Composite rib and serratus anterior pedicle transfer for reconstruction of an osteomyelitis of the humerus.

We report the case of a 40 year-old male with Staphylococcus aureus osteomyelitis of the proximal humerus after open reduction and internal fixation of a fracture from motor vehicle accident. Removal of the osteosynthesis, extensive debridement and intravenous antibiotics administration was done followed by external fixation stabilization and reconstruction with a combined pedicled flap using the serratus anterior reversed flap and the 6th rib. At the last follow-up, healing of the bone flap was observed; the patient experienced useful motion of his upper extremity without any evidence of recurrent infection.

Gunshot and blast injuries of the extremities: a review of 45 cases.

Gunshot wounds and blast injuries constitute a major public health problem, as the increasing availability of firearms and explosives in conjunction with increasing violence in the city setting have brought this reality into civilian life. Extremities are most commonly involved; therefore, orthopedic surgeons should be trained to manage these types of injuries. Complete and accurate assessment of the injury itself is of great importance, as it will determine the severity and the risk of patients. High-risk injuries from missiles and injuries from explosions are associated with moderate or poor outcomes, major complications, and increased need for multiple surgical procedures. On the other hand, low-risk injuries frequently present optimal results and rather low morbidity. The role of microsurgery is essential, especially in the high- and very high-risk injuries, since complex and multiple reconstructions have to be performed, which include the utilization of free flaps, nerve grafts, and tendon transfers.

The use of a combined bipedicled axial perforator based fasciocutaneous flap for the treatment of a traumatic diabetic foot wound: a case report.

The axial and perforator vascularised fasciocutaneous flaps are reliable and effective treatment methods for covering lower limb post-traumatic, septic, Charcot, and diabetic foot wounds. The authors describe the unique utilisation of a hybrid flap as an axial-perforator flap combination for the treatment of a traumatic diabetic foot wound.

Distal posterior tibial artery perforator flaps for the management of calcaneal and Achilles tendon injuries in diabetic and non-diabetic patients.

Management of Achilles tendon and heel area defects is a common challenge for the reconstructive surgeon due to the lack of soft tissue availability in that region. In this article, we present our experience in covering these defects by using the distal perforator propeller flaps based on the posterior tibial artery. Perforator flaps are based on cutaneous, small diameter vessels that originate from a main pedicle and perforate the fascia or muscle to reach the skin. Their development has followed the understanding of the blood supply from a source artery to the skin. Six patients (five males and one female) underwent reconstruction by using the posterior tibial artery distal perforator flap for covering defects in the distal Achilles tendon region in patients with and without diabetes mellitus. Postoperative complications included a hypertrophic scar formation in one patient, partial marginal flap necrosis in another patient, and a wound infection in a third patient. All wounds were eventually healed by the last postoperative visit. In conclusion, perforator flaps based on the distal posterior tibial artery may be a reliable option for the coverage of small to moderate size defects of the Achilles tendon and heel area regions.

The use of Papineau technique for the treatment of diabetic and non-diabetic lower extremity pseudoarthrosis and chronic osteomyelitis.

The treatment of 31 consecutive adult patients, ages 25-67 years with chronic draining osteomyelitis (12 cases) or infected pseudarthrosis (19 cases) by the Papineau technique was retrospectively reviewed. The initial injury was an open fracture in 24 patients and a closed fracture in 7 patients. In all cases an Ilizarov circular external fixation device was used for the stabilization of the fracture or for bone lengthening. Mean follow-up for the group was 20 months (range, 10 months to 5 years) and there was successful limb salvage in all cases with eradication of infection and bone consolidation was achieved. The Ilizarov circular external fixation was removed at a mean of 18 weeks (range, 14-24 weeks). The mean time to bone union was 5 months (range, 4-10 months). All patients returned to their pre-treatment activity levels or better.

The reverse sural fasciocutaneous flap for the treatment of traumatic, infectious or diabetic foot and ankle wounds: A retrospective review of 16 patients.

The authors present their experience with the use of sural fasciocutaneous flaps for the treatment of various soft tissue defects in the lower limb. This paper is a review of these flaps carried out between 2003 and 2008. The series consists of 16 patients, 11 men and 5 women with an average age of 41 years (17-81) and with a follow-up period between 2 and 7 years. The etiology was major velocity accident in six cases, diabetes mellitus with osteomyelitis after ORIF for fractures (2), work accident in five, and another two cases with complications of lower limb injuries. The defect areas were located on calcaneus, malleolar area, tarsal area and lower tibia. Associated risk factors in the patients for the flap performance were diabetes (five patients) and cigarette smoking (ten patients).The technique is based on the use of a reverse-flow island sural flap combined with other flaps in three cases (cross-leg, peroneal, gastrocnemius). The anatomical structures which constituted the pedicle were the superficial and deep fascia, the sural nerve, the lesser saphenous vein and skin.The flap was viable in all 15 patients. On 8 cases was achieved direct closure, on three cases occurred a superficial necrosis and was skin grafted, on one case was observed partial necrosis which was treated with a second flap (posterior tibial perforator flap) and another one occurred delayed skin healing.The sural fasciocutaneous flap is useful for the treatment of severe and complex injuries and their complications in diabetic and non diabetic lower limbs. Its technical advantages are easy dissection, preservation of more important vascular structures in the limb and complete coverage of the soft tissue defects in just one operation without the need of microsurgical anastomosis. Thus this flap offers excellent donor sites for repairing soft tissue defects in foot and ankle.

Surgical management of a diabetic calcaneal ulceration and osteomyelitis with a partial calcanectomy and a sural neurofasciocutaneous flap.

The treatment of calcaneal osteomyelitis in diabetic patients poses a great challenge to the treating physician and surgeon. The use of a distally based sural neurofasciocutaneous flap after an aggressive debridement of non-viable and poorly vascularized tissue and bone that is combined with a thorough antibiotic regimen provides a great technique for adequate soft tissue coverage of the heel. In this case report, the authors describe the aforementioned flap as a versatile alternative to the use of local or distant muscle flaps for diabetic patients with calcaneal osteomyelitis and concomitant large wounds.

Partial fasciectomy for Dupuytren's contractures.

One hundred ninety-six patients with Dupuytren's contractures were treated by partial fasciectomy and adequate postoperative rehabilitation. All patients had flexion contracture of the proximal interphalangeal joint of >20 degrees ; 93 patients had flexion contracture of the associated metacarpophalangeal joint of >30 degrees ; 143 patients had risk factors for Dupuytren's disease. Primary skin closure and splinting were done in all patients. Range of motion was begun by the 1st week. Splinting was discontinued by the 2nd week, followed by night-time splinting until the 8th week. The mean follow-up was 6.6 years (range, 2-9 years). At the latest examination, 72.5% of the patients had complete range of motion of the metacarpophalangeal and proximal interphalangeal joints; 20.2% had 5 degrees -10 degrees of extension deficit and 7.3% had recurrent contractures of >20 degrees at the proximal interphalangeal joint and were subjected to reoperation. Complications included digital neurovascular injury in 5%, complex regional pain syndrome in 10.1%, and wound-healing problems and superficial infections in 15.1%.

Treatment of complex hand trauma using the distal ulnar and radial artery perforator-based flaps.

SUMMARY: The clinical value of distal ulnar or radial artery adipofascial perforator flaps is shown in a series of 30 patients with severe hand and wrist injuries and major soft tissue defects requiring coverage. There were 22 men and 8 women, aged 16-73 years. The defects were dorsal and/or palmar, with or without transpalmar or transcarpal amputation, or amputation of the thumb and/or the digits. Tendon injuries have been treated primarily or secondarily, or reconstructed using silicon rods. In all cases, after surgical debridement of the wound, reconstruction of the defect was done using distal ulnar (21 patients, in 3 patients primary reconstruction) and distal radial artery (11 patients; in 2 patients primary reconstruction and in 2 patients after necrosis of distal ulnar perforator flap) adipofascial perforator flaps. Minimum follow-up was 6 months. Two ulnar flap showed partial necrosis and were revised successfully by distal radial adipofascial perforator flaps. One radial and one ulnar flap showed 50% and 60% necrosis, respectively, and were revised by groin flaps. All donor sites healed uneventfully. Functional and cosmetic result was very good in 15 patients and good or satisfactory in the remaining. Range of motion of the wrist and hand joints was almost within normal limits (less than 25 degrees extension or flexion deficits). Distal ulnar and radial artery adipofascial perforator flaps for traumatic defects of the hand and wrist offer several advantages compared to other local flaps; they are easy to obtain and cover effectively both dorsal and palmar defects without significant functional deficits or donor site complications to the upper limb.

Severe upper limb injuries with or without neurovascular compromise in children and adolescents--analysis of 32 cases.

The healing and regeneration capacity of the injured tissues in childhood, adolescence, and adult life differs significantly. As a result, the prognosis of compound injuries of the upper limb in different age groups varies; therefore, the decision making and management of these cases should be age-specific. This article presents a series of 32 patients aged 1.5-14 years, with compound injuries of the upper limb that have been treated in our hospital during the period of the last 6 years. Ten of the above cases involved major vascular lesions that required revascularization or replantation. The injuries were classified according to the SATT (Severity, Anatomy, Topography, Type) classification system. This study shows that the outcome of compound upper limb injuries is age-related, while the SATT classification system is a valuable tool in the decision making process. Further research should be undertaken to determine age group-specific indications for the management of compound upper limb injuries, based on the SATT classification system.

Distal radial and ulnar arteries perforator-based adipofascial flaps for covering hand traumatic defects.

AIM: The clinical value of adipofascial flaps based on distal ulnar or radial-artery perforators is demonstrated in a series of 14 patients with severe hand injuries and significant soft tissue defects requiring coverage. MATERIAL AND METHODS: There were 10 male and 4 female patients, aged between 23 and 72 years. The defects were 7 dorsal, 4 palmar, 1 combined dorsal-palmar, and 2 with thumb or total digit amputation. In the patients with a dorsal defect, the extensor tendons were intact in 2 cases, reconstructed in 2 cases, and reconstructed in 3 cases using silicon rods. Following debridement, a fascial flap based on a distal ulnar (12) or radial (4, 2 primarily and 2 secondarily) artery perforator was fashioned and used to cover the defect. A split thickness skin graft was used to cover the defect and the hand was immobilized for 2 weeks. RESULTS: All cases were followed up for at least 6 months. The donor and recipient sites healed uneventfully, and the functional result was very good in terms of wrist and hand joint range of motion, which approximated the normal rates. The extension or flexion deficit was less than 25 degrees. The esthetic result was satisfactory. Two ulnar flap partial (involving approximately 35% of the area) necroses have been treated using reversed radial-distal perforator flaps. CONCLUSION: The described fascial flaps offer several advantages over other local flaps, and are rather easy to perform and cover effectively both dorsal and palmar hand defects without causing significant functional deficits to the upper limb.

Diverse types of epineural conduits for bridging short nerve defects. An experimental study in the rabbit.

In this study the process of peripheral nerve regeneration through an epineural flap conduit was examined using four groups of 126 New Zealand rabbits. There were three study groups (A, B, and C) and 1 control group (D). A 10-mm long sciatic nerve defect was bridged either with 3 variations of an epineural flap (Groups A, B, and C) or with a nerve autograft (Group D). Animals from all groups were examined 21, 42, and 91 days postoperatively to evaluate nerve regeneration employing light microscopy and immunocytochemistry. Nerve regeneration was studied in transverse sections at 3, 6, and 9 mm from the proximal stump. The gastrocnemius muscle contractility was also examined prior to euthanasia at 91 days postsurgery in all groups using electromyography. Immunohistochemical, histochemical and functional evaluation showed the presence of nerve regeneration resembling the control group D, especially in group A, where an advancement epineural flap was used. In this experimental model an epineural flap can be used to bridge a nerve defect successfully.

Transdermal anaesthesia for percutaneous trigger finger release.

The purpose of this study was to evaluate the safety and efficiency of transdermal anaesthesia using eutectic mixture of lidocaine and prilocaine (EMLA) in patients undergoing percutaneous trigger finger release and to compare it with lidocaine infiltration. In this prospective, randomised study percutaneous release of the A1 annular pulley was performed to treat stenosing tenosynovitis (trigger finger syndrome) in 50 patients (50 fingers). The procedure was performed either under transdermal anaesthesia using EMLA applied transcutaneously 120 minutes prior to the operation (Group A, n = 25) or using local infiltration anaesthesia using lidocaine (Group B, n = 25). Pain experienced during administration of anaesthesia and during the operation was assessed using a 10-point Visual Analogue Pain Scale (VAPS), while all patients rated the effectiveness of anaesthesia with a 5-point scale. There were no significant differences between the two groups in the VAPS during the operation (1.33 +/- 0.52 versus 1.59 +/- 0.87) and the satisfaction scores (4.6 +/- 0.2 versus 4.4 +/- 0.3). The VAPS score during the administration of anaesthesia was statistically significantly less in the EMLA group (0 versus 5.96 +/- 2.41). All patients were satisfied with the final result of the operation. Percutaneous trigger finger release can be performed as an office procedure with the use of EMLA avoiding the use of injectable local infiltration anaesthesia.