Good Soft Tissue Coverage Research Articles

Erfahrungen und Ergebnisse mit der winkelstabilen Platte bei 603 Radiusfrakturen

Between January 1999 and December 2003 we have treated 603 patients with a fracture of the distal radius without concomitant injuries with the Synthes locked compression plate. The locked compression plate, the concept of the postoperative treatment, and our results are presented. In most cases we have used the palmar plate. We see an indication for the palmar plate in the A2 and A3, B2 and B3 and in all C fractures. It is also practicable for fractures with dorsal comminutions. Because of its permanent retention due to the subchondral fixation of the splints (internal fixation), this new plate makes early mobilization possible. The palmar approach with its good soft-tissue coverage not only reduces the risk of infections but also offers the possibility of not having to remove the plate. A cancellous bone graft is only seldom necessary.

Medial Gastrocnemius Flap in the Reconstruction of Infected Total Knee Arthroplasty

Purpose: To evaluate the results of the medial gastrocnemius muscle flap to cover the wound necrosis and dehiscence caused by repeated surgery in the reconstruction of infected total knee arthroplasty (TKA). Materials and Methods: Out of forty three reconstructions of infected TKA performed between 1995 and 2002, eleven cases (25.6%) underwent medial gastrocnemius flap to cover the anterior skin defects at the time of reimplantation in two cases and in an average 3.3 weeks after reimplantation in seven cases. Two cases which refused reimplantation were treated by arthrodesis and delayed flap coverage and by flap surgery only resulting in pseudarthrosis respectively. They were five male and six female patients of 61 years (range, 56-77 years) of age in average. Clinical and radiological assessments were done for minimum two years of follow-up. Results: Nine cases (81.8%) maintained TK prostheses with less range of motion (in average) than ordinary TKAs of primary healing. Two patients refused TKA which resulted in one arthrodesis and one pseudarthrosis. There was no case of recurrence of wound dehiscence or infection. Conclusion: Medial gastrocnemius flap can salvage the prostheses by providing good soft tissue coverage for compromised operative wounds caused by infected TKA and repeated surgical interventions.

Complications of forefoot and midfoot fractures.

Complications of the forefoot and midfoot are not as common as injuries to the hindfoot. The problem areas that the author will focus on with these injuries will be open injuries, unstable fractures, slow or poor healing fractures, and neurovascular injuries. The author also will discuss the toes, metatarsals, tarsometatarsal, cuneiforms, and talonavicular areas. Because the forefoot and midfoot must support as much as four times the body weight, alterations caused by injury to the weightbearing surface can have significant consequences. Treatment rationale to maintain a sound weightbearing plantar surface will be discussed. Each region will be highlighted with respect to the complications that can occur. Anatomic alignment with stable fixation and good soft tissue coverage in an appropriate rehabilitation program are the principles that should be followed and discussed.

Pyogenic vertebral osteomyelitis/disc infection

Spinal osteomyelitis has been known about for centuries. Granulomatous infection was the principal offender in the past, but nowadays, with an increased number of patients at 'risk', the proportion of pyogenic infections has risen. Awareness of this is the essence of early diagnosis. The advent of magnetic resonance imaging has proved a major milestone; with its high sensitivity and specificity, it is an essential part of the diagnostic work-up. The treatment of spinal osteomyelitis follows the same basic principles as for any infection. Once the diagnosis has been established, early conservative treatment is commenced. Debridement, drainage of any abscesses, spinal decompression and stabilization are options in surgical treatment. The successful use of metallic implants to achieve correction and stabilization is probably helped by good perfusion of the vertebral body and accompanying good soft tissue coverage. The eradication of infection is therefore still possible.

Reconstruction of skeletal defects in the forearm after trauma: treatment with cement spacer and delayed cancellous bone grafting.

Single forearm bone posttraumatic defects averaging 4 cm were successfully reconstructed by first using an antibiotic impregnated cement spacer followed by delayed cancellous bone grafting in three patients. A fourth patient, with a larger defect of 12 cm, had a satisfactory clinical result with this technique, but did not achieve a solid bony union. This method may be considered in contaminated segmental forearm defects amenable to traditional cancellous bone grafting. Thorough debridement, stable fixation, and good soft tissue coverage over the spacer are needed. For larger defects (> 6 cm), other treatment options may be more appropriate.

The use of muscle flaps for salvage of failed total knee arthroplasty

Deep infections occur in 1–5% of all patients undergoing total knee arthroplasty, and may result in failure of the prosthesis and subsequent arthrodesis. Two-stage reimplantation is often successful, but depends upon the presence of good soft tissue coverage. We have treated 9 patients in whom chronic infection developed which required removal of the prosthesis, debridement, and implantation of antibiotic impregnated spacers for control. These patients all had poor quality soft tissue cover precluding prosthesis reimplantation. The use of muscle flaps resulted in 7 of the 9 patients having successful reimplantation of a prosthesis and remaining free of infection in a follow-up ranging from 1–5 years.

Digital replantation at the level of the distal interphalangeal joint and the distal phalanx

Forty-two complete, single digit amputations at the level of the distal interphalangeal joint or distal phalanx are reviewed. Viability was 81%. Operative time averaged 4.6 hours. Average age of patients was 28 years and 90% were male. Forty-eight percent of the amputations involved the thumb; 79% were at the distal interphalangeal joint and 21% were more distal. One artery was repaired in 64% of replantations, two or three veins were repaired in 61%, and veins grafts were used in 19% of cases. Sixty-nine percent of the crush-avulsion injuries succeeded compared with 89% of lacerations. Two-point discrimination averaged 10 mm and proximal interphalangeal motion averaged 91 degrees. Patients returned to work an average of 2.5 months after replantation and none required additional procedures. The average total cost of treatment was $7500.00. Compared with conventional procedures, disadvantages of replantation at or distal to the distal interphalangeal joint are that it does require microsurgical training, initial operating time is longer, and it is more expensive. Advantages are that it is a one-stage procedure that gives good distal soft tissue coverage, adequate sensibility without painful neuroma, good metacarpophalangeal and proximal interphalangeal joint motion; it preserves the nail, maintains digit length, is cosmetically pleasing, and the patient is satisfied.

Vascularized Muscular and Musculocutaneous Flaps for Management of Osteomyelitis

Thirty-three cases of recalcitrant osteomyelitis treated by free tissue transfer are reviewed. The immediate success rate was 76 per cent; however, on follow-up for at least 1 year, there was a 12 per cent rate of recurrent drainage. The authors conclude that this is a good operation for this problem but that it is not a panacea because if followed long enough, a significant number of patients will develop recurrent drainage.

Late complications of peripheral arterial injuries.

THE MOST complete review of traumatic arterial injuries is that of DeBakey and Simeone,⁵who analyzed 2,471 cases from World War II. Hemorrhage, shock, distal ischemia, and infection were frequent early complications of injuries to major arteries. After the initial phase of the Korean War, care of arterial wounds improved with salvage of life and extremities.^13-16,32Civilian arterial injuries are often stab wounds, and when they are gunshot wounds are usually from weapons of low velocity, in comparison with those incurred in war. It has been emphasized that the principles of treating arterial injuries learned in Korea apply in civilian life.^22,31,37These include early treatment with control of hemorrhage, treatment of shock when present, adequate debridement of the wound including the injured artery, reconstruction of the vessel using accepted techniques, provision for good soft tissue coverage, and administration of appropriate antibiotics. Late complications of arterial injuries have