Intercalary Resection of the Tibia for Primary Bone Tumors: Are Vascularized Fibula Autografts With or Without Allografts a Durable Reconstruction?

BACKGROUND: Reconstruction with vascularized fibula grafts (VFG) after intercalary resection of sarcoma may offer longevity by providing early graft-host union and fracture healing. The ability of the fibula to hypertrophy under mechanical stress, as well as vascularized bone in the area, may also be advantageous, given that soft tissues may be compromised because of resection, chemotherapy, or radiation therapy. VFG with a massive allograft combines the primary mechanical stability of the graft with the biological potential of the vascularized fibula; however, complications and the durability of this combined reconstruction are not well described. QUESTIONS/PURPOSES: (1) What was the proportion of complications after reconstruction with VFG, with or without allografts? (2) What was the functional result after surgical treatment as assessed by the Musculoskeletal Tumor Society (MSTS) score? (3) What was the survivorship of these grafts free from revision and graft removal? METHODS: Between 1988 and 2021, 219 patients were treated at our institution for a primary malignant or aggressive benign bone tumor of the tibia with en bloc resection. Of those, 54% (119 of 219) had proximal tibial tumors with epiphyseal involvement and were treated with either intra-articular resection and reconstruction with an osteoarticular allograft, allograft-prosthesis composite (APC), or modular prosthesis according to age, diagnosis, and preoperative or postoperative radiotherapy. Nine percent (20) of patients had distal tibial tumors that were treated with intra-articular resection and reconstruction with ankle arthrodesis using allogenic or autologous grafts, and 0.5% (1 patient) underwent total tibial resection for extensive tumoral involvement of the tibia and reconstruction with an APC. Thirty-six percent (79) of patients had a metadiaphyseal bone tumor of the tibia and were treated with intercalary joint-sparing resection. We routinely use reconstruction with VFG after intercalary tibial resection for primary malignant or aggressive benign bone tumors in patients with long life expectancy and high functional demands and in whom at least 1 cm of residual bone stock of the proximal or distal epiphysis can be preserved. By contrast, we routinely use intercalary massive allograft reconstruction in short resections or in patients with metastatic disease who do not have long life expectancy. We avoid VFG in patients with tibial bone metastasis, patients older than 70 years, or primary bone tumors in patients who may undergo postoperative radiotherapy; in these patients, we use alternative reconstructive methods such as intercalary prostheses, plate and cement, or intramedullary nailing with cement augmentation. According to the above-mentioned indications, 6% (5 of 79) of patients underwent massive allograft reconstruction because they were young and had intercalary resections shorter than 7 cm or had metastatic disease at diagnosis without long life expectancy, whereas 94% (74) of patients underwent VFG reconstruction. The median age at operation was 16 years (range 5 to 68 years). The diagnosis was high-grade osteosarcoma in 22 patients, Ewing sarcoma in 19, adamantinoma in 16, low-grade osteosarcoma in five, fibrosarcoma in three, malignant fibrous histiocytoma and Grade 2 chondrosarcoma in two, and malignant myoepitelioma, angiosarcoma of bone, malignant peripheral nerve sheath tumor of bone, squamous cell carcinoma secondary to chronic osteomyelitis, and desmoplastic fibroma in one patient each. Median follow-up was 12.3 years (range 2 to 35 years). The median tibial resection length was 15 cm (range 7 to 27 cm), and the median fibular resection length was 18 cm (range 10 to 29 cm). VFG was used with a massive allograft in 55 patients, alone in 12 patients, and combined with allogenic cortical bone struts in seven patients. We used VFG combined with a massive allograft in patients undergoing juxta-articular, joint-sparing resections that left less than 3 cm of residual epiphyseal bone, for intra-epiphyseal resections, or for long intercalary resections wherein the allograft can provide better mechanical stability. In these clinical situations, the combination of a VFG and massive allograft allows more stable fixation and better tendinous reattachment of the patellar tendon. VFG was used with cortical bone struts in distal tibia intercalary resections where the narrow diameter of the allograft did not allow concentric assembling with the fibula. Finally, VFG alone was often used after mid- or distal tibia intercalary resection in patients with critical soft tissue conditions because of previous surgery, in whom the combination with massive allograft would result in a bulkier reconstruction. We ascertained complications and MSTS scores by chart review, and survivorship free from revision and graft removal was calculated using the Kaplan-Meier estimator. In our study, however, the occurrence of death as a competing event was observed in a relatively low proportion of patients, and only occurred after the primary event of interest had already occurred. Considering the nature of our data, we did not consider death after the primary event of interest as a competing event. RESULTS: In all, 49% (36 of 74) of patients experienced complications and underwent operative treatment. There were 45 complications in 36 patients. There was one instance of footdrop secondary to common peroneal nerve palsy, four wound problems, one acute vein thrombosis of the VFG pedicle and one necrosis of the skin island, two episodes of implant-related pain, 10 nonunions, six fractures, six deep infections, nine local recurrences, one Achilles tendon retraction, one varus deformity of the proximal tibia with postoperative tibial apophysis detachment, one knee osteoarthritis, and one hypometria. The median MSTS score was 30 (range 23 to 30); the MSTS score was assessed only in patients in whom the VFG was retained at the final clinical visit, although if we had considered those who had an amputation, the overall score would be lower. Revision-free survival of the reconstructions was 58% (95% confidence interval 47% to 70%) at 5 years, 52% (95% CI 41% to 65%) at 10 and 15 years, and 49% (95% CI 38% to 63%) at 20 and 30 years. Eight patients underwent VFG removal because of complications, with an overall reconstruction survival of 91% (95% CI 84% to 98%) at 5 years and 89% (95% CI 82% to 97%) at 10 to 30 years. CONCLUSION: VFG, alone or combined with an allograft, could be considered in reconstructing a lower extremity after intercalary resections of the tibia for primary bone tumors, and it avoids the use of a large endoprosthesis. However, this procedure was associated with frequent, often severe complications during the first postoperative years and complication-free survival of 58% at 5 years. Nearly 10% of patients ultimately had an amputation. For patients whose reconstruction succeeded, the technique provides a durable reconstruction with good MSTS scores, and we believe it is useful for active patients with long life expectancy. Fractures, frequently observed in the first 5 years postoperatively, might be reduced using long-spanning plate fixation, and that appeared to be the case in our study. Nonbridging fixation can be an option in intraepiphyseal resection when a spanning plate cannot be used or in pediatric patients to enhance fibula hypertrophy and remodeling. We did not directly compare VFG with or without allografts to other reconstruction options, so the decision to use this approach should be made thoughtfully and only after considering the potential serious risks. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Surgical Feasibility Study on Cadaver for Vascularized Wrist Joint Transplantation.

PURPOSE: Despite modern advancements in the treatment of late stages of wrist joint degeneration, few reliable options exist for patients requiring motion-preserving reconstruction of their radiocarpal and midcarpal joints. Vascularized composite allotransplantation (VCA) could be considered an option for wrist reconstruction in the future. The goal of this study was to describe the relevant anatomy and design a potential surgical technique for wrist VCA. METHODS: Anatomic studies were performed on 17 human upper extremities. The arterial system of each cadaver was injected with latex dye or radiographic contrast. After injecting a contrast medium visible on a computerized tomography (CT) scan, the initial three specimens were examined using microCT. This confirmed joint vascular patency and allowed for the dissection of the other specimens that were injected with latex for the study of joint vascularization and the design of the wrist VCA. We then outlined a donor and recipient surgical technique for transplant based on recipient CT scans. Customized cutting guides were designed for the transplant procedure. After the procedure, we performed angiography of the VCA to determine the vascularity of the transplant. RESULTS: Using a combined volar and dorsal approach, we were able to perform a complete wrist VCA procedure. After the completed transplant procedure, angiographic imaging of the specimens demonstrated that the flap dissection and transplantation preserved the nutrient endosteal supply to the distal end of the radius and ulna, as well as to the carpal bones and the metacarpal bases. CONCLUSIONS: The dissection of the donor, recipient, and the entire vascularized joint transplant procedure served to illustrate the anatomical feasibility of the cadaveric surgical technique. This establishes an anatomic basis for the possibility of future human clinical applications. CLINICAL RELEVANCE: This study helps investigate the anatomical feasibility of a wrist VCA.

Are Vascularized Fibula Autografts a Long-lasting Reconstruction After Intercalary Resection of the Humerus for Primary Bone Tumors?

BACKGROUND: A vascularized fibula graft (VFG) is the vascular autograft most frequently used to restore large segmental long bone defects, particularly in the upper limb. Because the use of a vascularized fibula involves an operation in an uninvolved extremity with potential morbidity, it is important to document that this type of reconstruction is successful in restoring function to the humerus. However, the long-term results of VFG after intercalary resection of the humeral diaphysis for bone tumors are still unknown. QUESTIONS/PURPOSES: (1) What was the complication rate of reconstruction? (2) What was the functional result after surgical treatment, as assessed by the Musculoskeletal Tumor Society (MSTS) score, the American Shoulder and Elbow Society (ASES) score, and Constant score? (3) What was the survivorship of these grafts free from revision and graft removal at 5, 10, and 15 years? METHODS: Between 1987 and 2021, 127 patients were treated at our institution with en bloc resection for a primary malignant or an aggressive benign bone tumor of the humerus; we excluded patients treated with extra-articular resection or amputation. Of those, 14% (18 of 127) were treated with intercalary resection of the humeral diaphysis for primary bone tumors and reconstruction with VFG, with or without a bulk allograft, and were analyzed in this retrospective study. Generally, our indications for reconstruction with VFG are intercalary resection of the humerus for primary malignant or aggressive benign bone tumors in patients with long life expectancy and high functional demands, in whom adequate bone stock of the proximal and distal epiphysis can be preserved. In 13 patients, VFG was used alone, whereas in five patients, a massive allograft was used. Our policy was to use VFG combined with a massive allograft in patients undergoing juxta-articular joint-sparing resections in which proximal osteotomy was performed close to the anatomic neck of the humerus to obtain more stable fixation and better tendinous reattachment of the rotator cuff and deltoid. All 18 patients who were treated with a VFG were available for follow-up at a minimum of 2 years (median follow-up 176 months, range 26 to 275 months), and although three have not been seen in the past 5 years and are not known to have died, they had 172, 163, and 236 months of follow-up, and were included. The median age at surgery was 25 years (range 2 to 63 years), the median humeral resection length was 15 cm (range 8 to 21 cm), and the median fibular length was 16 cm (range 12 to 23 cm). Complications and functional scores were ascertained by chart review that was performed by an individual not involved in patient care. Functional results were assessed with the MSTS score (range 0 to 30), the ASES score (range 0 to 100), and the Constant score (range 0% to 100%). Survivorship was estimated using a Kaplan-Meier survivorship estimator, which was suitable because there were few deaths in this series. RESULTS: Seven patients underwent a revision procedure (one radial nerve transient palsy because of screw impingement, four nonunions in three patients with one humeral head avascular necrosis, treatment for screw-related pain in one patient, and two VFG fractures), and one patient underwent VFG removal. Donor site complications were observed in four patients (one ankle valgus deformity and three claw toes-the first toe in two patients and the other toes in the third). At the final clinical control, at a median follow-up of 176 months (range 26 to 275 months), the median MSTS score was 30 of 30 (range 28 to 30), the median ASES score was 98.3 (range 93 to 100), and the median Constant score was 93.5% (range 79% to 100%). Revision-free survival was 71% (95% CI 53% to 96%) at 5 years and 57% (95% CI 37% to 88%) at 10 and 15 years; VFG removal-free survival was 94% (95% CI 83% to 100%) at 5, 10, and 15 years. CONCLUSION: VFG appears to be an effective reconstructive option after humeral intercalary resection for primary bone tumors. These are complex procedures and should be performed by an experienced team of surgeons who recognize that complications may occur frequently in the first years after the procedure. The frequency of mechanical complications observed in the first 5 years postoperatively may be lessened by using long spanning-plate fixation, and if successful, this reconstruction provides a long-term, durable reconstruction with excellent functional results. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Rhino-oropharingeal osteoradionecrotic soft-tissue and bony defect reconstruction with submental artery island flap: a case report.

BACKGROUND: The submental artery island flap is widely used in head and neck reconstruction, since it is easy and quick to harvest, and it can be successfully used for the coverage of perioral, intraoral and facial defects. We used this technique for the reconstruction of a complex soft-tissue and bony defect of rhino-oropharinx. CASE REPORT: Osteoradionecrosis of rhino-oropharingeal posterior wall with C2 necrotic body exposure occurred in a 77-year-old woman. After the failure of reconstruction with a Hadad-Bassagasteguy flap, a submental island flap with cervical spine stabilization was planned to be performed in a one-stage operation. The anterior arc of C1 and odontoid process of C2 were removed and, according to the defect size, a submental island flap was designed in an elliptical fashion. The flap was rotated 180° and tunnelized under the left parapharingeal-prevertebral space, then it was positioned in the rhino-oropharinx and fixed with reabsorbable sutures. The donor site was closed primarily. No peri- or post-operative complications occurred, neither in the recipient nor in the donor-site. At the latest follow-up, 15 months postoperatively, the patient was able to speak without any impairment and started swallowing rehabilitation with good results and an aesthetically satisfactory outcome. CONCLUSION: The submental island flap may be a reliable and versatile flap for reconstruction of head and neck defects, even though in the rhino-oropharingeal posterior wall.

New Robotic System with Wristed Microinstruments Allows Precise Reconstructive Microsurgery: Preclinical Study.

BACKGROUND: Microsurgery allows complex reconstruction of tissue defects after oncological resections or severe trauma. Performing these procedures may be limited by human tremor, precision, and manual dexterity. A new robot designed specifically for microsurgery with wristed microinstruments and motion scaling may reduce human tremor and thus enhance precision. This randomized controlled preclinical trial investigated whether this new robotic system can successfully perform microsurgical needle driving, suturing, and anastomosis. METHODS: Expert microsurgeons and novices completed six needle passage exercises and performed six anastomoses by hand and six with the new robot. Experienced microsurgeons blindly assessed the quality of the procedures. Precision in microneedle driving and stitch placement was assessed by calculating suturing distances and angulation. Performance of microsurgical anastomoses was assessed by time, learning curves, and the Anastomosis Lapse Index score for objective performance assessment. RESULTS: Refined precision in suturing was achieved with the robot when compared with the manual technique regarding suture distances (p = 0.02) and angulation (p < 0.01). The time required to perform microsurgical anastomoses was longer with the robot, however, both expert and novice microsurgeons reduced times with practice. The objective evaluation of the anastomoses performed by novices showed better results with the robot. CONCLUSIONS: This study demonstrated the feasibility of performing precise microsutures and anastomoses using a new robotic system. Compared to standard manual techniques, robotic procedures were longer in time, but showed greater precision.

Pelvic ring reconstruction with double-barreled fibular free flap: A systematic review.

INTRODUCTION: Pelvic ring reconstruction after internal hemipelvectomy is an extremely challenging surgical procedure, and mandatory reconstruction is to provide a durable and pain-free functional outcome, especially for young, active patients. One of the most widely employed techniques is reconstruction with a double-barreled fibular free flap (DBF). The aim of our work was an in-depth analysis of the outcome of pelvic ring reconstruction performed using the above-mentioned method, in particular looking for a correlation between the fixation technique and either ambulation status or complications. MATERIALS AND METHODS: A systematic review was performed in November 2020 using PubMed and MedLine Ovid databases according to the PRISMA guidelines and the results were statistically analyzed. RESULTS: Studies were published between 1994 and 2015. A DBF was used in each case, with a total of 30 patients. Reconstruction was performed with screws in 13 cases, Cotrel-Dubousset rod fixation in 6, screws and plate in 5, screws with external fixation in 4, and ISOLA in 2. Follow-up time ranged from 3 to 131 months. Functional outcome was excellent in 4 patients and good in 26 patients. Statistical analysis showed no statistical evidence of existing correlation between fixation technique and complications (p = .873), while statistical correlation between age and fixation technique was found (p < .001). CONCLUSION: Reconstruction of pelvic ring with DBF provides an overall good functional outcome. Our data indicate that there is no statistical evidence of existing correlation between the fixation technique and either complications or ambulation status.

Pediatric Malignant Mandibular Tumors: Personal Experience and Literature Options Discussion.

INTRODUCTION: Mandibular defects reconstruction could result challenging in childhood, due to facial and mandibular growth patterns. For these reasons, the choice of the most suitable reconstructive option in pediatric patients, affected by mandibular malignancies, still objects of debate. OBJECTIVE: The aim of our study was to compare our reconstructive schedules to the existing literature in order to give a personal contribute to the present panorama. METHODS: We performed, in October 2019, a retrospective evaluation of pediatric patients treated for biopsy-proven mandibular malignancies at our Institute between January 2013 and December 2016. All of them received multimodal therapy in accordance with standard guidelines and their demographic, clinical, treatment, and outcome parameters were collected and analyzed. RESULTS: We observed a shorter duration of surgery, a faster tracheostomy tube and feeding-tube removal, and a minor hospitalization in patients who received grafts transfer compared to those who underwent microsurgical mandibular reconstruction. After a 36-month period of follow-up, osteochondral grafts showed a pattern of growth similar to the mandibular epiphysis (condilylion-gonion linear and vertical ratio ranging to 0.96-1.03 and 1-1.02 at orthopantomogram, respectively). No bone consolidation delays and functional impairment were recorded. CONCLUSIONS: Free flaps mandibular reconstruction in children needs to be better assessed and proximal fibular epiphyseal free flap indication might deserve further studies. Osteochondral grafts find indication for lateral defects, 50-55 mm in maximum length and located in the mandibular ramus, without massive teeth or soft tissue defect. Condyle involvement does not represent an absolute contraindication to rib graft use.

Oromandibular reconstruction with double-skin paddle fibular free flap: A systematic review and meta-analysis.

BACKGROUND: Reconstruction of complex head and neck defects is challenging, especially when more than one soft-tissue subunit is involved. The osteocutaneous fibular flap underwent continual evolution to improve its soft-tissue characteristics, such as including a second skin island. The purpose of this study was to evaluate outcomes regarding oromandibular reconstruction with a double-skin paddle fibular free flap (DSPFFF) using three different techniques: central de-epithelialized skin paddle, distally-based double-skin paddle (DSP), or proximally and distally-based DSP. METHODS: A systematic review was performed in December 2020 using Pubmed and MedLine Ovid databases according to the PRISMA guidelines. A meta-analysis of functional outcome and complications was performed to estimate single incidence rates. RESULTS: A total of 449 patients were included, with a follow-up of 1-84 months, where 330 patients underwent reconstruction with the first technique, 23 patients with the second technique, and 96 patients with the third technique. The meta-analysis showed an overall good functional outcome and a low-complication rate for oromandibular reconstruction with DSPFFF. A better functional outcome and a lower complication rate were found when a distally-based DSPFFF was harvested compared to a proximally and distally-based DSPFFF. CONCLUSION: The DSPFFF was found to be useful and reliable for reconstructing composite and extensive head and neck defects, with an overall good functional outcome and a low-complication rate. The meta-analysis showed a better positive outcome on distally-based DSPFFF rather than proximally and distally-based DSPFFF. In addition, distally-based DSPFFF showed a lower complications rate when compared with proximally and distally-based DSPFFF.

Reconstruction after complete mandibular avulsion with double-paddle fibular free flap. A case report.

Reconstruction after maxillofacial trauma is extremely challenging. During the past several decades, the chimeric fibular-free flap has emerged as a leading reconstructive option for head and neck compound defects. This report describes a unique case of total mandibular reconstruction using a double-paddle osteocutaneous fibular free flap after facial traumatic injury. A 45-year-old man presented a severe maxillofacial trauma with complete mandibular avulsion. The shortest segment of a 24-cm fibular flap was used to reconstruct the symphysis while the longest segments were placed to rebuild the mandibular body. Microvascular anastomoses were performed with the external jugular vein and facial artery. The distal skin island (10 × 5 cm) was sutured to cover the endo-oral defect while the proximal one (12 × 6 cm) to restore the external tissues continuity of the facial lower third. The postoperative course was uneventful. One year after flap reconstruction, a first commissuroplasty was performed. After 3 months, secondary commissuroplasty was performed with an Estlander flap to rebuild the right lower lip. At latest follow-up, 60 months postoperatively, the patient was able to tolerate soft diet with maximal mouth opening of more than 4 cm; no impairment to mastication, deglutition, or phonation was observed. Speech was normal and the aesthetic outcome was judged good. Double-paddle fibular free flap allows reconstruction of extremely challenging defects, such in case of complete mandibular avulsion. The proximal perforator can provide extended soft-tissue coverage and greater volume than traditional osteocutaneous flaps, avoiding two flaps simultaneous harvest.

Gynecomastia and Chest Masculinization: An Updated Comprehensive Reconstructive Algorithm.

BACKGROUND: Gynecomastia is a common finding in males. Clinical aspect varies widely in world populations showing peculiar hallmarks according to different body shapes reflecting personal expectations; therefore, a surgical plan must be tailored on individual basis to all type of patients. MATERIALS AND METHOD: A total of 522 patients, treated for bilateral gynecomastia from January 2007 to January 2019, were included and reviewed in this retrospective study. Considering physical status BMI, muscular trophism, hypertrophy of the mammary region, nipple-areola disorder, gland and skin cover consistency, a four-tier classification system has been used to classify the deformity and to assess a surgical plan. In all cases, a subcutaneous mastectomy was performed under direct vision. RESULTS: No recurrence of the deformity was observed as well as major complications such as necrosis, and high level of satisfaction was observed in all groups. No breast cancer was found at the histological examinations Operative time ranged from 25 minutes up to 120 minutes and hospitalization time ranged from 1 to 3 days. CONCLUSION: Since the physical status is strictly related to the clinical features of the disorder, a comprehensive classification system and a reconstructive algorithm are proposed. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Study of the Expression and Function of Calcium-Sensing Receptor in Human Skeletal Muscle.

Skeletal muscle has an outstanding capacity for regeneration in response to injuries, but there are disorders in which this process is seriously impaired, such as sarcopenia. Pharmacological treatments to restore muscle trophism are not available, therefore, the identification of suitable therapeutic targets that could be useful for the treatment of skeletal reduced myogenesis is highly desirable. In this in vitro study, we explored the expression and function of the calcium-sensing receptor (CaSR) in human skeletal muscle tissues and their derived satellite cells. The results obtained from analyses with various techniques of gene and protein CaSR expression and of its secondary messengers in response to calcium (Ca2+) and CaSR drugs have demonstrated that this receptor is not present in human skeletal muscle tissues, neither in the established satellite cells, nor during in vitro myogenic differentiation. Taken together, our data suggest that, although CaSR is a very important drug target in physiology and pathology, this receptor probably does not have any physiological role in skeletal muscle in normal conditions.

Characterization of Skeletal Muscle Endocrine Control in an In Vitro Model of Myogenesis.

Skeletal muscle has remarkable regenerative abilities regulated by a highly orchestrated process involving the activation of cellular and molecular responses, which are dependent on satellite cells. These cells maintain the stem cell population and provide numerous myogenic cells that proliferate, differentiate, fuse and lead to new myofiber formation for a functional contractile tissue. We have isolated and characterized satellite cells obtained from human biopsies and established an in vitro model of myogenesis, evaluating muscle regeneration, monitoring the dynamic increases of the specific myogenic regulatory factors and the final formation of multinucleated myofibers. As the skeletal muscle is an endocrine tissue able of producing many substances that can act on distant organs, and it can be physiologically modulated by a variety of hormones, we embarked in a project of characterization of muscle cell endocrinology machinery. The expression of a large array of hormone receptors was quantified during the process of myogenesis. The results obtained showed a significant and generalized increase of all the tested hormone receptors along the process of differentiation of human cultured cells from myoblasts to myocytes. Interestingly, also the production of the myokine irisin increased in a parallel manner. These findings point to the human cultured myoblasts as an ideal model to characterize the skeletal muscle endocrine machinery and its hormonal regulation.

Mandibular ramus and condyle reconstruction with vascularized proximal fibular epiphyseal transfer in the pediatric patient: A case report.

Mandibular reconstruction in skeletally immature patients is challenging for the Plastic Surgeon. Indeed, it requires replacement of the bony defect with restoration of the growth capability and joint function, when condyle is involved. Vascularized transfer of the proximal epiphysis of the fibula meets all these reconstructive requirements providing an adequate bone stock which also contains a growth plate and an articular surface. The purpose of this article is to report a case of mandibular reconstruction in a 13-year-old boy who underwent resection of a high-grade osteosarcoma involving mandibular angle, ramus, and condyle. A fibular free flap including proximal epiphysis, with its growth plate and the articular surface, was harvested based on the anterior tibial vessels. The fibular head articular surface was placed facing the articular fossa of the temporal bone. A reverse-flow end-to-end anastomosis was performed with the facial vessels. Postoperatively, no infection nor anastomosis complications occurred. Surgical sites healed uneventfully. At latest follow-up, 1 year after surgery, no signs of recurrence were observed. The transferred bone survived and the growth plate was clearly open. Both functional and aesthetic outcomes were rated as good, with maximal mouth opening of more than 4 cm, neither impairment to mastication, deglutition nor phonation was observed. This technique may be a good option for pediatric reconstruction of large bony and articular mandibular defects, where functional restoration of temporomandibular joint and the growing capacity of the bone should be contemporary.

Reverse-flow latissimus dorsi myocutaneous flap in a multi-step approach for complex back defect reconstruction: A case report.

Reconstruction of complex back defects is challenging for reconstructive surgeons, as it should preserve function, provide adequate coverage, and minimize morbidity. We present a case of multiple-step reconstruction after resection of a large squamous cell carcinoma recurrence in a 68-year-old man, with local perforator flaps and a reverse-flow latissimus dorsi myocutaneous flap. After radical excision, four propeller perforator flaps were harvested to cover a 30 × 25 cm defect, based on the dorsal branch of the fifth posterior intercostal arteries (right 20 × 9 cm, left 17 × 9 cm) and on the superior gluteal arteries (right 20 × 11 cm, left 21 × 12 cm) bilaterally. In the second step, bilateral propeller perforator flaps based on the fourth lumbar arteries (right 18 × 13 cm, left 23 × 11 cm) were transposed to cover the residual loss of tissues. After 5 months, a recurrence occurred on the left midback. A wide en bloc excision of the last three ribs and pulmonary pleura was performed, and the synthetic mesh used for thoracic wall reconstruction was covered with an ipsilateral 20 × 10 cm reverse-flow latissimus dorsi myocutaneous flap based on the serratus anterior branch. All the flaps healed uneventfully and there were no donor-site complications. Two years postoperatively, the patient had a cosmetically acceptable result without any functional impairment. The reverse-flow latissimus dorsi myocutaneous flap can represent a salvage procedure in back complex defects reconstruction, especially when other local flaps have already been harvested in previous reconstructive procedures.

Extensor hallucis longus tendon and soft-tissue reconstruction with palmaris longus tendon included in a radial forearm free flap: A case report.

Reconstruction of foot structures is challenging because of the need to restore both anatomy and function. Extensor hallucis longus (EHL) excision without reconstruction could result in a flexion deformity of the toe at the interphalangeal joint. In this report, we present a case of the use of a palmaris longus tendon included in a fasciocutaneous radial forearm free flap to reconstruct EHL tendon and soft tissues of the distal foot dorsum. A 41-year-old woman presented with a recurrence of myxoinflammatory fibroblastic sarcoma on the medial part of the left foot dorsum. The EHL tendon was sacrificed, leaving a soft-tissue defect of 14 × 5 cm and 14-cm tendon gap. A 14 × 5 cm radial forearm flap with a 16-cm section of palmaris longus tendon was harvested from the left forearm. Radial artery and its comitant vein were anastomosed with dorsalis pedis artery and vein. EHL tendon repair was performed from the composite mass to the proximal and distal stumps. No complication in the postoperative period occurred. At latest follow-up, 12 months postoperatively, the patient showed a normal joint function and was satisfied with the treatment. Palmaris longus tendon included in a radial forearm free flap could be recommended for combined soft tissue and tendon defects, particularly on the foot dorsum.

Evaluation of Residual Neuro-Muscular Integrity in the Orbicularis Oculi Muscle After Lower Eyelid Transcutaneous Blepharoplasty According to Reidy Adamson-s Flap.

BACKGROUND: The aging process affects skin, muscle and fat of the eyes in a different manner. Their individual rejuvenation would require specific surgical treatment according to their particular demands during lower eyelid blepharoplasty. This would require the separate management of the skin and the muscle by separating them into two different flaps. Basing on the anatomy, during sub-ciliary myocutaneous incision in conventional lower eyelid transcutaneous blepharoplasty most of innervations of the lower orbicularis oculi muscle are transected and denervation sequelae at the pretarsal orbicularis oculi muscle would be expected. However, sub/ciliary approach is still popular. The absence of signs or symptom of denervation of in our large case series even though injury to the motor innervation of the orbicularis oculi muscle during the operation led the authors to investigate the discrepancy between the anatomical concept and clinical outcomes. The study aimed to investigate the residual functionality of the orbicularis oculi muscle after lower eyelid transcutaneous blepharoplasty according to Reidy Adamson-s flap. MATERIALS AND METHODS: Ten patients were enrolled in the study. Orbicularis oculi muscle functionality was investigated with electroneurography before and at least 6 months after the surgical procedure. Investigated parameters are: Compound Muscle Action Potential (CMAP) as expressions of quantity of activated muscular fibers by the electrical stimulation of the facial nerve. Pre- and post-op collected data were compared and statistically analyzed. RESULTS: The mean age was 52.9; minimum follow-up 6 months; twenty eyes were investigated; 1 patient was excluded. Postoperative data did not show any significant reduction in the CMAP at all. CONCLUSION: The study suggests that the buccal branch and medial branch of the zygomatic nerve of the facial nerve supplies efficiently to the orbicularis oculi innervation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Two-Step Immunomagnetic Microbead-Based Method for the Isolation of Human Primary Skin Telocytes/CD34+ Stromal Cells.

Telocytes (TCs), commonly referred to as TCs/CD34+ stromal cells, are a peculiar type of interstitial cells with distinctive morphologic traits that are supposed to exert several biological functions, including tissue homeostasis regulation, cell-to-cell signaling, immune surveillance, and reparative/regenerative effects. At present, the majority of studies investigating these cells are mainly descriptive and focus only on their morphology, with a consequent paucity of functional data. To gain relevant insight into the possible functions of TCs, in vitro analyses are clearly required, but currently, the protocols for TC isolation are only at the early stages and not fully standardized. In the present in vitro study, we describe a novel methodology for the purification of human primary skin TCs through a two-step immunomagnetic microbead-based cell separation (i.e., negative selection for CD31 followed by positive selection for CD34) capable of discriminating these cells from other connective tissue-resident cells on the basis of their different immunophenotypic features. Our experiments clearly demonstrated that the proposed method allows a selective purification of cells exhibiting the peculiar TC morphology. Isolated TCs displayed very long cytoplasmic extensions with a moniliform silhouette (telopodes) and presented an immunophenotypic profile (CD31-/CD34+/PDGFRα+/vimentin+) that unequivocally differentiates them from endothelial cells (CD31+/CD34+/PDGFRα-/vimentin+) and fibroblasts (CD31-/CD34-/PDGFRα+/vimentin+). This novel methodology for the isolation of TCs lays the groundwork for further research aimed at elucidating their functional properties and possible translational applications, especially in the field of regenerative medicine.

Quadriceps tendon reconstruction using a fascia lata included in a reverse-flow anterolateral thigh flap.

Quadriceps tendon re-rupture after surgical repair is an overall estimated 2% complication. We report a case of reconstruction in a large tendon and soft tissue defect using a reverse-flow anterolateral thigh (ALT) perforator flap including fascia lata in a 75-year-old man presented with septic necrosis of a reconstructed quadriceps tendon. A reverse-flow ALT flap was transferred to the knee defect; the fascia lata was sutured to the residual tendon. Post-operative flap congestion and infection were successfully treated with debridement and conservative treatment. One year after surgery, the patient was able to fully and actively extend the knee, with an acceptable aesthetic appearance. The reverse-flow anterolateral thigh flap including fascia lata may be a good option for coverage of soft-tissue defects around the knee and contemporary quadriceps tendon reconstruction, particularly in case of septic tendon necrosis, where the use of non-vascularised tissues is contraindicated.

Calcaneal reconstruction after total calcanectomy with iliac crest free flap.

INTRODUCTION: Calcaneal tumors being a rare occurrence, surgical options and outcomes are not well-known. Extensive defects following wide resection, especially in weight-bearing areas, still remain a challenge and different reconstructive techniques have been proposed. The aim of this report was to analyze the clinical and functional long-term outcomes of heel reconstruction using an iliac crest free flap. PATIENTS AND METHODS: Four patients who underwent calcaneal reconstruction between 1999 and 2012 were included. Two were females and mean age was 27 years, ranging 18-42 years. Each patient underwent total calcanectomy, for two osteoblastomas, one osteosarcoma, and one Ewing's sarcoma. An iliac crest flap was harvested and shaped to fit the residual space. After the articular cartilage at recipient site was debrided, the flap was fixed to the talus and the cuboid. RESULTS: The average size of the flaps was 2 x 7 x 5 cm. Postoperatively wound dehiscence, screw breaking, and graft fracture healed conservatively. All the arthrodesis healed successfully and no donor site complication occurred. At an average follow-up of 13 years (range 6-19 years) any patient claimed pain, evident limp or limitation of daily activities. Computerized pedobarographic examination and gait analysis revealed a satisfactory result and an acceptable weight-bearing area in the reconstructed limb in each patient. CONCLUSIONS: Calcaneal reconstruction with iliac crest free flap is likely to provide good chances of a long-lasting result, especially in young patients. Particularly, it provides the possibility to adequately shape the graft to fit the bone loss while using the crest as the weight-bearing surface.

Effects of Cutaneous Negative Pressure Application on Perforator Artery Flow in Healthy Volunteers: A Preliminary Study.

BACKGROUND: The creation of skin flaps based on small perforator vessels is an increasingly popular procedure nowadays; the optimization of their blood supply enhances surgical success. This study evaluates the effects on the flowmetries of 7 days' negative pressure application on the skin surface overlying the muscle fascia emergence of periumbilical perforators of the deep inferior epigastric artery (DIEA). METHODS: Ten volunteer participants were enrolled. In each subject, one periumbilical perforator of the DIEA was identified on each side of the abdomen using an eco-color-Doppler. One of them was used as the control group, while the other (the study group) underwent 80 mm Hg negative pressure for 7 days. The flowmetries of both perforators were measured before and after the application of negative pressure wound therapy. RESULTS: After the application of negative pressure, randomly applied on the skin surface over one of the two selected periumbilical perforators, an increase in the flowmetries was observed in both groups of perforators (2.74 cm/s; p < 0.0001). The relative flowmetry increase in the control group was 9.55% (2.735 cm/s), while in the study group it was 44.03% (8.748 cm/s). CONCLUSION: The application of negative pressure system on the skin surface over the muscle fascia emergence of the selected periumbilical perforators showed an increase in flowmetry. Although this is a preliminary study, this simple and economical procedure before surgery could be usefully employed to increase the rate of success in microsurgical procedures.