Management of Infected Gap Non-union of Distal Femur with Induced Membrane Technique using Limb Reconstruction System Followed by Augmentation Plating and Bone Grafting: A Case Report.

Introduction: Distal femur fractures are high-velocity injuries which accounts for 7-10% of all femoral fractures of which 5-10% are open fractures. Despite advances in techniques and implants, treatment remains a challenge, in many situations due to increased risk of infection, non-union and loss of range of motion. Surgical management of such complex injury includes radical debridement with stabilization followed by management of gap non-union with appropriate techniques and restores the range of motion. Case Report: We present a case of 20-year-old man who had suffered multiple orthopedic trauma following accident. The patient had open comminuted fracture of the right distal femur, closed fracture of the same side tibia shaft, and right side closed both bone forearm shaft fracture. The patient was initially treated with debridement and knee-spanning limb reconstruction system (LRS). The patient developed infection and subsequently osteomyelitis of the distal femur shaft and gap non-union of 8 cm. The patient was operated for two-stage-induced membrane technique (IMT) and bone grafting using LRS followed by non-vascularized fibula strut grafting and plating. Quadriceps contracture was later on treated with quadricepsplasty to get good functional and radiological outcome. Conclusion: A case of open distal femur comminuted fracture with a very small distal fragment complicated with osteomyelitis and gap non-union. We have shown that the use of IMT followed by non-vascularized fibula strut grafting and plating along with quadricepsplasty can give a very good outcome.

The economic impact of open lower limb fractures in the Netherlands: a cost-of-illness study.

PURPOSE: To estimate the one-year sum of direct costs related to open lower limb fracture treatment in an academic setting in the Netherlands. The secondary objective was to estimate the impact of deep infection and nonunion on one-year total direct costs. METHODS: A multi-center, retrospective cost analysis of open lower limb fractures treated in an academic setting in the Netherlands, between 1 January 2017 and 31 December 2018, was conducted. The costing methodology was based on patient level aggregation using a bottom-up approach. A multiple linear regression model was used to predict the total costs based on Fracture-related-infections, multitrauma, intensive care unit (ICU) admission, Gustilo-Anderson grade and nonunion. RESULTS: Overall, 70 fractures were included for analysis, the majority Gustilo-Anderson grade III fractures (57%). Median (IQR) one-year hospital costs were €31,258 (20,812-58,217). Costs were primarily attributed to the length of hospital stay (58%) and surgical procedures (30%). The median length of stay was 16 days, with an increase to 50 days in Fracture-related infections. Subsequent costs (46,075 [25,891-74,938] vs. 15,244 [8970-30,173]; p = 0.002), and total hospital costs (90,862 [52,868-125,004] vs. 29,297 [21,784-40,677]; p < 0.001) were significantly higher for infected cases. It was found that Fracture-related infection, multitrauma, and Gustilo-Anderson grade IIIA-C fractures were significant predictors of increased costs. CONCLUSION: In treatment of open lower limb fractures, deep infection, higher Gustilo-Anderson classification, and multitrauma significantly increase direct hospital costs. Considering the impact of infection on morbidity and total healthcare costs, future research should focus on preventing Fracture-related infections.

Evaluating the clinical efficacy of the anterolateral thigh flap in lower limb reconstruction surgeries: a systematic review and meta-analysis.

OBJECTIVE: To comprehensively assess the clinical efficacy of the anterolateral thigh flap in lower limb reconstruction (LLR) surgeries and explore its application value via a meta-analysis. METHODS: Published articles on the efficacy of anterolateral thigh flap in LLR were retrieved in English databases such as PubMed, Web of Science, Embase, and The Cochrane Library, which were searched from their inception to November 2023. The search terms included "anterolateral thigh flaps", "lower extremity", "free muscle" and "reconstruction". Subsequently, data extraction of eligible studies was carried out, and data analysis was conducted using RevMan 5.3 software. RESULTS: The final selection comprised 12 appropriate studies, encompassing a total of 577 patients. Meta-analysis demonstrated that negligible differences existed in the length of hospital stay among patients treated with different types of flaps (mean difference (MD) =-0.10, 95% confidence interval (CI) =-0.400.20, P>0.05). Additionally, the occurrence of complications differed slightly (Risk difference (RD) =-0.02, 95% CI=-0.090.05, P>0.05). The incidence of secondary surgeries also demonstrated non-significant differences (RD=-0.04, 95% CI=-0.11-0.04, P>0.05). Nevertheless, patients who underwent anterolateral thigh flap transplantation exhibited a drastic decrease in donor site morbidity (Odds ratio (OR) =0.22, 95% CI=0.10-0.49, P<0.05). CONCLUSION: The clinical efficacy of the anterolateral thigh flap in LLR surgeries shows no significant differences in hospital stay, complication rates, or the need for secondary surgeries compared to other flaps. However, using anterolateral thigh flap in LLR significantly reduces donor site morbidity.

Re-innovation of split lateral gastrocnemius muscle flap for complicated proximal tibia open fracture: Case report.

INTRODUCTION AND IMPORTANCE: Maintaining mobility and hence the productivity of individuals depends on the preservation of lower limb integrity. Increasing violence, mainly triggered by weapons, inversely impacts limb functionality, and the resulting wounds require proper care. CASE PRESENTATION: A 47-year-old African man without any previous medical conditions experienced an injury to his right leg from a high-speed accident, resulting in an open fracture in the upper third of the tibia with missing tissue. At first, he received care from orthopedic surgeons and had debridement done along with the use of an external fixation device to stabilize his limb. Two weeks later, he was referred to the plastic surgery unit and was preparing for urgent surgery. A split lateral gastrocnemius muscle flap was used to reconstruct him after a surgical debridement. CLINICAL DISCUSSION: Proximal leg trauma can be managed successfully by rearrangement of local tissue, resulting in a perfect outcome with less donor site morbidity and a long, complex surgery compared to free tissue transfer. Gastrocnemius muscle or myocutaneous flap, is a gold standard for proximal leg trauma, mainly when a cavity exists, and it is able to create satisfactory reconstruction. CONCLUSION: The split lateral gastrocnemius muscle flap is an effective modification of the flap, resulting in greater surface area coverage, less bulk and shape distortion, and reliable blood supply. Furthermore, it is easy to harvest and apply, deferring the need for step-curve microsurgical procedures.

Ilizarov External Fixator Versus Orthofix LRS in Management of Femoral Osteomyelitis: A Propensity Score Matched Analysis.

Purpose: Treatment of osteomyelitis (OM) is challenging. Ilizarov bone transport is a commonly used technique for management of OM. The recently introduced limb reconstruction system (LRS) has been effectively used for management of OM. It was suggested to be easier in use and less invasive. The present retrospective study aimed to compare LRS and Ilizarov bone transport in management of femoral OM using a propensity score matched analysis. Methods: The present retrospective study included 80 consecutive patients with femoral OM. The studied patients were managed either using Ilizarov external fixator (n = 40) or Orthofix LRS (n = 40). The clinical outcome measurements included union time, limb length discrepancy, additional operative procedures, refracture and infection. Results: Patients in the LRS group were exposed to significantly higher frequency of bone transport (30.0 versus 15.0%) and lower frequency of acute compression and lengthening (10.0 versus 32.5%). Patients in Ilizarov group had significantly higher frequency of tobramycin pellets as compared to their counterparts. The studied groups were comparable regarding the operative complications including pin-tract infection, non-union at docking site and refracture. Patients in the Ilizarov had significantly shorter time to union (8.2 ± 3.2 versus 11.0 ± 5.6 months, p = 0.012). No statistically significant differences were found between the studied groups regarding the quality-of-life domains. Conclusions: Use of Ilizarov external fixator and Orthofix LRS devices proved to be effective and reliable. Their influences on patients' quality appear to be comparable.

Reconstruction of gap non-union tibia with composite use of extramedullary fixation and bone transport by monorail fixator: a prospective case series.

Introduction: Non-union is a complex, multifactorial orthopaedic problem that requires multiple treatment modalities for its management. It can result from infection, segmental bone loss, soft-tissue loss, and associated host factors. External fixators as management of gap non-union are bulky and give rise to a number of complications In our study, we have described a technique where we have used extramedullary fixation in the form of a tibial locking plate and transportation of part of the tibial bone after corticotomy by a monorail fixator. Materials and Methods: The procedure was done in two stages where internal and external fixation was done after creating a gap at the non-union site. The bone was transported after corticotomy and fixed to the internal fixation device in the second stage. The external fixator was removed in the second stage and the patient was then followed up till the bony union. The evaluation was done by functional and radiological assessment along with the complications noted with the described procedure. Results: Ten patients were enrolled in the study with a mean age of 33 years. The mean age of the patients was 33.7 ± 11.32 years with a mean size of the defect was 4.8 ± 1.7 cm. At 30 weeks out of nine patients, three patients had excellent and six had good functional results on the Association of Surgeons for Application and Methodology of Ilizarov (ASAMI) scale. The composite Musculoskeletal Tumor Society (MSTS) score was 76.66 % at the end of 30 weeks of follow-up. The mean time of consolidation was 134.4 days, whereas the mean union time was 145 days from index surgery. Ankle stiffness was the most common complication affecting 50% of the patients. Following closely was pin tract infection, which was present in 40% of the patients. According to Paley's classification, there were 11 obstacles, two problems and none were true complications. Conclusion: The integrated fixation is both safe and effective and has the advantage of early removal of the external fixator and a low complication rate as compared to use of a bulky conventional fixator alone. Moreover, it gives protection to the regenerated bone for a long period. So, this technique can be recommended for the management of segmental tibial defects.

The use of peroneus brevis in lower limb reconstruction-What we have learned from 49 cases.

INTRODUCTION: There are many suitable techniques for the treatment of soft tissue defects of the lower limb. Older subjects often with multiple comorbidities, presenting with a laterally located and complex defect, can be challenging to treat. This cohort are often unsuited to long procedures or multi-stage reconstruction and so one is faced with a paucity of options. In such instances, we use the peroneus brevis (PB) muscle flap as a single stage procedure. METHODS: We performed a retrospective study evaluating the use of PB flaps in lower limb injury. Subjects were collated using a database and multiple variables were assessed including: patient demographics, comorbidities, defect size, peri-operative timings, time in theatre, use of inotropes / blood transfusion, mean hospital stay, patient morbidity / mortality, flap survival. RESULTS: During 2015-2023, 49 patients underwent lower limb reconstruction using PB muscle flaps. 42 cases involved PB and skin graft alone whilst seven were more complex requiring additional local and free tissue techniques. The most common indication (n = 28) was infection after closed fracture fixation, followed by open trauma (n = 21). Median patient age was 59 (20-93 years), and ASA grade 3. Median defect size was 4 × 7 cm (2-18 cm) and time from admission to definitive closure 4 days (0-21 days) with median time in theatre 120 min (45-520 min). 17 patients required inotropes and 13 had blood transfusion. Median length of hospital stay was 12 days (0-58 days), one patient (aged 90) died. 100 % of flaps survived and median Enneking score was 65. Heterotopic ossification was not identified in the post-operative imaging within the first year. DISCUSSION: Our experience highlights the benefits and risks of using the PB flap and advocates it as a reliable, cost-effective, 1-stage technique for reconstructing small lateral defects in the distal third of the lower limb.

Role of microsurgical techniques combined with Ilizarov techniques in limb salvage and functional reconstruction of thermal­crush injuries of the hand: A case report.

The Ilizarov technology was proposed by Former Soviet orthopedic physician Ilizarov. It is a medical method to reconstruct missing tissues. Ilizarov technology combined with soft tissue stretching technology is of great significance in the treatment of common orthopedic problems like bone defects, finger absence, joint contracture and joint stiffness following thermal-crush injuries of the hand. In the present study a 25-year-old male patient sought for limb salvage treatment 1 month after sustaining thermal-crush injuries of the right hand and forearm. The patient had been treated by another hospital with multiple procedures of debridement, and recommended for forearm amputation. The patient was diagnosed with: i) Postoperative infection of thermal-crush injuries of the right hand and right forearm; ii) comminuted open fractures of the proximal and distal phalanges of the right thumb; iii) osteomyelitis; iv) palm skin defects with exposed tendons; and v) skin defects of the opisthenar and the forearm. After a series of treatments including debridement, removal of necrotic tissue, tissue transplantation, skin pedicle, bone lengthening, external shaping, tissue release, joint fusion, traction and rehabilitation exercises, the patient recovered some hand function. Overall, thermal-crush injuries of the hand are severe, complicated combined injuries composed of both heat burn and compression injury and their treatment is challenging. Overall, microsurgery combined with Ilizarov technology can effectively reconstruct the function of complex thermal-crush injuries of the hand.

Limb Reconstruction Using the Ilizarov Technique Following Giant Cell Tumour Excision in the Proximal Tibia of a 19-Year-Old Female: A Case Report.

Giant cell tumours (GCTs) of the proximal tibia are a relatively uncommon lesion among all benign tumours. They can occur at various sites including distal femur, proximal tibia and distal end radius. Various management modalities of GCTs occurring in the knee joint have been described for reconstruction as well as arthrodesis. We present a case of a 19-year-old adolescent patient with GCT of the proximal tibia with cortical breach with the collapse of the medial articular surface of the tibia. The patient reported experiencing knee pain and swelling for a long duration. Radiological investigations were suggestive of GCT of the proximal tibia with the medial cortical breach and collapse of the medial tibial articular surface. The patient was managed with a resection followed by arthrodesis using intramedullary nails with bone grafting, followed by Ilizarov reconstruction due to osteomyelitis of the surgical site. When dealing with relatively aggressive tumours that have breached the cortex, wide resection of the tumour is required. Following this, the reconstruction procedure must ensure good biomechanical tenacity, biological healing, infection resistance, and intact function of the knee joint extension. One option for achieving this is total knee replacement with a customized prosthesis, though this can be costly. Another option is joint arthrodesis with intramedullary nailing or the Ilizarov fixator, which is strongly supported by the existing literature. This case was managed successfully with the above-described method, and complete healing was observed. In conclusion, periarticular long bone tumours, especially around the knee joint, can be managed effectively with the Ilizarov method. Though it has a few disadvantages, such as a long duration of external fixator, non-compliance, and pin tract infections, it still stands as a viable alternative for limb reconstruction due to its cost-effectiveness and time-tested efficacy.

Identifying Research Priorities in Limb Reconstruction Surgery in the United Kingdom.

Introduction: Limb reconstruction surgery (LRS) has a wide range of clinical applications within orthopaedic and trauma surgery. We sought a consensus view from limb reconstruction healthcare practitioners across the United Kingdom to help guide research priorities within LRS. Our aim is to guide future clinical research in LRS, and assist healthcare practitioners, clinical academics, and funding bodies in identifying key research priorities to improve patient care. Materials and methods: A modified Delphi approach was used; it involved an initial scoping survey and a 2-round Delphi process to identify the consensus research priorities in both adult and paediatric LRS. Participants were asked to rank approved submitted questions according to perceived importance on a 5-point Likert scale, where 1 represented lowest importance and 5 indicated highest importance. Mean scores were calculated to identify a consensus of the top ten research priorities for adult and paediatric LRS. Results: One hundred and fifteen participants primarily from across the United Kingdom working in LRS contributed to the modified Delphi process. Participants ranked and then re-ranked the presented research topics in terms of perceived importance. This led to the identification of a top ten research priorities in both adult and paediatric LRS, respectively, based on the collective responses of LRS practitioners. The highest-ranked questions in both adult and paediatric practice related to how to best assess and record patient-reported outcome measures (PROMs) in LRS patients. Other priorities included the effectiveness of specialist physiotherapy, the use of patient-focused psychological support, and the use of various operative management strategies for infection and limb length discrepancies. Conclusion: We present a consensus-driven research priority study that outlines the key research topics and themes determined by healthcare professionals within LRS in the United Kingdom. Clinical significance: These questions will assist funding bodies in prioritising where research funding may be best utilised and help drive future improvement in patient care. How to cite this article: British Limb Reconstruction Society Research Collaborative. Identifying Research Priorities in Limb Reconstruction Surgery in the United Kingdom. Strategies Trauma Limb Reconstr 2024;19(1):1-8.

Rehabilitation Techniques for Adults Undergoing External Fixation Treatment for Lower Limb Reconstruction: A Systematic Review.

Introduction: External fixation devices are commonly used in orthopaedic surgery to manage a range of pathologies. In this patient population, there is currently no consensus on optimal rehabilitation techniques. There exists a large variation in practice, with a limited understanding of how these affect treatment outcomes. Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines, a systematic review was conducted of Allied and Complementary Medicine Database (AMED), Cumulative Index to Nursing and Allied Health Literature (CINAHL), MEDLINE, PEDro, and COCHRANE databases, grey literature sources and forward and backward searching of included articles. Studies were selected following rigorous screening with predefined inclusion criteria. Data quality was assessed using validated appraisal tools. Articles were synthesised by rehabilitation type and descriptive analysis was subsequently performed. Results: From 1,156 articles identified, 18 were eligible for inclusion. The overall quality was low, with clinical commentaries and case studies being the most common study type. Studies were synthesised by rehabilitation type, the most common themes being gait re-education, strengthening, therapy-assisted, active exercises and weight-bearing exercises. Conclusion: There is a lack of high-quality evidence to support meaningful recommendations and guide rehabilitation practices for this patient cohort. Further research for patients being treated in external fixation, especially related to the potential effects of physical rehabilitation on bone healing, return of strength, mobility and independent function is likely to have transferability within wider orthopaedic populations. Clinical significance: This systematic review is unable to provide clinical recommendations due to the poor quality of the available literature. However, it is hoped this paper will provide a foundation for further research to improve rehabilitation for patients being treated with external fixation. How to cite this article: Pawson JR, Church D, Fletcher J, et al. Rehabilitation Techniques for Adults Undergoing External Fixation Treatment for Lower Limb Reconstruction: A Systematic Review. Strategies Trauma Limb Reconstr 2024;19(1):45-55.

Transtibial osseointegration following unilateral traumatic amputation: An observational study of patients with at least two years follow-up.

IMPORTANCE: Most patients use a traditional socket prosthesis (TSP) to ambulate independently following transtibial amputation. However, these patients generally require prosthesis repairs more than twice annually and an entirely new prosthesis every two years. Furthermore, transtibial amputation patients have four times the skin ulceration rate of transfemoral patients, prompting more frequent prosthesis refitting and diminished use. Trans-Tibial osseointegration (TTOI) is a promising technique to address the limitations of TSP, but remains understudied with only four cohorts totaling 41 total procedures reported previously. Continued concerns regarding the risk of infection and questions as to functional capacity postoperatively have slowed adoption of TTOI worldwide. OBJECTIVE: This study reports the changes in mobility, quality of life (QOL), and the safety profile of the largest described cohort of patients with unilateral TTOI following traumatic amputation. DESIGN: Retrospective observational cohort study. The cohort consisted of patients with data outcomes collected before and after osseointegration intervention. SETTING: A large, tertiary referral, major metropolitan center. PARTICIPANTS: Twenty-one skeletally mature adults who had failed socket prosthesis rehabilitation, with at least two years of post-osseointegration follow-up. MAIN OUTCOMES AND MEASURES: Mobility was evaluated by K-level, Timed Up and Go (TUG), and Six Minute Walk Test (6MWT). QOL was assessed by survey: daily prosthesis wear hours, prosthesis problem experience, general contentment with prosthesis, and Short Form 36 (SF36). Adverse events included any relevant unplanned surgery such as for infection, fracture, implant loosening, or implant failure. RESULTS: All patients demonstrated statistically significant improvement post osseointegration surgery with respect to K-level, TUG, 6MWT, prosthesis wear hours, prosthesis problem experience, general prosthesis contentment score, and SF36 Physical Component Score (p < 0.01 for all). Three patients had four unplanned surgeries: two soft tissue refashionings, and one soft tissue debridement followed eventually by implant removal. No deaths, postoperative systemic complications, more proximal amputations, or periprosthetic fractures occurred. CONCLUSIONS AND RELEVANCE: TTOI is likely to confer mobility and QOL improvements to patients dissatisfied with TSP rehabilitation following unilateral traumatic transtibial amputation. Adverse events are relatively infrequent and not further disabling. Judicious use of TTOI seems reasonable for properly selected patients. LEVEL OF EVIDENCE: 2 (Therapeutic investigation, Observational study with dramatic effect).

Management of Scar Contractures of the Hand-Our Therapeutic Strategy and Challenges.

The essence of treating scar contractures lies in covering the skin deficit after releasing the contractures, typically using flaps or skin grafts. However, the specific characteristics of scar contractures, such as their location, shape, and size, vary among patients, which makes surgical planning challenging. To achieve excellent outcomes in the treatment of scar contractures, we have developed a dimensional classification system for these contractures. This system categorizes them into four types: type 1 (superficial linear), type 2-d (deep linear), type 2-s (planar scar contractures confined to the superficial layer), and type 3 (planar scar contractures that reach the deep layer, i.e., three-dimensional scar contractures). Additionally, three factors should be considered when determining surgical approaches: the size of the defect, the availability of healthy skin around the defect, and the blood circulation in the defect bed. Type 1 and type 2-d are linear scars; thus, the scar is excised and sutured in a straight line, and the contracture is released using z-plasty or its modified methods. For type 2-s, after releasing the scar contracture band, local flaps are indicated for small defects, pedicled perforator flaps for medium defects, and free flaps and distant flaps for large defects. Type 2-s has good blood circulation in the defect bed, so full-thickness skin grafting is also a suitable option regardless of the defect's size. In type 3, releasing the deep scar contracture will expose important structures with poor blood circulation, such as tendons, joints, and bones. Thus, a surgical plan using flaps, rather than skin grafts, is recommended. A severity classification and treatment strategy for scar contractures have not yet been established. By objectively classifying and quantifying scar contractures, we believe that better treatment outcomes can be achieved.

Nationwide study on open tibial fractures in the Netherlands: Incidence, demographics and level of hospital care.

OBJECTIVES: Open tibial fractures are relatively common injuries following traffic accidents. The vulnerability of the soft tissues surrounding the tibia increases the susceptibility to complications, including infection and nonunion. To minimize complications, a multidisciplinary, timely approach is crucial. To date, the Dutch incidence and level of hospital treatment remain unknown due to a lack of condition-specific nationwide registries. This study aimed to estimate the incidence and management of open tibial fractures in the Netherlands, providing essential information for public health policymaking and guideline development. METHODS: The 2018 and 2019 Dutch National Hospital Care Basic Registration data, provided by the Dutch Hospital Data Foundation, were utilized to identify all patients admitted to Dutch hospitals with tibial fractures. Incidence rates, patient demographics, primary diagnoses, fracture classification, level of hospital, and length of hospital stays were analyzed using descriptive statistics. RESULTS: 1,079 ICD-10 codes for closed and open tibial fractures were identified in patients that were admitted to a Dutch hospital. Thirty-four percent were classified as open tibial fractures, accounting for an estimated incidence rate of 1.1 per 100,000 person-years (95 % CI 0.97-1.12). When categorized by age, the calculated incidence rate was higher in males for all age categories up until the age of 70. Notably, the overall highest incidence rate was found for females aged 90 and above (6.6 per 100,000 person-years). Open tibial fractures were predominantly treated in general or top clinical hospitals (comprising 69 % of open all tibia fractures). Notably, the minority (31 %) presented at university medical centers, all Level-1 trauma centers, equipped with orthoplastic teams. CONCLUSION: This is the first study to report the nationwide incidence rate of open tibial fractures in the Netherlands; 34 % of tibial fractures were registered as open. Notably, a limited proportion of open tibial fractures underwent treatment within Level-1 trauma centers. Consequently, in the majority of cases, the implementation of an orthoplastic team approach was unattainable. This study underscores the need for more comprehensive data collection to assess and improve the current treatment landscape.

Reverse Shoulder Megaprosthesis for Massive Proximal Humeral Bone Loss in Fracture Outcome Settings: A Report of Two Cases and Literature Review.

In trauma settings, including the management of outcomes, there is no consensus on the most appropriate reconstructive method in the presence of severe bone loss of the proximal humerus. The objective of this report is to evaluate the short-term functional outcomes of two patients in whom reverse shoulder megaprosthesis was used to treat the failure of trauma surgery with severe bone loss. The secondary objective was to compare the results obtained with the literature regarding the use of megaprosthesis in shoulder trauma surgery. The patients showed a satisfying functional recovery and increased quality of life. At the 12-month follow-up, no complications occurred. Regarding the risk of complications, especially the risks of mobilization of the megaprosthesis, the CT-based intraoperative navigation system optimizes the configuration of the screw for the initial fixation of the glenoid component. Shoulder megaprosthesis appears to be a viable option not only in oncologic surgery but also in cases of failed trauma surgery. The functional results, considering functional score and range of motion, are encouraging and allow patients to improve their quality of life.

Revisiting the reconstructive ladder for soft tissue reconstruction in the lower extremity.

Soft tissue reconstruction of the lower limb has seen a paradigm shift over the past two decades. Typically, these defects arise from trauma, infection or tumor. It is no longer enough to simply achieve coverage. Factors like patient-reported outcomes and aesthetic considerations are essential in the decision-making process. This is especially in light of increasing technological advancement, availability of dermal substitutes, microsurgical expertise and development of the field of microsurgical reconstruction as a whole with more novel flaps and techniques. Advancements in reconstructive modalities have also been equally matched by better emergency medical mobilization, transportation and access, early initiation of subspecialty care, accessibility and types of imaging, as well as oncological advances in radiotherapy and chemotherapy regimens. Yet, this has also meant that our patient profile has expanded to include older patients with more co-morbidities and other considerations such as frailty or the irradiated field which could influence what reconstructive modality is suitable and the goals of reconstruction specific to the patient. Previously deemed unsalvageable limbs are now being successfully reconstructed with good function and aesthesis. In the lower limb, this implicates the ability for early mobilization, range of motion and weight bearing which allow the patient to successfully partake in early rehabilitation. Expedient and reliable healing is also important in the oncological population where a proportion of these patients would need to go on to receive post-operative chemotherapy or radiotherapy. The reconstructive ladder has been what many reconstructive surgeons have been taught upon with regard to the basic principles of pre-operative planning and choosing the appropriate reconstructive modality. In this article, we examine the relevance of the reconstructive ladder in modern practice and the additional considerations in the approach to a soft tissue defect in the lower extremity.

Bone union and mobility outcomes for reconstructed open tibial fractures: a plastic surgical experience from a major trauma center.

Introduction: The goal in open tibial fracture management is to achieve a united tibia in an extremity that allows pain free mobilization. The objective of this study was to assess factors that lead to this functional outcome in lower limb reconstruction, from a plastic surgical perspective. Materials and methods: The Plastic and Reconstructive Surgery lower limb database at a tertiary trauma hospital was searched for open tibial injuries from February 2015 to March 2020. The nature and severity of injury, timing and details of all operations including reconstructions were collected prospectively. Mobility including gait aids, pain, and complications were retrospectively collected. Union was assessed in two ways, depending on fracture location. Metaphyseal and diaphyseal tibial fractures were provided mRUST scores (union defined as RUST > 13) and epiphyseal tibial fractures were categorically classified as "united" or "non-union" by two independent radiologists. Results: During the five-year study period there were 148 open leg injuries in the database. Twenty-one patients underwent a primary amputation due to severity of their initial injury. One hundred patients underwent primary limb salvage. Sixty-one patients in the limb salvage group achieved primary tibial union with a mean follow-up time of 19.4 months post injury. Twenty-three additional patients were confirmed to subsequently unite. Patient who achieved union were more likely to mobilise without gait aids. Discussion: In this study definitive external fixation and soft tissue infection were both associated with higher rates of non-union. Longer times to soft tissue reconstruction was not associated with an increase in acute soft tissue complications. More importantly bone union, pain and mobility did not decline. After undertaking a primary limb salvage pathway for 100 patients, the ultimate tibial fracture union rate was 84% and the confirmed ambulation rate was 96%.

Quality of Life in Children With Achondroplasia Undergoing Paired Limb Lengthening With an External Fixator and Modified Distraction Control: Observational Nonrandomized Study.

BACKGROUND: Transosseous distraction osteosynthesis is prioritized in orthopedic care for children with achondroplasia. However, difficulties encountered during treatment and rehabilitation directly impact patients' quality of life. Using rod external fixators within a semicircular frame for osteosynthesis is less traumatic compared to spoke circular devices. Their straightforward assembly and mounting on the limb segment can help significantly reduce treatment duration, thereby improving children's quality of life during treatment and rehabilitation. OBJECTIVE: This study aimed to conduct a comparative analysis of the quality of life (measured by postoperative pain syndrome, physical activity, and emotional state) among children with achondroplasia undergoing paired limb lengthening using either an external fixator with modified distraction control or a circular multiaxial system developed by the authors. METHODS: This was an observational, prospective, nonrandomized, and longitudinal study with historical control. The study group consisted of 14 patients ranging from 5 to 15 (mean 7.6, SD 2.3) years old with a genetically confirmed diagnosis of achondroplasia. All patients underwent paired limb lengthening with a rod external fixator and a modified distraction control developed by the authors. A total of 28 limb segments, among them 4 (14%) humeri, 8 (29%) femurs, and 16 (57%) tibias, were lengthened in 1 round. Unpublished data from the previous study served as the control group, comprising 9 patients (18 limb segments) of the same age group (mean age at surgery 8.6, SD 2.3 years), who underwent limb lengthening surgery using a circular multiaxial system-2 (11%) humeri, 6 (33%) femurs, and 10 (56%) tibias. The Wong-Baker Faces Rating Scale was used to measure pain symptoms, while the Russified Pediatric Quality of Life (PedsQL) v4.0 questionnaire assessed quality of life. RESULTS: During the latent phase (7 to 10 days after surgery), a more pronounced decrease in the indicators of physical activity and emotional state on the PedsQL v4.0 questionnaire was noted in the control group (mean 52.4, SD 4.8 versus mean 52.8, SD 5.5 points according to children's responses and their parents' responses, respectively) compared to the experimental group (mean 59.5, SD 6.8 points and mean 61.33, SD 6.5 points according to the children's responses and their parents' responses, respectively). The differences between the groups were statistically significant (P<.05 for children's responses and P<.01 for parents' responses). Importantly, 6 months after surgery, these quality-of-life indicators, as reported by children in the experimental group, averaged 70.25 (SS 4.8) points. Similarly, their parents reported a mean of 70.54 (SD 4.2) points. In the control group, the corresponding values were 69.64 (SD 5.6) and 69.35 (SD 6.2), respectively. There was no statistically significant difference between the groups. CONCLUSIONS: The external fixator with modified distraction control developed by the authors provides a higher standard of living compared with the circular multiaxial system during the latency phase.

[Current role of the latissimus dorsi flap in traumatology: Analysis of the activity of a plastic surgery department in a military hospital]. / Place actuelle du lambeau de grand dorsal en traumatologie : analyse de l'activité d'un service de chirurgie plastique en hôpital militaire.

Reconstructive surgery's workhorse, the latissimus dorsi flap is increasingly abandoned in favour of fasciocutaneous flaps. The purpose of this study was to analyse the methods used to perform this flap and the evolution of its indications in order to define its current place in traumatology. Forty-four cases were recorded retrospectively from January 2000 to December 2020 at HIA Percy, including 37 cases of free flaps, mainly performed for reconstruction of extensive loss of substance with bone and/or joint exposure. It was also performed in 10.8% of cases for salvage after failure of an alternative reconstruction solution. This analysis confirms the value of the latissimus dorsi flap in cases of significant substance loss in the lower limb, but also in burn patients for functional rehabilitation or to allow early rehabilitation.