Secondary Reconstructive Procedures Research Articles

ANALYSIS OF CLINICAL AND FUNCTIONAL OUTCOME AND COMPLICATIONS OF TALAR NECK FRACTURES

Objective: To evaluate the clinical, functional and radiographic results from talar neck fractures in patients treated at the Foot and Ankle Surgery Group of Santa Casa de Sao Paulo. Method: We evaluated 20 patients. The mean follow-up time was 71 months. One fracture was classified as Hawkins Type I, 12 as Hawkins type II, five as Hawkins type III, two as Hawkins type IV and four fractures were open. Results: One patient was treated conservatively, 16 were treated with open reduction and internal fixation (three with primary subtalar arthrodesis), one was treated with talectomy and two with tibiotalocalcaneal arthrodesis. The reduction obtained was anatomical in seven feet, acceptable in six feet and poor in four. Seven patients had early complications. There was one case of delayed consolidation and four of talar body osteonecrosis. Four patients required secondary reconstruction procedures. No significant radiographic impairment of the ankle joint was found in 62% of the patients and of the subtalar joint in 25%. Of the patients who did not undergo secondary procedures, 81% complained about the treated foot, 37.5% showed some deformity, 44% presented diminished sensitivity and 50% had to retire from work. The mean loss of motion in the ankle was 49%, and in the subtalar joint, 80%. The average AOFAS score was 73 points. Conclusion: Talar neck fractures are associated with high rates of clinical, functional and radiographic complications.

Distraction osteogenesis of the mandible for airway obstruction in children: Long-term results

Objective To determine the long-term results of distraction osteogenesis of the mandible for upper airway obstruction in children with micrognathia. Study Design Case series with chart review. Setting Tertiary care children's hospital. Subjects and Methods The records of a pediatric otolaryngology practice and tertiary children's hospital were searched for patients treated with bilateral mandibular distraction osteogenesis for upper airway obstruction. Patients were selected if greater than three years of follow-up data were available. Data were analyzed for airway and feeding outcomes, and long-term surgical complications were identified. Results Thirty-two patients met study criteria. Of the 11 patients who had tracheotomy prior to distraction, seven were decannulated after the procedure. Seventeen patients needed perioperative gastrostomy. Seven are now able to feed orally. Fifteen patients treated with mandibular distraction were able to avoid gastrostomy tube placement altogether. The complication of open bite deformity was experienced by nine patients (28%). Five of 32 patients (16%) had tooth malformation, tooth loss, or dentigerous cyst formation while an additional three patients (9%) had long-term facial nerve injury. Nineteen patients (59%) were under three months old at the time of their distraction. Only one of these patients (5.2%) required an additional distraction procedure. Conclusion Long-term follow-up data on patients treated with mandibular distraction for upper airway obstruction show sustained airway improvement. Additionally, micrognathic children treated with distraction have improved outcomes in oral feeding with a relatively low rate of long-term complications. It remains important to follow these patients to monitor the need for secondary reconstructive procedures.

Intra-articular calcaneal fracture: closed reduction and balloon-assisted augmentation with calcium phosphate cement: a case report

IntroductionFor decades, open reduction and internal fixation was the surgical treatment of choice for intra-articular calcaneal fractures, either with or without any augmentation. Delayed weight bearing and wound-related complications are still unresolved. Aiming at a minimally invasive therapy with accelerated mobilization, we applied closed reduction and balloon-assisted augmentation with calcium phosphate cement.Case presentationA 45-years-old Greek man with intra-articular calcaneal fracture was treated with closed reduction and balloon assisted augmentation with calcium phosphate cement. Follow-up was performed using the Maryland foot score, plain radiographs and multidirectional computerized tomography. Early full weight-bearing was performed at the end of the first week postoperatively. There was no need for secondary reconstructive procedures at the 2 year follow-up. The patient had minimal problems regarding the pain, subtalar motion and peroneal impingement. There was no significant further collapse of the subtalar calcaneal articular surface radiologically.ConclusionThe closed reduction and balloon assisted augmentation with calcium phosphate cement of intra-articular calcaneal fractures is a minimally invasive surgical procedure which led to early full weight bearing, good functional patient outcomes and a low complication rate.

Long-term results of treatment including creation of a gutter and muscle transposition for chronic sclerosing osteomyelitis

We evaluated long-term results of treatment including creation of a gutter and muscle transposition in patients with chronic sclerosing osteomyelitis (CSO). Between 1980 and 1996, 11 patients (5 women, 6 men; mean age 36 years; range 17 to 69 years) with CSO were treated with creation of a gutter and muscle transposition. Seven patients had femoral, and four patients had tibial involvement. The main complaint was pain. The patients were evaluated with respect to complaints and radiologically (X-ray, computed tomography, and magnetic resonance imaging) after a mean follow-up of 12.4 years (range 6 to 24 years). During the follow up period, all the patients remained symptom-free without the need for antibiotic treatment except for one patient with tibial involvement, whose pain recurred after five years. The patient's complaint disappeared following reoperation with the same technique. Histologic examination of surgical biopsies showed nonspecific changes consistent with low-grade chronic osteomyelitis. Cultures were negative in all cases. Control radiographies showed no progression of sclerosis. Computed tomography showed cortical bone formation surrounding the transposed muscle, and magnetic resonance imaging showed fatty degeneration in the transposed muscle, without any signs of active osteomyelitis. The aim of gutter creation and muscle transposition is to increase blood supply to the diseased bone segment, without the need for microsurgical interventions and secondary reconstructive procedures. Our long-term results show that this technique is efficacious in patients with femoral and tibial involvement.

The use of circular fine wire frames for the treatment of displaced intra-articular calcaneal fractures

BackgroundThe treatment of displaced intra-articular calcaneal fractures is still controversial.Materials and methodsSixteen consecutive patients admitted at University Hospital with intra-articular fractures were treated with fine wire circular frames and followed up at an average of 160 days from their injuries. We focused on radiological outcome and functional outcome using a patient-based questionnaire.ResultsWe had no secondary reconstruction procedures. With the numbers available, the difference between the preoperative values and the follow-up measurements for Böhler’s angle, Gissane’s angle and posterior subtalar joint space was not statistically significant (P = 0.8, P = 0.2, and P = 0.4, respectively). The standardized AAOS FAS ranged from 42 to 96, with a mean of 80 and a standard deviation of 19.ConclusionsFine wire circular frame is a good alternative to ORIF in displaced intra-articular calcaneal fractures, yielding good patient function, a high return-to-work rate and a low complication rate.

O.608 Orbital dysplasia and plexiform neuroflbroma in NF1

Surgical reduction of fractures involving the orbits, nasoethmoid complex, and adjacent cranium is challenging; adequate initial reduction and stabilization is essential because secondary reconstructive procedures usually provide less than satisfactory results. Our operative techniques for surgical exposure, as well as fracture reduction and fixation, have evolved from standard facial incisions and wire fixation to complete exposure of the orbits, nasoethmoid complex, and adjacent cranium using an extended bicoronal approach, application of ridged plating techniques, and cranial bone grafts when needed. This evolution of surgical technique has been accompanied by an overall improvement in immediate cosmetic and functional results.

O.605 Bioactive glass in fronto-orbital and skull surgery

Surgical reduction of fractures involving the orbits, nasoethmoid complex, and adjacent cranium is challenging; adequate initial reduction and stabilization is essential because secondary reconstructive procedures usually provide less than satisfactory results. Our operative techniques for surgical exposure, as well as fracture reduction and fixation, have evolved from standard facial incisions and wire fixation to complete exposure of the orbits, nasoethmoid complex, and adjacent cranium using an extended bicoronal approach, application of ridged plating techniques, and cranial bone grafts when needed. This evolution of surgical technique has been accompanied by an overall improvement in immediate cosmetic and functional results.

Abdominal aortic coarctation: Surgical treatment of 53 patients with a thoracoabdominal bypass, patch aortoplasty, or interposition aortoaortic graft

Abdominal aortic coarctation is uncommon and often complicated with coexisting splanchnic and renal artery occlusive disease. This study was undertaken to define the clinical and anatomic characteristics of this entity, as well as the technical issues and outcomes of its operative treatment. Fifty-three patients, 34 males and 19 females, underwent surgical treatment of abdominal aortic coarctations from 1963-2008 at the University of Michigan. Patient ages in years ranged from 2-4 (n = 4), 5-8 (n = 17), 9-14 (n = 16), 15-20 (n = 11) and 25-49 (n = 5). The mean age was 11.9 years. Developmental disease (n = 48), inflammatory aortitis (n = 4), and iatrogenic trauma (n = 1) were suspected etiologies. Aortic coarctations were suprarenal (n = 37), intrarenal (n = 12), or infrarenal (n = 4). Patients often had coexisting occlusive disease of the splanchnic (n = 33) and renal (n = 46) arteries. Major clinical manifestations included: aortic and renal artery-related secondary hypertension (n = 50), symptomatic lower extremity ischemia (n = 3), and intestinal angina (n = 3). Primary aortic reconstructive procedures included: thoracoabdominal bypass (n = 26), patch aortoplasty (n = 24), or an aortoaortic interposition graft (n = 3). Primary splanchnic (n = 19) or renal (n = 47) arterial reconstructions were performed as simultaneous (n = 45) or staged (n = 13) procedures in relation to the aortic surgery. Benefits existed regarding improved control of hypertension (n = 46), as well as elimination of extremity ischemia (n = 3) and mesenteric angina (n = 3). Secondary renal or splanchnic arterial reoperations (n = 8) were performed without mortality 5 days to 12 years postoperative for failed primary procedures. Secondary aortic procedures, 5 to 14 years postoperative, were performed for patch aortoplasties that became stenotic (n = 2) or aneurysmal (n = 1), and when thoracoabdominal bypasses developed an anastomotic narrowing (n = 1) or proved inadequate in size with patient growth (n = 1). No perioperative mortality accompanied either the primary or secondary aortic reconstructive procedures. Abdominal aortic coarctation represents a complex vascular disease. Individualized treatment changed little over the period of study, remaining dependent on the pattern of anatomic lesions, patient age, and anticipated growth potential. This experience documented salutary outcomes exceeding 90% following carefully performed operative therapy.

TRAUMATIC LESIONS OF THE BRACHIAL PLEXUS

To analyze retrospectively the outcomes of primary as well as secondary functional reconstructions in 49 patients with traumatic brachial plexus lesions from a single service. Guidelines for treatment might be extracted from this analysis. Among 152 cases of traumatic lesion of the brachial plexus presented to our clinic, 58 underwent primary brachial plexus reconstructive surgery. On exploration, all patients showed stretching and scarring of plexus elements; root avulsions were found in 28 patients (48%). Outcome evaluation was carried out in 49 of these patients with a follow-up period of 1 year or longer (mean follow-up, 27.9 mo; range, 12-72 mo). A total of 43 secondary reconstructive procedures to improve functionality of the involved arm were performed at a later stage in 25 of 58 patients. Outcomes of the secondary functional restorative procedures were evaluated (mean follow-up, 11.5 mo; range, 3-60 mo in 43 procedures). Patients with neurolysis as a stand-alone procedure (11 patients) showed an outcome grade of 4 or 5. The average outcome of the 19 patients with C5, C6, and C7 grafting was Grade 3, the same as in patients with nerve transfers to the upper plexus elements (C5-C6 root avulsions, 13 patients). Patients with multiple root avulsions (five cases) showed an overall poor outcome (Grades 0-2). Secondary functional restorative surgery was performed in 43% of the patients and helped improve individual outcomes, providing a favorable effect on the general functionality of the arm. Among the restorative operations performed, the Steindler procedure, wrist extension restoration, claw hand correction, and free functional muscle flap transfer to the arm and forearm were the most rewarding. A combination of primary brachial plexus reconstruction and carefully evaluated, selected, and planned function-restorative secondary procedures might offer favorable outcomes in patients with partial or total brachial plexus lesions.

HS01 MANAGEMENT OF OBSTETRIC BRACHIAL PLEXUS PALSY AT MIDDLEMORE HOSPITAL

In the year 2000 a surgical service for infants with obstetric brachial plexus palsy commenced at Middlemore Hospital in Auckland. This remains the only service available in New Zealand with the two founding surgeons remaining as its current providers. We present the seven‐year history of this service, the lessons learned from both primary and secondary reconstructive procedures and consider the direction for future treatment.

The Lesions of the Facial Nerve and a Surgical Reconstruction Algorithm

Paralysis of the facial nerve (FNP) has a widely varied etiology. Pathological lesions of the skull base causing facial nerve paralysis may be divided into three groups: lesions of the brainstem, the posterior fossa, and the temporal bone. In our experience, FNP is seldom caused by removal of posterior fossa lesions such as acoustic neurinomas, especially when the continuity of the nerve was preserved. However, lesions compressing the facial nucleus at the brainstem and infectious infiltration of the FN in the temporal bone are more frequent causes. The surgical reconstruction strategy of the injured FN depends on several factors: unimpaired brainstem facial nucleus, the availability of the proximal FN in the posterior fossa, and functional integrity of the target muscles. It has been shown that primary reconstruction of the facial nerve has its supremacy over secondary reconstructive procedures. Nerve reconstruction procedures include direct sutures and grafting, cross face grafting, XII-VII transfer, and others. Ancillary reconstruction options may be subdivided into two major categories: static and dynamic. Static reconstructions constitute face lifting, netting, and suspension. Dynamic procedures include local muscle transfers and free vascularized and innervated muscle transfer. The free vascularized and innervated muscle transfer may be performed as a two-stage procedure or a one-stage procedure. We use the one-stage procedure in our clinic. Based on our experience with 16 patients with FN reconstructions, 8 patients with secondary static corrections, and 15 patients with secondary dynamic free vascularized and innervated nerve transfers, we conclude the following: (1) XII-VII is best suited for old candidates, where a facial nuclear involvement is present; (2) if ipsilateral XII-N is affected, a VII-VII cross face transfer is the next option; (3) in long-standing FNP a local dynamic procedure is valuable in old candidates and a free vascularized and innervated muscle transfer in the young.

Reconstructive Options and Outcomes in Primary vs. Secondary Mandibular Reconstruction

The challenge of mandibular reconstruction is potentially increased in secondary reconstructive procedures as a result of scarring, wound bed contamination, and the greater likelihood of prior radiotherapy. Recipient vessels for microanastomosis may be more likely to be obliterated or encased in scar tissue. However, few reports have attempted to compare reconstructive options and their outcomes with respect to primary vs. secondary mandibular reconstruction. The authors' hypothesis was that factors specific to secondary mandibular reconstruction may increase the risk of flap failure and other postoperative complications, compared with primary reconstruction.

Total Lower Eyelid Reconstruction Using Paranasal Flap

The main aim of this study is to evaluate the advantages, disadvantages, and aesthetic results of the total lower eyelid reconstruction with paranasal flap. The other reconstruction methods are also revisited.Ten patients, who were operated for the reconstruction of total lower eyelid defects between November, 1999 and April, 2005 in our department were included in this study. The total lower eyelid defects of all patients were reconstructed using paranasal flap for anterior lamella and chondromucosal, chondrocutaneous or mucosal graft for posterior lamella. Follow-up time was ranged between 3-35 months. The advantages, disadvantages and complications were defined and aesthetic results of the patients were also evaluated by using a questionnaire which was filled by patients at third month after reconstruction. All flaps and grafts survived, partial or total necrosis was not encountered but one patient with ectropion had a secondary reconstructive procedure. The aesthetic results of the patients were also satisfactory. The paranasal flap is very reliable and safe method for total lower eyelid reconstruction.

Calcaneal Fractures: Indirect Reduction and External Fixation

The current treatment of displaced intra-articular calcaneal fractures has been surgical fixation. The objective of this study was to evaluate the use of indirect reduction with Ilizarov external fixation as a viable alternative in the surgical treatment of certain calcaneal fractures. Thirty-one patients with 33 fractures of the calcaneus (Sanders types II, III, and IV) were treated using small wire circular external fixation. A limited percutaneous plantar skin incision was used to improve reduction of the posterior facet. Fractures were evaluated by preoperative CT scans and classified by an independent observer. Patients were evaluated by physical examination as well as by the AOFAS hindfoot score questionnaire. Followup ranged from 6 months to 4 years. The average AOFAS score for 18 patients available for examination was 66 (42 to 92). The average score increased to 74 for patients with more than 10 months followup and to 77 for patients with isolated calcaneal fractures. Open fractures also had early debridement and soft-tissue coverage; no deep infections were seen in this subgroup. There were 11 complications, including nine superficial pin track infections, one superficial skin necrosis under an area of fracture blister, and one deep infection in a diabetic smoker with severe hemorrhagic fracture blisters. All superficial infections responded to local pin or wound care and oral antibiotics. No secondary reconstructive procedures, including osteotomies, subtalar fusions, or amputations, have been done. All open fractures healed and maintained soft-tissue coverage. Indirect reduction and external fixation is a viable surgical alternative for intra-articular calcaneal fractures. Particularly favorable results were obtained in open fractures when soft-tissue reconstruction also was done. Advantages include shorter time to surgery, immediate weightbearing, minimal invasiveness, few serious wound problems, and no residual hardware. Disadvantages include technical difficulty, incomplete reduction of fracture fragments, and the need for secondary surgery (fixator removal).

Successful microsurgical primary replantation of an amputated cheek

Standard secondary reconstruction procedures are usually applied for the amputation of facial soft tissue, although these procedures lead to unsatisfactory results: in case of an avulsed cheek, a number of important vital cheek functions cannot be restored. More importantly, patients with artificial cheeks often face considerable psychological and social difficulties. Therefore, it appeared to be of interest to conserve soft tissue amputated from the face and to perform a replantation, despite the known problem that cheek veins cannot be re-anastomosed, especially in avulsion injuries. Here, we report a successful microsurgical cheek replantation in a 55-year-old female patient, who had lost cheek soft tissue together with parts of her mouth.

Use of Precontoured Positioning Plates and Pericranial Flaps in Midfacial Reconstruction to Optimize Aesthetic and Functional Outcomes

To present our experience with reconstruction of midfacial defects using "precontoured positioning plates" with or without pericranial flaps and to describe our technique in detail. Thirty-two consecutive patients with midfacial defects subsequent to oncologic resection that were reconstructed primarily with cranial bone grafts and precontoured positioning plates were reviewed for type of defect, functional outcome, complications, and postoperative appearance. Primary reconstruction of all defects in this series was performed. Defects involved the orbital rim, orbital floor, or both in 28 patients (88%), the body of the zygoma in 24 patients (75%), and extended to the skull base in 16 patients (50%). Pericranial flaps were used to cover the bone grafts in 22 patients (69%). Postoperative radiotherapy was performed in 22 patients (69%), preoperative radiotherapy in 5 (16%), and the other 5 (16%) had no radiotherapy. There were no intraoperative complications, and postoperative complications included plate exposure (n = 2), ectropion (n = 3), and partial bone graft loss or resorption subsequent to completion of radiotherapy (n = 2). Postoperatively, appearance was excellent in 24 patients, fair in 6 patients, and poor in 2 patients. Secondary reconstructive procedures were performed in 4 patients (12%). Follow-up ranged from 12 months to 6 years (median, 4.2 years). Precontoured positioning plates with or without pericranial flaps enable precise reconstruction of midfacial defects with precise incorporation of cranial bone grafts. In our series we routinely covered the bone grafts with well-vascularized tissues, leading to a low incidence of complications and excellent aesthetic results.

Secondary Reconstructive Procedures in Obstetrical Brachial Plexus Palsy: Forearm, Wrist, and Hand Deformities

Obstetrical brachial plexus paralysis (OBPP) is a complex, multifaceted disorder with potentially disabling sequalae. Although the shoulder is the most frequently affected joint, the forearm, wrist, and hand may also display diabling deformities. In sequalae involving the forearm, the most frequent deformity is supination contractures followed by pronation contractures. Treatment of OBPP has recently focused on early microsurgical repair; nonetheless, palliative surgery still plays a critical role in the overall reconstructive planning in order to diminish the sequalae of OBPP and improve function of the upper extremity. The preferred palliative surgical proceures for the forearm and hand include flexor or extensor tendon transfers, free muscle transfers, opponensplasty, and bone fusion. The most commonly restored functions are elbow flexion and extension, finger flexion and extension, and, in some cases, shoulder abduction and intrinsic substitution.

Current Management of Obstetrical Brachial Plexus Injuries at Texas Children's Hospital Brachial Plexus Center and Baylor College of Medicine

Obstetrical brachial plexus injuries are reported in the medical literature at a rate of 0.38 to 2.6 per thousand live births. Historically, the management of these lesions has been conservative, with observation and physical therapy as the primary modalities of treatment. However, experience has shown that a small majority of these devastating lesions have required more direct and invasive approaches. The experience gathered over a 15-year time span of managing these cervical nerve injuries has afforded the Texas Children's Hospital Brachial Plexus team the opportunity to come to several conclusions regarding the global treatment of these patients. The first is that diagnosis, observation, and therapy are the initial approaches to these injuries and should be initiated immediately. Second, early surgical intervention is essential to maximizing the long-term improvements in select patients by helping to prevent residual growth deformities and underdevelopment of the affected limbs. Third, the development of secondary residual deformities must be addressed with secondary reconstructive procedures to arrest the underdevelopment of affected limbs. These goals of reconstruction have been implemented over a period of 15 years and have been shown to provide marked improvements in the functionality and quality of life in patients affected with these physically disabling lesions.

Frostbite Injuries Treated in the Helsinki Area from 1995 to 2002

: Exposure to cold results in frostbite, superficial or deeper tissue damage. In severe frostbites, amputations are life-saving but diminish quality of life (QOL). : Retrospective study was performed. RAND 36- questionnaire was administered to assess QOL. Our aim was to investigate risk factors and adjustment to everyday life of hospitalized patients. : 92 frostbites in 42 patients were recorded. One third of the patients were chronic alcoholics. Age and temperature were statistically significant factors for unfavorable outcome. 20% of patients required secondary reconstructive procedures. One-third reported their emotional well-being very poor. Half had limitations in social life. : Hospitalized cases of frostbite are rare. Anti-social behavior increases the risk in general, and patients present with complicated problems similar to those encountered in burns victims. We recommend that frostbite patients requiring hospital attendance are treated in specialized units, where sufficient expertise for acute as well as reconstructive surgery is available.

Congenital Brachial Plexus Exploration

Stanford's experience in the management of obstetrical brachial plexus palsy dates from 1983. A formal clinic service began in 1992. The tenets of management include early evaluations, a dependency on sequential evolution for decision-making, and very early neural surgery for babies with abnormal hands. We watch babies with normal hands for a longer time before advising surgery. At exploration, common patterns of injury are observed. Intraoperative evoked potentials are used to make surgical decisions. Reconstructive goals for upper plexus injuries include shoulder and elbow control. The paramount goal for babies with global palsies is hand function. Therapy throughout the child's growth years is vital. Sequelae, particularly shoulder contractures, require early surgical intervention. Secondary reconstructive procedures are typically beneficial in improving function. Since 1992, over 400 children have been examined, 62 have had neural reconstruction, and 102 have undergone secondary procedures. Surgery has been remarkably complication free. All children having neural reconstruction except 2 have been benefited.