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

2. 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.

3. 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

4. What is reconstructive plastic surgery?

6. soft tissue
vessel
nerve
muscle
bone

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

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

9. 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

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

11. 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

12. 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

13. 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

14. 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

15. photographs

16. 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

17. photograph

18. 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

19. 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

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

21. 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

22. 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

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

24. 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

25. 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

26. 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!

27. Thank you for
your attention!