Treatment of a chronic recurrent fistulized tibial osteomyelitis: administration of a novel antibiotic-loaded bone substitute combined with a pedicular muscle flap sealing.

Persistent osteomyelitis is a severe and challenging problem in bone surgery. We describe a surgical intervention in a young adult which combines a bone debridement process, a plastic muscle flap sealing and the administration of a novel bone substitution material with anti-infective properties. After 1 year, the patient showed no signs or symptoms of a reoccurrence of infection with full load capacity of the treated leg.

First results with the immediate reconstructive strategy for internal hardware exposure in non-united fractures of the distal third of the leg: case series and literature review.

BACKGROUND: Fractures of the distal third of the leg are increasingly common and are often handled by open reduction and internal fixation. Exposure and infection of internal hardware could occur, especially after high energy traumas, requiring hardware removal and delayed soft tissue reconstruction. Nevertheless immediate soft tissue reconstruction without internal hardware removal is still possible in selected patients. In this study the effectiveness and the complications of immediate soft tissue reconstruction without internal hardware removal is analyzed. METHODS: 13 patients, affected by internal hardware exposure in the distal leg, treated with immediate soft tissue reconstruction with pedicled flaps and hardware retention, are retrospectively analyzed, with special regard to flap survival and wound infection. RESULTS: Wound infection was observed in 10 cases before surgery and in 5 cases surgical debridement was necessary before reconstruction which was performed in a separate operative session. After reconstruction, wound dehiscence and infection occurred in 5 cases, and in 3 cases removal of internal hardware was necessary in order to achieve the complete healing of dehiscence. In one case the previous flap failed but prompt reconstruction with a sural fasciocutaneous flap was performed without hardware removal and without complications. Pre-operative infection and late reconstructive surgery are predictive for higher rates of post-operative complications (respectively p 0.018 and p 0.028). CONCLUSION: Our approach achieved full recovery in 53.8% of the treated cases after one-step surgery, therefore reducing hospitalization and allowing early mobilization. Controlled trials are needed to confirm the effectiveness of this strategy, although the present case series shows encouraging results.

Central upper lip reconstruction by two vermillion flaps and a rotational skin flap.

BACKGROUND: Lip cancer is the most frequent malignant neoplasm of the oral cavity. Defects larger than one-fourth of total upper lip length require reconstruction by established techniques or multiple procedures. METHODS: The patient was a 53-year-old man who presented with a 1.5 cm basal cell carcinoma in the central upper lip. Two opposed vermillion flaps were designed and advanced following radical tumor excision to create a new skin-vermilion border. A rotational skin flap was prepared to maintain the normal aspect of the filter area. RESULTS: The patient was evaluated 1 year after the operation. He showed well-healed flaps with excellent aesthetic and functional results of the filter area and Cupid's bow. CONCLUSION: Within certain limits (maximum one-third of total upper lip length), double vermillion opposing flaps with a rotational skin flap appear to be a valid method for upper lip reconstruction.

Distally based sural fasciomusculocutaneous flap for treatment of wounds of the distal third of the leg and ankle with exposed internal hardware.

Soft tissue reconstruction of the distal third of the lower limb with exposure of the internal hardware is a challenging problem with several potential complications, such as exposure of the fracture line, fracture instability and bacterial contamination. The treatment of these lesions usually consists of substitution of the internal hardware with external fixation devices and further flap coverage. We propose a different reconstructive approach, characterized by harvesting a sural fasciomusculocutaneous flap on the exposed internal hardware once a sterile ground has been obtained. Four patients were retrospectively analyzed. Soft tissue reconstruction was achieved in all cases. In one case hardware removal was necessary for complete healing. The sural fasciomusculocutaneous flap is a safe alternative to other pedicled and free flaps. Moreover, it allows direct coverage of internal fixators, thus completing the reconstruction in less time. This flap fits best to the morphology of the wound and internal hardware, leaving the main vascular trunk of the leg intact and at the same time providing a reliable vascular supply.