Soft Tissue Management of War Wounds to the Foot and Ankle

Department of Orthopaedics and Rehabilitation, Walter Reed Army Medical Center, Washington, DC 20307, USA.
Foot and ankle clinics (Impact Factor: 0.76). 03/2010; 15(1):113-38. DOI: 10.1016/j.fcl.2009.10.006
Source: PubMed


This article details the experiences of United States military reconstructive surgeons in the soft tissue management of war wounds of the foot and ankle resulting from the conflicts in Iraq and Afghanistan. War wounds from this conflict are commonly caused by blast and fragmentation, and are characteristically extensive, heterogeneous, and severe. Multiple serial débridement episodes are routinely necessary because of deterioration of the wounds over time, which is in contrast to civilian trauma wherein fewer débridement episodes are generally required. Wound therapy adjuncts, such as subatmospheric wound dressing and synthetic dermal replacement, have been used extensively with favorable results. Pedicled flaps, such as the distally based sural neurofasciocutaneous flap, are reliable, and avoid the risks and technical demands associated with microsurgery. Free tissue transfer, such as the anterolateral thigh flap, the latissimus dorsi muscle flap, and the rectus abdominis muscle flap, are powerful reconstructive tools, and have been extensively used in the reconstruction of war wounds of the foot and ankle.

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    • "In Achilles tendon injuries, granulation tissue cannot substitute for specialized fascia, subcutaneous, or dermis tissue, nor can it replace other highly specific tissues (bones, cartilage, and tendons). In addition, granulation tissue is relatively inelastic and its adherence and potential tendon tethering can cause further dysfunction of the lower extremity.33 The prolonged immobilization of the ankle necessary to achieve granulation tissue could further hamper range of motion and may require longer physical therapy postoperatively. "
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    ABSTRACT: Soft tissue coverage of the exposed Achilles tendon is a unique reconstructive challenge. In this report, we describe the management of a large posterior leg wound with exposed Achilles tendon using a free anterolateral thigh (ALT) flap. A careful review of alternative reconstructive options is included, along with their respective advantages and disadvantages. A 32-year-old white man suffered a fulminant right lower extremity soft tissue infection requiring extensive debridement of the entire posterior surface of the right leg. The resulting large soft tissue defect included exposure of the Achilles tendon. Reconstruction of the defect was achieved with an ALT flap and split-thickness skin graft for coverage of the Achilles tendon and gastrocnemius muscle, respectively. The patient was able to ambulate independently within 2 months of the procedure.
    Eplasty 09/2013; 13:e50.
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    • "Severe muscle injury often involves nerve damage, and this leads to denervation atrophy and permanent functional disability (Baechler et al., 2010; Fan et al., 2008; Grogan and Hsu, 2011; Jarvinen et al., 2005; Vekris et al., 2008). Current management options for traumatic injuries to muscle and nerve employ a vascularized muscle flap, which contains intact nerve to provide anatomical and functional tissue restoration. "
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    ABSTRACT: Tissue-engineered muscle has been proposed as a means of repairing volumetric muscle defects to restore anatomical and functional recovery. We have previously demonstrated that denervated muscle, which is analogous to engineered muscle construct, can be reinnervated by direct transplantation of host nerve (neurotization) in a rat model. However, the use of this approach is not possible if the length of host nerve is inadequate and cannot be mobilized to the insertion site of the engineered muscle. In this study we investigated whether neurotization coupled with nerve guidance channels would increase the regeneration of neuromuscular junctions (NMJs) in completely denervated muscle and encourage neurofunctional recovery. Seventy-two Lewis rats were evaluated in three groups, a normal control group (n = 8), a denervated group (n = 32) and a neurotization coupled with nerve guidance group (n = 32). Neurofunctional behaviour and histological evaluations were performed at 4, 8, 12 and 20 weeks postoperatively. Extensor postural thrust (EPT) and compound muscle action potential (CMAP) amplitude were significantly improved in the nerve guidance group when compared with the denervated group, even though these values were different from those of the normal control group at 20 weeks postoperation. Regeneration of axons and NMJs was demonstrated histologically in the nerve guidance group. Neurotization coupled with nerve guidance channels leads to regeneration of axons and NMJs in completely denervated muscle. To our knowledge, this is the first report to show that nerve guidance can allow re-innervation in denervated muscle containing long-gap nerve injuries. Copyright © 2013 John Wiley & Sons, Ltd.
    Journal of Tissue Engineering and Regenerative Medicine 01/2013; 9(7). DOI:10.1002/term.1696 · 5.20 Impact Factor
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    ABSTRACT: Severe traumatic events such as burns, and cancer therapy, often involve a significant loss of tissue, requiring surgical reconstruction by means of autologous muscle flaps. The scant availability of quality vascularized flaps and donor site morbidity often limit their use. Engineered vascularized grafts provide an alternative for this need. This work describes a first-time analysis, of the degree of in vitro vascularization and tissue organization, required to enhance the pace and efficacy of vascularized muscle graft integration in vivo. While one-day in vitro was sufficient for graft integration, a three-week culturing period, yielding semiorganized vessel structures and muscle fibers, significantly improved grafting efficacy. Implanted vessel networks were gradually replaced by host vessels, coupled with enhanced perfusion and capillary density. Upregulation of key graft angiogenic factors suggest its active role in promoting the angiogenic response. Transition from satellite cells to mature fibers was indicated by increased gene expression, increased capillary to fiber ratio, and similar morphology to normal muscle. We suggest a "relay" approach in which extended in vitro incubation, enabling the formation of a more structured vascular bed, allows for graft-host angiogenic collaboration that promotes anastomosis and vascular integration. The enhanced angiogenic response supports enhanced muscle regeneration, maturation, and integration.
    Proceedings of the National Academy of Sciences 09/2011; 108(36):14789-94. DOI:10.1073/pnas.1017825108 · 9.67 Impact Factor
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