Anterior tibial perforators of the leg: anatomic and doppler study

Catedra Ortopedie şi TraumatologieRecently, the reconstructive surgery of the leg has been exploring the perforators these originating from the main arteries of the leg. Anterior tibial perforators, along with the peroneal and tibial posterior perforators serve for harvesting multiple perforator flaps, which are useful in the reconstruction of soft tissue defects. High individual variability of perforators justifies the use of Doppler examination in order to choose the most suitable perforator for flap harvesting. The aim of this study was to examine the anterior tibial perforators of the leg in 10 fresh cadavers and to compare these results with the results of Doppler ultrasound obtained in 10 patients scheduled for reconstructive surgery of the leg. The results of the study confirm that the localization and caliber of anterior tibial perforators differ considerably between cadaveric and Doppler groups, the phenomenon explained by a high anatomic individual variability, justifying preoperative Doppler examination in reconstructive surgery of leg defects. Ultimii ani chirurgia reconstructivă a gambei explorează larg perforantele originare din cele trei artere principale ale gambei. Perforantele tibiale anterioare, la fel ca cele peroneale şi cele tibiale posterioare servesc la modelarea multiplelor lambouri perforante utile pentru reconstrucţia defectelor de ţesuturi moi. Variabilitatea individuală a perforantelor justifică examinarea Doppler preoperatorii în vederea selectării perforantei potrivite pentru modelarea lamboului. Scopul acestui studiu a fost de a examina perforantele tibiale anterioare la 10 cadavre şi de a compara rezultatele cu cele ale examenului Doppler la 10 pacienţi care au beneficiat de reconstrucţia defectelor gambei. Rezultatele studiului au evidenţiat faptul că calibrul şi localizarea perforantelor tibiale anterioare diferă semnificativ între lotul cadaveric şi cel dopplerografic, fenomen explicat de variabilitatea anatomică, care de altfel, justifică examinarea Doppler preoperatorie în chirurgia reconstructivă a defectelor gambei

Reconstrucţia defectelor regiunii distale a membrului inferior cu lambouri perforante peroneale propeller

Perforator propeller flaps open a new era in the history of perforator flap reconstructive surgery. These represent a useful reconstructive tool at the level of distal third of the lower limb with good functional and esthetic results. However, should be mentioned that in the defi nition of propeller fl ap are involved only „perforator flaps which achieve the recipient site by an axial rotation”, a technique which implies a torsion of the vascular pedicle from 90° to 180°; factor which is responsible for one of the most frequent complication of these fl aps – venous congestion, that can resolve spontaneously but sometimes can progress to marginal or total flap necrosis. In this report we present a clinical series of 16 patients which beneficiated of reconstructive surgery at the level of distal third of the inferior limb with perforator peroneal propeller flaps.Перфорирующие винтовые лоскуты открыли новую страницу в реконструктивной хирургии. Они представляют собой полезный инструмент для реконструкции дистальных конечностей с хорошими функциональными и эстетическими результатами. Тем не менее, нужно учитывать, что в определение винтовых перфорирующих лоскутов будут включены только те лоскуты, кoторые мигрируются осевым движением. Это хирургическая техника включает скручивание сосудистой ножки с 90° до 180°, что способствует развитию наиболее распространенного осложнения – венозный застой, который иногда может разрешиться самостоятельно, но иногда приводит к развитию маргинального или тотального некроза лоскута. Мы представляем клиническое исследование, включающее 16 пациентов, которым реконструировали дефекты дистальных отделов нижней конечности, применяя перфорирующие малоберцовые винтовые лоскуты

Particularităţi de vascularizaţie şi hemodinamică a lamboului perforant (Revista literaturii)

Acest reviu literar aduce în discuţie unele aspecte privitor la particularităţile de vascularizaţie şi hemodinamică a lamboului perforant. Deasemenea este prezentat şi conceptul de angiosom precum şi conceptul mai nou de perfarosom

Planning and surgical treatment aspects of tissue defects of the leg with tibial posterior peforator flap

IMSP SCT şi O, Conferinţa Naţională în cadrul Asociaţiei Ortopezilor – Traumatologi din Republica Moldova ”Actualităţi în microchirurgia reconstructivă”, Chișinău, Republica MoldovaThere are many treatment alternatives for reconstruction of leg and foot defects. Perforator flaps in the lower leg enable reconstruction of a variety of local defects without microvascular anastomoses and with minimal donor-site morbidity and this fact is quite important thus there has been a trend of decreasing donor-site morbidity in the evolution of flap reconstruction. A detailed understanding of the blood flow of the leg region is essential for producing new alternatives for the reconstruction of defects in this region. That is why our choise was to performed Doppler examination in a series of patients to determine the number and diameter of perforator in this area. Perforator flaps are a new concept in nonmicrosurgical perforator flap reconstruction and flaps designed on the basis of perforator from posterior tibial artery can provide the desired soft-tissue support for defects that expose the bones and tendons.Există mai multe alternative de tratament pentru reconstrucţia defectelor piciorului şi gambei. Lambourile perfrante la nivelul gambei distale permit reconstrucţia unei varietăţi mari de defecte fără anastomoze microvasculare şi cu morbiditate minimală a locului donator, iar acest fapt este deosebit de important aşa cum în evoluţia reconstrucţiei cu lambouri există o tendinţă de a reduce morbiditatea locului donator. O înţelegere detaliată a fluxului sangvin în regiunea gambei este esenţială pentru a elabora noi alternative de reconstrucţie a defectelor acestei regiuni. De aceea alegerea noastră a fost ca la o serie de pacienţi să se realizeze examinarea Doppler în vederea determinării numărului şi calibrului perforantelor acestei regiuni. Lambourile perforante reprezintă un concept nou în chirurgia reconstructivă non-microchirurgicală iar lambourile modelate în baza perforantelor arterei tibiale posterioare pot asigura un suport tisular dorit pentru acoperirea defectelor cu expunere de oase şi tendoane

Effective method for treatment of atrophic pseudoarthrosis with leg shortening, associated with chronic osteomyelitis. Clinical case

Background. Even if nowadays there are described many techniques for treatment of chronic osteomyelitis, pseudarthrosis and defects of the tibial bone, this combination of pathologies till now represents a challenge for orthopedics surgeons. Every surgical techniques, which will allow shortening of the length recovery period and providing bone consolidation, will be recommended. Aim. to obtain a new technique for treatment of septic pseudarthrosis of the tibial bone with severe leg shortening associated with hematogenous osteomyelitis. Material and methods. This surgical technique was realized in a 29 years old patient. The patient is considered ill from the 18 months old, when was identified acute hematogenous osteomyelitis localized at the level of proximal epimethaphisis of the left tibial bone, with involvement of the bone growth region. During childhood, the patient supported a few surgical interventions for removal of the septic foci. At 10 years old was performed correction osteotomy of the tibial bone with plate and screws. At adulthood there was detected a shortening of the left leg with 7 cm when comparing with right leg. At 29 years old, the patient supported a tibial osteotomy at the level of distal metaphysis, osteotomy of the fibula at the level of diaphysis. With extra focal fixator bone fragments were distracted 10 mm daily. After 7 days, the extra focal fixator was removed and the tibial bone defect was filled with fibular auto-graft and alo-ransplantation, fixation with plate and kwires. Four months after surgery there was detected degradation of the material of osteosynthesis. Re-osteosynthesis was performed with plate. After 6 months clinical evolution was complicated with septic process and again there was detected degradation of material of osteosynthesis. The treatment used by us comprises removal of material of osteosynthesis, removal of grafts, sanitation of septic foci, adaptation of bone fragments and fixation with extra focal Ilizarov device. After 3 weeks at the level of the bone defects were introduced stem cells, which were harvested from posterior-superior spina iliaca. After this, daily bone fragments distraction was performed with 0,5 mm. During a period of 4 months after this procedure, the left leg was 65 mm longer. Percutaneously, in the region of regenerate there was injected a second dose of stem cells harvested from posterior-superior spina iliaca. Bone consolidation was confirmed after 9 months. Results. Using this technique of treatment there was obtained an elongation of the left leg with 65 mm. Total period of lengthening and bone consolidation was 14 months. Conclusion. The method of bone distraction associated with injection of stem cells is an effective method for obtaining bone elongation in condition of osteosclerosis and vascular disorders at the level of bone fragments subjected to distraction

Reconstrucţie nazală prin plastie italiană VS lambou frontal preexpansionat

Fiabilitatea lamboului frontal pentru reconstrucţii nazale a fost demonstrată prin utilizarea acestuia timp de secole. Însă, pe lângă avantaje, cum ar fi fiabilitatea, asemănarea tegumentului în termen de textură şi culoare, acesta are şi dezavantaje, cum ar fi limitarea lungimii lamboului de linia de creştere a părului, limitarea lăţimii paletei tegumentare, necesare pentru reconstrucţia treimii distale a nasului, dificultatea de închidere a zonei donore, datorită disponibilităţii limitate de tegument. Toate aceste neajunsuri pot fi depăşite prin preexpansiunea lamboului frontal cu expander tisular implantat în regiunea frontală. Metoda de reconstrucţie nazală prin lambou Tagliacozzi, cunoscută şi ca “plastie italiană”, este cunoscută din secolul XVI, oferind o cantitate mare de ţesut pentru reconstrucţii în care nu pot fi utilizate lambourile locale sau din imediata vecinătate

SURGICAL APPROACH IN PERIPROTHETIC HIP INFECTION. CLINICAL CASE

Universitatea de Stat de Medicină şi Farmacie „Nicolae Testemiţanu”, Chişinău, Republica MoldovaIntroducere. Artroplastia de revizie reprezintă tratamentul chirurgical al complicațiilor endoprotezării primare, cu scopul de a reduce durerea și a restabili funcția. Din datele literaturii indicațiile pentru revizia șoldului sunt: degradare aseptică (55%), instabilitate (15%), infecție (8%), fracturi periprotetice (6%) și altele. Scop. Prezentarea abordării chirurgicale în infecția periprotetică de șold al unui caz din cadrul Spitalului Clinic de Traumatologie și Ortopedie. Materiale și metode. Pacientului de 57 de ani, cu necroza aseptica de cap femural pe dreapta, i s-a efectuat artroplastie totală necimentată care ulterior s-a complicat septic. Artroplastie de revizie în 2 etape este metoda de tratament al complicațiilor septice, acceptată și utilizată pe larg de specialiștii din domeniu. Utilizarea unui spacer „hibrid” are efect antimicrobian local, menține lungimea membrului și anumite mișcări, ce are impact pozitiv la recuperarea ulterioară. Rezultate. La o lună postoperator a fost aplicată metoda DAIR (debridare, antibioticoterapie și reținerea implantului). La 3 luni postoperator au reapărut semnele de infecție, s-a efectuat prima etapă de revizie cu înlăturarea protezei primare și aplicarea unui spacer artizanal „hibrid” cu ciment osos încărcat cu antibiotice. La 6 luni postoperator s-a efectuat etapa a doua, artroplastie de revizie cu proteză cimentată. Concluzii. Artroplastia de revizie în două etape rămâne standardul de aur pentru infecțiile periprotetice. În pofida posibilităților ortopedice avansate în managementul infecției periprotetice fiecare artroplastie de revizie este o provocare pentru chirurgul ortoped și necesită o abordare multidisciplinară și complexă.Background. Revision arthroplasty is the surgical treatment of the primary endoprosthesis complications, in order to reduce pain and restore function. From the literature data, the indications for hip revision are: aseptic loosening (55%), instability (15%), infection (8%), periprosthetic fractures (6%) and others. Purpose. Presentation of the surgical approach in the periprosthetic hip infection of a case from the Clinical Hospital of Traumatology and Orthopedics. Methods and materials. A 57-year-old patient with aseptic necrosis of the right femoral head underwent total non-cement arthroplasty followed by septic complication. 2-stage revision arthroplasty is the method of septic complications treatment, accepted and widely used by specialists. The use of a „hybrid” spacer has a local antimicrobial effect, maintains limb length and certain movements, which has a positive impact on subsequent recovery. Results. At one month postoperatively, the DAIR method (debridement, antibiotic therapy, and implant retention) was applied. At 3 months postoperatively, the signs of infection reappeared, the first stage of revision was performed with the removal of the primary prosthesis and the application of a „hybrid” artisanal spacer with antibiotic-loaded bone cement. At 6 months postoperatively performed the second stage, revision arthroplasty with cemented prosthesis. Conclusion. Two-stage revision arthroplasty remains the gold standard for periprosthetic infections. Despite the advanced orthopedic possibilities in the management of periprosthetic infection, each revision arthroplasty is a challenge for the orthopedic surgeon and requires a multidisciplinary and complex approach

Тактические аспекты лечения инфекций в длинных трубчатых костях конечностей

Despite recent advances in medicine, particularly in the field of antibiotics and reconstructive surgery, the treatment of osteomyelitis remains complex and expensive. The standard treatment is antibiotic therapy and surgical treatment, which includes sanitation, removing the dead space, restoring the blood supply, adequate coverage of the soft tissues, stabilization and reconstruction. In this article is described the general classification of osteomyelitis by Cierny-Mader, as well as performed volume of treatment depending on the type of osteomyelitis in 223 patients.Несмотря на последние достижения в медицине, особенно в области антибиотиков и реконструктивной хирургии, лечение остеомиелитов остаётся сложным и дорогостоящим. Стандартное лечение осуществляется антибиотикотерапией и оперативным лечением, которое включает санацию, устранение мёртвого пространства, воcстановление кровоснабжения, адекватное покрытие мягких тканей, стабилизацию и реконструкцию. В статье описаны общие принципы классификации остеомиелитов по Cierny-Mader, а также выполненный объём лечения в зависимости от типа остеомиелита у 223 пациентов

Abordare chirurgicală în infecția periprotetică de șold. Caz clinic

Background. Revision arthroplasty is the surgical treatment of the primary endoprosthesis complications, in order to reduce pain and restore function. From the literature data, the indications for hip revision are: aseptic loosening (55%), instability (15%), infection (8%), periprosthetic fractures (6%) and others. Purpose. Presentation of the surgical approach in the periprosthetic hip infection of a case from the Clinical Hospital of Traumatology and Orthopedics. Methods and materials. A 57-year-old patient with aseptic necrosis of the right femoral head underwent total non-cement arthroplasty followed by septic complication. 2-stage revision arthroplasty is the method of septic complications treatment, accepted and widely used by specialists. The use of a „hybrid” spacer has a local antimicrobial effect, maintains limb length and certain movements, which has a positive impact on subsequent recovery. Results. At one month postoperatively, the DAIR method (debridement, antibiotic therapy, and implant retention) was applied. At 3 months postoperatively, the signs of infection reappeared, the first stage of revision was performed with the removal of the primary prosthesis and the application of a „hybrid” artisanal spacer with antibiotic-loaded bone cement. At 6 months postoperatively performed the second stage, revision arthroplasty with cemented prosthesis. Conclusion. Two-stage revision arthroplasty remains the gold standard for periprosthetic infections. Despite the advanced orthopedic possibilities in the management of periprosthetic infection, each revision arthroplasty is a challenge for the orthopedic surgeon and requires a multidisciplinary and complex approach.Background. Revision arthroplasty is the surgical treatment of the primary endoprosthesis complications, in order to reduce pain and restore function. From the literature data, the indications for hip revision are: aseptic loosening (55%), instability (15%), infection (8%), periprosthetic fractures (6%) and others. Purpose. Presentation of the surgical approach in the periprosthetic hip infection of a case from the Clinical Hospital of Traumatology and Orthopedics. Methods and materials. A 57-year-old patient with aseptic necrosis of the right femoral head underwent total non-cement arthroplasty followed by septic complication. 2-stage revision arthroplasty is the method of septic complications treatment, accepted and widely used by specialists. The use of a „hybrid” spacer has a local antimicrobial effect, maintains limb length and certain movements, which has a positive impact on subsequent recovery. Results. At one month postoperatively, the DAIR method (debridement, antibiotic therapy, and implant retention) was applied. At 3 months postoperatively, the signs of infection reappeared, the first stage of revision was performed with the removal of the primary prosthesis and the application of a „hybrid” artisanal spacer with antibiotic-loaded bone cement. At 6 months postoperatively performed the second stage, revision arthroplasty with cemented prosthesis. Conclusion. Two-stage revision arthroplasty remains the gold standard for periprosthetic infections. Despite the advanced orthopedic possibilities in the management of periprosthetic infection, each revision arthroplasty is a challenge for the orthopedic surgeon and requires a multidisciplinary and complex approach

Osteomielita cronică: protocol clinic național PCN-387

Catedra Ortopedie şi Traumatologie a USMF „Nicolae Testemiţanu”, secția Traumatologie și ortopedie septică și reconstructivă, IMSP Spitalul Clinic de Traumatologie și OrtopedieAcest protocol a fost elaborat de grupul de lucru comun al IMSP Spitalul Clinic de Traumatologie şi Ortopedie şi Catedrei de Ortopedie şi Traumatologie a USMF „Nicolae Testemiţanu” pentru elaborarea şi implementarea Protocoalelor clinice naţionale în traumatologie şi ortopedie. Protocolul naţional este elaborat în conformitate cu ghidurile internaționale actuale privind osteomielita cronică şi va servi drept bază pentru elaborarea protocoalelor clinice instituționale. La recomandarea MSMPS RM, pentru monitorizarea protocoalelor instituţionale pot fi folosite formulare suplimentare, care nu sunt incluse în protocolul clinic naţional