Synergistic strategies for comprehensive management of Morel-Lavallee lesion

INTRODUCTION

A Morel-Lavallee lesion is a closed soft-tissue injury, with boggy swelling associated with underlying fluid collection resulting from the separation of the dermis from the underlying fascia due to shearing forces. This can be associated with high-energy trauma associated with other bony injuries or can rarely occur in low-energy injuries associated with only soft-tissue injuries.^[1] The first description of this injury was by Dr. Maurice Morel-Lavallée in the mid-19^th century in a patient who had fallen from a train.^[2] This is a relatively rare injury in which tangential forces on the soft-tissue result in the shearing of the overlying soft tissue from the underlying fascia, resulting in the rupture of the feeding blood vessels. These ruptured blood vessels bleed into the dead space created between the layers, resulting in a seroma formation, accumulation of lymphatic fluid, and, at times, overlying skin necrosis due to poor blood supply.^[1-3]

The soft tissues, if not addressed early, will continue to move abnormally, increasing the collection and, at times, resulting in secondary bacterial infection.^[2,3] These injuries are commonly seen in areas with an abundance of fat and increased subcutaneous tissue. Injuries around the hips, greater trochanters, buttocks, thighs, and abdomen are the most common anatomical areas where these injuries are frequently reported.^[1-3]

The incidence of these injuries is very low (0.7 % of total motor vehicle accidents).^[2] Despite their rarity, they are very challenging to treat. One of the reasons for such a low incidence is that these injuries are associated with other injuries; they are often undiagnosed or end up being diagnosed later. Rarely, these injuries can occur without bony injuries and tend to get neglected initially, which can result in poor outcomes or increased morbidity to the patient.^[4,5]

Conservative management, in the form of compression bandages and a wait-and-see approach, has been shown to yield poor results. Minimal invasive approaches, such as aspiration and injection of sclerosants, have been tried; however, higher rates of recurrence have been reported. Surgical management in the form of debridement, curetting the dead space, and suturing has been reported to yield better results; however, it is associated with complications, such as neurovascular injuries and skin necrosis. To date, there is no established gold standard treatment strategy for managing these injuries.^[3-5]

This paper aimed to present our treatment strategies for successfully managing these injuries using a combined approach, which includes extensive debridement, the use of tissue glue to facilitate adhesion between the separated layers, along with under-vision suturing/quilting, followed by the use of customized compression garments. Trying a combination of approaches is more rewarding in managing Morale-Lavallee lesions, which otherwise can become a nightmare for treating clinicians.

MATERIALS AND METHODS

This study was carried out in a tertiary hospital. The study period was from January 2020 to July 2023. Our sample size consisted of 11 patients diagnosed with Morel-Lavallee lesions. All patients were clinically diagnosed with a MorelLavallee lesion and underwent ultrasonography to assess the size and contents of the lesion.

Surgical technique

All our patients had lesions in the pelvis or the lower limb. Most cases were performed under spinal anesthesia, and a few were performed under general anesthesia. The lesion is first marked superficially with a skin marker. Depending on the location, a dependent area is chosen for the incision. The soft tissues are dissected and the dead space is reached and debrided. The fluid is collected for culture and sensitivity in all cases. A large curette is passed in multiple directions to curette out the floor and the roof of the dead space and the soft tissues are sucked out intermittently with suction. Tissue samples are also routinely sent for culture and sensitivity analysis. A thorough wash is performed to flush out the debris from the dead space.

The soft tissues are retracted and 2.0 non-absorbable (Ethilon^™) deep suture bites (quilting) are taken under vision, such that the skin and soft tissues are approximated with the underlying soft tissue or muscles. Care is taken while passing the suture needle in anatomical areas with close proximity to neurovascular bundles. In regions with safe zones, sutures are passed blindly.

Once the top layer is secured to the underlying layer with sutures, multiple vials of tissue glue are injected between the spaces, and a large-bore suction drain is placed. A tight compression bandage is put on. Care should be taken not to open the suction drain in the first 24 h postoperatively, as it would suck out all the tissue glue.

Two cases underwent intramedullary nailing of the femur on the same day, whereas one patient had to wait for a week. The suction drains are removed after 72 h, and the sutures are removed 2 weeks after surgery. Customized compression garments are measured a few days before suture removal and are kept ready for use once the sutures are removed. This is to facilitate the immediate application of pressure garments, which would minimize the chances of recurrence or any collections between the delaminated soft-tissue layers. The patients were instructed to use the garments for almost the entire day [Figures 1 and 2].

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Figure 1:

(a) Morel-Lavallee lesion over the gluteal region, (b) intraoperative picture showing the pseudo capsule formation (Blue arrow), (c) clinical picture at post-operative follow-up at 3 weeks, (d - e) clinical picture showing customized compression garments, and (f) clinical picture at 6 months follow-up showing no recurrence.

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Figure 2:

(a) Morel-Lavallee lesion over the left knee, (b) intraoperative picture showing the quilting suture and drain tube, (c) clinical picture at 3 weeks follow-up, (d) Clinical picture showing customized compression garments, and (e - f) clinical picture at 6 months follow-up showing no recurrence.

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RESULTS

Of the 11 patients, seven were male and four were female. All patients were primarily seen in our trauma center, except for patient number 2, who was referred from another hospital 1 week after the injury. Most patients underwent surgery on the 2^nd day of admission under the elective operation list.

Patients were followed up at 2 weeks, 1 month, and 6 months postoperatively. The pressure garments were discontinued 1 month after surgery. All patients had good outcomes with no recurrence. One of the patients had partial skin necrosis between the sutures, which went on to heal with secondary intention [Table 1].

DISCUSSION

Morel-Lavallee lesions are a type of degloving injury caused by tangential forces, resulting in an internal degloving or delamination between the soft-tissue layers. This results in a potential dead space which can get filled up with blood, lymph, and seroma. The shear forces result in the disruption of the blood vessels and lymphatics.^[1-3] Over a period of time, the fat undergoes necrosis and liquefaction, resulting in an ongoing seroma collection. This gradual process results in the formation of a pseudo capsule, which makes them more challenging to manage. These may then become infected due to a secondary bacterial infection, which can further complicate the treatment. Thus, the duration of injury and the timing of early intervention become crucial in successfully managing these cases.^[4-6]

These lesions are commonly noted in areas with a predominant amount of fat and subcutaneous tissue. The frequency per site has been reported as follows: Pelvic 69.1%, knee 15.7%, gluteal 6.4%, lumbosacral 3.4%, abdominal wall 1.5%, lower leg 1.5%, head 0.5%, and 2% unspecified.^[6]

Morel-Lavallee lesions are commonly associated with boggy, fluctuant swelling, redness, ecchymosis, bruising, and pain. However, in some patients, the clinical findings may not be apparent immediately following the injury. At times, MorelLavallee lesions can be easily missed in cases with other injuries, especially those associated with bony injuries, which would likely draw the attention of both patients and clinicians.^[3,5]

Investigation modalities such as ultrasonography and magnetic resonance imaging have been suggested for diagnosing Morel-Lavallee lesions. These modalities only aid in better understanding the dimensions of the lesions and their contents. A good history and thorough clinical examination, aided by the above-mentioned investigation, can confirm the diagnosis. However, the authors believe that Morel-Lavallee lesions are more of a clinical diagnosis and should not be dependent on any radiological investigation.^[1-3,6]

There are various treatment options for these lesions; however, no single treatment modality has been established as the gold standard for their management. Conservative approaches, such as a wait-and-see approach along with a compression bandage, have yielded poor results in the past. Lesions aspirated with <50 mL have shown better results with conservative management, as they are believed not to form a pseudo-capsule.^[5,7]

Minimal intervention in the form of repeated aspirations and injecting the sclerosants has also shown poor results and higher recurrence rates. The recurrence rates were higher, mainly due to persisting dead space with pseudo-capsule formation.^[4-6]

Minimal invasive procedures, such as endoscopic debridement and tissue glue application, have shown promising results by some authors. These procedures involve smaller incisions and less tissue handling, thereby reducing morbidity. However, authors believe that in larger lesions with more delaminated soft tissue, endoscopic aspiration alone may not be sufficient. Percutaneous drainage and quilting have been reported to yield good results.^[3] However, not all anatomical areas can be addressed with a percutaneous approach.^[3]

A formal open debridement with thorough curettage of the pseudo-capsules is very much essential to prevent recurrence. Surgeons must be mindful of not excessively curetting the superficial skin, which may lead to necrosis. Following the curettage, the delaminated/separated layers have to be approximated with deep sutures (quilting), aided by tissue glue.^[6,7]

In our case series, all the patients underwent open debridement, quilting, and tissue glue application. Tissue glue would facilitate the adhesion of the separated layers. This would be in addition to the quilting sutures. The minimally invasive procedure cannot be confidently done in areas with close proximity to neurovascular bundles, which is not the case with an open procedure. The authors believe that recurrence can be further minimized using customized compression garments during the post-operative period. None of our patients had a recurrence.

The smaller sample size is a limitation of our study. The authors believe that a larger sample size and a multicenter comparative study can lead to a more structured protocol for successfully managing Morel-Lavallee lesions.

CONCLUSION

Persistent dead space, pseudo-capsule, and superficial mobile soft tissue are the culprits in the Morel-Lavallee lesion. A Morel-Lavallee lesion requires a combination of debridement, securing of superficial mobile soft tissue with sutures and adhesive agents, along with providing soft tissue compression using customized compression garments. The authors emphasize that the treatment of Morel-Lavallee lesions requires a synergistic approach. The usage of customized pressure garments is as important as the surgical procedure itself. With customized pressure garments, the recurrence can be minimized. Our approach is easily reproducible with good results.