Requiring Flap Reconstruction Research Articles

Elevating Lower Extremity Reconstruction: An Algorithmic Approach to Free Flap Re-elevation.

Free flap (FF) reconstruction is frequently required for soft-tissue coverage after significant orthopaedic trauma of the lower extremity (LE). While usually the final step in limb salvage, re-elevation of the previously inset FF may be necessary to restore a functional limb. In this study, we present our algorithm for LE FF re-elevation and review our experience to identify factors associated with successful limb salvage and return to ambulation. A retrospective, single-institution review was conducted of adult patients with LE wounds who required FF reconstruction from 2016 to 2021. From this cohort, patients who required re-elevation of their LE FF were identified. Successful FF re-elevation was defined by limb salvage and return to ambulation. During the study period, 412 patients with LE wounds required flap reconstruction. Of these patients, 205 (49.8%) underwent free tissue transfer, and 39 (9.5%) met our inclusion criteria. From this cohort, 34 had successful FF re-elevation, while 1 was non-weight bearing and 4 were elected for amputation due to chronic complications unrelated to their FF. Univariate analysis revealed the total number of FF re-elevations (p < 0.001), the frequency of re-elevation indicated for orthopaedic access (p < 0.001), and infections necessitating return to the operating room (p = 0.001) were each negatively associated with limb salvage and return to ambulation. The described algorithm highlights the preoperative planning and meticulous flap preservation necessary for the successful coverage of critical structures following FF re-elevation. Our data demonstrate that LE FFs can be safely re-elevated for hardware access or flap revision. In these complex cases of LE trauma, management by a multidisciplinary team is essential for successful limb salvage.

Total Knee Arthroplasty Periprosthetic Joint Infection With Concomitant Extensor Mechanism Disruption and Soft-Tissue Defect: The Knee Arthroplasty Terrible Triad

BackgroundPeriprosthetic infection (PJI) with concomitant extensor mechanism disruption (EMD) and soft-tissue defect—hereinafter termed the “Terrible Triad”—is a devastating complication following total knee arthroplasty. The purpose of this study was to define the surgical and clinical outcomes following management of a cohort of patients who have the Terrible Triad. MethodsFrom 2000 to 2022, 127 patients underwent operative management for PJI alone, 25 for PJI with soft-tissue defects (defined as defects requiring flap reconstruction or being a factor contributing to the decision of performing above-knee amputation or arthrodesis), 14 for PJI with EMD, and 22 for the Terrible Triad. A composite outcome of infection status, range of motion, extensor lag, and ambulatory status at final follow-up was used to compare the proportion of patients in each group with a favorable overall knee outcome. Differences between groups were determined using one-way analyses of variance with post hoc Tukey’s tests and Pearson’s Chi-square tests or Fisher’s exact tests with post hoc Bonferroni adjustments, where applicable. Odds ratios (OR) were calculated for comparison of the overall knee outcome between groups. A Kaplan-Meier survival analysis for patient mortality was performed. ResultsThe mean follow-up was 8.4 years and similar between groups (P = .064). Patients who had the Terrible Triad had a 45.5% incidence of above-knee amputation, or arthrodesis, and an 86.4% incidence of an unfavorable outcome. Compared to patients in the PJI group, patients in the PJI who had a soft-tissue defect (OR = 5.8, 95% CI [confidence interval] 2.2 to 15.7), PJI with EMD (OR = 3.7, 95%CI 1.0 to 12.9), and Terrible Triad groups (OR = 11.6, 95% CI 3.3 to 41.5) showed higher odds of an unfavorable knee outcome. ConclusionsThis study demonstrates that the total knee arthroplasty Terrible Triad is a dreaded diagnosis with poor outcomes. Clinicians and patients might consider early treatment with amputation or arthrodesis. Level of EvidenceIII.

Intraoperative Near-infrared Spectroscopy Can Predict Skin Flap Necrosis.

The study aimed to validate the previously identified capacity of near-infrared spectroscopy (NIRS) to detect clinically relevant differences in tissue perfusion intraoperatively. Consecutive patients undergoing oncologic resection requiring flap reconstruction were analyzed. Clinicians were blinded to tissue oxygen saturation (StO2) measurements taken intraoperatively. Measurements were taken at (1) control areas not affected by the procedure, (2) areas at risk of necrosis based on distal location, and (3) areas of skin flap necrosis (SFN) identified during the follow-up period. Mean StO2 values were compared using a single-sample t test and analysis of variance (ANOVA) to determine differences in oxygenation. There were 102 patients included from April 2018 to May 2019. Reconstruction was undertaken following resection for breast cancer (46), melanoma (35), sarcoma (9), and other cutaneous malignancies (12). Breast reconstruction involved 38 alloplastic reconstructions and eight autologous free flaps. Other skin flap reconstruction involved 42 local/regional skin flaps, 13 pedicled flaps, and one free flap. Eighteen patients (17.6%) developed SFN. Mean intraoperative StO2 measurements for control areas, areas at risk, and areas of SFN were 74.8%, 70.9%, and 54.3%, respectively. StO2 values equal to or less than 60% were highly specific (96%) for SFN, whereas StO2 values above 85% were highly sensitive (96%) to rule out SFN. These results further support the use of NIRS to objectively assess variations in skin flap oxygenation and tissue perfusion that are correlated with the development of postoperative SFN.

Usefulness of the Keystone Flap in Lower Extremity Reconstruction in Patients with Anterior Tibial Artery Variation: A Case Report

Reconstruction of lower extremity wounds in patients with abnormalities in vascular anatomy is often challenging. A 71-year-old man was admitted to our hospital after sustaining two contact burns on his right leg while sleeping on an electric blanket. Fourth-degree burns amounting to approximately 3% of total body surface area were confirmed, with eschar formation on the right instep and pretibial area. Both wounds on the lower leg required flap reconstruction. In addition, the patient had anterior tibial artery hypoplasia. We considered a two-flap reconstruction method that should leave the source artery and muscle intact and generally has a good prognosis. A peroneal artery perforator-based keystone flap was used on the right lower leg, and a right dorsalis pedis island flap on the foot dorsum. Surgery was performed successfully, and at 8 months postoperatively, the patient walked naturally and had no complaints of discomfort. Additionally, cosmetic results were satisfactory. Accordingly, we introduce a surgical method that is useful in cases similar to that described.

Mesenchymal Stem Cells and Regenerative Therapy with Bilateral Gracilis Flaps for Perineal Reconstruction of a Wound Infection in the Setting of Anal Squamous Cell Carcinoma.

Many patients are affected by HIV/AIDS, and these conditions are highly prevalent worldwide. Patients with HIV/AIDS can experience debilitating wound infections that often require flap reconstruction and become challenging for surgeons to treat. In the past 5 years, mesenchymal stem cells have been tested and used as regenerative therapy to promote the growth of tissues throughout the body because of their ability to successfully promote cellular mitogenesis. To the authors' knowledge, the use of mesenchymal stem cell grafting following necrosis of a myocutaneous gracilis flap (as part of perineal wound reconstruction) has never been reported in the literature.In addition, the use of mesenchymal stem cells and regenerative medicine combined in the setting of squamous cell carcinoma of the anus with prior radiation (along with comorbid AIDS) has not been previously documented.In this report, the authors outline the case of a 60-year-old patient who had a recipient bed (perineum) complication from prior radiation therapy. Complicating the clinical picture, the patient also developed a Pseudomonal organ space infection of the pelvis leading to the failure of a vertical rectus abdominis myocutaneous flap and myocutaneous gracilis flaps. As a result, the patient underwent serial operative debridements for source control, with the application of mesenchymal stem cells, fetal bovine dermis, porcine urinary bladder xenograft, and other regenerative medicine products, achieving a highly successful clinical outcome. A procedural description for future use and replication of this method is provided.

Variations in Microcirculatory and Hemodynamic Parameters during Oncological Demolitive-Reconstructive Head and Neck Surgery: A Protocol for an Observational Study.

(1) Background: Oncological demolitive-reconstructive surgeries in the head and neck region cause significant stress on patients' biohumoural, cardiac, and vascular systems, leading to disturbances in macrocirculatory and microcirculatory parameters. Traditional monitoring addresses the symptoms, but not the underlying cause. Microcirculatory assessments complement macrocirculatory monitoring, and bladder-catheter-based technology offers a better representation of central microcirculation. Flap reconstruction surgeries involve demolitive and reconstructive phases, requiring optimal tissue perfusion. The literature lacks a consensus on macro-microcirculation coupling, and there is no agreement on the use of vasopressors during head and neck surgeries. Evidence-based guidelines are lacking, resulting in variations in vasopressor administration. (2) Methods: This is a 12-month observational, prospective study conducted in a single center. It aims to evaluate the impact of macro-microcirculation coupling on clinical complications in head and neck surgery. All consecutive patients undergoing oncologic surgery requiring flap reconstruction and meeting the inclusion criteria will be enrolled. The study will utilize standard hemodynamic monitoring and bladder catheterization for measuring urine output and temperature. (3) Conclusions: The study aims to evaluate the coupling of macro- and microcirculation in head and neck surgeries, assess hemodynamic parameters and microcirculatory changes, and investigate their association with postoperative complications. The results can enhance patient care and surgical outcomes.

Frailty as a Predictor of Post-Surgical Outcomes in Patients With Cutaneous Malignancies of the Scalp and Neck Requiring Flap Reconstruction.

Investigate the ability of frailty status to predict post-surgical outcomes in patients with cutaneous malignancies of the scalp and neck undergoing flap reconstruction. National Surgical Quality Improvement Program database was used to isolate patients with cutaneous malignancies of the scalp and neck who underwent surgical resection between 2015 to 2019. Univariate and multivariate analyses were performed to determine if frailty score correlated with negative post-operative outcomes. Receiver operating characteristic (ROC) curves allowed testing of the discriminative performance of age versus frailty. This study demonstrated an independent correlation between frailty and major complications as well as non-home discharge. In ROC curve analysis, frailty demonstrated superior discrimination compared to age for predicting major complications. Our study demonstrated an association between increasing frailty and major complications as well as the likelihood of a non-home discharge. When compared to age, frailty was also shown to be a better predictor of major complications.

Financial Toxicity is Common in Patients After Tibia Fracture.

To evaluate the presence of financial distress and identify risk factors for financial toxicity in patients after tibial shaft fracture. A cross-sectional analysis. Level I trauma center. All patients within 4 years after tibial shaft fracture (open, closed or fracture that required flap reconstruction). Injury-related financial distress. Financial distress related to the injury, as reported by the patient in a binary question. Financial toxicity using the LIMB-Q, scored from 0 to 100, with higher scores indicating more financial toxicity. Data were collected from 142 patients after tibial shaft fracture [44% closed (n = 62), 41% open (n = 58), and 15% flap (n = 22)]. The mean age was 44 years (SD 17), 61% were male, and the mean time from injury was 15 months. Financial distress was reported by 64% of patients (95% confidence interval, 56% to 72%). Financial toxicity did not differ by fracture severity (P = 0.12). Medical complications were associated with a 14-point increase in financial toxicity (P = 0.04). Age over 65 years (-15 points, P = 0.03) and incomes of $70,000 or more ($70,000-$99,999, -15 points, P = 0.02; >$100,000, -19 points, P < 0.01) protected against financial toxicity. We observed financial distress levels more than twice the proportion observed after cancer. Medical complications, lower incomes, and younger age were associated with increased financial toxicity. Level V. See Instructions for Authors for a complete description of levels of evidence.

Scalp Reconstruction Techniques for the General Surgeon – A Case Report

Scalp injuries are extremely common and although most scalp lacerations/ injuries can be primarily repaired, few require flap coverage. This article discusses the various ways in which we have reconstructed the scalp. This article is a case series of six different cases that required flap reconstruction where six different techniques were used to obtain wound cover with good outcomes. Patients who presented to various smaller hospitals/nursing homes with availability of only a general surgeon and no super specialists in Rural Bangalore with the need for scalp reconstruction were considered for the study. The operative outcome of six different methods of scalp reconstruction/ repair that include four different local flaps, a split skin graft with a wig and a pericranium burr hole drilling followed by split skin graft coverage have been studied.&#x0D; All six cases were followed up for a period of one month post intervention and all of them had good functional and cosmetic outcomes with no complications. There was no incidence of surgical site infection, seroma, or flap/graft failure in the 6 cases included in our study. Both grafts and flaps are equally good modalities in scalp reconstruction, but the choice for which to use should be based on the need of the patient and the type of wound. Grafts can be considered in conditions where there is adequate soft tissue cover over the scalp and in wounds with larger surface area. Grafts have the advantage of being technically simpler and are associated with fewer complications/failure but cannot be used in injuries where the bone is exposed. Flaps have better cosmetic outcome but are technically more challenging.

A V–Y fasciocutaneous flap for perineal reconstruction following abdominoperineal resection: quicker and better than a myocutaneous gluteal flap?

Abstract Background Abdominoperineal resection in patients with anorectal malignancies may require flap reconstruction for large perineal defects as an adjunct to the oncologic surgery. Perineal reconstruction should be timely, safe, and yield good long-term functional results. There is no agreement on the ideal approach. Methods We performed a retrospective observational cohort study to compare clinical outcomes and post-operative complications between a musculocutaneous gluteal flap and a fasciocutaneous V–Y flap for perineal reconstruction. We included all patients who underwent abdominoperineal resection at Karolinska University Hospital between 2016 and 2019. Patient demographics and comorbidities, as well as treatment data, post-operative complications, and follow-up data, were collected from medical records. Results A total of 44 patients were included with a mean age of 65 years where 73% were men. Reconstruction was made with a musculocutaneous gluteal flap in 19 patients (43%) and with a fasciocutaneous V–Y flap in 25 patients (57%). Flap-related post-operative complications occurred in 39% of the patients and the incidence did not differ between the groups (p = 0.831). Neither operative time, time to ambulant mobility, time to drain removal, nor time to epidural removal differed between the groups (p &gt; 0.05). Four patients in the gluteal flap group and one patient in the V–Y flap group presented with long-term complications. Conclusions Post-operative complications are common after perineal reconstruction following abdominoperineal resection regardless of reconstructive approach. Our study confirms that both a fasciocutaneous and a musculocutaneous flap are acceptable options for perineal reconstruction. Level of evidence: Level III, risk/prognostic study.

Surgical and patient-reported outcomes after total knee arthroplasty requiring soft tissue flap reconstruction – A 12-year experience from high-volume arthroplasty hospital

This study investigates the outcomes of complex knee joint reconstructions performed by an orthoplastic surgery team at a tertiary referral hospital. Retrospective review of all the total knee arthroplasty (TKA)/revision TKA (rTKA) procedures with soft tissue flap reconstruction performed between 2008 and 2019 was conducted. Patients were stratified into two groups according to the urgency of surgery: scheduled non-complicated (SNC) and emergent complicated (EC). The whole study cohort was also categorized into non-infected and infected groups. Of 20,184 TKAs operated, 58 patients required flap reconstruction (SNC group n=27; EC group n=31). The most common reconstruction was medial gastrocnemius flap (74%). Mean follow-up time was 31.9 months. Functional knee joint salvage was achieved in 96.3% the SNC group and in 80.6% the EC group patients (p=0.07). Transfemoral amputation rates were 3.7% in the SNC group vs. 6.5% in the EC group (p=0.36). Oxford Knee Score was 34.5vs. 25.5 (p=0.21), and range of motion was 100⁰ vs. 93⁰ (p=0.37) in the SNC and EC groups, respectively. Superior functional knee joint salvage rates were achieved in the non-infected group compared to the infected group (97.1% vs. 75.0%, p=0.004). However, the transfemoral amputation rate was nearly three-fold in the infected group (8.3% vs. 2.9%, p=0.36). Estimated five-year survival with functional knee joint was higher in the non-infected group (p=0.03). Both the SNC and EC groups had similar acceptable limb salvage rates, and functional and PROM outcomes. Infection reduces the probability of a functional knee joint after TKA and flap reconstruction.

Pelvic Exenteration for the Treatment of Locally Advanced Vulvar Cancer in South West Wales.

Simple SummaryThere is no consensus on the optimal treatment strategy for locally advanced vulvar cancer. In this paper, we aimed to highlight the outcomes from pelvic exenteration in our centre. Here, we not only demonstrated the role of pelvic exenteration in the treatment of locally advanced vulvar cancer, but we also revealed modifiable and non-modifiable factors that contribute to outcomes. Furthermore, we highlighted that tumours that are less than 40 mm diameter do not usually require flap reconstruction while tumours of 40 mm diameter or greater would often require flap reconstruction—a finding that we believe has not been previously reported in the literature. However, we recognise that research must continue into treatment options that limit the radicality of surgical resection, although such alternative approaches must offer comparable survival advantages.The treatment of locally advanced vulvar carcinoma (LAVC) represents a major challenge. We investigated the role of pelvic exenteration as a treatment of LAVC. Women who underwent pelvic exenteration for primary and recurrent LAVC in our centre between 2001 and 2019 were included. Among the 19 women included during the study period, 14 women (73.7%) had primary LAVC while 5 women (26.3%) had recurrent disease. Surgical resection margins were microscopically clear (R0) in 94.7% of patients—14/14 undergoing primary treatment and 4/5 undergoing treatment for recurrent disease. Complete closure of the wound was achieved in 100% of women, with no wound left to heal by secondary intention. Tumour size was a predictor of requiring myocutaneous flap reconstruction, with all tumours less than 40 mm undergoing primary closure, while almost all tumours 40 mm diameter or greater (14/15 women) required flap reconstruction (p = 0.001). The 30-day major morbidity rate was 42% and there was no perioperative death. The mean overall survival was 144.8 months (2–206 months), with 1-, 2- and 5-year survival rates of 89.5%, 75.1% and 66.7%, respectively. In our centre, a primary surgical approach to the management of LAVC has resulted in good survival outcomes with acceptable morbidity rates.

Patient-reported outcome and cost implication of acute salvage of infected implant-based breast reconstruction with negative pressure wound therapy with Instillation (NPWTi) compared to standard care

Implant loss due to infection is the most devastating complication of implant-based breast reconstruction. The use of negative pressure wound therapy with instillation(NPWTi) for salvage of infected implant-based breast reconstructions has shown promising results allowing early reinsertion of a new implant as an alternative to the current management with delayed reinsertion. This study compares the patient-reported outcome and cost implication of NPWTi to the current management. Twenty cases of infected breast implants treated with NPWTi(V.A.C. VERAFLO™ Therapy), followed by early reinsertion of new implants were compared to 20 cases that had delayed reinsertion(non-NPWTi). Patient satisfaction was evaluated using the BREAST-Q questionnaire. The average cost per patient was calculated using total operative expense, cost of inpatient stay, investigations, antibiotics, and outpatient visits. Treatment with NPWTi allowed earlier reinsertion of a new implant (NPWTi: 10.3±2.77days vs. non-NPWTi: 247.45±111.28days, p<0.001). Patients in the NPWTi group reported higher satisfaction. The average cost per patient for NPWTi and non-NPWTi was £14,343.13±£2,786.70 and £8,920.31±£3,005.73, respectively(p<0.001). All patients treated with NPWTi had one admission and spent 11.9±4.1days as inpatients, while non-NPWTi patients had 2.1±0.3 admissions(p<0.001) and spent 7.1±5.8days(p<0.004) as inpatients. Patients treated with NPWTi had more procedures (NPWTi:3.35±0.81 Vs. non-NPWTi:2.2±0.41, p=0.006); however, three non-NPWTi cases required flap reconstruction. Patients treated with NPWTi reported higher satisfaction, received a new and earlier implant, and had fewer admissions and outpatient visits; however, they incurred higher average costs, longer inpatient stays, and underwent more procedures. Early implant reinsertion preserves skin envelope; hence avoiding additional cost and stress related to further major autologous reconstruction.

Flap Reconstruction of Perineal Defects after Pelvic Exenteration: A Systematic Description of Four Choices of Surgical Reconstruction Methods.

The treatment of locally advanced or recurrent anorectal cancer requires radical surgery such as extralevator abdominoperineal resection and pelvic exenteration. Larger defects require flap reconstruction. The authors evaluated outcomes of different perineal reconstruction techniques. A systematic search was performed in the PubMed, Embase, and Cochrane databases. Studies reporting outcomes on perineal flap reconstruction in patients with anal or colorectal cancer were included. Data on patient characteristics, surgical details, perineal and donor-site complications, revision surgery, mortality, and quality of life were extracted. Articles were assessed using the Group Reading Assessment and Diagnostic Evaluation approach. The authors included 58 mainly observational studies comprising 1988 patients. Seventy-three percent of patients had rectal cancer. The majority of 910 abdominoperineal resection patients underwent reconstruction with rectus abdominis flaps (91 percent). Dehiscence (15 to 32 percent) and wound infection (8 to 16 percent) were the most common complications. Partial flap necrosis occurred in 2 to 4 percent and flap loss occurred in 0 to 2 percent. Perineal herniation was seen in 6 percent after gluteal flap reconstruction and in 0 to 1 percent after other types of reconstruction. Donor-site complications were substantial but were reported inconsistently. Clinical outcome data on perineal reconstruction after exenterative surgery are mostly of very low quality. Perineal reconstruction after pelvic exenteration is complex and requires a patient-tailored approach. Primary defect size, reconstruction aims, donor-site availability, and long-term morbidity should be taken into account. This review describes the clinical outcomes of four flap reconstruction techniques. Shared clinical decision-making on perineal reconstruction should be based on these present comprehensive data.

Flap Closure of Spinal Defects in High-Risk Patients: A 10-Year Institutional Experience.

Complication rates after spinal surgery are high, in part because of surgical advancements that have made procedures available to a broader range of medically complicated patients. The high rates of infection, hematoma, and dehiscence resulting in open wounds after spinal surgery often warrant plastic surgery involvement. In this study, we aim to examine the effects of preoperative and operative risk factors on complication rates, reoperation rates, and hospital length of stay after flap reconstruction of spinal defects. A retrospective review was performed of 373 patients who required flap reconstruction for spinal wound closure at our institution between 2003 and 2013. Data regarding demographics, comorbidities, operative variables, and postreconstructive course were collected. Of the 373 patients, 97.3% had at least 1 comorbid condition associated with poor wound healing, 91.2% had a significant wound condition at the time of reconstruction, and 81.8% had a history of 2 or more spinal surgeries. After reconstruction, average hospital stay was 14 days, with 35% of patients developing complications and 30% requiring reoperation. Risk factors including elevated body mass index, diabetes, tobacco use, steroid use, low prealbumin level, therapeutic anticoagulation, infection, history of spine surgery, multilevel spinal reconstruction, and spinal hardware were associated with complications, reoperations, and prolonged length of stay. Local muscle flap coverage is an effective strategy for the reconstruction of spinal defects in medically complex patients. To reduce the inherently high risks associated with paraspinous reconstruction in this challenging population, special consideration should be given to preoperative and operative variables associated with poor outcomes. Early coordination between spine and plastic surgeons should be considered in patients at high-risk of wound complications.

Inadvertent Inguinal Sarcoma Excision during Hernia Surgery: Outcomes, Gender Analysis, and Prevention.

Introduction Inadvertent excision of a soft tissue sarcoma during hernia surgery is a preventable clinical scenario that leads to unnecessary patient morbidity. Prior series are few, which only include male patients with little focus on prevention. The purpose of this study is to report the presenting features and outcomes of both male and female patients who underwent inadvertent inguinal sarcoma excision during hernia surgery. Methods A retrospective analysis of a single sarcoma referral center identified 33 patients who were referred for definitive treatment. Patients were divided into three clinically relevant groups based on intraoperative diagnosis, sex, and location of the mass relative to the inguinal ligament. T-tests and Fisher's exact tests were performed to compare continuous and categorical variables, respectively. Kaplan–Meier modeling was performed to assess sarcoma-specific survival. Results Females were younger (47 years vs. 61 years, p=0.003) and had smaller sarcomas (6.7 cm vs. 11 cm, p=0.012) compared to males. Only two sarcomas (2/33, 6%) were <4 cm in size. The majority of sarcomas in females were above the inguinal ligament (12/14, 86%). Twenty-nine (88%) underwent definitive R0 excision. The mean number of surgeries per patient was three (range 1–13), with nineteen (58%) patients requiring flap reconstruction and six (18%) requiring vascular bypass. Five patients locally recurred (15%) at a mean of 38 months after definitive excision (range 5–128 months). Overall sarcoma-specific disease-free survival was 64%, with no difference between males (80 ± 11%) and females (59 ± 17%) (p=0.885). Mean follow-up was 75 months (range 5–212). Conclusion This is the second largest study regarding inadvertent inguinal sarcoma excision and the first to include females. When a suspected hernia is >4 cm, irreducible, firm, and is growing, especially in females, consider obtaining preoperative advanced three-dimensional imaging (CT or MRI) that can differentiate a neoplasm from a hernia.

Degloving Soft Tissue Injuries of the Extremity: Characterization, Categorization, Outcomes, and Management

Background:We aimed to identify degloving soft tissue injury (DSTI) patient characteristics, injury and reconstruction patterns, and factors affecting outcomes of DSTI injuries to propose a reconstructive protocol for these injuries.Methods:A retrospective analysis of consecutive patients with DSTIs of an extremity over a 22-year period has been done.Results:188 patients with 201 extremity DSTIs were included. Mean patient age was 37 years, with follow-up of 19.6 months. In total, 96% of injuries were related to motor vehicles or machinery, and 74.6% of DSTIs had injuries to structures deep to skin/subcutis. The avulsed tissue was utilized in reconstruction in 71.6% of cases and 86.8% of these experienced some loss of the used avulsed tissues. Of the total cases, 82% employed skin grafting in reconstruction. Dermal regeneration templates were used in 32% of patients. An estimated 86.5% of patients had negative pressure wound therapy utilized. Of the injured patients, 21% required flap reconstruction and 22% required some form of amputation. Age, body mass index, and tobacco use did not increase perioperative complications or amputation. DSTIs with injury to structures deep to skin/subcutis were associated with negative pressure wound therapy use (P = 0.02). DSTIs with underlying fractures required more procedures to reach reconstruction completion (P = 0.008), had more minor (P = 0.49) and major perioperative complications (P = 0.001), longer time to heal (P = 0.002), and increased need for amputation (P = 0.02).Conclusions:Factors affecting the reconstructive management and outcome of DSTIs include injury to structures deep to the skin/subcutis. We categorized DSTIs based on the level of injury and proposed a systematic approach to extremity DSTIs which may be utilized by plastic surgeons and other surgical services to manage these complex injuries.

Complications and functional outcomes after transolecranon distal humerus fracture

Transolecranon distal humerus fractures are uncommon injuries. This is the first multipatient case series to describe outcomes and complications following transolecranon distal humerus fractures in the adult population. Design: retrospective; setting: single level 1 trauma center; patients/participants: 16 patients; intervention: surgical management of transolecranon distal humerus fracture; main outcome measurement: Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire after a minimum of 12 months. A total of 16 patients with open (n = 12) or closed (n = 4) transolecranon distal humerus fractures were identified. Nine female and 7 male patients with a mean age of 47 years were included. Mechanisms of injury included motor vehicle collisions (n = 3), motorcycle crashes (n = 4), ground-level falls (n = 3), falls from height (n = 4), train collision (n = 1), and an industrial accident (n = 1). Seven patients (44%) presented with nerve injury. Patients underwent open reduction with internal fixation (n = 15), external fixation (n = 6), or both (n = 5). Additional surgeries were ultimately required in 11 patients (69%), with a mean of 3 surgeries to manage each patient's elbow injuries. All patients returned for at least 3 clinical follow-up visits; mean clinical follow-up was 15.8 months and mean radiographic follow-up was 12.3 months. Complications were observed in 15patients (94%). Eleven patients (69%) had limited range of motion with a flexion arc of less than 100° at their last clinic visit. Seven patients (44%) developed deep wound infections requiring repeat débridement and intravenous antibiotics. Implant removal was performed in 10 patients (62.5%) because of infection (n = 5), symptomatic hardware (n = 4), or device failure (n = 1). Heterotopic ossification was seen in 8 patients (50%)and post-traumatic arthrosis in 4 (25%). Two patients (12.5%) required flap reconstruction for soft tissue defects. Nonunion occurred in 7 patients (44%). DASH scores were obtained for 10 patients (62.5%) at a mean of 3.8 years after injury. The mean DASH score was 40.2, ranging from 4.2 to 76.5. Among respondents, 7(70%) were able to resume working, with an average DASH work module score of25. Management of transolecranon distal humerus fractures remain a challenge for orthopedic surgeons. Complication rates, including deep infection and nonunion, are high, with frequent long-term functional limitations posed to the patient, as evidenced by DASH scores.

Factors associated with the use of vertical rectus abdominus myocutaneous flap reconstruction following abdominoperineal resection for anorectal cancer.

Following abdominoperineal resection (APR), primary closure of the perineal defect is often possible. Some patients, however, require flap reconstruction. Identifying these patients preoperatively is critical to facilitate comprehensive patient counseling and optimize surgical efficacy. A retrospective review of patients undergoing APR over a 10-year period was performed to identify predictive factors for patients requiring reconstruction with a vertical rectus abdominis myocutaneous (VRAM) flap as opposed to primary closure. Student's t and Fisher's exact tests were utilized for statistical analysis. A total of 158 patients underwent APR, 29 of whom (18%) required a VRAM flap. A higher average skin resection area was seen among those requiring flap reconstruction (P < .0001). Flap reconstruction was also associated with current smoking status (P = .0197), anal tumor location (P < .0001), and neoadjuvant radiation (P = .0457). Although not statistically significant, average tumor diameter was larger in the VRAM flap group compared with the primary closure group. While the appropriate method of closure for those undergoing APR should be considered on an individual case basis, patients who smoke, have a tumor located at the anus, or require large skin resection are more likely to need flap reconstruction.

Soft tissue reconstruction in the leg by orthopedic surgeons: Practices at an African trauma center

IntroductionSoft-tissue coverage is a crucial step when treating open tibial fractures, which is often performed by orthopedic surgeons in a low resource setting. The objective of this study was to analyze the use of non-microsurgical flaps to treat such injuries in a West African trauma center. HypothesisPedicled flaps are reliable procedures that can be used by any orthopedic surgeon for soft-tissue coverage in the leg. MethodsA retrospective study was conducted including patients treated between 2007 and 2011 for open tibial fractures or posttraumatic sequelae requiring flap coverage. Early flap necrosis and skin viability at the last follow-up were evaluated. ResultsFifty-five patients with mean age 34 years were included. They had 57 soft-tissue defects requiring flap reconstruction, 36 of which were infected. In total, 62 pedicled flaps were performed: 12 muscular flaps and 50 fasciocutaneous flaps, including 40 rotational flaps and 10 island flaps. The short-term result was successful in 55 flaps (89%). Seven flaps had partial or complete necrosis, including three soleus flaps and three lateral supramalleolar rotational flaps. At the average follow-up of 9 months, skin viability was inferior in the posttraumatic sequelae group and seemed to be altered by primary bone infection. ConclusionSoft-tissue coverage in the leg can be reliably achieved by orthopedic surgeons using simple and robust flaps that do not require pedicle dissection. Surgeon training in basic flap surgery is essential and still inadequate in emerging countries. Level of evidenceIV, Retrospective study.