Soft Tissue Complications Research Articles

Combining Shelf Osteotomy With Proximal Femoral Reconstruction After Oncologic Resection

Introduction: Oncologic proximal femoral resection and reconstruction in skeletally immature children remains a formidable task due to the risk of developing hip instability with patient growth or interval leg lengthening through the prosthesis. Shelf pelvic osteotomy increases femoral head coverage and containment, and favorable long-term results have been reported in the setting of developmental dysplasia of the hip and Perthes disease. We present a technique of combining shelf osteotomy with expandable proximal femoral endoprosthesis reconstruction in pediatric limb-sparing surgery. Materials and Methods: Four surgeons at 2 centers from 2012 to 2020 performed proximal femoral reconstruction with shelf osteotomy. Data were collected retrospectively on operative technique, radiographic measurements, and complications including dislocation, subluxation, implant loosening, pain, function, and radiographic outcomes. Results: Five patients were included in the study. The mean follow-up was 49 months (range: 17 to 104 mo). The mean lateral center edge angle status postproximal femoral resection and reconstruction shelf osteotomy was 56.1 degrees (±30.5). There were no reported incidences of subluxations, dislocations, periprosthetic fractures, or soft tissue complications. The 3 patients with the longest follow-up at 3, 5, and 8 years tolerated serial lengthening of the endoprosthesis totaling 1 cm, 7.25 cm, and 9 cm, respectively, and demonstrated earlier triradiate cartilage closure in the operative side compared with the nonoperative side. All patients have returned to independent ambulation. Discussion: Combining proximal femoral reconstruction with shelf osteotomy in limb salvage pediatric orthopedic oncology may help to improve hip stability with serial lengthening and patient growth.

Pilon fractures: Consensus and controversy.

Pilon fractures are complex injuries that require an individualized approach to treatment to avoid complications and achieve good outcomes. Staged open reduction internal fixation remains the gold standard for most cases to achieve anatomic articular reduction while minimizing soft tissue complications and infection. Careful preoperative planning based on computed tomography dictates the surgical approach for reduction. A subset of cases may be amenable to early definitive or provisional open reduction and internal fixation based on fracture pattern. In some cases of severe articular comminution where reconstruction is not possible, primary ankle arthrodesis may be a good alternative.

SOFT TISSUE COMPLICATIONS IN THE EARLY POSTOPERATIVE PERIOD AFTER OSTEOSYNTHESIS OF CALCANEU

Introduction. The complex anatomy and biomechanics of the calcaneal bone is an important component in stability of a lower extremity. According to the literature, calcaneus fractures occur in 2% of all skeletal bone fractures. The vast majority of such fractures (almost 75%) are intra-articular injuries resulting from high-energy trauma. The absolute majority of studies show the indisputable advantage of surgical tactics for the treatment of intra-articular fractures of the calcaneal bone in a remote period. Conservative treatment of displaced fractures, in turn, is considered as an alternative in cases where there are absolute contraindications to surgical treatment. An analysis of reliable sources demonstrates better long-term functional results in patients treated by applying minimally invasive techniques. To date, the question of the relationship between the choice of surgical treatment method and early postoperative complications from soft tissues remains not fully resolved. The purpose of this work is to analyze soft tissue complications in the early postoperative period after calcaneus osteosynthesis and to determine the relationship between the frequency of such complications and various methods of surgical treatment. Materials and methods. The treatment outcomes of 42 patients with displaced calcaneal fractures (47 fractures) were analyzed. Patients were divided into 3 groups depending on the surgical techniques used in the treatment: open direct reduction through an extended L-shaped approach followed by fixation with a plate, minimally invasive open reduction through access to the subtalar sinus followed by the fixation with a calcaneal mini-plate, closed reduction with transcutaneous cancellous screw fixation. Results. The main soft-tissue complications in the early postoperative period after calcaneus osteosynthesis among patients of different groups were recorded, and the relationship between the frequency of such complications and various methods of surgical treatment was established. Conclusion. The use of minimally invasive methods of surgical treatment for displaced calcaneus fracture prevents a number of early postoperative complications in soft tissues, promotes wound healing and prevents the development of secondary infectious complications.

Comparative Prospective Study: Treatment of Distal Third Tibial Fracture through Medial and Lateral Compression Plate Methods

The most frequent fracture of a long bone is a tibial fracture. Anatomical reduction and rigid fixing may arise from open reduction and plating. To assess and contrast the outcomes of medial and lateral locking compression plates for fractures in the distal part of the tibia. 32 patients with distal tibial fractures were enrolled in the prospective clinical study from November 22, 2019, to November 12, 2020, at Nangarhar University and Public Health Hospital. With a mean age of 34.57 years, 26 closed fractures, and 6 open fractures. Based on the manner of therapy, 32 patients were split into two groups, with the medial plating group (16) included (16 patients) and the lateral plating group. After being released, they were monitored for at least 5 months. The clinical assessment criteria developed by Tinny and Wiss were used to evaluate the functional outcomes. Malunion arose in two cases of the medial plating group and two cases of the lateral plating group as a result.4 cases of superficial and 2 cases of deep infections, 1 nonunion, and 2 wound dehiscence were found in the medial plating group. There were two cases of superficial and one case of deep infection as well as two nonunion in the group3 cases that were classified as excellent-1, good-7, fair-8, and poor. In the lateral plating group, the scores were Excellent 2, good 6, fair 7, and poor 1 respectively. Ankle dorsiflexion and plantar flexion ultimate ranges of motion in the medial plating group were 18.2° and 29.5°, respectively. The end range of motion for the lateral plating group was 20° for ankle dorsiflexion and 33.2° for ankle plantar flexion. Finally, it is safe and practical to plat the distal tibia laterally, which can provide biological fixation and avoid soft tissue complications.

A prospective case series on the efficacy of a cross-linked collagen matrix to increase buccal soft tissue thickness at large edentulous gaps: One-year results.

The objective of this study is to assess profilometric changes following soft tissue augmentation with a cross-linked porcine-derived collagen matrix (CMX) at large edentulous gaps of at least two units. Systemically healthy, nonsmoking patients with a large edentulous gap of at least two units demonstrating a horizontal soft tissue defect, were enrolled in a prospective case series. Soft tissue augmentation was performed in a one-stage approach with a 6 mm thick CMX at the time of implant placement. The primary outcome was the change in buccal soft tissue profile (BSP) at a mesial, central, and distal area of interest (AOI) up to 1 year when compared to the preoperative situation based on superimposed digital surface models. Secondary outcomes included the horizontal dimension of the soft tissue defect, complications, and marginal bone loss (MBL). Fifteen patients (eight females; mean age 58.73 years) were enrolled and 13 could be re-assessed at 1-year follow-up. The mean linear increase in BSP at 1 year was 0.66 mm (98.3% CI: 0.37-0.94), 0.80 mm (98.3% CI: 0.39-1.22), and 0.69 mm (98.3% CI: 0.32-1.06) at the mesial, central, and distal AOI, respectively. Substantial shrinkage of about 75% was observed in all areas between augmentation and 1-year follow-up. Even though 11 of 13 sites were fully augmented immediately postoperative, a soft tissue defect recurred in all sites at 1-year follow-up with a mean deficit of 2.30 mm. Altogether, 25% of the original soft tissue defect was eliminated by soft tissue augmentation. CMX was safe since no postoperative complications occurred and MBL was limited (0.70 mm). CMX is efficacious for horizontal soft tissue augmentation at large edentulous gaps. However, considerable graft resorption may be expected, and the clinical relevance of the augmentation may be questionable since all patients demonstrated a recurring and considerable soft tissue defect 1 year after surgery.

EFFECT OF PIEZO IN POST-OPERATIVE ECCHYMOSIS DURATION IN CLOSED RHINOPLASTY

Introduction: Rhinoplasty is one of the most performed surgeries all over the world and advances in surgical techniques have been happening progressively, although postoperative skin and soft tissue complications, such as edema and ecchymosis, can induce anxiety for patients. Piezo, an instrument that uses ultrasonic vibrations, can provide greater precision and less damage to adjacent soft tissues, causing less surgical trauma and better behavior of soft and hard tissues during healing. Objective: To evaluate the effect of Piezo in duration of postoperative ecchymosis in closed rhinoplasty and the degree of discomfort of patients with this complication. Material and methods: Prospective, longitudinal, analytical, and interventional study in patients undergoing primary closed rhinoplasty, which were divided into 2 groups: Group 1 (control): patients undergoing closed rhinoplasty with conventional osteotomies and Group 2: patients undergoing closed rhinoplasty with osteotomies using Piezo. The evolution of ecchymosis was recorded through photographs sent to the research team until it was not present, the degree of discomfort with ecchymosis was graded from 0-10 at the end of the first week. Results: 13 patients were evaluated, 6 in Group 1 (control) and 7 in Group 2 (Piezo). Age ranged between 18 and 53 years (mean 33.1 years). We had a prevalence of females (69.2%) and the duration of ecchymosis ranged from 0-16 days. The mean duration of ecchymosis was longer in the control group (8 days) compared to the group that used Piezo (4 days). The discomfort in relation to ecchymosis was greater in patients in the control group (5) compared to patients in which Piezo was used (3). Discussion: Piezo has been shown to decrease postoperative morbidity in open and closed rhinoplasties or other surgical procedures. It provides a safe, reproducible and accurate way to perform lateral osteotomies, minor surgical trauma and better soft and hard tissue behavior during healing. In this way, it provides less swelling and ecchymosis compared to conventional osteotomy and can significantly increase overall patient satisfaction. Conclusion: Piezo helps reduce the duration of postoperative ecchymosis after closed rhinoplasty and can reduce the degree of discomfort with this type of complication.

FACTORS AFFECTING FUNCTIONAL OUTCOME OF DISTAL TIBIA FRACTURES TREATED BY PLATING USING MINIMAL INVASIVE PERCUTANEOUS PLATE OSTEOSYNTHESIS TECHNIQUE

Introduction: Minimally invasive plate osteosynthesis (MIPO) is an established technique for fixation of fractures of the distal third tibia. Minimally invasive plating offers the advantage of fracture fixation without disturbing the soft tissue cover, less chances of infection, early mobilization of patient. Using a locking compression plate reduces the tendency for varus collapse and at the same time affords better stability Our study aimed to manage intra articular and extraarticular fractures of the distal third tibia by the minimally invasive plate osteosynthesis technique and follow them. Clinical and radiological outcomes were studied, and clinical indications & efficacy of the procedure reviewed. Materials and Methods: An ambispective analysis of 30 patients of closed distal tibial fractures were operated by MIPO technique. Bone and soft tissue healing and complications encountered were analyzed. Result: It has been a well-known fact that distal tibia fractures have recently been treated by minimally invasive techniques. Literature above says that there is risk of disrupting blood supply with open reduction internal fixation leading to soft tissue healing problems. However, we did not face any of these complications in our patients, infection or wound breakdown with implant exposure. Conclusion: Distal tibial fractures can successfully be treated by single stage MIPPO plating. Considering a proper surgical timing, respect for soft tissue handling, a good fixation can be achieved. Minimally Invasive Osteosynthesis of distal tibial fracture produced reliable results with acceptable range of movement and resuming early return to activities of daily living.

Risk factors for 30-day soft tissue complications after pelvic sarcoma surgery: A National Surgical Quality Improvement Program study.

Soft tissue (ST) complications after resection of bone and ST sarcomas of the pelvis occur more frequently than in appendicular tumors. We sought to identify risk factors for complications within 30 days of surgery. The National Surgical Quality Improvement Program database was used for this study. Patients with sarcomas of bone and ST of the pelvis were retrieved using Current Procedural Terminology and International Classification of Diseases codes. Outcomes assessed were ST complications, overall complication rates, 30-day reoperation, and mortality. A total of 770 patients with pelvic bone and ST sarcoma were included. The ST complication rate was 12.6%, including 4.9% superficial and 4.7% deep surgical site infections. Higher ST complication rates were seen in patients >30 years, with partially dependent health status, hematocrit <30%, bone tumors, tumor >5 cm, amputation procedures, and longer operative times. ST complication rates were 1.5 and 3 times higher in pelvic sarcoma surgeries than in the lower and upper extremities, respectively. Age >30 years (odds ratio [OR] = 5.07), hematocrit <30% (OR = 1.84), operative time 1-3 h (OR = 2.97), and >3 h (OR = 4.89) were risk factors for ST complications. One in nine patients with pelvic sarcoma surgery will develop ST complications within 30 days. Risk factors for ST complications were age >30, hematocrit <30%, and longer operative time.

Some European Gentiana Species Are Used Traditionally to Cure Wounds: Bioactivity and Conservation Issues

Wound care will always be among the main tasks in all surgical specialties. Several medicinal plants have proven efficacy to cure wounds. Ethnobotanical research and ethnopharmacological research have virtually endless potential to find new lead compounds. The aim of this research review is to assess the potential of some Gentiana species as sources of promising active compounds to support wound healing. Gentians are among the most popular medicinal plants used in many countries for a wide spectrum of health conditions. Traditionally, those used to cure wounds are Gentiana lutea, G. punctata, G. asclepiadea, G. cruciata, G. oliverii, G. septemphida, and G. gelida. Candidate compounds with skin regeneration and wound-healing potential isolated from gentians are isogentisin, isoorientin, mangiferin, lupeol, pinoresinol, syringaresinol, eustomoside, and sweroside. Based on the rich source of traditional knowledge on the properties of gentians to cure various skin and soft tissue complications; only very few modern pharmacological studies have been performed to test this potential. Our review demonstrates that this field deserves further investigation. Many gentians are declining in number and have high IUCN conservation status, and cultivation and micropropagation methods are the only solution for the development of new drugs based on gentian extracts.

Early Reduction of the Posterior Column: A Surgical Technique in AO/OTA C3 Tibial Pilon Fractures

Staged treatment for pilon fractures is widely accepted. It remains to be discussed how to reduce and fix posterior column fractures while avoiding clinical complications. We provided a staged treatment protocol with detailed surgical techniques for closed AO Foundation/Orthopaedic Trauma Association (AO/OTA) C3 tibial pilon fractures with fibular fractures. In the first stage, the internal fixation of the fibula and distal tibial posterior column is accompanied by an external fixator. After swelling, the medial and anterior columns were fixed via the posteromedial approach in the second stage. We advocate early reduction and fixation of the posterior column and lateral column. The right timing of surgery can ensure well-reduced articular surface and alignment while minimizing soft tissue complications.

A comparative study of the hemodynamic and clinical effects of using or not tourniquet in total knee arthroplasty.

Pneumatic tourniquet is widely used in lower limb surgery to provide a bloodless operating field. Previous studies on total knee arthroplasty (TKA) in which tourniquets have been applied during surgery have reported some vascular and soft tissue complications. Nevertheless, it is still not well known exactly how use of tourniquets contributes to hemodynamics of the lower limb and its clinical relevance following TKA. In this prospective study, we wished to determine whether tourniquet affects the hemodynamics and postoperative healing of the lower limb in the first few weeks and its clinical relevancies following TKA. We prospectively collected consecutive 110 patients with advanced osteoarthritis of the knee. All the subjects were randomly assigned to one of two TKA procedures: TKA with (Group T) or without (Group O) tourniquets. The hemodynamics of each operated leg was assessed by Doppler, firstly before the operation, then postoperatively on days 2, 6, 14 and 28. The operative and postoperative managements were done the same as those described in the papers done by the author. Parameters during the operative and postoperative course, including, demography, pre- or post-operative knee score, tourniquet time, operation time, estimated blood loss, peri-operative blood transfusion, hospital course and complications will all be recorded and compared in detail.All patients were measured for all response variables, which included demographic variables, results of Doppler, and important surgical outcomes. Fisher's exact test was used to compare differences between the two groups for each discrete variable, and a Mann-Whitney Rank Sum Test was used to analyze each continuous variable. The p-value was set for each test at 0.05 before analysis took place. In accordance with the repeated measures, the venous hemodynamic parameters were checked. If any significant differences appeared in the overall test, values were then compared in pairs using two sample t-tests for all statistical tests. The level of significance was set at p< 0.05. In our 110 patients (55 with tourniquet, 55 without), all checked clinical parameter were without significant difference except postoperative quadriceps muscle recovery. This implied tourniquet use influenced postoperative rehabilitation program. Blood loss amount were similar in both groups. There was only 1 DVT found. Tourniquet use in TKA must be managed very carefully. Not only because of immediate complication resulted from tourniquet but also influence on post-operational functional recovery, especially in quadriceps muscle function. According to this study, TKA without tourniquet use preserves better quadriceps muscle function to provide faster recovery and less transfusion need. It avoids complications from tourniquets as well.

Gracilis Muscle Interposition to Fill the Perianal Dead Space May Decrease Hospital Length of Stay in Fournier's Gangrene.

The treatment of Fournier's gangrene (FG) includes aggressive debridement of the affected necrotic area, broad-spectrum antibiotic therapy, and reconstructive procedures, respectively. One of the main reasons of unfavorable outcomes in FG surgery is that the dead space occurs in the perianal region because of destruction of fascias and soft tissues. In this study, we aimed to evaluate the results of gracilis muscle flap transposition to fill the FG-associated perianal dead spaces. Patients treated for FG-associated dead spaces in their perianal region between the years 2017 and 2021 were included in the study. The patients who underwent the pedicled gracilis muscle flap surgery were included in group 1, whereas group 2 consisted of the patients with no additional surgical procedure for dead spaces but only the reconstruction of the soft tissue defects. Demographic data (age, sex), comorbid diseases, localization and length of perianal dead space, and management method for the soft tissue defects and complications were noted. The length of hospital stay and discharge day after surgery were also recorded. In group 1, the mean duration of hospital stay was 23.5 ± 5.0 (range, 14-48) days, whereas the mean period between the surgery and discharge was 5.1 ± 2.2 (range, 3-12) days. These numbers were 31 ± 8.3 (range, 19-58) days and 12.7 ± 6.1 (range, 7-22) days in group 2, respectively. Statistical comparison of the periods between the surgery and discharge was found to be significantly different ( P = 0.022). The duration of hospital stay was also shorter in the patients with gracilis muscle flap ( P = 0.039). Perianal dead spaces accompanying many of the patients with FG provide appropriate conditions for bacterial colonization. Filling these pouches by the gracilis muscle flap prevented the progression of infection and enabled the patients to return to their normal life earlier.

Skin and soft tissue complications of bone-anchored hearing aids: Introducing a new classification system

ObjectivesThere have been significant surgical and technological advances in bone-anchored hearing aid (BAHA) design, function, and implantation technique, but peri-implant skin complications remain the most frequent complication. The most important aspect in dealing with cutaneous complications is to identify the type of cutaneous lesion.Although Holger's Classification has been an extremely useful clinical tool, this grading system has been shown to be unsuitable for some cases. We therefore propose a new consistent and easy assessment classification of cutaneous complications associated with BAHA. MethodsA retrospective clinical study was carried out at a tertiary centre, between January 2008 and December 2014. All patients under 18 years old with a unilateral BAHA were included in the study. ResultsA total of 53 children, with a BAHA, were included in the study. Post-operative skin complications were observed in 49.1% of the patients. Of the children, 28.3% presented with soft tissue hypertrophy, the most frequently reported skin complication, and grading according to the Holger's classification was not considered feasible.To overcome the difficulties we face in clinical practice, a new classification was developed and presented. ConclusionThe new proposed classification – Coutinho Classification – aims to fill the gaps in the one used currently by introducing new clinical features, most importantly the presence/absence of tissue overgrowth, and by providing a better description of what each category encompasses. This is an inclusive and objective new classification system, maintaining applicability, and useful in guiding the treatment.

Hybrid Percutaneous Management of Acute Midsubstance Achilles Tendon Ruptures

Background: Operative management techniques of Achilles tendon ruptures can be categorized into open repair, mini-open repair, or percutaneous repair. Indications: Surgical repair of acute ruptures of the Achilles tendon is indicated in athletic populations, with percutaneous repair being an effective technique with more favorable outcomes. Technique: With the patient prone, the Achilles rupture is identified and the Percutaneous Achilles Repair System (PARS) jig is inserted under the proximal paratenon. A series of Keith needles and flat braided SutureTape sutures are passed transversely across the proximal stump of the tendon. The sutures are then shuttled through the distal stump using a SutureLasso through medial and lateral percutaneous incisions on the distal medial and distal lateral borders of Achilles, respectively. Sutures are passed, tensioned, and secured to the posterior tuberosity of the calcaneus with two SwiveLock anchors. Results: Percutaneous repair, compared with open repair, results in lower wound complication rates, improved cosmetic appearance and fewer adhesions. Following surgery, patients follow a 5-stage rehabilitation protocol with return to sport when patients demonstrate dynamic neuromuscular control during multiplane activities without pain or swelling. Outcome studies have compared percutaneous repairs to open repairs, with percutaneous repairs demonstrating a quicker return to work or baseline activities (2.8 months versus 5.6 months) and a shorter return to play for athletes (average 18 weeks). Also, a greater number of PARS patients were able to return to baseline activities within 5 months (98%), compared with open repair patients (82%; P = .0001). In a prospective randomized controlled trial of 33 patients, Lim et al reported no postoperative wound infections in the percutaneous group and a 21% infection rate in the open repair group ( P = .01). Finally, in a recent systematic review of only percutaneous repairs, reported rates of sural nerve injury and rerupture were only 3.3% and 2.1%, respectively. Discussion/Conclusion: Compared to open repair, percutaneous Achilles repair allows for decreased risk of soft-tissue complications with comparable functional outcomes and earlier return to activity. Patient Consent Disclosure Statement: The author(s) attests that consent has been obtained from any patient(s) appearing in this publication. If the individual may be identifiable, the author(s) has included a statement of release or other written form of approval from the patient(s) with this submission for publication.

Implant Placement Using the Bone Ring Technique With and Without Membrane Placement: A Preclinical 12-Month Study in Dogs.

The bone ring technique is applied for vertical augmentation, in which the dental implant and autogenous block bone graft are simultaneously inserted. We investigated the healing of bone around implants placed simultaneously using the bone ring technique with and without membrane placement after a 12-month healing period. Vertical bone defects were created on both sides of the mandible of Beagle dogs. Implants were inserted into the defects through bone rings and fixed with membrane screws as healing caps. The augmented sites on one side of the mandible were covered with a collagen membrane. Samples were harvested 12 months after implantation and assessed histologically and by microcomputed tomography analysis. All implants remained throughout the healing period; however, except for 1 implant, they showed lost caps and/or exposure to the oral cavity. The implants had contact with newly formed bone despite frequent bone resorption. The surrounding bone appeared mature. The medians of bone volume and percentages of total bone area and bone-to-implant contact within the bone ring were slightly higher in the group with membrane placement than in that without membrane placement. Nevertheless, none of the evaluated parameters were significantly affected by the membrane placement. In the present model, soft tissue complication was frequent, and the membrane application did not reveal the effect at 12 months after implant placement using the bone ring technique. Sustained osseointegration and maturation of surrounding bone were observed in both groups after a 12-month healing period.

The effect of botulinum neurotoxin A on soft-tissue complications in intraoral reconstructions

Intraoral reconstruction has become more common in recent years. Patients may suffer from complications because of hypersalivation. This issue can be overcome with an aid aimed at reducing saliva production. In this study, patients who underwent flap reconstruction were examined. The aim was to compare the complication rates between those who were administered with botulinum neurotoxin type A (BTXA) to the salivary glands before the reconstruction and those who were not. Patients who underwent flap reconstruction between January 2015 and January 2021 were included in the study. The patients were divided into 2 groups. BTXA was applied to the parotid and submandibular glands in the 1st group at least 8 days before the operation to reduce the salivary secretion. BTXA application was not applied to the patients in the 2nd group before the operation. A total of 35 patients were included in the study. There were 19 patients in group 1 and 16 patients in group 2. The tumor type in both groups was squamous cell carcinoma. For patients in the 1st group, salivary secretion decreased in an average of 3.84 days. In the statistical analysis, no significant difference was found between the groups in terms of age, comorbidity, smoking-complication development, and comorbidity-complication development. When infection was excluded, there was a significant difference in the development of complications between the groups. BTXA application before the operation is beneficial to minimize complications in patients who plan to undergo elective intraoral reconstruction.

Osseointegration for Lower Limb Amputation: Understanding the Risk Factors and Time Courses of Soft Tissue Complications.

Lower-limb osseointegrated prostheses are a novel alternative to traditional socket-suspended prostheses, which are often associated with poor fit, soft tissue damage, and pain. Osseointegration eliminates the socket-skin interface and allows for weight-bearing directly on the skeletal system. However, these prostheses can also be complicated by postoperative issues that can negatively impact mobility and quality of life. Little is known about the incidence of or risk factors for these complications as few centers currently perform the procedure. A retrospective analysis was performed on all patients who underwent single-stage lower limb osseointegration at our institution between 2017 and 2021. Patient demographics, medical history, operative data, and outcomes were collected. Fisher exact test and unpaired t tests were performed to identify risk factors for each adverse outcome, and time-to-event survival curves were generated. Sixty patients met our study criteria: 42 males and 18 females with 35 transfemoral and 25 transtibial amputations. The cohort had an average age of 48 years (range, 25-70 years) and follow-up period of 22 months (range, 6-47 months). Indications for amputation were trauma (50), prior surgical complication (5), cancer (4), and infection (1). Postoperatively, 25 patients developed soft tissue infections, 5 developed osteomyelitis, 6 had symptomatic neuromas, and 7 required soft tissue revisions. Soft tissue infections were positively correlated with obesity and female sex. Neuroma development was associated with increased age at osseointegration. Neuromas and osteomyelitis were both associated with decreased center experience. Subgroup analysis by amputation etiology and anatomic location did not show significant differences in outcomes. Notably, hypertension (15), tobacco use (27), and prior site infection (23) did not correlate with worse outcomes. Forty-seven percent of soft tissue infections occurred in the 1 month after implantation, and 76% occurred in the first 4 months. These data provide preliminary insights into risk factors for postoperative complications arising from lower limb osseointegration. These factors are both modifiable (body mass index, center experience), and unmodifiable (sex, age). As this procedure continues to expand in popularity, such results are necessary to inform best practice guidelines and optimize outcomes. Further prospective studies are needed to confirm the above trends.

CORR Insights®: Have Surgery and Implant Modifications Been Associated With Reduction in Soft Tissue Complications in Transfemoral Bone-anchored Prostheses?

1Uniformed Services University — Walter Reed Department of Surgery, Bethesda, MD, USA B. K. Potter, Norman M. Rich Professor and Chair, Uniformed Services University of Health Sciences, 4310 Jones Bridge Road, A3011-SUR, Bethesda, MD 20814, USA, Email: [email protected] This CORR Insights® is a commentary on the article “Have Surgery and Implant Modifications Been Associated With Reduction in Soft Tissue Complications in Transfemoral Bone-anchored Prostheses?” by Atallah and colleagues available at: DOI: 10.1097/CORR.0000000000002535. The author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writer, and do not reflect the opinion or policy of CORR® or The Association of Bone and Joint Surgeons®.

Surgical Considerations of One-Stage Reconstruction of Large Extremity Defects Using a Thin Deep Inferior Epigastric Perforator Flap.

Background One-stage reconstruction with "thin perforator flaps" has been attempted to salvage limbs and restore function. The deep inferior epigastric perforator (DIEP) flap is a commonly utilized flap in breast reconstruction (BR). The purpose of this study is to present the versatility of DIEP flaps for the reconstruction of large defects of the extremities. Methods Patients with large tissue defects on extremities who were treated with thin DIEP flaps from January 2016 to January 2018 were included. They were minimally followed up for 36 months. We analyzed the etiology and location of the soft tissue defect, flap design, anastomosis type, outcome, and complications. We also considered the technical differences in the DIEP flap between breast and extremity reconstruction. Results Overall, six free DIEP flaps were included in the study. The flap size ranged from 15 × 12 to 30 × 16 cm 2 . All flaps were transversely designed similar to a traditional BR design. Three flaps were elevated with two perforators. Primary closure of the donor site was possible in all cases. Five flaps survived with no complications. However, partial necrosis occurred in one flap. Conclusion A DIEP flap is not the first choice for soft tissue defects, but it should be considered for one-stage reconstruction of large defects when the circulation zone of the DIEP flap is considered. In addition, this flap has many advantages over other flaps such as provision of the largest skin paddle, low donor site morbidity with a concealed scar, versatile supercharging technique, and a long pedicle.

Soft tissue related complications around anterior implants: commentary and clinical checklist.

Implant-based rehabilitation is a clinical challenge, especially in the esthetic area. Numerous factors influence the outcome of the rehabilitation; however, the two main factors are the bone and soft-tissue deficiencies at the intended implant site. Peri-implant soft tissue complications can arise from a combination of factors that can be summarized in two categories: diagnostic errors and surgical planning management errors. Most of the complications can be corrected after each step of the treatment and even after the delivery of the prosthetic restoration with adequate soft tissue management in order to give the patient an esthetically pleasing outcome. The aims of this article are: to present the current literature, to propose a clinical checklist that will guide clinicians in evaluating the prognosis of the treatment utilizing soft tissue grafting, to illustrate a case series partially employing the proposed clinical checklist. The proposed checklist could be helpful in evaluating the prognosis of the treatment utilizing only soft tissue grafting. In clinical cases, in which the prognosis is classified as good, soft tissue management could be a viable treatment option before attempting more radical procedures like implant removal.