Case 33 Foot and Ankle Reconstruction



Reena A. Bhatt

Case 33 Foot and Ankle Reconstruction

Case 33 (a-c) A 59-year-old female presents to the clinic. A car tire ran over her foot resulting in multiple metatarsal fractures that have been fixated.



33.1 Description




  • Roughly 17 cm × 6 cm region of necrosis of the plantar foot wrapping dorsally with obvious gangrene of the fourth and fifth digits, and evolving region of demarcation dorsally



  • Involves the weight-bearing region, with loss of soft tissue support and coverage for the plantar second and third metatarsals



  • Large region of soft tissue injury with tendinous and bony involvement



33.2 Work-Up



33.2.1 History




  • Etiology




    • Traumatic: Mechanism of injury



    • Tumor resection: Extent of resection



    • Chronic: Etiology of wound and history of previous management—fixation, debridement, history of osteomyelitis (cultures, antibiotics, debridements)



  • Age, Comorbidities (diabetes, peripheral vascular disease, coronary artery disease, smoking history, steroid use, history of or planned radiation, malnutrition, functional status)



33.2.2 Physical Examination




  • In acute trauma cases, evaluate ABCs



  • Assess wound




    • Soft tissue injury: Size, depth, and zone of injury



    • Degree of contamination and exposure of vital structures



    • Vascular supply to lower extremity, bony defect, and periosteal injury



    • Tendon exposure: Paratenon intact versus damaged



    • For foot injuries: Glabrous versus nonglabrous skin loss, weight bearing versus non-weight bearing



  • Vascular examination




    • Evaluate pulses, temperature, color, and turgor



    • Ankle-Arm Index (AAI) measurements and Doppler examination



  • Neurologic Examination: Check for sensibility, especially of plantar surface



33.2.3 Pertinent Imaging or Diagnostic Studies




  • Plain films: Evaluation of bony injuries and prior fixation, and for foreign bodies



  • Computed tomography angiography (CTA)/Magnetic resonance angiography (MRA)/Angiography indications: Preoperative planning for free flap reconstruction in patients with concern for peripheral vascular disease



33.3 Consultations




  • Trauma surgery: Depending on mechanism, acuity, and additional injuries



  • Vascular surgery: For vascular inflow concerns



  • Orthopedic surgery: Management of bony injury and fixation



  • Infectious disease: For complex infectious processes such as osteomyelitis

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Jul 17, 2021 | Posted by in General Surgery | Comments Off on Case 33 Foot and Ankle Reconstruction

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