Extensive Soft Tissue Loss Research Articles

Biomaterial Scaffolds for Periodontal Tissue Engineering.

Advanced periodontitis poses a significant threat to oral health, causing extensive damage and loss of both hard and soft periodontal tissues. While traditional therapies such as scaling and root planing can effectively halt the disease's progression, they often fail to fully restore the original architecture and function of periodontal tissues due to the limited capacity for spontaneous regeneration. To address this challenge, periodontal tissue engineering has emerged as a promising approach. This technology centers on the utilization of biomaterial scaffolds, which function as three-dimensional (3D) templates or frameworks, supporting and guiding the regeneration of periodontal tissues, including the periodontal ligament, cementum, alveolar bone, and gingival tissue. These scaffolds mimic the extracellular matrix (ECM) of native periodontal tissues, aiming to foster cell attachment, proliferation, differentiation, and, ultimately, the formation of new, functional periodontal structures. Despite the inherent challenges associated with preclinical testing, the intensification of research on biomaterial scaffolds, coupled with the continuous advancement of fabrication technology, leads us to anticipate a significant expansion in their application for periodontal tissue regeneration. This review comprehensively covers the recent advancements in biomaterial scaffolds engineered specifically for periodontal tissue regeneration, aiming to provide insights into the current state of the field and potential directions for future research.

A comparison of dislocation risk between dual mobility and traditional constructs used in proximal femoral replacement

BackgroundProximal femoral replacement (PFR) is a reconstruction technique after tumor resection or for revision of failed total hip arthroplasty (THA). However, despite acceptable long-term oncologic and functional outcomes, extensive soft tissue or bone loss increases the risk for prosthetic instability. Instability may depend on the construct chosen for reconstruction, with current options including bipolar, constrained, or dual mobility implants. Clinical studies comparing patient outcomes after PFR with these three different constructs are limited. MethodsThis study retrospectively examined a single tertiary academic institution's experience with PFR over a fifteen-year period. The medical records of patients who underwent PFR for indications such as tumor and failed THA with bone loss were reviewed. Patients were stratified into cohorts based on use of bipolar, constrained, or dual mobility implants. Patient demographics, disease characteristics, perioperative data, and data on prosthetic dislocations were recorded. ANOVA and chi-square testing was performed for continuous and categorical variables, respectively. The threshold for statistical significance was set to p < 0.05. Results106 patients were identified who underwent PFR. 46 underwent PFR with bipolar prosthesis (follow-up: 20 ± 24.57 months), 42 with constrained liner (follow-up: 30.45 ± 35.32 months), and 18 with dual mobility (follow-up: 15.38 ± 15.67 months). Only BMI (p = 0.036) and smoking history (P = 0.002) differed between groups. Dislocations occurred in 4 (8.7 %) patients who underwent reconstruction with bipolar prosthesis, compared to 8 (19.0 %) with constrained liner, and 3 (16.7 %) patients with dual mobility. Mean time to dislocation was significantly longer in dual mobility patients (P = 0.009). There were no differences in instances of early dislocation between groups (P = 00.238). ConclusionWhile study numbers are low, mean time to dislocation was significantly longer with dual mobility. Additional large-scale longitudinal studies are needed to fully elucidate the differences in outcomes amongst these three treatments.

Diatoms in maggots; a potential tool for drowning diagnosis - A preliminary study.

Advanced putrefaction causes extensive loss of soft tissue, rendering it difficult to use the diatom test as a reliable diagnostic tool for drowning investigations. A positive diatom test in carrion insect larvae may provide significant assistance in overcoming the challenge of decomposition. The studies determined the utility of diatom test in carrion larvae on severely decomposed bodies. A modified acid digestion method involving nitric acid, K2Cr2O7 and HCl, was used to digest the blowfly larvae feeding on piglet carrion previously drowned in freshwater and sea water, respectively. Extracted diatom frustules were analysed and characterised using light microscopy coupled to a digital camera. Diatoms recovered from maggots on sea-drowned piglets were similar to diatoms from sea water (drowning medium). Centric diatoms recovered in maggots were higher (200 ± 60 diatoms/ mL) than pennate diatoms (80 ± 20 diatoms/mL). Isolated diatoms common to both maggots and water samples included Coscinodiscus sp. and Navicular spp. Albeit, there were no diatoms recovered from maggots on freshwater-drowned piglets. The findings of this study suggest that the diatom test is still a reliable diagnostic tool to determine if drowning was involved in the death of a fully decomposed body. This is the first study that isolated diatoms from maggots feeding on drowned bodies. It serves as the basis for further research into the utility of maggots for drowning investigations.

Early versus delayed lower extremity amputations caused by firearm injury: A minimum 2-year follow-up.

High-energy casualties such as firearm injuries may result in extensive loss of soft tissue and bone in the lower extremities. Although the primary aim in these types of injuries is the preservation of the extremity, repeated surgical procedures for extremity salvage and subsequent restoration of function could have detrimental effects on the patient both physically and psychologically. The main aim of this study is to evaluate the physical and psychological outcomes of patients who underwent lower extremity amputation in the early period after a firearm injury compared with the results of patients who underwent amputation in the late period. We also evaluated the factors affecting the prognosis in patients undergoing late below-knee amputation (BKA). This retrospective study included patients who underwent BKA following a lower extremity injury caused by firearms between March 2016 and March 2022. Patients who underwent emergency BKA at the first center they were taken to immediately after the injury constituted the early amputation (EA) group. Patients who were transferred to our tertiary-level referral center for continuation of treatment after the first intervention at another center and later underwent BKA constituted the late amputation (LA) group. The patients were evaluated regarding age, gender, amputation side, presence of phantom limb pain (PLP), and post-traumatic stress disorder (PTSD). Information was available from hospital records for a total of 35 patients; 16 in the EA group and 19 in the LA group. All patients were male. The mean age at the time of injury was 25.5±5.3 years (range, 20-45 years), and the mean follow-up period was 37±17 months (range, 25-84 months). In the comparison of PLP experienced, the difference between the groups was statistically significant, with PLP experienced by 1 (10%) patient in the EA group and by 9 (90%) in the LA group (p=0.010). PTSD was diagnosed in 3 (23%) patients in the EA group and 10 (77%) patients in the LA group (p=0.039). Patients who underwent late BKA were found to be affected by PLP and PTSD at a higher rate. When deciding on extremity-preserving surgery for patients with severe open injuries to the lower extremity, it is crucial to consider the poor outcomes associated with late BKA. Patients should be thoroughly informed about these negative outcomes.

Challenges in the management of Buruli ulcer in Nigeria – A case report and literature review

Buruli ulcer (BU) is a disfiguring infective skin lesion caused by Mycobacteriumulcerans. If untreated, BU may lead to extensive soft-tissue loss and other complications. The objective of this study is to highlight the challenges encountered in the diagnosis and management of a patient with BU in our hospital. The patient is a 5-year-old boy who presented with an extensive nonhealing ulcer, knee deformity, and fever. He was initially managed as a case of nonspecific ulcer. A recurrence of the ulcer with loss of part of the skin grafts a week after discharge led to the clinical suspicion of BU which was confirmed using microscopy. In South Western Nigeria, the major constraint in the management of BU includes underdiagnosing of the disease because it is not often screened for due to absence or insufficient standard diagnostic instruments dedicated for that purpose.

Spare-parts free flap reconstruction in polytrauma with limb amputation: Pearls, pitfalls, and an illustrative case report

Spare-part free-flap reconstruction involves free tissue transfer from an unsalvageable extremity for reconstruction of a separate defect. In the setting of traumatic injury, spare-part surgery requires special attention to donor site zone of injury assessment and multidisciplinary coordination. Here we describe a case of upper extremity reconstruction using a free flap harvested from a lower extremity which was indicated for transfemoral amputation. Key pearls and pitfalls are reported in an effort to facilitate collaborative interdisciplinary reconstructive opportunities in cases where amputation is planned in the setting of multi-limb trauma. A 53-year-old male presented after a motorcycle collision with open fractures of the right elbow and tibia/fibula. After initial fracture stabilization and serial debridement, the upper extremity wound required flap coverage for the indication of exposed implants. Extensive bone and soft tissue loss of the lower limb indicated the patient for transfemoral amputation, and spare-part free flap reconstruction of the upper extremity defect was planned. Intra-operative venous pedicle thrombosis caused failure of an initial flap based on the posterior tibial artery. A second spare-part flap based on the anterior tibial artery was successfully transferred under the same anesthetic. When amputation is planned in the context of the multiply traumatized patient, coordinated orthopedic trauma and microsurgical care can facilitate spare-parts free-flap reconstruction. Though these cases require careful planning and intra-operative flexibility to accomplish flap harvest adjacent to a zone of injury, spare-part reconstruction worth pursuing as this strategy obviates the need for an additional donor site. • Spare-part free flaps are useful when amputation is planned in cases of polytrauma. • Collaboration and communication are critical to identify eligible patients. • Carefully assess the zone of injury adjacent to the donor site. • Harvest a large flap and assess with intraoperative fluorescence angiography. • Many unsalvageable limbs do not harbor an uninjured donor site.

Traumatic brachial artery dissection in a pediatric patient: An interdisciplinary approach to care

Severe traumatic arterial injuries are rarely seen in pediatric patients. Management decisions are often guided by anecdotal experience due to a lack of well documented evidence-based guidelines. This paper demonstrates success with multidisciplinary management and close, structured follow-up in a 5 year old boy with traumatic brachial artery dissection and extensive soft tissue loss.

Reconstruction of large midfoot bone loss using titanium spinal mesh cage with bone graft: A case report

High energy trauma injuries in the lower extremity represent unique challenges to surgeons and often involve complex, limb threatening wounds with extensive soft tissue and bone loss. In this case report, we present a case of a 20 year old male who was presented to us with a history of 8 months old high impetus road traffic trauma which resulted in multiple open fracture of the midfoot with ipsilateral closed tibial - fibular shaft and medial malleolar fracture. Open midfoot injury with severe bone loss included complete loss of navicular, all three cuneiforms, base of 1st and 2nd metatarsals. For reconstructing this severe midfoot defect, we have utilized a titanium mesh cage which is routinely used in spinal surgeries. This innovative technique and orthoplastic approach has given the patient a stable plantigrade foot with a near normal midfoot biomechanics and ultimately, restoration of this patient's quality of life.

Reconstruction of Complete Bilateral Maxillary Defects With Free Flaps.

Reconstruction of complete bilateral maxillary defects (CBMDs) can be challenging due to the extensive loss of bone and soft tissues. This is a retrospective case series of 46 consecutive patients with CBMDs that were reconstructed with different micro-vascular free flaps. The authors aimed to evaluate the surgical outcomes and discuss the different reconstruction options in this case series. Thirty-six patients underwent reconstruction following ablation surgery for malignant tumors, 6 for benign tumors, 3 patients were treated for osteomyelitis, and 1 patient underwent free flap reconstruction for posttraumatic defects. Free fibula flap (n = 26) is the most commonly used reconstruction method in this case series, which was used in all defect types. This is followed by anterolateral thigh flap (n = 10), 5 rectus abdominis myocutaneous free flap, 3 radial forearm free flaps, and 2 composite free flaps. In this series, 44 free flaps survived, whereas only 2 flaps were lost. All patients could resume a soft diet postoperatively. Reconstruction of CBMDs with vascularized free flaps is a safe and reliable procedure.

O40: PRE-OPERATIVE MANAGEMENT AND SENSITISATION IN VASCULARIZED COMPOSITE ALLOTRANSPLANTATION: A SYSTEMATIC REVIEW

Abstract Introduction Vascularised composite allotransplantation (VCA) permits like-for-like reconstruction following extensive soft tissue injuries. The initial management of extensive soft tissue injury can lead to the development of anti-HLA antibodies through injury, transfusion and cadaveric grafting. The role of antibody-mediated rejection, donor-specific antibodies and graft rejection in the context of VCA remains unclear. This systematic review aimed to determine whether pre-operative management strategies influence immunological outcome following VCA. Method A systematic review of MEDLINE, EMBASE and CINAHL using a PRISMA-compliant methodology up to February 2019 was conducted. Pre-operative, procedural and long-term outcome data were collected and recorded for all VCA recipients on an individual patient basis. Result The search revealed 3,847 records of which 114 met inclusion criteria and reported clinical data related to 100 patients who underwent 129 VCA transplants. Trauma (50%) and burns (15%) were the most frequent indications for VCA. Of all 114 studies, only one reported acute resuscitative management. Fifteen patients (14.7%) were sensitized prior to reconstructive transplantation with an 80% incidence of acute rejection in the first post-operative year. Seven patients demonstrated graft vasculopathy, only one of whom had demonstrated panel reactive antibodies. Conclusion Currently employed acute management strategies predispose to the development of anti-HLA antibodies, adding to the already complex immunological challenge of VCA. Early appropriate care is warranted in patients with extensive soft tissue loss where the resuscitative needs should be balanced against strategies to mitigate the immunological burden, particularly as reconstructive transplantation becomes a feasible option for future soft tissue coverage. Take-home message Acute resuscitative management may sensitise potential transplant recipients following major soft tissue injury. Early appropriate care is warranted.

Dual-mobility bearings in complex revision hip arthroplasty.

Revision total hip arthroplasty (rTHA) is associated with an increased dislocation risk. Dual-mobility (DM) bearings have been used to address this issue. Such constructs offer increased range of motion and enhanced stability whilst avoiding some issues associated with fully-constrained devices. DM bearings have been used in our unit since 2013. All rTHA cases since 2013 were reviewed using the following criteria: (1) use of a DM bearing; (2) extensive soft tissue or bone loss resulting from ARMD, infection or multiple revisions, or requiring custom or megaprosthetic reconstruction; (3) minimum 2-month follow-up. 52 cases were identified with a median of 2 previous operations (range 1-6) and mean follow-up of 14 (2-41) months. The Novae-Stick component was used in 50 cases, the Avantage in 2 and the Trident MDM in 1 case. 19 required acetabular reconstruction using trabecular metal and four required custom acetabular components. 19 required femoral reconstruction with a proximal or total femoral replacement.Postoperatively, 8 patients (15.4%) sustained a dislocation at a mean of 1.6 (range 1-3) months. 3 (5.8%) requiring re-revision. 1 required excision arthroplasty and 2 a constrained liner, 1 of which went on to have further instability. There were no intraprosthetic dislocations. Dual-mobility components are a viable option in the complex rTHA setting. Early dislocations can occur but the rate of instability is acceptable in this high-risk group.

Minimally Invasive Single-Point Stabilization of Zygomaticomaxillary Complex Fractures.

This study aimed to present a minimally invasive surgical management of zygomaticomaxillary complex (ZMC) fractures with reduction and single-point stabilization over the frontozygomatic buttress. This prospective cohort study was conducted on cases of ZMC fractures. The inclusion criteria were displaced tetrapod zygomatic factures, asymmetry of the facial bones, and unilateral lesion. The exclusion criteria were extensive skin or soft tissue loss, comminuted inferior orbital rim, limited ocular mobility, and enophthalmos. Surgical management included reduction and single-point stabilization over the zygomaticofrontal suture with miniplates and screws. The outcome measure was correction of the clinical deformity with less scarring and low postoperative morbidity. The late outcome was maintenance of a stable fixed reduced zygoma over the follow-up period. Forty-five patients were included in the study with a mean age of 30 ± 5.56years. The study included 40 men and 5 women. Motor vehicle accident was the most common cause of fracture (62.2%). They were managed via lateral eyebrow approach with single-point stabilization over the frontozygomatic suture after reduction. Preoperative and postoperative and radiologic images were available. All cases had optimum correction of the clinical deformity. Postoperative stability was excellent in the follow-up period, which had a mean of 18.5 ± 7.81months. There is an increased interest in minimally invasive procedures, and concerns about scarring have increased. Therefore, single-point stabilization over the frontozygomatic suture provides good support to the reduced ZMC with low morbidity.

Total Laryngectomy Following Severe Laryngeal Trauma: A Case of Surgical Dilemma.

External laryngeal trauma is a rather rare occurrence, and comprises a varying severity of injuries. Every laryngeal injury is unique and the management can be invariably complex. For the most severe forms of external laryngeal trauma, reparative procedures and laryngeal stenting (after control of the airway) are considered standard treatment. We present a case of a complex laryngeal trauma with extensive loss of tracheal cartilage and soft tissues which was treated with total laryngectomy.

One-stage procedure for open tibial fractures: feasible without orthoplastic surgery?

Background:Open tibial fractures are mostly the result of high-energy traumas and often involve severe injuries with extensive bone and soft tissue loss, damage of muscles and neurovascular structures. Over recent years, the growth of Ortho-Plastic teams, as a well-coordinated bone, joint and soft tissue treatment, contributed to change the approach to these fractures and to achieve higher successful results in lower limb salvage. Unfortunately, many hospitals cannot benefit of a combined team in emergency, and the orthopedic surgeon is forced to manage personally these kinds of traumas.Methods:We retrospectively reviewed all the open tibial fractures treated at our Orthopaedic Department over the last 10 years, in order to assess the treatments performed (one-stage fixation with Intramedullary Nailing or Open Reduction Internal Fixation – ORIF, versus two/multiple-stage fixation with temporary External Fixation followed by nailing or ORIF) and the differences in the outcome between the different methods.Purpose:Based on our experience and review of the literature, the purpose of this paper is to define what cases can be managed by a single-stage orthopaedic approach, and when the orthopaedist should lay down his arms in favor of other specialties. (www.actabiomedica.it)

Fixateur externe am Handgelenk – temporäre Fixation

a)Fixed-angle bridging of the wrist between radius diaphysis and metacarpus by percutaneous or minimally invasively inserted threaded pins and a frame (fixator) placed above the skin level (external); b)retention of fracture fragments by ligamentotaxis; c)temporary stabilization after bone loss at wrist and distal forearm. a)Initial treatment of fractures near the wrist or soft tissue injuries in multiple trauma patients; b)fractures of the distal radius and the distal ulna; c)dislocation of the carpus; d)infections of the wrist; e)instability after resection in the wrist area; f)fractures with impending or manifest compartment syndrome; g) fractures with extensive loss of soft tissues and lacking coverage of implants. a)Pathological changes at the site of pin application, as long as no alternative site is possible: infections, fractures, osteoporosis, tumors; b)fractures that are closed and not reduceable; c)exclusively intra-articular distal radius fractures; d)lack of compliance by the patient. Insertion of two threaded pins into the radial shaft proximal to the radiocarpal joint and two pins into the second metacarpal bone. Assembly of the fixator frame in advance of the definitive reduction. Subsequently, final reduction and fixation in the desired position by tightening of the screws on the fixator frame. Pin care and changes of wound dressing every 2-3days RESULTS: Reliable, low complication procedure for temporary fixation of the wrist for many indications.

Andrew's bridge system: A boon for huge ridge defect in aesthetic zone

Tooth loss may pose a challenge for prosthetics when several missing teeth are associated with huge vertical and horizontal bone defects due to cleft palate, road traffic accidents, congenital defects etc.This case report presents prosthetic rehabilitation of a 22 year old male patient of cleft lip and palate with missing upper front teeth along with severe ridge defect since 1 year due to surgical intervention in premaxillary region. The extensive soft and hard tissue defect in aesthetic region was evident and it made the prosthetic rehabilitation more challenging. Among treatment options, fixed partial denture (FPD) was not feasible due to long edentulous span and extensive soft and hard tissue loss. Psychologically, patient was not ready for removable prosthesis. Patient was also not ready for next implant or bone augmentation surgery procedure. The patient presented with Kennedy class IV edentulous area with Seibert's class III ridge defect, so fixed-removable prosthesis was planned to compensate soft and hard tissue defect. The patient with several missing teeth and extensive visible bony defect in the anterior region was successfully rehabilitated using fixed-removable Andrew's bridge system. Although it is not commonly used by dentist so this present case report shows effective management of huge defect case by very simple and conservative technique.

Current indications for abdominal-based flaps in hand and forearm reconstruction

Extensive soft tissue loss or injury of the hand and upper extremity is a challenging reconstructive problem traditionally treated with abdominal-based pedicled flaps. Options for coverage included the groin flap based on the superficial circumflex iliac artery, the Scarpa's fascia flap based on the superficial inferior epigastric artery, and the paraumbilical perforator flap from the deep inferior epigastric artery perforators. Despite the ability to provide consistent and pliable soft tissue coverage with ease of elevation, these flaps have several disadvantages including restriction of mobility, requirement for multiple procedures, bulkiness and patient discomfort. With the advent of microsurgery, pedicled regional flaps, and off-the-shelf skin substitutes, the applications for these flaps have narrowed. However several indications still remain. These include: patient and facility factors which deter microsurgery, the absence of recipient vessels after injury, prior surgical use of recipient vessels, the need to preserve major vessels for future reconstruction, and large multi-surface wounds requiring coverage. In this review we detail these indications and provide case examples for each.

Delayed reconstruction for olecranon fracture with extensive soft tissue injury and bone loss: A case report

Delayed surgery for intraarticular fractures of the elbow is usually avoided, especially to prevent complications such as stiffness. We described an interesting case of a young patient who presented with open fracture of right olecranon, with extensive soft tissue injury and bony loss. He was treated with a 3-stage surgical procedure, prioritising on the soft tissue healing first before undergoing a delayed, definitive fixation of the olecranon, which was done 4 weeks after the trauma. The 3 stages include initial debridement and temporary skeletal stabilisation using Kirschner wires and external fixator, second look debridement with shoelace (dermato-traction) technique of delayed wound closure, and a definitive, reconstructive surgery using tricortical iliac bone graft with anatomical locking plate. The subsequent radiographs showed restored articular congruency of the elbow joint, before the olecranon eventually achieved bony union. He recovered well with excellent outcomes, as the elbow range of motion achieved almost full flexion at 120° and the extension lag at 10° and the Disabilities of the Arm, Shoulder and Hand (DASH) score of 3.3 was recorded. Delayed reconstructive surgery for olecranon fracture with extensive soft tissue and bone loss is a viable option to avoid complications, including infection and non-union. A judicious consideration by prioritising soft tissue management over expeditious bony surgery is important to achieve excellent outcomes.

A Multicentre Study: The Use of Micrografts in the Reconstruction of Full-Thickness Posttraumatic Skin Defects of the Limbs-A Whole Innovative Concept in Regenerative Surgery.

The skin graft is a surgical technique commonly used in the reconstructive surgery of the limbs, in order to repair skin loss, as well as to repair the donor area of the flaps and cover the dermal substitutes after engraftment. The unavoidable side effect of this technique consists of unaesthetic scars. In order to achieve the healing of posttraumatic ulcers by means of tissue regeneration and to avoid excessive scarring, a new innovative technology based on the application of autologous micrografts, obtained by Rigenera technology, was reported. This technology was able to induce tissue repair by highly viable skin micrografts of 80 micron size achieved by a mechanical disaggregation method. The specific cell population of these micrografts includes progenitor cells, which in association with the fragment of the Extracellular Matrix (ECM) and growth factors derived by patients' own tissue initiate biological processes of regeneration enhancing the wound healing process. We have used this technique in 70 cases of traumatic wounds of the lower and upper limbs, characterized by extensive loss of skin substance and soft tissue. In all cases, we have applied the Rigenera protocol using skin micrografts, achieving in 69 cases the complete healing of wounds in a period between 35 and 84 days. For each patient, the reconstructive outcome was evaluated weekly to assess the efficacy of this technique and any arising complication. A visual analogue scale (VAS) was administered to assess the amount of pain felt after the micrografts' application, whereas we evaluated the scars according to the Vancouver scale and the wound prognosis according to Wound Bed Score. We have thus been able to demonstrate that Rigenera procedure is very effective in stimulating skin regeneration, while reducing the outcome scar.

Initial Assessment, Debridement, and Decision Making in the Salvage of Severely Injured Lower Extremity.

An open fracture with extensive skin and soft tissue loss is considered as a severely injured lower extremity. Advances in rapid transport, resuscitation, skeletal fixation, and microsurgical techniques to cover large soft tissue and bone defects have made possible the salvage of these severely injured limbs. Salvage exercise is skill and resource intensive and could take a long time frame. The goal of management is to obtain painless independent weight bearing walking in a time frame and cost that the patient can afford.Decisions taken and the quality of care provided on day 1 determine the ultimate success. Inappropriate decisions and treatment lead to increased morbidity and secondary amputation. Infection is the commonest complication. Limb salvage scores are helpful to predict salvage and guide the sequence of treatment. Once the decision is taken for salvage, debridement, early skeletal fixation, and soft tissue cover are the key to success.