Orthoplastic Surgery最新文献

Introduction

Open fractures with degloving injuries are commonly managed by serial debridements prior to definitive flap coverage in the United States (US). Some international institutions minimize the number of debridements prior to coverage. The purpose of this study was to compare clinical outcomes in patients with open tibia fractures requiring free flap coverage from institutions with differing debridement philosophies.

Methods

This was a multi-site retrospective cohort study of patients treated at two US tertiary care facilities (serial debridement cohort) and one in India (early total debridement cohort) with Type IIIB or IIIC open tibia fractures requiring free tissue transfer. The number of debridements prior to flap coverage were recorded and primary outcomes were rates of infection, non-union, and flap failure. Fischer's exact tests were used to compare outcomes between the cohorts.

Results

80 patients were included, 44 from India and 36 from the US. Patients in the serial debridement cohort underwent more debridements prior to flap coverage (mean 3.64 vs 1.84, p < 0.001) and had significantly higher rates of infection and non-union compared to patients in the early total debridement cohort (p < 0.05). There were no differences in rates of flap failure between the cohorts.

Conclusions

Patients with open tibia fractures treated at institutions favoring serial debridements underwent more debridements and had higher rates of infection and non-union compared to patients treated at a center favoring early total debridement. Serial debridements may not be necessary prior to flap coverage for open tibia fractures and the current practice should be further investigated.

Background

Given the multiple constraints preventing optimal management of open tibia fracture (OTF) and lack of plastic surgeons in the entire country, we developed a two-stage approach. This study aimed to assess the outcome of this approach and identify factors influencing the outcome.

Methods

Consecutive series of 158 patients with OTF managed according to our two-stage protocol, with a minimum follow-up period of 12 months, from July 2015 to June 2021 ​at a tertiary care hospital in Yaoundé (Cameroon), were retrospectively reviewed. Patients were invited to return for a prospective ultimate radio-clinical evaluation. Main outcomes included bone union, functional status, severe complications and reoperation rate. Multivariate logistic regression was used to determine the independent predictors of severe complications.

Results

The mean follow-up period was 30.02 ​± ​17.05 months. Surgical site infection (SSI) was the main early complication, found in 44 (36.4%) cases. The main delayed complications was fracture-related infection in 36 (29.8%) cases. At final follow-up, only 64 (52.9%) patients had achieved bone union without any complication. The reoperation rate was 36.02%. Severe complications at final follow-up included nonunion in 13 (10.3%) patients, chronic osteomyelitis in 17 (14%) patients and amputation in 5 (4.1%) patients. In multivariable logistic regression, the only independents predictors of severe complications were severe OTF [OR ​= ​0.08, 95%CI: 0.02–0.30, P ​< ​0.001] and SSI [OR ​= ​4.53, 95%CI: 1.36–15.02, P ​< ​0.01].

Conclusion

Despite the progress observed with our 2-stage approach, nearly half of patients still develop complications. This study highlights the need for orthoplastic approach of OTF in developing countries.

Background

Tibial malunion and nonunion are complications that may follow the repair of traumatic tibial shaft fractures. Management may sometime require osteotomy and bone transport. In recent years, there has been a paradigm shift in the management of intercalary tibial defects away from bone transport via external fixation towards intramedullary lengthening nails. This shift necessitates a re-evaluation of the approach to infection and soft tissue defects.

Cases

We describe the case of a young man with a two-year history of infected tibial nonunion who underwent osteotomy and debridement before requiring free tissue transfer and eventual bone transport. Second, we present the case of a middle-aged man with a 30-year history of infected tibial malunion. Prior to placement of the intramedullary nail, debridement and osteotomy were performed, followed by two free anterolateral thigh flaps and tissue rearrangement.

Discussion

The use of free tissue transfers and emphasis on achieving an anatomically correct lower extremity prior to the initiation of bone transport resulted in minimal external fixation time, treatment compliance, and satisfactory clinical outcomes. Although multiple treatments can produce successful bone transport, no cohesive treatment algorithm exists that addresses infection, external fixation time, healing, and psychological burden.

Conclusion

The paradigm shift towards intramedullary bone transport devices requires the use of antibiotic implants and prioritization of the soft tissue envelope prior to device implantation to prevent hardware infection and reoperation. An algorithmic management approach by an orthoplastic surgical team that includes an orthopedic surgeon and microsurgeon is recommended.

The Ewing Amputation is a modified approach to transtibial amputation (TTA) that incorporates the construction of agonist-antagonist myoneural interfaces (AMIs) at the time of limb sacrifice. We here present the lessons learned to date in our experience performing this procedure at a single institution, including those relevant to operative technique and perioperative management. It is our intent that, in providing this perspective, other providers are better facilitated to perform this procedure in a safe and efficient manner.

Background

The Below-Knee amputation (BKA) remains a viable reconstructive option for threatened limb loss due to trauma, oncology, and vascular disease. However, the current procedural gold standard of simple osteotomy, traction neurectomy, and closure with a long posterior myocutanoeus flap can lead to less-than-optimal outcomes. Traction neurectomy is often associated with disorganized nerve growth, resulting in both residual limb pain (RLP) and phantom limb pain (PLP). The long posterior flap may result in residual limb widening, edema, muscle atrophy, and need for revisions to optimize prosthetic fit. With recent literature describing the benefits of both targeted muscle reinnervation (TMR) and/or regenerative peripheral nerve interfaces (RPNI) at the time of amputation, we describe a new approach for the reconstruction of the residual limb after BKA via the utilization of these peripheral nerve techniques and a lateral compartment rotational muscle flap that remains innervated by the superficial peroneal nerve.

Methods

Survey data from 25 consecutive patients who had below-knee amputation from October 2019 through October, 2021 with peripheral nerve preparation using TMR or RPNI and innervated vascularized rotational lateral compartment flap closure were analyzed retrospectively using a novel, graphic patient reported outcome pain interface. Patients were excluded from the pain interface if they had active residual limb wounds or their survey was not complete.

Results

Satisfactory results were achieved in 21 patients with this combination of TMR/RPNI and an innervated, vascularized lateral compartment rotational flap. 67% (n ​= ​14) of the patients were completely pain free, with 33% (n ​= ​7) reporting residual limb pain (RLP), 21% (n ​= ​4) reporting phantom limb sensation, and 5.3% (n ​= ​1) reporting PLP. 76% (n ​= ​16) of patients opted for a prosthetic limb and completed fitting in a median average of 82.5 days (IQR ​= ​52) or 11.7 weeks. Of those sixteen, 81% (n ​= ​13) were ambulating in a median average of 185 days (IQR ​= ​28) or 6 months. Only two patients reported associated residual limb wounds that inhibited them from achieving optimal prosthetic use. The residual limb region that correlated with the underlying superficial peroneal nerve within the lateral compartment flap was only indicated as a cause of RLP in two patients (9.52%).

Conclusion

The reconstructive amputation technique described provides for preservation of additional functional muscle, additional soft tissue coverage over the distal residual limb, and integration of TMR and RPNI for mitigation of post amputation neuropathic pain. Performing the BKA with an innervated, vascularized lateral compartment flap provides reliable soft tissue coverage, resulting in a lower incidence of wound dehiscence, residual limb revision, and time to prosthetic fitting.

Introduction

While the ultrasonic bone scalpel (UBS) has shown benefits, including decreased surgical duration, blood loss, and local tissue thermal injury, its implementation has been limited to skull base and spinal surgery. This case series sought to determine the safety and advantages of the UBS for bony resections in limb reconstructive procedures.

Methods

A retrospective review of four patients with a median age of 42 ± 13.38 at the time of resection and bone segment transport (BST) surgery was performed with UBS. Patients with prior history of lower extremity trauma with sequelae including non-union (2), osteomyelitis (1), or both (1). Intraoperative and post-operative courses and complications were documented.

Results

Each patient underwent tibial resection with UBS with a median bone resection size of 6.6 ± 2.85. Three patients underwent BST using cables and external fixator and one underwent plate-assisted BST with an intramedullary device. All patients had proximal corticotomies and antegrade transport, with a formal docking procedure at the end of transport. Complications included fixator cable tensioning device failure, frame readjustment, and pin tract infections. Two patients required subsequent grafting for docking site nonunion. One patient terminated bone transport early. No neurovascular injuries, hematomas, or dead space infections were reported.

Conclusion

The UBS offers a safe mechanism for long bone resections in lower extremity limb reconstruction. Neurovascular structures within the resection zone were preserved and uninjured, demonstrating major advantages in using this technology. Further study is needed to assess the risk for docking site nonunion with UBS.

Background

Coverage of ankle and foot defects has been challenging. This study highlights the importance of microsurgical free tissue transfer as an opportunity for a surgeon to deal with composite foot defects with variable etiology.

Method

A retrospective case review of 28 patients with large Multizonal foot defects resulting from trauma and tumor resections presented to tertiary care hospitals from 2008-to 2021. All defects were reconstructed by free flaps. 14 patients had ALT flaps, 4 underwent free fibula flaps, and 6 had LD flaps and 4 Rectus Abdominis free flaps. Different modalities have been reviewed by literature for the type of flap used, zone involvement, and age groups.

Result

26 patients were male and 2 females. Most of our patients were adults presenting post-trauma including n ​= ​21 (75%) road traffic accidents n ​= ​17 (60.7%), mine blast injury n ​= ​4 (14.2%), and malignancy in n ​= ​3 (10.7%). Age range was from 5 years to 75 years. Most of the patients had involvement of subunits 3 and 4 followed by a combination with other sub-units. After free microsurgical tissue transfer, 2 patients needed immediate exploration, one had arterial compromise and one had venous insufficiency. All flaps survived. 3 patients underwent flap debulking in the follow-up period. All patients were followed for 2 years and returned to daily activities and near to normal ambulation.

Conclusion

Microsurgical free tissue transfer has not only proven its role in post-traumatic composite foot defects but also in malignancies where resection with free margins followed by foot reconstruction poses a major challenge.

Ankle arthrodesis and total ankle arthroplasty (TAA) are both approaches to surgical treatment of ankle arthroses, with the latter becoming increasingly popular as it maintains ankle mobility. TAA has been associated with complications, including wound persistence, periprosthetic osteolysis, infection, and implant failure, which can be attributed to the area's poor vascularization and soft-tissue quality. In particular, the anterior compartment - solely supplied by the anterior tibial artery – explains the heightened risk of poor outcomes in ankle surgery. The effect of a secondary reconstructive procedure, such as a skin graft or a muscle flap for prosthesis salvage, has been well described in the literature. Muscle flaps are indicated in soft tissue reconstructive procedures because they provide a reliable blood supply and significant tissue volume where there is dead space. Here we outline a case where a 53-year-old male patient received a gracilis muscle free flap after TAA to improve outcomes and as an alternative orthoplastic procedure for patients who otherwise would undergo limb amputation. After several months of physical therapy, the patient is pain-free and active. With this, it can be concluded that a free muscle flap has the potential to be used perioperatively in higher-risk patients to improve TAA outcomes and as an alternative to other procedures that can reduce a patient's quality of life, such as ankle arthrodesis or amputation.

Partial hand amputations have profound effects on individuals and are frequently associated with stigma, disability, and perceptions of inadequacy. When reconstructive measures inadequately restore hand form and function, partial hand prostheses may greatly improve independence and identity. Historically, partial hand prostheses were limited to iron hooks and hands, which were largely assistive rather than restorative. However, since the close of World War II, technological advances have dramatically increased the versatility and availability of prosthetic options. Mirroring the rise in prosthetic options, numerous surgical strategies to reconstruct the residuum and facilitate successful prosthetic fittings have been established in recent decades. To assist hand surgeons caring for partial hand amputees, this article provides a historical background of partial hand prostheses, describes the current prosthetic classes, and highlights key techniques that ease device fittings and improve overall hand function with a prosthesis. These orthoplastic concepts, coupled with multidisciplinary collaboration, will likely improve patient outcomes and provide life-restoring solutions for partial hand amputees.

Osseointegration (OI)

for amputees refers to the direct, transcutaneous attachment of a terminal prosthesis to bone. Once the purview of conceptual designs and case reports, OI has dramatically increased in frequency and associated advancements over the last decade. Compelling evidence now demonstrates consistent and significant improvements in patient reported outcomes and quality of life as well as functional outcome measures and performance testing following OI for transfemoral.

Amputations

While minor complications remain both frequent and manageable, major complications have been reported at an acceptable and gradually decreasing frequency, suggesting that OI is a realistic and reasonable consideration for both many surgeons and many patients living with limb loss. Herein, we review the current state of the art for amputation osseointegration including different implants and techniques, outcomes, complications, and adjunctive procedures, as well as discussing future directions and promising technologies on the near horizon.