Volume 11 Issue R1, 2009

LOWER EXTREMITY
RECONSTRUCTION
John R. Griffin, MD
James F. Thornton, MD
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Editor-in-Chief Jeffrey M. Kenkel, MD Reconstruction Topics

Editor Emeritus F. E. Barton, Jr, MD Breast Reconstruction
Cleft Lip and Palate
Contributing Editors Craniofacial
W. P. Adams, Jr, MD Eyelid Reconstruction
S. M. Bidic, MD Facial Fractures
G. Broughton II, MD, PhD Hand: Congenital
S. Brown, PhD Hand: Extensor Tendons
J. L. Burns, MD Hand: Flexor Tendons
J. J. Cheng, MD Hand: Peripheral Nerves
A. A. Gosman, MD Hand: Soft Tissue
J. R. Griffin, MD
Hand: Wrist, Joints, Rheumatoid Arthritis
K. A. Gutowski, MD
Head and Neck Reconstruction
R. Y. Ha, MD
Lip, Cheek, Scalp, and Hair Restoration
R. E. Hoxworth, MD
K. Itani, MD Lower Extremity Reconstruction
J. E. Janis, MD Nasal Reconstruction
R. K. Khosla, MD Surgery of the Ear
J. E. Leedy, MD Trunk Reconstruction
J. A. Lemmon, MD Vascular Anomalies
A. H. Lipschitz, MD Wounds and Wound Healing
J. H. Liu, MD
R. A. Meade, MD Cosmetic Topics
J. K. Potter, MD, DDS
S. M. Rozen, MD Blepharoplasty
M. Saint-Cyr, MD Body Contouring: Excisional Surgery
M. Schaverien, MRCS Body Contouring: Noninvasive, Liposuction, Fat Grafts
J. F. Thornton, MD Breast Augmentation
A. P. Trussler, MD Breast Reduction and Mastopexy
R. I. S. Zbar, MD Brow Lift
Facelift
Senior Manuscript Editor Dori Kelly Injectable Agents and Dermal Fillers
Lasers and Light Therapy
Business Managers Lynsi Chester Rhinoplasty
Becky Sheldon Skin Care
Corporate Sponsorship Barbara Williams

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 LOWER EXTREMITY
RECONSTRUCTION

John R. Griffin, MD*

James F. Thornton, MD†

*Private Practice, San Mateo, California, and Children’s Hospital

of Oakland, Oakland, California

†University of Texas Southwestern Medical Center at Dallas,

Dallas, Texas

HISTORY did not perform true débridement of the wound

Evolution of Principles
The literature on lower-limb wounds contains
numerous contributions by orthopaedic surgeons,
plastic surgeons, and trauma surgeons. Burkhalter1
and Aldea and Shaw2 traced the evolution of
principles of lower extremity wound healing,
wound management, and hard- and
soft-tissue reconstruction.
Fundamental Tenets and Debut of Plastic Surgery
Although treatment concepts for the traumatized
lower extremity did not change significantly until the
major wars, several fundamental tenets of care were
proposed early in its history. Pierre-Joseph Desault
(1744-1795) introduced deep incisions for drainage
and débridement of devitalized tissues. Louis Ollier
(1825-1900) introduced plaster of Paris casting
for fracture stabilization. Sir William Arbuthnot
Lane3 (1856-1943) wrote The Operative Treatment
of Fractures, which was originally published in 1905.
Lane subsequently sponsored Gillies and the debut
of plastic surgery at the Cambridge Hospital at
Aldershot in 1915.
Treatment Concepts and the World Wars
By the end of World War I, the concepts of fracture
immobilization and early secondary suture were
established. Winnett Orr4 developed a “closed plaster
treatment” that avoided frequent dressings, irrigation,
and wet antiseptic packs. With that technique, open
wounds were covered with dressings and casts. Orr
before the cast was applied but did advocate incisions
for drainage. The closed plaster method became the
standard of care for injuries of the lower extremity
after World War I.
Open wounds in the context of open fractures
treated with the method presented by Orr frequently
were complicated by osteomyelitis. This prompted
Trueta5 to perform more extensive débridement
before applying the plaster. Trueta favored
conservative débridement of skin together with
radical removal of devitalized subcutaneous tissue
and muscle; all bone was preserved. Trueta’s revision
of Orr’s teachings became the accepted management
from 1939 to early 1942, in the early years of World
War II. Trueta’s clinical experiences confirmed the
need to remove any tissue medium that was favorable
to bacterial growth.
The second phase of management of the
lower extremity lasted through 1943. It consisted
of initial wide débridement, plaster immobilization,
and secondary closure or skin graft as soon as clean
granulations appeared.
After 1943, fracture management entered a
third phase that involved wide débridement at the
forward surgical units. Closure was accomplished
by delayed primary suture or graft at the base unit
between the 4th and 6th days of injury. The closure
was ideally accomplished before the appearance of
granulation tissue. These were the origins of early
delayed primary wound closure. The significance
of these stages in the evolution of care is obvious
SRPS Volume 11 Issue R1, 2009
when one compares the incidence of postfracture
osteomyelitis after World War I (>80%) with that
at the end of World War II (≈25%).
CURRENT TRENDS
A fourth phase of lower extremity wound care
currently is underway. Advances in orthopaedic
and plastic surgery during the past 30 years have
influenced the management of open tibial fractures,
soft-tissue coverage, and chronic problems of the
lower extremity. Technical advances in bone fixation
and distraction, wound care, and soft-tissue healing
have greatly enhanced our ability to salvage the foot,
leg, and thigh after trauma. The contribution of
vacuum-assisted devices has been notable.
Nevertheless, patients who suffer severe
polytrauma or one of the more severe classes
of open lower extremity fractures might still be
better served by amputation rather than attempted
reconstruction. The modern dilemma is no longer
how to salvage a lower extremity but knowing
when attempted salvage is not the best option for
the patient.
Among recent trends in lower extremity
reconstruction is a resurgence of support for
local and fasciocutaneous flaps in leg and foot
reconstruction. The pedicled flaps are touted as
being similar to free flaps in terms of morbidity,
reliability, and even aesthetic results.6,7
Regarding microsurgery, many recent
articles focus on technical refinements of and
indications for certain flaps in specific defects.8,9
Perforator flaps, which are becoming more accepted
in breast and general reconstruction, are now also
used in the lower extremity.10−12 Striving beyond
form, contour, and optimal soft-tissue coverage,
some surgeons reported progress with sensitive free
flaps to the heel and weight-bearing foot.13,14
Several recent reviews have yielded a wealth of
information for the new plastic surgeon and veteran
alike. French and Tornetta15 presented a review of
the literature on lower extremity trauma. Options
for bone fixation and soft-tissue coverage are
considered, and the outcomes of reconstruction
versus early amputation are analyzed. Heller and
Levin16 presented a discussion of the updated
principles of management of lower extremity
2
wounds. Tomaino17 presented a review of the
outcome of treatment of severe open tibial fractures.
BONE HEALING
Rhinelander,18 Holden,19 and Macnab and De
Haas20 provided discussions of factors influencing
fracture healing of long bones and the cellular
events that take place in the healing fracture wound.
The tibia is a commonly used experimental and
clinical model of bone healing.
Sauer21 presented a review of the blood
supply of the lower extremity from the inguinal
region to the thigh, knee, and leg, including fascial
perforators, septocutaneous vessels, and major blood
vessels. He emphasized the regional circulation
pertinent to flap design.
Rhinelander18 and Macnab and De Haas20
described tibial vascularity in detail. The three main
sources of blood supply to the tibia are the nutrient
artery, the metaphyseal vessels, and the periosteal
vessels. Originating from the posterior tibial artery,
the nutrient artery penetrates the tibialis posterior
muscle and enters the posterior tibia at the junction
of the proximal and middle thirds. The cortical
groove containing the artery extends distally and
obliquely, traversing the cortex for approximately
5 cm. In this cortical canal, the nutrient artery is
vulnerable to injury by even a slightly displaced
fracture. Once in the medullary canal, the nutrient
artery divides and gives off a network of vessels
supplying the cortex from the endosteal surface. The
endosteal circulation thus supplies the inner two
thirds of the cortex, and the periosteal circulation
supplies the outer third (Fig. 1).22
The periosteal vessels derive from the
primary vessels of the limb and run perpendicular
to the long axis of the bone. When a long bone is
fractured, the nutrient vessels and the endosteal
circulation are disrupted to the point at which the
metaphyseal vessels enter the bone. The periosteal
blood supply is maintained on both sides of the
fracture line by virtue of its transverse orientation
and becomes the chief nutrient source to the
healing bone in many fractures.
The essential requirements for healing of
opposed fracture fragments are adequate blood
supply and proper stabilization.18 If stabilization is

adequate, the source of blood supply to the fracture
can be seen to influence the type of callus that
forms: medullary, periosteal, or intracortical.18
Figure 1. Illustrations depict the blood supply to the tibia.
Note the linear pattern of endosteal circulation (nutrient
artery and metaphyseal artery), subject to disruption with
displaced fractures. Periosteal circulation is maintained
unless soft tissues are avulsed (Type III). (Reprinted with
permission from Byrd et al.22)
Medullary bridging callus develops around
day 4 after injury in stable, nondisplaced fractures.
Time to union is shortest, and zone of fibrocartilage
is minimal. The medullary or endosteal circulation
is dominant throughout all healing phases of
nondisplaced fractures.18
Periosteal bridging callus provides ancillary
external support to the fracture and always contains
a significant zone of fibrocartilage. The callus first
appears approximately on day 3, and its initial
blood comes from the surrounding soft tissues
and periosteum. When the endosteal circulation
reconstitutes, the periosteum assumes a new blood
supply by the endosteal route. Periosteal bridging
callus is extremely important in the union of
displaced and comminuted fractures.
Intracortical uniting callus fills the space
between fracture fragments after reduction
and fixation. Its blood supply is intraosseous,
extraosseous, or a combination of both. Healing
SRPS Volume 11 Issue R1, 2009
occurs only in areas of cortical bone contact, not
just when bone fragments are in apposition, as
usually occurs with compression plate fixation.
Primary bone healing can take place in
nondisplaced fractures and stable fractures after
rigid fixation with plate and screws without an
intermediate stage of fibrocartilage. However,
primary bone healing in such cases might not
be the fastest course to full bony restoration or
restoration of strength. Intramedullary rodding,
casting, and external fixation are the usual methods
of treatment of tibial fractures. The bone thus passes
through a phase of cartilage-containing periosteal
callus, which assists in stabilizing and vascularizing
the wound.
Caplan23 suggested that pluripotential
progenitor cells, referred to as mesenchymal stem cells,
are attracted to the fracture site from nearby and
distant sites throughout the body. The mesenchymal
stem cells at the fracture site mitotically divide
to form a blastema that crosses the fracture site.
Depending on the local concentration of growth
factors, the blastema differentiates and begins
forming the missing skeletal tissues.
One of the reasons children’s bones heal
better and faster than adults’ bones might be that
children have more progenitor cells available.
Wray24 stated that the periosteum is the origin
of the pluripotential cells that enter the fracture
site and contribute to the formation of callus. The
delayed healing and inadequate callus that occur in
the presence of extensive periosteal destruction in
and about the fracture support this hypothesis.
The role of the soft tissues in fracture
healing is not clear. Studies by Macnab and
De Haas20 and by Gothman25 suggested that
the muscles contiguous to the fracture are the
immediate source of blood to the fracture. The
slow healing of certain displaced fractures might
be caused by scarce muscle tissue surrounding
them. Holden19 tested this concept experimentally
and successfully showed the importance of the
surrounding muscle in contributing vascular
ingrowth to the injured bony cortex. He further
showed that when the soft-tissue envelope was
rendered ischemic, initial revascularization occurred
first in the muscle and secondarily in the skin. The
3
SRPS Volume 11 Issue R1, 2009
restoration of intramedullary circulation in the
bone occurred after the revascularization of the
soft tissues. It was unclear whether the ischemic
muscle was parasitic on the feeder vessels that
would normally revascularize the bone or whether
ingrowth from the surrounding soft tissue was
necessary before bone revascularization could
occur. Either way, the author concluded that
bone revascularization essentially required well-
vascularized soft tissues around it.
Cell Signaling in Bone Healing
Mooney and Ferguson26 reported that
environmental factors affect the differentiation of
pluripotential mesenchymal cells. Their observations
hint at a “golden period” during which bone
formation can be manipulated through physical
measures. Stress in the form of compressive force
can be important during the first 3 weeks of fracture
healing.
Barnes et al.27 presented a review of recent
advances in cytokine and growth factor research and
bone healing. Lieberman et al.28 presented a review
of the potential clinical applications of several
growth factors for improving fracture healing.
Transforming growth factor beta, platelet-derived
growth factor, and insulin-derived growth factors
induce cellular proliferation in the laboratory, but
their clinical application has not been determined.
Locally instilled fibroblast-derived growth factor,
on the other hand, significantly increased healing
fracture strength over controls in a primate
fracture model.29 Fibroblast growth factor-2 in a
hyaluronidase gel accelerated fracture healing in
nonhuman primates.28−30
Bone morphogenic protein (BMP) has
also been shown to have clinical promise for
accelerating fracture healing.28,31,32 Sciadini and
Johnson33 showed that local BMP was as effective
as autogenous bone graft in achieving union in
experimental radius defects and was significantly
more effective than controls in achieving union. In
contrast to some of the cytokines, however, BMP
might have specific dose requirements that could
limit its clinical usefulness.
As the promise of growth factors
materializes, issues related to delivery mechanisms,
4
timing, and appropriate dosages become more
important. Molecular carriers, viruses, gels,
hyaluronidase matrixes, and creative use of gene
therapy are all being tested for delivery of growth
factors to healing fractures.28 Lieberman et al.28
listed the following potential clinical uses of growth
factor therapy:
• acceleration of fracture healing (in cases at
risk of nonunion)
• treatment of established nonunions
enhancement of primary spinal fusion
• treatment of established pseudoarthrosis of
the spine
• treatment of large bone-loss problems
OPEN TIBIAL FRACTURES
Demographics
Patients with severe lower extremity trauma often
share traits that can affect the management and
eventual outcome of treatment. MacKenzie et al.34
at Johns Hopkins Hospital prospectively studied the
broad demographic characteristics of 601 patients
with high-energy lower extremity trauma and noted
the following:
• 77% were male
• 72% were Caucasian
• 71% were between the ages of 20
and 45 years
• 70% were high-school graduates (versus
86% national average)
• 38% had no health insurance (versus
20% nationwide)
• they were twice as likely to have a history of
alcohol abuse than the national average
Francel identified three demographic factors
35
associated with reemployment after severe lower
extremity injury:
• age younger than 40 years
• history of higher education (beyond high
school)
• white-collar employment
A large, multicenter, prospective
observational study of severe lower extremity
injuries36 identified the following patient factors as
predictors of an eventually poor outcome:

• rehospitalized for a major complication
• low education level
• non-Caucasian race
• poor
• lacking private health insurance
• with poor social support network
• low self-sufficiency
Smoking and Tibial Fractures
Smoking adversely affects bone healing. In a
blinded retrospective study, Schmitz et al.37
demonstrated no significant difference in eventual
union between smokers and non-smokers with
closed and Gustilo type I tibial fractures treated by
either external or internal fixation. The study did
show that time to union in smokers was 69% longer
than in nonsmokers. As one would expect, the trend
toward delayed healing is also observed in the full
range of open tibial fractures in smokers. Adams
et al.38 compared matched demographic groups of
smokers and nonsmokers who had tibial fractures
and found the mean time to union for smokers to
be 4 weeks longer than for nonsmokers.
Limb Salvage versus Primary Amputation
Physicians who treat lower extremity trauma would
like to have a reliable way to predict prognosis for
each patient. The most important early decision
to be made in the event of severe leg trauma
is whether to reconstruct or to perform early
amputation. Orthopaedic and plastic surgeons
generally agree that some lower extremity injuries
are best served by reconstruction; others are
candidates for primary amputation. Delayed leg
amputation is considered a relative treatment
failure because it suggests possible errors in the
initial treatment rationale. Furthermore, delayed
amputation has been linked to increased hospital
costs, more operations, and increased patient
disability, including sepsis and death.39 For the
patient and for the physician, few failures of
treatment are as devastating as a nonfunctional
salvaged limb. Technical victories that result in
functional failures serve no purpose.
Before embarking on lower extremity
reconstruction of severe open fractures, it is
SRPS Volume 11 Issue R1, 2009
sobering to consider the complication rates,
multiple operations, and long hospital stays that
often are required in such cases. One recent study
evaluated 43 patients who had undergone attempts
at reconstruction of Gustilo type IIIB and IIIC
injuries.40 Methods of reconstruction included
the use of bone grafts, local flaps, free soft-tissue
flaps, and free bone-soft-tissue flaps. Overall,
approximately 63% of patients experienced some
form of infection during the postoperative period.
Union was achieved in 37 of 43 cases; the average
time to union was 9.5 months. The average number
of operations required for each patient was 8.7.
Hospital stays ranged from 49 to 62 days. Long-
term problems such as joint stiffness and pain were
common. In the end, 26 of 41 patients who worked
before the injury returned to work. It should be
noted that despite their long-term problems with
the rebuilt limbs, patients who had undergone
reconstruction preferred that outcome to the
prospect of amputation. A study by Pelissier et al.40
showed similar patient preference.
The concept that the most severe lower
extremity injuries are best served by amputation
makes sense, but reliable predictors of outcome
are not clearly defined. Keller41 reviewed 10,000
cases of tibial fractures and noted that the risk
of systemic complications rose in the presence of
comminution, displacement, bone loss, soft-tissue
injury, infection, and polytrauma. Fracture location,
configuration, and concomitant fibular fracture had
no prognostic significance.
Several authors have since attempted to use
scoring systems to help them decide between limb
reconstruction and amputation.42−44 In a frequently
cited study, Francel et al.45 reported improved
return-to-work rates after amputation (68%)
compared with reconstruction (28%). A more recent
study by Francel35 showed that early postinjury
reconstruction, appropriate soft-tissue coverage, and
early bone grafting significantly decreased the time
to ambulation. The reemployment rate improved
to 67% among patients who became ambulatory
soon after reconstruction but was low when
ambulation was delayed. The updated conclusion
is that reconstructed patients who ambulate at the
5
SRPS Volume 11 Issue R1, 2009
appropriate time might be able to return to work as
often as patients who undergo primary amputation.
Many studies have attempted to use
demographic data and trauma scoring systems
to determine prognosis. The Lower Extremity
Assessment Project (LEAP) was designed to
compare outcomes of patients with severe lower
extremity trauma. A large study by the LEAP group
prospectively applied five major trauma scoring
systems to more than 500 injured lower extremities.
The scoring systems used were as follows:46
• Mangled Extremity Severity Score
• Limb Salvage Index
• Predictive Salvage Index
• Nerve Injury, Ischemia, Soft Tissue Injury,
Skeletal Injury, Shock, and Age of
Patient Score
• Hannover Fracture Scale-97
Interestingly, low scores were useful in predicting
which limbs could be salvaged but high scores did
not predict which limbs could not be salvaged. In
conclusion, the five trauma scoring systems studied
do not reliably predict which injured limbs should
undergo primary amputation.46
Another study by MacKenzie et al.47
analyzed a broad range of factors that could
influence the ultimate outcomes for severe leg
and foot injuries. Bone loss was not found to be a
factor, but severe soft-tissue injury and absence of
plantar sensation at presentation were prospective
indicators of primary and delayed amputation.
Lange et al.43 reported a 61% amputation
rate for limbs with vascular injury (22% primary,
39% delayed). Crush injuries, segmental tibial
fractures, and fractures for which revascularization
was delayed more than 6 hours generally had
poor outcomes.
McNutt et al.48 reviewed the cases of 366
patients with tibial fractures occurring after blunt
trauma. Twelve percent of patients had clinical
evidence of tibial artery injury; of those, 27 had
angiographic evidence of at least one patent tibial
vessel and adequate distal flow. The other 17
patients required operative repair of the injured
tibial arteries because of persistent distal ischemia.
The amputation rate in the vascular repair group
6
was 35%. Patients who required amputation
experienced a significantly greater incidence of
three or more fascial compartments involved in
muscular injury, two or more injured tibial vessels,
failed vascular reconstruction, and a cadaveric foot
at initial examination. No extremity was salvaged
when more than two of these findings were present.
Failed reconstruction led to limb amputation in all
cases, even though three patients were noted to have
patent vascular repairs at the time of amputation.
Severe tibial nerve injury and an insensitive foot
generally are considered contraindications to
reconstruction. However, Higgins et al.49 The case
was an open tibial fracture that was salvaged with
external fixation, soft-tissue coverage, and tibial
nerve grafting. The patient recovered pressure
sensation and sharp-dull sensation at 27
months postoperatively.
The primary factors influencing outcomes
for leg injuries are as follows:17,50
• degree of soft-tissue damage
• presence or absence of plantar sensation
• severity of vascular injury
The absolute indications for primary
amputation in cases of open tibial fracture are
as follows:17,50
• anatomically complete disruption of the
posterior tibial nerve in adults
• crush injuries with warm ischemia time
>8 hours
The relative indications for primary
amputation in cases of open tibial fracture are
as follows:17,50
• serious associated polytrauma
• severe ipsilateral foot trauma
• anticipated protracted course to
obtain soft-tissue coverage and
tibial reconstruction
Bosse et al.36 compared outcomes in patients
with severe lower extremity trauma who had
undergone reconstruction versus amputation. The
cohorts were matched for severity of injury and
patient demographics. An evaluation conducted 2
years postoperatively indicated that those who had
undergone amputation had functional outcomes
that were similar to those who had undergone

reconstruction. A similar number of patients in
each group—nearly 50%—had returned to work
at 2 years.
Another study from the Netherlands51
showed that quality-of-life ratings were similar
between patients who had undergone amputation
and those who had undergone reconstruction.
It should be noted, however, that the studies did
not analyze the patients’ preferences regarding
reconstruction versus amputation or the patients’
levels of satisfaction with their outcomes.
The net costs of salvage versus amputation
are controversial. Hertel et al.52 analyzed social
and employment outcomes for patients with
severe leg injuries. They noted that the total costs
of care and rehabilitation are not limited to the
hospitalization costs alone. Although the return-
to-work rate was an amazing 100%, the number of
interventions was significantly lower in the group
of patients who had undergone reconstruction.
When the global costs of care to the community
were considered in that study, the patients who had
undergone reconstruction proved considerably less
expensive to finance than the patients who had
undergone below-knee amputations. This is mainly
because patients who undergo amputation often
are recipients of lifelong partial pension payments.
Unlike previous reports, the study by Hertel et
al. found that the long period of rehabilitation
did not induce chronic invalidity. Of note, the
reconstruction group compared favorably with
the amputation group in physical, social, and
psychosocial parameters.
Tomaino17 summarized considerations
regarding management of the patient with severe
open tibial fractures. On the basis of his experience
and analysis of the literature, he recommended
limb reconstruction for cases with reasonable hope
that the patient will return to ambulation within 1
year. He also emphasized that every technical and
rehabilitative effort must be made to achieve union
and ambulation as soon as possible.
It is important to note that a review of the
literature suggested similar functional outcomes
for reconstruction and amputation, not better
functional outcomes for reconstruction. It is also
important to note that analysis of outcomes after
SRPS Volume 11 Issue R1, 2009
open tibial fractures likely is more complex than can
be judged by trauma scoring systems.
Despite showing poor return-to-work
numbers for patients with reconstructed limbs,
a study by Francel et al.45 reported that patient
satisfaction after reconstruction was high: 96%
were satisfied with their reconstructed limb.
Dagum et al.53 noted that the vast majority of
patients who underwent reconstruction preferred
their reconstructed limbs to amputation despite
ongoing disability. No patient with a salvaged
limb in that study wished they had undergone
primary amputation instead. In addition, the
physical outcome scores were better overall in the
reconstructed group than in the amputated group.
In summary, some severe leg injuries are
not amenable to reconstruction. Other injured legs
might be amenable to reconstruction but are so
severely injured that reconstruction is not advisable.
Nevertheless, few patients elect to undergo primary
amputation when salvage is feasible, even when the
physician thinks that reconstruction is inadvisable.
The burden of educating the patient rests
with the physician. Functional outcomes and
return-to-work statuses improve with earlier
ambulation times. Once the decision is made to
reconstruct an injured leg, all effort should be made
to minimize complications and achieve expedient
bony union and stable soft-tissue coverage.
Ambulation is a major predictor and essential
prerequisite to successful lower limb reconstruction
and return to overall function.
Classification of Open Tibial Fractures
The severity of open wounds associated with tibial
fractures varies widely. It was long acknowledged by
orthopaedic and plastic surgeons that the severity of
the soft-tissue injury correlated well with long-term
limb function.54 Gustilo and Anderson55 published
their classification of open tibial injuries in 1976.
Their grading system drew a clear link between
severity of injury and prognosis for recovery.
Subsequent clinical studies confirmed the
usefulness of the Gustilo classification.55 In a series
presented by Emerson and Grabias,56 Gustilo
type III fractures comprised 77% of injuries and
generally required closure with skin grafts or flaps.
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2009

Healing time for that group was protracted, and the
overall infection rate was 39%. Other complications,
such as malunion and nonunion, were also frequent.
The authors concluded that the Gustilo type
III injury segregates itself as a unique fracture
predisposed to treatment failure.
Tscherne and Oestern57 and Oestern
and Tscherne58 later developed their own widely
referenced tibial injury classification system that
correlates well with clinical results. Over time, it
has become clear to practitioners that the Gustilo
type III injuries are a heterogenous group. In 1984,
Gustilo et al.59 published a revised classification
that divided the more severe injuries into three
subgroups. The Gustilo type IIIA group is clearly
different from the Gustilo type IIIB and IIIC
groups. Type IIIA fractures have stable soft tissue
over the comminuted fractures, whereas types IIIB
and IIIC require soft-tissue reconstruction (Table
1).60 Types IIIB and IIIC have worse bony injury
accompanying the soft-tissue injury. The type
IIIB fracture is defined by its need for soft-tissue
coverage and the type IIIC by its requirement for
some form of arterial vascular repair to salvage
the limb.
At approximately the same time the Gustilo
studies were published, a classification of open tibial
injuries by Byrd et al.61 was published. The system
presented by Byrd et al. is similar to the original
Gustilo classification regarding types I through III,
but it is not a simple modification of the Gustilo
scheme. In the classification presented by Byrd et
al., the type III group can be said to approximately
correspond to the original Gustilo type III. The
Byrd type III is a severe injury with devitalized
local soft tissues, but it might be amenable to local
muscle flap coverage. Select cases of Byrd type
III injuries require free flap coverage, particularly
in cases of injury to the distal third of the leg,
where pedicled flaps are less reliable. Based on the
definition presented by Byrd, the type IV injury is
severe enough that no opportunity exists for local
muscle transfer (Fig. 2). By definition, the Byrd type
IV injury requires free flap coverage in all cases.
Byrd’s classification is very useful for plastic
surgeons in particular because it correlates well with
requirements for soft-tissue reconstruction. The
system is widely referenced in the plastic surgery
literature but should be combined with other
physical findings and possibly other classification
schemes to fully describe an open tibial injury.
The revised Gustilo system is the standard
descriptive classification used by trauma and
orthopaedic surgeons, yet it has persistent
problems.60 The Gustilo type IIIB and IIIC groups
remain heterogeneous; the severity of injuries
within those groups varies widely. Many Gustilo
type IIIB injuries should undergo an attempt at
salvage, whereas others have a very poor prognosis
because of large zones of injury and influencing

Table 1
Gustilo Classification of Open Fractures of the Tibia60

Type Description

I Open fracture with a wound <1 cm

II Open fracture with a wound >1 cm without extensive soft-tissue damage
III Open fracture with extensive soft-tissue damage
IIIA Type III with adequate soft-tissue coverage
IIIB Type III with soft-tissue loss with periosteal stripping and bone exposure

IIIC Type III with arterial injury requiring repair

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 SRPS Volume 11 Issue R1

factors. The revised Gustilo system also implies comparing internal fixation and casting for the
that IIIC injuries are worse than IIIB injuries, treatment of low-energy tibial fractures have shown
which is not always the case. It makes no mention faster union times and lower incidence of malunion
of the status of the tibial nerve, which is an with internal fixation.63,64 High rates of conversion
important indicator of the quality of limb salvage.43 from casting to internal fixation because of loss of
Furthermore, the Gustilo type IIIC injury is reduction have been noted.63
defined as “an arterial injury requiring repair.”59
Although most surgeons will not attempt repair
of a vessel in the leg so long as the foot is still
perfused by at least one major artery, some surgeons
will try to restore two vessels to the foot in select
cases.60 This variability in clinical decision making
can actually alter the meaning of the Gustilo type
being applied. In the end, the revised Gustilo
classification scheme is very good but not perfect.

Fracture Management and Skeletal

Reconstruction
The management of open tibial fractures consists of
two general types of bone fixation and three types
of soft-tissue management. Bone fixation can be
accomplished internally with plates, rods, or screws
or externally with percutaneous pins. Pin fixation
can be either static or dynamic. Casting is an
option for less severe injuries that have stable soft
tissues over the fracture, but the method presented
by Trueta5 is no longer used for more
complicated wounds.

Closed Treatment
According to Byrd et al.,61 the closed plaster
method presented by Trueta involves wide
débridement of the soft tissues surrounding the
fracture while preserving all bone fragments. After
fracture reduction, dressings and a walking cast
are applied. Classically, patients start walking with
crutches the day after surgery and proceed to full
weight-bearing on the cast within 3 weeks. Many
wounds drain profusely during the first few weeks,
and casts often need to be replaced.
Casting alone is no longer considered
optimal for the treatment of high-energy open
injuries, as the soft tissues cannot be closely
Figure 2. Classification of open tibial fractures. (Reprinted
monitored and reduction is difficult to maintain.15,62 with permission from Byrd et al.61)
Casting is considered acceptable for low-energy
closed injuries and mild open tibial injuries. The
success of casting of such injuries is predicated
on maintaining good fracture reduction. Studies

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SRPS Volume 11 Issue R1, 2009
Another option for closed treatment is
functional bracing. It can be used with success to
treat some low-energy injuries but is not optimal
for high-energy injuries.15,65
AO Plate Fixation
Olerud and Karlström66 and Olerud et al.67
presented a review of the use of AO compression
osteosynthesis in the management of open tibial
fractures. The method requires exact opposition
and compression of bone by plates and screws. The
hardware must be covered with viable soft tissue.
Motion begins early and is gradually increased.
Full weightbearing is allowed at 10 to 14 weeks
if evidence of radiologic union is present. The
theoretical advantage of AO compression for tibial
fractures was thought to be primary bone healing,
but ultimately, plate fixation of tibial fractures has
not been proven to be as successful as plate fixation
of fractures in other areas of the body.
The periosteal blood supply is very
important in healing fractures. The more disrupted
the endosteal circulation is, the more important it is
to maintain periosteal and local soft-tissue viability
for fracture healing. When using plate fixation, an
area of periosteum that corresponds to the surface
area of the plate must be stripped. Just obtaining
exposure for the plate can cause additional
devascularization of soft tissues that are important
for tibial healing, and the devascularization of
bone can translate into suboptimal clinical results.
Some studies reported increased complication rates
overall, including infection and nonunion, when
plates were used to treat severe leg injuries.68−70 The
theory is that the plate ultimately creates stress
shielding and predisposes the bone to osteopenia.
In addition, the multiple screws through the bone
weaken the cortical bone stock. Finally, the plate
itself creates stress risers on both ends of the plate,
predisposing the bone to re-fracture. Plate fixation
is reserved for specific types of tibial fractures
that are not amenable to other types of fixation.
Plate fixation of high-energy tibial shaft fractures
generally is not recommended.15
10
Static and Dynamic External Pin Fixation
External fixation with pins is a safe choice for
high-energy tibial fractures. The method evolved
from the need to adequately stabilize open fractures
associated with soft-tissue loss. Percutaneous pins
are placed outside the area of the fracture. Bone
devascularization is minimal because no iatrogenic
periosteal stripping is needed to place the pins,
which are inserted through small incisions under
fluoroscopic guidance. External fixation is indicated
when rigid fixation is required, but internal fixation
cannot be used because of severe comminution,
segmental bone loss, severe osteoporosis, or severe
soft-tissue injury.55
Modern pin fixation frames are smaller
and less obstructive, resulting in easier soft-tissue
management.15 Overall, external fixation of Gustilo
type II and III fractures yields good results.15
The main disadvantages of external fixation
are complications associated with hardware.
Pin tract infections are common and increase
in frequency with the amount of time the pins
are left in place. The risk of frame loosening and
osteomyelitis limits the amount of time external
fixation can be used, although ideally, external
fixation should be continued until union. To win
this race against time, different modalities have
evolved to either prolong frame use or shorten time
to union. Meticulous pin care and close vigilance to
detect infection early are mandatory.
Another option for decreasing time to
union is prophylactic bone grafting.71 Blick et
al.72 analyzed the results of early prophylactic
bone grafting for high-energy tibial fractures
in 53 patients. Bone grafting was performed
approximately 10 weeks after injury and 8 weeks
after soft-tissue coverage. Time to union was
reduced to 12 weeks compared with 20 weeks in
a matched control group of tibial fractures treated
with delayed bone grafting.
Another option that some authors have
advocated is dynamization of the frame.15 With
dynamization, the frame is modified to allow some
movement and axial loading at the fracture.73,74
Some authors claim that controlled stress and
motion at the fracture site result in faster union.75

A final option is exchange nailing. The
external device is replaced with an intramedullary
nail after soft-tissue coverage is stable and before
union. The technique of exchange intramedullary
nailing can yield low infection rates and high rates
of union.76
Intramedullary Nailing
Primary intramedullary tibial nailing produces
high union rates and is associated with few
infections when used to treat closed fractures
and low-energy open fractures of the leg.77 With
grossly contaminated open fractures, the exposed
hardware is a risk factor for infection. For more
severe injuries, such as Gustilo types IIIB and IIIC,
therefore, some variant of external fixation likely is a
safer choice than internal fixation.
A recent meta-analysis of open tibial
fractures revealed that nail fixation is associated
with lower reoperation rates, lower malunion rates,
and lower infection rates than is external fixation.
It must be noted that the data apply to all types
of open tibial fractures, not necessarily Gustilo
type III injuries as a group. It might be physically
impossible to achieve stabilization with rods in
some of the more severe open tibial injuries.78
Rohde et al.79 retrospectively analyzed
complication rates associated with methods
of fixation of free flap reconstructed type IIIB
fractures. The study suggested that external fixation
might be more prudent in such cases. The set of
type IIIB fractures that underwent intramedullary
rod fixation experienced significantly higher rates of
wound infection, osteomyelitis, and nonunion than
did the external fixation group.
A controversial issue is whether reamed
or unreamed nails are better. Reamed nails can
produce endosteal devascularization and hinder
bone union, and the smaller unreamed nails have
lighter screws that can break.15,80−82 Finkemeier
et al.83 compared unreamed and reamed nails in
the treatment of closed and open tibial fractures
excluding Gustilo type IIIB and IIIC injuries. The
outcome of closed injuries was better with reamed
nails, and the complication rates of open injuries
were similar with either technique. The above cited
SRPS Volume 11 Issue R1, 2009
meta-analysis78 also suggested that reamed nails
lead to fewer secondary operations.
COMBINED SKELETAL AND
SOFT-TISSUE RECONSTRUCTION:
TIMING AND COORDINATION
The ultimate functional success of lower extremity
reconstruction depends on achieving union and
ambulation. The modern approach to reconstruction
of lower extremity injuries consists of seamless
coordination of bone and soft-tissue management.
Appropriate débridement is indicated for
early treatment of the open tibial injury, with pulse
lavage for effective wound irrigation. Débridement
and irrigation are performed soon after the patient
presents at the emergency department and are
repeated until definitive soft-tissue coverage is
secured. Bhandari et al.84 compared the benefits of
high-pressure lavage (70 lb/in2) versus low-pressure
pulse lavage (14 lb/in2) in an in vitro model. Both
methods resulted in lifting of periosteum in the
laboratory. Both were effective at removing bacteria
3 hours after injury, but high-pressure lavage was
more effective 6 hours after injury. The high-
pressure method, however, is powerful enough to
cause structural damage to cortical bone. The study
supported the argument that early débridement
is more effective than delayed débridement at
removing bacteria. It did not answer the question
of which of the two modalities results in lower rates
of infection.
Researchers and clinicians continue to
debate the optimal timing for institution of open
tibial fracture treatment. Harley et al.85 reviewed
241 open tibial fractures to determine which
factors were associated with nonunion. Prophylactic
antibiotics had been administered in all cases. The
risk of nonunion was higher in injuries that were
severe based on the Gustilo classification and in
cases of concurrent infection. Nonunion rates were
not affected by aggressive lavage and débridement
or by delay in definitive fixation up to 13 hours after
injury. After 13 hours, delay in definitive treatment
began to adversely affect outcomes.
Many fractures with various amounts of
bone loss are treated with antibiotic-impregnated
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SRPS Volume 11 Issue R1, 2009
bead spacers during an intermediate stage. In a
prospective study, Moehring et al.86 compared
antibiotic beads with intravenously administered
antibiotics and found no statistical difference in
infection rate between the groups; either method
alone is effective for prophylaxis. Regarding dosage
of intravenously administered antibiotics in cases of
open tibial fractures, once daily therapy can be
as effective as traditional dosing regimens
for prophylaxis.87
In 1970, Ger54 reviewed the management
of extensive soft-tissue defects over severe open
tibial fractures, emphasizing the need for thorough
débridement. In the 1980s, Byrd et al.61 noted
that complications worsen when an open tibial
fracture is allowed to enter a delayed (subacute)
phase of wound healing and contamination. Early
multimodality treatment was advocated to improve
outcomes. In a prospective review of open tibial
fractures, the authors proposed radical débridement
of bone and soft tissue with flap coverage in the
first 5 to 6 days after injury (acute phase) for the
most severe injuries. The complication rate for
Byrd type III wounds averaged 18%. Fractures not
treated by early muscle flaps predictably entered
a colonized subacute phase that extended from
1 to 6 weeks after injury. Complications after
treatment with flaps during that phase averaged
50%. Approximately 4 to 6 weeks after untreated
severe injuries, a chronic phase characterized by
a granulating wound, adherent soft tissue, and
decreasing areas of infection was noted. The
complication rate for the chronic group after
soft-tissue coverage was still high but decreased
to 40% relative to the complication rate for the
subacute group.
In summary, muscle flap coverage applied
during the acute period resulted in the fewest
complications and shortest hospitalization stays.
Flap coverage applied during the subacute and
chronic phases was associated with a number
of complications, both immediate and late. As
the limits of bone débridement become better
demarcated during the chronic phase, reliable
bleeding margins of bone become apparent and soft
tissues adhere to healthy cortex outside the fracture.
12
Other authors,61,88 although recognizing the
challenging characteristics of subacute and chronic
tibial wounds, have taken issue with the limitations
imposed by a subacute tibial fracture. Yaremchuk
et al.88 reviewed a series of patients who received
flap coverage a mean of 17 days after injury and
noted an overall infection rate of 14%. A difference
in management between the series presented
by Yaremchuk et al. and the series presented by
Byrd et al.61 was the more aggressive débridement
reported by Yaremchuk et al. The implication is that
aggressive débridement might be able to convert
a subacute open tibial fracture to an acute quality
wound, after which flap coverage can proceed with
relative safety.
Like Byrd et al.61 and Yaremchuk et
al.,88 Gustilo et al.59 emphasized that it is best to
perform early flap coverage of severe injuries. When
definitive soft-tissue coverage was achieved within
14 days of injury, complications, costs, and the
number of secondary procedures were decreased.
Similarly, Francel et al.45 noted a low (3.6%)
incidence of complications in cases of Gustilo type
IIIB injuries when definitive free flap coverage was
accomplished within the first 15 days. Others have
also shown that delay in covering the open tibial
wound is associated with a high rate
of complications.89
Godina90 retrospectively followed 532
patients after microsurgical reconstruction of their
traumatic leg wounds. Group I (134 patients)
underwent free flap transfer within 72 hours of
injury. Group II (167 patients) underwent flap
coverage between 72 hours and 3 months of injury.
Group III (231 patients) underwent flap coverage
between 3 months and 12.6 years after injury. The
flap failure rates were 0.75% in Group I, 12% in
Group II, and 9.5% in Group III. Postoperative
infection developed in 1.5% of Group I patients,
17.5% of Group II patients, and 6% of Group III
patients. Time to union was 6.8 months in Group I,
12.3 months in Group II, and 29 months in Group
III. At first glance, a reader might infer that the
intermediate time frame—between 3 days and 3
months—is the worst time to reconstruct and that
definitive management should be deferred until

after 3 months. However, the report did not support
those assumptions. Note that Group III had the
longest time to union and the longest hospital
stays, indicating that early, stable soft-tissue
coverage of severe open tibial fractures improves
the overall outcome.
It remains unclear whether aggressive
débridement of bone during delayed treatment
of wounds affects outcome. There is little doubt
that liberal débridement of all fragments of bone
in a fracture invariably lowers the infection rate.
The surgeon must weigh the risk of taking time to
observe fractured bone for viability versus allowing
a wound to enter the delayed period of wound
colonization. The risks, if any, of removing bone
that ultimately might have been viable must also
be considered. One point of view advocates early
aggressive débridement, early soft-tissue coverage,
and early or delayed replacement of missing bone.
The success of early soft-tissue coverage
is well established. The “fix and flap” model, with
which flap transfer is performed simultaneously
with the final débridement procedure, is
recommended by some. Advocates of the approach
reported improved results because of the minimal
time allowed for bacterial colonization. Gopal et
al.91 reported a 9% deep infection rate with the fix
and flap method and a worsening infection rate
when flap coverage was delayed by more than
1 week.
According to many, early soft-tissue
coverage after one to three thorough débridement
procedures remains the standard of care for open
tibial fractures.71 Heller and Levin16 stated that
soft-tissue coverage applied within 7 days of injury
produces optimal results.
Paired with early soft-tissue coverage is
bone replacement and prophylactic bone grafting
of severe fractures. Some authors have advocated
simultaneous soft-tissue reconstruction and bone
replacement, whether done emergently or simply
early.92 Many surgeons, however, prefer to graft after
stable coverage has been achieved—up to 2 months
after the soft tissues have been repaired.15,71,93
Arnez94 discussed the history, pros and
cons, and results of immediate reconstruction of
SRPS Volume 11 Issue R1, 2009
the lower extremity by “emergency” free flaps.
Tropet et al.95,96 advocated aggressive emergency
multimodality treatment of severe open tibial
fractures. The authors reported 18 cases of
Gustilo type IIIB injuries treated emergently
with intravenously administered antibiotics,
débridement, and locked intramedullary nails.
Six patients received free muscle coverage, and 12
received local muscle flaps. Immediate iliac crest
bone grafting was performed in three patients.
Bone union was achieved at a mean 6.5 months
after treatment. Primary union was achieved in
13 of 18 patients (72%), all of whom were able to
return to work; the five remaining patients required
further intervention. The intriguing study was
neither prospective nor randomized. Further study
is warranted to establish whether this early, one-
stage definitive approach improves outcomes.
METHODS OF BONE RECONSTRUCTION
TO TREAT OPEN TIBIAL FRACTURES
The basic ways to bridge a bone defect in the leg are
bone grafting, free osseous or osteocutaneous flap
transfer, and distraction osteogenesis, also known as
the Ilizarov technique.
Bone Grafts
For Gustilo type IIIB fractures with significant
comminution and small bone gaps, cancellous bone
grafts beneath vascularized muscle flaps often are
used. With massive bone harvests, it is possible
to bridge defects >10 cm by using this technique.
Christian et al.97 evaluated eight patients who had
type IIIB open tibial fractures associated with large
(average, 10 cm) diaphyseal defects. The defects
were filled with antibiotic-impregnated beads and
covered with free flaps. The beads served as spacers
to preserve the volume of the diaphyseal defect.
Approximately 3 to 6 weeks later, the tibia was
reconstructed with massive amounts of autogenous
cancellous bone grafts. The mean duration of
external fixation was 5.5 months, and time to
healing after bone grafting averaged 9 months.
Nevertheless, massive cancellous grafts usually
are not the first choice of treatment for large
tibial fractures.
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SRPS Volume 11 Issue R1, 2009
An intact fibula facilitates bone grafting
of longer defects by acting as a strut to keep the
extremity at length. If the fibula is not intact,
which often is the case with high-energy injuries,
other reconstructive methods might be necessary,
particularly for defects >8 cm.
Canovas et al.98 reported an alternative to
vascularized bone or massive cancellous grafts. In
the case reported by the authors, the contaminated,
devascularized tibial segment was sterilized and
used as a tibial autograft to fill a 12-cm defect. The
patient reportedly achieved union at 6 months and
walked normally at 10 months. The use of autograft
that has undergone débridement and has been
frozen and subsequently boiled deserves
further study.
Vascularized Bone Transfers
Vascularized autogenous bone transfers are useful
in bridging long bone gaps. Most commonly
transferred as vascularized bone in the repair of
posttraumatic leg defects are the fibula, iliac crest,
and scapula. Taylor99 detailed the vascular anatomy
of the iliac crest and fibula. He cited examples
of microvascular bone transfers and reviewed
the sequence of lower extremity reconstruction
with vascularized bone. He was the first to report
using the free fibula transfer to repair tibial
defects.100 Sekiguchi et al.101 described the use of
osteocutaneous free scapular flaps in the lower
extremity. Allen et al.102 reported successful transfer
of latissimus dorsi-scapular bone flaps for lower
extremity reconstruction in 12 patients. Lin et al.103
compared the results of three different free flaps
for posttraumatic tibial reconstruction. In their
retrospective study, 64 fibulae, 22 serratus flaps with
rib, and 11 iliac flaps were compared. The fibulae
had the best results overall, but the other two
options are recommended when the fibula is
not available.
Weiland et al.104 reported an early series of
41 autogenous vascularized bone grafts used in the
upper and lower extremities. The average size of the
defects was 16 cm. The iliac crest was used when
the bone gap was ≤10 cm, and free fibular transfers
were used when the gap was larger. Technical details
of fibular harvesting are presented in the article. Of
14
32 free fibular grafts, 28 (87.5%) were successful.
Failures generally resulted in amputation. Full
weight bearing did not occur until approximately 15
months postoperatively, corresponding to the time it
takes for a graft to hypertrophy.
In another study evaluating free fibular
hypertrophy in the lower extremity, El-Gammal
et al.105 stated that the rate of fibular hypertrophy
correlates directly with youth, particularly in
patients younger than 20 years. The amount of
fibular hypertrophy was also more robust in younger
patients. In 25 patients with tibial defects who
underwent free fibular reconstruction, the bone
hypertrophy leveled out at 30 months. It is worth
noting that none of the tibial defects in that study
were of traumatic origin, which hampers our ability
to draw meaningful comparisons with other studies.
Wood et al.106 noted the value of
vascularized bone grafts in posttraumatic limb
salvage but acknowledged that 50% of their
cases required secondary operations. Free bone
transplantation in cases of severe leg trauma is
technically demanding and time-consuming,
and probably should be performed by
experienced microsurgeons.
These studies have drawn attention to
the prolonged time of partial weight bearing that
patients must go through while waiting for graft
hypertrophy and stability. Patient compliance
becomes an issue, and many find it difficult to
wait up to 2 years before attempting unaided
ambulation. Tu et al.107 reported 48 cases of long
bone reconstruction with free bone flaps, most of
which were fibulae to tibiae. The average time to
union was 4.2 months. The series also included
upper extremity long bone reconstructions, and
the authors documented significantly more bone
hypertrophy in lower extremity grafts than in the
upper extremity grafts.
Full weight bearing on an incompletely
hypertrophied fibular interposition graft risks stress
fracture. In 1999, Lee and Park108 reported fractures
in 15 of 46 fibulae at an average 9.7 months after
transfer. Nevertheless, the authors recommended
that patients begin early weight bearing on the
flaps or the necessary hypertrophy might not occur.

When stress fractures are expected, they
are tolerated.
In a follow-up study 5 years later, Lee
et al. reported the long-term outcomes of the
109
original 46 study patients plus five more. Overall,
47 of 51 bone flaps united at 3 to 7.5 months.
Two delayed unions and two nonunions occurred.
Pathological fracture occurred in 16 cases and
usually healed with long-leg casting, although some
required open reduction and internal fixation and
bone grafting. The authors emphasized that weight
bearing is necessary to stimulate hypertrophy in a
fibular graft and started their patients on partial
weight bearing as soon as bone union was noted
radiographically. In general, patients began weight
bearing at 4 to 7 months postoperatively. Three
complete losses of the fibular skin paddle but only
one complete necrosis of the bone graft occurred;
the other two grafts were salvaged. Adjunctive
procedures to reestablish soft-tissue coverage,
immobilization, and bone grafts might be
required in cases in which the fibular graft lacks
adequate stability.
Toh et al.110 suggested a potential solution to
the stress fracture problem. The authors advocated
folding the fibular grafts to provide more stability
and bulk. That technique is possible with either
pedicled or free fibular transfer and can bridge
defects as large as 10 cm (a folded 20-cm graft). The
increased bulk of the folded fibula might decrease
fracture rates and time to full weight bearing.
The fibula usually is transferred as a free
flap with or without a skin paddle. Lee and Park108
and Lee et al.109 used free fibular transfers with
skin paddles for combined bone and soft-tissue
reconstruction of open tibial fractures. Still, many
large bone defects also have large skin defects
that can be difficult to cover with a fibular skin
paddle. Such cases might require additional free
flap(s) or alternative methods of reconstruction.
It also is possible to transfer the fibula on an
ipsilateral pedicle as a vascularized bone graft
or osteocutaneous flap. Pedicled fibular transfer
might be more useful for defects of the proximal
tibia and distal femur.110,111 Atkins et al.112 reported
ipsilateral vascularized fibular transport for tibial
reconstruction. The technique does not necessitate
SRPS Volume 11 Issue R1, 2009
an intact fibula because pre-transfer distraction
lengthens the fibula sufficiently to bridge the defect.
When transferring a free fibula, it is useful
to know that the flap can be sustained on its distal
pedicle via retrograde flow. Therefore, when the
proximal pedicle of a free fibula is damaged, the
flap can still be anastomosed to the distal peroneal
artery and vein.110,113
Free transfer of a previously fractured
fibula has also been reported.114 As long as the
arteriogram confirms a good pedicle, this transfer is
an option for tibial reconstruction.
Distraction Osteogenesis
Bone gaps ≥10 cm can be bridged with the
Ilizarov technique.115−119 The procedure begins with
débridement of the fractured ends. The cortical
bone is transected outside the zone of injury,
leaving the medullary bone and blood supply intact.
Pins are inserted near the bone ends on either side
of the gap, and the external distraction apparatus
is applied. A waiting period of approximately 7
days typically is allowed before distraction begins.
Distraction consists of turning the screw(s) on the
external fixation device to gradually apply tension
across the corticotomy site (Fig. 3). Distraction
usually proceeds at the rate of 1 mm per day until
the defect is spanned.120 The circular frame usually
remains in place for 1 year—the time needed for
the bone to regenerate, consolidate, and mature.
Cierny et al.117 discussed advantages of
the Ilizarov technique. First, the amount of bone
generated is anatomically correct for the size of the
defect. Second, soft-tissue defects can be closed
by the docking method during the same process.
Finally, blood transfusions usually are not required.
The authors noted that because the process is
slow and potentially arduous for the patient,
candidates must be chosen with care. Relative
contraindications are a defect >12 cm, which
necessitates two lengths of regenerated bone of ≥6
cm, and deficient residual bone stock that cannot
support serial corticotomy procedures.
Vasconez and Nicholls116 discussed
the benefits of and indications for the Ilizarov
technique versus bone grafts or free bone transfer
in the management of severe open tibial injuries.
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SRPS Volume 11 Issue R1, 2009
Figure 3. Illustrations show the Ilizarov technique for
managing segmental defects of the tibia. A corticotomy
made high on the tibia is the source of regenerate bone
after the bone is distracted with transfixion pins on an
external frame. (Reprinted with permission from Cierny
et al.117)
Patients who had significant soft-tissue and bone
loss or severe comminution were divided into
one of two treatment groups. In one group, the
tibia was placed at length with the use of external
fixation and received either bone graft or free
fibular flap. Soft-tissue defects were repaired with
skin grafts, local flaps, or free flaps. In the second
group, the Ilizarov technique was used to transfer
both bone and soft-tissue elements to reconstruct
the extremity. The soft-tissue wound was closed
when the ends approximated. Both treatment
groups shared three constants: 1) débridement was
immediate and complete; 2) all exposed vessels were
covered emergently; and 3) the bone was stabilized
16
before vascular and soft-tissue reconstruction. The
authors suggested that the Ilizarov technique offers
more options for soft-tissue closure because the
bone gap can be made smaller. As the bone is slowly
lengthened, local flaps and soft tissues also stretch,
which theoretically lessens the size of the flap
needed for cover or changes the indications from
a free flap to a local flap. Unfortunately, the dense
scar beds of free tissue transfers and the pedicles of
conventional flaps can hamper bone transport by
the Ilizarov technique.
Distraction osteogenesis over an intramedullary
nail has been reported. This combined technique is
reported to permit early removal of the frame, as
the nail provides stability while consolidation takes
place.121 If found to have an acceptable complication
rate, the technique has the theoretic potential to
significantly shorten frame time and perhaps time
to ambulation.
The Ilizarov distraction method is not without
morbidity; it has one of the highest rates of
complications among orthopaedic procedures.
Almost all patients suffer multiple minor
complications. Pin tract infections, stiffness of
adjacent joints, and severe pain122−124 are
very common.
McKee et al.125 prospectively followed 25
patients for whom Ilizarov bone transport was used
to treat posttraumatic deformities. The patients
had very low preoperative scores based on health
profile scoring systems. The scores remained low
throughout the prolonged treatment program but
climbed markedly as their general health improved.
In short, patients do obtain good results with
Ilizarov distraction, but they must pay for it with an
arduous treatment course. Also noteworthy is that
additional bone grafting often is required at the
docking phase of Ilizarov bone transport.
Summary of Bone Reconstructive Techniques
In summary, most Gustilo type IIIB and IIIC
injuries that are candidates for early bone flap
reconstruction can be managed by external fixation
and free flap coverage over antibiotic-impregnated
beads, plus autogenous bone grafting several
weeks later. Tibial bone gaps ≤3 cm are ideal
for cancellous grafting. Defects ≥6 cm warrant

consideration of either Ilizarov bone transport or
vascularized bone grafting.103,104 Bone gaps ≥12 cm
are difficult to bridge with bone transport117 and are
a clear indication for free or pedicled vascularized
bone flaps, although smaller defects might also be
good candidates for vascularized bone. Regardless
of the length of the bone deficit, the quality of the
soft tissues can be a deciding factor between the use
of a free bone flap (typically contralateral fibula) or
bone transport beneath a vascularized muscle free
flap.126 In other words, bone defects ≥6 cm that also
have large soft-tissue loss might be better served by
bone transport under a vascularized muscle free flap.
Many Gustilo IIIB and IIIC injuries require at least
one free flap. The reconstructive choices for treating
severe tibial injuries become free bone graft with
skin paddle; free bone graft plus free muscle flap; or
free muscle and bone transport.
Of course, any patient who has a large tibial
bone defect, with or without a large skin deficit,
might also be a strong candidate for primary
amputation. The minimum size of a defect that
requires vascularized bone for treatment
remains undetermined.
METHODS OF SOFT TISSUE
RECONSTRUCTION TO TREAT OPEN
TIBIAL FRACTURES
In 1970, Ger54 introduced innovative techniques
for soft-tissue coverage of open tibial wounds. He
described the soleus myoplasty, flexor digitorum
longus, abductor hallucis, and gastrocnemius flaps
for bone coverage. Although local pedicle flaps
might be appropriate for acute type III fractures,
Byrd et al.61 preferred free microvascular muscle
flaps for many type III wounds. Byrd type IV
wounds by definition require free flaps for coverage.
Because traumatic lower extremity wounds
that require soft-tissue reconstruction often are
characterized by local muscle damage, pedicled flaps
often are not appropriate. The LEAP Study Group
reported higher short-term complication rates
associated with traumatic leg wounds covered with
local flaps than with those covered with free flaps.127
When pedicled flaps are possible, the
gastrocnemius and soleus muscles generally are
first choices for the reconstruction. Viability of the
SRPS Volume 11 Issue R1, 2009
pedicled flaps must be verified before flap elevation
and rotation, especially in the context of severe
trauma. Other local flaps in the leg that are options
for smaller chronic or nontraumatic wounds might
not be reliable for Gustilo type IIIB and IIIC
wounds and therefore are considered distant
second choices.
The soleus muscle flap generally is the first
choice for midshaft tibial wounds, whereas the
gastrocnemius is better for the proximal third of
the leg. Either flap can cover defects up to 25 cm2.
Neither is considered appropriate for the distal third
of the leg.16 The soleus can reach the lower third of
the leg, but its reliability suffers.128
Reversed fasciocutaneous flaps have been
suggested, but in general, they might not be
reliable in the context of severe open leg fractures.
Singh and Naasan129 described a small series of
low velocity injuries of the lower leg that were
adequately treated with reversed sural artery flaps. A
few of the treated injuries were classified as Gustilo
type III.
Muscle free flaps generally are preferred
for severe leg trauma because they fill dead space,
provide additional vascularity to the wound,
and allow flexibility of positioning and pedicle
placement.16,130,131 The workhorse microvascular flaps
for open tibial reconstruction are the latissimus, the
serratus, the rectus, and the gracilis.
May et al.130 advocated the use of
microvascular free tissue transfer for coverage of
distal lower extremity wounds with exposed bone.
Their experience is consistent with other reports of
vascularized muscle tissue used to obliterate dead
space and to donate well-perfused soft tissues to
the wound.
Serafin and Voci131 reviewed microsurgical
composite tissue transplantation to the lower
extremity. Microvascular transfers can deliver both
soft-tissue and skeletal support to large, complex
wounds of the leg and are particularly useful in the
distal third of the leg and in the foot.
Francel et al.45 reported their results
achieved by using microvascular reconstruction
of open tibial fractures. Long-term retrospective
follow-up revealed successful limb salvage in 93%
of patients. Among the patients, 66% exhibited
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SRPS Volume 11 Issue R1, 2009
significantly decreased range of motion of the
ankle, 44% showed swelling and edema requiring
elastic support and activity modification, and 50%
occasionally needed assistance for ambulation.
Khouri and Shaw132 reviewed 304
consecutive microvascular flap reconstructions of
the lower extremity. The most common indications
for reconstruction were Gustilo type IIIB and
IIIC fractures. Approximately 75% of the defects
were below the level of the midtibia. The latissimus
dorsi, rectus abdominis, and scapular skin flaps
were used. The failure rate was 8%, compared with
3% for non-lower extremity cases. The magnitude
of the traumatic insult was the most significant
factor associated with anastomotic failure. The rate
of anastomotic thrombosis doubled in the presence
of vascular trauma, tripled in cases of large bony
defects, and quintupled when vein grafts
were needed.
Nieminen et al.133 presented a series
of 100 patients who underwent 104 free flap
reconstructions for open tibial fractures. The authors
reported a 5% amputation rate.
Park et al.134 reviewed technical points of
recipient vessel selection and anastomosis in severe
open injuries. They noted that antegrade vessels
distal to the zone of injury are safe for receiving free
flaps when the inflow is good. In certain cases, even
reverse flow can be used to sustain a flap.
Regarding donor site morbidity, Colen135
reported 31% donor-related complications for the
latissimus dorsi and 20% for the rectus abdominis
muscle flaps. More recently, Musharafieh et al.136
noted 93% flap viability in 40 free rectus flaps
used for lower extremity reconstruction. Donor
site morbidity was said to be negligible. Only one
patient was not ambulatory at 3.5 years.
Redett et al.137 revisited the gracilis free flap.
The gracilis is an elegant flap, but its surface area is
not large. It can be used in wounds no wider than
5 to 7 cm and up to 30 cm long. In their series
of gracilis flaps, 95% of the limbs were salvaged.
One patient had chronic osteomyelitis. Minor
flap complications occurred in 12% and donor site
complications in 10%, including hematomas, a
seroma, and cellulitis. The pedicle of the gracilis flap
18
is shorter than that of the latissimus and serratus
flaps, which can limit its usefulness in a large zone
of injury.
Wechselberger et al.138 described an
innovative, anatomically sound method of taking a
large, transverse skin paddle with the gracilis. Their
variant considerably extends the surface area of the
gracilis free flap. The free anterolateral thigh flap has
also been described for reconstruction in open
tibial fractures.139
The Ilizarov device is sometimes used to
achieve soft-tissue distraction for wound coverage
of the lower extremity. The distraction frame
stretches and compresses soft tissue while bone is
transported. Two reports present detailed creative
use of Ilizarov frames for soft-tissue coverage of
open tibial wounds.140,141 Based on the reports, it is
unclear whether distraction is sufficiently reliable
for delivering stable, vascularized soft tissue to open
tibial wounds.
Another issue is how to successfully
coordinate bone transport through the zone
of a free flap. One report described a technical
modification in which the free muscle flap can be
partially split at the time of transfer to allow for
unimpeded pin transport.142
Agarwal et al.143 described soft-tissue
problems that tend to recur in cases of simultaneous
tibial transport and soft-tissue distraction. The
authors detailed a set of useful local flap procedures
for dealing with soft-tissue compression and
problems associated with moving pins. The use
of vacuum-assisted closure devices might be
changing treatment algorithms for lower extremity
reconstruction after trauma. Parret et al.144 reported
their retrospective review of 290 soft-tissue
reconstructions over open tibial fractures. They
noted that optimal synchronization between the
orthopaedists and the plastic surgeons results in
better treatment. They also described increased
reliance on rotational flaps, such as sural flaps, in
select cases. The vacuum-assisted closure device
allowed the authors to temporize many acute
injuries while yielding stable granulation beds. The
device allowed many patients to become candidates
for local flaps and skin grafts (Fig. 4).

Figure 4. Flow chart shows method presented by Parrett
et al.144 for treating open tibia-fibula fractures. Initially,
such cases are treated emergently in the operating
room with débridement, orthopaedic fixation, and
vascular repair if needed. The wound is then assessed for
contamination, swelling, and necrosis, and a decision is
made regarding the timing of closure. Vacuum-assisted
closure sponges frequently are placed until the swelling
has resolved. Delayed primary closure, local flaps, and
skin grafts often can then be used for wound closure.
*, Primary or delayed primary closure. (Reprinted with
permission from Parrett et al.144)
RECONSTRUCTION OF THE
AMPUTATION STUMP
The most important considerations regarding
lower extremity amputation stump reconstruction
are preservation of length and creation of stable
soft-tissue coverage. Patients undergoing below-
knee amputations are considerably more likely to
ambulate on prostheses than those undergoing
above-knee amputations. Also, the metabolic
demand on patients with above-knee amputations
is significantly higher than for patients with below-
knee amputations.
The level of amputation for vascular disease
and diabetes usually is determined by the severity
of disease. When amputations are traumatic,
SRPS Volume 11 Issue R1, 2009
however, the length of the preserved limb might be
determined by adequacy of the soft-tissue coverage.
In children, amputation through the knee joint
often is performed to prevent bony overgrowth of
the stump.
Several recent publications address methods
of reconstructing the amputation stump. Every
attempt should be made to preserve length with
local muscle and skin. If that is not possible,
flaps and skin grafts should be used to prevent
conversion of traumatic below-knee amputations to
above-knee amputations.
If muscle covers the bone end, a skin graft
will suffice.145,146 In stumps that are healed but have
poor soft-tissue coverage, tissue expansion can be
an option.147 The results are likely to be much better
if the expansion is carried out in the distal thigh
rather than the leg.
Free muscle flaps with skin grafts, free
musculocutaneous flaps, and fasciocutaneous
flaps are well accepted for covering stumps and
preserving the length of the extremity.148,149 Free
flaps from the latissimus dorsi, anterolateral thigh,
lateral arm, and scapula and free and pedicled fillet
flaps from nonreplantable amputated parts have
been reported to be used for those purposes.150
In reviewing the literature, it is unclear how well
muscle flaps compare with fasciocutaneous flaps;
either type can require secondary debulking
procedures.
It also is possible to lengthen short
below-knee amputation stumps with
osteomusculocutaneous flaps.151 The best candidate
for such an aggressive reconstruction is a healthy
patient, highly motivated to ambulate, who is held
back by a short below-knee amputation stump with
poor soft-tissue coverage. Sometimes the foot of
an amputated leg can be used for spare parts. The
fillet of foot and/or sole flap, transferred free or on a
pedicle, can be used to preserve length and
provide sensitive coverage to a traumatic leg
amputation stump.152−154
Patients with traumatic amputations of the
lower extremity might not be stable enough at the
time of the first surgery to undergo major stump
coverage operations. In those cases, the sole of the
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SRPS Volume 11 Issue R1, 2009

amputated foot can be refrigerated to be used at a • hypesthesia or anesthesia in the sensory

later time. Shah et al.155 reported successful stump
reconstruction with a free foot fillet flap that was
cooled for 57 hours at 4°C. Alternatively, if the
patient is stable enough for major surgery but
the stump is too contaminated to tolerate acute
coverage, the amputated part can be preserved by
temporary ectopic microsurgical implantation at a
distant site. When the stump is clean enough for
reconstruction, the glabrous skin and plantar fascia
of the foot can be transferred to the stump.156 Spare
parts surgery should at least be considered in cases
of traumatic lower extremity amputation.
COMPARTMENT SYNDROME
Diagnosis
Since Vogt157 originally described acute anterior
compartment syndrome in 1943, other authors have
reported compartment syndrome as occurring in
all four anatomic compartments of the leg.158-161 A
diagnosis of compartment syndrome is made on the
following clinical signs and symptoms:
• pain disproportionate to the injury
• palpably swollen compartments
• pain on passive stretching of the
involved muscles
• diminished simple touch perception
• decreased strength of the involved
compartment muscles
distribution of the nerve in the
involved compartment
Physical examination identifies the involved
compartment(s) (Table 2).162
The distal pulses might or might not be
palpable. Most of the cardinal signs are actually
late findings, particularly diminished pulses and
symptoms of nerve compression. The best early
clinical sign in the awake patient is severe pain
with passive stretch of involved muscles. The
clinician should not wait for additional cardinal
signs to evolve when compartment syndrome is
highly suspected.
The normal intracompartmental pressure
is 30 to 40 mmHg ± 4.163,164 Allen et al.165
emphasized the value of continuous monitoring
of intracompartmental pressures to diagnose the
presence of clinically significant compartment
syndrome. Compartment pressure is monitored
with a slit catheter inserted via a 16-gauge Medikit
cannula (Eastern Medikit Limited, Delhi, India). A
heparin infusion pump maintains the patency of the
catheter. The authors concluded that transient rises
in compartment pressure can be tolerated as long as
the pressure does not remain above 40 mmHg for
longer than 6 hours. If it does, or if it at any time
rises to >50 mmHg, fasciotomy is indicated.
Spectroscopy has been tested for measuring
compartment oxygenation.166 Whether oxygenation

Table 2
Signs of Developing Compartment Syndrome162

Compartment Sign
Anterior compartment Pain on passive plantar flexion, especially of the big
toe, and foot eversion

Lateral compartment Pain on passive dorsiflexion and foot inversion

Superficial posterior Pain on passive dorsiflexion with knee extended and
compartment ankle flexed

Deep posterior compartment Pain on passive ankle dorsiflexion, foot eversion, and
toe extension (especially the big toe)

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correlates well with actual compartment syndrome, far outweighs the risk of performing fasciotomies
especially in the context of trauma, is unclear. that only in hindsight are determined to have
The results of spectroscopy must be viewed in been unnecessary.
the context of clinical signs and symptoms and Hyde et al.162 described a simple fasciotomy
other test findings in the awake patient. One for bedside decompression. Nghiem and Boland
can test a soft compartment, perhaps on the 171
and DeLee and Stiehl161 questioned the value
other leg, to assess whether the equipment reads of fibulectomy-fasciotomy for decompression of
true. When evaluating pressure measurements, all four compartments when weighed against the
serial readings are the standard for making the importance of the fibula in fracture stabilization.
diagnosis of compartment syndrome.167 A normal Pearse et al.167 advocated a fibula-sparing,
pressure reading must not deter the surgeon from two-incision method for full four-compartment
performing fasciotomy when the results of a clinical decompression. One incision medial to the
examination are positive. tibia decompresses both the superficial and
deep posterior compartments and stops at the
Epidemiology posteromedial tibial border. The second
Acute compartment syndrome can result incision courses laterally through and over the
from trauma, postoperative bleeding, tendon anterior compartment and enters the lateral
graft harvesting, casting over evolving soft- compartment (Fig. 5).
tissue swelling, electrical burns, thermal burns,
intracompartmental bleeding caused by systemic
disease or anticoagulation, and animal bites,
particularly snake bites.168−170
A retrospective review of 198 open tibial
fractures by Blick et al.164 revealed a 9.1% incidence
of compartment syndrome. The development of
compartment syndrome was directly related to
the degree of injury to the soft tissues and bone.
DeLee and Stiehl161 reviewed the occurrence of
compartment syndrome in fractures of the lower
extremity. Of 104 patients with open tibial fractures,
six (5.7%) developed compartment syndrome
involving all four compartments. In contrast,
only five of 411 patients (1.2%) with closed
tibial fractures met the criteria for compartment
syndrome. These data refute the notion that an
open fracture allows adequate decompression of
the compartments. It does not. Open injuries are
indicative of higher energy and might therefore be Figure 5. Cross-section through leg shows site of
at higher risk of compartment syndrome. fasciotomy incisions to decompress all four compartments.
(Reprinted with permission from Pearse et al.167)
Management
Compartment syndrome does not need to be
proven beyond a reasonable doubt. If compartment Although the wounds left after leg
syndrome cannot be ruled out, decompression fasciotomies are clinically impressive, they tend to
through four-compartment fasciotomy is be easy to manage. Prophylactic antibiotics often are
recommended within 6 hours of symptom onset. used but are not essential in all cases. Meticulous
The risk of not performing fasciotomy local wound care is the key to successful closure.

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SRPS Volume 11 Issue R1, 2009
Techniques such as lacing with vessel loops through
skin staples, dermatotraction, and suturing with
pull-through monofilament dermal running sutures
can close a wound primarily if gradual closure is
begun early during the postoperative period.172−174
The techniques produce better cosmetic results than
do split grafts over muscle.
Outcome
A chronic Volkmann-like contracture state, with or
without sensory loss, can result if compartments are
not released.159,161,162,164 Kikuchi et al.160 described
the clinical features of compartment syndrome in
20 patients. Saphenous nerve sensation is preserved,
because the nerve lies outside the compartments. In
their study, limb function deteriorated with length
of ischemia. Function was good after 3 hours, fair
after 14 hours, and poor after 21 hours of ischemia,
even in the context of released compartments. The
prognosis was especially poor when both the tibial
and peroneal nerves were involved and in cases of
severe venous insufficiency during the acute stage.
The authors advised against reconstruction of the
chronically affected limb before 18 months from
injury to allow for maximum return of function.
That interval is additionally needed to help the
clinician and the patient decide whether amputation
is preferable.
OPEN JOINT INJURIES
Patzakis et al.175 prospectively studied 140 patients
with open joint injuries. For the acute injury, they
recommended preoperative and intraoperative
cultures, broad-spectrum antibiotics until cultures
are read, copious irrigation, débridement of the joint
and injured soft tissues, and primary closure of the
wound without drains. Closed suction drains were
thought to be responsible for wound contamination
in 14.3% of patients who had negative cultures
before or during surgery. The most common
organisms were Pseudomonas and Klebsiella. The
authors concluded that the only indication for use
of an irrigation system in open joint injuries is the
presence of extensive soft-tissue and bone damage,
when closure of the joint would be advantageous.
Barfod and Pers176 reported their experience
using immediate gastrocnemius muscle flaps for
22
closure of five open knee joints. No infections
occurred. The notion of augmenting deficient soft
tissues by transposing muscle flaps seems logical
and possibly analogous to the improved results
achieved with early soft-tissue coverage of open
tibial fractures.
Chronically contaminated and open joints
present another problem. Soft-tissue closure alone
yields an unacceptable number of septic joints and
related sequelae. Per Byrd et al.,61 studies of the
closed plaster method presented by Trueta5 have
shown that joints allowed to remain open while
the patient ambulates can heal without loss of
the cartilaginous interface and without infection.
When large attendant soft-tissue losses have
occurred, however, scar contracture frequently
limits function of the joint. Secondary muscle or
soft-tissue coverage without water seal closure
and active ambulation might be beneficial in the
management of contaminated open knee and ankle
joints. Options for the knee include gastrocnemius
muscles, turn-down thigh muscles, and free flaps.
In the presence of a chronically infected and
granulating open joint, débridement of exposed
synovium and granulation can be considered before
muscle coverage.
Pu and Thomson177 presented two cases of
irradiated, chronic open knee joint salvage with
free muscle flaps. One patient retained 35 degrees
of extensor lag to 65 degrees of active flexion. The
other had 15 degrees of lag and flexed to 60 degrees.
Both patients were able to ambulate.
Cierny et al.178 reviewed their experience
with 36 refractory infections of the open ankle and
offered a comprehensive discussion of management
and surgical techniques for treating the wounds.
The authors concluded that after cartilaginous
débridement, when intact proximal and distal
cortices are present, the ideal treatment involves
free bone grafts placed between the tibia and the
talus. Fixators, staples, or plates external to the
graft achieve the necessary compression. The use of
medial and lateral osteocutaneous flaps for bone and
soft-tissue reconstruction and preservation
is discussed.

NONUNION
Nonunion results from insufficient stabilization
or insufficient perfusion of the fracture.18,24
Infection can contribute to either or both causes.
Radiographically, nonunion presents in one of two
forms: as a hypertrophic elephant foot callus or as a
porotic, resorptive process along the line of fracture.
A hypertrophic callus denotes inadequate
stabilization of the fracture segments. Union
is likely to occur if appropriate stabilization
is provided. A resorptive process, or atrophic
nonunion, occurs as a result of ischemia or a
septic process. If the nonunion occurs because
of inadequate blood supply without infection,
stabilization and bone grafting often will bring
about union. In contrast, an infected fracture
is chronic osteomyelitis and might require
multimodality therapy.
The standard treatment of aseptic nonunions
consists of stabilization and bone grafting.
Kettunen et al.179 described a novel technique of
percutaneous bone grafting to treat aseptic tibial
nonunions that resulted in bone healing in 37 of 41
fractures. Megas et al.,180 on the other hand, stated
that bone grafting is not always necessary for tibial
nonunions. They reported achieving union in 50
patients with aseptic tibial nonunions treated with
reamed intramedullary nails. Bone grafts were used
in only three patients in that series.
Ohtsuka et al.181 coated an intramedullary
nail with antibiotic-impregnated cement before
placing it within a Pseudomonas-infected tibial
nonunion. Bone grafting was accomplished
after the infection clinically receded, and union
eventually was achieved. The coated nail was later
removed, and the functional outcome was
deemed excellent.
Safoury182 treated 10 distal tibial nonunions
with a technique originally described by Hertel et
al.183 with which the fibula is pedicled on reverse
flow. The reverse flow is provided by distal crossover
vessels between the posterior tibial and peroneal
systems. Union was achieved in all fractures, and
the patients were full weight bearing by 9 months.
Erdinger et al.184 combined a latissimus and
scapula osteomuscular flap for effective treatment
of infected nonunions. The authors provided details
of the flap anatomy and harvest technique used in
SRPS Volume 11 Issue R1
five representative cases. The technique is an option
when a small to moderate amount of vascularized
bone and a large amount of soft tissue are needed.
Duffy et al.185 reported the results of onlay free
fibular transfer combined with cancellous grafts in
irradiated nonunions.
OSTEOMYELITIS AND
INFECTED NONUNION
Posttraumatic osteomyelitis is more commonly
associated with severe open tibial fractures than
with milder injuries. Patzakis et al.186 investigated
the effectiveness of prophylactic antibiotics in a
series of >1100 patients with open tibial fractures.
Patients who did not receive antibiotics had a 24%
infection rate. Only 4.5% of patients who received
prophylactic broad spectrum antibiotics for 3 days
developed infections. The most common pathogen
in both groups was coagulase positive Staphylococcus.
Ger and Efron187 and Ger188 identified
the major causes of persistent infection after
open fractures as retained necrotic and infected
bone, avascular or infected scar, dead space in
the surgical site, and inadequate skin cover. The
authors postulated that ischemia was responsible
for chronicity and for operative failures. They
are credited with voicing the currently accepted
principles of surgical treatment of osteomyelitis:
dead space obliteration and aggressive débridement.
Horwitz189 reviewed traditional
management options for chronic osteomyelitis, as
follows:
• ostectomy with primary wound closure and
closed suction drainage
• ostectomy with partial wound closure and
secondary split grafting
• ostectomy with partial wound closure and
packing
• resection with immediate delayed
wound closure
• amputation
The current mainstay of treatment for chronic
osteomyelitis is excision of pathological tissue,
including necrotic and infected bone, bone
sequestra, and poorly vascularized soft tissues.
Obliteration of dead space and enhancement
of blood supply with muscle flap coverage
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SRPS Volume 11 Issue R1, 2009
complements wound management after
débridement.
Mathes et al.190 expanded the débridement
procedure described by Ger to include nonviable
bone, scar, and chronic granulation tissue in
the medullary canal. Because of their superior
resistance to infection over conventional flaps, free
microvascular muscle flaps were used to obliterate
the dead space and to cover the exposed bone. At
an average follow-up duration of 1.8 years, all 11 of
the patients presented by Mathes et al. had achieved
resolution of the osteomyelitis.
In a follow-up study, Anthony et al.191
traced the postoperative course of 34 consecutive
patients with chronic osteomyelitis of the distal
lower extremity. Treatment was by débridement, a
10- to 14-day course of culture-specific antibiotics,
and muscle flap coverage. Long-term follow-up of
27 patients revealed that 24 (89%) healed with no
recurrence at >5 years and three (11%) experienced
recurrence of the osteomyelitis. Of the three
patients, two were cured after additional muscle
flap procedures.
May et al.192 reported their extensive
experience with chronic osteomyelitis of the leg.
Management was by radical débridement of bone
and soft tissue and reconstruction by a second-
or third-stage latissimus dorsi free flap transfer.
Discontinuity defects were filled with cancellous
bone grafts after soft-tissue coverage. Excellent
results were documented.
May et al.193 subsequently reviewed their 13-
year, 96-patient experience with bone débridement
and microvascular free tissue transfer for soft-tissue
reconstruction of chronic traumatic bone wounds.
After a mean follow-up of 77 months, 91 patients
enjoyed complete wound closure and absence
of drainage. Five patients ultimately required
amputation because of treatment failure and
recurrent infection.
Damholt194 reported 98% cure in 55 patients
treated for chronic osteomyelitis. His radical
operation removes all internal fixation devices
and includes sequestrectomy, partial decortication,
and primary wound closure with suction drainage.
Thirteen patients underwent wound closure by
24
flaps of various types. External fixation was used if
stabilization was necessary.
Significant gaps in the long bones secondary
to débridement can be bridged with secondary
block cancellous insert grafts. Survival of the bone
grafts depends on a well-vascularized soft-tissue
bed.195 Sudmann196 preferred surgical débridement
and grafting with cancellous and cortical-cancellous
bone in one operation. Of 13 consecutive patients
with osteomyelitis who were treated by that
protocol, 12 healed after a single operation and one
required three operations before his osteomyelitis
was eradicated. The grafts did not form sequestra.
Among the more experimental techniques
for managing chronic osteomyelitis is necrectomy
and packing of the defect with antibiotic beads.197
The technique delivers antibiotics in high
concentration and fills dead space. The beads are
then gradually removed to slowly collapse the size
of the cavity.
Tulner et al.198 analyzed their 11-year
experience with 47 patients who were treated for
posttraumatic osteomyelitis by the following a
three-step protocol:
1) Wide débridement of devitalized bone and
soft tissue with implantation of antibiotic
beads and external fixation are performed as
needed. The patient begins a 3- to
6-week course of intravenously
administered antibiotics.
2) Removal of the beads and insertion of
a spacer are performed at 10 to 14 days,
with soft-tissue coverage provided by either
pedicled muscle or free muscle flap.
3) Bone grafting is performed at 3 to 4 weeks
after the flap is applied.
The authors reported a 91% cure rate at a mean 7.8
years and 100% eradication of infection at the
final visit.
Another ingenious treatment is the
application of hyperbaric oxygen to the wound.199
At 3-atm absolute pressure, O2 diffusion into
avascular tissue increases several-fold, which has a
bactericidal effect and speeds up healing. Aggressive
surgical débridement might have contributed to the

good outcome in the study presented by Morrey
et al.199
Arnold et al.200 reported 90% cure of
osteomyelitis of the lower extremity 15 years after
treatment with local muscle flaps. Musharafieh
et al.201 reported high efficacy of free flaps in the
treatment of chronic osteomyelitis of the leg.
Wells et al.202 and Gonzalez et al.203 noted a trend
toward increased risk of free flap failure in chronic
wounds associated with osteomyelitis compared
with uninfected wounds. In a study of 42 free flaps
for chronic leg wounds, Gonzalez et al.203 noted
that osteomyelitis is a strong predictor of flap
failure and ultimate loss of limb. In the presence of
osteomyelitis, the flap failure rate was 22%; when
osteomyelitis was absent, the flap failure rate
was 7%.
Surgeons must beware of malignant
transformation in chronic osteomyelitis that never
seems to heal.204 Periodic biopsy and cultures are
warranted during long treatment courses.
Faden and Grossi205 evaluated 135 children
who had acute osteomyelitis. The causative agent
was identified as Staphylococcus aureus, Haemophilus
influenzae type B, and Pseudomonas aeruginosa
in 25%, 12%, and 6%, respectively. H. influenzae
occurred only in children younger than 3 years.
Currently, Haemophilus osteomyelitis is very rare
thanks to widespread vaccination against the
bacteria. Most pediatric cases of osteomyelitis result
from hematogenous spread of bacteria.
In the study by Faden and Grossi, all wounds
infected with P. aeruginosa were penetrating injuries
to the foot. Children with P. aeruginosa infection
were older than 9 years (100%), predominantly
male (88%), often afebrile (83%), and never
clinically bacteremic.
CHRONIC LEG ULCERS
Picascia and Roenigk206 reviewed the
dermatological and topical management of leg
ulcers. They recommend early adjunctive measures
for unstable areas before full ulcers develop.
The most common cause of cutaneous ulcers
is decreased skin perfusion and infection. Decreased
skin perfusion can result from disease in the large,
medium, or small arterial vessels or the capillary
SRPS Volume 11 Issue R1, 2009
bed, such as atherosclerosis, diabetes, or vasculitis.
Venous hypertension also decreases skin perfusion
and can result in tissue ischemia or death. Host
defenses are marginal in ischemic tissue, which
contributes to the development of
subclinical infections.
Venous Disease
Venous insufficiency affects millions of patients in
the United States and is associated with varicosities
or thrombophlebitic disease. An increased column
of blood from incompetent valves causes a rise in
hydrostatic pressure and produces chronic venous
insufficiency. The typical clinical signs include
edema, hyperpigmentation, and ulcerations around
the legs and ankles.
The venous system of the leg is comprised
of the superficial veins and venules, the perforating
or communicating veins, and the deep veins. Mild
forms of venous insufficiency are associated with
varicose veins. Severe forms are associated with
deep-system reflux about the popliteal area and leg.
Pathophysiology
Although the cause of chronic venous insufficiency
is understood, the pathophysiology of venous
ulceration is not clear. The major theories implicate
pericapillary fibrin deposition or white blood
cell plugging.
Pericapillary Fibrin Deposition—Moosa
et al. used transcutaneous oxygen monitoring to
207
prove the existence of a local pathological barrier to
oxygen diffusion in patients with venous ulcers.208,209
Balslev et al.,210 on the other hand, considered
fibrin deposition to be a secondary phenomenon
occurring in already ulcerated skin.
White Blood Cell Plugging—Occlusion of
capillary loops by white blood cell thrombi has been
blamed for venous ulcers. Thomas et al.211 showed
a significant decrease in the number of white blood
cells returning from the dangling legs of patients
with chronic venous insufficiency.
Coleridge Smith et al.212 counted the
number of capillary loops per mm2 with legs supine
and legs dependent. After 30 minutes of dangling,
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SRPS Volume 11 Issue R1, 2009
significantly fewer capillary loops were visible in
90% of subjects. The authors concluded that the
capillary loops become occluded with white blood
cell plugs and that activation of the trapped white
blood cells produces ischemia on a vascular basis.
Valvular Incompetence—Valvular
incompetence is a major factor in the development
of stasis, pigmentation, and ulceration. van
Bemmelen et al.213 studied the relation of
ulcerations to the functional status of the superficial
and deep venous valves. Doppler scanning showed
valvular incompetence in 22 of 25 ulcerated limbs.
The most commonly involved incompetent segment
was the popliteal vein, and the next most common
was the superficial femoral vein.
Management
The exact site of venous incompetence must
be determined preoperatively if therapy is to
be successful. McEnroe et al.214 evaluated the
hemodynamics of patients with chronic venous
insufficiency. Venous obstruction was uncommon
(5%); therefore, venous bypass surgery might be
of little value in resolving the problem of chronic
venous insufficiency. Patients who had venous
ulcerations tended to have deep venous insufficiency
alone (72%), suggesting that deep valvular
reconstruction might be a treatment option in
such cases.
It is estimated that 1% of people in the
United States will experience chronic venous stasis
ulcer at some time in their lives. Although most
chronic venous ulcers are secondary to alterations
in the deep venous system, 28% are caused by
superficial or combination superficial and deep
venous insufficiency.
Compression Therapy—Compression
therapy for the management of lower extremity
venous ulceration dates back to Hippocrates. The
method was later advocated by Paré in 1553.
The significant recurrence rate is almost always
related to failure of the patient to comply with
long-term therapy.
Mayberry et al.215 reviewed the course of 113
patients with severe, chronic venous insufficiency
26
and ulcerations. After treatment with ambulatory
compression therapy, 93% of patients experienced
complete ulcer healing in a mean 5.3 months.
Among patients followed for an average of 30
months, 80% continued to be compliant with
stockings and 16% had ulcer recurrence. All patients
who were noncompliant had recurrent ulcerations
by 36 months.
Subfascial Ligation—Subfascial ligation of
incompetent perforating veins is largely effective
in inducing healing of venous ulcers. Jamieson et
al.216 reported their experience in 118 limbs with
refractory venous stasis ulcers treated by subfascial
ligation. Postoperative complications were minimal.
The authors reported good to excellent results in
82% of cases at a mean follow-up duration of 8
years, with healing of ulcers and no recurrence
despite considerable noncompliance with support
stockings.
A modified Felder-Rob subfascial ligation217
in 45 limbs with chronic venous ulcers also
produced good results, with only 4.4% recurrence
of ulceration after 2 to 8 years of follow-up.218
Complications of subfascial ligation include skin
necrosis, exposure-induced necrosis of the Achilles
tendon, and equinus deformity of the ankle from
contracture of the tendon.
Vein Valve Transplants—Venous valve
transplantation has been recommended to
prevent reflux from the thigh veins and thus
lower ambulatory venous pressure at the ankle.
Nash219 presented his experience with venous valve
transplantation in 23 patients; before surgery,
17 had recurrent ulcers, six had severe pre-ulcer
skin damage, and 18 had undergone previous
unsuccessful venous operations. Duplex sonography
was used for preoperative and postoperative
evaluation of the popliteal vein to detect reflux
and graft patency. Ambulatory venous pressures
were measured directly in the dorsal foot of
all patients before and after surgery. A 5-cm
segment of brachial vein containing a competent
valve was transposed to an excised segment of
popliteal vein. Valve competence was tested before
completing the proximal anastomosis. Fifteen of

23 patients experienced complete healing of the
ulcers. All patients experienced relief of symptoms
of claudication. At 18 months, all transplants
remained patent but five had evidence of reflux
at the transplanted valves and one developed a
recurrent ulcer. Documented falls in ambulatory
venous pressure averaged only 18% despite
functioning popliteal valve transplants, probably
a reflection of the many remaining incompetent
valves in the posterior tibial and peroneal veins.
Rai and Lerner220 followed 25 patients with
end-stage venous insufficiency unresponsive to
conservative management. All patients experienced
ulcers of the lower extremities for more than 6
months (average, 4.5 years). Valvular incompetence
in the deep venous system was diagnosed in 15
patients, 12 of whom had brachial vein transplants.
Of the 12 patients, 10 had ulcers that healed within
1 to 6 weeks and two required skin grafts. All
patients experienced complete relief of pain and
were able to ambulate. Four patients noted
total resolution of lower extremity swelling, and
the rest experienced various degrees of
symptom improvement. A comparison of
pre- and postoperative venous pressures showed no
significant change to account for the
clinical improvement.
Ger188 emphasized the need to treat the
primary disease contributing to the ulcer and
detailed the management of venous ulcers by
various operative and nonoperative means. The
authors reviewed the advantages of coverage with
local muscle flaps and split-thickness skin graft,
including which muscle flaps are most appropriate
for particular areas of the lower extremity. They
additionally discussed the causes of primary muscle
flap failure.
Arterial Disease
Arterial insufficiency is a known cause of
chronic leg ulceration, recognized by symptoms
of claudication, pain while at rest, and the
characteristic appearance of arterial ulcers. Arterial
ulcers tend to occur distally on the leg and foot and
usually are accompanied by painful episodes. The
pain improves on dependency and is exacerbated by
elevation of the extremity.
SRPS Volume 11 Issue R1, 2009
Management
The management of ulcers caused by arterial
insufficiency differs drastically from that of venous
ulcers, even though arterial occlusion and venous
insufficiency might coexist in the same patient.
Sindrup et al.221 studied 94 consecutive patients
with stasis ulcers and noted that 50% had evidence
of obstructive arterial disease, more severe in cases
in which diabetes was also present. The authors
concluded that patients with obvious stasis ulcers
of the legs should be carefully examined for
coexisting arterial disease which, if present, is a
contraindication for compression therapy.
A large study from Scotland222 reviewed
600 patients (827 ulcerated legs) for the relation, if
any, between gangrene and the use of compression
bandages. Elastic bandages and compression
hosiery produce pressures of approximately
30 mmHg at the ankle level. Pressures are not
evenly distributed around the circumference of
the limb but instead tend to be much higher over
prominences such as the malleoli, the Achilles
tendon, and the anterior tendons of the ankle. Those
sites are at high risk of injury from compression
bandages, and reductions in blood flow might be
further aggravated by elevation of the affected
extremity. Doppler resting pressures of ≤0.9
indicated arterial insufficiency and were noted
in 21%.
In the Scotland study, 222 palpable pulses
in the foot did not preclude arterial insufficiency.
Approximately 50% of patients with arterial
impairment also showed clinical features of chronic
venous insufficiency. The authors concluded that
patients who have ulcerations anywhere on the foot
should be regarded as having arterial disease until
proved otherwise.
Arterial disease should be ruled out
before compression and elevation are instituted
for venous disease.223 Once the presence of
arterial insufficiency has been established, general
guidelines for management of vascular disease are
applied. Patients whose wounds fail to improve
preoperatively despite meticulous wound care
are chosen for arterial bypass grafts to avoid
amputation. Arterial disease to the level of the
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SRPS Volume 11 Issue R1, 2009
malleoli is common among diabetic patients, for
whom more distal bypass sites should be chosen.
Arterial inflow can be restored with a
saphenous vein bypass graft to the distal trifurcation
vessels. Andros et al.224 described lateral plantar
artery bypass grafting from the distal popliteal
artery in 17 patients with gangrene of the foot.
The foot salvage rate at 2 months was 89%. All
except four of 20 ulcers healed within 6 months.
Even with a functioning bypass graft, therefore,
local wound healing is protracted. Two patients
progressed to below-knee amputation, one despite
a patent graft. All patients who achieved successful
revascularization were able to walk eventually, and
seven returned to work full-time.
Similarly, Daane et al.225 reported a small
series of successful distal lower extremity bypass. In
that series, patients underwent inframalleolar bypass
grafting with arterial grafts using the operating
microscope. Five of six patients who underwent
the operation enjoyed graft patency at 52 months.
The technique might hold promise for patients
with distal arterial disease who suffer from arterial
ulcers and chronic pain. Another study reported
the use of dorsal venous arch arterialization for
revascularization of distal ischemia when poor
recipient vessels exist.226
Lepäntalo and Tukiainen227 presented a
series of combined lower extremity revascularization
and free flap coverage of arterial wounds. They
reported an overall limb salvage rate of 76% at
1 year. The authors noted that in some cases, the
free flap remained viable while the distal limb
progressed to worsening ischemia. The study
indicated the possibility of combining lower
extremity revascularization with free flap coverage
for peripheral vascular disease in select cases.
Gooden et al.228 reviewed their extensive
experience with microvascular flaps for
lower salvage. In a very difficult group of 26
patients—92% with exposed bone, joint, or tendon;
90% with diabetes; and 33% on dialysis—the
authors performed 27 free flaps of various types.
The selection criteria included patients with large
soft-tissue defects who were ambulatory and
functioning fairly well and patients with acceptable
28
cardiovascular risk to withstand a long operation
(average operative time, 5 hours 18 minutes). At a
mean 14 months after surgery, the limb salvage and
ambulation rate in that series was 88%. Similarly,
Quiñones-Baldrich et al.229 reported a 72% limb
salvage rate in 15 patients with a mean age of 60
years at 36 months after combined distal leg and
foot revascularization and free muscle flap coverage.
In a larger study, Illig et al.230 noted that
diabetes and dialysis-dependant renal failure
were the strongest predictors of limb loss when
existing together. Diabetes was the strongest
predictor of patient death. The authors considered
the comorbidities to be possible contraindications
to combined limb revascularization and free flap
coverage. In that study, 65% of patients recovered
good ambulation but the limb salvage rate was 57%
5 years postoperatively. Interestingly, age alone does
not seem to be a risk factor in cases of extremity
bypass graft and free tissue transfer surgery.
Like Gooden et al.,228 Moran et al.231
reported a 63% limb salvage rate at 5 years in 75
patients with severe peripheral vascular disease who
underwent free flap coverage of ischemic leg and
foot wounds. The perioperative mortality rate
was 5%.
An interesting technical twist was reported
by Maloney et al.232 who used free omentum
for upper and lower extremity reconstruction
in six patients, capitalizing on the large vessels
and flow-through properties of the omentum to
provide distal arterial vascularization. The authors
touted the overall robust blood supply of the flap
and its potential for revascularizing wound beds.
The omentum might be worthy of consideration
in difficult lower extremity reconstruction-
revascularization cases as a dual-use free flap and
arterial conduit to the foot. As an alternative to
free flap reconstruction in such cases, Isenberg233
reported transferring a pedicled sural flap in each of
nine patients for lower extremity revascularization
and wound coverage. The results 6 months
postoperatively were good.
The rehabilitation rates after below-
knee amputation exceed 90% in some series.234
Community-based studies note rehabilitation

rates of 40% to 60%,235 so for combined
revascularization and free flap coverage to be
hailed as a success, ambulation rates should be at
least that high. Attinger et al.236 presented a large
series of patients with difficult arterial wounds
and significant comorbidities. Forty-five patients
with renal failure and diabetes were treated by
aggressive multimodality therapy, including
limb revascularization and soft-tissue coverage
procedures. Several patients required free flaps for
wound coverage. Of the patients still alive at 3 years
after surgery, 89% retained their limbs and 73% had
achieved independent ambulation. Attinger et al.236
and others230 have shown the potential of functional
limb salvage when revascularization and wound
coverage are combined in select patients
despite comorbidities.
Diabetic Ulcers
The typical diabetic patient suffers from a
combination of distal sensory loss and reduced
peripheral arterial circulation. Abnormal physical
stresses, however minor, can cause ulceration. Of
note, poorly fitting shoes are the most common
cause of foot lesions in diabetics. Foot ulcers are the
most common cause of hospital admission for that
patient population.237 Lipsky et al.238 published a
recent excellent review of diabetic foot infections.
The review includes several detailed and applicable
algorithms for diabetic foot management.
Colen135 addressed common misconceptions
regarding the care of diabetic ulcers. The first
myth is that foot problems are caused by small
vessel disease. Histological staining of amputation
specimens from diabetic patients shows no
arteriolar occlusion. Blood flow measurements
during femoropopliteal bypass show no difference
in response to papaverine vasodilation, indicating
normal reactivity of the vessels. The second myth
involves purported endothelial proliferation in
small vessels of diabetic patients. No evidence of
intimal hyperplasia in the small vessels of diabetic
patients has been shown, suggesting that diabetic
neuropathy, and not microvascular disease, accounts
for foot lesions.
SRPS Volume 11 Issue R1, 2009
The cause of diabetic neuropathy
remains elusive. Stevens et al.239 implicated a
combination of closely interdependent metabolic
and vascular defects, such as reduced nerve blood
flow from structural changes in the endoneurial
microvasculature, abnormalities in vasoactive agents
regulating nerve blood flow, and altered tone of
autonomic nerves to blood vessels. Other metabolic
defects include disruption of the polyol pathway,
altered lipid metabolism, advanced glycosylated end
product formation, and diabetes-induced defects in
growth factors.
The cause of abnormal blood flow to
the feet in cases of diabetic neuropathy is not
known, although sympathetic denervation has
been suggested.240 Similarly, the interactions
among altered blood flow, painful neuropathy, and
neuropathic ulcers is unclear. Perfusion studies
indicate a blood flow pattern consistent with
reduced peripheral vascular resistance, probably
from arteriovenous shunting resulting from distal
sympathetic denervation.240
Boulton237 classified diabetic foot lesions
according to five grades of severity. Grade I lesions
occur under areas of weight bearing, such as the
toes and metatarsal heads. Grade II lesions occur at
similar sites but are much deeper, often with tendon
involvement and infection. Total contact casting of
the foot is indicated to remove pressure from the
ulcerated area. Grade III lesions require surgical
intervention after control of the infection. Grade
IV lesions require arteriography to determine
which can be treated surgically. Grade V lesions
necessitate amputation.
Treatment consists of reducing localized
pressure on prominent surfaces of the sole. In a
study conducted by Sinacore et al.,241 82% of ulcers
treated by total contact walking casts healed in an
average of 6 weeks. Casts must be carefully applied
and removed at regular intervals for foot inspection
because loose-fitting casts cause friction that can
lead to blisters and ultimately ulcers.242
Griffiths and Wieman243 reported 34
metatarsal head resections in 25 patients. Most
ulcers had been present for at least 9 months. Ulcers
healed an average 2.4 months after surgery, and
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SRPS Volume 11 Issue R1, 2009
no recurrences had occurred at 14 months. Three
patients required resection of another metatarsal
head on the same foot to treat a second ulcer,
presumably from shifting pressure points after
the first surgery. If a toe needs to be excised, a
ray amputation should be performed to prevent
ulceration of its metatarsal head.
Newman et al.244 found osteomyelitis in
68% of diabetic foot ulcers, only half of which
had been clinically suspected. Osteomyelitis was
present in all ulcers with exposed bone, although
68% had no exposed bone and 64% did not even
have inflammation. Among the diagnostic tests for
osteomyelitis, the leukocyte scan had the highest
sensitivity (89%) and was useful for assessing
antibiotic effectiveness.
Yuh et al.245 evaluated plain films, bone
scans, and magnetic resonance images of 24
diabetic patients suspected of having osteomyelitis.
Bone biopsies from 14 patients whose ulcers
did not respond to antibiotics were positive for
osteomyelitis in 87%. Magnetic resonance imaging
provided a correct diagnosis for all patients, plain
radiography was not diagnostic until extensive bony
destruction had occurred, and bone scanning had
the highest false-positive rate.
Advocates of limb salvage with free tissue
transfer have reported durable results when using
microsurgical techniques in specific patients. Lai et
al.246 reviewed limb salvage in 10 cases of infected
and gangrenous diabetic foot ulcers. Treatment
consisted of débridement and coverage with a free
gracilis muscle flap and split-thickness skin graft.
Flap perfusion equaled perfusion of the surrounding
tissue at approximately 8 weeks. No recurrence
of ulcer or infection was noted during the
follow-up period.
SOFT-TISSUE COVERAGE OPTIONS FOR
LOWER EXTREMITY WOUNDS
The goal of soft-tissue reconstruction in the
lower extremity should be satisfactory wound
coverage with restoration of function. Ancillary
considerations are acceptable appearance and
minimal donor site morbidity. For soft-tissue
coverage alone, muscle and fasciocutaneous
flaps remain primary choices in the lower
30
extremity. Random pattern cutaneous flaps
and musculocutaneous flaps have more limited
applications. Free flaps are the usual cover of choice
for most lower third extremity defects.247,248 With
any lower extremity reconstruction, three tenets are
essential to success, as follows:
1. adequate preparation, which includes
full débridement and control of any wound
infection before coverage
2. stabilization and management of
associated orthopaedic injuries
3. overall assessment of the patient’s
suitability for reconstruction
and rehabilitation
Vacuum-assisted closure is a very useful
adjunct to wound management in the lower
extremity, particularly after adequate débridement
and preparation of an ideal wound bed. The
vacuum-assisted closure device aids in wound bed
preparation and minimizes dressing changes.
Although a thorough understanding of local
flaps is crucial for lower extremity reconstruction,
many leg and foot wounds are not amenable to
reconstruction with local flaps. For instance, many
Gustilo type III wounds are not reliably covered by
local muscle flaps. Regardless of the cause, large
leg and foot wounds often are best covered with
free flaps.
Free Flaps
Microvascular transfers can deliver both soft-tissue
and skeletal support to large complex wounds of
the leg and are particularly useful in the distal third
of the leg and foot. Serafin and Voci131 offered the
following guidelines for free flap transfers in the
lower extremity:
• Anastomose the microvessels outside the
zone of injury.
• Make end-to-side arterial anastomoses
and end-to-side or end-to-end venous
anastomoses.
• Reconstruct the soft tissues first, and then
restore skeletal support.
Basheer et al.249 asserted that lower
extremity free flap success rates can be as high as
98% in the modern era. Heller and Levin16 reviewed

lower extremity microsurgical reconstruction and
proposed a useful reconstructive ladder. Defects
are categorized according to the tissues needed
and the status of the vascular supply. The authors
discussed free flaps for isolated replacement of
muscle, skin, fascia, or bone and more sophisticated
composite flaps, such as musculocutaneous,
osteocutaneous, and innervated musculocutaneous
flaps. Preoperative considerations include evaluation
of dead space, orthopaedic management of the bone
injury, and final orthopaedic disposition.
For soft-tissue coverage alone, a relatively
small number of muscle flaps typically are used. The
workhorse free muscle flaps commonly used for the
lower extremity are the latissimus, serratus, rectus,
and gracilis. Cutaneous, fascial, and fasciocutaneous
free flaps have also been described to cover lower
extremity defects. For a thorough encyclopedia of
available free flaps, see the textbook by Mathes
and Nahai.250
The latissimus dorsi flap has the advantage
of a large amount of bulk to fill dead space. Despite
its initial bulk, the latissimus flap will reliably
atrophy and recontour if inset under appropriate
tension and managed with compression garments.
The atrophy aids in restoring normal contour to
the leg. Using the single thoracodorsal pedicle,
the latissimus dorsi flap can be combined with the
serratus anterior muscle flap for coverage of massive
lower extremity defects.91
Another advantage of both the latissimus
and serratus flaps is the long vascular pedicle, which
allows anastomosis well outside the zone of injury
in most cases. Use of vein grafts can lengthen the
already generous pedicle. By placing the patient’s
upper body in a lateral decubitus position and the
lower body turned more supine, most latissimus
and serratus transfers can be performed without a
patient position change.
The rectus abdominis muscle flap also
provides a significant volume of muscle with an
acceptable pedicle. With the patient supine, the flap
has the advantage that it rarely requires a patient
position change for coverage of leg defects.136
On the basis of extensive clinical experience,
Rainer et al.8 discussed free flap choices and
presented technical details for optimizing cosmesis
SRPS Volume 11 Issue R1, 2009
in leg reconstruction. The type of defect, need for
bulk versus thin contour, and donor site morbidity
were all considered when choosing the flap for
reconstruction, which in the reported series
consisted of traditional free flaps and
perforator flaps.
Yildirim et al.251 have endorsed the use
of the anterolateral thigh perforator flap in lower
extremity reconstruction. For smaller volume
defects, the gracilis is an excellent muscle flap.137
It has demonstrable efficacy in the treatment of
traumatic and non-traumatic defects. The gracilis is
easy to harvest, produces little donor site morbidity,
and adapts itself well to leg contour. Wechselberger
et al.138 described an innovative and anatomically
sound method of taking a larger, transverse, and
more reliable skin paddle with the gracilis (Fig. 6).
The selection of appropriate recipient vessels
for free tissue transfer is critical. Relying on their
experience with 50 consecutive free flaps to the
lower extremity, Park et al.134 concluded
the following:
• The site of injury and the vascular status of
the lower extremity are the most important
factors in recipient vessel selection in lower
extremity reconstruction.
• The type of flap used, method, and site
of microvascular anastomosis are less
important factors in determining the
recipient vessel.
• The anterior tibial artery is easier to use than
the posterior tibial artery.
• Anterior donor flaps are more convenient
and are preferred for use when the anterior
tibial artery is used.
• An end-to-side anastomosis can be an
option when using the posterior tibial
artery; it rarely is used with the anterior
tibial artery.
• An anastomosis distal to the zone of injury
is a very useful method.
• An angiographic or Doppler confirmation
should precede an anastomosis using reverse
flow; intraoperative confirmation of pulsatile
flow is also important.
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 SRPS Volume 11 Issue R1, 2009
• The cross-leg free flap should be reserved as
a last resort.
Free tissue transfers to vessels distal to
the defect are well established for lower extremity
reconstruction as long as the anastomoses are
performed far outside the zone of injury.252 Local
flaps and free tissue transfers have been described
for lower extremity reconstruction in children.
Banic and Wulff253 used a free latissimus dorsi flap
for definitive repair of lower extremity wounds in
children. Stewart et al.254 described a series of large
transposition flaps and one free flap used to treat
children with open tibial fractures.
Performing free tissue transfer in elderly
patients with lower extremity wounds is an option.
Dabb and Davis255 transferred three latissimus dorsi
flaps in three elderly patients for limb salvage. The
authors advocated a thorough medical workup, with
emphasis on cardiac and peripheral vascular risk
factors. Although that series achieved success in a
few elderly patients, it is noted that elderly patients
with comorbidities might be better served by
primary amputation.
Furnas et al.256 and Goldberg et al.257
described their results with microsurgical tissue
transfer for lower extremity reconstruction in
elderly patients. Furnas et al. reported 10% failures
and a 30% complication rate. Goldberg et al. noted
that despite medical advances, the mortality rate
from surgery among patients older than 70 years
ranged from 8% to 10%.
Figure 6. Medial view of the thigh shows relation of the
axis of the skin paddle (transverse) to the axis of the gracilis
muscle (longitudinal) and to the adductor longus muscle
(1), the gracilis muscle (2), the adductor magnus muscle (3),
and the pubic tubercle (4). (Reprinted with permission from
Wechselberger et al.138)
32
Wettstein et al.258 retrospectively reviewed
197 lower extremity free flaps, analyzing the
effects of comorbidities on outcomes. Although
overall complication rates were as high as 40%,
no association with specific risk factors other than
patient age was shown. Elderly patients might
experience a mildly increased tendency toward flap
loss after revision.
Duteille et al.259 reported 16 free flaps for
lower extremity reconstruction after trauma in
children. The study illustrated very good results in
the pediatric population. The authors emphasized
the feasibility of microsurgical coverage in children
despite the small size of their vessels and the
tendency for vasospasm.
Fisher and Wood260 illustrated an important
point in microvascular free flap reconstruction in
compromised recipient sites. They presented a case
report of complete necrosis of a latissimus free flap
caused by blunt trauma 7 months postoperatively.
The authors postulated that free flaps with high
axial flow rates inset to poorly vascularized
soft-tissue beds might lack the stimulus for
neovascularization.
Salvage and options after lower extremity
free flap reconstruction remain an issue, but limb
salvage after free flap failure usually is possible.
Culliford et al.261 presented a series of 585 lower
extremity free flaps. Eighteen percent of patients
with failed flaps eventually required amputation, but
the remainder retained salvaged limbs. The 82% of
patients who underwent salvage received additional
free flaps, local flaps, and/or skin grafts.
Recent advances in perforator flaps afford
new options of lower extremity free flaps. The
primary benefit of perforator flaps is less donor
site morbidity.
Thigh
In general, soft-tissue defects of the thigh require
neither pedicled nor free flap reconstruction because
of the large amount of local muscle tissue that can
be advanced into the wound. Skin coverage usually
is accomplished by skin grafts on intact muscle.
For large contour defects of the anterior
thigh or when the femoral vessels are exposed, a

pedicled rectus flap or vertical rectus abdominis
myocutaneous flap can be used. A transverse rectus
abdominis myocutaneous flap can also be used
and has been described for reconstruction of large
upper thigh defects after tumor extirpation. The
gracilis and the tensor fascia lata can also be rotated
anteriorly to cover smaller defects when needed. In
250
their textbook, Mathes and Nahai reviewed the
pedicled flap options for the thigh. If free flaps are
required, the defect usually is so extensive that large
free flaps, such as the latissimus dorsi, are indicated.
Willcox et al.262 reported reconstruction of
quadriceps function with the use of a reinnervated
latissimus. Ihara et al.263 reported the repair of a
large defect of the buttocks with a reinnervated free
latissimus flap. The patient recovered hip abduction
and achieved improved hip stability.
Leg: Upper Third and Knee
Swartz and Jones264 reviewed the principles
of wound coverage in the lower extremity and
described options for the different territories of the
leg and foot. An overview of standard flap options
for the leg is found in the articles by Pers and
Medgyesi,265 Ger,188 and McCraw.266
As a rule, the upper third of the leg can
be covered with rotational muscle flaps. Special
consideration needs to be given to preserving or
reconstructing the knee extensor mechanism. Patel
et al.267 reported a novel technique for dual
coverage of the knee and functional reconstruction
of the knee extensor mechanism with the
gastrocnemius flap.
The following muscle flaps are available for
covering defects of the upper third of the tibia
and knee:
• medial head of the gastrocnemius
• lateral head of the gastrocnemius
• proximally based soleus
• bipedicled tibialis anterior (lower part of
the tibia)
The medial head of the gastrocnemius is
an excellent choice for proximal tibia and knee
coverage. It can be reliably transferred on its
proximally based neurovascular pedicle and is
sustained by a broad muscle belly. When a longer
SRPS Volume 11 Issue R1, 2009
advancement is required, careful dissection and
release of the muscle origin from the medial
condyle of the femur are indicated. Wide scoring of
the fascia can also facilitate long advancement.268
The lateral head of the gastrocnemius
provides similar but more restricted coverage. Care
must be taken to protect the lateral sural nerve.
The soleus muscle, based proximally, can
be reliably carried to a point approximately 5 cm
above its tendinous insertion. The soleus muscle is
responsible for the venous pump phenomenon and
is a “slow” muscle that aids in posture stabilization
and slow gait. Transfer of a single head of the
gastrocnemius or the entire soleus muscle creates
little if any functional deficit.
The tibialis anterior muscle is important
in dorsiflexion of the foot and is not considered
expendable but might be raised as a bipedicled flap
on its origin and insertion to preserve its function.
The tibialis anterior is a Mathis type IV muscle,
which requires maintenance of its segmental
vascular supply and innervation. Other limitations
are its relatively small volume and short arc. The
tibialis anterior is nevertheless a valuable option in
small open defects along the entire tibia. Hallock269
describes various methods of splitting and partially
rotating the muscle to provide maximum anterior
tibial coverage while preserving muscle function.
Yoshimura et al.270 described the peroneal
island flap, which allows transfer of skin from above
the knee or lateral leg based either proximally
or distally. Cutaneous perforators from the
peroneal system perfuse a large island of skin. The
neurovascular pedicle of the flap is equivalent in
length to the peroneal vessel as it courses distally in
the extremity. The authors reported no instances of
flap necrosis in 14 cases.
Fasciocutaneous flaps are another option for
coverage of defects in the proximal third of the leg.
The flaps are based on superficial perforating vessels
from the deep arterial system; preoperative Doppler
assessment of the circulatory status of the flaps is
recommended. Although the flaps are options for
the proximal third of the leg, the gold standard
rotational flap for the proximal third remains the
gastrocnemius muscle flap.
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SRPS Volume 11 Issue R1, 2009
Fix and Vasconez271 reviewed a broad range
of fasciocutaneous flaps in the lower extremity.
Variants of fasciocutaneous flaps that can be used in
the proximal third of the leg are described.
Walton and Bunkis272 described a posterior
calf fasciocutaneous flap perfused axially via a
descending cutaneous branch of the popliteal artery.
The flap allows pedicle or free transfer of large
segments of fascia and skin from the posterior calf.
Walton et al.273 reported using the fascial portion of
the posterior calf as a free flap for resurfacing the
hand and distal lower extremity. Peculiarities
of the blood supply of fascial flaps are described
in the article.
When free flaps are required around the
knee, it is helpful to know that the genicular system
can reliably provide inflow. One does not have to
isolate the popliteal system in all cases.274
Leg: Middle Third
The following muscle flaps are available for coverage
in the middle third of the tibia:
• medial head of the gastrocnemius
• lateral head of the gastrocnemius
• proximally based soleus
• flexor digitorum longus (for the lower
portion of the middle third)
• extensor digitorum longus
• extensor hallucis longus (for the lower
portion of the middle third)
• flexor hallucis longus muscle (for the lower
portion of the middle third)
• tibialis anterior
The flexor digitorum longus can be
transferred without significant functional loss,
but its spare muscle belly limits it to small defects
or to use in conjunction with other flaps. The
neurovascular pedicle usually enters the muscle
at the junction of its proximal and middle thirds,
although that is variable. Its function in toe
flexion is supplemented by the action of the flexor
digitorum brevis. Donor site morbidity is minimal.
The blood supply to the extensor digitorum
longus is via vessels from the anterior tibial artery.
The flap is used for closure of small wounds (<5 cm
diameter). An incision is made 2 cm lateral to the
34
tibia, and the muscle is located lateral to the tibialis
anterior muscle. The muscle is raised, taking care to
preserve the superficial peroneal nerve during flap
dissection. Ligation of perforators must be kept to
a minimum during harvest or the muscle will not
survive. The superficial peroneal nerve must not be
damaged in the dissection.
The extensor hallucis longus also has a
small muscle belly that limits its usefulness. During
harvest, the surgeon must be careful to leave the
distal tendon attached to the extensor digitorum
communis to avert great toe drop.
The flexor hallucis longus muscle is larger
than the adjacent flexor digitorum communis, but
its primary function is to “push off ” the great toe
and the muscle should not be sacrificed. The flap
can be used as an adjunct to other methods of
closure in the lower middle third and upper lower
third of the tibia.
Free tissue transfer remains a useful option
for the middle third of the leg, if local flaps cannot
suffice. Many severe open tibial fractures that
require substantial soft-tissue coverage are best
served by free flaps rather than local flaps. The local
muscle flaps that are available for the middle third
of the leg, other than the soleus, are good for only
small defects. The latissimus, rectus, serratus, and
gracilis tend to be the workhorse free flaps for the
middle third of the leg. In an interesting case report,
Maghari et al.275 described how tissue expansion
was used to create a massive free flap for coverage of
a massive knee defect.
Fasciocutaneous flaps for coverage of middle
third defects271 typically are based on medial or
posterolateral septocutaneous perforators, although
flaps can also be designed without an identifiable
perforating artery: In essence, these are random-
pattern fasciocutaneous flaps. The length:width ratio
can be extended to 3:1, or twice that of random
cutaneous flaps.271 Selection of one of these flaps
must be carefully weighed against the use of reliable
local muscle flaps, such as the soleus or free flaps.
Leg: Lower Third, Ankle, and Achilles Tendon
Distal leg and ankle wounds traditionally are
covered with microvascular free flaps because of the
insufficient soft tissue available for transposition at
 SRPS Volume 11 Issue R1, 2009

that level. A wide range of muscle flaps, perforator distal aspect of the flap, which might be the region
flaps, and fasciocutaneous free flaps are useful in needed to cover a wound.
the distal third of the leg. The following discussion Attinger et al.281 wrote a comprehensive
pertains to both distally based superficial flaps review of the local flap options for ankle and
and local muscle flaps. The flaps can be used when foot reconstruction. The authors emphasized the
the defect is small enough that local transposition anatomy and limitations of several useful local
flaps are sufficient for coverage or when free tissue flaps from the leg and foot (Fig. 7). Use of a delay
transfer is contraindicated. procedure is suggested before transferring some of
The flexor hallucis longus, flexor digitorum the leg muscle flaps. Most are useful for only small
longus, and tibialis anterior can be used in small- defects, but a judicious selection avoids the need for
volume closures of the distal third of the leg. free flap coverage in certain cases of foot and
The abductor hallucis pedicled muscle flap will ankle defects.
reach partly up the lower third of the tibia. The
muscle occupies the medial instep of the foot and
serves as an important springboard for the arch.
After transfer, the abductor hallucis is missed for
approximately 6 months; most patients eventually
adapt to its loss. The muscle is mobilized on the
lateral plantar artery and provides limited coverage
of the lateral malleolus.
The distally based soleus, although described
for these defects, generally is inferior to free flaps
for coverage of large defects of the distal lower
third. Beck et al.276 challenged that assertion in
a series of eight patients who underwent distal
leg reconstruction with the soleus. The authors
recommended trying the soleus flap, instead
of microsurgery, if the distal third of the flap
appears undamaged and can reach the defect. They
described the technical modifications.
The extensor digitorum brevis flap can also
be used for small defects of the ankle and proximal
foot. The downside is the sacrifice of the dorsalis
pedis artery to allow flap rotation and viability.277
The peroneus brevis rotation flap, dissected
free of the lateral compartment, can cover the lateral
lower third of the leg for exposed fibular defects.
The peroneus longus must remain intact to evert the
foot when the peroneus brevis is dissected. Eren et Figure 7. Distances of the maximal possible reach of the
al.278 and McHenry et al.279 described worthwhile muscles as measured from the tip of the medial malleolus.
technical details and clinical results from their (Reprinted with permission from Attinger et al.281)
experiences with peroneus brevis flaps used for
distal fibular defects. In a letter to the editor, Barr et
al.280 questioned the reliability of the distal aspect of A number of fasciocutaneous flaps have
the flap. Rotation of the peroneus brevis flap on its been described for coverage of the distal third of the
distal minor pedicle decreases perfusion to the most leg. They are primarily distally based, reverse-flow

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flaps perfused by septocutaneous perforators from losses in a series of 71 reverse sural island flaps.
the anterior tibial, posterior tibial, and peroneal Follmar et al.289 reported a large series of 79 sural
arteries and are best designed as rotation flaps flaps in their continuing medical education review
rather than island flaps. article that covered relevant anatomy, pitfalls, and
In the leg, the saphenous and sural flaps recommendations for use of the sural flap.
are most commonly transferred. The saphenous
fasciocutaneous flap is perfused by posteromedial
fasciocutaneous perforators off the saphenous
artery. The sural flap is supplied by perforators
from the medial superficial sural artery. Harvested
with the sural nerve, it becomes a neurosensory
flap. Based on cadaver injections with lead oxide
solutions, Yang and Morris282 stated that the arterial
supply of the flap is from the peroneal artery via
a distal septocutaneous perforator. Rajendra et
al.283 described the results of vascular studies of a
musculofasciocutaneous variant of the sural flap.
A number of distally based superficial
island flaps have been described for lower leg
reconstruction.129,284,285 Flap coverage has been
largely successful. Overall, transfer of the sural flap
does leave the posterior aspects of the lower leg
anesthetic and large flaps produce significant donor
site morbidity. Hallock286 analyzed complications
of 100 consecutive local fasciocutaneous flaps, 67 of
which were used for lower extremity reconstruction. Figure 8. A, Design of the lateral supramalleolar flap.
Major complications were reported in 15% of The superficial peroneal nerve is transected. B, Flap
patients and minor complications in 11%. The circulation: 1, peroneal artery; 2, anterior tibial artery; 3,
incidence of complications was noted to be much septocutaneous perforators; 4, malleolar branch of the
anterior tibial artery; 5, distal tibiofibular angle. Sometimes
lower in trauma cases than in older patients with
the septocutaneous perforators and the malleolar
concomitant peripheral vascular disease. The branch of the anterior tibial artery are divided during flap
complication rate associated with distally based elevation and the island is carried on retrograde flow from
flaps was 37.5%. Wound closure was ultimately the anterior tibial artery. (Reprinted with permission from
achieved in 97% of patients. Touam et al.6)
The reverse sural neurocutaneous and lateral
supramalleolar flaps (Fig. 8) were compared in a An interesting anatomic variant of the
series by Touam et al.6 The sural flap was superior lateral supramalleolar flap was proposed by
to the lateral supramalleolar flap in reliability. A Koshima et al.,290 who suggested using rotational
failure rate of 4.8% was noted for the reverse sural perforator flaps to cover distal leg and lateral or
flap versus 18.5% for the lateral supramalleolar posterior heel wounds. The flaps can be used for
flap. Both flaps have demonstrable usefulness for small defects around the ankle without disturbing
nontraumatic wounds, such as after resection of major vessels to the foot. They are, however,
skin cancers or ulcers. The series presented by limited by their small size. The authors described
Touam included only a few traumatic wounds. cadaver studies and clinical applications of the
Costa-Ferraira et al.287 reported six partial losses perforator flaps.
in 36 sural flaps transferred. Almeida et al.288 Ayyappan and Chadha291 reported successful
reported 21% partial flap losses and 4% total flap use of the sural flap in leg reconstruction after

36

trauma. The series included five sural flaps used
to cover traumatic heel wounds. One partial flap
necrosis occurred. The authors also pushed the
size limit of the skin paddle; their largest paddle
measured 272 cm2.
Suga et al.292 stressed the importance
of including both the sural nerve and the lesser
saphenous vein in the flap. The flap pedicle should
be raised with its surrounding soft tissues, and
compression at the angle must be avoided.
Hollier et al.7 transferred 11 sural flaps in
patients who were between the ages of 3 and 64
years who had undergone reconstructive surgery for
traumatic and postablative defects. Only one partial
flap necrosis ensued. The technical points of flap
elevation are described by the authors. Price et al.293
illustrated the technique of sural flap harvest and
transfer in exquisite detail (Fig. 9). Koladi et al.294
documented the safety and efficacy of the sural flap
in children.
Achilles—The Achilles tendon and its
overlying soft tissue deserve specific attention. If
the soft-tissue loss is moderate, grafts of tendon
or fascia can be combined with local flaps for
reconstruction.295,296 If the Achilles loss is subtotal
or complete but short, forearm tendon grafts can be
used. Flexor hallucis longus grafts have been used
to treat chronic tendinopathy297 and perhaps could
be used to treat traumatic defects. In complete or
large Achilles tendon defects, free tissue transfer
probably is the best option for reconstruction. The
goals of surgery are to restore function, smooth
contour, and cover the wound with stable soft tissue.
A denervated gracilis free flap with skin graft has
been successfully used to accomplish the goals.298
The latissimus dorsi muscle has been used in the
same way, with very good functional results.299 The
denervated muscle atrophies and becomes fibrotic,
eventually providing the rigidity needed for Achilles
function. Over time, the contour of the muscle flaps
improves to the point that no secondary debulking
procedures are needed.
Various authors reported successful
Achilles tendon reconstruction with a composite
anterolateral thigh-fascia lata flap.300,301 Kuo et al.301
achieved excellent functional and aesthetic results
SRPS Volume 11 Issue R1, 2009
in a small series of Achilles tendon reconstructions
with the composite flap. Potential donor site
problems include damage to the vastus lateralis,
which might compromise knee extension. Neither
the gracilis nor the latissimus muscle flap presents
such a risk.
Foot
The simplest cover for a defect on the plantar
surface of the foot is a thick split-thickness skin
graft. The split-thickness skin graft can be used
only when a substantial portion of the subcutaneous
plantar pad is intact; it is not recommended that
split grafts be placed on granulation tissue that is
directly over bone. Woltering et al.302 described
their experience with 13 patients whose skin grafts
included the heel and forefoot. The average time to
full weight-bearing without crutches was 80 days.
All grafts reportedly did well, including those at the
calcaneus and first metatarsal head. Postoperative
pressure-sensitive ink pad recordings showed the
patients’ gait patterns had changed to enhance
graft protection.
Sommerlad and McGrouther303 compared
techniques for coverage of the sole of the foot in
51 patients. Ink pad recordings showed altered gait
patterns regardless of the type of reconstruction
chosen, always favoring the reconstructed site. Skin
grafts in this comparative series fared well, although
hyperkeratosis was noted. Attinger et al.281 reviewed
local flap options in defects of the foot.
May et al.304 and May and Rohrich305
described the use of a free latissimus dorsi muscle
flap with thick split-thickness skin graft to treat
chronic defects of the foot. Three operative groups
were identified, as follows:
• Group I patients had flaps placed at or
below the level of the malleolus and were
not weight bearing on flap tissues.
• Group II patients were weight bearing on
flap tissues but not directly on the skin graft
covering the transferred muscle.
• Group III patients were weight bearing
directly on the skin graft covering the
transferred muscle.
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 SRPS Volume 11 Issue R1, 2009
Figure 9. A, Design of the skin paddle of the reverse sural artery flap. B, Sural arterial network with peroneal perforators.
C, Elevation of the RSA as a fasciocutaneous flap with a lazy T-shape skin paddle to alleviate tension on proximal sutured
closure. (Reprinted with permission from Price et al.293)
Gait analysis in the series presented by May et al.
indicated that the amount of time spent on the
resurfaced foot when walking was approximately
the same as that spent on the normal foot. All
patients experienced some deep pressure sensation
in the involved areas. Light touch sensation at the
graft was absent. Of significance was the presence of
shear planes between the skin graft and the muscle
and between the muscle and the underlying bone.
The shear planes could play a protective role in the
long-term durability of the graft. Nevertheless, two
patients experienced delayed skin-graft breakdown
in their usual footwear.
The debate continues whether distant
and free fasciocutaneous flaps have loading and
shearing characteristics that are as favorable as
free muscle with skin grafts. Karakostas et al.306
studied six patients who had undergone unilateral
heel fasciocutaneous free flap reconstructions. The
patients were well into their long-term recovery and
had been walking on their flaps. The contralateral
normal heels, with intact glabrous skin, served
as controls. The study revealed that in these six
38
patients, the free fasciocutaneous flaps were able
to sustain high loading pressure. The patients did
have altered gait patterns that decreased shearing
at the reconstructed heels in the anteroposterior
dimension. Ultimately, patients who undergo
heel coverage with anything other than plantar
skin must always be aware of the possibility
of breakdown.
Hong and Kim307 drew a possibly
clinically significant distinction between standard
anterolateral thigh fasciocutaneous free flaps and
thinner anterolateral thigh perforator flaps when
used for plantar foot reconstruction. They reported
a series of 69 patients who underwent plantar
reconstruction with anterolateral thigh perforator
flaps. They documented good success overall. The
authors concluded that the anterolateral thigh
perforator flap might be more ideal for the plantar
foot because of its thinner contour and potentially
better shear plane characteristics. Further study
comparing standard anterolateral thigh flaps and
perforator anterolateral thigh flaps at the sole are
needed (Figs. 10 and 11).

Figure 10. Clinical photographs of a 36-year-old patient
with chronic diabetic ulceration of the left third metatarsal
region. Left, Depth of ulceration extended to the bone,
and a large dead space was noted beneath the skin. Right,
Resurfaced foot at 11 months after surgery. No signs of
recurrence are present. (Reprinted with permission from
Hong and Kim.307)
Figure 11. Schematic drawings show the sliding effect of the flap on shearing forces. Note the difference between a
fasciocutaneous flap (above) and a perforator flap (below). The thin subcutaneous layer composed of superficial fat and the
small fat lobules surrounded by dense fibers allow the skin to anchor tightly to the surface and to glide less. (Reprinted with
permission from Hong and Kim.307)
SRPS Volume 11 Issue R1, 2009
Free muscle flaps with skin grafts are useful
for treating defects of the foot that are large, that
are anterior, that have no local tissue available,
that have dead space, that have damaged local
tissues or vessels, or for which local flaps have
failed. Stevenson and Mathes308 reported a similar
experience with the use of free muscle flaps to treat
foot injuries.
Heel
Reiffel and McCarthy309 reviewed flap options for
coverage of the heel. They described the anatomic
basis and surgical detail of an axial cutaneous
medial plantar artery instep flap and an axial
musculocutaneous lateral plantar flap containing
flexor brevis muscle. The flexor digitorum brevis,
with or without its overlying instep skin, seems to
be a reasonable alternative for heel defects because
it can be transferred without detaching the lateral
plantar artery calcaneal branch from the posterior
tibial artery.
The instep flap need not be
musculocutaneous or have a pedicle base.310 The flap
can be transferred as a true fasciocutaneous island
flap in a single stage (Fig. 12), either on a pedicle
or by microvascular anastomoses. The instep flap
39
 SRPS
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Figure 12. Instep island flap raised on the medial plantar
vessels and cutaneous nerve branches. The flap is raised
superficial to the flexor digitorum brevis. The nerves
and vessels do not pass through muscle. (Reprinted with
permission from Morrison et al.310)
has been carried on both the medial310 and lateral
plantar vessels311,312 and requires a skin graft on the
instep donor site.263,264
Benito-Ruiz et al.313 and Acikel et al.314
achieved good results with the medial plantar
artery fasciocutaneous flap. Hartrampf et al.315 used
the flexor digitorum brevis muscle for coverage of
the heel, Achilles tendon, and medial and lateral
malleolus. The flap is mobilized on the lateral
plantar vessels.
Shaw and Hidalgo316 reviewed the anatomy
of the plantar flap and its clinical applications. The
flap is elevated superficial to the plantar fascia to
avoid disruption of the normal plantar structures
40
and to maximize sensation distally and over the
heel. Sensation is preserved by including the medial
calcaneal nerve and by limiting the intraneural
dissection of the medial and lateral plantar nerves
(Fig. 13). This is a durable and reliable flap for heel
coverage, but it cannot reach the posterior and
vertical portions of the heel.
Rashid et al.317 compared the sensory
medial plantar flap versus the sural flap for
reconstruction in mostly posttraumatic heel defects.
The flap survival rates were similarly excellent.
Slightly earlier weight-bearing and significantly
shorter return-to-work time were achieved in the
plantar flap group, but a longer operative time was
also recorded for that group. The sural flap was
associated with more minor complications.
In general, amputation is considered in
the event of heel wounds with large bony defects,
although reconstruction occasionally is successful.
Stanec et al.318 presented a case report of a 35-year-
old healthy male patient who suffered traumatic
bone loss and extensive soft-tissue damage to
the heel. A large amount of the calcaneus was
missing, but the tibiotalar joint and Achilles tendon
insertions were intact. The patient underwent
calcaneal and heel soft-tissue reconstruction with
an osteocutaneous iliac free flap and began partial
weight bearing at 10 weeks postoperatively. After
several debulking procedures, he progressed to full
weight bearing on the reconstructed heel without
orthotics. At 10 years after surgery, the patient was
clinically well, had intact deep pressure sensation,
and had not experienced flap breakdown.
Forefoot
Split grafts or full-thickness grafts are perfectly
adequate for coverage of non-weight-bearing
surfaces of the forefoot. If the bony surface has
adequate pad but deficient local cutaneous cover,
a preliminary attempt at skin grafting might be
appropriate, reserving the muscle pad for
graft failures.
Weight-bearing surfaces should be covered
with similar plantar tissue when possible. An island
instep fasciocutaneous or musculocutaneous flap
that preserves sensation seems to be a suitable
 SRPS Volume 11 Issue R1

Figure 13. Plantar flap in foot reconstruction. Upper, illustrations depict superficial neurovascular supply of plantar flap.
Middle, clinical photographs show transfer of plantar flap to cover heel defect. Lower, illustrations show medially based plantar
flap raised over two abductor muscles and the plantar fascia, preserving the medial and lateral plantar nerve branches to the
flap. (Modified from Shaw and Hidalgo.316)

41
 SRPS
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choice for reconstruction in such cases. An excellent
technique for resurfacing defects in the weight-
bearing aspect of the forefoot makes use of tissues
obtained in the toe fillet flap. The donor defect is
not missed unless the fillet is taken from the great
toe. The skin is well vascularized, and innervation is
maintained. Snyder and Edgerton319 discussed the
anatomy and surgical principles of toe filleting, and
Buncke and Colen320 described use of the great toe
fillet for defects of the forefoot.
Dutch et al.321 reported the use of pedicled
common digital and proper digital artery flaps
for forefoot reconstruction. A 13% flap loss rate
was noted, and 73% of patients had minor
wound complications.
Butler and Chevray322 described an
ingenious modification of the medial plantar artery/
instep flap that bases the flap distally, with the
arterial supply derived from metatarsal perforating
branches. The authors reported successful forefoot
reconstruction with this method in two patients.
No arterial inflow problems were reported, although
one flap required venous supercharging. The
illustrated clinical results were good. The flap has
also been successfully used by Takahashi et al.323
When planning the design of local foot flaps
for lower extremity coverage, two points must be
remembered: 1) when possible, the incisions should
not be placed on weight-bearing surfaces, and 2) the
amount of tissue available after transfer often is less
than anticipated. Wound breakdown can ruin an
otherwise successful foot reconstruction with
local flaps.
Free muscle flaps and fascial flaps with skin
grafts are a consideration when bony surfaces have
no overlying subcutaneous pad and local cutaneous
cover is not available. Musharafieh et al.324 described
a series of 10 free radial forearm flaps used
successfully in foot and ankle reconstruction. All
patients must be monitored long-term for recurrent
ulceration, especially when non-plantar tissue is
used to cover a plantar defect.
Restoration of Sensation in the Foot
Matejcik et al.325,326 reported the results of lower
extremity reconstruction after major nerve injury.
As one would expect, blunt injuries with neurolysis
42
had the best overall results. Nerves that had been
transected and were discontinuous required direct
microsurgical repair or nerve grafts. The functional
return was better after direct repair than when the
nerve was grafted.
Mackinnon et al.327 presented a report
of seven patients who underwent nerve allograft
repair of major peripheral nerve gaps in the
lower and upper extremities. All patients received
immunosuppression for up to 6 months after nerve
regeneration was detected. The nerve graft was
rejected in one patient, but the other six experienced
some return of motor function. The study illustrated
the possible future of secondary reconstruction of
large peripheral nerves in the extremities.
Several recent studies addressed the
coverage of plantar traumatic defects with sensory
free flaps.328 Kim et al.329 reported a single case of
heel reconstruction with an innervated free flap
obtained from the contralateral posterior tibial
system. Santanelli et al.14 reviewed their experience
with plantar reconstruction, which consisted of
seven reinnervated and seven traditional radial
forearm flaps. Regardless of nerve coaptation at
the time of flap transfer, all 14 patients achieved
good, stable plantar cover. In the long term, both
reinnervated and non-reinnervated flaps provided
adequate protective sensation.
Kuran et al.13 reviewed their results of
lower extremity reconstruction with 12 flaps. The
defects varied in size and complexity. The larger
defects were covered with insensitive free flaps out
of necessity, and the smaller defects were repaired
with sensory free flaps. Patients who received
sensory flaps experienced earlier return of pressure
sensation, but over the long term, the functional
results between the two groups were similar.
Reconstruction and Orthopaedic Oncology
The use of vascularized free bone flaps has afforded
new options for patients with long-bone sarcomas.
Despite the potential for more complications,
patients who undergo reconstruction of long-bone
defects after sarcoma resection show better function
than do those who undergo amputation.330,331
El-Gammel et al.105 reported good results
with single-barrel free fibular reconstructions after

tumor resections in the leg. They emphasized that
full weight-bearing must wait until sufficient graft
hypertrophy has occurred. The risk of pathological
fracture of the single-barrel, isolated fibula
always exists.109,332
Zaretski et al.333 reported the results of 15
thigh and eight leg reconstructions after sarcoma
resection in adults and children. A free fibular
graft was used in all cases. Union was achieved in
all except one patient; another patient was lost to
follow-up, and his status could not be determined.
The average time to union was 4.8 months; the
average time to full weight bearing was 9.2 months.
Three infections occurred at the recipient site. The
authors recommended one of three variants of the
free fibular procedure according to the
weight-bearing needs of the recipient tissue,
as follows:
• High-stress areas, such as the femur and
proximal tibia in adults, are indications for
free fibula transfer surrounded by generous
amounts of cancellous graft. The potential
advantages of this technique, which was
originally described by Capanna et al.,334
are that ample bone stock is immediately
available for remodeling and weight
tolerance will not depend on hypertrophy of
the fibula.
• Intermediate load-bearing areas are
reconstructed with double-barreled fibulae.
• Light-load areas, such as partial-thickness
defects of the tibia in adults and
full-thickness tibial defects in young
children, are indications for reconstruction
with single-barrel free fibular transfer.
When significant joint excision is required,
endoprostheses are used with or without
vascularized fibula.109,335
Algorithms for timing of the reconstruction
and choice of reconstructive method are presented
in Figure 14. Definitive bony reconstruction is
delayed in cases that require prolonged courses
of adjuvant radiotherapy, such as cases of
Ewing sarcoma.
Allograft alone can be used for bone
reconstruction after tumor ablation that results
SRPS Volume 11 Issue R1
in small defects. Mastorakos et al.336 emphasized
that union is improved and infection rates are
lower when the allograft is covered by pedicled
or free muscle flaps. Unlike bone replacement,
early soft-tissue reconstruction is safe after
sarcoma extirpation, and pedicled flaps, free
flaps, and skin grafts tolerate radiation therapy
reasonably well. Spierer et al.337 noted that only
5% of reconstructions in their series developed
wound complications. Incidentally, more wound
complications occurred after brachytherapy than
after external beam radiation.
Cross-Leg Flap
Before the widespread use of free-tissue transfer,
the cross-leg flap was the procedure of choice for
typical wounds of the leg when local pedicled flaps
were unavailable.338 Today the indications for cross-
leg flaps are limited. Patients who are not free flap
candidates and patients who remain immobilized
for other reasons occasionally are cross-leg flap
candidates. Dawson339 analyzed the complications
encountered in 99 cross-leg flap procedures and
reported local flap necrosis in 40% and infection
in 28%.
As suggested by Barclay et al.,340 the design
of the cross-leg flap has been changed to include
the deep fascia of the leg. At present, cross-leg flaps
are transferred as fasciocutaneous tissue units with a
length:width ratio of 3:1 or 4:1.235,341,342
Cross-leg pedicled flaps and cross-leg free
flaps have been described for extremity salvage
in cases in which the existing vascular inflow of
the affected extremity is of poor quality, often
from severe trauma or tissue loss.343,344 Still, the
evaluating surgeon must realize that an open leg or
foot wound with recipient vessels not suitable for
free flap transfer might indicate an injury so bad
that limb salvage is not advisable.
Long et al.338 reported the use of current
external fixation technology for cross-leg
fasciocutaneous flaps. All flaps were based on the
axial blood supply of the posterior descending
subfascial cutaneous branch of the popliteal artery.
The external fixation allowed for physical therapy
43
 SRPS
SRPS Volume
Volume 12 R1, 2009
11 Issue

Figure 14. Upper, Algorithm shows immediate versus late reconstruction. Secondary definitive reconstruction is advised for
patients who are scheduled for postoperative radiation treatment. R.T., Radiation therapy. *, Patients with Ewing sarcoma
and favorable prognoses did not receive therapy. Lower, Algorithm shows lower extremity reconstruction. Autogenous
reconstruction is indicated primarily in cases that are not periarticular. The decision regarding type of fibular reconstruction
depends on the mechanical load expected based on the anatomic site. *, Avascular necrosis, osteoradionecrosis,
pathological fracture. **, Infectious complication, implant failure. ***, When enough fibular bone source is present, the bony
defect is not too big, and the patient is not too heavy. (Reprinted with permission from Zaretski et al.333)

44

and range-of-motion exercises of the extremities to
begin soon after surgery.
Soft-Tissue Expansion
The primary application of skin expansion in the
lower extremity is to resurface areas of unstable
soft tissue or unsightly scar.345 Infection rates
have historically ranged between 5% and 30%.
Conventional plastic surgical knowledge has held
that soft-tissue expansion is more difficult in the
lower extremity than in other parts of the body.
Manders et al.346 presented a report of 16
patients who underwent soft-tissue expansion in
the lower extremity. All expanders were placed
in the subcutaneous plane above the muscular
fascia. The pockets for expander placement were
closed-suction drained. Prophylactic antibiotics
were administered to all patients. Expansion was
begun 1 to 2 weeks after implantation. Ultimately,
good results were obtained in all patients who were
operated on for correction of contour deformities.
Successful results were obtained in patients
who had expanders placed in the thigh or buttocks.
In contrast, only 50% of expanders at or below the
knee were ultimately successful. Overall, in the
entire series,346 17 complications occurred during 13
expansions, with only three patients remaining free
of problems. Infection developed in seven patients.
Six of the seven patients had open wounds at or
below the knee, and another had an open wound at
the thigh. Infection resulted in wound dehiscence
in two of the seven patients and expander exposure
in one.
In an update of the series of lower extremity
reconstruction by soft-tissue expansion presented by
Manders et al.,346 Borges et al.347 discussed sites that
are not amenable to expansion, such as the ankle
and foot, particularly the plantar surface of the foot.
They noted the following points:
• There is a tendency toward periprosthetic
infection if the expander is placed next to an
open wound in the lower extremity.
• Expansions on the medial and lateral
surfaces of the knee have been accomplished
successfully even though the joint is in
constant motion.
SRPS Volume 12
• In most instances of soft-tissue
expansion designed to eliminate lower
extremity defects, one should plan for
transverse advancement of tissue, not
axial advancement.
• The plane of dissection for placement of the
expander is just above the muscle fascia.
• The most common causes of implant
exposure is an inadequately dissected pocket.
• Bed rest for several days with the leg
elevated is indicated after insertion of
expanders in the lower extremity.
The pediatric population might do better
than adults with lower extremity tissue expansion.
Kryger and Bauer348 reported their creative use
of tissue expansion for 50 children with giant
congenital nevi. Retrospectively, few complications
were noted in the report. Large nevi in thigh, leg,
and foot were treated with skin grafts, expanded
local flaps, and expanded free flaps. Images and
descriptions of selected cases in the report by
Kryger and Bauer are instructive and impressive,
and the article includes an algorithm for
treatment (Fig. 15).
RECONSTRUCTION OF THE NECROTIC
FEMORAL HEAD
Avascular necrosis (AVN) of the femoral head
can be idiopathic, secondary to steroid use,
posttraumatic, caused by systemic disease, or
associated with alcoholism. Adults and children
can be affected. Left untreated, AVN of the
femoral head can lead to osteoarthrosis of the
hip. Traditionally, this condition has been treated
nonsurgically, with core decompression, and/or with
total hip arthroplasty. Judet et al.349 and Judet and
Gilbert350 used microvascular free fibular grafts in
cases of AVN of the hip and in the reconstruction
of other large bony defects of the lower extremity.
Many authors351−353 have since published
their respective experiences with free fibular
transfers for proximal femora. In a series of 228 hips
treated with free fibular transfer, Soucacos et al.353
noted that patients in the earlier stages of disease
had better and more predictable results, although all
should be considered.
45
SRPS Volume 11 Issue R1, 2009
Figure 15. Algorithm for treating large and giant congenital pigmented nevi of the lower extremity. FTSG, full-thickness
skin graft. (Reprinted with permission from Kryger and Bauer.348)
Kane et al.354 prospectively compared core
decompression with free fibular transfer in stage II
and III femoral head AVN. Core decompression
failed to prevent total hip arthroplasty in 58% of
patients. The patients treated with free fibular grafts
went on to undergo arthroplasty 20% of the time. In
another study comparing free fibular transfer with
core decompression, Scully et al.355 also showed
better results with free fibular transfer for stage II
and III disease.
Dean et al.356 reviewed a large series of
pediatric patients with femoral head AVN and
noted that children treated with free fibular transfer
do better than their adult counterparts. However,
any long-term result of revascularization of the
46
femoral head should be weighed against the
good results that can be achieved with total
hip arthroplasty.
REPLANTATION
Although various reports of successful replantation
of lower extremities can be found in the literature,
large patient series do not exist to help determine
clear indications for replantation. Judicious selection
of individual candidates is a must. Certainly, no
other tissue in the body can perfectly replace the
specialized, weight-bearing skin and subcutaneous
tissues of the heel pad and plantar skin. For lower
extremity replantation to truly be a success, some
return of protective sensation must be present in

the plantar foot and trophic ulceration must
be absent.357
When replantation of the lower extremity
is considered, the patient must be informed of
the likelihood of multiple operations and blood
transfusions for some time in the future and must
be willing to accept those conditions in addition to
a significant risk of complications. Overall, carefully
selected heel pad and partial foot replantations
might be more predictable—and thus more
indicated—than whole foot and leg replantations.
Battiston et al.358 reported their experience
with 14 lower extremity replantations, five of which
were later amputated because of complications. Park
et al.359 reported a case of forefoot replantation in
a very young child that produced acceptable long-
term functional results.
Chiang et al.360 achieved a good result
in a rare case of heel pad replantation. Daigeler
et al.361 described the courses of seven patients
who received leg replants, including two cases of
bilateral amputation with successful heterotopic
single replantation. Gayle et al.357 reported a series
of five patients with various foot and lower leg
replantations. Their best results were obtained
when the amputation was at the level of the ankle
and distally. Patients who regained some sensation
avoided recurrent ulceration and achieved good
function of the replanted extremity.
In conclusion, the results of replantation
should be compared with those of a well-designed
form-fitting below-knee prosthesis. Patients with
lower extremity amputations often present with
other serious injuries that might contraindicate
replantation. Replantation of the lower limb can
be considered in ideal circumstances, such as in
children who have undergone amputations, require
minimal bone shortening, and are expected to
achieve return of protective sensation, and perhaps
in some cases of sharp amputation of the distal leg,
ankle, heel pad, or forefoot. Although less desirable,
a patient with bilateral leg amputations might also
be seriously considered for replantation of at least
one limb.
SRPS Volume 11 Issue R1, 2009
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59
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facial aesthetics

for their support of plastic surgery education

as a Platinum Education Partner.