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1.
Ivan P. Bhaskar Timothy J. J. Inglis Jacintha Bowman Gabriel Y. F. Lee 《Acta neurochirurgica》2013,155(2):367-371
Background
Autogenous cranioplasty infection requiring bone flap removal is under-recognised as a major complication causing significant morbidity. Microbial contamination of stored bone flaps may be a significant contributing factor. Current infection control practices and storage procedures vary. It is not known whether ‘superficial’ swabs or bone cultures provide a more accurate assessment.Method
Twenty-five skull flaps that were cryo-stored for more than 6 months were studied. Two swab samples (superficial and deep) and a bone biopsy sample were taken from each skull flap sample and cultured. Half blood agar and half chocolate agar plates were inoculated with the swabs for anaerobic and aerobic cultures respectively. The bone biopsy samples were cultured in brain-heart broth and subcultured similar to the swabs for 5 days.Results
Incidence of microbial contamination was 20 % in the bone flaps studied. One swab culture and five bone biopsy cultures were positive for bacterial growth, all of which contained Propionibacterium acnes (p?=?0.014). Positive cultures were from bone flaps stored less than 18 months, whereas no growth was obtained from bone flaps that were stored longer (p?=?0.014).Conclusions
Bone biopsy culture is a more sensitive technique of assessing microbial contamination of cryo-stored autogenous bone flaps than swab cultures. The clinical implications of in vitro demonstration of microbial contamination require further study. 相似文献2.
J. Sundseth A. Sundseth J. Berg-Johnsen W. Sorteberg K.-F. Lindegaard 《Acta neurochirurgica》2014,156(4):805-811
Background
Renewed interest has developed in decompressive craniectomy, and improved survival is shown when this treatment is used after malignant middle cerebral artery infarction. The aim of this study was to investigate the frequency and possible risk factors for developing surgical site infection (SSI) after delayed cranioplasty using autologous, cryopreserved bone.Methods
This retrospective study included 74 consecutive patients treated with decompressive craniectomy during the time period May 1998 to October 2010 for various non-traumatic conditions causing increased intracranial pressure due to brain swelling. Complications were registered and patient data was analyzed in a search for predictive factors.Results
Fifty out of the 74 patients (67.6 %) survived and underwent delayed cranioplasty. Of these, 47 were eligible for analysis. Six patients (12.8 %) developed SSI following the replacement of autologous cryopreserved bone, whereas bone resorption occurred in two patients (4.3 %). No factors predicted a statistically significant rate of SSI, however, prolonged procedural time and cardiovascular comorbidity tended to increase the risk of SSI.Conclusions
SSI and bone flap resorption are the most frequent complications associated with the reimplantation of autologous cryopreserved bone after decompressive craniectomy. Prolonged procedural time and cardiovascular comorbidity tend to increase the risk of SSI. 相似文献3.
Introduction
Intensive anatomical studies of the anterior ulnar artery system have given rise to many new options for reconstruction of soft tissue or bone defects of the hand using local proximal and distal pedicle flap transfer.Patients and Method
In 21 patients, consisting of 19 males and 2 females aged between 11 and 71 years, a flap transfer from the interosseus artery system has been performed. In a retrospective clinical study the following criteria were examined: type and size of flap, complications and subjective judgement of the donor site by the patient (very good, good, acceptable or fair).Results
A total of 15 fascio-cutaneous posterior interosseous flaps, 1 anterior interosseus flap and 5 proximally based pronator quadratus flaps (3 muscle and 2 muscle-bone flaps) were carried out. The mean flap size was 12x6 cm for the posterior interosseus flaps and 7x4 cm for the anterior interosseus flaps. The entire pronator quadratus muscle was used for proximally based muscle flaps. The size of each of the distally based myo-osseus pronator quadratus flaps was 1x 2 cm. In 14 patients primary healing was achieved. The donor site was judged by 13 patients to be good, by 6 as acceptable and by 2 as fair.Discussion
The posterior interosseus flap transfer is the preferred method of choice for defect reconstruction in the region of the distal third of the forearm, the first commissure of the hand and the metacarpal region because of its constant anatomy and minor functional donor site defects. The anterior interosseus flap technique has proven to be of minor value because of the large functional and aesthetic donor site defects compared to other treatment options. The proximally based pronator quadratus muscle flap is an elegant variation for defects of the distal forearm down to the rasceta. The distally based myo-osseus variation is one of the possible vascularized bone grafts in exceptional circumstances for reconstruction of therapy-resistant atrophic fractures at the carpal level. Because of the small vessel size distally based interosseous flaps seem to be contraindicated in patients with pre-existing trauma of the distal forearm and wrist level. 相似文献4.
5.
Dr. F. Ensat H. Schubert M. Hladik H. Reichl L. Larcher G. Wechselberger 《Operative Orthopadie und Traumatologie》2013,25(2):176-184
Objective
Stable soft tissue coverage of exposed bone, tendons, or hardware in the extremities or the head and neck area with a microsurgically grafted free flap.Indications
Soft tissue defects measuring up to 42?×?15 cm in the extremities and the head and neck region.Contraindications
Previous surgery or trauma in the anterolateral thigh region. Insufficient personnel and/or technical resources.Surgical technique
A line is marked from the anterior superior iliac spine to the superolateral patella pole, approaching the intermuscular septum between the rectus femoris and vastus lateralis muscle. The flap is centred on this line and after medial incision the perforators of the descending branch of the lateral circumflex femoral artery are identified and dissected to their origin. Afterwards the lateral incision is carried out and flap dissection is completed. After flap transfer microsurgical anastomoses are performed and the flap is sutured to the recipient region.Postoperative management
Flap monitoring for 1 week. Strict elevation and immobilization after flap transfer to the extremities; bedrest for 1 week. Thrombosis prophylaxis.Results
From 2008–2011, 41 free anterolateral thigh flaps in 5 women and 36 men with an average age of 53 years (38–70 years) were performed for microsurgical soft tissue reconstruction. Total flap loss rate was 2.4?% and reoperation due to complications, e.g., hematoma, problems with microsurgical anastomosis, and partial flap loss was necessary in 13.8?% of patients. 相似文献6.
Background
Large complex soft-tissue defects on the dorsum of the foot, with exposed tendons, joints, bones, nerves and vessels, have to be reconstructed by transplantation of free tissue grafts with good blood flow.Patients and methods
Evaluation of 19 patients with an average age of 38 years who underwent closure of defects on the dorsum of the foot with free muscle flaps (with split-thickness skin grafts) in 14 cases and with free fasciocutaneous flaps in 5 is presented. In 10 patients a gracilis muscle flap was used, in 4 patients a latissimus dorsi flap, and in 2 patients a groin flap, while in 1 patient each an anterolateral thigh flap, an anteromedial thigh flap and a lateral arm flap was used. The aesthetic outcome was evaluated with reference to skin texture, pigmentation, thickness of the free flap and scar formation. The Stanmore system was used to determine the postoperative functional results.Results
On average, patients were followed up for 29 months. We had no flap loss. A flap debulking procedure was performed in 6 patients. Better aesthetic results were obtained with muscle flaps plus skin graft than with fasciocutaneous flaps. Functional results were excellent in 6 patients, good in 5 and poor in 8 patients.Conclusion
Free muscle flaps with skin grafts, particularly the free gracilis muscle flap, are superior to fasciocutaneous flaps and perforating flaps in aesthetic outcome and donor site morbidity. 相似文献7.
Objective
Defect coverage especially in exposed bone of the lower leg by pedicled muscle flaps in association with a split-thickness skin graft. Defect coverage oropharyngeal or at the upper extremity by free soleus flaps.Indications
Defects of the proximal and middle thirds of the anterior lower leg for the proximally pedicled soleus flap; defects of the middle and distal third of the anterior lower leg for the distally pedicled soleus flap. The free flap is almost ubiquitously useable.Contraindications
Primary diseases that makes a 2-h operation impossible, relevant affection of supplying vessels (the posterior tibial artery and/or the peroneal artery). Inadequate perfusion of the lower leg due to angiopathy, extensive soft-tissue infection, and wound contamination.Surgical technique
Medial, longitudinal incision, slightly posterior to the tibia, according to the desired flap elevation (distally or proximally pedicled). Preparation of relevant vessels, mobilization of the muscle and transposition into local defects or use as a free graft. The pedicled flaps usually need a split-thickness skin graft to cover.Postoperative management
Close monitoring of blood flow, temperature and swelling situation (hourly). Pressure-free wound-dressing of the leg, no circular or constricting dressings. Bedrest for 10 days, then start of flap training with intermittent circular compression, thrombosis prophylaxis, nicotine abstinence, physiotherapy, which depends on the bony situation, compression stocking after 3 weeks.Results
Reliable results achieved at the middle and distal lower leg. 相似文献8.
Nikolaos Ioannis Karmiris Marios Nicolaou Mansoor S. Khan 《European journal of plastic surgery》2014,37(8):437-442
Background
The anterolateral thigh (ALT) perforator flap is a well-described and versatile flap, regularly used for resurfacing and reconstructing soft tissue defects, but it is often too bulky to produce an aesthetically satisfactory result. Although primary thinning of the ALT has been successful in Eastern populations, studies have demonstrated that this may be inadvisable in Caucasians. This is the biggest clinical study demonstrating the clinical safety of primary thinning of ALT flaps in Caucasians.Methods
A retrospective analysis was performed between January 2009 and August 2011 on 57 patients (mean age 43) undergoing ALT free flap reconstruction by three surgeons. They were all thinned via sharp dissection using loupe magnification except for 1–2 cm around the perforator by removing the larger fat globules of deep fascia and preserving the superficial fat layer. The resultant flap thickness was approximately 6 mm.Results
In 77 % of cases, the flap was used for lower limb, 16 % for upper limb and 7 % for head and neck reconstruction. The mean flap surface area was 124 cm2. There was one flap loss (1.8 %) and three flaps returned to theatre for perioperative complications.Conclusions
Careful primary thinning of ALT flaps is safe in Caucasian populations and can achieve improved cosmetic results. Level of Evidence: Level IV, risk/prognostic study. 相似文献9.
10.
Background
Complex and extensive limb defects involve difficult reconstructive problems, and lateral circumflex femoral artery (LCFA) system flaps provide an adequate reconstructive answer for these challenging wounds.Methods
A retrospective review on 50 patients treated with LCFA system flaps to cover lower extremity wounds was carried out. Data collected included age, gender, defect size, defect location, flap size, flap composition, anatomical findings, donor site closure, secondary procedures, and complications.Results
The overall flap survival rate was 96 %. We performed three flap re-explorations with two subsequent failures. Four different combinations of tissues from LCFA system flaps were employed to restore defects produced by open fractures in tibia (16), severe crushing or avulsion injury (15), chronic posttraumatic osteomyelitis (13), and others (6). The mean size of the skin flap was 162.56 cm2 (range 54–312 cm2) and the volume of the muscle flap was 160 cm3 (range 44–250 cm3). Debulking procedures were performed in seven patients. Donor sites were closed primarily in all but five patients who required a skin graft.Conclusions
The LCFA system is efficient and its use, versatility, and reliability in lower limb reconstruction have been proven. No other donor site in the body offers such a large amount of tissue with minimal donor morbidity. Level of Evidence: Level IV, therapeutic study. 相似文献11.
Background
Large, ulcerating tumors of the chestwall require soft tissue coverage after resection. Depending on size and location usually a latissimus dorsi flap, VRAM or TRAM flap is performed. In very large defects a combined split ALT/TFL flap is a new technique for coverage.Patient and methods
In 4 patients (3 female, 1 male) a soft tissue reconstruction after tumor resection was necessary. The mean age was 54 years. The mean size of the defect was 656 cm2.Results
In 3 cases the coverage was achieved by a unilateral, and in 1 case a bilateral combined split ALT/TFL flap. All flaps healed without flap loss. The donor site closure was achieved primarily in 2 cases. In 3 cases a small split skin graft was needed.Conclusion
The indications for combined split ALT/TFL flaps are large defects which cannot be covered by one single flap. The combination of these two long-known flaps on one pedicle is a new development. 相似文献12.
Dr. R. Winkel N. Tajsic H. Husum M. Schlageter G. Hanebuth R. Hoffmann 《Operative Orthopadie und Traumatologie》2013,25(2):152-161
Objective
Replacement of full thickness soft tissue defects in the lower leg and ankle, appropriate to the defect and following the course of blood vessels feeding the skin of a distally hinged fasciocutaneous flap most reliably based on the individual anatomy of distal perforators of the posterior tibial artery.Indications
Full thickness soft tissue defects, up to 12 cm in length and up to 8 cm in width. Sufficient vascularization of the foot required, in osteomyelitis, and when joints, fractures, implants and tendons are exposed and when a split skin graft, a local flap, a suralis perforator flap or a free flap is not indicated.Contraindications
For patients, in whom a 1–2 h operation is not possible; necessity of angioplasty; decollement or scars around the distal perforators of the posterior tibial artery; local infection or necrosis of soft tissues and/or bone, which cannot be totally excised.Surgical technique
Radical debridement; flap dissection without tourniquet; microdissection; design of the flap on the skin: pivot point ~?10 cm (6–14 cm) proximal of the tip of the medial malleolus; base ~?5 cm in width, between the course of the saphenous nerve and of the great saphenous vein and the Achilles tendon; adipofascial pedicle up to 15 cm in length sited over the septum between soleus and flexor digitorum muscles, following the course of the saphenous nerve, with a central skin stripe, which expands into a proximal skin island; skin island is outlined similar to the defect, but larger by 1 to 2 cm, surrounded by an adipofascial border: adjustment of the planning as well as of the elevation of these flaps according to the individual position and the caliber of perforators requires in each case the search for a perforator at the estimated pivot point. Delay of transposition, if the division of more than one perforator proximal to the pivot point obviously diminishes circulation. No “tunnelling “of the pedicle; defects of skin due to the elevation of the flap are replaced by split and meshed skin grafts or temporary by “artificial skin”. A gap in the bandage over the skin island allows for observation.Postoperative management
Protocol of controls of vascularization: color and time for revascularization; antibiotic treatment according to bacteriological testing. In case of edema or discoloration of the flap: immediate removal of sutures, administration of leeches, operative revision. Split skin graft 1 week after flap transposition, if the skin had been temporary substituted.Results
Retrospective uncontrolled study with over 70 saphenous perforator flaps from 1995–2011. Full soft tissue defects 62 times with osteomyelitis, 3 times with endoprothesis, 3 times with fractures, 2 times with exposed tendons. From 1995–2006, 44/50 (88?%) flaps healed completely or at least to 3/4 without the necessity of further flaps; from 2007–2011, 13/20 (65?%) flaps healed completely and 6/20 (30?%) flaps healed at least to 3/4 without the necessity of further flaps, loss of one flap (5?%). 相似文献13.
Nabi Mopuri Vasu Karri Nakul Patel Niri Niranjan 《European journal of plastic surgery》2013,36(11):701-706
Background
Reconstruction of soft tissue defects in the Achilles tendon region can be technically demanding. Perforator-based flaps can be an effective local solution, replacing like-for-like skin. We report our experience with perforator-based flap reconstruction of the Achilles tendon region with or without rupture of the Achilles tendon.Methods
Between January 1999 and 2011, 11 patients had perforator-based flaps based on peroneal and posterior tibial perforators. There were six V-Y advancement flaps, four propeller flaps and one peninsular flap. The mean defect size was 19.3 (range 9–36)?cm2. One patient had reconstruction of a composite Achilles tendon defect.Results
There were no flap failures. Mean follow-up was 26.4 (range 3–120)?months. Post-operative complications included haematoma in one patient and dehiscence of wound because of further sloughing of the tendon—at the distal edge of a V-Y advancement flap. This patient needed a second local flap. There were no wound breakdowns, painful sensitivity or difficulty with walking. All patients who had skin and soft tissue reconstruction only were partially weight bearing by 2 weeks and gradually increased weight bearing and fully weight bearing by 4 weeks.Conclusions
Perforator-based flaps are a robust method of covering small- to medium-sized defects in the Achilles tendon region. Presence of multiple perforators on either side of the Achilles tendon invites a number of flap designs, tailored to the defect. Level of Evidence: Level IV, Therapeutic study. 相似文献14.
15.
Dr. F. Stang F. Siemers T. von Wild I. Weyers P. Mailänder P. Stollwerck 《Operative Orthopadie und Traumatologie》2013,25(4):372-380
Objective
Defect coverage of the ulnar aspect of the hand, wrist and hypothenar with an abductor digiti minimi muscle flap and split skin graft.Indications
Soft tissue defects of the ulnar aspect of the hand, wrist and hypothenar. Osteomyelitis of the fifth metacarpal bone.Contraindications
Large defects >?3?×?5 cm, complex hand trauma, injuries of the ulnar artery or within the area of the pedicle.Surgical technique
Marking of the flap’s rotational radius, using the pisiform bone as the center point. Ulnar skin incision and exposure and detachment of the distal flap pole, which is located at the level of the metacarpophalangeal (MCP) joint. Dissection of the abductor digiti minimi muscle flap up to the vascular pedicle in the area of the pisiform bone. Transposition and fixation of the flap onto the defect after opening of the tourniquet. Coverage of the muscle flap with a split skin graft. Wound closure of the donor side.Postoperative management
Palmar cast splinting in intrinsic-plus position for 10 days physiotherapy. Scar care and compression glove for 3 months.Results
In total, 9 patients showed good results with a reliable defect coverage due to a constant anatomy and easy preparation. 相似文献16.
Libo Wang Jiedong Fu Ming Li Dong Han Li Yang 《Archives of orthopaedic and trauma surgery》2013,133(1):141-146
Introduction
There are very few reports on the use of a free composite flap from the toe to repair small tissue defects in the hand. Here, we describe our experience using a free composite flap from the great toe and second toe.Method
Fifteen patients sought surgical treatment for tissue defects of the hand at our medical institution from July 2008 to December 2010. These defects included: dorsal defect of the distal thumb, dorsal-radialis defect of the proximal thumb, degloving injury of distal index finger, pulp defect of the middle finger and these were repaired with toe side pulp flaps. In five subjects, treatment of the metatarsophalangeal joint (MPJ) or proximal interphalangeal joint (PIPJ) involved a combined extensor tendon defect with a composite flap with MPJs and PIPJs and the extensor tendon of the second toe. All flaps were transferred as free flaps.Results
All flaps survived. At 34.8 months of follow-up, the average subjective satisfaction score was 8. Eleven patients (73.3 %) experienced cold intolerance, and one patient (6.7 %) dysesthesia. The Semmes–Weinstein Sensitivity Score was 3.48–4.71 at the flap and 0–4.21 at the donor site. The mean two-point discrimination was 7.13 mm. Grip strength was 10 % less than in the unaffected hand. Mobility loss in the MPJ and PIPJ was <10°. No patients had complications at the donor sites.Conclusion
Based on the unique characteristics of the free flap from toes, we consider them to be good options for reconstruction of small tissue defects in the hand according to various sizes, shapes, and sites. 相似文献17.
18.
S. S. Shirol Geeta Nimbaragi Mahesh Prabhu Jaideep Ratkal 《European journal of plastic surgery》2014,37(4):227-232
Background
Diabetic foot ulcers (DFUs), a leading cause of amputations, affect 15 % of people with diabetes. Wound coverage in these patients is changelling due to concurrent infection, neuropathy and vascular compromise. Though local muscle flaps were described by Ger et al. and popularized by Attinger et al., these small muscle flaps should be more routinary than they are now.Methods
A retrospective review of all patients with DFUs with exposed bone and osteomyelitis reconstructed by abductor digiti minimi muscle flaps and free skin grafting between January 2010 and December 2011 was conducted.Results
This study included eight patients. Six patients had ulcers over the heel and two on the lateral aspect of the forefoot. All flaps survived well with no donor site complications. There was partial loss of skin graft in three cases and infection and total loss in one other case.Conclusions
Abductor digiti minimi is a safe and reliable flap that provides a durable cover. Level of evidence: Level IV, therapeutic study. 相似文献19.
Christopher R. Davis Ahmed Khattak Simon J. Cawthorn Umraz Khan 《European journal of plastic surgery》2013,36(12):749-756
Background
Breast cancer is a common female malignancy with numerous reconstructive options following mastectomy. However, in recurrent disease, few donor sites exist. The scapular flap may reconstruct ablative defects after recurrence. This paper describes its 5-year application.Methods
All patients with recurrent breast cancer necessitating chest wall reconstruction with a scapular flap were included in this 5-year study. Patients were prospectively followed up for clinical, surgical and patient-reported outcome measures.Results
Eight patients underwent scapular flap chest wall reconstruction for recurrent breast cancer. The majority of tumours were invasive ductal carcinomas (n?=?5; 62.5 %). Mean duration from primary breast cancer to scapular flap reconstruction was 12 years (range 2–32 years). All flaps survived, including patients who smoked and received adjuvant radiotherapy. Donor site morbidity was minimal with full ipsilateral limb functioning.Conclusions
Scapular flap reconstruction of the chest is a safe, reliable and consistent technique in recurrent breast cancer. Level of Evidence: Level IV, therapeutic study. 相似文献20.
Dr. E.L. Hierner C. Corterier Prof. Dr. R. Hierner 《Operative Orthopadie und Traumatologie》2013,25(2):122-130