Local anesthesia for surgery on the foot: efficacy in the ischemic or diabetic extremity

Foot reconstruction with the superficial circumflex iliac artery perforator flap under local anesthesia: Two case reports

RATIONALE

The superficial circumflex iliac artery perforator (SCIP) free flap is a popular method used in foot reconstruction. Although the SCIP flap has a relatively short pedicle and does not require intramuscular dissection, general anesthesia is largely preferred for SCIP flap reconstruction. We report 2 cases with the free SCIP flap for skin and soft tissue reconstruction of the foot under local anesthesia.

PATIENT CONCERNS

Case 1 was a 34-year-old man sustained a crush injury to the dorsal foot, resulting in a soft tissue defect with bone and tendon exposure. Case 2 was a 41-year-old man with type 2 diabetes was referred to our division for an intractable ankle wound after surgery for a calcaneal bone fracture.

DIAGNOSIS

The diagnosis was intractable wounds on feet caused by trauma and surgery. Patients were unable to receive general anesthesia because of asthma or elevated liver enzymes.

INTERVENTIONS

Two patients with tissue defects on their feet were treated with SCIP flaps under local anesthesia. Fifteen milliliter of 0.5% bupivacaine was injected for ankle block. SCIP flaps were harvested after injecting 10 to 15 mL of 1% lidocaine combined with epinephrine around the flap incisions.

OUTCOMES

No complications related to the use of local anesthesia developed during the operation or postoperatively. Two flaps survived and fully took without complications.

LESSONS

With proper local anesthesia, successful foot reconstruction with a free SCIP flap was possible. This method can be considered a sufficient option for foot reconstruction for patients unable to receive general anesthesia.

Surgical considerations in the geriatric patient

The geriatric patient has a high incidence of foot deformities and may be considered a good surgical candidate if healthy and psychologically ready for the surgical procedure. Foot problems in the geriatric population that may require surgical intervention can be grouped into approximately five categories, including (1) localized orthopedic disorders (ie, bunions, hammer toes, and so on); (2) skin and nail problems (ie, onychomycosis); (3) degenerative and inflammatory arthritis; (4) diabetic foot disorders; and (5) neuromuscular disease. However, age-related changes in cardiovascular, pulmonary, and renal function increase the risk of perioperative complications. The higher rates of complications seen in the older surgical patients result in part from existing comorbidity and age-associated changes in organ function. Extensive procedures depending on good bone healing for success should usually not be attempted on older patients. Office surgery for the geriatric patient should involve only the simplest procedures and should be kept to a minimum because of the increased possibility of postoperative complications. In the hospital there is better preoperative evaluation, operating room conditions, and postoperative care.

Elective foot and ankle surgery in the diabetic patient

The philosophy of treating diabetic foot pathology has changed dramatically throughout the years. No longer are old, unfounded fears considered the standard of care. The authors enumerate on their indications and goals of treating this complex entity. Clinical aids, as well as patient evaluations are discussed.