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Lower Extremity Reconstruction. Dale Reynolds, MD UTHSC Houston Plastic and Reconstructive Surgery. LE Trauma. Introduction Formidable Multiple injuries Airbags do not help MVC, falls, sports Salvage previously amputated. LE Trauma. Introduction

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Lower extremity reconstruction l.jpg
Lower Extremity Reconstruction

  • Dale Reynolds, MD

  • UTHSC Houston

  • Plastic and Reconstructive Surgery


Le trauma l.jpg
LE Trauma

  • Introduction

    • Formidable

    • Multiple injuries

    • Airbags do not help

    • MVC, falls, sports

    • Salvage previously amputated


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LE Trauma

  • Introduction

    • Mangled LE may require multiple procedures and years to RTW

      • Francel: 72 patients (IIIB)

        • 93% salvage 28% RTW @42 mo

          • Longer to weight bear

          • Less willing to RTW

          • Higher hospital charges

        • 7% BKA 68% RTW @42 mo

      • Bellvue 128 patients, 66 had 5 year follow-up

        • 60 % RTW (up to 10 years)


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LE Trauma

  • History

    • Hippocrates (400 BC) described amputation for gangrene

    • Celsus (5 BC) wound management with removal of FB and hemostasis

    • Ambroise Pare (1540) described basic principles of amputation still used today

      • Phantom pain

      • Stump revision


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LE Trauma

  • History

    • Pierre-Joseph Desault (1770) coined “debridement”

    • Incidence of post treatment osteomyelitis 80% WWI  25% WW II (Abx / aseptic technique)

    • Korean War 62% amputation  artery repair  13%

    • Plastic Surgery 1960 regional flaps

    • Plastic Surgery 1970 free flaps


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LE Trauma

  • Salvage

    • Wound care, antibiotics, fracture management, soft tissue management, nerve / arterial repair

  • Goal

    • Salvage an extremity that is more functional than an amputation with prosthesis


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LE Trauma

  • Anatomy

    • Bipedal human, LE bear 100% while erect

      • Plantar sensation is very important

      • Posterior tibial loss is relative contraindication to salvage (in less than very motivated patient)

    • Significant functional loss of leg muscle tolerable

    • Hydrostatic pressures  edema, DVT, venous stasis, atherosclerosis

    • Anteromedial tibia with skin and subcutaneous fat


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LE Trauma

  • Anatomy

    • Bones

      • Tibia

        • 85% weight bearing

        • Second longest bone in body

        • Knee: Articulates with femur

        • Ankle: Joins fibula to articulate with talus

        • Protected laterally by anterior compartment and posteriorly by posterior compartment


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LE Trauma

  • Anatomy

    • Bones

      • Fibula

        • Articulates with tibia proximally at tibiofibular joint and distally at tibiofibular syndesmosis

        • Connected to tibia in mid portion by interosseous membrane

        • Less of concern in trauma unless lateral malleolus involved

        • Excellent source of vascularized bone


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LE Trauma

  • Anatomy

    • Compartments

      • Anterior, Lateral, Posterior, Deep posterior

      • Table 1

      • Figure 1


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LE Trauma

  • Anatomy

    • Compartment Syndrome

      • Increased interstitial within osseofascial compartment of sufficient magnitude to cause compromise of the microcirculation leading to myoneural necrosis

        • DeLee 6/104 (5.8%) open, 5/411 (1.2%) closed

        • Blice 18/198 (9.1%) open

      • Cardinal signs: Pain out of proportion, pain on passiveflexion or extension, palpably tense

      • Loss of pulses is too late usually

      • 30 mmHg (some use 40 mmHg) with Stryker

      • If you suspect it then DO IT because morbidity of fasciotomy less than ischemia


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LE Trauma

  • Anatomy

    • General

      • Bipedal human, full weight-bearing erect

      • Significant functional muscle loss tolerable

      • Hydrostatic pressures  edema, DVT, venous stasis, high atherosclerosis (all less in UE)

      • Anteriomedial tibia with little soft tissue

      • Plantar sensation important for normal gait

        • PT nerve loss is relative contra indication


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LE Trauma

  • Anatomy

    • Bones

      • Fibula

        • Multiple muscular and fascial attachments

        • Lateral malleolus is usually only aspect to stabilize

        • Excellent source of vascularized bone

      • Tibia

        • Bears 85% of weight

        • Second longest bone

        • Knee and ankle joints

        • Articulates with fibula at tibiofibular joint (k) and tibiofibular syndesmosis (a)


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LE Trauma

  • Anatomy

    • Bones

      • Tibia

        • Interosseous membrane of shaft connects to fibula

        • Laterally protected by anterior compartment

        • Posteriorly protected by posterior compartment

        • Prone to injury medially


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LE Trauma

  • Anatomy

    • Compartments

      • Anterior, lateral, posterior, deep posterior

      • Table I, Figure I


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LE Trauma

  • Anatomy

    • Compartment Syndrome

      • Increased pressure in osseofascial compartment of magnitude to cause compression of microcirculation  myoneural necrosis

      • DeLee: 6/104 (6%) open, 5/411 closed (1.2%)

      • Blice 18/198 (9.1%)

      • Cardinal signs: Pain OOP, pain on passive flexion/extension, palpably swollen/dense compartments

      • Pulselessness is late and presence does not exclude

      • 30 mmHG (up to 40)

      • If you think about it do it, less morbid than necrosis


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LE Trauma

  • Anatomy

    • Fracture Classification

      • Gustilo

        • Often used but poor

      • Grade IIIB/IIIC need plastic surgeon

      • Table 2


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Management of mangled extremity

  • Initial Evaluation

    • ABC’s, stabilize and control bleeding

    • Treat serious injuries, amputate if unstable

    • Figure 3

  • Reconstructive Plan

    • Bone/fasciotomyvasculardebride--> cover or repeat

    • First week = 18% complication rate, weeks 1-6 = 50%

    • Some think 72 hours is most critical, others that complete debridement is most critical


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Management of mangled extremity

  • Soft tissue avulsion

    • Usually more extensive than appreciated initally

    • Progressive thrombosis of subdermal plexus

    • Be aggressive or willing to repeat

  • Vascular Injuries

    • Proximal to popliteal is emergency

    • Distal to trifurcation

      • All 3 vessels  repair at least one

      • 2 vessels  try to repair one

      • 1 vessel  can ligate

    • Angio OK if quick, O/W get on table if needed


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Management of mangled extremity

  • Nerve Injuries

    • Results often poor due to distance between spinal cord and motor end plates

    • Peroneal nerve  foot drop/dorsal foot sensation  life long splinting and tendon transfers

    • PT nerve  lose plantar flexion/plantar sensation  chronic wounding/ atrophy/ vasomotor changes (devastating)

      • Often results in amputation

      • Relative contraindication to salvage

    • Repair as soon as possible


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Fracture management

  • Fixate first to stabilize, for anastomotic stability and length

  • Traction: Rare, very sick, immobilize patient, upper leg

  • Cast /splint: Rare, closed leg or open tibia, window for would care possible, poor rigid fixation

  • IMN

    • Reamed nails

      • Ream canal, rigid fixation, tight fit, early ambulation, good fracture reduction and fixation

      • Only for minimally comminuted fractures without significant bone loss

      • Lose endosteal blood supply (not for massively traumatized leg)

    • Non-reamed nails

      • Stable fixation, early mobilization

      • Do not require stripping of entire canal

      • Require immediate soft tissue coverage (exposed hardware)

  • ORIF

    • Requires immediate soft tissue coverage

    • Requires periosteal stripping

    • Introduces FB into wound

  • External fixation

    • Severely traumatized lower extremity (IIIB and IIIC)

    • Can make free flaps difficult

    • Pins (placement, infection)


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Fracture Management

  • Bone gaps

    • Non-vascularized cancellous bone

      • Non-unions, < 2-5 cm,

    • Ilizarov bone lengthening

      • Distraction osteogenesis, 4-8 cm

    • Vascularized bone

      • <24 cm, leave proximal and distal 6 cm of fibula

      • 15 mo to full WB

  • Immediate

    • Adequate debridement

    • Confident in soft tissue coverage

  • Delayed

    • 6-12 weeks


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Soft Tissue Management

  • STSG

    • Muscle, parateneon, soft tissue


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Soft Tissue Management

  • Local flaps

    • Small defect often requires relatively large flap

    • Fasciocutaneous

      • Donor site almost always needs STSG

      • Complications: Distally based=37.5% , proximally=18.5%

      • Often not option in IIIB or IIIC

    • Muscle flaps

      • Often in zone of injury and not option

      • Proximal third

        • Gastrocnemius: Medial/ lateral

      • Middle third

        • Soleus

        • Tibialis anterior bipedicled flap


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Soft tissue Management

  • Free flaps

    • Usually required for distal third

    • High Energy wounds revolutionized

    • 90-98% success

  • Cross leg flaps

    • Last choice

    • Immobilize

    • Contracture


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Chronic osteomyelitis

  • Incidence

    • 4.5% (109) Grade III

    • 7% if debrided <5 hrs later, 38 % if >5 hrs later

  • Treatment

    • Adequate (often radical) debridement

    • Coverage with healthy tissue

      • Primary closure (46% success)

      • Local / free muscle flaps (>80% success)

    • Bone graft


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BKA Stumps

  • Preserve as much length as possible especially around knee

  • Work much reduced and function improved in BKA vs. AKA

  • Advantages of distal amputations

    • BKA 25% increased energy

    • AKA 65% increased energy

    • Quality if life (effort, stairs, hand controls to drive)

  • Free flap salvage of BKA Stumps

    • Ideal to have 6 cm of tibia below tubercle

    • Foot fillet free flap option if foot uninjured

      • No donor site morbidity

      • Sensate (tibial, peroneal, sural)

      • Galborous, durable skin


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Foot and ankle preservation

  • Introduction

  • Anatomy

    • Arterial supply

    • Angiosomes

    • Motor and sensory nerves

    • Muscle and fasciocutaneous flaps

      • Lower leg and ankle

      • Foot


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Wound care

  • Debridement

  • Vascular evaluation

  • Nutrition

  • Timing of closure


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Traumatic injuries

  • Initial treatment

  • Soft tissue repair


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Cancer

  • Post resection defects

  • Post radiation burns


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Infected diabetic foot

  • Scope of problem

  • Etiology

  • Neuropathic and ischemic diabetic foot ulcer

  • Treatment

    • Forefoot coverage

    • Midfoot coverage

    • Hindfoot coverage

    • Dorsum

    • Ankle

    • Post operative care


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