PubMed · 15919271
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Rudy Lackner. 2005. Invited commentary.. https://doi.org/10.1016/j.athoracsur.2005.02.014
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Giant exomphalos can be successfully managed using conservative or surgical techniques. However, if treatment is complicated by sepsis, early skin cover of the defect becomes necessary. Options include split skin grafting, but in the presence of ongoing infection the risk of graft failure is high and limited skin is available for regrafting. We describe the novel use of a skin substitute (Integra Artificial Skin, Integra Life Sciences Corporation, Plainsboro, NJ) as an alternative to primary grafting in the management of infected giant exomphalos.
OBJECTIVES: To evaluate the potential for limb salvage using the Ilizarov method to simultaneously treat bone and soft-tissue defects of the leg without flap coverage. DESIGN: Retrospective study. SETTING: Level I trauma centers at 4 academic university medical centers. PATIENTS/PARTICIPANTS: Twenty-five patients with bone and soft-tissue defects associated with tibial fractures and nonunions. The average soft-tissue and bone defect after debridement was 10.1 (range, 2-25) cm and 6 (range, 2-14) cm respectively. Patients were not candidates for flap coverage and the treatment was a preamputation limb salvage undertaking in all cases. INTERVENTION: Ilizarov and Taylor Spatial Frames used to gradually close the bone and soft-tissue defects simultaneously by using monofocal shortening or bifocal or trifocal bone transport. MAIN OUTCOME MEASUREMENTS: Bone union, soft-tissue closure, resolution or prevention of infection, restoration of leg length equality, alignment, limb salvage. RESULTS: The average time of compression and distraction was 19.7 (range, 5-70) weeks, and time to soft-tissue closure was 14.7 (range, 3-41) weeks. Bony union occurred in 24 patients (96%). The average time in the frame was 43.2 (range, 10-82) weeks. Lengthening at another site was performed in 15 patients. The average amount of bone lengthening was 5.6 (range, 2-11) cm. Final leg length discrepancy (LLD) averaged 1.2 (range, 0-5) cm. Use of the trifocal approach resulted in less time in the frame for treatment of large bone and soft-tissue defects. There were no recurrences of osteomyelitis at the nonunion site. All wounds were closed. There were no amputations. All limbs were salvaged. CONCLUSIONS: The Ilizarov method can be successfully used to reconstruct the leg with tibial bone loss and an accompanying soft-tissue defect. This limb salvage method can be used in patients who are not believed to be candidates for flap coverage. One also may consider using this technique to avoid the need for a flap. Gradual closure of the defect is accomplished resulting in bony union and soft-tissue closure. Lengthening can be performed at another site. A trifocal approach should be considered for large defects (>6 cm). Advances in technique and frame design should help prevent residual deformity.