Long-term results and costs of muscle flap coverage with Ilizarov bone transport in lower limb salvage

Methods to Manage Edema and Reduce Flap Compression in Postoperative Nursing Care Following Trauma to the Lower Extremity

Lower extremity edema and compression are potential causes of poor soft tissue healing and flap failure for patients who suffer lower extremity trauma. This review summarizes techniques aimed at reducing edema and mechanical pressure in these patients as well as those undergoing soft tissue coverage techniques. We conducted a literature review for postoperative nursing management to reduce edema in the lower extremity, following traumatic injury. To assist orthopaedic nurses in acute care settings, this review presents techniques for reducing edema and mechanical pressure in patients recovering from lower extremity trauma. The accompanying figures demonstrate how to apply these techniques. Techniques such as rope suspension, mini water mattresses, and pillow or blanket stacking were identified as measures that can reduce edema and compression for patients recovering from lower extremity trauma as well as those requiring soft tissue coverage procedures.

Orthoplastic Reconstruction of Distal Tibia High-Energy Fractures Using a Circular External Fixator-A Systematic Review

Background: Compound fractures of the distal tibia (with or without the middle third) represent a challenge for orthopedic and plastic surgeons because of the scarcity of available soft tissue reconstruction and the important comminution of the fractures that usually appear. Methods: The design of this study is based on the PRISMA guidelines. Databases were searched for articles published and available until the first half of 2023. Articles that presented the evolution of patients treated by combining circular external fixators with reconstructive methods were selected. Results: After searching the literature using keywords, we obtained 3355 articles, out of which 14 articles met all the inclusion criteria, with a total number of participants of 283. The bone loss varied between 0.7 and 18.2 cm, while the soft tissue defect was between 3/3 cm and 16/21 cm. The average period of fixation ranged from 4 to 22.74 months. The most used reconstruction methods were 80 free flaps and 73 pedicled flaps out of 249 interventions. Complete flap loss appeared only in 3/283 patients. Regarding the bone union, the percentage of non-union was low, and in all cases, it was achieved after reintervention. A low rate of major complications was observed. Conclusions: The orthoplastic team is the key to successfully treating the high-energy traumatism of the distal tibia (with or without a middle third). The Ilizarov external fixator can be used as a definitive limb-salvage treatment (secondary to the standard primary methods of fixation) in combination with a flap to cover the defects because it does not damage the pedicle, and it helps stabilize the soft tissues and bones around the flap to lower the complications.

Limb salvage and functional recovery in infected nonunion of the distal tibia treated with the Ilizarov techniques

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.

Preventing biological waste: Effective use of viable tissue in traumatized lower extremities

Severe open lower extremity trauma requires debridement to remove contamination and devitalized tissues. Aggressive debridement should be balanced with preservation of viable tissue. These often damaged but preserved viable tissues are "spare parts" that augment the options available for reconstruction. The long-term goal of reconstruction should be functional limb restoration and optimization. Injury patterns, levels, and patient factors will determine whether this endeavor is better accomplished with limb salvage or amputation. This article reviews the rationale and strategies for preserving spare parts throughout debridement and then incorporating them as opportunistic grafts in the ultimate reconstruction to facilitate healing and maximize extremity function.

Level of Evidence

5.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

LEVEL OF EVIDENCE

III, Case-control study.

Financial Toxicity Is Common in Patients After Tibia Fracture

OBJECTIVES

To evaluate the presence of financial distress and identify risk factors for financial toxicity in patients after tibial shaft fracture.

DESIGN

A cross-sectional analysis.

SETTING

Level I trauma center.

PATIENTS

All patients within 4 years after tibial shaft fracture (open, closed, or fracture that required flap reconstruction).

INTERVENTION

Injury-related financial distress.

MAIN OUTCOME MEASUREMENTS

Financial distress related to the injury, as reported by the patient in a binary question. Financial toxicity using the LIMB-Q, scored from 0 to 100, with higher scores indicating more financial toxicity.

RESULTS

Data were collected from 142 patients after tibial shaft fracture [44% closed (n = 62), 41% open (n = 58), and 15% flap (n = 22)]. The mean age was 44 years (SD 17), 61% were men, and the mean time from injury was 15 months. Financial distress was reported by 64% of patients (95% confidence interval, 56% to 72%). Financial toxicity did not differ by fracture severity ( P = 0.12). Medical complications were associated with a 14-point increase in financial toxicity ( P = 0.04). Age older than 65 years (-15 points, P = 0.03) and incomes of $70,000 or more ($70,000-$99,999, -15 points, P = 0.02; >$100,000, -19 points, P < 0.01) protected against financial toxicity.

CONCLUSION

We observed financial distress levels more than twice the proportion observed after cancer. Medical complications, lower incomes, and younger age were associated with increased financial toxicity.

LEVEL OF EVIDENCE

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

Intraoperative assessment of bone viability through improved analysis and visualization of dynamic contrast-enhanced fluorescence imaging: technique report

Bone devitalization is believed to be a critical determinant of complications such as infection or nonunion. However, intraoperative assessment of bone devitalization, particularly in open fractures and infections, remains highly subjective resulting in variation in treatment. Optical imaging tools, particularly dynamic contrast-enhanced fluorescence imaging, can provide real-time, intraoperative assessment of bone and soft tissue perfusion, which informs the tissues' ability to heal and fight infection. We describe a novel technique to apply indocyanine green-based fluorescence imaging, using a device that is frequently used in the operating room to assess skin or flap perfusion in plastic surgery, to assess bone and deep tissue perfusion in three pertinent cases: (1) a chronic infection/nonunion after a Gustilo type 3A tibia fracture (patient 1), (2) an acute Gustilo type 3C tibia open fracture with extensive degloving/soft tissue stripping (patient 2), and (3) an atrophic nonunion of the humerus (patient 3). In all three cases, fluorescence imaging (both time-specific fluorescence and maximum fluorescence) and derived kinetic maps of time-to-peak, ingress slope, and egress slope demonstrated clear spatial variation in perfusion that corresponded to the patient pathogenesis. The impact of this information on patient outcome will need to be evaluated in future clinical trials; however, these cases demonstrate in principle that optical imaging information has the potential to inform surgical practice, reduce the variation in treatment, and improve outcomes observed in these challenging patients.

Approach to Complex Lower Extremity Reconstruction

Composite injuries to the lower extremity from etiologies including trauma and infection present a complex dilemma for the reconstructive surgeon, and require multidisciplinary collaboration amongst plastic, vascular, and orthopaedic surgical specialties. Here we present our algorithm for lower-extremity reconstructive management, refined over the last decades to provide an optimized outcome for our patients. Reconstruction is predicated on the establishment of a clean and living wound, where quality of the wound-bed is prioritized over timing to soft-tissue coverage. Once established, soft-tissues and fractures are provisionally stabilized; our preference for definitive coverage is for microvascular free-tissue, due to the paucity of healthy soft-tissue available at the injury, and ability to avoid the zone of injury for microvascular anastomosis. Finally, definitive bony reconstruction is dictated by the length and location of long-bone defect, with a preference to utilize bone transport for defects longer than 5 cm.

Role of Perforating Artery Pedicled Neurotrophic Flap in the Treatment of Compound Tissue Defect of Tibia Using the Ilizarov Technique

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.

A case report on a IV-degree thermal crush injury of right upper arm：The application of functional prosthesis implantation technology

Severe IV-degree thermal crush injury of limbs involved the subcutaneous fascia, muscle and bone, which may lead to amputation and has a great impact on the patient's quality of life. We can repair wounds with pedicle flaps or even free flaps, However, there are still huge challenges in bone defect of extremities and functional reconstruction. In recent years, with the development of functional prostheses, we have reconstructed limb functions in many patients helping them to complete their daily lives. We report a case where the right upper arm was injured by thermal crush, leading severe burns to the skin, fascia, muscle and bone. We applied a pedicled latissimus dorsi flap and a free anterolateral thigh flap to repair the wound, and realized the function of limb salvage and movement of the right upper arm by implanting 3D printed scapula, upper arm and elbow joint prostheses. This case illustrates that IV-degree burns involving bones have new technologies to repair and achieve mobility now.

A Leg to Stand on: Trauma Center Designation and Association with Rate of Limb Salvage in Patients Suffering Severe Lower Extremity Injury

BACKGROUND

Mangled extremities are one of the most difficult injuries for trauma surgeons to manage. We compare limb salvage rates for a limb-threatening lower extremity injuries managed at Level I vs Level II trauma centers (TCs).

STUDY DESIGN

We identified all adult patients with a limb-threatening injury who underwent primary amputation or limb salvage (LS) using the American College of Surgeons (ACS) Trauma Quality Improvement Program database at ACS Level I vs II TCs between 2007 and 2017. A limb-threatening injury was defined as an open tibial fracture with concurrent arterial injury (Gustilo type IIIc). Multivariable analysis and propensity score matching were performed to minimize confounding by indication.

RESULTS

There were 712 records for analysis; 391 (54.9%) LS performed and 321 (45.1%) underwent amputation. The rate of LS was statistically higher among patients treated at Level I TCs vs those treated at Level II TCs (47.4% vs 34.8%; p = 0.01). Patients with penetrating injuries (13% vs 9.5%; p = 0.046) and tibial/peroneal artery injury (72.9% vs 50.4%; p < 0.001), as opposed to popliteal artery injury (30.8% vs 58.8%; p < 0.001), were more likely to have LS. The risk-adjusted odds of LS was 3.13 times higher at Level I TCs vs Level II TCs (95% CI, 1.59 to 6.34; p = 0.001). Limb salvage rates were significantly higher at Level I TCs compared with Level II TCs (53.0% vs 34.8%; p = 0.004), even after propensity matching.

CONCLUSIONS

In patients with a mangled extremity, limb salvage rates are 50% higher at Level I TCs compared with Level II TCs, independent of case mix and injury severity.

Simultaneous debridement, Ilizarov reconstruction and free muscle flaps in the management of complex tibial infection

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.

Evaluation of bone perfusion during open orthopedic surgery using quantitative dynamic contrast-enhanced fluorescence imaging

In this study, an indocyanine green (ICG)-based dynamic contrast- enhanced fluorescence imaging (DCE-FI) technique was evaluated as a method to provide objective real-time data on bone perfusion using a porcine osteotomy model. DCE-FI with sequentially increasing injury to osseous blood supply was performed in 12 porcine tibias. There were measurable, reproducible and predictable changes to DCE-FI data across each condition have been observed on simple kinetic curve-derived variables as well variables derived from a novel bone-specific kinetic model. The best accuracy, sensitivity and specificity of 89%, 88% and 90%, have been achieved to effectively differentiate injured from normal/healthy bone.

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

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.

Managing bone loss in open fractures

Segmental bone loss continues to pose substantial clinical and technical challenges to orthopaedic surgeons. While several surgical options exist for the treatment of these complex patients, there is not a clear consensus or specific guidelines on the optimal management of these injuries as a whole. Many factors must be taken into consideration when planning surgery for these individuals. In order for these techniques to yield optimal results, each injury must be approached in a step-wise and multidisciplinary fashion to ensure that care is taken in bone and wound bed preparation, that soft tissues are healthy and free of contaminants, and that the patient's medical condition has been optimized. Through this article, we will answer relevant questions and discuss common obstacles and challenges encountered with these complex injuries. We will also review the many treatment options available or in development to address this problem.

Postoperative Chronic Osteomyelitis in the Long Bones - Current Knowledge and Management of the Problem

Chronic postoperative osteomyelitis represents an important health problem due to its significant morbidity and low mortality rate. This pathology is challenging because of difficulties in understanding the pathogenesis and the decision-making involving the treatment. The present article had the goal of reviewing the definition, pathogenesis, clinical aspects, diagnosis, and treatment of chronic postoperative osteomyelitis, and of gathering this information in a single Brazilian updated publication.

The PubMed, LILACS, and the Cochrane Library medical databases were analyzed using pertinent keywords. Current and relevant articles were selected.

The present article gathered the established information, as well as innovations related to chronic osteomyelitis and its treatment, to offer updated data to assist the professionals involved in the management of chronic osteomyelitis.

Chronic Osteomyelitis of the tibia and ankle treated with Limb Salvage Reconstruction

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.

Five-Year Follow-Up of Distal Tibia Bone and Foot and Ankle Trauma Treated with a 3D-Printed Titanium Cage

Large bone defects from trauma or cancer are difficult to treat. Current treatment options include the use of external fixation with bone transport, bone grafting, or amputation. These modes of therapy continue to pose challenges as they are associated with high cost, failure, and complication rates. In this study, we report a successful case of bone defect treatment using personalized 3D-printed implant. This is the longest known follow-up using a 3D-printed custom implant for this specific application. Ultimately, this report adds to existing literature as it demonstrates successful and maintained incorporation of bone into the titanium implant. The use of patient-specific 3D-printed implants adds to the available arsenal to treat complex pathologies of the foot and ankle. Moreover, the technology's flexibility and ease of customization makes it conducive to tailor to specific patient needs.

Principles of Orthoplastic Surgery for Lower Extremity Reconstruction: Why Is This Important?

BACKGROUND

 Regardless of the antecedent etiology, lower extremity salvage and reconstruction attempts to avoid amputation, restore limb function, and improve quality of life outcomes. This goal requires a treatment team well versed in neurovascular pathology, skeletal and soft tissue reconstruction, and physical rehabilitation.

METHODS

 A review was performed of historical milestones that lead to the development of orthoplastic extremity reconstruction, principles of current management and the evidence that supports an orthoplastic approach. Based on available evidence and expert opinion, the authors further sought to provide insight into the future of the field centered around the importance of a multidisciplinary management protocol.

RESULTS

 Historically, orthopaedic and plastic surgeons worked separately when faced with challenging reconstructive cases involving lower extremity skeletal and soft tissue reconstruction. With time, many embraced that their seemingly separate skill-sets and knowledge could be unified in a collaborative orthoplastic approach in order to offer patients the best possible chance for success. First coined by the senior author (LSL) in the early 1990s, the collaborative orthoplastic approach between orthopaedic and plastic surgeons in limb salvage for the past several decades has resulted in a unique field of reconstructive surgery. Benefits of the orthoplastic approach include decreased time to definitive skeletal stabilization/soft tissue coverage, length of hospital stay, post-operative complications, need for revision procedures and improved functional outcomes.

CONCLUSION

 The orthoplastic approach to lower extremity reconstruction is a collaborative model of orthopaedic and plastic surgeons working together to expedite and optimize care of patients in need of lower extremity reconstruction. The implementation of protocols, systems, and centers that foster this approach leads to improve outcomes for these patients. We encourage centers to embrace the orthoplastic approach when considering limb salvage, as the decision to amputate is irreversible.

The Combined Use of a Neurocutaneous Flap and the Ilizarov Technique for Reconstruction of Large Soft Tissue Defects and Bone Loss in the Tibia

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.

The "Road to Union" protocol for the reconstruction of isolated complex high-energy tibial trauma

INTRODUCTION

The purpose of this study was to describe a standardized staged approach, "The Road to Union", for the reconstruction of isolated complex tibial trauma, both acute and chronic in nature.

METHODS

This retrospective study included all patients treated for complex tibial trauma at a specialized limb reconstruction centre, including acute open fracture as well as infected and aseptic non-unions. This standardized approach includes eight specific steps, employed in sequence. The time in external fixation (EFT), the external fixation index (EFI), and the distraction consolidation index (DCI) were the primary outcome measures. The relationship between EFI and DCI was assessed using Pearson's moment correlations.

RESULTS

Thirty-two patients with a mean age of 34.7±14.2years were included; 12 were treated for complex open tibial fractures with bone loss, 13 for infected non-unions, and 6 for aseptic non-union. The mean bone defect was 66±32mm. The total EFT was 42.5±14.8 weeks; the EFI measured 51.9±25.3 days/cm, and the DCI measured 48.3±21.4 days/cm. Union was achieved in 29 out of 32 patients (91%), and there was a strong and significant relationship between EFI and DCI (r=0.92, p=0.0001) measurements. Pin site infections were observed in 11 patients, and 3 patients had persistent non-union. Three patients underwent delayed amputations when reconstructive procedures were unable to achieve union.

CONCLUSION

The findings of this study demonstrate that a standardized staged treatment protocol of debridement, circular external fixation, soft-tissue management, distraction osteogenesis, and functional rehabilitation can result in a high rate of union in cases of complex tibial trauma, both acute and chronic in nature.

LEVEL OF EVIDENCE

Level IV; case series.

Treatment Options for Nonunion With Segmental Bone Defects: Systematic Review and Quantitative Evidence Synthesis

OBJECTIVES

To determine which reconstruction treatment of long bones nonunion with segmental bone defects (SBDs) is effective to restore bone length and union with good function.

DATA SOURCES

PubMed was used to identify published literature on treatment of SBD caused by fracture nonunion regardless of infection between January 1975 and December 2014.

STUDY SELECTION

We included retrospective cohort studies with a minimum sample size of 10 consecutive patients with minimum follow-up of 18 months and available data on radiographic and functional outcomes.

DATA EXTRACTION

Literature review revealed 24 publications with a sample size of 504 patients (395 males, 109 females). Data on bone union and functional outcome and complications were collected and analyzed based on validated classification systems.

DATA SYNTHESIS

Two outcome groups were categorized for bone union and functional outcome, success, and failure. We then performed heterogeneity test to examine the variability or differences in the methods used by these studies and based on that we determined whether the fixed effect or random effect method is appropriate in examining the summary or pool estimate. Pool estimate was examined for bone union and functional outcome in each surgical modality and in each anatomic location when data were available.

CONCLUSIONS

Treatment of SBD can be challenging. This quantitative evidence synthesis shows that bone union was achieved by different procedures with variable bone union and functional outcomes.

LEVEL OF EVIDENCE

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

Infected nonunion of tibia

Infected nonunions of tibia pose many challenges to the treating surgeon and the patient. Challenges include recalcitrant infection, complex deformities, sclerotic bone ends, large bone gaps, shortening, and joint stiffness. They are easy to diagnose and difficult to treat. The ASAMI classification helps decide treatment. The nonunion severity score proposed by Calori measures many parameters to give a prognosis. The infection severity score uses simple clinical signs to grade severity of infection. This determines number of surgeries and allows choice of hardware, either external or internal for definitive treatment. Co-morbid factors such as smoking, diabetes, nonsteroidal anti-inflammatory drug use, and hypovitaminosis D influence the choice and duration of treatment. Thorough debridement is the mainstay of treatment. Removal of all necrotic bone and soft tissue is needed. Care is exercised in shaping bone ends. Internal fixation can help achieve union if infection was mild. Severe infections need external fixation use in a second stage. Compression at nonunion site achieves union. It can be combined with a corticotomy lengthening at a distant site for equalization. Soft tissue deficit has to be covered by flaps, either local or microvascular. Bone gaps are best filled with the reliable technique of bone transport. Regenerate bone may be formed proximally, distally, or at both sites. Acute compression can fill bone gaps and may need a fibular resection. Gradual reduction of bone gap happens with bone transport, without need for fibulectomy. When bone ends dock, union may be achieved by vertical or horizontal compression. Biological stimulus from iliac crest bone grafts, bone marrow aspirate injections, and platelet concentrates hasten union. Bone graft substitutes add volume to graft and help fill defects. Addition of rh-BMP-7 may help in healing albeit at a much higher cost. Regeneration may need stimulation and augmentation. Induced membrane technique is an alternative to bone transport to fill gaps. It needs large amounts of bone graft from iliac crest or femoral canal. This is an expensive method physiologically and economically. Infection can resorb the graft and cause failure of treatment. It can be done in select cases after thorough eradication of infection. Patience and perseverance are needed for successful resolution of infection and achieving union.

Decorin reduces hypertrophic scarring through inhibition of the TGF-β1/Smad signaling pathway in a rat osteomyelitis model

Chronic osteomyelitis is a bone infection that results in hypertrophic scarring of the soft tissue surrounding the infected bone. This scarring can create functional problems and its treatment is challenging. The aim of the present study was to evaluate the efficacy of decorin in treating scar formation in osteomyelitis and the underlying mechanism of its action. A rat osteomyelitis model was used, and animals were divided into three groups, as follows: Group A (control), group B (osteomyelitis model) and group C (decorin-treated). X-ray scans, hematoxylin and eosin (H&E) staining and Masson's trichrome staining were performed to observe changes in femur and muscle tissue. In order to assess the role of the transforming growth factor β1 (TGF-β1)/Smad signaling pathway in scar formation in osteomyelitis, alterations in muscle tissue morphology and in the activation of key members of the TGF-β1/Smad signaling pathway were investigated in groups A and B. According to the results of H&E staining, evident fibrosis in muscle tissue were observed at days 14 and 28 in group B. Simultaneously, the expression levels of key members of the TGF-β1/Smad signaling pathway were increased. Subsequent to treatment with decorin in group C, scarring was reduced, and significant downregulation of collagen I, TGF-β1, phosphorylated (p)Smad2 and pSmad3 protein expression levels was observed at days 14 and 28 compared with the osteomyelitis group. In conclusion, these results suggest that activation of TGF-β1 may serve an important role in the formation of scars in osteomyelitis and that decorin can reduce scar formation in an osteomyelitis rat model through inhibition of the TGF-β1/Smad signaling pathway.

The management of tibial fracture non-union using the Taylor Spatial Frame

We reviewed 40 complex tibial non-unions treated with Taylor Spatial Frames. 39 healed successfully. Using the ASAMI scoring, we obtained 33 excellent, 5 good, 1 fair and 1 poor bone results. The functional results were excellent in 29 patients, good in 8, fair in two and poor in one. Mean patient satisfaction score was 95%. All but one patient would have the same treatment again. 28 of the 36 patients in work when injured, returned to work at the time of their final review. Four patients had an adverse event requiring significant intervention. Average treatment cost was approximately £26,000/patient.

Treatment of post-traumatic chronic osteomyelitis of lower limbs by bone transport technique using mono-lateral external fixator: Follow-up study of 18 cases

PURPOSE

To review the results of the treatment of post-traumatic chronic osteomyelitis of lower limbs by bone transport technique using mono-lateral external fixator.

PATIENTS AND METHODS

A total of 18 patients with post-traumatic chronic osteomyelitis of lower limbs were treated by bone transport technique using mono-lateral external fixator in this study. Seven cases (patients No. 1-7) were performed early BGPO (autologous ilium bone grafting and plate osteosynthesis) intervention after BT (bone transport). The end results were assessed by the criteria of ASAMI and Paley et al. Some data between the cases with and without the intervention of early BGPO were subjected to statistical analysis of Student's t-test.

RESULTS

The overall average time for union was 10.8 months. The average union time of the non-early BGPO cases was 52.27 ± 7.82 weeks while the early BGPO cases took a shorter time of 36.86 ± 5.34 weeks (P < 0.001). The overall average duration from bone transport to removal of external fixator was 10.0 months. The average duration from bone transport to removal of external fixator in the non-early BGPO cases was 51.55 ± 7.45 weeks while the early BGPO cases took a shorter time of 29.29 ± 5.47 weeks (P < 0.001). The overall average of BHI was 1.77 months cm(-1). The average of BHI in the non-early BGPO cases was 2.25 ± 0.25 months cm(-1) and the average BHI of the early BGPO cases was 1.22 ± 0.114 months cm(-1) (P < 0.001). There were 31 additional surgeries and 38 complications in total after bone transport treatment. The bone results were excellent in 15 cases, good in 3 cases. The functional results were excellent in 9 cases, good in 6 cases and fair in 3 cases.

CONCLUSIONS

1. Bone transport technique using mono-lateral external fixator is an effective method for the treatment of post-traumatic chronic osteomyelitis. 2. Early BGPO intervention after bone transport is a feasible method to shorten the external fixation time and the total duration of treatment.

Reconstruction of Long Bone Infections Using the Induced Membrane Technique: Tips and Tricks

The management of posttraumatic long bone osteomyelitis remains a challenging clinical problem. A systematic approach is necessary, beginning with eradication of the infected bone and soft tissue. There are a number of options for reconstruction of the remaining bone defect, including the induced membrane technique developed by Masquelet. We describe our technique for the 2-stage treatment of long bone osteomyelitis. The first stage involves a radical debridement, stabilization of the bone with either external fixation or an antibiotic-coated intramedullary nail, and placement of a polymethylmethacrylate spacer. The second stage includes excision of the spacer and placement of autologous bone graft. Various resection methods, fixation strategies, antibiotic additives, and types of bone grafts or substitutes can be used. The purpose of our technical article is to share our personal experience and describe several nuances that are critical for the success of this treatment strategy.

LEVEL OF EVIDENCE

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

Treatment of compound tibia fracture with microvascular latissimus dorsi flap and the Ilizarov technique: A cross-sectional study of long-term outcomes

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.

Does Integrated Fixation Provide Benefit in the Reconstruction of Posttraumatic Tibial Bone Defects?

BACKGROUND

Limb salvage in the presence of posttraumatic tibial bone loss can be accomplished using the traditional Ilizarov method of distraction osteogenesis with circular external fixation. Internal fixation placed at the beginning of the consolidation phase, so-called integrated fixation, may allow for earlier removal of the external fixator but introduces concerns about cross-contamination from the additional open procedure and maintenance of bone regenerate stability.

QUESTIONS/PURPOSES

Among patients deemed eligible for integrated fixation, we sought to determine: (1) Does integrated fixation decrease the time in the external fixator? (2) Is there a difference in the rate of complications between the two groups? (3) Are there differences in functional and radiographic results between integrated fixation and the traditional Ilizarov approach of external fixation alone?

METHODS

Between January 2006 and December 2012, we treated 58 patients (58 tibiae) with posttraumatic tibial bone loss using the Ilizarov method. Of those, 30 patients (52%) were treated with the "classic technique" (external fixator alone) and 28 (48%) were treated with the "integrated technique" (a combination of an external fixator and plating or insertion of an intramedullary nail). During that period, the general indications for use of the integrated technique were closed physes, no active infection, and a healed soft tissue envelope located at the intended internal fixation site; the remainder of the patients were treated with the classic technique. Followup on 30 (100%) and 28 (100%) patients in the classic and integrated techniques, respectively, was achieved at a minimum of 1 year (mean, 3 years; range, 1-8 years). Adverse events were reported as problems, obstacles, and complications according to the publication by Paley. Problems and obstacles are managed by nonoperative and operative means, respectively; in addition, they resolve completely with treatment. Complications, according to the Paley classification, result in permanent sequelae. Functional and radiographic results were reported using the Association for the Study and Application of Methods of Ilizarov scoring system.

RESULTS

Overall, there was a mean of four (range, 2-5) surgical procedures to complete the tibial reconstruction with a similar incidence of unplanned surgical procedures (obstacles) between the two groups (p = 0.87). Patients treated with integrated fixation spent less time in the external fixator, 7 months (range, 5-20 months) versus 11 months (range, 1-15 months; p < 0.001). There were seven problems, 15 obstacles, and zero complications in the classic group. Ten problems, 15 obstacles, and one complication occurred in the integrated fixation group. There was no difference in the severity (p = 0.87) or number (p = 0.40) of complications between both groups. Good to excellent Association for the Study and Application of Methods of Ilizarov function and bone scores were obtained in 100% and 98% of patients, respectively.

CONCLUSIONS

The integrated fixation method allows for a more efficient limb salvage surgical reconstruction in patients carefully selected for that approach, whereas the frequency of adverse events and ability to restore limb lengths was not different between the groups with the numbers available. Careful placement of external fixation pins is critical to decrease cross-contamination with planned internal fixation constructs. In this study of posttraumatic tibial bone defect reconstruction, good/excellent results were found in all patients after a mean of four surgical procedures; however, a larger multicenter prospective study would allow for more robust and generalizable conclusions.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Definitive management of significant soft tissue loss associated with open diaphyseal fractures utilising circular external fixation without free tissue transfer, a comprehensive review of the literature and illustrative case

Accepted management of diaphyseal fractures associated with significant tissue loss is rigid intramedullary stabilisation with free or rotational musculocutaneous flap coverage. Circular external fixation is a powerful tool in the management of limb trauma and with recent advances has been developed to provide multiple techniques for which even massive tissue loss can be addressed without the need for free tissue transfer. Gradual and acute shortening, acute fracture deformation and gradual lengthening with restoration of deformity combined with distraction tissue histiogenesis can provide the surgeon with an array of options which can be precisely tailored to the particular personality of a severe open diaphyseal fracture.

Ilizarov fixator combined with an intramedullary nail for tibial nonunions with bone loss: is it effective?

BACKGROUND

Treatment of tibial nonunion with bone loss is extremely difficult. A variety of techniques have been described, but each has shortcomings, in particular prolonged external fixation time as well as serious complications such as nonunion and infection. Accordingly, we developed a technique that seeks to reduce these complications by using a circular external fixator in addition to an intramedullary nail to achieve union, limb lengthening, and stability of the regenerated segment.

DESCRIPTION OF TECHNIQUE

First, the pseudoarthrosis area is resected, and acute compression is continued until bone contact at the docking site was achieved. Then primary grafting is applied to the docking site using a graft harvested from the patient's iliac bone, and the predrilled nail holes localized on the middle segment of the tibia are locked with a free-hand technique. Finally, lengthening is performed to overcome the leg-length discrepancy with an external fixator.

METHODS

Between 2008 and 2011, this technique was used to treat five patients with tibial nonunion with bone loss. All patients were available for a minimum of a 14-month followup (mean, 30 months; range, 14-58 months). General indications for the procedure were age older than 16 years, tibial nonunion with bone loss, and the absence of any psychiatric disorder. We evaluated external fixation time, external fixation index (defined as the duration of external fixation in months divided by the total amount of bone transported and/or the amount of lengthening in centimeters), and time to union on plain radiographs, clinical results using the Paley bone and functional assessment scores, and postoperative complications from chart review.

RESULTS

The external fixation time was 4 months (range, 3-5 months), and the average external fixation index was 0.4 months/cm. The mean time to bone union was 4.6 months (range, 3.5-5.5 months). All angles were determined to be in the normal range. No patients developed refracture or malalignment either on the docking site or the osteotomy site. Paley bone evaluation results were excellent in all five patients, and Paley functional results were excellent in four and good in one. We observed 10 pin-site infections as minor complications, and one patient was left with a residual equinus deformity of 5° as a major complication according to the Paley classification.

CONCLUSIONS

Our technique combining acute shortening and distraction osteogenesis had promising results for the treatment of tibial nonunion with bone loss in a small group of patients. However, future studies directly comparing available approaches to this difficult problem are required. Because this problem is uncommon, these studies will almost certainly require the cooperation of multiple large participating centers.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

[Implementation of a department of plastic surgery in a university clinic for trauma surgery]

BACKGROUND

Since May 2012 plastic surgery for trauma patients at the University Hospital Leipzig is provided by an autonomous department.

OBJECTIVES

This study analyzed the effect of plastic surgery on the changes in diagnosis-related groups (DRG) at a clinic for trauma surgery.

MATERIALS AND METHODS

Within the first 2 years 37 patients (29 male and 8 female of which 38 were inpatient cases) were admitted to the clinic for trauma surgery and additionally received plastic surgery treatment. The appropriate DRG assignment as well as associated codes and revenues were recorded and compared with and without plastic surgery.

RESULTS

A total of 261 operations were performed on these patients of which 71 were performed by the department of plastic surgery. The mean revenue was 22,156.44 EUR±20,578.22 EUR with a mean cost weighting of 7.2±6.7. Excluding plastic surgery treatment the mean revenue was 19,378.44 EUR±20,688.40 EUR and the mean cost weighting was 6.3±6.7. Thus, additional proceeds by the plastic surgery treatment were 2778.00 EUR±3857.01 EUR per case. The mean increase of the cost weighting was 0.9±1.3. A change of the DRG grouping occurred in 20 out of 38 cases treated. The mean length of stay (LoS) was 40.2±26.6 days. In the first year this was 17.9±22.4 days more than the mean national LoS of the appropriate DRG and 10.9±19.3 days in the second year. This means an average cost reduction of 4774.59 EUR per case.

CONCLUSION

The implementation of a department for plastic surgery increased the revenues. Additional profits should be achieved by process enhancement and not by prolonged LoS.

Treatment of Calcaneal Fracture With Severe Soft Tissue Injury and Osteomyelitis: A Case Report

Advancements in surgical technique have resulted in the ability to reconstruct lower extremity injuries that would have previously been treated by amputation. Currently, a paucity of data is available specifically addressing limb amputation versus reconstruction for calcaneal fractures with severe soft tissue compromise. Reconstruction leaves the patient with their native limb; however, multiple surgeries, infections, chronic pain, and a poor functional outcome are very real possibilities. We present the case of a complex calcaneal fracture complicated by soft tissue injury and osteomyelitis that highlights the importance of shared decision-making between patient and surgeon when considering reconstruction versus amputation. This case exemplifies the need for open communication concerning the risks and benefits of treatment modalities while simultaneously considering the patient's expectations and desired outcomes.

Principles of tibial fracture management with circular external fixation

There is a growing mass of literature to suggest that circular external fixation for high-energy tibial fractures has advantages over traditional internal fixation, with potential improved rates of union, decreased incidence of posttraumatic osteomyelitis, and decreased soft tissue problems. To further advance our understanding of the role of circular external fixation in the management of these tibial fractures, randomized controlled trials should be implemented. In addition to complication rates and radiographic outcomes, validated functional outcome tools and cost analysis of this method should be compared with open reduction with internal fixation.

Risk factors associated with complications in lower-extremity reconstruction with the distally based sural flap: a systematic review and pooled analysis

The distally based sural fasciocutaneous flap is one of the few options available for local flap reconstruction of soft-tissue defects in the lower one-third of the leg. Few studies have assessed risk factors associated with poor outcomes in this flap. A literature search was performed of MEDLINE, EMBASE, CINAHL and the Cochrane Library for articles evaluating the use of sural artery fasciocutaneous flaps for soft-tissue reconstruction of the leg. Data were pooled and a univariate analysis was performed to identify characteristics associated with increased morbidity. A logistic regression model was created, and odds ratios and p values associated with the development of complications were calculated. Sixty-one papers were identified which included data on 907 patients. The majority of sural flaps were used to cover defects of the heel (28.2%), foot (14.4%) or ankle (25.8%). Trauma was the most common indication, followed by ulcers and open fractures. Flap complications were recorded in 26.4% of cases with a flap loss rate of 3.2%. With multivariate analysis, venous insufficiency and increasing age were independent risk factors for complications. Patients with venous insufficiency had nine times the risk of developing a complication compared to patients without venous insufficiency.