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Table of Contents
CASE REPORT
Year : 2021  |  Volume : 11  |  Issue : 2  |  Page : 98-101

Limb salvage following snakebite using acute limb shortening and secondary lengthening


1 Department of Burns and Plastic Surgery, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Orthopedics, AIIMS, Rishikesh, Uttarakhand, India

Date of Submission07-Apr-2020
Date of Acceptance25-Sep-2020
Date of Web Publication29-Jun-2021

Correspondence Address:
Dr. Debarati Chattopadhyay
Department of Burns and Plastic Surgery, AIIMS, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/IJCIIS.IJCIIS_43_20

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   Abstract 


A case of 16-year-old boy from the remote tribal population of Uttarakhand is described, who sustained a viper snakebite. The patient after various interventions and referrals developed locoregional and systemic complications. He not only had an open tibiofibular fracture but a large bimalleolar defect over his lower limb. The wound infection with underlying osteomyelitis progressed to septic shock and failure of the conventional cross-leg flap. Computed tomography scan of the limb revealed a single patent vessel, eliminating the option of microvascular flap. Limb amputation was considered for source control; however, in an attempt to salvage the limb, the novel approach of acute limb shortening with secondary limb lengthening was performed with parental consent, an approach not previously reported in the management of snakebite injuries. Adequate infection control was achieved following removal of the osteomyelitic bone, and the defect was covered with overlapping tissue from the docked limb and a cross-thigh flap. Secondary lengthening was performed after 3 months, and following extensive surgical and rehabilitative interventions, the boy's limb was salvaged and he retains a near-normal gait. This case report entails a detailed account of how mutilating a snakebite injury could be and how unconventional techniques like acute limb shortening with secondary lengthening can be used in such injuries.

Keywords: Antivenin, case report, limb salvage, snakebite


How to cite this article:
Mahakalkar SS, Choudhury AK, Vathulya M, Goyal T, Chattopadhyay D. Limb salvage following snakebite using acute limb shortening and secondary lengthening. Int J Crit Illn Inj Sci 2021;11:98-101

How to cite this URL:
Mahakalkar SS, Choudhury AK, Vathulya M, Goyal T, Chattopadhyay D. Limb salvage following snakebite using acute limb shortening and secondary lengthening. Int J Crit Illn Inj Sci [serial online] 2021 [cited 2022 Dec 9];11:98-101. Available from: https://www.ijciis.org/text.asp?2021/11/2/98/319780




   Introduction Top


Snakebites remain a neglected public health problem in many tropical and subtropical countries. In India, up to 2 million people are envenomed by snakes annually and up to 50,000 deaths occur.[1] In addition to the mortality, snake envenoming causes a multitude of morbidities, most frequent of them being amputations and permanent disabilities.[2]

Frequently, the problem is associated with remote places where the primary attending medic is often a “Vish Vaidya,” who is unqualified and relies on applying local herbs to the wound to address the problem.[3] As such, this practice has no proved scientific benefit and usually serves only to delay the treatment.

Management of sequelae of snake envenoming in the limbs remains a reconstructive challenge because of the extensive tissue loss and limb ischemia as well as secondary infection at the bite site which may delay or complicate reconstruction.[4]

The goal of reconstruction in such a case should be to achieve as much functional recovery as possible. Often, the usual reconstructive techniques are found inadequate and an out of the box solution is put to use. The method of acute limb shortening with secondary lengthening has been described in the literature for major trauma in the leg, but the technique has never been used in snakebite.[5]

In this article, a case of snakebite injury to the lower limb of a young male and the unique mode of limb salvage is described. In addition, it also highlights the disastrous consequence of snakebite injury due to delay in proper treatment.


   Case Report Top


A 16-year boy from a remote village in Uttarakhand sustained a viperous snakebite over his left leg. He was initially managed by an indigenous medic called “Vish Vaidya.” A tight tourniquet was applied and he was treated with plant extracts. His condition deteriorated and he was admitted to the hospital after 3 days where he received anti-snake venom (ASV). However, extensive cellulitis had already ensued. Debridement was done and an external fixator applied for stabilization of the ankle joint. His general condition deteriorated further and he was referred to our center after a week.

He presented with sepsis, renal failure, and grossly swollen left leg and exposure of the entire ankle joint. He was febrile (101°C), had a heart rate of 110/min, systolic blood pressure was 80 mmHg (diastolic not recordable), respiratory rate was 24/min, and there was no urine output in the last 12 h. Blood investigations revealed a hemoglobin of 7.5 g/dl, hematocrit was 25%, and total leukocyte count was 42,000 (band cells: 12%). Creatinine was 5.5 mg/dl and blood urea nitrogen (BUN) was 210 mg/dl. Serum lactate was 5 mmol/L and bicarbonates were 12 mEq/L. There was a positive response to fluid repletion test and BUN: plasma creatinine ratio was 38:1, urine sodium: 15 mEq/L, urine osmolality: 600 mosmol/L H2O suggesting prerenal failure. The patient was kept on intravenous ceftriaxone and metronidazole initially. The patient also required inotropic support to normalize the blood pressure. Dialysis was done to improve the renal profile. Antibiotics were changed in accordance to cultures. Serial debridement was carried out once the patient was stabilized. An almost circumferential defect was created, encompassing both malleoli and lower third of the leg with preservation of a small anterior skin bridge. The underlying bone was necrotic due to envenomation and was also debrided [Figure 1]. Computed tomography angiogram revealed monophasic flow in only the anterior tibial artery.
Figure 1: Extensive defect of the left leg

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No locoregional flaps were deemed suitable for the large soft-tissue defect. A free flap could also not be planned owing to the poor general condition and the risk of interruption in the only surviving blood vessel. A cross-thigh flap was done. A cross-thigh flap is a fasciocutaneous flap taken from the normal limb to cover the defect on the affected limb. This flap also failed due to extensive purulent discharge from the underlying bone. Due to these enormous limitations, coverage of the defect was deemed impossible. As a last resort of limb salvage, acute limb shortening with secondary limb lengthening was planned, keeping in mind the only strength of the case, the patient's young age. The procedure was explained to the patient and his family and consent was obtained.

Five centimeter of the infected tibia and 5 cm of the fibula were removed. The bone was docked. The limb was stabilized with an external fixator with arthrodesis of the tibiotalar joint. The maximum leg defect was covered with the overlapping tissue from the docked limb. The remaining bimalleolar defect was resurfaced with a cross-thigh flap of size 30 cm × 9 cm. Three weeks later, the flap was divided. The resultant limb was thus shortened by 15 cm.

Three months later, secondary limb lengthening was done. Double corticotomy was performed in the proximal and distal parts of the tibia. A four-ring Ilizarov's external fixator was applied [Figure 2a and [Figure 2]b. Distraction continued at 1 mm/day for a total of 75 days at each corticotomy site. Once satisfactory limb lengthening was achieved, the external fixator was retained in the same position for a total of 150 days for the consolidation of the regenerate. Gradual weight-bearing was then allowed. Residual limb shortening of about 3 cm remained, for which he was provided customized footwear [Figure 3]a and [Figure 3]b.
Figure 2: (a) Leg with illzarov's external fixator with well-settled flap. (b) X-rays showing dual corticotomies with arthrodesis of the ankle joint

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Figure 3: (a) Both the limbs in the supine position after removal of distractors. .(b) The patient standing with customized footwear

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Two years' follow-up showed a tall young man of 18 years who had completed school and can take part in farming in his ancestral lands. He is now able to walk with corrective shoes and minimum support [Video 1].


   Discussion Top


Snakebite envenomation is a serious and important problem in tropical and subtropical countries. Prevalence is most common in rural areas among poor farming communities. The lower limb is the most common site of the bite (53.57%).[6]

Snakebite carries the consequences of envenomation ranging from localized ulceration to gross tissue necrosis. The proteolytic properties of snake venom cause extensive tissue destruction and devitalization. Despite the administration of ASV, this dead tissue can acquire secondary infection from the snake's oral flora inoculated at the time of the bite.[7]

Yet, another problem is its prevalence in rural locations. Delays in anti-venom treatment can lead to detrimental outcomes like gangrene and death. Added to this is the universal use of tight ligatures by local practitioners, despite being condemned by snakebite experts. Such ligatures add to the ischemic damage to the tissues, increasing the necrotizing effects of venoms and the potential adverse physiologic effects that may be seen on release, including hypotension, coagulopathy, and neurotoxicity.[8]

Even where the life is saved, limb salvage remains difficult. Snakebite injury poses a serious reconstructive challenge because of the enormous local and systemic complications involved. Apart from acute systemic toxic effects of envenomation, local complications such as compartment syndrome, cellulitis and skin necrosis, secondary infections, and extensive necrosis of muscles and bones are often present.[9],[10] These preclude the reconstructive surgeon from following the usual reconstructive ladder. Since the patients are mostly farmers or manual laborers, limb saving is of utmost importance for them to be able to earn at all. To achieve the maximum chance of limb saving and functional recovery, unusual methods have to be sought for.

The orthopedic procedure of acute bone shortening and docking followed by distraction has been described in severe trauma. However, the procedure has not been, to the author's knowledge, documented so far in snakebite injury. This method can be used in patients with contraindications to local/free flaps and it eliminates the need for long surgical procedures for soft tissue and bone reconstructions.[11],[12] Both these conditions arise in snakebite, and hence, this technique may be utilized. Moreover, since the entire necrotic tissue can be removed in one go, the systemic recovery is hastened.

Eventually, by application of this technique, salvage of the entire limb and a near-normal gait with minimal use of orthotics in a young person were achieved. Our case is the first described in the literature where acute limb shortening with secondary limb lengthening has been used successfully for limb salvage in snakebite injury.


   Conclusion Top


Snakebite injury is to be managed in a multidisciplinary team approach and all efforts to salvage the limb should be employed until all reconstructive options are exhausted in such complex limb defects to achieve optimum function. Limb shortening and secondary lengthening can be used as a last option when all other reconstructive options are exhausted. Considering the remote nature of this problem, public awareness and education along with strengthening community health centers and prudent early referral to centers with reconstruction facility will enhance the chance of life and limb survival.

Research quality and ethics statement

This case report did not require approval by the Institutional Review Board / Ethics Committee. The authors followed applicable EQUATOR Network (http://www.equator-network.org/) guidelines, specifically the CARE guideline, during the conduct of this research project.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Mohapatra B, Warrell DA, Suraweera W, Bhatia P, Dhingra N, Jotkar RM, et al. Snakebite mortality in India: A nationally representative mortality survey. PLoS Negl Trop Dis 2011;5:e1018.  Back to cited text no. 1
    
2.
Yadav AK, Bhandari R, Agrahari AK, Gupta R, Shah MK. Physiological amputation of limb (limb gangrene) after tourniquet application for 12 days following snake bite. J BP Koirala Institute Health Sci 2018;1:101-4.  Back to cited text no. 2
    
3.
Kala CP. Herbal treatment for snakebites in Uttarakhand state of India. Indian J Nat Prod Res 2015;6:56-61.  Back to cited text no. 3
    
4.
Lee JH, Jang SW, Kim CH, Ahn HC, Choi MS. Reconstruction of soft tissue defects after snake bites. Arch Plast Surg 2009;36:605-10.  Back to cited text no. 4
    
5.
Yokoyama K, Itoman M, Nakamura K, Uchino M, Tsukamoto T, Suzuki T. Primary shortening with secondary limb lengthening for Gustilo IIIB open tibial fractures: A report of six cases. J Trauma 2006;61:172-80.  Back to cited text no. 5
    
6.
Joshi SC, Prakash C, Joshi A, Joshi G, Nigam P. Profile of snakebite cases admitted at a tertiary care centre. J Indian Acad Forensic Med 2012;34:217-9.  Back to cited text no. 6
    
7.
Goldstein EJ, Citron DM, Gonzales H. Bacteriology of rattlesnake venom and implications of therapy. J Infect Dis 1979;140:818-21.  Back to cited text no. 7
    
8.
WHO/SEARO Guidelines for the clinical management of snake bites in the Southeast Asian region. Southeast Asian J Trop Med Public Health 1999;30 Suppl 1:1-85.  Back to cited text no. 8
    
9.
Waiddyanatha S, Silva A, Siribaddana S, Isbister GK. Long-term effects of snake envenoming. Toxins (Basel) 2019;11:125.  Back to cited text no. 9
    
10.
Jayawardana S, Arambepola C, Chang T, Gnanathasan A. Long-term health complications following snake envenoming. J. Multidiscip. Healthc 2018;11:279-85.  Back to cited text no. 10
    
11.
Tiefenboeck TM, Zak L, Bukaty A, Wozasek GE. Pitfalls in automatic limb lengthening-First results with an intramedullary lengthening device. Orthop Traumatol Surg Res 2016;102:851-5.  Back to cited text no. 11
    
12.
Lerner A, Fodor L, Soudry M, Peled IJ, Herer D, Ullmann Y. Acute shortening: Modular treatment modality for severe combined bone and soft tissue loss of the extremities. J Trauma 2004;57:603-8.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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