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LOWER EXTREMITY RECONSTRUCTION

John R Griffin MD and James F Thornton MD

HISTORY The literature of lower limb wounds contains numerous contributions by orthopedic surgeons and plastic surgeons. Burkhalter1 and Aldea and Shaw2 trace the evolution of principles of lower extremity wound healing, wound management, and hard and soft tissue reconstruction. Although treatment concepts for the traumatized lower extremity did not change significantly until the major wars, several fundamental tenets of care were proposed early in its history. Pierre-Joseph Desault (1744-1795) introduced deep incisions for drainage and debridement of devitalized tissues. Louis Ollier (1825-1900) introduced plaster of Paris casting for fracture stabilization. Sir Arbuthnot Lane (1856-1943) published The Operative Treatment of Fractures in 1905. Lane subsequently sponsored Gillies and the debut of plastic surgery at the Cambridge Hospital at Aldershot in 1915. By the end of World War I, the concepts of fracture immobilization and early secondary suture were established. Winnett Orr developed a closed plaster treatment that avoided frequent dressings, irrigation, and wet antiseptic packs. In this technique, open wounds were covered with dressings and casts. Orr did not perform true debridement of the wound before the cast was applied, but did advocate incisions for drainage. The closed plaster method became the standard of care for leg injuries after WWI. Open wounds in the context of open fractures treated by Orrs method were frequently complicated by osteomyelitis. This prompted Trueta to perform more extensive debridement before applying the plaster. Trueta favored conservative debridement of skin together with radical removal of devitalized subcutaneous tissue and muscle; all bone was preserved. This revision of Orrs teachings became the accepted management from 1939 to early 1942, in the early years of WWII. Truetas clinical experiences confirmed the need to remove any tissue medium favorable to bacterial growth.

The second phase of management of lower extremity fractures lasted through 1943 and consisted of initial wide debridement, plaster immobilization, and secondary closure or skin graft as soon as clean granulations appeared. After 1943 fracture management entered a third phase that involved wide debridement at the forward surgical units. Closure was accomplished by delayed primary suture or graft at the base unit between the 4th and 6th day of injury. The closure was ideally accomplished before the appearance of granulation tissue. These were the origins of early delayed primary wound closure. The significance of these stages in the evolution of care is obvious when one compares the incidence of postfracture osteomyelitis following World War I (>80%) with that at the end of World War II (@25%). A fourth phase of lower extremity wound care is currently underway. Advances in orthopedic and plastic surgery in the past 30 years have influenced the management of open tibial fractures, soft tissue coverage, and chronic problems of the lower extremity. Technical advances in bone fixation and distraction, wound care, and soft tissue healing have greatly enhanced our ability to salvage the foot, leg, and thigh after trauma. An important role for lower extremity primary amputation after trauma still exists, however. Patients who suffer severe polytrauma and/or the more severe classes of open leg fractures may be better served by amputation than by attempted reconstruction. The modern dilemma is no longer how to salvage a lower extremity, but knowing when attempted salvage is not the best option for the patient. French and Tornetta3 review the recent literature of lower extremity trauma. Options for bone fixation and soft tissue coverage are discussed and the outcomes of reconstruction versus early amputation are analyzed. Heller and Levin4 review the updated principles of management of lower extremity wounds. Tomaino5 discusses recent data regarding management outcomes in severe open tibial fractures.

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BONE HEALING Rhinelander,6 Holden,7 and Macnab and De Haas8 discuss factors influencing fracture healing of long bones and the cellular events that take place in the healing fracture wound. The tibia is the most commonly used experimental and clinical model for understanding the phenomenon of bone healing. Sauer9 reviews the blood supply of the lower extremity from the inguinal region to the thigh, knee, and lower leg, including fascial perforators and septocutaneous vessels as well as major blood vessels. The regional circulation pertinent to flap design is emphasized. The tibial vascularity is described in detail by Rhinelander6 and Macnab and De Haas.8 The three main sources of blood supply to the tibia are the nutrient artery, the metaphyseal vessels, and the periosteal vessels. Originating from the posterior tibial artery, the nutrient artery penetrates the tibialis posterior muscle and enters the posterior tibia at the junction of the proximal and middle thirds. The cortical groove containing the artery extends distally and obliquely, traversing the cortex for about 5 cm. In this cortical canal the nutrient artery is vulnerable to injury by even a slightly displaced fracture. Once in the medullary canal, the nutrient artery divides and gives off a network of vessels supplying the cortex from the endosteal surface. The endosteal circulation thus supplies the inner two thirds of the cortex and the periosteal circulation supplies the outer one third (Fig 1). The periosteal vessels derive from the primary vessels of the limb and run perpendicular to the long axis of the bone. When a long bone is fractured, the nutrient vessels are disrupted and the endosteal circulation is disrupted to the point where the metaphyseal vessels enter the bone. The periosteal blood supply is maintained on both sides of the fracture line by virtue of its transverse orientation and becomes the chief nutrient source to the healing bone in many fractures. The essential requirements for healing of opposed fracture fragments are an adequate blood supply and proper stabilization.6 If stabilization is adequate, the source of blood supply to the fracture can be seen to influence the type of callus that forms, whether mostly medullary, periosteal, or intracortical.6 Medullary bridging callus develops around day 4 after injury in stable, nondisplaced fractures. Time

Fig 1. Blood supply to the tibia. Note linear pattern of endosteal circulation (nutrient artery and metaphyseal artery) subject to disruption with displaced fractures. Periosteal circulation is maintained unless soft tissues are avulsed (Type III). (Reprinted with permission from Byrd HS, Cierny G, Tebbetts JB: The management of open tibial fractures with associated soft-tissue loss: External pin fixation with early flap coverage. Plast Reconstr Surg 68:73, 1981.)

to union is shortest and the zone of fibrocartilage is minimal. The medullary or endosteal circulation is dominant throughout all healing phases of nondisplaced fractures.6 Periosteal bridging callus provides ancillary external support to the fracture and always contains a significant zone of fibrocartilage. The callus first appears on or about day 3, and its initial blood supply comes from the surrounding soft tissues and periosteum. When the endosteal circulation reconstitutes, the periosteum will assume new blood supply by the endosteal route. Periosteal bridging callus is extremely important in the union of displaced and comminuted fractures. Intracortical uniting callus fills the space between fracture fragments after reduction and fixation. Its blood supply is intraosseous, extraosseous, or a combination of both. Healing occurs only in areas of cortical bone contact, not just when bone fragments are in close opposition, as usually seen in compression plate fixation. Primary bone healing can take place in nondisplaced fractures and stable fractures after rigid fixation with a plate and screws, without an intermediate stage of fibrocartilage. But primary bone

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healing in this circumstance may not be the fastest course to full bony restoration, or restoration of strength. In fact, the disadvantages of plate and screw fixation, together with the results achieved with intramedullary rods and external fixation, have led to infrequent use of plates and screws for most tibial fractures today. Therefore, primary bone healing in tibial fractures is mainly a theoretical concept today. When using rods, casts, or external fixation, which is the norm with modern tibial fracture treatment, the bone will pass through a phase of cartilage-containing periosteal callus that assists in stabilizing and vascularizing the wound. Caplan10 suggests that pluripotential progenitor cells, referred to as mesenchymal stem cells, are attracted to the fracture site from nearby and distant sites throughout the body. The mesenchymal stem cells at the fracture site divide mitotically to form a blastaema that crosses the fracture site. Depending on the local concentration of growth factors, the blastaema differentiates and begins forming the missing skeletal tissues. One of the reasons childrens bones heal better and faster than adults may be that children have more progenitor cells available. Wray11 states that the periosteum is the origin of the pluripotential cells that enter the fracture site and contribute to the formation of callus. The delayed healing and inadequate callus seen when there is extensive periosteal destruction in and about the fracture support this hypothesis. The role of the soft tissues in fracture healing is not clear. Studies by Macnab and De Haas8 as well as Gothman12 suggest that the muscles contiguous to the fracture are the immediate source of blood to the fracture. The slow healing of certain displaced fractures may be due to scarce muscle tissue surrounding them. Holden7 tested this concept experimentally and showed the contribution by the surrounding muscle of vascular ingrowth to the injured bony cortex. He further showed that when the soft tissue envelope was rendered ischemic, initial revascularization occurred first in the muscle and secondarily in the skin. The restoration of intramedullary circulation in the bone followed the revascularization of the soft tissues. It was unclear whether the ischemic muscle was parasitic on the feeder vessels that would normally revascularize the bone, or whether ingrowth from the surrounding soft tissue was necessary before bone revascularization could

occur. Either way, the author concluded that bone revascularization essentially required wellvascularized soft tissues around it. CELL SIGNALING IN BONE HEALING Mooney and Ferguson13 believe that environmental factors affect the differentiation of pluripotential mesenchymal cells. Their observations hint at a golden period during which bone formation can be manipulated through physical measures. Stress in the form of compressive force may be important in the first 3 weeks of fracture healing. Barnes and colleagues14 review recent advances in cytokine and growth factor research and bone healing. Lieberman et al15 review the evolving potential clinical applications of several growth factors for improving fracture healing. TGF-beta, PDGF, and insulin-derived growth factors induce cellular proliferation in the laboratory, but their clinical application has not been determined. Locally instilled fibroblast-derived growth factor (FGF), on the other hand, significantly increases healing fracture strength over controls in a primate fracture model.16 Fibroblast growth factor-2 in a hyaluronidase gel accelerates fracture healing in nonhuman primates.15-17 Bone morphogenic protein (BMP) has also demonstrated clinical promise in accelerating fracture healing.15,18,19 Sciadini and Johnson20 showed that local BMP was as effective as autogenous bone graft in achieving union in experimental radius defects and significantly more effective than controls. In contrast to some of the cytokines, however, BMP may have specific dose requirements that could limit its clinical usefulness. As the promise of growth factors materializes, issues related to delivery mechanisms, timing, and appropriate dosages arise. Molecular carriers, viruses, gels, hyaluronidase matrixes, and creative use of gene therapy are all being tested for delivery of growth factors to healing fractures.15 Lieberman15 lists the following potential clinical uses of growth factor therapy:

for acceleration of fracture healing (in cases at


risk of nonunion)

in the treatment of established nonunions for the enhancement of primary spinal fusion 3

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in the treatment of established pseudoarthrosis


of the spine

Smoking and Tibial Fractures Smoking adversely affects bone healing. In a blinded retrospective study, Schmitz and colleagues24 demonstrated no significant difference in eventual union between smokers and nonsmokers with closed and Gustilo I tibial fractures treated with either external or internal fixation. The study did show that time to union in smokers was 69% longer than in nonsmokers. As one would expect, this trend towards delayed healing is also seen in the full range of open tibial fractures in smokers. Adams and associates 25 compared matched demographic groups of smokers and nonsmokers with tibial fractures and found the mean time to union in smokers to be 4 weeks longer than for nonsmokers. Limb Salvage Versus Primary Amputation Physicians who treat lower extremity trauma would like to have a reliable way to predict prognosis for each patient. The most important early decision to be made in the event of severe leg trauma is whether to reconstruct or to perform early amputation. Orthopedic and plastic surgeons generally agree that some lower extremity injuries are best served by reconstruction; others are candidates for primary amputation. Delayed leg amputation is considered a relative treatment failure, as this outcome suggests possible errors in the initial treatment rationale. Furthermore, delayed amputation has been linked to increased hospital costs, more operations, and increased patient disability, including sepsis and death.26 For the patient and the physician, few failures of treatment are as devastating as a nonfunctional salvaged limb. Technical victories that result in functional failures must be avoided. The concept that the most severe lower extremity injuries are best served by amputation makes sense, but reliable predictors of outcome are not clearly defined. Keller27 reviewed 10,000 cases of tibial fractures and noted that the risk of systemic complications rose in the presence of comminution, displacement, bone loss, soft tissue injury, infection, and polytrauma. Fracture location, configuration, and concomitant fibular fracture had no prognostic significance. Several authors have since attempted to use scoring systems to help them decide between limb reconstruction and amputation.28-30 Francel31 pub-

in the treatment of large bone-loss problems


OPEN TIBIAL FRACTURES Demographics Patients with severe lower extremity trauma often share traits that may affect their management and eventual outcome of treatment. MacKenzie and coworkers21 at Johns Hopkins prospectively studied the broad demographic characteristics of 601 patients with high-energy lower extremity trauma and note the following:

77% were male 72% were white 71% were between 20 and 45 years old 70% were high-school graduates (versus 86%
national average) nationwide)

38% had no health insurance (versus 20% they were twice as likely to have a history of
alcohol abuse than the national average Francel22 identified three demographic factors associated with reemployment after severe lower extremity injury:

age under 40 history of higher education (post high-school) white-collar employment


Predictors of an eventually poor outcome were identified in a large, multicenter, prospective observational study of severe lower extremity injuries,23 and include the following:

rehospitalization for a major complication low education level nonwhite race poverty lack of private health insurance poor social-support network low self-sufficiency 4

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lished a commonly quoted study that shows improved return-to-work rates after amputation (68%) compared with reconstruction (28%). A more recent study by Francel 22 showed that early postinjury reconstruction, appropriate soft tissue coverage, and early bone grafting significantly decreased the time to ambulation. The reemployment rate improved to 67% among patients who became ambulatory soon after reconstruction, but not in those for whom ambulation was delayed. The updated conclusion is that reconstructed patients who ambulate at the appropriate time may be able to return to work as often as patients who undergo primary amputation. Many studies attempt to use demographic data and trauma scoring systems to determine prognosis. The Lower Extremity Assessment Project (LEAP) was designed to compare outcomes of patients with severe lower extremity trauma. A large study by the LEAP group prospectively applied five major trauma scoring systems to more than 500 injured lower extremities, as follows:32

MESS: Mangled Extremity Severity Score LSI: Limb Salvage Index PSI: Predictive Salvage Index NISSSA: Nerve Injury, Ischemia, Soft Tissue Injury, Skeletal Injury, Shock, and Age of Patient Score

HFS-97: Hannover Fracture Scale - 97


Low test scores were useful in predicting which limbs could be salvaged. However, high trauma scores did not predict which limbs could not be salvaged. In conclusion, the five trauma scoring systems studied do not reliably predict which injured limbs should undergo primary amputation.32 Another study by MacKenzie, Bosse and colleagues33 analyzed a broad range of factors that could influence the ultimate outcome in severe leg and foot injuries. Bone loss was not found to be a factor, but severe soft tissue injury and absence of plantar sensation on presentation were prospective indicators of primary and delayed amputation. Lange et al29 report a 61% amputation rate in limbs with vascular injury (22% primary, 39% delayed). Crush injuries, segmental tibial fractures, and fractures in which revascularization was delayed for more than 6 hours generally had poor outcomes.

McNutt and associates34 reviewed 366 patients with tibial fractures following blunt trauma. Twelve percent of patients had clinical evidence of tibial artery injury; of these, 27 patients had angiographic evidence of at least one patent tibial vessel and adequate distal flow. The other 17 patients required operative repair of the injured tibial arteries because of persistent distal ischemia. The amputation rate in the vascular repair group was 35%. Patients who required amputation had a significantly greater incidence of three or more fascial compartments involved in muscular injury, two or more injured tibial vessels, failed vascular reconstruction, and a cadaveric foot at initial examination. No extremity was salvaged when more than two of these findings were present. A failed reconstruction led to limb amputation in all cases, even though 3 patients were noted to have patent vascular repairs at the time of amputation. Severe tibial nerve injury and an insensate foot are generally considered contraindications to reconstruction, although sporadic reports suggest that limb salvage combined with nerve repair can yield an acceptable result in selected cases. Higgins and coworkers35 report a case of open tibial fracture that was salvaged with external fixation, soft tissue coverage, and tibial nerve grafting. The patient recovered pressure sensation and sharp-dull sensation at 27 months postoperatively. The primary factors influencing the outcome in leg injuries are 1) degree of soft tissue damage; 2) presence or absence of plantar sensation; and 3) severity of vascular injury. Langes36 indications for primary amputation in severe lower extremity trauma are listed in Table 1. The most recent study by the MacKenzie and Bosse group compares outcomes in patients who underwent reconstruction versus amputation for severe lower extremity trauma.23 On evaluation 2 years postoperatively, and when matched for severity of injury and patient characteristics, patients who underwent amputation had functional outcomes that were similar to those who were reconstructed. A similar number of patients in each groupnearly 50%had returned to work at 2 years. Another study from the Netherlands37 showed that quality of life ratings were similar between reconstructed patients and amputees. It should be noted, however, that these studies did not analyze the patients wishes regarding reconstruction vs

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TABLE 1 Indications for Primary Amputation for Open Tibial Fracture

(Reprinted with permission from Tomaino MM: Amputation or salvage of Type 3B/3C tibial fractures: What the literature says about outcomes. Am J Orthop 30(5):380, 2001.)

amputation nor the patients level of satisfaction with their outcomes. The net costs of salvage versus amputation are controversial. Hertel et al38 report an analysis of social and employment outcomes in severe leg injuries. They note that the total costs of care and rehabilitation are not limited to the hospitalization costs alone. Although the return-to-work rate was an amazing 100%, the number of interventions was significantly lower in the reconstructed group. When the global costs of care to the community were considered in this study, the reconstructed patients proved considerably less expensive to finance than patients who underwent below-knee amputations. This is mainly because patients who undergo amputation are often recipients of lifelong partial pension payments. Unlike previous reports, this study found that the long period of rehabilitation did not induce chronic invalidity. In fact, the reconstructed group compared favorably to the amputation group in physical, social, and psychosocial parameters. Tomaino5 summarizes considerations in management of the patient with severe open tibial fractures. On the basis of his experience and analysis of the literature, Tomaino recommends limb reconstruction if there is a reasonable hope that the patient will return to ambulation within 1 year. He also emphasizes that every technical and rehabilitative effort must be made to achieve union and ambulation as soon as possible. [Editors Note: It must be remembered that this review of the literature suggests similar functional outcomes for

reconstruction and amputation, not better for reconstruction.] The analysis of outcomes following open tibial fractures is probably more complex than can be judged by trauma scoring systems. Despite showing poor return-to-work numbers for patients with reconstructed limbs, Francels 31 study reported that patient satisfaction after reconstruction was high: 96% were satisfied with their limb. Dagum39 notes that the vast majority of patients who underwent reconstruction preferred their reconstructed limb to amputation despite ongoing disability in many. No patient with a salvaged limb wished they had had primary amputation instead. In addition, the physical outcome scores were better overall in the reconstructed group than in the amputated group. Some severe leg injuries are not amenable to reconstruction. Other injured legs may be amenable to reconstruction, but are so severely injured that reconstruction is not advisable. Nevertheless, few patients will elect to have primary amputation when salvage is feasible, even though the physician may feel that reconstruction is inadvisable. The burden of thorough education of the patient rests with the physician. Functional outcomes and returnto-work status improve with earlier ambulation times. Therefore, once the decision is made to reconstruct an injured leg, all efforts should be made to minimize complications and achieve expedient bony union and stable soft tissue coverage. Ambulation is a major predictor and essential prerequisite to successful lower limb reconstruction and a return to overall function. Classification of Open Tibial Fractures The severity of open wounds associated with tibial fractures varies widely. It was long acknowledged by orthopedic and plastic surgeons that the severity of the soft tissue injury correlated well with long-term limb function.40 Gustilo and Anderson41 published their classification of open tibial injuries in 1976. Their grading system drew a clear link between severity of the injury and prognosis for recovery. Subsequent clinical studies confirmed the utility of the Gustilo classification. In Emerson and Grabiass series, Type III fractures comprised 77% of injuries and generally required closure with skin

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grafts or flaps.42 Healing time for this group was markedly protracted, with a 39% overall infection rate. Other complications, including malunion and nonunion, were also frequent. The authors conclude that the type III injury segregates itself as a unique fracture predisposed to treatment failure. Oestern and Tscherne43,44 developed their own widely referenced tibial injury classification system that correlated well with clinical results. Over time it became clear that the Gustilo IIIs were a heterogenous group as well. In 1984 Gustilo45 published a revised classification that divided the more severe injuries into three subgroups. The Gustilo IIIA group was clearly different from the IIIB and IIIC groups. Type IIIA fractures had stable soft tissue over the comminuted fractures, whereas types IIIB and IIIC required soft tissue reconstruction (Table 2). Types IIIB and IIIC also tended to have worse bony injury to accompany the soft tissue injury. Essentially, the Gustilo IIIB fracture required soft tissue coverage and the IIIC injury required some form of arterial vascular repair in order to salvage the limb. TABLE 2 Gustilo Classification of Open Fractures of the Tibia

is located in the distal third of the leg and pedicled flaps are less reliable. The Byrd type IV injury is severe enough that no opportunity exists for local muscle transfer (Fig 2). By definition, the type IV injury requires free flap coverage in all cases.

(Reprinted with permission from Kasabian AK, Karp NS: Lower Extremity Reconstruction. In: Aston SJ, Beasley RW, Thorne CHM (eds), Grabb and Smiths Plastic Surgery, 5th ed. Philadelphia, Lippincott-Raven, 1997. Ch 86, pp 1031-47.)

Around the same time, Byrd and colleagues47 published their own classification of open tibial injuries. This system is similar to the original Gustilo classification with respect to types I through III, but it is not a simple modification of Gustilos scheme. In Byrds classification, the type III group can be said to correspond roughly to the original Gustilo III. The Byrd type III is a severe injury with devitalized local soft tissues, but may still be amenable to local muscle flap coverage. Selected cases of Byrd type III injuries require free flap coverageeg, if the injury

Fig 2. Classification of open tibial fractures. (Reprinted with permission from Byrd HS, Spicer TE, Cierny G III: Management of open tibial fractures. Plast Reconstr Surg 76:719, 1985.)

Byrds classification is very useful for plastic surgeons in particular because it correlates with methods of soft tissue reconstruction. This system is widely referenced in the plastic surgery literature but should be combined with other physical find-

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ings and possibly other classification schemes to fully describe an open tibial injury. The revised Gustilo system is the standard classification used by trauma and orthopedic surgeons, yet it has persistent problems.46 The IIIB and IIIC groups remain heterogeneousthat is, the severity of injuries within these groups varies widely. Many IIIB injuries should have an attempt at salvage while others have a very poor prognosis because of large zones of injury and other factors. The revised Gustilo system also implies that IIIC injuries are worse than IIIB injuries, which is not always the case. It makes no mention of the status of the tibial nerve, which is an important indicator of the quality of limb salvage.29 Furthermore, the Gustilo IIIC is defined as an arterial injury requiring repair.45 Although most surgeons will not attempt repair of a vessel in the leg so long as the foot is still perfused by at least one major artery, some surgeons will try to restore two vessels to the foot in selected cases.46 FRACTURE MANAGEMENT AND SKELETAL RECONSTRUCTION The management of open tibial fractures consists of two general types of bone fixation and three types of soft tissue management. Bone fixation may be internalwith plates, rods, or screwsor external with percutaneous pins. Pin fixation can be either static or dynamic. Casting is still an option for less severe injuries that have stable soft tissues over the fracture, but Truetas method is no longer used for more complicated wounds.

mild open tibial injuries. The success of casting in these injuries is predicated on maintaining good fracture reduction. Studies comparing internal fixation and casting for the treatment of low energy tibial fractures demonstrate faster union times and lower incidence of malunion with internal fixation.49,50 High rates of conversion from casting to internal fixation due to loss of reduction are noted.49 Another option for closed treatment is functional bracing. It can be used with success in some low energy injuries, but is not optimal for high energy injuries.3,51

AO PLATE FIXATION
The use of AO compression osteosynthesis in the management of open tibial fractures is reviewed by Olerud and Karlstrom.52,53 The method requires exact opposition and compression of bone by plates and screws. The hardware must be covered with viable soft tissue. Motion begins early and is gradually increased. Full weightbearing is allowed at 10 14 weeks if radiographic evidence of union is present. The theoretical advantage of AO compression for tibial fractures was thought to be primary bone healing. But ultimately, plate fixation of tibial fractures has not proven to be as successful as plate fixation of fractures in other areas of the body. The periosteal blood supply is very important in healing fractures. The more disrupted the endosteal circulation is, the more important it is to maintain periosteal and local soft tissue viability for fracture healing. When using plate fixation, an area of periosteum must be stripped that corresponds to the surface area of the plate. Just obtaining exposure for the plate may cause additional devascularization of soft tissues that are important for tibial healing, and this devascularization of bone translates into suboptimal clinical results. Several studies claim increased complication rates overall, including infection and nonunion, when plates are used in severe leg injuries.54-56 These failures are thought to be due to the plates ultimately creating stress shielding and predisposing the bone to osteopenia. In addition, the multiple screws through the bone weaken the cortical bone stock. Finally, the plate itself creates stress risers on both ends of the plate, predisposing the bone to re-fracture. Plate fixation is reserved for specific types of tibial fractures, that are not amenable to other types of fixation. Plate

CLOSED TREATMENT
Truetas closed plaster method involves wide debridement of the soft tissues surrounding the fracture while preserving all bone fragments. After fracture reduction, dressings and a walking cast are applied.47 Classically, patients start walking with crutches the day after surgery and proceed to full weightbearing on the cast within 3 weeks. Many wounds drain profusely during the first few weeks, and casts often need to be replaced. Casting alone is no longer considered optimal for the treatment of high energy open injuries, as the soft tissues cannot be closely monitored and reduction is difficult to maintain.3,48 Casting is considered acceptable in low energy closed injuries and

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fixation of high energy tibial shaft fractures is generally not recommended.3

STATIC AND DYNAMIC EXTERNAL PIN FIXATION


External fixation with pins is a safe choice for high energy tibial fractures. This method evolved from the need to adequately stabilize open fractures associated with soft tissue loss. Percutaneous pins are placed outside the area of the fracture. Bone devascularization is minimal because no iatrogenic periosteal stripping is needed for the pins, which are placed through small incisions with fluoroscopic guidance. External fixation is indicated when rigid fixation is required and internal fixation cannot be used due to severe comminution, segmental bone loss, severe osteoporosis, or severe soft tissue injury.41 Modern pin fixation frames are smaller and less obstructive, resulting in easier soft tissue management.3 Overall, external fixation of Gustilo II and III fractures yields good results (Table 3).3 The main disadvantages of external fixation are complications associated with hardware. Pin tract infections are common, increasing in frequency the longer the pins are left in place. The risk of frame loosening and osteomyelitis limits the amount of time external fixation can be used; although ideally external fixation should be continued until union. To win this race against time, different modalities have evolved to either prolong frame use or shorten time to union. Meticulous pin care and close vigilance to detect infection early are mandatory.

Another option for decreasing time to union is prophylactic bone grafting. 57 Blick and colleagues58 analyzed the results of early prophylactic bone grafting for high energy tibial fractures in 53 patients. Bone grafting was performed approximately 10 weeks after injury and 8 weeks after soft tissue coverage. Time to union was reduced to 12 weeks compared with 20 weeks in a matched control group of tibial fractures treated with delayed bone grafting. Another option that some authors have advocated is dynamization of the frame,3 in which the frame is modified to allow some movement and axial loading at the fracture.59,60 Some authors claim that controlled stress and motion at the fracture site may result in faster union.61 A final option is exchange nailing. When using external fixation, after soft tissue cover is stable and before union, the external device can be replaced with an intramedullary nail. This technique of exchange intramedullary nailing can yield low infection rates and high rates of union.62

INTRAMEDULLARY NAILING
Primary intramedullary tibial nailing produces high union rates and few infections in closed fractures and low energy open fractures of the leg.63 In grossly contaminated open fractures, the exposed hardware is a risk factor for infection. In more severe injuries such as Gustilo IIIB and IIIC, therefore, some variant of external fixation is probably a safer choice than internal fixation.

TABLE 3 Results of External Fixation of Open Tibial Fractures

(Reprinted with permission from French B, Tornetta P: Treatment of complex fractures. Orthop Clin North Am 33(1):211. 2002.)

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A recent meta-analysis of open tibial fractures revealed that nail fixation is associated with lower reoperation rates, lower malunion rates, and lower infection rates than external fixation. It must be noted that the data apply to all grades of open tibial fractures, not necessarily Gustilo IIIs as a separate group. It may be physically impossible to actually achieve stabilization in some of the more severe open tibial injuries with rods.64 A controversial issue is whether reamed or unreamed nails are better. Reamed nails may produce endosteal devascularization and hinder bone union, while the smaller unreamed nails have lighter screws that may break.3,66,67 Finkemeier and colleagues68 compared unreamed and reamed nails in the treatment of closed and open tibial fractures excluding Gustilo IIIB and IIIC injuries. The outcome of closed injuries was better with reaming, and the complication rates of open injuries were similar with either technique. The above-cited meta-analysis64 also suggested that reamed nails may lead to fewer secondary operations.

COMBINED BONE AND SOFT TISSUE RECONSTRUCTION: TIMING AND COORDINATION


The ultimate functional success of lower extremity reconstruction depends on achieving union and ambulation. The modern approach to these injuries consists of seamless coordination of bone and soft tissue management. Appropriate debridement is indicated for early treatment of the open tibial injury, with pulse lavage for effective wound irrigation. This is done soon after arrival at the emergency department, and is repeated until definitive soft tissue coverage is secured. Bhandari and coworkers69 compared the benefits of high pressure lavage (70 lb/ in2) versus low pressure pulse lavage (14 lb/in2) in an in vitro model. Both methods result in lifting of periosteum in the laboratory. Both were effective at removing bacteria 3 hr after injury, but high pressure lavage was more effective at 6 hours after injury. The high pressure method, however, is powerful enough to cause structural damage to cortical bone. This laboratory study lends evidence to the argument that early debridement is

more effective at removing bacteria than delayed debridement. Researchers and clinicians continue to debate the optimal timing of open tibial fracture treatment. Harley and colleagues70 reviewed 241 open tibial fractures to see which factors were associated with nonunion rates. Prophylactic antibiotics were administered in all cases. The risk of nonunion was increased by severe Gustilo grade and infection. Nonunion rates were not affected by aggressive lavage and debridement, nor by delay in definitive fixation up to 13 hours after injury. After 13 hours, treatment delay began to affect outcomes adversely. Many fractures with various amounts of bone loss are treated through an intermediate stage with antibiotic impregnated bead spacers. In a prospective study, Moehring and associates71 compared antiobiotic beads to intravenous antibiotics and found no statistical difference in infection rates between the groups; either method is effective for prophylaxis. Regarding dosage of IV antibiotics in open tibial fractures, once-daily therapy can be as effective as traditional dosing regimens for prophylaxis.72 In 1970 Ger40 reviewed the management of extensive soft tissue defects over severe open tibial fractures, stressing the need for thorough debridement. In the 1980s Byrd and colleagues47 noted that complications worsen when an open tibial fracture is allowed to enter a delayed (subacute) phase of wound healing and contamination. Early multimodality treatment improved outcomes. In a prospective review of open tibial fractures, the authors advocated radical debridement of bone and soft tissue with flap coverage in the first 5 to 6 days after injury (acute phase) for the most severe injuries. The complication rate for Byrd Type III wounds averaged 18%. Fractures not treated by early muscle flaps predictably entered a colonized subacute phase that extended from 16 weeks postinjury. Complications after treatment with flaps during this phase averaged 50%. Some 4 to 6 weeks after untreated severe injuries, a chronic phase begins that is characterized by a granulating wound, adherent soft tissue, and decreasing areas of infection. After soft tissue coverage, the complication rate for this chronic group was 40%.

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In summary, muscle flap coverage in the acute period resulted in the fewest complications and shortest hospitalization times. Flap coverage in the subacute and chronic phases was associated with a number of complications, both immediate and late. As the limits of bone debridement become better demarcated during the chronic phase, reliable bleeding margins of bone become apparent and the soft tissues adhere to healthy cortex outside the fracture. Other authors, while recognizing the challenging characteristics of subacute and chronic tibial wounds, have taken issue with the limitations imposed by a subacute tibial fracture. Yaremchuk and colleagues73 reviewed a series of patients who had flap coverage an average of 17 days after injury and noted an overall infection rate of 14%. The key difference in management between their series and that of Byrds is the more aggressive debridement reported by the Boston group. The implication is that aggressive debridement may be able to convert a subacute open tibial fracture to an acutequality wound, after which flap coverage can proceed with relative safety. Like Byrd and Yaremchuk, Gustilo and colleagues45 stress that flap coverage of severe injuries is best done early. When definitive soft tissue cover was achieved within 2 weeks of injury, complications, costs, and the number of secondary procedures were decreased. Similarly, Francel and colleagues31 noted a low 3.6% incidence of complications in Gustilo IIIB injuries when definitive free flap coverage was accomplished within the first 15 days. Others have also shown that delay in covering the open tibial wound is associated with a high rate of complications.74 Godina75 retrospectively followed 532 patients after microsurgical reconstruction of their traumatic leg wounds. Group I (134) had free flap transfer within 72 hours of injury. Group II (167) had flap coverage between 72 hours and 3 months of injury. Group III (231) had flap coverage between 3 months and 12.6 years of injury. The flap failure rate was 0.75% in Group I, 12% in Group II, and 9.5% in Group III. Postoperative infection developed in 1.5% of Group I, 17.5% of Group II, and 6% of Group III. Time to union was 6.8 months in Group I, 12.3 months in Group II, and 29 months in Group III. At first glance, a reader may infer that the inter-

mediate time frame between 3 days and 3 months is the worst time to reconstruct, and definitive management should be deferred until after 3 months. However, this report does not support those assumptions. Note that Group III had the longest time to union and the longest hospital stays, indicating that early, stable soft tissue coverage of severe open tibial fractures improves the overall outcome. Still unclear is whether or not aggressive debridement of bone in delayed wounds affects outcome by itself. There is little doubt that liberal debridement of all fragments of bone in a fracture invariably lowers the infection rate. The surgeon must weigh the risk of observing fractured bone for viability versus the risk of allowing a wound to enter the delayed period of wound colonization. The risks, if any, of removing bone that ultimately may have been viable must also be considered. One point of view advocates early aggressive debridement, early soft tissue coverage, and early or delayed replacement of missing bone. The success of early soft tissue coverage is well established. The fix and flap model, where flap transfer is done at the same time as the last debridement, is advocated by some. Advocates of this approach report improved results due to the minimal time allowed for bacterial colonization. Gopals group76 report a 9% deep infection rate with this method and a worsening infection rate when flap coverage was delayed by more than a week. Early soft tissue coverage after one to three thorough debridements is now the standard of care in open tibial fractures.57According to Heller and Levin,4 soft tissue coverage within 7 days of injury produces optimal results. Paired with early soft tissue coverage is bone replacement and prophylactic bone grafting of severe fractures. Some authors advocate simultaneous soft tissue reconstruction and bone replacement, whether done emergently or simply early.79 Most surgeons, however, prefer to graft after stable coverage has been achievedup to 2 months after the soft tissues have been repaired.3,57,77 Arnez80 discusses the history, pros and cons, and results of immediate reconstruction of the lower extremity by emergency free flaps. Tropet et al81,82 advocate emergency multimodality treatment of severe open tibial fractures. They report 18 cases of Gustilo IIIB injuries treated emergently with intravenous antibiotics, debridement, and locked

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intramedullary nails. Six patients had free muscle coverage and 12 had local muscle flaps. Immediate iliac crest bone grafting was used in 3 patients. Bone union was seen at a mean 6.5 months after treatment. Primary union was seen in 13/18 patients (72%) and these people were able to return to work; 5 required further intervention. This intriguing study was neither prospective nor randomized. Further study is warranted to establish if this early, onestage definitive approach improves outcomes.

to fill a 12-cm defect. The patient reportedly achieved union at 6 months and walked normally at 10 months. The use of debrided, frozen, and subsequently boiled autograft deserves further study. Vascularized Bone Transfers Vascularized autogenous bone transfers are useful in bridging long bone gaps. Most commonly transferred as vascularized bone in the repair of posttraumatic leg defects are the fibula, iliac crest, and scapula. Taylor85 details the vascular anatomy of the iliac crest and fibula. He cites examples of microvascular bone transfers, and reviews the sequence of lower extremity reconstruction with vascularized bone. Sekiguchi et al86 describe the use of osteocutaneous free scapular flaps in the lower extremity. Allen and coworkers87 report successful transfer of latissimus dorsi/scapular bone flaps for lower extremity reconstruction in 12 patients. Lin and colleagues88 compared the results of three different free flaps for posttraumatic tibial reconstruction. In this retrospective study 64 fibulas, 22 serratus flaps with rib, and 11 iliac flaps were compared. The fibulas had the best results overall, but the other two options are recommended when the fibula is not available. Weiland, Moore, and Daniel89 reported an early series of 41 autogenous vascularized bone grafts used in the upper and lower extremities. The average size of the defects was 16 cm. The iliac crest was used when the bone gap was 10 cm, and free fibular transfers used when the gap was larger. Technical details of fibular harvesting are given in the article. Of 32 free fibular grafts, 28 (87.5%) were successful. Failures generally resulted in amputation. Full weight-bearing did not occur until approximately 15 months postoperatively, corresponding to the time it takes for a graft to hypertrophy. Wood et al90 note the value of vascularized bone grafts in posttraumatic limb salvage, but acknowledge that 50% of their cases required a secondary operation. The surgical procedure of free bone transplantation is technically demanding and time consuming, and probably should be limited to centers with extensive microsurgical experience. Both of these studies draw attention to the prolonged time of partial weightbearing that patients must endure while waiting for graft hypertrophy and stability. This raises the issue of patient compli-

METHODS OF BONE RECONSTRUCTION IN OPEN TIBIAL FRACTURES


The basic ways to bridge a bone defect in the leg are 1) bone grafting, 2) free osseous or osseocutaneous flap transfer, and 3) distraction ostegenesisthe Ilizarov technique. Bone Grafts For Gustilo IIIB fractures with significant comminution and small bone gaps, cancellous bone grafts beneath vascularized muscle flaps are part of the modern standard of care. With massive bone harvests, it is possible to bridge defects >10 cm with this technique. Christian, Bosse, and Robb83 evaluated 8 patients who had Grade IIIB open tibial fractures associated with large (average 10 cm) diaphyseal defects. The defects were filled with antibiotic-impregnated beads and covered with free flaps. The beads served as spacers to preserve the volume of the diaphyseal defect. Some 3 to 6 weeks later the tibia was reconstructed with massive amounts of autogenous cancellous bone grafts. The mean duration of external fixation was 5 months, and time to healing after bone grafting averaged 9 months. An intact fibula facilitates bone grafting of longer defects by acting as a strut to keep the extremity at length. If the fibula is not intact, which is often the case in high energy injuries, then other reconstructive methods may be necessary, particularly in defects >8 cm. As an alternative to vascularized bone or massive cancellous grafts, Canovas and coworkers84 report a case where the contaminated devascularized tibial segment was sterilized and used as a tibial autograft

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ance: Many patients will find it difficult to wait 2 years before attempting unaided ambulation. Full weightbearing on an incompletely hypertrophied fibular interposition graft risks a pathologic (stress) fracture. In one series 15 of 46 transferred fibulas fractured an average of 9.7 months after transfer.91 As a potential solution, Toh and colleagues92 advocate folding the fibular grafts to provide more stability and bulk (Fig 3). This technique is possible with either pedicled or free fibulas and can bridge defects up to 10 cm (a folded 20-cm graft.) The folded fibula decreases fracture rates and time to full weightbearing. The fibula is usually transferred as a free flap with or without a large skin paddle. Lee and Park91 used free fibulas with skin paddles for combined bone and soft tissue reconstruction of open tibial fractures. It is also possible to transfer the fibula on an ipsilateral pedicle as a vascularized bone graft or osseocutaneous flap. Pedicled fibular transfer may be more useful in defects of the proximal tibia and distal femur.92,93 Atkins and colleagues94 report Ipsilateral Vascularized Fibular Transport (IVFT) for tibial reconstruction. This technique does not require a fully intact fibula because pretransfer distraction

lengthens the fibula sufficiently to bridge the tibial defect. When transferring a free fibula, it is useful to know that the flap can be sustained on its distal pedicle via retograde flow. Therefore, when the proximal pedicle of a free fibula is damaged, the flap can still be anastomosed to the distal peroneal artery and vein.92,95 Free transfer of a previously fractured fibula has also been reported.96 As long as the arteriogram confirms a good pedicle, this transfer is an option for tibial reconstruction. Distraction Osteogenesis Bone gaps 10 cm can be bridged with the Ilizarov technique.97-101 The procedure begins with debridement of the fractured ends. The cortical bone is transected outside the zone of injury, leaving the medullary bone and blood supply intact. Pins are inserted near the bone ends on either side of the gap, and the external distraction apparatus is applied. A waiting period of about 7 days is typically allowed before distraction begins. Distraction consists of turning the screw(s) on the external fixa-

Fig 3. Left, Compound defect of the soft tissues, tibia, and fibula. Angiogram shows good flow of the posterior tibial artery and communicating branch with the peroneal artery. Middle, Eight months after reconstruction with an ipsilateral folded fibula and skin flap transferred by anastomosis of the peroneal artery to the anterior tibial artery. Right, Clinical appearance of the donor and recipient sites. (Reprinted with permission from Toh S, Tsubo K, Nishikawa S, et al: Ipsilateral pedicle vascularized fibula grafts for reconstruction of tibial defects and non-unions. J Reconstr Microsurg 17(7): 487, 2001.)

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tion device to gradually apply tension across the corticotomy site (Fig 4). Distraction proceeds at the rate of 1 mm/day until the defect is spanned.102 The circular frame is usually kept in place for 1 year the time for the bone regenerate to consolidate and mature.

Fig 4. The Ilizarov technique for managing segmental defects of the tibia. A corticotomy made high on the tibia is the source of regenerate after the bone is distracted with transfixion pins on an external frame. (Reprinted with permission from Cierny G III, Zorn KE, Nahai F: Bony reconstruction in the lower extremity. Clin Plast Surg 19(4):905, 1992.)

Cierny and associates99 discuss advantages of the Ilizarov technique. First, the amount of bone generated is anatomically correct for the size of the defect. Second, soft-tissue defects can be closed by the docking method during the same process. Finally, blood transfusions are usually not required.

Cierny notes that because the process is slow and potentially arduous for the patient, candidates must be chosen with care. Relative contraindications are a defect >12 cm, which necessitates two lengths of regenerate 6 cm or greater, and deficient residual bone stock that cannot support two or three serial corticotomies. Vasconez and Nicholls98 discuss the benefits of and indications for the Ilizarov technique versus bone grafts or free bone transfer in the management of severe open tibial injuries. Patients who have significant soft tissue and bone loss or severe comminution are divided into one of two treatment groups. In one group the tibia is placed at length using external fixation and either bone grafted or treated with a free fibular flap. Soft tissue defects are repaired with skin grafts, local flaps, or free flaps. In the second group the Ilizarov technique is used to transfer both bone and soft tissue elements to reconstruct the extremity. The softtissue wound is closed when the ends approximate. Both treatment groups share three constants: (1) debridement should be immediate and complete; (2) all exposed vessels should be covered emergently; and (3) the bone is stabilized before vascular and soft tissue reconstruction. The authors suggest that the Ilizarov techniqe offers more options for soft tissue closure because the bone gap can be made smaller. As the bone is slowly lengthened, local flaps and soft tissues also stretch, which theoretically lessens the size of the flap needed for cover or changes the indications from a free flap to a local flap. Unfortunately, the dense scar beds of free tissue transfers and the pedicles of conventional flaps can hamper bone transport by the Ilizarov technique. Distraction osteogenesis over an intramedullary nail has been reported. This combined technique is reported to permit early removal of the frame, as the nail provides stability while consolidation takes place.103 If found to have an acceptable complication rate, this technique has the theoretic potential to significantly shorten frame time and perhaps time to ambulation. The Ilizarov distraction method is not without morbidity; in fact, it has one of the highest rates of complications among orthopedic procedures. Almost all patients suffer multiple minor complications. Pin track infections, stiffness of adjacent joints, and severe pain104-106 are very common.

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McKee et al107 prospectively followed 25 patients in whom Ilizarov bone transport was used for posttraumatic deformities. These patients had very low preoperative scores on health profile scoring systems. The scores remained low throughout the prolonged treatment program, but climbed markedly as their general health improved. In short, patients do obtain good results with Ilizarov distraction, but they must pay for it with an arduous treatment course. Also noteworthy is that additional bone grafting is often required at the docking phase of Ilizarov bone transport. Summary of Bone Reconstructive Techniques In summary, most cases of Gustilo IIIB and IIIC injuries that are candidates for reconstruction can be managed by external fixation and free flap coverage over antibiotic-impregnated beads, followed by autogenous bone grafting several weeks later. Tibial bone gaps up to 3 cm are ideal for cancellous grafting. Defects 6 cm warrant consideration of either Ilizarov bone transport or vascularized bone grafting. 88,89 Bone gaps 12 cm are difficult to bridge with bone transport99 and are a clear indication for free or pedicled vascularized bone flaps, although smaller defects may also be good candidates for vascularized bone. Of course, any patient that has a a large tibial bone defect may also be a strong candidate for primary amputation. The minimum size of a defect that requires vascularized bone for treatment remains undetermined.

IN

METHODS OF SOFT TISSUE RECONSTRUCTION OPEN TIBIAL FRACTURES


In 1970 Ger40 introduced innovative techniques for soft tissue coverage of open tibial wounds. He described the soleus myoplasty, flexor digitorum longus, abductor hallucis, and gastrocnemius flaps for bone coverage. While local pedicle flaps may be appropriate for acute Type III fractures, Byrd, Spicer, and Cierny47 prefer free microvascular muscle flaps for many Type III wounds. Byrd Type IV wounds by definition require free flaps for coverage. Because traumatic lower extremity wounds that require soft tissue reconstruction are often characterized by local muscle damage, pedicled flaps are often not appropriate. Traumatic leg wounds cov-

ered with local flaps have higher short-term complication rates than those covered with with free flaps.108 When pedicled flaps are possible, the gastrocnemius and soleus muscles are generally first choices for the reconstruction. Viability of the pedicled flaps must be verified before flap elevation and rotation, especially in the context of severe trauma. Other local flaps in the leg that are options in smaller chronic or nontraumatic wounds may not be reliable for Gustilo IIIB and IIIC wounds, and therefore are considered distant second choices. The soleus muscle flap is generally the first choice for midshaft wounds, while the gastrocnemius is better for the proximal third of the leg. Either flap may cover defects up to 25 cm2. Neither is considered appropriate for the distal one third of the leg.4 The soleus can reach the lower third of the leg, but its reliability suffers.109 Reversed fasciocutaneous flaps have been suggested, but in general they are not considered useful in the context of severe open leg fractures. Singh and Naasan110 describe a small series of low velocity injuries of the lower leg that were adequately treated with reversed sural artery flaps. A few of the treated injuries were reported as Gustilo III grades. Muscle free flaps are generally preferred for severe leg trauma because they fill dead space, provide additional vascularity to the wound, and allow flexibility of position and pedicle placement.4,111,112 The workhorse microvascular flaps for open tibia reconstruction are the latissimus, the serratus, the rectus, and the gracilis. May and associates 111 advocate the use of microvascular free tissue transfer for coverage of distal lower extremity wounds with exposed bone. Their experience is consistent with other reports of vascularized muscle tissue used to obliterate dead space and to bring well-perfused soft tissues to the excised scar bed in the treatment of chronic osteomyelitis. Serafin and Voci112 review microsurgical composite tissue transplantation to the lower extremity. Microvascular transfers can deliver both soft tissue and skeletal support to large, complex wounds of the leg, and are particularly useful in the distal third of the leg and in the foot. Francel and colleagues31 reported their results of microvascular reconstruction in open tibial fractures.

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Long term retrospective follow-up revealed successful limb salvage in 93% of patients. Of these, 66% exhibited significantly decreased range of motion of the ankle, 44% showed swelling and edema requiring elastic support and activity modification, and 50% occasionally needed assistance for ambulation. Khouri and Shaw113 reviewed 304 consecutive microvascular flap reconstructions of the lower extremity. The most common indication was reconstruction of Gustilo IIIB and IIIC fractures. Approximately 75% of the defects were below the level of the midtibia. The latissimus dorsi, rectus abdominis, and scapular skin flaps were used in this study. The failure rate was 8%, compared with 3% for non-lower extremity cases. The magnitude of the traumatic insult was the most significant factor associated with anastomotic failure. The rate of anastomotic thrombosis doubled in the presence of vascular trauma, tripled in cases of large bony defects, and quintupled when vein grafts were needed. In a series of 100 patients who underwent 104 free flap reconstructions for open tibial fractures, Nieminen et al114 report a 5% amputation rate. Park and colleagues115 review technical points of recipient vessel selection and anastmosis in severe open injuries. They note that antegrade vessels distal to the zone of injury are safe to receive a free flap when the inflow is good. In certain cases, even reverse flow can be used to sustain a flap (Fig 5). Regarding donor site morbidity, Colen 116 reported 31% donor related complications for the latissimus dorsi and 20% for the rectus abdominis muscle flaps. More recently, Musharafieh and colleagues117 noted 93% flap viability in 40 free rectus flaps used for lower extremity reconstruction. Donor site morbidity was said to be negligible. Only 1 patient was not ambulatory at 3 years. Redett and colleagues118 revisited the gracilis free flap. The gracilis is elegant for filling and contouring long and narrow defects, but its surface area is not large: It can be used in wounds no wider than 57 cm and up to 30 cm long. Minor flap complications occurred in 12% and donor site complications in 10%, including hematomas, a seroma, and cellulitis. Another minor problem appears to be the scar, which can be quite long depending on method

Fig 5. Algorithm for recipient vessel selection. ATA, anterior tibial vessel; P, popliteal vessel; PTA, posterior tibial vessel. (Redrawn with permission from Park S, Han SH, Lee TJ: Algorithm for recipient vessel selection in free tissue transfer to the lower extremity. Plast Reconstr Surg 103(7):1937.)

of harvest. Also, the pedicle of the gracilis flap is shorter than that of the latissimus and serratus flaps, which can limit its usefulness in a large zone of injury. Wechselberger and others119 describe an innovative, anatomically sound method of taking a larger and more reliable skin paddle with the gracilis. This variant extends the effective surface area of the gracilis free flap significantly.

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The free anterolateral thigh flap has also been described for reconstruction in open tibial fractures.120 The Ilizarov device is now being tried for soft tissue distraction in wound coverage of the lower extremity. The distraction frame stretches and compresses soft tissue while bone is transported. Two recent reports detail creative use of Ilizarov frames for soft tissue coverage of open tibial wounds.121,122 It is unclear from these reports whether distraction will be sufficiently reliable for delivering stable, vascularized soft tissue to open tibial wounds. Another issue is how to successfully coordinate bone transport through the zone of a free flap. One report describes a technical modification in which the free muscle flap can be partially split at the time of transfer to allow for unimpeded pin transport.123 Agarwal and associates124 describe soft tissue problems that tend to recur in cases of simultaneous tibial transport and soft tissue distraction. This article details a set of useful local flap procedures for dealing with soft tissue compression and problems associated with moving pins.

AMPUTATION STUMP RECONSTRUCTION


The most important consideration in lower extremity amputation stump reconstruction is preservation of length. Patients with below knee amputations are considerably more likely to ambulate on prostheses than those with AKAs. Also, the metabolic demand on patients with AKAs is significantly higher than for patients with BKAs. Regarding amputations for vascular disease and diabetes, the severity of disease usually determines the level of amputation. When amputations are traumatic, however, the length of the preserved limb may be determined by adequacy of soft tissue coverage. In children, amputation through the knee joint is often performed to prevent bony overgrowth of the stump. Several recent publications address methods of reconstructing the amputation stump. Every attempt should be made to preserve length with local muscle and skin; if this is not possible, flaps and skin grafts should be used to prevent conversion of traumatic BKAs to AKAs. If the local muscle coverage is adequate for the bone end, it is acceptable to resurface the muscle with skin grafts.125,126 In stumps that are healed but have poor soft tissue coverage, tissue expansion

can be an option for resurfacing.127 If the expansion is carried out in the distal thigh rather than the leg, the results are likely to be much better. Free muscle flaps with skin grafts and free musculocutaneous flaps for stump coverage and length preservation are well accepted.128,129 It may also be possible to lengthen short BKA stumps with osteomusculocutaneous flaps.130 The potential best candidate for such an aggressive reconstruction would likely be a healthy patient, highly motivated to ambulate, who is held back by a short BKA stump with poor soft tissue cover. Sometimes the foot of an amputated leg can be used for spare parts. The fillet of foot/sole flap, transferred free or on a pedicle, can be used to preserve length and provide sensate coverage to a traumatic leg amputation stump.131-133 Patients with traumatic amputations of the lower extremity or nonreconstructible limbs may not be stable enough at the time of the first surgery to undergo major stump coverage operations such as a free flap or a pedicled foot flap. In these cases the sole of the amputated foot can be refrigerated to be used at a later time. Shah and colleagues134 report successful stump reconstruction with a free foot fillet flap cooled for 57 hours at 4C. COMPARTMENT SYNDROME Diagnosis Since Vogt 135 originally described the acute anterior compartment syndrome in 1943, other authors have reported compartment syndrome in all four anatomic compartments of the leg (Fig 6).136-139

Fig 6. The four discrete compartments of the lower leg. (Reprinted with permission from DeLee JC, Stiehl JB: Open tibia fracture with compartment syndrome. Clin Orthop 160:175, 1981.)

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A diagnosis of compartment syndrome is made on the following clinical signs and symptoms: pain disproportionate to the injury palpably swollen compartments pain on passive stretching of the involved muscles diminished simple touch perception decreased strength of the involved compartment muscles hypesthesia or anesthesia in the sensory distribu tion of the nerve in the involved compartment Physical examination identifies the involved compartment(s) (Table 4).140 TABLE 4 Signs of Developing Compartment Syndrome

long as the pressure does not remain above 40 mmHg for more than 6 hours. If it does, or if it rises above 50 mmHg, fasciotomy is indicated. Spectroscopy has been tested for measuring compartment oxygenation.144 Whether oxygenation correlates well with actual compartment syndrome, especially in the context of trauma, is unclear; the results of spectroscopy must be viewed in the context of clinical signs and symptoms and other test findings in the awake patient. One can test a soft compartment, perhaps on the other leg, to see if the equipment reads true. When evaluating pressure measurements, serial readings are the standard for making the diagnosis of compartment syndrome.145 A normal pressure reading must not deter the surgeon from performing fasciotomy when the clinical exam is positive. Epidemiology Acute compartment syndrome can be caused by trauma, postoperative bleeding, after tendon graft harvest, casting over growing soft tissue swelling, electrical burns, thermal burns, intracompartmental bleeding due to systemic disease or anticoagulation, and animal bites, particularly from snakes.146-148 A retrospective review of 198 open tibial fractures by Blick et al142 revealed a 9.1% incidence of compartment syndrome. The development of compartment syndrome was directly related to the degree of injury to the soft tissues and bone. DeLee and Stiehl139 review the occurrence of compartment syndrome in fractures of the lower extremity. Of 104 patients with open tibial fractures, 6 (5.7%) developed compartment syndrome involving all four compartments. In contrast, only 5 of 411 patients (1.2%) with closed tibial fractures met the criteria for compartment syndrome. These figures refute the notion that an open fracture allows adequate decompression of the compartments. It does not. The open injuries are indicative of higher energy, and therefore might be at higher risk of compartment syndrome. Management Compartment syndrome does not need to be proven beyond a reasonable doubt. If compartment syndrome cannot be ruled out, decompression through four-compartment fasciotomy is rec-

(Adapted from Hyde GL, Peck D, Powell DC: Compartment syndromes. Early diagnosis and a bedside operation. Am Surg 49:563, 1983.)

The distal pulses may or may not be palpable. Most of the cardinal signs are actually late findings, particularly dimished pulses and symptoms of nerve compression. The best early clinical sign in the awake patient is severe pain with passive stretch of involved muscles. The clinician should not wait for additional cardinal signs to evolve when compartment syndrome is highly suspected. The normal intracompartmental pressure is 30 40 mmHg 4. 141,142 Allen and coworkers 143 emphasize the value of continuous monitoring of intracompartmental pressures to diagnose the presence of a clinically significant compartment syndrome. Compartment pressure is monitored with a slit catheter inserted via a 16-gauge Medikit catheter. A heparin infusion pump maintains patency of the catheter. The authors conclude that transient rises in compartment pressure can be tolerated so

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ommended within 6 hours of symptom onset. The risk of not doing fasciotomy far outweighs the risk of doing fasciotomies that only in hindsight are found to be unnecessary. Hyde and associates 140 describe a simple fasciotomy for bedside decompression. Nghiem and Boland149 and DeLee and Stiehl139 question the value of fibulectomy-fasciotomy for decompression of all four compartments when weighed against the importance of the fibula in fracture stabilization. Pearse and colleagues 145 advocate a fibulasparing, two-incision method for full fourcompartment decompression. One incision medial to the tibia decompresses both the superficial and deep posterior compartments and stops at the postero-medial tibial border. The second incision courses laterally through and over the anterior compartment and enters the lateral compartment (Fig 7).

dermatotraction, and pull-through monofilament dermal running sutures can close a wound primarily if gradual closure is begun early postoperatively.150-152 These techniques produce better cosmetic results than split grafts over muscle. Outcome A chronic Volkmann-like contracture, with or without sensory loss, may develop when compartment syndrome is missed, or if decompression is inadequate.137,139,140,142 Kikuchi and coworkers138 describe the clinical features of compartment syndrome in 20 patients. One clue on exam is persistent saphenous nerve sensation, as the nerve lies outside the compartments. Limb function deteriorated with length of ischemia: function was good after 3 hours, fair after 14 hours, and poor after 21 hours of ischemia. The prognosis was especially poor when both the tibial and peroneal nerves were involved, and during the acute stage in cases of severe venous insufficiency. The authors advise against reconstruction of the chronically affected limb before 18 months to allow for maximum return of function. This interval is also needed to help the clinician and the patient decide if amputation is preferable. OPEN JOINT INJURIES Patzakis et al153 prospectively studied 140 patients with open joint injuries. In the acute state they recommend preoperative and intraoperative cultures, broad-spectrum antibiotics until cultures are read, copious irrigation, debridement of the joint and injured soft tissues, and primary closure of the wound without drains. Closed suction drains were thought to be responsible for wound contamination in 14.3% of patients who had negative cultures before or during surgery. The most common organisms were Pseudomonas and Klebsiella. The authors believe that the only indication for use of an irrigation system in open joint injuries is the presence of extensive soft tissue and bone damage, when closure of the joint would be advantageous. Barford and Pers154 reported their experience with immediate gastrocnemius muscle flaps for closure of 5 open knee joints, with no infections. The notion of augmenting deficient soft tissues by transposing muscle flaps seems logical and may be analo-

Fig 7. Cross section through leg showing site of fasciotomy incisions to decompress all four compartments. (Reprinted with permssion from Pearse MF, Harry L, Nanchahal J: Acute compartment syndrome of the leg. Fasciotomies must be performed early, but good surgical technique is important. BMJ 325:557, 14 Sep 2002.)

Although the wounds left after leg fasciotomies are clinically impressive, they tend to be easy to manage. Prophylactic antibiotics are frequently used but are not essential. Meticulous local wound care is the key to successful closure. Techniques such as lacing with vessel loops through skin staples,

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gous to the improved results seen with early soft tissue coverage of open tibial fractures. Chronically contaminated and open joints present yet another problem. Soft tissue closure alone yields an unacceptable number of septic joints and related sequelae. Studies of Truetas closed plaster method have shown that joints allowed to remain open while the patient ambulates can heal without loss of the cartilaginous interface and without infection.47 When there are large attendant soft tissue losses, however, scar contracture frequently limits function of the joint. Secondary muscle or soft tissue cover without waterseal closure and active ambulation may be beneficial in the management of these wounds. Options for the knee include gastrocnemius muscles, turndown thigh muscles, and free flaps. In the presence of a chronically infected and granulating open joint, debridement of exposed synovium and granulation may be considered before muscle coverage. Pu and Thomson155 present two cases of irradiated, chronic open knee joints that were salvaged with free muscle flaps. One patient retained 35 of extensor lag to 65 of active flexion. The other had 15 of lag and flexed to 60. Both were able to ambulate. Cierny, Cook, and Mader 156 reviewed their experience with 36 refractory infections of the open ankle and offer a comprehensive discussion of management and surgical techniques for dealing with these wounds. The authors conclude that, after cartilaginous debridement, when intact proximal and distal cortices are present, the ideal treatment involves free bone grafts placed between the tibia and the talus. Fixators, staples, or plates external to the graft achieve the necessary compression. The use of medial and lateral osteocutaneous flaps for bone and soft tissue reconstruction and preservation is discussed. NONUNION Nonunion results from insufficient stabilization or insufficient perfusion of the fracture.6,11 Infection can contribute to either or both causes. Radiographically nonunion presents in one of two forms: as a hypertrophic elephant-foot callus or as a porotic resorptive process along the line of fracture. A hypertrophic callus denotes inadequate stabilization of the fracture segments; union should occur

if appropriate stabilization is provided. A resorptive process or atrophic nonunion occurs from ischemia or a septic process. If the nonunion is on the basis of inadequate blood supply without infection, stabilization and bone grafting often will bring about union. In contrast, an infected fracture is chronic osteomyelitis, and may require multimodality therapy. The standard treatment of aseptic nonunions is stabilization and bone grafting. Kettunen and colleagues157 described a novel technique of percutaneous bone grafting in aseptic tibial nonunions that resulted in bone healing in 37/41 fractures. Megas and coworkers,158 on the other hand, believe that bone grafting is not always necessary for tibial nonunions. They report union in 50 patients with aseptic tibial nonunions treated with reamed intramedullary nails. Bone grafts were used in only 3 patients in this series. Ohtsuka et al159 coated an intramedullary nail with antibiotic-impregnated cement before placing it within a Pseudomonas-infected tibial nonunion. Bone grafting was done after the infection clinically receded, and union was eventually achieved. The coated nail was later removed. The patients functional outcome was deemed excellent. Safoury160 used a technique originally described by Hertel161 in which the fibula is pedicled on reverse flow, to revascularize 10 distal tibial nonunions. Union was seen in all fractures and the patients were weightbearing by 9 months. The reverse flow is provided by distal crossover vessels between the posterior tibial and peroneal systems (Fig 8). Erdinger and coworkers162 combined a latissimus and scapula osseomuscular flap for effective treatment of infected nonunions (Fig 9). The flap anatomy and harvest technique in five representative cases are detailed in their article. This technique is an option when the need for a small to moderate amount of vascularized bone is needed, paired with a large soft tissue need. Duffy and colleagues163 report the results of onlay free fibular transfer combined with cancellous grafts in irradiated nonunions. OSTEOMYELITIS AND INFECTED NONUNION Posttraumatic osteomyelitis is more common after severe open tibial fractures than in milder inju-

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Fig 8. Technique for ipsilateral pedicled reverse fibula graft for nonunion of distal third of tibia. (Reprinted with permission from Safoury Y: Use of a reversed-flow vascularized pedicle fibular graft for treatment of nonunion of the tibia. J Reconstr Microsurg 15(1):23, 1999.)

Fig 9. Arterial blood supply of the latissimus dorsi muscle and the inferior angle of the scapula. 1, angular branch of the thoracodorsal artery; 2, thoracodorsal artery; 3, circumflex scapular artery; 4, subscapular artery; 5, axillary artery; 6, thoracodorsal nerve. (Reprinted with permission from Erdinger K, Windhofer C, Papp C: Osteomuscular latissimus dorsi scapula flap to repair chronic, posttraumatic osteomyelitis of the lower leg. Plast Reconstr Surg 107(6):1430, 2001.)

ries. Patzakis, Wilkins, and Moore164 investigated the effectiveness of prophylactic antibiotics in a large series of patients (>1100) with open tibial fractures. Patients who did not receive antibiotics had a 24% infection rate. Only 4.5% of patients who were given prophylactic broad spectrum antibiotics for 3 days developed infections. The most common pathogen in both groups was coagulase positive Staphylococcus. Ger166,167 identified the major causes of persistent infection after open fractures: retained necrotic and infected bone; avascular or infected scar; dead space in the surgical site; and inadequate skin cover. He postulated that ischemia was responsible for chronicity and for operative failures. He is credited with voicing the currently accepted principles of surgical treatment of osteomyelitisthat is, dead space obliteration and aggressive debridement.

Horwitz 168 reviews traditional management options for chronic osteomyelitis, as follows:

ostectomy with primary wound closure and


closed suction drainage

ostectomy with partial wound closure and secondary split grafting

ostectomy with partial wound closure and packing

resection with immediate delayed wound closure

amputation
The current mainstay of treatment in chronic osteomyelitis is excision of pathologic tissue, including necrotic and infected bone, bone sequestra, and poorly vascularized soft tissues. Obliteration of dead space and enhancement of blood sup-

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ply with muscle flap complements wound management following debridement. Mathes, Alpert, and Chang169 expanded Gers debridement to include nonviable bone, scar, and chronic granulation tissue in the medullary canal. Because of their superior resistance to infection over conventional flaps, free microvascular muscle flaps were used to obliterate the dead space and to cover the exposed bone. At 1.8 years average follow-up, all 11 of their patients had resolution of their osteomyelitis. In a follow-up study, Anthony, Mathes, and Alpert170 traced the postoperative course of 34 consecutive patients with chronic osteomyelitis of the distal lower extremity. Twenty-seven patients were available for long-term follow-up. Treatment was by debridement, a 1014-day course of culturespecific antibiotics, and muscle flap cover. Twentyfour patients (89%) healed with no recurrence at 5+ years, 3 (11%) had recurrence of their osteomyelitis, and 2 of these were cured after additional muscle flap procedures. May171 reports his own large experience with chronic osteomyelitis of the leg. Management was by radical debridement of bone and soft tissue and reconstruction by a second- or third-stage latissimus dorsi free flap transfer. Discontinuity defects were filled with cancellous bone grafts after soft tissue coverage. Excellent results are documented. May172 subsequently reviewed his 13-year, 96patient experience with bone debridement and microvascular free tissue transfer for soft tissue reconstruction in chronic traumatic bone wounds. After a mean follow-up of 77 months, 91 patients enjoyed complete wound closure and absence of drainage. Five patients ultimately required amputation because of treatment failure and recurrant infection. Damholt 173 reports 98% cure in 55 patients treated for chronic osteomyelitis. His radical operation removes all internal fixation devices and includes sequestrectomy, partial decortication, and primary wound closure with suction drainage. Thirteen patients had wound closure by flaps of various types. External fixation was used if stabilization was necessary. Significant gaps in the long bones secondary to debridement can be bridged with secondary block cancellous insert grafts. Survival of these bone grafts depends on a well vascularized soft tissue bed.174

Sudmann175 prefers surgical debridement and grafting with cancellous and corticalcancellous bone in one operation. Of 13 consecutive patients with osteomyelitis who were treated by this protocol, 12 healed after a single operation and 1 required three operations before his osteomyelitis was eradicated. The grafts did not form sequestra. Among the more experimental techniques for managing chronic osteomyelitis is necrectomy and packing of the defect with antibiotic beads.176 This technique delivers antibiotic in high concentration and fills dead space. The beads are then gradually removed to slowly collapse the size of the cavity. Another ingenious treatment is the application of hyperbaric oxygen to the wound.177 At 3-atm absolute pressure, O2 diffusion into avascular tissue increases several fold, and the improved oxygenation has a bactericidal effect and speeds up healing. Aggressive surgical debridement may have contributed to the good outcome in this study. Arnold178 reports 90% cure of osteomyelitis of the leg 15 years after treatment with local muscle flaps. Musharafieh and associates179 report high efficacy of free flaps in the treatment of chronic osteomyelitis of the leg. In a study of 42 free flaps for chronic leg wounds, Gonzalez and colleagues180 note that osteomyelitis is a strong predictor of flap failure and ultimate loss of limb. The flap failure rate in the presence of osteomyelitis was 22%; when osteomyelitis was absent, it was 7%. Surgeons must beware of malignant transformation in chronic osteomyelitis that never seems to heal.181 Biopsy and cultures are warranted periodically during long treatment courses. Faden and Grossi165 evaluated 135 children who had acute osteomyelitis. The etiologic agent was identified as Staphylococcus aureus, Hemophilus influenzae type B, and Pseudomonas aeruginosa in 25%, 12%, and 6% respectively. H. influenzae occurred only in children younger than 3 years of age. Currently, Hemophilus osteomyelitis is very rare due to widespread vaccination against the bacteria. Most pediatric cases of osteomyelitis are due to hematogenous spread; all wounds infected with P aeruginosa were penetrating injuries to the foot. Children with P aeruginosa infection were older than 9 years (100%), predominantly male

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(88%), often afebrile (83%), and never clinically bacteremic. CHRONIC LEG ULCERS Picascia and Roenigk182 review the dermatologic and topical management of leg ulcers. They recommend early adjunctive measures for unstable areas before a full ulcer develops. The most common cause of cutaneous ulcers is decreased skin perfusion and infection. Decreased skin perfusion may occur from disease in the large, medium, or small arterial vessels as well as the capillary bedeg, atherosclerosis, diabetes, or vasculitis. Venous hypertension also decreases skin perfusion, resulting in tissue ischemia or death. Host defenses are marginal in ischemic tissue, which contributes to the development of subclinical infections. Venous Disease Venous insufficiency affects millions of patients in the United States and is associated with varicosities or thrombophlebitic disease. An increased column of blood from incompetent valves causes a rise in hydrostatic pressure and produces chronic venous insufficiency. The typical clinical signs include edema, hyperpigmentation, and finally ulcerations around the lower legs and ankles. The venous system of the leg comprises the superficial veins and venules, the perforating or communicating veins, and the deep veins. Mild forms of venous insufficiency are seen with varicose veins. Severe forms are seen with deepsystem reflux about the popliteal area and lower leg. It is estimated that 1% of people in the United States will have a chronic venous stasis ulcer at some time in their lives. Although most chronic venous ulcers are secondary to alterations in the deep venous system, 28% are due to superficial or combination superficial and deep venous insufficiency. Pathophysiology Although the cause of chronic venous insufficiency is understood, the pathophysiology of venous ulceration is not clear. The major theories impli-

cate pericapillary fibrin deposition or white blood cell plugging. Pericapillary Fibrin Deposition. Moosa183 used transcutaneous oxygen monitoring to prove the existence of a local pathologic barrier to oxygen diffusion in patients with venous ulcers.184,185 Balslev and colleagues,186 on the other hand, feel that fibrin deposition is a secondary phenomenon occurring in already ulcerated skin. White Blood Cell Plugging. Occlusion of capillary loops by white blood cell thrombi has been blamed for venous ulcers. Thomas and associates187 showed a significant decrease in the number of white blood cells returning from the dangling legs of patients with chronic venous insufficiency. Coleridge Smith et al188 counted the number of capillary loops per mm2 with legs supine and legs dependent. After 30 minutes of dangling, significantly fewer capillary loops were visible in 90% of subjects. The authors conclude that the capillary loops become occluded with white blood cell plugs, and that activation of the trapped WBC produces ischemia on a vascular basis. Valvular Incompetence. Valvular incompetence is a major factor in the development of stasis, pigmentation, and ulceration. Van Bemmelen and coworkers189 studied the relation of ulcerations to the functional status of the superficial and deep venous valves. Doppler scanning showed valvular incompetence in 22 of 25 ulcerated limbs. The most commonly involved incompetent segment was the popliteal vein, followed by the superficial femoral vein. Management The exact site of venous incompetence must be determined preoperatively if therapy is to be successful. McEnroe and coauthors190 evaluated the hemodynamics of patients with chronic venous insufficiency. Venous obstruction was uncommon (5%), suggesting that venous bypass surgery may be of little value in resolving the problem of chronic venous insufficiency. Patients who had venous ulcerations tended to have deep venous insufficiency alone (72%), suggesting that deep valvular reconstruction might be a treatment option in these cases.

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Compression Therapy. Compression therapy for the management of lower extremity venous ulceration dates back to Hippocrates. This method was later advocated by Par in 1553. The significant recurrence rate is almost always related to failure of the patient to comply with long-term therapy. Mayberry and colleagues191 reviewed the course of 113 patients with severe, chronic venous insufficiency and ulcerations. After treatment with ambulatory compression therapy, 93% of patients experienced complete ulcer healing in a mean 5.3 months. Among patients followed for an average of 30 months, 80% continued to be compliant with stockings and 16% suffered recurrence. All patients who were noncompliant had recurrent ulcerations by 36 months. Subfascial Ligation. Subfascial ligation of incompetent perforating veins is largely effective in inducing healing of venous ulcers. Jamieson, DeRose, and Harris192 report their experience in 118 limbs with refractory venous stasis ulcers treated by subfascial ligation. Postoperative complications were minimal. At a mean follow-up of 8 years, the authors report good to excellent results in 82% of cases, with healing of ulcers and no recurrence despite considerable noncompliance with support stockings. A modified Felder-Rob subfascial ligation193 in 45 limbs with chronic venous ulcers also produced good results,with only 4.4% recurrence of ulceration after 28 years of follow-up.194 Complications of subfascial ligation include skin necrosis, exposure-induced necrosis of the Achilles tendon, and equinus deformity of the ankle from contracture of the tendon. Vein Valve Transplants. Venous valve transplantation has been recommended to prevent reflux from the thigh veins and thus lower ambulatory venous pressure at the ankle. Nash195 presents his experience with venous valve transplantation in 23 patients. Before surgery, 17 had recurrent ulcers, 6 had severe preulcer skin damage, and 18 had previous unsuccessful venous operations. Duplex sonography was used for preoperative and postoperative evaluation of the popliteal vein to detect reflux and graft patency. Ambulatory venous pressures were measured

directly in the dorsal foot before and after surgery. A 5-cm segment of brachial vein containing a competent valve was transposed to an excised segment of popliteal vein. Valve competence was tested before completing the proximal anastomosis. Results: 15/23 patients had complete healing of their ulcers. All patients had relief of symptoms of claudication. At 18 months, all transplants remained patent but 5 had evidence of reflux at the transplanted valves and 1 developed a recurrent ulcer. Documented falls in ambulatory venous pressure averaged only 18% despite functioning popliteal valve transplants, probably a reflection of the many remaining incompetent valves in the posterior tibial and peroneal veins. Rai and Lerner196 followed 25 patients with endstage venous insufficiency unresponsive to conservative management. All patients had ulcers of the lower extremities present for more than 6 months (average 4 years). Valvular incompetence in the deep venous system was diagnosed in 15 patients, 12 of whom had brachial vein transplants. Of these, 10 ulcers healed within 16 weeks and 2 needed skin grafts. All patients had complete relief of pain and were able to ambulate. Four patients noted total resolution of lower extremity swelling, and the rest experienced various degrees of improvement in their symptoms. A comparison of pre- and postoperative venous pressures showed no significant change to account for the clinical improvement. Ger167 stresses the need to treat the primary disease contributing to the ulcer and details the management of venous ulcers by various operative and nonoperative means. The advantages of coverage with local muscle flaps and STSG are reviewed, including which muscle flaps are most appropriate for particular areas of the lower extremity. The causes of primary muscle flap failure are discussed. Arterial Disease Arterial insufficiency is a known cause of chronic leg ulceration, recognized by symptoms of claudication and rest pain as well as the characteristic appearance of arterial ulcers. Arterial ulcers tend to occur distally on the leg and foot and are usually accompanied by painful episodes. The pain improves on dependency and is exacerbated by elevation of the extremity.

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Management The management of ulcers caused by arterial insufficiency differs drastically from that of venous ulcers, even though arterial occlusion and venous insufficiency may coexist in the same patient. Sindrup et al197 studied 94 consecutive patients with stasis ulcers and noted 50% had evidence of obstructive arterial disease, more severe if diabetes was also present. They conclude that patients with obvious stasis ulcers of the legs should be carefully examined for coexisting arterial disease, which, if present, is a contraindication for compression therapy. A large study from Scotland reviewed 600 patients (827 ulcerated legs) for the relation, if any, between gangrene and the use of compression bandages.198 Elastic bandages and compression hosiery produce pressures around 30 mmHg at ankle level. Pressures are not evenly distributed around the circumference of the limb but instead tend to be much higher over prominences such as the malleoli, the Achilles tendon, and the anterior tendons of the ankle. These sites are at high risk of injury from compression bandages, and reductions in blood flow may be further aggravated by elevation of the affected extremity. Doppler resting pressures of 0.9 indicated arterial insufficiency and were noted in 21%. Palpable pulses in the foot did not preclude arterial insufficiency: Approximately 50% of patients with arterial impairment also showed clinical features of chronic venous insufficiency. The authors conclude that patients who have ulcerations anywhere on the foot should be regarded as having arterial disease until proved otherwise. Arterial disease should be ruled out before compression and elevation are instituted for venous disease.199 Once the presence of arterial insufficiency has been established, general guidelines for management of vascular disease are applied. Patients whose wounds fail to improve preoperatively despite meticulous wound care are chosen for arterial bypass grafts to avoid amputation. Arterial disease to the level of the malleoli is common among diabetic patients, in whom more distal bypass sites should be chosen. Arterial inflow can be restored with a saphenous vein bypass graft to the distal trifurcation vessels. Andros et al200 describe lateral plantar artery bypass

grafting from the distal popliteal artery in 17 patients with gangrene of the foot. The foot salvage rate at 2 months was 89%. All but 4/20 ulcers healed within 6 months. Even with a functioning bypass graft, therefore, local wound healing is protracted. Two patients progressed to below-knee amputation, one despite a patent graft. All patients who had successful revascularization were able to walk eventually, and 7 returned to work full-time. Daane and colleagues201 report a small series of successful distal lower extremity bypass. Patients underwent inframalleolar bypass grafting with arterial grafts using the operating microscope. Five of six operated patients enjoyed graft patency at 52 months. This technique may hold future promise for patients with distal arterial disease who suffer from arterial ulcers and chronic pain. Another study reports the use of dorsal venous arch arterialization (DVAA) for revascularization of distal ischemia when poor recipient vessels exist.202 Lepantalo and Tukiainen203 report a series of combined lower extremity revascularization and free flap coverage of arterial wounds. The limb salvage rate was 76% at 1 year. In some cases, the free flap remained viable while the distal limb progressed to worsening ischemia. This study shows the feasibility of combining lower extremity revascularization with free flap coverage for peripheral vascular disease in select cases. Gooden and coworkers204 reviewed their extensive experience with microvascular flaps for lower limb salvage. In a very difficult group of 26 patients 92% with exposed bone, joint, or tendon; 90% with diabetes; and 33% on dialysisthey performed 27 free flaps of various types. The selection criteria included patients with 1) large soft tissue defects who were ambulatory and functioned fairly well; and 2) acceptable cardiovascular risk to withstand a long operationaverage 5 hours, 18 minutes. At a mean 14 months from surgery, the limb salvage and ambulation rate was 88%. This figure must be compared with the rehabilitation rates of patients after below-knee amputation, which in some centers exceeds 90%.205 Community-based studies report rehabilitation rates of 40% to 60%;206 for combined revascularization and free flap coverage to be hailed as a success, therefore, ambulation rates must be high.

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Attinger and colleagues207 report a large series of patients with difficult arterial wounds and significant comorbidities. Forty-five patients with renal failure and diabetes were treated by aggressive multimodality therapy, including limb revascularization procedures and soft tissue coverage procedures. Several patients required free-flaps for wound coverage. At 3 years, limb salvage rate was 89% and the independent ambulation rate was 73%. This article and others illustrate the potential of functional limb salvage when revascularization and wound coverage are combined in selected patients despite comorbidities.207,208 Diabetic Ulcers The typical diabetic patient suffers from a combination of distal sensory loss and reduced peripheral arterial circulation. Abnormal physical stresses, however minor, may cause ulceration; in fact, poorly fitting shoes are the most common cause of foot lesions in diabetics. Foot ulcers are the most common cause of hospital admission in this population.209 Colen116 addresses common misconceptions in the care of diabetic ulcers. The first myth is that foot problems are due to small vessel disease. Histologic staining of amputation specimens from diabetic patients shows no arteriolar occlusion, and blood flow measurements during femoropopliteal bypass demonstrate no difference in response to papaverine vasodilation, indicating normal reactivity of the vessels. The second myth involves purported endothelial proliferation in small vessels of diabetic patients. There is no evidence of intimal hyperplasia in the small vessels of diabetic patients, suggesting that diabetic neuropathy, and not microvascular disease, accounts for foot lesions. The etiology of diabetic neuropathy remains elusive. Stevens and associates210 implicate a combination of closely interdependent metabolic and vascular defects, such as reduced nerve blood flow from structural changes in the endoneurial microvasculature, abnormalities in vasoactive agents regulating nerve blood flow, and/or altered tone of autonomic nerves to blood vessels. Other metabolic defects include disruption of the polyol pathway, altered lipid metabolism, advanced glyco-

sylated end product formation, and diabetesinduced defects in growth factors. The cause of abnormal blood flow to the feet in diabetic neuropathy is not known, although sympathetic denervation has been suggested.211 Similarly, the interaction between altered blood flow, painful neuropathy, and neuropathic ulcers is unclear. Perfusion studies indicate a blood flow pattern consistent with reduced peripherovascular resistance, probably from arteriovenus shunting resulting from distal sympathetic denervation.211 Boulton209 classifies diabetic foot lesions according to five grades of severity. Grade I lesions occur under areas of weight bearing such as the toes and metatarsal heads. Grade II lesions occur at similar sites but are much deeper, often with tendon involvement and infection. Total contact casting of the foot is indicated to remove pressure from the ulcer area. Grade III lesions require surgical intervention after control of the infection. Grade IV ulcers require arteriography to determine which lesions can be treated surgically. Grade V lesions require amputation. Treatment consists of reducing localized pressure on prominent surfaces of the sole. In Sinacores212 study, 82% of ulcers treated by total contact walking casts healed in an average of 6 weeks. Casts must be carefully applied and removed at regular intervals for foot inspection, since a loosefitting cast will cause friction that can lead to blisters and ultimately ulcers.213 Griffiths and Wieman214 report 34 metatarsal head resections in 25 patients. Most ulcers had been present for at least 9 months. Ulcers healed an average 2.4 months after surgery and no recurrences were seen at 14 months. Three patients required resection of another metatarsal head on the same foot to treat a second ulcer, presumably from shifting pressure points after the first surgery. Conclusion: If a toe needs to be excised, a ray amputation should be performed to prevent ulceration of its metatarsal head. Newman and colleagues215 found osteomyelitis in 68% of diabetic foot ulcers, only half of which had been clinically suspected. Osteomyelitis was present in all ulcers with exposed bone, although 68% had no exposed bone and 64% did not even have inflammation. Among the diagnostic tests for osteomyelitis, the leukocyte scan had the highest

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sensitivity (89%) and was useful for assessing antibiotic effectiveness. Yuh et al216 evaluated plain films, bone scan, and magnetic resonance imaging (MRI) in 24 diabetic patients suspected of having osteomyelitis. Bone biopsies from 14 patients whose ulcers did not respond to antibiotics were positive for osteomyelitis in 87%. MRI gave a correct diagnosis in all patients, plain films were not diagnostic until extensive bony destruction was present, and bone scan had the highest false-positive rate. Advocates of limb salvage with free tissue transfer report durable results when using microsurgical techniques in specific patients. Lai and associates217 reviewed limb salvage of 10 infected and gangrenous diabetic foot ulcers. Treatment consisted of debridement and coverage with a free gracilis muscle flap and STSG. Flap perfusion equaled perfusion of the surrounding tissue at about 8 weeks. No recurrence of ulcer or infection was noted during the follow-up period. SOFT TISSUE COVERAGE OPTIONS FOR LOWER EXTREMITY WOUNDS The goal of soft tissue reconstruction in the lower extremity should be satisfactory wound coverage with restoration of function. Ancillary considerations are an acceptable appearance and minimal donor site morbidity. For soft tissue coverage alone, muscle and fasciocutaneous flaps remain primary choices in the lower extremity. Random pattern cutaneous flaps and musculocutaneous flaps have more limited applications. Free flaps are generally the soft tissue coverage of choice for most defects of the lower third of the leg.218,219 With any lower extremity reconstruction, three tenets are essential: 1. Adequate preparation, which includes full debridement and control of any wound infection prior to coverage. 2. Stabilization and management of associated orthopedic injuries. 3. Overall assessment of the patients suitability for reconstruction and rehabilitation. These factors need to be optimized before undertaking lower extremity reconstruction. Vacuum-assisted closure (VAC) is a very useful adjunct to wound management in the lower

extremity, particularly after adequate debridement and preparation of an ideal wound bed. The VAC device aids in wound bed preparation and minimizes dressing changes. Although a thorough understanding of local flaps is crucial for lower extremity reconstruction, many leg and foot wounds are not amenable to local flap reconstruction. For instance, many Gustilo grade III wounds are not reliably covered by local muscle flaps. Regardless of etiology, large leg and foot wounds are often best served by free flap coverage. The basic principles and options for free flap reconstruction of the lower extremity are essential to leg and foot reconstruction, and are therefore discussed first. Local and free flaps are compared for specific zones and defects in the section following. Free Flaps Microvascular transfers can deliver both soft tissue and skeletal support to large complex wounds of the leg, and are particularly useful in the distal third of the leg and foot. Free vascularized bone transfers are reviewed above. Serafin112 offered the following useful guidelines for free flap transfers in the lower extremity:

anastomose the microvessels outside the zone


of injury

make end-to-side arterial anastomoses and endto-side or end-to-end venous anastomoses

reconstruct the soft tissues first and then restore


skeletal support Heller and Levin4 review lower extremity microsurgical reconstruction and propose a useful reconstructive ladder. Defects are categorized according to the tissues needed and status of the vascular supply. Free flaps for isolated replacement of muscle, skin, fascia, or bone are discussed, as well as more sophisticated composite flaps such as musculocutaneous, osteocutaneous, and innervated musculocutaneous flaps. Preoperative considerations include evaluation of dead space, orthopedic management of the bone injury, and final orthopedic disposition. For soft tissue cover alone, a relatively small number of muscle flaps are typically employed. The

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workhorse free muscle flaps commonly used for the lower extremity are the latissimus, serratus, rectus, and gracilis. Cutaneous, fascial, and fasciocutaneous free flaps have also been described to cover lower extremity defects. For a thorough encyclopedia of available free flaps, see the textbook by Mathes and Nahai.220 The latissimus dorsi flap has the advantage of a large amount of bulk to fill dead space. Despite its initial bulk, the latissimus flap will reliably atrophy and re-contour if inset under appropriate tension and managed with compression garments. The atrophy aids in restoring normal contour to the leg. Using the single thoracodorsal pedicle, the latissimus dorsi flap can be combined with the serratus anterior muscle flap for coverage of massive lower extremity defects. Another advantage of both the latissimus and serratus flaps is the long vascular pedicle, which allows anastomosis well outside the zone of injury in most cases. The use of vein grafts can lengthen this already generous pedicle. By placing the patients upper body in a lateral decubitis position and the lower body turned more supine, most latissimus and serratus transfers can be performed without a patient position change. The rectus abdominis muscle flap also provides a significant volume of muscle with an acceptable pedicle. With the patient supine, this flap rarely requires a patient position change for coverage of leg defects.117 For smaller volume defects, the gracilis is an ideal muscle flap.118 The gracilis muscle is easy to harvest, has little donor site morbidity, and adapts itself well to leg contour. Wechselberger and colleagues119 describe an innovative and anatomically sound method of taking a larger, transverse, and more reliable skin paddle with the gracilis (Fig 10). The selection of appropriate recipient vessels for free tissue transfer is critical. Park, Han, and Lee115 conclude the following on the basis of 50 consecutive lower extremity free flaps:
1. The site of injury and the vascular status of the lower extremity are the most important factors in recipient vessel selection in lower extremity reconstruction. 2. The type of flap used, method, and site of microvascular anastomosis are less important factors in determining the recipient vessel.

Fig 10. Medial view of the thigh showing the relation of the axis of the skin paddle (transverse) to the axis of the gracilis muscle (longitudinal) and to the pubic tubercle (4), the adductor longus muscle (1), the gracilis muscle (2) and the adductor magnus muscle (3). (Reprinted with permission from Wechselberger T et al: Surgical technique and clinical application of the transverse gracilis myocutaneous free flap. Br J Plast Surg 54(5):423, 2001.)

3. The anterior tibial artery is easier to use than the posterior tibial artery. 4. Anterior donor flaps are more convenient and are preferred for use when the anterior tibial artery is used. 5. An end-to-side anastomosis can be an option when using the posterior tibial artery; it is rarely used with the anterior tibial artery. 6. An anastomosis distal to the zone of injury is a very useful method. 7. An angiographic or Doppler confirmation should precede an anastomosis using reverse flow; intraoperative confirmation of pulsatile flow is also important. 8. The cross-leg free flap should be reserved as a last resort. Park, Han, Lee (1999)

Free tissue transfers to vessels distal to the defect are acceptable as long as the anastomoses are performed outside the zone of injury.221 Local flaps as well as free tissue transfers have been described for lower extremity reconstruction in children. Banic and Wulff222 use a free latissimus dorsi flap for definitive repair of lower extremity wounds in children. Stewart223 describes a series of large transposition flaps and one free flap used to treat children with open tibial fractures. Free tissue transfer in elderly patients with lower extremity wounds has also been described. Dabb and Davis224 transferred three latissimus dorsi flaps in three elderly patients for limb salvage. The authors advocate a thorough medical workup, tabulating a

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cardiac risk index score prior to surgery and especially including a peripheral vascular workup before surgery is contemplated. Although this series reports success with limb revascularization and free tissue transfer in a few elderly patients, it must be noted that elderly patients with comorbidities may be better served by primary amputation. Furnas and colleagues 225 and Goldberg and coworkers226 described their results with microsurgical tissue transfer for lower extremity reconstruction in elderly patients. Furnas225 reports 10% failures and a 30% complication rate. Goldberg226 notes that, despite medical advances, the mortality rate from surgery among patients older than 70 ranged from 8% to 10%. A case report by Fisher and Wood227 illustrates an important point in microvascular free flap reconstruction in the severely injured lower extremity. Seven months after surgery, complete necrosis of the latissimus dorsi free muscle flap developed as a result of blunt trauma to the vascular pedicle. The authors suggest that clinical free flaps with high flow rates and poorly vascularized soft tissue beds may lack the stimulus for neovascularization. In contrast, neovascularization of free flap transplants in animals can be seen only 5-10 days after transfer. These observations suggest a reversal of the parasitic role of flaps on the soft tissue bed when the muscle itself is well vascularized. Thigh In general, soft tissue defects of the thigh require neither pedicled nor free flap reconstruction because of the large amount of local muscle tissue that can be advanced into the wound. Skin coverage can usually be accomplished by skin grafts on top of intact muscle. For large contour defects of the anterior thigh, or when the femoral vessels are exposed, a pedicled rectus flap or VRAM can be used. The gracilis and the tensor fascia lata can also be rotated anteriorly to cover smaller defects, if indicated. The textbook by Mathes and Nahai220 describes the pedicled flap options for the thigh. If free flaps are required, the defect is usually so extensive that large free flapseg, the latissimus dorsiare indicated.

Leg Upper Third and Knee Swartz and Jones228 review the principles of wound coverage in the lower extremity and describe five options for the different territories of the leg and foot. An overview of standard flap options for the leg is found in the articles by Pers and Medgyesi,229 Ger,167 and McCraw.230 As a rule, the upper third of the leg can be covered with rotational muscle flaps. Special consideration needs to be given to preserving or reconstructing the knee extensor mechanism. Patel and colleagues231 report a novel technique for dual coverage of the knee and functional reconstruction of the knee extensor mechanism with the gastrocnemius flap. The following muscle flaps are available for covering defects of the upper third of the tibia and kne:

medial head of the gastrocnemius lateral head of the gastrocnemius proximally based soleus bipedicled tibialis anterior (lower part of the tibia)

The medial head of the gastrocnemius is an excellent choice for proximal tibia and knee coverage because of its proximally based neurovascular pedicle and broad belly. When a longer advancement is required, careful dissection and release of the muscle origin from the medial condyle of the femur are indicated. Wide scoring of the fascia can also facilitate long advancement.232 The lateral head of the gastrocnemius provides similar but more restricted coverage. Care must be taken to protect the lateral sural nerve. The soleus muscle, based proximally, can be reliably carried to a point approximately 5 cm above its tendinous insertion. Although muscle action is not missed after transfer, the soleus muscle is responsible for the venous pump phenomenon as well as being a slow muscle, aiding in posture stabilization and slow gait. Usually mimimal to no functional deficit ensues from using a single head of the gastrocnemius or the entire soleus muscle. The tibialis anterior muscle is important in dorsiflexion of the foot and is not considered expendable. However, by maintaining its origin and insertion, the muscle might be raised as a bipedicled

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flap to provide coverage and preserve function. The tibialis anterior is a Mathes Type IV muscle which requires maintenance of its segmental vascular supply and innervation. Other limitations are its relatively small volume and short arc for transposition. Nevertheless, the tibialis anterior remains a valuable option in small open defects along the entire tibia. Hallock233 describes various methods of splitting and partially rotating the muscle to provide maximum anterior tibial coverage while preserving muscle function (Fig 11).

Fasciocutaneous flaps are based on superficial perforating vessels from the deep arterial system; preoperative Doppler assessment of the circulatory status of these flaps is recommended. Although these flaps are options for the proximal third of the leg, the standard rotational flap for the proximal third remains the gastrocnemius muscle flap. Fix and Vasconez235 review a broad range of fasciocutaneous flaps in the lower extremity. Variants of fasciocutaneous flaps that can be used in the proximal third of the leg are described. Walton and Bunkis236 describe a posterior calf fasciocutaneous flap perfused axially via a descending cutaneous branch of the popliteal artery. This flap allows pedicled or free transfer of large segments of fascia and skin from the posterior calf. Walton et al237 subsequently reported using the fascial portion of the posterior calf as a free flap for resurfacing the hand and distal lower extremity. Peculiarities of the blood supply of fascial flaps are described in the article. Leg Middle Third The following muscle flaps are available for coverage in the middle third of the tibia:

Fig 11. The techniques to allow function preservation when transferring the tibialis muscle flap. (A) A superior-based rotation flap with part of the muscle dissected completely from the central tendon. (B) A posterior advancement flap with a lateral hinge. (C) The anterior turnover flap with a medial hinge. (D) A sagittal split flap. (Reprinted with permission from Hallock GG: Sagittal split tibialis anterior muscle flap. Ann Plast Surg 49(1):39, 2002.)

medial head of the gastrocnemius lateral head of the gastrocnemius proximally based soleus flexor digitorum longus (for the lower portion of the middle third)

extensor digitorum longus extensor hallucis longus (for the lower portion of
the middle third)

flexor hallucis longus muscle (for the lower portion of the middle third)

Yoshimura and colleagues described the peroneal island flap, which allows transfer of skin from above the knee or lateral leg based either proximally or distally. Cutaneous perforators from the peroneal system perfuse a large island of skin whose neurovascular pedicle has an effective length equivalent to the length of the peroneal vessel as it courses distally in the extremity. The authors report no flap necrosis in 14 cases.
234

tibialis anterior
The functional significance of the gastrocnemius, soleus, and tibialis anterior muscles has already been discussed. The flexor digitorum longus can be transferred without significant functional loss, but its spare muscle belly limits it to small defects or to be used in conjunction with other flaps. The neurovascular pedicle usually enters the muscle at the junction of its proximal and middle thirds, although this is vari-

Fasciocutaneous flaps are another option for coverage of defects in the proximal third of the leg.

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able. Its function in toe flexion is supplemented by the action of the flexor digitorum brevis. Donor site morbidity is minimal. The blood supply to the extensor digitorum longus is via vessels from the anterior tibial artery. The flap is used for closure of small wounds (<5 cm in diameter). An incision is made 2 cm lateral to the tibia and the muscle is located lateral to the tibialis anterior muscle. The muscle is raised, taking care to preserve the superficial peroneal nerve during the flap dissection. Ligation of perforators must be kept to a minimum during harvest or the muscle will not survive. The superficial peroneal nerve must not be damaged in the dissection. The extensor hallucis longus also has a small muscle belly that limits its usefulness. During harvest, the surgeon must be careful to leave the distal tendon attached to the extensor digitorum communis to avert great toe drop. The flexor hallucis longus muscle is larger than the adjacent flexor digitorum communis, but its primary function is to push off the great toe, and should not be sacrificed. The flap can be used as an adjunct to other methods of closure in the lower middle third and upper lower third of the tibia. Free tissue transfer remains a useful option in the middle third of the leg, if local flaps cannot suffice. In fact, many severe open tibial fractures that require substantial soft tissue coverage, are best served by free flaps, rather than local flaps. It must be remembered that the local muscle flaps that are available for the middle third of the leg, other than the soleus, are only good for small defects. Again, the latissimus, rectus, serratus, and gracilis tend to be the workhorse free flaps for this area of the leg; but a number of other options exist as well. In an interesting case report, Maghari and colleagues 238 describe how tissue expansion was used to create a massive free flap for coverage of a massive knee defect. Fasciocutaneous flaps for coverage of middlethird defects235 are typically based on medial or posterolateral septocutaneous perforators. Many fasciocutaneous flaps for coverage of middle third defects can be designed without an identifiable perforating artery: In essence, these are randompattern fasciocutaneous flaps. The length:width ratio can be extended to 3:1, or twice that of random

cutaneous flaps.235 Selection of one of these flaps must be carefully weighed against excellent, reliable local muscle flaps such as the soleus or the use of free flaps. Leg Lower Third and Ankle Distal leg and ankle wounds are usually covered with microvascular free flaps due to the insufficient soft tissue available for transposition at this level. The following discussion pertains to both distally based superficial flaps as well as local muscle flaps. These flaps can be used when free tissue transfer is contraindicated or when the defect is small enough that small transposition flaps are sufficient for coverage. The previously described flexor hallucis longus, flexor digitorum longus, and tibialis anterior can all be used in small-volume closures of the distal third of the leg. The abductor hallucis pedicled muscle flap will reach partly up the lower third of the tibia. The muscle occupies the medial instep of the foot and serves as an important springboard for the arch. Following transfer, the abductor hallucis is missed for approximately 6 months; most patients eventually adapt to its loss. The muscle is mobilized on the lateral plantar artery and provides limited coverage of the lateral malleolus. The distally based soleus, although described for these defects, is generally inferior to free flaps for coverage of large defects of the distal lower third. The extensor digitorum brevis flap may also be used for small defects of the ankle and proximal foot. The downside is necessary sacrifice of the dorsalis pedis artery to allow flap rotation and viability.239 The peroneus brevis rotation flap, dissected free of the lateral compartment, can provide coverage for the lateral lower third of the leg for exposed fibula defects. The peroneus longus must remain intact to evert the foot when the peroneus brevis is dissected. Articles by Eren and colleagues240 and McHenry and Schacherer241 describe worthwhile technical details and clinical results from their experience of peroneus brevis flaps used for distal fibula defects. In a subsequent letter to the editor, Barr242 questions the reliability of the distal aspect of this flap. Rotation of the peroneus brevis flap on its distal minor pedicle decreases perfusion to the

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most distal aspect of the flap, which may be the region needed to cover a wound. Attinger and colleagues243 have written a comprehensive review of the local flap options for ankle and foot reconstruction This review emphasizes the anatomy and limitations of several useful local flaps from the leg and foot (Fig 12). Use of a delay procedure is suggested prior to transfer of some of the leg muscle flaps. Most of these flaps are only useful for small defects, but a judicious selection can help avert the need for free flap coverage in certain cases of foot and ankle defects.

arteries. Distal third fasciocutaneous flaps for lower leg coverage are best designed as rotation flaps rather than island flaps. In the leg, the saphenous and sural flaps are most commonly transferred. The saphenous fasciocutaneous flap is perfused by posteromedial fasciocutaneous perforators off the saphenous artery. The sural flap is supplied by perforators from the medial superficial sural artery. Harvested with the sural nerve, it becomes a neurosensory flap.

Fig 13. Design of the sural neurocutaneous flap. The short saphenous vein in the pedicle improves flap drainage. (Reprinted with permission from Touam C, Rostoucher P, Bhatia A, Oberlin C: Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot. Plast Reconstr Surg 107(2): 383, 2001.)

Fig 12. Distances of the maximal possible reach of the muscles as measured from the tip of the medial malleolus. (Reprinted with permission from Attinger CE, Ducic I, Zelen C: The use of local muscle flaps in foot and ankle reconstruction. Clin Podiatr Med Surg 17(4):681, 2000.)

A number of fasciocutaneous flaps have been described for coverage of the distal one third of the leg. They are primarily distally based, reverse-flow flaps perfused by septocutaneous perforators from the anterior tibial, posterior tibial, and peroneal

The reverse sural neurocutaneous flap (Fig 13) and lateral supramalleolar flaps (Fig 14) are compared in a series by Touam.244 The sural flap was superior to the lateral supramalleolar flap in reliability: 4.8% failure for the reverse sural flap vs 18.5% for the lateral supramalleolar flap. Both flaps are more useful in nontraumatic wounds, such as after resection of skin cancers or ulcers. Touams series included only a few traumatic wounds. A number of distally based superficial island flaps have been described for lower leg reconstruction.110,245,246 Flap coverage was largely successful. Transfer of the sural flap does leave the posterior

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Fig 14. A, Design of the lateral supramalleolar flap. The superficial peroneal nerve is transected. B, Flap circulation: (1) peroneal artery; (2) anterior tibial artery; (3) septocutaneous perforators; (4) malleolar branch of the ant. tibial artery; (5) distal tibiofibular angle. Sometimes (3) and (4) are divided during flap elevation and the island is carried on retrograde flow from the ant. tibial a. (Reprinted with permission from Touam C, Rostoucher P, Bhatia A, Oberlin C: Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot. Plast Reconstr Surg 107(2): 383, 2001.)

is intact; split grafts are not recommended on top of granulation tissue that is directly over bone. Woltering et al248 describe their experience in 13 patients whose skin graft included the heel and forefoot. The average time to weightbearing without crutches was 80 days. All grafts reportedly did well, including those on the calcaneus and first metatarsal head. Postoperative pressure-sensitive ink pad recordings showed the patients gait patterns had changed to enhanced graft protection despite weightbearing. Sommerlad and McGrouther249 compared techniques for coverage of the sole of the foot in 51 patients. Regardless of the type of reconstruction chosen, ink pad recordings showed altered gait patterns that always favored the reconstructed site. Skin grafts in this comparative series fared well, although hyperkeratosis was noted as a problem. Attinger243 reviews local flap options in defects of the foot. May and coworkers250,251 describe the use of a free latissimus dorsi muscle flap with thick STSG in chronic defects of the foot. Three operative groups were identified, as follows:

Group I patients with flaps placed at or below


the level of the malleolus who were not weightbearing on flap tissues.

Group II patients who were weightbearing on


flap tissues but not directly on the skin graft covering the transferred muscle.

aspects of the lower leg anesthetic, and large flaps produce significant donor site morbidity. Hallock247 analyzed complications of 100 consecutive local fasciocutaneous flaps, 67 of which were used for lower extremity reconstruction. Major complications were reported in 15% of patients and minor complications in 11%. The incidence of complications was noted to be much lower in trauma cases than in older patients with concomitant peripherovascular disease. The complication rate in distally based flaps was 37.5%. Wound closure was ultimately achieved in 97% of patients. Foot The simplest cover for a defect on the plantar surface of the foot is a thick split-thickness skin graft (STSG). These grafts can only be used when a substantial portion of the subcutaneous plantar pad

Group III patients who were weightbearing


directly on the skin graft covering the transferred muscle. All patients were ambulatory in normal footwear after the procedure. Gait analysis indicated that the amount of time spent on the resurfaced foot during a normal walking cycle was approximately the same as that on the normal foot. All patients had an appreciation of deep pressure sensation in the involved areas, but light touch sensation in the graft was absent. Of significance was the presence of a shear plane between the skin graft and the muscle tissue and between the muscle tissue and the underlying bone. These shear planes could play a protective role in the long-term durability of the graft. Two patients from Group III experienced delayed skin-graft breakdown in their usual footwear. The authors recommend keeping the outer

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fascia of the latissimus dorsi muscle intact at the time of transfer and using the fascia to inset the muscle without redundancy. Clearly, patients that undergo heel coverage with anything other than plantar skin must always be aware of the possibility of breakdown. Free muscle flap with skin graft coverage is useful in defects of the foot that are large, anterior, when local tissue is not available, there is dead space after bony debridement, local tissues or vessels are damaged, or local flaps have failed. One should consider resecting bony prominences at the time of flap inset. Mays conclusions are substantiated by Stevenson and Mathes,252 who report a similar experience with the use of free muscle flaps in foot injuries. Reiffel and McCarthy253 review flap options for coverage of the heel. They describe the anatomic basis and surgical detail of an axial cutaneous medial plantar artery instep flap and an axial musculocutaneous lateral plantar flap containing flexor brevis muscle. The flexor digitorum brevis, with or without its overlying instep skin, appears to be a reasonable alternative for heel defects because it can be transferred without detaching the lateral plantar artery calcaneal branch from the posterior tibial artery. The instep flap need not be musculocutaneous or have a pedicle base.254 The flap can be transferred as a true fasciocutaneous island flap in a single stage (Fig 15), either on a pedicle or by microvascular anastomoses. The instep flap has been carried on both the medial and lateral plantar vessels and requires skin graft coverage of the instep donor site.255,256 Shaw and Hidalgo257 review the anatomy of the plantar flap and its clinical applications. The flap is elevated superficial to the plantar fascia to avoid disruption of the normal plantar structures and to maximize sensation distally and over the heel. Sensation is preserved by including the medial calcaneal nerve and by limiting the intraneural dissection of the medial and lateral plantar nerves (Fig 16). This is a durable and functional flap for heel coverage, but it cannot reach the posterior and vertical portions of the heel. Hartrampf, Scheflan, and Bostwick258 used the flexor digitorum brevis muscle for coverage of the heel, Achilles tendon, medial and lateral malleolus. The flap is mobilized on the lateral plantar vessels (Fig 17).

Fig 15. The instep island flap raised on the medial plantar vessels and cutaneous nerve branches. The flap is raised superficial to the flexor digitorum brevis; the nerves and vessels do not pass through muscle. (Reprinted with permission from Morrison WA et al: The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast Reconstr Surg 72:56, 1983.)

Forefoot. Split grafts or full-thickness grafts are perfectly adequate for coverage of non-weightbearing surfaces of the forefoot. If the bony surface has adequate pad but there is deficient local cutaneous cover, a preliminary attempt at skin grafting may well be appropriate, reserving muscle pad for failure of the graft. Weightbearing surfaces should be covered with similar plantar tissue when possible. An island instep fasciocutaneous or musculocutaneous flap that preserves sensation appears to be a suitable choice for reconstruction in these cases. An excellent technique for resurfacing defects in the weightbearing aspect of the forefoot makes use of tissues obtained in the toe fillet flap. The donor defect is not missed unless the fillet is taken from the great toe. The skin is well vascularized and innervation is maintained.

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Fig 16. The plantar flap in foot reconstruction. Right, Neurovascular supply of the plantar flap is superficial. Below, Plantar flap transferred to cover a heel defect.

Right, Medially based plantar flap raised over two abductor muscles and the plantar fascia, preserving the medial and lateral plantar nerve branches to the flap. (Modified from Shaw WW, Hidalgo DA: Anatomic basis of plantar flap design: clinical applications. Plast Reconstr Surg 78(5):637, 1986.)

Snyder and Edgerton 259 discuss the anatomy and surgical principles of toe filleting, and Buncke and Colen 260 describe use of the great toe fillet for defects of the forefoot. When planning the design of local foot flaps for lower extremity coverage, two points must be remembered: The incisions should not be placed on weightbearing surfaces, and the amount of tissue available after transfer is often less than expected.

Wound breakdown can ruin an otherwise successful foot reconstruction with local flaps. Free muscle flaps and fascial flaps with skin grafts are a consideration when bony surfaces have no overlying subcutaneous pad and local cutaneous cover is not available. Musharafieh and colleagues261 describe a series of 10 free radial forearm flaps which were used successfully in foot and ankle reconstruction. All patients must be monitored long-

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Fig 17. The lateral neurovascular pedicle of the plantar flap courses obliquely from medial to lateral under the flexor digitorum brevis and over the quadratus plantae muscles. It then assumes a midlateral position between the abductor digiti minimi and the short flexor. The neurovascular bundle then bifurcates to form the deep and superficial plantar arches. Note the proximal pedicle to the flexor brevis. (Reprinted with permission from Hartrampf CR Jr, Scheflan M, Bostwick J III: The flexor digitorum brevis muscle island pedicle flap: A new dimension in heel reconstruction. Plast Reconstr Surg 66:264, 1980.)

may occasionally be cross-leg flap candidates. Dawson263 analyzed the complications encountered in 99 cross-leg flap procedures and reports local flap necrosis in 40% and infection in 28%. As suggested by Barclay,264 the design of the crossleg flap was changed to include the deep fascia of the leg. At present cross-leg flaps are transferred as fasciocutaneous tissue units with a length:width ratio of 3:1 or 4:1.262,265,266 Cross-leg pedicled flaps and cross-leg free flaps have been described for extremity salvage where the existing vascular inflow of the affected extremity is of poor quality, often due to severe trauma or tissue loss.267,268 Still, the evaluating surgeon must realize that an open leg or foot wound with recipient vessels not suitable for free flap transfer may indicate an injury so bad that limb salvage is not advisable in the first place. Long et al 262 report the use of cross-leg fasciocutaneous flaps using current external fixation technology. His series included one patient who was 65 years old. All flaps were based on the axial blood supply of the posterior descending subfascial cutaneous branch of the popliteal artery. The external fixation allowed for physical therapy and range of motion exercises of the extremities to begin soon after surgery. Soft Tissue Expansion The primary application of skin expansion in the lower extremity is to resurface areas of unstable soft tissue or unsightly scar.269 Infection rates range between 5% and 30%. Most surgeons agree that soft-tissue expansion is more difficult in the lower extremity than in other parts of the body. Tissue expansion in the thigh is still done, but most surgeons will avoid attempting tissue expansion in the leg. Manders and coworkers270 report an experience in 16 patients with soft tissue expansion in the lower extremity. All expanders were placed in the subcutaneous plane above the muscular fascia. The pockets for expander placement were drained via closed suction-drainage systems and prophylactic antibiotics were administered to all patients. Expansion was begun 1 to 2 weeks after implantation. Good results were obtained in all patients who were operated on for correction of contour deformities. Good results were also obtained in all patients who had

term for recurrent ulceration whenever nonplantar tissue is used to cover a plantar defect. Cross-Leg Flap Before the widespread use of free tissue transfer, the cross-leg flap was the procedure of choice for typical wounds of the leg when local pedicled flaps were unavailable.262 Today the indications for cross-leg flaps are limited. Patients who are not free flap candidates and patients who remain immobilized for other reasons

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expanders placed in the thigh or buttocks. In contrast, only 50% of expanders at or below the knee were ultimately successful. Overall, 17 complications occurred during 13 expansions, with only 3 patients remaining free of problems. Infection developed in 7 patients, 6 with open wounds at or below the knee and another with an open wound in the thigh. An open wound below the knee forecasted a complication if expansion was undertaken at that site. Infection resulted in wound dehiscence in 2/7 patients and expander exposure in 1/7. The authors state that in the thigh, incisions can be confidently placed at the edge of the defect. In every location, large expanders should be chosen so that they are as long as or longer than the adjacent defect. In an update of their series of lower extremity reconstruction by soft tissue expansion,271 Manders and colleagues discuss sites that are not amenable to expansion, such as the ankle and foot, and in particular the plantar surface of the foot. In addition, they note the following points:

there is a tendency toward periprosthetic infection if the expander is placed next to an open wound in the lower extremity

expansions on the medial and lateral surfaces of


the knee have been accomplished successfully even though the joint is in constant motion

in most instances of soft tissue expansion


designed to eliminate lower extremity defects, one should plan for transverse advancement of tissue, not axial advancement

can lead to osteoarthrosis of the hip. Traditionally this problem was treated either nonsurgically by core decompression or by total hip arthroplasty. Judet, Gilbert, and Judet272,273 report using microvascular free fibular grafts in AVN of the hip as well as in the reconstruction of other large bony defects of the lower extremity. The surgical technique is detailed in their articles. Many authors have since published their respective experiences with free fibulas for proximal femur reconstruction.274-276 In a series of 228 hips treated with free fibular transfer, Soucacos and colleagues276 noted that earlier stages of the disease had better and more predictable results, although even later stages may be candidates for this procedure. Kane and colleagues277 prospectively compared core decompression to free fibulas in stage II and III femoral head AVN. Core decompression failed to prevent total hip arthroplasty in 58% of patients. The patients treated with free fibular grafts went on to arthroplasty 20% of the time. In another study comparing free fibulas to core decompression, Scully and colleagues278 also showed better results with free fibulas for stage II and III disease. Dean and colleagues279 review a large series of pediatric patients with femoral head AVN and note that children treated with free fibulas may do better than their adult counterparts. In conclusion, any long term results of revascularization of the femoral head should be weighed against the good results that are now possible with total hip arthroplasty. REPLANTATION Various reports of successful replantation of lower extremities can be found in the literature, yet large patient series are lacking to help establish clear indications for replantation. Judicious selection of candidates is a must. Replantation of the lower extremity is considered only when the patient is willing to accept multiple operations and blood transfusions as well as a significant risk of complications.280 On the one hand, no other tissue in the body can completely replace the specialized, weightbearing skin and subcutaneous tissues of the heel pad and plantar skin. On the other hand, for a lower extremity replantation to be a success there

the plane of dissection for placement of the


expander is just above the muscular fascia

the most common causes of implant exposure is


an inadequately dissected pocket

bed rest for several days with the leg elevated is


indicated following insertion of expanders in the lower extremity RECONSTRUCTION OF THE NECROTIC FEMORAL HEAD Avascular necrosis (AVN) of the femoral head can be idiopathic, secondary to steroid use, posttraumatic, due to systemic disease, or associated with alcoholism. Adults and children may be affected. Left untreated, AVN of the femoral head

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must be some return of protective sensation to avoid trophic ulceration.280 Carefully chosen heel pad and partial foot replantations may be more predictableand thus more indicatedthan whole foot and leg replantations. Battiston and coworkers281 report their experience with 14 lower extremity replantations, 5 of which were later amputated because of complications. Park and colleagues282 report a case of forefoot replantation in a very young child, with acceptable long-term functional results. Chiang283 notes a good result in a rare case of heel pad replantation. Gayle and colleagues280 at Davies Medical Center report a series of 5 patients with foot and lower leg replantations. Their best results

were at the level of the ankle and distally. Patients who regained some sensation had good functional results and no recurrent ulceration.280 In conclusion, the results of replantation should be compared with those of a well-designed, formfitting below-knee prosthesis. Replantation of the lower limb can be considered in the most ideal circumstances, namely amputations in children requiring minimal bone shortening and expected to have return of protective sensation, and some sharp amputations at the distal leg, ankle, heel pad and forefoot. Patients with lower extremity amputations often present with other serious injuries which may contraindicate lower extremity replantation.

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Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 24:742, 1984. Kasabian AK, Karp NS: Lower Extremity Reconstruction. In: Aston SJ, Beasley RW, Thorne CHM (eds), Grabb and Smiths Plastic Surgery, 5th ed. Philadelphia, Lippincott-Raven, 1997. Ch 86, pp 1031-47. Byrd HS, Spicer TE, Cierny G III: Management of open tibial fractures. Plast Reconstr Surg 76:719, 1985. Edwards P: The effect of crush injury to the skin on healing of fracture of the shaft of the tibia in dogs. Acta Orthop Scand 36:89, 1965. Hooper G, Keddell R, Penny I: Conservative management or closed nailing for tibial shaft fractures: a randomized, prospective trial. J Bone Joint Surg 73:83, 1991. Puno RM, Teynor JT, Nagaro J, et al: Critical analysis of results of treatment in 201 tibial shaft fractures. Clin Orthop 212:113, 1986. Sarmiento A, Gersten LM, Sobol PA, et al: Tibial shaft fractures treated with functional braces. J Bone Joint Surg 71:340, 1989. Olerud S, Karlstrom G: Tibial fractures treated by AO compression osteosynthesis. Experiences from a five year material. Acta Orthop Scand (Suppl 140):1, 1972. Olerud S, Karlstrom G, Danckwardt-Lilliestrom G: Treatment of open fractures of the tibia and ankle. Clin Orthop 136:212, 1978. Bach AW, Hansen ST Jr: Plates versus external fixation in severe open tibial shaft fractures: a randomized trial. Clin Orthop 241:89, 1989. Johner R, Wruhs C: Classification of tibial shaft fractures and correlation with results after rigid internal fixation. Clin Orthop 178:7, 1983. Ruedi T, Webb JK, Allgower M: Experience with the dynamic compression plate in 418 recent fractures of the tibial shaft. Injury 7:252, 1976. 57. 58. 59. 60. 61. 62. 63. 64. 65. Trabulsy PP, Kerley SM, Hoffman WY: A prospective study of early soft tissue coverage of grade III-B tibial fractures. 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80. 81. 82. 83. 84. 85. 86. 87. 88. Arnez ZM: Immediate reconstruction of the lower extremity An update. Clin Plast Surg 18(3):449, 1991. Tropet Y, Garbuio P, Obert L, Ridoux PE: Emergency management of type IIIB open tibial fractures. Br J Plast Surg 52:462, 1999. Tropet Y, Garbuio P, Obert L, et al: One-stage emergency treatment of open grade IIIB tibial shaft fractures with bone loss. Ann Plast Surg 46:113, 2001. Christian EP, Bosse MJ, Robb G: Reconstruction of large diaphyseal defects, without free fibular transfer, in Grade-IIIB tibial fractures. J Bone Joint Surg 71A:994, 1989. Canovas F, Bonnel F, Faure P: Extensive bone loss in an open tibial shaft fracture (immediate bone boiling reimplantation). Injury 30:709, 1999. Taylor GI: The current status of free vascularized bone grafts. Clin Plast Surg 10:185, 1983. Sekiguchi J, Kobayashi S, Ohmori K: Use of the osteocutaneous free scapular flap on the lower extremities. Plast Reconstr Surg 91:103, 1993. 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128. Shenaq SM, Krouskop T, Stal S, Spira M: Salvage of amputation stumps by secondary reconstruction utilizing microsurgical free-tissue transfer. Plast Reconstr Surg 79:861, 1987. 129. Tukiainen EJ, Saray A, Kuokkanen HOM, Asko-Seljavaara SL: Salvage of major amputation stumps of the lower extremity with latissimus dorsi free flaps. Scand J Plast Reconstr Hand Surg 36:85, 2002. 130. Pelissier P, Pistre V, Casoli V, et al: Reconstruction of short lower leg stumps with the osteomusculocutaneous latissimus dorsi-rib flap. Plast Reconstr Surg 109:1013, 2002. 131. Dubert T, Oberlin C, Alnot JY: Partial replantation after traumatic proximal lower limb amputation: a one-stage reconstruction with free osteocutaneous transfer from the amputated limb. Plast Reconstr Surg 91:537, 1993. 132.Stiebel M, Lee C, Fontes R: Calcaneal fillet of sole flap: durable coverage of the traumatic amputation stump. J Trauma 49:960, 2000. 133. 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179. Musharafieh R, Osmani O, Musharafieh U, et al: Efficacy of microsurgical free-tissue transfer in chronic osteomyelitis of the leg and foot: review of 22 cases. J Reconstr Microsurg 15:239, 1999. 180. Gonzalez MH, Tarandy DI, Troy D, et al: Free tissue coverage of chronic traumatic wounds of the lower leg. Plast Reconstr Surg 109:592, 2002. 181. Patetsios P, George M, Ghosh BC: Squamous-cell carcinoma from chronic osteomyelitis. J Am Coll Surg 191:217, 2000. 182. Picascia DD, Roenigk HH Jr: Surgical management of leg ulcers. Dermatol Clin 5(2):303, 1987. 183. Moosa HH et al: Oxygen diffusion in chronic venous ulceration. J Cardiovasc Surg 28:464, 1987. 184. Starling EH: On the absorption of fluids from the connective tissue spaces. J Physiol 19:312, 1896. 185. Lofgren KA: Surgical management of chronic venous insufficiency. Acta Chir Scand Suppl 544:62, 1988. 186. 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Gooden MA, Gentile AT, Mills JL, et al: Free tissue transfer to extend the limits of limb salvage for lower extremity tissue loss. Am J Surg 174:644, 1997. 205. Malone JM, Moore W, Leal JM, Childers SJ: Rehabilitation for lower extremity amputation. Arch Surg 116:93, 1981. 206. Kucan JO, Robson MC: Diabetic foot infections: fate of the contralateral foot. Plast Reconstr Surg 77:439, 1986. 207. Attinger CE, Ducic I, Neville RF, et al: The relative roles of aggressive wound care versus revascularization in salvage of the threatened lower extremity in the renal failure diabetic patient. Plast Reconstr Surg 109:1281, 2002. 208. Illig KA, Moran S, Serletti J, et al: Combined free tissue transfer and infrainguinal bypass graft: an alternative to major amputation in selected patients. J Vasc Surg 33:17, 2001. 209. Boulton AJM: Clinical presentation and management of diabetic neuropathy and foot ulceration. Diabet Med 8 (Suppl):S52, 1991. 210. 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232. Dibbell DG, Edstrom LE: The gastrocnemius myocutaneous flap. Clin Plast Surg 7:45, 1980. 233. Hallock GG: Sagittal split tibialis anterior muscle flap. Ann Plast Surg 49:39, 2002. 234. Yoshimura M et al: Peroneal island flap for skin defects in the lower extremity. J Bone Joint Surg 67A:935, 1985. 235. Fix RJ, Vasconez LO: Fasciocutaneous flaps in reconstruction of the lower extremity. Clin Plast Surg 18(3):571, 1991. 236. Walton RL, Bunkis J: The posterior calf fasciocutaneous free flap. Plast Reconstr Surg 74:76, 1984. 237. Walton RL, Matory WE Jr, Petry JJ: The posterior calf fascial free flap. Plast Reconstr Surg 76:914, 1985. 238. Maghari A, Forootan KS, Fathi M, Manafi A: Free transfer of expanded parascapular, latissimus dorsi, and expander capsule flap for coverage of large lower-extremity soft-tissue defect. Plast Reconstr Surg 106:402, 2000. 239. Pai CH, Lin GT, Lin SY, et al: Extensor digitorum brevis rotational muscle flap for lower leg and ankle coverage. J Trauma 49:1012, 2000. 240. Eren S, Ghofrani A, Reifenrath M: The distally pedicled peroneus brevis muscle flap: a new flap for the lower leg. Plast Reconstr Surg 107:1443, 2001. 241. McHenry TP, Early JS, Schacherer TG: Peroneus brevis rotation flap: anatomic considerations and clinical experience. J Trauma 50:922, 2001. 242. Barr ST, Rowley JM, ONeill PJ, et al: How reliable is the distally based peroneus brevis muscle flap? (Letter). Plast Reconstr Surg 110:360, 2002. 243. Attinger CE, Ducic I, Zelen C: The use of local muscle flaps in foot and ankle reconstruction. Clin Podiatr Med Surg 17:681, 2000. 244. Touam C, Rostoucher P, Bhatia A, Oberlin C: Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot. Plast Reconstr Surg 107:383, 2001. 245. Coskunfirat OK, Velidedeoglu HV, Sahin U, Demir Z: Reverse neurofasciocutaneous flaps for soft-tissue coverage of the lower leg. Ann Plast Surg 43:14, 1999. 246. Fraccalvieri M, Verna G, Dolcet M, et al: The distally based superficial sural flap: our experience in reconstructing the lower leg and foot. Ann Plast Surg 45:132, 2000. 247. Hallock GG: Complications of 100 consecutive local fasciocutaneous flaps. Plast Reconstr Surg 88:264, 1991. 248. Woltering EA et al: Split thickness skin grafting of the plantar surface of the foot after wide excision of neoplasms of the skin. Surg Gynecol Obstet 149:229, 1979. 249. Sommerlad BC, McGrouther DA: Resurfacing the sole: Longterm follow-up and comparison of techniques. Br J Plast Surg 31:107, 1978. 250. May JW Jr, Holls MJ, Simon SR: Free microvascular muscle flaps with skin graft reconstruction of extensive defects of the foot: A clinical and gait analysis study. Plast Reconstr Surg 75:627, 1985. 251. May JW Jr, Rohrich RJ: Foot reconstruction using free microvascular muscle flaps with skin grafts. Clin Plast Surg 13(4):681, 1986. 252. Stevenson TR, Mathes SJ: Management of foot injuries with free-muscle flaps. Plast Reconstr Surg 78:665, 1986. 253. Reiffel RS, McCarthy JG: Coverage of heel and sole defects: A new subfascial arterialized flap. Plast Reconstr Surg 66:250, 1980. 254. Morrison WA et al: The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast Reconstr Surg 72:56, 1983. 255. Curtin JW: Functional surgery for intractable conditions of the sole of the foot. Plast Reconstr Surg 59:806, 1977. 256. Miyamoto Y et al: Current concepts of instep island flap. Ann Plast Surg 19:97, 1987. 257. Shaw WW, Hidalgo DA: Anatomic basis of plantar flap design: Clinical applications. Plast Reconstr Surg 78:637, 1986. 258. Hartrampf CR Jr, Scheflan M, Bostwick J III: The flexor digitorum brevis muscle island pedicle flap: A new dimension in heel reconstruction. Plast Reconstr Surg 66:264, 1980. 259. Snyder GB, Edgerton MT Jr: The principle of the island neurovascular flap in the management of ulcerated anesthetic weightbearing areas of the lower extremity. Plast Reconstr Surg 36:518, 1965. 260. Buncke HJ Jr, Colen LB: An island flap from the first web space of the foot to cover plantar ulcers. Br J Plast Surg 33:242, 1980. 261. Musharafieh R, Atiyeh B, Macari G, Haidar R: Radial forearm fasciocutaneous free-tissue transfer in ankle and foot reconstruction: review of 17 cases. J Reconstr Microsurg 17:147, 2001. 262. Long CD, Granick MS, Solomon MP: The cross-leg flap revisited. Ann Plast Surg 30:560, 1993. 263. Dawson RLG: Complications of the cross-leg flap operation. Proc R Soc Med 65:2, 1972. 264. Barclay TL, Sharpe DT, Chisholm EM: Cross-leg fasciocutaneous flaps. Plast Reconstr Surg 72:843, 1983. 265. Townsend PLG: Indications and long-term assessment of 10 cases of cross-leg free DCIA flaps. Ann Plast Surg 19:225, 1987. 266. Lai C-S, Lin S-D, Chou C-K, Cheng Y-M: Use of a cross-leg free muscle flap to reconstruct an extensive burn wound involving a lower extremity. Burns 17:510, 1991. 267. Ninkovic MM, Schwabegger AH, Hausler JW, et al: Limb salvage after fulminant septicemia using a free latissimus dorsi cross-leg flap. J Reconstr Microsurg 16:603, 2000. 268. Ladas C, Nicholson R, Ching V: The cross-leg soleus muscle flap. Ann Plast Surg 45:612, 2000. 269. Radovan C: Tissue expansion in soft-tissue reconstruction. Plast Reconstr Surg 74:482, 1984. 270. Manders EK et al: Soft-tissue expansion in the lower extremities. Plast Reconstr Surg 81:208, 1988. 271. Borges Filho PT et al: Soft-tissue expansion in lower extremity reconstruction. Clin Plast Surg 18(3):593, 1991. 272. Judet H, Judet J, Gilbert A: Vascular microsurgery in orthopedics. Int Orthop 5(2):61, 1981. 273. Judet H, Gilbert A: Long-term results of free vascularized fibular grafting for femoral head necrosis. Clin Orthop 386:114, 2001. 274. Brunelli G, Brunelli G: Free microvascular fibular transfer for idiopathic femoral head necrosis: long-term follow-up. J Reconstr Microsurg 7:285, 1991. 275. Urbaniak JR, Harvey EJ: Revascularization of the femoral head in osteonecrosis. J Am Acad Orthop Surg 6(1):44, 1998. 276. Soucacos PN, Beris AE, Malizos K, et al: Treatment of avascular necrosis of the femoral head with vascularized fibular transplant. Clin Orthop 368:120, 2001. 277. Kane SM, Ward WA, Jordan LC, et al: Vascularized fibular grafting compared with core decompression in the treatment of femoral head osteonecrosis. Orthopedics 19:869, 1996. 278. Scully SP, Aaron RK, Urbaniak JR: Survival analysis of hips treated with core decompression or vascularized fibular grafting because of avascular necrosis. J Bone Joint Surg 80A:1270, 1998. 279. Dean GS, Kime RC, Fitch RD, et al: Treatment of osteonecrosis in the hip of pediatric patients by free vascularized fibular graft. Clin Orthop 386:106, 2001. 280. Gayle LB, Lineaweaver WC, Buncke GM, et al: Lower extremity replantation. Clin Plast Surg 18(3):437, 1991. 281. Battiston B, Tos P, Pontini I, Ferrero S: Lower limb replantations: indications and a new scoring system. Microsurgery 22:187, 2002. 282. Park EH, Mackay DR, Manders EK, Segal LS: Replantation of the midfoot in a childsix-year follow-up with pedobarographic analysis. J Reconstr Microsurg 15:337, 1999. 283. Chiang YC, Wei FC, Chen LM: Heel replantation and subsequent analysis of gait. Plast Reconstr Surg 91:729, 1993.

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SRPS Volume 9, Number 37

RECOMMENDED READING
French B, Tornetta P 3rd: High-energy tibial shaft fractures. Orthop Clin North Am 33(1):211, 2002. Lieberman JR, Daluiski A, Einhorn TA: The role of growth factors in the repair of bone: biology and clinical applications. J Bone Joint Surg 84A:1032, 2002. Ruedi T, Webb JK, Allgower M: Experience with the dynamic compression plate in 418 recent fractures of the tibial shaft. Injury 7:252, 1976. Trabulsy PP, Kerley SM, Hoffman WY: A prospective study of early soft tissue coverage of grade III-B tibial fractures. J Trauma 36:661, 1984. Bhandari M, Guyatt GH, Tong D, et al: Reamed versus unreamed intramedullary nailing of lower extremity long bone fractures: a systemic overview and meta-analysis. J Orthop Trauma 14:2, 2000. Blick SS, Brumback RJ, Lakatos R, et al: Early prophylactic bone grafting in high-energy tibia fractures. Clin Orthop 240:21, 1989. Lin C-H, Wei F-C, Chen H-C, Chuang DCC: Outcome comparison in traumatic lower-extremity reconstruction by using various composite vascularized bone transplantation. Plast Reconstr Surg 104:984, 1999. Sinclair JS, McNally MA, Small JO, et al: Primary free flap cover of open tibial fractures. Injury 28:581, 1997. Gopal S, Majumder S, Batchelor AG, et al: Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg 82B:959, 2000. Heller L, Levin LS: Lower extremity microsurgical reconstruction. Plast Reconstr Surg 108:1029, 2001. Bosse MJ, MacKenzie EJ, Kellam JF, et al: An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med 347(24):1924, 12 Dec 2002. Agarwal S, Agarwal R, Jain UK, Chandra R: Management of soft-tissue problems in leg trauma in conjunction with application of the Ilizarov fixator assembly. Plast Reconstr Surg 107:1732, 2001. Tukiainen EJ, Saray A, Kuokkanen HOM, Asko-Seljavaara SL: Salvage of major amputation stumps of the lower extremity with latissimus dorsi free flaps. Scand J Plast Reconstr Surg Hand Surg 36:85, 2002. Janzing HM, Broos PL: Dermatotraction: an effective technique for the closure of fasciotomy wounds: a preliminary report of fifteen patients. J Orthop Trauma 15(6):438, 2001. Megas P, Panagiotopoulos E, Skriviliotakis S, Lambiris E: Intramedullary nailing in the treatment of aseptic tibial nonunion. Injury 32:233, 2001. Safoury Y: Use of a reversed-flow vascularized pedicle fibular graft for treatment of nonunion of the tibia. J Reconstr Microsurg 15(1):23, 1999. Cierny G 3rd, Zorn KE, Nahai F: Bony reconstruction in the lower extremity. Clin Plast Surg 19(4):905, 1992. Arnold PG, Yugueros P, Hanssen AD: Muscle flaps in osteomyelitis of the lower extremity: a 20-year account. Plast Reconstr Surg 104:107, 1999. Wechselberger G, Schoeller T, Bauer T, et al: Surgical technique and clinical application of the transverse gracilis myocutaneous free flap. Br J Plast Surg 54:423, 2001. Attinger CE, Ducic I, Zelen C: The use of local muscle flaps in foot and ankle reconstruction. Clin Podiatr Med Surg 17(4):681, 2000. Fraccalvieri M, Verna G, Dolcet M: The distally based superficial sural flap: our experience in reconstructing the lower leg and foot. Ann Plast Surg 45:132, 2000. Touam C, Rostoucher P, Bhatia A, Oberlin C: Comparative study of two series of distally based fasciocutaneous flaps for coverage of the lower one-fourth of the leg, the ankle, and the foot. Plast Reconstr Surg 107:383, 2001. Judet H, Gilbert A: Long-term results of free vascularized fibular grafting for femoral head necrosis. Clin Orthop 386:114, 2001. Gayle LB, Lineaweaver WC, Buncke GM, et al: Lower extremity replantation. Clin Plast Surg 18(3):437, 1991.

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