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Zheng Y, Zhang S, Hong JP, Hallock GG, Levin LS, Zhang Y, Min P. Medial Plantar Artery Perforator Kiss Flap for Salvage of Extensive Palmar Skin Defect. Plast Reconstr Surg 2024; 153:1348-1357. [PMID: 37400951 DOI: 10.1097/prs.0000000000010909] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2023]
Abstract
BACKGROUND Flaps based on the medial plantar artery (MPA) accomplish favorable surgical outcomes in palmar resurfacing because of their outstanding texture, pliability, and contour, but primary closure cannot be achieved at the donor site when the flap is designed to be relatively large. In this study, the kiss technique was used for the reconstruction of extensive palmar defects, which minimized donor-site morbidity. METHODS A modified flap surgical strategy was systemically developed based on the perforator distribution of the MPA through a cadaver study. Two or three narrow, small skin paddles based on the MPA were raised and resembled at the recipient site as a larger flap. Static two-point discrimination, hypersensitivity and range of motion, QuickDASH, gait, and patient satisfaction were evaluated 6 months to 12 months after the operation. RESULTS From June of 2015 to July of 2021, 20 cases of reconstruction using the MPA perforator kiss flap were performed for the resurfacing of palmar skin defects. All flaps survived uneventfully, with coverage matching the texture and color of the recipients, except one flap that exhibited venous congestion and recovered after revision. Twelve flaps (60%) were double-paddled, and eight flaps (40%) were triple-paddled, with a resurfacing area of 27.19 cm 2 and 41.1 cm 2 , respectively. All donor sites achieved primary closure without major complications. CONCLUSIONS Versatile kiss flap combinations were developed based on further understanding of the MPA system. Durable and pliable characteristics of the MPA perforator flap provide excellent reconstruction for extensive palmar defects while minimizing donor-site complications. CLINICAL QUESTION/LEVEL OF EVIDENCE Therapeutic, IV.
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Affiliation(s)
- Youmao Zheng
- From the Department of Hand and Foot Surgery, Taizhou Hospital of Zhejiang Province, affiliated with Wenzhou Medical University
| | - Shunuo Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University College of Medicine
| | - Joon Pio Hong
- Department of Plastic Surgery, Asan Medical Center, University of Ulsan
| | | | - L Scott Levin
- Department of Orthopedic Surgery, University of Pennsylvania
| | - Yixin Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University College of Medicine
| | - Peiru Min
- Department of Plastic and Reconstructive Surgery, Shanghai 9th People's Hospital, Shanghai Jiao Tong University College of Medicine
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Zhou JD, Zhang XF, Xu TL, Yang WB, Xu YJ. Super-thin anterolateral thigh flap for reconstruction of the medial plantar artery perforator flap donor site. J Orthop Surg (Hong Kong) 2023; 31:10225536231181706. [PMID: 37268597 DOI: 10.1177/10225536231181706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND The medial plantar artery perforator (MPAP) flap is widely used to reconstruct the weight-bearing area of the foot. Traditionally, its donor site is closed using a skin graft, which is associated with several complications, including walking disability. This study aimed to examine our experience with using a super-thin anterolateral thigh (ALT) flap to reconstruct the MPAP flap donor site. METHODS We examined 10 patients who underwent reconstruction of the MPAP flap donor site using a super-thin ALT flap between August 2019 and March 2021. The vascular pedicle was anastomosed to the proximal end of the medial plantar vessels or the end of the posterior tibial vessels. RESULTS All reconstruction flaps survived and all patients were satisfied with the aesthetic appearance. No blisters, ulcerations, hyperpigmentation, or contractures occurred. All patients gained protective sensation in the super-thin ALT flap. The average visual analog scale score for the aesthetic appearance of the reconstructed foot was 8.5 ± 0.7 (range, 8-10). All patients were able to ambulate without aids and could wear regular shoes. The average revised Foot Function Index score was 26.4 ± 4.1 (range, 22-34). CONCLUSION Reconstruction of the MPAP flap donor site using a super-thin ALT flap is reliable and provides satisfactory functional recovery, aesthetic appearance, and protective sensation while minimizing postoperative morbidity.
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Affiliation(s)
- Jian-Dong Zhou
- Department of Foot and Ankle Surgery, Wuxi 9th People's Hospital, Affiliated to Soochow University, Wuxi, China
| | - Xing-Fei Zhang
- Department of Foot and Ankle Surgery, Wuxi 9th People's Hospital, Affiliated to Soochow University, Wuxi, China
| | - Tong-Long Xu
- Department of Foot and Ankle Surgery, Wuxi 9th People's Hospital, Affiliated to Soochow University, Wuxi, China
| | - Wen-Bo Yang
- Department of Orthopaedic Surgery, Nanjing 1st Hospital, Nanjing, China
| | - Ya-Jun Xu
- Department of Foot and Ankle Surgery, Wuxi 9th People's Hospital, Affiliated to Soochow University, Wuxi, China
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Sporer ME, Bertelli JA. Reverse Neurocutaneous Flap Based on the Dorsal Branch of the Ulnar Artery for Palm Coverage in Children: Long-Term Results. J Hand Surg Am 2022; 47:1192-1201. [PMID: 36270860 DOI: 10.1016/j.jhsa.2022.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/10/2022] [Accepted: 09/01/2022] [Indexed: 11/15/2022]
Abstract
PURPOSE Although the palm is spared mostly in severe burn injuries, it often is affected in children and requires radical excision of contracting scar tissue to allow normal hand development. Since alternatives are limited for palmar coverage, we primarily use a reverse-perfused, neurocutaneous dorsal ulnar artery flap. We report here our long-term follow-up results. METHODS We reviewed the long-term results of 10 postburn palmar contracture release and flap coverage procedures in 10 children. The applied flap was based distally on the dorsal branch of the ulnar artery and harvested along the ulnar aspect of the hand and wrist. The pivot point of the flap was located dorsally, close to the 4th and 5th metacarpal base. Patients were followed for a median period of 6 years (range, 4-20 years). RESULTS Flap size ranged from 60-130 mm in length and 20-35 mm in width. This variation in flap dimensions resulted from different hand sizes, because of the various patient ages at surgery. All flaps survived, donor site healing was uneventful, and marginal flap necrosis occurred only once. Satisfactory restoration of range of motion without secondary contractures was observed. Moreover, we detected adequate progressive growth, adaptability and sensory recovery in all flaps. Over time, the flaps mostly become hairless and progressively flattened without debulking. CONCLUSIONS The importance of this flap lies in the potential for considerable tissue mobilization to cover palmar defects without sacrificing any major vascular axis. The adequate progressive growth of the flap facilitates functional hand development in children. The predictable vascular anatomy, wide range, and durable, thin, and pliable skin make the reverse neurocutaneous dorsal ulnar artery flap an appealing option for soft tissue reconstruction of the palm in children. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic V.
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Affiliation(s)
- Matthias E Sporer
- Clinical Laboratory for Bionic Extremity Reconstruction, Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria; Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Brasil
| | - Jayme A Bertelli
- Department of Orthopedic Surgery, Governador Celso Ramos Hospital, Florianópolis, Brasil; Department of Plastic Surgery, Joana de Gusmão Children Hospital, Florianópolis, Brasil.
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Xu X, Wang C, Chen Z, Li J. Medial plantar artery perforator (MPAP) flap is an ideal option for reconstruction of complex soft tissue defect in the finger: Clinical experience from 11 cases. Front Surg 2022; 9:934173. [PMID: 35959121 PMCID: PMC9360503 DOI: 10.3389/fsurg.2022.934173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionSoft tissue defects of fingers are common in reconstructive plastic surgery, and reconstruction of the defects remains challenging for plastic surgeons. In our study, we reported our experience in finger reconstruction with a medial plantar artery perforator (MPAP) flap, especially using a lobulated MPAP flap for the complex multifinger soft defect.Patients and methodsFrom the period April 2012 to October 2018, 11 patients (9 males and 2 females) with an average age of 44 years old (ranging from 11 to 58) received finger reconstruction with a free MPAP flap. In total, 11 flaps (8 single-lobulated flaps and 3 two-lobulated flaps) were raised from the ipsilateral or contralateral instep area. Trauma and scar contracture caused hand soft tissue loss in all cases.ResultsThe sizes of the flaps ranged from 2×3 to 5×7.5 cm2. All flaps survived intact with no complications. One donor site was closed primarily, and other donor sites were covered with a full-thickness skin graft. The mean follow-up time was 6 months (ranging from 3 to 8 months). During the follow-up period, the patients were satisfied with their appearance without any traces of flap plastic surgery.ConclusionThe MPAP flap is a reliable and acceptable option for the reconstruction of complex soft tissue defects in the finger. Depending on the two branches of the medial plantar artery, the use of the lobulated MPAP flap holds promise in the treatment of multifinger soft tissue defects.
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Extensor digitorum brevis muscle flap for lower extremity coverage in a context of posttraumatic sepsis. Orthop Traumatol Surg Res 2021; 107:102901. [PMID: 33766678 DOI: 10.1016/j.otsr.2021.102901] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2019] [Revised: 07/20/2020] [Accepted: 09/14/2020] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Traumatic injuries to the distal quarter of the leg present a significant risk of skin necrosis and exposure of the underlying fracture site or the osteosynthesis material that often result in bone and joint infection. In the case of small or medium-sized bone exposure, local muscles may be one of the best options for lower extremity coverage. We describe our experience using the extensor digitorum brevis muscle flap in a context of posttraumatic bone and joint infection in fourteen patients. Our main objective was to assess the outcomes and the donor-site morbidity of the extensor digitorum brevis muscle flap. MATERIALS AND METHODS A single-center retrospective study in a French reference center for bone and joint infection from 2014 to 2018 reviewed cases of traumatic injuries with skin complications and bone and joint infection that required an extensor digitorum brevis muscle flap coverage. Fourteen patients were evaluated for early and late complications, 11 men and three women with a mean age of 51.4±17.72 (19-71) years. Seven of these were open fractures and nine cases were pilon fractures. Donor-site morbidity was assessed in nine patients. RESULTS Early flap complications included two cases (14.2%) of hematoma, one case (7.1%) of partial necrosis and four cases (28.5%) of donor-site dehiscence. Late complications caused by persistent infection were found in two patients (14.2%), with one case (7.1%) of chronic osteoarthritis and one case (7.1%) of septic pseudarthrosis. From a functional and cosmetic point of view, eight patients (89%) were satisfied, to very satisfied. CONCLUSION Experience and a multidisciplinary approach are keys in providing an optimal treatment strategy for complex cases of bone and joint infection. The extensor digitorum brevis muscle is a reliable flap for small defects with underlying infection. Being made up of muscle tissue, this flap offers good resistance to infection and enables satisfactory distribution of antibiotics. LEVEL OF EVIDENCE IV.
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Mabvuure NT, Pinto-Lopes R, Iwuagwu FC, Sierakowski A. A systematic review of outcomes following hand reconstruction using flaps from the superficial palmar branch of the radial artery (SUPBRA) system. J Plast Reconstr Aesthet Surg 2020; 74:79-93. [PMID: 33067122 DOI: 10.1016/j.bjps.2020.08.132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Accepted: 08/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Flaps based on the superficial branch of the radial artery (SUPBRA) are indicated when homo- or heterodigital flaps are inappropriate, but glabrous or like-for-like reconstruction is required. AIM To systematically review the outcomes of hand reconstruction using SUPBRA flaps. METHODS PubMed was searched for English-language articles studying SUPBRA flaps in November 2019. Data collected included flap vascular supply, dimensions, complications, donor site closure, and two-point discrimination. RESULTS Twenty-six papers were eligible (410 flaps). Flaps were classified as glabrous, nonglabrous or combined. Nonglabrous flaps were either free- (52%) or reverse-flow pedicled (1.7%) wrist flaps. Glabrous flaps were either free palmar (36.3%), reverse-flow pedicled palmar (2%), antegrade-flow pedicled palmar (0.2%) or perforator-based island palmar flaps (3.7%). Combined glabrous/nonglabrous flaps formed 4.1% of flaps. Maximal flap dimensions allowing direct closure were: 3.1 × 6 cm for wrist flaps and <3 × 10 cm for glabrous palmar flaps. Combined flaps can be 10 × 16 cm. Overall, complete and partial flap failure rates were 3.17% and 0.98%, respectively. Most complete failures were due to venous thrombosis. All 220 wrist donor sites were closed directly. Two out of 173 palmar donor sites (≥3.1) could not be primarily closed. Wound complications were rare, but 53.4% of free palmar flaps required debulking. The results of neurorrhaphy were inconsistent. CONCLUSIONS Flaps based on the SUPBRA are robust, provide like-for-like reconstruction of glabrous skin defects in one-stage, offer versatility due to diverse skin paddle orientation patterns and are in the same operative field as the defect.
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Affiliation(s)
- N T Mabvuure
- St Andrews Centre for Plastic Surgery, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, United Kingdom.
| | - R Pinto-Lopes
- St Andrews Centre for Plastic Surgery, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, United Kingdom
| | - F C Iwuagwu
- St Andrews Centre for Plastic Surgery, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, United Kingdom
| | - A Sierakowski
- St Andrews Centre for Plastic Surgery, Broomfield Hospital, Court Road, Chelmsford CM1 7ET, United Kingdom
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Systematic reappraisal of the reverse-flow medial plantar flap: From vascular anatomical concepts to surgical applications. J Plast Reconstr Aesthet Surg 2020; 73:421-433. [DOI: 10.1016/j.bjps.2019.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/24/2019] [Accepted: 10/20/2019] [Indexed: 11/17/2022]
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Successful Balanced Gait after Reconstruction of the Weight-bearing Mid Plantar Region Using a Free Contralateral Medial Plantar Flap. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 7:e2456. [PMID: 31942409 PMCID: PMC6908391 DOI: 10.1097/gox.0000000000002456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Accepted: 07/23/2019] [Indexed: 11/26/2022]
Abstract
Although soft tissue sarcoma, especially in the sole of the foot, is a rare disease, weight-bearing region reconstruction considering postoperative gait is needed. For functionally satisfactory sole reconstruction, it is important to cover the weight-bearing region with a nonbulky but durable skin paddle that can withstand a significant amount of shear pressure. We herein present a case in which a free contralateral medial plantar flap was used for reconstruction of the weight-bearing mid plantar region for a 41-year-old man who suffered from mid-foot sarcoma. Gait analysis was performed 6 months after the operation with the lower limb loading gauge sheet, and the result indicated that postoperative balanced gait was obtained. The free medial plantar flap transfer after sole sarcoma resection has several advantages. First, the characteristic of this flap with solid anchoring to deep tissue to resist shearing makes it possible to lower the chances of postoperative ulceration. Second, the medial plantar flap has optimal thickness and good color and texture match for sole reconstruction. Third, a sensate flap can be achieved if the medial plantar nerve is included. Although further clinical investigations such as long-term follow-up will be required to confirm its efficacy, this method would be one option for treating sole sarcoma.
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Kodama A, Kurose Y, Mizuseki T, Tanimoto K, Adachi N. Plantar Partial Pressure Analysis in a Patient with Reverse Extensor Digitorum Brevis Flap for the Treatment of Hallux Injury. J Orthop Case Rep 2019; 9:75-78. [PMID: 31559234 PMCID: PMC6742865 DOI: 10.13107/jocr.2250-0685.1430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Introduction An extensor digitorum brevis (EDB) flap can be used to cover a small soft-tissue defect and has been widely used as pedicled flap to cover defects around the ankle and foot. However, its post-operative functional recovery is unknown. Few reports have evaluated gait after foot flap surgeries, although gait assessment is considered to be necessary for functional evaluation after foot reconstruction. We performed a reverse EDB flap to treat a right hallux injury and conducted a plantar partial pressure (PPP) analysis as a postoperative functional evaluation. Case Report A 30-year-old laborer suffered an injury resulting in necrosis of the distal phalanx and soft-tissue defect of the proximal phalanx. After amputation, the proximal phalanx was covered with a reverse EDB flap. PPP analysis involved a 4-m-long platform system (P-Walk) and was conducted 3- and 12-month post-surgery. Walking velocity and the single-support phase on the affected limb had increased markedly after 12 months. After 12 months, the PPP of the first metatarsal head was greater than on the unaffected side, and the cadence and single-leg support rate were equal to the unaffected side. Conclusion A nearly normal gait was obtained by covering the basal part of the hallux with an EDB flap and preserving the metatarsophalangeal joint.
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Affiliation(s)
- Akira Kodama
- Department of Orthopaedic Surgery, Hiroshima Prefectural Rehabilitation Center, Higashi-Hiroshima, Hiroshima, Japan.,Department of Orthopaedic Surgery, Biomedical and Health Sciences, Hiroshima University, Higashi-Hiroshima, Hiroshima, Japan
| | - Yasuo Kurose
- Department of Orthopaedic Surgery, Hiroshima Prefectural Rehabilitation Center, Higashi-Hiroshima, Hiroshima, Japan
| | - Takaya Mizuseki
- Department of Orthopaedic Surgery, Hiroshima Prefectural Rehabilitation Center, Higashi-Hiroshima, Hiroshima, Japan
| | - Kaguna Tanimoto
- Department of Orthopaedic Surgery, Hiroshima Prefectural Rehabilitation Center, Higashi-Hiroshima, Hiroshima, Japan
| | - Nobuo Adachi
- Department of Orthopaedic Surgery, Biomedical and Health Sciences, Hiroshima University, Higashi-Hiroshima, Hiroshima, Japan
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Liu C, Liu L, Liu G, Tian S, Bai J, Yu K, Tian D. Repair of thumb defect by using the toenail flap: biomechanical analysis of donor foot-a retrospective cohort study. J Orthop Surg Res 2019; 14:287. [PMID: 31477182 PMCID: PMC6721015 DOI: 10.1186/s13018-019-1330-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 08/19/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The thumb accounts for 50% of the total hand function. This study reports the functional outcomes and complications of people with traumatic thumb amputations who underwent toe-to-thumb reconstruction. METHODS From January 2013 to January 2018, 29 patients with second-degree thumb defect underwent thumb reconstruction with distal phalangeal braided toenail flap. The footscan foot pressure gait analysis system was used to measure the index changes of the same foot before and after 1, 3 and 6 months. The contact area, peak pressure, impulse value, contact time of each gait phase, centre of gravity coordinate and foot balance were analysed statistically. RESULTS Twenty-nine cases of thumb reconstruction recovered well. After following up for 6-15 months, the appearance of the reconstructed thumb was close to normal, and the sensation was restored to S3+. The two-point discrimination was 6-8 mm, and the function of the thumb was good. The function of the donor foot was well restored, and no skin ulceration, pain and claudication were noted during walking. Compared with that before the operation, the biomechanical indices of the donor foot were basically restored to normal 6 months after the operation. Only the stress and impulse values of the third metatarsal head were significantly increased, forming a stress concentration area centred on the third metatarsal head. CONCLUSIONS This study confirmed that the toenail flap with distal phalangeal bone restored the second-degree thumb defect without destroying the main functional structure of the sole. The biomechanical indices of the donor foot were basically restored to normal 6 months after the operation. Only the stress concentration area centred on the third metatarsal head, and the pain on the forefoot was induced after the operation. Discomfort, callus formation, metatarsal fasciitis, etc., can lead to fatigue fracture of the third metatarsal bone in severe cases, which requires further follow-up and observation. TRIAL REGISTRATION Clinicaltrials.gov , NCT03879941; registered on 10 March 2019, retrospectively.
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Affiliation(s)
- Chunjie Liu
- Department of Orthopedics, Tangshan Workers Hospital, Tangshan, 063000, Hebei, People's Republic of China
| | - Lei Liu
- Department of Orthopedics, Changping District Hospital, Beijing, 102200, People's Republic of China
| | - Guoli Liu
- Department of Orthopedics, The Second Hospital Of Tangshan, Tangshan, 063000, Hebei, People's Republic of China
| | - Siyu Tian
- Department of Hand Surgery, The Third Affiliated Hospital Of Hebei Medical University, Shijiazhuang, 050017, Hebei, People's Republic of China
| | - Jiangbo Bai
- Department of Hand Surgery, The Third Affiliated Hospital Of Hebei Medical University, Shijiazhuang, 050017, Hebei, People's Republic of China
| | - Kunlun Yu
- Department of Hand Surgery, The Third Affiliated Hospital Of Hebei Medical University, Shijiazhuang, 050017, Hebei, People's Republic of China
| | - Dehu Tian
- Department of Hand Surgery, The Third Affiliated Hospital Of Hebei Medical University, Shijiazhuang, 050017, Hebei, People's Republic of China.
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Khadim MF, Emam A, Wright TC, Chapman TWL, Khan U. A comparison between the Major Trauma Centre management of complex open lower limb fractures in children and the elderly. Injury 2019; 50:1376-1381. [PMID: 31128908 DOI: 10.1016/j.injury.2019.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 04/29/2019] [Accepted: 05/02/2019] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Open lower limb fractures can be devastating with outcomes determined by tissue damage and adherence to strictly defined care pathways. Managing such injuries in paediatric and elderly populations presents logistical and technical challenges to achieve best outcomes. Orthoplastic principles were developed mainly in the young adult population whereas requirements for paediatric and elderly patients need further understanding. METHODS A retrospective analysis was performed on two groups of patients at the extremes of age, with type IIIb (severe) open lower limb fractures, presenting to a Major Trauma Centre (MTC) with orthoplastic services over a six-year period - the first group being under 16 years; the second group being over 65. The timelines of combined surgery to both fix the fracture and flap the soft-tissue defect were strictly observed. Each group were followed-up for a minimum of nine months. Data were analysed according to patient demographics, mechanism of trauma, time to wound excision, time to definitive surgery, fixation technique, soft-tissue reconstruction type, deep infection rate, flap survival, bony union, secondary amputation and functional outcome (Enneking score). RESULTS 33 paediatric patients and 99 elderly patients were identified. Paediatric: The median age was 12 years. All the children were ASA Grade I. Open tibial fractures were most common (76%) followed by ankle fracture dislocation (12%). The majority were high-energy injuries and were commonly managed with external fixators (or frames) and free flap coverage. Median hospital stay was 12 days, and time to union 114 days, with median Enneking scores of 85%. There was one flap failure and no deep infections. Elderly: The median age was 76 years. ASA grades varied and reflected multiple comorbidities. High-energy injuries required free flaps, while more common, low-energy fragility fractures were covered with loco-regional flaps. Internal fixation with intramedullary nails was most commonly used. Median hospital stay was 13 days, and time to union was 150 days, with median Enneking scores of 70%. There was one flap failure, one deep infection, and one delayed amputation. DISCUSSION These results reflect both similarities and important differences in managing open fractures in the extremes of age. The specific challenges of each group of patients are discussed, including surgical aspects, but also the importance of orthoplastics infrastructure within the MTC and input from allied professionals to facilitate patient pathways.
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Affiliation(s)
| | - Ahmed Emam
- Southmead Hospital, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK
| | - Thomas C Wright
- Southmead Hospital, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK
| | - Thomas W L Chapman
- Southmead Hospital, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK
| | - Umraz Khan
- Southmead Hospital, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK.
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Javed MU, Josty IC. Salvage of a complex first metatarso-phalangeal joint injury and synchronous reconstruction of medial collateral ligament and soft tissue with a distally based medial plantar artery flap. J Plast Reconstr Aesthet Surg 2016; 69:e61-3. [DOI: 10.1016/j.bjps.2015.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Accepted: 12/22/2015] [Indexed: 11/26/2022]
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