Complex combined post-traumatic leg injuries. Early versus delayed treatment
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Published:
Apr 20, 2015
Keywords:
Soft tissue defects, Bone loss, Leg, Flaps
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Abstract
BackroundThe objective of this study is to evaluate treatment of complex combined post-traumatic injuries of the distal and middle third of the leg, and compare the results obtained with early versus delayed treatment.MethodsFourteen patients treated between 2004 and 2012 were retrospectively evaluated. They were divided into two groups: those with soft tissues coverage performed during the first 10 days following trauma (group I, 6 cases) and those with coverage performed after 10 days (group II, 8 cases). Coverage was performed using six latissimus dorsi free flaps in group I, and with six muscle free flaps and two rotational fasciocutaneous flaps in group II.ResultsFollow-up averaged 39.5 months in group I and 50.6 months in group II. Hospital stay averaged 20.8 days for group I and 42.4 days for group II. Staged bony reconstruction was performed in two patients from group I and six patients from group II, all with distal tibia bone loss. In two patients, one in each group, the muscle free flap dyed, and an amputation was performed.ConclusionsIn lesions treated early coverage using free flaps should be favored; but in chronic ones, our practice has changed towards using rotatory fasciocutaneous flaps when possible.
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Allende, C., Fernandez Savoy, I., Allende, B. L., Ruchelli, L., & Gutierrez, N. (2015). Complex combined post-traumatic leg injuries. Early versus delayed treatment. Revista De La Asociación Argentina De Ortopedia Y Traumatología, 80(3), 196-206. https://doi.org/10.15417/393
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Clinical Research
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References
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Plast Reconstr Surg 2004;114(6):1457-66.
2. Bellidenty L, Chastel R, Pluvy I, Pauchot J, Tropet Y. Emergency free flap in reconstruction of the lower limb. Thirty-five years
of experience. Ann Chir Plast Esthet 2014;59(1):35-41.
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4. Melvin JS, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S. Open tibial shaft fractures: definitive management and
limb salvage. J Am Acad Orthop Surg 2010;18(2):108-17.
5. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78(3):285-92.
6. Cierni IIIG, Byrd HS, Jones RE. Primary versus delayed soft tissue coverage for severe open tibia fractures: a comparison of
results. Clin Orthop 1983;178:54-63.
7. Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome comparison between free muscle and free fasciocutaneous flaps for
reconstruction of distal third and ankle traumatic open tibia fractures. Plast Reconstr Surg 2006;117(7):2468-77.
8. Izadi D, Paget JT, Haj-Basheer M, Khan UM. Fasciocutaneous flaps of the subscapular artery axis to reconstruct large extremity
defects. J Plast Reconstr Aesthet Surg 2012;65(10):1357-62.
9. Titley OG, Spyrou GE, Fatah MF. Preventing seroma in the latissimus dorsi flap donor site. Br J Plast Surg 1997;50(2):106-8.
10. Button J, Scott J, Taghizadeh R, Weiler-Mithoff E, Hart AM. Shoulder function following autologous latissimus dorsi breast
reconstruction. A prospective three year observational study comparing quilting and non-quilting donor site techniques. J Plast
Reconstr Aesthet Surg 2010;63(9):1505-12.
11. Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am
2010;41(1):27-37.
12. Malikov S, Casanova D, Magnan PE, Branchereau A, Champsaur P. Anatomical bases of the bypass-flap: study of the
thoracodorsal axis. Surg Radiol Anat 2005;27(2):86-93.
13. Malikov S, Magnan PE, Casanova D, Lepantalo M, Valerio N, Ayari R, et al. Bypass flap reconstruction, a novel technique for
distal revascularization: outcome of first 10 clinical cases. Ann Vasc Surg 2009;23(6):745-52.
14. Hou Z, Irgit K, Strohecker KA, Matzko ME, Wingert NC, DeSantis JG, et al. Delayed flap reconstruction with vacuum-assisted
closure management of the open IIIB tibia fracture. J Trauma 2011;71(6):1705-8.
15. Gaston MS, Simpson AH. Inhibition of fracture healing. J Bone Joint Surg 2007;89(12):1553-60.
16. Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery
2008;28(8):632-4.
17. Allende C, Fattor E, Valdez D, Díaz P, Bagliardelli J. Reconstrucciones complejas postraumáticas de los tejidos blandos.
Principios de tratamientos y resultados. Rev Asoc Argent Ortop Traumatol 2009;74(2):122-33.
18. Steiert AE, Gohritz A, Schreiber TC, Krettek C, Vogt PM. Delayed flap coverage of open extremity fractures after previous
vacuum-assisted closure (VAC) therapy – worse or worth? J Plast Reconstr Aesthet Surg 2009;62(5):675-83.
19. Liu DS, Sofiadellis F, Ashton M, MacGill K, Webb A. Early soft tissue coverage and negative pressure wound therapy optimizes
patient outcomes in lower limb trauma. Injury 2012;43(6):772-8.
20. Stannard JP, Volgas DA, Stewart R, Mc Gwin G Jr, Alonso JE. Negative pressure wound therapy after severe open fractures: a
prospective randomized study. J Orthop Trauma 2009;23:552-7.
21. Bhattacharyya T, Mehta P, Smith M, Pomahac B. Routine use of wound vacuum–assisted closure does not allow coverage delay
for open tibia fractures. Plast Reconstr Surg 2008;121:1263-6.
22. Karşıdağ S, Akçal A, Turgut G, Uğurlu K, Baş L. Lower extremity soft tissue reconstruction with free flap based on subscapular
artery. Acta Orthop Traumatol Turc 2011;45(2):100-8.
23. Pinsolle V, Reau AF, Pelissier P, Martin D, Baudet J. Soft-tissue reconstruction of the distal lower leg and foot: are free flaps the
only choice? Review of 215 cases. J Plast Reconstr Aesthet Surg 2006;59(9):912-7.
24. Keeling JJ, Hsu JR, Shawen SB, Andersen RC. Strategies for managing massive defects of the foot in high-energy combat
injuries of the lower extremity. Foot Ankle Clin 2010;15:139–49.
25. Lerman OZ, Kovach SJ, Levin LS. The respective roles of plastic and orthopedic surgery in limb salvage. Plast Reconstr Surg
2011;127(1):215-27.
26. Nayagam S, Graham K, Pearse M, Nanchahal J. Reconstructive surgery in limbs: the case for the orthoplastic approach. Ann
Plast Surg 2011;66(1):6-8.
27. Hamnett NT, Mishra A, Nayagam S, Graham K, Duncan C. Preexpanded muscle-sparing latissimus dorsi free flap in complex
lower limb trauma: the orthoplastic approach. Plast Reconstr Surg 2010;126(4):211e-3e.
28. Court-Brown CM, Wheelwright EF, Christie J, McQueen MM. External fixation for type III open tibial fractures. J Bone Joint
Surg Br 1990;72(5):801–4.
29. Bellidenty L, Chastel R, Pluvy I, Pauchot J, Tropet Y. Emergency free flap in reconstruction of the lower limb. Thirty-five years
of experience. Ann Chir Plast Esthet 2014;59(1):35-41.
30. Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic
soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group. J Bone Joint Surg Am
2000;82(12):1681-91.
31. Olson SA. Open fractures of the tibial shaft. Current treatment. J Bone Joint Surg Am 1996;78(9):1428-37.
32. Parrett BM, Pribaz JJ, Matros E, Sampson C, Orgill DP. Risk analysis for the reverse sural fasciocutaneous flap in distal leg
reconstruction. Plast Reconstr Surg 2009;123:1499-1504.
33. Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304
consecutive cases. J Trauma 1989;29(8):1086-94.
34. Kojima T, Kohno T, Ito T. Muscle flap with simultaneous mesh skin graft for skin defects of the lower leg. J Trauma 1979;
19(10):724-9.
Plast Reconstr Surg 2004;114(6):1457-66.
2. Bellidenty L, Chastel R, Pluvy I, Pauchot J, Tropet Y. Emergency free flap in reconstruction of the lower limb. Thirty-five years
of experience. Ann Chir Plast Esthet 2014;59(1):35-41.
3. Ong YS, Levin LS. Lower limb salvage in trauma. Plast Reconstr Surg 2010;125(2):582-8.
4. Melvin JS, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S. Open tibial shaft fractures: definitive management and
limb salvage. J Am Acad Orthop Surg 2010;18(2):108-17.
5. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78(3):285-92.
6. Cierni IIIG, Byrd HS, Jones RE. Primary versus delayed soft tissue coverage for severe open tibia fractures: a comparison of
results. Clin Orthop 1983;178:54-63.
7. Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome comparison between free muscle and free fasciocutaneous flaps for
reconstruction of distal third and ankle traumatic open tibia fractures. Plast Reconstr Surg 2006;117(7):2468-77.
8. Izadi D, Paget JT, Haj-Basheer M, Khan UM. Fasciocutaneous flaps of the subscapular artery axis to reconstruct large extremity
defects. J Plast Reconstr Aesthet Surg 2012;65(10):1357-62.
9. Titley OG, Spyrou GE, Fatah MF. Preventing seroma in the latissimus dorsi flap donor site. Br J Plast Surg 1997;50(2):106-8.
10. Button J, Scott J, Taghizadeh R, Weiler-Mithoff E, Hart AM. Shoulder function following autologous latissimus dorsi breast
reconstruction. A prospective three year observational study comparing quilting and non-quilting donor site techniques. J Plast
Reconstr Aesthet Surg 2010;63(9):1505-12.
11. Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am
2010;41(1):27-37.
12. Malikov S, Casanova D, Magnan PE, Branchereau A, Champsaur P. Anatomical bases of the bypass-flap: study of the
thoracodorsal axis. Surg Radiol Anat 2005;27(2):86-93.
13. Malikov S, Magnan PE, Casanova D, Lepantalo M, Valerio N, Ayari R, et al. Bypass flap reconstruction, a novel technique for
distal revascularization: outcome of first 10 clinical cases. Ann Vasc Surg 2009;23(6):745-52.
14. Hou Z, Irgit K, Strohecker KA, Matzko ME, Wingert NC, DeSantis JG, et al. Delayed flap reconstruction with vacuum-assisted
closure management of the open IIIB tibia fracture. J Trauma 2011;71(6):1705-8.
15. Gaston MS, Simpson AH. Inhibition of fracture healing. J Bone Joint Surg 2007;89(12):1553-60.
16. Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery
2008;28(8):632-4.
17. Allende C, Fattor E, Valdez D, Díaz P, Bagliardelli J. Reconstrucciones complejas postraumáticas de los tejidos blandos.
Principios de tratamientos y resultados. Rev Asoc Argent Ortop Traumatol 2009;74(2):122-33.
18. Steiert AE, Gohritz A, Schreiber TC, Krettek C, Vogt PM. Delayed flap coverage of open extremity fractures after previous
vacuum-assisted closure (VAC) therapy – worse or worth? J Plast Reconstr Aesthet Surg 2009;62(5):675-83.
19. Liu DS, Sofiadellis F, Ashton M, MacGill K, Webb A. Early soft tissue coverage and negative pressure wound therapy optimizes
patient outcomes in lower limb trauma. Injury 2012;43(6):772-8.
20. Stannard JP, Volgas DA, Stewart R, Mc Gwin G Jr, Alonso JE. Negative pressure wound therapy after severe open fractures: a
prospective randomized study. J Orthop Trauma 2009;23:552-7.
21. Bhattacharyya T, Mehta P, Smith M, Pomahac B. Routine use of wound vacuum–assisted closure does not allow coverage delay
for open tibia fractures. Plast Reconstr Surg 2008;121:1263-6.
22. Karşıdağ S, Akçal A, Turgut G, Uğurlu K, Baş L. Lower extremity soft tissue reconstruction with free flap based on subscapular
artery. Acta Orthop Traumatol Turc 2011;45(2):100-8.
23. Pinsolle V, Reau AF, Pelissier P, Martin D, Baudet J. Soft-tissue reconstruction of the distal lower leg and foot: are free flaps the
only choice? Review of 215 cases. J Plast Reconstr Aesthet Surg 2006;59(9):912-7.
24. Keeling JJ, Hsu JR, Shawen SB, Andersen RC. Strategies for managing massive defects of the foot in high-energy combat
injuries of the lower extremity. Foot Ankle Clin 2010;15:139–49.
25. Lerman OZ, Kovach SJ, Levin LS. The respective roles of plastic and orthopedic surgery in limb salvage. Plast Reconstr Surg
2011;127(1):215-27.
26. Nayagam S, Graham K, Pearse M, Nanchahal J. Reconstructive surgery in limbs: the case for the orthoplastic approach. Ann
Plast Surg 2011;66(1):6-8.
27. Hamnett NT, Mishra A, Nayagam S, Graham K, Duncan C. Preexpanded muscle-sparing latissimus dorsi free flap in complex
lower limb trauma: the orthoplastic approach. Plast Reconstr Surg 2010;126(4):211e-3e.
28. Court-Brown CM, Wheelwright EF, Christie J, McQueen MM. External fixation for type III open tibial fractures. J Bone Joint
Surg Br 1990;72(5):801–4.
29. Bellidenty L, Chastel R, Pluvy I, Pauchot J, Tropet Y. Emergency free flap in reconstruction of the lower limb. Thirty-five years
of experience. Ann Chir Plast Esthet 2014;59(1):35-41.
30. Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic
soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group. J Bone Joint Surg Am
2000;82(12):1681-91.
31. Olson SA. Open fractures of the tibial shaft. Current treatment. J Bone Joint Surg Am 1996;78(9):1428-37.
32. Parrett BM, Pribaz JJ, Matros E, Sampson C, Orgill DP. Risk analysis for the reverse sural fasciocutaneous flap in distal leg
reconstruction. Plast Reconstr Surg 2009;123:1499-1504.
33. Khouri RK, Shaw WW. Reconstruction of the lower extremity with microvascular free flaps: a 10-year experience with 304
consecutive cases. J Trauma 1989;29(8):1086-94.
34. Kojima T, Kohno T, Ito T. Muscle flap with simultaneous mesh skin graft for skin defects of the lower leg. J Trauma 1979;
19(10):724-9.