Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table to facilitate access to both the foot for skeletal fixation and the thigh for gracilis muscle harvest.

Anatomical surgical approach:  A percutaneous approach was utilized for the insertion of Kirschner wires to restore forefoot alignment. A separate incision was made medially for the placement of a bridge plate along the medial column of the foot. The gracilis muscle was harvested from the ipsilateral thigh, including its vascular pedicle, and transferred to the foot wound site.

The surgical team performed two debridements prior to definitive wound coverage. The gracilis free flap was placed by plastic surgery colleagues, with microvascular anastomosis to an artery and vein proximal to the ankle. The muscle was embedded in the wound, and while initially bulky, it is expected to atrophy over time, resulting in a more normal foot contour. The medial column bridge plate was placed to maintain foot architecture during healing, with plans for removal at 4-6 months postoperatively.

Postoperative protocol:   Postoperative rehabilitation included non-weight bearing on the affected foot for an initial period, followed by gradual weight-bearing as tolerated after removal of the Kirschner wires at 8 weeks. The patient is expected to achieve midfoot auto-fusion over time.

Follow up:   Not specified.

Orthopaedic implants used:   Kirschner wires, Medial column bridge plate.