Radical Debridement Research Articles

Deep sternal wound infection and pectoralis major muscle flap reconstruction: A single-center 20-year retrospective study.

BackgroundOne of the most drastic complications of median sternal incision is deep sternal wound infection (DSWI), as it can lead to prolonged hospitalization, increased expected costs, re-entry into the ICU and even reoperation. Since the pectoralis major muscle flap (PMMF) technique was proposed in the 1980s, it has been widely used for sternal reconstruction after debridement. Although numerous studies on DSWI have been conducted over the years, the literature on DSWI in Chinese population remains limited. The purpose of this study was to investigate the clinical characteristics of DSWI in patients and the clinical effect of the PMMF at our institution.MethodsThis study retrospectively analyzed all 14,250 consecutive patients who underwent cardiac surgery in the Department of Cardiothoracic Surgery of Drum Tower Hospital from 2001 to 2020. Ultimately, 134 patients were diagnosed with DSWI.,31 of whom had recently undergone radical debridement and transposition of the PMMF in the cardiothoracic surgery or burns and plastic surgery departments because of DSWIs, while the remaining patients had undergone conservative treatment or other methods of dressing debridement.ResultsIn total, 9,824 patients were enrolled in the study between 2001 and 2020, of whom 134 met the DSWI criteria and 9690 served as controls. Body mass index (OR = 1.08; P = 0.02; 95% CI, 1.01∼1.16) and repeat sternotomy (OR = 5.93; P < 0.01; 95% CI, 2.88∼12.25) were important risk factors for DSWI. Of the 134 patients with DSWI, 31 underwent the PMMF technique, and the remaining 103 served as controls. There were significant differences in coronary artery bypass grafting (CABG) (P < 0.01), valve replacement (P = 0.04) and repeat sternotomy (P < 0.01) between the case group and the control group. The postoperative extubation time (P < 0.001), ICU time (P < 0.001), total hospitalization time (P < 0.001) and postoperative hospitalization time (P < 0.001) in the PMMF group were significantly lower than those in the control group. The results of multivariate regression analysis showed that PMMF surgery was an important protective factor for the postoperative survival of DSWI patients (OR = 0.12; P = 0.04; 95% CI, 0.01∼0.90).ConclusionsStaphylococcus aureus was the most common bacteria causing DSWI, which was associated with BMI and reoperation, and can be validly treated with PMMF.

Imaging of COVID-19 Patients to assess predisposing factors causing mucormycosis

Introduction: With the second wave of Covid 19, the incidence of mucormycosis has seen an upsurge in patients recovered from Covid 19 infection. Aims &amp; Objectives: The present study aims to describe the various symptoms reported by the patients and to describe the various CT findings in the patients suffering from Mucormycosis. Materials and methods: This prospective study was done on 21 post Covid cases from May 2021 to July 2021 at Department of Radiology, VMKV Medical College &amp; Hospitals. Patients who have presented with chest complaints and symptoms of sinusitis such as facial pain, headache, nasalblock, orbital swelling and pain were subjected to CT-Chest, CT-PNS. Imaging findings were correlated with clinical history and findings. Results: Radiological findings showed involvement of ethmoid 19/21(90.78 %) maxillary 17/21 (80.95 %) sinus, followed by sphenoid13/21 (61.90%) and frontal 6/21(28.57 %).Out of 2 patients studied, 15 patients (71.43%) had type 2 diabetes mellitus, 5(23.81%) patients had chronic renal failure, 5(23.81%) patients developed acute renal failure and 2(9.52%) patients received immunosuppressive therapy due to myelodysplastic syndrome. Conclusion: Early diagnosis, control of predisposing factors prompt initiation of antifungal therapy and radical debridement of involved sinuses are very essential for improving outcomes.

Imaging of COVID-19 Patients to assess predisposing factors causing mucormycosis

Introduction: With the second wave of Covid 19, the incidence of mucormycosis has seen an upsurge in patients recovered from Covid 19 infection. Aims &amp; Objectives: The present study aims to describe the various symptoms reported by the patients and to describe the various CT findings in the patients suffering from Mucormycosis. Materials and methods: This prospective study was done on 21 post Covid cases from May 2021 to July 2021 at Department of Radiology, VMKV Medical College &amp; Hospitals. Patients who have presented with chest complaints and symptoms of sinusitis such as facial pain, headache, nasalblock, orbital swelling and pain were subjected to CT-Chest, CT-PNS. Imaging findings were correlated with clinical history and findings. Results: Radiological findings showed involvement of ethmoid 19/21(90.78 %) maxillary 17/21 (80.95 %) sinus, followed by sphenoid13/21 (61.90%) and frontal 6/21(28.57 %).Out of 2 patients studied, 15 patients (71.43%) had type 2 diabetes mellitus, 5(23.81%) patients had chronic renal failure, 5(23.81%) patients developed acute renal failure and 2(9.52%) patients received immunosuppressive therapy due to myelodysplastic syndrome. Conclusion: Early diagnosis, control of predisposing factors prompt initiation of antifungal therapy and radical debridement of involved sinuses are very essential for improving outcomes.

Successful treatment of severely burned pediatric patient with comorbid disease burden

Combustion pathology remains one of the most topical and social important problems of practical public health. A special category of burned patients are children with numerous comorbidities. Purpose - to present the clinical case of successful management of severe burn victim – the child with numerous birth defects and comorbidities. Materials and methods. A 7-year-old male patient V. The diagnosis «Third-degree flame burn, 45% of the total body surface area in the regions of upper extremities, buttocks, lower extremities. Mummification of the feet and legs - to the middle third. Inhalation injury. Burn disease. Burn shock, grade IV. Cerebral palsy. Unbalanced chromosome pathology. Statokinetic development delay. Psychomotor development retardation. Hyperhomocysteinemia. Muscle hypotension syndrome. Acute gastritis. Congenital heart disease. Arachnoid cyst. Partial optic nerve atrophy. Concomitant convergent strabismus. Right-sided abdominal cryptorchidism. Aphthous dermatitis. Polyvalent food allergy». The patient underwent early necrectomy-amputation, three necrectomies followed by wound closure with xenoderm grafts, and four skin autografting procedures. Results. Extremely severe thermal trauma in patients with serious congenital pathology was previously thought by experts to be the injury incompatible with life. In the clinical case presented, the patient’s life was saved due to early surgical treatment, which included guillotine amputation-necrectomy of lower extremities aimed at radical debridement to prevent the development of severe burn disease, along with appropriate infusion and pharmacological therapy. Subsequent surgical procedures stabilized the patient’s condition, decreased the severity of injury, arrested the progression of burn disease, thus leading to his recovery. By the time of discharge from the hospital (on day 91 post injury), the wounds had completely healed, laboratory parameters were within normal limits. Conclusions. The prognoses like “the injury is not compatible with life, and treatment is symptomatic" should not be pronounced by clinicians in general and by burn experts in particular. To save the patient’s life by all possible means should be the primary goal for all medical professionals. The research was carried out in accordance with the principles of the Helsinki Declaration. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors. Keywords: burns, children, congenital malformations, concomitant pathology, treatment.

Treatment options in non-unions of the pelvis: A retrospective analysis of a single center experience over 12 years

BackgroundNon-unions and chronic instability of the pelvis remain rare complications after complex high velocity injuries with vertical and rotational instability of the pelvis. Treatment options are insufficiently supported by data evidence due to the rareness of this condition. Patients and methodswe conducted a single center, retrospective study of all non-unions and pelvic instabilities between 1.1.2008 and 1.1.2019, excluding fragility fractures. Patients’ characteristics, fracture patterns, procedures and outcomes with regard to developing treatment options and successful union in the follow-up were obtained. Results26 patients were included in this retrospective analysis. The mean age was 55 years (range 34–78 years). Seventy-seven percent of the patients were male. The standard procedure consisted of radical debridement of the non-union, interposition of autologous bone graft and rigid stabilization systems. Three patients were lost to follow up. In the remaining n = 23 patients (88%) consolidation of the non-union was achieved. The mean follow up was 31.3 months (range 6–144). Follow up showed that an iliolumbar fixation seems to be favorable regarding outcome and complications. DiscussionNon-union and remaining instability of the pelvic ring represent a rare complication after high grade pelvic trauma. There are only limited data regarding the incidence and the treatment regimen is based on small study populations only. Based on our findings we recommend to combine autologous bone grafts with rigid fixation systems especially for non-union of the pelvis to restore the posterior sacroiliac arch.

Matched comparative study of trifocal bone transport versus induced membrane followed by trifocal bone transport in the treatment of segmental tibial defects caused by posttraumatic osteomyelitis

ObjectivesTo compare the efficacy and clinical outcomes of trifocal bone transport (TBT) versus induced membrane followed by trifocal bone transport (IM + TBT) in the treatment of tibial defects > 6 cm caused by posttraumatic osteomyelitis.MethodsA total of 69 eligible patients with tibial defects > 6 cm who were treated between January 2010 and January 2018 were retrospectively reviewed. Overall, 18 patients treated by IM + TBT and 18 treated by TBT were matched by propensity score analysis. The mean tibial defect after radical debridement was 6.97 ± 0.76 cm (range, 6.0 to 8.9 cm). The measurements, including demographic data, external fixation index (EFI), external fixation time (EFT), duration of docking union, bone and functional outcomes evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system, and postoperative complications evaluated by Paley classification during follow-up were recorded.ResultsAge, gender, injury mechanism, affected side, defect size, previous operation time, and follow-up time were not significantly different between the two groups (P > 0.05). The mean EFT was 293.8 ± 12.1 days in the TBT group vs. 287.5 ± 15.3 days in the IM + TBT group. The mean EFI was 36.02 ± 2.76 days/cm vs. 34.69 ± 2.83 days/cm, respectively. The mean duration of docking union was 210.7 ± 33.6 days vs. 179.7 ± 22.9 days, respectively. There was no significant difference in postoperative bone and functional results between the two groups. Delayed union or nonunion and soft tissue incarceration were significantly reduced in the IM + TBT group compared to those in the TBT group.ConclusionBoth TBT and IM + TBT achieved satisfactory postoperative bone and functional outcomes in patients with segmental tibial defects > 6 cm following posttraumatic osteomyelitis, while IM + TBT had a significantly lower incidence of postoperative complication in delayed union or nonunion and soft tissue incarceration, as well as faster docking union.

Clinical effectiveness of early internal fixation combined with free flap technique in the treatment of Gustilo IIIB open forearm fracture

IntroductionGustilo IIIB open forearm fractures are severe injuries often associated with extensive bone and soft tissue injuries. The treatment of Gustilo IIIB open forearm fractures remains a challenging problem, with a high morbidity rate such as infection, nonunion, even amputation. External fixation is preferred for open lower limb fractures. However, there are significant differences between open bone injuries of the upper and lower extremity in terms of treatment plans. Use of internal fixation methods for open fractures is a controversial issue, as it requires early coverage of skin and soft tissue defects after radical debridement and irrigation. The optimal approach for open forearm fractures remains to be determined. The present study evaluated whether early internal fixation combined with free flap placement is effective for the treatment of Gustilo IIIB open forearm fracture. HypothesisEarly internal fixation combined with the free flap technique in the treatment of Gustilo IIIB open forearm fracture provides good consolidation results. Material and methodsFrom January 2015 to January 2020, 20 patients with Gustilo IIIB open forearm fracture treated with early internal fixation combined with free skin flap placement were retrospectively analyzed. There were 9 males and 11 females, with an average age of 40 years. In all cases, the injuries were classified as Gustilo type IIIB. The area of the wounds ranged from 9×3cm to 27×10cm. Fist-stage plate fixation was adopted in 16 cases. Four patients presenting with major contamination received first-stage fixation with Kirschner wires and external fixation, and the second-stage surgery of surgical treatment included flap placement and internal fixation within 10 days. The rates of limb salvage and complications were recorded. The Anderson scoring system was utilized to assess limb function. ResultsLimb salvage was successful in all 20 cases. The average length of hospital was 19 days (range, 7–28 days). Four patients developed superficial infections. After debridement, the wounds were covered with skin grafts. No deep infections or osteomyelitis occurred. Three patients developed nonunion, and bone grafts achieved bone healing later. The donor skin flaps healed well, with partial pigmentation. No complete necrosis of the flaps occurred. Only the distal part of flaps became necrotic in two cases, which were then successfully treated by debridement and skin grafting. The average follow-up duration was 14.7 months (range, 8–24 months). According to the Anderson scoring system, 7 cases were graded as excellent, 6 cases as good, 5 cases as fair, and 2 cases as poor. ConclusionFor Gustilo IIIB type injuries, early and thorough debridement along with early internal fixation and skin flap coverage of the wound can achieve satisfactory clinical results, shorten the treatment cycle, and maximize limb function recovery. Level of evidenceIV, retrospective study without control group.

Dual-Perforator Flap With Wide Pedicle Versus Sural Neurocutaneous Flap With Peroneal Artery Perforator in the Treatment of Soft Tissue Defects of Foot and Ankle

How to deal with large soft tissue defects around the foot and ankle is still controversial. The aim of this study was: (1) to display a new pedicled flap, also named the dual-perforator flap with wide pedicle (DPFWP), and (2) to compare it with the sural neurovascular flap with peroneal artery perforator (SNFPAP) in foot and ankle reconstruction. According to different surgical methods, 82 patients were divided into 2 groups: the DPFWP group (42 cases) and the SNFPAP group (40 cases). All cases underwent a flap surgery after radical debridement. The 2 groups were homogeneous in terms of age, sex, body mass index (BMI), etiology, location, and follow-up duration. Operation indexes were compared, including flap length, flap width, operation time and blood loss. Complications, cosmetic appearance, and functional outcome were analyzed, and statistical analysis was performed. The DPFWP group had larger flap length (24.5 ± 4.6 cm vs 16.3 ± 3.8 cm), and flap width (10.5 ± 2.7 cm vs 7.8 ± 1.7 cm) than the SNFPAP group. In postoperative follow-up, DPFWP group showed a lower complication rate and better cosmetic, functional outcomes than SNFPAP group. In conclusion, this study showed that a DPFWP flap brought better results than a SNFPAP flap in terms of complications, cosmetic appearance, and functional outcomes for patients undergoing reconstruction of foot and ankle defects.

Tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique in the treatment of distal tibial defect—preliminary outcomes of 12 cases and a description of the surgical technique

ObjectiveTo evaluate the preliminary outcomes of tetrafocal (three osteotomies) and pentafocal (four osteotomies) bone transport using Ilizarov technique for the treatment of distal tibial defect and describe the surgical technique. MethodsA total of 12 eligible patients with distal tibial defect > 6 cm caused by direct trauma or posttraumatic osteomyelitis who were admitted to our institution from January 2017 to January 2019 were treated by tetrafocal or pentafocal bone transport using Ilizarov technique. Detailed demographic data, including age, sex, etiology, defect size, number of osteotomies (three or four), external fixation time (EFT) and external fixation index (EFI), were collected, and the bone and functional outcomes were evaluated by the Association for the Study and Application of the Method of Ilizarov (ASAMI) scoring system. Complications during the surgery and the follow-up period were recorded and evaluated by the Paley classification at a minimum follow-up of two years after removal of the fixator. ResultsThere were 9 men and 3 women with an average age of 37.4±7.8 years. The etiology included posttraumatic osteomyelitis in 8 cases and posttraumatic bone loss in 4 cases. The mean bone defect after radical debridement was 7.1±0.6 cm. Tetrafocal bone transport was applied in 9 cases, and pentafocal bone transport was applied in 3 cases. The average EFT and EFI were 5.2±0.8 months and 0.7±0.2 months/cm, respectively. The average time of follow-up after removal of the external fixator was 28.5±3.3 months without recurrence of osteomyelitis. The bone results were good in 7 cases, fair in 4 cases, and poor in 1 case, and the functional results were good in 5 cases, fair in 6 cases, and poor in 1 case. The most common complication was pin tract infection, which occurred in all cases, but there were no major complications, such as nerve or vascular injury. ConclusionTetrafocal and pentafocal bone transport using Ilizarov technique could be an alternative treatment option in selected cases with distal tibial defect > 6 cm. It could shorten the distraction period, fasten regeneration, and reduce the associated complications.

Role of Perforating Artery Pedicled Neurotrophic Flap in the Treatment of Compound Tissue Defect of Tibia Using the Ilizarov Technique.

ObjectiveTo describe our experience with the combined use of pedicled neurotrophic flap and distraction osteogenesis in the management of complex lower extremity injuries with composite bone and soft tissue defects and assess the functional and cosmetic results of this method.MethodsA pedicled flap with a marked perforator artery was applied for soft tissue coverage after radical debridement and temporary external fixation. In the second stage, the Ilizarov external fixator was used in place of the temporary external fixator for reconstruction of the segmental bone defect by distraction osteogenesis. Twenty‐five patients (16 men and nine women; mean age, 39.2 years) were treated by using this combined technique between 2008 and 2016. All cases were graded initially as Gustilo–Anderson grade IIIB open fractures. The soft tissue defect after radical debridement ranged from 9 cm × 5 cm to 14 cm × 11 cm, and the average size of segmental defect was 5.2 (Range, 2.5–8.5) cm. Seventeen of these patients had a history of local infection. The bone structure and function were evaluated by two independent evaluators using Paley's criteria.ResultsTwenty‐five patients were followed up for an average of 28.96 (Range, 15–48) months. The distally based sural neurovascular flap was applied in 13 patients, and the greater saphenous neurocutaneous perforator flap in 12 patients. The flap area ranged from 10 cm × 5 cm to 14 cm × 12 cm. Sufficient coverage of soft tissue defect was achieved in all cases. All flaps survived completely without complications. The bone defects were corrected by a mean lengthening of 6.94 (Range, 4.5–9.5) cm. The residual discrepancy was <1 cm in all cases, which was not clinically significant. The function was evaluated as excellent in 12 patients and good in 13 patients. Bone results were graded as excellent in 18 patients and good in seven patients. Complications during treatment included pain, pin tract infections, ankle midfoot joint stiffness, and docking site nonunion. No recurrence of infection was observed in infected patients. All cases achieved successful limb salvage and satisfactory function recovery without recurrence of infection.ConclusionsThe combined technique of a perforator artery pedicled neurotrophic flap and distraction osteogenesis is an effective alternative approach in the salvage treatment of massively traumatized and chronically infected lower extremities.

Flap combined with induced membrane technique in treatment of post-traumatic tibial osteomyelitis with soft tissue defect

To investigate the effectiveness of flap combined with induced membrane technique in treatment of post-traumatic tibial osteomyelitis with soft tissue defect. A clinical data of 33 patients with post-traumatic tibial osteomyelitis with soft tissue defect who met the selection criteria between August 2015 and October 2018 was retrospectively analyzed. There were 21 males and 12 females. The age ranged from 19 to 70 years, with an average of 39 years. The osteomyelitis located in the upper 1/3 of tibia in 8 cases, in the middle 1/3 of tibia in 14 cases, and in the lower 1/3 of tibia in 11 cases. According to Cierny-Mader classification standard, 19 cases of osteomyelitis were type Ⅲ and 14 cases were type Ⅳ. The duration of osteomyelitis ranged from 2 months to 20 years (median, 3 months). In the first-stage operation, after radical debridement, the length of bone defect was 1.5-12.5 cm (mean, 5.0 cm) and the size of soft tissue defects ranged from 5 cm×4 cm to 15 cm×12 cm. Bone cement containing antibiotics was implanted into the bone defect and the personalized flap was used to repair the wound. After the wound healed at 6-8 weeks and the infection was controlled, bone grafting was performed to repair bone defects in the second-stage operation. The flaps survived completely after the first-stage operation in 29 cases. Partial necrosis of the flap occurred in 4 cases and healed after surgical dressing change. All the incisions healed by first intention after the second-stage operation. All patients were followed up 24-32 months (mean, 28 months). All the bone grafts healed after operation, and the radiographic healing time was 3-9 months (mean, 5 months). The clinical healing time was 4-14 months (mean, 8 months). There was no recurrence of osteomyelitis during follow-up. At last follow-up, according to Johner-Wruhs evaluation criteria, the limb function was excellent in 27 cases, good in 4 cases, and fair in 2 cases, with an excellent and good rate of 93.9%. For the post-traumatic tibial osteomyelitis with soft tissue defect, the flap combined with induced membrane technique is a reliable and effective method and can effectively restore the function of lower limbs with satisfactory effectiveness.

Treatment of Gustilo-Anderson ⅢB type injury of distal femur complicated with bone defect by membrane induction technique

To evaluate the effectiveness of membrane induction technique in the treatment of Gustilo-Anderson ⅢB type injury of distal femur complicated with bone defect. The clinical data of 20 patients with Gustilo-Anderson ⅢB type injury of distal femur complicated with bone defects admitted between January 2019 and December 2020 were retrospectively analyzed, including 15 males and 5 females, with an average age of 35 years (range, 19-70 years). Causes of injuries included 15 cases of traffic accidents and 5 cases of falling from height. Bone defect located at metaphyseal in 11 cases and at proximal metaphyseal in 9 cases. The time from injury to primary first-stage surgery was 4-28 hours, with an average of 11 hours. After primary radical debridement, the length of bone defect was 3-12 cm, with an average of 6 cm. Antibiotic-containing bone cement was implanted in the bone defect site to induce membrane formation. At 34-56 days (mean, 45 days) after the first-stage surgery, bone grafting was performed in the induced membrane for the repair and reconstruction of bone defects; 16 patients received a combination of autogenous cancellous and allogeneic bone grafts and 4 patients received cancellous bone grafts. The bone graft healing time after the second-stage surgery was recorded; the visual analogue scale (VAS) score and Lysholm score were compared before the second-stage bone graft and at last follow-up to evaluate the pain and functional improvement of the affected limb; and the knee joint range of motion at last follow-up was recorded. None of the patients had a second revision after the first-stage surgery, 1 patient recieved flap transfer and the flap survived well after operation. All patients were followed up 12-36 months after the second-stage surgery, with an average of 23 months. All patients achieved bone union, and the bone union time was 7-10 months (mean, 8.4 months). No bone nonunion or donor site related complications occurred. The Lysholm score and VAS score at last follow-up were 85.6±4.1 and 1.7±0.8, respectively, and they were significantly improved when compared with those before the second-stage bone defect repair (42.7±4.6 and 7.1±0.8, respectively) ( t=37.410, P<0.001; t=21.962, P<0.001). Knee flexion range of motion was 60°-120°, with an average of 95°; the limit of elongation was 0°-10°, with an average of 5°. For Gustilo-Anderson ⅢB type injury of distal femur complicated with bone defect, induction membrane technique can effectively control infection, promote bone healing of the defect site, and effectively restore the function of lower limbs with satisfactory effectiveness.

Outcome of monolateral rail fixator in infected nonunion of femur diaphysis developing after intramedullary fixation.

Consensus is lacking regarding management of posttraumatic infected diaphyseal nonunions of femur following intramedullary nailing. Present study reports outcomes of single stage standardised treatment protocol using monolateral rail external fixator/limb reconstruction system in this type of infected diaphyseal femoral nonunions. This retrospective study included 26 patients with mean age of 31.7years having posttraumatic infected diaphyseal femoral nonunions following intramedullary nailing and managed with radical debridement and monolateral rail fixator. The results were assessed by Association for the Study and Application of the Method of Ilizarov criteria. Mean intraoperative bone gap was 4.34 (range, 2-7) cm. Mean gain in bone length was 4.04 (range, 0-7) cm. Fracture united primarily in 22 cases and after freshening of edges, fixator adjustment and fibular grafting in three more patients. Infection persisted in one patient. Most common complications were superficial pin tract infection (15 patients) and loss of more than 30° knee flexion (13 patients). The bone results were excellent, good, and poor in 15, 9, and 2 patients, respectively. The functional results were excellent, good, fair, and poor in 11,13,1 and 1 patient, respectively. Single stage procedure including radical debridement, acute docking, distraction osteogenesis at corticotomy site and stabilization with monolateral rail fixator reliably achieves good to excellent bone and functional results, union and eradication of infection in majority of infected nonunions of femoral diaphysis developing after intramedullary fixation. We recommend acute docking in bone gap ≤ 5cm.

Comparison of anterior or posterior approach in surgical treatment of thoracic and lumbar tuberculosis: a retrospective case–control study

BackgroundWith the widespread use of the posterior surgery, more and more surgeons chose posterior surgery to treat thoracic and lumbar tuberculosis. But others still believed that the anterior surgery is more conducive to eradicating the lesions, and easier to place larger bone pieces for bone graft fusion. We compared the clinical and radiological outcomes of anterior and posterior surgical approaches and presented our views.MethodsThis study included 52 thoracic and lumbar tuberculosis patients at Sun Yat-sen Memorial Hospital from January 2010 to June 2018. All cases underwent radical debridement, nerve decompression, intervertebral bone graft fusion and internal fixation. Cases were divided into anterior group (24 cases) and posterior group (28 cases). Statistical analysis was used to compare the clinical effectiveness, radiological outcomes, complications and other related information.ResultsPatients in the anterior group and the posterior group were followed up for an average of 27.4 and 22.3 months, respectively. There were no statistically significant differences between groups in the preoperative, postoperative and last follow-up VAS score, ASIA grade and Cobb angle of local kyphosis. Moreover, there were no statistically significant differences in the improvement of neurological function, loss of kyphotic correction, total incidence of complications, operative time, intraoperative blood loss and hospital stay between the two groups (P > 0.05). But there was greater correction of kyphosis, earlier bone fusion, lower incidence of poor wound healing, less interference with the normal spine and less internal fixation consumables and medical cost in the anterior group (P < 0.05).ConclusionsBoth anterior and posterior approaches are feasible for thoracic and lumbar tuberculosis. While for thoracic and lumbar tuberculosis patients with a single lesion limited in the anterior and middle columns of the spine without severe kyphosis, the anterior approach surgery may have greater advantages in kyphosis correction, bone fusion, wound healing, protection of the normal spine, and medical consumables and cost.

Combined anteroposterior approaches in lateral position treatment of lumbosacral tuberculous in single-stage

BackgroundThe local anatomy of the lumbosacral region of spine is complicated, with special biomechanical characteristics. For surgical management of tuberculous spondylitis reported in the literature, the methods would be two-stage anterior and posterior approaches or one-stage anterior and posterior approach with patient’s intraoperative position being changed. These types of surgery approaches would result in long operative duration and more intraoperative blood loss, and most important there is no coordination between anterior and posterior procedures.MethodsThe purpose of this study was to introduce a new procedure called in the lateral position single -stage combined anteriorposterior approaches for treatment of lumbosacral tuberculous spondylitis and to evaluate its preliminary surgical outcomes. Fifteen patients with lumbosacral tuberculous spondylitis who underwent single-stage anterior and posterior radical focal debridement and reconstruction in lateral position in our hospital from April 2005 to June 2012 were included in the study. There were 6 males and 9 females with the average age of 46.8 years. The tuberculous lesions involved the following regions: L3-4 in 5cases, L4-5 in 5 cases, L5-S1 in 2 cases, L4 in one case, and L5 in 2 cases. The assessment of surgical outcomes was conducted with clinical symptoms and radiological findings,including operative time, blood loss. deformity angle, Frankel grade and Kirkaldy-Willis evaluation.ResultsOperation posture: The right lateral position was used for 11 patients and the left lateral position was used for the remaining 4 patients. The average duration of operation for the 15 patients was 270 min. The average intraoperative blood loss was 1720 ml. The mean follow-up period was 4.2 years. There was no recurrence. The postoperative radiological findings showed that the interbody bone grafts were fixed without any dislodgment. There was significant difference between preoperative and postoperative lumbosacral lordotic angles. Kirkaldy-Willis classification rating for the 13 cases with satisfactory results.ConclusionSingle-stage combined anterior and posterior surgical management of lumbosacral tuberculous spondylitis with patient in lateral position can achieve radical focal debridement, anterior and posterior procedure coordination and spinal reconstruction.

Vascularised periosteal free flap reconstruction for medication-related osteonecrosis of the jaw: a case series

Introduction: The standard of care for medication-related osteonecrosis of the jaw (MRONJ) involves anti-biotics and local debridement to promote tissue healing over exposed bone. We compare outcomes for patients with advanced MRONJ managed with vascularised periosteal radial forearm free flap (RFFF) ver-sus local nasolabial flap and conservative dental measures. Methods: A retrospective case series of patients presenting to the Alfred Hospital for evaluation and man-agement of stage II or above MRONJ between 1 January 2014 and 30 June 2018. The hospital database was searched And a medical record review performed. Results of pre- and post-treatment imaging were ana-lysed bya single senior radiologist blinded to treatment modality . Asymptomatic wound closure, radio-logical evidence of disease cessation and patient satisfaction at six months post-treatment according to treatment type were assessed. Results: Of the ten patients included in the study, four received dental measures, three received local na-solabial flap and three received RFFF flap. All flap reconstruction (6/6) showed asymptomatic wound clo-sure and patient satisfaction at six months follow-up compared to patients managed with dental measures (1/4). All RFFF patients (3/3) showed increased bone deposition radiologically at six months compared to the dental group who showed a mixed (3/4) picture or worsened (1/4) picture. Nasolabial flap patients showed a mixed (2/3) or improved radiological picture (1/3). Conclusion: MRONJ is a relapsing disease. Preliminary evidence suggests that radical debridement with local nasolabial flap or RFFF reconstruction for advanced MRONJ is more effective at halting the disease and alleviating morbidity than conservative dental measures alone.

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.

Local Fixation of Colistin With Fibrin Spray: An in vivo Animal Study for the Therapy of Skin and Soft Tissue Infections

ObjectiveSkin and soft tissue infections (SSTI) are a commonly known entity of diseases associated with difficult treatment procedures. The current gold standard when there is a rapidly progressing infection of soft tissues with a risk of sepsis is radical surgical debridement accompanied by systemic antibiotic therapy. In clinical settings, local antibiotics alone or formulated within carrier material are commonly used alongside this therapy regimen. One possibility of local antibiotic application is the fixation of colistin with fibrin glue spray. It is not yet sufficiently researched how the local antibiotic concentrations remain as high as possible over time.MethodsWe conducted an animal study including 29 male Wistar rats inducing sterile back sores reaching the muscle fascia. We sprayed only colistin, simultaneously or consecutively, with fibrin glue in different groups in order to measure the tissue concentration of the antibiotic applied locally.ResultsAfter liquid chromatography and quadrupole mass spectrometry analysis, it could be demonstrated that in comparison to the colistin group, tissue concentrations of colistin stayed significantly higher in the wound tissue when it was fixed with fibrin glue. This was observed in both groups, the simultaneous as well as in the consecutively fibrin glue sprayed groups after colistin application.ConclusionThe fixation of colistin with the fibrin-glue-spray technique as a carrier for local antibiotic therapy is an easy and inexpensive method and shows promising potential for the treatment of SSTI.

Calcaneogenesis: the use of tibial bone transport for treatment of massively infected hindfoot defects.

We retrospectively reviewed 10 patients which were treated by radical debridement of the infected area, Ilizarov frame application and arthrodesis with bone reconstruction by the Ilizarov apparatus using tibial transport for Hindfoot salvage. The mean age at presentation was 33.5 years (range; 24-57) and the mean follow-up was 5.1 years (range; 2-12).Patients clinical and radiographic data were assessed according to the American Orthopaedic Foot & Ankle Society (AOFAS) Ankle- Hindfoot score. The mean preoperative American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot Score was 48.3(range; 38-86) while the mean postoperative (AOFAS) was 58.5 (range; 45-73) , p value < 0.01 . Clinically all patients had anatomically stable feet with deformity correction and no signs of infection recurrence. The use of Ilizarov distal tibial bone transport to fill massive hindfoot defects proved to be a reliable method for elimination of infection and reconstruction of large defects without the need for bony or soft tissue plastic procedures. The technique also has the ability to produce a rigid limb fixation following debridement and to fill in massive hindfoot defects due to other etiologies as well.

Successful Reconstruction of a Lower Chest Wall Defect with Delayed Fungal Deep Sternal Wound Infection following a Blast Injury in South Korea: A Case Report

Although blast injuries have been considered a problem unique to military practice or warfare, accidental civilian blast-related injuries due to misplaced landmines have been reported in South Korea. A 71-year-old man was admitted to the emergency room due to multiple severe blast injuries after the detonation of an unknown explosive device. After shrapnel that penetrated the pericardium was removed via median sternotomy in an emergency operation, an extensive defect remained on the lower third of the anterior chest wall. After debriding the contaminated wound several times, chest wall reconstruction with a skin-paddled vertical rectus abdominis muscle (VRAM) flap was successfully performed. However, the patient presented a delayed fungal infection of the deep sternal wound 28 days postoperatively. To salvage the previous flap, antifungal agents were administered and negative-pressure wound therapy was performed between serial radical debridement. The previous flap was successfully salvaged with infection control, and the final defect was covered by re-rotating the previous flap. This case presents the successful reconstruction of a chest wall defect using a skin-paddled VRAM flap notwithstanding a delayed sternal wound infection from a rare civilian blast injury in South Korea.