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 Table of Contents  
Year : 2021  |  Volume : 8  |  Issue : 2  |  Page : 117-124

Use of flaps in orthopedics in a peripheral trauma center in Nepal without plastic surgery services

1 Department of Orthopedics, Unit 3, CMC, Vellore, Tamil Nadu, India
2 Department of Orthopedics, United Mission Hospital, Tansen, Nepal
3 Department of Orthopedics, Green Pastures Hospital, Pokhara, Nepal
4 United Mission Hospital, Tansen, Nepal

Date of Submission17-Nov-2019
Date of Decision20-Nov-2020
Date of Acceptance05-Jul-2021
Date of Web Publication27-Oct-2021

Correspondence Address:
Bhim Bahadur Shreemal
Department of Orthopedics, Unit 3, CMC, Vellore, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cjhr.cjhr_113_19

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Background: Soft tissue cover after surgical debridement, skeletal stabilization is an integral part of optimal management of high-velocity orthopedic injuries and orthopedic infections which is preferably done in collaboration with plastic surgeons. In our peripheral hospital, since plastic surgery service is not available, it has been our practice as orthopedic surgeons to be involved in the comprehensive surgical care of such patients including flap cover of the resulting soft-tissue defect. We reviewed the results of our flaps from June 2013 to May 2015 which were exclusively done by orthopedic surgeons. Materials and Methods: All patients from June 2013 to May 2015 with an open fracture or orthopedic infections who underwent flap cover of any kind in both the upper and lower limbs were retrospectively reviewed. Results: We had thirty-eight flaps in 36 patients. Two were lost to follow-up. There were eight (22.22%) upper limb flaps and 28 (77.77%) lower limb flaps. Average follow-up was 3 months (6 weeks–12 months). The average age was 35 years (17 years–65 years). Ten (27.7%) of the patients had flap done for infection and the rest 26 (72.2%) for an open fracture. The dimension of the flap ranged from 1 cm × 1 cm to 15 cm × 16 cm. Thirty-one out of thirty-six (83.33%) of the flaps healed primarily. Six (16.66%) patients had minor complications. There was no total flap loss. Conclusion: Comprehensive care of soft-tissue defects by orthopedic surgeons themselves seem to be a viable option with good outcome and acceptable complications in orthopedic trauma and infections when plastic surgery service in not available.

Keywords: Comprehensive care of soft-tissue defects, flaps by orthopedic surgeons, local flaps in orthopedic trauma

How to cite this article:
Shreemal BB, Pun TB, Maharjan D, Bhat DS. Use of flaps in orthopedics in a peripheral trauma center in Nepal without plastic surgery services. CHRISMED J Health Res 2021;8:117-24

How to cite this URL:
Shreemal BB, Pun TB, Maharjan D, Bhat DS. Use of flaps in orthopedics in a peripheral trauma center in Nepal without plastic surgery services. CHRISMED J Health Res [serial online] 2021 [cited 2022 Jan 18];8:117-24. Available from: https://www.cjhr.org/text.asp?2021/8/2/117/329444

  Introduction Top

Open fractures and orthopedics infections complicated by soft-tissue loss pose a considerable challenge to treating orthopedic surgeons, reconstructive surgeons, and healthcare professionals all over the world, at times amounting to even late amputations.[1] The projected figures for accidents in the future are even more alarming in Asian countries.[2],[3] There is an increasing incidence of high-velocity injuries probably owing to more roads, faster but unsafe vehicles and unsafe driving discipline in our part of the world.[4] Soft tissue consideration in these patients is even more important. A compromised soft tissue envelope, like skin and soft tissue loss, adherent scar, soft tissue contractures, and circumferential eschar complicates the treatment in such a situation.[5] Principles involved in the management of high-velocity orthopedic injuries involve a thorough surgical debridement, skeletal stabilization, and soft tissue coverage.[1],[6] Similarly in the case of orthopedic infection, after a radical debridement, addressing the resulting soft tissue and a bone defect is an integral part of a surgical plan. Underlying tissue if left uncovered is sure to desiccate and get infected quickly.[7] The prevalent approach used in most tertiary care centers and urban centers in such a clinical situation is a multidisciplinary team approach. Debridement and skeletal stabilization are done by an orthopedic surgical team and reconstruction and coverage of resulting soft-tissue defect is managed by the plastic surgical team. This approach is the ideal approach and is effective but is limited by the inherent need for the availability of at least two very specialized surgical teams for the care of the patient which is difficult in rural settings. This approach also relies on easy availability and smooth communication between different surgical teams which is sometimes is not easy in some centers.[8],[9] This model could work in a developed country and in urban setting but in the developing world, ground realities are different, and thus direct adoption of this approach might not be appropriate and practical in all centers, especially in rural centers. Such services though available in a few centers are not affordable and accessible to certain group of patients. In a developing country like ours where plastic surgeons are not readily available in rural centers, it might be worthwhile to revisit the prevalent approach to this problem especially since there seems to be increasing burden of injuries and infections requiring soft-tissue reconstruction in the developing countries.[10] Most of the patients like in other developing countries come from poorer families and sometimes the only breadwinners for the entire family. It can be impractical and inconvenient for them to travel to a faraway city where all the facilities are available under one roof. Most of our patients have to pay for treatment from their savings which is a huge financial burden for the family.[11],[12] A large percentage of disability-adjusted life years lost from road traffic accidents comes from the developing world.[13] Nepal has very few plastic surgeons and they are not available in smaller centers. It is very unlikely that we will have an adequate number of plastic surgeons in the future to meet the demand of projected open fractures which is bordering at epidemic levels. An orthopedic surgeon in a developing world sees many times more open fractures compared to his counterpart in developed countries.[9] Careful handling of soft tissues is now at the core of any orthopedic training. Orthopedic surgeons are also familiar with limb anatomy since they are required to operate on the limb regularly for various other conditions. It is with this understanding that we believe a large number of the flaps related to orthopedic trauma and infections can be done by a well-trained orthopedic surgeon especially if placed in a situation when plastic surgery service is not available. This comprehensive care of patients including flaps cover of open wounds by orthopedic surgeons themselves though practiced in few centers across the world, is far from being the norm. There are few reports of comprehensive care of open injury patients by orthopedic surgeons in literature to our knowledge, there is no such report from a peripheral set up and a nonteaching hospital where resources are limited and surgeons are often required to go beyond their comfort zone to operate on patients across specialties.[14],[15] Flaps required from a technical standpoint are of two types, those which require microvascular technical expertise and those which do not. The former has a steep learning curve and requires specialized set up while the later can be carried out by all surgeons with thorough knowledge and understanding of local anatomy without the need for microsurgical skill. We have seen in our experience that a vast majority of patients can be managed by nonmicro surgical flaps. In our hospital, since we do not have plastic surgery services, it has been our practice as orthopedic surgeons to be involved in the comprehensive surgical care of such patients including flap surgeries. Three of the authors were trained in an institute where this approach was already being used and several reports have been published from the same to this effect.[15],[16],[17],[18],[19],[20],[21] Surgical rotation to vascular surgery and hand and reconstructive surgery further increased authors' confidence in handling the soft tissues delicately. Two of the authors have also undergone additional hands-on cadaveric soft tissue reconstruction in a developed country under the supervision of plastic surgeons. It was our practice to involve at least two senior surgeons when such a flap was carried out to minimize error. There was no additional financial benefit to the surgeons because of this and the procedures were performed with patients' best interest in mind. Some patients, very small proportion of our patients, who would require microvascular free tissue transfer for soft tissue are therefore referred to hospitals with plastic surgery facilities. Ours is a secondary-level peripheral hospital known for trauma care in the region for many decades. We have been providing comprehensive orthopedic care for many years in response to felt local needs. We present a retrospective review of our results from 2013 to 2015.

  Materials and Methods Top

We retrospectively reviewed all patients who underwent flap surgery by an orthopedic surgeon in our hospital from June 2013 to May 2015. All flaps irrespective of different indications were included. The study was cleared by the institutional review board and written consent was taken from the patients for the study. We had a total of 38 flaps in 36 patients during the study period. Two (5.2%) patients were lost to follow-up. Our indications for flap surgery were exposed tendon without paratenon, exposed bone without periosteum, exposed joint, and exposed hardware. They were reviewed on follow-up for any loss of the flap, marginal necrosis, healing, and infection and also for complications associated with secondary defect whenever appropriate.

  Results Top

Of the 36 flaps who were available for follow-up, flap distribution and types are given in [Table 1]. The average follow-up was 3 months (6 weeks–12 months). The average age was 35 years (17 years–65 years). The flap dimension ranged from 1 cm × 1 cm the dorsum to the proximal phalanx of the ring finger to 15 cm × 16 cm of medial and lateral gastrocnemius flap for knee extensor reconstruction.
Table 1: Flap Distribution by location and Flap types

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Specific indications for flap in our series have been given in [Table 2].
Table 2: Indications for Flap surgery

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Thirty-one out of thirty-six (83.33%) of the flaps healed primarily.

Representative flaps are presented in pictures.

Figure 1: Gastroc soleus flap for tibia osteomyelitis

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Figure 2: Mediolateral gastrocnemius flap for open knee with extensor mechanism loss

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Figure 3: Hemisoleus flap for open tibia

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Figure 4: Reverse sural artery flap for open distal tibia fracture with soft tissue loss

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Figure 5: Medial plantar artery flap for chronic heel wound

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Figure 6: Transposition flap leg

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Figure 7: Rhomboid flap for infected interlock site

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Figure 8: First dorsal metacarpal artery flap for infected thumb with skin loss

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Figure 9: Reverse cross finger flap for dorsal injury over proximal interphalangeal joint

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Figure 10: Transposition flap finger

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Figure 11: Radial artery flap for blasted hand

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Figure 12: Groin flap for open distal radius with delayed presentation

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We had complications in six patients (16.66%) which have been tabulated in [Table 3].
Table 3: Complications: 6 (16.66%)

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One patient, a 50-year-old man presented to us with open ankle fracture dislocation after 2 weeks of injury. The ankle was infected and contaminated. Initial treatment involved debridement and ankle spanning external fixation followed by regular dressing in the ward. He was later taken for formal ankle fixation and reverse sural artery flap cover for anterior flap defect. He had marginal necrosis but went onto heal without any secondary procedure [Figure 13].
Figure 13: Healing after marginal necrosis of the reverse sural flap

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One more patient with reverse sural artery flap had marginal necrosis which healed on its own with regular dressing.

The second patient, a 16-year-old girl with reverse sural flap done for long-standing (>10 years) chronic discharging osteomyelitis of distal tibia with an adherent scar and skin loss developed infection without the loss of flap. She underwent debridement and later went onto have healing. Flap showed complete healing primarily [Figure 14].
Figure 14: Infection under the flap in patient with long-standing osteomyelitis

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A 21-year-old volleyball player who had open tibia fracture mid-shaft and a resulting soft-tissue defect following debridement underwent soleus flap. Butterfly fragment was retained because of its attachment to soft tissue, but the flap had delayed healing and required debridement of the butterfly fragment for it to heal [Figure 15].
Figure 15: Infection and delayed flap healing

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A 59-year-old man presented to us 42 years after injury to his heel followed by chronic discharging sinus. After debridement a medial plantar artery flap was done which took 5 weeks to integrate with the recipient tissue requiring re suturing and prolonged waiting [Figure 5].

One patient with a spinal fracture and ASIA A neurological injury was brought to us with bedsore for which debridement and double VY plasty was done. It got infected and it required repeated bedside debridement and dressing and eventually, it healed with partial loss of flap secondary intention at the edges [Figure 16].
Figure 16: Healed by secondary intention after infection

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  Discussion Top

It's challenging for trauma surgeons and other associated health care professionals to deal with open fractures and orthopedic infections.[10] The treatment becomes more complex when soft-tissue reconstruction is also required like in the case of Gustillo Anderson Type 3B fractures and extensive infections involving soft tissue loss after debridement. Soft tissue reconstruction follows a reconstructive ladder approach where primary closure and simple procedures like split-thickness graft occupy the lower rungs of the ladder and more complex procedures like microsurgical free tissue transfer occupy the higher rung. There has been a decreasing interest in microsurgical flaps in a trauma situation in resource-poor settings whenever an alternative option is available because free tissue transfer apart from requiring a higher surgical skill, takes more theatre time, and is associated with more complications apart from requiring longer hospital stay and having higher chance of loss of flap.[21] For the soft-tissue coverage ideally, whenever possible, plastic surgeons are involved after the orthopedic surgeons do debridement and skeletal stabilization. If the soft-tissue cover is delayed infection is the likely eventuality it has been our observation that our patients do not commonly use protective wears like clothing, boots, gloves, etc., at work and are therefore more prone to direct contamination of deeper tissues during open injuries resulting in higher chances of infection.[7] This is further worsened by our lack of good primary wound care and antibiotics in a rural setup. The paucity of a prompt referral system, lack of reliable transportation in remote areas make the situation even worse.[13] So getting the wound covered early of paramount importance. It's the standard of care now to take care of these patients in a single sitting whenever possible and appropriate rather than subject patients to a series of surgeries by many teams over many days. In our country, plastic surgeons are not available in most centers and none in the periphery. When they are available, timely coordination and smooth communication between the plastic surgeons and orthopedic team is sometimes difficult.[9] Both the parties are already overwhelmed by the amount of work they are required to do. Delay in treatment can therefore be a common possibility when multiple teams are involved. In addition, we have noticed that it is impossible for most of our rural patients to travel to the urban centers for specialized care of open injuries both for financial reasons and also because they find it extremely difficult to navigate through the complexities of the urban health care system. It has been a felt need therefore to venture into undertaking the soft-tissue coverage as well by orthopedic surgeons ourselves in our hospital. The primary responsibility lies with the orthopedic surgeon when it comes to treating patients with limb injuries who sees them in the emergency department, takes care of them in the operation theater and in the wards. The modern orthopedic surgeon is well versed with the surgical anatomy of the limb and therefore only makes sense to involve themselves more in patient care including the cover of the soft. Biological surgical approach and gentle soft tissue handling are always emphasized in modern orthopedic practices so acquiring these new techniques of soft tissue cover should not be very difficult for a well-trained orthopedic surgeon. Our approach involves that a single team takes comprehensive care of the patient when they present with open fractures and complex orthopedic infections. To the best of our knowledge, there are only a handful of reports, all from tertiary level teaching institutions which use this approach of patient care. Boopalan et al. reported 105 flaps below the leg in 120 patients with good outcomes in local flap cover of the lower limb in open fractures of the leg.[14] They didn't include upper limb and infection-related flaps. Kamath et al. presented 151 cases of flap for open tibia fracture with encouraging results.[15] To the best of our knowledge, we have not come across any similar report from a rural peripheral center. We have also not aware of reports including upper limb flaps and flaps done for infections. It is our understanding that this approach is even more applicable and handy in a peripheral setup where plastic surgery expertise is extremely difficult to find. None of our patients had major complications only corroborating this fact.

The primary flap survival rate in our study was 83.33% which is comparable to other similar studies. Kamath et al. reported an incidence of flap failure in open fractures from 16.5% to 55.25% between different groups.[15] Flaps done later than 6 weeks had more complications. Boopalan et al. reported 79% primary healing in 120 flaps done below the knee.[22] Riechelman et al. had 86.7% primary healing in their series.[1],[14] Scharfenberger et al. presented 4% infection in his series of 82 patients with open fracture where primary soft tissue cover was done.[23] Difference between the outcome in the setting of trauma and infection was not calculated in our study since only 27% of our flaps were done for trauma and the number of overall complications were few.

Our study is limited by a relatively small number. We have also included both infection and trauma in the study which might behave differently at least from theoretical perspective. We have not been able to establish the economic advantage of this approach of comprehensive care of patients requiring flaps since we didn't do cost analysis and this calls for further research. Learning from our experience we believe that surgical skills in doing local flaps should be integrated in the training of postgraduate orthopedic training program so that more and more orthopedic surgeons can undertake comprehensive care of most orthopedic injuries and infections complicated by soft-tissue loss.

  Conclusion Top

Comprehensive care by orthopedic surgeons for open soft tissue defects is a very applicable alternative to the current way of practice and especially so in resource-poor settings like ours. Most of the defects can be covered without specialized plastic surgical help in areas on need with acceptable complications and reasonable success. It is worthwhile to include trauma flap workshop as a part of orthopedic training in developing countries.

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Conflicts of interest

There are no conflicts of interest.

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Riechelmann F, Kaiser P, Arora R. Primary soft tissue management in open fracture. Oper Orthop Traumatol 2018;30:294-308.  Back to cited text no. 1
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Rajasekaran S, Sabapathy SR. A philosophy of care of open injuries based on the Ganga hospital score. Injury 2007;38:137-46.  Back to cited text no. 9
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Babu NV, Chittaranjan S, Abraham G, Bhattacharjee S, Prem H, Korula RJ. Reconstruction of the quadriceps apparatus following open injuries to the knee joint using pedicled gastrocnemius musculotendinous unit as bridge graft. Br J Plast Surg 1994;47:190-3.  Back to cited text no. 18
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  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16]

  [Table 1], [Table 2], [Table 3]


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