Reconstruction of a Traumatic Transmetatarsal Amputation with Use of a Latissimus Dorsi Free Tissue Transfer and the Ilizarov Technique

Abstract

Many protocols have been established to treat the sequelae of severe lower extremity trauma. These include early aggressive and repeated debridement of necrotic tissue, soft-tissue coverage with local muscle flaps or free muscle transfers1-3, and staged skeletal reconstruction4-8 of bone defects. The reconstructive strategies for failed midfoot amputations are less clearly defined. We performed a staged reconstruction, combining the Ilizarov bone-lengthening technique with a latissimus dorsi free muscle transfer. The fundamental goals of the treatment were to improve the patient’s quality of life as well as to provide a functional and durable reconstruction of the musculoskeletal defect. The patient was informed that data concerning the case would be submitted for publication, and she consented. The right forefoot of a sixteen-year-old girl was run over by a train. Wound debridement and amputation of the foot at the base of the metatarsals was performed, and a split-thickness skin graft was applied. Subsequently, the patient could walk on crutches but chronic breakdown of the skin graft developed and she had persistent pain. At the age of eighteen years, when first seen by us, she had an amputation at the midfoot level with unstable skin coverage (Figs. 1-A and 1-B). The surgical treatment plan we recommended was accepted by the patient. Fig. 1-A Fig. 1-B Fig. 1-A This photograph of the residual right foot shows recurrent breakdown of the split-thickness skin graft. Fig. 1-B The amputation level was at the bases of the metatarsals. The first of a two-stage reconstruction included debridement of the previous skin graft and coverage of the resultant defect with a free latissimus dorsi muscle transfer covered by a split-thickness skin graft. The free muscle flap was purposefully left bulky to permit later metatarsal lengthening (Figs. 2-A and 2-B). Fig. 2-A Fig. 2-B Fig. 2-A …