Anterior Tibial to Dorsalis Pedis Bypass to Manage Acute Ischemia Attributed to Pilon Fracture

Pilon fractures of the distal tibia are usually the result of a high-energy trauma and can affect seriously the arterial vasculature carrying an increased risk of amputation at the malleolar level or higher. Such cases represent a challenge for the orthopedic surgeons and a multidisciplinary approach is mandatory in order to salvage the threatened limb. We present an unusual case of a closed pilon fracture with injury of all tibial vessels leading to acute limb threatening ischemia. The patient was treated successfully with external fixation and a short tibial-pedal bypass with use of an autologous reversed saphenous vein graft. This example dictates how a distal leg fracture can be dramatic and that awareness of vascular examination coupled with high suspicion of vascular damage can be limb-saving. Multidisciplinary approach is warranted since the topology and complexity of the ankle lesions necessity staged orthopedic reconstructions with tibio-distal bypass and appropriate skin coverage of the distal anastomosis.

Efficacy and safety of external tissue expansion technique in the treatment of soft tissue defects: a systematic review and meta-analysis of outcomes and complication rates

Background

Currently, various external tissue expansion devices are becoming widely used. Considering the scarcity of relevant application standards, this systematic review was performed to explore the effectiveness and safety of external tissue expansion techniques for the reconstruction of soft tissue defects.

Method

A systematic review and meta-analysis on the efficacy and safety of external tissue expansion technique was conducted. A comprehensive search was performed in the following electronic databases: PubMed/Medline, Embase, Cochrane Library (Wiley Online Library), and Web of Science. Studies reporting patients with soft tissue defects under the treatment of external tissue expansion technique were included.

Results

A total of 66 studies with 22 different types of external tissue expansion devices met the inclusion criteria. We performed a descriptive analysis of different kinds of devices. A single-arm meta-analysis was performed to evaluate the efficacy and safety of the external tissue expansion technique for different aetiologies. The pooled mean wound healing time among patients with defects after fasciotomy was 10.548 days [95% confidence interval (CI) = 5.796–15.299]. The pooled median wound healing times of patients with defects after excisional surgery, trauma, chronic ulcers and abdominal defects were 11.218 days (95% CI = 6.183-16.253), 11.561 days (95% CI = 7.062-16.060), 15.956 days (95% CI = 11.916-19.996) and 12.853 days (95% CI=9.444-16.227), respectively. The pooled wound healing rates of patients with defects after fasciotomy, excisional surgery, trauma, chronic ulcers and abdominal defects were 93.8% (95% CI=87.1-98.2%), 97.2% (95%CI=92.2-99.7%), 97.0% (95%CI=91.2-99.8%), 99.5% (95%CI=97.6-100%), and 96.8% (95%CI=79.2-100%), respectively. We performed a subgroup analysis in patients with diabetic ulcers and open abdominal wounds. The pooled median wound healing time of patients with diabetic ulcers was 11.730 days (95% CI = 10.334-13.125). The pooled median wound healing time of patients with open abdomen defects was 48.810 days (95% CI = 35.557–62.063) and the pooled successful healing rate was 68.8% (95% CI = 45.9-88.1%). A total of 1686 patients were included, 265 (15.7%) of whom experienced complications. The most common complication was dehiscence (n = 53, 3.14%).

Conclusions

Our systematic review is the first to demonstrate the efficacy and safety of external tissue expansion in the management of soft tissue defects. However, we must interpret the meta-analysis results with caution considering the limitations of this review. Large-scale randomized controlled trials and long-term follow-up studies are still needed to confirm the effectiveness and evaluate the quality of healing.

External Tissue Expansion in Complex Extremity Reconstruction

Skin grafting and flap-based reconstruction have been the conventional treatments for complex extremity wounds. However, these methods can be associated with relatively high complication rates and involve increasing levels of complexity. External tissue expansion has recently emerged as an attractive alternative to its conventional counterparts. It is a technically simple and low-morbidity technique for complex wound reconstruction. This article provides a review of internal and external tissue expansion with a focus on the evolution, indications, and recent successes of external expansion for soft tissue coverage.

Closure of Complex Wounds by a Simple Skin Stretching System Associated With Vacuum Sealing Drainage-Clinical Outcome of 34 Patients

Management of complex wounds with large skin defects presents a real challenge for orthopedic or reconstructive surgeons. We developed a simple skin stretching system associated with vacuum sealing drainage to examine the efficiency and complication. A total of 34 patients with different types of complex wounds were retrospectively included from January 2015 to March 2021. All patients in the study were underwent the treatment by 2 stages. The method was used to the wounds from 4.71 to 169.65 cm² with a median defect size of 25.13 cm². The median time for wound closure was 11.5 days (range: 5-32 days), although the median absolute reduction was 2.08 cm²/day (range: 0.15-25.66 cm²/day). Depending on the site of the wounds, the cause of the wound, and the rate of max-width/max-length (W/L), these complex wounds could be separately divided into several groups. There were statistically significant differences in the median value of the above variables (P < .05 Kruskal-Wallis test). The results showed that different anatomical sites had different viscoelastic properties, the complex wounds caused by trauma were easier to close than caused by diabetic foot and the complex wounds in group A (W/L ＞ 0.5) were more difficult to close than in group B (W/L ≤ 0.5). No major complications were encountered in this study. In summary, the results of our study showed that the simple skin stretching system associated with vacuum sealing drainage was a safe approach for closure of complex wounds. Nevertheless, more attention should be paid to the viscoelasticity of the wounds to ensure closure and avoid undue complications when applying the method.

A novel skin-stretching device for closing large skin-soft tissue defects after soft tissue sarcoma resection

BACKGROUND

Closure of large skin-soft tissue defects following soft tissue sarcoma (STS) resection has been a great challenge. The objective of this study was to evaluate the effectiveness of a novel, simple, and cheap skin-stretching device (bidirectional regulation-hook skin closure system, BHS) for closing large skin-soft tissue defects resulting from the removal of STS and the complications associated with the use of the BHS.

METHODS

From January 2017 to September 2018, 25 patients with STS underwent BHS therapy after tumor resection. BHS was used for two main clinical applications: securing wound closure after high-tension suture closure and delayed wound closure. We described a detailed reconstruction procedure regarding this therapy. Wound closure and complications associated with BHS therapy were recorded. We also analyzed tumor recurrence and metastases.

RESULTS

All patients were observed for 16-36 months with an average follow-up of 25.6 months. During the follow-up period, no significant functional restriction was observed and the final scar was aesthetically acceptable. Superficial wound infection occurred in six patients, wound edge ischemia in two patients, and small skin tears in two patients. Two patients developed pulmonary metastasis, two patients had a local recurrence, and one patient died of pulmonary metastasis.

CONCLUSIONS

BHS therapy can effectively close large skin-soft tissue defects following STS resection and obtain acceptable functional results, without severe complications. However, larger studies are required to further evaluate the effectiveness, indications, and complications of BHS therapy.