CC BY-NC-ND 4.0 · Indian J Plast Surg 2020; 53(02): 313-314
DOI: 10.1055/s-0040-1716441
Letter to the Editor

Modified Continuous Irrigation Suction System as A Tool in Limb Salvage with Impending Implant Exposure and Eschar

Rajan Ganapathy Bhagavathi
1  Department of Plastic Surgery, Apollo Cancer Speciality Hospitals, Teynampet, Chennai, India
,
Jijo Joseph
1  Department of Plastic Surgery, Apollo Cancer Speciality Hospitals, Teynampet, Chennai, India
,
Harikrishna Muram Reddy
1  Department of Plastic Surgery, Apollo Cancer Speciality Hospitals, Teynampet, Chennai, India
,
S. Raja Sabapathy
2  Division of Plastic Surgery, Hand Surgery, Reconstructive Microsurgery and Burns, Ganga Hospital, Coimbatore, India
,
Mayil Vahanan Natarajan
3  No. 4, Lakshmi Street, Kilpauk, Chennai, Tamil Nadu, India
,
Smriti Nathani
1  Department of Plastic Surgery, Apollo Cancer Speciality Hospitals, Teynampet, Chennai, India
› Author Affiliations
 

We report a successful limb salvage using a modified continuous irrigation system (CIS) to maintain an infection-free interval of 3 months for an exposed implant. Multiple attempts of primary cover had failed before the successful cover was achieved.

A 10-year-old girl with osteosarcoma of the left tibia, following neoadjuvant chemotherapy, underwent wide resection of osteosarcoma of the knee joint, tibia, ankle joint, and middle third of fibula. For limb salvage procedure, a titanium custom megaprosthesis (CMP) for the tibia, and soft-tissue cover with pedicled medial gastrosoleus muscle flap cover and skin closure were done. Unfortunately, the patient developed skin necrosis, causing exposure of the implant. ([Fig. 1a]). This was debrided and covered with a large microvascular (ALT) anterolateral thigh myocutaneous flap at the end of 3 weeks. A concurrent CIS system was applied based on stream flow (SF) theory, in that if the local environment of any wound is irrigated continuously and the excess drained off, the risk of infection can be mitigated significantly. Three days later, a 30 cm2 area of the distal end of the flap also became nonviable ([Fig. 1b]). This was debrided and covered with a superiorly based lateral malleolar flap after an interval delay. The business end of this, too, turned nonviable but was retained as a biological dressing ([Fig. 1c]).

Zoom Image
Fig. 1 (a) Marginal necrosis along suture line. (b) Venous congestion of distal end of anterolateral thigh (ALT) flap. Irrigation and suction tubes can be noted. (c) Eschar turned distal end of lateral supramalleolar flap. Irrigation, suction, and flushing tubes can be noted

The problem of frequent blockages of the 16G drain tube, due to the vacuum drying of the exudate particles in the setting of long duration of the CIS system, was solved by introducing a third (Flushing) 7 size tube into the mouth of the 16G (Suction) tube of the CIS system from a direction diagonally opposite, with a 3 cm lumen-to-lumen overlap and through a separate percutaneous incision ([Fig. 2]). This was based on the principle that a blocked drain tube cannot be unblocked by any further amount of suction pressure nor should it be flushed from outside for fear of introducing infection. This tube was flushed with 20 mL of saline every 48 hours under aseptic precautions.

Zoom Image
Fig. 2 Schematic diagram of modified continuous irrigation suction (CIS) system.

Finally, successful skin cover for the implant was achieved by a “cross-leg flap” executed in three stages of delay, transfer, and division for the residual defect ([Figs. 3a] [b]). The patient was discharged with the ability to ambulate with a walker frame and do partial weight-bearing in 3 months. During this protracted course, there was no obvious discharge from the wound and infection. Periodic wound cultures did not show any growth. We attribute this to the administration of the modified CIS system as an interim measure until flap cover was finalized. A similar concept has been used in managing abdominal abscess.[1]

Zoom Image
Fig. 3 (a) Cross-leg flap before inset. Note the defect exposing the implant. (b) Final appearance after division of cross-leg flap with the modified continuous irrigation suction (CIS) in situ.

It is our opinion that a wound environment can be maintained infection-free for a prolonged period by the inclusion of an interim modified CIS system in the treatment protocol, even in a scenario of an impending implant exposure or the presence of eschar in its vicinity. This study conforms to the Declaration of Helsinki.


#

Conflict of Interest

None declared.


Address for correspondence

Dr. G. B. Rajan M.S. (Gen.), DNB (Plastic Surgery), Senior Consultant
Department of Plastic Surgery
C Block, Second floor, Apollo Cancer Speciality Hospitals, Teynampet, Chennai-35
India   

Publication History

Publication Date:
29 August 2020 (online)

© .

Thieme Medical and Scientific Publishers Private Ltd.
A-12, Second Floor, Sector -2, NOIDA -201301, India


  
Zoom Image
Fig. 1 (a) Marginal necrosis along suture line. (b) Venous congestion of distal end of anterolateral thigh (ALT) flap. Irrigation and suction tubes can be noted. (c) Eschar turned distal end of lateral supramalleolar flap. Irrigation, suction, and flushing tubes can be noted
Zoom Image
Fig. 2 Schematic diagram of modified continuous irrigation suction (CIS) system.
Zoom Image
Fig. 3 (a) Cross-leg flap before inset. Note the defect exposing the implant. (b) Final appearance after division of cross-leg flap with the modified continuous irrigation suction (CIS) in situ.