Inadequate Soft Tissue Coverage Research Articles

Applying 3D-printed prostheses to reconstruct critical-sized bone defects of tibial diaphysis (> 10 cm) caused by osteomyelitis and aseptic non-union

BackgroundClinical repair of critical-sized bone defects (CBDs) in the tibial diaphysis presents numerous challenges, including inadequate soft tissue coverage, limited blood supply, high load-bearing demands, and potential deformities. This study aimed to investigate the clinical feasibility and efficacy of employing 3D-printed prostheses for repairing CBDs exceeding 10 cm in the tibial diaphysis.MethodsThis retrospective study included 14 patients (11 males and 3 females) with an average age of 46.0 years. The etiologies of CBDs comprised chronic osteomyelitis (10 cases) and aseptic non-union (4 cases), with an average defect length of 16.9 cm. All patients underwent a two-stage surgical approach: (1) debridement, osteotomy, and cement spacer implantation; and (2) insertion of 3D-printed prostheses. The interval between the two stages ranged from 8 to 12 weeks, during which the 3D-printed prostheses and induced membranes were meticulously prepared. Subsequent to surgery, patients engaged in weight-bearing and functional exercises under specialized supervision. Follow-up assessments, including gross observation, imaging examinations, and administration of the Lower Extremity Functional Scale (LEFS), were conducted at 3, 6, and 12 months postoperatively, followed by annual evaluations thereafter.ResultsThe mean postoperative follow-up duration was 28.4 months, with an average waiting period between prosthesis implantation and weight-bearing of 10.4 days. At the latest follow-up, all patients demonstrated autonomous ambulation without assistance, and their LEFS scores exhibited a significant improvement compared to preoperative values (30.7 vs. 53.1, P < 0.001). Imaging assessments revealed progressive bone regeneration at the defect site, with new bone formation extending along the prosthesis. Complications included interlocking screw breakage in two patients, interlocking screw loosening in one patient, and nail breakage in another.ConclusionsUtilization of 3D-printed prostheses facilitates prompt restoration of CBDs in the tibial diaphysis, enabling early initiation of weight-bearing activities and recovery of ambulatory function. This efficacious surgical approach holds promise for practical application.

Functional outcomes of the knee and associated factors after intramedullary nailing of tibial diaphysial fractures at Addis Ababa Emergency, burn, and Trauma Hospital (AaEBT) hospital, Ethiopia

BackgroundTibial shaft fractures are the most common long bone fractures requiring treatment. High-energy trauma often causes tibia bone injuries, causing severe complications and long-term disability due to inadequate soft tissue coverage. Tibial shaft fractures can be treated using casts, external fixators, plating, or intramedullary nails. Intramural nailing leads to faster union and reduced complications like malunion and shortening. However, patients often report subjective and objective difficulties after Surgical Instrument generation network (SIGN) nail fixation, affecting knee range of motion, quality of life, and sport activities. Tibial nails and plates are associated with increased knee pain, which negatively affects functional outcomes. No study has been conducted in a poor resource setting like Ethiopia. This study aims to assess functional outcomes of the knee and associated factors after intramedullary nailing of Tibial Diaphysial Fractures at AaBET hospital in Ethiopia.MethodsA retrospective health facility based cross-sectional study was conducted on functional outcomes of the knee and associated factors after intramedullary nailing of tibial diaphysial fractures done at AaBET hospital. A medical record review form and a structured questionnaire from patient chart and SIGN nail database collected data. The study was conducted on 151 patients registered on the SIGN nail database using a simple random sampling. Knee injury and Osteoarthritis Outcome Score (KOOS) was used to assess the knee functional outcome. Descriptive statistics such as frequency and percentage were used to summarize the results and binary logistic regression was used to describe the association between variables. P value < 0.05 was considered statistically significant association.ResultsThe study constituted 151 patients with tibial shaft fractures; 113(74.8%) males and 38(25.2%) females with a mean age of 31.4 years, with a standard deviation of [10.5]. The prevalence of patients with good knee functional outcomes was 87(57.6%), while 64(42.4%) patients had poor knee functional outcomes. Associated factors identified include sex, age, soft tissue status, postoperative infection postoperative physiotherapy and comminuted fracture pattern.Conclusion and recommendation: This study determined the magnitude of knee functional outcomes revealed that more than half (57.6% ) of patients had good knee functional outcomes with identified factors increseaes odds of poor knee functional outcomes were sex, age, soft tissue injuries, post operative infection, postoperative physiotherapy and comminuted fracture patterns respectively. Therefore, Policymakers and health planners should closely monitor postoperative physiotherapy treatment courses among tibial shaft fractures treated with intramedullary nailing to increases good knee functional outcomes.

Open fractures of the hand: a new classification based on risk score to predict infection requiring re-debridement.

We developed a classification for open hand fractures based on risk score to predict the risk of infection requiring re-debridement. A total of 846 retrospectively included patients underwent multivariable analysis with backward elimination to derive the predictive risk score from independent predictors. The incidence of infection requiring re-debridement was 4%. Independent predictors include diabetes mellitus or immunocompromised condition, injuries from a bite, fractures with comminution/bone loss, neurovascular injuries and inadequate soft tissue coverage. The area under the receiver operating characteristic curve of the prediction score was 0.79. The new classification system for open hand fractures divides patients into three groups: low-risk open fractures (Type I, score <1); moderate-risk open fractures (Type II, score 1 to 2.5); and high-risk open fractures (Type III, score >2.5), based on the risk of infection requiring re-debridement. Re-debridement and delayed primary closure are suggested for type III open fractures.Level of evidence: III.

Transtibial Amputation with Fibulectomy and Fibular Collateral Ligament-Biceps Reconstruction: Surgical Technique and Clinical Experience.

To describe our clinical experience and surgical technique of transtibial amputation with fibulectomy and fibular collateral ligament-biceps reconstruction for management of, particularly short, transtibial amputations with proximal fibula prominence, overt instability, or inadequate soft tissue coverage. Retrospective review. Level II trauma center. Twelve consecutive patients who underwent transtibial amputation with fibulectomy and fibular collateral ligament-biceps reconstruction between 2008-2021. We reviewed patient medical records, radiographs, and clinical photographs. Complications, instability, pain. Eight patients underwent acute transtibial amputation with fibulectomy and reconstruction, whereas four patients underwent amputation revision with fibulectomy and reconstruction for chronic pain. All 12 patients were male, with a median age of 39 years [interquartile range (IQR), 33-46]. All injuries were due to high-energy mechanisms, including improvised explosive device (n=8), rocket propelled grenade (n=2), gunshot wound (n=1), and motor vehicle accident (n=1). After a median follow-up of 8.5 years (IQR, 3.4-9.3), there was one complication, a postoperative suture abscess. No patients had subjective lateral knee instability following the procedure and average pain scores decreased from 4.75 to 1.54 (p=0.01). All patients returned to regular prosthesis wear and maintained independent functioning with activities of daily living. Our experience with fibulectomy and fibular collateral ligament-biceps reconstruction demonstrated no subjective or clinical postoperative instability and may be a useful adjunct for managing transtibial amputations with fibular instability or prominence, pain, or skin breakdown at the fibular head. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Degree of Soft Tissue Injury is a Major Determinant of Successful Arterial Repair in the Extremity: A New Classification of Extremity Arterial Injury?

Background This study aimed to investigate outcomes after extremity arterial injury repair and examined the association between outcomes and the degree of soft tissue injury and vascular repair methods. Methods A retrospective study was conducted on 106 patients (108 cases) who underwent emergent microsurgical repair of extremity arterial injury due to trauma and non-perfusion of the affected extremity. The cases were divided into three groups by degree of associated soft tissue injuries: (A) adequate soft tissue coverage over the injured major vessels after radical debridement, (B) inadequate soft tissue coverage over the injured major vessels after radical debridement, and (C) radical debridement was not feasible due to unclear extent of injured soft tissue. Differences in vascular repair methods and outcomes among the three groups were analyzed. Results In Group A (n = 61), microvascular suture and vessel graft achieved 95.1% and 85.0% successful limb reperfusion, respectively. In Group B (n = 31), vessel reconstruction with flap coverage achieved 100% successful reperfusion. Vessel graft achieved 28.6% successful limb reperfusion, while there were no cases of successful reperfusion using microvascular sutures. In Group C (n = 16), no vascular repair method achieved successful reperfusion. There were significant differences among the three groups in successful reperfusion (p < 0.001) and limb salvage (p < 0.001). Conclusion The extent of associated soft tissue injury was associated with different vascular repair methods and outcomes. We propose a new system for classifying these injuries according to the degree of associated soft tissue injury.

Beyond Limb Salvage: Limb Restoration Efforts Following Remote Combat-Related Extremity Injuries Optimize Outcomes and Support Sustained Surgical Readiness.

As the combat operational tempo of the military conflicts in Iraq and Afghanistan has declined over the last decade, there has been a decrease in the number of patients requiring acute limb salvage. In their place, a growing population of patients with persistent functional deficits, pain, and inadequate soft tissue coverage stemming from prior limb salvage strategies have returned to our institution seeking revision surgery. Herein, we examine our institution's evolving surgical approach to extremity reconstruction from 2011 through 2019, culminating in the development of our limb restoration concept. We also discuss the impact of this orthoplastic approach on the acute management of complex extremity trauma and its role in providing sustained surgical readiness during interwar years. We retrospectively reviewed all limb reconstructive procedures performed at our tertiary care military treatment facility between September 1, 2011 to December 31, 2019 to characterize the trends in extremity reconstruction procedures performed at our institution. Cases were identified as limb restoration procedures if they involved secondary/revision reconstructive procedures designed to optimize function, treat pain, or improve the durability of the injured extremity following initial reconstruction efforts. Nearly 500 limb restoration procedures were performed during the study period. These procedures steadily increased since 2011, reaching a maximum of 120 in 2018. Orthoplastic procedures such as osseointegration, targeted muscle reinnervation, regenerative peripheral nerve interface, agonist-antagonist myoneural interface, and soft tissue resurfacing flap reconstruction accounted for the rise in secondary/revision reconstruction performed during this time period. Limb restoration is a collaborative orthoplastic approach that utilizes state-of-the-art surgical techniques for treating complex extremity trauma. Although limb restoration originally developed in response to managing the long-term sequelae of combat extremity trauma, the concept can be adapted to the acute management setting. Moreover, limb restoration provides military surgeons with a means for maintaining critical war-time surgical skills during the current low casualty rate era. Level of Evidence: V, therapeutic.

Nasal alar rim redraping method to prevent alar retraction in rhinoplasty for Asian men: A retrospective case series.

BackgroundFor an attractive and natural tip contour in Asian rhinoplasty, insertion of a nasal implant and reinforcement of the cartilaginous framework are essential. However, scar contracture, which often results from augmentation with implant insertion and inadequate soft tissue coverage of the framework, is one of the most common causes of alar retraction. This study reports a novel method of redraping soft tissue along the alar rim to prevent alar retraction in Asians.MethodsTwenty young Asian men who underwent primary rhinoplasty with septoplasty were retrospectively reviewed. After the usual rhinoplasty procedures, alar rim redraping was conducted for the soft tissue along the transcolumellar and bilateral infracartilaginous incisions. The longest axis of the nostril (a) and the height of the nostril from that axis (b) were measured in anterior-posterior and lateral views. The preoperative and postoperative ratios (b/a) were analyzed using the paired t-test.ResultsAll 20 patients showed natural contours of the nasal tip, nostrils, and alae after a mean follow-up of 53.6 weeks (range, 52–60 weeks). The ratio of the nostril axes significantly decreased postoperatively in all patients except one, by an average of 11.08%±6.52% in the anterior-posterior view and 17.74%±8.49% in the lateral view (P<0.01). There were no complications, including asymmetry, contracture, subdermal plexus injury, flap congestion, or infection.ConclusionsA quantitative analysis of alar retraction by evaluating the ratio of nostril axes showed that alar rim redraping is a simple and effective adjuvant technique for preventing alar retraction in rhinoplasty for young Asian men.

The Impact of Inadequate Soft-tissue Coverage following Severe Open Tibia Fractures in Tanzania.

Background:Managing lower extremity fractures complicated by large soft-tissue defects is challenging for surgeons in low- and middle-income countries, and long-term quality of life (QOL) for these patients is unclear.Methods:We examined QOL, surgical complications, and longitudinal outcomes in 10 patients with Gustilo-Anderson Classification Type IIIB open tibia fractures seen at an orthopedic institute in Tanzania, from December 2015 to March 2017. Patients completed follow-up at 2-, 6-, 12-, 26-, and 52-week time points, and returned for qualitative interviews at 2.5 years. The primary outcome was QOL, as measured using EuroQoL-5D scores and qualitative semi-structured interview responses. The secondary outcome was rate of complication, as defined by reoperation for deep infection or nonunion.Results:Ten patients enrolled in the study and 7 completed 1-year follow-up. All fractures were caused by road traffic accidents and treated by external fixation. No patients received initial soft-tissue (flap) coverage of the wound. All patients developed an infected nonunion. No patients returned to work at 6 weeks, 3 months, or 6 months. EQ-5D index scores at 1 year were poor (0.71 ± 0.09). Interview themes included ongoing medical complications, loss of employment, reduced income, and difficulty with activities of daily living.Conclusions:Patients in low- and middle-income countries with IIIB open tibia fractures not treated with appropriate soft-tissue coverage experience poor QOL, high complication rates, and severe socioeconomic effects as a result of their injuries. These findings illustrate the need for resources and training to build capacity for extremity soft-tissue reconstruction in LMICs.

Novel technique to manage pacemaker exposure with buried flap reconstruction: case series

ObjectiveExposure of implantable electrical devices may increase morbidity and mortality significantly. Usually superficial infections are conservatively managed whereas invasive infections necessitate complete capsulectomy, sub-pectoral placement or implant exchange. Most commonly...

Curative effect of vancomycin-loaded calcium sulfate for one-stage treatment of chronic osteomyelitis

Objective To observe the effect of vancomycin-loaded calcium sulfate for one-stage treatment of chronic osteomyelitis. Methods A retrospective case series study was made on 26 patients with chronic osteomyelitis treated from January 2014 to April 2016. There were 23 males and 3 females, with a mean age of 35.8 years (range, 16-90 years). After focus debridement of osteomyelitis, the cavities were filled with vancomycin-loaded calcium sulfate and systemic antibiotics were used. Meanwhile, gentamicin was added to patients showing unclear pathogens. Three patients underwent flap transfer surgery simultaneously due to the inadequate soft tissue coverage. Wound healing, local redness and swelling, sinus recurrence, recovery of osteomyelitis and repair of bone defect were detected after operation. Results All patients were followed up for 6-30 months (mean, 19.5 months). Primary healing was achieved in all patients. One patient experienced wound exudate and was effectively managed by dressing change, one patient experienced inadequate local soft tissue coverage and was effectively managed by a second flap transfer surgery, and one patient remained wound unhealing after two surgeries and was cured by infected bone resection using the Masquelet induced membrane technique. Follow-up showed local bone defect was repaired in all patients without bone infection recurrence. Conclusions For patients with chronic osteomyelitis, one-stage surgery with vancomycin-loaded calcium sulfate can control infection with simultaneous repair of bone defect. Therefore, the procedure is a simple and effective method and worthy of clinical practice. Key words: Calcium sulfate; Vancomycin; Chronic steomyelitis

Free-Flap Transfer for Coverage of Transmetatarsal Amputation Stump to Preserve Residual Foot Length.

Surgical management of soft-tissue defects of the forefoot and midfoot caused by trauma or diabetic complications can be challenging because locoregional tissue is insufficient to provide adequate flap. This deficiency necessitates higher-level amputations, such as Chopart or even transtibial amputation, resulting in far more debilitating functional outcomes than are seen with partial foot amputation. The purpose of this study was to examine the surgical outcomes after transmetatarsal amputation and a free-flap transfer to preserve foot length. This prospective case series was conducted from January 2011 to December 2015 at the Department of Plastic and Reconstructive Surgery at our institute. A total of 16 patients (11 men and 5 women) were enrolled in this study, all of whom were candidates for higher-level amputation because of inadequate soft-tissue coverage after debridement. Each patient underwent transmetatarsal amputation and reconstruction of the amputation stump using free-flap transfers to preserve foot length. Preoperative and postoperative data were collected to evaluate the postoperative outcomes. All 16 free-flap transfers were successful, with no major complications. In 2 cases, partial flap necrosis required additional skin grafting. The mean follow-up period was 24.3 months (range = 7-55 months). Flap coverage was stable, and all the patients were comfortable with their prostheses at long-term follow-up. Use of a free flap to reconstruct a transmetatarsal amputation stump provided stable coverage, preserved maximal foot length, and resulted in good functional outcomes.

Minimizing osteoradionecrosis after mandibular reconstruction and radiation in advanced head and neck cancer patients.

Osteoradionecrosis may develop on the residual mandible or reconstructed fibula because of inadequate soft tissue coverage and compromised tissue perfusion post mandibular reconstruction, and radiation. This study was to investigate the incidence of osteoradionecrosis following class III mandibular defect reconstructions with an OPAC flap versus a fibula OSC flap. A retrospective review of a consecutive series of mandibular reconstructions between 1999 and 2010 was performed. Mandibular defects and corresponding flap types were analyzed with emphasis on outcome, complications, and rates of osteoradionecrosis among the two subgroups. A total of 121 fibula flaps were performed, consisting of 53 OPAC and 68 fibula OSC flaps. Complications trended higher for OPAC flaps in partial and total flap loss rates as well as venous congestion when compared with the OSC flap cohort. The OPAC group had statistically significant lower rates of osteoradionecrosis and plate exposure than the OSC group (P = 0.04). The OPAC flap may be preferable to fibula OSC flap in mandibular reconstruction given its lower rates of osteoradionecrosis and plate exposure. This flap type may be the flap of choice for class III defects where additional vascularized tissue may be critical for addressing significant soft tissue deficiency. J. Surg. Oncol. 2016;114:399-404. © 2016 Wiley Periodicals, Inc.

Management of infection following reconstruction in bone tumors.

Limb salvage surgery in bone tumors has evolved in recent years and includes all of the surgical procedures designed to accomplish removal of a malignant tumor and reconstruction of the limb with an acceptable oncologic, functional, and cosmetic result. This dramatic change came about as the result of three important developments, i.e. effective chemotherapy, improved precision imaging techniques and advances in reconstructive surgery. Reconstruction with a modular custom-made oncological endoprosthesis (megaprosthesis) has become a common procedure nowadays. These large foreign bodies make infection a common and feared complication. However, the occurrence of complications may be multifactorial, including a poor nutritional and compromised immune status due to chemotherapy and/or radiotherapy, a lengthy operation, extensive dissection and resection of soft tissues, inadequate soft-tissue coverage, a longer exposure of the wound resulting in infection, etc. Management of postoperative infection in these cases remains a challenge. This article analyses the current literature available for these cases and summarizes the cause and different available methods of treatment.

Application of the Orthoplastic Reconstructive Ladder to Preserve Lower Extremity Amputation Length

A primary goal in traumatic lower extremity amputation management is preservation of limb length. Energy expenditure during ambulation directly correlates with residual limb length, preserved limb segments, and stable joint preservation. An additional factor affecting limb function includes achieving adequate residual limb soft tissue coverage. This report describes techniques for achieving a stable soft tissue envelope to facilitate limb length and joint preservation. A series of traumatic amputation cases with inadequate soft tissue coverage are reviewed. Concepts from the reconstructive surgery ladder were used to achieve residual limb soft tissue coverage and to preserve lower extremity amputation length. Soft tissue coverage was accomplished through a series of methods including delayed primary closure with assistance from an external tissue expander, use of acellular dermal regenerative templates combined with split-thickness skin grafting and negative-pressure wound therapy, use of biologic scaffolds such as extracellular porcine urinary bladder matrix combined with delayed skin grafting, and local pedicle flaps or adjacent tissue rearrangements and free tissue transfers. The preservation of residual limb length in lower extremity amputations is crucial to optimize prosthetic fitting and to obtain the maximal functional outcome. A series of cases are presented that outline soft tissue coverage options for preserving maximal residual limb length. Applying various concepts from the reconstructive ladder may allow for viable soft tissue coverage to maximize functional outcome.

One‐stage Versus Two‐stage Exchange

Liaison: Paul Lichstein MD, MSLeaders: Thorsten Gehrke MD (International), Adolph Lombardi MD, FACS (US), Carlo RomanoMD (International), Ian Stockley MB, ChB, MD, FRCS (International)Delegates: George Babis MD, Jerzy Bialecki MD, La´szlo´ Bucsi MD, Xu Cai MD, Li Cao MD, Briande Beaubien MD, Johannes Erhardt MD, Stuart Goodman MD, PhD, FRCSC, FACS, FBSE,William Jiranek MD, Peter Keogh, David Lewallen MD, MS, Paul Manner MD, WojciechMarczynski MD, J. Bohannon Mason MD, Kevin Mulhall MB, MCh, FRCSI, Wayne PaproskyMD, Preetesh Patel MD, Francisco Piccaluga MD, Gregory Polkowski MD, Luis Pulido MD, IanStockley MBBS, ChB, FRCS, Juan Suarez MD, Fritz Thorey MD, Rashid Tikhilov MD, JobDiego Velazquez MD, Heinz Winkler MD

Use of a Continuous External Tissue Expander in the Conversion of a Type IIIB Fracture to a Type IIIA Fracture

Various methods have been used for soft tissue coverage of Gustilo-Anderson type IIIB open fractures. These injuries are often contaminated and, by definition, are associated with extensive periosteal stripping and inadequate soft tissue coverage. These characteristics predispose the patient to infection, delayed union, nonunion, and the likelihood of multiple surgeries to achieve durable soft tissue coverage. Although free tissue transfer and rotational flap coverage are the mainstay of treatment for Gustilo-Anderson type IIIB fractures, these procedures typically require additional modalities, such as local wound care, negative-pressure wound therapy, and skin grafting, to expedite wound coverage. Numerous undesirable aspects of these tissue coverage techniques exist, including the requirement for repeated application, potential anesthesia complications, near-constant surveillance, patient compliance, graft failure, and cost. External tissue expanders offer the surgeon a device that can rapidly facilitate closure of full-thickness soft tissue defects. This technique offers the benefit of a 1-time application that is easy to apply and cost-effective and can significantly improve fracture coverage options with a cosmetically acceptable result. Although this technique has been previously described for fasciotomy and ulcer coverage, to the authors' knowledge, continuous external expansion has never been reported in open fracture wound management, specifically in converting type IIIB to type IIIA open fractures. The authors' early success with this method indicates that it may be a valuable tool in the management of Gustilo-Anderson type IIIB open fractures.

Schraubenarthrodese der Schulter

The aim of the procedure is arthrodesis of the shoulder by osteosynthesis of the glenohumeral and the acromiohumeral joint each with three screws, which results in preservation of scapulothoracic motion and pain relief. Traumatic brachial plexus lesions, palsy in infancy, poliomyelitis with preserved or restorable function of the elbow and the hand. Paralysis of the deltoid muscle and the rotator cuff. Nonrestorable vast defect of the rotator cuff with pseudoparalysis. Chronic infectious arthritis resistant to therapy. Unsuccessful attempts to treat glenohumeral instability. Alternative procedure to shoulder arthroplasty in young patients with omarthrosis, who perform hard physical work. Insufficient strength of the scapular muscles (< grade4, <75% of normal strength). Insufficient scapulothoracic passive motion. Inadequate soft tissue coverage after burns, excessive previous surgery or radiotherapy. Incomplete rehabilitation (<3years) after neurosurgical interventions (neurolysis, nerve transplantation). Cases of resection of the proximal humerus. Acampsia of the shoulder joint in 20° of abduction, 30° of anteversion, and 40° of internal rotation using three glenohumeral and three acromiohumeral spongiosa screws as a compression arthrodesis. Thorax-arm-abduction splint (20° of abduction, 30° of anteversion, and 40° of internal rotation) until the week6 postoperatively with removal for physiotherapy and personal hygiene. Assisted active and passive motion exercises for the elbow, hand, and fingers after the postoperative day1. Weaning from the splint after the end of the week6 postoperatively, full range of motion allowed. In a prospective study from January 2007 to September 2008, 4patients with a medium age of 35.7years underwent screw arthrodesis of the shoulder with a follow-up of 1.0 (0.6-1.5)year. Primary fusion of all arthrodesis surfaces was achieved in all patients; no revision surgery was necessary. All patients improved in shoulder function with an average range of motion of 60° abduction and 40° anteversion.

Surgical Difficulties Encountered With Use of Modular Endoprosthesis for Limb Preserving Salvage of Failed Allograft Reconstruction After Malignant Tumor Resection

We reviewed outcomes and discussed surgical difficulties encountered in 10 patients who had modular endoprosthesis for limb preserving salvage of failed allograft reconstruction after malignant tumor resection. Mean allograft survival time before failure was 127.4 months (range, 14-264 months). Mean length of follow-up since endoprosthesis revision surgery was 62.8 months (range, 16-132 months). There was one endoprosthesis failure, resulting in a mean endoprosthesis survival time of 56.9 months (range, 16-132). Complications included arterial laceration, nerve injury, periprosthetic crack fracture, aseptic loosening, and infection. Modular endoprosthesis remain a viable option that should be considered in any limb preserving salvage of failed allograft reconstructions. However, altered anatomy, poor/short remnant host bone, periprosthetic fractures, inadequate soft tissue coverage and infection remain important difficulties encountered.

Effect of Recombinant Factor VIIa as an Adjunctive Therapy in Damage Control for Wartime Vascular Injuries: A Case Control Study

Military casualties with vascular injuries often present with severe acidosis and coagulopathy that can negatively influence limb salvage decisions. We previously reported the value of a damage control resuscitation (DCR) strategy that can correct physiologic shock during simultaneous vascular reconstruction. The effect of recombinant factor VIIa (rFVIIa) on the repair of injured vessels and vascular grafts when used as an adjunctive therapy during DCR is unclear in the setting of wartime vascular injuries. The primary aim of this study was to assess the effect of rFVIIa use during DCR for vascular trauma and the impact on vessel repair. A retrospective two cohort case control study was performed using the Joint Theater Trauma Registry to identify patients with major vascular injury and DCR. Group 1 (n = 12) had DCR and repair of the injured vessels. Group 2 (n = 41) included early rFVIIa as an adjunctive therapy with DCR to control bleeding and perform simultaneous vascular reconstruction. Age, injury severity score, presenting physiology, and operative time were similar between groups. Postoperative data show that early physiologic recovery from acidosis, coagulopathy, and anemia was associated with rFVIIa and DCR. Extremity graft failures in groups 1 and 2 (follow-up range, 10-26 months) were either from early thrombosis (1 vs. 5 p = 1), graft dehiscence (1 vs. 2 p = 0.55), or infection (1 vs. 1 p = 0.41) and were the result of inadequate soft tissue coverage or technical factors that eventually resulted in eight (15%) amputations. All cause mortality (group 1: 0% vs. group 2: 7.3%, p = 1) and amputation rates (group 1: 25% vs. groups 2: 12.2%, p = 0.36) were similar between the two groups. DCR using rFVIIa is effective for controlling hemorrhage and reversing coagulopathy for severe vascular injuries. Early graft failures seem unrelated to rFVIIa use in the setting of wartime vascular injuries. No differences in amputation rate or mortality were seen. Although rFVIIa may be a useful damage control adjunct during vessel repair, the overall impact of this strategy on long-term outcomes such as mortality and limb salvage remains to be determined.

Gustilo Grade IIIB Tibial Fractures Requiring Microvascular Free Flaps

Gustilo IIIB fractures involve high-energy tibial fractures for which there is inadequate soft tissue coverage. In addition to orthopedic fixation, these injuries require soft tissue reconstruction, often in the form of a microvascular free flap. Although the majority of orthopedic literature favorably compares intramedullary rod fixation to external fixation in open tibial fractures, these studies have not focused on the role of either method of fixation in relation to the soft tissue reconstruction. Because we had noted numerous complications after providing free-flap coverage over intramedullary rodded fractures, we sought to investigate whether there were differences in outcomes between free flap-covered lower-extremity fractures which were fixated by external fixation versus intramedullary rods. A retrospective chart review was performed on all patients in our institution who had lower-extremity free flaps for coverage of Gustilo IIIB fractures from 1995-2005 in relation to the type of bony fixation. Of the 38 patients studied, 18 underwent external fixation of the tibial fracture, and 20 had intramedullary rodding. Overall flap survival was 95%, with 1 failure in each group. However, the intramedullary rod group had higher incidences of wound infection, osteomyelitis, and bony nonunion (25%, 25%, and 40%, respectively) than the external fixation group (6%, 11%, 17%, respectively). For Gustilo IIIB fractures that require free-flap coverage, the added bony and soft tissue manipulation required for intramedullary rodding may disrupt the surrounding blood supply and lead to higher rates of complications that threaten the overall success of the reconstruction. Plastic and orthopedic surgeons should discuss the optimal method of bony fixation for complex tibial fractures when a free flap will likely be needed for soft tissue coverage. This integrated team approach may help minimize complications.