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

OBJECTIVE: To 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. METHODS: A 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. RESULTS: Twenty-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. CONCLUSIONS: The 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.

Full recovery of elective orthopedic surgery in the age of COVID-19: an 8-month retrospective cohort study.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has led to dramatic disruptions to orthopedic services. The purpose of this study is to quantify the reinstatement of elective orthopedic surgeries of our institution in Shanghai, China, and share our first-hand experiences of how this region is managing the post-outbreak period. METHODS: The number of patients receiving elective orthopedic surgeries was analyzed in the timeframe of 8 months since the start of the pandemic (from January 20 to September 16) and compared with the patients receiving the same treatment during the same period in 2019. And a detailed workflow for handling patients about to receive elective surgeries in the COVID-19 post-outbreak period was described. RESULTS: The number of the selective surgeries in the first 3 months only accounted for 31.72% of the same period in 2019 (p = 0.0031), and the ratio reached 97.47% when it came to the last 5 months (p > 0.9999). The selective surgeries even surpassed the pre-epidemic level in months 7 and 8. And the difference of the surgeries was not significant in the whole eight observed months between 2019 and 2020 (p = 0.1526). No health care providers or hospitalized patients in orthopedic departments in Shanghai have been infected nosocomially. CONCLUSIONS: Elective orthopedic surgeries have been fully recovered from the COVID-19 pandemic in our institution, and the new normalcy established during the post-outbreak period helped this region co-exist with the impact of the virus well. TRIAL REGISTRATION: Retrospectively registered, registration number: ChiCTR2000039711 , date of registration: November 6, 2020.

L-shaped corticotomy with bone flap sliding in the management of chronic tibial osteomyelitis: surgical technique and clinical results.

BACKGROUND: We described the use of the technique of L-shaped corticotomy with bone flap sliding to treat chronic osteomyelitis of the tibia in eight patients and presented the preliminary results. METHODS: L-shaped corticotomy with bone flap sliding was performed in eight patients between 2007 and 2014. All patients had chronic tibial osteomyelitis involving the anterior tibial cortex with intact and healthy posterior cortex. The size of bone defects following sequestrectomy and radical debridement was 8.1 cm on average. One patient required a latissimus dorsi flap. The mean follow-up period was 34.1 months. The functional and bone results were evaluated at the time of the latest follow-up. RESULTS: Complete eradication of infection and union of docking sites were achieved in all patients. Functional results were judged excellent in five patients and good in the rest three patients. Bone results were graded as excellent in all cases. The mean external fixation time was 169.9 days and external fixation index was 21.2 days/cm. Pain was the most common complaint that we faced during lengthening. Pin tract infections were observed in four patients, and mild transient stiffness of ankle joint was observed in three patients. CONCLUSIONS: We have found this technique to be safe and effective, significantly diminishing the external fixation index. The earlier removal of the external fixator may result in increased patient comfort, a reduced complication rate, and a rapid and convenient rehabilitation.

Resection arthrodesis using distraction osteogenesis then plating as a hybrid surgical technique for the management of bone sarcomas of the distal tibia.

PURPOSE: We report the oncological and functional results of limb salvage for bone sarcomas involving the distal tibia using hybrid surgical technique of resection arthrodesis by bone transport then plating. METHODS: Five patients (mean age 18.6 years) with primary distal tibial sarcomas (two Ewing's sarcomas and three osteosarcomas) were treated by this method. The average duration of follow-up is 53 months. All patients accepted distraction osteogenesis with a standard technique using external fixator after wide (four cases) or marginal (one case) resection in the first operation. They were re-admitted for the second surgical treatment (plate insertion and removal of the external fixator) one to two months after they achieved the necessary limb length and desired alignment. RESULTS: Solid union of the lengthening site and sound fusion of the ankle were achieved in all five patients with full and unassisted weight bearing. The mean lengthening was 11.8 cm (range 8-14 cm) and the external fixation index (EFI) was 29.3 days/cm (range 22.8-36.3 days/cm). The mean functional score according to the rating system of the Musculoskeletal Tumour Society was 88% (83-90%). One patient showed poor response to chemotherapy, had local recurrence of sarcoma one year after plating, and was treated with above-knee amputation. CONCLUSIONS: In carefully selected patients with primary distal tibial sarcomas, this hybrid method can effectively eliminate tumor lesion, reconstruct function, and shorten the length of wearing an external fixator by a meticulous conversion to internal fixator.