|Year : 2019 | Volume
| Issue : 1 | Page : 11-15
Soft-tissue reconstruction for exposed orthopedic implants in injured extremities
Vaibhav Jain1, Pradeep Jain1, Shivi Jain2
1 Department of Plastic Surgery, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
2 Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India
|Date of Web Publication||14-Oct-2019|
Department of Radiodiagnosis and Imaging, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Exposure of orthopedic implants before fracture union is quite frequent in clinical practice. There is no definite rule as of now whether to retain or replace the exposed implant with an external fixator.
Objectives: The aim of the study was to find the ultimate outcome after retaining the exposed implant and providing a skin and soft-tissue cover.
Materials and Methods: Thirty-two patients with exposed orthopedic implants reported to us with an average of 6 weeks after the original orthopedic procedure. The local soft-tissue infection was treated with a targeted antibiotic therapy. There was delay in the soft-tissue reconstruction for an average of 24 days. Six patients also received “negative pressure wound therapy.” The soft-tissue defects (ranging from 4 cm × 3 cm to 25 cm × 10 cm) were compounded with exposure of olecranon plate in four and intramedullary tibia nails in five, and 23 exposed plates and screws. The various muscle and fasciocutaneous flaps were used according to the region of the defect.
Results and Conclusions: All the flaps behaved well except one. One of the patients suffered from wound discharge and chronic sinus, but none suffered from pain or fracture nonunion up to 9 months follow-up. Removal of the implant was required in only one patient because of sharp edge. Thus, coverage of exposed implants should always be considered as the first option before replacing it with external fixator.
Keywords: Exposed implants, exposed orthopedic hardware, soft-tissue resurfacing for exposed implants
|How to cite this article:|
Jain V, Jain P, Jain S. Soft-tissue reconstruction for exposed orthopedic implants in injured extremities. J Med Soc 2019;33:11-5
|How to cite this URL:|
Jain V, Jain P, Jain S. Soft-tissue reconstruction for exposed orthopedic implants in injured extremities. J Med Soc [serial online] 2019 [cited 2020 Feb 20];33:11-5. Available from: http://www.jmedsoc.org/text.asp?2019/33/1/11/269108
| Introduction|| |
Gone are the days when the fracture of extremity bones was immobilized by plaster of Paris cast. This used to be quite cumbersome and also bothered the patients immensely. They often interfered with joint functions, leading to their stiffness. This was overcome by internal fixating devices, such as intramedullary (IM) nails and plates and screws. However, these metallic implants very often get exposed due to edematous and traumatized skin and soft tissue, which do not tolerate the added surgical insult. Closure of skin incisions under tension also results into tissue necrosis. To facilitate the process of osteosynthesis unhindered, it is very crucial to provide a reliable and well-vascularized skin and soft-tissue cover.
| Materials and Methods|| |
Thirty-two patients (27 males and 5 females) with exposed orthopedic implants, referred to us from the department of orthopedics at the trauma center of a tertiary care hospital, were the subjects of this study. Their mean age was 41 years with an age range of 21–63 years. All the females in the study had exposed implants in the lower limb. Six among the males were smokers. The average time from the original orthopedic procedure to presentation at our department was 6 weeks. The soft-tissue defects ranged from 4 cm × 3 cm to 25 cm × 10 cm. The patients had local soft-tissue infection, which was efficaciously treated with a targeted antibiotic therapy. The presence and treatment of infection delayed the reconstruction by 24 days (range 15–36 days). Four of these patients were diabetic, and euglycemic status was achieved in all before taking up the reconstructive procedure. Six patients also received “negative pressure wound therapy (NPWT)” at 125 mmHg in continuous manner after thorough staged debridement with change of dressing at 3 days' interval and for 2–3 cycles.
Four patients had exposure of olecranon plate, 5 had exposure of IM tibia nails, and the rest 23 had exposed plates and screws (3 on fibula). All the wounds were subjected to swab culture, and the antibiotic therapy was started as per the sensitivity report. None of the patients had undergone bone biopsy. The various flaps used in the upper limb to cover the exposed implants were distally based lateral arm fasciocutaneous flap-2, chest wall fasciocutaneous flap-1 [Figure 1], and hypogastric flap-1 [Table 1]. Those in the lower limb were gastrocnemius muscle flap [medial head: 6, [Figure 2]; lateral head: 2] with split-thickness skin graft, propeller flap-1 [Figure 3], distally based sural neurovenofasciocutaneous flap, proximally based posterior tibial artery perforator based flap-1 (PTAPF-1) [Figure 4], distally based PTAPF-6, distally based peroneal artery perforator-based flap (PAFP-2), cross-leg fasciocutaneous flap (one distally based PTAPF), bipedicled advancement flap-1, and free anterolateral thigh perforator-based flap-2 [Figure 5].
|Figure 1: Lateral chest wall flap. (a) Exposed olecranon plate, (b) posteriorly based chest wall flap raised (c) before division and insetting|
Click here to view
|Table 1: Site of exposed implant and method of soft-tissue reconstruction|
Click here to view
|Figure 2: Exposed implant upper one-third leg. (a) Exposed hardware, (b) medial head gastrocnemius muscle flap, (c) muscle flap in situ, (d) late follow-up|
Click here to view
|Figure 3: Exposed implant upper one-third leg. (a) Exposed implant, (b) propeller flap raised, (c) propeller flap in situ, (d) late follow-up|
Click here to view
|Figure 4: Exposed metal at knee and upper one-third leg. (a) Preoperative view, (b) posterior tibial artery perforator flap in situ|
Click here to view
|Figure 5: Exposed plate at ankle. (a) Preoperative view, (b) anterolateral thigh flap in situ|
Click here to view
| Results|| |
All the patients with exposed implants had wound infection. However, the exposed implants were retained in all. In one of the patients with exposed olecranon plate with sharp border, it was filed to reduce its sharpness before covering it with a flap. However, the plate got exposed 6 weeks later. The plate was removed and the original flap was advanced. In another patient with antibiotic bead and chronic sinus, the bead had to be removed and the sinus healed.
The most common organism isolated was Acinetobacter sp. (20, 62.5%) followed by Pseudomonas sp. (5, 15.62%), Klebsiella (4, 12.5%), and Staphylococcus (3, 9.37%). All the flaps behaved well except one of the sural flaps which showed superficial congestion at the margin but improved without any untoward effect. Graft take on the muscle flaps was 100%. None of the patients suffered from pain or nonunion up to 9 months' follow-up (highest follow-up 18 months in 28 patients). Removal of the metallic implant was required in only one patient because of sharp edge and re-exposure and the antibiotic bead in another.
| Discussion|| |
Internal fixation has been an invaluable method in stabilizing the fractured ends of a bone. Recently, fracture of virtually all bones has been managed with internal fixation devices of various shapes, sizes, and configuration. In traumatic orthopedic surgery, the treatment of the tibia fractures with plates or IM nails has become a universal procedure. However, the postoperative implant-related infection (IRI), challenging and expensive to treat, may lead to serious morbidity. The conventional management of IRI includes irrigation and debridement, obliteration of dead space, intravenous antibiotics, and removal of the hardware.,,, However, this may not be sufficient for tackling the infection. Vancomycin cement, negative pressure-assisted closure, external fixators, and new flap choices have all been used to tide over the crisis.
Further, newer and better internal fixation devices or implants, such as especially designed IM nails and plates and screws, have increased treatment efficacy and union rates. Even after the fracture union, there is no clear guideline for removing such purposeless implants.
When implants get prematurely exposed, whether they should be kept or removed, becomes important. When this happens in the presence of soft-tissue infection, the chances of lurking infection in the wounds because of bacterial biofilm over the implants make the situation more complex. Among many factors responsible for the persistence of infection, one requiring serious attention is the invincible bacterial biofilm. The other risk factors are severity of fracture and soft-tissue damage. Among various causes of implant removal, Haseeb et al. found infection to be responsible for implant removal in about 29% of the patients. Trampuz and Widmer found that about 5% of all internal fixation devices got infected.
Despite the increasing number of clinical, laboratory, and imaging techniques on the one hand, the diagnosis of orthopedic implant infection can be very difficult and there is no gold standard. The implant infection may be suspected or confirmed >2 weeks postoperatively. Abnormalities of both bone and soft tissues detected on imaging studies can be suggestive of implant-associated infections., Serial plain radiographs (14% sensitivity and 70% specificity) may be helpful in detecting implant-associated infections. Detection of sinus tracts and collections has a positive predictive value of 100%. Fifty percent of radiographs remain normal despite the presence of infection. Tigges et al. reported that 20% of the radiographs showed bone findings consistent with infection, 20% had signs of mechanical loosening, and 10% had nonspecific findings. Despite these limitations, radiography serves as a reference to monitor the progression of bone abnormalities.
Further, computed tomography with some modification can show sequestra very well, difficult to detect on plain radiographs in early phase. Magnetic resonance imaging is also good for detecting inflammatory edema of soft tissue or bone or the collections therein. If required, the bone scan (99mTc) may be done as it predicts infection with excellent sensitivity (90%–100%).
Exposed implants in all of our cases were associated with gross soft-tissue infection and with devitalized tissue in many before fracture union. Normally, it would have required removal of the internal fixators due to possibility of biofilm formation and therefore risk of persistent infection and stabilization of the fracture with an external fixator. However, as our orthopedic colleagues wished to retain the implants, we debrided devitalized tissue and applied NPWT in six patients to reduce the edema and the wound surface area and to achieve a possible reduction in bacterial burden in the wound. In others who were reluctant to undergo NPWT due to financial reasons, repeated wound irrigation and dressings were carried out. Together with two weeks' course of an appropriate antibiotic, all the implants were covered with a variety of muscle/fasciocutaneous flaps.
We turned to NPWT with the negative pressure marginally higher (125–150 mmHg) than that used for the management of chronic wounds as higher negative pressure is supposed to remove the bacterial slime and exudates from the wound more rapidly. However, NPWT has not been frequently used in IRI. A newer version of NPWT wherein intermittent instillation of antibiotic along with NPWT has been devised by Kinetics Concepts Incorporated and is known as vacuum-assisted closure-instill system. Maddineni et al. also did not remove the metallic implants in any of their cases following early use of NPWT device after laying open the infected wound. Only one patient in our series required removal of implant, and in another, the exposed antibiotic bead had to be removed.
As mechanical stability is important for an adequate bone healing, some authors consider at least temporary implant retention and suggest eradication of infection once bone healing is complete. On the other hand, the maintenance of the biofilm-covered implants may contribute as additional risk factor for persistent or recurrent infection in bones. Xu et al. also made several attempts to maintain the internal implants during the treatment of IRI, but their success rate was very low. They suggested proper use of the external fixators and strongly recommended a rather aggressive surgical strategy with radical debridement and removal of all internal implants.
Defects of the lower leg with exposed tendons, bones, and implants still remain one of the most challenging areas in plastic and reconstructive surgery due to the paucity of reliable local cutaneous or muscle flaps and highly skilled technical expertise required for free tissue transfer. Naturally, local flaps are the first choice for the proximal lower limb soft-tissue defects and free flaps more distally. Although “free” flaps are often recommended as the treatment of choice for large tissue defects in the distal part of lower limb, they are relatively complex and time-consuming. Furthermore, not all patients are willing for free flaps due to financial reasons or are unfit for long surgery.
Although local perforator flap technique requires microsurgical dissection, it does not require vascular suturing and can thus be defined as a microsurgical nonmicrovascular flap, as termed by Georgescu et al. Raising a perforator flap is much quicker compared with microvascular flap, and the pedicle can be skeletonized under magnification with a loupe. We also chose pedicled perforator flaps for small-sized defects in some patients.
Free vascularized muscle transfers were once supposed to bring in a blood supply important for host defense mechanisms, antibiotic delivery, and healing of fracture and soft tissue. However, it should be remembered that the new tissue brought in has its blood supply from the host vessel present in the zone of injury or in the vicinity. They are therefore justified for large size and deep defects unmanageable by locally available tissue. Undisputedly, the muscle flaps do help in filling up the dead space and provide a better contour to the lower extremity. In the event of secondary surgery, an orthopedician should be foretold not to divide the muscle flap in the middle and rather should raise it from the margins opposite to the pedicle of the flap. This practical tip is important, because if not adhered to, it would result into the necrosis of part of the muscle flap as there is no additional blood supply gained from the margins of the original wound contrary to what one finds with fasciocutaneous flap.
It is also important to decide when to provide the soft-tissue cover for the exposed implants. As the exposure of the implants is associated with gross soft tissue and peri-implant infection, the key to the success would be adequate control/removal of the bacterial burden. Following fracture stabilization of Gustilo Grade 3B–C injuries, healing of soft tissue still remains a point of concern as the damage to microcirculation may result into necrosis of the soft tissue little later and result into its breakdown exposing the metallic implants. In such situations, it is better to follow the concept of “damage control orthopedics” rather than adopting “fix and flap” principle.
As of now, the muscle and the fasciocutaneous flaps are equally viable options, but the site of the exposed implant also determines the nature of the flap. Exposed implants in the upper third of leg may be covered by transposition of muscle flap such as gastrocnemius or tibialis anterior muscle, more preferably the former. Patellar region is amenable to propeller flap on perforator from deep femoral artery or the distally based medial thigh fasciocutaneous or extended medial head gastrocnemius flap.
Exposed implants in the middle third of the leg may well be covered with Soleus muscle flap or fasciocutaneous perforator flaps based on the posterior tibial or peroneal artery, antegrade or retrograde, without harming the main vessel. Cross-leg flap in the open book fashion may also be used for such defects. Small distal third leg wounds are amenable to reverse or distally based Soleus flap or near the ankle with peroneus brevis muscle. Reverse sural artery flap is also a viable option but may prove to be bulky in the region. Besides these flaps, free flap can be applied to any location with sizable wounds using anterolateral thigh flap, latissimus dorsi, or others. However, before contemplating free flap in an injured extremity, angiographic evaluation of its vascular status is mandatory. In case of a single intact vessel, end-to-side anastomosis is a challenging task to accomplish free tissue transfer.
| Conclusions|| |
Soft-tissue cover for exposed implants still poses a challenge to a reconstructive surgeon. Implants exposed before the complete union of fractures may be managed with judicious conservative approach using multimodality treatment with NPWT, suitable antibiotics for sufficient length of time, and later muscle or fasciocutaneous flap cover, pedicled, or free. Decision for immediate and elaborate reconstruction in a severely injured extremity should be taken only after careful thought to minimize or avoid second hit surgery.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Lew DP, Waldvogel FA. Osteomyelitis. Lancet 2004;364:369-79.
Xu YQ, Zhu YL, Fan XY, Jin T, Li Y, He XQ, et al.
Implant-related infection in the tibia: Surgical revision strategy with vancomycin cement. ScientificWorldJournal 2014;2014:124864.
Lazzarini L, Mader JT, Calhoun JH. Osteomyelitis in long bones. J Bone Joint Surg Am 2004;86:2305-18.
Ziran BH. Osteomyelitis. J Trauma 2007;62:S59-60.
Aytaç S, Schnetzke M, Swartman B, Herrmann P, Woelfl C, Heppert V, et al.
Posttraumatic and postoperative osteomyelitis: Surgical revision strategy with persisting fistula. Arch Orthop Trauma Surg 2014;134:159-65.
Vos DI, Verhofstad MH. Indications for implant removal after fracture healing: A review of the literature. Eur J Trauma Emerg Surg 2013;39:327-37.
Busam ML, Esther RJ, Obremskey WT. Hardware removal: Indications and expectations. J Am Acad Orthop Surg 2006;14:113-20.
Shrestha R, Shrestha D, Dhoju D, Parajuli N, Bhandari B, Kayastha SR. Epidemiological and outcome analysis of orthopedic implants removal in Kathmandu university hospital. Kathmandu Univ Med J (KUMJ) 2013;11:139-43.
Hanson B, van der Werken C, Stengel D. Surgeons' beliefs and perceptions about removal of orthopaedic implants. BMC Musculoskelet Disord 2008;9:73.
Haseeb M, Butt MF, Altaf T, Muzaffar K, Gupta A, Jallu A. Indications of implant removal: A study of 83 cases. Int J Health Sci (Qassim) 2017;11:1-7.
Trampuz A, Widmer AF. Infections associated with orthopedic implants. Curr Opin Infect Dis 2006;19:349-56.
Canner GC, Steinberg ME, Heppenstall RB, Balderston R. The infected hip after total hip arthroplasty. J Bone Joint Surg Am 1984;66:1393-9.
Goitz HT, Goitz RJ, Watson JT, Schurman JR 2nd
, Roth HJ. Orthopedic implants: A guide to radiographic analysis. Curr Probl Diagn Radiol 1996;25:109-68.
Tumeh SS, Aliabadi P, Weissman BN, McNeil BJ. Disease activity in osteomyelitis: Role of radiography. Radiology 1987;165:781-4.
Rabin DN, Smith C, Kubicka RA, Rabin S, Ali A, Charters JR, et al.
Problem prostheses: The radiologic evaluation of total joint replacement. Radiographics 1987;7:1107-27.
Tigges S, Stiles RG, Roberson JR. Appearance of septic hip prostheses on plain radiographs. AJR Am J Roentgenol 1994;163:377-80.
Kinahan PE, Hasegawa BH, Beyer T. X-ray-based attenuation correction for positron emission tomography/computed tomography scanners. Semin Nucl Med 2003;33:166-79.
White LM, Kim JK, Mehta M, Merchant N, Schweitzer ME, Morrison WB. Complications of total hip arthroplasty: MR imaging-initial experience. Radiology 2000;215:254-62.
Elgazzar AH, Abdel-Dayem HM, Clark JD, Maxon HR 3rd
. Multimodality imaging of osteomyelitis. Eur J Nucl Med 1995;22:1043-63.
Zimmerli W. Clinical presentation and treatment of orthopaedic implant-associated infection. J Intern Med 2014;276:111-9.
Lehner B, Fleischmann W, Becker R, Jukema GN. First experiences with negative pressure wound therapy and instillation in the treatment of infected orthopaedic implants: A clinical observational study. Int Orthop 2011;35:1415-20.
Maddineni NK, Koduru SK, Surath H, Dakshina Murthy AV, Reddy MR, Surath A. Negative pressure wound therapy in orthopaedic post operative infections: Role in implant retention and dead space management. J NTR Univ Health Sci 2015;4:257-62. [Full text]
Rosen H. The treatment of nonunions and pseudarthroses of the humeral shaft. Orthop Clin North Am 1990;21:725-42.
Rightmire E, Zurakowski D, Vrahas M. Acute infections after fracture repair: Management with hardware in place. Clin Orthop Relat Res 2008;466:466-72.
Vaienti L, Marchesi A, Palitta G, Gazzola R, Parodi PC, Leone F. Limb trauma: The use of an advanced wound care device in the treatment of full-thickness wounds. Strategies Trauma Limb Reconstr 2013;8:111-5.
Georgescu AV, Matei I, Ardelean F, Capota I. Microsurgical nonmicrovascular flaps in forearm and hand reconstruction. Microsurgery 2007;27:384-94.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]