Fixation Of Implants Research Articles

Heat Development During Medical Drilling: Influencing Factors and Examination Methods - Overview and First Results.

In many medical disciplines, the process of drilling into the bone plays a crucial role for the implantation or fixation of implants or reconstruction plates. During the bone drilling process, heat is generated on the drill head and within the surrounding tissue. As a result, the increased temperature can lead to thermal damage and related necrosis of the (bone) tissue. This tissue damage is dependent on different drilling parameters and can have important influence on the following tissue healing cascade and finally on implant surveillance. In this context, the present short review elucidates the current state of scientific knowledge with regard to the heat-triggering factors during the bony drilling process and how these factors can be better understood and prevented, now and in the future, through new research approaches. External and internal influencing factors during the drilling process are distinguished and methods to examine the temperature changes are compared. This mini-review further demonstrates first preliminary results of the inflammatory tissue reactions to inadequate drilling processes. Furthermore, possible solutions of new standardized ex vivo-measurement methods to better understand the factors influencing the development of heat and to reduce animal experiments are herein discussed.

The use of cement in revision total knee arthroplasty

Despite the availability of modern implants and techniques, Revision Total Knee Arthroplasty (R-TKA) still poses a challenge to surgeons, particularly the management of bone loss/defects and the secure fixation of implants. Polymethylmethacrylate (PMMA) bone cement plays an important role for fixation as fully uncemented fixation in RTKA is rarely used. Cement can be employed as part of a full cementing construct or as a hybrid construct. While in fully cemented implants, the diaphyseal stem as well as any couplers or connectors in the metaphysis are cemented, in hybrid cementing, only the component parts at the joint surface and metaphysis are cemented, while the diaphyseal stem is fixed in a press-fit manner. In this article the literature on the in vitro as well on the in vivo results of both fixation options is reviewed.Although the fixation mechanism of both constructs are different, radiographic and clinical survivorship appear similar for both techniques. Although there appears to be a trend towards a hybrid fixation method, the choice of which technique to employ in revision total knee arthroplasty will depend on the surgeons' familiarity with each technique as well as the factors peculiar to each patients anatomy.

An investigation on the degradation behaviors of Mg wires/PLA composite for bone fixation implants: influence of wire content and load mode

Abstract Poly-lactic acid based biocomposite strengthened with magnesium alloy wires (Mg wires/PLA composite) is prepared for bone fixation implantation. The influence of wire content and load mode on the degradation performances of the composite and its components is studied. The result suggests the degradation of Mg wires could slow down the pH decrease originated from the degradation of PLA, while a relatively high wire content contributes to descend the degradation rate of Mg wire in the composite. Dynamic load significantly promotes the mechanical loss of the specimens. After 30 days immersion, the Sb retention is about 65%, 52% and 55%, respectively for pure PLA, the composite at 10 vol% and 20 vol% under dynamic load, comparing to 75%, 70% and 72% under no load. Moreover, dynamic load could further mitigate the degradation of Mg wires by increasing convective transport of acidic products out of the composite.

Results of stress-strain states study in prosthetics of different types of atrophy of edentulous mandible

Complete dentures remain still popular due to the economic component of such prosthetic treatment. However, additional fixation on intraosseous implants provides a greater clinical and functional effectiveness and a greater level of satisfaction with the results of prosthetics in edentulous patients. At the moment, the biomechanical aspects of complete denture prosthetics and prosthetics with fixation on implants, taking into account the degree of atrophy of the edentulous jaws, are not complete understood. Such studies make it possible to create recommendations on the choice of prosthetic tactics for edentulous patients. The aim of the research was to study the distribution of stress-strain states in prosthetics of the edentulous mandible with complete dentures and with designs supported on intraosseous implants, taking into account the type of atrophy. It was carried out computer simulation of 8 virtual finite element models of mandible with different types of atrophy. According to Keller they were 4 models: of the biomechanical system simulation "complete denture – mandible" and 4 ones – "denture – intraosseous implants – mandible". In each of the models, a chewing load of 100 N was simulated (symmetrically and asymmetrically). The ANSIS 12.1 finite element analysis was used to calculate the stress-strain states in the described calculation systems. It was estimated the distribution of stresses in cortical bone and displacements of the dentures on the prosthetic bed. Under using complete dentures, the maximum stresses in the bone tissue of the prosthetic bed were observed for the third type of mandible atrophy with all types of power load, the smallest ones – for the fourth type. Additional fixation of removable dentures in simulation models of biomechanical systems “denture – intraosseous implants – mandible” lead to a significant increase in stresses in the alveolar bone. The maximum stresses were observed in the area of the marginal bone, while their greatest values were in the well-expressed alveolar part of the mandible for first and third types by Keller. The movements of bases of complete dentures were insignificant and fluctuated within hundredths of a millimeter for all types of atrophy. The use of intraosseous implants for fixation of dentures caused increase in movements by several times. Besides, displacement fields were characteristic: they were uniform for complete dentures but in the use of implants – not. The expressed alveolar process in the first and third types of atrophy of the edentulous mandible caused an increase in the displacements of the distal sections of the dentures on both sides with a symmetrical force load and on one side – with an asymmetric one. It can be assumed that such a distribution of stress-strain states accelerates atrophy of prosthetic bed tissues. As a result of prosthetics of complete defects of lower dentitions, both with traditional complete dentures and with additional support on implants, different distribution of stress-strain states occurs in different phases of the chewing act in the bone of the prosthetic bed, the character of which is determined by the shape of the alveolar part described by Keller's classification. The results allow us to develop an algorithm for determining the kind of prosthetics for edentulous patients, depending on the type of mandible atrophy.

In Vitro and In Vivo Biosafety Analysis of Resorbable Polyglycolic Acid-Polylactic Acid Block Copolymer Composites for Spinal Fixation.

Herein, spinal fixation implants were constructed using degradable polymeric materials such as PGA–PLA block copolymers (poly(glycolic acid-b-lactic acid)). These materials were reinforced by blending with HA-g-PLA (hydroxyapatite-graft-poly lactic acid) and PGA fiber before being tested to confirm its biocompatibility via in vitro (MTT assay) and in vivo animal experiments (i.e., skin sensitization, intradermal intracutaneous reaction, and in vivo degradation tests). Every specimen exhibited suitable biocompatibility and biodegradability for use as resorbable spinal fixation materials.

Peri-implant fractures proximal to a long retrograde femoral nail – A case series

Low energy peri-trochanteric fractures may happen in the presence of a retrograde nail in the femur. The management of these peri-implant fractures are very rarely reported. This is a series of seven cases from a level one trauma centre in Hong Kong. All fractures arose from low energy falls and were either inter-trochanteric or subtrochanteric. Removal of previous implants to allow cephalo-medullary fixation of the new fracture could be considered, but this is often difficult, time-consuming, and may inflict damage to the articular cartilage. Furthermore, this is not an option if the distal fracture is not yet well healed. Six of the seven fractures presented here were treated operatively with an extra-medullary device fixed to the proximal shaft with cerclage cables. The choice of fixation implants were based on the fracture type and available space above the proximal end of the retrograde nail. All seven fractures healed with no implant failure and major complications. There were no thirty-day and one-year mortality. A treatment algorithm is proposed for the management of these uncommon but difficult cases.

Facial Fractures

The understanding and management of craniofacial fractures have evolved through remarkable innovations in high-resolution imaging, surgical and fixation techniques, endoscopy, biomaterials and implants, bone grafting, new and refined classification frameworks, and algorithms for intervention. The concept of facial buttresses first described forty years ago now serves as a guide to reconstruction of the underlying skeleton to re-establish the height, width, and projection of the face. With the advent of 3D computed tomography and intraoperative imaging, surgeons have expanded the armamentarium for surgical planning and navigation, especially beneficial for accurate repair in complex cases. All of these advances have improved patient outcomes and raised expectations for functionally and aesthetically acceptable results. A brief overview of the assessment and management of facial fractures is presented. This review contains 1 figure, 4 tables, and 43 references. Key words: facial fracture, facial trauma, plastic surgery, orbital, maxillofacial, injury, Le Fort, malocclusion, skeletal buttress

Laser Surface Texturing and Electropolishing of CoCr and Ti6Al4V-ELI Alloys for Biomedical Applications.

The interplay between a prosthetic and tissue represents an important factor for the fixation of orthopedic implants. Laser texturing tests and electropolishing were performed on two materials used in the fabrication of medical devices, i.e., CoCr and Ti6Al4V-ELI alloys. The material surface was textured with a diode-pumped solid state (DPSS) laser and its effect on the surface quality and material modification, under different combinations of laser power and marking speed, were investigated. Our results indicate that an increment of energy per unit length causes an incremental trend in surface roughness parameters. Additionally, phase transformation on the surface of both alloys was achieved. Chemical analysis by energy dispersive X-ray spectrometer (EDX) shows the formation of (Co(Cr,Mo)) phase and the M23C6 precipitate on the CoCr surface; while quantitative analysis of the X-ray diffractometer (XRD) results demonstrates the oxidation of the Ti alloy with the formation of Ti2O and Ti6O from the reduction of the α-Ti phase. The behaviors were both related with an increase of the energy per unit length. Control of the final surface roughness was achieved by an electropolishing post-treatment, minimizing the as-treated values. After polishing, a reduction of surface roughness parameters was obtained in a range between 3% and 44%, while no changes in chemical composition or present phases were observed.

Research progress of medial buttress plate assisted fixation for femoral neck fractures in young adults

To summarize the research progress of medial buttress plate assisted fixation for femoral neck fractures in young adults. The literature about buttress plate assisted fixation for femoral neck fractures in young adults was widely reviewed and analyzed. The design principle, background, biomechanical characteristics, and clinical results of buttress plate were summarized. Medial buttress plate assisted fixation is the latest treatment of femoral neck fractures in young adults, which can convert the shear force at the fracture sides into compression force and promote fracture healing. Medial buttress plate can improve the biomechanical stability of femoral neck fractures and reduce the maximum stress of fixation implants. In clinical, the medial buttress plate can maintain fracture reduction, reduce the incidences of nonunion and surgical failure, and improve hip joint function. Medial buttress plate assisted fixation can achieve good effectiveness for femoral neck fractures in young adults. However, due to the preliminary application, its indications, fixation implants, and long-term effectiveness need to be further studied and improved.

Reinforcement and Fatigue of a Bioinspired Mineral-Organic Bioresorbable Bone Adhesive.

Bioresorbable bone adhesives may provide remarkable clinical solutions in areas ranging from fixation and osseointegration of permanent implants to the direct healing and fusion of bones without permanent fixation hardware. Mechanical properties of bone adhesives are critical for their successful application in vivo. Reinforcement of a tetracalcium phosphate-phosphoserine bone adhesive is investigated using three degradable reinforcement strategies: poly(lactic-co-glycolic) (PLGA) fibers, PLGA sutures, and chitosan lactate. All three approaches lead to higher compressive strengths of the material and better fatigue performance. Reinforcement with PLGA fibers and chitosan lactate results in a 100% probability of survival of samples at 20 MPa maximum compressive stress level, which is almost ten times higher compared to compressive loads observed in the intervertebral discs of the spine in vivo. High adhesive shear strength of 5.1 MPa is achieved for fiber-reinforced bone adhesive by tuning the surface architecture of titanium samples. Finally, biological and biomechanical performance of the fiber-reinforced adhesive is evaluated in a rabbit distal femur osteotomy model, showing the potential of the bone adhesive for clinical use.

Multimodal imaging of composite carbon fiber-based implants for orthopedic spinal fixation.

As cancer treatments continue to improve, the incidence of spinal metastases and the need for surgical management of these with fixation procedures are growing rapidly. Traditionally metallic implants, composed of titanium alloy, have been used in surgical fixation of unstable or symptomatic vertebral metastases or traumatic injuries. Metallic implants, however, cause significant artifact on post-operative imaging, degrading image quality and limiting interpretation, and can also impair the planning and delivery of radiotherapy. Composite carbon fiber-based materials, such as carbon fiber-reinforced polyetheretherketone (PEEK), have been developed to overcome these issues and are now available for spinal fixation procedures. We aimed to review the multimodal imaging features of these new implants. Current literature and a case example from our institution were used to describe the multimodal imaging characteristics and considerations of new carbon fiber-based spinal fixation implants. New carbon fiber-based spinal implants allow far greater visualization of surrounding structures on post-operative cross-sectional imaging, significantly improving diagnostic accuracy and precision of radiotherapy planning, and do not significantly absorb or scatter X-ray photons during radiotherapy delivery. There are, however, important surgical and radiologic considerations associated with the use of carbon fiber-based implants which radiologists must be aware of, such as implications for surgical planning and intra-operative fluoroscopic and post-operative plain radiographic imaging. The use of carbon fiber-based implants, rather than traditional metallic implants, for spinal fixation offers significant advantages for post-operative diagnostic imaging and radiotherapy planning and delivery.

Deformation Analysis of Internal Fixation Plate on Femur Bone Fracture: A Study Case on Local Raw

In the case of femur bone fracture, internal fixation is usually applied for the treatment due to the convenience and amenities of follow-up care. Due to a high demand for internal fixation implants in Indonesia, causing Pelopor Teknologi Implantindo Inc. (PTI Inc., Mojokerto - Indonesia) produces conventional implant material made from annealed local raw material of 316L stainless steel, with a yield strength of 317 MPa and ultimate tensile strength of 580 MPa. Compared to implant material in ASTM F138, it has a little higher value of both yield and ultimate tensile strength. To determine the effects of material type, normal stresses will be used to evaluate the fractured bone, while von Mises stresses will be used to analyze the strength of fixation plate. Besides, influence of material variation to the bone healing process is also discussed. Transversal-type fracture is chosen for fracture modeling of femoral shaft. The loading is taken from body weight of Asians, which is applied at femur head. The simulation result indicates that in the case of conventional fixation plate, there is no significant influence on the bone healing caused by different material type.

Bio-Integration and Bone Fixation Performance of Continuous Mineral Fiber-Reinforced Implants

Category:Basic Sciences/Biologics; OtherIntroduction/Purpose:The integration of an implant into surrounding tissue as remodeling occurs is a characteristic associated with bone grafts or bone fillers, some of which are osteoconductive or osteostimulative. Many bioabsorbable polymer implants lack quiescent degradation and are associated with adverse inflammation. Recently, new bio-integrative bone fixation implants comprised of continuous mineral fibers and polymer were introduced. The implant’s high mineral content is intended to encourage an increased bio-integrative response, while the continuous fiber structure provides mechanical bone fixation strength. The study objectives were to evaluate the implant’s long-term bio-integration and ability to maintain fixation in a load bearing in- vivo model.Methods:Twenty-four rabbits were studied over 104-week period to evaluate the bio-integration of fiber-reinforced bone fixation pins. The continuous reinforcing mineral fibers made up approximately 50% of the implant, comprised of elements found in native bone, including calcium, silica, and magnesium. The other 50% was comprised of poly (L-lactide-co-D, L lactide) (PLDLA) at a 70:30, L:DL ratio. Pins were implanted bilaterally, with three fiber-reinforced pins (test) implanted into the mid-shaft of one femur and three PLDLA polymer pins (control) into the mid-shaft of the other femur. Implantation sites were scored histologically at multiple timepoints to assess bio-integration by means of implant degradation profile, surrounding bone quality and tissue ingrowth. A separate group of twelve rabbits was studied clinically, radiographically and histologically over 12 weeks to evaluate the fiber-reinforced implant performance, compared to a stainless-steel implanted group, in a lateral femur condyle osteotomy model under full load bearing conditions.Results:At 104 weeks, implant material fully eliminated in 11 out of 12 fiber-reinforced implants and in 6 out of 12 PLDLA implants. The fiber-reinforced group showed increased propensity for bio-integration throughout the course of the study, demonstrating a gradual degradation profile and much higher score of tissue ingrowth. Amount of polymer decreased from a score of 4.0 at 4 weeks to score 1.7 at week 26, score 1.0 at week 78 and 0.1 at 104 weeks. The polymer control underwent abrupt late stage degradation, with amount of polymer dropping from a score of 4.0 to 0.7 from 78 to 104 weeks. In the load bearing osteotomy model, the fiber-reinforced implants performed comparable to stainless-steel, demonstrating tighter bone-to- implant interface with no intervening fibrotic tissue.Conclusion:This study represents the first long term in-vivo evaluation of mineral fiber-reinforced implants demonstrating both bio-integration and orthopedic fixation. Quiescent bio-integration is a significant challenge for degradable orthopedic fixation implants. The implants must be mechanically strong for stable fixation while able to gradually integrate with surrounding bone without adverse effects. Continuous fiber reinforced implants proved the unique potential to meet this challenge with a fiber structure that provides fixation strength and is comprised entirely of minerals found in native bone. An increased level of mesenchymal tissue ingrowth, combined with the absence of local or systemic adverse response, demonstrates excellent bio- integration.

Novel design of additive manufactured hollow porous implants

ObjectiveOur aim is to examine the mechanical properties of two types of additive manufactured hollow porous dental implants and 6 and 12-week bone ingrowth after insertion in animals. A 3D numerical model is also developed to show detailed tissue differentiation and to provide design guidelines for implants. MethodsThe two porous and a commercial dental implant were studied by series of in vitro mechanical tests (three-point bending, torsional, screwing torque, and sawbone pull-out tests). They also evaluated by in vivo animal tests (micro-CT analysis) and ex vivo pull-out tests. Moreover, the mechano-regulation algorithm was implemented by the 3D finite element model to predict the history of tissue differentiation around the implants. ResultsThe results showed that the two porous implants can significantly improve osseointegration after 12-week bone healing. This resulted in good fixation and stability of implants, giving very high maximum pull-out strength 413.1 N and 493.2 N, compared to 245.7 N for the commercial implant. Also, several features were accurately predicted by the mechano-regulation model, such as transversely connected bone formation, and bone resorption occurred in the middle of implants. SignificanceSystematic studies on dental implants with multiple approaches, including new design, mechanical tests, animal tests, and numerical modeling, were performed. Two hollow porous implants significantly improved bone ingrowth compared with commercial implants, while maintaining mechanical strength. Also, the numerical model was verified by animal tests. It improved the efficiency of design and reduce the demand for animal sacrifice.

Osseointegration of Antimicrobial Acrylic Bone Cements Modified with Graphene Oxide and Chitosan

Acrylic bone cement (ABC) is one of the most used materials in orthopedic surgery, mainly for the fixation of orthopedic implants to the bone. However, ABCs usually present lack of biological activity and osseointegration capacity that leads to loosening of the prosthesis. This work reports the effect of introducing graphene oxide (GO) and chitosan (CS), separately or together, in the ABC formulation on setting performance, mechanical behavior, and biological properties. Introduction of both CS and GO to the ABC decreased the maximum temperature by 21% and increased the antibacterial activity against Escherichia coli by 87%, while introduction of only CS decreased bending strength by 32%. The results of cell viability and cell adhesion tests showed in vitro biocompatibility. The in vivo response was investigated using both subdermal and bone parietal implantations in Wistar rats. Modified ABCs showed absence of immune response, as confirmed by a normal inflammatory response in Wistar rat subdermal implantation. The results of the parietal bone implantation showed that the addition of CS and GO together allowed a near total healing bone–cement interface, as observed in the micrographic analysis. The overall results support the great potential of the modified ABCs for application in orthopedic surgery mainly in those cases where osseointegration is required.

Simultaneous internal fixation and soft tissue coverage by soleus muscle flap and variances: a reproducible strategy for managing open fractures of tibial shaft

The role of internal fixation and local muscle flaps for open tibial fractures is still not specifically determined. We describe the integration of internal fixation and soleus muscle flap for open fractures complicated with soft tissue loss of the tibial shaft. Twenty-seven patients with Gustilo IIIB open fractures of the tibial shaft were operated on by internal fixation and soft tissue coverage by soleus muscle flaps and variances. Data were collected on types of implants, types of flaps, union time, postoperative complications, and objective clinical measurement. Regarding implants for fixation, plates and screws were selected in 22 patients, and intramedullary nails in 5. Proximally based soleus flap was used in 17 patients, hemisoleus in 6, and reversed hemisoleus in 4. All flaps survived and all fractures were united with a mean union time of 21.8weeks (range 14-30). One patient had unplanned reoperations due to delayed union and equinus deformity of the ankle. All patients had good-to-excellent Puno functional score results. Internal fixation and soft tissue coverage, frequently referred to as 'fix and flap', by a local soleus muscle flap is safe and effective for open fractures accompanied with small-to-medium size soft tissue defect of the tibial shaft.

Technique for Removal of Entrapped Screw and Washer Fixation of the Posterior Pelvic Ring.

Removal of internal fixation implants previously placed to stabilize posterior pelvic ring injuries may be technically challenging. Described techniques for extraction require specialized equipment, extensile measures, or purchase of additional implants. We describe a technique for removal of large diameter cannulated screws and washers from the posterior pelvic ring, which requires no additional equipment or implants beyond the instrumentation used for implant insertion, as well as a series of 15 cases in which the technique was applied.

Complex Revision Arthroplasty Planning with Telemedicine Expert Advice

Relevance. An increase in the number of revisions is an inevitable consequence of the growth of primary arthroplasty number. The imperfection of implants and the lag in patient’s seeking medical help significantly increase the number of complex revisions. Extensive bone defects after removal of an unstable implant urge us to think about the better methods of these defects compensation and implants fixation. The purpose — was to assess the modern telemedicine opportunities for improving the preoperative planning of the complex revision arthroplasties. Materials and Methods. The study comprised 13 patients undergone revisions for implant instability in a regional orthopedic department using telemedicine differed advices including 11 hip and 2 knee arthroplasties. All patients had extensive bone defects. Results. In 12 cases, the surgeries were performed according to the recommendations from the expers of the Vreden National Medical Research Center of Traumatology and Orthopedics, St. Petersburg, Russian Federation. In one case, an individual system had been proposed as the main choice, but the preoperative plan was changed in favor of standard revision components. The short-term results of the surgeries were assessed as satisfactory. Conclusion. The use of modern information technologies for preoperative planning makes it possible to more accurately determine the indications for choosing implants. In particularly difficult cases, it becomes necessary to use individual implants. The right final choice depends on high-quality preoperative planning and effective interaction among medical hospitals of various levels.

Biomechanical evaluation of internal fixation implants for femoral neck fractures: A comparative finite element analysis

Background and ObjectiveIt remains controversial regarding the optimal type of fixation implant for the treatment of femoral neck fractures (FNFs). Biomechanical rational for implant choices can benefit from the integration of finite element analysis (FEA) in device evaluation and design improvement. In this study, we aim to evaluate biomechanical performance of several internal fixation implants for Pauwels type III FNFs under physiological loading conditions using FEA, as well as to assess the biomechanical contribution of medial buttress plate (MBP) augmentation. MethodsSeveral fixation styles for FNFs have been analyzed numerically by the finite element method. Five groups of models were developed with different FNFs fixation implants, including dynamic hip screw (DHS), cannulated screws (CSs), proximal femoral nail antirotation (PFNA), DHS with MBP augmentation (DHS+MBP), and CSs with MBP (CSs+MBP). For each group, four FE models were established to evaluate strain in bone and stress in devices during walking and stair climbing conditions, which simulated the hip contact force using static and dynamic loadings respectively. ResultsNo notable differences were observed in peak strain within implanted bone and maximum stress values of the device between DHS and CSs. The implanted femur with PFNA was in a lower state of bone strain and implant stress. Although the buttress plate did not decrease peak bone strain, it alleviated stress concentration on device, especially for CSs under dynamic loadings. ConclusionsCompared to the other fixation styles, the PFNA showed biomechanical advantages of decreasing risk of implant failure and bone yielding. The MBP augmentation provided an additional load path to bridge fracture fragments, which reduced failure risk of DHS and CSs, especially during dynamic loading scenarios. Although further studies are needed for patients with other types of FNFs, our findings may provide valuable references for device design optimization in terms of complex physiological loadings, as well as for clinical decision making in surgical treatment of FNFs.

Combined medial gastrocnemius and hemisoleus flap: a reproducible alternative for open tibial fractures complicated with large or double soft tissue defects.

Utilization of combined local muscle flaps for Gustilo type IIIB open tibial fractures has not been clearly delineated. We describe a combination of medial gastrocnemius and hemisoleus flaps for managing open tibial fractures accompanying large or double soft tissue defects. Twelve patients with Gustilo IIIB open fractures of the tibial shaft with large (9) or double (3) defects were operated on by fracture stabilization and combined medial gastrocnemius and hemisoleus flap coverage. Data were collected on types of implants, types of flaps, union time, postoperative complications, and Puno functional scores. Regarding implants for fixation, an intramedullary nail was used in three patients, plate and screws in five, combined plate and intramedullary nail in one, and definitive external fixation was used in three. Regarding soft tissue coverage, combined medial gastrocnemius and hemisoleus flaps were used in ten patients, combined hemigastrocnemius and hemisoleus in one, and combined medial gastrocnemius and reversed hemisoleus in one. All flaps survived, and all fractures were united with a mean union time of 19.7weeks (range 16-24). Tip necrosis of the hemisoleus flap occurred in two patients. Regarding Puno functional score, one was determined to be excellent, nine was good and two was fair. Combined medial gastrocnemius and hemisoleus flaps are reliable and effective for open tibial fractures complicated with large or double soft tissue defects.