Challenges in reconstructive surgery - soft tissue reconstruction

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Presentation transcript:

Challenges in reconstructive surgery - soft tissue reconstruction LtCol.Dr. Meike Wendlandt AMSUS 2017

Disclosures Soft tissue Reconstruction Presenter has no interest to disclose. AMUS and PESG staff have no interest to disclose. This continuing education activity is managed and accredited by Professional Education Services Group in cooperation with AMSUS. PESG, AMSUS, planning committee members and all accrediting organizations do not support or endorse any product or service mentioned in this activity.

Learning objectives Soft tissue reconstruction At the conclusion of this activity, the participant will be able to see how soft tissue defects can be reconstructed decide which reconstructive method e.g. pedicled or free flap is necessary and will provide the best coverage, functionality and esthetic outcome foresee possible problems and complications of soft tissues reconstruction in wounds caused by war trauma  

What is reconstructive plastic surgery?

soft tissue vessel nerve muscle bone

integrity of the body goal of reconstruction function asthetic body-image asthetic function integrity of the body goal of reconstruction

Reconstructive ladder Primary closure Secondary closure Skin transplantation Pedicled flaps (local, regional) Free flaps

Fascio-cutaneous flaps Muscle flaps e.g. latissimus dorsi pedicled flap free flap Fascio-cutaneous flaps e.g. ALT pedicled Free Combination flaps e.g. free fibula with skin island osteocutaneous flaps

complex reconstructive surgeries require teamwork of Radiology Vascular surgery Anesthesiology Traumalogie Plastic surgery

Case II – the reconstructive path History This 31 year old soldier was wounded in the beginning of june 2017 Explosion injury of his right upper arm – treated with external fixateur GSW on his left shoulder The injury of his right brachial artery was treated with a vein graft in Ukraine Arrived in Germany in the end of june 2017

Case II – the quick one? Diagnostics microbiological swabs Acinetobacter baumannii (4 MRGN) in several swabs Neurological findings Rupture of the median nerve ENT findings typanum perforation

Case II – the quick one? Therapy mutliple Debridement of the right upper arm, changing the PMMA Spacer with Gentamicin and placing a VAC Instill using Taurolidine. Neuolysis of the right median nerve ORIF of the right humerus combined with nerval reconstruction of the medial nerve using sural nerve cables and pedicled latissimus dorsi muscle flap

Case II – the quick one? Lessons learned Eradication of a 4 MRGN is almost impossible if it is found around the anus Not every multiresistant germ is very pathogen or aggressive Do not spent to much time on eradicating 3 and 4 MRGN germs if you see no improvement Reconstruction with muscle flaps or fasciocutaneous is possible and necessary Use safe and not fancy procedures

photographs

Case III – the short one? History Explosion injury of his right upper leg with open femur fracture OREF of right femur in Ukraine Suspected for osteomyelitis

photograph

Case III – the short one? Diagnostics microbiological swabs Acinetobacter baumannii (3 MRGN) in the wound MRSA in several swabs Clinical findings Reduced ROM of the right hip and knee joint

Case III – the short one? Therapy Repeated Debridements of the right femur, changing the PMMA Spacer with Gentamicin and placing a VAC Instill using Taurolidine/Polyhexanide. ORIF of the right femur Reconstruction of soft tissue with av-loop plus Gracislis flap Failure of av-loop VAC Reconstruction with free latissimus dorsi flap

Case III – the short one? Lessons learned Chose a safe flap instead of fancy procedure

Case IV – the most complex one? History Explosion injury of his right leg with a non displaced femur fracture, open knee joint injury and 3rd degree open multi fragment tibia fracture OREF of right femur in Ukraine with fistula of the right knee Suspected for osteomyelitis

Case IV – the most complex one? Therapy Repeated Debridements of the right leg, placing a VAC Instill using Taurolidine. ORIF of the right femur with two screws, allograft (quadriceps tendon, patella, patellar tendon, tibial tuberosity) Soft tissue reconstruction using free latissimus dorsi flap Failure of distal tip of free latissimus flap Reconstruction with pedicled gastrocnemius flap

Case IV – the most complex one? Lessons learned Even the safest flap can show symptoms of failure Always have plan b in mind

Possible problems to be aware of Young patients being imobilized shortly after being active in war Depression PTBS Pain Drug abuse Cigarette and alcohol abuse

Learning objectives From these three cases with war injuries of the extremities we learned, that... War injuries to the extremities are always contaminated and complex Bony, nerval and vessel reconstruction is only possible with good coverage Chosing the right flap is crucial Contaminated wounds, i.e. osteomyelitis tend to develop fistulas Wounds need to be observed closely If fistulas or wound healing problems occur fast treatment is necessary Plan B is essential for success of reconstruction

Learning objectives From these three cases with war injuries of the extremities we learned, that... the key to success in war injuries of the extremities is the interdiciplinary approach which requires at least the following experts: microbiologist pharmacists/internist radiologist/nuclear medicine specialist trauma and orthopaedic surgeon plastic surgeon wound nurse the bone is nothing without the soft tissue around it!

Thank you for your attention!