Reliability and Versatility of Reverse Sural Island Neurofasciocutaneous Leg Flaps.

BACKGROUND: Distally based sural neurofasciocutaneous (NFC) flaps are a commonly used method for foot and ankle reconstruction given that they are much simpler and, at the same time, still efficient alternative to perforator flaps and free style free flaps. OBJECTIVE: This study aims to evaluate the reliability and versatility of reverse sural island NFC flaps as a powerful and efficient method that can be used for repair of lower leg skin defects. This method does not require microsurgical facilities or extensive training. METHODOLOGY: Patients with soft tissue defects of the distal third of the leg and ankle region received reverse sural island NFC flaps. Inclusion criteria included an absence of damage to the sural neurovascular axis or communicating perforators, absence of peripheral vascular disease, and the presence of soft tissue defects deep enough to expose tendon or bone. Patients were assessed for flap (defect) size, pedicle length and location of defects, postoperative flap survival rates, and complications. Donor sites were closed directly or skin grafted. RESULTS: Of 24 consecutive patient (20 male; 4 female), all flaps except 1 (4.16%), survived, although partial necrosis was observed in 2 patients (8.33%). The overall major complication rate was 12.50%. Epidermolysis was noted in 1 patient (4.16%). Three cases of transient venous congestion resolved without additional complications. The overall minor complication rate was 16.66%. Minimal complications were associated with healing of donor sites. CONCLUSIONS: Reverse sural island NFC flaps provide adequate and aesthetically very acceptable coverage of soft tissue defects of the distal lower leg and proximal foot with no functional impairment.

Results of open tibial fracture treatment using external fixation.

Introduction: Open lower leg fractures are the most common open fractures of the locomotor system and their treatment is associated with a number of complications. Objective: The aim of the paper was to present the results of the treatment of 68 patients with open lower leg fractures, as well as the complications that accompany the treatment of these fractures. Methods: In the analyzed group, there were 45 (66.18%) men and 23 (33.82%) women. The majority of patients ­ 33 (48.53%) of them ­ were injured in motor vehicle accidents, whereas 24 (35.29%) patients sustained injuries due to falls from heights. In two (2.94%) patients the cause of open tibial fractures was gunshot injuries. In the analyzed group, there were 18 (26.47%) type I open fractures, 21 (30.88%) type II open fractures, 19 (27.94%) type IIIA open fractures, seven (10.29%) type IIIB open fractures, and three (4.41%) type IIIC open fractures. Results: The tibial shaft fracture healed without serious complications in 50 (73.53%) patients, whereas in 18 (26.47%) patients we observed some complications. Nonunion was found in 10 (14.71%) patients, osteitis in four (5.88), malunion in two (2.94%) patients. Milder complications such as soft tissue pin tract infection developed in 13 (19.12%) patients, infection of the open fracture wound soft tissue was observed in four (5.88%) patients. Conclusion: Basic principles in the treatment of open lower leg fractures in this study are thorough primary open fracture wound treatment followed by the delayed wound closure, stable fracture fixation using unilateral external skeletal device, proper antibiotic treatment and tetanus prophylaxis. The results correlate with similar studies.

Treatment of open tibial fracture with bone defect caused by high velocity missiles: a case report.

INTRODUCTION: Tibia fracture caused by high velocity missiles is mostly comminuted and followed by bone defect which makes their healing process extremely difficult and prone to numerous complications. CASE OUTLINE: A 34-year-old male was wounded at close range by a semi-automatic gun missile. He was wounded in the distal area of the left tibia and suffered a massive defect of the bone and soft tissue. After the primary treatment of the wound, the fracture was stabilized with an external fixator type Mitkovic, with convergent orientation of the pins. The wound in the medial region of the tibia was closed with the secondary stitch, whereas the wound in the lateral area was closed with the skin transplant after Thiersch. Due to massive bone defect in the area of the rifle-missile wound six months after injury, a medical team placed a reconstructive external skeletal fixator type Mitkovic and performed corticotomy in the proximal metaphyseal area of the tibia. By the method of bone transport (distractive osteogenesis), the bone defect of the tibia was replaced. After the fracture healing seven months from the secondary surgery, the fixator was removed and the patient was referred to physical therapy. CONCLUSION: Surgical treatment of wounds, external fixation, performing necessary debridement, adequate antibiotic treatment and soft and bone tissue reconstruction are essential in achieving good results in patients with the open tibial fracture with bone defect caused by high velocity missiles. Reconstruction of bone defect can be successfully treated by reconstructive external fixator Mitkovic.

[Minimally invasive treatment of bilateral femoral shaft fractures in polytrauma patient using selfdinamisibile internal fixator. A case report].

Proper timing and surgical method in management of femur fractures in polytrauma patients can greatly reduce the mortality, morbidity and disability. The aim of this paper is to present the treatment of bilateral femoral fractures in polytrauma patient with dominant chest trauma by selfdynamisable internal fixator Mitkovic (SIF) as a definitive method of fractures treatment. A 23 years old female was injured in a traffic accident. After resuscitation and treatment of the dominant chest injuries, surgical treatment of bilateral femur fractures performed on the fourth day after the injury. Length of surgery was 65 minutes. There was not blood substitution during the intervention and blood loss through the operative wounds drainage. There was no worsening of the pulmonary function after orthopaedic surgery. The patient discharged from hospital postoperative day ten. Postoperative follow-up was 9 months. The fractures healed with an excellent functional result. Application of selfdynamisable internal fixator (SIF) with minimally invasive technique for the treatment of bilateral femoral fractures in polytrauma patients is a good operative method because poses minimally additional operative trauma and provides excellent biomechanical conditions for fracture healing.

[Open segmental fractures of the tibia treated by external fixation].

INTRODUCTION: Open segmental fractures of the tibia are rare but severe injuries. In these fractures the wide zone of injury (damage of all structures of the lower leg) creates very unsuitable biological conditions for healing of the fracture. OBJECTIVE: The aim of our work was to present the results of treatment of patients with segmental open fractures of the tibia treated by external fixation. METHODS: We analyzed treatment results of 21 patients with open segmental tibial fractures who were treated using the method of external fixation at the Clinical Center Nis from January 1, 1995 to July 31, 2010. The average age of the patients was 53 years; the youngest patient was 27 years and the oldest one 80 years. According to the Gustilo open fracture classification, there were 3 (14.3%) type 1, 6 (28.6%) type 11, 8 (38.1%) type IIIA, and 4 (19.0%) type IIIB. All the patients were treated by a unilateral type Mitkovic external fixator by Traffix Company. RESULTS: Union was attained in 16 (76.2%) fractures without severe complications (pseudoarthrosis, chronic osteitis and angular deformities of over 10 degrees). Among severe complications associated with open segmental tibial fractures, in two cases we registered septic pseudoarthrosis, in one aseptic pseudoarthrosis and in two large angular deformities of the tibia after union, with a valgus of over 10 degrees and extremity shortening of over 2 cm which required additional surgery. CONCLUSION: External fixation by the use of Mitkovic external fixator is one of the methods of choice in the treatment of open segmental tibial fractures, which incorporated with antibiotic therapy provides good biomehanical conditions for segmental fracture healing that enables good stability of the segmental tibial fracture and decreases the risk of deep infections.

[Surgical treatment of tibial nonunion after wounding by high velocity missile and external fixators: a case report].

INTRODUCTION: The missiles of modern firearms can cause severe fractures of the extremity. High velocity missile fractures of the tibia are characterized by massive tissue destruction and primary contamination with polymorphic bacteria. Treatment of these fractures is often complicated by delayed healing, poor position healing, nonhealing and bone tissue infection. CASE OUTLINE: We present the management of tibial nonunion after wounding by high velocity missile and primary treatment by external fixation in a 25-year-old patient. The patient was primarily treated with external fixation and reconstructive operations of the soft tissue without union of the fracture. Seven months after injury we placed a compression-distraction external fixator type Mitkovic and started with compression and distraction in the fracture focus after osteotomy of the fibula and autospongioplasty. We recorded satisfactory fracture healing and good functional outcome. CONCLUSION: Contamination and devitalization of the soft-tissue envelope increase the risk of infection and nonunion in fractures after wounding by high velocity missile. The use of the compression-distraction external fixator type Mitkovic may be an effective method in nonunions of the tibia after this kind of injury.

[External fixation in the treatment of shooting proximal humeral fracture with bone defect: a case report].

INTRODUCTION: Shooting injuries of shoulder with destruction of proximal humerus are rare and severe orthopaedic injuries. CASE OUTLINE: A 74-year-old patient was wounded at close range by a shotgun. He was wounded in the left shoulder and suffered a massive defect of the proximal humerus and soft tissue. The neurocirculatory finding of the injury extremity was normal. After a short resuscitation, x-ray of the thorax and the left shoulder registered a complete destruction of humeral head. After the primary treatment of the wound under general endotracheal anesthesia, the shoulder was stabilized with an external fixator type Mitkovic, with convergent orientation of the pins, where two pins were placed in the neck of scapula and two in the humeral shaft, because the left scapular acromion was fractured by shotgun projectiles. CONCLUSION: After radical wound debridement, external fixation is the method of choice for shoulder stabilisation in shooting injury of shoulder with bone defect. If this is not possible, pins of the left external skeletal fixator should be placed into the coracoid process and acromion. The pins can be also placed into the humeral shaft, as done in the presented case, and by which a good stability of the injured proximal humerus, easy approach to the wound for bandaging and reconstructive surgery can be achieved.

Treatment of open tibial shaft fracture with soft tissue and bone defect caused by aircraft bomb--case report.

INTRODUCTION: Aircraft bombs can cause severe orthopaedic injuries. Tibia shaft fractures caused by aircraft bombs are mostly comminuted and followed by bone defects, which makes the healing process extremely difficult and prone to numerous complications. The goal of this paper is to present the method of treatment and the end results of treatment of a serious open tibial fracture with soft and bone tissue defects resulting from aircraft bomb shrapnel wounds. CASE OUTLINE: A 26-year-old patient presented with a tibial fracture as the result of a cluster bomb shrapnel wound. He was treated applying the method of external bone fixation done two days after wounding, as well as of early coverage of the lower leg soft tissue defects done on the tenth day after the external fixation of the fracture. The external fixator was removed after five months, whereas the treatment was continued by means of functional plaster cast for another two months. The final functional result was good. CONCLUSION: Radical wound debridement, external bone fixation of the fracture, and early reconstruction of any soft tissue and bone defects are the main elements of the treatment of serious fractures.

[Penetrating injury of the lungs and multiple injuries of lower extremities caused by aircraft bombs splinters].

INTRODUCTION: Injuries caused by aircraft bombs cause severe damages to the human body. They are characterized by massive destruction of injured tissues and organs, primary contamination by polymorph bacterial flora and modified reactivity of the body. Upon being wounded by aircraft bombs projectiles a victim simultaneously sustains severe damages of many organs and organ systems due to the fact that a large number of projectiles at the same time injure the chest, stomach, head and extremities. CASE REPORT: We presented a patient, 41 years of age, injured by aircraft bomb with hemo-pneumothorax and destruction of the bone and soft tissue structures of the foot, as well as the treatment result of such heavy injuries. After receiving thoracocentesis and short reanimation, the patient underwent surgical procedure. The team performed thoracotomy, primary treatment of the wound and atypical resection of the left lung. Thoracic drains were placed. The wounds on the lower leg and feet were treated primarily. Due to massive destruction of bone tissue of the right foot by cluster bomb splinters, and impossibility of reconstruction of the foot, guillotine amputation of the right lower leg was performed. Twelve days after the wounding caused by cluster bomb splinters, soft tissue of the left lower leg was covered by Tirsch free transplant and the defect in the area of the left foot was covered by dorsalis pedis flap. The transplant and flap were accepted and the donor sites were epithelized. Twenty-six days following the wounding reamputation was performed and amputation stump of the right lower leg was closed. The patient was given a lower leg prosthesis with which he could move. CONCLUSION: Upon being wounded by aircraft bomb splinters, the injured person sustains severe wounds of multiple organs and organ systems due to simultaneous injuries caused by a large number of projectiles. It is necessary to take care of the vital organs first because they directly threaten the life of the wounded patient. Despite adequate surgical treatment of war wounds of the feet, because of massive defect of bone and soft tissue, amputation may be the only rational solution of the treatment. The resection of the lung may be succesfull method for the severe destruction of the lung.

[Treatment of multiple fractures in a patient wounded by aircraft bombing].

INTRODUCTION: Aircraft cluster bombs can cause severe fractures characterized by extensive destruction of affected tissues and organs. CASE OUTLINE: We present the methods and results of treatment of multiple fractures (left supracondilar humeral fracture, comminuted fracture of the distal right tibia, fracture of right trochanter major without dislocation and fracture of the right second metacarpal bone) in a 24-year old soldier after multiple wounding by a cluster bomb. After short pre-operative preparation a surgical debridement of all wounds was done in general anaesthesia and the fractures of the humerus and tibia were stabilized with the Mitkovic-type external fixator after adequate reposition. For the reconstruction of bone defect of the tibia we used the method of bone transport using the Ilizarov external fixator. CONCLUSION: Radical wound debridement, abundant rinsing, leaving the wound open, administration of antibiotics and antitetanus immunization, external fixation and early reconstruction of soft tissue and bone defects are the basic elements of the treatment of serious fractures caused by war injuries and aimed at saving the extremities.

[External fixation in the treatment of open tibial shaft fractures].

BACKGROUND/AIM: Besides the conquasant fractures, open tibia shaft fractures belong to the group of the most severe fractures of tibia. Open tibia shaft fracture is one of the most common open fractures of long bones. They most frequently occur as a result of traffic accidents caused by the influence of a strong direct force. METHODS: Within the period from January, 2000 to December 31, 2005 at the Clinic for Orthopaedics and Traumatology, Clinical Center Nis, 107 patients with open tibial fractures were treated. We analyzed 96 patients with open tibial fracture. In the series analyzed, the male sex was prevalent--there were 74 men (77.08%). The mean age was 47.3 years. The youngest patient was 17 years old, while the oldest patient was 79. According to the classification of the Gustilo et al. in the analysed group there were 30 (31.25%) open tibial fractures of the I degree, 31 (32.29%) of the II degree, 25 (26.05%) of the III A degree, 8 (8.33%) of the III B degree and 2 (2.08%) of the III C degree. In 95 of the patients the treatment of open tibia shaft fractures consisted of the surgical treatment of wound and the external fixation of the fractured bone using "Mitkovic" type external fixator with a convergent method of pin applications. One primary amputations had been done in patients with grade IIIC open tibial fracture with large soft tissue defect. RESULTS: Of the 96 open tibial fractures available for follow-up, 73 (76.04%) healed without severe complications (osteitis, pseudoarthrosis, valgus malunion and amputation). There were nine (9.38%) soft tissue pin track infections and six (6.25%) superficial wound infections. The mean time of union was 21 (14-36) week. Among severe local complications associated with open tibial fractures, in eight patients (8.33%) was registered osteitis, and in nine patients (9.38%) fracture nonunion and the development of pseudoarthrosis. Three of the patients (3.13%) had more than 10 degree valgus malunion. In one patients (1.04%) deep pin track infection developed. Two patients (2.08%) had below the knee amputation (one primary in patient with type III C open fracture and one secondary after the development of deep infections). CONCLUSION: Surgical treatment of wounds, external fixation, leaving the wounds open and performing necessary debridements, adequate drug therapy administration are essential for obtaining good results in patients with open tibial shaft fractures.