Chronic posttraumatic osteomyelitis and infected nonunion of the tibia: current management concepts

Chronic posttraumatic osteomyelitis and infected nonunion of the tibia are complex problems that result in considerable morbidity and can threaten viability of the limb. Development of infection may result from compromised soft tissue and bone vascularity, systemic compromise of the host, and virulent or resistant organisms. Biofilm formation on implant and devascularized bone surfaces protects pathogens and may lead to persistence of infection. Management is based on a detailed evaluation of the patient, the involved bone and soft tissues, degree of associated lower extremity injury, and type of bacterial pathogens. Infection control is achieved with radical débridement, skeletal stabilization, and microbial-specific antibiotics. Local antibiotic delivery is a useful supplement to systemic administration. Local or free muscle flaps may be necessary to achieve soft-tissue coverage. Restoration of bone defects and bony union can be accomplished with bone grafting. However, large defects require complex reconstructive procedures, such as distraction osteogenesis and vascularized bone grafting.     

Reconstruction of distal lower extremities defect using the free peroneal artery perforator vessel based flap

Soft tissue defects of the distal lower extremities are challenging. The purpose of this paper is to present our experiences with the free peroneal artery perforator flap for the reconstruction of soft tissue defects of the distal lower extremity. Nine free peroneal artery perforator flaps were used to reconstruct soft tissue defects of the lower extremities between April 2006 and October 2011. All flaps were used for distal leg and foot reconstruction. Peroneal artery perforator flaps ranged in size from 2 cm × 4 cm to 6 cm × 12 cm. The length of the vascular pedicle ranged from 2 to 6 cm. Recipient vessels were: medial plantar vessels in seven cases, the dorsalis pedis vessel in one, metatarsal vessel in one. All flaps survived completely, a success rate of 100%. Advantages of this flap are that there is no need to sacrifice any main artery in the lower leg, and minimal morbidity at the donor site. This free perforator flap may be useful for patients with small to medium soft tissue defects of the distal lower extremities and feet. © 2014 Wiley Periodicals, Inc. Microsurgery 34:629–632, 2014.     

小腿肿瘤保肢术皮肤缺损的修复

目的：比较游离皮瓣和局部皮瓣转移对于肢体肿瘤保肢术中皮缺损修复的安全性。方法：1995年9月-1999年10月，分别用游离皮瓣移植和局部皮瓣转移修复15例小腿恶性骨肿瘤和软组织肿瘤保肢术后形成的皮缺损，9例游离皮瓣移植，6例局部旋转皮瓣。结果：游离皮瓣移植切口均一期愈合，无感染，皮瓣坏死，化疗对游离皮瓣成活无影响。6例局部皮瓣3例在术后5d出现皮瓣循环障碍，皮瓣坏死，伤口开裂，灭活的肿瘤骨外露。结论：小腿肿瘤保肢治疗中，采用局部皮瓣安全性较差。带血管蒂皮瓣游离移植是小腿肿瘤保肢术修复皮肤缺损的理想方法。     

应用股前外侧皮瓣修复Gustilo Ⅲ B型小腿开放性骨折并软组织缺损

目的 探讨股前外侧皮瓣在Gustilo ⅢB型小腿开放性骨折软组织缺损修复中的应用价值.方法 对GustiloⅢB胫骨骨折合并软组织缺损42例,分别行股前外侧皮瓣急诊修复创面10例,早期修复创面16例和晚期修复创面16例,术后随访,对各组疗效进行分析.结果 移植皮瓣全部成活,无截肢病例,术后随访11～47个月,骨愈合时间6～13个月.和急诊、早期修复组相比,晚期修复组骨折愈合时间延长,骨感染、骨不连发生率明显升高,76%的病例需要行二期骨移植修复骨缺损和骨不连,下肢功能评分低于前两组.结论 对Gustilo Ⅲ B型骨折尽早行创面修复手术,可以缩短治疗周期,改善治疗效果,对严重开放性骨折创伤的治疗有较大临床指导意义.

Abstract：

Objective To investigate the clinical results of the anterolateral thigh free flaps for the soft tissue coverage of Gustilo grade-Ⅲ B open bone fractures in lower extremities.Methods The anterolateral thigh free flaps were applied to treat 42 Gustilo grade-11Ⅲ B open fractures.Ten flaps were performed through an emergency procedure.Sixteen were performed at early stage and the other 16 were performed at later stage .The results of the therapy were analyzed after long time follow up. Results All limbs were salvaged and all the flaps survived without protracted course to obtain soft tissue coverage.The follow up ranged 11 to 47 months.The healing time of the bones were significant prolonged in the later stage therapy group compared with the emergency therapy group and the early stage therapy group.In the later stage therapy group,the incidences of the bone infection and nonunion were also higher than the other two groups,and the second stage bone transplantation to repair bone defect and nonunion were needed in 76% patients in this group.The lower limb functions of the later stage treated group were worse than those of the other two groups.Compared to the early stage treated group,better lower limb functions could be obtained in the emergency treated group. Conclusion Delayed soft tissue coverage resulted in higher incidence of complications.The immediate soft tissue coverage of severely injured limbs complicated by Gustilo grade-Ⅲ B open fractures and massive soft tissue defects had the advantages over traditional methods.Hard work though it was,one-stage soft tissue coverage using anterolateral thigh free flaps could obtain better lower limb function.     

Reconstruction of Lower Extremity Fractures with Soft Tissue Defects

Abstract Reconstruction of osseous and soft tissue defects after high-energy lower extremity trauma remains a challenge in trauma surgery. An initial planning of the reconstruction management is crucial in the therapeutic concept of these severe injuries. In Gustilo type II and IIIa fractures with minimal contamination a primary definite osseous stabilization by internal fixation along with primary soft tissue reconstruction is preferable. A variety of local, regional, and even free microvascular flaps are available for acute wound closure in such cases. Staged reconstruction with initial external fixation and vacuum-assisted wound closure is recommended for severe contaminated wounds and extended defects. Early secondary osseous reconstruction of larger osseous defects can be performed either by distraction lengthening technique or by a free vascularized bone graft. Early secondary soft tissue reconstruction necessitates a wide therapeutic repertoire in order to plan the optimal individual strategy. With a modern therapeutic strategy limb salvage with an adequate function after reconstruction of lower extremity fractures with soft tissue defects can be achieved in the majority of patients.     

背阔肌皮瓣游离移植修复下肢巨大软组织缺损

目的探讨背阔肌皮瓣游离移植修复足跟合并小腿或足底、足背巨大软组织缺损的临床效果。方法1998年3月~2005年5月,采用背阔肌皮瓣游离移植修复10例足跟合并小腿或足底、足背软组织缺损的巨大创面。其中男9例,女1例,年龄32~60岁。病程:2h~2个月。耕田机损伤5例,交通事故伤2例,毒蛇咬伤2例,电击伤1例。其中足跟后侧合并小腿后侧皮肤、腓肠肌及跟腱不同程度缺损8例,缺损范围21cm×12cm~35cm×15cm;足跟合并足底、足背和踝部皮肤软组织缺损2例,缺损分别为27cm×14cm和30cm×21cm。均合并骨外露,6例合并骨折,2例合并胫后血管及胫神经损伤,4例合并踝关节开放感染。切取背阔肌皮瓣25cm×14cm~33cm×24cm,其中1例背阔肌皮瓣达38cm×18cm。供区均采用大张中厚皮片移植覆盖。结果术后10例背阔肌皮瓣全部成活,无血管危象和感染发生,创面均期愈合。术后获随访3~24个月,其中5例皮瓣外形臃肿,影响穿鞋,二期行皮瓣修薄整形术;重建感觉的5例患者3例恢复保护性感觉,2例胫神经损伤患者足底痛、温觉恢复,足内在肌功能无明显恢复;5例桥接腓肠肌的背阔肌肌力恢复至级,踝关节功能部分恢复。无继发溃疡发生,所有患者均恢复负重与行走功能。3例供区植皮部分坏死,其中2例经换药后治愈,1例二期植皮修复,余供区植皮均成活。结论背阔肌皮瓣血运丰富,切取范围大,肌瓣可填塞死腔,抗感染能力强,是修复足跟合并邻近巨大皮肤软组织缺损和骨外露感染创面的一种理想皮瓣。     

Technical refinements of composite thoracodorsal system free flaps for 1-stage lower extremity reconstruction resulting in reduced donor-site morbidity

A multitude of local flaps has been suggested for lower extremity reconstruction. However, the gold standard for defect coverage remains free tissue transfer. In this regard, the scapular vascular axis is a well-established source of expendable skin, fascia, muscle, and bone for use in free flap reconstruction of defects requiring bone and soft tissue in complex 3-dimensional relationships.Composite bone and soft-tissue flaps derived from the subscapular vascular axis include the osteocutaneous scapular flap, the "latissimus/bone flap," and the thoracodorsal artery perforator-scapular osteocutaneous flap.Patient outcome following reconstruction of lower extremity defects with composite free flaps from the thoracodorsal system were analyzed. Here, we demonstrate the execution of technical refinements on free composite flap transfers based on the thoracodorsal vascular axis, thus resulting in a stepwise reduction of donor-site morbidity.     

A case report of cross-leg free latissimus dorsi myocutaneous flap transplantation

One of the significant reconstructive challenges is closure of large soft tissue defects of the lower extremity. A patient with a large traumatic defect in the lower extremity was treated with a cross-leg free latissimus dorsi myocutaneous flap. The size of the flap was 32×12 cm. The pedicle was divided 22 days after the initial operation. The result was satisfactory after a 2-year follow-up. This technique allows the transfer of large flaps to cover compromised wounds, with the advantage of using suitable recipient vessels. Received: 4 March 1998 / Accepted: 25 March 1999     

Vascularised bone graft applications in upper extremity problems

Between 1990 and 1996, 16 cases of bone defects were treated by vascularised bone grafting by the authors. Free vascularised fibula was used in 10 cases and one free iliac crest graft was used for upper extremity bone defects. Four vascular pedicled first metacarpal bone and one radial styloid bone were used for scaphoid nonunion. Average follow-up was 26 months (6–78 months) and success rate was 94%. We recommend vascularised bone grafts in the upper extremity when there is risk of infection; the defect is greater than five centimeters when the forearm rotation is unlimited. The avascularity of the scaphoid pseudarthrosis must be verified radiologically or through magnetic resonance imaging. This technique should only be used when other reconstructive techniques are unlikely to succeed. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:160–162 1998     

Reconstruction of soft tissue defects in the extremities with a pedicled perforator flap: series of 25 patients

Since the introduction of perforator-based flaps, new flaps have been described for reconstruction of soft tissue defects in the extremities. Pedicled perforator flaps, often called propeller flaps, are based on a single perforator and are local axial flaps that can be rotated up to 180(0) with the single perforator as the pivotal point. Pedicle perforator flaps have gained popularity because they have a shorter operating time than free flaps. However, some concern has been raised about their reliability. Here we report our results of 11 soft tissue reconstructions in the lower leg and 14 in the upper extremity. The defects were mostly traumatic or caused by release of burn scars. The mean size of the flaps in the lower leg was 52 cm(2) (range 126-15 cm(2)). In the upper extremity it was 24 cm(2) (range 12-35 cm(2)). All patients were followed until the wound had healed. In the upper extremity there was only one partial necrosis of the flap, and one patient had an infected wound. One haematoma was evacuated postoperatively, and all the rest healed uneventfully. In the lower leg we had one total necrosis and one partial necrosis of the flap and one infected wound. A free scapular flap was used for salvage in one case, and revision and skin grafting in two. The pedicled perforator flap is reliable, particularly in the upper extremity. The operation is quick and can be done under regional anaesthesia. The flap is thin and has a local texture that gives a good functional and aesthetic result. The pedicled perforator flap is a little unpredictable in the lower leg, probably because the directions of the vessels that arise from the perforator are not consistent.     

The use of free flap for limb salvage in children with tumors of the extremities

Background

The purpose of this study was to evaluate long-term functional outcomes in pediatric oncology patients who underwent limb salvage using free flaps.

Methods

All 22 pediatric oncology patients treated with a free flap for extremity salvage were included in the study from 1999 to 2008.

Results

The median patient age was 13.5 years. All but one patient had sarcoma, which involved lower extremity in 45% and upper extremity in 55%. The median bone defect length was 13.9 cm: reconstructed with vascularized free fibula in 68% (in 23% osseous allograft was also used) and used fibula growth plate transfer in 23%. The mean soft tissue defect area was 108 cm²: reconstructed with latissimus dorsi flap in 4 patients, vertical rectus abdominus muscle flap in 2, and anterolateral thigh flap in 1. The majority of the complications were nonunion (14%) and wound infection/dehiscence (14%). The median Musculoskeletal Tumor Society score was 70. Patients with tumors in the upper extremity had significantly higher Musculoskeletal Tumor Society scores compared with lower extremity tumor patients (80 vs 50, P = .04); and among those with lower extremity tumors, patients with distal defects had better outcomes than patients with proximal defects (70 vs 40, P = .03).

Conclusion

In pediatric oncology patients who need limb salvage, use of free flaps can result in good long-term functional outcomes.     

Can indications for lower limb replantation and revascularization be expanded with simultaneous free-flap transfer for limb salvage?

High-energy trauma from road accidents and work-related injuries is the most common cause of lower-limb traumatic amputations. Many of these cases require extensive debridement and substantial bone shortening for primary closure because of crushing and/or avulsion of the involved parts. Since 1998, the authors have replanted or revascularized five lower limbs in five patients. Free tissue transfers have been used to cover soft-tissue defects during replantation and revascularization in all patients. The numbers and kinds of free flaps include one latissimus dorsi muscle, two transverse rectus abdominis musculocutaneous (TRAM), and two anterolateral thigh fasciocutaneous flaps. Survival of the replanted and revascularized limbs and transferred flaps was obtained in four patients. Below-knee amputation was performed because of flap necrosis and extensive infection in one patient. Simultaneous free-tissue transfers may be used simultaneously with lower limb replantation or revascularization to obtain functional extremities in appropriately selected patients. The indications for lower limb salvage may be enhanced and successful results may be obtained in one stage, with low complication rates and shorter hospital stays. The authors report their experience with simultaneous free tissue transfers and lower limb replantation or revascularization.     

Die Deckung von Weichteildefekten und instabilen Narben über der Achillessehne durch freie mikrochirurgische Lappenplastiken

INTRODUCTION: Coverage of the exposed Achilles tendon requires thin, supple tissue to provide adequate range of motion and a satisfying aesthetic result for the distal lower extremity. Various local flaps and free flaps have been described for reconstruction of small and large defects. Small defects can be closed with local tissue, whereas free flap coverage may be necessary for coverage of large defects. METHODS: From July 1993 to September 1998 14 patients between the age of 15 and 74 years (mean 47 years; 3 female, 11 male) underwent free flap coverage for the exposed Achilles tendon due to primary trauma, chronic wounds or tumors. The mean duration of follow-up was 33.3 months. The defect size ranged from 8 x 8 to 25 x 28 cm. RESULTS: Six parascapular flaps (three with a vascularized scapular fascial extension), four radial forearm flaps and four latissimus dorsi flaps (one combined with free serratus fascia) were used for soft tissue coverage over the Achilles tendon. Thirteen flaps survived. In one case a parascapular flap had to be removed due to venous thrombosis and a free latissimus dorsi flap was used as secondary salvage procedure. The donor site morbidity was acceptable for most patients after flap harvesting in the subscapular region and also satisfactory in the forearm region. Average active range of motion in the upper ankle joint was 15-0-40 degrees for extension/flexion. All patients were satisfied with the functional and aesthetic result. CONCLUSION: Soft tissue coverage over the exposed Achilles tendon requires an optimal solution for each patient to achieve an aesthetically pleasing result and acceptable function. Microvascular free flaps can be used to reconstruct medium and large defects and to provide gliding tissue for the Achilles tendon. The complication rate of microvascular flaps is comparable with that of local flaps.     

Lower‐limb reconstruction with chimeric flaps: The quad flap*

Early soft‐tissue coverage is critical for treating traumatic open lower‐extremity wounds. As free‐flap reconstruction evolves, injuries once thought to be nonreconstructable are being salvaged. Free‐tissue transfer is imperative when there is extensive dead space or exposure of vital structures such as bone, tendon, nerves, or blood vessels. We describe 2 cases of lower‐extremity crush injuries salvaged with the quad flap. This novel flap consists of parascapular, scapular, serratus, and latissimus dorsi free flaps in combination on one pedicle. This flap provides the large amount of soft‐tissue coverage necessary to cover substantial defects from skin degloving, tibia and fibula fractures, and soft‐tissue loss. In case 1, a 51‐year‐old woman was struck by an automobile and sustained bilateral tibia and fibula fractures, a crush degloving injury of the left leg, and a right forefoot traumatic amputation. She underwent reconstruction with a contralateral quad free flap. In case 2, a 53‐year‐old man sustained a right tibia plateau fracture with large soft‐tissue defects from a motorcycle accident. He had a crush degloving injury of the entire anterolateral compartment over the distal and lower third of the right leg. The large soft‐tissue defect was reconstructed with a contralateral quad flap. In both cases, the donor site was closed primarily and without early flap failures. There was one surgical complication, an abscess in case 2; the patient was taken back to the operating room for débridement of necrotic tissue. There have been no long‐term complications in either case. Both patients achieved adequate soft‐tissue coverage, avoided amputation, and had satisfactory aesthetic and functional outcomes. With appropriate surgical technique and patient selection, the quad‐flap technique is promising for reconstructing the lower extremity.     

Utility of both muscle and fascia flaps in severe lower extremity trauma

BACKGROUND: The evolving technology in trauma management today permits salvage of many severe lower extremity injuries previously even considered to be lethal. An essential component for any such treatment protocol must be adequate soft tissue coverage that often will use vascularized flaps. Traditionally, calf muscles have been used proximally and free flaps for the distal leg and foot. The reintroduction of reliable local fascia flaps has challenged this dictum, proving to be a simpler and yet versatile option. MATERIALS AND METHOD: The role of both muscle and fascia flaps in lower extremity injuries has been retrospectively reviewed from a 2-decade experience. Soft tissue deficits requiring some form of vascularized flap occurred in 160 limbs in 155 patients. The frequency of use of flap types, specific complications and benefits, effect of timing of wound closure, and rate of limb salvage were compared. RESULTS: Initial coverage after significant lower extremity trauma in these 160 limbs required 60 local muscle flaps, 50 local fascia flaps, and 74 free flaps. These flaps had been selected on a nonrandom basis according to wound location, its severity, and flap availability. Complications were directly related to the severity of injury, and for free flaps as a group (39%), although these were not independent variables. Local muscle (27%) or fascia flaps (30%) were similar with regard to this morbidity. Healing was more likely to be uneventful if coverage were accomplished during the acute period after injury, regardless of flap type. Muscle flaps were still used in two thirds of all cases, with the soleus muscle used as often for the distal leg as the mid-leg. Local fascia flaps were most valuable for smaller defects, especially in the distal leg or foot, and often as a reasonable alternative to a free flap. CONCLUSION: The traditional role of the gastrocnemius muscles for flap coverage of knee and proximal leg defects and the soleus muscle for the middle third of the leg was reaffirmed. The soleus muscle often also reached distal leg defects as could local fascia flaps, where classically, otherwise, a free flap would have been necessary. The largest or most severe wounds, irrespective of limb location, required free flap coverage. Local fascia flaps proved to be a valuable alternative.     

上肢大面积皮肤缺损合并感染的显微外科治疗

目的 探讨上肢大面积皮肤缺损合并感染的临床特点，治疗方法及预后等相关因素。方法 对6例上肢大面积皮肤缺损合并感染的患者，采用股前外侧皮瓣游离移植3例，背阔肌皮瓣转位1例，预制骨间背动脉逆行岛状皮瓣2例（其中1例同时用腹股沟皮瓣）。结果 6例皮瓣全部存活，感染得到有效的控制。结论 对于上肢大面积皮肤缺损合并感染的患者，在控制感染的基础上，用皮瓣移植（或移位）覆盖创面是最有效的治疗方法。     

Kn?cherne Segmentdefekte des Unterschenkels

Segmental bone defects mostly result from high energy accidents and are characterized by combined injuries in many types of tissue. The most important requirement for success of bony reconstruction and salvage of the extremity is a sufficient soft tissue covering with vital, well-perfused and infection-free tissue. After radical sequential debridement all techniques in the plastic surgery reconstruction repertoire can be used. Free flaps in particular fulfil all requirements for such compound defects. In cases of segmental defects >6?cm a ??one-stage reconstruction?? with free vascularized bone transfer is the current state of the art. If an infection is additionally present, a well-perfused muscle flap, such as a musculocutaneous latissimus dorsi flap or gracilis flap should be selected. The optimal time point of reconstruction is early secondary defect covering within the first 24-72?h after trauma. An acute defect covering with emergency free-flaps is rarely indicated. All operative procedures should be performed in an interdisciplinary cooperation between trauma and plastic surgeons. However, despite the high success rate of extremity salvage due to modern combined treatment techniques, a permanent restriction of function and reduction in quality of life should be considered and integrated into treatment concepts.     

Nicht chronisch infizierter Knochen-Weichteil-Defekt

A prerequisite for successful treatment of severe trauma to an extremity is radical débridement of the bone and soft tissue destroyed by the trauma. The inevitable bone and soft tissue injuries that ensue have to be accepted so as not to endanger the infection-free healing process. For subsequent reconstruction of the defects, particularly the well-established autologous methods are available. Soft tissue reconstruction is combined with local or free flaps in a one-stage procedure to rebuild the bone defect by fibular transfer, staged reconstruction with autologous cancellous bone, or segment transfer according to Ilisarov. The duration of the entire treatment process is often quite long and can be considerably shortened by modification of the bone reconstruction (conditioning the defect before autologous bone graft, nail support of the distraction procedure).     

Reconstruction of foot defects due to mine explosion using muscle flaps

Landmine explosions bring a formidable challenge to both patients and reconstructive surgeons. Free tissue transfer is the only method of repairing such extensive soft tissue defects of the foot after serial debridements. Sixty-five consecutive free muscle flap transfers were performed in 54 patients who had foot defects involving soft tissue and bone due to mine explosions. Although posttraumatic vessel disease had complicated most of the cases, overall flap survival rate was 83%. Each patient was ambulatory. Ulceration in long-term period was seen in only one patient. Eighty-five percent of patients with successful bone reconstruction and 41.6% of patients without adequate bone replacement demonstrated normal weightbearing in footprints and gait analysis. Free muscle flaps with split thickness skin graft and bone replacement are recommended for the reconstruction of such devastating wounds. © 1998 Wiley-Liss, Inc. MICROSURGERY 18:182–188 1998     

Free style perforator based propeller flaps: Simple solutions for upper extremity reconstruction!

Background:

The introduction of perforator flaps by Koshima et al. was met with much animosity in the plastic surgery fraternity. The safety concerns of these flaps following the intentional twist of the perforators have prevented widespread adoption of this technique. Use of perforator based propeller flaps in the lower extremity is gradually on the rise, but their use in upper extremity reconstruction is infrequently reported, especially in the Indian subcontinent.

Materials and Methods:

We present a retrospective series of 63 free style perforator flaps used for soft tissue reconstruction of the upper extremity from November 2008 to June 2013. Flaps were performed by a single surgeon for various locations and indications over the upper extremity. Patient demographics, surgical indication, defect features, complications and clinical outcome are evaluated and presented as an uncontrolled case series.

Results:

63 free style perforator based propeller flaps were used for soft tissue reconstruction of 62 patients for the upper extremity from November 2008 to June 2013. Of the 63 flaps, 31 flaps were performed for trauma, 30 for post burn sequel, and two for post snake bite defects. We encountered flap necrosis in 8 flaps, of which there was complete necrosis in 4 flaps, and partial necrosis in four flaps. Of these 8 flaps, 7 needed a secondary procedure, and one healed secondarily. Although we had a failure rate of 12-13%, most of our failures were in the early part of the series indicative of a learning curve associated with the flap.

Conclusion:

Free style perforator based propeller flaps are a reliable option for coverage of small to moderate sized defects.

Level of Evidence:

Therapeutic IV.KEY WORDS: Hand defects, perforator flaps, propeller flaps, perforator based propeller flaps, upper extremity, wrist defects