Donor Site Pain Research Articles

Anterior cervical discectomy and fusion using interbody cage packed with autologous clavicle bone Graft: Novel technique

ObjectivesThe aim of this study is to assess the fusion power, donor site pain, patient satisfaction and safety of autologous cancellous clavicle bone graft in ACDF. Summary of Background DataTraditional autologous iliac graft was the most popular graft done for ACDF, however seeking for better outcomes for patients and avoiding extensive bony loss with its sequences of postoperative pain had raised our concern to use autologous clavicle cancellous graft as an alternative. MethodsBetween May 2016 and August 2020, 72 patients indicated for anterior cervical discectomy and fusion (ACDF), 33 males and 39 females, ranging in age from 30 years to 70 years, were divided into 2 groups, group A included 36 patients operated upon with traditional way with bone harvested from iliac crest, group B included 36 patients operated upon using cancellous bone harvested from clavicle. History of patients, clinical status and radiological data were registered. We used VAS scores; patient satisfaction and ODI to assess clinical outcomes in both groups with a period of one year follow up. ResultsIn all patients fusion was 0%, 25%, and 100% in 1 month, 3 months and 6 months of radiological follow up respectively. VAS pain score of donor site was zero at 1 month postoperative in all patients of clavicle group while only 27 patients of iliac group reached zero 6 months postoperative. ConclusionACDF with autologous clavicle cancellous bone graft has the advantage of reducing donor-site morbidities and complications; it reaches an excellent level of fusion and patient satisfaction with postoperative donor site pain, healing and cosmetically.

Pain management with popliteal block for fibular graft harvesting in head and neck reconstruction; a randomised double-blind placebo-controlled study

Background and objectivesCurative treatment for locally advanced head and neck tumours often includes reconstructive surgery using a microvascular free flap. Effective recuperation is essential but may be impeded by postoperative donor site pain. The aim of this study was to evaluate the effects of a continuous popliteal block on postoperative pain after fibular graft harvesting. Material and methodsIn this randomized double-blind placebo-controlled study adult patients scheduled for reconstructive head and neck surgery with a microvascular free fibular graft received an indwelling popliteal nerve block catheter and were randomized to receive continuous levobupivacaine/ropivacaine or placebo during the first postoperative week. Primary outcome was postoperative extremity pain assessed using the numerated rating scale (NRS). Secondary outcomes included opioid consumption. ResultsIn total 24 patients were included. The median (median, IQR [range]) postoperative extremity NRS scores was lower in the local anaesthetic (LA) group (2, 0–3 [0–10]) compared to the placebo group (2, 1–4 [0–10]), p = 0.008. The LA group also experienced fewer episodes of breakthrough pain, defined as NRS ≥ 4 (17% vs 33% of observations), p = 0.009. Furthermore, median (median, IQR [range]) opioid consumption the first postoperative week was lower in the LA group (109 mg, 74–134 [19–611]) compared to the placebo group (202 mg, 135–241 [78–749]), p = 0.010. No complications attributed to the blocks were observed. ConclusionContinuous popliteal block significantly reduced postoperative extremity pain and opioid consumption in patients undergoing fibular graft harvesting for head and neck reconstructive surgery.

29 Efficacy of a Novel LAM Femoral Cutaneous Block Technique for Acute Donor Site Pain

IntroductionPatients with severe burn injuries often require split thickness skin grafting to expedite would healing with the thigh being a common donor site. Uncontrolled pain is associated with increased opioid consumption, longer lengths of stay, and delay in functional recovery. Regional nerve blocks are increasing in popularity although supportive literature is limited, and techniques vary. Recently, we presented a case demonstrating a novel LAM (lateral, anterior, medial) femoral cutaneous block technique. The purpose of the case series is to assess the safety, feasibility, and clinical efficacy in a larger cohort.MethodsThe study was a dual IRB approved, observational case series from a single verified burn center. The electronic health record was retrospectively reviewed for patients admitted between June 2018 to June 2020 who had the LAM block placed for donor site pain by the acute pain service (APS) team. Patient demographics, and data pertinent to the LAM regional anesthesia block were collected (eg opioid usage before and after the block, pain, and physical therapy outcomes). The data were tabulated and analyzed using Microsoft Excel© and SPSS version 27.0. Descriptive statistics were utilized to describe the patient demographics and LAM block feasibility & safety. Morphine Milligram Equivalent (MME) were statistically compared utilizing repeated measures ANOVA on ranks and graphically presented.ResultsTwenty-four patients had total of 27 blocks placed, where 3 patients received the LAM block on two separate occasions. One patient had bilateral LAM blocks placed and was included as the single instance for the analysis. The majority were Caucasian males, but mechanism of injury varied. Two-thirds had a neurologic or psychiatric history. Seventy-one percent used tobacco and a quarter had a history of polysubstance abuse. Median area of the donor site was 360 cm2 (207, 1140). Median day from admission to LAM was 8 (3, 12) with a median duration of 4 (3, 5) days. Median day until first ambulation after LAM was 3 (1,3). Eighty percent reported a decreased temperature sensation at the donor site. Pain was adequately controlled, and there were no adverse events or quadricep weakness noted. There was a significant reduction in MME after block placement (Figure 1).ConclusionsRegional nerve blocks offer an advantageous means of analgesia, while reducing potential adverse events associated with opioids. While the novel LAM technique reduced some sensation, early ambulation was not inhibited and patients able to participate with rehabilitation therapy.

31 Regional Anesthesia for Reducing Postoperative Opioid Use in Split Thickness Skin Grafting

IntroductionSplit thickness skin grafting is ubiquitous in the management of acute burns and burn reconstruction. Patients describe the resulting partial-thickness donor site wound as one of the most painful aspects of burn care. Managing donor site pain is challenging and frequently involves potent opioid regimens. Rapid reepithelization of the donor site makes long-acting local and regional anesthesia an attractive option for reducing opioid use. This study aims to determine the efficacy of graft donor site regional anesthesia at reducing postoperative opioid consumption in burn patients.MethodsA retrospective review of burn patients undergoing split-thickness skin grafting at our institution was performed. Patient demographics, burn mechanism, and percent burned total body surface area were collected. The type of regional anesthesia, when it was performed, and the anesthetic agents used were also determined. Milligram morphine equivalents (MME) were calculated for three 24-hour periods postoperatively to quantify opioid usage. The total MME in 72h postoperatively was also determined and used to calculate per day MME requirements. Mean, and peak pain scores in the first 24h postoperatively were collected. Univariate and multivariate analyses were performed to determine the efficacy of regional anesthesia.ResultsTwenty-five patients were identified, 14 who received donor site regional anesthesia and 11 who did not. The two groups did not differ significantly in age, gender, race, BMI, or burn mechanism. The regional anesthesia group had a significantly lower percent burned TBSA (5.3 vs. 21.6, p < 0.001). Still, donor site dimensions did not differ significantly between groups (363 cm2 vs. 411 cm2, p = 0.247). The use of regional anesthesia was associated with significantly lower MME requirements in the first 24h postoperatively (22.5 vs. 84.9, p = 0.023), lower total requirements after 72h (47.3 vs. 147.8, p = 0.016), and lower per day requirements (17.6 vs., 51, p = 0.014). The regional anesthesia group was discharged on average one week sooner (5.1 days vs. 12.4 days, p = 0.031). Multivariate analysis demonstrated the use of regional anesthesia independently predicted decreasing MME requirements in the first 24h after surgery, decreasing MME requirements in total, and decreasing per day MME requirements. No patients experienced anesthesia-related complications.ConclusionsIn a cohort of burn patients undergoing split-thickness skin grafting, the use of regional anesthesia was highly effective at reducing opioid requirements in the immediate postoperative period. We believe regional anesthetic blockades should be considered to provide long-lasting donor site analgesia. More investigation is warranted into ideal anesthetic agents, the maximum donor site dimensions, and the extent of cost savings.

Anterior debridement, bone grafting and fixation for cervical spine tuberculosis: an iliac bone graft versus a structural manubrium graft

BackgroundAnterior debridement, decompression, bone grafting, and instrumentation are safe and effective techniques for patients with lower cervical spine tuberculosis. However, there is no consensus regarding the methods for using autogenous bone grafts. The purpose of this retrospective study was to compare the clinical outcomes of anterior surgical management for cervical spine tuberculosis by using an iliac bone graft versus a structural manubrium graft.MethodsFrom January 2009 to September 2018, 23 patients with cervical spine tuberculosis were treated with anterior debridement, autogenous structural bone grafting and fixation at our spinal department. The patients were divided into 2 groups according to the different graft materials, namely, iliac crest bone grafts (Group A) and structural manubrium grafts (Group B). The clinical and radiographic results of the 2 groups were analyzed and compared.ResultsThe mean duration of follow-up was 24 months. Bony fusion was achieved in all patients without failure of internal fixation. There were no significant differences between the two groups with respect to the operation time, blood loss, fusion time, neurological outcomes, or postoperative local Cobb angle (P > .05). However, the donor site complication rate in Group A was greater than that in Group B. The postoperative ambulation time in Group A was later than that in Group B. The mean visual analog scale (VAS) score for donor site pain in Group A was higher than that in Group B at 1 week after surgery (P < 0.05). However, there was no significant difference between the 2 groups at the last visit (P > .05).ConclusionBoth iliac bone grafts and sternal manubrium grafts can effectively reconstruct anterior column defects in anterior surgery. However, structural sternal manubrium autografts cause fewer complications associated with donor site morbidities than iliac bone grafts.

Persistent Postsurgical Pain in Oral Cancer Patients Reconstructed with Anterolateral Thigh Free Flap.

Background and Objectives: The anterolateral thigh (ALT) flap is widely used in head and neck reconstruction, but the postoperative thigh sensory function lacks sufficient evaluation. The present study reports the postsurgical pain and cancer-related quality of life (QoL) in different stages of oral cancer patients receiving anterolateral thigh (ALT) flap reconstruction. Materials and Methods: Patients were subgrouped into postoperative early-, mid-, and late-recovery stages (postoperative 0.5–1 years, 1–2 years, and above 2 years) according to the time point of assessment. The QoL was examined using the EORTC C-30. Postsurgical donor and receipt site pain was evaluated through subjective reports and sensory tests. Results: Ninety-four patients were included in the final analysis. The functional and global health-related QoL significantly improved with time after surgery. However, spontaneous pain was reported in 57.7%, 72.3%, and 42% of patients in early-, mid-, and late-recovery stages, mainly in donor sites rather than in receipt sites. The highest incidence of donor site pain after ALT flap reconstruction in oral cancer surgery was in the mid-recovery stage but remained high in the late-recovery stage (56.8% and 36.7%, respectively). Conclusions: The postsurgical pain in the donor site might persist to or exhibit delayed onset one to two years postoperatively but is much improved after postoperatively two years later. A longer postsurgical follow-up for over two years for pain and sensory dysfunction is indicated.

Iliac Crest Bone Graft Harvesting: Modified Technique for Reduction of Complications.

bone grafting; complications; iliac crest; pain.

Quantification and Further Refinement of Lateral Calcaneal Artery Flap for Complicated Heel Defect Reconstruction.

Background:Reconstruction of posterior heel defects requires tissues with adequate blood supply, good elasticity, and sensate; because of the traumatic origin in the young population, it ends up with morbidity. The lateral calcaneal artery is the arterial supply of the lateral calcaneal artery flap. This is one of the viable choices for coverage of hind foot soft-tissue defects. The objective of this study was to determine the outcome of the lateral calcaneal artery flap in terms of function, donor site morbidity, and duration of surgery.Method:This was a descriptive case series. Patients with complicated heel defects of small to medium size were included. The follow-up period was 6 months to 1 year of posttreatment. Outcome measures were noted and assessed in all patients in terms of function, donor area morbidity, and total duration of surgery. Significance was determined by assessing the gait, donor site pain, physical appearance at the surgical site, and time needed for surgery.Results:Twelve patients [men: eight (62.5%), women: four (37.5%)] were selected for this study, with their mean age being 14.4 ± 7.4 years. Mean defect size was (4.4 ± 0.5) cm. Mean flap size was 3.5–5.5 cm (P < 0.001). There was a near-normal gait in all patients, with a pain score of (0–2) on the visual analogue scale score, physical appearance by Vancouver scar scale score (0–3), and the mean duration of surgery was 45 ± 4.5 minutes.Conclusion:The lateral calcaneal artery flap is more effective for reconstruction of posterior heel and tendon Achilles defects in terms of function, donor area morbidity, and duration of surgery.

Osteochondral autograft transplantation in the treatment of AO/OTA type C3 tibial plafond fractures with irreducibly comminuted area and/or cartilage delamination in the distal tibial facet

IntroductionTibial plafond fractures, especially the AO/OTA type C3 ones that take place in young patients with excessive facet fragmentation and cartilage loss that preclude anatomical reduction and effective internal fixation, are devastating situations that often subject to primary arthrodesis. The aim of the current study is to introduce a joint preserving technique by using osteochondral autograft to treat such difficult cases and to evaluate its short-term outcome. MethodsA total of 11 patients suffering AO-OTA type C3 tibial plafond fractures with irreparable area treated with osteochondral autograft and ORIF, with an average follow-up period of 34 months, were analyzed. Visual analogue scale (VAS), short-form 36 (SF-36), American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score, and ankle range of motion (ROM) were assessed for functional outcome evaluation. The weight-bearing AP and lateral radiograph, as well as CT reconstructive images were examined to evaluate bony union and the occurrence of post-traumatic arthritis. ResultsAt the final follow-up, the mean VAS scale was 2.2. The mean AOFAS and SF-36 scores were 86.3 and 84.5 respectively. Among all the included patients, 8 achieved both AOFAS and SF-36 scores above 80. The average ankle range of motion was 29.9°. No infection, compartment syndrome, post-traumatic arthrosis or donor site pain was noted in the current study. No patient received secondary ankle arthrodesis at the end of the follow-up. ConclusionsAlthough primary ankle arthrodesis is an effective method, routine ankle arthrodesis should be carried out with second thoughts in patients, especially patients with relatively young age, suffering AO-OTA type C3 tibial plafond fractures with irreducible area. On the other hand, osteochondral autograft transplantation may provide a chance to relieve pain without sacrificing the joint.

Anterior Cervical Discectomy and Fusion (ACDF) with Stabilization by cervical locking plate and screw in traumatic sub-axial incomplete cervical spine injury: Early experience

Introduction: Cervical spine injuries represent 2 to 6% of adult blunt trauma, and one third of all spinal injuries. Anterior approach of operative management of cervical spinal injury with incomplete neurological lesion has least analyzed in our settings, the present study has been designed to evaluate the outcome of ACDF and stabilization by cervical plate and screw for managing traumatic cervical spine injury with incomplete neurological deficit.Methods: This study was conducted at NITOR, Dhaka, from July 2016 to June 2018.Twenty available patients meeting the inclusion & exclusion criteria were included. All cases were properly evaluated pre-operatively and underwent ACDF & stabilization with cervical plate and screws. Follow up was done for 5 to 12 months. The final assessment was done by ASIA impairment scale, MRC grading, Bridewell fusion grade, Denis work & pain scale and modified Odom’s criteria.Results: Highest number of patients 10 (50%) were in ASIA grade B, 7(35.0%) patients were in ASIA grade D and 3(15.0%) patients were in ASIA grade C on admission. But in last follow up, highest number of patients were in ASIA grade E (45%). The ASIA grade has improved 1 grade in 55% cases. Bridewell fusion grade showed anterior fusion grade I in 55% of cases, grade II in 45% cases. 60% of cases were in W2 group of Denis work scale after last follow up. Early post-operative complications were dysphagia (20%), respiratory distress (5%) and neck pain (20%). Late post-operative complications were neck pain (10%), donor site pain (5%) and bed sore (5%). According to modified Odom’s criteria, 65% of the cases were found excellent.Conclusion: On the basis of the results in this study, it can be said that anterior cervical decompression, stabilization and fusion by bone graft of the patients who have traumatic unstable cervical spine injury with incomplete neurological lesion will provide effective benefit.

Human-engineered auricular reconstruction (hEAR) by 3D-printed molding with human-derived auricular and costal chondrocytes and adipose-derived mesenchymal stem cells

Microtia is a small, malformed external ear, which occurs at an incidence of 1–10 per 10 000 births. Autologous reconstruction using costal cartilage is the most widely accepted surgical microtia repair technique. Yet, the method involves donor-site pain and discomfort and relies on the artistic skill of the surgeon to create an aesthetic ear. This study employed novel tissue engineering techniques to overcome these limitations by developing a clinical-grade, 3D-printed biodegradable auricle scaffold that formed stable, custom-made neocartilage implants. The unique scaffold design combined strategically reinforced areas to maintain the complex topography of the outer ear and micropores to allow cell adhesion for the effective production of stable cartilage. The auricle construct was computed tomography (CT) scan-based composed of a 3D-printed clinical-grade polycaprolactone scaffold loaded with patient‐derived chondrocytes produced from either auricular cartilage or costal cartilage biopsies combined with adipose-derived mesenchymal stem cells. Cartilage formation was measured within the construct in vitro, and cartilage maturation and stabilization were observed 12 weeks after its subcutaneous implantation into a murine model. The proposed technology is simple and effective and is expected to improve aesthetic outcomes and reduce patient discomfort.

Single-stage debridement via autogenous iliac bone graft through the OLIF corridor and lateral fixation in treating spontaneous single-level lumbar pyogenic spondylodiscitis

BackgroundThe aim of the present study was to investigate the efficacy and safety of mini-open oblique debridement and lumbar interbody fusion combined with lateral screw fixation for treating single-level pyogenic spondylodiscitis.MethodsTwelve patients with single-level lumbar pyogenic spondylodiscitis underwent OLIF combined with lateral screw fixation were analyzed. Patients underwent follow-up for 12 to 24 months. The clinical characteristics, etiological examinations, operative time, intraoperative blood loss, Oswestry Disability Index (ODI), visual analog scale score (VAS), postoperative complications, and the bony fusion rate were recorded.ResultsThe mean follow-up period of time was 14.8 months. The average operative time and intra-operative blood loss were 129.0 ± 19.76 min and 309.2 ± 92.96 mL, respectively. No severe intra-operative complications were observed during surgery, except in 1 case that develops abdominal pain and distension after surgery, 2 cases that develop left-sided transient thigh pain/numbness and 8 cases that complains of donor site (iliac crest) pain. All of these symptoms disappeared 8 weeks after surgery. Tissue sample cultures were obtained from all patients intraoperatively and four (33.3%) were positive, including 2 with Staphylococcus aureus, 1 with Staphylococcus epidermidis, and 1 with Escherichia coli. During an average of 22.5 ± 2.1 days (range, 14–29 days) after surgery, WBC, CPR, and ESR levels in all patients had returned to normal. All patients were pain free with no recurring infection. Solid bony fusions were observed in all cases within 6 months, including 10 with I grade fusion, 2 with II grade fusion according to the classification suggested by Burkus et al. No fixation failure was observed during follow up and solid bony fusions were observed in all 12 patients at finally follow-up. A significant postoperative increase was also observed in the mean segmental height and lordosis (P < 0.05), followed by a slight decrease of segmental height and lordosis at final follow-up. At the final follow up, the mean VAS (1.5 ± 0.6) and ODI (18.9 ± 7.6) were significantly lower than VAS (8.4 ± 2.7) and ODI (71.2 ± 16.5) before surgery (P < 0.01).ConclusionSingle-stage debridement with autogenous iliac bone graft through the OLIF corridor and lateral fixation was a feasible surgical approach in our consecutive 12 cases of pyogenic spondylitis.

803 Management of An Intra-Oral Resection with Integra® Dermal Regeneration Template – Worth A Bite?

Abstract Introduction There are a spectrum of treatment options available for reconstruction of oral mucosal defects including secondary healing, skin grafts, local flaps and microvascular free flaps. We present the use of an alternative intra-oral reconstruction with Integra® Dermal Regeneration Template. Case Report An 85-year-old patient with a severe gag reflex and history of oral cancer presented with biopsy proven severe dysplasia of the right palate extending to the hamular notch. She was treated with wide local excision, extraction of teeth, buccal fat pad advancement for closure of an oral-antral communication and placement of Integra® Dermal Regeneration Template. Discharge was possible the same day as the patient was able to eat and had minimal pain. Discussion Integra® Dermal Regeneration Template is a bilayer wound matrix consisting of silicone in the outer layer with bovine collagen and glycosaminoglycan from shark cartilage in the inner layer. Oral cancer predominantly affects the older population, and this method can reduce surgical time, remove donor site pain, reduce post-operative pain and avoid use of a cover plate where a strong gag reflex was present. The area heals quickly and aids quick restoration of oral function. Conclusion Integra® Dermal Regeneration Template has been used for head and neck defects with good outcomes. It is being increasingly used intra-orally with good outcomes, suggesting a further application of the material with advantages over traditional techniques in specific patient groups.

Evaluation of liposomal bupivacaine infiltration at reconstructive skin graft donor sites in adolescent and young adult burn patients: A retrospective analysis

BackgroundPostoperative pain at skin graft donor sites is frequently undertreated in burn patients, which can impair reconstructive outcomes and result in harmful psychological consequences. We find a critical need to explore and promote non-opioid, multimodal analgesics. Donor site infiltration of the local anesthetic liposomal bupivacaine in adolescent and young adult burn patients has not been previously investigated. Therefore, the goal of this study was to evaluate intraoperative liposomal bupivacaine infiltration for postoperative donor site pain control in adolescent and young adult burn patients undergoing reconstructive skin graft procedures. MethodsThis retrospective analysis included patients aged 14–25 years, who underwent at least two reconstructive skin graft procedures, one that received donor site infiltration of the standard treatment (bupivacaine hydrochloride) and one that received donor site infiltration of liposomal bupivacaine. The final sample included 30 patients with a total of 44 liposomal bupivacaine cases and 53 standard treatment cases analyzed. ResultsIn the authors’ five-year experience, the use of liposomal bupivacaine compared to standard treatment was associated with statistically significant decreases in 0–4 h postoperative pain scores (mean 1.4/10 versus 2.3/10, p = 0.04) and 0–24 h postoperative pain scores (mean 1.7/10 versus 2.4/10, p = 0.02). Neither analgesic was associated with adverse events. Differences in length of stay and inpatient postoperative opioid usage were not regarded as significant. ConclusionIn this retrospective analysis, the authors report the first results that suggest intraoperative liposomal bupivacaine donor site infiltration may be associated with statistically improved patient outcomes in adolescent and young adult burn patients. However, the reported differences are most likely not clinically significant, establishing the necessity for further evaluation of using liposomal bupivacaine in this unique patient population.

Use of a topical mix of lidocaine and prilocaine during split-thickness skin graft harvest improves postoperative recovery—A prospective randomized controlled trial

PurposeTo provide evidence of efficacy and postoperative benefit of topical anesthesia (TA) for harvesting split-thickness skin graft (STSG) in an Asian population. Materials and methodsPatients with well-granulating wounds with skin grafting were randomized into TA or general anesthesia (GA) groups. In the TA group, an eutectic mixture of lidocaine and prilocaine (EMLA) was applied. Perioperative heart rate, postoperative donor site pain, adverse effects, patients’ satisfaction, duration of surgery, and operation room (OR) stay duration were recorded. ResultsThirty-nine patients (19 males, 20 females; mean age 54.9 ± 17.8) were included. Twenty underwent TA and 19 underwent GA for STSG. The TA group patients had tolerable pain during skin graft harvesting (VAS, 0.85 ± 1.5). Average EMLA exposure duration was 180.3 ± 65.8 min, and the amount applied was 1.72 ± 0.43 g/10 cm2. The TA group had lower donor site pain score at one hour postoperatively (1.34 ± 1.49 vs 3.08 ± 1.90, p = 0.005), lower OR stay duration (36.5 ± 6.5 min vs 65.1 ± 17.2 min, p < 0.001) and less adverse effects than the GA group. ConclusionHarvesting STSG under TA with EMLA is an effective and efficient approach for most Asian patients with less early postoperative donor site pain and fewer adverse effects.

Prospect of Bone Xenograft as Alternate to Autologous Bone Graft: A Survey of Orthopaedic Surgeons Perspective in Nigeria

This study aimed at evaluating the problems associated with autografts in orthopaedic practice and the acceptability of alternative bone graft products to orthopaedic surgeons in Nigeria. Google form, an electronic questionnaire platform was designed and used for the purpose of this study. Orthopaedic surgeons in the designation of consultants and senior registrars were the respondents. Various questions were asked to know the complications associated with bone autograft and to deduce if locally available bone xenografts will benefit their practice. The data generated were analysed using descriptive statistics. A total number of 83 responses were received from this survey. This survey reported limited supply of autologous bone graft (83, 100%), donor site pain (77, 92.77%), donor site infection (44, 53.01%), haemorrhage (50, 60.24%) and prolonged duration of surgery (77, 92.77%) among other problems associated with harvesting bone autograft. Fifty-five (66.27%) responded that if the bone xenograft is prepared hygienically with consistency taking ethics and tissue rejection into consideration, it will circumvent the problems of autograft. We therefore conclude that efforts should be made toward research on how biocompatible bone xenograft could be locally prepared in developing countries that will be acceptable and affordable for orthopaedic practice to overcome the challenges of autologous bone graft and high cost of commercially available bone substitute.

Minimal graft site morbidity using autogenous semitendinosus graft from the uninjured leg: a randomised controlled trial

PurposeTo quantify the effect on strength of semitendinosus (ST) graft harvest by comparing isokinetic and isometric muscle strength.MethodsA cohort of 140 patients underwent anterior cruciate ligament (ACL) reconstruction (ACLR) and were randomized to ipsilateral or contralateral ST graft harvest. Isokinetic and isometric muscle strength testing using a dynamometer were collected for the operated and non-operated leg. Patients were assessed pre-surgery and at 6, 12 and 24 months after reconstruction.ResultsST graft harvest reduced isokinetic flexion muscle strength for 6 months. At 12 months follow up there was no significant difference between the two groups and they were all stronger than pre-injury. No other significant differences were found in any primary or secondary outcome measurements.ConclusionSolitary ST graft harvest does not appear to result in a permanent reduced isometric or isokinetic quadriceps muscle strength on the side where the graft is harvested. A reduction in hamstring muscle strength of less than 10% can be seen at short-term follow-up with full recovery by 12 months. Most patients report little or no donor site pain. Given these findings, ST autograft is an alternative graft choice that could be used for various reconstructions in terms of donor site morbidity.Level of evidence Level II.

4: Four-flap Breast Reconstruction: Assessing Breast-q And Donor Site Morbidity In Bilateral Stacked Autologous Breast Reconstruction

Purpose:Patients undergoing bilateral autologous breast reconstruction may benefit from increased flap volume using bilateral stacked deep inferior epigastric perforator (DIEP) and profunda artery perforator (PAP) flaps. Four-flap reconstruction patients are a unique population in which to compare donor site morbidity of the two most commonly used free flaps in breast reconstruction (DIEP and PAP). Our aim was to characterize the donor site morbidity and overall patient outcomes of four-flap breast reconstruction patients.Methods:Retrospective chart review was performed for all patients undergoing four-flap breast reconstruction by two surgeons between 2014-2019 at a single academic medical center. Inpatient surgical site pain location and pain scores by Numeric Pain Rating Scale (NPRS) were recorded during the immediate post-operative admission. All patients were contacted to complete the BREAST-Q reconstructive module and the Lower Extremity Functional Scale (LEFS). Four-flap BREAST-Q scores were compared to bilateral DIEP and to bilateral PAP patients as reference populations.Results:A total of 63 patients undergoing four-flap breast reconstruction were identified. BREAST-Q (n=38) scores demonstrated mean Satisfaction With Breasts of 66.1+/-32.2, Psychosocial Well-Being 70.8+/-34.3, Sexual Well-Being 44.5+/-36.5, Physical Well-Being Chest 72.8+/-32.5, and Physical Well-Being Abdomen 63.6+/-34.9. In comparison to bilateral DIEP (n=180), and bilateral PAP reconstruction patients (n=43), four-flap BREAST-Q scores were similar. No difference in BREAST-Q scores remained after matching four-flap patients to bilateral DIEP patients by Age, Race, BMI, Zip Code, and radiation history. With regard to donor site morbidity, mean instances of donor site pain location recorded at the abdomen (9.72, 95%CI[7.78-11.66]) were significantly higher than the thigh (2.82, 95%CI[1.63-4.00]) during the post-operative admission (p=<0.0001). Mean pain scores by NPRS were similar between abdomen, thigh, and breast surgical sites. Subjective survey data revealed more donor site pain at the PAP site, a patient preference for the DIEP donor site, and easier post-operative care for the DIEP donor site. Further, a majority of patients felt the thighs were aesthetically improved post-operatively (54.29%). Long term survey outcomes from the LEFS (n=35) demonstrated a mean score of 92.4% (SD 10.9). The majority of women would make the same decision for four flap breast reconstruction (81.82%).Conclusion:This is the largest consecutive series of four-flap breast reconstruction outcomes reported to date. Patients undergoing four-flap breast reconstruction have more immediate donor site pain at the abdomen than the thigh, but more thigh pain after discharge home once ambulating. BREAST-Q scores in four-flap patients demonstrate overall high patient satisfaction that is similar to both bilateral DIEP and bilateral PAP reconstruction patients. In patients who require increased flap volume for body appropriate breast reconstruction, four-flap reconstruction is comparable to bilateral DIEP and bilateral PAP by BREAST-Q scores.

Calcaneal Reconstruction With Free Deep Circumflex Iliac Artery Osseocutaneous Flap Following Aggressive Benign Bone Tumor Resection.

Advances in limb-salvage techniques have made total calcanectomy and primary reconstruction possible in managing calcaneal aggressive benign tumors and selected cases of intraosseous malignant tumors. However, there is still no consensus on the operative approach, oncologic margin, and the best reconstruction method to date. These 2 cases describe our experience in calcaneal reconstruction with the free deep circumflex iliac artery (DCIA) osseocutaneous flap in benign aggressive calcaneal tumors. We reported 2 consecutive male and female patients, with an average age of 25 years (age 19 and 31, respectively), who underwent total calcanectomy and primary calcaneal reconstruction with the free DCIA osseocutaneous flaps for calcaneal chondroblastoma and giant cell tumor. A marginal resection of the entire calcaneus through the subtalar and calcaneocuboid joints (intra-articular approach) was performed in the first case and a wide local resection leaving 1 cm normal calcaneal bone margin anterosuperiorly (intraosseous approach) was performed in the second case. The follow-up period averaged 48 months. Negative oncologic margins were achieved in both cases. The first case was complicated with venous thrombosis; however, the graft remained viable after emergency reexploration. Normal foot function was restored with good solid osseous union and bony hypertrophy observed. Both patients achieved good short-term functional and aesthetic outcomes with no donor site pain or disability. No local recurrence was reported either. Primary calcaneal reconstruction with the free DCIA osseocutaneous flap can lead to good short-term functional and aesthetic outcomes. Level IV, case series.

Adjustable, Skin-Stretching External Fixation Device and Negative Pressure Wound Therapy Application for Infected Full-Thickness Skin Defects: A Case Series Study.

Skin defects-especially infected, massive full-thickness defects-can be challenging to manage. Traditionally, defects are repaired using free flaps or musculocutaneous flaps.Many side effects and complications are associated with flaps, however, such as infection, pain, donor site pain, and poor cosmesis. This case series evaluates the use of an adjustable, skin-stretching external fixation device and negative pressure wound therapy (NPWT) to repair soft tissue defects. In this retrospective series, 7 patients with skin defects were treated with an adjustable, skin-stretching external fixation device and NPWT between January 2014 and December 2017. All patients were followed until complete healing was achieved. Each patient's age, sex, defect size, mechanism of injury, healing time, results, and complications were recorded. The average patient age was 37.43 years ± 10.47 SD (range, 26-55 years). The average skin defect area was 14.5 cm2 ± 5.26 * 23.25 ± 9.01 cm2 (range, 7-15 cm2 * 10-30 cm2), and average healing time was 3.29 months ± 1.60 (range, 1-6 months). All defects healed, and 2 patients developed ulcers. This series showed the adjustable, skin-stretching external fixation device and NPWT to be a simple, safe, and effective means of managing skin defects, with minimal complications.