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LOWER EXTREMITY
RECONSTRUCTION
John R. Griffin, MD
James F. Thornton, MD
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when one compares the incidence of postfracture wounds. Tomaino17 presented a review of the
osteomyelitis after World War I (>80%) with that outcome of treatment of severe open tibial fractures.
at the end of World War II (≈25%).
BONE HEALING
CURRENT TRENDS Rhinelander,18 Holden,19 and Macnab and De
A fourth phase of lower extremity wound care Haas20 provided discussions of factors influencing
currently is underway. Advances in orthopaedic fracture healing of long bones and the cellular
and plastic surgery during the past 30 years have events that take place in the healing fracture wound.
influenced the management of open tibial fractures, The tibia is a commonly used experimental and
soft-tissue coverage, and chronic problems of the clinical model of bone healing.
lower extremity. Technical advances in bone fixation Sauer21 presented a review of the blood
and distraction, wound care, and soft-tissue healing supply of the lower extremity from the inguinal
have greatly enhanced our ability to salvage the foot, region to the thigh, knee, and leg, including fascial
leg, and thigh after trauma. The contribution of perforators, septocutaneous vessels, and major blood
vacuum-assisted devices has been notable. vessels. He emphasized the regional circulation
Nevertheless, patients who suffer severe pertinent to flap design.
polytrauma or one of the more severe classes Rhinelander18 and Macnab and De Haas20
of open lower extremity fractures might still be described tibial vascularity in detail. The three main
better served by amputation rather than attempted sources of blood supply to the tibia are the nutrient
reconstruction. The modern dilemma is no longer artery, the metaphyseal vessels, and the periosteal
how to salvage a lower extremity but knowing vessels. Originating from the posterior tibial artery,
when attempted salvage is not the best option for the nutrient artery penetrates the tibialis posterior
the patient. muscle and enters the posterior tibia at the junction
Among recent trends in lower extremity of the proximal and middle thirds. The cortical
reconstruction is a resurgence of support for groove containing the artery extends distally and
local and fasciocutaneous flaps in leg and foot obliquely, traversing the cortex for approximately
reconstruction. The pedicled flaps are touted as 5 cm. In this cortical canal, the nutrient artery is
being similar to free flaps in terms of morbidity, vulnerable to injury by even a slightly displaced
reliability, and even aesthetic results.6,7 fracture. Once in the medullary canal, the nutrient
Regarding microsurgery, many recent artery divides and gives off a network of vessels
articles focus on technical refinements of and supplying the cortex from the endosteal surface. The
indications for certain flaps in specific defects.8,9 endosteal circulation thus supplies the inner two
Perforator flaps, which are becoming more accepted thirds of the cortex, and the periosteal circulation
in breast and general reconstruction, are now also supplies the outer third (Fig. 1).22
used in the lower extremity.10−12 Striving beyond The periosteal vessels derive from the
form, contour, and optimal soft-tissue coverage, primary vessels of the limb and run perpendicular
some surgeons reported progress with sensitive free to the long axis of the bone. When a long bone is
flaps to the heel and weight-bearing foot.13,14 fractured, the nutrient vessels and the endosteal
Several recent reviews have yielded a wealth of circulation are disrupted to the point at which the
information for the new plastic surgeon and veteran metaphyseal vessels enter the bone. The periosteal
alike. French and Tornetta15 presented a review of blood supply is maintained on both sides of the
the literature on lower extremity trauma. Options fracture line by virtue of its transverse orientation
for bone fixation and soft-tissue coverage are and becomes the chief nutrient source to the
considered, and the outcomes of reconstruction healing bone in many fractures.
versus early amputation are analyzed. Heller and The essential requirements for healing of
Levin16 presented a discussion of the updated opposed fracture fragments are adequate blood
principles of management of lower extremity supply and proper stabilization.18 If stabilization is
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adequate, the source of blood supply to the fracture occurs only in areas of cortical bone contact, not
can be seen to influence the type of callus that just when bone fragments are in apposition, as
forms: medullary, periosteal, or intracortical.18 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
Figure 1. Illustrations depict the blood supply to the tibia. to form a blastema that crosses the fracture site.
Note the linear pattern of endosteal circulation (nutrient
Depending on the local concentration of growth
artery and metaphyseal artery), subject to disruption with
displaced fractures. Periosteal circulation is maintained factors, the blastema differentiates and begins
unless soft tissues are avulsed (Type III). (Reprinted with forming the missing skeletal tissues.
permission from Byrd et al.22) One of the reasons children’s bones heal
better and faster than adults’ bones might be that
children have more progenitor cells available.
Medullary bridging callus develops around Wray24 stated that the periosteum is the origin
day 4 after injury in stable, nondisplaced fractures. of the pluripotential cells that enter the fracture
Time to union is shortest, and zone of fibrocartilage site and contribute to the formation of callus. The
is minimal. The medullary or endosteal circulation delayed healing and inadequate callus that occur in
is dominant throughout all healing phases of the presence of extensive periosteal destruction in
nondisplaced fractures.18 and about the fracture support this hypothesis.
Periosteal bridging callus provides ancillary The role of the soft tissues in fracture
external support to the fracture and always contains healing is not clear. Studies by Macnab and
a significant zone of fibrocartilage. The callus first De Haas20 and by Gothman25 suggested that
appears approximately on day 3, and its initial the muscles contiguous to the fracture are the
blood comes from the surrounding soft tissues immediate source of blood to the fracture. The
and periosteum. When the endosteal circulation slow healing of certain displaced fractures might
reconstitutes, the periosteum assumes a new blood be caused by scarce muscle tissue surrounding
supply by the endosteal route. Periosteal bridging them. Holden19 tested this concept experimentally
callus is extremely important in the union of and successfully showed the importance of the
displaced and comminuted fractures. surrounding muscle in contributing vascular
Intracortical uniting callus fills the space ingrowth to the injured bony cortex. He further
between fracture fragments after reduction showed that when the soft-tissue envelope was
and fixation. Its blood supply is intraosseous, rendered ischemic, initial revascularization occurred
extraosseous, or a combination of both. Healing first in the muscle and secondarily in the skin. The
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restoration of intramedullary circulation in the timing, and appropriate dosages become more
bone occurred after the revascularization of the important. Molecular carriers, viruses, gels,
soft tissues. It was unclear whether the ischemic hyaluronidase matrixes, and creative use of gene
muscle was parasitic on the feeder vessels that therapy are all being tested for delivery of growth
would normally revascularize the bone or whether factors to healing fractures.28 Lieberman et al.28
ingrowth from the surrounding soft tissue was listed the following potential clinical uses of growth
necessary before bone revascularization could factor therapy:
occur. Either way, the author concluded that • acceleration of fracture healing (in cases at
bone revascularization essentially required well- risk of nonunion)
vascularized soft tissues around it. • treatment of established nonunions
enhancement of primary spinal fusion
Cell Signaling in Bone Healing • treatment of established pseudoarthrosis of
Mooney and Ferguson26 reported that the spine
environmental factors affect the differentiation of • treatment of large bone-loss problems
pluripotential mesenchymal cells. Their observations
hint at a “golden period” during which bone
OPEN TIBIAL FRACTURES
formation can be manipulated through physical
Demographics
measures. Stress in the form of compressive force
Patients with severe lower extremity trauma often
can be important during the first 3 weeks of fracture
share traits that can affect the management and
healing.
eventual outcome of treatment. MacKenzie et al.34
Barnes et al.27 presented a review of recent
at Johns Hopkins Hospital prospectively studied the
advances in cytokine and growth factor research and
broad demographic characteristics of 601 patients
bone healing. Lieberman et al.28 presented a review
with high-energy lower extremity trauma and noted
of the potential clinical applications of several
the following:
growth factors for improving fracture healing.
• 77% were male
Transforming growth factor beta, platelet-derived
growth factor, and insulin-derived growth factors • 72% were Caucasian
induce cellular proliferation in the laboratory, but • 71% were between the ages of 20
their clinical application has not been determined. and 45 years
Locally instilled fibroblast-derived growth factor, • 70% were high-school graduates (versus
on the other hand, significantly increased healing 86% national average)
fracture strength over controls in a primate • 38% had no health insurance (versus
fracture model.29 Fibroblast growth factor-2 in a 20% nationwide)
hyaluronidase gel accelerated fracture healing in • they were twice as likely to have a history of
nonhuman primates.28−30 alcohol abuse than the national average
Bone morphogenic protein (BMP) has Francel identified three demographic factors
35
also been shown to have clinical promise for associated with reemployment after severe lower
accelerating fracture healing.28,31,32 Sciadini and extremity injury:
Johnson33 showed that local BMP was as effective
as autogenous bone graft in achieving union in • age younger than 40 years
experimental radius defects and was significantly • history of higher education (beyond high
more effective than controls in achieving union. In school)
contrast to some of the cytokines, however, BMP • white-collar employment
might have specific dose requirements that could A large, multicenter, prospective
limit its clinical usefulness. observational study of severe lower extremity
As the promise of growth factors injuries36 identified the following patient factors as
materializes, issues related to delivery mechanisms, predictors of an eventually poor outcome:
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appropriate time might be able to return to work as was 35%. Patients who required amputation
often as patients who undergo primary amputation. experienced a significantly greater incidence of
Many studies have attempted to use three or more fascial compartments involved in
demographic data and trauma scoring systems muscular injury, two or more injured tibial vessels,
to determine prognosis. The Lower Extremity failed vascular reconstruction, and a cadaveric foot
Assessment Project (LEAP) was designed to at initial examination. No extremity was salvaged
compare outcomes of patients with severe lower when more than two of these findings were present.
extremity trauma. A large study by the LEAP group Failed reconstruction led to limb amputation in all
prospectively applied five major trauma scoring cases, even though three patients were noted to have
systems to more than 500 injured lower extremities. patent vascular repairs at the time of amputation.
The scoring systems used were as follows:46 Severe tibial nerve injury and an insensitive foot
• Mangled Extremity Severity Score generally are considered contraindications to
• Limb Salvage Index reconstruction. However, Higgins et al.49 The case
was an open tibial fracture that was salvaged with
• Predictive Salvage Index
external fixation, soft-tissue coverage, and tibial
• Nerve Injury, Ischemia, Soft Tissue Injury, nerve grafting. The patient recovered pressure
Skeletal Injury, Shock, and Age of sensation and sharp-dull sensation at 27
Patient Score months postoperatively.
• Hannover Fracture Scale-97 The primary factors influencing outcomes
Interestingly, low scores were useful in predicting for leg injuries are as follows:17,50
which limbs could be salvaged but high scores did • degree of soft-tissue damage
not predict which limbs could not be salvaged. In • presence or absence of plantar sensation
conclusion, the five trauma scoring systems studied • severity of vascular injury
do not reliably predict which injured limbs should The absolute indications for primary
undergo primary amputation.46 amputation in cases of open tibial fracture are
Another study by MacKenzie et al.47 as follows:17,50
analyzed a broad range of factors that could • anatomically complete disruption of the
influence the ultimate outcomes for severe leg posterior tibial nerve in adults
and foot injuries. Bone loss was not found to be a
• crush injuries with warm ischemia time
factor, but severe soft-tissue injury and absence of
plantar sensation at presentation were prospective
>8 hours
indicators of primary and delayed amputation. The relative indications for primary
Lange et al.43 reported a 61% amputation amputation in cases of open tibial fracture are
rate for limbs with vascular injury (22% primary, as follows:17,50
39% delayed). Crush injuries, segmental tibial • serious associated polytrauma
fractures, and fractures for which revascularization • severe ipsilateral foot trauma
was delayed more than 6 hours generally had • anticipated protracted course to
poor outcomes. obtain soft-tissue coverage and
McNutt et al.48 reviewed the cases of 366 tibial reconstruction
patients with tibial fractures occurring after blunt Bosse et al.36 compared outcomes in patients
trauma. Twelve percent of patients had clinical with severe lower extremity trauma who had
evidence of tibial artery injury; of those, 27 had undergone reconstruction versus amputation. The
angiographic evidence of at least one patent tibial cohorts were matched for severity of injury and
vessel and adequate distal flow. The other 17 patient demographics. An evaluation conducted 2
patients required operative repair of the injured years postoperatively indicated that those who had
tibial arteries because of persistent distal ischemia. undergone amputation had functional outcomes
The amputation rate in the vascular repair group that were similar to those who had undergone
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reconstruction. A similar number of patients in open tibial fractures likely is more complex than can
each group—nearly 50%—had returned to work be judged by trauma scoring systems.
at 2 years. Despite showing poor return-to-work
Another study from the Netherlands51 numbers for patients with reconstructed limbs,
showed that quality-of-life ratings were similar a study by Francel et al.45 reported that patient
between patients who had undergone amputation satisfaction after reconstruction was high: 96%
and those who had undergone reconstruction. were satisfied with their reconstructed limb.
It should be noted, however, that the studies did Dagum et al.53 noted that the vast majority of
not analyze the patients’ preferences regarding patients who underwent reconstruction preferred
reconstruction versus amputation or the patients’ their reconstructed limbs to amputation despite
levels of satisfaction with their outcomes. ongoing disability. No patient with a salvaged
The net costs of salvage versus amputation limb in that study wished they had undergone
are controversial. Hertel et al.52 analyzed social primary amputation instead. In addition, the
and employment outcomes for patients with physical outcome scores were better overall in the
severe leg injuries. They noted that the total costs reconstructed group than in the amputated group.
of care and rehabilitation are not limited to the In summary, some severe leg injuries are
hospitalization costs alone. Although the return- not amenable to reconstruction. Other injured legs
to-work rate was an amazing 100%, the number of might be amenable to reconstruction but are so
interventions was significantly lower in the group severely injured that reconstruction is not advisable.
of patients who had undergone reconstruction. Nevertheless, few patients elect to undergo primary
When the global costs of care to the community amputation when salvage is feasible, even when the
were considered in that study, the patients who had physician thinks that reconstruction is inadvisable.
undergone reconstruction proved considerably less The burden of educating the patient rests
expensive to finance than the patients who had with the physician. Functional outcomes and
undergone below-knee amputations. This is mainly return-to-work statuses improve with earlier
because patients who undergo amputation often ambulation times. Once the decision is made to
are recipients of lifelong partial pension payments. reconstruct an injured leg, all effort should be made
Unlike previous reports, the study by Hertel et to minimize complications and achieve expedient
al. found that the long period of rehabilitation bony union and stable soft-tissue coverage.
did not induce chronic invalidity. Of note, the Ambulation is a major predictor and essential
reconstruction group compared favorably with prerequisite to successful lower limb reconstruction
the amputation group in physical, social, and and return to overall function.
psychosocial parameters.
Tomaino17 summarized considerations Classification of Open Tibial Fractures
regarding management of the patient with severe The severity of open wounds associated with tibial
open tibial fractures. On the basis of his experience fractures varies widely. It was long acknowledged by
and analysis of the literature, he recommended orthopaedic and plastic surgeons that the severity of
limb reconstruction for cases with reasonable hope the soft-tissue injury correlated well with long-term
that the patient will return to ambulation within 1 limb function.54 Gustilo and Anderson55 published
year. He also emphasized that every technical and their classification of open tibial injuries in 1976.
rehabilitative effort must be made to achieve union Their grading system drew a clear link between
and ambulation as soon as possible. severity of injury and prognosis for recovery.
It is important to note that a review of the Subsequent clinical studies confirmed the
literature suggested similar functional outcomes usefulness of the Gustilo classification.55 In a series
for reconstruction and amputation, not better presented by Emerson and Grabias,56 Gustilo
functional outcomes for reconstruction. It is also type III fractures comprised 77% of injuries and
important to note that analysis of outcomes after generally required closure with skin grafts or flaps.
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Healing time for that group was protracted, and the but it is not a simple modification of the Gustilo
overall infection rate was 39%. Other complications, scheme. In the classification presented by Byrd et
such as malunion and nonunion, were also frequent. al., the type III group can be said to approximately
The authors concluded that the Gustilo type correspond to the original Gustilo type III. The
III injury segregates itself as a unique fracture Byrd type III is a severe injury with devitalized
predisposed to treatment failure. local soft tissues, but it might be amenable to local
Tscherne and Oestern57 and Oestern muscle flap coverage. Select cases of Byrd type
and Tscherne58 later developed their own widely III injuries require free flap coverage, particularly
referenced tibial injury classification system that in cases of injury to the distal third of the leg,
correlates well with clinical results. Over time, it where pedicled flaps are less reliable. Based on the
has become clear to practitioners that the Gustilo definition presented by Byrd, the type IV injury is
type III injuries are a heterogenous group. In 1984, severe enough that no opportunity exists for local
Gustilo et al.59 published a revised classification muscle transfer (Fig. 2). By definition, the Byrd type
that divided the more severe injuries into three IV injury requires free flap coverage in all cases.
subgroups. The Gustilo type IIIA group is clearly Byrd’s classification is very useful for plastic
different from the Gustilo type IIIB and IIIC surgeons in particular because it correlates well with
groups. Type IIIA fractures have stable soft tissue requirements for soft-tissue reconstruction. The
over the comminuted fractures, whereas types IIIB system is widely referenced in the plastic surgery
and IIIC require soft-tissue reconstruction (Table literature but should be combined with other
1).60 Types IIIB and IIIC have worse bony injury physical findings and possibly other classification
accompanying the soft-tissue injury. The type schemes to fully describe an open tibial injury.
IIIB fracture is defined by its need for soft-tissue The revised Gustilo system is the standard
coverage and the type IIIC by its requirement for descriptive classification used by trauma and
some form of arterial vascular repair to salvage orthopaedic surgeons, yet it has persistent
the limb. problems.60 The Gustilo type IIIB and IIIC groups
At approximately the same time the Gustilo remain heterogeneous; the severity of injuries
studies were published, a classification of open tibial within those groups varies widely. Many Gustilo
injuries by Byrd et al.61 was published. The system type IIIB injuries should undergo an attempt at
presented by Byrd et al. is similar to the original salvage, whereas others have a very poor prognosis
Gustilo classification regarding types I through III, because of large zones of injury and influencing
Table 1
Gustilo Classification of Open Fractures of the Tibia60
Type Description
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factors. The revised Gustilo system also implies comparing internal fixation and casting for the
that IIIC injuries are worse than IIIB injuries, treatment of low-energy tibial fractures have shown
which is not always the case. It makes no mention faster union times and lower incidence of malunion
of the status of the tibial nerve, which is an with internal fixation.63,64 High rates of conversion
important indicator of the quality of limb salvage.43 from casting to internal fixation because of loss of
Furthermore, the Gustilo type IIIC injury is reduction have been noted.63
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.
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
Figure 2. Classification of open tibial fractures. (Reprinted
monitored and reduction is difficult to maintain.15,62 with permission from Byrd et al.61)
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
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Another option for closed treatment is Static and Dynamic External Pin Fixation
functional bracing. It can be used with success to External fixation with pins is a safe choice for
treat some low-energy injuries but is not optimal high-energy tibial fractures. The method evolved
for high-energy injuries.15,65 from the need to adequately stabilize open fractures
associated with soft-tissue loss. Percutaneous pins
AO Plate Fixation are placed outside the area of the fracture. Bone
Olerud and Karlström66 and Olerud et al.67 devascularization is minimal because no iatrogenic
presented a review of the use of AO compression periosteal stripping is needed to place the pins,
osteosynthesis in the management of open tibial which are inserted through small incisions under
fractures. The method requires exact opposition fluoroscopic guidance. External fixation is indicated
and compression of bone by plates and screws. The when rigid fixation is required, but internal fixation
hardware must be covered with viable soft tissue. cannot be used because of severe comminution,
Motion begins early and is gradually increased. segmental bone loss, severe osteoporosis, or severe
Full weightbearing is allowed at 10 to 14 weeks soft-tissue injury.55
if evidence of radiologic union is present. The Modern pin fixation frames are smaller
theoretical advantage of AO compression for tibial and less obstructive, resulting in easier soft-tissue
fractures was thought to be primary bone healing, management.15 Overall, external fixation of Gustilo
but ultimately, plate fixation of tibial fractures has type II and III fractures yields good results.15
not been proven to be as successful as plate fixation The main disadvantages of external fixation
of fractures in other areas of the body. are complications associated with hardware.
The periosteal blood supply is very Pin tract infections are common and increase
important in healing fractures. The more disrupted in frequency with the amount of time the pins
the endosteal circulation is, the more important it is are left in place. The risk of frame loosening and
to maintain periosteal and local soft-tissue viability osteomyelitis limits the amount of time external
for fracture healing. When using plate fixation, an fixation can be used, although ideally, external
area of periosteum that corresponds to the surface fixation should be continued until union. To win
area of the plate must be stripped. Just obtaining this race against time, different modalities have
exposure for the plate can cause additional evolved to either prolong frame use or shorten time
devascularization of soft tissues that are important to union. Meticulous pin care and close vigilance to
for tibial healing, and the devascularization of detect infection early are mandatory.
bone can translate into suboptimal clinical results. Another option for decreasing time to
Some studies reported increased complication rates union is prophylactic bone grafting.71 Blick et
overall, including infection and nonunion, when al.72 analyzed the results of early prophylactic
plates were used to treat severe leg injuries.68−70 The bone grafting for high-energy tibial fractures
theory is that the plate ultimately creates stress in 53 patients. Bone grafting was performed
shielding and predisposes the bone to osteopenia. approximately 10 weeks after injury and 8 weeks
In addition, the multiple screws through the bone after soft-tissue coverage. Time to union was
weaken the cortical bone stock. Finally, the plate reduced to 12 weeks compared with 20 weeks in
itself creates stress risers on both ends of the plate, a matched control group of tibial fractures treated
predisposing the bone to re-fracture. Plate fixation with delayed bone grafting.
is reserved for specific types of tibial fractures Another option that some authors have
that are not amenable to other types of fixation. advocated is dynamization of the frame.15 With
Plate fixation of high-energy tibial shaft fractures dynamization, the frame is modified to allow some
generally is not recommended.15 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 meta-analysis78 also suggested that reamed nails
external device is replaced with an intramedullary lead to fewer secondary operations.
nail after soft-tissue coverage is stable and before
union. The technique of exchange intramedullary COMBINED SKELETAL AND
nailing can yield low infection rates and high rates SOFT-TISSUE RECONSTRUCTION:
of union.76 TIMING AND COORDINATION
The ultimate functional success of lower extremity
Intramedullary Nailing reconstruction depends on achieving union and
Primary intramedullary tibial nailing produces ambulation. The modern approach to reconstruction
high union rates and is associated with few of lower extremity injuries consists of seamless
infections when used to treat closed fractures coordination of bone and soft-tissue management.
and low-energy open fractures of the leg.77 With Appropriate débridement is indicated for
grossly contaminated open fractures, the exposed early treatment of the open tibial injury, with pulse
hardware is a risk factor for infection. For more lavage for effective wound irrigation. Débridement
severe injuries, such as Gustilo types IIIB and IIIC, and irrigation are performed soon after the patient
therefore, some variant of external fixation likely is a presents at the emergency department and are
safer choice than internal fixation. repeated until definitive soft-tissue coverage is
A recent meta-analysis of open tibial secured. Bhandari et al.84 compared the benefits of
fractures revealed that nail fixation is associated high-pressure lavage (70 lb/in2) versus low-pressure
with lower reoperation rates, lower malunion rates, pulse lavage (14 lb/in2) in an in vitro model. Both
and lower infection rates than is external fixation. methods resulted in lifting of periosteum in the
It must be noted that the data apply to all types laboratory. Both were effective at removing bacteria
of open tibial fractures, not necessarily Gustilo 3 hours after injury, but high-pressure lavage was
type III injuries as a group. It might be physically more effective 6 hours after injury. The high-
impossible to achieve stabilization with rods in pressure method, however, is powerful enough to
some of the more severe open tibial injuries.78 cause structural damage to cortical bone. The study
Rohde et al.79 retrospectively analyzed supported the argument that early débridement
complication rates associated with methods is more effective than delayed débridement at
of fixation of free flap reconstructed type IIIB removing bacteria. It did not answer the question
fractures. The study suggested that external fixation of which of the two modalities results in lower rates
might be more prudent in such cases. The set of of infection.
type IIIB fractures that underwent intramedullary Researchers and clinicians continue to
rod fixation experienced significantly higher rates of debate the optimal timing for institution of open
wound infection, osteomyelitis, and nonunion than tibial fracture treatment. Harley et al.85 reviewed
did the external fixation group. 241 open tibial fractures to determine which
A controversial issue is whether reamed factors were associated with nonunion. Prophylactic
or unreamed nails are better. Reamed nails can antibiotics had been administered in all cases. The
produce endosteal devascularization and hinder risk of nonunion was higher in injuries that were
bone union, and the smaller unreamed nails have severe based on the Gustilo classification and in
lighter screws that can break.15,80−82 Finkemeier cases of concurrent infection. Nonunion rates were
et al.83 compared unreamed and reamed nails in not affected by aggressive lavage and débridement
the treatment of closed and open tibial fractures or by delay in definitive fixation up to 13 hours after
excluding Gustilo type IIIB and IIIC injuries. The injury. After 13 hours, delay in definitive treatment
outcome of closed injuries was better with reamed began to adversely affect outcomes.
nails, and the complication rates of open injuries Many fractures with various amounts of
were similar with either technique. The above cited bone loss are treated with antibiotic-impregnated
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bead spacers during an intermediate stage. In a Other authors,61,88 although recognizing the
prospective study, Moehring et al.86 compared challenging characteristics of subacute and chronic
antibiotic beads with intravenously administered tibial wounds, have taken issue with the limitations
antibiotics and found no statistical difference in imposed by a subacute tibial fracture. Yaremchuk
infection rate between the groups; either method et al.88 reviewed a series of patients who received
alone is effective for prophylaxis. Regarding dosage flap coverage a mean of 17 days after injury and
of intravenously administered antibiotics in cases of noted an overall infection rate of 14%. A difference
open tibial fractures, once daily therapy can be in management between the series presented
as effective as traditional dosing regimens by Yaremchuk et al. and the series presented by
for prophylaxis.87 Byrd et al.61 was the more aggressive débridement
In 1970, Ger54 reviewed the management reported by Yaremchuk et al. The implication is that
of extensive soft-tissue defects over severe open aggressive débridement might be able to convert
tibial fractures, emphasizing the need for thorough a subacute open tibial fracture to an acute quality
débridement. In the 1980s, Byrd et al.61 noted wound, after which flap coverage can proceed with
that complications worsen when an open tibial relative safety.
fracture is allowed to enter a delayed (subacute) Like Byrd et al.61 and Yaremchuk et
phase of wound healing and contamination. Early al.,88 Gustilo et al.59 emphasized that it is best to
multimodality treatment was advocated to improve perform early flap coverage of severe injuries. When
outcomes. In a prospective review of open tibial definitive soft-tissue coverage was achieved within
fractures, the authors proposed radical débridement 14 days of injury, complications, costs, and the
of bone and soft tissue with flap coverage in the number of secondary procedures were decreased.
first 5 to 6 days after injury (acute phase) for the Similarly, Francel et al.45 noted a low (3.6%)
most severe injuries. The complication rate for incidence of complications in cases of Gustilo type
Byrd type III wounds averaged 18%. Fractures not IIIB injuries when definitive free flap coverage was
treated by early muscle flaps predictably entered accomplished within the first 15 days. Others have
a colonized subacute phase that extended from also shown that delay in covering the open tibial
1 to 6 weeks after injury. Complications after wound is associated with a high rate
treatment with flaps during that phase averaged of complications.89
50%. Approximately 4 to 6 weeks after untreated Godina90 retrospectively followed 532
severe injuries, a chronic phase characterized by patients after microsurgical reconstruction of their
a granulating wound, adherent soft tissue, and traumatic leg wounds. Group I (134 patients)
decreasing areas of infection was noted. The underwent free flap transfer within 72 hours of
complication rate for the chronic group after injury. Group II (167 patients) underwent flap
soft-tissue coverage was still high but decreased coverage between 72 hours and 3 months of injury.
to 40% relative to the complication rate for the Group III (231 patients) underwent flap coverage
subacute group. between 3 months and 12.6 years after injury. The
In summary, muscle flap coverage applied flap failure rates were 0.75% in Group I, 12% in
during the acute period resulted in the fewest Group II, and 9.5% in Group III. Postoperative
complications and shortest hospitalization stays. infection developed in 1.5% of Group I patients,
Flap coverage applied during the subacute and 17.5% of Group II patients, and 6% of Group III
chronic phases was associated with a number patients. Time to union was 6.8 months in Group I,
of complications, both immediate and late. As 12.3 months in Group II, and 29 months in Group
the limits of bone débridement become better III. At first glance, a reader might infer that the
demarcated during the chronic phase, reliable intermediate time frame—between 3 days and 3
bleeding margins of bone become apparent and soft months—is the worst time to reconstruct and that
tissues adhere to healthy cortex outside the fracture. definitive management should be deferred until
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after 3 months. However, the report did not support the lower extremity by “emergency” free flaps.
those assumptions. Note that Group III had the Tropet et al.95,96 advocated aggressive emergency
longest time to union and the longest hospital multimodality treatment of severe open tibial
stays, indicating that early, stable soft-tissue fractures. The authors reported 18 cases of
coverage of severe open tibial fractures improves Gustilo type IIIB injuries treated emergently
the overall outcome. with intravenously administered antibiotics,
It remains unclear whether aggressive débridement, and locked intramedullary nails.
débridement of bone during delayed treatment Six patients received free muscle coverage, and 12
of wounds affects outcome. There is little doubt received local muscle flaps. Immediate iliac crest
that liberal débridement of all fragments of bone bone grafting was performed in three patients.
in a fracture invariably lowers the infection rate. Bone union was achieved at a mean 6.5 months
The surgeon must weigh the risk of taking time to after treatment. Primary union was achieved in
observe fractured bone for viability versus allowing 13 of 18 patients (72%), all of whom were able to
a wound to enter the delayed period of wound return to work; the five remaining patients required
colonization. The risks, if any, of removing bone further intervention. The intriguing study was
that ultimately might have been viable must also neither prospective nor randomized. Further study
be considered. One point of view advocates early is warranted to establish whether this early, one-
aggressive débridement, early soft-tissue coverage, stage definitive approach improves outcomes.
and early or delayed replacement of missing bone.
The success of early soft-tissue coverage METHODS OF BONE RECONSTRUCTION
is well established. The “fix and flap” model, with TO TREAT OPEN TIBIAL FRACTURES
which flap transfer is performed simultaneously The basic ways to bridge a bone defect in the leg are
with the final débridement procedure, is bone grafting, free osseous or osteocutaneous flap
recommended by some. Advocates of the approach transfer, and distraction osteogenesis, also known as
reported improved results because of the minimal the Ilizarov technique.
time allowed for bacterial colonization. Gopal et
al.91 reported a 9% deep infection rate with the fix Bone Grafts
and flap method and a worsening infection rate For Gustilo type IIIB fractures with significant
when flap coverage was delayed by more than comminution and small bone gaps, cancellous bone
1 week. grafts beneath vascularized muscle flaps often are
According to many, early soft-tissue used. With massive bone harvests, it is possible
coverage after one to three thorough débridement to bridge defects >10 cm by using this technique.
procedures remains the standard of care for open Christian et al.97 evaluated eight patients who had
tibial fractures.71 Heller and Levin16 stated that type IIIB open tibial fractures associated with large
soft-tissue coverage applied within 7 days of injury (average, 10 cm) diaphyseal defects. The defects
produces optimal results. were filled with antibiotic-impregnated beads and
Paired with early soft-tissue coverage is covered with free flaps. The beads served as spacers
bone replacement and prophylactic bone grafting to preserve the volume of the diaphyseal defect.
of severe fractures. Some authors have advocated Approximately 3 to 6 weeks later, the tibia was
simultaneous soft-tissue reconstruction and bone reconstructed with massive amounts of autogenous
replacement, whether done emergently or simply cancellous bone grafts. The mean duration of
early.92 Many surgeons, however, prefer to graft after external fixation was 5.5 months, and time to
stable coverage has been achieved—up to 2 months healing after bone grafting averaged 9 months.
after the soft tissues have been repaired.15,71,93 Nevertheless, massive cancellous grafts usually
Arnez94 discussed the history, pros and are not the first choice of treatment for large
cons, and results of immediate reconstruction of tibial fractures.
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An intact fibula facilitates bone grafting 32 free fibular grafts, 28 (87.5%) were successful.
of longer defects by acting as a strut to keep the Failures generally resulted in amputation. Full
extremity at length. If the fibula is not intact, weight bearing did not occur until approximately 15
which often is the case with high-energy injuries, months postoperatively, corresponding to the time it
other reconstructive methods might be necessary, takes for a graft to hypertrophy.
particularly for defects >8 cm. In another study evaluating free fibular
Canovas et al.98 reported an alternative to hypertrophy in the lower extremity, El-Gammal
vascularized bone or massive cancellous grafts. In et al.105 stated that the rate of fibular hypertrophy
the case reported by the authors, the contaminated, correlates directly with youth, particularly in
devascularized tibial segment was sterilized and patients younger than 20 years. The amount of
used as a tibial autograft to fill a 12-cm defect. The fibular hypertrophy was also more robust in younger
patient reportedly achieved union at 6 months and patients. In 25 patients with tibial defects who
walked normally at 10 months. The use of autograft underwent free fibular reconstruction, the bone
that has undergone débridement and has been hypertrophy leveled out at 30 months. It is worth
frozen and subsequently boiled deserves noting that none of the tibial defects in that study
further study. were of traumatic origin, which hampers our ability
to draw meaningful comparisons with other studies.
Vascularized Bone Transfers Wood et al.106 noted the value of
Vascularized autogenous bone transfers are useful vascularized bone grafts in posttraumatic limb
in bridging long bone gaps. Most commonly salvage but acknowledged that 50% of their
transferred as vascularized bone in the repair of cases required secondary operations. Free bone
posttraumatic leg defects are the fibula, iliac crest,
transplantation in cases of severe leg trauma is
and scapula. Taylor99 detailed the vascular anatomy
technically demanding and time-consuming,
of the iliac crest and fibula. He cited examples
and probably should be performed by
of microvascular bone transfers and reviewed
experienced microsurgeons.
the sequence of lower extremity reconstruction
with vascularized bone. He was the first to report These studies have drawn attention to
using the free fibula transfer to repair tibial the prolonged time of partial weight bearing that
defects.100 Sekiguchi et al.101 described the use of patients must go through while waiting for graft
osteocutaneous free scapular flaps in the lower hypertrophy and stability. Patient compliance
extremity. Allen et al.102 reported successful transfer becomes an issue, and many find it difficult to
of latissimus dorsi-scapular bone flaps for lower wait up to 2 years before attempting unaided
extremity reconstruction in 12 patients. Lin et al.103 ambulation. Tu et al.107 reported 48 cases of long
compared the results of three different free flaps bone reconstruction with free bone flaps, most of
for posttraumatic tibial reconstruction. In their which were fibulae to tibiae. The average time to
retrospective study, 64 fibulae, 22 serratus flaps with union was 4.2 months. The series also included
rib, and 11 iliac flaps were compared. The fibulae upper extremity long bone reconstructions, and
had the best results overall, but the other two the authors documented significantly more bone
options are recommended when the fibula is hypertrophy in lower extremity grafts than in the
not available. upper extremity grafts.
Weiland et al.104 reported an early series of Full weight bearing on an incompletely
41 autogenous vascularized bone grafts used in the hypertrophied fibular interposition graft risks stress
upper and lower extremities. The average size of the fracture. In 1999, Lee and Park108 reported fractures
defects was 16 cm. The iliac crest was used when in 15 of 46 fibulae at an average 9.7 months after
the bone gap was ≤10 cm, and free fibular transfers transfer. Nevertheless, the authors recommended
were used when the gap was larger. Technical details that patients begin early weight bearing on the
of fibular harvesting are presented in the article. Of flaps or the necessary hypertrophy might not occur.
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SRPS Volume 11 Issue R1, 2009
When stress fractures are expected, they an intact fibula because pre-transfer distraction
are tolerated. lengthens the fibula sufficiently to bridge the defect.
In a follow-up study 5 years later, Lee When transferring a free fibula, it is useful
et al. reported the long-term outcomes of the
109
to know that the flap can be sustained on its distal
original 46 study patients plus five more. Overall, pedicle via retrograde flow. Therefore, when the
47 of 51 bone flaps united at 3 to 7.5 months. proximal pedicle of a free fibula is damaged, the
Two delayed unions and two nonunions occurred. flap can still be anastomosed to the distal peroneal
Pathological fracture occurred in 16 cases and artery and vein.110,113
usually healed with long-leg casting, although some Free transfer of a previously fractured
required open reduction and internal fixation and fibula has also been reported.114 As long as the
bone grafting. The authors emphasized that weight arteriogram confirms a good pedicle, this transfer is
bearing is necessary to stimulate hypertrophy in a an option for tibial reconstruction.
fibular graft and started their patients on partial
weight bearing as soon as bone union was noted Distraction Osteogenesis
radiographically. In general, patients began weight Bone gaps ≥10 cm can be bridged with the
bearing at 4 to 7 months postoperatively. Three Ilizarov technique.115−119 The procedure begins with
complete losses of the fibular skin paddle but only débridement of the fractured ends. The cortical
one complete necrosis of the bone graft occurred; bone is transected outside the zone of injury,
the other two grafts were salvaged. Adjunctive leaving the medullary bone and blood supply intact.
procedures to reestablish soft-tissue coverage, Pins are inserted near the bone ends on either side
immobilization, and bone grafts might be of the gap, and the external distraction apparatus
required in cases in which the fibular graft lacks is applied. A waiting period of approximately 7
adequate stability. days typically is allowed before distraction begins.
Toh et al.110 suggested a potential solution to Distraction consists of turning the screw(s) on the
the stress fracture problem. The authors advocated external fixation device to gradually apply tension
folding the fibular grafts to provide more stability across the corticotomy site (Fig. 3). Distraction
and bulk. That technique is possible with either usually proceeds at the rate of 1 mm per day until
pedicled or free fibular transfer and can bridge the defect is spanned.120 The circular frame usually
defects as large as 10 cm (a folded 20-cm graft). The remains in place for 1 year—the time needed for
increased bulk of the folded fibula might decrease the bone to regenerate, consolidate, and mature.
fracture rates and time to full weight bearing. Cierny et al.117 discussed advantages of
The fibula usually is transferred as a free the Ilizarov technique. First, the amount of bone
flap with or without a skin paddle. Lee and Park108 generated is anatomically correct for the size of the
and Lee et al.109 used free fibular transfers with defect. Second, soft-tissue defects can be closed
skin paddles for combined bone and soft-tissue by the docking method during the same process.
reconstruction of open tibial fractures. Still, many Finally, blood transfusions usually are not required.
large bone defects also have large skin defects The authors noted that because the process is
that can be difficult to cover with a fibular skin slow and potentially arduous for the patient,
paddle. Such cases might require additional free candidates must be chosen with care. Relative
flap(s) or alternative methods of reconstruction. contraindications are a defect >12 cm, which
It also is possible to transfer the fibula on an necessitates two lengths of regenerated bone of ≥6
ipsilateral pedicle as a vascularized bone graft cm, and deficient residual bone stock that cannot
or osteocutaneous flap. Pedicled fibular transfer support serial corticotomy procedures.
might be more useful for defects of the proximal Vasconez and Nicholls116 discussed
tibia and distal femur.110,111 Atkins et al.112 reported the benefits of and indications for the Ilizarov
ipsilateral vascularized fibular transport for tibial technique versus bone grafts or free bone transfer
reconstruction. The technique does not necessitate in the management of severe open tibial injuries.
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consideration of either Ilizarov bone transport or pedicled flaps must be verified before flap elevation
vascularized bone grafting.103,104 Bone gaps ≥12 cm and rotation, especially in the context of severe
are difficult to bridge with bone transport117 and are trauma. Other local flaps in the leg that are options
a clear indication for free or pedicled vascularized for smaller chronic or nontraumatic wounds might
bone flaps, although smaller defects might also be not be reliable for Gustilo type IIIB and IIIC
good candidates for vascularized bone. Regardless wounds and therefore are considered distant
of the length of the bone deficit, the quality of the second choices.
soft tissues can be a deciding factor between the use The soleus muscle flap generally is the first
of a free bone flap (typically contralateral fibula) or choice for midshaft tibial wounds, whereas the
bone transport beneath a vascularized muscle free gastrocnemius is better for the proximal third of
flap.126 In other words, bone defects ≥6 cm that also the leg. Either flap can cover defects up to 25 cm2.
have large soft-tissue loss might be better served by Neither is considered appropriate for the distal third
bone transport under a vascularized muscle free flap. of the leg.16 The soleus can reach the lower third of
Many Gustilo IIIB and IIIC injuries require at least the leg, but its reliability suffers.128
one free flap. The reconstructive choices for treating Reversed fasciocutaneous flaps have been
severe tibial injuries become free bone graft with suggested, but in general, they might not be
skin paddle; free bone graft plus free muscle flap; or reliable in the context of severe open leg fractures.
free muscle and bone transport. Singh and Naasan129 described a small series of
Of course, any patient who has a large tibial low velocity injuries of the lower leg that were
bone defect, with or without a large skin deficit, adequately treated with reversed sural artery flaps. A
might also be a strong candidate for primary few of the treated injuries were classified as Gustilo
amputation. The minimum size of a defect that type III.
requires vascularized bone for treatment Muscle free flaps generally are preferred
remains undetermined. for severe leg trauma because they fill dead space,
provide additional vascularity to the wound,
METHODS OF SOFT TISSUE and allow flexibility of positioning and pedicle
RECONSTRUCTION TO TREAT OPEN placement.16,130,131 The workhorse microvascular flaps
TIBIAL FRACTURES for open tibial reconstruction are the latissimus, the
In 1970, Ger54 introduced innovative techniques serratus, the rectus, and the gracilis.
for soft-tissue coverage of open tibial wounds. He May et al.130 advocated the use of
described the soleus myoplasty, flexor digitorum microvascular free tissue transfer for coverage of
longus, abductor hallucis, and gastrocnemius flaps distal lower extremity wounds with exposed bone.
for bone coverage. Although local pedicle flaps Their experience is consistent with other reports of
might be appropriate for acute type III fractures, vascularized muscle tissue used to obliterate dead
Byrd et al.61 preferred free microvascular muscle space and to donate well-perfused soft tissues to
flaps for many type III wounds. Byrd type IV the wound.
wounds by definition require free flaps for coverage. Serafin and Voci131 reviewed microsurgical
Because traumatic lower extremity wounds composite tissue transplantation to the lower
that require soft-tissue reconstruction often are extremity. Microvascular transfers can deliver both
characterized by local muscle damage, pedicled flaps soft-tissue and skeletal support to large, complex
often are not appropriate. The LEAP Study Group wounds of the leg and are particularly useful in the
reported higher short-term complication rates distal third of the leg and in the foot.
associated with traumatic leg wounds covered with Francel et al.45 reported their results
local flaps than with those covered with free flaps.127 achieved by using microvascular reconstruction
When pedicled flaps are possible, the of open tibial fractures. Long-term retrospective
gastrocnemius and soleus muscles generally are follow-up revealed successful limb salvage in 93%
first choices for the reconstruction. Viability of the of patients. Among the patients, 66% exhibited
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significantly decreased range of motion of the is shorter than that of the latissimus and serratus
ankle, 44% showed swelling and edema requiring flaps, which can limit its usefulness in a large zone
elastic support and activity modification, and 50% of injury.
occasionally needed assistance for ambulation. Wechselberger et al.138 described an
Khouri and Shaw132 reviewed 304 innovative, anatomically sound method of taking a
consecutive microvascular flap reconstructions of large, transverse skin paddle with the gracilis. Their
the lower extremity. The most common indications variant considerably extends the surface area of the
for reconstruction were Gustilo type IIIB and gracilis free flap. The free anterolateral thigh flap has
IIIC fractures. Approximately 75% of the defects also been described for reconstruction in open
were below the level of the midtibia. The latissimus tibial fractures.139
dorsi, rectus abdominis, and scapular skin flaps The Ilizarov device is sometimes used to
were used. The failure rate was 8%, compared with achieve soft-tissue distraction for wound coverage
3% for non-lower extremity cases. The magnitude of the lower extremity. The distraction frame
of the traumatic insult was the most significant stretches and compresses soft tissue while bone is
factor associated with anastomotic failure. The rate transported. Two reports present detailed creative
of anastomotic thrombosis doubled in the presence use of Ilizarov frames for soft-tissue coverage of
of vascular trauma, tripled in cases of large bony open tibial wounds.140,141 Based on the reports, it is
defects, and quintupled when vein grafts unclear whether distraction is sufficiently reliable
were needed. for delivering stable, vascularized soft tissue to open
Nieminen et al.133 presented a series tibial wounds.
of 100 patients who underwent 104 free flap Another issue is how to successfully
reconstructions for open tibial fractures. The authors coordinate bone transport through the zone
reported a 5% amputation rate. of a free flap. One report described a technical
Park et al.134 reviewed technical points of modification in which the free muscle flap can be
recipient vessel selection and anastomosis in severe partially split at the time of transfer to allow for
open injuries. They noted that antegrade vessels unimpeded pin transport.142
distal to the zone of injury are safe for receiving free Agarwal et al.143 described soft-tissue
flaps when the inflow is good. In certain cases, even problems that tend to recur in cases of simultaneous
reverse flow can be used to sustain a flap. tibial transport and soft-tissue distraction. The
Regarding donor site morbidity, Colen135 authors detailed a set of useful local flap procedures
reported 31% donor-related complications for the for dealing with soft-tissue compression and
latissimus dorsi and 20% for the rectus abdominis problems associated with moving pins. The use
muscle flaps. More recently, Musharafieh et al.136 of vacuum-assisted closure devices might be
noted 93% flap viability in 40 free rectus flaps changing treatment algorithms for lower extremity
used for lower extremity reconstruction. Donor reconstruction after trauma. Parret et al.144 reported
site morbidity was said to be negligible. Only one their retrospective review of 290 soft-tissue
patient was not ambulatory at 3.5 years. reconstructions over open tibial fractures. They
Redett et al.137 revisited the gracilis free flap. noted that optimal synchronization between the
The gracilis is an elegant flap, but its surface area is orthopaedists and the plastic surgeons results in
not large. It can be used in wounds no wider than better treatment. They also described increased
5 to 7 cm and up to 30 cm long. In their series reliance on rotational flaps, such as sural flaps, in
of gracilis flaps, 95% of the limbs were salvaged. select cases. The vacuum-assisted closure device
One patient had chronic osteomyelitis. Minor allowed the authors to temporize many acute
flap complications occurred in 12% and donor site injuries while yielding stable granulation beds. The
complications in 10%, including hematomas, a device allowed many patients to become candidates
seroma, and cellulitis. The pedicle of the gracilis flap for local flaps and skin grafts (Fig. 4).
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Table 2
Signs of Developing Compartment Syndrome162
Compartment Sign
Anterior compartment Pain on passive plantar flexion, especially of the big
toe, and foot eversion
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, far outweighs the risk of performing fasciotomies
especially in the context of trauma, is unclear. that only in hindsight are determined to have
The results of spectroscopy must be viewed in been unnecessary.
the context of clinical signs and symptoms and Hyde et al.162 described a simple fasciotomy
other test findings in the awake patient. One for bedside decompression. Nghiem and Boland
can test a soft compartment, perhaps on the 171
and DeLee and Stiehl161 questioned the value
other leg, to assess whether the equipment reads of fibulectomy-fasciotomy for decompression of
true. When evaluating pressure measurements, all four compartments when weighed against the
serial readings are the standard for making the importance of the fibula in fracture stabilization.
diagnosis of compartment syndrome.167 A normal Pearse et al.167 advocated a fibula-sparing,
pressure reading must not deter the surgeon from two-incision method for full four-compartment
performing fasciotomy when the results of a clinical decompression. One incision medial to the
examination are positive. tibia decompresses both the superficial and
deep posterior compartments and stops at the
Epidemiology posteromedial tibial border. The second
Acute compartment syndrome can result incision courses laterally through and over the
from trauma, postoperative bleeding, tendon anterior compartment and enters the lateral
graft harvesting, casting over evolving soft- compartment (Fig. 5).
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 Figure 5. Cross-section through leg shows site of
at higher risk of compartment syndrome. fasciotomy incisions to decompress all four compartments.
(Reprinted with permission from Pearse et al.167)
Management
Compartment syndrome does not need to be
proven beyond a reasonable doubt. If compartment Although the wounds left after leg
syndrome cannot be ruled out, decompression fasciotomies are clinically impressive, they tend to
through four-compartment fasciotomy is be easy to manage. Prophylactic antibiotics often are
recommended within 6 hours of symptom onset. used but are not essential in all cases. Meticulous
The risk of not performing fasciotomy local wound care is the key to successful closure.
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Techniques such as lacing with vessel loops through closure of five open knee joints. No infections
skin staples, dermatotraction, and suturing with occurred. The notion of augmenting deficient soft
pull-through monofilament dermal running sutures tissues by transposing muscle flaps seems logical
can close a wound primarily if gradual closure is and possibly analogous to the improved results
begun early during the postoperative period.172−174 achieved with early soft-tissue coverage of open
The techniques produce better cosmetic results than tibial fractures.
do split grafts over muscle. Chronically contaminated and open joints
present another problem. Soft-tissue closure alone
Outcome yields an unacceptable number of septic joints and
A chronic Volkmann-like contracture state, with or related sequelae. Per Byrd et al.,61 studies of the
without sensory loss, can result if compartments are closed plaster method presented by Trueta5 have
not released.159,161,162,164 Kikuchi et al.160 described shown that joints allowed to remain open while
the clinical features of compartment syndrome in the patient ambulates can heal without loss of
20 patients. Saphenous nerve sensation is preserved, the cartilaginous interface and without infection.
because the nerve lies outside the compartments. In When large attendant soft-tissue losses have
their study, limb function deteriorated with length occurred, however, scar contracture frequently
of ischemia. Function was good after 3 hours, fair limits function of the joint. Secondary muscle or
after 14 hours, and poor after 21 hours of ischemia, soft-tissue coverage without water seal closure
even in the context of released compartments. The and active ambulation might be beneficial in the
prognosis was especially poor when both the tibial management of contaminated open knee and ankle
and peroneal nerves were involved and in cases of joints. Options for the knee include gastrocnemius
severe venous insufficiency during the acute stage. muscles, turn-down thigh muscles, and free flaps.
The authors advised against reconstruction of the In the presence of a chronically infected and
chronically affected limb before 18 months from granulating open joint, débridement of exposed
injury to allow for maximum return of function. synovium and granulation can be considered before
That interval is additionally needed to help the muscle coverage.
clinician and the patient decide whether amputation Pu and Thomson177 presented two cases of
is preferable. irradiated, chronic open knee joint salvage with
free muscle flaps. One patient retained 35 degrees
OPEN JOINT INJURIES of extensor lag to 65 degrees of active flexion. The
Patzakis et al.175 prospectively studied 140 patients other had 15 degrees of lag and flexed to 60 degrees.
with open joint injuries. For the acute injury, they Both patients were able to ambulate.
recommended preoperative and intraoperative Cierny et al.178 reviewed their experience
cultures, broad-spectrum antibiotics until cultures with 36 refractory infections of the open ankle and
are read, copious irrigation, débridement of the joint offered a comprehensive discussion of management
and injured soft tissues, and primary closure of the and surgical techniques for treating the wounds.
wound without drains. Closed suction drains were The authors concluded that after cartilaginous
thought to be responsible for wound contamination débridement, when intact proximal and distal
in 14.3% of patients who had negative cultures cortices are present, the ideal treatment involves
before or during surgery. The most common free bone grafts placed between the tibia and the
organisms were Pseudomonas and Klebsiella. The talus. Fixators, staples, or plates external to the
authors concluded that the only indication for use graft achieve the necessary compression. The use of
of an irrigation system in open joint injuries is the medial and lateral osteocutaneous flaps for bone and
presence of extensive soft-tissue and bone damage, soft-tissue reconstruction and preservation
when closure of the joint would be advantageous. is discussed.
Barfod and Pers176 reported their experience
using immediate gastrocnemius muscle flaps for
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complements wound management after flaps of various types. External fixation was used if
débridement. stabilization was necessary.
Mathes et al.190 expanded the débridement Significant gaps in the long bones secondary
procedure described by Ger to include nonviable to débridement can be bridged with secondary
bone, scar, and chronic granulation tissue in block cancellous insert grafts. Survival of the bone
the medullary canal. Because of their superior grafts depends on a well-vascularized soft-tissue
resistance to infection over conventional flaps, free bed.195 Sudmann196 preferred surgical débridement
microvascular muscle flaps were used to obliterate and grafting with cancellous and cortical-cancellous
the dead space and to cover the exposed bone. At bone in one operation. Of 13 consecutive patients
an average follow-up duration of 1.8 years, all 11 of with osteomyelitis who were treated by that
the patients presented by Mathes et al. had achieved protocol, 12 healed after a single operation and one
resolution of the osteomyelitis. required three operations before his osteomyelitis
In a follow-up study, Anthony et al.191 was eradicated. The grafts did not form sequestra.
traced the postoperative course of 34 consecutive Among the more experimental techniques
patients with chronic osteomyelitis of the distal for managing chronic osteomyelitis is necrectomy
lower extremity. Treatment was by débridement, a and packing of the defect with antibiotic beads.197
10- to 14-day course of culture-specific antibiotics, The technique delivers antibiotics in high
and muscle flap coverage. Long-term follow-up of concentration and fills dead space. The beads are
27 patients revealed that 24 (89%) healed with no then gradually removed to slowly collapse the size
recurrence at >5 years and three (11%) experienced of the cavity.
recurrence of the osteomyelitis. Of the three Tulner et al.198 analyzed their 11-year
patients, two were cured after additional muscle experience with 47 patients who were treated for
flap procedures. posttraumatic osteomyelitis by the following a
May et al.192 reported their extensive three-step protocol:
experience with chronic osteomyelitis of the leg. 1) Wide débridement of devitalized bone and
Management was by radical débridement of bone soft tissue with implantation of antibiotic
and soft tissue and reconstruction by a second- beads and external fixation are performed as
or third-stage latissimus dorsi free flap transfer. needed. The patient begins a 3- to
Discontinuity defects were filled with cancellous 6-week course of intravenously
bone grafts after soft-tissue coverage. Excellent administered antibiotics.
results were documented.
2) Removal of the beads and insertion of
May et al.193 subsequently reviewed their 13- a spacer are performed at 10 to 14 days,
year, 96-patient experience with bone débridement with soft-tissue coverage provided by either
and microvascular free tissue transfer for soft-tissue pedicled muscle or free muscle flap.
reconstruction of chronic traumatic bone wounds.
After a mean follow-up of 77 months, 91 patients 3) Bone grafting is performed at 3 to 4 weeks
enjoyed complete wound closure and absence after the flap is applied.
of drainage. Five patients ultimately required The authors reported a 91% cure rate at a mean 7.8
amputation because of treatment failure and years and 100% eradication of infection at the
recurrent infection. final visit.
Damholt194 reported 98% cure in 55 patients Another ingenious treatment is the
treated for chronic osteomyelitis. His radical application of hyperbaric oxygen to the wound.199
operation removes all internal fixation devices At 3-atm absolute pressure, O2 diffusion into
and includes sequestrectomy, partial decortication, avascular tissue increases several-fold, which has a
and primary wound closure with suction drainage. bactericidal effect and speeds up healing. Aggressive
Thirteen patients underwent wound closure by surgical débridement might have contributed to the
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good outcome in the study presented by Morrey bed, such as atherosclerosis, diabetes, or vasculitis.
et al.199 Venous hypertension also decreases skin perfusion
Arnold et al.200 reported 90% cure of and can result in tissue ischemia or death. Host
osteomyelitis of the lower extremity 15 years after defenses are marginal in ischemic tissue, which
treatment with local muscle flaps. Musharafieh contributes to the development of
et al.201 reported high efficacy of free flaps in the subclinical infections.
treatment of chronic osteomyelitis of the leg.
Wells et al.202 and Gonzalez et al.203 noted a trend Venous Disease
toward increased risk of free flap failure in chronic Venous insufficiency affects millions of patients in
wounds associated with osteomyelitis compared the United States and is associated with varicosities
with uninfected wounds. In a study of 42 free flaps or thrombophlebitic disease. An increased column
for chronic leg wounds, Gonzalez et al.203 noted of blood from incompetent valves causes a rise in
that osteomyelitis is a strong predictor of flap hydrostatic pressure and produces chronic venous
failure and ultimate loss of limb. In the presence of insufficiency. The typical clinical signs include
osteomyelitis, the flap failure rate was 22%; when edema, hyperpigmentation, and ulcerations around
osteomyelitis was absent, the flap failure rate the legs and ankles.
was 7%. The venous system of the leg is comprised
Surgeons must beware of malignant of the superficial veins and venules, the perforating
transformation in chronic osteomyelitis that never or communicating veins, and the deep veins. Mild
seems to heal.204 Periodic biopsy and cultures are forms of venous insufficiency are associated with
warranted during long treatment courses. varicose veins. Severe forms are associated with
Faden and Grossi205 evaluated 135 children deep-system reflux about the popliteal area and leg.
who had acute osteomyelitis. The causative agent
was identified as Staphylococcus aureus, Haemophilus Pathophysiology
influenzae type B, and Pseudomonas aeruginosa Although the cause of chronic venous insufficiency
in 25%, 12%, and 6%, respectively. H. influenzae is understood, the pathophysiology of venous
occurred only in children younger than 3 years. ulceration is not clear. The major theories implicate
Currently, Haemophilus osteomyelitis is very rare pericapillary fibrin deposition or white blood
thanks to widespread vaccination against the cell plugging.
bacteria. Most pediatric cases of osteomyelitis result
from hematogenous spread of bacteria. Pericapillary Fibrin Deposition—Moosa
In the study by Faden and Grossi, all wounds et al. used transcutaneous oxygen monitoring to
207
infected with P. aeruginosa were penetrating injuries prove the existence of a local pathological barrier to
to the foot. Children with P. aeruginosa infection oxygen diffusion in patients with venous ulcers.208,209
were older than 9 years (100%), predominantly Balslev et al.,210 on the other hand, considered
male (88%), often afebrile (83%), and never fibrin deposition to be a secondary phenomenon
clinically bacteremic. occurring in already ulcerated skin.
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SRPS Volume 11 Issue R1, 2009
significantly fewer capillary loops were visible in and ulcerations. After treatment with ambulatory
90% of subjects. The authors concluded that the compression therapy, 93% of patients experienced
capillary loops become occluded with white blood complete ulcer healing in a mean 5.3 months.
cell plugs and that activation of the trapped white Among patients followed for an average of 30
blood cells produces ischemia on a vascular basis. months, 80% continued to be compliant with
stockings and 16% had ulcer recurrence. All patients
Valvular Incompetence—Valvular who were noncompliant had recurrent ulcerations
incompetence is a major factor in the development by 36 months.
of stasis, pigmentation, and ulceration. van
Bemmelen et al.213 studied the relation of Subfascial Ligation—Subfascial ligation of
ulcerations to the functional status of the superficial incompetent perforating veins is largely effective
and deep venous valves. Doppler scanning showed in inducing healing of venous ulcers. Jamieson et
valvular incompetence in 22 of 25 ulcerated limbs. al.216 reported their experience in 118 limbs with
The most commonly involved incompetent segment refractory venous stasis ulcers treated by subfascial
was the popliteal vein, and the next most common ligation. Postoperative complications were minimal.
was the superficial femoral vein. The authors reported good to excellent results in
82% of cases at a mean follow-up duration of 8
Management years, with healing of ulcers and no recurrence
The exact site of venous incompetence must despite considerable noncompliance with support
be determined preoperatively if therapy is to stockings.
be successful. McEnroe et al.214 evaluated the A modified Felder-Rob subfascial ligation217
hemodynamics of patients with chronic venous in 45 limbs with chronic venous ulcers also
insufficiency. Venous obstruction was uncommon produced good results, with only 4.4% recurrence
(5%); therefore, venous bypass surgery might be of ulceration after 2 to 8 years of follow-up.218
of little value in resolving the problem of chronic Complications of subfascial ligation include skin
venous insufficiency. Patients who had venous necrosis, exposure-induced necrosis of the Achilles
ulcerations tended to have deep venous insufficiency tendon, and equinus deformity of the ankle from
alone (72%), suggesting that deep valvular contracture of the tendon.
reconstruction might be a treatment option in
such cases. Vein Valve Transplants—Venous valve
It is estimated that 1% of people in the transplantation has been recommended to
United States will experience chronic venous stasis prevent reflux from the thigh veins and thus
ulcer at some time in their lives. Although most lower ambulatory venous pressure at the ankle.
chronic venous ulcers are secondary to alterations Nash219 presented his experience with venous valve
in the deep venous system, 28% are caused by transplantation in 23 patients; before surgery,
superficial or combination superficial and deep 17 had recurrent ulcers, six had severe pre-ulcer
venous insufficiency. skin damage, and 18 had undergone previous
unsuccessful venous operations. Duplex sonography
Compression Therapy—Compression was used for preoperative and postoperative
therapy for the management of lower extremity evaluation of the popliteal vein to detect reflux
venous ulceration dates back to Hippocrates. The and graft patency. Ambulatory venous pressures
method was later advocated by Paré in 1553. were measured directly in the dorsal foot of
The significant recurrence rate is almost always all patients before and after surgery. A 5-cm
related to failure of the patient to comply with segment of brachial vein containing a competent
long-term therapy. valve was transposed to an excised segment of
Mayberry et al.215 reviewed the course of 113 popliteal vein. Valve competence was tested before
patients with severe, chronic venous insufficiency completing the proximal anastomosis. Fifteen of
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SRPS Volume 11 Issue R1, 2009
malleoli is common among diabetic patients, for cardiovascular risk to withstand a long operation
whom more distal bypass sites should be chosen. (average operative time, 5 hours 18 minutes). At a
Arterial inflow can be restored with a mean 14 months after surgery, the limb salvage and
saphenous vein bypass graft to the distal trifurcation ambulation rate in that series was 88%. Similarly,
vessels. Andros et al.224 described lateral plantar Quiñones-Baldrich et al.229 reported a 72% limb
artery bypass grafting from the distal popliteal salvage rate in 15 patients with a mean age of 60
artery in 17 patients with gangrene of the foot. years at 36 months after combined distal leg and
The foot salvage rate at 2 months was 89%. All foot revascularization and free muscle flap coverage.
except four of 20 ulcers healed within 6 months. In a larger study, Illig et al.230 noted that
Even with a functioning bypass graft, therefore, diabetes and dialysis-dependant renal failure
local wound healing is protracted. Two patients were the strongest predictors of limb loss when
progressed to below-knee amputation, one despite existing together. Diabetes was the strongest
a patent graft. All patients who achieved successful predictor of patient death. The authors considered
revascularization were able to walk eventually, and the comorbidities to be possible contraindications
seven returned to work full-time. to combined limb revascularization and free flap
Similarly, Daane et al.225 reported a small coverage. In that study, 65% of patients recovered
series of successful distal lower extremity bypass. In good ambulation but the limb salvage rate was 57%
that series, patients underwent inframalleolar bypass 5 years postoperatively. Interestingly, age alone does
grafting with arterial grafts using the operating not seem to be a risk factor in cases of extremity
microscope. Five of six patients who underwent bypass graft and free tissue transfer surgery.
the operation enjoyed graft patency at 52 months. Like Gooden et al.,228 Moran et al.231
The technique might hold promise for patients reported a 63% limb salvage rate at 5 years in 75
with distal arterial disease who suffer from arterial patients with severe peripheral vascular disease who
ulcers and chronic pain. Another study reported underwent free flap coverage of ischemic leg and
the use of dorsal venous arch arterialization for foot wounds. The perioperative mortality rate
revascularization of distal ischemia when poor was 5%.
recipient vessels exist.226 An interesting technical twist was reported
Lepäntalo and Tukiainen227 presented a by Maloney et al.232 who used free omentum
series of combined lower extremity revascularization for upper and lower extremity reconstruction
and free flap coverage of arterial wounds. They in six patients, capitalizing on the large vessels
reported an overall limb salvage rate of 76% at and flow-through properties of the omentum to
1 year. The authors noted that in some cases, the provide distal arterial vascularization. The authors
free flap remained viable while the distal limb touted the overall robust blood supply of the flap
progressed to worsening ischemia. The study and its potential for revascularizing wound beds.
indicated the possibility of combining lower The omentum might be worthy of consideration
extremity revascularization with free flap coverage in difficult lower extremity reconstruction-
for peripheral vascular disease in select cases. revascularization cases as a dual-use free flap and
Gooden et al.228 reviewed their extensive arterial conduit to the foot. As an alternative to
experience with microvascular flaps for free flap reconstruction in such cases, Isenberg233
lower salvage. In a very difficult group of 26 reported transferring a pedicled sural flap in each of
patients—92% with exposed bone, joint, or tendon; nine patients for lower extremity revascularization
90% with diabetes; and 33% on dialysis—the and wound coverage. The results 6 months
authors performed 27 free flaps of various types. postoperatively were good.
The selection criteria included patients with large The rehabilitation rates after below-
soft-tissue defects who were ambulatory and knee amputation exceed 90% in some series.234
functioning fairly well and patients with acceptable Community-based studies note rehabilitation
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SRPS Volume 11 Issue R1, 2009
no recurrences had occurred at 14 months. Three extremity. Random pattern cutaneous flaps
patients required resection of another metatarsal and musculocutaneous flaps have more limited
head on the same foot to treat a second ulcer, applications. Free flaps are the usual cover of choice
presumably from shifting pressure points after for most lower third extremity defects.247,248 With
the first surgery. If a toe needs to be excised, a any lower extremity reconstruction, three tenets are
ray amputation should be performed to prevent essential to success, as follows:
ulceration of its metatarsal head. 1. adequate preparation, which includes
Newman et al.244 found osteomyelitis in full débridement and control of any wound
68% of diabetic foot ulcers, only half of which infection before coverage
had been clinically suspected. Osteomyelitis was 2. stabilization and management of
present in all ulcers with exposed bone, although associated orthopaedic injuries
68% had no exposed bone and 64% did not even 3. overall assessment of the patient’s
have inflammation. Among the diagnostic tests for suitability for reconstruction
osteomyelitis, the leukocyte scan had the highest and rehabilitation
sensitivity (89%) and was useful for assessing Vacuum-assisted closure is a very useful
antibiotic effectiveness. adjunct to wound management in the lower
Yuh et al.245 evaluated plain films, bone extremity, particularly after adequate débridement
scans, and magnetic resonance images of 24 and preparation of an ideal wound bed. The
diabetic patients suspected of having osteomyelitis. vacuum-assisted closure device aids in wound bed
Bone biopsies from 14 patients whose ulcers preparation and minimizes dressing changes.
did not respond to antibiotics were positive for Although a thorough understanding of local
osteomyelitis in 87%. Magnetic resonance imaging flaps is crucial for lower extremity reconstruction,
provided a correct diagnosis for all patients, plain many leg and foot wounds are not amenable to
radiography was not diagnostic until extensive bony reconstruction with local flaps. For instance, many
destruction had occurred, and bone scanning had Gustilo type III wounds are not reliably covered by
the highest false-positive rate. local muscle flaps. Regardless of the cause, large
Advocates of limb salvage with free tissue leg and foot wounds often are best covered with
transfer have reported durable results when using free flaps.
microsurgical techniques in specific patients. Lai et
al.246 reviewed limb salvage in 10 cases of infected Free Flaps
and gangrenous diabetic foot ulcers. Treatment Microvascular transfers can deliver both soft-tissue
consisted of débridement and coverage with a free and skeletal support to large complex wounds of
gracilis muscle flap and split-thickness skin graft. the leg and are particularly useful in the distal third
Flap perfusion equaled perfusion of the surrounding of the leg and foot. Serafin and Voci131 offered the
tissue at approximately 8 weeks. No recurrence following guidelines for free flap transfers in the
of ulcer or infection was noted during the lower extremity:
follow-up period.
• Anastomose the microvessels outside the
zone of injury.
SOFT-TISSUE COVERAGE OPTIONS FOR
LOWER EXTREMITY WOUNDS • Make end-to-side arterial anastomoses
The goal of soft-tissue reconstruction in the and end-to-side or end-to-end venous
lower extremity should be satisfactory wound anastomoses.
coverage with restoration of function. Ancillary • Reconstruct the soft tissues first, and then
considerations are acceptable appearance and restore skeletal support.
minimal donor site morbidity. For soft-tissue Basheer et al.249 asserted that lower
coverage alone, muscle and fasciocutaneous extremity free flap success rates can be as high as
flaps remain primary choices in the lower 98% in the modern era. Heller and Levin16 reviewed
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SRPS Volume 11 Issue R1, 2009
lower extremity microsurgical reconstruction and in leg reconstruction. The type of defect, need for
proposed a useful reconstructive ladder. Defects bulk versus thin contour, and donor site morbidity
are categorized according to the tissues needed were all considered when choosing the flap for
and the status of the vascular supply. The authors reconstruction, which in the reported series
discussed free flaps for isolated replacement of consisted of traditional free flaps and
muscle, skin, fascia, or bone and more sophisticated perforator flaps.
composite flaps, such as musculocutaneous, Yildirim et al.251 have endorsed the use
osteocutaneous, and innervated musculocutaneous of the anterolateral thigh perforator flap in lower
flaps. Preoperative considerations include evaluation extremity reconstruction. For smaller volume
of dead space, orthopaedic management of the bone defects, the gracilis is an excellent muscle flap.137
injury, and final orthopaedic disposition. It has demonstrable efficacy in the treatment of
For soft-tissue coverage alone, a relatively traumatic and non-traumatic defects. The gracilis is
small number of muscle flaps typically are used. The easy to harvest, produces little donor site morbidity,
workhorse free muscle flaps commonly used for the and adapts itself well to leg contour. Wechselberger
lower extremity are the latissimus, serratus, rectus, et al.138 described an innovative and anatomically
and gracilis. Cutaneous, fascial, and fasciocutaneous sound method of taking a larger, transverse, and
free flaps have also been described to cover lower more reliable skin paddle with the gracilis (Fig. 6).
extremity defects. For a thorough encyclopedia of The selection of appropriate recipient vessels
available free flaps, see the textbook by Mathes for free tissue transfer is critical. Relying on their
and Nahai.250 experience with 50 consecutive free flaps to the
The latissimus dorsi flap has the advantage lower extremity, Park et al.134 concluded
of a large amount of bulk to fill dead space. Despite the following:
its initial bulk, the latissimus flap will reliably • The site of injury and the vascular status of
atrophy and recontour if inset under appropriate the lower extremity are the most important
tension and managed with compression garments. factors in recipient vessel selection in lower
The atrophy aids in restoring normal contour to extremity reconstruction.
the leg. Using the single thoracodorsal pedicle,
the latissimus dorsi flap can be combined with the • The type of flap used, method, and site
serratus anterior muscle flap for coverage of massive of microvascular anastomosis are less
lower extremity defects.91 important factors in determining the
Another advantage of both the latissimus recipient vessel.
and serratus flaps is the long vascular pedicle, which • The anterior tibial artery is easier to use than
allows anastomosis well outside the zone of injury the posterior tibial artery.
in most cases. Use of vein grafts can lengthen the • Anterior donor flaps are more convenient
already generous pedicle. By placing the patient’s and are preferred for use when the anterior
upper body in a lateral decubitus position and the tibial artery is used.
lower body turned more supine, most latissimus
• An end-to-side anastomosis can be an
and serratus transfers can be performed without a
option when using the posterior tibial
patient position change.
artery; it rarely is used with the anterior
The rectus abdominis muscle flap also
tibial artery.
provides a significant volume of muscle with an
acceptable pedicle. With the patient supine, the flap • An anastomosis distal to the zone of injury
has the advantage that it rarely requires a patient is a very useful method.
position change for coverage of leg defects.136 • An angiographic or Doppler confirmation
On the basis of extensive clinical experience, should precede an anastomosis using reverse
Rainer et al.8 discussed free flap choices and flow; intraoperative confirmation of pulsatile
presented technical details for optimizing cosmesis flow is also important.
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• The cross-leg free flap should be reserved as Wettstein et al.258 retrospectively reviewed
a last resort. 197 lower extremity free flaps, analyzing the
Free tissue transfers to vessels distal to effects of comorbidities on outcomes. Although
the defect are well established for lower extremity overall complication rates were as high as 40%,
reconstruction as long as the anastomoses are no association with specific risk factors other than
performed far outside the zone of injury.252 Local patient age was shown. Elderly patients might
flaps and free tissue transfers have been described experience a mildly increased tendency toward flap
for lower extremity reconstruction in children. loss after revision.
Banic and Wulff253 used a free latissimus dorsi flap Duteille et al.259 reported 16 free flaps for
for definitive repair of lower extremity wounds in lower extremity reconstruction after trauma in
children. Stewart et al.254 described a series of large children. The study illustrated very good results in
transposition flaps and one free flap used to treat the pediatric population. The authors emphasized
children with open tibial fractures. the feasibility of microsurgical coverage in children
Performing free tissue transfer in elderly despite the small size of their vessels and the
patients with lower extremity wounds is an option. tendency for vasospasm.
Dabb and Davis255 transferred three latissimus dorsi Fisher and Wood260 illustrated an important
flaps in three elderly patients for limb salvage. The point in microvascular free flap reconstruction in
authors advocated a thorough medical workup, with compromised recipient sites. They presented a case
emphasis on cardiac and peripheral vascular risk report of complete necrosis of a latissimus free flap
factors. Although that series achieved success in a caused by blunt trauma 7 months postoperatively.
few elderly patients, it is noted that elderly patients The authors postulated that free flaps with high
with comorbidities might be better served by axial flow rates inset to poorly vascularized
primary amputation. soft-tissue beds might lack the stimulus for
Furnas et al.256 and Goldberg et al.257 neovascularization.
described their results with microsurgical tissue Salvage and options after lower extremity
transfer for lower extremity reconstruction in free flap reconstruction remain an issue, but limb
elderly patients. Furnas et al. reported 10% failures salvage after free flap failure usually is possible.
and a 30% complication rate. Goldberg et al. noted Culliford et al.261 presented a series of 585 lower
that despite medical advances, the mortality rate extremity free flaps. Eighteen percent of patients
from surgery among patients older than 70 years with failed flaps eventually required amputation, but
ranged from 8% to 10%. 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.
Thigh
In general, soft-tissue defects of the thigh require
neither pedicled nor free flap reconstruction because
Figure 6. Medial view of the thigh shows relation of the of the large amount of local muscle tissue that can
axis of the skin paddle (transverse) to the axis of the gracilis
be advanced into the wound. Skin coverage usually
muscle (longitudinal) and to the adductor longus muscle
(1), the gracilis muscle (2), the adductor magnus muscle (3), is accomplished by skin grafts on intact muscle.
and the pubic tubercle (4). (Reprinted with permission from For large contour defects of the anterior
Wechselberger et al.138) thigh or when the femoral vessels are exposed, a
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SRPS Volume 11 Issue R1, 2009
pedicled rectus flap or vertical rectus abdominis advancement is required, careful dissection and
myocutaneous flap can be used. A transverse rectus release of the muscle origin from the medial
abdominis myocutaneous flap can also be used condyle of the femur are indicated. Wide scoring of
and has been described for reconstruction of large the fascia can also facilitate long advancement.268
upper thigh defects after tumor extirpation. The The lateral head of the gastrocnemius
gracilis and the tensor fascia lata can also be rotated provides similar but more restricted coverage. Care
anteriorly to cover smaller defects when needed. In must be taken to protect the lateral sural nerve.
250
their textbook, Mathes and Nahai reviewed the The soleus muscle, based proximally, can
pedicled flap options for the thigh. If free flaps are be reliably carried to a point approximately 5 cm
required, the defect usually is so extensive that large above its tendinous insertion. The soleus muscle is
free flaps, such as the latissimus dorsi, are indicated. responsible for the venous pump phenomenon and
Willcox et al.262 reported reconstruction of is a “slow” muscle that aids in posture stabilization
quadriceps function with the use of a reinnervated and slow gait. Transfer of a single head of the
latissimus. Ihara et al.263 reported the repair of a gastrocnemius or the entire soleus muscle creates
large defect of the buttocks with a reinnervated free little if any functional deficit.
latissimus flap. The patient recovered hip abduction The tibialis anterior muscle is important
and achieved improved hip stability. in dorsiflexion of the foot and is not considered
expendable but might be raised as a bipedicled flap
Leg: Upper Third and Knee on its origin and insertion to preserve its function.
Swartz and Jones264 reviewed the principles The tibialis anterior is a Mathis type IV muscle,
of wound coverage in the lower extremity and which requires maintenance of its segmental
described options for the different territories of the vascular supply and innervation. Other limitations
leg and foot. An overview of standard flap options are its relatively small volume and short arc. The
for the leg is found in the articles by Pers and tibialis anterior is nevertheless a valuable option in
Medgyesi,265 Ger,188 and McCraw.266 small open defects along the entire tibia. Hallock269
As a rule, the upper third of the leg can describes various methods of splitting and partially
be covered with rotational muscle flaps. Special rotating the muscle to provide maximum anterior
consideration needs to be given to preserving or tibial coverage while preserving muscle function.
reconstructing the knee extensor mechanism. Patel Yoshimura et al.270 described the peroneal
et al.267 reported a novel technique for dual island flap, which allows transfer of skin from above
coverage of the knee and functional reconstruction the knee or lateral leg based either proximally
of the knee extensor mechanism with the or distally. Cutaneous perforators from the
gastrocnemius flap. peroneal system perfuse a large island of skin. The
The following muscle flaps are available for neurovascular pedicle of the flap is equivalent in
covering defects of the upper third of the tibia length to the peroneal vessel as it courses distally in
and knee:
the extremity. The authors reported no instances of
• medial head of the gastrocnemius
flap necrosis in 14 cases.
• lateral head of the gastrocnemius Fasciocutaneous flaps are another option for
• proximally based soleus coverage of defects in the proximal third of the leg.
• bipedicled tibialis anterior (lower part of The flaps are based on superficial perforating vessels
the tibia) from the deep arterial system; preoperative Doppler
The medial head of the gastrocnemius is assessment of the circulatory status of the flaps is
an excellent choice for proximal tibia and knee recommended. Although the flaps are options for
coverage. It can be reliably transferred on its the proximal third of the leg, the gold standard
proximally based neurovascular pedicle and is rotational flap for the proximal third remains the
sustained by a broad muscle belly. When a longer gastrocnemius muscle flap.
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SRPS Volume 11 Issue R1, 2009
Fix and Vasconez271 reviewed a broad range tibia, and the muscle is located lateral to the tibialis
of fasciocutaneous flaps in the lower extremity. anterior muscle. The muscle is raised, taking care to
Variants of fasciocutaneous flaps that can be used in preserve the superficial peroneal nerve during flap
the proximal third of the leg are described. dissection. Ligation of perforators must be kept to
Walton and Bunkis272 described a posterior a minimum during harvest or the muscle will not
calf fasciocutaneous flap perfused axially via a survive. The superficial peroneal nerve must not be
descending cutaneous branch of the popliteal artery. damaged in the dissection.
The flap allows pedicle or free transfer of large The extensor hallucis longus also has a
segments of fascia and skin from the posterior calf. small muscle belly that limits its usefulness. During
Walton et al.273 reported using the fascial portion of harvest, the surgeon must be careful to leave the
the posterior calf as a free flap for resurfacing the distal tendon attached to the extensor digitorum
hand and distal lower extremity. Peculiarities communis to avert great toe drop.
of the blood supply of fascial flaps are described The flexor hallucis longus muscle is larger
in the article. than the adjacent flexor digitorum communis, but
When free flaps are required around the its primary function is to “push off ” the great toe
knee, it is helpful to know that the genicular system and the muscle should not be sacrificed. The flap
can reliably provide inflow. One does not have to can be used as an adjunct to other methods of
isolate the popliteal system in all cases.274 closure in the lower middle third and upper lower
third of the tibia.
Leg: Middle Third Free tissue transfer remains a useful option
The following muscle flaps are available for coverage for the middle third of the leg, if local flaps cannot
in the middle third of the tibia: suffice. Many severe open tibial fractures that
• medial head of the gastrocnemius require substantial soft-tissue coverage are best
• lateral head of the gastrocnemius served by free flaps rather than local flaps. The local
• proximally based soleus muscle flaps that are available for the middle third
• flexor digitorum longus (for the lower of the leg, other than the soleus, are good for only
portion of the middle third) small defects. The latissimus, rectus, serratus, and
gracilis tend to be the workhorse free flaps for the
• extensor digitorum longus
middle third of the leg. In an interesting case report,
• extensor hallucis longus (for the lower Maghari et al.275 described how tissue expansion
portion of the middle third) was used to create a massive free flap for coverage of
• flexor hallucis longus muscle (for the lower a massive knee defect.
portion of the middle third) Fasciocutaneous flaps for coverage of middle
• tibialis anterior third defects271 typically are based on medial or
The flexor digitorum longus can be posterolateral septocutaneous perforators, although
transferred without significant functional loss, flaps can also be designed without an identifiable
but its spare muscle belly limits it to small defects perforating artery: In essence, these are random-
or to use in conjunction with other flaps. The pattern fasciocutaneous flaps. The length:width ratio
neurovascular pedicle usually enters the muscle can be extended to 3:1, or twice that of random
at the junction of its proximal and middle thirds, cutaneous flaps.271 Selection of one of these flaps
although that is variable. Its function in toe must be carefully weighed against the use of reliable
flexion is supplemented by the action of the flexor local muscle flaps, such as the soleus or free flaps.
digitorum brevis. Donor site morbidity is minimal.
The blood supply to the extensor digitorum Leg: Lower Third, Ankle, and Achilles Tendon
longus is via vessels from the anterior tibial artery. Distal leg and ankle wounds traditionally are
The flap is used for closure of small wounds (<5 cm covered with microvascular free flaps because of the
diameter). An incision is made 2 cm lateral to the insufficient soft tissue available for transposition at
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SRPS Volume 11 Issue R1, 2009
that level. A wide range of muscle flaps, perforator distal aspect of the flap, which might be the region
flaps, and fasciocutaneous free flaps are useful in needed to cover a wound.
the distal third of the leg. The following discussion Attinger et al.281 wrote a comprehensive
pertains to both distally based superficial flaps review of the local flap options for ankle and
and local muscle flaps. The flaps can be used when foot reconstruction. The authors emphasized the
the defect is small enough that local transposition anatomy and limitations of several useful local
flaps are sufficient for coverage or when free tissue flaps from the leg and foot (Fig. 7). Use of a delay
transfer is contraindicated. procedure is suggested before transferring some of
The flexor hallucis longus, flexor digitorum the leg muscle flaps. Most are useful for only small
longus, and tibialis anterior can be used in small- defects, but a judicious selection avoids the need for
volume closures of the distal third of the leg. free flap coverage in certain cases of foot and
The abductor hallucis pedicled muscle flap will ankle defects.
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 Figure 7. Distances of the maximal possible reach of the
al.278 and McHenry et al.279 described worthwhile muscles as measured from the tip of the medial malleolus.
technical details and clinical results from their (Reprinted with permission from Attinger et al.281)
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 A number of fasciocutaneous flaps have
the flap. Rotation of the peroneus brevis flap on its been described for coverage of the distal third of the
distal minor pedicle decreases perfusion to the most leg. They are primarily distally based, reverse-flow
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SRPS Volume 11 Issue R1, 2009
flaps perfused by septocutaneous perforators from losses in a series of 71 reverse sural island flaps.
the anterior tibial, posterior tibial, and peroneal Follmar et al.289 reported a large series of 79 sural
arteries and are best designed as rotation flaps flaps in their continuing medical education review
rather than island flaps. article that covered relevant anatomy, pitfalls, and
In the leg, the saphenous and sural flaps recommendations for use of the sural flap.
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. Figure 8. A, Design of the lateral supramalleolar flap.
Major complications were reported in 15% of The superficial peroneal nerve is transected. B, Flap
patients and minor complications in 11%. The circulation: 1, peroneal artery; 2, anterior tibial artery; 3,
incidence of complications was noted to be much septocutaneous perforators; 4, malleolar branch of the
anterior tibial artery; 5, distal tibiofibular angle. Sometimes
lower in trauma cases than in older patients with
the septocutaneous perforators and the malleolar
concomitant peripheral vascular disease. The branch of the anterior tibial artery are divided during flap
complication rate associated with distally based elevation and the island is carried on retrograde flow from
flaps was 37.5%. Wound closure was ultimately the anterior tibial artery. (Reprinted with permission from
achieved in 97% of patients. Touam et al.6)
The reverse sural neurocutaneous and lateral
supramalleolar flaps (Fig. 8) were compared in a An interesting anatomic variant of the
series by Touam et al.6 The sural flap was superior lateral supramalleolar flap was proposed by
to the lateral supramalleolar flap in reliability. A Koshima et al.,290 who suggested using rotational
failure rate of 4.8% was noted for the reverse sural perforator flaps to cover distal leg and lateral or
flap versus 18.5% for the lateral supramalleolar posterior heel wounds. The flaps can be used for
flap. Both flaps have demonstrable usefulness for small defects around the ankle without disturbing
nontraumatic wounds, such as after resection of major vessels to the foot. They are, however,
skin cancers or ulcers. The series presented by limited by their small size. The authors described
Touam included only a few traumatic wounds. cadaver studies and clinical applications of the
Costa-Ferraira et al.287 reported six partial losses perforator flaps.
in 36 sural flaps transferred. Almeida et al.288 Ayyappan and Chadha291 reported successful
reported 21% partial flap losses and 4% total flap use of the sural flap in leg reconstruction after
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trauma. The series included five sural flaps used in a small series of Achilles tendon reconstructions
to cover traumatic heel wounds. One partial flap with the composite flap. Potential donor site
necrosis occurred. The authors also pushed the problems include damage to the vastus lateralis,
size limit of the skin paddle; their largest paddle which might compromise knee extension. Neither
measured 272 cm2. the gracilis nor the latissimus muscle flap presents
Suga et al.292 stressed the importance such a risk.
of including both the sural nerve and the lesser
saphenous vein in the flap. The flap pedicle should Foot
be raised with its surrounding soft tissues, and
The simplest cover for a defect on the plantar
compression at the angle must be avoided.
surface of the foot is a thick split-thickness skin
Hollier et al.7 transferred 11 sural flaps in
graft. The split-thickness skin graft can be used
patients who were between the ages of 3 and 64
only when a substantial portion of the subcutaneous
years who had undergone reconstructive surgery for
plantar pad is intact; it is not recommended that
traumatic and postablative defects. Only one partial
split grafts be placed on granulation tissue that is
flap necrosis ensued. The technical points of flap
directly over bone. Woltering et al.302 described
elevation are described by the authors. Price et al.293
their experience with 13 patients whose skin grafts
illustrated the technique of sural flap harvest and
transfer in exquisite detail (Fig. 9). Koladi et al.294 included the heel and forefoot. The average time to
documented the safety and efficacy of the sural flap full weight-bearing without crutches was 80 days.
in children. All grafts reportedly did well, including those at the
calcaneus and first metatarsal head. Postoperative
pressure-sensitive ink pad recordings showed the
Achilles—The Achilles tendon and its
overlying soft tissue deserve specific attention. If patients’ gait patterns had changed to enhance
the soft-tissue loss is moderate, grafts of tendon graft protection.
or fascia can be combined with local flaps for Sommerlad and McGrouther303 compared
reconstruction.295,296 If the Achilles loss is subtotal techniques for coverage of the sole of the foot in
or complete but short, forearm tendon grafts can be 51 patients. Ink pad recordings showed altered gait
used. Flexor hallucis longus grafts have been used patterns regardless of the type of reconstruction
to treat chronic tendinopathy297 and perhaps could chosen, always favoring the reconstructed site. Skin
be used to treat traumatic defects. In complete or grafts in this comparative series fared well, although
large Achilles tendon defects, free tissue transfer hyperkeratosis was noted. Attinger et al.281 reviewed
probably is the best option for reconstruction. The local flap options in defects of the foot.
goals of surgery are to restore function, smooth May et al.304 and May and Rohrich305
contour, and cover the wound with stable soft tissue. described the use of a free latissimus dorsi muscle
A denervated gracilis free flap with skin graft has flap with thick split-thickness skin graft to treat
been successfully used to accomplish the goals.298 chronic defects of the foot. Three operative groups
The latissimus dorsi muscle has been used in the were identified, as follows:
same way, with very good functional results.299 The • Group I patients had flaps placed at or
denervated muscle atrophies and becomes fibrotic, below the level of the malleolus and were
eventually providing the rigidity needed for Achilles not weight bearing on flap tissues.
function. Over time, the contour of the muscle flaps
improves to the point that no secondary debulking • Group II patients were weight bearing on
procedures are needed. flap tissues but not directly on the skin graft
Various authors reported successful covering the transferred muscle.
Achilles tendon reconstruction with a composite • Group III patients were weight bearing
anterolateral thigh-fascia lata flap.300,301 Kuo et al.301 directly on the skin graft covering the
achieved excellent functional and aesthetic results transferred muscle.
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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)
Gait analysis in the series presented by May et al. patients, the free fasciocutaneous flaps were able
indicated that the amount of time spent on the to sustain high loading pressure. The patients did
resurfaced foot when walking was approximately have altered gait patterns that decreased shearing
the same as that spent on the normal foot. All at the reconstructed heels in the anteroposterior
patients experienced some deep pressure sensation dimension. Ultimately, patients who undergo
in the involved areas. Light touch sensation at the heel coverage with anything other than plantar
graft was absent. Of significance was the presence of skin must always be aware of the possibility
shear planes between the skin graft and the muscle of breakdown.
and between the muscle and the underlying bone. Hong and Kim307 drew a possibly
The shear planes could play a protective role in the clinically significant distinction between standard
long-term durability of the graft. Nevertheless, two anterolateral thigh fasciocutaneous free flaps and
patients experienced delayed skin-graft breakdown thinner anterolateral thigh perforator flaps when
in their usual footwear. used for plantar foot reconstruction. They reported
The debate continues whether distant a series of 69 patients who underwent plantar
and free fasciocutaneous flaps have loading and reconstruction with anterolateral thigh perforator
shearing characteristics that are as favorable as flaps. They documented good success overall. The
free muscle with skin grafts. Karakostas et al.306 authors concluded that the anterolateral thigh
studied six patients who had undergone unilateral perforator flap might be more ideal for the plantar
heel fasciocutaneous free flap reconstructions. The foot because of its thinner contour and potentially
patients were well into their long-term recovery and better shear plane characteristics. Further study
had been walking on their flaps. The contralateral comparing standard anterolateral thigh flaps and
normal heels, with intact glabrous skin, served perforator anterolateral thigh flaps at the sole are
as controls. The study revealed that in these six needed (Figs. 10 and 11).
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SRPS Volume 11 Issue R1, 2009
Heel
Reiffel 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
Figure 10. Clinical photographs of a 36-year-old patient flexor brevis muscle. The flexor digitorum brevis,
with chronic diabetic ulceration of the left third metatarsal with or without its overlying instep skin, seems to
region. Left, Depth of ulceration extended to the bone, be a reasonable alternative for heel defects because
and a large dead space was noted beneath the skin. Right,
it can be transferred without detaching the lateral
Resurfaced foot at 11 months after surgery. No signs of
recurrence are present. (Reprinted with permission from plantar artery calcaneal branch from the posterior
Hong and Kim.307) 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 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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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 had the best overall results. Nerves that had been
technique for resurfacing defects in the weight- transected and were discontinuous required direct
bearing aspect of the forefoot makes use of tissues microsurgical repair or nerve grafts. The functional
obtained in the toe fillet flap. The donor defect is return was better after direct repair than when the
not missed unless the fillet is taken from the great nerve was grafted.
toe. The skin is well vascularized, and innervation is Mackinnon et al.327 presented a report
maintained. Snyder and Edgerton319 discussed the of seven patients who underwent nerve allograft
anatomy and surgical principles of toe filleting, and repair of major peripheral nerve gaps in the
Buncke and Colen320 described use of the great toe lower and upper extremities. All patients received
fillet for defects of the forefoot. immunosuppression for up to 6 months after nerve
Dutch et al.321 reported the use of pedicled regeneration was detected. The nerve graft was
common digital and proper digital artery flaps rejected in one patient, but the other six experienced
for forefoot reconstruction. A 13% flap loss rate some return of motor function. The study illustrated
was noted, and 73% of patients had minor the possible future of secondary reconstruction of
wound complications. large peripheral nerves in the extremities.
Butler and Chevray322 described an Several recent studies addressed the
ingenious modification of the medial plantar artery/ coverage of plantar traumatic defects with sensory
instep flap that bases the flap distally, with the free flaps.328 Kim et al.329 reported a single case of
arterial supply derived from metatarsal perforating heel reconstruction with an innervated free flap
branches. The authors reported successful forefoot obtained from the contralateral posterior tibial
reconstruction with this method in two patients. system. Santanelli et al.14 reviewed their experience
No arterial inflow problems were reported, although with plantar reconstruction, which consisted of
one flap required venous supercharging. The seven reinnervated and seven traditional radial
illustrated clinical results were good. The flap has forearm flaps. Regardless of nerve coaptation at
also been successfully used by Takahashi et al.323 the time of flap transfer, all 14 patients achieved
When planning the design of local foot flaps good, stable plantar cover. In the long term, both
for lower extremity coverage, two points must be reinnervated and non-reinnervated flaps provided
remembered: 1) when possible, the incisions should adequate protective sensation.
not be placed on weight-bearing surfaces, and 2) the Kuran et al.13 reviewed their results of
amount of tissue available after transfer often is less lower extremity reconstruction with 12 flaps. The
than anticipated. Wound breakdown can ruin an defects varied in size and complexity. The larger
otherwise successful foot reconstruction with defects were covered with insensitive free flaps out
local flaps. of necessity, and the smaller defects were repaired
Free muscle flaps and fascial flaps with skin with sensory free flaps. Patients who received
grafts are a consideration when bony surfaces have sensory flaps experienced earlier return of pressure
no overlying subcutaneous pad and local cutaneous sensation, but over the long term, the functional
cover is not available. Musharafieh et al.324 described results between the two groups were similar.
a series of 10 free radial forearm flaps used
successfully in foot and ankle reconstruction. All Reconstruction and Orthopaedic Oncology
patients must be monitored long-term for recurrent The use of vascularized free bone flaps has afforded
ulceration, especially when non-plantar tissue is new options for patients with long-bone sarcomas.
used to cover a plantar defect. Despite the potential for more complications,
patients who undergo reconstruction of long-bone
Restoration of Sensation in the Foot defects after sarcoma resection show better function
Matejcik et al.325,326 reported the results of lower than do those who undergo amputation.330,331
extremity reconstruction after major nerve injury. El-Gammel et al.105 reported good results
As one would expect, blunt injuries with neurolysis with single-barrel free fibular reconstructions after
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tumor resections in the leg. They emphasized that in small defects. Mastorakos et al.336 emphasized
full weight-bearing must wait until sufficient graft that union is improved and infection rates are
hypertrophy has occurred. The risk of pathological lower when the allograft is covered by pedicled
fracture of the single-barrel, isolated fibula or free muscle flaps. Unlike bone replacement,
always exists.109,332 early soft-tissue reconstruction is safe after
Zaretski et al.333 reported the results of 15 sarcoma extirpation, and pedicled flaps, free
thigh and eight leg reconstructions after sarcoma flaps, and skin grafts tolerate radiation therapy
resection in adults and children. A free fibular reasonably well. Spierer et al.337 noted that only
graft was used in all cases. Union was achieved in 5% of reconstructions in their series developed
all except one patient; another patient was lost to wound complications. Incidentally, more wound
follow-up, and his status could not be determined. complications occurred after brachytherapy than
The average time to union was 4.8 months; the after external beam radiation.
average time to full weight bearing was 9.2 months.
Three infections occurred at the recipient site. The
Cross-Leg Flap
authors recommended one of three variants of the
free fibular procedure according to the Before the widespread use of free-tissue transfer,
weight-bearing needs of the recipient tissue, the cross-leg flap was the procedure of choice for
as follows: typical wounds of the leg when local pedicled flaps
• High-stress areas, such as the femur and were unavailable.338 Today the indications for cross-
proximal tibia in adults, are indications for leg flaps are limited. Patients who are not free flap
free fibula transfer surrounded by generous candidates and patients who remain immobilized
amounts of cancellous graft. The potential for other reasons occasionally are cross-leg flap
advantages of this technique, which was candidates. Dawson339 analyzed the complications
originally described by Capanna et al.,334 encountered in 99 cross-leg flap procedures and
are that ample bone stock is immediately reported local flap necrosis in 40% and infection
available for remodeling and weight in 28%.
tolerance will not depend on hypertrophy of As suggested by Barclay et al.,340 the design
the fibula. of the cross-leg flap has been changed to include
• Intermediate load-bearing areas are the deep fascia of the leg. At present, cross-leg flaps
reconstructed with double-barreled fibulae. are transferred as fasciocutaneous tissue units with a
• Light-load areas, such as partial-thickness length:width ratio of 3:1 or 4:1.235,341,342
defects of the tibia in adults and Cross-leg pedicled flaps and cross-leg free
full-thickness tibial defects in young flaps have been described for extremity salvage
children, are indications for reconstruction in cases in which the existing vascular inflow of
with single-barrel free fibular transfer. the affected extremity is of poor quality, often
When significant joint excision is required, from severe trauma or tissue loss.343,344 Still, the
endoprostheses are used with or without evaluating surgeon must realize that an open leg or
vascularized fibula.109,335 foot wound with recipient vessels not suitable for
Algorithms for timing of the reconstruction free flap transfer might indicate an injury so bad
and choice of reconstructive method are presented that limb salvage is not advisable.
in Figure 14. Definitive bony reconstruction is Long et al.338 reported the use of current
delayed in cases that require prolonged courses external fixation technology for cross-leg
of adjuvant radiotherapy, such as cases of fasciocutaneous flaps. All flaps were based on the
Ewing sarcoma. axial blood supply of the posterior descending
Allograft alone can be used for bone subfascial cutaneous branch of the popliteal artery.
reconstruction after tumor ablation that results 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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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)
Kane et al.354 prospectively compared core femoral head should be weighed against the
decompression with free fibular transfer in stage II good results that can be achieved with total
and III femoral head AVN. Core decompression hip arthroplasty.
failed to prevent total hip arthroplasty in 58% of REPLANTATION
patients. The patients treated with free fibular grafts
Although various reports of successful replantation
went on to undergo arthroplasty 20% of the time. In
another study comparing free fibular transfer with of lower extremities can be found in the literature,
core decompression, Scully et al.355 also showed large patient series do not exist to help determine
better results with free fibular transfer for stage II clear indications for replantation. Judicious selection
and III disease. of individual candidates is a must. Certainly, no
Dean et al.356 reviewed a large series of other tissue in the body can perfectly replace the
pediatric patients with femoral head AVN and specialized, weight-bearing skin and subcutaneous
noted that children treated with free fibular transfer tissues of the heel pad and plantar skin. For lower
do better than their adult counterparts. However, extremity replantation to truly be a success, some
any long-term result of revascularization of the return of protective sensation must be present in
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19. Holden CE. The role of blood supply to soft tissue in 35. Francel TJ. Improving reemployment rates after limb
the healing of diaphyseal fractures. J Bone Joint Surg Am salvage of acute severe tibial fractures by microvascular
1972;54:993–1000. soft-tissue reconstruction. Plast Reconstr Surg 1994;93:1028–
20. Macnab I, De Haas WG. The role of periosteal blood 1034.
supply in the healing of fractures of the tibia. Clin Orthop 36. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb
Relat Res 1974;105:27–33. LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew
21. Sauer PF. Blood supply of the lower extremity. Clin Plast MP, Patterson BM, McCarthy ML, Travison TG, Castillo RC. An
Surg 1991;18:553–557. analysis of outcomes of reconstruction or amputation after
leg-threatening injuries. N Engl J Med 2002;347:1924–1931.
22. Byrd HS, Cierny G III, Tebbetts JB. The management of
open tibial fractures with associated soft-tissue loss: External 37. Schmitz MA, Finnegan M, Natarajan R, Champine J.
pin fixation with early flap coverage. Plast Reconstr Surg Effect of smoking on tibial shaft fracture healing. Clin Orthop
1981;68:73−82. Relat Res 1999;365:184–200.
23. Caplan AI. The mesengenic process. Clin Plast Surg 38. Adams CI, Keating JF, Court-Brown CM. Cigarette
1994;21:429–435. smoking and open tibial fractures. Injury 2001;32:61–65.
24. Wray JB. Treatment of ununited fractures of the long 39. Bondurant FJ, Cotler HB, Buckle R, Miller-Crotchett P,
bones: Factors in the pathogenesis of non-union. J Bone Browner BD. The medical and economic impact of severely
Joint Surg Am 1965;47:168–173. injured lower extremities. J Trauma 1988;28:1270–1273.
25. Gothman L. Arterial changes in experimental fractures 40. Pelissier P, Boireau P, Martin D, Baudet J. Bone
in the rabbit’s tibia treated with intramedullary nailing: A reconstruction of the lower extremity: Complications and
microangiographic study. Acta Chir Scand 1960;120:289–302. outcomes. Plast Reconstr Surg 2003;111:2223–2229.
26. Mooney V, Ferguson AB Jr. The influence of 41. Keller CS. The principles of the treatment of tibial shaft
immobilization and motion on the formation of fractures: A review of 10,145 cases from the literature.
fibrocartilage in the repair granuloma after joint resection in Orthopedics 1983;6:993–106.
the rabbit. J Bone Joint Surg Am 1966;48:1145–1155.
42. Russell WL, Sailors DM, Whittle TB, Fisher DF Jr, Burns RP.
27. Barnes GL, Kostenuik PJ, Gerstenfeld LC, Einhorn TA. Limb salvage versus traumatic amputation: A decision based
Growth factor regulation of fracture repair. J Bone Miner Res on a seven-part predictive index. Ann Surg 1991;213:473–
1999;14:1805–1815. 480.
28. Lieberman JR, Daluiski A, Einhorn TA. The role of 43. Lange RH, Bach AW, Hansen ST Jr, Johansen KH. Open
growth factors in the repair of bone: Biology and clinical tibial fractures with associated vascular injuries: Prognosis
applications. J Bone Joint Surg Am 2002;84–A:1032–1044. for limb salvage. J Trauma 1985;25:203–208.
29. Radomsky ML, Thompson AY, Spiro RC, Poser JW.
44. Hansen ST Jr. The type-IIIC tibial fracture: Salvage or
Potential role of fibroblast growth factor in enhancement of
amputation. J Bone Joint Surg Am 1987;69:799–800.
fracture healing. Clin Orthop Relat Res 1998;355[suppl]:S283–
S293. 45. Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN,
30. Radomsky ML, Aufdemorte TB, Swain LD, Fox WC, Yaremchuk MJ. Microvascular soft-tissue transplantation
Spiro RC, Poser JW. Novel formulation of fibroblast growth for reconstruction of acute open tibial fractures: Timing of
factor-2 in a hyaluronan gel accelerates fracture healing in coverage and long-term functional results. Plast Reconstr
nonhuman primates. J Orthop Res 1999;17:607–614. Surg 1992;89:478–487.
31. Gerhart TN, Kirker-Head CA, Kriz MJ, Holtrop ME, 46. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb
Hennig GE, Hipp J, Schelling SH, Wang E. Healing segmental LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew
femoral defects in sheep using recombinant human bone MP, Patterson BM, McCarthy ML, Cyril JK. A prospective
morphogenetic protein. Clin Orthop Relat Res 1993;293:317– evaluation of the clinical utility of the lower-extremity
326. injury-severity scores. J Bone Joint Surg Am 2001;83:3–14.
32. Bostrom MP, Camacho NP. Potential role of bone 47. MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb
morphogenetic proteins in fracture healing. Clin Orthop LX, Swiontkowski MF, Sanders R, Jones AL, McAndrew MP,
Relat Res 1998;355[suppl]:S274–S282. Patterson B, McCarthy ML, Rohde CA; LEAP Study Group.
Factors influencing the decision to amputate or reconstruct
33. Sciadini MF, Johnson KD. Evaluation of recombinant
after high-energy lower extremity trauma. J Trauma
human bone morphogenetic protein-2 as a bone-graft
2002;52:641–649.
substitute in a canine segmental defect model. J Orthop Res
2000;18:289–302. 48. McNutt R, Seabrook GR, Schmitt DD, Aprahamian C,
34. MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb Bandyk DF, Towne JB. Blunt tibial artery trauma: Predicting
LX, Swiontkowski MF, Sanders RW, Jones AL, McAndrew MP, the irretrievable extremity. J Trauma 1989;29:1624–1627.
Patterson TM, McCarthy ML. Characterization of patients 49. Higgins TF, DeLuca PA, Ariyan S. Salvage of open tibial
with high-energy lower extremity trauma. J Orthop Trauma fracture with segmental loss of tibial nerve: Case report and
2000;14:455–466. review of the literature. J Orthop Trauma 1999;13:380–385.
48
SRPS Volume 11 Issue R1, 2009
50. Lange RH. Limb reconstruction versus amputation 66. Olerud S, Karlström G. Tibial fractures treated by AO
decision making in massive lower extremity trauma. Clin compression osteosynthesis: Experiences from a five year
Orthop Relat Res 1989;243:92–99. material. Acta Orthop Scand Suppl 1972;140:1–104.
51. Hoogendoorn JM, van der Werken C. Grade III open 67. Olerud S, Karlström G, Danckwardt-Lillieström G.
tibial fractures: Functional outcome and quality of life in Treatment of open fractures of the tibia and ankle. Clin
amputees versus patients with successful reconstruction. Orthop Relat Res 1978;136:212–224.
Injury 2001;32:329–334. 68. Bach AW, Hansen ST Jr. Plates versus external fixation
52. Hertel R, Strebel N, Ganz R. Amputation versus in severe open tibial shaft fractures: A randomized trial. Clin
reconstruction in traumatic defects of the leg: Outcome and Orthop Relat Res 1989;241:89–94.
costs. J Orthop Trauma 1996;10:223–229. 69. Johner R, Wruhs O. Classification of tibial shaft fractures
53. Dagum AB, Best AK, Schemitsch EH, Mahoney JL, and correlation with results after rigid internal fixation. Clin
Mahomed MN, Blight KR. Salvage after severe lower- Orthop Relat Res 1983;178:7–25.
extremity trauma: Are the outcomes worth the means? Plast 70. Rüedi T, Webb JK, Allgöwer M. Experience with the
Reconstr Surg 1999;103:1212–1220. dynamic compression plate (DCP) in 418 recent fractures of
54. Ger R. The management of open fracture of the tibia the tibial shaft. Injury 1976;7:252–257.
with skin loss. J Trauma 1970;10:112–121. 71. Trabulsy PP, Kerley SM, Hoffman WY. A prospective
55. Gustilo RB, Anderson JT. Prevention of infection in the study of early soft tissue coverage of grade IIIB tibial
treatment of one thousand and twenty-five open fractures fractures. J Trauma 1994;36:661–668.
of long bones: Retrospective and prospective analyses. J 72. Blick SS, Brumback RJ, Lakatos R, Poka A, Burgess AR.
Bone Joint Surg Am 1976;58:453–458. Early prophylactic bone grafting of high-energy tibial
fractures. Clin Orthop Relat Res 1989;240:21–41.
56. Emerson RH Jr, Grabias SL. A retrospective analysis
of severe diaphyseal tibial fractures treated with external 73. Kenwright J, Goodship AE. Controlled mechanical
fixation. Orthopedics 1983;6:43–49. stimulation in the treatment of tibial fractures. Clin Orthop
Relat Res 1989;241:36–47.
57. Tscherne H, Oestern HJ. A new classification of soft-
tissue damage in open and closed fractures [in German]. 74. Marsh JL, Nepola JV, Wuest TK, Osteen D, Cox K,
Unfallheilkunde 1982;85:111–115. Oppenheim W. Unilateral external fixation until healing with
the dynamic axial fixator for severe open tibial fractures. J
58. Oestern HJ, Tscherne H. Pathophysiology and Orthop Trauma 1991;5:341–348.
classification of soft tissue injuries associated with fractures.
In, Tscherne H, Gotzen L (ed): Fractures with Soft Tissue 75. Kenwright J, Richardson JB, Cunningham JL, White SH,
Injuries. Berlin: Springer Verlag; 1984:1–9. Goodship AE, Adams MA, Magnussen PA, Newman JH. Axial
movement and tibia fractures: A controlled randomised trial
59. Gustilo RB, Mendoza RM, Williams DN. Problems of treatment. J Bone Joint Surg Br 1991;73:654–659.
in the management of type III (severe) open fractures:
76. Henry SL. Secondary intramedullary nailing of complex
A new classification of type III open fractures. J Trauma
open tibia fractures after external fixation: A new protocol.
1984;24:742–746.
Am J Orthop 1999;28[suppl 1]:17–22.
60. Kasabian AK, Karp NS. Lower extremity reconstruction. 77. Bone LB, Johnson KD. Treatment of tibial fractures by
In, Aston SJ, Beasley RW, Thorne CH (ed): Grabb and Smith’s reaming and intramedullary nailing. J Bone Joint Surg Am
Plastic Surgery. 5th ed. Philadelphia: Lippincott-Raven; 1986;68:877–887.
1997:1031–1047.
78. Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch
61. Byrd HS, Spicer TE, Cierney G III. Management of open EH. Treatment of open fractures of the shaft of the tibia. J
tibial fractures. Plast Reconstr Surg 1985;76:719–730. Bone Joint Surg Br 2001;83:62–68.
62. Edwards P. The effect of crush injury to the skin on 79. Rohde C, Greives MR, Cetrulo C, Lerman OZ, Levine
healing of fracture of the shaft of the tibia in dogs. Acta JP, Hazen A. Gustilo grade IIIB tibial fractures requiring
Orthop Scand 1965;36:89–94. microvascular free flaps: External fixation versus
63. Hooper GJ, Keddell RG, Penny ID. Conservative intramedullary rod fixation. Ann Plast Surg 2007;59:14–17.
management or closed nailing for tibial shaft fractures: 80. Schemitsch EH, Kowalski MJ, Swiontkowski MF, Senft D.
A randomised prospective trial. J Bone Joint Surg Br Cortical bone blood flow in reamed and unreamed locked
1991;73:83–85. intramedullary nailing: A fractured tibia model in sheep. J
64. Puno RM, Teynor JT, Nagaro J, Gustilo RB. Critical Orthop Trauma 1994;8:373–382.
analysis of results of treatment in 201 tibial shaft fractures. 81. Bhandari M, Guyatt GH, Tong D, Adili A, Shaughnessy
Clin Orthop Relat Res 1986;212:113–121. SG. Reamed versus nonreamed intramedullary nailing of
65. Sarmiento A, Gersten LM, Sobol PA, Shankwiler JA, lower extremity long bone fractures: A systematic overview
Vangsness CT. Tibial shaft fractures treated with functional and meta–analysis. J Orthop Trauma 2000;14:2–9.
braces: Experience with 780 fractures. J Bone Joint Surg Br 82. Keating JF, O’Brien PJ, Blachut PA, Meek RN, Broekhuyse
1989;71:602–609. HM. Locking intramedullary nailing with and without
49
SRPS Volume 11 Issue R1, 2009
reaming for open fractures of the tibial shaft: A prospective 98. Canovas F, Bonnel F, Faure P. Extensive bone loss in
randomized study. J Bone Joint Surg Am 1997;79:334–341. an open tibial shaft fracture (immediate bone boiling
83. Finkemeier CG, Schmidt AH, Kyle RF, Templeman reimplantation). Injury 1999;30:709–710.
DC, Varecka TF. A prospective randomized study of 99. Taylor GI. The current status of free vascularized bone
intramedullary nails inserted with and without reaming grafts. Clin Plast Surg 1983;10:185–209.
for the treatment of open and closed fractures of the tibial
100. Taylor GI, Miller GD, Ham FJ. The free vascularized bone
shaft. J Orthop Trauma 2000;14:187–193.
graft: A clinical extension of microvascular techniques. Plast
84. Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Reconstr Surg 1975;55:533–544.
Shaughnessy SG. High and low pressure pulsatile lavage
of contaminated tibial fractures: An in vitro study of 101. Sekiguchi J, Kobayashi S, Ohmori K. Use of the
bacterial adherence and bone damage. J Orthop Trauma osteocutaneous free scapular flap on the lower extremities.
1999;13:526–533. Plast Reconstr Surg 1993;91:103–112.
85. Harley BJ, Beaupre LA, Jones CA, Dulai SK, Weber DW. 102. Allen RJ, Dupin CL, Dreschnack PA, Glass CA, Mahon–
The effect of time to definitive treatment on the rate of Deri B. The latissimus dorsi/scapular bone flap (the
nonunion and infection in open fractures. J Orthop Trauma “latissimus/bone flap”). Plast Reconstr Surg 1994;94:988–996.
2002;16:484–490. 103. Lin CH, Wei FC, Chen HC, Chuang DC. Outcome
86. Moehring HD, Gravel C, Chapman MW, Olson SA. comparison in traumatic lower-extremity reconstruction by
Comparison of antibiotic beads and intravenous antibiotics using various composite vascularized bone transplantation.
in open fractures. Clin Orthop Relat Res 2000;372:254–261. Plast Reconstr Surg 1999;104:984–992.
87. Russell GV Jr, King C, May CG, Pearsall AW IV. Once daily 104. Weiland AJ, Moore JR, Daniel RK. Vascularized bone
high-dose gentamicin to prevent infection in open fractures autografts: Experience with 41 cases. Clin Orthop Relat Res
of the tibial shaft: A preliminary investigation. South Med J 1983;174:87–95.
2001;94:1185–1191. 105. El-Gammal TA, El-Sayed A, Kotb MM. Hypertrophy
88. Yaremchuk MJ, Brumback RJ, Manson PN, Burgess AR, after free vascularized fibular transfer to the lower limb.
Poka A, Weiland AJ. Acute and definitive management of Microsurgery 2002;22:367–370.
traumatic osteocutaneous defects of the lower extremity.
106. Wood MB, Cooney WP, Irons GB. Post-traumatic lower
Plast Reconstr Surg 1987;80:1–14.
extremity reconstruction by vascularized bone graft transfer.
89. Caudle RJ, Stern PJ. Severe open fractures of the tibia. J Orthopedics 1984;7:255–262.
Bone Joint Surg Am 1987;69:801–807.
107. Tu YK, Yen CY, Yeh WL, Wang IC, Wang KC, Ueng WN.
90. Godina M. Early microsurgical reconstruction of Reconstruction of posttraumatic long bone defect with free
complex trauma of the extremities. Plast Reconstr Surg vascularized bone graft: Good outcome in 48 patients with 6
1986;78:285–292. years’ follow-up. Acta Orthop Scand 2001;72:359–364.
91. Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer 108. Lee KS, Park JW. Free vascularized osteocutaneous
P, Smith RM. Fix and flap: The radical orthopaedic and plastic fibular graft to the tibia. Microsurgery 1999;19:141–147.
treatment of severe open fractures of the tibia. J Bone Joint
Surg Br 2000;82:959–966. 109. Lee KS, Han SB, Baek Jr. Free vascularized
osteocutaneous fibular graft to the tibia in 51 consecutive
92. Musharrafieh R, Osmani O, Saghieh S, Elhassan B,
cases. J Reconstr Microsurg 2004;20:277–284.
Atiyeh B. Microvascular composite tissue transfer for the
management of type IIIB and IIIC fractures of the distal 110. Toh S, Tsubo K, Nishikawa S, Narita S, Kanno H,
leg and compound foot fractures. J Reconstr Microsurg Harata S. Ipsilateral pedicle vascularized fibula grafts for
1999;15:501–507. reconstruction of tibial defects and non-unions. J Reconstr
93. Sinclair JS, McNally MA, Small JO, Yeates HA. Primary Microsurg 2001;17:487–496.
free flap cover of open tibial fractures. Injury 1997;28:581– 111. Heller L, Phillips K, Levin LS. Pedicled osteocutaneous
587. fibula flap for reconstruction in the lower extremity. Plast
94. Arnez ZM. Immediate reconstruction of the lower Reconstr Surg 2002;109:2037–2042.
extremity: An update. Clin Plast Surg 1991;18:449–457. 112. Atkins RM, Madhavan P, Sudhakar J, Whitwell D.
95. Tropet Y, Garbuio P, Obert L, Ridoux PE. Emergency Ipsilateral vascularized fibular transport for massive defects
management of type IIIB open tibial fractures. Br J Plast Surg of the tibia. J Bone Joint Surg Br 1999;81:1035–1040.
1999;52:462–470. 113. Akin S, Ozcan M. Salvage of the lower leg using a
96. Tropet Y, Garbuio P, Obert L, Jeunet L, Elias B. One-stage reversed long free fibular flap. Ann Plast Surg 1999;42:170–
emergency treatment of open grade IIIB tibial shaft fractures 173.
with bone loss. Ann Plast Surg 2001;46:113–119. 114. Sharma S, Tiwari P, Kasabian AK, Longaker MT.
97. Christian EP, Bosse MJ, Robb G. Reconstruction of large Reconstruction of a tibial defect with microvascular transfer
diaphyseal defects, without free fibular transfer, in Grade-IIIB of a previously fractured fibula. Ann Plast Surg 2000;45:202–
tibial fractures. J Bone Joint Surg Am 1989;71:994–1004. 206.
50
SRPS Volume 11 Issue R1, 2009
115. Alonso JE, Regazzoni P. Bridging bone gaps with 131. Serafin D, Voci VE. Reconstruction of the lower
the Ilizarov technique: Biologic principles. Clin Plast Surg extremity: Microsurgical composite tissue transplantation.
1991;18:497–504. Clin Plast Surg 1983;10:55–72.
116. Vasconez HC, Nicholls PJ. Management of extremity 132. Khouri RK, Shaw WW. Reconstruction of the
injuries with external fixator or Ilizarov devices: Cooperative lower extremity with microvascular free flaps: A 10-
effort between orthopedic and plastic surgeons. Clin Plast year experience with 304 consecutive cases. J Trauma
Surg 1991;18:505–513. 1989;29:1086–1094.
117. Cierny G III, Zorn KE, Nahai F. Bony reconstruction in 133. Nieminen H, Kuokkanen H, Tukiainen E, Asko-
the lower extremity. Clin Plast Surg 1992;19:905–916. Seljavaara S. Free flap reconstructions of 100 tibial fractures.
118. Ilizarov GA, Ledyaev VI. The replacement of long J Trauma 1999;46:1031–1035.
tubular bone defects by lengthening distraction osteotomy
134. Park S, Han SH, Lee TJ. Algorithm for recipient vessel
of one of the fragments: 1969. Clin Orthop Relat Res
selection in free tissue transfer to the lower extremity. Plast
1992;280:7–10.
Reconstr Surg 1999;103:1937–1948.
119. Ilizarov GA, Devyatov AA, Kamerin VK. Plastic
reconstruction of longitudinal bone defects by means of 135. Colen LB. Limb salvage in the patient with severe
compression and subsequent distraction. Acta Chir Plast peripheral vascular disease: The role of microsurgical free-
1980;22:32–41. tissue transfer. Plast Reconstr Surg 1987;79:389–395.
120. Naggar L, Chevalley F, Blanc CH, Livio JJ. Treatment 136. Musharafieh R, Macari G, Hayek S, Elhassan B, Atiyeh
of large bone defects with the Ilizarov technique. J Trauma B. Rectus abdominis free-tissue transfer in lower extremity
1993;34:390–393. reconstruction: Review of 40 cases. J Reconstr Microsurg
2000;16:341–345.
121. Carrington NC, Smith RM, Knight SL, Matthews SJ.
Ilizarov bone transport over a primary tibial nail and free 137. Redett RJ, Robertson BC, Chang B, Girotto J, Vaughan T.
flap: A new technique for treating Gustilo grade 3b fractures Limb salvage of lower-extremity wounds using free gracilis
with large segmental defects. Injury 2000;31:112–115. muscle reconstruction. Plast Reconstr Surg 2000;106:1507–
122. Dendrinos GK, Kontos S, Lyritsis E. Use of the Ilizarov 1513.
technique for treatment of non-union of the tibia associated 138. Wechselberger G, Schoeller T, Bauer T, Schwabegger
with infection. J Bone Joint Surg Am 1995;77:835–846. A, Ninkovic M, Rainer C, Ninkovic M. Surgical technique and
123. Saleh M, Rees A. Bifocal surgery for deformity and clinical application of the transverse gracilis myocutaneous
bone loss after lower-limb fractures: Comparison of bone- free flap. Br J Plast Surg 2001;54:423–427.
transport and compression-distraction methods. J Bone 139. Luo S, Raffoul W, Luo J, Luo L, Gao J, Chen L, Egloff DV.
Joint Surg Br 1995;77:429–434. Anterolateral thigh flap: A review of 168 cases. Microsurgery
124. Ghoneem HF, Wright JG, Cole WG, Rang M. The 1999;19:232–238.
Ilizarov method for correction of complex deformities:
140. Bundgaard KG, Christensen KS. Tibial bone loss and
Psychological and functional outcomes. J Bone Joint Surg Am
soft-tissue defect treated simultaneously with Ilizarov-
1996;78:1480–1485.
technique: A case report. Acta Orthop Scand 2000;71:534–
125. McKee MD, Yoo D, Schemitsch EH. Health status 536.
after Ilizarov reconstruction of post-traumatic lower-limb
deformity. J Bone Joint Surg Br 1998;80:360–364. 141. Lerner A, Ullmann Y, Stein H, Peled IJ. Using the Ilizarov
external fixation device for skin expansion. Ann Plast Surg
126. Amr SM, El-Mofty AO, Amin SN. Anterior versus 2000;45:535–537.
posterior approach in reconstruction of infected nonunion
of the tibia using the vascularized fibular graft: Potentialities 142. Delaere OP, Barbier OJ. Split free flap and monofixator
and limitations. Microsurgery 2002;22:91–107. distraction osteogenesis for leg reconstruction. Plast
Reconstr Surg 2000;105:178–182.
127. Pollak AN, McCarthy ML, Burgess AR. Short-term
wound complications after application of flaps for coverage 143. Agarwal S, Agarwal R, Jain UK, Chandra R.
of traumatic soft-tissue defects about the tibia: The Lower Management of soft-tissue problems in leg trauma in
Extremity Assessment Project (LEAP) Study Group. J Bone conjunction with application of the Ilizarov fixator assembly.
Joint Surg Am 2000;82:1681–1691. Plast Reconstr Surg 2001;107:1732–1738.
128. Hallock GG. Utility of both muscle and fascia flaps in 144. Parrett BM, Matros E, Pribaz JJ, Orgill DP. Lower
severe lower extremity trauma. J Trauma 2000;48:913–917. extremity trauma: Trends in the management of soft-tissue
129. Singh S, Naasan A. Use of distally based superficial reconstruction of open tibia-fibula fractures. Plast Reconstr
sural island artery flaps in acute open fractures of the lower Surg 2006;117:1315–1322.
leg. Ann Plast Surg 2001;47:505–510. 145. Açikel C, Peker F, Akmaz I, Ulkür E. Muscle transposition
130. May JW Jr, Gallico GG III, Lukash FN. Microvascular and skin grafting for salvage of below-knee amputation
transfer of free tissue for closure of bone wounds of the level after bilateral lower extremity thermal injury. Burns
distal lower extremity. N Engl J Med 1982;306:253–257. 2001;27:849–852.
51
SRPS Volume 11 Issue R1, 2009
146. Anderson WD, Stewart KJ, Wilson Y, Quaba AA. Skin 162. Hyde GL, Peck D, Powell DC. Compartment syndromes:
grafts for the salvage of degloved below-knee amputation Early diagnosis and a bedside operation. Am Surg
stumps. Br J Plast Surg 2002;55:320–323. 1983;49:563–568.
147. Watier E, Georgieu N, Manise O, Husson JL, Pailheret JP. 163. Rorabeck CH. The treatment of compartment
Use of tissue expansion in revision of unhealed below-knee syndromes of the leg. J Bone Joint Surg Br 1984;66:93–97.
amputation stumps. Scand J Plast Reconstr Surg Hand Surg 164. Blick SS, Brumback RJ, Poka A, Burgess AR, Ebraheim
2001;35:193–196. NA. Compartment syndrome in open tibial fractures. J Bone
148. Shenaq SM, Krouskop T, Stal S, Spira M. Salvage of Joint Surg Am 1986;68:1348–1353.
amputation stumps by secondary reconstruction utilizing 165. Allen MJ, Stirling AJ, Crawshaw CV, Barnes MR.
microsurgical free-tissue transfer. Plast Reconstr Surg Intracompartmental pressure monitoring of leg injuries: An
1987;79:861–870. aid to management. J Bone Joint Surg Br 1985;67:53–57.
149. Tukiainen EJ, Saray A, Kuokkanen HO, Asko-Seljavaara 166. Arbabi S, Brundage SI, Gentilello LM. Near-infrared
SL. Salvage of major amputation stumps of the lower spectroscopy: A potential method for continuous,
extremity with latissimus dorsi free flaps. Scand J Plast transcutaneous monitoring for compartmental syndrome in
Reconstr Surg Hand Surg 2002;36:85–90. critically injured patients. J Trauma 1999;47:829–833.
150. Erdmann D, Sundin BM, Yasui K, Wong MS, Levin 167. Pearse MF, Harry L, Nanchahal J. Acute compartment
LS. Microsurgical free flap transfer to amputation sites: syndrome of the leg. BMJ 2002;325:557–558.
Indications and results. Ann Plast Surg 2002;48:167–172. 168. Kalb RL. Preventing the sequelae of compartment
151. Pelissier P, Pistre V, Casoli V, Martin D, Baudet J. syndrome. Hosp Pract (Minneap) 1999;34:105–107.
Reconstruction of short lower leg stumps with the 169. Cawrse NH, Inglefield CJ, Hayes C, Palmer JH. A snake
osteomusculocutaneous latissimus dorsi-rib flap. Plast in the clinical grass: Late compartment syndrome in a child
Reconstr Surg 2002;109:1013–1017. bitten by an adder. Br J Plast Surg 2002;55:434–435.
152. Dubert T, Oberlin C, Alnot JY. Partial replantation after 170. Taras JS, Fitzpatrick MJ. Compartment syndrome of the
traumatic proximal lower limb amputation: A one-stage leg after plantaris tendon harvest: A case report. J Hand Surg
reconstruction with free osteocutaneous transfer from the [Am] 2001;26:1135–1137.
amputated limb. Plast Reconstr Surg 1993;91:537–540. 171. Nghiem DD, Boland JP. Four-compartment fasciotomy
153. Stiebel M, Lee C, Fontes R. Calcaneal fillet of sole flap: of the lower extremity without fibulectomy: A new
Durable coverage of the traumatic amputation stump. J approach. Am Surg 1980;46:414–417.
Trauma 2000;49:960–963. 172. Wiger P, Blomqvist G, Styf J. Wound closure by
154. Cavadas PC, Bakliñska MI, Soler S, Navarro A. Pedicled dermatotraction after fasciotomy for acute compartment
foot fillet flap based on the tibialis anterior vessels: Case syndrome. Scand J Plast Reconstr Surg Hand Surg
report. J Reconstr Microsurg 2002;18:87–89. 2000;34:315–320.
155. Shah M, Kulkarni J, Shelley M, Whitby DJ. Refrigeration 173. Chiverton N, Redden JF. A new technique for delayed
of a “spare part”: A salvage procedure for preservation of the primary closure of fasciotomy wounds. Injury 2000;31:21–24.
knee joint in a patient with multiple trauma. Plast Reconstr 174. Janzing HM, Broos PL. Dermatotraction: An effective
Surg 2001;108:1289–1294. technique for the closure of fasciotomy wounds: A
preliminary report of fifteen patients. J Orthop Trauma
156. Kayikçioğlu A, Ağaoğlu G, Nasir S, Keçik A. Crossover
2001;15:438–441.
replantation and fillet flap coverage of the stump after
ectopic implantation: A case of bilateral leg amputation. 175. Patzakis MJ, Dorr LD, Ivler D, Moore TM, Harvey JP Jr.
Plast Reconstr Surg 2000;106:868–873. The early management of open joint injuries: A prospective
study of one hundred and forty patients. J Bone Joint Surg
157. Vogt PR. Ischemic muscular necrosis following Am 1975;57:1065–1070.
marching. Presented to the Oregon State Medical Society,
September 4, 1943, Portland, OR. 176. Barfod B, Pers M. Gastrocnemius-plasty for primary
closure of compound injuries of the knee. J Bone Joint Surg
158. Leach RE, Hammond G, Stryker WS. Anterior tibial Br 1970;52:124–127.
compartment syndrome: Acute and chronic. J Bone Joint
Surg Am 1967;49:451–462. 177. Pu LL, Thomson JG. Salvage of the exposed irradiated
knee joint with free tissue transfer. Ann Plast Surg
159. Willhoite DR, Moll JH. Early recognition and treatment 2000;44:334–339.
of impending Volkmann’s ischemia in the lower extremity.
178. Cierny G III, Cook WG, Mader JT. Ankle arthrodesis in
Arch Surg 1970;100:11–16.
the presence of ongoing sepsis: Indications, methods, and
160. Kikuchi S, Hasue M, Watanabe M. Ischemic contracture results. Orthop Clin North Am 1989;20:709–721.
in the lower limb. Clin Orthop Relat Res 1978;134:185–192. 179. 179.. Kettunen J, Mäkelä EA, Turunen V, Suomalainen
161. DeLee JC, Stiehl JB. Open tibia fracture with O, Partanen K. Percutaneous bone grafting in the treatment
compartment syndrome. Clin Orthop Relat Res of the delayed union and non-union of tibial fractures. Injury
1981;160:175–184. 2002;33:239–245.
52
SRPS Volume 11 Issue R1, 2009
180. Megas P, Panagiotopoulos E, Skriviliotakis S, Lambiris 197. Vécsei V, Barquet A. Treatment of chronic osteomyelitis
E. Intramedullary nailing in the treatment of aseptic tibial by necrectomy and gentamicin-PMMA beads. Clin Orthop
nonunion. Injury 2001;32:233–239. Relat Res 1981;159:201–207.
181. Ohtsuka H, Yokoyama K, Higashi K, Tsutsumi A, 198. Tulner SA, Schaap GR, Strackee SD, Besselaar PP, Luitse
Fukushima N, Noumi T, Itoman M. Use of antibiotic- JS, Marti RK. Long-term results of multiple-stage treatment
impregnated bone cement nail to treat septic nonunion for posttraumatic osteomyelitis of the tibia. J Trauma
after open tibial fracture. J Trauma 2002;52:364–366. 2004;56:633–642.
182. Safoury Y. Use of a reversed-flow vascularized pedicle 199. Morrey BF, Dunn JM, Heimbach RD, Davis J. Hyperbaric
fibular graft for treatment of nonunion of the tibia. J oxygen and chronic osteomyelitis. Clin Orthop Relat Res
Reconstr Microsurg 1999;15:23–28. 1979;144:121–127.
183. Hertel R, Pisan M, Jakob RP. Use of the ipsilateral 200. Arnold PG, Yugueros P, Hanssen AD. Muscle flaps in
vascularized fibula for tibial reconstruction. J Bone Joint Surg osteomyelitis of the lower extremity: A 20-year account.
Br 1995;77:914–919. Plast Reconstr Surg 1999;104:107–110.
184. Erdinger K, Windhofer C, Papp C. Osteomuscular 201. Musharafieh R, Osmani O, Musharafieh U, Saghieh
latissimus dorsi scapula flap to repair chronic, posttraumatic S, Atiyeh B. Efficacy of microsurgical free-tissue transfer
osteomyelitis of the lower leg. Plast Reconstr Surg in chronic osteomyelitis of the leg and foot: Review of 22
2001;107:1430–1435. cases. J Reconstr Microsurg 1999;15:239–244.
185. Duffy GP, Wood MB, Rock MG, Sim FH. Vascularized 202. Wells MD, Bowen CV, Manktelow RT, Graham J,
free fibular transfer combined with autografting for the Boyd JB. Lower extremity free flaps: A review. Can J Surg
management of fracture nonunions associated with 1996;39:233–239.
radiation therapy. J Bone Joint Surg Am 2000;82:544–554.
203. Gonzalez MH, Tarandy DI, Troy D, Phillips D, Weinzweig
186. Patzakis MJ, Wilkins J, Moore TM. Use of antibiotics in N. Free tissue coverage of chronic traumatic wounds of the
open tibial fractures. Clin Orthop Relat Res 1983;178:31–35. lower leg. Plast Reconstr Surg 2002;109:592–600.
187. Ger R, Efron G. New operative approach in the 204. Patetsios P, George M, Ghosh BC. Squamous-cell
treatment of chronic osteomyelitis of the tibial diaphysis: A carcinoma from chronic osteomyelitis. J Am Coll Surg
preliminary report. Clin Orthop Relat Res 1970;70:165–169. 2000;191:217.
188. Ger R. Chronic ulceration of the leg. Surg Annu
205. Faden H, Grossi M. Acute osteomyelitis in children:
1972;4:123–149.
Reassessment of etiologic agents and their clinical
189. Horwitz T. Surgical treatment of chronic osteomyelitis characteristics. Am J Dis Child 1991;145:65–69.
complicating fractures: A study of 50 patients. Clin Orthop
Relat Res 1973;96:118–128. 206. Picascia DD, Roenigk HH Jr. Surgical management of
leg ulcers. Dermatol Clin 1987;5:303–312.
190. Mathes SJ, Alpert BS, Chang N. Use of the muscle
flap in chronic osteomyelitis: Experimental and clinical 207. Moosa HH, Falanga V, Steed DL, Makaroun MS,
correlation. Plast Reconstr Surg 1982;69:815–829. Peitzman AB, Eaglstein WH, Webster MW. Oxygen diffusion
in chronic venous ulceration. J Cardiovasc Surg (Torino)
191. Anthony JP, Mathes SJ, Alpert BS. The muscle flap in 1987;28:464–467.
the treatment of chronic lower extremity osteomyelitis:
Results in patients over 5 years after treatment. Plast 208. Starling EH. On the absorption of fluids from the
Reconstr Surg 1991;88:311–318. connective tissue spaces. J Physiol 1896;19:312–326.
192. May JW Jr, Gallico GG III, Jupiter J, Savage RC. Free 209. Löfgren KA. Surgical management of chronic venous
latissimus dorsi muscle flap with skin graft for treatment insufficiency. Acta Chir Scand Suppl 1988;544:62–68.
of traumatic chronic bony wounds. Plast Reconstr Surg 210. Balslev E, Thomsen HK, Danielsen L, Warburg F. The
1984;73:641–651. occurrence of pericapillary fibrin in venous hypertension
193. May JW Jr, Jupiter JB, Gallico GG III, Rothkopf DM, and ischaemic leg ulcers: A histopathological study. Br J
Zingarelli P. Treatment of chronic traumatic bone wounds: Dermatol 1992;126:582–585.
Microvascular free tissue transfer: A 13-year experience in 96 211. Thomas PR, Nash GB, Dormandy JA. White cell
patients. Ann Surg 1991;214:241–250. accumulation in dependent legs of patients with venous
194. Damholt VV. Treatment of chronic osteomyelitis: hypertension: A possible mechanism for trophic changes in
A prospective study of 55 cases treated with radical the skin. Br Med J (Clin Res Ed) 1988;296:1693–1695.
surgery and primary wound closure. Acta Orthop Scand 212. Coleridge Smith PD, Thomas P, Scurr JH, Dormandy
1982;53:715–720. JA. Causes of venous ulceration: A new hypothesis. Br Med J
195. Nicoll EA. The treatment of gaps in long bones by (Clin Res Ed) 1988;296:1726–1727.
cancellous insert grafts. J Bone Joint Surg Br 1956;38:70–82. 213. van Bemmelen PS, Bedford G, Beach K, Strandness DE
196. Sudmann E. Treatment of chronic osteomyelitis by free Jr. Status of the valves in the superficial and deep venous
grafts of cancellous autologous bone tissue: A preliminary system in chronic venous disease. Surgery 1991;109:730–
report. Acta Orthop Scand 1979;50:145–150. 734.
53
SRPS Volume 11 Issue R1, 2009
214. McEnroe CS, O’Donnell TF Jr, Mackey WC. Correlation of 229. Quiñones-Baldrich WJ, Kashyap VS, Taw MB,
clinical findings with venous hemodynamics in 386 patients Markowitz BL, Watson JP, Reil TD, Shaw WW. Combined
with chronic venous insufficiency. Am J Surg 1988;156:148– revascularization and microvascular free tissue transfer
152. for limb salvage: A six year experience. Ann Vasc Surg
215. Mayberry JC, Moneta GL, Taylor LM Jr, Porter JM. 2000;14:99–104.
Fifteen-year results of ambulatory compression therapy for 230. Illig KA, Moran S, Serletti J, Quriel K, Orlando G, Smith
chronic venous ulcers. Surgery 1991;109:575–581. A, Shortell CK, Green RM. Combined free tissue transfer
and infrainguinal bypass graft: An alternative to major
216. Jamieson WG, DeRose G, Harris KA. Management
amputation in selected patients. J Vasc Surg 2001;33:17–23.
of venous stasis ulcer: Long-term follow-up. Can J Surg
1990;33:222–223. 231. Moran SL, Illig KA, Green RM, Serletti JM. Free-tissue
transfer in patients with peripheral vascular disease: A 10-
217. Healey PJ, Healey EH, Wong R, Schaberg FJ Jr. Surgical year experience. Plast Reconstr Surg 2002;109:999–1006.
management of the chronic venous ulcer: The Rob
procedure. Am J Surg 1979;137:556–559. 232. Maloney CT Jr, Wages D, Upton J, Lee WP. Free omental
tissue transfer for extremity coverage and revascularization.
218. Ananthakrishnan N, Parkash S, Banerjee SN. A new Plast Reconstr Surg 2003;111:1899–1904.
technique for chronic venous ulcers of the lower limb:
Modified Felder-Rob procedure. Aust N Z J Surg 1989;59:157– 233. Isenberg JS. When less is more: Revascularization and
160. sural artery fasciocutaneous flaps in ischemic limb salvage. J
Reconstr Microsurg 2003;19:235–240.
219. Nash T. Long term results of vein valve transplants
234. Malone JM, Moore W, Leal JM, Childers SJ.
placed in the popliteal vein for intractable post-phlebitic
Rehabilitation for lower extremity amputation. Arch Surg
venous ulcers and pre-ulcer skin changes. J Cardiovasc Surg
1981;116:93–98.
(Torino) 1988;29:712–716.
235. Kucan JO, Robson MC. Diabetic foot infections: Fate of
220. Rai DB, Lerner R. Chronic venous insufficiency disease: the contralateral foot. Plast Reconstr Surg 1986;77:439–441.
Its etiology: A new technique for vein valve transplantation.
Int Surg 1991;76:174–178. 236. Attinger CE, Ducic I, Neville RF, Abbruzzese MR, Gomes
M, Sidawy AN. The relative roles of aggressive wound care
221. Sindrup JH, Groth S, Avnstorp C, Tønnesen KH, versus revascularization in salvage of the threatened lower
Kristensen JK. Coexistence of obstructive arterial disease extremity in the renal failure diabetic patient. Plast Reconstr
and chronic venous stasis in leg ulcer patients. Clin Exp Surg 2002;109:1281–1290.
Dermatol 1987;12:410–412.
237. Boulton AJ. Clinical presentation and management
222. Callam MJ, Harper DR, Dale JJ, Ruckley CV. Arterial of diabetic neuropathy and foot ulceration. Diabet Med
disease in chronic leg ulceration: An underestimated 1991;[suppl 8]:S52–S57.
hazard?: Lothian and Forth Valley leg ulcer study. Br Med J
(Clin Res Ed) 1987;294:929–931. 238. Lipsky BA, Berendt AR, Deery HG, Embil JM, Joseph
WS, Karchmer AW, LeFrock JL, Lew DP, Mader JT, Norden C,
223. Castronuovo JJ Jr, Adera HM, Smiell JM, Price RM. Skin Tan JS; Infectious Diseases Society of America. Diagnosis
perfusion pressure measurement is valuable in the diagnosis and treatment of diabetic foot infections. Plast Reconstr Surg
of critical limb ischemia. J Vasc Surg 1997;26:629–637. 2006;117[suppl 7]:212S–238S.
224. Andros G, Harris RW, Salles-Cunha SX, Dulawa LB, 239. Stevens MJ, Feldman EL, Greene DA. The aetiology of
Oblath RW. Lateral plantar artery bypass grafting: Defining diabetic neuropathy: The combined roles of metabolic and
the limits of foot revascularization. J Vasc Surg 1989;10:511– vascular defects. Diabet Med 1995;12:566–579.
519. 240. Corbin DO, Young RJ, Morrison DC, Hoskins P,
225. Daane SP, Lawrence PF, Rockwell WB. Arterial grafts in McDicken WN, Housley E, Clarke BF. Blood flow in the foot,
microscope-assisted pedal bypass for limb salvage. Ann Plast polyneuropathy and foot ulceration in diabetes mellitus.
Surg 2002;49:355–361. Diabetologia 1987;30:468–473.
226. Rowe VL, Hood DB, Lipham J, Terramani T, Torres G, 241. Sinacore DR, Mueller MJ, Diamond JE, Blair VP III, Drury
Katz S, Kohl R, Weaver FA. Initial experience with dorsal D, Rose SJ. Diabetic plantar ulcers treated by total contact
venous arch arterialization for limb salvage. Ann Vasc Surg casting: A clinical report. Phys Ther 1987;67:1543–1549.
2002;16:187–192. 242. Boulton AJ, Bowker JH, Gadia M, Lemerman R,
227. Lepäntalo M, Tukiainen E. Combined vascular Caswell K, Skyler JS, Sosenko JM. Use of plaster casts in the
reconstruction and microvascular muscle flap transfer for management of diabetic neuropathic foot ulcers. Diabetes
salvage of ischaemic legs with major tissue loss and wound Care 1986;9:149–152.
complications. Eur J Vasc Endovasc Surg 1996;12:65–69. 243. Griffiths GD, Wieman TJ. Metatarsal head resection for
228. Gooden MA, Gentile AT, Mills JL, Berman SS, Demas diabetic foot ulcers. Arch Surg 1990;125:832–835.
CP, Reinke KR, Hunter GC, Westerband A, Greenwald D. Free 244. Newman LG, Waller J, Palestro CJ, Schwartz M, Klein
tissue transfer to extend the limits of limb salvage for lower MJ, Hermann G, Harrington E, Harrington M, Roman SH,
extremity tissue loss. Am J Surg 1997;174:644–648. Stagnaro-Green A. Unsuspected osteomyelitis in diabetic
54
SRPS Volume 11 Issue R1, 2009
foot ulcers: Diagnosis and monitoring by leukocyte A single institution’s experience over 25 years. Ann Plast Surg
scanning with indium in 111 oxyquinoline. JAMA 2007;59:18–21.
1991;266:1246–1251. 262. Willcox TM, Smith AA, Beauchamp C, Meland NB.
245. Yuh WT, Corson JD, Baraniewski HM, Rezai K, Shamma Functional free latissimus dorsi muscle flap to the proximal
AR, Kathol MH, Sato Y, el-Khoury GY, Hawes DR, Platz CE. lower extremity. Clin Orthop Relat Res 2003;410:285–288.
Osteomyelitis of the foot in diabetic patients: Evaluation 263. Ihara K, Kishimoto T, Kawai S, Doi K. Reconstruction
with plain film, 99m Tc-MDP bone scintigraphy, and MR of hip abduction using free muscle transplantation: A
imaging. AJR Am J Roentgenol 1989;152:795–800. case report and description of technique. Ann Plast Surg
246. Lai CS, Lin SD, Yang CC, Chou CK, Wu SF, Chang 2000;45:177–180.
CH. Limb salvage of infected diabetic foot ulcers with 264. Swartz WM, Jones NF. Soft tissue coverage of the lower
microsurgical free-muscle transfer. Ann Plast Surg extremity. Curr Probl Surg 1985;22:1–59.
1991;26:212–220.
265. Pers M, Medgyesi S. Pedicle muscle flaps and
247. Guzman-Stein G, Fix RJ, Vasconez LO. Muscle their applications in the surgery of repair. Br J Plast Surg
flap coverage for the lower extremity. Clin Plast Surg 1973;26:313–321.
1991;18:545–552.
266. McCraw JB. Selection of alternative local flaps in the
248. Galumbeck M, Colen LB. Soft tissue reconstruction:
leg and foot. Clin Plast Surg 1979;6:227–246.
Coverage of lower leg: Rotational flap. Orthop Clin North Am
1993;24:473–480. 267. Patel NS, Ibrahim DT, Finn HA. Knee extensor
mechanism reconstruction with medial gastrocnemius flap.
249. Basheer MH, Wilson SM, Lewis H, Herbert K.
Clin Orthop Relat Res 2002;398:176–181.
Microvascular free tissue transfer in reconstruction of the
lower limb. J Plast Reconstr Aesthet Surg 2008;61:525–528. 268. Dibbell DG, Edstrom LE. The gastrocnemius
250. Mathes SJ, Nahai F. Clinical Applications for Muscle and myocutaneous flap. Clin Plast Surg 1980;7:45–50.
Musculocutaneous Flaps. St Louis: Mosby; 1982. 269. Hallock GG. Sagittal split tibialis anterior muscle flap.
251. Yildirim S, Gideroğlu K, Aköz T. Anterolateral thigh Ann Plast Surg 2002;49:39–43.
flap: Ideal free flap choice for lower extremity soft-tissue 270. Yoshimura M, Shimada T, Imura S, Shimamura K,
reconstruction. J Reconstr Microsurg 2003;19:225–233. Yamauchi S. Peroneal island flap for skin defects in the lower
252. Minami A, Kato H, Suenaga N, Iwasaki N. Distally-based extremity. J Bone Joint Surg Am 1985;67:935–941.
free vascularized tissue grafts in the lower leg. J Reconstr 271. Fix RJ, Vasconez LO. Fasciocutaneous flaps in
Microsurg 1999;15:495–499. reconstruction of the lower extremity. Clin Plast Surg
253. Banic A, Wulff K. Latissimus dorsi free flaps for total 1991;18:571–582.
repair of extensive lower leg injuries in children. Plast 272. Walton RL, Bunkis J. The posterior calf fasciocutaneous
Reconstr Surg 1987;79:769–775. free flap. Plast Reconstr Surg 1984;74:76–85.
254. Stewart KJ, Tytherleigh-Strong G, Bharathwaj S, Quaba 273. Walton RL, Matory WE Jr, Petry JJ. The posterior calf
AA. The soft tissue management of children’s open tibial fascial free flap. Plast Reconstr Surg 1985;76:914–926.
fractures. J R Coll Surg Edinb 1999;44:24–30. 274. Park S, Eom JS. Selection of the recipient vessel in the
255. Dabb RW, Davis RM. Latissimus dorsi free flaps in the free flap around the knee: The superior medial genicular
elderly: An alternative to below-knee amputation. Plast vessels and the descending genicular vessels. Plast Reconstr
Reconstr Surg 1984;73:633–640. Surg 2001;107:1177–1182.
256. Furnas H, Canales F, Lineaweaver W, Buncke GM, Alpert 275. Maghari A, Forootan KS, Fathi M, Manafi A. Free
BS, Buncke HJ. Microsurgical tissue transfer in patients more transfer of expanded parascapular, latissimus dorsi,
than 70 years of age. Ann Plast Surg 1991;26:133–139. and expander “capsule” flap for coverage of large
257. Goldberg JA, Alpert BS, Lineaweaver WC, Buncke HJ. lower-extremity soft-tissue defect. Plast Reconstr Surg
Microvascular reconstruction of the lower extremity in the 2000;106:402–405.
elderly. Clin Plast Surg 1991;18:459–465. 276. Beck JB, Stile F, Lineaweaver W. Reconsidering the
258. Wettstein R, Schürch R, Banic A, Erni D, Harder Y. soleus Muscle flap for coverage of wounds of the distal third
Review of 197 consecutive free flap reconstructions in the of the leg. Ann Plast Surg 2003;50:631–635.
lower extremity. J Plast Reconstr Aesthet Surg 2008;61:772– 277. Pai CH, Lin GT, Lin SY, Lin SD, Lai CS. Extensor digitorum
776. brevis rotational muscle flap for lower leg and ankle
259. Duteille F, Lim A, Dautel G. Free flap coverage of upper coverage. J Trauma 2000;49:1012–1016.
and lower limb tissue defects in children: A series of 22 278. Eren S, Ghofrani A, Reifenrath M. The distally pedicled
patients. Ann Plast Surg 2003;50:344–349. peroneus brevis muscle flap: A new flap for the lower leg.
260. Fisher J, Wood MB. Late necrosis of a latissimus dorsi Plast Reconstr Surg 2001;107:1443–1448.
free flap. Plast Reconstr Surg 1984;74:274–281. 279. McHenry TP, Early JS, Schacherer TG. Peroneus
261. Culliford AT IV, Spector J, Blank A, Karp NS, Kasabian A, brevis rotation flap: Anatomic considerations and clinical
Levine JP. The fate of lower extremities with failed free flaps: experience. J Trauma 2001;50:922–926.
55
SRPS Volume 11 Issue R1, 2009
280. Barr ST, Rowley JM, O’Neill PJ, Barillo DJ, Paulsen SM. 296. Dumont CE, Kessler J. A composite medial plantar flap
How reliable is the distally based peroneus brevis muscle for the repair of an achilles’ tendon defect: A case report.
flap? Plast Reconstr Surg 2002;110:360–362. Ann Plast Surg 2001;47:666–668.
281. Attinger CE, Ducic I, Zelen C. The use of local muscle 297. Tashjian RZ, Hur J, Sullivan RJ, Campbell JT, DiGiovanni
flaps in foot and ankle reconstruction. Clin Podiatr Med Surg CW. Flexor hallucis longus transfer for repair of chronic
2000;17:681–711. achilles tendinopathy. Foot Ankle Int 2003;24:673–676.
282. Yang D, Morris SF. Reversed sural island flap supplied 298. Feibel RJ, Jackson RL, Lineaweaver WC, Buncke HJ.
by the lower septocutaneous perforator of the peroneal Management of chronic achilles tendon infection with
artery. Ann Plast Surg 2002;49:375–378. musculotendinous gracilis interposition free-flap coverage. J
Reconstr Microsurg 1993;9:321–325.
283. Rajendra Prasad JS, Cunha-Gomes D, Chaudhari
C, Bhathena HM, Desai S, Kavarana NM. The 299. Ronel DN, Newman MI, Gayle LB, Hoffman LA. Recent
advances in the reconstruction of complex Achilles tendon
venoneuroadipofascial pedicled distally based sural island
defects. Microsurgery 2004;24:18–23.
myofasciocutaneous and muscle flaps: Anatomical basis of a
new concept. Br J Plast Surg 2002;55:203–209. 300. Inoue T, Tanaka I, Imai K, Hatoko M. Reconstruction
of Achilles tendon using vascularised fascia lata with free
284. Coşkunfirat OK, Velidedeoğlu HV, Sahin U, Demir Z. lateral thigh flap. Br J Plast Surg 1990;43:728–731.
Reverse neurofasciocutaneous flaps for soft-tissue coverage
of the lower leg. Ann Plast Surg 1999;43:14–20. 301. Kuo YR, Kuo MH, Chou WC, Liu YT, Lutz BS, Jeng SF.
One-stage reconstruction of soft tissue and Achilles tendon
285. Fraccalvieri M, Verna G, Dolcet M, Fava R, Rivarossa A, defects using a composite free anterolateral thigh flap with
Robotti E, Bruschi S. The distally based superficial sural flap: vascularized fascia lata: Clinical experience and functional
Our experience in reconstructing the lower leg and foot. Ann assessment. Ann Plast Surg 2003;50:149–155.
Plast Surg 2000;45:132–139. 302. Woltering EA, Thorpe WP, Reed JK Jr, Rosenberg SA.
286. Hallock GG. Complications of 100 consecutive local Split thickness skin grafting of the plantar surface of the foot
fasciocutaneous flaps. Plast Reconstr Surg 1991;88:264–268. after wide excision of neoplasms of the skin. Surg Gynecol
287. Costa-Ferreira A, Reis J, Pinho C, Martins A, Amarante J. Obstet 1979;149:229–232.
The distally based island superficial sural artery flap: Clinical 303. Sommerlad BC, McGrouther DA. Resurfacing the sole:
experience with 36 flaps. Ann Plast Surg 2001;46:308–313. Long-term follow-up and comparison of techniques. Br J
288. Almeida MF, da Costa PR, Okawa RY. Reverse-flow Plast Surg 1978;31:107–116.
island sural flap. Plast Reconstr Surg 2002;109:583–591. 304. May JW Jr, Halls MJ, Simon SR. Free microvascular
muscle flaps with skin graft reconstruction of extensive
289. Follmar KE, Baccarani A, Baumeister SP, Levin LS,
defects of the foot: A clinical and gait analysis study. Plast
Erdmann D. The distally based sural flap. Plast Reconstr Surg
Reconstr Surg 1985;75:627–641.
2007;119:138e–148e.
305. May JW Jr, Rohrich RJ. Foot reconstruction using free
290. Koshima I, Itoh S, Nanba Y, Tsutsui T, Takahashi Y. Medial microvascular muscle flaps with skin grafts. Clin Plast Surg
and lateral malleolar perforator flaps for repair of defects 1986;13:681–689.
around the ankle. Ann Plast Surg 2003;51:579–583.
306. Karakostas T, Hsiang SM, Sarantopoulos C, Krause J.
291. Ayyappan T, Chadha A. Super sural Dynamic loading performance of fasciocutaneous flaps
neurofasciocutaneous flaps in acute traumatic heel and implications for gait. Clin Biomech (Bristol, Avon)
reconstructions. Plast Reconstr Surg 2002;109:2307–2313. 2007;22:478–485.
292. Suga H, Oshima Y, Harii K, Asato H, Takushima A. 307. Hong JP, Kim EK. Sole reconstruction using
Distally-based sural flap for reconstruction of the lower leg anterolateral thigh perforator free flaps. Plast Reconstr Surg
and foot. Scand J Plast Reconstr Surg Hand Surg 2004;38:16– 2007;119:186–193.
20. 308. Stevenson TR, Mathes SJ. Management of foot injuries
293. Price MF, Capizzi PJ, Watterson PA, Lettieri S. Reverse with free-muscle flaps. Plast Reconstr Surg 1986;78:665–671.
sural artery flap: Caveats for success. Ann Plast Surg 309. Reiffel RS, McCarthy JG. Coverage of heel and sole
2002;48:496–504. defects: A new subfascial arterialized flap. Plast Reconstr Surg
294. Koladi J, Gang RK, Hamza AA, George A, Bang RL, 1980;66:250–260.
Rajacic N. Versatility of the distally based superficial sural 310. Morrison WA, Crabb DM, O’Brien BM, Jenkins A. The
flap for reconstruction of lower leg and foot in children. J instep of the foot as a fasciocutaneous island and as a free
Pediatr Orthop 2003;23:194–198. flap for heel defects. Plast Reconstr Surg 1983;72:56–65.
295. Babu V, Chittaranjan S, Abraham G, Korula RJ. Single- 311. Curtin JW. Functional surgery for intractable conditions
stage reconstruction of soft-tissue defects including the of the sole of the foot. Plast Reconstr Surg 1977;59:806–811.
Achilles tendon using the dorsalis pedis arterialized flap 312. Miyamoto Y, Ikuta Y, Shigeki S, Yamura M. Current
along with the extensor digitorum brevis as bridge graft. concepts of instep island flap. Ann Plast Surg 1987;19:97–
Plast Reconstr Surg 1994;93:1090–1094. 102.
56
SRPS Volume 11 Issue R1, 2009
313. Benito-Ruiz J, Yoon T, Guisantes-Pintos E, Monner J, 329. Kim SW, Hong JP, Chung YK, Tark KC. Sensate sole-to-
Serra-Renom JM. Reconstruction of soft-tissue defects of sole reconstruction using the combined medial plantar and
the heel with local fasciocutaneous flaps. Ann Plast Surg medialis pedis free flap. Ann Plast Surg 2001;47:461–464.
2004;52:380–384. 330. Renard AJ, Veth RP, Schreuder HW, van Loon CJ, Koops
314. Acikel C, Celikoz B, Yuksel F, Ergun O. Various HS, van Horn JR. Function and complications after ablative
applications of the medial plantar flap to cover the defects and limb-salvage therapy in lower extremity sarcoma of
of the plantar foot, posterior heel, and ankle. Ann Plast Surg bone. J Surg Oncol 2000;73:198–205.
2003;50:498–503. 331. Bach AD, Kopp J, Stark GB, Horch RE. The versatility of
315. Hartrampf CR Jr, Scheflan M, Bostwick J III. The the free osteocutaneous fibula flap in the reconstruction
flexor digitorum brevis muscle island pedicle flap: A new of extremities after sarcoma resection. World J Surg Oncol
dimension in heel reconstruction. Plast Reconstr Surg 2004;2:22.
1980;66:264–270. 332. El-Gammal TA, El-Sayed A, Koth MM. Reconstruction of
316. Shaw WW, Hidalgo DA. Anatomic basis of plantar lower limb bone defects after sarcoma resection in children
flap design: Clinical applications. Plast Reconstr Surg and adolescents using free vascularized fibular transfer. J
1986;78:637–649. Pediatr Orthop B 2003;12:233–243.
317. Rashid M, Hussain SS, Aslam R, Illahi I. A comparison 333. Zaretski A, Amir A, Meller I, Leshem D, Kollender Y,
of two fasciocutaneous flaps in the reconstruction of Barnea Y, Bickels J, Shpitzer T, Ad-El D, Gur E. Free fibula long
defects of the weight-bearing heel. J Coll Physicians Surg Pak bone reconstruction in orthopedic oncology: A surgical
2003;13:216–218. algorithm for reconstructive options. Plast Reconstr Surg
2004;113:1989–2000.
318. Stanec Z, Krivić A, Stanec S, Zic R, Budi S. Heel
reconstruction with an iliac osteocutaneous free flap: 10- 334. Capanna R, Bufalini C, Campanacci M. A new technique
year follow-up. Ann Plast Surg 2004;53:174–177. for reconstructions of large metadiaphyseal bone defects:
A combined graft (Allograft shell plus vascularized fibula).
319. Snyder GB, Edgerton MT Jr. The principle of the Orthop Traumatol 1993;2:159–177.
island neurovascular flap in the management of ulcerated
335. Wodajo FM, Bickels J, Wittig J, Malawer M. Complex
anesthetic weightbearing areas of the lower extremity. Plast
reconstruction in the management of extremity sarcomas.
Reconstr Surg 1965;36:518–528.
Curr Opin Oncol 2003;15:304–312.
320. Buncke HJ Jr, Colen LB. An island flap from the first 336. Mastorakos DP, Disa JJ, Athanasian E, Boland P, Healey
web space of the foot to cover plantar ulcers. Br J Plast Surg JH, Cordeiro PG. Soft-tissue flap coverage maximizes limb
1980;33:242–244. salvage after allograft bone extremity reconstruction. Plast
321. Dutch WM, Arnz M, Jolly GP. Digital artery flaps for Reconstr Surg 2002;109:1567–1573.
closure of soft tissue defects of the forefoot. J Foot Ankle 337. Spierer MM, Alektiar KM, Zelefsky MJ, Brennan MF,
Surg 2003;42:208–214. Cordiero PG. Tolerance of tissue transfers to adjuvant
322. Butler CE, Chevray P. Retrograde-flow medial plantar radiation therapy in primary soft tissue sarcoma of the
island flap reconstruction of distal forefoot, toe, and extremity. Int J Radiat Oncol Biol Phys 2003;56:1112–1116.
webspace defects. Ann Plast Surg 2002;49:196–201. 338. Long CD, Granick MS, Solomon MP. The cross-leg flap
323. Takahashi A, Tamura A, Ishikawa O. Use of a reverse- revisited. Ann Plast Surg 1993;30:560–563.
flow plantar marginal septum cutaneous island flap for 339. Dawson RL. Complications of the cross-leg flap
repair of a forefoot defect. J Foot Ankle Surg 2002;41:247– operation. Proc R Soc Med 1972;65:626–629.
250. 340. Barclay TL, Sharpe DT, Chisholm EM. Cross-leg
324. Musharafieh R, Atiyeh B, Macari G, Haidar R. Radial fasciocutaneous flaps. Plast Reconstr Surg 1983;72:843–847.
forearm fasciocutaneous free-tissue transfer in ankle and 341. Townsend PL. Indications and long-term assessment
foot reconstruction: Review of 17 cases. J Reconstr Microsurg of 10 cases of cross-leg free DCIA flaps. Ann Plast Surg
2001;17:147–150. 1987;19:225–233.
325. Matejcik V. Surgical repair of peripheral nerves in lower 342. Lai CS, Lin SD, Chou CK, Cheng YM. Use of a cross-leg
extremities. Bratisl Lek Listy 2001;102:282–285. free muscle flap to reconstruct an extensive burn wound
326. Matejcik V, Benetin J, Hulin I Jr. Our experience with involving a lower extremity. Burns 1991;17:510–513.
surgical treatment of ischial nerve injuries. Bratisl Lek Listy 343. Ninkovic MM, Schwabegger AH, Hausler JW, Ninkovic
2001;102:462–466. M, Schmutzhard E. Limb salvage after fulminant septicemia
327. Mackinnon SE, Doolabh VB, Novak CB, Trulock EP. using a free latissimus dorsi cross-leg flap. J Reconstr
Clinical outcome following nerve allograft transplantation. Microsurg 2000;16:603–607.
Plast Reconstr Surg 2001;107:1419–1429. 344. Ladas C, Nicholson R, Ching V. The cross-leg soleus
328. Potparić Z, Rajacić N. Long-term results of weight- muscle flap. Ann Plast Surg 2000;45:612–615.
bearing foot reconstruction with non-innervated and 345. Radovan C. Tissue expansion in soft-tissue
reinnervated free flaps. Br J Plast Surg 1997;50:176–181. reconstruction. Plast Reconstr Surg 1984;74:482–492.
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346. Manders EK, Oaks TE, Au VK, Wong RK, Furrey JA, core decompression in the treatment of femoral head
Davis TS, Graham WP III. Soft-tissue expansion in the lower osteonecrosis. Orthopedics 1996;19:869–872.
extremities. Plast Reconstr Surg 1988;81:208–219. 355. Scully SP, Aaron RK, Urbaniak JR. Survival analysis of
347. Borges Filho PT, Neves RI, Gemperli R, Kaweski S, Kahler hips treated with core decompression or vascularized fibular
SH, Banducci DR, Manders EK. Soft-tissue expansion in lower grafting because of avascular necrosis. J Bone Joint Surg Am
extremity reconstruction. Clin Plast Surg 1991;18:593–599. 1998;80:1270–1275.
348. Kryger ZB, Bauer BS. Surgical management of large 356. Dean GS, Kime RC, Fitch RD, Gunneson E, Urbaniak JR.
and giant congenital pigmented nevi of the lower extremity. Treatment of osteonecrosis in the hip of pediatric patients
Plast Reconstr Surg 2008;121:1674–1684. by free vascularized fibular graft. Clin Orthop Relat Res
349. Judet H, Judet J, Gilbert A. Vascular microsurgery in 2001;386:106–113.
orthopaedics. Int Orthop 1981;5:61–68. 357. Gayle LB, Lineaweaver WC, Buncke GM, Oliva A, Alpert
350. Judet H, Gilbert A. Long-term results of free BS, Billys JB, Buncke HJ. Lower extremity replantation. Clin
vascularized fibular grafting for femoral head necrosis. Clin Plast Surg 1991;18:437–447.
Orthop Relat Res 2001;386:114–119. 358. Battiston B, Tos P, Pontini I, Ferrero S. Lower limb
351. Brunelli G, Brunelli G. Free microvascular fibular replantations: Indications and a new scoring system.
transfer for idiopathic femoral head necrosis: Long-term Microsurgery 2002;22:187–192.
follow-up. J Reconstr Microsurg 1991;7:285–295. 359. Park EH, Mackay DR, Manders EK, Segal LS.
352. Urbaniak JR, Harvey EJ. Revascularization of the Replantation of the midfoot in a child: Six-year follow-
femoral head in osteonecrosis. J Am Acad Orthop Surg up with pedobarographic analysis. J Reconstr Microsurg
1998;6:44–54. 1999;15:337–341.
353. Soucacos PN, Beris AE, Malizos K, Koropilias A, Zalavras 360. Chiang YC, Wei FC, Chen LM. Heel replantation and
H, Dailiana Z. Treatment of avascular necrosis of the femoral subsequent analysis of gait. Plast Reconstr Surg 1993;91:729–
head with vascularized fibular transplant. Clin Orthop Relat 733.
Res 2001;386:120–130. 361. Daigeler A, Fansa H, Schneider W. Orthotopic and
354. Kane SM, Ward WA, Jordan LC, Guilford WB, Hanley heterotopic lower leg reimplantation: Evaluation of seven
EN Jr. Vascularized fibular grafting compared with patients. J Bone Joint Surg Br 2003;85:554–558.
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SRPS Volume 11 Issue R1, 2009
59
We thank the
Aesthetic Surgery Journal
and
Plastic and Reconstructive Surgery
for their support.
facial aesthetics