Gastrocnemius muscle flap with vancomycin/gentamicin-calcium sulfate and autogenous iliac bone graft for the phase I treatment of localized osteomyelitis after tibial plateau fracture surgery.

PURPOSE: To investigate the clinical effect of gastrocnemius muscle flaps combined with vancomycin/gentamicin-calcium sulfate combined and autologous iliac bone graft in the phase I treatment of traumatic focal osteomyelitis (Cierny-Mader type III) after tibial plateau fracture surgery. METHODS: From July 2009 to January 2018, 35 patients with localized osteomyelitis (Cierny-Mader type III) who met the inclusion criteria were followed up and treated. All patients were infected after undergoing internal fracture fixation surgery. Among them, 18 cases were plate-exposed, 14 cases were due to sinus tracts, two were due to skin necrosis, and one was bone-exposed. We treated patients with several measures. All cases were then followed up. The follow-up indicators included Hospital for Special Surgery knee scores (HSS), the time of laying drainage pipe, bone healing time, infection control rate, and the incidence of nonunion and other complications. RESULTS: All patients were followed up for 24-60 months. None of them underwent amputation. For repairing soft tissue defects, 17 cases were covered with a muscle flap using the medial head of gastrocnemius alone, 15 cases were treated with the lateral head of gastrocnemius muscle, and three cases were covered with the combination of the two heads. Compared to the preoperative score, we found that the average HSS improved at the 1-year and 2-year follow-up (54 vs. 86 vs. 87). CONCLUSION: Using a gastrocnemius muscle flap combined with vancomycin/gentamicin-calcium sulfate and autogenous iliac bone was an effective method for the phase I treatment of osteomyelitis (Cierny-Mader type III) after tibial plateau fracture surgery. In the primary treatment of focal traumatic osteomyelitis, it can decrease the treatment time, number of surgeries, pain of patients, time of bone healing, postoperative exudation, and infection recurrence rate and increase the healing bone's strength.

Healing Heel Ulcers in High-Risk Patients: Distally Based Peroneus Brevis Muscle Flap Case Series.

The purpose of this study was to demonstrate use of a distally based peroneus brevis muscle flap in high-risk patients with diabetes and peripheral vascular disease for limb salvage of nonhealing heel ulcerations. Seventeen patients were referred for a below-knee amputation because of nonhealing heel ulcerations and peripheral vascular disease. As a last resort, 17 distally based peroneus brevis muscle flaps were elevated in 17 patients with full-thickness heel ulcerations measuring an average defect size of 14.11 cm2. All flaps were supplemented with concentrated bone marrow aspirate, negative pressure wound therapy, bilayer wound matrix, and static external fixation for an average time of 10.3 weeks. Split-thickness skin graft was delayed by an average of 17.5 days. All procedures were performed on patients diagnosed with diabetes, advanced peripheral arterial disease and a nonhealing heel ulcer present >1 year. All flaps survived at 1.5 years follow-up. The average time to healing was 10.3 weeks. No major amputations were performed to date. Partial tip necrosis occurred in 2 patients and healed uneventfully with local wound care. Distally based peroneus brevis muscle flaps in patients with diabetes and peripheral vascular disease offer a reliable alternative to limb salvage for full-thickness heel ulcerations measuring up to 7 × 6 cm. Combinatorial procedures are necessary to improve outcomes in high-risk patients whose alternative is a major amputation.

Graciloplasty, electrostimulation, electromyography. Clinical implications of electrophysiological phenomena in the neo-sphincter created from the gracilis muscle.

UNLABELLED: The aim of the study was to compare the electrophysiological phenomena occurring in the gracilis muscle, transposed into the pelvic floor during the graciloplasty procedure, subjected to continuous electrical stimulation by means of implanted stimulator, or regular stimulation by means of an external device, as well as the long-term functional results of the graciloplasty procedure. MATERIAL AND METHODS: A total of 27 patients were included in the analysis. The study group consisted of 7 patients after dynamic graciloplasty, 11 patients after graciloplasty followed by transrectal stimulation, 4 patients after graciloplasty with transcutaneous stimulation, and 5 patients after graciloplasty without any stimulation. All patients had a surface electromyographic examination of the transposed gracilis muscle performed, the signal for each patient was compared to the signal acquisited from a non-transposed gracilis in the same patient. In addition, each subject underwent a clinical operation results assessment, as well as an anorectal manometry examination. RESULTS: In the electromiographic examination, the mean frequency of motor units action potentials of the gracilis muscle in the thigh was 64 Hz, and in the muscle after transposition and stimulation period mean frequency was 62 Hz. There was no statistically significant difference in the frequency of action potentials before and after treatment in any of the analyzed groups, or between groups with different methods of stimulation (p> 0.05). We found a significant correlation between the clinical outcome of the procedure, and the average amplitude of the EMG signal from the transposed muscle, as well as between the amplitude of the EMG signal and the basal pressure in the anal canal in manometric examination. There were no significant correlations in the remaining manometric parameters. CONCLUSIONS: Despite the different methods of postoperative stimulation, including expensive implantable stimulators, there was no difference in the electrical activity between the transposed gracilis muscle, and the gracilis muscle left in situ. There was no signoficant advantage of the dynamic graciloplasty procedure over the graciloplasty with transanal or transcutaneous stimulation.

Current surgical strategies to treat fecal incontinence.

Fecal incontinence is a devastating condition, vastly under-reported, and may affect up to 18% of the population. While conservative management may be efficacious in a large portion of patients, those who are refractory will likely benefit from appropriate surgical intervention. There are a wide variety of surgical approaches to fecal incontinence management, and knowledge and experience are crucial to choosing the appropriate procedure and maximizing functional outcome while minimizing risk. In this article, we provide a comprehensive description of surgical options for fecal incontinence to help the clinician identify an appropriate intervention.

Dynamic article: composite antropyloric valve and gracilis muscle transposition for total anorectal reconstruction: a preliminary report.

BACKGROUND: Technique and functional outcomes of anorectal reconstruction using an antropyloric graft have been reported previously. This technique had reasonable initial outcomes but lacked voluntary function. OBJECTIVE: We hereby report the initial results of patients who underwent gracilis muscle wrapping around the perineally transposed antropyloric valve in an attempt to improve voluntary fecal control. SETTING: This study was conducted at a single tertiary care institution. PATIENTS: Eight adult patients (7 men and 1 woman) with a median age of 38 years (range, 19-51 years) underwent this procedure. Seven patients already had anorectal reconstruction with a transposed antropyloric valve, and 1 patient with severely damaged anal sphincter complex underwent single-stage composite antropylorus transposition with a gracilis muscle wrap. MAIN OUTCOME MEASURES: The primary outcome measures were anatomical integrity and functional status of the composite graft in the perineum. RESULTS: No operative mortality or serious procedure-related morbidity occurred in any patient. The median postoperative resting pressure was 29 mmHg (range, 22-38 mmHg) and squeeze pressure was 72.5 mmHg (range, 45-267 mmHg). There was a significant improvement in the squeeze pressure following surgery (p = 0.039). Also, the St. Mark's incontinence scores significantly improved in all patients and varied between 7 and 9 (p = 0.003). The ability to defer defecation and the reduced frequency of leakage accidents were the prime reasons for improved postgraciloplasty outcomes in these patients. On personal interviews, all patients who underwent this procedure were satisfied with the results of their surgery. LIMITATIONS: A longer follow-up with a larger sample size is required. Quality-of-life data have not been evaluated in this study. CONCLUSIONS: Gracilis muscle wrapping around a perineally transposed antropyloric valve is possible and improves the voluntary control and overall functional outcomes in a select group of patients with end-stage fecal incontinence requiring anal replacement (Supplemental Digital Content 1, http://links.lww.com/DCR/A173).

It could suddenly happen: delayed rupture of the trachea after total thyroidectomy. A case report.

INTRODUCTION: We report the case of a patient who presented with subcutaneous emphysema, dyspnea and cough 7 days after total thyroidectomy for cancer. In addition we review the Literature and discuss the therapeutic challenges as well as management options. CASE REPORT: A 17-year old female patient underwent a total thyroidectomy with right cervical lymph adenectomy for papillar cancer. Lung metastases are present. On postoperative day 7 she presented with face and neck swelling due to subcutaneous emphysema, dyspnea and persistent cough. The radiological evaluation revealed a tear on the right antero-lateral wall of the trachea. The patient underwent surgical exploration of the neck which confirmed the tracheal rupture and showed an important tracheal necrosis all around the tear. Due to the impossibility to make primary closure of the trachea or a tracheal resection, the tear was repaired with muscular flap interposition, (around the trachea as a scarf ), using the contralateral clavicular part of sternocleidomastoid muscle and prethyroid muscles bilaterally. The postoperative course was uneventful and the patient is alive 20 months after surgery and iodine induced adjuvant therapy. CONCLUSION: Delayed tracheal rupture should be suspected in all patients who present subcutaneous emphysema after thyroid surgery. The lesion should be promptly treated with primary closure or tracheal resection when possible. Muscular flap interposition could be a safe alternative option when the other procedures are contraindicated.

Anorectal incontinence: a challenge in diagnostic and therapeutic approach.

Anorectal incontinence is a symptom of a complex multifactorial disorder involving the pelvic floor and anorectum, which is a severe disability and a major social problem. Various causes may affect the anatomical and functional integrity of the pelvic floor and anorectum, leading to the anorectal continence disorder and incontinence. The most common cause of anorectal incontinence is injury of the sphincter muscles following delivery or anorectal surgeries. Although the exact incidence of anorectal incontinence is unknown, various studies suggest that it affects ~2.2-8.3% of adults, with a significant prevalence in the elderly (>50%). The successful treatment of anorectal incontinence depends on the accurate diagnosis of its cause. This can be achieved by a thorough assessment of patients. The management of incontinent patients involves conservative therapeutic procedures, surgical techniques, and minimally invasive approaches.

Use of gracilis muscle as a "walking" flap for repair of a rectovaginal fistula.

Rectovaginal fistula is a rare but debilitating complication of a variety of pelvic operations. Management remains challenging with high incidence of failure. The majority of patients eventually require surgical intervention. Several surgical procedures have been described including local repair, muscle transposition, or laparotomy. Among the muscles used for rectovaginal fistula repair, the gracilis muscle interposition flap is an excellent option. However, in a small percentage of cases it fails, and alternative techniques should be entertained. We describe the case of a 50-year-old female who underwent stapled hemorrhoidopexy that was complicated by a 30 mm rectovaginal fistula, and required fecal diversion. Four months later, gracilis muscle interposition flap was performed but failed. The right gracilis flap was then re-used successfully as a "walking" flap. At three months the patient underwent closure of the temporary loop ileostomy, and continues to do well with no evidence of rectovaginal fistula recurrence one year later. To our knowledge, this is the first report of the use of a gracilis muscle as a "walking" flap for repair of a rectovaginal fistula, and should be considered as an alternative appropriate treatment for persistent rectovaginal fistulas after failure of initial gracilis muscle interposition flap.

Total glossectomy with preservation of the larynx: oncological and functional results.

Our aim was to analyse the overall and disease-free survival (DFS), time to recovery of oral feeding, and morbidity, in a consecutive series of patients who had total glossectomy with preservation of the larynx for advanced cancer of the tongue at the European institute of Oncology (Milan). From June 2002 to April 2011, 37 patients who were treated for advanced cancer of the tongue had total glossectomy, bilateral neck dissection, and preservation of the larynx. Various flaps were used for reconstruction. Overall and disease-free survival were assessed from the day of operation to the latest outpatient examination. Postoperative morbidity and rehabilitation of feeding were also assessed. Six patients had major complications, four of whom had a second operation for necrosis of the flap. Actuarial five-year overall survival (OS) and disease-free survival were 54% and 47%. Twenty-four patients (65%) were operated on as their first treatment, and had 79% five-year overall survival and 61% 5-year disease-free survival. Twenty-six patients were eventually able to feed orally postoperatively. Although this retrospective study include a limited number of patients, the results support the validity of total glossectomy as a safe procedure for advanced cancer of the tongue. Pretreated patient were previously treated with surgery, radiotherapy or chemoradiotherapy with curative purposes. Nevertheless, the long period required for recovery of oral feeding indicates that total glossectomy should be reserved for highly motivated patients.

[Surgery for anal incontinence: developments in the past two decades and future directions]. / Chirurgie de l'incontinence anale: évolution depuis vingt ans et perspectives.

Studies showing the frequency of anal incontinence and its social and economic impact have driven progress in surgical treatment, from muscle repair by myorraphy (mainly posterior myorraphy) or sphincteroplasty by direct suture of the external anal sphincter some 20 years ago, to invasive surgery with implantation of an artificial anal sphincter in 1993, mini-invasive surgery based on sacral nerve stimulation in 1998, failure of mini-invasive procedures with injection of a bulking agent or radiofrequency in 2000-2010, and development in 2012 of cellular therapy based on injection of autologous myoblasts. Progress in functional gut exploration (anorectal manometry, electrophysiological tests, endoanal ultrasonography, MRI, colonic transit time) and better knowledge of colonic and ano-rectal physiology will lead to further surgical advances.

[Oncologic, functional, and aesthetics results; evaluation of the quality of life after latissimus dorsi flap breast reconstruction. About a retrospective series of 450 patients]. / Résultats oncologiques, fonctionnels et esthétiques ; évaluation de la qualité de vie après reconstruction mammaire par lambeau de muscle grand dorsal. À propos d'une série rétrospective de 450 patientes.

Retrospective assesssment from 1998 to 2005 from women who have a breast reconstruction by autologus latissimus flap or by latissimus flap and silicone breast implant for differed breast reconstruction (DBR) or mastectomy and immediate breast reconstruction (MIBR). PATIENTS AND METHOD: Analysis of oncologic results on 450 patients. Analysis of aesthetic, functional results and of quality of life by an anonymous questionnaire in the non progressive patients (407): 263 appraisable answers (13 DBR, 127 MIBR). Middle age: 49.8 years. RESULTS ONCOLOGIC: Forty-three patients (9.5%) had a relapse of their disease, 33 patients died (7.2%). The relapse of the disease was done in the form of metastasis alone: 29 (67.4%), metastasis and local recurrence: three (7%), local recurrence only: four (9.3%), not specified: seven (16.3%). The average time between the breast reconstruction and the relapse was 18.25±15.4 months. AESTHETIC RESULTS: The overall assessment is of 7.68/10. There is no statistical difference between immediate reconstruction and delayed reconstruction. A total of 11.2% patients considered it to be bad (<5/10). The symmetry between the two breasts in time is of 6.6/10 and 19.9% patients considered it to be bad (<5/10). The scar ransom, considered to be most important, is mostly in the back (4.1/10) then on the controlateral breast and then the breast reconstruction. This ransom is not easily acceptable in 15 to 20% of the patients. FUNCTIONAL RESULTS: The discomfort and the pain prevail above all in the back (3.56 and 2.59/10). Weaker symptoms in the event of immediate reconstruction than delayed reconstruction. We noted that 77.2% had kinesitherapy after surgery and 18.9% continues to have kinesitherapy, long time after surgery, mainly for massages of the back. The handicap is considered to be overall low 2.5/10 but 10% of the patients keep a feeling of important handicap (>7.5/10). QUALITY OF LIFE RESULTS: Seventy-one of the patients are serene. The discomfort to wear a bathing suit or to look at bare-chested is low (2.59 and 2.44/10). However 8.9% are in a very discomfort to see themselves bare-chested and 17.6% to show themselves to their spouse, with an impact on their emotional and sexual life in 36.4% of the cases. There is no significant difference between MIBR and DBR but on the other hand according to the judgement of the woman of her aesthetic result. A total of 95.7% do not regret having made this breast reconstruction. CONCLUSION: This study makes it possible to concentrate on the group of non satisfied patient for better determining the causes and the improvements of the surgical techniques to bring but also the overall surgical management of the patient even if most of the patients were mainly satisfied with their breast reconstruction.

Reanimation of the middle and lower face in facial paralysis: review of the literature and personal approach.

Facial paralysis refers to a condition in which all or portions of the facial nerve are paralysed. The facial nerve controls the muscles of facial expression, paralysis which results in a lack of facial expression which is not only an aesthetic issue, but has functional consequences as the patient cannot communicate effectively. The treatment of long-standing facial paralysis has challenged plastic surgeons for centuries, and still the ultimate goal of normality of the paralysed hemi-face with symmetry at rest as well as the generation of a spontaneous symmetrical smile with corneal protection has not yet fully been reached. Until the end of the 19th century, the treatment of this condition involved non-surgical means such as ointments, medicines and electrotherapy. With the advent and refinement of microvascular surgical techniques in the latter half of the 20th century, vascularised free muscle transfers coupled with cross-facial nerve grafts were introduced, allowing the possibility of spontaneous emotion being restored to the paralysed face became reality. The aim of this article is to revisit the surgical evolution and current options available as well as outcomes for patients suffering from facial paralysis concentrating on middle and lower face reanimation.

[Muscle regeneration and the state of the thymus in adult rats under laser irradiation and alloplasty of the gastrocnemius muscles and diaphragm of newborn rats].

The regeneration of gastrocnemius muscles of adult rats under implantation conditions in areas of muscle tissue damage in newborn rats has been studied. Alloplasty was performed using minced gastrocnemius and diaphragm muscles, which differs at birth in animals by degree of differentiation. The rat-recipient area of alloplasty was subjected to He-Ne laser radiation before operation, with the aim of reducing the immune response to allogenic muscle tissue. It has been shown that the number of regenerating myofibers produced in implanted gastrocnemius muscles is more than in alloplants from diaphragms. However, the formation of cartilage, bone, and adipose tissue foci were observed in the alloplastic region throughout the whole regeneration period. After implantation of minced diaphragm muscles, cartilage nodes were observed only in 7-day regenerates. At the end of observation, in the first instance, the area of muscle trauma in adult rat muscles was replaced by adipose tissue, even in the case of initial laser irradiation. During the implantation of diaphragm muscles, the area of trauma was filled with regenerating muscle tissue.

[Conservative treatment and rehabilitation in peripheral facial palsy]. / Physikalische Therapiemassnahmen bei peripherer Fazialisparese: Indikationen, Zeitpunkte und praktische Anwendungen.

Facial paralysis may be treated by physical therapies with different therapeutic strategies and devices. Exercise therapy, electrotherapy, massage, lymph-drainage, biofeedback therapy are applied. Therapeutic strategies are based on the course of disease. It may be assumed that paralysis in moderate and moderate to severe courses of disease in acute lesions, moreover in chronic partial lesions and after gracilis muscle transplantation will benefit best from physical therapies. Course of disease depends on the degree of lesion, low-grade lesion will improve earlier and prognosis of motor recovery is good. To predict the course of disease in idiopathic facial paralysis nerve conduction studies can render valuable information by measuring the amplitude of the motor evoked potential in side to side comparison. In regard to scientific studies there is limited evidence that exercise therapy and biofeedback therapy improve the course of disease, motor performance recovers earlier and motor synkinesis are decreased. There is no evidence for electrotherapy to improve the course of disease nor to have any adverse effects. There is no relevant literature for massage and lymph-drainage in regard to facial paralysis. Every patient with facial paralysis--regardless to the degree of lesion--should receive a brochure with mimic exercises and instructions to support facial symmetry as basic intervention.

Gracilis muscle as neoanal sphincter for faecal incontinence.

Faecal incontinence is a debilitating chronic clinical condition which may affect the patient and care givers. Modality of treatment is based on severity of the symptoms as well as the anatomical defect itself, availability of resources and expertise. We describe a modified technique of dynamic graciloplasty as neoanal sphincter for the treatment severe faecal incontinence who has failed previous over lapping sphincteroplasty. In our modified version, instead of using implanted intramuscular electrodes and subcutaneous neurostimulator to provide continuous stimulation, the patient will undergo an external stimulation on the nerve of transplanted gracilis periodically and concurrent biofeedback therapy. We believe the technique is relatively easy to learn and very cost effective without any electrodes or neurostimulator related complications.

Distally based saphenous nerve-great saphenous veno-fasciocutaneous compound flap with nutrient vessels: microdissection and clinical application.

Improvements were made by us in several distally based pedicled flaps of the nutrient vessels of the saphenous nerve with lower rotation points. However, these flaps are still insufficient for trauma complicated by bone defects. Accordingly, we conducted a systematic study of the anatomic theory on distally based pedicled compound flaps of the nutrient vessels of the saphenous nerve and great saphenous vein with 30 lower limbs of adult cadavers injected with red gelatin through the femoral artery. It is found that the nutrient vessels of the saphenous nerve-great saphenous vein consist of arteria saphena, fascial cutaneous branches of the inferior medial genicular artery intermuscular spatium branches of the posterior tibial artery, osteocutaneous perforators, superior ankle perforators, medial anterior malleolus perforators, and fascial perforators of the ankle tunnel region. Musculocutaneous perforators of the interior gastrocnemius muscle also enter the nutrient vessels of cutaneous nerve-superficial vein. From May 2004 to February 2007, 23 cases of skin flaps for treating defective and infectious wound, 10 cases of musculocutaneous flaps for treating ulcus in the lower segment of the leg, medullitis, and exposure of bone, 3 cases for medial calcaneus medullitis, 7 cases of skeletal flaps for treating tibial defects and nonunion of calcaneal bone. In 2-15-month follow-ups all cases presented with survived flaps, and healed surfaces of the wound and the osteomyelitis. For cases of bone nonunion, it showed that the nonunion healed after 18 weeks, with recovery of work ability after year. Three types of the distally based pedicled flaps or compound flaps of vessels of different perforating branches can be designed for repairing tissue defects caused by trauma, such as bone defects in the distal leg, nonunion, large necrotic space as well as traumatic surface of the foot and ankle.

Bioceramic orbital implant exposure repaired by a retroauricular myoperiosteal graft.

A patient with a painful, blind eye underwent enucleation and bioceramic orbital implantation. The bio-ceramic implant was wrapped with polyglactin 910 mesh and anteriorly capped with a scleral patch graft. Because there was tension on the wound, a relaxing conjunctival incision on the fornix was performed. Implant exposure with a diameter of 9 mm occurred 4 months after surgery. The exposed bioceramic implant was successfully repaired by a retroauricular myoperiosteal graft. The graft contains myofibrovascularized tissue, provides durable and vascularized coverage of exposed implants, and only requires a nearby harvesting site. The exposure completely resolved without recurrence after 2 years of follow-up.