Plastic Surgical Reconstruction in Foot and Ankle Trauma

Plastic Surgical Reconstruction in Foot and Ankle Trauma and

the Diabetic Foot: STSG to Free Flap

Paul M. Glat, MDDrexel University School of Medicine

Philadelphia, PA

Open Fractures

4th Annual International External Fixation Symposium

December 11-14, 2008

General Concepts of Wound Management

• Complete wound closure – Reconstructive Ladder = simple to more complex

• Complete coverage with well vascularized tissue is imperative

• Wound bed preparation is vital – serial debridements until clean

Reconstructive LadderReconstructive Ladder

Pedicled Flaps

Free Flaps

Integra

Simple skin grafts are usually inadequate

Reconstruction of Open Fractures

PEDICLED FLAPS

Pedicled Flaps: Pedicled Flaps:

Flap With Defined Blood Supply

Consists Of Any Combination Of – Skin – Fascia – Muscle – Bone

Pedicled Flaps: Pedicled Flaps:

Advantages

–Ankle Block –Short Operation –No Icu

Disadvantages

– Limited Reach – Limited Bulk – Requires More Precise Anatomic Knowledge – High Complication Rate (34%)

–Shorter Hospital Stay –Palpable Or Tri-

phasic Flow Not Needed

–Minimal Loss Of Function

Gastrocnemius/Soleus FlapsGastrocnemius/Soleus FlapsBlood Supply:Branches of Popliteal Artery (Post tib and Peroneal for SoleusIndications:Gastroc – proximal 1/3 of lower leg – medial and lateral headsSoleus – middle 1/3 of lower legAdvantages:Fast, easy dissectionLarge amount of muscle - Gastroc can reach above kneeReliable Disadvantages:Needs STSG Peroneal n at risk

Gastrocnemius/Soleus FlapsGastrocnemius/Soleus Flaps

Reverse Sural Flap Reverse Sural Flap

Blood Supply:Perforating Br. Of Peroneal Artery Pivot Point: 5 Cm. Above The Lateral Malleolus

Indications:

Advantages:

Disadvantages:

Large Defects (8x12 Cm.) Heel, Ankle & Forefoot Defects Lower Leg Defects

Easy To Dissect May Be Used W/o Pulses

Partial Flap Loss (Venous)

Pedicle Compression Supine Donor Site Stsg (?Bka ?) Sural Nerve Deficit / Neuroma Dog Ear

Reversed sural flap

LESSER PERFORATING SAPHENOUS

BRANCH VEIN

WIDE PEDICLE

PERFORATING BRANCH

Reversed sural flap

Reversed sural flapReversed sural flap

Reversed Sural Flap: Reversed Sural Flap: Complications Complications

1) PAINFUL PROXIMAL SURAL N. NEUROMA 2) DONOR SITE SCAR IF BKA NEEDED 3) DISTAL FLAP DEATH

Reversed Sural Flap:Reversed Sural Flap:Avoiding Pitfalls Avoiding Pitfalls

Delay Flap Include Skin In Pedicle Use Ilizarov To Protect Flap As It Heals

Lateral Calcaneal Flap:

Blood Supply: Lateral Calcaneal Artery

Pivot Point: Upper Lateral Malleolus

Lateral Calcaneal Flap: Lateral Calcaneal Flap:

Posterior Heel / Achilles Tendon Defects Lat. Malleolus Defects

Local Tissue

Hard To Dissect ( Pedicle Deep) Loss Of Distal Sensation Short Reach Not Pliable

Indications:

Advantages:

Drawbacks:

Lateral Calcaneal Flap: Lateral Calcaneal Flap: Sural N.

Calcaneal Br. Peroneal Art.

DISSECTION: NEED TO LIFT FLAP OFF OF PERIOSTEUM!!!

TRAUMATIC ACHILLES TENDON DEFECT IN A HEALTHY PATIENT

Lateral Calcaneal Flap: Lateral Calcaneal Flap: COMPLICATION COMPLICATION

DISSECTION TOO SUPERFICIAL = DAMAGE TO PEDICLE

Lateral Calcaneal Flap: Lateral Calcaneal Flap: Avoiding Pitfalls Avoiding Pitfalls

Doppler Out Calcaneal Branch Of Peroneal Artery Start Distally & Stay On Top Of Periosteum

Supra-malleolar Flap:

Blood Supply: Anterior Perforating Branch Of Peroneal Artery Pivot Point: Anterior Portion Of Lateral Malleolus

SupraSupra--malleolar Flap: malleolar Flap:

Indications:

Advantages:

Drawbacks:

Anterior Ankle Defects Lat. Malleolus Defects

Thin No Donor Site Deficit (Fascial Flap)

Insensate Limited Reach Tedious Dissection

SupraSupra--malleolar Flap: malleolar Flap:

FRACTURED ANKLE & OSTEOMYELITIS SUPRA-MALLEOLAR FLAP COVERAGE ANKLE

AT, EHL, EDL Flap

Blood Supply: Anterior Tibial Artery Pivot Point: Variable

AT, EHL, EDL Flap AT, EHL, EDL Flap : :

NON UNION FIBULA WITH OSTEO EHL FLAP HARVESTED

AT, EHL, EDL Flap AT, EHL, EDL Flap

Anterior Medial And Lateral Ankle Defects

Rapid Good Blood Flow

Sacrifice Major Artery Insensate Need Stsg Loose Function

Indications:

Advantages:

Drawbacks:

AT, EHL, EDL Flap: AT, EHL, EDL Flap:

Abductor Hallucis Muscle Flap:

Artery: Medial Plantar Artery

Pivot Point: Distal Tarsal Tunnel

Abductor Hallucis Muscle Flap: Abductor Hallucis Muscle Flap:

Indications:

Advantages:

Drawbacks:

Calcaneus Osteomyelitis Plantar Heel Defects Medial Ankle Defects

Easy & Quick Dissection Excellent Donor Site

Small Amt. Distal Tissue Limited Reach Needs Stsg

Abductor Hallucis Muscle Flap Abductor Hallucis Muscle Flap & Local Flap& Local Flap

OSTEO ANKLE JOINT

Abductor Hallucis Muscle Flap Abductor Hallucis Muscle Flap & Local Flap& Local Flap

FREE FLAPS

Wound Closure: Wound Closure: Microsurgery Microsurgery Muscle And Stsg For Plantar Foot and Leg

Fascicutaneous For Dorsal Foot

Large Enough To Cover Defect And Pedicle

Free FlapsFree Flaps: :

Brings Fresh Healthy Tissue To Wound

Excellent Option when local tissue inadequate eg. Distal 1/3 of lower leg

Failure Rate ≤ 5%

6-8 Hours Of Surgery

Week Long Hospital Stay

Free Flaps: Free Flaps: Principles Principles

Angiogram Think Pedicle Length And Avoid Vein Graft Artery: End To Side Two Veins Distal To Defect Is Ok Tailor Flap Tightly

Free Flaps:Free Flaps:

Disadvantage – Need Palpable Or Tri-phasic Flow

– Longer Op

– Icu Stay

– Longer Hospital Stay

-Flap loss can be disasterous – create 2nd

Advantage – Choice Of Tissue

– Choice Of Size

– Minimal Loss Of Function

– Low Complication Rate (17%)

Free Flaps in Trauma: Free Flaps in Trauma: Know A Few Options Well Know A Few Options Well

Muscle Flaps with STSG are best to cover hardware– Rectus Abdominus M. – Gracilis M. – Serratus M.

-Latissimus M. for very large defect

Osteocutaneous fibula flap for large bone defects

Latissimus Flap

INTEGRA

IntegraINTEGRA Dermal Regeneration Template

• biosynthetic, implantable, bilayered membrane system for skin replacement

• composed of a dermal regeneration layer and a temporary epidermal layer.

Integra– Dermal Regeneration Layer:

• Three-dimensional porous matrix of cross-linked bovine collagen and glycosaminoglycan (chondroitin-6-sulfate)

• Controlled porosity• Defined degradation rate• Promotes cellular in-growth

– Temporary Epidermal Substitute Layer:• Composed of synthetic polysiloxane polymer

(silicone)• Controls moisture loss from wound• Mechanically protects the wound

Mechanism of Action• Integra allows successful revascularization and

engraftment followed by organized regeneration of autologous dermal tissue

• Eventually a Neodermis of autologous connective tissue is created that has a 3-D structure that resembles dermis, not scar

• When the dermal layer is vascularized, the temporary silicone layer is removed and a thin epidermal autograft is placed

Histology of IntegraHistology of Integra

Cellular infiltration of matrix

Cellular infiltration of matrix Histology of neodermis following

silicone removal at 21 daysHistology of neodermis following

silicone removal at 21 days

Epidermis

Dermis

Fibroblast

Matrix

New collagen

Basement membrane

Advantages

– Minimize size/number of reconstructive procedures– Immediate physiologic wound closure– No temporary coverings– No risk of rejection– Early ambulation/rehabilitation– Delay creating donor site wounds – Faster donor site healing

Disadvantages

– Requires multiple operations (minimum 2)– Requires rigorous surgical technique and

monitoring– Labor intensive post-operatively– Cost

Acute Traumatic Wounds

• Eliminates need for large reconstructive procedure – flap or graft

• May cover exposed tendons, nerve, bone• Eliminates immediate need for donor site• Earlier rehabilitation, discharge

New ConceptsDelay

New ConceptsBridging

New ConceptsBridging/Delay

Plastic Surgical Reconstruction in Foot and Ankle Trauma and

the Diabetic Foot: STSG to Free Flap

Paul M. Glat, MDDrexel University School of Medicine

Philadelphia, PA

Diabetic Foot

General Concepts of Wound Management

• Wound bed preparation is vital • Excision of devitalized tissue and exposure

of clean wound bed• Coverage of wound bed• Complete wound closure – Reconstructive

Ladder = simple to more complex

Reconstructive LadderReconstructive Ladder

Diabetic limb salvage: Diabetic limb salvage: Team approach Team approach

• Diabetologist • Podiatrist • Pedorthetist • Surgical correction of biomechanical abnormalities

• Wound healing team & VNA • Vascular surgeon • Foot & ankle surgeon • Infectious disease • Plastic surgeon • Diabetologist • Hyperbarist

Diabetic limb salvage: Diabetic limb salvage: • Etiology of diabetic ulcers

• Optimize the wound bed

• Need adequate blood flow & skeletal stability

• Simple & sound biomechanical reconstr

• Must individualize for each patient

Chronic wound: Chronic wound: MUST CHECK PULSES FIRST!MUST CHECK PULSES FIRST!

Vascularity NO issue • Palpable pulses

Vascularity an issueCompressible vessels

• A.B.I. < 0.9 • Tri-phasic or biphasic doppler signals Non-compressible vessel

• Flat pulse volume recordings

• Monophasic doppler signal • Toe pressures < 30 mm Hg • TCPO2 < 40 mm Hg

Vascular Surgery vs. Vascular Surgery vs. Endovascular Intervention Endovascular Intervention

Percutaneous atherectomy

Angioplasty

Angioplasty + Stenting Excimer laser

Goal: Goal: AAchieving a healthy chieving a healthy wound base or healed wound wound base or healed wound

correct dx medical rx good blood flow debridement antibiotics modern wound care adjuncts: VAC growth factor cultured skin hyperbaric oxygen

Healing soft tissue: Healing soft tissue:

• Debridement • Control of infection • Stimulation of healthy granulation tissue • Close wound

Debridement: Debridement: Sharp = Nonselective Sharp = Nonselective

Serial excision

More precise: VersajetMore precise: Versajet

Most preciseMost precise: Biosurgery eg. Maggots : Biosurgery eg. Maggots

• Indications • Awaiting revascularization • Too sick to go to OR • MRSA, VRE

Sherman Ra; Arch Phys Med & Rehab. 81:1226, 2001

BiosurgeryBiosurgery

Post debridement: Post debridement: wait for signs of healing wait for signs of healing

• Wrinkled skin edges • Healthy granulation

tissue • Neo-epithelialization at

border • Increased peri-wound

Wound healing adjuncts: Wound healing adjuncts: options options

• Negative pressure therapy • Xenograft / cadaver skin • Cultured skin • Growth factor • Hyperbaric oxygen

Post debridement dressing Post debridement dressing NPWTNPWT

• Principle effects of VAC • Peri-wound edema • Blood flow • Granulation • Bacterial count

Xenograft: Xenograft: Preparation of Preparation of STSG bed STSG bed

Apligraf: Apligraf: BiBi--layer live skin substitute layer live skin substitute

• Epidermis / dermis • Fibroblast and keratinocyte derived from foreskin • Fresh culture • 7 day ‘shelf life’• FDA approved • Diabetic foot ulcers (May 1998) • Venous leg ulcers (June 2000) • 7.5cm round single use

Apligraf Apligraf -- CytokinesCytokinesHuman Keratinocytes

Human Skin

Human Dermal Fibroblasts

+ + + + + + + + + + + + + + + +

+ + + + –+ + + ––+ –+ + + –

+ ––––– + + + + ––––– +

FGF-1 FGF-2 FGF-7 ECGF IGF-1 IGF-2

* PDGF-A * PDGF-B * TGF-α IL-1α IL-6 IL-8 IL-11

* TGF-β1 TGF-β3 VEGF *Enzyme-linked immunosorbent assay confirmation. FGF = fibroblast growth factor; ECGF = endothelial cell growth factor; IGF = insulin-like growth factor; PDGF = platelet-derived growth factor; TGF = transforming growth factor; IL = interleukin; VEGF = vascular endothelial growth factor.

Diabetic foot ulcer: Diabetic foot ulcer: Topical growth factor Topical growth factor -- PDGF PDGF

Becaplermin/RegranexBecaplermin/Regranex

• PDGF on 382 diabetic wounds in phase 3 trial

• 43% improvement in wound closure • 50% PDGF healed completely • vs. 35% placebo

• 32% shorter time to heal • PDGF85 days • vs. placebo 127 days

Steed D, J Vasc Surg 1995, 21:79

Hyperbaric Oxygen TherapyHyperbaric Oxygen Therapy

GRADIENT TCPO2

• Oxygen gradient • Main signal for initiation of wound healing cascade • Stimulates neo-vascularization • Key to laying down wound healing matrix • Potentiate WBC killing of bacteria

Grafts-STSG or FTSG

Pedicled Flaps

Free Flaps

Integra

Surgical Options

PEDICLED FLAPS

Blood Supply:Perforating Br. Of Peroneal Artery Pivot Point: 5 Cm. Above The Lateral Malleolus

Reversed sural flap

Lateral Calcaneal Flap:

Blood Supply: Lateral Calcaneal Artery

Pivot Point: Upper Lateral Malleolus

Supra-malleolar Flap:

Blood Supply: Anterior Perforating Branch Of Peroneal Artery Pivot Point: Anterior Portion Of Lateral Malleolus

AT, EHL, EDL Flap

Blood Supply: Anterior Tibial Artery Pivot Point: Variable

AT, EHL, EDL Flap: AT, EHL, EDL Flap:

Medial Plantar Flap: Medial Plantar Flap:

Indications:

Advantages:

Drawbacks:

Plantar Heel Defect Medial Ankle Defect

Glabrous Skin Sensate No Major Vessels Excellent Donor Site

Vessel Not Always There Tedious Dissection Graft donor site

Medial Plantar Flap

Artery: Superficial or Deep Branch Of Medial Plantar Artery Pivot Point: Distal Tarsal Tunnel

Toe Flaps:

Artery: Digital Artery

Pivot Point: Distal Plantar Transverse Crease

Toe Flaps: Toe Flaps:

Indications:

Advantages:

Drawbacks:

Small Forefoot Defects

Easy & Quick (Filet) Excellent Donor Site (Island)

Small Amt. Distal Tissue Limited Reach Sacrifice Toe (Filet) Tedious Dissection (Island)

TOE ISLAND FLAP

OSTEO HALLUX IP JOINT

Toe Island Flap: Toe Island Flap:

DX: OSTEO 3RDMTP HEAD

Filet Of Toe: Filet Of Toe:

DX: OSTEO 1STMETATARSAL

Filet Of Toe: Filet Of Toe:

DX: OSTEO 1STMTP HEAD

Extensor Digitorum Brevis Flap: Extensor Digitorum Brevis Flap:

Indications:

Advantages:

Drawbacks:

Anterior Ankle Defects Lat. Calcaneus Defects Lat. Malleolus Defects

Easy To Dissect Increase Reach By Cutting Dp Distally

Donor Site Problems Limited Mobility Tedious Dissection

Extensor Digitorum Brevis Flap:

Blood Supply: Lateral Tarsal Artery

Pivot Point: Takeoff Lateral Tarsal A.

X (Reach Can Be Extended If D.P. Art. Or A.T. Art. Ligated)

Abductor Digiti Minimi Flap: Abductor Digiti Minimi Flap:

Calcaneal Osteomyelitis Plantar Heel Defects Lateral Ankle Defects

Small Amt. Distal Tissue Limited Reach Needs Stsg

Indications:

Advantages:

Drawbacks:

Abductor Digiti Minimi Flap:

Artery: Lateral Plantar Artery Pivot Point: Distal Tarsal Tunnel

DOMINANT PEDICLE

Flexor Digitorum Brevis Flap: Flexor Digitorum Brevis Flap:

Indications:

Advantages:

Drawbacks:

Calcaneous Osteomyelitis Plantar Heel Defect

Small Amt. Distal Tissue Limited Reach May Need Stsg

Flexor Digitorum Brevis Flap:

Artery: Lateral Plantar Artery

Pivot Point: Distal Plantar Heel

FREE FLAPS

Wound Closure: Wound Closure: Microsurgery Microsurgery Muscle And Stsg For Plantar Foot and Leg

Fascicutaneous For Dorsal Foot

Large Enough To Cover Defect And Pedicle

Free Flap: Free Flap:

Muscle – Rectus Abdominus M. – Gracilis M. – Serratus M.

Not The Latissimus M. - need upper extremity strength

Fasciocutaneous Flap – Radial Forearm – Lateral Arm – Parascapular – Anterolateral Thigh Flap (Thin Pt.)

Rectus Abdominal Muscle: Rectus Abdominal Muscle: 12 Cm Pedicle 12 Cm Pedicle

Rx: RECTUS ABDOMINUS FLAP & STSG

Gracilis Muscle: Gracilis Muscle: 8 Cm Pedicle 8 Cm Pedicle

GRACILIS MUSCLE FLAP & STSG

Serratus Muscle: Serratus Muscle: 18 Cm. Pedicle 18 Cm. Pedicle

SERRATUS M. + STSG

ParaPara--scapular Free Flapscapular Free Flap: : 12 Cm Pedicle 12 Cm Pedicle

Rx: PARA-SCAPULAR FLAP

Lateral Arm Free FlapLateral Arm Free Flap: : 8 Cm. Pedicle 8 Cm. Pedicle

Rx: LATERAL ARM FLAP + TRICEPS TENDON

Radial Forearm Free FlapRadial Forearm Free Flap:: 10 Cm Pedicle 10 Cm Pedicle

Rx: RADIAL FOREARM FLAP

PALMARIS TENDON

ANTE-BRACHIAL CUTANEOUS

Radial Forearm Free FlapRadial Forearm Free Flap:: 10 Cm Pedicle 10 Cm Pedicle

DONOR SITE

SENSATE NORMAL FLEXION & EXTENSION OF TOES

EXCEPT

INTEGRA

IntegraINTEGRA Dermal Regeneration Template

Chronic Wounds

• Often contaminated• Donor sites frequently high morbidity• May cover exposed tendons, nerve, bone• Eliminates need for large reconstructive

procedure – flap or graft

Chronic Wounds

Chronic WoundsVenous Ulcers

THANK YOU

Plastic Surgical Reconstruction in Foot and Ankle Trauma

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