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Martel I.I., Grebenyuk L.A.
Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics, Kurgan, Russia
SOFT TISSUE DEFECTS OF THE FOOT SUPPORTING SURFACE REPAIRED WITH THE ILIZAROV METHOD UNDER CONTROL OF MECHANICAL AND BIOLOGICAL CONDITION OF THE SKIN
The problem of efficient treatment of patients
with severe opened injuries to the lower extremities is conditioned by
complexity and duration of treatment, possible development of infectious
complications and rude scars, and slow regeneration [1-4]. The successful
treatment of such patients is related to correction of posttraumatic defects of
soft tissues with use of various types of tissue plasty. We think that for such
cases it is appropriate to use dermotension technique with Ilizarov devices [4,
5, 6].
The literature describes some tactical errors
relating to treatment of patients with the above-mentioned pathology, with
situation when reposition of bone fragments is conducted to the detriment of
favorable conditions for recovery of soft tissue wounds [3, 5]. According to
the literature data, the recent two decades are characterized by significant
advancement in treatment of wounds: the physiological mechanisms of recovery at
different levels of tissue structures have been identified; social and
financial costs for long term treatment of chronic wounds have been considered
by the different funds of public healthcare. It is noted that transosseous
fixation is a unique alternative in treatment of severe injuries to the
extremities, with some advantages such as minimization of additional disorder
of peripheral perfusion, supporting and preservation of soft tissues and
decrease in potential risk of infection [7]. The treatment is to be primarily
oriented not to the problem of bone fractures, but to development of optimal
conditions for recovery of soft tissues [8]. It is known that the anatomical
distal one-third of the leg and the foot are the most complex region of the
lower extremity for reconstructive interventions, when it is appropriate to use
the external fixation [8].
Objective – to review
a clinical case of soft tissue defects of the foot supporting surface repaired
with the Ilizarov method under control of mechanical and biological condition
of the skin.
MATERIALS AND METHODS
The patient (age of 16, female) was admitted
to the clinic of Russian Ilizarov Scientific Center for Restorative
Traumatology and Orthopaedics. The diagnosis at admission was: “Consequences of
crushing injury to the left foot. Malunions of the instep bones 1-4,
scarry-ulcerous changes in the foot at the background of lymph-venous
insufficiency”. There was a scar (4 × 6 cm) in the plane of the supporting
surface of the calcaneal region. The scar was connected to the bone and had an
ulcer of 1.5 cm diameter. A road traffic accident with a truck happened. The left
foot was injured. The conservative treatment was performed according the place
of residence. Six months later, the patient was admitted to the clinic of Russian
Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics. At
admission, some ulcerous-trophic defects of 1 × 3 cm were found in the middle
part of the left foot, as well as defects of 1 × 4 cm along the anterior
surface of the foot and defects of 1 × 2 cm along the internal surface. The
regions were without subcutaneous fat. The surgical treatment included:
1. Osteosynthesis of the foot and the ankle
joint with Ilizarov device for improvement in trophism and preparation for
dermotension.
2. Replanting of the heterobone in the calcaneal
region with subsequent lengthening of the skin for creation of tissue reserve.
3.
Plantotomy. Osteotomy of the first instep bone.
Besides the clinical and laboratory techniques of the examination, we
estimated the mechanical and biological condition of the foot skin. The
quantitative estimation of the tissue condition near the wound of the injured
segment was conducted with our technique for assessment of surface acoustic
wave velocity (SAWV) with ASA skin acoustic analyzer (Moscow-Belgrade). The
fields for testing were separated in the skin regions adjacent to the wound
surface. Each field was divided into the regions of 1 cm2. With
consideration of skin anisotropism, the calculations were performed in two
different directions in relation to traction forces – longitudinally (C
longitudinal) and transversely (C transverse). Then the comparative analysis of
SAWV modules in symmetrical fields of the skin of the lesioned and intact
segments was conducted. Also the time course of the studied values in relation
to the initial values was estimated during the first day of distraction. The
picture shows the procedure of measurements in mechanical and acoustic
properties of the skin (Fig. 1).
Figure 1. The photo illustration of the monitoring
procedure of biomechanical condition of the skin of the injured foot with use
of mechanic-acoustic skin analyzer ASA (Moscow-Beograd production)
The present study was conducted in compliance with World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013. The patient gave her informed consent for participation in the study and for surgical treatment. The approval from the ethical committee of Russian Ilizarov Scientific Center for Restorative Traumatology and Orthopaedics was received.
RESULTS AND DISCUSSION
Correction of the soft tissue foot defect with
local tissues has the advantage of restoration of the full skin surface, i.e.
the favorable anatomical conditions for recovery of the supporting function of
the extremity appear. It is known that one of the most common methods for
creation of reserve of covering tissues in different parts of the human body is
use of tissue expanders. The literature describes the experience with use of
tissue expanders for correction of scar changes in the region of the Achilles
tendon [9]. As for possible complications, the authors note the development of
boundary necrosis along the line of a surgical suture, migration of the expander
port, transitory edema of the foot. Early closure of soft tissue defects is considered
for severe opened fractures of the leg bones with aim of minimization of risk
of complications [10]. In most cases, the degree of tissue extension is
estimated visually and with palpation, considering the pain feelings of the
patient [11].
Absence of objective techniques of
identification of skin overdistension causing the ischemic disorders can lead
to necrotic changes in the extended region and formation of a bedsore under the
expander [11]. It is noted that adequate estimation of adaptation of tissues to
extension is possible with the thermal imaging technique. Previously, the
technique for estimating the skin extension in extremities lengthening in
conditions of transosseous fixation with ASA mechanic acoustic skin analyzer
was offered [12, 13]. The quantitative criteria were determined that testify
the borderline states of stretched skin of the extremities, with their excess
leading to appearance of signs of tissue microinjuries, striate atrophy of skin
and tissue ischemia. It was one of the indications for correction of management
of patients.
The following stages of the surgical treatment
were conducted for closing the soft tissue defects of the left foot in the
patient S.
The first stage. After two
weeks of preparation, the surgery was conducted: osteotomy of the first instep
bone, fool and ankle joint fixation with Ilizarov technique (Fig. 2, 3). The
foot arch was restored. The patient received the successful complex drug and
physical functional treatment of lymph-venous insufficiency (two courses of hyperbaric
oxygenation, massage for the left and the foot with use of troxevasin,
isometric gymnastics). Ilizarov device was dismounted one and a half month later.
The wounds and the fistulas were treated successfully.
The second stage of the surgical
treatment. There were some scarry tissues on the dorsal and lateral surfaces of
the left foot, the rough scars of 5-6 cm (connected to the bone) on the dorsal
surface containing some trophic ulcers (diameter of each – 1 cm2) at
the moment of admission. The arteriography showed the preserved perfusion in
the external part of the foot. Two surgical interventions were conducted for
plasty of the scarry tissues on the supporting surface (Fig. 2, 3): the first
surgery – creation of the reserve of soft tissues with Ilizarov technique, the
second surgery – plasty with local tissues of the left calcaneal region. Foot
and ankle fixation with Ilizarov technique, plantotomy, osteotomy of the first
instep bone and implantation of heterobone in the calcaneal region for creation
of the reserve of soft tissues were conducted. In the postsurgical period,
traction towards the tissue defect was gradually performed. Its aim was
creation of the skin reserve. After that, the heterobone was removed, the scar
tissue was dissected and the defect was replaced with the local tissues.
Figure 2. The photo illustration of the patient S. during
the surgical treatment and two years after it:
a) at the moment of
admission to the clinic of Russian Ilizarov Center for Restorative Traumatology and Orthopaedics for the first stage of
treatment (March 2004)
b) during the process of dermotension for tissues
of plantar surface of the foot (June 2005)
c) long term period (2 years)
after surgical treatment
Figure 3. The photo illustration of the X-ray images of
the patient S. Diagnosis: «Condition after crushing damage of the left foot
tissues after a road traffic accident. Posttraumatic trophic ulcers of the left
foot. Malunions of the instep bones 1-5»:
a) before treatment
b) dermotension
c) long term result of surgical treatment with left foot dermoplasty for
closure of the soft tissue defect in the calcaneal region
The monitoring of the mechanical and biological state of the extended skin surface was realized during the process of dermotension (the table, Fig. 4). On the seventh day of distraction, the extremely high tensioned and deformed condition of the stretched skin was identified. It testified the risk of the overdistension and development of ischemic disorders in soft tissues. Dermotension was stopped. After three days of the break, the distraction was initiated with the lower rate (0.5 mm per day). It was successfully completed under the control of the parameters of biomechanical condition of the foot skin.
Table. The time course of SAWV in the skin surface of the affected foot of the patient S., age of 17, during dermotension process
|
Traction (days) |
V long. (m/s) |
% of 1st day of distraction |
V trans. (m/s) |
% of 1st day of distraction |
|
1 |
111 |
100 % |
134 |
100 % |
|
7 |
207 |
186.5 % |
196 |
146.30 % |
|
13 |
56 |
48 % |
68.5 |
51 % |
|
16 |
156 |
140.5 % |
144 |
107.5 % |
|
18 |
182,5 |
164.4 % |
120 |
89.5 % |
|
20 |
157,5 |
141.9 % |
136 |
101.50 % |
|
24 |
205 |
184.7 % |
183 |
136.60 % |
|
38 |
201 |
181.1 % |
181 |
135.10 % |
Note: V (long.) – SAWV in longitudinal direction, S (trans.) – SAWV in transverse direction.
Figure 4. The time course of SAWV in the foot skin in
dermotension
The analysis of the results of the monitoring
of the mechanical and biological condition of the skin during dermotension of
the injured foot showed that along with the gradual closure of the soft tissue
defect using the stretched skin (i.e. by the day 7), the value of SAWV with
traction (C transverse) had increased by 86 % as compared to the basic values
and had reached 207 m/s and 46 % for C transverse (the table, Fig. 4).
Clinically, the stretched tissues showed some signs of disordered trophism
(skin paleness) and increasing pain feelings. The distraction was arrested
temporarily.
By completion of the relaxation period, i.e.
by the 13th day after initiation of extension, we could observe the decrease in
the level of tensioned and deformed state of the foot skin. SAWV decreased to
52 % (along with extension) and to 49 % (in relation to traction). After resumption
of the dermotension, SAWV increased the traction forces by 40.5-84.1 % as
compared to the basic values. SAWV increased by 35.1-36.6
% in transverse direction.
Therefore, the correction of the management
was made owing to the signs of ischemia and significant increase in SAWV, and
the distraction was temporarily stopped. After sufficient relaxation (testified
by decreasing SAWV in the stretched foot skin), the distraction was resumed for
completed closure of the soft tissue defect.
The heterogeneity coefficient of the
mechanical and acoustic properties of the stretched skin [the ratio of C
(transverse) and C (longitudinal)] was 0.82 after temporary discontinuation of
the distraction. After resumption, it increased to 1.52, and later reached
1.11-1.12. In the skin of the intact foot, the coefficient did not exceed 1.0.
Therefore, the plastic operations with own
tissues were carried out for closure of the soft tissue defect in the calcaneal
region and for restoration of adequate supporting ability of the foot. The
correct union of the instep bones and restoration of the foot arches were
achieved.
Two years after completion of the treatment,
the patient did not have any complaints during the control examination. She
wore her usual shoes and continued her university education. Tactile and
nociceptive sensitivity of the injured foot restored. The
patient was satisfied with
the treatment results.
The literature analysis showed the
insufficient use of techniques for non-invasive monitoring of the mechanical
and biological conditions of recovery of the injured soft tissues in patients
with opened injuries to the extremities. The conducted studies testify the high
information capability of biomechanical testing of the skin and solution of the
problem of closure of the soft tissue defects in the injured extremities. The
conclusion was made about the appropriateness of the objective control of the
biomechanical condition of the skin surface and, therefore, timely correction
of management for creation of adequate mechanical conditions in the soft
tissues which do not cause the overdistension or ischemia.
Seven patients received the treatment with use
of the above-mentioned technique of foot tissue dermotension with Ilizarov
device for the last ten years in the clinic of the center. Currently, we
successfully use the techniques for replacement of soft tissue defects, which
were developed with consideration of the wound type, and a possibility for
healing primary adhesion. In this case, the size, the direction of a wound in
relation to the axis of the segment, and anatomical and topographical features
of soft tissues in the injured segment are considered [6].
Some authors note that treatment of injuries
to the lower extremities remains the complex problem for surgeons, especially,
in presence of extensive damages of soft tissues and bone tissue loss. Surgical
management of such injuries can be difficult due to limitation of reserves of local
tissues for replacement of the defect [14].
In our center, we have developed and
implemented the transosseous fixation techniques for treating soft tissue
defects without transplantation, correcting the extensive wounds and preserving
the optimal conditions for recovery and union of fractures. A possibility of
the single-moment achievement of union of bone fragments and recovery of soft
tissue wounds with preservation of function of the injured extremity has
appeared after clinical implementation of the devices for transosseous
fixation, with Ilizarov device that is the most appropriate for using. Skin
surface testing near wounds in patients with opened injuries has become
practical for identification of signs of overdistension during the process of
dosed extension and skin “cultivation”. Timely correction of management
promotes the increase in quality of medical care and achievement of good anatomical
and functional results.
CONCLUSION
The analysis of the long term results of the treatment with use of the technique for correcting the soft tissue defect of the supporting surface of the foot has shown the good anatomical, functional and cosmetic results with positive estimation by the patient. Tactile and nociceptive sensitivity of the tissues in the injured foot was preserved. The supporting ability of the injured extremity, which is necessary for locomotor activity in daily life, has restored. Integration of the surgical techniques with Ilizarov method and estimation of mechanical and acoustic condition of the skin in patients with soft tissue defects of the extremities is appropriate for control of the dermotension process.
Information about financing and conflict of interests
The
study was conducted without sponsorship.
The authors declare the absence of any
clear and potential conflicts of interests relating to publication of this
article.
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