Role of plastic surgery in Lower Limb Trauma - Mr Charles Loh
Summary
This engaging teaching session will delve into the management of complex lower limb trauma and its intersection with plastic surgery. Key concepts such as zones of injuries, the stress response, and managing soft tissue are tackled through practical examples and analysis of interesting cases. You'll also explore the principles of managing open injuries from a soft tissue perspective to enhance orthopedic outcomes. Special attention will be given to identifying viable tissue and understanding the zone of injury in trauma management. Other topics include managing secondary intention healing, the role of early fracture stabilization, optimization of debridement, and the procedure for reconstructing any size defects. Attendees are encouraged to participate by asking questions and clarifying any misconceptions. The session promises to boost your trauma management knowledge base, offering invaluable insights into achieving better long-term patient outcomes. Whether this is your area of specialization or an area you wish to learn more about, you'll find it a practical and enlightening discussion.
Learning objectives
- Recognize and understand the importance of managing both the orthopedic and soft tissue aspects of lower limb trauma for more positive patient outcomes.
- Identify the zones of injury from a soft tissue point of view for better decision making in regards to debridement and surgical reconstruction.
- Become familiar with various types of wound reconstruction methods, namely primary healing and secondary intention healing, and understand the circumstances where each method would be ideal.
- Understand the importance of early intervention in the case of lower limb trauma, especially in regards to wound closure and bone fixation.
- Develop a better understanding of the importance of patient-specific management, considering factors such as patient's premorbid status, age, and other injuries, when determining the best approach for managing lower limb trauma.
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The following transcript was generated automatically from the content and has not been checked or corrected manually.
From our experience in managing with you guys sort of complex lower limb trauma and the plastic surgery. So feel free to ask any questions time. I'll go through some relatively basic stuff in general and we'll skip through to a few more interesting cases at the end. Ok. So again, the focus of lower limb trauma and trauma, you can't deviate from what actually happens from the basic science point of view, which everybody knows it's a stress response in particular multicomponent sort of a composite type approach, not only from the factor point of view about soft tissue as well. So the principles that will go through in terms of managing the open in terms of soft tissue, in that point of view, to complement the orthopedic of the bone and to get the best outcome. So again, it's quite like burns in general. What I think of when we talk about trauma, I think we think of it as um zones of injuries from the soft tissue point of view. So a burn as an initial insult where there's the zone of coagulation where the direct trauma, for example, uh for whatever blunt or trauma, the tissue suffers directly or the burn in particular. So that's the same blood vessels die when blood supply is interrupted to any to any patch of tissue, that's where problems occur. And there is a surrounding sort of Jackson zone model. Um, in plastic surgery, there's a zone of stasis where it's kind of a reversible area. As you can see here from this point of view, it's bruised. We don't really know whether it's pull through. That's why often we stage the reconstruction because we can decrease morbidity by giving it some. I take it that presentation is finished for everybody, right? Sorry. Was there a problem or can everybody hear me? I? Is that? Yeah, I can hear you. Yeah. Yeah. So again, that's why we're sort of trying to limit the zone of stasis where uh further trauma can recur or you know, more soft tissue provide them because if the soft tissue is not sorted, then we have a problem with long term outcomes, especially with bone infection. So, identifying the viable tissue and zone of injury is quite important. This tends to be uh you know, you can visibly see it often. It's quite interesting we could, if it's bleeding, it may go through um in bone sort of lower limb. I tend to think of primary healing as the goal rather than um allowing secondary intention healing, especially if we were to put metalwork underneath. Um any sort of slower healing would result in possible colonization and problems down the line. So that's where come into. Uh that's my sort of philosophy about dealing with it. Um It's almost like cancer in a way. Um, if you cut away the nonvascularized tissue and if you have a lower threshold for reconstructing any soft tissue defect, then I believe it's been shown in multiple studies that sort of outcomes will be better. Um They, a lot of papers talk about zone of injury and we tend to try and avoid or for example, doing anastomosis, we do it outside the zone of injury because soft tissues not only affect the skin, the fat, but also the main vessels that we plumb into. So, uh inflammation tends to cause further issues. So again, the uh most of the examination is all done by you guys and, and we tend to do the right together with the first set. Everybody knows about that. Um That's the examination, your vascular status, you document the, the ty. Um Again, it's more academic, but from my point of view, it, we have a low threshold of reconstructing any size defect. And I'm quite happy to do that. Uh as long as we get to healthy tissues, um again, not forgetting salvage versus amputation, some angle are beyond salvage, of course, and determining what's best for a patient is often quite important and it's AM VT approach. Um often sensation tends to be one of the main factors, but again, not necessarily this can be reconstructed however, to a certain degree, um unless it's life saving, then normally the imputation tends to be delayed, the decision to be uh the multiple sort of salvage indexes and prediction scores of how patients will do from our experience. So far at an Brooks Hospital, the this tends to be not too important from our point of view. Um because it's often quite, um it presents itself quite specifically to what needs to be done and the potential outcomes. Then we talk about the sleep study, which was a study done mainly in the States. Um That, that solv it versus amputation. Again, as you guys know, would know, better amputation tends to be um quite a good option, but um often by reconstruction experiences of the unit and if we speak to Mr Pooch, um and he has certain, um I'm sure he'll tell you more in terms of what potential loan could be. So and not, and we're happy to help along with that reconstruction from that point of view. So again, we talk about the early the role of that, making sure that the fracture stabilize, that's quite important, very important actually for our flat reconstruction. Afterwards, often we've seen sort of if the X is not as stable or it's quite difficult in multiple areas that been fractured, movement of the limb tends to affect the vessels that we plumb into and can result in sort of flat compromise as well. Because of lack of um stability of the fracture. So that's very crucial. Uh Often debridement is done. Uh generous debridement. I often I take uh if it's not, not bleeding, that should go any fact that looks bruised or traumatized, that should be divided um and should have low threshold for doing so. Um I do not hesitate to delay any debridement if you need a second look, that may tend to happen. I interrupt you. Are you able to move your speaker a bit closer to yourself a bit, the microphone. Yeah. OK. Is it better? Uh That's a bit better. Yeah. Thank you a bit better. OK, I'll thanks. OK. So again with the um as early as possible within daylight hours, as we say within um in an orthoplastic um facility in theater, temporizing it with a back dressing. Everybody knows that and given appropriate antibiotics and timing sort of fixing flat lists is quite important for these type of fractures, maybe three B and above antibiotics. You have plenty of guidelines for that. But um I'd look at the local guidelines as well and what's suitable. Um We're mainly guided by um you guys and orthopedics. But from my point of view, often I tend to carry on antibiotics after the reconstruction only because from our point of view, any soft tissue skin. By the time the skin barrier is not fully restored, there's always a risk of colonization of the wound and slow wound healing. So I tend to give prophylactic antibiotics for at least a few more days, post fixation, um and flat reconstruction from the skin point of view. So we talk about both function and form in plastic surgery. Um The flat or soft tissue coverage has to be robust. It has to be unique in certain areas of the lower limb. In particular weight bearing areas, we call the sort of heel area, glabrous skin that's resistant to shearing. It's often difficult to reconstruct that because they only found on the soles of the feet and the hand. And if you place any other type of tissue on the heel, it doesn't tend to do very well. It is wobbly, the foot sort sort of the anatomy of the fat pads in the heel also tend to be quite septated. They are fibers that go from the supporting structures all the way down to the dermis of the skin that gives it a sheer resistant property, reconstructing it with say tissue from the thigh. For example, they don't have that kind of sheer resistance quality and it can be quite wobbly to, to, to stand on. Um, again, it will be tailored to the patient's premorbid status. You know how, how well they were before the footwear, bulkiness of the flap tend to tend to need to try and do it in two stages. The priority of course is to try and get the wound healed and then think about aesthetics. And then we'll talk about a bit more about the swelling after that, which we are looking into in the future to try and reduce. So, a few principles that I think um that would increase the success of limb salvage would be optimally uh removing any non vascularized tissue, making sure that vascularized tissue is, is sort of forming layers over your metalwork covering it. Reducing any dead space, dead space in plastic surgery is not great because that space for collection body fluids, uh seroma hematoma that can infect get infected even in a break in the skin and that can lead on to infection into metalwork. So, meticulous sort of obliteration of dead space is important to me uh create multiple layers over the metalwork again to provide multiple protective barriers. Um Of course, working with infectious disease, colleagues in a hospital has been great. They often tend to have better clinical input in my opinion, compared to the microbiologists who may want a lot of specimens and target specific antibiotics to it. However, infectious diseases tend to provide the duration and type of antibiotics and suspected type of uh bacteria before they're grown. So often suppression is quite important. Um as I do sort of bone infection as well, that tends to carry on in sort of severe open lower limb. I'll show a few cases and um we tend to, well, there's a lot of me work but um after we do the flap with uh long, prolonged antibiotics, they tend to heal quite well and we haven't seen a problem so far. And of course timing of wound closure and bone uh bone fixation. I talked briefly on the reconstructive ladder in plastic surgery. Um It used to be said the ladder as you climb up the ladder in particular. However, now with microscopes and microsurgical techniques, we talk about the elevator. Instead, you can choose which level you like to go, depending on which type of patient you need to sort out. The younger ones. Of course, you go for your own sort of free tissue transfer. There are more elderly ones, you wanna do something simple, local flap skin graft, even secondary healing if if possible. Um a bit more about the theory of it, we often do ct angiograms to look for planning in particular for flat vessel choice, especially you've got a bit quiet. Again. Let me see. Is there any better? Yeah. Yeah, that's better. Thank you. Sure. Um Again, yeah, if you've got one vessel leg that tends to change things a bit, especially if we have to do a free flap on it. So again, the risks are higher and the patient has to be brought on board really um in terms of what we can do and what we can't um and back up plans and helps us with that plan ABC to try and get things covered. Uh If not, it means amputation for a patient. So again, evidence and lots of it's not new, early coverage is better, um, soft tissue wise and further sort of delaying it, not only is the stress response increased. If the surgery is delayed, often patients tend to other injuries as well, sort of head injuries or other chest injuries that prevent uh extremity fixation. So, in those cases, we can't really do anything and we just have to deal with it. That's the interesting aspect of trauma. And often it's a multisystem disease. They have um they may need um BP, vasopressors again with a labile BP that doesn't help with any flat reconstruction, especially free, flat, free tissue transfer. You need blood to be shooting out. If not the flap will fail. And if that happens, then, um you know, it's pointless. So often getting the timing right is quite crucial. Uh We'll talk about a bit about, about areas in the lower limb. Often I won't go into too much detail. But in certain areas, we tend to have different types of tissue reconstruction that can be done. This is a fas cutaneous flap, meaning it's just a fascia skin and fat really without muscle. So that tends to be based on a perforator. Perforator is a blood vessel that comes off the main vessel that supplies a patch of skin. It's like a tree. It's one of the branches that goes to the leaf. So mobilizing part of the branches and sort of reconnecting it. Um So from that point of view, that allows primary healing, which is great. It's a longer scar. But we tend to have to do that to get mobility, to get the, the, the skin to move and to maintain the vascularity of the, of the flap that's moved. So we around the knee, you want it to be kind of thin, the lower limb trauma, we tend to see knee injuries as well. Often, you know, it depends on the the size of the defect. Again, that plays a big role. The commonest one that you see would be more in infected knee replacements and us doing a gastroc flap, which is quite common in our point. And from our point of view, in studies in plastic surgery, gastro especially just taking the medial head doesn't result in much morbidity from our point of view other than the cosmetic one. And often that tends to be our favorite um flap of choice amongst others. Um So there are various different types, fasciocutaneous, a combination of a gastric flap. This is a medial gastric nus flap that's been harvested. Um the soleus is preserved. So a lot of the function still remains and it's based on the medial sural artery that we tunnel it or swing it to cover the defect. But as you can see from this second photograph here, the it's reach is quite limited. So it tends to be slightly more for the lower part of the knee or the central part of the knee. Um, there are other types of flaps, especially local regional flaps that we tend to do these mean without the need for microscopes or microsurgery. Uh, again, we're moving sort of local flaps here. I'll show you some of the other cases in particular at Edinburgh. Um, a lot of these tend to be, uh, I quite like Peroneus brevis as well. I'll show another case. Um muscle flaps can be pedicled as well. They don't just have to be skin and fat. Um uh small muscles can be immobilized and used and to cover any sort of non graftable defects. A graftable defect is where a vascularized wound bed allows a skin graft. Now, if there's exposed bone or multiple holes, then um a skin graft will not work even though that may be the simplest way of reconstructing it. And lastly examples of free tissue transfer. Of course, this allows the greatest morbidity of and freedom of choice of transplanting any patch of skin and fat or muscle throughout the body to a defect. But that requires pretty much quite complex reconstruction and it can be associated with a lot of problems. Uh This is a lattice in dorsi flap which allows a big piece of muscle as you can see a big area to cover. But in my experience, I like to use a combination of other flaps. I don't really like to sacrifice the lattice dorsi only because I've got to turn the patient to take it when working with you guys. It's a bit difficult to keep repositioning the patient. Um It is a useful adjunct, however, taking it off in a young patient especially and will affect the sort of shoulder stability and strength. So it's not my preferred choice. However, it's one commonly quoted in the textbooks, special locations like the foot, like I mentioned, they have to be sensate, thin pliable and glabrous, that sort of septated, sheer resistant type skin. Again, we try and use local flaps from the sole of the foot to try and reconstruct any defect in that will be replacing another principle from plastic surgery, replacing light with light. So that will result in the best type of reconstruction, doing a free muscle flap for sole or foot is also tends to be quite a good option. The sole itself tends to, the muscle tends to be quite sheer resistant as it atrophies and sort of sticks to the surface and you put a skin graft over it, the skin graft might ulcerate, however, it thins out quite nicely. And compared to a fat muscle, a sort of fas exane flap, the fat doesn't quite wobble, there's no fat in this, it's just muscle. So it'll be like uh walking a muscle. So that's our tends to be our choice as well if it needs to be done on the foot. So, uh again, it depends on patient uh sort of surgeon choice and there's been studies that show is muscle or fat and skin type flaps better. They say muscle tends to fill my personal choice. Muscle tends to fill dead space quite well. So if there's a suspicion of infection in the bone, I tend to mobilize muscle to cover up infected bone ends. Um and to fill up dead space, I often take them together as you can. I'll show you a few examples. So a few examples in particular, um this patient had extensive comorbidities. Secondary healing tends to be a choice, especially if there's no metal work or the bones tend to be, you know, we've run a plan for conservative and we're not putting any metalwork in it. I tend to say allowing it to heal by dressings is the best way forward rather than do anything too aggressive, which may cause more risks than benefits a bit on the dressings. From our point of view. Uh We often cover uh sort of a moist environment that tends to allow these type of wounds to heal better. Um That's why we tend to cover it up something nonstick for patient um comfort. Uh If it's quite wet, we tend to put something a layer and interface to try and absorb it. Aqua cle also tends to be used in plastic surgery a lot which tends to absorb uh ex and changed relatively frequently till it dries up. I know a lot of us are trying to use incisional vacs, especially in lower limbs. A lot of my colleagues also do so. They are, there have been sort of studies and basic signs to show that applying a negative pressure reduces local edema increases angiogenesis decreases tension. However, I feel it doesn't really, it is not a good substitute for tension, free closure wounds don't like to be under tension. Any tension would cause it to break down. A back dressing doesn't um you know, take away the need to reduce the risk of tension. So then hence, a good reconstruction is necessary, in my opinion, more important than a incisional back. However, sometimes we have no choice, especially if you don't want to do or the patient is not suitable for complex reconstruction. Then back dressing may help skin grafting again. It's uh I'll do briefly. It's transplanting skin on from one area to the other. This is a split thickness skin graft. As compared to a full thickness skin graft, we don't harvest the full layer of the dermis. We leave a bit of the dermis behind. We often take 10 of 1/1000 of an inch with the dermatome to shave it. It's like a graze that heals up and we stick it on it. Um This is no, there's no need to do any sort of microsurgery or anything. It allows um nutrients to form and blood vessels to form and that normally heals up in about 7 to 10 days, we mesh it because we allow it to expand and reduce the joy area that needs to be harvested. Um However, the downside is there's more contracture, especially over an ankle joint, you can have contracture down the line. There is a quick way of healing things. The cosmesis wise, it might not be as good as a full thickness. Skin graft, it ulcerates more readily. It doesn't contain any sebaceous or oil glands. So the skin becomes very dry and can break down in the future. But it is a quick way of healing things. A local tissue reconstruction. This one was another elderly patient that you saw. Um I did a local flap that covers any ankle. It's quick to perform 30 minutes. You can do it with you guys in the primary department and fixation. For example, if, if we were around and to do it as a joint approach that will help it heal quicker. Here's another case recently, again, with similar type, these are based on the peroneal artery perforators. Um What I do is I uh there's sort of this wouldn't really close, primarily the skin graft wouldn't really work here because there's dead space. There's, you know, this bit will break down and get infected. We need to cover it with skin and fat. So I make a back cut here to get mobility, but I preserve the blood vessels that supply it and keep a wide base that's a, that's always blood supply and then I mobilize it. This is more of a rotation type flap. I like to put a Yates strain here because I don't like um collection or hematoma underneath it. I know sometimes if there's metalwork in it, um, we don't wanna have the drain for too long, however, any tension underneath the flap, for whatever reason, a collection hematoma can compromise the flap and it can break down and we need to do something more that healed up quite well. Another case of a perforator flap, for example, this was too tight to close. It's based on the medial side of the foot, the posterior tibial artery perforators. Again, the posterior tibial artery runs here. When you do your fasciotomies, we tend to avoid that corridor. Um Again, I'm looking for a, I don't really need to Doppler it out. I normally I take it with a certain amount. I keep the blood vessels attached and releasing enough of the skin all around. It allows me to slide it and get this forward to get that healed over that fracture site. Again, it's a quick option to perform. Um It gives a good contour. As you see, the downside is, it's got a quite a ugly scar. It's quite long that will fade over time. It's quick to perform. It doesn't need microsurgery uh from that respect, similar another horn flap. So all these are local flaps and quick to perform a gastro flap, as I mentioned with open fracture here, easy to perform, quick, takes about an hour. Uh The other thing to watch out is the donor site that can collect with blood that can get infected. So we talk about pre transfer again. That's in my opinion, the gold standard if the patient can allow it, um whether the conditions are right for doing it, they're young, they're suitable, they're not too sick and it's for salvage. This is an example of an artery and a vein anastomosis that we do. This is a hand stitched anastomosis and that one's a couple, a coupler is a vessel coupling device that we use. It has little spikes on a silicone ring. We but the two ends of the vein attach them to the rings of it and close it together and it squashes two edges of the vessel together and allows it to reperfuse quickly. So that takes, you know, five minutes to do it's quite quick. Um An artery takes about 10 minutes. I mentioned about um certain cases where there was a extensive metal work, especially in the knee here, a gastrocnemius flat wouldn't quite do it with such a long plate over it. We want robust vascularized soft tissue cover. Again, this chap, I believe he was doing some home explosive device or something and it blew up in his knee. So that was all fixed. However, that soft tissue uh defect had to be reconstructed. What I quite find in these type of injuries, especially tibial plateau type injuries, the recipient vessels often tend to be quite deep and they tend to be quite injured as the posterior tibial runs right behind it. And often the fracture would have compressed or kinked or caused an issue. The artery tends to be ok. So we struggled a bit because the artery managed to flow. And the veins were the ones that packed up because they had some clot further down. What I did here was a retrograde approach. So the veins also can drain to the limb and drain further out. So I connected up the veins to the distal end as a retrograde type flow that worked again, suppressing the patient with this guy got a month's worth of oxic orally because we spoke to the infectious diseases team and we felt that he was high risk dirty wound with a lot of metalwork and he turned and he healed up pretty well. There were no need, there was no need for any further revisions. It's pretty thin there, no infections which was quite nice. This is a derma. We take, we call it at flap. It's the anterolateral five flat. It's very useful. In my opinion. It's been used a lot popularized in Taiwan by one of the plastic surgeons. Um We, we can take it the sort of work for us in the young group of plastic surgeons. Uh donor site, morbidity is minimal. You can take uh there will be a numb thigh because the lateral cutaneous nerve of the thigh is sacrificed. We can take chunks of vs lateralis vascularis with the pedicle. And that can be used to reconstruct big areas I'll show in a, in a, in a bit. Um I did this saphenous artery flap from the medial side of the thigh. Again, this comes with the saphenous artery and the nerve that I hooked up to the lateral peroneal nerve of the foot to give him some sensation. That's also possible with all these microscopes and stuff. So that's quite useful. An option to have that area of the foot sensate with a nice small sort of quite a thin contour as well. That's possible. Um There are other types of flaps. We can take it from all over the body, but I tend to when I do it with you guys in orthopedics. Um I like to do it potentially, especially if it's a fix and flap. When you guys are nailing it or plating it, harvesting it from the contra thigh or somewhere would make it quite useful because we can save time operatively and get that done. Once you guys are fixed, you can dig out the vessels and reconnect it. But that's a nice small flap. You can take it as big as you want or as small as you want. Again, free tissue transfer, allowing primary healing. So that allows it to heal uh directly and quickly that reduces the risk of infection and studies. Um This was an interesting case in a bariatric patient who twisted and fell again, low energy type, by definition because she fell on herself, but she was 100 and 90 kg. Um, you know, massive uh leg, woody, uh tight and swollen. As you can see here, you just wouldn't come together. She had lymphedema um to top it off. So what we did here in using plastic surgery principles because I do lymphedema treatment as well. Uh lymphedema liposuction, we when the limb builds up with lymphedema, again, fat becomes fibrotic, we call it lipedema. Um blood flow, that's why blood flow gets impaired. They get multiple bouts of cellulitis, um and soft tissue and wound healing is really bad and she was a bad, she was a smoker as well. So I liposucked 500 mils of fat after infiltration and the tissues become much softer and without free tissue transfer or local flaps because local flaps, it would be a nightmare in her. In her leg. You manage to get this closed. And I think it was a, I think it was screws and it was mainly screws that were used in the ankle. Uh That's why there was a back cut here and a plate, I think in the fibular side that needed to be covered. So that was one useful aspect. Again, talking about thin flaps, complex areas, especially on both the medial and the lateral side can be a difficult issue in terms of reconstructing it because we've got both lateral and medial malleolus areas to consider uh local. Often in the distal third. One more thing to say is a very, there are not many local options to reconstruct such a defect. So free tissue transfer up intensity. The case, I take a superficial circumflex, eyelid artery flap um based on the artery here, that's quite thin as you can see. And that would be plumbed in here. And I do a local flap here as a combination, a peroneous Brevis type flap turn upon itself to cover the metalwork and close the skin on top again, creating layers to protect the metalwork in case of wound breakdown. Another issue of dealing with two different types of different sites on the medial ankle and the lateral angle. Two different areas difficult complex, not enough to soft tissue for coverage and both nongraftable because they've got lots of exposed metalwork and bone fractures. Um What's possible here is we could split the flap again from one donor site because of the the orientation of the blood vessels. You can take it on two different pedicles and do two free flaps to reconstruct. And this time I tend to not sacrifice the vessels if need be, I do end to side. So the anterior tibial still flows to the foot and we make a hole in arteriotomy in the in the in the artery and, and connect up the artery to that. So it supplies both sides. So this one on the lateral ankle went to the anterior tibial and on the medial side, went to the posterior tibial to reconstruct. Um, the ankle. Uh Yeah, that was it. Uh This one was quite interesting. Um He had bilateral femur fractures and two nails were placed on both femurs so that uh obviates our usual uh donor site, the anterolateral thigh flap when it's bruised when it's badly traumatized. When there's metal work, we don't want to go back in and harvest the flap there. We have to look for alternative sites. Again, the lattice of his dorsi tends to be the flap of choice. There was still this defect to be reconstructed. However, he works as a mechanic. He lifts heavy objects. He may have shown the weakness. It was not something that I really wanted to, to use in this 27 year old. So again, as you can see here when we talked about soft tissue zone of trauma, this was after the first debridement and it's still not great at this age. You can tell it's bruised, it doesn't look vascularized, doesn't look pink and healthy. So I removed that area and it was quite a big defect as you can see here. Now, the the green clips here on the on the posterior tibial artery vessels. So what I tend to do, uh you may have heard of the Diep flap or the deep inferior the gastric flap. We use that for breast reconstruction. Uh This is the first time I did it in a lower limb patient. So, but it provides a lot of tissue, uh his own lower abdomen. Um So he gave him a tummy tuck and this is the deep inferior epigastric vessels that we used. Um And then placed it on his leg really uh with the posterior tibial artery divided and one to supply one end and the other to supply the other. And he gets a tummy tuck. So that point of view, it's disposable tissue um can be used to reconstruct large areas. It's fas cutaneous, it allows primary healing. And in this case, he would be going for ATS f um oxygens in the future, there was a bit of a bone gap. So Mr Kovic Adam will be doing that in the future. Now I talk about chimeric and chimeric flaps. Again, we talk about being able to take vastus lateralis with a flap. Any dead space, as I mentioned tends to collect. And quite interestingly at Adam Brooks, what Mr Kovich found when he does the corticotomy at the later stages when they start to distract their bone, if the flap is sinking into the bone defect, because there is a gap. For example, I'll show it here, there's a gap here in the soft tissues and the skin sort of fold into it. The bone tends to grow across and cut into the flap. So he's seen that and when that happens, it gets infected and there's a bit of a bit of a mess. So what we, what I tend to do is I plug the gap with a chunk of muscle attached to skin and fat that will uh plug up the soft tissue defect and the bone will cut through the muscle. Uh The muscle does atrophy over time because it's not innervated. There's no, there's no, there's no nerve supply to it. So that tends to help with healing and soft tissue. Um you know, reducing any soft tissue um connection, that's the vastest naturalist chunk that we use. And that's the skin and fat that can be transplanted to his leg. So this one and uh again, can be used for large defects, especially in this area. The muscle can be used to fill up any defects and, and close it. And then we do a skin graft over it that will heal up uh lastly a local flap again, for such a defect. Again, we talk about uh we could do a free tissue transfer or I could do an adipofascial flap. Again, that's just to cover it. The skin and fat is vascularized based on the uh first metarsal artery and the dorsalis pedis. So that can be skin grafted and is nice and thin. Uh Lastly, in terms of function, uh this patient had uh this defect as you saw here, he was, I believe, plated and that broke down was infected again, lower limb but not acute trauma. It was more of a, a secondary complication to it with the skin breaking down infection. All that doesn't look very healthy. That was divided. The tendon was the tib and tendon was also strict. That was the end of it. And that was the defect in the tib tendon, which was quite long. Either we do a case with Mr Barrett over in Adrs where he does tendon transfers, for example, um and rerouting it or what I did here was roll fasciata uh with a free tissue transfer in the same setting. So it sort of rolled like a cigar sort of to double breast it and use fiber wire to connect it up and bridge both ends underneath the flap uh from here to here uh to give the patient not only soft tissue transfer and I took muscle as well because he was going to have TS F placed for distraction afterwards. And that was E HL that was ruptured. So um that was him with a CSF on um lost fraction from that point of view. Mhm So in general, the learning point from our point of view would be complex, slow limb trauma often limits what we can do or what we can't. It's often a multidisciplinary team approach and deciding what's best and trying to push the boundaries at the same time doing what's best for the patient. And in my opinion, vascularized tissue is key to reducing infection and nobody wants to have the patient dragging on for too long under their care. With multiple return to theaters, debridement, multiple flaps resulting in amputation at the end. Um I touched a bit on our dangling protocol. You, you may or may not have heard. Um We tend to do this in plastic surgery, especially on the lower limb with flaps because we have transplanted tissue to a separate area in the body and it has to go against gravity. We tend to dangle it to condition the flap uh to getting used to pumping blood against gravity back into the venous system. This is our protocol at Adam Brooks Hospital again for we do it over three days. We increase the amount of time and the number of times eight times per day, five minutes for the first day, 10 minutes, eight times per day, eight times again in 20 minutes, everybody, every unit is a bit different, but we tend to do that. Um Just to because we've seen if a patient dangles or then a flap becomes dependent for too long. On the first day, it tends to become purple and if that happens, it gets congested and the flap dies. So, in summary, uh we do the ATL S uh we treat it as a multidisciplinary team. We decide limb salvage or amputation, limb salvage is the, we do the creative bit and work together to with those principles, as mentioned before. Firstly, bony stabilization, deciding on how we want to reconstruct the leg in an MDT and then deciding on what type of soft tissue reconstruction and what will fit. Um And then we talk about the function and cosmesis and lastly talking about prophylactic antibiotics. In my opinion, it's very important and postoperatively, we talk about edema, control dangling and compression to reduce uh swelling, ulceration and subsequent wound complications in the leg. What I tend to do now in the future is tend to do, try and look at reducing swelling in the flap and the leg often trauma to the lower limb results in damage to lymphatics. And that would result in lymphedema normally that resolves by itself. However, in the flap, for example, because you've cut the whole flap and isolated it island. It, it tends to swell, we call it pincushion. What we tend to do now is if possible find a lymphatic which is one of these and hook it up to a vein that's in, in, in the, in the sort of surrounding tissues you divert the lymphatics to a vein and that will help to reduce the, the swelling, the hardness of the flap and the swelling and fibrotic nature of the flap in the future because they tend to become quite hard after a while. Thank you. Uh Thank you, Mister Low. That's uh excellent talk on um, um, plastics involvement, open fractures. Thank you. Um, I'll just check Ed. Does anyone have any questions from the audience at the moment? I can't see anything on the chart. Er, Mister Low, a quick question. Uh, one question, uh, something else. Um, firstly, do you have any good sort of resources that any orthopedic trainees are interested in? Obviously, we're not trained to be plastic surgeons, but some introduction to all of the different reconstructive, um, options that we can have a look at. Um, the options here. The, there's this website called microsurgeon.org. It's American. They tend to, if you look at the lower limb section, they tend to have different flaps there and sort of different types of flaps that tend to be used. Um, again, yeah, it's quite tricky because I tried to, a lot of it is dependent on, uh, my, in my point of view, it's, uh, quite a, a judgment call and every plastic surgeon is a bit different as you can see, that makes it a bit difficult because every unit has their different threshold of what they would reconstruct or what's what they can do, uh, or what, you know, um, it's often you find working in different areas, people have different things to say about what they can reconstruct or what they can't. Um, again, it's because it's so varied in terms of plastic surgery, what can be done. It quite varies. But the general sort of advice would be on that website in terms of types of flaps local to free. Yeah, that's great because it's helpful when we talk to our classic surgical colleagues. Obviously we've had this teaching session, but also just we know what sort of we're talking the same language will be. Yeah, absolutely. II recognize that it's the same like me learning what you guys do. Uh you know, and what, what's preferred excess wise, you know, if you need to extend it to get to the, to put a screw in the media. Malleolus, how to extend it, whether we close it. Um You know, stuff that I learn working with the team at Adam Brooks as well as lots that even plugging the, I never knew that, you know, from my point of view, you know, for Mr Kovic, he doesn't want the flap to, to, to dive down between the bone ends, for example. And when he distracts it, the bone cuts across it. So that's something we try and avoid. And we found that by plugging it with muscle, it doesn't, you know, the muscle doesn't die or it doesn't become necrotic, the bone, you know, nothing stops the bone from growing through. So, you know, plugging it with some tissue, soft tissue even doesn't really, from our experience doesn't really cause an issue, but in fact, helps it heal quite quick and we don't really get to see the complications, you know, once the soft tissue is sorted, then you guys can crack on and, and fix the bone and, and get the patient sorted. And I think the patients really do appreciate it some sort of a follow up of about a year of some of the patients as well. And from what II, I've spoken to them, a lot of them, I haven't really had to revise one just yet and a lot of them are quite satisfied with the look and the sort of they're walking about the, the skin's ok. They accept that there's a longer scar and they know that their injury has been quite severe, but they're happy to keep their leg and they haven't had to have multiple operations, bone infection wise, which is a bit of a heart sync moment. As Mister Koko will say that we don't really get rid of bone infection and the patient tends to live with it. It's suppressed in, in some form. I mean, that's the technique of sort of interposing some muscle was really useful because um I actually saw a patient a few weeks ago, Mr Kirk at his clinic where some of the uh because it was such a transport gap, some of the soft, the flap had actually started to fall into the fracture site space. And the patient was asking, how is this uh the bone gonna reach the other side of the skin anyway. And I realized that, well, it wasn't, we had to reverse the uh prescription to bring the flap back out. And then, um, I think the patient actually went for something recently, but I haven't seen what was done, I think. Um, but no, I think the, the muscle interposition probably definitely helps prevent that from happening, which is a great idea. Um, I suppose the other question I had, uh, regarding cos obviously some patients have had flaps and then later on many years down the line, they'll have some other man of injury. Um Is there any precautions we need to consider when, if we have to incise through a flap? Um, obviously, the underlying vasculature may have changed. Um What, what would you advise regarding that? That's a great question. I think um, often if it's after a year, it tends to rebus toise on the edges. So the skin flap, you know, has sort of its own blood supply. It doesn't depend on the actual anastomosis per se. So you could cut right through it. Uh As long as you keep the edges intact through the scar, then it shouldn't cause an issue. And if we were to do another flap, for example, then we'd have to find a new vessel. That's, that's our, our bit we have to solve, but it's, that's obviously we get patients with a young injury when they're young and obviously later on down the line, they're gonna need, they may need something else. So it going through the edge and lifting it off is always not a problem. As long as the other half of 50% of the flap is still attached and you haven't fully island it again. Then, you know, it's got its own blood supply for sure. Um And then one other thing that we encountered recently, he had a patient who had a transverse laceration down the length of their ulnar shaft, they had an ulnar shaft fracture. So we had to get to the ulnar shaft which usually a longitudinal incision down the subcutaneous border between the FC EC I had uh one was I was advised initially to just make a cruise fix type incision straight down the middle. Does that what's sort of the risk of the angles of the, of the skin? Um rather than lifting it up because I only ended up making a sort of z sort of shaped incision. What's the risk of sort of making a cruise fix type cut in general? I think from a plastic surgery point of view, if it crosses a joint, we always say to cross a joint like in hand surgery, as you guys would have been told, you know, doing brinner incisions do not cross a joint. Um you know, perpendicular joint always cross it at an angle. That's our general principle as well. You know, if it's on the subcutaneous border, you know, normally we don't really tend to need to curb it if, unless we need to get access to certain structures. Um If it crosses the wrist or crosses the elbow, then, you know, you tend to curb it because it tends everything contracts in a line. So if it contracts, if you curve it, it doesn't contract as much in a line. So the patient doesn't get that much of a tight sensation or pull. That's the main general principles as to why incisions are planned a certain way. They are, whether they're in AZ or S shape or crucifix, that's all sort of surgeon choice, but it's either a straight line or not a straight line. So the precautions more actually more around contracture rather than vasculature to the, to the edges. From my point of view, there's a certain vessel that, that we tend to use that comes off the ulnar artery, six centimeters from the, from the crease, we call it, we call it a Becker flat br but it gives off a perforator off from the ulnar artery. You can quite see it in a lot of people and that can be used to reconstruct a lot of things. So maybe from that point of view that you would try and avoid it. But you know, that's just a potential. Uh we only, you know, you talk about curing it if you want to get access to certain areas because a linear skull will make it more difficult to retract areas. So by creating little uh uh flaps or triangles, then you can sort of retract and get access to a greater degree. But the wider yours, your cuts are, the more the further away your triangles are from the blood supply. So you have to be careful. Same for brunner's incisions in the, in the, in the finger. If you make a brunner's incision and the tips very far and narrow, the blood supply can occur. So in, in sort of, for example, acute infection, flexor sheath, for example, if you do a very, we don't, I don't quite like brunner's incisions for them because the inflammation tends to restrict blood flow. So I tend to make it as a wide base type flap with not narrow tips. So the more narrow your your triangles are the more the the increased chance of poor vascularity and sort of flat necrosis leading to exposure of structures. For sure. Thank you. Um Any other questions from the audience too? Um I think some uh Mr Lowe, someone was asking if you'd be able to share your powerpoint slides. Is that possible or there's some patient uh details to it? But I think the, I think Nicholas has recorded it. Ast Sure. Yeah. Yeah. Yeah, that's what, that's what I thought as well. That that's no worries. Um I think that's about it, Mr Low. So thank you very much for that. That's really helped