Lower Extremity, Trunk And Genitourinary Reconstruction

A 32-year-old man sustains a Gustilo type IIIB open tibial shaft fracture. After repeat radical debridement, the fracture is stable, the wound is clean, and a 10 × 14 cm anteromedial tibial defect remains with exposed bone and fixation hardware. What is the most appropriate reconstructive plan?

A 67-year-old woman develops an anterior knee wound after total knee arthroplasty. Following debridement, the prosthesis and patellar tendon are exposed through a 7-cm defect. The medial gastrocnemius muscle remains viable. What is the most appropriate reconstruction?

A 45-year-old man has a distal-third leg and ankle defect after a crush injury. Debridement leaves exposed hardware and extensor tendons. The surrounding skin is extensively scarred, and computed-tomographic angiography shows no dependable local perforator near the defect. What is the most appropriate reconstructive option?

A 38-year-old man has a 5 × 6 cm weight-bearing plantar heel defect after excision of a melanoma. The calcaneus is not exposed, protective sensation is important, and posterior tibial artery flow is normal. What is the most appropriate reconstruction?

A 56-year-old man has chronic tibial osteomyelitis with a draining sinus and a large intramedullary dead space after previous fracture fixation. Radical debridement removes all necrotic bone and infected scar, leaving exposed viable tibia. What is the most appropriate reconstructive principle?

A 59-year-old man undergoes resection of an anterolateral chest-wall sarcoma, including four adjacent ribs. The resulting defect is 12 cm wide with exposed pleura and inadequate soft tissue for closure. What is the most appropriate reconstructive plan?

A 64-year-old man develops a dehisced lumbosacral incision with exposed spinal fixation hardware after oncologic spine surgery. The hardware remains mechanically necessary, and debridement leaves a midline defect with paraspinal muscles available bilaterally. What is the most appropriate reconstruction?

A 63-year-old woman undergoes abdominoperineal resection in a previously irradiated pelvis. The operation leaves a large perineal defect with pelvic dead space and insufficient local tissue for tension-free closure. What is the most appropriate reconstruction?

A 48-year-old man undergoes serial debridement for Fournier gangrene. The infection is controlled, both testes are viable, and approximately 70% of the scrotal skin is absent. The wound bed is healthy and well vascularized. What is the most appropriate reconstructive option?

A 29-year-old man sustains circumferential degloving of the penile shaft. Debridement leaves Buck fascia intact, the urethra is uninjured, and the wound is clean. What is the most appropriate definitive reconstruction?

A 72-year-old man develops breakdown of a groin incision after femoral artery bypass. Debridement leaves a clean 6 × 8 cm defect with an exposed but patent vascular graft. The sartorius muscle is viable, and there is no uncontrolled systemic infection. What is the most appropriate reconstruction?

A 48-year-old man has a 6 × 7 cm posterior ankle wound after debridement of an infected Achilles tendon repair. The remaining tendon is exposed without paratenon, posterior tibial flow is intact, and the peroneal perforators are patent. What is the most appropriate reconstruction?

A 63-year-old man with diabetes has a dorsal foot wound with exposed metatarsals after debridement. The foot is cool, pedal pulses are absent, ankle-brachial index is 0.38, and computed-tomographic angiography shows severe multilevel arterial disease. What is the most appropriate next step?

A 41-year-old woman presents six months after a high-energy pelvic injury with a recurrent fluctuant collection over the greater trochanter. Repeated aspirations have failed, and magnetic resonance imaging shows a chronic encapsulated Morel-Lavallée lesion. What is the most appropriate definitive management?

A 66-year-old man develops deep sternal wound infection after median sternotomy. After removal of necrotic tissue and unstable wires, the sternum is adequately debrided but a large central defect remains with exposed mediastinal structures. What is the most appropriate reconstruction?

A 50-year-old woman undergoes resection of a large abdominal-wall desmoid tumor. The operation leaves a clean full-thickness central defect with a 14-cm fascial gap and insufficient native fascia for tension-free primary closure. The overlying skin can be preserved. What is the most appropriate reconstructive principle?

A 69-year-old woman undergoes radical vulvectomy in a previously irradiated field. The resulting defect exposes the vaginal wall and pelvic floor, and local vulvar skin is insufficient for closure. What is the most appropriate reconstruction?

A 55-year-old paraplegic man has a recurrent stage IV trochanteric pressure sore with an infected bursa and exposed greater trochanter. After nutritional optimization and pressure-relief planning, radical excision removes the ulcer, bursa, and prominent infected bone. What is the most appropriate reconstruction?

A 46-year-old man with morbid obesity has an acquired buried penis, chronic balanitis, urinary spraying, and cicatricial penile shaft skin. Examination shows a large suprapubic fat pad and insufficient healthy shaft skin after release. What is the most appropriate reconstruction?

A 52-year-old man undergoes serial debridement for extensive Fournier gangrene. Infection is controlled, but a large perineoscrotal defect remains with exposed testes, proximal penile structures, and insufficient residual scrotal skin. Healthy medial-thigh tissue is available bilaterally. What is the most appropriate reconstruction?

A 54-year-old man has a 4 × 5 cm anteromedial distal-leg defect after removal of infected fixation hardware. The wound is clean, the tibia remains exposed, and Doppler examination identifies a reliable posterior tibial artery perforator outside the traumatized zone. What is the most appropriate reconstruction?

A 71-year-old man develops an infected groin wound with exposure of a prosthetic femoral vascular graft. The sartorius muscle was divided during previous operations, but the rectus femoris muscle and its pedicle are intact. After debridement, what is the most appropriate reconstructive option?

A 43-year-old man requires free-flap coverage of a distal tibial defect. Angiography shows that the posterior tibial artery is the only patent artery supplying the foot. The vessel is suitable for microvascular anastomosis, and distal perfusion must be preserved. What is the most appropriate recipient-vessel strategy?

A 58-year-old man has chronic calcaneal osteomyelitis with a large plantar-posterior heel defect after radical debridement. The wound contains substantial dead space, exposed viable calcaneus, and no dependable local flap tissue. What is the most appropriate reconstruction?

A 49-year-old woman survives abdominal-wall necrotizing infection and multiple laparotomies. She now has a stable split-thickness skin graft over granulated bowel, no active sepsis, and a large planned ventral hernia with widely separated fascial edges. What is the most appropriate long-term reconstructive plan?

A 60-year-old man undergoes partial sacrectomy for a chordoma. The operation leaves a large midline lumbosacral defect with exposed hardware and pelvic dead space. Both superior gluteal vascular systems and most of the gluteus maximus muscles remain intact. What is the most appropriate reconstruction?

A 57-year-old woman undergoes resection of a recurrent lateral chest-wall sarcoma in a previously irradiated field. Five ribs are removed, the pleural cavity is exposed, and the ipsilateral latissimus dorsi was used in a previous operation. What is the most appropriate reconstructive plan?

A 46-year-old man has massive chronic penoscrotal lymphedema causing buried penis, recurrent cellulitis, difficulty voiding, and inability to maintain hygiene. Conservative compression has failed, and the penile shaft and testes are viable beneath thick fibrotic skin. What is the most appropriate definitive reconstruction?

A 35-year-old man sustains an open pelvic fracture with extensive perineal degloving, fecal contamination, and hemodynamic instability. Large portions of the perineal skin are nonviable, but the exact zone of tissue loss is not yet demarcated. What is the most appropriate initial reconstructive strategy?

A 68-year-old woman develops a painful perineal hernia one year after abdominoperineal resection. Imaging shows pelvic contents descending through a wide pelvic-floor defect, and the overlying perineal skin is thin but intact. What is the most appropriate reconstructive principle?

A 44-year-old man undergoes radical debridement of an infected open tibial fracture. A 6 × 9 cm defect remains over the middle third of the tibia with exposed bone, while the soleus muscle and posterior tibial vascular system are intact. What is the most appropriate reconstruction?

A 51-year-old woman develops a lateral knee wound after resection of a soft-tissue sarcoma. Debridement leaves the lateral joint capsule, fibular head, and proximal tibia exposed. The lateral gastrocnemius muscle and its vascular pedicle are intact. What is the most appropriate reconstruction?

A 36-year-old man has a traumatic below-knee amputation with breakdown of the anterior stump. After debridement, the tibial end is exposed and local tissue is insufficient for durable padding. Knee function is good, and preserving below-knee length would significantly improve prosthetic rehabilitation. What is the most appropriate reconstruction?

A 29-year-old man sustains a circumferential degloving injury of the thigh. The avulsed skin is largely intact but has lost its subcutaneous blood supply. After debridement, the underlying muscle is viable and the avulsed skin shows no independent perfusion. What is the most appropriate use of the avulsed skin?

A 47-year-old woman develops early-stage unilateral lower-extremity lymphedema after pelvic lymph-node dissection. Swelling is soft and pitting, improves partially with elevation, and lymphatic imaging demonstrates functioning lymphatic channels with focal obstruction. Conservative therapy has provided incomplete relief. What is the most appropriate physiologic surgical option?

A 60-year-old man has longstanding lower-extremity lymphedema with massive enlargement, recurrent cellulitis, thickened verrucous skin, and nonpitting fibrofatty tissue. Lymphatic imaging shows minimal functioning superficial lymphatics, and compression has failed. What is the most appropriate reconstructive principle?

A 55-year-old woman has an infected abdominal-wall defect with an enterocutaneous fistula, exposed bowel, malnutrition, and ongoing intra-abdominal contamination. The fascial edges are widely separated. What is the most appropriate initial reconstructive strategy?

A 62-year-old woman undergoes total pelvic exenteration in a previously irradiated field. The procedure leaves a circumferential vaginal defect and a large pelvic dead space. Bilateral gracilis muscles and their pedicles are intact. What is the most appropriate reconstruction?

A 34-year-old man has loss of the anterior penile urethra and surrounding shaft skin after severe infection. The wound is clean, the corporal bodies are viable, and a staged reconstruction is planned. What is the most appropriate reconstructive principle?

A 28-year-old man undergoes external hemipelvectomy for a massive pelvic sarcoma. The amputated limb is oncologically free distally, and the thigh contains viable skin and muscle supplied by intact vessels that can be transferred. The pelvic defect is too large for primary closure. What is the most appropriate reconstruction?

A 39-year-old man has a 7 × 9 cm dorsal foot defect after debridement of a crush injury. The extensor tendons and metatarsal joints are exposed, local tissues are damaged, and the reconstruction must remain thin enough for shoe wear. What is the most appropriate reconstructive option?

A 58-year-old paraplegic man has a recurrent stage IV ischial pressure sore with a thick infected bursa and exposed ischial tuberosity. After nutritional optimization, pressure-relief planning, bursectomy, and removal of prominent infected bone, a deep cavity remains. What is the most appropriate reconstruction?

A 46-year-old woman undergoes resection of a recurrent sarcoma involving the left lower lateral abdominal wall. The operation removes skin, external oblique, internal oblique, and transversus abdominis, leaving a large full-thickness defect. The ipsilateral tensor fascia lata muscle and vascular pedicle are intact. What is the most appropriate reconstruction?

A 67-year-old man develops an infected lower sternal wound after cardiac surgery. Radical debridement leaves an inferior sternal defect with exposed mediastinal tissue. Both pectoralis major muscles were previously divided and cannot reach the lower defect, while the superior epigastric blood supply is intact. What is the most appropriate reconstruction?

A 62-year-old woman develops a midline upper thoracic wound with exposed spinal instrumentation after tumor resection. Debridement leaves a 6 × 10 cm defect between the scapulae. The lower trapezius muscle and transverse cervical vascular system are intact. What is the most appropriate reconstruction?

A 42-year-old man undergoes debridement for localized Fournier gangrene. Infection is controlled, both testes are viable, and approximately 35% of the scrotal skin is absent. The remaining scrotal skin is healthy, mobile, and sufficient for tension-free advancement. What is the most appropriate reconstruction?

A 65-year-old woman undergoes partial radical vulvectomy for squamous-cell carcinoma. The resection leaves a unilateral 5 × 7 cm vulvar defect with exposed deep fascia. The surrounding tissue is not irradiated, and local internal pudendal artery perforators are intact. What is the most appropriate reconstruction?

A 49-year-old woman has stage II secondary lower-extremity lymphedema after pelvic lymph-node dissection. The limb remains partly pitting, but lymphatic imaging shows few usable distal lymphatics and marked regional lymph-node loss. Conservative therapy has reduced but not controlled recurrent cellulitis. What is the most appropriate physiologic reconstructive option?

A 70-year-old man develops breakdown over a revision total hip arthroplasty. Debridement leaves exposed prosthetic material and a large lateral hip dead space. The vastus lateralis muscle and descending branch of the lateral circumflex femoral artery are intact. What is the most appropriate reconstruction?

A 34-year-old man with a below-knee amputation has severe focal stump pain and an unstable soft-tissue envelope. Examination identifies painful tibial and common peroneal neuromas, and stump revision is planned to improve prosthetic tolerance. What is the most appropriate nerve-management strategy?

A 36-year-old man presents after a motorcycle collision with a Gustilo type IIIB distal tibial fracture. Initial debridement reveals gross contamination, crushed skin margins, and muscle whose viability remains uncertain. External fixation has restored alignment, but the wound is not yet suitable for definitive closure. What is the most appropriate reconstructive strategy?

A 48-year-old man undergoes debridement after an infected Achilles tendon repair. A 9-cm tendon gap remains together with an 11 × 7 cm posterior ankle skin defect. The wound is clean, and ankle plantar flexion must be restored. Local tissue is insufficient. What is the most appropriate reconstruction?

A 27-year-old man sustains a traumatic plantar heel-pad avulsion. The heel pad remains attached by a broad medial soft-tissue bridge, has capillary bleeding, and retains protective sensation. Imaging shows no calcaneal fracture. What is the most appropriate management?

A 30-year-old man has an 8-cm segmental tibial defect and an overlying soft-tissue defect after radical debridement of an infected open fracture. Infection is now controlled, limb perfusion is adequate, and the knee and ankle are functional. What is the most appropriate definitive reconstruction?

A 42-year-old man has a distal-leg crush injury with a 7-cm anterior tibial artery segment loss and a large soft-tissue defect exposing the tibia and ankle tendons. The posterior tibial artery is patent but should be preserved as the main remaining supply to the foot. What is the most appropriate reconstruction?

A 61-year-old man undergoes resection of a posterior chest-wall tumor involving two ribs beneath the scapula. The defect is 6 cm wide, the scapula provides external support, respiratory mechanics are stable, and healthy latissimus muscle is available for closure. What is the most appropriate reconstruction?

A 55-year-old woman undergoes resection of a recurrent flank sarcoma. The operation removes the lateral abdominal-wall muscles, fascia, and overlying irradiated skin, creating a large full-thickness defect with exposed retroperitoneal contents. The ipsilateral latissimus dorsi muscle and thoracodorsal pedicle are intact. What is the most appropriate reconstruction?

A 63-year-old woman develops a persistent rectovaginal fistula after pelvic radiotherapy and previous failed local repair. The surrounding tissues are fibrotic, but there is no active malignancy or uncontrolled infection. What is the most appropriate reconstructive approach?

A 24-year-old man presents 90 minutes after complete traumatic penile amputation by a sharp mechanism. The amputated part was immediately wrapped in moist gauze, placed in a sealed bag, and cooled on ice. The patient is hemodynamically stable, and the amputated segment is clean and intact. What is the most appropriate definitive management?

A 38-year-old man develops a 1.5-cm urethrocutaneous fistula three months after radial forearm free-flap phalloplasty. The wound is no longer infected, but the surrounding tissue remains indurated and inflamed after a recent urinary infection. He voids adequately through the neourethra. What is the most appropriate management?

A 64-year-old man with diabetes undergoes transmetatarsal amputation for irreversible forefoot infection. After debridement, the plantar skin flap is viable and sensate, but the dorsal forefoot skin is insufficient for closure. The metatarsal ends can be shortened slightly without compromising the planned stump length. What is the most appropriate reconstruction?

A 35-year-old man has a distal-leg wound with exposed tibia after multiple failed local flaps. Angiography shows severely damaged recipient vessels in the injured leg, and vascular reconstruction is not currently feasible. The opposite leg is healthy, and the patient wishes to preserve the limb. What is the most appropriate salvage reconstruction?

A 72-year-old woman develops an infected anterior knee wound after multiple revision arthroplasties. Debridement leaves exposed prosthetic components and a large dead space. Both gastrocnemius muscles were damaged during previous operations, but the prosthesis remains stable and the infection is considered salvageable. What is the most appropriate reconstructive option?

A 40-year-old man undergoes resection of a proximal tibial sarcoma. The extensor mechanism, including a 7-cm segment of patellar tendon, is removed together with overlying skin. The knee joint and remaining quadriceps mechanism are preserved. What is the most appropriate reconstructive plan?

A 58-year-old man undergoes sacral tumor resection that leaves a dural defect with cerebrospinal fluid leakage, exposed spinal hardware, and a large posterior soft-tissue cavity. What is the most appropriate reconstructive approach?

A 61-year-old man has chronic postpneumonectomy empyema with a persistent bronchopleural fistula and a large infected pleural cavity. Drainage and antibiotics have controlled systemic sepsis, but the cavity does not close. What is the most appropriate definitive reconstructive principle?

A 22-year-old woman with congenital vaginal agenesis has normal external genitalia and functioning ovaries. She desires vaginal reconstruction, and there is adequate space between the bladder and rectum to create a neovaginal cavity. What is the most appropriate reconstructive option?

A 45-year-old man presents with painful penile deformity, chronic inflammation, and multiple firm subcutaneous nodules after previous injection of liquid paraffin for penile enlargement. Magnetic resonance imaging confirms extensive foreign material within the shaft skin and subcutaneous tissue, while Buck fascia and the erectile bodies are preserved. What is the most appropriate definitive treatment?

A 57-year-old woman has a chronic draining sinus and recurrent abscesses three years after synthetic mesh repair of a ventral hernia. Imaging shows folded exposed mesh within the abdominal wall but no enterocutaneous fistula. Antibiotics have repeatedly produced only temporary improvement. What is the most appropriate management?

A 39-year-old man undergoes penile replantation after sharp traumatic amputation. Twelve hours later, the glans and shaft are markedly swollen and cyanotic with brisk dark bleeding, while arterial Doppler signals remain present. What is the most appropriate next step?

A 46-year-old woman undergoes wide excision of a synovial sarcoma from the anterior ankle. The resection leaves a 10 × 8 cm defect with exposed extensor tendons, ankle capsule, and fixation hardware. Local perforators lie within the operative field, and the reconstruction must permit tendon gliding and shoe wear. What is the most appropriate reconstruction?

A 29-year-old man develops a severe posterior knee flexion contracture one year after a deep burn. Complete release restores near-full extension but creates a broad popliteal defect with exposed neurovascular structures. What is the most appropriate reconstruction?