Operative technique
The patient was supine under general anesthesia, padding the left
gluteal area. The incisions started in the midline of the medial and
lateral aspects of the thigh. The medial incision was carried down,
starting ten centimeters below the inguinal fold until the distal third
of the leg. The lateral incision began from the lateral aspect of the
greater trochanter to the same level as the medial incision distally.
The anterior flap was cut 10 centimeters proximal to the joint line in
the knee and the posterior flap at the distal third of the leg, ensuring
the complete excision of the previous scar tissue and sinus tracts
(Figure 2 ).
We proceeded with distal femur endoprosthesis extraction and aggressive
debridement of the infected tissues (Figure 3A ).
The superficial femoral artery and vein were accessed from the medial
incision, and careful dissection was performed through the adductor
hiatus until the popliteal fossa. At the lower border of the poplìteus
muscle, we ligated the anterior tibial artery, and the tibioperoneal
trunk was preserved.
The posterior tibial artery was dissected distally and ligated at the
level of the distal third of the leg, preserving the posterior tibial
neurovascular bundle as distally as possible that is required to provide
perfusion and sensation to the flap. Traction neurectomies were
performed on the superficial and deep peroneal nerves. The tibial
osteotomy and foot amputation were performed at the distal diaphyseal
metaphyseal junction approximately 6 cm proximal to the ankle joint. The
fasciocutaneous distal cut was made 3 cm distal to the tibial cut. The
fibula was disarticulated proximally and excised from the interosseous
membrane. It was used later as an autogenous strut graft to augment the
medullary canal, bridging the remaining femur and the tibia autograft
(Figure 3B ).
The lateral and anterior muscular compartments of the leg were
transected completely, and the superficial and posterior muscular
regions were preserved with their tibial osseous attachments. Then, the
distal tibia and the posterior myofasciocutaneous flap were rotated 180
degrees proximally, joining the distal end of the tibia with the distal
end of the femur (Figure 3C ).
The front surface of the tibia was then lying with the posterior
compartment and thigh muscles. The osteosynthesis was made with a 4,5
dynamic compression plate alongside the new femorotibial construct,
achieving compression between the fragments and with a fibular autograft
strut spanning the osteotomy site inside the medullary canals
(Figure 3D ). The stump coverage was complete without skin tension
of the flaps.
The resultant total construct length using the technique was 35 cm,
contrasting to 13 cm in the case of unaugmented amputation
(Figure 4 ).