stsg & local random flaps for the diabetic foot & ankle

STSG & Local Random Flaps for the STSG & Local Random Flaps for the Diabetic Foot & Ankle Diabetic Foot & Ankle

ThomasThomas ZgonisZgonis DPM FACFASDPM FACFASThomas Thomas ZgonisZgonis, DPM, FACFAS, DPM, FACFASAssociate Professor, Department of Associate Professor, Department of OrthopaedicsOrthopaedicsChief, Division of Podiatric Medicine & Surgery Chief, Division of Podiatric Medicine & Surgery

Director, Residency & Reconstructive Foot & Ankle FellowshipDirector, Residency & Reconstructive Foot & Ankle FellowshipFounder, International External Fixation Symposium (IEFS)Founder, International External Fixation Symposium (IEFS)

Foot & Ankle Soft Tissue ReconstructionFoot & Ankle Soft Tissue Reconstruction

Challenging problem for the F&A SurgeonChallenging problem for the F&A SurgeonLocal tissues are NOT usually availableLocal tissues are NOT usually availableLocal tissues are NOT usually availableLocal tissues are NOT usually availableNumerous reconstructive methods are availableNumerous reconstructive methods are available

Allow the soft tissue defect to heal by secondary intentionAllow the soft tissue defect to heal by secondary intentionPrimary Closure Primary Closure Skin grafting (Split vs Full Thickness)Skin grafting (Split vs Full Thickness)Local fascial, fasciocutaneous, muscle, musculocutaneous & pedicle flapsLocal fascial, fasciocutaneous, muscle, musculocutaneous & pedicle flapsMicrovascular free flapMicrovascular free flap

Roukis TS, Zgonis T. Skin grafting techniques for soft tissue coverage Roukis TS, Zgonis T. Skin grafting techniques for soft tissue coverage of diabetic foot and ankle wounds. J Wound Care 2005; 14: 173of diabetic foot and ankle wounds. J Wound Care 2005; 14: 173--6.6.

4th Annual International External Fixation Symposium

December 11-14, 2008

Soft Tissue Reconstruction of the Diabetic FootSoft Tissue Reconstruction of the Diabetic FootSplit Thickness Skin Graft (STSG)Split Thickness Skin Graft (STSG)

ADVANTAGESADVANTAGES

“Easy take” in the foot & lower extremity“Easy take” in the foot & lower extremityBetter Chance of Survival Better Chance of Survival Simple to Perform and Easily AvailableSimple to Perform and Easily AvailableReliable & Minimally Invasive Reliable & Minimally Invasive Can Cover Large Open Wounds & AmputationsCan Cover Large Open Wounds & AmputationsCost Effective if needed to be repeated Cost Effective if needed to be repeated Dorsal aspect and NWB areasDorsal aspect and NWB areasDorsal aspect and NWB areasDorsal aspect and NWB areasClosing donor sites in the arch or NWB areasClosing donor sites in the arch or NWB areasContains epidermis & part of dermisContains epidermis & part of dermisDonor sites: thigh/buttock/calf/foot Donor sites: thigh/buttock/calf/foot


Thin (0.008Thin (0.008--0.012 inches)0.012 inches)H l dilH l dilHeals readilyHeals readilyWound contracts a lotWound contracts a lot

Intermediate (0.012Intermediate (0.012--0.018 inches)0.018 inches)More durable / best choice!More durable / best choice!

Thick (0.018Thick (0.018--0.030 inches)0.030 inches)Greater chance of failureGreater chance of failureAll of epidermis & dermisAll of epidermis & dermisWound contracts very littleWound contracts very little





4 WEEKS POST4 WEEKS POST--OP & STENT REMOVALOP & STENT REMOVAL



Local Random Skin FlapsLocal Random Skin Flaps

Categorized by their type of movement.Categorized by their type of movement.Ad t t ti t itiAd t t ti t itiAdvancement, rotation, transposition.Advancement, rotation, transposition.

Allow transfer of similar tissue for adjacent coverage.Allow transfer of similar tissue for adjacent coverage.Especially useful in diabetic patients.Especially useful in diabetic patients.Advantage of providing durability.Advantage of providing durability.Usually based on geometric designs.Usually based on geometric designs.Include epidermis, dermis, and subcutaneous tissues.Include epidermis, dermis, and subcutaneous tissues.

LOCAL RANDOM SKIN FLAPSLOCAL RANDOM SKIN FLAPSZgonis T etal. Unstable acute and chronic Charcot’s deformity: staged skeletal and soft tissue reconstruction. J Wound Zgonis T etal. Unstable acute and chronic Charcot’s deformity: staged skeletal and soft tissue reconstruction. J Wound

Care 2006; 15: 276Care 2006; 15: 276--80.80.

AdAdAdvancement Advancement RotationalRotationalTranspositionTranspositionBilobedBilobedRhomboidRhomboidDouble Z rhomboidDouble Z rhomboid



AngiosomesAngiosomes

Taylor and Palmer defined an angiosome as a Taylor and Palmer defined an angiosome as a ““block of block of tissue (skin subcutaneous tissue fascia muscletissue (skin subcutaneous tissue fascia muscletissue (skin, subcutaneous tissue, fascia, muscle tissue (skin, subcutaneous tissue, fascia, muscle and bone) fed by a source artery.”and bone) fed by a source artery.”Knowing vascular anatomy allows:Knowing vascular anatomy allows:

Surgeon to plan safe incisions Surgeon to plan safe incisions Provide sufficient blood flow on either side of the incision Provide sufficient blood flow on either side of the incision for the surgical wound to healfor the surgical wound to healfor the surgical wound to healfor the surgical wound to healAssess which pedicle flaps can be harvested successfullyAssess which pedicle flaps can be harvested successfully

AngiosomesAngiosomes

There are 3 major angiosomes of the foot:There are 3 major angiosomes of the foot:P i Tibi l AP i Tibi l APosterior Tibial Artery:Posterior Tibial Artery:

Medial and medialMedial and medial--posterior ankleposterior ankleSole of the footSole of the foot

Anterior Tibial Artery:Anterior Tibial Artery:Dorsum of the footDorsum of the footAnterior ankleAnterior ankle

Peroneal Artery:Peroneal Artery:Lateral Supramalleolar areaLateral Supramalleolar areaLateral and plantar heelLateral and plantar heel



Local Rotational FlapsLocal Rotational Flaps

•• Excise the defect as a Excise the defect as a triangletriangle –– most ofmost oftriangle triangle most of most of timestimes

•• RRotate a semicircular flap otate a semicircular flap about the pivot point to about the pivot point to close the circular or close the circular or triangular defect. triangular defect. Th d d fTh d d f•• The secondary defect The secondary defect may then be closed may then be closed primarily or skin grafted. primarily or skin grafted.

LOCAL RANDOM FLAPSLOCAL RANDOM FLAPSCASE # 1CASE # 1

Zgonis T etalZgonis T etal. Surgical management of the unstable diabetic Charcot . Surgical management of the unstable diabetic Charcot deformity using the Taylor Spatial frame. deformity using the Taylor Spatial frame. Oper Tech Orthop 2006; 16:10Oper Tech Orthop 2006; 16:10--1717



Rhomboid FlapRhomboid Flap

•• Used to close a Used to close a rhomboid shaped defectrhomboid shaped defectrhomboid shaped defect rhomboid shaped defect with internal angles of 60 with internal angles of 60 and 120 degrees. and 120 degrees.

•• A flap with identical A flap with identical dimensions is designed dimensions is designed

h id f h d fh id f h d fon the side of the defect on the side of the defect judged to have the most judged to have the most available tissue.available tissue.

LOCAL RANDOM FLAPSLOCAL RANDOM FLAPSZgonis T etat. Plastic surgery reconstruction of the diabetic foot. AORN 2008




MUSCLE FLAPSMUSCLE FLAPSTYPE 2 MUSCLE FLAPS PROVIDE A WELL TYPE 2 MUSCLE FLAPS PROVIDE A WELL VASCULARIZED TISSUE ISLANDVASCULARIZED TISSUE ISLANDUSEFUL FOR:USEFUL FOR:

FILLING BONE DEFECTS FILLING BONE DEFECTS NERVE WRAPSNERVE WRAPS

EXAMPLES: ABDUCTOR HALLUCIS, FDB & EXAMPLES: ABDUCTOR HALLUCIS, FDB & ABDUCTOR DIG MIN ABDUCTOR DIG MIN EASILY COVERED WITH SKIN GRAFTEASILY COVERED WITH SKIN GRAFT

Mathes and Nahai Reconstructive Surgery: Principles, Anatomy and Technique Churchill and Livingston NY P. 115, vol 1, 1997



ABDUCTOR DIGITI MINIMI MUSCLE FLAPABDUCTOR DIGITI MINIMI MUSCLE FLAPZgonisZgonis T T etaletal. . Use of a muscle flap and a splitUse of a muscle flap and a split--thickness skin graft for a thickness skin graft for a calcanealcalcaneal

osteomyelitisosteomyelitis after an open reduction and internal fixation. JAPMA 2008after an open reduction and internal fixation. JAPMA 2008

ABDUCTOR DIGITI MINIMI ABDUCTOR DIGITI MINIMI MUSCLE FLAPMUSCLE FLAP



CONCLUSIONSCONCLUSIONS

“Out of the box” thinking…“Out of the box” thinking…T A hT A hTeam ApproachTeam ApproachCareful Patient Selection!!!Careful Patient Selection!!!Reconstructive F&A SurgeonReconstructive F&A Surgeon

THANK YOU!THANK [email protected]@uthscsa.edu



stsg & local random flaps for the diabetic foot & ankle

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