Reconstruction

Question 1

Tibia

Answer 1

25mL bone (cancellous), 1 x 2cm cortical block
2cm incision over Gerdy's tubercle (parallel to tibial plateau)

Question 2

Calavarial

Answer 2

2cm from midline, 2cm from thin squamous portion of temporal bone
Raney clips
6.3mm thickness
SCALP layers

Question 3

AICBG

Answer 3

50mL of cancellous bone
2cm from ASIS, 2cm lateral from crest in step
Iliohypogastric (L1/L2) - courses over tubercle of the ilium, lateral anterior third sensory
Lateral cutaneous branch of subcostal nerve (T12/L1) - courses over ASIS
Lateral femoral cutaneous nerve (L2/L3) - perforates TFL to innervate skin of lateral thigh (1cm from ASIS in 2.5% of people)
Superior gluteal artery - medial aspect of ilium
4cm incision
Skin, subcutaneous tissue, Camper;s and Scarpa’s fascia, aponeuroses of TFL and external oblique. Iliacus muscle reflected medially.
Medial - increase ileus, intra-abdominal injury, meralgia paresthetica
Lateral - pain, gait disturbance
Complications - hematoma, seroma, meralgia paresthetica, gait disturbance, fracture, intra-abdominal injury / hernia

Question 4

PICBG

Answer 4

100mL of cancellous bone
Superior cluneal nerve (L1-L3) - superior to iliac crest, posterior medial buttocks
Middle cluneal nerve (S1-S3) - sacra foramina, medial buttocks
Sciatic nerve (L4-L5, S1-S3) - 6-8cm below crest
Subgluteal artery / deep iliac circumflex artery
6cm incision between superior and medial cluneal nerves (inferior-medial termination 3cm lateral to gluteal crease)
Skin, subcutaneous, tissue, lumbodorsal fascia, periosteum
Gluteus maximus muscle stripped from lateral cortex
5cm x 5cm cortical osteotomy to access bone (4cm from PSIS)
Complications - gluteal compartment syndrome, ureteral injury (greater sciatic notch), gait disturbance (gluteus medius)

Question 5

ALT

Answer 5

Fasciocutaneous perforator flap
Lateral circumflex femoral artery (1.5 - 3mm diameter)
Between rectus femoris and vastus lateralis muscles
Incision from ASIS to the superolateral patella, through skin, subcutaneous tissue, to expose the rectus femoris muscle
Perforators identified and harvested
Pedicle = 8-16cm
Size = 10cm x 25cm

Question 6

Radial forearm

Answer 6

Fasciocutaneous perforator flap
Radial artery, venae comitantes and cephalic vein (2-4mm diameter)
Pre-op: “No stick” order, nondominant hand, Allen test with pulse oximeter, tourniquet (250mmhg)
Incision based on radial artery, up to 1cm distal of the flexor wrist crease
Distal incision, radial artery and cephalic vein identified. Radial distal edge = superficial dorsal branches of the radial nerve
Releasing incision made to antecubital fossae. Cephalic vein identified. Brachioradialis muscle retracted and elevated.
Tourniquet deflated for 20 minutes
Close releasing incision, STSG for defect

Question 7

Fibula Free Flap

Answer 7

Osteocutaneous flap
Peroneal artery, venae comitantes (2-4mm diameter)
9-15mm (width) x 22cm (length)
Pedicle length: 2-6cm
Pre-op: Clinical exam (PVD, varicosities, induration, edema, pallor, hairless/shiny skin), CTA, torniquet (250mmHg)
Curvilinear incision is made overlying the peroneus muscles. The intermuscular septum and perforators are identified (middle and distal thirds). Anterior dissection of peroneus longus, peroneus brevis, and extensor hallucis longus reveals the interosseous membrane. Proximal/distal bone cuts completed (leaving 6cm superior and inferior of tibia). Posterior skin cuts down to the subfascial plane help mobilize the fibula. Lateral retraction of the fibula exposes the interosseous membrane, which houses the peroneal pedicle below. Ligate distal pedicle. Dissect pedicle from distal to proximal, separating the tibialis posterior. Transect flexor hallucis longus (with cuff attached to flap) and ligate pedicle proximally. Reapproximate lateral muscle groups to the soleus.

Question 8

Kim-Lippert’s Classification

Answer 8

I: Normal
II: High division of PA
III: Hypoplastic/Aplastic branching
IIIA: PT deficiency (63%)
IIIB: AT deficiency (29%)
IIIC: Single vessel runoff (8%)
IV: PA vessel caliber
IVA: Hypoplastic
IVB: Aplastic

Question 9

STSG vs full thickness

Answer 9

Increased survivability, increased contracture, can be placed on mobile tissues, less vascularity required

Question 10

STSG

Answer 10

0.012 inches thick
Harvest 20% larger graft for contracture
Pie crusting or 2:1 mesh

Question 11

Tracheostomy

Answer 11

Mark out thyroid notch, cricoid, bilateral SCM, and sternal notch
4cm horizontal incision made halfway between sternal notch and cricoid through skin/subcutaneous tissue. Start dividing deep cervical fascia vertically, proceed with retracting infrahyoid strap muscles. Thyroid isthmus can be retracted with a cricoid hook or divided with clips and thorough cautery. A Bjork flap is utilized with a horizontal incision just above the 3rd cartilage ring.