Soft tissue Reconstruction in the lower Limb intro

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Soft tissue Reconstruction in the lower Limb intro

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  1. Soft tissue Reconstruction in the lower Limb

    Slide 1 - Soft tissue Reconstruction in the lower Limb

    • Level D evidence
    • Dr Vaikunthan RajaratnamSenior Consultant Hand SurgeonDepartment of Orthopaedic Surgery
    • KTPH Alexandra Health
    • Singapore
  2. Medicine used to be simple, ineffective and relatively safe.

    Slide 2 - Medicine used to be simple, ineffective and relatively safe.

    • Now it is complex, effective and potentially dangerous.
    • Chantler C ( 1999 ) The role and education of doctors in the
    • delivery of healthcare
  3. Resources

    Slide 3 - Resources

    • Flaps and Reconstructive Surgery,
    • Fu-Chan Wei MD FACS ,  Samir Mardini MD 
    • Surgery of the Injured Hand: Towards Functional Restoration 
    • R Venkataswami
    • SEMINARS IN PLASTIC SURGERY/VOLUME 24, NUMBER 1 2010
    • The Reconstruction of the Mutilated Hand ,M Neumeister ,A Amalfi,
    • www.handsurgerymanual.com
    • www.handsurgeryedu.com – register courses soft tissue reconstruction
    • http://www.facebook.com/handsurgeryedu
    • https://twitter.com/handsurgeryedu
    • http://www.linkedin.com/groups/Hand-Surgery-International-3804094
  4. Problem identification

    Slide 4 - Problem identification

    • Clear and concise description of the problem
    • Identification of the needs
    • Identify and list constraints and limits
    • Aetiology
    • Structural analysis
    • Functional analysis
    • Right Leg – 10 X 3 cm skin loss over the right tibia, bone exposed
  5. Reconstructive ladder

    Slide 5 - Reconstructive ladder

    • Rung 1: Secondary intentionRung 2: Primary closureRung 3: Delayed closureRung 4: SSGRung 5: FTSGRung 6: Tissue expansionRung 7: Random flapRung 8: Axial flapRung 9: Free flap
    • Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation.Plast Reconstr Surg. Feb 1981;67(2):177-87
  6. Constraint analysis

    Slide 6 - Constraint analysis

    • Assessment – anatomy, patient, surgeon, therapist,
    • Time and timing
    • Resources – expertise, experience, equipment, energy
    • Ethics
    • Aesthetics
  7. Assessment of viability/reconstruction

    Slide 8 - Assessment of viability/reconstruction

    • Best undertaken in theatre
    • Obtain 2nd opinion
    • Especially- amputation
    • Senior/ more experienced surgeon
  8. Generating options

    Slide 9 - Generating options

    • Begin with the end in mind
    • Priorities
    • Holistic consideration
    • Keep the patient in the centre
    • Go beyond anatomy
    • Think outside the ladder!
  9. Role of soft tissue

    Slide 10 - Role of soft tissue

    • Sensation
    • Animation
    • Efferent Execution
    • Social
    • Communication
    • Aesthetics
  10. Requirements- reconstruction

    Slide 11 - Requirements- reconstruction

    • Wound debridement
    • Vascualrity
    • Adequate skin cover
    • Stabilisation of bone
    • Skin with good vascularity for bone healing
  11. Early versus delayed closure of open fracturesL. Scott LevinInjury, Int. J. Care Injured (2007) 38, 896—899

    Slide 12 - Early versus delayed closure of open fracturesL. Scott LevinInjury, Int. J. Care Injured (2007) 38, 896—899

    • all comes down to personnel, dialogue, and communication between the traumatologist, vascular surgeons, orthopaedic surgeons, nurses, PA’s, and plastic surgeons.
    • The question remains–— who is available, when can they do it, are they willing to do it, and if they do it, can they do it with a degree of certainty that will assure complete and ‘‘living coverage’’, once coverage is provided? In those circumstances, it is better to delay coverage or even transfer a patient to another centre, than have an inexperienced team of personnel try to provide coverage with an unsuccessful outcome. The latter certainly creates terrible morbidity, increases hospitalisation costs, and generates emotional trauma to patients. In the polytrauma patient with open fractures, particularly in the extremities, coverage is just one part of total care that includes haemodynamic stabilisation, fracture stabilisation, definitive fixation, perhaps provisional coverage, definitive coverage, and then reconstruction down the line of missing bone segments, motor tendon units, or peripheral nerves.