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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3648_Библиотеки_им_академика_М_И_Перельмана
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488
J. M. Felder and J. P. Hong
a
d
b
e
c
f
Fig. 32.14 Use of aps with long pedicles for plantar
forefoot reconstruction: when plantar coverage is needed
to salvage a TMA, the TDAP is a good choice because of
its thick skin and long pedicle. (a) Salvage of a TMA
defect with signicant plantar tissue loss. (b) Initially,
reconstruction was performed with a SCIP ap to the distal FDMA vessels. (c) The ap covered the distal bone
stumps, but provided inadequate coverage of the plantar
surface, with a need for skin grafting that broke down with
weight bearing. (d) Distal recipient vessels in the plantar
forefoot (e.g., for another SCIP ap) are relatively poor,
and therefore a TDAP ap was chosen with a long pedicle
created by intramuscular dissection. The pedicle had adequate reach for anastomosis to the PTA vessels. The
patient did not have ischemic disease, and so the incision
to accommodate the pedicle could be undermined and
closed gently over the pedicle without creating compression. (e, f) Healed SCIP/TDAP on left allowed return to
normal ambulation without assistive devices (the patient
also had reconstruction of a complex TMA defect on the
right with a latissimus myocutaneous ap)
32 Advanced Plastic Surgical Reconstruction Options intheLower Extremity
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489
Midfoot Wounds
Dorsal wounds of the midfoot, as with the forefoot, are favorable for reconstruction, with few
functional implications. Coverage should be thin,
so as to allow for tting into footwear. The SCIP,
PIA, and suprascarpal ALT aps (Figs.32.8 and
32.9) are excellent options here.
Plantar midfoot wounds frequently result from
biomechanical abnormalities such as Charcot
arthropathy and must be carefully evaluated for
underlying cause before considering reconstruction (Fig.32.2). Uncorrectable Charcot (or similar biomechanical abnormality) will create a high
likelihood for recurrence of the ulcer. Infected
Charcot arthropathy (osteomyelitis) should
prompt strong consideration for amputation, as
removal of bones of the midfoot generally leads
to worsening biomechanical abnormalities that
affect ambulation negatively. Scenarios where
salvage is most indicated for the plantar midfoot
a
are defects limited to soft tissue that result from
infection or trauma, with the underlying skeletal
structure intact. Instances of underlying skeletal
abnormality that can be corrected to preserve
ambulation (e.g., treatment of Charcot arthropathy with triple arthrodesis) are also good indications for soft tissue reconstruction [16–18].
Finally, occasionally, salvage in the setting of
biomechanical abnormalities and infection may
be reasonable if the goal is not ambulation, but
length preservation for transfer (Fig.32.15).
Hindfoot Wounds
Hindfoot generally refers to the plantar heel, as
dorsal and lateral defects at this level will be of
the ankle. Defects are commonly the result of
neuropathic ulceration and infection. Plantar heel
reconstruction has the opposite positive and negative considerations as forefoot reconstruction.
b
c
Fig. 32.15 Reconstruction of severe midfoot defect. (a)
A nonambulatory, wheelchair-bound, morbidly obese diabetic female with leukemia, a contralateral BKA, and
ankle varus deformity resulting from chemotherapyinduced peroneal neuropathy presented with a complex
lateral midfoot wound resulting from osteomyelitis of the
fth metatarsal. Reconstruction was indicated only in an
attempt to preserve limb length for independent transfers.
For an ambulatory or healthier patient, amputation would
d
have been a more functional result. (b) Anastomosis was
to the terminal perforating branch of the peroneal vessels,
with resection of the remaining intervening angiosome of
the wound. (c) The gracilis ap was chosen due to the
need for obliteration of extensive dead space, and an ETE
anastomosis was performed given the terminal position of
the vessels with respect to the wound angiosome. (d) With
a healed wound and a brace, the patient was able to use the
leg for transfer in and out of a wheelchair
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J. M. Felder and J. P. Hong
Blood supply is most likely to be preserved or
accessible, while bone sacrice is of high functional consequence. Thus, osteomyelitis of the
calcaneus requiring signicant bony resection,
regardless of vascular status, should prompt
strong consideration for amputation, as ambulatory function will be compromised (Fig.32.16).
Exceptions, again, are patients who are minimally or nonambulatory and require maximal
limb length preservation for independent transfer
(Fig. 32.1). In ambulatory patients where the
extent of calcaneal osteomyelitis is limited and a
limited partial calcanectomy can be performed
that will preserve functional ambulation, salvage
is indicated.
Isolated wounds of the medial, lateral, and
posterior heel without osteomyelitis are generally
excellent indications for reconstruction
(Fig.32.17). For wounds of the plantar heel, consideration should be given to using a ap with
thicker skin, such as gluteal and thoracodorsal
artery perforator aps, or aps from the circumex scapular system. Muscle can be used to cover
the heel, and conforms well, but has the propensity to atrophy, allowing the calcaneal tuberosity
to erode through the ap with time. A useful technique is to resect the tuberosity of the calcaneus
when approaching plantar heel reconstruction in
order to prevent this delayed erosion [19].
Reconstruction of heel wounds in the isch-
emic foot is a challenging scenario with a higher
failure rate than elsewhere in the foot. The heel
is a watershed area, which normally has a dual
supply from the posterior tibial and peroneal
arteries. However, in advanced PVD, the anterior tibial artery may be the only supply to the
foot. Therefore, when debriding according to
the angiosome concept, two angiosomes may
need to be debrided, resulting in a very large
defect. The success rates of heel reconstruction
are markedly higher when at least one of the
native vessels (PT or peroneal) is intact. When
only the AT artery is intact, reconstruction has a
high chance of failure. Surgeons must examine
the preoperative angiogram with these considerations in mind before deciding on reconstruction [20].
Ankle Wounds
Generally, an attempt at reconstruction should
always be made for ankle wounds. Good options
for bony fusion procedures or long-term antibiotic spacer placement make even infected
arthropathy of the ankle relatively salvageable
compared to the midfoot or plantar heel. Easy
access to three distinct recipient vessel systems
provides a hospitable environment for free tissue
transfer. Thin skin coverage is the ideal reconstruction at the ankle, and aps such as the SCIP,
suprascarpal ALT (Figs.32.7, 32.8), suprascarpal
SIEA (Fig. 32.18), PIA, distal lateral arm
(Figs. 32.19 and 32.20), and radial forearm
(Fig. 32.21) t the defect requirements nicely.
Muscle aps are an alternative that provide thin
coverage by atrophy.
Common scenarios requiring coverage at the
ankle are posterior defects involving the Achilles
tendon (Figs.32.8, 32.17, 32.18 and 32.20), ante-
rior defects related to failed arthroplasty or fusion
procedures (Fig.32.21), and lateral ankle defects
related to vascular (frequently venous) disease or
prior surgery (Fig.32.19).
ab
32 Advanced Plastic Surgical Reconstruction Options intheLower Extremity
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c
491
d
Fig. 32.16 Patients who are strong ambulators but have
extensive osteomyelitis of the calcaneus should be
strongly considered for below knee amputation, regardless of the wound size or vascular status. (a) A 46-year-old
diabetic man with a 2 year history of a chronic plantar
heel ulcer with osteomyelitis developed extension of the
infection to the Achilles tendon with acute abscess formation. The wounds are shown after incision and drainage.
Many options exist for ap coverage. (b) Plain radio-
graphs of the foot demonstrate advanced osteomyelitis of
the calcaneus, with cortical disruption and multiple areas
of cystic degeneration of the calcaneus. (c) MRI T1
images show avascular necrosis of the majority of the calcaneus. (d) MRI T2 images show osteomyelitis of the
entire calcaneus that is conuent with the plantar heel
wound. The patient went on to have an Ertl BKA and
regained the ability to run using a prosthetic within
3months
492
ab
J. M. Felder and J. P. Hong
c
Fig. 32.17 Defects of the non-weightbearing hindfoot
are very favorable for salvage, as only skin coverage is
required. (a) A 74-year-old ambulatory diabetic man with
history of prior TMA presented with acute infection of a
d
chronic posterior heel wound. (b) Defect following
debridement. (c, d) Stable coverage with ALT ap with
ETS anastomosis to PTA
a
32 Advanced Plastic Surgical Reconstruction Options intheLower Extremity
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493
b
c
Fig. 32.18 Coverage of the ankle with ultrathin skin
aps. (a) A 61-year-old obese female with a history of
diabetes and smoking presented with a chronic would of
18 months duration after surgical repair of a ruptured
Achilles tendon. (b) Because obesity made other skin ap
donor sites unfavorable, an ultrathin supercial inferior
epigastric artery (SIEA) ap was chosen and raised in the
subdermal plane just deep to the SIEV. (c) Healed ap at
3months with satisfactory contour match to the thin skin
of the ankle
494
J. M. Felder and J. P. Hong
a
b
d
c
f
e
g
Fig. 32.19 Thin skin coverage options for ankle defects.
Lateral ankle wound resulting from chronic venous dermatitis. In chronic cases, the zone of scar tissue surrounding the
wound may encompass the local perforating vessels, making perforator-to-perforator anastomosis undesirable. The
distal lateral arm/forearm ap is a useful very thin alternative to the SCIP, with a long pedicle to reach outside the
zone of scarring. The peroneal vessels can be easily accessed
behind the bula for lateral ankle wounds. (a) Chronic
venous stasis wound with surrounding zone of scarring. (b)
Design of distal lateral arm ap using very thin skin overlying lateral epicondyle. (c) Flap pedicle in situ adjacent to
radial nerve, demonstrating generous length of pedicle. (d)
Exposure of the peroneal vessels behind the bula. (e)
Completed end-to-side anastomosis to the peroneal vessels.
(f, g) Healed ap with satisfactory contour to lateral ankle
32 Advanced Plastic Surgical Reconstruction Options intheLower Extremity
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a
c
b
d
Fig. 32.20 The lateral arm ap can provide thin coverage
for the ankle in morbidly obese patients. (a) A 53-year-old
morbidly obese diabetic female with a BMI of 56 presented with a chronic Achilles wound of 7years duration.
(b) The forearm was the only anatomical area with a reasonable skin thickness match to the posterior ankle. A distal lateral arm ap is elevated. (c, d) Healed ap at
3months post-op with appropriate contour to the ankle
496
abc
J. M. Felder and J. P. Hong
Fig. 32.21 Anterior ankle wounds are often favorable for
reconstruction because bony fusion or arthroplasty procedures can address osteomyelitis. (a) A morbidly obese
diabetic man presented with a chronic, draining anterior
ankle wound with osteomyelitis following failed arthroplasty and multiple attempts at closure with biologic
matrices and skin grafting. (b) Defect following debride-
Massive Wounds
Massive wounds generally result from necrotizing infection or abscess and may cross anatomical areas, for instance, from the plantar foot up to
the proximal leg. These wounds often occur in
the setting of poorly controlled diabetes and noncompliance. Candidacy and methods for reconstruction must be selected on an individual basis
considering the extent of pathology, functional
status of the patient, and likelihood of compliance with a complex reconstructive effort that
may take months to heal. At times, necrotizing
soft tissue infection leaves a mostly skin-level
defect that is amenable to salvage even if massive. In the setting of massive wounds, large mus-
ment and placement of antibiotic cement spacer. (c) Stable
coverage with radial forearm ap. The radial forearm ap
was chosen rather than the SCIP because of the multiply
reoperative eld, with heavy scarring, which made anastomosis well outside the zone of injury preferable. The
patient returned to ambulation in a brace with the antibiotic spacer left in place
cle aps such as the latissimus may be the best
option to provide coverage (Fig.32.22). If skin
aps are used, then several aps may be necessary, and these can be performed to separate
recipient vessels, or “stacked” as ow-through
aps (Fig.32.23). However, our experience has
been that in the case of circumferential wounds
of the lower leg with circumferential disruption
of the lymphatic system, skin ap reconstructions are more prone to chronic edema than muscle ap reconstructions (Figs.32.23 and 32.24).
All of these factors should be considered when
approaching Step 1 of our algorithm above:
• “Consider the wound and the reconstructive
requirements.”
a
32 Advanced Plastic Surgical Reconstruction Options intheLower Extremity
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497
b
c
d
e
Fig. 32.22 Massive wounds often result from gas gangrene or necrotizing fasciitis. (a, b) A 37-year-old man
with Prader-Willi syndrome and type II diabetes developed gas gangrene resulting from an infected hallux ulcer.
The resulting defect included exposure of the anterior
compartment tendons in the distal leg, ankle, and dorsal
foot, as well as a rst metatarsal ray amputation defect of
f
the medial forefoot. (c, d) Coverage was achieved with a
split-latissimus dorsi muscle with a distal skin paddle.
The transverse branch of the muscle covered the proximal
leg wound. The descending branch of the muscle covered
the ankle and dorsal foot. (e, f) 8 months postoperative
demonstrating stable coverage with satisfactory contour
for shoe wear
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