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Journal of Surgery & Transplantation Science

Cite this article: Daniel S, Arish A, Raymond K, Ryan E, Bradley K (2017) Retention Sternal Wires as a Salvage Closure Method for an Infected Tibial Wound after a Gunshot Injury, and a Local Muscle Flap Failure. J Surg Transplant Sci 5(3): 1057.

*Corresponding authorSchlatterer Daniel, Orthopedic Trauma, Atlanta Medical Center, Atlanta, Georgia, USA, Tel: 770-262-1927; Fax: 404-265-6992; Email:

Submitted: 07 August 2017

Accepted: 19 September 2017

Published: 21 September 2017

ISSN: 2379-0911

Copyright© 2017 Daniel et al.

OPEN ACCESS

Keywords•Gunshot•Tibia injury•Wound closure•Muscleflaps•Sternal wire closure method•Reconstruction ladder

Case Report

Retention Sternal Wires as a Salvage Closure Method for an Infected Tibial Wound after a Gunshot Injury, and a Local Muscle Flap FailureSchlatterer Daniel1*, Amersi Arish2, Kessler Raymond1, Eggers Ryan1, and Kessler Bradley1

1Orthopedic Trauma, Atlanta Medical Center, USA2Department of Chemistry, Georgia State University, USA

Abstract

Introduction: Gunshot injuries may present a myriad of surgical challenges in wound closure and soft tissue reconstruction. Due to a broad variation in soft tissue damage and the degree of remaining bony integrity, the treatment of gunshot injuries may only be carried out after a thorough examination of the wound and debridement of all devitalized tissue. The definitive management will vary by case. On occasion, a wound may remain after debridements or infection onset that requires a unique closure approach. Especially, when a previous muscle flap has failed, or the patient refuses additional muscle flaps.

Materials and method: A young male presented with an isolated GSW to his leg was treated initially with irrigations, debridements and an external fixator. A local soleus muscle flap with skin grafting achieved wound closure. In few weeks, a deep bony infection ensued. The resulting wound after infection debridement was closed with a series of sternal wires over rubber bolsters.

Results: Following 8 weeks of culture specific antibiotics, the wound healed and the infection resolved. The patient resumed unrestricted weight bearing activities.

Discussion: The soft tissue reconstructive ladder could benefit from an additional wound closure technique in complex situations such the case presented. Due to prior muscle flap complication, the patient’s preference for additional muscle flaps was understandably small.

Conclusion: This novel closure technique is simple to perform, with little expense to the patient. This method helped close an infected complex wound with a minimal biologic cost. Further work is required to define the limits and indications for this method.

be permissible, nor successful long term. Events and factors that prohibit successful wound closure include the onset of a deep bony infection, or when there is a severe loss of skin, or soft tissue damage such as muscle disruption, bone fractures, and nerve damage [3,20]. Therefore, these injuries require innovative techniques for soft tissue reconstruction, as well as extensive meticulous wound care. This case report presents a novel method of closing a complex leg wound.

The soft tissue reconstructive ladder begins with tension free primary closure when possible. The next option is delayed secondary intention closure utilizing a preferred serial dressing change protocol. More advanced wound closure methods continue with the use of free muscle flaps, local rotational muscle flaps, fasciocutaneous flaps, skin grafting and on occasion a cross leg flap [4]. These numerous options are by no means sufficient to close the myriad of gunshot wounds encountered more and more frequently in all hospital settings. One typical location and example of gunshot wounds beyond the scope of the classic reconstructive ladder are tibial gunshot wounds. These wounds

ABBREVIATIONS CDC: Centers for Disease Control and Prevention; OSH:

Outside Hospital; NPWT: Negative Pressure Wound Therapy; SWCM: Sternal Wire Closure Method; IMSCIS: Inflammatory Mediator Storm-Induced Soft-Tissue Compartment Syndrome; GSW: Gun Shot Wound

INTRODUCTIONThe rising prevalence of gunshot injuries in recent years

proportionately consumes many hospital resources and has provided more surgical challenges in wound closure. In 2014 the Centers for Disease Control and Prevention (CDC) reported a total of 33,599 deaths in the United States occurring as the result of injuries by firearm. Furthermore, 16.8% of all deaths in 2014 were related to firearm injuries [1]. Survivors of gunshots are often left with debilitating soft tissue and bony defects [2]. For example, large wounds from gunshot injuries to the lower extremity can result in sizable, and complex wounds whereby closure by any means along the reconstructive ladder may not

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are frequently complicated due to highly comminuted fracture patterns with added bone loss after the initial debridement and expansive soft tissue damage, or the delayed onset of a deep bony infection [5]. We present a case that had all of these components. The purpose of this case report is to illustrate an innovative alternative method of closing a large complex injury from a tibial gunshot wound through the usage of sternal wires, specifically to verify the effectiveness of using sternal wires in apposition of wound edges. This salvage method may find its place on a middle rung of the soft tissue reconstructive ladder. Unlike muscle flaps, this never before reported method has no morbidity to the patient, and does not prevent consideration of a muscle flap at a later stage of limb salvage if required.

CASE PRESENTATIONIn 2008, a 25-year-old male presented to an outside hospital

(OSH) with an accidental gunshot wound to his left lower extremity from a handgun. The patient was initially treated at the OSH with an aggressive debridement, irrigation, and placement of an external fixator and negative pressure wound therapy (NPWT) [6-19] (Figure 1). Three days later the patient was transferred to an experienced limb salvage surgeon (author-DRS) for definitive management. The most relevant detail in the patient’s past medical and surgical history was that he was an occasional smoker. The pertinent findings on physical examination at the receiving institution were extensive soft tissue damage to the mid anterolateral tibial region. The wound dimensions were 4cm width x 12 cm length and 5 cm deep open wound (Figure 1). The wound edges were retracted and non-mobile. Primary closure was not possible, only a muscle flap of some sort could fill this defect. The patient’s motor control and sensation were intact beyond the wound. His vascular exam revealed no significant damage in the left leg, foot, or ankle. The anterior medial and lateral tibial cortices were comminuted, and the posterior tibial cortex was relatively continuous (Figure 2).

Surgical closure method

Once the patient transferred to our institution, several discussions were had between the surgeon and the patient

regarding definitive treatment options including contingency plans, and the possibility of a below the knee amputation, if complications arose. On the second day of admission, the patient had a repeat irrigation and debridement of the left tibia fracture, wound exploration and NPWT application with a sponge greater than 50 cm2. On hospital day #5 (now post-injury day #7), a third operative procedure was completed including bony stabilization, which was performed prior to placing a left soleus rotational muscle flap to cover the open wound, with a meshed split thickness skin graft over the muscle flap, and NPWT over the entire wound. Bony stabilization started first with a removal of the external fixator from the left tibia, a repeat irrigation and debridement followed by placement of a statically locked tibial rod. All non-viable tissue was debrided previously and a favorable response in the wound bed to NPWT was noted, therefore the authors felt comfortable following the “fix and flap” protocol advocated first by Godina in 1986 and again by Gopal in 2000 [20-23]. Extremity re-prepping and re-draping were done after the I&D but before the rodding portion of the procedure. Postoperatively the patient returned to the surgical floor with the NPWT dressing to bolster the skin graft securely in place. Subsequently five days later, the NPWT dressing was removed bedside and only to discovery of a wound infection had caused partial break down of the skin graft. The next day in the operating room, the muscle flap and skin graft were removed along with the removal of the intramedullary nail for an in-depth and thorough sequential canal reaming and washout. Multiple soft tissue and bony samples were sent for culture analysis. At the conclusion of these steps, a wound remained slightly larger than the one upon presentation (Figure 1). The patient was a professional sprinter and opposed any additional muscle (local or free) flap procedures during preoperative discussions. The wound edges at this point could not be mobilized for a tension free closure, and not without suture breakage upon knotting. It was noted however the wound edges could be approximated proximally and distally but less so centrally in the wound using a series of towel clamps. It was decided by the surgical team to replace the metal towel clamps with 18-gauge sternal wires (Millennium Surgical Instruments Narberth, PA ) over rubber bolsters from a resorbable bone

Figure 1 These intra-operative images depict the wound after soleus flap removal, and the Sternal Wire Closure Method (SWCM), where wires were passed through a green rubber mold, six times along the length of the wound and sequentially twisted into a closed wound. Each hemostat is holding the tail ends of suture. The sutures were pulled taught and then the suture above and below was knotted. The twisted wire tails are left long and folded over to permit bedside retightening.

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Figure 2 The image on the left is after initial debridement and external fixation. The middle and right images are 8 month post-operative X-rays demonstrating successful bone remodeling, and union.

Figure 3 Clinical images that display a complete left leg soft tissue recovery with no signs of infections. The image on the far right is at 4 months post sternal wire removal.

cementing bead kit (Osteoset resorbable bead kit Wright Medical Memphis, Tennessee) to distribute the pressure imparted to the skin under the wires (Figure 1). Sternal wires were chosen due to their greater resistance to failure upon twist knotting, and with the hope, the smoothness of the material would be less prone to harbor residual bacteria than standard braided or knotted non-braided suture material [16-18,21]. The technique employed cutting a number of sternal wire segments of approximately 30cm in length. The wire was passed through the skin a distance of 1-2cm from the wound edge. From within the wound, the wire was advanced and pushed through and out the opposite side of the leg a similar distance from the far wound edge. At this point, the wire was pushed through one well of the rubber resorbable bone cement template. An intact template is approximately 5cm x 10cm and was green in color in recent years. Using scissors the bead template was cut into smaller pieces. Each piece had at least two bead wells side-by-side. Two intact templates held together are intended in this kit to make a mold for small antibiotic laden cement beads. Continuing with the surgical technique, once the wire was through one of the bead wells, it was gently bent and passed back out the other side of the rubber mold advancing

enough wire length to reach the other side of the wound edge where the wire first entered the wound. For its return path, the wire was now 1cm from the wound edge on either side. On the near side of the wound edge where the tails of the wire resided each wire tail was passed through a second rubber bolster. This was repeated a dozen times or so along the length of the wound (Figure 1). This was the most tedious part of our novel method requiring roughly 45 minutes to one hour of time. Once the entire wound had wire and rubber bolsters in place a gentle twisting motion of the wires removed all slack in the wire. This was done twice sequentially from proximal to distally along the wound, leading to a tension free closure of the wound. Non-braided suture was used to approximate any minor wound edge gaps remaining (Figure 1). We repeated the wire twisting bedside once to reinforce the closure with no discomfort to the patient. There were no complications from the technique. Postoperative care included serial non-adherent dressing changes, a long leg splint which was exchanged for a short leg cast at the two week postoperative office visit and 8 weeks of culture specific intravenous antibiotics. The patient fully recovered without any further surgical interventions and bone remodeling was noted

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on the radiographs (Figure 2). At a recent two-year follow-up visit, the patient had returned to professional sprinting, he had no complaints in his left leg, no signs of infection (Figure 3), and he was discharged to return as needed.

DISCUSSIONThe primary advantage of the sternal wire closure method

(SWCM) described is that it was completely successful with no biologic cost to the patient. With this method, the dead space was managed, culture specific IV antibiotics were administered for 8 weeks and in the end the infection was eradicated, the bone healed and the patient returned to his professional sprinting occupation. If this method were to fail other options were not eliminated by this approach such as bone transport, or even a free muscle flap if the patient is so inclined if and when the time arose [4,6]. The limits of this technique in terms of wound dimensions, based upon this one case, appear similar to the most muscle flaps for this leg region, except that for the fact that the location does not limit the SWCM in the leg. Historically a local gastrocnemius flap was for proximal 1/3 leg defects, and the local soleus flap provided coverage for middle 1/3 leg defects [7]. This SWC overlapped both leg regions with great success. Nonetheless, the limits and potential complications of SWCM require a larger cohort.

The method presented is not entirely new. Retention suture techniques have been reported in a variety of general surgery and obstetric situations for the distended abdomen [8,19]. This is a novel application for an orthopaedic wound and novel employment of surgical wire over a bolster system. Attempts were made to use monofilament suture but they kept breaking so we turned to wire. An Ethibond or fiberwire suture over bolsters may have worked equally as well. Future studies can include this variable.

The primary challenges in this case in addition to the fracture and infection were the inability to close the wound after debridement. Wound closure requires a very systematic approach depending on the complexity of the injury. The soft tissue reconstructive ladder at its highest level involves technically challenging muscle flap procedures. A study done in Brazil regarding the use of muscle flaps to treat open bone exposure found an approximate of 92.5 % approval rate and a total of 7.5% regular and or unsatisfactory outcome [8]. The morbidity of muscle flap procedures also warrants innovation for less complicated methods of wound closure with similar rates of wound closure success compared to traditional methods. Thus, in a limb salvage practice, it is important to consider the physiology and anatomy of each wound [4]. All wounds are unique and not solely defined by their wound dimensions. The functional goals of the patient must also be given full consideration as should the patient’s education level, family support system and other hard to measure metrics such as psychological distress [9]. The goal of limb salvage should include both minimizing any threat it may soon impact the patient’s life due to infection, blood loss or other pathophysiologic cascades [10,20]. Every plan for limb salvage begins with an aggressive and thorough debridement and irrigation, and liberal use of NPWT to avoid the inflammatory mediator storm-induced soft-tissue compartment

syndrome (IMSICS) described by Webb [11]. This critical first step ensures containment of the zone of injury and theoretically prevents additional tissue necrosis and infection risk. The initial debridements may not have aggressive enough which in addition to technical errors with the Soleus muscle flap may have been the contributing factors to the ensuing deep infection early on.

Sometimes the most thorough debridements come at a cost to preserving the soft tissue envelope in their attempt to remove all residual contamination and/or devitalized tissue to prevent the IMSICS [11]. In the future, more traumatic wounds may receive the best possible initial I&D if the salvage team had simple wound closure methods in their minds as the debridement commenced as a bailout if the wound became more complex as a direct result of the I&D. The case presented herein is meant to advocate for further research in understanding, preventing, and managing the IMSICS pathway and to seek less complicated wound closure methods in the hope that initial debridement’s are aggressive enough to improve GSW complications and limb salvage rates of all etiologies.

One issue in the case presented is the onset of the infection despite the aggressive serial debridement and irrigations being performed, and that these measures including “fixing with an intramedullary device and flapping” were within the often recommended 7-day window, a deep bony infection still ensued [12]. This is precisely the point of this report. Muscle flaps are and will continue to be the workhorse of limb salvage, but they are not infallible. Arguably there may have been an error in the technical performance of the soleus rotational flap procedure. It was not inset with any tension, possibly the infectious agent (Staph Aureus in this patient) had taken refuge in local osteoblasts only to re-emerge at a later date [13,21-23]. Unlike the soft tissue reconstructive ladder for complex wounds, there is no clear-cut algorithm for the treatment of gunshot injuries [14]. A plan of treatment must be carried out after a careful investigation of the wound deficits and employing treatments varying by each case, and surgeon experience.

CONCLUSIONThe case presented using an SWCM to salvage a leg ravished

with an infection after a gunshot injury was completely successful with no biologic cost to the patient. Complex traumatic orthopedic wound management can be summarized as having three critical steps. The first is the I&D to avoid the IMSICS. Second, the limb salvage should be approached with a team experienced with innovative wound closure techniques as presented herein and for example with the recently described gradual muscle expansion flap technique [15]. As the understanding of wound pathophysiology improves and the limb salvage interventions simplify, hopefully the outcomes will improve as well. Finally, the authors acknowledge that this is a single case report and that wound size, location, and dimensional limits require much further study.

ACKNOWLEDGEMENTSThe authors wish to acknowledge Bruce Ziran, M.D. for his

vast experience with infections and for his suggestion to try this technique.

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Daniel S, Arish A, Raymond K, Ryan E, Bradley K (2017) Retention Sternal Wires as a Salvage Closure Method for an Infected Tibial Wound after a Gunshot Injury, and a Local Muscle Flap Failure. J Surg Transplant Sci 5(3): 1057.

Cite this article

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