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Lower limb ipras 2013

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Conferencia magistral. Congreso mundial de Cirugía Plástica reparadora y Estética.
IPRAS 2013

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Lower limb ipras 2013

  1. 1. Treatment of complex open lower limbs wounds at “Instituto Traumatológico”. A 30 year experience Dr. Jorge Villegas Servicio de Quemados Hospital de Urgencia Asistencia Pública Instituto Traumatológico Clínica INDISA Santiago. CHILE www.cirugiaplasticayquemados.cl
  2. 2. Wellcome
  3. 3. How did we begin?1979. Children at Hospital Exequiel Gonzalez Cortes1980. Victims of employment injuries at“Hospital del Trabajador “1983. At “ Instituto Traumatológico”What were our first cases?What did we learn? ►Osteomyelitis ►Open Fractures ►Degloving
  4. 4. DeglovingMesh graft
  5. 5. Pigskin heterograft
  6. 6. 1979. Osteomyelitis saucering Pathological fracture Design
  7. 7. What did we learn?►The muscle flaps helpcontrol infection►The muscle flaps help bonereparation►We didnt like the shapeneither the scars ofmuslucutaneus flap in legs
  8. 8. 1979.- III B open fracturestabilized with Kirschner wire External Fixator
  9. 9. The best bone fixationis necessary Leg saved but shortened
  10. 10. Wound by shotgun pellets Our alternative Soleus. Distal pedicle1980. Emblematic case
  11. 11. What did we learn? not to use ischemia
  12. 12. Long-term outcome
  13. 13. Where do we work? The “Instituto Traumatológico Teodoro Gebauer” Old and traditional Hospital Founded in 1937, Since 1968 It is part of the Chilean Public Health network
  14. 14. What is our Mission?►Resolve 54 % of the traumatic pathology needs of the Metropolitan Area►12 % of the traumatic pathology needs nation wide.►Teach generations of orthopaedic surgeons
  15. 15. What is our context? The “Instituto” keeps some of its old structural characteristics ►Focused on Traumatology ►Four operating rooms ►No Intensive Care Unit ►Small medical staff ►No Plastic Surgeon staff ►No vascular surgeon staff Medical staff composition Orthopeadic surgeons 31 Anesthesiologists 9 Internist 1
  16. 16. Why that?What are our resources?
  17. 17. . Income and per capita health expenditure H e 4500 a USA l 4000 t 3500 h 3000 Suiza e 2500 Japon x Canadá p 2000 Francia e Israel n 1500 d 1000 i Argentina España Singapur t 500 Perú Chile Mexico u 0 Brasil r e 0 5.000 10.000 15.000 20.000 25.000 30.000 35.000 Income Per CapitaFuente: WHO en US$ PPP 2004
  18. 18. Per capita expenditure on health. OECD Countries Estado s Unido s 6.401 Luxemburgo 5.352 No ruega 4.364 Suiza 4.177 A ustria 3.519 Islandia 3.443 B élgica 3.389 Francia 3.374 Canadá 3.326 A lemania 3.287 A ustralia (2) 3.128 Dinamarca 3.108 Ho landa (1,3) 3.094 Grecia 2.981 Irlanda 2.926 Suecia 2.918OCDE OCDE 2.759 Reino Unido 2.724 Italia 2.532 Japó n (1) 2.358 Nueva Zelandia 2.343 Finlandia 2.331 España 2.255 P o rtugal 2.033 República Checa 1.479 Hungría 1.337 Co rea 1.318 Eslo vaquia 1.137 P o lo nia 867 M éxico 675Chile Chile Turquía 668 586 0 1.000 2.000 3.000 4.000 5.000 6.000 7.000 Fuente: OECD. Health data 2011
  19. 19. Composition of health expenditures. Public - Private. OECD Reino Unido Suecia Japón Francia Finlandia Nueva Zelandia Alemania Italia Portugal España Canadá OCDE Australia Holanda Suiza Corea del Sur Chile México Estados Unidos 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Público Privado Sourse: OECD. Health data 2007
  20. 20. Chile:Health Expenditure distribution isFifty-fifty Public and Private SystemPublic Health System serves 75% of populationPublic System Per capita is actually about 450 $ US a year
  21. 21. What resources do we have for plastic surgery? Plastic Surgery ►3 hours for plastic surgery a week ►Control ►Follow up ►Outcome assessment Are done by the orthopedic surgeons
  22. 22. What is our experience? First Stage. 1983 to 2000 Degloving Osteomyelitis Open Fractures Since 2000 Musculoskeletal tumors surgery was developed Complementary or secondary plastic surgery was necessary Second Stage Degloving Osteomyelitis Open Fractures Muscoloskeletal tumors
  23. 23. What were our goals? First Stage ►To Select and perform surgical techniques: Simple to perform Safe Short surgical time Low morbidity Low complications High cost-effectiveness ►To overcome a vicious circle
  24. 24. It Cannot be repaired because it is infectedIt is infected because it is not repaired
  25. 25. What is our protocol? Early reparation. Between the 4th and 7th day Flaps by segment. Main Indications►Knee and proximal third of leg: gastrocnemius,►Medial third: Soleus at proximal pedicle►Internal Distal third and ankle : Soleus at distal pedicle►Outer distal third and ankle: reverse fasciocutaneous flap.
  26. 26. Who are our patients? Gender Distribution Women 31% Men 69% Men Women
  27. 27. Patients with lower limb flaps. 1997 - 2000Etiology %Actinic ulcer 2Infected ostheosynthesis 6Infected pseudoarthrosis 2Open Fractures III B 73Chronic Osteomyelitis 8Osteosarcoma 8Gunshot Wound 2Total 100
  28. 28. Patients distribution according to age 30 27 25 19Percentage distribution 20 16 14 15 10 8 10 5 5 0 < 20 21 to 30 31 to 40 41 to 50 51 to 60 61 to 70 > 71 Age (years)
  29. 29. Pre-existent diseases Yes, 30% Yes NoNo, 70%
  30. 30. Preexistent diseasesPrevious Disease %Hypertension 11Liver Cirrhosis 3Diabetes Mellitus 5Alcoholism 5hypothyroidism 3Chronic kidney disease 3 30
  31. 31. Involved segments 43 45 40 35Percentage by segment 30 25 19 20 16 14 15 8 10 5 0 Knee Proximal Medial third Distal third Ankle third
  32. 32. Wound Infection Yes, 57% Yes NoNo, 43%
  33. 33. Wound Infection 5% 10%10% Staphylococcus aureus 47% Pseudomona Proteus Klebsiella 28% Acinetobacter
  34. 34. Why so hight wound infection percentage? Time before reparation. Porcentage distribution. 58% 60% Porcentage distribution of patients 50% 40% 30% 24% 20% 8% 10% 5% 5% 0% < 10 11 to 30 31 to 90 91 to 180 > 180 Tíme before reparation (days)
  35. 35. Why the delay in repairing? Two reasons: ►Workload ►Lack of plastic surgeon staff in the emergency service Therefore the first surgical toilet is not necessarily performed by an expert. Therefore it is necessary to repeat the procedure more than once. During this Period the wound gets infected
  36. 36. What types of flaps do we use? Flaps in lower limbs. Flaps Muscle flaps 80% Fasciocutaneous flaps 20%
  37. 37. Flaps in open Fractures III BFlaps %Medial gastrocnemius muscle 22Proximal soleus muscle 40Distal soleus musle 19fasciocutaneous 16cross-leg flaps 3Total 100
  38. 38. 2000. Musculoskeletal tumor surgery Emerging issues Caused by ►the extent of resection ►the impact of the radiotherapy ►the impact of the chemotherapy
  39. 39. The new issues ►Skin defects ►Infections ►Prosthetics Joints exposure ►Allograft bone ExposureThe new goal To avoid amputation
  40. 40. Our Goal To achieve the greatest therapeutic efficacy with the best possible functional aesthetic outcome , minimal complications and the highest cost- effectiveness
  41. 41. What are our criteria for procedure choiceCriteria for procedure choice ►Therapeutic efficacy ►Quantity and quality of tissue available ►Ease of performance ► Short surgical time ►Security ►Low morbidity associated ►Cost-effectiveness
  42. 42. Illustrating our experiencecases per segment.
  43. 43. Improving the thigh stump cover Rectus abdominis musculocutaneous flap at distal pedicle
  44. 44. Hip Chondrosarcoma operatedExposed Prosthesis
  45. 45. Rectus abdominis muscle flap based at distal pedicle
  46. 46. Raised The Flap passed it through a tunnel
  47. 47. covering the prosthesis
  48. 48. Outcomecovered prosthesis
  49. 49. Allograft bone exposed
  50. 50. Knee Proximal Third of leginternal gatrocnemiusMuscle flap
  51. 51. Widening the gastrocnemius Removing the aponeurosisMesh grafted
  52. 52. Exposed Knee External sideExternal gastrocnemiusRotated and widened
  53. 53. Mesh Grafted
  54. 54. Exposed Knee prosthesis Reversed adipofacial flap
  55. 55. Short-term result
  56. 56. Middle third Open Fracture Soleus Flap Proximal PedicleWithout aponeurosis
  57. 57. Soleus sutured to thetibialis anterior musclecovering fractured tibia
  58. 58. ExposedHomograft
  59. 59. Short-term result
  60. 60. Open Fracture and Degloving. Middle and distal third of leg
  61. 61. Soleus Double flap Proximal pedicle and distal pedicleLong-term outcome
  62. 62. III B Open Fracture Distal Third Soleus muscle flap distal pedicle
  63. 63. Using only the internal part of distal soleus
  64. 64. using the internal half
  65. 65. Crush Injury10 days after
  66. 66. Posterior tibial nerveexposed but viable
  67. 67. Cross-leg fasciocutaneousreverse flap
  68. 68. Long-term outcome
  69. 69. Tumor resectionExposed homograft boneCross-leg at Distal pedicle
  70. 70. Crush injury . Not apparent degloving
  71. 71. Exposed Heel andAquilles region
  72. 72. Covering heel firstDistal Pedicle coversAquilles Region
  73. 73. Long-term outcome
  74. 74. repairing the dorsum of the foot
  75. 75. Surgical time and Porcentage distribution 60% 53% 50%Porcentage distribution of cases 40% 32% 30% 20% 10% 10% 5% 0% <1 1 to 2 2 to 3 >3 Surgical time (hours)
  76. 76. Flap Survival 81% 90%Porcentage distribution of patients 80% 70% 60% 50% 40% 30% 16% 20% 0% 0% 3% 10% 0% 0% 25% 50% 75% 100% Flap Survival (%)
  77. 77. Skin Graft take 65% 70%Porcentage distribution of patients 60% 50% 40% 27% 30% 20% 3% 5% 10% 0% 0% 0% 25% 50% 75% 100% Skin Graft take (%)
  78. 78. Complications 63% 70%POrcenrtage distribution of patients 60% 50% 40% 30% 14% 15% 20% 3% 5% 10% 0% No Osteomyelitis Dehiscence Haematoma Infection Complications
  79. 79. In summary ► The majority of patients were men ►Most of them young people without preexistent disease. ►The most common etiology was open fractures. ►More than a half of wounds were infected
  80. 80. ►The most frequently compromised segment was the middle third►More than fifty % of wounds were more than 31 daysold at the time of reparation►The soleus flap was the most used.
  81. 81. • ►The majority of cases had no complications. ►Our complications were infection and dehiscence. ►Flap survival was 100 % in more than 80% ►The losses were only marginal. ►The long term result was satisfactory in most cases ►Surgery time was about two hours.
  82. 82. We achieved the objectives that we wanted to achieveThe Techniques demonstrated their already knowneffectiveness.We managed to avoid amputationsFrom the point of view of quality care.The most important problem was the delay inreparationThe delay facilitates the infection and subsequentcomplications
  83. 83. our keysStrategic PlanningAccording to our particular resourcesKeep in mind Patients’ personal conditions and goalsNot cause additional damageAnticipate ComplicationsKeep in mind Cost-effectiveness

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