Cases (III)
12.6 Skill level II: Case 1
David A Volgas
Case history
35-year-old white male patient
Unemployed construction worker
Single
Smoker, occasional alcohol use, history of cocaine abuse
No other medical problems
While riding a motorcycle, the patient was involved in a single-vehicle crash. He was unresponsive at the scene and intubated in the field. He was not wearing a helmet. A spine board and air splint were applied in the field and intravenous fluids were administered. The patient was classified as 3T on the Glasgow coma scale and transported to a level I trauma center.
In the trauma bay, the patient underwent the advanced trauma life support (ATLS) protocol, which identified:
intraparenchymal left frontal lobe hemorrhage
right pulmonary contusion
closed fracture of the right navicular bone
Gustilo type IIIB fracture of the left tibia ( Fig 12.6-1a–b ).
The patient underwent initial resuscitation by the trauma team and emergency ventriculostomy. The wound was debrided and irrigated in the emergency department, but the patient was not deemed stable enough for a full debridement and irrigation in the operating room on the day of admission.
The next morning, the patient was taken to the operating room for formal debridement, irrigation, and fracture fixation by intramedullary nailing ( Fig 12.6-2a–b ). On the patient′s fourth day in hospital, debridement and irrigation were repeated and a negative-pressure wound-therapy device was applied. On the eighth day in hospital, a meshed, split-thickness skin graft was placed over the wound and again immobilized with a negative-pressure wound-therapy device.
After being discharged from the hospital, the patient had a follow-up in the orthopaedic clinic and was found to have a slough of the skin graft and a deep wound infection at the site of the tibial wound. After initially attempting to manage the wound and infection as an outpatient, he was rehospitalized because he continued to have purulent discharge from both the traumatic wound and the proximal surgical incision at the nail insertion site.
Wound conditioning: In this situation, he was taken to the operating room for removal of the intramedullary nail as well as debridement and irrigation of the wound ( Fig 12.6-3 ). Consideration was given to the placement of an external fixator, but the surgeon decided against this since he feared continued infection in the medullary canal and did not wish to cross the knee and ankle joints with a fixator. Intraoperative cultures demonstrated the presence of methicillinsensitive Staphylococcus aureus. The wound was closed over antibiotic beads and intramedullary antibiotics, but the situation of the skin was tenuous. A negative-pressure wound-therapy device was again employed. The patient was discharged with home intravenous antibiotics and a splint in order to allow for dressing changes.
Present status
On a follow-up 2 weeks later, there was an 8 × 3 cm wound with exposed bone. The previous nail insertion site was dry, but there was serous discharge from the traumatic wound.
In the past, compliance with wound care by nurses at home as well as cessation of smoking have been issues with this patient. This patient then presented with an unstable fracture, a deep infection, and a wound on the anterior aspect of the mid-distal tibia.
Decision making
Open questions
What are the priorities for management of this injury: stabilization of the fracture, control of infection and skin coverage?
What type of coverage should be used for this wound?
What type of implant should be used in order to provide bone stability?
Options and plan
The three problems—fracture instability, infection, and skin defect—which this case presents, are neither discrete, nor are they separate. Wounds heal much better when the bone is stable. However, implants placed into an infected wound, are likely to become an ongoing source of infection, as bacteria adhere to the implant. This may result in chronic osteomyelitis or, worse, an infected nonunion. Wound closure is much more successful if the wound is not infected or can be converted to a noninfected wound. However, the challenge is to convert an open wound bed or a previously infected wound into a noninfected one.
Therefore, all three problems must ideally be addressed simultaneously. Some surgeons prefer to leave implants in place even in the face of infection as long as they are providing stability to the bone. In this case, however, the nail was removed because there was copious discharge from the nail insertion site.
All in all, the initial plan consisted of a planned staged open reduction and internal fixation of the fracture with primary wound closure after an attempt to decrease bacterial load and achieve near-sterile wound conditions by removing hardware and necrotic material, placing antibiotics beads and administering systemic antibiotics. This plan had to be changed when the primarily closed wound showed dehiscence. At this time, there was not gross purulence at the wound, so the plate was left in place.
In order to provide fracture stability, a variety of options are available. These options include another reamed intramedullary nail, external fixator or plate and screw fixation. An intramedullary nail would have been an acceptable option, but the patient had had a prior intramedullary infection. The surgeon felt that the risk of an intraarticular infection developing in this patient, who was not diligent about follow-up, was fairly high unless the intramedullary infection was completely cleared.
An external fixator would be an option, but with the history of intramedullary infection, pin-track site problems jeopardizing the stability of the fixation would probably be more likely than if there had been no previous intramedullary infection. One should also keep in mind that wound care would be considerably more difficult with an external fixator in place, and this again would require patient compliance. Nevertheless, an external fixator bridging both knee and ankle to avoid pin placement into the infected medullary canal would have been a reasonable alternative.
Although there is a lack of evidence in the literature concerning rigid versus nonrigid fixation in the face of infection, the surgeon decided to use a rigid internal fixation consisting of a plate and screws. Careful placement of the plate without further periosteal stripping will minimize additional damage to the vascularity of the bone. Also, if the bone should not heal or an ongoing infection makes amputation an option, choosing an implant which does not extend proximal to the level of the prospective amputation will reduce the risk of chronic osteomyelitis.
The choice of fixation used in this case is debatable and there are valid reasons to use another intramedullary nail or an external fixator. Also, the timing of placement of metal implants is debatable. An unstable fracture usually will not heal, especially in the presence of infection. Moreover, infection control is difficult with hardware in place. In this case, the surgeon felt that a short period of instability might allow the infection to be controlled sufficiently in order to reduce the likelihood of infection of the plate. This is certainly a judgment call and needs to be determined on a case-by-case basis.
In order to provide coverage, several options were considered. The soleus muscle may sometimes be used to cover wounds at the junction of the middle to the distal tibial third, but is often too tendinous to provide good cover. Anyway, in this case, during the initial debridement, the soleus muscle was noted to be severely contused.
A local tissue transfer was considered using a randomly perfused fasciocutaneous flap (chapter 10.4). A reverse-flow sural flap was also considered (chapter 10.5.2), but the surgeon felt that it would require more postoperative care than a local fasciocutaneous flap in the context of limited compliance. Furthermore, during the placement of the plate, an attempt was made to identify the sural artery in case the primary closure failed. However, it could not be located by Doppler ultrasound.
A plastic surgery consult was obtained. An angiogram was taken, which showed single-vessel runoff in the leg. The plastic surgery consultant was unwilling to place a free flap because of the history of vascular injury, smoking, infection, and noncompliance. Moreover, in such a situation, an end-to-side anastomosis may even induce a so-called steal phenomenon (chapter 10.6) from the distal end of the anastomosis into the flap, which could finally jeopardize the vascularity of the foot. Finally, amputation was considered, primarily because of the patient′s poor compliance.
After considering all these options, a local transposition skin flap was determined to have the greatest chance of success with the least risk.
Procedure
The patient returned to the operating room for definitive management of the unstable fracture and soft-tissue defect. The bone was stabilized with a locking plate ( Fig 12.6-4a–b ). A silver-impregnated dressing was applied, with a negative-pressure wound-therapy device. A week later, the silver dressing was removed and the wound examined ( Fig 12.6-5 ). A randomly perfused fasciocutaneous flap was transposed to the defect ( Fig 12.6-6a–b ). The donor site was covered with a split-thickness skin graft ( Fig 12.6-7a–b ). Cultures were obtained during surgery and following debridement. Although the cultures were negative, the patient remained on intravenous antibiotics throughout the course of treatment. He was discharged on home intravenous antibiotics for 6 weeks.
Follow-up
The fasciocutaneous flap healed completely within 2 weeks ( Fig 12.6-8a–b ). After 10 months, the fracture had healed, there was no more discharge, and the patient was back to work ( Fig 12.6-9a–b ). He was able to walk without pain.
Points to remember
Complex problems may often be reduced to relatively simple choices by clearly defining the goals of reconstruction and the methods available to accomplish each goal.
It may not always be possible to carry out initial plans after all the facts are discovered or complications develop.
Be prepared to use a variety of reconstructive techniques when approaching any problem. The safest procedure must be offered in order to have the highest chance of healing. Unfortunately, these procedures are not always the simplest ones.
Give as much consideration to the personality of the patient as to that of the fracture when choosing a plan.
12.7 Skill level II: Case 2
Yves Harder
Case history
34-year-old white male patient
Laborer
Married
Smoker
No other medical problems
The patient was involved in a motorcycle crash with a car at high speed. There was no loss of consciousness. The patient sustained a Gustilo type II fracture of the junction mid-distal third of the tibia.
Following transport to a level I trauma center, the patient was surveyed by the trauma surgeon on call. Clinical and paraclinical examination revealed the above mentioned isolated trauma of the right leg ( Fig 12.7-1a–b ). Accordingly, debridement and irrigation of the wound was performed, followed by fracture stabilization using an intramedullary nail. Subsequently, the patient had to undergo an exchange of the intramedullary nail ( Fig 12.7-2a–b ) as the fracture had failed to heal. One year later, the fracture still had not healed ( Fig 12.7-3a–b ). The nail was removed and a plate fixation with screws was used to stabilize the bone after treatment of the nonunion. Thereafter, the postoperative course was complicated by wound dehiscence located over the fracture site with exposure of bone and plate. The wound measured ~ 4 × 3 cm.
Wound conditioning: The wound was treated with petroleum gauze based dressings changed every 3 days for 2 weeks as an outpatient. Negative-pressure wound therapy was used for another 2 weeks.
Present status
Soft-tissue defect at the anterior aspect of the right lower leg between the middle third and the distal third of ~ 4 cm in diameter.
Macroscopically the granulation tissue seems clean with visible plate and palpable bone ( Fig 12.7-4 ).
Following debridement and irrigation, the surgeon found healthy tissue but bone devoid of periosteum as well as an exposed plate with screws. The swabs taken superficially and deep within the wound after debridement and irrigation revealed no bacterial contamination. The surrounding tissues were soft and appeared to be healthy.
Decision making
Open questions
What are realistic treatment goals in a young, healthy, active smoker without comorbidities?
What coverage option offers the greatest chance of success?
Options and plan
The primary goal in this case is the functional restoration of the limb, which requires bone union. However, in order to achieve bone union, complete soft-tissue coverage must be obtained.
Because of the exposed plate and the presence of a nonunion, it is necessary to provide well-vascularized tissue to close this skin defect. Dressing changes alone are not likely to result in rapid closure of the wound and would ultimately result in an infection of the implant material and underlying fracture site. Negative-pressure wound therapy did not produce adequate granulation tissue to support a split-thickness skin graft (chapter 10.2) and, in the face of an exposed plate, its continued use is unlikely to be successful. In the long run, the resulting scar would remain unstable or the patient would possibly develop a fistula, indicating chronic infection such as osteitis.
Both the small size of the defect as well as the elasticity and quality of the adjacent skin allow for a local flap with tissues adjacent to the defect (chapter 10.4). Reliable muscle flaps from the calf, ie, gastrocnemius and soleus muscle have their dominant pedicles within the proximal area of the leg. Accordingly, they would not reach a defect at the transition zone of the middle and distal third of the lower leg. The distally based soleus/hemisoleus flap is not very reliable in a smoker. Furthermore, its donor site has been heavily traumatized and must therefore be associated with fibrotic changes. Although always an option, coverage by a free flap is not always required, especially if infrastructure is limited or surgical experience for microsurgical techniques unavailable. A fasciocutaneous flap such as the distally based sural flap would be possible from the point of view of the defect localization (chapter 10.5), yet this flap is rather unreliable, particularly in smokers. The free-style perforator flap (chapter 10.4) based on a perforating vessel adjacent to the defect is usually more reliable and, therefore, an option for such defects, as is the local transposition flap (chapter 10.4), in this case a bipedicled or bridge flap ( Fig 12.7-5a–b ).
Procedure
Four weeks after decortication and plate fixation of the nonunion, a debridement of the soft-tissue defect at the anterior tibial crest was performed, including the radical excision of granulation and scar tissue within the wound. Then, the surgical scar at the anterior tibial crest was incised. A parallel counter-incision was performed at the lateral aspect of the right lower leg to elevate a randomly perfused, bipedicled fasciocutaneous flap with a length of 15 cm and a width of 6 cm (width-to-length ratio of almost 1:1 due to both pedicles) (chapter 10.3). The flap was elevated in a subfascial plane. In order to increase its width, stab incisions were performed to “mesh” the flap′s fascia. Thereafter, the flap was easily transposed to the skin border at the anterior tibial crest in order to cover the soft-tissue defect. Tension-free skin closure was performed using intradermal and transcutaneous stitches ( Fig 12.7-6a ). At the lateral aspect of the leg, the resulting donor-site defect was covered with a meshed split-thickness skin graft harvested on the ipsilateral thigh ( Fig 12.7-6b ).
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