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Shastov A, Mikhailov A, Kliushin N, Malkova T. Limb salvage and functional recovery in infected nonunion of the distal tibia treated with the Ilizarov techniques. J Clin Orthop Trauma 2023; 44:102255. [PMID: 37817763 PMCID: PMC10561033 DOI: 10.1016/j.jcot.2023.102255] [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] [Received: 02/06/2023] [Revised: 06/30/2023] [Accepted: 09/21/2023] [Indexed: 10/12/2023] Open
Abstract
Introduction Treatment of infected nonunion of the distal juxta-articular tibia is a challenge due to a short distal fragment, deformity, thin soft-tissue envelope, and active infection. There is still no consensus on the approach that is able to maximally salvage the limb and ankle function. Material and methods Infected juxta-articular nonunion of the distal tibia was managed with two Ilizarov techniques, monofocal compression (MC) used in 12 patients and bifocal compression-distraction (BCD) in 6 patients. The choice of the technique depended on the size of the postresection defect, ≥3 cm or ≤3 cm, respectively. The tactics of functional approach were careful debridement, insertion of wires in the distal fragment so that they do not penetrate the ankle joint, stable fixation, and temporary bridging of the ankle and forefoot. MSCT was used along with regular radiography to assess the union and regeneration. Ankle functions were evaluated with AOFAS ankle-hindfoot score system. Results Bone consolidation, infection arrest and ankle function improvement were achieved in all patients. External fixation continued 221.7 ± 15.1 days for MC and 235 ± 25.8 days for BCD. Complications were wound divergence, wire-tract infection, premature consolidation of the fibula, and hypoplastic regeneration in one case. The mean functional AOFAS score after treatment was 90.7 ± 2.5 points in MC and 89.7 ± 1.3 in BCD patients. Residual limb discrepancy after MC ranged 0-4 cm. Bone shortening was compensated in BCD patients. Conclusion Limb-salvage and functional approach to the treatment of infected nonunion of the juxta-articular distal tibia with the Ilizarov techniques achieves good outcomes. It provides bone infection arrest, consolidation, defect compensation and significantly improves the ankle joint function.
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Affiliation(s)
- A.L. Shastov
- Orthopaedic Surgeon, Bone and Joint Infection Clinic Department # 3, National Ilizarov Medical Research Centre for Traumatology and Orthopaedics, 6 M. Ulianova street, Kurgan, Russia
| | - A.G. Mikhailov
- Orthopaedic Surgeon, Head of Bone Infection Clinical Department # 3, National Ilizarov Medical Research Centre for Traumatology and Orthopaedics, 6 M. Ulianova street, Kurgan, Russia
| | - N.M. Kliushin
- Orthopaedic Surgeon, Bone and Joint Infection Clinic, National Ilizarov Medical Research Centre for Traumatology and Orthopaedics, 6 M. Ulianova street, Kurgan, Russia
| | - T.A. Malkova
- Expert of the Department for Analysis of Medical Information, National Ilizarov Medical Research Centre for Traumatology and Orthopaedics, 6 M. Ulianova street, Kurgan, Russia
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Wu YJ, Zhang YB, Hamushan M, Zhang WJ, Zhang T, Li XJ, Han P, Lou TF. Role of Perforating Artery Pedicled Neurotrophic Flap in the Treatment of Compound Tissue Defect of Tibia Using the Ilizarov Technique. Orthop Surg 2022; 14:1294-1299. [PMID: 35585657 PMCID: PMC9251288 DOI: 10.1111/os.13309] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 03/17/2022] [Accepted: 04/19/2022] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To describe our experience with the combined use of pedicled neurotrophic flap and distraction osteogenesis in the management of complex lower extremity injuries with composite bone and soft tissue defects and assess the functional and cosmetic results of this method. METHODS A pedicled flap with a marked perforator artery was applied for soft tissue coverage after radical debridement and temporary external fixation. In the second stage, the Ilizarov external fixator was used in place of the temporary external fixator for reconstruction of the segmental bone defect by distraction osteogenesis. Twenty-five patients (16 men and nine women; mean age, 39.2 years) were treated by using this combined technique between 2008 and 2016. All cases were graded initially as Gustilo-Anderson grade IIIB open fractures. The soft tissue defect after radical debridement ranged from 9 cm × 5 cm to 14 cm × 11 cm, and the average size of segmental defect was 5.2 (Range, 2.5-8.5) cm. Seventeen of these patients had a history of local infection. The bone structure and function were evaluated by two independent evaluators using Paley's criteria. RESULTS Twenty-five patients were followed up for an average of 28.96 (Range, 15-48) months. The distally based sural neurovascular flap was applied in 13 patients, and the greater saphenous neurocutaneous perforator flap in 12 patients. The flap area ranged from 10 cm × 5 cm to 14 cm × 12 cm. Sufficient coverage of soft tissue defect was achieved in all cases. All flaps survived completely without complications. The bone defects were corrected by a mean lengthening of 6.94 (Range, 4.5-9.5) cm. The residual discrepancy was <1 cm in all cases, which was not clinically significant. The function was evaluated as excellent in 12 patients and good in 13 patients. Bone results were graded as excellent in 18 patients and good in seven patients. Complications during treatment included pain, pin tract infections, ankle midfoot joint stiffness, and docking site nonunion. No recurrence of infection was observed in infected patients. All cases achieved successful limb salvage and satisfactory function recovery without recurrence of infection. CONCLUSIONS The combined technique of a perforator artery pedicled neurotrophic flap and distraction osteogenesis is an effective alternative approach in the salvage treatment of massively traumatized and chronically infected lower extremities.
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Affiliation(s)
- Yuan-Jian Wu
- Orthopaedic Department, Zhujiajiao People's Hospital, Shanghai, China
| | - Yu-Bo Zhang
- Orthopaedic Department, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Musha Hamushan
- Orthopaedic Department, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Wen-Jun Zhang
- Orthopaedic Department, Zhujiajiao People's Hospital, Shanghai, China
| | - Tao Zhang
- Orthopaedic Department, Zhujiajiao People's Hospital, Shanghai, China
| | - Xu-Jun Li
- Orthopaedic Department, Minhang Branch, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Pei Han
- Orthopaedic Department, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Teng-Fei Lou
- Orthopaedic Department, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
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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. Injury 2022; 53:1430-1437. [PMID: 35177265 DOI: 10.1016/j.injury.2022.02.028] [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] [Received: 07/13/2021] [Accepted: 02/08/2022] [Indexed: 02/02/2023]
Abstract
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.
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Nasser AAH, Fenton P, Bose D. Single stage versus two-stage orthoplastic management of bone infection. Injury 2022; 53:984-991. [PMID: 35063261 DOI: 10.1016/j.injury.2022.01.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 01/10/2022] [Accepted: 01/11/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Bone infection cases with major soft tissue loss have conventionally been treated with a staged orthoplastic approach, addressing the infection first followed by definitive management to achieve bony stability and soft tissue cover. In the last few decades, specialist centers have advocated for single stage bony stabilization with soft tissue coverage. We aimed to investigate the outcomes of patients that underwent a single stage versus a two-stage orthoplastic intervention. METHODS Using an existing 2009-2019 database from a single major trauma centre, we identified all adults with a diagnosis of fracture related infection (FRI) or osteomyelitis (OM). The primary outcome was resolution of infection. Secondary outcomes included time to bony union, amputation, failure of orthopaedic fixation, mortality, and return to theatre. RESULTS A total of 96 patients were included. 71 patients (74%) underwent a single stage procedure; out of which 61 were FRI. 25 patients (26%) underwent a two-stage procedure; out of which 24 were FRI. The average follow up for the single stage and two-stage cohorts was 32.1 and 30.3 months, respectively. Resolution of infection without the need for an amputation was achieved in 67 (94.4%) patients in the single stage cohort and in 23 (92%) patients in the two-stage cohort. When compared to the two-stage group, the single stage cohort had less recurrence of infection (9.9% versus 12%, p = 0.72), lower rates of amputation (8.5% versus 12%, p = 0.69), lower rates of failure of orthopaedic fixation (11.1% versus 13%, p = 0.82), but higher average time to bony union (15.25 months versus 12.35, p = 0.42). The differences were not statistically significant. A total of 37 patients (52.1%) had an unplanned return to theatre in the single stage compared to 12 (48%) in the two-stage cohort. In subgroup analysis of FRI cases, open fractures had a longer time to bony union when compared to closed fractures (19.7 versus 11.6 months, p = 0.01). No mortality was observed in both cohorts. CONCLUSIONS The single stage orthoplastic approach to bone infection is effective if planned carefully with clinical outcomes comparable to the two-stage approach. Further research should examine factors associated with unplanned return to theatre and any variation in treatment of bone infection across regions.
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Affiliation(s)
- Ahmed A H Nasser
- Ortho-Plastic Extremity Trauma Unit, Trauma and Orthopaedic Specialty Registrar, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Mindelsohn Way, Birmingham B15 2TH, UK.
| | - Paul Fenton
- Ortho-Plastic Extremity Trauma Unit, Trauma and Orthopaedic Specialty Registrar, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Mindelsohn Way, Birmingham B15 2TH, UK
| | - Deepa Bose
- Ortho-Plastic Extremity Trauma Unit, Trauma and Orthopaedic Specialty Registrar, University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital Mindelsohn Way, Birmingham B15 2TH, UK
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Klifto KM, Azoury SC, Klifto CS, Mehta S, Levin LS, Kovach SJ. Treatment of Posttraumatic Tibial Diaphyseal Bone Defects: A Systematic Review and Meta-Analysis. J Orthop Trauma 2022; 36:55-64. [PMID: 34633778 DOI: 10.1097/bot.0000000000002214] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/14/2021] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Kevin M Klifto
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Missouri School of Medicine, Columbia, MO
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Saïd C Azoury
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Christopher S Klifto
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC; and
| | - Samir Mehta
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - L Scott Levin
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Stephen J Kovach
- Division of Plastic Surgery, Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
- Department of Orthopaedic Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
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Li Y, Chen Y, Gan T, Qin B, Liu X, Zhang H. An alternative therapeutic strategy for infected large bone defect and massive soft-tissue loss of leg-is free flap reconstruction inevitable? INTERNATIONAL ORTHOPAEDICS 2021; 45:3033-3043. [PMID: 34338812 DOI: 10.1007/s00264-021-05154-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 07/17/2021] [Indexed: 02/08/2023]
Abstract
PURPOSE This study aims to report the clinical and radiographic outcomes of a non-flap therapeutic strategy for the limb salvage of infected composite bone and soft-tissue defects of a leg, attempting to describe some new techniques regards the docking of bone ends. METHODS Twelve patients with infected large tibial bone defect (mean size 12.1 ± 2.8 cm) and massive soft-tissue loss (mean size 254.5 ± 60.2 cm2) who were treated with the non-flap therapeutic strategy between 2014 and 2019 were retrospectively reviewed. Clinical and radiographic results were evaluated and analyzed. The results of bone and function were assessed by the Paley criteria. The exercise capacity of patients was evaluated based on the following four aspects: walking, running, jumping, squatting, and going up/down the stairs. RESULTS During the treatment, shortening and re-lengthening technique was applied in six patients, bone transport technique in 12, submarine technique (SMT) in six, balloon dilatation technique (BDT) in seven, and soft-tissue incarceration creating technique (SICT) in seven. The mean external fixation time (EFT) and external fixation index (EFI) were 675.6 ± 179.2 days (range, 366-1040 days) and 60.1 ± 13.9 days/cm (range, 47.0-95.5 days/cm), respectively. Soft-tissue defect was successfully repaired for all patients. After a mean follow-up of 43.5 ± 23.2 months (range, 13-103 months), bone result was classified as "excellent" in ten patients, as "good" in one and "poor" in one, while functional result was graded as "excellent" in four patients and "good" in eight. CONCLUSIONS The non-flap therapeutic strategy could be cautiously considered as an alternative treatment for the large lower limb composite defects.
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Affiliation(s)
- Yaxing Li
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Avenue, Chengdu, 610041, Sichuan Province, China.,Disaster Medicine Center, Sichuan University, Chengdu, 610041, Sichuan Province, China
| | - Yu Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Avenue, Chengdu, 610041, Sichuan Province, China
| | - Tingjiang Gan
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Avenue, Chengdu, 610041, Sichuan Province, China
| | - Boquan Qin
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Avenue, Chengdu, 610041, Sichuan Province, China
| | - Xi Liu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Avenue, Chengdu, 610041, Sichuan Province, China
| | - Hui Zhang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 37, Guoxue Avenue, Chengdu, 610041, Sichuan Province, China. .,Disaster Medicine Center, Sichuan University, Chengdu, 610041, Sichuan Province, China.
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7
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Cohen-Shohet RN, Samant SS, Chim H. Technical Considerations and Clinical Applications of the Free Anterior Branch Split Latissimus Dorsi Flap. Ann Plast Surg 2021; 86:S473-S477. [PMID: 33833158 DOI: 10.1097/sap.0000000000002858] [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: 11/26/2022]
Abstract
BACKGROUND The free anterior branch split latissimus dorsi flap has a reliable anatomy and advantages over the traditional latissimus dorsi flap. By preserving the posterior branch of the thoracodorsal nerve, morbidity at the donor site is reduced, preserving shoulder strength. METHODOLOGY The purpose of this article is to review our experience with the split latissimus flap, describe our surgical technique, and finally review representative cases of reconstruction in different anatomical regions. RESULTS From April 2017 to October 2020, 39 free split latissimus flaps were performed at a single center. Flaps were performed for coverage in the upper extremity (n = 2), lower extremity (n = 32), and head and neck (n = 5). Flap success rate was 97.4%. Mean dimensions of the flap were 17.0 × 8.3 cm, with a mean area of 145 cm2. CONCLUSIONS The flap has a broad application and can be utilized in many different reconstructive scenarios including for coverage of defects in the extremities, trunk, and head and neck.
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Affiliation(s)
- Rachel N Cohen-Shohet
- From the Division of Plastic and Reconstructive Surgery, University of Florida College of Medicine, Gainesville, FL
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8
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Bezstarosti H, Metsemakers WJ, van Lieshout EMM, Voskamp LW, Kortram K, McNally MA, Marais LC, Verhofstad MHJ. Management of critical-sized bone defects in the treatment of fracture-related infection: a systematic review and pooled analysis. Arch Orthop Trauma Surg 2021; 141:1215-1230. [PMID: 32860565 PMCID: PMC8215045 DOI: 10.1007/s00402-020-03525-0] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022]
Abstract
PURPOSE This systematic review determined the reported treatment strategies, their individual success rates, and other outcome parameters in the management of critical-sized bone defects in fracture-related infection (FRI) patients between 1990 and 2018. METHODS A systematic literature search on treatment and outcome of critical-sized bone defects in FRI was performed. Treatment strategies identified were, autologous cancellous grafts, autologous cancellous grafts combined with local antibiotics, the induced membrane technique, vascularized grafts, Ilizarov bone transport, and bone transport combined with local antibiotics. Outcomes were bone healing and infection eradication after primary surgical protocol and recurrence of FRI and amputations at the end of study period. RESULTS Fifty studies were included, describing 1530 patients, the tibia was affected in 82%. Mean age was 40 years (range 6-80), with predominantly male subjects (79%). Mean duration of infection was 17 months (range 1-624) and mean follow-up 51 months (range 6-126). After initial protocolized treatment, FRI was cured in 83% (95% CI 79-87) of all cases, increasing to 94% (95% CI 92-96) at the end of each individual study. Recurrence of infection was seen in 8% (95% CI 6-11) and amputation in 3% (95% CI 2-3). Final outcomes overlapped across treatment strategies. CONCLUSION Results should be interpreted with caution due to the retrospective and observational design of most studies, the lack of clear classification systems, incomplete data reports, potential underreporting of adverse outcomes, and heterogeneity in patient series. A consensus on classification, treatment protocols, and outcome is needed to improve reliability of future studies.
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Affiliation(s)
- H Bezstarosti
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands.
| | - W J Metsemakers
- Department of Trauma Surgery, University Hospitals Leuven, Louvain, Belgium
- Department of Development and Regeneration, KU Leuven, Louvain, Belgium
| | - E M M van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - L W Voskamp
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - K Kortram
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
| | - M A McNally
- Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - L C Marais
- Department of Orthopaedics, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - M H J Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA, Rotterdam, The Netherlands
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Shah HN, Jones RE, Borrelli MR, Robertson K, Salhotra A, Wan DC, Longaker MT. Craniofacial and Long Bone Development in the Context of Distraction Osteogenesis. Plast Reconstr Surg 2021; 147:54e-65e. [PMID: 33370054 PMCID: PMC7773036 DOI: 10.1097/prs.0000000000007451] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Bone retains regenerative potential into adulthood, and surgeons harness this plasticity during distraction osteogenesis. The underlying biology governing bone development, repair, and regeneration is divergent between the craniofacial and appendicular skeleton. Each type of bone formation is characterized by unique molecular signaling and cellular behavior. Recent discoveries have elucidated the cellular and genetic processes underlying skeletal development and regeneration, providing an opportunity to couple biological and clinical knowledge to improve patient care. METHODS A comprehensive literature review of basic and clinical literature regarding craniofacial and long bone development, regeneration, and distraction osteogenesis was performed. RESULTS The current understanding in craniofacial and long bone development and regeneration is discussed, and clinical considerations for the respective distraction osteogenesis procedures are presented. CONCLUSIONS Distraction osteogenesis is a powerful tool to regenerate bone and thus address a number of craniofacial and appendicular skeletal deficiencies. The molecular mechanisms underlying bone regeneration, however, remain elusive. Recent work has determined that embryologic morphogen gradients constitute important signals during regeneration. In addition, striking discoveries have illuminated the cellular processes underlying mandibular regeneration during distraction osteogenesis, showing that skeletal stem cells reactivate embryologic neural crest transcriptomic processes to carry out bone formation during regeneration. Furthermore, innovative adjuvant therapies to complement distraction osteogenesis use biological processes active in embryogenesis and regeneration. Additional research is needed to further characterize the underlying cellular mechanisms responsible for improved bone formation through adjuvant therapies and the role skeletal stem cells play during regeneration.
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Affiliation(s)
- Harsh N. Shah
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Ruth E. Jones
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Mimi R. Borrelli
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Kiana Robertson
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Ankit Salhotra
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
| | - Derrick C. Wan
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael T. Longaker
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Stanford, CA, USA
- Institute for Stem Cell Biology and Regenerative Medicine, Stanford University School of Medicine, Stanford, CA, USA
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10
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Mifsud M, Ferguson JY, Stubbs DA, Ramsden AJ, McNally MA. Simultaneous debridement, Ilizarov reconstruction and free muscle flaps in the management of complex tibial infection. J Bone Jt Infect 2020; 6:63-72. [PMID: 33552880 PMCID: PMC7852407 DOI: 10.5194/jbji-6-63-2020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 12/04/2020] [Indexed: 02/06/2023] Open
Abstract
Chronic bone infections often present with complex bone and soft tissue
loss. Management is difficult and commonly delivered in multiple stages over
many months. This study investigated the feasibility and clinical outcomes
of reconstruction in one stage. Fifty-seven consecutive patients with chronic osteomyelitis (n=27) or
infected non-union (n=30) were treated with simultaneous debridement,
Ilizarov method and free muscle flap transfer. 41 patients (71.9 %) had
systemic co-morbidities (Cierny-Mader group Bs hosts). Infection was
confirmed with strict criteria. 48 patients (84.2 %) had segmental
defects. The primary outcome was eradication of infection at final follow-up.
Secondary outcomes included bone union, flap survival and complications or
re-operation related to the reconstruction. Infection was eradicated in 55/57 cases (96.5 %) at a mean follow-up of 36 months (range 12–146). No flap failures occurred during distraction but 6
required early anastomotic revision and 3 were not salvageable (flap failure
rate 5.3 %). Bony union was achieved in 52/57 (91.2 %) with the initial surgery alone.
After treatment of the five un-united docking sites, all cases achieved bony
union at final follow-up. Simultaneous reconstruction with Ilizarov method and free tissue transfer is
safe but requires careful planning and logistic considerations. The outcomes
from this study are equivalent or better than those reported after staged
surgery.
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Affiliation(s)
- Max Mifsud
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, University Hospitals NHS Foundation Trust, Windmill Road, Oxford, OX3 7HE, UK
| | - Jamie Y Ferguson
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, University Hospitals NHS Foundation Trust, Windmill Road, Oxford, OX3 7HE, UK
| | - David A Stubbs
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, University Hospitals NHS Foundation Trust, Windmill Road, Oxford, OX3 7HE, UK
| | - Alex J Ramsden
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, University Hospitals NHS Foundation Trust, Windmill Road, Oxford, OX3 7HE, UK
| | - Martin A McNally
- The Oxford Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, University Hospitals NHS Foundation Trust, Windmill Road, Oxford, OX3 7HE, UK
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Chim H, Cohen-Shohet R, McLaughlin MM, Ehanire T. Function-Sparing Free Split Latissimus Dorsi Flap for Lower-Extremity Reconstruction: Five-Year Consecutive Single-Surgeon Series. J Bone Joint Surg Am 2020; 102:1714-1723. [PMID: 32598120 DOI: 10.2106/jbjs.20.00022] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The free split latissimus dorsi flap for lower-extremity reconstruction has some advantages over the traditional latissimus dorsi flap. The flap is harvested with the patient in the supine position and is associated with minimal morbidity as the function of the remaining latissimus dorsi muscle is preserved through the posterior division of the thoracodorsal nerve. METHODS A consecutive single-surgeon 5-year series of free split latissimus dorsi muscle flaps for lower-extremity reconstruction (n = 42) was evaluated. Donor site morbidity was evaluated through assessment of the strength of the remaining latissimus dorsi at least 1 month after surgery. Shoulder function was evaluated postoperatively using the Disabilities of the Arm, Shoulder and Hand (DASH) score, American Shoulder and Elbow Surgeons (ASES) score, and Shoulder Pain and Disability Index (SPADI). RESULTS The mean age of the 42 patients was 40.7 years. The mean length and width of the flaps were 17.9 cm and 8.6 cm. The majority (71%) of the wounds were due to acute trauma. Of the 42 flap procedures performed, 95% (40) were successful. Assessment of remaining latissimus dorsi strength at least 1 month postoperatively, during 3 activities, showed a Medical Research Council (MRC) grade of 5 in all patients. The mean and median scores were 6.4 and 0 according to the DASH, 6.0/6.4 and 0/0 on the SPADI pain/disability scales, and 90.7 and 100 on the ASES. CONCLUSIONS The free split latissimus dorsi flap is a large reliable muscle flap with negligible donor site morbidity that is particularly advantageous for lower-extremity resurfacing following trauma. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Harvey Chim
- Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, Florida
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Multidisciplinary management of the bone and joint infection complicating treatment of an open fracture of the lower limb. ANN CHIR PLAST ESTH 2020; 65:380-393. [PMID: 32800464 DOI: 10.1016/j.anplas.2020.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/21/2020] [Indexed: 11/24/2022]
Abstract
Bone and joint infections (BJI) of the lower limb can cause functional sequelae and in some cases have an impact on patient's life prognostic. One of the main objectives of multidisciplinary consultation team meetings (MTM) in the treatment of bone and joint infections is to provide an appropriate medical-surgical care, pooling skills of different organ specialists: infectious disease physicians, microbiologists, orthopedic surgeons and plastic surgeons. Treatment is based on aggressive debridement, bone stabilization, adequate antibiotic therapy, long-term coverage of the loss of skin substance and close clinical monitoring. The authors present their multidisciplinary diagnostic and therapeutic approaches to BJI complicating an open fracture at a referent center in the management of complex bone and joint infections.
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Abdou SA, Stranix JT, Daar DA, Mehta DD, McLaurin T, Tejwani N, Saadeh PB, Levine JP, Leucht P, Thanik VD. Free Tissue Transfer with Distraction Osteogenesis and Masquelet Technique Is Effective for Limb Salvage in Patients with Gustilo Type IIIB Open Fractures. Plast Reconstr Surg 2020; 145:1071-1076. [PMID: 32221236 DOI: 10.1097/prs.0000000000006696] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Osteocutaneous reconstruction can be challenging because of concomitant injuries and limited donor sites. There is a paucity of data on limb salvage outcomes following combined soft-tissue reconstruction and bone transport or Masquelet procedures. The authors reviewed a consecutive series of open tibia fracture patients undergoing soft-tissue reconstruction with either distraction osteogenesis or Masquelet technique. Endpoints were perioperative flap complications and bone union. Fourteen patients with Gustilo type IIIB open tibia fractures were included. Half of the group received muscle flaps and the remaining half received fasciocutaneous flaps. Ten patients (71.4 percent) underwent distraction osteogenesis and the remaining patients underwent Masquelet technique. Average bone gap length was 65.7 ± 31.3 mm (range, 20 to 120 mm). In the bone transport group, the average external fixation duration was 245 days (range, 47 to 686 days). In the Masquelet group, the average duration of the first stage of this two-stage procedure (i.e., time from cement spacer placement to bone grafting) was 95 days (range, 42 to 181 days). Bone union rate, as determined by radiographic evidence, was 85.7 percent. There was one complete flap failure (7.1 percent). One patient underwent below-knee amputation after failing bone transport and developing chronic osteomyelitis and subsequent infected nonunion. Our case series demonstrates that nonosteocutaneous flap methods of limb reconstruction are a viable option in patients with segmental long bone defects, with a bone union rate of 85 percent and a limb salvage rate over 90 percent in patients with Gustilo type IIIB fractures. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.
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Affiliation(s)
- Salma A Abdou
- From the Hansjörg Wyss Department of Plastic Surgery and the Department of Orthopaedic Surgery, New York University School of Medicine; and the Department of Plastic Surgery, University of Virginia Health System
| | - John T Stranix
- From the Hansjörg Wyss Department of Plastic Surgery and the Department of Orthopaedic Surgery, New York University School of Medicine; and the Department of Plastic Surgery, University of Virginia Health System
| | - David A Daar
- From the Hansjörg Wyss Department of Plastic Surgery and the Department of Orthopaedic Surgery, New York University School of Medicine; and the Department of Plastic Surgery, University of Virginia Health System
| | - Devan D Mehta
- From the Hansjörg Wyss Department of Plastic Surgery and the Department of Orthopaedic Surgery, New York University School of Medicine; and the Department of Plastic Surgery, University of Virginia Health System
| | - Toni McLaurin
- From the Hansjörg Wyss Department of Plastic Surgery and the Department of Orthopaedic Surgery, New York University School of Medicine; and the Department of Plastic Surgery, University of Virginia Health System
| | - Nirmal Tejwani
- From the Hansjörg Wyss Department of Plastic Surgery and the Department of Orthopaedic Surgery, New York University School of Medicine; and the Department of Plastic Surgery, University of Virginia Health System
| | - Pierre B Saadeh
- From the Hansjörg Wyss Department of Plastic Surgery and the Department of Orthopaedic Surgery, New York University School of Medicine; and the Department of Plastic Surgery, University of Virginia Health System
| | - Jamie P Levine
- From the Hansjörg Wyss Department of Plastic Surgery and the Department of Orthopaedic Surgery, New York University School of Medicine; and the Department of Plastic Surgery, University of Virginia Health System
| | - Philipp Leucht
- From the Hansjörg Wyss Department of Plastic Surgery and the Department of Orthopaedic Surgery, New York University School of Medicine; and the Department of Plastic Surgery, University of Virginia Health System
| | - Vishal D Thanik
- From the Hansjörg Wyss Department of Plastic Surgery and the Department of Orthopaedic Surgery, New York University School of Medicine; and the Department of Plastic Surgery, University of Virginia Health System
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The Muscle-Sparing Descending Branch Latissimus Dorsi Free Flap for Lower Extremity Reconstruction. Plast Reconstr Surg 2020; 145:412e-420e. [DOI: 10.1097/prs.0000000000006522] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Lam A, Richardson SS, Buksbaum J, Markowitz J, Henry MW, Miller AO, Rozbruch SR, Fragomen AT. Chronic Osteomyelitis of the tibia and ankle treated with Limb Salvage Reconstruction. J Bone Jt Infect 2019; 4:306-313. [PMID: 31966963 PMCID: PMC6960027 DOI: 10.7150/jbji.40337] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 11/03/2019] [Indexed: 11/23/2022] Open
Abstract
Introduction: To confirm the success of our limb salvage treatment protocol and determine what factors are predictive of success versus failure in limb salvage techniques for patients with chronic osteomyelitis of the tibia and ankle. Methods: Retrospective case series analyzing factors and outcomes in patients who underwent limb salvage techniques for chronic osteomyelitis of tibia or ankle. Main outcome measurements included infection controlled without the need for amputation or chronic antibiotic suppression and union of infected non-unions. Results: Mean follow-up was 3.9 years. Out of the sixty-seven patients (mean age: 51.4 years) treated for chronic osteomyelitis, fifty-four had an associated non-union. Sixty-one patients (91.0%) had their infection controlled by limb salvage. Five ultimately required amputation and one remained on daily chronic antibiotics. Diabetics complicated with neuropathy and increasing numbers of limb salvage surgeries were associated with a significantly higher failure rate. Forty-eight out of fifty-four patients (88.9%) also had successful healing of their infected non-union. Diabetes and need for more limb salvage surgeries were also found to have a significantly higher failure rate. Conclusions: Limb salvage is a reliable and successful treatment for patients with chronic osteomyelitis and infected non-unions of the lower extremities. Diabetic neuropathy is a risk factor that impedes success. Level of Evidence: Prognostic Level IV.
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Affiliation(s)
- Aaron Lam
- Maimonides Medical Center, 4802 10th Ave, Brooklyn, NY 11219, USA
| | - Shawn S Richardson
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
| | - Josh Buksbaum
- Emory University, 201 Dowman Dr, Atlanta, GA 30322, USA
| | | | - Michael W Henry
- Infectious Disease Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
| | - Andy O Miller
- Infectious Disease Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
| | - S Robert Rozbruch
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
| | - Austin T Fragomen
- Limb Lengthening and Complex Reconstruction Service, Hospital for Special Surgery, Weill Cornell Medical College, 535 East 70th Street, New York, NY 10021, USA
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Black CK, Ormiston LD, Fan KL, Kotha VS, Attinger C, Evans KK. Amputations versus Salvage: Reconciling the Differences. J Reconstr Microsurg 2019; 37:32-41. [PMID: 31499559 DOI: 10.1055/s-0039-1696733] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND There are many factors to consider when choosing between amputations versus salvage in lower extremity reconstructive surgery. Postoperative functionality and survival benefit are critical factors when deciding between limb salvage and amputation. METHODS In this review, we present the evidence and the risks and benefits between these two options in the setting of the acute, trauma population and the chronic, diabetes population. RESULTS The trauma population is on average young without significant comorbidities and with robust vasculature and core strength for recovery. Therefore, these patients can often recover significant function with anamputation and prosthesis. Amputation can therefore be the more desirable in this patient population, especially in the case of complete traumatic disruption, unstable patients, high risk of extensive infection, and significant nerve injury. However, traumatic lower extremity reconstruction is also a viable option, especially in the case of young patients and those with intact plantar sensation and sufficient available tissue coverage. The diabetic population with lower extremity insult has on average a higher comorbidity profile and often lower core strength. These patients therefore often benefit most from reconstruction to preserve limb length and improve survival. However, amputation may be favored for diabetics that have no blood flow to the lower extremity, recalcitrant infection, high-risk comorbidities that preclude multiple operations, and those with end stage renal disease. CONCLUSION Many patient-specific factors should be considered when deciding between amputation vs. salvage in the lower extremity reconstruction population.
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Affiliation(s)
- Cara K Black
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Laurel D Ormiston
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Kenneth L Fan
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Vikas S Kotha
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Christopher Attinger
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
| | - Karen Kim Evans
- Department of Plastic Surgery, MedStar Georgetown University Hospital, Washington DC
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Bezstarosti H, Van Lieshout EMM, Voskamp LW, Kortram K, Obremskey W, McNally MA, Metsemakers WJ, Verhofstad MHJ. Insights into treatment and outcome of fracture-related infection: a systematic literature review. Arch Orthop Trauma Surg 2019; 139:61-72. [PMID: 30343322 PMCID: PMC6342870 DOI: 10.1007/s00402-018-3048-0] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2018] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Standardized guidelines for treatment of fracture-related infection (FRI) are lacking. Worldwide many treatment protocols are used with variable success rates. Awareness on the need of standardized, evidence-based guidelines has increased in recent years. This systematic literature review gives an overview of available diagnostic criteria, classifications, treatment protocols, and related outcome measurements for surgically treated FRI patients. METHODS A comprehensive search was performed in all scientific literature since 1990. Studies in English that described surgical patient series for treatment of FRI were included. Data were collected on diagnostic criteria for FRI, classifications used, surgical treatments, follow-up protocols, and overall outcome. A systematic review was performed according to the PRISMA statement. Proportions and weighted means were calculated. RESULTS The search yielded 2051 studies. Ninety-three studies were suitable for inclusion, describing 3701 patients (3711 fractures) with complex FRI. The population consisted predominantly of male patients (77%), with the tibia being the most commonly affected bone (64%), and a mean of three previous operations per patient. Forty-three (46%) studies described FRI at one specific location. Only one study (1%) used a standardized definition for infection. A total of nine different classifications were used to guide treatment protocols, of which Cierny and Mader was used most often (36%). Eighteen (19%) studies used a one-stage, 50 (54%) a two-stage, and seven (8%) a three-stage surgical treatment protocol. Ten studies (11%) used mixed protocols. Antibiotic protocols varied widely between studies. A multidisciplinary approach was mentioned in only 12 (13%) studies. CONCLUSIONS This extensive literature review shows a lack of standardized guidelines with respect to diagnosis and treatment of FRI, which mimics the situation for prosthetic joint infection identified many years ago. Internationally accepted guidelines are urgently required to improve the quality of care for patients suffering from this significant complication.
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Affiliation(s)
- H. Bezstarosti
- 000000040459992Xgrid.5645.2Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - E. M. M. Van Lieshout
- 000000040459992Xgrid.5645.2Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - L. W. Voskamp
- 000000040459992Xgrid.5645.2Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - K. Kortram
- 000000040459992Xgrid.5645.2Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
| | - W. Obremskey
- 0000 0001 2264 7217grid.152326.1Vanderbilt University, Nashville, USA
| | - M. A. McNally
- 0000 0001 0440 1440grid.410556.3Nuffield Orthopaedic Centre, Oxford University Hospitals, Oxford, UK
| | - W J. Metsemakers
- 0000 0004 0626 3338grid.410569.fDepartment of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - M. H. J. Verhofstad
- 000000040459992Xgrid.5645.2Trauma Research Unit Department of Surgery, Erasmus MC, University Medical Center Rotterdam, P.O. Box 2040, 3000 CA Rotterdam, The Netherlands
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Comparing Radiographic Progression of Bone Healing in Gustilo IIIB Open Tibia Fractures Treated With Muscle Versus Fasciocutaneous Flaps. J Orthop Trauma 2018; 32:381-385. [PMID: 30035755 DOI: 10.1097/bot.0000000000001190] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To investigate how muscle and fasciocutaneous flaps influence the progression of bone healing in acute Gustilo IIIB tibia fractures. DESIGN Retrospective Chart Review. SETTING Urban Academic Level I Trauma Center. PATIENTS/PARTICIPANTS Between 2006 and 2016, 39 patients from a database of operatively treated long bone fractures met the inclusion criteria, which consisted of adults with acute Gustilo IIIB tibia shaft fracture requiring flap coverage and having at least 6 months of radiographic follow-up. INTERVENTION Soft tissue coverage for patients with Gustilo IIIB open tibia fractures was performed with either a muscle flap or fasciocutaneous flap. MAIN OUTCOME MEASUREMENTS A radiographic union score for tibia (RUST) fractures, used to evaluate fracture healing, was assigned to patients' radiographs postoperatively, at 3, 6, and 12 months from the initial fracture date. Mean RUST scores at these time points were compared between those of patients with muscle flaps and fasciocutaneous flaps. Union was defined as a RUST score of 10 or higher. RESULTS There was a significant difference (P = 0.026) in the mean RUST score at 6 months between the muscle group (8.54 ± 1.81) and the fasciocutaneous group (6.92 ± 2.46). There was no significant difference in the mean RUST score at 3 months (P = 0.056) and at 12 months (P = 0.947) between the 2 groups. There was also significance in the number of fractures reaching union, favoring muscle flaps, at 6 months (P = 0.020). CONCLUSIONS Patients with acute Gustilo IIIB tibia fractures who received muscle flaps have significantly faster radiographic progression of bone healing in the first 6 months than do patients who received fasciocutaneous flaps. Furthermore, according to radiographic evaluation, more Gustilo IIIB tibia fractures receiving muscle flaps reach union by 6 months than those flapped with fasciocutaneous tissue. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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del Pozo EG, Collazos J, Cartón JA, Camporro D, Asensi V. Bacterial osteomyelitis: microbiological, clinical, therapeutic, and evolutive characteristics of 344 episodes. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2018; 31:217-225. [PMID: 29756429 PMCID: PMC6166254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVE Osteomyelitis is a difficult-to-cure infection, with high relapse rate despite adequate therapy. Large published osteomyelitis series in adults are rare. METHODS A total of 344 adult osteomyelitis patients were studied and followed > 12 months after hospital discharge. Demographic, microbiological, clinical, therapeutic and outcome data were analyzed. RESULTS Mean age was 52.5 ± 18.3 years and 233 (67.7%) were male. Main osteomyelitis types were post-surgical (31.1%), post-traumatic (26.2%) and hematogenous (23%). Tibia (24.1%) and femur (21.8%), and methicillin-susceptible S. aureus (29.6%) were the most commonly involved bone and bacteria, respectively. Median follow-up was 12.0 (IQR 0-48) months. Inflammatory markers were increased in 73.6%. Overall, patients were treated by IV and oral routes with one (IV: 44.5%, oral: 26.7%), two (IV: 30.1%, oral: 21.8%) or ≥ 2 (IV: 15.2%, oral: 6.1%) antibiotics. Median duration on IV/oral antimicrobials was 28.0 (IQR 24-28) and 19.5 (IQR 4-56) days, respectively. Anti-staphylococcal β-lactams cloxacillin/cefazolin (19.2%) and ciprofloxacin (5.5%) were the most frequently used IV and orally, respectively. Overall 234 (68.0%) underwent surgery, 113 (32.8%) debridement, 97 (27.4%) debridement + muscle flap and 24 (7%) amputation. At the end of follow-up 208 patients (60.6%) did not have relapsed. Operated patients had significantly less relapses (p<0.0001). A total of 23 (6.7%) died, 11 (3.2%) by infectious complications and 48 (14%) were lost in the follow-up. CONCLUSIONS Osteomyelitis is due to different causes complicating its therapy. Risk factors or causal microorganism could influence its treatment and outcome. Aggressive surgery along with adequate antimicrobial therapy are mandatory for cure.
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Affiliation(s)
- Elena García del Pozo
- Plastic Surgery Service, Hospital Universitario Central de Asturias (HUCA), Oviedo University School of Medicine, Oviedo, Spain
| | - Julio Collazos
- Infectious Diseases Unit, Hospital de Galdácano, Vizcaya, Spain
| | - José Antonio Cartón
- Infectious Diseases Unit, Hospital Universitario Central de Asturias (HUCA), Oviedo University School of Medicine, Oviedo, Spain,Group of Translational Research in Infectious Diseases, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA)
| | - Daniel Camporro
- Plastic Surgery Service, Hospital Universitario Central de Asturias (HUCA), Oviedo University School of Medicine, Oviedo, Spain
| | - Víctor Asensi
- Infectious Diseases Unit, Hospital Universitario Central de Asturias (HUCA), Oviedo University School of Medicine, Oviedo, Spain,Group of Translational Research in Infectious Diseases, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA)
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The Combined Use of a Neurocutaneous Flap and the Ilizarov Technique for Reconstruction of Large Soft Tissue Defects and Bone Loss in the Tibia. Ann Plast Surg 2018; 78:543-548. [PMID: 28403000 DOI: 10.1097/sap.0000000000000921] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Management of posttraumatic large soft tissue defects and bone loss remains a therapeutic and surgical challenge for orthopedic surgeons. We assessed the use of a neurocutaneous flap and the Ilizarov technique in the reconstruction of severe composite defects in the tibia. METHODS We retrospectively reviewed 18 consecutive patients with trauma-related soft tissue defects and bone loss. The size of the soft tissue defect ranges from 8 × 9 cm to 14 × 18 cm. The mean size of bone loss was 4.5 cm. A great saphenous neurocutaneous flap or sural neurocutaneous flap was created to reconstruct the soft tissue defect. The Ilizarov external fixator was applied to reconstruct bony loss by means of distraction osteogenesis. RESULTS The mean follow-up period was 38.8 months. All transferred flaps survived completely. The area covered ranged from 9 × 10 cm to 15 × 20 cm. The mean distraction length and duration of use of the external fixator were 6 cm and 11.4 months, respectively. All patients achieved final union. Complications of superficial pin-tract infections and mild Achilles tendon contracture were observed, but these were resolved over time. All patients were satisfied with the outcome of the surgery. CONCLUSIONS A well-vascularized neurocutaneous flap is a safe and effective option in lower extremity reconstruction under a stable mechanical environment, which can be created using the Ilizarov technique. It is a good option for reconstructing severe complex defects in the lower limb.
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Shen Y, Chen H, Hu X, Huang L, Ma C. [Tissue flap combined with sequential bone lengthening technique for repairing severe soft tissue and bone defects of lower extremity after burn injury]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:160-164. [PMID: 29786246 DOI: 10.7507/1002-1892.201609117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Objective To investigate the effectiveness of tissue flap grafting and sequential bone lengthening for repairing severe soft tissue and bone defects of the lower extremity after burn injury. Methods Between January 2010 and December 2015, 11 cases of large segmental bone and soft tissue defects in the leg were treated. There were 10 males and 1 female, with a mean age of 28 years (range, 19-37 years). The causes included traffic accident in 8 cases, high voltage electric burn in 2 cases, CO poisoning burn in 1 case. The time from injury to admission was 3-14 days (mean, 6.5 days). The bone defect length was 8-18 cm (mean,14 cm); the skin soft tissue defect ranged from 13 cm × 8 cm to 25 cm × 19 cm. After complete removal of necrotic tissue and lesions of the femur or the tibia, the tissue flaps were used to repair soft tissue defect of the lower extremity in one-stage operation; bone defect was treated by Orthofix single side external fixation or Ilizarov ring external fixation in two-stage operation. Results Eleven flaps survived completely, primary healing of incision was obtained in the others except for 1 patient who had necrotic bone infection, which was cured after removing necrosed femoral bone and filling with antibiotic bone cement spacer. During bone lengthening, pin tract infection occurred in 1 patient, and infection was controlled after dressing change. Bone lengthening ranged from 8 to 18 cm, with an average of 14 cm. After prolonged extension, the external fixator was retained for 4-12 months (mean, 6.5 months). All bone defects were repaired with bone healing time of 12-22 months (mean, 17 months). All patients were followed up 8-24 months (mean, 15 months). No vascular and neurological complication occurred during operation; no osteomyelitis or re-fracture occurred after operation, and the recovery of the lower extremity function was good. Conclusion Tissue flap grafting combined with bone lengthening is an effective method to repair severe bone and soft tissue defects of lower extremity.
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Affiliation(s)
- Yuming Shen
- Department of Burns, Beijing Jishuitan Hospital, Beijing, 100035,
| | - Hui Chen
- Department of Burns, Beijing Jishuitan Hospital, Beijing, 100035, P.R.China
| | - Xiaohua Hu
- Department of Burns, Beijing Jishuitan Hospital, Beijing, 100035, P.R.China
| | - Lei Huang
- Department of Orthopedic Surgery, Beijing Jishuitan Hospital, Beijing, 100035, P.R.China
| | - Chunxu Ma
- Department of Burns, Beijing Jishuitan Hospital, Beijing, 100035, P.R.China
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Fang C, Wong TM, To KK, Wong SS, Lau TW, Leung F. Infection after fracture osteosynthesis - Part II. J Orthop Surg (Hong Kong) 2017; 25:2309499017692714. [PMID: 28219306 DOI: 10.1177/2309499017692714] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
In the first part of this article, we have discussed the pathogenesis, clinical presentation, diagnosis and classification of infection after fracture osteosynthesis with implants, termed here as osteosynthesis-associated infection (OAI). Prolonged antibiotic treatment is usually necessary. Implant retention and maintenance of fracture stability to allow for fracture healing in spite of infection are allowed for OAI. Depending on the severity of infection, status of fracture healing and host status, the treatment follows five common pathways. These are non-operative treatment, debridement with implant retention, conversion of fixation, implant removal and suppression therapy. The decision-making process leading to each treatment pathway and challenging scenarios is discussed in detail.
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Affiliation(s)
- Christian Fang
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Tak-Man Wong
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong.,3 Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Kelvin Kw To
- 2 Department of Microbiology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Samson Sy Wong
- 2 Department of Microbiology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Tak-Wing Lau
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong
| | - Frankie Leung
- 1 Department of Orthopaedics and Traumatology, Queen Mary Hospital, University of Hong Kong, Pokfulam, Hong Kong.,3 Shenzhen Key Laboratory for Innovative Technology in Orthopaedic Trauma, University of Hong Kong-Shenzhen Hospital, Shenzhen, China
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Repo JP, Barner-Rasmussen I, Roine RP, Sintonen H, Tukiainen EJ. Treatment of compound tibia fracture with microvascular latissimus dorsi flap and the Ilizarov technique: A cross-sectional study of long-term outcomes. J Plast Reconstr Aesthet Surg 2016; 69:524-32. [PMID: 26843265 DOI: 10.1016/j.bjps.2015.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 12/13/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Extensive compound tibial fractures present reconstructive challenges. The present study aimed to assess the outcomes of microvascular latissimus dorsi (LD) flap combined with the Ilizarov technique for extensive compound tibial fractures with bone loss and bone healing complications. METHODS Patient records were reviewed retrospectively. The Lower Extremity Functional Scale (LEFS), the Disabilities of the Arm, Hand and Shoulder (DASH), and the 15D health-related quality of life (HRQoL) instrument were applied. RESULTS Between 1989 and 2014, 16 patients underwent reconstruction with a microvascular LD flap and bone transport (11/16) or late bone lengthening (5/16). The mean clinical follow-up time was 6.6 (standard deviation (SD): 6.5) years. Three patients had minor complications requiring reoperation. Partial necrosis of one flap required late flap reconstruction in one case. Late bone grafting was used to enhance union in eight of 16 cases. The mean new bone gain was 3.8 cm (SD: 2.5). Overall, 11 patients completed the questionnaires in a mean of 22.3 years (SD: 2.4) after surgery. The main findings revealed a relatively good function of the reconstructed limb and good shoulder function. The mean HRQoL was comparable to that of an age-standardized sample of the general population. CONCLUSION Segmental tibia transport and lengthening to correct limb length discrepancy do not compromise the microvascular muscle flap. Combined microvascular LD flap reconstruction and the Ilizarov technique can be used in treating acute compound tibial defects, pseudoarthrosis, and osteitis, all associated with significant amputation risk. Fair long-term functional outcomes and HRQoL are achieved when these combined techniques are used.
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Affiliation(s)
- J P Repo
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, HUS, Helsinki, Finland.
| | - I Barner-Rasmussen
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, HUS, Helsinki, Finland
| | - R P Roine
- Group Administration, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Health and Social Management, Research Centre for Comparative Effectiveness and Patient Safety, University of Eastern Finland, Kuopio, Finland
| | - H Sintonen
- Department of Public Health, University of Helsinki, Helsinki, Finland
| | - E J Tukiainen
- Department of Plastic Surgery, University of Helsinki and Helsinki University Hospital, HUS, Helsinki, Finland
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Bose D, Kugan R, Stubbs D, McNally M. Management of infected nonunion of the long bones by a multidisciplinary team. Bone Joint J 2015; 97-B:814-7. [PMID: 26033062 DOI: 10.1302/0301-620x.97b6.33276] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Infected nonunion of a long bone continues to present difficulties in management. In addition to treating the infection, it is necessary to establish bony stability, encourage fracture union and reconstruct the soft-tissue envelope. We present a series of 67 infected nonunions of a long bone in 66 patients treated in a multidisciplinary unit. The operative treatment of patients suitable for limb salvage was performed as a single procedure. Antibiotic regimes were determined by the results of microbiological culture. At a mean follow-up of 52 months (22 to 97), 59 patients (88%) had an infection-free united fracture in a functioning limb. Seven others required amputation (three as primary treatment, three after late failure of limb salvage and one for recalcitrant pain after union). The initial operation achieved union in 54 (84%) of the salvaged limbs at a mean of nine months (three to 26), with recurrence of infection in 9%. Further surgery in those limbs that remained ununited increased the union rate to 62 (97%) of the 64 limbs treated by limb salvage at final follow-up. The use of internal fixation was associated with a higher risk of recurrent infection than external fixation.
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Affiliation(s)
- D Bose
- Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - R Kugan
- Gloucester Royal Infirmary, 8 Meadow Close, Sutton Coldfield B76 2QQ, UK
| | - D Stubbs
- Oxford University Hospitals NHS Trust, Windmill Road, Oxford OX3 7HE, UK
| | - M McNally
- Oxford University Hospitals NHS Trust, Windmill Road, Oxford OX3 7HE, UK
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Abstract
LEARNING OBJECTIVES After studying this article, the participant should be able to: 1. Understand the steps for evaluation of a patient with a lower extremity wound before initiating medical or surgical intervention. 2. Acknowledge that limb amputation and salvage can both be appropriate definitive treatment options. 3. Select proper nonsurgical or surgical techniques for wound management. 4. Appreciate the difference in the expected outcome according to the perspective of the physician versus the patient. SUMMARY Lower extremity acute trauma is a common occurrence. Ultimate functional outcomes are similar whether amputation or salvage by limb reconstruction is the treatment pathway chosen. The reconstructive surgeon must be knowledgeable enough to assist in making the correct decision for either option. Débridement is the cornerstone of management before embarking on definitive wound closure. Nonsurgical devices have provided a transition to optimize the wound, sometimes even replacing or lessening the need for vascularized tissues to permit this coverage. Nevertheless, flaps will always have a role varying according to the involved region of the lower extremity. Traditional muscle flaps can often today be supplemented by the use of perforator flaps. The latter have great versatility as pedicled flaps for all zones of the lower limb, in addition to being a dependable free flap alternative. Horrendous injuries can now be expected to be salvaged, with a reasonable aesthetic result possible and with minimal donor-site morbidity. Preferences by both physicians and patients tend to favor the course to limb salvage, but it must be appreciated by the caregiver that it is always the patient who has to live with the residua of an altered limb and lifestyle.
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Abstract
High-energy open fractures of the tibia have traditionally been fraught with challenges to include bone comminution or loss, soft tissue loss, nonunion, and infection. A number of techniques have been implemented to treat the severe soft tissue loss typically involving the anteromedial surface of the tibia to include wet-to-dry dressings or Papineau techniques, negative pressure wound therapy, acellular dermal matrices, and rotational or free tissue transfer with Masquelet technique, primary shortening, and distraction osteogenesis to address bone loss. We present a novel technique and subsequent case series that obviates the need of free tissue transfer while treating high-energy type IIIB open tibia fractures by performing an acute shortening and angulation of the tibia and rotational muscle flap coverage and split-thickness skin grafting of the soft tissue defect. Distraction histiogenesis with circular external fixation is then used to correct the residual osseous deformity while stretching the rotational muscle flap.
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Cetrulo CL, Barone AAL, Jordan K, Chang DS, Louie K, Buntic RF, Brooks D. A multi‐disciplinary approach to the management of fungal osteomyelitis: Current concepts in post‐traumatic lower extremity reconstruction: A case report. Microsurgery 2011; 32:144-7. [DOI: 10.1002/micr.20956] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Curtis L. Cetrulo
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital‐Harvard Medical School, 15 Parkman Street, WACC 435, Boston, MA 02114
| | - Angelo A. Leto Barone
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital‐Harvard Medical School, 15 Parkman Street, WACC 435, Boston, MA 02114
| | - Kathleen Jordan
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital‐Harvard Medical School, 15 Parkman Street, WACC 435, Boston, MA 02114
| | - David S. Chang
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital‐Harvard Medical School, 15 Parkman Street, WACC 435, Boston, MA 02114
| | - Kevin Louie
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital‐Harvard Medical School, 15 Parkman Street, WACC 435, Boston, MA 02114
| | - Rudolf F. Buntic
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital‐Harvard Medical School, 15 Parkman Street, WACC 435, Boston, MA 02114
| | - Darrell Brooks
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital‐Harvard Medical School, 15 Parkman Street, WACC 435, Boston, MA 02114
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