The 'reconstructive ladder' prioritises wound closure from simplest to most complex. For a 6 cm × 4 cm wound on the dorsum of the foot in a 50-year-old diabetic patient after debridement, with exposed but viable extensor tendons, which level of the reconstructive ladder is MOST appropriate as the first-line option?
- A Split-thickness skin graft (STSG)
- B Primary closure
- C Local flap (e.g. reverse sural artery flap) ✓
- D Healing by secondary intention
Explanation
Split-thickness skin grafts do not take on exposed tendons without peritenon coverage; grafts require a vascularised bed. Exposed tendons in a diabetic patient on the foot require flap coverage to provide adequate vascularisation and durability. The reverse sural artery flap is a workhorse flap for distal lower leg and foot coverage. Primary closure is not possible for a 6×4 cm defect. Secondary intention healing over bare tendons would lead to desiccation and tendon necrosis. The reconstructive ladder 'skip' directly to flap coverage when graft conditions are inadequate is the appropriate principle here.
Reference: Bailey & Love's Short Practice of Surgery, 27th ed.
High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP
Written and medically reviewed by the StethoPrep medical team.