Lower Extremity, Foot, and Ankle Reconstruction Flashcards by M A

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

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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

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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.

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Plantaris Supply by peroneal art

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Soleus supply by tibial art

F Sural art

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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

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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.

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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

External fixation was the traditional management of open fractures

external fixation has increased healing times and higher rate of malunion and nonunion

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

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.

Formal angiograms are more expensive and invasive, but they may be necessary if CTA has too much scatter from hardware

Formal angiograms are particularly helpful in >>>>>

vasculopaths and patients requiring concomitant vascular reconstruction

Hyperglycemia inhibits white blood cell phagocytosis and increases postoperative complication rates

Pedicled flaps also have a higher complication rate in diabetics patients

Pedicled flaps have a higher rate of success than extremity-free flaps in diabetics patients

Microsurgery can be very difficult as local vessels are needed for inflow and tend to be calcified

Radiation causes an inflammatory and vascular insult to tissues

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

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.

Replantation is usually not performedfor patients with cadaveric foot because prostheses can make a functional lower limb

Patients who have Gustilo IIIB and IIIC injuries necessitate lower extremity reconstructive surgery.

early flap closure (within the first 72 hours) of open tibial fractures leads to a lower flap failure rate

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

The failer rate in delay reconstruction 12% and in the late reconstruction 10%

exposed critical structures (vessels and nerves) require immediate coverage

with a wound vacuum there will decrease the fibrosis

Use VAC technology can allow for free flap reconstruction outside the 72-hour window with an acceptable complication rate

Patients with lesions less than 6 cm can be treated with traditional, or nonvascularized, bone grafts,

greater than 6 cm loss should undergo distraction osteogenesis or a vascularized bone graft (free flap)

bone grafting heals by creeping substitution

bone grafting limited by significant graft resorption, even in a well-vascularized recipient site

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

The surrounding membrane maintain length and space of the defect, prevents fibrous ingrowth and infection, and creates a vascularized space for the graft

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

By using a spacer and then bone graft increase the union rate 90%

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

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.

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.

Occasionally reconstructive elevator should be utilized, using a more complex reconstructive option to maximize the final result

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

a wide pedicle and a generous arc of rotation are needed to preserve flow

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

Sural Flap has a high complication rate and lower aesthetic appeal

Lateral and Medial Calcaneal Artery Flaps are fasciocutaneous flaps good for small defects of the malleolar area or plantar heel region

Medial Calcaneal Artery Flap based on peroneal art

F posterior tibial arteries.

Lateral Calcaneal Artery Flaps based on the peroneal

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

Keythe width of the flap is similar to the widest portion of the flap

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

Instep Flap

The plantar instep flap can be used as a fasciocutaneous island flap or as a free flap.

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

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

Random pattern flaps should maintain a length-to-width ratio of3:l.

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

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

Flexor digitorum longus supply by Posterior tibial artery useful for Middle third

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.

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.

the classic option is a soleus flap for middle third defect

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

small volume closures can be treated with flexor hallucis longus, flexor digitorum longus, and tibialis anterior in distal thirds

In patients who are not free flap candidates, a distally based soleus or a reverse sural artery flap may be options

It is best to think about foot reconstruction by subunits to obtain the best functional and aesthetic results.

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

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%)

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

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

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

VAC will increase the survival of random pattern flaps

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

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

Bony nonunions are more common in the foot because of the tenuous vascular supply of the talus and navicular bones

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

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

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)

Muscle flaps covered by skin grafts tend to have a less aesthetic result

If the cosmetic result after the initial reconstruction is poor, a revised reconstruction with a fasciocutaneous free flap may provide a better resuit

Most acute reconstructions are prone to venous and lymphatic insufficiency early on.