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Treatment of hardware exposure after severe infections in spine surgery with pedicled muscular flaps.

Cho AB, Rodrigues LM, Nicolau RJ, Rugiero GM, Fukushima WY, Milani C - Clinics (Sao Paulo) (2008)

View Article: PubMed Central - PubMed

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In this situation, the pedicled latissimus dorsi and trapezius muscle flaps have proven to be the most reliable methods of treatment. – We present our experience in the management of these more complex wounds with hardware exposure in two patients, where we used combined pedicled flaps... A 48 –year-old man presented with severe pain in the thoracolumbar area that did not respond to conservative therapy... He was submitted to decompression and fusion from T5 to T9 with pedicled screw fixation... The motor deficit was significantly improved and the patient partially recovered his ability to walk... From May 2006 to May 2007, we performed three latissimus dorsi flaps and one partial trapezius flap in two patients... They were both dissected on the left side of the patient and performed simultaneously to cover a small thoracic and large lumbar defect... All flaps survived without major complications, and the spine defects were successfully covered with hardware preservation... Likewise, in our initial experience, the pedicled latissimus dorsi and trapezius flaps proved to be reliable tools for the treatment of severe back wound infections with exposed hardware... They illustrated the arc of rotation of the flaps when they were used in both turnover and rotation/ advancement fashions... Although there is frequent mention of the pedicled latissimus dorsi flap by other authors in a larger series of patients, they did not address its application as a musculocutaneous flap. – We found that the possibility of taking a transverse skin island over a laterally based latissimus dorsi flap was significantly advantageous because it allowed primary closure of the back wound without necessitating a skin graft... It is important to remember that some defects located within the middle and high thoracic levels could be managed with either the trapezius or latissimus dorsi flaps... The pedicled latissimus dorsi flap proved to be a valuable and reliable tool to treat large and deep back wound infections with hardware exposure... It can be used as a musculocutaneous advancement or rotation flap, when laterally based (thoracodorsal vessels), or as a muscular turnover flap, when medially based (paraspinous perforators)... This versatility enabled the latissimus dorsi flap arc of rotation to reach midline spine defects from high thoracic through lower lumbar levels.

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Final aspect of the healed wound after rotation of the right latissimus dorsi musculocutaneous flap
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f5-cln63_2p0277: Final aspect of the healed wound after rotation of the right latissimus dorsi musculocutaneous flap

Mentions: A 48 –year-old man presented with severe pain in the thoracolumbar area that did not respond to conservative therapy. During the initial investigation, an advanced multiple myeloma was diagnosed. The patient underwent chemotherapy, but the tumor grew fast, causing instability at the thoracic level and motor deficits. He was submitted to decompression and fusion from T5 to T9 with pedicled screw fixation. The motor deficit was significantly improved and the patient partially recovered his ability to walk. However, there was an early dehiscence of the incision with infection that was not responsive to conventional treatment with serial wound debridements, antibiotic treatment, and hyperbaric oxygen therapy. At the end of the third month of hospitalization, the wound was very wide and deep, exposing the instrumentation and the vertebral bodies (Figure 1). The patient underwent a left latissimus dorsi pedicled flap with a large transverse skin paddle (Figure 2). The flap was laterally based through the thoracodorsal vessels. The muscle was used to fill the cavity while the skin paddle was primarily used to close the wound. However, in the early postoperative period, the distal extremity of the flap developed a moderate congestion with retraction and partial necrosis of the muscle and skin (Figure 3). This resulted in recurrence of the dehiscence and infection re-exposing about 20% of the instrumentation (Figure 4). Two weeks later, after proper wound debridement, the right latissimus dorsi was rotated. At this time, the skin island was drawn more proximally over the muscle to improve its vascularization. With this second flap, the wound was completely covered and filled, and the infection was resolved (Figure 5).


Treatment of hardware exposure after severe infections in spine surgery with pedicled muscular flaps.

Cho AB, Rodrigues LM, Nicolau RJ, Rugiero GM, Fukushima WY, Milani C - Clinics (Sao Paulo) (2008)

Final aspect of the healed wound after rotation of the right latissimus dorsi musculocutaneous flap
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC2664215&req=5

f5-cln63_2p0277: Final aspect of the healed wound after rotation of the right latissimus dorsi musculocutaneous flap
Mentions: A 48 –year-old man presented with severe pain in the thoracolumbar area that did not respond to conservative therapy. During the initial investigation, an advanced multiple myeloma was diagnosed. The patient underwent chemotherapy, but the tumor grew fast, causing instability at the thoracic level and motor deficits. He was submitted to decompression and fusion from T5 to T9 with pedicled screw fixation. The motor deficit was significantly improved and the patient partially recovered his ability to walk. However, there was an early dehiscence of the incision with infection that was not responsive to conventional treatment with serial wound debridements, antibiotic treatment, and hyperbaric oxygen therapy. At the end of the third month of hospitalization, the wound was very wide and deep, exposing the instrumentation and the vertebral bodies (Figure 1). The patient underwent a left latissimus dorsi pedicled flap with a large transverse skin paddle (Figure 2). The flap was laterally based through the thoracodorsal vessels. The muscle was used to fill the cavity while the skin paddle was primarily used to close the wound. However, in the early postoperative period, the distal extremity of the flap developed a moderate congestion with retraction and partial necrosis of the muscle and skin (Figure 3). This resulted in recurrence of the dehiscence and infection re-exposing about 20% of the instrumentation (Figure 4). Two weeks later, after proper wound debridement, the right latissimus dorsi was rotated. At this time, the skin island was drawn more proximally over the muscle to improve its vascularization. With this second flap, the wound was completely covered and filled, and the infection was resolved (Figure 5).

View Article: PubMed Central - PubMed

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

In this situation, the pedicled latissimus dorsi and trapezius muscle flaps have proven to be the most reliable methods of treatment. – We present our experience in the management of these more complex wounds with hardware exposure in two patients, where we used combined pedicled flaps... A 48 –year-old man presented with severe pain in the thoracolumbar area that did not respond to conservative therapy... He was submitted to decompression and fusion from T5 to T9 with pedicled screw fixation... The motor deficit was significantly improved and the patient partially recovered his ability to walk... From May 2006 to May 2007, we performed three latissimus dorsi flaps and one partial trapezius flap in two patients... They were both dissected on the left side of the patient and performed simultaneously to cover a small thoracic and large lumbar defect... All flaps survived without major complications, and the spine defects were successfully covered with hardware preservation... Likewise, in our initial experience, the pedicled latissimus dorsi and trapezius flaps proved to be reliable tools for the treatment of severe back wound infections with exposed hardware... They illustrated the arc of rotation of the flaps when they were used in both turnover and rotation/ advancement fashions... Although there is frequent mention of the pedicled latissimus dorsi flap by other authors in a larger series of patients, they did not address its application as a musculocutaneous flap. – We found that the possibility of taking a transverse skin island over a laterally based latissimus dorsi flap was significantly advantageous because it allowed primary closure of the back wound without necessitating a skin graft... It is important to remember that some defects located within the middle and high thoracic levels could be managed with either the trapezius or latissimus dorsi flaps... The pedicled latissimus dorsi flap proved to be a valuable and reliable tool to treat large and deep back wound infections with hardware exposure... It can be used as a musculocutaneous advancement or rotation flap, when laterally based (thoracodorsal vessels), or as a muscular turnover flap, when medially based (paraspinous perforators)... This versatility enabled the latissimus dorsi flap arc of rotation to reach midline spine defects from high thoracic through lower lumbar levels.

Show MeSH