Stratégie thérapeutique initiale dans les pertes de substance distales du membre inférieur d'origine traumatique. À propos de 15 cas

Treatment options for soft tissue defects in severe foot trauma in children

OBJECTIVE

Severe foot trauma in children is a therapeutic challenge, with presence of devitalised and soiled distal tissues. Several reconstruction and covering procedures can be applied, including artificial dermis (AD), negative pressure wound therapy (NPWT), fasciocutaneous flaps and free flaps. Here, we have developed and evaluated an algorithm for treating severe foot injuries with skin defects in children.

METHOD

Paediatric cases of severe foot injury treated over a 16-year period were retrospectively reviewed. Characteristics of the injuries, surgical procedures, complications and the modified Kitaoka score (clinical and functional rating score of the ankle and foot) were recorded.

RESULTS

A total of 18 children were included. The mean age at the time of injury was four years and 10 months (range: 1-11 years). The mean follow-up period was 6.2 years. Of the children, 13 presented with an amputation (12 partial foot amputations and one whole ankle and foot). The skin defect was combined with tendon exposure in nine cases, and/or bone and cartilage in seven cases, and heel damage in two cases. A flap was implemented in eight cases, of which one failed. NPWT was used in 13 patients (for an average of 21 days) and was combined with AD in six patients. The mean modified Kitaoka score was 68 (range: 55-80). Additional surgery during the follow-up period was required in seven patients (dorsal skin retraction, a thick flap, osteoma, trophic ulcer or ankle deviation).

CONCLUSION

Our algorithm suggests different therapeutic strategies for skin coverage and healing, depending on the size of the lesion and the exposed structures, and seems to offer good results. These procedures should be combined with NPWT to optimise these results (improved healing, reduced infections, decreased skin defects and enhanced granulation tissue) and so should be used more frequently.

The interest of "ortho-plastic" collaboration in management of complex limb injury

Constantly evolving knowledge on fracture management, soft tissue coverage, microsurgery and vasculo-nervous repair now permits salvage of limbs that previously would have had to be amputated. Management of complex limb injuries of which the severity inevitably entails functional and esthetic sequelae calls for mastery of the full spectrum of bone and soft tissue reconstruction. Such mastery is rarely attainable by a single surgical specialty; individually and isolatedly, an orthopedic or plastic surgeon cannot ensure optimal management of the above-mentioned patients. While the orthopedist performs a key function in provisional or definitive fixation, the plastic surgeon's expertise is essential to restoration of the cutaneous envelope. Collaboration between the two specialties from the outset and throughout treatment characterizes the modern-day concept of "ortho-plastic" surgery. Through unification of the theoretical competence and practical skills of orthopedists and plastic surgeons, it provides a patient with the best possible functional and esthetic results in a wide range of clinical situations. In this article, we present a review of the literature illustrating the interest of "ortho-plastic" collaboration in management of complex limb injury; concrete examples will be given through evocation of clinical cases encountered by the team that was put together in August 2015 at the university hospital (CHU) of Lille.