4.1 Introduction

Just as in the craft of carpentry, a stable foundation and framework is absolutely essential to uphold the final function of a building, but no more important than the sheetrock, trim, and paint that make the building functional, durable, and livable. Reconstruction of the lower extremity is similar, where the orthopaedic surgeon must obtain stable fixation of the damaged bone while the plastic or orthopaedic soft-tissue surgeon must provide vascularized, stable coverage over that damaged bone. These two components are complementary, not adversarial, and both contribute to the success or failure of functional limb restoration. The quality of bone repair and healing will predict the ultimate weight-bearing status, while the vascularized envelope will bring nourishment, immune system elements, antibiotics, and protection to the repaired bone. When both aspects are properly attended to, the result is often a functional limb with an acceptable appearance. While a single surgeon need not perform both of these tasks (although some may choose to do so), the orthopaedic and plastic surgeons involved in this care must have a clear understanding of the other’s role and the importance of each other for a good outcome. This is what we call the orthoplastic approach to reconstructive surgery of the extremities, that is, the application of the principles of both the specialties of orthopaedic and plastic surgery simultaneously to optimize the outcomes in limb reconstruction. ^{1 ,​ 2 ,​ 3 ,​ 4} We plan to discuss the pertinent history and key elements of orthoplastic surgery along with the factors that lead to good outcomes in lower extremity reconstruction. These will always include a thorough orthopaedic evaluation of the extremity; the role and timing of debridement and then flap coverage; the key elements of bone fixation, limb salvage versus amputation; and other applications of orthoplastic surgery.

4.2 The Orthoplastic Approach

Since the days of Hippocrates, surgeons have treated traumatized extremities by providing fracture stabilization using splints or external fixators, and soft-tissue injuries have been treated with various potions and salves. The need for proper limb alignment and healing of soft tissue and bone has been the subject of medicine throughout both the ancient and modern eras. It is the history of medicine that allows us to introduce the concept of orthoplastic surgery. Individuals such as Ambroise Pare, Gaspar Tagliacozzi, Dupuytren, Velpau, and Malgaigne had careers as master surgeons ranging from the 16th century to the middle of the 19th century. If we read the history of orthopaedic surgery or the history of plastic surgery, each of these individuals is mentioned as founding fathers of these respected specialties.

The evolution of distinct surgical specialties really developed at the conclusion of the 19th century. Modern plastic surgery has its roots in the trenches of World War I and is approximately 100 years old. Probably the first modern orthopaedic plastic collaboration was between W. Arbuthnot Lane and Sir Harold Gilles. In 1919, Lane, an orthopaedic surgeon, wrote the preface for Major Gilles’ textbook, and so began the modern era of “orthoplastic surgery.” ⁴

The development of reconstructive microsurgery allowed modern orthoplastic surgery to develop. In 1960, Jacobsen and Suarez introduced the operating microscope for the suture of small vessels. ^{5 ,​ 6} In 1968, Tamai reported the first successful digital replantation. ^{7 ,​ 8} Other microsurgical successes evolved in the later part of the 1960s. ^{5 ,​ 9} Composite transfer of vascularized tissues became commonplace in the 1980s, with an explosion of techniques, flaps, and the popularization of microvascular surgery not just for the traumatic injury of the extremities and replantation but also for elective reconstructive surgery. Refinements such as flap expansion, prefabrication, and modification of tissue transfers continued to take place in the 1990s. ⁷ During this era, innovations have continued including a better understanding of the angiosome concept and the microvasculature territories of skin, leading to a wide array of new free tissue transfer options for complex defects, for example, by utilizing perforator-based flaps. ¹⁰ The modern reconstructive microsurgeon today has an armamentarium of flap options: skin, fascia, adipofascial, fasciocutaneous, muscle, or vascularized bone flaps, as well as combined tissue flaps or chimeric flaps. Over the last two decades, vascularized composite allotransplantation has also developed to become the highest rung on the reconstructive ladder. ^{11 ,​ 12} This explosion of microsurgical advancements has become one of the pillars of orthoplastic surgery.

A better understanding of orthoplastic surgery can be obtained by analyzing the two specialties involved. Plastic surgery specialization over the last 50 years has come to include:

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  Microsurgery.

  
  
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  Hand surgery.

  
  
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  Burn care.

  
  
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  Aesthetic surgery.

  
  
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  Breast reconstruction.

  
  
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  Craniofacial surgery.

Plastic surgeons tend to place emphasis on:

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  Careful soft-tissue handling and reconstruction.

  
  
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  Detailed suture and layered closure techniques.

  
  
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  Aesthetics and improving appearance.

Similarly, orthopaedic specialization has occurred with development of separate societies concentrating on:

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  Pediatric orthopaedics.

  
  
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  Trauma.

  
  
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  Musculoskeletal oncology.

  
  
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  Joint reconstruction.

  
  
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  Hand surgery.

  
  
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  Sports medicine.

Orthopaedic surgeons tend to focus on:

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  Functional outcomes.

  
  
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  Biomechanics.

  
  
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  Stable bone and joint reconstruction.

  
  
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  Rehabilitation.

Therefore, the blending of all these strengths of the two specialties constitutes the definition of orthoplastic surgery:

“The principles and practices of both specialties applied to clinical problems simultaneously, either by a single provider or team of providers working in concert for the benefit of the patient.” ^{1 ,​ 6}

This combined “orthoplastic” approach to patients with severe injuries to the lower extremities will lead to not only better outcomes such as quicker time to bone union, more durable soft-tissue coverage, less pain, and better function, but also fewer complications, shorter hospital stays, and higher patient satisfaction, which are all important in the current health care climate of bundled payments and outcomes-based reimbursement, a landmine more easily traversed by always obtaining optimal results.

4.3 Orthopaedic Evaluation of the Injured Extremity

Combined bone and soft-tissue injuries to the lower extremity come in many different shapes, locations, and sizes. The Gustilo classification has become the most widely accepted and simple way to classify open fractures of the lower extremity. ^{13 ,​ 14} This classification consists of three main categories of open fractures with three subtypes (Table 4‑1).

The group from New York University Langone Medical Center has further substratified the Gustilo grade 3B category with a 3–2-1 modification with the numbers stating the total of uninjured source vessels intact in the limb at the initial evaluation. ^{15 ,​ 16} This better reflects the difficulties to be expected by the reconstructive surgeon, as unplanned returns to the operating room and flap failure rates were found to be significantly greater the fewer the vessels that remained. ¹⁵ A grade 3B-3 limb with all vessels intact intuitively would appear to have been less injured than a grade 3B-1 limb with only vessel intact, and therefore the former would be expected to have a superior outcome.

Other key elements of the orthopaedic evaluation of the traumatized lower extremity include ¹ :

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  Timing and environment of injury.

  
  
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  Mechanism and amount of energy absorption.

  
  
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  Fracture configuration and amount of bone loss.

  
  
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  Systemic conditions, medical status, other associated injuries.

  
  
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  Extent of surrounding soft-tissue injury, shearing, tissue loss (including integument, muscle, fascia, and periosteum).

  
  
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  Vascularity, sensibility, and motor function of the limb.

  
  
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  Possibility of compartment syndrome.

Location of soft-tissue injuries along the axis of the leg is also an important factor to analyze. Traditionally, the traumatized lower extremity has been divided into thirds in an algorithmic manner to help guide treatment:

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  Upper one-third: gastrocnemius pedicled flaps.

  
  
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  Middle one-third: hemisoleus pedicled flaps.

  
  
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  Lower one-third: free tissue transfer.

However, with modern-day microsurgical techniques including perforator-based local flaps such as propeller flaps and reverse flow flaps, and improvement in free tissue transfers, many options now exist for each region of the extremity. A more modern approach to analyzing a lower extremity defect is to focus on the nature of the defect, what is missing and therefore what needs to be replaced, and what local or distant options exist for the achievement of a well-vascularized sealed wound regardless of specific location. However, vital to the success of any reconstruction is the process of preparing the wound by thorough debridement.

4.4 The Role and Timing of Debridement

4.4.3 Timing of Wound Closure

There are currently no objective clinical guidelines to determine the timing of wound closure. ³⁴ Multiple debridements may be required in the case of gross wound contamination or tenuous soft-tissue envelope. ¹⁷ In these scenarios, delayed wound closure allows for repeated reassessment of the wound, more precise operative planning, and thorough cleansing of the tissue bed. ¹⁷ Lenarz et al ³⁴ instituted a protocol wherein an open fracture underwent serial debridement until cultures were negative before definitive wound culture. Mean number of days to closure ranged from 0.76 for Gustilo grade I to 18.5 for IIIC injuries, indicating that several debridements are often necessary with the increasing complexity of the wound. Using this approach, they obtained an impressively low infection rate of 4.3%. ³⁴ Russell et al in an early study found wounds closed primarily after the first debridement had significantly greater risk of infection compared with those closed in delayed fashion (20 vs. 3%). ³⁵ However, more recent studies have challenged this approach and have consistently shown that delays in reconstructive wound coverage are associated with increased infection and flap failure rates. ³⁶ Godina’s classic work demonstrated that delayed reconstruction beyond 72 hours resulted in an increase in infection rate from 1.5 to 17.5% and a higher free-flap failure rate. ³⁷ Fischer et al showed that soft-tissue coverage beyond 10 days of injury was associated with a higher infection rate (18 and 69%). ³⁸ Nevertheless, it must be recognized that the magnitude of the soft-tissue damage may affect outcomes. For example, Hohmann et al compared low-grade open tibia fractures and found no difference in the infection rate between primary closure and delayed closure, with a significant cost reduction in the primary closure group. ³⁹

In our practice, the following principles of irrigation, debridement, and coverage have proven successful:

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  Get the patient to the operating room as soon as reasonably possible (considering vascular status, level of contamination, concomitant injuries, availability of qualified personnel, etc.).

  
  
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  Perform a “radical necrectomy,” treating the wound as a “pseudotumor” by removing all devitalized soft tissue, bone, and surface contaminated tissue.

  
  
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  If unhappy with the wound’s appearance (continued bacterial colonization, purulent appearance, or ongoing necrotic or fibrinous debris), take the patient back for a second or third look.

  
  
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  Irrigation with normal saline at low pressure.

  
  
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  Use a Versajet for surface decontamination or minor debridements.

  
  
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  Keep wound moist at all times.

  
  
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  Negative pressure wound therapy can keep the wound clean and buy more time.

  
  
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  Early coverage desirable.

  
  
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  Manage edema.

  
  
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  Prevent equinus contracture.

Fig. 4‑1 demonstrates a representative case of an 8-year-old child with a Gustilo 3C injury to the lower extremity where these principles were applied. This orthoplastic approach led to successful limb salvage and a good outcome.

4.5 Basic Principles of Bone Fixation

Open fractures with soft-tissue defects necessitate coordinated care to achieve bony union, guard against infection, and maximize functional outcome. In the late 1950s, the Arbetigemenschaft fur Osteosythesfragen (AO) group developed four basic principles for the surgical treatment of fractures. These include:

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   Fracture reduction and fixation to restore anatomical relationships.

   
   
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   Fracture fixation providing absolute or relative stability as the fracture, patient, or injury requires.

   
   
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   Preservation of blood supply to soft tissues and bone by gentle reduction techniques and careful handling.

   
   
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   Early mobilization and rehabilitation of the injured part and patient as a whole.

The development of these principles emphasized the importance of soft tissue, and has led to the awareness that successful management of major orthopaedic trauma is inseparable from successful management of the soft-tissue envelope.

Mutilating extremity injuries often involve significant bony comminution and contamination which require temporary external fixation and repeated irrigation and debridements. If the bone contamination is significant or there is concern for ongoing infection, these fractures require external fixation as the definitive treatment until bone healing. Important soft-tissue reconstruction principles must be considered with placement of external fixation pins and bars as follows:

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  Pins should be as far from the wound as possible while maintaining fracture stability.

  
  
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  Bars should not obstruct the soft-tissue window around the zone of injury.

  
  
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  In the leg, mid anterior pins are better than medial or lateral pins to allow for vascular access for free flaps and rotational muscle and perforator flaps.

  
  
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  The frame must be easily loosened for adjustments needed during reconstruction.

Conversion from external fixation to plates or intramedullary nails in open fractures that have been thoroughly debrided in combination with immediate soft-tissue coverage has proven effective in the treatment of severe extremity trauma (Fig. 4‑1). ^{40 ,​ 41} This approach is ideal when possible and allows for reconstruction to proceed without interference of external fixator devices.

It is imperative that both the orthopaedic surgeon and the reconstructive plastic surgeon be familiar with the needs and approaches of the other to optimize a functional outcome for the patient. This orthoplastic approach to limb salvage will maximize outcomes, although at times amputation must be considered before embarking on the often lengthy limb salvage journey. ⁴