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

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CHAPTER 6 • Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
protected this nerve, the dissection proceeds into the popliteal
fossa deep to this fascia. There is great variability in the sural
nerve anatomy.54 At the ankle, this is actually the common
sural nerve. If the commonest variation is present, there will
be one large sural nerve present with two fascicles and an
artery, having been formed from a short medial sural branch
from the tibial nerve and a short lateral sural nerve from the
common peroneal nerve. A nerve stimulator is used to prove
this is not an anomalous motor branch to a gastrocnemius or
foot flexor. Then bupivacaine is infiltrated into the nerve
proximally under very little pressure so that it is not forced
proximally towards the sciatic nerve. The nerve is cauterized
distally and proximally, the intervening 3 cm segment sub­
mitted to pathology, and the proximal end allowed to retract
into the popliteal fossa proximal to the knee joint.
About 20% of the time, there will be a separate medial and
a separate lateral sural nerve already present in the popliteal
fossa, each going distally to join somewhere in the distal leg
to form the common sural nerve. If the popliteal fossa explora­
tion identifies a single fascicle, then you must continue the
dissection into the medial part of the popliteal fossa to search
for the second component. If the sural branches cannot be
interrupted intradermal sutures, and 5-0 interrupted and
continuous sutures to the skin.
A neuroma of the deep peroneal nerve can be due to injury
over the dorsum of the foot or a stretch traction injury that
causes problems with the nerve that innervates the sinus tarsi
proximal to the ankle (Fig. 6.3A). In either situation, the surgi­
cal technique to resect the deep peroneal nerve is through an
incision about 5 cm in length centered about 10 cm proximal
to the lateral malleolus. Both the anterior and lateral compart­
ments must be opened to gain access. A neurolysis of the SPN
must be done to insure its safety. Then a dissection is done
across the interosseous membrane, using the bipolar to lift the
muscle origins from the membrane. The dissection continues
until the tibia is reached. The retractor is then elevated, and
the neurovascular bundle is visualized. The deep peroneal
nerve is dissected from the artery and vein. Bupivacaine is
injected into the nerve proximally (Fig. 6.6). A 2.5 cm segment
of the nerve is resected, cauterizing the nerve proximally and
distally with the bipolar coagulator first. The nerve proximally
does not have to be implanted formally into muscle since it is
surrounded by muscle. Bupivacaine is then injected into the
muscle and skin edges, and the wound is closed with 4-0
Monocryl interrupted intradermal sutures, and 5-0 inter­
rupted and continuous sutures of the skin.
A neuroma of the distal saphenous nerve is most often due
to a previous surgical procedure, such as ankle arthroscopy,
harvesting the saphenous vein, or a tarsal tunnel release. The
incision for the neuroma resection must be proximal to the
previous site of injury. Once the saphenous vein is identified,
if it has not been harvested, you must explore both the sides
of the vein, anteriorly and posteriorly for small (<1 mm)
nerves. The saphenous nerve has often branched at this point
to send the posterior branch into the region of the tarsal tunnel
incision and the anterior branch into the region of the ankle
arthroscopy. The nerves are each divided distally, dissected
proximally, and a window opened into the fascia overlying
the soleus muscle (Fig. 6.7). A tunnel is created into the muscle,
and the nerves are loosely implanted. Bupivacaine is then
placed, and the skin closed as above.52
A neuroma of the sural nerve is due to previous surgery
about the ankle, most often during procedures to tighten the
ankle from repeated inversion sprains, but often due to
approaches used for open reduction and internal fixation of
fractures. Somewhat more proximally, the nerve may have
been injured during a sural nerve biopsy or excision of a skin
lesion, or from a direct injury. The approach to the sural nerve
must recognize that resecting the sural nerve in the leg, while
technically easier, places the nerve at a location where shoes
or boots will rub against the site into which the nerve is
implanted, and if the nerve is implanted into the gastrocne­
mius muscle, then plantar flexion and extension may stimulate
the nerve at the implantation site. From the practice of har­
vesting the sural nerve as a source of nerve graft material,
there is considerable experience with leaving the proximal
end of the nerve in the popliteal fossa. Therefore my preferred
approach (Fig. 6.8) is to make an incision over the fibular neck,
extending posteriorly into the popliteal fossa.
First, the common peroneal nerve is identified beneath the
fascia then followed distally and a neurolysis completed by
releasing the fascia of the peroneus muscle group and elevat­
ing these muscles to release a fibrous band, found in about
20% of normal cases.53 Then, having safely identified and
Fig. 6.7  The saphenous nerve innervates the skin of the proximal portion of the
tarsal tunnel incision and can be the source of this scar hurting. Ankle arthroscopy
can injure it as well. (A) The incision is made at the site of the Tinel’s sign, and
either one or two small branches will be identified, most commonly one on each
side of the saphenous nerve. Each must be resected, dissected proximally, and then
(B) a window created in the soleus fascia and the proximal ends of the nerves
implanted into this muscle.
A
B

153
Surgical technique
A neuroma of the calcaneal nerve is due to an injury, most
often during neurolysis of the tibial nerve during tarsal tunnel
surgery or during an open or endoscopic plantar fasciotomy.44
It is now appreciated that the posterior branch of the distal
saphenous nerve innervates the part of the tarsal tunnel inci­
sion that is most proximal,55 can be identified as a distally
radiating sign anterior and proximal to this incision, and can
be relieved with a block. Pain in the tarsal tunnel scar distal
to this, or at the site of the medial plantar fasciotomy site, is
due to a neuroma of one or more branches of the calcaneal
nerve. This anatomy has been well defined.56 For the most
distal site of pain, this is a calcaneal branch that arises from
the medial plantar nerve, crosses the vessels, and goes through
the fascia of the abductor hallucis to enter the skin of the
medial arch. This distal site is resected, and gentle traction
will reveal the fascicle giving origin to it as the most anterior
fascicle of the medial plantar nerve within the tarsal tunnel.
This fascicle can be divided and implanted into the flexor
hallucis longus muscle, the most distal muscle in the leg (Fig.
6.9). If the heel pain is more proximal, then it is due to a
neuroma of one or more of the traditionally depicted branches
of the lateral plantar nerve, or even the tibial nerve, arising
on the posterior aspect of the tibial or lateral plantar nerve.
This nerve is identified, divided, and implanted into the flexor
hallucis longus muscle. This often requires microdissection,
intraneural neurolysis, in order to preserve the distal sensory
and motor branches of the lateral plantar nerve.
A neuroma of the interdigital plantar nerve is a true
neuroma. The so-called Morton’s neuroma, on the other hand,
is not a true neuroma. It is a compression caused by the
intermetatarsal ligament, and the treatment is neurolysis by
division of this ligament.45 If the Morton’s neuroma is resected
through the typical dorsal incision and pain returns, then
there is a true neuroma of this plantar interdigital nerve. If
there has been an injury, due to a penetrating foreign body or
fracture fixation, then there is a true neuroma. The treatment
of the true neuroma is to identify the correct interdigital nerve
through a plantar incision in the non-weight-bearing surface
of the foot.46,47 First, the plantar fascia is split longitudinally
and the flexor brevis muscle is dissected from this origin to
permit inspection of both the medial and lateral plantar nerves
as they exit the medial and lateral plantar tunnels. The branch
to the medial side of the hallux and the branch to the lateral
side of the fifth toe will not be seen as they originate more
proximally. You must identify the branch to the first/second
webspace and the fourth/fifth webspace and preserve these.
The motor branches are identified with a nerve stimulator.
The remaining branches, those to the second/third and third/
fourth webspaces, can be resected if necessary depending
upon the exact distal injury or previous surgery. These resected
nerves then require microdissection, intraneural neurolysis,
proximally until the point where they can be rotated and
implanted into the arch of the foot without placing tension on
the remaining intact nerves. These nerves must be implanted
into the arch of the foot.
While it is hard to place a suture into the arch of the foot,
this can be done, and the epineurium of the resected nerves
can be attached loosely to that suture. My current preferred
technique is to use a mini- (not micro-) Mitek anchor (Fig.
6.10). Remove the large suture that comes with it, and replace
it with a 6-0 nylon. Suture the nerve loosely to the anchor, and
then gently press the anchor into the fibrous structures of the
identified with certainty, then you must make an incision over
the distal lateral leg, identify the common sural nerve, and
gently put it under traction to identify the proximal compo­
nents. In some patients, even after the proximal resection,
there will still be some sensation and pain in the sural distri­
bution. This is almost certainly due to the lateral sural nerve
sending some axons along with the SPN. In this situation,
there will be a posterior branch from the sural nerve that can
be identified about 10 cm proximal to the ankle, and if pain
is persistent after the proximal resection of the sural nerve,
then a neurolysis of the SPN is indicated to identify and resect
this branch.
Fig. 6.8  The sural nerve ideally should be resected so its proximal end lies in the
popliteal fossa. The sural nerve at the ankle is the common sural nerve. In the
popliteal fossa there is one branch, the lateral sural nerve, arising from the common
peroneal nerve and a second branch, the medial sural nerve, arising from the tibial
nerve. (A) The common peroneal nerve is approached first, doing a neurolysis to
protect it from harm. This large nerve is noted in the superior aspect of the incision.
The incision has an extension into the popliteal fossa. The dissection goes beneath
the deep fascia, and here the lateral sural nerve is usually found first, as seen in the
vessel loop. (B) Two distinct fascicles should be identified, and a deeper dissection
then demonstrates the medial sural nerve, shown in the second vessel loop. If the
two branches have joined quite proximally, there may be one large nerve with two
fascicles and one artery. Intraoperative electrical stimulation should be done to be
sure these are not aberrant motor fascicles.
A
B

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CHAPTER 6 • Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
proximally within their tunnel into one of the adductor
muscles. This is done “blindly” without actually seeing the
muscle (Fig. 6.11).50
A neuroma of the saphenous nerve in the adductor canal
is are. Often, the adductor canal must be opened to identify
branches of saphenous nerve at this level, especially if more
distal resection failed to due to resolve the pain problem. This
is often due to anomalous saphenous and/or obturator nerve
branches. The nerves are first stimulated to prevent inadver­
tent vastus medial denervation, followed by implantation of
proximal stump of resected nerve to the adductor magnus
muscle (Fig. 6.12).
A neuroma of the innervation of the knee joint, the medial
and/or lateral retinacular nerve is due to previous surgery,
whether to reconstruct the ligaments, or endoscopy, or to total
knee replacement. The innervation of the knee joint has been
described and is constant (Fig. 6.3).32 Depending upon the
arch. The nerve(s) are then suspended and covered with the
plantar quadratus and the flexor brevis muscles. The plantar
fascia is loosely closed with 4-0 Monocryl. The skin is closed
with interrupted and continuous sutures of 4-0 nylon. Please
note that about 75% of these patients also have tarsal tunnel
syndrome, and this needs to be addressed at the same
operation.47
A neuroma of the infrapatellar branch of the saphenous
nerve is most often due to previous knee surgery with a
midline incision. There is numbness over the lateral infrapa­
tellar skin with a painful trigger over the insertion of the
adductor muscles at Gerdy’s tubercle. There can be two or
three branches at this level. The surgical approach is through
a longitudinal incision, identifying the branch or branches
deep to the fascia, dissecting them proximally through their
well-defined tunnel, injecting them with bupivacaine, divid­
ing them distally after cauterization, and implanting them
Fig. 6.9  The calcaneal nerve is resected whenever it has been injured by previous surgery, usually for plantar fasciitis, or in previous tarsal tunnel surgery. (A) There is
often more than one calcaneal branch. Here there are branches related to the medial plantar nerve, held with vessel loops, and from the lateral plantar nerves, also held with
vessel loops. The tibial nerve has had a neurolysis from the previous tarsal tunnel decompression scar. (B) The proximal end of the divided calcaneal nerve is ready to be
implanted into the flexor hallucis longus muscle, just posterior to the tibial nerve.
A
B
Fig. 6.10  True neuroma of the plantar interdigital nerve. (A) After resection of the nerve compression, incorrectly termed Morton’s neuroma, a true neuroma will form. If it
becomes symptomatic, it must be approached plantarly, and the presumed anatomy is drawn. (B) After making an incision on the non-weight-bearing skin and incising the
plantar fascia, the flexor brevis is retracted laterally to dissect the medial plantar nerve. (C) Then the lateral plantar nerve is dissected and the branches to the neuroma, in
this case, one from each, are encircled with the vessel loop. (D) The divided nerves have been dissected proximally, brought into the wound, and inserted onto a mini-Mitek
metal suture to be implanted into the fibrous structures of the arch of the foot.
A
B
C
D

155
Surgical technique
Fig. 6.11  The infrapatellar branch of the saphenous nerve is most often injured
proximally during total knee arthroplasty, as shown here. (A) The incision is made
over Gerdy’s tubercle and is distal to the incision for the medial knee denervation
(shown). While the leg is exsanguinated, the knee is left with some blood still
present, and this helps identify the nerve adjacent to the vein. (B) The nerve is
divided distally, cauterized to prevent bleeding from its end, and its tunnel is
dissected. (C) The proximal end of the nerve is then pushed backwards into the
tunnel with a clamp that is used to implant the nerve into an adductor muscle
proximal to the knee joint.
A
B
C
nerve block, these nerves, usually both of them, must be
resected. If the patient has had a total knee arthroplasty, the
implant is not exposed. Longitudinal incisions are made
midmedial and midlateral. Medially (Fig. 6.13), the medial
retinaculum is opened, and just distal to the vastus medialis,
the medial retinacular nerve will be identified next to the
recurrent geniculate vessels. The nerve is blocked proximally,
cauterized distally, and then dissected proximally where its
proximal end is implanted into the vastus medialis muscle.
Laterally (Fig. 6.14), the iliotibial tract is incised longitudinally,
at which location it has become the lateral retinacular, and just
distal to the vastus lateralis and adjacent to the recurrent
geniculate vessels is the lateral retinacular nerve. It is blocked
proximally with bupivacaine, cauterized distally, dissected
proximally to where it goes deep to the biceps femoris inser­
tion, cauterized again, and resected under tension and
dropped into the popliteal fossa, since it originates from the
sciatic nerve.5,49,50,57
Patients with amputation stump pain should be approached
with a surgical technique analogous to those described above.
The nerves most commonly involved are the saphenous,
medial and lateral sural, tibial, and superficial and deep
peroneal in below-knee amputation stumps. In above-knee
stumps, the posterior femoral cutaneous, anterior femoral
cutaneous, and sciatic nerves are most commonly involved.
In all cases, the suspected nerve is approached from proximal
to the site of the scar to avoid distortion of the anatomy and
surgical field. Once identified, the nerve is transected and
implanted into locally available muscle.38
A study of 100 neuroma specimens submitted to pathology
revealed that in no case was there evidence of occult malig­
nancy or anything beyond “expected” traumatic neuroma
tissue. Thus we no longer routinely submit typical-appearing
resected neuromas to pathology.58
Chronic nerve compression (Box 6.3)
The diagnosis and treatment of lower extremity chronic nerve
compression are the same as that for upper extremity chronic
nerve compression: only the anatomy differs. To begin treat­
ing patients with lower extremity peripheral nerve compres­
sion, it is advisable to review your anatomy and to do a
cadaver dissection.
The fact that many patients with chronic nerve compres­
sion syndromes are not referred is due to many issues, not
least of which is an ignorance on the part of the primary care
physician of the various nerve compressions and the symp­
toms associated with them. There is also a degree of ignorance

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CHAPTER 6 • Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
Fig. 6.13  Medial knee denervation (A) is approached through an incision just distal to the vastus medialis, where the medial retinaculum is opened. The medial retinacular
nerve is adjacent to the recurrent geniculate vessels, which are visible because the knee region has not been exsanguinated by the tourniquet. (B) The medial retinacular
nerve is dissected proximally from its origin beneath the vastus medialis muscle and implanted deep into this muscle.
A
B
Fig. 6.12  The adductor canal should contain the saphenous nerve. Distal to the
canal, this nerve divides into the infrapatellar and distal branches, but these divisions
may exist within the canal already. (A) The incision for either decompression of the
saphenous nerve or resection of the nerve is the same and is located at about the
junction of the middle and distal third of the medial thigh at the site of the maximum
tenderness. This patient had seven previous attempts to resect the infrapatellar
branch at more distal sites. (B) A femoral nerve motor branch is often in the canal to
the vastus medialis, and here electrical stimulation is used before resecting a nerve
to be sure that just a sensory nerve is being resected. (C) Two distinct nerves are
apparent in this patient. Each will be resected and implanted proximally into an
adductor muscle.
A
B
C

157
Surgical technique
Decompression of the four medial ankle tunnels has been
described in detail.1,2,35,40 An incision is made proximal and
posterior to the medial malleolus extending to the end of the
tarsal tunnel. If there has been no previous injury, edema, or
surgery, the deep fascia is thin and immediately subjacent is
the thicker, but usually loose, flexor retinaculum that used to
be called the lancinate ligament. Once this has been divided
the tarsal tunnel is officially released. If there is no space-
occupying lesion, the surgery is done, and it is appreciated
that not much has been decompressed. It is appropriate to
elevate the tibial artery and veins from the tibial nerve, and
evaluate if there is intraneural fibrosis or not, if there is a high
division of the tibial nerve or not, and the number of calcaneal
nerves originating within the tarsal tunnel. It has been dem­
onstrated that the pressure within the tarsal tunnel of patients
with neuropathy is no different than in the tarsal tunnel of
cadavers.59 The pressure here does increase with ankle plantar
flexion and pronation, and this is no longer occurs after release
of the flexor retinaculum. With the realization that the tarsal
tunnel is analogous to the carpal tunnel in the human forearm,
an operation was developed that decompressed the medial
and lateral plantar tunnels and the calcaneal tunnel(s) and
to the fact that there are subspecialists who are interested in
conditions of the peripheral nerve. Towards these ends, the
American Society for Peripheral Nerve was initiated in 1990
and includes surgeons from plastic surgery, orthopedic
surgery, and neurosurgery. Compression of the tibial and
peroneal nerves were among the first to be recognized.1 The
principles used to evaluate and treat these nerves were the
same as those developed to treat the upper extremity nerves
and relied upon detailed neurosensory and motor evaluation
and careful attention to surgical technique. Without much
change, the approach today should be the same as the
approach recorded then.
The most common nerve entrapment is the tibial nerve and
its branches at the tarsal tunnel region. The next most frequent
is entrapment of the common peroneal nerve at the fibular
neck. The third most common is the deep peroneal nerve
over the dorsum of the foot. The fourth most common is the
SPN. Interdigital plantar nerve compression may be treated
more commonly than many of the above, but most of these
are treated conservatively. Calcaneal nerve entrapment may
be common but often goes misdiagnosed as plantar fasciitis
(Box 6.4).
Fig. 6.14  Lateral knee denervation (A) is approached through an incision just distal
to the vastus lateralis, by incising the iliotibial band, which is the lateral retinaculum.
The lateral retinacular nerve is adjacent to the recurrent geniculate vessels, which
are visible because the knee region has not been exsanguinated by the tourniquet.
(B) The lateral retinacular nerve is dissected proximally from its origin beneath the
biceps tendon and (C) is resected so it drops into the popliteal fossa.
A
B
C

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CHAPTER 6 • Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
removed the septum that is between the medial and lateral
plantar tunnels in order to create a larger volume for these
nerves (Fig. 6.15). To accomplish this in surgery, an incision is
made towards the plantar aspect of the foot and proximally
to join the incision for the tarsal tunnel release (Fig. 6.16). Of
course, these two incisions can be drawn and made at the
same time, but it is important conceptually to appreciate that
these distal tunnels are at the foot level, and the entrapment
sites are not within the tarsal tunnel. The tarsal tunnel ends
at the origin of the abductor hallucis. The fascia superficial to
the abductor is incised, taking care not to injure the branch
from the medial plantar nerve, often through this fascia, and
into the skin of the medial arch. This little nerve remains
unnamed, after its initial description.53 The abductor muscle
is then retracted to reveal its ligamentous origin, which forms
the roof of the medial and lateral plantar tunnels. Each roof
is incised. The septum between them is cauterized and then
longitudinally released and excised. This septum is of variable
size. Sometimes the medial, sometimes the lateral, and some­
times both plantar tunnels are small and constricting of the
nerves within them. Intraoperative pressure measurements in
patients with neuropathy demonstrate that these are the sites
of elevated pressures, even with the ankle in the neutral posi­
tion, and these pressures increase dramatically with plantar
flexion and pronation. It is necessary to release each of these
tunnels and excise the septum to get maximum reduction of
these pressures.59 If the patient has had complaints of heel
pain and has not responded to treatment for plantar fasciitis,
it is likely that the source of heel pain is compression of the
calcaneal nerve(s). Often there are more than one of these and
more than one tunnel. Each must be decompressed to relieve
the heel pain.
Neurolysis of the common peroneal nerve at the fibular
head is well known60 (Fig. 6.17). However, it is an operation
BOX 6.3  Successful neurolysis
Take time listening to patients’ complaints: diagnosis often comes
from the history.
Document the sensory and motor exam for the peripheral nerves in
question.
Localize site of entrapment with your own physical diagnosis: use
the Tinel’s sign.
Remember that more than one nerve may be compressed in the
same extremity.
Remember that the same nerve can be compressed at more than
one site along its path.
Remember: an underlying systemic disease, a neuropathy,
predisposes to compressions.
External neurolysis separates the peripheral nerve from surrounding
structures.
Intraneural fibrosis, determined intraoperatively, requires intraneural
neurolysis.
Segmental blood flow can be disrupted: respect longitudinal blood
flow of the nerve.
Postoperative mobilization is a critical aspect of neurolysis.
Don’t become a wrapper!
BOX 6.4  New in neurolysis
Intraoperative tibial nerve pressures have documented the necessity
to decompress four medial ankle tunnels for the treatment of
tarsal tunnel syndrome.*
Superficial peroneal neurolysis requires fasciotomy of both anterior
and lateral compartments: 25% of people have a branch in the
anterior compartment,† and, rarely, it can be within the septum
itself.‡
Deep peroneal neurolysis almost never requires release of the
anterior tarsal tunnel.
Common peroneal neurolysis potentially requires release of several
structures.§
In the diabetic, there can be multiple peripheral nerve entrapments
in the same limb.¶,∥
The proximal tibial nerve can be entrapped at the soleal sling
– soleal sling syndrome.**,††
(Adapted from *Rosson GD, Larson AR, Williams EH, et al. Release of medial ankle
compartments reduces pressure upon tibial nerve branches in patients with dia-
betic neuropathy. Plast Reconstr Surg. 2009;124:1202–1210. †Ducic I, Dellon AL,
Graw KS. The clinical importance of variations in the surgical anatomy of the
superficial peroneal nerve in the mid-third of the leg. Ann Plast Surg. 2006;56:635–
638. ‡Williams E, Dellon AL. Intra-septal superficial peroneal nerve. Microsurg.
2007;27:477–480. §Aszmann OC, Ebmer JM, Dellon AL. The cutaneous innerva-
tion of the medial ankle: an anatomic study of the saphenous, sural and tibial nerve
and their clinical significance. Foot Ankle. 1998;19:753–756. ¶Dellon AL. The Dellon
Approach to neurolysis in the neuropathy patient with chronic nerve compression.
Handchir Mikrochir Plast Chir. 2008;40:1–10. ∥Dellon AL. The four medial ankle
tunnels; a critical review of perceptions of tarsal tunnel syndrome and neuropathy.
Clin Neurosurg. 2009;19:629–648. **Williams EH, Dellon AL. Anatomic site for
proximal tibial nerve compression: a cadaver study. Ann Plast Surg. 2009;62:322–
325. ††Williams EH, Williams CG, Rosson GD, et al. Combined peroneal and tibial
nerve palsy. Microsurgery. 2009;29:259–264.)
that is usually deferred by orthopedic surgeons as their litera­
ture supports expectant waiting once a foot drop develops
after a hip or knee procedure, or a sports injury. From a
peripheral nerve perspective, the position can be defended to
do the neurolysis at 3 months or earlier.61 In addition to foot
drop, neurolysis is indicated to relieve chronic pain related to
this compression. The incision does not have to be longer than
4–5 cm in a normal-sized leg. The incision is oblique in case
you must extend the surgery into the popliteal fossa or distally
in the leg (Fig. 6.18). There is sometimes a cutaneous nerve in
this location, the lateral cutaneous nerve of the calf, and this
should be preserved. The deep fascia, in the absence of trauma,
will not be adherent to the common peroneal nerve. This
nerve is white in the absence of glucose intolerance, in which
case it is swollen and infiltrated by yellow fat, giving it almost
the appearance of a lipoma. This is not a lipoma, so it is
important not to excise it! The nerve is released into the
popliteal fossa, but the entrapment site, again in the absence
of trauma, is completely between the neck of the fibula and
the overlying structures related to the peroneus muscles.
Begin by releasing the superficial peroneus fascia transversely,
proximally, and distally in a stellate fashion. There is often a
septum between muscles that should be released, taking care
not to extend the scissor tips too deeply and injure the nerve.
Then retract the muscle. In cadavers, there is a fibrous band
of fascia deep to the muscle in 20% of cases, but this is present
to some extent in 80% of those coming to surgery,55 and this
band must be carefully released to reveal the compressed,

159
Surgical technique
Fig. 6.15  Release of the four medial ankle tunnels.
(A) The tarsal tunnel is opened. (B) The abductor hallucis
is retracted, protecting the calcaneal branch from the
medial plantar nerve to the arch. (C) The roof of the
medial and the lateral plantar tunnels is incised. (D) The
calcaneal tunnel is incised. (E) The septum between the
medial and lateral plantar tunnels is excised. (With
Permission from Dr. Dellon.)
Medial plantar
nerve
Septum removed;
vessels and nerves
share a common
tunnel
Fascial roof of
medial and lateral
tunnels divided
Calcaneal
tunnel
Posterior tibial
nerve
Flexor
retinaculum
Lateral plantar
vessels and nerve
Abductor hallucis
muscle retracted to
expose fascia
Septum divided at
origin; roof of
calcaneal tunnel
opened
Medial plantar
vessels and nerve
Calcaneal branch of
medial plantar nerve
A
B
C
D
E
Fig. 6.16  Intraoperative views of tarsal tunnel surgery. (A) Left tarsal tunnel opened
to demonstrate a high division of the medial and lateral plantar nerves, proximal to
the tunnel, encircled with vessel loops, with the distal medial plantar nerve identified
with a loop just entering the medial plantar tunnel, and from the lateral plantar nerve,
a high originating calcaneal nerve, also encircled with a loop. (B) After release of the
distal tunnels and resection of the septum, a finger can pass into the plantar aspect
of the foot. (C) Variation in which the medial and lateral plantar nerves exchange
fascicles within the tarsal tunnel. The calcaneal branch originating from the medial
plantar and one from the lateral plantar are also noted.
A
B
C

160
SECTION I
CHAPTER 6 • Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
flattened, ischemic soft nerve below. Then the nerve is gently
elevated. In about 15% of patients there will be a fibrous origin
on the lateral head of the gastrocnemius.55 This must be cau­
terized and divided. In a few patients the opening into the
anterior compartment also needs to be widened by releasing
some of the fibrous muscle origins. If there is intraneural
fibrosis, a very gentle intraneural dissection can be done.
Intraoperative electrical stimulation that demonstrates motor
function is very useful in giving the patient with a foot drop
a good prognosis upon awakening from surgery. Be sure not
to get any bupivacaine on the nerve during the infiltration of
the skin edges in order to avoid the patient awaking with poor
motor function.
Neurolysis of the SPN is misleadingly simple. Despite all
anatomy books illustrating the location of this nerve in the
lateral compartment, the author has had the experience of
resecting this nerve in this location, only to find that the
patient still had sensation over the dorsum of the foot that
could be relieved by a local block at the anterior ankle. The
paradox is resolved by realizing that 25% of people have
either the entire SPN in the anterior compartment, or, instead
of this nerve dividing into its dorsomedial and dorsolateral
branches at the level of the ankle, it has a high division and
will have a branch not only in the lateral compartment but
also in the anterior compartment or a subcutaneous location
(Fig. 6.19).51 Therefore it is critical that when you make an
incision over the site of the Tinel’s sign, which is often where
there is a slight bulge as the nerve exits the fascia accompanied
by some fat, that you take care not to injure a small branch to
the skin at this location, and also plan to do a fasciotomy of
both the anterior and the lateral compartment. This location
is on average centered 10 cm proximal to the lateral malleolus
but can range from 4 to 20 cm, so be prepared to lengthen
your incision if you cannot find the entrapment (exit) point.
This fascia is well vascularized and can lead to postoperative
bruising or hematoma, and therefore each incised side/edge
should be cauterized. The SPN must be released proximally
until it is surrounded by muscle, and if it is pressed up against
the septum, a section of septum should be cauterized and
removed. If there is no nerve identified in either compart­
ment, it may be in the septum itself, so care should be taken
when dividing this septum.
Neurolysis of the deep peroneal nerve does not require
opening the anterior tarsal tunnel. The anterior tarsal tunnel
is a relatively large space, and unless there has been a crush
injury to the ankle, or previous surgery in this region, the
usual site of compression of the deep peroneal nerve is over
the dorsum of the foot, not the ankle. In this location, electro­
diagnostic testing will not be helpful because the sensory
nerve is small and too distal. Neurosensory testing can docu­
ment this sensory loss in the dorsal first webspace, and there
will be a Tinel’s sign beneath the extensor hallucis brevis
tendon where it compresses the nerve against the underlying
prominence of the junction of the first metatarsal and the
cuneiform bone. This is often the site of an exostosis, and the
most common site for a ganglion. The common LisFranc
fracture/dislocation can also cause this compression, as will
wearing high heels or tight sports shoes, such as in ice-skating.
If there has been direct trauma or antecedent surgery, then it
may be more appropriate to resect this nerve in the lower leg,
but if not, then neurolysis is the appropriate choice. A 2 cm
oblique incision is made between the first and second
Fig. 6.17  Illustration of the sites of compression of the peroneal nerves. Common
peroneal nerve entrapment at the fibular neck. Superficial peroneal nerve
entrapment as it exits the fascia in the distal leg. Deep peroneal nerve entrapment
beneath the tendon of the extensor hallucis brevis. (With permission from Dellon.
com.)
Deep peroneal
nerve
Common
peroneal
nerve
Deep
peroneal
nerve
Deep
peroneal
nerve
Nerve to
tarsal sinus
Superficial
peroneal
nerve
Skin incision
Head of fibula
Common peroneal
nerve
Peroneus
longus
Extensor
digitorum
brevis

161
Surgical technique
popliteal fossa laterally and then inferiorly. The distal saphe­
nous nerve travels in this location and is preserved. The fascia
is released to bluntly dissect and posteriorly retract the medial
head of the gastrocnemius muscle. The tibial nerve will be
noted to be just beneath the soleal sling and just posterior (in
front for the surgeon) of the popliteal vein (Fig. 6.20B–D). The
safest approach is to cauterize the soleus overlying the course
of the tibial nerve and then lift up on the deep posterior
compartment fascia and release it. The tibial nerve can be
separated from the popliteal vein, and the fascicles in this
location can be stimulated to demonstrate recovery of toe
flexion (Fig. 6.20E). Movement in the big toe can be restored.
Finally, compression of the lateral femoral cutaneous nerve
(LFCN) is occasionally seen, particularly amongst those who
wear heavy belts (security guards and carpenters) and kick­
boxers. Although some advocate division of this nerve with
retraction into the retroperitoneum for treatment of meralgia
paresthetica, the most sensible treatment is to begin treatment
of this compression neuropathy with decompression. Neu­
rolysis of the LFCN is accomplished by making a longitudinal
incision over the proximal origin of the Sartorius muscle.
Dissection is carried down to the Sartorius sheath, where the
nerve is usually identified within or adjacent to the sheath.
The nerve is freed from surrounding compressive structures
metatarsals and the cuneiform bone. The SPN is protected.
The deep fascia is opened overlying the visible oblique tendon
or muscle belly of the extensor hallucis brevis. This tendon is
resected, and the nerve is elevated from its adherence to the
underlying bone.62 There is often a clear indentation of the
nerve. Proximally, the nerve is released until it is loose at
the inferior extensor retinaculum. Distally, there is often a
second site of compression beneath a thin fibrous band just
before the nerve becomes subcutaneous in location. A small
branch innervating the metatarsocuneiform joints can be
observed here.
A new site of compression of the proximal tibial nerve
beneath the soleal sling has been described anatomically.63
Compression at this site is best termed “soleal sling syn­
drome”. As the tibial nerve travels beneath the fibrous origin
of the soleus muscle, it can become compressed. The sensory
complaints are similar to those of tarsal tunnel syndrome
except that they are not present at night. The sensory findings
are the same as tarsal tunnel syndrome. The physical findings
can differ in that there is weakness of toe flexion, particularly
weakness in flexion of the big toe (Fig. 6.20A). The innervation
of the flexor hallucis longus occurs at the level of the soleal
sling, causing this finding. Neurolysis at this anatomic site can
recover toe flexion.64,65 The incision is made from the medial
Fig. 6.18  The common peroneal nerve is (A) approached through an oblique incision over the fibular neck. In this location, the lateral cutaneous nerve of the calf should
be protected. (B) The deep fascia is opened to identify the common peroneal nerve, and then the fascia of the peroneus muscles is released and these muscles are
retracted. The site of compression is the fibrous band just deep to the retracted muscles. This band is carefully divided. (C) The swollen proximal nerve is noted. The
discontinuation of the longitudinal blood supply along the nerve is noted. The flattened, compressed nerve beneath the band is noted. The deep from the superficial
peroneal nerve divisions is apparent. (D) This view, in another patient, shown after release of the steps above, demonstrates a white fibrous band present deep to the
common peroneal nerve, part of the gastrocnemius fascia, which, when present, also must be released.
A
B
C
D

162
SECTION I
CHAPTER 6 • Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
place where the nerve proximally has been implanted. That
site remains tender in about half of patients. The water
walking will send new stimuli to the cortex to cause reorga­
nization of the cortex, and facilitate learning about the new
sensation, or lack thereof, following the denervation of that
skin territory. Water therapy will help the 50% of people in
whom collateral sprouting from the adjacent intact nerve (e.g.,
from the sural and deep peroneal and saphenous if the SPN
has been resected) causes paresthesias during the 3rd–12th
week postoperatively. Once the water walking and swimming
have been accomplished, progression to the stationary bicycle
and the elliptical machine can begin. Treadmill use is discour­
aged. By the fourth or fifth postoperative week, the patient
can resume usual exercises again. At this point, if the patient
had been habituated to narcotics, a withdrawal program can
be initiated under the care of a certified pain management
specialist.28
Chronic nerve compression
The same time sequence for dressing change and suture
removal is used for these procedures as for the painful
proximally up to and beneath the inguinal ligament, taking
care to avoid the deep circumflex iliac vessels at the most
proximal portion of the dissection.66,67
Postoperative care/rehabilitation
The painful neuroma
The patient is allowed to ambulate immediately after surgery.
The patient is instructed to change chairs and walk around
the bed every 2 h to minimize the risk of postoperative venous
thrombosis. A cane or walker can be utilized. In general,
crutches are discouraged, as the patient may fall, and hurt the
hands and armpits. Walking should not be for distances
longer than about 50 feet (15.25 m). For distances greater
than that, a wheelchair is encouraged. Following final suture
removal, the patient begins a “water walking program”,
beginning with 10–15 minutes a day, working up to about an
hour a day, doing this 4–6 times a week (Fig. 6.21B). This is a
form of desensitization for the lower extremity. A therapist
should not touch the leg. The patient should not touch the
Fig. 6.19  Neurolysis of the superficial peroneal nerve must begin with the
knowledge that, although this nerve is supposed to be in the lateral compartment,
there is considerable variation and both the anterior and the lateral compartment
must be opened. (A) Note a branch of this nerve in each compartment. If no nerve
is found in either compartment, carefully open the septum (B) as the nerve can be
intraseptal. (C) In some patients, one of the two branches may already be
subcutaneously located.
A
B
C

163
Postoperative care/rehabilitation
Fig. 6.20  Neurolysis of the proximal tibial nerve beneath the soleal sling. (A) At
this level, the innervation of the flexor hallucis longus can be compressed giving
weakness of toe flexion. (B) The incision is in the medial side of the leg, entering
the popliteal fossa. Here the gastrocnemius muscle is retracted posteriorly after
dividing the fascia to the soleus. The purple popliteal vein is noted adjacent to the
white tibial nerve. (C) The curved clamp is beneath the fibrous arch of the soleal
sling that is compressing the tibial nerve. (D) After bipolar cauterization of the
soleus, the fibrous arch can be divided along with the posterior compartment fascia
to release the nerve and, if needed, the posterior compartment. Note the difference in
color and vascularity of the tibial nerve proximal and distal to the compression site.
(E) Note flexion of the big toe has been achieved postoperatively.
A
B
C
D
E
neuroma procedures. Since it is critical that the peripheral
nerve, which has been neurolysed, gets immediate mobiliza­
tion, it is imperative that the patient walks immediately after
the operative procedure. A walker is recommended so that the
patient can hold on with both hands, carry some weight on
the foot that had the surgery, and not lose balance and fall
(Fig. 6.21A). For walking, on the side that had the surgery, the
operated extremity begins its step by lifting from the knee and
then leaning forward. The ankle is often prevented from
moving too much, especially in those patients who have had
tarsal tunnel decompression, so that ankle movement does
not pull out the sutures. This is so critical in the patient with

164
SECTION I
CHAPTER 6 • Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
Failure to treat a painful neuroma also carries a risk of poor
outcome. Untreated chronic pain may sensitize the peripheral
and central nervous system, leading over time to wind-up
and centrally-mediated pain that can no longer be effectively
treated by surgery of the peripheral nervous system.68,69
Untreated painful neuroma may in fact result in CRPS type
II. Patients who are not treated and continue to live with
chronic pain that they cannot effectively cope with also risk
marginalization, psychological sequelae such as depression,
and long-term dependence on pain medications. For all of
these reasons, it is important that patients with chronic post­
operative or post-traumatic pain lasting beyond the expected
time course be evaluated in a timely fashion by a peripheral
nerve surgeon after other potential causes for the pain have
been ruled out.
Chronic nerve compression
Success for neurolysis approaches 90% in the lower extrem­
ity,45,51,60,64,62–71 as it does in the upper extremity. Table 6.5
contains a review of the results for tarsal tunnel decompres­
sion. Prognosis is based upon the degree of axonal loss. If
there is just demyelination, with primarily intermittent symp­
toms and some weakness, the success can be above 90%, and
recovery of function can occur in the early postoperative
period. Sometimes motor function recovers dramatically in
the recovery room. If there is severe axonal loss, with loss of
two-point discrimination, with muscle wasting or paralysis,
then the success may not only be much lower, but recovery of
function may extend over 1 year, and the nerve regeneration
may be painful. If there are comorbidities, like diabetes or
another form of neuropathy, the same general guidelines
apply, but the expected recovery is 80% relief of pain, 80%
neuropathy who usually cannot tell that ankle movement is
tearing out the sutures. It is precisely for this reason that the
large Robert Jones, bulky, ankle dressing is used to protect the
ankle suture line in patients with insensitive feet.
The walker is used for 3 weeks. Once the sutures are out,
then the same rehabilitation with water therapy is used with
the same schedule as given above for the patient who has had
a painful neuroma excised (Fig. 6.21B).28
Outcomes, prognosis, and recurrence
The painful neuroma
As a general rule, if the patient responds with pain relief after
a nerve block of the suspected nerve, or nerves, whether
cutaneous or joint afferent, then the prognosis is 90% that the
patient will achieve good to excellent relief of pain.4,5,43,44,46–50,52
Failure to obtain the desired result is usually due to the pres­
ence of another injured nerve, whose presence was masked
by the severity of the original pain. A clue to this is the original
pain level of 8–10 not being reduced to 1 or 2 after the block.
Of course, not all surgery can be 100% successful, but neuroma
resection with muscle implantation is highly predictable and
successful. It is “OK to lose your nerve”. The historic concern
over “anesthesia dolorosa” is unfounded today if the nerve
block is successful, and if the muscle implantation is main­
tained. The most common nerve to require repeat surgery is
the SPN, which may pull from the extensor digitorum com­
munis muscle during vigorous athletic jumping or repeat
ankle injury. If this occurs, the nerve must be resected at a
more proximal level, additional septum resected, and the
nerve implanted again into the same muscle.
Fig. 6.21  Postoperative management following release of the four medial ankle tunnels for tarsal tunnel syndrome requires immediate mobilization of the tibial nerve and
its branches, but sufficient support so that the sutures do not pull out. (A) The extensive soft bulky supportive dressing applied to the foot and ankle permits immediate
ambulation with a walker, with the patient being reminded to lift from the knee and hip. This is continued for 3 weeks. (B) Following removal of the sutures at 3 weeks, a
water therapy program is begun and progressed. This is helpful not only for those patients having nerve decompressions but, and perhaps even more importantly, for those
patients following neuroma resection for complex regional pain syndrome.
A
B

165
Outcomes, prognosis, and recurrence
recovery of sensation, plus prevention of ulceration and
amputation.35,40,72 Unless there has been a new trauma, recur­
rence of symptoms is unusual once successful recovery has
occurred. For patients in whom the first neurolysis was not
successful, repeat surgery can be done, but with a reduced
expectation for success73 and with an increased risk for
complications.
The prognosis for recovery of untreated chronic compres­
sion neuropathy is invariably poor. Delay of intervention
leads to progressive irreversible changes that combine to
inhibit nerve regrowth, including atrophy of the muscle and
neuromuscular junction as well as a reduced capacity of the
Schwann cells to support regenerating axons.74–76 Currently,
timely surgical decompression is the only means of prevent­
ing these degenerative changes.
Table 6.5  Results of tarsal tunnel decompression
Clinical study (n)*
Excellent
Good
Poor
Failure
Worse
Tarsal tunnel syndrome
Byank*
(51)
26%
53%
12%
8%
Pfeiffer and Crachhilo†
(32)
15%
29%
18%
32%
Mullick and Dellon‡
(88)
82%
11%
5%
2%
*n = number of tarsal tunnel decompressions in study.
(Adapted from *Byank RP, Curtis MJ. Diagnosing tarsal tunnel syndrome. Compl Orthoped. 1992;7:202–206. †Pfeiffer WH, Cracchiolo A. Clinical results after tarsal tunnel
decompression. J Bone Joint Surg. 1994;76:1222–1230. ‡Mullick T, Dellon AL. Results of treatment of four medial ankle tunnels in tarsal tunnels syndrome. J Reconstr
Microsurg. 2008;24:119–126.)
Complications
Complication rates in peripheral nerve surgery are typically
very low. A retrospective review of 5219 procedures found an
overall complication rate of 2.91%, with a minor complication
rate of 2.47%, an intermediate complication rate of 0.44%, and
a major complication rate of 0%. Minor complications included
seroma, superficial wound dehiscence, or localized wound
infection. Intermediate complications include full wound
dehiscence or infection, hematoma, or DVT. Severe complica­
tions such as unintentional nerve injury, injury to adjacent
structures, limb loss, or mortality should never occur with
proper knowledge of anatomy and careful technique.77
2. Dellon AL. Pain Solutions. Lightning Source Publications: Dellon.
com; 2007. A comprehensive review, told as patient vignettes, with
historical background, anatomic illustrations, intraoperative photos of real
patients with problems related to neuropathy, joint pain, Morton’s
neuroma, pain stimulators, and much more. Only available online.
4. Dellon AL. Partial joint denervation I: wrist, shoulder, elbow. Plast
Reconstr Surg. 2009;123:197–207.
5. Dellon AL. Partial joint denervation II: knee, ankle. Plast Reconstr
Surg. 2009;123:208–217. Partial joint denervation is the concept of
preservation of joint function and relief of joint pain by interrupting
neural pathways that transmit the pain message from the joint to the
brain. This review article focuses on the application of these principles to
the knee and ankle and demonstrates that the results obtained for partial
joint denervation of the upper extremity can be successfully applied to the
knee and ankle joints.
30. Weber RA, Schuchmann JA, Albers JH, et al. A prospective blinded
evaluation of nerve conduction velocity versus pressure-specified
sensory testing in carpal tunnel syndrome. Ann Plast Surg.
2000;45:252. A level I study comparing neurologists’ use of the classic
electrodiagnostic test (using painless, non-invasive neurosensory testing)
with the Pressure-Specified Sensory Device, demonstrating that the same
information is obtainable without pain (p < 0.001), yet with the same
sensitivity and specificity. This approach is used in the lower extremity.
35. Dellon AL. The Dellon Approach to neurolysis in the neuropathy
patient with chronic nerve compression. Handchir Mikrochir Plast
Chir. 2008;40:1–10. A systematic review of the literature demonstrating
80% relief of pain, 80% recovery of sensation, prevention of ulceration
and amputation when the Dellon triple nerve decompression is done in
patients with neuropathy plus superimposed compression of the tibial
nerve in the tarsal tunnels and compression of the peroneal nerves.
41. Dellon AL. Neurosensory testing. In: Slutsky D, ed. Master Skills in
Nerve Repair; Tips and Techniques. Elsevier; 2008:575–586.
43. Dellon AL, Aszmann OC. Treatment of dorsal foot neuromas by
translocation of nerves into anterolateral compartment. Foot Ankle.
1998;19:300–303.
45. Dellon AL. Treatment of Morton’s neuroma as a nerve compression:
the role for neurolysis. J Am Podiatr Med Assoc. 1992;82:399.
47. Wolfort S, Dellon AL. Treatment of recurrent neuroma of the
interdigital nerve by neuroma resection and implantation of
proximal nerve into muscle in the arch. J Foot Ankle Surg.
2001;40:404–410.
Access the complete reference list online at

165.e1
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patients with problems related to neuropathy, joint pain, Morton’s
neuroma, pain stimulators, and much more. Only available online.
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treatment. Foot Ankle Int. 2001;22:890–894.
45. Dellon AL. Treatment of Morton’s neuroma as a nerve compression:
the role for neurolysis. J Am Podiatr Med Assoc. 1992;82:399.
46. Dellon AL. Treatment of recurrent metatarsalgia by neuroma
resection and muscle implantation: case report and algorithm for
management of Morton’s “neuroma”. Microsurgery. 1989;10:256–258.
47. Wolfort S, Dellon AL. Treatment of recurrent neuroma of the
interdigital nerve by neuroma resection and implantation of
proximal nerve into muscle in the arch. J Foot Ankle Surg.
2001;40:404–410.

165.e2
SECTION I
CHAPTER 6 • Diagnosis and treatment of painful neuroma and nerve compression in the lower extremity
48. Dellon AL, Barrett S. Sinus tarsi denervation: clinical results. J Am
Podiatr Med Assoc. 2005;95:108–113.
49. Dellon AL, Mont MA, Hungerford DS. Partial denervation for
treatment of persistent neuroma pain after total knee arthroplasty.
Clin Orthop Relat Res. 1995;316:145–150.
50. Dellon AL, Mont MA, Hungerford DS. Partial Denervation for the
Treatment of Painful Neuromas. 2nd ed. Philadelphia: WB Saunders;
2001:1772–1786.
51. Ducic I, Dellon AL, Graw KS. The clinical importance of variations
in the surgical anatomy of the superficial peroneal nerve in the
mid-third of the leg. Ann Plast Surg. 2006;56:635–638.
52. Kim J, Dellon AL. Tarsal tunnel incisional pain due to neuroma of
the posterior branch of saphenous nerve. J Am Podiatr Med Assoc.
2001;91:109–113.
53. Dellon AL, Ebmer J, Swier P. Anatomic variations related to
decompression of the common peroneal nerve at the fibular head.
Ann Plast Surg. 2002;48:30–34.
54. Coert JH, Dellon AL. Clinical implications of the surgical anatomy
of the sural nerve. Plast Reconstr Surg. 1994;94:850–855.
55. Aszmann OC, Ebmer JM, Dellon AL. The cutaneous innervation of
the medial ankle: an anatomic study of the saphenous, sural and
tibial nerve and their clinical significance. Foot Ankle.
1998;19:753–756.
56. Kim J, Spaulding CM, Dellon AL. Variations in the origin of the
medial calcaneal nerve. J Am Podiatr Med Assoc. 2001;92:97–101.
57. Ducic I, Levin M, Larson EE, Al-Attar A. Management of chronic
leg and knee pain following surgery or trauma related to
saphenous nerve and knee neuromata. Ann Plast Surg.
2010;64(1):35–40.
58. Ducic I, Endara M, Mohan R. Routine pathological evaluation of
neuroma specimens: is there a rationale? J Reconstr Microsurg.
2010;26(8):497–500.
59. Rosson GD, Larson AR, Williams EH, et al. Release of medial ankle
compartments reduces pressure upon tibial nerve branches in
patients with diabetic neuropathy. Plast Reconstr Surg.
2009;124:1202–1210.
60. Mont MA, Dellon AL, Chen F, et al. Operative treatment of
peroneal nerve palsy. J Bone Joint Surg. 1996;78A:863–869.
61. Dellon AL. Post-arthroplasty palsy and systemic neuropathy: a
peripheral nerve management algorithm. Ann Plast Surg.
2005;55:638–642.
62. Dellon AL. Entrapment of the deep peroneal nerve on the dorsum
of the foot. Foot Ankle. 1990;11:73–80.
63. Williams EH, Dellon AL. Anatomic site for proximal tibial nerve
compression: a cadaver study. Ann Plast Surg. 2009;62:322–325.
64. Williams EH, Williams CG, Rosson GD, et al. Combined peroneal
and tibial nerve palsy. Microsurgery. 2009;29:259–264.
65. Williams EH, Rosson GD, Hagan RR, et al. Soleal sling syndrome
(proximal tibial nerve compression): results of surgical
decompression. Plast Reconstr Surg. 2012;129(2):454–462.
66. Ducic I, Dellon AL, Taylor NS. Decompression of the lateral femoral
cutaneous nerve in the treatment of meralgia paresthetica. J Reconstr
Microsurg. 2006;22(2):113–118.
67. Ducic I, Iorio ML. Modified approach for lateral femoral cutaneous
nerve decompression in patients with meralgia paresthetica. Plast
Reconstr Surg. 2011;127(3):82e–83e.
68. Woolf CJ, Salter MW. Neuronal plasticity: increasing the gain in
pain. Science. 2000;288(5472):1765.
69. Woolf CJ. Central sensitization: implications for the diagnosis and
treatment of pain. Pain. 2011;152(3 suppl):S2–S15.
70. Byank RP, Curtis MJ. Diagnosing tarsal tunnel syndrome. Compl
Orthoped. 1992;7:202–206.
71. Pfeiffer WH, Cracchiolo A. Clinical results after tarsal tunnel
decompression. J Bone Joint Surg. 1994;76:1222–1230.
72. Ducic I, Taylor NS, Dellon AL. Relationship between peripheral
nerve decompression and gain of pedal sensibility and balance in
patients with peripheral neuropathy. Ann Plast Surg.
2006;56(2):145–150.
73. Barker AR, Rosson GD, Dellon AL. Outcome of neurolysis for failed
tarsal tunnel surgery. J Reconstr Microsurg. 2008;24:111–118.
74. Gutmann E, Young JZ. The re-innervation of muscle after various
periods of atrophy. J Anat. 1944;78(Pt 1–2):15–43.
75. Sulaiman OA, Gordon T. Effects of short- and long-term Schwann
cell denervation on peripheral nerve regeneration, myelination, and
size. Glia. 2000;32(3):234–246.
76. Gordon T, Tyreman N, Raji MA. The basis for diminished
functional recovery after delayed peripheral nerve repair. J Neurosci.
2011;31(14):5325–5334.
77. Ducic I, Hill L, Maher P, Al-Attar A. Perioperative complications in
patients undergoing peripheral nerve surgery. Ann Plast Surg.
2011;66(1):69–72.

SECTION I • Lower Extremity Surgery
7 
Skeletal reconstruction
Arash Momeni, Stephen J. Kovach III, and L. Scott Levin
SYNOPSIS
■ The reconstruction of defects of the appendicular and axial skeletal
structures has been an evolving clinical endeavor that has mirrored our
understanding of the basic science of bone biology.
■ This chapter serves as an overview of the basic tenets of bone biology
and the methods of skeletal reconstruction, and a discussion of the
most common skeletal defects and how the reconstructive surgeon
can reasonably approach them.
■ Perhaps no other clinical tool has had as much of an impact on the
ability to reconstruct skeletal defects as the microsurgical transfer of
bone. Thus no chapter on skeletal reconstruction would be complete
without a review of the microsurgical principles of bony reconstruction.
■ The reader should understand how to approach skeletal defects and
the algorithm for their reconstruction upon reading this chapter.
Access the Historical Perspective section and Figs. 7.2,
7.3, and 7.6 online at

Introduction
Skeletal reconstruction remains a challenging problem for
both orthopedic and plastic surgeons. While skeletal defects
may be encountered in isolation, such as after oncologic resec­
tion, more commonly coexisting soft-tissue defects complicate
the clinical picture, such as after trauma or chronic infections.
Additionally, traumatic injuries that have been treated with
definitive fixation may subsequently develop a nonunion
(either aseptic or septic) requiring bony debridement and
subsequent reconstruction of the skeletal defect. The majority
of these skeletal defects are of the appendicular skeleton, but
the reconstructive surgeon may also be called upon to recon­
struct defects of the axial skeleton or pelvis. Successful
reconstruction requires not only a comprehensive assessment
of the patient and existing defect as well as meticulous techni­
cal execution of the surgical procedure, but also demands a
thorough understanding on the underlying biology of osseous
healing. This chapter will serve as an overview regarding
skeletal reconstruction.
Biology of bone healing and
bone grafts
While tissue repair is the mode by which most other tissues
and organs heal, bone has an incredible restorative capacity
that allows true regeneration with return to its pre-injured
state.1 Understanding the basic requirements necessary for
uninterrupted bone healing to occur is critical. Although the
importance of adequate immobilization has been known for
thousands of years, we are beginning to understand other
biologic components critical to successful bone healing, such
as the importance of progenitor cells and establishment of a
favorable scaffold, as well as adequate perfusion. Disruption
of any of these components invariably results in impeded
bone healing.
Bone healing is a complex process that requires a coordi­
nated interplay of local and systemic progenitor cells (i.e.,
mesenchymal stem cells [MSCs]), production of an extracel­
lular matrix for support and proliferation of MSCs, as well as
secretion of a variety of growth factors.2–7 The most thoroughly
investigated group of growth factors are certainly members
of the transforming growth factor beta (TGF-β) superfamily
known as bone morphogenetic proteins (BMPs).8–13
Understanding these biologic principles is important as
they have direct therapeutic consequences. An example is the
patient presenting with a nonunion after osteosynthesis.
Using radiographic imaging a nonunion may be classified as
hypertrophic, oligotrophic, or atrophic. While the presence
of hypertrophic nonunion is indicative of excessive motion as
a result of inadequate fixation, the diagnosis of atrophic
nonunion poses greater therapeutic challenges. The former
  Access video content for this chapter online at expertconsult.com

167
Patient evaluation
reconstruction. Drawbacks of autologous bone, such as limited
autogenous supply of bone and donor site morbidity, are thus
averted. Allografts are functionally strong, but their incorpo­
ration remains questionable, due to the fact that they exhibit
merely osteoconductive properties. As they do not contain
viable cells they are not osteogenic; however, they may
have osteoinductive properties when combined with growth
factors, e.g., BMPs. Also, they have been associated with rela­
tively high complication rates that include nonunion, fracture,
and infection, all of which necessitate their removal.20–22 There
are methods to combine the initial structural integrity of the
allograft with a vascularized autograft to take advantage of
both methods.23,24 This will be discussed in a subsequent
section.
In summary, the decision regarding the mode of bone graft­
ing depends on a variety of different factors, including the
anatomic location and 3D configuration of the defect, soft-
tissue envelope, limb vascularity, overall patient condition, as
well as availability of donor bone. An ideal reconstruction is
characterized by rapid bone healing and minimal donor site
morbidity, ultimately resulting in functional restoration of the
extremity.
Patient evaluation
It is the reconstructive surgeon’s responsibility to apply these
basic science principles to the specific clinical situation that is
encountered in treating patients with skeletal defects. Injuries
to the appendicular and axial skeleton are commonly encoun­
tered at most major medical centers. Both plastic and ortho­
pedic surgeons are called upon to treat these challenging
patients on a routine basis. These patients are best served with
the “orthoplastic” approach in a multidisciplinary setting.32,33
Members of this multidisciplinary team supporting the ortho­
pedic and plastic surgeons include prosthetists, physical
therapists, vascular surgeons, infectious disease physicians,
musculoskeletal radiologists, and nursing staff well-versed in
patients undergoing extremity and skeletal reconstruction
and convalescence.
As with any clinical problem, the approach begins with the
clinical assessment of the patient. One must consider the
nature of the defect, including its anatomic position, length of
bony defect, associated injuries of the ipsilateral and contra­
lateral extremity, concomitant traumatic injuries, potential for
a functional recovery, patient compliance, and cost associated
with reconstruction, both financial and social. Furthermore,
potentially available donor sites for vascularized and non-
vascularized bone grafts should be determined. While this
may seem straightforward, numerous injured patients, e.g.,
polytrauma patients, may have limited donor sites. Both form
and function must be considered when establishing a recon­
structive plan.
One of the key concerns in reconstruction of the appendicu­
lar skeleton is the blood supply to the bone graft. In non-
vascularized bone transfer the condition of the wound bed,
i.e., its vascularity, determines the likelihood of bone graft
survival. If there is poor blood supply to the wound bed, the
likelihood of success of a non-vascularized bone graft is poor
despite meticulous surgical technique. It is important to
determine, however, if the poorly vascularized wound bed is
secondary to a reversible, i.e., treatable, flow-limiting lesion.
clinical scenario reflects adequate healing capacity and is best
treated by rigid fixation, while the latter requires additional
measures to augment local bone healing, such as bone
grafting.14,15
A profound understanding of the mechanisms by which
bone grafts and bone substitutes facilitate bone healing is
mandatory to allow the reconstructive surgeon to make the
correct choices when attempting reconstruction. Bone grafts
heal through a variety of mechanisms known as osteoconduc­
tion, osteoinduction, and osteogenesis.
Osteoconduction represents the ingrowth of MSCs, capil­
laries, and perivascular tissues from the recipient site into the
transplanted graft, i.e., scaffold. Osteoinduction is the recruit­
ment of MSCs with subsequent differentiation to chondro­
blasts and osteoblasts. This process is modulated by growth
factors, e.g., BMPs. Osteogenesis is synthesis of new bone by
viable cells within the graft.15,16
Autologous bone grafting is considered the gold standard
as it allows osteoconductive, osteoinductive, and osteogenic
mechanisms to augment bone healing. Differences exist,
however, as to the distribution of these various mechanisms,
based on the type of graft chosen for reconstruction. Autolo­
gous bone grafts may be classified as non-vascularized (i.e.,
conventional cancellous and cortical bone grafts) and vascu­
larized bone grafts.
Cancellous bone grafting is certainly the most commonly
used mode of bone grafting and is characterized by a remark­
able osteogenic potential, which is due to the large number of
osteocytes and osteoblasts that remain viable due to the rapid
revascularization that occurs as long as the graft is placed in
a well-vascularized wound bed. Its drawback, however, is its
limited structural integrity. In contrast, cortical bone grafts are
strong constructs. However, the density of the cortex results
in slower revascularization of the graft. As such, these grafts
incorporate by a process known as “creeping substitution”,
which represents gradual resorption of the graft with subse­
quent deposition of new bone (i.e., osteoconduction).
Vascularized bone grafts are segments of bone that are
harvested with their vascular pedicle. Thus after successful
transfer and revascularization at the recipient site, cells within
the graft survive and heal to the surrounding bone by primary
and secondary bone healing, rather than by “creeping substi­
tution”. Advantages of vascularized bone grafts include the
fact that these are live constructs that are capable of growth
and hypertrophy in response to stress, load bearing (Wolff
law), vascularity, and additional environmental signals.
The perfusion pattern of any given bone determines the
technique of flap harvest. The blood supply to long bones is
derived from multiple sources. The nutrient artery supplies
the marrow and inner cortex, while the periosteal vessels
supply the outer cortex of the diaphysis. Additional metaphy­
seal and epiphyseal vessels traverse the cortex and have an
anastomotic arcade with the nutrient artery.17 For example, a
long-bone free flap, such as the fibula, can remain viable with
its periosteal blood supply only.
The dual blood supply of long bones is contrasted by the
predominantly periosteal blood supply of membranous bone.
An example is the free iliac crest flap, which is based on a
periosteal pedicle derived from the deep circumflex iliac
artery (DCIA) and was first described by Taylor.18,19
In contrast to autologous bone, the reconstructive surgeon
has the option to use allografts for the purpose of skeletal

167.e1
Historical perspective
Historical perspective
The quest for a means to reconstruct skeletal defects of
the axial and appendicular skeleton has been an ongoing
process. In the 17th century, Dutch surgeon Van Mee’kren
used a xenograft (i.e., dog’s skull) to reconstruct the cranium
of a soldier.25 The first experimental autologous bone graft
model was established in Germany in 1821, and Sir William
MacEwen presented a case of humeral reconstruction using
an allograft in 1881.26 In addition, Erich Lexer was a pioneer
in the field of bone and total joint allotransplantation in the
early 20th century.27
An ongoing debate existed as to which components of bone
must be transferred for osteogenesis to be observed. Barth
observed that the graft itself did not survive after transfer, but
that ultimately grafting worked via replacement of the dead
bone by live bone growing into it by creeping substitution.28
Phemister demonstrated that diffusion of oxygen and nutri­
ents from the underlying recipient bed was likely to result in
survival of some of the osteogenic cells on the surface of the
bone graft.29 Gallie and Robertson noted improved osteogen­
esis with the use of cancellous bone rather than with cortical
bone.30 Improved diffusion of nutrients through cancellous
bone, rather than through the dense cortex of cortical bone,
as well as the higher cellular content in cancellous bone, as
opposed to cortical bone, is responsible for those observations
made. The fate of the cellular content of cortical bone grafts
was elucidated in the 1950s and 1960s when it was demon­
strated that bone cells within the cortical graft only survived
if they were within 300 µm of the surface of cortical bone in
contact with a healthy wound bed.8,31
Numerous innovations in the latter half of the last
century profoundly changed the way skeletal reconstruction
is approached today. Perhaps the two most profound
effects may be secondary to the introduction of distraction
osteogenesis into clinical practice by Ilizarov as well as dem­
onstration of the feasibility of microsurgical vascularized
bone grafting.

168
SECTION I
CHAPTER 7 • Skeletal reconstruction
modalities are not mutually exclusive and may be combined
to extend the capability of one approach alone.
Bone grafting
Traditionally, corticocancellous bone grafts had been used for
bone defects that are 5 cm or less in length. The main tenets
of bone grafting were put forth by Kazanjian in 1952 and still
hold true today.49 These principles include adequate blood
supply to the recipient site to ensure survival of the graft,
establishment of bone-to-bone contact, immobilization at the
fracture/defect site through the use of rigid fixation, and
absence of infection. For defects greater than 5–6 cm in length,
graft resorption typically prevents complete healing.50,51
Interestingly, Masquelet described a technique that has
been used with success for intercalary defects ranging from 5
to 24 cm.52 This two-stage approach involves inducing a bio­
active membrane that permits reconstruction of large defects
with non-vascularized autograft.52,53 The principles of recon­
struction with this technique begin with the basic tenets of
wound preparation that include radical debridement of devi­
talized tissue and delineation of the intercalary defect. Next,
a cement spacer is inserted into the bony defect and, in cases
of a deficient soft-tissue envelope, soft-tissue reconstruction
performed with a muscle or skin flap. In a second stage,
approximately 6–8 weeks later, the spacer is removed and the
membrane that is induced by the spacer is left in place. The
resultant cavity is then packed with cancellous bone graft
derived from the iliac crest. The induced membrane is then
closed over the autograft, resulting in a contained system. The
induced membrane has been shown to have biologic proper­
ties, including a rich vascular network, a synovial-like epithe­
lial lining, as well as biologic activity as evidenced by its
ability to secrete growth factors such as vascular endothelial
growth factor (VEGF) and transforming growth factor beta-1
(TGF-β-1). Additionally, extracts from the membrane have
been shown to stimulate bone marrow cell proliferation and
differentiation to osteoblastic cell lines.54
Donor sites for bone grafts have evolved over time. In the
early 20th century, the tibia was the preferred site for cortical
as well as cancellous bone grafts. However, large grafts cannot
be obtained from the tibia without a significant donor defect
and the risk of chronic pain at the donor site as well as second­
ary pathologic fractures. Non-vascularized autografts are
now harvested routinely from the iliac crest. The iliac crest
contains an abundant source of cancellous corticocancellous
bone for grafting that may be harvested from an anterior or
posterior approach depending on the positioning needs of the
patient. In general, 50 cc of bone graft can be obtained from
either the anterior or posterior approach, which is typically
adequate for defects amenable to reconstruction with cancel­
lous grafts.
Vascularized bone transfer
Intercalary defects that are larger than 5 cm typically require
reconstruction with vascularized bone. Vascularized bone
grafts have significant advantages over their non-vascularized
counterparts.55 Additionally, composite osteocutaneous flaps
permit single-stage microsurgical reconstruction of both bone
and soft-tissue defects. A variety of parameters influence the
decision-making when choosing a free vascularized graft.
An intervention by vascular surgery may successfully address
the underlying problem in these cases, thus allowing convert­
ing the local environment into a more favorable one. As such,
a thorough vascular exam should be part of every extremity
examination. In patients with an abnormal vascular exam,
angiography is indicated to discern the vascular anatomy and
to determine if there is a reversible flow-limiting lesion. Fur­
thermore, evaluation of the vascular anatomy is critical prior
to performing a vascularized bone graft, as adequate inflow
and outflow vessels are mandatory to achieve success.
In patients with an abnormal vascular exam with weakly
palpable or non-palpable pulses, it is the authors’ preference
to obtain a formal arteriogram to aid in preoperative plan­
ning. It has been the convention to obtain an invasive arterio­
gram to delineate the vascular anatomy.34 However, invasive
arteriograms are not a morbid-free procedure, and computed
angiography has become widely available. CT angiography
has the advantage of concomitantly assessing the venous
system, skeletal defect, as well as surrounding soft tissues.35
Patients with known vascular disease and limited inflow with
soft-tissue defects can be successfully reconstructed with free
tissue transfer with acceptable flap success rates if patient
selection is appropriate.36,37
Perhaps the most challenging question when evaluating
patients with skeletal defects, particularly in the acute trau­
matic setting, is who should be offered salvage versus ampu­
tation. Much of the data regarding the utility of limb salvage
has been derived from the Lower Extremity Assessment
Project. Functional outcomes of amputation versus limb
salvage for limb-threatening injuries have been extensively
studied.38–47 Outcomes between patients undergoing recon­
struction and those receiving amputation are equivalent.
Those patients who elect to undergo reconstruction for trau­
matic skeletal defects will require an increased number of
operative interventions compared to those patients undergo­
ing amputations, but if patients are carefully selected, they
have the potential to have a superior functional outcome.
Obviously, the overwhelming majority of patients desire to
keep the injured extremity if at all possible.39,48 Ultimately, the
decision to proceed with complex extremity reconstruction
must be individualized to the patient and his or her potential
for recovery.
Methods of skeletal reconstruction
Patients requiring skeletal reconstruction are frequently
readily identified, such as those with traumatic skeletal
defects, osteomyelitis, or neoplasms requiring osseous resec­
tion. More challenging clinical situations involve patients
who have bone loss, e.g., osteoradionecrosis, as a result of
prior oncologic treatment or those with recalcitrant nonunion
following a fracture. What is not always straightforward is
how to achieve a stable skeletal reconstruction within the
available means. To maximize the potential for skeletal stabil­
ity, one must have a thorough understanding of the methods
of skeletal reconstruction and the limitations of each approach.
A variety of treatment modalities exist. These include
conventional, i.e., non-vascularized, cancellous or cortico-
cancellous bone grafts, non-vascularized allografts, pedicled
or free vascularized bone grafts (with or without associated
soft-tissue component), and distraction osteogenesis. These

169
Methods of skeletal reconstruction
These include pedicle length, available bone stock, graft
dimension, its osteogenic potential, and ease of harvest at the
time of surgery if concomitant orthopedic procedures are to
be performed.
Since it was first described in 1975, the fibula has become
the preferred source for vascularized bone in reconstruction
of defects of the axial and appendicular skeleton.56 The fibula
is well suited for use as a free vascularized bone graft given
the length of bone that can be harvested, the ability to perform
multiple osteotomies, its reliable anatomy, as well as its
acceptable donor site morbidity.56 Up to 26 cm of vascularized
bone can be harvested from the fibula in the typical adult
patient (Fig. 7.1). The fibula is triangular in shape and primar­
ily a cortical bone with a small medullary component. These
anatomic characteristics allow it to resist angular and rota­
tional stress and to remodel with graduated weight-bearing
in the postoperative period after reconstruction of intercalary
defects. The blood supply to the diaphysis of the fibular is
based on an endosteal and musculoperiosteal component,
which is provided by the peroneal artery and vein. In a small
number of patients the peroneal artery is the dominant supply
to the lower extremity.57 Peroneus magnus may not be evident
on preoperative clinical exam, but if it is encountered intra­
operatively, the fibular harvest should be abandoned so as not
to render the foot ischemic. If the patient has an abnormal
pulse exam or has a traumatized extremity that suggests
possible underlying vascular injury, preoperative vascular
imaging is indicated. A skin paddle may be harvested with
the fibula to reconstruct associated soft-tissue defects con­
comitantly. Perforators supplying the skin paddle exit through
the posterior crural septum and are found in greatest concen­
tration between the middle third and the distal third of the
fibula (Fig. 7.2
).58
Fig. 7.2 appears online only.
The blood supply to the epiphysis of the fibular head is
derived from the anterior tibial artery.59 If epiphyseal growth,
i.e., longitudinal growth, of the fibula is needed for skeletal
reconstruction in the immature skeleton, the epiphyseal blood
supply needs to be included in the graft.60 However, there is
no need to harvest both pedicles if only a small, proximal
diaphyseal segment is needed for reconstruction as survival
of this segment is ensured via small musculoperiosteal
branches. If a significant length of the fibular diaphysis is
needed, then both the anterior tibial and peroneal arteries
must be included with the graft to ensure adequate survival
of the segments (Fig. 7.3
).
Fig. 7.3 appears online only.
Several important technical aspects must be followed
during the harvest. A thin cuff of muscle (1 mm) is usually
left attached to the graft in order to preserve the periosteal
circulation to the bone segment. Furthermore, the distal 6 cm
of the fibula should be preserved in adults in order to maintain
ankle stability. If there is a question of ankle stability follow­
ing fibular harvest in children, a syndesmotic screw should
be placed for additional stability of the ankle joint and to
prevent hindfoot valgus deformity with growth.
Harvest of the fibula is not without consequences. Large
series have demonstrated persistent long-term morbidity,
including pain, ankle instability, and weakness, after free
fibula harvest. In fact, up to 11% of patients may have persis­
tent pain in the donor leg.61 In a prospective cohort study,
17% of patients were found to have long-term morbidities
postoperatively. These included ankle instability (4%), leg
weakness (8%), great toe contracture (9%), and decreased
ankle mobility (12%).62 While leg weakness rarely causes a
disability in the patient’s postoperative functioning, compara­
tive isokinetic testing does demonstrate a significant decrease
in strength at the knee and ankle after fibula harvest.63 Despite
these potential complications, however, the combination of
surgical experience, meticulous surgical technique, and com­
prehensive postoperative care minimize the potential for
untoward long-term sequelae.64
A variety of additional flaps are available to the reconstruc­
tive surgeon. While this will not serve as an exhaustive review
of vascularized bone flaps, there are additional flaps worth
mentioning due to their common use in vascularized bone
reconstruction.
The scapular vascular axis is a well-established source of
expendable skin, fascia, muscle, and bone for use in microsur­
gical reconstruction of defects requiring bone and soft tissue
in complex 3D relationships. Composite bone and soft-tissue
flaps derived from the subscapular vascular axis include the
osteocutaneous scapular flap (based on the circumflex scapu­
lar artery), the “latissimus/bone flap”, and the thoracodorsal
artery perforator-scapular osteocutaneous flap. The osseous
segment in the latter two flaps is based on the angular artery,
which derives either from the thoracodorsal artery or the
serratus branch.65–69
The radial forearm flap provides for a thin fasciocutaneous
skin paddle and can be harvested with a segment of the distal
radius approximately 8–10 cm in length and 1–1.5 cm in
width. The available bone stock is of reasonable length but by
virtue of its thickness does not permit use for larger intercalary
defects, with the exception of metacarpal or metatarsal recon­
struction. Its chief advantage is a long reliable vascular pedicle
and fasciocutaneous component. Bone harvest exposes the
radius to fracture postoperatively. Thus avoidance of stress
risers is important when performing osteotomies for harvest
of the bone segment.
The free osteocutaneous lateral arm flap is a fasciocutane­
ous flap that is supplied by the posterior radial collateral
artery. The vascular pedicle length can be up to 8 cm but is
more typically 4–6 cm. The external arterial diameter of the
posterior radial collateral artery is small, with an average
diameter of 1.5 mm. This flap can be raised with an osseous
segment up to 1 cm in width and 10 cm in length that is
harvested from the lateral cortex of the humerus along a line
parallel to the attachment of the lateral intermuscular septum.
Much like the radial forearm, the bone stock available with
this flap does not permit reconstruction of large intercalary
defects, with the exception of metatarsal or metacarpal defects.
The vascularized iliac crest bone flap was popularized in
the 1980s and is based on the DCIA. It has the advantage of
allowing the harvest of a large segment of bone as well as skin.
A segment of vascularized bone up to 4 × 11 cm can be har­
vested with a skin paddle measuring 8 × 18 cm. Limitations of
this flap include the curve of the native ileum, which limits
its usefulness in intercalary defect reconstruction, as well as
the fact that the skin/soft-tissue component is rather bulky
and not mobile, thus not allowing independent inset from the
bone segment. In general, reconstruction of intercalary defects
with the free iliac crest flap is limited to 10 cm. If defects are
more than 10 cm, then osteotomies are required to account for
the curvature of the graft. Further disadvantages of this flap

169.e1
Methods of skeletal reconstruction
Fig. 7.2  Reconstruction of scaphoid nonunion with osteocutaneous medial femoral
condyle (MFC) flap. (A,B) Dissection of recipient site with establishment of
intercalary defect. (C–E) Harvest of osteocutaneous MFC flap.
A
B
C
D
E

169.e2
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CHAPTER 7 • Skeletal reconstruction
Fig. 7.3  Reconstruction of scaphoid nonunion with free medial femoral condyle (MFC) flap. (A,B) Preoperative radiographs demonstrating scaphoid nonunion with
avascular proximal pole. (C,D) Postoperative radiographs at 8 weeks. (E,F) Postoperative radiographs at 2 years postoperatively with successful union of the scaphoid.
A
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C
D
E
F

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Fig. 7.1  Free vascularized fibula graft for reconstruction of avascular necrosis of the hip. (A) Harvest of the fibula as a “bone-only” vascularized graft. (B) Recipient vessel
dissection, i.e., ascending branches of the lateral femoral circumflex system. (C) Fibula graft isolated on peroneal vessels. (D) Demonstration of peroneal vessel take-off at
the tibioperoneal trunk. (E,F) Follow-up radiograph at 2.5 years following core decompression of right femoral head and reconstruction with free vascularized fibula graft.
A
B
D
C
F
E

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Methods of skeletal reconstruction
include the potential for hernia formation postoperatively as
well as anesthesia in the distribution of the lateral femoral
cutaneous nerve. In a large series it was noted that 9.7% of
patients developed a hernia after flap harvest. These donor-
site hernias are challenging to repair secondary to their ana­
tomic location. Also, persistent pain is a problem and was
reported in 8.4% of patients at 1 year after harvest.70
Periosteal and other bone flaps (Video 7.1 )
Periosteum has long been known to have significant osteo­
genic activity.71,72 In addition, it is suggested that periosteum
provides a major source of osteoblast precursor cells.1 The
osteogenic properties of the periosteum can be utilized by
harvesting a vascularized periosteal flap. The clinical corre­
lates of this concept are the periosteal and osteoperiosteal
grafts that are raised from the medial femoral condyle. These
were first used as pedicled flaps and subsequently as free
flaps.73,74 The free vascularized MFC flap has a constant blood
supply via the descending genicular artery (1.5–3.5 mm in
diameter at its origin) and is ideal for treatment of smaller
nonunions.75 It may be harvested as an osteogenic periosteal,
an osteoperiosteal, or a cutaneous osteoperiosteal flap
depending on the needs of the reconstruction. The versatility
of this flap is reflected in its numerous clinical applications,
ranging from reconstruction of scaphoid nonunions76 to
mandibular and midface reconstructions,77–79 as well as a
variety of other indications involving the axial and appen­
dicular skeleton (Figs. 7.4 & 7.5).80–85
The MFC flap is harvested via a medial longitudinal inci­
sion along the posterior border of the vastus medialis muscle.
Upon visualization of the muscle fascia, the vastus medialis
muscle is retracted anteriorly, thus exposing the descending
geniculate artery. If reconstruction of a composite defect is
required, perforators to the skin can be spared, thus adding a
skin component to the MFC flap (Fig. 7.2
). Once
the pedicle is traced towards the medial femoral condyle,
an osseous segment is harvested with a sagittal saw or
osteotomes.85
Distraction osteogenesis
The Ilizarov technique, developed in the 1950s by Gavril A.
Ilizarov, has profoundly changed our ability to treat fractures,
nonunions, segmental bone loss, malrotation, and congenital
abnormalities.86,87 While it was initially developed for man­
agement of lower extremity pathology, it is now widely used
for a variety of indications, including craniofacial disorders.88,89
The basic principle of the Ilizarov technique is that osteogen­
esis can occur at an osteotomy site given the appropriate
degree of retained vascularity, fixation, and quantified distrac­
tion. As such, it becomes evident that therapeutic success is
dependent on a variety of factors that may be categorized into
biologic, clinical, and technical factors.90 The postoperative
period is characterized by (1) a period of latency, defined by
the period between corticotomy and distraction, followed by
(2) a period of distraction, during which the Ilizarov frame is
adjusted to allow for a distraction rate ranging between 1 and
2 mm per day, and finally (3) the period of consolidation.
Interestingly, it is not just bone that expands but rather
muscles, nerves, blood vessels, and skin and soft tissues,
which similarly expand in response to the tension applied by
virtue of tissue proliferation at the cellular level.91,92 In many
patients, however, coexisting soft-tissue defects preclude the
use of the Ilizarov method as the sole treatment modality. In
these complex cases of composite defects the Ilizarov method
may be combined with conventional soft-tissue reconstruc­
tion, i.e., flaps. Furthermore, an existing bony defect may be
reconstructed primarily with a free vascularized bone graft,
which is subsequently distracted. The Ilizarov technique has
been used successfully for reconstruction of defects up to
17 cm and may be combined with free vascularized bone
grafts in order to achieve reconstruction.93,94 The utility of
this combined approach was first elucidated by Fiebel et al.
in 1994 and subsequently expanded upon by numerous
authors.95–97
Despite the impressive outcomes that can be achieved by
means of the Ilizarov technique, a subset of patients will still
require an amputation. An overall limb salvage rate of 84%
has been reported, with the only predictor of amputation
being the inability to achieve primary bony union.93 Given
these encouraging clinical results along with a lifetime cost
benefit over amputation,98 an aggressive approach to achiev­
ing bony union seems justified.
In addition to combining various surgical modalities with
the Ilizarov technique, advances in the construct of the frame
itself are noteworthy. The Taylor spatial frame has shown
promise in the treatment of traumatic injuries with acute
bone loss as well as tibial nonunions with associated bone
defects.99–102 The spatial frame differs from the standard
Ilizarov construct in that it is a thin wire frame with virtual
hinges and computer software support to facilitate fine cor­
rections of bone length, angulation, and rotation. The spatial
frame allows the reconstructive surgeon to have control over
multiple variables through utilization of a hexapod construct
and sophisticated computer algorithms to correct underlying
deformities without frame modification, as is the case with a
standard Ilizarov frame. Additionally, the spatial frame allows
for potential early weight-bearing and range of motion, which
may lead to improved rates of union.
Allograft reconstruction
Bone allograft is sterilely processed bone from human cadav­
ers that is readily available in a variety of different forms. Its
main advantage is the lack of donor site morbidity associated
with its use. Allografts may be used as cortical grafts for
support, osteochondral grafts, cancellous grafts, or as demin­
eralized bone matrix (DBX). They are cataloged and selected
based on their specific anatomic characteristics and recon­
structive needs.103 Given their acellularity, they do not have
osteogenic potential and merely display osteoconductive
capability. As such, incorporation is a rather slow process and
typically incomplete. This is reflected by a nonunion rate of
up to 35%.104
Time to bony union can vary considerably depending on
the anatomic position and size of the allograft. While union
times for allografts placed in the intercalary position may be
as long as 23 months, time to union in the osteoarticular
position takes up to 12 months.105–108 Time to union, however,
is influenced by a variety of additional factors. The need for
chemotherapy, for example, can contribute to a delay in
healing time. Despite their widespread use and availability,
the avascular nature of these grafts predisposes them to

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CHAPTER 7 • Skeletal reconstruction
Fig. 7.4  Sequential images demonstrating bony callus
formation and hypertrophy after reconstruction of an
ulnar nonunion with a vascularized osteocutaneous
medial femoral condyle graft based on the medial
geniculate artery. (A) Preoperative image; (B–D) 2
months postoperatively; (E–F) 14 months
postoperatively.
A
B
D
C
F
E

173
Methods of skeletal reconstruction
placement of the free fibula bone graft within the medullary
canal. Typically, the ends of the free fibula are left longer than
the allograft so that they will overlap with the proximal and
distal ends of the native bone. A canal or trough is cut within
the allograft for the vascular pedicle and to facilitate micro­
vascular anastomoses. This method can be used to reconstruct
defects of the femur, tibia, and humerus. It may be used in the
immediate setting after tumor resection, or in a delayed
setting for nonunion of a previously placed allograft. For
patients undergoing resection for sarcoma and immediate
reconstruction, the allograft will provide mechanical stability
and allow for earlier ambulation without the requisite delay
for hypertrophy of the free fibula graft. Using this technique,
a mean time for bony union of 8.6 months has been reported
in addition to a limb salvage rate of up to 94%.124,127
The authors have modified the method and have incorpo­
rated an approach we call the “hemi-Capanna” in which the
cortical allograft is bisected. This simplifies not only position­
ing of the fibula free flap and vascular pedicle but also further
facilitates microvascular anastomosis. Yet, it still takes advan­
tage of the mechanical strength provided by the allograft.
Furthermore, the authors believe that the additional space
provided by the “hemi-Capanna” allows the fibula graft to
hypertrophy without facing restrictions from the surrounding
allograft.
Reconstruction by anatomic area
Clavicle
Clavicular defects most commonly result from tumor resec­
tion, chronic infection, or trauma.128,129 In fact, fractures of the
clavicle represent one of the most common fractures of the
complications, including infections and fractures in addition
to the need for surgical revisions.109,110 Successful outcome is
furthermore dependent on the condition of the surrounding
soft tissues. Allograft placement in the setting of a compro­
mised soft-tissue envelope, e.g., post-traumatic or radiation-
induced, is certainly associated with a higher complication
rate, including infections, fractures, and nonunions.22,111–115
When looking at a large series of long-bone reconstructions
with allografts, a failure rate of 14% for intercalary grafts, a
significantly longer time to union (compared to autografts),
as well as a wide-ranging complication rate are reported, e.g.,
a complication rate of up to 35% and failure rate of 37%.116–118
The majority of these failures occur within the first 3–4 years
following reconstruction, with return to function being much
better for allografts in the intercalary position than when
combined with a prosthesis or when used in an allograft
arthrodesis.103 Data, however, suggest that intercalary allograft
reconstruction fares much better than any other.114,119–121 This
fact has bearing on the current discussion, as most reconstruc­
tive surgeons will be primarily involved in reconstruction of
intercalary defects, with most osteoarticular or reconstruc­
tions combined with a prosthesis being performed by an
orthopedic surgeon.
The combination of allograft and vascularized autograft,
i.e., Capanna technique, merges the favorable characteristics
of both and is particularly suitable for reconstruction of
massive skeletal defects.24,122–125 The intercalary allograft pro­
vides initial stability and mechanical strength, while the free
vascularized bone allows integration, the capacity for bony
remodeling, and long-term viability of the construct and bony
union.126 The technique involves cutting the cortical allograft
to the appropriate size to fit the skeletal defect. Next, the
medullary portion of the allograft is enlarged to facilitate
Fig. 7.5  Postoperative appearance after reconstruction of ulnar nonunion with osteocutaneous medial femoral condyle (same patient as in Fig. 7.2).
A
B
C
D

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CHAPTER 7 • Skeletal reconstruction
preferred whenever possible due to easy access to the brachial
vessels, thus, facilitating microvascular anastomosis. It is
important to maintain an intact circumferential cortex at the
proximal and distal end of the bone defect, as this facilitates
inset of the vascularized fibula graft into the intramedullary
canal of the residual humerus proximally and distally. Ideally,
about 1–2 cm of fibula should be impacted proximally and
distally within the humerus. The entire construct can then
be stabilized with dynamic compression plates, transcortical
screws, Kirschner wires, or external fixators. The ability to
harvest the fibula as a skin–muscle–bone composite graft is
particularly helpful in cases in which overlying scars need to
be replaced or soft-tissue contractures need to be corrected.
Using this technique, primary osseous union was achieved
in 11 of 15 patients (73%). Three patients were noted to have
early failure of graft fixation at the proximal or distal fixation
site. These patients subsequently underwent open reduction
and internal fixation with compression plates as well as can­
cellous bone grafting for augmentation at the graft junction
with the native humerus. One patient in the series required a
second free fibula graft for graft resorption. In three patients
who achieved primary union, a secondary fracture of the
fibula was noted. These patients were also subsequently
treated with open reduction and internal fixation with com­
pression plating as well as additional bone grafting. They
went on to achieve union within 4 months.141
In patients who have an existing construct with an underly­
ing atrophic nonunion or a pathologic fracture associated
with a prior allograft reconstruction, the fibula graft may be
placed in an onlay fashion as a strut that spans the nonunion.
There have been encouraging reports in the literature of this
technique in salvage of pathologic fractures associated with
allografts of the humerus and other long bones.142–144 In the
largest series in the literature on the use of the free fibula graft
for salvage of pathologic fractures, 4 of the 25 patients never
obtained union, for a failure rate of 16% of the attempted
fibula salvage of the allograft. The overall limb salvage rate
was 90%; however, the limbs that were salvaged after failure
of the fibula were done so with an endoprosthesis.145
Reconstruction of the humerus with the vascularized fibula
graft is a well-recognized modality. Interestingly, the outcome
of reconstruction of the humerus is worse when compared to
the use of the fibula for radial forearm reconstruction. The
relatively high rate of fracture of the fibula when used for
humeral reconstruction seems to be consistent across multiple
studies.141,146 Certainly, there is an inherent rate of complica­
tion associated with complex reconstructions of the humerus.
In patients who underwent oncologic resection followed by
vascularized fibula reconstruction in the form of glenohu­
meral arthrodesis, intercalary autograft, or onlay for patho­
logic fracture, a mean of 2.8 operations per patient was
required to achieve the desired outcome. This included 3 of
the 15 patients requiring the use of their contralateral fibula
for a second vascularized fibula transfer. Fracture and infec­
tion were the most common complications, all of which were
treated successfully for limb salvage.125
Forearm
The free osteoseptocutaneous fibula graft is well suited for
reconstruction of the radius or ulna due comparable osseous
dimensions. Furthermore, in many cases of composite defects
appendicular skeleton, constituting 5–10% of all fractures.130,131
Despite the common occurrence of clavicular fractures, the
nonunion rate, defined as an ununited fracture 16 weeks after
injury, is surprisingly low and reported to be less than 1%.130,131
While the initial treatment of a clavicular nonunion is repeat
open reduction and internal fixation, this approach is associ­
ated with a failure rate of 8%. These patients may suffer from
persistent pain and restricted shoulder motion.132–134 A symp­
tomatic nonunion can even result in a space occupying
pseudoarthrosis, with resultant neurovascular compromise
and gross deformity.135
Although the importance of the clavicle for full shoulder
motion is well known, controversy exists regarding whether
bony reconstruction of the clavicle is indeed indicated.
A small case series in the pediatric population demonstrated
comparable shoulder function following total clavicular
resection in patients with and without reconstruction.
Li et al. similarly reported favorable functional outcomes in
patients undergoing total claviculectomy without reconstruc­
tion.136 Despite these reports it is agreed upon that some
loss of shoulder function ensues subsequent to loss of clavicu­
lar integrity, i.e., clavicular resection. As such, bony recon­
struction is recommended, particularly in patients with
high functional demands as well as those with cosmetic
concerns.135
Given the hostile wound environment, which is typically
present secondary to chronic inflammation, infection, and
scarring, non-vascularized bone grafts are not suggested for
the purpose of clavicle reconstruction. The use of vascularized
bone grafts is strongly recommended if bony reconstruction
of the clavicle is desired. The free vascularized fibula and
MFC graft are particularly suitable for this indication.137–139
Humerus
Skeletal reconstruction of any upper extremity defect must be
tailored to the specific reconstructive needs of the patient.
Many younger patients with osseous malignancies will
require a functional reconstruction due to the high functional
demands of the extremity. Although reconstructions of the
upper extremity are not considered weight-bearing per se, a
high degree of physiologic stress is placed on any reconstruc­
tion. Small (<6 cm) defects in well-vascularized, non-radiated,
non-articular defects may be reconstructed with conventional
bone grafting. If the defect is articular, prosthetic reconstruc­
tion or a composite of prosthesis and allograft may be
considered.
The established treatment of segmental bone defects of the
upper extremity greater than 6 cm is with the vascularized
fibula graft. Its application to large defects of the humerus,
with and without a skin paddle, has become routine for the
reconstruction of defects after recalcitrant nonunion, tumor
extirpation, hardware infection, or failure of conventional
bone grafting.33,94,125,140 The fibula is well suited for intercalary
reconstruction of the humerus given its size, length, and ease
of harvest.
A two-team approach allows an efficient and expeditious
reconstruction. While one team establishes the humeral defect
by resecting any non-viable bone and prepares the recipient
site, a second team harvests the fibula. The approach to the
humerus is determined by previous incisions as well as exist­
ing soft-tissue defects; however, the medial approach is

175
Methods of skeletal reconstruction
Scaphoid
The scaphoid is the most commonly fractured carpal bone,
accounting for 50–80% of all carpal fractures.168 Despite high
union rates, approximately 10% of all scaphoid fractures
progress to nonunion.169 Risk factors for the development
of scaphoid nonunion include proximal fracture location,
avascular necrosis, instability, displacement, and delay in
treatment.170 While conventional bone grafting such as the
Matti–Russe inlay graft technique may result in union rates
of 70–90%, reconstructions based on the use of non-vascularized
bone grafts are typically not successful in cases of proximal
nonunion or avascular necrosis (AVN) of the proximal
pole.171,172 In these more challenging cases, reconstruction with
vascularized bone grafts should be strongly considered. The
objectives for treatment of scaphoid nonunion include resto­
ration of scaphoid anatomy (e.g., correction of humpback
deformity), primary osseous union, pain relief, improvement
of range of motion and grip strength, as well as prevention of
future arthritis.173,174
A variety of bone graft donor sites have been proposed for
the purpose of scaphoid reconstruction; however, the distal
radius and medial femur have become the most popular in
recent years. This is related to the favorable profile of these
graft sites with respect to donor site morbidity. In a recent
systematic review, harvest of a non-vascularized iliac crest
bone graft was associated with an overall incidence of com­
plications of 9% vs. only 1% in patients with distal radius bone
grafts.175
The distal radius as a source for a pedicled vascularized
bone graft was first reported in 1991.176 Perfusion to this flap
is provided by the 1,2 intercompartmental supraretinacular
artery (ICSRA).170,177 Despite initial enthusiasm, a critical
review of the literature reveals a rather heterogeneous success
rate with this treatment modality. High success rates of greater
than 90% have indeed been reported.170,176,178 However, a union
rate of only 12.5% in cases of nonunion with avascular proxi­
mal poles portends the limitations of this treatment modal­
ity.179 The advantages of using a pedicled vascularized bone
graft from the distal radius are quite evident and include ease
of dissection, minimal donor site morbidity, and avoidance of
microsurgical technique. It certainly represents a valuable tool
for treatment of scaphoid nonunion in carefully selected
patients. A disadvantage, however, is related to the limited
degrees of freedom when attempting to inset the graft.
An alternative to the pedicled vascularized radius bone
graft is the MFC corticoperiosteal flap (Figs. 7.3 & 7.6
). The
versatility of the MFC flap is reflected in the wide range of
reported applications, ranging from use for reconstructions of
the cranio-maxillofacial skeleton, radius, ulna, humerus, and
clavicle, to lower extremity reconstructions. However, it has
most commonly been used for treatment of scaphoid non-
union.78,83,139,180–188 Its malleable quality and osteogenic poten­
tial have made it particularly suitable for this indication. This
flap is based on either the descending articular genicular or
the superomedial genicular artery, thus allowing harvest of
an osteoperiosteal or corticoperiosteal flap. The flap has a
consistent vascular supply that has been studied extensively
and allows inclusion of a skin island as well.75,189,190 Superior
outcomes with the free MFC flap have been reported when
compared to the pedicled vascularized distal radius graft in
the setting of scaphoid nonunion with carpal collapse and
of the forearm, the skin and soft tissues associated with the
fibula can be used for reconstruction.147 The dynamic nature
of the forearm and the ability of the forearm to perform
supination and pronation are crucial in the function of the
upper extremity. Reconstruction of the forearm and restora­
tion of length with osseous union may not completely provide
for the restoration of forearm rotation.148,149 Any associated
contracture of the interosseous space from loss of bony length
can result in decreased forearm rotation and disability. It is
therefore crucial to reconstruct the radius and ulna with the
kinematics of the forearm in mind.150
Forearm defects are typically the result of trauma, oncologic
resection, or nonunion after a prior traumatic injury. However,
with modern methods of internal fixation the nonunion rates
of diaphyseal fractures of the radius and ulna are typically
less than 5%.151–154 The reconstruction of diaphyseal defects
less than 6 cm is amenable to cancellous autograft as long as
there is no underlying infection or prior radiation therapy. In
a large series of patients with diaphyseal atrophic nonunions,
all patients were healed in 6 months after conventional cancel­
lous bone grafting and compression plating. The diaphyseal
defect averaged 2.2 cm and involved both bones in approxi­
mately 4% of patients.155 This study demonstrates that excel­
lent results can be achieved in reconstruction of diaphyseal
defects with conventional, time-honored means in appropri­
ately selected patients.
The vascularized free fibula graft remains the gold stan­
dard for reconstruction of large segmental defects of the
forearm (e.g., the setting of defects longer than 6 cm) or of
diaphyseal defects in the setting of infected nonunion, and
prior to radiation therapy within the anticipated field of
reconstruction.147,156,157
One should plan for excess length of the fibula graft
in order to achieve the ideal final length. Having an
appropriately sized fibula graft is crucial to ensure that the
distal radioulnar joint is in alignment.158 During the course
of reconstruction, the fibula graft is temporarily placed
in its anticipated final position and a radiograph is obtained
with the wrist in neutral position. This allows for verifica­
tion of the appropriate anatomic position of the fibula as
well as the forearm length, ulnar variance, and congruity of
the distal radioulnar joint. Microvascular anastomoses are
done either to the distal brachial artery or to the radial or
ulnar artery, ideally in an end-to-side fashion to preserve
maximal flow into the distal extremity. Venous anastomoses
may be performed to the venae comitantes or to a subcuta­
neous vein.
The outcome following forearm reconstruction with the
free fibula graft is well documented. A survey of the literature
regarding time to union of the fibula graft to the native bone
reveals a mean time to union ranging from 3.8 to 4.8 months,
with the majority of patients able to achieve a primary
union.147,159–165 A small subset of patients will require a second­
ary procedure such as adjunctive cancellous grafting to
achieve union.
An interesting application of the vascularized fibula
for forearm reconstruction is the “double-barrel” technique.
This allows reconstruction of both the radius and ulna with
or without an associated soft-tissue defect with a single vas­
cularized flap.149,166,167 However, the issue of decreased range
of motion secondary to limited pronation and supination
remains.

175.e1
Methods of skeletal reconstruction
Fig. 7.6  Postoperative appearance
after reconstruction of scaphoid
nonunion with free medial femoral
condyle (MFC) flap.
A
B
C

176
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CHAPTER 7 • Skeletal reconstruction
end-to-side anastomosis to the aorta can be performed. An
aortic punch that is commonly used in cardiac surgery may
be used to facilitate the anastomosis.210 For reconstructions of
the lumbar spine or pelvis the iliac vessels may be used in an
end-to-side fashion.
The use of free vascularized bone reconstruction for spinal
defects is a relatively rare procedure. Most reports in the lit­
erature are small series or technique papers and lack long-
term outcomes data. In a large case series, 12 patients
underwent vascularized free fibula grafting after multilevel
resection of the spine. Two of these patients underwent bilat­
eral simultaneous reconstruction with a free fibula graft after
resection of one or more vertebral bodies or a partial or total
sacrectomy. Successful outcome was defined as bony union
between the fibula and the native bone. All patients required
posterior fixation, and 7 of the 12 patients had additional
autologous bone grafts placed at the junction of the fibula
and native bone at the time of reconstruction. All patients
who underwent surgery for tumor or infection were able to
achieve bony union, with a mean time to union of 4.5 months.
While there was a relatively high complication rate associated
with these reconstructions, these are difficult, complex cases
without other alternatives for reconstruction.211 The authors
of this series are to be commended for their reconstructions
in this very difficult patient population.
Resections of the lumbosacral skeleton have significant
functional implications as they result in discontinuity between
the bony pelvis and the spine. As such, patients are unable
to bear weight without reconstruction. Any resection of the
bony pelvis which involves the sacroiliac joint will need res­
toration of its mechanical continuity in order to distribute
the weight to the lower extremities.212 It is imperative to
reconstruct this defect and give patients undergoing this
complex surgical procedure the best opportunity to achieve
bony union and weight distribution through their axial and
appendicular skeleton with the functional goal being return
to ambulation. In instances of large defects, there is little
choice other than large vascularized bone transfers to span
the significant bony gap. These large bone defects have been
successfully reconstructed with vascularized fibula grafts.
A multidisciplinary approach, however, is mandatory for
optimal outcomes.211,213–217
Femur
The femur is the longest bone in the human body and is
subject to large amounts of axial loading as well as significant
rotational angular stresses. Skeletal defects of the femoral
shaft typically result from tumor resection, traumatic loss,
chronic osteomyelitis, failed allografts, infected nonunion,
and congenital anomalies. The principles of bony reconstruc­
tion as outlined above are applied to the clinical problems that
are encountered. In defects of 6 cm or less, conventional bone
grafting can be performed if the wound bed is clean, ade­
quately vascularized, and free of infection. While the Masque­
let technique has been successfully used for defects greater
than 6 cm in length, the most common mode of reconstruction
is vascularized bone transfer. Iliac crest may used, but its
utility is limited given its curvature that necessitates osteotomy
when used for reconstruction of intercalary defects. Hence the
vascularized fibula graft has established itself as the gold
standard for reconstruction of large femur defects.
avascular necrosis. Furthermore, an improvement in carpal
alignment and architecture has been associated with the use
of the MFC flap.140,186,191
Figs. 7.3 and 7.6 appear online only.
An elegant solution for the treatment of proximal pole
scaphoid nonunions with inadequate proximal fragment bone
quality to permit pole-preserving reconstructions is the use of
the medial femoral trochlea (MFT) flap.192,193 The similarities
between the convex surface of the MFT and the greater cur­
vature of the proximal scaphoid make this osteocartilaginous
flap an ideal solution for this challenging problem. In a series
of 16 patients, computed tomography confirmed healing in 15
patients, with all patients experiencing either complete or
incomplete pain relief.193 A pedicle length of 8 cm with
an arterial diameter of 1.2 mm facilitates pedicle positioning
and microsurgical anastomosis. Of note, reported donor site
morbidity with this procedure is minimal.193
While favorable outcomes with the various vascularized
bone grafts have been reported, a recent systematic review
concluded that there continues to be no optimal treatment of
scaphoid nonunion. As this is related to a paucity of clinical
series that are comparable, standardized reporting is recom­
mended to facilitate comparability of clinical findings.175
Pelvis and spine
The use of bone grafts as an adjunct in spinal surgery is
indicated after tumor resection, traumatic defects, failed
spinal fusions, and kyphoscoliosis. Historically, thoracic
spinal defects were reconstructed with pedicled rib grafts.
Anterior placement of a vascularized pedicled rib graft
has demonstrated the ability to achieve bony union but is
limited in its applicability to the thoracic spine.194,195 The use
of conventional cancellous bone grafting is indicated for
small defects with a suitable wound bed. Non-vascularized
bone strut grafts have also been described for defects greater
than 4 cm. However, these grafts have a high fracture rate
and may result in nonunion, loss of spinal height, and
potentially neurologic compression.194,196 For larger defects,
free vascularized bone grafting is indicated. Both the iliac
crest as well as the free fibula flap have been described as
surgical options.197 The versatility of the free fibula flap is
evidenced by its use for reconstruction of defects along the
entire spine.197–208
Vertebrectomy defects can be reconstructed with prosthe­
ses. However, if the underlying hardware is involved in
infection or osteomyelitis is present, hardware removal is
mandatory. Vascularized bone grafting of spinal defects after
removal of hardware represents a salvage procedure. Several
options are available for vascularized bone grafting. Vascular­
ized rib grafts can be utilized and rotated on their vascular
pedicle to facilitate reconstruction of the thoracic spine.
However, one is limited by the pedicle length and proximity
to the thoracic cage.194,209 In most instances free vascularized
bone grafting is required, and most of these cases are effec­
tively treated with the free fibular vascularized graft. Recipi­
ent vessels in the cervical region are branches of the external
carotid artery for inflow and tributaries to the internal jugular
vein for outflow. For defects in the thoracic, thoracolumbar,
and lumbar defects, segmental intercostal vessels may be used
in an end-to-end fashion for inflow and outflow. However,
if there are no suitable intercostal vessels for inflow, an

177
Methods of skeletal reconstruction
and may represent the only alternative to amputation. The
oncologic safety of tumor resection and knee arthrodesis for
management of malignant knee tumors has been demon­
strated, with local disease control being comparable to thigh
amputation.233
Knee arthrodesis is a time-honored procedure after exten­
sive resections around the knee joint with initial reports by
Lexer in the first half of the past century.27 The first large case
series documenting functional outcomes following resection
arthrodesis with segmental autologous bone grafts was pub­
lished by Enneking and Shirley in 1977.233 Since then a variety
of different approaches have been proposed for knee arthro­
desis, including variations in the mode of fixation as well as
material for bone reconstruction.228,233,234 Over time, however,
vascularized fibula grafts have proven to be particularly suit­
able for this indication. Reasons include the ability of the
fibula graft to bridge a large bony defect, its osteogenic poten­
tial, as well as its ability to hypertrophy.235 High rates of bony
consolidation have been reported with this technique.232,236
However, challenges remain and are related to the morbidity
of the procedure. The complication rate is rather high with
septic complications and mechanical failure being the most
common complications encountered postoperatively.231 Infec­
tion rates and graft fracture rates up to 53% have been
reported.231 Additional complications include peroneal nerve
palsy and deep venous thrombosis.231,232
In light of existing concerns regarding the mechanical sta­
bility of the fibula in the setting of knee arthrodesis, techniques
have been introduced that overcome this limitation. One
option is the technique proposed by Capanna et al. in which
a vascularized fibular graft is combined with an allograft.24 In
addition to the stability provided by the bone graft, the issue
of fixation has been a focus of investigation. While the use of
a centromedullary nail has been quoted to represent the best
way of securing knee arthrodeses, rigid assemblies, which
exclude mechanical graft loading, are made responsible for
weakening the bone graft with resultant high rates of postop­
erative stress fractures.235,237,238
Surgical treatment of neoplasms around the knee joint is
not the only indication for performing a knee arthrodesis.
Additional clinical scenarios in which this procedure might
be indicated include failed knee arthroplasty secondary to
recurrent infections as well as extensive trauma involving the
tibial plateau with destruction of the knee joint and loss of
soft tissue.237,239 These cases are particularly challenging and
represent a patient population distinctly different from tumor
patients. In patients undergoing oncologic resection the bone
defect is created in a controlled fashion with minimal compro­
mise to the surrounding soft-tissue envelope. As such, recon­
structive attempts with non-vascularized bone grafts may be
successful. In contrast, post-traumatic defects are not only
characterized by large bony gaps but also display a deficient,
scarred, or colonized soft-tissue envelope. As such, recon­
struction with vascularized bone grafts is almost mandatory
to ensure success. Despite these challenges, the pedicled
vascularized fibula graft provides for a reliable reconstruction
in these patients. Given the compromised soft-tissue envelope,
however, the vascularized fibula graft is ideally harvested as
an osteoseptocutaneous graft for simultaneous reconstruction
of the soft-tissue envelope.239
From a technical standpoint it is important to highlight that
in the majority of cases of knee arthrodesis the vascularized
The maximum length of the fibula that can be harvested
for reconstruction of the segmental defect is about 26 cm in a
typical adult patient and depends on the body habitus of the
individual patient. If the defect is longer than the available
fibula length, an option is to combine free fibular reconstruc­
tion of the femoral shaft with subsequent distraction osteo­
genesis in order to correct any limb length discrepancy and
rotational abnormality.218 Additional cross-sectional strength
may be obtained with the free fibula graft by making a
“double-barrel” fibula segment, while taking care to protect
the vascular pedicle. This “double-barrel” reconstruction
allows the construct to bear more force in the early postopera­
tive period and may aid in postoperative stabilization, as it is
inherently a more structurally stable construct.219,220 However,
there is a requisite period of non-weight-bearing until there is
adequate hypertrophy of the fibular segment as well as union
to the native femur. There is adequate evidence to demonstrate
that vascularized fibula grafts have superior strength when
compared with avascular bone grafts. This observation is
explained by the inevitable loss in strength as the graft under­
goes creeping substitution.221–223 For most patients, after
demonstration of bony incorporation of the fibula into the
native femur as well as healed soft-tissue envelope, graduated
weight-bearing may begin. This typically starts at approxi­
mately 6 months postoperatively, at which time the patient is
followed though plain radiographs every several months to
ensure ongoing hypertrophy of the fibula.
Successful microsurgical reconstruction requires adequate
arterial inflow and venous drainage. Depending on the
approach to the femur, pedicle length, and quality of recipient
vessels, interposition vein grafts may be needed. The saphe­
nous vein is the most commonly used for this purpose. The
authors have previously reported a modification for the use
of the ipsilateral fibula in microvascular reconstruction of the
femur that allows a reduction in the number of microsurgical
anastomoses. The ipsilateral greater saphenous vein is trans­
posed for the purpose of establishing venous outflow, while
arterial inflow is created by means of a conventional interposi­
tion graft. Thus the number of anastomoses is reduced from
four to three.224 Alternative recipient vessels to consider
include the descending branch of the lateral femoral circum­
flex artery and its venae comitantes. Using these vessels
obviates the need for interposition vein grafting altogether.
Overall, the outcome of long bone reconstruction using the
vascularized fibula graft is favorable. Within large series of
extremity reconstruction, the functional outcome is good and
there is a high rate of bony union.161,225–227 Hence the fibula
should be considered the first choice for autologous vascular­
ized reconstruction of the femur.
Knee
The knee is a common site for osseous neoplasms. Reconstruc­
tive options following resection are numerous and include
endoprostheses, osteoarticular allografts, and knee arthro­
desis with intercalary allografts, non-vascularized, or vascu­
larized autologous bone grafts.228–231 Despite advances in
implant technology, knee arthrodesis remains a valuable
reconstructive option, particularly in young patients as well
as those with large bony defects and avascular segments of
infected bone.232 Furthermore, arthrodesis may be a salvage
procedure in cases of failed prosthetic-based reconstructions

178
SECTION I
CHAPTER 7 • Skeletal reconstruction
and remodeling. The use of autologous bone that can grow
and remodel with the patient is a particularly attractive option
in younger patients requiring oncologic resection of their
tibial shaft. Most authors utilize the Capanna technique with
a free fibular graft, but it has also been reported with a pedicled
fibular graft as well.244,245 Utilization of the Capanna technique
allows more rapid weight-bearing without the requisite time
to allow fibular hypertrophy, and takes advantage of both
allograft and free vascularized bony reconstruction. When
one considers the anatomic location of tibial diaphyseal
defects, they are more challenging than other long-bone
reconstructions within the appendicular skeleton. The tibia is
subject to large physical loads and has a relatively thin soft-
tissue envelope, which makes it more prone to complications
compared to other skeletal defects. If the tibial defect involves
the articular surface, the reconstruction may be combined
with an endoprosthesis. A comprehensive discussion of
reconstructive options of the joint in conjunction with a
diaphyseal defect is beyond the scope of this chapter.
Foot and ankle
The vascular anatomy of the foot predisposes certain anatomic
areas to be prone to complications subsequent to trauma or
operative intervention. The blood supply to the navicular
bone and talus is particularly tenuous in this regard. Similar
to the scaphoid, these bones have a large cartilaginous surface
with limited entry points for nutrient vessels.246 As such, it is
not surprising that any insult, be it iatrogenic or post-
traumatic, predisposes patients to develop complications
such as AVN and nonunion.247 It is important to understand
that even anatomic reduction of fractures in this region does
not reliably prevent AVN. Untoward sequelae include non-
union, subsidence, and degenerative joint disease that ulti­
mately require arthrodesis.248 While primary arthrodesis is
associated with high success rates, nonunion rates up to 40%
have been reported in patients with comorbidities.249–252 In the
setting of failed arthrodesis, particularly after non-vascularized
bone grafting, the transfer of vascularized bone should be
considered.
These patients pose several challenges, including the fact
that they have typically undergone numerous previous
attempts at surgical correction prior to being referred to the
reconstructive surgeon. Furthermore, a history of osteomyeli­
tis as well as coexisting peripheral vascular disease is not
uncommon in this patient population.248
Options for vascularized bone transfer for the purpose of
foot and ankle reconstruction include iliac crest, fibula, MFC,
and scapula. In the authors’ practice, however, the fibula and
MFC have established themselves as routine vehicles for
skeletal reconstruction of the foot and ankle. While the iliac
crest allows harvest of adequate bone stock, the donor site
morbidity can be problematic. Additionally, the skin compo­
nent, when raised as a composite flap, is unreliable at
times.175,253 A sound treatment algorithm was recently pub­
lished outlining the indications for the fibula vs. MFC flap for
foot and ankle reconstruction.248
The main parameter influencing flap choice is the size of
the bone defect. In isolated cases of tarsal bone AVN as well
as nonunion, reconstruction with a free MFC flap is recom­
mended. Similarly, an osseous defect less than 3.5 cm is ideally
reconstructed with a free MFC flap (Figs. 7.7 & 7.8). In a recent
fibula graft may be transferred as a pedicled graft, thus avoid­
ing microsurgical anastomoses. While technical expertise in
microsurgical vessel dissection is mandatory, the ability to
avoid microsurgical anastomoses undoubtedly simplifies the
procedure. However, in cases where the femoral defect is
larger than 10 cm then free transfer of the fibula becomes
mandatory.232 This is an important point to consider when
planning the reconstruction.
Tibia
Segmental tibial defects are common and typically seen after
trauma or after tumor resection. The use of the fibula for tibial
reconstruction is a time-honored approach. Tibiofibular syn­
ostosis was described as early as 1941 and persisted as a
means for tibial reconstruction into the 1960s. This approach,
however, had significant limitations, including the need for
large amounts of interposed cancellous bone grafts in addi­
tion to taking a long time for consolidation. Despite advance­
ments in microsurgical techniques in the 1970s that permitted
transfer of vascularized fibula grafts, small series of pedicled
vascularized tibial reconstructions with ipsilateral fibula
persisted in the literature with overall good results and
union.240,241 Use of the pedicled, ipsilateral fibula flap for tibial
shaft reconstruction remains a reasonable choice. However,
most reconstructive surgeons prefer a free ipsilateral or
contralateral vascularized fibula for tibial shaft reconstruc­
tion. Harvesting the fibula as a free flap allows an additional
degree of freedom regarding mobility, positioning, and inset
of the graft that is not afforded with a pedicled flap.
Diaphyseal tibial defects can be quite challenging to recon­
struct, particularly when associated with overlying tissue loss.
Those gaps associated with soft-tissue loss, such as are seen
in complex tibia fractures, may require concomitant soft-tissue
reconstruction. Patients with a segmental tibial defect greater
than 6 cm with associated soft-tissue loss are ideal candidates
for reconstruction with an osteocutaneous vascularized free
flap, such as the free vascularized fibula graft. The concept of
reconstruction of the tibial shaft with a vascularized fibular
graft was first suggested in 1981 when Chacha and colleagues
utilized the ipsilateral fibula as a vascularized pedicle graft
for nonunion of the tibia.242 The use of the ipsilateral vascular­
ized fibula for tibial reconstruction has been shown to be a
reliable technique.243 Hertel et al. used a pedicled ipsilateral
fibula for tibial shaft reconstruction and were able to achieve
full, unprotected weight-bearing at a mean of 5.5 months.
However, the majority of these patients required additional
soft-tissue reconstruction in the form of a free or pedicled
soft-tissue flap either pre- or postoperatively in addition to
the tibial shaft reconstruction. Additionally, two of these
patients required cancellous bone grafting. Since that time,
microvascular reconstruction has evolved and become a reli­
able means for diaphyseal tibial reconstruction.
Patients undergoing segmental tibial resection for limb-
sparing, oncologic surgery are candidates for the adjunctive
use of an allograft in conjunction with the free fibula graft via
the Capanna technique. While an allograft provides for sig­
nificant mechanical strength initially via its strong cortical
bone, it is associated with a risk of nonunion at the allograft–
host junction as well as fracture of the allograft itself. The
addition of vascularized fibula adds osteogenic capacity to the
construct, thus providing the potential for revascularization

179
Methods of skeletal reconstruction
Fig. 7.7  Reconstruction of talonavicular nonunion with a free osteomyocutaneous medial femoral condyle (MFC) flap. (A,B) Preoperative radiographs demonstrating
talonavicular nonunion; (C,D) 1-month postoperative radiographs; (E,F) 6-month postoperative radiographs demonstrating successful talonavicular fusion.
A
B
D
C
F
E

180
SECTION I
CHAPTER 7 • Skeletal reconstruction
vascularized epiphyseal transfer. The restoration of growth
potential is not possible with non-vascularized autografts,
allografts, prostheses, or vascularized bone grafts without an
epiphysis. Only through epiphyseal transfer is the potential
for longitudinal growth maintained.254 The donor site for a
vascularized epiphyseal reconstruction is the proximal fibular
epiphysis with its adjacent diaphyseal shaft. The proximal
epiphysis of the fibula is supplied by an epiphyseal branch
from the anterior tibial artery that also supplies the proximal
two-thirds of the diaphysis through small, musculoperiosteal
branches.59 Initially, it was thought that the diaphysis was
perfused via the peroneal artery, thus necessitating harvest of
both anterior tibial and peroneal arteries to ensure survival of
the epiphysis and the diaphysis. It has been demonstrated,
however, that adequate perfusion of the proximal diaphysis
is maintained without the need to harvest both pedicles. The
dissection can be challenging, as the branches that supply the
proximal fibular epiphysis are small. Furthermore, the pero­
neal nerve is at risk for iatrogenic injury. Innocenti et al. have
provided a beautifully illustrated dissection technique of this
challenging flap.254,255
The proximal fibular epiphysis has several advantages over
other vascularized bone grafts. The proximal head of the
fibula has an articular surface and provides for a true physis
and epiphysis as well as a proximal diaphysis, which facili­
tates bone fixation and diaphyseal reconstruction. The ana­
tomic structure of the fibula and its proximal epiphysis lends
itself to reconstruction of the long bones of the forearm as well
as the humerus in the growing child. The addition of a true
physis and epiphysis with the proximal fibular graft provides
for growth in addition to being capable of adapting to the new
functional requirements as the immature skeleton grows. CT
studies of children who underwent reconstruction of their
distal radius with a vascularized proximal fibular epiphyseal
graft revealed progressive remodeling of the articular surface
to adapt to the proximal carpal row, which translated into
improvement in function of the reconstructed joint.255 This
ability to provide a vascularized articular surface, and to
preserve the capacity for longitudinal growth and adaptation,
retrospective analysis of post-traumatic patients with complex
foot and ankle pathology, a 100% union rate was achieved
with the free MFC flap. Given the favorable clinical outcomes
obtained the authors concluded that the MFC flap has become
the ideal donor location when reconstructing small bone
defects.85 Advantages of the MFC flap include ease of harvest,
reliable anatomy, minimal donor site morbidity, as well as
ability to include a skin island that can be inset fairly inde­
pendently from the osseous component.
Bone defects greater than 3.5 cm and pantalar degenerative
joint disease are best treated with vascularized fibula trans­
fer.248 Procedural aspects to consider include which fibula to
use (i.e., ipsilateral vs. contralateral) as well as how to revas­
cularize the fibula without compromising perfusion to the
foot. Options include transferring the fibula as a pedicled
graft based on retrograde perfusion. While the authors have
done this successfully, the technical difficulties, as they relate
to flap rotation, pedicle position, as well as bone inset and
fixation, cannot be underestimated.248 Hence the authors
prefer to use the fibula as a free vascularized bone graft. The
ipsilateral fibula is preferred so as to limit the procedure to
one extremity. The free fibula graft may be revascularized by
the anterior tibial vessels when using an anterior approach to
the ankle. A more elegant solution, however, particularly
when a lateral approach is chosen, is to use the proximal
peroneal vessels to revascularize the fibula via extension
interposition vein grafts. Hence vascularity to the foot is
preserved to the greatest extent possible. Radiographic and
clinical outcome after ankle arthrodesis for management
of talar AVN using a free fibula graft is shown in Figs. 7.9
and 7.10.
Vascularized epiphyseal reconstruction
Vascularized epiphyseal reconstruction has a capacity to
restore joint function as well as growth potential of the
reconstructed limb. If the epiphysis is resected or lost second­
ary to tumor or trauma, respectively, growth potential can
be restored in a child with skeletal immaturity through
Fig. 7.8  Postoperative appearance of free
osteomyocutaneous medial femoral condyle (MFC)
flap (same patient as in Fig. 7.6). (A) Immediate
postoperative appearance with exposed vastus
medialis muscle. (B) Final postoperative
appearance after flap revision and split-thickness
skin grafting.
A
B

181
Postoperative care
evaluation represents the gold standard of postoperative flap
monitoring, this mode of monitoring is not possible after
transfer of vascularized bone alone, unless a skin or other
soft-tissue component is included and exposed to permit
clinical evaluation. In osteoseptocutaneous flaps, for example,
the skin island is evaluated clinically as well as with a Doppler
probe. In order to facilitate Doppler examination the site of
the skin perforator is marked with a 5-0 non-absorbable
suture.
The ideal method of monitoring should allow an objective
evaluation of the transferred tissue, be promptly reactive to
changes in blood flow, and allow continuous monitoring even
by nursing and ancillary staff. In light of these criteria, the
is unique to vascularized epiphyseal reconstruction. In
patients with an immature skeleton who require the capacity
for growth to prevent limb length discrepancy or deformity,
vascularized epiphyseal transfer from the proximal fibula
should be considered (Fig. 7.9).
Postoperative care
Postoperative monitoring
A multitude of options exist for postoperative monitoring
following free vascularized tissue transfer.256 While clinical
Fig. 7.9  (A) Malunion and degenerative changes of the ankle with avascular necrosis of the talus and distal tibia. (B–D) Postoperative radiographs following ankle fusion
with intramedullary rod fixation and free osteocutaneous fibula flap transfer. The proximal peroneal vessels were used to revascularize the fibula via extension interposition
vein grafts. Hence vascularity to the foot was preserved to the greatest extent possible.
A
B
D
C

182
SECTION I
CHAPTER 7 • Skeletal reconstruction
extremity. One must be careful not to place the scar over
the flexor surface of the joint, however, as this may result in
scar contracture with resultant functional compromise, i.e.,
decreased joint mobility.
Erythematous scars may be treated with laser resurfacing
to improve their appearance and aid with blending into the
surrounding soft tissue. This may be performed in the office
under topical or no anesthesia. The authors use the Candela
Vbeam laser for vascular scars with acceptable results.
Patients who have had prior extremity reconstruction with
a soft-tissue free flap or an osteocutaneous free flap with a
bulky soft-tissue component may benefit from a contouring
procedure. This can be achieved by direct excision of excess
tissue or via liposuction. Any attempt at contouring, however,
is delayed until a stable reconstruction is achieved and the
long-term results are evident, typically after a minimum of
3–6 months from the time of the initial reconstruction. If
patients who have had a prior reconstruction require revision
or adjunctive bone grafting, the stable soft-tissue portion of
the flap may be raised and thinned at the time of the
revision.
Conclusion
Reconstruction of the skeleton remains a challenging task.
There are several modalities to accomplish reconstruction of
the skeleton. The optimal means of skeletal reconstruction for
any existing defect is at the discretion of the reconstructive
surgeon. This chapter cannot be an exhaustive review but
rather an outline of the general principles to consider when
approaching these complex patients. One must be familiar
with all the available techniques and the associated outcomes,
as well as the risks and benefits of each method of skeletal
reconstruction. With most reconstructive procedures there is
not only the defect to consider but also the donor site morbid­
ity associated with the proposed reconstructive plan. The
goal of skeletal reconstruction is to achieve osseous union
along with a stable and aesthetically appealing soft-tissue
reconstruction. This endeavor mandates a multidisciplinary
approach in order to achieve an optimal outcome. One needs
a dedicated multidisciplinary team to facilitate efficient and
optimal care of patients undergoing skeletal reconstruction
and rehabilitation.
authors believe that the inherent characteristics of the implant­
able Doppler probe allow this device to replace clinical moni­
toring in the appropriate setting.257 As such, the authors
routinely use the implantable Cook Doppler for postoperative
monitoring.
While monitoring the vascular status is critical in the early
postoperative period, the critical long-term outcome measure
after skeletal reconstruction is osseous union. This is typically
assessed through serial conventional radiographs or cross-
sectional imaging, such as CT or MRI. An additional technique
for assessing viability of the skeletal construct is by means of
technetium-99 bone scans.258
Postoperative aesthetic considerations
Many patients who undergo skeletal reconstruction will be
left with a significant scar burden or contour deformity of the
reconstructed extremity. While functional considerations are
most important, it is prudent to provide the patient with the
aesthetically most appealing reconstruction possible. Adjunc­
tive measures, such as scar revisions, contouring procedures,
etc., should be offered liberally. A variety of treatment options
exist to improve the appearance of a reconstructed limb.
The scar burden may be reduced through serial excision.
Another method that has long been recognized as a valuable
adjunct to soft-tissue reconstruction of the extremity is tissue
expansion.259–261 Placement of an expander in the fascial cleft
of the extremity allows recruitment of additional soft tissue,
thus allowing excision of disfiguring scars and coverage with
regional tissue. Expanders may be placed through a minimally
invasive approach, which shortens the time needed for recon­
struction and yields a similar, more compliant flap.224 The final
result of this treatment modality is a linear scar in the affected
Fig. 7.10  Clinical appearance of right ankle after reconstruction with
osteocutaneous fibula flap (same patient as in Fig. 7.9).
Bonus images for this chapter can be found online at

Fig. 7.2 Reconstruction of scaphoid nonunion with osteocutaneous medial
femoral condyle (MFC) flap. (A,B) Dissection of recipient site with
establishment of intercalary defect. (C–E) Harvest of osteocutaneous MFC flap.
Fig. 7.3 Reconstruction of scaphoid nonunion with free medial femoral condyle
(MFC) flap. (A,B) Preoperative radiographs demonstrating scaphoid nonunion
with avascular proximal pole. (C,D) Postoperative radiographs at 8 weeks. (E,F)
Postoperative radiographs at 2 years postoperatively with successful union of
the scaphoid.
Fig. 7.6 Postoperative appearance after reconstruction of scaphoid nonunion
with free medial femoral condyle (MFC) flap.

183
Conclusion
11. Friedlaender GE, Perry CR, Cole JD, et al. Osteogenic protein-1
(bone morphogenetic protein-7) in the treatment of tibial
nonunions. J Bone Joint Surg Am. 2001;83-A(suppl 1 Pt 2):
S151–S158.
24. Capanna R, Campanacci DA, Belot N, et al. A new reconstructive
technique for intercalary defects of long bones: the association of
massive allograft with vascularized fibular autograft. Long-term
results and comparison with alternative techniques. Orthop Clin
North Am. 2007;38(1):51–60, vi. This paper describes the use of an
allograft combined with a vascularized fibula for the reconstruction of
intercalary defects. It details the advantages and power of this technique,
which takes advantage of the strong mechanical properties of the allograft
with the ability of the vascularized fibula to hypertrophy and remodel as
a living graft of bone.
25. De Long WG Jr, Einhorn TA, Koval K, et al. Bone grafts and bone
graft substitutes in orthopaedic trauma surgery. A critical analysis.
J Bone Joint Surg Am. 2007;89(3):649–658.
39. 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. This prospective study examined
the functional outcomes of patients with severe lower extremity trauma
who underwent amputation or limb salvage. Patients were rated on a
self-reported health scale. This study demonstrated equivalent outcomes
between amputation and limb salvage, and lends credence to attempts at
limb salvage if medically feasible.
40. MacKenzie EJ, Bosse MJ, Kellam JF, et al. Factors influencing the
decision to amputate or reconstruct after high-energy lower
extremity trauma. J Trauma. 2002;52(4):641–649.
52. Masquelet AC, Fitoussi F, Begue T, Muller GP. Reconstruction of
the long bones by the induced membrane and spongy autograft.
Ann Chir Plast Esthet. 2000;45(3):346–353. This paper elucidates the
Masquelet technique of inducing a bioactive membrane for the
reconstruction of skeletal defects. It demonstrates that the scope of
conventional bone grafting can be greatly improved by allowing the
formation of a bioactive membrane to consolidate bony defects that would
typically be reconstructed with vascularized bone grafting.
86. Ilizarov GA. The tension-stress effect on the genesis and growth of
tissues: part II. The influence of the rate and frequency of
distraction. Clin Orthop Relat Res. 1989;239:263–285.
87. Ilizarov GA. The tension-stress effect on the genesis and growth of
tissues. Part I. The influence of stability of fixation and soft-tissue
preservation. Clin Orthop Relat Res. 1989;238:249–281. These are
seminal papers for distraction osteogenesis as initially elucidated by
Ilizarov. The principles of distraction as they relate to extremity
reconstruction are found in these papers. In addition, these papers
demonstrate the power of distraction to generate additional soft tissue
and bone length and to correct rotational deformities.
102. Feldman DS, Shin SS, Madan S, Koval KJ. Correction of tibial
malunion and nonunion with six-axis analysis deformity
correction using the Taylor Spatial Frame. J Orthop Trauma.
2003;17(8):549–554.
105. Bauer TW, Muschler GF. Bone graft materials. An overview of the
basic science. Clin Orthop Relat Res. 2000;371:10–27.
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CHAPTER 7 • Skeletal reconstruction
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183.e6
SECTION I
CHAPTER 7 • Skeletal reconstruction
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223. Shaffer JW, Field GA, Goldberg VM, Davy DT. Fate of vascularized
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224. Erdmann D, Kovach SJ, Lawson RD, Levin LS. Ipsilateral
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1984;74(4):493–507.

SECTION I • Lower Extremity Surgery
8 
Foot reconstruction
Michael V. DeFazio, Kevin D. Han, and Christopher E. Attinger
SYNOPSIS
■ Successful wound healing is dependent upon accurate determination
of wound etiology, biomechanical optimization, establishment of
adequate blood supply, and proper identification/eradication of
infection.
■ Functional limb salvage mandates a multidisciplinary team approach
comprising, at the very least, a vascular surgeon, foot and ankle
surgeon, plastic surgeon, infectious disease specialist, endocrinologist,
pedorthotist, and prosthetist.
■ Planned surgical incisions and flap design should be based on a
detailed knowledge of anatomy, angiosomes, and vascular status.
■ Adequate debridement of the wound, prior to closure, is critical and
may require the implementation of a staged reconstructive approach.
■ The reconstructive plan must be individually tailored to provide the
best biomechanical result given the patient’s age, goals, and functional
capacity. This may involve local wound care, grafting, local–regional
flaps, free tissue transfer, and/or amputation for similar wounds
presenting in different hosts.
■ Postoperative wound care and biomechanical offloading are essential
to ensure successful reconstruction and prevent unnecessary
complications such as wound breakdown and delayed healing.
Introduction
The distal lower extremity has unique structural and func­
tional significance, serving as a dynamic platform for posture
and ambulation that is subject to repetitive trauma from large
stress loads. Considering the complex anatomic variations
and functional demands of the foot and ankle, restoration of
defects in this region poses a significant reconstructive chal­
lenge. Trauma, infection, oncologic resection, and alterations
in blood supply, sensation, and mechanical alignment can
compromise skeletal stability and increase the likelihood of
soft-tissue breakdown. Inability to salvage the injured foot
often results in major amputation, which carries its own phys­
ical, psychological, and socioeconomic morbidity, including
a lifetime dependence on prosthetic devices. Still, even with
adequate resources and rehabilitation, a significant percent­
age of patients never regain their capacity for ambulation
and instead are condemned to a wheelchair-bound existence.
In diabetics, major amputation is associated with a 5-year
mortality rate as high as 78%, with a 50% risk of contralateral
lower extremity amputation within 2 years.1–4 Therefore a
reconstructive strategy that incorporates measures to mitigate
risk, restore biomechanical function, and promote successful
wound healing is paramount and has significant implications
with respect to patient survival, functional prognosis, and
quality-of-life.
Successful foot/ankle reconstruction and functional limb
salvage begins with a multidisciplinary team approach that
includes collaboration between a vascular surgeon skilled in
endovascular and open vascular bypass, a foot and ankle
surgeon competent in internal/external skeletal stabilization
techniques, a plastic surgeon familiar with principles of
modern wound healing and soft-tissue reconstruction, and an
infectious disease physician specializing in surgical infections.
For the at-risk or biomechanically unstable foot, a podiatrist
and pedorthotist specializing in routine foot care and
orthotics/shoe wear are critical in preventing recurrent
wound breakdown. In the setting of major amputation, a
skilled prosthetist is necessary for the creation of a customized
prosthesis capable of optimizing the biomechanical potential
of the residual limb. In addition, endocrinology, nephrology,
cardiology, hematology, rheumatology, and dermatology
consultations may be indicated to address the patient’s
comorbid medical conditions.
The reconstructive plan must be individualized to provide
the best biomechanical result given the patient’s age, goals,
and functional capacity. This may involve local wound care,
grafting, local–regional flaps, free tissue transfer, and/or
amputation for similar wounds presenting in different hosts.
Surgical goals in foot and ankle reconstruction center on the
“3 Bs”: (1) blood supply, (2) bioburden, and (3) biomechanics.
Ensuring adequate local blood flow, aggressive debridement
to a clean wound base, and correction of biomechanical/

185
Anatomy
Above the ankle, the peroneal artery bifurcates into (1) the
anterior perforating branch and (2) the calcaneal branch. The
anterior perforating branch pierces through the distal anterior
intermuscular septum and sends a branch superiorly overly­
ing the intermuscular septum (this encompasses the area from
which the lateral supramalleolar flap7 can be harvested). The
anterior perforating artery then connects directly with the
anterior lateral malleolar artery (anterior tibial artery) and
supplies the anterolateral ankle angiosome. At the level of the
lateral malleolus, the lateral calcaneal artery emerges laterally
between the Achilles tendon and the peroneal tendons. It
curves with the peroneal tendons 2 cm distal to the lateral
malleolus and gives rise to four or five small calcaneal
branches. The lateral calcaneal artery terminates at the level
of the fifth metatarsal tuberosity, where it connects with the
lateral tarsal artery (dorsalis pedis). The lateral calcaneal
branch supplies the lateral and plantar heel angiosome.
The posterior tibial artery has three terminal branches: (1)
the calcaneal branch, (2) the medial plantar artery, and (3) the
lateral plantar artery. The medial calcaneal artery arises infe­
riorly and arborizes into multiple branches that travel in a
coronal direction to supply the medial and plantar heel. Thus
the plantar heel receives dual blood supply form the calcaneal
branches of the posterior tibial and peroneal arteries, which
ensures adequate flow to an area regularly traumatized during
ambulation. Development of heel gangrene, on the other
hand, usually implies severe vascular disease involving both
the peroneal and posterior tibial arteries. The posterior tibial
artery then enters the calcaneal canal, underneath the flexor
structural abnormalities prior to reconstruction offers the best
opportunity for durable, efficient, and uncomplicated wound
healing. Following adequate preparation and subsequent
wound closure, effective offloading and graduated postopera­
tive rehabilitation are essential to prevent relapse and optimize
long-term functional outcomes, respectively. With these con­
siderations in mind, most reconstructions can be successfully
accomplished utilizing simple techniques (90%), whereas
only a minority of cases will require complex flap reconstruc­
tion (10%). This chapter will focus on the critical aspects of
foot and ankle reconstruction including anatomy, evaluation,
diagnosis, and treatment with commonly used reconstructive
modalities.
Anatomy
Angiosomes of the foot
G. Ian Taylor first introduced the concept of “angiosomes” in
human anatomy to describe a 3D unit of tissue supplied by a
single source artery.5 Attinger et al.6 further developed this
principle as it applies to the foot and ankle, eventually illus­
trating six specific angiosomes of the foot originating from
three primary source arteries. All vascular supply to the foot
and ankle enters through the popliteal fossa as the three ter­
minal branches of the popliteal artery: (1) the anterior tibial
artery, (2) the posterior tibial artery, and (3) the peroneal artery
(Fig. 8.1).
Fig. 8.1  This injection study demonstrates the angiosomes of the foot and ankle. (A) The anterior tibial artery supplies the anterior ankle and continues distally as the
dorsalis pedis artery to supply the dorsum of the foot. (B) The peroneal artery supplies the anterolateral ankle and the lateral heel via the anterior perforating and lateral
calcaneal branches, respectively. (C) The medial plantar heel, instep, and lateral plantar midfoot and forefoot are fed by the calcaneal, medial plantar, and lateral plantar
branches of the posterior tibial artery, respectively. Note that the heel receives dual blood supply from the medial calcaneal (posterior tibial artery) and lateral calcaneal
(peroneal artery) angiosomes. Depending on anatomic variability, the blood supply to the hallux may be derived from either the plantar or dorsal circulation. (From: Attinger
CE, Evans KK, Bulan E, et al. Angiosomes of the foot and ankle and clinical implications for limb salvage: reconstruction, incisions, and revascularization. Plast Reconstr Surg.
2006;117(7 Suppl):261S–293S.)
A
B
C

186
SECTION I
CHAPTER 8 • Foot reconstruction
Distal to the tarsal tunnel, the tibial nerve trifurcates into the
calcaneal (S1, S2), medial (L4, L5), and lateral plantar nerves
(S1, S2), which supply motor branches to the intrinsic muscles
of the foot (except the extensor digitorum brevis [EDB]
muscle). Additionally, the calcaneal branch supplies sensibil­
ity to the plantar heel pad; the lateral plantar nerve supplies
the lateral two-thirds of the sole and the fifth and lateral
fourth toes; and the medial plantar nerve supplies the medial
one-third of the sole as well as the first, second, third, and
medial fourth toes.
The common peroneal nerve passes around the lateral
aspect of the fibular head before splitting into the superficial
(L4–S1) and deep (L4–S1) branches. The deep peroneal nerve
innervates the extensor muscles of the anterior compartment,
passing deep to the extensor retinaculum to innervate the
EDB muscle in the foot. It provides sensory innervation to the
ankle and midfoot joints, sinus tarsi, and first webspace. In
the leg, the superficial peroneal nerve innervates the everting
peroneal muscles of the lateral compartment. The nerve
pierces the fascia, 10–12 cm proximal to the lateral ankle, to
become subcutaneous and provide sensibility to the lateral
lower leg, dorsum of the foot, and skin of all toes except the
lateral fifth toe (sural nerve) and first webspace (deep peroneal
nerve).
The sural nerve (L5, S1), derived from both the tibial and
common peroneal nerves, descends distally in the posterior
subcutaneous plane of the calf along the course of the lesser
saphenous vein. It provides sensibility to the posterior and
lateral skin of the distal third of the leg, prior to passing
between the anterolateral border of the Achilles tendon and
the lateral malleolus to supply the dorsolateral skin of the foot
and lateral fifth toe. The skin of the medial half of the distal
leg and dorsomedial foot is innervated by the saphenous
nerve (L5, S1) – a cutaneous branch of the femoral nerve.
The dorsum of the foot has communicating branches between
the saphenous, sural, and superficial and the deep peroneal
nerves; thus there is often an overlap in their respective
sensory distributions. The same is true for the medial and
lateral plantar nerves, which often overlap in their territories
with the saphenous and sural nerves, respectively.
Wound comorbidities
The etiology of foot and ankle wounds is commonly traumatic,
with the patient’s underlying systemic pathophysiology
complicating the healing process. Significant comorbid disease
processes include diabetes, infection, ischemia, neuropathy,
venous hypertension, lymphatic obstruction, immunologic
abnormalities, hypercoagulability, vasospasm, neoplasm, self-
mutilation, or any combination of the preceding. The more
frequent of these comorbidities, including diabetes, neuropa­
thy, peripheral vascular disease, connective tissue disorders,
and venous hypertension, are discussed in greater detail
below.
Diabetes mellitus
In the USA, approximately 29.1 million (9.3%) people have
been diagnosed with diabetes.10 Nearly 15% of the healthcare
budget in the USA goes toward the management of diabetes,
with 20% of hospitalizations and 25% of diabetic hospital days
retinaculum, and bifurcates into the medial and lateral plantar
arteries at the level of the transverse septum between the
abductor halluces longus and flexor digitorum brevis muscles.
The medial plantar artery’s angiosome encompasses the
instep, while the lateral plantar artery supplies the lateral
plantar surface as well as the plantar forefoot.
At the level of the lateral malleolus, the anterior tibial
artery gives off (1) the lateral malleolar artery that joins with
the anterior perforating branch of the peroneal artery. At the
same level, the medial malleolar artery arises and anastomo­
ses with the posteromedial artery of the posterior tibial artery.
The anterior tibial artery then emerges under the extensor
retinaculum of the ankle to become the (2) dorsalis pedis
artery, which supplies the entire dorsum of the foot.
Clinical relevance of the angiosome model
In the absence of vascular anomalies or disease, blood flow to
the foot and ankle is redundant with multiple arterial–arterial
connections that provide a margin of safety in the setting of
distal source vessel occlusion. For example, the anterior per­
forating branch (peroneal artery) connects with the lateral
malleolar artery (anterior tibial artery) at the ankle. At the
Lisfranc joint, the dorsalis pedis artery dives into the first
interspace to connect directly with the lateral plantar artery
(posterior tibial artery). This vascular loop is critical in deter­
mining the direction of flow within the anterior and posterior
tibial arteries, which can be antegrade, retrograde, or both.
Furthermore, the plantar and dorsal metatarsal arteries are
linked to one another at the Lisfranc joint by proximal perfo­
rators and at the webspace by distal perforators. The posterior
tibial and peroneal arteries connect via one to three perfora­
tors crossing deep to the distal Achilles tendon.
Using a Doppler ultrasound probe and selective occlusion,
it is possible to determine the patency of these interconnec­
tions as well as the direction of blood flow. This is critical to
optimize the success of any planned treatment or procedure.
Incision placement along the boundary of two adjoining
angiosomes ensures optimal blood flow from either side,
thereby facilitating safe exposure of underlying skeletal struc­
tures as well as the design of vascularly reliable flaps. Among
patients with infrapopliteal disease, angiosome-directed
revascularization has manifested higher rates of healing (91%
vs. 38%) and fewer amputations (9.1% vs. 38.1%) than indirect
revascularization through arterial connections in the foot and
ankle.8 Similar findings have also been confirmed for infrap­
opliteal lesions treated with endovascular techniques.9 This
detailed knowledge of vascular anatomy further aids the
surgeon in determining the likelihood of limb salvage for a
given wound and existing blood supply. When salvage is not
possible, early recognition and effective design of amputa­
tions minimizes the risk of distal tissue necrosis and spares
the patient needless, costly, and potentially dangerous proce­
dures that have little chance of success.
Innervation
Proximal to the popliteal fossa, the sciatic nerve bifurcates into
the tibial and common peroneal nerves. The tibial nerve
continues distally within the deep posterior compartment of
the leg where it innervates muscles of the deep and superficial
posterior compartments (except gastrocnemius muscle).

187
Wound comorbidities
(PMNs), macrophages, and lymphocytes to destroy bacteria.
In addition, the diabetic’s capacity to coat bacteria with anti­
biotics is diminished, which further shields bacteria from
phagocytosis. As a result of this immunocompromised state,
diabetics are especially prone to Streptococcal and Staphylococ­
cal skin infections. Deeper infections tend to be polymicrobial,
with gram-positive cocci, gram-negative rods, and anaerobes
frequently detected on culture. Postoperative complication
rates also correlate directly with the degree of chronic and
perioperative glycemic control. At our institution, a periop­
erative blood glucose level less than 200 mg/dL and hemo­
globin A1C level less than 6.5% (48 mmol/mol) serves as the
preferred threshold for minimizing complications and dehis­
cence after wound closure in high-risk diabetic patients.25
Neuropathic changes
Neuropathic changes observed in the diabetic foot result from
abnormalities in the motor, sensory, and autonomic nervous
systems. The loss of pseudomotor function from autonomic
neuropathy leads to anhidrosis and hyperkeratosis. Fissuring
of the desiccated skin facilitates bacterial entry and subse­
quent infection. The lack of sensibility over bony prominences
and between the toes often delays detection of skin barrier
disruptions. In addition to the nerve changes discussed previ­
ously, diabetic patients are unusually susceptible to peripheral
nerve compression as evidenced by histologic similarities
between chronically entrapped nerves and those seen in
diabetic neuropathy.26,27 When a Tinel’s sign is present on
exam, early peripheral nerve release, at known anatomic sites
of compression, may prevent the progression of neuropathy
and subsequent loss of protective sensibility.28 Currently,
however, there are no randomized studies to substantiate the
benefits of this approach over medical therapy alone.
Charcot neuroarthropathy is a destructive process of the
bones, joints, and soft tissues of the foot, occurring in 0.1–2.5%
of diabetic patients.29,30 When present, the tarsometatarsal
joints (30%), metatarsophalangeal joints (30%), intertarsal
joints (24%), and interphalangeal joints (4%) are commonly
involved. Etiologically, these degenerative changes are
thought to be mediated by the interplay between sensorimo­
tor and autonomic neuropathy, repetitive trauma, and abnor­
mal bony metabolism.31 The process likely begins with a
ligamentous soft-tissue injury accompanied by synovitis and
joint effusion. In the absence of pain perception, continued
use of the extremity exacerbates the inflammatory process.
Eventual distension of the joint capsule leads to ligament
attenuation and joint instability. The destructive changes that
occur result in collapse of the medial longitudinal arch, which
alters gait biomechanics. The normal calcaneal pitch becomes
distorted, causing severe strain to the ligaments that bind the
metatarsal, cuneiform, navicular, and other small bones that
form the long arch of the foot.
Motor neuropathy further contributes to Charcot deformi­
ties as the intrinsic foot musculature atrophies and becomes
fibrotic. The resulting metatarsophalangeal joint extension
and interphalangeal joint flexion produces excessive pressure
on the metatarsal heads and the distal phalanges. Loss of both
the transverse and longitudinal arches of the foot exacerbates
the unfavorable weight distribution across the midfoot and
metatarsal heads. Patients who continue to ambulate abnor­
mally load weight over new bony prominences – precipitating
for the treatment of diabetic foot ulcers.11 In patients with
diabetes, the estimated annual and lifetime risk of developing
a foot ulcer is in the range of 1–2 % and 15%, respectively.11–14
Once an ulcer develops, the risk of amputation increases to
1% per year. Indeed, 1 in every 4 patients who present to the
emergency room with diabetic foot ulceration or gangrene
undergo immediate amputation, which in itself carries devas­
tating prognostic implications.15 Following major amputation
in the diabetic, the risk of a second amputation in the contra­
lateral limb approaches 50% within the first 2 years. Further­
more, 3-year postamputation mortality rates range from
20–50% and have been reported as high as 78% after 5 years.1,12
Despite widespread strategies to improve glucose control and
monitor for impaired sensibility, the number of diabetes-
related amputations in the USA continues to rise from 54 000
in 1990 to 73 000 in 2010.10
Diabetic peripheral polyneuropathy is the major culprit
behind non-healing diabetic foot wounds – accounting for
80–85% of amputations in diabetic patients.16 Elevated intra­
neural concentration of sorbitol, a glucose byproduct, is
thought to be a principle mechanism mediating peripheral
nerve damage. Resultant swelling of the injured nerve within
anatomically tight confines (i.e., tarsal tunnel) leads to the
“double crush syndrome”, which may be partially reversible
with early surgical release.17 Unregulated glucose levels
elevate advanced glycosylated end products that induce
microvascular injury by cross-linking collagen molecules.
Decreased insulin levels, along with altered concentrations of
neurotropic peptides, may interfere with the maintenance
and/or repair of damaged nerve fibers. Other factors impli­
cated in the development of peripheral polyneuropathy
include altered fat metabolism, oxidative stress, and abnormal
levels of vasoactive substrates, such as nitric oxide.
Although peripheral neuropathy is generally considered
the primary cause of diabetic foot wounds, the presence of
infrapopliteal arterial occlusive disease significantly increases
the risk of ulceration, reconstructive failure, and amputation in
diabetic patients.18 However, the lack of a PO2 gradient between
arterial blood and foot skin among diabetic patients (with and
without ulceration) and non-diabetic patients (with normal
transcutaneous oxygen tension) implicates a non-ischemic
etiology for the majority of diabetic foot ulcers.19 Previous
misconceptions regarding an increased prevalence of “small-
vessel” disease and intimal hyperplasia as the primary etiology
of foot ulceration in diabetics have not been corroborated by
findings from more recent prospective studies.20–24 Neverthe­
less, the detrimental effects of hyperglycemia on capillary
blood flow and tissue perfusion are significant. Erythrocyte
aggregation and stiffness as well as the increased oxygen affin­
ity result from non-enzymatic glycosylation of spectrin (red
blood cell membrane protein) and hemoglobin, respectively,
and contribute to reduced blood flow and relative tissue ische­
mia in diabetics. The altered flow characteristics that result
trigger a compensatory rise in perfusion pressure, with
increased transudation across capillary beds further perpetu­
ating a rise in blood and plasma viscosity (Fig. 8.2
).
Fig. 8.2 appears online only.
In general, the importance of tight glycemic control in the
promotion of wound healing and prevention of infection
cannot be overemphasized. Hyperglycemia itself can impair
the body’s ability to combat infection. Chronic hyperglycemia
diminishes the ability of polymorphonuclear leukocytes

187.e1
Wound comorbidities
Fig. 8.2  Effects of elevated serum glucose on blood flow and tissue perfusion.
Glycosylation of
hemoglobin
Increased
oxygen affinity
Elevated blood
glucose
Stiffened
erythrocytes
Decreased
blood flow
Increased
blood viscosity
Increase in
transudation
Increased
erythrocyte aggregation
Increase in
perfusion pressure
Glycosylation of
spectrin
Ischemia