Cases (V)
12.17 Skill level IV: Case 1
Authors Maxime Servaes, Yves Harder
Case history
25-year-old male patient
Flight engineer
Engaged
Sportsman
Smoker
No other medical problems
The patient crashed on his motorcycle into a security barrier at high speed. There was a prolonged extrication, taking nearly 1 hour to evacuate the patient.
Clinical findings in the trauma bay included:
Glasgow coma scale score 15/15
no other apparent lesions except for the injuries to both lower legs.
Clinical and radiological findings of the right lower leg:
considerable swelling with axial displacement of 45°
bluish discoloration of the calf
stocking-like dysesthesia of the foot
cold and pale foot, no palpable distal pulses
at the middle third of the leg an anteromedial wound measuring 12 × 6 cm with a large, proximally-based skin flap
displaced, comminuted tibial and fibular fracture (Gustilo type IIIC fracture) ( Fig 12.17-1a–b ).
Clinical and radiological findings of the left lower leg:
two small wounds at the anteromedial aspect of the lower leg
no neurovascular deficit
displaced, comminuted tibial and fibular fracture (Gustilo type II fracture) ( Fig 12.17-2a–b )
one wound on the thigh measuring 3 × 4 cm.
The right lower leg was realigned under analgesia and pulses recovered rapidly. The patient was taken to the operating room and both tibial fractures were stabilized using intramedullary nails with static locking. On the right side, anteromedial and anterolateral fasciotomies were performed to release all four muscle compartments (chapter 11.1). At that time, arterial bleeding was detected at the posteromedial aspect of the fracture site, matching a transection of the posterior tibial artery. The vascular surgeon on call performed a segmental repair of the artery using an autologous reversed saphenous vein graft. The skin flap covering the wound at the middle third of the lower leg was assessed intraoperatively to be viable and sutured back into place. All other wounds were left open because of the swelling, including the ones on the other leg. Postoperative angiography of the right leg confirmed patency of the three arteries including the repaired posterior tibial artery.
Wound conditioning: On the second day, the patient was taken back to the operating room for another irrigation and debridement of all the wounds of the right leg. Medially, the fasciotomy wound was partially closed with the help of staples and elastic vessel loops (chapter 10.1). A negative-pressure wound-therapy device was placed over the larger wound and changed every 3 days (chapter 9.3). One week later, another debridement and irrigation was performed including the excision of the now necrotic skin flap (chapter 7). On the twelfth day, the lateral fasciotomy wound could be closed.
Present status
Fifteen days after the injury the patient was first presented to the plastic surgeon for advice. The patient presented with an anteromedial soft-tissue defect of the right leg that was clean and covered with ample granulation tissue in the periphery except for the exposed, necrotic appearing tibia in the center of the defect ( Fig 12.17-3 ). X-rays of the right leg showed adequate stabilization ( Fig 12.17-4a–b ). Bacterial swabs revealed bacterial contamination of the granulation tissue with a mixed flora including Pseudomonas aeruginosa, Streptococcus mitis, α-hemolytic streptococci, and coagulase-negative staphylococci, which were sensitive to common antibiotics. According to the infectiologist, systemic treatment with ciprofloxacin and ceftazidime was initiated to protect the bone.
Decision making
Open questions
What type of coverage provides the lowest risk of complications (eg, nonunion, infection)?
How to get the timing of coverage right?
Options and plan
Delayed primary closure in this case is not possible because of the loss of tissue. Healing by secondary intention using various types of dressings including negative-pressure wound therapy is not recommended because it is very unlikely that granulation tissue will form over exposed bone, ie, bone without periosteum, while there is an increased risk of infection resulting in osteomyelitis, which would eventually compromise bone healing.
A considerable soft-tissue defect in a young patient with exposed, bare bone needs to be repaired with a vascularized flap. At this point, three issues must be discussed:
origin of the flap
composition of the tissue used for repair
timing of coverage.
There was considerable energy involved in the initial injury as evidenced by the development of vascular injury and compartment syndrome. It is therefore reasonable to assume that the surrounding tissues such as local muscle and subcutaneous tissue were also exposed to such significant energy. In view of this fact, an appropriate coverage procedure has to be selected.
Local rotation flaps such as a soleus or sural flap are associated with a high rate of complications in the case of severe trauma to the lower extremities. A free muscle flap is not necessary because there is neither a bone defect to be plugged nor gross infection to be treated. Furthermore, the muscle flap would need to be covered by a skin paddle (too bulky a coverage) or a split-thickness skin graft (imperfect match of color and texture) (chapter 10.2). Since the soft-tissue defect is confined to the skin, a fasciocutaneous free flap tailored to the defect, such as a free lateral arm flap, would be ideal (chapter 10.6). The repair to the motto “like with like” results in a good match of color and texture. A free flap would utilize vessels that were not in the zone of injury (chapter 10.3.3), which would be advantageous in this patient.
Flaps in general, but free flaps in particular, are associated with an increased failure rate when applied between 3–5 days and 4–6 weeks following trauma, which equals an increased inflammatory state within the zone of inquiry (chapter 10.3). Accordingly, some surgeons advocate immediate flap coverage or delayed coverage beyond the 4–6 week period.
Procedure
After 5 weeks, the soft-tissue coverage was planned, using a fasciocutaneous free flap from the lateral aspect of the nondominant left arm. A new, preoperative arteriography confirmed the distal patency of the anterior tibial and fibular arteries as well as the successful repair of the posterior tibial artery and served as a roadmap for the anastomosis.
First, the arm flap was planned using a handheld Doppler device. A tailored skin paddle of 15 × 6 cm to match the defect was outlined. It was centered on perforating vessels of the collateral posterior radial artery ( Fig 12.17-5 ). Second, the lateral arm flap was dissected in a subfascial plane. Simultaneously another team isolated the anterior tibial artery and its concomitant veins. Third, the flap was anastomosed end-to-end to the recipient vessels with standard microsurgical techniques. Finally, the flap was trimmed and sutured into the defect except for a small area close to the pedicle in order to avoid any tension and inevitable congestion of the flap. The donor site was closed primarily. One week later, the remaining wound was closed under local anesthesia.
Follow-up
The postoperative course was uneventful, in particular in regard to the integration of the flap as well as the healing of the donor site. Gradual verticalization was initiated, beginning on the fifth postoperative day. After uneventful wound healing including the secondary closure of the distal surgical wound, the aftercare consisted of an intensive rehabilitation program. The patient was motivated and compliant. A significant edema on the right lower leg in connection with the flap necessitated regular lymphatic drainage and the wearing of surgical stocking.
Four weeks after flap surgery, ie, 10 weeks after trauma, partial consolidation of the tibial fractures was observed on x-rays, allowing for partial weight bearing (10 kg). Complete bone union of the right lower leg was observed 3 months after the accident ( Fig-12.17-6a–b ) and the patient started with full weight bearing. The flap showed good integration within the adjacent tissues and a perfect match of thickness, texture, and color ( Fig-12.17-7a–b ). The donor site did not reveal any functional sequelae. Physical therapy was initiated to begin muscle strengthening in order to compensate for atrophy.
Points to remember
This case demonstrates the importance of early multidisciplinary planning. Although the end result of a healed fracture with no infection was obtained, the course of healing was delayed and undue risks were taken because there was no early multidisciplinary plan.
12.18 Skill level IV: Case 2
Stefan Langer
Case history
69-year-old white male patient
Pensioner
Married
Nonsmoker
Arterial hypertension
The patient was riding a bicycle at reduced speed when he was hit by a car. He was transported to the hospital with a splint in place to stabilize the leg.
On presentation to the trauma bay of a tertiary hospital the patient was examined by the surgeon on duty. The patient was conscious and presented with the following isolated injury of his right lower leg:
axial deformity
bruised but intact skin envelope on the distal half of the leg
palpable pulses on the dorsum of the foot and posteriorly to the medial malleolus
normal sensation distally
closed distal tibial and fibular fracture (42-B3.3).
After 2 days of bed rest and elevation of the leg, open reduction and internal fixation of the tibial fracture was performed using a plate and screws. The patient was administered a perioperative antibiotic (second-generation cephalosporin) that was continued for 7 days due to the extensive initial swelling. The patient further received subcutaneous heparin as thromboprophylaxis.
The initial postoperative course was uneventful. From approximately day 3 on, the patient developed a circumscribed discoloration of the skin on the right lower leg, which resulted in skin necrosis. Two weeks after initial surgery and complete demarcation of the necrosis, the patient was referred to a level I hospital with a specialized trauma unit.
Initial clinical investigation showed a well-demarcated, full-thickness skin necrosis of 4 × 6 cm that was located on the medial side of the surgical incision ( Fig 12.18-1 ).
Wound conditioning: Radical excision of all necrotic skin was essential. At the same time, exposure of the hardware was inevitable.
Present status
After irrigation and debridement, the soft-tissue defect ended up being much larger in comparison to the circumscribed skin necrosis, ie, ~ 4 × 8 cm. Implant material was clearly exposed but clean, and there was no evidence of loosening, which was confirmed by an x-ray ( Fig 12.18-2a–b ). According to the consulting trauma surgeon, replacement was not necessary but additional bone grafts were recommended to increase the likelihood of bone healing.
Decision making
Open questions
What are realistic goals of treatment?
What are the definitive treatment options?
How should the defect be covered?
Options and plan
This fracture should heal within 6 months without significant late sequelae. The ankle may require a long time to recover its entire range of motion.
The persisting soft-tissue defect still revealed exposed bone and implant. Coverage using a negative-pressure wound-therapy device (chapter 9.3) in order to create granulation tissue was unlikely to succeed since bone and implant do not provide adequate vascularity to support this. Therefore, the soft-tissue defect needed to be covered with vascularized tissue.
Vascularized tissue may be obtained from many sources. Local flaps might provide adequate tissue (chapter 10.4). The defect was too distal for a muscle flap (gastrocnemius or soleus flap) to provide coverage (chapter 10.5). A fasciocutaneous flap such as a sural flap could also have been an option. Free flaps could have been used as well, either from the lateral arm, radial forearm or lateral thigh. All of these techniques, however, require microsurgical skills.
The surgeon felt that in this case, due to local trauma to the soft tissues, a random-pattern flap or fasciocutaneous flap would potentially involve a higher risk of failure, so a free flap was chosen, specifically a lateral thigh flap. The decision in favor of the anterolateral thigh flap was based on the surgeon′s experience as well as the patient′s constitution, pedicle length, congruity of donor and recipient vessels, matching of flap thickness, color, texture, and elasticity with the surrounding tissues and donor-site morbidity (primary closure versus skin grafting). Since there was no bone defect, ie, osseous cavity, a bulky muscle or musculocutaneous flap was not necessary. More complicated flaps such as a free muscle were not indicated because the bulk of the muscle flap might preclude ankle motion or the wearing of regular footwear.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
