- Email: [email protected]
Flap within a flap: The benefit of a musculocutaneous flap over a pure muscle flap
286
Correspondence and communications Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan E-mail address: [email protected]
ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.08.011
Flap within a flap: The benefit of a musculocutaneous flap over a pure muscle flap Dear Sir, Open lower limb fractures are a difficult problem and often present with significant bone loss and soft tissue damage, particularly in patients with contaminated crush injuries.1,3 Despite an initial thorough wound debridement, there maybe further soft tissue loss due infection or further compromise of the residual lower limb soft tissue vascularity. The recent BAPRAS/BOA National Lower Limb Guidelines re-emphasised the importance of several aspects of lower limb trauma management, including early wound closure.2 Following reconstruction of these defects it is sometimes necessary to undertake secondary wound debridement and closure by import of tissue in the form of a secondary free-flap to cover a new adjacent defect.4 We present a challenging case and a practical method to treat this potentially intractable problem in an area with limited surgical management options, which has already had successful free-flap reconstruction to close the initial soft tissue defect. The case in question was that of a 31-year-old man who sustained an open fracture to his right foot following a crush injury caused by a fork lift truck. The patient was taken to theatre for immediate exploration and debridement and was found to have sustained extensive soft tissue damage with skin loss over his hind foot and over 80% calcaneal bone loss. This was stabilised on the day of injury with external fixation and he returned to theatre on day 3 post-injury for definitive internal calcaneal fixation. On day 4 of admission, the patient underwent further debridement of his right heel, with coverage of the soft tissue defect and exposed bridging metal plate with a free gracilis musculocutaneous flap. The flap was harvested with a longitudinal skin paddle and anastomosed end to end to the anterior tibial artery and vein, at the level of the extensor retinaculum. Unfortunately, distal tissue and underlying bone necrosis led to exposed metalwork which required further debridement, thus leading to a large defect. As a result of the poor residual bone quality and increased bone necrosis adjacent to the exposed metalwork, the patient developed osteomyelitis of his calcaneum five weeks post-injury and required removal of the calcaneal plate, inpatient
Figure 1 Covering of the secondary defect with a perforator based fasciocutaneous propeller flap, raised on the previous free gracilis musculocutaneous flap.
administration of intravenous antibiotics and topical negative pressure dressings to the open fracture site and associated dead space. Overall, a total of 5 debridements of necrotic soft tissue adjacent to the free-flap were carried out over a 7-week period following the reconstruction, with the first debridement taking place 9 days after the primary free-flap procedure. This gentleman now presented with a very difficult problem. His right heel had a large soft tissue defect at the distal end of a healthy musculocutaneous gracilis free-flap with exposed bone at his fracture site and grumbling osteomyelitis. The decision was made to further debride the osteomyelitis and cover this secondary defect with a perforator based fasciocutaneous propeller flap, raised on the previous free gracilis musculocutaneous flap, 7 weeks after the initial reconstruction. The flap was isolated on a single perforator, rotated through 120 , with the distal portion de-epithelialised and transposed into the cavity to obliterate the dead space created by the bone loss and plate removal (Figure 1). Subsequently, the patient’s wound healing, function and mobility has continued to improve four months following the initial trauma (Figure 2). The soft tissue of patients with significant degloving injuries may completely demarcate to obviously viable and
Figure 2
Healed wound 4 months post-trauma.
Correspondence and communications non-viable tissue prior to reconstruction. However, due to the complexity of the injury, the associated fracture and bony fixation required, underlying deep seated infection may result requiring further debridements and a resultant delayed soft tissue defect. This case highlights the potential benefits of a musculocutaneous flap over a pure muscle flap, as it provided secondary flap options in addition to giving a more robust plantar tissue support. This case also demonstrated that fasciocutaneous perforator flaps can be confidently raised on a previous musculocutaneous free or pedicle flap within weeks of the primary reconstruction, resulting in further reconstructive options to these otherwise notoriously difficult wounds.
Conflicts of interest None of the authors have any conflicting interests.
Funding Not applicable.
References 1. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004 Nov;114(6):1457e66. 2. British Association of Plastic, Reconstructive and Aesthetic Surgeons. Standards for the management of open fractures of the lower limb. Royal Society of Medicine Press; 2009. 3. Schwabe P, Haas NP, Schaser KD. Fractures of the extremities with severe open soft tissue damage. Initial management and reconstructive treatment strategies. Unfallchirurg 2010 Aug; 113(8):647e70 [quiz 671e2]. 4. Lo CH, Leung M, Baillieu C, Chong EWT, Cleland H. Trauma centre experience: flap reconstruction of traumatic lower limb injuries. ANZ J Surg 2007;77(8):690e4.
A.E. Sayers R.J. Bramhall A. Akali Department of Plastic Surgery, Hull and East Yorkshire NHS Trust, Castle Hill Hospital, United Kingdom E-mail address: [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.08.010
Tetanus prophylaxis: Are we getting it right?
Dear Sir, A significant proportion of the work undertaken by Plastic Surgical and Burns teams involve traumatic wounds. Many of these wounds are susceptible to infection by the
287 Gram-positive bacterium Clostridium Tetani thereby giving rise to potential clinical tetanus. It is therefore imperative that those assessing such wounds have a thorough understanding of the guidelines, as outlined by the Department of Health, pertaining to the prophylaxis against such infection. The prophylaxis may include the tetanus toxoid (TT) vaccine (commonly administered as Revaxis) and/or tetanus immunoglobulin (TIG), depending on the previous immunisation history of the patient and the type of wound encountered (Table 1). Highrisk tetanus-prone wounds require prophylaxis, regardless of immunisation history, with tetanus immunoglobulin1 as the vaccine does not provide adequate protection in the early phases of infection. This letter provides a snapshot of current practices related to tetanus prophylaxis in Plastic Surgery Centres across the United Kingdom (UK). To identify adherence to the current guidelines we performed a telephone survey to assess the current clinical practice of tetanus prophylaxis amongst plastic surgical trainees working within the UK. 32 plastic surgery units were contacted over the space of two days. The response rate was 87.5% (n Z 28). 81.25% (n Z 26) were Senior House Officers (SHO) and 6.25% (n Z 2) were Specialist Registrars (SpR). The questionnaire consisted of asking two case-scenarios along with a question on the classification of tetanus-prone wounds (Table 2). Out of 28 plastic surgical on-call trainees contacted only 7.14% (n Z 2) correctly identified the need for immunoglobulin (TIG) in case 1. Worryingly, case 1 represented a clear case of being at ‘high-risk’ for tetanus infection. Also, only 7.14% (n Z 2) trainees (both SHO’s) correctly identified the needs for TT þ TIG in case 2. In question 3, 25% (n Z 7) trainees ‘correctly’ identified all the scenarios provided as tetanus-prone wounds. However, only 1 trainee provided the correct reason. Other reasons provided were: ‘all because contaminated’; ‘all but not sure why’; ‘all wounds are tetanus-prone’; and; ‘all wounds are contaminated so all are tetanus prone’. 8 (28.57%) out of the 28 trainees suggested giving TT (Revaxis) to case 1, where no vaccine was actually required. Tetanus infection, a notifiable disease in the UK with an incidence of 0.2 per million,2 is caused by the exotoxin tetanospasmin released from Clostridium Tetani spores in anaerobic conditions and within devitalised tissues.3 These spores are concentrated in a number of environments most notably in soil and manure. The incubation period ranges between 1 and 60 days.3 Worldwide, neonatal tetanus is the most prevalent and is caused by the use of non-sterile surgical equipment during separation of the umbilical cord at birth.4 In developed countries the majority of cases occur in patients aged over 65 years of age.2 Within the UK this probably results from the fact that primary immunisations programmes were only rolled out nationally in the early 1960’s. Symptoms of tetanus infection are variable and depend on severity of the infection: local (muscle spasms); general (systemic unwell, generalised skeletal muscle spasms, rigidity, lockjaw, opisthotonus), and; cephalic (facial spasms and symptoms associated with infection of the spinal cord).3 Immunisation schedules are combined with vaccinations for other diseases especially in children (Table 3). Five full courses of tetanus-containing vaccination provides lifelong immunity.1
Correspondence and communications Department of Plastic and Reconstructive Surgery, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan E-mail address: [email protected]
ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.08.011
Flap within a flap: The benefit of a musculocutaneous flap over a pure muscle flap Dear Sir, Open lower limb fractures are a difficult problem and often present with significant bone loss and soft tissue damage, particularly in patients with contaminated crush injuries.1,3 Despite an initial thorough wound debridement, there maybe further soft tissue loss due infection or further compromise of the residual lower limb soft tissue vascularity. The recent BAPRAS/BOA National Lower Limb Guidelines re-emphasised the importance of several aspects of lower limb trauma management, including early wound closure.2 Following reconstruction of these defects it is sometimes necessary to undertake secondary wound debridement and closure by import of tissue in the form of a secondary free-flap to cover a new adjacent defect.4 We present a challenging case and a practical method to treat this potentially intractable problem in an area with limited surgical management options, which has already had successful free-flap reconstruction to close the initial soft tissue defect. The case in question was that of a 31-year-old man who sustained an open fracture to his right foot following a crush injury caused by a fork lift truck. The patient was taken to theatre for immediate exploration and debridement and was found to have sustained extensive soft tissue damage with skin loss over his hind foot and over 80% calcaneal bone loss. This was stabilised on the day of injury with external fixation and he returned to theatre on day 3 post-injury for definitive internal calcaneal fixation. On day 4 of admission, the patient underwent further debridement of his right heel, with coverage of the soft tissue defect and exposed bridging metal plate with a free gracilis musculocutaneous flap. The flap was harvested with a longitudinal skin paddle and anastomosed end to end to the anterior tibial artery and vein, at the level of the extensor retinaculum. Unfortunately, distal tissue and underlying bone necrosis led to exposed metalwork which required further debridement, thus leading to a large defect. As a result of the poor residual bone quality and increased bone necrosis adjacent to the exposed metalwork, the patient developed osteomyelitis of his calcaneum five weeks post-injury and required removal of the calcaneal plate, inpatient
Figure 1 Covering of the secondary defect with a perforator based fasciocutaneous propeller flap, raised on the previous free gracilis musculocutaneous flap.
administration of intravenous antibiotics and topical negative pressure dressings to the open fracture site and associated dead space. Overall, a total of 5 debridements of necrotic soft tissue adjacent to the free-flap were carried out over a 7-week period following the reconstruction, with the first debridement taking place 9 days after the primary free-flap procedure. This gentleman now presented with a very difficult problem. His right heel had a large soft tissue defect at the distal end of a healthy musculocutaneous gracilis free-flap with exposed bone at his fracture site and grumbling osteomyelitis. The decision was made to further debride the osteomyelitis and cover this secondary defect with a perforator based fasciocutaneous propeller flap, raised on the previous free gracilis musculocutaneous flap, 7 weeks after the initial reconstruction. The flap was isolated on a single perforator, rotated through 120 , with the distal portion de-epithelialised and transposed into the cavity to obliterate the dead space created by the bone loss and plate removal (Figure 1). Subsequently, the patient’s wound healing, function and mobility has continued to improve four months following the initial trauma (Figure 2). The soft tissue of patients with significant degloving injuries may completely demarcate to obviously viable and
Figure 2
Healed wound 4 months post-trauma.
Correspondence and communications non-viable tissue prior to reconstruction. However, due to the complexity of the injury, the associated fracture and bony fixation required, underlying deep seated infection may result requiring further debridements and a resultant delayed soft tissue defect. This case highlights the potential benefits of a musculocutaneous flap over a pure muscle flap, as it provided secondary flap options in addition to giving a more robust plantar tissue support. This case also demonstrated that fasciocutaneous perforator flaps can be confidently raised on a previous musculocutaneous free or pedicle flap within weeks of the primary reconstruction, resulting in further reconstructive options to these otherwise notoriously difficult wounds.
Conflicts of interest None of the authors have any conflicting interests.
Funding Not applicable.
References 1. Yazar S, Lin CH, Wei FC. One-stage reconstruction of composite bone and soft-tissue defects in traumatic lower extremities. Plast Reconstr Surg 2004 Nov;114(6):1457e66. 2. British Association of Plastic, Reconstructive and Aesthetic Surgeons. Standards for the management of open fractures of the lower limb. Royal Society of Medicine Press; 2009. 3. Schwabe P, Haas NP, Schaser KD. Fractures of the extremities with severe open soft tissue damage. Initial management and reconstructive treatment strategies. Unfallchirurg 2010 Aug; 113(8):647e70 [quiz 671e2]. 4. Lo CH, Leung M, Baillieu C, Chong EWT, Cleland H. Trauma centre experience: flap reconstruction of traumatic lower limb injuries. ANZ J Surg 2007;77(8):690e4.
A.E. Sayers R.J. Bramhall A. Akali Department of Plastic Surgery, Hull and East Yorkshire NHS Trust, Castle Hill Hospital, United Kingdom E-mail address: [email protected] ª 2013 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.bjps.2013.08.010
Tetanus prophylaxis: Are we getting it right?
Dear Sir, A significant proportion of the work undertaken by Plastic Surgical and Burns teams involve traumatic wounds. Many of these wounds are susceptible to infection by the
287 Gram-positive bacterium Clostridium Tetani thereby giving rise to potential clinical tetanus. It is therefore imperative that those assessing such wounds have a thorough understanding of the guidelines, as outlined by the Department of Health, pertaining to the prophylaxis against such infection. The prophylaxis may include the tetanus toxoid (TT) vaccine (commonly administered as Revaxis) and/or tetanus immunoglobulin (TIG), depending on the previous immunisation history of the patient and the type of wound encountered (Table 1). Highrisk tetanus-prone wounds require prophylaxis, regardless of immunisation history, with tetanus immunoglobulin1 as the vaccine does not provide adequate protection in the early phases of infection. This letter provides a snapshot of current practices related to tetanus prophylaxis in Plastic Surgery Centres across the United Kingdom (UK). To identify adherence to the current guidelines we performed a telephone survey to assess the current clinical practice of tetanus prophylaxis amongst plastic surgical trainees working within the UK. 32 plastic surgery units were contacted over the space of two days. The response rate was 87.5% (n Z 28). 81.25% (n Z 26) were Senior House Officers (SHO) and 6.25% (n Z 2) were Specialist Registrars (SpR). The questionnaire consisted of asking two case-scenarios along with a question on the classification of tetanus-prone wounds (Table 2). Out of 28 plastic surgical on-call trainees contacted only 7.14% (n Z 2) correctly identified the need for immunoglobulin (TIG) in case 1. Worryingly, case 1 represented a clear case of being at ‘high-risk’ for tetanus infection. Also, only 7.14% (n Z 2) trainees (both SHO’s) correctly identified the needs for TT þ TIG in case 2. In question 3, 25% (n Z 7) trainees ‘correctly’ identified all the scenarios provided as tetanus-prone wounds. However, only 1 trainee provided the correct reason. Other reasons provided were: ‘all because contaminated’; ‘all but not sure why’; ‘all wounds are tetanus-prone’; and; ‘all wounds are contaminated so all are tetanus prone’. 8 (28.57%) out of the 28 trainees suggested giving TT (Revaxis) to case 1, where no vaccine was actually required. Tetanus infection, a notifiable disease in the UK with an incidence of 0.2 per million,2 is caused by the exotoxin tetanospasmin released from Clostridium Tetani spores in anaerobic conditions and within devitalised tissues.3 These spores are concentrated in a number of environments most notably in soil and manure. The incubation period ranges between 1 and 60 days.3 Worldwide, neonatal tetanus is the most prevalent and is caused by the use of non-sterile surgical equipment during separation of the umbilical cord at birth.4 In developed countries the majority of cases occur in patients aged over 65 years of age.2 Within the UK this probably results from the fact that primary immunisations programmes were only rolled out nationally in the early 1960’s. Symptoms of tetanus infection are variable and depend on severity of the infection: local (muscle spasms); general (systemic unwell, generalised skeletal muscle spasms, rigidity, lockjaw, opisthotonus), and; cephalic (facial spasms and symptoms associated with infection of the spinal cord).3 Immunisation schedules are combined with vaccinations for other diseases especially in children (Table 3). Five full courses of tetanus-containing vaccination provides lifelong immunity.1