- See:
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Arteriography:
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Foot Reconstuctive Surgery:
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Microanastomosis:
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Pharmocological Agents in Vascular Surgery:
- Soft Tissue Coverage Following Tibial Frx: (
Tibia Frx)
- STSG;
- split thickness skin grafts require a tissue bed such as periosteum that is capable of granulating;
- skin graft will not take exposed bone stripped of its periosteum;
- mechanical closure techniques:
- references:
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The shoelace technique for wound closure in open fractures: report of early experience.
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The "rubber band technique": a simple method for closing large skin defects.
- multiple relaxing incisions:
- technique involves creation of multiple 5-10 mm incisions (made w/ 15 blade scapel) thru the dermis made in
1 cm wide rows parallel to the wound (w/ the initial MRI made 1 cm from the wound;
- the number of rows of relaxing incisions depends on the tightness of soft tissue;
- w/ in 3 weeks the relaxing incisions heal by contraction;
- this technique was demonstrated to be effective in 22 patients w/ lower extremity orthopaedic trauma;
- there were no skin sloughs or wound infections;
- technique can also be used to close fasciotomy incisions;
- relative contra-indication: degloving injuries and possible tranverse wounds;
- references:
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Multiple Relaxing Skin Incisions in Orthopaedic Lower Extremity Trauma.
A.J. DiStasio, T.W. Dugdale, and M.K. Deafenbaugh.
J. Orthop. Trauma. 1993. Vol 7. No 3. p 270-274.
- wound VAC;
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The use of a subatmospheric pressure dressing to salvage a Gustilo grade IIIB open tibial fracture with concomitant osteomyelitis to avert a free flap.
- Wound Bullet
- fasciocutaneous flaps:
- Distally-based random fasciocutaneous flaps for multi-staged reconstruction of defects in the lower third of the leg, ankle and heel.
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Distally-based random fasciocutaneous flaps for one-stage reconstruction of defects in the upper two-thirds of the leg.
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Distal lower leg local random fasciocutaneous flaps.
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Local fasciocutaneous flaps for cutaneous coverage of lower extremity wounds.
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Perforator based flap coverage from the anterior and lateral compartment of the leg for medium sized traumatic pretibial soft tissue defects--a simple solution for a complex problem.
- local muscle flaps;
- wounds located over the proximal third of tibia can usually be covered with local muscle flaps;
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gastrocnemius Flap
- anterior and medial surfaces of tibia usually can be covered w/ medial head of the
gastrocnemius muscle;
- lateral defects are best covered with a lateral gastrocnemius muscle.
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soleus flap:
- reserved for defects in the middle third of leg;
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dorsalis pedis fasciocutaneous flap:
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tibialis anterior flap:
- ref:
The tibialis anterior used as a local muscle flap over the tibia after soft tissue loss.
- in the report by Tunç Cevat Ögün, MD et al., the authors report on a distally based superficial sural artery flap,
first described as a distally based neuroskin flap by Masquelet et al., is a skin island flap supplied by
the vascular axis of the sural nerve;
- it has the largest arc of rotation of all flaps that have been described in this region;
- most important advantage is that it does not compromise a major artery;
- it is simple to dissect and has a low donor morbidity;
- the authors reported our experience with this new flap in 15 cases and also described a new
indication for the patients with neglected ruptures of the Achilles tendon;
- in 13 patients, the flap was successfully transferred;
- in two cases, partial necrosis of the flap ensued, which healed with secondary intention;
- ref: An Easy and Versatile Method of Coverage for Distal Tibial Soft Tissue Defects.
Tunç Cevat Ögün, MD et al.
J Trauma 2001 January;50(1):53-59
- free tissue transfer:
- used for massive defects that cannot be covered by local muscle in middle and proximal thirds of leg
or enlarged defects in distal third of leg;
- in the report by AN. Pollak M.D et al. (JBJS 82-A: 1681-91, 2000), 190 patients (195 limbs) required flap
coverage and had six months of follow-up;
- the authors found that use of a free flap to treat limbs with a severe underlying osseous injury was
significantly less likely to lead to a wound complication requiring operative intervention than was use of
a rotational flap. (JBJS 82-A: 1681-91, 2000) Quick Access Outline
- common choices:
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epigastric and rectus abdominis flap:
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latissimus dorsi
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gracilis
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dorsalis pedis fasciocutaneous flap
- early coverage of soft-tissue deficits of the extremity is indicated in order to minimize infection risk, promote
vascularization of underlying bone, and prevent dessication of exposed tissues;
- Prognosis: (following free flap coverage);
- long term free flap survival can be expected in about 85% of patients;
- ultimate result depends on obtaining frx union and a non-draining wound;
- about 20% will end up undergoin BKA;
- when infection deep infection is present, drainage may persist for over 1 year;
- references:
Late Functional Outcome in Patients with Tibial Fractures Covered with Free Muscle Flaps.
R.T. Laughlin, K.L. Smith, R.C. Russell, and J.M. Hayes. J. Orthop. Trauma 1993. Vol 7. No 2. p 123-129.
Microvascular Soft-Tissue Transplantation for Reconstruction of Acute Open Tibial Fractures: Timing of Coverage and Long-Term Functional Results.
Distally-based random fasciocutaneous flaps for multi-staged reconstruction of defects in the lower third of the leg, ankle and heel.
Muscle flap transposition for traumatic soft tissue defects of the lower extremity.
Lentz MW.
Noyes FR.
Neale HW.
Clinical Orthopaedics & Related Research.
(143):200-10, 1979 Sep.
The reversed fasciosubcutaneous flap in the leg [see comments.
Muscle transposition in lesions of the ischemic leg.
Skin Island Flaps Supplied by the Vascular Axis of the Sensitive Superficial Nerves: Anatomic Study and Clinical Experience in the Leg.
Preferential Use of the Posterior Approach to Blood Vessels of the Lower Leg in Microvascular Surgery.
The Muscle Flap in the Treatment of Chronic Lower Extremity Osteomyelitis: Results in Patients Over 5 Years After Treatment.
Management of ulcers of the leg by muscle transposition.
Muscle transposition for treatment and prevention of chronic post-traumatic osteomyelitis of the tibia.
Use of the Osteocutaneous Free Scapular Flap on the Lower Extremities.
Distal lower leg local random fasciocutaneous flaps.
Local fasciocutaneous flaps for cutaneous coverage of lower extremity wounds.
The Vasculature and Clinical Application of the Posterior Tibial Perforator-Based Flap.
Free-Tissue Transfers for Limb Salvage Utilizing in Situ Saphenous Vein Bypass Conduit as the Inflow.
Transfer of Vascularized Grafts of Iliac Bone to the Extremities.
Peroneal island flap for skin defects in the lower extremity.
The role of non-invasive vascular studies in determining levels of amputation.
Free-Tissue Transfers for Limb Salvage Utilizing in Situ Saphenous Vein Bypass Conduit as the Inflow.
Efficacy of epidural anesthesia in free flaps to the lower extremity.
Primary versus delayed soft tissue coverage for severe open tibial fractures. A comparison of results.
Acute and definitive management of traumatic osteocutaneous defects of the lower extremity.
Yaremchuk MJ, Brumback RJ, Manson PN, et al: Plast Reconstr Surg 1987;80:1-14.
Early microsurgical reconstruction of complex trauma of the extremities.
The Timing of Flap Coverage, Bone-Grafting, and Intramedullary Nailing in Patients Who Have a Fracture of the Tibial Shaft With Extensive Soft-Tissue Injury.
Anatomic Basis of Local Muscle Flaps in the Distal Third of the Leg.
Primary or delayed closure for open tibial fractures.
Distally-based random fasciocutaneous flaps for multi-staged reconstruction of defects in the lower third of the leg, ankle and heel.
Free tissue transfer for type III tibial fractures. Microsurgery in 19 cases.
The management of open tibial fractures with associated soft-tissue loss: external pin fixation with early flap coverage.
Postoperative course of patients treated with iliac osteocutaneous free flaps. A two- to five-year follow-up study.
The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury.
Primary versus delayed soft tissue coverage for severe open tibial fractures. A comparison of results.
Free tissue transfer for type III tibial fractures. Microsurgery in 19 cases.
Distally-based random fasciocutaneous flaps for one-stage reconstruction of defects in the upper two-thirds of the leg.
Distal lower leg local random fasciocutaneous flaps.
Local fasciocutaneous flaps for cutaneous coverage of lower extremity wounds.
Microvascular Soft-Tissue Transplantation for Reconstruction of Acute Open Tibial Fractures: Timing of Coverage and Long-Term Functional Results.
Use of the soleus muscle flap to cover part of the distal tibia.
Wright JK, Watkins RP:
Plast Reconstruct Surg 1981;68:957.
Acute and definitive management of traumatic osteocutaneous defects of the lower extremity.
Yaremchuk MJ, Brumback RJ, Manson PN, et al:
Plast Reconstruct Surg 1987;80:1-12.
Free tissue transfer to the lower extremity.
Rotation fasciocutaneous flap repair of lower limb defects.
