Great omentum plasty - original method of treatment of the septic complications of hip and pelvis surgery
H. Orban, I. Dinulescu, S. Neagu, M. VlaseArticole originale, no. 1, 2008
* Elias University Hospital
* University Emergency Hospital, Bucharest, Romania
The increase, in the last decade, of the hip prosthetic surgery, together with the pelvic surgery, is remarkable, with a total number of almost half of the orthopedic surgery procedures that are performed today. Every year in the Department of Orthopedics of the University Hospital Bucharest, 500 total hip arthroplasty are performed; if we also count the other procedures as well - hemiarthroplasties, proximal femur osteotomies, pelvic osteotomies and the resection-reconstruction of the pelvis for tumors, the number exceeds almost 800 interventions. Unfortunately the post operator complications are proportional. In this article we try to deal with one of the fearest of all, infection. The sepsis in orthopedic surgery, particularly in the prosthetic surgery, is a serious complication, difficult to treat, highly consumptive, with disability potential and cost consuming. In the hip replacement surgery the situation is particular due to the fact that if the primar implant is removed the benefits of arthroplasty are lost. However, the eradication of the septic process rate with the hardware in place is about 30 to 40 %, despite the early and radical interventions: large debridements from skin to bone-cement-stem junction, closure over a lavaje-drainage system with antiseptic solution and long-term proper antibiotic therapy. If the eradication of the septic process fail the last possibility available is removing the implants, femuroiliac cooptation and revision surgery after a free time period of at least 6 months. In order to avoid these successive interventions we imagined a new surgery technique of eradication of a periprosthetic infection that may occure in the hip surgery, using the pediculised great omentum, in the septic area.
Due to its important biological properties (reach arterial supply, the presence on its surface of a high number of fixed macrophage cells that can be easily mobilized if needed, well developed lymphatic matrix - a large lymph node), the great omentum plasty was used in many surgical procedures for covering defects or eradication of sepsis. The reach arterial supply trigger the neovascularisation process thus improving the local nutrition and increasing the antibiotic action that otherwise cannot penetrate a sclerous and ischemic tissue. Due to its well-developed lymphatic circulation the septic process is under control and the resorbtion of extracellular fluids is improved (1).
Kusiak S.F. and Rosenblum N.G.(2), in 1996 used the great omentum for reconstruction of the vagina after pelvectomy, in a 20 patients study. The results were very good, without complications and with restauration of the sexual function at almost 80% of the patients.
In 1995 Wornom I.L., Maragh H., Pozez A. and Guerraty A.J.(3) published the paper "The use of great omentum in the management of septic sternal wounds after cardiac transplantation". In this paper the authors followed up for a period of 3 years 7 patients with deep infected sternal wounds after cardiac transplantation, with pericardic abcesses, mediastinitis and osteomielitis, treated successfully using a great omentum flap pediculised with the right gastroepiploic artery.
Guedon C.E., Marmuse J.P., Gehanno P. and Barry B.(4) in 1994 used the same procedure for covering defects in the neck area. 18 patients with large defects involving the skin, the larynx and the pharynx were treated with free flaps transfer of great omentum and gastric wall; the functional outcome was very good also.
Giordano P.A., Griffet J. and Argenson C.(5) in 1994 used the pedicled great omentum transplantation for treatment of chronic persistent postoperator spinal infection, again with excellent results.
The great omentum transfer is also used in plastic surgery as support for skin grafts, in the reconstructive surgery after total mastectomy or massive breast septic necrosis after radiation therapy and in vascular surgery for covering the vascular grafts.
Starting from this previous experience we have imagined a new surgical technique - the epiploonoplasty, for eradication of septic processes in the hip and pelvis surgery.
Material and Method
This technique consists in mobilization of the great omentum (fig. 1), pediculisation on the right or left gastroepiploic artery according to the affected hip and fixation in the septic area after passing it anterior or posterior (through the neuromuscular lacuna) of inguinal ligament (fig. 2, 3). In this manner it can be obtained a pediculised flap that can be lowered as far as the level of knee joint.
Between 1997 and 2004 we used this technique for treat 7 patients (5 men and 2 women), age between 24 and 60 years old, who had presented for chronic septic fistula after total hip replacement (5 cases) and after pelvic resection type I and reconstruction of the ilium with massive allograft (2 cases).
The patients with ilium reconstruction had chronic persistent fistula for 60 days and 30 days respectively, with failed previous interventions for eradication of the sepsis. With our procedure the septic process was eradicated, with discharge of the patients at 14 days after surgery; the long distance evolution was very good, without local recidive and normal integration of the bone graft.
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The patients with infected prosthesis were treated in the same way.
The first case was a female patient with infected revision arthroplasty for loosening. After the revision surgery a local fibrinolysis process occurred leading to acute renal failure that had required hemodialisation. The operative wound has infected with pyocianic, and dehiscence occurred with severe periprosthetic infection. According to the classic protocol, we should have been removed the prosthesis, performed hip debridements, 4 to 6 weeks parenteral antibiotics and
prosthesis reimplantation after completion of the full course of antibiotics.
Using our technique we successfully managed to eradicate the sepsis in 14 days. After one year the patient presented with loosening and the prosthesis was removed.
The second case was a 60 years old male patient with septic failure of prosthesis who has been removed and persistent septic fistula at one year, despite the previous successive
surgical interventions including abdominal rectum muscle flap plasty. In this case we performed local debridements, reimplantation of a new prosthesis and epiploonoplasty in the same session. Despite the excellent postoperator evolution, with discharge at 14 days, the patient presented 6 month later another discharging sinus treated by local debridements without removing the implant. One year after the last surgery he presented loosening of the prosthesis. The hardware was removed and we discovered that the great omentum flap has been retracted from the hip.
The third case is a 39 years old patient with septic loosening at 4 years after total hip replacement. The prosthesis was removed and local debridements and implantation of a cement spacer was performed (fig. 1a ); after one year, after completion of full antibiotic course, revision surgery was performed using a Kent prosthesis (fig. 1b ). A septic recidive occurred. We performed epiploonoplasty with excellent results. The follow up at three years after epiploonoplasty is very good, without loosening or septic recidive .
Another patient is a 60 years old male with septic
prosthesis; we performed the epiploonoplasty without
removing the implant. Skin grafts were also needed for
covering the large hip defect (fig. 4, 5). Postoperative
evolution was very good. There was no complication
regarding the epiploonoplasty whatsoever, except for an abdominal incisional herniation treated in the general
surgery unit. All cases received proper antibiotic treatment according to antibiogram for 14 days.
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Discussion
The main advantage of our method is shorting the patient hospitalization reducing the treatment costs. The wound closure occurs at 14 days posoperator with patient discharge and antibiotic therapy in ambulation.
This method is extremely effective in the septic complication after pelvic reconstruction surgery, with complete healing, without recidive at 7 years posoperator. In the
prosthetic surgery the results are different according to the type of implant (cemented or press-fit) and the time elapsed from the septic process occurred.
In the infected cemented total hip arthroplasty the immediate results are very good, the periprosthetic septic process is eradicated in a short period of time (14 to 21 days), but the late results are closely related to the elapsed time since the sepsis occurred. In cases of infected prosthesis with previous multiple debridements, successive drainage muscular flaps, etc, with failure of treatment after more than 6 month, the epiploonoplasty procedure is
successful in eradication of the sepsis. However, the long time evolution of the septic process with germ fixation at the cement-bone-prosthesis jonction leads to loosening (1 year after primary operation), but without acute discharging periprosthetic sinuses or deep septic collections.
In the infected press-fit total hip arthroplasty the results was very good, with a 3 years follow-up after epiploonoplasty. Our results with this technique recommend the epiploonoplasty as first intention intervention in infected prosthesis. Even thought that it is a large intervention, the short time of eradication of the septic process greatly improve the survival time of the primar implant and improve the local conditions thus the revision arthroplasty for late loosening could be performed in one-stage procedure. This new method is sometimes the only effective therapeutic method in hip and pelvis septic surgery, shortening the biologic depletion of the patient and also the material costs of unsuccessful and long treatment. It is a new surgical procedure that involves the collaboration between both the orthopedic and the general surgeon.
References
1. Ciuce, C., Galea, Fl., Andercou, A., Todoran, M.. - Plagã complexã a bratului rezolvatã prin autotransplant de epiploon. Tehnicã de microchirurgie. Chirurgia (Bucur.), 1988, 4:283.
2. Kusiak, J.F., Rosenblum, N.G. - Neovaginal reconstruction after exenteration using an omental flap and split - thickness skin graft. Plast. Reconstr. Surg., 1996, 97:775.
3 . Wornom, I.L. 3rd, Maragh, H., Pozez, A., Guerratay, A.J. - Use of the opmentum in the management of sternal wound infection after cardiac transplantation. Plast. Reconstr. Surg., 1995, 95:697.
4. Guedon, C.E., Marmuse, J.P., Gehanno, P., Barry, B. - Use of gastro-omental free flaps in major neck defects. Am. J. Surg., 1994, 168:491.
5. Giordano, P.A., Griffet, J., Argenson, C. - Pedicled greater omentum transferred to the spine in case of postoperative infection. Plast. Reconstr. Surg., 1994, 93:1508.