Week 2- Emily Laurilliard

I can’t believe we are already through our second week of immersion! Time is really flying by here with so much going on. I started this week off by shadowing Dr. Spector and his team in the clinic. These appointments range from consultations, post-surgery follow-ups, to office procedures that can be done outside the operating room. One patient we saw Monday had his lung removed due to lung cancer. A negative result of this surgery was that he had a bronchial fistula. Similar to the surgery I had observed last week, they used a local muscle to create a flap that covers the hole in the airway. In this patient’s case, they used the pectoral muscle to cover the bronchial fistula. One of the downsides is that this patient had some difficulty raising his arm since he had lost the function of that pectoral muscle. While, use of donor muscle flaps is used quite often in these cases, there are still downsides like this that present a need for improved treatment options.

In addition, we saw another patient in the clinic post-surgery who had benefited from use of a muscle flap. This patient suffered severe trauma to their upper left leg in a traumatic accident. As a result of the trauma, muscle was severely damaged in the upper leg and the patient had suffered a hip fracture. It was shocking to hear that this patient had undergone 18 surgeries and would need an additional surgery to remove hardware that was in his hip to aid in fracture healing. Something that made this case so complicated was that he had an infection after the orthopedic surgery for his hip. Dr. Spector told us that most of those 18 surgeries were done to clean out the wound before closing it. They had to continue going in to debride and ensure the wound was clean. They had to do this in small increments to limit muscle tissue death. A muscle flap was taken from the right rectus femoris muscle and placed over the volumetric muscle injury on the left leg. Dr. Spector said that the key to a successful flap is healthy and adequate vascularization. If the muscle flap is not appropriately vascularized, the underlying tissue and muscle that the flap is covering will have necrosis. In addition to the muscle flap, this patient had multiple skin grafts taken from healthy tissue and placed over the wound site to aid in adequate closure of the wound. In the figure below you can see the muscle flap placed over the upper portion of the leg and the darker red skin is one of the several sites where skin grafts were taken to help close the wound. The injury site was so large that more muscle flap would have been useful however, there was not enough donor tissue to take to cover the entire area, therefore skin grafts were needed to cover up the remaining area.

 In this patient, part of the area that had not been covered by the muscle flap, there was heterotopic ossification. This is a term I had never come across in reading about muscle injury. Heterotopic ossification is the formation of bone in soft tissue, where there should not be bone growth. I have read a lot about the formation of a fibrotic scar after severe muscle trauma instead of healthy muscle tissue, but had never known about bone formation following muscle injury. It was interesting to note that this ossification was occurring in the area that had not been covered with the muscle flap. Perhaps the muscle flap provided factors that prevented this heterotopic ossification? After seeing this case, I immediately wanted to read about this and learn about the underlying biology attributing to this condition. The pathophysiology behind this condition is still not exactly known but it is thought to be caused by local and systemic factors causing osteoblastic differentiation of mesenchymal stem cells. Some work has been done on the role of BMP signaling in this ectopic bone formation. However, there is still so much unknown about the cause of this ossification and therefore more research is needed. Dr. Spector said that the risks of having this heterotopic ossification is that if there is enough bone, it can go through the skin causing pain and risk for infection. In addition, bone formation where there should be muscle, can limit range of motion.

After Dr. Spector saw the patient, all those shadowing with him were able to spend some time talking with the patient. When we were talking with the patient, he said that he was just so grateful to have been able to keep his leg. Dr. Spector said that the injury was about 5 mm from the sciatic nerve and if it had been deeper, they would not have been able to salvage the limb. It has really been an invaluable experience being able to talk to the patients who have the injuries I read about day after day. You definitely don’t get this patient perspective in all the scientific journal articles. I was able to talk to the patient about the recovery from here and learned a lot about the physical therapy plan they are on. The biggest thing now is regaining as much muscle strength as possible both in the right leg where the muscle flap was taken and of course in the left leg following the severe trauma and injury to the muscle. Out of all of this, what stood out the most to me was the positivity and gratefulness of the patient. Seeing firsthand the affect good medical treatment can have on the patients has been truly inspiring.