In-Service Exam
Lower Extremity - 2003





An ambulatory 75-year-old man has a 6-cm grade IV pressure ulcer on the sacrum. The most appropriate management is reconstruction with which of the following?

(A) Bilateral gluteal myocutaneous advancement flaps
(B) Unilateral superior/inferior gluteal myocutaneous rotation flap
(C) Unilateral superior gluteal artery perforator flap
(D) Thin split-thickness skin graft

The correct response is Option C.

The unilateral superior gluteal artery perforator flap is most appropriate for reconstruction of the area of the sacrum affected by the pressure ulcer. Perforator flaps can be based on either the superior or inferior gluteal artery. They provide adequate myocutaneous coverage and at the same time preserve the gluteal muscles on the involved side. As a result, morbidity at the donor site will be minimized, which is especially important in this patient because he is ambulatory.

Although a bilateral superior/inferior gluteal myocutaneous advancement flap supplies sufficient soft-tissue coverage for pressure ulcers, harvest of the inferior and superior gluteal muscles will result in significant morbidity at the donor site. Harvest of a gluteal myocutaneous rotation flap sacrifices muscle function and also is not the procedure of choice in an ambulatory patient. Thin split-thickness skin grafts do not provide stable coverage of pressure ulcers.

References
1. Higgins JP, Orlando GS, Blondeel PN. Ischial pressure sore reconstruction using an inferior gluteal artery perforator (IGAP) flap. Br J Plast Surg. 2002;55:83.
2. Ramirez OM, Orlando JC, Hurwitz DJ. The sliding gluteus maximus myocutaneous flap: its relevance in ambulatory patients. Plast Reconstr Surg. 1984;74:68.
3. Verpaele AM, Blondeel PN, Van Landuyt K, et al. The superior gluteal artery perforator flap: an additional tool in the treatment of sacral pressure sores. Br J Plast Surg. 1999;52:385.

A 78-year-old man has an infection of the groin wound after undergoing femoral popliteal artery bypass grafting. A sartorius muscle flap is to be used for coverage of the exposed prosthetic graft. Which of the following arteries provide the blood supply for this flap?

(A) Lateral femoral circumflex artery and superficial femoral artery
(B) Lateral femoral circumflex artery and deep femoral artery
(C) Medial circumflex femoral artery and superficial circumflex iliac artery
(D) Medial circumflex femoral artery and deep femoral artery
(E) Superficial circumflex iliac artery and superficial femoral artery

The correct response is Option E.

The superficial circumflex iliac and superficial femoral arteries provide vascularity to the sartorius muscle flap. The superficial circumflex iliac artery is a branch of the external iliac artery; it courses laterally to provide the primary blood supply to the groin flap and the proximal part of the sartorius muscle. The external iliac artery then continues as the common femoral artery and branches into the profunda femoris and superficial femoral arteries at a point distal to the inguinal ligament. The superficial femoral artery travels distally in the thigh and gives off segmental branches to the sartorius muscle.

Because the groin is one of the most common areas of graft exposure, the sartorius muscle can be used to cover small defects. This muscle can be detached from its proximal origin on the iliac crest and turned over to cover groin wounds. Other options for coverage in this region include the gracilis, rectus femoris, vastus lateralis, tensor fascia lata, and rectus abdominis muscles.

The lateral femoral circumflex artery, which is a branch of the profunda femoris artery, supplies blood to the rectus femoris, tensor fascia latae, and vastus lateralis muscles. The medial circumflex femoral artery is a branch of the profunda femoris artery. This vessel provides the blood supply to the gracilis muscle.

References
1. Budny PJ, Fix RJ. Salvage of prosthetic grafts and joints in the lower extremity. Clin Plast Surg. 1991;18:583-591.
2. Mathes SJ, Eshima I. The principles of muscle and musculocutaneous flaps. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;1:379-411.

A 27-year-old man has a 12-cm defect of the tibia after sustaining open comminuted fractures of the tibia and fibula in a motorcycle accident. On physical examination, sensation is intact. The wounds are irrigated and debrided, and an external fixator is applied. Which of the following is most appropriate for reconstruction of the defect?

(A) Bone allograft
(B) Contralateral free vascularized fibula graft
(C) Free vascularized iliac crest graft
(D) Ipsilateral pedicle fibula graft
(E) Nonvascularized iliac crest graft

The correct response is Option B.

In a patient who has a 12-cm bone defect, the most appropriate management is reconstruction using a well-vascularized, uninjured segment of bone graft, such as a contralateral free vascularized fibula graft. The contralateral fibula will provide more than 20 cm of bony length.

Neither allograft nor nonvascularized autograft would provide the required bone length for revascularization. For this reason, nonvascularized bone graft is also not appropriate.

Vascularized iliac crest graft can be used for reconstruction in the upper and lower extremities but would not provide a large enough segment of bone graft.

Because of this patient's injuries, the ipsilateral fibula should not be used. In addition, harvest of an ipsilateral bone graft would remove the ipsilateral supplemental support.

References
1. Thorne CH, Siebert JW, Grotting JC, et al. Reconstructive surgery of the lower extremity. In: McCarthy JG, ed. Plastic Surgery. Philadelphia, Pa: WB Saunders Co; 1990;6:4029.
2. Weiland AJ, Yaremchuk MJ. Vascularized bone transfers. In: Yaremchuk MJ, Burgess AR, Brumback RJ, eds. Lower Extremity Salvage and Reconstruction: Orthopedic and Plastic Surgical Management. Stamford, Conn: Appleton & Lange; 1989.

Six months after undergoing plate fixation and primary wound closure for management of open fractures of the distal tibia and fibula sustained in a motorcycle accident, a 43-year-old man has purulent drainage from the wound site. Radiographs show bony nonunion at the fracture sites.

Which of the following is the most appropriate initial management?

(A) Continuous irrigation
(B) Debridement of bone
(C) Coverage with a muscle flap
(D) Bone grafting
(E) Insertion of an intramedullary rod

The correct response is Option B.

Osteomyelitis is a frequent complication of open fractures associated with soft-tissue injury, fibrosis, and localized ischemia. Measures to prevent the development of osteomyelitis, including removal of dead and devitalized bone, closure of dead space, and coverage with well-vascularized soft tissue, are recommended. In patients with established osteomyelitis, the most appropriate initial management is debridement of devascularized bone and necrotic or scarred tissues and removal of any nonautologous material, such as fixation devices. Because local soft tissue is frequently inadequate, free tissue transfer is often performed for soft-tissue coverage in the lower third of the leg. In patients who have unhealed fractures, an external fixation device is used to stabilize the fracture pattern. An Ilizarov frame may be applied if lengthening is required.

Continuous irrigation alone will not treat the osteomyelitis. Coverage with a well-vascularized muscle flap should be performed following bony debridement, and bone grafting should be delayed until the bone and soft tissues are stabilized and the osteomyelitis has resolved. Insertion of an intramedullary rod may further compromise bony perfusion.

References
1. Anthony JP, Mathes SJ. The muscle flap in the treatment of chronic lower extremity osteomyelitis: results in patients over 5 years after treatment. Plast Reconstr Surg. 1991;88:311-324.
2. Anthony JP, Mathes SJ. Update on chronic osteomyelitis. Clin Plast Surg. 1991;18:515-523.