Microsurgery and external fixation in orthoplastic reconstruction of tibial injuries

Abstract

Background “Orthoplastics” is a relatively new approach to lower limb reconstruction, where an integration of both plastic and orthopedic expertise is required, together with the availability of well-equipped facilities. Acute shortening and long-term frames for lengthening are generally considered alternatives to length preservation and soft tissue microsurgical reconstruction, but an integration of external fixation and reconstructive microsurgery is gaining an increasing role with refinements of joint approaches.

Material and methods Data on sixteen patients who underwent microsurgical lower limb reconstruction and external fixation with an orthoplastic approach, following acute or chronic tibial injury, were retrospectively reviewed. All patients presented a post traumatic soft tissue defect associated with a Gustilo III tibial fracture or a tibial septic pseudarthrosis. Data on type and timing of bone and soft tissue reconstruction, outcomes, complications and need for re-operation were extrapolated and compared to an historic group of patients treated with an orthopedic-based approach.

Results In the orthoplastic group, soft tissues were reconstructed with an ALT flap in most cases; a muscle-sparing VL or ALT-VL chimeric flap was necessary in cases with a very extensive defect. In the orthopedic group, soft tissues were left to heal by second intention or patients were lately referred to plastic surgeons. Statistical comparison between the two groups has showed significant differences on the following data: time for soft tissue healing, time to bone union, number of reinterventions, post-operative deep infection rate, time to return to work.

Conclusion The orthoplastic approach to complex leg defects yields shorter treatment time and better functional results compared to the orthopedic-based approach. External fixation and microsurgical reconstruction are not necessarily alternative procedures but can integrate in an orthoplastic path to address at best both soft tissue and bone reconstruction.

Zusammenfassung

Hintergrund Die „Orthoplastie“ ist ein relativ neuer Ansatz zur Rekonstruktion der unteren Extremitäten, der eine Integration von plastisch-chirurgischer und orthopädischer Fachkompetenz sowie die Verfügbarkeit gut ausgestatteter Einrichtungen erfordert. Die akute Verkürzung mit längerfristig angelegtem Rahmen zur Verlängerung gelten generell als Alternativen zum Längenerhalt mit mikrochirurgischer Weichteilrekonstruktion, doch gewinnt die integrierte Behandlung mit Fixateur externe und rekonstruktiver Mikrochirurgie zunehmend an Bedeutung und die gemeinsamen Ansätze werden weiter verfeinert.

Material und Methoden Es erfolgte eine retrospektive Analyse der Daten von sechzehn Patienten, die sich nach akuter oder chronischer Tibiaverletzung einem orthoplastischen Verfahren mit mikrochirurgischer Rekonstruktion der unteren Extremität und Fixateur externe unterzogen. Bei allen Patienten fand sich ein posttraumatischer Weichteildefekt in Verbindung mit einer Tibiafraktur vom Grad III nach Gustilo oder einer septischen Pseudarthrose der Tibia. Die Daten zu Art und Zeitpunkt der Knochen- und Weichteilrekonstruktion, Ergebnissen, Komplikationen und Notwendigkeit einer Reoperation wurden extrapoliert und mit denen einer historischen Patientengruppe verglichen, die orthopädisch behandelt worden war.

Ergebnisse In der orthoplastischen Gruppe wurden die Weichteile in den meisten Fällen mit einem anterolateralen Oberschenkellappen (ALT-Flap) rekonstruiert. Bei Patienten mit großflächigem Defekt war eine muskelschonende Vastus-lateralis-Lappenplastik (VL) oder eine chimäre ALT-VL-Lappenplastik erforderlich. In der orthopädischen Gruppe wurden die Weichteile einer Sekundärheilung überlassen oder die Patienten wurden später an einen plastischen Chirurgen überwiesen. Ein statistischer Vergleich zwischen den beiden Gruppen ergab signifikante Unterschiede hinsichtlich folgender Daten: Zeit bis zur Heilung der Weichteile, Zeit bis zur knöchernen Durchbauung, Anzahl der Reinterventionen, Rate tiefer postoperativer Infektionen und Zeit bis zur Wiederaufnahme der Berufstätigkeit.

Schlussfolgerung Der orthoplastische Ansatz bei komplexen Beindefekten bietet im Vergleich zu orthopädischen Verfahren kürzere Behandlungszeiten und liefert bessere funktionelle Ergebnisse. Die Behandlung mit Fixateur externe und die mikrochirurgische Rekonstruktion müssen sich nicht gegenseitig ausschließen, sondern können in einem orthoplastischen Behandlungspfad miteinander kombiniert werden, um eine bestmögliche Rekonstruktion sowohl der Weichteile als auch des Knochens zu erzielen.

Key words

Microsurgery - orthoplastic reconstruction - lower limb reconstruction - external fixation

Schlüsselwörter

Mikrochirurgie - Interdisziplinäre plastische Chirurgie - Unterschenkelrekonstruktion - Interdisziplinäre plastische Chirurgie - orthoplastische Rekonstruktion - Fixateur externe

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