Radical Debridement, Free Flap Coverage, and Immediate Reconstruction of the Upper Extremity (original) (raw)
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“Close-open-close free-flap technique” for the cover of severely injured limbs
Injury, 2019
The treatment of severely injured extremities still presents a very difficult task for trauma orthopaedic surgeons. Despite improvements in technology and surgical/microsurgical techniques, sometimes a limb must be amputated, otherwise severe and potentially fatal complications may develop. There is a wellestablished belief that severe open fractures should be left open. However, Godina proved wound coverage in the first 72 h (after an injury) to be safe and to bring good final results. So early wound cover (no later than one week after an injury) with well vascularized free flaps became the gold standard. Yet for many patients (some of whom have serious health problems), operative treatment needs to be postponed when they arrive to specialized microsurgical departments for microsurgical reconstruction much later than one week after incurring an injury. As the definite wound cover period from one week to 3 months seems to be hazardous, especially due to the potential of infection, we developed a safe, original flap technique that prevents infection and covers important structures such as exposed bones, tendons, nerves and vessels. We named this technique the "close-open-close free flap technique". It enables difficult wound cover in any biological phase of the wound, by combining complete flap cover first, with the removal of stitches from one side of the flap after 6-12 h. This technique works very well for borderline cases as well; where even after a complete debridement, dead tissue still remains in the wound-making wound cover very dangerous. Closing completely severe open fractures with free (or pedicled) flaps and removing the stitches on one side after 6-12 h, enables orthopaedic surgeons to safely cover any kind of wound in any biological phase of the wound. Additional debridements, lavages and reconstructions can easily be performed under the flap and after the danger of a serious infection has disappeared, definitive wound closure can be carried out.
Treatment of open wounds of the leg by using local flaps
Revista Brasileira de Cirurgia Plástica (RBCP) – Brazilian Journal of Plastic Sugery, 2015
Introduction: Until the 70s, repairing loss of tissue in the leg was almost always difficult, or even impossible. Currently, only the most experienced surgeons are able to repair open wounds of the leg. Nevertheless, several reliable and simple techniques are currently available. This work aimed to evaluate repair techniques for leg wounds by using local tissues. Method: The authors performed a retrospective study of cases of leg reconstruction using local flaps. Dermoadipose, fasciocutaneous, fasciosubcutaneous, and muscle flaps were used. Results: Seventy patients who had open areas in the leg due to tibial fractures, osteomyelitis, ischemic tissue loss, chronic ulcer, or skin tumor underwent surgery. Results were evaluated according to etiology, type of surgical procedure, and complications. Conclusions: The option of treating open wounds of the lower limbs by using local flaps is very valid. Selection of the flap type depended on local conditions in the leg, and the anatomical region affected. In the upper third of the leg, we used fasciocutaneous flaps, based on the vascular network of the knee, or gastrocnemius flaps. In the middle third of the leg, we used the soleus muscle as the primary flap, and fasciosubcutaneous flaps in the calf region. In the lower third of the leg, a fasciosubcutaneous flap of the calf was primarily used.
Distant pedicle flaps for soft tissue coverage of severely burned hands: an old idea revisited
Burns, 2001
Burns to the hand that are complicated by exposure of bone, joint or tendon cannot be closed with conventional skin grafts and require flap procedures to prevent further damage. Local or regional flaps may be unavailable if electrical or blast trauma produces a large zone of injury, or when forearm burn injury extends beyond fascia. Free tissue transfer may not be tolerated by critically ill burn patients. In these circumstances, distant pedicle flaps are one option for safe and effective soft tissue coverage. Over a 5-year period, we have performed six distal pedicle flaps for coverage of exposed hand structures when local or free flaps were contraindicated or unavailable. The patients required an average of 4.5 surgical procedures to complete hand reconstruction and soft tissue coverage. Soft tissue coverage was completely successful in five patients and partially successful in one patient. Single stage local or free flaps remain the treatment of choice when burned hands cannot be covered with skin grafts. When these flap options are not available, distant pedicle flaps provide a safe alternative.
Journal of Orthopaedics and Traumatology, 2013
Lower limb reconstruction with pedicled or free flaps can be commonly compromised by venous insufficiency. This complication often leads to partial/ complete flap necrosis and increases the risk of superinfection. Negative-pressure wound therapy (NPWT) is known to increase local blood flow, decrease edema, promote tissue granulation, and reduce the likelihood of soft tissue infection. This study aims to evaluate the effectiveness of NPWT in the treatment of congested pedicled and free flaps of the lower limb after reconstructions in lower limb traumas. A retrospective analysis was performed on four congested (pedicled and free) flaps on the lower limbs. NPWT was applied in all cases after partial flap debridement. NPWT was able to improve and resolve tissue edema and venous insufficiency, avoid further flap necrosis, and promote granulation. On NPWT removal, a split-thickness skin graft was applied on the wound, achieving complete and uneventful healing. NPWT is a useful instrument in managing flaps affected by venous insufficiency in lower limb reconstruction, although larger studies are necessary to better define the effectiveness and indications of NPWT in this setting.
The use of flaps in the treatment of fingertip injuries
World Journal of Surgery, 1991
Fingertip injuries constitute a large portion of the traumatic injuries sustained to the hand and are frequently associated with significant disability for the patient. While many methods are available for the treatment of such injuries, quite often only certain procedures are appropriate for a particular digit in any given patient. The use of flaps in such instances provides an important tool for coverage of the exposed fingertip bone when more simple measures are inadequate. Herein follows a discussion of the indications and potential pitfalls for a variety of flaps which may be employed in the treatment of fingertip injuries. Les lésions de la pulpe constituent une proportion importante des lésions traumatiques de la main, et sont souvent responsables d'une incapacité de travail non négligeable. Alors qu'il existe de nombreuse méthodes pour traiter ces lésions, très souvent, un nombre plus restreint de procédés de reconstruction sied parfaitement à tel ou tel doigt chez un patient donné. L'utilisation d'un lambeau dans cette situation constitue un outil capital pour couvrir la pulpe ainsi exposée alors des techniques beaucoup plus simples ne sont pas suffisantes. On présente alors les indications et les écueils potentiels d'une large gamme de lambeaux qui trouvent leurs indications dans le traitement des lésions de la pulpe digitale. Las amputationes distales de los dedos representan una proporción considerable de las lesiones taumáticas de la mano y con frecuencia aparecen asociadas con incapacidad importante para el paciente. Aunque existen muchos métodos disponibles para el tratamiento de tales lesiones, es frecuente que sólo algunos procedimientos resulten apropiados para el manejo de un dedo en particular en un determinado paciente. El uso de colgajos en tales circunstancias constituye un método importante de cobertura del hueso expuesto del dedo, en aquellos casos en que otros métodos más sencillos resulten inadecuados. Se incluye una discusión sobre las indicaciones y potenciales fallas de una variedad de colgajos que pueden ser utilizados en el tratamiento de las lesiones de las puntas de los dedos.
Superficial Circumflex Iliac Artery Free Flap for Coverage of Hand Injuries
Cureus
Open de-gloving hand injuries with exposed tendons and bones require coverage by a flap. Conventionally used groin or abdominal flaps are cumbersome to patients due to extensive dressing and prolonged passive positioning of the hand until pedicle division. Superficial circumflex iliac artery (SCIA) flap is evolved from a traditional groin flap, and because of its thinness, pliability, and concealed donor site, it is an ideal option for single-stage reconstruction of traumatic hand defects avoiding discomforting passive hand position, joint stiffness, and unexpected flap avulsion which were associated with traditional groin flap. All patients with exposed bones or tendons due to traumatic hand injuries who opted for free flap coverage during the year 2018 to 2020 were enrolled in our study. After initial debridement, the wound was covered with a free SCIA flap. Duration of hospital stay, days out of work, the number of dressings required, postoperative complications, and any secondary procedures for flap readjustment were noted till six months postoperatively. A total of eight patients were included in the study. The mechanism of injury was road traffic accidents in a single patient and occupational injury in eight patients. The average duration of hospital stay was six days after reconstructive surgery. The average number of dressings a patient had was 18, and only two patients required flap thinning. Only one patient had a postoperative infection which was managed with dressings and antibiotics. One patient had peripheral flap necrosis. We had zero flap reexploration. Therefore, we conclude that hand defects coverage with SCIA flap leads to a smaller number of working days lost and rarely requires secondary procedures.
Comparison of perioperative complications of pedicled island flap in reconstruction of extremities
Journal of Surgical Research, 2017
The aim of this study was to analyze the differences in perioperative complications for pedicled island flaps in the reconstruction of extremities and to identify the factors contributing to pedicled island flap necrosis. Furthermore, the flap indications based on these outcomes are summarized. Methods: Based on the inclusion criteria, 228 skin flaps were included in this study. Univariate and multivariate analyses were used to identify the risk factors for pedicled island flap necrosis. Differences in perioperative complications between upper and lower extremities were analyzed using the chi-square test or Fisher's exact test. Results: The average age of the patients was 38 years. The overall complication rate was 21.93%, including partial flap necrosis (10.09%) and total flap necrosis (5.70%). The overall complication rate and flap necrosis rate in upper extremity reconstruction were significantly lower than the rates in lower extremity reconstruction. Flap area and postoperative wound infection were statistically significant risk factors for pedicled island flap necrosis in extremity reconstruction. Preoperative contamination of the wound bed was a statistically significant risk factor for postoperative wound infection. Conclusions: The flap area and postoperative wound infection were both independent risk factors for pedicled island flap necrosis in extremity reconstruction. The causes contributing to the differences in perioperative complications between upper and lower extremities reconstruction included preoperative contamination of the wound bed, postoperative wound infection, and the flap area but were also related to anatomical factors of the skin flap. Pedicled island flaps are more suitable for small-and medium-sized soft tissue defects.