Free Tissue Transfer with Distraction Osteogenesis and Masquelet Technique Is Effective for Limb Salvage in Patients with Gustilo Type IIIB Open Fractures

Outcomes of Free Muscle Flaps versus Free Fasciocutaneous Flaps for Lower Limb Reconstruction following Trauma: A Systematic Review and Meta-Analysis

BACKGROUND

 Free flap reconstruction of the lower limb following trauma often suffers higher complication rates than other areas of the body. The choice of muscle or fasciocutaneous free flap is an area of active debate.

METHODS

 A systematic review of EMBASE, MEDLINE, PubMed, and Cochrane Register from inception to April 1, 2022 was performed. Articles were assessed using the methodological index for non-randomized studies instrument. The primary outcome was to assess and compare the major surgical outcomes of partial or total flap failure, reoperation, and amputation rates.

RESULTS

 Seventeen studies were included. All studies were retrospective in nature, of level three evidence, and published between 1986 and 2021. The most common muscle and fasciocutaneous free flaps used were latissimus dorsi flap (38.1%) and anterolateral thigh (ALT) flap (64.8%), respectively. Meta-analysis found no significance difference in rates of total flap failure, takeback operations, or limb salvage, whereas partial flap failure rate was significantly lower for fasciocutaneous flaps. The majority of studies found no significant difference in complication rates, osteomyelitis, time to fracture union, or time to functional recovery. Most, 82.4% (14/17), of the included studies were of high methodological quality.

CONCLUSION

 The rate of total flap failure, reoperation, or limb salvage is not significantly different between muscle and fasciocutaneous free flaps after lower limb reconstruction following trauma. Partial flap failure rates appear to be lower with fasciocutaneous free flaps. Outcomes traditionally thought to be managed better with muscle free flaps, such as osteomyelitis and rates of fracture union, were comparable.

Efficacy comparison of vascularized iliac crest bone flap and Ilizarov bone transport in the treatment of traumatic bone defects of the tibia combined with large soft tissue defects

BACKGROUND

Traumatic tibial defect complicated with soft tissue defect is a difficult problem in clinic. Vascularized iliac crest bone flap (VIBF) and Ilizarov bone transport are effective methods to treat tibial defects with limited defect length, which most need to be explored accordingly.

METHODS

In this study, a total of 68 patients with traumatic tibial defect (ranging from 4 to 10 cm) and large soft tissue defect were collected retrospectively. The soft tissue defects were repaired by latissimus dorsal musculocutaneous flap (LD), anterolateral thigh flap (ALTF) or both. Thirty-three cases were treated with vascularized iliac crest bone flap transplantation and 35 cases were treated with Ilizarov bone transport. Intraoperative and postoperative follow-up data (including operation time, blood loss, bone union time, external fixation time, external fixation index, complication rate, reoperation rate, and functional evaluation) were recorded, and comparative analysis was performed.

RESULTS

The median follow-up time was 32 months. Compared with Ilizarov group, the VIBF group exhibited statistically faster bone union time (6.3 ± 1.0 vs. 18.2 ± 3.0 months). Moreover, the VIBF group showed shorter EFT (7.3 ± 1.0 vs. 19.2 ± 3.0 months) and a better EFI (34.8 ± 9.2 vs. 84.2 ± 23.7 days/cm). The excellent and good rate of lower limb appearance evaluation in VIBP group was significantly better than that in Ilizarov group. The complication rate and reoperation rate were significantly higher in Ilizarov group.

CONCLUSION

In summary, compared with Ilizarov bone transport, VIBP has the advantages of faster healing, shorter external fixation time, lower complication and reoperation rate, and better appearance within the limited defect length. Ilizarov bone transport is still preferred when the defect length exceeds the maximum repair length of the iliac flap. The daily handling required by bone transport process is painful.

LEVEL OF EVIDENCE

III, Case-control study.

Ilizarov Bone Transfer for Treatment of Large Tibial Bone Defects: Clinical Results and Management of Complications

BACKGROUNDS

The purpose of this study is to present our clinical experience using the Ilizarov bone transfer technique and free-flap technique in the reconstruction of large tibial bone and soft tissue defects, including an evaluation of both the management of postoperative complications and long-term outcomes.

METHODS

From January 2010 to May 2020, 72 patients with tibia bone and soft tissue defects were retrospectively evaluated. Either an anterolateral thigh perforator flaps (ALTP) or latissimus dorsi musculocutaneous flaps (LD), solely or in combination, were used to cover soft tissue defects. Once the flap was stabilized, an Ilizarov external fixator was applied to the limb. Follow-up was postoperatively performed at 1, 3, 6, 9, and 12 months.

RESULTS

Postoperatively, there were two cases of total and five of partial flap necrosis, and two cases of subcutaneous ulcers, which were caused by vascular crisis, infection, and hematoma, respectively. All the patients underwent Ilizarov external fixator surgery after flap recovery. A total of 16 complications occurred, including 3 cases of simple needle tract infection (antibiotic treatment) and 13 cases of complications requiring reoperation. A correlation factor analysis revealed that the main factors affecting the healing time were the defect length and operative complications. All patients with complications treated with the vascularized iliac flap eventually healed completely.

CONCLUSIONS

The Ilizarov method used together with an ALTP, LD, or a combination thereof yields good clinical results for repairing large bone and soft tissue defects of the tibia, thus reducing the incidence of amputations. However, longer treatment times may be involved, and postoperative complications can occur. The vascularized iliac flap may be a suitable choice for the treatment of postoperative complications of this type of Ilizarov bone transport.

Combined treatment using cross-leg free flap and the Masquelet technique: a report of two cases

We introduce a treatment that combines the cross-leg free flap with the Masquelet technique and describe two cases using this method for bone and soft tissue reconstruction. Both patients were successfully treated and ambulatory. This novel method can be safely performed using the delay technique, indocyanine-green angiography and near-infrared spectroscopy.

One-stage reconstruction of extensive composite extremity defects with low donor site morbidity: A retrospective case series of combined transfer of a vascularized fibula flap and a perforator flap

BACKGROUND

Extensive composite extremity defects remain a challenge in plastic and reconstructive surgery. To preserve the extremity, we used combined transfer composed of the vascularized fibula flap and a perforator flap from various body parts to reconstruct extensive composite extremity defects.

PATIENTS AND METHODS

From January 2004 to December 2018, 14 male patients aged 9 to 55 years with extensive composite extremity defects (large soft-tissue and long bone defect) underwent reconstructive surgery in our institution. The combined transfer surgery consisted of the vascularized fibula bone flap and a perforator flap, such as anterolateral thigh flap, deep inferior epigastric perforator flap, or thoracodorsal artery perforator flap.

RESULTS

All fourteen patients were treated successfully using the combined transfer method. The dimensions of the different perforator flaps ranged from 13 × 6 cm² to 26 × 11 cm², and the size of the skin paddle of the fibular osteocutaneous flap ranged from 9 × 3 cm² to 21 × 7 cm². The median length of the fibular graft was 15 cm. No serious donor site complications were observed. Only one patient developed venous congestion and was salvaged. Another patient had hematoma at the recipient site and underwent debridement. Though all patients achieved bone union (median time of 8 months), two developed a stress fracture of the transferred free fibula.

CONCLUSION

We were able to minimize donor site morbidity and avoid amputation in these patients using the combined transfer technique Our results show that the combined transfer of perforator flap and vascularized fibula flap with or without a skin paddle is a feasible reconstruction option for the treatment of the extensive composite extremity defects.

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.

Free Flap Coverage for Complex Primary and Revision Total Knee Arthroplasty

BACKGROUND

Free flap coverage in the setting of a total knee arthroplasty is rare. The purpose of the current study was to evaluate the outcome of patients who underwent a free flap to assist with soft-tissue coverage following a complex total knee arthroplasty.

METHODS

The authors used their institutional total joint registry to retrospectively review patients undergoing a free soft-tissue flap in the setting of complex primary and revision total knee arthroplasty. Among 29,069 primary and 6433 revision total knee arthroplasties from 1994 to 2017, eight (0.02 percent) required a free flap for wound coverage. This included three primary total knee arthroplasties (0.01 percent) for posttraumatic arthritis and five revision total knee arthroplasties (0.07 percent) in the setting of infection. Median follow-up was 4 years.

RESULTS

Free flaps included vertical rectus abdominis (n = 3), anterior lateral thigh (n = 2), latissimus (n = 2), and transverse rectus abdominis (n = 1). There were no total flap losses; however, one patient required additional skin grafting. Reoperation occurred in six patients, of which four were revisions of the total knee arthroplasty for infection (n = 2) and tibial component loosening (n = 2). One patient ultimately underwent transfemoral amputation for persistent infection. Following reconstruction, there was improvement in the median Knee Society Score (49 versus 82; p = 0.03) and total range of motion between preoperative and postoperative assessments (70 degrees versus 85 degrees; p = 0.14).

CONCLUSION

Free flap coverage in the setting of total knee arthroplasty was associated with a high rate of reoperation; however, the limb was able to be preserved in the majority of patients, with a reasonable functional outcome.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Timing of Flap Coverage With Respect to Definitive Fixation in Open Tibia Fractures

OBJECTIVES

We conducted a large, U.S wide, observational study of type III tibial fractures, with the hypothesis that delays between definitive fixation and flap coverage might be a substantial modifiable risk factor associated with nosocomial wound infection.

DESIGN

A retrospective analysis of a multicenter database of open tibial fractures requiring flap coverage.

SETTING

Fourteen level-1 trauma centers across the United States.

PATIENTS

Two hundred ninety-six (n = 296) consecutive patients with Gustilo III open tibial fractures requiring flap coverage at 14 trauma centers were retrospectively analyzed from a large orthopaedic trauma registry. We collected demographics and the details of surgical care. We investigated the patient, and treatment factors leading to infection, including the time from various points in care to the time of soft-tissue coverage.

INTERVENTION

Delay definitive fixation and flap coverage in tibial type III fractures.

MAIN OUTCOME MEASUREMENTS

(1) Results of multivariate regression with time from injury to coverage, debridement to coverage, and definitive fixation to coverage in the model, to determine which delay measurement was most associated with infection. (2) A second multivariate model, including other factors in addition to measures of flap delay, to provide the estimate between delay and infection after adjustment for confounding.

RESULTS

Of 296 adults (227 M: 69 F) with open Gustilo type III tibial fractures requiring flap coverage, 96 (32.4%) became infected. In the multivariate regression, the time from definitive fixation to flap coverage was most predictive of subsequent wound infection (odds ratio 1.04, 95% confidence interval 1.01 to 1.08, n = 260, P = 0.02) among the time measurements. Temporary internal fixation was not associated with an increased risk of infection in both univariate (P = 0.59) or multivariate analyses (P = 0.60). Flap failure was associated with the highest odds of infection (odds ratio 6.83, 95% confidence interval 3.26 to 14.27, P < 0.001).

CONCLUSION

Orthoplastic teams that are dedicated to severe musculoskeletal trauma, that facilitate coordination of definitive fixation and flap coverage, will reduce the infection rates in Gustilo type III tibial fractures.

LEVEL OF EVIDENCE

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

A Systematic Review and Meta-Analysis of Combined Antibiotic Spacer with Ilizarov Methods in the Treatment of Infected Nonunion of Tibia

Background

The objective of this systematic review was to evaluate current studies available reporting the antibiotic spacer combined with Ilizarov methods in the treatment of infected nonunion of tibia and to perform meta-analysis of bone results and infection recurrence to assess the efficacy of an antibiotic spacer combined with Ilizarov methods.

Methods

The MEDLINE, Embase, Cochrane Library, CNKI, and CBM (Chinese Biological Medicine) databases were searched for articles published between January 2000 and July 2020. Assessment of study quality was performed using a modified version of the Newcastle-Ottawa scale. Effect size and 95% confidence intervals were calculated for the main outcome. Heterogeneity was assessed. Fixed-effect modeling and Stata version 15.1 were used to analyze the data. Sensitivity analyses were conducted with the evidence of heterogeneity.

Results

11 studies involving 210 patients with infected nonunion of tibia were finally included in our meta-analysis. Bone results and infection recurrence were analyzed based on the single-arm meta-analysis. The average of external fixation index (EFI) was 46.88 days/cm in all studies included. The excellent rate in bone results and the rate of infection recurrence was 65% (95% CI: [0.22, 0.97], I² = 0.0%, P = 0.932) and 6.99% (95% CI: [0.052, 0.325], I² = 0.0%, P = 1.000) in patients with infected nonunion of tibia treated with an antibiotic spacer combined with Ilizarov methods.

Conclusions

Our meta-analysis revealed that the patients with infected nonunion of tibia treated with an antibiotic spacer combined with Ilizarov methods had a high rate of excellent bone results and a low rate of infection recurrence. Therefore, combining the antibiotic spacer with Ilizarov methods may be an applicable choice for repairing and reconstructing infected nonunion of tibia.

Single Artery Upper Extremity Salvage with Two Free Flap End-to-Side Brachial Artery Anastomoses

Background A 36-year-old male was involved in a motor vehicle accident, presenting with a Guistillo's IIIB crush injury to the upper extremity. A severely comminuted ulnar fracture resulted in a 10-cm bone defect with significant overlying soft tissue injury.

Methods The injury resulted in a wide zone of injury with inadequate collateral vascularity at the level of the elbow and distal viability dependent on the brachial artery. An osteocutaneous free fibular flap and fasciocutaneous anterolateral thigh flap were used to reconstruct the defect with both flaps anastomosed in an end-to-side fashion to the brachial artery.

Results The upper extremity was successfully salvaged, and the patient discharged from hospital at postoperative day 10. Both free flaps survived with no donor or recipient site complications at a follow-up period of 2 years.

Conclusion The case illustrates the challenges inherent to significant Guistillo's IIIB injuries with insufficient recipient vessels over a large zone of injury. While performing anastomoses outside the zone of injury is preferred, this case demonstrates the success of performing multiple anastomoses to the brachial artery in an end-to-side fashion within the zone of injury.