John R. Griffin, MD James F. Thornton, MD - pustaka.kk.usm.my · John R. Griffin, MD* James F....

Volume 11 Issue R1, 2009

LOWER EXTREMITY RECONSTRUCTIONJohn R. Griffin, MDJames F. Thornton, MD

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Reconstruction TopicsBreast ReconstructionCleft Lip and PalateCraniofacialEyelid ReconstructionFacial FracturesHand: CongenitalHand: Extensor TendonsHand: Flexor TendonsHand: Peripheral NervesHand: Soft TissueHand: Wrist, Joints, Rheumatoid ArthritisHead and Neck ReconstructionLip, Cheek, Scalp, and Hair RestorationLower Extremity ReconstructionNasal ReconstructionSurgery of the EarTrunk ReconstructionVascular AnomaliesWounds and Wound Healing

Cosmetic TopicsBlepharoplastyBody Contouring: Excisional SurgeryBody Contouring: Noninvasive, Liposuction, Fat GraftsBreast AugmentationBreast Reduction and MastopexyBrow LiftFaceliftInjectable Agents and Dermal FillersLasers and Light �erapyRhinoplastySkin Care

Selected Readings in Plastic Surgery (ISSN 0739-5523) is published approximately 5 times per year by Selected Readings in Plastic Surgery, Inc. A volume consists of 30 issues distributed over 6 years. Please visit us at www.SRPS.org for more information.

Published as an electronic journal.

Je�rey M. Kenkel, MD

F. E. Barton, Jr, MD

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LOWER EXTREMITY RECONSTRUCTION

John R. Griffin, MD* James F. Thornton, MD†

*Private Practice, San Mateo, California, and Children’s Hospital of Oakland, Oakland, California †University of Texas Southwestern Medical Center at Dallas, Dallas, Texas

HISTORYEvolution of PrinciplesThe literature on lower-limb wounds contains numerous contributions by orthopaedic surgeons, plastic surgeons, and trauma surgeons. Burkhalter1 and Aldea and Shaw2 traced the evolution of principles of lower extremity wound healing, wound management, and hard- and soft-tissue reconstruction.

Fundamental Tenets and Debut of Plastic SurgeryAlthough treatment concepts for the traumatized lower extremity did not change significantly until the major wars, several fundamental tenets of care were proposed early in its history. Pierre-Joseph Desault (1744-1795) introduced deep incisions for drainage and débridement of devitalized tissues. Louis Ollier (1825-1900) introduced plaster of Paris casting for fracture stabilization. Sir William Arbuthnot Lane3 (1856-1943) wrote The Operative Treatment of Fractures, which was originally published in 1905. Lane subsequently sponsored Gillies and the debut of plastic surgery at the Cambridge Hospital at Aldershot in 1915.

Treatment Concepts and the World WarsBy the end of World War I, the concepts of fracture immobilization and early secondary suture were established. Winnett Orr4 developed a “closed plaster treatment” that avoided frequent dressings, irrigation, and wet antiseptic packs. With that technique, open wounds were covered with dressings and casts. Orr

did not perform true débridement of the wound before the cast was applied but did advocate incisions for drainage. The closed plaster method became the standard of care for injuries of the lower extremity after World War I.

Open wounds in the context of open fractures treated with the method presented by Orr frequently were complicated by osteomyelitis. This prompted Trueta5 to perform more extensive débridement before applying the plaster. Trueta favored conservative débridement of skin together with radical removal of devitalized subcutaneous tissue and muscle; all bone was preserved. Trueta’s revision of Orr’s teachings became the accepted management from 1939 to early 1942, in the early years of World War II. Trueta’s clinical experiences confirmed the need to remove any tissue medium that was favorable to bacterial growth.

The second phase of management of the lower extremity lasted through 1943. It consisted of initial wide débridement, plaster immobilization, and secondary closure or skin graft as soon as clean granulations appeared.

After 1943, fracture management entered a third phase that involved wide débridement at the forward surgical units. Closure was accomplished by delayed primary suture or graft at the base unit between the 4th and 6th days of injury. The closure was ideally accomplished before the appearance of granulation tissue. These were the origins of early delayed primary wound closure. The significance of these stages in the evolution of care is obvious

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when one compares the incidence of postfracture osteomyelitis after World War I (>80%) with that at the end of World War II (≈25%).

CURRENT TRENDSA fourth phase of lower extremity wound care currently is underway. Advances in orthopaedic and plastic surgery during the past 30 years have influenced the management of open tibial fractures, soft-tissue coverage, and chronic problems of the lower extremity. Technical advances in bone fixation and distraction, wound care, and soft-tissue healing have greatly enhanced our ability to salvage the foot, leg, and thigh after trauma. The contribution of vacuum-assisted devices has been notable.

Nevertheless, patients who suffer severe polytrauma or one of the more severe classes of open lower extremity fractures might still be better served by amputation rather than attempted reconstruction. The modern dilemma is no longer how to salvage a lower extremity but knowing when attempted salvage is not the best option for the patient.

Among recent trends in lower extremity reconstruction is a resurgence of support for local and fasciocutaneous flaps in leg and foot reconstruction. The pedicled flaps are touted as being similar to free flaps in terms of morbidity, reliability, and even aesthetic results.6,7

Regarding microsurgery, many recent articles focus on technical refinements of and indications for certain flaps in specific defects.8,9 Perforator flaps, which are becoming more accepted in breast and general reconstruction, are now also used in the lower extremity.10−12 Striving beyond form, contour, and optimal soft-tissue coverage, some surgeons reported progress with sensitive free flaps to the heel and weight-bearing foot.13,14

Several recent reviews have yielded a wealth of information for the new plastic surgeon and veteran alike. French and Tornetta15 presented a review of the literature on lower extremity trauma. Options for bone fixation and soft-tissue coverage are considered, and the outcomes of reconstruction versus early amputation are analyzed. Heller and Levin16 presented a discussion of the updated principles of management of lower extremity

wounds. Tomaino17 presented a review of the outcome of treatment of severe open tibial fractures.

BONE HEALING Rhinelander,18 Holden,19 and Macnab and De Haas20 provided discussions of factors influencing fracture healing of long bones and the cellular events that take place in the healing fracture wound. The tibia is a commonly used experimental and clinical model of bone healing.

Sauer21 presented a review of the blood supply of the lower extremity from the inguinal region to the thigh, knee, and leg, including fascial perforators, septocutaneous vessels, and major blood vessels. He emphasized the regional circulation pertinent to flap design.

Rhinelander18 and Macnab and De Haas20 described tibial vascularity in detail. The three main sources of blood supply to the tibia are the nutrient artery, the metaphyseal vessels, and the periosteal vessels. Originating from the posterior tibial artery, the nutrient artery penetrates the tibialis posterior muscle and enters the posterior tibia at the junction of the proximal and middle thirds. The cortical groove containing the artery extends distally and obliquely, traversing the cortex for approximately 5 cm. In this cortical canal, the nutrient artery is vulnerable to injury by even a slightly displaced fracture. Once in the medullary canal, the nutrient artery divides and gives off a network of vessels supplying the cortex from the endosteal surface. The endosteal circulation thus supplies the inner two thirds of the cortex, and the periosteal circulation supplies the outer third (Fig. 1).22

The periosteal vessels derive from the primary vessels of the limb and run perpendicular to the long axis of the bone. When a long bone is fractured, the nutrient vessels and the endosteal circulation are disrupted to the point at which the metaphyseal vessels enter the bone. The periosteal blood supply is maintained on both sides of the fracture line by virtue of its transverse orientation and becomes the chief nutrient source to the healing bone in many fractures.

The essential requirements for healing of opposed fracture fragments are adequate blood supply and proper stabilization.18 If stabilization is


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adequate, the source of blood supply to the fracture can be seen to influence the type of callus that forms: medullary, periosteal, or intracortical.18

Medullary bridging callus develops around day 4 after injury in stable, nondisplaced fractures. Time to union is shortest, and zone of fibrocartilage is minimal. The medullary or endosteal circulation is dominant throughout all healing phases of nondisplaced fractures.18

Periosteal bridging callus provides ancillary external support to the fracture and always contains a significant zone of fibrocartilage. The callus first appears approximately on day 3, and its initial blood comes from the surrounding soft tissues and periosteum. When the endosteal circulation reconstitutes, the periosteum assumes a new blood supply by the endosteal route. Periosteal bridging callus is extremely important in the union of displaced and comminuted fractures.

Intracortical uniting callus fills the space between fracture fragments after reduction and fixation. Its blood supply is intraosseous, extraosseous, or a combination of both. Healing

occurs only in areas of cortical bone contact, not just when bone fragments are in apposition, as usually occurs with compression plate fixation.

Primary bone healing can take place in nondisplaced fractures and stable fractures after rigid fixation with plate and screws without an intermediate stage of fibrocartilage. However, primary bone healing in such cases might not be the fastest course to full bony restoration or restoration of strength. Intramedullary rodding, casting, and external fixation are the usual methods of treatment of tibial fractures. The bone thus passes through a phase of cartilage-containing periosteal callus, which assists in stabilizing and vascularizing the wound.

Caplan23 suggested that pluripotential progenitor cells, referred to as mesenchymal stem cells, are attracted to the fracture site from nearby and distant sites throughout the body. The mesenchymal stem cells at the fracture site mitotically divide to form a blastema that crosses the fracture site. Depending on the local concentration of growth factors, the blastema differentiates and begins forming the missing skeletal tissues.

One of the reasons children’s bones heal better and faster than adults’ bones might be that children have more progenitor cells available. Wray24 stated that the periosteum is the origin of the pluripotential cells that enter the fracture site and contribute to the formation of callus. The delayed healing and inadequate callus that occur in the presence of extensive periosteal destruction in and about the fracture support this hypothesis.

The role of the soft tissues in fracture healing is not clear. Studies by Macnab and De Haas20 and by Gothman25 suggested that the muscles contiguous to the fracture are the immediate source of blood to the fracture. The slow healing of certain displaced fractures might be caused by scarce muscle tissue surrounding them. Holden19 tested this concept experimentally and successfully showed the importance of the surrounding muscle in contributing vascular ingrowth to the injured bony cortex. He further showed that when the soft-tissue envelope was rendered ischemic, initial revascularization occurred first in the muscle and secondarily in the skin. The

Figure 1. Illustrations depict the blood supply to the tibia. Note the linear pattern of endosteal circulation (nutrient artery and metaphyseal artery), subject to disruption with displaced fractures. Periosteal circulation is maintained unless soft tissues are avulsed (Type III). (Reprinted with permission from Byrd et al.22)

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restoration of intramedullary circulation in the bone occurred after the revascularization of the soft tissues. It was unclear whether the ischemic muscle was parasitic on the feeder vessels that would normally revascularize the bone or whether ingrowth from the surrounding soft tissue was necessary before bone revascularization could occur. Either way, the author concluded that bone revascularization essentially required well-vascularized soft tissues around it.

Cell Signaling in Bone Healing Mooney and Ferguson26 reported that environmental factors affect the differentiation of pluripotential mesenchymal cells. Their observations hint at a “golden period” during which bone formation can be manipulated through physical measures. Stress in the form of compressive force can be important during the first 3 weeks of fracture healing.

Barnes et al.27 presented a review of recent advances in cytokine and growth factor research and bone healing. Lieberman et al.28 presented a review of the potential clinical applications of several growth factors for improving fracture healing. Transforming growth factor beta, platelet-derived growth factor, and insulin-derived growth factors induce cellular proliferation in the laboratory, but their clinical application has not been determined. Locally instilled fibroblast-derived growth factor, on the other hand, significantly increased healing fracture strength over controls in a primate fracture model.29 Fibroblast growth factor-2 in a hyaluronidase gel accelerated fracture healing in nonhuman primates.28−30

Bone morphogenic protein (BMP) has also been shown to have clinical promise for accelerating fracture healing.28,31,32 Sciadini and Johnson33 showed that local BMP was as effective as autogenous bone graft in achieving union in experimental radius defects and was significantly more effective than controls in achieving union. In contrast to some of the cytokines, however, BMP might have specific dose requirements that could limit its clinical usefulness.

As the promise of growth factors materializes, issues related to delivery mechanisms,

timing, and appropriate dosages become more important. Molecular carriers, viruses, gels, hyaluronidase matrixes, and creative use of gene therapy are all being tested for delivery of growth factors to healing fractures.28 Lieberman et al.28 listed the following potential clinical uses of growth factor therapy:

• acceleration of fracture healing (in cases at risk of nonunion)

• treatment of established nonunions enhancement of primary spinal fusion

• treatment of established pseudoarthrosis of the spine

• treatment of large bone-loss problems

OPEN TIBIAL FRACTURES Demographics Patients with severe lower extremity trauma often share traits that can affect the management and eventual outcome of treatment. MacKenzie et al.34 at Johns Hopkins Hospital prospectively studied the broad demographic characteristics of 601 patients with high-energy lower extremity trauma and noted the following:

• 77% were male • 72% were Caucasian • 71% were between the ages of 20

and 45 years• 70% were high-school graduates (versus

86% national average) • 38% had no health insurance (versus

20% nationwide) • they were twice as likely to have a history of

alcohol abuse than the national averageFrancel35 identified three demographic factors associated with reemployment after severe lower extremity injury:

• age younger than 40 years• history of higher education (beyond high

school)• white-collar employment

A large, multicenter, prospective observational study of severe lower extremity injuries36 identified the following patient factors as predictors of an eventually poor outcome:


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• rehospitalized for a major complication• low education level• non-Caucasian race • poor• lacking private health insurance• with poor social support network• low self-sufficiency

Smoking and Tibial Fractures Smoking adversely affects bone healing. In a blinded retrospective study, Schmitz et al.37 demonstrated no significant difference in eventual union between smokers and non-smokers with closed and Gustilo type I tibial fractures treated by either external or internal fixation. The study did show that time to union in smokers was 69% longer than in nonsmokers. As one would expect, the trend toward delayed healing is also observed in the full range of open tibial fractures in smokers. Adams et al.38 compared matched demographic groups of smokers and nonsmokers who had tibial fractures and found the mean time to union for smokers to be 4 weeks longer than for nonsmokers.

Limb Salvage versus Primary Amputation Physicians who treat lower extremity trauma would like to have a reliable way to predict prognosis for each patient. The most important early decision to be made in the event of severe leg trauma is whether to reconstruct or to perform early amputation. Orthopaedic and plastic surgeons generally agree that some lower extremity injuries are best served by reconstruction; others are candidates for primary amputation. Delayed leg amputation is considered a relative treatment failure because it suggests possible errors in the initial treatment rationale. Furthermore, delayed amputation has been linked to increased hospital costs, more operations, and increased patient disability, including sepsis and death.39 For the patient and for the physician, few failures of treatment are as devastating as a nonfunctional salvaged limb. Technical victories that result in functional failures serve no purpose.

Before embarking on lower extremity reconstruction of severe open fractures, it is

sobering to consider the complication rates, multiple operations, and long hospital stays that often are required in such cases. One recent study evaluated 43 patients who had undergone attempts at reconstruction of Gustilo type IIIB and IIIC injuries.40 Methods of reconstruction included the use of bone grafts, local flaps, free soft-tissue flaps, and free bone-soft-tissue flaps. Overall, approximately 63% of patients experienced some form of infection during the postoperative period. Union was achieved in 37 of 43 cases; the average time to union was 9.5 months. The average number of operations required for each patient was 8.7. Hospital stays ranged from 49 to 62 days. Long-term problems such as joint stiffness and pain were common. In the end, 26 of 41 patients who worked before the injury returned to work. It should be noted that despite their long-term problems with the rebuilt limbs, patients who had undergone reconstruction preferred that outcome to the prospect of amputation. A study by Pelissier et al.40 showed similar patient preference.

The concept that the most severe lower extremity injuries are best served by amputation makes sense, but reliable predictors of outcome are not clearly defined. Keller41 reviewed 10,000 cases of tibial fractures and noted that the risk of systemic complications rose in the presence of comminution, displacement, bone loss, soft-tissue injury, infection, and polytrauma. Fracture location, configuration, and concomitant fibular fracture had no prognostic significance.

Several authors have since attempted to use scoring systems to help them decide between limb reconstruction and amputation.42−44 In a frequently cited study, Francel et al.45 reported improved return-to-work rates after amputation (68%) compared with reconstruction (28%). A more recent study by Francel35 showed that early postinjury reconstruction, appropriate soft-tissue coverage, and early bone grafting significantly decreased the time to ambulation. The reemployment rate improved to 67% among patients who became ambulatory soon after reconstruction but was low when ambulation was delayed. The updated conclusion is that reconstructed patients who ambulate at the

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appropriate time might be able to return to work as often as patients who undergo primary amputation.

Many studies have attempted to use demographic data and trauma scoring systems to determine prognosis. The Lower Extremity Assessment Project (LEAP) was designed to compare outcomes of patients with severe lower extremity trauma. A large study by the LEAP group prospectively applied five major trauma scoring systems to more than 500 injured lower extremities. The scoring systems used were as follows:46

• Mangled Extremity Severity Score• Limb Salvage Index• Predictive Salvage Index• Nerve Injury, Ischemia, Soft Tissue Injury,

Skeletal Injury, Shock, and Age of Patient Score

• Hannover Fracture Scale-97Interestingly, low scores were useful in predicting which limbs could be salvaged but high scores did not predict which limbs could not be salvaged. In conclusion, the five trauma scoring systems studied do not reliably predict which injured limbs should undergo primary amputation.46

Another study by MacKenzie et al.47 analyzed a broad range of factors that could influence the ultimate outcomes for severe leg and foot injuries. Bone loss was not found to be a factor, but severe soft-tissue injury and absence of plantar sensation at presentation were prospective indicators of primary and delayed amputation.

Lange et al.43 reported a 61% amputation rate for limbs with vascular injury (22% primary, 39% delayed). Crush injuries, segmental tibial fractures, and fractures for which revascularization was delayed more than 6 hours generally had poor outcomes.

McNutt et al.48 reviewed the cases of 366 patients with tibial fractures occurring after blunt trauma. Twelve percent of patients had clinical evidence of tibial artery injury; of those, 27 had angiographic evidence of at least one patent tibial vessel and adequate distal flow. The other 17 patients required operative repair of the injured tibial arteries because of persistent distal ischemia. The amputation rate in the vascular repair group

was 35%. Patients who required amputation experienced a significantly greater incidence of three or more fascial compartments involved in muscular injury, two or more injured tibial vessels, failed vascular reconstruction, and a cadaveric foot at initial examination. No extremity was salvaged when more than two of these findings were present. Failed reconstruction led to limb amputation in all cases, even though three patients were noted to have patent vascular repairs at the time of amputation. Severe tibial nerve injury and an insensitive foot generally are considered contraindications to reconstruction. However, Higgins et al.49 The case was an open tibial fracture that was salvaged with external fixation, soft-tissue coverage, and tibial nerve grafting. The patient recovered pressure sensation and sharp-dull sensation at 27 months postoperatively.

The primary factors influencing outcomes for leg injuries are as follows:17,50

• degree of soft-tissue damage• presence or absence of plantar sensation• severity of vascular injury

The absolute indications for primary amputation in cases of open tibial fracture are as follows:17,50

• anatomically complete disruption of the posterior tibial nerve in adults

• crush injuries with warm ischemia time >8 hoursThe relative indications for primary

amputation in cases of open tibial fracture are as follows:17,50

• serious associated polytrauma• severe ipsilateral foot trauma• anticipated protracted course to

obtain soft-tissue coverage and tibial reconstructionBosse et al.36 compared outcomes in patients

with severe lower extremity trauma who had undergone reconstruction versus amputation. The cohorts were matched for severity of injury and patient demographics. An evaluation conducted 2 years postoperatively indicated that those who had undergone amputation had functional outcomes that were similar to those who had undergone


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reconstruction. A similar number of patients in each group—nearly 50%—had returned to work at 2 years.

Another study from the Netherlands51 showed that quality-of-life ratings were similar between patients who had undergone amputation and those who had undergone reconstruction. It should be noted, however, that the studies did not analyze the patients’ preferences regarding reconstruction versus amputation or the patients’ levels of satisfaction with their outcomes.

The net costs of salvage versus amputation are controversial. Hertel et al.52 analyzed social and employment outcomes for patients with severe leg injuries. They noted that the total costs of care and rehabilitation are not limited to the hospitalization costs alone. Although the return-to-work rate was an amazing 100%, the number of interventions was significantly lower in the group of patients who had undergone reconstruction. When the global costs of care to the community were considered in that study, the patients who had undergone reconstruction proved considerably less expensive to finance than the patients who had undergone below-knee amputations. This is mainly because patients who undergo amputation often are recipients of lifelong partial pension payments. Unlike previous reports, the study by Hertel et al. found that the long period of rehabilitation did not induce chronic invalidity. Of note, the reconstruction group compared favorably with the amputation group in physical, social, and psychosocial parameters.

Tomaino17 summarized considerations regarding management of the patient with severe open tibial fractures. On the basis of his experience and analysis of the literature, he recommended limb reconstruction for cases with reasonable hope that the patient will return to ambulation within 1 year. He also emphasized that every technical and rehabilitative effort must be made to achieve union and ambulation as soon as possible.

It is important to note that a review of the literature suggested similar functional outcomes for reconstruction and amputation, not better functional outcomes for reconstruction. It is also important to note that analysis of outcomes after

open tibial fractures likely is more complex than can be judged by trauma scoring systems.

Despite showing poor return-to-work numbers for patients with reconstructed limbs, a study by Francel et al.45 reported that patient satisfaction after reconstruction was high: 96% were satisfied with their reconstructed limb. Dagum et al.53 noted that the vast majority of patients who underwent reconstruction preferred their reconstructed limbs to amputation despite ongoing disability. No patient with a salvaged limb in that study wished they had undergone primary amputation instead. In addition, the physical outcome scores were better overall in the reconstructed group than in the amputated group.

In summary, some severe leg injuries are not amenable to reconstruction. Other injured legs might be amenable to reconstruction but are so severely injured that reconstruction is not advisable. Nevertheless, few patients elect to undergo primary amputation when salvage is feasible, even when the physician thinks that reconstruction is inadvisable.

The burden of educating the patient rests with the physician. Functional outcomes and return-to-work statuses improve with earlier ambulation times. Once the decision is made to reconstruct an injured leg, all effort should be made to minimize complications and achieve expedient bony union and stable soft-tissue coverage. Ambulation is a major predictor and essential prerequisite to successful lower limb reconstruction and return to overall function.

Classification of Open Tibial FracturesThe severity of open wounds associated with tibial fractures varies widely. It was long acknowledged by orthopaedic and plastic surgeons that the severity of the soft-tissue injury correlated well with long-term limb function.54 Gustilo and Anderson55 published their classification of open tibial injuries in 1976. Their grading system drew a clear link between severity of injury and prognosis for recovery.

Subsequent clinical studies confirmed the usefulness of the Gustilo classification.55 In a series presented by Emerson and Grabias,56 Gustilo type III fractures comprised 77% of injuries and generally required closure with skin grafts or flaps.

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Healing time for that group was protracted, and the overall infection rate was 39%. Other complications, such as malunion and nonunion, were also frequent. The authors concluded that the Gustilo type III injury segregates itself as a unique fracture predisposed to treatment failure.

Tscherne and Oestern57 and Oestern and Tscherne58 later developed their own widely referenced tibial injury classification system that correlates well with clinical results. Over time, it has become clear to practitioners that the Gustilo type III injuries are a heterogenous group. In 1984, Gustilo et al.59 published a revised classification that divided the more severe injuries into three subgroups. The Gustilo type IIIA group is clearly different from the Gustilo type IIIB and IIIC groups. Type IIIA fractures have stable soft tissue over the comminuted fractures, whereas types IIIB and IIIC require soft-tissue reconstruction (Table 1).60 Types IIIB and IIIC have worse bony injury accompanying the soft-tissue injury. The type IIIB fracture is defined by its need for soft-tissue coverage and the type IIIC by its requirement for some form of arterial vascular repair to salvage the limb.

At approximately the same time the Gustilo studies were published, a classification of open tibial injuries by Byrd et al.61 was published. The system presented by Byrd et al. is similar to the original Gustilo classification regarding types I through III,

but it is not a simple modification of the Gustilo scheme. In the classification presented by Byrd et al., the type III group can be said to approximately correspond to the original Gustilo type III. The Byrd type III is a severe injury with devitalized local soft tissues, but it might be amenable to local muscle flap coverage. Select cases of Byrd type III injuries require free flap coverage, particularly in cases of injury to the distal third of the leg, where pedicled flaps are less reliable. Based on the definition presented by Byrd, the type IV injury is severe enough that no opportunity exists for local muscle transfer (Fig. 2). By definition, the Byrd type IV injury requires free flap coverage in all cases.

Byrd’s classification is very useful for plastic surgeons in particular because it correlates well with requirements for soft-tissue reconstruction. The system is widely referenced in the plastic surgery literature but should be combined with other physical findings and possibly other classification schemes to fully describe an open tibial injury.

The revised Gustilo system is the standard descriptive classification used by trauma and orthopaedic surgeons, yet it has persistent problems.60 The Gustilo type IIIB and IIIC groups remain heterogeneous; the severity of injuries within those groups varies widely. Many Gustilo type IIIB injuries should undergo an attempt at salvage, whereas others have a very poor prognosis because of large zones of injury and influencing

Table 1Gustilo Classification of Open Fractures of the Tibia60

Type Description

I Open fracture with a wound <1 cm

II Open fracture with a wound >1 cm without extensive soft-tissue damage

III Open fracture with extensive soft-tissue damage

IIIA Type III with adequate soft-tissue coverage

IIIB Type III with soft-tissue loss with periosteal stripping and bone exposure

IIIC Type III with arterial injury requiring repair

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factors. The revised Gustilo system also implies that IIIC injuries are worse than IIIB injuries, which is not always the case. It makes no mention of the status of the tibial nerve, which is an important indicator of the quality of limb salvage.43 Furthermore, the Gustilo type IIIC injury is defined as “an arterial injury requiring repair.”59 Although most surgeons will not attempt repair of a vessel in the leg so long as the foot is still perfused by at least one major artery, some surgeons will try to restore two vessels to the foot in select cases.60 This variability in clinical decision making can actually alter the meaning of the Gustilo type being applied. In the end, the revised Gustilo classification scheme is very good but not perfect.

Fracture Management and Skeletal Reconstruction The management of open tibial fractures consists of two general types of bone fixation and three types of soft-tissue management. Bone fixation can be accomplished internally with plates, rods, or screws or externally with percutaneous pins. Pin fixation can be either static or dynamic. Casting is an option for less severe injuries that have stable soft tissues over the fracture, but the method presented by Trueta5 is no longer used for more complicated wounds.

Closed Treatment According to Byrd et al.,61 the closed plaster method presented by Trueta involves wide débridement of the soft tissues surrounding the fracture while preserving all bone fragments. After fracture reduction, dressings and a walking cast are applied. Classically, patients start walking with crutches the day after surgery and proceed to full weight-bearing on the cast within 3 weeks. Many wounds drain profusely during the first few weeks, and casts often need to be replaced.

Casting alone is no longer considered optimal for the treatment of high-energy open injuries, as the soft tissues cannot be closely monitored and reduction is difficult to maintain.15,62 Casting is considered acceptable for low-energy closed injuries and mild open tibial injuries. The success of casting of such injuries is predicated on maintaining good fracture reduction. Studies

comparing internal fixation and casting for the treatment of low-energy tibial fractures have shown faster union times and lower incidence of malunion with internal fixation.63,64 High rates of conversion from casting to internal fixation because of loss of reduction have been noted.63

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Figure 2. Classification of open tibial fractures. (Reprinted with permission from Byrd et al.61)

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Another option for closed treatment is functional bracing. It can be used with success to treat some low-energy injuries but is not optimal for high-energy injuries.15,65

AO Plate Fixation Olerud and Karlström66 and Olerud et al.67 presented a review of the use of AO compression osteosynthesis in the management of open tibial fractures. The method requires exact opposition and compression of bone by plates and screws. The hardware must be covered with viable soft tissue. Motion begins early and is gradually increased. Full weightbearing is allowed at 10 to 14 weeks if evidence of radiologic union is present. The theoretical advantage of AO compression for tibial fractures was thought to be primary bone healing, but ultimately, plate fixation of tibial fractures has not been proven to be as successful as plate fixation of fractures in other areas of the body.

The periosteal blood supply is very important in healing fractures. The more disrupted the endosteal circulation is, the more important it is to maintain periosteal and local soft-tissue viability for fracture healing. When using plate fixation, an area of periosteum that corresponds to the surface area of the plate must be stripped. Just obtaining exposure for the plate can cause additional devascularization of soft tissues that are important for tibial healing, and the devascularization of bone can translate into suboptimal clinical results. Some studies reported increased complication rates overall, including infection and nonunion, when plates were used to treat severe leg injuries.68−70 The theory is that the plate ultimately creates stress shielding and predisposes the bone to osteopenia. In addition, the multiple screws through the bone weaken the cortical bone stock. Finally, the plate itself creates stress risers on both ends of the plate, predisposing the bone to re-fracture. Plate fixation is reserved for specific types of tibial fractures that are not amenable to other types of fixation. Plate fixation of high-energy tibial shaft fractures generally is not recommended.15

Static and Dynamic External Pin FixationExternal fixation with pins is a safe choice for high-energy tibial fractures. The method evolved from the need to adequately stabilize open fractures associated with soft-tissue loss. Percutaneous pins are placed outside the area of the fracture. Bone devascularization is minimal because no iatrogenic periosteal stripping is needed to place the pins, which are inserted through small incisions under fluoroscopic guidance. External fixation is indicated when rigid fixation is required, but internal fixation cannot be used because of severe comminution, segmental bone loss, severe osteoporosis, or severe soft-tissue injury.55

Modern pin fixation frames are smaller and less obstructive, resulting in easier soft-tissue management.15 Overall, external fixation of Gustilo type II and III fractures yields good results.15

The main disadvantages of external fixation are complications associated with hardware. Pin tract infections are common and increase in frequency with the amount of time the pins are left in place. The risk of frame loosening and osteomyelitis limits the amount of time external fixation can be used, although ideally, external fixation should be continued until union. To win this race against time, different modalities have evolved to either prolong frame use or shorten time to union. Meticulous pin care and close vigilance to detect infection early are mandatory.

Another option for decreasing time to union is prophylactic bone grafting.71 Blick et al.72 analyzed the results of early prophylactic bone grafting for high-energy tibial fractures in 53 patients. Bone grafting was performed approximately 10 weeks after injury and 8 weeks after soft-tissue coverage. Time to union was reduced to 12 weeks compared with 20 weeks in a matched control group of tibial fractures treated with delayed bone grafting.

Another option that some authors have advocated is dynamization of the frame.15 With dynamization, the frame is modified to allow some movement and axial loading at the fracture.73,74 Some authors claim that controlled stress and motion at the fracture site result in faster union.75


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A final option is exchange nailing. The external device is replaced with an intramedullary nail after soft-tissue coverage is stable and before union. The technique of exchange intramedullary nailing can yield low infection rates and high rates of union.76

Intramedullary Nailing Primary intramedullary tibial nailing produces high union rates and is associated with few infections when used to treat closed fractures and low-energy open fractures of the leg.77 With grossly contaminated open fractures, the exposed hardware is a risk factor for infection. For more severe injuries, such as Gustilo types IIIB and IIIC, therefore, some variant of external fixation likely is a safer choice than internal fixation.

A recent meta-analysis of open tibial fractures revealed that nail fixation is associated with lower reoperation rates, lower malunion rates, and lower infection rates than is external fixation. It must be noted that the data apply to all types of open tibial fractures, not necessarily Gustilo type III injuries as a group. It might be physically impossible to achieve stabilization with rods in some of the more severe open tibial injuries.78

Rohde et al.79 retrospectively analyzed complication rates associated with methods of fixation of free flap reconstructed type IIIB fractures. The study suggested that external fixation might be more prudent in such cases. The set of type IIIB fractures that underwent intramedullary rod fixation experienced significantly higher rates of wound infection, osteomyelitis, and nonunion than did the external fixation group.

A controversial issue is whether reamed or unreamed nails are better. Reamed nails can produce endosteal devascularization and hinder bone union, and the smaller unreamed nails have lighter screws that can break.15,80−82 Finkemeier et al.83 compared unreamed and reamed nails in the treatment of closed and open tibial fractures excluding Gustilo type IIIB and IIIC injuries. The outcome of closed injuries was better with reamed nails, and the complication rates of open injuries were similar with either technique. The above cited

meta-analysis78 also suggested that reamed nails lead to fewer secondary operations.

COMBINED SKELETAL AND SOFT-TISSUE RECONSTRUCTION: TIMING AND COORDINATIONThe ultimate functional success of lower extremity reconstruction depends on achieving union and ambulation. The modern approach to reconstruction of lower extremity injuries consists of seamless coordination of bone and soft-tissue management.

Appropriate débridement is indicated for early treatment of the open tibial injury, with pulse lavage for effective wound irrigation. Débridement and irrigation are performed soon after the patient presents at the emergency department and are repeated until definitive soft-tissue coverage is secured. Bhandari et al.84 compared the benefits of high-pressure lavage (70 lb/in2) versus low-pressure pulse lavage (14 lb/in2) in an in vitro model. Both methods resulted in lifting of periosteum in the laboratory. Both were effective at removing bacteria 3 hours after injury, but high-pressure lavage was more effective 6 hours after injury. The high-pressure method, however, is powerful enough to cause structural damage to cortical bone. The study supported the argument that early débridement is more effective than delayed débridement at removing bacteria. It did not answer the question of which of the two modalities results in lower rates of infection.

Researchers and clinicians continue to debate the optimal timing for institution of open tibial fracture treatment. Harley et al.85 reviewed 241 open tibial fractures to determine which factors were associated with nonunion. Prophylactic antibiotics had been administered in all cases. The risk of nonunion was higher in injuries that were severe based on the Gustilo classification and in cases of concurrent infection. Nonunion rates were not affected by aggressive lavage and débridement or by delay in definitive fixation up to 13 hours after injury. After 13 hours, delay in definitive treatment began to adversely affect outcomes.

Many fractures with various amounts of bone loss are treated with antibiotic-impregnated

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bead spacers during an intermediate stage. In a prospective study, Moehring et al.86 compared antibiotic beads with intravenously administered antibiotics and found no statistical difference in infection rate between the groups; either method alone is effective for prophylaxis. Regarding dosage of intravenously administered antibiotics in cases of open tibial fractures, once daily therapy can be as effective as traditional dosing regimens for prophylaxis.87

In 1970, Ger54 reviewed the management of extensive soft-tissue defects over severe open tibial fractures, emphasizing the need for thorough débridement. In the 1980s, Byrd et al.61 noted that complications worsen when an open tibial fracture is allowed to enter a delayed (subacute) phase of wound healing and contamination. Early multimodality treatment was advocated to improve outcomes. In a prospective review of open tibial fractures, the authors proposed radical débridement of bone and soft tissue with flap coverage in the first 5 to 6 days after injury (acute phase) for the most severe injuries. The complication rate for Byrd type III wounds averaged 18%. Fractures not treated by early muscle flaps predictably entered a colonized subacute phase that extended from 1 to 6 weeks after injury. Complications after treatment with flaps during that phase averaged 50%. Approximately 4 to 6 weeks after untreated severe injuries, a chronic phase characterized by a granulating wound, adherent soft tissue, and decreasing areas of infection was noted. The complication rate for the chronic group after soft-tissue coverage was still high but decreased to 40% relative to the complication rate for the subacute group.

In summary, muscle flap coverage applied during the acute period resulted in the fewest complications and shortest hospitalization stays. Flap coverage applied during the subacute and chronic phases was associated with a number of complications, both immediate and late. As the limits of bone débridement become better demarcated during the chronic phase, reliable bleeding margins of bone become apparent and soft tissues adhere to healthy cortex outside the fracture.

Other authors,61,88 although recognizing the challenging characteristics of subacute and chronic tibial wounds, have taken issue with the limitations imposed by a subacute tibial fracture. Yaremchuk et al.88 reviewed a series of patients who received flap coverage a mean of 17 days after injury and noted an overall infection rate of 14%. A difference in management between the series presented by Yaremchuk et al. and the series presented by Byrd et al.61 was the more aggressive débridement reported by Yaremchuk et al. The implication is that aggressive débridement might be able to convert a subacute open tibial fracture to an acute quality wound, after which flap coverage can proceed with relative safety.

Like Byrd et al.61 and Yaremchuk et al.,88 Gustilo et al.59 emphasized that it is best to perform early flap coverage of severe injuries. When definitive soft-tissue coverage was achieved within 14 days of injury, complications, costs, and the number of secondary procedures were decreased.

Similarly, Francel et al.45 noted a low (3.6%) incidence of complications in cases of Gustilo type IIIB injuries when definitive free flap coverage was accomplished within the first 15 days. Others have also shown that delay in covering the open tibial wound is associated with a high rate of complications.89

Godina90 retrospectively followed 532 patients after microsurgical reconstruction of their traumatic leg wounds. Group I (134 patients) underwent free flap transfer within 72 hours of injury. Group II (167 patients) underwent flap coverage between 72 hours and 3 months of injury. Group III (231 patients) underwent flap coverage between 3 months and 12.6 years after injury. The flap failure rates were 0.75% in Group I, 12% in Group II, and 9.5% in Group III. Postoperative infection developed in 1.5% of Group I patients, 17.5% of Group II patients, and 6% of Group III patients. Time to union was 6.8 months in Group I, 12.3 months in Group II, and 29 months in Group III. At first glance, a reader might infer that the intermediate time frame—between 3 days and 3 months—is the worst time to reconstruct and that definitive management should be deferred until


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after 3 months. However, the report did not support those assumptions. Note that Group III had the longest time to union and the longest hospital stays, indicating that early, stable soft-tissue coverage of severe open tibial fractures improves the overall outcome.

It remains unclear whether aggressive débridement of bone during delayed treatment of wounds affects outcome. There is little doubt that liberal débridement of all fragments of bone in a fracture invariably lowers the infection rate. The surgeon must weigh the risk of taking time to observe fractured bone for viability versus allowing a wound to enter the delayed period of wound colonization. The risks, if any, of removing bone that ultimately might have been viable must also be considered. One point of view advocates early aggressive débridement, early soft-tissue coverage, and early or delayed replacement of missing bone.

The success of early soft-tissue coverage is well established. The “fix and flap” model, with which flap transfer is performed simultaneously with the final débridement procedure, is recommended by some. Advocates of the approach reported improved results because of the minimal time allowed for bacterial colonization. Gopal et al.91 reported a 9% deep infection rate with the fix and flap method and a worsening infection rate when flap coverage was delayed by more than 1 week.

According to many, early soft-tissue coverage after one to three thorough débridement procedures remains the standard of care for open tibial fractures.71 Heller and Levin16 stated that soft-tissue coverage applied within 7 days of injury produces optimal results.

Paired with early soft-tissue coverage is bone replacement and prophylactic bone grafting of severe fractures. Some authors have advocated simultaneous soft-tissue reconstruction and bone replacement, whether done emergently or simply early.92 Many surgeons, however, prefer to graft after stable coverage has been achieved—up to 2 months after the soft tissues have been repaired.15,71,93

Arnez94 discussed the history, pros and cons, and results of immediate reconstruction of

the lower extremity by “emergency” free flaps. Tropet et al.95,96 advocated aggressive emergency multimodality treatment of severe open tibial fractures. The authors reported 18 cases of Gustilo type IIIB injuries treated emergently with intravenously administered antibiotics, débridement, and locked intramedullary nails. Six patients received free muscle coverage, and 12 received local muscle flaps. Immediate iliac crest bone grafting was performed in three patients. Bone union was achieved at a mean 6.5 months after treatment. Primary union was achieved in 13 of 18 patients (72%), all of whom were able to return to work; the five remaining patients required further intervention. The intriguing study was neither prospective nor randomized. Further study is warranted to establish whether this early, one-stage definitive approach improves outcomes.

METHODS OF BONE RECONSTRUCTION TO TREAT OPEN TIBIAL FRACTURESThe basic ways to bridge a bone defect in the leg are bone grafting, free osseous or osteocutaneous flap transfer, and distraction osteogenesis, also known as the Ilizarov technique.

Bone Grafts For Gustilo type IIIB fractures with significant comminution and small bone gaps, cancellous bone grafts beneath vascularized muscle flaps often are used. With massive bone harvests, it is possible to bridge defects >10 cm by using this technique. Christian et al.97 evaluated eight patients who had type IIIB open tibial fractures associated with large (average, 10 cm) diaphyseal defects. The defects were filled with antibiotic-impregnated beads and covered with free flaps. The beads served as spacers to preserve the volume of the diaphyseal defect. Approximately 3 to 6 weeks later, the tibia was reconstructed with massive amounts of autogenous cancellous bone grafts. The mean duration of external fixation was 5.5 months, and time to healing after bone grafting averaged 9 months. Nevertheless, massive cancellous grafts usually are not the first choice of treatment for large tibial fractures.

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An intact fibula facilitates bone grafting of longer defects by acting as a strut to keep the extremity at length. If the fibula is not intact, which often is the case with high-energy injuries, other reconstructive methods might be necessary, particularly for defects >8 cm.

Canovas et al.98 reported an alternative to vascularized bone or massive cancellous grafts. In the case reported by the authors, the contaminated, devascularized tibial segment was sterilized and used as a tibial autograft to fill a 12-cm defect. The patient reportedly achieved union at 6 months and walked normally at 10 months. The use of autograft that has undergone débridement and has been frozen and subsequently boiled deserves further study.

Vascularized Bone Transfers Vascularized autogenous bone transfers are useful in bridging long bone gaps. Most commonly transferred as vascularized bone in the repair of posttraumatic leg defects are the fibula, iliac crest, and scapula. Taylor99 detailed the vascular anatomy of the iliac crest and fibula. He cited examples of microvascular bone transfers and reviewed the sequence of lower extremity reconstruction with vascularized bone. He was the first to report using the free fibula transfer to repair tibial defects.100 Sekiguchi et al.101 described the use of osteocutaneous free scapular flaps in the lower extremity. Allen et al.102 reported successful transfer of latissimus dorsi-scapular bone flaps for lower extremity reconstruction in 12 patients. Lin et al.103 compared the results of three different free flaps for posttraumatic tibial reconstruction. In their retrospective study, 64 fibulae, 22 serratus flaps with rib, and 11 iliac flaps were compared. The fibulae had the best results overall, but the other two options are recommended when the fibula is not available.

Weiland et al.104 reported an early series of 41 autogenous vascularized bone grafts used in the upper and lower extremities. The average size of the defects was 16 cm. The iliac crest was used when the bone gap was ≤10 cm, and free fibular transfers were used when the gap was larger. Technical details of fibular harvesting are presented in the article. Of

32 free fibular grafts, 28 (87.5%) were successful. Failures generally resulted in amputation. Full weight bearing did not occur until approximately 15 months postoperatively, corresponding to the time it takes for a graft to hypertrophy.

In another study evaluating free fibular hypertrophy in the lower extremity, El-Gammal et al.105 stated that the rate of fibular hypertrophy correlates directly with youth, particularly in patients younger than 20 years. The amount of fibular hypertrophy was also more robust in younger patients. In 25 patients with tibial defects who underwent free fibular reconstruction, the bone hypertrophy leveled out at 30 months. It is worth noting that none of the tibial defects in that study were of traumatic origin, which hampers our ability to draw meaningful comparisons with other studies.

Wood et al.106 noted the value of vascularized bone grafts in posttraumatic limb salvage but acknowledged that 50% of their cases required secondary operations. Free bone transplantation in cases of severe leg trauma is technically demanding and time-consuming, and probably should be performed by experienced microsurgeons.

These studies have drawn attention to the prolonged time of partial weight bearing that patients must go through while waiting for graft hypertrophy and stability. Patient compliance becomes an issue, and many find it difficult to wait up to 2 years before attempting unaided ambulation. Tu et al.107 reported 48 cases of long bone reconstruction with free bone flaps, most of which were fibulae to tibiae. The average time to union was 4.2 months. The series also included upper extremity long bone reconstructions, and the authors documented significantly more bone hypertrophy in lower extremity grafts than in the upper extremity grafts.

Full weight bearing on an incompletely hypertrophied fibular interposition graft risks stress fracture. In 1999, Lee and Park108 reported fractures in 15 of 46 fibulae at an average 9.7 months after transfer. Nevertheless, the authors recommended that patients begin early weight bearing on the flaps or the necessary hypertrophy might not occur.


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When stress fractures are expected, they are tolerated.

In a follow-up study 5 years later, Lee et al.109 reported the long-term outcomes of the original 46 study patients plus five more. Overall, 47 of 51 bone flaps united at 3 to 7.5 months. Two delayed unions and two nonunions occurred. Pathological fracture occurred in 16 cases and usually healed with long-leg casting, although some required open reduction and internal fixation and bone grafting. The authors emphasized that weight bearing is necessary to stimulate hypertrophy in a fibular graft and started their patients on partial weight bearing as soon as bone union was noted radiographically. In general, patients began weight bearing at 4 to 7 months postoperatively. Three complete losses of the fibular skin paddle but only one complete necrosis of the bone graft occurred; the other two grafts were salvaged. Adjunctive procedures to reestablish soft-tissue coverage, immobilization, and bone grafts might be required in cases in which the fibular graft lacks adequate stability.

Toh et al.110 suggested a potential solution to the stress fracture problem. The authors advocated folding the fibular grafts to provide more stability and bulk. That technique is possible with either pedicled or free fibular transfer and can bridge defects as large as 10 cm (a folded 20-cm graft). The increased bulk of the folded fibula might decrease fracture rates and time to full weight bearing.

The fibula usually is transferred as a free flap with or without a skin paddle. Lee and Park108 and Lee et al.109 used free fibular transfers with skin paddles for combined bone and soft-tissue reconstruction of open tibial fractures. Still, many large bone defects also have large skin defects that can be difficult to cover with a fibular skin paddle. Such cases might require additional free flap(s) or alternative methods of reconstruction. It also is possible to transfer the fibula on an ipsilateral pedicle as a vascularized bone graft or osteocutaneous flap. Pedicled fibular transfer might be more useful for defects of the proximal tibia and distal femur.110,111 Atkins et al.112 reported ipsilateral vascularized fibular transport for tibial reconstruction. The technique does not necessitate

an intact fibula because pre-transfer distraction lengthens the fibula sufficiently to bridge the defect.

When transferring a free fibula, it is useful to know that the flap can be sustained on its distal pedicle via retrograde flow. Therefore, when the proximal pedicle of a free fibula is damaged, the flap can still be anastomosed to the distal peroneal artery and vein.110,113

Free transfer of a previously fractured fibula has also been reported.114 As long as the arteriogram confirms a good pedicle, this transfer is an option for tibial reconstruction.

Distraction Osteogenesis Bone gaps ≥10 cm can be bridged with the Ilizarov technique.115−119 The procedure begins with débridement of the fractured ends. The cortical bone is transected outside the zone of injury, leaving the medullary bone and blood supply intact. Pins are inserted near the bone ends on either side of the gap, and the external distraction apparatus is applied. A waiting period of approximately 7 days typically is allowed before distraction begins. Distraction consists of turning the screw(s) on the external fixation device to gradually apply tension across the corticotomy site (Fig. 3). Distraction usually proceeds at the rate of 1 mm per day until the defect is spanned.120 The circular frame usually remains in place for 1 year—the time needed for the bone to regenerate, consolidate, and mature.

Cierny et al.117 discussed advantages of the Ilizarov technique. First, the amount of bone generated is anatomically correct for the size of the defect. Second, soft-tissue defects can be closed by the docking method during the same process. Finally, blood transfusions usually are not required. The authors noted that because the process is slow and potentially arduous for the patient, candidates must be chosen with care. Relative contraindications are a defect >12 cm, which necessitates two lengths of regenerated bone of ≥6 cm, and deficient residual bone stock that cannot support serial corticotomy procedures.

Vasconez and Nicholls116 discussed the benefits of and indications for the Ilizarov technique versus bone grafts or free bone transfer in the management of severe open tibial injuries.

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Patients who had significant soft-tissue and bone loss or severe comminution were divided into one of two treatment groups. In one group, the tibia was placed at length with the use of external fixation and received either bone graft or free fibular flap. Soft-tissue defects were repaired with skin grafts, local flaps, or free flaps. In the second group, the Ilizarov technique was used to transfer both bone and soft-tissue elements to reconstruct the extremity. The soft-tissue wound was closed when the ends approximated. Both treatment groups shared three constants: 1) débridement was immediate and complete; 2) all exposed vessels were covered emergently; and 3) the bone was stabilized

before vascular and soft-tissue reconstruction. The authors suggested that the Ilizarov technique offers more options for soft-tissue closure because the bone gap can be made smaller. As the bone is slowly lengthened, local flaps and soft tissues also stretch, which theoretically lessens the size of the flap needed for cover or changes the indications from a free flap to a local flap. Unfortunately, the dense scar beds of free tissue transfers and the pedicles of conventional flaps can hamper bone transport by the Ilizarov technique.Distraction osteogenesis over an intramedullary nail has been reported. This combined technique is reported to permit early removal of the frame, as the nail provides stability while consolidation takes place.121 If found to have an acceptable complication rate, the technique has the theoretic potential to significantly shorten frame time and perhaps time to ambulation.The Ilizarov distraction method is not without morbidity; it has one of the highest rates of complications among orthopaedic procedures. Almost all patients suffer multiple minor complications. Pin tract infections, stiffness of adjacent joints, and severe pain122−124 are very common.

McKee et al.125 prospectively followed 25 patients for whom Ilizarov bone transport was used to treat posttraumatic deformities. The patients had very low preoperative scores based on health profile scoring systems. The scores remained low throughout the prolonged treatment program but climbed markedly as their general health improved. In short, patients do obtain good results with Ilizarov distraction, but they must pay for it with an arduous treatment course. Also noteworthy is that additional bone grafting often is required at the docking phase of Ilizarov bone transport.

Summary of Bone Reconstructive Techniques In summary, most Gustilo type IIIB and IIIC injuries that are candidates for early bone flap reconstruction can be managed by external fixation and free flap coverage over antibiotic-impregnated beads, plus autogenous bone grafting several weeks later. Tibial bone gaps ≤3 cm are ideal for cancellous grafting. Defects ≥6 cm warrant

Figure 3. Illustrations show the Ilizarov technique for managing segmental defects of the tibia. A corticotomy made high on the tibia is the source of regenerate bone after the bone is distracted with transfixion pins on an external frame. (Reprinted with permission from Cierny et al.117)


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consideration of either Ilizarov bone transport or vascularized bone grafting.103,104 Bone gaps ≥12 cm are difficult to bridge with bone transport117 and are a clear indication for free or pedicled vascularized bone flaps, although smaller defects might also be good candidates for vascularized bone. Regardless of the length of the bone deficit, the quality of the soft tissues can be a deciding factor between the use of a free bone flap (typically contralateral fibula) or bone transport beneath a vascularized muscle free flap.126 In other words, bone defects ≥6 cm that also have large soft-tissue loss might be better served by bone transport under a vascularized muscle free flap. Many Gustilo IIIB and IIIC injuries require at least one free flap. The reconstructive choices for treating severe tibial injuries become free bone graft with skin paddle; free bone graft plus free muscle flap; or free muscle and bone transport.

Of course, any patient who has a large tibial bone defect, with or without a large skin deficit, might also be a strong candidate for primary amputation. The minimum size of a defect that requires vascularized bone for treatment remains undetermined.

METHODS OF SOFT TISSUE RECONSTRUCTION TO TREAT OPEN TIBIAL FRACTURESIn 1970, Ger54 introduced innovative techniques for soft-tissue coverage of open tibial wounds. He described the soleus myoplasty, flexor digitorum longus, abductor hallucis, and gastrocnemius flaps for bone coverage. Although local pedicle flaps might be appropriate for acute type III fractures, Byrd et al.61 preferred free microvascular muscle flaps for many type III wounds. Byrd type IV wounds by definition require free flaps for coverage.

Because traumatic lower extremity wounds that require soft-tissue reconstruction often are characterized by local muscle damage, pedicled flaps often are not appropriate. The LEAP Study Group reported higher short-term complication rates associated with traumatic leg wounds covered with local flaps than with those covered with free flaps.127

When pedicled flaps are possible, the gastrocnemius and soleus muscles generally are first choices for the reconstruction. Viability of the

pedicled flaps must be verified before flap elevation and rotation, especially in the context of severe trauma. Other local flaps in the leg that are options for smaller chronic or nontraumatic wounds might not be reliable for Gustilo type IIIB and IIIC wounds and therefore are considered distant second choices.

The soleus muscle flap generally is the first choice for midshaft tibial wounds, whereas the gastrocnemius is better for the proximal third of the leg. Either flap can cover defects up to 25 cm2. Neither is considered appropriate for the distal third of the leg.16 The soleus can reach the lower third of the leg, but its reliability suffers.128

Reversed fasciocutaneous flaps have been suggested, but in general, they might not be reliable in the context of severe open leg fractures. Singh and Naasan129 described a small series of low velocity injuries of the lower leg that were adequately treated with reversed sural artery flaps. A few of the treated injuries were classified as Gustilo type III.

Muscle free flaps generally are preferred for severe leg trauma because they fill dead space, provide additional vascularity to the wound, and allow flexibility of positioning and pedicle placement.16,130,131 The workhorse microvascular flaps for open tibial reconstruction are the latissimus, the serratus, the rectus, and the gracilis.

May et al.130 advocated the use of microvascular free tissue transfer for coverage of distal lower extremity wounds with exposed bone. Their experience is consistent with other reports of vascularized muscle tissue used to obliterate dead space and to donate well-perfused soft tissues to the wound.

Serafin and Voci131 reviewed microsurgical composite tissue transplantation to the lower extremity. Microvascular transfers can deliver both soft-tissue and skeletal support to large, complex wounds of the leg and are particularly useful in the distal third of the leg and in the foot.

Francel et al.45 reported their results achieved by using microvascular reconstruction of open tibial fractures. Long-term retrospective follow-up revealed successful limb salvage in 93% of patients. Among the patients, 66% exhibited

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significantly decreased range of motion of the ankle, 44% showed swelling and edema requiring elastic support and activity modification, and 50% occasionally needed assistance for ambulation.

Khouri and Shaw132 reviewed 304 consecutive microvascular flap reconstructions of the lower extremity. The most common indications for reconstruction were Gustilo type IIIB and IIIC fractures. Approximately 75% of the defects were below the level of the midtibia. The latissimus dorsi, rectus abdominis, and scapular skin flaps were used. The failure rate was 8%, compared with 3% for non-lower extremity cases. The magnitude of the traumatic insult was the most significant factor associated with anastomotic failure. The rate of anastomotic thrombosis doubled in the presence of vascular trauma, tripled in cases of large bony defects, and quintupled when vein grafts were needed.

Nieminen et al.133 presented a series of 100 patients who underwent 104 free flap reconstructions for open tibial fractures. The authors reported a 5% amputation rate.

Park et al.134 reviewed technical points of recipient vessel selection and anastomosis in severe open injuries. They noted that antegrade vessels distal to the zone of injury are safe for receiving free flaps when the inflow is good. In certain cases, even reverse flow can be used to sustain a flap.

Regarding donor site morbidity, Colen135 reported 31% donor-related complications for the latissimus dorsi and 20% for the rectus abdominis muscle flaps. More recently, Musharafieh et al.136 noted 93% flap viability in 40 free rectus flaps used for lower extremity reconstruction. Donor site morbidity was said to be negligible. Only one patient was not ambulatory at 3.5 years.

Redett et al.137 revisited the gracilis free flap. The gracilis is an elegant flap, but its surface area is not large. It can be used in wounds no wider than 5 to 7 cm and up to 30 cm long. In their series of gracilis flaps, 95% of the limbs were salvaged. One patient had chronic osteomyelitis. Minor flap complications occurred in 12% and donor site complications in 10%, including hematomas, a seroma, and cellulitis. The pedicle of the gracilis flap

is shorter than that of the latissimus and serratus flaps, which can limit its usefulness in a large zone of injury.

Wechselberger et al.138 described an innovative, anatomically sound method of taking a large, transverse skin paddle with the gracilis. Their variant considerably extends the surface area of the gracilis free flap. The free anterolateral thigh flap has also been described for reconstruction in open tibial fractures.139

The Ilizarov device is sometimes used to achieve soft-tissue distraction for wound coverage of the lower extremity. The distraction frame stretches and compresses soft tissue while bone is transported. Two reports present detailed creative use of Ilizarov frames for soft-tissue coverage of open tibial wounds.140,141 Based on the reports, it is unclear whether distraction is sufficiently reliable for delivering stable, vascularized soft tissue to open tibial wounds.

Another issue is how to successfully coordinate bone transport through the zone of a free flap. One report described a technical modification in which the free muscle flap can be partially split at the time of transfer to allow for unimpeded pin transport.142

Agarwal et al.143 described soft-tissue problems that tend to recur in cases of simultaneous tibial transport and soft-tissue distraction. The authors detailed a set of useful local flap procedures for dealing with soft-tissue compression and problems associated with moving pins. The use of vacuum-assisted closure devices might be changing treatment algorithms for lower extremity reconstruction after trauma. Parret et al.144 reported their retrospective review of 290 soft-tissue reconstructions over open tibial fractures. They noted that optimal synchronization between the orthopaedists and the plastic surgeons results in better treatment. They also described increased reliance on rotational flaps, such as sural flaps, in select cases. The vacuum-assisted closure device allowed the authors to temporize many acute injuries while yielding stable granulation beds. The device allowed many patients to become candidates for local flaps and skin grafts (Fig. 4).


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RECONSTRUCTION OF THE AMPUTATION STUMPThe most important considerations regarding lower extremity amputation stump reconstruction are preservation of length and creation of stable soft-tissue coverage. Patients undergoing below-knee amputations are considerably more likely to ambulate on prostheses than those undergoing above-knee amputations. Also, the metabolic demand on patients with above-knee amputations is significantly higher than for patients with below-knee amputations.

The level of amputation for vascular disease and diabetes usually is determined by the severity of disease. When amputations are traumatic,

however, the length of the preserved limb might be determined by adequacy of the soft-tissue coverage. In children, amputation through the knee joint often is performed to prevent bony overgrowth of the stump.

Several recent publications address methods of reconstructing the amputation stump. Every attempt should be made to preserve length with local muscle and skin. If that is not possible, flaps and skin grafts should be used to prevent conversion of traumatic below-knee amputations to above-knee amputations.

If muscle covers the bone end, a skin graft will suffice.145,146 In stumps that are healed but have poor soft-tissue coverage, tissue expansion can be an option.147 The results are likely to be much better if the expansion is carried out in the distal thigh rather than the leg.

Free muscle flaps with skin grafts, free musculocutaneous flaps, and fasciocutaneous flaps are well accepted for covering stumps and preserving the length of the extremity.148,149 Free flaps from the latissimus dorsi, anterolateral thigh, lateral arm, and scapula and free and pedicled fillet flaps from nonreplantable amputated parts have been reported to be used for those purposes.150 In reviewing the literature, it is unclear how well muscle flaps compare with fasciocutaneous flaps; either type can require secondary debulking procedures.

It also is possible to lengthen short below-knee amputation stumps with osteomusculocutaneous flaps.151 The best candidate for such an aggressive reconstruction is a healthy patient, highly motivated to ambulate, who is held back by a short below-knee amputation stump with poor soft-tissue coverage. Sometimes the foot of an amputated leg can be used for spare parts. The fillet of foot and/or sole flap, transferred free or on a pedicle, can be used to preserve length and provide sensitive coverage to a traumatic leg amputation stump.152−154

Patients with traumatic amputations of the lower extremity might not be stable enough at the time of the first surgery to undergo major stump coverage operations. In those cases, the sole of the

Figure 4. Flow chart shows method presented by Parrett et al.144 for treating open tibia-fibula fractures. Initially, such cases are treated emergently in the operating room with débridement, orthopaedic fixation, and vascular repair if needed. The wound is then assessed for contamination, swelling, and necrosis, and a decision is made regarding the timing of closure. Vacuum-assisted closure sponges frequently are placed until the swelling has resolved. Delayed primary closure, local flaps, and skin grafts often can then be used for wound closure. *, Primary or delayed primary closure. (Reprinted with permission from Parrett et al.144)


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amputated foot can be refrigerated to be used at a later time. Shah et al.155 reported successful stump reconstruction with a free foot fillet flap that was cooled for 57 hours at 4°C. Alternatively, if the patient is stable enough for major surgery but the stump is too contaminated to tolerate acute coverage, the amputated part can be preserved by temporary ectopic microsurgical implantation at a distant site. When the stump is clean enough for reconstruction, the glabrous skin and plantar fascia of the foot can be transferred to the stump.156 Spare parts surgery should at least be considered in cases of traumatic lower extremity amputation.

COMPARTMENT SYNDROME Diagnosis Since Vogt157 originally described acute anterior compartment syndrome in 1943, other authors have reported compartment syndrome as occurring in all four anatomic compartments of the leg.158-161 A diagnosis of compartment syndrome is made on the following clinical signs and symptoms:

• pain disproportionate to the injury• palpably swollen compartments• pain on passive stretching of the

involved muscles• diminished simple touch perception• decreased strength of the involved

compartment muscles

• hypesthesia or anesthesia in the sensory distribution of the nerve in the involved compartment

Physical examination identifies the involved compartment(s) (Table 2).162

The distal pulses might or might not be palpable. Most of the cardinal signs are actually late findings, particularly diminished pulses and symptoms of nerve compression. The best early clinical sign in the awake patient is severe pain with passive stretch of involved muscles. The clinician should not wait for additional cardinal signs to evolve when compartment syndrome is highly suspected.

The normal intracompartmental pressure is 30 to 40 mmHg ± 4.163,164 Allen et al.165 emphasized the value of continuous monitoring of intracompartmental pressures to diagnose the presence of clinically significant compartment syndrome. Compartment pressure is monitored with a slit catheter inserted via a 16-gauge Medikit cannula (Eastern Medikit Limited, Delhi, India). A heparin infusion pump maintains the patency of the catheter. The authors concluded that transient rises in compartment pressure can be tolerated as long as the pressure does not remain above 40 mmHg for longer than 6 hours. If it does, or if it at any time rises to >50 mmHg, fasciotomy is indicated.

Spectroscopy has been tested for measuring compartment oxygenation.166 Whether oxygenation

Table 2Signs of Developing Compartment Syndrome162

Compartment Sign

Anterior compartment Pain on passive plantar flexion, especially of the big toe, and foot eversion

Lateral compartment Pain on passive dorsiflexion and foot inversion

Superficial posterior compartment

Pain on passive dorsiflexion with knee extended and ankle flexed

Deep posterior compartment Pain on passive ankle dorsiflexion, foot eversion, and toe extension (especially the big toe)


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correlates well with actual compartment syndrome, especially in the context of trauma, is unclear. The results of spectroscopy must be viewed in the context of clinical signs and symptoms and other test findings in the awake patient. One can test a soft compartment, perhaps on the other leg, to assess whether the equipment reads true. When evaluating pressure measurements, serial readings are the standard for making the diagnosis of compartment syndrome.167 A normal pressure reading must not deter the surgeon from performing fasciotomy when the results of a clinical examination are positive.

Epidemiology Acute compartment syndrome can result from trauma, postoperative bleeding, tendon graft harvesting, casting over evolving soft-tissue swelling, electrical burns, thermal burns, intracompartmental bleeding caused by systemic disease or anticoagulation, and animal bites, particularly snake bites.168−170

A retrospective review of 198 open tibial fractures by Blick et al.164 revealed a 9.1% incidence of compartment syndrome. The development of compartment syndrome was directly related to the degree of injury to the soft tissues and bone. DeLee and Stiehl161 reviewed the occurrence of compartment syndrome in fractures of the lower extremity. Of 104 patients with open tibial fractures, six (5.7%) developed compartment syndrome involving all four compartments. In contrast, only five of 411 patients (1.2%) with closed tibial fractures met the criteria for compartment syndrome. These data refute the notion that an open fracture allows adequate decompression of the compartments. It does not. Open injuries are indicative of higher energy and might therefore be at higher risk of compartment syndrome.

ManagementCompartment syndrome does not need to be proven beyond a reasonable doubt. If compartment syndrome cannot be ruled out, decompression through four-compartment fasciotomy is recommended within 6 hours of symptom onset. The risk of not performing fasciotomy

far outweighs the risk of performing fasciotomies that only in hindsight are determined to have been unnecessary.

Hyde et al.162 described a simple fasciotomy for bedside decompression. Nghiem and Boland 171 and DeLee and Stiehl161 questioned the value of fibulectomy-fasciotomy for decompression of all four compartments when weighed against the importance of the fibula in fracture stabilization.

Pearse et al.167 advocated a fibula-sparing, two-incision method for full four-compartment decompression. One incision medial to the tibia decompresses both the superficial and deep posterior compartments and stops at the posteromedial tibial border. The second incision courses laterally through and over the anterior compartment and enters the lateral compartment (Fig. 5).

Although the wounds left after leg fasciotomies are clinically impressive, they tend to be easy to manage. Prophylactic antibiotics often are used but are not essential in all cases. Meticulous local wound care is the key to successful closure.

Figure 5. Cross-section through leg shows site of fasciotomy incisions to decompress all four compartments. (Reprinted with permission from Pearse et al.167)


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Techniques such as lacing with vessel loops through skin staples, dermatotraction, and suturing with pull-through monofilament dermal running sutures can close a wound primarily if gradual closure is begun early during the postoperative period.172−174 The techniques produce better cosmetic results than do split grafts over muscle.

Outcome A chronic Volkmann-like contracture state, with or without sensory loss, can result if compartments are not released.159,161,162,164 Kikuchi et al.160 described the clinical features of compartment syndrome in 20 patients. Saphenous nerve sensation is preserved, because the nerve lies outside the compartments. In their study, limb function deteriorated with length of ischemia. Function was good after 3 hours, fair after 14 hours, and poor after 21 hours of ischemia, even in the context of released compartments. The prognosis was especially poor when both the tibial and peroneal nerves were involved and in cases of severe venous insufficiency during the acute stage. The authors advised against reconstruction of the chronically affected limb before 18 months from injury to allow for maximum return of function. That interval is additionally needed to help the clinician and the patient decide whether amputation is preferable.

OPEN JOINT INJURIES Patzakis et al.175 prospectively studied 140 patients with open joint injuries. For the acute injury, they recommended preoperative and intraoperative cultures, broad-spectrum antibiotics until cultures are read, copious irrigation, débridement of the joint and injured soft tissues, and primary closure of the wound without drains. Closed suction drains were thought to be responsible for wound contamination in 14.3% of patients who had negative cultures before or during surgery. The most common organisms were Pseudomonas and Klebsiella. The authors concluded that the only indication for use of an irrigation system in open joint injuries is the presence of extensive soft-tissue and bone damage, when closure of the joint would be advantageous.

Barfod and Pers176 reported their experience using immediate gastrocnemius muscle flaps for

closure of five open knee joints. No infections occurred. The notion of augmenting deficient soft tissues by transposing muscle flaps seems logical and possibly analogous to the improved results achieved with early soft-tissue coverage of open tibial fractures.

Chronically contaminated and open joints present another problem. Soft-tissue closure alone yields an unacceptable number of septic joints and related sequelae. Per Byrd et al.,61 studies of the closed plaster method presented by Trueta5 have shown that joints allowed to remain open while the patient ambulates can heal without loss of the cartilaginous interface and without infection. When large attendant soft-tissue losses have occurred, however, scar contracture frequently limits function of the joint. Secondary muscle or soft-tissue coverage without water seal closure and active ambulation might be beneficial in the management of contaminated open knee and ankle joints. Options for the knee include gastrocnemius muscles, turn-down thigh muscles, and free flaps. In the presence of a chronically infected and granulating open joint, débridement of exposed synovium and granulation can be considered before muscle coverage.

Pu and Thomson177 presented two cases of irradiated, chronic open knee joint salvage with free muscle flaps. One patient retained 35 degrees of extensor lag to 65 degrees of active flexion. The other had 15 degrees of lag and flexed to 60 degrees. Both patients were able to ambulate.

Cierny et al.178 reviewed their experience with 36 refractory infections of the open ankle and offered a comprehensive discussion of management and surgical techniques for treating the wounds. The authors concluded that after cartilaginous débridement, when intact proximal and distal cortices are present, the ideal treatment involves free bone grafts placed between the tibia and the talus. Fixators, staples, or plates external to the graft achieve the necessary compression. The use of medial and lateral osteocutaneous flaps for bone and soft-tissue reconstruction and preservation is discussed.


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NONUNION Nonunion results from insufficient stabilization or insufficient perfusion of the fracture.18,24 Infection can contribute to either or both causes. Radiographically, nonunion presents in one of two forms: as a hypertrophic elephant foot callus or as a porotic, resorptive process along the line of fracture.

A hypertrophic callus denotes inadequate stabilization of the fracture segments. Union is likely to occur if appropriate stabilization is provided. A resorptive process, or atrophic nonunion, occurs as a result of ischemia or a septic process. If the nonunion occurs because of inadequate blood supply without infection, stabilization and bone grafting often will bring about union. In contrast, an infected fracture is chronic osteomyelitis and might require multimodality therapy.

The standard treatment of aseptic nonunions consists of stabilization and bone grafting. Kettunen et al.179 described a novel technique of percutaneous bone grafting to treat aseptic tibial nonunions that resulted in bone healing in 37 of 41 fractures. Megas et al.,180 on the other hand, stated that bone grafting is not always necessary for tibial nonunions. They reported achieving union in 50 patients with aseptic tibial nonunions treated with reamed intramedullary nails. Bone grafts were used in only three patients in that series.

Ohtsuka et al.181 coated an intramedullary nail with antibiotic-impregnated cement before placing it within a Pseudomonas-infected tibial nonunion. Bone grafting was accomplished after the infection clinically receded, and union eventually was achieved. The coated nail was later removed, and the functional outcome was deemed excellent.

Safoury182 treated 10 distal tibial nonunions with a technique originally described by Hertel et al.183 with which the fibula is pedicled on reverse flow. The reverse flow is provided by distal crossover vessels between the posterior tibial and peroneal systems. Union was achieved in all fractures, and the patients were full weight bearing by 9 months.

Erdinger et al.184 combined a latissimus and scapula osteomuscular flap for effective treatment of infected nonunions. The authors provided details of the flap anatomy and harvest technique used in

five representative cases. The technique is an option when a small to moderate amount of vascularized bone and a large amount of soft tissue are needed. Duffy et al.185 reported the results of onlay free fibular transfer combined with cancellous grafts in irradiated nonunions.

OSTEOMYELITIS AND INFECTED NONUNION Posttraumatic osteomyelitis is more commonly associated with severe open tibial fractures than with milder injuries. Patzakis et al.186 investigated the effectiveness of prophylactic antibiotics in a series of >1100 patients with open tibial fractures. Patients who did not receive antibiotics had a 24% infection rate. Only 4.5% of patients who received prophylactic broad spectrum antibiotics for 3 days developed infections. The most common pathogen in both groups was coagulase positive Staphylococcus.

Ger and Efron187 and Ger188 identified the major causes of persistent infection after open fractures as retained necrotic and infected bone, avascular or infected scar, dead space in the surgical site, and inadequate skin cover. The authors postulated that ischemia was responsible for chronicity and for operative failures. They are credited with voicing the currently accepted principles of surgical treatment of osteomyelitis: dead space obliteration and aggressive débridement.

Horwitz189 reviewed traditional management options for chronic osteomyelitis, as follows:

• ostectomy with primary wound closure and closed suction drainage

• ostectomy with partial wound closure and secondary split grafting

• ostectomy with partial wound closure and packing

• resection with immediate delayed wound closure

• amputation The current mainstay of treatment for chronic osteomyelitis is excision of pathological tissue, including necrotic and infected bone, bone sequestra, and poorly vascularized soft tissues. Obliteration of dead space and enhancement of blood supply with muscle flap coverage

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complements wound management after débridement.

Mathes et al.190 expanded the débridement procedure described by Ger to include nonviable bone, scar, and chronic granulation tissue in the medullary canal. Because of their superior resistance to infection over conventional flaps, free microvascular muscle flaps were used to obliterate the dead space and to cover the exposed bone. At an average follow-up duration of 1.8 years, all 11 of the patients presented by Mathes et al. had achieved resolution of the osteomyelitis.

In a follow-up study, Anthony et al.191 traced the postoperative course of 34 consecutive patients with chronic osteomyelitis of the distal lower extremity. Treatment was by débridement, a 10- to 14-day course of culture-specific antibiotics, and muscle flap coverage. Long-term follow-up of 27 patients revealed that 24 (89%) healed with no recurrence at >5 years and three (11%) experienced recurrence of the osteomyelitis. Of the three patients, two were cured after additional muscle flap procedures.

May et al.192 reported their extensive experience with chronic osteomyelitis of the leg. Management was by radical débridement of bone and soft tissue and reconstruction by a second- or third-stage latissimus dorsi free flap transfer. Discontinuity defects were filled with cancellous bone grafts after soft-tissue coverage. Excellent results were documented.

May et al.193 subsequently reviewed their 13-year, 96-patient experience with bone débridement and microvascular free tissue transfer for soft-tissue reconstruction of chronic traumatic bone wounds. After a mean follow-up of 77 months, 91 patients enjoyed complete wound closure and absence of drainage. Five patients ultimately required amputation because of treatment failure and recurrent infection.

Damholt194 reported 98% cure in 55 patients treated for chronic osteomyelitis. His radical operation removes all internal fixation devices and includes sequestrectomy, partial decortication, and primary wound closure with suction drainage. Thirteen patients underwent wound closure by

flaps of various types. External fixation was used if stabilization was necessary.

Significant gaps in the long bones secondary to débridement can be bridged with secondary block cancellous insert grafts. Survival of the bone grafts depends on a well-vascularized soft-tissue bed.195 Sudmann196 preferred surgical débridement and grafting with cancellous and cortical-cancellous bone in one operation. Of 13 consecutive patients with osteomyelitis who were treated by that protocol, 12 healed after a single operation and one required three operations before his osteomyelitis was eradicated. The grafts did not form sequestra.

Among the more experimental techniques for managing chronic osteomyelitis is necrectomy and packing of the defect with antibiotic beads.197 The technique delivers antibiotics in high concentration and fills dead space. The beads are then gradually removed to slowly collapse the size of the cavity.

Tulner et al.198 analyzed their 11-year experience with 47 patients who were treated for posttraumatic osteomyelitis by the following a three-step protocol:

1) Wide débridement of devitalized bone and soft tissue with implantation of antibiotic beads and external fixation are performed as needed. The patient begins a 3- to 6-week course of intravenously administered antibiotics. 2) Removal of the beads and insertion of a spacer are performed at 10 to 14 days, with soft-tissue coverage provided by either pedicled muscle or free muscle flap. 3) Bone grafting is performed at 3 to 4 weeks after the flap is applied.

The authors reported a 91% cure rate at a mean 7.8 years and 100% eradication of infection at the final visit.

Another ingenious treatment is the application of hyperbaric oxygen to the wound.199 At 3-atm absolute pressure, O2 diffusion into avascular tissue increases several-fold, which has a bactericidal effect and speeds up healing. Aggressive surgical débridement might have contributed to the


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good outcome in the study presented by Morrey et al.199

Arnold et al.200 reported 90% cure of osteomyelitis of the lower extremity 15 years after treatment with local muscle flaps. Musharafieh et al.201 reported high efficacy of free flaps in the treatment of chronic osteomyelitis of the leg. Wells et al.202 and Gonzalez et al.203 noted a trend toward increased risk of free flap failure in chronic wounds associated with osteomyelitis compared with uninfected wounds. In a study of 42 free flaps for chronic leg wounds, Gonzalez et al.203 noted that osteomyelitis is a strong predictor of flap failure and ultimate loss of limb. In the presence of osteomyelitis, the flap failure rate was 22%; when osteomyelitis was absent, the flap failure rate was 7%.

Surgeons must beware of malignant transformation in chronic osteomyelitis that never seems to heal.204 Periodic biopsy and cultures are warranted during long treatment courses.

Faden and Grossi205 evaluated 135 children who had acute osteomyelitis. The causative agent was identified as Staphylococcus aureus, Haemophilus influenzae type B, and Pseudomonas aeruginosa in 25%, 12%, and 6%, respectively. H. influenzae occurred only in children younger than 3 years. Currently, Haemophilus osteomyelitis is very rare thanks to widespread vaccination against the bacteria. Most pediatric cases of osteomyelitis result from hematogenous spread of bacteria. In the study by Faden and Grossi, all wounds infected with P. aeruginosa were penetrating injuries to the foot. Children with P. aeruginosa infection were older than 9 years (100%), predominantly male (88%), often afebrile (83%), and never clinically bacteremic.

CHRONIC LEG ULCERSPicascia and Roenigk206 reviewed the dermatological and topical management of leg ulcers. They recommend early adjunctive measures for unstable areas before full ulcers develop.

The most common cause of cutaneous ulcers is decreased skin perfusion and infection. Decreased skin perfusion can result from disease in the large, medium, or small arterial vessels or the capillary

bed, such as atherosclerosis, diabetes, or vasculitis. Venous hypertension also decreases skin perfusion and can result in tissue ischemia or death. Host defenses are marginal in ischemic tissue, which contributes to the development of subclinical infections.

Venous DiseaseVenous insufficiency affects millions of patients in the United States and is associated with varicosities or thrombophlebitic disease. An increased column of blood from incompetent valves causes a rise in hydrostatic pressure and produces chronic venous insufficiency. The typical clinical signs include edema, hyperpigmentation, and ulcerations around the legs and ankles.

The venous system of the leg is comprised of the superficial veins and venules, the perforating or communicating veins, and the deep veins. Mild forms of venous insufficiency are associated with varicose veins. Severe forms are associated with deep-system reflux about the popliteal area and leg.

PathophysiologyAlthough the cause of chronic venous insufficiency is understood, the pathophysiology of venous ulceration is not clear. The major theories implicate pericapillary fibrin deposition or white blood cell plugging.

Pericapillary Fibrin Deposition—Moosa et al.207 used transcutaneous oxygen monitoring to prove the existence of a local pathological barrier to oxygen diffusion in patients with venous ulcers.208,209 Balslev et al.,210 on the other hand, considered fibrin deposition to be a secondary phenomenon occurring in already ulcerated skin.

White Blood Cell Plugging—Occlusion of capillary loops by white blood cell thrombi has been blamed for venous ulcers. Thomas et al.211 showed a significant decrease in the number of white blood cells returning from the dangling legs of patients with chronic venous insufficiency.

Coleridge Smith et al.212 counted the number of capillary loops per mm2 with legs supine and legs dependent. After 30 minutes of dangling,

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significantly fewer capillary loops were visible in 90% of subjects. The authors concluded that the capillary loops become occluded with white blood cell plugs and that activation of the trapped white blood cells produces ischemia on a vascular basis.

Valvular Incompetence—Valvular incompetence is a major factor in the development of stasis, pigmentation, and ulceration. van Bemmelen et al.213 studied the relation of ulcerations to the functional status of the superficial and deep venous valves. Doppler scanning showed valvular incompetence in 22 of 25 ulcerated limbs. The most commonly involved incompetent segment was the popliteal vein, and the next most common was the superficial femoral vein.

Management The exact site of venous incompetence must be determined preoperatively if therapy is to be successful. McEnroe et al.214 evaluated the hemodynamics of patients with chronic venous insufficiency. Venous obstruction was uncommon (5%); therefore, venous bypass surgery might be of little value in resolving the problem of chronic venous insufficiency. Patients who had venous ulcerations tended to have deep venous insufficiency alone (72%), suggesting that deep valvular reconstruction might be a treatment option in such cases.

It is estimated that 1% of people in the United States will experience chronic venous stasis ulcer at some time in their lives. Although most chronic venous ulcers are secondary to alterations in the deep venous system, 28% are caused by superficial or combination superficial and deep venous insufficiency.

Compression Therapy—Compression therapy for the management of lower extremity venous ulceration dates back to Hippocrates. The method was later advocated by Paré in 1553. The significant recurrence rate is almost always related to failure of the patient to comply with long-term therapy.

Mayberry et al.215 reviewed the course of 113 patients with severe, chronic venous insufficiency

and ulcerations. After treatment with ambulatory compression therapy, 93% of patients experienced complete ulcer healing in a mean 5.3 months. Among patients followed for an average of 30 months, 80% continued to be compliant with stockings and 16% had ulcer recurrence. All patients who were noncompliant had recurrent ulcerations by 36 months.

Subfascial Ligation—Subfascial ligation of incompetent perforating veins is largely effective in inducing healing of venous ulcers. Jamieson et al.216 reported their experience in 118 limbs with refractory venous stasis ulcers treated by subfascial ligation. Postoperative complications were minimal. The authors reported good to excellent results in 82% of cases at a mean follow-up duration of 8 years, with healing of ulcers and no recurrence despite considerable noncompliance with support stockings.

A modified Felder-Rob subfascial ligation217 in 45 limbs with chronic venous ulcers also produced good results, with only 4.4% recurrence of ulceration after 2 to 8 years of follow-up.218 Complications of subfascial ligation include skin necrosis, exposure-induced necrosis of the Achilles tendon, and equinus deformity of the ankle from contracture of the tendon.

Vein Valve Transplants—Venous valve transplantation has been recommended to prevent reflux from the thigh veins and thus lower ambulatory venous pressure at the ankle. Nash219 presented his experience with venous valve transplantation in 23 patients; before surgery, 17 had recurrent ulcers, six had severe pre-ulcer skin damage, and 18 had undergone previous unsuccessful venous operations. Duplex sonography was used for preoperative and postoperative evaluation of the popliteal vein to detect reflux and graft patency. Ambulatory venous pressures were measured directly in the dorsal foot of all patients before and after surgery. A 5-cm segment of brachial vein containing a competent valve was transposed to an excised segment of popliteal vein. Valve competence was tested before completing the proximal anastomosis. Fifteen of


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23 patients experienced complete healing of the ulcers. All patients experienced relief of symptoms of claudication. At 18 months, all transplants remained patent but five had evidence of reflux at the transplanted valves and one developed a recurrent ulcer. Documented falls in ambulatory venous pressure averaged only 18% despite functioning popliteal valve transplants, probably a reflection of the many remaining incompetent valves in the posterior tibial and peroneal veins.

Rai and Lerner220 followed 25 patients with end-stage venous insufficiency unresponsive to conservative management. All patients experienced ulcers of the lower extremities for more than 6 months (average, 4.5 years). Valvular incompetence in the deep venous system was diagnosed in 15 patients, 12 of whom had brachial vein transplants. Of the 12 patients, 10 had ulcers that healed within 1 to 6 weeks and two required skin grafts. All patients experienced complete relief of pain and were able to ambulate. Four patients noted total resolution of lower extremity swelling, and the rest experienced various degrees of symptom improvement. A comparison of pre- and postoperative venous pressures showed no significant change to account for the clinical improvement.

Ger188 emphasized the need to treat the primary disease contributing to the ulcer and detailed the management of venous ulcers by various operative and nonoperative means. The authors reviewed the advantages of coverage with local muscle flaps and split-thickness skin graft, including which muscle flaps are most appropriate for particular areas of the lower extremity. They additionally discussed the causes of primary muscle flap failure.

Arterial Disease Arterial insufficiency is a known cause of chronic leg ulceration, recognized by symptoms of claudication, pain while at rest, and the characteristic appearance of arterial ulcers. Arterial ulcers tend to occur distally on the leg and foot and usually are accompanied by painful episodes. The pain improves on dependency and is exacerbated by elevation of the extremity.

Management The management of ulcers caused by arterial insufficiency differs drastically from that of venous ulcers, even though arterial occlusion and venous insufficiency might coexist in the same patient. Sindrup et al.221 studied 94 consecutive patients with stasis ulcers and noted that 50% had evidence of obstructive arterial disease, more severe in cases in which diabetes was also present. The authors concluded that patients with obvious stasis ulcers of the legs should be carefully examined for coexisting arterial disease which, if present, is a contraindication for compression therapy.

A large study from Scotland222 reviewed 600 patients (827 ulcerated legs) for the relation, if any, between gangrene and the use of compression bandages. Elastic bandages and compression hosiery produce pressures of approximately 30 mmHg at the ankle level. Pressures are not evenly distributed around the circumference of the limb but instead tend to be much higher over prominences such as the malleoli, the Achilles tendon, and the anterior tendons of the ankle. Those sites are at high risk of injury from compression bandages, and reductions in blood flow might be further aggravated by elevation of the affected extremity. Doppler resting pressures of ≤0.9 indicated arterial insufficiency and were noted in 21%.

In the Scotland study, 222 palpable pulses in the foot did not preclude arterial insufficiency. Approximately 50% of patients with arterial impairment also showed clinical features of chronic venous insufficiency. The authors concluded that patients who have ulcerations anywhere on the foot should be regarded as having arterial disease until proved otherwise.

Arterial disease should be ruled out before compression and elevation are instituted for venous disease.223 Once the presence of arterial insufficiency has been established, general guidelines for management of vascular disease are applied. Patients whose wounds fail to improve preoperatively despite meticulous wound care are chosen for arterial bypass grafts to avoid amputation. Arterial disease to the level of the

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malleoli is common among diabetic patients, for whom more distal bypass sites should be chosen.

Arterial inflow can be restored with a saphenous vein bypass graft to the distal trifurcation vessels. Andros et al.224 described lateral plantar artery bypass grafting from the distal popliteal artery in 17 patients with gangrene of the foot. The foot salvage rate at 2 months was 89%. All except four of 20 ulcers healed within 6 months. Even with a functioning bypass graft, therefore, local wound healing is protracted. Two patients progressed to below-knee amputation, one despite a patent graft. All patients who achieved successful revascularization were able to walk eventually, and seven returned to work full-time.

Similarly, Daane et al.225 reported a small series of successful distal lower extremity bypass. In that series, patients underwent inframalleolar bypass grafting with arterial grafts using the operating microscope. Five of six patients who underwent the operation enjoyed graft patency at 52 months. The technique might hold promise for patients with distal arterial disease who suffer from arterial ulcers and chronic pain. Another study reported the use of dorsal venous arch arterialization for revascularization of distal ischemia when poor recipient vessels exist.226

Lepäntalo and Tukiainen227 presented a series of combined lower extremity revascularization and free flap coverage of arterial wounds. They reported an overall limb salvage rate of 76% at 1 year. The authors noted that in some cases, the free flap remained viable while the distal limb progressed to worsening ischemia. The study indicated the possibility of combining lower extremity revascularization with free flap coverage for peripheral vascular disease in select cases.

Gooden et al.228 reviewed their extensive experience with microvascular flaps for lower salvage. In a very difficult group of 26 patients—92% with exposed bone, joint, or tendon; 90% with diabetes; and 33% on dialysis—the authors performed 27 free flaps of various types. The selection criteria included patients with large soft-tissue defects who were ambulatory and functioning fairly well and patients with acceptable

cardiovascular risk to withstand a long operation (average operative time, 5 hours 18 minutes). At a mean 14 months after surgery, the limb salvage and ambulation rate in that series was 88%. Similarly, Quiñones-Baldrich et al.229 reported a 72% limb salvage rate in 15 patients with a mean age of 60 years at 36 months after combined distal leg and foot revascularization and free muscle flap coverage.

In a larger study, Illig et al.230 noted that diabetes and dialysis-dependant renal failure were the strongest predictors of limb loss when existing together. Diabetes was the strongest predictor of patient death. The authors considered the comorbidities to be possible contraindications to combined limb revascularization and free flap coverage. In that study, 65% of patients recovered good ambulation but the limb salvage rate was 57% 5 years postoperatively. Interestingly, age alone does not seem to be a risk factor in cases of extremity bypass graft and free tissue transfer surgery.

Like Gooden et al.,228 Moran et al.231 reported a 63% limb salvage rate at 5 years in 75 patients with severe peripheral vascular disease who underwent free flap coverage of ischemic leg and foot wounds. The perioperative mortality rate was 5%.

An interesting technical twist was reported by Maloney et al.232 who used free omentum for upper and lower extremity reconstruction in six patients, capitalizing on the large vessels and flow-through properties of the omentum to provide distal arterial vascularization. The authors touted the overall robust blood supply of the flap and its potential for revascularizing wound beds. The omentum might be worthy of consideration in difficult lower extremity reconstruction-revascularization cases as a dual-use free flap and arterial conduit to the foot. As an alternative to free flap reconstruction in such cases, Isenberg233 reported transferring a pedicled sural flap in each of nine patients for lower extremity revascularization and wound coverage. The results 6 months postoperatively were good.

The rehabilitation rates after below-knee amputation exceed 90% in some series.234 Community-based studies note rehabilitation


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rates of 40% to 60%,235 so for combined revascularization and free flap coverage to be hailed as a success, ambulation rates should be at least that high. Attinger et al.236 presented a large series of patients with difficult arterial wounds and significant comorbidities. Forty-five patients with renal failure and diabetes were treated by aggressive multimodality therapy, including limb revascularization and soft-tissue coverage procedures. Several patients required free flaps for wound coverage. Of the patients still alive at 3 years after surgery, 89% retained their limbs and 73% had achieved independent ambulation. Attinger et al.236 and others230 have shown the potential of functional limb salvage when revascularization and wound coverage are combined in select patients despite comorbidities.

Diabetic UlcersThe typical diabetic patient suffers from a combination of distal sensory loss and reduced peripheral arterial circulation. Abnormal physical stresses, however minor, can cause ulceration. Of note, poorly fitting shoes are the most common cause of foot lesions in diabetics. Foot ulcers are the most common cause of hospital admission for that patient population.237 Lipsky et al.238 published a recent excellent review of diabetic foot infections. The review includes several detailed and applicable algorithms for diabetic foot management.

Colen135 addressed common misconceptions regarding the care of diabetic ulcers. The first myth is that foot problems are caused by small vessel disease. Histological staining of amputation specimens from diabetic patients shows no arteriolar occlusion. Blood flow measurements during femoropopliteal bypass show no difference in response to papaverine vasodilation, indicating normal reactivity of the vessels. The second myth involves purported endothelial proliferation in small vessels of diabetic patients. No evidence of intimal hyperplasia in the small vessels of diabetic patients has been shown, suggesting that diabetic neuropathy, and not microvascular disease, accounts for foot lesions.

The cause of diabetic neuropathy remains elusive. Stevens et al.239 implicated a combination of closely interdependent metabolic and vascular defects, such as reduced nerve blood flow from structural changes in the endoneurial microvasculature, abnormalities in vasoactive agents regulating nerve blood flow, and altered tone of autonomic nerves to blood vessels. Other metabolic defects include disruption of the polyol pathway, altered lipid metabolism, advanced glycosylated end product formation, and diabetes-induced defects in growth factors.

The cause of abnormal blood flow to the feet in cases of diabetic neuropathy is not known, although sympathetic denervation has been suggested.240 Similarly, the interactions among altered blood flow, painful neuropathy, and neuropathic ulcers is unclear. Perfusion studies indicate a blood flow pattern consistent with reduced peripheral vascular resistance, probably from arteriovenous shunting resulting from distal sympathetic denervation.240

Boulton237 classified diabetic foot lesions according to five grades of severity. Grade I lesions occur under areas of weight bearing, such as the toes and metatarsal heads. Grade II lesions occur at similar sites but are much deeper, often with tendon involvement and infection. Total contact casting of the foot is indicated to remove pressure from the ulcerated area. Grade III lesions require surgical intervention after control of the infection. Grade IV lesions require arteriography to determine which can be treated surgically. Grade V lesions necessitate amputation.

Treatment consists of reducing localized pressure on prominent surfaces of the sole. In a study conducted by Sinacore et al.,241 82% of ulcers treated by total contact walking casts healed in an average of 6 weeks. Casts must be carefully applied and removed at regular intervals for foot inspection because loose-fitting casts cause friction that can lead to blisters and ultimately ulcers.242

Griffiths and Wieman243 reported 34 metatarsal head resections in 25 patients. Most ulcers had been present for at least 9 months. Ulcers healed an average 2.4 months after surgery, and

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no recurrences had occurred at 14 months. Three patients required resection of another metatarsal head on the same foot to treat a second ulcer, presumably from shifting pressure points after the first surgery. If a toe needs to be excised, a ray amputation should be performed to prevent ulceration of its metatarsal head.

Newman et al.244 found osteomyelitis in 68% of diabetic foot ulcers, only half of which had been clinically suspected. Osteomyelitis was present in all ulcers with exposed bone, although 68% had no exposed bone and 64% did not even have inflammation. Among the diagnostic tests for osteomyelitis, the leukocyte scan had the highest sensitivity (89%) and was useful for assessing antibiotic effectiveness.

Yuh et al.245 evaluated plain films, bone scans, and magnetic resonance images of 24 diabetic patients suspected of having osteomyelitis. Bone biopsies from 14 patients whose ulcers did not respond to antibiotics were positive for osteomyelitis in 87%. Magnetic resonance imaging provided a correct diagnosis for all patients, plain radiography was not diagnostic until extensive bony destruction had occurred, and bone scanning had the highest false-positive rate.Advocates of limb salvage with free tissue transfer have reported durable results when using microsurgical techniques in specific patients. Lai et al.246 reviewed limb salvage in 10 cases of infected and gangrenous diabetic foot ulcers. Treatment consisted of débridement and coverage with a free gracilis muscle flap and split-thickness skin graft. Flap perfusion equaled perfusion of the surrounding tissue at approximately 8 weeks. No recurrence of ulcer or infection was noted during the follow-up period.

SOFT-TISSUE COVERAGE OPTIONS FOR LOWER EXTREMITY WOUNDS The goal of soft-tissue reconstruction in the lower extremity should be satisfactory wound coverage with restoration of function. Ancillary considerations are acceptable appearance and minimal donor site morbidity. For soft-tissue coverage alone, muscle and fasciocutaneous flaps remain primary choices in the lower

extremity. Random pattern cutaneous flaps and musculocutaneous flaps have more limited applications. Free flaps are the usual cover of choice for most lower third extremity defects.247,248 With any lower extremity reconstruction, three tenets are essential to success, as follows:

1. adequate preparation, which includes full débridement and control of any wound infection before coverage2. stabilization and management of associated orthopaedic injuries3. overall assessment of the patient’s suitability for reconstruction and rehabilitationVacuum-assisted closure is a very useful

adjunct to wound management in the lower extremity, particularly after adequate débridement and preparation of an ideal wound bed. The vacuum-assisted closure device aids in wound bed preparation and minimizes dressing changes.

Although a thorough understanding of local flaps is crucial for lower extremity reconstruction, many leg and foot wounds are not amenable to reconstruction with local flaps. For instance, many Gustilo type III wounds are not reliably covered by local muscle flaps. Regardless of the cause, large leg and foot wounds often are best covered with free flaps.

Free Flaps Microvascular transfers can deliver both soft-tissue and skeletal support to large complex wounds of the leg and are particularly useful in the distal third of the leg and foot. Serafin and Voci131 offered the following guidelines for free flap transfers in the lower extremity:

• Anastomose the microvessels outside the zone of injury.

• Make end-to-side arterial anastomoses and end-to-side or end-to-end venous anastomoses.

• Reconstruct the soft tissues first, and then restore skeletal support.Basheer et al.249 asserted that lower

extremity free flap success rates can be as high as 98% in the modern era. Heller and Levin16 reviewed


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lower extremity microsurgical reconstruction and proposed a useful reconstructive ladder. Defects are categorized according to the tissues needed and the status of the vascular supply. The authors discussed free flaps for isolated replacement of muscle, skin, fascia, or bone and more sophisticated composite flaps, such as musculocutaneous, osteocutaneous, and innervated musculocutaneous flaps. Preoperative considerations include evaluation of dead space, orthopaedic management of the bone injury, and final orthopaedic disposition.

For soft-tissue coverage alone, a relatively small number of muscle flaps typically are used. The workhorse free muscle flaps commonly used for the lower extremity are the latissimus, serratus, rectus, and gracilis. Cutaneous, fascial, and fasciocutaneous free flaps have also been described to cover lower extremity defects. For a thorough encyclopedia of available free flaps, see the textbook by Mathes and Nahai.250

The latissimus dorsi flap has the advantage of a large amount of bulk to fill dead space. Despite its initial bulk, the latissimus flap will reliably atrophy and recontour if inset under appropriate tension and managed with compression garments. The atrophy aids in restoring normal contour to the leg. Using the single thoracodorsal pedicle, the latissimus dorsi flap can be combined with the serratus anterior muscle flap for coverage of massive lower extremity defects.91

Another advantage of both the latissimus and serratus flaps is the long vascular pedicle, which allows anastomosis well outside the zone of injury in most cases. Use of vein grafts can lengthen the already generous pedicle. By placing the patient’s upper body in a lateral decubitus position and the lower body turned more supine, most latissimus and serratus transfers can be performed without a patient position change.

The rectus abdominis muscle flap also provides a significant volume of muscle with an acceptable pedicle. With the patient supine, the flap has the advantage that it rarely requires a patient position change for coverage of leg defects.136

On the basis of extensive clinical experience, Rainer et al.8 discussed free flap choices and presented technical details for optimizing cosmesis

in leg reconstruction. The type of defect, need for bulk versus thin contour, and donor site morbidity were all considered when choosing the flap for reconstruction, which in the reported series consisted of traditional free flaps and perforator flaps.

Yildirim et al.251 have endorsed the use of the anterolateral thigh perforator flap in lower extremity reconstruction. For smaller volume defects, the gracilis is an excellent muscle flap.137 It has demonstrable efficacy in the treatment of traumatic and non-traumatic defects. The gracilis is easy to harvest, produces little donor site morbidity, and adapts itself well to leg contour. Wechselberger et al.138 described an innovative and anatomically sound method of taking a larger, transverse, and more reliable skin paddle with the gracilis (Fig. 6). The selection of appropriate recipient vessels for free tissue transfer is critical. Relying on their experience with 50 consecutive free flaps to the lower extremity, Park et al.134 concluded the following:

• The site of injury and the vascular status of the lower extremity are the most important factors in recipient vessel selection in lower extremity reconstruction.

• The type of flap used, method, and site of microvascular anastomosis are less important factors in determining the recipient vessel.

• The anterior tibial artery is easier to use than the posterior tibial artery.

• Anterior donor flaps are more convenient and are preferred for use when the anterior tibial artery is used.

• An end-to-side anastomosis can be an option when using the posterior tibial artery; it rarely is used with the anterior tibial artery.

• An anastomosis distal to the zone of injury is a very useful method.

• An angiographic or Doppler confirmation should precede an anastomosis using reverse flow; intraoperative confirmation of pulsatile flow is also important.

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• The cross-leg free flap should be reserved as a last resort. Free tissue transfers to vessels distal to

the defect are well established for lower extremity reconstruction as long as the anastomoses are performed far outside the zone of injury.252 Local flaps and free tissue transfers have been described for lower extremity reconstruction in children. Banic and Wulff253 used a free latissimus dorsi flap for definitive repair of lower extremity wounds in children. Stewart et al.254 described a series of large transposition flaps and one free flap used to treat children with open tibial fractures.

Performing free tissue transfer in elderly patients with lower extremity wounds is an option. Dabb and Davis255 transferred three latissimus dorsi flaps in three elderly patients for limb salvage. The authors advocated a thorough medical workup, with emphasis on cardiac and peripheral vascular risk factors. Although that series achieved success in a few elderly patients, it is noted that elderly patients with comorbidities might be better served by primary amputation.

Furnas et al.256 and Goldberg et al.257 described their results with microsurgical tissue transfer for lower extremity reconstruction in elderly patients. Furnas et al. reported 10% failures and a 30% complication rate. Goldberg et al. noted that despite medical advances, the mortality rate from surgery among patients older than 70 years ranged from 8% to 10%.

Wettstein et al.258 retrospectively reviewed 197 lower extremity free flaps, analyzing the effects of comorbidities on outcomes. Although overall complication rates were as high as 40%, no association with specific risk factors other than patient age was shown. Elderly patients might experience a mildly increased tendency toward flap loss after revision.

Duteille et al.259 reported 16 free flaps for lower extremity reconstruction after trauma in children. The study illustrated very good results in the pediatric population. The authors emphasized the feasibility of microsurgical coverage in children despite the small size of their vessels and the tendency for vasospasm.

Fisher and Wood260 illustrated an important point in microvascular free flap reconstruction in compromised recipient sites. They presented a case report of complete necrosis of a latissimus free flap caused by blunt trauma 7 months postoperatively. The authors postulated that free flaps with high axial flow rates inset to poorly vascularized soft-tissue beds might lack the stimulus for neovascularization.

Salvage and options after lower extremity free flap reconstruction remain an issue, but limb salvage after free flap failure usually is possible. Culliford et al.261 presented a series of 585 lower extremity free flaps. Eighteen percent of patients with failed flaps eventually required amputation, but the remainder retained salvaged limbs. The 82% of patients who underwent salvage received additional free flaps, local flaps, and/or skin grafts.

Recent advances in perforator flaps afford new options of lower extremity free flaps. The primary benefit of perforator flaps is less donor site morbidity.

ThighIn general, soft-tissue defects of the thigh require neither pedicled nor free flap reconstruction because of the large amount of local muscle tissue that can be advanced into the wound. Skin coverage usually is accomplished by skin grafts on intact muscle.

For large contour defects of the anterior thigh or when the femoral vessels are exposed, a

Figure 6. Medial view of the thigh shows relation of the axis of the skin paddle (transverse) to the axis of the gracilis muscle (longitudinal) and to the adductor longus muscle (1), the gracilis muscle (2), the adductor magnus muscle (3), and the pubic tubercle (4). (Reprinted with permission from Wechselberger et al.138)


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pedicled rectus flap or vertical rectus abdominis myocutaneous flap can be used. A transverse rectus abdominis myocutaneous flap can also be used and has been described for reconstruction of large upper thigh defects after tumor extirpation. The gracilis and the tensor fascia lata can also be rotated anteriorly to cover smaller defects when needed. In their textbook, Mathes and Nahai250 reviewed the pedicled flap options for the thigh. If free flaps are required, the defect usually is so extensive that large free flaps, such as the latissimus dorsi, are indicated. Willcox et al.262 reported reconstruction of quadriceps function with the use of a reinnervated latissimus. Ihara et al.263 reported the repair of a large defect of the buttocks with a reinnervated free latissimus flap. The patient recovered hip abduction and achieved improved hip stability.

Leg: Upper Third and KneeSwartz and Jones264 reviewed the principles of wound coverage in the lower extremity and described options for the different territories of the leg and foot. An overview of standard flap options for the leg is found in the articles by Pers and Medgyesi,265 Ger,188 and McCraw.266

As a rule, the upper third of the leg can be covered with rotational muscle flaps. Special consideration needs to be given to preserving or reconstructing the knee extensor mechanism. Patel et al.267 reported a novel technique for dual coverage of the knee and functional reconstruction of the knee extensor mechanism with the gastrocnemius flap.

The following muscle flaps are available for covering defects of the upper third of the tibia and knee:

• medial head of the gastrocnemius • lateral head of the gastrocnemius • proximally based soleus • bipedicled tibialis anterior (lower part of

the tibia) The medial head of the gastrocnemius is

an excellent choice for proximal tibia and knee coverage. It can be reliably transferred on its proximally based neurovascular pedicle and is sustained by a broad muscle belly. When a longer

advancement is required, careful dissection and release of the muscle origin from the medial condyle of the femur are indicated. Wide scoring of the fascia can also facilitate long advancement.268

The lateral head of the gastrocnemius provides similar but more restricted coverage. Care must be taken to protect the lateral sural nerve.

The soleus muscle, based proximally, can be reliably carried to a point approximately 5 cm above its tendinous insertion. The soleus muscle is responsible for the venous pump phenomenon and is a “slow” muscle that aids in posture stabilization and slow gait. Transfer of a single head of the gastrocnemius or the entire soleus muscle creates little if any functional deficit.

The tibialis anterior muscle is important in dorsiflexion of the foot and is not considered expendable but might be raised as a bipedicled flap on its origin and insertion to preserve its function. The tibialis anterior is a Mathis type IV muscle, which requires maintenance of its segmental vascular supply and innervation. Other limitations are its relatively small volume and short arc. The tibialis anterior is nevertheless a valuable option in small open defects along the entire tibia. Hallock269 describes various methods of splitting and partially rotating the muscle to provide maximum anterior tibial coverage while preserving muscle function. Yoshimura et al.270 described the peroneal island flap, which allows transfer of skin from above the knee or lateral leg based either proximally or distally. Cutaneous perforators from the peroneal system perfuse a large island of skin. The neurovascular pedicle of the flap is equivalent in length to the peroneal vessel as it courses distally in the extremity. The authors reported no instances of flap necrosis in 14 cases. Fasciocutaneous flaps are another option for coverage of defects in the proximal third of the leg. The flaps are based on superficial perforating vessels from the deep arterial system; preoperative Doppler assessment of the circulatory status of the flaps is recommended. Although the flaps are options for the proximal third of the leg, the gold standard rotational flap for the proximal third remains the gastrocnemius muscle flap.

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Fix and Vasconez271 reviewed a broad range of fasciocutaneous flaps in the lower extremity. Variants of fasciocutaneous flaps that can be used in the proximal third of the leg are described.

Walton and Bunkis272 described a posterior calf fasciocutaneous flap perfused axially via a descending cutaneous branch of the popliteal artery. The flap allows pedicle or free transfer of large segments of fascia and skin from the posterior calf. Walton et al.273 reported using the fascial portion of the posterior calf as a free flap for resurfacing the hand and distal lower extremity. Peculiarities of the blood supply of fascial flaps are described in the article.

When free flaps are required around the knee, it is helpful to know that the genicular system can reliably provide inflow. One does not have to isolate the popliteal system in all cases.274

Leg: Middle Third The following muscle flaps are available for coverage in the middle third of the tibia:

• medial head of the gastrocnemius• lateral head of the gastrocnemius• proximally based soleus • flexor digitorum longus (for the lower

portion of the middle third) • extensor digitorum longus • extensor hallucis longus (for the lower

portion of the middle third) • flexor hallucis longus muscle (for the lower

portion of the middle third) • tibialis anterior

The flexor digitorum longus can be transferred without significant functional loss, but its spare muscle belly limits it to small defects or to use in conjunction with other flaps. The neurovascular pedicle usually enters the muscle at the junction of its proximal and middle thirds, although that is variable. Its function in toe flexion is supplemented by the action of the flexor digitorum brevis. Donor site morbidity is minimal.

The blood supply to the extensor digitorum longus is via vessels from the anterior tibial artery. The flap is used for closure of small wounds (<5 cm diameter). An incision is made 2 cm lateral to the

tibia, and the muscle is located lateral to the tibialis anterior muscle. The muscle is raised, taking care to preserve the superficial peroneal nerve during flap dissection. Ligation of perforators must be kept to a minimum during harvest or the muscle will not survive. The superficial peroneal nerve must not be damaged in the dissection.

The extensor hallucis longus also has a small muscle belly that limits its usefulness. During harvest, the surgeon must be careful to leave the distal tendon attached to the extensor digitorum communis to avert great toe drop.

The flexor hallucis longus muscle is larger than the adjacent flexor digitorum communis, but its primary function is to “push off ” the great toe and the muscle should not be sacrificed. The flap can be used as an adjunct to other methods of closure in the lower middle third and upper lower third of the tibia.

Free tissue transfer remains a useful option for the middle third of the leg, if local flaps cannot suffice. Many severe open tibial fractures that require substantial soft-tissue coverage are best served by free flaps rather than local flaps. The local muscle flaps that are available for the middle third of the leg, other than the soleus, are good for only small defects. The latissimus, rectus, serratus, and gracilis tend to be the workhorse free flaps for the middle third of the leg. In an interesting case report, Maghari et al.275 described how tissue expansion was used to create a massive free flap for coverage of a massive knee defect.

Fasciocutaneous flaps for coverage of middle third defects271 typically are based on medial or posterolateral septocutaneous perforators, although flaps can also be designed without an identifiable perforating artery: In essence, these are random-pattern fasciocutaneous flaps. The length:width ratio can be extended to 3:1, or twice that of random cutaneous flaps.271 Selection of one of these flaps must be carefully weighed against the use of reliable local muscle flaps, such as the soleus or free flaps.

Leg: Lower Third, Ankle, and Achilles TendonDistal leg and ankle wounds traditionally are covered with microvascular free flaps because of the insufficient soft tissue available for transposition at


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that level. A wide range of muscle flaps, perforator flaps, and fasciocutaneous free flaps are useful in the distal third of the leg. The following discussion pertains to both distally based superficial flaps and local muscle flaps. The flaps can be used when the defect is small enough that local transposition flaps are sufficient for coverage or when free tissue transfer is contraindicated.

The flexor hallucis longus, flexor digitorum longus, and tibialis anterior can be used in small-volume closures of the distal third of the leg. The abductor hallucis pedicled muscle flap will reach partly up the lower third of the tibia. The muscle occupies the medial instep of the foot and serves as an important springboard for the arch. After transfer, the abductor hallucis is missed for approximately 6 months; most patients eventually adapt to its loss. The muscle is mobilized on the lateral plantar artery and provides limited coverage of the lateral malleolus.

The distally based soleus, although described for these defects, generally is inferior to free flaps for coverage of large defects of the distal lower third. Beck et al.276 challenged that assertion in a series of eight patients who underwent distal leg reconstruction with the soleus. The authors recommended trying the soleus flap, instead of microsurgery, if the distal third of the flap appears undamaged and can reach the defect. They described the technical modifications.

The extensor digitorum brevis flap can also be used for small defects of the ankle and proximal foot. The downside is the sacrifice of the dorsalis pedis artery to allow flap rotation and viability.277

The peroneus brevis rotation flap, dissected free of the lateral compartment, can cover the lateral lower third of the leg for exposed fibular defects. The peroneus longus must remain intact to evert the foot when the peroneus brevis is dissected. Eren et al.278 and McHenry et al.279 described worthwhile technical details and clinical results from their experiences with peroneus brevis flaps used for distal fibular defects. In a letter to the editor, Barr et al.280 questioned the reliability of the distal aspect of the flap. Rotation of the peroneus brevis flap on its distal minor pedicle decreases perfusion to the most

distal aspect of the flap, which might be the region needed to cover a wound.

Attinger et al.281 wrote a comprehensive review of the local flap options for ankle and foot reconstruction. The authors emphasized the anatomy and limitations of several useful local flaps from the leg and foot (Fig. 7). Use of a delay procedure is suggested before transferring some of the leg muscle flaps. Most are useful for only small defects, but a judicious selection avoids the need for free flap coverage in certain cases of foot and ankle defects.

A number of fasciocutaneous flaps have been described for coverage of the distal third of the leg. They are primarily distally based, reverse-flow

Figure 7. Distances of the maximal possible reach of the muscles as measured from the tip of the medial malleolus. (Reprinted with permission from Attinger et al.281)

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flaps perfused by septocutaneous perforators from the anterior tibial, posterior tibial, and peroneal arteries and are best designed as rotation flaps rather than island flaps.

In the leg, the saphenous and sural flaps are most commonly transferred. The saphenous fasciocutaneous flap is perfused by posteromedial fasciocutaneous perforators off the saphenous artery. The sural flap is supplied by perforators from the medial superficial sural artery. Harvested with the sural nerve, it becomes a neurosensory flap. Based on cadaver injections with lead oxide solutions, Yang and Morris282 stated that the arterial supply of the flap is from the peroneal artery via a distal septocutaneous perforator. Rajendra et al.283 described the results of vascular studies of a musculofasciocutaneous variant of the sural flap.

A number of distally based superficial island flaps have been described for lower leg reconstruction.129,284,285 Flap coverage has been largely successful. Overall, transfer of the sural flap does leave the posterior aspects of the lower leg anesthetic and large flaps produce significant donor site morbidity. Hallock286 analyzed complications of 100 consecutive local fasciocutaneous flaps, 67 of which were used for lower extremity reconstruction. Major complications were reported in 15% of patients and minor complications in 11%. The incidence of complications was noted to be much lower in trauma cases than in older patients with concomitant peripheral vascular disease. The complication rate associated with distally based flaps was 37.5%. Wound closure was ultimately achieved in 97% of patients.

The reverse sural neurocutaneous and lateral supramalleolar flaps (Fig. 8) were compared in a series by Touam et al.6 The sural flap was superior to the lateral supramalleolar flap in reliability. A failure rate of 4.8% was noted for the reverse sural flap versus 18.5% for the lateral supramalleolar flap. Both flaps have demonstrable usefulness for nontraumatic wounds, such as after resection of skin cancers or ulcers. The series presented by Touam included only a few traumatic wounds. Costa-Ferraira et al.287 reported six partial losses in 36 sural flaps transferred. Almeida et al.288 reported 21% partial flap losses and 4% total flap

losses in a series of 71 reverse sural island flaps. Follmar et al.289 reported a large series of 79 sural flaps in their continuing medical education review article that covered relevant anatomy, pitfalls, and recommendations for use of the sural flap.

An interesting anatomic variant of the lateral supramalleolar flap was proposed by Koshima et al.,290 who suggested using rotational perforator flaps to cover distal leg and lateral or posterior heel wounds. The flaps can be used for small defects around the ankle without disturbing major vessels to the foot. They are, however, limited by their small size. The authors described cadaver studies and clinical applications of the perforator flaps.

Ayyappan and Chadha291 reported successful use of the sural flap in leg reconstruction after

Figure 8. A, Design of the lateral supramalleolar flap. The superficial peroneal nerve is transected. B, Flap circulation: 1, peroneal artery; 2, anterior tibial artery; 3, septocutaneous perforators; 4, malleolar branch of the anterior tibial artery; 5, distal tibiofibular angle. Sometimes the septocutaneous perforators and the malleolar branch of the anterior tibial artery are divided during flap elevation and the island is carried on retrograde flow from the anterior tibial artery. (Reprinted with permission from Touam et al.6)


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trauma. The series included five sural flaps used to cover traumatic heel wounds. One partial flap necrosis occurred. The authors also pushed the size limit of the skin paddle; their largest paddle measured 272 cm2.

Suga et al.292 stressed the importance of including both the sural nerve and the lesser saphenous vein in the flap. The flap pedicle should be raised with its surrounding soft tissues, and compression at the angle must be avoided.

Hollier et al.7 transferred 11 sural flaps in patients who were between the ages of 3 and 64 years who had undergone reconstructive surgery for traumatic and postablative defects. Only one partial flap necrosis ensued. The technical points of flap elevation are described by the authors. Price et al.293 illustrated the technique of sural flap harvest and transfer in exquisite detail (Fig. 9). Koladi et al.294 documented the safety and efficacy of the sural flap in children.

Achilles—The Achilles tendon and its overlying soft tissue deserve specific attention. If the soft-tissue loss is moderate, grafts of tendon or fascia can be combined with local flaps for reconstruction.295,296 If the Achilles loss is subtotal or complete but short, forearm tendon grafts can be used. Flexor hallucis longus grafts have been used to treat chronic tendinopathy297 and perhaps could be used to treat traumatic defects. In complete or large Achilles tendon defects, free tissue transfer probably is the best option for reconstruction. The goals of surgery are to restore function, smooth contour, and cover the wound with stable soft tissue. A denervated gracilis free flap with skin graft has been successfully used to accomplish the goals.298 The latissimus dorsi muscle has been used in the same way, with very good functional results.299 The denervated muscle atrophies and becomes fibrotic, eventually providing the rigidity needed for Achilles function. Over time, the contour of the muscle flaps improves to the point that no secondary debulking procedures are needed.

Various authors reported successful Achilles tendon reconstruction with a composite anterolateral thigh-fascia lata flap.300,301 Kuo et al.301 achieved excellent functional and aesthetic results

in a small series of Achilles tendon reconstructions with the composite flap. Potential donor site problems include damage to the vastus lateralis, which might compromise knee extension. Neither the gracilis nor the latissimus muscle flap presents such a risk.

Foot The simplest cover for a defect on the plantar surface of the foot is a thick split-thickness skin graft. The split-thickness skin graft can be used only when a substantial portion of the subcutaneous plantar pad is intact; it is not recommended that split grafts be placed on granulation tissue that is directly over bone. Woltering et al.302 described their experience with 13 patients whose skin grafts included the heel and forefoot. The average time to full weight-bearing without crutches was 80 days. All grafts reportedly did well, including those at the calcaneus and first metatarsal head. Postoperative pressure-sensitive ink pad recordings showed the patients’ gait patterns had changed to enhance graft protection.

Sommerlad and McGrouther303 compared techniques for coverage of the sole of the foot in 51 patients. Ink pad recordings showed altered gait patterns regardless of the type of reconstruction chosen, always favoring the reconstructed site. Skin grafts in this comparative series fared well, although hyperkeratosis was noted. Attinger et al.281 reviewed local flap options in defects of the foot.

May et al.304 and May and Rohrich305 described the use of a free latissimus dorsi muscle flap with thick split-thickness skin graft to treat chronic defects of the foot. Three operative groups were identified, as follows:

• Group I patients had flaps placed at or below the level of the malleolus and were not weight bearing on flap tissues.

• Group II patients were weight bearing on flap tissues but not directly on the skin graft covering the transferred muscle.

• Group III patients were weight bearing directly on the skin graft covering the transferred muscle.


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Gait analysis in the series presented by May et al. indicated that the amount of time spent on the resurfaced foot when walking was approximately the same as that spent on the normal foot. All patients experienced some deep pressure sensation in the involved areas. Light touch sensation at the graft was absent. Of significance was the presence of shear planes between the skin graft and the muscle and between the muscle and the underlying bone. The shear planes could play a protective role in the long-term durability of the graft. Nevertheless, two patients experienced delayed skin-graft breakdown in their usual footwear. The debate continues whether distant and free fasciocutaneous flaps have loading and shearing characteristics that are as favorable as free muscle with skin grafts. Karakostas et al.306 studied six patients who had undergone unilateral heel fasciocutaneous free flap reconstructions. The patients were well into their long-term recovery and had been walking on their flaps. The contralateral normal heels, with intact glabrous skin, served as controls. The study revealed that in these six

patients, the free fasciocutaneous flaps were able to sustain high loading pressure. The patients did have altered gait patterns that decreased shearing at the reconstructed heels in the anteroposterior dimension. Ultimately, patients who undergo heel coverage with anything other than plantar skin must always be aware of the possibility of breakdown. Hong and Kim307 drew a possibly clinically significant distinction between standard anterolateral thigh fasciocutaneous free flaps and thinner anterolateral thigh perforator flaps when used for plantar foot reconstruction. They reported a series of 69 patients who underwent plantar reconstruction with anterolateral thigh perforator flaps. They documented good success overall. The authors concluded that the anterolateral thigh perforator flap might be more ideal for the plantar foot because of its thinner contour and potentially better shear plane characteristics. Further study comparing standard anterolateral thigh flaps and perforator anterolateral thigh flaps at the sole are needed (Figs. 10 and 11).

Figure 9. A, Design of the skin paddle of the reverse sural artery flap. B, Sural arterial network with peroneal perforators. C, Elevation of the RSA as a fasciocutaneous flap with a lazy T-shape skin paddle to alleviate tension on proximal sutured closure. (Reprinted with permission from Price et al.293)


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Free muscle flaps with skin grafts are useful for treating defects of the foot that are large, that are anterior, that have no local tissue available, that have dead space, that have damaged local tissues or vessels, or for which local flaps have failed. Stevenson and Mathes308 reported a similar experience with the use of free muscle flaps to treat foot injuries.

HeelReiffel and McCarthy309 reviewed flap options for coverage of the heel. They described the anatomic basis and surgical detail of an axial cutaneous medial plantar artery instep flap and an axial musculocutaneous lateral plantar flap containing flexor brevis muscle. The flexor digitorum brevis, with or without its overlying instep skin, seems to be a reasonable alternative for heel defects because it can be transferred without detaching the lateral plantar artery calcaneal branch from the posterior tibial artery.

The instep flap need not be musculocutaneous or have a pedicle base.310 The flap can be transferred as a true fasciocutaneous island flap in a single stage (Fig. 12), either on a pedicle or by microvascular anastomoses. The instep flap

Figure 10. Clinical photographs of a 36-year-old patient with chronic diabetic ulceration of the left third metatarsal region. Left, Depth of ulceration extended to the bone, and a large dead space was noted beneath the skin. Right, Resurfaced foot at 11 months after surgery. No signs of recurrence are present. (Reprinted with permission from Hong and Kim.307)

Figure 11. Schematic drawings show the sliding effect of the flap on shearing forces. Note the difference between a fasciocutaneous flap (above) and a perforator flap (below). The thin subcutaneous layer composed of superficial fat and the small fat lobules surrounded by dense fibers allow the skin to anchor tightly to the surface and to glide less. (Reprinted with permission from Hong and Kim.307)


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has been carried on both the medial310 and lateral plantar vessels311,312 and requires a skin graft on the instep donor site.263,264

Benito-Ruiz et al.313 and Acikel et al.314 achieved good results with the medial plantar artery fasciocutaneous flap. Hartrampf et al.315 used the flexor digitorum brevis muscle for coverage of the heel, Achilles tendon, and medial and lateral malleolus. The flap is mobilized on the lateral plantar vessels.

Shaw and Hidalgo316 reviewed the anatomy of the plantar flap and its clinical applications. The flap is elevated superficial to the plantar fascia to avoid disruption of the normal plantar structures

and to maximize sensation distally and over the heel. Sensation is preserved by including the medial calcaneal nerve and by limiting the intraneural dissection of the medial and lateral plantar nerves (Fig. 13). This is a durable and reliable flap for heel coverage, but it cannot reach the posterior and vertical portions of the heel.

Rashid et al.317 compared the sensory medial plantar flap versus the sural flap for reconstruction in mostly posttraumatic heel defects. The flap survival rates were similarly excellent. Slightly earlier weight-bearing and significantly shorter return-to-work time were achieved in the plantar flap group, but a longer operative time was also recorded for that group. The sural flap was associated with more minor complications.

In general, amputation is considered in the event of heel wounds with large bony defects, although reconstruction occasionally is successful. Stanec et al.318 presented a case report of a 35-year-old healthy male patient who suffered traumatic bone loss and extensive soft-tissue damage to the heel. A large amount of the calcaneus was missing, but the tibiotalar joint and Achilles tendon insertions were intact. The patient underwent calcaneal and heel soft-tissue reconstruction with an osteocutaneous iliac free flap and began partial weight bearing at 10 weeks postoperatively. After several debulking procedures, he progressed to full weight bearing on the reconstructed heel without orthotics. At 10 years after surgery, the patient was clinically well, had intact deep pressure sensation, and had not experienced flap breakdown.

ForefootSplit grafts or full-thickness grafts are perfectly adequate for coverage of non-weight-bearing surfaces of the forefoot. If the bony surface has adequate pad but deficient local cutaneous cover, a preliminary attempt at skin grafting might be appropriate, reserving the muscle pad for graft failures.

Weight-bearing surfaces should be covered with similar plantar tissue when possible. An island instep fasciocutaneous or musculocutaneous flap that preserves sensation seems to be a suitable

Figure 12. Instep island flap raised on the medial plantar vessels and cutaneous nerve branches. The flap is raised superficial to the flexor digitorum brevis. The nerves and vessels do not pass through muscle. (Reprinted with permission from Morrison et al.310)


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Figure 13. Plantar flap in foot reconstruction. Upper, illustrations depict superficial neurovascular supply of plantar flap. Middle, clinical photographs show transfer of plantar flap to cover heel defect. Lower, illustrations show medially based plantar flap raised over two abductor muscles and the plantar fascia, preserving the medial and lateral plantar nerve branches to the flap. (Modified from Shaw and Hidalgo.316)


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choice for reconstruction in such cases. An excellent technique for resurfacing defects in the weight-bearing aspect of the forefoot makes use of tissues obtained in the toe fillet flap. The donor defect is not missed unless the fillet is taken from the great toe. The skin is well vascularized, and innervation is maintained. Snyder and Edgerton319 discussed the anatomy and surgical principles of toe filleting, and Buncke and Colen320 described use of the great toe fillet for defects of the forefoot. Dutch et al.321 reported the use of pedicled common digital and proper digital artery flaps for forefoot reconstruction. A 13% flap loss rate was noted, and 73% of patients had minor wound complications.

Butler and Chevray322 described an ingenious modification of the medial plantar artery/instep flap that bases the flap distally, with the arterial supply derived from metatarsal perforating branches. The authors reported successful forefoot reconstruction with this method in two patients. No arterial inflow problems were reported, although one flap required venous supercharging. The illustrated clinical results were good. The flap has also been successfully used by Takahashi et al.323

When planning the design of local foot flaps for lower extremity coverage, two points must be remembered: 1) when possible, the incisions should not be placed on weight-bearing surfaces, and 2) the amount of tissue available after transfer often is less than anticipated. Wound breakdown can ruin an otherwise successful foot reconstruction with local flaps.

Free muscle flaps and fascial flaps with skin grafts are a consideration when bony surfaces have no overlying subcutaneous pad and local cutaneous cover is not available. Musharafieh et al.324 described a series of 10 free radial forearm flaps used successfully in foot and ankle reconstruction. All patients must be monitored long-term for recurrent ulceration, especially when non-plantar tissue is used to cover a plantar defect.

Restoration of Sensation in the FootMatejcik et al.325,326 reported the results of lower extremity reconstruction after major nerve injury. As one would expect, blunt injuries with neurolysis

had the best overall results. Nerves that had been transected and were discontinuous required direct microsurgical repair or nerve grafts. The functional return was better after direct repair than when the nerve was grafted.

Mackinnon et al.327 presented a report of seven patients who underwent nerve allograft repair of major peripheral nerve gaps in the lower and upper extremities. All patients received immunosuppression for up to 6 months after nerve regeneration was detected. The nerve graft was rejected in one patient, but the other six experienced some return of motor function. The study illustrated the possible future of secondary reconstruction of large peripheral nerves in the extremities.

Several recent studies addressed the coverage of plantar traumatic defects with sensory free flaps.328 Kim et al.329 reported a single case of heel reconstruction with an innervated free flap obtained from the contralateral posterior tibial system. Santanelli et al.14 reviewed their experience with plantar reconstruction, which consisted of seven reinnervated and seven traditional radial forearm flaps. Regardless of nerve coaptation at the time of flap transfer, all 14 patients achieved good, stable plantar cover. In the long term, both reinnervated and non-reinnervated flaps provided adequate protective sensation.

Kuran et al.13 reviewed their results of lower extremity reconstruction with 12 flaps. The defects varied in size and complexity. The larger defects were covered with insensitive free flaps out of necessity, and the smaller defects were repaired with sensory free flaps. Patients who received sensory flaps experienced earlier return of pressure sensation, but over the long term, the functional results between the two groups were similar.

Reconstruction and Orthopaedic OncologyThe use of vascularized free bone flaps has afforded new options for patients with long-bone sarcomas. Despite the potential for more complications, patients who undergo reconstruction of long-bone defects after sarcoma resection show better function than do those who undergo amputation.330,331

El-Gammel et al.105 reported good results with single-barrel free fibular reconstructions after


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tumor resections in the leg. They emphasized that full weight-bearing must wait until sufficient graft hypertrophy has occurred. The risk of pathological fracture of the single-barrel, isolated fibula always exists.109,332

Zaretski et al.333 reported the results of 15 thigh and eight leg reconstructions after sarcoma resection in adults and children. A free fibular graft was used in all cases. Union was achieved in all except one patient; another patient was lost to follow-up, and his status could not be determined. The average time to union was 4.8 months; the average time to full weight bearing was 9.2 months. Three infections occurred at the recipient site. The authors recommended one of three variants of the free fibular procedure according to the weight-bearing needs of the recipient tissue, as follows:

• High-stress areas, such as the femur and proximal tibia in adults, are indications for free fibula transfer surrounded by generous amounts of cancellous graft. The potential advantages of this technique, which was originally described by Capanna et al.,334 are that ample bone stock is immediately available for remodeling and weight tolerance will not depend on hypertrophy of the fibula.

• Intermediate load-bearing areas are reconstructed with double-barreled fibulae.

• Light-load areas, such as partial-thickness defects of the tibia in adults and full-thickness tibial defects in young children, are indications for reconstruction with single-barrel free fibular transfer.

When significant joint excision is required, endoprostheses are used with or without vascularized fibula.109,335

Algorithms for timing of the reconstruction and choice of reconstructive method are presented in Figure 14. Definitive bony reconstruction is delayed in cases that require prolonged courses of adjuvant radiotherapy, such as cases of Ewing sarcoma.

Allograft alone can be used for bone reconstruction after tumor ablation that results

in small defects. Mastorakos et al.336 emphasized that union is improved and infection rates are lower when the allograft is covered by pedicled or free muscle flaps. Unlike bone replacement, early soft-tissue reconstruction is safe after sarcoma extirpation, and pedicled flaps, free flaps, and skin grafts tolerate radiation therapy reasonably well. Spierer et al.337 noted that only 5% of reconstructions in their series developed wound complications. Incidentally, more wound complications occurred after brachytherapy than after external beam radiation.

Cross-Leg Flap Before the widespread use of free-tissue transfer, the cross-leg flap was the procedure of choice for typical wounds of the leg when local pedicled flaps were unavailable.338 Today the indications for cross-leg flaps are limited. Patients who are not free flap candidates and patients who remain immobilized for other reasons occasionally are cross-leg flap candidates. Dawson339 analyzed the complications encountered in 99 cross-leg flap procedures and reported local flap necrosis in 40% and infection in 28%.

As suggested by Barclay et al.,340 the design of the cross-leg flap has been changed to include the deep fascia of the leg. At present, cross-leg flaps are transferred as fasciocutaneous tissue units with a length:width ratio of 3:1 or 4:1.235,341,342

Cross-leg pedicled flaps and cross-leg free flaps have been described for extremity salvage in cases in which the existing vascular inflow of the affected extremity is of poor quality, often from severe trauma or tissue loss.343,344 Still, the evaluating surgeon must realize that an open leg or foot wound with recipient vessels not suitable for free flap transfer might indicate an injury so bad that limb salvage is not advisable.

Long et al.338 reported the use of current external fixation technology for cross-leg fasciocutaneous flaps. All flaps were based on the axial blood supply of the posterior descending subfascial cutaneous branch of the popliteal artery. The external fixation allowed for physical therapy

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Figure 14. Upper, Algorithm shows immediate versus late reconstruction. Secondary definitive reconstruction is advised for patients who are scheduled for postoperative radiation treatment. R.T., Radiation therapy. *, Patients with Ewing sarcoma and favorable prognoses did not receive therapy. Lower, Algorithm shows lower extremity reconstruction. Autogenous reconstruction is indicated primarily in cases that are not periarticular. The decision regarding type of fibular reconstruction depends on the mechanical load expected based on the anatomic site. *, Avascular necrosis, osteoradionecrosis, pathological fracture. **, Infectious complication, implant failure. ***, When enough fibular bone source is present, the bony defect is not too big, and the patient is not too heavy. (Reprinted with permission from Zaretski et al.333)

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and range-of-motion exercises of the extremities to begin soon after surgery.Soft-Tissue ExpansionThe primary application of skin expansion in the lower extremity is to resurface areas of unstable soft tissue or unsightly scar.345 Infection rates have historically ranged between 5% and 30%. Conventional plastic surgical knowledge has held that soft-tissue expansion is more difficult in the lower extremity than in other parts of the body.

Manders et al.346 presented a report of 16 patients who underwent soft-tissue expansion in the lower extremity. All expanders were placed in the subcutaneous plane above the muscular fascia. The pockets for expander placement were closed-suction drained. Prophylactic antibiotics were administered to all patients. Expansion was begun 1 to 2 weeks after implantation. Ultimately, good results were obtained in all patients who were operated on for correction of contour deformities.

Successful results were obtained in patients who had expanders placed in the thigh or buttocks. In contrast, only 50% of expanders at or below the knee were ultimately successful. Overall, in the entire series,346 17 complications occurred during 13 expansions, with only three patients remaining free of problems. Infection developed in seven patients. Six of the seven patients had open wounds at or below the knee, and another had an open wound at the thigh. Infection resulted in wound dehiscence in two of the seven patients and expander exposure in one.

In an update of the series of lower extremity reconstruction by soft-tissue expansion presented by Manders et al.,346 Borges et al.347 discussed sites that are not amenable to expansion, such as the ankle and foot, particularly the plantar surface of the foot. They noted the following points:

• There is a tendency toward periprosthetic infection if the expander is placed next to an open wound in the lower extremity.

• Expansions on the medial and lateral surfaces of the knee have been accomplished successfully even though the joint is in constant motion.

• In most instances of soft-tissue expansion designed to eliminate lower extremity defects, one should plan for transverse advancement of tissue, not axial advancement.

• The plane of dissection for placement of the expander is just above the muscle fascia.

• The most common causes of implant exposure is an inadequately dissected pocket.

• Bed rest for several days with the leg elevated is indicated after insertion of expanders in the lower extremity. The pediatric population might do better

than adults with lower extremity tissue expansion. Kryger and Bauer348 reported their creative use of tissue expansion for 50 children with giant congenital nevi. Retrospectively, few complications were noted in the report. Large nevi in thigh, leg, and foot were treated with skin grafts, expanded local flaps, and expanded free flaps. Images and descriptions of selected cases in the report by Kryger and Bauer are instructive and impressive, and the article includes an algorithm for treatment (Fig. 15).

RECONSTRUCTION OF THE NECROTIC FEMORAL HEAD Avascular necrosis (AVN) of the femoral head can be idiopathic, secondary to steroid use, posttraumatic, caused by systemic disease, or associated with alcoholism. Adults and children can be affected. Left untreated, AVN of the femoral head can lead to osteoarthrosis of the hip. Traditionally, this condition has been treated nonsurgically, with core decompression, and/or with total hip arthroplasty. Judet et al.349 and Judet and Gilbert350 used microvascular free fibular grafts in cases of AVN of the hip and in the reconstruction of other large bony defects of the lower extremity.

Many authors351−353 have since published their respective experiences with free fibular transfers for proximal femora. In a series of 228 hips treated with free fibular transfer, Soucacos et al.353 noted that patients in the earlier stages of disease had better and more predictable results, although all should be considered.


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Kane et al.354 prospectively compared core decompression with free fibular transfer in stage II and III femoral head AVN. Core decompression failed to prevent total hip arthroplasty in 58% of patients. The patients treated with free fibular grafts went on to undergo arthroplasty 20% of the time. In another study comparing free fibular transfer with core decompression, Scully et al.355 also showed better results with free fibular transfer for stage II and III disease.

Dean et al.356 reviewed a large series of pediatric patients with femoral head AVN and noted that children treated with free fibular transfer do better than their adult counterparts. However, any long-term result of revascularization of the

femoral head should be weighed against the good results that can be achieved with total hip arthroplasty.REPLANTATION Although various reports of successful replantation of lower extremities can be found in the literature, large patient series do not exist to help determine clear indications for replantation. Judicious selection of individual candidates is a must. Certainly, no other tissue in the body can perfectly replace the specialized, weight-bearing skin and subcutaneous tissues of the heel pad and plantar skin. For lower extremity replantation to truly be a success, some return of protective sensation must be present in

Figure 15. Algorithm for treating large and giant congenital pigmented nevi of the lower extremity. FTSG, full-thickness skin graft. (Reprinted with permission from Kryger and Bauer.348)


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the plantar foot and trophic ulceration must be absent.357

When replantation of the lower extremity is considered, the patient must be informed of the likelihood of multiple operations and blood transfusions for some time in the future and must be willing to accept those conditions in addition to a significant risk of complications. Overall, carefully selected heel pad and partial foot replantations might be more predictable—and thus more indicated—than whole foot and leg replantations.

Battiston et al.358 reported their experience with 14 lower extremity replantations, five of which were later amputated because of complications. Park et al.359 reported a case of forefoot replantation in a very young child that produced acceptable long-term functional results. Chiang et al.360 achieved a good result in a rare case of heel pad replantation. Daigeler et al.361 described the courses of seven patients who received leg replants, including two cases of bilateral amputation with successful heterotopic single replantation. Gayle et al.357 reported a series of five patients with various foot and lower leg replantations. Their best results were obtained when the amputation was at the level of the ankle and distally. Patients who regained some sensation avoided recurrent ulceration and achieved good function of the replanted extremity.

In conclusion, the results of replantation should be compared with those of a well-designed form-fitting below-knee prosthesis. Patients with lower extremity amputations often present with other serious injuries that might contraindicate replantation. Replantation of the lower limb can be considered in ideal circumstances, such as in children who have undergone amputations, require minimal bone shortening, and are expected to achieve return of protective sensation, and perhaps in some cases of sharp amputation of the distal leg, ankle, heel pad, or forefoot. Although less desirable, a patient with bilateral leg amputations might also be seriously considered for replantation of at least one limb.

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A single institution’s experience over 25 years. Ann Plast Surg 2007;59:18–21.262. Willcox TM, Smith AA, Beauchamp C, Meland NB. Functional free latissimus dorsi muscle flap to the proximal lower extremity. Clin Orthop Relat Res 2003;410:285–288.263. Ihara K, Kishimoto T, Kawai S, Doi K. Reconstruction of hip abduction using free muscle transplantation: A case report and description of technique. Ann Plast Surg 2000;45:177–180.264. Swartz WM, Jones NF. Soft tissue coverage of the lower extremity. Curr Probl Surg 1985;22:1–59.265. Pers M, Medgyesi S. Pedicle muscle flaps and their applications in the surgery of repair. Br J Plast Surg 1973;26:313–321.266. McCraw JB. Selection of alternative local flaps in the leg and foot. Clin Plast Surg 1979;6:227–246.267. Patel NS, Ibrahim DT, Finn HA. Knee extensor mechanism reconstruction with medial gastrocnemius flap. Clin Orthop Relat Res 2002;398:176–181.268. Dibbell DG, Edstrom LE. The gastrocnemius myocutaneous flap. Clin Plast Surg 1980;7:45–50.269. Hallock GG. Sagittal split tibialis anterior muscle flap. Ann Plast Surg 2002;49:39–43.270. Yoshimura M, Shimada T, Imura S, Shimamura K, Yamauchi S. Peroneal island flap for skin defects in the lower extremity. J Bone Joint Surg Am 1985;67:935–941.271. Fix RJ, Vasconez LO. Fasciocutaneous flaps in reconstruction of the lower extremity. Clin Plast Surg 1991;18:571–582.272. Walton RL, Bunkis J. The posterior calf fasciocutaneous free flap. Plast Reconstr Surg 1984;74:76–85.273. Walton RL, Matory WE Jr, Petry JJ. The posterior calf fascial free flap. Plast Reconstr Surg 1985;76:914–926.274. Park S, Eom JS. Selection of the recipient vessel in the free flap around the knee: The superior medial genicular vessels and the descending genicular vessels. Plast Reconstr Surg 2001;107:1177–1182.275. Maghari A, Forootan KS, Fathi M, Manafi A. Free transfer of expanded parascapular, latissimus dorsi, and expander “capsule” flap for coverage of large lower-extremity soft-tissue defect. Plast Reconstr Surg 2000;106:402–405.276. Beck JB, Stile F, Lineaweaver W. Reconsidering the soleus Muscle flap for coverage of wounds of the distal third of the leg. Ann Plast Surg 2003;50:631–635.277. Pai CH, Lin GT, Lin SY, Lin SD, Lai CS. Extensor digitorum brevis rotational muscle flap for lower leg and ankle coverage. J Trauma 2000;49:1012–1016.278. Eren S, Ghofrani A, Reifenrath M. The distally pedicled peroneus brevis muscle flap: A new flap for the lower leg. Plast Reconstr Surg 2001;107:1443–1448.279. McHenry TP, Early JS, Schacherer TG. Peroneus brevis rotation flap: Anatomic considerations and clinical experience. J Trauma 2001;50:922–926.

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280. Barr ST, Rowley JM, O’Neill PJ, Barillo DJ, Paulsen SM. How reliable is the distally based peroneus brevis muscle flap? Plast Reconstr Surg 2002;110:360–362.281. Attinger CE, Ducic I, Zelen C. The use of local muscle flaps in foot and ankle reconstruction. Clin Podiatr Med Surg 2000;17:681–711.282. Yang D, Morris SF. Reversed sural island flap supplied by the lower septocutaneous perforator of the peroneal artery. Ann Plast Surg 2002;49:375–378.283. Rajendra Prasad JS, Cunha-Gomes D, Chaudhari C, Bhathena HM, Desai S, Kavarana NM. The venoneuroadipofascial pedicled distally based sural island myofasciocutaneous and muscle flaps: Anatomical basis of a new concept. Br J Plast Surg 2002;55:203–209.284. Coşkunfirat OK, Velidedeoğlu HV, Sahin U, Demir Z. Reverse neurofasciocutaneous flaps for soft-tissue coverage of the lower leg. Ann Plast Surg 1999;43:14–20.285. Fraccalvieri M, Verna G, Dolcet M, Fava R, Rivarossa A, Robotti E, Bruschi S. The distally based superficial sural flap: Our experience in reconstructing the lower leg and foot. Ann Plast Surg 2000;45:132–139.286. Hallock GG. Complications of 100 consecutive local fasciocutaneous flaps. Plast Reconstr Surg 1991;88:264–268.287. Costa-Ferreira A, Reis J, Pinho C, Martins A, Amarante J. The distally based island superficial sural artery flap: Clinical experience with 36 flaps. Ann Plast Surg 2001;46:308–313.288. Almeida MF, da Costa PR, Okawa RY. Reverse-flow island sural flap. Plast Reconstr Surg 2002;109:583–591.289. Follmar KE, Baccarani A, Baumeister SP, Levin LS, Erdmann D. The distally based sural flap. Plast Reconstr Surg 2007;119:138e–148e.290. Koshima I, Itoh S, Nanba Y, Tsutsui T, Takahashi Y. Medial and lateral malleolar perforator flaps for repair of defects around the ankle. Ann Plast Surg 2003;51:579–583.291. Ayyappan T, Chadha A. Super sural neurofasciocutaneous flaps in acute traumatic heel reconstructions. Plast Reconstr Surg 2002;109:2307–2313.292. Suga H, Oshima Y, Harii K, Asato H, Takushima A. Distally-based sural flap for reconstruction of the lower leg and foot. Scand J Plast Reconstr Surg Hand Surg 2004;38:16–20.293. Price MF, Capizzi PJ, Watterson PA, Lettieri S. Reverse sural artery flap: Caveats for success. Ann Plast Surg 2002;48:496–504.294. Koladi J, Gang RK, Hamza AA, George A, Bang RL, Rajacic N. Versatility of the distally based superficial sural flap for reconstruction of lower leg and foot in children. J Pediatr Orthop 2003;23:194–198.295. Babu V, Chittaranjan S, Abraham G, Korula RJ. Single-stage reconstruction of soft-tissue defects including the Achilles tendon using the dorsalis pedis arterialized flap along with the extensor digitorum brevis as bridge graft. Plast Reconstr Surg 1994;93:1090–1094.

296. Dumont CE, Kessler J. A composite medial plantar flap for the repair of an achilles’ tendon defect: A case report. Ann Plast Surg 2001;47:666–668.297. Tashjian RZ, Hur J, Sullivan RJ, Campbell JT, DiGiovanni CW. Flexor hallucis longus transfer for repair of chronic achilles tendinopathy. Foot Ankle Int 2003;24:673–676.298. Feibel RJ, Jackson RL, Lineaweaver WC, Buncke HJ. Management of chronic achilles tendon infection with musculotendinous gracilis interposition free-flap coverage. J Reconstr Microsurg 1993;9:321–325.299. Ronel DN, Newman MI, Gayle LB, Hoffman LA. Recent advances in the reconstruction of complex Achilles tendon defects. Microsurgery 2004;24:18–23.300. Inoue T, Tanaka I, Imai K, Hatoko M. Reconstruction of Achilles tendon using vascularised fascia lata with free lateral thigh flap. Br J Plast Surg 1990;43:728–731.301. Kuo YR, Kuo MH, Chou WC, Liu YT, Lutz BS, Jeng SF. One-stage reconstruction of soft tissue and Achilles tendon defects using a composite free anterolateral thigh flap with vascularized fascia lata: Clinical experience and functional assessment. Ann Plast Surg 2003;50:149–155.302. Woltering EA, Thorpe WP, Reed JK Jr, Rosenberg SA. Split thickness skin grafting of the plantar surface of the foot after wide excision of neoplasms of the skin. Surg Gynecol Obstet 1979;149:229–232.303. Sommerlad BC, McGrouther DA. Resurfacing the sole: Long-term follow-up and comparison of techniques. Br J Plast Surg 1978;31:107–116.304. May JW Jr, Halls MJ, Simon SR. Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: A clinical and gait analysis study. Plast Reconstr Surg 1985;75:627–641.305. May JW Jr, Rohrich RJ. Foot reconstruction using free microvascular muscle flaps with skin grafts. Clin Plast Surg 1986;13:681–689.306. Karakostas T, Hsiang SM, Sarantopoulos C, Krause J. Dynamic loading performance of fasciocutaneous flaps and implications for gait. Clin Biomech (Bristol, Avon) 2007;22:478–485.307. Hong JP, Kim EK. Sole reconstruction using anterolateral thigh perforator free flaps. Plast Reconstr Surg 2007;119:186–193.308. Stevenson TR, Mathes SJ. Management of foot injuries with free-muscle flaps. Plast Reconstr Surg 1986;78:665–671.309. Reiffel RS, McCarthy JG. Coverage of heel and sole defects: A new subfascial arterialized flap. Plast Reconstr Surg 1980;66:250–260.310. Morrison WA, Crabb DM, O’Brien BM, Jenkins A. The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast Reconstr Surg 1983;72:56–65.311. Curtin JW. Functional surgery for intractable conditions of the sole of the foot. Plast Reconstr Surg 1977;59:806–811.312. Miyamoto Y, Ikuta Y, Shigeki S, Yamura M. Current concepts of instep island flap. Ann Plast Surg 1987;19:97–102.


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314. Acikel C, Celikoz B, Yuksel F, Ergun O. Various applications of the medial plantar flap to cover the defects of the plantar foot, posterior heel, and ankle. Ann Plast Surg 2003;50:498–503.

315. Hartrampf CR Jr, Scheflan M, Bostwick J III. The flexor digitorum brevis muscle island pedicle flap: A new dimension in heel reconstruction. Plast Reconstr Surg 1980;66:264–270.

316. Shaw WW, Hidalgo DA. Anatomic basis of plantar flap design: Clinical applications. Plast Reconstr Surg 1986;78:637–649.

317. Rashid M, Hussain SS, Aslam R, Illahi I. A comparison of two fasciocutaneous flaps in the reconstruction of defects of the weight-bearing heel. J Coll Physicians Surg Pak 2003;13:216–218.

318. Stanec Z, Krivić A, Stanec S, Zic R, Budi S. Heel reconstruction with an iliac osteocutaneous free flap: 10-year follow-up. Ann Plast Surg 2004;53:174–177.

319. Snyder GB, Edgerton MT Jr. The principle of the island neurovascular flap in the management of ulcerated anesthetic weightbearing areas of the lower extremity. Plast Reconstr Surg 1965;36:518–528.

320. Buncke HJ Jr, Colen LB. An island flap from the first web space of the foot to cover plantar ulcers. Br J Plast Surg 1980;33:242–244.

321. Dutch WM, Arnz M, Jolly GP. Digital artery flaps for closure of soft tissue defects of the forefoot. J Foot Ankle Surg 2003;42:208–214.

322. Butler CE, Chevray P. Retrograde-flow medial plantar island flap reconstruction of distal forefoot, toe, and webspace defects. Ann Plast Surg 2002;49:196–201.

323. Takahashi A, Tamura A, Ishikawa O. Use of a reverse-flow plantar marginal septum cutaneous island flap for repair of a forefoot defect. J Foot Ankle Surg 2002;41:247–250.

324. Musharafieh R, Atiyeh B, Macari G, Haidar R. Radial forearm fasciocutaneous free-tissue transfer in ankle and foot reconstruction: Review of 17 cases. J Reconstr Microsurg 2001;17:147–150.

325. Matejcik V. Surgical repair of peripheral nerves in lower extremities. Bratisl Lek Listy 2001;102:282–285.

326. Matejcik V, Benetin J, Hulin I Jr. Our experience with surgical treatment of ischial nerve injuries. Bratisl Lek Listy 2001;102:462–466.

327. Mackinnon SE, Doolabh VB, Novak CB, Trulock EP. Clinical outcome following nerve allograft transplantation. Plast Reconstr Surg 2001;107:1419–1429.

328. Potparić Z, Rajacić N. Long-term results of weight-bearing foot reconstruction with non-innervated and reinnervated free flaps. Br J Plast Surg 1997;50:176–181.

329. Kim SW, Hong JP, Chung YK, Tark KC. Sensate sole-to-sole reconstruction using the combined medial plantar and medialis pedis free flap. Ann Plast Surg 2001;47:461–464.330. Renard AJ, Veth RP, Schreuder HW, van Loon CJ, Koops HS, van Horn JR. Function and complications after ablative and limb-salvage therapy in lower extremity sarcoma of bone. J Surg Oncol 2000;73:198–205.331. Bach AD, Kopp J, Stark GB, Horch RE. The versatility of the free osteocutaneous fibula flap in the reconstruction of extremities after sarcoma resection. World J Surg Oncol 2004;2:22.332. El-Gammal TA, El-Sayed A, Koth MM. Reconstruction of lower limb bone defects after sarcoma resection in children and adolescents using free vascularized fibular transfer. J Pediatr Orthop B 2003;12:233–243.333. Zaretski A, Amir A, Meller I, Leshem D, Kollender Y, Barnea Y, Bickels J, Shpitzer T, Ad-El D, Gur E. Free fibula long bone reconstruction in orthopedic oncology: A surgical algorithm for reconstructive options. Plast Reconstr Surg 2004;113:1989–2000.334. Capanna R, Bufalini C, Campanacci M. A new technique for reconstructions of large metadiaphyseal bone defects: A combined graft (Allograft shell plus vascularized fibula). Orthop Traumatol 1993;2:159–177.335. Wodajo FM, Bickels J, Wittig J, Malawer M. Complex reconstruction in the management of extremity sarcomas. Curr Opin Oncol 2003;15:304–312.336. Mastorakos DP, Disa JJ, Athanasian E, Boland P, Healey JH, Cordeiro PG. Soft-tissue flap coverage maximizes limb salvage after allograft bone extremity reconstruction. Plast Reconstr Surg 2002;109:1567–1573.337. Spierer MM, Alektiar KM, Zelefsky MJ, Brennan MF, Cordiero PG. Tolerance of tissue transfers to adjuvant radiation therapy in primary soft tissue sarcoma of the extremity. Int J Radiat Oncol Biol Phys 2003;56:1112–1116.338. Long CD, Granick MS, Solomon MP. The cross-leg flap revisited. Ann Plast Surg 1993;30:560–563.339. Dawson RL. Complications of the cross-leg flap operation. Proc R Soc Med 1972;65:626–629.340. Barclay TL, Sharpe DT, Chisholm EM. Cross-leg fasciocutaneous flaps. Plast Reconstr Surg 1983;72:843–847.341. Townsend PL. Indications and long-term assessment of 10 cases of cross-leg free DCIA flaps. Ann Plast Surg 1987;19:225–233.342. Lai CS, Lin SD, Chou CK, Cheng YM. Use of a cross-leg free muscle flap to reconstruct an extensive burn wound involving a lower extremity. Burns 1991;17:510–513.343. Ninkovic MM, Schwabegger AH, Hausler JW, Ninkovic M, Schmutzhard E. Limb salvage after fulminant septicemia using a free latissimus dorsi cross-leg flap. J Reconstr Microsurg 2000;16:603–607.344. Ladas C, Nicholson R, Ching V. The cross-leg soleus muscle flap. Ann Plast Surg 2000;45:612–615.345. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg 1984;74:482–492.

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346. Manders EK, Oaks TE, Au VK, Wong RK, Furrey JA, Davis TS, Graham WP III. Soft-tissue expansion in the lower extremities. Plast Reconstr Surg 1988;81:208–219.347. Borges Filho PT, Neves RI, Gemperli R, Kaweski S, Kahler SH, Banducci DR, Manders EK. Soft-tissue expansion in lower extremity reconstruction. Clin Plast Surg 1991;18:593–599.348. Kryger ZB, Bauer BS. Surgical management of large and giant congenital pigmented nevi of the lower extremity. Plast Reconstr Surg 2008;121:1674–1684.349. Judet H, Judet J, Gilbert A. Vascular microsurgery in orthopaedics. Int Orthop 1981;5:61–68.350. Judet H, Gilbert A. Long-term results of free vascularized fibular grafting for femoral head necrosis. Clin Orthop Relat Res 2001;386:114–119.351. Brunelli G, Brunelli G. Free microvascular fibular transfer for idiopathic femoral head necrosis: Long-term follow-up. J Reconstr Microsurg 1991;7:285–295.352. Urbaniak JR, Harvey EJ. Revascularization of the femoral head in osteonecrosis. J Am Acad Orthop Surg 1998;6:44–54.353. Soucacos PN, Beris AE, Malizos K, Koropilias A, Zalavras H, Dailiana Z. Treatment of avascular necrosis of the femoral head with vascularized fibular transplant. Clin Orthop Relat Res 2001;386:120–130.354. Kane SM, Ward WA, Jordan LC, Guilford WB, Hanley EN Jr. Vascularized fibular grafting compared with

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355. Scully SP, Aaron RK, Urbaniak JR. Survival analysis of hips treated with core decompression or vascularized fibular grafting because of avascular necrosis. J Bone Joint Surg Am 1998;80:1270–1275.

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RECOMMENDED READINGAttinger CE, Ducic I, Neville RF, Abbruzzese MR, Gomes M, Sidawy AN. The relative roles of aggressive wound care versus revascularization in salvage of the threatened lower extremity in the renal failure diabetic patient. Plast Reconstr Surg 2002;109:1281–1290.

Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH. Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br 2001;83:62–68.

Bondurant FJ, Cotler HB, Buckle R, Miller-Crotchett P, Browner BD. The medical and economic impact of severely injured lower extremities. J Trauma 1988;28:1270–1273.

Byrd HS, Spicer TE, Cierney G III. Management of open tibial fractures. Plast Reconstr Surg 1985;76:719–730.

Carrington NC, Smith RM, Knight SL, Matthews SJ. Ilizarov bone transport over a primary tibial nail and free flap: A new technique for treating Gustilo grade 3b fractures with large segmental defects. Injury 2000;31:112–115.

Culliford AT IV, Spector J, Blank A, Karp NS, Kasabian A, Levine JP. The fate of lower extremities with failed free flaps: A single institution’s experience over 25 years. Ann Plast Surg 2007;59:18–21.

Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453–458.

Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 1984;24:742–746.

Harley BJ, Beaupre LA, Jones CA, Dulai SK, Weber DW. The effect of time to definitive treatment on the rate of nonunion and infection in open fractures. J Orthop Trauma 2002;16:484–490.

Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg 2001;108:1029–1041.

Ilizarov GA, Ledyaev VI. The replacement of long tubular bone defects by lengthening distraction osteotomy of one of the fragments: 1969. Clin Orthop Relat Res 1992;280:7–10.

Kryger ZB, Bauer BS. Surgical management of large and giant congenital pigmented nevi of the lower extremity. Plast Reconstr Surg 2008;121:1674–1684.

Lange RH. Limb reconstruction versus amputation decision making in massive lower extremity trauma. Clin Orthop Relat Res 1989;243:92–99.

MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, Sanders R, Jones AL, McAndrew MP, Patterson B, McCarthy ML, Rohde CA; LEAP Study Group. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma 2002;52:641–649.

Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower extremity trauma: Trends in the management of soft-tissue reconstruction of open tibia-fibula fractures. Plast Reconstr Surg 2006;117:1315–1322.

Pelissier P, Boireau P, Martin D, Baudet J. Bone reconstruction of the lower extremity: Complications and outcomes. Plast Reconstr Surg 2003;111:2223–2229.

Rohde C, Greives MR, Cetrulo C, Lerman OZ, Levine JP, Hazen A. Gustilo grade IIIB tibial fractures requiring microvascular free flaps: External fixation versus intramedullary rod fixation. Ann Plast Surg 2007;59:14–17.

Tomaino MM. Amputation or salvage of type 3B/3C tibial fractures: What the literature says about outcomes. Am J Orthop 2001;30:380–385.

Yaremchuk MJ, Brumback RJ, Manson PN, Burgess AR, Poka A, Weiland AJ. Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstr Surg 1987;80:1–14.

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