Multimodal Approach in the Reconstruction of Firing Defects of the Lower Limbs (Clinical Case)

Abstract

According connection with the global trends, manifested by an increase in the number of illegal firearms, an increase in social, political, ethnic, racial and religious conflicts, accompanied by the use of firearms, the problem of treating gunshot wounds is becoming increasingly important. It is especially acute during local and widespread hostilities, during peacekeeping missions, anti-terrorist operations, in cases of massive gunshot wounds. The aim of the work is to improve the surgical tactics in the reconstruction of severe wounded with soft tissue gunshot defects due to the multimodal scheme. Improvement of dynamic audio and thermal imaging diagnostics of the damaged anatomical area, analysis and modeling of the shape and direction of movement of the donor flap. A clinical case of closure of a bullet-through bullet wound of the left thigh (03.25.19 year) with a gunshot multi-fragment fracture of the left femoral pigtail in the middle third, damage to the superficial femoral vein and marginal damage to the superficial femoral artery was demonstrated.In the preoperative period, the first stage was dynamic digital thermography of the surface of wounds and surrounding soft tissues, which allowed thermal imaging to assess the state of damaged structures, to identify areas of preservation of blood supply. The second stage was the audio control of the identified areas of the "supply" - perforating vessels with a comparison of the blood flow velocity. The results obtained formed the basis for modeling the donor zone and monitoring its movement. The described clinical case of soft tissue defect closure consisted of three stages: The first stage - preparatory (diagnostics and cleaning) - (9 days of inpatient treatment) - repeated surgical treatment of wounds using low-frequency ultrasound (cavitation of the wound surface), controlled negative pressure (in a pulsed mode - 125 mm Hg), the imposition of secondary early sutures, due to which the wound area decreased by 35% compared to the wound area at the time of admission to the VICC of the Southern region. The second stage - the final (reconstructive) - (12 days after the injury) - plastic reconstruction of the defect of the posterior surface of the middle third of the left thigh by moving a ball-and-socket flap from the outer surface of the thigh using the Keystone technique. Conclusions: A multimodal algorithm with dynamic control of changes in the perfusion of the defect zone and surrounding structures is at the heart of the successful reconstruction of a gunshot defect in the soft tissues of the lower extremities, which reduces the treatment time by 1.5 times.