Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3600_Библиотеки_им_академика_М_И_Перельмана

If appropriate recipient vessels are not available within the defect to be reconstructed, the principle of access is to con­nect the defect to the safe fasciotomy lines [7] via the short­est necessary incisions (see Fig. 49.2). The incisions go through skin, subcutaneous fat, fascia and into the relevant plane retracting tendons/muscles/nerves to isolate the selected recipient vessels with the nal preparation per­formed under the microscope. The most commonly used recipient vessels are the anterior or posterior tibials. There are pros/cons of each and we are aware of past schools of thought preferring the PTA [8], with Godina describing a mid-axial approach splitting the medial and lateral gastroc­nemius muscle [9]. More recent experience shows the ATA to be just as reliable, even when the vessels are damaged in the zone of trauma, they have equivalent ap success rates when dissected proximal to injury [10]. Other not infre­quently utilised recipient vessels include the dorsalis pedis, supercial femoral and its descending genicular branches. Less commonly utilised ‘get out of jail’ vessels include the bular, popliteal and vein grafts or AV loops to more proxi­mal thigh vessels. The PTA is commonly dominant in sup­plying blood distally, so we rarely perform end-to-end anastomosis on this artery. It has predictable perforators to surrounding muscles and medial leg skin (described at 5, 10 and 15cm above the medial malleolus) and these are ideal recipients for free ap microsurgery. We prefer to perform end-to-side arterial anastomoses to maintain axial limb blood ow, especially when less than three healthy vessels perfuse the distal leg or in patients with peripheral vascular disease [11]. In a ‘one vessel’ leg our preference is to use a ‘ow­through’ free ap to reconstruct the damaged vessels, and some surgeons believe these may be associated with improved ap survival [12]. Some cases with gures to illus­trate vessel access follow.

face landmarked by the line joining the mid-point of the malleoli and the proximal rst metatarsal interval. Find the pulse just lateral to Extensor Hallucis Longus (EHL) and medial to Extensor Digitorum Longus (EDL) most readily palpable at the distal navicular bony prominence. During dissection, identify and protect the adjacent deep peroneal nerve.

[49.14].

These vessels are useful in cases of higher leg, knee or thigh defects that require reconstruction. The SFA is sur­face marked by the upper two-thirds of a line from the mid- inguinal point (midpoint between Pubic Symphasis Pubis and Anterior Superior Iliac Spine) and the Adductor Tubercle. As aforementioned, it travels under Sartorius and can be accessed between Adductor Longus (easily pal­pable with the relaxed thigh abducted and externally rotated). The SFA usually gives off a branch medially called the Descending Genicular Artery (DGA) approxi­mately 13cm above the knee joint, which travels between Sartorius and Vastus Medialis in close proximity to the Saphenous nerve. This nerve and the GSV should be iden­tied and protected when preparing these vessels. See Fig.49.14 for an image showing DGA vessel preparation to receive an LD free ap to reconstruct a proximal tibial Gustillo 3B fracture with single vessel distal run off and poor Popliteal branches on CTA.

2. Surface landmarks and hand-held Doppler conrm access

blood return to vein on clamps down and usual ap obser­vations noting colour of bleeding from dermal edges with low threshold to revision/additional vein anastomoses or Vein Grafts if required.

This classic paper by Marco Godina describes a mild muscle splitting approach that provides a wide exposure to the posterior tibial artery. End to side anastomosis can be performed in the lateral decubitus position.