MOC-PS(SM) CME Article: Lower Extremity Reconstruction

Learning Objectives: After studying this article, the participant should be able to: 1. Understand the evaluation of a patient with a lower extremity wound. 2. Determine when an attempt at wound salvage is likely to be successful. 3. Select an appropriate technique for wound management. 4. Anticipate and identify wound complications. Summary: Successful management of a patient’s wound at or distal to the knee includes accurate site assessment, meticulous debridement, planning, and execution of a reasonable operative procedure. Outlining a reconstructive plan requires consideration of alternatives from basic to most complex, then selection of the simplest technique likely to achieve wound closure with minimal donor-site morbidity. Healing by secondary intention, with or without vacuum-assisted closure, demands few surgical resources. A skin graft may close a well-vascularized wound. A local skin, fasciocutaneus, or muscle flap can provide vascularized tissue to an otherwise ischemic area. A plastic surgeon may use free tissue transfer in the more difficult anatomic regions, particularly for defects of the distal one-third of the lower leg. Other issues demand consideration when treating a patient with a lower extremity wound. Anesthetic options range from none in the case of secondary intention healing, through prolonged general anesthesia in the circumstance of free tissue transfer. Early recognition of a complication makes successful treatment of that problem more rapid and more likely to be successful. Accurate CPT coding ensures appropriate reimbursement for the reconstructive surgeon and fairness to the payer. Finally, some wounds are so extensive and patients so ill from related or unrelated pathologic processes that attempts at reconstruction are ill advised. These patients are better served by early amputation and prompt rehabilitation. The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented.