Chapter 15: Bone and Soft Tissue Reconstruction

Harvey Chim, Steven L. Moran, Alexander Y. Shin

Chapter Outline

Introduction

Open fractures and their associated soft tissue injuries are difficult to treat and often require a multidisciplinary approach for wound management. These injuries place a significant financial burden on the patient and society because of prolonged patient disability. Despite the great diversity among the individuals who sustain open fractures, a majority of these patients are typically young active adults who tend to be injured in automobile or motorcycle collisions or while engaged in sporting activities.66 
Successful management of these open fractures and soft tissue wounds requires treatment of the bone as well as soft tissue injuries. Advances in microsurgical techniques and our knowledge of the vascular anatomy of the extremities have led to novel advances in wound coverage that can allow for rapid coverage of these wounds and replacement of injured bone, nerve, and muscle. In this chapter, we will review a multidisciplinary approach for the management of bone and soft tissue defects, which includes a combination of orthopedic surgery, neurosurgery, and plastic surgery expertise, in addition to providing the reader with a variety of reconstructive options for upper and lower extremity open fracture management. 

History

Advances in vascular reconstruction, external and internal fixations, and antimicrobial agents have maximized the rate of limb salvage after severe injuries to the extremities. Continuing advances in the field of microsurgery, including refinement and development of new perforator flaps for free tissue transfer as well as a better understanding of wound pathophysiology have improved surgeons’ ability to obtain rapid wound coverage, allowing patients to return to ambulation and the workforce. However, many challenges remain and the patient may still succumb to local infection or other soft tissue or bony complications requiring amputation after major limb trauma. 

Complex Musculoskeletal Injuries

The open wound should be inspected carefully and the wound pattern and any contamination documented. Photographic documentation is tremendously helpful when available. Wounds should not be explored in the emergency department setting. Instead, exploration should be performed whenever possible in the sterile conditions of an operating room. With polytrauma patients, where the workup of other injuries takes priority over treatment of the open fracture/soft tissue injuries, careful packing of the wound with a sponge moistened with saline and dilute antiseptic solution (Betadine or chlorhexidine) prevents desiccation of the exposed bone and soft tissues until they can be addressed formally in the operating suite. 

Initial Management of Complex Musculoskeletal Injuries

Decision Making

Open fractures are by definition a multisystem injury, and the management of the soft tissue is often as important as the treatment of the fracture itself.338 Historically, the outcome of the treatment of open fractures was typically determined by the soft tissue defect. In 1966, Carpenter41 stated, “If the soft tissues overlying the tibia are not preserved, any hope of primary healing of the underlying fracture is lost forever.” Although Carpenter was referring to the tibia, the importance of the soft tissue envelope to bone healing is real and applicable throughout the body. If soft tissue reconstruction is successful in these injuries, the bone often becomes the problematic area, and the final outcome depends on the extent of bone devascularization and contamination.132 
Often the fear of not being able to cover a wound has prevented the orthopedic surgeon from adequately debriding the soft tissues. This has resulted in “expectant” management of the soft tissues, an approach that unfortunately still prevails in some surgeons’ minds today. Waiting for devitalized tissue to “declare itself” prolongs definitive fracture management, increases the risk of infection, and attenuates the inflammatory response. Pedicled flaps and free tissue transfers are capable of covering large soft tissue defects, thus allowing the surgeon the freedom to perform a wide and thorough initial debridement. Early multidisciplinary collaboration and communication with surgeons skilled in these techniques is crucial for successful outcomes. 
The basic principle of complex musculoskeletal injury management begins with application of Advanced Trauma Life Support (ATLS) protocols.5 Once the basics of ATLS are satisfied, a complete assessment of each wound can be made. Understanding the mechanism of injury and the patient’s unique medical and social history are imperative. When possible, the reconstructive options should be discussed with the patient and family. 

Principles of Management

During the management of any complex musculoskeletal injury there are several principles one should keep in mind to expedite patient care and maximize patient outcome (Table 15-1). 
Table 15-1
The Eight General Principles of Management of Soft Tissue Injuries Associated with Fractures
Principle 1: Prevent further injury.
Principle 2: When debridement of injured tissue is undertaken, an aggressive tumor-like debridement of all necrotic and nonviable tissues, including bone, is essential.
Principle 3: Achieve bone stability.
Principle 4: Strive for early bone coverage when possible.
Principle 5: Do not ignore secondary reconstructive needs when addressing initial bone coverage (i.e., plan for future reconstructive procedures).
Principle 6: Replace damaged tissues with similar tissues when possible (replace like with like).
Principle 7: Know when a salvage procedure, such as an amputation, may be the better reconstructive option.
Principle 8: Know when you have taken on too much and seek assistance and advice.
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Principle 1

The first principle is to prevent further injury. After understanding the mechanism of injury, one must determine whether a compartment syndrome107 may be an issue or if ongoing vascular compromise is present. Any salvage of the extremity is dependent on the prevention of further injury or the neutralization of ongoing injury including chemical, mechanical, or traumatic injury. 

Principle 2

When debridement of injured tissue is undertaken, an aggressive tumor-like debridement of all necrotic and nonviable tissue, including bone, is essential.111 This is often considered the most important single step in the management of soft tissue trauma and will be further discussed later in this chapter. Often reconstructive plans impede adequate soft tissue debridement, as the surgeon is afraid to lose further soft tissues, which would make the reconstruction more complicated or difficult. 

Principle 3

Once adequate debridement of soft tissue and bone has been accomplished, bone stability should be achieved. Bone stability can be achieved with external fixation, internal fixation, or a combination of both. In highly contaminated wounds or wounds that have poor soft tissue coverage, external fixation is often preferred. In wounds that are adequately debrided with good soft tissue coverage of the bone, internal fixation can be used. 

Principle 4

When soft tissue coverage is needed, acute coverage should be considered. Use of the reconstructive ladder163,204 can be helpful in reconstructing the injured extremity (Fig. 15-1). When soft tissue coverage is considered, a surgeon should evaluate the simplest type of procedure needed to achieve wound coverage, and increase in the complexity only as needed. The reconstructive ladder progresses as follows: Primary closure, skin grafting, local cutaneous flaps, fasciocutaneous transposition flaps, island fascial or fasciocutaneous flaps, local or distant one-stage muscle or myocutaneous transposition, distant temporary pedicle flaps, and microvascular free tissue transfer. When evaluating the wound for possible coverage options, it is imperative to consider patient factors; defect genesis; the location, size, and depth of the defect; exposed structures; structures needing reconstruction; the degree of contamination; and the quality of the surrounding tissues. 
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Figure 15-1
The reconstructive ladder.
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The concept of achieving wound coverage within 72 hours was popularized by Godina.118 Although the data presented by Godina is compelling, achieving wound coverage within 72 hours can be difficult secondary to both hospital system issues (operating room and surgeon availability) and patient factors. With advances in wound management with vacuum-assisted closure (VAC) devices (Fig. 15-2) and antibiotic bead pouches, wound coverage can occur later than the 72 hours initially recommended without untoward complications.111 
Figure 15-2
A vacuum-assisted closure device properly placed on a wound after debridement.
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Principle 5

When the initial task at hand is to cover the wound, secondary reconstructive needs are often ignored. It is important to determine these needs before the soft tissue coverage and the initial reconstructive procedure are undertaken. If nerve grafts need to be placed in the future, the vascular pedicle of the free flap should be placed as far away from the nerve graft sites whenever possible. If future bone grafting (vascularized or conventional) or tendon work needs to be performed, planning of the location of the free flap or pedicled flap needs to occur early to prevent future injury to the vascular supply of the flap, potentially compromising its survival or soft tissue coverage. 

Principle 6

When composite soft tissue loss occurs, composite soft tissue reconstruction should be considered. Composite reconstruction refers to the use of flaps that contain more than one type of tissue. Such an example is an osteocutaneous flap, such as a free fibula, which may contain bone, skin, and muscle. This piece of composite tissue can then be used to replace segmental defects of the tibia and replace any overlying skin loss at the same time. The concept of replacing like tissue with like when possible can be applied to upper extremity injuries as well. As a general rule when there is a need for bone, muscle, and skin, one should always consider the possibility of reconstructing the defect with a composite flap. 

Principle 7

A salvage procedure, such as an amputation, may be a reasonable solution in selected situations. Although technically feasible, some heroic efforts to reconstruct a limb can lead to prolonged recovery times with loss of gainful employment, psychological problems, and increased morbidity for the patient. 

Principle 8

The surgeon should know when he or she has taken on too much and should seek assistance and advice. This is the most humbling of the principles, but can be one of the most important. Collaboration with other surgeons may be extremely helpful in difficult cases. A different perspective can often drastically change the patient’s outcome. 
Patients with open or closed fractures associated with severe soft tissue injury are typically polytrauma patients with multiple organ systems affected. As such, their fractures and soft tissue injuries must be considered in the context of the polytrauma, recognizing the patient as a whole. Care of these patients and their injuries progresses in three phases: Acute stabilization, reconstruction, and rehabilitation. The acute phase includes wound debridement, fracture stabilization, soft tissue reconstruction, and initiating muscle function and joint mobility. The reconstructive phase addresses indirect sequelae of injury, such as nonunions, infections, and malunions. Finally the rehabilitative phase focuses on returning the patient to society. 

To Reconstruct or Not: Amputation Versus Limb Salvage

In complex extremity injuries, the treating physician must make two critical decisions early within the reconstructive process. The first is to determine if it is technically possible to save the injured extremity and the second is to determine whether salvaging the limb is in the best interest of the patient. An insensate, painful, or chronically unstable leg may provide no benefit over a prosthesis. Many factors have historically come into play when making these decisions, such as patient age, comorbid injuries, and preinjury ambulation status. Several algorithms have been designed to aid the surgeon in this decision-making process.197,244 
Absolute indications for amputation of the lower extremity in an adult include sciatic nerve transection and irreparable vascular injury. Relative indications for amputation include life-threatening multisystem trauma, a warm ischemia time of greater than 6 hours, an insensate plantar foot, a crushed foot with fracture comminution, extensive bone loss, and multiple joint disruption with multilevel injury, advanced peripheral vascular disease, and rehabilitation concerns.149,167,233 
Before an amputated limb is discarded, the salvage of uninjured soft tissues should be considered with the goal of maintaining maximum limb length and functioning joints, because this will minimize energy expenditure during ambulation. For example, the glabrous sole of the foot can provide durable stump coverage and an intact ankle joint can be rotated to simulate a missing knee joint.175,380 Often these salvaged parts may be transferred without microsurgery if their sensory and vascular supply remains intact. 
Some investigators have suggested that the function of a salvaged extremity is often poorer than can be achieved with early amputation and prosthetic fitting.69,95,104,316 The Lower Extremity Assessment Project (LEAP) was a multicenter prospective study of severe lower extremity trauma in the United States civilian population designed to answer this question. The investigators collected prospective outcome data on patients with Gustilo grade IIIB and grade IIIC open fractures. Patient outcomes were evaluated through the use of the Sickness Impact Profile, which is a self-reported health status questionnaire. At 2 and 7 years after injury, patients who underwent amputation had functional outcomes that were similar to those who underwent reconstruction. Predictors of poor outcome after reconstruction included a low education level, nonwhite race, poverty, lack of private health insurance, smoking status, a poor social support network, and involvement in disability compensation litigation. Approximately 50% of the patients in each group were able to return to work at 2 years.29,217 
An additional finding from this study suggested that sensation within the injured extremity had no bearing on long-term outcome. Patients with an insensate extremity at the time of presentation did not demonstrate significantly worse outcomes at 2 years when compared with patients who presented with a sensate foot. Approximately 55% of those with absent or abnormal plantar sensation had recovered normal sensation at 2 years after injury. This study also suggested that initial plantar sensation is not a prognostic factor for long-term plantar sensation and should not be used as a component of the limb salvage decision algorithm.30 
Overall the study’s findings seemed to indicate that outcome is more significantly affected by the patient’s economic, social, and personal resources than by the bony injury or the level of amputation. If the patient is still adamant about limb salvage and understands the long-term potential for future surgery; however, we still remain aggressive in our attempts to salvage the severely injured extremity. 

Bone Reconstruction

When bone defects are present there are three basic reconstruction options: Distraction osteogenesis (Ilizarov technique), nonvascularized bone grafting, or vascularized bone grafting. The specific technique employed is dependent on the size of the defect, the quality of the soft tissue envelope, and the location of the defect. 

Distraction Osteogenesis (Ilizarov Technique)

Distraction osteogenesis was popularized by Ilizarov, who in the western Siberian city of Kurgan, discovered that normal tissue could be generated under carefully applied tension.156159 The tension-stress effect on bone resulted in neovascularization, increased metabolic activity, and cellular proliferation, similar to but not identical to normal endochondral ossification at the physis. The resulting fibrous tissue in between the distracted bone segments ossifies in an orderly fashion, resulting in structurally sound bone. The soft tissues concomitantly grow linearly in response to the applied tension.162 
The Ilizarov technique employs a modular system of rings that are held in place by fine wires that are crossed and secured to the ring. The wires are tensioned to between 60 and 130 kg. A series of rings are constructed and bridged together with threaded posts, each with a distraction or compression device that can be adjusted every several hours. Many modifications to this system have been described. 
When applied to bone loss, the defect of long bones can be filled with one of the two methods: acutely shortening the bone and then gradually lengthening it to restore the original bone length; or transporting bone from either proximal or distal to the bone defect to gradually fill in the defect.51,78,79,123 
In addition to application of the external ring fixator device, a free tissue transfer can be performed to address complex lower extremity bone injury with associated significant soft tissue defects. In the acute setting, the external ring fixator or modifications of the fine-wire fixators can be applied as the primary management of the fracture. When these devices are applied it is imperative that if soft tissue coverage is required, discussions between the microsurgeon and the orthopedic surgeon occur early in the care of the injured extremity. The presence of a ring fixator can make microsurgery extremely challenging, and it is preferable that straight external fixators are used instead.51 

Nonvascularized Bone Grafts

Nonvascularized bone grafts include autografts as well as allografts. They are ideal for small defects and voids and can be obtained from a number of anatomic locations and are typically cancellous or corticocancellous in composition. Autografts are superior in general to allograft material. For most bone defects of less than 6 cm with a well-vascularized bed, adequate soft tissue coverage and absence of infection, a conventional cancellous or corticocancellous bone graft is generally recommended.26 The most common areas for nonvascularized autograft bone harvest include the iliac crest (anterior or posterior), distal radius, and olecranon.372 Cancellous bone has greater inductive capacity than cortical bone and should be used unless mechanical stability is required. 
The process of bone graft incorporation is by “creeping substitution,” a process in which vascular ingrowth gradually occurs with resorption and replacement of the necrotic bone graft with viable bone.156 Creeping substitution results in rapid revascularization in small cancellous grafts, but is slow and incomplete in cortical bone. As much as 40% to 50% of lamellar bone remains necrotic, and the revascularization process that does occur causes significant mechanical weakening because of bone resorption at 6 to 12 months.26,35,315 Allografts, like autografts, must also be replaced by living bone. They are replaced more slowly and less completely, and they invoke a local and systemic immune response that reduces the stimulus of new bone formation. This effect may be diminished by freezing, freeze drying, irradiating, or decalcifying the graft; or eliminated with the use of immunosuppressive drugs.119,120,151,161,264,265,308,372 Structural nonvascularized grafts of all types have substantial problems with fatigue fracture, even years after implantation. Successful grafting requires a well-vascularized bed, adequate immobilization, and protection from excessive stress by rigid internal fixation.91 

Vascularized Bone Grafts

Unlike conventional bone grafts, the cellular elements of a vascularized bone graft remain alive and dynamic in its new site. Because of its preserved circulation, cell viability is greater than in conventional grafts,10,23 obviating the need for the gradual creeping substitution of living bone into nonvascularized bone.26,35,170 During healing, extensive osteopenia is not seen with vascularized bone grafts as it is in conventional bone grafts.68 Vascularized grafts have improved strength, healing and stress response as compared with nonvascularized bone grafts.24,43,86,114,199,304,379,382 The incidence of stress fracture is lower than in massive structural autografts or allografts.134,268,317,355 Finally, union is more rapid, and bone hypertrophy in response to applied stress may occur with time.109 Bone healing is more likely in difficult circumstances including scarred or irradiated beds, or in an avascular bone bed.105,106 
In addition to superior cell survival, maintained circulation, and better mechanical properties, vascularized grafts have other significant advantages over conventional grafts. These include the possibility to restore longitudinal growth by inclusion of the growth plate,235,335,378 revascularize necrotic bone,154,203,221,229,280,307,324,340,341 improve local blood flow in scarred soft tissue beds,269,299 and reconstruct composite tissue loss in one procedure by the inclusion of skin, muscle, tendon, nerve, and other tissues with the bone graft. 

Vascularized Bone Graft Indications

Based on the information reported in the preceding, it would seem that vascularized autografts would be ideal for grafting under most circumstances. Their use as free tissue transfers is technically demanding however, and pedicle grafts are often more limited in dimension and pedicle length and hence their indications are limited. Prolonged operative times and extensive dissection increase the risk of complications, and donor site morbidity may be significant. Therefore, for bone defects of less than 6 to 8 cm with normal soft tissues, conventional techniques remain the method of choice under many circumstances. 
Iliac crest can be used as a pedicled vascularized bone graft. The principal advantages of a vascularized autogenous iliac crest graft are its largely cancellous nature and the large amount of soft tissue that may be raised with the bone as a combined osteomusculocutaneous flap. In such flaps, a more reliable skin flap may be obtained with inclusion of both superficial and deep circumflex iliac vessels. The advantages of this osteocutaneous flap include the ability to (i) supply vascularized bone to what is frequently a poor recipient bed for a bone graft, (ii) reconstruct both soft tissue and bony defects simultaneously, and (iii) be used in facilities without a capability for microvascular surgery when used as a pedicle flap for the upper extremity.278 It may also be used for smaller defects. 

Segmental Bone Loss

Vascularized transfer is indicated in segmental bone defects larger than 6 to 8 cm due to tumor resection,1,59,87,115,202,237,245,276,331,370 traumatic bone loss,27,93,155,208,220,255,258,362 osteomyelitis, or infected nonunion.27,141,142,171,173,238,246 
Vascularized transfer in smaller defects is reasonable in cases in which “biologic failure” of bone healing is likely or has already occurred.250 Examples include persistent nonunion after conventional treatment, poorly vascularized bone and/or its soft tissue bed because of scarring, infection or irradiation, and congenital pseudarthrosis.6,228,259,343,356 
Other indications include osteonecrosis, composite tissue loss requiring complex reconstruction, joint arthrodesis in exceptional circumstances, and the need for longitudinal growth with physeal transfer. 

Fibula

The fibula is the most commonly used vascularized bone graft because its structure and shape are appropriate for diaphyseal reconstruction (Fig. 15-3). A long, straight segment of 26 to 30 cm in length can be harvested, and osteosynthesis can be securely obtained to the recipient bone. The blood supply to the fibula, as to other long bones, is derived normally from a nutrient artery via radially oriented branches that penetrate the cortex and anastomose with the periosteal vessels. The resulting blood flow is centrifugal from the medullary cavity to the cortex. This arrangement is the norm for the fibula, which has a single nutrient vessel entering its middle third from the peroneal artery. Additional periosteal branches from the peroneal and anterior tibial arteries also supply the diaphysis.360 The proximal epiphysis is supplied by an arcade of vessels, of which the lateral inferior genicular vessel is the most important.235 This vessel must be anastomosed if physeal growth is desired after transfer of the fibular head.106,235 
Figure 15-3
 
A, B: Following a gunshot wound to the foot, there was loss of the first and second metatarsals and an extensive dorsal foot wound. C: Intraoperative view of the fibular osteocutaneous flap with a longitudinally split fibula. D–G: Clinical photographs and x-rays 16 months following the free fibular osteocutaneous flap for first and second metatarsal ray reconstruction. The patient was able to ambulate without difficulty and play soccer.
A, B: Following a gunshot wound to the foot, there was loss of the first and second metatarsals and an extensive dorsal foot wound. C: Intraoperative view of the fibular osteocutaneous flap with a longitudinally split fibula. D–G: Clinical photographs and x-rays 16 months following the free fibular osteocutaneous flap for first and second metatarsal ray reconstruction. The patient was able to ambulate without difficulty and play soccer.
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Figure 15-3
A, B: Following a gunshot wound to the foot, there was loss of the first and second metatarsals and an extensive dorsal foot wound. C: Intraoperative view of the fibular osteocutaneous flap with a longitudinally split fibula. D–G: Clinical photographs and x-rays 16 months following the free fibular osteocutaneous flap for first and second metatarsal ray reconstruction. The patient was able to ambulate without difficulty and play soccer.
A, B: Following a gunshot wound to the foot, there was loss of the first and second metatarsals and an extensive dorsal foot wound. C: Intraoperative view of the fibular osteocutaneous flap with a longitudinally split fibula. D–G: Clinical photographs and x-rays 16 months following the free fibular osteocutaneous flap for first and second metatarsal ray reconstruction. The patient was able to ambulate without difficulty and play soccer.
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The vascularized bone may be transferred with a fasciocutaneous skin paddle of up to 10 to 20 cm. This is possible because a series of fasciocutaneous or myocutaneous perforators from the peroneal artery typically pierce the soleus muscle adjacent to the lateral intermuscular septum.189,377 The location of the perforators may be determined in the operating room prior to skin incision with the use of a Doppler ultrasound probe. Osteomuscular flaps including the flexor hallucis longus (FHL) muscle or portions of the soleus or peroneal muscles may also be raised using the same peroneal artery pedicle.25,49,361 The peroneal pedicle has a length of 6 to 8 cm and an arterial diameter of 1.5 to 3 mm. 
Multiple series have reported the successful salvage in the upper and lower extremities with the use of the free fibula flap in cases of osteomyelitis,352 pathologic fracture,296 and segmental bone loss of the femur,352 tibia,363 radius and ulna,3,368 humerus,368 and pelvis (Fig. 15-4).2 The bone is capable of hypertrophy over time through a process of fracture and callus healing.248 In addition, single or multiple osteotomies may be made in the bone as long as one preserves a periosteal sleeve and the nutrient vessel. This then allows for double fibular strut reconstruction in cases of segmental bony injuries.47,352 
Figure 15-4
 
A, B: A 44-year-old woman sustained a gunshot wound to the left humerus resulting in a large entrance and exit wound (greater than 15 cm each) with segmental bone loss of the humerus exceeding 10 cm in length. The fractures were temporarily stabilized with external fixation and the soft tissue defect addressed with an ipsilateral free latissimus dorsi flap. C–E: Once the soft tissues were stabilized, a free vascularized fibula was used to bridge the bony defect after an intramedullary nail had been placed. F, G: The fibula had incorporated into the proximal and distal ends of the humerus by 3 months, resulting in a salvaged and very functional upper extremity.
A, B: A 44-year-old woman sustained a gunshot wound to the left humerus resulting in a large entrance and exit wound (greater than 15 cm each) with segmental bone loss of the humerus exceeding 10 cm in length. The fractures were temporarily stabilized with external fixation and the soft tissue defect addressed with an ipsilateral free latissimus dorsi flap. C–E: Once the soft tissues were stabilized, a free vascularized fibula was used to bridge the bony defect after an intramedullary nail had been placed. F, G: The fibula had incorporated into the proximal and distal ends of the humerus by 3 months, resulting in a salvaged and very functional upper extremity.
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Figure 15-4
A, B: A 44-year-old woman sustained a gunshot wound to the left humerus resulting in a large entrance and exit wound (greater than 15 cm each) with segmental bone loss of the humerus exceeding 10 cm in length. The fractures were temporarily stabilized with external fixation and the soft tissue defect addressed with an ipsilateral free latissimus dorsi flap. C–E: Once the soft tissues were stabilized, a free vascularized fibula was used to bridge the bony defect after an intramedullary nail had been placed. F, G: The fibula had incorporated into the proximal and distal ends of the humerus by 3 months, resulting in a salvaged and very functional upper extremity.
A, B: A 44-year-old woman sustained a gunshot wound to the left humerus resulting in a large entrance and exit wound (greater than 15 cm each) with segmental bone loss of the humerus exceeding 10 cm in length. The fractures were temporarily stabilized with external fixation and the soft tissue defect addressed with an ipsilateral free latissimus dorsi flap. C–E: Once the soft tissues were stabilized, a free vascularized fibula was used to bridge the bony defect after an intramedullary nail had been placed. F, G: The fibula had incorporated into the proximal and distal ends of the humerus by 3 months, resulting in a salvaged and very functional upper extremity.
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The flap is typically harvested under tourniquet control through a lateral approach with the patient in the supine or lateral position. Preoperative vascular studies, although controversial in the literature, have been very useful to us in preoperative planning in cases of posttraumatic reconstruction and in patients with peripheral vascular disease.84,216 We obtain a CT angiogram in all patients in preparation for free fibular transfer. Unlike a formal angiogram, a CT angiogram has no additional morbidity while providing information on inflow and outflow vessels in both legs. In 10% of the population the peroneal artery is the dominant arterial supply to the leg, and is referred to as the peroneal arteria magna; in such cases the contralateral leg should be considered for flap harvest.84,216 
The incision is centered over the posterior margin of the fibula in a line running from the fibular head to the lateral malleolus. We have found it helpful to always include a skin paddle in the flap design; it facilitates closure as well as postoperative flap monitoring. Inclusion of a cuff of soleus muscle or FHL muscle can improve the reliability of the skin paddle if skin perforators are small. Dissection is initiated between the plane of the soleus and peroneal muscles. Once the fibula is visualized laterally, the peroneal nerve is identified and protected as dissection then continues superficial to the periosteum in a medial direction (Fig. 15-5). The interosseous membrane is incised. The bone is then divided proximally and distally with the use of a Gigli saw or sagittal saw, taking care to protect the surrounding neurovascular structures. Six centimeters of the distal fibula must remain intact to stabilize the ankle. In the skeletally immature patients, we always perform a synostosis at the lateral malleolus after fibula harvest.251 Six centimeters of fibula bone is also preserved proximally (below the head of the fibula) to preserve the stability of the knee. This is achieved by maintaining the attachment of the tibia to the fibula, and the attachments of the biceps femoris muscle and the fibular collateral ligament to the head of the fibula. The proximal part of the fibula hosts parts of the origins of the peroneus longus, the extensor digitorum longus, the extensor hallucis longus, the soleus, and the tibialis posterior muscles. Minimizing dissection at the level of the fibular head will also help to avoid injury to the peroneal nerve. 
Figure 15-5
The superficial peroneal nerve is shown in the lateral compartment of the right leg during free fibula osteoseptocutaneous flap harvest.
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Once the bone has been divided, the peroneal artery is identified distally deep to the tibialis posterior muscle and just dorsal to the FHL. The artery is divided and ligated distally. Dissection proceeds proximally to the peroneal-posterior tibial arterial bifurcation. Here the artery is ligated distal to the junction, preserving the posterior tibial artery. The surgeon should always verify the position of the tibial nerve and posterior tibial artery before ligation of the peroneal vessels. 
If a skin paddle is taken with the fibular graft, a meshed skin graft is always used to cover the donor site; a tight primary closure can increase the risk of compartment syndrome within the donor leg and should be avoided. Meticulous closure of the donor site, with particular attention to the FHL muscle, is critical to decreasing donor limb morbidity. Patients are typically able to resume pain free weight-bearing ambulation 4 to 6 weeks after fibular harvest. 
Bone fixation using a fibular graft needs to be performed with care as inadvertent screw placement can injure or avulse the pedicle or nutrient vessels. Plates applied to the surface of the fibula should use unicortical screws and ideally the plate and screws should be placed on the lateral surface of the fibula, away from the vascular pedicle. The periosteum at the bone/plate interface should not be stripped and only minimal periosteal stripping should be performed at the points of screw insertion. The bone-to-bone contact between the fibula and the recipient site can be maximized by creating step cuts, or the fibula can be telescoped into the recipient bone when the size is appropriate, such as the femur or humerus. Spanning plates are ideal as they allow for firm fixation above and below the intercalated fibula, yet allow for unicortical purchase of the fibula for stabilization.329 

Iliac Crest

The iliac crest receives a dual blood supply from the superficial circumflex iliac artery and deep circumflex iliac artery (DCIA).315 Of the two, the DCIA system is most important.296 Musculocutaneous perforators penetrating the abdominal wall 1 cm proximal to the iliac crest provide its nutrition. In the experience of several authors, the skin paddle has been less reliable than a standard groin flap, particularly if it is slightly rotated in relation to the underlying bone.234,294 Its size, when based on the DCIA, is quite variable, ranging between 7 to 10 and 15 to 30 cm. The entire iliac bone, however, is well supplied by the DCIA via multiple perforating arteries at the points of muscle attachment.260 It remains the pedicle of choice for osteocutaneous flaps, although double-pedicle flaps have been described using both the superficial and deep circumferential iliac vessels and may be desirable.189 
Although the entire crest may be harvested, it has a practical limit of 10 cm in length as a vascularized graft because of its curved shape. It is relatively less suited for diaphyseal reconstruction than the fibula, as remodeling to tolerate weight bearing is prolonged. Further, osteosynthesis is difficult and weak. 

Vascularized Periosteal Grafts

Periosteal grafts have been demonstrated experimentally to produce predictable new bone formation, provided they have adequate vascularity.186,327 Bone formation after free vascularized transfer of periosteum may be enhanced by enclosing a cancellous bone graft in a periosteal wrap.283 A variety of donor sites have been identified, including clavicle, fibula, ilium, humerus, tibia and femur, among others.67,85,201,267 In the upper extremity, thin corticoperiosteal grafts and small periosteal bone grafts harvested from the supracondylar region of the femur have proved to be of great use, based on either the descending genicular or medial superior genicular artery and vein (Fig. 15-6). This graft is elastic and can be readily conformed to the shape of small tubular bones. It has been successfully used for clavicle, humerus, and forearm applications, including pathologic fractures from radiation necrosis and other recalcitrant nonunions.85 
Figure 15-6
Medial femoral condyle corticoperiosteal grafts can be used to span shorter defects or be used to wrap around difficult fractures to provide a vascularized bone graft option.
 
After elevating the vastus medialis, the medial femoral condyle is exposed to demonstrate a ring of periosteal vessels based on the descending genicular or medial superior genicular artery and vein (A), a corticocancellous graft is elevated (B). The graft is quite flexible and can be molded around the bones at the recipient site (C, D).
After elevating the vastus medialis, the medial femoral condyle is exposed to demonstrate a ring of periosteal vessels based on the descending genicular or medial superior genicular artery and vein (A), a corticocancellous graft is elevated (B). The graft is quite flexible and can be molded around the bones at the recipient site (C, D).
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Figure 15-6
Medial femoral condyle corticoperiosteal grafts can be used to span shorter defects or be used to wrap around difficult fractures to provide a vascularized bone graft option.
After elevating the vastus medialis, the medial femoral condyle is exposed to demonstrate a ring of periosteal vessels based on the descending genicular or medial superior genicular artery and vein (A), a corticocancellous graft is elevated (B). The graft is quite flexible and can be molded around the bones at the recipient site (C, D).
After elevating the vastus medialis, the medial femoral condyle is exposed to demonstrate a ring of periosteal vessels based on the descending genicular or medial superior genicular artery and vein (A), a corticocancellous graft is elevated (B). The graft is quite flexible and can be molded around the bones at the recipient site (C, D).
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Vascularized Medial Femoral Condyle Structural Grafts

Vascularized bone grafts from the medial femoral condyle are particularly useful for treating fracture nonunion, which often occurs in areas that are poorly vascularized. The medial femoral condyle has become a popular donor site as it provides a large quantity of cancellous bone graft of excellent quality and density with a robust blood supply, and it is technically straightforward to harvest.169 The periosteum of the medial femoral condyle is supplied by the descending genicular artery (DGA) and the superomedial genicular artery (SGA). 
The graft is harvested with the patient in the supine position and the leg externally rotated and flexed at hip and knee. A longitudinal incision is made along the posterior border of the vastus medialis extending proximally to the adductor hiatus. The vastus medialis is retracted anteriorly to expose the underlying descending genicular vessels, which emerge from the adductor hiatus proximally. Either the DGA or the SGA is used as the pedicle for the bone graft, depending on which is larger.17 A bone graft up to 8 cm long and 6 cm wide can be harvested, with care taken to preserve the attachment of the periosteum to underlying bone. The size of the corticoperiosteal flap that can be harvested is limited anteriorly by the medial patellar facet, posteriorly by the posterior border of the femur, distally by the origin of the medial collateral ligament, and proximally by the flare of the medial femoral condyle.108 Caution should be taken in harvesting larger bone grafts as this may result in fracture of the femur. 
Vascularized medial femoral condyle bone grafts have been used successfully for the treatment of scaphoid,169 clavicle,108 metacarpal,295 humerus, radius, femur, and tibial17,54 nonunions, and have been found to result in faster bony union compared to distal radial pedicle grafts when used to treat scaphoid waist nonunions.168 

Rib Plus Serratus and Latissimus Dorsi

The rib, although used in early reports,139 is generally not suitable for upper extremity reconstruction because of its membranous, weak structure and curved shape. When based on its anterior internal mammary or supracostal arterial blood supply, only periosteal vessels are supplied.139 The posterior rib graft, which includes its nutrient artery, requires ligation of the dorsal branch of the posterior intercostal artery. Because this vessel supplies the spinal cord, the potential for causing paraplegia exists. Further, dissection is difficult and usually requires a thoracotomy. 
Composite vascularized bone grafts including a muscle flap with vascularized bone graft on a single pedicle have multiple advantages, including the ability to have a vascularized bone graft and then cover it with healthy muscle. One such vascularized bone graft and muscle flap composite graft is the rib, serratus anterior, and latissimus dorsi flap.182,212,254,266,328,375 Based on the thoracodorsal vessel and its branches to the serratus and latissimus, up to two nonadjacent ribs can be harvested with the overlying serratus muscle which provides the vascularity to the bone. A significant length of rib can be harvested and by making a corticotomy on its concave side, the curved rib can be straightened to be applied to a long bone or long bone defect (Fig. 15-7). Hypertrophy of the ribs, in comparison to a fibular graft, does occur with time. 
Figure 15-7
A–C: This 19-year-old man sustained open distal tibia and fibula fractures with significant bone and soft tissue loss.
 
His injury was first stabilized with an external fixator. The zone of injury of the open fracture extended far beyond the margins of the wound, and with segmental bone loss, skin loss, and extensive soft tissue injury, the decision for a composite rib, serratus, and latissimus flap was made. The latissimus was raised with a cutaneous paddle (D) and after elevation, the serratus and its branch of the thoracodorsal artery and vein were identified over the fourth and sixth ribs (E). F, G: The sixth and fourth ribs were elevated extraperiosteally, leaving the serratus attachments intact. The entire flap is shown in (H). I–K: The ribs were inset into the bone defect. L–N: Seven months after reconstruction, the flap has contoured nicely and there was consolidation of the ribs to the tibia.
His injury was first stabilized with an external fixator. The zone of injury of the open fracture extended far beyond the margins of the wound, and with segmental bone loss, skin loss, and extensive soft tissue injury, the decision for a composite rib, serratus, and latissimus flap was made. The latissimus was raised with a cutaneous paddle (D) and after elevation, the serratus and its branch of the thoracodorsal artery and vein were identified over the fourth and sixth ribs (E). F, G: The sixth and fourth ribs were elevated extraperiosteally, leaving the serratus attachments intact. The entire flap is shown in (H). I–K: The ribs were inset into the bone defect. L–N: Seven months after reconstruction, the flap has contoured nicely and there was consolidation of the ribs to the tibia.
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His injury was first stabilized with an external fixator. The zone of injury of the open fracture extended far beyond the margins of the wound, and with segmental bone loss, skin loss, and extensive soft tissue injury, the decision for a composite rib, serratus, and latissimus flap was made. The latissimus was raised with a cutaneous paddle (D) and after elevation, the serratus and its branch of the thoracodorsal artery and vein were identified over the fourth and sixth ribs (E). F, G: The sixth and fourth ribs were elevated extraperiosteally, leaving the serratus attachments intact. The entire flap is shown in (H). I–K: The ribs were inset into the bone defect. L–N: Seven months after reconstruction, the flap has contoured nicely and there was consolidation of the ribs to the tibia.
View Original | Slide (.ppt)
His injury was first stabilized with an external fixator. The zone of injury of the open fracture extended far beyond the margins of the wound, and with segmental bone loss, skin loss, and extensive soft tissue injury, the decision for a composite rib, serratus, and latissimus flap was made. The latissimus was raised with a cutaneous paddle (D) and after elevation, the serratus and its branch of the thoracodorsal artery and vein were identified over the fourth and sixth ribs (E). F, G: The sixth and fourth ribs were elevated extraperiosteally, leaving the serratus attachments intact. The entire flap is shown in (H). I–K: The ribs were inset into the bone defect. L–N: Seven months after reconstruction, the flap has contoured nicely and there was consolidation of the ribs to the tibia.
View Original | Slide (.ppt)
Figure 15-7
A–C: This 19-year-old man sustained open distal tibia and fibula fractures with significant bone and soft tissue loss.
His injury was first stabilized with an external fixator. The zone of injury of the open fracture extended far beyond the margins of the wound, and with segmental bone loss, skin loss, and extensive soft tissue injury, the decision for a composite rib, serratus, and latissimus flap was made. The latissimus was raised with a cutaneous paddle (D) and after elevation, the serratus and its branch of the thoracodorsal artery and vein were identified over the fourth and sixth ribs (E). F, G: The sixth and fourth ribs were elevated extraperiosteally, leaving the serratus attachments intact. The entire flap is shown in (H). I–K: The ribs were inset into the bone defect. L–N: Seven months after reconstruction, the flap has contoured nicely and there was consolidation of the ribs to the tibia.
His injury was first stabilized with an external fixator. The zone of injury of the open fracture extended far beyond the margins of the wound, and with segmental bone loss, skin loss, and extensive soft tissue injury, the decision for a composite rib, serratus, and latissimus flap was made. The latissimus was raised with a cutaneous paddle (D) and after elevation, the serratus and its branch of the thoracodorsal artery and vein were identified over the fourth and sixth ribs (E). F, G: The sixth and fourth ribs were elevated extraperiosteally, leaving the serratus attachments intact. The entire flap is shown in (H). I–K: The ribs were inset into the bone defect. L–N: Seven months after reconstruction, the flap has contoured nicely and there was consolidation of the ribs to the tibia.
View Original | Slide (.ppt)
His injury was first stabilized with an external fixator. The zone of injury of the open fracture extended far beyond the margins of the wound, and with segmental bone loss, skin loss, and extensive soft tissue injury, the decision for a composite rib, serratus, and latissimus flap was made. The latissimus was raised with a cutaneous paddle (D) and after elevation, the serratus and its branch of the thoracodorsal artery and vein were identified over the fourth and sixth ribs (E). F, G: The sixth and fourth ribs were elevated extraperiosteally, leaving the serratus attachments intact. The entire flap is shown in (H). I–K: The ribs were inset into the bone defect. L–N: Seven months after reconstruction, the flap has contoured nicely and there was consolidation of the ribs to the tibia.
View Original | Slide (.ppt)
His injury was first stabilized with an external fixator. The zone of injury of the open fracture extended far beyond the margins of the wound, and with segmental bone loss, skin loss, and extensive soft tissue injury, the decision for a composite rib, serratus, and latissimus flap was made. The latissimus was raised with a cutaneous paddle (D) and after elevation, the serratus and its branch of the thoracodorsal artery and vein were identified over the fourth and sixth ribs (E). F, G: The sixth and fourth ribs were elevated extraperiosteally, leaving the serratus attachments intact. The entire flap is shown in (H). I–K: The ribs were inset into the bone defect. L–N: Seven months after reconstruction, the flap has contoured nicely and there was consolidation of the ribs to the tibia.
View Original | Slide (.ppt)
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Soft Tissue Reconstruction

Classification of Soft Tissue Injury

Soft tissue injury may be of several varieties: Lacerations, abrasions, contusions, degloving injuries, and burns. In addition, soft tissue damage can occur in the absence of frank skin lacerations and can result in tissue damage that is even more extensive than that seen in open fractures.336,337 Closed injuries that are associated with skin contusions, deep abrasions, burns, or frank separation of the dermal layer from the subcutaneous tissues have been classified by Tscherne et al. (Table 15-2).336,337 Although not critically validated, this classification system has heightened our awareness of the importance of soft tissue injuries associated with closed fractures. 
Table 15-2
Classification of Soft Tissue Injury Associated with Closed Fractures
Grade 0 Minimal soft tissue injury, indirect injury causing simple fracture. A typical example is a spiral fracture of the tibia in a skiing injury.
Grade 1 Injury from within, superficial abrasion/contusion, resulting in simple or medium to severe fracture types. A typical example is a pronation–external rotation fracture-dislocation of the ankle joint, with soft tissue damage occurring from fragment pressure at the medial malleolus.
Grade 2 Direct injury with localized skin or muscle contusions, more extensive soft tissue injury or deep contaminated abrasions. Injury results in transverse or complex fracture patterns. A typical example is a segmental fracture of the tibia from a direct blow by a car fender. Imminent compartment syndrome also falls in this group.
Grade 3 Severe degloving with destruction of subcutaneous muscle and/or subcutaneous tissue, extensive skin contusions. Fracture patterns are complex. This grade includes manifest compartment syndrome and vascular injuries.
 

Adapted from: Tscherne H, Gotzen L. Fractures with Soft Tissue Injuries. Berlin: Springer-Verlag; 1984 and Tscherne H, Oestern HJ. Die Klassifizierung des Weichteilschadens bei offenen und geschlossenen Frakturen. Unfallheilkunde. 1982;85:111–115.

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The mechanism of injury will also provide clues as to the severity of the underlying soft tissue injury. Penetrating injury will cause local and immediate surrounding tissue trauma; therefore, the surgical debridement required will typically be limited to the surrounding region of penetration. Blunt force resulting from motor vehicle crashes or falls will lead to more extensive soft tissue trauma and possible associated neurovascular injury with increased muscle contusion, devascularization, and necrosis. A ringer injury or press injury typically carries a poorer prognosis because of the amount of associated tissue damage. Electrical injuries associated with fractures may appear innocuous but will always be associated with significant underlying soft tissue damage. 

Wound Healing

To fully appreciate the nature of the soft tissue injury the surgeon must have some understanding of the normal wound healing process. Surgically induced wounds heal in several stages. The wound passes through phases of coagulation, inflammation, matrix synthesis and deposition, angiogenesis, fibroplasia, epithelialization, contraction, and remodeling. These processes have been divided into three main stages: Inflammation, fibroplasia, and maturation. Interruption in any of these stages can lead to wound healing complications.165 
The inflammatory phase of wound healing involves cellular responses to clear the wound of debris and devitalized tissue. Increased capillary permeability and leukocyte infiltration occur secondary to inflammatory mediators and vasoactive substances. Inflammatory cells clean the wound of harmful bacteria and devitalized tissue. Fibronectin and hyaluronate deposition from fibroblasts in the first 24 to 48 hours provides scaffolding for further fibroblast migration.96,318 
The fibroblast proliferation phase starts within the first 2 to 3 days as large populations of fibroblasts migrate to the wound. Secretion of a variety of substances is necessary for wound healing and includes large quantities of glycosaminoglycans and collagen. Collagen levels rise for approximately 3 weeks corresponding to increasing wound tensile strength. After 3 weeks the rate of degradation of collagen equals the rate of deposition. Angiogenesis is an important aspect of the fibroblast proliferation phase, as it helps to support new cells in the healing wound. 
The maturation phase starts at around 3 weeks lasting up to 2 years. It is characterized by collagen remodeling and wound strengthening. Collagen is the principal building block of connective tissue and is found in at least 13 different types. Early wounds are composed of a majority of type III collagen. As the wound matures, type III collagen is replaced by type I collagen. Collagen cross-linking improves tensile strength. There is a rapid increase in the strength of the wound by 6 weeks as the wound reaches 70% of the strength of normal tissue. The wound then gradually plateaus to 80% of normal strength, but never returns to preinjury levels.165 
Wound re-epithelialization occurs as adjacent cells migrate through a sequence of mobilization, migration, mitosis, and cellular differentiation of epithelial cells. Wound contraction starts at about 1 week. It is facilitated by the transformation of certain fibroblasts into myofibroblasts. These cells adhere to the wound margins as well as to each other and effect contraction of the wound. These stages are imperative for proper wound healing, as interruption of these processes results in chronic wound complications.96,318 
Large wounds, or wounds incapable of primary healing, heal through a process of “secondary wound healing,” which is dominated by wound contraction and re-epithelialization. If infection, ischemia, or ongoing trauma inhibit the wound from completing the re-epithelialization process, it will then enter into a protracted inflammatory state.266 In these chronic wounds the environment is predominated by neutrophils with the increased production of proteolytic enzymes.81 In most situations a chronic wound must be converted to a clean acute wound through the process of surgical debridement for healing to occur. Surgical debridement re-establishes a normal healing environment, allowing the wound to heal through primary or secondary intention. 

Debridement

Debridement is the cornerstone of success for the management of any traumatic wound. Adequate debridement requires the complete removal of foreign material and devitalized tissue. Inadequate debridement can promote wound infection, delay surgical healing, and attenuate the inflammatory response. 
Careful wound evaluation and wound debridement should take place as soon as possible after the injury, under general anesthesia in the operating room. Debridement performed in the emergency room or on the ward is often inadequate, as it is limited by poor lighting and inadequate patient analgesia. Debridement in the operating room also allows the surgeon to have on hand the appropriate surgical tools for the removal of devitalized bone and soft tissue and to obtain hemostasis. 
For all trauma patients, the surgeon must determine the “zone of injury,” which refers to the area throughout which trauma has occurred. The extent of the zone of injury is not always apparent on initial assessment, particularly in degloving, crush, and electrical injuries. If one cannot assure complete excision of all necrotic tissue, soft tissue and bony reconstruction should be postponed and a second debridement planned within 24 hours. The need for fasciotomy should be considered at the first debridement. Injuries sustained in an agricultural setting or in industrial machinery are subject to heavier and deeper contamination. Mechanical roller injuries involving crushing, avulsion, or degloving will also result in more severe tissue damage and have a worse prognosis than blunt trauma or guillotine-type injuries.33,125,126,179 Such injuries should routinely undergo serial debridements over the course of 48 hours to ensure that all devitalized tissue is removed before soft tissue reconstruction begins. 
After sharp debridement, all wounds should be irrigated to remove additional loose debris and decrease bacterial contamination. Several different solutions are available for irrigation. Antibiotic solutions (bacitracin, neomycin, and polymyxin) and detergents (Castile soap, benzalkonium chloride) are used by many surgeons in an attempt to minimize infection rates. Although wound irrigation with antibiotic solutions has been effective in some experimental studies,82,284 there is still a lack of convincing clinical data that it provides a benefit over soap lavage alone. 
High pressure flow, although beneficial for decreasing bacterial counts, should be used prudently. When using high pressure irrigation, one should avoid driving foreign material further into the wound bed, hydrodissection of uninjured areas, and tissue insufflation.113,232 High pressure irrigation should be utilized judiciously in the hand, as the water jet can injure or avulse nerves or digital vessels. In such cases, copious amounts of gravity fed irrigation in conjunction with careful debridement will suffice. 
Newer debridement devices have been designed to exert variable pressure throughout the debridement process. Devices such as the Versajet Hydrosurgery System (Smith and Nephew, USA) use a controlled fluid jet that allows for precise debridement over tendons in addition to gross debridement of acute and chronic wounds.39,187,303 In a prospective trial, this device has been shown to decrease operative times and allow for increased precision during the debridement process.122 
Inadequate debridement can often result from the surgeon’s concerns over wound closure. If the surgeon is at all concerned about wound closure, early consultation with a plastic surgeon or other wound management specialist should be carried out to allow for a multidisciplinary approach to wound management. Such collaborations will allay concerns and allow for an aggressive initial debridement minimizing late wound complications. 

Debridement of Acute Wounds

The first step in any major reconstructive effort is an adequate debridement. With each debridement the surgeon’s goal should be to remove all foreign and necrotic tissues. Wound debridement and careful wound evaluation should take place as soon as possible after the injury, under general anesthesia in the operating room. The debridement process starts with a careful wound scrub using a surgical brush and sterile soap or iodine solution, followed by irrigation with 4 to 8 L of sterile saline, ideally heated to 37°C to avoid excessive cooling of the patient. If there is excessive bleeding, a tourniquet may be inflated before the irrigation process. 
Important structures including nerves and vessels should be identified, marked, and protected before sharp debridement of the nonviable soft tissues. Major motor nerves should never be debrided, but rather dissected from necrotic tissue and preserved. Free bony fragments that are completely denuded of soft tissue attachments, and therefore avascular, should be removed from the wound. Avulsed parts can often be used as a source of “spare-parts” for wounds requiring skin grafting or flap closure, and this option should always be considered before discarding them.32 After debridement, the final assessment of tissue viability must be made with the tourniquet deflated. 
Skin that is insensate, and does not blanch or bleed at the wound edges should be removed. Clotted venules are a sign of skin devitalization and they should be debrided with the surrounding skin and soft tissue. Healthy muscle is bright red and shiny and will contract when grasped with the forceps. If there is any question regarding muscle viability it may be stimulated with the electrocautery; if there is no evidence of contraction, it should be debrided. 
If the surgeon has removed all foreign material and devitalized tissue, immediate reconstruction can be considered. Clean surgical instruments, ideally on a separate operating tray, should be used for any immediate reconstructive procedure, as it has been shown that instruments used for debridement can carry a bacterial concentration in excess of 103 organisms.14 If one cannot assure complete excision of all necrotic tissue, reconstruction should be postponed and a second debridement planned within 24 hours. Debridement should continue at 24- to 48-hour intervals until the wound is clean and ready for reconstruction. 

Debridement of Chronic Wounds

As discussed, a chronic wound is a wound that has failed to progress through the normal stages of healing and remains arrested in the inflammatory stage.14,165 In traumatic cases, such wounds exist because of an infection associated with a retained sequestrum, hardware, or other foreign material. To allow these wounds to heal, all necrotic and infected materials must be removed before any attempt at soft tissue reconstruction. Thus, one must turn the chronic wound into an acute wound through the process of thorough debridement. The one caveat to this recommendation is the removal of hardware that is providing critical and stable fracture fixation. If the application of an external fixator is not possible, hardware can be maintained within an infected field until more definitive fixation is possible or bony healing has occurred, providing systemic antibiotics have been administered and the hardware is covered with well-vascularized tissue.38,279 
Chronic wounds present a greater challenge, as vital structures are often hidden within scar and granulation tissue. Debridement must be extended beyond the zone of injury, into normal tissue, to ensure complete resection of all contaminated tissue. Use of a tourniquet early in the case is important to best visualize and avoid injury to vital structures such as nerves and blood vessels. The tourniquet should be released before closure or dressing application to confirm the removal of all devascularized tissue. 
A centripetal approach should be used working from superficial tissues to deep, from the margins to the center of the wound. Every effort is made to preserve nerves and blood vessels crossing the zone of injury. If nerves must be transected, they should be tagged with dyed monofilament suture and documented in the operative records so that they may be more easily identified during later wound debridements or reconstructive efforts. Tissue from the wound should always be sent for bacterial cultures as well as pathologic analysis to rule out the possibility of osteomyelitis or vasculitis.14 

Adjuvants to Debridement

Management of the wound between debridements is an issue of some debate. Normal saline wet to dry dressings have been the most common form of wound dressing after surgical debridement. They help to prevent soft tissue desiccation and obliterate dead space, and the dressing changes provide an opportunity for continuous surveillance of the wound, in addition to providing excellent mechanical wound debridement. One disadvantage is patient discomfort with dressing changes, which may be alleviated by moistening the gauze before removal. For contaminated wounds immediately after injury, Dakin solution or Betadine solution may be used judiciously. Dakin solution is bacteriostatic and Betadine is bactericidal. Their use is controversial, especially if used for more than 3 days, because of soft tissue toxicity and their negative effects on wound healing.18,190 In cases of established infection, the application of topical antibiotics such as silver sulfadiazine, Sulfamylon (mafenide acetate), and silver nitrate has been shown to reduce bacterial counts.103,194 For Pseudomonas infections, 0.25% acetic acid may be used to reduce surface bacterial counts. Consultation with an infectious disease specialist is recommended in such cases. 
The advantage of all these forms of dressing changes is that they ensure consistent monitoring of the wound site. This is in contrast specifically to the use of a VAC device, in which the sponge is commonly not changed for 2 to 4 days, thus preventing wound surveillance by the surgeon who will be performing the reconstruction. 
Emollient-type soft tissue coverage with various wound gels, semipermeable films, or even antibiotic impregnated ointments may be used in cases in which there has been avulsion of the dermal surface but without damage to the underlying muscle. The dressings may take the form of a hydrogel, antibiotic impregnated gauze, or a simple semipermeable film. Semipermeable films and semiocclusive hydrogels are impermeable to water and bacteria but permeable to oxygen and water vapor. Occlusive hydrocolloids are impermeable to even water vapor and oxygen. Thus these dressings are not as useful in wounds that require mechanical debridement or wounds that are exudative because of accumulation of fluid under them. 
Vessels and nerves that are exposed in the wound should always be covered with a nonadherent gauze or hydrogel dressing to protect them until soft tissue coverage can be obtained. Nerve repairs and blood vessel repairs should be covered with local soft tissue, immediately after repair, to allow for a moist healing environment, as opposed to gauze dressings. 

Vacuum-Assisted Closure

If the wound is clean and wound reconstruction is not going to be performed immediately, whether because of concomitant life-threatening injuries or other medical issues, a negative pressure dressing can be used until definitive closure. A wound VAC can help to remove surrounding edema, decrease local metalloproteinases and other inhibitors of wound healing while promoting angiogenesis.11,253 
The VAC consists of an open polyurethane ether foam sponge, in some cases impregnated with silver for more contaminated cases, sealed by an adhesive drape and attached to suction. All pores in the sponge communicate so that negative pressure applied to the sponge by the suction is applied equally and completely to the entire wound surface. The effects of the VAC on the wound are multiple. The application of negative pressure causes the sponge to collapse toward its center. Traction forces are thus applied to the wound perimeter pulling the wound edges together progressively making the wound smaller. The VAC sponge should be cut to fit inside the wound to maximize these traction forces on the wound edges. The sponge should not overlap intact skin, as skin maceration may occur. In addition, the VAC removes wound edema fluids, and it appears to increase circulation and decrease bacterial counts (see Fig. 15-2).253 
The use of the VAC in traumatic lower extremity wounds has been associated with a decreased requirement for skin grafting, free tissue transfers, and flap coverage.74,99 Herscovici et al. reported on 21 patients, 16 of whom had lower extremity wounds because of high-energy trauma. At the time of initial presentation, all wounds “would have required flap coverage”; however, after an average of 19 days of VAC treatment, 12 of the wounds no longer required flap procedures to achieve wound coverage.143 
Vacuum-assisted therapy must be used with caution over tendons and nerves, as continuous suction can produce desiccation and injury to these structures. When neurovascular structures are exposed, local tissue or flap coverage should be performed in an urgent or emergent manner to prevent desiccation. If wounds remain contaminated despite surgical debridement, wet to dry dressing changes can be performed every 8 hours until the next scheduled surgical debridement or until the wound is clean enough to accept a VAC device. 

Hyperbaric Oxygen Therapy

Hyperbaric oxygen therapy (HBOT) involves the intermittent inhalation of 100% oxygen in specialized chambers at pressures greater than that at sea level (>1 atmosphere absolute, ATA). Typical protocols recommended by the Undersea and Hyperbaric Medical Society (UHMS) for treating wounds expose the patient to pressures of 2 to 2.5 ATA lasting 90 to 120 minutes per session for approximately 40 treatments. Oxygen tensions can approach 500 mm Hg in soft tissue and 200 mm Hg in bone.178 
Traumatized and osteomyelitic limbs and bones have been shown to be hypoxic, with a partial pressure of 20 to 25 mm Hg in animal models, and thus oxygen content can be dramatically raised under hyperbaric conditions.219 The hypoxic conditions in the diseased bone reduce the ability of neutrophils to generate the reactive oxygen species necessary to kill bacteria. Hyperbaric oxygen (HBO), therefore, enhances bactericidal activity by increasing oxygen tension in tissues.21 The processes of collagen synthesis and osteogenesis are also inhibited in a hypoxic state, and studies have suggested that improved oxygen tension can normalize, if not enhance, these functions.188 A review of 57 studies examining HBOT350 concluded that it had potential beneficial adjunctive effects for conditions such as chronic nonhealing diabetic wounds, compromised skin grafts, osteoradionecrosis, soft tissue radionecrosis, gas gangrene, and chronic osteomyelitis. However, the definitive value of HBOT remains to be determined through prospective randomized trials. 

Timing of Soft Tissue Reconstruction

The timing of soft tissue reconstruction in the trauma setting is often debated, and different authors have advocated different time scales including immediate (emergency) closure,214 early closure (before 5 days), and delayed closure (6 to 21 days).80 In our opinion, the requirements for wound closure should be no different when dealing with primary closure, pedicled flaps, or free tissue transfer; wounds must be free of necrotic tissue and infection. There is experimental and clinical evidence that quantitative bacteriology obtained immediately before wound closure correlates with the likelihood of subsequent infection.44,64 Breidenbach and Trager31 evaluated 50 free tissue transfers carried out for complex wound closure in the extremities to determine predictors of subsequent infection, and found that quantitative cultures had the highest positive-predictive value (89%), negative-predictive value (95%), sensitivity, and specificity. Mechanism of injury, type and degree of contamination, wound location, and systemic factors such as diabetes, corticosteroid use, immunosuppression, advanced age, and malnutrition also affect the likelihood of clinical infection. 
In 1986, Godina published the results of 532 free flaps used for extremity reconstruction. In that study, he was able to reduce the postoperative infection rate in patients with open fractures to 1.5% in a subset of patients undergoing reconstruction within 72 hours.118 Many subsequent studies support these data, and when free tissue transfer is to be used, reconstruction within 5 days of the injury is a commonly adopted guideline. This approach has been extrapolated into the general practice of trauma reconstruction. “Emergency” free flap reconstruction in the upper limb (within 24 hours of injury) potentially can allow for earlier rehabilitation and a quicker resolution of the inflammatory response after trauma. Several authors have reported successful series of emergency free flaps in the upper extremity.48,214,256 Nevertheless, no prospective comparative studies have examined the benefits of very early versus later coverage with regard to outcome or functionality. In contrast, studies have shown that flap reconstruction performed beyond the frequently quoted critical interval of 72 hours with or without temporary VAC coverage yields results similar to those of immediate reconstruction within the first 3 days.176,319 
Yaremchuk373 proposed that treatment of the severely injured lower extremity be done in four distinct phases: (i) emergency evaluation, orthopedic stabilization, and debridement of obviously devitalized structures and tissues; (ii) wound management with serial debridement; (iii) soft tissue coverage; and (iv) delayed bone reconstruction. Soft tissue coverage and bone reconstruction may be performed simultaneously using osteocutaneous flaps. In summation, a wound should be closed when it is clean. The quicker the wound is made clean, the sooner reconstruction may occur. When the surgeon is sure all necrotic material has been removed from the wound, then reconstruction should proceed. 

Wound Coverage Options

Once the wound is clean and the decision for limb salvage has been made, definitive bony fixation and wound coverage may proceed. Wound coverage may be obtained by multiple means, including primary closure, local flaps, and free tissue transfer. As experience and success with free tissue transfer has increased, surgeons have moved away from the classic reconstructive ladder and now opt to reconstruct defects with more complex procedures if they can provide a more rapid and complete reconstructive solution.225 The most common reconstructive techniques will now be discussed in detail. 

Skin Grafting

Skin grafting involves the transfer of the most superficial epidermal and dermal elements of the skin to a new location where the graft is capable of re-establishing blood flow. Skin grafts may be taken as split thickness (including only part of the dermis) or full thickness (including all of the dermis).231 Full-thickness grafts have greater primary contracture rates (the amount the graft rolls or shrinks initially once it is harvested) because of a higher percentage of elastin retained within the graft; however, full-thickness grafts are less likely to contract secondarily (after healing has occurred) because of greater preservation of the deep dermal architecture when compared with split-thickness grafts.300,347 Return of sensation is also superior when compared with split-thickness grafts.4 
Split-thickness grafts have fewer dermal components and thus undergo less primary contracture but have greater secondary contracture rates. Because of high secondary contracture rates, split-thickness grafts should be avoided over joints (Fig. 15-8). Split-thickness grafts are more likely to take over compromised beds as compared with full thickness grafts.65 The split-thickness graft donor site heals through a process of re-epithelialization and contraction as keratinocytes migrate out of retained hair follicles within the donor site.19,298 In contrast, the full graft donor site heals by primary intention. 
Figure 15-8
Late effects of skin grafting over the popliteal fossa.
 
Although the wound is healed, the split-thickness skin graft has not provided durable coverage and is subject to chronic breakdown with knee extension.
Although the wound is healed, the split-thickness skin graft has not provided durable coverage and is subject to chronic breakdown with knee extension.
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Figure 15-8
Late effects of skin grafting over the popliteal fossa.
Although the wound is healed, the split-thickness skin graft has not provided durable coverage and is subject to chronic breakdown with knee extension.
Although the wound is healed, the split-thickness skin graft has not provided durable coverage and is subject to chronic breakdown with knee extension.
View Original | Slide (.ppt)
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Skin grafts require a well-nourished tissue bed to survive and will not do well in an area of frank infection or when placed on tendon devoid of paratenon, bone, or cartilage. In wounds in which these structures predominate, local, regional, or free tissue transfers are required for successful wound closure. In addition, skin grafting should be avoided in areas that may require secondary surgery for bone or nerve grafting. The greatest risks for graft failure include infection, shearing, motion at the graft site, seroma or hematoma accumulation beneath the graft, and finally poor wound bed vascularity.231 
Skin grafts survive for the first several days through a process called serum imbibition. During this stage of healing, the graft obtains nutrients from the underlying wound bed through a diffusion process. This commonly occurs in the first 24 to 48 hours. After this point the skin graft undergoes revascularization through an ingrowth of capillary buds primarily from the wound bed.22,62,63 Clinically most grafts are adherent to the wound bed by the fourth to fifth postoperative day. 
The wound bed or recipient site must be debrided and clean before attempts at skin grafting. Infection is one of the leading causes of skin graft failure. Because skin grafts are completely dependent on the wound bed they are transplanted to for nutrition, they possess no intrinsic ability to resolve infection.192 
Tissue expansion may have a role in resurfacing healed skin grafted wounds subsequently to optimize the aesthetic result but it has no role in acute coverage of wounds. 

Flaps

Classification of Flaps

A flap consists of tissue transferred from one anatomic location to another. The flap may be based on a random or axial pattern blood supply. Random flaps have no named or defined blood supply. They are raised in a subdermal or subfascial plane and rely on the subdermal vascular plexus of the skin for circulation. To ensure adequate circulation, random flaps should be limited to a length no greater than 2.5 times the width of their base, which is the uncut border of the flap. This ratio may be even more limited in poorly perfused extremities. Varied random pattern flaps include z-plasty, four flap z-plasty, rhomboid flap, banner flap, V-Y advancement flaps, and rotational flaps. 
Axial pattern flaps can be raised pedicled regional flaps or used as a free tissue transfer. The flaps can contain more than one type of tissue. Fasciocutaneous flaps contain skin and the underlying fascia, musculocutaneous flaps contain skin, fascia, and muscle, and osteocutaneous flaps contain bone, fascia, and skin. 
Muscle flaps are classified on the basis of five patterns of muscle circulation.227 A muscle for free tissue transfer must be able to survive on one vascular pedicle that is dominant and that will support the entire muscle mass. The classification (with examples) is as follows. 
  •  
    Type I: One vascular pedicle (extensor digitorum brevis or tensor fascia latae)
  •  
    Type II: One dominant pedicle and minor pedicles (gracilis muscle)
  •  
    Type III: Two dominant pedicles (rectus abdominis muscle)
  •  
    Type IV: Segmental vascular pedicles (sternocleidomastoid)
  •  
    Type V: One dominant pedicle and secondary vascular pedicles (latissimus dorsi, pectoralis major)
Animal studies have shown that muscle flaps are able to control a 10-fold higher bacterial count than fasciocutaneous flaps, and improve antibiotic delivery to the wound site.37 Although the potential antimicrobial advantages of muscle flaps have also been demonstrated clinically, a recent study by Yazar et al.374 comparing lower limb wounds reconstructed with free fasciocutaneous or free muscle flaps in a total of 177 cases showed no difference in outcomes or infection rates. This highlights the important role of adequate debridement, regardless of the type of flap used. 

Free Flaps

The coverage of traumatic wounds of the extremities has historically been accomplished with the use of pedicled, local, or distant rotational flaps. However, when defects are very large or encompass multiple structures including nerve, bone, or muscle, the use of composite free tissue transfer provides a reliable and single stage means of reconstruction. 
The benefits of free tissue transfer within the extremity include the transfer of additional vascularized tissue to the injured area, the ability to carry vascularized nerve, bone, skin, and muscle to the injured area in one procedure, and the avoidance of any additional functional deficits to the injured limb that may be incurred with the use of a local or pedicled flap. Free flaps are not tethered at one end, as is the case for pedicled laps, and this allows for more freedom in flap positioning and insetting. More recently developed fasciocutaneous and perforator flaps also allow for primary closure of donor sites with minimal sacrifice of donor site muscle. With current microsurgical techniques free flap loss rates range between 1% and 4% for elective free tissue reconstruction.16,180 The upper extremity is particularly suited for free tissue transfer as the majority of recipient blood vessels utilized for anastomosis are located close to the skin, and are of relatively large caliber. 
Major indications for free tissue transfer include: (i) the primary coverage of large traumatic wounds with exposed bone, joint, tendons, or hardware; (ii) the coverage of complex composite defects requiring bone and soft tissue replacement; (iii) the coverage of soft tissue deficits resulting from the release of contractures or scarring from previous trauma; and (iv) the coverage of extensive burns or electrical injuries.191,205,206,286,297 
There are few absolute contraindications for free flap transfer within the upper and lower extremities, and in many cases free tissue transfer may be the only option for limb salvage after severe soft tissue loss. Despite this, relative contraindications to free tissue transfer include a history of a hypercoagulable state, a history of a recent upper extremity deep venous thrombosis, and evidence of ongoing infection within the traumatic defect. Other contraindications would include an inadequate recipient vessel for flap anastomosis. Disregarding technical error, the status of the recipient vessel used for flap anastomosis may play the greatest role in flap failure; recipient vessels within the zone of injury are prone to postoperative and intraoperative thrombosis. Recipient vessels for microvascular transfer ideally should be located out of the zone of injury, radiation, or infection. Petechial staining of the adventitia, a ribbon-like appearance of the recipient vessels, and poor flow at the time of arteriotomy are all suggestive of vessel injury, and alternative vessels should be chosen as recipient vessels for microvascular anastomosis. In rare cases, arterial-venous fistulas may be created proximally within the upper extremity or axilla using the cephalic or saphenous vein. These fistulas can be brought into the zone of injury and divided to provide adequate inflow and outflow for a free tissue transfer.210 Commonly used recipient vessels in the upper extremity are the thoracodorsal, thoracoacromial, circumflex scapular, transverse cervical, brachial, circumflex humeral, superior ulnar collateral, radial collateral, ulnar, radial, and digital vessels.359 Common recipient vessels in the lower extremity are the superficial femoral, the popliteal, the posterior tibial, and the anterior tibial arteries.207 
The choice of flap should take into account both functional requirements and the surgeon’s experience. Muscle flaps are useful for large three-dimensional defects when soft tissue bulk is necessary; however, direct coverage of tendons with muscle flaps encourages dense adhesions limiting postoperative tendon excursion. In general, fascial or fasciocutaneous flaps are more useful for coverage of exposed tendons and areas in which a gliding tissue plane needs to be preserved. 

Soft Tissue Reconstructive Algorithms by Region

Lower Extremity Reconstructive Options

Lower extremity reconstruction has historically followed an algorithm that is based on the location of the defect (Table 15-3). The gastrocnemius muscle flap has been used to cover defects around the knee and proximal tibia; the soleus muscle flap has been used to cover defects within the middle third of the tibia, and free flaps have been reserved to cover defects overlying the lower third of the tibia and ankle. Nonetheless, with continuing advancements in microsurgery, there are now several reliable fasciocutaneous flaps and free flaps that may be used for proximal and distal defects in addition to the standard options. An overview of the standard options will be provided with a subsequent explanation of newer approaches for soft tissue coverage. 
 
Table 15-3
Reconstructive Options for the Lower Extremity
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Table 15-3
Reconstructive Options for the Lower Extremity
Pelvis/groin Rectus abdominis muscle
Rectus femoris muscle
Transverse rectus abdominis myocutaneous flap
Tensor fascia lata
Free flap
Thigh Pedicled anterolateral thigh flap
Rectus abdominis muscle
Rectus femoris muscle
Tensor facia lata
Vastus lateralis
Gracilis
Sartorius
Free flap
Knee/proximal third of tibia Gastrocnemius muscle
Reversed anterolateral thigh flap
Anterior tibial perforator flap
Free flap
Middle third of tibia Soleus
Free flap
Lower third of tibia/ankle Free flap
Sural artery island flap
Posterior tibial perforator flap
Posterior tibial flap
Reverse soleus muscle flap
Foot/dorsum Free flap
Sural artery island flap
Foot/plantar STSG/FTSG
Free flaps
Medial plantar island flap
Abductor hallucis muscle
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Upper Thigh, Groin, and Pelvis

Wounds within the pelvis and upper thigh rarely require flap coverage. The bone in this area is covered with enough soft tissue that most defects can be covered with skin grafts. Should the size of the defect prohibit primary closure or skin grafting, the rectus abdominis or the rectus femoris muscle flap may be used in a pedicled fashion to cover most defects in this region. The anterolateral thigh (ALT) flap and tensor fascia lata muscle can also be used to cover wounds surrounding the femur and the greater trochanter. 

Anterolateral Thigh Flap

The ALT flap is a versatile flap harvested from the anterolateral region of the thigh. It is most often used as a free flap for lower third injuries in the leg or for reconstruction in the upper extremities, but it may also be pedicled to cover defects in the groin and thigh. Its blood supply is through the descending branch of the lateral femoral circumflex artery. Several branches of this vessel supply the overlying skin. These skin vessels are either septocutaneous or they take a course through the vastus lateralis muscle before supplying the skin.196 Inclusion of the lateral femoral cutaneous nerve allows for the flap to become sensate. The length of the pedicle is approximately 8 cm, but it can have a longer effective length when the skin paddle is designed so that the perforator is eccentrically located. The flap is easy to design and can be as large as 40 × 20 cm (Fig. 15-9). The skin is relatively pliable and the flap can be thinned to a great degree without compromising the blood supply. This flap can also be used as a flow-through flap that maintains distal blood supply in the extremity,9 which is particularly useful in extremities that have compromise of one or more vessels.110,224 
Figure 15-9
Anterolateral thigh flap with a vastus lateralis muscle component prior to pedicle division.
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The ALT flap can be dissected to include a variety of tissue components such as muscle (vastus lateralis or rectus femoris), fascia, and skin in a variety of combinations.52 It has disadvantages such as a color mismatch (when reconstructing defects in distant locations) and the presence of hair in some patients. When large defects are reconstructed, skin grafts are required at the donor site. Donor site morbidity is minimal when the donor site is closed primarily, and some residual functional deficit is sometimes noted when a large skin graft is required.195 If necessary the flap can be thinned down to a 5-mm thickness. This allows for an aesthetically appealing reconstruction while providing a tendon gliding surface when necessary. 
The ALT flap can also be harvested as an adipofascial flap for areas with adequate skin but a lack of soft tissue. This type of flap can then be buried or skin grafted. When reconstructing lower extremity defects, the flap is designed with a variation in tissue types tailored to the recipient site requirement. Certain areas such as the foot and ankle will require thin cutaneous flaps, whereas other areas will require more tissue bulk. For defects closer to the thigh such as the groin or knee, a pedicled flap can be elevated with the pedicle based proximally or distally. A distally based pedicled ALT flap is based on retrograde blood flow from the descending branch of the lateral femoral circumflex artery with the pivot point greater than 2 cm above the knee. Longer pedicle length can be achieved by designing the flap more proximally on the upper thigh. 
This flap is also extremely useful in lower extremity reconstruction.261,262,376 Areas such as the foot and ankle, which require a pliable thin flap for defect coverage, can be covered with a cutaneous flap. Harvested as a myocutaneous flap, it can be used to cover amputation stump defects. A strip of fascia lata can be incorporated with the flap and used for tendon reconstruction.46 For areas with exposed bone or extensive soft tissue loss, the cutaneous portion is often adequate for reconstruction147; however, if necessary, a myocutaneous flap can be used. 

Knee and Proximal Third of Tibia

Proximal third tibial injuries and injuries around the knee may be covered with the medial or lateral gastrocnemius muscle flap. These flaps may be used in conjunction with each other for large defects. The medial head of the gastrocnemius will cover the inferior thigh, knee, and proximal tibia and is more frequently used than the lateral head as it is larger in size. The lateral head may also be used alone or in combination with the medial head for coverage of lateral knee defects and lateral distal thigh wounds. The tendinous inferior margin of the gastrocnemius muscle may be used to augment the repair of an injured quadriceps tendon. For coverage of extremely large defects, or in situations in which compromise of the gastrocnemius muscles will hinder ambulation, a free flap can be used for proximal third coverage. Other nonmicrosurgical options for proximal third coverage include the reverse ALT flap. 

Gastrocnemius

The gastrocnemius muscle is located in the superficial posterior compartment and its function is to flex the knee and plantar flex the foot. It has two heads, which lie superficial to the soleus. It is dispensable only if the soleus muscle is intact. Its blood supply is via the medial and lateral sural arteries, which are branches from the popliteal artery. This is a type I muscle and the pedicle length is 6 cm. Ideally, only one head of the gastrocnemius is needed for a reconstruction around the knee; however, both heads may be used, depending on the reconstructive requirements. Each head is considered a separate unit for the purpose of flap design. The medial head is longer and its muscular fibers extend more inferiorly. The distal soleus tendon unites with the gastrocnemius to form the Achilles tendon. For defects at the level of the midportion of the tibia, the gastrocnemius may not provide adequate coverage and the soleus muscle is preferred for coverage. 
Contraindications to the use of the gastrocnemius muscle flap include active infection and/or significant disruption of the soft tissue and/or vascular pedicle. Additional contraindications for the flap include any procedure or injury that may have traumatized or injured the sural artery, such as a previous repair of a popliteal arterial laceration or repair of a popliteal aneurysm. Occasionally, severe compartment syndromes may render the muscle fibrotic and unusable for transfer. 
Although the medial and lateral heads of the gastrocnemius can support a skin paddle, a paddle is not commonly used because of its unreliability and the limitation in size of the skin. The medial gastrocnemius is dissected through a posterior midline incision. The sural nerve and lesser saphenous vein are two key landmarks that are seen superficial to the muscle belly and preserved. The muscle fascia is split, and the junction between the two heads is incised (Fig. 15-10). Blunt dissection in the plane between the gastrocnemius and the soleus is gently done with the finger. The superficial dissection is then performed, and the muscle is transected distally with a cuff of tendon attached for use in fixation to the wound edge. The tunnel through which the muscle is passed should be of adequate size so as to not constrict the blood supply of the flap. To expand the muscle area, the fascia may be incised, with careful attention being paid to not injure the underlying muscle. The flap may be used as an advancement flap to cover part of an amputation stump or upper tibial defects, or as a cross leg flap. 
Figure 15-10
Gastrocnemius muscle flap after separation of the medial and lateral heads along the raphe.
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Middle Third of Tibia

Historically the soleus has been the muscle of choice for reconstruction of middle third tibia defects; however, we use this flap sparingly, and often opt for free tissue coverage in this area, especially if there is comminution of the bone.53 There are several factors that may prohibit the successful transfer of the soleus muscle: (i) the size of the defect, (ii) the status of the muscle, and (iii) the status of the surrounding tissue and bone.200 The standard soleus flap can cover most defects under 75 cm2. Large defects occupying the majority of the middle third and lower third of the leg are best covered with a free tissue transfer. The soleus can be used in conjunction with the medial or lateral gastrocnemius muscles for larger defects spanning the upper aspect of the leg, but doing so will compromise active plantar flexion. 
Because the soleus muscle is closely adherent to the deep posterior surface of the interosseous membrane, tibia, and fibula, it can often be traumatized with comminuted fractures of the tibia and fibula. Often, during initial wound evaluation and debridement, the muscle can be inspected through the soft tissue defect. If the muscle is extensively lacerated by fracture fragments or contains a significant amount of intramuscular hematoma, one should use another flap for soft tissue coverage. In addition, any associated injury to the popliteal, peroneal, or posterior tibial arteries can adversely affect the survival of the soleus muscle.200 

Soleus

The soleus muscle is a type II muscle, with dominant pedicles from the posterior tibial, popliteal, and peroneal arteries and minor segmental pedicles from the posterior tibial artery. The muscle originates from the posterior surface of the tibia, the interosseous membrane, and the proximal fibula. It lies in the superficial posterior compartment deep to the plantaris muscle and distally joins the gastrocnemius muscle as the conjoined, Achilles tendon. It is a bipennate muscle with the medial and lateral muscle bellies each receiving an independent neurovascular supply; this allows the lateral and medial portions to be mobilized independently while preserving some function of the remaining soleus muscle. The medial head originates from the tibia and receives the majority of its blood supply from the posterior tibial artery. The lateral head originates from the fibula and receives the majority of its blood supply from the peroneal artery. Typically the soleus muscle is used as a proximally based flap (Fig. 15-11). Dividing the muscle longitudinally at the level of the septum allows for the elevation of medial and lateral hemisoleus flaps; however, the proximal dissection is typically more tedious because the distinction between the two heads is often not clear. 
Figure 15-11
A medial hemisoleus flap was used to cover this healed infected tibia fracture in a 75-year-old diabetic woman after the hardware was removed.
 
A: Preoperative image. B: Postoperative view at 6 months. The infection is resolved, and the patient is ambulating without difficulty.
A: Preoperative image. B: Postoperative view at 6 months. The infection is resolved, and the patient is ambulating without difficulty.
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Figure 15-11
A medial hemisoleus flap was used to cover this healed infected tibia fracture in a 75-year-old diabetic woman after the hardware was removed.
A: Preoperative image. B: Postoperative view at 6 months. The infection is resolved, and the patient is ambulating without difficulty.
A: Preoperative image. B: Postoperative view at 6 months. The infection is resolved, and the patient is ambulating without difficulty.
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In the distal one-third of the muscle, the soleus receives segmental arterial perforators from the posterior tibial artery. These distal perforators may be absent in up to 26% of patients; in these cases distal perfusion to the muscle is provided by axial blood flow from more proximal perforators. The diameter and position of these distal perforators is variable but, if present and of large enough caliber, they can allow for a portion of the muscle to be harvested in a reverse fashion (Fig. 15-12). 
Figure 15-12
 
A: An infected Gustilo IIIB distal tibia-fibular fracture after open reduction and internal fixation. B: Intraoperative view shows the raised, distally based right hemisoleus flap. Blue markers indicate the distally based perforating vessels from the posterior tibial artery. C: One year after surgery, the wound is healed.
A: An infected Gustilo IIIB distal tibia-fibular fracture after open reduction and internal fixation. B: Intraoperative view shows the raised, distally based right hemisoleus flap. Blue markers indicate the distally based perforating vessels from the posterior tibial artery. C: One year after surgery, the wound is healed.
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Figure 15-12
A: An infected Gustilo IIIB distal tibia-fibular fracture after open reduction and internal fixation. B: Intraoperative view shows the raised, distally based right hemisoleus flap. Blue markers indicate the distally based perforating vessels from the posterior tibial artery. C: One year after surgery, the wound is healed.
A: An infected Gustilo IIIB distal tibia-fibular fracture after open reduction and internal fixation. B: Intraoperative view shows the raised, distally based right hemisoleus flap. Blue markers indicate the distally based perforating vessels from the posterior tibial artery. C: One year after surgery, the wound is healed.
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Knee and ankle motion may begin once the skin graft is adherent to the underlying muscle bed. Weight-bearing status is determined by the stability of the underlying fractures. In a study by Hallock of 29 soleus flaps, 24 were used for coverage of high-energy impact defects. All of the flaps in this study were based on a proximal pedicle. The complication rate was low (13.8%) and there were no cases of total flap loss.131 Similar results were found by both Pu and Tobin,217,332 when using a proximally based flap. 

Distal Third of Tibia/Ankle

Free tissue transfer has historically been recommended for lower third tibia coverage; however, other nonmicrosurgical options for soft tissue closure of ankle defects include the reversed soleus flap (described above) and the sural artery flap. 

Sural Artery Flap

The distally based sural artery flap is perfused by reverse flow through the anastomosis between the superficial sural artery and the lowermost perforator of the peroneal artery. This flap has been used for the successful coverage of defects of the posterior and inferior surface of the heel, the Achilles tendon, the middle and distal one-third of the leg, the dorsum of the foot, and the medial and lateral malleoli. The flap is contraindicated in patients with destruction of the vascular pedicle or the lowermost perforator of the peroneal artery. Sacrifice of the sural nerve results in hyposensitivity of the lateral border of the foot and a higher rate of complications may be anticipated in patients with comorbid conditions such as peripheral vascular disease, diabetes mellitus, and venous insufficiency. In this patient population, a delay procedure (wherein the flap is incised along its boundary but not elevated until a subsequent second surgery 2 to 3 weeks later, to optimize blood supply through its pedicle) may be performed to increase its survival rate. 
Many different methods have been described for flap harvest all in an effort to decrease its main problem of vascular congestion. Our technique is as follows. 
  •  
    The patient is placed in the prone position
  •  
    An axial line is drawn from the superior aspect of the lateral malleolus to the midpoint of the popliteal flexion crease. The skin island, at least 2 to 3 cm distal to the popliteal flexion crease, is centered on this axis and planned according to defect size.
  •  
    The pivot point of the subcutaneous pedicle is at least three finger breadths (4 to 6 cm) superiorly from the superiormost aspect of the lateral malleolus.
  •  
    The subcutaneous pedicle should be at least 3 to 4 cm wide and the skin raised over the subcutaneous pedicle must be very thin so as to not injure the pedicle.
  •  
    Dissection is performed in a plane deep to the fascia with an incision isolating the skin paddle and dividing the proximal blood supply if a delay is not planned (Fig. 15-13).
  •  
    The distally based sural flap is then transferred to the recipient site usually with the division of the intervening skin bridge to alleviate any possible compression of the subcutaneous pedicle.
  •  
    Skin grafts are used liberally over the flap pedicle and at the donor site of the flap.
Figure 15-13
 
A: Intraoperative view of a distally based sural flap being raised for coverage of a calcaneal wound. Note the superior skin bridge has not been divided. B: Intraoperative view of the distally based sural flap at the time of flap inset with division of the skin bridge over the pedicle and liberal use of skin grafts over the pedicle of the flap and the donor site. C: View of the healed distally based sural flap 16 months postoperatively.
A: Intraoperative view of a distally based sural flap being raised for coverage of a calcaneal wound. Note the superior skin bridge has not been divided. B: Intraoperative view of the distally based sural flap at the time of flap inset with division of the skin bridge over the pedicle and liberal use of skin grafts over the pedicle of the flap and the donor site. C: View of the healed distally based sural flap 16 months postoperatively.
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Figure 15-13
A: Intraoperative view of a distally based sural flap being raised for coverage of a calcaneal wound. Note the superior skin bridge has not been divided. B: Intraoperative view of the distally based sural flap at the time of flap inset with division of the skin bridge over the pedicle and liberal use of skin grafts over the pedicle of the flap and the donor site. C: View of the healed distally based sural flap 16 months postoperatively.
A: Intraoperative view of a distally based sural flap being raised for coverage of a calcaneal wound. Note the superior skin bridge has not been divided. B: Intraoperative view of the distally based sural flap at the time of flap inset with division of the skin bridge over the pedicle and liberal use of skin grafts over the pedicle of the flap and the donor site. C: View of the healed distally based sural flap 16 months postoperatively.
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Postoperatively, the most important issue is prevention of congestion or compression of the vascular pedicle. This can be achieved either by an adequately elevated position of the leg and/or by the use of conventional splints with a gap over the flap; however, some authors prefer the use of external fixation devices that serve to not only immobilize the limb, but also obviate the need for tight compressive dressings. External fixation also allows the treatment of concomitant fractures and prevents the development of an equinus deformity as well as facilitating elevation of the limb. 
Surveillance of flap perfusion in terms of arterial as well as venous flow must be performed regularly during the first several postoperative days. Capillary refill should be tested every several hours in the postoperative period so that interventions may be made to prevent flap loss. A revision procedure should be performed if any signs of poor arterial perfusion or venous congestion are identified. The administration of anticoagulants in the postoperative period after pedicled flap reconstruction remains controversial; however, we commonly will use anticoagulation therapy such as heparin and/or aspirin in mildly congested flaps reserving leech therapy for those with more significant congestion.50,241 If serious compromise of the flap is evident, the flap may be laid back in the donor site bed as a last resort, in essence creating a delayed flap. 
The patient should be at complete bed rest for approximately 4 to 5 days after the procedure with a gradual dangling protocol of the limb to assess tissue tolerance. If signs of significant edema or venous compromise are evident in the flap tissue after 10 to 15 minutes of dangling the extremity, bed rest with elevation should be prolonged for several more days until the flap can tolerate the dependent position. Donor site morbidity is generally low, with the most common finding being sural nerve neuroma and scarring. Neuromas that are painful and significantly distressing to the patient may be resected and the nerve stump buried in the gastrocnemius muscle. 

Foot/Dorsum

Most dorsal foot wounds may be treated with a split-thickness skin graft if there is no exposed tendon or bone. Local toe fillet flaps are capable of covering smaller distal defects. Transmetatarsal amputation may be considered if there is extensive concomitant injury to the toes. In such cases, the plantar surface can be advanced to cover the remaining dorsal defect. When tendon or bone is exposed, free tissue transfer provides the most reliable means of durable coverage and preserves the remaining foot function. Smaller defects can be treated with the sural artery flap. 

Foot/Plantar

Free flaps are good options for heel wounds as well as defects covering the majority of the plantar surface of the foot. Another option for heel coverage is the medial plantar artery flap, which provides sensate coverage of heel defects without the need for microsurgery. This flap is based on the medial plantar artery. The sural artery flap can also be extended to cover moderate-sized heel defects (Fig. 15-14). 
Figure 15-14
Small- to moderate-sized foot and ankle defects can be covered with the sural artery flap.
 
A: This 55-year-old man has developed wound breakdown following ankle fracture fixation. B: The sural artery flap is harvested and pedicled to cover the defect. C: The donor site is skin grafted. D, E: The flap allows for thin pliable coverage of the area and will eventually allow for normal shoe wear.
A: This 55-year-old man has developed wound breakdown following ankle fracture fixation. B: The sural artery flap is harvested and pedicled to cover the defect. C: The donor site is skin grafted. D, E: The flap allows for thin pliable coverage of the area and will eventually allow for normal shoe wear.
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Figure 15-14
Small- to moderate-sized foot and ankle defects can be covered with the sural artery flap.
A: This 55-year-old man has developed wound breakdown following ankle fracture fixation. B: The sural artery flap is harvested and pedicled to cover the defect. C: The donor site is skin grafted. D, E: The flap allows for thin pliable coverage of the area and will eventually allow for normal shoe wear.
A: This 55-year-old man has developed wound breakdown following ankle fracture fixation. B: The sural artery flap is harvested and pedicled to cover the defect. C: The donor site is skin grafted. D, E: The flap allows for thin pliable coverage of the area and will eventually allow for normal shoe wear.
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Free Flaps for Lower Extremity Coverage

We have found the latissimus dorsi muscle, gracilis muscle, ALT, and scapular flaps to be the most versatile for lower extremity coverage. For osteocutaneous defects, we most frequently use a free fibular flap or a fibular flap in combination with a latissimus dorsi muscle flap. For moderate-sized ankle defects the gracilis muscle is our flap of choice as it produces minimal donor site morbidity and can be contoured nicely to the malleolar region and will not interfere with normal shoewear. 

Latissimus Dorsi

The latissimus dorsi has proved to be a very reliable muscle for coverage of soft tissue defects for the chest, shoulder, and elbow. The muscle provides a workhorse flap for extremity coverage and is based on the thoracodorsal artery as the major pedicle and on branches of the intercostals and lumbar arteries as secondary segmental vessels. It is a type IV muscle and has a pedicle length of 8 to 12 cm, which can be obtained by dissecting the thoracodorsal vessels proximally toward the axillary artery and vein. Its innervation is the thoracodorsal nerve, which is a direct branch of the brachial plexus, and it enters the muscle 10 cm from the apex of the axilla. It is important to identify the anterior border of the muscle preoperatively by having the patient contract the muscle with the hand supported on the hip in a standing position. Preoperative marking of the skin over the posterior–superior iliac spine and the scapular tip is helpful also. 
The indication for the use of this flap is to cover a large skin and soft tissue defect that cannot be managed with local flaps. Contraindications for flap use include previous injury, or in some cases, axillary lymphadenectomy. Breast cancer surgery, in particular, axillary node dissection, may injure the nerve or arterial supply, rendering the muscle fibrotic and inadequate for transfer. 
The latissimus dorsi flap may be harvested as not only a muscle flap but also a musculocutaneous flap. A muscle flap covered with a split-thickness skin graft is often less bulky and can seal deep defects (Fig. 15-15), whereas musculocutaneous flaps give better aesthetic reconstruction because the skin paddle can conform to the skin texture of the surrounding tissues, particularly when it is used as a pedicled flap. 
Figure 15-15
 
A: A below-knee amputation stump following resection of poor quality skin. B: Following thorough debridement of osteomyelitis of the distal tibia, the stump was covered with a latissimus dorsi muscle flap and split-thickness skin graft. C: At 6 months postoperatively, the stump has been resurfaced nicely. D: The latissimus dorsi flap donor site at 6 months.
A: A below-knee amputation stump following resection of poor quality skin. B: Following thorough debridement of osteomyelitis of the distal tibia, the stump was covered with a latissimus dorsi muscle flap and split-thickness skin graft. C: At 6 months postoperatively, the stump has been resurfaced nicely. D: The latissimus dorsi flap donor site at 6 months.
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Figure 15-15
A: A below-knee amputation stump following resection of poor quality skin. B: Following thorough debridement of osteomyelitis of the distal tibia, the stump was covered with a latissimus dorsi muscle flap and split-thickness skin graft. C: At 6 months postoperatively, the stump has been resurfaced nicely. D: The latissimus dorsi flap donor site at 6 months.
A: A below-knee amputation stump following resection of poor quality skin. B: Following thorough debridement of osteomyelitis of the distal tibia, the stump was covered with a latissimus dorsi muscle flap and split-thickness skin graft. C: At 6 months postoperatively, the stump has been resurfaced nicely. D: The latissimus dorsi flap donor site at 6 months.
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Technique

The patient under general anesthesia is placed in a lateral decubitus position with an axillary roll. Dissection is most easily accomplished beginning from the anterior border of the muscle, and this method allows early pedicle identification. If a skin paddle is chosen, then it may be oriented along the muscle fibers with care being taken to center the paddle on the muscle belly. If no skin paddle is selected, the skin flaps are elevated commonly parallel to the muscle fibers to expose the muscle origins and insertions. The muscle is released from the lumbosacral fascia and iliac crest. The pedicle is identified and the serratus branch is then divided so that the muscle may be reflected toward the axilla. Pedicle dissection should be performed with loupe magnification (2.5× or greater). If performing a functional muscle transfer, marking sutures should be placed along the long axis of the muscle to allow adequate tension adjustment at the recipient site. The muscle can be split longitudinally into halves based on the medial and lateral branches of the thoracodorsal artery, which bifurcate upon entering the muscle. 
Upon dissection of the neurovascular pedicle, the insertion of the muscle at the humerus is divided. Additional distal coverage, if it is being used as a pedicled flap for extremity reconstruction, can be obtained by releasing its insertion from the intertubercular groove of the humerus as well. When the latissimus dorsi flap is transferred as a free flap, the vascular pedicle is divided at the juncture with the axillary artery and vein to obtain the maximum pedicle length. Large suction drains should be left beneath the skin flaps and in the axilla to avoid postoperative hematoma or seroma problems. Frequently there is difficulty elevating the flap simultaneously with donor site preparation, particularly when it is used for upper extremity reconstruction. In addition, if used as a musculocutaneous flap it may be excessively thick in obese patients. 
Donor site seroma is the most common complication after harvest of a latissimus dorsi flap. Seromas can be relieved with frequent aspiration and compressive garments. Scarring over the donor site is inevitable, and endoscopic harvest can be entertained to minimize subsequent scarring.366 Total flap necrosis is rare when used as a pedicled flap; however, partial flap necrosis because of an inconsistent blood supply to the lower third of the muscle is not uncommon. Bleeding at the distal edge of the flap should be checked when it is elevated. Kinking and tension on the pedicle can cause a disturbance of flap circulation and must be recognized immediately. 

Rectus Abdominis

The rectus abdominis muscle may be harvested with the patient in the supine position. This vertically oriented, type III muscle (two dominant vascular pedicles), extends between the costal margin and the pubic region and is enclosed by the anterior and posterior rectus sheaths. The superior blood supply is from the superior epigastric artery, which is a continuation of the internal mammary artery. Distally the blood supply is from the inferior epigastric artery, which is a branch of the external iliac artery. The pedicle length is 5 to 7 cm superiorly and 8 to 10 cm inferiorly. Because of the larger size of the inferior epigastric artery and the venae comitantes, it is more commonly used as a free tissue transfer. Large defects of the thigh, where local soft tissues are either not sufficient in area or unusable because of radiation, for example, may be covered with pedicled rectus muscle only or myocutaneous flaps (Fig. 15-16). 
Figure 15-16
 
A: After resection of a recurrent liposarcoma in a radiated field in the thigh, there is extensive exposure of the femur and the scarred wound bed. B: Six months after a pedicled vertical rectus abdominis myocutaneous flap for soft tissue coverage. Anteriorly, a skin graft was used over a portion of the flap to minimize the size of the skin paddle and facilitate abdominal wall closure.
A: After resection of a recurrent liposarcoma in a radiated field in the thigh, there is extensive exposure of the femur and the scarred wound bed. B: Six months after a pedicled vertical rectus abdominis myocutaneous flap for soft tissue coverage. Anteriorly, a skin graft was used over a portion of the flap to minimize the size of the skin paddle and facilitate abdominal wall closure.
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Figure 15-16
A: After resection of a recurrent liposarcoma in a radiated field in the thigh, there is extensive exposure of the femur and the scarred wound bed. B: Six months after a pedicled vertical rectus abdominis myocutaneous flap for soft tissue coverage. Anteriorly, a skin graft was used over a portion of the flap to minimize the size of the skin paddle and facilitate abdominal wall closure.
A: After resection of a recurrent liposarcoma in a radiated field in the thigh, there is extensive exposure of the femur and the scarred wound bed. B: Six months after a pedicled vertical rectus abdominis myocutaneous flap for soft tissue coverage. Anteriorly, a skin graft was used over a portion of the flap to minimize the size of the skin paddle and facilitate abdominal wall closure.
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The motor innervation is supplied by the seventh through twelfth intercostal nerves that enter the deep surface of the muscle at its middle to lateral aspects. The size of the muscle is up to 25 × 6 cm2. The skin territory that can be harvested is 21 × 14 cm2 and its blood supply is based on musculocutaneous perforators. The donor site created via the fascial incision in the anterior rectus sheath to access a muscle-only flap may be closed primarily with a running or interrupted absorbable or nonabsorbable suture on a tapered needle. When harvesting a myocutaneous flap, a portion of the anterior rectus sheath is taken with the flap and a mesh or biologic implant may be used to reinforce the closure of the abdominal wall fascia to prevent hernia or bulge. Drains are commonly used under the raised skin flaps after muscle harvest. An abdominal wall binder may be used to aid in postoperative recovery in cases of a free tissue transfer. Although the rectus abdominis muscle is considered a workhorse flap, its popularity has decreased slightly because of the lower donor site morbidity that other muscle and nonmuscle flaps have to offer. 

Gracilis

The gracilis muscle is a very commonly chosen donor site for free tissue transfer to cover foot and ankle soft tissue defects.277 Typically, the ipsilateral limb is chosen so that only one limb is immobilized. The blood supply to the muscle is from the medial femoral circumflex artery, which originates from the profunda femoris artery. The major pedicle can be identified 8 to 10 cm inferior to the pubic tubercle. The flap also has a minor arterial pedicle, which enters the muscle at the level of the midthigh. This artery originates from the superficial femoral artery. The muscle receives its innervation from the anterior branch of the obturator nerve. This branch can be harvested with the muscle if there are requirements for a functional muscle transfer. 
The muscle is exposed through a medial thigh incision as it lies between the adductor longus medially and the semitendinous muscle inferiorly. It lies superficial to the adductor magnus. The gracilis may be confused with the sartorius and is differentiated from the sartorius and semimembranous by identification of its musculotendinous portion. At the level of the medial femoral condyle the gracilis consists of muscle and tendon, whereas the semimembranous is entirely composed of tendon and the sartorius is entirely muscular. 
Once the major pedicle has been identified with loupe magnification and determined to be adequate for a microvascular anastomosis, the secondary pedicle is divided. The origin of the muscle and the branch of the obturator nerve are then divided. The muscle is left to perfuse on its major pedicle until the recipient vessels have been prepared for microvascular anastomosis. Before muscle transfer, a final definitive debridement of the defect site is performed and the flap transfer is performed (Fig. 15-17). 
Figure 15-17
 
A: A gunshot wound to the dorsum of the foot with severe comminution of the metatarsals and loss of the hallux and second toe. B: The donor site after gracilis muscle harvest using two incisions and preserving a central skin bridge. C: One and a half years after gracilis muscle transfer for coverage of the dorsal foot wound.
A: A gunshot wound to the dorsum of the foot with severe comminution of the metatarsals and loss of the hallux and second toe. B: The donor site after gracilis muscle harvest using two incisions and preserving a central skin bridge. C: One and a half years after gracilis muscle transfer for coverage of the dorsal foot wound.
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Figure 15-17
A: A gunshot wound to the dorsum of the foot with severe comminution of the metatarsals and loss of the hallux and second toe. B: The donor site after gracilis muscle harvest using two incisions and preserving a central skin bridge. C: One and a half years after gracilis muscle transfer for coverage of the dorsal foot wound.
A: A gunshot wound to the dorsum of the foot with severe comminution of the metatarsals and loss of the hallux and second toe. B: The donor site after gracilis muscle harvest using two incisions and preserving a central skin bridge. C: One and a half years after gracilis muscle transfer for coverage of the dorsal foot wound.
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Upper Extremity Reconstructive Options

Advances in microsurgery have expanded our reconstructive armamentarium over the last three decades, and the options for most soft tissue defects are now extensive (Table 15-4). As innovations in flap design continue to develop, reconstructive algorithms move away from the traditional reconstructive ladder toward delivering composite flaps to provide the best possible reconstructive solution.45 Although free flaps are often the preferred method of reconstruction, all surgeons should be familiar with other options for upper limb reconstruction. The major factors determining flap choice are location, size, and tissue involvement.144 
 
Table 15-4
Reconstructive Options for the Upper Extremity
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Table 15-4
Reconstructive Options for the Upper Extremity
Palm Radial forearm flap
Ulnar forearm flap
Free flap
Groin flap
Dorsal hand Radial forearm flap
Posterior interosseous flap
Free flap
Groin flap
Forearm Radial forearm flap
Posterior interosseous flap
Free flap
Elbow Radial forearm flap
Posterior interosseous flap
Pedicled latissimus dorsi flap
Anconeus muscle flap
Reverse lateral arm flap
Free flap
Humerus Pedicled latissimus dorsi flap
Scapular flap
Parascapular flap
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Skin Grafting

As discussed previously, wounds with exposed muscle and subcutaneous tissue will accept skin grafts; however, exposure of vital structures such as tendons devoid of paratenon, nerves, vessels, bone, and hardware requires flap coverage. Although a split skin graft (Fig. 15-18) will typically survive when grafted onto major nerves, vessels, periosteum, and paratenon large areas of exposed bone need durable coverage, nerves and vessels need robust protection, and the preservation of tendon excursion requires that the overlying tissue is not firmly adherent to the paratenon. Flap coverage is also indicated in situations in which there is a need for the restoration of sensation. 
Figure 15-18
A split-thickness skin graft on the patient’s forearm shown (A) 1 week and (B) 8 months after surgery.
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Fasciocutaneous Flaps

Within the upper extremities, fasciocutaneous flaps can be either pedicled or free. The two most common pedicled fasciocutaneous flaps used in the upper extremity are the radial forearm flap and the posterior interosseous flap. Both can be used in an anterograde or retrograde fashion and can provide thin pliable coverage for most defects involving the dorsum of the hand, the palm, the forearm, and the elbow. 

Radial Forearm Flap

This can be used as a local pedicled flap, or as a free flap from the contralateral limb (Fig. 15-19). The radial artery gives off fasciocutaneous perforators along its length, to supply the radial two-thirds of the forearm skin, and it also gives branches to the distal half of the radius. A flap measuring up to 15 × 35 cm can be raised as a fascial flap, a fasciocutaneous flap, or an osteocutaneous flap, in an antegrade or retrograde manner.177 Palmaris longus, flexor carpi radialis, and the lateral and medial antebrachial nerves can also be included.102,367 The pivot point can be as proximal as the origin of the radial artery, approximately 1 to 4 cm distal to the intercondylar line of the humerus, or as distal as the wrist crease, allowing it to be used for defects anywhere from the elbow to the dorsum of the hand. The versatility of this flap and the relative ease in flap elevation have made it a workhorse flap for forearm and hand reconstruction. 
Figure 15-19
 
A: A 34-year-old man with chronic wound of the elbow with osteomyelitis of the olecranon, after a fall from a bike. B: Intraoperative view of radial forearm pedicled flap for elbow reconstruction. C: Appearance at 6 months postoperatively.
A: A 34-year-old man with chronic wound of the elbow with osteomyelitis of the olecranon, after a fall from a bike. B: Intraoperative view of radial forearm pedicled flap for elbow reconstruction. C: Appearance at 6 months postoperatively.
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Figure 15-19
A: A 34-year-old man with chronic wound of the elbow with osteomyelitis of the olecranon, after a fall from a bike. B: Intraoperative view of radial forearm pedicled flap for elbow reconstruction. C: Appearance at 6 months postoperatively.
A: A 34-year-old man with chronic wound of the elbow with osteomyelitis of the olecranon, after a fall from a bike. B: Intraoperative view of radial forearm pedicled flap for elbow reconstruction. C: Appearance at 6 months postoperatively.
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An adequate collateral circulation to the hand must be confirmed before the flap is elevated. The patient should have a normal Allen test to ensure safe flap harvest. If there is concern about the patency of the ulnar artery during the surgical procedure, the radial artery can be temporarily clamped, before flap division, and perfusion to the hand can be examined. The importance of checking collateral circulation to the hand when raising the flap from the already traumatized forearm cannot be overemphasized. 

Posterior Interosseous Flap

The posterior interosseous flap was designed in an attempt to find alternatives to the radial forearm flap. The posterior interosseous artery, which this flap is based on, arises from the common interosseous artery in the antecubital fossa and passes dorsally through the interosseous membrane. The descending branch runs in the septum between the extensor carpi ulnaris and extensor digiti minimi, giving rise to several fasciocutaneous perforators to the skin. A fasciocutaneous flap up to 8 cm in width and 12 cm in length can be raised centered over a line drawn from the lateral epicondyle to the distal radioulnar joint. 
The posterior interosseous branch of the radial nerve, which also runs in this septum, gives off its branches to the extensor digitorum communis and extensor carpi ulnaris at this level, and these branches are prone to injury when dissecting the flap. The posterior interosseous flap can also be used in a retrograde manner, making use of the collateral flow to the posterior interosseous artery through its distal anastomosis with the anterior interosseous artery. The principal advantages of this flap are as an alternative when the radial or ulnar artery has already been damaged or sacrificed, and when a thin pliable skin flap is needed.7,230 

Free Fasciocutaneous Flaps

These flaps can be used anywhere throughout the upper extremity. If joints are to be crossed, fasciocutaneous flaps are much preferred as muscle flaps can undergo atrophy and restrict flexion and extension across joints. Some fasciocutaneous free flaps, such as the lateral arm flap and scapular flap, have limitations in size and overall thickness. If a larger skin island is needed, tissue expansion can be performed before flap transfer. 

Scapular Flap

The scapular flap provides a large area of fasciocutaneous tissue based on the circumflex scapular branch of the subscapular artery.322 This is an excellent choice for coverage of large wounds of the forearm. The dissection is relatively easy, and a flap of up to 10 × 25 cm (scapular flap) or 15 × 30 cm (parascapular flap) can be raised and used to reconstruct large defects of the forearm. For defects involving the radius or ulna, the scapular flap can be harvested as an osteocutaneous flap by incorporating the lateral part of the scapula, with very little extra morbidity.342 Coverage can be extended even further by combining this flap with the latissimus dorsi or serratus anterior muscle flaps on one pedicle.366 Donor sites of up to 7 to 8 cm in width can usually be closed directly. 

Parascapular Flap

This flap has similar characteristics to the scapular flap but is based on the descending branch of the circumflex scapular artery. Similarly, it provides a large area of pliable and relatively thin tissue for forearm coverage, but the donor site usually requires skin grafting. 

Anterolateral Thigh Flap

This flap has been previously discussed. It has recently seen a huge gain in popularity as a free flap, with some authors proclaiming it as the ideal soft tissue flap. Its vascular pedicle is reliably at least 8 cm long and can be lengthened up to 20 cm, the flap is easy to design and can be made up to 40 × 20 cm in size. It can be thinned to 3 to 5 mm without compromising its vascularity.185,274 Some subcutaneous fat can be included to minimize tendon adhesion in the forearm and hand. Wei et al.353 reviewed a series of 672 flaps with a success rate of over 98%. Its many advantages make it a versatile flap that has been reliably used in upper limb reconstructions including defects of the forearm and elbow (Fig. 15-20).164,351 
Figure 15-20
 
A: A 48-year-old man had a roller press injury resulting in loss of most of the palmar and forearm skin. B: Coverage was obtained with use of an anterolateral thigh flap. C: The flap appearance at 3 months, at the time of secondary flexor tendon tenolysis surgery.
A: A 48-year-old man had a roller press injury resulting in loss of most of the palmar and forearm skin. B: Coverage was obtained with use of an anterolateral thigh flap. C: The flap appearance at 3 months, at the time of secondary flexor tendon tenolysis surgery.
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Figure 15-20
A: A 48-year-old man had a roller press injury resulting in loss of most of the palmar and forearm skin. B: Coverage was obtained with use of an anterolateral thigh flap. C: The flap appearance at 3 months, at the time of secondary flexor tendon tenolysis surgery.
A: A 48-year-old man had a roller press injury resulting in loss of most of the palmar and forearm skin. B: Coverage was obtained with use of an anterolateral thigh flap. C: The flap appearance at 3 months, at the time of secondary flexor tendon tenolysis surgery.
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Lateral Arm and Reverse Lateral Arm Flaps

The lateral arm flap is a fasciocutaneous flap perfused by the septal perforators of the posterior radial collateral artery, the terminal branch of the profunda brachii. An area of thin, pliable skin can be harvested up to 20 × 14 cm in size; however, only donor sites 6 cm in width or less can be closed primarily. This flap has a very short vascular leash, and its use as a pedicle flap is therefore limited, with most surgeons preferring to use it as a free flap. The radial recurrent artery provides the retrograde flow when this flap is used as a reversed flap. The reverse lateral arm flap has been used successfully for olecranon and antecubital coverage. As a free flap, the lateral arm flap is extremely versatile, capable of carrying bone (the humerus) and nerve (the posterior antebrachial nerve). Historically this has been a workhorse flap for upper extremity reconstruction.21,257,339 

Muscle Flaps

The muscle flaps most commonly used to reconstruct the forearm, elbow, and humerus are the latissimus dorsi, rectus abdominis, serratus anterior, and gracilis muscles. The choice of muscle flap depends on the size of the defect, donor site availability, and donor site morbidity. 
Latissimus Dorsi.
This is the largest single muscle flap and has a long pedicle (8 to 11 cm), making it one of the most versatile flaps for reconstructing large defects in the upper extremity. In addition, in the majority of patients, the thoracodorsal trunk has two major divisions, allowing the surgeon to harvest only a portion of the muscle if a narrower flap is needed. Conversely, if a broader flap is required, the serratus muscle (± a vascularized rib) can be raised with the flap, taking care to preserve its arterial supply, which arises as a branch from the thoracodorsal artery. 
As a pedicle flap, the latissimus dorsi can be transferred as a functional muscle to re-establish lost biceps or triceps function. It can be used in a pedicled fashion for coverage of the elbow, but should not be used for elbow defects extending distal to the olecranon. For such defects the radial forearm flap has been found to provide more reliable coverage.55,164 Functional morbidity of the donor site is variable, with conflicting reports in the literature. If it is anticipated that a resulting degree of shoulder weakness (adduction, as in patients who walk with crutches and those with paraplegia) would have a major impact on the patient, then an alternative flap should be considered. 
Serratus Anterior.
The lower three slips of the serratus can be harvested with or without the underlying ribs, based on the thoracodorsal pedicle. This flap is a relatively thin, broad sheet of muscle but can be very versatile when combined with components of rib or the latissimus dorsi muscle. 
Rectus Abdominis.
This muscle has a consistent vascular pedicle (5 to 7 cm) arising from the deep inferior epigastric vessels, and can be used for coverage in most situations encountered in forearm trauma. Its main disadvantage is an abdominal wall hernia, which can sometimes occur at the donor site, especially if the fascia is harvested. 
Gracilis.
This muscle is well suited for small defects requiring muscle coverage. The dominant pedicle is the medial femoral circumflex artery arising from the profunda femoris; it is usually approximately 6 to 7 cm in length. The muscle is unipennate, and has an excursion of approximately 10 cm. The main advantage of this muscle flap in the forearm is its use as a functional motor unit as discussed previously. 

Distant Pedicled Flaps

Groin Flap

The workhorse flap before the advent of microsurgery was the groin flap. This flap is based on the superficial femoral circumflex artery, which arises from the femoral artery along with the superficial inferior epigastric artery in the femoral triangle.249,312 The flap has shown great versatility. It may include the lateral cutaneous branch of the femoral nerve if a sensate flap is required.172 The flap may be combined with the abdominohypogastric flap for large defects or it may be expanded before transfer. If bone is required, a portion of the iliac crest may be harvested.98 The flap may also be split longitudinally to cover defects on both aspects of the hand.313 
The flap can often be divided safely at 3 weeks, especially if the wound is well healed at the flap’s distal margin. Any compromise to the arm’s vascularity, such as preoperative radiation or electrical injury may prolong the period of revascularization. If there is doubt about the vascularity of the flap prior to division, the pedicle may be occluded with a tourniquet and the vascular flow assessed.365 The disadvantage of the groin flap is the mandatory period of hand immobilization before pedicle division. This can result in hand, elbow, and shoulder stiffness. Despite this the groin flap still remains a reliable means of providing soft tissue coverage for large hand wounds without the need for microvascular experience (Fig. 15-21).249 
Figure 15-21
A: The groin flap can provide versatile coverage of the hand.
 
Here a groin flap was designed with two separate skin paddles to cover both the palmar (B) and dorsal (C) surfaces of the hand. D: The hand was temporarily stabilized to the groin with the use of an external fixator. E: The appearance of the hand following flap division and insetting.
Here a groin flap was designed with two separate skin paddles to cover both the palmar (B) and dorsal (C) surfaces of the hand. D: The hand was temporarily stabilized to the groin with the use of an external fixator. E: The appearance of the hand following flap division and insetting.
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Figure 15-21
A: The groin flap can provide versatile coverage of the hand.
Here a groin flap was designed with two separate skin paddles to cover both the palmar (B) and dorsal (C) surfaces of the hand. D: The hand was temporarily stabilized to the groin with the use of an external fixator. E: The appearance of the hand following flap division and insetting.
Here a groin flap was designed with two separate skin paddles to cover both the palmar (B) and dorsal (C) surfaces of the hand. D: The hand was temporarily stabilized to the groin with the use of an external fixator. E: The appearance of the hand following flap division and insetting.
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Upper Extremity Reconstructive Pearls

For free flap options, our preferred flaps for soft tissue reconstructions of the forearm are the ALT flap and the scapular flap. If bone is required, the fibular osteocutaneous flap is a good match for the radius or ulna. Flaps based on the subscapular or thoracodorsal system and taken with rib are also very versatile for the reconstruction of smaller bony defects.112,153,174,222,321 
Musculocutaneous flaps such as the latissimus dorsi and rectus abdominis flaps result in functional loss and donor site morbidity including, particularly in the abdomen, the potential for hernia formation. In addition, in the coverage of joint surfaces, muscle flaps tend to undergo fibrosis and atrophy over time, which may limit joint excursion, particularly when they are placed over the elbow or the dorsum of the hand. Muscle is still indicated for those circumstances involving osteomyelitis or soft tissue contamination. 

Postoperative Care and Monitoring of Patients after Flap Transfer

Free flap success is not always guaranteed at the completion of the case, as 5% to 25% of transferred flaps require re-exploration for microcirculatory compromise, which can be caused by arterial or venous thrombosis.34,46,180 Free flap salvage rates after thrombosis range from 42% to 85%.46,193 Early recognition of vascular compromise has been shown to provide the best chance of successful flap salvage.46,145,302 
Methods for monitoring free tissue transfers have advanced from clinical observation to implantable Doppler probes. The best method for monitoring has yet to be established. Clinical observation of the nonburied free flap remains the gold standard to which monitoring systems are generally compared.83 Monitoring devices should ideally be sensitive enough to supersede clinical evidence of vascular thrombosis but specific enough to avoid unnecessary re-exploration. Here we review the current literature regarding monitoring methods and protocols. 

Conventional Flap Monitoring Methods

Clinical Observation

In clinical observation, the flap is observed by assessing capillary refill, temperature, swelling, and flap color. Its use is confined to monitoring surface skin flaps and is less reliable in the monitoring of muscle flaps and buried flaps.83 Capillary refill can be assessed by simply applying deep pressure to the transferred tissue using one’s finger or the flat end of a surgical instrument and then releasing the pressure and evaluating capillary refill time, which is commonly 2 to 3 seconds. With increasing disturbance of the blood supply, a livid bluish discoloration (shortened capillary refill of less than 2 seconds) or paleness of the flap (delayed capillary refill of greater than 3 seconds) appears in a venous congested or ischemic flap, respectively. When these criteria cannot be reliably assessed or for confirmation, one may then use the pin prick test. 
It is important to remember that for clinical observation to be effective, the person performing flap evaluation needs to be educated with regard to the signs of flap failure. Nursing units and new house staff members require annual in-service education to improve their diagnostic acumen, as these two groups are in constant flux in most medical centers. 

Pin Prick Testing

The pin prick test is commonly used on flaps with a cutaneous component. The test is performed by puncturing the cutaneous paddle of the flap with a 24- or 25-gauge needle. The puncture should not be too deep into the tissue, and it should be in a portion of the flap that is not in close proximity to the vascular pedicle and microanastomosis. An indicator of flap viability is a stream of continuous bright red blood upon puncture. A congested flap will produce a continuous stream of dark venous blood. Care should be taken not to perform this test too frequently, particularly in patients on anticoagulants, because repeated puncture trauma may lead to a bruised flap, which may hinder further evaluation of the tissue. This test is certainly the least expensive of the various methods of flap monitoring. 

Surface Temperature Monitoring

A difference of greater than 3°C between the surface temperature of the flap and the adjacent skin is associated with arterial compromise and a difference of between 1°C and 2°C is more indicative of venous compromise. A simple liquid crystal temperature probe may be placed on the flap tissue with a second probe placed on the adjacent normal skin. Temperature changes in flaps such as toe flaps placed on an extremity will be more accurate than flaps placed on the trunk, where the flap temperature may be a direct reflection of the body part on which it is placed. 

Hand-held Doppler Ultrasonography

Currently, there is no single adjunctive monitoring technique widely accepted as the method of choice, but ultrasonography with a hand-held Doppler (5 to 8 MHz) device is the most common technique in use.290,314,345 Its most important limitation is differentiating between the recipient vessels and the flap’s vascular pedicle because of their potential close proximity. A clinician may detect the Doppler signal of the recipient vessels instead of the signal from the flap’s vascular pedicle, which may mislead the observer into believing that the flap’s pedicle is patent when in reality a thrombosis has occurred. This limitation may be overcome by performing a Doppler ultrasound examination of an arterial signal within the flap tissue intraoperatively and then simultaneously compressing the donor (flap) artery to ensure that this is a true artery within the flap. Upon compression of the donor (flap) artery there should be loss of the arterial ultrasonic signal within the flap. 
Hand-held Doppler ultrasonography is also an effective method of determining the status of the vein of a flap. The Doppler signal of a vein is detected intraoperatively after flap revascularization and a suture may be placed to mark it. The venous sound is at times difficult to detect but, when heard, it is a clear indication that the vein is patent. When a venous signal is detected, the flap can be compressed and a “venous augment” sound should be heard. 

Implantable Doppler Ultrasonography

The implantable Doppler device can measure blood flow across a microvascular anastomosis and is an effective tool to monitor flap perfusion and improve salvage rates, especially in buried flaps.72 Initial research demonstrated a 3% false-positive rate, which led to unnecessary re-explorations, and a 5% false-negative rate when the probe was placed on the artery.326 Further, up to a 5-hour delay was found between a venous obstruction and the loss of the arterial signal in large muscle flaps. Best results occur if an implantable probe is placed on the vein instead of the artery allowing the detection of venous obstruction immediately followed by the detection of arterial thrombosis. 

Pulse Oximetry

The pulse oximeter consists of two light-emitting diodes that transmit two separate wavelengths of visible red (660 nm) and infrared (940 nm) light and a photodiode receiver. It can distinguish the difference in light absorption between oxyhemoglobin and reduced hemoglobin and thereby measure oxygen saturation. By the way of photoplethysmography, the oximeter can identify pulsatile flow and will therefore provide a continuous display of both the pulse rate and arterial saturation. This is an excellent monitor for replanted and revascularized digits and toe-to-hand transfers.121 

Laser Doppler

Light from a helium neon laser of uniform wavelength will penetrate 1.5 mm below the surface of the flap, and this light is reflected by the red blood cells moving within the capillaries enclosed within a 1-mm3 volume of tissue. The frequency shift between the transmitted and reflected light is directly proportional to the velocity of capillary blood flow. This flow value provides an objective measurement of flap perfusion. Laser Doppler interpretation requires experience, as values differ depending on tissue type and patient. Furthermore, perfusion readings may fluctuate for any given patient because of physiologic microcirculation variation or artifacts. Therefore, the observer must monitor the trend rather than the absolute values. This method is limited to monitoring cutaneous circulatory phenomena, as the probe only penetrates 1.5 mm into the flap. Estimated sensitivity and specificity values have been reported at 93% and 94%, respectively, and this technique has been found to be superior to thermometry when used alone for the evaluation of replantations.148 

Authors’ Preferred Method

 
 

How often and for how long flap monitoring should be performed has been debated, but most series recommend a minimum of hourly monitoring for the first 24 to 48 hours after surgery.146,193 The majority (greater than 80%) of vascular complications occur within the first 48 to 72 hours postoperatively. Postoperative venous thrombosis is the most common vascular complication.193 With these factors in mind our current recommendations for flap monitoring include the following.

  1.  
    Placement of an implantable venous Doppler probe when feasible.
  2.  
    Flap inspection every hour by experienced nursing staff for first 48 hours, moving to every 2 hours for the next 24 hours.
  3.  
    Discontinuation of flap monitoring after day 4, unless there are extenuating circumstances.

Anticoagulation Considerations in Free Flap Surgery

Ninety-six percent of reconstructive surgeons use some type of anticoagulation regimen after free tissue transfer, and in pedicled flap reconstruction the frequency of use is dependent on its vascular supply.70,117 Unfortunately, there is no consensus on anticoagulation therapy after free tissue transfer, and a full discussion of all pertinent studies pertaining to postoperative anticoagulation is beyond the scope of this chapter. It is sufficient to say that scientific findings are often clouded by anecdotal experience. The three most common anticoagulants in use are aspirin, heparin, and dextran. 
Aspirin, through its activity on the cyclooxygenase pathway, decreases the production of thromboxane and prostacyclin, both of which are powerful platelet aggregators. Aspirin’s effectiveness in decreasing macrovascular graft occlusion has been clearly demonstrated in several studies.15,60 The effective dose of aspirin to inhibit thromboxane while preserving some of the provasodilatory effects of prostacyclin function is relatively low, within the range of 50 to 100 mg per day.58,61,358 Despite its use postoperatively to prevent thrombosis, aspirin’s most beneficial effect may be when it is given several hours before surgery. The administration of aspirin 10 hours before surgery has been shown to result in a significant increase in vessel patency and a decrease in platelet aggregation.288 
Heparin has been shown to provide a beneficial effect on anastomotic patency in animal models.124 Large prospective randomized human trials are not yet in existence. Hematoma formation with the potential for flap loss has been linked to full systemic postoperative anticoagulation. In Pugh’s retrospective study, the incidence of hematoma formation after lower-leg reconstruction and systemic anticoagulation with heparin was 66%.272 The use of subcutaneous heparin or low-molecular-weight heparin (LMWH) is warranted for prevention of deep venous thrombosis, while also providing a benefit with regard to vessel patency. Khouri et al.180 found, in the largest multicenter prospective free flap tissue study, that only postoperatively administered subcutaneous heparin had a statistically significant effect on the prevention of postoperative free flap thrombosis. 
The combination of subcutaneous heparin and low-dose aspirin has been shown to produce no increase in the rate of postoperative hematoma formation. In our opinion, this combination of drugs provides a safe and economical means of providing thrombosis prophylaxis for routine free flap procedures. This combination therapy also provides the benefits of coronary protection and deep venous thrombosis prophylaxis.57 Subcutaneous heparin does not require monitoring of coagulation factors, and both medications may be given without intravenous access. LMWH also provides the benefits of higher bioavailability, a longer plasma half-life, and a steady dose-response curve and it causes fewer cases of hematoma formation and thrombocytopenia when compared with unfractionated heparin.13 
Finally, dextran, like heparin, has shown benefit in improving patency rates in the immediate postoperative period when given as a single preoperative bolus289,381; however, the effectiveness of prolonged administration is debatable.270,285,287 An increasing number of reports have noted significant morbidity associated with the use of dextran and have questioned its use in routine microsurgical cases.135,137 Complications from dextran administration can include renal failure, congestive heart failure, myocardial infarction, pulmonary edema, pleural effusion, and pneumonia. 
Because flap failure rates are so low, large prospective randomized multicenter trials will be necessary to definitively decide which anticoagulation therapy is the most effective in preventing postoperative flap thrombosis. Until that time we feel that a combination of low-dose aspirin and subcutaneous or low-molecular-weight heparin provides adequate flap protection with minimal associated morbidity and little additional cost. 

Hemodynamic Management

Effective medical management of all patients with flaps will improve flap survival and prevent morbidity and mortality. From a cardiac standpoint, surgical patients with coronary artery disease or risk factors for coronary artery disease who undergo tissue transfer surgery should undergo an appropriate evaluation by their cardiologist or internist before surgical intervention. The administration of beta-blockade with Atenolol has been shown to have reduced cardiovascular complications and mortality for up to 2 years in this patient population.223 Hyperglycemia associated with relative insulin resistance or diabetes has been reported to increase the incidence of complications in the surgical patient.97,247 For this patient population, intensive insulin therapy to maintain blood sugar levels between 80 and 110 mg/dL has been shown to substantially reduce morbidity and mortality from 8% to 4.6%.346 
Patients must also have adequate intravenous fluid hydration in the perioperative period, and commonly a Foley catheter will be used to record and maintain a urine output of at least 50 cm3/hour. In our institution, patients commonly are given nothing by mouth until the morning after surgery in the event reoperation is necessary. Hematocrit levels are kept at greater than 30% in patients with coronary artery disease and greater than 25% in those without it. 

Flap Failures and Management

Despite our greatest efforts in reconstructive microsurgery, flap failure will occur. The failure can be partial or complete. It is important to recognize the cause of flap failure so it may be reversed or prevented in the next reconstructive attempt. Arterial insufficiency leading to flap complications can be recognized by decreased capillary refill, pallor, reduced temperature, and the absence of bleeding on pin prick testing. This complication can result from arterial spasm, vessel plaque, torsion of the pedicle, pressure on the flap, technical error with injury to the pedicle, a flap harvested that is too large for its blood supply, or small vessel disease secondary to diabetes or smoking. If pharmacologic agents do not relieve spasm at the level of arterial inflow, the vessel anastomosis should be redone. 
Venous outflow obstruction can be suspected when the flap has a violaceous color and brisk capillary refill, and dark blood is seen after pin prick. Venous obstruction can occur as a result of flap edema, hematoma, tight closure over the pedicle, or pedicle torsion. Venous compromise will lead to microvascular thrombi, which will then compromise arterial flow if not promptly addressed.239 Conservative treatment in the acute phase, besides pharmacologic therapy as discussed, may include drainage of an underlying hematoma with suture release to decrease the pressure. Leeches may also be helpful if sufficient venous outflow cannot be established despite a patent venous anastomosis. The leeches work by biting the venous congested tissue and extracting blood via direct suction and injecting hirudin, a potent anticoagulant present in their saliva. Aeromonas hydrophila is an important microbe present in the leech, and prophylactic antibiotics (usually a second- or third-generation cephalosporin or an aminoglycoside or fluoroquinolone) must be given when patients are undergoing leech therapy.71,236 Because of blood loss from the therapy, it is also important to check serial hemoglobin levels and have the patient typed and cross-matched for blood transfusion at all times. 
Nonviable flaps should be debrided promptly as they may serve as a source of infection in an already compromised limb. The timing of removal is dependent on the recipient bed on which it was inset. Scarred, radiated, or dysvascular wound beds only provide minimal blood supply to the overlying flap tissue; therefore, upon flap compromise more flap tissue is lost.293,357 If a second free flap is considered, obvious errors that led to the original flap compromise need to be recognized and avoided. 

Nerve Reconstruction

Nerve Injuries Associated with Fractures

Much of our modern understanding of the treatment of acute nerve injuries comes from the works of Seddon,301 which stemmed from the treatment of World War II patients. Seddon introduced a simple classification of traumatic nerve injuries: Neurapraxia, which was minimal injury with localized ischemic demyelination of the nerve; axonotmesis, characterized by interruption of the axons and their myelin sheath with the endoneurial tubes remaining intact; and neurotmesis, which is a completely severed nerve or one that is so seriously disorganized that spontaneous regeneration is impossible. Sunderland325 in 1951 proposed a five-level classification that related to the internal structure of the nerve; however, it relied on pathologic examination of the nerve, which is quite impractical in the trauma setting. 
The treatment of the injured nerve is dependent on the type of injury to it (neurapraxic, axonotmetic, and neurotmetic), the time from the injury, the soft tissue bed quality, the defect size if the nerve is transected, and associated nerve/muscle injuries. In acute fractures with nerve injury, there is tremendous debate on whether to explore or observe. Depending on the energy of the trauma, the decisions may vary. In particular, debate continues regarding treatment of radial nerve injury associated with distal humeral fractures (see Chapter 36).73,88,89,90,101,136,152,160,181,198,215,275,281,305,310,311 Generally in acute closed fractures, observation of the nerve injury with serial examination for 3 to 6 months should be undertaken. If no recovery is seen, electrodiagnostic testing should be considered as early as 6 weeks after injury. If no improvement is observed by 4 to 6 months, exploration with interposition nerve grafting or alternatively nerve transfers should be considered. 
In injuries where the nerve is obviously sectioned with a high degree of trauma (i.e., not a sharp laceration) with associated soft tissue injuries, the nerve ends should be tagged and the soft tissue and bone injury addressed. The greatest challenge is the determination of the zone of injury of the nerve.76,77,94,218,333,348 If acute nerve grafting is to be performed, resecting the injured portion is imperative. Unfortunately, intraoperative assessment by histologic section, touch, or visualization of the injured nerve cannot inform us of the zone of injury. Delay of a few weeks allows the development of intraneural fibrosis, and allows tactile and pathologic visualization of the zone of injury; however, the scarred tissues make the surgical reconstruction more difficult. If acute soft tissue reconstruction is performed, and a delayed nerve reconstruction is planned, the surgeon should consider placing the nerve to be reconstructed in a location where it can be easily accessed. Finally, if more than 6 to 12 months pass between injury and reconstruction, tendon transfers or free functioning muscle transfers should be considered as there is a time dependent, irreversible degradation of the motor endplate that occurs after motor nerve injury.309 

Brachial Plexus Injuries

Treatment recommendations for complete nerve root avulsions have varied widely over the past 50 years, and the results of treatment have ranged from fair to dismal. After World War II, the standard approach was surgical reconstruction by shoulder fusion, elbow bone block, and finger tenodesis.140 In the 1960s, transhumeral (above elbow) amputation combined with shoulder fusion in slight abduction and flexion was advocated.100 Yeoman and Seddon noted the tendency for injured patients to become “one-handed” within 2 years of injury, which led to a dramatic reduction in successful outcomes regardless of the treatment approach. Their retrospective study revealed no good results from the primitive surgical reconstruction of that era, but predominantly good and fair outcomes when amputation plus shoulder fusion were performed within 24 months of injury. They also noted that the loss of glenohumeral motion caused by brachial plexus injuries limited the effectiveness of body-powered prostheses and that manual laborers seemed to accept hook prostheses much more readily than did office workers with similar injuries. Although these observations remain valid today, there have been advances in brachial plexus reconstruction that have yielded outcomes superior to the historical results. A better understanding of the pathophysiology of nerve injury and repair, as well as the recent advances in microsurgical techniques, have allowed reliable restoration of elbow flexion and shoulder abduction in addition to useful prehension of the hand in some cases. The specific treatment of these injuries is beyond the scope of this chapter; however, there are multiple modalities, including nerve grafting, nerve repair, nerve transfers, tendon transfers, and free tissue transfers that can be used to improve function and outcome.20,40,252 

Recent Advances in Reconstructive Surgery of the Extremities

Aesthetic Improvements in Reconstructive Surgery of the Extremities

As with any reconstructive surgical procedure, the goal is to restore form and function. In some areas of the body, the priority of improving the aesthetic outcome of the procedure is higher than others. Clearly, when reconstructing a facial defect, this becomes a high focus of the reconstruction. With advancements in the understanding of flap anatomy, major advancements have been seen in the aesthetic refinements that can be achieved when reconstructing defects in the extremities as well.273 Improvements in aesthetic outcomes come at two stages in the reconstruction. The first is during the initial reconstructive procedure, when a flap is chosen to meet the functional needs at the recipient site and to achieve a reasonable aesthetic outcome. Choosing a flap that has qualities that match the recipient site, such as color, thickness, and pliability is important. Primary flap thinning can be performed in the operating room to achieve the best aesthetic outcome in the initial setting. The second stage is carried out with the use of additional surgical procedures to refine flap shape; several months after the initial procedure, secondary procedures may be performed, such as flap debulking through direct excision or liposuction364 or even using the arthroscopic shaver device,330 flap advancement, and serial excision of the flap.306 Workhorse flaps in reconstructive surgery that are thin include the radial forearm flap, the lateral arm flap, and many of the discussed perforator flaps. In addition, depending on the needs at the recipient site, fascia flaps covered with skin grafts often produce aesthetically and functionally good results. These flaps include the temporoparietal fascia flap,282 the posterior rectus sheath flap,292 the lateral arm fascia flap,323 as well as the ALT fascia flap.150 
Another important concept in improving aesthetics in reconstructive surgery is tissue expansion. This tool has been used in both upper and lower extremity reconstructions.129,130 The flap is expanded before harvest and transfer to the defect site.133,334 Alternatively tissue expanders can be used to expand the tissue surrounding a defect to provide additional tissue to help in reconstruction, minimizing flap requirements. After acute reconstruction, if the patient is unhappy with the shape or color of the flap, tissue expanders can be placed around the flap, under the normal skin of the extremity, and once expansion is complete the flap can be excised, with the native expanded local skin used to cover the resultant defect. Tissue expansion is associated with complications including infection and implant extrusion, and is usually not recommended in cases of acute reconstruction of contaminated wounds. 
Endoscopic harvest and minimally invasive dissection of flaps provide another refinement in reconstructive surgery,291 the benefit of which has not been fully used at this point. Endoscopic technique now allows for the successful harvest of flaps such as the latissimus dorsi,240 the rectus abdominis,213 the gracilis, the temporoparietal fascia flap,56 and others. It is also used in harvesting vein grafts and nerve grafts which are often used in reconstructive surgery.209 Comparative studies between open and endoscopically assisted muscle harvest have found patients to have less donor site pain and shorter scar lengths after endoscopic harvest.211 

Perforator Flaps and Free Style Flaps

One of the most significant advancements in limiting donor site morbidity has been the advent of perforator flap surgery. Whereas the muscle was always thought to be a necessary carrier of the blood supply in musculocutaneous flaps, perforator flaps are performed by harvesting the skin and subcutaneous tissue, with a variety of tissue components, while preserving the muscle at the donor site. The skin and subcutaneous tissue are elevated and a large perforator is found. This perforator is then dissected from the surrounding muscle and traced to the origin vessel. The flap is harvested while the muscle is left intact. The remaining muscle is supplied through its secondary blood supply, and innervation of the muscle is maintained by preserving the nerves in the region. Functionally, the patient experiences minimal donor site morbidity. The blood supply to the flap is through a perforator that is clearly visualized intraoperatively, with its anatomic basis as has been studied through anatomic dissections.344 Hence the flap can be thinned during the initial reconstructive procedure, preserving the perforator, to provide a nicely contoured flap without the need for a second surgery to thin the flap.75 Preoperative planning with the aid of CT and ultrasound to identify perforating blood vessels can improve surgical success.28,42,116,128 Once the surgeon’s skill in microsurgical techniques and flap dissection has reached a high level, one can perform microdissection of a perforator, which allows a detailed visualization of the arterial anatomy of the flap, eventually allowing for aggressive and accurate thinning of that flap.92,183,184,369 
Commonly used perforator flaps include the deep inferior epigastric perforator (DIEP) flap based on the deep inferior epigastric artery (DIEA), the ALT flap, the thoracodorsal artery perforator (TAP) flap,8 and the gastrocnemius perforator flap.127 As previously discussed, the most commonly used perforator flap is the ALT perforator flap because of its versatility and the ability to include a variety of structures as well as the ability to thin and tailor the flap to fit the defect.376 Harvest of the ALT flap has previously been described in this chapter in the section entitled “Lower Extremity Reconstructive Options.” 

Deep Inferior Epigastric Perforator Flap

The DIEP flap is an abdominal flap based on a single or multiple transmuscular perforators originating from the DIEA. The DIEA originates from the external femoral artery and then travels superomedially in the extraperitoneal tissue and subsequently pierces the transversalis fascia. The DIEA then enters the rectus sheath and usually divides into a lateral and medial branch which gives off perforators which pierce the rectus muscle to supply the overlying skin and subcutaneous tissue. The DIEP flap is used extensively for breast reconstruction. However, it can also be used for extremity reconstruction as it allows a large skin paddle measuring on average 34 × 13 cm to be harvested. The flap is harvested with the patient supine, and is usually designed as an ellipse extending over the infraumbilical region of abdomen from one anterior superior iliac spine to the other. Preoperative identification and marking of major perforators using a Doppler probe, CT, or MRI angiography are useful adjuncts to aid perforator dissection. 

Lateral Thoracic Perforator Flaps

Perforator flaps in the lateral thoracic region were developed as an attempt to utilize the skin over the lateral thoracic region without the requirement for harvesting the underlying latissimus dorsi muscle, therefore reducing the bulk of the flap and obviating sacrifice of the latissimus dorsi muscle. Three distinct rows of perforators supply the skin of the lateral thoracic region. The most anterior row usually consists of direct cutaneous perforators, and originates from the lateral thoracic vessels, usually found on the serratus anterior muscle at the lateral border of the pectoralis major muscle. The middle row consists of septocutaneous perforators from the thoracodorsal system and the posterior row consists of musculocutaneous perforators through the latissimus dorsi muscle. When harvested off perforators from the lateral thoracic vessels, the flap is termed a lateral thoracic perforator flap; when harvested off the middle row it is called a TAP flap; and when harvested off the posterior row it is called a latissimus dorsi perforator flap. Flaps in this region have the advantage of reduced donor site morbidity, with flap harvest leaving a small linear scar. In addition, the flap is thin, providing supple tissue for limb resurfacing. Furthermore, composite flaps consisting of muscle and/or bone can be harvested with skin and subcutaneous tissue off the subscapular artery system. Disadvantages are an inconsistent perforator anatomy, which can make the learning curve for flap harvest steep. In addition, for female patients, harvest of a large flap may cause deviation and deformity of the breast. 

Free Style Flaps

Free style flaps have been proposed by Wei and Mardini,354 and greatly increase the repertoire of the reconstructive surgeon. Instead of harvesting a flap off a named axial vessel, the flap is based on a perforator in any area of the body, which is usually detected with the aid of the Doppler probe. Retrograde dissection until a pedicle of sufficient length is obtained allows utilization as a local or free flap. Typically these flaps are harvested as skin and subcutaneous only flaps in the suprafascial or subfascial plane. The donor site is matched to the recipient site such that tissue which most closely approximates the recipient site in terms of thickness, color, and texture is harvested. In the extremities, these flaps have particular application as local flaps utilized in a propeller flap fashion, or as small free flaps used for resurfacing of areas such as the digits of the hand. 

New Modalities for Soft Tissue Coverage

Artificial Skin

The role of artificial skin has advanced significantly over the past 15 years; materials are now available which can provide a scaffold for the ingrowth of fibroblasts and blood vessels over avascular or minimally vascularized structures such as tendon and bone. Integra dermal regeneration template (Integra Life Sciences, Plainsboro, NJ) was initially developed in the late 1980s as a means of facilitating burn wound management.36,371 More recently, the indications for this material have been extended to include the treatment of acute and chronic traumatic wounds (Fig. 15-22).138,243,349 
Figure 15-22
The application of Integra can allow for skin grafting to be performed over wounds previously requiring flap coverage.
 
A: This 32-year-old man sustained an extensive degloving injury to the dorsum of his hand. Integra was applied over the exposed tendons and then VAC therapy was instituted for 14 days. B: After the establishment of a neodermis, the Integra was covered with a split-thickness skin graft providing stable and functional coverage of the hand.
A: This 32-year-old man sustained an extensive degloving injury to the dorsum of his hand. Integra was applied over the exposed tendons and then VAC therapy was instituted for 14 days. B: After the establishment of a neodermis, the Integra was covered with a split-thickness skin graft providing stable and functional coverage of the hand.
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Figure 15-22
The application of Integra can allow for skin grafting to be performed over wounds previously requiring flap coverage.
A: This 32-year-old man sustained an extensive degloving injury to the dorsum of his hand. Integra was applied over the exposed tendons and then VAC therapy was instituted for 14 days. B: After the establishment of a neodermis, the Integra was covered with a split-thickness skin graft providing stable and functional coverage of the hand.
A: This 32-year-old man sustained an extensive degloving injury to the dorsum of his hand. Integra was applied over the exposed tendons and then VAC therapy was instituted for 14 days. B: After the establishment of a neodermis, the Integra was covered with a split-thickness skin graft providing stable and functional coverage of the hand.
View Original | Slide (.ppt)
X
The material is bilayered, consisting of a deep layer of a collagen glycosaminoglycan biodegradable matrix and a superficial semipermeable silicone layer. The deep layer allows for the ingrowth of native fibroblasts. Fibroblasts can form a “neodermis” upon the collagen scaffold, which is similar in appearance to normal dermis.242,320 This neodermis can then support a thin split-thickness skin graft. The silicone layer prevents desiccation during the ingrowth period and it is removed before the application of a skin graft. Major contraindications to the use of this material include ongoing infection and open fractures exposed within the wound. 
Helgeson described the use of Integra in conjunction with skin grafting in 16 combat-related soft tissue wounds. The average wound size was 87 cm2. Eleven wounds contained exposed tendon and five wounds had exposed bone devoid of overlying periosteum. Integra application was combined with overlying VAC therapy for an average of 19 days before the application of a split-thickness skin graft to the wounds. Treatment was successful in 83% cases. Failure was associated with the application over cortical bone.138 
Acceleration of fibroblast ingrowth can be accomplished with the use of fibrin glue for fixation of the Integra and subsequent VAC therapy. In a retrospective review, Jeschke et al. found the use of fibrin glue and VAC therapy improved the “take rate” of split-thickness skin grafts from 78% to 98% and shortened the time to skin grafting. The overall hospital stay was also decreased.166 
The use of the VAC and Integra has led to a decrease in the need for flap coverage for many traumatic wounds.263 Despite this trend, the surgeon should exercise restraint in trying to apply these technologies to exposed bone, tendon, and large defects. Pedicled flaps and free tissue transfer provide reliable solutions to even the largest soft tissue defects, and should be considered the standard of care until formal comparative outcome studies are available to assess functional outcome and long-term consequences of these newer reconstructive technologies. 

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