Coverage of exposed hardware after lower leg fractures with free flaps or pedicled flaps

Abstract. – OBJECTIVE: The placement of osteosynthetic materials in the leg may be complicated by hardware exposure. Successful soft tissue reconstruction often provides a critical means for limb salvage in patients with hardware exposure in the leg. Free flaps are currently considered the standard surgical procedure for soft tissue coverage of the wounds with internal hardware exposure. However, to date, no conclusive literature shows the superiority of a specific type of flap. MATERIALS AND METHODS: The current review compares data from the literature concerning outcomes and complications of free and pedicled flaps for exposed osteosynthetic material preservation in the leg. RESULTS: A total of 81 cases from twelve different articles presenting internal hardware exposure of the leg were analyzed in our study. Thirty-two patients underwent immediate reconstructive surgery with pedicled flaps, while forty-nine patients underwent free flap reconstruction. The overall survival rate for pedicled flaps was 96.77%, while for free flaps it was 97.77%. The overall implant preservation rate was 78.12% for pedicled flaps and 53.33% for free flaps. With reference to postoperative complications, the overall complication rate was 46.87% for pedicled flaps and 10.20% for free flaps. CONCLUSIONS: No significant difference was found in terms of overall flap survival. However, a significant difference was found regarding successful implant preservation (78.12% in the pedicled flap group vs. 53.33% in the free flap group). In particular, the first observation appears to be in contrast with the current trend of considering the free flaps the first choice procedure for soft tissue coverage of the wounds with internal hardware exposure. Nevertheless, a higher occurrence of postoperative complications was observed in the pedicled flap group (46.87% vs. 10.20%). The choice of the most appropriate reconstructive procedure should take into account several issues including the size of the wounds with internal hardware exposure, the possibility of soft tissue coverage with pedicled flaps, the availability of recipient vessels, general conditions of the patients (such as age, diabetes, smoking history), patients’ preference and presence of a microsurgical team. However, according to the results of this review, we believe that pedicled flap reconstruction should be reconsidered as a valid alternative procedure for skin tissue loss with hardware exposure whenever it is possible

Vertical rectus abdominis myocutaneous versus alternative flaps for perineal repair after abdominoperineal excision of the rectum in the era of laparoscopic surgery

Aims: Plastic surgical reconstruction of the perineum is often required after abdominoperineal excision of the rectum. Options for this reconstruction include a vertical rectus abdominis myocutaneous (VRAM) flap, gluteal fasciocutaneous flap, and gracilis myocutaneous flap. Although the VRAM flap is well established at most centers, less experience exists with the gluteal and gracilis flaps. In the era of laparoscopic colorectal resection, plastic surgeons are being forced to use gluteal and gracilis flaps because the VRAM flap must be tunnelled intra-abdominally requiring laparotomy. We therefore aimed to systematically review the evidence comparing VRAM, gluteal, and gracilis flaps. Methods: A comprehensive, structured literature search was conducted using Medline, Google Scholar, and Science Direct. Studies included were randomized control trials and observational studies documenting complication rates associated with the VRAM, gluteal, or gracilis flap. Results: Eleven studies meeting all inclusion and exclusion criteria were identified. When meta-analyzed, the overall rate of any perineal wound or flap complication among VRAM patients (35.8%) was significantly lower than gluteal flap (43.7%) and gracilis flap patients (52.9%) (P = 0.041). Conclusions: The VRAM flap is well established for perineal reconstruction, and this study suggests that it may be superior to the gluteal and gracilis flaps in terms perineal wound and flap complication rates. This should be taken into account when weighing up the risks and benefits of a laparoscopic approach to abdominoperineal excision of the rectum. Large studies making direct comparisons between the flap options should be conducted

Improvement of the Rotation Arch of the Posterior Interosseous Pedicle Flap Preserving Both Reverse Posterior and Anterior Interosseous Vascular Sources.

Abstract PURPOSE: The reverse posterior interosseous artery flap has several advantages, not sacrificing any major blood vessel, but its relatively short pedicle limits the use to cover defects up to the metacarpophalangeal joint. Our purpose is to demonstrate that the ligature of the anterior interosseous artery (AIA), proximal to the communicating branch with the posterior interosseous artery, leads to an improved flap rotation arch, preserving both vascular sources. METHODS: Sixteen fresh cadavers with latex perfusion were analyzed before and after our technique of elongation, and the so-obtained measures were standardized in "percentage of elongation of the pedicle." Eight patient with the loss of substance at the dorsal aspect of the hand have been treated with this technique, and results were evaluated in terms of flap survival and complication rates. RESULTS: The medium length of the pedicle in the normal flap was 10.8\u2009cm, and after the section of the AIA, the medium length of the pedicle was 13.6\u2009cm with a medium increase of 2.8\u2009cm. It means a medium increase of 24% of the length of the pedicle. In all patients treated, full coverage of the defect was obtained, and we did not experience major complications. CONCLUSIONS: This anatomical study supported by our clinical experience demonstrates that the use of the variant described above permits to reach more distal part of the hand without being afraid to stretch the pedicle because of the connection with the anastomotic arcades of the AIA at the wrist reducing the risk of ischemia of the flap

Use of a biomechanical tongue model to predict the impact of tongue surgery on speech production

This paper presents predictions of the consequences of tongue surgery on speech production. For this purpose, a 3D finite element model of the tongue is used that represents this articulator as a deformable structure in which tongue muscles anatomy is realistically described. Two examples of tongue surgery, which are common in the treatment of cancers of the oral cavity, are modelled, namely a hemiglossectomy and a large resection of the mouth floor. In both cases, three kinds of possible reconstruction are simulated, assuming flaps with different stiffness. Predictions are computed for the cardinal vowels /i, a, u/ in the absence of any compensatory strategy, i.e. with the same motor commands as the one associated with the production of these vowels in non-pathological conditions. The estimated vocal tract area functions and the corresponding formants are compared to the ones obtained under normal condition

Reconstruction of maxillofacial bone defects: Contemporary methods and future techniques

Reconstruction of maxillofacial continuity defects has always been a challenging tasks for the scientist and surgeons over the years. The main goal of the reconstruction of the maxillofacial region is to restore facial form, function, full rehabilitation of occlusion and articulation. A refinement in surgical technique and methods of reconstruction has improved patient’s quality of life. This manuscript reviewed exciting methods of bone reconstruction and confirms that the ideal system for reconstruction of critical size continuity defect of the jaw bones has yet to be found. Shortcoming and limitation of each method has been discussed. The author highlight recent advances on how tissue engineering which could offer biological substitute to restore, maintain, or improve oro-facial function

The axillary approach to raising the latissimus dorsi free flap for facial re-animation: a descriptive surgical technique

The latissimus dorsi flap is popular due to the versatile nature of its applications. When used as a pedicled flap it provides a robust solution when soft tissue coverage is required following breast, thoracic and head and neck surgery. Its utilization as a free flap is extensive due to the muscle's size, constant anatomy, large caliber of the pedicle and the fact it can be used for functional muscle transfers. In facial palsy it provides the surgeon with a long neurovascular pedicle that is invaluable in situations where commonly used facial vessels are not available, in congenital cases or where previous free functional muscle transfers have been attempted, or patients where a one-stage procedure is indicated and a long nerve is required to reach the contra-lateral side. Although some facial palsy surgeons use the trans-axillary approach, an operative guide of raising the flap by this method has not been provided. A clear guide of raising the flap with the patient in the supine position is described in detail and offers the benefits of reducing the risk of potential brachial plexus injury and allows two surgical teams to work synchronously to reduce operative time

Management of skin-sparing mastectomy: Results of a survey of German Hospitals

Background: The aim of this study was to evaluate the current management of skin-sparing mastectomy in German hospitals and to determine its oncologic safety. For this purpose, 100 surgeons were surveyed regarding their use of skin-sparing mastectomy. Results: Almost all surveyed hospitals performed skin-sparing mastectomy. Most of them believe that the recurrence rate is equal to that of conventional mastectomy. 95% regard inflammatory cancer as a contraindication to skin-sparing surgery. Most of the hospitals thin out the skin without leaving any macroscopic glandular tissue behind, and 73% leave the nipple-areola complex (NAC) on the basis of frozen sections. Volume replacement is most commonly done with latissimus dorsi muscle flaps and pedicled TRAM flaps. In 76% of the surveyed hospitals, reconstruction after mastectomy is performed by the gynecological department. Conclusion: Skin-sparing mastectomy is considered to be the best cosmetic option for breast reconstruction in selected breast cancer patients. At present, statistical proof of its oncologic safety is lacking. The surgical techniques used for skin-sparing mastectomy have not yet been standardized. In order to achieve standardization, careful discussion-making and evaluation remain important

Versatility of Bicoronal flap approach in Head and neck surgeries

Bicoronal approach popularised by Tessier is one of the versatile approaches for skulland frontal region (1-6).In this article we present our experience regarding Bicoronal flapapproach in 3 different cases. Each patient had different pathologies in frontal region forwhich the same approach had been used. We also describe in detail about the incision, itsindications and contra indications, advantages and disadvantages. Incision was made in hairbearing area. Hence post operatively, cosmetic results were appealing in all the patients 9. Itpreserves the supraorbital neurovascular bundle, so complaints related to that are avoided. Inthis article, we discuss about the individual patient, merits and demerits of this particularapproach in each patient. 

Building a Bird: Musculoskeletal Modeling and Simulation of Wing-Assisted Incline Running during Avian Ontogeny

Flapping flight is the most power-demanding mode of locomotion, associated with a suite of anatomical specializations in extant adult birds. In contrast, many developing birds use their forelimbs to negotiate environments long before acquiring “flight adaptations,” recruiting their developing wings to continuously enhance leg performance and, in some cases, fly. How does anatomical development influence these locomotor behaviors? Isolating morphological contributions to wing performance is extremely challenging using purely empirical approaches. However, musculoskeletal modeling and simulation techniques can incorporate empirical data to explicitly examine the functional consequences of changing morphology by manipulating anatomical parameters individually and estimating their effects on locomotion. To assess how ontogenetic changes in anatomy affect locomotor capacity, we combined existing empirical data on muscle morphology, skeletal kinematics, and aerodynamic force production with advanced biomechanical modeling and simulation techniques to analyze the ontogeny of pectoral limb function in a precocial ground bird (Alectoris chukar). Simulations of wing-assisted incline running (WAIR) using these newly developed musculoskeletal models collectively suggest that immature birds have excess muscle capacity and are limited more by feather morphology, possibly because feathers grow more quickly and have a different style of growth than bones and muscles. These results provide critical information about the ontogeny and evolution of avian locomotion by (i) establishing how muscular and aerodynamic forces interface with the skeletal system to generate movement in morphing juvenile birds, and (ii) providing a benchmark to inform biomechanical modeling and simulation of other locomotor behaviors, both across extant species and among extinct theropod dinosaurs