Surgical Technique for Osteocutaneous Pedicle Flap Transfer for Salvage of Transtibial Amputation After Severe Lower-Extremity Injury.

INTRODUCTION: Osteocutaneous pedicle flap transfer from the foot can be used to "salvage" a transtibial amputation level when the severity of an injury precludes a transtibial amputation. STEP 1 PREOPERATIVE ASSESSMENT: If the posterior tibial artery is not palpable, obtain an angiogram to determine the vascular supply distal to the traumatic zone and to prepare for conversion to a composite free microvascular transfer. STEP 2 REMOVE PROVISIONAL IMPLANTS: Remove provisional stabilization implants and minimize surgery about the knee. STEP 3 DEVELOP THE FLAP: The dissection about the tarsal tunnel is the critical portion of the operative technique. STEP 4 CONTOUR THE CALCANEUS: Any deviation from perpendicular will translate to an axial deformity in the reconstructed limb. STEP 5 PREPARE THE PROXIMAL PART OF THE TIBIA AND SURROUNDING TISSUES: Retain viable soft tissues and bone, but resect the fibula obliquely. STEP 6 SECURE THE CALCANEUS TO THE TIBIA: Avoid varus and recurvatum malalignment. STEP 7 REPAIR AND RECONSTRUCT THE SOFT TISSUES: The injured limb is routinely very swollen, and in some cases complete coverage requires split-thickness skin-grafting. STEP 8 POSTOPERATIVE CARE AND REHABILITATION: As the initial reconstruction is sometimes extremely bulbous, continually advise the patient that the shape will improve dramatically over time with shrinkage of the limb.
RESULTS: In our original study, ten men and four women with a mean age of 43.2 years (range, twenty-four to sixty-four years) underwent an osteocutaneous pedicle flap transfer with use of the ipsilateral foot for salvage to achieve a transtibial amputation level. WHAT TO WATCH FOR: IndicationsContraindicationsPitfalls & Challenges.