Complex Lower Limb Trauma Research Articles

ADDUCTOR CANAL BLOCKS: PROOF OF CONCEPT FOR THE MANAGEMENT OF CHRONIC PAIN FOLLOWING COMPLEX LOWER LIMB INJURIES?

IntroductionThe regionalisation of major trauma in the UK has significantly improved outcomes for patients with severe, lower limb injuries. Chronic pain after complex lower limb injuries is well documented, but seems to remain a problem despite better clinical and radiological outcomes. We hypothesised that pain was mediated through the saphenous nerve, especially as most tibial injuries affected the soft tissues medially. As a proof of concept, we undertook adductor canal blocks to understand pain aetiology.Materials & MethodsPatients with chronic pain following complex lower limb trauma or congenital deformity correction have been selected and underwent an adductor canal block by one of our trauma anaesthetist that specialises in this procedure. Their outcomes were recorded in their clinical records and patients were contacted by phone to document their experiences.Results14 patients with chronic, treatment refractory lower limb pain who were being managed in our orthoplastics clinic following complex, lower limb trauma were identified. Six of those patients had required plastic coverage. Of these 14 patients, all stated their pain completely resolved after the procedure and then returned between 24 hours and 4 weeks after the procedure. Two patients underwent a saphenous nerve diversion after conduction of the blocks, reporting subsequent resolution of their complaints.ConclusionsAs a proof of concept, we report that the saphenous nerve underlies chronic pain in patients with complex lower limb injuries. An adductor canal block is an effective diagnostic tool for these patients. Saphenous diversion may offer a permanent solution in patients who respond well to saphenous nerve block. A prospective study is planned to objectively measure pain and quality of life scores after treatment of complex injuries and pre and post adductor canal block.

POSTOPERATIVE OUTCOMES OF ILIZAROV FRAME FIXATION IN THE LOWER LIMB: AN EVALUATION OF PATIENT-REPORTED OUTCOME MEASURES AND ALIGNMENT

IntroductionBy utilising the inherent variability achievable with circular frames, surgeons can manage a wide spectrum of complex injuries, and can deal with deformity at multiple levels, in multiple planes. The aim of this study was to assess functional outcomes utilising patients reported outcome measures (PROMs) of patients being treated with circular (Ilizarov) frame fixation for complex lower limb injuries and assess these results in conjunction with the observed postoperative alignment of the patients’ limbs.Materials & MethodsCases were identified using a prospectively collected database of adult patients presenting between July 2018 and August 2021. Functional outcomes were assessed using the American Orthopaedic Foot and Ankle Score (AOFAS), the 5-level EQ-5D (EQ5D5L), the Lysholm Knee Scoring Scale (LKSS), the Olerud-Molendar Ankle Score (OMAS), and the Tegner Activity Scale (TAS). Postoperative radiographs were analysed for fracture union and to quantify malunion (as described in Dror Paleys Principles of Deformity Correction).ResultsThe mean AOFAS, EQ5D5L, LKSS and OMAS scores showed an initial drop from pre-op to early time points and then steady increase over the early, mid, late and frame-off time points, with a resultant score higher than pre-op. Malunion was found in 35 (41.7%) patients, 7 patients had a malunion within 5 degrees of normal, 15 from 5–10 degrees of normal, 12 from 10–15 degrees of normal and 2 out with 15 degrees of normal.ConclusionsCircular frame fixation is an attractive option in complex lower limb trauma where alternative fixation methods are unsuitable. Whilst post-operative success to the surgeon might be determined radiographically, patient reported outcomes give a functionally important, objective measure of the success of the surgery to the patient.

Complex lower limb trauma and reconstructive surgery: understanding health service resource use

Complex lower limb trauma is a challenging problem. Achieving optimal long-term outcomes requires multi-disciplinary input, while patients are in hospital, and after discharge. The aim of this study was to evaluate the long-term health services resource use of patients with such injuries, in the context of a publicly funded health system. This is a population-based retrospective cohort study. Data were obtained from the Information Services Division (ISD) Scotland. We included patients with isolated lower extremity injuries, sustained between 1997 and 2015, with follow-up to 2017. Cases were identified defined by ICD-10 and OPCS-4 procedural codes and divided into two groups, complex and simple injuries and analysed for their subsequent contacts with the health service. There were 42,601 patients with isolated lower limb injuries. 2976 (7.0%) had suffered complex injuries. The in-hospital mortality of these patients was 1.9%. 538 (18.1%) of the patients who sustained complex injuries underwent reconstructive surgery. Just over half attended an orthopaedic outpatient clinic in the first year, and 31.7% attended a plastic surgery clinic. Very few patients attended pain management clinics, or other clinics that might provide pain services. Only a small proportion of patients who undergo reconstructive surgery are followed up by specialist services. The reasons for such low follow-up rates are not obvious. Our findings raise the question of whether the health service in Scotland has sufficient resources to optimise functional outcome in this patient group. Level of evidence: Level III, risk / prognostic study

Smoking and the patient with a complex lower limb injury.

Smoking is known to increase the risk of peri-operative complications in Orthoplastic surgery by impairing bone and wound healing. The effects of nicotine replacement therapies (NRTs) and electronic cigarettes (e-cigarettes) has been less well established. Previous reviews have examined the relationship between smoking and bone and wound healing separately. This review provides surgeons with a comprehensive and contemporaneous account of how smoking in all forms interacts with all aspects of complex lower limb trauma. We provide a guide for surgeons to refer to during the consent process to enable them to tailor information towards smokers in such a way that the patient may understand the risks involved with their surgical treatment. We update the literature with recently discovered methods of monitoring and treating the troublesome complications that occur more commonly in smokers effected by trauma.

Lower limb paediatric trauma with bone and soft tissue loss: Ortho-plastic management and outcome in a major trauma centre

AimWe examined the management and outcome of patients suffering complex paediatric lower limb injuries with bone and soft tissue loss. MethodPatients were identified from our prospective trauma database (2013-2018). Inclusion criteria were age (<18 years) and open lower-limb trauma. We assessed severity of soft tissue and/or bone loss, fracture complexity, surgical techniques and time to surgery. Paediatric quality of life and psychological trauma impact scores (HRQOL and CRIES), Ganga Hospital Injury Severity score (GHISS), union and complication rates were measured. ResultsWe identified 32 patients aged between 4 and 17 years. Twenty-nine patients had open tibia fractures including 14 patients with bone loss, one patient had an open femur fracture, one patient an open talus fracture and one an open ankle fracture with dorsal degloving. Thirty injuries were classified intra-operatively as Gustilo IIIB (or equivalent) and two injuries as Gustilo IIIC. In 10 patients primary skin closure was achieved by acute shortening following segmental bone loss. Twenty-two patients required soft tissue coverage: 17 free vascularised flaps, two fascio-cutaneous flaps and three split skin grafts were used. Two patients required vascular repair. Soft tissue coverage was achieved within 72 hours in 26 patients (81%) and within a week in 30 patients (94%). The surgical techniques applied were: circular fine wire frame (19), monolateral external fixator (4) and open reduction internal fixation (8). Median follow up time was 18 (7-65) months. Paediatric quality of life scores were available in 30 patients (91%) with a median total score of 77.2 out of 100. The psychological trauma impact scores showed one in three patients was at risk of developing post-traumatic stress symptoms (PTSD). The GHISS scores ranged from 6-13. All fractures went on to unite over a median time of 3.8 (2-10) months. Three patients (9%) had major complications; two flap failures requiring revision, one femur non-union requiring revision fixation. ConclusionLimb salvage and timely fracture union is possible in children with complex lower limb trauma. Early intervention providing adequate debridement, skeletal stabilisation and early soft-tissue cover including the option of free microvascular reconstruction in small children when required, delivers acceptable outcomes. A multidisciplinary team approach including clinical psychologists to address the psychological impact of trauma provides optimal holistic care for these children and adolescents. Therefore, treatment for these patients should only be performed in paediatric major trauma centres.

Local perforator flaps for soft tissue defects in lower limb trauma

Complex lower limb trauma is a common and major challenge. Limited lower limb local flap options especially in the distal third often necessitate free flap surgery. Fasciocutaneous perforator flaps are an exciting option presenting with less overall morbidity, requiring less specialised expertise than free flaps and can provide excellent cover for small to moderate size defects. To assess the outcomes of fasciocutaneous perforator flaps at our hospital over a 3-year period. Retrospective analysis of all fasciocutaneous perforator flaps performed over that period. There were 20 patients with an average age of 29.8 years (range 10–80). Fifteen were males and five were females. Four were children. Pedestrian vehicle accidents (n = 10), motor vehicle accidents (n = 4), cyclist accident (n = 1), gunshot (n = 1), falls (n = 3) and blunt trauma (n = 1) resulted in Gustillo 3B lower limb fractures (n = 13), full thickness degloving wounds (n = 5) and crush injuries (n = 4). Location of the defects includes the distal third (n = 9), middle third (n = 6), combination middle-distal third (n = 4) and proximal third (n = 1). Average procedure was 129 min (range 70–180) and average time to surgery was 4.3 days (range 0–11). All flaps survived at a mean follow-up of 7 months (range 1–12 months). Complications included epidermolysis (n = 2), partial necrosis requiring limited debridement and split skin graft (n = 3), partial necrosis that healed through secondary intention (n = 1) and tip necrosis (n = 2). No donor site complications were experienced. There were no skin graft losses. Evidence for fasciocutaneous perforator flaps in the lower limb is abundant. This study further substantiates the literature since free style perforator flaps can also be successfully employed in complex traumatic lower limb defects. They appear to be reliable when based on the posterior tibial artery system of perforators for middle and/or distal defects. They are associated with reduced operative time, preservation of the source artery and underlying muscle function, superior aesthetics and fewer complications when compared to free flaps. It has evolved into our first choice for small to moderate size complex defects of the lower limb. Level IV, risk/prognostic study.

Combined free flap and ilizarov bone reconstruction in complex lower limb trauma: our experience

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Reconstruction of complex lower limb trauma is a major concern for both plastic and Orthopedic surgeons. The use of free flap with Ilizarov method for soft tissue coverage and bone reconstruction not only gives the patient near normal shape and function but also allows early mobilization of the patient, even during the process of distraction with Ilizarov method.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; In this study patients with bone and soft tissue defects of the lower leg were included in the study. Our protocol was immediate wound debridement along with application of external fixator and early free flap coverage within 48-72 hours. After 3-4 weeks of the free flap transfer definitive bone reconstruction is done with Ilizarov method.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; 122 flaps survived fully and distal flap necrosis occurred in 4 patients. Necrosis of flap occurred before the start of bone reconstruction with Ilizarov and was managed conservatively or with skin graft. Pin tract infection occurred in 45 (35.71%) patients and was treated by pin care and antibiotics. Other complications in treated patients included pain due to distraction (33.33%). delayed union at docking site (11.90%), discrepancy of limb size (9.52%) and union with deformity (6.35%). The functional outcome was satisfactory in majority of the cases.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Combined use of free flap and Ilizarov provides a more reliable soft tissue coverage and bone reconstruction with almost near normal shape and function. It has advantages like regenerating same quality bone and allowing the early mobilization of the patient with acceptable rate of complications.&lt;/p&gt;

Outcome of bilateral circular fixators in complex lower limb fractures

Circular external fixators are increasingly being used for complex lower limb trauma. When these injuries are sustained to both lower limbs, the ideal management is unclear. We present the results of 25 consecutive patients who were treated with bilateral circular external fixators for complex tibial trauma. The final cohort consisted of 23 men and two women with a mean age of 31.8 years (range 21-62 years) and a median follow-up was 16.4 months (range 6-37 months). Bony union was achieved in 96% (48 out of 50) of the tibia fractures. The mean time to union was 26 weeks (range 13-71 weeks). Serious complications included chronic osteomyelitis that developed in one patient following a high-grade open fracture and unilateral non-unions in two patients. Bilateral circular external fixators are a viable treatment option for patients who sustain bilateral complex lower limb trauma.

Propeller flaps for lower-limb trauma

Thee propeller flap has become a versatile and important component in our reconstructive algorithm following complex lower limb trauma. First described by Hyakusoku in 1991, it has since been adapted and modified by Hallock and Teo. This article outlines our experience specifically with perforator pedicled propeller flaps (as per the Tokyo consensus) for traumatic defects of the leg. In this procedure, the reconstructive surgeon skeletonises a single perforator and rotates the skin island on its axis between 90° and 180° to close the defect.The minor blade of the propeller may be designed to close the donor defect completely for the 180° version. The propeller flap has the advantages of local flaps (reliability, contour, texture, 'like-with-like') with additional versatility of design and donor site management, and requires minimal expertise and operative time.

Is the Injury Severity Score Relevant in Complex Lower Limb Trauma?

First described by Baker et al in 1974, the injury severity score (ISS) is an anatomical scoring system that provides an overall score for patients with multiple injuries. It was developed initially to evaluate motor vehicle victims with multiple injuries, with an original study group of 2,128 patients. The ISS is an established score to assess trauma severity and its application has extended beyond motor vehicle injuries to cover all aspects of trauma.

Is the injury severity score (ISS) relevant in complex lower limb trauma?

Is the injury severity score (ISS) relevant in complex lower limb trauma?

Costs and coding—Free-flap reconstruction in lower-limb trauma

Introduction The provision of a complex lower-limb trauma service has significant resource implications. This financial burden is not recognised by the current fixed price tariff system (Payment by Results). The aim of this study was to compare the actual costs of treatment with reimbursement. Methods We conducted a prospective study in two large regional plastic surgery centres in the UK, Salisbury Foundation Trust (SFT) and the Frenchay Hospital, Bristol (FH). The total cost of treatment for consecutive patients with complex lower limb trauma requiring free tissue transfer was calculated and compared with the Health Resource Group (HRG) tariff. Results A cost analysis was performed on 20 patients (10 Salisbury, 10 Frenchay) with open tibial fractures (all grade IIIb Gustillo & Anderson) requiring free-flap reconstruction (15 anterolateral thigh (ALT) flaps, one serratus, one latissimus dorsi (LD), one scapular and two gracilis). The mean treatment cost of performing a free flap was £12 792 ± £970 SEM (SFT) and £10 953 ± £650 (FH). In both centres, the cost was more than double the HRG tariff (£4220 SFT, £4892 FH, p < 0.05). Conclusions Our study highlights the considerable disparity between the cost of managing patients with severe lower-limb trauma and the remuneration by Primary Care Trusts (PCTs). Accurate cost analysis of these cases will allow hospital trusts to negotiate appropriate tariffs with PCTs and develop services, which are cost neutral.

Preexpanded Muscle-Sparing Latissimus Dorsi Free Flap in Complex Lower Limb Trauma: The Orthoplastic Approach

Sir: Reconstruction of large defects of the knee may require free flaps with a large surface area of pliable skin along with a long pedicle. Flaps that have been described to cover such defects include free latissimus dorsi and free expanded latissimus dorsi flaps; however, these can be too bulky and may leave large defects on the back. We present the case of a 15-year-old boy who was involved in a road traffic collision 4 years previously, in which he sustained a degloving injury to the posterior knee complicated by an open femoral fracture. Initial treatment involved stabilization of the fracture, bony cover with local tissue, and split skin graft for reconstruction of the skin defect. Subsequently, there was growth arrest caused by significant injury to the growth plate, compounded by severe soft-tissue contracture resulting in a fixed flexion deformity of the left knee (Fig. 1).Fig. 1.: Preoperative flexion contracture and tissue expander in situ (digitally acquired leg length images).According to the joint British Association of Plastic, Reconstructive, and Aesthetic Surgery and the British Orthopaedic Association guidelines, the patient was assessed by the multidisciplinary lower limb trauma and reconstruction team. It was immediately apparent that tissue coverage of the deformity would require a sizable skin paddle of approximately 36 × 20 cm. Given the patient's clinical needs and the lack of a suitable immediate donor site, the decision was made to expand a large fasciocutaneous skin flap on the patient's back. During the first stage, a customized three-chambered tissue expander was placed in the subfascial plane in the back, and a Doppler device was used to identify and therefore avoid the perforator to the left latissimus dorsi. Over a 3-month period, expansion of 2440 ml was achieved, creating a sizable soft-tissue paddle. At definitive surgery, the flexion deformity was corrected with femoral valgus and derotational osteotomy, along with application of a rail fixator for femoral lengthening by distraction. The area of split skin graft covering the popliteal fossa was excised. This allowed correction of a significant component of the flexion deformity. This large-sized soft-tissue defect (36 × 20 cm) was covered with the preexpanded muscle-sparing latissimus dorsi free flap, incorporating much of the expanded skin but still leaving enough to allow primary closure of the secondary defect. Three months postoperatively, the patient had good range of movement at the knee, with no flap or donor-site complications (Fig. 2).Fig. 2.: Postoperative flap and femoral distractor (left), and the donor site (right).Complex and large soft-tissue defects of the knee require coverage with a large flap. Both free latissimus dorsi and expanded latissimus dorsi flaps have been described to cover such defects.1,2 The muscle-sparing latissimus dorsi flap has been described mainly in breast reconstruction.3–5 The advantages of this flap are reduced seroma rates and lack of functional morbidity, without cosmetic sequelae.4,5 To our knowledge, this is the first report of this flap being used for this purpose. We believe that preexpanded muscle-sparing latissimus dorsi free flap reconstruction has a role in large, complex, lower limb trauma cases. It provides large amounts of skin with minimum donor-site morbidity and shows the versatility of the muscle-sparing latissimus dorsi flap beyond the realms of breast reconstruction. DISCLOSURE No funding was received to support this work. The authors have no commercial associations or financial interest to declare. Nathan T. J. Hamnett, M.R.C.S. Anuj Mishra, M.R.C.S. Selvadurai Nayagam, M.Ch.(Orth.), F.R.C.S.(Plast.) Ken Graham, F.R.C.S.(Plast.) Christian Duncan, F.R.C.S.(Plast.) Department of Plastic Surgery Alder Hey Children's NHS Foundation Trust Liverpool, England

The Free Latissimus Dorsi Flap as Primary Free Flap and Crane Flap with Secondary Pedicled Transfer

We are reporting a case of a 43-year-old woman, who developed a soft tissue defect of the knee region following complex lower limb trauma. The defect was covered with a microvascular latissimus dorsi (LD) flap. The patient required a total knee replacement and developed a defect at the anterior aspect of the knee. This defect was covered by a second free LD flap from the ipsilateral side with anastomosis to the superficial femoral artery. Thrombosis of the superficial femoral artery resulted in complete flap loss. The soft tissue defect was covered with a pedicled medial gastrocnemius flap. Further surgery was undertaken to reconstruct the extensor mechanism of the knee. The resulting soft tissue defect was covered with a free anterolateral thigh (ALT) flap, which failed. The resulting defect left the knee prosthesis exposed. We used the first free LD flap covering the medial aspect of the lower leg as a pedicled axial myocutaneous flap. The deep portion of the flap remained in situ, covering the original soft tissue defect of the lower leg, and the main bulk of the LD was rotated by 180 degrees to the anterior defect of the knee. The crane flap healed uneventfully with a good outcome.

Intravascular shunts in complex lower limb trauma

Vascular injuries of the lower limb in the presence of extensive soft tissue loss, fractures, or other life-threatening injuries are associated with a high amputation rate. Five patients underwent temporary intravascular shunting during the period of treatment of such injuries. Rapid reperfusion of the limb via such shunts permitted more comprehensive evaluation and management of the lower limb and other associated injuries than would have been possible in the presence of prolonged ischemia.