Letters to Editor
Emergent free flow-through anterolateral thigh flaps for Gustilo-Anderson III fracture of the upper extremity Sir, Gustilo-Anderson III C open fracture requires both bony and soft tissue reconstruction, as well as vascular repair. The main problem of this severe injury is the total absence or extreme deficiency of blood flow to bone fragment or fractured stumps. Late resurfacing with local flap sometimes leads to sequestration and osteomyelitis, necessitating prolongation of the period of external fixation.  What is the best treatment for these complex sever injuries? We believe the answer should be an early wound resurfacing with well-vascularized soft-tissue. We present a successful case of a Gustilo-Anderson III C bone-exposing wound surgical treatment with emergent use of a free flow-through anterolateral thigh flap. A 32-year-old male patient was referred to our emergency unit complaining of a Gustilo-Anderson III C fracture of the right forearm due to being crashed by a falling telephone pole [Figure 1]. Patient had an open fracture of the radius and severe crush of the forearm muscles with wide abrasion of the skin and flexor muscles. Circulation of the right hand had ceased because the ulnar artery was mutilated and about 5 cm the radial artery had been lost [Figure 2].
Figure 1: A Gustilo-Anderson III C open fracture of the radius
Figure 2: Patient also suffered wide abrasion of the skin and flexor muscles. Circulation of the right hand had ceased due to interruption of both ulnar and radial arteries
After the crushed radius was destructed and underwent external fixation, the bone-exposing wound was repaired with a free anterolateral thigh flap with a 12 cm × 5 cm elliptical skin island [Figure 2]. The T-portion of the descending branch of the lateral circumflex femoral vessel was interposed to the defect of the radial artery. Two veins were connected to the cutaneous veins. Consequently, the interrupted radial artery resumed normal blood flow [Figures 3 and 4]. The viability of the skin flap was favorable without infection or necrosis [Figures 5-7]. The conventional options to treat Gustilo-Anderson III C injuries are vascular repair and bone reduction along with a skin graft or local or distant flap. Conservative treatments Journal of Emergencies, Trauma, and Shock I 7:1 I Jan - Mar 2014
Figure 3: The harvested anterolateral thigh flap. The descending branch of the lateral circumflex femoral vessels and its proximal transverse vessels can be noted 53
Letters to Editor
Figure 4: Illustration of transferred anterolateral thigh flap, which shows the descending branch of the lateral circumflex femoral vessel was interposed to the defect of the radial artery
Figure 5: View of the immediate post-operative forearm, showing favorable resurfacing
Figure 7: An X-ray photo 3 months after surgery Figure 6: View of the reconstructed forearm 3 months after surgery. The patient resumed the pinch function. As the patient lost all forearm flexor muscles, he could not resume power grip function. However, he could flex the fingers and pinch owing to the intrinsic muscles’ function
cannot lead to a favorable wound bed on bone; thus, it requires some flap surgeries to resurface the wound. Sometimes, the reconstruction is planned as a two-stage surgery. However, early wound coverage with a free flap within 72 h was recommended, because the highest risk of infection and flap loss occurred in the delayed period. These vascular injuries requires vascular repair immediately after an injury, such as direct repair, an interposed vein graft and bypass graft, to supply sufficient blood flow to the distal area of the injured extremity. On the other hand, microsurgical flow-through flaps is beneficial, because blood flow of the distal forearm can be maintained normally while the soft-tissueinsufficient wound can be resurfaced at one time. The lateral circumflex femoral arterial system is a favorable source of the T-anastomosis pedicle as it has a long descending branch and a reliable proximal transverse branch. This technique enables both vascular and soft-tissue reconstruction at once with minimal 54
donor site problems, which are potential advantages over conventional methods. In conclusion, we believe that emergent use of free flowthrough anterolateral thigh flap is the primary choice for reconstruction for Gustilo-Anderson III C fracture with softtissue defects.
Masaki Fujioka1,2, Kenji Hayashida2, Chikako Murakami2 Departments of Plastic and Reconstructive Surgery, Nagasaki University,2Clinical Research Center, National Hospital
Organization, Nagasaki Medical Center, Nagasaki, Japan E-mail: [email protected]
Fujioka M, Hayashida K, Murakami C. Artificial dermis is not effective for resurfacing bone-exposing wounds of Gustilo-Anderson III fracture. J Plast Reconstr Aesthet Surg 2013;66:e119-21. Journal of Emergencies, Trauma, and Shock I 7:1 I Jan - Mar 2014
Letters to Editor
Soni A, Tzafetta K, Knight S, Giannoudis PV. Gustilo IIIC fractures in the lower limb: Our 15-year experience. J Bone Joint Surg Br 2012;94:698-703.
Karanas YL, Nigriny J, Chang J. The timing of microsurgical reconstruction in lower extremity trauma. Microsurgery 2008;28:632-4.
Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285-92.
Halvorson JJ, Anz A, Langfitt M, Deonanan JK, Scott A, Teasdall RD, et al. Vascular injury associated with extremity trauma: Initial diagnosis and management. J Am Acad Orthop Surg 2011;19:495-504. Access this article online Quick Response Code: Website: www.onlinejets.org
Novel emergency management of descending colon cancer presenting with retroperitoneal perforation Sir, Retroperitoneal perforations of descending colon cancer (CCA) are exceedingly rare. Only one report of a flank abscess resulting from retroperitoneal perforation of descending CCA exists in the literature. Ours appears to be the first United States’ patient reported with this presentation. We describe our novel emergency management approach that ensured an excellent outcome for this patient. A 44-year-old male patient presented with 3 weeks of left flank swelling, fevers and weight loss. He was tachycardic and hypotensive. Examination revealed rebound tenderness in the left lower quadrant and an erythematous fluctuant left flank mass. Laboratory investigation revealed leukocytosis to 39.4 × 103/μL (normal 13.5). Computed tomography demonstrated a particulate 15.4 cm left retroperitoneal collection communicating with the descending colon through a focal perforation [Figure 1]. Journal of Emergencies, Trauma, and Shock I 7:1 I Jan - Mar 2014
After resuscitation and initiation of broad-spectrum antibiotics, an exploratory laparotomy was performed. A markedly inflamed segment in the mid-descending colon adherent to the retroperitoneum was mobilized, revealing a focal perforation. A left hemicolectomy was performed. The feculent retroperitoneum required wide debridement [Figure 2a]. We elected to leave the patient in colonic discontinuity and a temporary vacuum-assisted abdominal closure was performed. The patient was then turned to the right lateral decubitus position and external debridement of this collection was performed via an S-shaped counter-incision [Figure 2b]. The following day, an end transverse colostomy was performed, the left retroperitoneal defect sealed with a pedicled omental flap [Figure 2c] and the abdominal fascia closed. A vacuum-assisted closure device was employed to manage the left flank incision. Eventually, this incision was closed utilizing a myocutaneous advancement flap. Pathologic analysis revealed a marginnegative 2.8 cm adenocarcinoma with peritoneal invasion, but without nodal involvement (T4bN0M0). Having completed
Figure 1: (a and b) Axial and sagittal sections of abdominal computed tomography scan showing large feculent left retroperitoneal collection communicating with an abnormally thickened segment of the descending colon via a focal perforation (white arrow)
c Figure 2: (a) Left retroperitoneal defect (arrow) after operative debridement of feculent retroperitoneal abscess. (b) S-shaped counter-incision in the left flank through, which an external debridement of the left retroperitoneum was performed. (c) Use of an omental patch (broken lines) to cover the left retroperitoneal defect during the second-look laparotomy 55
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