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

Questions
1. A 55-year-old man is undergoing a surgical repair of a recurrent ventral hernia. At the end of the
case, the anesthesiologist asks the surgical resident whether or not they should provide a local
anesthetic block to help with pain control. Where is the correct abdominal wall anatomic location to
provide maximal local anesthesia in this patient?
a. 1 cm medial to the lateral border of the rectus sheath
b. Lateral to the femoral artery on a line connecting the anterior superior iliac spine (ASIS) and
pubic tubercle, superficial to the iliopsoas muscle
c. Three fingerbreadths below the ASIS, between the sartorious and tensor fascia lata muscles
d. 2 cm lateral to the rectus sheath, between internal oblique and transversalis muscle
e. 2 cm medial and inferior to the ASIS
2. In a standard component separation as described by Ramirez, where do you get the least
advancement in a component separation?
a. Epigastric region
b. Suprapubic region
c. Umbilical region
d. All regions are equal
3. In a high-risk patient with an incisional midline hernia, which one of the following reconstructions
is most likely to decrease the chance of hernia recurrence?
a. Bridge repair with mesh
b. Primary fascial closure no mesh
c. Bilateral component separation with mesh placement and primary fascial closure
d. Unilateral component separation, primary fascial closure, no mesh
e. Unilateral component separation with bridged mesh placement without primary fascial
closure
4. What is the primary blood supply to a vertical rectus abdominis muscle flap used to reconstruct a
chest wall and xiphoid wound?
a. Superficial circumflex iliac artery
b. Superficial epigastric artery
c. Deep Inferior epigastric artery
d. Musculophrenic artery
e. Superior Epigastric Artery
5. What is the optimal abdominal wall primary fascial closure technique?
a. Double looped 0-polydioxanone suture (PDS) continuous suture with 2-cm fascial bites every
2 cm
b. #1 PDS interrupted simple sutures with 1 cm fascial bites every 1 cm
c. #0 Polyester braided nonabsorbable continuous suture with 1-cm fascial bites every 1 cm
d. #1 PDS continuous suture with 5 mm fascial bites every 5 mm
e. #0 Prolene continuous suture with 2-cm fascial bites every 2 cm
1. Answer: d. Transversus abdominis plane block is a peripheral nerve block of T6-L1 intercostal
nerves that has been shown to improve postoperative pain control in midline laparotomies and
abdominal-based breast reconstruction. The correct location of the sensory nerves is between the
internal oblique and transversus abdominis muscle lateral to the rectus sheath. The femoral nerve is
found lateral to the femoral artery along the inguinal ligament. The lateral femoral cutaneous nerve
is found inferior to the ASIS between the sartorious and TFL muscles. The correct location for an
mebooksfree.net

ilioinguinal nerve block is 2 cm medial and inferior to the ASIS.
2. Answer: b. Components separation described by Ramirez 
 et al. in 1990 states that approximately
5-, 10-, and 3-cm advancements can be made in a unilateral or 10-, 20-, and 6-cm advancements in a
bilateral in the epigastric, umbilical, and suprapubic regions, respectively. Of note, to obtain these
advancements, Ramirez described both anterior component release and release of the rectus muscle
from the posterior sheath.
3. Answer: c. Although hernia reconstruction remains controversial, hernia recurrence is significantly
reduced with the addition of mesh and the ability to obtain primary fascial closure. Component
separation strives to advance the abdominal wall toward the midline to achieve primary fascial
closure. The addition of mesh further decreases risk of recurrence.
4. Answer: e. In a superiorly based rectus abdominis flap, the primary blood supply is the superior
epigastric artery, which is a continuation of the internal mammary artery. The internal mammary
branches into the musculophrenic and Superior Epigastric Artery, which is the primary blood supply
to the superiorly based rectus abdominis muscle flap. The superficial epigastric artery is incorrect
nomenclature. The superficial circumflex iliac artery supplies the superficial circumflex iliac artery
perforator flap or groin flap and the deep inferior epigastric artery is the primary blood supply for an
inferiorly based rectus abdominis muscle flap.
5. Answer: d. Midline laparotomy fascial closure has been shown to have the highest closure strength
and resistance to hernia occurrence with the use of a slowly absorbable, monofilament suture with
small fascial bites in smaller increments. This technique increases the suture to incision length ratio
to greater than 4:1, which provides the additional strength of the closure.
mebooksfree.net

References
Le Huu Nho, R, Mege, D, Ouaissi, M, et al. Incidence and prevention of ventral incisional hernia. J Visc Surg. 2012;149:e3-e14.
Bhangu, A, Nepogodiev, D, Futaba, K; West Midlands Research Collaborative . Systematic review and meta-analysis of the incidence of
incisional hernia at the site of stoma closure. World J Surg. 2012;36:973-983.
Sanders, DL, Kingsnorth, AN. The modern management of incisional hernias. BMJ. 2012;344:e2843.
Wechter, ME, Pearlman, MD, Hartmann, KE. Reclosure of the disrupted laparotomy wound: a systematic review. Obstet Gynecol.
2005;106:376-383.
Pauli, EM, Rosen, MJ. Open ventral hernia repair with component separation. Surg Clin North Am. 2013;93:1111-1133.
Parker, SG, Wood, CPJ, Butterworth, JW, et al. A systematic methodological review of reported perioperative variables, postoperative
outcomes and hernia recurrence from randomised controlled trials of elective ventral hernia repair: clear definitions and standardised
datasets are needed. Hernia. 2018;22:215-226.
Peralta, R, Latifi, R. Long-term outcomes of abdominal wall reconstruction: what are the real numbers? World J Surg. 2012;36:534-538.
Luijendijk, RW, Hop, WC, van den Tol, MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med.
2000;343:392-398.This landmark RCT studied the ideal closure technique for patients undergoing primary incisional ventral hernia or repair of a first
hernia recurrence and compared suture versus mesh repair. Hernia repair with mesh was found to reduce recurrence by approximately 50%. Patients
who already had a recurrence had an even more profound decreased rate of hernia development with the use of mesh.
Burger, JW, Luijendijk, RW, Hop, WC, et al. Long-term follow-up of a randomized controlled trial of suture versus mesh repair of incisional
hernia. Ann Surg. 2004;240:578-583.
Poulose, BK, Shelton, J, Phillips, S, et al. Epidemiology and cost of ventral hernia repair: making the case for hernia research. Hernia.
2012;16:179-183.
Abo-Ryia, MH, El-Khadrawy, OH, Abd-Allah, HS. Prophylactic preperitoneal mesh placement in open bariatric surgery: a guard against
incisional hernia development. Obes Surg. 2013;23:1571-1574.
Cleveland, RD, Zitsch, RP III, Laws, HL. Incisional closure in morbidly obese patients. Am Surg. 1989;55:61-63.
Sugerman, HJ. Weight reduction after gastric bypass and horizontal gastroplasty for morbid obesity. Eur J Surg. 1996;162:157-158.
Jairam, AP, Timmermans, L, Eker, HH, et al. Prevention of incisional hernia with prophylactic onlay and sublay mesh reinforcement versus
primary suture only in midline laparotomies (PRIMA): 2-year follow-up of a multicentre, double-blind, randomised controlled trial.
Lancet. 2017;390:567-576.This double-blind multicenter RCT examined the optimal abdominal closure pattern in elective midline laparotomy patients
that were high risk for incisional hernia development. Patients were randomized to either prophylactic onlay synthetic mesh placement, sublay synthetic
mesh placement, or primary fascial closure. Prophylactic onlay mesh placement had a significant reduction in hernia occurrence rate at 2 years
compared to sublay mesh placement and primary fascial closure.
Punekar, IRA, Khouri, JS, Catanzaro, M, et al. Redefining the rectus sheath: implications for abdominal wall repair. Plast Reconstr Surg.
2018;141:473-479.
Harrison, B, Sanniec, K, Janis, JE. Collagenopathies: implications for abdominal wall reconstruction: a systematic review. Plast Reconstr Surg
Glob Open. 2016;4:e1036.
Fink, C, Baumann, P, Wente, MN, et al. Incisional hernia rate 3 years after midline laparotomy. Br J Surg. 2014;101:51-54.
Tolstrup, MB, Watt, SK, Gogenur, I. Reduced rate of dehiscence after implementation of a standardized fascial closure technique in patients
undergoing emergency laparotomy. Ann Surg. 2017;265:821-826.
Muysoms, FE, Antoniou, SA, Bury, K, et al. European Hernia Society guidelines on the closure of abdominal wall incisions. Hernia. 2015;19:1-
24.
Deerenberg, EB, Harlaar, JJ, Steyerberg, EW, et al. Small bites versus large bites for closure of abdominal midline incisions (STITCH): a
double-blind, multicentre, randomised controlled trial. Lancet. 2015;386:1254-1260.This article is a double-blinded multicenter RCT that
addressed the optimal closure technique of midline laparotomies in an effort to decrease ventral hernia occurrence. They compared small-bite (every
5 mm) to large-bite (every 10 mm) closures in elective midline laparotomy patients. The article found that the smaller bite closure was more effective in
preventing incisional hernia without increased adverse outcomes.
Lintin, LA, Kingsnorth, AN. Mechanical failure of a lightweight polypropylene mesh. Hernia. 2014;18:131-133.
Majumder, A, Winder, JS, Wen, Y, et al. Comparative analysis of biologic versus synthetic mesh outcomes in contaminated hernia repairs.
Surgery. 2016;160:828-838.
Purnell, CA, Souza, JM, Park, E, Dumanian, GA. Repair of recurrent hernia after biologic mesh failure in abdominal wall reconstruction. Am J
Surg. 2014;208:788-793.
Giordano, S, Garvey, PB, Baumann, DP, et al. Primary fascial closure with biologic mesh reinforcement results in lesser complication and
recurrence rates than bridged biologic mesh repair for abdominal wall reconstruction: a propensity score analysis. Surgery. 2017;161:499-
508.
van’t Riet, M, de Vos van Steenwijk, PJ, Kleinrensink, GJ, et al. Tensile strength of mesh fixation methods in laparoscopic incisional hernia
repair. Surg Endosc. 2002;16:1713-1716.
Jamal, K, Ratnasingham, K, Shaunak, S, et al. A novel technique for modified onlay incisional hernia repair with mesh incorporation into the
fascial defect: a method for addressing suture line failure. Hernia. 2015;19:473-477.
Ibrahim, MM, Poveromo, LP, Glisson, RR, et al. Modifying hernia mesh design to improve device mechanical performance and promote
mebooksfree.net

tension-free repair. J Biomech. 2018;71:43-51.
Evans, KK, Chim, H, Patel, KM, et al. Survey on ventral hernias: surgeon indications, contraindications, and management of large ventral
hernias. Am Surg. 2012;78:388-397.
Krpata, DM, Schmotzer, BJ, Flocke, S, et al. Design and initial implementation of HerQLes: a hernia-related quality-of-life survey to assess
abdominal wall function. J Am Coll Surg. 2012;215:635-642.
Slater, NJ, van der Kolk, M, Hendriks, T, van Goor, H, Bleichrodt, RP. Biologic grafts for ventral hernia repair: a systematic review. Am J
Surg. 2013;205:220-230.
Ventral Hernia Working Group ; Breuing, K, Butler, CE, Ferzoco, S, et al. Incisional ventral hernias: review of the literature and
recommendations regarding the grading and technique of repair. Surgery. 2010;148:544-558.This systematic review provides recommendations
on the repair of ventral hernia by the Ventral Hernia Working Group. Recommendations are made on repair techniques and on the use of biologic and
synthetic mesh. A novel grading scale of hernias is also described in relation to patient risk factors and wound contamination.
Warren, JA, McGrath, SP, Hale, AL, et al. Patterns of recurrence and mechanisms of failure after open ventral hernia repair with mesh. Am
Surg. 2017;83:1275-1282.
Conze, J, Rosch, R, Klinge, U, et al. Polypropylene in the intra-abdominal position: influence of pore size and surface area. Hernia. 2004;8:365-
372.
Chatzimavroudis, G, Kalaitzis, S, Voloudakis, N, et al. Evaluation of four mesh fixation methods in an experimental model of ventral hernia
repair. J Surg Res. 2017;212:253-259.
Lanier, ST, Fligor, JE, Miller, KR, Dumanian, GA. Reliable complex abdominal wall hernia repairs with a narrow, well-fixed retrorectus
polypropylene mesh: a review of over 100 consecutive cases. Surgery. 2016;160:1508-1516.
Harris, HW, Hope, WH, Adrales, G, et al. Contemporary concepts in hernia prevention: selected proceedings from the 2017 international
symposium on prevention of incisional hernias. Surgery. 2018;164(2):319-326.
Althubaiti, G, Butler, CE. Abdominal wall and chest wall reconstruction. Plast Reconstr Surg. 2014;133:688e-701e.
Blatnik, J, Jin, J, Rosen, M. Abdominal hernia repair with bridging acellular dermal matrix an expensive hernia sac. Am J Surg. 2008;196:47-50.
Patel, NG, Ratanshi, I, Buchel, EW. The best of abdominal wall reconstruction. Plast Reconstr Surg. 2018;141:113e-36e.
Israelsson, LA, Millbourn, D. Prevention of incisional hernias: how to close a midline incision. Surg Clin North Am. 2013;93:1027-1040.
Ramirez, OM, Ruas, E, Dellon, AL. “Components separation” method for closure of abdominal-wall defects: an anatomic and clinical study.
Plast Reconstr Surg. 1990;86:519-526.Anatomic and clinical study that introduced the concept of “components separation” in abdominal wall
reconstruction. Release of anterior and posterior layers of the abdominal musculature provide medial advancement of myofascial layers to provide
primary abdominal wall closure and improved hernia outcomes. This study provides detailed description on the surgical techniques and intricacies that
are relevant to this day.
Heller, L, McNichols, CH, Ramirez, OM. Component separations. Semin Plast Surg. 2012;26:25-28.
Ko, JH, Wang, EC, Salvay, DM, et al. Abdominal wall reconstruction: lessons learned from 200 “components separation” procedures. Arch
Surg. 2009;144:1047-1055.
Garvey, PB, Bailey, CM, Baumann, DP, et al. Violation of the rectus complex is not a contraindication to component separation for abdominal
wall reconstruction. 
 J Am Coll Surg. 2012;214:131-139.
Pauli, EM, Wang, J, Petro, CC, et al. Posterior component separation with transversus abdominis release successfully addresses recurrent
ventral hernias following anterior component separation. Hernia. 2015;19:285-291.
LeBlanc, KA, Booth, WV. Laparoscopic repair of incisional abdominal hernias using expanded polytetrafluoroethylene: preliminary findings.
Surg Laparosc Endosc. 1993;3:39-41.
Awaiz, A, Rahman, F, Hossain, MB, et al. Meta-analysis and systematic review of laparoscopic versus open mesh repair for elective incisional
hernia. Hernia. 2015;19:449-463.
Muysoms, FE, Detry, O, Vierendeels, T, et al. Prevention of incisional hernias by prophylactic mesh-augmented reinforcement of midline
laparotomies for abdominal aortic aneurysm treatment: a randomized controlled trial. Ann Surg. 2016;263:638-645.
Bhangu, A, Fitzgerald, JE, Singh, P, et al. Systematic review and meta-analysis of prophylactic mesh placement for prevention of incisional
hernia following midline laparotomy. Hernia. 2013;17:445-455.
Borab, ZM, Shakir, S, Lanni, MA, et al. Does prophylactic mesh placement in elective, midline laparotomy reduce the incidence of incisional
hernia? A systematic review and meta-analysis. Surgery. 2017;161:1149-1163.
mebooksfree.net

C H A P T E R 9 6
mebooksfree.net

Lower Extremity, Foot, and Ankle Reconstruction
Jessica F. Rose and Stephen J. Kovach, and L. Scott Levin
Key Points
Lower extremity injury is commonly associated with other trauma, and therefore appropriate
workup and patient stabilization (advanced trauma life support protocol) are necessary before
determining reconstructive options.
Primary amputation may sometimes be more beneficial than lower extremity salvage.
When caring for patients with lower extremity injuries, timing of the reconstruction must be
considered, and patients may benefit from initial external fixation and negative pressure therapy
prior to staged definitive reconstruction.
The reconstructive ladder may be a helpful guide to reconstructive options, although certain
circumstances benefit from microsurgical intervention (reconstructive elevator).
Reconstructing the leg can be thought of as a rule of thirds, with gastrocnemius being the classic
option for the proximal third, soleus for the middle third, and free flap for the distal third.
Appropriate care of these patients likely utilizes a combination of specialties including orthopedic,
plastic, trauma, and vascular surgeons.
The orthoplastic approach guides all treatments.
Patients may have many confounding factors and comorbidities that need to be considered and
appropriately managed, such as diabetes and vascular disease, in order to have a successful
reconstruction.
mebooksfree.net

Anatomy
Vasculature
To effectively treat and reconstruct the lower extremity, extensive knowledge of the anatomy is when
choosing flaps based on and understanding which muscles are viable options in different clinical
scenarios the vascular supply of the leg. The blood supply to the leg begins at the common iliac vessels, as
they branch from the aorta, and then divide into the internal and external iliac arteries. The external iliac
artery and its branches supply the thigh, with the external iliac artery becoming the femoral artery below
the inguinal ligament. The femoral artery branches into the superficial femoral artery and the profunda
femoris artery, both giving off many muscular branches, but the superficial femoral artery continues as
the popliteal artery after the adductor hiatus and the profunda gives rise to the circumflex femoral
system. The popliteal artery gives off genicular branches at the knee and then divides into the anterior
tibial artery and the tibioperoneal trunk. The anterior tibial artery continues as the dorsalis pedis artery in
the foot, whereas the tibioperoneal trunk further divides into peroneal and posterior tibial branches, the
later continuing into the foot to become plantar and then finally digital arteries. The venous anatomy,
with the exception of the saphenous vein, mimics the arterial anatomy.
mebooksfree.net

Bones
The lower extremity is a specialized structure, functioning exclusively for bipedal locomotion. The
extremity itself comes off the pelvic girdle, becoming a free limb. The femur is the largest bone and
stabilizes the thigh, whereas the bony structure of the leg is made up of the tibia and fibula, with the
patella articulating between both to help form the knee joint and the tibia stabilizing the leg. The foot is
made up of 26 bones (the tarsus has 7 bones, the metatarsus has 5 bones, and the forefoot has 14
phalanges). The blood supply to the long bones consists of a nutrient artery, metaphyseal vessels, and
periosteal vessels. Proper healing requires an adequate blood supply. 1
mebooksfree.net

Neurosensory
The neurosensory anatomy is also important for reconstruction, particularly to design sensate flaps.
Figure 96.1 shows neurosensory distribution in the lower extremity.
FIGURE 96.1 Sensory innervation of the lower extremity.
mebooksfree.net

Muscles and Compartments
The muscles of the lower extremity are best understood by dividing them into compartments by location
(Table 96.1). The thigh has three compartments, the anterior, posterior, and adductor compartments. The
anterior compartment is made up of the extensors (sartorius and the quadriceps: rectus femoris, vastus
medialis, vastus lateralis, vastus intermedius) and innervated by the femoral nerve. The posterior
compartment is composed of the flexors (biceps femoris, hamstrings: semimembranosus, semitendinosus)
and primarily innervated by the tibial nerve. The adductor group (adductor longus, adductor brevis,
adductor magnus, adductor minimus, gracilis) is mainly innervated by the obturator nerve.
TABLE 96.1
Compartments of the Leg
Compartment
Muscle
Function
Nerve
Artery
Anterior
Anterior tibialis
Extend, invert foot
Deep peroneal
Anterior tibial
Extensor hallucis longus
Extend great toe, dorsiflex
foot
Extensor digitorum
longus
Extend toes II–V, extend foot
Peroneus tertius
Extend, evert foot
Lateral
Peroneus longus
Peroneus brevis
Flex, evert foot
Superficial peroneal
Anterior tibial, peroneal
Superficial posterior
Gastrocnemius
Flex foot, flex knee
Tibial
Posterior tibial, peroneal, sural
Soleus
Plantar flex foot
Sural
Popliteus
Flex knee, rotate
tibia
Popliteal, genicular branches
Plantaris
Flex foot
Peroneal
Deep posterior
Flexor hallucis longus
Flex foot, great toe
Tibial
Peroneal
Flexor digitorum profundus
Flex foot, toes II–V
Posterior tibial
Tibialis posterior
Flex, invert foot
Peroneal
The compartments of the lower extremity are commonly affected by compartment syndrome. There are
four compartments: anterior, lateral, superficial posterior, and deep posterior. Generally, the anterior
compartment contains the extensors, the lateral compartment contains muscles that flex and evert the
foot, and the posterior compartments contain muscles that flex the foot and the toes.
Compartment syndrome arises when pressures in osseofascial compartments are high enough to decrease
the capillary perfusion and can be caused by trauma, intracompartmental bleeding, swelling, burns and
venomous bites, and ischemic reperfusion, 1,2 but most commonly occurs because of tibial fractures.
Typically, this is compartment pressure >40 mm Hg or 20 mm Hg below the diastolic pressure or
30 mm Hg below the mean arterial blood pressure, resulting in anoxia, ischemia, and muscle death. 1,2 It
causes pain that is disproportionate to the injury, palpably swollen compartments, pain on passive
stretch, diminished sensation, decreased muscle strength, and hypesthesia/anesthesia of the involved
nerves. 1 The earliest and most important sign is increasing pain, particularly to passive stretch of the
involved muscles. If compartment syndrome is suspected, rapid treatment should be initiated, and the
involved compartments should be released with a fasciotomy 1,2 (Figure 96.2).
mebooksfree.net

FIGURE 96.2 Compartments of the lower extremity.
Many of the muscles of the foot can be used as local flaps to close small wounds of the foot. The muscles
are separated into compartments by location and function. First are the dorsal intrinsic muscles, which
include extensor digitorum brevis and extensor hallucis brevis, and are innervated by the deep fibular
nerve. Next are the more traditional compartments, starting with the lateral compartment, including the
abductor digiti minimi, flexor digiti minimi, and opponens digiti minimi, all innervated by the lateral
plantar nerve. The interosseous compartment (dorsal and planter interossei) is innervated by the lateral
plantar nerve. The central compartment is made up of three separate levels. The first level contains
adductor hallucis and is innervated by the lateral plantar nerve. The next (second level) contains
quadratus plantae, lumbricals, and flexor digitorum longus, which are innervated by medial and lateral
plantar nerves. The third level contains flexor digitorum brevis, supplied by the medial plantar nerve.
The final compartment is the medial compartment, which contains abductor hallucis and flexor hallucis
brevis, innervated by medial and lateral plantar nerves.
mebooksfree.net

Fracture Classification
Many systems have been created to classify open tibial fractures, mostly to better describe the injury and
prognosis. The most commonly used system is the Gustilo-Anderson classification 3 :
Grade I: Open fracture, wound <1 cm in length
Grade II: Open fracture, wound >1 cm in length without extensive soft-tissue damage
Grade IIIA: Open fracture with extensive soft-tissue injury
Grade IIIB: Open fracture with extensive soft-tissue injury, bone damage, periosteal stripping,
massive contamination, often needs soft-tissue coverage
Grade IIIC: Open fracture with extensive soft-tissue injury and arterial injury requiring vascular
repair
This system is aimed to classify the soft-tissue injury related to the likelihood of development of infection.
1,3,4 . Plastic surgeons are most likely required to assist with patients who have Gustilo IIIB and IIIC
injuries.
The next system is the Byrd classification, which was designed to classify open tibial fractures and to
determine the usefulness of muscle flaps based on severity of injury 5 (Figure 96.3):
Type I: Low-energy forces, spiral or oblique fracture, <2 cm laceration, relatively clean; healing
process is prompt and uncomplicated
Type II: Moderate-energy forces, comminuted or displaced fracture, skin laceration >2 cm,
contusions, no devitalized muscle; also heal normally
Type III: High-energy forces, displaced fracture with significant comminution or segmental with or
without bone defect, skin loss, devitalized muscle; require vascularized coverage with debridement
of nonviable muscle and closure and filling of dead space
Type IV: High-energy forces or high-velocity gunshot, Type III fractures, crush or degloving,
significant local damage, vascular injury requiring vascular repair; require free flaps to obliterate
dead space and cover the wound
FIGURE 96.3 Byrd classification of tibial fractures.
mebooksfree.net

Management of Lower Extremity Trauma
Traumatic injuries are the cause of more than 60% of lower extremity reconstructions. 6 Management of
the mangled extremity is complex, as it involves a combination of injuries to the soft tissue, bone,
vasculature, and nerves. 7 Appropriate trauma management is key to caring for this patient population.
The first thing to assess is patient stability, focusing on the whole patient and following the advanced
trauma life support guidelines. 8 Resuscitation and management of life-threatening injuries take priority
to extremity salvage. 7 The extremity examination should focus on the sensibility and vascularity of the
extremity and include assessment of soft-tissue and bony trauma. 6,9 Compartment pressures and Doppler
assessment of vascular signals may be necessary. 6 Patients are typically stabilized by the trauma and
orthopedic surgeons first, including the management of compartment syndrome, open fractures, and
arterial injuries. 10 Vascular injuries typically require management before fracture stabilization; however,
sometimes temporary shunting and definitive repair after fracture fixation may be prudent. 7 Figure 96.4
is an algorithm for trauma management.
mebooksfree.net

FIGURE 96.4 Algorithm for the treatment of lower extremity trauma.
Once the patient is stable, care for the mangled extremity begins, which is often best done with a
multidisciplinary approach including orthopedic and plastic surgeons. 8 Early management includes
mebooksfree.net

complete wound debridement and skeletal stabilization by either internal or external fixation. 8
Debridement is the most important step. Historically, serial debridement was performed, but it is better
to perform one thorough debridement (termed radical necrectomy) with early reconstruction and avoid
desiccation of the wound bed. 8,11 However, if the wound is severely contaminated, an external fixator is
beneficial for complete, staged, debridement, and coverage can be temporarily maintained with a wound
vacuum during this phase. 4 Injured structures such as bone, tendon, blood vessels, and nerves should be
reconstructed immediately for better and earlier functional rehabilitation. 8 External fixation was the
traditional management of open fractures, to keep permanent hardware out a potentially contaminated
field. It is still the preferred method if there is active wound infection or for infected nonunion or
malunion. However, external fixation has increased healing times and higher rate of malunion and
nonunion, along with the practicality of both the patient and surgeons working around the device. If
infection is not an issue, internal fixation is recommended. This can be executed with plates,
intermedullary nails, or minimally invasive plate osteosynthesis, all at the discretion of our orthopedic
colleagues. 8
mebooksfree.net

Angiography and Imaging Studies
For patients with possible or suspected vascular injuries, diagnostic studies may be necessary. Patients
need imaging if there are abnormal pulses, Doppler signals, or ankle brachial indexes, the recipient
vessels are located in the zone of injury, there is an extensive injury with a high-energy mechanism, or the
patient has preexisting arterial disease. 10 Occasionally, imaging will elucidate injuries on patients who
had a normal clinical examination. 10 Angiographic imaging can help determine which regional muscles
are appropriately vascularized and usable for coverage and can determine which vessels are uninjured
and available for free flap inflow. 10 This can be particularly useful if the anterior tibial artery might be
needed, as it is superficial and has the highest rate of injury, so imaging would help determine its
viability. The final and most important benefit of preoperative imaging is the ability to visualize the blood
flow to the lower extremity. 10 If there is three-vessel runoff, an end-to-end anastomosis is possible,
whereas if there is only one vessel flow, an end-to-side anastomosis is mandatory.
There are two options if imaging of the lower extremity vasculature is necessary—computed tomography
angiogram (CTA) and formal angiography. The benefits of CTA are ease of imaging, cost-effectiveness,
and low complication rate. It is less invasive and uses less contrast and radiation than traditional
angiography. CTA also shows other anatomical information relative to the soft tissues, veins, and bones,
while it also shows information about stenosis and obstruction. Formal angiograms are more expensive
and invasive, but they may be necessary if CTA has too much scatter from hardware. Formal angiograms
are particularly helpful in vasculopaths and patients requiring concomitant vascular reconstruction. 10
mebooksfree.net

Comorbidities
Many patients have comorbidities that can compromise or complicate their care. Particularly in the case
of the lower extremity, diabetes and vascular disease are important to understand and manage.
mebooksfree.net

Diabetes
Twenty-four million Americans have diabetes mellitus, many of whom will end up with a wound or a
foot ulcer during their lifetime. Major amputation is a risk factor for morbidity and mortality in this
patient population. Using flaps for limb salvage can therefore affect their long-term survival. However,
there is often nihilism surrounded reconstructing this population. This stems from high complication
rates due to small-vessel disease, hyperglycemia, neuropathy, and noncompliance. Hyperglycemia inhibits
white blood cell phagocytosis and increases postoperative complication rates. Diabetic patients need to
have optimized glucose before and after surgical procedures. 4 Neuropathy leads to sensory loss, muscle
atrophy, Charcot arthropathy, anhidrosis, and increased risk of wounding and ulceration. Reconstruction
is a challenge because the wound bed tends to have decreased vascularization, making it difficult for skin
graft take. Local flaps tend to be unreliable in this patient population as the area tends to be scarred.
Pedicled flaps also have a higher complication rate in this population, although they also have a higher
rate of success than extremity free flaps in these patients. 12 Microsurgery can be very difficult as local
vessels are needed for inflow and tend to be calcified. 13
mebooksfree.net

Vascular Disease
Patients with vascular disease require imaging (either CTA or angiogram) to assess their vascular inflow
before a reconstruction is attempted. 4 Ischemic limbs where no major vessel runoff is evident or those
that are severely calcified cannot be used as recipient vessels. 13 These patients may require
revascularization procedures first. Although they are higher risk, reconstruction has been successful even
when performed simultaneously with a vascular bypass procedure.
mebooksfree.net

Smoking
Smoking has a deleterious effect on perfusion and healing. Smokers have longer healing times and have
higher rates of infection, nonunion, and osteomyelitis. Smoking also increases the rate of thrombosis with
lower extremity reconstruction. 1,4
mebooksfree.net

Radiation
Radiation causes an inflammatory and vascular insult to tissues, which has a detrimental effect on donor
vessels. 4 Radiated vessels are also technically challenging to use as donor vessels, as the walls are friable,
inelastic, and difficult to suture.
mebooksfree.net

Steroids
Steroids are immunosuppressive and have a negative impact on wound healing. These effects can be
lessened with the use of 
 vitamin A.
mebooksfree.net

Salvage Versus Primary Amputation
In the trauma population, the decision to proceed with primary amputation versus proceeding with
reconstruction can be very difficult to make. The decision should be made on an individual basis by
considering the patient’s occupation, age, associated injuries, and socioeconomic status. 8 Multiple scoring
systems have been developed to attempt to make the decision clearer. The Lower Extremity Assessment
Project was a randomized, prospective trial carried out at eight trauma centers, developed to determine
who would benefit from salvage versus who would not. Microvascular techniques and external fixation
can typically result in a successful salvage. However, patients who failed extremity salvage suffered more
complications and some ultimately underwent amputation. Primary amputation in these patients would
have avoided prolonged, costly, and futile procedures. The study evaluated existing injured extremity
scoring systems but found that these scoring systems were effective in determining which limbs could be
salvaged but could not predict who would fare better from primary amputation. 1,8,14,15 Lower Extremity
Assessment Project showed that a patient’s ability to function afterward was more attributed to their
functional ability before trauma, regarding their social, economic, and personality disadvantages.
Reconstruction does come with a higher rate of complication and rehospitalization rate than amputation,
with 4% ultimately ending in amputation. Absent plantar sensation at presentation was not an indicator
for amputation or functional outcome. Results 2 years after trauma show equivalent outcomes for those
who underwent amputation versus those who underwent reconstruction, for patients with equivalent
Sickness Impact Profiles. 14,15
Making the decision to amputate on a case-by-case basis is also recommended. However, there are
several prognostic factors for limb salvage to consider. There is a linear relationship between time to
revascularization and limb loss (longer than 8 hours warm ischemia time is an indication for amputation).
Patients with high-velocity penetrating injuries and blunt injuries have worse outcomes. Associated
injuries and comorbidities should be considered. Those presenting with a cadaveric foot, severe tibial or
sciatic nerve injury, severe polytrauma, shock, or extremis, and those with failed revascularization
procedures will benefit from primary amputation. 1,4,7
Replantation is usually not performed because prostheses can make a functional lower limb. However,
replantation can be considered if there is minimal warm ischemia time and a durable, sensate, and
painless foot seems possible. 8
mebooksfree.net

Reconstructive Planning
Plastic surgeons become necessary to aid in the reconstructive process in patients who have fractures
with overlying soft-tissue loss. 10 Patients who have Gustilo IIIB and IIIC injuries necessitate lower
extremity reconstructive surgery. 6 Early involvement by plastic surgeons helps in incision planning, or
access to flaps or vessels necessary for the reconstruction. The so-called orthoplastic approach or the fix and
flap approach may help decrease the wounds created for reconstruction and lead to earlier coverage. 9,10
Goals of the reconstruction are to promote fracture healing, prevent osteomyelitis, restore function,
optimize aesthetics, and enhance conduct of secondary procedures. 10
mebooksfree.net

Timing of Reconstruction
Marko Godina 11 showed that early flap closure (within the first 72 hours) of open tibial fractures leads to
a lower flap failure rate, lower infection rate, quicker healing times, and shorter hospital stays. 4,8 His
study grouped the patients according to when their reconstruction was performed:
Early reconstruction: within first 72 hours
Delayed reconstruction: between 72 hours and 3 months
Late reconstruction: >3 months after injury
He then assessed infections, flap failure rates, number of anesthetics, hospitalization time, and time to
healing. The early reconstruction group had the fewest flap failures and infections with shorter
hospitalizations, decreased time to bone healing, and fewer anesthetics, indicating that this was the ideal
time frame for flap closure (Table 96.2). 11
TABLE 96.2
How Timing of Free Flap Coverage Affect Outcome in the Treatment of Open Fractures11
Timing
Failure Rate
Infection Rate
Bone Healing Time
Hospital 

Time
<72 h
1%
2%
68 mo
27 d
72 h to 3 wk
12%
18%
123 mo
130 d
>3 wk
10%
6%
29 mo
256 d
Although Godina’s work ushered in a new paradigm in lower extremity reconstruction, it is not always
possible or necessary to obtain coverage in the first 72 hours. Wounds must be adequately debrided, and
in some instances, this requires several serial operations. 4 If there is a question of tissue viability, a staged
approach with a planned second operation or serial operations is warranted. 9 However, exposed critical
structures (vessels and nerves) require immediate coverage. 4 Although early coverage decreases
infection, fibrosis, and edema that make reconstruction more challenging, it is not always feasible because
of concomitant injuries or delayed referral. In these patients, damage control orthopedics model with
temporary fixation and secondary management can be useful. In this patient population, provisional
closure can be obtained with a wound vacuum, which will decrease edema and fibrosis (and extremity
circumference) and increase granulation tissue. Use of the vacuum device simplifies wound care until
definitive closure, increasing sterility and decreasing the frequency of dressing changes. Use of this
technology can allow for free flap reconstruction outside the 72-hour window with an acceptable
complication rate. 16
mebooksfree.net

Management of Bone Gaps
Patients who have bone loss, as the result of trauma or tumor extirpation, have several treatment options,
with the size of the bony defect predictive of the type of reconstruction used. 4,8 Patients with lesions less
than 6 cm can be treated with traditional, or nonvascularized, bone grafts, whereas those with greater
than 6 cm loss should undergo distraction osteogenesis or a vascularized bone graft (free flap). 4,6,9
Conventional bone grafting heals by creeping substitution. As a result, it can be limited by significant
graft resorption, even in a well-vascularized recipient site. 17,18 Cancellous grafts are preferred and are
usually placed about 6 weeks after coverage to fill the bony defect or used to supplement osteosynthesis
sites. 8 To mitigate graft resorption, the Masquelet, or induced membrane technique, can be instituted.
This is a two-stage technique that stimulates membrane formation for graft placement. A foreign body (in
this case, an antibiotic impregnated cement spacer) is placed in the bony defect and left for several weeks
causing a pseudosynovial membrane to form. This membrane is similar to a capsule around a breast
implant, and it helps maintain length and space of the defect, prevents fibrous ingrowth and infection,
and creates a vascularized space for the graft. At 4 to 12 weeks after spacer placement, the second stage is
performed and the spacer is removed and a cancellous bone graft (likely from the iliac crest) is placed.
This method gives the soft tissues or soft-tissue reconstruction time to heal before definitive bony
reconstruction and provides vascularization and growth factors to aid in bone graft healing and prevent
resorption. This method leads to union in 90% of cases. 4,17,19
Intercalary transport was first successfully used by Ilizarov in 1943. 20 Intercalary transport can be used to
correct malunion or nonunion, used immediately after shortening and corticotomy and coverage to
regain length, or used as the definitive external fixator. 21 It is an alternative to free flaps for large bony
defects and may be preferential in one-vessel extremities; however, its use is best tolerated in defects of 4
to 8 cm. Ilizarov transport works by placing a dynamic frame and using a combination of osteotomy and
transport segment distraction osteogenesis. The transport segment is moved toward the defect to fill the
space. An osteotomy can be created on both the proximal and distal bone segments, using two transport
segments moving toward each other. The frame enables lengthening of the bone segments, while
maintaining length and alignment of the extremity, and with simultaneous stretching of the soft-tissue
envelope tissue. 1,8,22 The device requires long periods of treatment, pain with the transport, risk of pin site
infections, and risks nonunion at the docking site. 19
The final method of managing bone gaps, particularly those greater than 6 cm, is with vascularized bone
grafts. These can be either pedicled (ipsilateral fibula), but are more commonly performed as free flaps 9
(Table 96.3). The free fibula graft was first described by Dr. Taylor in 1975. 23 This is an ideal
reconstruction as the bone remains organized, does not resorb, and can hypertrophy to increase strength.
23 Large segments can be transferred with retaining osteocyte and osteoblast viability because the nutrient
blood supply remains intact, creating a potential for primary healing, with improved healing times and
strength. 18,23 The fibula is ideal, as it can be taken from the contralateral leg, has a reliable blood supply
from the peroneal artery, and can be taken as a chimeric flap with a skin paddle or muscle as needed. 6
The pitfalls of using a free flap are flap failure (necrosis and anastomotic failure), donor site morbidity
(operating on the uninjured or unaffected leg), and the risk of stress fractures. 19 Other options for bony
free flaps can be taken from the iliac crest, scapula, or medial femoral condyle (Figures 96.5 and 96.6).
TABLE 96.3
Commonly Used Bone Free Flaps
Flap
Blood Supply/Pedicle
Size
Common Use/Advantages
Caveats/Disadvantages
Scapula
Thoracodorsal or
circumflex scapular
systems
10 × 1–
2 cm
Multiple options to make
chimeric flaps
Lateral positioning
mebooksfree.net

Fibula (see Figure 96.5)
Peroneal artery
Long
Good length, pedicle
Can have skin paddle and can
take muscle
Ability to hypertrophy
Requires use of
uninjured leg
Iliac crest
Deep circumflex iliac
vessels
15 × 6 cm
Large bone, has cancellous with
it, can be uni or bicortical
Risk of hernia
Medial geniculate/medial femoral
condyle (see Figure 96.6)
Descending genicular
artery
3 × 2 cm
Good vascularized cancellous
bone
Good for nonunions
Not for bone gaps
>4 cm
FIGURE 96.5 This is a patient with avascular necrosis of the head of the femur who was treated with a free fibula. A. Initial X-
ray. B. Initial magnetic resonance imaging. C. Elevation of the fibula. D. Prepared fibula. E. Fibula in situ. F. Final X-ray
showing fibula in situ.
mebooksfree.net

FIGURE 96.6 This is a patient with avascular necrosis of the tibiotalar joint. He was treated with a medial femoral condyle free
flap. A. The defect after debridement of necrotic bone. B. Markings for the medial femoral condyle free flap. C. Elevation of the
flap and skin paddle. D. On table result.
mebooksfree.net

Soft-Tissue Management
Soft-tissue injuries are typically best managed with local available tissues; however, the nature of the
defect and the state of the other local muscles (which may have also been traumatized) will dictate the
reconstructive needs. 1 The goal is to reconstruct with tissues that have similar properties. 4 As previously
mentioned, all defects need to be adequately prepared and debrided before coverage is attempted and all
associated fractures need to be stabilized. The reconstructive ladder is useful in guiding reconstructive
choices because it is a stepwise technique for closure of wounds that mandates starting with the simplest
possibility and moving to more complicated procedures only when required. 24 The first step of the
reconstructive ladder is primary closure and the final rung of the ladder is free flap reconstruction, with
skin grafts, local flaps, and regional flaps in between. 9 Occasionally reconstructive elevator should be
utilized, using a more complex reconstructive option to maximize the final result, and may be a better
way to describe it, and progression is based on what will offer the best form and function. 4,24
mebooksfree.net

Skin Grafts
For many small wounds that cannot be closed primarily and do not have critical structures exposed, skin
grafting can be a simple solution. Skin grafts are particularly useful for foot coverage, especially on the
non-weight-bearing aspects of the foot. 1
mebooksfree.net

Local Flaps
A variety of local flaps can be used based on the location in the extremity. Fasciocutaneous flaps can be
very useful for wound closure and offer the advantage of not risking functional loss with muscle use. The
most commonly used fasciocutaneous flaps are described below.
mebooksfree.net

Reverse Sural Artery Flap
The reverse sural artery flap is supplied by perforators from the peroneal artery and can be a sensate flap
if the sural nerve is included with flap harvest. 1,10 The perforators are usually found about 5 to 6 cm
above the lateral malleolus and are supplied by retrograde flow, so a design with a wide pedicle and a
generous arc of rotation are needed to preserve flow 1,10,25 (Figure 96.7). The lesser saphenous vein needs
to be included in the flap for venous outflow, and a delay procedure may improve viability in high-risk
patients. 4 Maximal flap sizes can be 20 cm by 12 cm. 25 This flap can be good for heel coverage in high-
risk patients. However, it has a high complication rate and lower aesthetic appeal. 1
FIGURE 96.7 This is a patient with an exposed Achilles tendon treated with a reverse sural artery flap. A. Initial wound. B.
After debridement. C. After flap elevation. D. After flap inset and skin graft. E. Final healed result.
mebooksfree.net

Lateral and Medial Calcaneal Artery Flaps
These are fasciocutaneous flaps good for small defects of the malleolar area or plantar heel region. They
are based on terminal branches of the peroneal (lateral flap) and posterior tibial (medial flap) arteries
(Figure 96.8). The sural nerve can be included for sensation, and the abductor hallucis muscle can be
included with the medial flap. 1,25
FIGURE 96.8 Location of perforators of the lower extremity.
mebooksfree.net

Keystone Flap
The keystone flap is a trapezoidal-shaped fasciocutaneous perforator flap, which is essentially made of
two V-Y flaps on either end (Figure 96.9). It fits well into body contours and can reconstruct larger
defects. The borders of the defect are extended on either side to 90° angles, the width of the flap is similar
to the widest portion of the flap. The deep fascia is cut to allow advancement and superficial nerves and
veins are incorporated into the flap design. 4,26
FIGURE 96.9 Keystone flap. A. Red area shows the defect, and the skin tone area is the flap design. The flap is cut only
through the skin and subcutaneous tissues. If needed for mobility, the deep fascia of the far outer curve can be cut, with care
taken not to sacrifice any perforators. B. The flap is advanced into the wound, with V-Y advancements used to close the
superior and inferior positions. C. Appearance of closed wound.
mebooksfree.net

Propeller Flap
Propeller flaps are a perforator-based local adipocutaneous flap. They can be designed off of a known
source vessel or in a free-style fashion over a perforator found by Doppler. They can be rotated up to 180°
to fill the defect. 27
mebooksfree.net

Instep Flap
The plantar instep flap can be used as a fasciocutaneous island flap or as a free flap. It comes from the
non-weight-bearing aspect of the plantar foot but provides similar tissue quality as the weight-bearing
surface. It is most commonly based on the medial plantar artery (although laterally basing is possible as
well) and can maintain sensation through the medial plantar nerve. This flap is ideal for plantar heel
reconstruction. 28
mebooksfree.net

Cross-Leg Flap
With the widespread use of microsurgery, a cross-leg flap is rarely indicated. However, if the patient has
no local donor sites, they lack appropriate inflow for a free flap, or are otherwise not a free flap candidate,
a cross-leg flap is an option. The flap is fashioned on the opposite leg and transferred with a length-to-
width ratio of 3:1. It requires prolonged immobilization and is not practical unless there are no other
options. 29 Rarely, a free flap version of the cross-leg flap can be performed when there are no appropriate
vessels for anastomosis in the injured leg.
mebooksfree.net

Random Pattern
Other flaps can be used as well for smaller wounds. Standard V-Y advancement flaps or random pattern
flaps can be utilized. Random pattern flaps should maintain a length-to-width ratio of 3:1. 1
mebooksfree.net

Muscle Flaps
Local muscle flaps tend to be preferable for lower extremity reconstruction; however, their viability must
be confirmed before use. 1 They are highly vascularized, good for filling dead space, and improve local
defenses to decrease infection. 6 Many muscles are available for lower extremity reconstruction and are
listed in Table 96.4 by location.
TABLE 96.4
Local Muscle Flaps for Foot and Ankle Reconstruction
Muscle
Blood
Supply/Pedicle
Mathes and

 Nahai Type
Common Use/Advantages
Caveats/Disadvantages
Abductor digiti
minimi (see Figure
96.12)
Lateral plantar
artery
II
Useful for lateral ankle and
calcaneal defects
Loss of abduction and flexion of fifth
toe
Abductor hallucis
Medial plantar
artery branches
II
Useful for medial midfoot, heel,
and ankle defects
Loss of great toe abduction and foot
spring
Extensor digitorum
brevis
Dorsalis pedis
I
The malleoli, lateral and medial
calcaneus, and pretibial region
Only dorsal foot muscle
Requires sacrifice of the dorsalis pedis
artery
Extensor digitorum
longus
Anterior tibial
artery
IV
Middle third
Requires care not to damage superficial
peroneal nerve
Extensor hallucis
longus
Anterior tibial
artery
IV
Middle third
Cannot be completely sacrificed
Requires care not to injure the extensor
digitorum communis tendon
Flexor digitorum
brevis
Medial plantar
artery
II
Useful for plantar heel defects
Minimal donor site morbidity
Very small volume and sometimes
requires an additional flap
Flexor digiti minimi
Lateral plantar
artery
IV
Useful for lateral foot
Small with limited arc of rotation
Flexor digitorum
longus
Posterior tibial
artery
IV
Middle third
Functional defect if taken with
Peroneus brevis
Peroneal artery
II
Distal third, fibula
Need to keep peroneus longus intact
for eversion
Peroneus longus
Peroneal artery
II
Distal third, fibula
Need to keep peroneus brevis intact for
eversion
mebooksfree.net

Free Flaps
The lower extremity can be a difficult area to reconstruct, as associated vascular injuries can make local
tissues unusable, and there are increased rates of flap thrombosis (about 10%). It is always necessary to
perform the anastomosis outside the zone of injury, which may require vein grafts or arteriovenous
loops, and can be performed either proximal or distal to the injury. 1,4,8,30 However, the paucity of local
tissues and functional requirement of the lower extremity frequently require bringing healthy tissue from
a distant location, via free flap and microsurgery. 9 These techniques are applied for complex
reconstructions, such as sensate flaps, functional muscle flaps, composite flaps with tendons, and flow
through flaps for concomitant vascular repair, and are preferred if a large amount of tissue is required. 1,9
Because very large free flaps can be designed, they are also ideal for reconstructing a large tumor
resection wound or after the removal of infected tissue. 6
Anastomoses can be performed either end to end or end to side. Godina encouraged end-to-side
anastomosis because it prevented disruption of the distal perfusion, and this remains the preferred choice
in an extremity at risk for vascular insufficiency. When the recipient vessel is no longer in continuity from
trauma, the anastomosis may be performed end to end. Importantly, the complication profile is similar
with either type of anastomosis. Depending on the needs of the patient and the reconstruction, the patient
can be positioned lateral decubitus, which is preferable for latissimus or subscapular flap access, or
supine if other flaps are chosen. Positioning will determine which access is preferable to expose the donor
vessels, whether it be posterior, lateral, or medial. 30
mebooksfree.net

Muscle/Myocutaneous Flaps
Historically, muscle flaps were the preferred treatment for lower extremity reconstruction. They are good
at filling dead space, they bring additional blood supply, and they are flexible for ease of inset. It was
thought that muscle was superior to fasciocutaneous flaps for fracture healing and infection prevention,
but this theory has been disproven. 1,8,10
mebooksfree.net

Fasciocutaneous Flaps
Fasciocutaneous free flaps are preferable for many reasons; most notably, they minimize deficits by
sparing muscles. These flaps are better for resurfacing as they restore contour without added bulk and
can be treated with liposuction to improve contour. Fasciocutaneous flaps are easier to raise for
secondary procedures. 8,10
mebooksfree.net

Reconstructive Choice by Location
The goal of reconstruction is to achieve soft-tissue coverage to aid the skeletal reconstruction, replacing
like with like when possible. It is necessary to preserve both sensory and motor function in order to
ambulate. To make the best reconstructive decision, the defect size, tissue deficit (types of tissues lost),
location, length of vascular pedicle needed, and state of the wound have to be considered. 4,8,10 This is best
approached by looking at the extremity by regions.
mebooksfree.net

Thigh
The thigh is the least challenging area of the extremity to reconstruct. There is a large bulk of muscle to
provide vascularized tissue. Typically, there are limited functional demands on the tissue other than
coverage. In most cases, remaining muscle or fascia can be covered with skin grafts. Otherwise, a local
muscle flap can be used to cover critical structures (like the femoral vessels) which then can be skin
grafted. 1,4,10
mebooksfree.net

Knee and Proximal Third of Leg
Tissue in this area needs to remain thin for flexion at the knee. Generally, the upper third can be
reconstructed with local flaps, minding the need to preserve the extensor function. The calf itself is mostly
muscle in the upper third, so typically the only functional demand of the reconstruction is coverage. The
tibia is just covered with skin, so the anterior part of the reconstruction needs to be thin. In this area, the
gastrocnemius is the typical choice for reconstruction and is usually used as a muscle-only flap and
covered with a skin graft. Secondary options include proximally based soleus (Figure 96.10), bipedicled
tibialis anterior, and distally based pedicled anterolateral thigh (ALT) or vastus lateralis flap. 1,4,6,9,10
FIGURE 96.10 Open tibial fracture treated with soleus flap coverage. A. Initial wound. B. Soleus flap elevation. C. Immediate
result after skin graft. D. Final healed result.
mebooksfree.net

Middle Third of Leg
The middle third of the leg is more difficult to reconstruct, as available options are likely to have been
damaged by trauma. However, the classic option is a soleus flap. Other local flaps available include the
gastrocnemius, flexor digitorum longus, extensor digitorum longus, extensor hallucis longus, tibialis
anterior, and flexor hallucis longus. Large defects in this area require treatment with a free flap. 1,4,6
mebooksfree.net

Distal Third of Leg
The distal third of the leg is the most challenging part of the leg to reconstruct, as there is minimal
available local tissue for coverage. Characteristically, this area requires a free flap for reconstruction.
However, small volume closures can be treated with flexor hallucis longus, flexor digitorum longus, and
tibialis anterior. In patients who are not free flap candidates, a distally based soleus or a reverse sural
artery flap may be options, but both have high complication profiles. Flaps that are situated near the
ankle and foot need to have appropriate contour so that the foot can still comfortably accommodate a
shoe flap 1,4,6,25 (Figure 96.11).
FIGURE 96.11 Example of a free latissimus with skin graft. This was a patient with an open tibial fracture treated with a plate.
A. Image of the wound and plate. B. Zoomed in image of the wound. C. Immediate postoperative image of the latissimus flap
with skin graft. D. Healed result at 6 months.
mebooksfree.net

Foot
Like the distal lower leg, the foot is also a difficult area to reconstruct, and it is prone to injury and
disease. It is best to think about foot reconstruction by subunits to obtain the best functional and aesthetic
results. Generally, small wounds of the foot are best reconstructed with local muscle flaps (Figure 96.12).
The whole plantar foot has glabrous skin and needs to withstand weight-bearing and shear. The dorsal
foot needs to remain contoured to fit a shoe (Figure 96.13). Hollenbeck et al. created a subunit list and
discussed flaps that best fit (Figure 96.14, Table 96.5). 6,10
FIGURE 96.12 Abductor digit minimi and abductor hallucis brevis muscle flaps.
mebooksfree.net

FIGURE 96.13 This patient with a gunshot wound to his foot was treated initially with an antibiotic spacer to preserve his
metatarsal space and a medial sural artery perforator flap. A. Initial wound. B. Flap marking. C. Flap elevation showing the
perforator. D. Immediate postoperative result. E. Healed result before final bone grafting.
mebooksfree.net