New developments in flap techniques

Knee Joint Rescue in a Traumatic Amputation With Coverage by a Fillet-Free Flap From the Amputated Leg

Traumatic amputation is a severe injury that requires urgent surgical care. A fillet-free flap from the amputated limb is the most conservative way to ensure proper coverage of the stump when replantation is not possible. We report the case of a male patient who suffered from a traumatic limb amputation in a motorcycle accident. A free fillet flap from the posterior compartment of the leg carrying the posterior tibial pedicle, the soleus muscle, and skin tissue harvested from the amputated limb was performed to cover the amputation stump and thus allow preservation of the knee joint. In our case report, the patient conserved almost maximal knee joint range of motion (130°). He regained the ability to walk only two months after the initial trauma. Prosthetic fitting occurred quickly and without any particular issues throughout the process. Regarding quality of life, after one year, our patient had a five-level EQ-5D version (EQ-5D-5L) score of 21,221, and his 36-Item Short Form Survey (SF-36) score was divided between the five components in 85 points in physical functioning, 100 points in role limitations due to physical health, 100 points in role limitations due to emotional problems, 50 points in energy/fatigue, 68 points in emotional well-being, 75 points in social functioning, 45 points in pain, and 95 points in general health. This technique helped provide good coverage of the stump while preserving a functional knee joint, allowing for effective prosthetic fitting in the future and therefore optimizing our patient's quality of life.

From replantation to transplantation: The evolution of orthoplastic extremity reconstruction

For more than six decades, the use of the operating microscope for extremity surgery has led to remarkable advances in the management of orthopedic trauma, tumors, infections, and congenital differences. The microsurgical reconstructive ladder ascends from basic microsurgical procedures such as a digital artery or nerve repair to more complex procedures such as autologous tissue transplantation. Functional muscle transfers, toe-to-hand transfers, and recently vascularized composite allotransplantation are the highest rungs on this ladder that help restore extremity function. The development of the orthoplastic approach over the last three decades simultaneously integrates the principles and practices of both orthopedic surgery and plastic surgery for optimal care and salvage of extremities. Clinical, anatomic, and basic science research in reconstructive microsurgery has resulted in significant improvements in extremity salvage, reconstruction, and restoration.

Management of post-traumatic long bone defects: A comparative study based on long-term results

BACKGROUND

Reconstruction of post-traumatic long bone defects is a formidable problem. To date, the approaches for bony reconstruction remain controversial. Thus, we aimed to compare the different methods in the treatment of patients with post-traumatic long bone defects, based on the long-term functional and self-evaluation results.

METHODS

We retrospectively reviewed data on patients with post-traumatic long bone defects of the lower extremities from January 2006 to January 2015. The patients were divided into three groups according to the surgical method used to treat the defects (group 1, free vascularized fibular transfer; group 2, distraction osteogenesis; group 3, the induced membrane technique). Data including the complication rates, entire treatment period, long-term visual analog scale scores, and Sickness Impact Profile (SIP) scores during follow-up were recorded.

RESULTS

A total of 317 patients were included, with 106, 132, and 79 patients in groups 1, 2, and 3, respectively. The major complication rates were 22.6%, 25.8%, and 26.6% for the groups (P > 0.05), respectively. The mean treatment durations for bony defects, from surgery to non-protected weight-bearing, were 65.1, 46.5, and 56.6 weeks for each group, respectively. At 2 years postoperatively, the average SIP scores for each group were 10.5, 11.7, and 11.5, respectively (P > 0.05).

CONCLUSION

Patients who sustained long bone defects can be advised that either one of these three methods which typically results in long-term outcomes equivalent to others.

LEVEL OF EVIDENCE

retrospective study.

Soft Tissue Reconstruction and Flap Coverage for Revision Total Knee Arthroplasty

BACKGROUND

Total knee arthroplasty is a successful operation for treatment of arthritis. However, devastating wound complications and infections can compromise the knee joint, particularly in revision situations.

METHODS

Soft tissue loss associated with poor wound healing and multiple operations can necessitate the need for reconstruction for wound closure and protection of the prosthesis.

RESULTS

Coverage options range from simple closure methods to complex reconstruction, including delayed primary closure, healing by secondary intention, vacuum-assisted closure, skin grafting, local flap coverage, and distant microsurgical tissue transfer.

CONCLUSION

Understanding the advantages and pitfalls of each reconstructive option helps to guide treatment and avoid repeated operations and potentially devastating consequences such as knee arthrodesis or amputation.

An algorithmic approach for managing orthopaedic surgical wounds of the foot and ankle

BACKGROUND

Wound breakdown after orthopaedic foot and ankle surgery may necessitate secondary soft tissue coverage. The foot and ankle region is challenging to reconstruct for orthopaedic and plastic surgeons owing to its complex bony anatomy and unique functional demands. Therefore, identifying strategies for plastic surgery of these wounds may help guide surgeons in defining the best treatment plan.

QUESTIONS/PURPOSES

We evaluated our current algorithmic approach for managing orthopaedic surgical wounds of the foot and ankle with respect to whether (1) prophylactic or simultaneous soft tissue coverage affected wound-healing complications (secondary plastic surgery, orthopaedic hardware removal, malunion, further orthopaedic surgery, ultimate failure) and (2) postoperative referral for soft tissue management was associated with wound location, size, and orthopaedic procedure.

METHODS

We retrospectively reviewed 112 patients who underwent elective orthopaedic foot or ankle surgery and required concomitant plastic surgery at our institution. Study end points included secondary plastic surgery procedures, hardware removal for infection, foot or ankle malunion, further orthopaedic surgery, and wound-healing failure as defined by a chronic nonhealing wound or need for amputation. Minimum followup was 0.6 months (mean, 24.9 months; range, 0.6-197 months). Four patients were lost to complete followup. We developed an algorithm that centers on two critical points of care: preoperative evaluation by the orthopaedic surgeon and evaluation and treatment by the plastic surgeon after referral.

RESULTS

Compared with postoperative intervention, prophylactic or simultaneous soft tissue coverage did not lead to differences in frequency of secondary plastic surgery procedures (p = 0.55), hardware removal procedures (p = 0.13), malunions (p = 0.47), further orthopaedic surgery (p = 0.48), and ultimate failure (p = 0.27). Patients referred postoperatively for soft tissue management most frequently had dorsal ankle wounds (p < 0.001) of smaller size (p = 0.03), most commonly associated with total ankle arthroplasty (p = 0.004).

CONCLUSIONS

Using our algorithmic approach, prophylactic or simultaneous soft tissue coverage did not improve the study end points. In addition, unexpected postoperative wound breakdown necessitating a plastic surgery consultation most commonly occurred on the dorsal ankle after total ankle arthroplasty. Our algorithm facilitates early identification of skin instability and enables prompt soft tissue coverage before or concurrently with orthopaedic procedures. The effect of prophylactic or simultaneous soft tissue coverage on postoperative wound healing requires further investigation.

LEVEL OF EVIDENCE

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

Microvascular reconstructive surgery in Operations Iraqi and Enduring Freedom: the US military experience performing free flaps in a combat zone

BACKGROUND

Local nationals with complex wounds resulting from traumatic combat injuries during Operations Iraqi Freedom and Enduring Freedom usually must undergo reconstructive surgery in the combat zone. While the use of microvascular free-tissue transfer (free flaps) for traumatic reconstruction is well documented in the literature, various complicating factors exist when these intricate surgical procedures are performed in a theater of war.

METHODS

The microvascular experiences of six military surgeons deployed during a 30-month period between 2006 and 2011 in Iraq and Afghanistan were retrospectively reviewed.

RESULTS

Twenty-nine patients presented with complex traumatic wounds. Thirty-one free flaps were performed for the 29 patients. Location of tissue defects included the lower extremity (15), face/neck (8), upper extremity (6). Limb salvage was successful in all but one patient. Six of eight patients with head and neck wounds were tolerating oral intake at the time of discharge. There were three flap losses in 3 patients; two patients who experienced flap loss underwent a successful second free or regional flap. Minor complications occurred in six patients.

CONCLUSION

Microvascular free tissue transfer for complex tissue defects in a combat zone is a critically important task and can improve quality of life for host-nation patients. Major US combat hospitals deployed to a war zone should include personnel who are trained and capable of performing these complex reconstructive procedures and who understand the many nuances of optimizing outcomes in this challenging environment.

The reconstructive microsurgery ladder in orthopaedics

Since the advent of the operating microscope by Julius Jacobson in 1960, reconstructive microsurgery has become an integral part of extremity reconstruction and orthopaedics. During World War I, with the influx of severe extremity trauma Harold Gillies introduced the concept of the reconstructive ladder for wound closure. The concept of the reconstructive ladder goes from simple to complex means of attaining wound closure. Over the last half century microsurgery has continued to evolve and progress. We now have a microsurgical reconstructive ladder. The microsurgical reconstruction ladder is based upon the early work on revascularization and replantation extending through the procedures that are described in this article.

Microsurgery of the upper extremity

In the past 50 years, hand surgeons have made considerable contributions to microsurgery. The unique demands of complex upper extremity care have driven many of the technical and scientific advances of this discipline, including functional muscle transfers, nerve transfers, and composite tissue allotransplantation. The purpose of this article was to review the current applications of microsurgery to the upper extremity.

The respective roles of plastic and orthopedic surgery in limb salvage

The evolution of techniques in plastic surgery and orthopedic surgery over the past few decades has enabled a great level of success in limb salvage. Limb salvage can now be achieved when faced with trauma, tumor, sepsis, or vascular disease. In fact, "What can be salvaged?" is now a less common debate among clinicians than "What should be salvaged?" Often discussions among surgeons from various subspecialties, including orthopedics, plastics, trauma, and vascular surgery, are characterized by how each of them can perform their respective part of the salvage operation, be it bony fixation, revascularization, or soft-tissue coverage, but none of them is certain whether it should be attempted. What is needed in these clinical situations is an interdisciplinary team approach led by individual or groups of clinicians who are familiar not only with their own subspecialized skills but also with those of their colleagues and the outcomes associated with integrated efforts at limb salvage. The concept of orthoplastic surgery is based on such an idea, where the combined skills and techniques of the orthopedic surgeon and reconstructive microsurgeon are used in concert to direct efforts toward limb salvage or decide against it when it is not indicated. This article presents a review of the roles of the two subspecialties and how an orthoplastic team can function with the current techniques to improve outcomes in limb salvage surgery.

Extremity war injuries: challenges in definitive reconstruction

The third annual Extremity War Injuries Symposium was held in January 2008 to review challenges related to definitive management of severe injuries sustained primarily as a result of blast injuries associated with military operations in the Global War on Terror. Specifically, the symposium focused on the management of soft-tissue defects, segmental bone defects, open tibial shaft fractures, and challenges associated with massive periarticular reconstructions. Advances in several components of soft-tissue injury management, such as improvement in the use of free-tissue transfer and enhanced approaches to tissue-engineering, may improve overall care for extremity injuries. Use of distraction osteogenesis for treatment of large bone defects has been simplified by the development of computer-aided distraction protocols. For closed tibial fractures, evidence and consensus support initial splinting for transport and aeromedical evacuation, followed by elective reamed, locked intramedullary nail fixation. Management of open tibial shaft fractures sustained as a result of high-energy combat injuries should include serial débridements every 48 hours until definitive wound closure and stabilization are recommended. A low threshold is recommended for early utilization of fasciotomies in the overall treatment of tibial shaft fractures associated with war injuries. For management of open tibial fractures secondary to blast or high-velocity gunshot injuries, good experiences have been reported with the use of ring fixation for definitive treatment. Treatment options in any given case of massive periarticular defects must consider the specific anatomic and physiologic challenges presented as well as the capabilities of the treating surgeon.

Composite tissue transfer in upper extremity trauma

Unlike congenital malformations or defects resulting from tumour ablation, trauma of the upper extremity is more complex to manage. Also because of the structural complexity of the upper extremity, tissue defects often result in exposure of vital structures such as bone, nerve, blood vessels and tendons. Thus, a successful reconstruction after upper extremity trauma must be approached with the goals of not only providing stable coverage but most importantly, restoring function. We present the state-of-the-art material on composite tissue transfer in upper extremity trauma. This chapter describes the modern philosophy of emergency wound management, the optimal timing of reconstruction, and the basic principles in selection of coverage tissue, as well as outlining the advantages, disadvantages, and indications of several most commonly used flaps. In our opinion, radical debridement followed by primary reconstruction is always the first choice when treating traumatic injuries. Microsurgical transplantation of composite tissue to the upper extremity results in the best wound coverage and early functional rehabilitation. Simultaneously, multicomponent reconstruction can also be achieved with minimal donor site morbidity and aesthetically acceptable donor sites.