Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 13  |  Issue : 1  |  Page : 8-11

Reconstruction of lower limb traumatic soft tissue defects in Togo


Departement of Traumatology Orthopedic and Reconstructive Surgery, University of Lome, Lome, Togo

Date of Web Publication16-Aug-2017

Correspondence Address:
Komla S Amouzou
Department of Traumatology Orthopedic and Reconstructive Surgery, Mix Faculty of Medicine and Pharmacy, University of Lome, Lome 02BP20752
Togo
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njps.njps_23_16

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  Abstract 

Background: The management of lower limb soft tissue defects is still a challenge in our setting.
Aims: This study aimed to review the clinical and socio-demographic characteristics of the patients with traumatic lower limbs defect and evaluate the results of surgical management in our setting.
Settings and Design: Retrospective descriptive study.
Materials and Methods: The charts of 30 adults patients treated surgically for lower limb soft tissue defects in the period from 1 January to 31 December 2014 were reviewed. Socio-demographic, clinical and therapeutic characteristics were documented.
Statistical Analysis Used: The results were as general descriptive statistics, presented as medians, percentages and ranges.
Results: The mean age was 34 years (range 18–60 years). The sex ratio was 3.28 for men. In 83% of the cases (20/30), injuries were due to collision between motorcycle and other vehicles. Soft tissue defects were type III B (50%, 15/30) and III A (47%, 14/30) of Gustilo-Anderson classification. The mean time between injury and reconstructive surgery was 48 days (range 14–118 days). Reconstruction techniques were mostly split skin graft (53%, 16/30) and neuro-sural distal pedicled flaps (20%, 6/30). Five cases of persistent osteomyelitis were observed.
Conclusion: The non-availability of microsurgery limited our practice to regional and local flaps that gave good results and protected bone fractures that mainly healed in acceptable time.

Keywords: Flap, lower limb, open fracture, reconstructive surgery, skin graft


How to cite this article:
Amouzou KS, Bakriga B, Kouevi-Koko TE, Amegble KJ, Abalo A, Dossim A. Reconstruction of lower limb traumatic soft tissue defects in Togo. Nigerian J Plast Surg 2017;13:8-11

How to cite this URL:
Amouzou KS, Bakriga B, Kouevi-Koko TE, Amegble KJ, Abalo A, Dossim A. Reconstruction of lower limb traumatic soft tissue defects in Togo. Nigerian J Plast Surg [serial online] 2017 [cited 2017 Nov 20];13:8-11. Available from: http://www.njps.org/text.asp?2017/13/1/8/213030


  Introduction Top


Possibilities for the reconstruction of lower limbs osteocutaneous defects have considerably expanded with the improved knowledge of vascular anatomy and microsurgical techniques. New procedures such as perforators (free or pedicled flaps) have been developed to cover all types of lower limbs defects. Amputation which was the rule at the beginning of the last century has become rare.[1],[2],[3],[4],[5],[6],[7],[8] Soft tissue reconstruction secures fracture stabilisation and avoids complications for a sustainable bone healing for good functional and cosmetic outcome. This necessitates a good multidisciplinary collaboration between plastic and orthopaedic surgeons for lower limb traumatic defect management. The reconstruction of lower limb defects is still a challenge in the emergency trauma departments of low-income countries. In Togo, the surgical reconstruction of extended defects is at its beginning and have to deal with the absence of microsurgery, limited human and material resources and unfavourable economic conditions. To the best of our knowledge, this is the first publication over this topic in our country.

We aimed to review the clinical and socio-demographic characteristics of patients with traumatic lower limbs defects and evaluate the results of surgical management of lower limb traumatic defects in our setting.


  Materials and methods Top


A retrospective review of charts of 30 adults patients (aged more than 16 years) admitted for lower limbs traumatic soft tissue defects that required surgical reconstruction in the period from 1 January to 31 December 2014 in the Traumatology, Orthopaedics and Reconstructive department, University public hospital Sylvanus Olympio in Lome (Togo) was conducted for this study.

We documented the following parameters:
  1. Demographics (age, gender, past medical history, ambulation before the accident);
  2. Injury characteristics (mechanism of injury, clinical wound classification according to Gustilo-Anderson, anatomical site, number of lesions, associated bone fracture);
  3. Therapeutic characteristics included duration between trauma and first debridement and antibiotic, the initial bone stabilisation systems and reconstructive methods used.


The postoperative course at days 3, 7, 30, 90, 6 months and 1 year was documented for the following items:
  1. Wound healing (complete healing, partial breakdown, total breakdown);
  2. Infection (absence of infection, superficial suppuration, deep suppuration);</LIST>
  3. Healing duration time.


A staff of orthopaedics assessed bone fractures outcome.

The processing of data was performed using Microsoft Excel 2010 spreadsheet. The results were as general descriptive statistics, presented as medians, percentages and ranges.


  Results Top


Among the 30 patients of the study, 23 (77%) were male whereas seven (23%) were female (sex-ratio: 3.28). The mean age was 34 years (range 18–60 years).

All patients ambulated independently before the accident. No patient presented a particular concern in his past social medical history.

Injury mechanisms were:
  1. Cars versus motorcycle accidents in 13 patients (43%);
  2. Motorcycle versus motorcycle in 12 patients (40%);
  3. Cars versus pedestrian in three patients (11%);
  4. Not specified in two patients (6%).


Defects were type III B in 15 patients (50%), type III A in 14 patients (47%) and type III C in one patient (3%) of Gustilo-Anderson classification.

In 25 patients (83%), the injuries were unique. Five patients (17%) presented multiple injuries (knee and leg upper third, third distal leg and ankle, ankle and foot). In 10 patients (33%), injuries were located in the distal part of the leg (distal 1/3, ankle, foot). In nine patients (30%), injuries were located in the middle 1/3 of the leg and in six patients (20%) in the proximal 1/3.

Bone fracture (femur, tibia and/or fibula fracture) was associated in 28 patients (93%). In two patients (7%), there was bone exposure with periosteal loss without fracture. No patients presented considerable bone loss that required bone graft.

Mean time between trauma and the first debridement was 19 h (range 6–36 h). The first antibiotic treatment made of intravenous third generation cephalosporin, aminoglycoside and metronidazole was giving within the same period. Initial fracture fixation was performed of plaster of Paris in 11 patients (37%) and external fixation in nine patients (30%). Other systems were used in the eight other patients. [Table 1] shows the details of initial treatment (dressing of wounds and processing of bone fractures).
Table 1: Initial wound management and fracture fixation

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Soft tissue reconstruction was performed after the mean time of 48 days (range 14–118 days).

Local infections were seen in 19 patients treated by frequent dressings with antiseptics and intravenous antibiotics based on the bacteriological findings, prior to reconstructive surgery that was performed when the clinical signs of infection disappeared.

Reconstructive procedures [Table 2] were split thickness skin graft (16 patients, 53%), neuro-sural distal pedicled flap (six patients, 20%), gastrocnemius or soleus muscle flaps (four patients, 14%). Postoperative course [Table 3] was marked by early deep infection in six patients, venous congestion of distal pedicled neuro-sural flaps in three patients leading to total breakdown in one patient that was infected as well and finally leg amputated. Among the six patients who presented early infection, chronic osteomyelitis and pseudarthrosis were observed in five patients. In the 24 other patients (80%), total healing of bone fractures has been obtained in a mean time of 6 months (range 4–8 months). [Table 4] reports infectious complications according to the severity of primary injury and reconstructive procedure.
Table 2: Reconstructive procedures

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Table 3: Complications in the postoperative course

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Table 4: Surgical procedures and surgical site infection according to wound severity

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  Discussion Top


The management of open lower limb trauma have the main goal of functional and social reintegration by achieving bone healing. The success of this surgery aims to achieve a pain-free functional extremity, a healed fracture and reliable durable soft tissue coverage. Social integration has not been evaluated in our study.

Patients in this study were young male in majority, mostly victims of road traffic accidents involving motorcycles. This finding is shared by other authors and has been interpreted as the taste of danger in young male adults.[2],[4],[5] Additionally, in our setting, socially, few women ride motorcycles. Accidents involving motorcycles were described by Yaremchuck et al. as being often high-energy with a significant bruising of the soft tissues.[4] In our study, injuries were mostly type III of Gustilo-Anderson classification as well. The treatment of those injuries involves early initial antibiotics and debridement followed by bone stabilisation and final soft tissues reconstruction.[2],[4],[5],[6] This first resuscitation in our area started in an average time of 19 h postinjury. This long delay, as reported by other authors, could explain infections in some patients prior and postreconstructive surgery that may be delayed as well.[4],[5],[9],[10] In some patients, the delay of reconstructive surgery may have impacted the indications as well. Some patients presenting with tendon exposure that needed initial coverage with a flap would have ended in a skin graft because of necrosis of exposed tendon and appearance of granulation tissue. In case of large bone exposition, as depicted in [Table 4], and in the absence of microsurgery, local and regional flaps have represented the only choice in our flap surgery. Distal neuro-sural flaps have been reported by other authors to be reliable and versatile for the reconstruction of lower limbs wounds located in the distal third and foot. This flap has the advantage of not sacrificing a major vascular axis. Its harvest is straightforward, with an acceptable donor site scar.[2],[10],[11],[12],[13],[14],[15] Although Chang et al.[14] argued that the neuro-sural flap could be raised with the lower part of the gastrocnemius muscle to make a neuromyocutaneous flap, we preferred when needed, a pure muscle flap instead. We used muscle flaps when defects were deep with an important bone exposed, for filling dead spaces and to promote good vascularisation of the injured bone as described by other authors.[2],[10],[13],[15],[16],[17] The postoperative courses in our practice is the mirror of local conditions in patients, general economic concerns and a learning curve for neuro-sural flaps that had congestion in 50% of the cases and failed in one patient.This study has found that the traumatic soft tissue defects of lower limbs in Togo mainly occurred in young male adults. Road traffic accidents often involving motorcycles lead to the extended deep defects of soft tissue. The initial resuscitation and the final reconstructive surgery were performed late and marked by infectious complications. The non-availability of microsurgery limited our practice to regional and local flaps that gave good results, and protected bone fractures that mainly healed in acceptable time. The future of our practice should rely on perforator flaps when waiting for microsurgery training and instrumentation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fochtmann A, Mittlböck M, Binder H, Köttstorfer J, Hajdu S. Potential prognostic factors predicting secondary amputation in third-degree open lower limb fractures. J Trauma Acute Care Surg 2014;76:1076-81.  Back to cited text no. 1
    
2.
Franken JM, Hupkens P, Spauwen PH. The treatment of soft-tissue defects of the lower leg after a traumatic open tibial fracture. Eur J Plast Surg 2010;33:129-33.  Back to cited text no. 2
    
3.
Jordan DJ, Malahias M, Hindocha S, Juma A. Flap decisions and options in soft tissue coverage of the lower limb. Open Orthop J 2014;8:423-32.  Back to cited text no. 3
    
4.
Yaremchuck MJ, Brumback RJ, Manson PN, Burgess AR, Poka A, Weiland A. Acute and definitive management of traumatic osteocutaneous defects of the lower extremity. Plast Reconstr Surg 1987;80:1-12.  Back to cited text no. 4
    
5.
Govina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78;285-92.  Back to cited text no. 5
    
6.
Bhattacharyya T, Mehta P, Malcolm Smith M, Pomahac B. Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg 2008;121:1263-6.  Back to cited text no. 6
    
7.
Bajantri B, Ravindra Bharathi R, Raja Sabapathy S. Wound coverage considerations for defects of the lower third of the leg. Indian J Plast Surg 2012;45:283-90.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Shin IS, Lee DW, Rah DK, Lee WJ. Reconstruction of pretibial defect using pedicled perforator flaps. Arch Plast Surg 2012;39:360-6.  Back to cited text no. 8
    
9.
Tripuraneni K, Ganga S, Quinn R, Gehlert R. The effect of time delay to surgical debridement of open tibia shaft fractures on infection rate. Orthopedics 2008;31.pii: orthosupersite.com/view.asp?rID= 32925.  Back to cited text no. 9
    
10.
Yarrow J, Rahman S, Marsden N, Pallister I, Hemington-Gorse S. Management of open lower limb injuries in South West England and Wales. Ann R Coll Surg Engl 2015;97:35-9.  Back to cited text no. 10
    
11.
Pinsolle V, Reau AF, Pelissier P, Martin D, Baudet J. Soft-tissue reconstruction of the distal lower leg and foot: Are free flaps the only choice? Review of 215 cases. J Plast Reconstr Aesthet Surg 2006;59:912-7.  Back to cited text no. 11
    
12.
Ayyappan T, Chadha A. Supersural neurofasciocutaneous flaps in acute traumatic heel reconstruction. Plast Reconstr Surg 2002;109:2307-13.  Back to cited text no. 12
    
13.
Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg 2006;117:2468-75.  Back to cited text no. 13
    
14.
Chang SM, Li XH, Gu YD. Distally based perforator sural flaps for foot and ankle reconstruction. World J Orthop 2015;6:322-30.  Back to cited text no. 14
    
15.
Ríos-Luna A, Villanueva-Martínez M, Fahandezh-Saddi H, Villanueva-Lopez F, del Cerro-Gutiérrez M. Versatility of the sural fasciocutaneous flap in coverage defects of the lower limb. Injury 2007;38:824-31.  Back to cited text no. 15
    
16.
Yazar S, Lin CH, Wei FC. Outcome comparison between free muscle and free fasciocutaneous flaps for reconstruction of distal third and ankle traumatic open tibial fractures. Plast Reconstruct Surg 2006;117:2468-75.  Back to cited text no. 16
    
17.
Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group. J Bone Joint Surg Am 2000;82:1681-91.  Back to cited text no. 17
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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