CFB OT04 Reconstruction
CFB OT04 Reconstruction refers to a surgical procedure involving the rebuilding or repair of the common femoral bifurcation (the junction where the common femoral artery divides into the superficial and deep femoral arteries), typically performed to restore blood flow in patients with peripheral arterial occlusive disease.
Reconstruction — Exam-Ready Comprehensive Notes
Lecture Map
Reconstruction is the systematic rebuilding of tissues, organs, or body parts after destruction by disease, trauma, congenital malformation, or surgical resection. This lecture (CFB OT04, Dr. WY Ip) uses an orthopaedic/hand-surgery lens but the principles are universal across all surgical subspecialties. The overarching framework is the 5 Rs (Remove, Repair, Replace, Regenerate, Rehabilitate), applied across every tissue type and every diagnostic category in orthopaedics. [1]
To understand the whole range of conditions & tissues requiring reconstruction; to appreciate multiple methods of reconstruction; to understand such with examples; to be motivated by the challenges with reconstruction. [1]
- In-house summative MCQs directly test the objectives of reconstruction, the 5 R framework, and which modalities are "usual" vs "unusual" — three MCQ-style questions appear at the end of the slide deck. [1]
- Viva/OSCE may ask you to walk through how you reconstruct a specific defect (e.g., necrotising fasciitis, tumour resection, congenital anomaly).
- The reconstructive ladder concept (from GC 192 and senior notes) integrates directly with this lecture's operative techniques. [2][3]
Reconstruction is the rebuilding of something after it has been destroyed. The activity of constructing something again involving 5 "R": Remove, Repair, Replace, Regenerate, Rehabilitate. [1]
Why the 5 Rs Matter
Think of reconstruction as a sequential thought process for every surgical case:
| R | Meaning | First-Principle Rationale | Example |
|---|---|---|---|
| Remove | Excise pathological tissue (tumour, infection, necrosis, duplicated/fibrous tissue) | You cannot rebuild on a diseased foundation; source control is paramount | Debridement in necrotising fasciitis, excision of extra digit |
| Repair | Fix what is damaged but salvageable (fracture fixation, ligament tightening, wound closure) | Restoring structural continuity preserves biomechanical function | Fracture ORIF, tendon repair, skin closure |
| Replace | Substitute irretrievably lost tissue with graft, flap, prosthesis, or biomaterial | Lost tissue cannot regenerate quickly enough → need immediate structural/functional substitute | Skin graft for burn, joint arthroplasty, free flap |
| Regenerate | Harness biological processes (stem cells, growth factors, tissue engineering) to grow new tissue | Avoids donor-site morbidity; future of reconstructive surgery | PRP for ulcer healing, scaffolds for skin, stem cell therapy |
| Rehabilitate | Restore function through physiotherapy, splintage, orthoses, training | Reconstruction without rehabilitation = suboptimal functional outcome | Hand therapy after tendon transfer, foot orthosis post-polydactyly |
High Yield — 5 Rs
Every case in this lecture is framed through the 5 Rs. For exams, practise applying this framework to any reconstructive scenario — the examiners expect you to demonstrate systematic thinking, not just list operations.
Prevent potential harm; Relieve pain; Improve function; Improve cosmesis; Restore esteem; Better quality of life. [1]
Why each matters clinically:
| Objective | Clinical Rationale |
|---|---|
| Prevent potential harm | E.g., removing a malignant tumour before it metastasises; correcting a deformity before secondary joint damage |
| Relieve pain | Pain is often the primary indication driving patients to seek surgery (e.g., OA) |
| Improve function | The most important surgical outcome — a beautiful reconstruction that doesn't work is a failure |
| Improve cosmesis | Especially important in head/neck, hand, and breast reconstruction; affects psychosocial wellbeing |
| Restore esteem | Disfigurement profoundly impacts self-image and social functioning |
| Better quality of life | The ultimate measure of reconstructive success |
Exam MCQ Trap
"Prevent aging" is NOT an objective of reconstruction. This is tested directly in the lecture's built-in MCQ #1. Reconstruction addresses pathology, not normal physiological aging. [1]
Absence; Extra (lump); Mal-alignment; Contracture. [1]
These four categories cover virtually every deformity you will encounter:
- Absence — Congenital (e.g., absent radius) or acquired (e.g., post-amputation, post-tumour resection)
- Extra — Congenital duplication (polydactyly) or neoplasms (lumps)
- Mal-alignment — Fracture malunion, angular deformity, rotational mismatch
- Contracture — Scarring, Dupuytren's, joint contracture from disuse or inflammation
Congenital and developmental abnormalities; Infections; Rheumatic disorders; Metabolic dysfunction; Degenerative disorders; Tumors and lesions that mimic them; Sensory disturbance and muscle weakness; Injury and mechanical derangement. [1]
This is the complete differential diagnosis framework for orthopaedic pathology. Every condition falls into one of these eight categories.
Skin; Scar; Blood vessel; Nerve; Muscle/Tendon; Bone; Joint/Cartilage; Ligament; Composite; Biomaterials (e.g., metal, organic or inorganic). [1]
Why "composite" matters: Many reconstructions involve multiple tissue types simultaneously (e.g., an osteomyocutaneous free flap contains bone + muscle + skin + blood vessels). Real-world defects are rarely single-tissue.
Cosmetics; Prosthesis; Orthosis; Physiotherapy; Splintage; Medication (e.g., Botox). [1]
| Technique | Definition & Key Distinction | Example |
|---|---|---|
| Prosthesis | An artificial device that replaces a missing body part | Artificial limb, breast implant |
| Orthosis | An external device that supports/corrects a body part (does NOT replace it) | AFO (ankle-foot orthosis), wrist splint |
| Physiotherapy | Passive/active mobilisation to correct deformity, strengthen muscles, restore ROM | Passive mobilisation for mild deformity [1] |
| Splintage | Immobilisation to reduce pain, protect repaired tissue, or prevent deformity | Splint for OA digits, post-op hand splint [1] |
| Botox | Chemodenervation — temporarily paralyses overactive muscles | Spasticity management, cosmetic wrinkle reduction |
Exam MCQ Trap — Lecture MCQ #2
"Oral medication for pain relief" is NOT a usual reconstruction means. Pain relief is supportive, not reconstructive. The other choices (operation for tendon, prosthesis, physiotherapy, splintage) are all legitimate reconstruction modalities. [1]
Bone: Osteotomy, bone lengthening, graft. Joint/cartilage: transplant of small area, in vitro regeneration, osteotomy, arthrodesis, arthroplasty. Skin: skin graft, skin expansion, skin flap (flap = transplantation with blood supply). Muscle & tendon: tendon transfer, release, tenodesis. Nerve: graft, neurotization. Ligament: replaced with tendon, artificial materials. [1]
Key Definitions and First-Principle Explanations
| Tissue | Technique | What It Is | Why It Works |
|---|---|---|---|
| Bone | Osteotomy | Cutting bone to realign it | Corrects angular/rotational deformity; redistributes load across joint |
| Bone lengthening | Gradual distraction osteogenesis (Ilizarov principle) | New bone forms in the gap created by slow, controlled distraction (~1 mm/day) | |
| Bone graft | Transplanting bone (autograft, allograft, or synthetic) | Provides scaffold + osteoinductive factors for new bone formation | |
| Joint | Arthrodesis | Surgical fusion of a joint | Eliminates painful motion in a destroyed joint; sacrifices movement for stability and pain relief |
| Arthroplasty | Joint replacement with prosthetic implant | Restores motion in a destroyed joint; preferred when motion preservation is critical | |
| Cartilage transplant | Autologous chondrocyte implantation or osteochondral graft | Regenerates hyaline-like cartilage over small focal defects | |
| Skin | Skin graft | Transplanted skin WITHOUT its own blood supply; depends on recipient bed vascularity | Split-thickness (epidermis + partial dermis) or full-thickness (entire dermis); requires healthy, vascularised wound bed [3] |
| Skin expansion | Balloon placed under skin, gradually inflated over weeks | Generates extra local skin with matching colour/texture for reconstruction | |
| Skin flap | Transplanted tissue WITH its own blood supply (pedicled or free) | Survives independently of wound bed; used when bed is avascular or critical structures exposed [3] | |
| Muscle/Tendon | Tendon transfer | Rerouting a functioning tendon to replace a non-functioning one | Borrows function from a redundant motor to restore lost movement |
| Tenodesis | Fixing a tendon to bone to provide passive stabilisation | Creates a passive check-rein effect (e.g., wrist tenodesis for tendon imbalance) | |
| Nerve | Nerve graft | Interposition graft (usually sural nerve) to bridge a nerve gap | Provides a conduit for axonal regrowth |
| Neurotization | Transferring a functioning nerve to a denervated muscle | Bypasses the injured nerve entirely; donor nerve reinnervates the target | |
| Ligament | Tendon graft | Using autologous tendon (e.g., hamstring, palmaris longus) to reconstruct ligament | Tendons can function as ligament substitutes after biological remodelling ("ligamentisation") |
| Artificial materials | Synthetic ligament (e.g., LARS) | Provides immediate mechanical stability but risks long-term failure/wear |
The lecture's operative techniques align with the classic reconstructive ladder described in GC 192 and senior notes [2][3]:
Principle: Start at the simplest method that will achieve the reconstructive goal. Escalate only when simpler methods are inadequate. However, modern practice also uses a "reconstructive elevator" — jumping directly to the optimal method (e.g., free flap) when clinical context demands it.
From GC 192: Area to be resected determined primarily by the pathology and reconstruction comes second. Adequate resection with clear margin for cancer surgery e.g., BCC 2–3 mm margin, SCC 1 cm margin, Sarcoma 2–3 cm margin. [2]
Key Principle
Never compromise oncological resection to make reconstruction easier. Resect adequately first, then reconstruct. [2]
Clinical Case-Based Application of the 5 Rs
The lecture walks through eight diagnostic categories with specific examples. Below is a consolidated table:
Remove: extra digit. Repair: various tissue layers after trimming. Rehabilitate: foot orthosis or hand splint to protect repaired tissue during early stage. [1]
| Tissue | Operative Technique |
|---|---|
| Bone | Excise duplicated bone, realign digital bones |
| Skin | Excise redundant skin, close |
| Muscle/Tendon | Combine tendons of 2 digits into one |
| Ligament | Tighten lax ligaments |
Remove: fibrous tissue connection between digits. Replace: skin deficit with skin graft. Rehabilitate: hand function training. [1]
| Tissue | Operative Technique |
|---|---|
| Bone | Trim to good shape |
| Skin | Cut at webs, skin graft |
| Muscle/Tendon | Nothing can be done (often absent/hypoplastic) |
Multiple-stage operations to further improve function; cosmesis not the key concern. [1]
Why multiple stages? The hand is a complex structure; staged procedures allow tissue healing and growth between operations, and each stage addresses a specific functional deficit.
Remove: infected & necrotic tissues. Repair: cut tissue repaired. Replace: skin deficit with skin graft, lost muscle with tendon transfer if can be done. Rehabilitate: maximise remaining muscle function with training. [1]
Why aggressive debridement? Necrotising fasciitis spreads rapidly along fascial planes. Incomplete debridement → continued sepsis → death. The wound is left open initially (secondary intention or NPWT) and grafted/flapped once infection is controlled.
Remove: inflamed tissue. Repair: lax ligament. Replace: damaged joint by fusion or arthroplasty. Rehabilitate: protect reconstructed tissue initially with splintage, training after tissue healing. [1]
| Tissue | Operative Technique |
|---|---|
| Bone | No need to operate (unless erosion) |
| Joint | Arthrodesis of lax, damaged joint |
| Muscle/Tendon | Tendon transfer for ruptured tendons |
| Ligament | Tightening if joint salvageable |
Why tendon transfer in RA? Chronic synovitis erodes tendons (especially extensor tendons over the dorsal wrist). The ruptured tendon cannot be repaired directly because the ends are frayed and attenuated. A working tendon is transferred to restore the lost function.
Remove: tophaceous material. Repair: lax ligament. Rehabilitate: protect reconstructed tissue initially with splintage. [1]
| Tissue | Technique |
|---|---|
| Joint | Arthrodesis if joint damaged |
| Skin | Skin flap if skin loss |
| Ligament | Replaced with tendon if damaged by tophus |
Conservative treatment comes first (weight loss, physiotherapy, analgesics, walking aids, splintage for OA digits). [1]
Operative options: [1]
- Osteotomy — Realigns the limb to shift load from the diseased compartment to the healthy one. Best for young patients with unicompartmental disease.
- Total joint replacement (arthroplasty) — Definitive treatment for end-stage OA. Replaces both articular surfaces with prosthetic components.
- Arthrodesis (fusion) — Eliminates joint motion entirely; used when arthroplasty is not feasible (e.g., young labourer needing a durable solution for ankle OA).
| Tissue | Technique |
|---|---|
| Bone | Osteotomy |
| Joint | Arthrodesis, arthroplasty |
| Ligament | Reconstruct if joint salvageable and there is imbalance |
Remove: tumour with a cuff of normal tissue. Repair: cut tissue. Replace: lost tissue with composite tissue. Rehabilitate: protect reconstructed tissue initially with splintage, training after tissue healing. [1]
| Tissue | Technique |
|---|---|
| Skin | Skin flap to cover large defect |
| Muscle/Tendon | Latissimus dorsi muscle transfer to replace lost muscles (finger & wrist extensors) |
| Nerve | Preserved |
Latissimus dorsi muscle with skin island for wound coverage & coverage of post-operative radiotherapy tubes & restore finger extension. [1]
Why latissimus dorsi? It is a large, expendable muscle with a reliable vascular pedicle (thoracodorsal artery). It can be transferred as a pedicled or free flap. The skin island provides soft-tissue coverage, while the muscle belly can be reinnervated or used as a motor for tendon transfer to restore finger/wrist extension.
Remove: fibrous band & fascial layers. Repair: skin. Regenerate: axon distal to compression at 1 mm per day. Rehabilitate: mobilisation exercise and splintage to prevent deformity while waiting nerve regeneration. [1]
Key fact: Axon regeneration rate = 1 mm/day. [1] This is a high-yield number. It means that after ulnar nerve decompression at the elbow, recovery of intrinsic hand muscles (distance ≈ 25–30 cm) takes approximately 8–10 months.
Endoscopic-assisted release is a minimally invasive option. [1]
Remove: necrotic tissue. Repair: fix fracture. Replace: lost tissue with composite tissue. Rehabilitate: protect reconstructed tissue initially with splintage, training after tissue healing. [1]
| Tissue | Technique |
|---|---|
| Bone | Fixation, bone graft |
| Joint | Arthrodesis of PIPJ (PIP joint) |
| Skin | Skin flap from adjacent finger |
Use tissue in neighbouring digit for coverage. Fix the bone. Preserve the severely damaged digit. [1]
Why arthrodesis of PIPJ? If the articular surface is destroyed, the PIP joint cannot function. Fusing it in a functional position (30–40° flexion) provides stability for grip while the DIP joint and MCP joint compensate for lost motion.
Future: no need for donor site. Stem cells present in adult can be stimulated to differentiate into various cell lines under proper stimulation in proper environment e.g., appropriate growth factors. Concept of tissue engineering: in vivo or in vitro production of certain tissue for replacement of lost tissue & function. [1]
Current/emerging applications mentioned in the lecture:
- Autogenous stem cells to promote ulcer healing [1]
- Platelet-rich plasma (PRP) to stimulate wound healing [1]
- Scaffolds for new skin regeneration [1]
Tissue engineering triad (not explicitly in slides but useful context):
- Cells (stem cells or differentiated cells)
- Scaffold (biological or synthetic matrix providing 3D structure)
- Signals (growth factors, mechanical stimuli)
Reconstruction usually does NOT involve: Addition of bone from a donor. [1]
Why? While allograft bone is used in some settings (e.g., massive defects after tumour resection), it is NOT the "usual" source in routine orthopaedic reconstruction. Autograft bone (from the patient's own iliac crest) is the gold standard because it provides osteogenic cells, osteoinductive factors, and osteoconductive scaffold — all three components needed for bone healing. Allograft bone lacks living cells and only provides scaffold + some osteoinductive factors. Donor skin (split-thickness skin grafts from cadavers) is a temporary biological dressing, not a definitive reconstruction.
Exam MCQ Trap — Lecture MCQ #3
The correct answer is D (Addition of bone from a donor). Reconstruction usually involves: excision of tissue (A), addition of tissue from other part of body (B — autograft), addition of skin from a donor (C — temporary bio-dressing in burns is accepted), and addition of biomaterial without donor (E — metal implants, synthetic scaffolds). But routine addition of donor bone is unusual. [1]
No cook book approach. Demands creativity. Requires dedicated team for good function & cosmesis. Improves quality of life of patient. High satisfaction for the team & patient. [1]
This is a philosophical point but examiners love to hear that reconstruction is individualised and multidisciplinary — the surgeon, physiotherapist, occupational therapist, prosthetist/orthotist, and the patient all contribute to the outcome.
Integration with Other GC Lectures
- Surgical approaches: Open surgery, minimally invasive surgery (minimise scar), other destructive devices (cauterisation, cryosurgery, topical agents, laser ablation, radiofrequency, focused ultrasound)
- Resection margins for cancer: BCC 2–3 mm, SCC 1 cm, Sarcoma 2–3 cm
- Principle: Pathology dictates resection; reconstruction follows
- Free cutaneous flaps after intraoral tumour resection → improve tongue mobility → better function
- Free osteocutaneous flaps for mandibular reconstruction → restore swallowing and speech
- Myocutaneous flaps or free jejunal grafts for pharyngeal reconstruction after laryngopharyngectomy
- Stomach pull-up for oesophageal reconstruction after total laryngopharyngo-oesophagectomy
- Prosthesis (implant) — Silicone or saline, placed submuscular or subglandular
- Autologous — TRAM flap, DIEP flap, latissimus dorsi flap
- Combination — Implant + autologous tissue
The formal reconstructive ladder from senior notes:
- Healing by secondary intention
- Primary closure
- Skin grafting (requires vascularised, uninfected bed)
- Local tissue transfer (flaps)
- Distant tissue transfer (pedicled flaps)
- Free tissue transfer (microsurgical)
| Classification | Types |
|---|---|
| By composition | Fasciocutaneous, myocutaneous, osteomyocutaneous |
| By contiguity | Local, regional, distant |
| By blood supply | Random, axial, perforator |
| By transfer | Pedicled, free (microsurgical) |
Likely Exam Questions
Q1. Which of the following is NOT an objective of reconstruction?
- A. Prevent aging ✓ (CORRECT — this is the answer; it is NOT an objective)
- B. Relieve pain
- C. Improve function
- D. Improve cosmesis
- E. Better quality of life
Q2. Which of the following is NOT a usual reconstruction means?
- A. Operation for tendon
- B. Prosthesis
- C. Oral medication for pain relief ✓ (CORRECT)
- D. Physiotherapy
- E. Splintage
Q3. Reconstruction usually does NOT involve:
- A. Excision of tissue
- B. Addition of tissue from other part of body
- C. Addition of skin from a donor
- D. Addition of bone from a donor ✓ (CORRECT)
- E. Addition of biomaterial without donor
Q4. A 45-year-old man presents with a large soft-tissue sarcoma of the forearm requiring wide excision with loss of all finger and wrist extensors. Describe the reconstructive plan using the 5 R framework.
Markscheme points:
- Remove: tumour with adequate cuff of normal tissue (2–3 cm margin for sarcoma)
- Repair: cut tissue layers
- Replace: latissimus dorsi myocutaneous free flap for soft tissue coverage AND motor reconstruction of finger/wrist extensors
- Rehabilitate: post-operative splintage initially, then graded hand therapy
- Also mention: skin island provides coverage for post-op radiotherapy field; nerve preservation during tumour excision
Q5. What is the rate of axonal regeneration after peripheral nerve decompression? How does this affect clinical recovery after cubital tunnel release?
Markscheme: Axon regeneration rate = 1 mm/day. Distance from elbow to intrinsic muscles of hand ≈ 25–30 cm → recovery takes approximately 8–10 months. During this time, splintage prevents clawing; mobilisation exercises maintain joint ROM.
Q6. Distinguish between a skin graft and a skin flap.
Markscheme: Skin graft = transplanted skin WITHOUT its own blood supply; survives by imbibition/inosculation from recipient bed; requires healthy, vascularised, uninfected wound bed. Skin flap = transplanted tissue WITH its own blood supply (pedicled or free); can survive over avascular beds (e.g., exposed bone, tendon, irradiated tissue).
| Theme | How It Appears | Key Discriminators |
|---|---|---|
| Objectives of reconstruction | MCQ: "Which is NOT an objective?" | "Prevent aging" is the distractor; all others are valid objectives [1] |
| 5 Rs | SAQ: "Describe reconstructive plan for [condition]" | Must mention all applicable Rs; Rehabilitate is often forgotten |
| Graft vs flap | MCQ/SAQ: "What is the difference?" | Blood supply is the key distinction |
| Reconstructive ladder | SAQ: "List methods in order of complexity" | Secondary intention → primary closure → graft → local flap → distant flap → free flap [3] |
| Axonal regeneration rate | SAQ/viva factoid | 1 mm/day — memorise this number [1] |
| Resection margins | MCQ: "What margin for BCC/SCC/sarcoma?" | BCC 2–3 mm, SCC 1 cm, Sarcoma 2–3 cm [2] |
| Arthrodesis vs arthroplasty | MCQ: "Which is preferred for [scenario]?" | Arthrodesis = pain relief but sacrifices motion; Arthroplasty = preserves motion but has implant-related complications |
High Yield Summary
Reconstruction = 5 Rs: Remove → Repair → Replace → Regenerate → Rehabilitate.
Objectives: Prevent harm, relieve pain, improve function, improve cosmesis, restore esteem, better QoL. NOT "prevent aging."
Non-operative: Prosthesis (replaces), Orthosis (supports), Physiotherapy, Splintage, Botox. NOT "oral medication for pain relief."
Tissue-specific operative techniques: Bone (osteotomy, graft, lengthening), Joint (arthrodesis, arthroplasty), Skin (graft = no blood supply, flap = with blood supply), Nerve (graft, neurotisation; regeneration rate 1 mm/day), Tendon (transfer, tenodesis), Ligament (tendon graft, synthetic).
Reconstructive ladder: Secondary intention → Primary closure → Skin graft → Local flap → Regional flap → Distant flap → Free flap. Always start simple; escalate only when needed.
Cancer resection margins: BCC 2–3 mm, SCC 1 cm, Sarcoma 2–3 cm. Resection dictated by pathology; reconstruction comes second.
Regeneration (future): Stem cells, PRP, scaffolds — tissue engineering eliminates donor-site morbidity.
Reconstruction is individualised, creative, and multidisciplinary. No cookbook approach.
Active Recall - Reconstruction
[1] Lecture slides: CFB (OT04) Reconstruction.pdf (Dr. WY Ip) [2] Lecture slides: GC 192. I want to look better Plastic and reconstructive surgery.pdf (Resection & Reconstruction slide) [3] Senior notes: MBBS Final MB (Surgery) (Felix PY Lai).pdf (Plastic surgery diseases — Reconstruction in surgery, pp. 1172–1178) [4] Lecture slides: CFB 26_Lecture Note_ENT (I).pdf (Functional restoration and extensive resection sections) [5] Lecture slides: The Managment of breast cancer_Prof A Kwong 20_2_2020.pdf (Breast Reconstruction slide) [6] Senior notes: Maksim Surgery Notes.pdf (Wound healing and reconstruction, p. 343)
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