ONE-STAGE RECONSTRUCTION OF SOFT TISSUES WITH NEUROTROPHIC ULCERS OF THE FOREFOOT IN LONG TERM PERIOD OF POLYTRAUMA

ONE-STAGE RECONSTRUCTION OF SOFT TISSUES WITH NEUROTROPHIC ULCERS OF THE FOREFOOT IN LONG TERM PERIOD OF POLYTRAUMA 

Minasov B.Sh., Valeev M.M., Biktasheva E.M., Yakupov R.R., Minasov T.B., Mavlyutov T.R., Atmanskiy I.A., Kopylov V.A. 

Bashkir State Medical University, Ufa, Russia 

Deep, painless and small defects of soft tissues with low discharge and bad smell without trend to independent recovery of a denervated foot are usually called neurotrophic ulcers. At the background of poor granulated tissue, the tendons and (or) bone tissue are located in the bottom of ulcers. The borders of ulcers are crateriform deepenings with cornified epidermis [1, 2, 3].
Involvement of bone tissue into the inflammatory process determines the development of the most threatening complication – contact osteomyelitis. The false effect of radical sequestrnecrectomy with formation of viable tissue often disorients the surgeons. Without restoration of appropriate soft tissue coverage of the bone, necrosis of the following part of the exposed bone develops rapidly [4, 5].
The problem of replacement of soft tissues in neurotrophic ulcers of the foot is still important in the modern medical practice. Modern high tech wound and cut management materials give only partial solution of the problem of care and temporary coverage of such soft tissue defects. The radicality of solution of this problem consists in reconstruction of appropriate skin coverage, which withstands the pressure of the body and pressure during walking [6-17].
Objective – to show the result of one-stage reconstruction of soft tissues with neurotrophic ulcers of the forefoot.
The study and the publishing were approved by the ethical committee of Bashkir State Medical University. The patient gave the agreement for publishing the results of the study. 

CLINICAL CASE

The patient S., age of 53, addressed to the Ufa Emergency Care Hospital. He had some complaints of neurotrophic ulcers on the supporting surface of the forefoot, constant smell and limited support to the foot during walking (Fig. 1). The patient received a spinal cord injury 30 years ago. Neurotrophic ulcers of the foot appeared later.

Figure 1. The presurgical picture of the right foot


The surgery was conducted on October 14, 2012. Both neurotrophic ulcers with regions of cornified epidermis of the right foot were dissected under regionary analgesia (Fig. 2). The dorsal artery of the foot and the subcutaneous vein were separated for anastomosing on the dorsal surface of the foot.The skin incision and separation of the radial artery with the accompanyingveins were performed in the plane of the radial vein under regionary analgesia of the upper extremity. Two cutaneous fascial flaps with single delivering vessels were cut in the middle one-third of the forearm (Fig. 3a). The flap was placed onto the region of a soft tissue defect of the right foot (Fig. 3b). The delivering vessels of the cutaneous fascial flaps were anastomosed to the dorsal artery of the foot and the subcutaneous vein. The wound was sutured with local tissues in donor region.

Figure 2. The surgery stage. The picture of the right foot after dissection of neurotrophic ulcers



Figure 3. The surgery stages: a) planning the borders of separation of the skin fascial flap in the donor forearm; b) the autograft has been transferred to the region of the recipient’s foot

  

The wounds in the donor region and in the foot healed with primary tension. There were not any signs of necrosis of the autograft. Five years after the surgery (Fig. 4), the quality of life improved significantly since the supporting surface of the extremity improved, need for daily dressings passed out and unpleasant smell of the foot ulcers disappeared.

Figure 4. The picture of the right foot after surgery

DISCUSSION

According to the different publications and own experience, we have concluded that some patients with successful surgery have the wrong idea of success; comfort life begins, specific smell of the foot wound disappear, and daily burdensome dressings are cancelled. But one must remember that the foot is still insensitive.
The decision on surgical treatment depended on importance of surgery and readiness of the patient for competent and correct adherence to medical recommendations for the postsurgical period and for possible change in subsequent life style. We think that one of the most important principles of prevention of recurrent neurotrophic ulcer is appropriate and sometimes precise care for the injured foot with daily preparation of skin surface with ointments, constant wearing of special footwear and prevention of damages of the problem foot. 

CONCLUSION

The complex flaps with autonomous type of perfusion can be successfully used for closing the defects of soft tissues of the foot after neurotrophic disorders. Such flaps can be used both without transection of the vascular pedicle and, in free position, with application of microvascular anastomoses. The flaps in the recipient’s region require for appropriate care in the postsurgical period and during the whole life of patients.

Information on financing and conflict of interests

The study was conducted without sponsorship.
The authors declare the absence of clear and potential conflicts of interests relating to publication of this article.

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