1
|
Boyce L, Jordan C, Pafitanis G. A simple and rapid technique to achieving an airtight seal for negative pressure wound therapy in externally fixated lower limb open fractures. Ann R Coll Surg Engl 2024; 106:389-390. [PMID: 37983020 PMCID: PMC10981978 DOI: 10.1308/rcsann.2023.0062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 11/21/2023] Open
Affiliation(s)
- L Boyce
- Barts Health NHS Trust, London, UK
| | - C Jordan
- Barts Health NHS Trust, London, UK
| | - G Pafitanis
- Barts Health NHS Trust, London, UK
- University of Cyprus, Nicosia, Cyprus
| |
Collapse
|
2
|
Alt V, Rupp M, Kerschbaum M, Prantl L, Geis S. [Treatment strategies for fracture-related infections with concurrent soft tissue damage]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024; 127:103-109. [PMID: 38167783 DOI: 10.1007/s00113-023-01403-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/07/2023] [Indexed: 01/05/2024]
Abstract
Fracture-related infections are the predominant complication following surgical fracture treatment. The distal lower leg, e.g., in pilon tibial fractures, is at a high risk of infection due to poor soft tissue coverage, particularly in cases of open fractures in this area. Fracture-related infections with significant soft tissue damage require special attention alongside treatment of the infection itself. In general, the principle is that healing of fracture-related infection is not possible without sufficient soft tissue coverage. Therefore, it is crucial to integrate both soft tissue damage and fracture-related infection into a comprehensive treatment plan from the beginning. An interdiscpilinary treatment approach between trauma and plastic surgery is often necessary and beneficial. In cases, where fracture fixation devices or bone is exposed, mid- or long-term use of vacuum-assisted wound therapy is not advisable due to a higher risk of reinfection. Hence, an interdisciplinary treatment strategy involving trauma and plastic surgery should prioritize early soft tissue closure, referred to as the "orthoplastic approach". If this cannot be done in the own hospital, early patient transfer is indicated to ensure optimal interdisciplinary therapy with early soft tissue closure and simultaneous trauma surgical treatment to control the infection and enable bone healing. Free fasciocutaneous or muscle flap techniques in combination with adequate trauma surgical and antibiotic therapy lead to good reliable results in these situations.
Collapse
Affiliation(s)
- Volker Alt
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland.
| | - Markus Rupp
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Maximilian Kerschbaum
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg (UKR), Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Deutschland
| | - Lukas Prantl
- Abteilung für Plastische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg (UKR), Regensburg, Deutschland
| | - Sebastian Geis
- Abteilung für Plastische, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Regensburg (UKR), Regensburg, Deutschland
| |
Collapse
|
3
|
Correlation of Time to Soft Tissue Coverage With Clinical Outcome in Lower Extremity Trauma in the Modern Era: A Single-Center Retrospective Review. EPLASTY 2023; 22:eX. [PMID: 36793618 PMCID: PMC9891769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
Background Lower extremity salvage in the setting of severe trauma requires the consideration of multiple surgical specialties and treatment algorithms. We hypothesized that time to first ambulation, ambulation without an assistive device, chronic osteomyelitis, and delayed amputation were not affected by the time to soft tissue coverage in Gustilo IIIB and IIIC fractures at our institution. Methods We evaluated all patients treated for open tibia fractures at our institution from 2007 to 2017. Patients requiring any form of soft tissue coverage to the lower extremity during their initial hospitalization and who had at least 30 days of follow-up from time of hospital discharge were included. Univariable and multivariable analysis was performed for all variables and outcomes of interest. Results Of 575 patients included, 89 required soft tissue coverage. On multivariable analysis, the time to soft tissue coverage, length of negative pressure wound therapy treatment, and number of wound washouts were not found to be associated with development of chronic osteomyelitis, decreased 90-day return to any ambulation, decreased 180-day return to ambulation without assistive device, or delayed amputation. Conclusions Time to soft tissue coverage in open tibia fractures did not affect time to first ambulation, ambulation without an assistive device, chronic osteomyelitis, or delayed amputation in this cohort. It remains difficult to definitively prove that time to soft tissue coverage meaningfully impacts lower extremity outcomes.
Collapse
|
4
|
Sweere V, Sliepen J, Haidari S, Depypere M, Mertens M, IJpma F, Metsemakers WJ, Govaert G. Use of negative pressure wound therapy in patients with fracture-related infection more than doubles the risk of recurrence. Injury 2022; 53:3938-3944. [PMID: 36424686 DOI: 10.1016/j.injury.2022.10.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/11/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE Fracture-related infection (FRI) is one of the most serious complications in orthopedic trauma surgery. Despite its widespread use, the role of Negative Pressure Wound Therapy (NPWT) remains controversial in the management pathway of FRI. The aim of this study was to assess the relationship between the application of NPWT and its duration and recurrence of infection in operatively treated FRI patients. PATIENTS AND METHODS This is a retrospective cohort study based on the FRI database of three level 1 Trauma Centres. Included patients had to be at least 16 years of age and surgically treated for FRI between January 1st 2015 and September 1st 2020. Patients were subdivided in either the NPWT group, when NPWT was applied as part of the FRI treatment, or in the control group, when no NPWT had been applied. To limit confounding, patients were excluded if they (also) underwent NPWT prior to the diagnosis of FRI. The relation between the duration of NPWT during FRI treatment and the recurrence rate of infection was analyzed using a multivariable logistic regression model. RESULTS A total of 263 patients were included, 99 in the NPWT group and 164 in the control group. The median duration of NPWT was 18.0 (IQR 15.8) days. In the NPWT group, 28 patients (28.3%) developed a recurrent FRI. In the control group, 19 patients (11.6%) had a recurrent FRI (p = 0.001, 95% CI [0.174 - 0.635]). In the NPWT group there were no significant differences in baseline characteristics between the recurrence and non-recurrence group. The duration of NPWT was associated with a higher risk of recurrence of infection (p = 0.013, OR 1.036, 95% CI [1.008 - 1.066]). CONCLUSION Delayed wound closure with the application of NPWT increased the risk of recurrence of infection in patients with soft tissue defects after FRI treatment. Therefore, it is advised to consider NPWT only as a short-term (e.g. few days) necessity to bridge the period until definitive wound closure can be established.
Collapse
Affiliation(s)
- Vera Sweere
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jonathan Sliepen
- Department of Trauma Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Susan Haidari
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Melissa Depypere
- Department of Laboratory Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Maarten Mertens
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Frank IJpma
- Department of Trauma Surgery, University Medical Centre Groningen, Groningen, The Netherlands
| | - Willem-Jan Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium; KU Leuven - University of Leuven, Department of Development and Regeneration, Leuven, Belgium
| | - Geertje Govaert
- Department of Trauma Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands.
| |
Collapse
|
5
|
Mahajan RK, Srinivasan K, Jain A, Bhamre A, Narayan U, Sharma M. Management of Complex Upper Extremity Trauma with Associated Vascular Injury. Indian J Plast Surg 2022; 55:224-233. [DOI: 10.1055/s-0042-1744453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Abstract
Introduction Combined soft tissue and vascular injuries of the upper extremity pose several challenges at once to the plastic surgeon. Many decisions have to be taken urgently that will influence the salvage or amputation of the affected extremity. The aim of this article was to provide an evidence-based outline for the management of such injuries. Learning objectives of this article are as follows: (1) approach to a patient with upper extremity composite tissue and vascular injury presenting to the emergency, (2) decision-making as to when to salvage and when to go for amputation of the traumatized upper extremity, (3) role of imaging in emergency situation, (4) role of fasciotomy, (5) intraoperative sequencing of steps, and (6) options for vascular reconstruction and the flaps used for coverage. After reading this article, the reader should have a clear understanding of the management of vascular injury in a patient with composite defects of upper extremity.
Collapse
Affiliation(s)
- Ravi K. Mahajan
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Krishnan Srinivasan
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Adish Jain
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Abhishek Bhamre
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Udit Narayan
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| | - Manish Sharma
- Department of Plastic and Reconstructive Surgery, Amandeep Hospital, Amritsar, Punjab, India
| |
Collapse
|
6
|
Tierny C, Casoli V, Chadefaux G, Dauchy FA, Fabre T, Belaroussi Y, Delgove A. Management of Chronic Osteomyelitis by an Orthoplastic Team: 7-Year Experience of a University Hospital. Plast Reconstr Surg 2021; 148:443-453. [PMID: 34181596 DOI: 10.1097/prs.0000000000008175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Treating chronic osteomyelitis of the lower extremities is challenging. The treatment of acute lower limb trauma by orthoplastic teams has shown good results over the past few decades. This study aimed to characterize surgical outcomes of leg and heel chronic osteomyelitis by an orthoplastic team. METHODS The cases of 113 consecutive leg and heel chronic osteomyelitis patients undergoing soft-tissue reconstruction with an orthopedic procedure were reviewed in this retrospective single-center observational study. The main objective was to assess surgical outcomes of skin healing and gait recovery at the 1-year follow-up. The secondary objective was to evaluate the global success rate at the last follow-up. RESULTS The median follow-up was 19.7 months. A free flap was performed for 33 patients (29.2 percent) and a locoregional flap was used in 79 patients (69.9 percent). Seventy-two patients (63.7 percent) had chronic osteomyelitis on continuous bone. The others had a septic pseudarthrosis with a mean bone defect length of 42.9 mm. Forty-four patients (38.9 percent) underwent curettage only, eight (7.1 percent) underwent curettage and cement, 20 (17.7 percent) underwent curettage and bone fixation, and 39 (34.5 percent) underwent the Masquelet technique. At the 1-year follow-up, 72 patients (63.7 percent) had achieved skin healing and had recovered their gait. The success rate at all follow-up time points was 82.3 percent. The median time to achieve skin healing was 6.5 months and that to bone union in cases of septic pseudarthrosis was 7.9 months. CONCLUSION Orthoplastic management of leg and heel chronic osteomyelitis patients with combined soft-tissue reconstruction using an orthopedic procedure was a viable strategy that offered good results even though the time to complete healing was long. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
Collapse
Affiliation(s)
- Chloé Tierny
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| | - Vincent Casoli
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| | - Grégoire Chadefaux
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| | - Frédéric-Antoine Dauchy
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| | - Thierry Fabre
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| | - Yaniss Belaroussi
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| | - Anaïs Delgove
- From the Plastic Surgery and Burns Unit, Centre FX Michelet, Bordeaux University Hospital; Surgery School, University of Bordeaux; Department of Anesthesiology and Critical Care, Bordeaux University Hospital; Department of Infectious and Tropical Diseases and South-Western France Referral Center for Complex Bone and Joint Infections (Crioac GSO), Bordeaux University Hospital; Department of Orthopedic Surgery, Bordeaux University Hospital; and Department of Thoracic Surgery, Bordeaux University Hospital
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|
8
|
Holler JT, MacKechnie MC, Albright PD, Morshed S, Shearer DW, Terry MJ. The Impact of Inadequate Soft-tissue Coverage following Severe Open Tibia Fractures in Tanzania. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3272. [PMID: 33425587 PMCID: PMC7787316 DOI: 10.1097/gox.0000000000003272] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 10/01/2020] [Indexed: 12/31/2022]
Abstract
Managing lower extremity fractures complicated by large soft-tissue defects is challenging for surgeons in low- and middle-income countries, and long-term quality of life (QOL) for these patients is unclear. METHODS We examined QOL, surgical complications, and longitudinal outcomes in 10 patients with Gustilo-Anderson Classification Type IIIB open tibia fractures seen at an orthopedic institute in Tanzania, from December 2015 to March 2017. Patients completed follow-up at 2-, 6-, 12-, 26-, and 52-week time points, and returned for qualitative interviews at 2.5 years. The primary outcome was QOL, as measured using EuroQoL-5D scores and qualitative semi-structured interview responses. The secondary outcome was rate of complication, as defined by reoperation for deep infection or nonunion. RESULTS Ten patients enrolled in the study and 7 completed 1-year follow-up. All fractures were caused by road traffic accidents and treated by external fixation. No patients received initial soft-tissue (flap) coverage of the wound. All patients developed an infected nonunion. No patients returned to work at 6 weeks, 3 months, or 6 months. EQ-5D index scores at 1 year were poor (0.71 ± 0.09). Interview themes included ongoing medical complications, loss of employment, reduced income, and difficulty with activities of daily living. CONCLUSIONS Patients in low- and middle-income countries with IIIB open tibia fractures not treated with appropriate soft-tissue coverage experience poor QOL, high complication rates, and severe socioeconomic effects as a result of their injuries. These findings illustrate the need for resources and training to build capacity for extremity soft-tissue reconstruction in LMICs.
Collapse
Affiliation(s)
- Jordan T. Holler
- From the UCSF School of Medicine, University of California, San Francisco, Calif
| | - Madeline C. MacKechnie
- Institute for Global Orthopedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Calif
| | - Patrick D. Albright
- Department of Orthopaedic Surgery, University of Minnesota – Medical School, Minneapolis, Minn
| | - Saam Morshed
- Institute for Global Orthopedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Calif
| | - David W. Shearer
- Institute for Global Orthopedics and Traumatology, Orthopaedic Trauma Institute, Department of Orthopaedic Surgery, University of California, San Francisco, Calif
| | - Michael J. Terry
- Division of Plastic and Reconstructive Surgery, Institute for Global Orthopaedics and Traumatology, University of California, San Francisco, Calif
| |
Collapse
|
9
|
Deng L, Yu A, Qi B, Lei J, De Souza C, Zhu S, Yu L. The Masquelet technique combined with the muscle flap for use in emergency management of acute Gustilo type III trauma of the lower limb with segmental bone loss:Case series. Int J Surg 2020; 81:85-93. [DOI: 10.1016/j.ijsu.2020.07.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/05/2020] [Accepted: 07/08/2020] [Indexed: 01/09/2023]
|
10
|
Pasquesoone L, Barry L, Sturbois-Nachef N, Duquennoy-Martinot V, Chantelot C, Guerre E. The interest of "ortho-plastic" collaboration in management of complex limb injury. ANN CHIR PLAST ESTH 2020; 65:423-446. [PMID: 32654841 DOI: 10.1016/j.anplas.2020.05.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 05/21/2020] [Indexed: 01/26/2023]
Abstract
Constantly evolving knowledge on fracture management, soft tissue coverage, microsurgery and vasculo-nervous repair now permits salvage of limbs that previously would have had to be amputated. Management of complex limb injuries of which the severity inevitably entails functional and esthetic sequelae calls for mastery of the full spectrum of bone and soft tissue reconstruction. Such mastery is rarely attainable by a single surgical specialty; individually and isolatedly, an orthopedic or plastic surgeon cannot ensure optimal management of the above-mentioned patients. While the orthopedist performs a key function in provisional or definitive fixation, the plastic surgeon's expertise is essential to restoration of the cutaneous envelope. Collaboration between the two specialties from the outset and throughout treatment characterizes the modern-day concept of "ortho-plastic" surgery. Through unification of the theoretical competence and practical skills of orthopedists and plastic surgeons, it provides a patient with the best possible functional and esthetic results in a wide range of clinical situations. In this article, we present a review of the literature illustrating the interest of "ortho-plastic" collaboration in management of complex limb injury; concrete examples will be given through evocation of clinical cases encountered by the team that was put together in August 2015 at the university hospital (CHU) of Lille.
Collapse
Affiliation(s)
- L Pasquesoone
- Service de chirurgie plastique, reconstructrice et esthétique, Centre de traitement des brûlés, CHU, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France.
| | - L Barry
- Service de chirurgie plastique, reconstructrice et esthétique, Centre de traitement des brûlés, CHU, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| | - N Sturbois-Nachef
- Service d'orthopédie B, CHU Lille, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| | - V Duquennoy-Martinot
- Service de chirurgie plastique, reconstructrice et esthétique, Centre de traitement des brûlés, CHU, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| | - C Chantelot
- Service de traumatologie, CHU Lille, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| | - E Guerre
- Service d'orthopédie B, CHU Lille, Hôpital Roger-Salengro, avenue Emile-Laine, 59037 Lille, France
| |
Collapse
|
11
|
Agarwal S, Sarkar S, Agarwal M. “A journey from doom to bloom” – A rare case of low-energy pediatric open supracondylar fracture of humerus with brachial artery laceration managed with “Orthoplastic Approach”. JOURNAL OF ORTHOPAEDICS AND SPINE 2020. [DOI: 10.4103/joasp.joasp_16_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
12
|
Jayaramaraju D, Venkataramani H, Rajasekaran RB, Agraharam D, Sabapathy SR, Rajasekaran S. Modified Capanna's Technique (Vascularized Free Fibula Combined with Allograft) as a Single-Stage Procedure in Post-traumatic Long-Segment Defects of the Lower End of the Femur: Outcome Analysis of a Series of 19 Patients with an Average Gap of 14 cm. Indian J Plast Surg 2019; 52:296-303. [PMID: 31908367 PMCID: PMC6938445 DOI: 10.1055/s-0039-3400672] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 09/11/2019] [Indexed: 11/26/2022] Open
Abstract
Objectives
Salvage and reconstruction of posttraumatic defects of the long bone are complex due to the multiple procedures involved and increased chances of poor outcomes. We present the outcomes of the modified Capanna’s technique—a reliable single-stage procedure of combining allograft and free vascularized fibular graft—in treating large posttraumatic bone defects in the distal third of the femur.
Study Design
This is a retrospective analysis.
Materials and Methods
Between April 2012 and September 2016, 19 patients with an average age of 33.8 years (range: 18–49 years) and an average defect of 14.5 cm (range: 9.5–20 cm) in the distal femur were managed by the modified Capanna’s technique. Bone union time and functional outcome using lower extremity functional score (LEFS) after union were noted.
Outcomes and Results
Eighteen grafts went onto achieve bony union at an average of 6.6 months (range: 5–9), with an average knee flexion of 80 degrees (range: 45–110 degrees) and an average LEFS of 63 (range: 46–72). One patient had a nonunion with graft resorption at 8 months following persistent infection and was revised with debridement and augmenting the vascularized fibula from the other leg which went on to achieve union. Three patients had superficial infection, and three patients had delayed union.
Conclusion
The modified Capanna’s technique provided increased biology and enhanced structural stability and therefore is a good single-stage procedure in the reconstruction of posttraumatic long-segment defects of the distal femur.
Level of Evidence
Level 4.
Level of Clinical Care
Level I tertiary trauma center.
Collapse
Affiliation(s)
| | - Hari Venkataramani
- Department of Plastic, Hand and Reconstructive Surgery, Ganga Medical Centre & Hospitals, Coimbatore, Tamil Nadu, India
| | - Raja Bhaskara Rajasekaran
- Department of Orthopaedics & Trauma, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Devendra Agraharam
- Department of Orthopaedics & Trauma, Ganga Medical Centre and Hospitals, Coimbatore, Tamil Nadu, India
| | - Shanmuganathan Raja Sabapathy
- Department of Plastic, Hand and Reconstructive Surgery, Ganga Medical Centre & Hospitals, Coimbatore, Tamil Nadu, India
| | | |
Collapse
|
13
|
Barriers to Performing Soft Tissue Reconstruction Procedures among Orthopedic Surgeons in Low- and Middle-income Countries: Results of a Surgical Skills Training Course. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2019; 7:e2420. [PMID: 31772876 PMCID: PMC6846298 DOI: 10.1097/gox.0000000000002420] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 07/09/2019] [Indexed: 02/07/2023]
Abstract
Appropriate management of soft tissue injury associated with orthopedic trauma is challenging in low- and middle-income countries (LMICs) due to the lack of available reconstructive surgeons. The Surgical Management and Reconstructive Training (SMART) course teaches orthopedic surgeons reconstructive techniques aimed at improving soft tissue management. This study aims to identify additional barriers to implementing these techniques for surgeons in LMICs who have attended SMART courses.
Collapse
|
14
|
van Niekerk AH, Birkholtz FF, de Lange P, Tetsworth K, Hohmann E. Circular external fixation and cemented PMMA spacers for the treatment of complex tibial fractures and infected nonunions with segmental bone loss. J Orthop Surg (Hong Kong) 2018. [PMID: 28639529 DOI: 10.1177/2309499017716242] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE The purpose of this study was to compare the outcome of combined circular external fixation and cemented polymethylmethacrylate (PMMA) spacer application between a cohort of patients with grade 3 open fractures and infected tibial nonunions and concomitant segmental bone loss. METHODS The study was designed as a retrospective cohort study. All patients who were treated for complex tibial fractures or infected nonunions with segmental bone loss between 2009 and 2013 were included if they were aged between 16 years and 60 years, sustained acute traumatic grade 3 open tibial fractures, presented with infected nonunion, and were followed up for a minimum of 12 months. Patients with a history of ipsilateral tibial fractures, contralateral lower extremity fractures, polytrauma, chest, or abdominal trauma and patients with head injuries were excluded. Both groups were treated with aggressive debridement, circular external fixation, and antibiotic-impregnated PMMA spacer. Outcome measures were the time in the external fixator (EFT) and the external fixation index (EFI). RESULTS Twenty-four patients with a mean age of 32 ± 14.7 years were included. Twelve patients with a mean age of 32 + 14 years and a mean bone defect of 82 + 36 mm were treated for acute complex grade 3 open tibial fractures, and 12 patients with a mean age of 35.1 + 15.7 years and a mean bone defect of 50 + 26 mm were treated for infected nonunions. There was no significant difference ( p = 0.44) between the groups for EFT (249 ± 99 days-tibial fractures; 255 ± 142 days-infected nonunion). There were significant between group differences ( p = 0.027) for EFI (37.3 ± 9.1 cm/days-tibial fractures; 56 ± 14.5 cm/days-infected nonunion). CONCLUSION The findings of this study suggest that patients were treated for infected nonunion with segmental bone loss using circular external fixation, distraction osteogenesis, and antibiotic-impregnated PMMA spacers, and the spacers may not offer any advantage over a conventional approach using the principles of osteogenesis only. In contrast, antibiotic-impregnated spacers for open tibial trauma were advantageous and reduced the EFI considerably.
Collapse
Affiliation(s)
- Andries H van Niekerk
- 1 Department of Orthopaedic Surgery, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa
| | - Franz F Birkholtz
- 1 Department of Orthopaedic Surgery, University of Pretoria, Steve Biko Academic Hospital, Pretoria, South Africa.,2 Walk-a-Mile Centre for Advanced Orthopaedics, Netcare Unitas Hospital, Mediclinic Midstream Hospital, Pretoria, South Africa
| | - Phillip de Lange
- 2 Walk-a-Mile Centre for Advanced Orthopaedics, Netcare Unitas Hospital, Mediclinic Midstream Hospital, Pretoria, South Africa
| | - Kevin Tetsworth
- 3 Department of Orthopaedic Surgery, Royal Brisbane Hospital, Brisbane, Australia.,4 Queensland University of Technology, Brisbane, Australia.,5 University of Queensland School of Medicine, Brisbane, Australia.,6 Orthopaedic Research Centre of Australia, Brisbane, Queensland, Australia
| | - Erik Hohmann
- 2 Walk-a-Mile Centre for Advanced Orthopaedics, Netcare Unitas Hospital, Mediclinic Midstream Hospital, Pretoria, South Africa.,6 Orthopaedic Research Centre of Australia, Brisbane, Queensland, Australia.,7 Medical School, University of Queensland, Queensland, Australia.,8 School of Medicine, University of Pretoria, Pretoria, South Africa
| |
Collapse
|
15
|
Abstract
Open fractures in children differ from adults owing to their better healing potential. Management strategies for open fracture in children are changing with improvement in our understanding of soft-tissue reconstruction and fracture fixation. A literature review was performed for articles covering management of open fractures in children. The cornerstones of management include prevention of infection, debridement, and skeletal stabilization with soft-tissue coverage. The injury should be categorized according to the established trauma classification systems. Timely administration of appropriate antibiotics is important for preventing infections. Soft-tissue management includes copious irrigation and debridement of the wound. Fractures can be stabilized by a variety of nonoperative and operative means, taking into consideration the special needs of the growing skeleton and the role of a thick and active periosteum in the healing of fractures. The soft-tissue coverage required depends on the grade of injury.
Collapse
Affiliation(s)
- Akshat Sharma
- Department of Paediatric Orthopaedics, KUMC GURO Hospital, Seoul, Korea,Address for correspondence: Dr. Akshat Sharma, 15, Nav Vikas Apartments, Sector – 15, Rohini, New Delhi - 110 089, India. E-mail:
| | - Vikas Gupta
- Central Institute of Orthopaedics, Safdarjung Hospital, New Delhi, India
| | - Kumar Shashikant
- Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India
| |
Collapse
|
16
|
Microbiological and functional outcomes after open extremity fractures sustained overseas: The experience of a UK level I trauma centre. JPRAS Open 2017; 15:36-45. [PMID: 32158796 PMCID: PMC7061582 DOI: 10.1016/j.jpra.2017.09.003] [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] [Received: 08/21/2017] [Accepted: 09/22/2017] [Indexed: 11/20/2022] Open
Abstract
Background Open extremity fractures carry a high risk of limb loss and poor functional outcomes. Transfer of extremity trauma patients from developing countries and areas of conflict adds further layers of complexity due to challenges in the delivery of adequate care. The combination of extensive injuries, transfer delays and complex microbiology presents unique challenges. Methods A retrospective review was conducted to analyse the surgical and microbiological themes of patients with open extremity fractures transferred from overseas to our institution (Imperial College NHS Trust) between January 2011 and January 2016. Results Twenty civilian patients with 21 open extremity fractures were referred to our unit from 11 different countries. All patients had poly-microbial wound contamination on initial surveillance cultures. Five patients (25%) underwent amputation depending on the extent of osseous injury; positive surveillance cultures did not preclude limb reconstruction, with seven patients undergoing complex reconstruction and eight undergoing simple reconstruction to achievewound coverage. Hundred percent of patients demonstrated infection-free fracture union on discharge. Conclusion Patients with open extremity fractures transferred from overseas present the unique challenge of poly-microbial infection in addition to extensive traumatic wounds. Favourable outcomes can be achieved despite positive microbiological findings on tissue culture with adequate antimicrobial therapy. The decision to salvage the limb and the complexity of reconstruction used should be based on the chance of achieving meaningful functional recovery, mainly determined by the extent of bony injury. The complexity of reconstruction was based on the predicted long-term functionality of the salvaged limb.
Collapse
|
17
|
Hohmann E, Birkholtz F, Glatt V, Tetsworth K. The "Road to Union" protocol for the reconstruction of isolated complex high-energy tibial trauma. Injury 2017; 48:1211-1216. [PMID: 28351547 DOI: 10.1016/j.injury.2017.03.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Revised: 03/07/2017] [Accepted: 03/15/2017] [Indexed: 02/02/2023]
Abstract
INTRODUCTION The purpose of this study was to describe a standardized staged approach, "The Road to Union", for the reconstruction of isolated complex tibial trauma, both acute and chronic in nature. METHODS This retrospective study included all patients treated for complex tibial trauma at a specialized limb reconstruction centre, including acute open fracture as well as infected and aseptic non-unions. This standardized approach includes eight specific steps, employed in sequence. The time in external fixation (EFT), the external fixation index (EFI), and the distraction consolidation index (DCI) were the primary outcome measures. The relationship between EFI and DCI was assessed using Pearson's moment correlations. RESULTS Thirty-two patients with a mean age of 34.7±14.2years were included; 12 were treated for complex open tibial fractures with bone loss, 13 for infected non-unions, and 6 for aseptic non-union. The mean bone defect was 66±32mm. The total EFT was 42.5±14.8 weeks; the EFI measured 51.9±25.3 days/cm, and the DCI measured 48.3±21.4 days/cm. Union was achieved in 29 out of 32 patients (91%), and there was a strong and significant relationship between EFI and DCI (r=0.92, p=0.0001) measurements. Pin site infections were observed in 11 patients, and 3 patients had persistent non-union. Three patients underwent delayed amputations when reconstructive procedures were unable to achieve union. CONCLUSION The findings of this study demonstrate that a standardized staged treatment protocol of debridement, circular external fixation, soft-tissue management, distraction osteogenesis, and functional rehabilitation can result in a high rate of union in cases of complex tibial trauma, both acute and chronic in nature. LEVEL OF EVIDENCE Level IV; case series.
Collapse
Affiliation(s)
- Erik Hohmann
- School of Medicine, University of Pretoria, South Africa; Valiant Clinic/Houston Methodist Group, Dubai, United Arab Emirates.
| | - Franz Birkholtz
- Walk-a-Mile Centre for Advanced Orthopaedics, Pretoria, South Africa; Department of Orthopaedic Surgery, University of Pretoria, Steve Biko Academic Hospital, South Africa
| | - Vaida Glatt
- Department of Orthopaedic Surgery, University of Texas Health Science Center, San Antonio, TX, USA
| | - Kevin Tetsworth
- Department of Orthopaedic Surgery, Royal Brisbane Hospital, Herston, Australia; Department of Surgery, School of Medicine, University of Queensland, Australia; Queensland University of Technology, Orthopaedic Research Institute, Australia
| |
Collapse
|
18
|
Boriani F, Ul Haq A, Baldini T, Urso R, Granchi D, Baldini N, Tigani D, Tarar M, Khan U. Orthoplastic surgical collaboration is required to optimise the treatment of severe limb injuries: A multi-centre, prospective cohort study. J Plast Reconstr Aesthet Surg 2017; 70:715-722. [DOI: 10.1016/j.bjps.2017.02.017] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Revised: 01/30/2017] [Accepted: 02/17/2017] [Indexed: 02/08/2023]
|
19
|
|