Use of the vascular pedicle of a previously transferred muscle as the recipient vessel for a subsequent vascularized bone flap

Treatment of Posttraumatic Tibial Diaphyseal Bone Defects: A Systematic Review and Meta-Analysis

OBJECTIVE

To describe evidenced-based treatment options for patients who sustained trauma and/or posttraumatic osteomyelitis of the tibia resulting in diaphyseal bone defects and to compare outcomes between patients treated with nonvascularized bone grafts (NBGs), bone transport (BT), or vascularized bone grafts (VBGs).

DATA SOURCE

The Preferred Reporting Items for Systematic Review and Meta-Analyses of individual participant data and Cochrane guidelines were followed. PubMed, EMBASE, Cochrane Library, Web of Science, Scopus, and CINAHL were searched from inception to June 2020.

STUDY SELECTION

Patients who were ≥18 years, had sustained trauma to the tibia resulting in fracture and/or osteomyelitis with measurable diaphyseal bone defects, and were treated by interventions such as NBGs, BT, or VBGs were eligible. Excluded studies were non-English, reviews, nonreviewed literature, cadavers, animals, unavailable full texts, nondiaphyseal defects, atrophic nonunions, malignancy, and replantations.

DATA EXTRACTION

A total of 108 studies were included with 826 patients. Two reviewers systematically/independently screened titles/abstracts, followed by full texts to ensure quality, accuracy, and consensus among authors for inclusion/exclusion of studies. A third reviewer addressed disagreements if investigators were unable to reach a consensus. Studies were quality assessed using "Methodological Quality and Synthesis of Case Series and Case Reports".

DATA SYNTHESIS

Analyses were performed with IBM SPSS version 25.0 (IBM Corporation, Armonk, NY) and G*Power3.1.9.2.

CONCLUSIONS

NBGs may be considered first line for trauma defect sizes ≤ 10 cm or posttraumatic osteomyelitis defect sizes <5 cm. BT may be considered first line for posttraumatic osteomyelitis defect sizes <5 cm. VBGs may be considered first line for trauma and posttraumatic osteomyelitis defect sizes ≥5 cm.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A "green" approach to secondary reconstruction: the concept of the recycle flap and a classification

BACKGROUND

Harvesting soft tissue from a previously transferred flap allows for flap reshaping and simultaneously raising tissue for a secondary procedure. This is done without increasing the number of donor sites and is therefore a very attractive reconstructive option.

METHODS

Between March of 2011 and October of 2013, the authors performed 60 recycle flaps on 60 patients (three women and 57 men) who had undergone previous flap reconstruction (52 free and eight pedicled). The recycle flaps were raised as either random pattern or perforator flaps. Mean time between primary reconstruction and the recycle procedure was 28.3 months (range, 6 months to 20 years), and the mean age of our patients was 57 years (range, 21 to 78 years).

RESULTS

Of 60 recycle flaps raised for secondary reconstruction, 58 survived completely (97 percent). Two cases of total flap necrosis were encountered resulting from pedicle damage during attempted perforator dissection within a previously irradiated flap. Twenty-nine flaps were raised as random pattern flaps, 29 were raised as pedicled perforator flaps (20 with perforator skeletonization), and two were raised as free perforator flaps.

CONCLUSIONS

There are a number of ways to safely "recycle" the soft tissues used in a previous reconstruction. This provides new tissue for a secondary procedure while debulking and refining the primary flap. Raising perforator flaps from previously irradiated flaps is, however, technically challenging and carries a high risk of flap necrosis (40 percent in our series) and should be advised against.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Current Practice in the Management of Open Fractures Among Orthopaedic Trauma Surgeons. Part B: Management of Segmental Long Bone Defects. A Survey of Orthopaedic Trauma Association Members

OBJECTIVES

Treatment of segmental long bone defects is one of the areas of substantial controversy in current orthopaedic trauma. The main purpose of this survey was to determine current practice and practice variation within the Orthopaedic Trauma Association (OTA) membership on this topic.

DESIGN

Survey.

SETTING

Web-based survey.

PARTICIPANTS

Three hundred seventy-nine orthopaedic trauma surgeons.

METHODS

A 15-item questionnaire-based study titled "OTA Open Fracture Survey" was constructed. The survey was delivered to all OTA membership categories. Different components of the data charts were used to analyze various aspects of open fracture management, focusing on definitive treatment and materials used for grafting in "critical-sized" segmental bone defects.

RESULTS

Between July and August 2012, a total of 379/1545 members responded for a 25% response rate. Overall, 89.5% (339/379) of respondents use some sort of antibiotic cement spacer before bone grafting. It was found that 92% of respondents preferred to use some type of autograft at time of definitive grafting of segmental defects. When using a grafting technique, 88% said they used some type of antibiotic cement. Within that context, 60.1% said graft placement should be done at 6 weeks.

CONCLUSIONS

There continues to be substantial variation in the timing of bone graft placement after soft tissue healing and the source and form of graft used. The use of antibiotic cement is common in segmental defects that require delayed bone grafting. Obtaining base-line practice characteristics on controversial topics will help provide a foundation for assessing research needs and, therefore, goals.

LEVEL OF EVIDENCE

Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Free-style puzzle flap: the concept of recycling a perforator flap

Theoretically, a flap can be supplied by any perforator based on the angiosome theory. In this study, the technique of free-style perforator flap dissection was used to harvest a pedicled or free skin flap from a previous free flap for a second difficult reconstruction. The authors call this a free-style puzzle flap. For the past 3 years, the authors treated 13 patients in whom 12 pedicled free-style puzzle flaps were harvested from previous redundant free flaps and recycled to reconstruct soft-tissue defects at various anatomical locations. One free-style free puzzle flap was harvested from a previous anterolateral thigh flap for buccal cancer to reconstruct a foot defect. Total flap survival was attained in 12 of 13 flaps. One transferred flap failed completely. This patient had received postoperative radiotherapy after the initial cancer ablation and free anterolateral thigh flap reconstruction. Another free flap was used to close and reconstruct the wound. All the donor sites could be closed primarily. The free-style puzzle flap, harvested from a previous redundant free flap and used as a perforator flap to reconstruct a new defect, has proven to be versatile and reliable. When indicated, it is an alternative donor site for further reconstruction of soft-tissue defects.

Reconstruction of major traumatic segmental bone defects of the tibia with vascularized bone transfers

BACKGROUND

Segmental bone defects of the tibia after high-energy trauma are limb-threatening conditions. Multiple treatment options have been proposed, including nonvascularized bone grafts, vascularized bone transfers, and callus distraction. A series of 41 patients with major segmental defects of the tibia treated with vascularized bone reconstruction is presented.

METHODS

Forty-one acute or nonacute segmental bone defects of the tibia, 4 cm or more in length, were included in the series. In acute defects (nine cases), a single-stage or two-stage reconstruction with vascularized bone transfer was performed. In nonacute segmental infected bone defects (32 cases), single-stage reconstruction with vascularized bone transfer (seven cases) or two-stage reconstruction with vascularized bone transfer (25 cases) was performed. Reconstruction was performed with fibular flaps in 38 cases (36 contralateral free and two ipsilateral pedicled flaps) and iliac flaps in three cases. Bone fixation was performed with screws and external fixation, with early conversion to locking plate internal fixation.

RESULTS

Two fibular flaps needed urgent revision for venous congestion. One fibular flap was lost. Infection after vascularized bone transfer occurred in two delayed reconstructions. Bone healing occurred in all cases. Stress fractures occurred in three fibular flaps. Time to bone union was 5 to 9 months, and time to full weight bearing was 9 to 14 months.

CONCLUSIONS

The use of vascularized bone transfer in the treatment of major segmental tibial defects was successful in the present series. The management of bone fixation and infection in these cases is discussed.

Primary shortening with secondary limb lengthening for Gustilo IIIB open tibial fractures: a report of six cases

BACKGROUND

The treatment of type IIIB open tibial fractures remains a challenge for orthopedic surgeons, particularly with respect to the soft-tissue and subsequent bony reconstruction. The primary shortening and limb lengthening (PSLL) simplifies wound closure for severe open injuries without requiring microsurgical procedures as a main advantage. This method is thought to be also useful for type IIIB patients with polytrauma and other life-threatening injuries because it helps to control both wound sepsis and their general state. In the present study, we attempted to assess the problems, long-term functional outcome, and quality of life (QOL) of patients who were treated by PSLL for Gustilo type IIIB open tibial fractures in our facility.

METHODS

Six patients with type IIIB open tibial fractures treated with PSLL were retrospectively reviewed. The mean shortening length was 7.4 cm (range, 4.5-10.3 cm). The mean percent shortening of the entire bone was 18.7% (range, 12.3-29.7%). Limb lengthening started at a mean interval of 10.3 months (range, 3-18 months) after the original injury. The mean healing index was 56.5 days/cm (range, 31.3-86.7 days/cm). The complications, functional outcome, and quality of life were evaluated for all cases.

RESULTS

One superficial infection at the initial corticotomy, one deep infection around the shortening site, one refracture at the healed docking site, several wire breaks in external frames in two cases, and two severe equinovarus deformities occurred as complications of these procedures. Regarding functional outcome, three patients showed good outcome, two showed fair outcome, and one showed poor outcome. The percent shortening of the entire bone in the two fair cases were more than 25%. The median scale of physical health summary, mental health summary, and total general health summary in Short Form-36 (QOL) were lower than the standard scale in age-matched individuals.

CONCLUSION

This PSLL treatment was thought to be a useful option for severe open fracture of the tibia, which had bony defect in more than 4.5 cm in length after serial debridement, although several complications occurred in this regimen. However, it is difficult to achieve an excellent function and QOL using these techniques. In addition, it is difficult for patients who underwent limb lengthening after shortening more than 25% of the total length of bone to gain good function.

Concomitant ipsilateral pedicled fibular transfer and free muscle flap for compound tibial defect reconstruction

Three patients with compound injuries of the lower extremities were treated with pedicle fibular grafts and a free muscle flap concomitantly. There were 1 female and 2 male patients, all of whom sustained high-energy trauma in a motor vehicle accident. The bone defect of the tibia ranged from 8 to 12 cm. The size of the soft-tissue defect ranged from 24 x 15 cm to 28 x 15 cm. All patients underwent preoperative angiography to ensure the patency of the peroneal artery and to avoid its use by risking viability of the leg. All patients were treated with an antegrade-flow pedicle fibular graft. The fibular graft was inserted as a single strut in 2 patients and as a double-barrel strut in 1 patient. The pedicle of the free muscle flap was anastomosed to the distal runoff of the fibular bone flap. All free muscle flap transfers succeeded without complication. Bone scans performed on postoperative day 7 showed viability of transferred bone. The average time to radiological union was 9 months, and the average time to full weight bearing was 12 months. Screw loosening occurred in 2 patients and osteomyelitis was noted in another patient who was treated successfully with sequestrectomy and antibiotics. Indications for this technique are a large segmental bone defect with a huge soft-tissue defect, and patency of the peroneal artery and at least one other major artery. This method provides the advantages of one-stage reconstruction, avoidance of contralateral donor site morbidity, easy control of infection, and chance for early weight bearing. When selected carefully, this technique can be considered when one wants to avoid a two-stage, two free flap transfer.