|Year : 2014 | Volume
| Issue : 5 | Page : 608-611
A simple and noninvasive technique using Bohlers stirrup facilitating management of posterior soft tissue injuries of heel
Nikil Jayasheelan, Jagannath Kamath, Premjit Sujir
Department of Orthopaedics, Kasturba Medical College Mangalore, Manipal University, Manipal, Karnataka, India
|Date of Web Publication||10-Sep-2014|
Room No. 306, Horizon Homes, Bejai, Mangalore - 575 004, Karnataka
Source of Support: None, Conflict of Interest: None
Introduction: Many techniques have been devised to solve the problems associated with posterior soft tissue injuries. A noninvasive technique with plaster of Paris cast mold has been described by Ravishankar. Plaster casting techniques have been associated with problems such as tight cast and cast damage. Invasive techniques using external fixators as described by Berkowitz and Kim using tubular fixators like "kick back stand" and by Kamath using ring Illizarov fixators. The external fixators have their own problems like maintaining them for weeks and pin tract infection. Materials and Methods: We have tried to achieve as noninvasive technique using a Bohler stirrup incorporated with slab for patients with only soft tissue in injury and in a fixator for patients with skeletal injury already on tubular fixators. Results: In all the 12 cases where this method was used, the authors achieved the purpose of protecting the split skin graft in four cases and flap in eight cases. We did not encounter any problems related to this method such as skin maceration, sores including loosening of the frame. Conclusion: It is a simple and noninvasive method, which can be easily and reliably performed to maintain adequate limb elevation and soft tissue protection, which can be done is any hospital setup.
Keywords: Bohler′s stirrup, heel flap, noninvasive, posterior soft tissue
|How to cite this article:|
Jayasheelan N, Kamath J, Sujir P. A simple and noninvasive technique using Bohlers stirrup facilitating management of posterior soft tissue injuries of heel. Med J DY Patil Univ 2014;7:608-11
|How to cite this URL:|
Jayasheelan N, Kamath J, Sujir P. A simple and noninvasive technique using Bohlers stirrup facilitating management of posterior soft tissue injuries of heel. Med J DY Patil Univ [serial online] 2014 [cited 2020 May 25];7:608-11. Available from: http://www.mjdrdypu.org/text.asp?2014/7/5/608/140436
| Introduction|| |
It has always been a challenge for orthopedic and plastic surgeon in protecting the posterior aspect of heel and leg from the effects of pressure following grafting and for facilitating limb elevation and the ease of maintaining elevation. Many techniques have been devised to take care of this problem. A noninvasive technique with plaster of Paris cast mold has been described by Ravishankar.  Plaster casting techniques have been associated with problems such as tight cast and cast damage. Invasive techniques using tubular fixators like "kick back stand" by Berkowitz and Kim  and ring Illizarov fixators Kamath  are presently being used. The difficulty in maintaining them for 3-4 weeks, the discomfort of position for the patient and the complications associated with the pins, especially in diabetics as described by Wukich et al.  are some of the known drawbacks. Moreover, these fixators may not be readily available with a plastic surgeon. Again application of fixators in patients with associated skeletal injury is one thing, but an invasive technique for soft tissue protection without concomitant skeletal injury in another thing to be considered. Hence, there is a need for a simple alternative method to solve this problem of posterior leg soft tissue protection.
| Materials and Methods|| |
We have tried to achieve as noninvasive technique as possible using readily available equipment. We have achieved this by using a simple Bohler stirrup  incorporated with slab for patients with only soft tissue in injury and in a fixator for patients with skeletal injury already on tubular fixators. In patients with only posterior soft tissue injury, after grafting or flap surgery a dorsal short leg well-padded plaster of Paris slab is applied [Figure 1]a. The Bohler stirrup is placed over the slab with an eye of the stirrup facing dorsal and the limbs facing posteriorly on either sides of the leg [Figure 1]b, this is then reinforced with a six inch plaster of Paris slab after making a vertical slit on the slab for the eye of the stirrup [Figure 1]c. A Steinman pin was then passed through the stirrup and tightened in place. This acts like the base of the construct. The placement of the Bohlers stirrup depends on the size and location of soft tissue injury to be protected. However, the stirrup is ideally placed over the distal third and middle third junction of leg. If the patient is already on a tubular fixator, the Bohlers stirrup can be used by connecting it to the frame using connecting clamp as shown in [Figure 2]a or by jamming the eye of the stirrup between the distal clamp and an addition clamp added at the end of the fixator tube.
By placing soft pillow below the knee, the Bohlers stirrup construct takes the pressure off the posterior graft/flap by keeping the limb adequately elevated. If required, the elevation can be maintained by applying horizontal traction through the eye of the stirrup over a Balkan frame as shown in [Figure 2]b. This construct also helps patient to change posture with ease. More so, this construct can be maintained for weeks without any associated complications. This method of pedicle/graft protection is maintained generally for a period of 2 weeks or until such time the graft/flap settles. In our experience, we have never used it beyond 3 weeks. The Bohlers stirrup and slab can be removed once the graft/flap has healed and when used with external fixator the stirrup can be removed, and the fixator to be maintained for management of the fracture.
| Results|| |
All the 12 cases where this method was used, the authors achieved the purpose of this method of protecting the split skin graft (SSG) in four cases and fl ap in eight cases as shown in [Figure 3] a-d and [Figure 4] a-c. We did not encounter any problems related to this method such as skin maceration, sores including loosening of the frame.
| Discussion|| |
Many invasive and noninvasive methods are being currently used in the management of posterior soft tissue injury with the aim of trying to keep the limb elevated so as to relieve pressure of the graft or the pedicle. Patients are at-risk of developing pressure sores over the heel when immobilized in the same position for a long time. As far as our knowledge goes the only noninvasive technique by using plaster of Paris cast was described by Ravishankar.  However, we are all familiar with complications associated with application of tight cast and cast damage. The invasive techniques which are being commonly used in the form of fixators are a simple and reliable method for maintaining limb elevation. They are associated with problems, especially if they have to be maintained for more than 3-4 weeks. When the fixators are applied on patients who do not have any associated fractures will have to experience a considerable amount of pain and discomfort. The Bohler's stirrup method as described by us is simple and reliable which is easy to perform The Bohler's stirrup is readily available in every hospital and it considerably low cost as compared to external fixator. We have found that it is far more comfortable for the patient in positioning the limb as well as in ambulation. There is no need to worry about pin tract infections or other complications associated with external fixators especially in diabetics when using our Bohlers stirrup method. We have used this method in 12 patients for the past 3 years (one case of open tendo-achilles tear treated with perforated based V-Y flap, four cases of superficial soft tissue loss of distal leg and the heel was treated with SSG, one case was treated with posterior tibial artery flap and rest six cases with soft tissue loss of distal leg and the heel was treated with sural artery flap). We have never experienced any untoward effects, which could be directly attributed to this method. Patient compliance has been excellent.
This report extends the importance and one more use of the Bohlers stirrup in the management of posterior soft tissue injury of leg. It is a simple and noninvasive method, which can be easily and reliably performed to maintain adequate limb elevation and soft tissue protection, which can be done is any hospital setup.
| References|| |
|1.||Ravishankar R. Pedicle protection for flap surgery for posterior heel defects. Indian J Plastic Surg 2004;37:81. |
|2.||Berkowitz MJ, Kim DH. Using an external fixation "kickstand" to prevent soft-tissue complications and facilitate wound management in traumatized extremities. Am J Orthop (Belle Mead NJ) 2008;37:162-4. |
|3.||Kamath JB. A simple method for pedicle protection in flap surgery for posterior heel defects. Indian J Plastic Surg 2003;36:104-5. |
|4.||Wukich DK, Belczyk RJ, Burns PR, Frykberg RG. Complications encountered with circular ring fixation in persons with diabetes mellitus. Foot Ankle Int 2008;29:994-1000. |
|5.||John DM, Stewart JP. Traction and Orthopedic Appliances. 2 nd ed. Hallett: Churchill Livingstone; 1983. p. 5. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4]