Orthoplastic Surgery最新文献

Lower extremity trauma is an important cause of patient morbidity and disability-adjusted life years (DALYs). It also presents a significant reconstructive challenge for surgeons. Mangled extremity injuries can result in an amputation when limb salvage procedures are unsuccessful. Identifying strategies to optimize limb salvage attempts is necessary to improve postoperative outcomes. Establishing a constructive relationship between orthopaedic and plastic surgeons has been shown to be beneficial and subject to a growing interest in the trauma literature. We present the case of a 42-year-old male referred to our institution for limb salvage after sustaining severe bilateral lower extremity injuries. These included a right open Gustilo 3B tibia shaft fracture with a critical bone defect combined with a left floating knee (closed femur fracture and open Gustilo 3C tibia fracture). Bilateral tibia fracture-related infections were treated in conjunction with successful flap coverage. Following eradication of the infections, adequate soft tissue coverage and stable bony fixation, the tibia critical bone defect of close to 8 cm was treated with bone transport. Limb salvage was successful; amputation was avoided, and good function of both limbs was achieved. This manuscript shares a great clinical success in the extensive collaboration between two surgical subspecialties.

The purpose of this study is to describe the efficacy of lateral supramalleolar flap as an option for soft tissue repair in open fractures of foot and ankle and to present the experience in 2 trauma units: Hospital Susana López de Valencia, Popayán Colombia, and Hospital Universitario de Santander, Bucaramanga Colombia.

This is an observational, case series study including all patients with open fractures of foot and ankle who were treated from January 2016 to June 2021 and who required soft tissue coverage. Patients whose soft tissue injury was located on the anatomical area of the perforating peroneal artery, those with less than 6 months of follow-up and those who refused the proposed treatment were excluded. On the other hand, although literature reports flaps of up to 100 cm² [1], in our hands, this flap unsuitable for skin defects larger than 60 cm², and other procedures such as free flaps should be considered in these cases.

Thirteen patients were selected, 9 men and 4 women, with a mean age of 30 years (12–62 years) and mean follow-up duration of 10.3 months [[6], [7], [8], [9], [10], [11], [12], [13], [14]]. In 11 patients, the mechanism of trauma involved a motorcycle accident. Mean flap size was 40 cm² (30–48 cm²). Ten flaps survived with no acute problems, 2 presented with venous congestion and epidermolysis, which were treated conservatively, and 1 developed complete necrosis requiring reintervention. All interventions were performed by the authors belonging to the orthopedic trauma units from the involved hospitals.

The lateral supramalleolar flap is an excellent alternative for the treatment of coverage defects caused by open foot and ankle fractures, producing satisfactory and predictable results in the hands of orthopedic surgeons with no specific training in microsurgical techniques.

Level of clinical evidence: 4.

Severe flexion contracture of the hallux secondary to excessive fibroblastic proliferation in Ledderhose disease can result in the cavus-like deformity. There are few references in the literatures regarding the operative methods for rigid deformities combined with progressive gait disturbance in patients with plantar fibromatosis. We report a case who achieved satisfactory clinical and esthetic outcomes through one-stage surgical correction with bilateral subtotal plantar fasciectomy and the first metatarsophalangeal arthrodesis.

Limb-threatening upper and lower extremity traumas are life-changing events that are frequently treated with either replantation or amputation. Given the severity of impact on a patient's life, establishing proper shared decision-making is essential when communicating with patients the options of amputation versus limb salvage. Despite the widespread prevalence of shared decision-making in healthcare, it remains the exception, rather than the rule in limb-threatening traumas. This paper therefore seeks to describe existing shared decision-making frameworks in the hopes of improving utilization of such models in limb salvage cases.

Background

Focal soft-tissue and bony injuries secondary to pressure can result in significant morbidity, including sepsis and in some cases, death. In the setting of severe wounds or recalcitrant infection, an infrequent modality of treatment is a pelvic amputation such as hemipelvectomy or hemicorporectomy. There is little data to guide the perioperative management and optimization prior to the procedure.

Methods

Patients with decubitus ulcers who underwent hemipelvectomy or hemicorporectomy at the University of Colorado and had follow-up from 2012 to 2021 were identified. Patients were categorized as “planned” or “emergent” based on sepsis criteria and performing the procedure within 90 days of index admission.

Results

Nine patients met criteria for inclusion. Three underwent hemicorporectomy, six underwent hemipelvectomy with one patient additionally undergoing hemipelvectomy of the contralateral side (ten total cases). Of these 10 cases, 90% reported complication and 40% had recurrence. Five patients required revision with “emergent” patients requiring on average 2.8 revisions and planned cases requiring 1.0 (p = 0.15). “Emergent” cases had lower albumin levels versus “planned” (2.3 g/dl, 3.3 g/dl p = 0.02) as well as 75% mortality (3/4) compared to 0% mortality (0/6) (p = 0.03).

Conclusions

Hemipelvectomy and hemicorporectomy represent a morbid treatment modality for recalcitrant decubitus ulcer. In the emergent setting in which patients are ill and significantly deconditioned it can have significant mortality. In those able to be staged and optimized with additional perioperative planning, recurrence and revision rates remain high, but mortality decreases significantly.

Level of Evidence

III.

Introduction

Traumatic injuries, metabolic, vascular and malignant diseases are among the main causes of soft tissue defects in the lower limb. The limited tissue resources and the peculiarities of the blood supply make reconstructive treatment a challenge. Various modalities of fasciocutaneous flaps have been gaining popularity in the treatment of soft tissue defects in the lower extremity.

Material and methods

A retrospective analysis including a group of 19 patients with soft tissue defects in the lower limb, treated in the period June 2019–July 2021 in the Department of Burns and Plastic Surgery, UMHATEM “N. I. Pirogov” was conducted. Twenty fasciocutaneous flaps were performed (6 - Keystone flaps, 6 - Reverse flow Sural flaps, 4 - Perforator Propeller flaps, 2- V–Y perforator flap, 2 - Axial Rotation flap). Demographic and clinical data is analyzed. Functional (LEFS) and aesthetic evaluation (POSAS 2.0) of the achieved results is obtained.

Results

Patients were of both sexes, aged between 23 and 78 years. All of the flaps survived. Minor complications occurred in 3 cases. Significant functional improvement and satisfactory aesthetic results were reported.

Discussion

Free tissue transfer, considered as the “gold standard” in the reconstruction of complex defects involving the lower limb, has its drawbacks. Fasciocutaneous flaps are a good alternative option to free flaps. They are characterized by good functional results and rare complications.

Conclusion

Utilization of the fasciocutaneous flap strategy is a reliable method for ensuring the integrity and the function of the lower limb.

Background

This study aims to identify risk factors as well as proper indications for forefoot or midfoot amputations at the transmetatarsal, Lisfranc or Chopart level as a potential avenue for distal limb salvage and avoid below knee amputation (BKA).

Methods

This study utilized the PearlDiver national database encompassing 91 million unique patients from 2010 to 3/31/2020 to identify patients who underwent foot amputation (CPT-28800, CPT-28805). The primary endpoint is conversion to BKA within 6 months. Propensity matched cohorts were created using age, gender and common comorbidities. Logistic regression utilizing the matched cohorts determined odds ratios for conversion to BKA based on indication. Indications included abscess, gangrene, osteomyelitis, and diabetic wounds. Analysis was repeated at 1, 2 and five years. Chi-square analysis was used to assess the impact of comorbid peripheral vascular disease (PVD) in a subgroup of patients with osteomyelitis. Time to conversion to BKA was tabulated.

Results

The database identified 17,875 patients who underwent forefoot or midfoot amputation . Conversion to BKA occurred in 2400 patients with median time of 71 days. Logistic regression of the matched cohorts revealed that gangrene was a significant risk factor for conversion to BKA, while osteomyelitis was protective. Subgroup analysis of the osteomyelitis cohort revealed a higher rate of conversion to BKA for patients with concomitant PVD (OR 1.44; P = 0.01).

Conclusion

Based on our data, forefoot or midfoot amputation should be cautiously considered in patients with gangrene or osteomyelitis with concomitant PVD because of a significantly higher rate of conversion to BKA.

Level of evidence

IV.

Purpose

The study aimed to analyze the firecracker blast injury to the hand in children and assess the functional outcome. In addition, the article classified the firecracker blast injury pattern to the thumb in children.

Methods

A retrospective cohort study was conducted between 2012 and 2020, analyzing 31 children sustaining firecracker blast injuries. The functional outcome was assessed. The author also proposed a classification based on the injury involving the webspace, flexor pollicis longus, thenar, adductor, and flexor muscles, neurovascular injury, and fractures/dislocations.

Results

There were 30 males and one female with a mean age of 6 years (range 2–13 years). The mean follow-up was 25 months (Range, 12–36 months). The author classified the injury into grades 1 (n = 9 children), 2 (n = 12), 3A (n = 8) and 3B (n = 2) based on the involved structures. All children had better functional outcomes following the reconstructive procedures based on the classification. The grades of injury did not significantly impact the functional outcome (p = 0.96).

Conclusions

Despite the complexity and multitude of firecracker blast injuries, children performed better. The classification based on firecracker blast injury involving vital structures is simple, straightforward, and meaningful. It is helpful for decision-making at the first surgery and subsequent secondary reconstructive procedures.

Level of evidence

IV.

This article describes a complex case where an open tibial pilon fracture in a 39-year-old male resulted in septic pseudoarthrosis with articular involvement and skin necrosis. The infection was managed through a debridement with extended margins and an obliteration of the defect with an antibiotic-impregnated spacer. Once the infection was treated, the bone defect was filled by a bone transport procedure combined with a tibiotalar arthrodesis. The soft tissues were covered by means of a propeller flap. Although the final result of the case was satisfactory several lessons were learned, among them the need to always suspect an infection when treating open fractures in the distal tibia, the fact that a wide resection with application of local antibiotics contributes to successful management of osteomyelitis, and the usefulness of combining bone transport with flaps as a limb reconstruction procedure.