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210
Fig. 15.7 Clinical case: A 60-year-old woman; osteomyelitis on open fracture Gustilo IIIB
C. Tiengo et al.
its proximal pedicle, which will be ligated and
sectioned at its origin in the posterior tibial
artery, or it is preserved to create a pedicled
ap (Fig.15.8). A skin island is drawn on the
middle third of the leg that will be included in
the transplant (Fig.15.9).
15.2.6 Peroneal Artery Perforator-
Based Propeller Flap
The peroneal artery perforator-based ap can be
readily elevated for use as a propeller ap following dissection [14]. A localized fasciocutaneous
ap that arises from a dissected perforator is an
example of this type of ap. Here, the proximal
leg’s skin can be used for surgical reconstruction
in the distal lower extremity, utilizing a propeller
ap with a 180-degree perforator to reliably ll
the soft tissue defect [15] (Fig.15.10).
15.2.6.1 Surgical Technique
Patient Positioning: The peroneal artery
perforator- based propeller aps are typically
positioned along the lateral aspect of the lower
leg from the lateral malleolus and can be iden-
tied preoperatively by Doppler ultrasound
scanning. The propeller ap’s size and form
must then be planned in the vicinity of the
principal perforator that is closest to the aw.
The distance between the perforator closest to
the defect location plus the longitudinal length
of the defect equals the longitudinal length of
the ap.
Incision: An anterior or posterior incision is
done, depending on where the defect is
located.
The shape and size of the propeller ap based on
a perforator are contingent upon the defect
region and the perforator’s limiting spatial
constraint.
In order to create an isolated and mobilized fas-
ciocutaneous ap that can be rotated 180
degrees to match the defect, the perforator is
dissected to allow for rotation and mobility.
The donor-site area that was opened by the
ap’s rotation can either be sutured directly or
closed with skin grafting.
In brief, the following is a description of the spe-
cics of the surgical procedures: Step 1: To
construct the ap prior to surgery, the peroneal
perforator was located and marked using a
Doppler ultrasonography. Step 2: The ap was
created using the perforator location that was
15 Orthoplasty intheManagement ofLower Limb BJI
Fig. 15.8 Tibial resection with extensive debridement; Tibial pro-gap bula perforator bone ap
211
Fig. 15.9 At 7months full weight with extended knee brace; no pain
assessed before surgery; the perforator vessel
was used as the rotational axis, and the pos-
terolateral border of the bula was used as an
axis. The large propeller is located close to the
axis. The distance between the pivot point and
the distal point of the wound is less than the
length of the large propeller by 0.5–1cm. The
region between the axis point and the aw is
the tiny propeller. Step 3: The anterior edge of
the ap was dissected in accordance with the
preoperative design. The width of the ap is
1–2cm wider than the defect, and this size difference is determined by the thickness of the
subcutaneous fat. Step 4: In order to lessen the
obstruction to venous drainage caused by the
compression of the vascular pedicle following
rotation, the fascia tissues of the intermuscular
septum surrounding it were also carefully
212
Fig. 15.10 Clinical case: male; 40-year old; calcalnear fracture previously treated with plates and screws and primary
closure
C. Tiengo et al.
Fig. 15.11 Dissection of the perforator enables rotation
and allows sufcient mobility so that a fasciocutaneous
ap can be isolated and is then rotated 180 degrees like a
“propeller.” The opened section due to the rotated ap
being moved away from its point of origin is then repaired
removed. Step 5: The vascular pedicle’s con-
ditions were observed following its twisting
and compression due to the 180-degree rota-
tion. Step 6: If blood circulation was good
after the rotation, the ap was sutured to the
wound and the donor site of the ap was
sutured directly (Figs.15.11 and 15.12).
15.2.7 Sural Flap
The sural ap is a pedicled option for restoration
of small defects of the Achilleal and the lateral
malleolar region (Fig.15.13). It is based on the
sural artery that extends on the posterior aspect of
the calf with numerous anastomosis with the
with direct suturing or skin grafting. The proximal point
of the propeller ap and the pivot point of the ap (the
position of the peroneal perforator visible in the third,
fourth, and fth gures); and (last gure) the distal point
of the wound
Fig. 15.12 Eight month follow-up showing satisfactory
mobility recovery and excellent functional-esthetic
outcome
peroneal artery; the most distal is found approximately three ngers above the lateral malleolus
and is generally considered the pivot point. This
gh
15 Orthoplasty intheManagement ofLower Limb BJI
ac f
b
d
e
213
Fig. 15.13 Case report of a 79-year-old male with
chronic osteomyelitis due to posttraumatic tibial and bular fractures, treated with plaques (a). Radiological ndings showing delay of osteosintesis (b) and an augmented
metabolic activity at the tibial surgical site, suggesting
fasciocutaneous ap contains the sural nerve, the
sural artery, and the sural vein that ensures the
venous drainage [16]. It cannot be inset proximally to the junction of the two heads of the gastrocnemius muscle, as above this level nerve and
artery runs beneath the fascia.
15.2.7.1 Surgical Technique
Patient Positioning: the patient is placed in a
prone position.
Incision: The ap is usually raised from the junc-
tion of the two heads of the gastrocnemius
muscle, with the incision prolonged distally
among the expected course of the sural vein
and artery.
Harvest and ap transfer: The dissection is then
performed until the aforementioned pivot
point, therefore allowing isolation of the neu-
rovascular pedicle and its aponeurosis. Small
anastomosis branches from the peroneal artery
must be ligated in order to isolate the desired
underlying infection (c, d). After debridement of non-vital
tissue (e) the patient was positioned in a prone position
and a sural ap was harvested and elevated (f, g).
Postoperative result with inset of the ap to cover the initial tibial defect (h)
vessel. Finally, a distal incision is performed
to properly bury the pedicle.
Closure: A distal incision is performed to prop-
erly bury the pedicle, while the donor site can
be either closed with a skin graft or primarily.
15.3 Microsurgical Flaps
15.3.1 Anterolateral Thigh Flap
The anterolateral thigh (ALT) ap is a wellknown and versatile free ap that is based on the
lateral circumex femoral artery (LCFA) perforators. This branch of the profunda femoris artery
originates 8–10cm distal to the anterior superior
iliac spine, and it divides into three main
The descending one runs on the medial side of
the vastus lateralis giving off several perforator
vessels to the fascia and the overlying fat and
214
C. Tiengo et al.
skin. This ap can be raised as fasciocutaneous,
fascial, composite, including a portion of the rectus femoris muscle, or chimeric with a part of the
vastus lateralis muscle (Figs. 15.9 and 15.10).
Preoperative Angio–CT scan is mandatory to
properly plan the ap, especially in patients
where damage of the vascular system is
suspected.
15.3.1.1 Surgical Technique
Patient Positioning: The patient is placed in
the supine position; if the defect is contra-
lateral to the donor site, the lower extremi-
ties are usually parallel, otherwise there are
no specific position for the unaffected lower
limbs.
Incision: The skin island is generally taken cen-
trally over the chosen perforator, with a vari-
able dimension based on the defect size: skin
island up to 8 cm may be closed primarily,
although greater dimensions have been
described [17]. The pedicle length is around
11cm with a caliber of 2.1mm. The venous
drainage depends on a series of vessels that
drains in the greater saphenous vein.
Harvest: The ap is raised medially to laterally,
in the subfascial plan, isolating the chosen
perforator.
Vascular Pedicle Dissection: Once identied, the
perforator is carefully dissected retrogradely
through the muscle to its origin from the
descending branch of the LCFA. Depending
on the necessity of the pedicle length, dissection of the LCFA can be continued
proximally.
Flap Transfer: The ap is then inset to the recipi-
ent site. The vascular pedicle is anastomosed
using microsurgical techniques.
Closure: The incision in the thigh is closed in lay-
ers, and a drain is generally used to prevent
uid accumulation.
Postoperative Care: The patient is closely moni-
tored at least every two2 h for the rst 72h,
both clinically and with doppler technology,
in order to promptly intercept any sign of vascular compromise (Figs.15.14 and 15.15).
a
bc de
l
fghi
Fig. 15.14 Management of a patient with radiographically diagnosed chronic osteomielitis (a–c). After surgical
debridement of non-vital tissue (d), an ALT free ap was
elevated (e) and inset in the dorsal aspect of the foot, with
the lateral part disepithelized (f) and then buried to cover
the Achilles tendon for a better gliding (g). Postoperative
images show adequate functional outcomes (h, i) and
radiographical signs of healing (j)
fg
15 Orthoplasty intheManagement ofLower Limb BJI
215
a
c
be
d
ij k
Fig. 15.15 Clinical case of a calcaneal osteosarcoma (a,
b) reconstructed with a titanium prosthesis (c, d). The
orthopaedic device then suffered from local infection that
caused necrosis of the soft tissue (e, f). Microsurgical
reconstruction with an ALT-free ap was then performed:
ap planning (g), pedicle isolation (h), and inset (i).
Postoperative results are shown in images (j) and (k)
h
15.3.2 Latissimus Dorsi Muscle Flap
With a maximum size of 20 by 40cm, the latissimus dorsi muscle is the biggest muscle in the
body, and thus able to cover extensive soft tissue
defects (Fig.15.11). Despite its size, the removal
of the muscle causes no functional impairment
in the patient. It is the biggest ap that can be
harvested on a single pedicle and can also be
combined with the scapular, parascapular, and
serratus aps to form a chimeric ap that may
cover even larger wounds. Because of the muscle thickness (<1cm in the normal population),
this ap can be placed over uneven surfaces
with ease.
The muscle originates from the thoracolumbar
fascia posteriorly and from the inferior iliac crest
inferiorly. It inserts into the humerus where it
adducts and internally rotates the arm. The posterior axillary fold is formed by the narrowing of
the superior aspect of the muscle before transitioning into the tendon of insertion. Innervation
is from the thoracodorsal nerve, a branch of the
posterior cord of the brachial plexus that accom-
panies the thoracodorsal artery that is usually the
second branch of the subscapular artery (after the
circumex scapular branch). From its origin on
the axillary artery, the subscapular axis can provide a pedicle up to 15cm long. The pedicle can
be harvested either distally from the undersurface
of the muscle or proximally from the axilla. The
thoracodorsal vessels are normally split into two
muscular branches, the transverse and the lateral
(or vertical) branch that diverge at a 45-degree
angle. Thus, the muscle can be divided
longitudinally to form a bilobed or two-tongued
ap, or the muscle paddle can be formed by the
irroration territory of only one distal branch of
the thoracodorsal artery.
15.3.2.1 Surgical Technique
Incision: The lateral border of the latissimus is pal-
pably identied and outlined with a marking
pen. The incision is then marked from the axilla
or the posterior axillary fold inferiorly and
medially over the latissimus muscle, with the
recipient site defect dictating the incision length.
If a skin paddle is necessary, a pencil Doppler is
216
ij
C. Tiengo et al.
used to identify and map out the perforators of
the distal branches of the thoracodorsal artery
that are then marked over the ap.
Harvest: Anterior and posterior skin aps are
raised to expose the muscle, with dissection
proceeding to the extent of the pocket neces-
sary for an adequate muscle size harvest.
Smaller muscles can be taken if the entirety of
the muscle is not needed. Vascular supply of
the remaining muscle will be granted from
perforators of the lumbar and intercostal arter-
ies. The inferior angle of the scapula is where
the superior edge of the latissimus is located.
It is important not to dissect underneath the
serratus when raising the ap from inferior to
superior. Once identied, the superior edge of
the latissimus is elevated and dissection then
proceeds toward the midline, where the mus-
a
b c
cle is divided from its insertion. Harvest then
continues inferiorly to free the medial muscle
insertion and then underneath the muscle
toward the axilla.
Vascular Pedicle Dissection: On this plane, the
pedicle is identied and followed proximally
up to the desired length. The branch to serratus is ligated, as well as the circumex scapular branch if more length is necessary.
Closure: The donor site is closed primarily.
Suction drains are usually placed and the
patient is allowed to move the ipsilateral arm
postoperatively.
Postoperative Care: The patient is closely moni-
tored at least every 2h for the rst 72h, both
clinically and with doppler technology, in
order to promptly intercept any sign of vascular compromise (Fig.15.16).
e
gh
Fig. 15.16 Management of chronic osteomyelitis after
osteosynthesis of a tibial fracture with plaque (a, b). After
hydrodebridement of non-vital soft tissue (c, d), a latissimus dorsi ap with a skin paddle was drawn (e). The ap
was elevated (f) and inset (g) distally in the medial aspect
d
of the leg, with the remaining tegmental defect covered
with a skin graft. Postoperative image shows no recurrence of bone infection (h), while radiographic images
demonstrate preoperative sign of a lack of osteosynthesis
(i) and a follow-up with good healing of the tibia (j)
f
15 Orthoplasty intheManagement ofLower Limb BJI
217
15.3.3 Gracilis Free-Flap
Both the reversed gracilis pedicle ap and the
gracilis free ap offer reliable soft tissue coverage
and promote wound healing in complex knee
injuries. However, there are some key differences
between the two techniques. The reversed gracilis
pedicle ap is a simpler and less invasive procedure compared to the gracilis free ap, which
requires microvascular anastomosis. The reversed
gracilis pedicle ap is also associated with a lower
risk of donor site morbidity, as it does not require
the sacrice of the gracilis muscle. On the other
hand, the gracilis free ap allows for a greater
degree of customization, as it can be harvested as
a muscle-only, muscle-skin, or muscle- bone composite ap. This allows for better matching of the
contour and volume of the defect. Additionally,
the gracilis free ap can provide stable soft tissue
coverage and promote bone healing, making it
suitable for more complex cases. The reversed
gracilis pedicle ap and the gracilis free ap are
both valuable tools in the armamentarium of
orthopedic and trauma surgeons. The choice
between the two techniques depends on the specic needs of the patient and the extent of the soft
tissue defect. Further research and renement of
surgical techniques will continue to enhance the
role of these aps in soft tissue reconstruction.
The gracilis free ap is a versatile surgical
technique used for the reconstruction of soft tissue defects and bone defects around the knee.
This procedure involves harvesting the gracilis
muscle, along with its vascular pedicle, from the
inner thigh and transferring it to the recipient site,
where it is used to cover the defect and promote
healing. The gracilis free ap is indicated for
cases of soft tissue trauma, such as open fractures, degloving injuries, and extensive soft tissue
loss, as well as for bone defects resulting from
trauma, infection, or tumor resection. It is particularly useful in cases where local tissue is insufcient or compromised. Preoperative planning is
crucial for the success of the gracilis free ap.
The surgeon must carefully assess the size and
location of the defect, as well as the quality of the
surrounding tissue. Imaging studies, such as CT
of the defect and the condition of the bone.
15.3.3.1 Surgical Technique
Patient Positioning: The patient is placed in the
supine position with the affected limb elevated
and the thigh abducted and externally rotated
to expose the inner thigh.
Incision: A longitudinal incision is made along
the medial aspect of the thigh, starting at the
pubic tubercle and extending distally to the
knee. The incision is deepened through the
subcutaneous tissue to expose the gracilis
muscle.
Muscle Harvest: The gracilis muscle is identied
and dissected free from its surrounding attachments, preserving its vascular pedicle. The
muscle is then divided at its origin and insertion, leaving the vascular pedicle intact.
Vascular Pedicle Dissection: The vascular pedi-
cle of the gracilis muscle is carefully dissected, preserving the main artery and vein.
The pedicle is then ligated distally to prevent
bleeding.
Flap Transfer: The gracilis muscle, along with its
vascular pedicle, is transferred to the recipient
site. The muscle is positioned over the defect
and secured in place using sutures. The vascular
pedicle is then anastomosed to the recipient
vessels using microsurgical techniques.
Closure: The incision in the thigh is closed in lay-
ers, and a drain may be placed to prevent uid
accumulation.
Postoperative Care: The patient is closely moni-
tored for signs of ap or vascular compromise.
Physical therapy may be initiated to promote
early mobilization and prevent contractures.
The gracilis free ap is a valuable technique
for the reconstruction of soft tissue and bone
defects around the knee. Through careful preoperative planning and meticulous surgical technique it can provide several advantages including
reliable soft tissue coverage, preservation of the
main artery and vein, minimal donor site morbidity, ability to provide muscle, skin, or muscle- skin
composite aps and a good esthetic outcome.
Clinical Case 16-year-old male, unstable open
fracture of Gustilo type III B in the right lower limb.
The open fracture led to the diagnosis of osteomyelitis affecting the site of the open fracture.
218
C. Tiengo et al.
The patient was involved in a road accident
that resulted in an unstable open fracture of
Gustilo type III B in the right lower limb. The
open fracture led to the diagnosis of osteomyelitis affecting the site of the open fracture.
The patient underwent intensive treatment,
which included the application of negative pressure therapy (NPWT) for 23days with continuous instillation. The treatment aimed at mitigating
the infection and promoting healing of the unstable open fracture, while simultaneously reducing
the risk of complications such as sepsis and
osteomyelitis.
After the treatment, the patient showed signs
of improvement, with a reduction in pain and an
increase in the mobility of the affected limb.
Laboratory tests conrmed a decrease in signs of
infection and a better response from the immune
system. The patient was then discharged with
instructions for regular follow-up and oral antibiotic therapy to complete the treatment of osteomyelitis. The case illustrates the importance of
timely and appropriate treatment for unstable
open fractures, especially when associated with
complications such as osteomyelitis. The use of
NPWT with continuous instillation has proven to
be effective in treating such conditions, reducing
the risk of complications and promoting optimal
healing.
Then, a gracilis microsurgical ap has been
positioned with bone transport technique.
15.4 Conclusion andPossible
Complications
It is essential to properly and treat possible soft
tissue complications early, mainly because they
can result in delay of the orthopedic operations
that are sometimes necessary, especially in
trauma, where external xation is necessary.
Flap failure is the most tragic scenario in these
operations, while wound dehiscence, infection,
seroma, or hematoma formation are among the
most common complications. Simple wound
healing disorders such as dehiscences or infections are oftentimes consequential to the surgical
expertise, whereas drains are effective to avoid
hematoma or seroma formations that can further
lead to a reduction of the blood support and ultimately lead to a failure of the procedure. Flap
congestion or ischemia usually depends on the
15 Orthoplasty intheManagement ofLower Limb BJI
219
accuracy of the anastomosis and the status of the
patient’s vessels. In pedicled and propeller aps,
necrosis can also be caused by an improper placement of the ap itself that leads to a reduced
blood ow because the pedicle is squeezed or
twisted beneath the soft tissues. To promptly recognize possible suffering of the pedicle, it is
mandatory that at least in the rst 72h the microsurgical ap is clinically inspected to identify
early signs of venous or arterial deciency (i.e.,
congested or pale skin paddle), alongside with
Doppler examination of the pedicle.
The goals of surgical therapy for chronic
osteomyelitis are skeletal stability restoration,
dead space management, and debridement. The
primary objectives are skin closure, bone union,
and infection healing. The so-called radical
resection of all contaminated bone and soft tissues is a crucial step in the management of osteitis, and it may lead to a very difcult restoration.
Our ndings and the literature suggest that onestage surgical treatment of chronic osteomyelitis
may be a useful strategy for some patients, particularly when there is a signicant impairment
of local soft tissue and bone exposition and when
immediate bone coverage with vascularized soft
tissue is required [18]. Introducing healthy blood
vessels from vascularized tissues to damaged tissues protects against further tissue loss from
brosis, infection, and desiccation and creates an
ideal setting for bone mending. Based on related
disorders, defect characteristics (wound location,
size, and insufcient tissue components), and the
patient’s reconstructive needs, the right ap must
be chosen.
Single-stage management has been introduced
with limited indications for persistent osteomyelitis. The benets include decreasing and shortening the patient’s morbidity due to a single
surgical procedure; enabling a full debridement
without worrying about the size of the resulting
defect because of simultaneous skin and bone
reconstruction, which can eliminate the problem
of lling dead spaces; and providing immediate
bone reconstruction and coverage with a wellvascularized tissue that has its blood supply independent of surrounding tissue and, as a result,
delivers oxygen and antibiotics to the bone.
Depending on the location and the size of
the soft tissue defect, divers aps can be used to
successfully preserve the underlying osteosynthesis material and be responsible for the nal
treatment of the chronic osteomyelitis: for
proximal small defects, a variety of local aps
are available, while distal tissue coverage, as
well as open fractures (that thus usually require
large debridements), free aps are the primary
options.
Vascularized fasciocutaneous or musculocutaneous aps offer signicant advantages in the
healing of bone infections by providing a robust
blood supply to the affected area. These aps,
though differing in volume, share the crucial
characteristic of being vascularized tissues,
which play a pivotal role in stabilizing bone
infection. Furthermore, these aps contribute to
wound coverage and protection, minimizing the
risk of further contamination and promoting a
favorable environment for bone healing. Overall,
the incorporation of vascularized fasciocutaneous or musculocutaneous aps represents a valuable strategy in the management of bone
infections, facilitating improved outcomes and
reduced morbidity for patients.
An orthoplastic approach is then crucial to
better coordinate surgical timing to obtain the
best outcome for each patient that needs to be
planned individually.
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