Lower Extremity Reconstruction

1
Lower Extremity Reconstruction

• Dale Reynolds, MD
• UTHSC Houston
• Plastic and Reconstructive Surgery

2
LE Trauma

• Introduction
• Formidable
• Multiple injuries
• Airbags do not help
• MVC, falls, sports
• Salvage previously amputated

3
LE Trauma

• Introduction
• Mangled LE may require multiple procedures and
  years to RTW
• Francel 72 patients (IIIB)
• 93 salvage 28 RTW _at_42 mo
• Longer to weight bear
• Less willing to RTW
• Higher hospital charges
• 7 BKA 68 RTW _at_42 mo
• Bellvue 128 patients, 66 had 5 year follow-up
• 60 RTW (up to 10 years)

4
LE Trauma

• History
• Hippocrates (400 BC) described amputation for
  gangrene
• Celsus (5 BC) wound management with removal of FB
  and hemostasis
• Ambroise Pare (1540) described basic principles
  of amputation still used today
• Phantom pain
• Stump revision

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LE Trauma

• History
• Pierre-Joseph Desault (1770) coined debridement
• Incidence of post treatment osteomyelitis 80 WWI
  ? 25 WW II (Abx / aseptic technique)
• Korean War 62 amputation ? artery repair ? 13
• Plastic Surgery 1960 regional flaps
• Plastic Surgery 1970 free flaps

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LE Trauma

• Salvage
• Wound care, antibiotics, fracture management,
  soft tissue management, nerve / arterial repair
• Goal
• Salvage an extremity that is more functional than
  an amputation with prosthesis

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LE Trauma

• Anatomy
• Bipedal human, LE bear 100 while erect
• Plantar sensation is very important
• Posterior tibial loss is relative
  contraindication to salvage (in less than very
  motivated patient)
• Significant functional loss of leg muscle
  tolerable
• Hydrostatic pressures ? edema, DVT, venous
  stasis, atherosclerosis
• Anteromedial tibia with skin and subcutaneous fat

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LE Trauma

• Anatomy
• Bones
• Tibia
• 85 weight bearing
• Second longest bone in body
• Knee Articulates with femur
• Ankle Joins fibula to articulate with talus
• Protected laterally by anterior compartment and
  posteriorly by posterior compartment

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LE Trauma

• Anatomy
• Bones
• Fibula
• Articulates with tibia proximally at tibiofibular
  joint and distally at tibiofibular syndesmosis
• Connected to tibia in mid portion by interosseous
  membrane
• Less of concern in trauma unless lateral
  malleolus involved
• Excellent source of vascularized bone

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LE Trauma

• Anatomy
• Compartments
• Anterior, Lateral, Posterior, Deep posterior
• Table 1
• Figure 1

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LE Trauma

• Anatomy
• Compartment Syndrome
• Increased interstitial within osseofascial
  compartment of sufficient magnitude to cause
  compromise of the microcirculation leading to
  myoneural necrosis
• DeLee 6/104 (5.8) open, 5/411 (1.2) closed
• Blice 18/198 (9.1) open
• Cardinal signs Pain out of proportion, pain on
  passiveflexion or extension, palpably tense
• Loss of pulses is too late usually
• 30 mmHg (some use 40 mmHg) with Stryker
• If you suspect it then DO IT because morbidity of
  fasciotomy less than ischemia

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LE Trauma

• Anatomy
• General
• Bipedal human, full weight-bearing erect
• Significant functional muscle loss tolerable
• Hydrostatic pressures ? edema, DVT, venous
  stasis, high atherosclerosis (all less in UE)
• Anteriomedial tibia with little soft tissue
• Plantar sensation important for normal gait
• PT nerve loss is relative contra indication

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LE Trauma

• Anatomy
• Bones
• Fibula
• Multiple muscular and fascial attachments
• Lateral malleolus is usually only aspect to
  stabilize
• Excellent source of vascularized bone
• Tibia
• Bears 85 of weight
• Second longest bone
• Knee and ankle joints
• Articulates with fibula at tibiofibular joint (k)
  and tibiofibular syndesmosis (a)

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LE Trauma

• Anatomy
• Bones
• Tibia
• Interosseous membrane of shaft connects to fibula
• Laterally protected by anterior compartment
• Posteriorly protected by posterior compartment
• Prone to injury medially

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LE Trauma

• Anatomy
• Compartments
• Anterior, lateral, posterior, deep posterior
• Table I, Figure I

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LE Trauma

• Anatomy
• Compartment Syndrome
• Increased pressure in osseofascial compartment of
  magnitude to cause compression of
  microcirculation ? myoneural necrosis
• DeLee 6/104 (6) open, 5/411 closed (1.2)
• Blice 18/198 (9.1)
• Cardinal signs Pain OOP, pain on passive
  flexion/extension, palpably swollen/dense
  compartments
• Pulselessness is late and presence does not
  exclude
• 30 mmHG (up to 40)
• If you think about it do it, less morbid than
  necrosis

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LE Trauma

• Anatomy
• Fracture Classification
• Gustilo
• Often used but poor
• Grade IIIB/IIIC need plastic surgeon
• Table 2

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Management of mangled extremity

• Initial Evaluation
• ABCs, stabilize and control bleeding
• Treat serious injuries, amputate if unstable
• Figure 3
• Reconstructive Plan
• Bone/fasciotomy?vascular?debride--gt cover or
  repeat
• First week 18 complication rate, weeks 1-6
  50
• Some think 72 hours is most critical, others that
  complete debridement is most critical

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Management of mangled extremity

• Soft tissue avulsion
• Usually more extensive than appreciated initally
• Progressive thrombosis of subdermal plexus
• Be aggressive or willing to repeat
• Vascular Injuries
• Proximal to popliteal is emergency
• Distal to trifurcation
• All 3 vessels ? repair at least one
• 2 vessels ? try to repair one
• 1 vessel ? can ligate
• Angio OK if quick, O/W get on table if needed

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Management of mangled extremity

• Nerve Injuries
• Results often poor due to distance between spinal
  cord and motor end plates
• Peroneal nerve ? foot drop/dorsal foot sensation
  ? life long splinting and tendon transfers
• PT nerve ? lose plantar flexion/plantar sensation
  ? chronic wounding/ atrophy/ vasomotor changes
  (devastating)
• Often results in amputation
• Relative contraindication to salvage
• Repair as soon as possible

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Fracture management

• Fixate first to stabilize, for anastomotic
  stability and length
• Traction Rare, very sick, immobilize patient,
  upper leg
• Cast /splint Rare, closed leg or open tibia,
  window for would care possible, poor rigid
  fixation
• IMN
• Reamed nails
• Ream canal, rigid fixation, tight fit, early
  ambulation, good fracture reduction and fixation
• Only for minimally comminuted fractures without
  significant bone loss
• Lose endosteal blood supply (not for massively
  traumatized leg)
• Non-reamed nails
• Stable fixation, early mobilization
• Do not require stripping of entire canal
• Require immediate soft tissue coverage (exposed
  hardware)
• ORIF
• Requires immediate soft tissue coverage
• Requires periosteal stripping
• Introduces FB into wound
• External fixation
• Severely traumatized lower extremity (IIIB and
  IIIC)
• Can make free flaps difficult

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Fracture Management

• Bone gaps
• Non-vascularized cancellous bone
• Non-unions, lt 2-5 cm,
• Ilizarov bone lengthening
• Distraction osteogenesis, 4-8 cm
• Vascularized bone
• lt24 cm, leave proximal and distal 6 cm of fibula
• 15 mo to full WB
• Immediate
• Adequate debridement
• Confident in soft tissue coverage
• Delayed
• 6-12 weeks

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Soft Tissue Management

• STSG
• Muscle, parateneon, soft tissue

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Soft Tissue Management

• Local flaps
• Small defect often requires relatively large flap
• Fasciocutaneous
• Donor site almost always needs STSG
• Complications Distally based37.5 ,
  proximally18.5
• Often not option in IIIB or IIIC
• Muscle flaps
• Often in zone of injury and not option
• Proximal third
• Gastrocnemius Medial/ lateral
• Middle third
• Soleus
• Tibialis anterior bipedicled flap

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Soft tissue Management

• Free flaps
• Usually required for distal third
• High Energy wounds revolutionized
• 90-98 success
• Cross leg flaps
• Last choice
• Immobilize
• Contracture

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Chronic osteomyelitis

• Incidence
• 4.5 (109) Grade III
• 7 if debrided lt5 hrs later, 38 if gt5 hrs later
• Treatment
• Adequate (often radical) debridement
• Coverage with healthy tissue
• Primary closure (46 success)
• Local / free muscle flaps (gt80 success)
• Bone graft

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BKA Stumps

• Preserve as much length as possible especially
  around knee
• Work much reduced and function improved in BKA
  vs. AKA
• Advantages of distal amputations
• BKA 25 increased energy
• AKA 65 increased energy
• Quality if life (effort, stairs, hand controls to
  drive)
• Free flap salvage of BKA Stumps
• Ideal to have 6 cm of tibia below tubercle
• Foot fillet free flap option if foot uninjured
• No donor site morbidity
• Sensate (tibial, peroneal, sural)
• Galborous, durable skin

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Foot and ankle preservation

• Introduction
• Anatomy
• Arterial supply
• Angiosomes
• Motor and sensory nerves
• Muscle and fasciocutaneous flaps
• Lower leg and ankle
• Foot

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Wound care

• Debridement
• Vascular evaluation
• Nutrition
• Timing of closure

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Traumatic injuries

• Initial treatment
• Soft tissue repair

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Cancer

• Post resection defects
• Post radiation burns

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Infected diabetic foot

• Scope of problem
• Etiology
• Neuropathic and ischemic diabetic foot ulcer
• Treatment
• Forefoot coverage
• Midfoot coverage
• Hindfoot coverage
• Dorsum
• Ankle
• Post operative care