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Müller SLC, Morgenstern M, Kuehl R, Muri T, Kalbermatten DF, Clauss M, Schaefer DJ, Sendi P, Osinga R. Soft-tissue reconstruction in lower-leg fracture-related infections: An orthoplastic outcome and risk factor analysis. Injury 2021; 52:3489-3497. [PMID: 34304885 DOI: 10.1016/j.injury.2021.07.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Revised: 07/02/2021] [Accepted: 07/13/2021] [Indexed: 02/02/2023]
Abstract
Introduction Fracture-related infection (FRI) is a severe post-traumatic complication which is occasionally accompanied by a deficient or even avital soft-tissue envelope. In these cases, a thoroughly planned orthoplastic approach is imperative as a vital and intact soft-tissue envelope is mandatory to achieve fracture union and infection eradication. The aim of this study was, to analyse if soft-tissue reconstruction (STR) without complications is associated with a better long-term outcome compared to FRI patients with STR complications. In particular, it was investigated if primary flap failure represented a risk factor for compromised fracture union and recurrence of infection. Patients and Methods Patients with a lower leg FRI requiring STR (local, pedicled and free flaps) who were treated from 2010-18 at the University Hospital Basel were included in this retrospective analysis. The main outcome measure was the success rate of STR, further outcome measures were fracture nonunion and recurrence of infection. Results Overall, 145 patients with lower leg FRI were identified, of whom 58 (40%) received STR (muscle flaps: n = 38, fascio-cutaneous flaps: n=19; composite osteo-cutaneous flap: n = 1). In total seven patients required secondary STR due to primary flap failure. All failures and flap-related complications occurred within the first three weeks after surgery. Secondary STR was successful in all cases. A high Charlson Comorbidity Index Score was a significant risk factor for flap failure (p = 0.011). Out of the 43 patients who completed the 9-month follow-up, 11 patients presented with fracture nonunion and 12 patients with a recurrent infection. Polymicrobial infection was a significant risk factor for fracture nonunion (p = 0.002). Primary flap failure was neither a risk factor for compromised fracture consolidation (p = 0.590) nor for recurrence of infection (p = 0.508). Conclusion: A considerable number of patients with lower-leg FRI required STR. This patient subgroup is complex and rich in complications and the long-term composite outcome demonstrated a high rate of compromised fracture consolidation and recurrent infections. It appears that secondary STR should be performed, as primary flap failure was neither a risk factor for compromised fracture consolidation nor for recurrence of infection. We propose to monitor these patients closely for three weeks after STR.
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Affiliation(s)
- Seraina L C Müller
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Mario Morgenstern
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland.
| | - Richard Kuehl
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland
| | - Thaddaeus Muri
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Daniel F Kalbermatten
- Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Martin Clauss
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland
| | - Dirk J Schaefer
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
| | - Parham Sendi
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Orthopaedic and Trauma Surgery, University Hospital Basel, Switzerland; Department of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Switzerland; Institute for Infectious Diseases, University of Bern, Switzerland
| | - Rik Osinga
- Center for Musculoskeletal Infections, University Hospital Basel, Spitalstrasse 21, Basel CH-4031 Switzerland; Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, University Hospital Basel, Switzerland
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Loh B, Lim JA, Seah M, Khan W. Perioperative management of open fractures in the lower limb. J Perioper Pract 2021; 32:100-107. [PMID: 34214004 PMCID: PMC9073073 DOI: 10.1177/17504589211012150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
An open fracture is a fracture which communicates with the external environment through a wound in the skin. Severe open fractures are managed by both orthopaedic and plastic surgeons to address injuries in both the bone and soft tissue. This review outlines the management of open fractures in the lower limb from the initial patient presentation to operative management (including debridement, skeletal fixation, definitive soft tissue coverage) according to the standards jointly published by the British Orthopaedic Association (BOA) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Additionally, the decision-making between limb salvage or amputation will be explored. Finally, this review will discuss the patient’s postoperative care including wound care and management of potential complications that may arise such as infection, flap failure and fracture non-union.
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Affiliation(s)
- Bryan Loh
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK.,School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Jiang An Lim
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK.,School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Matthew Seah
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
| | - Wasim Khan
- Department of Trauma and Orthopaedics, Addenbrookes Major Trauma Unit, Cambridge University Hospitals, Cambridge, UK
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Jitprapaikulsarn S, Sukha K, Patamamongkonchai C, Gromprasit A, Thremthakanpon W. Utilizing the various forms of the gastrocnemius muscle in fix & flap protocol: a reliable remedy for open proximal tibial fractures with accompanying soft tissue defect. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:505-513. [PMID: 34021790 DOI: 10.1007/s00590-021-03013-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/18/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Open proximal tibial fractures accompanied by soft tissue loss are substantially challenging to accomplish both bony consolidation and wound healing. The authors retrospectively delineated the utility of the various forms of the gastrocnemius muscle in fix & flap regimen for management of such complicated injuries. METHODS Thirty-one patients with open fracture accompanied by soft tissue loss of proximal tibia were managed by the protocol of fix & gastrocnemius flap. The collected data included implant for fixation, form of the gastrocnemius flap, postoperative complications, union time, and clinical assessment. RESULTS According to fixation devices, lateral anatomical locking compression plates were selected in 28 cases, dual plates in 1, and interlocking nails in 2. According to the forms of the gastrocnemius flap, medial gastrocnemius flap was utilized in 22 cases, medial hemigastrocnemius flap in 2, medial myocutaneous gastrocnemius flap in 2, lateral gastrocnemius flap in 3, and combined medial and lateral gastrocnemius flaps in 2. All flaps completely survived without any flap-related complications. Fracture consolidation was established in all patients with an average period of 19.9 weeks (range 16-26). Surgical site infection occurred in 3 cases, and delayed union in 1. By functional score of Puno, 3 cases were determined to be excellent, 27 to be good, and 1 to be fair. CONCLUSION Concurrent use of internal fixation and gastrocnemius flap reconstruction is a reliable and efficient protocol in managing open fractures with accompanying soft tissue defect of proximal tibia.
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Affiliation(s)
- Surasak Jitprapaikulsarn
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand.
| | - Kritsada Sukha
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Chawanan Patamamongkonchai
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Arthit Gromprasit
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
| | - Witoon Thremthakanpon
- Department of Orthopedics, Buddhachinaraj Hospital, 90 Srithamtraipidok Road, Phitsanulok, 65000, Thailand
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Mathieu L, Potier L, Ndiaye R, Sene M, Mbaye E, Faye M, Niang CD. Soft tissue reconstruction in the leg by orthopedic surgeons: Practices at an African trauma center. Orthop Traumatol Surg Res 2020; 106:825-829. [PMID: 32534898 DOI: 10.1016/j.otsr.2020.03.021] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 01/17/2020] [Accepted: 03/27/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Soft-tissue coverage is a crucial step when treating open tibial fractures, which is often performed by orthopedic surgeons in a low resource setting. The objective of this study was to analyze the use of non-microsurgical flaps to treat such injuries in a West African trauma center. HYPOTHESIS Pedicled flaps are reliable procedures that can be used by any orthopedic surgeon for soft-tissue coverage in the leg. METHODS A retrospective study was conducted including patients treated between 2007 and 2011 for open tibial fractures or posttraumatic sequelae requiring flap coverage. Early flap necrosis and skin viability at the last follow-up were evaluated. RESULTS Fifty-five patients with mean age 34 years were included. They had 57 soft-tissue defects requiring flap reconstruction, 36 of which were infected. In total, 62 pedicled flaps were performed: 12 muscular flaps and 50 fasciocutaneous flaps, including 40 rotational flaps and 10 island flaps. The short-term result was successful in 55 flaps (89%). Seven flaps had partial or complete necrosis, including three soleus flaps and three lateral supramalleolar rotational flaps. At the average follow-up of 9 months, skin viability was inferior in the posttraumatic sequelae group and seemed to be altered by primary bone infection. CONCLUSION Soft-tissue coverage in the leg can be reliably achieved by orthopedic surgeons using simple and robust flaps that do not require pedicle dissection. Surgeon training in basic flap surgery is essential and still inadequate in emerging countries. LEVEL OF EVIDENCE IV, Retrospective study.
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Affiliation(s)
- Laurent Mathieu
- Department of orthopedics, traumatology and reconstructive surgery, Percy Military Hospital, Clamart, France; French Military Health Service Academy, École du Val-de-Grâce, Paris, France.
| | - Loïc Potier
- Department of orthopedics and traumatology, Clermont-Tonnerre Military Hospital, Brest, France
| | - René Ndiaye
- Department of orthopedics and traumatology, Hôpital Principal, Dakar, Sénégal
| | - Momar Sene
- Department of orthopedics and traumatology, Hôpital Principal, Dakar, Sénégal
| | - Elimane Mbaye
- Department of orthopedics and traumatology, Hôpital Principal, Dakar, Sénégal
| | - Moussa Faye
- French Military Health Service Academy, École du Val-de-Grâce, Paris, France; Department of orthopedics and traumatology, Hôpital Principal, Dakar, Sénégal
| | - Coumba Diouf Niang
- French Military Health Service Academy, École du Val-de-Grâce, Paris, France; Department of orthopedics and traumatology, Hôpital Principal, Dakar, Sénégal
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Commentary on: "Two-Stage Combined Ortho-plastic Management of Type IIIB Open Diaphyseal Tibial Fractures Requiring Flap Coverage: Is the Timing of Debridement and Coverage Associated With Outcomes?". J Orthop Trauma 2019; 33:597-599. [PMID: 31577648 DOI: 10.1097/bot.0000000000001660] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
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Management of Gustilo type IIIB open tibial shaft fractures with limited resources: experience from an African trauma center. Eur J Trauma Emerg Surg 2019; 47:217-223. [PMID: 31482301 DOI: 10.1007/s00068-019-01223-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/28/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE We sought to evaluate the management of Gustilo type IIIB open tibia diaphyseal fractures in an African trauma center with respect to soft tissue defect management and bone union achievement. Functional outcome assessment was the secondary objective. METHODS A retrospective review was conducted including patients treated for open tibia fractures requiring flap coverage between 2007 and 2011. As plastic surgeons were lacking in availability, all procedures were performed by orthopedic surgeons trained in completing nonmicrosurgical flap transfers. RESULTS Twenty-seven patients with a mean age of 36 years were included. Although the mean time to debridement was 11 h, early infection occurred in 16 (59%) patients. The mean time to flap coverage was 27 days. Among the 29 primary local flap transfers performed, only 4 failed. Secondary amputation was required in one patient after flap failure. Bone reconstruction procedures were required in nine patients and were performed after a mean period of 97 days. At the mean follow-up time of 13 months, 23 (88%) of the 26 remaining fractures had united. There were three septic nonunions and two cases of chronic osteomyelitis. Functional result was negatively influenced by the soft tissue defect area and low-quality flap coverage. CONCLUSIONS To our knowledge, this is the first series reporting flap reconstructions performed by orthopedic surgeons for Gustilo type IIIB tibia fractures in an African hospital. Local pedicled flap transfers permitted the achievement of soft tissue coverage and bone union in most cases. Subsequent bone grafting was required in one-third of the cases.
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Identifying Predictors of Time to Soft-Tissue Reconstruction following Open Tibia Fractures. Plast Reconstr Surg 2018; 142:1620-1628. [DOI: 10.1097/prs.0000000000005007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
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Ivanov PA, Shibaev EU, Nevedrov AV, Vlasov AP, Lasarev MP. Emergency Soft Tissue Reconstruction Algorithm in Patients With Open Tibia Fractures. Open Orthop J 2016; 10:364-74. [PMID: 27583057 PMCID: PMC4981698 DOI: 10.2174/1874325001610010364] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 04/29/2016] [Accepted: 05/10/2016] [Indexed: 12/02/2022] Open
Abstract
Introduction: Tactic of emergency closing of soft tissue defect allows to significantly improve the treatment results concerning patients with severe open fractures. However, a number of certain factors make the implementation of this tactic rather difficult. Injured people’s unstable conditions are mong these crucial factors which include, polytrauma in lots of cases, absence of exact recommendations for recovery terms, choice of definite tissue flaps and a type of circulation. The Aim of Study: is to develop exact, usable and in practice algorithm of emergency reconstruction of leg soft tissues in patients with severe open tibia fractures, based on the usage of the most foolproof and simple methods. Data (Patients) and Methods: 85 patients with open tibia fractures complicated by soft tissue defects were included in our study. Patients were divided into two groups. The control group consisted of 56 patients. Soft tissue reconstruction in this group was provided without an exact algorithm, after continuous attempts on local healing. After analyzing the treatment process and the treatment results we have developed the algorithm of emergency soft tissue reconstruction. It was used in 29 patients (the study group). This algorithm allows choosing optimal timing for tissue reconstruction and appropriate method to be applied, depending on the patient’s condition, the mechanism of soft tissue defect formation, and its square and localization. Results: We observed a statistical decrease in deep wound infection frequency, partial tibia necrosis frequency, chronic osteomyelitis frequency, duration of hospitalization in patients with severe open tibia fractures because of using our algorithm.
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Affiliation(s)
- P A Ivanov
- Sklifosovsky Clinical and Research Institute for Emergency Medicine, Polytrauma Department, Moscow, Russia
| | - E U Shibaev
- Sklifosovsky Clinical and Research Institute for Emergency Medicine, Emergency Reconctructive and Plastic Surgery Department, Moscow, Russia
| | - A V Nevedrov
- Sklifosovsky Clinical and Research Institute for Emergency Medicine, Polytrauma Department, Moscow, Russia
| | - A P Vlasov
- Sklifosovsky Clinical and Research Institute for Emergency Medicine, Emergency Reconctructive and Plastic Surgery Department, Moscow, Russia
| | - M P Lasarev
- Sklifosovsky Clinical and Research Institute for Emergency Medicine, Emergency Reconctructive and Plastic Surgery Department, Moscow, Russia
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Millar IL, McGinnes RA, Williamson O, Lind F, Jansson KÅ, Hajek M, Smart D, Fernandes T, Miller R, Myles P, Cameron P. Hyperbaric Oxygen in Lower Limb Trauma (HOLLT); protocol for a randomised controlled trial. BMJ Open 2015; 5:e008381. [PMID: 26068515 PMCID: PMC4466757 DOI: 10.1136/bmjopen-2015-008381] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
INTRODUCTION Open fractures with significant soft tissue injury are associated with high rates of complications, such as non-union, infection, chronic pain and disability. Complications often require further inpatient care, and in many cases, multiple operations and prolonged rehabilitation. Use of hyperbaric oxygen therapy as an adjunct to standard orthopaedic trauma care has the potential to reduce the complications of musculoskeletal injury and thus improve outcomes. Two previous randomised trials have suggested some positive effect, but neither functional measures nor long-term outcomes were reported. METHODS AND ANALYSIS An international, multicentre, randomised, open-label, clinical trial. Patients with trauma with an acute open fracture of the tibia with severe soft tissue injury (Gustilo grade 3) and high risk of injury-related complications were recruited from participating major trauma hospitals with hyperbaric facilities. Patients were enrolled with the expectation of commencing 12 sessions of hyperbaric oxygen therapy within 48 h of injury. The primary outcome measure is the incidence of acute complications of the open fracture wound at 14 days. Other short-term outcome measures include amputation, need for fasciotomy, time until wound closure, breakdown of closed wounds, time until definitive orthopaedic fixation, number of operative procedures, intensive care stay and hospital stay. Long-term follow-up will continue for 2 years postinjury. ETHICS AND DISSEMINATION Ethics approval was given by The Alfred Health Human Ethics Committee (206/04) and the Monash University Human Research Ethics Committee (CF07/4208). Approval was also obtained from the institutional research ethics committee at each participating site. This study will make a significant contribution to the trauma literature and should answer the question of whether hyperbaric oxygen therapy can significantly improve outcomes in severe lower limb trauma. Collective study results will be published in international journals and presented at relevant conferences. TRIAL REGISTRATION NUMBER Clinicaltrials.gov: NCT00264511; Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12607000559415.
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Affiliation(s)
- Ian L Millar
- Hyperbaric Service, Department of Intensive Care & Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rosemary A McGinnes
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Owen Williamson
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Folke Lind
- Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care Medicine, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Karl-Åke Jansson
- Department of Molecular Medicine and Surgery, Karolinska Institutet at Karolinska University Hospital, Stockholm, Sweden
| | - Michal Hajek
- Ostrava City Hospital, Ostrava, Czech Republic
- University of Ostrava, Ostrava-Zabreh, Czech Republic
| | - David Smart
- Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Tiago Fernandes
- Hospital Pedro Hispano, Rua Dr. Eduardo Torres, Matosinhos, Portugal
| | - Russell Miller
- Department of Orthopaedic Surgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Paul Myles
- Department of Anaesthesia and Perioperative Medicine, The Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Management of major limb injuries. ScientificWorldJournal 2014; 2014:640430. [PMID: 24511296 PMCID: PMC3913364 DOI: 10.1155/2014/640430] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Accepted: 10/02/2013] [Indexed: 12/16/2022] Open
Abstract
Management of major limb injuries is a daunting challenge, especially as many of these patients have severe associated injuries. In trying to save life, often the limb is sacrificed. The existing guidelines on managing such trauma are often confusing. There is scope to lay down such protocols along with the need for urgent transfer of such patients to a multispecialty center equipped to salvage life and limb for maximizing outcome. This review article comprehensively deals with the issue of managing such major injuries.
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Filobbos G, Salim F, Khan U. Is the Injury Severity Score Relevant in Complex Lower Limb Trauma? ACTA ACUST UNITED AC 2013. [DOI: 10.1308/147363513x13588739440816] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
First described by Baker et al in 1974, the injury severity score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. It was developed initially to evaluate motor vehicle victims with multiple injuries, with an original study group of 2,128 patients. The ISS is an established score to assess trauma severity and its application has extended beyond motor vehicle injuries to cover all aspects of trauma.
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Affiliation(s)
- G Filobbos
- Plastic Surgery Registrar, North Bristol NHS Trust
| | - F Salim
- Plastic Surgery Registrar, North Bristol NHS Trust
| | - U Khan
- Consultant Plastic Surgeon, North Bristol NHS Trust
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Liu DSH, Sofiadellis F, Ashton M, MacGill K, Webb A. Early soft tissue coverage and negative pressure wound therapy optimises patient outcomes in lower limb trauma. Injury 2012; 43:772-8. [PMID: 22001504 DOI: 10.1016/j.injury.2011.09.003] [Citation(s) in RCA: 86] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2011] [Accepted: 09/07/2011] [Indexed: 02/07/2023]
Abstract
BACKGROUND The timing of soft tissue reconstruction for severe open lower limb trauma is critical to its successful outcome, particularly in the setting of exposed metalware and pre-existing wound infection. The use of negative pressure wound therapy (NPWT) may allow a delay in soft tissue coverage without adverse effects. This study evaluated the impact of delayed free-flap reconstruction, prolonged metalware exposure, pre-flap wound infection, and the efficacy of NPWT on the success of soft tissue coverage after open lower limb injury. METHODS Retrospective review of all free-flap reconstructions for lower limb trauma undertaken at a tertiary trauma centre between June 2002 and July 2009. RESULTS 103 patients underwent 105 free-flap reconstructions. Compared with patients who were reconstructed within 3 days of injury, the cohort with delayed reconstruction beyond 7 days had significantly increased rates of pre-flap wound infection, flap re-operation, deep metal infection and osteomyelitis. Pre-flap wound infection independently predicted adverse surgical outcomes. In the setting of exposed metalware, free-flap transfer beyond one day significantly increased the flap failure rate. These patients required more surgical procedures and a longer hospital stay. The use of NPWT significantly lowered the rate of flap re-operations and venous thrombosis, but did not allow a delay in reconstruction beyond 7 days from injury without a concomitant rise in skeletal and flap complications. CONCLUSIONS Following open lower limb trauma, soft tissue coverage within 3 days of injury and immediately following fracture fixation with exposed metalware minimises pre-flap wound infection and optimises surgical outcomes. NPWT provides effective temporary wound coverage, but does not allow a delay in definitive free-flap reconstruction.
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Affiliation(s)
- David Shi Hao Liu
- Department of Plastics and Reconstructive Surgery, The Royal Melbourne Hospital, Australia
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[Fractures of the extremities with severe open soft tissue damage. Initial management and reconstructive treatment strategies]. Unfallchirurg 2011; 113:647-70; quiz 671-2. [PMID: 20680241 DOI: 10.1007/s00113-010-1801-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The successful management of open extremity injuries continues to represent a surgical challenge requiring a structured and multidisciplinary treatment concept. The treatment strategy depends on specific parameters, including the overall injury severity, life threatening trauma components, the degree oft soft tissue injury, the ischemia time, the contamination of the wound as well as the age and accompanying diseases of the patient. The treatment of fractures with a high-grade open soft tissue injury is guided by the severity of soft tissue damage including neurovascular damages, type of the fracture, overall state of the patient and is based on a clearly defined reconstructive algorithm sequentially employing initial wound treatment (debridement), stabilisation of the fracture and soft tissue coverage. The initial wound management includes radical and serial debridements and vessel reconstruction, followed by the gradual reconstruction of bone, tendons and nerves and a subsequent plastic soft tissue coverage.The sequential and priority-orientated implementation of these treatment steps is decisive for the long term outcome, which ideally results in an regular healing of bone and soft tissue without the presence of infection and good regain of extremity function.
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Abstract
BACKGROUND Modern war ballistics and blast injuries inflict devastating extremity injuries, violating soft tissue, bone, and neurovascular structures. Despite advances in complex wound management, appropriate timing of war wound closure remains subjective. In addition, the pathophysiology of acute wound failure is poorly defined. METHODS Patients with penetrating extremity wounds sustained during combat were prospectively studied and followed for 30 days after definitive wound closure. The primary outcome was wound healing. Wound dehiscence was defined as spontaneous partial or complete wound disruption after closure. Serum, wound effluent, and wound bed tissue biopsy were collected at each surgical wound debridement. Serum and wound effluent were analyzed with a multiplex array of 22 cytokines and chemokines, and wound tissue for corresponding gene transcript expression. RESULTS Fifty-two penetrating extremity war wounds in 33 male patients were investigated. Nine (17%) wounds dehisced. Concomitant vascular injury, increased wound size, and higher injury severity score correlated with wound dehiscence. Both serum and wound effluent cytokine and chemokine protein profiles were statistically associated with healing outcome at various time points. Wound biopsy gene transcript expression demonstrated increased tissue inflammation associated with wound failure. Multiple protein and gene transcript biomarkers predictive of wound healing were identified. CONCLUSIONS The cytokine and chemokine protein and gene transcript expression patterns demonstrate a condition of inflammatory dysregulation associated with war wound failure. A molecular biomarker panel may predict combat wound healing outcome and warrants prospective validation.
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Prantl L, Babilas P, Roll C, Jung M, Nerlich M, Kinner B, Schreml S, Fuechtmeier B. The use of ‘fasciocutaneous’ and ‘osteofasciocutaneous’ parascapular flaps for lower limb reconstruction: a retrospective study of 20 patients. J Plast Reconstr Aesthet Surg 2009; 62:973-80. [DOI: 10.1016/j.bjps.2007.11.070] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2006] [Revised: 09/05/2007] [Accepted: 11/24/2007] [Indexed: 10/22/2022]
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Early Intervention of Negative Pressure Wound Therapy Using Vacuum-Assisted Closure in Trauma Patients. Adv Skin Wound Care 2009; 22:128-32. [DOI: 10.1097/01.asw.0000305451.71811.d5] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Routine Use of Wound Vacuum-Assisted Closure Does Not Allow Coverage Delay for Open Tibia Fractures. Plast Reconstr Surg 2008; 121:1263-1266. [DOI: 10.1097/01.prs.0000305536.09242.a6] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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