Surgical treatment of a Morel-Lavallée lesion of the distal thigh with the use of lymphatic mapping and fibrin sealant

Cervico-thoracic Morel-Lavallée lesion

Morel-Lavallée lesions (MLLs) result from high-energy trauma causing separation of subcutaneous tissue from the underlying tissue, most commonly in the gluteal region or thigh.We report the case of a woman in her 40s with a fluctuant collection of the cervico-thoracic region following trauma. Further imaging identified an MLL. An orthoplastic approach resulted in non-operative management with a spinal brace. Three months from initial injury, the lesion completely resolved. She was symptom free at final follow-up and discharged.We present the only recorded case of MLL developing in the cervico-thoracic region. Management posed difficultly as no literature currently exists. We demonstrated conservative management for cervico-thoracic MLL can be effective.We have described the first documented case of cervico-thoracic MLL. MLL is not exclusive to pelvic injuries and can develop in the cervico-thoracic region. We have shown conservative management is a viable treatment of atypical MLL.

The Morel-Lavallée Lesion: Review and Update on Diagnosis and Management

Morel-Lavallée lesion is a closed soft tissue degloving injury usually associated with high-velocity trauma. It most commonly occurs in the thigh, hip, and pelvis. Because such lesions are prone to a missed or delayed diagnosis, it may present a potential risk of infection at the fracture site once it progresses. Therefore, timely identification and management of Morel-Lavallée lesion is crucial. Moreover, there are no relevant guidelines for the treatment of Morel-Lavallée lesion. Based on the above facts, we reviewed the etiology, epidemiology, pathophysiology, clinical presentation, imaging features, treatment, prognosis, and complications of Morel-Lavallée lesion with the aim of providing a comprehensive overview of Morel-Lavallée lesion, increasing awareness of this injury among orthopaedic surgeons, and thus providing a management algorithm that can be applied to this injury.

Practical Review of the Comprehensive Management of Morel-Lavallée Lesions

Morel-Lavallée lesions have been described in the literature since the mid-19th century, yet contemporary clinical management continues to be challenging and remains variable. These closed degloving injuries are usually seen in the setting of blunt trauma and are due to shearing forces, creating a space for the collection of hemolymphatic fluid. These fluid collections can be persistent despite conservative treatment attempts and can require staged surgical interventions.

Percutaneous Debridement of and Fibrin Glue Injection Into a Pretibial Morel-Lavallée Lesion: A Case Report and Literature Review

ABSTRACT

The Morel-Lavallée lesion (MLL) is a posttraumatic close degloving injury, which is often underdiagnosed at first. Patients with MLLs usually present with tender and enlarging soft tissue swelling with fluctuation, decreased skin sensation, ecchymosis, or even skin necrosis hours to days after the inciting injury. The lesion can lead to intractable morbidity if it remains untreated. There is no consensus regarding the treatment for MLL at present. Here, we report an MLL in the pretibial region of a 43-year-old woman who experienced a low-energy contusion in a motorbike accident. The pretibial lesion was diagnosed using sonography and fine-needle aspiration. We successfully treated the patient by performing percutaneous debridement via a small incision and injections of fibrin after conservative treatment failed. The method we herein propose achieved the goal of open surgical debridement, providing faster recovery and a high degree of patient comfort. We reviewed the available pertinent literature and propose our own treatment protocol with the aim to establish common therapies ofMLL.

Occult thoracoacromial artery injury during reverse total shoulder arthroplasty resulting in a cascade of postoperative complications: A case report

We report a case of a 78-year old female patient got the reverse total shoulder arthroplasty with a series of events. After diagnosed with anterior shoulder dislocation and coracoid process fracture at a local hospital, she received conservative care after reduction but persistent reduction loss occurred. Preoperative Magnetic Resonance Imaging confirmed underlying massive fatty infiltration and severe retraction of rotator cuff muscles. Considering underlying chronic rotator cuff arthropathy on preoperative X-ray and Computed Tomography scan with irreparable rotator cuff tears, we decided to perform reverse total shoulder arthroplasty. After unexpected vessel injury possibly due to underlying bleeding tendency or intra-operative procedure, severe complications occurred including active arterial bleeding, brachial plexus palsy and skin necrosis. Serial managements which included embolization of the artery, wound management while implant exposure status, and operative coverage of a skin defect by Latissimus Dorsi pedicled flap and Split Thickness Skin Graft were done. This series of events suggests that surgeons should be more careful than we were about possible injuries of small vessel branches that can cause unexpected complications, and keep in mind the importance of immediate cooperation with other medical professionals such as radiologists, plastic surgeons, and thoracic surgeons.

Lymphatic Leaks of the Thigh and Inguinal Region: Combined Plastic Surgery Approaches for an Effective Treatment Algorithm

BACKGROUND

Surgical procedures interfering with the draining nodes in the inguinal region carry the intrinsic risk of lymphatic complications. Lesions of the inguinal lymphatic network can lead to lymphocele or lymphocutaneous fistulas and can eventually be associated to limb lymphedema with consequent high morbidity.

OBJECTIVES

This article describes a new surgical algorithm based on wound properties to properly address lymphatic complications of the inguinal area. Based on our experience, surgical solutions ranged from selective lymphatic vessel ligation to microsurgical lymphatic fistula treatment and free tissue transfer.

METHODS

Fourteen consecutive patients underwent surgery in our department following failed attempts to address persistent lymphatic leaks. Patient characteristics such as smoking, previous surgeries, comorbidities, and wound properties were considered. Identification of the leak was performed using blue patent dye and indocyanine green fluorescence. Surgical reconstruction occurred, according to our algorithm.

RESULTS

Lymphatic leaks were visualized in 11 of 14 patients. Direct closure of the wound after leak ligation could be performed in 4 of 14 patients. Multilymphatic into vein anastomosis was performed in 3 of 14 patients, and the remaining patients benefited from flap surgery based on the wound defects. All 14 patients had successful outcomes (100%) with early drain removal (average, 6 [SD, 6] days) and definitive wound healing 2 weeks postoperatively. After a mean follow-up of 12 (SD, 2.9) months, no clinical infection, lymphatic complication, or wound breakdown occurred. One patient had a partial recurrence that did not require surgical intervention.

CONCLUSIONS

A stepwise approach, combining lymphatic surgery principles and plastic surgery flap techniques, can lead to an effective treatment algorithm where surgical options are wound tailored to guarantee the best functional outcomes.

The Morel-Lavallée lesion and its management: A review of the literature

Background

Morel-Lavallée lesions can occur in polytrauma patients. Post-operative seroma is more frequently encountered, holds many pathological similarities with MLLs and continues to challenge plastic surgeons. We aimed to provide a comprehensive overview of MLLs to increase awareness of optimum treatment options amongst plastic surgery teams, and to provide a management algorithm that may also be applied to post-operative seromas.

Methods

PubMed, Google Scholar and the Cochrane Library were searched using the terms "Morel-Lavallée", "management" and "treatment", which yielded 52 results. One reviewer screened titles and abstracts for relevance. Seventeen full text articles were retrieved. Review of reference lists provided a further three articles for inclusion.

Findings

Morel-Lavallée lesions (MLLs) represent closed injuries with internal degloving of superficial soft tissues from fascial layers. Main causes of MLLs include high-energy, blunt force trauma or crush injuries. They are commonly found overlying the greater trochanter. MLLs should be actively looked for when treating patients with pelvic trauma. MRI is the investigation of choice. Currently no guidelines for the management of MLLs exist. Compression bandaging, percutaneous aspiration, sclerodesis and mass resection have all been utilised.

Conclusions

Our algorithm recommends avoidance of conservative management. For chronic lesions, percutaneous aspiration should not be used in isolation. Sclerodesis using doxycycline is appropriate for lesions up to 400 ml, where evidence suggests high degrees of efficacy. Larger lesions should be treated with open surgery. Quilting sutures, curettage and low suction drains are useful adjuncts. We hypothesise this algorithm would also be effective for post-operative seromas.

Morel-Lavallée lesions: a phenomenon in cats? Case report and review of the literature

Case summary

A 3-year-old male neutered domestic shorthair cat sustained a severe sacrococcygeal luxation post-motor vehicle trauma. Six days post-trauma, a fluid-filled swelling was noticed over the caudoventral abdomen and inguinal regions. Needle aspiration, closed suction drain placement and debridement with subcutaneous tacking were all attempted but failed to resolve the continued accumulation of serosanguinous lymphocyte-rich fluid in the subcutaneous pocket. Clinical resolution was ultimately achieved after surgical debridement and omentalisation of the lesion.

Relevance and novel information

Morel-Lavallée lesions are post-trauma closed soft tissue degloving injuries described infrequently in people. The avulsion of subcutaneous tissue from deep muscle fascia results in the accumulation of haemolymph and necrotic fat, which can persist for several days to months after the inciting incident. In people, they are commonly seen in the proximal thigh. This article proposes the existence of Morel-Lavallée lesions in cats.

[Morel-Lavallée syndrome and post-traumatic nodular fat necrosis: Two post-traumatic complications mimicking cellulitis]

BACKGROUND

Dermal and subcutaneous inflammation following direct trauma is initially evocative of soft-tissue infection. However, two differential diagnoses must be considered: Morel-Lavallée syndrome and post-traumatic nodular fat necrosis.

PATIENTS AND METHODS

Case 1: a 51-year-old woman fell off her motorbike and had dermabrasions on her right and left tibial ridges that rapidly developed into dermo-hypodermitis of the entire limb. There was no improvement after 3 weeks of antibiotics. The patient was apyretic. She had a soft, non-inflammatory tumefaction on the inner aspect of her left knee. Ultrasound revealed subcutaneous collection in both legs. The surgeons confirmed a diagnosis of Morel-Lavallée syndrome and drained the two collections. Progress was good and the patient healed without major consequences. Case 2: following a fall on her stairs, a 40-year-old woman presented dermabrasions and haematomas on her left leg. Antibiotic therapy failed to prevent the progression of dermo-hypodermitis. The patient remained apyretic and there was no inflammatory syndrome. A CT scan showed thickening of a subcutaneous fat and fluid collection, resulting in diagnosis of post-traumatic nodular fat necrosis. Management was surgical and the outcome was good.

DISCUSSION

These two cases show two post-traumatic cutaneous complications: Morel-Lavallée syndrome and post-traumatic nodular fat necrosis. Morel-Lavallée syndrome occurs after tangential trauma next to richly vascularized tissue. Post-traumatic nodular fat necrosis is defined as necrosis of adipocytes. In both cases, diagnosis is confirmed by imagery (Ultrasonography, tomography).

CONCLUSION

Our two case reports show that inflammatory presentation of both Morel-Lavallée syndrome and post-traumatic nodular fat necrosis can lead to diagnostic and therapeutic errors while a surgical procedure is necessary since tissue necrosis can occur.

Endoscopic debridement and fibrin glue injection of a chronic Morel-Lavallée lesion of the knee in a professional soccer player: A case report and literature review

A Morel-Lavallée lesion is a post-traumatic closed degloving injury of soft tissue. The lesion is due to a shearing trauma with separation of subcutaneous tissue from underlying fascia. When conservative treatment fails, surgical treatment is imperative. Commonly, open drainage and debridement is performed. This case report describes a Morel-Lavallée lesion of the knee in a professional soccer player who was successfully treated with endoscopic debridement and fibrin glue injection after failure of conservative management. This method achieves the goal of an open surgical debridement without exposing patients to an increased morbidity.

Oxytetracycline as a sclerosant in the management of Morel-Lavallee lesions

Morel-Lavallee lesions are haemolymphatic collections that occur following blunt trauma. These are due to closed degloving injuries which cause shearing injury deep to the subcutaneous plane, causing disruption of capillaries and lymphatics. This results in a persistent collection containing blood, lymph and necrotic fat. Magnetic resonance imaging is the investigation of choice in the evaluation of these post-traumatic lesions. Early diagnosis and management is beneficial and can avoid infection or skin necrosis. Surgical excision, including complete excision of the capsule of the Morel-Lavalle lesion, is required. For recurrent lesions and to prevent recurrence after the primary excision, oxytetracycline instillation, as a sclerosant, is a novel adjunct and we report two successful cases.

Morel-LAvallee lesion initially diagnosed as quadriceps contusion: ultrasound, MRI, and importance of early intervention

Morel-Lavallee lesions (MLL) are rare, closed degloving injuries caused by trauma that delivers a shearing force to the soft tissue most commonly of the hip. If not treated in the acute and subacute setting these lesions are often complicated by re-accumulation of fluid, infection, or chronic pain. We present a unique case of a recurrent, massive medial knee/thigh MLL in which proper treatment was delayed due to initial diagnosis of a quadriceps contusion. We describe the ultrasound and magnetic resonance imaging findings of this patient and based on a review of recent literature propose that the initial management should have included early drainage/debridement, which likely could have prevented recurrence and significantly shortened the clinical course.

Diagnosis and Management of Closed Internal Degloving Injuries: The Morel-Lavallée Lesion

BACKGROUND

Morel-Lavallée (ML) lesions are closed degloving injuries described as posttraumatic subcutaneous fluid collections. They are most commonly seen in the proximal thigh. They can present several days to months after the inciting event.

CASE REPORT

A 55-year-old woman with a recent admission for trauma presented to the Emergency Department with increasing swelling and pain in the right thigh for the previous 3 days. Ultrasound of the thigh was negative. Magnetic resonance imaging performed to further evaluate for leg swelling revealed a "Morel-Lavallée lesion" of the thigh that required drainage. The patient recovered completely after the surgery. WHY SHOULD THE EMERGENCY PHYSICIAN BE AWARE OF THIS?: Emergency physicians should be aware of these rare lesions because they are often mistaken for tumors or hematomas. Early recognition may avoid subsequent complications and help in obtaining prompt specialist care.

Morel-Lavallee lesion in distal thigh: A case report

It is a relatively rare condition involving a close degloving injury due to direct trauma with tangential force followed by the separation of the subcutaneous tissue from the underlying fascia. The rupture of small perforating vessels in this area, resulting in the formation of a cavity that filled with blood, lymph and fat foci, the latter being sometimes necrotic. Morel-Lavallée lesion was originally described in the lateral aspect of the proximal thigh, which is the most common site of this lesion; however other anatomic sites such as periscapular, lumbar and gluteal regions, ankles and knees have been described in the literature. Various methods of treatment has been described, but open debridement can result in a successful functional outcome.

The therapeutic challenges of degloving soft-tissue injuries

BACKGROUND

Degloving soft-tissue injuries are serious and debilitating conditions. Deciding on the most appropriate treatment is often difficult. However, their impact on patients' outcomes is frequently underestimated.

OBJECTIVES

We aimed to study the incidence, clinical presentation, management and outcome of degloving soft-tissue injuries.

MATERIALS AND METHODS

We conducted a narrative traditional review using the key words; degloving injury and soft-tissue injuries through search engines PubMed, Science Direct, and Scopus.

RESULTS

There are several therapeutic options for treating degloving soft-tissue injuries; however, no evidence-based guidelines have been published on how to manage degloving soft-tissue injuries, although numerous articles outline the management of such injuries.

CONCLUSION

Degloving soft-tissue injuries are underreported and potentially devastating. They require early recognition, and early management. A multidisciplinary approach is usually needed to ensure the effective rehabilitation of these patients.

A Huge Morel-Lavallée Lesion Treated Using a Quilting Suture Method

The Morel-Lavallée lesion is a collection of serous fluid that develops after closed degloving injuries and after surgical procedures particularly in the pelvis and abdomen. It is a persistent seroma and is usually resistant to conservative methods of treatment such as percutaneous drainage and compression. Various methods of curative treatment have been reported in the literature, such as application of fibrin sealant, doxycycline, or alcohol sclerodhesis. We present a case of a huge recurrent Morel-Lavallée lesion in the lower back and buttock region that was treated with quilting sutures, fibrin sealant, and compression, with a review of the literature.

Poor outcome of bilateral lower extremity morel-lavallee lesions: a case report

The Morel-Lavallee lesion is a closed, internal degloving injury that results when a strong, shearing force is applied parallel to the plane of injury, as is common in vehicular trauma. It is an underdiagnosed entity that is often missed during the initial trauma workup as symptoms can be subtle. There are few reports of lesions occurring below the knee. Most cases affect the proximal thigh and trochanter, as these tend to be dependent areas in high velocity trauma. To the best of our knowledge, this is the first literature report of bilateral lower extremity Morel-Lavallee lesions.

Fibrin Sealant: The Only Approved Hemostat, Sealant, and Adhesive-a Laboratory and Clinical Perspective

Background. Fibrin sealant became the first modern era material approved as a hemostat in the United States in 1998. It is the only agent presently approved as a hemostat, sealant, and adhesive by the Food and Drug Administration (FDA). The product is now supplied as patches in addition to the original liquid formulations. Both laboratory and clinical uses of fibrin sealant continue to grow. The new literature on this material also continues to proliferate rapidly (approximately 200 papers/year). Methods. An overview of current fibrin sealant products and their approved uses and a comprehensive PubMed based review of the recent literature (February 2012, through March 2013) on the laboratory and clinical use of fibrin sealant are provided. Product information is organized into sections based on a classification system for commercially available materials. Publications are presented in sections based on both laboratory research and clinical topics are listed in order of decreasing frequency. Results. Fibrin sealant remains useful hemostat, sealant, and adhesive. New formulations and applications continue to be developed. Conclusions. This agent remains clinically important with the recent introduction of new commercially available products. Fibrin sealant has multiple new uses that should result in further improvements in patient care.

A prepatellar Morel-Lavallée lesion in a pedestrian vs automobile collision

A small truck collided with a 67-year-old female pedestrian. She sustained blunt, closed trauma to her right knee, and developed a prepatellar Morel-Lavallée lesion (MLL). A MLL is a closed soft tissue degloving injury, resulting from high-energy shearing forces, which separate the skin and subcutaneous tissue from the underlying fascia. The resultant space collects fluid and is prone to infection, tissue necrosis, and symptoms of ongoing mass effects. The diagnosis is elusive because of its rarity and often subtle initial symptoms. Prompt diagnosis is critical, given the potentially severe complications when missed, and less invasive and more successful treatment when found early. Most reported cases are proximal to the pelvis, whereas the few reported peri–knee MLLs involve young athletes or postsurgical complications. To our knowledge, this is the third reported case of a non–sport-related MLL of the knee, all of which involved high-inertia force to the knee. Therefore, MLL of the knee should be considered in patients with knee trauma, particularly in the setting of pedestrians struck by motor vehicles.