Umraz Khan

Classification of soft-tissue degloving in limb trauma

Compressive, tortional and abrasive deforming forces are translated to the limbs during high energy trauma. The long bones may be fractured in many patterns with a varying extent of fragmentation and comminution but the soft-tissues appear to absorb the forces in a predictable way. We retrospectively reviewed a series of 79 complex limb injuries treated in a dedicated centre where the clinical notes and photo-documentation were meticulously kept and where the outcomes were known. The soft-tissue injuries were then described and revealed four patterns of injury: abrasion/avulsion, non-circumferential degloving, circumferential single plane and circumferential multi-plane degloving. These patterns occurred either in isolation or occasionally in combination. Resuturing of degloved skin was only successful in non-circumferential (pattern 2) cases. Radical excision of devitalised tissue followed by soft-tissue reconstruction in a single procedure was successful in all patterns apart from pattern 4 (circumferential multi-plane degloving). In pattern 4 we recommend serial wound excision prior to reconstruction.

Serum complement-reactive protein (CRP) trends following local and free-tissue reconstructions for traumatic injuries or chronic wounds of the lower limb

BACKGROUND Soft-tissue reconstructions of the lower limb for open fractures, chronic infections and nonunion carry a high risk of infection, nonunion, osteomyelitis and amputation. Inflammatory markers can be difficult to interpret in the context of recent surgery and trauma and little is known of their behaviour. AIM To profile the behaviour of complement-reactive protein (CRP) following soft-tissue reconstructions for the lower limb performed for acute injuries(open fractures) and chronic wounds(nonunion and osteomyelitis). PATIENTS AND METHODS Patients who had soft-tissue reconstructions following open fractures of the lower limbs, chronic infection, osteomyelitis and nonunion were identified and their notes and postoperative CRP levels reviewed. RESULTS 52 patients were identified. 41 reached peak CRP < or =4 days of surgery. A peak CRP >4 days indicated infection or further surgery (p<0.01). Acute and chronic groups showed a peak in mean CRP at day 2. Chronic wound patients showed significantly elevated CRP levels compared to acute wound patients at day 7 (p=0.05) and 8 (p<0.001). Muscle and fasciocutaneous flaps showed similar CRP profiles. Patients with nonunion or deep infections showed persistently elevated CRP levels. CONCLUSIONS CRP peaks on day 2 following soft-tissue coverage and falls thereafter. Peaks after day 4 indicate infective complications or further surgery. Patients with chronic wounds show a slower decrease in their CRP. Persistently elevated CRP following surgery is associated with infection and nonunion.

Immediate free tissue transfer for coverage of Achilles tendon injury or reconstruction

BACKGROUND The restoration of function and contour to the Achilles region is a complex problem. This is reflected in the variety of reconstructive options described in the literature. The aim however remains to normalise the range of movement at the ankle joint and restore the power of plantar flexion. Few techniques have demonstrated this. METHODS Six patients underwent soft tissue reconstruction over the Achilles tendon with a free scapular flap. Two ruptured Achilles tendons were reconstructed with FHL transfers. RESULTS All six flaps remained viable and achieved stable coverage over the Achilles tendon. Five of the six required thinning for use of normal foot wear. Those that had FHL transfer normalised their range of movement. CONCLUSIONS It has previously been shown that FHL transfer provides optimum results in terms of functional outcome while here the scapular flap has fulfilled the requirement to restore the contour of this region.

Donor site morbidity of the medial plantar artery flap studied with gait and pressure analysis

BACKGROUND The medial plantar artery flap (MPA) allows transfer of both glabrous (smooth and free from hair) and sensate tissue. It has been suggested that the non-weight bearing instep area of the foot provides tissue for transfer with minimal donor morbidity. However the abductor hallucis muscle and plantar fascia are dissected during flap harvest which may affect foot mechanics. METHODS Patients were included who had undergone MPA flap harvest and were walking unaided. The majority of the patients studied had problems with soft tissues of their heels rather than trauma as a starting point. Laboratory normals and the patients contralateral limb were used as controls. Gait and pressure analysis were performed using 3D gait analysis and high resolution pressure analysis. RESULTS This study included 6 patients, with 5 chronic wounds (4 ipsilateral, 1 contralateral) and 1 traumatic ankle defect. QUESTIONNAIRE RESULTS Enneking scores: 67.9% return to function; Foot Function Index scores: 39.1% loss of function. GAIT ANALYSIS Significant differences were seen in kinetic and kinematic data. PRESSURE ANALYSIS The donor site group had significantly less pressure in the great toe (38.1kPa vs. 78.1kPa, p=0.013), significantly slower transition through the midfoot (445.2ms vs. 352.07ms, p=0.016) and increased impulse in the heel (3.1kPa/s vs. 11.7kPa/s, p=0.038). CONCLUSIONS This study demonstrates subjective and objective evidence of MPA donor site morbidity. Comparison to other studies looking at gait and pressure changes seen after flap reconstruction of the plantar region suggest that much of this difference may be attributable to ipsilateral reconstruction. As the majority had chronic problems with the soft tissues over the heel some of these biomechanical responses could be related to learned behaviour preoperatively or continued discomfort in the heel pad. Nonetheless it demonstrates accurately the effect of the technique overall on the function of the foot. The changes in the region of the great toe may be solely attributable to MPA harvest. These results suggest that MPA harvest is not free of donor morbidity.

Management of soft tissue defects of the foot

A 57 year old man presented to his general practitioner with a pigmented lesion on the heel of his left foot. He had not previously sought medical advice about the lesion but had recently become worried that it was growing in size. He was fit and well with no medical history of note. Excision biopsy confirmed that the lesion was a malignant melanoma and he was referred urgently for wide local excision according to melanoma guidelines. The histological margins were clear with no residual disease seen. Staging examinations were negative. The tumour was less than 1 mm thick and there was no evidence of locoregional or distant metastasis. The resultant excision defect measured 4×4 cm and was not amenable to primary closure. Initially a split skin graft was used to reconstruct the wound. However, this was not durable enough and failed, so a plastic surgeon who specialised in lower limb reconstruction was consulted (fig 1⇓). Fig 1 Reconstruction of a post-excisional wound on the patient’s left foot ### 1. Why is wound reconstruction in the foot challenging? #### Short answer The foot is subject to weight bearing stresses and requires sensate tissue reconstruction that can withstand the shearing forces present during ambulation. Reconstruction options are limited by the paucity of available adjacent soft tissue. #### Long answer The plantar skin of the foot is perfectly adapted to weight bearing. It is thicker than skin found elsewhere in the body and more heavily keratinised. Deep to the plantar skin is the strong plantar fascia, which provides …

Long-term sensation in the medial plantar flap: a two-centre study.

BACKGROUND Reconstruction in the foot and ankle region is challenging. This study aimed to quantify objective sensation return when a sensate medial plantar flap is used for like-for-like reconstruction of foot and ankle defects. METHODS Two-point discrimination (2PD) was assessed in flap and normal tissue at a minimum of 1 year post-operatively. A paired T-test assessed for significance. RESULTS 8 patients were included. Mean 2PD in normal tissue and flap was 29 mm (SD: 11.9) and 33 mm (SD: 9.97) respectively with no statistically significant difference between the two (two-tailed p-value: 0.1898). Mean age was 53.2 years (range: 15-84). There was no statistically significant correlation between age and 2PD in flap tissue (r=0.6, p=0.15). CONCLUSIONS This is the largest case series of its kind. Our results suggest that sensation in medial plantar flaps can return to near normal and demonstrate the important role the medial plantar flap plays in soft tissue reconstruction in this region.

Orthoplastics: an evolving concept for integrated surgical care of complex limb trauma and abnormality.

by conducting a more rigorous screening consisting of the plastic surgeon, the anesthesiologist, the pediatrician, the nutritionist, and the dentist on the patient’s first site visit. This ensures that the patient fulfills criteria for surgery, including certain age, hemoglobin, weight, and nutrition requirements, raising the chances of successful surgical intervention.8 On the day of surgery, a team consisting of a surgeon, anesthesiologist, scrub, and circulator works together to repair clefts. This year-round setup leads to a high volume of cleft repair that can facilitate efficiency and better outcomes9; the repetition can expedite the surgical process without compromising safety and potentially can lower the cost per operation. Ultimately, an experience of this sort engenders a collaborative spirit, where all participants take ownership of the patient, striving to overcome any setbacks, all for achieving the overarching goal of delivering the best care to the patient. Furthermore, in the comprehensive care model, the surgeon performing the original operation participates in follow-up care at 1 week, 2 months, and 6 months, permitting continuity of care in an effort to improve patient outcomes. If academic plastic surgeons visit these centers, an incredible exchange of knowledge can occur.10 For example, given the specialization and repetitive nature, some centers tend to perform a selected cleft repair (e.g., Millard rotation advancement, Furlow double Zplasty) with little variation; however, with visiting craniofacial surgeons, other options can be introduced, stimulating change that could be beneficial. Simultaneously, with the cleft center’s tremendous potential clinical volume, quality improvement research investigations with institutional support can be conducted ranging from basic science to clinical outcomes. Above all, the permanent establishment permits the visiting medical professionals the opportunity to return and continue their efforts from where they left off. The comprehensive care center provides a permanent, year-round, high-volume, dedicated cleft facility with a robust screening process and long-term, adequate follow-up that together can improve surgical outcomes. This model could prove to be a paradigm shift in how plastic surgeons will repair clefts as they endeavor to decrease the global surgical burden of disease. DOI: 10.1097/PRS.0b013e31827a294a

Proximally pedicled medial plantar flap based on superficial venous system alone for venous drainage

The proximally pedicled medial plantar flap is well described for coverage of wounds around the ankle and heel. This flap is usually based on the deep venae comitantes for venous drainage, with the superficial veins divided during dissection. Usually any disruption of the deep venous system of the flap would result in abandoning this choice of flap. Venous congestion is a recognised complication of medial plantar flaps. The patient described in this case report had a medial ankle defect with exposed bone, for which a proximally pedicled medial plantar flap was used. As we raised the flap, both venae comitantes of the medial planter artery were found to be disrupted. The flap was raised based on the superficial veins draining into the great saphenous, as the only system for venous drainage, with no evidence of venous congestion. The flap was successfully transposed into the defect and healed with no complications. The proximally pedicled medial plantar flap can safely rely on the superficial venous system alone for drainage. In addition, preserving the superficial veins minimise the risk of venous congestion in this flap. We recommend preservation of superficial venous system when possible.

The descending branch of the lateral circumflex femoral artery: a reliable and robust alternative blood supply in the free fibular transfer for avascular necrosis of hip

Avascular necrosis (AVN) of the femoral head is a disastrous condition and even more tragic when affecting the young adult. The fact that AVN has a number of aetiological trigger conditions underpins the fact that ultimately there is loss of vascularity to the caput. Early aggressive treatment through core decompression and vascularised bone grafting has been shown to successfully arrest disease progression. We describe here in a patient series the descending branch of the lateral circumflex femoral artery and vein as reliable alternative vascular recipient vessels to convention for receiving the bone flap. Further refinements are described to expedite the procedure and promote success. It is believed that this is the first described experience of this technique for AVN of the hip.

Lower limb trauma and posttraumatic stress disorder: A single UK trauma unit's experience

INTRODUCTION The incidence and factors influencing posttraumatic stress disorder (PTSD) in victims of severe lower extremity injuries are largely unknown. We studied a cohort of patients treated in a specialist centre to try and elucidate these unknowns. MATERIALS AND METHODS The Posttraumatic Stress Disorder Checklist Scale (PCL-S) was used as a reliable and reproducible patient-reported outcome measure (PROM) assessing all patients for PTSD. Sixty patients were included in the study. This was a prospective analysis of the progression of the PCL-S scores. The data were analysed using a non-parametric Wilcoxon test. RESULTS Sixty patients were recruited into the study cohort. We found that the incidence in this cohort of PTSD was 30%. We found that age had an influence on outcome. Those who were 50 years old or over had a significantly lower incidence of PTSD according to the PCL-S scores and appeared to recover from it significantly more effectively. CONCLUSIONS Up to a third of patients suffering from a severe lower extremity injury will develop PTSD. Patients of the younger age group are more severely affected and will need psychological support to overcome their distress.