Delayed microsurgical reconstruction of the extremities for complex soft-tissue injuries

Abstract

The treatment of severe wounds of the extremities, characterized by large posttraumatic tissue loss, represents a clinical problem difficult to resolve, especially when the lesion is surrounded by large areas of ischemic distrophic tissue which progressively aggravate and extend the initial lesion, with frequent exposure of bone and joint structures making the amputation of the limb an inevitable outcome. The authors present their experience based on combined treatments by medical support methods such as hyperbaric oxygen (HBO) and vacuum-assisted closure therapy (VAC) and microsurgical reconstruction of the limbs, within a precise therapeutic protocol. The use of this protocol in appropriate times and ways allowed us to successfully treat severe posttraumatic sequelae of the limbs, avoiding the delayed healing typical of these pathologies, both on the donor site of the flap and on the repaired area, and avoiding unsuitable microsurgical reconstruction of limbs, allowing satisfactory morpho-functional restoration and a reduction of the hospitalization period.

Creation of a prevascularized site for cell transplantation in rats

“…Previous studies suggested the VAC treatment to stimulate angiogenesis and the ingrowth of granulation tissue [48,49]. Up to date, two studies have examined the effect of a combined HBO and VAC therapy on wound healing [50,51] in reconstructive surgery.…”

Functional donor-site morbidity after soleus muscle-flap procedure in the treatment of lower limb severe injuries

“…This flap is simpler to use compared to a free flap and may be transferred with a reliable pedicle with satisfactory cosmetic outcome of the donor site. Adequate coverage of the soft-tissue and bone defect after debridement may be ensured due to optimal tissue vascularisation, removing dead space, improving vascularity and enhancing leukocyte function [7,9], as well as avoiding the risk of vascular steal syndrome when the anterior tibial artery is damaged. However, the Soleus muscle may not be available due to high energy trauma or subsequent infection and may cause further motor function loss to an existing injured lower limb [6].…”

“…Literature has described treatment "guidelines" regarding severe lesions of the lower limbs, with aggressive debridement of devitalised and contaminated tissue to reduce the rate of nonunion, osteomyelitis and amputation [6,7] as well as the use of free flap transfer, within 24-72 hours [8].…”

“…We propose three steps to treat similar injuries affecting the medium-lower third of the leg: 1. aggressive early multiple debridement. In case of bone substance loss, an external fixator is applied, and the wound is adequately prepared using vacuum assisted closure therapy and/or hyperbaric oxygen therapy, in combination with specific antibiotic treatment and antibiogram, to prevent multi-resistant bacteria infection [7]. 2.…”

Lower Extremity Trauma: A Multidimensional Reconstructive Approach with Hyperbaric Oxygen Therapy

“…The timing of soft tissue reconstruction after lower extremity trauma is not well detailed in the literature. It is defined as preferably within 2 weeks of the injury; however, the patient should be medically optimized and the wounds clean [ 1 , 10 ]. If this is not the case, it is advisable to delay the time to reconstruction by employing neoadjuvant therapies such as hyperbaric oxygen (HBO) therapy or vacuum-assisted closure (VAC) therapy, and to perform further debridement to clean the wound [ 10 ].…”