartilage degeneration. I. Anatomy and
pathology of the aging joint. J Hand Surg. 1991;16(6):967-974.
Bettinger, PC, Linscheid, RL, Berger, RA, et al. An Anatomic study of the stabilizing ligaments of the trapezium and trapeziometacarpal joint.
J Hand Surg. 1999;24(4):786-798.
Muller, GM. Arthrodesis of the trapezio-metacarpal joint for osteoarthritis. J Bone Jt Surg Br. 1949;31B:540-542.
Poulter, RJ, Davis, TRC. Management of hyperextension of the metacarpophalangeal joint in association with trapeziometacarpal joint
osteoarthritis. J Hand Surg Eur Vol. 2011;36(4):280-284.
Vermeulen, GM, Slijper, H, Feitz, R, et al. Surgical management of primary thumb carpometacarpal osteoarthritis: a systematic review. J
Hand Surg. 2011;36(1):157-169.
Freedman, DM, Eaton, RG, Glickel, SZ. Long-term results of volar ligament reconstruction for symptomatic basal joint laxity. J Hand Surg.
2000;25(2):297-304. doi:10.1053/jhsu.2000.jhsu25a0297.
Vermeulen, GM, Brink, SM, Slijper, H, et al. Trapeziometacarpal arthrodesis or trapeziectomy with ligament reconstruction in primary
trapeziometacarpal osteoarthritis: a randomized controlled trial. J Bone Jt Surg Am. 2014;96A:726-733.A randomized, single-blind trial for
treatment of basal joint arthritis comparing CMC arthrodesis to trapeziectomy with LRTI was designed and halted on midterm analysis due to the
higher complication rate in the arthrodesis group. In those who completed the study, functional outcomes were equivalent.
Burton, RI, Pellegrini, VD. Surgical management of basal Joint arthritis of the thumb. Part II: ligament reconstruction with tendon
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interposition arthroplast. J Hand Surg. 1986;11(3):324-332.Burton and Pellegrini’s first description of the trapeziectomoy and ligament
reconstruction tendon interposition, which remains the most widely used reconstruction for thumb CMC arthritis in the US today.
Yuan, F, Aliu, O, Chung, KC, Mahmoudi, E. Evidence-based practice in the surgical treatment of thumb carpometacarpal joint arthritis. J
Hand Surg. 2017;42(2):104-112, e1.
Gangopadhyay, S, McKenna, H, Burke, FD, Davis, TRC. Five- to 18-year follow-up for treatment of trapeziometacarpal osteoarthritis: a
prospective comparison of excision, tendon interposition, and ligament reconstruction and tendon interposition. J Hand Surg.
2012;37(3):411-417.A randomized, single blinded trial for treatment of basal joint arthritis comparing trapeziectomy with temporary kwire fixation,
trapeziectomy with palmaris interposition and trapeziectomy with LRTI. Five year follow-up was obtained, and no difference found in function (grip,
key pinch, or tip pinch strength) or pain relief. Complications were equivalent.
Rikli, DA, Honigmann, P, Babst, R, et al. Intra-articular pressure measurement in the radioulnocarpal joint using a novel sensor: in vitro and
in vivo results. J Hand Surg. 2007;32(1):67-75.A novel pressure transducer was verified in this study in cadavers and then introduced into the wrist
of a human subject to properly quantify the distribution of forces in the wrist. Contrary to previous cadaver studies, they demonstrated that >50% of the
load is transmitted through the lunate fossa and intermediate column of the forearm, which has important implications for reconstruction in the setting
of wrist arthritis.
Palmer, AK, Werner, FW, Murphy, D, Glisson, R. Functional wrist motion: a biomechanical study. J Hand Surg. 1985;10(1):39-46.
Watson, HK, Ryu, J. Evolution of arthritis of the wrist. Clin Orthop Relat Res. 1986;(202):57-67.
Watson, HK, Ballet, FL. The SLAC wrist: scapholunate advanced collapse pattern of degenerative arthritis. J Hand Surg. 1984;9(3):358-365.
Vender, MI, Watson, HK, Wiener, BD, Black, DM. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg. 1987;12(4):514-519.
Strauch, RJ. Scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis—update on evaluation and treatment. J
Hand Surg. 2011;36(4):729-735.
Wall, LB, DiDonna, ML, Kiefhaber, TR, Stern, PJ. Proximal row carpectomy: minimum 20-year follow-up. J Hand Surg. 2013;38(8):1498-1504.
DiDonna, ML, Kiefhaber, TR, Stern, PJ. Proximal row carpectomy: study with a minimum of ten years of follow-up. J Bone Jt Surg Am.
2004;86A:2359-2365.
Mulford, JS, Ceulemans, LJ, Nam, D, Axelrod, TS. Proximal row carpectomy vs four corner fusion for scapholunate (Slac) or scaphoid
nonunion advanced collapse (Snac) wrists: a systematic review of outcomes. J Hand Surg Eur Vol. 2009;34(2):256-263.
Siegel, JM, Ruby, LK. A critical look at intercarpal arthrodesis: review of the literature. J Hand Surg. 1996;21(4):717-723.
Cohen, MS, Kozin, SH. Degenerative arthritis of the wrist: proximal row carpectomy versus scaphoid excision and four-corner arthrodesis. J
Hand Surg. 2001;26(1):94-104.Cohen and Kozin present a well-designed cohort study comparing PRC to 4CF. Key in the selection of their cohort is the
presence of two centers, each of which performed exclusively one of the two procedures, creating a “pseudorandomization.” They found equivalent
outcomes in grip strength, range of motion, pain relief and satisfaction.
Wolff, AL, Garg, R, Kraszewski, AP, et al. Surgical treatments for scapholunate advanced collapse wrist: kinematics and functional
performance. J Hand Surg. 2015;40(8):1547-1553.
De Smet, L, Truyen, J. Arthrodesis of the wrist for osteoarthritis: outcome with a minimum follow-up of 4 years. J Hand Surg Br.
2003;28(6):575-577.
Sagerfors, M, Gupta, A, Brus, O, Pettersson, K. Total wrist arthroplasty: a single-center study of 219 cases with 5-year follow-up. J Hand Surg.
2015;40(12):2380-2387.
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PA R T I X
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Trunk and Lower Extremity
94. Reconstruction of the Chest, Sternum, and Posterior Trunk
95. Abdominal Wall Reconstruction
96. Lower Extremity, Foot, and Ankle Reconstruction
97. Perineal Reconstruction
98. Diagnosis and Treatment of Lymphedema
99. Pressure Injuries
100. Gender-Affirming Surgery
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C H A P T E R 9 4
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Reconstruction of the Chest, Sternum, and
Posterior Trunk
Alexander F. Mericli and Mark W. Clemens II
Key Points
A cohesive multidisciplinary approach is particularly important in thoracic reconstruction. A
preoperative discussion with the thoracic surgeon should be made regarding the possibility of a
latissimus-sparing thoracotomy.
Anterior and lateral chest wall defects involving three or more adjacent ribs or that are 5 cm in width
or greater will benefit from skeletal reconstruction. Posterior defects and resections in previously
irradiated chest walls can tolerate a larger defect before skeletal reconstruction is necessary.
Bioprosthetic mesh should be used for skeletal chest wall reconstruction in patients at high risk for
wound healing complications, such as those with a history of radiation.
Adequate treatment of a sternal wound infection includes adequate debridement, culture-directed
antibiotics, and reconstruction with well-vascularized soft tissue.
The pectoralis major muscle flap is the workhorse flap for sternal and anterior chest wall
reconstruction.
Unlike other clinical scenarios involving infection and hardware, spinal instrumentation should be
maintained at all costs in cases of acute wound infection.
The paraspinous muscle advancement flap is the workhorse flap for midline posterior trunk wounds
and is an adequate option at any spinal level.
Prophylactic spinal wound reconstruction is prudent in high-risk situations, such as large
resections/instrumentations, patients with multiple previous spinal surgeries, or a history or
radiation, diabetes, obesity, or steroid use.
Defects of the chest wall and intrathoracic space can result from tumor resection, infection, radiation
injury, or trauma, whereas sternal wounds are most frequently associated with infectious complications
after cardiothoracic procedures, such as mediastinitis or sternal osteomyelitis. Soft tissue reconstruction
of the posterior trunk is often related to tumor resection or infectious complications following spinal
instrumentation. Thoracic and spinal wound reconstructions share a relatively unique distinction in
plastic surgery in that the creation of a reliable, durable wound closure is truly a life-saving procedure.
Therefore, an in-depth knowledge of and familiarity with these patients and surgical maneuvers are
critical for all plastic and reconstructive surgeons. Although differing in anatomic location as well as
etiology, the reconstructions of the chest, sternum, and posterior trunk share many of the same key
principles, including adequate debridement, recruitment of well-vascularized soft tissue to fill dead
space, and protection of vital structures and hardware using a durable external coverage.
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Chest Wall, Sternum, and Intrathoracic Reconstruction
Anatomy and Physiology
In addition to its role in protecting the heart, lungs, and mediastinum, the chest wall also serves an
important physiologic function by harboring the muscles of respiration and maintaining a negative
intrathoracic pressure. 1 The primary respiratory muscles include the diaphragm and the intercostal
muscles. The intercostal muscles can be divided into three layers: the external, internal, and innermost.
The intercostal neurovascular bundle runs along the interior surface of each rib, at the inferior border,
between the internal and innermost muscle fibers; the nerve is most inferior, followed by the artery and
then the vein. The thoracic skeleton serves to protect and contain the heart, lungs, and mediastinal
structures and is an attachment point for the respiratory muscles. It comprises seven paired true ribs
(which articulate with the sternum via costal cartilages), eight pairs of false ribs (which do not articulate
with the sternum), and two pairs of floating ribs (11th and 12th), so called because they lack any
connection to the sternum or the ribs superior to them (Figure 94.1). The sternum provides additional
protection and structural support and consists of the manubrium, body, and xiphoid. The intrathoracic
space, or pleural cavity, must remain intact to maintain a negative intrathoracic pressure. The parietal
pleura lines the inner surface of the skeletal chest wall; a distinct structure termed as the visceral pleura
lines the surface of the lungs and travels within each fissure, separating the lobes. Between the two
pleurae is the fluid-filled pleural cavity.
FIGURE 94.1 Musculoskeletal anatomy of the chest wall.
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Etiology
Chest wall defects can encompass soft tissue, skeletal structures, or both. The depth of the wound can
involve only the skin and subcutaneous tissue or extend to full-thickness and into the intrathoracic space.
A number of etiologies can contribute to these defects including neoplastic disease, infectious processes,
osteoradionecrosis of the ribs and/or sternum, and trauma (Table 94.1).
TABLE 94.1
Common Etiologies of Thoracic Defects Requiring Reconstruction
Malignant Neoplasm
Locally advanced tumor
Breast carcinoma
Lung carcinoma
Primary tumor
Soft tissue sarcoma
Chondrosarcoma
Ewing sarcoma
Metastatic tumor
Sarcoma
Renal cell carcinoma
Gastrointestinal malignancy
Benign Neoplasm
Osteochondroma
Chondroma
Fibrous dysplasia
Desmoid
Infection
Soft tissue
Mediastinitis
Osteomyelitis
Trauma
Osteoradionecrosis
The majority of chest wall wounds are the result of either the treatment or palliation of malignancy.
Among these, the most common are locally invading tumors from adjacent structures, including breast
cancer, lung cancer, mediastinal tumors, and mesothelioma. 2 A minority of chest wall lesions are caused
by the hematogenous metastasis of solid tumors, most commonly sarcoma, followed by renal cell
carcinoma, and gastrointestinal adenocarcinoma. 3 Adequate debridement of various infectious processes,
such as mediastinitis, necrotizing fasciitis, or osteomyelitis, can result in a chest wall or sternal defect in
need of reconstruction, as can trauma from ballistic, blunt-force, or blast injury. Lastly, osteoradionecrosis
of the skeletal chest wall can emerge many years after the completion of radiation therapy, necessitating
wide debridement and reconstruction with well-vascularized tissue.
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Preoperative Planning and Patient Selection
Compared to many other patient populations familiar to plastic surgery, those requiring thoracic
reconstruction are often plagued with a multitude of comorbidities, such as obesity, diabetes, congestive
heart failure, ischemic heart disease, and pulmonary disease. Patients must be optimized preoperatively
to minimize potential complications. Glucose should be well controlled, nutrition and pre-albumin
should be improved, and if possible, general deconditioning should be mitigated through preoperative
physical therapy. For surgeries involving chest wall resection, partial, or complete lobectomy,
preoperative pulmonary function testing is beneficial. Metrics such as forced vital capacity and forced
expiratory volume in 1 second can help estimate the patient’s ability to tolerate their extirpative surgery,
which, in turn provides a more accurate prediction of their capacity for a complete recovery. 4
A cohesive multidisciplinary approach is particularly important in thoracic reconstruction. A standard
lateral thoracotomy will divide the latissimus dorsi muscle and a portion of the serratus anterior; both
these muscles are workhorse flaps for the chest and must be preserved in case of their potential use. A
preoperative discussion with the thoracic surgeon regarding the surgical approach and the possibility of a
latissimus-sparing thoracotomy can be helpful. Regarding mediastinal defects after cardiac surgery, any
reconstructive surgery or debridement should be performed in a cardiac surgery operating room, with
the ability to accommodate a bypass pump if necessary, with a cardiac anesthesiologist and a
cardiothoracic surgeon available. The plastic surgeon must have intimate knowledge of the coronary
artery bypass grafts used, if any, so that well-vascularized flaps can be planned. Additionally, the plastic
surgeon should be aware of any sternal wires or plating.
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Chest Wall Skeletal Reconstruction
The goals of skeletal chest wall reconstruction include minimizing paradoxical motion, aiding pulmonary
mechanics, protecting underlying thoracic viscera, and maintaining a normal chest contour. Functionally,
reconstruction has been shown to decrease postoperative mechanical ventilation and length of stay. 5,6
The indications for chest wall skeletal reconstruction are controversial and should be determined on an
individual basis. In general, guidelines suggest that defects involving three or more adjacent ribs along
the anterior or lateral chest wall or defects with a diameter of 5 cm or greater will benefit from rigid
reconstruction. 2,7,8 Posterior chest wall resections can typically tolerate a larger resection without the need
for reconstruction given the additional stabilizing forces provided by the scapula and thoracic vertebrae.
Similarly, defects in previously irradiated chest walls often do not require skeletal reconstruction because
the radiation-related fibrosis will decrease chest wall compliance, which in turn, decreases the likelihood
of paradoxical motion.
The ideal thoracic skeletal reconstruction promotes tissue ingrowth and is inert, malleable, and
radiolucent. 9 Techniques using synthetic and biologic materials have been described. In general,
synthetic materials are preferred in clean defects with minimal risk for complication (no history of
radiation, few comorbidities, no current or past infection, nonfungating tumor, etc.). A variety of
synthetic mesh materials have been described in chest wall reconstruction, the most common of which
are polyethylene (Marlex; C.R. Bard, Inc., Bard Medical Division, Covington, GA), polypropylene
(Prolene) (Ethicon LLC, Bridgewater, NJ), and expanded polytetrafluoroethylene (Gore-Tex; Gore &
Associates, Newark, DE). Each material has its own advantages and disadvantages, summarized in Table
94.2. In general, all synthetic materials carry a risk of infection of up to 5% depending on the material and
study. 5,10–12 Although not common, a wound infection in this situation can be a devastating complication,
necessitating prolonged intravenous antibiotics, readmission, reoperation, and removal of the construct.
In their extensive review of synthetic mesh chest wall reconstruction at M.D. Anderson Cancer Center,
Spicer and colleagues identified a relatively low wound infection rate of 2.8%, and no significant
association with the material used. In another study from the same institution, patients with and without
Marlex chest wall stabilization were compared. 5 Patients with Marlex had 5% infection rate compared to
0% in those without Marlex. However, all patients with infection had coexistent necrosis of the overlying
skin flaps; therefore, the authors recommend that any synthetic construct should be covered with a well-
vascularized tissue, such as a muscle flap (Figure 94.2).
TABLE 94.2
Materials Used for Skeletal Chest Wall Reconstruction
Material
Advantages
Disadvantages
Polyethylene
Inexpensive
Macroporous, permitting ingrowth
Prone to fraying and fragmentation
Contraindicated
in
contaminated/complex
wounds
Infection necessitates removal
Polypropylene
Inexpensive
Macroporous, permitting ingrowth
Double-knitted; flexible in two dimensions
Contraindicated
in
contaminated/complex
wounds
Infection necessitates removal
Expanded
polytetrafluoroethylene
Watertight seal
Ease of handling
Encapsulates; no tissue ingrowth
Seroma formation
Contraindicated
in
contaminated/complex
wounds
Infection necessitates removal
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Methylmethacrylate
Used in combination with porous synthetic
mesh
Can be molded to chest contour
Cures by an exothermic reaction, putting tissues
at risk for thermal injury
May fracture
Rigidity is non-anatomic
No tissue ingrowth
Seroma formation
Bioprosthetic
Semi-rigid, dynamic
Incorporates into host tissues
Decreased risk of infection
Can be used in irradiated wounds
Expensive
Permeable
Will not maintain chest contour in large defects
Infection/exposure does not necessitate removal
Titanium rib plating
Anatomic design, recreating chest contour, and
physiologic compliance
Improved pulmonary function
Expensive
Long term durability unknown
Requires an underlay synthetic or biologic mesh
for pleural reconstruction
Requires specialty instrumentation
Radiopaque
FIGURE 94.2 Skeletal chest wall reconstruction. A. A 56-year-old woman with locally advanced breast cancer invading the
chest wall. She had been previously treated with radiation, and therefore a bioprosthetic mesh was used to reconstruct the
anterior chest wall after resection of four adjacent ribs. B. Postoperative result after coverage with a pedicled TRAM flap. C. A
58-year-old woman with metastatic colon cancer to the lateral right eighth rib. Three adjacent ribs were resected and the defect
was reconstructed with a polyethylene-methylmethacrylate sandwich. D. The synthetic chest wall construct was covered with a
pedicled right latissimus dorsi muscle flap. E. Postoperative result.
A bioprosthetic mesh is often favored in patients at high risk for wound healing complications (Figure
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94.2). Due to their ability to incorporate into the patient and revascularize, these products have been
shown to be resistant to infection and to function well in the irradiated defect. 13–15 Bioprosthetic meshes
are classified by the source material—either xenograft or allograft. Initially human dermal allograft was
most commonly used for chest wall reconstruction; however, more recent evidence suggests that porcine
or bovine-derived material may be preferred for this application because of the lower amount of elastin
compared to human dermis. 15,16 The decreased elastin content translates to a more anatomic, semirigid
reconstruction, which better approximates normal chest wall biomechanics.
For large skeletal chest wall defects, synthetic and bioprosthetic meshes alone are unable to maintain the
natural thoracic curvature. This has important implications not only for aesthetics, but also for pulmonary
mechanics. Most commonly, sandwiching methylmethacrylate cement between two layers of porous
synthetic mesh ameliorates this situation (Figure 94.2). Methylmethacrylate, however, has several
disadvantages, including a tendency to fracture as well as an association with infection and seroma
formation. 5,17 Because of these shortcomings, titanium rib plating osteosynthesis systems are gaining in
popularity. These systems were initially utilized for the reconstruction of flail segments in the trauma
patient. In flail chest injuries, rib osteosynthesis is associated with a decreased incidence of pneumonia,
improved pulmonary function, faster return to work, and improved quality of life. 18 Recent design
iterations have yielded spanning rib plates, which are useful for oncologic defects. 19,20 Spanning plate
reconstructions have been associated with a low complication rate, good cosmetic result, and superior
pulmonary function. 21,22 Rib spanning plates should always be combined with a synthetic or biologic
mesh underlay for reconstruction of the parietal pleura and restoration of the negative intrathoracic
pressure; and then should be covered anteriorly with a well-vascularized tissue, such as a muscle flap, to
protect against possible exposure 20 (Figure 94.3).
FIGURE 94.3 A 63-year-old woman with locally advanced lung cancer necessitating a latissimus-sparing thoracotomy, five-rib
chest wall resection, and right lung lobectomy. A,B. Pleural defect reconstructed with Gore-Tex mesh, chest wall reconstructed
with four titanium rib-spanning plates and pedicled latissimus myocutaneous flap.
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Chest Wall Soft Tissue Reconstruction
Well-vascularized soft tissue coverage is vital to the success of any chest wall reconstruction. Adequate
soft tissue is necessary for minimizing infection, protecting alloplastic implants, and promoting
expeditious wound healing. This is especially critical after oncologic resection, in the setting of previous
radiation or osteoradionecrosis, or in the presence of underlying prosthetic materials.
The principles illustrated by the reconstructive ladder can easily be applied to soft tissue chest wall
reconstruction. Depending on the extent of the wound, patient comorbidities, and indications,
reconstruction can be as simple as a skin graft or as complicated as a free tissue transfer. 23–27 Smaller
defects can be reconstructed with a local flap or skin graft; a local flap may offer a superior cosmetic
result, but its applicability is limited to smaller wounds. Alternatively, large partial thickness defects will
require a skin graft. If the underlying rib, sternum, or hardware is exposed or if there is a history of
radiation to the area, skin grafts or local random flaps are unlikely to be successful. In this scenario, a
regional flap from outside the zone of radiation is a more appropriate choice; there are many options
available, as the location of the chest is particularly conducive to regional reconstructive techniques
(Table 94.3). 28,29 Many advocate for muscle flap coverage of underlying mesh or plates in patients
requiring skeletal chest wall reconstruction. 5 Considering the devastating nature of a chest wall mesh
infection or exposure, this technique is especially efficacious for patients at elevated risk for delayed
healing (previous infection, high BMI, diabetes, history of radiation, smoking, etc).
TABLE 94.3
Common Regional Flaps Used for Chest Wall Coverage 28,29
Flap
Included Tissues
Approximate 

Size (cm)
Vascular Supply
Common Applications
Pectoralis major
Muscle or
myocutaneous
15 × 23
Thoracoacromial
Internal mammary perforators
Anterior chest
Sternal wound
Intrathoracic space
Serratus anterior
Muscle
15 × 20
Serratus
branch
of
thoracodorsal
Lateral thoracic vessels
Intrathoracic space
Latissimus dorsi
Muscle or
myocutaneous
25 × 35
Thoracodorsal vessels
Intercostal
and
lumbar
perforators
Anterior,
lateral,
and
posterior chest
Intrathoracic space
Rectus abdominis
Muscle or
myocutaneous
25 × 6
Deep inferior and superior
epigastric vessels
Anterior chest
Sternal wound
External oblique
Myocutaneous
15 × 30
Lumbar perforators
Inferior third of anterior
chest
Omentum
Visceral adipose
Variable
Right or left gastroepiploic
Sternal wound
Intrathoracic space
Thoracodorsal artery
perforator flap
Fasciocutaneous
8 × 35
Thoracodorsal
Anterior,
lateral,
and
posterior chest
Intercostal artery
perforator flap
Fasciocutaneous
5 × 15
Intercostal perforator
Small
anterior
chest
wounds
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Despite the numerous regional flap options, large chest wall defects such as those resulting from
extensive oncologic resection, invasive infection, or osteoradionecrosis may require microsurgical
techniques. Microsurgical tissue transfer provides great freedom in the reconstruction, as flap design and
inset are not constrained by the length and positioning of the pedicle. Furthermore, provided that the
anastomosis is technically excellent, the vascular supply of a free flap tends to be more robust and reliable
than that of a pedicled flap, translating to a lower incidence of partial flap loss. Arya and colleagues
report an extensive experience in microsurgical chest wall reconstruction, demonstrating a low
complication rate and a 96% flap success rate. 30 Limiting the reconstructive indication to oncologic chest
defects, Cordeiro et al. demonstrate a 100% free flap success rate. 27 Recipient vessel options in
microsurgical chest wall reconstruction have been extensively described in the breast reconstruction
literature and most commonly include the internal mammary or thoracodorsal vessels.
Radiation is commonly employed as part of the modern multimodality approach to thoracic malignancy.
Neoadjuvant and adjuvant treatment plans may include radiation for the treatment of breast and lung
cancers. Certain connective tissue tumors, such as Ewing sarcoma, are treated primarily with radiation
therapy. Other sarcomas, such as angiosarcoma, may occur as a side effect of previous radiation therapy,
necessitating wide resection in an irradiated field. Treatment of a radiation-related wound often requires
a wide resection, by continuing tissue resection until a well-vascularized tissue is encountered (Figure
94.4). Given the blunted angiogenesis exhibited by irradiated tissue, skin grafts and local flaps have low
utility, with most plastic surgeons preferring regional flaps instead. 2,31–35 The avoidance of synthetic
materials in the irradiated chest wall is recommended; if skeletal reconstruction is necessary,
bioprosthetic mesh is better tolerated due to its ability to revascularize. Unfortunately, despite an
adequate debridement and reconstruction, wounds in an irradiated field are incredibly complex and
continue to be prone to infection, wound dehiscence, and soft tissue fibrosis.
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FIGURE 94.4 A. Osteoradionecrosis of the sternum and ribs presenting as a draining sinus. B. Resulting defect after
adequate debridement, consisting of partial sternectomy. C. Right pedicled TRAM flap for reconstruction of the defect. D.
Postoperative result.
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Sternal Wound Reconstruction
Most commonly, sternal wound reconstruction is required as part of the surgical treatment of an infected
median sternotomy incision. A similar defect may be created after oncologic sternectomy, however this
etiology is less common. Mediastinitis occurs in 0.25% to 5% of patients after cardiac surgery. 36–38 Risk
factors include advanced age, chronic obstructive pulmonary disorder, smoking, diabetes, steroid use,
immunosuppression, morbid obesity, reoperative surgery, and off-midline sternotomy. Pairolero and
Arnold classified sternal wound infections into three distinct subtypes. 39 Type 1 infections are defined by
faint erythema and serosanguinous incisional drainage within the first few postoperative days. These
wounds are typically sterile and not infected, therefore their classification as a type 1 infection is a
misnomer. On the contrary, the type 1 wound is caused by mechanical failure of the sternal wire closure;
in the absence of infection, these wounds can be treated effectively with conservative debridement and
irrigation. If the type 1 patient proceeds to a symptomatic sternal nonunion, as defined by pain or a
bothersome click, then the ineffective wires can be removed and the residual sternum can be rigidly
fixated with titanium plates. Type 2 infections occur within the first few weeks and exhibit frankly
purulent drainage and significant cellulitis. A type 3 infection is indicative of a chronic infection, due to
osteomyelitis, costochondritis, or a retained foreign body. In general, type 2 and 3 infections require at
least one significant debridement followed by a muscle flap wound reconstruction. Patients presenting
with signs and symptoms of mediastinitis should have wound and blood cultures obtained. A CT scan of
the chest can be helpful for identifying drainable abscesses. If osteomyelitis is suspected, an MRI permits
visualization of the extent of disease and is useful for planning the debridement.
An adequate debridement is the cornerstone of the surgical management of mediastinitis. Such
debridements are aggressive, including removal of all nonviable soft tissue, cartilage, and bone, until
uniform bleeding is appreciated from the remaining tissues. All hardware and sternal wires should be
removed. If definitive reconstruction is not possible after the first debridement, negative pressure therapy
may be used to temporize the wound and stabilize the tissues. Negative pressure therapy decreases the
number of days between the initial operative debridement and definitive closure, expedites the formation
of granulation tissue within the wound, encourages angiogenesis, promotes wound contraction, and
reduces the number and frequency of dressing changes. 40
The need for rigid sternal fixation is controversial. Many believe that median sternotomy wound
reconstruction is successful with soft tissue flaps only. This is based on the concept that limiting the
number of foreign bodies within the wound (i.e., wires and plates) minimizes the risk of persistent
infection. Other reconstructive surgeons prefer to adhere to the principles of osteosynthesis, which state
that rigid skeletal fixation, such as titanium plating, reduces or eliminates micromotion at the osteotomy
site, thereby promoting healing and decreasing infection. Titanium sternal plating systems may be best
reserved for high-risk patients with multiple comorbidities contributing to poor healing. Indeed, in this
patient population, prophylactic sternal plating may reduce or even prevent mediastinitis. 41,42
Sternal wound soft tissue reconstruction is most commonly achieved with pectoralis major muscle flaps.
Based on the thoracoacromial vessels, the pectoralis major muscle can be disinserted from its humeral
attachment and advanced medially. Uni- or bilateral advancement flaps can resurface the superior two-
thirds of the sternum. If the wound has a significant dead space component, or involves the inferior third
of the sternum, a turnover pectoralis flap based on the internal mammary perforating vessels may be a
better option. A turnover flap is contraindicated if the internal mammary artery has been used for
coronary revascularization. Second-line options for soft tissue reconstruction of the median sternotomy
wound include the superiorly-based rectus abdominis flap or an omentum flap. A vertically or
transversely-oriented skin paddle can be included with the rectus abdominis muscle if additional volume
or cutaneous resurfacing is needed. Although there are reports of designing a superiorly-based rectus
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abdominis flap on the eighth intercostal vessels when the internal mammary vessels have been disrupted,
doing so is not advisable if other flap options are available. In such a scenario, the omentum flap can be
designed on either the left or right gastroepiploic vessels and routed into the mediastinum either through
the diaphragm or externally out through the epigastric abdominal wall and into the chest. The omentum
provides a large surface area of well-vascularized tissue that can easily fill and resurface the entire
mediastinum. Depending on the cutaneous requirement of the wound, the native chest skin can be closed
over the omentum flap or, if skin coverage is limited, the flap can be skin grafted. Disadvantages of the
omentum flap are the possibility of an epigastric or diaphragmatic hernia, the need to enter the abdomen,
and the inherent complications of doing so (ileus, bowel obstruction, injury to viscera) and the
unpredictable size and quality of the omentum in thin individuals or in those with previous abdominal
surgery. To minimize abdominal donor site morbidity, the omentum flap may be elevated
laparoscopically in select patients.
Midline sternal defects may also occur after partial or total sternectomy for oncologic purposes. Similar to
the lateral chest wall, metastatic tumors are the most common indication for oncologic sternectomy,
followed by primary bone or soft tissue tumor and osteoradionecrosis. 43 The pectoralis major muscle flap
is a reliable option for soft tissue reconstruction unless there is a large cutaneous resection, in which case
a free tissue transfer may be more appropriate 43 (Figure 94.5).
FIGURE 94.5 A. Partial sternectomy with exposure of right lung and great vessels after resection of metastatic thyroid cancer.
B. Chest wall and great vessels covered with bilateral pectoralis major advancement flaps. C. Postoperative result. D. Total
sternectomy after resection of locally advanced squamous cell carcinoma. The skeletal defect was reconstructed with a
bioprosthetic mesh and, due to the significant skin resection, the cutaneous defect was reconstructed with a free TRAM flap. E.
Postoperative result.
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Intrathoracic Reconstruction
Intrathoracic, or pleural cavity, reconstruction is most commonly associated with the presence of an
empyema or bronchopleural fistula. An empyema is a purulent infection between the visceral and
parietal pleura. A bronchopleural fistula, often coexistent with an empyema, is a communication between
the bronchiolar airway and the pleural cavity. If not appropriately treated, these complications are
associated with a high mortality rate after pneumonectomy. Similar to the pelvis, the intrathoracic cavity
is a bony, noncollapsible space. Therefore, deep space infections are unlikely to resolve unless the cavity
is either collapsed down or filled with vascularized tissue. Historically, this was addressed via the
thoracoplasty, in which multiple ribs were removed to collapse of the chest wall, or through the creation
of an Eloesser flap, which is essentially a marsupialization of the pleural cavity to form a controlled
fistula for spontaneous drainage. 44 Although still sometimes performed in certain clinical scenarios, these
antiquated techniques have now largely fallen out of favor.
The omentum, latissimus dorsi, serratus anterior, rectus abdominis, and pectoralis major muscles are all
options for filling the pleural cavity with well-vascularized tissue (Figure 94.6). After an adequate
debridement, such flaps can help to heal an empyema cavity or seal a dehisced bronchial stump. Flaps
can also be transferred prophylactically in patients thought to be at high risk for bronchial stump
dehiscence after pneumonectomy such as those with previous radiation or multiple past thoracic
procedures. 45 The latissimus, serratus, and pectoralis muscles are transferred into the chest cavity
through the space created by a removal of a rib, whereas the rectus abdominis muscle and omentum are
passed into the chest through a surgically created diaphragmatic window. Transposition of well-
vascularized tissue into the pleural cavity for the treatment of empyema and bronchopleural fistula is an
effective maneuver associated with a 73% resolution of infection in Arnold and Pairolero’s landmark
series. 46
FIGURE 94.6 A. Intrathoracic defect in a 28-year-old woman after left pneumonectomy for tuberculosis. B. Bronchus stump
closure reinforced with an intrathoracic pedicled serratus anterior muscle flap, passed into the thorax via a partial rib resection
superior to the thoracotomy. Note the transected latissimus muscle, as this was not a latissimus-sparing thoracotomy.
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Posterior Trunk Reconstruction
Anatomy and Physiology
A thorough understanding of the cross-sectional musculoskeletal anatomy at the cervical, thoracic, and
lumbosacral regions is essential in undertaking a posterior trunk reconstruction (Figure 94.7). The spinal
cord travels through the vertebral foramen; the anterior wall of the foramen is the posterior aspect of the
vertebral body; the posterior wall of the foramen consists of the bilateral lamina and spinal process, and
the side walls are made up of the bilateral pedicles. The cord ends at L1/L2 and the dural sac terminates
at S3. The paired paraspinous muscles, also known as the erector spinae, parallel the spine and function
to stabilize and extend the vertebrae. The paraspinous muscles are made up of three distinct muscle
bellies—spinalis, longissimus, and iliocostalis—and travel the length of the spine. The trapezius muscle is
the most superficial muscle in the midline posterior trunk, extending from the occiput to the T12 spinous
process and fanning out laterally to attach to the bilateral scapular spines. More inferiorly, the trapezius
overlaps with the latissimus dorsi muscle from T7 to T12. The latissimus dorsi muscle transitions into the
thoracolumbar fascia medially; this is most prominent in the lumbar region. The paraspinous muscles are
immediately deep to the latissimus dorsi, except in the T10-L1 location, where the serratus posterior
inferior muscle fibers may be found sandwiched between the paraspinous and latissimus dorsi.
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FIGURE 94.7 Cross-sectional musculoskeletal anatomy at the cervical, thoracic, and lumbar levels.
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Etiology
Reconstruction of the lateral posterior trunk is most commonly required after the surgical resection of soft
tissue malignancy. Cutaneous malignancies such as melanoma or connective tissue tumors such as
sarcoma often necessitate a wide local excision, making primary approximation of the resulting wound
difficult.
Reconstruction of the midline posterior trunk wound is most commonly related to spinal instrumentation
and fusion. Spinal hardware has evolved and improved tremendously over the past two decades. Long
posterior constructs spanning the length of the spine are now routinely performed for the correction of
deformity. Simultaneous anterior and posterior spine exposures for multilevel oncologic vertebrectomies
are possible, allowing for curative resection of what was previously considered unresectable disease.
However, such extensive instrumentations come at a cost: to achieve the necessary exposure, the
surrounding soft tissues are widely stripped and elevated away from the vertebrae, creating significant
dead space and a challenging environment for normal wound healing.
Soft tissue reconstruction of the midline posterior trunk wound may be requested after the occurrence of
a wound healing complication (infection, hematoma, seroma, skin edge separation, hardware exposure,
etc.) following any variety of spine surgeries. In high-risk patients, such as those with a history of
multiple previous spine surgeries, radiation therapy to the spine, neoadjuvant chemotherapy, obesity, or
diabetes, the plastic surgeon may be asked to perform an immediate muscle flap reconstruction at the
time of the index surgery to protect the hardware and obliterate dead space—with the intention of
preventing a wound healing complication. 47–49 Although most reconstruction in the posterior trunk
involves soft tissue, the plastic surgeon may play a role in skeletal reconstruction as well. The mainstay of
bony fusion in spine surgery is a nonvascularized particulate bone graft in conjunction with rigid
fixation; however, in spinal osseous defects >4 cm, up to 50% of patients fail to progress to fusion. 50 In
these long constructs—often seen after vertebrectomy or sacroiliac joint resection—vascularized bone
flaps can be a useful adjunct in addition to the standard instrumentation and particulate bone graft 51–53
(Figure 94.8).
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FIGURE 94.8 Six-month postoperative radiographs of a 36-year-old woman after L2 vertebrectomy for chordoma with free
fibula flap plus polyetheretherketone expandable cage for vertebral body reconstruction.
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Approach to Patient and Patient Selection
Wound healing complications after spinal instrumentation should be approached systematically and
aggressively. Deep space infections, skin edge separations, seromas, and hematomas can easily lead to
hardware exposure or loss—a devastating complication in spine surgery, associated with the possibility
of paralysis and death. The plastic surgeon should communicate directly with the spine surgery team and
have a thorough understanding of the surgical approach used and other important details. Is the
hardware low profile? Was there a durotomy/is there concern for a cerebrospinal fluid leak? Was the
spine approached anteriorly, posteriorly, or both? Has this patient had other spine surgeries? What
disease process necessitated the spine surgery? Are there any fluid collections on imaging? The patient’s
wound healing physiology should also be optimized. A high protein diet should be initiated. If the
patient is being treated with steroids, vitamin A supplementation should be considered. If the patient is
paralyzed or otherwise immobile due to polytrauma or obesity, a low-pressure bed should be provided.
In the paralyzed patient, involuntary muscle spasms and joint contractures that could result in additional
wound closure tension should be ameliorated. Early infections (<6 weeks from the index procedure) are
usually adequately treated with antibiotics, aggressive surgical debridement, and muscle flap
reconstruction with maintenance of the spinal instrumentation. Chronic hardware infections, defined as a
deep space infection at least 6 months after hardware placement, are difficult to effectively eradicate. In
this situation, an MRI should be obtained to evaluate for vertebral osteomyelitis. In addition to
debridement, the patient may require hardware removal and replacement for definitive treatment.
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Lateral Defect
Nonmidline posterior trunk wounds are caused by a variety of pathologies, and therefore require a
variety of solutions. Compared to midline spine wounds, the reconstructive approach to the lateral defect
is more standard, following the typical dogma of plastic surgery. If the wound cannot be closed
primarily, it can be skin grafted, provided there is a well-vascularized base. Aesthetically, some surgeons
prefer local flap reconstructions in wounds that could be otherwise closed with a skin graft (Figure 94.9).
Other wounds, due to exposed bone, hardware, or previous radiation, may not reliably heal with a skin
graft, thereby necessitating a flap. Available regional flaps are the latissimus dorsi, trapezius, and lumbar
perforator flaps. Free tissue transfer is complicated by the relative paucity of recipient vessels. The
thoracodorsal vessels may be an option, but a vein graft or arteriovenous loop is needed.
FIGURE 94.9 Defects of the lateral posterior trunk reconstructed with local flaps. A,B. Wide local excision of melanoma
reconstructed with a hatchet flap. C–E. A 55-year-old man with recurrent posterolateral trunk sarcoma in an irradiated field. He
was previously reconstructed with a fasciocutaneous rotation flap. Mass excised and defect reconstructed with readvancement
of the rotation flap and split-thickness skin grafting of the donor site.
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Midline Posterior Trunk Defects
A thorough debridement is a critical first step in the reconstruction of postsurgical back wounds. The
entire incision should be opened in the operating room and all spine instrumentation exposed. The plastic
surgeon should be knowledgeable about the initial spine surgery performed; if a laminectomy or
partial/total vertebrectomy has been performed, the spinal cord and dura are vulnerable to injury during
the debridement. All nonviable soft tissue and unincorporated bone graft should be removed. The wound
should be copiously irrigated with antibiotic saline, and all purulent fluid should be drained. If the
wound can be adequately debrided with a single procedure, then it should be fully closed over multiple
drains, with the addition of a well-vascularized muscle flap for dead space obliteration, protection of the
cord and hardware. If the wound is frankly purulent or still not clearly demarcated and therefore will
require additional debridements, the drains should be placed in the deep space and the paraspinous
muscles should be loosely approximated over the vertebra and hardware. The skin can be left open and a
negative pressure wound dressing applied. Once the wound has declared itself and been fully debrided,
it can be definitely closed with muscle flap transposition and skin reapproximation. Because of the
proximity of the central nervous system, in this scenario it is advisable to return to the operating room
and perform all dressing changes under general anesthesia.
Unlike the extremity, in which hardware present in an infected or dehisced wound is oftentimes
removed, spine hardware should be maintained if at all possible. 54 Hardware maintains spinal stability,
protects the spinal cord, and acts to stabilize the wound. Hardware that is well fixed promotes healing
and prevents infection by eliminating micromotion and shearing of the fragile, traumatized soft tissues.
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Paraspinous Muscle Flaps
As indicated by their name, the paraspinous muscles parallel the spine, traveling from the occiput and
mastoid process down to terminate in the lumbosacral recess. These paired muscles represent the
workhorse flaps for reconstruction of midline posterior trunk defects. On each side, the paraspinous
muscles consist of three separate muscles: spinalis, longissimus, and iliocostalis. These muscle bellies can
be indistinct, interdigitating, and creating the illusion of a single muscle on either side of the spine. The
paraspinous muscles are perfused through a medial and lateral row of segmental perforating vessels
from the lumbar, intercostal, or vertebral vessels, depending on the level, making them Mathes and
Nahai type 4 flaps. Dissection must be performed immediately superficial to the paraspinous muscles
until the lateral border is reached; at this point, the fascia is divided allowing for medial advancement.
The muscles are then imbricated into the midline defect using a Lembert suture, which nicely directs the
medial third of the flap into the dead space 55 (Figure 94.10). A summary of other common flaps for
midline posterior trunk reconstruction can be found in Table 94.4.
FIGURE 94.10 Bilateral paraspinous muscle advancement flaps for protection of exposed spinal cord and posterior
instrumentation.
TABLE 94.4
Common Flaps for Midline Posterior Trunk Reconstruction
Flap
Included Tissues
Vascular Supply
Spinal Level
Paraspinous
Muscle
Thoracic and lumbar perforators
Cervical, 
 thoracic, 

lumbar
Trapezius
Muscle or myocutaneous
Transverse
cervical;
dorsal
scapular
Cervical
Upper 
 thoracic
Latissimus dorsi
Muscle or myocutaneous
Thoracodorsal
Thoracic
Reverse latissimus
dorsi
Muscle or myocutaneous
Thoracic and lumbar perforators
Lower 
 thoracic
Lumbar
Omentum
Visceral adipose
Right or left gastroepiploic
Lower thoracic
Lumbar
Lumbar perforator
Fasciocutaneous
Lumbar perforator
Lumbar
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Gluteal
Muscle, myocutaneous, or
fasciocutaneous
Superior gluteal
Lumbosacral
Sacral
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