Reverse Sural Flap with Bifocal Ilizarov Technique for Tibial Osteomyelitis with Bone and Soft Tissue Defects

Tibial osteomyelitis, in association with bone loss and a soft tissue defect, poses a significant reconstructive challenge, especially in high-risk patients. We describe a case of methicillin-resistant Staphylococcus aureus tibial osteomyelitis with intercalary bone loss successfully managed with bifocal Ilizarov compression osteogenesis at the bone resection site and proximal distraction osteogenesis, accompanied by a reverse sural fasciocutaneous flap performed with a delayed technique. When free tissue transfer is not a reconstructive option owing to medical comorbidities or patient refusal, the reverse sural flap combined with bifocal Ilizarov compression and distraction osteogenesis can provide a reconstructive option to achieve limb salvage for these challenging cases.     

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.     

Role of Perforating Artery Pedicled Neurotrophic Flap in the Treatment of Compound Tissue Defect of Tibia Using the Ilizarov Technique

ObjectiveTo describe our experience with the combined use of pedicled neurotrophic flap and distraction osteogenesis in the management of complex lower extremity injuries with composite bone and soft tissue defects and assess the functional and cosmetic results of this method.MethodsA pedicled flap with a marked perforator artery was applied for soft tissue coverage after radical debridement and temporary external fixation. In the second stage, the Ilizarov external fixator was used in place of the temporary external fixator for reconstruction of the segmental bone defect by distraction osteogenesis. Twenty‐five patients (16 men and nine women; mean age, 39.2 years) were treated by using this combined technique between 2008 and 2016. All cases were graded initially as Gustilo–Anderson grade IIIB open fractures. The soft tissue defect after radical debridement ranged from 9 cm × 5 cm to 14 cm × 11 cm, and the average size of segmental defect was 5.2 (Range, 2.5–8.5) cm. Seventeen of these patients had a history of local infection. The bone structure and function were evaluated by two independent evaluators using Paley''s criteria.ResultsTwenty‐five patients were followed up for an average of 28.96 (Range, 15–48) months. The distally based sural neurovascular flap was applied in 13 patients, and the greater saphenous neurocutaneous perforator flap in 12 patients. The flap area ranged from 10 cm × 5 cm to 14 cm × 12 cm. Sufficient coverage of soft tissue defect was achieved in all cases. All flaps survived completely without complications. The bone defects were corrected by a mean lengthening of 6.94 (Range, 4.5–9.5) cm. The residual discrepancy was <1 cm in all cases, which was not clinically significant. The function was evaluated as excellent in 12 patients and good in 13 patients. Bone results were graded as excellent in 18 patients and good in seven patients. Complications during treatment included pain, pin tract infections, ankle midfoot joint stiffness, and docking site nonunion. No recurrence of infection was observed in infected patients. All cases achieved successful limb salvage and satisfactory function recovery without recurrence of infection.ConclusionsThe combined technique of a perforator artery pedicled neurotrophic flap and distraction osteogenesis is an effective alternative approach in the salvage treatment of massively traumatized and chronically infected lower extremities.     

Refinements in the one-stage procedure for management of chronic osteomyelitis

Posttraumatic osteomyelitis remains a frequent problem and requires aggressive surgical treatment to be cured. Radical debridement of all involved soft and hard tissues, obliteration of dead space, and neovascularization of the involved area are obligatory for successful management of the disease. Microvascular free tissue transfer provides the necessary tissue bulk and neovascularization to reconstruct the resulting defect. The transplanted muscle can be optimally mobilized and adjusted in size to obliterate the dead space in contrast to local transposition flaps. This is facilitated by smoothening the bony cavity using a rotating drill system. With an optimal interface between the muscle and the wall of the cavity, small foci of infection can be eliminated. Moreover after free muscle transfer, the optimal environment for secondary bone reconstruction is created. These principles of radical debridement combined with muscle transfer for dead space obliteration, are generally accepted in literature. Nevertheless to achieve this goal several different treatment schedules of repetitive debridements, prolonged antibiotic regimes, and finally various flap transfers have been advocated. We present 16 patients with chronic osteomyelitis treated with radical debridement and immediate free muscle transfer using the latissimus dorsi muscle preferably. Postoperatively an antibiotic course of only 12 days was given. With a mean follow-up of 2 years all patients remained symptom free. Therefore, our results indicate that this long-term problem can be solved by a one-stage procedure using a free flap combined with a short course of antibiotics. However definite conclusions should be reserved for 20 years. © 1995 Wiley-Liss, Inc.     

Omental free flap for surgical treatment of chronic osteomyelitis of lower limb: A technical note

Soft tissue reconstruction of chronic lower extremity wounds with bone infection entails an important challenge in reconstructive surgery. We report our experience using the omentum free flap to provide coverage in two patients suffering chronic osteomyelitis of the lower limbs. After extensive soft tissue and bone debridement, an omentum free flap was performed in both cases, providing dead space obliteration and soft tissue coverage in behalf of its large size and pliability. As a result, the chronic illness was eradicated in both patients, with satisfactory outcomes and infection resolution.     

Limb salvage using distraction osteogenesis

Distraction osteogenesis is a novel technique for the biological restoration of segmental bone defects. Definitive treatment of musculoskeletal tumors often requires large bony resections that can leave patients with significant osseous defects. Limb salvage using distraction osteogenesis is an attractive reconstructive alternative that may, in fact, offer advantages over other conventional techniques. We present our initial experience with the use of distraction osteogenesis in limb salvage.     

Reconstruction of juxta-articular huge defects of distal femur with vascularized fibular bone graft and Ilizarov's distraction osteogenesis

BACKGROUND: We evaluate the effect of reconstructing huge defects (mean, 15.8 cm) of the distal femur with Ilizarov's distraction osteogenesis and free twin-barreled vascularized fibular bone graft (TVFG). METHODS: We retrospectively reviewed a consecutive series of five patients who had cases of distal femoral fractures with huge defects and infection that were treated by the Ilizarov's distraction osteogenesis. After radical debridement, two of the five cases had free TVFG and monolocal distraction osteogenesis, and another two cases had multilocal distraction osteogenesis with knee fusion because of loss of the joint congruity. The other case with floating knee injury had bilocal distraction osteogenesis and a preserved knee joint. The mean defect of distal femur was 15.8 cm (range, 14-18 cm) in length. RESULTS: The mean length of distraction osteogenesis by Ilizarov's apparatus was 8.2 cm. The mean length of TVFG was 8 cm. The average duration from application of Ilizarov's apparatus to achievement of bony union was 10.2 months (range, 8-13 months). At the end of the follow-up, ranges of motion of three knees were 0 to 45 degrees, 0 to 60 degrees, and 0 to 90 degrees. Two cases had knee arthrodesis with bony fusion because of loss of the joint congruity. There were no leg length discrepancies in all five patients. In addition, three patients had pin tract infections and one case had a 10 degree varus deformity of the femur. CONCLUSIONS: Juxta-articular huge defect (>10 cm) of distal femur remains a challenge to orthopedic surgeons. Ilizarov's technique provides the capability to maintain stability, eradicate infection, restore leg length, and to perform adjuvant reconstructive procedure easily. In this study, we found that combining Ilizarov's distraction osteogenesis with TVFG results in improved patient outcome for patients with injuries such as supracondylar or intercondylar infected fractures or nonunion of distal femur with huge bone defect.     

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.     

Use of gracilis muscle free flap for reconstruction of chronic osteomyelitis of foot and ankle

Despite low donor-site morbidity and a straightforward dissection, the gracilis muscle flap is still for many surgeons a second choice in microsurgical reconstruction of the lower extremity in cases of osteomyelitis. They underscore the difficulty of the procedure, and the problems of insufficient muscle volume and a small sized vascular pedicle. The aim of this study was to assess the reliability of the gracilis muscle free flap in the treatment of osteomyelitis of the foot and ankle. Between 1992 and 1999, 12 consecutive cases (age 9 to 71 years) of osteomyelitis of the foot and ankle were treated using a skin-grafted gracilis free muscle flap. Criteria for osteomyelitis were the presence of exposed bone, positive cultures and bone scans. The wound defect surface ranged from 9 to 90 cm2 (mean 50.5 cm2). Six flaps were applied on the weight bearing area of the foot. Flap harvesting time never exceeded 30 minutes. The mean follow-up is 15 months (range 2 to 60 months). All flaps survived completely. Secondary skin grafts were needed in two cases. One hematoma was noted at the flap donor site. Two patients (18%) had persistent osteomyelitis due to insufficient debridement in the presence of what appeared to be extensive bone involvement. Attempt to salvage the extremity was first performed but ultimately led to amputation. No patients complained of any donor site morbidity. Failure to cure the osteomyelitis was never caused by inadequate flap coverage. Gracilis muscle flap reliability in terms of vascular supply and ease of dissection made it our first choice in osteomyelitis of the foot and ankle. In the presence of extensive bone involvement, complex bone reconstruction is necessary to avoid amputation.     

The reverse sural artery fasciomusculocutaneous flap for small lower-limb defects: the use of the gastrocnemius muscle cuff as a plug for small bony defects following debridement of infected/necrotic bone

The reverse sural artery fasciomusculocutaneous flap is a modification of the original fasciocutaneous flap in which a midline gastrocnemius muscle cuff around the buried sural pedicle is included in the flap. This modification was done to improve the blood supply of the distal part of the flap, which is harvested from the upper leg. The aim of this paper is to demonstrate that there is another important advantage of the modified flap: the use of the muscle cuff as a "plug" for small lower limb defects following debridement of infected/necrotic bone. A total of 10 male adult patients with small complex lower-limb defects with underlying bone pathology were treated with the modified flap using the muscle component to fill up the small bony defects. The bony pathology included necrotic exposed bone without evidence of osteomyelitis or wound infection (n = 1), an underlying neglected tibial fracture with wound infection (n = 4), and a sinus at the heel with underlying calcaneal osteomyelitis (n = 5). Primary wound healing of the flap into the defect was noted in all patients. No recurrence of calcaneal osteomyelitis was seen and all tibial fractures united following appropriate orthopedic fixation. It was concluded that the reverse sural artery fasciomusculocutaneous flap is well suited for small complex lower-limb defects with underlying bone pathology.     

An aggressive treatment approach for adult osteomyelitis

Osteomyelitis in the adult patient has been associated with failure of eradication, late recurrence, nonunion, and prolonged hospitalization. A staged aggressive approach has been used for the past seven years to treat 53 patients with adult osteomyelitis. This approach includes: evaluation of bone necrosis and identification of the etiologic organisms by deep bone culture; radical surgical debridement of devascularized tissue; intensive systemic antibiotics; and early bone and soft tissue reconstruction. All patients have been followed at least 1 year (mean, 33 months). Lower extremity bones predominated in the series (24 tibias, 13 femurs); and 19 patients had bony instability. Thirty-seven patients had initial successful eradication of their infections with 26 of these returning to full activity status. The remaining 16 patients developed recurrent infection; however, 11 patients totally responded to further aggressive treatment. Of the five failures in the total series, three patients required amputation and two patients have persistent infection. Fifteen of the 19 patients with bony instability healed with initial treatment, and the remaining four patients healed with subsequent treatment. Six patients had primary muscle flap soft tissue reconstruction, and an additional two patients had reconstruction as a secondary procedure. In all these patients with tibial instability, bony union was accelerated compared to those patients with tibial instability not receiving muscle flaps (4 months vs 12 months). The muscle coverage provided by either pedicled flaps or transferred by microvascular anastomoses.(ABSTRACT TRUNCATED AT 250 WORDS)     

An immunocompetent patient with primary Scedosporium apiospermum vertebral osteomyelitis

Scedosporium apiospermum, the asexual anamorph of Pseudallescheria boydii, is a ubiquitous saprophytic fungus that usually causes cutaneous/subcutaneous infection but may manifest as an invasive disease, often in immunocompromised hosts. Following an extensive literature review, we think that this case represents the first documented report of a primary infection of the spine in an immunocompetent patient. Despite extensive surgical debridement and itraconazole therapy, the patient died of multisystem organ failure of unknown etiology. Our case and three previously reported cases of P. boydii vertebral osteomyelitis highlight the importance of obtaining repeat cultures in patients with culture-negative vertebral osteomyelitis who fail to adequately respond to empiric standard antibacterial and/or antimycobacterial therapy. Combined surgical debridement and antifungal therapy have been required for eradication of P. boydii spinal infections in two previously reported immunocompromised patients, although the optimal antifungal regimen for this infection has not been established.     

Vascularized tissue transfer in the treatment of osteomyelitis

In conclusion, the efficacy of free tissue transfer in the treatment of osteomyelitis is geared mainly at enabling the surgeon to perform a wide radical debridement of infected and nonviable soft tissue and bone. Definitive bony management does not have to be performed concurrently with the soft-tissue coverage procedure and may be effectively staged. The type of free tissue transfer employed will depend upon the size and location of the defect, the condition of the contiguous structures, and the experience of the surgeon. Free tissue transfer that is used judiciously after the eradication of all infected bone and soft tissue appears to be a useful technique for controlling osteomyelitis.     

A treatment strategy for complex cases of osteomyelitis in children and its applicability on three exemplary cases

The aim of this study was to carry out a two-step surgical approach for complex cases of pediatric osteomyelitis. The surgical technique used here involved initial bone debridement and stabilization by a customized spacer (intramedullary Kirschner wires mantled with refobacin-palacosa cement). After infection eradication, the spacer was removed and distraction osteogenesis performed. This study included one boy and two girls (aged 7-10 years) with severe osteomyelitis (tibia: two, femur: one). At least 50% of the bone was initially resected, and either a bifocal physeal distraction (tibia) or callus distraction (subtrochanteric osteotomy) was performed. At discharge they were able to walk without assistance. Complete infection eradication and load restraining reconstruction was achieved in all three children.     

Prophylactic external fixation and extensive bone debridement for chronic osteomyelitis

There is universal agreement that treatment of osteomyelitis should consist of debridement, obliteration of dead space, tissue coverage and antibiotic therapy, with debridement as the most important factor for therapeutic success. Four patients, 27 to 72 years old, with chronic osteomyelitis after a fracture of the femur (two), or of the tibia (two), were included in this study. The patients had already undergone 5 to 15 (mean: 9) surgical procedures. The same surgical technique was used in all of them: sinuses were carefully excised down to the bone, and necrotic bone was aggressively resected until normal bleeding was seen. A prophylactic circular external fixation frame, built on one proximal and one distal ring connected to the bone by thin wires and half pins, was used to protect and support the limbs, significantly weakened by radical debridement. Bone grafting or distraction osteogenesis was not necessary. All wounds healed without complications, and the infection did not recur. The average follow-up period was 43 months (range: 38 to 54).     

Limb salvage of infected diabetic foot ulcers with microsurgical free-muscle transfer

This study was comprised of 9 diabetic patients with 10 infected foot ulcers, including osteomyelitis in 4 limbs and gangrene in 3 limbs. Adequate debridement of these complicated wounds inevitably resulted in exposure of bones or tendons. All defects were successfully reconstructed with free gracilis muscle flaps covered with split-thickness skin grafts. No recurrence of ulcer or infection was noted in the muscle-transplanted area during the follow-up period. Laser Doppler perfusion monitor measurement showed that the perfusion unit of the denervated free muscle flap increased to a peak at the second week after transplantation; the neovascularization of the grafted skin, the progressive decrease of the muscle swelling, and the decreased interstitial pressure may be the main contributing factors. The perfusion unit of the muscle flap reached equilibrium with the surrounding tissue at about 8 weeks after microsurgical transfer. Lower extremity amputation is a major health problem in the diabetic population. The microvascular free-muscle transfer was proved to play an effective and important role in limb salvage in diabetic patients with infected foot ulcers. The gracilis muscle flap was recommended due to its lack of bulkiness and minimal donor site deformity.     

Free tissue transfer: an advanced strategy for postinfection soft-tissue defects in the upper extremity

Surgical treatment of severe, necrotizing infections frequently leave compound defects that require complex reconstructive procedures. In the upper extremity, local flap coverage is limited because of the size of the lesions. Regarding the results of early microsurgical coverage of complex postinfectious defects of the lower extremity, the goal of this study was to evaluate the role of free tissue transfer in the treatment of severe infections in the upper extremity. Between 1994 and 1999, 24 patients with major defects as a result of severe necrotizing infections in the upper extremity underwent free tissue transfer. Parameters assessed included the success of infection control, flap survival rate, salvage of the extremity, and an outcome analysis by the Disability of Arm-Shoulder-Hand score and a visual analog scale. Patient age ranged from 17 to 75 years (average age, 50.8 years). Previous treatment of 11 patients in outlying hospitals included 4.2 operative procedures and a delay of admission to the authors' unit of 89 days. The average defect size after debridement was 10.0 x 14.4 cm. Twenty-four free flaps including 16 muscle or musculocutaneous flaps, 4 chimeric flaps from the subscapular system, and 4 osteocutaneous flaps were performed for reconstruction. The overall flap survival was 95.8%. One temporalis fascia flap (TPF) was lost as a result of vascular thrombosis, and three flaps underwent successful revision of the anastomoses. Eight patients required further minor surgical treatment. The Disability of Arm-Shoulder-Hand score yielded an average of 41.5 points, which represents a moderate impairment of activities of daily living. Visual analog scale assessment demonstrated an overall high satisfaction (9.5 points; range, 1-10 points). The data demonstrate that even in severe necrotizing infections resulting in complex acute or chronic defects, limb salvage and infection control can be achieved successfully with radical debridement and early free tissue transfer.     

Soft-tissue injury management and flap reconstruction for mangled lower extremities

SUMMARY: The treatment for mangled lower extremities poses a clinical challenge for orthopaedic surgeons. The complexities of soft-tissue injury combined with open fractures and osteomyelitis have frequently resulted in amputation of the lower extremity. The current advances in soft-tissue flap reconstruction techniques have significantly improved the results of limb-salvage attempts. Understanding the reconstructive ladders around the zone of injury, debridement, timing and nuances of techniques regarding skin graft, local and distant flaps and microsurgical reconstruction is necessary to complete limb salvage in a timely and appropriate fashion. Various soft-tissue flap applications have been described, including emergent flow-through flap, acute soft-tissue flap, acute combined soft-tissue and bone flap, pedicle gastrocnemius/soleus flap, pedicle sural artery flap, soft-tissue flap for chronic osteomyelitis, composite osseous-myocutaneous flap for chronic osteomyelitis and free functioning muscle flap for functional reconstruction of mangled lower limbs. Clinical experience of 850 flaps reconstructions for mangled lower limbs in both acute and chronic stages has revealed that adequate application of flap technique was able to achieve quite acceptable results. This article provides a comprehensive review of the soft-tissue injury management and flap reconstruction for mangled lower limbs.     

Bone Propeller Flap: A Staged Procedure

The ideal reconstruction technique for complex defects of the lower limb consists of replacing tissue with similar tissue in an attempt to achieve a good functional result. A 23-year-old white male sustained a crush injury with a grade IIIB open ankle dislocation. After open reduction and fixation, the patient developed severe osteomyelitis at the tibiotalar joint requiring a staged and radical debridement with a substantial combined soft tissue and bony defect over the distal tibia, fibula, and talus area. The reconstructive approach consisted of a modified model of the propeller flap, implementing the spare part concept in a 2-stage procedure using a prefabricated and vascularized “double-barrel” fibular graft. At 17 months postoperatively, a plain radiograph showed bony union with complete and stable coverage of the soft tissue defect. The patient was fully weightbearing. In conclusion, there is evidence to suggest that the established concept of a soft tissue propeller flap can be implemented on bone.     

Radical excision and reconstruction of chronic tibial osteomyelitis with microvascular muscle flaps

We report a series of 21 patients with chronic osteomyelitis of the tibia treated with microvascular muscle flap reconstruction. All patients underwent a radical bone and soft-tissue excision until healthy, well-bleeding tissue was exposed. Six patients required cancellous bone grafting. Latissimus dorsi was used in 14 patients, gracilis in 4, and rectus abdominis in 4. One gracilis flap was lost due to vessel thrombosis and was replaced with a rectus abdominis free flap. Average follow-up was 2.5 years. There was no evidence of clinical infection in 20 patients at follow-up; the bone had healed, the soft-tissue cover was stable, and the laboratory parameters were normal. Bone infection recurred in 1 patient, resulting in a below-knee amputation. The radical excision of infected bone and affected soft tissue and reconstruction with a well-vascularized large free-muscle flap is an excellent solution in most difficult chronically infected cases.