Conferencia magistral en Congreso Mundial de Cirugóa Plástica. IPRAS 2013

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. Wellcome

3. How did we begin?
1979. Children at Hospital Exequiel Gonzalez Cortes
1980. 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. Degloving
Mesh graft

6. Pigskin heterograft

7. 1979. Osteomyelitis
saucering
Pathological fracture Design

8. What did we learn?
►The muscle flaps help
control infection
►The muscle flaps help bone
reparation
►We didn't like the shape
neither the scars of
muslucutaneus flap in legs

9. 1979.- III B open fracture
stabilized with Kirschner wire
External Fixator

10. The best bone fixation
is necessary
Leg saved but shortened

11. Wound by shotgun pellets
Our alternative
Soleus. Distal pedicle
1980. Emblematic case

12. What did we learn?
not to use ischemia

13. Long-term outcome

14. 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

15. 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

16. 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

17. Why that?
What are our resources?

18. .
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 Capita
Fuente: WHO en US$ PPP 2004

19. 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 2.918
OCDE 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 675
Chile Chile
Turquía
668
586
0 1.000 2.000 3.000 4.000 5.000 6.000 7.000
Fuente: OECD. Health data 2011

20. 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

21. Chile:
Health Expenditure distribution is
Fifty-fifty Public and Private System
Public Health System serves
75% of population
Public System Per capita is actually
about 450 $ US a year

22. 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

23. 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

24. 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

25. It Cannot be repaired because it is infected
It is infected because it is not repaired

26. 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.

27. Who are our patients?
Gender Distribution
Women
31%
Men
69%
Men
Women

28. Patients with lower limb flaps. 1997 - 2000
Etiology %
Actinic ulcer 2
Infected ostheosynthesis 6
Infected pseudoarthrosis 2
Open Fractures III B 73
Chronic Osteomyelitis 8
Osteosarcoma 8
Gunshot Wound 2
Total 100

29. Patients distribution according to age
30 27
25
19
Percentage 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)

30. Pre-existent diseases
Yes, 30%
Yes
No
No, 70%

31. Preexistent diseases
Previous Disease %
Hypertension 11
Liver Cirrhosis 3
Diabetes Mellitus 5
Alcoholism 5
hypothyroidism 3
Chronic kidney disease 3
30

32. Involved segments
43
45
40
35
Percentage by segment
30
25
19
20 16
14
15
8
10
5
0
Knee Proximal Medial third Distal third Ankle
third

33. Wound Infection
Yes, 57%
Yes
No
No, 43%

34. Wound Infection
5%
10%
10% Staphylococcus aureus
47%
Pseudomona
Proteus
Klebsiella
28% Acinetobacter

35. 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)

36. 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

37. What types of flaps do we use?
Flaps in lower limbs.
Flaps
Muscle flaps 80%
Fasciocutaneous flaps 20%

38. Flaps in open Fractures III B
Flaps %
Medial gastrocnemius muscle 22
Proximal soleus muscle 40
Distal soleus musle 19
fasciocutaneous 16
cross-leg flaps 3
Total 100

39. 2000. Musculoskeletal tumor surgery
Emerging issues
Caused by
►the extent of resection
►the impact of the radiotherapy
►the impact of the chemotherapy

40. The new issues
►Skin defects
►Infections
►Prosthetics Joints exposure
►Allograft bone Exposure
The new goal
To avoid amputation

41. Our Goal
To achieve the greatest therapeutic efficacy with
the best possible functional aesthetic outcome ,
minimal complications and the highest cost-
effectiveness

42. What are our criteria for procedure choice
Criteria for procedure choice
►Therapeutic efficacy
►Quantity and quality of tissue available
►Ease of performance
► Short surgical time
►Security
►Low morbidity associated
►Cost-effectiveness

43. Illustrating our experience
cases per segment.

44. Improving the thigh stump cover Rectus abdominis
musculocutaneous
flap at distal pedicle

45. Hip Chondrosarcoma operated
Exposed Prosthesis

47. Rectus abdominis muscle flap based at distal pedicle

48. Raised The Flap passed it through a tunnel

49. covering the prosthesis

50. Outcome
covered prosthesis

51. Allograft bone exposed

55. Knee
Proximal Third of leg
internal gatrocnemius
Muscle flap

56. Widening the gastrocnemius
Removing the aponeurosis
Mesh grafted

57. Exposed Knee
External side
External gastrocnemius
Rotated and widened

58. Mesh Grafted

61. Exposed Knee prosthesis
Reversed adipofacial flap

64. Short-term result

65. Middle third
Open Fracture
Soleus Flap
Proximal Pedicle
Without aponeurosis

66. Soleus sutured to the
tibialis anterior muscle
covering fractured tibia

67. Exposed
Homograft

68. Short-term result

69. Open Fracture and Degloving. Middle and distal third of leg

70. Soleus
Double flap
Proximal pedicle and
distal pedicle
Long-term outcome

71. III B Open Fracture Distal Third Soleus muscle flap distal pedicle

72. Using only the internal part of distal soleus

73. using the internal half

74. Crush Injury
10 days after

75. Posterior tibial nerve
exposed but viable

76. Cross-leg fasciocutaneous
reverse flap

78. Long-term outcome

79. Tumor resection
Exposed homograft bone
Cross-leg at Distal pedicle

81. Crush injury . Not apparent degloving

82. Exposed Heel and
Aquilles region

84. Covering heel first
Distal Pedicle covers
Aquilles Region

86. Long-term outcome

87. repairing the dorsum of the foot

88. 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)

89. 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 (%)

90. 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 (%)

92. Complications
63%
70%
POrcenrtage distribution of patients
60%
50%
40%
30%
14% 15%
20%
3% 5%
10%
0%
No Osteomyelitis Dehiscence Haematoma Infection
Complications

93. 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

94. ►The most frequently compromised segment was the
middle third
►More than fifty % of wounds were more than 31 days
old at the time of reparation
►The soleus flap was the most used.

95. •
►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.

96. We achieved the objectives that we wanted to achieve
The Techniques demonstrated their already known
effectiveness.
We managed to avoid amputations
From the point of view of quality care.
The most important problem was the delay in
reparation
The delay facilitates the infection and subsequent
complications

97. our keys
Strategic Planning
According to our particular resources
Keep in mind Patients’ personal conditions and goals
Not cause additional damage
Anticipate Complications
Keep in mind Cost-effectiveness