FIG. 21-72. Complete closure after a serratus MVT with skin grafting. Side view. The muscle was not neurotized because the patient had severe neuropathy.

FIG. 21-73. Plantar view. Unfortunately, the area broke down again after 2 years secondary to complete diabetic neuropathy, and the leg was amputated. Without protective sensation, such wounds are extremely difficult to manage.

CASE 15

An 18-year-old woman suffered a crush/devascularizing injury to her left foot, with metatarsal fractures to all toes.

FIG. 21-74. The wound was closed primarily, resulting in a severe valgus deformity of all toes as seen in preoperative x ray.

FIG. 21-75. The wound has been reopened and the metatarsal fractures osteotomized and repositioned. The increased length created a V-shaped through-and-through wound that required additional soft tissue for closure.

FIG. 21-76. The serratus has been transplanted to the foot and anastomosed to the dorsalis pedis artery, providing dorsal and lateral plantar coverage. The fifth toe was resected. Muscle next to defect.

FIG. 21-77. Muscle inset.

FIG. 21-78. Late follow-up shows maintenance of length and fracture healing. The patient is now able to wear normal shoes without pain.

FIG. 21-79. X ray shows healed, realigned metatarsals.

CASE 16

A patient had a recurrent skin graft breakdown from an old crush amputation through the metatarsal heads.

FIG. 21-80. The foot was exquisitely tender because of multiple traumatic neuromas of the common plantar nerve trapped in scar.

FIG. 21-81. The skin graft was removed and the neuromas transplanted proximally, well away from the weight-bearing area.

FIG. 21-82. Neuromas.

FIG. 21-83. Two slips of serratus were transplanted to provide closure and bone coverage. The serratus vessels were anastomosed to the dorsalis pedis artery and VC and the nerve to the serratus to the deep peroneal nerve.

next page...