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Orthoplasty intheManagement
ofLower Limb BJI
CesareTiengo, FrancescaMazzarella,
DanieleBrunelli, PasqualeZona, FrancoBassetto,
MariachiaraCerchiaro, AndreaAngelini,
andPietroRuggieri
15
15.1 Introduction
Osteomyelitis, a severe and debilitating bone
infection, poses a signicant challenge to both
patients and healthcare professionals, necessitating innovative approaches for effective treatment
and reconstruction. In the realm of plastic surgery, the management of osteomyelitis has witnessed a transformative change with the evolution
of both microsurgical and non-microsurgical
approaches. Through an in-depth analysis of the
current literature, case studies, and expert
insights, this chapter seeks to bridge the gap
between theoretical knowledge and practical
application, facilitating a nuanced understanding
C. Tiengo (*)
Reconstructive and Aesthetic Surgery at the
University of Padua, Padua, Italy
e-mail: cesare.tiengo@unipd.it
F. Mazzarella
Loughborough University, London, UK
e-mail: francesca.mazzarella@aopd.veneto.it
D. Brunelli
University of Modena, Modena, Italy
e-mail: daniele.brunelli@aopd.veneto.it
P. Zona · F. Bassetto
University of Padua, Padua, Italy
e-mail: franco.bassetto@unipd.it
M. Cerchiaro · A. Angelini · P. Ruggieri
Department of Orthopedics and Traumatology and
Oncological Orthopedics, University of Padua,
Padua, Italy
e-mail: andrea.angelini@unipd.it; pietro.ruggieri@
unipd.it
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2025
P. Ruggieri et al. (eds.), Bone and Joint Infections, https://doi.org/10.1007/978-3-031-96383-4_15
of the intricacies involved in the plastic surgical
treatment of osteomyelitis, providing perspectives on the multifaceted strategies employed to
address incapacitating bone infections.
The integration of microsurgery into the plastic surgeon’s armamentarium has revolutionized
the treatment of osteomyelitis by providing precision and exibility in reconstructive options.
Vascularized bone grafts, free aps, and composite tissue transfers have become instrumental
in not only eradicating infection but also restoring form and function. This chapter will delve
into the intricate details of microsurgical and
non- microsurgical interventions, exploring the
selection criteria, surgical techniques, and outcomes associated with these cutting-edge
procedures.
Furthermore, a holistic understanding of
osteomyelitis demands an exploration of the
underlying etiology, diagnostic modalities, and
antimicrobial therapies that form the foundation
of any successful treatment plan.
Concurrently, non-microsurgical approaches to
osteomyelitis have also demonstrated signicant
advancements, offering viable alternatives in certain clinical scenarios. Local and regional aps,
antibiotic impregnated bone cement and bioengineered scaffolds are among the non- microsurgical
techniques that have gained success [1].
While dehiscence of the soft tissue overlying
the incision may occur, most patients undergoing
arthroplasty or osteosynthesis have a
201
202
C. Tiengo et al.
straightforward postoperative wound healing
course. A soft tissue, bone, or implant infection
may exacerbate the ensuing abnormalities in
1–12% of patients. Severe soft tissue loss or
supercial skin loss may coexist with such infections. Therefore, the presence of exposed metal
or bone frequently adds to the complexity of the
issue. There is no universal agreement on how to
treat wound exposure, despite the fact that it puts
the implant and the bone at danger. The numerous factors affecting the management alternatives
are mostly to blame for this.
15.1.1 Conservative Approach
We have witnessed an increased number of infections resulting from surgical procedures related
to these traumatic lesions, which frequently take
the form of posttraumatic osteomyelitis and serious soft tissue infections. This is due to highenergy trauma with extensive damage to soft
tissues, necessitating more aggressive treatments
for open and closed fractures. In the given situation, osteomyelitis, especially posttraumatic
osteomyelitis, is a serious public health concern
due to the steady rise in traumatic injuries and the
consequences they cause [2].
Treatment for osteomyelitis, especially those
involving implants, is largely dependent on
both appropriate antibiotic therapy and signicant surgical debridement. The hazards of bacteremia resulting from surgical manipulation of
infection without sufcient antibiotic coverage
are mitigated by initiating empirical antibiotics
during anesthetic induction. However, it has no
effect on the positive cultures obtained during
the process. When non-septic patients’ culture
samples are collected, empirical antibiotics can
also be administered. Given the signicance of
Staphylococcus aureus in epidemiology, empirical coverage of this agent is advised. Even in cases
that were community-acquired, the local prevalence of methicillin resistance varies and needs
to be monitored. Initial treatment for acute infections may need thorough surgical cleansing followed by 4–6weeks of antibiotic administration.
Treatment for chronic infections should
involve extensive surgical debridement,
implant removal, and a 3–6month course of
antibiotics.
For more than 30years, the reconstructive ladder has operated in its contemporary, conventional
form. Its gradually more complex procedures to
treat wounds and other soft tissue defects are still
valid, as long as closure stays within these three
categories: (1) direct closure (primary or secondary); (2) nonoperative, topical wound healing
(advanced secondary intention methods, including NPWT); and (3) tissue transfer, which
includes both vascularized and nonvascularized
transfers (e.g., split- or full-thickness skin grafts,
fat transfer, cartilage or bone grafts, etc.) [3].
A guide for varying degrees of open wound
interventions is the reconstructive ladder. The use
of the ladder is altered by NPWT and, more
recently, NPWTi-d, as it is now simpler to move
between the ladder’s “rungs” by altering the initial defect during initial wound care. The parameters of the defect will frequently change during
the strategy selection process for wound treatment, making a less invasive method possible. As
a result, the reconstructive plan becomes more
exible and is modied at each NPWTi-d review.
Additionally, NPWTi-d can improve closure and
minimize the use of certain reconstruction
techniques.
15.1.2 Reconstructive Approach
While some authors have recommended free tissue transfers or pedicled fasciocutaneous aps,
such as an anterolateral thigh ap for the treatment
of periprosthetic infections of the knee, local muscle aps are considered the most useful for reconstruction in cases of an exposed prosthesis.
Primary soft tissue coverage with a medial or lateral gastrocnemius transposition ap has become
the primary reconstructive method of choice. The
proximally based gracilis and semimembranosus
muscles have been used for supplemental coverage after detachment of their tendon distally [4].
The gracilis muscle has been used both as a
free ap and as a proximally based pedicled ap,
df
15 Orthoplasty intheManagement ofLower Limb BJI
203
secondary to the adequacy of its proximal vascular pedicle and minimal associated morbidity. A
distally based gracilis muscle ap nourished by
distal vascular pedicles has been proposed to
cover areas of proximal tendon exposure in the
knee. In cases where a lateral or medial gastrocnemius ap is not available, or to treat large
defects of the soft tissues in combination with the
use of a gastrocnemius ap, we proposed the use
of an extended reversed gracilis ap based on
secondary pedicles (the GReSP ap) for the
reconstruction of large defects of the knee.
15.2 Pedicled Flaps
15.2.1 Rectus Abdominis Musculocutaneous Flap
The rectus abdominis musculocutaneous ap is
type III according to the Mathes and Nahai classication. It can be used as a muscular or as a
musculocutaneous ap, allowing several types of
reconstructions. Depending on the orientation of
its skin paddle, it is divided into transverse rectus
abdominis musculocutaneous (TRAM) ap and
vertical rectus abdominis musculocutaneous
(VRAM) ap. It is based on two main pedicles:
the deep inferior epigastric artery (DIEA) and the
superior epigastric artery. The rectus abdominis
muscle measures about 30 x 10cm and can be
used as pedicled or microsurgical ap. The principal vessel, the DIEA, measures 14–18 cm in
length and has a caliber of about 3–4mm [5]. It
arises from the external femoral artery and travels superomedially in the extraperitoneal tissue
piercing the transversalis fascia. After leaving
several branches, it enters the rectus sheath anterior to the arcuate line. Normally, it divides into
two or three major vessels that run cranially into
the muscle belly, originating several muscular or
musculocutaneous perforators. These vessels,
which are usually bigger when originating from
the medial raw, supply the skin paddle. The main
venous drainage is granted by the deep inferior
epigastric vein, which is connected to the external iliac vein. Preoperatively, an angio-TC is
advisable to investigate the abdominal wall vessels. The VRAM is one of the principal solutions
for periacetabular reconstructions (Fig.15.1).
15.2.1.1 Surgical Technique
Patient Positioning: The patient is placed in the
supine position.
Incision: The orientation of the skin paddle is tai-
lored to the extension and on the orientation of
the defect.
Harvest: The ap is raised medially to laterally,
in the subfascial plan, isolating the chosen
perforator.
a b
c
Fig. 15.1 Management of an acetabular chronic infection using a VRAM pedicled ap (a), together with an
acetabular custom prosthesis (b). The ap is harvested
and inset (c, d), with postoperative outcomes demonstrat-
ge
ing total coverage of the initial defect (e). Radiographic
pre- and postoperative images are shown in images (f) and
(g)
204
C. Tiengo et al.
Vascular Pedicle Dissection: Usually, the rectus
sheath is approached medially, far from the
skin paddle, in order to preserve the skin perforators. The muscle can be easily separated from
the posterior fascia, but care must be taken
when handling the pedicle, which usually lies
on the posterior surface of the muscle belly.
Flap Transfer: The ap is then inset to the recipi-
ent site. For acetabular defects, the ap is
tubulized onto the inguinal area and inset at
the desired site; the insetting of the ap must
be tension-free to avoid necrosis, ap loss, or
dehiscences. In case a free ap is necessary,
the pedicle is ligated proximally and transferred to cover the damage.
Closure: In the case of large defects, a synthetic
mesh or an acellular dermal matrix can be used
to restore the integrity of the donor site. Even
though both alternatives have been described,
most authors prefer the synthetic options, especially to avoid long-term hernias or bulging,
which are costly and may be challenging to
manage. It is very important that the mesh does
not decubitate on the pedicle and its course is
regular and without twistings or kinkings.
Postoperative Care: To minimize dehiscences,
the patient is placed in a semi-orthostatic position with the bed inclined at 45 degrees for the
rst 3 days after the operation. Additional
abdominal girdle must be worn for approximately 40–60days.
15.2.2 Reversed Gracilis Pedicle Flap
forCoverage ofaTotal Knee
Prosthesis
Total knee arthroplasty (TKA) is a common
procedure for end-stage knee arthritis.
However, complications such as wound dehiscence, infection, and exposure of the prosthesis can occur, necessitating soft tissue coverage.
The reversed gracilis pedicle ap, introduced
by Masquelet etal. in 2018, has gained popularity for its simplicity and reliability in providing soft tissue coverage around the knee.
The ap is based on the descending branch of
the medial circumex femoral artery (MCFA),
which supplies the gracilis muscle. The pedicle
is dissected in a retrograde manner, preserving
the main trunk of the MCFA.The ap is then
rotated 180 degrees and tunnelled subcutaneously to cover the exposed prosthesis. The
gracilis muscle provides a robust and well-vascularized soft tissue cover, reducing the risk of
infection and promoting wound healing. The
reversed gracilis pedicle ap has been shown
to have a low complication rate and excellent
functional outcomes in patients undergoing
TKA.
The gracilis muscle belly is depicted during
its mobilization as a reversed ap based on its
secondary pedicles. The muscular dissection is
carried to the entry of the proximal secondary
pedicle. The proximal tendon of the gracilis
muscle is then transected to provide the maximal length for the muscle ap. After adequate
blood ow is conrmed, the main vascular and
nervous pedicles are ligated. The muscle ap is
reversed 180 degrees and tunnelled under the
residual skin of the anterior aspect of the distal
part of the thigh, in order to reach the exposed
prosthesis.
Clinical Case Total knee prosthesis exposition
in a 72-year-old woman with preliminary CT
angiographic study and its repair through reversed
gracilis pedicle ap.
15 Orthoplasty intheManagement ofLower Limb BJI
205
One of the most challenging problems for surgeons performing knee joint reconstructions is skin
necrosis after total knee arthroplasty, which is a signicant complication. The greatest approach to
lower the likelihood of deep infection, prosthetic
implant removal, or amputation is through early
reconstructive intervention. Rather than employing
local fasciocutaneous aps or tissue expanders to
cover such lesions, the presence of many scars over
the knee area and the resulting poor skin vascularization sometimes need the use of a pedicled muscle
ap dissected from the leg. A common and proximally based pedicled ap is the gracilis muscle,
which is distantly based and fed by secondary vascular pedicles and can be an effective addition or
substitute to a medial or lateral gastrocnemius ap.
206
C. Tiengo et al.
15.2.3 Gastrocnemius Flap
The gastrocnemius ap is probably the most useful for covering the leg and knee (Figs. 15.2,
15.3, 15.4, 15.5 and 15.6). The sampling tech-
nique is simple and the blood supply is reliable.
Both upper extremities of the gastrocnemius are
supplied by the sural arteries which come from
the popliteal artery and which are accompanied
by motor nerves. Both can be mobilized on their
own neurovascular peduncle. The blood supply
is type 1 sec. The Mathes and Nahai classication [6].
The medial upper extremity is used more often
than the lateral. The medial head is longer and its
rotation arc allows easy coverage of the proximal
third of the tibia and the anterior and medial
aspect of the knee.
Fig. 15.2 Clinical case
of a 60-year-old man
with Gustilo II fracture
15.2.3.1 Surgical Technique
Patient positioning: the patient is supine with an
extra-rotated limb and semi-exed knee. The
incision begins in the middle of the calf,
behind the posteromedial edge of the shinbone, and then curves proximally to reach the
popliteal fossa.
Incision: the incision may be extended along the
thigh. Particular care must be taken to avoid
injury to the vein and saphenous nerve. The
deep aponeurosis is incised on the same line
as the skin incision [7]. The muscular plane is
developed by inserting a nger between the
soleus and the medial head [8]. The sural
nerve is located on the posterior surface of the
gastrocnemius, enclosed in an aponeurotic
layer. The nerve is freed and separated posteriorly. The space between the two ends of the
Fig. 15.3 Sculpt of the gastrocnemius ap and its transposition to cover the bloody area and its coverage with dermoepidermal graft
15 Orthoplasty intheManagement ofLower Limb BJI
207
Fig. 15.4 Fu after 1year with good functional recovery
muscle is identied, sparing the neurovascular
peduncle. The distal tendon is dissected. The
muscle is gradually raised distally/proximally.
The motor nerve must be interrupted to avoid
postoperative pain caused by muscle contrac-
tion. The arc of rotation can be increased to
free the origin of the muscle from the femur
(Figs.15.3 and 15.4). The medial head of the
gastrocnemius, isolated on its vascular pedun-
cle, must be passed underneath the semitendi-
nosus and the gracilis, so as to reach the
anterior surface of the knee [9].
15.2.4 Soleus Flap
The soleus is particularly useful to cover the
leg’s defects. It is located supercially in the
posterior compartment and often it remains
unharmed in open fractures of the middle third
of the shinbone, also for this reason its elective is
the middle third of the leg. Due to its size, often
it is necessary to resort to the preparation of a
medial hemisoleus which is simpler than trans-
ferring the entire muscle. The muscle is type II
sec. The Mathes and Nahai classication [6]. It
is vascularized by the posterior tibial and peroneal arteries which send many branches to the
muscle. Each of the arteries supplies a proximal
pedicle, a large median pedicle, and smaller,
variable pedicles along the distal third [10]. The
entire muscle can survive if supplied by the two
main proximal peduncles and for this reason the
muscle can be transferred without separating it
from its origin [11].
15.2.4.1 Surgical Technique
Patient positioning: the patient is placed supine
with the limb extrarotated and the knee
semi-exed.
Incision: the incision is made halfway between
the medial melleolus and the Achilles tendon.
It is carried proximally up to the upper quarter
of the leg posterior to the medial edge of the
shinbone, taking care not to damage the vein
and saphenous nerve. The plane between the
soleus and gastrocnemius is identied and
numerous subcutaneous peduncles are cauter-
208
ij
C. Tiengo et al.
a
bc
df
e
g
Fig. 15.5 Clinical case of a patient with surgical stula
(a) after posttraumatic reconstruction with a double knee
prosthesis (b, c). After pulsatile lavage of the orthopedical
device (d, e) a pedicled gastrocnemius ap was elevated
h
ized. It is important during the dissection to
spare the intermuscular fascia that divides the
two compartments in order to protect the pos-
terior shinbone neurovascular bundle. Halfway
between the medial malleolus and the knee
joint there is a large peduncle that derives
from the posterior shinbone vessels which
must be tied to allow rotation. The distal lib-
eration of the supercial aspect of the soleus
from the gastrocnemius, with which the soleus
forms the Achilles tendon, it represents
another crucial point. In this case, it will be
(f) and inset (g) to cover the soft tissue that was then covered with skin graft (h). Postoperative images (i, j) show
8months outcomes
necessary to free the soleus aponeurosis from
the gastrocnemius and incised to separate it
completely from the Achilles tendon, saving a
thin layer of aponeurosis to avoid retracting
effects on the distal part of the muscle. The
nal phase will consist of freeing the muscle
from its lateral insertions, the lateral margin
must be freed as proximally as possible to
allow rotation of the ap. The distal two-thirds
are then mobilized and once rotated to cover
defects on the anterior surface of the middle
third of the shinbone.
gi
15 Orthoplasty intheManagement ofLower Limb BJI
209
a
b
Fig. 15.6 Case report of patellar region necrosis following double knee prosthesis (a, b). To cover the soft tissue
a combination of medial gastrocnemius (c, d) and reverse
gracilis (e, f) pedicled aps was used: image g shows the
c
d
e
f
15.2.5 Vascularized Fibula Flap
In limb reconstructive surgery, the vascularized
bula transplant plays a very important role. The
vascularized bula represents one of the main
reconstructive aps for the repair of long bone
defects, in fact many bone areas and joints can
make use of this procedure, especially in cases of
serious trauma or surgery to remove tumors
(Fig.15.7). Removal of the bula does not produce functional decit. The main indication for
use is represented by long defects of the leg, particularly useful in defects greater than 5 cm.
Complex transfers benet from the inclusion of
the lateral hemisoleum or a skin package supplied by the peroneal artery in the transplant.
The bula is supplied by the artery of the same
name. The artery penetrates the bone at the junction between the proximal third and the middle
third [8]. Periosteum and muscle insertions contribute to vascularization. From a hemodynamic
point of view it is good to lift a muscular cuff
together with the bula, e.g., exor hallucis longus or tibialis posterior [12]. The raised peroneal
artery together with the bony tract can be useful
for restoring the continuity of the main vascular
axis of the recipient limb [8, 13].
15.2.5.1 Surgical Technique
Patient positioning: the patient is supine with the
limb slightly internally rotated and the knee
semi-exed, with a soft aid placed under the
ipsilateral buttock. The operation is performed
h
two muscles inset (gc: gastrocnemius, gr: gracilis). A skin
graft was then used to cover the area (h). Postoperative
images demonstrate good esthetical outcomes (i)
in the ischemic band. We proceed by incising
at the level of the middle third of the leg and
the aponeurosis is incised on the same line as
the skin incision to identify and develop the
plane between the soleus and peroneal muscles. The separation of the soleus and peroneal
muscles allows the exposure of the lateral
aspect of the bula. On the front of this bone,
there is the septum which separates the peroneal compartment from the extensor compartment and which is incised. Behind the bula,
the arch of the soleus is freed in its upper part.
The liberation of the soleus, posteriorly, projects the posterior tibial artery and the origin of
the peroneal artery [13]. The interosseous
membrane is incised near the bula. The exor
of the hallucis is freed extra-periosteally,
although a small section of the exor of the
hallucis must be left inserted on the bone, in
order to protect the peroneal vessels. Its divarication allows the exposure of the peroneal
vessels and the posterior tibial nerve. To
remember the vessels occupy a medial position with respect to the nerve. At the front, it
will be necessary to include a section of the
tibialis posterior muscle in the transplant. This
curtailment avoids injury to the peroneal vessels and improves venous return. The periosteum is incised and separated at the two ends
of the transplant. The transplant is isolated and
externally rotated to expose the tibialis
posterior. After ligating the vessels and sectioning distally, the graft remains connected to