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Microvascular reconstructive techniques in orthopaedic traumatology
ARTICLE IN PRESS
JID: JINJ
[m5G;November 7, 2019;15:58]
Injury xxx (xxxx) xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Microvascular reconstructive techniques in orthopaedic traumatology ✩ A. Gkotsi a, R. Wirtz b, F. Schuind a,∗ a b
Department of Orthopaedics and Traumatology, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université libre de Bruxelles, Brussels, Belgium Department of Orthopaedics and Traumatology, Centre Hospitalier de L’Ardenne, Libramont, Belgium
a r t i c l e
i n f o
Article history: Available online xxx Keywords: Free flaps Fibular graft Vascularized graft Microanastomosis
a b s t r a c t Great evolution has taken place in Orthopaedic Traumatology, regarding techniques, surgical means and equipment. However, we still encounter complicated cases of limb trauma that necessitate microvascular reconstruction. Through three different illustrative cases (one emergency foot revascularization by a free flap, covering an ankle arthrodesis and bridging the anterior tibial artery, one cure of a complex infected tibial non-union with extensive skeletal defect by double barrel fibular transfer and one osteo-chondral reconstruction of the scaphoid proximal pole using a vascularized graft harvested from the femoral medial condyle), the authors remind the Orthopaedic community about the benefits of microsurgery, especially if used in proper indication and timing. This article is a plea to preserve the knowledge and develop the technical abilities of microvascular techniques in the departments of Orthopaedics and Traumatology. © 2019 Elsevier Ltd. All rights reserved.
Introduction Much progress has been made over the years in Orthopaedic Traumatology. New imaging facilities have allowed to better define operative indications. Many bone fixation implants are available, allowing minimally invasive techniques of insertion. Bone allografts and substitutes are at our disposal to fill up bone defects. Protocols of faster return to patients’ previous activities are routine. These methods, heavily promoted by our biomedical industrial partners, give the false impression that all problems regarding management of complex traumas have now been solved. However, final success needs solid bone healing, or there will be, sooner or later, failure of the osteosynthesis. Indeed, nonunions remain frequent and challenging to treat, especially if septic, and some cases still end up in an amputation. Microvascular techniques are available to prevent the infection of an open fracture and to provide a relatively easy and safe solution to bone defects, whether infected or not. However, in many departments of Orthopaedics and Traumatology, microsurgery is still regarded as complex, time consuming and leading to questionable outcomes. In many programs, microsurgical techniques are forgotten or have been cancelled from the basic training of the Orthopaedic surgeon, except maybe for those specializing in hand surgery, who will not be later in charge of
✩ This paper is part of a Supplement supported by the European Federation of Societies of Microsurgery (EFSM) and the Serbian Society for Reconstructive Microsurgery (SSRM). ∗ Corresponding author. E-mail address: [email protected] (F. Schuind).
cases like open infected nonunions of the tibia. The possibilities of microvascular techniques are therefore not well known in the surgical Orthopedic community, and many Orthopedic surgeons don’t think of microsurgery when faced to a major open fracture or a complex posttraumatic defect. Instead they try all other ‘’simpler’’ techniques and when microsurgery seems the only left solution, they refer the case with great delay to a plastic surgeon, who masters the microvascular techniques, but has frequently limited background in bone fixation and fracture healing. Microsurgery is part of the Orthopaedic armamentarium, like arthroscopy for the treatment of selected articular fractures. When there is indication for microsurgical reconstruction in a traumatic case, it should not be ignored or delayed because of insufficient competence among the treating surgeons. This article presents three exemplative cases of the efficacy of microsurgical techniques to solve complex traumatic problems. Example case 1 (Fig. 1) A 22 y.o. student was the victim of a motorcycle accident, resulting among other lesions in a Gustilo type III-C open fracturedislocation of the ankle, with massive contamination by soil and dirty canal water. More precisely, there was a comminuted tibial pilon fracture, an anterior tibio-talar dislocation, severe chondral defects at the talar dome, and foot devascularization. Immediate reduction allowed some restoration of the blood supply to the foot, but the traumatic disruption of the anterior tibial pedicle, rendered the spasmed posterior tibial artery the foot’s only blood supply. A large soft-tissue defect, centered on the anterolateral aspect of
https://doi.org/10.1016/j.injury.2019.10.055 0020-1383/© 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: A. Gkotsi, R. Wirtz and F. Schuind, Microvascular reconstructive techniques in orthopaedic traumatology, Injury, https://doi.org/10.1016/j.injury.2019.10.055
JID: JINJ 2
ARTICLE IN PRESS
[m5G;November 7, 2019;15:58]
A. Gkotsi, R. Wirtz and F. Schuind / Injury xxx (xxxx) xxx
Fig. 1. Traumatic status (a, b), immediate post operative status: note the well vascularized free flap and foot and the tibio-calcaneal external fixator (c), clinical aspect one year after surgery (d), X-rays ten years after trauma (e).
Fig. 2. Pre-operative status (a), Postoperative X-rays, note the use of external fixation pins to stabilize the grafts (b), X-rays 2,5 years after the initial trauma (c).
the ankle, exposed the destroyed joint. The patient rapidly underwent debridement, lavage and immediate reconstruction. Given the non-reconstructible character of the ankle fracturedislocation, immediate tibio-talar arthrodesis was performed by removal of the remains of cartilage, interposition of cancellous bone autografts, harvested from the proximal tibial metaphysis through a small cortical window, and external fixation. Bone coverage was immediately performed by a 10 × 14 cm lateral antebrachial fasciocutaneous free flap (Chinese flap). Termino-terminal microvascular anastomoses were performed proximally between the flap’s radial artery and the anterior tibial artery at a non-injured level and with the dorsalis pedis artery distally, restoring through the flap the arterial flow to the foot (bridging by-pass flap). One of the flap’s radial vena comitant was anastomosed to the anterior tibial vein and a superficial radial vein to the lesser saphenous vein. The donor site was immediately covered by a non-expanded dermoepidermal skin graft. The postoperative evolution was uneventful. Bone healing of the arthrodesis was achieved after four months. At ten years follow-up, tibio-talar fusion is total, subtalar and increased mid-tarsal motion allow an apparently normal foot motion and the patient has practically no functional limitation. He is now an active realty and practices various sports. Example case 2 (Fig. 2) A 47 y.o. smoker military patient was the victim of a left closed tibial pilon fracture (associated open fibular fracture). He underwent plate fixation in another hospital, but got MRSA-infected. Multiple operations were then performed and the patient was transferred to our institution nine months later, with a large bone defect in the distal diaphysis of the tibia, discharging pus. Although the original fracture line was intra-articular, the ankle joint was
still relatively preserved, but ankylosed in 40° equinus. The preoperative angiogram revealed interruption of the anterior tibial artery above the nonunion but patency of the posterior tibial artery. A first operation according to Masquelet [1–3] took place, with radical excision of all necrotic and infected bone at the nonunion site, insertion of a cement spacer with gentamicin and vancomycin, and skeletal stabilization by Hoffmann tibio-talar external fixation. Subsequently, the patient was treated with a 3-week intravenous administration of vancomycin, associated to oral rifampicin, followed by oral co-trimoxazole and rifampicin. Six weeks after the first operation, all infection signs had ceased. Because of the length of skeletal defect (8 cm), the choice to perform the reconstruction by “double barrel” free vascularized fibular bone graft [4] from the contralateral side was made. Eighteen cm of the diaphysis of the right fibula were harvested with the fibular vessels dissected up to their origin at the tibio-fibular trunk, preserving a limited muscular cuff around the bone and periosteum. At the middle of the graft, one cm of bone was resected, keeping soft-tissues and vessels, allowing to divide the graft in two segments of 8.5 cm [5]. The grafts were impacted in place, between the tibial extremities, filling the intertibiofibular space. Autologous anterior iliac crest cancellous bone grafts mixed with lyophilized and demineralized allografts were added to fill the entire cavity surrounded by the induced membrane. The struts were fixed by 3 mm external fixation pins to the main external fixator. Bone revascularization was achieved by termino-lateral arterial anastomosis between the graft’s fibular artery and the tibial artery, as well as one termino-terminal anastomosis to a deep vein for venous drainage. The postoperative evolution was uneventful and solid bone union was obtained five months later. Oral antibiotic treatment duration was of 6 months in total. At 2.5 years follow-up, X-rays show solid bone union and some signs of degenerative tibio-talar
Please cite this article as: A. Gkotsi, R. Wirtz and F. Schuind, Microvascular reconstructive techniques in orthopaedic traumatology, Injury, https://doi.org/10.1016/j.injury.2019.10.055
JID: JINJ
ARTICLE IN PRESS
[m5G;November 7, 2019;15:58]
A. Gkotsi, R. Wirtz and F. Schuind / Injury xxx (xxxx) xxx
3
Fig. 3. preoperative status, note the proximal pole fragmentation (a), immediate post operative status (b), X-rays at ten-months time, consolidation confirmed by CT scan (c).
osteo-arthrosis. Clinically, there is no sign of infection, the patient is free of pain, has no walking limitations, but complains of ankle stiffness with joint motion amplitudes of 40°−20°−0°. The 1 cm anisomelia is compensated by the use of an orthopaedic insole. No functional deficit is noted on the donor site. Example case 3 (Fig. 3) A 28 y.o. right-handed roof contractor suffered from a proximal pole carpal scaphoid nonunion of his dominant hand, after a closed injury, four years before presentation. At the time of the accident he had been conservatively treated by a two-month cast immobilization. The nonunion was very proximal, with proximal pole fragmentation, unsuitable for a classical bone autograft or screw fixation. There was no evidence of degenerative osteoarthrosis, being therefore a good indication for a free vascularized osteochondral graft from the medical condyle [6], according to the technique of Sakai–Doi–Brüger [7,8]. The size and shape of the osteochondral graft were evaluated on the basis of a cement template of the defect, inserted after excision of the proximal pole. Osteosynthesis was made by a retrograde headless cannulated screw. The palmar branch of the radial artery and one of its comitant veins were used as recipient vessels for termino-terminal anastomoses with the descending genicular vessels of the graft. No procedure of scapholunate ligament reconstruction took place. The postoperative evolution was uneventful with evidence of bone union at five months. Protrusion of the screw through the cartilage of the reconstructed proximal pole obliged its removal. At ten months, the patient is back to work, demonstrates pain free, normal wrist range of motion and gradually recovers his grasping strength (right, 32 kg; left, 44 kg, Jamar in position II). Discussion These three cases illustrate well the benefits of mastering microsurgical techniques in the treatment of difficult cases of Orthopaedic traumatology. In the first case, it was possible in a single operation performed by an Orthopaedic surgeon in an emergency setting, to ensure the final treatment of a complex open fracture-dislocation by tibio-talar arthrodesis [9], to cover an extensive soft tissue defect exposing the ankle, and to revascularize the ischemic foot [10], via the flap constituting the arterial graft; solid ankle fusion was obtained in only four months and the functional and cosmetic results were excellent. The advantages of early soft tissue coverage in open fractures have been well recognized since the initial publications of Godina [11]. The second case had a less severe initial trauma, but despite the neighboring skin opening at the fibula, the initial surgeon took the risk of an
internal implant instead of external fixation, further impairing soft tissues, resulting in a severe septic nonunion, a classical indication of amputation. The use of microsurgery in two stages – firstly, thorough debridement, insertion of a cement spacer, allowing for local antibiotherapy and development of an induced membrane, of course completed with intravenous then oral antibiotherapy, and secondly a double barrel fibular transfer − allowed to cure the infection [10] and save the limb, resulting in relatively good final function. Indeed, vascularized bone autograft have excellent osteogenic potential and remodel over time, as function of the applied loads. The third reported case illustrates the possibilities of microsurgery to perform custom-made vascularized osteo-chondral bone autografts allowing almost anatomic reconstructions. There are many other indications of microvascular surgery in Orthopaedics. Traumatic amputations are frequent, replantation and toe transfer surgery need mastering the techniques of microanastomosis and expertise in bone, nerve and tendon repair. Not only are free vascularized bone transfers indicated in selected cases of septic or aseptic nonunions, but also in congenital pseudoarthroses and extensive skeletal defects resulting from the resection of bone tumors [12,13]; regarding the latter, the classical technique of reconstruction, when the joints can be preserved, is by fresh frozen allografts. Mid- and long term complications are frequent, including fracture, nonunion and bone resorption [14], problems that are usually not seen after vascularized bone autografts. Finally, microvascular expertise is necessary to perform vascularized allografts, like hand transplantation [15], rare as they may be. The risks of microsurgery are related to the possibility of postoperative thrombosis of the micro-anastomoses. If this occurs on the only left artery of the limb, ischemia affecting the whole extremity will follow. A good technique and performance of terminolateral anastomoses on intact vessels limit the risk, but, the patient has to be, nevertheless, warned in advance. To conclude, regardless of the undisputed complexity of the aforementioned surgical techniques, their application offers reproducible results. This article is a plea to preserve the knowledge and develop the technical abilities of microvascular techniques in the departments of Orthopaedics and Traumatology. Declration of Competing of Interest All authors have nothing to declare in relation to this work. References [1] Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am 2010;41(1):27–37. [2] Giannoudis PV, Faour O, Goff T, Kanakaris N, Dimitriou R. Masquelet technique for the treatment of bone defects: tips-tricks and future directions. Injury Jun 2011;42(6):591–8.
Please cite this article as: A. Gkotsi, R. Wirtz and F. Schuind, Microvascular reconstructive techniques in orthopaedic traumatology, Injury, https://doi.org/10.1016/j.injury.2019.10.055
JID: JINJ 4
ARTICLE IN PRESS
[m5G;November 7, 2019;15:58]
A. Gkotsi, R. Wirtz and F. Schuind / Injury xxx (xxxx) xxx
[3] Masquelet AC. Induced membrane technique: pearls and pitfalls. J Orthop Trauma. 2017;31(Suppl 5):S36–8. [4] Jones NF, Swartz WM, Mears DC, Jupiter JB, Grossman A. The “double barrel” free vascularized fibular bone graft. Plast Reconstr Surg 1988;81(3):378–85. [5] Coulet B, Pflieger J-F, Arnaud S, Lazerges C, Chammas M. Double-barrel fibular graft for metaphyseal areas reconstruction around the knee. Orthop Traumatol Surg Res OTSR 2010;96(8):868–75. [6] Yamamoto H, Jones DB, Moran SL, Bishop AT, Shin AY. The arterial anatomy of the medial femoral condyle and its clinical implications. J Hand Surg Eur Vol Sep 2010;35(7):569–74. [7] Bürger HK, Windhofer C, Gaggl AJ, Higgins JP. Vascularized medial femoral trochlea osteocartilaginous flap reconstruction of proximal pole scaphoid nonunions. J Hand Surg 2013;38(4):690–700. [8] Sakai K, Doi K, Kawai S. Free vascularized thin corticoperiosteal graft. Plast Reconstr Surg Feb 1991;87(2):290–8. [9] Zelle BA, Gruen GS, McMillen RL, Dahl JD. Primary arthrodesis of the tibiotalar joint in severely comminuted high-energy pilon fractures. J Bone Joint Surg Am 2014;96(11):e91.
[10] Wagels M, Rowe D, Senewiratne S, Read T, Theile DR. Soft tissue reconstruction after compound tibial fracture: 235 cases over 12 years. J Plast Reconstr Aesthetic Surg JPRAS 2015;68(9):1276–85. [11] Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78(3):285–92. [12] Schuind F, Burny F, Lejeune FJ. Microsurgical free fibular bone transfer: a technique for reconstruction of large skeletal defects following resection of high– grade malignant tumors. World J Surg 1988;12(3):310–17. [13] Schuind F, Pay-Pay E, Burny F. Vascularized bone transfer for tibial pseudarthrosis. Part II: Vascularized bone and muscle transfers. Exclusive free fibular bone graft. Acta Orthop Belg. 1992;58(Suppl 1):204–9. [14] Delloye C, van Cauter M, Dufrane D, Francq BG, Docquier P-L, Cornu O. Local complications of massive bone allografts: an appraisal of their prevalence in 128 patients. Acta Orthop Belg 2014;80(2):196–204. [15] Schuind F. Hand transplantation and vascularized composite tissue allografts in orthopaedics and traumatology. Orthop Traumatol Surg Res OTSR 2010;96(3):283–90.
Please cite this article as: A. Gkotsi, R. Wirtz and F. Schuind, Microvascular reconstructive techniques in orthopaedic traumatology, Injury, https://doi.org/10.1016/j.injury.2019.10.055
JID: JINJ
[m5G;November 7, 2019;15:58]
Injury xxx (xxxx) xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
Microvascular reconstructive techniques in orthopaedic traumatology ✩ A. Gkotsi a, R. Wirtz b, F. Schuind a,∗ a b
Department of Orthopaedics and Traumatology, Cliniques Universitaires de Bruxelles, Hôpital Erasme, Université libre de Bruxelles, Brussels, Belgium Department of Orthopaedics and Traumatology, Centre Hospitalier de L’Ardenne, Libramont, Belgium
a r t i c l e
i n f o
Article history: Available online xxx Keywords: Free flaps Fibular graft Vascularized graft Microanastomosis
a b s t r a c t Great evolution has taken place in Orthopaedic Traumatology, regarding techniques, surgical means and equipment. However, we still encounter complicated cases of limb trauma that necessitate microvascular reconstruction. Through three different illustrative cases (one emergency foot revascularization by a free flap, covering an ankle arthrodesis and bridging the anterior tibial artery, one cure of a complex infected tibial non-union with extensive skeletal defect by double barrel fibular transfer and one osteo-chondral reconstruction of the scaphoid proximal pole using a vascularized graft harvested from the femoral medial condyle), the authors remind the Orthopaedic community about the benefits of microsurgery, especially if used in proper indication and timing. This article is a plea to preserve the knowledge and develop the technical abilities of microvascular techniques in the departments of Orthopaedics and Traumatology. © 2019 Elsevier Ltd. All rights reserved.
Introduction Much progress has been made over the years in Orthopaedic Traumatology. New imaging facilities have allowed to better define operative indications. Many bone fixation implants are available, allowing minimally invasive techniques of insertion. Bone allografts and substitutes are at our disposal to fill up bone defects. Protocols of faster return to patients’ previous activities are routine. These methods, heavily promoted by our biomedical industrial partners, give the false impression that all problems regarding management of complex traumas have now been solved. However, final success needs solid bone healing, or there will be, sooner or later, failure of the osteosynthesis. Indeed, nonunions remain frequent and challenging to treat, especially if septic, and some cases still end up in an amputation. Microvascular techniques are available to prevent the infection of an open fracture and to provide a relatively easy and safe solution to bone defects, whether infected or not. However, in many departments of Orthopaedics and Traumatology, microsurgery is still regarded as complex, time consuming and leading to questionable outcomes. In many programs, microsurgical techniques are forgotten or have been cancelled from the basic training of the Orthopaedic surgeon, except maybe for those specializing in hand surgery, who will not be later in charge of
✩ This paper is part of a Supplement supported by the European Federation of Societies of Microsurgery (EFSM) and the Serbian Society for Reconstructive Microsurgery (SSRM). ∗ Corresponding author. E-mail address: [email protected] (F. Schuind).
cases like open infected nonunions of the tibia. The possibilities of microvascular techniques are therefore not well known in the surgical Orthopedic community, and many Orthopedic surgeons don’t think of microsurgery when faced to a major open fracture or a complex posttraumatic defect. Instead they try all other ‘’simpler’’ techniques and when microsurgery seems the only left solution, they refer the case with great delay to a plastic surgeon, who masters the microvascular techniques, but has frequently limited background in bone fixation and fracture healing. Microsurgery is part of the Orthopaedic armamentarium, like arthroscopy for the treatment of selected articular fractures. When there is indication for microsurgical reconstruction in a traumatic case, it should not be ignored or delayed because of insufficient competence among the treating surgeons. This article presents three exemplative cases of the efficacy of microsurgical techniques to solve complex traumatic problems. Example case 1 (Fig. 1) A 22 y.o. student was the victim of a motorcycle accident, resulting among other lesions in a Gustilo type III-C open fracturedislocation of the ankle, with massive contamination by soil and dirty canal water. More precisely, there was a comminuted tibial pilon fracture, an anterior tibio-talar dislocation, severe chondral defects at the talar dome, and foot devascularization. Immediate reduction allowed some restoration of the blood supply to the foot, but the traumatic disruption of the anterior tibial pedicle, rendered the spasmed posterior tibial artery the foot’s only blood supply. A large soft-tissue defect, centered on the anterolateral aspect of
https://doi.org/10.1016/j.injury.2019.10.055 0020-1383/© 2019 Elsevier Ltd. All rights reserved.
Please cite this article as: A. Gkotsi, R. Wirtz and F. Schuind, Microvascular reconstructive techniques in orthopaedic traumatology, Injury, https://doi.org/10.1016/j.injury.2019.10.055
JID: JINJ 2
ARTICLE IN PRESS
[m5G;November 7, 2019;15:58]
A. Gkotsi, R. Wirtz and F. Schuind / Injury xxx (xxxx) xxx
Fig. 1. Traumatic status (a, b), immediate post operative status: note the well vascularized free flap and foot and the tibio-calcaneal external fixator (c), clinical aspect one year after surgery (d), X-rays ten years after trauma (e).
Fig. 2. Pre-operative status (a), Postoperative X-rays, note the use of external fixation pins to stabilize the grafts (b), X-rays 2,5 years after the initial trauma (c).
the ankle, exposed the destroyed joint. The patient rapidly underwent debridement, lavage and immediate reconstruction. Given the non-reconstructible character of the ankle fracturedislocation, immediate tibio-talar arthrodesis was performed by removal of the remains of cartilage, interposition of cancellous bone autografts, harvested from the proximal tibial metaphysis through a small cortical window, and external fixation. Bone coverage was immediately performed by a 10 × 14 cm lateral antebrachial fasciocutaneous free flap (Chinese flap). Termino-terminal microvascular anastomoses were performed proximally between the flap’s radial artery and the anterior tibial artery at a non-injured level and with the dorsalis pedis artery distally, restoring through the flap the arterial flow to the foot (bridging by-pass flap). One of the flap’s radial vena comitant was anastomosed to the anterior tibial vein and a superficial radial vein to the lesser saphenous vein. The donor site was immediately covered by a non-expanded dermoepidermal skin graft. The postoperative evolution was uneventful. Bone healing of the arthrodesis was achieved after four months. At ten years follow-up, tibio-talar fusion is total, subtalar and increased mid-tarsal motion allow an apparently normal foot motion and the patient has practically no functional limitation. He is now an active realty and practices various sports. Example case 2 (Fig. 2) A 47 y.o. smoker military patient was the victim of a left closed tibial pilon fracture (associated open fibular fracture). He underwent plate fixation in another hospital, but got MRSA-infected. Multiple operations were then performed and the patient was transferred to our institution nine months later, with a large bone defect in the distal diaphysis of the tibia, discharging pus. Although the original fracture line was intra-articular, the ankle joint was
still relatively preserved, but ankylosed in 40° equinus. The preoperative angiogram revealed interruption of the anterior tibial artery above the nonunion but patency of the posterior tibial artery. A first operation according to Masquelet [1–3] took place, with radical excision of all necrotic and infected bone at the nonunion site, insertion of a cement spacer with gentamicin and vancomycin, and skeletal stabilization by Hoffmann tibio-talar external fixation. Subsequently, the patient was treated with a 3-week intravenous administration of vancomycin, associated to oral rifampicin, followed by oral co-trimoxazole and rifampicin. Six weeks after the first operation, all infection signs had ceased. Because of the length of skeletal defect (8 cm), the choice to perform the reconstruction by “double barrel” free vascularized fibular bone graft [4] from the contralateral side was made. Eighteen cm of the diaphysis of the right fibula were harvested with the fibular vessels dissected up to their origin at the tibio-fibular trunk, preserving a limited muscular cuff around the bone and periosteum. At the middle of the graft, one cm of bone was resected, keeping soft-tissues and vessels, allowing to divide the graft in two segments of 8.5 cm [5]. The grafts were impacted in place, between the tibial extremities, filling the intertibiofibular space. Autologous anterior iliac crest cancellous bone grafts mixed with lyophilized and demineralized allografts were added to fill the entire cavity surrounded by the induced membrane. The struts were fixed by 3 mm external fixation pins to the main external fixator. Bone revascularization was achieved by termino-lateral arterial anastomosis between the graft’s fibular artery and the tibial artery, as well as one termino-terminal anastomosis to a deep vein for venous drainage. The postoperative evolution was uneventful and solid bone union was obtained five months later. Oral antibiotic treatment duration was of 6 months in total. At 2.5 years follow-up, X-rays show solid bone union and some signs of degenerative tibio-talar
Please cite this article as: A. Gkotsi, R. Wirtz and F. Schuind, Microvascular reconstructive techniques in orthopaedic traumatology, Injury, https://doi.org/10.1016/j.injury.2019.10.055
JID: JINJ
ARTICLE IN PRESS
[m5G;November 7, 2019;15:58]
A. Gkotsi, R. Wirtz and F. Schuind / Injury xxx (xxxx) xxx
3
Fig. 3. preoperative status, note the proximal pole fragmentation (a), immediate post operative status (b), X-rays at ten-months time, consolidation confirmed by CT scan (c).
osteo-arthrosis. Clinically, there is no sign of infection, the patient is free of pain, has no walking limitations, but complains of ankle stiffness with joint motion amplitudes of 40°−20°−0°. The 1 cm anisomelia is compensated by the use of an orthopaedic insole. No functional deficit is noted on the donor site. Example case 3 (Fig. 3) A 28 y.o. right-handed roof contractor suffered from a proximal pole carpal scaphoid nonunion of his dominant hand, after a closed injury, four years before presentation. At the time of the accident he had been conservatively treated by a two-month cast immobilization. The nonunion was very proximal, with proximal pole fragmentation, unsuitable for a classical bone autograft or screw fixation. There was no evidence of degenerative osteoarthrosis, being therefore a good indication for a free vascularized osteochondral graft from the medical condyle [6], according to the technique of Sakai–Doi–Brüger [7,8]. The size and shape of the osteochondral graft were evaluated on the basis of a cement template of the defect, inserted after excision of the proximal pole. Osteosynthesis was made by a retrograde headless cannulated screw. The palmar branch of the radial artery and one of its comitant veins were used as recipient vessels for termino-terminal anastomoses with the descending genicular vessels of the graft. No procedure of scapholunate ligament reconstruction took place. The postoperative evolution was uneventful with evidence of bone union at five months. Protrusion of the screw through the cartilage of the reconstructed proximal pole obliged its removal. At ten months, the patient is back to work, demonstrates pain free, normal wrist range of motion and gradually recovers his grasping strength (right, 32 kg; left, 44 kg, Jamar in position II). Discussion These three cases illustrate well the benefits of mastering microsurgical techniques in the treatment of difficult cases of Orthopaedic traumatology. In the first case, it was possible in a single operation performed by an Orthopaedic surgeon in an emergency setting, to ensure the final treatment of a complex open fracture-dislocation by tibio-talar arthrodesis [9], to cover an extensive soft tissue defect exposing the ankle, and to revascularize the ischemic foot [10], via the flap constituting the arterial graft; solid ankle fusion was obtained in only four months and the functional and cosmetic results were excellent. The advantages of early soft tissue coverage in open fractures have been well recognized since the initial publications of Godina [11]. The second case had a less severe initial trauma, but despite the neighboring skin opening at the fibula, the initial surgeon took the risk of an
internal implant instead of external fixation, further impairing soft tissues, resulting in a severe septic nonunion, a classical indication of amputation. The use of microsurgery in two stages – firstly, thorough debridement, insertion of a cement spacer, allowing for local antibiotherapy and development of an induced membrane, of course completed with intravenous then oral antibiotherapy, and secondly a double barrel fibular transfer − allowed to cure the infection [10] and save the limb, resulting in relatively good final function. Indeed, vascularized bone autograft have excellent osteogenic potential and remodel over time, as function of the applied loads. The third reported case illustrates the possibilities of microsurgery to perform custom-made vascularized osteo-chondral bone autografts allowing almost anatomic reconstructions. There are many other indications of microvascular surgery in Orthopaedics. Traumatic amputations are frequent, replantation and toe transfer surgery need mastering the techniques of microanastomosis and expertise in bone, nerve and tendon repair. Not only are free vascularized bone transfers indicated in selected cases of septic or aseptic nonunions, but also in congenital pseudoarthroses and extensive skeletal defects resulting from the resection of bone tumors [12,13]; regarding the latter, the classical technique of reconstruction, when the joints can be preserved, is by fresh frozen allografts. Mid- and long term complications are frequent, including fracture, nonunion and bone resorption [14], problems that are usually not seen after vascularized bone autografts. Finally, microvascular expertise is necessary to perform vascularized allografts, like hand transplantation [15], rare as they may be. The risks of microsurgery are related to the possibility of postoperative thrombosis of the micro-anastomoses. If this occurs on the only left artery of the limb, ischemia affecting the whole extremity will follow. A good technique and performance of terminolateral anastomoses on intact vessels limit the risk, but, the patient has to be, nevertheless, warned in advance. To conclude, regardless of the undisputed complexity of the aforementioned surgical techniques, their application offers reproducible results. This article is a plea to preserve the knowledge and develop the technical abilities of microvascular techniques in the departments of Orthopaedics and Traumatology. Declration of Competing of Interest All authors have nothing to declare in relation to this work. References [1] Masquelet AC, Begue T. The concept of induced membrane for reconstruction of long bone defects. Orthop Clin North Am 2010;41(1):27–37. [2] Giannoudis PV, Faour O, Goff T, Kanakaris N, Dimitriou R. Masquelet technique for the treatment of bone defects: tips-tricks and future directions. Injury Jun 2011;42(6):591–8.
Please cite this article as: A. Gkotsi, R. Wirtz and F. Schuind, Microvascular reconstructive techniques in orthopaedic traumatology, Injury, https://doi.org/10.1016/j.injury.2019.10.055
JID: JINJ 4
ARTICLE IN PRESS
[m5G;November 7, 2019;15:58]
A. Gkotsi, R. Wirtz and F. Schuind / Injury xxx (xxxx) xxx
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Please cite this article as: A. Gkotsi, R. Wirtz and F. Schuind, Microvascular reconstructive techniques in orthopaedic traumatology, Injury, https://doi.org/10.1016/j.injury.2019.10.055