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

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)

Unusual explosive growth of a squamous cell carcinoma of the scalp after electrical burn injury and subsequent coverage by sequential free flap vascular connection – a case report

BACKGROUND: Squamous cell carcinomos may arise from chronic ulcerating wounds in scars, most commonly postburn scars. Tumour growth usually takes place over months to years. Localization on the scalp is a relatively rare condition. CASE PRESENTATION: This report presents the case of a 63-year-old man with chronic ulceration of a postburn scar of the scalp due to an electrical burn 58 years ago. Sudden tumour growth started within weeks and on presentation already had extended through the skull into frontal cortex. After radical tumour resection, defect was covered with a free radial forearm flap. Local recurrence occurred 6 weeks later. Subsequent wide excision including discard of the flap and preservation of the radial vessels was followed by transfer of a free latissimus dorsi muscle flap, using the radial vessels of the first flap as recipient vessels. The patient received radiotherapy post-operatively. There were no problems with flap survivals or wound healing. Due to rapidly growing recurrence the patient died 2 months later. CONCLUSION: Explosive SCC tumour growth might occur in post-burn scars after more than 50 years. As a treatment option the use of sequential free flap connections might serve in repeated extensive tumour resections, especially in the scalp region, where suitable donor vessels are often located in distance to the defect

Complex reconstructions in head and neck cancer surgery: decision making

Defects in head and neck after tumor resection often provide significant functional and cosmetic deformity. The challenge for reconstruction is not only the aesthetic result, but the functional repair. Cancer may involve composite elements and the in sano resection may lead to an extensive tissue defect. No prospective randomized controlled studies for comparison of different free flaps are available. There are many options to cover defects and restore function in the head and neck area, however we conclude from experience that nearly all defects in head and neck can be closed by 5 different free flaps: radial forearm flap, free fibula flap, anterior lateral thigh flap, lateral arm flap and parascapular flap

Closed reduction and percutaneus Kirschner wire fixation for the treatment of dislocated calcaneal fractures: surgical technique, complications, clinical and radiological results after 2–10 years

Introduction To reduce complications, a minimally invasive technique for the treatment of dislocated intraarticular fractures of the calcaneus was used. Therefore previously described closed reduction and internal fixation techniques were combined and modified. Materials and methods Sixty-seven out of 92 calcaneal fractures could be retrospectively evaluated with an average follow-up time of 5.7 years (minimum 2-10 years follow-up). For radiographic evaluation, plain radiographs and CT scans were obtained. The Zwipp score was used for clinical evaluation. Sanders type II, III and IV fractures were diagnosed. Results Length of surgery averaged 61 min (range 20-175 min). The incidence of subtalar arthritis was correlated to the severity of fracture. Bohler's angle was restored in 70.1% (47 of 67) of the cases. On the last follow-up evaluation the average Zwipp score was 130 points (range 48-186 points). The majority (77.7%) of patients were content with their treatment result. The rate of significant complications was 6.5%. Discussion Compared to open techniques the presented minimally invasive technique showed comparable results with a low rate of serious complications and is a viable alternative for the treatment of intraarticular, dislocated calcaneal fractures

Female Urethral Reconstruction

Female urethral strictures are rare; thus, the literature describing stricture management in women is sparse. Although urethral dilation continues to be performed at a high frequency in women despite lack of proven efficacy, this procedure is used for a variety of voiding complaints other than stricture. Hence, the long-term utility of dilation and urethrotomy for urethral stricture in women is unknown. This review describes the various urethroplasty techniques used in the management of female urethral stricture. Although grafts using a dorsal approach have been shown to be feasible in women, ventral flap techniques offer good long-term outcomes with minimal morbidity. Acute and delayed management of pelvic fracture–associated urethral distraction defects in women is also described. Unlike in men, immediate urethroplasty in women should be performed once the patient is hemodynamically stable

The Gracilis Myocutaneous Free Flap: A Quantitative Analysis of the Fasciocutaneous Blood Supply and Implications for Autologous Breast Reconstruction

BACKGROUND: Mastectomies are one of the most common surgical procedures in women of the developed world. The gracilis myocutaneous flap is favoured by many reconstructive surgeons due to the donor site profile and speed of dissection. The distal component of the longitudinal skin paddle of the gracilis myocutaneous flap is unreliable. This study quantifies the fasciocutaneous vascular territories of the gracilis flap and offers the potential to reconstruct breasts of all sizes. METHODS: Twenty-seven human cadaver dissections were performed and injected using lead oxide into the gracilis vascular pedicles, followed by radiographic studies to identify the muscular and fasciocutaneous perforator patterns. The vascular territories and choke zones were characterized quantitatively using the 'Lymphatic Vessel Analysis Protocol' (LVAP) plug-in for Image J® software. RESULTS: We found a step-wise decrease in the average vessel density from the upper to middle and lower thirds of both the gracilis muscle and the overlying skin paddle with a significantly higher average vessel density in the skin compared to the muscle. The average vessel width was greater in the muscle. Distal to the main pedicle, there were either one (7/27 cases), two (14/27 cases) or three (6/27 cases) minor pedicles. The gracilis angiosome was T-shaped and the maximum cutaneous vascular territory for the main and first minor pedicle was 35 × 19 cm and 34 × 10 cm, respectively. CONCLUSION: Our findings support the concept that small volume breast reconstructions can be performed on suitable patients, based on septocutaneous perforators from the minor pedicle without the need to harvest any muscle, further reducing donor site morbidity. For large reconstructions, if a 'T' or tri-lobed flap with an extended vertical component is needed, it is important to establish if three territories are present. Flap reliability and size may be optimized following computed tomographic angiography and surgical delay