Microvascular reconstruction of traumatic compound bone and soft tissue defects of the tibia and ankle : Long-term patient-reported outcomes

Extensive compound fractures with bone and soft tissue defects or sequelae of prolonged complications in the tibia and the ankle region can be treated with microvascular reconstruction techniques in selected patients. The aim of this study was to assess the reliability and validity of the new Finnish version of the Lower Extremity Functional Scale (LEFS) among foot and ankle patients and to evaluate the reliability and long-term outcomes of microvascular iliac crest, latissimus dorsi scapula, and latissimus dorsi flap combined with Ilizarov distraction osteogenesis in the treatment of traumatic compound bone and soft tissue defects in the tibia and ankle region. First, the Finnish version of the LEFS was validated and psychometrically tested among 165 foot and ankle patients postoperatively. Second, 55 patients who had undergone free flap surgery to reconstruct compound defects of the lower leg were included in the study population. The first group of 26 patients was reconstructed using a free osteomuscular latissimus dorsi scapula flap in the treatment of extensive compound tibial fractures or prolonged traumatic complications. The second group consisted of 11 compound tibial fracture patients who were treated with a free latissimus dorsi flap combined with the Ilizarov bone transport technique to reconstruct absolute bone loss of the tibia, pseudarthrosis, or infected non-union, and a further five patients who underwent secondary tibial lengthening to correct limb-length discrepancy after latissimus dorsi free flap soft tissue reconstruction. The third group included 13 patients who underwent reconstruction using a free osteocutaneous iliac crest flap in treatment of extensive compound defect of the foot and ankle. Patient records were retrospectively reviewed. Thereafter, a cross-sectional long-term assessment was performed using patient-reported outcomes and clinical and radiological evaluations. The main conclusions drawn from these studies were as follows: 1) The Finnish version of the LEFS is a reliable and valid patient-reported outcome instrument to assess foot and ankle function. 2) The free osteomuscular latissimus dorsi scapula flap is a reliable option in the treatment of fragmented or comminuted compound tibial fractures and complicated traumatic compound tibial defects of both bone and soft tissue loss. Flap loss is rare: one of the 26 flaps was lost to infection, leading to late below-knee amputation. Full weight bearing and clinical fracture site stability can be achieved in a median of five months. The estimated median time to complete radiographic bone union is seven months. The long-term outcomes support the use of this technique for these indications. 3) The free latissimus dorsi flap soft tissue reconstruction combined with the bone transport using the Ilizarov technique is reliable in the treatment of massive soft tissue defects with absolute bone loss, pseudarthrosis, or infected non-union of the tibia. The bone lengthening of the tibia using the Ilizarov technique is suitable to correct limb-length discrepancy after free muscle flap reconstruction. Tissue stretching associated with the Ilizarov technique does not compromise the free flap. Long-term outcomes vary from reasonable to fair when these combined techniques are used to reconstruct traumatic compound defects of the tibia. 4) The free osteocutaneous iliac crest flap is a reliable option in reconstruction of extensive traumatic compound defects of bone and soft tissue in the foot and ankle and in achieving ankle arthrodesis. In one of the 13 patients, late below-knee amputation was performed due to chronic pain of the reconstructed ankle. One graft never achieved union. Full weight bearing and clinical stability of the reconstructed site can be achieved in a median of five months. The estimated median time to radiological bone union is considered to be 22 months. The long-term outcomes are acceptable taking into consideration the high risk of amputation and the severity of these rare pathologies. There is a slight risk of donor site morbidity when raising the free iliac crest flap.Mikrokirurgisten hoitomenetelmien tavoitteena on paras mahdollinen toimintakyky sekä terveyteen liittyvä elämänlaatu laajojen avomurtumien sekä murtuman jälkeisten pitkittyneiden komplikaatioiden hoidossa. Tutkimuksen tavoitteena oli selvittää Lower Extremity Functional Scale (LEFS) -alaraajan toimintakykymittarin suomenkielisen käännöksen luotettavuutta ja validiteettia jalkaterän ja nilkan leikkausten jälkeisessä arviossa. Tavoitteena oli myös arvioida mikrovaskulaarisen latissimus dorsi scapula - luu-lihaskielekkeen toimivuutta sääriluun avomurtumien ja niiden myöhäiskomplikaatioiden hoidossa. Lisäksi tutkimuksessa pyrittiin arvioimaan mikrovaskulaarisen latissimus dorsi (LD) -lihaskielekkeen ja Ilizarovin luunvenytystekniikan luotettavuutta ja pitkäaikaistuloksia laajan sääriluun avomurtuman hoidossa sekä luunpidennystä raajan pituuseron korjauksessa. Viimeisenä tavoitteena oli tarkastella mikrovaskulaarisen suoliluun harjun etuosan luu-ihokielekkeen toimivuutta jalkaterän ja nilkan luu-pehmytkudosvaurioiden korjauksessa. Ensimmäisessä osiossa LEFS-mittarin suomenkielisen version luotettavuus ja validiteetti testattiin 165 potilaalla, joille oli suoritettu jalkaterän tai nilkan leikkaus. Osatöiden II-IV otanta koostui kolmen erilaisen potilasryhmän 55 potilaasta, joille oli suoritettu sääriluun, jalkaterän tai nilkan rekonstruktio laajan yhdistelmäkudosvaurion hoitona mikrokirurgisilla menetelmillä. Tutkimus sisälsi takautuvan potilasasiakirjakatsauksen, poikkileikkaustutkimuksen siitä miten potilas itse kokee sen hetkisen tilanteensa sekä kliinisiä ja radiologisia arviointeja. Terveyteen liittyvää elämänlaatua verrattiin osatöissä III ja IV ikä- ja sukupuolivakioituun suomalaiseen verrokkiväestöön. Tulosten perusteella voidaan todeta että suomenkielinen LEFS -alaraajan toimintakykymittari on luotettava ja validi jalkaterän ja nilkan toimintakyvyn arvioimisessa. Latissimus dorsi -lihaskieleke yhdistettynä osaan lapaluun ulkoreunaa on luotettava tekniikka sääriluun avomurtumien ja myöhäiskomplisoituneiden luu-pehmytkudospuutosten hoidossa. Yksi siirre menetettiin (1/26). Täysipaino-varaus ja kliininen luun stabiliteetti saavutettiin viidessä kuukaudessa. Täydellinen radiologinen luutuminen kesti keskimäärin seitsemän kuukautta. Ilizarovin menetelmä on luotettava tekniikka yhdistettynä LD-lihaskielekerekonstruktioon hoidettaessa säären laajoja traumaattisia luu-pehmytkudospuutoksia ja niiden pitkäaikaiskomplikaatioita sekä raajojen pituuseron korjaamisessa kielekerekonstruktion jälkeen. Täysipainovaraus ja luun kliiininen stabiliteetti saavutettiin keskimäärin viidessä kuukaudessa. Täydellinen radiologinen luutuminen kesti keskimäärin 23 kuukautta. Uutta luuta saatiin muodostettua keskimäärin 3,8 cm. Mikrovaskulaarisen anteriorisen suoliluun harjun luu-ihokielekkeen käyttäminen osoittautui hyväksi vaihtoehdoksi jalkaterän ja nilkan alueen laajojen traumaattisten luu-pehmytkudospuutosten hoidossa.Yhdelle (1/13) potilaalle tehtiin myöhemmin amputaatio kroonisen rekonstruktiokohdan kivun takia. Keskimääräinen aika radiologiseen luutumiseen oli 22 kuukautta. Yhdellä potilaalla (1/13) siirre ei luutunut. Toiminnalliset pitkäaikaistulokset ja terveyteen liittyvä elämänlaatu ovat yleensä hyvät, kun ottaa huomioon näiden harvinaisten traumaattisten kudospuutosten vaikeusasteen. Siirteen ottokohdan morbiditeetti on hyväksyttävä

Traumatic Rupture and Herniation of the Peroneus Tertius Muscle Leading to Compartment Syndrome and Entrapment of the Superficial Peroneal Nerve : A Case Report

We present a patient with compartment syndrome and entrapment of the superficial peroneal nerve due to a direct hit to the lateral part of the right lower extremity. The diagnosis of evolving compartment syndrome was made without delay and the patient was quickly taken to the operating theater. Intraoperatively, the entrapment of the superficial peroneal nerve caused by rupture and herniation of the peroneus tertius muscle was surprisingly observed at the site, where the nerve pierces the anterior compartment. The nerve was successfully released in conjunction with fasciotomies of the anterior and lateral compartments. Meticulous diagnosis of compartment syndrome is critical to prevent ischemic injury to muscles and nerves. Recognition of anatomy and anatomical variations is important to prevent iatrogenic injury in unusual circumstances.Peer reviewe

Health-Related Quality of Life After Breast Reconstruction : Comparing Outcomes Between Reconstruction Techniques Using the BREAST-Q

Background Reconstruction of the breast following mastectomy can improve patients' health-related quality of life (HRQL). We aimed to assess HRQL in women after mastectomy and breast reconstruction and to identify differences in HRQL related to the reconstruction method used. Methods A cross-sectional study was performed on patients who had undergone breast reconstruction in Helsinki University Hospital between 08/2017 and 7/2019. The postoperative HRQL was assessed using the BREAST-Q (2.0) Reconstruction Module. The results were compared between patients with different reconstruction methods using the Kruskal-Wallis test. Results A total of 146 patients were identified. Microvascular flaps (n = 77) were the most common method for primary breast reconstruction, followed by latissimus dorsi (LD) flaps (n = 45), fat grafting (n = 18) and implant reconstruction (n = 6). The satisfaction with breasts was high in all groups (median 61, IQR 49-71). The physical well-being of the chest was high regardless of the reconstructive method (median 100, IQR 80-100). However, women with fat grafting reported more adverse effects of radiation (median 17, IQR 14-17 vs. 18, IQR 17-18 for other groups, p = 0.02). Donor site morbidity was low, and patients reported high satisfaction with the back (median 66/100, IQR57-90) and abdomen (median 9/12, IQR 8-10), and physical well-being of the back (median 61/100, IQR 53-70) and abdomen (median 65/100, IQR 60-86). Conclusions The patient-reported HRQL after breast reconstruction is high. Most women report being satisfied with the reconstruction, irrespective of the reconstruction method used. The reconstruction method can thus be chosen individually in cooperation between the patient and the surgeon.Peer reviewe

Facile synthesis of vanillin from fractionated Kraft lignin

More than 90 % of global lignin production comes from Kraft pulp mills but due to shortage of economical viable methods to valorise lignin, it is commonly burned for energy. Therefore, finding new routes to utilize Kraft lignin (KL) as a renewable raw material for the chemical industry is of significant economic and environmental importance. Herein we report a novel, two-step procedure for facile synthesis of vanillin from technical KL by combining solvent fractionation and catalytic oxidation reaction. From the studied green solvents, 1-propanol was the most attractive for one-step, single solvent fractionation as it afforded uniform, low molecular weight lignin fractions (Mw=1300 g·mol−1, Mn=580 g·mol−1) with yield of 46 wt%. Using this homogeneous lignin as a raw material, CuSO4 catalyzed oxidation reaction proceeds smoothly, and under optimized conditions a high vanillin yield of 10.9 wt% was achieved. The method reported herein is promising as it facilitates straightforward and high yield vanillin synthesis from commercially available technical KL.Peer reviewe

Validation of the Finnish FACE-Q for use in patients undergoing surgery for functional problems or malignancy

The aim of this study was to produce a Finnish version of the FACE-Q scales Satisfaction with Forehead and Eyebrows, Adverse effects: Forehead, Eyebrows and Scalp, and Adverse effects: Cheeks, Lower face and Neck, and assess the performance of these scales and the Satisfaction with Facial Appearance, Satisfaction with Outcome and Appearance-related Psychosocial Distress in patients who had undergone surgery for functional problems or malignancy affecting the forehead or cheeks. The general health-related outcomes instrument 15 D was used as a reference. Patients who had undergone a frontal lift, a direct brow lift, a facelift or an excision of a facial tumor in Helsinki University Hospital plastic surgery department in 2009-2019 were identified. A postal survey study was conducted with 305 patients, of whom 135 (44%) responded. Diagnoses included facial nerve dysfunction (53%), brow ptosis (21%) and skin, mucosal or salivary gland tumor (20%). The FACE-Q scales displayed high internal consistency (Cronbach's alphas >= 0.80) and good reliability on repeat administration. The exploratory factor analysis revealed unifactorial influences for all scales except the Adverse effects: Forehead, Eyebrows and Scalp. Weak correlations with 15 D dimensions were detected. The FACE-Q scales evaluated here are suitable for use in patients with functional problems or malignancy.Peer reviewe

Association between sagittal spinal alignment and mechanical complications after primary total hip arthroplasty : a systematic review

Objective: Total hip arthroplasty (THA) affects pelvic posture and spinal alignment. These postural changes may further predispose patients to mechanical complications (MCs) after THA. The aim of this study was to conduct a systematic review to investigate whether any high-quality studies have assessed the association between sagittal spinal alignment and MCs after primary THA. Methods: Inclusion criteria for studies were adult patients (age ≥18 years), primary THA, pre- and postoperative spinopelvic standing sagittal radiographs acquired preoperatively and at a minimum of 6-month follow-up, measurements of spinopelvic parameters, and reporting of possible MCs after THA. The review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Results: Six articles met the inclusion criteria. Although several studies confirmed the importance of spinal alignment when planning THA, these mainly investigated pelvic mobility as a risk factor for THA dislocation. Radiological follow-up imaging practices varied, and studies focused on different individual spinopelvic parameters. Conclusion: Based on our study findings, no conclusions can be drawn regarding the association between sagittal spinal alignment and MCs after primary THA. Further research is needed to improve our knowledge of the connection between MCs after THA and sagittal spinal alignment.publishedVersionPeer reviewe

Longitudinal Validity and Minimal Important Change for the Modified Lower Extremity Functional Scale (LEFS) in Orthopedic Foot and Ankle Patients

The lower extremity functional scale (LEFS) is a patient-reported outcome measure for lower extremity disorders. Aim of this study was to assess the longitudinal validity including responsiveness and test-retest reliability of the revised 15-item version, and to define the minimal important change (MIC) of the modified LEFS in a generic sample of orthopedic foot and ankle patients who underwent surgery. Responsiveness, effect size, and standardized response mean were measured by determining the score change between the baseline and 6 months administration of the LEFS from 156 patients. There was no significant difference between preoperative (median 78, interquartile range [IQR] 64.2-90.3) and postoperative (median 75.0, IQR 61.7-95.0) scores. Both effect size and standardized response mean were low (0.06 and 0.06, respectively). Test-retest reliability of the LEFS was satisfactory. Intraclass correlation coefficient was 0.85 (95% confidence interval 0.81-0.88). MIC value could not be estimated due to the lack of significant score change. The modified LEFS presented with relatively low longitudinal validity in a cohort of generic orthopedic foot and ankle patients. The findings of this study indicate that the modified LEFS might not be the optimal instrument in assessing the clinical change over time for these patients. (c) 2021 The Author(s). This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/)Peer reviewe

Structural and Construct Validity of the Foot and Ankle Ability Measure (FAAM) With an Emphasis on Pain and Functionality After Foot Surgery : A Multicenter Study

The Foot and Ankle Ability Measure (FAAM) is a patient-reported outcome measure that is available in several languages. We aim to assess the structural and construct validity of the FAAM with an emphasis on pain and functionality after foot surgery. The activities of daily living (ADL) and Sports subscales of the Finnish version of the FAAM were completed by 182 patients who underwent operative treatment for disorders of the foot. Convergent validity was assessed by principal component analysis using Spearman's correlation coefficient between the FAAM subscales and the principal components (Function-PC and Pain-PC) derived from validated patient-reported outcome measures. Subscales were studied for floor and ceiling effects, internal consistency and unidimensionality. Internal consistency was examined with Cronbach's alpha and the subscale structure with exploratory factor analysis. FAAM-ADL had high correlation with the Function-PC (r = 0.87, 95% confidence interval [CI] 0.81-0.91) and the Pain-PC (r = 0.75, 95% CI 0.65-0.83). FAAM-Sports had moderate correlation (r = 0.64, 95% CI 0.50-0.74) with the Function-PC and high correlation (r = 0.74, 95% CI 0.64-0.82) with the Pain-PC. No floor or ceiling effects were observed. Cronbach's alpha was 0.97 (95% CI 0.96-0.98) for the ADL and 0.93 (95% CI 0.91-0.95) for the Sports subscales. The results supported the unidimensionality of the FAAM-Sports. Within the ADL subscale, 3 factors were identified, suggesting a 3-factor model for the FAAM overall. Results highlighted the inter-relationship of pain and physical function. Further research on longitudinal validity is needed. (C) 2021 The Author(s).Peer reviewe

Application of the FACE-Q rhinoplasty module in a mixed reconstructive and corrective rhinoplasty population in Finland

The FACE-Q Rhinoplasty module is a patient-reported outcome instrument developed for the assessment of primarily aesthetic outcomes of rhinoplasty. The aim of our study was to produce a Finnish version of the instrument and validate it for use in patients undergoing nasal reconstruction as well as those treated with a rhinoplasty. Finnish versions of the FACE-Q scales Satisfaction with Nose, Satisfaction with Nostrils and Adverse Effects: Nose, were translated following established guidelines. Patients undergoing nasal resection, reconstruction or rhinoplasty in Helsinki University Hospital plastic surgery department in 2009-2019 were identified using theatre records. A total of 240 Finnish-speaking patients 18-85 years old were approached with a postal survey questionnaire. The questionnaire included the translated FACE-Q modules and those for Satisfaction with Facial Appearance, Appearance-Related Psychosocial Distress and Satisfaction with Outcome, as well as the general health-related quality of life instrument 15 D. The FACE-Q scales translated readily to Finnish. Eighty-three patients (35%) responded to the survey. Most FACE-Q scales performed well with high internal consistency (Cronbach's alphas 0.87-0.92) and repeatability. Only the Adverse Effects: Nose scale displayed poor consistency and a floor effect with 18% of the patients reporting no adverse outcomes. Answers to the Appearance-Related Psychosocial Distress scale were skewed towards no experienced stress. Answers to the other scales were normally distributed with weak correlation with 15 D dimensions. The Finnish translations of the FACE-Q Rhinoplasty scales perform well at assessing a diverse group of patients including those undergoing nasal reconstruction as well as those undergoing rhinoplasty.Peer reviewe

Reliability and validity of the Finnish version of the Lower Extremity Functional Scale (LEFS)

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