Lower Extremity, Foot, and Ankle Reconstruction Flashcards
The external iliac artery and its branches supply the
thigh
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the external iliac artery becoming the femoral artery
below the inguinal ligament
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the superficial femoral
artery continues as the popliteal artery after the adductor hiatus
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popliteal artery gives off genicular branches at the knee and then
divides into the anterior tibial artery and the tibioperoneal trunk
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The anterior tibial artery continues as the dorsalis pedis artery
in the foot, whereas the tibioperoneal trunk further divides into
peroneal and posterior tibial branches
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The
venous anatomy, with the exception of the saphenous vein, mimics the arterial anatomy.
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The blood supply to the long bones consists of a nutrient artery, metaphyseal vessels, and periosteal vessels.
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The thigh has three
compartments, the anterior, posterior, and adductor compartments.
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The anterior compartment is made up of the extensors (sartorius and
the quadriceps: rectus femoris, vastus medialis, vastus lateralis, vastus intermedius) and innervated by the Tibial nerve
F innervated by the femoral nerve
The posterior
the compartment is composed of the flexors (biceps femoris, hamstrings:
semimembranosus, semitendinosus) innervated by the
tibial nerve
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The adductor group (adductor longus, adductor brevis,
adductor magnus, adductor minimus, gracilis) is mainly innervated
by the obturator nerve.
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the lateral compartment
contains muscles that flex and evert the foot and toes
F the lateral compartment
contains muscles that flex and evert the foot
posterior compartments contain muscles that flex the foot and the toes
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Most common cause of compartment syndrom is tibial fractures
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compartment pressure >40 mm Hg or 20 mm Hg below thediastolic pressure or 30 mm Hg below the mean arterial blood pressure
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The earliest and most
important sign in compartment syndrom is increasing pain, particularly to passive stretch of
the involved muscles
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Foot Compartments
First are the dorsal intrinsic muscles, which include extensor digitorum brevis and extensor hallucis brevis, and are innervated by the deep fibular nerve
lateral compartment, including the abductor digiti minimi, flexor digiti
minimi, and opponens digiti minimi, all innervated by the lateral plantar nerve.
The interosseous compartment (dorsal and planter interossei) is innervated by the lateral plantar nerve.
The central compartment is made up of three separate levels. The first
the level contains adductor hallucis and is innervated by the lateral plantar nerve. The next (second level) contains quadratus plantae,
lumbricals, and flexor digitorum longus, which are innervated by
medial and lateral plantar nerves. The third level contains the flexor
digitorum brevis, supplied by the medial plantar nerve.
the medial compartment, which contains abductor hallucis and flexor hallucis brevis, innervated by medial and
lateral plantar nerves.
Plantaris Supply by peroneal art
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Soleus supply by tibial art
F Sural art
Flexor digitorum profundus the only muscle in the deep posterior compartment supplied by Posterior tibial
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the Gustilo-Anderson classification
Grade I: Open fracture, wound <1 cm in length.
Grade II: Open fracture, wound >1 cm in length without extensive soft-tissue damage.
Grade IHA: Open fracture with extensive soft-tissue injury
Grade IIIB: Open fracture with extensive soft-tissue injury, bone
damage, periosteal stripping, massive contamination, often
needs soft-tissue coverage
Grade IIIC: Open fracture with extensive soft-tissue injury and
arterial injury requiring vascular repair
The first thing to assess is patient stability,
focusing on the whole patient and following the advanced trauma
life support guidelines
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examination should focus on the sensibility and vascularity of the
extremity and include assessment of soft-tissue and bony trauma
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Compartment pressures and Doppler assessment of vascular signals
is mandatory
F Compartment pressures and Doppler assessment of vascular signals
may be necessary.
Vascular
injuries typically require management before fracture stabilization
T sometimes temporary shunting and definitive repair after fracture fixation may be prudent
Debridement is the most important
step
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External fixation was the traditional management of
open fractures
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external
fixation has increased healing times and higher rate of malunion and
nonunion
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All Patients need imaging in case of lower limp injury
F Only if there are abnormal
pulses, Doppler signals, or ankle brachia! indexes, the recipient vessels are located in the zone of injury, there is an extensive injury with
a high-energy mechanism, or the patient has preexisting arterial disease
Angiocarphy most commonly needed for the posterior tibial art
F useful if
the anterior tibial artery might be needed, as it is superficial and has
the highest rate of injury, so imaging would help determine its viability.
benefit of preoperative imaging
is the ability to visualize the blood flow to the lower extremity
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The benefits of CTA
are ease of imaging,
cost-effectiveness, and low complication rate. It is less invasive and
uses less contrast and radiation than traditional angiography.
CTA
also shows other anatomical information relative to the soft tissues,
veins, and bones, while it also shows information about stenosis and
obstruction.
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Formal angiograms are more expensive and invasive,
but they may be necessary if CTA has too much scatter from hardware
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Formal angiograms are particularly helpful in»_space;»>
vasculopaths and
patients requiring concomitant vascular reconstruction
Hyperglycemia inhibits white blood cell phagocytosis and increases postoperative complication rates
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Pedicled flaps also have a higher complication rate in
diabetics patients
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Pedicled flaps have a higher rate of success than
extremity-free flaps in diabetics patients
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Microsurgery can be very difficult as local vessels are needed for inflow and tend to be calcified
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Radiation causes an inflammatory and vascular insult to tissues
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Absent plantar sensation at presentation is an indicator for
amputation
F Absent plantar sensation at presentation was not an indicator for
amputation or functional outcome.
longer than 8 hours warm ischemia time is an indication for amputation
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Those
presenting with a cadaveric foot, severe tibial or sciatic nerve injury,
severe polytrauma, shock, or extremis, and those with failed revascularization procedures will benefit from primary amputation.
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Replantation is usually not performedfor patients with cadaveric foot because prostheses can
make a functional lower limb
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Patients who have Gustilo IIIB and IIIC injuries necessitate lower
extremity reconstructive surgery.
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early flap closure (within the first
72 hours) of open tibial fractures leads to a lower flap failure rate
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Benefit of early flap closure (within the first
72 hours)
lower flap failure rate,
lower infection rate, quicker healing times, and shorter hospital stays
Late reconstruction: > 6 months after injury
F Late reconstruction: >3 months after injury
Delayed reconstruction: between 72 hours and 3 months
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The failer rate in delay reconstruction 12% and in the late reconstruction 10%
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exposed critical structures (vessels and nerves) require
immediate coverage
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with a wound vacuum there will decrease the fibrosis
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Use VAC technology can allow for free flap reconstruction outside the 72-hour window with an acceptable complication rate
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Patients with
lesions less than 6 cm can be treated with traditional, or nonvascularized, bone grafts,
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greater than 6 cm loss should
undergo distraction osteogenesis or a vascularized bone graft (free
flap)
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bone grafting heals by creeping substitution
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bone grafting limited by significant graft resorption, even in a
well-vascularized recipient site
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Cortical grafts are preferred for bone graft
F Cancellous grafts are preferred
impregnated cement spacer) is placed in the bony defect and left
for several weeks causing a pseudo synovial membrane to form
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The surrounding membrane maintain length and space of the defect, prevents fibrous ingrowth
and infection, and creates a vascularized space for the graft
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At 4 to
12 weeks after spacer placement, the second stage is performed and
the spacer is removed and a cancellous bone graft (likely from the
iliac crest) is placed
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By using a spacer and then bone graft increase the union rate 90%
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Intercalary transport It is an
alternative to free flaps for large bony defects and may be preferential
in one-vessel extremities; however, its use is best tolerated in defects
of 4 to 8 cm
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Ilizarov transport works by placing a dynamic frame and
using osteotomy only
F Ilizarov transport works by placing a dynamic frame and
using a combination of osteotomy and transport segment distraction
osteogenesis
bone gaps, particularly those
greater than 6 cm, is with vascularized bone grafts.
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The free fibula graft can undergo resorption
F bone remains organized, does not resorb, and can hypertrophy to increase strength
The pitfalls of
using a free flap are flap failure (necrosis and anastomotic failure),
donor site morbidity (operating on the uninjured or unaffected leg),
and the risk of stress fractures.
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Occasionally reconstructive elevator should be utilized, using a more complex reconstructive option to
maximize the final result
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The reverse sural artery flap is supplied by perforators from the Tibial
F The reverse sural arteryflap is supplied by perforators from the peroneal
artery
Sural flap can be a sensate flap if the sural nerve is included with flap
harvest
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a wide pedicle and a generous arc of rotation are needed to preserve
flow
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The greater saphenous vein needs to be included
in the flap for venous outflow, and a delay procedure may improve viability in high-risk patients
F The lesser saphenous vein needs to be included
in the flap for venous outflow, and a delay procedure may improve viability in high-risk patients
Maximal sural flap sizes can be 20 cm by 12 cm
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Sural Flap has a high complication rate and lower aesthetic appeal
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Lateral and Medial Calcaneal Artery Flaps are fasciocutaneous flaps good for small defects of the malleolar area or plantar heel region
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Medial Calcaneal Artery Flap based on peroneal art
F posterior tibial arteries.
Lateral Calcaneal Artery Flaps based on the peroneal
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Lateral and Medial Calcaneal Artery Flaps are sensory flap
The sural nerve can be included for sensation, and the abductor hallucis muscle can be included with the
medial flap
Keystone Flap It fits well into body contours and can reconstruct
larger defects
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Keythe width of the flap is similar to the widest
portion of the flap
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The dissection of the keystone flap til facia
The deep fascia is cut to allow advancement
and superficial nerves and veins are incorporated into the flap
design
Propeller flaps are a perforator-based local faciocutaneous flap
F Propeller flaps are a perforator-based local adipocutaneous flap
Propeller flapscan be designed offof a known source vessel or in a free-style fashion
over a perforator found by Doppler
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Instep Flap
The plantar instep flap can be used as a fasciocutaneous island flap
or as a free flap.
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The quality of the skin in the instep flap is the same in the weight-bearing surface.
It comes from the non-weight-bearing aspect of the
plantar foot but provides similar tissue quality as the weight-bearing surface.
Blood supply of the medial planter foot from medial planter artery only
F t is most commonly based on the medial plantar artery although laterally basing is possible as well
Instep Flap maintain sensation through the medial plantar nerve
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Instep flap used for forefoot reconstruction
F This flap is ideal for plantar
heel reconstruction
Rarely, a free flap version of the cross-leg flap can be performed when
there are no appropriate vessels for anastomosis in the injured leg
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Random
pattern flaps should maintain a length-to-width ratio of3:l.
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Sometime we need to perform the anastomosis outside the zone of injury,
It is always necessary to perform the anastomosis outside the zone of injury, which
may require vein grafts or arteriovenous loops
the preferred
choice in an extremity at risk for vascular insufficiency is end-to-end anastomosis
F End to side
The complications are more with end to end more than end ti side
f the complication
the profile is similar to either type of anastomosis
It was thought
that muscle was superior to fasciocutaneous flaps for fracture healing
and infection prevention, but this theory has been disproven
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Extensor hallucis longus OR Extensor digitorum longus flap supply by Anterior tibial artery used for reconstraction of the Middle third of the leg and it type IV Nahai
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Flexor digitorum longus supply by Posterior tibial artery useful for Middle third
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Extensor digitorum brevis is type II muscle
Type 1
The thigh is the most challenging area of the extremity to reconstruct
F The thigh is the least challenging area of the extremity to reconstruct
The gastrocnemius is the typical choice
for reconstruction of the upper third of the leg and is usually used as a muscle-only flap and
covered with a skin graft.
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Secondary option for the upper third of the leg reconstraction
Secondary options include proximally
based soleus. bipedicled tibialis anterior, and distally based pedicled anterolateral thigh (ALT) or vastus lateralis
flap.
The middle third of the leg is more difficult to reconstruct, as
available options are likely to have been damaged by trauma.
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the classic option is a soleus flap for middle third defect
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Other option for middle third
The local flaps available include the gastrocnemius, flexor digitorum longus, extensor digitorum longus, extensor hallucis longus, tibialis anterior, and flexor hallucis longus
distal third of the leg requires a free flap for reconstruction
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small volume closures can be treated with flexor hallucis
longus, flexor digitorum longus, and tibialis anterior in distal thirds
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In patients who
are not free flap candidates, a distally based soleus or a reverse sural
artery flap may be options
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It is best to think about foot
reconstruction by subunits to obtain the best functional and aesthetic
results.
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How many subunits for the foot ?
7 subunits
Tissue expansion can be used in acute setting
f It is difficult to use in
the acute setting and is more suitable for chronic conditions
It is best
to expand tissue transversely from the defect, as the tissue moves better in that plane
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The best shape of an expander used for extremities is the rectangular shape
F Large, crescent-shaped expanders work best
Expanders do have high infection rates (up to 30%)
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The
more distal they are placed, the more common the complications and
are infrequently successful below the knee, making the lower leg a
relative contraindication to their use
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VAC system
it promotes granulation tissue formation on a cellular level
and increases blood flow, while grossly contracting the wound and
decreasing bacterial contarnination
The wound VAC is most useful as a temporizing measure
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It can safely be placed on soft tissue, bone, and tendon
and produce adequate granulation tissue to take a skin graft or even
achieve secondary healing in some cases
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VAC will increase the survival of random pattern flaps
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The collagen matrix of Integra allows epidermal regeneration, whereas the
silicone is a temporary protective barrier.
F The collagen matrix allows dermal regeneration, whereas the
silicone is a temporary protective barrier.
Use of integra
For burned patient
patients who do not have adequate local donor tissue.
for vascular ulcers, for wounds from lesion excision, and for tendon and bone exposure
It is placed on the wound
bed and left in place for three or more weeks
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Then, the silicone barrier is removed and a thick skin graft is placed over the Integra
F Then, the silicone barrier is removed and a thin skin graft is placed over the Integra
Treatment of chronic wounds and osteomyelitis
require conversion to an acute wound again
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Bony nonunions are more common in the foot because of the tenuous vascular supply of the talus and navicular bones
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The donor site of the femoral condyle has significant morbidities
F The donor site at
the distal femur is well tolerated and does not cause any instability; the
the patient can be weight-bearing on the donor site immediately
the much the length of the length of the leg below knee to suit the the prosthesis
14 CM
The common peroneal nerve is the most frequent nerve injury of the
lower extremity
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Peroneal nerve injury treatment
Surgery or foot brace
posterior tibialis tendon to anterior tibial tendon transfer
is the standard tendon transfer to treat foot drop
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Most bony defects are amenable to reconstruction with a free
fibula. However, the femur and tibia require strength, which can be
accomplished with a double-barreled fibula or a fibula placed in an
allograft (Capanna technique)
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Muscle flaps covered by skin grafts tend to have a less aesthetic result
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If the cosmetic result after the initial reconstruction is
poor, a revised reconstruction with a fasciocutaneous free flap may
provide a better resuit
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Most acute
reconstructions are prone to venous and lymphatic insufficiency early
on.
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