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Surgical Technique for Osteocutaneous Pedicle Flap Transfer for Salvage of Transtibial Amputation After Severe Lower-Extremity Injury
Heather A. Vallier, MD1; Brendan M. Patterson, MD1; John K. Sontich, MD1
1 Department of Orthopaedic Surgery, 2500 MetroHealth Drive, Cleveland, OH 44109. E-mail address for H.A. Vallier: hvallier@metrohealth.org. E-mail address for B.M. Patterson: bpatterson@metrohealth.org. E-mail address for J.K. Sontich: jsontich@metrohealth.org
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Based on an original article: J Bone Joint Surg Am. 2012 Mar 7;94(5):447-54.

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2012 by The Journal of Bone and Joint Surgery, Inc.
JBJS Essential Surgical Techniques, 2012 Nov 14;2(4):e21 1-12. doi: 10.2106/JBJS.ST.K.00044
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Osteocutaneous pedicle flap transfer from the foot can be used to “salvage” a transtibial amputation level when the severity of an injury precludes a transtibial amputation.

Step 1: Preoperative Assessment

If the posterior tibial artery is not palpable, obtain an angiogram to determine the vascular supply distal to the traumatic zone and to prepare for conversion to a composite free microvascular transfer.

Step 2: Remove Provisional Implants

Remove provisional stabilization implants and minimize surgery about the knee.

Step 3: Develop the Flap

The dissection about the tarsal tunnel is the critical portion of the operative technique.

Step 4: Contour the Calcaneus

Any deviation from perpendicular will translate to an axial deformity in the reconstructed limb.

Step 5: Prepare the Proximal Part of the Tibia and Surrounding Tissues

Retain viable soft tissues and bone, but resect the fibula obliquely.

Step 6: Secure the Calcaneus to the Tibia

Avoid varus and recurvatum malalignment.

Step 7: Repair and Reconstruct the Soft Tissues

The injured limb is routinely very swollen, and in some cases complete coverage requires split-thickness skin-grafting.

Step 8: Postoperative Care and Rehabilitation

As the initial reconstruction is sometimes extremely bulbous, continually advise the patient that the shape will improve dramatically over time with shrinkage of the limb.


In our original study, ten men and four women with a mean age of 43.2 years (range, twenty-four to sixty-four years) underwent an osteocutaneous pedicle flap transfer with use of the ipsilateral foot for salvage to achieve a transtibial amputation level.

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    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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