Rev. bras. ortop. vol.50 número2

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Original

Article

Results

from

surgical

treatment

of

Morel-Lavallée

lesions:

prospective

cohort

study

夽

Evandro

Pereira

Palacio

∗

_,

_Gabriel

_Guimarães

_Di

_Stasi,

Ewerton

Henrique

Rodrigues

Teixeira

Lima,

Roberto

Ryuiti

Mizobuchi,

Alcides

Durigam

Júnior,

José

Antônio

Galbiatti

FaculdadedeMedicinadeMarília,Marília,SP,Brazil

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Articlehistory:

Received23February2014 Accepted20March2014

Availableonline28February2015

Keywords:

Woundsandinjuries Soft-tissueinjuries/pathology Soft-tissueinjuries/surgery Multipletrauma

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Objective:Topresenttheresultsfromearlydiagnosisanddelayedsurgicaltreatmentofa cohortofpatientswhowerediagnosedwithMorel-Lavalléelesions.

Methods:BetweenJanuary2006andDecember2013,weperformeddelayedsurgical debride-mentonMorel-Lavalléelesions,afterdelimitationofthelocaltissuenecrosis,followedby closurethroughsecondintentionand/oruseofgrafts/flaps.

Results:All thepatients evolved with complete closureof thelesion after the delayed debridement,granulationoftheoperativewoundandprimarysuturingorconstructionof pedunculatedflaps.Threepatients(50%)evolvedwithdeepinfectiousprocessesduetothe successiveoperativeprocedures.

Conclusion:Whateverthetreatmentmethodsusedare,theyshouldbeperformedinaradical manner.Ifnot,thepatientwillbeatriskofevolutiontosepticemiaanddeath.

Resultados

do

tratamento

cirúrgico

da

lesão

de

Morel-Lavallée.

Estudo

coorte

prospectivo

Palavras-chave:

Ferimentoselesões

Lesõesdostecidosmoles/patologia Lesõesdostecidosmoles/cirurgia Traumatismomúltiplo

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Objetivo:apresentarosresultadosdodiagnósticoprecoceedotratamentocirúrgicotardio deumacoortedepacientesdiagnosticadacomalesãodeMorel-Lavallée(LML).

Métodos:dejaneirode2006adezembrode2013osautoresfizeramodesbridamentocirúrgico tardiodaLML,apósadelimitac¸ãodanecroseteciduallocal,seguidodefechamentopor segundaintenc¸ãoe/ouenxertos/retalhos.

Resultados:todosospacientesevoluíramcomfechamentototaldalesãoapóso desbrida-mentotardioagranulac¸ãodaferidaoperatóriaea(os)suturaprimária/retalhospediculados. Trêspacientes(50%)evoluíramcomprocessoinfecciosoprofundodevidoaossucessivos procedimentosoperatórios.

夽

WorkdevelopedattheDepartmentofOrthopedicsandTraumatology,FaculdadedeMedicinadeMarília,Marília,SP,Brazil.

∗ _{Corresponding}_author_.

E-mail:palacio@famema.br(E.P.Palacio). http://dx.doi.org/10.1016/j.rboe.2015.02.011

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Conclusão:sejamquaisforemosmétodosdetratamentoempregados,estesdevemserfeitos demaneiraradical,sobriscodeevoluc¸ãodospacientesparasepticemiaeóbito.

Introduction

Morel-Lavallée lesions (MLLs), also known as degloving injuries,werefirstdescribedbytheFrenchphysicianMaurice Morel-Lavalléein1853.Theyareraresoft-tissueinjuriesthat areassociatedwithhighratesofmorbidityandmortality.1–8 Theyoccurbecauseofsudden applicationofhigh-intensity forcestoacertainareaofthebodyandtheireffectisto sepa-rateskinandsubcutaneoustissuefromtheunderlyingmuscle fascia.9,10 _The_space_thus_created_becomes_filled_with_blood, lymphornecroticfattytissue,andthisnotuncommonlyleads tosevereinflammatoryandinfectiousprocesses.3,7–10

DiagnosingMLLsisnotaneasytask.Inthegreatmajorityof thecases,theseareclosedinjuriesandthisoftencauses con-fusionorevenfailuretodiagnosethecondition.Duringcareful clinicalexamination,itcanbeseenthatintheacutephase, thevolumeoftheareaaffectedisgreater,andthisis accom-paniedbyfloating,hypermobilityandhypoesthesia.4,5,7,9_The lesionusuallyaffectsanareagreaterthantheareathatcan initiallybeassessedinthecourseofthephysicalexamination, duringemergencyattendance.3,10_The_circulation_of_the_skin andsubcutaneoustissueintheinjuredsegmentiscommonly compromisedandthereisoftengreatdifficultyin determin-ingwhetherthesetissuesarerecoverable.3_In_normal_tissues, theviabilityofthecapillaryperfusioncangenerallybe eas-ilyestimatedbymeansofapplyinglocalcompressionusing afingerorthroughidentifyingactivebleedingintheregion affected.However,inthecaseofcomplextissuedamage,as occursinMLL,thesetestsmaynotbethemostreliabletype fordiagnosticpurposes. Typically,the treatmentcomprises early radical debridement of the tissuesaffected, followed bysecond-intentionhealingofthewound.5–8,11,12 _However, someauthors havetakenthe viewthatpostponingthe ini-tialtreatmentuntilthetimewhendelimitationornecrosisof thetissueshasoccurredisthebestapproach.13_Whatever_the therapyused,thereisunanimitythatsuchpatientswilloften havetoundergomultipleproceduresandsurgicalrevisions, withahigherriskofinfection.3,5–7,9

Giventhepoorprognosisofthistypeofinjuryandthe diffi-cultyinmakingprecisediagnosesandtreatments,alongwith thecompletelackofinformationonthistopicinthevarious databasesavailable,andparticularlyintheBrazilian orthope-dicdatabases,thepresentstudywasproposedwiththeaimof evaluatingtheresultsfromlatediagnosisandsurgical treat-mentofMLL.

Patients

and

methods

This was a prospective cohort study that was approved byourinstitution’s ethicscommitteeforresearchinvolving humanbeings(CAAE04497812.4.0000.5413).Allthepatients,

or theirlegalguardians, agreedtoparticipateandsigneda freeand informedconsentstatementafterhavingreceived detailed information about the content and form of the study.

Thesamplesizewas determined beforehand,bymeans ofspecificstatisticaltests. The␣ risk(5%)and ␤risk(20%) weretakenintoconsideration,alongwiththevariabilityofthe variables(p1=0.13andp2=0.9),thusarrivingataminimum numberoffiveindividuals.

Initially,11patientswithadiagnosisofMLLconfirmedby meansoftomographyand/ormagneticresonance examina-tionwereselected,betweenJanuary2006andDecember2013. Patientswereexcludediftheypresentedanyofthefollowing: previousclinicalorsurgicaltreatmentonthelesionin ques-tion(n=3);generalstateofhealththatwasconsideredtobe poororserious(n=1);refusaltosignthefreeandinformed consentstatement(n=1).Thus,thefinalcohortconsistedof sixpatients.

Alltheoperativeprocedureswereperformedbythesame orthopedicteam,alwaysunderthesamepreand postopera-tiveprotocols.

Afterthepatientshadarrivedattheemergencyserviceand had gonethrough theadvancedtraumalifesupport(ATLS) protocol, simpleradiographs of the contused regionswere produced,always intwoorthogonalviews.On thebasisof specificabnormalitiesseenintheclinicalexamination (exces-sivelocalpainthatwasoutoflinewiththeintensityofthe trauma;extensiveecchymosisorhematomas;andespecially, local/regional hypermobilityofthe skin),the patients then underwenttomographyormagneticresonanceexaminations, inordertoconfirmthediagnosisofMLL.

Afterobtainingconfirmationthatdetachmentoftheskin and/orsubcutaneouscellulartissuehadoccurred,wewaited anotherfourtofivedaysforthelesiontobecomedelimited with the first signs of necrosis. Atthat time, the patients were taken tothe surgicalcenter to undergo debridement procedures,alwaysinassociationwithirrigationandprofuse washing(Figs.1–5).

Once the infectious processes had been brought under control,granulationoftheoperativewoundwasawaited,in ordertobeabletoconstructmyocutaneousflapsand/or per-formprimaryclosureofthegranulatededgesofthewound (Figs.6and7).

Results

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Table1–Generalcharacteristicsofthepatients.

Gender Age Anatomicalregion Injurysize Traumamechanism

Patient1 Female 25 Posteriorfaceofforearm/elbow Approx.20cm Fallfrom

motorbike

Patient2 Male 44 Thighandgluteus Morethan30cm Fallfromaheight

Patient3 Male 37 Knee/calf Approx.15cm Caraccident

Patient4 Male 31 Hipandflank Morethan30cm Caraccident

Patient5 Male 55 Lateralfaceofhip Approx.20cm Directtrauma

(workaccident)

Patient6 Female 47 Anteriorfaceofthigh Approx.15cm Caraccident

Fig.1–Coronaltomographicsliceshowinglarge accumulationoffluid(arrow),betweenthesubcutaneous tissueandmusclefascia.

Fig.2–Axialtomographicsliceshowinglarge

accumulationoffluid(arrow),betweenthesubcutaneous tissueandmusclefascia.

Discussion

MLL,ordegloving injury,isarareformofsoft-tissueinjury thatisassociatedwithhighmorbidity.12,14,15_The_areas_that

Fig.3–Imageofflankandhipafterinitialdebridement, showingnecrosisandinfection.

Fig.4–Imageofflankandhip,undergoingsecondary healingprocess(granulationtissue).

are mostlikelytosuffersuchinjuriesare theanterolateral thigh,gluteal,lumbodorsalandscapularregions.6–8,12,14

ThepatientsaffectedbyMLLaregenerallyyoung.Inthis study,thecohortofpatientsconsistedofindividualsbetween theagesof25and55yearswhowereeconomicallyactive.They weremostlymale(Table1).9,13

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Fig.5–Imageofflankandhip,undergoingsecondary healingprocess(granulationtissue).

Fig.6–Attempttobringtogethertheedgesofthewound, beforeconstructingmyocutaneousflaps.

that the subcutaneous tissue becomes detached from the musclefascia,therebyinjuringthevesselsthatpassthrough theselayers.1,5,15_The_hemolymph_fluid_becomes_surrounded bygranuloustissue,whichmayleadtoformationofafibrous pseudocapsule,preventionoffluidreabsorptionand predis-positiontowardbacterialcolonizationandinfection.9,11–14

Historically,thetreatmentforsuchinjurieshascomprised serialopendebridementfollowedbysecond-intention heal-ing.Recently,methodsthatarelessinvasivehavebeentried out.OneoftheseiscompressionbymeansofaVicrylmesh, which distributes the surface tension in the region ofthe woundtoalargersurface,therebyprovidingreliefforthe ten-sionintheopenarea.However,thereisnoevidencethatthis treatmentisfreefromsequelae.10,11,16_Some_lesions_may per-sist,despiteconventionaltreatments.Inthesecases,methods thatare moreaggressiveare commonlyindicated, such as serialaspirationandtheuseofchemicalsclerosis,incases offormationofpseudocysts.3,8,13,15

Compromisedcirculation in the skinand subcutaneous tissue in the injured segment is always observed and

Fig.7–Finalimageafterperforminggrafting.

it is often difficult to determine whether the tissue is recoverable.3,10–12,15 _Cutaneous _capillary _filling _tests _and bleedingtests havedubiousvalueinevaluatingMLL cases, giventhatthelocalorregionalcapillaryfilling mayremain withinnormalparametersforupto36h,duetotheactionof thecapillarynetworkadjacenttotheinjuredarea.Thelack ofreliableparametersmaymaketheinitialdiagnosisofthe injurydifficult,therebyleadingtosevereconditionsof necro-sisandsepticemia.

Inthisstudy,althoughthediagnosiswasinvariablymade during the acute phase, by means of detailed physical examinationandimagingexaminations,itwasdecidedto per-formed latedebridement,four or fivedaysafter theinitial injury.Overthisperiod,localsignsoftissuenecrosisand con-sequentdelimitationoftheregionaffectedcouldalreadybe observed.Infact,overaseven-dayperiodfollowingtheinitial injury,threeofthepatientsinoursample(50%)evolvedwith extensiveareasofsuperficialanddeepnecrosis(skin, subcu-taneoustissue,fascias,muscles,tendonsandnerves)8,10,13–16 andtheypresentedsevereinfectiousprocesses.Debridement, withradicalremovalofallthedevitalizedstructures,therefore becameimperative,duetotheriskofsepticemiaand progres-siontodeath.

Itwasalsoseenthatlatedebridementofthelesion,only afterthenecroticareahadbecomedelimited,greatly dimin-ished the chances of inadvertent removal of healthy soft tissues,i.e.thosethatstillpresentedeffectivecirculation.

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Finally,scarsretractinmanycases,andthisparticularly wors-enstheprognosisforthesepatients,giventhatnewsurgical proceduresareneedsinordertoachieveaminimumdegree ofjointmovement.

Conclusion

MLLisstillalittleknownconditionamongtheprofessionals whoworkonthefrontlineofemergencyservices,including orthopedicsurgeons.Perhapsforthisreason,itisan under-diagnosedtypeofinjury.Whatever thetreatment methods usedare,theyshouldbeimplementedinaradicalmanner, becauseoftheriskofevolutiontosepticemiaanddeath.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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