Adequate Soft Tissue Coverage Research Articles

Posterior Tibial Artery Perforator Based Propeller Flap for Reconstruction of 143 Skin and Soft Tissue Defect Around Ankle Joint

Background: Soft tissue coverage of distal leg and ankle region represents a challenge and such defect usually requires a free flap. However, this needs facility of microsurgery, may lead to donor site morbidity and is time consuming. With the introduction of perforator flap, management of small and medium size defects of distal leg and ankle region is easier, less time consuming, and with minimal donor site morbidity. When local perforator flap is designed as propeller and rotated to 180-degree, donor site can be closed primarily and increases the distance crossed by flap, thus increasing versatility. Objectives: To observe the outcome of soft tissue coverage of defects around ankle joint by posterior tibial artery perforator based propeller flaps. Methods: This was a prospective type of observational study carried out on 20 patients with skin and soft tissue defects in and around ankle joint for a period of 14 months in the Department of Burn and Plastic Surgery, Dhaka Medical College and Hospital. Results: Among 20 cases 17 were male and 3 females; age ranged from 11 to 60 years. Post operative outcome of flap were excellent in 11 cases, good in 6 cases, poor in 3 cases as per defined criteria. Uneventful outcome was observed in 14 cases and minor complications were observed in 5 cases; and total flap loss occurred in 1 case which required revision surgery. Conclusions: Perforator flap provides adequate soft tissue coverage for small & medium size wound around ankle. It is an easy, reliable & effective procedure with reasonable outcome. J Dhaka Med Coll. 2022; 31(2) : 243-250

Posterior Tibial Artery Perforator Based Propeller Flap for Reconstruction of 143 Skin and Soft Tissue Defect Around Ankle Joint

Background: Soft tissue coverage of distal leg and ankle region represents a challenge and such defect usually requires a free flap. However, this needs facility of microsurgery, may lead to donor site morbidity and is time consuming. With the introduction of perforator flap, management of small and medium size defects of distal leg and ankle region is easier, less time consuming, and with minimal donor site morbidity. When local perforator flap is designed as propeller and rotated to 180-degree, donor site can be closed primarily and increases the distance crossed by flap, thus increasing versatility. Objectives: To observe the outcome of soft tissue coverage of defects around ankle joint by posterior tibial artery perforator based propeller flaps. Methods: This was a prospective type of observational study carried out on 20 patients with skin and soft tissue defects in and around ankle joint for a period of 14 months in the Department of Burn and Plastic Surgery, Dhaka Medical College and Hospital. Results: Among 20 cases 17 were male and 3 females; age ranged from 11 to 60 years. Post operative outcome of flap were excellent in 11 cases, good in 6 cases, poor in 3 cases as per defined criteria. Uneventful outcome was observed in 14 cases and minor complications were observed in 5 cases; and total flap loss occurred in 1 case which required revision surgery. Conclusions: Perforator flap provides adequate soft tissue coverage for small & medium size wound around ankle. It is an easy, reliable & effective procedure with reasonable outcome. J Dhaka Med Coll. 2022; 31(2) : 243-250

Management of osteosarcoma by total knee joint replacement with ALT-free flap transfer: Case series

In the past, surgeries to treat osteosarcoma involved amputation, but now they have become more conservative with prosthesis replacement. To reduce the incidence of complications, it is essential to consider suitable and adequate soft tissue cover. Our patients underwent surgery to resect osteosarcoma of the upper and lower head of the tibia and femur, respectively and were given knee joint prostheses. We chose the anterolateral thigh flap (ALT) as the suitable material to cover the defect and the prosthesis. All flaps were used for the surgery, two of which were fasciocutaneous, and the other two were musculocutaneous. All flaps had good blood supply, and no complications were reported. Conservative surgery for osteosarcoma has become increasingly popular, particularly for bone or joint replacement. The free ALT flaps offer many advantages when reconstructing the soft tissue defect and covering the prosthesis. The lower donor site morbidity of ALT free-flap makes it a more favorable choice for reconstruction after joint replacement.

Single-stage revision in the management of prosthetic joint infections after total knee arthroplasty – A review of current concepts

IntroductionProsthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA); and the gold standard surgical approach involves a two-staged, revision TKA (TSR). Owing to the newer, emerging evidence on this subject, there has been gradual shift towards a single-stage revision approach (SSR), with the purported benefits of mitigated patient morbidity, decreased complications and reduced costs. However, there is still substantial lacuna in the evidence regarding the safety and outcome of the two approaches in chronic PJI. This study aimed to comprehensively review of the literature on SSR; and evaluate its role within Revision TKA post PJI. MethodsThe narrative review involved a comprehensive search of the databases (Embase, Medline and Pubmed), conducted on 20th of January 2024 using specific key words. All the manuscripts discussing the use of SSR for the management of PJI after TKA were considered for the review. Among the screened manuscripts, opinion articles, letters to the editor and non-English manuscripts were excluded. ResultsThe literature search yielded a total 232 studies. Following a detailed scrutiny of these manuscripts, 26 articles were finally selected. The overall success rate following SSR is reported to range from 73 % to 100 % (and is comparable to TSR). SSR is performed in PJI patients with bacteriologically-proven infection, adequate soft tissue cover, immuno-competent host and excellent tolerance to antibiotics. The main difference between SSR and TSR is that the interval between the 2 stages is only a few minutes instead of 6 weeks. Appropriate topical, intraoperative antibiotic therapy, followed by adequate postoperative systemic antibiotic cover are necessary to ascertain good outcome. Some of the major benefits of SSR over TSR include reduced morbidity, decreased complications (such as arthrofibrosis or anesthesia-associated adverse events), meliorated extremity function, earlier return to activities, mitigated mechanical (prosthesis-associated) complications and enhanced patient satisfaction. ConclusionSSR is a reliable approach for the management of chronic PJI. Based on our comprehensive review of the literature, it may be concluded that the right selection of patients, extensive debridement, sophisticated reconstruction strategy, identification of the pathogenic organism, initiation of appropriate antibiotic therapy and ensuring adequate follow-up are the key determinants of successful outcome. To achieve this will undoubtedly require an MDT approach to be taken on a case-by-case basis.

The role of surgical timing in upper extremity free flap reconstruction following trauma: a 10-year single-center, single-surgeon experience

Purpose: Complex traumatic upper extremity injuries often require microvascular free tissue transfer for adequate soft tissue coverage or functional reconstruction. The need for rapid coverage is acknowledged, but the optimal timing for reconstruction remains a subject of debate.Methods: A retrospective review was conducted of patients who underwent free flap reconstruction for upper extremity injuries after trauma from March 2012 to August 2018 in South Korea at a facility specializing in extremity trauma. Surgical timing was categorized according to the classification of Godina into early (within 72 hours after injury) and delayed (from 72 hours to 3 months after injury) reconstruction. Patients’ demographic characteristics, methods of free tissue transfer, flap failure rates, postoperative infections, total hospital stays, and the number of operations required were analyzed.Results: In total, 80 free tissue transfers were conducted on 76 patients. The demographics and characteristics of patients in the early and delayed reconstruction groups showed no significant differences. Early reconstruction was associated with a significantly lower infection rate, shorter average hospital stay, and a lower average number of operations, without showing a significant difference in the flap failure rate.Conclusion: The results of this study indicate that early reconstruction within 72 hours after trauma significantly reduces infection rates, the length of hospital stays, and the number of required operations. This study underscores the importance of timely intervention in upper extremity free flap reconstruction for optimal patient outcomes.

Functional and Radiographic Outcomes of Open Proximal Femoral Fractures Caused by Gunshot Wounds in Yemen: A Prospective Cohort Study.

Open proximal femoral fractures caused by gunshot wounds are rare but devastating injuries that pose considerable challenges for prognosis and management. The aim of this study was to evaluate the functional and radiographic outcomes of patients with open proximal femoral fractures caused by gunshot wounds treated at 3 Level-I trauma centers in Yemen and to identify the factors that influence them. We prospectively enrolled 174 patients with open proximal femoral fractures caused by gunshot wounds. The fractures were classified according to the Gustilo-Anderson and OTA/AO systems. The primary outcome measures were fracture union, infection, and functional outcomes. The secondary outcome measures were the Harris hip score (HHS) and the Short Form-36 (SF-36) health survey score. We performed multivariable logistic regression modeling to identify the predictors of complications and poor functional outcomes. The overall rate of fracture union was 87%. The complication rates were 18% for infection, 13% for nonunion, 23% for reoperation, 12% for delayed union, 4% for osteonecrosis, 6% for heterotopic ossification, and 2% for amputation. The mean HHS at the final follow-up was 78.4, and the mean SF-36 score was 67.3. Open proximal femoral fractures caused by gunshot wounds are associated with high rates of complications and poor functional outcomes in Yemen. Early debridement, appropriate fixation, infection control, and adequate soft-tissue coverage are essential for achieving satisfactory results. The type of wound, the type of fracture, and the type of definitive fixation are significant predictors of the outcomes. Future studies should compare different fixation methods and evaluate the long-term outcomes and complications of these injuries. Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Study of Various Modalities of Management of Lower One-third Leg Defects in a Tertiary Care Hospital

Background: Lower extremity reconstruction is essential to plastic surgery and focuses on treating wounds and defects secondary to trauma, cancer, or chronic disease processes. Anatomical features of the lower third of the leg like subcutaneous bone surrounded by tendons with no muscles and vessels in isolated compartments with little intercommunication between them make the coverage of the wounds in the region a challenging problem. Aim: to study the various modalities of surgical management of lower 1/3rd leg defects. The study also aims to study the defect size and region in planning various flaps possible in the reconstruction ladder. Methods: The study was conducted from September 2014 to June 2017 on patients admitted to the Department of Burns, Plastic & Reconstructive Surgery and referred patients from the Department of General Surgery & Orthopaedic Surgery, S C B Medical College & Hospital, Cuttack. The Study includes all lower 3rd Leg defect varieties for different surgical treatment modalities. Results: Various reconstructive methods were used to cover the lower 1/3rdleg defects; the maximum was the free muscle transfer in 9 cases. The following typical flap used was the reverse sural flap. Conclusion: The goal in lower limb reconstruction involves needing a stable skeleton, allowing weight-bearing status, with adequate soft tissue coverage to nourish and protect the underlying bone. What one would use for reconstruction depends upon the surgeon’s familiarity and comfort levels with the technique as much as the various circumstances.

Risk Factors and Management of Prosthetic Joint Infections in Megaprostheses-A Review of the Literature.

Prosthetic joint infection (PJI) is the most common mode of failure of megaprostheses, yet the literature on the topic is scarce, and studies report conflicting data regarding the optimal treatment strategy. Patients with megaprostheses PJI are often immunosuppressed, and surgeons must balance the trade-off between treatment efficacy and morbidity associated with the surgery aiming for infection eradication. Our review on megaprostheses PJI focuses on two axes: (1) risk factors and preventative strategies; and (2) surgical strategies to manage this condition. Risk factors were classified as either unmodifiable or modifiable. Attempts to decrease the risk of PJI should target the latter group. Strategies to prevent PJI include the use of silver-coated implants, timely discontinuation of perioperative antibiotic prophylaxis, and adequate soft tissue coverage to diminish the amount of dead space. Regarding surgical treatment, main strategies include debridement, antibiotics, implant retention (DAIR), DAIR with modular component exchange, stem retention (DAIR plus), one-stage, and two-stage revision. Two-stage revision is the "gold standard" for PJI in conventional implants; however, its success hinges on adequate soft tissue coverage and willingness of patients to tolerate a spacer for a minimum of 6 weeks. DAIR plus and one-stage revisions may be appropriate for a select group of patients who cannot endure the morbidity of two surgeries. Moreover, whenever DAIR is considered, exchange of the modular components should be performed (DAIR plus). Due to the low volume of megaprostheses implanted, studies assessing PJI should be conducted in a multi-institutional fashion. This would allow for more meaningful comparison of groups, with sufficient statistical power. Level of evidence: IV.

Application of Staged Negative Pressure Wound Therapy and Flap Surgery for Infection Control After Patellar Internal Fixation Surgery.

The anatomic position of the patella is superficial, making it vulnerable to injuries. Treatment of patella infection after internal fixation surgery remains a big challenge due to minimal soft tissue coverage and vital tissue exposure. Forty-two patients aged 10 to 59 years were admitted to the institution's burn unit between January 2010 and December 2019. Each presented with infection after patellar fracture surgery. Twenty-seven infections were superficial, whereas 15 were deep with pyogenous arthritis of the knee. Negative pressure wound therapy (NPWT) was applied after radical debridement to remove necrotic subcutaneous tissues and internal fixation devices. In addition, cases with septic arthritis were irrigated continuously with normal saline. After 5 to 10 days of NPWT treatment and irrigation, wound infection was well controlled. Afterward, 42 wounds were resurfaced with pedicled flaps, the 42 patients received 17 reverse-flow anterolateral thigh (ALT) perforator flap, 12 medial sural artery perforator flaps, 7 gastrocnemius musculocutaneous flaps, as well as 6 saphenous artery flaps. Thirty-seven flaps survived uneventfully. However, 3 flaps developed venous congestion in the distal end. Two flaps developed tip necrosis. All patients were followed up between 3 and 48 months. Infection beneath the flap occurred in 3 patients and healed after an additional debridement surgery. The staged NPWT and flap surgery strategy focus on thorough debridement and immediate internal fixation devices removal, effective fracture fixation, efficient NPWT application, targeted administration of antibiotics, and adequate soft tissue coverage. This study established that the procedure was effective in infection control after patellar internal fixation surgery.

Simplified soft tissue coverage of the distal lower extremity: The reverse sural flap.

Soft tissue defects involving the distal lower extremity present challenging problems for orthopaedic surgeons to manage. Historically, wounds not amenable to primary closure have necessitated assistance from multidisciplinary teams using plastic surgeons to obtain adequate soft tissue coverage through rotational flap or free tissue transfer procedures. Techniques related to soft tissue rearrangement and local rotational flap coverage have advanced over the years with a growing knowledge of local anatomy and vasculature. The reverse sural flap may be performed to cover soft tissue defects within 10 cm of the foot or ankle region, negating the need for microvascular intervention. The simplistic nature of the reverse sural flap is appealing to orthopaedic surgeons as a means to provide timely patient care without additional support because it does not require microvasculature work or the need for intraoperative microscopes and has been popularized among orthopaedic trauma surgeons as a necessary tool to possess. Here, we discuss the reverse sural flap to include history, relevant anatomy, clinical indications, and a description of the technique for application.

Reconstruction of Upper and Lower Limb Defects with Medial Sural Artery Perforator Flaps: Is Aesthetics Worth the Effort? A Retrospective Analysis

Abstract Background One of the most essential goals in managing complex limb defects is obtaining adequate soft tissue coverage with excellent functional and aesthetic outcomes. Free perforator skin flaps represent an optimal option for such defects. Therefore, our intention was to reconstruct these kinds of defects with thin fasciocutaneous flaps without the need for debulking. Herein, we define the legitimate use of the medial sural artery perforator (MSAP) flaps for small-moderate size defect coverage of the hand and foot. Patients and Methods Seven patients received MSAP flaps for reconstruction of different hand and foot defects, of which the majority were males (4/7). Age, sex, flap size, location, number of perforators, recipient vessel, type of anastomosis, technique of donor site closure, and postoperative morbidity were recorded. Patients' age ranged from 48 to 84 years. Results Single-stage debridement followed by reconstruction was performed. Flap sizes ranged from 6 to 18 cm in length and 4 to 10 cm in width. The pedicles of 6 flaps were anastomosed to the tibial artery system (three posterior tibial artery, three dorsalis pedis artery) and one to the ulnar artery. Conclusion MSAP flap can be a versatile option for single-stage reconstruction of small-moderate size defects of the extremities, where thin, soft tissue envelope is required. This flap has lower donor site morbidity, more tedious elevation process, and has a good reconstructive and aesthetic result without the need for debulking in the future.

Readmission Rate of Outpatient Distal Radius Fixation Surgery with Brachial Plexus Block and Midline Pronator Quadratus Approach in the COVID-19 Era: A Retrospective Case Series Report in a Secondary Care Hospital in Thailand

Objective: To demonstrate the readmission rate after distal radius fixation surgery performed with a brachial plexus block and the midline pronator quadratus approach in an ambulatory manner in a secondary care hospital. Materials and Methods: This retrospective study analyzed data on distal radius fracture patients treated with ambulatory surgery. The patients were enrolled from 1 January 2020 to 28 February 2022, which was during the COVID-19 pandemic. The primary outcome was the readmission rate within 30 days after the surgery. The secondary outcomes were complications, postoperative pain, radiographic outcome, and functional score. All patients were followed up for at least 1 year after the surgery. Results: Thirty-one patients were enrolled in this study. Their mean age was 58.5 years, and the fractures were mainly caused by low-energy trauma. No postoperative complications were reported, and no readmission after surgery was observed. Overall radiographic parameters were in the acceptable range (radial inclination = 21.9, radial height = 10.26, volar tilt = 2.65, and ulna variance = 1.33). All patients returned to their preinjury statuses within 5 months. Conclusion: Distal radius fixation surgery can be managed in an ambulatory manner with a low readmission rate, even in secondary care hospitals. This repair technique provides adequate soft tissue coverage of the volar radius plate while decreasing the risk of iatrogenic radial artery injuries.

Hemipelvectomy following Trauma: Burden less Identified. A Ten-year Experience from the Level-1 Trauma Center

Introduction:Hemipelvectomy occurs seldom, yet it is a serious injury. Hemipelvectomy following trauma is associated with high incidence of morbidity and mortality. Successful management requires early recognition with a multi-speciality approach and meticulous surgical technique.Method:Retrospective data from hospital records of the Level-1 Trauma Center, between December 2011 through September 2022 was obtained. Clinical details including mechanism of injury, trauma scoring, associated injuries, hemodynamic status, surgical procedures, wound complications, ICU stays, hospital stay, prosthesis application, and their outcome were analyzed. Patients were followed up physically in OPD or telephonically.Results:Total footfall 615,274 patients with 16,786 admissions in trauma surgery, 1,299 amputations and 13 hemipelvectomy patients during the study period of ten years. Seven were in shock on presentation, of which, four were non responders and three responded to initial resuscitation. Seven patients had associated Genitourinary injuries, four had anorectal involvement, five had vascular injuries and six had associated extremity injuries. Six patients underwent hemipelvectomy in the primary surgery and seven ended up in hemipelvectomy on consecutive surgeries. Multiple surgeries were required for all the patients both for control of local sepsis and adequate soft tissue cover. Eight of thirteen patients developed wound infections, and related sepsis, one survived a covid infection and three had MODS. Four out of thirteen patients died and of the nine survivors, prosthesis is being used by three patients, two returned to work without prosthesis and two lost to follow up.Conclusion:With a multidisciplinary and dedicated team approach, we can expect favorable outcomes in post-trauma hemipelvectomy patients.

Outcomes of Cranioplasty Reconstructions: Review of Cranioplasty Implants and Free Flap Coverage Variables that Affect Implant Exposure.

Complex scalp wounds with cranial/dural involvement are challenging to reconstruct. Successful reconstruction can be achieved with cranial implants/hardware and free flap coverage. Wounds can breakdown and require revision procedures. We addressed reconstructive outcomes of different implants requiring free flaps. To determine the factors associated with implant exposure. Multi-institutional retrospective review of 82 patients, 2000-2020, repaired with cranial implants and free flap coverage. Implant exposure occurred in 13/82 (16%) reconstructions. Flap atrophy or thinning leading to implant exposure occurred in 11/82 (13%) reconstructions, including partial flap atrophy OR 0.05 (95% CI 0.0-0.35) and total flap atrophy OR 0.34 (95% CI 0.02-19.66). Revision surgeries that occurred subsequent to flap reconstruction were also associated with implant exposure (OR 0.02 (95% CI 0.0-0.19)). Implant exposure was not associated with radiation therapy, patient health history, implant type, flap type, or postoperative complications. Implant exposure is associated with free flap atrophy, leading to inadequate implant coverage and the need for revision surgeries. Completing reconstruction with adequate soft tissue bulk and coverage and avoiding revision surgery may decrease the risk for implant exposure over time. 4 Laryngoscope, 133:2954-2958, 2023.

Scalp Reconstruction Techniques for the General Surgeon – A Case Report

Scalp injuries are extremely common and although most scalp lacerations/ injuries can be primarily repaired, few require flap coverage. This article discusses the various ways in which we have reconstructed the scalp. This article is a case series of six different cases that required flap reconstruction where six different techniques were used to obtain wound cover with good outcomes. Patients who presented to various smaller hospitals/nursing homes with availability of only a general surgeon and no super specialists in Rural Bangalore with the need for scalp reconstruction were considered for the study. The operative outcome of six different methods of scalp reconstruction/ repair that include four different local flaps, a split skin graft with a wig and a pericranium burr hole drilling followed by split skin graft coverage have been studied.
 All six cases were followed up for a period of one month post intervention and all of them had good functional and cosmetic outcomes with no complications. There was no incidence of surgical site infection, seroma, or flap/graft failure in the 6 cases included in our study. Both grafts and flaps are equally good modalities in scalp reconstruction, but the choice for which to use should be based on the need of the patient and the type of wound. Grafts can be considered in conditions where there is adequate soft tissue cover over the scalp and in wounds with larger surface area. Grafts have the advantage of being technically simpler and are associated with fewer complications/failure but cannot be used in injuries where the bone is exposed. Flaps have better cosmetic outcome but are technically more challenging.

Application of External Nasal Skin Stretching in Asian Rhinoplasty.

Asian nasal characteristics include a low dorsum, short nose, and thick skin envelope, usually requiring lengthening and elevating the nose during rhinoplasty ( Facial Plast Surg Clin North Am 2007;15(3):293-307, v). The increase in rhinoplasty popularity has resulted in a greater prevalence of complications. In a severely short and contracted nose, an extensively scarred or contracted soft tissue envelope results in weak laxity and extensibility of the nasal skin. For these patients, the essential component of rhinoplasty is to improve skin texture and obtain a sufficient nasal skin soft tissue envelope. Tissue expanders have previously been utilized to expand nasal skin and soft tissue ( Plast Reconstr Surg 2006;118(6):1447-1452; Facial Plast Surg 2019;35(1):68-72). However, nasal anatomical characteristics have limited the clinical application of tissue expanders. This article introduces a simple, noninvasive, and easily adopted method of external nasal skin stretching, which was first proposed by the senior author. This approach has been accepted by rhinoplasty surgeons in China and widely used in clinic. The approach can improve skin laxity, yield extra nasal soft tissue, and create adequate soft tissue coverage of the reconstructed nasal framework to reduce the difficulty of surgery with a reliable clinical effect.

Outcome of vacuum assisted dressing in open comminuted tibial fracture with primary fixation

Background/Aim: Wound management of the compound open tibia (Gustilo-Anderson grade 2, 3a, 3b) is complicated by a higher infection and the problem of adequate soft tissue coverage is significant. Primary wound closure is not easily advisable in these types of compound open tibial fractures. Early tissue flap or graft procedure might increase the complication rate due to temporary graft rejection and wound infections. The aim of this study was to analyse the duration required for formation of healthy granulation tissue, duration required for making wound fit for skin cover procedure and duration of hospital stay in compound open tibia fracture treated with vacuum assisted closure (VAC). Methods: A prospective interventional study of 22 patients aged 18 to 60 years was done. After assessing the size of the wound, primary bone fixation and wound debridement were carried out as soon as possible and then VAC was applied. Assessment of VAC therapy was based on mean decreases in wound size and "modified Johner and Wruh's criteria", used for assessment of the functional outcome of tibial shaft fracture was recorded during each follow-up. Results: Twenty two patients suffered comminuted open fractures of tibia-fibula. Primary fixation of bone were done with vacuum dressing. During follow-up, the good decrease in wound size considering vacuum dressing remedy was once 18.75 ± 18.36 cm2 (p = 0.001). Six patients achieved excellent results according to "modified Johner and Wruh's criteria" of tibial shaft fracture. Conclusion: This technique effectively reduced wound size, accelerated the formation of healthy granulation tissue of wound with open fracture bone and provided a better functional outcome. The VAC treatment had suggestively increased wound closure rate, decreased morbidity and costs for patients.

Calcanectomy in primary high-grade sarcomas: Foot salvage without the need for any reconstruction

The calcaneum is a rare site for primary bone sarcomas. Calcanectomy is not considered for high-grade malignancies due to anticipated issues with obtaining negative margins, providing adequate soft-tissue coverage, and preserving satisfactory function. A below-knee amputation overcomes these difficulties and is very functional and, thus, the preferred local control option. The aim of this study is to evaluate the role of total calcanectomy, without any formal reconstruction, in high-grade calcaneal sarcomas. Over 14 years, three patients with high-grade calcaneal sarcomas underwent limb salvage surgery as opposed to amputation for their primary malignancy. Total calcanectomy was undertaken using a Cincinnati incision. No formal “calcaneal” reconstruction was undertaken after resection, essentially leaving the patient with an excision arthroplasty through the subtalar joint. The Achilles tendon was reattached to the posterior talus. Negative resection margins were achieved in all cases with the primary wound closure. Two patients are alive with no evidence of disease at 15 and 10 years. The third patient, at over 1 year postoperatively, has no evidence of local disease recurrence but has had metastasectomy for documented pulmonary metastases at the presentation. The average musculoskeletal tumor society score was 85.5%, and the average Toronto extremity salvage score was 88.5%. In our experience, even high-grade malignancies at this unusual site are potentially amenable to limb salvage. Our results show that perhaps ablative surgery should not be considered inevitable. Good functional outcomes can be achieved without reconstruction, thus minimizing potential “construct”-related morbidities.

Radial Flap in Reconstructions of the Hand - Case Series Study

Abstract Radial forearm flap is an axial flap that has become an important technique in reconstructive surgery as a free flap or as a pedicled flap. Defects of the skin and other tissues on the hand are very common and most often they are work-related injuries. In deep defects, flap must be used, as well as in reconstruction of the amputated thumb. There are many flaps that provide adequate soft tissue coverage for the hand. Therefore, the aim of this paper is to present the results of the use of radial forearm flap in various reconstructions on the hand. The retrospective study included 35 patients who underwent reconstruction with radial forearm flaps due to defects of the skin and other tissues on the hand, in the period 1997-2019. Results and complications of the surgery were analyzed. The functional and aesthetic outcome was assessed using Michigan Hand Outcome Qusteionnarire. All patients were followed for a minimum of 1 year. Fasciocutaneous flap was the most commonly used (65.71%), followed by adiposofascial (20%) and osteocutaneous (14.29%). The size of the fasciocutaneous flap ranged from 2.2×3.1cm to 9×13.5cm. The majority of donor sites were closed with split-thickness skin grafts (56.52%), and less frequently with direct suture, local skin flap, and full-thickness skin graft. There were no complete flap losses in the study. Marginal necrosis was noted in 8.57%, and graft failure at the donor site in 14.29%. Secondary surgical procedures were performed in 13 patients. The functional-aesthetic result of the operation, based on the MHQ score, ranged from 31 (1/35) to 130 points (3/35). The ultimate aim of hand reconstruction is to restore sufficient function and form, also, closing the wound within three days following the injury is desirable. Meticulous intraoperative dissection of radial flap and early physical therapy after surgery are mandatory. The radial flap is a suitable method, especially for large and more distal skin defects on the hand, and a very good method for thumb reconstruction.

Tissue Expanders in Staged Calvarial Reconstruction: A Systematic Review

Cranioplasties are common procedures in plastic surgery. The use of tissue expansion (TE) in staged cranioplasties is less common. We present two cases of cranioplasties with TE and systematically review literature describing the use of TE in staged cranioplasties and postoperative outcomes. A systematic review was performed by querying multiple databases. Eligible articles include published case series, retrospective reviews, and systematic reviews that described use of TE for staged bony cranioplasty. Data regarding study size, patient demographics, preoperative characteristics, staged procedure characteristics, and postoperative outcomes were collected. Of 755 identified publications, 26 met inclusion criteria. 85 patients underwent a staged cranioplasty with TE. Average defect size was 122 cm 2 , and 30.9% of patients received a previous reconstruction. Average expansion period was 14.2 weeks. The most common soft tissue closures were performed with skin expansion only (75.3%), free/pedicled flap (20.1%), and skin graft (4.7%). The mean postoperative follow-up time was 23.9 months. Overall infection and local complication rates were 3.53 and 9.41%, respectively. The most common complications were cerebrospinal fluid leak (7.1%), hematoma (7.1%), implant exposure (3.5%), and infection (3.5%). Factors associated with higher complication rates include the following: use of alloplastic calvarial implants and defects of congenital etiology ( p = 0.023 and 0.035, respectively). This is the first comprehensive review to describe current practices and outcomes in staged cranioplasty with TE. Adequate soft tissue coverage contributes to successful cranioplasties and TE can play a safe and effective role in selected cases.