Microvascular free flap coverage for salvage of the infected total knee arthroplasty.

AIMS: The integrity of the soft tissue envelope is crucial for successful treatment of infected total knee arthroplasty (TKA). The purpose of this study was to evaluate the rate of limb salvage, infection control, and clinical function following microvascular free flap coverage for salvage of the infected TKA. METHODS: We retrospectively reviewed 23 microvascular free tissue transfers for management of soft tissue defects in infected TKA. There were 16 men and seven women with a mean age of 61.2 years (39 to 81). The median number of procedures performed prior to soft tissue coverage was five (2 to 9) and all patients had failed at least one two-stage reimplantation procedure. Clinical outcomes were measured using the Knee Society Scoring system for pain and function. RESULTS: In all, one patient was lost to follow-up prior to 12 months. The remaining 22 patients were followed for a mean of 46 months (12 to 92). At latest follow-up, four patients (18%) had undergone amputation for failure of treatment and persistent infection. For the other 18 patients, 11 patients (50%) had maintained a knee prosthesis in place while seven patients had undergone resections for persistent infection but retained their limbs (32%). Reoperations were common following coverage and reimplantation. The median number of additional procedures was two (0 to 6). Clinical function was poor in patients who underwent reimplantation and retained a knee prosthesis following free flap coverage with a mean KSS score for pain and function of 44 (0 to 70) and 30 (0 to 65), respectively. All patients required an assistive device. Extensor mechanism problems and extensor lag requiring bracing were common following limb salvage and prosthesis reimplantation. CONCLUSION: Microvascular tissue transfer for management of infected TKA can be successful in limb salvage (82%) but clinical outcomes in salvaged limbs were poor. Cite this article: Bone Joint J 2020;102-B(6 Supple A):176-180.

Outcomes of sympathectomy and vascular bypass for digital ischaemia in connective tissue disorders.

All patients (36 hands) with connective tissue disorders who underwent periarterial sympathectomy of the hand alone or in conjunction with vascular bypass at our institution between 1995-2013 were reviewed. The durable resolution of ulcers was significantly higher in patients treated by periarterial sympathectomy and bypass than in patients treated by periarterial sympathectomy alone. Although there were more digital amputations in patients treated by periarterial sympathectomy alone, the difference was not statistically significant. Vascular bypass in conjunction with sympathectomy may be better than sympathectomy alone in patients with digital ischaemia related to connective tissue disorders. LEVEL OF EVIDENCE: IV.

To reverse or not to reverse? A systematic review of autograft polarity on functional outcomes following peripheral nerve repair surgery.

BACKGROUND: The literature describing the best clinical practice for proximal-distal autograft orientation, otherwise known as nerve graft polarity, is inconsistent. With existing disparities in the peripheral nerve literature, the clinical question remains whether reversing nerve autograft polarity bears an advantage for nerve regeneration. METHODS: A comprehensive review of the literature using Embase and PubMed databases (1940-June 2015) was performed to retrieve all original articles on the effects of nerve autograft polarity on nerve regeneration and functional recovery following primary repair of peripheral nerve defects. RESULTS: The initial database search yielded 318 titles. Duplicate exclusion, title review and full text review yielded six articles which directly compared nerve autograft polarity. Histological, morphometric, electrophysiological, and behavioral outcomes were reviewed. All retained articles were animal studies, of which none demonstrated significant differences in outcomes between the normal and reversed polarity groups. A reversed graft may ensure that regenerating nerve fibers are not lost at branching points, however this may not translate into improved function. CONCLUSION: There is insufficient data to suggest that nerve autograft polarity has an impact on nerve regeneration and functional outcomes.

Osteocutaneous defects of the clavicle: two case reports, analysis of the literature, and a novel management algorithm.

Osteocutaneous defects of the clavicle follow surgical management of chronic infections, tumors, and trauma. There are several reconstructive options, but it is unknown whether the bone needs to be reconstructed, which flaps are the best for reconstruction, nor why certain flaps favored over other options for a given scenario. Factors such as wound etiology, defect size, patient demographics, and co-morbidities guide therapy. The management of osteocutaneous defects of the clavicle is herein reviewed. Two clinical cases are presented, literature discussing clavicle form and function, disease pathogenesis, and reconstructive approaches are analyzed, and a resultant algorithm proposed.

Immunology of vascularized composite allotransplantation: a primer for hand surgeons.

Vascularized composite allotransplantation is a recent innovation in the fields of transplantation surgery, plastic and reconstructive surgery, and orthopedic surgery. The success of hand and face transplantation has been based on extensive experience in solid organ transplantation. Advances in understanding the immunology of transplantation have had a major role in achieving excellent results in this new field. The purpose of this article is to introduce the basics of human immunology (innate and adaptive systems) and the immunological basis of human transplantation (the importance of human leukocyte antigen, direct and indirect pathways of antigen recognition, the 3 signals for T-cell activation, and mechanisms and types of allograft rejection) and focus on the mode of action of immunosuppressive drugs that have evolved as the mechanisms and pathways for rejection have been defined through research. This includes recent studies involving the use of costimulatory blockade, regulatory T cells, and tolerance induction that have resulted from research in understanding the mechanisms of immune recognition and function.

Quadrimembral amputation: indications and contraindications for vascularized composite allotransplantation.

INTRODUCTION: Quadrimembral amputees, as patients who have lost both upper and lower extremities, may benefit greatly from hand transplantation. The objective of this study is to evaluate the indications and contraindications for transplantation in this subset of patients. METHODS: A retrospective review was conducted of five quadrimembral amputees evaluated by our program for transplantation. Information collected included age, sex, level of amputations, time since amputations, etiology, level of dependence, medical stability, psychosocial status, and the ability to tolerate immunosuppression. Indications and contraindications for transplantation were reviewed for each patient. RESULTS: All etiologies were based in extremity ischemia: three from septic shock, one from myocardial infarction, and one from drug overdose. All patients are completely dependent. Of the five patients, two needed further reconstructive surgery and two others had a history of resolved hepatic/renal insufficiency. After thorough evaluation, two patients were selected as potential transplant candidates. They demonstrated strong psychosocial support systems, a thorough understanding of hand transplantation, along with its risks and postoperative requirements. They had also completed a full regimen of rehabilitation along with prosthetic fitting and utilization. CONCLUSIONS: Clearance for transplantation is based on medical stability, absence of infection or systemic diseases, and strong psychosocial support systems. Contraindications for transplantation are drug dependence and noncompliant behavior. Relative contraindications include a history of hepatic/renal insufficiency which if not resolved may preclude the use of postoperative immunosuppression.

WITHDRAWN: The extended abdominal wall flap for transplantation.

INTRODUCTION: Patients with extensive loss of abdominal wall tissue have few options for restoring the abdominal cavity. Composite tissue allotransplantation has been used for limited abdominal wall reconstruction in the setting of visceral transplantation, yet replacement of the entire abdominal wall has not been described. The purpose of this study was to determine the maximal abdominal skin surface available through an external iliac/femoral cuff-based pedicle. MATERIALS AND METHODS: Five human cadaver abdominal walls were injected with methylene blue to analyze skin perfusion based on either the deep inferior epigastric artery (DIEA; n = 5) or a cuff of external iliac/femoral artery (n = 5) containing the deep circumflex iliac, deep inferior epigastric, superficial inferior epigastric, and the superficial circumflex iliac arteries. RESULTS: Abdominal wall flaps were taken full thickness from the costal margin to the mid-axial line and down to the pubic tubercle and proximal thigh. In all specimens, the deep inferior epigastric, deep circumflex iliac, superficial inferior epigastric, and the superficial circumflex iliac arteries were found to originate within a 4-cm cuff of the external iliac/femoral artery. Abdominal wall flaps injected through a unilateral external iliac/femoral segment had a significantly greater degree of total flap perfusion than those injected through the DIEA alone (76.5 +/- 4% versus 57.2 +/- 5%; Student t test, P < .05). CONCLUSIONS: Perfusion of a large portion of the abdominal wall is possible using single-vessel anastomosis through a short segment of the external iliac/femoral system. Perfusion is significantly greater than that based on the DIEA vessel alone.

The extended abdominal wall flap for transplantation.

INTRODUCTION AND AIMS: Patients with extensive loss of the abdominal wall tissue have few options for restoring the abdominal cavity. Composite tissue allotransplantation has been used for limited abdominal wall reconstruction in the setting of visceral transplantation, yet replacement of the entire abdominal wall has not been described. The purpose of this study was to determine the maximal abdominal skin surface available through an external iliac/femoral cuff-based pedicle. MATERIALS AND METHODS: Five human cadaveric abdominal walls were injected with methylene blue to analyze skin perfusion based on either the deep inferior epigastric artery (DIEA; n = 5) or a cuff of external iliac/femoral artery (n = 5) containing the deep circumflex iliac, deep inferior epigastric, and superficial inferior epigastric, and superficial circumflex iliac arteries. RESULTS: Abdominal wall flaps were taken full thickness from the costal margin to the midaxillary line and down to the pubic tubercle and proximal thigh. In all specimens, the deep inferior epigastric, deep circumflex iliac, superficial inferior epigastric, and superficial circumflex iliac arteries were found to originate within a 4-cm cuff of the external iliac/femoral artery. Abdominal wall flaps injected through a unilateral external iliac/femoral segment had a significantly greater degree of total flap perfusion than those injected through the DIEA alone (76.5% ± 4% vs 57.2% ± 5%; Student t test, P < .05). CONCLUSIONS: Perfusion of a large portion of the abdominal wall is possible using a single-vessel anastomosis through a short segment of the external iliac/femoral system. Perfusion is significantly greater than that based on the DIEA vessel alone.

A model of sequential heart and composite tissue allotransplant in rats.

BACKGROUND: Some of the 600,000 patients with solid organ allotransplants need reconstruction with a composite tissue allotransplant, such as the hand, abdominal wall, or face. The aim of this study was to develop a rat model for assessing the effects of a secondary composite tissue allotransplant on a primary heart allotransplant. METHODS: Hearts of Wistar Kyoto rats were harvested and transplanted heterotopically to the neck of recipient Fisher 344 rats. The anastomoses were performed between the donor brachiocephalic artery and the recipient left common carotid artery, and between the donor pulmonary artery and the recipient external jugular vein. Recipients received cyclosporine A for 10 days only. Heart rate was assessed noninvasively. The sequential composite tissue allotransplant consisted of a 3 x 3-cm abdominal musculocutaneous flap harvested from Lewis rats and transplanted to the abdomen of the heart allotransplant recipients. The abdominal flap vessels were connected to the femoral vessels. No further immunosuppression was administered following the composite tissue allotransplant. Ten days after composite tissue allotransplantation, rejection of the heart and abdominal flap was assessed histologically. RESULTS: The rat survival rate of the two-stage transplant surgery was 80 percent. The transplanted heart rate decreased from 150 +/- 22 beats per minute immediately after transplant to 83 +/- 12 beats per minute on day 20 (10 days after stopping immunosuppression). CONCLUSIONS: This sequential allotransplant model is technically demanding. It will facilitate investigation of the effects of a secondary composite tissue allotransplant following primary solid organ transplantation and could be useful in developing future immunotherapeutic strategies.

[Thoracic wall defect reconstruction and dead space obliteration with an intra-/extrathoracic free flap]. / Thoraxwandrekonstruktion und Totraumobliteration. Einsatz einer intra-/extrathorakalen freien Lappenplastik.

Presented is the case of a 61-year-old male patient with a chronic thoracic wall defect, including a bronchopleural fistula, after multiple resections of a desmoid tumor. After partial lung resection to remove the bronchopleural fistula, dead space was partially obliterated and the thoracic wall reconstructed with a free combined intra- and extrathoracic rectus abdominis muscle flap.

Current indications for hand and face allotransplantation.

There is growing excitement centered on the possibilities of composite tissue allotransplantation (CTA) in many medical centers around the United States. As CTA programs begin to form, criteria to guide patient selection for these highly complex procedures is warranted. At this time the contraindications for CTA are more easily defined than the indications. What is clear is that a thorough multidisciplinary evaluation of each individual patient will be needed to determine the global impact and complexity of the defect. The role of the surgeon is to identify the feasibility of the CTA reconstruction and balance this with a complete knowledge of conventional reconstructive techniques. Conventional treatments may be used in place of CTA or as salvage for CTA failure.

Increased signs of acute rejection with ischemic time in a rat musculocutaneous allotransplant model.

BACKGROUND: Composite tissue allotransplantation (CTA) may restore a variety of tissue defects, but carries the potential risks of graft failure and/or immunosuppression-related complications. Ischemia-reperfusion injury has been documented in CTA is known to contribute to acute rejection of solid organ grafts. This study describes the influence of subcritical ischemic time (ie, ischemia sufficient to generate reversible cell damage) on signs of rejection of musculocutaneous allograft components of subcritical ischemic time, namely, ischemia sufficient to generate reversible cell injury. Although skin is considered the most antigenic component of a composite allograft and is currently used for rejection surveillance, muscle and adipose are more susceptible to ischemia-related injury. METHODS: Vascularized epigastric flaps were transplanted from WKY to Fisher 344 rats after 1 or 3 hours of ischemia. Biopsies taken on postoperative day 6 were graded for signs of acute rejection according to criteria modified from previously published grading systems for CTA rejection. RESULTS: Skin and muscle exposed to 3 hours of ischemia showed significantly higher rejection scores than after 1 hour of ischemia, as evidenced by a more aggressive diffuse lymphocytic infiltration with disruption of tissue architecture. The rejection score in skin with 3-hour ischemia was 5.0 +/- 0.1 versus 3.7 +/- 0.2 with 1-hour (Mann-Whitney U test; P < .05). The rejection score in muscle exposed to 3-hour ischemia was 3.6 +/- 0.3 versus 2.5 +/- 0.1 with 1-hour (P < .05). CONCLUSIONS: Muscle and skin demonstrated increased acute rejection of allotransplants with increased subcritical ischemic time. This study supports the use of aggressive methods to reduce subcritical ischemic injury during allotransplantation of composite tissue and inclusion of muscle in postoperative biopsies in this early investigational period of CTA.

[Facial allograft transplantation: fiction or reality? Surgical techniques in a fresh human cadaver model]. / Allogene Gesichtstransplantation: Fiktion oder Realität? : Darstellung chirurgischer Techniken am Leichenmodel.

BACKGROUND: The aim of this study was to describe two methods of face-harvesting techniques -- a skin and soft tissue flap and a combined osteocutaneous flap -- and to demonstrate the compatibility between donor and recipient in a human fresh cadaver model. METHODS: In fresh human cadavers the skin and soft tissue of the face (type 1) and a combined osteocutaneous flap (including a le Fort III segment, type 2) were harvested. The faces were subsequently exchanged among the donor crania, simulating full-face transplantation. RESULTS: Both flaps are based on the external blood supply of the faciotemporal vessels and the external jugular vein. The end branches of the trigeminal nerve could potentially be used for restoration of sensation (type 1 flap). With type 2 flaps the facial expression may be restored with the inclusion of the facial nerve. Four morphological parameters determine the donor/recipient compatibility: skin color and texture, anthropometric head dimensions, specific soft tissue components (nose, lip, cheek, and eyebrow), and gender. CONCLUSION: Apart from ethical considerations, long-term immunosuppression will remain the limiting factor of full facial transplantation in the near future.

[Literature and own strategies concerning soft-tissue reconstruction and exposed osteosynthetic hardware]. / Weichteildefekt und exponiertes Osteosynthesematerial--Metallerhalt oder Entfernung? Literaturübersicht und eigene Strategien.

BACKGROUND: In the event of exposed hardware from reconstructive surgery, it must be decided whether to retain or remove it prior to plastic surgical soft-tissue reconstruction to ensure long-term freedom from infection and stable wound closure. MATERIAL AND METHODS: Treatment options and results in the literature are reviewed. A treatment algorithm is proposed under consideration of our personal experience. RESULTS AND CONCLUSION: Hardware used in spine surgery is commonly left in situ until bony consolidation has been achieved. The indications for hardware removal depend on length of exposure or infection, implant failure, and location. Osteosynthetic devices in the extremities may be removed and replaced by external fixators or immobilisation. Removal of prostheses requires complex second-stage reimplantation or arthrodesis. A treatment algorithm is suggested that might ease the decision whether exposed hardware can remain or requires removal before reconstruction of soft-tissue defects.

[The infragluteal perforator flap]. / Die infragluteale Perforans-Lappenplastik.

PURPOSE: Pressure sores of the ischial tuberosities are mostly covered with fascio- or myocutaneous flaps of the posterior thigh. In doing so, vascular territories of adjacent flaps are violated, which are not available any more in case of ulcer recurrences. In consideration of the high recurrence rates of pressure sores in paraplegics, we developed an infragluteal perforator flap that spares adjacent vascular territories. PATIENTS/MATERIAL AND METHOD: Infragluteal perforator flaps were dissected in five fresh human cadavers to investigate the anatomic relations of the cutaneous branches of the inferior gluteal artery and the inferior clunial nerves and to define the anatomic landmarks for clinical application of an innervated flap. In six paraplegic patients with primary (5/6) and secondary (1/6) pressure sores of the ischial tuberosity, infragluteal perforator flaps were used for wound coverage. The donor defect was closed primarily and postoperative care and patient mobilisation followed a standardised protocol. RESULTS: In eleven infragluteal perforator flaps that were dissected in cadavers and patients, we found one or two cutaneous branches of the descending branch of the inferior gluteal artery at the lower border of the gluteus maximus muscle that supplied the infragluteal skin. Infragluteal perforator flaps could be harvested on these perforator vessels and transferred to the ischial defects without tension due to the excellent mobility of the skin island. The descending branch of the inferior gluteal artery could be spared in all cases for future flaps. In one patient with multiple recurrences of an ischial pressure sore flap necrosis occurred due to venous congestion. The other five infragluteal perforator flaps healed without complications. CONCLUSION: The infragluteal perforator flap is suitable for the closure of pressure sores of the ischial tuberosities and can be used as a sensitised flap by inclusion of the inferior clunial nerves. Compared to traditional pedicled flaps of the posterior thigh, the infragluteal perforator flap reduces donor site morbidity and spares the vascular territories of adjacent flaps for future recurrent ulcers.

[Free fibula transfer. Analysis of 76 consecutive microsurgical procedures and review of the literature]. / Freier Fibulatransfer. Analyse einer Serie von 76 konsekutiven mikrochirugischen Operationen und Literaturübersicht.

Since its introduction by Taylor in 1975, microvascular free fibula transfer has become the gold standard in osseous reconstructions requiring vascularized bone transfer. Various modifications of the free fibula have been described in the literature. We reviewed a series of 76 free vascularized fibula transfers during a 7-year period. Data was retrospectively analyzed with respect to type of procedure and outcome, general surgical complications, and flap-related (specific) complications. Of all 76 free fibula flaps, 47 cases healed uneventfully (62%). Interestingly, 53% of all extremity reconstruction cases had at least one of the above complications, whereas in maxillofacial cases the complication rate was only 25%. Complete osseous consolidation at the time of evaluation was confirmed in 58 patients (76%). Complete flap failure occurred in four patients (5%). The complication rates reflect the complexity of the procedures and appear strongly related to the underlying disease and predisposing medical risk factors. Time will tell if advances, e.g., in the field of tissue engineering, will eventually replace autologous vascularized bone transfer.

Distraction lengthening of thumb metacarpal.

The purpose of this retrospective study was to evaluate the clinical outcome of distraction lengthening of the thumb metacarpal without bone grafting in seven patients with traumatic thumb loss. The distraction was stopped after 57 (range, 42 to 91) days, giving a median lengthening of 28 (range, 20-36)mm. It took an average of 155 (range, 118-196) days for bony consolidation to occur. The mean pinch power was 72% of that of the uninjured hand. The two-point discrimination on the pulp of the reconstructed thumb was 10 (range, 8-12)mm. There were no major complications.

[Role of a sensory innervated plantar fillet free flap for reconstruction of sacral pressure sores in paraplegic patients. Last resort for reconstruction of sacral pressure sores in paraplegics]. / Plantare neurovaskuläre Filetlappenplastik. Ultima ratio zur Rekonstruktion sakraler Dekubitalulzera bei Paraplegikern.

Sensory denervation is the key factor for the high rate of recurrent sacral pressure sores in paraplegic patients. This paper summarizes the results after reconstruction of recurrent sacral pressure sores using a sensory innervated plantar fillet free flap. Five plantar fillet free flaps were utilized for defect reconstruction of sacral pressure sores in five male patients during a 9-year period (1989-1998). Data were analyzed retrospectively. Patients'age ranged between 32 and 51 years. The level of spinal cord injury was between T10 and L1. The average defect size was 20 x 16 cm. All flaps were microsurgical free tissue transfers. The posterior tibial nerve was coapted to two intercostal nerves from above the spinal cord injury level. All patients developed sensation within 3-6 months. A stable sensate coverage was achieved in each case. The data show that the concept of a sensory innervated plantar fillet free flap may facilitate defect reconstruction in most complex or even seemingly hopeless cases.

Treatment of segmental defects of the humerus with an osteoseptocutaneous fibular transplant.

BACKGROUND: There are limited reconstructive options for the treatment of segmental bone defects of the upper extremity that are >6 cm in length, especially those that are associated with soft-tissue defects. The purpose of the present review was to report on our experience with fifteen patients who received an osteoseptocutaneous fibular transplant for reconstruction of a humeral defect. METHODS: The study cohort included eight male patients and seven female patients with an average age of forty-one years. The indications for the procedure included segmental nonunion (nine patients), a gunshot wound (three), a defect at the site of a tumor resection (two), and failure of an allograft-prosthesis reconstruction (one). The fibular graft was fixed by means of intramedullary impaction in eleven patients, was used as an onlay graft in three, and was used as a strut between the intact diaphysis and the humeral head in one. RESULTS: The average length of the segmental humeral defect was 9.3 cm. The average length of the fibular graft was 16.1 cm, and the average length and width of the skin paddle were 8.1 and 4.5 cm. The average duration of follow-up was twenty-four months. Three patients had venous thrombosis and underwent a successful revision of the anastomosis. Four patients had early failure of graft fixation. Three patients had a fracture of the fibular graft within the first year postoperatively. All but one of these latter seven patients were successfully treated with open reduction, internal fixation, and additional bone-grafting. One patient with an infection at the site of a nonunion and signs of graft resorption required a second fibular transplant. CONCLUSIONS: The osteoseptocutaneous fibular transplant is an effective treatment for combined segmental osseous and soft-tissue defects of the arm. However, the application of this technique to the arm is more complex than application to the forearm and is associated with a higher rate of complications.

[Fasciocutaneous radial artery perforator vessels - an anatomic study]. / Die fasziokutanen Perforansgefässe der A. radialis - Eine anatomische Studie.

PURPOSE/BACKGROUND: Distal and proximal pedicled forearm flaps that are nourished by radial perforator vessels have been described. These flaps spare the radial artery during flap harvest. The question is, whether it is possible to raise individual free fasciocutaneous radial perforator flaps. METHOD AND MATERIAL: The number, external vessel diameter, and distribution of fasciocutaneous radial perforator vessels were investigated on 20 fresh cadaver arms. All specimen were then treated with the Spalteholz technique to demonstrate the arborizing of the perforator vessels. RESULTS: There was an average of 12 (range 9 to 16) fasciocutaneous perforator vessels per radial artery. The most proximal perforator vessel had an external diameter of 0.8 (range 0.5 to 1.0) mm, the others were measured smaller then 0.5 mm. There was a rich network of anastomoses at the level of the fascia up to the level of the subdermal plexus. CONCLUSIONS: The anatomic basis of the proximally and distally based radial perforator flaps was confirmed. Free flaps based exclusively on fasciocutaneous radial perforators would require supra-microsurgical skills due to the small vessel diameter. For practical reason it seems to be advisable to include parts of the radial artery into such a flap design.