Orthoplastic Techniques in Lower Extremity Reconstruction

Review Article

Orthoplastic Techniques in Lower Extremity Reconstruction

Edgardo Rodriguez-Collazo¹^*, Adam Finzen², Tom Campbell², Luis Sanchez² and Michae^l Regan²
¹Department of Surgery, Chicago Foot and Ankle Deformity Correction Center, Presence Saint Joseph Hospital, Chicago, Illinois, USA
²Department of Surgery, Section of Podiatric Surgery, Presence Saint Joseph Hospital, Chicago, Illinois, USA

^*Corresponding author: Edgardo Rodriguez-Collazo, Department of Surgery, Chicago Foot and Ankle Deformity Correction Center, Presence Saint Joseph Hospital, Chicago, Illinois 60657, USA

Published: 21 Sep, 2017
Cite this article as: Rodriguez-Collazo E, Finzen A, Campbell T, Sanchez L, Regan M. Orthoplastic Techniques in Lower Extremity Reconstruction. Clin Surg. 2017; 2: 1632.

Abstract

Lower extremity limb salvage is a costly and difficult aspect of health care. Inadequate preparation, planning, and execution can lead to unsatisfactory results. In an effort to advance the surgical skills for lower extremity surgeons, this paper offers several different procedures focusing on the orthoplastic aspect of limb salvage. The medial hemi-soleus, the lateral hemi-soleus, and peroneus brevis muscle flaps can be excellent tools in the arsenal of a surgeon attempting to preserve a patient’s limb. These procedures, among many others in the lower extremity, create large wounds that are in need of closure and are described in detail. Therefore, the authors also provide a novel method for wound closure consisting of skin staples and vessel loops which can be used in a multitude of surgical and clinical scenarios, supported by several case presentations.

Introduction

Limb salvage procedures in the lower extremity involve complex preoperative, perioperative, and postoperative management. Such procedures create large wounds that are difficult to close and can create debilitating sequelae for the patient [1]. Muscle flaps can be utilized for many lower extremity limb salvage procedures including chronic ulcerations, trauma, and soft tissue defects. This paper presents a technique guide for three types of reverse muscle flaps that can be utilized to treat such conditions and prevent amputation [1,2]. It also presents a novel technique for delayed closure of large wounds of any etiology.

Muscle Flap Technique Guides

Peroneus brevis (Appendix 1)
The patient is induced under general anesthesia and is placed on the surgical table in a lateral or ‘jack knife’ position. The knee is partially flexed and lateral malleolus is superior. A thigh tourniquet is placed on the same extremity. The lower extremity is prepped and draped in the usual aseptic manner. A surgical skin ink marker is used to draw the incision on the lateral aspect of the leg. The line should be drawn starting 10cm proximal to the tip of the lateral malleolus and extending proximal along the long axis of the bone to cover 2/3 of the fibula. The incision is made with a #10 blade and handle in a full thickness, cutaneous-adipose-fascial fashion. Small bleeders are clamped and electrocauterized as necessary. Medium caliber vessels are clamped and tied with 3-0 vicryl suture. It is important to preserve the soft tissues surrounding the three peroneal artery perforators that are located on the lateral leg compartment at the distal third of the leg. These arterial perforators are located at 5 cm, 10 cm and 15 cm proximal to the lateral malleolus [2]. This is the reason the incision ends distally at 10 cm proximal to the lateral malleolus.
Dissection through the peroneal fascia is completed at this time with care being taken to separate the fascia from the underlying muscle bellies prior to transection. The peroneus longus tendon and muscle can be visualized at this time. Anatomically, the peroneus brevis muscle is deep to the peroneus longus. Between the muscle bellies lies a thin fascia which is dissected under loop magnification to avoid injury of the superficial peroneal nerve which travels deep to the longus muscle and superficial to the brevis muscle. This nerve leaves the lateral compartment between the peroneal tendons and at the inferior 1/3 of the leg it perforates the superficial crural fascia to travel deep to the skin and to the anterior leg compartment, just lateral to the tibialis anterior tendon. Care should be taken to avoid traumatic injury to this nerve by atraumatic retraction techniques. Proper identification of the peroneus brevis tendon and muscle belly can be performed at this time. A hand held intraoperative arterial Doppler is used to first identify the peroneus brevis muscle distal segmental arteries. There must be at least two segmental arteries providing blood flow to the muscle belly at the distal end for adequate perfusion of the flap. After identification of the arteries, the muscle is dissected and removed from its origins on the fibula. Hydrogen peroxide should be used to flush the surgical site and muscle for assistance with hemostasis [3]. Once the muscle is freed, it can be carefully transferred to the soft tissue defect or open wound. The range of this flap can include the anterior inferior 1/3 of the tibia, the anterior ankle joint, or the lateral malleolus. To reach these areas, an incision must be created connecting the wound to the peroneal incision site. This new incision is only through the skin and superficial fascial layers. The flap site is prepared by careful sharp debridement. The lightly bleeding belly of the peroneus brevis muscle is applied to the wound defect, and four simple interrupted sutures are applied to the muscle/skin conjoined areas at 2, 5, 8 and 11 o’clock sites. A large drain can be applied at the fascial level and the drain exits the incision site at a separate skin small incision created at the anterior or posterior leg compartment of the leg. The skin incisions between the wound site and the large peroneal incision site is partially closed with subdermal 3-0 vicryl suture, and closed on the skin with skin staples. The original large peroneal incision is closed in layers by closing the fascial layer with 3-0 vicryl suture material, then closing the subdermal layer with 3-0 vicryl suture material. Final skin closure is performed with skin staples and the surgeon prefers to utilize the vessel loop closure described later in the paper to assist with decrease of incision site tension.
Lateral soleus muscle (Appendix 2)
The patient is positioned and the incision is drawn and created in the same fashion as the previous procedure. Again, care should be taken to preserve the three constant perforators at this area. The incision is carried through the deep fascia following the posterior aspect of the peroneus longus muscle belly. The lateral soleus muscle belly and fascia can be identified and is separated from the peroneus longus muscle. The dissection is continued along the dorsal and posterior aspect of the lateral soleus muscle belly, separating it from the fascia of the lateral head of the gastrocnemius muscle. Care is taken to preserve arterial and venous irrigation to the central and medial portion of the soleus muscle. The soleus muscle is then dissected from its attachment to the tibia and dissected distally to the distal third of the leg. Care is taken to mark on the skin, with a pen marker, the areas of the peroneal perforator arteries supplying this muscle at its distal third of the leg. These perforators are found with the use of a hand held arterial intraoperative Doppler. After the lateral half of the soleus muscle is reflected distally, an incision is made from its distal attachment to the wound defect area on the distal tibia, anterior ankle, or the lateral malleoli wound or defect area. The incision is deepened to the fascia, preserving any nerves and major arterial/venous tributaries. The harvested muscle belly is laid down through this incision and covers the wound defect. It is sutured at 4 sites surrounding the wound in the same manner as the previous procedure. The skin incision sites are closed at fascial and subdermal level with 3-0 vicryl suture material. A JP suction drain is placed deep to this area. The skin is closed with skin staples, and again the preference of the surgeon is to provide the vessel loop closure described later in this paper.
Medial soleus muscle (Appendix 3)
The patient may be positioned supine with external rotation of the leg. The leg is prepped and draped in the usual aseptic manner. A skin marker is utilized to draw the planned incision, starting at approximately 15 cm proximal to the medial malleolus and continues proximal approximately 4 cm posterior to the palpable posterior aspect of the tibia, and extending proximally to about 2/3 of the length of the leg. Again, follow the 5 cm, 10 cm, 15 cm rule for identifying the leg perforators [2]. This reasoning is crucial for determining that the distal muscle dissection and deep incision ends right around 15 cm proximal to the ankle medial malleolus. Again, these 3 segmental arteries are identifying with an intraoperative arterial Doppler, with the patient on the operative table and before any incision are performing on the leg. Once identified, the incision is a single, cutaneous-adipose-fascial incision. The superficial fascia of the lateral head of the gastrocnemius muscle belly is identified, and a linear incision is done between the gastrocnemius lateral border and the underlying medial aspect of the soleus muscle. Separation of the soleus is performed, leaving the fascia of the muscle attached to the underlying gastrocnemius fascia. The lateral and deep dissection of the soleus is performed, with care taken to preserve the fascia of the muscle attached to its surrounding tissue. The entire lateralcentral soleus muscle is dissected, preserving the surrounding fascial septums, including the septum dividing the posterior from lateral compartment. The deep posterior septum where is where the tibial artery, nerve and vein is located. After harvesting the soleus medial muscle belly, an incision as carried from the distal incision site to the wound defect area. The defect can be reached on the tibia, ankle, or calcaneus. Prepare the recipient site by sharply debriding the wound area. The medial bleeding muscle belly is then applied along the deep part of this new incision and filling the wound or defect. It is secured to its transfer wound defect area with 4 sutures on the skin in the same manner mentioned previously. The fascia is closed with absorbable 3-0 vicryl suture material and the skin is closed with a vacuum drain.

Appendix 1

Appendix 1
Line is drawn from 5 cm proximal to malleolus proximally 2. Incision is created through adipose layer
3. The superficial fascia is transected
4. The muscular fascia is exposed
5. The muscular fascia is transected
6. Separation from the fascia of the longus and brevis
7. Identify any perforators and vital structures
8. Separation of brevis from fibula for free flap

Appendix 2

Appendix 2
(From top left)
1. Chronic, open wound with lateral ankle plate exposure
2. Dissection of free flap of lateral soleus
3. Application of graft overlying lateral ankle
4. External fixator construction and progressed healing

Appendix 3

Appendix 3
(From top left)
1. Incision is drawn and created 5 centimeters proximal to ankle joint and continuing proximally
2. The superficial fascia is transected to expose the muscle
3. The medial soleus is separated from the gastrocnemius
4. Dissection of medial soleus from superficial compartment
5. Dissection of medial soleus from deep compartment
6. Further deep compartment dissection
7. Mobile soleus muscle
8. Resection of soleus muscle from origin on tibia, leaving proximal perforators intact
9. Application of muscle to lateral heel
10. Application of muscle to posterior heel
11. Application of muscle to ankle joint and medial malleolus
12. Application of muscle to anterior tibia

Figure 1

Figure 1
Patient was considered closed after six weeks of treatment.

Figure 2

Figure 2
Patient was considered closed after 4 weeks of treatment

Figure 3

Figure 3
Healing was noted at 6 weeks post debridement.

Surgical Considerations and Pearls

External fixation Any motion to the lower extremity will decrease success of the muscle flap due to the interruption of the microvasculature. This may lead to graft necrosis and subsequent failure. External fixation is for skeletal stabilization and requires the patient to be non-weight bearing for 4-6 weeks or until complete incorporation of the flap. Once this occurs, to construct, two olive wires are placed into the calcaneus, and two smooth wires or half pins are placed into the tibia. This allows for adequate exposure of the graft and incision sites for wound vacuum changes every five to seven days. Avoidance of the muscle flap site is crucial for placement of wires and pins.
Postoperative protocols
Initial dressings are changed at the seven day post-operative visit. This allows the graft ample time incorporate beneath the wound vacuum. At this point, the vacuum is changed every five to seven days with the settings remaining at 125 mmHg of continuous negative pressure. If there are any large drains, they are typically pulled 24-28 hours post operatively once it is determined that less than 10 milliliters is collected from said drain. This decreases the risk of hematoma formation or compartment syndrome. Incision site staples are removed at the surgeon’s discretion, and close monitor of the patient is required. At the third postoperative visit, muscle and skin graft viability are able to be determined. Secondary skin grafting could be scheduled at this time. At the four to six week mark the external fixation device is removed and the patient is placed in a CAM boot with slow transition into weight bearing status based on surgeon preference.
Vessel loop “shoelace” closure
Traditional primary closure of large wounds can be exceedingly difficult. Post-operative edema can lead to dehiscence, infection, and possibly amputation. To reduce this risk, the vessel loop “shoelace” technique is provided for the delayed closure of large wounds. This technique uses dermatotraction via silastic vessel loops and with staple fixation to provide gradual primary closure through the viscoelastic properties of the skin with little need for grafting [4-6]. This procedure is demonstrated through the presented case studies involving large incision surgeries such as fasciotomies or abscess drainage. The presented patients had the closure technique applied and were tensioned as needed until sufficient closure was obtained. This closure provided a simple, cost-effective method for dynamic reapproximation of the skin margins.
Surgical technique
An incision is re-approximated via the deep structures, and two staples are placed at the apex of the incision and a vessel loop is passed through. The surgeon has found that the larger the vessel loop, the easier it is to provide traction. If a larger vessel loop is unavailable, the surgeon typically “doubles” the vessel loop either by folding in half or running a second vessel loop alongside the first. While under mild tension, staples and vessel loops are placed along the incision in a crisscross manner, approximately one centimeter from the wound margins and one centimeter between staples. While the 1 centimeter suggestion is routinely utilized, poor skin quality may impair the area. Utilize healthy, viable skin only for this type of closure. Upon reaching the opposite end of the wound, two staples are placed at the end, and the vessel loops are tied off. If the vessel loops do not reach the end of the incision, they may be tied off and stapled to the skin as distance allows. A non-adherent dressing is applied between the skin and vessel loops as to relieve pressure should edema occur or the patient’s skin reacts to the vessel loops. Postoperative care for the wound sites provides convenience for the clinician and patient. Retensioning can be performed in the office as needed, should slacking be discovered upon change of dressing. With heavy granulation tissue formation, some surgeons perform silver nitrate applications to reduce such issues and assist with resolution of the open wounds more quickly.
Cases
1. 19 year old male with history of 3 year old gunshot wound to the left calf, developed an abscess with cellulitis and subsequent compartment syndrome. Patient underwent an incision and drainage with four compartment fasciotomy. Following serial debridements, a shoelace closure was applied. The patient was seen in clinic three times a week for local wound care and to re-tension the vessel loops as needed. Patient was considered closed after six weeks of treatment Figure 1.
2. 11 year old female presented with purulent drainage following laceration to third interdigital web space of left foot. After imaging discovered abscess to foot, patient underwent emergent incision and drainage. Incision spanned the entire dorsum of foot. Following serial debridements, a shoelace closure was applied. The patient was seen in clinic three times a week for local wound care and to re-tension the vessel loops as needed. Patient was considered closed after 4 weeks of treatment Figure 2.
3. 28 year old man with history of transmetatarsal amputation developed a wound to the ipsilateral leg secondary to improper use of CAM boot. After undergoing several weeks of local wound care, purulent drainage and malodor was noted to wound. Incision and drainage was performed in the operating room and the shoelace closure was applied. Healing was noted at 6 weeks post debridement Figure 3.

Discussion

Large wounds have many etiologies. They all share the difficulty in closure using traditional techniques. Muscle flap techniques are an excellent way to provide wound closure and filling of deficits. The aforementioned methods can provide a unique limb salvage procedure to many areas of the lower extremity. With such flaps, wound healing can be accomplished and many limbs can be saved, decreasing mortality for those affected. With larger incisions, wound dermatotraction, which uses silastic vessel loops and staple eyelets to address these difficulties by providing gradual primary closure through constant tension of the wound margins. Studies have shown that when a constant force is applied to skin, such as dermatotraction, mechanical creep occurs by realigning collagen fibers and fragmenting the elastic fibers, allowing the skin to stretch beyond the normal limits promoting closure without the need for grafting [6,7]. The wounds presented here closed via granulation over four to six weeks. Other studies have used primary closure after using this technique for 7-21 days. The discrepancy between times of closure is related to how frequently the closure was re-tensioned [5,8-11]. While encouraged, 100% closure of the wounds is not the primary goal of the technique, rather acceleration of closure itself. This technique can be utilized in conjunction with staging for primary closure should reapproximation prove difficult. This technique has several benefits. It provides constant pressure on the wound margins while allowing for stretch should swelling occur. The closure can be paired with other wound care modalities such as hydrotherapy and negative pressure wound therapy. It avoids the complications of using skin grafts. It is relatively inexpensive and requires little preparation as the materials are often readily available in most operating rooms. There are noted disadvantages to the shoelace technique. Tension is not uniform across the incision. With no way of monitoring tension in the vessel loops, it relies on the surgeon to determine how much tension is appropriate for the site. Periods between re-tensioning varies from daily to as needed, depending on the surgeon’s preference. Local ischemia can occur with too much tension and the vessel loops should be removed or re-tensioned if there is discoloration/blanching to the wound margins. This technique should be avoided in ischemic limbs as application may cause further insult to the skin, decreasing healing potential [12].

Review Article