JBUR-4418; No. of Pages 7 burns xxx (2014) xxx–xxx
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns Erol Kesiktas, Cengiz Eser *, Eyuphan Gencel, Emrah Efe Aslaner, Metin Yavuz Cukurova University Plastic Reconstructive and Aesthetic Surgery Clinic, 01330 Saricam, Adana, Turkey
article info
abstract
Article history:
Injury due to high-voltage (>1000 V) electricity is one of the most challenging problems in
Accepted 6 July 2014
emergency medicine and plastic surgery. Extremity amputation because of electrical injury yields a stump that leaves vital structures, such as bone, muscle, blood vessels, and nerves,
Keywords:
exposed; these structures should be covered with appropriate tissue. We designed a
Electrical burn
retrospective study that included twelve patients with a high-voltage electrical injury
Transhumeral amputation
followed by trans-humeral amputation who were evaluated between 2004 and 2013. The
Stump reconstruction
ages of the patients ranged between 8 and 35 years (mean, 16.9 years). Following amputa-
Latissimus dorsi flap
tion, the defects were covered with an ipsilateral pedicled latissimus dorsi (LD) myocutaneous flap for stump protection and functional transfer. We concluded that the use of an ipsilateral LD myocutaneous flap is an adequate surgical operation in upper extremity amputations resulting from high-voltage electrical burn injuries and that this procedure permits stump length maintenance, contributes to arm functioning, avoids extended operation times, and prepares patients for prosthesis usage. # 2014 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
High-voltage (>1000 V) electrical injury is one of the most challenging problems in emergency medicine and plastic surgery. Electrical current may cause irreversible damage to the tissues through which it passes. Despite recent medical advances, salvaging an extremity after a high-voltage electrical injury may not be achievable, and amputation may be necessary [1]. Extremity amputation yields a stump that leaves vital structures, such as bones, muscles, blood vessels, and nerves, exposed; the stump should be covered with appropriate tissue. The wide spectrum of stump closure options ranges from
simple suturing to a complex free flap procedure [2]. After extremity amputations, the length and quality of the stump are associated with quality of life. Short stumps cause prosthesis instability and affect daily life, esthetic appearance, and social interactions [3]. The latissimus dorsi (LD) muscle can be used in upper and lower extremity stump coverage and can be used in a pedicled or free manner, as described previously [2,4,5]. The LD has been used for functional muscle transfer for restoring upper extremity dysfunction [6,7]. In this study, we demonstrated that there are many advantages using an ipsilateral pedicled latissimus dorsi myocutaneous flap in trans-humeral amputations resulting from high-voltage electrical injuries. These advantages include
* Corresponding author. Tel.: +90 5323163317. E-mail address: [email protected] (C. Eser). http://dx.doi.org/10.1016/j.burns.2014.07.011 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
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the following: covering and maintaining the length of the stump, protecting vital structures, restoring arm function, avoiding extended operation times, and facilitating prosthesis usage.
2.
Materials and methods
We designed a retrospective study that was approved by the Institutional Review Board of the Cukurova University, Adana, Turkey. Twelve patients who were exposed to a high-voltage electrical injury to one of the upper extremity were evaluated between 2004 and 2013. The ages of the patients ranged from 8 to 35 years (mean age 16.9 years). Eight of the twelve patients were male, and four patients were female. All of the patients were evaluated in the emergency room (ER) between 1 and 3 h (mean 2 h) after the burn injury. None of the patients had any chronic illnesses, such as diabetes or cardiovascular insufficiency, and they did not have cardiogenic or hypovolemic shock symptoms. None of the patients had experienced a major trauma, such as an intracranial injury or a bone fracture. The calculated total burned body surface area of the patients ranged from 9% to 25% (mean 15.5%). In the ER, acute fluid resuscitation of patients was administered according to the ‘‘Parkland Formula,’’ taking into account the duration of time since the burn event. Urgent fasciotomy was performed in seven cases for a suspected or obvious compartment syndrome (Fig. 1). If needed, serial debridements were performed during the hospitalization. The appearance of viable deltoid muscle, which is a major muscle responsible for movement of the proximal arm, was noted at the final debridement. After a detailed clinical follow-up, all of the patients’ upper extremities were amputated at the transhumeral level (five on the left side and seven on the right side) by an orthopedic surgeon between 0 and 12 days (mean 5.58
Fig. 1 – Electrically burned right arm on the 6th day of hospitalization. The fasciotomy was performed on day 0 in the emergency room.
days) after the burn. After the amputations, the bone stump length was measured from the gleno-humeral joint to the distal end of the humeral bone using a ruler. The patients’ total shoulder range of motion (ROM) measurements combined with the scapular contribution were calculated using a universal goniometer and noted at twelve months after the LD transfers. The patients were followed up for 1–3 years (mean 19.58 months) after the surgery. The patient characteristics are shown in Tables 1 and 2.
3.
Operative technique
All of the operations were performed under general anesthesia. During a prompt debridement and amputation, the
Table 1 – Patient characteristics. Gender/age Affected Total Follow-up days Prosthesis Complications Follow-up Fasciotomy side burned surface prior to amputation period usage (months) area (%) surgery Patient 1 Patient 2
M/19 M/21
L R
12 18
+
2 9
+ +
Patient 3
F/8
R
9
+
11
+
Seroma in donor area Suture dehiscence in donor area
M/14 M/12 F/10 M/35 M/18
L L L R R
14 15 14 25 20
+
Reamputation
+
Seroma in donor area
Patient 9 Patient 10
M/4 M/12
R L
16 18
+ +
12 6
Patient 11
M/28
R
10
+
8
Patient 12
M/22
R
15
Patient Patient Patient Patient Patient
4 5 6 7 8
+ +
0 8 7 1 1
2
+ +
+
Partial skin graft loss in recipient area Partial skin graft loss in recipient area
12 17 36
12 26 14 16 12 30 18
24
18
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
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Table 2 – Amount of viable deltoid muscle and bone stump length, after debridement.
Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient
1 2 3 4 5 6 7 8 9 10 11 12
Viable deltoid muscle (%)
Bone stump length (cm)
75 75 100 50 75 100 75 75 100 50 75 75
11 12 14 10 10 8 13 11 7 9 12 12
3
triceps brachii, and coracobrachialis muscles, were aggressively debrided. After the amputations, the exposed arm structures, such as the bone (humerus), nerves (which pass through the proximal arm), muscles, and vessels (axillary artery and vein), were covered with an ipsilateral pedicled LD myocutaneous flap. During a total LD harvest, an elliptical dorsal skin slice was kept over the muscle to obtain stiff tissue at the end of the stump. The dimensions of the dorsal skin were individually determined based on a pinch test of the primary closed donor area. After harvesting the LD, its origin was oriented such that it covered the semi- or completely bare humeral bone in a fan shape. The distal end of the LD muscle was sutured to the remaining deltoid muscle fibers. During the harvest, the thoracodorsal nerve and the serratus branch of the thoracodorsal vessel were kept intact in all of the flaps to allow for functional muscle transfer and reliable vascular supply. The raw surfaces of the LD were covered with a split-thickness skin graft (Fig. 3). The donor area of the LD myocutaneous flaps was sutured primarily. Drains were inserted into the recipient and donor areas.
humeral bone stumps were left as long as possible (average 10.75 cm), and the deltoid muscle was kept intact as much as possible (average 77.08%) (Table 2 and Fig. 2). The pectoral muscle and shoulder muscles, such as the supraspinatus, infraspinatus teres minor, and teres major muscles, were minimally affected or not affected by the electrical current and were not debrided. The muscles with insertions in the inferior humeral region, such as the brachialis, biceps brachii,
All of the patients’ follow-up periods were 1–3 years (Fig. 4). Seroma formation was observed in two patients in the early
Fig. 2 – Trans-humeral amputation stump.
Fig. 3 – End of the operative procedure. The raw surface of the muscle was covered with a meshed skin graft.
4.
Results
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
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Fig. 4 – Patient on the 3rd day of hospitalization after a high-voltage electrical injury. Urgent fasciotomy was performed when the patient was admitted to the emergency room (upper left). Perioperative view of the same patient. The latissimus dorsi muscle and skin island were harvested (upper right). Twenty-four-month postoperative views. Note that the patient is able to move her arm in all directions (middle left, right, and lower left). Thirty-six-month postoperative anterior view of the patient with a static prosthesis (lower right). H: Humerus, LD: Latissimus dorsi muscle, DS: Dorsal skin.
postoperative period; these seromas were drained daily (Patients 2 and 8). Two patients had partial skin graft loss on the raw surface of the LD muscle, and repeat skin grafts were performed in these patients (Patients 10–11). One patient experienced suture dehiscence in the distal part of the stump, and the region was sutured after a prompt debridement (Patient 3). In one patient, a pressure ulcer was observed in the skin island of the LD flap due to prosthetic usage (Patient 5). This issue was solved by shortening the stump. We did not observe any total or partial loss of the
myocutaneous LD flaps. After completion of all the operations, all of the patients were directed to an exercise program in the physical therapy department. The results of the ROM measurements obtained one year after surgery are presented in Table 3, and changes or alterations from the normal ROM are presented in Fig. 5. Eight patients used an upper extremity prosthesis, while four patients chose not to use a prosthesis. However, these patients were able to move their stump during the follow-up period.
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
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Table 3 – Shoulder range of motion of the amputated arm (degrees).
Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient
4.1.
Forward flexion
Extension
Abduction
External rotation
Internal rotation
175 160 170 140 175 165 140 155 175 165 175 180
50 55 30 45 35 50 30 35 40 45 45 35
150 145 135 125 145 140 150 115 155 150 140 155
55 50 65 60 50 70 50 55 70 70 60 55
60 60 65 55 60 65 50 55 60 55 60 60
1 2 3 4 5 6 7 8 9 10 11 12
Statistical analysis
The statistical analysis was performed using the SPSS statistical software package (Version 17.0, SPSS, Inc., Chicago, IL, USA). If continuous variables were normal, they were described as the means standard deviation (p > 0.05 in the Kolmogorov–Smirnov or Shapiro–Wilk test (n < 30)); if the continuous variables were not normal, they were described as the medians. The continuous variables were compared using a one-sample t test. Values of p < 0.05 were considered statistically significant.
5.
Discussion
High-voltage electrical injuries can cause serious damage to extremities and can result in amputations [1,8,9]. Tissue destruction of an extremity in patients exposed to an electrical burn is reduced in a distal-to-proximal direction [10,11]. During emergency resuscitation, compartment syndrome of a limb should be noted. After a physical examination, escharotomy or fasciotomy could be an extremity-salvaging or life-saving procedure [12]. Amputations may be required in third-degree full-thickness burns or in cases in which the extremity circulation cannot be achieved by fasciotomy [13]. Since our burn center is a unique advanced facility of this region; most of our cases included critical burn patients.
Fig. 5 – Graph of the normal and study group ROM measurements. As authors of this article, we confirm that we have no conflict of interest to declare.
Therefore overall amputation rate of our center is approximately 21.4% in high voltage electrical burns. Amputations can be made above (trans-humeral or shoulder disarticulation) or below the elbow, depending on the level of necrosis in the upper limb. It is difficult to predict which tissues will be affected and the extent of the involvement of an electrical burn. However, histological, Doppler, scintigraphic, and angiographic studies can support the assessment of tissue destruction. Close clinical follow-up and the performance of serial debridements are the most important evaluation guidelines [1,14]. The basic principle of burn surgeries, especially in cases of electrical burns, is to repair the defect with a vascularized flap after serial debridements [14–17]. The level of the amputation and the stump length are important for prosthesis fit and quality of life in amputees. Thus, a patient’s esthetic and functional satisfaction is better when the prosthesis is compatible with his/her body [2,3,18]. In our study, the amputation levels were maintained distal to the deltoid muscle insertion as often as possible to allow for motion of the trans-humeral amputated arm. The deltoid muscle is a major movement effector of the upper arm in almost all directions. Therefore, an amputation above the deltoid insertion is functionally considered to be a shoulder disarticulation [19]. A pedicled LD flap has been used in various reconstructive procedures since it was first described by Tansini in 1906 [7]. Reconstruction with the LD muscle is suitable for large, infected, and vascularly compromised areas because it has a large surface area and abundant vascularity. In our study, defects that included injured bone and soft tissue were covered with an ipsilateral pedicled LD myocutaneous flap. This flap provides a viable environment for all of the vital arm structures after their exposure. Sufficient soft tissue coverage is the most important factor for a good outcome in amputations, whereas limitation of the adjacent joint function may have a detrimental effect on the clinical results [20]. When the arm skin is sufficient for covering a trans-humeral stump, an LD myocutaneous flap with a skin graft could close the entire defect around the injured bone in a three-dimensional manner; as we described, this method does not negatively affect shoulder movements after a prompt debridement. Additionally, injured bone can heal well when it is covered with abundant muscle. Because the muscle tissue can
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
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potentiate osteogenesis, promoting the healing of semiviable bone segments [21]. In all of our cases, during the flap-harvesting procedure, a skin island was designed over the muscle to provide stiff tissue in the area in contact with the prosthesis and stump. Additionally, the LD muscle with a skin island covers the defect and provides increased soft tissue elongation to the stump without a secondary bone elongation procedure [21]. Bone stump lengthening can be achieved using the Ilizarow System. However, several problems have been encountered with the Ilizarow technique regarding the soft-tissue reconstruction and recovery time [22]. In our study, the muscle and skin located at the end of the bone stump facilitated stump lengthening without the need for a bone lengthening procedure after a trans-humeral amputation. In functional muscle transfer, proper orientation of the muscle assists with motor function of the transposed area [23]. The LD muscle can also be transferred with its motor nerve (thoracodorsal nerve) as a functional unit. This flap is more useful, especially in electrical burns, as it contributes to elbow function [6,24]. We used the LD muscle with its motor nerve to provide shoulder function in all of the patients. Thus, the functional transfer of the LD to the amputated arm contributes to the movement of the stump even in patients who cannot use a prosthesis. In the present study, the transferred LD did not pass over a joint between its origin and insertion. However, the end of the LD muscle was sutured to the remaining deltoid muscle. Thus, the LD muscle could assist with deltoid muscle movements as a continuation of deltoid muscle fibers, up to the intertubercular area. In this situation, the majority of arm movements could be considered to be dependent on viable deltoid muscle, some of which is associated with the transferred LD. ROM measurements after twelve months showed significant differences in forward flexion (p = 0.002) and internal and external rotation (p = 0.0001) (Table 4). The reduction in forward flexion may be a result of deltoid muscle damage. However, the mean ROM was calculated to be 164 degrees in our study, and this result was interpreted as clinically insignificant. Additionally, extension and abduction movements were almost within the normal range. In our study, there was no electrical damage or minimal electrical damage observed in the posterior and superior shoulder muscles. Thus, extension and abduction movements may not be affected or may be minimally affected. The reason for the statistically significant difference in internal and external rotations could be due to loss of the muscle that inserts into
the forearm in amputations. However, these results are only theoretical, and which muscle is a major movement effector of an amputated shoulder or how much strength is derived from the transferred LD muscle cannot be predicted. Because the vascular pedicle of the LD is further away from the injury site, it can safely be used in upper extremity electrical injuries. During harvesting, care was taken to avoid damaging the serratus branch of the thoracodorsal vessels in the case of thrombosis in the thoracodorsal pedicle. Because of this dual vascularity of the LD, we did not encounter any total or partial flap loss in our study. There may be sudden changes in the general condition of electrically burned patients. A free flap operation can be a prolonged procedure and can compromise the overall condition of the patient. For example, the free fibula flap procedure allows for maximal lengthening of a short humeral stump; however, the fibula must be covered by another flap, such as the LD flap. This option requires a complex procedure with a free flap associated with a pedicled or free flap covering [25]. We opted to perform a simpler operation instead of a free flap procedure in our patients. Therefore, the operative anesthesia-related risks and cardiovascular risks were reduced. Some of the major disadvantages of using an LD flap are the following: a long scar on the dorsum, possible seroma accumulation in the donor area, and loss of LD muscle on the ipsilateral side. Seroma accumulation in the donor area of the LD was noted in two cases in the early postoperative period (Patients 2 and 8). Both of the seromas disappeared within two weeks following daily aspirations and the applications of compressive dressings. In two patients (Patients 10 and 11), a partial loss of the split-thickness skin grafts that were used to cover the raw LD surface was encountered. One of these patients was treated with regrafting, and the graft in the other patient healed with secondary intention. Suture dehiscence in the donor area of the LD caused by skin stretching occurred in one patient (Patient 3). In this patient, resuturing was performed, and healing was uneventful. Neither stump shortening nor debridement was performed for any remaining necrosis of bone or muscle in the long term. However, in one of the eight patients who chose to use a prosthesis (Patient 5), a decubitus ulcer developed on the distal skin of the stump because of overcontact with the prosthesis. In that patient, ulcer debridement and bone shortening (1 cm) were performed. One limitation of this study is that we did not perform objective and subjective tests evaluating the overall satisfaction
Table 4 – Statistical analysis of ROM. Study group N Forward flexion Extension Abduction External rotation Internal rotation
12 12 12 12 12
Normal range of motion 180 45–60 150 90 90
Mean SD 164.5 13.5 41.2 8.3 142.1 12.1 59.2 7.9 58.7 4.3
Med (Min-Max) 167(140–180) 42(30–55) 145(115–155) 57(50–70) 60(50–65)
p 0.002 0.107 0.055 0.0001 0.0001
p: One-sample t-test. The bold numbers represent statistical significance.
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
JBUR-4418; No. of Pages 7 burns xxx (2014) xxx–xxx
with the prosthesis and functional abilities. Another limitation is that the patients included in the study had amputated extremities with no concomitant body injuries. A mechanical prosthesis was offered to all of the patients 12 weeks after the operations, as described in the literature [26]. However, only eight of the patients applied for a prosthesis; the other patients did not choose to use a prosthesis. Excess soft tissue in the distal stump is not required for prosthetic stability [19]. The LD muscle can be edematous and thick in the early postoperative period; however, this thickness decreases over time. Thus, a permanent prosthesis can be applied in the long term after using a temporary prosthesis.
6.
Conclusion
[8]
[9] [10]
[11]
[12]
[13] [14]
The use of an ipsilateral LD myocutaneous flap is an adequate surgical operation for upper extremity amputations caused by high-voltage electrical burn injuries. This method allows for the stump length to be maintained, contributes to arm functioning, avoids extended operation times, and prepares patients for prosthesis usage.
Conflict of interest As authors of this article, we confirm that we have no conflict of interest to declare.
[15] [16]
[17]
[18]
[19]
references
[1] Ko¨mu¨rcu¨ F, Stuffer M, Hussl H, Anderl H. Maintenance of stump length of both upper extremities after severe electrical burn injury. Burns 1990;16:227–9. [2] Vavloy VN, Kalakutsky NV, Agrachyova IG. Reconstruction of very short humeral stumps. Ann Plast Surg 1994;32:145–7. [3] Demet K, Martinet NL, Guillemin F, Paysant J, Andre´ JM. Health related quality of life and related factors in 539 persons with amputation of upper and lower limb. Disabil Rehabil 2003;25:480–6. [4] Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 1986;78:285–92. [5] Tukiainen EJ, Saray A, Kuokkanen HO, Asko-Seljavaara SL. Salvage of major amputation stumps of the lower extremity with latissimus dorsi free flaps. Scand J Plast Reconstr Surg Hand Surg 2002;36:85–90. [6] Tan O, Atik B, Ergen D. Versatile use of pedicled latissimus dorsi flap as a salvage procedure in reconstruction of complex injuries of the upper extremity. Ann Plast Surg 2007;59:501–6. [7] Behnam AB, Chen CM, Pusic AL, Mehrara BJ, Disa JJ, Athanasian EA, et al. The pedicled latissimus dorsi flap for
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shoulder reconstruction after sarcoma resection. Ann Surg Oncol 2007;14:1591–5. Zhu ZX, Xu XG, Li WP, Wang DX, Zhang LY, Chen LY, et al. Experience of 14 years of emergency reconstruction of electrical injuries. Burns 2003;29:65–72. John JR, Sharma RK. Microsurgery and limb salvage after electrical burn injury. Burns 2013;39:1647–8. Zelt ZG, Daniel RK, Ballard PA, Brissette Y, Heroux P. Highvoltage electrical injury: chronic wound evolution. Plast Reconstr Surg 1988;82:1027–41. Sauerbier M, Ofer N, Germann G, Baumeister S. Microvascular reconstruction in burn injuries of the severely traumatized upper extremity. Plast Reconstr Surg 2007;119:605–15. Cancio LC, Jimenez-Reyna JF, Barillo DJ, Walker SC, McManus AT, Vaughan GM. One hundred ninety-five cases of high-voltage electric injury. J Burn Care Rehabil 2005;26:331–40. Tarim A, Ezer A. Electrical burn is still a major risk factor for amputations. Burns 2013;39:354–7. Duman H, Er E, Turegu¨n M, Sengezer M. Bilateral free myocutaneous latissimus dorsi flap repair of the upper limb amputation stumps due to electrical injury. Burns 2003;29:87–91. Orgill DP, Pribaz JJ. Functional reconstruction following electrical injury. Ann N Y Acad Sci 1999;888:96–104. Saint-Cyr M, Daigle JP. Early free tissue transfer for extremity reconstruction following high-voltage electrical burn injuries. J Reconstr Microsurg 2008;24(4):259–66. McCauley RL, Barret JP. Electrical injuries. In: Achauer BM, Eriksson E, editors. Plastic surgery indications, operations, and outcomes. 1st ed. Philadelphia: Mosby; 2000. p. 375. Bernstein RM, Watts HG, Setoguchi Y. The lengthening of short upper extremity amputation stumps. J Pediatr Orthop 2008;28:86–90. Bowker JH, Michael JW. Atlas of limb prosthetics. 2nd ed. St. Louis: CV Mosby Co.; 1992: 81–345. Park HW, Jahng JS, Hahn SB, Shin DE. Lengthening of an amputation stump by the Ilizarov technique: a case report. Int Orthop 1997;21:274–6. Dalay C, Kesiktas E, Yavuz M, Ozerdem G, Acarturk S. Coverage of scalp defects following contact electrical burns to the head: a clinical series. Burns 2006;32:201–7. Eldridge JC, Armstrong PF, Krajbich JI. Amputation stump lengthening with the Ilizarov technique: a case report. Clin Orthop Relat Res 1990;256:76–9. O’Ceallaigh S, Mehboob Ali KS, O’Connor TP. Functional latissimus dorsi muscle transfer to restore elbow flexion in extensive electrical burns. Burns 2005;31:113–5. Kesiktas E, Dalay C, Ozerdem G, Acarturk S. Reconstruction of deep cubital fossa defects with exposure of brachial artery due to high tension electrical burns and treatment algorithm. Burns 2005;31:629–36. Pinsolle V, Tessier R, Casoli V, Martin D, Baudet J. The pedicled vascularised scapular bone flap for proximal humerus reconstruction and short humeral stump lengthening. J Plast Reconstr Aesthet Surg 2007;60:1019–24. Jo¨nsson S, Caine-Winterberger K, Bra˚nemark R. Osseointegration amputation prostheses on the upper limbs: methods, prosthetics and rehabilitation. Prosthet Orthot Int 2011;35:190–200.
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
7
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/burns
Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns Erol Kesiktas, Cengiz Eser *, Eyuphan Gencel, Emrah Efe Aslaner, Metin Yavuz Cukurova University Plastic Reconstructive and Aesthetic Surgery Clinic, 01330 Saricam, Adana, Turkey
article info
abstract
Article history:
Injury due to high-voltage (>1000 V) electricity is one of the most challenging problems in
Accepted 6 July 2014
emergency medicine and plastic surgery. Extremity amputation because of electrical injury yields a stump that leaves vital structures, such as bone, muscle, blood vessels, and nerves,
Keywords:
exposed; these structures should be covered with appropriate tissue. We designed a
Electrical burn
retrospective study that included twelve patients with a high-voltage electrical injury
Transhumeral amputation
followed by trans-humeral amputation who were evaluated between 2004 and 2013. The
Stump reconstruction
ages of the patients ranged between 8 and 35 years (mean, 16.9 years). Following amputa-
Latissimus dorsi flap
tion, the defects were covered with an ipsilateral pedicled latissimus dorsi (LD) myocutaneous flap for stump protection and functional transfer. We concluded that the use of an ipsilateral LD myocutaneous flap is an adequate surgical operation in upper extremity amputations resulting from high-voltage electrical burn injuries and that this procedure permits stump length maintenance, contributes to arm functioning, avoids extended operation times, and prepares patients for prosthesis usage. # 2014 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
High-voltage (>1000 V) electrical injury is one of the most challenging problems in emergency medicine and plastic surgery. Electrical current may cause irreversible damage to the tissues through which it passes. Despite recent medical advances, salvaging an extremity after a high-voltage electrical injury may not be achievable, and amputation may be necessary [1]. Extremity amputation yields a stump that leaves vital structures, such as bones, muscles, blood vessels, and nerves, exposed; the stump should be covered with appropriate tissue. The wide spectrum of stump closure options ranges from
simple suturing to a complex free flap procedure [2]. After extremity amputations, the length and quality of the stump are associated with quality of life. Short stumps cause prosthesis instability and affect daily life, esthetic appearance, and social interactions [3]. The latissimus dorsi (LD) muscle can be used in upper and lower extremity stump coverage and can be used in a pedicled or free manner, as described previously [2,4,5]. The LD has been used for functional muscle transfer for restoring upper extremity dysfunction [6,7]. In this study, we demonstrated that there are many advantages using an ipsilateral pedicled latissimus dorsi myocutaneous flap in trans-humeral amputations resulting from high-voltage electrical injuries. These advantages include
* Corresponding author. Tel.: +90 5323163317. E-mail address: [email protected] (C. Eser). http://dx.doi.org/10.1016/j.burns.2014.07.011 0305-4179/# 2014 Elsevier Ltd and ISBI. All rights reserved.
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
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burns xxx (2014) xxx–xxx
the following: covering and maintaining the length of the stump, protecting vital structures, restoring arm function, avoiding extended operation times, and facilitating prosthesis usage.
2.
Materials and methods
We designed a retrospective study that was approved by the Institutional Review Board of the Cukurova University, Adana, Turkey. Twelve patients who were exposed to a high-voltage electrical injury to one of the upper extremity were evaluated between 2004 and 2013. The ages of the patients ranged from 8 to 35 years (mean age 16.9 years). Eight of the twelve patients were male, and four patients were female. All of the patients were evaluated in the emergency room (ER) between 1 and 3 h (mean 2 h) after the burn injury. None of the patients had any chronic illnesses, such as diabetes or cardiovascular insufficiency, and they did not have cardiogenic or hypovolemic shock symptoms. None of the patients had experienced a major trauma, such as an intracranial injury or a bone fracture. The calculated total burned body surface area of the patients ranged from 9% to 25% (mean 15.5%). In the ER, acute fluid resuscitation of patients was administered according to the ‘‘Parkland Formula,’’ taking into account the duration of time since the burn event. Urgent fasciotomy was performed in seven cases for a suspected or obvious compartment syndrome (Fig. 1). If needed, serial debridements were performed during the hospitalization. The appearance of viable deltoid muscle, which is a major muscle responsible for movement of the proximal arm, was noted at the final debridement. After a detailed clinical follow-up, all of the patients’ upper extremities were amputated at the transhumeral level (five on the left side and seven on the right side) by an orthopedic surgeon between 0 and 12 days (mean 5.58
Fig. 1 – Electrically burned right arm on the 6th day of hospitalization. The fasciotomy was performed on day 0 in the emergency room.
days) after the burn. After the amputations, the bone stump length was measured from the gleno-humeral joint to the distal end of the humeral bone using a ruler. The patients’ total shoulder range of motion (ROM) measurements combined with the scapular contribution were calculated using a universal goniometer and noted at twelve months after the LD transfers. The patients were followed up for 1–3 years (mean 19.58 months) after the surgery. The patient characteristics are shown in Tables 1 and 2.
3.
Operative technique
All of the operations were performed under general anesthesia. During a prompt debridement and amputation, the
Table 1 – Patient characteristics. Gender/age Affected Total Follow-up days Prosthesis Complications Follow-up Fasciotomy side burned surface prior to amputation period usage (months) area (%) surgery Patient 1 Patient 2
M/19 M/21
L R
12 18
+
2 9
+ +
Patient 3
F/8
R
9
+
11
+
Seroma in donor area Suture dehiscence in donor area
M/14 M/12 F/10 M/35 M/18
L L L R R
14 15 14 25 20
+
Reamputation
+
Seroma in donor area
Patient 9 Patient 10
M/4 M/12
R L
16 18
+ +
12 6
Patient 11
M/28
R
10
+
8
Patient 12
M/22
R
15
Patient Patient Patient Patient Patient
4 5 6 7 8
+ +
0 8 7 1 1
2
+ +
+
Partial skin graft loss in recipient area Partial skin graft loss in recipient area
12 17 36
12 26 14 16 12 30 18
24
18
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
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Table 2 – Amount of viable deltoid muscle and bone stump length, after debridement.
Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient
1 2 3 4 5 6 7 8 9 10 11 12
Viable deltoid muscle (%)
Bone stump length (cm)
75 75 100 50 75 100 75 75 100 50 75 75
11 12 14 10 10 8 13 11 7 9 12 12
3
triceps brachii, and coracobrachialis muscles, were aggressively debrided. After the amputations, the exposed arm structures, such as the bone (humerus), nerves (which pass through the proximal arm), muscles, and vessels (axillary artery and vein), were covered with an ipsilateral pedicled LD myocutaneous flap. During a total LD harvest, an elliptical dorsal skin slice was kept over the muscle to obtain stiff tissue at the end of the stump. The dimensions of the dorsal skin were individually determined based on a pinch test of the primary closed donor area. After harvesting the LD, its origin was oriented such that it covered the semi- or completely bare humeral bone in a fan shape. The distal end of the LD muscle was sutured to the remaining deltoid muscle fibers. During the harvest, the thoracodorsal nerve and the serratus branch of the thoracodorsal vessel were kept intact in all of the flaps to allow for functional muscle transfer and reliable vascular supply. The raw surfaces of the LD were covered with a split-thickness skin graft (Fig. 3). The donor area of the LD myocutaneous flaps was sutured primarily. Drains were inserted into the recipient and donor areas.
humeral bone stumps were left as long as possible (average 10.75 cm), and the deltoid muscle was kept intact as much as possible (average 77.08%) (Table 2 and Fig. 2). The pectoral muscle and shoulder muscles, such as the supraspinatus, infraspinatus teres minor, and teres major muscles, were minimally affected or not affected by the electrical current and were not debrided. The muscles with insertions in the inferior humeral region, such as the brachialis, biceps brachii,
All of the patients’ follow-up periods were 1–3 years (Fig. 4). Seroma formation was observed in two patients in the early
Fig. 2 – Trans-humeral amputation stump.
Fig. 3 – End of the operative procedure. The raw surface of the muscle was covered with a meshed skin graft.
4.
Results
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
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Fig. 4 – Patient on the 3rd day of hospitalization after a high-voltage electrical injury. Urgent fasciotomy was performed when the patient was admitted to the emergency room (upper left). Perioperative view of the same patient. The latissimus dorsi muscle and skin island were harvested (upper right). Twenty-four-month postoperative views. Note that the patient is able to move her arm in all directions (middle left, right, and lower left). Thirty-six-month postoperative anterior view of the patient with a static prosthesis (lower right). H: Humerus, LD: Latissimus dorsi muscle, DS: Dorsal skin.
postoperative period; these seromas were drained daily (Patients 2 and 8). Two patients had partial skin graft loss on the raw surface of the LD muscle, and repeat skin grafts were performed in these patients (Patients 10–11). One patient experienced suture dehiscence in the distal part of the stump, and the region was sutured after a prompt debridement (Patient 3). In one patient, a pressure ulcer was observed in the skin island of the LD flap due to prosthetic usage (Patient 5). This issue was solved by shortening the stump. We did not observe any total or partial loss of the
myocutaneous LD flaps. After completion of all the operations, all of the patients were directed to an exercise program in the physical therapy department. The results of the ROM measurements obtained one year after surgery are presented in Table 3, and changes or alterations from the normal ROM are presented in Fig. 5. Eight patients used an upper extremity prosthesis, while four patients chose not to use a prosthesis. However, these patients were able to move their stump during the follow-up period.
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
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Table 3 – Shoulder range of motion of the amputated arm (degrees).
Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient Patient
4.1.
Forward flexion
Extension
Abduction
External rotation
Internal rotation
175 160 170 140 175 165 140 155 175 165 175 180
50 55 30 45 35 50 30 35 40 45 45 35
150 145 135 125 145 140 150 115 155 150 140 155
55 50 65 60 50 70 50 55 70 70 60 55
60 60 65 55 60 65 50 55 60 55 60 60
1 2 3 4 5 6 7 8 9 10 11 12
Statistical analysis
The statistical analysis was performed using the SPSS statistical software package (Version 17.0, SPSS, Inc., Chicago, IL, USA). If continuous variables were normal, they were described as the means standard deviation (p > 0.05 in the Kolmogorov–Smirnov or Shapiro–Wilk test (n < 30)); if the continuous variables were not normal, they were described as the medians. The continuous variables were compared using a one-sample t test. Values of p < 0.05 were considered statistically significant.
5.
Discussion
High-voltage electrical injuries can cause serious damage to extremities and can result in amputations [1,8,9]. Tissue destruction of an extremity in patients exposed to an electrical burn is reduced in a distal-to-proximal direction [10,11]. During emergency resuscitation, compartment syndrome of a limb should be noted. After a physical examination, escharotomy or fasciotomy could be an extremity-salvaging or life-saving procedure [12]. Amputations may be required in third-degree full-thickness burns or in cases in which the extremity circulation cannot be achieved by fasciotomy [13]. Since our burn center is a unique advanced facility of this region; most of our cases included critical burn patients.
Fig. 5 – Graph of the normal and study group ROM measurements. As authors of this article, we confirm that we have no conflict of interest to declare.
Therefore overall amputation rate of our center is approximately 21.4% in high voltage electrical burns. Amputations can be made above (trans-humeral or shoulder disarticulation) or below the elbow, depending on the level of necrosis in the upper limb. It is difficult to predict which tissues will be affected and the extent of the involvement of an electrical burn. However, histological, Doppler, scintigraphic, and angiographic studies can support the assessment of tissue destruction. Close clinical follow-up and the performance of serial debridements are the most important evaluation guidelines [1,14]. The basic principle of burn surgeries, especially in cases of electrical burns, is to repair the defect with a vascularized flap after serial debridements [14–17]. The level of the amputation and the stump length are important for prosthesis fit and quality of life in amputees. Thus, a patient’s esthetic and functional satisfaction is better when the prosthesis is compatible with his/her body [2,3,18]. In our study, the amputation levels were maintained distal to the deltoid muscle insertion as often as possible to allow for motion of the trans-humeral amputated arm. The deltoid muscle is a major movement effector of the upper arm in almost all directions. Therefore, an amputation above the deltoid insertion is functionally considered to be a shoulder disarticulation [19]. A pedicled LD flap has been used in various reconstructive procedures since it was first described by Tansini in 1906 [7]. Reconstruction with the LD muscle is suitable for large, infected, and vascularly compromised areas because it has a large surface area and abundant vascularity. In our study, defects that included injured bone and soft tissue were covered with an ipsilateral pedicled LD myocutaneous flap. This flap provides a viable environment for all of the vital arm structures after their exposure. Sufficient soft tissue coverage is the most important factor for a good outcome in amputations, whereas limitation of the adjacent joint function may have a detrimental effect on the clinical results [20]. When the arm skin is sufficient for covering a trans-humeral stump, an LD myocutaneous flap with a skin graft could close the entire defect around the injured bone in a three-dimensional manner; as we described, this method does not negatively affect shoulder movements after a prompt debridement. Additionally, injured bone can heal well when it is covered with abundant muscle. Because the muscle tissue can
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
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potentiate osteogenesis, promoting the healing of semiviable bone segments [21]. In all of our cases, during the flap-harvesting procedure, a skin island was designed over the muscle to provide stiff tissue in the area in contact with the prosthesis and stump. Additionally, the LD muscle with a skin island covers the defect and provides increased soft tissue elongation to the stump without a secondary bone elongation procedure [21]. Bone stump lengthening can be achieved using the Ilizarow System. However, several problems have been encountered with the Ilizarow technique regarding the soft-tissue reconstruction and recovery time [22]. In our study, the muscle and skin located at the end of the bone stump facilitated stump lengthening without the need for a bone lengthening procedure after a trans-humeral amputation. In functional muscle transfer, proper orientation of the muscle assists with motor function of the transposed area [23]. The LD muscle can also be transferred with its motor nerve (thoracodorsal nerve) as a functional unit. This flap is more useful, especially in electrical burns, as it contributes to elbow function [6,24]. We used the LD muscle with its motor nerve to provide shoulder function in all of the patients. Thus, the functional transfer of the LD to the amputated arm contributes to the movement of the stump even in patients who cannot use a prosthesis. In the present study, the transferred LD did not pass over a joint between its origin and insertion. However, the end of the LD muscle was sutured to the remaining deltoid muscle. Thus, the LD muscle could assist with deltoid muscle movements as a continuation of deltoid muscle fibers, up to the intertubercular area. In this situation, the majority of arm movements could be considered to be dependent on viable deltoid muscle, some of which is associated with the transferred LD. ROM measurements after twelve months showed significant differences in forward flexion (p = 0.002) and internal and external rotation (p = 0.0001) (Table 4). The reduction in forward flexion may be a result of deltoid muscle damage. However, the mean ROM was calculated to be 164 degrees in our study, and this result was interpreted as clinically insignificant. Additionally, extension and abduction movements were almost within the normal range. In our study, there was no electrical damage or minimal electrical damage observed in the posterior and superior shoulder muscles. Thus, extension and abduction movements may not be affected or may be minimally affected. The reason for the statistically significant difference in internal and external rotations could be due to loss of the muscle that inserts into
the forearm in amputations. However, these results are only theoretical, and which muscle is a major movement effector of an amputated shoulder or how much strength is derived from the transferred LD muscle cannot be predicted. Because the vascular pedicle of the LD is further away from the injury site, it can safely be used in upper extremity electrical injuries. During harvesting, care was taken to avoid damaging the serratus branch of the thoracodorsal vessels in the case of thrombosis in the thoracodorsal pedicle. Because of this dual vascularity of the LD, we did not encounter any total or partial flap loss in our study. There may be sudden changes in the general condition of electrically burned patients. A free flap operation can be a prolonged procedure and can compromise the overall condition of the patient. For example, the free fibula flap procedure allows for maximal lengthening of a short humeral stump; however, the fibula must be covered by another flap, such as the LD flap. This option requires a complex procedure with a free flap associated with a pedicled or free flap covering [25]. We opted to perform a simpler operation instead of a free flap procedure in our patients. Therefore, the operative anesthesia-related risks and cardiovascular risks were reduced. Some of the major disadvantages of using an LD flap are the following: a long scar on the dorsum, possible seroma accumulation in the donor area, and loss of LD muscle on the ipsilateral side. Seroma accumulation in the donor area of the LD was noted in two cases in the early postoperative period (Patients 2 and 8). Both of the seromas disappeared within two weeks following daily aspirations and the applications of compressive dressings. In two patients (Patients 10 and 11), a partial loss of the split-thickness skin grafts that were used to cover the raw LD surface was encountered. One of these patients was treated with regrafting, and the graft in the other patient healed with secondary intention. Suture dehiscence in the donor area of the LD caused by skin stretching occurred in one patient (Patient 3). In this patient, resuturing was performed, and healing was uneventful. Neither stump shortening nor debridement was performed for any remaining necrosis of bone or muscle in the long term. However, in one of the eight patients who chose to use a prosthesis (Patient 5), a decubitus ulcer developed on the distal skin of the stump because of overcontact with the prosthesis. In that patient, ulcer debridement and bone shortening (1 cm) were performed. One limitation of this study is that we did not perform objective and subjective tests evaluating the overall satisfaction
Table 4 – Statistical analysis of ROM. Study group N Forward flexion Extension Abduction External rotation Internal rotation
12 12 12 12 12
Normal range of motion 180 45–60 150 90 90
Mean SD 164.5 13.5 41.2 8.3 142.1 12.1 59.2 7.9 58.7 4.3
Med (Min-Max) 167(140–180) 42(30–55) 145(115–155) 57(50–70) 60(50–65)
p 0.002 0.107 0.055 0.0001 0.0001
p: One-sample t-test. The bold numbers represent statistical significance.
Please cite this article in press as: Kesiktas E, et al. Reconstruction of transhumeral amputation stumps with ipsilateral pedicled latissimus dorsi myocutaneous flap in high voltage electrical burns. Burns (2014), http://dx.doi.org/10.1016/j.burns.2014.07.011
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with the prosthesis and functional abilities. Another limitation is that the patients included in the study had amputated extremities with no concomitant body injuries. A mechanical prosthesis was offered to all of the patients 12 weeks after the operations, as described in the literature [26]. However, only eight of the patients applied for a prosthesis; the other patients did not choose to use a prosthesis. Excess soft tissue in the distal stump is not required for prosthetic stability [19]. The LD muscle can be edematous and thick in the early postoperative period; however, this thickness decreases over time. Thus, a permanent prosthesis can be applied in the long term after using a temporary prosthesis.
6.
Conclusion
[8]
[9] [10]
[11]
[12]
[13] [14]
The use of an ipsilateral LD myocutaneous flap is an adequate surgical operation for upper extremity amputations caused by high-voltage electrical burn injuries. This method allows for the stump length to be maintained, contributes to arm functioning, avoids extended operation times, and prepares patients for prosthesis usage.
Conflict of interest As authors of this article, we confirm that we have no conflict of interest to declare.
[15] [16]
[17]
[18]
[19]
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