a total volume of 120 ml in the tissue expander. made expander was rectangular in shape. 7 cm x 3 cm with a microfill valve and a fill volume of 80 ml (Mentor.
THE
USE
IN
OF
CLUB-FOOT
A CASE
DAN
ATAR,
ALFRED
D. GRANT,
SILVER,
the Hospitalfor
Primary skin closure after the surgical use of a tissue expander to provide sufficient completion
of the surgical
correction
Insertion expander
of the tissue tube is brought
of club-foot,
L. Silver, MD, Chief of the Children’s Surgical Unit Beth Israel Medical Center, First Avenue NewYork 10003, USA.
Plastic
Correspondence Omer, 84965,
Atar,
©
to Dr
1990 British Editorial Society ofBone 030l-620X/90/4083 $2.00 J Bone Joint Surg [Br] 1990; 72-B : 574-7.
574
B. LEHMAN,
Diseases,
New
1980),
lateral
The
a local
of
pocket. The incision.
D.
at
and
16th
port and
and
We report
the
a case
Joint
risks
of the
use of a tissue
of a
made
at
the
surgeon’s of a plastic
2 are
connected pocket.
to prepare We believe
to the
general
we used
expander
use
1976 ; Pont#{233}n
is usually
of repeated
in which
preliminary procedure primary skin closure.
a tissue
expander
tube
anaesthesia. expander
at a
sufficient skin to allow this to be the first report
in club-foot
surgery.
Reconstructive
Street,
New
CASE
York,
The patient,
and
filling valve in a subcutaneous
placed
(Bethem the
and will depend on the orthopaedic with skin flaps, the availability
The injection before being
surgeon
and
flap (Ger
procedure
the
flap medially
et al 1987),
or fasciocutaneous and Shaw 1986).
choice
operation, familiarity
with
1978 ; Lehman
myocutaneous 1981 ; Hidalgo
WATER
may be diflicult. We describe of the use of the method.
release
Weiner
M. STRONG
York
of severe club-foot some aspects
and
ALLAN
Fig.
expander into the subcutaneous out through a proximal transverse
be sent
WALLACE
1
D. Atar, MD, Fellow, Department of Paediatric Orthopaedic Surgery A. D. Grant, MD, Directorofthe Children’sOrthopaedic and Arthritis Institute W. B. Lehman, MD, ChiefofPaediatric Orthopaedic Surgery A. M. Strongwater, MD, Associate Director of the Department of Bioengineering Hospital for Joint Diseases Orthopaedic Institute, 301 East 17th Street, New York, New York 10003, USA.
should Israel.
REVIEW
skin, and review
primary skin closure may be difficult or even impossible especially in severe cases and revision operations (Lehman et al 1987). Solutions to this problem include: primary skin closure in an undercorrected position followed by weekly manipulation and casting under general anaesthesia (Herold and Torok 1973 ; Lehman
Fig.
AND
Joint
correction
EXPANDER
SURGERY
REPORT
LESTER
From
After
A TISSUE
14 Eucalyptus
Surgery
Street,
his
family,
a 15-month-old with
pregnancy and ulnar deviation diagnosis
REPORT
was
boy, was the second
a healthy
delivery of both
older
After
severe bilateral hands were noted
arthrogryposis, THE
sister.
JOURNAL
probably OF BONE
club-foot at birth. inherited
AND
child
JOINT
in
a normal
and The in an
SURGERY
THE
USE OF A TISSUE
EXPANDER
IN cLUB-FooT
autosomal dominant pattern from the father, who also had bilateral club-foot. Initial treatment was by serial
made
expander
was
with
a microfill
valve
casting
Corporation,
At
closure
for the feet and splinting 21 days, the child had
of a patent
of inguinal tissue
ductus
hernias.
release
was
At
for the hands. open heart surgery
arteriosus nine
months
performed
were
performed
problems
to achieve
on that
The
necessary as a long
was inserted the posterior the
repair
extensive
gap prevented so the skin
a fully-corrected
of saline
soft-
The
medial
was
filling
in shape
a fill volume
expander.
applied.
15 ml of saline
primary was closed
and
were closed
in the
splint
At the
7 cm
x 3 cm
of 80 ml (Mentor
valve
of filling
to two-week
added
percutaneously
a 23 gauge
being
no drains
At one-
were
using
with
based
leaving
A carefully-padded
on
needle
the
intervals
10 to
through
(Fig.
3), the
and
tension
colour
5 ml
posterior
the
amount of the
At weekly anaesthesia
skin. When 120 ml of saline had been added we felt that sufficient expansion had been achieved (Fig. 4). The
position.
child
At
session a tissue expander was right leg, anticipating similar
then
closure
had
a complete
was achieved
position
(see
soft-tissue
release.
without tension 5 to 7) and healing
Figs
Primary
in the fully corrected was uneventful.
side.
skin anterior
and
subcutaneous
rectangular
cover
flap.
The
was
DISCUSSION
expander
through an incision along what was to be edge of the flap, and placed superficial to
fascia.
proximal
an
foot in the deformed position. four manipulations under general
the fourth manipulation carefully placed in the
planned
bilateral
for the left club-foot.
end of the operation a huge skin closure in the corrected position,
with the intervals,
and
rectangular
California).
The wounds
for
575
SURGERY
filling
incision
valve
was
(Figs
led
1 and
out
through
2). The
a
custom-
Soft-tissue
expansion
surface
area
nancy
and
Tissue
is
of the
the skin
ofthe
expansion
1940s
was
by Jaime
expanded
to reconstruct
absence
of the
rubber
balloon
Radovan
double breast
used
(Jackson
air-inflated ear. In 1976
may
developing
congenital
der, inflated placed under
physiological
first
Planas
skin
a
abdomen
preg-
therapeutically
the pinna
used
(1957)
with used
an
an amputated
first
silicone
expan-
by way of a sealed remote-injection the skin. The technique has been
utilised in breast reconstruction head and neck surgery (Argenta,
the
of a patient
Neumann
the
in the
who
to reconstruct
designed
: the
during
also stretches.
et al 1987)
ear.
process
(Radovan Watanabe
port widely
1978, and
1979), Grabb
1983; Buhrer et al 1988), and in the limbs (MacKinnon and Gruss 1985; Jackson et al 1987; Hallock 1988; Manders et al l984b, 1988). Most tissue expanders have subcutaneous Fig. Test injection in the out-patient
in the operating clinic.
3
room
; the
same
method
was
used
later
separate expander prevent
remote-injection
ports
placed
through
a
incision in a pocket dissected at the time of placement, and anchored locally by sutures to movement. Several modifications have been
suggested.
Lapin,
expander
with
difficulty
in
Elliott
a
and
Jun
(1985)
self-contained
palpating
the
used
injection
port
can
cause
a tissue
port,
but
inadvertent
puncture of this type of expander (Cohen 1985). Elliott and Dubrul (1988) included a magnet at the base of the injection
port,
using
a magnetic
finder
to locate
the
site
of injection, while Austad and Rose (1982) developed a self-inflating expander by using a hypertonic solution inside a semipermeable silicone enve’ope. Tissue expan-
ders with external injection ports have also been described (Jackson et al 1987; Jackson 1988). Injections are usually done weekly with careful observation for tension, blanching or discomfort (Ar-
7)
genta
1984;
Manders
Pietil#{228} et al 1988). how Fig. The leg and foot tissue expander.
VOL.
72-B,
before
No. 4, JULY
operation,
1990
4 with
a total
volume
of 120 ml in the
to do
this,
et
Family but
there
al
1984a,b;
members are
now
Radovan
1984;
are sometimes
taught
more
ways to monitor the microcirculation saturation of the distended skin (Hallock Pietil#{228} et al 1988).
sophisticated
and the oxygen and Rice 1986;
576
D. ATAR,
A. D. GRANT,
L. SILVER,
W. B. LEHMAN,
A. M. STRONG
WATER
The skin responds to this stretching and increased pressure, as shown in histological studies in guinea pigs (Austad et al 1982) and in man (Pasyk, Argenta and Hassett 1988), by thickening of the epidermis, thinning ofthe dermis and the formation ofa fibrous capsule. This capsule had totally resolved after two years ; the epidermis and dermis and subcutaneous tissue had returned to their pre-expansion thickness. The reported complication rate in patients varies from 5% to 25% (Manders et al 1984a; Jackson
rate
et al 1987).
than
seroma,
the
The
lower
haematoma,
breast
has
a lower
complication
limb ; complications infection,
can
implant
include
puncture
and
reservoir leakage. Skin necrosis and implant exposure are rare, and usually related to unrecognised overexpansion (Hallock and Rice 1986). Conclusion. Soft-tissue expansion, which has been in use for more than a decade, provides a tool with many uses. We
used
it successfully
surgical
correction
We wish to thank of this manuscript. No benefits from a commercial this article.
to prepare
the
of a severe
club-foot
M. Long
for her assistance
Claire
in any party
form have been related directly
skin
before
Fig. The
inflated
tissue
5
expander
before
removal.
the
deformity.
in the preparation
received or will be received or indirectly to the subject of
REFERENCES
Argenta LC. Controlled JP/astSurg 1984;
tissue expansion 37:520-9.
Argenta LC, Watanabe MJ, Grabb head and neck reconstruction.
in reconstructive
WC. The Ann P/ast
surgery.
Br
use of tissue expansion Surg 1983 ; 1 1 :31-7.
Fig.
in The
Austad
ED, Rose GL. A self-inflating Surg 1982; 70:588-94.
Austad
ED, Pasyk KA, McClatchey KD, Cherry GW. Histomorphologic evaluation of guinea pig skin and soft tissue after controlled tissue expansion. P/ast Reconstr Surg 1982; 70 :704-10.
Bethem
D, Weiner resistantclubfoot.
Buhrer
DP, Huang ‘IT, alopecia with tissue 1988; 81:512-5.
Cohen
IK. Silicon ReconstrSurg
Elliott
MP, injection
tissue
D. Radical one-stage C/in Orthop 1978; Yee HW, expanders
expander with 1985; 75 :279-80.
Dubrul W. Magna-site site location. P/ast
Ger R. The
management muscle transposition 29:199-204.
of chronic and free
self-contained tissue Reconstr
of the Reconstr
Hallock
GG,
DC. Objective monitoring Surg 1986; 77:416-20.
Herold
HZ, older
Rice Reconstr
capsule
6
around
the
tissue
expander.
Reconstr
release
for
the
Treatment of P/ast Reconstr
burn Surg
valve
P/ast
(letter).
expander : an innovation Surg 1988 ; 81 :605-7.
for
ulcers of the dorsum of the foot by skin grafting. Br J P/ast Surg 1976;
GG.
P/ast
P/ast
posteromedial 131:214-23.
Blackwell SJ. in children.
HaHock skin
Refinement expansion. P/ast
expander.
fibrous
radial Surg
forearm flap donor 1988; 81 :21-5. for safe
tissue
site
using
expansion. y-#{149}::..
Torok G. Surgical correction of neglected club foot in the child and adult. J Bone Joint Surg [Am] 1973 ; 55-A : 1 385-95.
Hidalgo DA, Shaw ReconstrSurg
WW. 1986;
Anatomic 78 :627-36.
basis
Jackson IT. Use ReconstrSurg
of external reservoirs 1988; 81:640-1.
of plantar in
tissue
flap
design.
expansion.
P/ast P/ast
Fig. Skin closure with not under tension.
the
foot
THE
in the
JOURNAL
7
fully-corrected
OF BONE
position.
AND
JOINT
The
skin
SURGERY
is
THE Jackson
IT, external 80:266-71.
Lapin
Sharpe DT, Polley reservoirs in tissue
Elliott M,
R, primary
Lehman
breast
WB.
Jun
H. The
The clubfoot.
Lehman WB, Silver anatomical basis surgery. BuilHosp
C, Rosenberg P/ast Reconsir
J, Costanzo expansion. use of an
reconstruction.
internal
Aesthetic
Philadelphia,
USE OF A TISSUE
P/ast
tissue Surg
L Surg
Use of 1987;
expander
for
1985
etc : JB Lippincott
EXPANDER
; 9:221-6. Co,
1980.
L, Grant AD, Strongwater AM, Weg 0. The for incisions around the foot and ankle in clubfoot Jt Dis Orthop Inst 1987 ; 47:218-27.
MacKinnon SE, Gruss JHandSurg[Am]
JS. Soft
Manders EK, Graham to eliminate large
WP III, Schenden MJ, Davis iS. Skin expansion scalp defects. Ann P/ast Surg l984a; 12:305-12.
Manders EK, concepts 493-507. Manders EK, extremities.
VOL.
72-B,
1985;
tissue expanders 10-A :749-54.
Schenden MJ, Furrey and complications. Oaks
JA, P/ast
in upper
et al. Soft-tissue Reconstr Surg
TE, Au VK, et al. Soft-tissue expansion P/ast Reconstr Surg 1988 ; 81 :208-17.
No. 4, JULY
1990
limb
surgery.
IN CLUB-FOOT
CG. The expansion of an area of skin by progressive distension of a subcutaneous balloon : use of the method for securing skin for subtotal reconstruction of the ear. P/ast Reconstr Surg 1957; 19:124-30.
Neumann
PasykKA,Argenta of human expansion 81:516-23.
in the lower
LC, HassettC.
lowerleg.
Quantitative analysisofthe and subcutaneous tissue following a silicone implant. P/ast Reconstr
skin with
Pietil#{228}JP, Nordstrom AE. Accelerated P/astReconstrSurg
Pont#{233}n B. The
expansion: l984b; 74:
577
SURGERY
REA, Virkkunen tissue expansion 1988; 81:204-7.
fasciocutaneous BrJP/ast
Surg
Radovan C. Reconstruction temporary expander. Radovan C. Development P/ast Surg Forum RadovanC. Surg
PJ, with
Voutilainen the “overfilling”
flap : its use in soft tissue 1981 ; 34 :215-20.
thickness controlled Surg 1988; PEJ, Rintala technique. defects
ofthe breast after radical mastectomy P/ast Surg Forum 1978 ; 1 :41-2. ofadjacent 1979; 2:62-4.
Tissue expansion 1984; 74:482-90.
flaps
in soft-tissue
using
a temporary
reconstruction.
of the using
expander. P/ast
Reconsir
