Muscle-only versus chimeric musculocutaneous gastrocnemius pedicled flap in complex orthoplastic reconstructions of the knee region: A retrospective study.

BACKGROUND: The knee region represents a challenging area of soft tissue reconstruction. Specifically, in the context of total knee arthroplasty (TKA) or following high-energy trauma with fractures and hardware fixation, soft tissue defects can expose critical structures such as joint, bone or tendon, besides the implant/plates themselves, with dramatic consequences in terms of postoperative infection and hardware contamination. METHODS: A retrospective study was conducted on a prospectively maintained database from January 2016 to February 2021. Inclusion criteria involved all patients who underwent an implant-associated infection of the knee and upper third of the leg coupled with a soft tissue reconstruction (STR) using the traditional gastrocnemius muscle (GM) pedicled flap or the chimeric GM-MSAP (medial sural artery perforator) flap. RESULTS: Thirty-eight patients were included (group A, GM flap, 22 patients; group B, chimeric GM-MSAP flap, 16 patients). No statistically significant differences were detected in terms of age, comorbidities, defect size, follow-up, and flap complications. A statistically significant difference was seen among the groups in terms of successful flap re-raise (required because of a persistent infection of the implant or in a two-stage procedure setting, including the use of a cemented spacer) in favour of the GM-MSAP group. CONCLUSION: The chimeric GM-MSAP, being safer to reraise if required, can be a significantly more powerful tool in those cases in which a two-stage procedure is planned or when there is a high probability for secondary intervention need, reducing the need to convert to either free flap coverage or amputation.

Distal Brachial Artery Perforator flap: a new chimeric option for complex hand and digits defects.

INTRODUCTION: Reconstruction of fingers pose unique challenges, as a thin and flexible flap is needed in order to guarantee a good functional outcome. For the first time, in this report, we present the DBAp (distal brachial artery perforator) flap, based on the distal perforator closer to the medial epicondyle. The DBAp flap was used to reconstruct complex digit defects as free flap, and to cover an elbow defect while raised as a propeller. METHODS: Four patients underwent finger reconstruction (free flaps): two patients presented an unstable finger scar following previous surgery, whereas the other two patients presented a terminalized finger at the level of the middle phalanx. A further patient presented a post-traumatic loss of substance at the elbow and was reconstructed using a perforator propeller DBAP flap. RESULTS: Loss of tissues included skin and subcutaneous tissue in all patients and in one patient it included a bone component. Flap dimensions ranged from 48 to 18 cm2 (average: 32 cm2). Among complications, patient n.2 flap presented a marginal flap necrosis requiring a small skin graft after necrosis debridement. CONCLUSION: The DBAp flap provides a slim, glabrous and pliable skin tissue with a well-hidden donor site scar and thanks to the anatomic location of the distal perforator can be designed to include a vascularized bone graft from the medial epicondyle. Despite the low number of cases, we believe that this flap should be considered as a dependable and effective source for complex reconstructions of both soft tissue and bone in fingers.

Partial trapeziectomy and pyrocarbon interpositional implant (Pyrodisk) for trapeziometacarpal osteoarthritis in the active working population: outcomes of a 10 years-experience.

The treatment of trapeziometacarpal (TM) osteoarthritis is still debated, as many surgical options are available, and no technique has proven to be superior. Prosthetic treatment in this context has been described since the early 60s. Recently, the use of pyrolytic carbon-based prosthesis has revolutionized arthroplasty surgery in the hand. We performed a retrospective investigation of our surgical management of TM osteoarthritis since 2010 including the study only patients treated with partial trapeziectomy and Pyrodisk implant, with at least 5 years follow-up. After the application of inclusion criteria, 26 patients (6 males and 20 females) were retained. Despite the literature suggesting that implant TM surgery is well suited for older patients, in our experience, the procedure was mainly proposed to the young manual worker, with high demands in terms of thumb strength and stability (mean age of 53 years old, range 37-65). A statistically significant improvement in post-operative DASH, Kapandji and scores was observed. As well, strength measurements, particularly pinch strength and grip strength, increased significantly after the surgery. According to our findings, the Pyrodisk implant provides satisfactory results in terms of thumb strength and stability even in young and active patients and should therefore be considered as a valuable option in selected cases. Meticulous surgical procedure is mandatory in order to avoid complications and should therefore be executed by an expert surgeon. Abbreviation: IV: level of evidence.

Lower limb reconstruction involving osteosynthesis material: A retrospective study on propeller flaps outcomes.

INTRODUCTION: Reconstruction of soft tissue defects in lower limb fractures requiring internal fixation remains a challenging scenario with the optimal surgical treatment still debated. This study aims to recommend, and eventually redefine, surgical indications for propeller flaps reconstruction in the distal lower limb, with a particular focus on the presence or not of metalwork. METHODS: A retrospective study of lower limb soft tissue reconstructions performed between January 2015 and July 2018 was carried out including all patients treated with a propeller perforator flap (PPF) with at least 6-month follow-up. Patients were further divided in 2 groups depending on the presence of metalwork fixation beneath the flap (F group, propeller on Framework; NF group, propeller with No-Framework). RESULTS: 21 patients were retained (F group, 11 patients; NF group, 10 patients). There were no significant differences between the two groups in age, BMI, ASA scores, comorbidities or defect size. There was a statistically significant difference between the groups (p<0.05) in the cumulative hospital stay with a mean cumulative hospital stay of 22 ± 9 days in the F group and 12 ± 8 days in NF group. Failures were higher where PPF were used to cover hardware material, with 3 patients requiring a major secondary procedure in F group versus 1 patient in NF group. CONCLUSION: The presence of underlying metalwork significantly reduced the margin for small, day-case revision procedures such as flap readvancement or STSG. This study emphasizes clinical intuition that whilst PPF are a useful and elegant tool in lower limb reconstruction, their use should be limited when underlying metalwork is present.

Surgical treatment of symmastia: A systematic review of techniques, outcomes and complications.

BACKGROUND: The term "symmastia" defines a confluence across the mid-sternal line of the breast mounds and subsequent loss of adhesion between sternum and pre-sternal skin. This condition can be congenital or, more frequently, iatrogenic. Despite the number of different treatments published in literature, no systematic review or surgical techniques classification has been attempted in literature. There is, therefore, a concrete need to elucidate surgical options and propose a treatment algorithm, improving surgical practice and patient's care. OBJECTIVE: This systematic review aims to collect and evaluate the published evidence on surgical procedures to correct symmastia deformities (both congenital and acquired) in order to clearly overview possible treatments and outcomes related to this surgery, providing a surgical classification guide as well. METHODS: In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, PubMed database was queried for papers describing symmastia surgical treatment, along with operative indications, outcomes, and complications. RESULTS: In this review, 23 articles and 118 patients were finally included. Four main categories of treatment were identified: dermo-sternal adhesions, capsulorrhaphy, neopocket creation, and muscle repair. Symmastia correction was achieved and satisfactory in 108 of patients, despite varying techniques. Globally, recurrence was the most frequent complication, reported in the 8.5% of cases. CONCLUSION: Symmastia represent a difficult condition to treat and recurrence is a common problem. Because of the low number of patients involved in the studies, it is difficult to make conclusions as to the superiority of one technique over another. However, this review, collecting comprehensively for the first time the surgical knowledge over this topic, could guide the surgeon to choose the best surgical treatment based on nowadays evidence.

Treatment of Recurrent Tracheocutaneous Fistulas in the Irradiated Neck with a Two Layers-Two Flaps Combined Technique.

The development of a tracheocutaneous fistula (TCF) is a well-documented complication after tracheostomy, especially in chronic morbid patients, in whom tubes or cannulas are left in place over time, or in irradiated patients. Surgical treatments are therefore needed which range from simple curettage and dressings to local skin flaps, muscle flaps and, in the more complex cases, microsurgical free tissue transfers. We present a novel combined technique used to successfully treat recurrent TCFs in irradiated patients, involving a superiorly based turnover fistula flap and a sternocleidomastoid transposition flap.

ALT flap with vascularized fascia lata for one-stage functional patellar tendon reconstruction.

INTRODUCTION: Composite anterolateral thigh (ALT) flap with vascularized fascia lata can reconstitute patellar tendon integrity and knee soft tissue coverage in one stage. However, long-term evidence of outcomes is lacking. This work analyzes long-term functional results, compares subtotal and total reconstruction of patellar tendon, and assesses the respective function of the extensor apparatus. PATIENTS AND METHODS: Outcomes of reconstruction using 10 ALT flaps in 9 patients (age range 21-87 years) were analyzed (mean follow-up 30 ±â€¯6 months). Knee Society Scores, isometric knee extensor strength (M1-M5), and sensory recovery were evaluated, together with active range of motion and extensor lag of the reconstructed limb, compared to contralateral. RESULTS: Ten flaps were used for tendon replacement in 9 patients. Eight (80%) free flaps and 2 (20%) propeller distally based flaps were used. Complications requiring the harvest of a second flap were seen in 2 patients. All patients could return to their daily activities without the use of walking supports. Mean active ROM was 94.4° with an extensor lag of 9.4°, without a significant difference between partial and total patellar tendon reconstruction. The mean knee and functional scores of the Knee Society were 81/100 and 77/100, respectively. CONCLUSION: Composite ALT flap with fascia lata can satisfy the twofold needs of functional restoration and soft tissue coverage, thus ensuring stable results in total and subtotal knee extensor mechanism reconstruction. Distally based flaps should be carefully considered, as they lead to higher complication rates.

[Environmental spread of Taenia proglottids: an atypical yet interesting public health problem in schools]. / Dispersione ambientale di proglottiti di Taenia: un'atipica ed interessante problematica di sanità pubblica in ambiente scolastico.

We report herein a new case of teniasis caused by Taenia saginata (tapeworm) in a pediatric patient with done-on-purpose dispersion of proglottids happened in an elementary school inside the health district ASL CN-1. This new case highlights how teniasis in children is not as rare, as it is not so rare dispersal of proglottids in the environment, made on purpose, by the same subjects that have been parasitized. The environmental dispersion of proglottids is an important public health problem that requires a rapid and joint management of the problem aiming to identify the parasite as quickly as possible, given the different pathogenic larval stage of three species of tapeworm that can infest the man.