Lower Extremity Reconstruction with Dr JP Hong and Bauback Safa

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Topics Covered:

  • How much lower extremity would you say encompasses your practice?
  • What kind of trauma does your hospital mainly see?  
  • What led to your interest in lower extremity reconstruction?
  • What are your overall goals when approaching a patient in need of lower extremity reconstruction?
  • What are the limits in which you will attempt salvage of an extremity? (trauma examples, diabetic foot, vascular patients etc.)
  • How important is a sensate extremity? Is Tibial Nerve transection a contraindication to limb-salvage in your practice?
  • What is your approach to degloving injuries of the foot? Do you attempt to salvage a de-gloved skin envelope? Do you stage reconstruction in these patients? 
  • Pre-operative examination
    • What is your approach to evaluating the vascular status of patients? 
    • Do you obtain advanced imaging for vascular status in all patients or just those without palpable pulses?
  • Talk about vessel harvest- how proximal will you go to get out the zone of injury and what are you looking for? How do you know you are outside of the zone of injury?
  • Do you have a preference for recipient vessel? 
  • End to end or end to side? 
  • Retrograde recipient vessels, would you consider retrograde arterial flow? How about retrograde venous outflow?
  • What is the role of superficial venous outflow (vs. deep – i.e. VC’s) such as the GSV as outflow?
  • Radical early debridement versus serial debridement?
  • Do you wait for negative cultures prior to flap coverage? 
  • Timing of LE reconstruction. Does it really matter? 
    • A sometimes forgotten important component of the discussion about timing of reconstruction is the aggressiveness of early debridement. Many orthopedic surgeons prefer to serially debride patients, which invariably leads to soft tissue coverage >72h. Alternatively if you know you have plastic surgery available for coverage, maybe this allows some surgeons to be more aggressive at early debridement. 
  • Do you have a go-to flap for lower extremity coverage? 
  • In general- do you prefer muscle or fasciocutaneous free flaps for lower extremity reconstruction? What are instances in which you would use one verses the other?
  • Favorite flap for LE coverage? 
  • What do you think provides a better contour, easier for elevation, better for well vascularized coverage in the setting of infection, etc.
  • Let’s talk about osseous defects –> when do you use vascularized bone? How do you work with your orthopaedic surgeon in deciding non-vascularized options, such as distraction osteogenesis vs. masqulet technique and bone grafting?
  • Do you have preferences on the method of osseous fixation? Ex-fix vs. IMN vs. plating or do you defer to your orthopaedic traumatologist on this? 
  • Post-operative care: 
    • Talk about your protocols for recovery- bed rest, dangle, PT, discharge, wrapping for compression or edema control? When do you allow weight bearing?
  • How would you define success in LE reconstruction?
  • What are some of the most important unanswered questions in lower extremity trauma? 
  • What advice do you have for medical students and residents interested in lower extremity trauma?
  • What do you think the ideal post-residency training is to prepare for a career in lower extremity trauma?

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