Phẫu Thuật Tạo Hình (Tập 4): Chi Dưới, Thân Mình Và Bỏng – Neligan (2018)

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Outcomes, prognosis, and complications
remnants of the patellar tendon to reconstruct knee
extension. The postoperative course was uneventful with the
exception of a small wound dehiscence applicable for
conservative local wound care at the midabdomen flap
harvest site. The patient underwent radiation therapy as well
as chemotherapy due to metastases in the lung. Two years
postsurgery the patient was able to extend his leg and had
no recurrence of the tumor or the metastases in the lung
(Fig. 4.6I).
Case 4.4 (Fig. 4.7)
A 6 × 7 × 5 cm large painless mass was detected in the right
calf of this 31-year-old male patient. Contrast-enhanced MRI
showed a lesion highly suspicious for a soft-tissue sarcoma.
This diagnosis was confirmed by a longitudinal incision
biopsy according to oncologic guidelines, and the definitive
tumor resection was planned (Fig. 4.7A). The tumor
resection was performed according to international
standards for wide excision to leave a cuff of tissue
surrounding the tumor of at least 2 cm to the depth and at
least 4 cm to the sides (Fig. 4.7B & C). Due to encasement of
the posterior tibial vessels and the tibial nerve by the tumor,
they had to be resected as well (Fig. 4.7D). The tibial nerve
was immediately reconstructed microsurgically by a free
sural nerve harvested from the contralateral side (Fig. 4.7E &
F). The sural nerve was doubled as a cable graft to allow
cross-sectional matching to the tibial nerve and was set at
180° to improve neurotization. The resection defect was
controlled for a perfect hemostasis, and drains were placed.
As the tumor provided a “tissue-expansion-like” stretching
of the calf, the wound could easily be closed primarily
without having relevant dead spaces or skin “tenting” over
unsupported wound cavities (Fig. 4.7G). Further follow-up
showed uneventful healing and recurrence of sensation at
the plantar side of the foot after 2 years.
Case 4.5 (Fig. 4.8)
A 70-year-old female complained of a painless mass in the
lower extremity (Fig. 4.8A). The preoperative MRI imaging
showed a tumor in the posterior and lateral compartment
that also affects the fibula (Fig. 4.8B). Due to the overall age
and the amount of resection, which included the peroneal
vessels, a preoperative angiogram was done demonstrating a
well-vascularized tumor as well as appropriate vessels for a
free tissue transplantation and limb perfusion (posterior
tibial vessels, Fig. 4.8C). After an incisional biopsy, which
demonstrated a liposarcoma G2, the planned resection was
outlined (Fig. 4.8D) and a 13 × 11 cm specimen resected en
bloc including a fibula segment (Fig. 4.8E & F). The defect
was closed with a free fasciocutaneous parascapular flap,
and radiation therapy was initiated. After 2 years, the
patient was doing well without any metastases or local
tumor recurrence (Fig. 4.8G).
Case 4.6 (Fig. 4.9)
Fig. 4.9A shows the foot of a 51-year-old-female with a mass
5 × 5 cm at the dorsum of the right foot. Diagnostic MRI
demonstrated a tumor that encased the extensor tendons of
the first ray (Fig. 4.9B). The incisional biopsy (Fig. 4.9C)
a free functional musculocutaneous latissimus dorsi flap was
harvested (Fig. 4.4E) and connected to local vessels. Nerve
coaptation was done to a branch of the femoral nerve close
to the groin that could be spared from the resection. The
muscle transplant was fixed at the anterior superior iliac
spine, and the remaining vastus medialis head and its
tendon were woven into the quadriceps tendon and fixed
securely with 1-0 non-resorbable sutures. To assist leg
function until the latissimus muscle was reinnervated, we
simultaneously also transferred a functional biceps femoris
flap through a separate posterior incision (Fig. 4.4F) around
the distal lateral femur and sutured it into the new
latissimus–quadriceps–tendon extensor apparatus with an
adequate pretension. The muscle bulk of the latissimus
easily obliterated the space of the resected quadriceps
muscle, while the skin island served for tension-free closure
of the integument. For protection of the tendomuscular
reconstructions, an external fixator across the knee
was applied for 6 weeks. Healing was uneventful, the
pathology showed clear and adequate margins
(R0-situation). The fixator was removed in an outpatient
procedure and physiotherapy begun. At 3 months after
the resection and simultaneous reconstruction procedure,
the patient showed an almost completely normal gait
(Fig. 4.4G & H).
Case 4.2 (Fig. 4.5)
This 48-year-old male patient was referred to us with a
horizontal (non-oncologic) incision of the right anterior
lower leg (Fig. 4.5A & B) after a non-oncologic resection of
an MFH leaving positive margins (R1) elsewhere.
Re-operation with a wide excision (9 × 8 cm) (Fig. 4.5C & D)
was performed in our center and the defect closed with a
pedicled medial gastrocnemius muscle flap (Fig. 4.5E) and
split-thickness skin graft from the ipsilateral thigh. Histology
now showed adequately wide and clear margins of this R0
resection. Further healing was uneventful. Fig. 4.5G & I
demonstrate follow-up results at 3 months after flap
transposition and defect closure.
Case 4.3 (Fig. 4.6)
This 56-year-old male patient demonstrated a large
intramuscular tumor highly suspicious of a soft-tissue
sarcoma in the proximal left thigh close to the groin. His
clinical complaints were swelling and pain over 6 months.
MRI demonstrated close proximity to the superficial femoral
vessels; however, the femoral nerve could not be identified
in the MRI (Fig. 4.6A & B). The incisional biopsy showed a
highly malignant synovial-cell sarcoma (G3). After
preoperative planning in the tumor board, a wide resection
including most of the extensor muscles (Fig. 4.6C) was
performed according to oncologic guidelines, yielding a
23 × 18 × 20 cm large tissue specimen including the tumor
(Fig. 4.6D & F). The femoral nerve was encased by tumor
tissue and required resection according to oncologic
principles. From the contralateral abdomen, a pedicled
vertical musculocutaneous rectus abdominis muscle (VRAM)
flap (30 × 18 cm) was harvested and transferred into the
defect (Fig. 4.6G & H). Additionally, the biceps femoris as
well as the semitendinosus muscles where transferred to the

110
SECTION I
CHAPTER 4 • Lower extremity sarcoma reconstruction
A
B
C
D
E
F
Fig. 4.5  (A,B) Clinical situation on admission
after non-axial (i.e., non-oncologic) incision
biopsy and secondary non-oncologic resection of
a malignant fibrous histiocytoma (MFH) with
positive margins (R1) elsewhere. (C) Clinical
situation after wide R0 excision (9 × 8 cm).
(D) Excised specimen including the scar
of the former biopsy and primary resection.
(E) A pedicled medial gastrocnemius muscle flap
was used for closure. (F) Serial incision of the
muscle tendon and fascia was performed to
expand the reach of the flap and to allow supple
wound closure. (G–I) Clinical result 3 months after
resection and flap closure.
G
H
I

111
Outcomes, prognosis, and complications
A
B
C
D
E
F
Fig. 4.6  (A,B) Large intramuscular tumor highly suspicious of a soft-tissue sarcoma in the proximal left thigh close to the groin with close proximity to the superficial
femoral vessels; however, the femoral nerve could not be identified in the MRI. (C) After the incisional biopsy, wide resection including most of the extensor muscles was
planned. (D,E) Resection specimen 23 × 18 × 20 cm including the tumor. (F) The femoral nerve was encased by tumor tissue and had to be resected according to
oncologic principles.
Continued

112
SECTION I
CHAPTER 4 • Lower extremity sarcoma reconstruction
G
H
I
(G) A contralateral pedicled vertical musculocutaneous rectus
abdominis muscle flap (30 × 18 cm) was harvested. (H) Flap closure of the defect.
(I) Clinical picture 2 years after surgery.
Fig. 4.6, cont’d
confirmed an MFH G2. A wide excision including the
extensor tendons of the first ray, the dorsal half of the first
and second metatarsal bones, as well as the capsule of the
metatarsophalangeal joint 1 was performed (Fig. 4.9D). Due
to the resulting instability of this joint of the first ray an
immediate arthrodesis was carried out and the defect
covered with a free ALT perforator flap. One year after the
operation and radiation therapy the patient was tumor free
and able to walk and exercise (Fig. 4.9E).
Case 4.7 (Fig. 4.10)
The patient was a 12-year-old girl with an osteosarcoma of
the right distal femur (Fig. 4.10A). She received four cycles
of neoadjuvant chemotherapy consisting of doxorubicin and
intra-arterial cisplatin. A total segment of 15 cm was then
resected from the femur, with the distal transepiphyseal cut
3 cm proximal to the lateral joint line of the knee. A 2 cm
fibula bone flap was harvested (Fig. 4.10B). The bone defect
was repaired with an intercalary allograft and a vascularized
fibula bone flap placed into the medullary canal of the
allograft (Fig. 4.10C). The vascular pedicle of the fibula flap
was brought out through a side hole burred into the
allograft. The allograft was fixed to the native bone with a
12-hole lateral locking plate (Fig. 4.10D). Proximally, 4 cm of
vascularized fibula bone flap was inserted into the host
femur; and, distally, 2 cm of fibula flap was inserted into the
host femur (Fig. 4.10E). Microvascular anastomoses were
performed end-to-end to branches of the femoral artery and
vein.
Postoperatively, the patient received two additional cycles
of chemotherapy. At 2 months, radiographs showed signs of
healing with no complications, and touch weight-bearing
was started. At 5 months, radiographs showed a small
amount of callus formation and remodeling at the proximal
and distal allograft-host junctions (Fig. 4.10F). The patient
was allowed partial weight-bearing on the leg with a limit of
10–20 pounds. Another 6 months later, the patient
progressed to full weight-bearing, with the restrictions of no
running and no sports activity until full radiographic union
(Fig. 4.10G).
(Case courtesy of David W. Chang, MD, MD Anderson Cancer Center,
Houston, TX, USA).39

A
B
C
D
E
F
Fig. 4.7  (A) A 6 × 7 × 5 cm large painless mass in the right calf suspicious for a soft-tissue sarcoma. A longitudinal incision biopsy according to oncologic guidelines and
the definitive tumor resection was planned. (B,C) The tumor resection was performed according to international standards for wide excision to leave a cuff of tissue
surrounding the tumor of at least 2 cm to the depth and at least 4 cm to the sides. (D) Posterior tibial vessels and tibial nerve were encased and had to be resected as well.
(E,F) The tibial nerve was immediately reconstructed microsurgically by a free sural nerve harvested from the contralateral side. The sural nerve was doubled as a cable
graft to allow cross-sectional matching to the tibial nerve and was set at 180° to improve neurotization. (G) Postoperative view after primary closure without having relevant
dead spaces or skin “tenting” over unsupported wound cavities.
G

114
SECTION I
CHAPTER 4 • Lower extremity sarcoma reconstruction
A
B
C
D
E
Fig. 4.8  (A) Clinical picture of a painless mass in the right lower extremity. (B) Preoperative MRI showing a tumor in the posterior and lateral compartment also affecting
the fibula. (C) Preoperative angiogram demonstrating a well-vascularized tumor including the peroneal vessels. (D) After an incisional biopsy, which demonstrated a
liposarcoma G2, the planned resection was outlined. (E) En bloc resected, 13 × 11 cm large specimen including a fibula segment.

F
G
(F) The tumor was not seen during surgery and was covered well with muscle according to adequate tumor margins. (G) Clinical picture 2 years after
free parascapular flap closure.
Fig. 4.8, cont’d
A
B
Fig. 4.9  (A) A 51-year-old-female with a 5 × 5 cm large mass at the dorsum of the right foot. (B) Preoperative MRI showing encasement of the extensor tendons of the first
ray. (C) Clinical picture after incisional biopsy. (D) Clinical picture after wide excision including the extensor tendons of the first ray, the dorsal half of the first and second
metatarsal bone, as well as the capsule of the metatarsophalangeal joint 1. (E) One year after the operation and radiation.
C
D
E

116
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CHAPTER 4 • Lower extremity sarcoma reconstruction
Fig. 4.10  (A) The right distal femur of a 12-year-old girl showing an osteosarcoma. (B) A 21 cm fibula bone flap was harvested. (C) The 15 cm long intercalary allograft
and a vascularized fibula bone flap placed into the medullary canal of the allograft. (D) Fixation of the allograft with a 12-hole lateral locking plate. (E) Postoperative
radiograph. Proximally, 4 cm of vascularized fibula bone flap was inserted into the host femur diaphysis and, distally, 2 cm of fibula flap was inserted into the host femur
metaphysis. (F) Radiograph 5 months later, showing a small amount of callus formation and remodeling at the proximal and distal allograft–host junctions. (G) Radiograph
after 11 months before progression to full weight-bearing. (Fig. 4.10D: Courtesy of Dr. David W. Chang, Department for Plastic Surgery, MD Anderson Cancer Center,
Houston, TX.)
A
B
C
D
E
F
G

117
Outcomes, prognosis, and complications
1. Weitz J, Antonescu CR, Brennan MF. Localized extremity soft tissue
sarcoma: improved knowledge with unchanged survival over time.
J Clin Oncol. 2003;21(14):2719–2725. This comprehensive single
institution overview analyzes the risk factors of soft-tissue sarcoma
treatment in 1261 patients.
6. Enzinger FM, Weiss SW. Soft Tissue Tumors. 3rd ed. St. Louis:
Mosby; 1995. This comprehensive textbook still provides the basics of
tumor biology and describes the vast majority of the soft-tissue tumors in
great detail.
12. Grimer RJ, Taminiau AM, Cannon SR. Surgical outcomes in
osteosarcoma. J Bone Joint Surg Br. 2002;84(3):395–400. This paper
describes the outcomes of 202 patients treated in 3 different tumor centers
of the European Osteosarcoma Intergroup. A very detailed paper that
provides a comprehensive view of current osteosarcoma prognosis.
13. Fong Y, Coit DG, Woodruff JM, Brennan MF. Lymph node
metastasis from soft tissue sarcoma in adults. Analysis of data from
a prospective database of 1772 sarcoma patients. Ann Surg.
1993;217(1):72–77. This paper examines the natural history of lymph
node metastasis in sarcomas and the utility of therapeutic
lymphadenectomy in various tumor types. The data is based on a
prospective sarcoma database including 1772 patients.
22. Abraham JA, Baldini EH, Butrynski JE. Management of adult
soft-tissue sarcoma of the extremities and trunk. Expert Rev
Anticancer Ther. 2010;10(2):233–248. This very recent paper summarizes
the current treatment strategy in soft-tissue sarcomas seen from a single
institution viewpoint but with a current and extensive reference list. It is
more therapeutically oriented and serves well as an addendum and update
to reference 3 above.
Access the complete references list online at

117.e1
References
References
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treatment in 1261 patients.
2. Papagelopoulos PJ, Mavrogenis AF, Mastorakos DP, et al. Current
concepts for management of soft tissue sarcomas of the extremities.
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osteosarcoma. J Bone Joint Surg Br. 2002;84(3):395–400. This paper
describes the outcomes of 202 patients treated in 3 different tumor centers
of the European Osteosarcoma Intergroup. A very detailed paper that
provides a comprehensive view of current osteosarcoma prognosis.
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metastasis from soft tissue sarcoma in adults. Analysis of data from
a prospective database of 1772 sarcoma patients. Ann Surg.
1993;217(1):72–77. This paper examines the natural history of lymph
node metastasis in sarcomas and the utility of therapeutic
lymphadenectomy in various tumor types. The data is based on a
prospective sarcoma database including 1772 patients.
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soft tissue sarcomas: a single center analysis of 1,597 patients.
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nonmetastatic osteogenic sarcoma: the Memorial Sloan-Kettering
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treatment of adult soft tissue sarcoma of the extremities. Recent
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biopsy a practical alternative to open biopsy for the primary
diagnosis of sarcoma? Experience with 140 patients. Am J Clin
Pathol. 2001;115(1):59–68.
22. Abraham JA, Baldini EH, Butrynski JE. Management of adult
soft-tissue sarcoma of the extremities and trunk. Expert Rev
Anticancer Ther. 2010;10(2):233–248. This very recent paper summarizes
the current treatment strategy in soft-tissue sarcomas seen from a single
institution viewpoint but with a current and extensive reference list. It is
more therapeutically oriented and serves well as an addendum and update
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23. Mankin HJ, Lange TA, Spanier SS. The hazards of biopsy in
patients with malignant primary bone and soft-tissue tumors. J Bone
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extremities: recent developments in surgical therapy – analysis of
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27. Wafa H, Grimer RJ. Surgical options and outcomes in bone
sarcoma. Expert Rev Anticancer Ther. 2006;6(2):239–248.
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29. Bickels J, Kollender Y, Wittig JC, et al. Vacuum-assisted wound
closure after resection of musculoskeletal tumors. Clin Orthop Relat
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30. Gottlieb LJ, Krieger LM. From the reconstructive ladder to the
reconstructive elevator. Plast Reconstr Surg. 1994;93(7):1503–1504.
31. Levin LS. The reconstructive ladder. An orthoplastic approach.
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the elevator? Plast Reconstr Surg. 2000;105(6):2266.
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surgical method in therapy of malignant bone tumors and
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35. Heitmann C, Levin LS. The orthoplastic approach for management
of the severely traumatized foot and ankle. J Trauma.
2003;54(2):379–390.
36. Sauerbier M, Giessler GA. Lateral arm flap for hand and wrist
coverage. In: Moran SL, Cooney WP 3rd, eds. Master Techniques in
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with intramedullary free fibular flap for limb salvage in a pediatric
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arteriovenous fistula for simultaneous microsurgical tissue transfer
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44. Cavadas PC, Landin L. Treatment of recalcitrant distal tibial
nonunion using the descending genicular corticoperiosteal free flap.
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group study of 118 patients. J Bone Joint Surg Br. 2008;90(6):786–794.

SECTION I • Lower Extremity Surgery
5 
Reconstructive surgery: Lower
extremity coverage
Joon Pio Hong
SYNOPSIS
■ Reconstructive surgery for the lower extremity has evolved from
staged approach to proving best solutions for functional and cosmetic
outcome.
■ This chapter covers from the classical approach to the gradual change
towards the principle that advocates a one-stage elevator approach.
■ Special considerations are required to overcome the complexities of
lower extremity reconstruction, such as diabetes and chronic infection.
■ Finally, introduction of perforator flaps, the use of multiple flaps by
combination, and supermicrosurgery will help you design and widen
the reconstructive choices for the lower extremity.
Access the Historical Perspective section online at

Introduction
Lower extremity reconstruction following severe trauma,
cancer ablation, and chronic infections remains challenging.
The involvement of multiple structures from bone, muscle,
vessel, nerve, to skin makes it difficult to achieve the goals
of lower extremity reconstruction where restoration of
limb function, coverage for vital structures, and satisfactory
appearance is achieved.
In the recent years, the management of the lower extremity
has evolved with numerous new techniques and innovations
and thus extremities are salvaged that would have been
amputated in the past. Introduction of vascularized bone
grafting, Ilizarov lengthening, bone matrix, and growth
factors to manage the bone defects along with new ideas for
coverage like perforator flaps, propeller flaps, and negative
pressure therapy as well as increased knowledge for anatomy
have led to successful management of lower extremity soft
tissue and bone defects. If the extremity cannot be salvaged,
the next goal would be to maintain maximal functional length
with good soft-tissue coverage on the stump to bear the
prosthesis for functional gait.
Extremity salvage is a long and complex process for the
medical professionals as well as patients. Patients and family
members must be educated and included in the decision-
making process and made aware of the expected prognosis.
Patient’s motivation and compliance along with family’s
support will be critical during physical and psychological
recovery.
Although early amputation and prosthetic treatment was
thought to offer the potential for faster recovery and lower
cost, recent reports have provided different views. A multi-
center, prospective, observational study to determine the
functional outcome of 569 patients with severe leg injuries
resulting in reconstruction or amputation has provided infor-
mation based on Sickness Impact Profile, a measure of self-
reported health status.1 Although reconstruction may be faced
with more challenging processes, the Lower Extremity Assess-
ment Project (LEAP) showed no significant difference in
outcome at 2 years. Costs following amputation and salvage
were also derived from data in a study that emerged from
LEAP concluding that amputation is more expensive than
salvage and amputation yields fewer quality-adjusted life-
years than salvage.2 Other reports have shown similar find-
ings where projected lifetime healthcare costs for amputation
may be as high as three times.3,4
Treatment of salvage evolves as with the coverage strategy.
But still this process can be long and complicated. Despite that
normal function and appearance can be difficult to achieve,
it may be warranted to support successful reconstruction
leading to successful salvage of the extremity.
Principles
The primary goal of surgical reconstruction of the lower
extremity wound is to restore or maintain function. Function

118.e1
Historical perspectives
Historical perspectives
The early history of lower extremity reconstruction dates back
to Hippocrates (460–370 BC) and amputation and procedures
trying to improve the success of amputation and survival
have been the main practice up to WWI.5
Although the term flap originated in the 16th century from
the Dutch word flappe, meaning something hanging by one
side, and the concept dates back as far as 600 BC when Sush-
ruta Samhita described nasal reconstruction using a cheek
flap, it was not until WWI and II that pedicled flaps were used
extensively for reconstruction of the extremity. The next
evolution came as surgeons started to use axial pattern flaps.
The term “axial pattern” as used to describe flaps with named
pedicles was presented by McGregor and Morgan and this
concept, along with contributions from many surgeons,
led to the understanding of the hemodynamic aspect of flap
circulation.6–8 The first muscle flap for lower extremity cover-
age was first described by Stark for coverage of debridement
sites for osteomyelitis, but went unnoticed until Ger reported
that the leg muscles were reliable for leg coverage with abun-
dant blood supply.9,10 These progresses led to the distinction
between axial and random flaps and muscle and musculocu-
taneous flaps that led to the introduction of free tissue
transfer.
Prior to the introduction of microsurgery, limitations
existed for the reconstruction of large and extensive wounds
including bone defects. Entry into the era of microsurgery,
with tissue coverage for extensive and complex defects, even
after severe trauma and radical debridement, truly allowed
advances in lower extremity coverage. In 1986, a landmark
publication on reconstructive microsurgery of the extremity
was presented by Marko Godina and established the principle
of early debridement, free tissue transfer, and aggressive
rehabilitation to achieve functional limb after salvage.11 Based
on this principle, and advances made in the new millennium,
treatment for infected wounds like osteomyelitis, complicated
wounds such as diabetic foot ulcers and ischemic limb, and
large defects after cancer ablation now turns routinely to soft-
tissue coverage using microsurgery. With respect to function,
free functioning muscle transfer using rectus femoris muscle
and gracilis muscle and composite free flaps such as dorsalis
pedis with extensor tendons or fibula osteocutaneous flaps
may achieve acceptable functional results in the extremity
with composite defects.12–15 Innervated flaps utilizing micro-
surgical coaptation of nerves may help regain early protective
sensation for sole reconstruction.16–18 Tissue expansion tech-
nique combined with or without microsurgery may allow
coverage for large chronic defects or healed scars minimizing
donor morbidity.19 The most recent advances in flap surgery
came in the 1990s with the introduction of perforator flaps.
Koshima and Soeda described the use of an inferior epigastric
artery skin free flap without rectus abdominis muscle for
reconstruction.20 This implied reduction in donor site morbid-
ity, ability to tailor with regard to thickness, and increased
freedom of orientation of the pedicle allowing more flexibility
while providing coverage of the defect.21,22 Advances in
wound healing science have synergistically made closure of
lower extremity wounds more successful. The vacuum-
assisted closure may provide a stable temporary dressing that
allows increased blood flow and decreased bacterial counts to
enable a better environment for flap coverage.23,24
Currently, state-of-the art technologies in tissue engineer-
ing, genetic engineering, diagnostic technology, wound
healing, limb transplantation, and supermicrosurgery will
widen the possibility for increased salvage with better func-
tion and appearance. Nevertheless, the concept of soft-tissue
coverage with or without microsurgery will remain an essen-
tial part of functional and cosmetic recovery for lower extrem-
ity reconstruction.

119
Principles
is addressed through a well-vascularized extremity, a skeletal
structure able to support gait and weight-bearing, and an
innervated plantar surface to provide protective sensation.
Without proper function, the value of reconstruction will be
reduced, which significantly increases emotional and financial
burden to the patient.
An evaluation of the patient as a whole allows proper
decisions to be made with regard to systemic conditions,
socioeconomic status, and rehabilitative potential. Extremity
injuries are best approached by teams of surgeons with
knowledge of skeletal, vascular, neurological, and soft-tissue
anatomy. Although evaluations such as the Mangled Extrem-
ity Severity Score (MESS), the Predictive Salvage Index, and
the Limb Salvage Index can assist the team in making a deci-
sion for amputation, they must not be the sole criteria and
the decision to amputate must be individualized for each
patient.19,25–28
The value of autologous tissue
Whether acute or chronic, evaluation of lower extremity
wounds and the eligibility for soft-tissue reconstruction
begins with vascular status evaluation. If clinical and diagnos-
tic examination reveals inadequate perfusion and the value of
reconstruction is minimal, amputation should be individually
decided. An amputated or avulsed tissue should never be
disregarded, especially in acute traumas, unless severely
contaminated or lacks vascular structure. Nothing can mimic
the superiority of an autologous tissue, and all tissues from
amputated parts should be considered as potential donor
tissues for reconstruction. The skin harvested from the
degloved or amputated part can be utilized as biologic dress-
ings to permanent skin grafts (Fig. 5.1A–E).29 The leg length
can be preserved using soft tissue distal form the zone of
injury as fillet pedicled or free flaps.30–33 Amputated bones can
be banked or used as a flap to reconstruct the leg.34,35
The reconstructive elevator
Once the wound is evaluated to have good vascular supply,
stable skeletal structures, and a relatively clean wound, soft-
tissue coverage is then considered. The concept of a recon-
structive ladder was proposed to achieve wounds with
adequate closure using a stepladder approach from simple to
complex procedures (Fig. 5.2A). Although still valued and
widely taught, the reconstructive ladder comes from the
concept of the wound-closure ladder that dates back beyond
the era of modern reconstructive surgery.36 In the era of
modern reconstructive surgery, one must consider not only
adequate closures but also form and function. A skin graft
after mastectomy can still provide coverage, but a pedicled
TRAM (transverse rectus abdominis muscle) flap will provide
superior results in addition to coverage. Now with the intro-
duction of DIEP (Deep Inferior Epigastric Perforator) flaps the
reconstructive ladder approach seems to show more flaws.
Other techniques including tissue expansion, skin stretching,
and vacuum-assisted closure have made new changes in
approaching reconstructive options. A simpler reconstructive
option may not necessarily produce optimal results. This is
especially true for lower extremity coverage, where conse-
quences of inadequate coverage will lead to complications
such as additional soft-tissue loss, osteomyelitis, functional
loss, increased medical cost, and even amputation. Thus to
provide optimal form and function, we jump up and down
the rungs of the ladder. The reconstructive elevator requires
creative thoughts and consideration of multiple variables to
achieve the best form and function rather than a sequential
climb up the ladder (Fig. 5.2B). This paradigm of thought does
not eliminate the concept of the reconstructive ladder but
replaces it with a ladder of wound closure that makes its mark
in the field where a variety of advanced reconstructive proce-
dures and techniques is not readily available. Based on the
reconstructive elevator, the method of reconstruction should
be chosen based on procedures that result in optimal function
as well as appearance.
Skin grafts and substitutes
Autologous skin grafts are used in a variety of clinical situa-
tions. They can be full or partial thickness and require a
recipient bed that is well vascularized and free of bacterial
contamination. The split-thickness grafts are usually used as
the first line of treatment where wounds cannot be closed
primarily or undue tension is suspected. In the extremity with
complex wounds, bone exposure and/or avascular beds,
infected wounds, and wounds with dead space and poorly
coagulated beds, skin grafts should be avoided. Autologous
cultured keratinocytes can be used where split-thickness
donor sites are limited. However, the use of cultured epithelial
autograft has been hampered by reports that show it to be
more susceptible to bacterial contamination, have a variable
take rate, and be costly.37
A skin substitute is defined as a naturally occurring or
synthetic bioengineered product that is used to replace the
skin in a temporary, semipermanent, or permanent fashion.38
Temporary epidermal replacements may be beneficial in
superficial to mid-dermal depth wounds. In deeper wounds,
dermal replacements are of primary importance. Bioengi-
neered products for superficial wounds are porcine products
such as EZ Derm and Mediskin (Brennen Medical, LLC, Saint
Paul, Minnesota), which help to close the wound, decrease
pain, and improve the rate of healing.38 Biobrane (UDL Labo-
ratories Inc., Rockford, Illinois) is a bilaminate skin substitute
that is used temporarily. The outer layer is formed with a thin
silicone layer with pores that allow removal of exudates and
penetration of antibiotics. The inner layer is composed of a 3D
nylon filament weave impregnated with type I collagen to
adhere to the wound. Bioengineered products that are used
for deep wounds are allograft, Alloderm (Life Cell Corpora-
tion, Woodlands, Texas), Integra (Integra Life Sciences,
Plainsboro, New Jersey), and Apligraf (Organogenesis Inc.,
Canton, Massachusetts). The gold standard for temporary
skin coverage is cadaver skin or allograft. Allograft is used to
cover extensive partial- and full-thickness wounds. It prevents
tissue desiccation; decreases pain and insensible loss of water,
electrolytes, and protein; suppresses the proliferation of bac-
teria; and decreases the hypermetabolic component of thermal
injuries.39,40 Alloderm is an acellular dermal matrix engineered
from banked human cadaver skin. It can also provide single
stage reconstruction when used with a split-thickness
skin graft.41 Alloderm is known to improve functional and
cosmetic results in deep burn wounds (Fig. 5.3).42 Integra is
an acellular collagen matrix composed of type I bovine col-
lagen cross-linked with chondroitin-6-sulfate and covered by

120
SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
Fig. 5.1  (A) This 67-year-old patient was involved in a pedestrian traffic accident,
which left her with ≈90% degloving injury of the entire left leg. (B,C) The injury
involved major artery and nerve defects making salvage impossible and resulting
in below knee amputation. The skin was harvested and defatted from the
degloved tissues and grafted in hope for primary take as well as biologic dressings.
(D,E) Only about 15% of the initial graft was taken, but healthy granulation was
noted underneath the biologic dressing and made a favorable bed for secondary
graft procedure.
A
B
C
D
E
a thin silicone layer that serves as an epidermis.43 It is readily
available, does not require a donor site, coverts open to
closed wounds, and decreases metabolic demand on the
patient. However, Integra must be used on clean wounds
and requires a two-stage procedure later for the graft. Simul-
taneous use with negative wound pressure therapy may
accelerate the vascularization. Apligraf is a bilaminate human
epidermal and dermal analogue that can act as a permanent
skin substitute. The epidermal layer is formed by human
keratinocytes with a well-differentiated stratum corneum.
The dermal layer is formed with bovine type I collagen lattice
impregnated with human fibroblasts from neonatal foreskin.
Apligraf is not antigenic, and the dermal layer incorporates
into the wound bed. Apligraf has been shown to significantly
decrease the time of venous ulcer healing compared to
compression.44

121
Principles
any perforator can be chosen as a source of vascular supply
to the skin flap and be rotated to cover a defect. This is known
as the propeller flap.45–47 When the use of local flaps is not
feasible due to the complexity of the wound, free tissue
transfer is indicated.
The midthigh wound, due to the anatomic character where
femur is surrounded by a thick layer of soft tissue, rarely
requires reconstruction using free tissue transfer and often is
sufficiently reconstructed by skin graft or local flap. Local
muscle or musculocutaneous flaps based on the lateral or
medial femoral circumflex artery can be used when available.
Also, any perforator can be chosen as a source of vascular
supply to the skin flap and rotated to cover a defect. However,
if the patient has undergone massive resection or has special
considerations such as postoperative radiation therapy, it may
warrant free tissue coverage.
The wounds of the distal thigh (supracondylar knee) can
be very difficult due to the limit of rotation from previously
described local muscle or musculocutaneous flaps from the
thigh. Pedicled medial gastrocnemius muscle or musculocu-
taneous flap from the lower leg can be extended to cover this
region. However, extensive or complex defects may require
free tissue transfer or coverage using a perforator-based rota-
tion (propeller) skin flap (Fig. 5.4).
Lower leg
The traditional planning for reconstruction of the lower
extremity has been approached according to the location of
the defect. Divided into thirds: gastrocnemius muscle flap for
proximal third, soleus muscle flap for middle third, and free
Approach by location (local flaps)
Thigh
The thigh can be divided into 3 parts: proximal thigh,
midthigh, and distal thigh (supracondylar knee). The proxi-
mal thigh wounds can result from various causes such as
complications from hip fractures, infected bypass vascular
grafts, after tumor resection, and trauma. The medial portion
of the proximal thigh can be especially challenging due to
location of vital structures and the likely formation of dead
space. Local lower extremity muscle or myocutaneous flap
options include using the flaps based from the lateral circum-
flex femoral artery such as tensor fascia lata, vastus lateralis,
and rectus femoris flaps. Vertical rectus abdominis muscle or
myocutaneous flap using the deep inferior epigastric artery
can allow stable coverage of the proximal thigh. The gracilis
muscle or myocutaneous flap based on the medial femoral
circumflex artery may lack muscle bulk but is a good option
when the dead space is not extensive. With the increased
knowledge of perforator and perforator-based flaps, basically
Fig. 5.2  The reconstructive elevator requires creative thoughts and considerations
of multiple variables to achieve the best form and function rather than a sequential
climb up the ladder. This paradigm of thought does not eliminate the concept of a
reconstructive ladder, but replaces it as a ladder of wound closure and makes its
mark in the field where variety of advanced reconstructive procedures and
techniques are not readily available. Based on the reconstructive elevator, method of
reconstruction should be chosen based on procedures that result in optimal
function as well as appearance.
Reconstructive ladder
Reconstructive elevator
Complex
Simple
Complex
Simple
Free flaps
Distant flaps
Local flaps
Skin grafts
Direct closure, secondary intension
Free flaps
Distant flaps
Local flaps
Skin grafts
Direct closure, secondary intension,
negative pressure wound therapy
B
A
Fig. 5.3  A 10-year-old patient was seen 3 years after reconstruction of one-stage
dermal allograft, an acellular dermal matrix engineered from banked human cadaver
skin, and split-thickness skin graft. The patient is seen to have good elasticity and
acceptable cosmetic results.

122
SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
A
B
C
Fig. 5.4  (A) A 70-year-old patient is noted with chronic drainage after failed total knee replacement. (B) After complete debridement, a perforator-based flap was elevated
and advanced using a perforator (dissected until just beneath the fascia) with visible pulse. (C) Long-term follow-up shows no recurrence of any infections, allowing her to
undergo total knee replacement.
flap transfer for the distal third of the leg. Like the reconstruc-
tive ladder concept, this traditional approach can be useful,
but the surgeon must individualize each wound and choose
the initial procedure that can yield the best chance of success
and avoid morbidity.
Microvascular free tissue transfer
One must choose a proper surgical plan to achieve optimal
function and cosmesis. Flaps are selected based on accessibil-
ity of local tissue and donor morbidity. Frequently, lower
extremity trauma due to high-energy impact results in exten-
sive and complex wounds. Workhorse for soft-tissue coverage
includes muscle or musculocutaneous flaps such as latissimus
dorsi, rectus abdominis, and gracilis. The perforator flap
where a skin flap is based on a single or multiple perforators,
such as the anterolateral thigh flap or thoracodorsal artery
perforator flap, can be added to the list.
Whichever flap you select, the guideline for lower extrem-
ity reconstruction using free flaps remains the same: anasto-
mose the vessel outside the zone of injury, make end-to-side
arterial anastomosis and end-to-side or end-to-end venous
anastomosis, and reconstruct the soft tissues first and then
restore the skeletal support.48
Treatment approach
Preoperative evaluation
The initial evaluation of the lower extremity wound involves
visual and manual examination. An examination on the loca-
tion, size, depth, and character of the wound is made. Neuro-
logical evaluation as well as vascular and skeletal evaluation
is made to develop a plan for reconstruction. Also, presence
of comorbidities including smoking, diabetes, obesity, and
peripheral vascular disease should be accounted for. The
initial evaluation enables assessment of the overall function
and consideration of the possible outcome. One must not
make the mistake of addressing the wound locally but rather
approach the patient as a whole and take into consideration
socioeconomic status, rehabilitative potential, and patient’s
motivation and compliance.
After the decision is made to reconstruct the lower extrem-
ity, the first preoperative evaluation should start with vascular
status. Physical examination of palpable pulse, color, capillary
refill, and turgor of the extremity allows assessment of the
initial status, and Doppler examination can provide additional
information.49 The use of preoperative arteriography for lower
extremity reconstruction is considered when physical/
Doppler exam reveals inconclusive vascular status or chronic
vascular disease is suspected (Fig. 5.5). The use of computed
tomography angiography may obtain vascular information of
the recipient region without the risk of complications from
arterial puncture of the groin and can also provide vascular
information of the donor flap facilitating the planning and the
Fig. 5.5  Preoperative computed tomographic angiogram revealing collateral flows
on bilateral femoral arteries for a patient with diabetes and poor pedal pulses. The
use of computed tomography angiography may obtain vascular information of the
recipient region without the risk of complications. The preoperative is selectively
recommended in patients who have loss of one or more peripheral pulses, a
neurological deficit secondary to the injury, or a compound fracture of the extremity
that has undergone reduction and either external or internal fixation.

123
Treatment approach
foot trauma, and anticipated protracted course to obtain soft-
tissue coverage and tibial reconstruction.
In these cases where limb salvage is not possible, an attempt
should be made to salvage as much limb length as possible.
Every effort should be made to save the functional knee joint
as below-knee amputation results in far superior ambulatory
outcome and up to 2–3 times more full mobility compared to
above knee amputation.58 The energy consumption is far less
for below-knee amputation, and this allows these patients
to walk significant daily distances, thus maintaining good
quality of life.59 Though the ideal stump length below the knee
is greater than 6 cm, any length of tibia should be preserved.60
The stump may be closed primarily if adequate soft tissue
exists, and where local tissue is inadequate then microsurgery
enables preservation of the maximum length of the stump. If
the tissue distal to the amputation is usable, a fillet flap can
be performed. Other flaps, such as muscle, musculocutane-
ous, fasciocutaneous, and perforator, can be used for micro-
surgical reconstruction and achieve the same goal as well.
Muscle flaps may have a tendency to heal slowly and to
shrink due to muscle atrophy while skin flaps may provide
better contours and sensibility.61
Debridement
Bony stability is first established using external or internal
fixation devices. An external device is usually preferred if
there is significant bone loss or bone revascularization and
may facilitate coverage procedure. Debridement must cover
devitalized soft tissue and bone and be performed until fresh
bleeding is noted. Multiple stages of debridement may be
needed to achieve adequate wound bed prior to soft-tissue
coverage.
The vacuum-assisted closure can be used to optimize the
wound bed and minimize dressing changes until definitive
reconstruction. It must be used with caution and in conjunc-
tion with serial debridement. It does not replace surgical
debridement and should not be used in heavily contaminated
wounds with necrotic tissues. If a lower extremity wound is
clean, bony stability is present, and no vital structures are
exposed, application may be indicated.54 This device facilitates
dressing of the wound and often promotes healing.
Timing of reconstruction
Regardless of the degree of contamination and extent of injury
when indicated for salvage, there is no need to delay definitive
coverage provided that the general condition of the patient
and the status of the wound are appropriate. General consen-
sus favors early aggressive wound debridement and soft-issue
coverage. Byrd et al. described acute, subacute, and chronic
phases of an open tibial fracture.62 Ideally, the wound is
covered in the first 5–6 days after injury at the acute phase of
the wound. In severe Gustilo type IIIB and type IIIC injuries,
free muscle transplantation obtained the best results. At 1–6
weeks the wound enters the subacute phase where wounds
have a higher tendency for infections and flap failures. Between
4 and 6 weeks, the wound enters the chronic phase and clear
demarcation between viable and non-viable bone becomes
apparent. Godina further demonstrated that radical debride-
ment and coverage within 72 h results in the best outcome
where only 0.75% of flaps fail, 1.5% are infected, and 6.8
surgical procedure.50–52 In association with prior injuries to the
lower extremity, the routine preoperative use of angiogram
is controversial.24,49,50,53–55 It is selectively recommended in
patients who have loss of one or more peripheral pulses, a
neurological deficit secondary to the injury, or a compound
fracture of the extremity that has undergone reduction and
either external or internal fixation.54
Nerve injuries that are irreversible may require special
considerations. Peroneal nerve injury results in foot drop and
loss of sensation of the dorsum of the foot. Thus lifelong
splinting or tendon transfers may be required. Complete loss
of tibial nerve function results in loss of plantar flexion and is
an absolute contraindication for reconstruction.56 The loss of
plantar sensation can be devastating and may hinder the need
for reconstruction but is not an absolute contraindication.57An
algorithm of approach is outlined in Fig. 5.6.
Primary limb amputation
A study by Lange describes absolute and relative indications
for primary amputation of limbs with open tibial fractures.56
Absolute indications include anatomically complete disrup-
tion of the posterior tibial nerve in adults and crush injuries
with warm ischemia time greater than 6 h. Relative indica-
tions include serious associated polytrauma, severe ipsilateral
Fig. 5.6  Algorithm of approach for soft-tissue reconstruction of the lower extremity.
Yes
Bypass graft
Angioplasty
Debridement and
establish bone stability
Vascular supply
Amputation
Amputation
No
Complete disruption of
posterior tibial n. Ischemic leg
(ischemic time greater than 6 h)
Serial debridement
Negative pressure
Wound therapy
Conservative wound care
Negative pressure wound therapy
Hyperbaric oxygen therapy
Inadequate
Adequate
Inadequate
wound bed
Adequate
wound bed
Inadequate
wound bed
Adequate
wound bed
Skin graft
Cross leg flap
Elective
reconstruction

124
SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
Special considerations
Osteomyelitis
Osteomyelitis often follows severe open leg fractures with
massive contamination or devascularized soft tissue and
bone. Inadequate debridement or delayed coverage of the
wound increases the chance for osteomyelitis, and early
debridement remains the key to prevention.69 Osteomyelitis
should be seen as a spectrum of disease and should be indi-
vidualized and managed accordingly. Factors known to be of
prognostic significance include the duration of infection, the
extent of bony involvement, the presence of associated frac-
ture or nonunion, and overall immune status of the patient.70
The wound is composed of exposed bone, infected bone,
devitalized bone, and scarred tissue surrounding the bone.
These components have diminished vascular supply making
antibiotics difficult to reach. Thus to achieve the goal of infec-
tion control and the restoration of function, treatment prin-
ciples for chronic osteomyelitis are debridement including the
complete resection of involved bone, flap coverage with vas-
cularized tissue, and a brief course of antibiotic treatment (Fig.
5.7). Local methods of antibiotic delivery can be used when
complete debridement of bone is not possible. Although there
has been controversy over selecting the type of flap for cover-
age, muscle flaps, rather than fasciocutaneous flaps, have
been shown experimentally to have increased blood flow
and antibiotics delivery, increased oxygen tension, increased
phagocytic activity, and decreased bacterial counts.71–73 Clini-
cally, complete debridement and obliteration of dead space
are the most important steps in treating osteomyelitis and the
type of flaps seems less crucial.74,75 Bone defects can be
managed with vascularized bone flap, secondary bone graft-
ing, bone distraction lengthening, or a combination of these
techniques.
Not all chronic osteomyelitis can be salvaged. As with the
indication for amputation, legs with nerves too damaged
after osteomyelitis should not be salvaged. The general and
months are needed for union of the bone.11 The failure rate
compares remarkably well to that of 12% when reconstructed
from day 3 to 3 months and 9.5% when reconstructed after 3
months of injury. Yaremchuk et al. recommended early cover-
age between days 7 and 14 after several debridements to allow
better identification of zone of injury.63 The common idea
behind early intervention is that it minimizes the risk for
increasing bacterial colonization and inflammation leading to
complications. Acute coverage by day 5–7 is generally accepted
as having a good prognosis in terms of decreased risk of
infection, flap survival, and fracture healing.11,24,62,63 If the
patient condition does not allow prolonged surgical proce-
dures, then the wound should be debrided as early as possible
and a clean and well-vascularized recipient bed maintained
until conditions allow definitive reconstruction.64
Selection of recipient vessel
Many lower extremity wounds resulting from trauma are
high-energy injuries with a substantial “zone of injury”. This
thrombogenic zone is known to extend beyond what is mac-
roscopically evident, and failure to recognize the true extent
of this zone is cited as a leading cause of microsurgical anas-
tomotic failure. Within the zone, perivascular changes such as
increased friability of vessels and increased perivascular scar
tissue may lead to difficult dissection of recipient vessels and
higher incidence of thrombosis after anastomosis.65 The extent
of this is very difficult to realize clinically. Thus Isenberg and
Sherman demonstrated that clinical presentation of the recipi-
ent vessel (vessel wall pliability and the quality of blood from
the transected end of the vessel) is more important than the
distance from the wound.66 Park et al. also concluded that
site of injury and vascular status of the lower extremity are
the most important factors in choosing a recipient vessel.67
This was further supported by successful anastomosis of
perforator to perforator adjacent to or within the zone of
injury.68 Based on these findings, one of the most important
factors in selecting the recipient vessel may be the vascular
quality itself.
Fig. 5.7  (A) A patient with chronic osteomyelitis is noted with soft-tissue defect. (B) Complete debridement including resection of the involved bone was performed.
(C) Flap coverage with well-vascularized anterolateral thigh flap combined with vastus lateralis muscle tissue was used with 6 weeks of antibiotic treatment.
A
B
C

125
Special considerations
Coverage after tumor ablation
As with any reconstructive procedure, the aim of reconstruc-
tion after tumor ablation is to maintain quality of life by
preserving function and achieving acceptable appearance. In
addition, coverage must be able to withstand adjuvant treat-
ment with radiation therapy and/or chemotherapy and play
a role in achieving long-term local control of the disease.
Surgeons should have close cooperation with the oncologists
and must acquire adequate knowledge of tumor characteris-
tics, behavior, and adjuvant treatment in order to plan and
choose the type of reconstructive procedure. Knowing that
reconstruction is feasible allows the oncologic surgeon to
achieve a comfortable and satisfactory excision margin and
may lead to a better outcome. Skin grafts are always an
option especially for very extensive defects where flap cov-
erage is not available. But for wounds scheduled for postop-
erative radiation therapy or located over joints and high
friction regions, skin grafts should be avoided and recon-
struction should be with a durable flap.82 Special consider-
ation should be given to preoperative radiation therapy
where skin would become fibrotic and ischemic around the
cancer and thus will not allow local coverage. Regarding
adjuvant chemotherapy, free flap procedures will not inter-
fere with chemotherapy nor will chemotherapy have an
impact on free flap survival.83,84 Overall success rate was
shown to be 96.6% in a series of 59 free flaps in 57 patients
undergoing lower extremity reconstruction after tumor abla-
tion, with 12% major and 7% minor complications.83 Various
flaps such as omentum, muscle with skin graft, musculocu-
taneous, and perforator can be used for reconstruction
depending on location, size, depth, adjuvant therapy, func-
tion, and cosmetic appearance (Fig. 5.10).
Exposed prosthesis
The traditional method to manage exposed hardware includes
irrigation, debridement, antibiotics, and likely removal of
hardware. However, several factors should be taken into
account to manage exposed hardware before considering
removal that may set back the treatment plan. Factors such as
location of the hardware, infection (type of bacteria and dura-
tion of infection), duration of exposure of hardware, and
hardware loosening should be considered as important prog-
nostic factors for successful management of exposed hard-
ware.85 In the retrospective review by Viol et al. they concluded
that if hardware is clinically stable, time of exposure is less
than 2 weeks, infection is controlled, and the location of the
hardware is for bony consolidation, then there is an increase
in the likelihood that hardware can be salvaged using surgical
soft-tissue coverage (Fig. 5.11).85
Exposed vascular grafts present life and limb threatening
complications. They should be managed with early debride-
ment and muscle flap coverage to salvage the graft. Synthetic
grafts can be susceptible to bacterial colonization, and consid-
eration should be given to replacement with an autologous
graft. Local muscle flaps such as gracilis, sartorius, and tensor
fascia lata are very useful in providing adequate coverage for
exposed groin synthetic vascular prosthesis. If the defect is
extensive, then an inferiorly based vertical rectus abdominis
musculocutaneous flap can be considered. The management
of exposed vascular grafts requires close cooperation with the
socioeconomic condition of the patient should also be consid-
ered, and they should be offered the option of amputation and
early rehabilitation.
Diabetes
Patients with diabetes provide additional concerns ranging
from chronic renal failure, nutrition, to blood sugar control.
These multiple issues are best approached by a multidisci-
plinary team.76–79 Patients will frequently have chronic
bacterial colonization, osteomyelitis, complex wounds, bone
deformity, local wound ischemia, and vascular disease. The
etiology behind these complicated wounds is from macrovas-
cular angiopathy, bony deformities leading to pressure points,
neuropathy, and poor metabolic control. When patients with
diabetes are required to undergo a reconstructive procedure
of the extremity, vascular status must be evaluated to ensure
success.80,81 Any vascular problems must be addressed first
and corrected. If not correctable, the surgeon may be faced
with a high risk of failure. One must consider the probability
of successful reconstruction based on eliminating the underly-
ing problems of the diabetic wound and also take into account
long-term ambulation after reconstruction. In a retrospective
study by Hong, only 71 patients out of 216 were deemed
functionally salvageable using a microsurgical approach and
a successful outcome was reported for 66 patients (Figs. 5.8 &
5.9).80 Large and composite diabetic wounds must be aggres-
sively debrided, including the necrotic bone, and covered
with well-vascularized tissue.
Fig. 5.8  Algorithm for diabetic foot reconstruction.
Systemic condition
and wound evaluation
Small/shallow
Large/deep
Simple
Complex
Reliable
Unreliable
Free flap
Bypass surgery
Conservative
care
Skin graft/
local flap
Evaluate
vascular status
Surgical
(salvage) care
Failure
No benefit
Failure
Amputation
Outpatient program
Failure

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SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
use in the lower extremity has been associated with a high
rate of infection and extrusion of the implant. Wound infec-
tion and dehiscence are the most common complications, but
seroma, implant displacement, neurapraxia, hematoma, and
contour defects can also occur. The technique can be reserved
for unstable soft tissues or scars of moderate size. The implant
is placed in a suprafascial position in the subcutaneous pocket
of the lower extremity, and application on the ankle and
foot region must be avoided. Transverse expansion has a
lower failure rate compared to longitudinal advancement. For
vascular surgeon, aggressive debridement, and coverage with
a well-vascularized tissue.
Soft tissue expansion
The use of tissue expansion in the lower extremity has not
been as successful as in other areas of the body, such as the
breast and scalp. The potential advantages of using expanded
skin in the lower extremity include improved contours, cover-
age with like tissue, and improved aesthetic result. However,
Fig. 5.9  A diabetic patient after partial
amputation of the foot was noted with
poorly healing stump. (A,B) The angiogram
revealed poor flow to the lower leg, and
femoral popliteal bypass was performed.
(C,D) With improved circulation, the patient
underwent reconstruction with anterolateral
thigh perforator flap and the foot was
salvaged.
A
B
C
D

127
Postoperative care
Fig. 5.10  (A) A patient with soft-tissue sarcoma of the knee region was noted. (B,C) After wide excision including the bone, a hemi-gastrocnemius muscle was elevated to
resurface the knee joint. (D) Long-term results show good contour with acceptable function and appearance.
A
B
C
D
avoidance of wound dehiscence, neurapraxia, and fat necro-
sis, expansion should proceed slowly, stopping before the
onset of pain or, if it is measured, before intraexpander pres-
sure exceeds 40 mmHg.86 Flap prefabrication with tissue
expansion may have a role in select reconstructions of the
lower extremity.87
Postoperative care
Monitoring
During the postoperative period the patient as a whole and
the flap should be closely monitored. It is especially important
to monitor hemodynamic and pulmonary function as adequate
hydration and oxygenation are critical to flap survival. Input
and output of fluid should be monitored closely as distal
perfusion is primarily affected by hypotensive episodes. This
can be a problem for patients with chronic renal failure who
require dialysis that often removes large volumes of fluid.
Limiting range of motion may be needed for flaps covering
the joints as extension or flexion may increase the tension of
the pedicle. Monitoring flaps, especially free flaps, in the first
24 h is essential as the majority of thromboses occur during
this time. According to Chen et al., up to 85% of the compro-
mised flaps can be salvaged when the first sign of vascular
compromise is clinically noted during the first 3 days after
microsurgery.88 There is no ideal method of flap monitoring,
but recent techniques such as tissue oxygen measurement,
implantable Doppler device, laser Doppler flowmetry, and
fluorescent dye injections may assist the judgment made from
clinical evaluation, which remains the golden standard of
monitoring. Emergent re-exploration should be performed
once pedicle compromise is noted.
Management of flap complications
Although there are no clinical reviews that conclusively show
any agents that increase flap survival rate, about 96% of the
106 microsurgeons surveyed use some form of prophylactic
antithrombotic treatment, such as heparin, dextran, and alone
or in combination with other agents.89–91 The routine use of
dextran should be carefully approached due to allergic reac-
tion and pulmonary edema, but aspirin, heparin, or low
molecular weight heparin can be considered based on theory
and related studies from different disciplines. Thrombolytics
such as urokinase can be used when flow is not immediately
reestablished after pedicle rearrangement or revision anasto-
mosis.91 But no agent can replace the meticulous surgical
technique and early diagnosis of flap compromise.
Leeches have a role in the postoperative care of jeopardized
flaps. In cases of venous congestion, by injecting a salivary
component called hirudin, which inhibits platelet aggregation
and coagulation cascade, leeches can decongest by extracting
blood directly and by the oozing that occurs after it detaches.
The use of leeches for 5–7 days can sometimes help salvage
the flaps that do not resolve despite re-exploration of the
venous flow.
Secondary operations
Bone grafts are usually placed 6 weeks after soft-tissue recon-
struction to allow time for transferred tissue to settle in and
sterilize the wound.19 Cancellous autograft or vascularized

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SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
impossible, a reasonable endpoint should be set and efforts to
minimize scars and achieve good contours should be made.
Debulking by surgical excision or liposuction can improve the
contour of the flap, and fat grafts can be added to elevate
depressed scars. Scar revision by Z-plasties or expanders
can help to alleviate not only physical but psychological
problems.
Muscle/musculocutaneous flaps
Tensor fascia lata
The tensor fascia lata is a small, thin, and short muscle with
a long fascial extension from the iliotibial tract of the facia lata
to the lateral aspect of the knee. The muscle originates at the
anterior 5–8 cm of the external lip of the anterior superior iliac
crest, immediately behind the satorius, and inserts to the
iliotibial tract. It abducts, medially rotates, and flexes the hip,
acting to tighten the fascia lata and iliotibial tract but is an
expendable muscle. Its flat shape, excellent length, and reli-
able type I circulation pattern (dominant pedicle is the ascend-
ing branch of the lateral femoral circumflex artery and venae
comitantes) make it useful in many reconstructive scenarios,
both as a pedicled flap for local and regional coverage and as
a free, composite unit that incorporates skin, muscle, and iliac
bone. Motor innervation is from the superior gluteal nerve
entering the deep surface between the gluteus medius and the
gluteus maximus. Sensation is derived from T12, which
innervates the upper skin territory, and the lateral femoral
cutaneous nerve of the thigh (L2–3), which innervates the
lower skin.
When based on the dominant pedicle, located 8–10 cm
below the anterior superior iliac spine, the anterior arc of
location will reach the abdominal areas, groin, and perineum
while the posterior arc can reach the greater trochanter,
ischium, perineum, and sacrum (Fig. 5.12).92,93 The flap can
also be advanced superiorly as a V–Y flap to cover trochanteric
wounds.94 The skin overlying the muscle and fascia lata can
be harvested as a unit with the flap and can extend to within
10 cm above the knee.
The marking begins by identifying the major landmarks:
the anterior superior iliac spine, lateral condyle of femur, and
the pubic tubercle. A line from the anterior superior iliac spine
straight down the thigh to a point 10–12 cm above the knee
joint presents the anterior border of the flap, and a parallel
line 12–15 cm posterior to the first line is drawn straight down
the thigh, curving anteriorly as it crosses posterior to the
lateral epicondylar area, to meet at the same point. The skin
island can be designed within this long strip, according to the
needs and distance to the recipient defect. The distal margin
of the flap is entered, carrying the incision through the fascia
lata and dissecting deep to the fascia lata and iliotibial tract.
The pedicle is located approximately 10 cm below the anterior
iliac spine along the line drawn. One must modify the flap
when composite tissues are taken for reconstruction.
Rectus femoris
The rectus femoris is located superficially on the middle of
the anterior thigh extending between ilium and patella. It is
a central muscle of the quadriceps femoris extensor muscles
bone transfers can be chosen depending on the length of the
bone gap. In addition, the bone transfer mechanism can be an
alternative to free bone transfer for bone defects longer than
6 cm.
To achieve optimal motion of tendons of the lower extrem-
ity, secondary tenolysis procedure may be needed. The risk
for adhesion may increase when skin graft is performed over
granulated tissue directly above the tendons and may warrant
flap coverage.
The final stage to consider after reasonable functional
recovery is appearance of the extremity. Patients after recovery
frequently show scars, depression, bulky flaps, and donor
site morbidities. Although complete restoration is nearly
Fig. 5.11  A patient with total knee replacement, after contraction of the knee due
to a traffic accident, presented with unstable skin and pending exposure of the knee
implant for 1 month. (A) The unstable region of the skin was completely debrided
and irrigated. (B) Upon debridement there were no apparent signs of infection. A
large anterolateral thigh perforator flap including the deep fascia was taken to
resurface the exposed prosthesis and showed stable recovery after 2 years.
A
B

129
Muscle/musculocutaneous flaps
rectus femoris muscle to be identified and separated from the
vastus medialis and lateralis. The skin island is then incised
circumferentially down to the fascia of the muscle. The rectus
is elevated from distal to proximal and from medial to lateral
so that the pedicle and nerve can be identified and protected
medially along the underside of the muscle. The dominant
pedicle enters the posterior medial muscle at a variable dis-
tance of 7–10 cm below the symphysis pubis and care must
be given to preserve the motor branches from the femoral
nerve to the adjacent vastus lateralis and tensor fascia lata.
The donor area should be repaired by careful suturing together
of the tendinous fascia of the vastus medialis and lateralis
above the patella in an effort to preserve full knee extension.
Biceps femoris
This large, well-vascularized posterior muscle of the mid- and
lateral thigh is useful for coverage of ischial pressure sores.
The muscle has two heads; the long head originates on the
ischial tuberosity and the short head originates on the linea
aspera of the femur and both insert to the head of the fibula.
The long head extends the hip, and both heads flex the leg at
Fig. 5.13  Rectus femoris muscle flap elevation. It is a type II pattern of circulation
(the dominant pedicle is the descending branch of the lateral circumflex femoral
artery with minor pedicles from the ascending branch of the same vessel as well as
from muscle branches of the superficial femoral artery) and can reach to cover the
inferior abdomen, groin, perineum, and ischium.
Rectus femoris
Pectineus
Adductor longus
Vastus medialis
Vastus lateralis
Lateral circumflex
artery (descending
and transverse
branches)
Fig. 5.12  Tensor fascia lata flap elevation. When based on the dominant pedicle,
located 8–10 cm below the anterior superior iliac spine, anterior arc of location will
reach the abdominal areas, groin, and perineum while the posterior arc can reach
the greater trochanter, ischium, perineum, and sacrum. TFL, tensor fascia lata.
Tensor fascia lata
Branch from
superior gluteal
nerve
“Transverse”
branch of lateral
femoral circumflex
artery to TFL
Vastus lateralis
Rectus femoris
group and acts to extend the leg at the knee. The muscle
originates with two tendons, one from the anterior inferior
iliac spine and one from the acetabulum, and inserts to the
patella. It is a thigh flexor and a leg extensor that is important
in stabilizing the weight-bearing knee and thus is not consid-
ered expendable. It has a type II pattern of circulation (the
dominant pedicle is the descending branch of the lateral cir-
cumflex femoral artery with minor pedicles from the ascend-
ing branch of the same vessel, as well as from muscle branches
of the superficial femoral artery) and can reach to cover the
inferior abdomen, groin, perineum, and ischium.95,96 Motor
innervation is from the femoral nerve, and muscle branches
enter adjacent to the dominant pedicle. The motor innerva-
tions and the adequate dimension of the flap allows it to be
used as a functional muscle flap (Fig. 5.13).97 In addition, the
intermediate anterior femoral cutaneous nerve (L2–3) pro-
vides sensation. The skin perforators are most reliable over
the midanterior two-thirds of the muscle itself in the central
strip up to 12 × 20 cm.
A longitudinal incision is marked from 3 cm below the
anterior superior iliac spine to just above the superior margin
of the patella. With the anterior thigh muscle contraction, the
lateral border of the vastus medialis and the medial border of
the vastus lateralis are visualized creating a depression of
skin. The tendon of the rectus femoris can be easily noted
below the depression and above the patella. The skin island
should be designed on the middle third of the thigh as the
majority of the perforators are located in this region. Incision
at the distal edge of the skin island, along the axis, allows the

130
SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
the knee and thus are not expendable. The pattern of circula-
tion is type II (the long head has dominant and minor pedicles
from the first and second perforating branches of the profunda
femoris artery, respectively, and the short head receives
the second (or third) perforating branch of the profunda and
a minor source from the lateral superior geniculate artery)
and can be turned over to cover the ischial regions based on
the dominant pedicle.98 The long head derives its motor
innervations from the tibial division of the sciatic nerve, and
the short head from the peroneal division of the sciatic nerve.
The postcutaneous nerve of the thigh (S1–3) supplies the
sensation.
The entire skin of the posterior thigh can be elevated and
advanced in V–Y fashion as a musculocutaneous unit. The
upper base of the skin flap is horizontally marked along
the buttock crease and the apex just above the popliteal fossa.
The relatively short pedicles make the flap unsuitable for
wide rotation flaps but serve well in sliding the muscle proxi-
mally along the femur toward the pelvis. The medial thigh
skin may also be left uncut, preserving skin as a rotation
advancement modification of the flap.99
With the skin island isolated, the tendon is divided distally.
The tendon is sectioned, and the dissection proceeds from the
distal thigh toward the ischium, freeing the muscle on its deep
aspect from the femur and from the adductor group of muscles
medially until enough mobility is attained so that the defect
can easily be filled. The flap should be inset and sutured with
the patient in a jackknife position and the hips flexed to
prevent dehiscence of the flap.
Gracilis
The gracilis is located on the medial thigh extending between
the pubis and the medial knee. It is a thin, flat muscle that lies
anteriorly bordered by adductor longus and sartorius and
posteriorly by adductor magnus and semimembranosus
muscles. It originates on the pubic symphysis and inserts onto
the medial tibial condyle. The gracilis functions as a thigh
adductor but is expandable from the compensation made
Medial femoral
circumflex artery
Adductor longus
Adductor brevis
Branch from
obturator nerve
Abductor magnus
Sartorius
Semimembranous
Gracilis
Gracilis
tendon (cut)
Fig. 5.14  Gracilis muscle flap elevation. It is a type II
circulation pattern (the dominant pedicle is the terminal branch
of the medial circumflex femoral artery and one or two minor
pedicles arise as branches of the superficial femoral artery) and
can reach to cover the abdomen, ischium, groin, and perineum
as a muscle or musculocutaneous flap.
from abductor longus and magnus muscle. The muscle has a
type II circulation pattern (the dominant pedicle is the termi-
nal branch of the medial circumflex femoral artery and one or
two minor pedicles arise as branches of the superficial femoral
artery) and can reach to cover the abdomen, ischium, groin,
and perineum as a muscle or musculocutaneous flap (Fig.
5.14). Motor innervation is from the anterior branch of the
obturator nerve and enters the gracilis on its deep medial
surface immediately superior to the entry of the dominant
pedicle. The motor nerve allows gracilis to be used as a func-
tional muscle flap for facial reanimation and upper extrem-
ity.100 The sensory innervation is from the anterior femoral
cutaneous nerve (L2–3) that provides sensation to the anterior
medial thigh.101
When skin is harvested with the gracilis muscle, the flap is
generally oriented longitudinally, centered over the proximal
third of the muscle, where the majority of the musculocutane-
ous perforators are located. A proximal transversely oriented
skin flap is optional, and the bulky fat of the medial thigh
even makes this flap suitable for breast reconstruction.102–104
The symphysis pubis and the medial condyle of the femur are
major landmarks. The muscle extends the full length of the
medial thigh and averages about 6 cm in width proximally
and tapers to about 2–3 cm in the distal third of the muscle.
Although the width may be narrow, the muscle can be fanned
out to provide coverage over larger defects. With the patient
in lithotomy position and slight extension of the knee will
allow the gracilis to be seen and felt, and it tends to be more
posterior than expected.
For muscle elevation, an incision is made 2–3 cm posterior
to the line drawn connecting the symphysis pubis and medial
condyle of the knee. The muscle is identified posterior to the
adductor longus. If a skin flap is planned, the skin territory
should be designed on the proximal part of the inner thigh.
Usually the dissection is easily approached by a distal incision
identifying the tendon of the gracilis posterior to the saphe-
nous vein and the distal sartorius muscle. The tendinous
insertion of semimembranous and semitendinosus muscle
can be identified posterior to the gracilis. Traction on the

131
Fasciocutaneous/perforator flap
Gastrocnemius
The gastrocnemius muscle is the most superficial muscle of
the posterior calf and has two heads, medial and lateral, that
form the distal boundary of the popliteal space. Each head can
be used as a separate muscle or musculocutaneous unit based
on its own pedicle. The medial head originates from the
medial condyle of the femur and the lateral from the lateral
condyle of the femur, and both heads insert to the calcaneus
through the Achilles tendon. It contributes to the plantar
flexion of the foot, and either or both heads of the gastrocne-
mius are expandable if the soleus is intact. The pattern of
circulation is type I (the medial muscle is supplied by
the medial sural artery, and the lateral muscle is supplied by
the lateral sural artery) and provides reliable coverage to the
upper third of the tibia, suprapatellar thigh, and knee regions
(Fig. 5.16). Both heads receive a minor source across the raphe
that joins them as anastomotic vessels within the muscle
substance. Motor innervation derives from branches of the
tibial nerve. The sensation to the skin overlying the medial
head is from the saphenous nerve and that to the lateral and
distal skin overlying the lateral head is from the sural nerve.107
The arc of rotation of the medial head after complete eleva-
tion can cover the inferior thigh, knee, and upper third of the
tibia. When the origin of the muscle is divided, an extended
arc of rotation by 5–8 cm can be achieved to extend to the
upper part of the knee. The lateral head can be elevated to
cover the suprapatellar region, knee, and proximal third of
the tibia. It can also be extended with the division of the
muscle origin. Both heads can be inferiorly rotated based on
the vascular anastomosis across the raphe between the two
muscle heads to reach the middle third of the leg. A skin
paddle can be designed, based on the perforating vessels,
with the following dimension: 10 × 15 cm for the medial and
8 × 12 cm for the lateral head. But the use of a skin paddle
leaves an unsightly donor scar.
A line is drawn either 2 cm medial to the medial edge of
the tibia or along the posterior midleg. If the muscle alone is
employed, a midline posterior incision affords excellent access
to both heads. During elevation care is taken to protect the
neurovascular structures, especially the more superficial
saphenous and sural nerves. In the proximal third, the medial
surface of the medial head is easily separated from the soleus.
The dissection starts at the medial edge of the gastrocnemius
muscle, and the plantaris can be easily noted below the gas-
trocnemius and above the soleus. The midline muscular raphe
is located and, with finger dissection, the underlying soleus
muscle is separated from the gastrocnemius proximally and
distally. The musculotendinous raphe is then separated
sharply. Distally, the thick tendinous layer is sharply dissected
free from the remaining calcaneal tendon. The transaction of
the origin of the muscle allows increased freedom. If a tunnel
is made over the lateral proximal leg, care must be given not
to violate the deep peroneal nerve.
Fasciocutaneous/perforator flap
A perforator flap is defined as a flap based on a musculocu-
taneous perforating vessel that is directly visualized and dis-
sected free of surrounding muscles and an adequate pedicle
length is achieved.108 This concept may still be confusing
tendon will highlight the proximal outline of the muscle and
allow accurate estimation of the location. This is an important
step to minimize faulty elevation of the skin component as the
medial thigh is mobile and makes it easy to incorrectly predict
the skin position over the muscle. Dissection of the anterior
and posterior skin borders then precedes proximally approxi-
mately half the length of the muscle, whereby the distal
tendon is divided and the distal muscle elevated. During the
elevation of the middle and distal third of the flap, one or two
minor perforators from the superficial femoral artery will be
identified and ligated. Retraction of the adductor longus
muscle will expose the major pedicle passing over the deep
adductor magnus approximately 10 cm below the pubic
symphysis.
Soleus
The soleus is a very broad, large bipenniform muscle lying
deep to the gastrocnemius muscle. The muscle has two muscle
bellies, medial and lateral, separated by a midline intramus-
cular septum in the distal half. The lateral belly originates
from the posterior surface of the head of the fibula and pos-
terior surface of the body of the fibula, and the medial belly
originates from the middle one-third of the medial border of
the tibia. Both bellies of the soleus insert into the calcaneus
bone through the Achilles tendon and contribute to the plantar
flexion of the foot. The soleus is expandable taken that at least
one head of the gastrocnemius is intact with function. The
pattern of circulation is type II (with dominant pedicles from
the popliteal, posterior tibial, and peroneal arteries and minor
pedicles from the posterior tibial and peroneal arteries sup-
plying the distal medial and lateral bellies, respectively) and
can cover the middle and lower third of the leg (Fig. 5.15A).
The motor nerve is derived from the posterior tibial and
popliteal nerves.105
The arc of rotation for a proximally based soleus flap after
division of minor pedicles and elevation of the distal two-
thirds of the muscle can cover the middle third of the tibia.
Hemisoleus flaps may improve the arc of rotation and pre-
serve soleus function while sacrificing flap coverage area. The
medial reversed hemisoleus pivots around the most superior
distal minor perforator of the posterior tibial artery, approxi-
mately 7 cm above the malleolus; the lateral reversed hemi-
soleus has a tenuous blood supply through minor perforators
from the peroneal and a shorter arc of rotation. The distal half
of the muscle can be reversely transposed based on minor
segment pedicles and cover the distal third of the leg.106
The medial border of the tibia is the landmark for medial
exposure, and the fibula itself is the landmark for lateral
exposure. A line can be drawn 2 cm medial to the medial edge
of the tibia or laterally along the fibula. Subcutaneous neuro-
vascular structures are identified and preserved, and the
posterior compartment fascia is opened. The plane between
the soleus and the gastrocnemius is usually well defined
superiorly, but sharp scalpel dissection is needed to separate
the tendons and maintain the gastrocnemius contributions to
the Achilles tendon. For proximally based flaps, distal perfo-
rators are divided in the deep plane, and the tendon is divided
distally. The dominant pedicle is usually located on the upper
one-third of the muscle for both bellies of the soleus. Identifi-
cation and dissection of the midline raphe allow a hemisoleus
flap to be developed (Fig. 5.15B–D).

132
SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
Fig. 5.15  Soleus muscle flap elevation. (A) It is a type II circulation pattern (with dominant pedicles from the popliteal, posterior tibial, and peroneal arteries and the minor
pedicles rise from posterior tibial and peroneal arteries supplying the distal medial and lateral bellies, respectively) and can cover the middle and lower-third of the leg.
(B–D) A patient with chronic osteomyelitis of the middle-third of the tibia is reconstructed using a hemisoleus flap.
A
B
C
D
because the same flap can be a septocutaneous flap when
it is based on a vessel traveling intermuscular septum and
becomes a perforator flap if the pedicle is from a direct mus-
culocutaneous perforator. However, despite the confusion in
nomenclature, this approach helps to achieve better accuracy
by alleviating concerns of anatomic variations and minimiz-
ing donor site morbidity. This kind of flap that may be based
on any perforator, “freestyle free flap”, allows the freedom of
flap selection from anywhere on the body.108 This principle is
used in local flaps as well where a flap can be rotated based
on a single perforator to cover the defect as well as minimize
donor site morbidity.47 This flap can also be rotated based on
the perforator to allow maximal arc of rotation and is also
known as a propeller flap.109 With the introduction of free
style elevation of perforator flaps, different layers are now
being used to elevate the flap. The classical fasciocutaneous
flap is the elevation of flaps beneath the deep fascial layer.
The subfascial elevation allows easiest dissection and clear
identification of the perforator. However, elevation of the
deep fascia may result in muscle herniation and suboptimal
aesthetic results. The report by Chang et al. showed that eleva-
tion can be made above the deep fascia on the radial forearm
free flap.110 Recent reports now show that elevation can be
made safely between the layers of deep and superficial fat
based on a perforator able to achieve harvesting thinner flaps
for resurfacing (Fig. 5.17).111,112 Thus the term fasciocutaneous
flap can depict the flaps elevated with the deep fascia and the
term skin flap or suprafacial perforator flap can be used for
flaps elevated above the deep fascia. The natural evolution of
skin flaps is now moving toward achieving minimal donor
site morbidity. Koshima et al. showed that the flap and the
pedicle can be taken above the deep fascia as a perforator flap
allowing decreased donor site.113,114 But anastomosis can be
difficult with a vessel diameter of less than 1 mm, hence this
technique is known as supermicrosurgery. Hong et al. have
also stretched the boundaries of microsurgery by introducing
the possibility of using perforators as recipient vessels and
the concept of “freestyle reconstruction”.115 Since the basic
approach may be similar, septocutaneous and perforator flaps
will be discussed together when necessary.

133
Fasciocutaneous/perforator flap
Fig. 5.16  Gastrocnemius flap elevation. It is a type I circulation pattern (the medial
muscle is supplied by the medial sural artery, and the lateral muscle is supplied by
the lateral sural artery) and provides coverage to the upper-third of the tibia,
suprapatellar thigh, and knee regions.
Medial sural artery,
nerve, and vein
Lateral sural nerve,
vein, and artery
Common
peroneal nerve
Medial head of
gastrocnemius (cut)
Lateral head of
gastrocnemius (cut)
Small saphenous
vein and sural
cutaneous nerve
retracted
Soleus
Gastrocnemius
insertion (cut)
Fig. 5.17  The elevation for fasciocutaneous flaps is made
underneath (subfascial dissection) and including the deep
fascia. The skin flap can be harvested over the deep fascia
(suprafascial dissection) or between the deep and the
superfical fat (superficial fascia dissection). Note the
distinctive layers for elevation
Sartorius
Direct linking vessels
Deep fascia
Indirect linking vessels
Superficial circumflex
iliac artery
Superficial fascia
Superficial
vein
Superficial fat
Deep
Femoral artery
Femoral vein
Skin

134
SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
to 180°. In addition, although the extent of survival associated
with the concept of angiosome is not clearly understood,
venous charging of the flap may help to decrease the chance
of congestion when the flap extends beyond two or three
angiosomes.109
The propeller flap in the lower extremity is very useful.
When the donor site is able to be closed after the rotation, it
provides excellent coverage and a superb donor site. The
thigh region can easily resurface moderate sized defects and
close primarily. The use of the freestyle concept allows basing
on any perforator around the defect (Fig. 5.19A–D).
Groin/superficial circumflex iliac perforator
The groin flap may be elevated extending between the femoral
vessels and the posterior iliac spine. This flap was one of the
early introduced fasciocutaneous flaps. The dominant pedicle
is the superficial circumflex iliac artery, with venae comitantes
and superficial circumflex iliac vein. A variation in anatomy
with superior inferior epigastric artery have been reported,
but Harii et al. conclude either source can supply the flap
efficiently (Fig. 5.20).116 The pedicle is very short: up to only
3 cm. Koshima defined that the superficial circumflex iliac
perforator flap is different from the groin flap in that it is
nourished by only a perforator of the superficial circumflex
femoral system (Fig. 5.21).117 The T12 sensory innervation is
at the lateral margin of the flap away from the pedicle, pre-
cluding use as a sensate flap.
The long axis of the flap is centered over a line parallel and
3 cm inferior to the inguinal ligament with a flap width of
6–10 cm. The flap can be used as a free or pedicled flap. For
pedicled flaps, the dissection should proceed from lateral to
medial and distal to proximal. Elevation is begun in a plane
superficial to the fascia lata and, when the sartorius muscle is
visualized, the flap is elevated deep to the fascia and superfi-
cial to the muscle. The perforator flap is elevated suprafascially
until a sizable perforator is located and is used either as a
pedicled or free flap.
The groin flap as a septocutaneous flap may provide a large
amount of skin and soft tissue and may need debulking where
excess tissue is not needed. However, the perforator flap
enables elevation with the thin skin above the fascia. The
donor site is well tolerated and well hidden, but the pale skin
and frequent hair growth of the donor site make for a poor
match, particularly with head and neck reconstructions.
Medial thigh/anteromedial perforator and
gracilis perforator
The medial thigh skin is supplied by musculocutaneous as
well as septocutaneous perforators. The medial thigh flap is
located at the midthigh, and the dominant blood supply for
this fasciocutaneous flap is the anterior septocutaneous artery,
and venae comitantes are from the superficial femoral artery
and vein at the apex of the femoral triangle (Fig. 5.22).118 The
coverage extends to the abdomen, groin, and perineum. The
saphenous vein may be elevated with the flap for improved
venous drainage. The sensory innervations are from medial
anterior cutaneous nerve of the thigh (L2–3). When the flap is
based more anteriorly, it is termed the anteromedial thigh flap
and is based on a branch of the lateral femoral circumflex
artery emerging from the lateral border of the sartorius. Minor
Propeller flaps
A propeller flap can be defined as an “island flap that reaches
the recipient site through an axial rotation”. Every skin island
flap can become a propeller flap. However, island flaps that
reach the recipient site through an advancement movement
and flaps that move through a rotation but are not completely
islanded are excluded from this definition (Fig. 5.18).109 When
a perforator propeller flap is being elevated, the perforator is
dissected free from the fascial and fat adhesions to minimize
the chance of kinking. Although less rotation reduces the
chance for kinking, the skin island may be safely rotated up
Fig. 5.18  Note the propeller flap rotated up to 180° based on the perforator.
A
B

135
Fasciocutaneous/perforator flap
Fig. 5.19  (A) 45-year old patient with cancer on the thigh. (B) After the cancer resection, a perforator was found near the defect and enabled a free style propeller flap to
be designed. (C) A near 180° rotation was made based on this perforator. (D) The patient at 2-year follow-up shows good contour and reconstruction results.
A
B
C
D
pedicles are contributed by musculocutaneous perforating
vessels of the sartorius and gracilis muscles. When the flap is
moved proximally to the groin, a perforator from the gracilis
muscle is found originating from the profunda femoris vessel
or the medial femoral circumflex vessel. All these flaps men-
tioned can be elevated as a perforator-based flap and named
medial thigh perforator flap, anteromedial thigh perforator
flap, and gracilis perforator (medial circumflex femoral artery
perforator) flap, respectively.119–122
For the medial thigh septocutaneous flap, the dominant
pedicle is typically located at the apex of the femoral triangle
approximately 6–8 cm below the inguinal ligament and is
bordered medially by the adductor longus and laterally by the
sartorius. A proximal incision is made to locate the vessels at
the apex of the femoral triangle. The remainder of the flap is
then incised and elevated subfascially.
Lateral thigh/profunda femoris perforator flap
The lateral thigh flap located along the lateral aspect of the
thigh between the greater trochanter and the knee can be
based on the three perforating branches of the profunda
femoris (Fig. 5.23).118 The first perforator arises just below the
insertion of the gluteus maximus, and flaps based on this
perforator are used for proximally based flaps to reach the
trochanteric and ischial areas. The third perforator arises
between the vastus lateralis and the biceps femoris muscles,
midway between the greater trochanter and the lateral condyle
of the femur, and the flaps based on second or third perforator
are for use as microvascular transplantation because of the
long pedicle. The flap is innervated from the lateral cutaneous
nerve of the thigh (L2–3).
Anterolateral thigh perforator
The anterolateral thigh perforator flap is one of the most
widely used perforator flaps. This flap was first reported as a
fasciocutaneous flap by Baek and Song et al.118,123 The skin can
be elevated from a septocutaneous or musculocutaneous
perforator. Numerous perforators are found along the region
of intermuscular septum between the vastus lateralis and
rectus femoris. These perforators usually drain into the
descending branch of the lateral femoral circumflex artery,
then proximally to the lateral circumflex artery, and then to
the profunda femoris artery (Fig. 5.24). When perforators are
traced to the source vessel, it allows the pedicle to have long
length and thicker diameter. Innervation of the anterolateral
thigh region is from the lateral femoral cutaneous nerve
(L2–3). The perforator frequently dissected is usually located
on the midpoint of the line drawn between the anterior

136
SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
superior iliac spine and the superior lateral border of the
patella. The perforator branches are identified with Doppler
near the midpoint of this line. According to our clinical experi-
ence, about 90% of perforators are found within a 3 cm
diameter drawn at the midpoint of the line. The skin flap is
designed to include the perforator and is then elevated from
the medial border. The flaps can be as large as 35 × 25 cm
based on a single perforator.124 The incision is made through
the deep fascia and raised subfascially until the intermuscular
septum between the rectus femoris and the vastus lateralis
muscle is reached. Now with increased knowledge of the
perforator flap anatomy, flaps can be easily elevated suprafas-
cially taking just a small cuff of fascia. At that point, the
descending branch of the lateral femoral circumflex is explored
Fig. 5.20  Groin flap elevation. The dominant pedicle is the superficial circumflex
iliac artery (A), with venae comitantes and superficial circumflex iliac vein (B).
A
B
Inguinal ligament
Superficial
circumflex
iliac artery
Sartorius
Saphenous vein
Superficial
circumflex
iliac artery
and vein
Sartorius
fascia
Fig. 5.21  The superficial circumflex iliac perforator flap is nourished by only a
perforator of the superficial circumflex iliac system. A large dimension of skin from
the inguinal region can be sufficiently supplied by a single perforator.
A
B
Fig. 5.22  The medial thigh flap located at the midthigh. The dominant blood
supply for this fasciocutaneous flap is the anterior septocutaneous artery, and venae
comitantes are from the superficial femoral artery and vein at the apex of the
femoral triangle.
Perforating branch to
fasciocutaneous flap
Superficial femoral artery
along with the perforator to the skin flap. The flap can be
harvested either as a perforator flap including only the perfo-
rator branch to the skin or combined with the vastus lateralis
muscle as a musculocutaneous flap. According to the need,
the skin paddle may be defatted up to a 3–4 mm thickness
except for the portion that the perforator branch enters. The
motor branch of the femoral nerve running medial to the

137
Fasciocutaneous/perforator flap
tissue transplantation, proximal superficial veins should be
dissected and preserved for possible anastomosis because the
venae comitantes are small.
Thoracodorsal artery perforator
This flap was first described by Angrigiani et al.128 The vascu-
lar territory lies on top of the latissimus dorsi muscle. The
main perforators are located along the course of the descend-
ing branch of the thoracodorsal artery or from the lateral
branch. The most proximal perforator reaches the subcutane-
ous tissue at a point located 2–3 cm posterior to the lateral
edge of the muscle and 8 cm below the posterior axillary
fold.129 The patient is positioned in a lateral decubitus position
with the upper arm in 90° abduction and 90° flexion at the
elbow. The lateral border of the latissimus is palpated and
marked. Doppler can be used to identify potential perforators
for the flap, and the most proximal perforator can be antici-
pated as mentioned above. Once perforators are identified,
the flap can be designed based on the perforator. Although
larger flap dimensions have been reported, flap dimensions
under 255 cm2 within its vascular territory are safe from
partial necrosis.130 Incision is made from the anterointerior
border of the flap allowing the identification of the anterior
border of the latissimus dorsi muscle. The dissection is
performed between the fat and the deep fascia covering
the muscle. This plane is easy to dissect as it is in a loose
areolar plane. While dissecting for the perforator, care should
be given when dissecting the proximal portion as direct
descending branch of the lateral circumflex femoral artery
should be preserved. To elevate as a sensate flap, a branch of
the lateral femoral cutaneous nerve should be included. The
donor site can be primarily closed depending on the laxity of
the skin (Fig. 5.25).
Sural
The sural flap is located between the popliteal fossa and the
midportion of the leg over the midline raphe between the two
heads of the gastrocnemius muscle. It is one of the longest
fasciocutaneous flaps of the lower leg based on the direct
cutaneous artery (sural artery branch) in the upper central calf
and extending to the Achilles tendon distally.125,126 The lesser
saphenous vein provides venous drainage. It can cover defects
of the knee, popliteal fossa, and upper third of the leg. When
used distally, based on a reverse flow through anastomoses
between the peroneal artery and the communicating vascular
network of the medial sural nerve, it can reach difficult defect
areas in the lower leg, ankle, and heel region (Fig. 5.26).127 It
is innervated by the medial sural cutaneous nerve (S1–2).
The flap is raised from distal to proximal, in the plane
beneath the deep fascia and above the gastrocnemius muscles.
The sural nerve and lesser saphenous vein are divided
distally and elevated with the flap. The pedicle should be
visualized and protected in the popliteal fossa, with continued
dissection of the pedicle for free tissue harvesting. For free
Fig. 5.23  The lateral thigh flap. This is located along the lateral aspect of the thigh
between the greater trochanter and the knee and can be based on the three
perforating branches of the profunda femoris.
Gluteus
Profunda femoral
artery (deep)
IIiotibial tract
Vastus lateralis
Biceps femoris
3rd perforating
branch of profunda
femoral artery
Fig. 5.24  The anterolateral thigh flap. Numerous perforators are found along the
region of the intermuscular septum between the vastus lateralis and the rectus
femoris. These perforators usually drain into the descending branch of the lateral
femoral circumflex artery, then proximally to the lateral circumflex artery, and then
to the profunda femoris artery.
Anterolateral thigh
flap isolated on lateral
branch of descending
lateral femoral circumflex
artery and lateral femoral
cutaneous nerve

138
SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
be maneuvered and placed in a 3D manner to achieve an ideal
one-stage reconstruction. Now as complex and complicated
defects are challenged, reconstruction using these compound
flaps is becoming routine for these cases.
According to Hallock’s classification, the subdivisions of
compound flaps are those with a solitary source of vascular-
ization and those with combinations of sources of vasculariza-
tion (Fig. 5.28).132 Those with a solitary source include
composite flaps, defined as multiple tissue components all
served by the same single vascular supply, and thereby con-
sisting of dependent parts. Those flaps with combinations of
sources of vascularization include conjoined flaps and chime-
ric flaps. Conjoined flaps are defined as multiple flap territo-
ries, dependent because of some common physical junction,
yet each retaining its independent vascular supply. Chimeric
flaps are defined as multiple flap territories, each with an
independent vascular supply, and independent of any physi-
cal interconnection except where linked by a common source
vessel (Fig. 5.29).
cutaneous or perforators adjacent to the anterior borders are
easily missed. After a suitable perforator is identified, the
design of the flap in accordance with the defect and pedicle
can be made. Perforators can be isolated or taken with a
muscle cuff reaching down to the main pedicle. Total pedicle
length depends on the location of perforator and the intra-
muscular course of the pedicle. Pedicle length can be acquired
up to 14–18 cm (Fig. 5.27).
Compound flaps
The complexity of reconstruction has changed from simple
coverage to addressing the issue of function and cosmetics.
Frequently a simple flap can result in adequate reconstruction
and may undergo several revisions until the final outcome
becomes acceptable. A compound flap consists of multiple
tissue components linked together in a manner that allows
their simultaneous transfer.131 These separate components can
Fig. 5.25  (A,B) The deep fat portion of the
anterolateral thigh can be debulked to
obtain a thinner pliable flap. (C,D) The
patient with soft-tissue defect of the ankle
region is seen with excellent contour after
reconstruction without further debulking.
A
B
C
D

139
Supermicrosurgery
Fig. 5.26  The reverse sural artery flap is a fasciocutaneous flap based on the
median superficial sural artery and its communication with the perforating branch of
the peroneal artery situated in the region of the lateral malleolar gutter. Reverse flow
is established after elevation of the flap and with division of the sural artery and the
nerve proximally.
Fig. 5.27  Thoracodorsal artery perforator flap. The main perforators are located
along the course of the descending branch of the thoracodorsal artery or from the
lateral branch. The most proximal perforator reaches the subcutaneous tissue in a
point located 2 or 3 cm posterior to the lateral edge of the muscle and 8 cm below
the posterior axillary fold. DB, descending branch; TD, thoracodorsal.
A
B
DB of TD
artery
Supermicrosurgery
The supermicrosurgery technique is defined as microsurgical
anastomosis of vessels, with a diameter <0.8 mm.109,129 This
technique, although reported frequently on lymphaticovenous
shunting to treat lymphedema and sporadically in soft-tissue
reconstruction with specific indications, is a relatively new
concept for lower extremity reconstruction.129–132 For the
lower extremity soft-tissue reconstruction, one of the applica-
tions can be seen in the perforator-to-perforator anastomoses
approach.68,111 With an evident pulse on the perforating artery,
it can be successfully used as a recipient vessel to supply a
sizable flap. This approach will allow an increase in the selec-
tion of recipient pedicles. By using a perforator-to-perforator
anastomosis approach, less time is consumed to secure the
recipient vessel as the flap can be elevated by taking just a short
segment of the perforator pedicle, which minimizes any risk
for major vessel injury, or can utilize collateral circulation
without apparent flow of major vessels while having accept-
able flap survival (Fig. 5.30). Further, studies on physiology and
anatomy will be needed to evaluate the extent of application.

140
SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
Fig. 5.28  Classification of compound flaps.
Composite
Conjoined
Chimeric
Fig. 5.29  The chimeric flaps defined as multiple flap territories, each with an
independent vascular supply, and independent of any physical interconnection except
where linked by a common source vessel. Example of complex extremity
reconstruction is shown using a chimeric approach. The source vessel of the
descending branch of the lateral femoral circumflex artery feeding the vastus lateralis
and the anterolateral thigh perforator flap. A gracilis is connected using a branch
from the source vessel.
A
B
Gracilis
Vastus lateralis
Anterolateral thigh
perforator flap
Descending branch of
lateral femoral circumflex
C

141
Supermicrosurgery
Fig. 5.30  (A) The application of supermicrosurgery (perforator-to-perforator anastomosis) on the lower extremity is shown. A patient with chronic osteomyelitis is seen after
debridement. (B) A recipient perforator was located adjacent to the defect margin piercing the fascia with a good visual pulse. (C) After the elevation of anterolateral thigh
with a short perforator pedicle segment, anastomosis is performed. (D) The flap is shown to have good contour without recurrence of infection.
A
B
C
D
1. Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes
of reconstruction or amputation after leg-threatening injuries. N
Engl J Med. 2002;347(24):1924–1931. The authors from Carolinas
Medical Center performed a multicenter, prospective, observational study
of 569 patients with severe leg trauma and evaluated the sickness-impact
profile: a multidimensional self-reported health status to determine the
long-term outcomes after amputation or limb reconstruction. They report
that at 2 years, there was no significant difference in scores for the
Sickness Impact Profile between the amputation and the reconstruction
groups. They advise that patients with limbs at high risk for amputation
may undergo reconstruction and will have results in 2 years that are
equivalent to those for amputation.
2. Chung KC, Saddawi-Konefka D, Haase SC, et al. A cost-utility
analysis of amputation versus salvage for Gustilo type IIIB and
IIIC open tibial fractures. Plast Reconstr Surg. 2009;124(6):1965–
1973. The authors from the University of Michigan Health System
evaluated the cost following amputation and salvage using the data
presented in a study from the LEAP. The authors extracted relevant data
on projected lifetime costs and analyzed them to include discounting and
sensitivity analysis by considering patient age. They report amputation
is more expensive than salvage, independently of varied ongoing
prosthesis needs, discount rate, and patient age at presentation.
Moreover, amputation yields fewer quality-adjusted life-years than
salvage. Salvage is deemed the dominant, cost-saving strategy.
11. Godina M. Early microsurgical reconstruction of complex trauma
of the extremities. Plast Reconstr Surg. 1986;78(3):285–292.
19. Ong YS, Levin LS. Lower limb salvage in trauma. Plast Reconstr
Surg. 2010;125(2):582–588. The authors from the Duke University
Medical Center review the approach to lower limb salvage. They state
that the primary goal of limb salvage is to restore or maintain function
based on proper patient selection, timely reconstruction, and choosing the
best procedure that should be individualized for each patient. Aggressive
debridement and skeletal stabilization, followed by early reconstruction,
are the current standard of practice and give better results than the more
traditional approach of repeated debridements and delayed flap cover. For
reconstruction, they state that free tissue transfer remains the best choice
for large defects, but local fasciocutaneous flaps are a reasonable
alternative for smaller defects and cases in which free flaps are deemed
not suitable.
36. Gottlieb LJ, Krieger LM. From the reconstructive ladder to
the reconstructive elevator. Plast Reconstr Surg.
1994;93(7):1503–1504.
56. Lange RH. Limb reconstruction versus amputation decision
making in massive lower extremity trauma. Clin Orthop Relat Res.
1989;(243):92–99. This study from the University of Wisconsin describes
the absolute and relative indications for primary amputation of limbs
with open tibial fractures. Absolute indications include anatomically
Access the complete reference list online at

142
SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
complete disruption of the posterior tibial nerve in adults and crush
injuries with warm ischemia time greater than 6 h. Relative indications
include serious associated polytrauma, severe ipsilateral foot trauma, and
anticipated protracted course to obtain soft-tissue coverage and tibial
reconstruction. However, he states that individual patient variables,
specific extremity injury characteristics, and associated injuries must all
be weighed before a decision can be reached and further prospective
studies are necessary before a well-defined protocol for primary
amputation can be properly developed.
68. Hong JP. The use of supermicrosurgery in lower extremity
reconstruction: the next step in evolution. Plast Reconstr Surg.
2009;123(1):230–235.
69. Kindsfater K, Jonassen EA. Osteomyelitis in grade II and III open
tibia fractures with late debridement. J Orthop Trauma.
1995;9(2):121–127.
88. Chen KT, Mardini S, Chuang DC, et al. Timing of presentation of the
first signs of vascular compromise dictates the salvage outcome of
free flap transfers. Plast Reconstr Surg. 2007;120(1):187–195.
108. Wei FC, Celik N. Perforator flap entity. Clin Plast Surg.
2003;30(3):325–329. The authors from the Chang Gung Memorial
Hospital state that the perforator flap is not a new concept in
microsurgery, but there is still confusion, and studies about the
differences between these flaps and the conventional flaps, including
donor site morbidity and long-term follow-ups, are increasing in
literature. Better accuracy in reconstruction, including the use of only
cutaneous tissue, minimization of the morbidity, and preserving the same
survival rate in free flaps are reassurances to microsurgeons with regard
to performing perforator flaps. He believes that in the near future, with
refinements in the techniques and instruments, perforator flaps will be
the first choice.

142.e1
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N Engl J Med. 2002;347(24):1924–1931. The authors from Carolinas
Medical Center performed a multicenter, prospective, observational study
of 569 patients with severe leg trauma and evaluated the sickness-impact
profile: a multidimensional self-reported health status to determine the
long-term outcomes after amputation or limb reconstruction. They report
that at 2 years, there was no significant difference in scores for the
Sickness Impact Profile between the amputation and the reconstruction
groups. They advise that patients with limbs at high risk for amputation
may undergo reconstruction and will have results in 2 years that are
equivalent to those for amputation.
2. Chung KC, Saddawi-Konefka D, Haase SC, et al. A cost-utility
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1973. The authors from the University of Michigan Health System
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presented in a study from the LEAP. The authors extracted relevant data
on projected lifetime costs and analyzed them to include discounting and
sensitivity analysis by considering patient age. They report amputation
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prosthesis needs, discount rate, and patient age at presentation.
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31. Jupiter JB, Tsai TM, Kleinert HE. Salvage replantation of lower
limb amputations. Plast Reconstr Surg. 1982;69(1):1–8.
32. Russell RC, Vitale V, Zook EC. Extremity reconstruction using the
“fillet of sole” flap. Ann Plast Surg. 1986;17(1):65–72.
33. Kuntscher MV, Erdmann D, Homann HH, et al. The concept of
fillet flaps: classification, indications, and analysis of their clinical
value. Plast Reconstr Surg. 2001;108(4):885–896.
34. Akyurek M, Fudem G, Leclair W, et al. Salvage of a lower
extremity by microsurgical transfer of tibial bone from the
contralateral extremity traumatically amputated at the ankle level.
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35. Weinberg A, Mosheiff R, Liebergall M, et al. Amputated lower
limbs as a bank of organs for other organ salvage. Injury.
1999;30(suppl 2):B34–B38.
36. Gottlieb LJ, Krieger LM. From the reconstructive ladder to
the reconstructive elevator. Plast Reconstr Surg. 1994;93(7):
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37. Meuli M, Raghunath M. Burns (Part 2). Tops and flops using
cultured epithelial autografts in children. Pediatr Surg Int.
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38. Lou RB, Hickerson WL. The use of skin substitutes in hand burns.
Hand Clin. 2009;25(4):497–509.
39. Burke JF, May JW Jr, Albright N, et al. Temporary skin
transplantation and immunosuppression for extensive burns. N
Engl J Med. 1974;290(5):269–271.
40. Delmonico FL, Cosimi AB, Russell PS. Temporary skin
transplantation for the treatment of extensive burns. Ann Clin Res.
1981;13(4–5):373–381.

142.e2
SECTION I
CHAPTER 5 • Reconstructive surgery: Lower extremity coverage
41. Kim EK, Hong JP. Efficacy of negative pressure therapy to enhance
take of 1-stage allodermis and a split-thickness graft. Ann Plast
Surg. 2007;58(5):536–540.
42. Callcut RA, Schurr MJ, Sloan M, Faucher LD. Clinical experience
with Alloderm: a one-staged composite dermal/epidermal
replacement utilizing processed cadaver dermis and thin
autografts. Burns. 2006;32(5):583–588.
43. Burke JF, Yannas IV, Quinby WC Jr, et al. Successful use of a
physiologically acceptable artificial skin in the treatment of
extensive burn injury. Ann Surg. 1981;194(4):413–428.
44. Kirsner RS. The use of Apligraf in acute wounds. J Dermatol.
1998;25(12):805–811.
45. Ali RS, Bluebond-Langner R, Rodriguez ED, Cheng MH. The
versatility of the anterolateral thigh flap. Plast Reconstr Surg.
2009;124(6 suppl):e395–e407.
46. Gravvanis AI, Tsoutsos DA, Karakitsos D, et al. Application of the
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47. Hyakusoku H, Yamamoto T, Fumiiri M. The propeller flap
method. Br J Plast Surg. 1991;44(1):53–54.
48. Serafin D, Voci VE. Reconstruction of the lower extremity.
Microsurgical composite tissue transplantation. Clin Plast Surg.
1983;10(1):55–72.
49. Lutz BS, Ng SH, Cabailo R, et al. Value of routine angiography
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50. Duymaz A, Karabekmez FE, Vrtiska TJ, et al. Free tissue transfer
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posttraumatic setting. Plast Reconstr Surg. 2009;124(2):523–529.
51. Mun GH, Lee SJ, Jeon BJ. Perforator topography of the
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52. Masia J, Clavero JA, Larranaga J, et al. Preoperative planning of
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53. Dublin BA, Karp NS, Kasabian AK, et al. Selective use of
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54. Reddy V, Stevenson TR. MOC-PS(SM) CME article: lower
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55. Haddock NT, Weichman KE, Reformat DD, et al. Lower extremity
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56. Lange RH. Limb reconstruction versus amputation decision
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1989;(243):92–99. This study from the University of Wisconsin describes
the absolute and relative indications for primary amputation of limbs
with open tibial fractures. Absolute indications include anatomically
complete disruption of the posterior tibial nerve in adults and crush
injuries with warm ischemia time greater than 6 h. Relative indications
include serious associated polytrauma, severe ipsilateral foot trauma, and
anticipated protracted course to obtain soft-tissue coverage and tibial
reconstruction. However, he states that individual patient variables,
specific extremity injury characteristics, and associated injuries must all
be weighed before a decision can be reached and further prospective
studies are necessary before a well-defined protocol for primary
amputation can be properly developed.
57. Bosse MJ, McCarthy ML, Jones AL, et al. The insensate foot
following severe lower extremity trauma: an indication for
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58. Dormandy J, Heeck L, Vig S. Major amputations: clinical patterns
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59. Gonzalez EG, Corcoran PJ, Reyes RL. Energy expenditure in
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60. Gallico GG 3rd, Ehrlichman RJ, Jupiter J, May JW Jr. Free flaps to
preserve below-knee amputation stumps: long-term evaluation.
Plast Reconstr Surg. 1987;79(6):871–878.
61. Kasabian AK, Colen SR, Shaw WW, Pachter HL. The role of
microvascular free flaps in salvaging below-knee amputation
stumps: a review of 22 cases. J Trauma. 1991;31(4):495–500,
discussion 500–501.
62. Byrd HS, Cierny G 3rd, Tebbetts JB. The management of open
tibial fractures with associated soft-tissue loss: external pin fixation
with early flap coverage. Plast Reconstr Surg. 1981;68(1):73–82.
63. Yaremchuk MJ, Brumback RJ, Manson PN, et al. Acute and
definitive management of traumatic osteocutaneous defects of the
lower extremity. Plast Reconstr Surg. 1987;80(1):1–14.
64. Guzman-Stein G, Fix RJ, Vasconez LO. Muscle flap coverage for
the lower extremity. Clin Plast Surg. 1991;18(3):545–552.
65. Arnez ZM. Immediate reconstruction of the lower extremity-an
update. Clin Plast Surg. 1991;18(3):449–457.
66. Isenberg JS, Sherman R. Zone of injury: a valid concept in
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Plast Surg. 1996;36(3):270–272.
67. Park S, Han SH, Lee TJ. Algorithm for recipient vessel selection in
free tissue transfer to the lower extremity. Plast Reconstr Surg.
1999;103(7):1937–1948.
68. Hong JP. The use of supermicrosurgery in lower extremity
reconstruction: the next step in evolution. Plast Reconstr Surg.
2009;123(1):230–235.
69. Kindsfater K, Jonassen EA. Osteomyelitis in grade II and III open
tibia fractures with late debridement. J Orthop Trauma.
1995;9(2):121–127.
70. Anthony JP, Mathes SJ. Update on chronic osteomyelitis. Clin Plast
Surg. 1991;18(3):515–523.
71. Calderon W, Chang N, Mathes SJ. Comparison of the effect of
bacterial inoculation in musculocutaneous and fasciocutaneous
flaps. Plast Reconstr Surg. 1986;77(5):785–794.
72. Chang N, Mathes SJ. Comparison of the effect of bacterial
inoculation in musculocutaneous and random-pattern flaps. Plast
Reconstr Surg. 1982;70(1):1–10.
73. Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic
osteomyelitis: experimental and clinical correlation. Plast Reconstr
Surg. 1982;69(5):815–829.
74. Hong JP, Shin HW, Kim JJ, et al. The use of anterolateral thigh
perforator flaps in chronic osteomyelitis of the lower extremity.
Plast Reconstr Surg. 2005;115(1):142–147.
75. Yildirim S, Gideroglu K, Akoz T. The simple and effective choice
for treatment of chronic calcaneal osteomyelitis: neurocutaneous
flaps. Plast Reconstr Surg. 2003;111(2):753–760, discussion 61–62.
76. Lipsky BA, Berendt AR, Deery HG, et al. Diagnosis and treatment
of diabetic foot infections. Plast Reconstr Surg. 2006;117(7
suppl):212S–238S.
77. Caputo GM, Cavanagh PR, Ulbrecht JS, et al. Assessment and
management of foot disease in patients with diabetes. N Engl J
Med. 1994;331(13):854–860.
78. Dargis V, Pantelejeva O, Jonushaite A, et al. Benefits of a
multidisciplinary approach in the management of recurrent
diabetic foot ulceration in Lithuania: a prospective study. Diabetes
Care. 1999;22(9):1428–1431.
79. Jolly GP, Zgonis T, Blume P. Soft tissue reconstruction of the
diabetic foot. Clin Podiatr Med Surg. 2003;20(4):757–781.
80. Hong JP. Reconstruction of the diabetic foot using the anterolateral
thigh perforator flap. Plast Reconstr Surg. 2006;117(5):1599–1608.
81. Banis JC Jr, Richardson JD, Derr JW Jr, Acland RD. Microsurgical
adjuncts in salvage of the ischemic and diabetic lower extremity.
Clin Plast Surg. 1992;19(4):881–893.
82. Tran NV, Evans GR, Kroll SS, et al. Postoperative adjuvant
irradiation: effects on transverse rectus abdominis muscle flap
breast reconstruction. Plast Reconstr Surg. 2000;106(2):313–317,
discussion 8–20.
83. Cordeiro PG, Neves RI, Hidalgo DA. The role of free tissue
transfer following oncologic resection in the lower extremity. Ann
Plast Surg. 1994;33(1):9–16.
84. Evans GR, Black JJ, Robb GL, et al. Adjuvant therapy: the effects
on microvascular lower extremity reconstruction. Ann Plast Surg.
1997;39(2):141–144.

142.e3
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87. Furukawa H, Yamamoto Y, Kimura C, et al. Clinical application of
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88. Chen KT, Mardini S, Chuang DC, et al. Timing of presentation of
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90. Glicksman A, Ferder M, Casale P, et al. 1457 years of microsurgical
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91. Hanasono MM, Butler CE. Prevention and treatment of thrombosis
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92. Nahai F, Silverton JS, Hill HL, Vasconez LO. The tensor fascia lata
musculocutaneous flap. Ann Plast Surg. 1978;1(4):372–379.
93. Nahai F, Hill L, Hester TR. Experiences with the tensor fascia lata
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94. Lewis VL Jr, Cunningham BL, Hugo NE. The tensor fascia lata
V–Y retroposition flap. Ann Plast Surg. 1981;6(1):34–37.
95. Bhagwat BM, Pearl RM, Laub DR. Uses of the rectus femoris
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96. Ger R. The surgical management of decubitus ulcers by muscle
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2009;62(2):e1–e5.
98. Quaba AA, Chapman R, Hackett ME. Extended application of the
biceps femoris musculocutaneous flap. Plast Reconstr Surg.
1988;81(1):94–105.
99. Tobin GR, Sanders BP, Man D, Weiner LJ. The biceps femoris
myocutaneous advancement flap: a useful modification for ischial
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100. Sassoon EM, Poole MD, Rushworth G. Reanimation for facial
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101. Giordano PA, Abbes M, Pequignot JP. Gracilis blood supply:
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266–272.
102. Schoeller T, Huemer GM, Wechselberger G. The transverse
musculocutaneous gracilis flap for breast reconstruction:
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103. Yousif NJ, Matloub HS, Kolachalam R, et al. The transverse gracilis
musculocutaneous flap. Ann Plast Surg. 1992;29(6):482–490.
104. Arnez ZM, Pogorelec D, Planinsek F, Ahcan U. Breast
reconstruction by the free transverse gracilis (TUG) flap. Br J Plast
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105. Tobin GR. Hemisoleus and reversed hemisoleus flaps. Plast
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107. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of
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108. Wei FC, Celik N. Perforator flap entity. Clin Plast Surg.
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but there is still confusion, and studies about the differences between these
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on propeller flaps. Plast Reconstr Surg. 2011;127(2):716–722.
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compound flaps. Plast Reconstr Surg. 2006;117(7):151e–160e.

SECTION I • Lower Extremity Surgery
6 
Diagnosis and treatment of painful
neuroma and nerve compression in the
lower extremity
Ivica Ducic, John M. Felder, and A. Lee Dellon
SYNOPSIS
■ Neuroma pain is due to regenerating axon sprouts trapped in the scar:
• Nerve block may identify the peripheral nerve causing the pain
• Remember that more than one peripheral nerve may be involved
• If possible, a critical sensory nerve should be reconnected to its
target
• A non-critical sensory nerve should have the neuroma resected
• It is OK to “lose your nerve”: trade pain for anesthesia
• The proximal end of the resected nerve must be placed into a
“quiet place”
• Implantation of a sensory nerve into a normal muscle is
evidence-based
• Choose an appropriate muscle for the location of the peripheral
nerve
• Remember that the painful neuroma may be in a painful joint
• Postoperative rehabilitation to include water walking, not only
massage.
■ Chronic nerve compression is common in the lower extremity:
• The most common site of entrapment is the distal tibial nerve
• Next most common site is the peroneal nerve at the
fibular neck
• Next most common site is the deep peroneal nerve at the foot
dorsum
• Superficial peroneal nerve (SPN) can be entrapped too
• Remember to look in both anterior and lateral compartments for
SPN
• Tarsal tunnel is not carpal tunnel, but analogous to the
forearm
• Must neurolyse medial and lateral plantar nerves distal to the tarsal
tunnel
• Must neurolyse calcaneal nerve in its tunnel distal to the tarsal
tunnel
• Postoperative rehab must include immediate ambulation.
■ Standards of care:
• Use of tourniquet, loupe magnification, and bipolar
coagulation.
Access the Historical Perspective section online at

Introduction
Though frequently ignored, misunderstood, or misdiagnosed,
nerve injuries and nerve compression syndromes are a fre-
quent occurrence in the lower extremity.
Painful neuromas, which occur following trauma or surgery
to the lower extremity, may be an unremitting source of pain
for affected patients, with detrimental effects on quality-of-
life. As an entity, they are frequently missing from the diag-
nostic tree of many physicians. They may be mistaken for
complex regional pain syndrome (CRPS) or other pain syn-
dromes with which they share some clinical features, relegat-
ing patients to chronic medical pain management therapy
rather than a direct, surgical approach to the problem. In this
chapter we will discuss the pathophysiology of painful neu-
romas and then explain how to select and treat surgical can-
didates to achieve pain relief.
Lower extremity nerve compression syndromes are largely
analogous to the well-recognized nerve compression syn-
dromes of the upper extremity, yet they and the surgical
approach to addressing them are often the subject of dispute
or incredulity among medical practitioners without training
in peripheral nerve surgery. These syndromes lead to loss of
sensation or motor function and can be the source of signifi-
cant morbidity for affected patients. In this chapter, we will
discuss the pathophysiology of nerve compression and then
explain how to select and treat surgical candidates to achieve
nerve decompression. We will also discuss CPRS: how to
distinguish it from neuromas or nerve compression and how
to manage it.
The principles for surgical treatment of lower extremity
neuromas and nerve compression syndromes were largely
elucidated by Mackinnon and Dellon, in the 1980s and 1990s,1
  Access video content for this chapter online at expertconsult.com

144
SECTION I
CHAPTER 6 • Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
Fig. 6.1  The spinal nerve is formed from a ventral (motor)
root and a dorsal (sensory) root of the spinal cord. Note that
the dorsal root is joined to dorsal ganglia that contain the
cell bodies of the sensory neurons, whereas the cell bodies
of the motor neurons are contained within the spinal cord
itself. When the spinal nerve exits the vertebral foramen, it
becomes ensheathed by Schwann cells and is termed a
peripheral nerve. This particular peripheral nerve is
illustrated as arising from the thoracic spine region, in which
region its sensory branches directly innervate the skin
without formation of a plexus, as occurs for the lower
extremity from the lumbosacral plexus. Note that the dorsal
ramus of the spinal nerve can be entrapped in its passage to
the lower back, causing symptoms of chronic nerve
entrapment termed “notalgia paraesthetica”.
Vein
Artery
Innermost intercostal
Internal intercostal
External intercostal
Nerve
Branches 1 and 2
Gray and white rami communicantes
Sympathetic ganglion
Branch 5
Anterior cutaneous branch
Branch 3
Dorsal rami
Branch 4
Lateral cutaneous branch
addressing, for example, the problems related to the tibial
nerve at the level of the ankle and the problems related to the
peroneal nerve at the knee, leg, and foot level, as well as the
problems with the sural nerve and the interdigital nerve. Dr.
Dellon also wrote extensively about these topics in the previ-
ous edition of this chapter, upon which this edition draws
heavily.
Basic science/disease process
The painful neuroma
The cell body for a sensory neuron of the peripheral nervous
system lies in a dorsal root ganglion and from the exit of this
nerve from the vertebral foramen it is covered with Schwann
cells (Fig. 6.1).
A painful neuroma develops following a discrete trauma
to a peripheral nerve. Typically, complete transection divides
the proximal and distal portions of the nerve. The axons of the
proximal segment regenerate via growth cones and attempt
to reach the axonal tubules of the distal segment (Fig. 6.2).6–8,9
However, if this process is disrupted by misalignment, scar
tissue, or other factors, the growing axons of the proximal
segment may fail to reach their distal target and instead
form a tangled mass of axonal sprouts, Schwann cells, and
fibrous tissue. This tangled mass is known as a neuroma,
and the nerve endings it contains are prone to spontaneous
or ephaptic depolarization that is often centrally interpreted
as pain. Physical tension on the neuroma with mechanical
deformation can further stimulate depolarization, and this is
often seen when the neuroma is encased in a surgical scar or
has healed in a superficial location prone to physical disrup-
tion, such as near a joint or subjacent to a weight-bearing
surface.10
In concordance with these underlying pathophysi-
ologic principles, treatment of an end neuroma focuses on
separating the proximal nerve from the neuromatous bulb
and placing it in an environment that will (1) discourage
growth of another neuroma and (2) not produce tension or
mechanical stimulation of the cut nerve end. Implanting
the proximal transected nerve end securely within a bulky
muscle has been shown experimentally to accomplish both of
these goals.11–13
Chronic nerve compression
Chronic compression of a nerve has sequential effects on the
anatomic subcomponents making up the peripheral nerve:
the endoneurium, perineurium, Schwann cells, vasa nervo-
rum, and axons are all involved in turn. As each of these
components is involved, a corresponding sign or symptom
becomes present in the patient presentation, permitting gra-
dations in diagnosis and treatment that correspond to the
degree of compression.
How the structure and function of the peripheral nerve are
altered with increasing degrees of pressure and with increas-
ing lengths of time have been investigated in rat, rabbit, and
monkey models,14–24 many of which have used the sciatic
nerve.

144.e1
Historical perspective
Historical perspective
The history of peripheral nerve surgery related to the painful
neuroma and chronic nerve compression is well documented.1–5
It should be noted that the terms “reflex sympathetic dystro-
phy” and “causalgia” are replaced by “CRPS I” and “CRPS
II”, respectively, according to modern usage in the pain man-
agement community.
It should be noted further that the nerve that causes a
painful joint is a peripheral nerve and can be treated by the
same techniques applied to a neuroma of a cutaneous periph-
eral nerve.

145
Basic science/disease process
Fig. 6.2  (A) A transection injury to a peripheral nerve results in degeneration of the axon distal to the site of transection (Wallerian degeneration). (B) The Schwann cells
along this distal segment of the axon survive, upregulate, and produce nerve growth factor, while the axons of the proximal segment produce sprouts for distal regeneration.
(C) When neural regeneration proceeds unimpeded, the axons will return to their distal target organ, with the creation of an in-continuity neuroma. (D) When neural
regeneration is impeded by scar tissue from the injury, distal regeneration does not occur and an end-bulb neuroma forms.
Peripheral Nerve
Skeletal
muscle
Normal nerve innervating
skeletal muscle.
The blue lines indicate
the basement membrane
The nerve has been
transected, and Wallerian
degeneration has begun.
There is corresponding
atrophy in the muscle
Proximal nerve terminals
send sprouts toward the
Schwann cell tubes
Some of the sprouts
make it into tubes and
reinnervate the muscle,
which has undergone
neurogenic rearrangement
A
B
C
D
A review of this literature indicates that if there is a con-
striction of greater than 20% placed upon the diameter of the
peripheral nerve, then acute axonal degeneration will occur.
If there is a pressure of greater than 20 mmHg applied to the
peripheral nerve, there will be a decrease in blood flow. In the
acute situation, these conditions produce pain. If this degree
of compression comes on over a gradual period of time, and
over a length of the peripheral nerve that is several times the
diameter of the nerve, then the conditions produce chronic
nerve compression. After about 2 months of compression by
a silicone tube that does not constrict the diameter of the
nerve, the first changes in the pathophysiology occur. These
are a weakening of the tight junctions of the endothelial cells
in the perineurium, and this results in serum entering the
endoneurial space. This creates endoneurial edema. When
this occurs in the relatively tight confines of the perineurium,
there is an increase in pressure that will decrease blood flow.
The conscious perception of this is paresthesia. At this point
in time, the only clinical findings will be related to the cutane-
ous sensory threshold for touch, which will first become ele-
vated for static two-point discrimination, or will manifest
itself as a change in perception of vibratory stimuli applied
with a tuning fork or a vibrometer.25,26 These pathophysiologic
concepts provide a basis for staging chronic nerve compres-
sion (Tables 6.1–6.4).
After about 6 months of this degree of compression, the
first histologic changes in myelin can be observed. This con-
sists of thinning of the myelin. With progressive compression,
there will be increasing loss of myelin, so that under slides in
which a myelin stain has been used, it appears as if there has
been a loss of the large myelinated, touch, fibers. They will
not actually have begun to degenerate yet, as demonstrated
by electron microscopy, in which the unmyelinated large
fibers can be demonstrated still to be present. At this stage,
the patient will have weakness in the motor system related to
the muscles supplied by that nerve and increasing numbness
in the territory (fingers) related to the sensory supply of that
nerve. Pinch and grip strength can be measured directly.
There will be no atrophy because without true loss of the
motor axons, there will be no decrease in bulk of the muscles.
Table 6.1  Numeric grading scale for any peripheral nerve
Grade
Description
  0
Normal
  1
Intermittent sensory symptoms
  2
Increased sensorimotor threshold
  3
Increased sensorimotor threshold
  4
Increased sensorimotor threshold
  5
Persistent sensory symptoms
  6
Sensorimotor degeneration
  7
Sensorimotor degeneration
  8
Sensorimotor degeneration
  9
Anesthesia
10
Muscle atrophy, severe
(Adapted from Dellon AL. A numerical grading scale for peripheral nerve
function. J Hand Ther. 1993;4:152.)

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CHAPTER 6 • Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
Table 6.2  Numeric grading scale for the median nerve at the
wrist level
Numeric score
Description of impairment
Sensory
Motor
0
0
None
1
Paresthesia, intermittent
2
Abnormal pressure threshold (pressure-
specified sensory device)
<45 years old: ≤3 mm, at 1.0–20 g/mm2
≥45 years old: ≤4 mm, at 2.2–20 g/mm2
3
Weakness, thenar muscles
4
Abnormal pressure threshold (pressure-
specified sensory device)
<45 years old: ≤3 mm, at >20 g/mm2
≥45 years old: ≤4 mm, at 20 g/mm2
5
Paresthesias, persistent
6
Abnormal innervation density (pressure-
specified sensory device)
<45 years old: ≥4 mm <8 mm, at any g/mm2
≥45 years old: ≥5 mm <9 mm, at any g/mm2
7
Muscle wasting (1–2/4)
8
Abnormal innervation density (pressure-
specified sensory device)
<45 years old: ≥8 mm, at any g/mm2
>45 years old: ≥9 mm, at any g/mm2
9
Anesthesia
10
Muscle wasting (3–4/4)
(Adapted from Dellon AL. A numerical grading scale for peripheral nerve
function. J Hand Ther. 1993;4:152.)
Table 6.3  Numeric grading scale for the ulnar nerve at the
elbow level
Numeric score
Description of impairment
Sensory
Motor
0
0
None
1
Paresthesia, intermittent
2
Weakness: pinch/grip (lb)
Female: 10–14/26–39
Male: 13–19/31–59
3
Abnormal pressure threshold (pressure-
specified sensory device)
<45 years old: ≤3 mm, at 1.0–20.0 g/mm2
≥45 years old: ≤4 mm, at 1.9–20.0 g/mm2
4
Weakness: pinch/grip (lb)
Female: 6–9/15–25
Male: 6–12/15–30
5
Paresthesia, persistent
6
Abnormal innervation density (pressure-
specified sensory device)
<45 years old: ≥4 mm <8 mm, at any g/mm2
≥45 years old: ≥9 mm, at any g/mm2
9
Anesthesia
10
Muscle wasting (3–4/4)
(Adapted from Dellon AL. A numerical grading scale for peripheral nerve
function. J Hand Ther. 1993;4:152.)
At this stage of compression, the cutaneous pressure thresh-
olds will be elevated increasingly for the quickly adapting
fibers, measured either with vibrometry or moving two-point
discrimination using the pressure-specified sensory device
(PSSD),27 and for the slowly adapting fibers, measured with
static two-point discrimination using the PSSD. Although no
longitudinal study using the Semmes–Weinstein nylon mono-
filaments has been published in patients with chronic nerve
compression,28 the analogous measurement, made with the
PSSD, which is one-point static touch, is still normal at this
stage of compression.9 Two-point discrimination, measured in
millimeters, is still normal because no nerve fibers have died.
At this stage in chronic nerve compression, with myelin thin-
ning, traditional electrodiagnostic testing may begin to detect
increases in the distal sensory latency. Amplitudes will still be
normal because no nerve fibers have died yet. In general,
quantitative neurosensory testing is more sensitive than tra-
ditional electrodiagnostic testing (nerve conduction study/
electromyogram), so it is more likely to detect this stage of
nerve compression. Neurosensory testing is less expensive
than nerve conduction study/electromyogram and will not
cause the patient any pain.29,30
If either the length of time is increased for this degree of
compression or the degree of compression increases, whether
due to work or metabolic or rheumatologic disease, then
neural degeneration occurs. As suggested in the preceding
paragraph, this will be detected in the motor system by muscle
wasting and in the sensory system by abnormal distance at
which one from two points can be distinguished. Examples of
these changes are given in Table 6.2 for median nerve com-
pression at the wrist, Table 6.3 for ulnar nerve compression at
the elbow, and Table 6.4 for tibial nerve compression in the
tarsal tunnel.23,25 Using the PSSD, this change occurs first for
static two-point discrimination and then for moving two-
point discrimination. This was demonstrated in a retrospec-
tive analysis of patients with carpal and cubital tunnel
syndrome. The one-point static touch measurement will
become abnormal some time after the change in two-point
discrimination distance, and is therefore a relatively insensi-
tive tool for detecting the onset of this stage. Vibrometry and
tuning fork use can identify this stage but does not permit the
therapist to identify correctly which nerve is being compressed
without additional testing. It must be remembered that the
vibratory stimulus travels as a wave, whereas the pressure
stimulus remains localized to the applied test site.19,20,27 For
example, if the involved nerve is the tibial nerve and the
hallux pulp is tested, there may still be relatively preserved
sensation mediated by the peroneal nerve. Testing of both the
dorsum of the foot and hallux pulp and medial heel may
permit distinction of which nerve is involved.

147
Diagnosis/patient presentation
Presentation and management of a single painful neuroma
may be relatively straightforward. However, because multiple
nerves may be injured and have neuromas, the distribution of
pain may not follow that of a single nerve. Instead, the pain
may correspond to a “region” of the limb. When this is the
case, it is paramount to differentiate whether this “region of
pain” is in fact caused by painful neuromas of adjacent nerves
with overlapping innervation territories or is caused by
another regional pain syndrome that is often treated non-
surgically: CRPS.
Classically, patients with painful neuromas will present
with a discrete tender area with distal paresthesias or anes-
thesia at an old scar or area of injury, and the pain will be
alleviated by local anesthetic blockade. If the symptoms are
as described above and sequential blockade of adjacent nerves
eliminates the pain, then multiple painful neuromas are likely
responsible for creating the region of pain and surgical treat-
ment is indicated. Patients with CRPS likewise have a region
of spontaneous pain that may spread beyond the anatomic
territory of a single nerve, but in contrast they will also present
with edema, atrophy, vasomotor, and/or sudomotor abnor-
malities in the skin of the affected limb. Patients with CRPS
may or may not have a history of obvious nerve injury. If there
is a history of known or suspected nerve injury, the syndrome
is called “CRPS type II” (formerly “causalgia”) – in these
cases, surgical treatment of the underlying nerve injury has
potential to reverse the pain syndrome, although the physiol-
ogy of this disease is complex and incompletely understood,
and not all patients are helped by surgery. Undertaking
surgery on such patients requires a more sophisticated
approach to diagnosis and perioperative management that is
discussed elsewhere in this book.31 If a patient with CRPS does
not have a known or suspected nerve injury, this is called
“CRPS type I” (formerly reflex sympathetic dystrophy), and
this syndrome is never treated with peripheral nerve surgery
because there is no obvious peripheral pain generator that
would be a target for surgical intervention. Instead, these
patients are treated with multimodal care including physical
therapy, sympathetic blocks, chronic pain management, and,
at times, spinal cord stimulators.
One particular area of presentation that can become confus-
ing is that of the painful joint. When a biomechanical abnor-
mality has been ruled out and a patient complains of a painful
joint after previous surgery or an injury, the diagnostic
dilemma of multiple painful neuromas vs. CRPS again pre-
sents itself. Because most joints are innervated by multiple
afferent nerves, and these nerves are small and often not
found in textbooks, there is a temptation to consider the joint
a “region” and label the patient with CRPS. However, it is
mandatory for the peripheral nerve surgeon to exclude the
possibility that multiple, treatable neuromas of joint afferents
are causing the problem by first excluding the presence of the
ancillary “sympathetic” features of CRPS on exam, and then
performing sequential local anesthetic blockades of the joint
afferents, looking for elimination of pain.
Anatomy books do not show nerves innervating joints, and
this knowledge required cadaver dissections, which have
been published for the knee (Fig. 6.3B & C)32 and the ankle
(Fig. 6.3A).33 Clinical approaches and results for the lower
extremity were reviewed in 2009.5 Beginning with the knee
and then extending this approach to the ankle, anatomic dis-
sections were performed to identify joint innervation. With
If there is some limitation on the gliding of the peripheral
nerve through its site of anatomic narrowing, then, when the
adjacent joint moves, there will be an increase in tension along
the length of the nerve, which may manifest itself as a further
increase in pressure upon the nerve. This limitation of gliding
may come from some injury or anatomic variant that limits
excursion of the nerves. This subject will be discussed in detail
related to individual nerve compression syndromes.
Diagnosis/patient presentation
(Videos 6.1, 6.2, 6.3 )
The painful neuroma
The patient with a painful neuroma will complain of an area
of skin or a joint that causes pain either at rest or, more com-
monly, when the part is touched or moved. When an area of
pain relates to the territory of a peripheral nerve, and the
patient has had an injury or an operation in that area, then
consideration must be given to the presence of a painful
neuroma of that peripheral nerve. If there is no history of
trauma or prior surgery, a “true” peripheral nerve tumor may
be suspected instead.
Table 6.4  Numeric grading scale for the tibial nerve at ankle
level
Numeric score
Description of impairment
Sensory
Motor
0
0
None
1
Paresthesia, intermittent
2
Abnormal pressure threshold (pressure-
specified sensory device)
<45 years old: ≤5.6 mm, at 1.0–20 g/mm2
≥45 years old: ≤7.8 mm, at 2.2–20 g/mm2
3
Weakness, abductor hallucis
4
Abnormal pressure threshold (pressure-
specified sensory device)
<45 years old: ≤5.6 mm, at 20 g/mm2
≥45 years old: ≤7.8 mm, at 20 g/mm2
5
Paresthesias, persistent
6
Abnormal innervation density (pressure-
specified sensory device)
<45 years old: ≥7 mm <10 mm, at any g/
mm2
≥45 years old: ≥9 mm <12 mm, at any g/
mm2
7
Intrinsic muscle wasting, clawing (1–2/4)
8
Abnormal innervation density (pressure-
specified sensory device)
<45 years old: ≥11 mm, at any given g/mm2
≥45 years old: ≥15 mm, at any g/mm2
9
Anesthesia
10
Intrinsic muscle wasting, clawing (3–4/4)

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CHAPTER 6 • Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
may not use muscles that cause ankle movement, leading to
disuse atrophy of the muscles. Secondly, there is often wasting
of the extensor digitorum brevis associated with ankle pain,
since the nerve that innervates this muscle, the deep peroneal
nerve, has been injured, usually with the stretch/traction
associated with an inversion sprain.
Chronic nerve compression
The signs and symptoms of compression neuropathy are well
known: the patient with chronic compression of a peripheral
nerve will complain of numbness or paresthesias in the skin
territory innervated by that nerve. The patient will complain
of weakness in the muscles innervated by that nerve. However,
just as multiple painful neuromas must be distinguished from
CRPS, there is an analogous diagnostic overlap between
multiple nerve compressions and metabolic neuropathies. For
instance, if both the peroneal and tibial nerves have chronic
compression at the same time, the patient will have numbness
over the dorsal and plantar aspects of the foot that arises
this knowledge, routes for the administration of local anes-
thetic were identified. Demonstrating that pain relief is pos-
sible by anesthetic blockade in patients who failed traditional
musculoskeletal approaches led to the creation of surgical
approaches to resect involved nerve(s).
A special category of patients with painful neuromas refers
to those who have undergone lower extremity amputation
and have developed painful neuromas of the amputation
stump that prevent them from using their prostheses. Forma-
tion of such neuromas can be discouraged during the initial
amputation by finding each major sensory or mixed nerve
and implanting it to muscle or effectively doing so by cutting
them on tension. However, many patients who undergo
amputation will have painful stumps without a biomechani-
cal or bony explanation and, if this pain can be localized and
relieved with anesthetic block, they may be candidates for
surgical treatment.34
In the patient with a painful neuroma, motor function
should be normal physiologically with the exception of two
considerations. Firstly, if there is ankle pain, then the patient
Fig. 6.3  Illustrations of the innervation of lower extremity joints. (A) The sinus tarsi is innervated by branches of the deep peroneal nerve that arise proximal to the lateral
malleolus, just before the branch to the extensor digitorum brevis. (B) The medial aspect of the knee joint is innervated by a branch of the femoral nerve. After the femoral
nerve innervates the vastus medialis, at which point anatomy books show the nerve terminating, the nerve continues distally and past the end of the muscle to innervate the
medial knee structures. (C) The lateral aspect of the knee joint is innervated by a branch of the sciatic nerve, which, after it innervates the posterior knee capsule, travels
anterior, deep to the biceps tendon, and then innervates the lateral knee structures. The medial and lateral retinacular nerves likely overlap anteriorly, although this has not
been proven. (With Permission from Dr. Dellon.)
A
B
C
Deep peroneal
nerve
Nerve to tarsal
sinus
Extensor
digitorum
brevis

149
Patient selection
injection. Once the pain has lasted 6 months, the patient enters
the phase of chronic pain and is now traditionally referred to
a pain management physician. At this point, the patient will
usually be tried on neuropathic pain medication, such as
nortriptyline, Neurontin, Cymbalta, or Lyrica, and often a
combination of these.
A nerve block is critical in patient selection. In the manage-
ment of the patient with chronic pain, the pain management
physician will often do a nerve block with or without cortisone
to identify and treat the peripheral nerve believed to be the
source of the pain. If the pain resolves for a few hours and
then returns, this block was actually a diagnostic block. If the
pain partially resolves, then perhaps more than one peripheral
nerve is the source of the pain. If the block fails to resolve,
then the local anesthetic failed to achieve its effect either due
to the presence of a second involved nerve or due to an ana-
tomic variation in the peripheral nerve that was supposed to
be blocked. If the block actually relieves pain for a prolonged
period of time, then it was therapeutic, and it should be
repeated by the pain management physician when or if the
pain recurs. Failure of the repeat block to achieve pain relief
signals an appropriate time for surgical intervention. A
sequence of nerve blocks for a painful foot dorsum is given
in Fig. 6.4.
proximal to the ankle. This will give the same appearance as
if the patient had a peripheral neuropathy, especially if the
problem occurs in both legs. This type of situation occurs in
patients who have sports injuries, or other injuries. As a
contrast in etiology, but with the same clinical presentation,
will be patients who do have a metabolic neuropathy, for
example, those with diabetes, or chemotherapy-induced
neuropathy, who have secondary chronic nerve compressions.
These patients will present with a history of neuropathy and
frequently will not have been examined to identify the pres-
ence of a chronic nerve compression.35 If the nerve compres-
sion is diagnosed and treated in such patients, they will
frequently experience sensory recovery despite the presence
of diabetic neuropathy.36,37
The pathognomonic feature of chronic nerve compression
on physical examination is the presence of a positive Hoffman–
Tinel sign. With an understanding of the pathophysiology of
chronic nerve compression (see above), it becomes clear that in
the earliest stage there will be intermittent symptoms and there
will be no physical findings present. This is often the situation
with musicians, such as the pianist or violinist who complains
of numbness in the little finger, from playing with the elbow
bent, but has no Hoffman–Tinel sign over the ulnar nerve at the
cubital tunnel. In the lower extremity, an analogous situation
occurs with the soccer player whose leg may seem to give out,
and who has received many a blunt trauma to the outside of
the knee or repeated ankle inversion sprains, and has compres-
sion of the common peroneal nerve at the fibular neck. With
further time and a greater degree of compression, axons will
demyelinate and there will be an increase in the threshold
required to produce a sensory response: a higher degree of
vibration with the tuning fork, or a greater pressure required
to discriminate one from two points when touching the big-toe
pulp with the PSSD while two-point discrimination distance
remains normal. In the motor system, this will correspond
to weakness on manual muscle testing. At this point, the
Hoffman–Tinel sign will become positive. With more time and
a greater degree of compression, axons will die, there will be a
decrease in two-point static touch discrimination (the distance
before two points can be distinguished will increase), and
muscle atrophy will occur. The Hoffman–Tinel sign will remain
positive. With a very advanced degree of compression, the
peripheral nerve seems to stop its attempt to remyelinate and
regenerate, and the Hoffman–Tinel sign becomes negative.
This variation in the presence of the Hoffman–Tinel sign over
time is understandable in terms of progression of compression
and changes within the peripheral nerve and should not be
interpreted as a failure of the Hoffman–Tinel sign to be a
valuable clinical examination technique.38,39
Patient selection
The painful neuroma
Selection of the patient for surgical treatment of the painful
neuroma begins after the first 6 months of pain. During the
first 6 months of the patient’s pain, management will usually
be done by the primary care physician and/or the original
treating surgeon, often in conjunction with a therapist.
Most often, the patient will have tried opiates, non-steroidal
anti-inflammatory drugs, massage, ultrasound, and steroid
Fig. 6.4  Sequence of nerve blocks to identify source of dorsal foot pain. The nerve
block is done using a sterile technique. After swabbing the skin with Betadine, a
mixture is prepared that contains half 1% xylocaine and half 0.5% bupivacaine, each
without epinephrine, is prepared. This is injected first next to the saphenous nerve,
proximal to the medial malleolus. This is for a painful tarsal tunnel incision, a
crushed foot, or a painful bunion incision. Then the deep peroneal nerve is blocked
next, above the ankle, between the extensor hallucis longus and the extensor
digitorum communis tendons. At this level, the block will also denervate the sinus
tarsi. If sinus tarsi pain is only partially eliminated, then you must block the sural
nerve, posterior to the lateral malleolus (not shown) as this nerve contributes to
sinus tarsi innervation in 25% of patients. Finally, the superficial peroneal nerve is
blocked next. This can be done as shown here at the site of a positive Tinel’s sign,
or just dorsolateral to the ankle joint. Following this the patient must attempt to
walk, squat, and touch the top of the foot to determine the effect of the block on
pain.

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CHAPTER 6 • Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
is involved too. If the patient has back symptoms that radiate
into the foot, then it is appropriate to obtain electrodiagnostic
studies to be sure that there is not an L5 or L4 radiculopathy
present.
Surgical technique
The painful neuroma (Box 6.1)
The common lower extremity neuromas of cutaneous nerves
requiring surgical treatment are those of the SPN,43 deep
peroneal nerve,43 saphenous nerve,43 sural nerve,43 and calca-
neal nerve.44 A Morton’s neuroma is not a true neuroma, but
a chronic nerve compression of an interdigital nerve caused
by the intermetatarsal ligament, and the treatment is therefore
neurolysis by division of the intermetatarsal ligament.45
However, since most foot and ankle surgeons treat a Morton’s
neuroma by excision of the interdigital nerve, failure of that
approach does create a true neuroma of an interdigital nerve,
and this must be treated as a neuroma.46,47 The most common
lower extremity neuroma of a joint afferent is that of the deep
It is the goal of a nerve block to place the local anesthetic
adjacent to, not into, the peripheral nerve. If the patient has
immediate pain when the needle is inserted, and the pain
radiates in the territory of that nerve, then the needle is in the
nerve and you should not inject the anesthetic or you will
cause a nerve injection injury. You should pull the needle
slightly away and then inject. Success of the nerve block
requires the patient to say that the pain has gone and, if it is
a cutaneous nerve, that the expected area of skin has become
numb.
Chronic nerve compression
Selection of the patient for surgical decompression of a
peripheral nerve requires that at least four conditions are met:
1. The patient’s symptoms fit with both the motor and the
sensory distribution of the given peripheral nerve.
2. The impairment is documented by appropriate
measurement of the motor and sensory function of that
nerve.
3. There is a positive Tinel’s sign at the known site of
anatomic narrowing of that nerve.
4. All possible non-operative measures have been
employed for 3 months without success in relieving the
symptoms.
Note that it is not essential for an electrodiagnostic test to
be performed and it is not essential that the results of that test
demonstrate chronic nerve compression. This is because, even
where traditional nerve conduction and electromyography
are best for the median nerve at the wrist, the false-negative
rate is 33%, and in patients with diabetes this type of testing
cannot be relied upon to identify the presence of a chronic
nerve compression in the presence of an underlying neuropa-
thy.40 In the lower extremity, in a patient over the age of 55,
the false-positive rate for the medial plantar and electromyo-
gram of the medial plantar-innervated muscles is 50%, and
therefore, in the adult even without neuropathy, this testing
is prone to error. Since traditional testing cannot identify
nerve compression in the presence of neuropathy at the wrist,
it certainly cannot identify it reliably at the ankle. Therefore
the clinician must rely upon the presence of a positive
Hoffman–Tinel sign to indicate the location of the chronic
nerve compression.
Neurosensory testing with the PSSD is the most sensitive
method of documenting sensibility in a piece of skin (Fig. 6.5).
This has been documented to be valid and reliable for both
the upper and lower extremity,27,28,29,40–43 and to be essentially
equivalent to the information obtained with traditional elec-
trodiagnostic studies of the median nerve at the wrist in a
level I study.30 For the patient with heel pain, for example,
the medial calcaneal nerve will have an abnormal pressure
threshold with normal distance for distinguishing one-point
from two-point static touch, with normal measurements for
both the medial plantar (hallux pulp) and over the dorsum of
the foot. When treatment for plantar fasciitis continues to fail
after 3 months, and when the two-point static distance
becomes abnormal, then it is appropriate to do a neurolysis
of the calcaneal nerve. If the measurements for the hallux pulp
are also abnormal, then tarsal tunnel syndrome is present. If
the measurements for the dorsum of the foot are abnormal in
addition to those for the tibial nerve, then the peroneal nerve
Fig. 6.5  The pressure-specified sensory device is shown with its components for
grip and pinch strength, as well as the device with the two prongs, each of which is
attached to a pressure transducer (silver attachment with prongs). The configuration
shown is the PDA platform, which is portable between offices. No needlestick or
electrical stimulation is used. Once the patient perceives the stimulus correctly,
they can push a button that ends the digital signal acquisition, and therefore this is
a subjective test of sensibility. (With permission from Sensory Management
Services, LLC, Towson, Maryland, USA.)
BOX 6.1  Successful treatment of the painful neuroma
Obtain complete relief of pain with a preoperative nerve block.
Remember that more than one nerve may be involved.
Remember that an afferent joint may be involved.
Remember that part of the pain may be from a compressed nerve.
Resect the painful neuroma.
Implant the proximal end of the divided nerve into a normal muscle.