Case 33 Foot and Ankle Reconstruction
33.1 Description
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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
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Involves the weight-bearing region, with loss of soft tissue support and coverage for the plantar second and third metatarsals
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Large region of soft tissue injury with tendinous and bony involvement
33.2 Work-Up
33.2.1 History
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Etiology
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Traumatic: Mechanism of injury
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Tumor resection: Extent of resection
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Chronic: Etiology of wound and history of previous management—fixation, debridement, history of osteomyelitis (cultures, antibiotics, debridements)
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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
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In acute trauma cases, evaluate ABCs
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Assess wound
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Soft tissue injury: Size, depth, and zone of injury
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Degree of contamination and exposure of vital structures
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Vascular supply to lower extremity, bony defect, and periosteal injury
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Tendon exposure: Paratenon intact versus damaged
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For foot injuries: Glabrous versus nonglabrous skin loss, weight bearing versus non-weight bearing
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Vascular examination
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Evaluate pulses, temperature, color, and turgor
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Ankle-Arm Index (AAI) measurements and Doppler examination
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Neurologic Examination: Check for sensibility, especially of plantar surface
33.2.3 Pertinent Imaging or Diagnostic Studies
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Plain films: Evaluation of bony injuries and prior fixation, and for foreign bodies
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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
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Trauma surgery: Depending on mechanism, acuity, and additional injuries
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Vascular surgery: For vascular inflow concerns
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Orthopedic surgery: Management of bony injury and fixation
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Infectious disease: For complex infectious processes such as osteomyelitis