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Rekonstruktion der unteren Extremität im Alter – ein interdisziplinärer Ansatz

Unfallchirurgische, gefäßchirurgische und plastisch-chirurgische Strategien

Reconstruction of lower limbs in old age—an interdisciplinary approach

Strategies for trauma surgery, vascular surgery and plastic surgery

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Zusammenfassung

Die Behandlung komplexer Verletzungen der unteren Extremität bei geriatrischen und/oder multimorbiden Patienten erfordert zusätzlich zu einem optimierten prä- und perioperativen Management auch eine differenzierte interdisziplinäre chirurgische Herangehensweise. Eine frühzeitige definitive Versorgung sollte zur Vermeidung längerer Immobilisierungsphasen angestrebt werden. Nach einer ggf. erforderlichen vorübergehenden Stabilisierung im Fixateur externe sollte eine primär belastungsstabile Osteosynthese mit internen Verfahren durchgeführt werden. Bei Weichteildefekten sollte nach dem Wunddébridement eine stabile Defektrekonstruktion unter Einsatz aller verfügbaren plastisch-chirurgischen Techniken bis hin zu mikrovaskulären Lappenplastiken das Ziel sein. Im Kontext angestrengter und perfusionskompromittierter Weichteilverhältnisse kann ein temporärer Verschluss mittels Unterdruckverbänden einen sterilen Wundverschluss bis zur definitiven Defektrekonstruktion ermöglichen. Eine Abklärung des Gefäßstatus bei geriatrischen Patienten ist unabdingbar und relevante Perfusionsstörungen sollten vor komplexen rekonstruktiven Eingriffen entweder interventionell oder offen-chirurgisch konsequent therapiert werden. Dabei ist eine enge interdisziplinäre Koordination der verschiedenen chirurgischen Eingriffe zwingend erforderlich, um eine stabile Rekonstruktion mit vertretbaren Risiken in enger zeitlicher Abfolge sicherzustellen. Unter Berücksichtigung der in diesem Artikel dargestellten Prinzipien ist die Rekonstruktion komplex traumatisierter Extremitäten auch bei geriatrischen Patienten in Zentren mit entsprechender interdisziplinärer Expertise mit exzellenten funktionellen Ergebnissen durchführbar.

Abstract

The treatment of complex injuries of the lower extremities in geriatric and/or multimorbid patients requires optimized preoperative and perioperative management as well as differentiated and interdisciplinary surgical approaches. Timely and definitive treatment should be strived for to avoid longer periods of immobilization. Temporary external stabilization of complex fractures, when necessary, should be followed by permanent loading stable internal osteosynthesis as soon as possible. Accompanying soft tissue defects are reconstructed after wound débridement using the full armamentarium of plastic and reconstructive surgical procedures, including microvascular free flap. In the context of perfusion compromised soft tissue situations, negative pressure wound therapy can provide sterile temporary defect coverage and aid in preconditioning poorly vascularized tissue before definitive reconstruction. A clarification of the vascular status in geriatric patients is paramount and relevant perfusion disorders should be treated either by intervention or open surgery before complex reconstructive interventions. Close interdisciplinary coordination of the various surgical procedures is imperative in order to guarantee an optimized stable reconstructive outcome with acceptable patient risk. Taking these principles into account, the reconstruction of complex trauma to the extremities can be carried out even in geriatric or multimorbid patients in specialized interdisciplinary surgical centers with excellent functional results.

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Literatur

  1. Ravikumar KJ et al (2000) Internal fixation versus heimarthroplasty versus total hip arthroplasty for displaced subkapital fractures of femur—13 year results of a randomised study. Injury 31:793–797

    Article  CAS  PubMed  Google Scholar 

  2. Bliemel C et al (2014) Treatment standards for proximal femoral fractures in the elderly. Osteologie 1:22–28

    Google Scholar 

  3. Zwipp H, Amlang M (2014) Treatment of fractures of the ankle in the elderly. Orthopade 43:332–338

    Article  CAS  PubMed  Google Scholar 

  4. Rammelt S, Heim D, Hofbauer C, Grass R, Zwipp H (2011) Problems and controversies in the treatment of ankle fractures. Unfallchirurg 114:847–860

    Article  CAS  PubMed  Google Scholar 

  5. Kannus P, Palvanen M, Niemi S, Parkkari J, Jarvinen M (2002) Increasing number and incidence of low-trauma ankle fractures in elderly people: Finnish statistics during 1970–2000 and projections for the future. Bone 31:430–433

    Article  CAS  PubMed  Google Scholar 

  6. Donken CC, Al-Khateeb H, Verhofstad MH et al (2012) Surgical versus conserva tive interventions for treating ankle fractures in adults. Cochrane Database Syst Rev (8):CD008470. https://doi.org/10.1002/14651858.CD008470.pub2

    Article  PubMed  Google Scholar 

  7. Neumann M et al (2016) Complications after surgical management of distal lower leg fractures. Scand J Trauma Resusc Emerg Med 24:146

    Article  PubMed  PubMed Central  Google Scholar 

  8. Ludolph I, Lehnhardt M, Arkudas A, Kneser U, Pierer G, Harder Y, Horch RE (2017) Plastisch rekonstruktive Mikrochirurgie beim alten Patienten. Handchirurgie – Mikrochirurgie – Plastische Chirurgie 50(02):118–125

    Google Scholar 

  9. Reddy V, Stevenson TR (2008) Lower extremity reconstruction. Plast Reconstr Surg 121(S):1–7

    Article  PubMed  Google Scholar 

  10. Engel H, Hirche C, Lehnhardt M, Wei F‑C, Daigeler A, Gazyakan E (2013) Aspekte der mikrochirurgischen Rekonstruktion an der unteren Extremität. Handchirurgie – Mikrochirurgie – Plastische Chirurgie 45(02):59–66

    Article  CAS  Google Scholar 

  11. Daigeler A, Kneser U, Fansa H, Riester T, Uder M, Horch R (2014) Rekonstruktion der vaskulär kompromittierten unteren Extremität. Handchirurgie – Mikrochirurgie – Plastische Chirurgie 46(04):248–255

    Article  CAS  Google Scholar 

  12. Steiert et al (2009) Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy—worse or worth? J Plast Reconstr Aesthet Surg 62(5):675–683

    Article  PubMed  Google Scholar 

  13. Liu DS et al (2012) Early soft tissue coverage and negative pressure wound therapy optimises patient outcomes in lower limb trauma. Injury 43(6):772–778

    Article  PubMed  Google Scholar 

  14. Heymans O, Verhelle N (2004) Local and regional flaps. In: Téot L, Banwell PE, Ziegler UE (Hrsg) Surgery in Wounds. Springer, Berlin, Heidelberg

    Google Scholar 

  15. Wong C‑H, Tan B‑K (2007) Perforator-sparing transposition flaps for lower limb defects. Ann Plast Surg 58(6):614–621

    Article  CAS  PubMed  Google Scholar 

  16. Schmidt V, Kneser U (2019) Regionale Weichteilrekonstruktion an der unteren Extremität. Z Orthop Unfall 157(01):95–108

    Article  PubMed  Google Scholar 

  17. Gravvanis A (2014) Flap reconstruction of the knee: a review of current concepts and a proposed algorithm. World J Orthop 5(5):603

    Article  PubMed  PubMed Central  Google Scholar 

  18. Pu LLQ (2006) Soft-tissue coverage of an open tibial wound in the junction of the middle and distal thirds of the leg with the medial Hemisoleus muscle flap. Ann Plast Surg 56(6):639–643

    Article  CAS  PubMed  Google Scholar 

  19. Kneser U, Bach AD, Polykandriotis E et al (2005) Delayed reverse sural flap for staged reconstruction of the foot and lower leg. Plast Reconstr Surg 116:1910–1917

    Article  CAS  PubMed  Google Scholar 

  20. Bach AD, Leffler M, Kneser U et al (2007) The versatility of the distally based peroneus brevis muscle flap in reconstructive surgery of the foot and lower leg. Ann Plast Surg 58:397–404

    Article  CAS  PubMed  Google Scholar 

  21. Kneser U, Brockmann S, Leffler M et al (2011) Comparison between distally based peroneus brevis and sural flaps for reconstruction of foot, ankle and distal lower leg: an analysis of donor-site morbidity and clinical outcome. J Plast Reconstr Aesthet Surg 64:656–626

    Article  PubMed  Google Scholar 

  22. Jakubietz RG, Jakubietz MG, Gruenert JG et al (2007) The 180-degree perforator-based propeller flap for soft tissue coverage of the lower extremity: a new method to achieve reliable coverage of the distal lower extremity with a local, fasciocutaneous peforator flap. Ann Plast Surg 59:667–671

    Article  CAS  PubMed  Google Scholar 

  23. Lo CH, Leung M, Baillieu C, Chong EWT, Cleland H (2007) Trauma centre experience: flap reconstruction of traumatic lower limb injuries. ANZ J Surg 77(8):690–694

    Article  PubMed  Google Scholar 

  24. Small JO, Mollan RA (1992) Management of the soft tissues in open tibial fractures. Br J Plast Surg 45(8):571–577

    Article  CAS  PubMed  Google Scholar 

  25. Wong AK, Nguyen TJ, Peric M, Shahabi A, Vidar EN et al (2015) Analysis of risk factors associated with microvascular free flap failure using a multi-institutional database. Microsurgery 35(1):6–12

    Article  PubMed  Google Scholar 

  26. Xiong L, Gazyakan E, Kremer T, Hernekamp FJ, Harhaus L et al (2016) Free flaps for reconstruction of soft tissue defects in lower extremity: a meta-analysis on microsurgical outcome and safety. Microsurgery 36(6):511–524

    Article  PubMed  Google Scholar 

  27. Verhelle N, Preud’homme L, Dequanter D, den Hof B, Heymans O, Vico P (2005) Free flaps in the elderly population. Eur J Plast Surg 28(3):149–151

    Article  Google Scholar 

  28. Coskunfirat OK, Chen H, Spanio S, Tang Y (2005) The safety of Microvascular free tissue transfer in the elderly population. Plast Reconstr Surg 115(3):771–775

    Article  CAS  PubMed  Google Scholar 

  29. Knobloch K, Herold C, Vogt PM (2012) Freier Latissimus-dorsi-Transfer zur Rekonstruktion von Weichteildefekten der unteren Extremität. Oper Orthop Traumatol 24(2):122–130

    Article  CAS  PubMed  Google Scholar 

  30. Cho EH, Shammas RL, Carney MJ, Weissler JM, Bauder AR, Glener AD, Levin LS (2018) Muscle versus Fasciocutaneous free flaps in lower extremity traumatic reconstruction. Plast Reconstr Surg 141(1):191–199

    Article  CAS  PubMed  Google Scholar 

  31. Dayan JH, Lin C‑H, Wei FC (2009) The versatility of the Anterolateral thigh flap in lower extremity reconstruction. Handchirurgie – Mikrochirurgie – Plastische Chirurgie 41(04):193–202

    Article  CAS  Google Scholar 

  32. Thomas B, Gazyakan E, Falkner F, Schmidt VJ, Hirche C, Kneser U, Bigdeli AK (2019) Free tissue transfer with the free Rectus Abdominis flap in high-risk patients above 65 years—A retrospective cohort study. J Plast Reconstr Aesthet Surg 72(4):555–564. https://doi.org/10.1016/j.bjps.2019.01.005

    Article  PubMed  Google Scholar 

  33. Henn D, Wähmann MST, Horsch M, Hetjens S, Kremer T, Gazyakan E, Kneser U (2018) One stage versus two-stage arteriovenous loop reconstructions—An experience on 103 cases from a single center. Plast Reconstr Surg 143(3):912–924. https://doi.org/10.1097/PRS.0000000000005386

    Article  CAS  Google Scholar 

  34. Henn D, Bigdeli AK, Horsch M et al (2019) Venous bypass grafts versus arteriovenous loops as recipient vessels for microvascular anastomosis in lower extremity reconstructions: a matched-pair analysis. Microsurgery. https://doi.org/10.1002/micr.30428

    Article  PubMed  Google Scholar 

  35. Eichhorn W, Haase M, Kluwe L, Zeuch J, Smeets R, Hanken H, Rendenbach C (2015) Increased postoperative bleeding risk among patients with local flap surgery under continued Clopidogrel therapy. Biomed Res Int 2015:120903. https://doi.org/10.1155/2015/120903

    Article  PubMed  PubMed Central  Google Scholar 

  36. Riml S, Wallner H, Kompatscher P (2015) Friend or foe? Discussion about dual platelet inhibition as a salvage procedure from imminent flap failure. Plast Reconstr Surg 131(1):121e–123e

    Article  CAS  Google Scholar 

  37. Kearns MC, Baker J, Myers S, Ghanem A (2018) Towards standardization of training and practice of reconstructive microsurgery: an evidence-based recommendation for anastomosis thrombosis prophylaxis. Eur J Plast Surg 4(14):379–386

    Article  Google Scholar 

  38. DeFazio M, Economides J, Anghel E, Tefera E, Evans K (2018) Lower extremity free tissue transfer in the setting of Thrombophilia: analysis of Perioperative Anticoagulation protocols and predictors of flap failure. J Reconstr Microsurg 35(4):270–286. https://doi.org/10.1055/s-0038-1675145

    Article  PubMed  Google Scholar 

  39. Roy M, Patel A, Haykal S (2018) Meta-analysis of timing for microsurgical free-flap reconstruction for lower limb injury: evaluation of the Godina principles. J Reconstr Microsurg 34(4):277–292

    Article  PubMed  Google Scholar 

  40. Bradbury AW, Adam DJ, Bell J et al (2010) Bypass versus Angioplasty in severe Ischaemia of the leg (BASIL) trial: an intention-to-treat analysis of amputation-free and overall survival in patients randomized to a bypass surgery-first or a balloon angioplasty-first revascularization strategy. J Vasc Surg 51:5–17

    Article  Google Scholar 

  41. S3-Leitlinie. Zur Diagnostik, Therapie und Nachsorge der Peripheren Arteriellen Verschlusskrankheit http://www.awmf-online.de/ bzw. http://leitlinien.net zugänglich.

  42. Balzer JO et al (2010) Angioplasty of the pelvic and femoral arteries in PAOD: results and review of the literature. Eur J Radiol 75(1):48–56

    Article  PubMed  Google Scholar 

  43. Jongkind V et al (2010) A systematic review of endovascular treatment of extensive aortoiliac occlusive disease. J Vasc Surg 52(5):1376–1383

    Article  PubMed  Google Scholar 

  44. Soder HK, Manninen HI, Jaakkola P et al (2000) Prospective trial of infrapopliteal artery balloon angioplasty for critical limb ischemia: angiographic and clinical results. J Vasc Interv Radiol 11:1021–1031

    Article  CAS  PubMed  Google Scholar 

  45. Twine CP, Mc Lain AD (2010) Graft type for femoro-popliteal bypass surgery. Cochrane Database Syst Rev 5:CD1487

    Google Scholar 

  46. van der Feen C, Neijens FS, Kanters SD, Mali WP, Stolk RP, Banga JD (2002) Angiographic distribution of lower extremity atherosclerosis in patients with and without diabetes. Diabet Med 19:366–370

    Article  PubMed  Google Scholar 

  47. Diehm N, Shang A, Silvestro A et al (2006) Association of cardiovascular risk factors with pattern of lower limb atherosclerosis in 2659 patients undergoing angioplasty. Eur J Vasc Endovasc Surg 31:59–63

    Article  CAS  PubMed  Google Scholar 

  48. Conrad MF et al (2009) Infrapopliteal balloon angioplasty for the treatment of chronic occlusive disease. J Vasc Surg 50(4):799–805

    Article  PubMed  Google Scholar 

  49. Kneser U, Arkudas A, Beier JP, Dragu A, Stübinger A, Lang W, Horch RE (2013) Extended skin and soft tissue defects after vascular wounds: plastic surgical concepts. Zentralbl Chir 138(5):536–554

    Article  CAS  PubMed  Google Scholar 

  50. Bergman BA, Zamboni WA, Brown RE (1992) Microvascular anastomosis of a rectus abdominis free flap into a prosthetic vascular bypass graft. J Reconstr Microsurg 8:9–12

    Article  CAS  PubMed  Google Scholar 

  51. Kasabian AK, Glat PM, Eidelman Y et al (1995) Limb salvage with microvascular free flap reconstruction using simultaneous polytetrafluoroethylene graft for inflow. Ann Plast Surg 35:310–315

    Article  CAS  PubMed  Google Scholar 

  52. Engel H, Pelzer M, Sauerbier M, Germann G, Heitmann C (2007) An innovative treatment concept for free flap reconstruction of complex central chest wall defects—the cephalic-thoraco-acromial (CTA) loop. Microsurgery 27(5):481–486

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Klinik für Unfallchirurgie und Orthopädie, Sektion für Septische Chirurgie, BG Unfallklinik Ludwigshafen, Ludwig-Guttmann-Str. 13, Ludwigshafen, Deutschland

    G. Reiter, F. Weil & P. A. Grützner

  2. Klinik für Hand‑, Plastische und Rekonstruktive Chirurgie, – Schwerbrandverletztenzentrum –, BG Unfallklinik Ludwigshafen, Ludwigshafen, Deutschland

    B. Thomas, G. Hundeshagen & U. Kneser

  3. Klinik für Plastische und Handchirurgie, Ruprecht-Karls-Universität Heidelberg, Heidelberg, Deutschland

    B. Thomas, G. Hundeshagen & U. Kneser

  4. Klinik für Gefäßchirurgie, Klinikum der Stadt Ludwigshafen, Ludwigshafen, Deutschland

    C. Kühner & S. Kloos

  5. Klinik für Anästhesie, Intensivmedizin und Schmerztherapie, BG Unfallklinik Ludwigshafen, Ludwigshafen, Deutschland

    G. Wittenberg

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  1. G. Reiter
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Interessenkonflikt

G. Reiter, B. Thomas, C. Kühner, G. Hundeshagen, F. Weil, G. Wittenberg, S. Kloos, P. A. Grützner und U. Kneser geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Reiter, G., Thomas, B., Kühner, C. et al. Rekonstruktion der unteren Extremität im Alter – ein interdisziplinärer Ansatz. Chirurg 90, 806–815 (2019). https://doi.org/10.1007/s00104-019-01023-7

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