Treatment of segmental bone and soft-tissue defects of the forearm with the free osteocutaneous lateral arm flap.

BACKGROUND: Complex defects of the forearm often require microvascular reconstruction with osteocutaneous free flaps to salvage the limb. In this review, we report our experience with the use of the free osteocutaneous lateral arm flap to reconstruct such defects in four patients. METHODS: Three male patients with osseous defects of the ulna and one defect of the radius with associated soft-tissue defects were treated with a free osteocutaneous lateral arm flap between 2004 and 2007. The indications for the procedure included posttraumatic osteitis (3) and bone with soft-tissue defects after trauma (1). We evaluated the patients with respect to postoperative results by evaluating the range of motion, pain, strength, and score on the disabilities of the arm, shoulder, and hand questionnaire. Donor-site morbidity was also documented. RESULTS: The average length of segmental bone defects was 5.75 cm. The average dimension of the skin paddle was 99.5 cm. The average duration of follow-up was 43.3 months. All bone flaps healed without nonunion; the fasciocutaneous flaps healed without complications. No problems related to microanastomoses were found. Functional results were very satisfactory; disabilities of the arm, shoulder, and hand questionnaire scores showed a median of 5.8 (0-10.8). All patients had returned to their preinjury occupations. CONCLUSION: This analysis demonstrates that the free osteocutaneous lateral arm flap is an effective treatment for combined segmental osseous and soft-tissue defects of the forearm that are caused by osteitis and trauma.

Vasopressin for hemorrhagic shock management: revisiting the potential value in civilian and combat casualty care.

The evolution of trauma care is driven by a synergistic relationship between civilian and military medical systems. Although the characteristics of civilian injuries differ from those encountered on the battlefield, the pathophysiologic process of dying is the same and dominated by exsanguination and central nervous trauma. As such, therapies that interfere with the physiologic ability to compensate hemorrhage may play a key role to buy time until hemostatic surgery can be initiated. From a variety of remedies with the potential to prolong the compensation phase or to reverse the decompensation phase of shock, arginine vasopressin (AVP) is one of the most promising and best-evaluated drugs. Animal studies and various case report series provide some evidence that AVP may improve blood pressure even when conventional therapies fail, thus preventing hypovolemic cardiac arrest and enabling resuscitation from fatal hemorrhage. On the basis of this civilian experience, it seems reasonable to consider AVP for hypotensive resuscitation in the austere, resource-constrained battlefield environment. However, the significance of AVP as a rescue medication for life-threatening hemorrhage has yet to be proven.

Bone, tendon, and soft tissue reconstruction in one stage with the composite tensor fascia lata flap.

A 46-year-old patient sustained a dia-infracondylar tibial fracture after a ski accident. Open reduction and internal fixation (ORIF) was carried out. After an initially uneventful postoperative course the patient was readmitted because of local and systemic infection signs. Radical surgical debridement was carried out following by Vacuum-Assisted Closure (VAC) therapy. The resulting defect consisted of bone defect of the tibia tuberosity, and complete loss of the patellar tendon and the overlying soft tissue. Reconstruction was carried out with a combined tensor fascia lata (TFL) flap including the TFL muscle with the ilio-tibial tract, vascularized part of the iliac crest and the overlying soft tissue. Bone healing took place without signs of osteomyelitis recurrence, and full weight bearing was possible 4 months after reconstruction. Successful reconstruction of the patellar tendon using the ilio-tibial tract, enables the patient full active knee joint motion. The soft tissue coverage shows stable conditions. The donor site showed inconspicuous healing without pain and normal range of motion of the hip joint. So this composite TFL flap is an interesting flap not only for defects following trauma, but also for combined defects following extensive infections after knee implants.

Retrograde femoral nailing in elderly patients: outcome and functional results.

Functional outcome after retrograde femoral intramedullary nailing was investigated in 35 patients older than 60 years (mean, 86 years) with 36 fractures, comprising 15 (41.7%) shaft and 21 (58.3%) distal fractures; overall, 7 (19.4%) periprosthetic fractures occured. Twenty-two (62.9%) of 35 patients were evaluated at a mean 16.5-month follow-up with the Lyshom-Gillquist score and the SF-8 questionaire. Primary union rate was 97.8%, with no significant differences in duration of surgery, bone healing, mobilization, and weight bearing among different fracture types; periprosthetic fractures revealed a significantly delayed mobilization (P=.03). Complications occured significantly more often among distal femoral fractures (P=.009), including all revision surgeries. The most frequently encountered complication was loosening of distal locking bolts (n=3). Lysholm score results were mainly influenced by age-related entities and revealed fair results in all fractures (mean in the femoral shaft fracture group, 78.1 vs mean in the distal femoral fracture group, 74.9; P=.69), except in the periprosthetic subgroup, which had good results (mean, 84.8; P=.23). This group also had increased physical parameters according to SF-8 score (P=.026). No correlation existed between SF-8 physical parameters and patient age or surgery delay, whereas a negative correlation existed between patient age and SF-8 mental parameters (P=.012). Retrograde femoral intramedullary nailing is commonly used in elderly patients due to reliable bone healing, minimal soft tissue damage, and immediate full weight bearing. It also offers a valid alternative to antegrade nailing in femoral shaft fractures.