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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_705_Библиотеки_им_академика_М_И_Перельмана
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478
J. M. Felder and J. P. Hong
a
d
Fig. 32.6 An example of “advanced reconstruction” is to
utilize low-morbidity free aps to prevent even minor levels of amputation, such as toe amputations. Flaps can be
used in combination with simpler methods such as local
aps when appropriate. (a) A 65-year-old diabetic male
presented with chronic osteomyelitis of the rst toe and
small defects of the rst and second toes. After debridement, a SCIP ap was used to reconstruct the rst toe.
second toe, llet ap was used. Free ap used Digital
e
b
c
f
artery end-to-side and supercial vein. Let me know your
thoughts. (b) The wounds after debridement. (c, d) A
supercial circumex iliac artery perforator (SCIP) ap
was used to reconstruct the great toe defect, with end-toside arterial anastomosis to the digital artery and end-toend venous anastomosis to a supercial vein. A llet ap
was used to close the second toe defect. (e, f) Final
appearance
elegant than ablative techniques. And so, if the
surgeon is capable of performing such reconstructions with minimal morbidity, we advocate
their use.
Dorsal forefoot wounds, such as those with
exposed tendon or bone, generally result from
infection or unintentional injury and subsequent
debridement. Dorsal or medial/lateral foot
wounds are the most favorable for reconstruction,
as many options exist for ap coverage, and soft
tissue coverage alone generally sufces, without
the need for any specialized considerations. The
anterior tibial vascular system is easily accessible
throughout the dorsum of the foot, for use as convenient recipient vessels. The SCIP ap excels in
providing dorsal foot reconstruction and is a
workhorse in this regard (Fig.32.8). Other fasciocutaneous aps elevated at the suprascarpal
plan (e.g., ALT) also work well (Fig.32.9).
Combined wounds of the toes and dorsal foot
should be strongly considered for transmetatarsal
amputation (TMA). An excellent indication for a
ap is for dorsal foot coverage to allow salvage of
a transmetatarsal amputation with intact plantar
skin (Figs.32.5 and 32.10).
Plantar wounds of the forefoot are either simple or highly problematic. These tend to occur as
pressure ulcers related to altered weight bearing
patterns in the diabetic foot. Biomechanical
changes such as tendon contracture or arthropa-
bd
32 Advanced Plastic Surgical Reconstruction Options intheLower Extremity
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a
c
ef
479
Fig. 32.7 This case demonstrates use of supermicrosurgery for toe salvage as well as superthin ap for achieving
thin contour at the ankle. (a, b) A 62-year-old male with a
history of diabetes and smoking presented after a chemical burn involving the distal leg, medial ankle, dorsal forefoot, and medial rst MTP joint. (c, d) Initial attempts to
manage the burns with excision and grafting failed, due to
a failure to consider the vascular status of the limb. The
wounds converted to wet gangrene. (e) Angiography demonstrated a short segment chronic total occlusion of the
proximal popliteal artery, which responded to angioplasty.
The patient was placed on aspirin, clopidogrel, and heparin by vascular surgery following the angioplasty. (f) The
wounds following revascularization and debridement with
exposure of toe extensor tendons, ankle extensor tendons,
and tibial bone. (g) The toe wounds were reconstructed
with a posterior interosseous artery (PIA) free ap anastomosed end-to-side to the second toe digital vessel, with
venous anastomosis to a supercial vein. (h) A suprascarpal ALT ap was used to cover the ankle and leg defect. (i)
In cases where anticoagulation cannot be held, it can be
benecial to loosely inset the free ap so that bleeding can
drain from beneath the ap as seen here. The patient is
then returned to the operating room on postoperative day
5–7 for denitive closure when bleeding risk has passed.
(j, k) Healed aps at 3months post-op with good contour
for footwear
480
gh
ij k
J. M. Felder and J. P. Hong
Fig. 32.7 (continued)
32 Advanced Plastic Surgical Reconstruction Options intheLower Extremity
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abc
de
481
Fig. 32.8 The SCIP ap is a workhorse in diabetic foot
reconstruction and excels at providing thin coverage for
the dorsal foot. A 55-year-old female presented with bilateral diabetic foot wounds, including (a) a dorsal foot
wound with dry gangrene of the toes on the right and (b)
a posterior ankle wound on the left with exposure of the
Achilles tendon and an equinus contracture. Again the
cases you shared with me were beautifully done using a
superthin ALT.Here is a case for the chapter if you decide
to use them. A 55-year-old female patient with bilateral
DM foot. Right foot with exposed tendon and necrosis of
the toes. Covered with SCIP ap by end to side on the
dorsalis pedis artery. Left foot with chronic ulcer that
ended in tightening of the Achilles and tendon exposure.
One stage Achilles lengthening and ALT free ap end to
side on the posterior tibial artery. Both wounds were
reconstructed on the same day all at once. This case shows
the importance of orthoplastic thinking and approach. The
follow-up at 3years shows good function and coverage.
(c) The right foot wound was treated with rst and second
toe amputation, followed by debridement of the dorsal
foot wound and coverage with a SCIP ap. (d, e) the left
ankle wound was treated with open lengthening of the
Achilles tendon to treat the contracture and immediate
coverage with an ALT ap. (f, g) Healed result at 3years
demonstrating good function and coverage. This case
shows the importance of the orthoplastic thinking and
approach, respecting biomechanical abnormalities as well
as soft tissue coverage
482
fg
J. M. Felder and J. P. Hong
Fig. 32.8 (continued)
thy combine with loss of protective sensation and
susceptibility to tissue injury caused by peripheral vascular disease. The result is a callous or
ulcer that then becomes infected, frequently leading to osteomyelitis of the metatarsophalangeal
joints. It is critical to seek the underlying biome-
chanical mechanism for these wounds and correct it. Most commonly, this is an equinus
contracture of the Achilles tendon, and Achilles
tendon lengthening must be performed along
with reconstruction, or else early recurrence is
certain [13, 14]. Metatarsophalangeal joint resection, metatarsal head resection, or even in situ
metatarsal neck osteotomy may be required to
remove infection or pressure points and are welltolerated biomechanically. Those wounds that
can heal with biomechanical correction and traditional wound care are considered simple. Wounds
that are severe enough to threaten the foot even
with biomechanical correction (e.g., extensive
osteomyelitis, extensive soft tissue loss, and particularly those associated with PVD) require
advanced reconstruction.
Reconstruction of plantar forefoot wounds is
indicated because, if successfully reconstructed,
normal ambulation can be restored. Unfortunately,
they are also highly challenging to reconstruct
with free tissue transfer. This is because they are
the furthest from accessible large vessels at the
ankle, and management of recipient vessels and
pedicle length become challenging. “Workhorse”
aps must have a very long pedicle (12+ cm) to
reach from the posterior tibial vessels at the ankle
to the plantar ball of the foot (Figs.32.11, 32.12
and 32.13). Conversely, the use of short-pedicle
aps such as the SCIP can be limited by absence
ab
cd
32 Advanced Plastic Surgical Reconstruction Options intheLower Extremity
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483
Fig. 32.9 The suprascarpal ALT is an alternative option to
provide thin dorsal foot coverage for larger wounds. A
41-year-old diabetic man presented with wet gangrene
stemming from a plantar ulcer beneath the fth MTP joint.
(a) He underwent amputation of the second-fth toes and
extensive dorsal foot debridement, removing much of the
dorsalis pedis angiosome. (b) Diagnostic angiogram demonstrated 3 vessel runoff to the foot. (c) A suprascarpal ALT
ap was used for reconstruction, with end-to-end anastomosis to the distal anterior tibial artery. End- to- end anastomosis to major vessels of the leg and foot should rarely be
performed in patients with diabetes. However, in cases
where the wound encompasses the entire distal angiosome,
it may be appropriate. (d) The use of drains is critical when
reconstruction with superthin skin aps is performed. The
thin aps are very vulnerable to injury by pressure from
underlying uid collections. In this case, despite the use of
closed-suction drainage, a seroma formed that threatened to
compromise the proximal ap integrity. The ap recovered
with prompt drainage. (e–g) Healed and stable result at
1year post-op. The contour was appropriate for normal diabetic shoes without any revision surgery
484
Fig. 32.9 (continued)
ab
J. M. Felder and J. P. Hong
feg
Fig. 32.10 Dorsal foot coverage with a thin ap to allow
TMA closure is a strong indication for a free ap, because
the TMA level of amputation is highly functional for
ambulation. The SCIP ap excels in this context. This ap
has the advantage of thin, pliable coverage, with minimal
pedicle dissection. (a) A 55-year-old active diabetic man
presented with a necrotic dehiscence of a TMA site, with
adequate plantar skin for weight bearing, but inadequate
of suitable recipients immediately adjacent to the
wound, particularly in the presence of concomitant PVD. Further, thin aps such as the SCIP
have lower capacity for dead space obliteration
and weight bearing durability. Partial resection of
metatarsals and phalanges is commonly necessary in the setting of osteomyelitis and creates
signicant dead space within the wound that
must be addressed.
dorsal skin for bone coverage. (b) Result at 6months post op following coverage with SCIP ap. Terminal distal
vessels were used as recipients: the ap artery was anastomosed to the rst dorsal metatarsal artery (FDMA) and
the supercial circumex iliac vein (SCIV) to the medial
marginal vein, within 1cm of the wound edge. The patient
returned to ambulation at 6weeks post-op
Strategies to combat these challenges include
use of aps with very long pedicles, components
that adequately address dead space, and components such as thick skin or fascia to add durability
for weight bearing. Flaps such as the partial
medial rectus (Fig.32.11), TDAP (thoracodorsal
artery perforator) (Fig.32.12), and radial forearm
(Fig.32.13) can be harvested with very long pedicles to provide reliable long-term inow from
32 Advanced Plastic Surgical Reconstruction Options intheLower Extremity
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485
a
b
c
d
e
Fig. 32.11 Reconstruction of plantar forefoot wounds is
the most challenging scenario in diabetic foot reconstruction but is indicated because of the possibility of restoring
a foot with normal function. (a) An ischemic neuropathic
diabetic plantar forefoot ulcer caused by equinus contracture and severe PVD.The patient was status post remote
popliteal to posterior tibial artery bypass but developed
stenosis of the bypass origin and progression of intrapedal disease. Angioplasty of the bypass origin was performed to restore inow. (b) In the setting of ischemia,
robust ow from the ankle is desirable. A ap with a very
long pedicle is needed, and the surgeon must manage the
intervening tissue without tunneling. In this case, the partial medial rectus ap was chosen to allow length extension of the inferior epigastric pedicle by dissection into
the muscle. Rectus fascia was included to add durability
to the weight bearing surface of the foot. The ap was
anastomosed end to side to the distal extent of the bypass
graft. A trough was created along the medial glabrous
junction of the foot for the pedicle to lay in. (c) Options
for coverage of the exposed pedicle include skin grafting
directly onto the pedicle. Skin undermining to allow closure should not be performed in the setting of PVD. (d, e)
Outcome at 3years post-op
486
J. M. Felder and J. P. Hong
a
d
Fig. 32.12 The thoracodorsal artery perforator (TDAP)
ap provides another option for plantar forefoot coverage.
The TDAP ap has the advantages of thick skin and a long
pedicle for reach to the forefoot. (a) This defect resulted
from squamous cell carcinoma excision in a diabetic man
without PVD and resulted in exposure of the secondfourth metatarsal heads in a critical area of weight bearing. An incision is designed along the glabrous junction to
allow inset of the pedicle between the recipient vessels at
the ankle and the wound in the distant plantar forefoot. (b)
The TDAP ap is designed centered preferentially around
the most distal perforator in order to achieve maximal
pedicle length. (c) Although not necessary for perfusion, a
small portion of the muscle can be included around the
b
e
c
f
perforator to assist in dead space obliteration while still
maintaining a thin ap at the skin level. (d) The ap was
anastomosed end-to-end to the medial plantar vessels
beneath the abductor hallucis. The medial plantar vessels
can be considered minor vessels in patients without PVD
and are appropriate for end-to-end anastomosis. The subcutaneous tissue and fascia beneath the glabrous junction
incision are removed in a 1cm swath to create room for
the pedicle. An implantable Doppler probe is placed
around the recipient vein. The glabrous junction incision
is carefully and loosely closed unless or until the venous
signal is lost. In this case, sutures in areas that were too
tight to close were placed loosely and then tied at the bedside on postoperative day 7. (e, f) Healed ap at 6months
the posterior tibial vessels at the ankle. Generally
speaking, the pedicle cannot be completely covered by the ap, and it is necessary to create a
trough between the anastomosis and wound and
cover the ap vessels with skin graft, biologic
matrices, or carefully planned chimeric components of the ap (Fig. 32.11). In patients with
normal blood supply and good tissue quality, the
skin edges of the trough can occasionally be
undermined enough to close over the pedicle
without tension, although this must be done
carefully while listening for loss of venous
Doppler signal. More often, we place sutures
loosely and delay closure to 1week post-op at the
bedside, once the pedicle has had time to brose
and develop resistance to compression
(Fig.32.12). Skin edges should never be undermined in patients with PVD. Tunneling of ap
pedicles on the dorsal and lateral foot is possible,
although risky from the point of view of venous
compression. Tunneling of ap pedicles on the
plantar foot is not generally possible.
Severe plantar forefoot wounds also present
a challenge for salvage of the partial foot with a
transmetatarsal amputation. This is because
integrity of the distal plantar skin is necessary
to close a traditional TMA that will withstand
the weight bearing demands of the foot.
Because the TMA is a highly functional level of
amputation, attempts to salvage a TMA with
distal plantar reconstruction are warranted
(Fig.32.14) [15].
32 Advanced Plastic Surgical Reconstruction Options intheLower Extremity
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487
a
d
b
e
c
f
g
Fig. 32.13 Reconstruction of plantar forefoot wound
with long-pedicle free aps—radial forearm ap. (a, b) A
diabetic man with neuropathy and severe PVD presented
with a lateral plantar forefoot ulcer and dorsal toe wounds.
(c) After revascularization, a radial forearm ap was
designed to cover the plantar and critical dorsal defect at
the rst metatarsophalangeal joint capsule. (d) The ap
was harvested with a very long pedicle to reach the plantar
forefoot through a trough cut into the medial glabrous
junction. Anastomosis was performed end to side to the
posterior tibial artery at the ankle. Anastomosis to major
vessels at the ankle was performed because of the severity
of the PVD.The distal venous arch of the foot was arterialized end to side to the radial artery to improve ow to
the ischemic toes. (e, f) Healed ap at 2 months. The
patient initially dehisced his ap due to inattention in the
early postoperative period. A total contact cast was then
used to allow delayed healing. (g) Upon resumption of
ambulation, the ulcer began to recur due to uncorrected
prominence of the third and fourth metatarsal heads.
Attention to biomechanics with adequate bony resection
before reconstruction would have prevented this complication. The ulcer resolved with Achilles tendon
lengthening
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