RSS-Feed abonnieren
DOI: 10.1055/a-1017-3013
Microsurgery and external fixation in orthoplastic reconstruction of tibial injuries
Mikrochirurgie und externe Fixation bei der orthoplastischen Rekonstruktion von TibiaverletzungenPublikationsverlauf
01. Februar 2019
13. August 2019
Publikationsdatum:
07. November 2019 (online)
![](https://www.thieme-connect.de/media/hamipla/201906/lookinside/thumbnails/10-1055-a-1017-3013-1.jpg)
Abstract
Background “Orthoplastics” is a relatively new approach to lower limb reconstruction, where an integration of both plastic and orthopedic expertise is required, together with the availability of well-equipped facilities. Acute shortening and long-term frames for lengthening are generally considered alternatives to length preservation and soft tissue microsurgical reconstruction, but an integration of external fixation and reconstructive microsurgery is gaining an increasing role with refinements of joint approaches.
Material and methods Data on sixteen patients who underwent microsurgical lower limb reconstruction and external fixation with an orthoplastic approach, following acute or chronic tibial injury, were retrospectively reviewed. All patients presented a post traumatic soft tissue defect associated with a Gustilo III tibial fracture or a tibial septic pseudarthrosis. Data on type and timing of bone and soft tissue reconstruction, outcomes, complications and need for re-operation were extrapolated and compared to an historic group of patients treated with an orthopedic-based approach.
Results In the orthoplastic group, soft tissues were reconstructed with an ALT flap in most cases; a muscle-sparing VL or ALT-VL chimeric flap was necessary in cases with a very extensive defect. In the orthopedic group, soft tissues were left to heal by second intention or patients were lately referred to plastic surgeons. Statistical comparison between the two groups has showed significant differences on the following data: time for soft tissue healing, time to bone union, number of reinterventions, post-operative deep infection rate, time to return to work.
Conclusion The orthoplastic approach to complex leg defects yields shorter treatment time and better functional results compared to the orthopedic-based approach. External fixation and microsurgical reconstruction are not necessarily alternative procedures but can integrate in an orthoplastic path to address at best both soft tissue and bone reconstruction.
Zusammenfassung
Hintergrund Die „Orthoplastie“ ist ein relativ neuer Ansatz zur Rekonstruktion der unteren Extremitäten, der eine Integration von plastisch-chirurgischer und orthopädischer Fachkompetenz sowie die Verfügbarkeit gut ausgestatteter Einrichtungen erfordert. Die akute Verkürzung mit längerfristig angelegtem Rahmen zur Verlängerung gelten generell als Alternativen zum Längenerhalt mit mikrochirurgischer Weichteilrekonstruktion, doch gewinnt die integrierte Behandlung mit Fixateur externe und rekonstruktiver Mikrochirurgie zunehmend an Bedeutung und die gemeinsamen Ansätze werden weiter verfeinert.
Material und Methoden Es erfolgte eine retrospektive Analyse der Daten von sechzehn Patienten, die sich nach akuter oder chronischer Tibiaverletzung einem orthoplastischen Verfahren mit mikrochirurgischer Rekonstruktion der unteren Extremität und Fixateur externe unterzogen. Bei allen Patienten fand sich ein posttraumatischer Weichteildefekt in Verbindung mit einer Tibiafraktur vom Grad III nach Gustilo oder einer septischen Pseudarthrose der Tibia. Die Daten zu Art und Zeitpunkt der Knochen- und Weichteilrekonstruktion, Ergebnissen, Komplikationen und Notwendigkeit einer Reoperation wurden extrapoliert und mit denen einer historischen Patientengruppe verglichen, die orthopädisch behandelt worden war.
Ergebnisse In der orthoplastischen Gruppe wurden die Weichteile in den meisten Fällen mit einem anterolateralen Oberschenkellappen (ALT-Flap) rekonstruiert. Bei Patienten mit großflächigem Defekt war eine muskelschonende Vastus-lateralis-Lappenplastik (VL) oder eine chimäre ALT-VL-Lappenplastik erforderlich. In der orthopädischen Gruppe wurden die Weichteile einer Sekundärheilung überlassen oder die Patienten wurden später an einen plastischen Chirurgen überwiesen. Ein statistischer Vergleich zwischen den beiden Gruppen ergab signifikante Unterschiede hinsichtlich folgender Daten: Zeit bis zur Heilung der Weichteile, Zeit bis zur knöchernen Durchbauung, Anzahl der Reinterventionen, Rate tiefer postoperativer Infektionen und Zeit bis zur Wiederaufnahme der Berufstätigkeit.
Schlussfolgerung Der orthoplastische Ansatz bei komplexen Beindefekten bietet im Vergleich zu orthopädischen Verfahren kürzere Behandlungszeiten und liefert bessere funktionelle Ergebnisse. Die Behandlung mit Fixateur externe und die mikrochirurgische Rekonstruktion müssen sich nicht gegenseitig ausschließen, sondern können in einem orthoplastischen Behandlungspfad miteinander kombiniert werden, um eine bestmögliche Rekonstruktion sowohl der Weichteile als auch des Knochens zu erzielen.
-
References
- 1 Gopal S. et al. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 2000; 82 (07) 959-966
- 2 Rohde C. et al. Gustilo grade IIIB tibial fractures requiring microvascular free flaps: External fixation versus intramedullary rod fixation. Ann Plast Surg 2007; 59 (01) 14-17
- 3 Mundy LR. et al. Acute Treatment Patterns for Lower Extremity Trauma in the United States: Flaps versus Amputation. J Reconstr Microsurg 2017; 33 (08) 563-570
- 4 Xiong L. et al. Free flaps for reconstruction of soft tissue defects in lower extremity: A meta-analysis on microsurgical outcome and safety. Microsurgery 2016; 36 (06) 511-524
- 5 Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986; 78 (03) 285-292
- 6 Sommar P. et al. Effects of a formalized collaboration between plastic and orthopedic surgeons in severe extremity trauma patients; a retrospective study. J Trauma Manag Outcomes 2015; 9: 3
- 7 Boriani F. et al. Orthoplastic surgical collaboration is required to optimise the treatment of severe limb injuries: A multi-centre, prospective cohort study. J Plast Reconstr Aesthetic Surg 2017; 70: 715-722
- 8 Lerman OZ, Kovach SJ, Levin LS. The respective roles of plastic and orthopedic surgery in limb salvage. Plast Reconstr Surg 2011; 127: 215-227
- 9 Cho EH. et al. Muscle versus Fasciocutaneous Free Flaps in Lower Extremity Traumatic Reconstruction: A Multicenter Outcomes Analysis. Plast Reconstr Surg 2018; 141 (01) 191-199
- 10 J. Jordan D, Malahias M, Khan W. et al. The Ortho-Plastic Approach to Soft Tissue Management in Trauma. Open Orthop. J. 8: 399-408 2014;
- 11 Heitmann C, Levin LS. The Orthoplastic Approach for Management of the Severely Traumatized Foot and Ankle. 2003; 54 (02) 379-390
- 12 BOA/BAPRAS Standards for the management of open fractures of the lower limb. Im Internet: http://www.bapras.org.uk/professionals/clinical-guidance/open-fractures-of-the-lower-limb last date of access: october 7th, 2019
- 13 Rodriguez ED. et al. Functional outcomes of posttraumatic lower limb salvage: A pilot study of anterolateral thigh perforator flaps versus muscle flaps. J Trauma – Inj Infect Crit Care 2009; 66: 1311-1314
- 14 Song Y, Qi X, Shen J. Free Flap Combined with External Fixator in the Treatment of Open Fractures of the Calf. Cell Biochem Biophys 2014; 70: 549-552
- 15 Ciudad P. et al. A simple and effective method to optimize limb position after complex lower limb free flap reconstruction with concurrent external fixation. Microsurgery 2018; 2-3
- 16 Bar-Meir E. et al. Combined Iliazarov and free flap for severe recurrent flexion-contracture release. J Burn Care Res 2006; 27: 529-534
- 17 Salih S, Mills E, McGregor-Riley J. et al. Transverse debridement and acute shortening followed by distraction histogenesis in the treatment of open tibial fractures with bone and soft tissue loss. Strateg Trauma Limb Reconstr 2018; 13 (03) 129-135
- 18 Meng YC, Zhou XH. External fixation versus open reduction and internal fixation for tibial pilon fractures: A meta-analysis based on observational studies. Chinese J Traumatol – English Ed 2016; 19: 278-282
- 19 Rayan A. et al. Open reduction internal fixation versus external fixation with limited internal fixation for displaced comminuted closed pilon fractures: A randomised prospective study. J Orthop Trauma Rehabil 2018; 24: 84-89
- 20 Lister G, Scheker L. Emergency free flaps to the upper extremity. J Hand Surg Am 1988; 13 (01) 22-28
- 21 Herter F, Ninkovic M, Ninkovic M. Rational flap selection and timing for coverage of complex upper extremity trauma. Journal of Plastic. Reconstructive and Aesthetic Surgery 2007; 60 (07) 760-769
- 22 Ninković M, Schoeller T, Benedetto KP. et al. Emergency free flap cover in complex injuries of the lower extremities. Scand J Plast Reconstr Surg Hand Surg 1996; 30 (01) 37-47
- 23 Georgescu AV, Ivan O. Emergency free flaps. Microsurgery 2003; 23 (03) 206-216
- 24 Toia F. et al. Segmental anatomy of the vastus lateralis: Guidelines for muscle-sparing flap harvest. Plast Reconstr Surg 2015; 135 (01) 185e-198e
- 25 Agostini T, Lazzeri D, Spinelli G. Anterolateral thigh flap: Systematic literature review of specific donor-site complications and their management. J Cranio-Maxillofacial Surg 2013; 41: 15-21
- 26 Lakhiani C, Lee MR, Saint-Cyr M. Vascular anatomy of the anterolateral thigh flap: A systematic review. Plast Reconstr Surg 2012; 130: 1254-1268
- 27 Marchaland JP, Ollat D, Mathieu L. et al. How to cover soft-tissue defects after injuries to the leg in precarious conditions. Eur J Trauma Emerg Surg 2009; 35: 3-9
- 28 Zheng X. et al. Reconstruction of complex soft-tissue defects in the extremities with chimeric anterolateral thigh perforator flap. Int J Surg 2016; 26: 25-31
- 29 Posch NAS, Mureau MAM, Flood SJ. et al. The combined free partial vastus lateralis with anterolateral thigh perforator flap reconstruction of extensive composite defects. Br J Plast Surg 2005; 58: 1095-1103
- 30 Cavadas PC, Teran-Saavedra PP. Combined latissimus dorsi thoracodorsal artery perforator free flap: The ‘razor flap’. J Reconstr Microsurg 2002; 18 (01) 29-31
- 31 Lee KT, Mun GH. A systematic review of functional donor-site morbidity after latissimus dorsi muscle transfer. Plast Reconstr Surg 2014; 134: 303-314
- 32 D’arpa S. et al. Variability and reliability of the vastus lateralis muscle anatomy. Acta Chir Belg 2016; 116 (04) 203-212
- 33 Philandrianos C. et al. Soft Tissue Coverage in Distal Lower Extremity Open Fractures: Comparison of Free Anterolateral Thigh and Free Latissimus Dorsi Flaps. J Reconstr Microsurg 2018; 34 (02) 121-129
- 34 Tamimy MS. et al. Has the anterolateral thigh flap replaced the latissimus dorsi flap as the workhorse for lower limb reconstructions?. J Pak Med Assoc 2010; 60 (02) 76-81
- 35 Hong JP, Choi DH, Suh H. A new plane of elevation: the superficial fascial plane for perforator flap elevation. J Reconstr Microsurg 2014; 30: 491-496
- 36 Diamond S, Seth AK, Chattha AS. et al. Outcomes of Subfascial, Suprafascial, and Super-Thin Anterolateral Thigh Flaps: Tailoring Thickness without Added Morbidity. J Reconstr Microsurgn 2018; 34: 176-184
- 37 Fox P, Endress R, Sen S. et al. Fascia-only anterolateral thigh flap for extremity reconstruction. Ann Plast Surg 2014; 72: 9-13
- 38 Xie S. et al. Reconstruction of foot and ankle defects with a superthin innervated anterolateral thigh perforator flap. J Plast Surg Hand Surg 2016; 50: 367-374
- 39 Maruccia M. et al. Suprafascial versus traditional harvesting technique for free antero lateral thigh flap: A case-control study to assess the best functional and aesthetic result in extremity reconstruction. Microsurgery 2017; 37: 851-857
- 40 Seth AK, Iorio ML. Super-Thin and Suprafascial Anterolateral Thigh Perforator Flaps for Extremity Reconstruction. J Reconstr Microsurg 2017; 33: 466-473
- 41 Bhadkamkar MA. et al. The ultra-thin, fascia-only anterolateral thigh flap. J Reconstr Microsurg 2014; 30: 599-605