Reconstruction of post-traumatic long bone defect with vascularised free fibula: A series of 28 cases

Introduction:

The severe long bone defects usually follow high-energy trauma and are often associated with a significant soft-tissue injury. The goal of management of these open long bone defects is to provide stable fixation with maintenance of limb length and soft-tissue coverage. The purpose of this article is to present the clinic-radiological outcome, complications and treatment of post-traumatic long bone defect with vascularised fibula transfer.

Materials and Methods:

Retrospective records of 28 patients were analysed who presented with post-traumatic long bone defects and in whom reconstruction with vascularised free fibula was done. Demographic data were recorded and clinical and radiological assessment was done.

Results:

Out of 28 patients in whom vascularised free fibula transfer was carried out three flaps were lost while non-union occur in three patients. Three patients developed a stress fracture of transferred free fibula in the post-operative period. Few of the patients experienced some problems in the donor leg; however, all of them improved in subsequent follow-up.

Discussion:

It is clearly evident from this study that timing of surgery plays an important role in the micro-vascular reconstruction in trauma cases. All the complication like flap loss, non-union or delayed union occur in patients in whom reconstruction was delayed.

Conclusion:

The free vascularised fibula graft is a viable method for the reconstruction of skeletal defects of more than 6 cm, especially in cases of scarred and avascular recipient sites or in patients with combined bone and soft-tissue defects. Results are best when the reconstruction is done within 1 week of trauma.KEY WORDS: Long bone defect, post-traumatic, vascularised free fibula     

Skin paddle vascularity of free fibula flap �C A study of 386 cases and a classification based on contribution from axial vessels of the leg

Objective:

The skin paddle of the free fibula flap receives its vascular supply from septocutaneous perforators, musculocutaneous perforators or from both, and these perforators might originate from the peroneal or posterior tibial vessels or from both. The objective of this study was to classify the skin paddles based on the dominance of vascular contribution by these axial vessels through their different perforator systems.

Materials and Methods:

A retrospective analysis of 5-year data of 386 free fibula flaps used in oro-mandibular reconstruction was done and the skin paddle vascularity was studied. While majority of the skin paddles received their blood supply from the peroneal septocutaneous perforators, a few had their dominant supply from the soleus musculocutaneous perforators in addition to peroneal septocutaneous perforators. In few cases, the soleus musculocutaneous perforators were the sole source of blood supply to the skin paddle. The limitation in this study was the inability to augment the clinical observation with cadaveric study.

Results:

The skin paddle of the free fibula flap was classified into four different types (a–d) based on the dominance of vascular contribution by axial vessels of the leg.

Conclusion:

The skin paddle of the free fibula flap has reliable blood supply, but a thorough knowledge of the variations in vascular pattern of the skin paddle is required especially to salvage the larger paddles used in the reconstruction complex oro-mandibular defects.KEY WORDS: Free fibula flap, musculocutaneous perforators, septo cutaneous perforators, skin paddle, vascular supply     

There is no donor side specificity of fibula free flap for complex oromandibular reconstruction

Background:

The objective of this study was to prove that there is no significance to the donor side (right or left) of the free fibula osteocutaneous flap (FFOCF) in the reconstruction of complex oromandibular defects (COMD) and proper flap planning, designing and tailoring are important in reconstructing different types of COMD after tumour-ablative surgery.

Materials and Methods:

Three hundred and eighty-six consecutive patients who where reconstructed with FFOCF for COMD from Jan 2005 to Dec 2009 over a period of 5 years were studied. Except in seven patients, all fibula flaps were harvested from the left leg as per convenience and to facilitate a simultaneous, two-team approach. Depending on the condition of the neck vessels, vascular anastomosis was performed on the right or the left side, irrespective of the side of the defect.

Results:

Complete flap survival was seen in 334 patients (86.52%). Superficial skin necrosis was seen in 20 patients, and was managed conservatively (5.18%). Partial flap loss was seen in 20 patients (5.18%). There were 39 re-explorations. Complete flap loss was seen in 12 patients (3.10%).

Conclusion:

We found no significance in terms of the results as far as the side of flap donor leg or primary defect were concerned. Flap tailoring in terms of meeting the tissue requirement and vessel orientation were rather more important.     

Harvesting the free fibular graft: A modified approach

Background:

The conventional technique of free non-vascularized fibular grafting is attended with some amount of morbidity and a long scar. We report a technique with little interference to the surrounding soft tissues to harvest more than one-third of whole length fibula.

Patients and Methods:

Thirty four patients of average age 23.5 years (range 8 to 51 years) having various pathologies like simple bone cysts (n=9), fibrous dysplasias (n=6), giant cell tumors (n=7), fracture non-union (n=10) and aneurysmal bone cysts (n=2) were taken up for the study. The fibula were harvested by two separate incisions, 1 cm each at proximal and distal extent of proposed donor site for taking out of graft after elevating the periosteum circumferentially using a periosteum stripper. Compression bandage and above knee plaster immobilization was applied to reduce the dead space collection.

Results:

The mean followup is 34 months. The patients were evaluated clinicoradiology. Thirty three patients showed good results. One patient had fair result due to delayed wound healing from hematoma which was treated surgically.

Conclusion:

The approach of harvesting fibula suggested by author reduces donor site morbidity and is safer than conventional approach.     

Pseudarthrosis of the surgical neck of humerus treated by buttressing with a medial cortico-cancellous graft

Background:

Pseudarthrosis of surgical neck of humerus is uncommon condition. Different methods of improving the stability of fixation have been described, including impaling the shaft into the head, placing a tension suture through the rotator cuff, or using an intramedullary cortical graft. We report our results of cortico-cancellous strut graft medially to counter the varus force, in conjunction with a fixed-angle implant on the lateral side.

Materials and Methods:

We used this technique in seven cases of pseudarthrosis of surgical neck of the humerus. There were four women and three men, ranging in age from 22 to 65 years. All were treated with a tricortical medial buttress bone graft and fixed-angle fixation device on the lateral side. A locking proximal humerus plate (Synthes) was used in six cases, and a bent reconstruction plate (Synthes) was applied in one case. The one in which reconstruction plate was applied was operated before the advent of locking plates. The limb was immobilized in 30° of abduction over a cushion for 6 weeks, followed by a sling for another 6 weeks.

Results:

The followup varied from 18 to 96 months. All our cases healed within mean 5.1 months (range 4–6 months). There was one case of avascular necrosis. All cases had useful function of shoulder.

Conclusion:

The medial buttressing by strut graft with external fixation by laterally placed fixed angle plate is successful to achieve fracture union in pseudarthrosis of surgical neck of humerus.     

Microvascular free flap reconstruction for head and neck cancer in a resource-constrained environment in rural India

Introduction:

Reconstruction with free flaps has significantly changed the outcome of patients with head and neck cancer. Microsurgery is still considered a specialised procedure and is not routinely performed in the resource-constrained environment of certain developing parts of India.

Materials and Methods:

This article focuses on the practice environment in a cancer clinic in rural India. Availability of infrastructure, selection of the case, choice of flap, estimation of cost and complications associated with treatment are evaluated and the merits and demerits of such an approach are discussed.

Results:

We performed 22 cases of free flaps in a six-month period (2008-2009). Majority (17) of the patients had oral cancer. Seven were related to the tongue and eight to the buccal mucosa. Radial forearm free flap (RFF: 9) and anterolateral thigh flap (ALT: 9) were the most commonly used flaps. A fibula flap (1) was done for an anterior mandible defect, whereas a jejunum free flap (1) was done for a laryngopharyngectomy defect. There were six complications with two re-explorations but no loss of flaps.

Conclusion:

Reconstruction with microvascular free flaps is feasible in a resource-constrained setup with motivation and careful planning.KEY WORDS: Free flap, head and neck cancer, microvascular surgery, reconstruction, resource constrained, reconstruction of head and neck     

Facial contour deformity correction with microvascular flaps based on the 3-dimentional template and facial moulage

Introduction:

Facial contour deformities presents with varied aetiology and degrees severity. Accurate assessment, selecting a suitable tissue and sculpturing it to fill the defect is challenging and largely subjective. Objective assessment with imaging and software is not always feasible and preparing a template is complicated. A three-dimensional (3D) wax template pre-fabricated over the facial moulage aids surgeons to fulfil these tasks. Severe deformities demand a stable vascular tissue for an acceptable outcome.

Materials and Methods:

We present review of eight consecutive patients who underwent augmentation of facial contour defects with free flaps between June 2005 and January 2011. De-epithelialised free anterolateral thigh (ALT) flap in three, radial artery forearm flap and fibula osteocutaneous flap in two each and groin flap was used in one patient. A 3D wax template was fabricated by augmenting the deformity on facial moulage. It was utilised to select the flap, to determine the exact dimensions and to sculpture intraoperatively. Ancillary procedures such as genioplasty, rhinoplasty and coloboma correction were performed.

Results:

The average age at the presentation was 25 years and average disease free interval was 5.5 years and all flaps survived. Mean follow-up period was 21.75 months. The correction was aesthetically acceptable and was maintained without any recurrence or atrophy.

Conclusion:

The 3D wax template on facial moulage is simple, inexpensive and precise objective tool. It provides accurate guide for the planning and execution of the flap reconstruction. The selection of the flap is based on the type and extent of the defect. Superiority of vascularised free tissue is well-known and the ALT flap offers a versatile option for correcting varying degrees of the deformities. Ancillary procedures improve the overall aesthetic outcomes and minor flap touch-up procedures are generally required.KEY WORDS: Facial contour deformity, facial moulage, microvascular reconstruction of contour deformity     

Reverse peroneal artery flap for large defects of ankle and foot: A reliable reconstructive technique

Background:

Large soft tissue defects around the lower third of the leg, ankle and foot always have been challenging to reconstruct. Reverse sural flaps have been used for this problem with variable success. Free tissue transfer has revolutionised management of these problem wounds in selected cases.

Materials and Methods:

Twenty-two patients with large defects around the lower third of the leg, ankle and foot underwent reconstruction with reverse peroneal artery flap (RPAF) over a period of 7 years. The mean age of these patients was 41.2 years.

Results:

Of the 22 flaps, 21 showed complete survival without even marginal necrosis. One flap failed, where atherosclerotic occlusion of peroneal artery was evident on the table. Few patients had minor donor site problems that settled with conservative management.

Conclusions:

RPAF is a very reliable flap for the coverage of large soft tissue defects of the heel, sole and dorsum of foot. This flap adds versatility in planning and execution of this extended reverse sural flap.KEY WORDS: Distally based peroneal flaps, extended reverse sural flaps, foot reconstruction, peroneal artery, reverse peroneal flaps     

Tuberculosis of the hip in children: A retrospective analysis of 27 patients

Background:

We retrospectively evaluated the pretreatment radiological presentation and the clinicoradiological outcome at the completion of 1 year chemotherapy in osteoarticular tuberculosis of hip in children to prognosticate correlation between them.

Materials and Methods:

We retrospectively analyzed the clinical and plain radiographic findings in 27 patients with an age of 12 years or younger in whom hip tuberculosis was diagnosed and treated between 2006 and 2010. The diagnosis was based on histopathology in 14 and clinicoradiological basis in 13 patients. The pre and post treatment plain radiographs were evaluated according to Shanmugasundaram radiological classification and our observations regarding unclassified cases which were not fit in this classification were suggested. The functional outcome at the completion of chemotherapy was assessed using modified Moon''s criteria.

Results:

The male female ratio was 11:16. The left hip was involved more frequently than the right (17:10). The average age was 7.37 years (range, 2-12 years). In the pretreatment radiographs, 9 hips were normal, 6 traveling, 4 dislocating, 1 protrusio acetabuli, 3 atrophic and 4 unclassified types (3 triradiate; 1 pseudarthrosis coxae). There were no Perthes and mortar pestle at the initial presentation. Posttreatment, the types changed to 9 normal, 3 Perthes, 1 protrusio acetabuli, 1 atrophic, 4 mortar pestle and 9 unclassified types (3 triradiate, 3 pseudarthrosis coxae and 3 ankylosed). There were 37% excellent, 18.5% good, 26% fair and 18.5% poor results. The prognosis was best with initial “triradiate” and normal types and worst with posttreatment atrophic and “ankylosed” types.

Conclusions:

The Shanmugasundaram radiological types accurately predict prognosis only in normal types and “triradiate” pattern. The functional outcome is independent of radiological morphology of the hip in smaller children.     

Surgical management of scalp arterio-venous malformation and scalp venous malformation: An experience of eleven cases

Aims:

Scalp arterio-venous malformation (AVM) and scalp venous malformation (SVM) are rare conditions that usually need surgical treatment. Here, we have reported our experience of the surgical management of such lesions with a short review of the literature.

Materials and Methods:

In this prospective study, 11 patients with scalp AVM and SVM, who underwent surgical excision of lesion in our hospital from 2006 to 2012, were included. All suspected high-flow AVM were investigated with the selective internal and external carotid digital subtraction angiogram (DSA) ± computed tomography (CT) scan of brain with CT angiogram or magnetic resonance imaging (MRI) of brain with MR angiogram, and all suspected low-flow vascular malformation (VM) was investigated with MRI of brain + MR angiogram. Eight were high-flow and three were low-flow VM.

Results:

All lesions were successfully excised. Scalp cosmetic aspects were acceptable in all cases. There was no major post-operative complication or recurrence till last follow-up.

Conclusions:

With preoperative appropriate surgical planning, scalp AVM and SVM can be excised without major complication.KEY WORDS: Arterio-venous malformation, cavernous angioma, cirsoid aneurysm, scalp AVM, scalp venous malformatiom, sinus pericranii     

Cross-leg flap: Its role in limb salvage

Background:

Pedicled cross-extremity flaps for lower limb wound coverage have been replaced by free tissue transfer in the last two decades. However, there are certain difficult situations where the free flap cannot be employed and alternative methods are needed. We describe our experience with cross-leg flap in 18 patients for the reconstruction of difficult leg defects in which no suitable recipient vessels were available for microvascular anastomosis in the vicinity of the defect.

Materials and Methods:

18 patients (17 men and 1 woman) with mean range 31.5 yrs(range 18-70 yrs) grade III B tibial fractures were included in the study. fasciocuteneous cross leg flap was employed and extremities were immobilized by external Fixator.

Results:

Fifteen flaps were completely available with two had marginal necrosis and one supsficial epidermal necrosis. No complications were related to the donor site, flap, or by immobilization are noted. Each patient resumed essentially normal gait and activity without any stiffness of joints related with the flap or external fixator.

Conclusion:

The addition of external fixator stabilization aids greatly in wound care, as well as for general ease of the patient mobility and positioning. Cross-leg flap offers the possibility of salvaging limbs that are otherwise nonreconstructable.     

Stress Fracture of the Proximal Fibula in Military Recruits

Background

We wanted to report on stress fracture of the proximal fibula and to suggest the pathomechanism of this fracture.

Methods

Between April 2004 through April 2005, the military recruits who complained of leg pain during the 6 weeks basic training in the Republic of Korea Marine Corps education and training group were evaluated according to their clinical manifestations and plain radiographs.

Results

Twelve recruits of 635 recruits who complained leg pain were diagnosed as having fibular stress fracture. Eleven cases (10 recruits) appeared at the junction of the proximal and middle 1/3 of the fibula and 2 cases (2 recruits) were in the middle 1/3 of the fibula, as assessed radiologically. Tenderness was the most reliable clinical manifestation. All the fractures occurred after repetitive walking or jumping in a squatting position. Conservative treatments that included bed rest, immobilization and non-steroidal anti-inflammatory drugs administration according to the symptom severity were satisfactory.

Conclusions

Proximal fibular stress fracture is not rare in military recruits. The shearing force on the proximal fibula and the repetitive stress by walking or jumping in a squatting position contribute to the stress fracture of the proximal fibula.     

Cephalic vein: Saviour in the microsurgical reconstruction of breast and head and neck cancers

Background:

Reconstruction with microvascular free flaps is considered the reconstructive option of choice in cancer of the head and neck regions and breast. Rarely, there is paucity of vessels, especially the veins, at the recipient site. The cephalic vein with its good caliber and constant anatomy is a reliable recipient vein available in such situations.

Materials and Methods:

It is a retrospective study from January 2010 to July 2012 and includes 26 patients in whom cephalic vein was used for free-flap reconstruction in head and neck (3 cases) and breast cancers (23 cases).

Results:

All flaps in which cephalic vein was used survived completely.

Conclusion:

Cephalic vein can be considered as a reliable source of venous drainage when there is a non-availability/unusable of veins during free-flap reconstruction in the head and neck region and breast and also when additional source of venous drainage is required in these cases.KEY WORDS: Breast reconstruction, cephalic vein, free flap, head and neck reconstruction     

Experience with peroneus brevis muscle flaps for reconstruction of distal leg and ankle defects

Objective:

Peroneus brevis is a muscle in the leg which is expendable without much functional deficit. The objective of this study was to find out its usefulness in coverage of the defects of the lower leg and ankle.

Patients and Methods:

A retrospective analysis of the use of 39 pedicled peroneus brevis muscle flaps used for coverage of defects of the lower leg and ankle between November 2010 and December 2012 was carried out. The flaps were proximally based for defects of the lower third of the leg in 12 patients and distally based for reconstruction of defects of the ankle in 26 patients, with one patient having flaps on both ankles.

Results:

Partial flap loss in critical areas was found in four patients requiring further flap cover and in non-critical areas in two patients, which were managed with a skin graft. Three of the four critical losses occurred when we used it for covering defects over the medial malleolus. There was no complete flap loss in any of the patients.

Conclusion:

This flap has a unique vascular pattern and fails to fit into the classification of the vasculature of muscles by Mathes and Nahai. The unusual feature is an axial vessel system running down the deep aspect of the muscle and linking the perforators from the peroneal artery and anterior tibial artery, which allows it to be raised proximally or distally on a single perforator. The flap is simple to raise and safe for the reconstruction of small-to moderate-sized skin defects of the distal third of the tibia and all parts of the ankle except the medial malleolus, which is too far from the pedicle of the distally based flap. The donor site can be closed primarily to provide a linear scar. The muscle flap thins with time to provide a good result aesthetically at the primary defect.KEY WORDS: Ankle defects, lateral malleolus defects, lower leg defect, muscle flap, peroneus brevis flap, pedicle flap, tendo achilles defects     

Massive lumbar disc herniation with complete dural sac stenosis

Background:

Large lumbar disc herniation (LDH) has been reported to have a greater tendency to resolve in clinical and pathomorphological evolutions. However, various definitions of large LDH have been used without validation, and the clinical symptoms of large LDH have not been fully elucidated. We conducted a retrospective analysis to determine the clinical characteristics and treatment outcome of massive LDH with complete dural sac stenosis

Materials and Methods:

We retrospectively reviewed 33 cases of LDH with complete dural sac stenosis on magnetic resonance imaging. Complete dural sac stenosis was defined as no recognizable rootlet and cerebrospinal fluid signal on T2-weighed axial MR images. The clinical outcome parameters included back pain, leg pain, Oswestry disability index (ODI), and neurological dysfunction. The paired t-test and Wilcoxon''s signed rank test were used to compare serial changes in back pain, leg pain and neurological dysfunction.

Results:

Mean duration of followup was 66 months (range 24 - 108 months). There were 24 male and 9 female. The mean age was 37 years (range 20 - 53 years). At presentation, mean visual analogue scales for back pain and leg pain were 75.3 ± 19.1 (range 12 - 100) and 80.2 ± 14.6 (range 0 -100), respectively. Mean ODI was 67.1 ± 18.8 (range 26 - 88). Neurological dysfunction was found in 9 patients (27.3%), and the bowel/bladder dysfunction was found in 2 patients (3.1%). Conservative treatment was performed in 21 patients (63.6%) with satisfactory results. Seven patients underwent decompressive surgery, and 5 underwent posterolateral fusion.

Conclusions:

A massive LDH with complete dural sac stenosis was found to be associated with severe back and leg pain at presentation, however surgical treatment can be deferred unless significant neurological symptoms occur.     

The use of the temporoparietal fascia flap in various clinical scenarios: A review of 71 cases

Objective:

This report details our experience with the use of the temporoparietal fascia flap in different scenarios of reconstruction and to discuss our technique of harvest, clinical applications, and review of literature of this versatile flap.

Materials and Methods:

A retrospective study of 82 cases of temporoparietal fascia flap in 71 patients, operated over a period of 10 years was conducted. Patients were grouped based on various clinical indications. The follow up period ranged from a minimum of 1 to a maximum of 10 years (Mean-four and a half years). All patients were analyzed for functional and aesthetic outcome using preoperative and postoperative photographs.

Results:

No significant complications were seen in our series. Only 2 out of 82 flaps had partial necrosis of flap (2.44%). Two patients who were operated for release of submucous fibrosis developed recurrence due to continued use of tobacco. The final outcome in one patient of ear reconstruction was unsatisfactory due to flap failure. The remaining patients had satisfactory functional and aesthetic outcomes (95.77%). None had other complications like temporal branch of facial nerve injury or alopecia along the scar line.

Conclusion:

The TPFF is one of the most reliable and versatile flap in the head and neck region. It can also be reliably used as free fascial flap. When its advantages are combined with the surgeon''s resourcefulness, various defects can be successfully reconstructed using the temporoparietal facia flap with satisfactory aesthetic and functional outcome.KEY WORDS: Head and neck reconstruction, temporoparietal fascia flap, TPFF     

Augmentation rhinoplasty with custom-made S-shape silicone implant in Asians: A 15-year experience

Background:

Asians have low nasal dorsum, thick skin envelope, low defined alar cartilage, low projection of nasal tip and broad alar base. Augmentation rhinoplasty with silicone prosthesis has been performed with predictable results, but unfavourable results and complications still present. This series show techniques and results from single surgeon experience.

Materials and Methods:

We retrospectively reviewed 548 patients chart during January 1995 to December 2009. All patients underwent custom-made S-shape implant silicone augmentation rhinoplasty operated by a single surgeon. There were three major operative steps: (1) Intra-operative S-shape implant carving; (2) pocket dissection through bilateral rim incision and (3) tension adjustment before closure. All the patients were recorded for early surgical complications and satisfaction.

Results:

There were 519 women and 29 men. The mean age is 25.5 years (18-56 years). Mean follow-up period was 6 months (1-60 months). The majority of patient were appointed for esthetic augmentation (86.8%). 515 cases (94.9%) showed well satisfaction following the operation. The total complication rate was 6.5% (4.9% deviation, 0.7% extrusion, 0.5% hematoma and 0.3% infection). All the complications were corrected with uneventful sequelae.

Conclusion:

Augmentation rhinoplasty with custom-made S-shape silicone implant by closed approach provides high satisfaction with acceptable early complication rate.KEY WORDS: Aesthetic surgery, Asians, augmentation rhinoplasty, silicone implant, surgical complication     

Free Boomerang-shaped Extended Rectus Abdominis Myocutaneous flap: The longest possible skin/myocutaneous free flap for soft tissue reconstruction of extremities

Background:

A soft tissue defect requiring flap cover which is longer than that provided by the conventional “long” free flaps like latissimus dorsi (LD) and anterolateral thigh (ALT) flap is a challenging problem. Often, in such a situation, a combination of flaps is required. Over the last 3 years, we have managed nine such defects successfully with a free “Boomerang-shaped” Extended Rectus Abdominis Myocutaneous (BERAM) flap. This flap is the slightly modified and “free” version of a similar flap described by Ian Taylor in 1983.

Materials and Methods:

This is a retrospective study of patients who underwent free BERAM flap reconstruction of soft tissue defects of extremity over the last 3 years. We also did a clinical study on 30 volunteers to compare the length of flap available using our design of BERAM flap with the maximum available flap length of LD and ALT flaps, using standard markings.

Results:

Our clinical experience of nine cases combined with the results of our clinical study has confirmed that our design of BERAM flap consistently provides a flap length which is 32.6% longer than the standard LD flap and 42.2% longer than the standard ALT flap in adults. The difference is even more marked in children. The BERAM flap is consistently reliable as long as the distal end is not extended beyond the mid-axillary line.

Conclusion:

BERAM flap is simple in design, easy to harvest, reliable and provides the longest possible free skin/myocutaneous flap in the body. It is a useful new alternative for covering long soft tissue defects in the limbs.KEY WORDS: Extended rectus abdominis free flap, longest myocutaneous free flap, soft tissue reconstruction of extremities     

The management of non-melanocytic skin malignancies of the scalp and calvarium

Background:

The management of advanced cutaneous malignancies has been controversial. Thirteen patients with nonmelanoma skin neoplasias that had invaded the bone of the calvarium and scalp were treated in our centre.

Objective:

The purpose of this study was to evaluate our experience in treating these malignancies with scalp resection and full or partial thickness cranium reconstruction.

Patients and Methods:

From June 2008 to March 2012, thirteen patients with locally advanced tumours of the scalp invading the calvarium were treated with wide local excision of the scalp combined with an underlying craniectomy and dural resection if needed.

Results:

Using histopathological diagnosis eleven patients were diagnosed with basal cell carcinoma and two patients with squamous cell carcinoma. A full thickness cranium resection was performed in seven patients and partial in six patients.

Conclusion:

These large cancers occasionally invade adjacent structures, as well as bone, presenting a challenging surgical problem. In general, giant rotational or island scalp flaps and free tissue transfers are needed to close the area. Finding clean margins are an important part of treating patients with bone involvement and can usually be attained using outer tabula curettage thus preventing unnecessary morbidity.KEY WORDS: Bone invasion, calvarium, non-melanocytic, reconstruction, scalp, skin malignancies     

Open reduction and internal fixation of clavicular nonunions with allograft bone substitute

Background:

Biologic augmentation with allograft has shown equivalent healing rates to autograft in several nonunion models. No literature exists clearly demonstrating this in the clavicle. The purpose of this study was to evaluate the healing and complication rates of clavicle nonunions treated solely with open reduction and internal fixation (ORIF) and allograft.

Materials and Methods:

Nineteen clavicle nonunions treated with ORIF and allograft were evaluated retrospectively to assess healing rates and complications based on clinical symptoms and radiographic findings.

Results:

For the 19 patients included and treated with ORIF and allograft, clinical follow-up averaged 15 months. Seven patients were smokers. Although complete radiographic healing was achieved in only 68% of patients, clinical success occurred in 16 (84%) patients who demonstrated full range of motion and strength without pain. The three patients who did not demonstrate full radiographic healing were completely pain free. Five patients experienced complications (26%). Two underwent hardware removal due to persistent irritation after union. Three had a persistent painful nonunion. Each of these three patients was a smoker (P=0.08). Two proceeded to union after revision fixation. The other had hardware failure, which was removed, with a persistent nonunion and did not wish any further treatment.

Conclusion:

ORIF with allograft bone substitute is an acceptable treatment alternative to iliac crest bone graft for clavicle nonunions. However, we did not demonstrate equivalent healing rates to published results utilizing autograft. Smokers were identified to have a trend toward higher failure rates with ORIF augmented with allograft and therefore these patients may be better served by augmenting fixation with autograft.

Level of Evidence:

IV; retrospective comparative study.