The Efficacy of Modified Ilizarov Distraction-Tension Device on Limb Wound Difficult to Cover with Skin Flaps

Abstract

Introduction: Closure of complex limb wounds poses challenges and requires innovative approaches. This research aimed to evaluate the effectiveness of a modified distraction-tension device using Ilizarov external fixation for wound closure in challenging cases.

Methods: A retrospective analysis was conducted on 43 patients with extremity wounds that were difficult to cover with skin flaps between January 2019 and December 2022. Tension-relieving traction was applied using the Ilizarovexternal fixator apparatus, tailored to individual wound characteristics. Three types of wire–pin connections were used in this study. The distraction begins on the third postoperative day, with a speed of 0.5mm/d. Clinical wound healing scores were evaluated at 5 and 30 days postoperatively. Complications were documented following the Paley classification system.

Results: Traction using modified Ilizarovexternal fixation promoted a significant reduction in wound size. The mean traction period was 11.2 ± 7.3 days, and the mean healing duration was 17.0 ± 3.7 days. The clinical wound healing score improved from 3.7 ± 2.9 at 5 days to 1.7 ± 0.7 at 30 days postoperatively (p < 0.05). Complications were minimal, with no significant obstacles or sequelae observed. Direct closure healing was achieved in 21 cases, skin graft healing in 13 cases, and suture healing in 9 cases. No recurrences were reported. Using Paley’s classified complications, there were 17 problems, 9 obstacles, and 0 sequelae.

Conclusion: The Ilizarov tension-relieving traction shows promise in facilitating wound closure that is challenging to manage with skin flaps. The modified three types of pin–skin connection configuration could satisfy various types of wound closure.

Keywords

Complex Limb Wounds / Ilizarov Tension-Relieving Traction / Modified Ilizarov external fixation / Skin Flaps / Wound Closure Effectiveness

References

[1] Teot L, Ohura N. Challenges and Management in Wound Care. Plast Reconstr Surg. 2021; 147: 9S–15S.

[2] Alga A, Haweizy R, Bashaireh K, Wong S, Lundgren KC, von Schreeb J, et al. Negative pressure wound therapy versus standard treatment in patients with acute conflict-related extremity wounds: a pragmatic, multisite, randomised controlled trial. Lancet Glob Health. 2020; 8: e423–e429.

[3] Zhang YX, Hayakawa TJ, Levin LS, Hallock GG, Lazzeri D. The economy in autologous tissue transfer: part 1. The kiss flap technique. Plast Reconstr Surg. 2016; 137: 1018–1030.

[4] Rajput S, Kuruoglu D, Salinas CA, Sen I, Kalra M, Moran SL. Flap management of groin wounds following vascular procedures: a review of 270 flaps for vascular salvage. J Plast Reconstr Aesthet Surg. 2023; 78: 38–47.

[5] Jia Z, Liang G, Duan C, Zhang Z, Guo Y, Teng Y. Flow-through Dorsoulnar perforator flap repair of soft-tissue defect of the finger with segmental digital arterial defect. J Coll Physicians Surg Pak. 2022; 32: 685–687.

[6] Ilizarov GA, Shved SI, Karagodin GE. Potentials of transosseous osteosynthesis in preventing posttraumatic osteomyelitis in open fractures. Vestn Khir Im I I Grek. 1987; 138: 95–99.

[7] Xu YQ, Fan XY, He XQ, Wen HJ. Reconstruction of massive tibial bone and soft tissue defects by trifocal bone transport combined with soft tissue distraction: experience from 31 cases. BMC Musculoskelet Disord. 2021; 22: 34.

[8] Prem H, Zenios M, Farrell R, Day JB. Soft tissue Ilizarov correction of congenital talipes equinovarus–5 to 10 years postsurgery. J Pediatr Orthop. 2007; 27: 220–224.

[9] Green SA, Ilizarov GA. The transosseous osteosynthesis: theoretic growth of tissue. Berlin: Springer-Verlag; 1992:800.

[10] Freeman LJ, Pettit GD, Robinette JD, Lincoln JD, Person MW. Tissue reaction to suture material in the feline linea alba. A retrospective, prospective, and histologic study. Vet Surg. 1987; 16: 440–445.

[11] Paley D. Problems, obstacles, and complications of limb lengthening by the Ilizarov technique. Clin Orthop Relat Res. 1990; 250: 81–104.

[12] Qing L, Wu P, Yu F, Zhou Z, Tang J. Use of a sequential chimeric perforator flap for one-stage reconstruction of complex soft tissue defects of the extremities. Microsurgery. 2020; 40: 167–174.

[13] Chim H. The Superthin Profunda artery perforator flap for extremity reconstruction: clinical implications. Plast Reconstr Surg. 2022; 150: 915–918.

[14] Visconti G, Bianchi A, Hayashi A, Cina A, Maccauro G, Almadori G, et al. Thin and superthin perforator flap elevation based on preoperative planning with ultrahigh-frequency ultrasound. Arch Plast Surg. 2020; 47: 365–370.

[15] Broussard KC, Powers JG. Wound dressings: selecting the most appropriate type. Am J Clin Dermatol. 2013; 14: 449–459.

[16] Shpichka A, Butnaru D, Bezrukov EA, Sukhanov RB, Atala A, Burdukovskii V, et al. Skin tissue regeneration for burn injury. Stem Cell Res Ther. 2019; 10: 94.

[17] Huang C, Leavitt T, Bayer LR, Orgill DP. Effect of negative pressure wound therapy on wound healing. Curr Probl Surg. 2014; 51: 301–331.

[18] Faust E, Opoku-Agyeman JL, Behnam AB. Use of negative-pressure wound therapy with instillation and dwell time: An overview. Plast Reconstr Surg. 2021; 147: 16S–26S.

[19] Cui Y, Yuan B, Zhang Y, Ren G, Dou M, Peng C, et al. Reverse-traction skin-stretching device for primary closure of large skin defects. Arch Dermatol Res. 2023; 315: 751–760.

[20] Pietramaggiori G, Liu P, Scherer SS, Kaipainen A, Prsa MJ, Mayer H, et al. Tensile forces stimulate vascular remodeling and epidermal cell proliferation in living skin. Ann Surg. 2007; 246: 896–902.

[21] Zhang Z, Tang X, Wei Z, Jin W, Wang D, Wang B, et al. Repair of large skin defect of upper limb with abdominal pedicled flap. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi. 2017; 31: 1102–1105.

[22] Ciudad P, Escandon JM, Manrique OJ, Llanca L, Reynaga C, Mayer HF. Cross-leg free flaps and cross-leg vascular cable bridge flaps for lower limb salvage: experience before and after COVID-19. Eur J Plast Surg. 2023; 46: 1–11.

[23] Wei M, Bu X, Wang G, Zhen Y, Yang X, Li D, et al. Expanded forehead flap in Asian nasal reconstruction. Sci Rep. 2023; 13: 5496.

[24] Yang DP, Zhang P. Facial resurfacing with prefabricated induced expanded skin flap. J Craniofac Surg. 2019; 30: 1131–1134.

[25] Baker SR. Fundamentals of expanded tissue. Head Neck. 1991; 13: 327–333.

[26] Stahl S, Har-Shai Y, Hirshowitz B. Closure of wounds in the upper extremity using a skin stretching device. J Hand Surg Br. 1996; 21: 534–537.

[27] Hirshowitz B, Lindenbaum E, Har-Shai Y. A skin-stretching device for the harnessing of the viscoelastic properties of skin. Plast Reconstr Surg. 1993; 92: 260–270.

[28] Bashir AH. Wound closure by skin traction: an application of tissue expansion. Br J Plast Surg. 1987; 40: 582–587.

[29] Kocialkowski A, Marsh DR, Shackley DC. Closure of the skin defect overlying infected non-union by skin traction. Br J Plast Surg. 1998; 51: 307–310.

[30] Liu Z, Xu C, Yu YK, Tu DP, Peng Y, Zhang B. Twenty years development of Tibial cortex transverse transport surgery in Pr China. Orthop Surg. 2022; 14: 1034–1048.

RIGHTS & PERMISSIONS

2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.