Wound Coverage Techniques for the Injured Extremity

Wound Coverage Techniques for the Injured Extremity
3/31/2017 Wound Coverage Techniques for the Injured Extremity Gil Ortega, MD, MPH Original Author: David Sanders, MD; Created January 2006 New Author: Gil Ortega, MD, MPH; Revised September 2009 General References Serafin, Donald M.D.: Atlas of Microsurgical Composite Tissue Transplantation. W.B. Saunders Company, 1996. Webster, Martyn H. C. MBChB, FRCS (Glasg.), Soutar, David S. MBChB, FRCS (ED.): Practical Guild to Free Tissue Transfer. Butterworth & Co, 1986. McCraw, John B. M.D., F.A.C.S., Arnold, Phillip G. M.D., F.A.C.S., et al: McCraw and Arnold’s Atlas of Muscle and Musculocutaneous Flaps, Hampton Press Publishing Co.,1986. Cormack, George C. MA, MB, ChB, FRCS(ED), Lamberty, B. George H. MA, MB, BChir, FRCS: The Arterial Anatomy of Skin Flaps. Churchill Livingstone, 1986. Moy, Owen J. M.D., et al: Soft Tissue Management of Complex Upper Extremity Wounds. W.B. Saunders Company, 13-2: , May 1997.

3/31/2017 Objectives Review multi-disciplinary approach to evaluation and treatment of Soft Tissue injuries Review up to date methods of coverage Open Primary vs. Secondary Skin grafting Flap Review Non-surgical and Surgical Options for Soft-Tissue injuries Review current literature concerning Soft-Tissue injuries and Wound Coverage Techniques Objectives of this talk are as stated. Options for coverage will be discussed for the tibia, foot, elbow and hand. More proximal sites such as the shoulder and hip are generally covered with rotation flaps if skin grafting is not adequate.

Initial Assessment History Time and mechanism of injury
3/31/2017 History Time and mechanism of injury Functional demands of the patient Patient variables Age Diabetes Malnutrition Obesity Infection Smoker Medications Underlying physiology Occupation Evaluation of the injured extremity should begin with a targeted and thorough history and physical examination. With regard to history, all details listed should at a minimum be taken into account. If there is vascular compromise, the time from injury takes a higher precedence. In upper extremity injuries, hand dominance is important to know.

Initial Assessment Physical exam Severity of Injury Energy of Injury
3/31/2017 Initial Assessment Physical exam Severity of Injury Energy of Injury Morphology of associated fracture Bone loss Blood supply Location The physical exam should be systematic including an evaluation of all these components. If the injured extremity is dysvascular, restoration of circulation becomes a treatment priority if salvage is anticipated. The extent of injury, depth and size of the wound and degree of contamination should be ascertained at the initial debridement, however, the degree of tissue viability may not be readily apparent and may require several debridements before a final determination can be made.

Initial Treatment Management of soft tissue injury requires:
3/31/2017 Initial Treatment Management of soft tissue injury requires: Early aggressive debridement in OR Early intravenous antibiotics Skeletal stabilization Timely soft tissue coverage Tetanus prophylaxis Prophylactic antibiotics: 1st generation cephalosporin Clindamycin if penicillin allergy Penicillin for clostridia-prone wounds Tetanus prophylaxis

Wide Variety of Soft Tissue Injuries; Similar Initial Treatment Options
Injury: Realignment/splint Neurovascular exam Cover wound with sterile dressing Radiographs

Wound Colonization Initial colonization of traumatic wound
Increases with time Need to debride necrotic muscle, dead space, and poorly vascularized tissue including bony injuries

Wound Excision- Debridement
3/31/2017 Wound Excision- Debridement Conversion of traumatic wound to a “surgical” wound with debridement of all devitalized tissue – skin, fascia, and bone Unless gross contamination, evidence unclear as to best time for operative debridement as to whether 0-6 hours, 6-12 hours or > 12 hours to decrease risk of infection, however, patient must receive IV antibiotics promptly Tripuraneni K et al. The Effect of Time Delay to Surgical Debridement of Open Tibia Shaft Fractures on Infection Rate. ORTHOPEDICS 2008; 31:1195. Debridement should be carried out promptly, ideally within 6-8 hours from the time of injury to lessen the chance of infection. All devitalized skin, fascia, and bone should be removed, hence the term wound excision. Picture of dorsal soft tissue avulsion injury of the hand from roll-over MVA. Injury will require wound excision and eventually reconstruction of extensor tendons and coverage with some type of vascularized tissue (flap).

Initial Management After Debridement
3/31/2017 Initial Management After Debridement Restore vascularity Stabilize skeletal injury Splinting External Fixation Early Total Orthopaedic Care vs. Damage Control Orthopaedics Repair nerves Repair musculotendinous units PLAN reconstruction When patient is best physiologically stable When best team is available for reconstruction(s) Obviously if injured extremity is dysvascular at initial presentation, the priority of treatment is to restore the vascularity, however, a quick debridement of obviously dead and contaminated tissue should be carried out while preparing for revascularization. The choice of restoring vascularity or stabilizing the fracture should be made in conjunction with the vascular surgeon and in most circumstances will be dictated by the ischemic time of the injured extremity.

Reconstructive Ladder
3/31/2017 Methods Types Direct closure Skin Grafts Local and Regional Flaps Distant Pedicle Flaps Free Flaps Primary Secondary STSG FTSG Random Axial (See next slide) In general, soft tissue coverage of an injured extremity should be performed using the simplest and most reliable method taking into account the size and extent of the injury and the expertise of the surgeon. A stepladder approach should be considered starting with the easiest method. Obviously, direct closure either by primary or secondary means would be the simplest means of obtaining closure. If this cannot be accomplished, skin grafting should be considered followed by local/ regional flaps, distant pedicled flaps and finally free flaps.

Reconstructive Ladder
3/31/2017 Reconstructive Ladder Free flaps Cutaneous Fascial/ Fasciocutaneous Muscle/ Musculocutaneous Osteocutananeous The ability to move tissue from one area of the body to an entirely different area has revolutionized methods of soft tissue coverage. Free tissue transfer is now an established and reliable method for reconstructive surgery, however, microsurgical skills are a prerequisite, as a minimum of one arterial and one venous anastomosis are required for successful transfer of soft tissue as free flap. Free flaps are classified by the type of tissue being transferred. For example, if a latissimus muscle is transferred with a paddle of skin it would be classified as a free latissimus musculocutaneous flap. A radial forearm flap is transferred with skin and fascia and therefore would be classified as a free radial forearm fasciocutaneous flap.

3/31/2017 Direct Closure Direct closure is simplest and often most effective means of achieving viable coverage May need to “recruit” more skin to achieve a tension free closure

Direct closure Decreasing wound tension can be accomplished by:
3/31/2017 Direct closure Decreasing wound tension can be accomplished by: Relaxing skin incisions “Pie crusting” of the skin under tension (perpendicular to the direction of tension) Application of negative pressure wound therapy

Negative pressure therapy
3/31/2017 Negative pressure therapy Advantages: Increased neovascularization Increased granulation tissue formation, Decreased bacterial count Decreased seroma formation Wound contracture Disadvantages: Device Cost Can’t see wound when sponge is in place

3/31/2017 Negative pressure therapy Components: Apply a polyvinyl sponge to wound Impermeable membrane sealing wound from the external environment Low or intermittent negative pressure vacuum suction [i.e. KCI Vacuum Assisted Closure, or V.A.C.® Therapy System]

3/31/2017 Negative pressure therapy Routine use of VAC with open tibia fractures is safe According to Bhattacharyya et al, in Gustilo Type IIIB tibia fractures, vacuum-assisted closure therapy does not allow delay of soft-tissue coverage past 7 days without a concomitant elevation in infection rates Bhattacharyya et al. Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg Apr;121(4):

Skin Grafting Split thickness (STSG) Full thickness (FTSG) 3/31/2017
Skin grafting is the simplest form of coverage. This graft by definition is non-vascularized and requires capillary in growth from the recipient tissue being covered for the dermal elements of the graft to survive The graft may be harvested as a split thickness or full thickness graft. In general, most wounds on injured extremities are covered with STSG’s. Small areas or wounds on the volar side of the hand are generally covered with a FTSG. Critical areas of the sole of the foot may also benefit from FTSG.

STSG Advantages Disadvantages May be meshed Large area
3/31/2017 STSG Advantages May be meshed Large area Require less revascularization Temporary coverage Disadvantages Poor cosmesis Limited durability Contracts over time Donor site problems Pain Infection Advantages and disadvantages of STSG as listed. Split grafts may provide a “biologic” dressing over critical structures such as nerve, vessels, tendon or bone while awaiting definitive (free tissue) coverage preventing dessication.

FTSG Disadvantages Advantages No wound contracture
3/31/2017 FTSG Disadvantages Longer to revascularize Cannot mesh Recipient site must have rich vasculature Advantages No wound contracture Increased sensibility Increased durability Better cosmesis Primary closure of donor site Advantages and disadvantages of FTSG’s as listed

Wound Preparation for Grafts
3/31/2017 Wound Preparation for Grafts Vascularity Hemostasis Debride all necrotic tissue Optimize co-morbid conditions In order for a skin graft to survive, the wound to be covered must be prepared. The surface to be covered must contain a capillary bed capable of ingrowth. Bleeding must be controlled meticulously. A hematoma which forms under a graft will prohibit capillary ingrowth which is a frequent cause of failure. All necrotic tissue must be thoroughly debrided. A quantitative tissue culture may be a useful tool for determining graft-bed suitability, especially in cases of gross contamination. Systemic medical conditions and nutritional status must be optimized prior to graft placement.

Donor Site Selection STSG FTSG
3/31/2017 Donor Site Selection STSG 0.015 inches thick (thickness #15 scalpel) Lateral buttock Ant. and Lat. Thigh Lower abdomen Avoid medial thigh and forearm FTSG Depends on area to be covered Large grafts-lower abdomen and groin Small- medial brachium and volar wrist crease Plantar skin from instep The goal of harvesting donor tissue is to approximate the appearance and durability of the original tissue while causing minimal morbidity at the donor site. The thicker the graft the more donor site morbidity.

Skin Harvest for STSG Sterile preparation Lubricate
3/31/2017 Skin Harvest for STSG Sterile preparation Lubricate Set depth (0.012 inch most common) Traction with tongue blade May use mineral oil for skin Numerous power dermatomes are available for harvesting STSG’s Generally the width of the dermatome is set to the thickness of a #15 scalpel blade (0.012 to inch). When just the bevel fits, the thickness will be .01 inches. It is important to lubricate the undersurface of the dermatome to allow it to smoothly advance. By providing traction to the skin surfaces, the skin surface flattens allowing the dermatome to function more efficiently.

Skin Harvest for FTSG Use template Cut out ellipse Defat after harvest
3/31/2017 Skin Harvest for FTSG Use template Cut out ellipse Defat after harvest Apply and compress with moist bolster Most areas can be safely covered by a STSG, however, the palm of the hand is probably best covered with a FTSG. Prior to suturing the FTSG it is important to defat the graft which is best done with a pair of sharp scissors. Do not scrape the fat of with a scalpel because this will cause unnecessary damage to the dermis. Suturing a moist bolster over the graft will keep it adherent to the underlying recipient bed and encourage capillary ingrowth.

Donor Site Care Open Semi-open Semi-occlusive Occlusive Biologic
3/31/2017 Donor Site Care Open Semi-open Semi-occlusive Occlusive Biologic There are several techniques for managing the donor site. For STSG’s the dermis is covered with regenerated epithelium in 7-14 days. Leaving the wound open to air can be accomplished after hemostasis has been obtained using a fine mesh gauze saturated with lidocaine containing a 1:200,000 epinephrine solution which is left in place for 10 min. until a fibrin layer develops. Disadvantage is that it is painful during the 1st 24 hrs until the wound dries. Fine mesh gauzes are considered semi-open and allow for egress of fluid and bacteria from the wound. Disadvantage is pain when removing the adherent gauze. Biobrane is a composite of a silicone membrane and flexible nylon fabric covalently bonded to porcine collagen peptides which diminishes the adherence and lessens the pain with removal. Disadvantage is the expense of the product. Opsite and Tegaderm are considered semi-occlusive dressings because the are vapor permeable and bacteria and liquid impermeable. Disadvantage: seromas may develop under the material and increase the risk of infection. Duoderm is completely occlusive. Exudate is more acidic which potentially limits bacterial growth Excess skin graft or porcine xenografts can be used as a biologic dressing but may not be practical in most situations. For FTSG’s primary closure should be performed if possible.

Indications for Flap Coverage
3/31/2017 Indications for Flap Coverage Skin graft cannot be used Exposed cartilage, tendon (without paratenon), bone, open joints, metal implants Flap coverage is preferable Secondary reconstruction anticipated, flexor joint surfaces, exposed nerves and vessels, durablitiy required, multiple tissues required, dead space present There are two general indications for performing soft tissue coverage with a flap which are listed on this slide .

Classification of Soft Tissue Flaps
3/31/2017 Classification of Soft Tissue Flaps Random Axial Local Advancement Rotation Distant Direct Tubed Free There are several classifications for soft tissue flap. McGregor (1972) introduce the concept of random and axial flaps. A random flap is one that lacks any significant bias in its vascular pattern. Without a definitive recognized arteriovenous system, elevation of the flap is generally restricted, that is the length of the flap to be raised should be no greater than the width of the base of the flap which is providing the necessary blood flow thru the sub-dermal plexus. There are several techniques for extending the length of random flaps. One such technique is known as delay where parallel incisions are created and the base of the flap is undermined and then sutured back in place for a period of about 2-3 weeks. The blood flow is then “channeled” and thus allow extension of the flap margin beyond the 1:1 ratio. An Axial pattern flap is single pedicled flap that has an anatomically recognized arteriovenous system running along its long axis. An axial pattern flap is not restricted to the same 1:1 ratio of flap elevation. Flaps may also be classified as either local or distant on the basis of their proximity of the donor site to the recipient site. Local flaps can be further categorized by the nature of their pedicle into advancement or rotation flaps.

Classification of Soft Tissue Flaps
3/31/2017 Classification of Soft Tissue Flaps Direct cutaneous Musculocutaneous Septocutaneous As the knowledge of skin vascularity has increased, the incorporation of tissues other than skin and subcutaneous tissues in the coverage of more substantial defects has become more successful By default, a nomenclature system has developed based on flap composition. The terms cutaneous, fasciocutaneous and myocutaneous are used to describe the incorporation of skin, fascia, or muscle. Eventually, other structures such as bone, nerve and tendon have been incorporated into the flap. These are known as compound flaps. Since most flaps are designed around the tissue’s vascular pedicle, perhaps the most justified method of classification is one based on the flap’s vascular origin. It is now accepted that there are three basic patterns of blood supply: Direct cutaneous Musculocutaneous Septocutaneous Each of these flaps will be discussed on the following slides.

Direct Cutaneous Flaps
3/31/2017 Direct Cutaneous Flaps Groin flap- superficial circumflex iliac artery Deltopectoral flap-2nd and 3rd perforating br. Of int thoracic artery The direct cutaneous flap has arteries that run immediately above the muscle and fascia in the subdermal fat with a specific directional orientation. An excellent example is the direct cutaneous flap is the groin flap which is supplied by the superficial circumflex iliac artery.

Musculocutaneous Flaps Mathes Classification
3/31/2017 Musculocutaneous Flaps Mathes Classification Type I- one vascular pedicle Gastrocnemius Tensor fascia Lata Muscle flaps have been categorized by Mathes. (Clinical Applications for Muscle and Musculocutaneous Flaps. St. Louis, Toronto, London; CV Mosby, 1982, pp3-27) Musculocutaneous flaps have been categorized according to the five muscle types depending on their vascular anatomy. Each pattern has significance for arc of rotation skin territory , whether it can be elevated as a distally based flap and whether it can be elevated as a free flap. A type I flap has one dominant pedicle. They cannot be raised as distally based rotation flaps because there are no secondary vessels perforating distally. Examples are listed. Mathes, Clinical Applications for Muscle and Musculocutaneous Flaps. Mosby 1982 Type I: Tensor Fascia Lata

3/31/2017 Musculocutaneous Flaps Mathes Classification Type II- one dominant vascular pedicle close to insertion with additional smaller pedicles entering along the course of the muscle Brachioradialis Gracilis Soleus These flaps can be raised as free flaps based on the dominant proximal vessel or as distally based rotation flaps based on the smaller pedicles entering along the course of the muscle. Examples are listed. The BR is based on a dominant perforator off the radial artery in the mid-substance of the muscle. The Gracilis is supplied by the ant. Br of the obturator artery. The soleus is supplied by a branch off the post. tibial artery. Mathes, Clinical Applications for Muscle and Musculocutaneous Flaps. Mosby 1982 Type II: gracilis

3/31/2017 Musculocutaneous Flaps Mathes Classification Type III - two dominant vascular pedicles Rectus abdominis Gluteus maximus A type III flap has two dominant vessels which allows for rotation from either end. The rectus abdominis flap is supplied by the deep inferior epigastric artery, which is the dominant vessel and will reliably supply the entire muscle. The superior epigastric artery will reliably supply the upper two-thirds of the muscle . The gluteus maximus is supplied by both the superior and inferior gluteal arteries. The inferior gluteal vessel is dominant but an excellent intramuscular vascular connection allow the gluteus to be supplied by either vessel. These vessels are separated by the piriformis muscle as they exit the pelvis. Mathes, Clinical Applications for Muscle and Musculocutaneous Flaps. Mosby 1982 Type III: Gluteus Maximus

3/31/2017 Musculocutaneous Flaps Mathes Classification Type IV- multiple pedicles of similar size Generally of less use in reconstruction than single or double pedicled muscles Type IV muscles are generally not used for soft tissue reconstruction because they lack a distinct pedicle and cannot be rotated reliably on the small perforating branches. Mathes, Clinical Applications for Muscle and Musculocutaneous Flaps. Mosby 1982 Type IV: Sartorius

3/31/2017 Musculocutaneous Flaps Mathes Classification Type V- one dominant pedicle and several smaller segmental vascular pedicles Latissimus Dorsi Pectoralis major The type V flaps have a dominant pedicle which allows them to elevated as a free flap or rotation flap. Since there is segmental blood supply to the muscle at the distal end, half the muscle can be harvested on the dominant pedicle while the remainder of the muscle is nourished from the segmental vascular pedicles. The latissimus dorsi which is the “workhorse” muscle flap for soft tissue coverage is an example of a type V muscle Mathes, Clinical Applications for Muscle and Musculocutaneous Flaps. Mosby 1982 Type V: Latissimus Dorsi

Septocutaneous Flaps Cormack, et. al
3/31/2017 Septocutaneous Flaps Cormack, et. al Type A- flap dependent on multiple fasciocutaneous perforators Septocutaneous flaps have arteries which traverse between the overlying muscles in distinct intermuscular septae and therefore are known as septocutaneous vessels. Septocutaneous flaps are classified into 4 types based on the location and number of the vascular pedicles as well as flap composition A Type A flap is a pedicled flap containing fascia and skin that depends on multiple fasciocutaneous perforators at the base and that is oriented with the long axis of the flap at the level of the deep fascia

3/31/2017 Septocutaneous Flaps Cormack, et. al Type B-based on single fasciocutaneous perforator of moderate size consistent in presence and location Parascapular flap- circumflex scapular artery Saphenous artery flap Lateral thigh flap- 3rd profunda perforator This is a pedicled or free flap depending upon a single and consistent fasciocutaneous perforator off an artery feeding a plexus at the level of the deep fascia. The sural artery fasciocutaneous flap is supplied by the last perforator of the peroneal artery which can be found approximately 5-7 cm above the lateral malleolus. The parascapular flap is based on the parascapular br of the circumflex scapular artery. Remember, these flaps are all supplied by well defined perforating vessels. Shown is a picture of a distally based sural artery flap with the pedicle easily visualized.

3/31/2017 Septocutaneous Flaps Cormack, et. al Type C- supported by multiple perforators which pass from a deep artery thru a fascial septum Radial forearm flap Posterior Interosseous flap A Type C flap is supported by multiple small perforators along its length which reach it from a deep artery by passing along a fascial septum. The radial forearm flap was one of the first of of this type to be described.

3/31/2017 Septocutaneous Flaps Cormack, et. al Type D -type C septocutaneous flap removed in continuity with adjacent muscle and bone to create a osteo- myo-fasciocutaneous flap Free fibula osteocutaneous flap This is a compound flap which incorporates other structures such as muscle and bone. A radial forearm flap can be raised with a half the diameter of the radius. Another example of this flap is the fibula osteocutaneous flap

Principles of Free Tissue Transfer
3/31/2017 Principles of Free Tissue Transfer Pre-operative Assessment Physical Examination Vascular Status Arteriogram Alternative methods Choice of donor site Length and width necessary to fill defect Vascular pedicle length Innervated or composite with bone A complete physical examination is essential with particular importance given to the vascularity of the injured extremity. The absence of suitable vessels is a contraindication for free tissue transfer. A careful clinical evaluation by palpating peripheral pulses and occluding vessels distally is often sufficient. Noninvasive studies such as doppler evaluation is useful. However if there is significant ASPVD or significant trauma to the extremity, further evaluation with an arteriogram should performed. Simpler, alternative measures should always be considered prior to embarking on free tissue transfer. The choice of donor site is ever-increasing and is dependent on a number of factors such as the length and width of the pedicle , the thickness of the flap, and whether sensory reinnervation or composite tissue is desired. Finally, and the surgeon’s own experience with a particular flap will be an important factor to consider.

3/31/2017 Principles of Free Tissue Transfer Surgical Considerations Team approach Comfortable setting Anesthesia- regional block/ epidural Temperature Volume replacement Careful surgical technique PREVENT SPASM Performing a free tissue transfer is a complex task that requires a team approach from the surgeon, assistant surgeon, anesthesiologist and the nursing personnel. The room should be comfortable and familiar with the surgeons sitting in a relaxed position. Many advances have been made in anesthesia, particularly regional anesthesia which may have a role in promoting vasodilation of the vessels and minimizing spasm. Temperature should be closely monitored and maintained throughout the procedure. A reduction in the circulating volume will cause a reflex vasoconstriction and therefore, it is vital to fluids need to be replaced prior to losses. Careful surgical technique goes without saying. The majority of failures can be attributed to poor technique. Spasm can be a very difficult problem. Ways to control spasm involve items discussed above as well as direct application of a local anesthetic(4%lidocaine) or verapamil hydrochloride.

3/31/2017 Principles of Free Tissue Transfer Post-operative Management ICU for monitoring Maintain body temperature Fluid balance Good pain relief Monitoring flap- temperature, doppler, photoplethysmography Strong consideration should be given to monitoring these patients for the first hours in the ICU where body temperature, fluid balance and pain relief can be monitored closely. Monitoring the flap post-operatively is very much surgeon dependent. Several of the methods are listed but such technology should not replace good sound clinical judgement such capillary refill, color, and turgor. If thrombosis is suspected early exploration is essential if the free tissue transfer is to be saved.

Soft Tissue Coverage for the Tibia
3/31/2017 Soft Tissue Coverage for the Tibia Conventional teaching Proximal 1/3 Tibial defect- Gastrocnemius rotational flap Middle 1/3 Tibial defect - Soleus rotational flap Distal 1/3 Tibial defect - free flap Large defect- Latissimus Dorsi Smaller defect- radial forearm, Sural artery Fasciocutaneous flap Conventional teaching for soft tissue coverage of the tibia

Medial Gastrocnemius for Proximal 1/3 Tibia
3/31/2017 Medial Gastrocnemius for Proximal 1/3 Tibia Medial head of Gastrocnemius based on the sural artery (branch from the popliteus) is a proximally based flap that can be rotated to cover proximal 1/3 defect of the tibia. Can also be used in the distal femur and knee. Careful release of the origin preserving the artery can provide additional length as can crosshatching the fascia. Lateral gastrocs can also be used if the medial gastrocs is unavailable, or in addition to the medial for larger wounds. Disadvantages include less rotational mobility and careful dissection required to mobilize around the peroneal nerve.

Soft Tissue Coverage for the Middle 1/3 Tibia
3/31/2017 Soft Tissue Coverage for the Middle 1/3 Tibia Soleus flap Narrower muscle belly compared to gastrocs and a somewhat less robust vascular supply Less tolerant of tension compared to gastrocs flap so harvesting and mobilization of muscle belly can be technically demanding

Soft Tissue Coverage for the Distal 1/3 Tibia
3/31/2017 Soft Tissue Coverage for the Distal 1/3 Tibia There are seldom local flap coverage options for defects in the distal 1/3 of the leg. Generally free flaps are required as demonstrated above (latissimus dorsi free flap).

3/31/2017 Soft Tissue Coverage for the Tibia When treating limbs with severe underlying bone injury (ASIF/ OTA type C), use of a free flap for soft tissue coverage was less likely to have a wound complication than use of a rotational flap, regardless of location. Zone of injury may be larger than anticipated and may include rotated muscle More muscle tissue available in free flaps Pollak, A et.al. Short-Term Wound Complications After Application of Flaps for Coverage of Traumatic Soft-Tissue Defects About the Tibia. JBJS 82-A: , 2000.

3/31/2017 Timing: best results obtained with early soft tissue coverage (< 72 hours) for Type III-B open tibial fractures Definitive bony and soft tissue surgery may not always be possible within 72 hours because of concomitant injuries or delayed referral Therefore, according to Steiert AE and Karanas et al., both groups have showed high success rates with delayed (> 72 hours) with meticulous microsurgical treatment planning and vessel anastomoses outside of zone of injury Steiert et al. have shown that the use of Damage Control Orthopaedics may enable surgeon to treat injury definitely beyond 72 hour window with similar results to that of definitive surgeries within 72 hours Local tissue flaps are frequently compromised during the accident and should be used with caution in the acute post traumatic setting. Steiert AE et al. J Plast Reconstr Aesthet Surg May;62(5): Karanas et al. Microsurgery. 2008;28(8):632-4 Cierny G. et al. Clin Orthop 178: 54-63, 1983 Fischer et al. JBJS 73-A: , 1991 Godina M. Plat Reconstr Surg 78: , 1986

Soft Tissue Coverage of the Ankle/ Foot
3/31/2017 Soft Tissue Coverage of the Ankle/ Foot Open wounds in this area remain a challenge Donor site options Medial plantar flap for reconstruction of the heel Abductor hallucis flap Flexor digitorum brevis Coverage of defect in some areas of the ankle and foot remain a challenge to reconstructive surgeons. The difficulty comes from the limited mobility and availability of the overlying skin, the unique weight-bearing requirements and the relatively poor circulation of the skin. Possible reconstructive options include local distant and free flaps. Local flap reconstruction remains popular because it is a simple reliable one-stage procedure. Options include the medial plantar flap which is the best option for coverage overlying the exposed calcaneus. Other smaller flaps include the Abductor hallucis and flexor digitorum flap are helpful for covering small defects but have limited use because of their small arc of motion.

3/31/2017 Soft Tissue Coverage of the Ankle/ Foot

3/31/2017 Soft Tissue Coverage of the Ankle/ Foot Increasingly popular method among reconstructive surgeons is use of a distally based sural artery flap Supplied by most distal perforating artery of peroneal artery which is located approximately 5-7 cm above tip of lateral malleolus According to Ríos-Luna et al, the sural fasciocutaneous offers technical advantages such as easy dissection with preservation of more important vascular structures in limb, complete coverage of soft tissue defect without need of microsurgical anastomosis Ríos-Luna et al. Versatility of the sural fasciocutaneous flap in coverage defects of the lower limb. Injury Jul;38(7):

Soft Tissue Coverage of the Elbow
3/31/2017 Soft Tissue Coverage of the Elbow Skin graft for wounds that are well-vascularized without injury to neurovascular or osseous structures. As stated

Soft Tissue Coverage of the Elbow
3/31/2017 Soft Tissue Coverage of the Elbow Flaps Infection or dead space-use muscle flap Extensive soft tissue avulsion- parascapular flap Functional restoration of elbow flexion - latissimus dorsi

Considerations for Flap Coverage of the Elbow
3/31/2017 Considerations for Flap Coverage of the Elbow Regional FCU- Ulnar recurrent artery Brachioradialis- radial recurrent artery Intermediate Radial artery fascio-cutaneous flap Posterior Interosseous flap Distant pedicle Latissimus dorsi - Thoracodorsal artery Serratus anterior- Thoracodorsal artery Free tissue transfer Latissimus dorsi Rectus Abdominis - deep inferior epigastric Parascapular - circumflex scapular artery There are a number of regional and pedicled flaps which can be used to gain coverage of elbow wounds. Listed on this slide are some of the flaps one might consider.

3/31/2017 Flap Coverage of the Elbow: Example of Latissimus Dorsi Local Transfer Flap

Soft tissue coverage of the Hand
3/31/2017 Sheet STSG for dorsum of hand When wound closure cannot be obtained by primary means, flexor and extensor tendons are not exposed and there are no plans for subsequent reconstructive procedures then STSG can be used for the dorsum of the hand and generally FTSG is used for the palm of the hand. FTSG for volar aspect of hand

Soft Tissue Coverage of the Hand
3/31/2017 Soft Tissue Coverage of the Hand Common flaps Cross finger flap Thenar flap Radial forearm flap Posterior interosseous flap Groin flap An in-depth discussion on soft tissue coverage of the hand is beyond the scope of this lecture but listed are common flaps that are used that the general orthopaedic surgeon should be familiar with. Cross finger flap covers volar defects on ;the finger from an adjacent digit Thenar flap- provides coverage to the IF/ MF fingertip. Generally it is not a good choice for the elderly patient because of flexion contractures of the PIPJ Radial Forearm Flap is a common flap use for soft tissue avulsion injuries, particularly for the dorsum of the hand. Must ensure that the hand has a complete arch by performing either non-invasive doppler evaluation or arteriogram if there is a question. Posterior Interosseous Flap is gaining more popularity as a retrograde flap. The post. Interosseous artery is found between the EDQ and ECU and the nerve to the ECU from the PIN may limit its elevation. The groin flap is still an excellent method of obtaining coverage over the back of the hand and first web space. The disadvantage is that it is bulky and may require subsequent operations to defat the flap.

Flaps for Hand Reconstruction
3/31/2017 Flaps for Hand Reconstruction Dorsal soft tissue avulsion injuries are a common injury in rollover motor vehicle accidents oftentimes requiring extensor tendon reconstruction. There are several methods for obtaining coverage over the dorsum of the hand such as shown with this radial forearm flap. Groin flaps and free flaps such as the temporal mandibular flap and lateral forearm flap have been use for soft tissue coverage of the dorsum of the hand. Dorsal Soft tissue avulsion injury Coverage with radial forearm flap

Limb Salvage Vs. Amputation
3/31/2017 Limb Salvage Vs. Amputation Lower Extremity Assessment Project (LEAP) study provides evidence for outcomes of limb salvage Largest study with followup up to 7 years Compares functional outcome of patients with limb salvage vs. amputation Bosse et al. A prospective evaluation of the clinical utility of the lower extremity injury severity scores. JBJS Am. 83: 3-14, 2001.

LEAP Study Major Conclusions
3/31/2017 LEAP Study Major Conclusions Limb threatening injuries severely impair patient outcome When comparing limb salvage vs. amputation, the patient outcome is generally the same at 1-5 years Lack of plantar sensation does not predict poor outcome after limb salvage

LEAP Study Patients with Poor Outcomes
3/31/2017 LEAP Study Patients with Poor Outcomes Rehospitalization of major complication Lower level of education Non white Poverty Smokers Poor social support Involved in social legal compensation

Summary 3/31/2017 Appropriate debridement with first debridement being most important Appropriate antibiotic regime Appropriate bony stability Early coverage to prevent dessication of critical structures and decrease risks of wound infection Choose appropriate coverage method Defect requirements Patient needs Surgeon factors Protect limb to appropriate healing

3/31/2017 References Classical Cierny G. et al. Primary versus delayed soft tissue coverage for severe open tibial fractures. A comparison of results. Clin Orthop 178: 54-63, 1983. Fischer et al. The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. JBJS 73-A: , 1991. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plat Reconstr Surg 78: , 1986. Serafin, Donald M.D.: Atlas of Microsurgical Composite Tissue Transplantation. W.B. Saunders Company, 1996. Webster, Martyn H. C. MBChB, FRCS (Glasg.), Soutar, David S. MBChB, FRCS (ED.): Practical Guild to Free Tissue Transfer. Butterworth & Co, 1986.

3/31/2017 References Classical McCraw, John B. M.D., F.A.C.S., Arnold, Phillip G. M.D., F.A.C.S., et al: McCraw and Arnold’s Atlas of Muscle and Musculocutaneous Flaps, Hampton Press Publishing Co.,1986. Cormack, George C. MA, MB, ChB, FRCS(ED), Lamberty, B. George H. MA, MB, BChir, FRCS: The Arterial Anatomy of Skin Flaps. Churchill Livingstone, 1986. Moy, Owen J. M.D., et al: Soft Tissue Management of Complex Upper Extremity Wounds. W.B. Saunders Company, 13-2: , May 1997.

References Technique/Outcomes/Recent articles
3/31/2017 References Technique/Outcomes/Recent articles Tripuraneni K et al. The Effect of Time Delay to Surgical Debridement of Open Tibia Shaft Fractures on Infection Rate. ORTHOPEDICS 2008; 31:1195. Bhattacharyya et al. Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg Apr;121(4): Pollak, et.al. Short-Term Wound Complications After Application of Flaps for Coverage of Traumatic Soft-Tissue Defects About the Tibia. JBJS 82-A: , 2000. Steiert AE et al. Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy - worse or worth? J Plast Reconstr Aesthet Surg May;62(5): Karanas et al. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery. 2008;28(8):632-4 Bosse et al. A prospective evaluation of the clinical utility of the lower extremity injury severity scores. JBJS Am. 83: 3-14, 2001.

References Technique/Outcomes/Recent articles
3/31/2017 References Technique/Outcomes/Recent articles Reuss BL et al. Effect of delayed treatment on open tibial shaft fractures. Am J Orthop Apr;36(4): 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 Sep;82(7): Yazar S et al. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg Nov;114(6): Yazar S et al. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg Jun;117(7): ; discussion

3/31/2017 Thank You Gil Ortega, MD, MPH Sonoran Orthopaedic Trauma Surgeons Site Director, Phoenix Orthopaedic Residency Program Scottsdale Healthcare Trauma Center Scottsdale, AZ OTA about Questions/Comments Return to General/Principles Index

Wound Coverage Techniques for the Injured Extremity

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Wound Coverage Techniques for the Injured Extremity

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