4 . 2018

The microsurgical tissue autotransplantation in the treatment of late radiation tissue injuries with complicated osteomyelitis of the tibia

Abstract

Aim. Study of the remote results free flaps usage in treatment of patients with the late radiation injuries complicated by tibial bone osteomyelitis.

Material and methods. Our work is based on a retrospective study of treatment of eight patients with late radiation tissue injuries and chronic osteomyelitis of the tibia. In them we performed 9 operations using free, vascularized flaps. According to RTOG/EORTC Late Radiation Morbidity Scoring Scheme, skin lesions corresponded to grade IV, bone damage – grade II–III. In the zone of the late radiation injuries, the lesion of the cortical plate of the tibia was detected in 5 patients, a lesion that occurred more than a third of the tibial circumference – in 3 patients. 6 patients had cicatricial osteomyelitis form, and 2 had osteomyelitis with the inclusion of a chronic draining fistula. Late radiation ulcer was emerged in all patients after previous radiotherapy in a total dose of 40 to 60 Gy for different types of neoplasms. For 7 patients, the timing of the previous radiotherapy ranged from 5 to 19 years before the appearance of a late radiation tissue injury. Three patients received radiotherapy in childhood. In one patient, with posttraumatic osteomyelitis of the tibia, in remission, squamous cell carcinoma was diagnosed. Patients underwent radiation therapy in a total dose of 60 Gy. Later it was associated a radiation ulcer with open defects of the tibia.

The objectives of surgical treatment included the preservation of the limb, adequate surgical debridement and the replacement of the tissues defect. The surgical technique included a radical resection of the affected areas of the bone tissue. To fill dead space, a musculo-fasciocutaneous thoracodorsal flap was used in all paients. In 2 out of 3 patients with localized form of osteomyelitis, the autograft complex, supplementary to the thoracodorsal component, included additionally a fragment of the anterior serratus muscle for tamponade of the osteomyelitis cavity. For one patient with localized osteomyelitis, a tamponade method of the post osteomyelitis bone defects included use of the distal part of the fragment of the latissimus muscle flap. 1 patient originally addressed concerning a late radiation ulcer on the back surface of a crus without involvement of bone structures. Two years after elimination of cicatricial and ulcer defect the torakodorsal skin and muscular flap, created a late radiation ulcer on the forward surface of a shin with defeat of a cortical plate of a tibial bone.

Discussion. Fundamental difference of patients with local radiation injury from patients with traumatic osteomyelitis and investing tissue extensive defects is the feature of a course of wound process against the background of the progressing depression of a reparation both in the focus, and in surrounding tissues with lack of a clear boundary defeat.

Morphological basis of local late radiation defeat are permanent damages of blood and lymphatic vessels with tissue fibrosis progressing.
In the conditions of local reserve opportunities decrease, free revascularised flaps application, with one's own axial blood supply, allows to save an extremity, to receive the best immediate and long-term results of tissues defects elimination in the irradiated zone. It can be confirmed with the fact that directly under the replaced skin and muscular revascularised flap the covered functional structures purulent defeat stopped and patients achieved osteomyelitic process permanent remission.

Results. In all observations the full flap engraftment has received. All patients have achieved osteomiyelitic process remission.

Conclusions. The radical debridement of the affected zones, followed by the filling of the bone defect with muscle tissue and the defect elimination of the tissues by the skin portion of the vascularized musculocutaneous autograft is the method of choice in the treatment of patients with local post radiation injuries, complicated by osteomyelitis of the tibia.

Keywords:local radiation injury, osteomyelitis, microsurgical tissue autotransplantation, late radiation ulcer

Clin Experiment Surg. Petrovsky J. 2018; 6 (4): 6–16.

doi: 10.24411/2308-1198-2018-14001. Received: 11.05.2018. Accepted: 24.10.2018.

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