November 6, 2023

“Limb reconstruction team” - who does what?

Written by Matija Krkovic

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Limb reconstruction team consist of multiple disciplines - orthopaedic surgeons, plastic surgeons, vascular surgeons, anaesthetist, infectious diseases specialists, frame nurse, physiotherapists and nursing staff.

In the initial phase, the main job of the orthopaedic and plastic surgeons is to ensure adequate debridement of the injury. Adequate debridement means that non-viable tissue is removed to prevent further complications, particularly infection. After the initial debridement is completed, a spanning external fixator is applied to the injured limb. The soft tissue wound gets covered by either a standard or VAC dressing. If required, the wound is looked at again in the next two to three days before the definitive soft tissue cover is completed and this should be within three to five days post injury.  This needs to happen in such a short period of time because the human body experiences changes after an injury and those changes will make soft tissues, particularly vessels, more fragile and more likely to fail when the soft tissue cover is attempted. In addition, if the soft tissues and bones are exposed to the environment for a longer period of time and not covered by healthy tissue they are at increased risk of infection.  

If the injury of the bone is less severe i.e. there are no bone defects or loose or missing bone, usually the bone fixation and soft tissue cover is performed in one sitting. In cases where there are bone defects, the soft tissue cover and fixation can be performed in one or two separate sessions. In our centre we perform soft tissue and fixation of fractures with bone defects in two separate sessions, around 4 to 6 weeks apart. In this scenario we allow optimal soft tissue and access for plastic surgeons to the injured limb. When the leg soft tissue cover is restored, and the tissue healed, a reconstruction of the bone can start. This allows for optimal fracture fixation and management.  

Plastic surgeons play a pivotal role in the whole process and without them the limb reconstruction methods we use these days would be almost impossible. On the other hand, vascular surgeons usually become involved early in the process, when there is either a suspected or confirmed vascular injury which can affect viability of the limb and potentially preclude limb reconstruction.

At around four to six weeks after the soft tissue cover, the bone reconstruction will start. At this point the orthopaedic surgeons will apply a fine wire frame to the leg to stabilise the bone and will perform corticotomy of the healthy bone to allow for new bone to grow. Corticotomy is when the fragments of bone are pulled apart using the Ilizarov method. Fine wireframe is applied under image intensifier control. Patients are then transferred to the ward where they start rehabilitation.

If there is any suspicion about infection, infectious diseases doctors get involved by administering relevant antibiotics and monitoring the patients throughout. The length of the antibiotic treatment is usually six weeks or more but can depend on the severity of the infection, bacteria causing the infection, condition of the patient and type of fixation.  

Postoperatively, limb reconstruction patients are approached by a physiotherapist on the same day or on the first day post after the procedure. The physiotherapist explains how the physiotherapy will help them through the recovery, including the weight bearing regime. Majority of the patients with fine wire frame are allowed to weight bear as tolerated. The time to weight bearing post operatively heavily depends on the type of the procedure done and the general fitness of the patient.  

A frame nurse will perform regular pin site checks, remove pin site dressings when required and prepare the prescription for correction of the deformity. A frame nurse will be also able to advise about any other problems which may arise after the operation. The nursing staff will advise patients and help them through the post operative days whilst on the ward.  

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