Our Premise for Lower Extremity Reconstruction
18 September 2019
29 September 2019
21 November 2019 (online)
Few would argue that of all body regions, the lower extremity throughout the world is the most challenging for salvage, regardless of the etiology of the perplexity encountered. The top priority should be maintenance of the function of ambulation so that the individual can lead as independent and self-sufficient life as possible. Aesthetics and donor site morbidity are always key issues, but perhaps of secondary importance here. To emphasize the approach, recognize the problems encountered, and hopefully provide some solutions that will be highly beneficial, we have invited our other colleagues in this special issue to provide their unique insights.
As always, our major focus that we constantly advocate is to have an awareness of how orthopaedic and plastic surgeons should team together, each combining their different skills to solve the ever difficult lower extremity dilemmas in the best possible way. This is known as the orthoplastic approach, and should there be any other? We also recognize that sometimes the individual is better served by a proper amputation of the limb rather than futile attempts at reconstruction, as Karen Evans has thoughtfully as always provided us some guidelines. Any such decision of whatever will be the course should be a consensus with involvement by both the attending orthopedic and plastic surgeons!
However, if limb retention is determined to be a worthy goal, all reconstructive surgeons must be prepared to use whatever options remain available, and dutifully those that are current and within the standard of care for wherever that care is given. Of foremost importance, then is a complete knowledge of the pertinent anatomy, as Taylor and Palmer long ago proselytized, and their disciple Ashton here has reconsidered. A thorough knowledge of anatomy is not just for appropriate flap selection for bony or soft tissue deficits as will be further discussed in detail in the papers to follow, but to have an awareness of potential recipient vessels if a microvascular tissue transfer were needed, and to understand how to make any incisions and perform the proper debridement before undertaking such steps.
Even though this is a journal theoretically dealing with microsurgery, many answers can be solved more simply with local flaps as will also be demonstrated. Remember Georgescu, et al's admonition that even though these may be nonmicrovascular flaps, still an ability to perform a microsurgical dissection as needed is a prerequisite that will always be an advantage of the true microsurgeon. Also, remember that although the rage today may be perforator flaps, traditional muscle flaps as Hollenbeck reiterates cannot be forgotten!
No one can deny that change is always inevitable, so do not overlook several articles that have introduced, perhaps, controversial new concepts in their authors' approach to flaps or support unusual indications for the same. We encourage all to dive in to find what you need now, or remember some point that in the future will change your direction to be even better. And then let us know by writing yourself about your improved solution so that we can all together progress forward. The written word is priceless. Remember that this is a difficult task, but the reward will always be the gratitude of our patients whose lives we have somehow enriched.
- 1 Lerman OZ, Kovach SJ, Levin LS. The respective roles of plastic and orthopedic surgery in limb salvage. Plast Reconstr Surg 2011; 127 (Suppl. 01) 215S-227S
- 2 Taylor GI, Palmer JH. , The Vascular Territories. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987; 40 (02) 113-141
- 3 Koh K, Goh TLH, Song CT. , et al. Free versus pedicled perforator flaps for lower extremity reconstruction: a multicenter comparison of institutional practices and outcomes. J Reconstr Microsurg 2018; 34 (08) 572-580
- 4 Georgescu AV, Matei I, Ardelean F, Capota I. Microsurgical nonmicrovascular flaps in forearm and hand reconstruction. Microsurgery 2007; 27 (05) 384-394
- 5 Hallock GG. The four P's that make a microsurgeon: perfectionist, pragmatist, persistent, and paranoid. J Reconstr Microsurg 2013; 29 (07) 425-426