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Thomas B, Falkner F, Gazyakan E, Harhaus L, Kneser U, Bigdeli AK. [The conjoined latissimus dorsi and parascapular free flap for reconstruction of extensive soft tissue defects]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2023:10.1007/s00064-023-00806-w. [PMID: 37154965 DOI: 10.1007/s00064-023-00806-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/08/2021] [Accepted: 02/14/2021] [Indexed: 05/10/2023]
Abstract
OBJECTIVE Durable and resilient soft tissue reconstruction of vast defects of the extremities or the torso. INDICATIONS Reconstruction of disproportionately large defects, particularly in cases of simultaneous bone and joint reconstruction. CONTRAINDICATIONS History of surgery or irradiation of upper back and axilla, impossibility of surgery under lateral positioning; relative contraindications in wheelchair users, hemiplegics, or amputees. SURGICAL TECHNIQUE General anesthesia and lateral positioning. First, the parascapular flap is harvested, with the initial skin incision made medially in order to identify the medial triangular space and the circumflex scapular artery. Flap raising then proceeds from caudal to cranial. Second, the latissimus dorsi is harvested, with the lateral border being dissected free first, before the thoracodorsal vessels are visualized on its undersurface. Flap raising then proceeds from caudal to cranial. Third, the parascapular flap is advanced through the medial triangular space. If the circumflex scapular and thoracodorsal vessels originate separately from the subscapular axis, an in-flap anastomosis is warranted. Subsequent microvascular anastomoses should be performed outside the zone of injury, typically in an end-to-end fashion of the vein and end-to-side fashion of the artery. POSTOPERATIVE MANAGEMENT Postoperative anticoagulation with low-molecular-weight heparin under anti-Xa monitoring (semitherapeutic in normal-risk and therapeutic in high-risk cases). Hourly clinical assessment of flap perfusion for 5 consecutive days, followed by stepwise relaxation of immobilization and commencement of dangling procedures in cases of lower extremity reconstruction. RESULTS Between 2013 and 2018, 74 conjoined latissimus dorsi and parascapular flaps were transplanted to cover vast defects of the lower (n = 66) and upper extremity (n = 8). The mean defect size was 723 ± 482 cm2 and the mean flap size was 635 ± 203 cm2. Eight flaps required in-flap anastomoses for separate vascular origins. There was no case of total flap loss.
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Affiliation(s)
- Benjamin Thomas
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Florian Falkner
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Emre Gazyakan
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Leila Harhaus
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Ulrich Kneser
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland
| | - Amir Khosrow Bigdeli
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum der Ruprecht-Karls-Universität Heidelberg, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen am Rhein, Deutschland.
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Kotsougiani-Fischer D, Fischer S, Warszawski J, Gruetzner PA, Reiter G, Hirche C, Kneser U. Multidisciplinary team meetings for patients with complex extremity defects: a retrospective analysis of treatment recommendations and prognostic factors for non-implementation. BMC Surg 2021; 21:168. [PMID: 33781250 PMCID: PMC8006355 DOI: 10.1186/s12893-021-01169-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/17/2021] [Indexed: 12/24/2022] Open
Abstract
Background This study aimed to assess a multidisciplinary team (MDT) meeting approach for the management of patients with complex extremity defects, analyze treatment recommendations, and evaluate factors influencing non-implementation. Methods All patients introduced to an MDT meeting for complex extremity defects from 2015 to 2017 were included in a retrospective cohort study. Patients’ characteristics and defect causes were evaluated. Treatment recommendations (TR) of MDT meetings and subsequent implementation were reviewed (cohort with implementation of TR versus cohort with non-implementation of TR), and factors associated with non-adherence to recommendations were statistically analyzed using logistic regression. Results Fifty-one patients (41 male) with a mean age of 54 years were presented in 27 MDT meetings. Most of the patients (70%) suffered from reconstructive challenging or combined bone- and soft tissue defects, primarily located at the lower extremity (88%). Large skeletal defects, chronic osteomyelitis, and multi-fragmented fractures were present in 65% of cases. Forty-five percent of the patients suffered from peripheral vascular disease, necessitating surgical optimization. Of the 51 MDT decisions, 40 were implemented (78%; (32/40) limb salvage versus 22%; (8/40) limb amputation). Limb salvage was successfully achieved in 91% (29/32) of the cases. Failed limb salvages were due to flap failure (33%; 1/3), recurring periprosthetic joint infections (66%; 2/3) and concomitant reconstructive failure. Patients who underwent limb amputation, as recommended, showed proper stump healing and regained mobility with a prosthesis. Overall the MDT treatment plan was effective in 92.5% (37/40) of the patients, who adhered to the MDT treatment recommendation. In eleven patients (22%; 11/51), the MDT treatment was not implemented. MDT decisions were less likely to be implemented, if amputation was recommended (p = 0.029). Conclusions MDT meetings represent a valid tool to formulate individualized treatment plans, avoiding limb amputation in most patients with severe extremity defects. Recommendation for limb amputation is less likely to be implemented than plans for limb salvage. Trial registration: Retrospectively registered
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Affiliation(s)
- Dimitra Kotsougiani-Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany.
| | - Sebastian Fischer
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Jan Warszawski
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Paul A Gruetzner
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwig Gutmann Strasse 13, Ludwigshafen, 67071, Germany
| | - Gregor Reiter
- Department of Trauma and Orthopedic Surgery, BG Trauma Center Ludwigshafen, Ludwig Gutmann Strasse 13, Ludwigshafen, 67071, Germany
| | - Christoph Hirche
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
| | - Ulrich Kneser
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center-BG Trauma Center Ludwigshafen, Hand and Plastic Surgery of the University of Heidelberg, Ludwig Guttmann Str. 13, 67071, Ludwigshafen, Germany
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Stolberg-Stolberg J, Milstrey A, Schliemann B, Horn D, Abshagen KF, Raschke M, Roßlenbroich S. [Competence, creativity and communication: basics for quality improvement in traumatology : Reality and future challenges]. Chirurg 2021; 92:210-216. [PMID: 33512560 PMCID: PMC7845268 DOI: 10.1007/s00104-020-01347-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 11/06/2022]
Abstract
Interdisciplinary collaboration is one of the key factors for successful treatment of patients with complex injuries and diseases. Hence, several innovative concepts have been initiated to improve the treatment quality within the field of trauma surgery. The implementation of a ward pharmacist with the daily discussion of prescribed medications shows a reduction of side effects, costs for medicaments and the use of antibiotics. An interdisciplinary and multimodal delirium team was introduced and every patient over the age of 65 years was screened for the risk of perioperative and postoperative delirium, the medication was adjusted and expert advice was available in the case of acute delirium. Corresponding to the well-established tumor boards, an interdisciplinary musculoskeletal conference to decide on the treatment of complex interdisciplinary injuries of the musculoskeletal system should be established. The future challenges will include the digital connection of hospitals within the already existing trauma networks in order to provide rapid access to this interdisciplinary expertise also outside maximum care hospitals.
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Affiliation(s)
- Josef Stolberg-Stolberg
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
| | - Alexander Milstrey
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
| | - Benedikt Schliemann
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
| | - Dagmar Horn
- Geschäftsbereich Apotheke, Universitätsklinikum Münster, Münster, Deutschland
| | - Karl-Friedrich Abshagen
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
| | - Michael Raschke
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland
| | - Steffen Roßlenbroich
- Klinik für Unfall‑, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Münster, Albert-Schweitzer-Campus 1, Gebäude W1, 48149, Münster, Deutschland.
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Cordts T, Bigdeli AK, Hirche C, Hernekamp JF, Grützner PA, Reiter G, Kneser U. [Options for soft tissue reconstruction in pseudarthrosis]. Unfallchirurg 2020; 123:694-704. [PMID: 32737514 DOI: 10.1007/s00113-020-00852-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pseudarthrosis can develop as a complication after conservative or operative fracture treatment and after elective orthopedic surgery. The treatment is challenging and is made more difficult when accompanied by large soft tissue defects or impairments in wound healing. In this case close and early coordination between trauma and plastic surgeons is crucial in order to develop a coherent and interdisciplinary treatment plan. METHODS Due to the positive effects on bone consolidation and osteomyelitis, timely soft tissue reconstruction via a pedicled vascularized flap or free flap coverage should be preferred. If blood circulation in the affected extremity appears to be compromised, this should first be optimized by vascular intervention or bypass surgery. In atrophic, aseptic pseudarthrosis, bone and soft tissue reconstruction can be performed consecutively in one single procedure, whereas septic pseudarthrosis always require complete resection of all infected debris prior to wound closure. Examples of two commonly used free flaps are the latissimus dorsi muscle flap and the fasciocutaneous anterolateral thigh (ALT) flap. As multiple variations have been described for both procedures, the reconstructive portfolio lists many additional options available for soft tissue reconstruction. Fasciocutaneous flaps should be preferred whenever bone consolidation requires additional surgical interventions in the future.
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Affiliation(s)
- T Cordts
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland.
| | - A K Bigdeli
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
| | - C Hirche
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
| | - J F Hernekamp
- Klinik für Plastische, Rekonstruktive und Ästhetische Chirurgie, Handchirurgie, Martin Luther Krankenhaus, Berlin, Deutschland
| | - P A Grützner
- Klinik für Unfallchirurgie und Orthopädie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
| | - G Reiter
- Klinik für Unfallchirurgie und Orthopädie, BG Klinik Ludwigshafen, Ludwigshafen, Deutschland
| | - U Kneser
- Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie - Schwerbrandverletztenzentrum, BG Klinik Ludwigshafen, Ludwig-Guttmann-Str. 13, 67071, Ludwigshafen, Deutschland
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