Reconstructive strategies for soft-tissue defects in pediatric spine surgery

BACKGROUND: Wound dehiscence following a spinal procedure is likely one of the main problems in spine surgery because of the few options to achieve skin covering. This occurrence hardly ever happens in healthy children after scoliosis correction or bone fracture fixation, whereas it is a frequent problem of children affected by spinal dysraphism and neuromuscular spinal deformities. These patients represent a subgroup of the pediatric population with multiple risk factors for wound complications. Healing of soft-tissue defects with dressings often fails, so coverage is better achieved with fascio-cutaneous, muscle, or musculo-cutaneous flaps. We report a case series from the Scoliosis Treatment Center of IRCCS Giannina Gaslini Institute and discuss flap-planning basing on the defect size, the region, and the available soft-tissues as donors. METHODS: From 2007 to 2019, 36 patients surgically treated for spinal deformity experienced a complication: seroma in 4 patients, early surgical site infection in 16 patients, pressure sores in 9 patients, late exposure of spinal instrumentation in 7 patients. Coverage of the defect was achieved by local flaps (advancement or rotational) in 14 patients and pedicle flaps in 22 patients (4 gluteus maximus myocutaneous flaps, 3 gluteal fasciocutaneous flaps, 5 biceps femoriss myocutaneous flaps, 1 gracilis myocutaneous flap, 5 reverse latissimus dorsi myocutaneous flaps, 3 superior gluteal artery perforator flaps, 1 inferior gluteal artery perforator flap). RESULTS: After soft-tissue reconstruction, major complications occurred in 4 patients (11%) with partial loss of flap requiring revision surgery; minor complications occurred in 3 (8.3%) patients with partial wound dehiscence. Additional surgery was needed and the complete healing occurred in all cases. CONCLUSIONS: Management of complex wounds of the back after surgery is challenging. Early treatment requires radical debridement and flap coverage to reduce the risk of hardware removal. Prophylactic coverage of the hardware with muscle flaps may improve the outcome.