Bone and soft tissue reconstruction with tendon balance in severe foot trauma

In severe foot trauma, it is difficult to determine the level of amputation when the crush injury is severe. We report a case of amputation near Lisfranc that achieved forefoot amputation-like results by using bone and soft tissue reconstruction while considering tendon balance. The patient was a 40-year-old male. The patient's left leg was caught in a garbage truck and sustained a crush injury. The second to fifth metatarsals were amputated at the diaphysis, and a high degree of instability of the Lisfranc joint was observed. A high degree of contamination was detected in the patient's wound, and the second to fifth toes were amputated at the Lisfranc joint during the initial treatment. The ends of the tibialis anterior, tibialis posterior and peroneus longus were preserved. On day 5 in the hospital, Lisfranc joint fixation of the hallux, amputation of the first metatarsal and reconstruction of the peroneus brevis were performed. On day 13, extensor hallucis longus tendon transfer and free anterolateral thigh flap were performed. On day 80, the patient was able to walk in regular shoes or non-orthopedic shoes. One year after reconstructive surgery, the patient had an average SAFE-Q score of 86.2 and mild varus deformity of the foot remained. In cases of severe foot trauma, the aim of reconstruction should be partial forefoot amputation whenever possible.

Clinical outcomes of perforator-based propeller flaps versus free flaps in soft tissue reconstruction for lower leg and foot trauma: a retrospective single-centre comparative study

BACKGROUND

The efficacy and safety of perforator-based propeller flaps (PPF) versus free flaps (FF) in traumatic lower leg and foot reconstructions are debated. PPFs are perceived as simpler due to advantages like avoiding microsurgery, but concerns about complications, such as flap congestion and necrosis, persist. This study aimed to compare outcomes of PPF and FF in trauma-related distal lower extremity soft tissue reconstruction.

METHODS

We retrospectively studied 38 flaps in 33 patients who underwent lower leg and foot soft tissue reconstruction due to trauma at our hospital from 2015 until 2022. Flap-related outcomes and complications were compared between the PPF group (18 flaps in 15 patients) and the FF group (20 flaps in 18 patients). These included complete and partial flap necrosis, venous congestion, delayed osteomyelitis, and the coverage failure rate, defined as the need for secondary flaps due to flap necrosis.

RESULTS

The coverage failure rate was 22% in the PPF group and 5% in the FF group, with complete necrosis observed in 11% of the PPF group and 5% of the FF group, and partial necrosis in 39% of the PPF group and 10% of the FF group, indicating no significant difference between the two groups. However, venous congestion was significantly higher in 72% of the PPF group compared to 10% of the FF group. Four PPFs and one FF required FF reconstruction due to implant/fracture exposure from necrosis. Additionally, four PPFs developed delayed osteomyelitis post-healing, requiring reconstruction using free vascularized bone graft in three out of four cases.

CONCLUSIONS

Flap necrosis in traumatic lower-leg defects can lead to reconstructive failure, exposing implants or fractures and potentially causing catastrophic outcomes like osteomyelitis, jeopardizing limb salvage. Surgeons should be cautious about deeming PPFs as straightforward and microsurgery-free procedures, given the increased complication rates compared to FFs in traumatic reconstruction.

DATA ACCESS STATEMENT

The datasets generated during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Cranioplasty is not required in the reconstruction of small combined scalp and calvarial defects

BACKGROUND

Treatment of scalp malignancies may include the need for craniectomy. The decision to perform cranioplasty is not straightforward and is frequently subjective. The purpose of this study was to assess the clinical outcomes after reconstruction of complex scalp and calvarial defects by comparing patients with and without cranioplasty.

METHODS

Retrospective review of the clinical records of a consecutive series of patients who underwent scalp soft tissue reconstruction after craniectomy for malignancy or osteoradionecrosis between 2014 and 2022 at Royal Melbourne Hospital was conducted. Demographics, previous treatments, surgical details, and post-operative complications were assessed. Traumatic injuries and decompressive craniectomies were excluded. Minimum follow-up of 6 months.

RESULTS

Thirty-seven patients were included in the study. Indications for surgery included skin malignancies, osteoradionecrosis, or both. There was one reconstructive failure (in the non-cranioplasty group). Infection and metalware exposure were common complications in patients who underwent cranioplasty (38.5%). No patient developed neurological symptoms subsequent to craniectomy. One patient needed revision surgery due to esthetic reasons (cranioplasty group). Transposition flaps were associated with more complications and revision procedures.

CONCLUSION

Combined scalp and calvarial defects pose a difficult reconstructive challenge. Stable soft tissue coverage is more reliably achieved with free flap reconstruction. Cranioplasty is not always mandatory and should be reserved for cases with a very large bony defect or when the defect is located in a cosmetically sensitive area.

Autologous Skin Cell Suspension for Full-Thickness Skin Defect Reconstruction: Current Evidence and Health Economic Expectations

Despite differing etiologies, acute thermal burn injuries and full-thickness (FT) skin defects are associated with similar therapeutic challenges. When not amenable to primary or secondary closure, the conventional standard of care (SoC) treatment for these wound types is split-thickness skin grafting (STSG). This invasive procedure requires adequate availability of donor skin and is associated with donor site morbidity, high healthcare resource use (HCRU), and costs related to prolonged hospitalization. As such, treatment options that can facilitate effective healing and donor skin sparing have been highly anticipated. The RECELL® Autologous Cell Harvesting Device facilitates preparation of an autologous skin cell suspension (ASCS) for the treatment of acute thermal burns and FT skin defects. In initial clinical trials, the approach showed superior donor skin-sparing benefits and comparable wound healing to SoC STSG among patients with acute thermal burn injuries. These findings led to approval of RECELL for this indication by the US Food and Drug Administration (FDA) in 2018. Subsequent clinical evaluation in non-thermal FT skin wounds showed that RECELL, when used in combination with widely meshed STSG, provides donor skin-sparing advantages and comparable healing outcomes compared with SoC STSG. As a result, the device received FDA approval in June of 2023 for treatment of FT skin defects caused by traumatic avulsion or surgical excision or resection. Given that health economic advantages have been demonstrated for RECELL ± STSG versus STSG alone when used for burn therapy, it is prudent to examine similarities in the burn and FT skin defect treatment pathways to forecast the potential health economic advantages for RECELL when used in FT skin defects. This article discusses the parallels between the two indications, the clinical outcomes reported for RECELL, and the HCRU and cost benefits that may be anticipated with use of the device for non-thermal FT skin defects.

Revisiting the reconstructive ladder for soft tissue reconstruction in the lower extremity

Soft tissue reconstruction of the lower limb has seen a paradigm shift over the past two decades. Typically, these defects arise from trauma, infection or tumor. It is no longer enough to simply achieve coverage. Factors like patient-reported outcomes and aesthetic considerations are essential in the decision-making process. This is especially in light of increasing technological advancement, availability of dermal substitutes, microsurgical expertise and development of the field of microsurgical reconstruction as a whole with more novel flaps and techniques. Advancements in reconstructive modalities have also been equally matched by better emergency medical mobilization, transportation and access, early initiation of subspecialty care, accessibility and types of imaging, as well as oncological advances in radiotherapy and chemotherapy regimens. Yet, this has also meant that our patient profile has expanded to include older patients with more co-morbidities and other considerations such as frailty or the irradiated field which could influence what reconstructive modality is suitable and the goals of reconstruction specific to the patient. Previously deemed unsalvageable limbs are now being successfully reconstructed with good function and aesthesis. In the lower limb, this implicates the ability for early mobilization, range of motion and weight bearing which allow the patient to successfully partake in early rehabilitation. Expedient and reliable healing is also important in the oncological population where a proportion of these patients would need to go on to receive post-operative chemotherapy or radiotherapy. The reconstructive ladder has been what many reconstructive surgeons have been taught upon with regard to the basic principles of pre-operative planning and choosing the appropriate reconstructive modality. In this article, we examine the relevance of the reconstructive ladder in modern practice and the additional considerations in the approach to a soft tissue defect in the lower extremity.

Dual Network Hydrogels Based on PRP and SA Promote the Retention Rate and Vascularization of Transplanted Fat

BACKGROUND

Autologous adipose tissue often experiences ischemia and hypoxia after transplantation, leading to low retention rates and unstable operative impacts due to necrotic absorption. Platelet-rich plasma (PRP) can enhance fat regeneration and increase the fat retention rate after transplantation. However, the quick release of growth factors (GFs) in PRP decreases therapeutic efficiency. This study aimed to achieve a slow release of PRP to promote fat retention.

METHODS

We prepared a dual-network hydrogel (DN gel) based on FDA-approved PRP and sodium alginate (SA) through a simple "one-step" activation process. In vivo study, adipose tissue with saline (control group), SA gel (SA gel group), PRP gel (PRP gel group), and DN gel (DN gel group) was injected subcutaneously into the dorsum of nude mice. At 4 and 12 weeks after injection, tissues were assessed for volume and weight. Hematoxylin and eosin staining (HE) and immunofluorescence staining were performed for histological assessment.

RESULTS

DN gel exhibits long-lasting growth factor effects, surpassing conventional clinical PRP gel regarding vascularization potential. In fat transplantation experiments, DN gel demonstrated improved vascularization of transplanted fat and increased retention rates, showing promise for clinical applications.

CONCLUSIONS

DN gel-assisted lipofilling can significantly improve the retention rate and quality of transplanted fat. DN gel-assisted lipofilling, which is considered convenient, is a promising technique to improve neovascularization and fat survival.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Augmented reality-assisted systematic mapping of anterolateral thigh perforators

PURPOSE

In soft tissue reconstructive surgery, perforator localization and flap harvesting have always been critical challenges, but augmented reality (AR) has become a dominant technology to help map perforators.

METHODS

The lateral circumflex femoral artery (LCFA) and its perforators were reconstructed by CTA in consecutive patients (N = 14). Then, the anterolateral thigh perforators and the points from which the perforators emerged from the deep fascia were marked and projected onto the skin surface. As the virtual images were projected onto patients according to bony markers, the courses of the LCFA and its perforators were depicted on the skin surface for intraoperative guidance. Finally, the locations of the emergence points were verified by intraoperative findings and compared to those determined by handheld Doppler ultrasound.

RESULTS

The sources, locations, and numbers of perforators were determined by CTA. The perforators and their emergence points were accurately mapped on the skin surface by a portable projector to harvest the anterolateral thigh perforator flap. During the operation, the accuracy of the CTA & AR method was 90.2% (37/41), and the sensitivity reached 97.4% (37/38), which were much higher than the corresponding values of Doppler ultrasound. Additionally, the differences between the AR-marked points and the intraoperative findings were much smaller than those seen with Doppler ultrasound (P < 0.001). Consequently, all of the flaps were well designed and survived, and only one complication occurred.

CONCLUSION

Augmented reality, namely, CTA combined with projection in this study, plays a vital and reliable role in locating the perforator emergence points and guiding the procedure to harvest flaps and has fewer potential risks.

The Keystone Flap: A Multi-centric Experience in Elderly Patients Treatment

Soft tissue reconstruction in elderly patients must be rapid and reliable. The keystone island flap (KF) offers an effective solution, with low complication rates and quick recovery. This multi-centric study aims to show authors' experience with KFs in treating soft tissue defects of trunk and limbs. Patients with soft tissue defects suitable for KF reconstruction were recruited from March 2019 to December 2019. Active inflammation and previous surgeries in the same region were considered exclusion criteria. Complications that occurred during follow-up were recorded, and their incidence pattern was assessed with the Fisher test. Seventy-two patients with mean age of 76.2 years old were selected. They presented lesions in torso (46; 63.9%) or in upper (4; 5.6%) or lower (22; 30.6%) limb regions. Fifteen (20.8%) wounds were non-oncologic lesions, and the others were oncologic lesions, mostly non-melanoma skin cancers. KF type I was carried out in 42 (58.3%) cases, KF type II-A in 13 (18%) cases, double opposed type III KF in 16 (22.2%) patients, and 1 (1.4%) case required partial flap's undermining (IV KF). Mean post-operative recovery period was 4.3 days (range, 1-9 days). Post-surgical complications occurred in 15 (20.8%) cases, 7 (9.7%) of them were considered major complications. No statistically significant difference in complications' incidence, nor among different surgical sites nor among KF types, was registered. Reconstructive surgeons have to adapt their work to elderly patients. The KF allows rapid operative times, low morbidity rates, and short post-operative recovery time, thus appearing as a feasible solution.

Radical treatment of severe open fractures of extremities by orthoplastic surgery: a 10-year retrospective study

OBJECTIVE

This study aimed to retrospectively analyze clinical data of a series of patients with severe open fractures of extremities (Gustilo IIIb or IIIc), who achieved a satisfactory outcome through radical orthoplastic surgery, so as to provide a reference for determining the treatment of severe open fractures of extremities.

METHODS

The clinical data of 41 consecutive patients with severe open fracture (Gustilo IIIb or IIIc) of the limb, who underwent successful surgical debridement, fixation, and soft tissue reconstruction in one stage between January 2008 and January 2019, were retrospectively reviewed. Postoperative indicators, including infection rate and union time, were acquired by a regular follow-up and analyzed.

RESULTS

The mean (±SD) age of the patients was 38 ± 16 years. A total of 90 open fractures and severe soft tissue damages were analyzed. The soft tissue cover was achieved within 72 h. The overall rate of infection was 14.6% (6/41). Sex and the Mangled Extremity Severity Score were associated with infection. The median union time of 40 patients (one amputation) was 32 weeks.

CONCLUSION

The overall rate of infection exhibited a lower tendency in this study compared with previous studies on high-grade open fractures following a two-stage orthopedic approach. The consequence of infection rate and union time was similar to that in previous studies. These results indicated that the single-stage radical orthoplastic treatment was an effective and reliable option for reconstructing severe open fractures.

Omental free flap for surgical treatment of chronic osteomyelitis of lower limb: A technical note

Soft tissue reconstruction of chronic lower extremity wounds with bone infection entails an important challenge in reconstructive surgery. We report our experience using the omentum free flap to provide coverage in two patients suffering chronic osteomyelitis of the lower limbs. After extensive soft tissue and bone debridement, an omentum free flap was performed in both cases, providing dead space obliteration and soft tissue coverage in behalf of its large size and pliability. As a result, the chronic illness was eradicated in both patients, with satisfactory outcomes and infection resolution.

The Medial Sural Artery Perforator Flap in Lower Extremity Reconstruction

Medial sural artery perforator (MSAP) flap is a thin, pliable, and versatile flap. It is a fasciocutaneous flap with chimeric design capacity. The donor site permits the synchronous harvesting of nonvascularized tendons and nerves. Free MSAP flap is suitable for foot, ankle, and distal one-third of the leg reconstructions. Pedicled MSAP flap is an alternative flap for knee and proximal two-thirds of leg defects, covering classical lower limb reconstruction territories of soleus, medial, and lateral gastrocnemius muscle flap. Computed tomography angiography, indocyanine green, and endoscopic-assist dissection enhances MSAP flap surgical planning and reduces its technical adversities and complications.

Complex Soft Tissue Defects in Operative Urology: Pedicled Perforator Flaps of the Anterior Lateral Thigh for Tissue Reconstruction of the Lower Trunk

BACKGROUND

Complex soft tissue defects involving the lower abdomen, perineum, and groin (LAPG) represent reconstructive challenges following urologic surgery. Consequently, these often require an interdisciplinary approach involving plastic surgery. While pedicled flaps from the lower abdomen are a reliable option, previous placement of colostomies and urinary urostomies renders these flap types unavailable. Here, the pedicled anterolateral thigh perforator (ALT) flap represents a reliable pedicled alternative which can harvest from the thigh.

MATERIALS AND METHODS

A retrospective data analysis of pedicled perforator flaps harvested from the thigh to reconstruct soft tissue defects was conducted. Seven patients treated in the urology department with soft tissue defects following tumor resection, infection, and dehiscence were included.

RESULTS

In all patients, the ALT flap was utilized successfully to reconstruct soft tissue defects up to 450 cm2 in size. All flaps survived. In 1 case, prolonged wound healing was observed. All defects were adequately addressed with no recurrence of dehiscence or fistula formation.

CONCLUSIONS

Pedicled perforator flaps represent a valid option for the soft tissue reconstruction of the lower abdomen and perineum when a pedicled rectus abdominis flap is no longer available. This flap is, therefore, a good option in an interdisciplinary approach to soft tissue reconstruction, especially following urologic surgery, which is predominantly performed in the LAPG region.

Perforator-Plus Flaps in Lower Extremity Reconstruction

The perforator-plus flap is a new concept for lower extremity reconstruction. It combines a perforator flap with a traditional skin rotation flap. It can be another option for lower extremity soft tissue defects since the flap has an augmented blood supply. The ability to detect cutaneous perforators has improved with the Duplex scan imaging technique. These advances have made the perforator-plus flap a viable option for soft tissue reconstruction. It can be versatile and reduces donor site morbidity; it is technically simple to perform and faster than traditional free flaps. It achieves durable soft tissue coverage for lower extremity wounds.

Outcomes of major musculoskeletal oncological reconstructions using prolene mesh-a retrospective analysis from a tertiary referral centre

BACKGROUND

Adequate reconstruction of the soft tissue defect following resection of bone tumors is challenging. Prolene mesh, despite being a useful tool, is not widely used due to the fear of deep infection. The aim of this study was to evaluate the functional outcome and complications of using a Prolene mesh in oncological reconstructions.

METHODS

A retrospective study was conducted in bone tumor patients with soft tissue reconstruction using Prolene mesh between January 2017 and June 2019. Functional evaluation was done using MSTS 93 score. Complications were recorded and were classified as mechanical (dislocation and extension lag) or biological failure (wound problems and deep infection). Comparison was performed between groups with and without biological failure to identify predictive variables.

RESULTS

Of 116 patients, 68 were males and 48 were females, with median age of 22.5 years. Thirty nine patients had tumors of proximal tibia, 23 of proximal femur, 25 of proximal humerus, 24 of pelvis, and five tumors at other sites. Approximately two-thirds (62.9%) of our patients underwent endoprosthetic reconstruction while the rest underwent either biological or cement spacer reconstructions. Excellent or good functional outcomes were reported in 98.3% patients as per MSTS 93 scoring. Complications were noted in 22 patients (18.9%), of which 16 had biological failure, with four patients requiring debridement and mesh removal. Dislocation of prosthesis occurred in 2 patients of proximal femur replacement. Overall re-surgery rate was 5.1% (6 patients). There was no statistically significant difference between the groups with or without biological failure with respect to demographics, site of tumor, type of procedure, blood loss, duration of surgery and history of chemotherapy.

CONCLUSION

Prolene mesh is a useful tool to reconstruct the soft tissue defects following bone tumor resections. It is readily available, reliable and provides reproducible results, with no added risk of wound complications.

A smart less used flap for soft tissue reconstruction of the weight-bearing foot

BACKGROUND

The lateral circumflex femoral artery one of the most favoured donor-site for a wide array of free flaps including either cutaneous, fascial and muscle components or a combination thereof. Here, we provide evidence on the safe use of the free vastus lateralis muscle flap and its feasibility for optimal soft tissue coverage of the weight-bearing foot.

METHODS

Eighteen consecutive patients with soft tissue defects of the heel (n = 3, 16.6%) and plantar aspect of the mid- and forefoot (n = 15, 83.3%) of either post traumatic (n = 10), diabetic (n = 6) or ischemic (n = 2) etiology, received nineteen free vastus lateralis muscle free flaps covered with split-thickness skin grafts. The postoperative results in terms of wound healing, weight-bearing function, patient satisfaction were evaluated. In patients with chronic conditions (n = 8) the AOFAS (American Orthopaedic Foot and Ankle Society) scoring system was used preoperatively and 6 months postoperatively for evaluation of reconstruction outcomes.

RESULTS

All flaps survived. Their complete anatomical integration allowed regaining normal walking in all patients. In five patients, partial loss of the skin graft which either healed spontaneously or necessitated a redo skin grafting was noted. One patient developed a late flap-skin interface ulcer, which was solved by primary excision and direct closure. Compared with the preoperative values, the mean AOFAS score in the evaluated patients (n = 8) improved significantly (34.13 vs. 77.63, p < 0.001).

CONCLUSION

The skin-grafted free vastus lateralis muscle flap can safely be used as a "smart" tool for coverage of weight-bearing foot providing optimal cushioning and functional results without fearing donor-side morbidity.

[Moschella island flap for coverage of thumb defects]

OBJECTIVE

The homodigital island flap according to Moschella is used to cover palmar and radiodorsal soft tissue defects of the thumb.

INDICATIONS

Soft tissue reconstruction of the thumb with exposed bone and/or tendon if reconstruction of the soft tissue is required.

CONTRAINDICATIONS

Extensive scars in the harvesting area of the flap; vascular occlusions of the radial artery.

SURGICAL TECHNIQUE

After Doppler sonographic imaging of the origin of the vessel radially at the thumb, the pivot point is determined. The flap is then cut from ulnar to radial, including the dorsoradial artery of the thumb. Removal of the origin of the vessel from the radial artery in the tabatiére and preparation from proximal to distal to the pivot point of the flap at the junction of the artery with the palmar vessels. If necessary, a part of the skin can remain palmar to the pivot point to improve venous drainage. The donor site of the flap can primarily close defect sizes up to 5 × 4 cm.

POSTOPERATIVE MANAGEMENT

Until wound healing, soft cotton dressing should protect the vascular pedicle from pressure; immobilisation on a palmar splint may be helpful.

RESULTS

In 9 men, sufficient soft tissue reconstruction of thumb defects could be achieved with the described Moschella flap. Eight patients had additional injuries to the fingers and hand.

Effectiveness of circular hexapod external fixation with soft tissue reconstruction in treating severe knee dislocation due to burn scarring: a case report

Background

Severe varus deformity and soft tissue injury caused by a burn around a complex knee dislocation is a rare injury. Soft tissue reconstruction and deformity correction with circular hexapod external fixation of the knee and hinged total knee arthroplasty (TKA) are challenging and can lead to major complications if not performed appropriately. We present a case in which a combination of soft tissue reconstruction, circular hexapod external fixation, and TKA was used treat severe knee dislocation due to burn scarring.

Case presentation

We report the case of a 58-year-old woman who presented for knee surgery with soft tissue reconstruction, deformity correction with circular hexapod external fixation, and hinged TKA for a severe complex deformity and soft tissue injury caused by a burn injury at 6 months of age. The left leg was shorter by 35 mm in terms of functional leg length discrepancy. She walked with a limp, with a marked varus deformity of the left knee during the stance phase of walking. After a 3-stage repair, the patient was able to walk without assistance, confirming improvement of mobility.

Conclusion

The treatment method was an effective use of a combination of soft tissue reconstruction, circular hexapod external fixation, and rehearsal surgery using a 3D printed bone model of the modular rotating hinge component of TKA, which was successfully used to treat a severe knee dislocation due to burn scarring. This staged surgery maintained the leg length and ultimately achieved a satisfactory alignment.

Soft Tissue Reconstruction with Diabetic Foot Tissue Loss

Although substantial advances have been made in treatment of diabetic foot disease with respect to patient education, preventative measures, early intervention, and prophylactic procedures, most surgical interventions for this condition are reactionary. Patients still primarily present to emergency departments with acute infections and tissue necrosis. The surgical intervention for this results in soft tissue deficit, often with partial foot amputation, through excisional debridement of pathologic tissue. Minimizing this initial soft tissue loss, with subsequent reconstruction of the defect, forms the focus of this article with a detailed anatomic assessment of structures at risk in the forefoot, midfoot and rearfoot.

Total elbow arthroplasty under unfavourable soft tissue conditions

PURPOSE

To evaluate the clinical and radiographic outcomes of patients with total elbow arthroplasty (TEA) and soft tissue reconstruction.

METHODS

We investigated six patients who underwent TEA and soft tissue reconstruction (two elbows with 1-stage surgery and four elbows with 2-stage surgery). The mean patient age at the time of the surgical procedure was 43.2 years; the mean follow-up duration was 88.2 months.

RESULTS

The mean pain visual analogue scale (VAS) during motion was improved from 6.3 pre-operatively to 0.7 at the last follow-up. The mean Mayo Elbow Performance Score (MEPS) improved from 26.7 pre-operatively to 81.7 at the last follow-up. The mean flexion-extension arcs of the 1- and 2-stage surgery groups increased from 12.5° and 13.8° pre-operatively to 72.5° and 100° at the last follow-up, respectively. The mean MEPS of the one and two stage surgery groups were 75 and 85, respectively, at the last follow-up. One of the six elbows had loosening on the simple radiograph at the last follow-up, and there were no cases with bushing wear. Three elbows needed additional skin debridement owing to wound complications (2/2 elbows in the 1-stage surgery group and 1/4 elbows in the 2-stage surgery group).

CONCLUSIONS

Under unfavorable soft tissue conditions, performing soft tissue reconstruction with TEA provides satisfactory functional improvement and pain relief. The two stage surgery provided a lower rate of wound complication and better elbow function than the one stage surgery, which led to high patient satisfaction post-operatively.

LEVEL OF EVIDENCE

Therapeutic Level IV.

Bipolar fracture dislocation of clavicle: A report of osteosynthesis and early soft tissue reconstruction

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Bipolar fracture-dislocation of the clavicle in concomitant with coracoid fracture are uncommon traumatic injuries.

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The scarce number of published cases have made the treatment of these injuries still controversial.

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Osteosynthesis and early soft tissue reconstruction are an option treatment to be considered.

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Anatomic reconstruction is the key to achieve success and good functional outcome in bipolar fracture- dislocation

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Re-dislocation of acromioclavicle and sternoclavicle joint, as bipolar clavicle fracture dislocation, can be prevented after achieving the graft's biological healing.

Introduction

Bipolar dislocation of the clavicle, also called bifocal or pan-articular dislocation or floating clavicle, is an uncommon traumatic injury. The injury of this case is also concomitant with distal third clavicle and coracoid fracture. This article aimed to report the experience of performing osteosynthesis and early soft tissue reconstruction on these injuries.

Case report

We reported a case of bipolar clavicle fracture-dislocation in concomitant with coracoid fracture in a man, aged 32 years old, successfully treated 24 days after accident by fixation of both fractures and early simultaneous reconstruction of sternoclavicular- acromioclavicular-coracoclavicular joints.

Discussion

These injuries are rare and capable of causing many complications if they are treated improperly. It is compulsory to carefully assess any fractured clavicle along its whole length, both clinically and radiologically. Various options, from non-operative to operative, have been reported to manage such of these cases. Early bony fixation and soft tissue reconstruction can correct the alignment of clavicle and recover the function of sterno-clavicular and acromio-clavicular- joints promptly.

Conclusion

Fracture osteosynthesis and early soft tissue reconstruction can be regarded as an option treatment for bipolar fracture-dislocation of the clavicle to facilitate prompt treatment and early rehabilitation.

Unhappy triad in limb reconstruction: Management by Ilizarov method

AIM

To evaluate the results of the Ilizarov method in management of cases with bone loss, soft tissue loss and infection.

METHODS

Twenty eight patients with severe leg trauma complicated by bone loss, soft tissue loss and infection were managed by distraction osteogenesis in our institution. After radical debridement of all the infected and dead tissues the Ilizarov frame was applied, corticotomy was done and bone transport started. The wounds were left open to drain. Partial limb shortening was done in seven cases to reduce the size of both the skeletal and soft tissue defects. The average follow up period was 39 mo (range 27-56 mo).

RESULTS

The infection was eradicated in all cases. All the soft tissue defects healed during bone transport and plastic surgery was only required in 2 cases. Skeletal defects were treated in all cases. All patients required another surgery at the docking site to fashion the soft tissue and to cover the bone ends. The external fixation time ranged from 9 to 17 mo with an average of 13 mo. The complications included pin tract infection in 16 cases, wire breakage in 2 cases, unstable scar in 4 cases and chronic edema in 3 cases. According to the association for study and application of methods of Ilizarov score the bone results were excellent in 10, good in 16 and fair in 2 cases while the functional results were excellent in 8, good in 17 and fair in 3 cases.

CONCLUSION

Distraction osteogenesis is a good method that can treat the three problems of this triad simultaneously.

Middle and Lower Face Soft Tissue Reconstruction: A 10-Year Retrospective Study

Retrospectively analyze the reconstruction methods and surgical outcomes of patients with middle and lower face soft tissue defects treated at our hospital over the past 10 years. 200 patients with middle and lower face soft tissue defects were surgically reconstructed at our hospital. Medical charts were retrospectively reviewed and analyzed to abstract the pertinent information. The lesion was mainly at the eyelid, lips, chin and nasal-cheek region. There were 41 (63.08 %) men and 24 (36.92 %) women. In our study, male to female ratio = 1.7:1. We used direct closure for night patients, local flap for 141 patients, free flap for 38 patients, combined flap for 12 patients involving extensive mid face and lower face defects. Most patients had their tumor resected and reconstructed in single stage procedure mostly with local advancement flap, and no flap failure was presented post-operatively. Middle and lower face soft tissue defects can be successfully treated with local flap in a single stage approach and step-by-step approach.

Creation of a Large Adipose Tissue Construct in Humans Using a Tissue-engineering Chamber: A Step Forward in the Clinical Application of Soft Tissue Engineering

Tissue engineering is currently exploring new and exciting avenues for the repair of soft tissue and organ defects. Adipose tissue engineering using the tissue engineering chamber (TEC) model has yielded promising results in animals; however, to date, there have been no reports on the use of this device in humans. Five female post mastectomy patients ranging from 35 to 49 years old were recruited and a pedicled thoracodorsal artery perforator fat flap ranging from 6 to 50 ml was harvested, transposed onto the chest wall and covered by an acrylic perforated dome-shaped chamber ranging from 140 to 350 cm³. Magnetic resonance evaluation was performed at three and six months after chamber implantation. Chambers were removed at six months and samples were obtained for histological analysis. In one patient, newly formed tissue to a volume of 210 ml was generated inside the chamber. One patient was unable to complete the trial and the other three failed to develop significant enlargement of the original fat flap, which, at the time of chamber explantation, was encased in a thick fibrous capsule. Our study provides evidence that generation of large well-vascularized tissue engineered constructs using the TEC is feasible in humans.

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Tissue engineering has the potential to offer exciting alternatives for the repair of soft tissues and organ development,

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The tissue-engineering chamber has been shown to support tissue growth and the generation of specialized organs in animals.

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Here we report on the use of this chamber in humans for the successful generation of new adipose tissue.

Tissue engineering has traditionally relied on the combination of cells and scaffolds, which are subsequently implanted into the patient. However, such paradigm is limited to tissues that are thin enough to rely on diffusion for survival or that have a low metabolic rate. The tissue-engineering chamber represents an interesting approach to circumvent these obstacles, as it is able to support the growth of well-vascularized blocks of specialized tissues of varying kinds. This work presents the use of such chamber in five human patients, one of which generated a large three-dimensional well-vascularized piece of adipose tissue, probably the largest and thickest engineered tissue construct reported to date.

The mangled foot and ankle: soft tissue salvage techniques

The mangled foot and ankle can be defined as a severe injury to multiple organ systems of this appendage that can include bone, muscle, tendon, and neurovascular structures. The magnitude and often rate-limiting parameter most likely to affect the decision to attempt foot salvage is the degree of soft tissue destruction. If irreplaceable or if function cannot be restored, amputation should be considered. If reconstruction is attempted, all nonviable tissues regardless of intrinsic function must first be removed by meticulous débridement.

Reconstruction of traumatic losses of substance at the elbow

Traumatic lesions at the elbow involving great loss of substance are uncommon, but represent a significant problem when such cases are referred to a trauma department. Most of these injuries may cause severe final functional impairment, thereby jeopardising future activities, particularly in cases where treatment was delayed or inappropriate. The timing and method of treatment are critical. The trauma may involve soft tissues only, or bone and joint, or several structures at the same time, which results in combined complex tissue defects. Each type of tissue loss should be managed by choosing the most suitable technique from the armamentarium of reconstructive surgery, taking into account different priorities and the optimum timing (immediate or delayed, one- or two-stages). The authors describe a spectrum of indications and techniques that can be useful tools in managing these injuries.

Integra™ permits early durable coverage of improvised explosive device (IED) amputation stumps

INTRODUCTION

Improvised explosive device (IED) blasts cause serious injury. Survivors are left with multiple amputations, considerable soft tissue loss and open fractures with gross contamination. We present our early experience of Integra™ in the acute management of military wounds.

METHOD

The clinical records of all patients with IED injuries who underwent early reconstruction with Integra™ during the six month period between August and December 2009 in our unit were reviewed and data gathered prospectively.

RESULTS

There were 7 male soldiers, aged 21-31 years (mean=26). All sustained trunk and limb injuries, including multiple amputations. Number of procedures prior to application of Integra™ was 4-10 (mean=5). Application of Integra™ took place 6-24 days post-injury (mean=13). Size of wounds covered with Integra™ was 1-11.5% TBSA (mean=5%). Anatomical sites reconstructed included amputation stumps, and both upper and lower limbs. There was partial take of Integra in 3 wounds in 2 patients. All wounds were eventually treated with delayed split skin grafting and healed satisfactorily.

CONCLUSION

IEDs produce a large zone of injury with massive soft tissue damage, multiple discontinuous wounds which are significantly contaminated. The physiological insult is equivalent to a large cutaneous burn and there is a paucity of available donor sites. Multiple amputees also have a greater energy and power requirement(1-4) and cannot spare remaining functional muscles as donors. The literature suggests that microvascular flaps have a high failure rate in military patients.(5) Reconstruction began as soon as wounds were considered sufficiently clean. Integra™ was applied with the aim of providing higher quality coverage than that provided by split skin grafting alone (particularly for amputation stumps) whilst minimising operative time and morbidity. Integra™ allows timely closure of battlefield wounds with minimal operative time and morbidity. The procedure can begin whilst still in the acute phase and certainly before one would consider lengthy complex operations such as free flaps. Our experience suggests that Integra™ can allow early closure with robust tissue, promoting early rehabilitation and return to duties.

Free dermal fat graft for restoration of soft tissue defects in maxillofacial surgery

Various local flaps have been used for reconstruction of developmental and post surgical soft tissue defects of maxillofacial region. They include nasolabial flap, palatal pedicled flap, buccal fat pad, temporalis muscle and fascia flap. An ideal flap for all indications is yet to be found. Our experience with free dermal fat graft in the correction of deformities associated with Parry Romberg syndrome and oral submucous fibrosis is presented.

Necrotizing Fasciitis of the Extremities. Eur J Trauma Emerg Surg. 2008;34:229-236. [PMID: 26815743 PMCID: PMC7095926 DOI: 10.1007/s00068-008-8074-0]

Necrotizing fasciitis (NF) describes a life threatening soft tissue infection characterized by a rapid spreading infection of the subcutaneous tissue and in particular the fascia. Various synonyms for this type of infection are used, often due to the difficult diagnosis. Necrotizing fasciits of the extremities is found after simple skin lacerations and often in rural, farming or garden setting environments. Many of the infections are found in immunologically healthy people, but persons revealing a compromised wound healing are endangered additionally, e.g., diabetes. In the majority of the microbiological analyses, streptococci alone or a mixture with mainly anaerobic bacteria may be detected. The management of infected extremities requires a rapid diagnosis, dedicated aggressive surgical management as soon as possible, and a wide debridement extending the border of the infected fascia. Timely surgical revisions within the first day or days together with antibiotic treatment are the only measures to stop the infection. Depending on the status of the patient a hyperbaric oxygenation treatment seems to be useful in order to limit the infection. In fulminated cases early amputations, maximal intensive care treatment of the septic patient are required, where all means are warranted to save the patients life. As a consequence, early clinical diagnoses with thorough surgical debridement of the infected liquid necrotic fascia as well as correct antibiotic treatment are needed. Secondary plastic reconstruction of the soft tissue defects will generally be required.

The use of polymethyl-methacrylate (Artecoll) as an adjunct to facial reconstruction

BACKGROUND

Injectable polymethyl-methacrylate (PMMA) microspheres, or Artecoll, has been used for the last few years in aesthetic surgery as long-term tissue filler for the correction of wrinkles and for lip augmentation. This paper presents three cases of the use of PMMA microsphere injection for reconstructive patients with defects of varying etiologies. These cases provide examples of a novel adjunct to the repertoire of the reconstructive surgeon.

OBJECTIVES

To evaluate the effectiveness (short- and long-term) of PMMA injection for the correction of small soft tissue defects of the face.

METHODS

Three case histories are presented. They include the origin of the defect; previous reconstructions of the defect; and area, volume, timing and technical particularities of PMMA administration.

RESULTS

All three cases showed improvement of the defect with the PMMA injection with respect to both objective evidence and patient satisfaction. The improvements can still be seen after several years.

CONCLUSIONS

PMMA microsphere injection can be effectively used to correct selected small facial defects in reconstructive cases and the results are long lasting.