Bone-anchored prostheses for lower limb amputation in a French cohort with 1-15 years of follow-up: implant survival rates, mechanical complications, and reported outcomes.

PURPOSE: To evaluate the implant survival rate, mechanical complications, and reported patient outcomes of bone-anchored prostheses for patients with lower limb amputation in France after 1-15 years of follow-up. METHODS: This retrospective cohort study included patients who underwent surgery at a single center in France between 2007 and 2021. The primary outcomes were the implant survival rate and functional scores assessed by the Questionnaire for Transfemoral Amputees (Q-TFA). Secondary outcomes were adverse events that occurred during follow-up. RESULTS: The cohort consisted of 20 bone-anchored prostheses in 17 patients. The main level of amputation was transfemoral (82%, n = 14). The main reason for amputation was trauma (n = 15). The mean age at amputation was 32 (range 15-54) years, and the mean age at the first stage of osseointegration was 41 (range 21-58) years. The Kaplan-Meier survival curve showed respective survival rates of 90%, 70%, and 60% at 2, 10, and 15 years. All Q-TFA scores were significantly improved at last the follow-up. Eleven patients (65%) experienced mechanical complications. In total, 37 infectious events occurred in 13 patients (76%), mainly comprising stage 1 infections (68%, n = 25). Only two cases of septic loosening occurred (12%), leading to implant removal. CONCLUSION: This is the first French cohort of bone-anchored prostheses and among the series with the longest follow-up periods. The findings indicate that bone-anchored prostheses are safe and reliable for amputee patients who have difficulties with classic prostheses.

Medial Sural Artery Perforator Flap for Leg and Knee Coverage: Extended Skin Paddle With 2 Perforators.

BACKGROUND: For soft-tissue defect coverage in the lower leg and around the knee joint, the gastrocnemius muscle flap is the most commonly used. Having constant anatomy, a long pedicle, and decreased donor site morbidity, the medial sural artery perforator (MSAP) flap may represent a good reconstructive alternative. The aim of this report was to present the experience of using a dual perforator MSAP pedicled flap. METHODS: Nineteen patients underwent soft-tissue reconstruction by MSAP flap in the one third of the lower leg and around the knee joint. Eleven patients were injured in traffic accidents. Exposure of a knee prosthesis required flap coverage in 4 cases. The other defect etiologies were a gunshot wound, bone abscess due to a sickle cell anemia, bone exposure due to a full thickness burn, and sarcoma resection. Defect dimensions ranged from 7 × 5 cm to 15 × 8 cm. Seventeen flaps were harvested with 2 perforators. Donor sites were closed primary in 16 of the 19 cases. RESULTS: The sizes of the MSAP flaps ranged from 7 to 22 cm × 5 to 8 cm. The procedure was uneventful in 17 cases. The 2 unsuccessful flaps developed a distal necrosis, for which an excision with direct suture was made secondary. Complete healing was achieved in all cases. CONCLUSIONS: The pedicled MSAP flap represents a versatile option in soft-tissue defect coverage of the lower leg and around the knee joint. Inclusion of 2 perforators could render the flap safer and increase its skin paddle, making it suitable for larger defects.

Indications and functional outcome of the use of integra® dermal regeneration template for the management of traumatic soft tissue defects on dorsal hand, fingers and thumb.

INTRODUCTION: Few studies have been conducted to explore the utility of the Integra® dermal regeneration template (IDRT) combined with a delayed split-thickness skin graft (STSG) for reconstructing complex dorsal hand, digit, and thumb injuries. This study reports the indications and outcomes for 14 patients treated with this technique via a two-stage process. MATERIALS AND METHODS: We retrospectively reviewed all patients treated by IDRT combined with STSG from May 2015 to October 2018. The inclusion criterion was traumatic or post-infectious soft tissue defects (STDs) of the dorsal hand, fingers, and thumb, not suitable for direct wound closure and requiring local, pedicle, or free flap reconstruction. After debridement, a two-stage procedure was applied, namely IDRT followed by STSG. Indications, functional outcomes, aesthetic results, complications, patient satisfaction, and the STSG take rate were evaluated over a 36-month follow-up using standardised instruments. RESULTS: A total of 14 patients with 15 reconstructions (average age = 48 years) were included. The dominant hand was involved in 50% of cases. Dorsal STDs involved the hand, fingers, thumb, and hand and thumb in 7, 3, 2 and 2 cases, respectively. The mean STD size was 35 cm2 (range: 3-150 cm2). The wound was associated with exposed tendons (without peritenon), bone (without periosteum), and joints (without a capsule) in eight cases (57%). The IDRT/STSG take rate was 97%. The average Vancouver Scar Scale score was 2 (1-4). CONCLUSION: The 36-month follow-up demonstrated that IDRT is a safe and reliable technique that can be considered a viable alternative to flap reconstruction for the management of traumatic STDs in selected patients. The aesthetic outcomes are acceptable, functional recovery of the fingers is excellent, patient satisfaction is very high and the rate of complications is very low.

A new local muscle flap for elbow coverage-the medial triceps brachii flap: anatomy, surgical technique, and preliminary outcomes.

BACKGROUND: The medial triceps brachii is vascularized by the middle collateral artery and the arterial circle of the elbow. This vascularization allows a distal pedicled use to cover soft tissue defects of the elbow. We report our experience using this flap to cover traumatic and postsurgical wounds. METHODS: Patients who underwent a pedicled medial triceps brachii flap procedure between 2008 and 2015 were included. Data concerning characteristics of the patients, wound size, surgical technique, and complications were retrospectively reviewed. An independent observer examined patients and assessed outcome of the coverage procedure: wound healing, scar length, range of elbow motion, and patient satisfaction. RESULTS: Eight patients were included (70.6 ± 17.7 years old at the time of surgery). All patients had serious comorbidities and risk factors of poor wound healing. Defects were due to postoperative healing complications (5 patients), skin necrosis secondary to an underlying olecranon fracture (1 patient), and direct open fractures (2 patients). Soft tissue defects had a median surface of 17 (14-22) cm2. The olecranon was exposed in 7 cases and the medial humeral epicondyle in 1 case. Mean procedure duration was 83 ± 14 minutes. There was no intraoperative or postoperative complication. All patients healed properly at 3 weeks of follow-up. No wound recurrence or surgery-related complication was reported after a median follow-up of 40.5 (21.5-69.5) months. CONCLUSION: Favorable outcomes in all of our 8 patients make this flap an interesting option to cover small to medium-sized defects of the posterior aspect of the elbow.

Medial triceps brachii free flap in reconstructive surgery: a prospective study in eight patients.

INTRODUCTION: In this study, we present a prospective series of medial triceps free flaps for ankle and foot complex defects coverage and discuss its numerous advantages. MATERIALS AND METHODS: Between January 2011 and December 2012, eight patients, two women and six men underwent medial triceps brachii (MTB) free flap procedure to cover defects localized at the ankle and foot in our department. Patient mean age was 37.3 ± 15.2 years at the time of surgery (range of 13-53 years). Mean defect size to be covered was 21.8 ± 9.9 cm(2). The bone was exposed at the level of the calcaneum in six cases, at the level of the forefoot in one case, and at the level of the lateral malleolus in one case. Special attention was accorded to intra-operative findings. Flap survival and complications on both the donor and recipient site were prospectively evaluated. RESULTS: Mean MTB flap raising time was 51.3 ± 6.0 min. All the flaps survived and there was no partial flap necrosis. A skin graft was performed after a mean time of 11.8 ± 2.1 days post-operative. The mean follow-up was 18.1 ± 3.8 months. Complications at the donor site level included one hematoma and a case of hypertrophic scar. Complete healing of both the donor and recipient sites was achieved in all cases. CONCLUSIONS: MTB free flap appears to be a useful option for covering small to medium defects in lower limb extremities. Due to the constant anatomy of the MTB nerve, we suggest that the flap could also be used as an innervated free flap for small or medium muscular reanimation such as sequelae of forearm and hand muscle impairment, or facial palsy.

Long-term results of first row carpectomy with proximal capitate resurfacing using a pyrocarbon implant.

The functional results of proximal row carpectomy with a proximal capitate resurfacing using a pyrocarbon implant were evaluated in a retrospective, multicentric, multi-operator study. The outcomes of patients operated on at five surgical centres between January 2005 and December 2018 were reviewed. The data were collected by an independent observer during standardized consultations. Based on 30 patients with a mean follow-up of 7 years, the median range of flexion and extension was 65° and the median radioulnar tilt was 45°. The median Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) score was 14 and the improvements in strength and pain were good. Compared with the preoperative values, significant improvements were seen in the flexion and extension range of motion, radioulnar tilt and pain score. No postoperative complications were recorded.Level of evidence: IV.

Time to return to work after total trapeziometacarpal prosthesis.

OBJECTIVES: This study assessed return to work and prosthesis survival after trapeziometacarpal prosthesis surgery. MATERIAL AND METHODS: A multicenter retrospective study was carried out on patients operated on between 2002 and 2020. All working patients who had undergone trapeziometacarpal prosthesis surgery were included. Return to work was defined as resuming the same full-time position. Postoperative events and their specific treatment and failure to return to work were reported. RESULTS: 240 prostheses in 211 patients were included. The complications rate was 7.5%, with 97% prosthesis survival. 94.3% of patients returned to work, at a mean 48 days (range, 29-210 days; SD, 22.7 days), with no significant difference according to age. Twelve patients did not return to work, half of whom because of prosthetic complications. CONCLUSION: Trapeziometacarpal arthroplasty enables most patients to return to work within 6 weeks. In this series, the prosthetic survival rate was 97%.

The Homodigital Propeller Flap: A New Tool for Fingertip Reconstruction. Surgical Technique, Anatomical Study, and Clinical Relevance.

BACKGROUND: An ideal flap for fingertip injuries should cover a significant loss of substance and avoid joint flexion to prevent later contracture and joint stiffness. In this study, the authors describe a modified homodigital island flap-the homodigital propeller flap-to better meet these requirements. METHODS: An anatomical model of fingertip loss is used to analyze the advancement achieved without flexion of the finger. Twenty-four fresh-frozen fingers were dissected. Wires were inserted to maintain joints in extension. The skin paddle was similar in location to a homodigital island flap. The neurovascular bundle was dissected without exceeding the proximal interphalangeal joint and was released from the proximal half of the paddle. Then, the homodigital propeller flap was rotated 180 degrees to cover the defect. A mixture of India ink and barium sulfate was injected into the pedicle artery after the release of the proximal half of the flap from the neurovascular pedicle to assess residual flap vascularization. India ink highlights the residual subcutaneous vascularization network of the cutaneous paddle. A radiographic study of the flap was then performed to visualize the subcutaneous vascular network of the cutaneous paddle. RESULTS: The homodigital propeller flap achieved an average cutaneous advancement of 18 mm (range, 15 to 22 mm) and allowed full coverage of cutaneous defects for all fingers while maintaining the proximal interphalangeal joint in strict extension. CONCLUSIONS: The homodigital propeller flap is a refinement of the classic homodigital island flap. It allows efficient coverage of fingertip defects because of a large advancement without flexion of the finger, reducing the risk of stiffness.

Index Finger Pollicization Incisions for Congenital Thumb Aplasia: Review and Design of an Educational Anatomical Model for Skin Incisions.

BACKGROUND: Pollicization of the index finger can be considered the gold standard technique for the treatment of congenital thumb aplasia. The aim of this study was to review the described incisions for pollicization and to create an anatomical framework enabling the study and comparison of these incisions. METHODS: A systematic review was performed to collect descriptions of incision sets. An anatomical model was created from the two upper limbs of the same cadaver. Thumb aplasia was modeled on both hands of this cadaver by severing the thumbs; an index finger pollicization was performed on one of the two hands. Comparative analysis of scar positions, first web size, and neothumb aspect of each incision set was conducted using a surgical glove modeling the skin. The glove was fitted onto the aplastic model to draw the incisions and then onto the pollicized hand to adjust the resulting flaps after cutting. RESULTS: Twelve articles, two textbooks, and one DVD were included in the review, either containing an original description of incisions, or describing an incision pattern with figures and references to the initial author. A total of five different incision sets, described by Buck-Gramcko, Blauth, Foucher, Ezaki, and Malek, were identified and compared using the anatomical model. CONCLUSIONS: This work summarizes five original incisions described for index pollicization in thumb aplasia and presents a standardized and reliable model to study and compare these different sets. The model can be used for educational purposes, either to teach or to optimize an incision set.

Management of Chronic Osteomyelitis by an Orthoplastic Team: 7-Year Experience of a University Hospital.

BACKGROUND: Treating chronic osteomyelitis of the lower extremities is challenging. The treatment of acute lower limb trauma by orthoplastic teams has shown good results over the past few decades. This study aimed to characterize surgical outcomes of leg and heel chronic osteomyelitis by an orthoplastic team. METHODS: The cases of 113 consecutive leg and heel chronic osteomyelitis patients undergoing soft-tissue reconstruction with an orthopedic procedure were reviewed in this retrospective single-center observational study. The main objective was to assess surgical outcomes of skin healing and gait recovery at the 1-year follow-up. The secondary objective was to evaluate the global success rate at the last follow-up. RESULTS: The median follow-up was 19.7 months. A free flap was performed for 33 patients (29.2 percent) and a locoregional flap was used in 79 patients (69.9 percent). Seventy-two patients (63.7 percent) had chronic osteomyelitis on continuous bone. The others had a septic pseudarthrosis with a mean bone defect length of 42.9 mm. Forty-four patients (38.9 percent) underwent curettage only, eight (7.1 percent) underwent curettage and cement, 20 (17.7 percent) underwent curettage and bone fixation, and 39 (34.5 percent) underwent the Masquelet technique. At the 1-year follow-up, 72 patients (63.7 percent) had achieved skin healing and had recovered their gait. The success rate at all follow-up time points was 82.3 percent. The median time to achieve skin healing was 6.5 months and that to bone union in cases of septic pseudarthrosis was 7.9 months. CONCLUSION: Orthoplastic management of leg and heel chronic osteomyelitis patients with combined soft-tissue reconstruction using an orthopedic procedure was a viable strategy that offered good results even though the time to complete healing was long. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Epicardial course of the septopulmonary bundle: Anatomical considerations and clinical implications for roof line completion.

BACKGROUND: Gaps in the roof line have been ascribed to epicardial conduction using the septopulmonary bundle. OBJECTIVES: We sought to evaluate the frequency of septopulmonary bundle bypass during roof line ablation, to describe anatomical conditions favoring this epicardial gap, and to propose an alternative strategy when present. METHODS: One hundred consecutive patients underwent atrial fibrillation ablation. A de novo roof line was created between the superior pulmonary veins. In cases of residual gaps, a floor line was created between the inferior pulmonary veins. Microtomography imaging and histological analyses of 5 human donor hearts were performed: a specific focus was made on the dome and the posterior wall. RESULTS: Residual gaps were more frequent in roof lines than floor lines (33% vs 15%; P = .049). Electrogram morphologies, activation sequences, and pacing maneuvers indicated an epicardial bypass of the roof line in all cases. Conduction block was obtained in 67 roof lines and 28 floor lines, resulting in a 95% success rate of linear block, without "box" isolation. Between the superior pulmonary veins, the atrial myocardium was thicker and consistently displayed adipose tissue separating the septopulmonary bundle from the septoatrial bundle. CONCLUSION: Epicardial conduction across the roof line is common and requires careful electrogram analysis to detect. In such cases, a floor line can be an effective alternative strategy, with clear validation criteria. Myocardial thickness and fat interposition may explain difficulties in achieving lesion transmurality during roof line ablation.

Efficacy, pain, and overall patient satisfaction with pediatric upper arm fracture reduction in the emergency department.

INTRODUCTION: Immediate closed reduction and cast immobilization performed under sedation in the emergency room is the mainstay management for most isolated displaced or angulated upper limb fractures in children. We aimed to determine if this approach is safe, effective and if patients, parents and staff are satisfied with this approach.Our working hypothesis was this management provides a high satisfaction rate. PATIENTS AND METHODS: Between January 2017 and October 2017 we included 118 children presenting with upper arm fractures amenable to closed reduction under our institutional analgesia protocol. Children received 0.4mg/kg of Oramorph oral solution, they were then evaluated 40minutes later, and if their Face Legs Activity Cry Consolability (for children under 16 years-old) and/or Visual Analog Scale (for children over 6 years-old) were under 4, they underwent closed reduction by an orthopaedic resident under Nitrous oxide. If their pain assessment scale was above 4, they received an extra 0.4mg/kg of Oramorph oral solution and underwent closed reduction 40minutes later under nitrous oxide. These children were managed without hospitalization, as outpatients. Children>6, families and nursing staff were also given a visual satisfaction scale (using a 1-10 score) just before being discharged from the ER in order to evaluate their experience. RESULTS: Closed reduction in the ER was judged satisfactory from an orthopedic point-of-view in 115 cases (97.6%). Parents, children and the nursing team gave the experience in the ER an average satisfaction score of 9 out of 10. CONCLUSION: ER reduction is not only safe and effective but is also associated with a high satisfaction rate amongst children, their families and the nursing staff.

Optimal postoperative immobilisation for supracondylar humeral fractures.

BACKGROUND: Supracondylar humeral fractures (SCHFs) are very common in paediatric patients. In France, percutaneous fixation with two lateral-entry pins is widely used after successful closed reduction. Postoperative immobilisation is typically with a long arm cast combined with a tubular-bandage sling that immobilises the shoulder and holds the arm in adduction and internal rotation to prevent external rotation of the shoulder, which might cause secondary displacement. The objective of this study was to compare this standard immobilisation technique to a posterior plaster splint with a simple sling. HYPOTHESIS: Secondary displacement is not more common with a posterior plaster splint and sling than with a long arm cast. MATERIAL AND METHODS: One hundred patients with extension Gartland type III SCHFs managed by closed reduction and percutaneous fixation with two lateral-entry pins between December 2011 and December 2015 were assessed retrospectively. Postoperative immobilisation was with a posterior plaster splint and a simple sling worn for 4 weeks. Radiographs were obtained on days 1, 45, and 90. RESULTS: Secondary displacement occurred in 8% of patients. No patient required revision surgery. DISCUSSION: The secondary displacement rate was comparable to earlier reports. Of the 8 secondary displacements, 5 were ascribable to technical errors. The remaining 3 were not caused by rotation of the arm and would probably not have been prevented by using the tubular-bandage sling. CONCLUSION: A posterior plaster splint combined with a simple sling is a simple and effective immobilisation method for SCHFs provided internal fixation is technically optimal. LEVEL OF EVIDENCE: IV retrospective observational study.