Case reportA three-dimensional virtual reality model for limb reconstruction in burned patients
Introduction
Electrical burns are a common cause of injuries. Despite many developments in the treatment of high-tension electrical burns, this type of injury still shows high-morbidity rates. Recently, the use of free flaps for reconstruction in burned patients has increased due to advances in the field of microvascular free tissue transplantation [1]. Free flaps have reached a high level of sophistication. For instance, re-expanded flaps, composite tissue flaps, fascial flaps, multiple autologous flap transplantations and combined flaps (“chimeric flaps”) based on a single vascular pedicle have been performed in patients with severe burns and large defects in extremities [2].
Traditional methods of learning have helped generations of surgeons to familiarize themselves with flaps anatomy. Nevertheless, even texts with the highest level of accuracy and image quality are limited by the two-dimensional nature of printed material, which cannot impart three-dimensional (3D) views. Video material is similarly limited as to deliver a 3D experience. Another restriction of most traditional methods for the study of anatomy relates to the lack of interactivity and feedback. As a supplement to the knowledge gained from books and observation, cadaver dissections can play an important role in mastering anatomy. Unfortunately, however, their limited availability and high cost severely conditions this alternative in most teaching institutions. Even when cadavers are available, learning from cadaver dissection may be limited by poorly delineated anatomical structures and altered dissection planes due to chemical preservatives as well as by the relatively brief time spent in the dissection laboratories. The 3-dimensionally complex interplay of soft tissue, vessels and bony elements makes difficult the mastery of free flaps anatomy, and conventional methods to learn this anatomy often involve a steep learning curve. Computerized models and virtual reality applications are being used to facilitate teaching in a number of other complex anatomical regions, such as the human temporal bone and pelvic floor as well as in severe facial burn injuries undergoing reconstructive procedures [3], [4], [5], [6]. In this study we present a 3D virtual reality model of a free flap in microvascular reconstruction for the forearm and hand in electrical burn injury.
Section snippets
Case report
A 34-year-old heavy industry worker presented with a history of third-degree electrical burn that caused a large wound over the dorsal distal third of the right forearm and volar wrist with exposure of the flexor tendons and median nerve (Fig. 1). The point of entry was his right hand and the exit point was his left leg. The worker sustained this injury while working on a pylon and making contact to high-tension electrical lines. As a result he also suffered a 10 m fall and a burned total body
Results
The flap survived well postoperatively and no complication was observed regarding wound healing in early and late follow-ups. Donor site healing was uneventful. A satisfactory coverage was seen in the recipient areas (Fig. 5). The patient was discharged from the hospital 7 days later.
Total matching was observed between the dominant perforators shown in the 3D virtual thigh model and those observed when raising the anterolateral thigh free flap. An obliteration of the cubital artery was found
Discussion
To obtain the best functional result in third-degree burn defects of the hand and forearm an immediate attention and meticulous wound care is required [7], [8]. An early reconstruction is mandatory when the injury is very extensive and also in cases in which important anatomic components (i.e. a neurovascular bundle, tendons or bone) are either exposed or missed [9]. Adequate soft-tissue coverage is a cornerstone for successful hand reconstruction aimed to hand mobilization and rehabilitation
Acknowledgements
The modular software programming tools used in this study were developed at Alcala Innova and Reina Mercedes Foundation in collaboration with the University of Sevilla. The virSSPA project is being developed and financed by the Andalusian Department of Health, Spain.
References (17)
- et al.
Virtual temporal bone: creation and application of new computer-based teaching tool
Otolaryngol Head Neck Surg
(2000) - et al.
Computer aided surgical reconstruction after complex facial burn injuries—opportunities and limitations
Burns
(2005) - et al.
Innovations in flap design: modified groin flap for closure of multiple finger defects
Burns
(2000) - et al.
Experience of 14 years of emergency reconstruction of electrical injuries
Burns
(2003) - et al.
Free tissue transfer in the management of burns
Burns
(1996) - et al.
Current concepts of microvascular reconstruction for limb salvage in electrical burn injuries
J Plast Reconstr Aesth Surg
(2007) - et al.
Principles of microvascular reconstruction in burn and electrical burn injuries
Burns
(2005) - et al.
Expanded latissimus dorsi free flap for the treatment of extensive post-burn neck contracture
J Reconstr Microsurg
(2002)
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