Background: Skin grafting is one of the simplest techniques of providing skin cover following enbloc resection of soft tissue sarcomas on extremities. But many authors have questioned the tolerance of skin graft to post operative radiotherapy. Aim: To assess the integrity of skin grafts following post operative radiotherapy for soft tissue sarcomas on extremities. Material and methods: During the period between 1997 and 2003, 10 patients received postoperative external beam radiotherapy following excision of soft tissue sarcomas on extremities and skin grafting at this regional soft tissue sarcoma unit. Age of these patients ranged from 26 years to 92 years. Malignant fibrous histiocytoma was the commonly encountered tumour. Commonest site of resection and skin grafting was lower leg. These patients were analysed for interval between skin grafting and radiotherapy, dose, type and fractions of radiation, break in radiotherapy, adjuvant chemotherapy and effect of radiation on skin graft. Results: One patient developed moist desquamation and two developed dry desquamation during the course of treatment. All acute skin reactions were healed within 3 weeks of completion of radiotherapy. No patients required further soft tissue reconstruction. Conclusion: Adjuvant external beam radiotherapy can be delivered to skin-grafted areas on extremities following enbloc excision of soft tissue sarcomas without any major complications. Our experience indicates that the radiation reaction can be minimised if the graft is allowed to heal adequately prior to the initiation of radiotherapy

Background: Skin grafting is one of the simplest techniques of providing skin cover following enbloc resection of soft tissue sarcomas on extremities. But many authors have questioned the tolerance of skin graft to post operative radiotherapy. Aim: To assess the integrity of skin grafts following post operative radiotherapy for soft tissue sarcomas on extremities. Material and methods: During the period between 1997 and 2003, 10 patients received postoperative external beam radiotherapy following excision of soft tissue sarcomas on extremities and skin grafting at this regional soft tissue sarcoma unit. Age of these patients ranged from 26 years to 92 years. Malignant fibrous histiocytoma was the commonly encountered tumour. Commonest site of resection and skin grafting was lower leg. These patients were retrospectively analysed for interval between skin grafting and radiotherapy, dose, type and fractions of radiation, break in radiotherapy, adjuvant chemotherapy and effect of radiation on skin graft. Results: One patient developed moist desquamation and two developed dry desquamation during the course of treatment. All acute skin reactions were healed within 3 weeks of completion of radiotherapy. No patients required further soft tissue reconstruction. Conclusion: Adjuvant external beam radiotherapy can be delivered to skin-grafted areas on extremities following enbloc excision of soft tissue sarcomas without any major complications. Our experience indicates that the radiation reaction can be minimised if the graft is allowed to heal adequately prior to the initiation of radiotherapy

Introduction. Negative pressure wound therapy (NPWT) and vessel loop assisted closure are two common methods used to assist with the closure of fasciotomy wounds. This retrospective review compares these two methods using a primary outcome measurement of skin graft requirement. Methods. A retrospective search was performed to identify patients who underwent fasciotomy at our institution. Patient demographics, location of the fasciotomy, type of assisted closure, injury characteristics, need for skin graft, length of stay and evidence of infection within 90 days were recorded. Results. A total of 56 patients met the inclusion criteria. Of these, 49 underwent vessel loop closure and seven underwent NPWT assisted closure. Patients who underwent NPWT assisted closure were at higher risk for requiring skin grafting than patients who underwent vessel loop closure, with an odds ratio of 5.9 (95% confidence interval 1.11 to 31.24). There was no difference in the rate of infection or length of stay between the two groups. Demographic factors such as age, gender, fracture mechanism, location of fasciotomy and presence of open fracture were not predictive of the need for skin grafting. Conclusion. This retrospective descriptive case series demonstrates an increased risk of skin grafting in patients who underwent fasciotomy and were treated with NPWT assisted wound closure. In our series, vessel loop closure was protective against the need for skin grafting. Due to the small sample size in the NPWT group, caution should be taken when generalising these results. Further research is needed to determine if NPWT assisted closure of fasciotomy wounds truly leads to an increased requirement for skin grafting, or if the vascular injury is the main risk factor

Aims. Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections. Methods. Between January 2019 and December 2022, 106 patients with bone and joint infections were treated by five surgeons in five hospitals. Surgical debridement and calcium sulphate bead insertion was performed for local elution of antibiotics in high concentration. In all, 100 patients were available for follow-up at regular intervals. Choice of antibiotic was tailor made for each patient in consultation with microbiologist based on the organism grown on culture and the sensitivity. In majority of our cases, we used a combination of vancomycin and culture sensitive heat stable antibiotic after a thorough debridement of the site. Primary wound closure was achieved in 99 patients and a split skin graft closure was done in one patient. Mean follow-up was 20 months (12 to 30). Results. Overall, six out of 106 patients (5.6%) presented with sepsis and poorly controlled comorbid conditions, and died in the hospital within few days of index surgery. Out of the remaining 100 patients, control of infection was achieved in 95 patients (95%). Persistence of infection was noted in five (5%) patients. Out of these 95 patients that had good control of infection, four patients (4.2%) with gap nonunion needed Masquelet procedure to achieve union. Conclusion. Our multicentre experience confirmed that surgical debridement along with calcium sulphate bead insertion was effective in treating bone and joint infections without any side effects and complications. Cite this article: Bone Jt Open 2023;4(7):516–522

Introduction. Fracture related infection (FRI) is a challenging complication to manage in an orthoplastic setting. Consensus guidelines have been created to standardise the diagnosis of FRI and comprise confirmatory and suggestive criteria. In this study, the aim is to assess the diagnostic criteria and management of FRI with a particular focus on soft tissue reconstruction. Materials & Methods. A retrospective study to identify the outcomes of FRI in the lower limb over a five year period at a Major Trauma Centre. Fracture specific information that was analysed includes: open versus closed, fractured bone(s) and site, initial fracture management, method of diagnosis and soft tissue management. Results. A total of 40 patients were identified, 80% of whom were male (n= 32). The mean age for FRI diagnosis was 54 years (range 18–83 years). In our patient cohort, 10% were immunosuppressed and another 12.5% had a formal diagnosis of Diabetes Mellitus. A diagnosis of acute FRI (i.e. < six weeks from time of injury) was made in 9 patients (22.5%). Chronic FRI was noted in 25 patients (62.5%). There was equal incidence of FRI in patients with closed fractures and open fractures (42.5%). Tibia and fibula fractures were most common (87.5%, n=35). Regardless of fractured bone(s), the more distal the fracture the higher the incidence of FRI (60% distal versus 12.5% proximal). Gram-positive cocci were the most commonly identified pathogens, identified in 25% of patients. Five patients underwent free flap reconstruction, two patients received pedicled muscle flaps and another two patients received split thickness skin grafts. Conclusions. The diagnosis of FRI can be confirmed through the presence of a combination of confirmatory and suggestive criteria. We advocate a staged approach in the management of FRI with radical wound excision and temporary coverage followed by definitive soft tissue reconstruction

Aim. In the context of total knee arthroplasty (TKA), trauma with perigenicular fracture fixation or oncological surgical treatment, soft tissue defects can expose critical structures such as the extensor apparatus, the knee joint, bone or implants. This work compares soft tissue reconstruction (STR) between a classical pedicled gastrocnemius (GC) muscle flap and a pedicled chimeric sural artery perforator (SAP) musculocutaneous GC flap in complex orthoplastic scenarios. Method. A retrospective study was conducted on prospectively maintained databases in three University Hospitals from January 2016 to February 2021 after orthopaedic, traumatological or oncological treatment. All patients with a perigenicular soft tissue defect and implant-associated infection were included undergoing STR either with a pedicled GC flap or with a pedicled chimeric SAP-GC flap. The outcome analysis included successful STR and flap related complications. The surgical timing, preoperative planning and surgical technique are discussed together with the postoperative rehabilitation protocol. Results. 43 patients were included (22 GC muscle flaps, 21 SAP-GC musculocutaneous flaps). The GC and SAP-GC patient group were comparable in terms of age, comorbidities, defect size and follow-up. The incidence of flap related complications was comparable among the two groups. Specifically, in the SAP-GC group 1 wound dehiscence at the recipient site occurred as well as 1 distal muscle flap necrosis, 1 distal skin flap necrosis, 1 donor site infection and 1 donor site wound dehiscence. Furthermore, the donor site was closed in 9 patients while a skin graft was used in 12 patients. A significant difference was recorded with regard to re-raising the flap for further orthopaedic treatment: In the SAP-CG group (re-raise in 11 patients) no problems occurred while in the GC group (re-raise in 14 patients) in 6 patients the soft tissue did not heal completely. Conclusions. According to our clinical experience, the pedicled chimeric SAP-CG musculocutaneous flap is a relevant further development of the classical GC workhorse flap for perigenicular STR, in multiple staged procedures

Introduction. Cerament, a bioresorbable hydroxyapatite and calcium sulfate cement, is known to be used as a bone-graft substitute in traumatic bone defect cases. However, its use in open fractures has not previously been studied. Materials and Methods. Retrospective, single-centre review of cases between November 2016 and February 2021. Open fractures were categorised according to the Orthopaedic Trauma Society classification (OTS). Cases were assessed for union, time to union, and associated post-operative complications. Results. Twenty-four patients were identified. Fifteen cases were classified as OTS simple open fractures, and nine cases were complex open fractures requiring soft tissue reconstruction. Four cases were lost to follow-up. Four cases had limited follow-up beyond 6 months but showed evidence of progressive radiographic union. Of the remaining 16 cases, eight cases (50%) went on to union with a mean time to union of 6.7 months (5 to 12 months). Persistent non-union remained in six cases (38%). Two cases required return to theatre due to an infected skin graft and wound dehiscence respectively. One case had the complication of persistent weeping of Cerament from the wound. This self-resolved within two weeks. Limitations of this case series include the lack of complete follow-up in eight patients (33%) and the lack of patient reported outcome measures. Conclusions. Cerament can be a useful adjunct in managing open fractures. However, it should be noted there is a high rate of non-union which may be reflective of the significant morbidity associated with open fractures with structural bone defects

Introduction. A significant burden of disease exists with respect to critical sized bone defects; outcomes are unpredictable and often poor. There is no absolute agreement on what constitutes a “critically-sized” bone defect however it is widely considered as one that would not heal spontaneously despite surgical stabilisation, thus requiring re-operation. The aetiology of such defects is varied. High-energy trauma with soft tissue loss and periosteal stripping, bone infection and tumour resection all require extensive debridement and the critical-sized defects generated require careful consideration and strategic management. Current management practice of these defects lacks consensus. Existing literature tells us that tibial defects 25mm or great have a poor natural history; however, there is no universally agreed management strategy and there remains a significant evidence gap. Drawing its origins from musculoskeletal oncology, the Capanna technique describes a hybrid mode of reconstruction. Mass allograft is combined with a vascularised fibula autograft, allowing the patient to benefit from the favourable characteristics of two popular reconstruction techniques. Allograft confers initial mechanical stability with autograft contributing osteogenic, inductive and conductive capacity to encourage union. Secondarily its inherent vascularity affords the construct the ability to withstand deleterious effects of stressors such as infection that may threaten union. The strengths of this hybrid construct we believe can be used within the context of critical-sized bone defects within tibial trauma to the same success as seen within tumour reconstruction. Methodology. Utilising the Capanna technique in trauma requires modification to the original procedure. In tumour surgery pre-operative cross-sectional imaging is a pre-requisite. This allows surgeons to assess margins, plan resections and order allograft to match the defect. In trauma this is not possible. We therefore propose a two-stage approach to address critical-sized tibial defects in open fractures. After initial debridement, external fixation and soft tissue management via a combined orthoplastics approach, CT imaging is performed to assess the defect geometry, with a polymethylmethacrylate (PMMA) spacer placed at index procedure to maintain soft tissue tension, alignment and deliver local antibiotics. Once comfortable that no further debridement is required and the risk of infection is appropriate then 3D printing technology can be used to mill custom jigs. Appropriate tibial allograft is ordered based on CT measurements. A pedicled fibula graft is raised through a lateral approach. The peroneal vessels are mobilised to the tibioperoneal trunk and passed medially into the bone void. The cadaveric bone is prepared using the custom jig on the back table and posterolateral troughs made to allow insertion of the fibula, permitting some hypertrophic expansion. A separate medial incision allows attachment of the custom jig to host tibia allowing for reciprocal cuts to match the allograft. The fibula is implanted into the allograft, ensuring nil tension on the pedicle and, after docking the graft, the hybrid construct is secured with multi-planar locking plates to provide rotational stability. The medial window allows plate placement safely away from the vascular pedicle. Results. We present a 50-year-old healthy male with a Gustilo & Anderson 3B proximal tibial fracture, open posteromedially with associated shear fragment, treated using the Capanna technique. Presenting following a fall climbing additional injuries included a closed ipsilateral calcaneal and medial malleolar fracture, both treated operatively. Our patient underwent reconstruction of his tibia with the above staged technique. Two debridements were carried out due to a 48-hour delay in presentation due to remote geographical location of recovery. Debridements were carried out in accordance with BOAST guidelines; a spanning knee external fixator applied and a small area of skin loss on the proximal medial calf reconstructed with a split thickness skin graft. A revision cement spacer was inserted into the metaphyseal defect measuring 84mm. At definitive surgery the external fixator was removed and graft fixation was extended to include the intra-articular fragments. No intra-operative complications were encountered during surgeries. The patient returned to theatre on day 13 with a medial sided haematoma. 20ml of haemoserous fluid was evacuated, a DAIR procedure performed and antibiotic-loaded bioceramics applied locally. Samples grew Staphylococcus aureus and antibiotic treatment was rationalised to Co-Trimoxazole 960mg BD and Rifampicin 450mg BD. The patient has completed a six-week course of Rifampicin and continues on suppressive Co-Trimoxazole monotherapy until planned metalwork removal. There is no evidence of ongoing active infection and radiological evidence of early union. The patient is independently walking four miles to the gym daily and we believe, thus far, despite accepted complications, we have demonstrated a relative early success. Conclusions. A variety of techniques exist for the management of critical-sized bone defects within the tibia. All of these come with a variety of drawbacks and limitations. Whilst acceptance of a limb length discrepancy is one option, intercalary defects of greater than 5 to 7cm typically require reconstruction. In patients in whom fine wire fixators and distraction osteogenesis are deemed inappropriate, or are unwilling to tolerate the frequent re-operations and potential donor site morbidity of the Masqualet technique, the Capanna technique offers a novel solution. Through using tibial allograft to address the size mismatch between vascularised fibula and tibia, the possible complication of fatigue fracture of an isolated fibula autograft is potentially avoidable in patients who have high functional demands. The Capanna technique has demonstrated satisfactory results within tumour reconstruction. Papers report that by combining the structural strength of allograft with the osteoconductive and osteoinductive properties of a vascularised autograft that limb salvage rates of greater than 80% and union rates of greater than 90% are achievable. If these results can indeed be replicated in the management of critical-sized bone defects in tibial trauma we potentially have a treatment strategy that can excel over the more widely practiced current techniques

Compartment syndrome is a devastating complication of limb trauma requiring prompt decompression by means of fasciotomy; however to date little is known about the long term morbidity directly related to the fasciotomy procedure. This is a retrospective study from June 2001 to July 2008 of all patients undergoing fasciotomy in a tertiary referral centre following trauma to a limb. In total this comprised of 66 patients and of these one had since died and five were uncontactable. Therefore 60 patients were surveyed, 48 of whom underwent lower limb fasciotomy and 12 underwent upper limb fasciotomy. Patients were subjected to a phone survey with end points including weakness, parasthaesia and dysasthaesia which had persisted for more than one year post-op. The results were then correlated with time to fasciotomy, site of fasciotomy, initial post-op complications and Methods: of closure. 42 out of 60 patients (70%) reported persistent symptoms. Of these 20 (33%) reported that their symptoms limited them severely either occupationally or socially. Lower morbidity was seen in the upper versus the lower limb fasciotomy group, with decreased incidence of persistent severe symptoms (16.7% versus 35%). Twelve patients had early post-op complications (seven wound infections, 1 cardiac arrest, 2 amputations, 2 haematomas requiring evacuation). Amongst those with post-op complications, 10 out of 12 had persistent symptoms with severe symptoms seen in 80%. In terms of Methods: of closure, 39 patients had delayed primary closure, six were allowed to heal by secondary intention and 15 patients underwent skin grafting. All patients who underwent skin graft were symptomatic at the time of survey with 80% being severely symptomatic. Meanwhile of the patients allowed to heal by seconday intention 83% were asymptomatic. Mean time to closure of fasciotomy was four days. In those patients who were closed in three days or less, 47% were asymptomatic with 23% mildly symptomatic. In the group closed between 8–14 days 37% were symptomatic while all patients closed after 14 days were severely symptomatic. These results demonstrate significant morbidity associated with the fasciotomy procedure. Incidence was highest amongst those undergoing leg or thigh fasciotomy, those who had early post-op complications, those who were closed late and those who were closed with split/ full thickness skin graft. This was most dramatic in those who underwent skin grafting, a vast majority of whom were severely symptomatic. Long term sequelae were lowest in those with upper limb fasciotomies, those undergoing early primary closure and those that were allowed to heal by secondary intention

Aim. This study investigated the management and clinical outcomes of patients treated for confirmed fracture-related infection (FRI) at 3 centres, in the UK and the Netherlands between 2015 and 2019. Method. All patients with FRI, confirmed by the FRI Consensus Definition. 1. and treated surgically, were included. Data were collected on patient characteristics, time from injury to FRI surgery, soft tissue reconstruction, type of stabilization and use of local antibiotics. All patients were followed up for at least one year. The rates of eradication of infection and union were assessed. The associations between treatment methods, time from injury and outcomes were determined. Results. 433 FRIs were treated in patients with mean age 49.7 years (range 14–84). FRI affected the tibia in 226(52.2%), femur in 94(21.7%), pelvis in 26(6%), humerus in 20(4.6%) and foot bones in 19(4.4%). Patients were followed up for a mean of 26 months (range 12–72). Overall, eradication of infection was successful in 86.4% of cases and 86% of unhealed infected fractures were healed at final review. 3.3% required amputation. Successful outcome was not dependent on age, or time from injury (recurrence rate 16.5% in FRI treated at 1–10 weeks after injury; 13.1% at 11–52 weeks; 12.1% at >52 weeks: p=0.52). Method of stabilization had a major affect on outcome. Debridement and retention of a stable infected implant (DAIR) had a failure rate of 22.3%, implant exchange (to new internal fixation) 16.7%, conversion to external fixation 7.4%. DAIR was significantly worse than conversion to external fixation (p=0.01). There was no effect of the time from injury on the outcome of DAIR or any other fixation method. The use of a free flap in the tibia improved the success rate from 80.4% to 92.1% (p=0.044). Outcome was adversely affected by use of a split skin graft alone in soft tissue reconstruction (44% failure) (p=0.006). The use of local antibiotics reduced the recurrence rate from 18.3% to 10.3% (p=0.022). Conclusions. This study is the first to consider outcome for all FRIs, at all-time points, with all treatment modalities. Treatment was mostly successful but may be improved with better directed use of free flaps, local antibiotics, and limitation of DAIR. The results suggest that the division of FRIs into categories based on time from injury, may not be helpful with modern treatment

Syndactyly and polysyndactyly of the feet are common congenital conditions of the foot, and surgery to reconstruct the toes may be indicated for cosmetic, psychological, and practical reasons. A dorsal flap is traditionally used for the web space reconstruction, with skin grafts for the bases of the toes. Skin grafting has associated morbidity, and can result in pigmentation mis-match. Single-stage direct closure using a specially designed dorsal pentagonal island flap has advantages including a reduction of morbidity from avoidance of skin grafting, and shorter surgery. Four patients with six feet were included in the study. There were two cases of syndactyly, and two cases of polysyndactyly. Bilateral involvement occurred in two patients. The average age was eighteen months at time of first surgery. Direct closure was achieved with a dorsal pentagonal island flap with dorsal and plantar triangular flaps. The average duration of follow-up was 19.8 months. At final follow-up, all patients had acceptable web depth and pulp contour. The distance between bilateral proximal interphalangeal joints of adjacent toes, and the web slope of the reconstructed web space were compared. Complications included partial synechiae, cellulitis and keloid formation. The dorsal pentagonal island flap is an acceptable technique in providing another means for single-stage reconstruction of the web space in syndactyly and polysyndactyly. Good functional and cosmetic outcomes can be expected. However, the potential complication of keloid formation can affect cosmesis and overall outcome, and must be understood by patients and parents

Full thickness skin grafting has been used following dermo-fasiectomy for Dupuytren’s contracture. We have used a conservative approach following excision of the contracture. Following radical excision through Brunner’s incision, an elliptical full thickness skin graft is harvested from the volar aspect of the wrist. This is applied to the wound on the volar aspect of the proximal phalanx to cover the gap with the finger held in extension. Patients who have undergone primary Dupuytren’s excision between 1990–1998 were recalled and evaluated in special clinic. Clinical notes were reviewed for pre-operative deformity, wound problems if any and recurrence of deformity at annual follow-up. Patients were reviewed for present status of deformity, ROM, sensation, 2-point discrimination, evidence of recurrence and patient satisfaction. One hundred and six fingers were evaluated in 80 patients. Average duration of follow-up was 52 months. Sixty-five patients had bilateral disease and 29 patients had family history of Dupuytren’s disease. Average pre-operative flexion deformity of the PIP joint was 68.6 degrees and 12 patients had deformity of the DIP joint. Mean flexion deformity at review of the PIP joint was 26.4 degrees. 29 patients reported sensitivity to cold. Two-point discrimination was abnormal in 24 patients. Skin tightness was noted in 8 fingers and 7 cases had recurrence. In 2 fingers the recurrence was away from the graft and in remaining 5 fingers it was proximal to the graft not crossing the grafted area. Thirty-three patients had progressive disease in the adjacent fingers away from the operated area. There was no case of graft loss. Seventy patients were satisfied with the end results of the operation. Our study has shown a very low incidence of recurrence following radical dissection and similar result as dermo-fasciectomy, and the skin graft acting as a barrier in cases of recurrence. Also graft harvested from the wrist matches the colour of the palm with increased patient satisfaction

Background. Infected total knee arthroplasties present in a variety of different clinical settings. With severe local compromise and draining sinus tract around the knee, after adequate debridement, the resultant patellectomy with need for free muscle transfer and split thickness skin graft for closure, usually results in loss of quadriceps function. This necessitates the need for drop lock brace. No good mechanisms are available for reconstruction of large anterior defects in total infected total knees where this occurs. Questions. Can proximal placement of the knee joint with longer tibial segments aid in closure in patients with large anterior skin defects, and can this placement aid in quadriceps reconstruction to alleviate the need for drop lock braces while ambulating?. Methodology. 10 patients with 2 year follow-up with stage III-C-3 McPherson infected total knees presented with large soft tissue defects over the anterior aspect of the knee with sinus tract and scarring from multiple surgeries. The patients underwent a one stage treatment of the infected total joint. 4 required a free muscle flap and split thickness skin graft. Patellectomy with some quadriceps resection was required in the debridement process. Distal femur and proximal tibial replacements were performed with proximal placement of the knee joint. The patients were analyzed for extension control in gait and soft tissue closure over the operational knee joint. The quadraceps mechanism was over attached to the proximal tibial component. Results. Of 10 with 2 year follow up, none recurred with infection. There was no erosion of the soft tissue over the knee joint commonly seen in free flaps directly over the joint in these type of resection –replacements. 50% of the patients had enough extensor use to walk with a cane or walker as opposed to needing a drop lock knee brace. Discussion. Proximal placement of the knee joints in patients with large anterior soft tissue defects may lessen need for free flaps and provide for extension to lock hinges. Conclusion. Proximal placement of the total knee in case of infected total knees with large anterior soft tissue defect, provides for more quadriceps function and soft tissue coverage and lessened the need for free flaps

Whilst emergency fasciotomy for acute compartment syndrome (ACS) of the leg is limb and potentially lifesaving, there remains a perception that such surgery may result in excessive morbidity, which may deter surgeons in providing expeditious care. There are limited long-term studies reporting on the morbidity associated with fasciotomy. A total of 559 patients with a tibial diaphyseal fracture were managed at our centre over a 7-year period (2009–2016). Of these patients, 41 (7.3%) underwent fasciotomies for the treatment of ACS. A matched cohort of 185 patients who did not develop ACS were used as controls. The primary short-term outcome measure was the development of any complication. The primary long-term outcome measure was the patient reported EQ-5D. There was no significant difference between fasciotomy and non-fasciotomy groups in the overall rate of infection (17% vs 9.2% respectively; p=0.138), deep infection (4.9% vs 3.8%; p=0.668) or non-union (4.9% vs 7.0%; p=1.000). There were 11 (26.8%) patients who required skin grafting of fasciotomy wounds. There were 206 patients (21 ACS) with long-term outcome data at a mean of 5 years (1–9). There was no significant difference between groups in terms of the EQ-5D (p=0.81), Oxford Knee Score (p=0.239) or the Manchester-Oxford Foot Questionnaire (p=0.629). Patient satisfaction on a linear analogue scale was reduced in patients who developed ACS (77 vs 88; p=0.039). These data suggest that when managed with urgent decompressive fasciotomies, ACS does not appear to have a significant impact on the long-term patient reported outcome, although overall patient satisfaction is reduced

We reviewed 100 consecutive primary sarcoma patients identified from coding records from January 2009 to April 2011. A computerised system was used to access theatre records, and operative details were checked against patient notes to ensure accuracy. Data on demographics, pathology, surgical and oncological management was collected. Of the 100 patients reviewed, 52 were male and 48 female with an average age of 64.9 years (range 23–102 years). Of the 100 operations performed, 13 had primary reconstruction with a myocutanoeus flap, of which 9 varieties were used. Twenty-five patients had reconstruction with a split or full thickness skin graft and 9 patients had a limb amputation. Length of inpatient stay ranged from 0 to 63 days and was greatest for our amputee's. Mean operative time did not increase significantly with rise in case complexity. 31 of our patients received post-operative radiotherapy, one patient had induction radiotherapy whilst another had induction chemotherapy. 5 out of the 100 patients underwent re-excision due to incomplete margins being obtained at primary wide local excisions. We had one patient with a failed free latissimus dorsi flap, in which secondary reconstruction with pedicled gastrocnemius and skin grafting was successful. One patient had a scalp flap following a re-excision of a positive margin of an angiosarcoma. Using a combined oncological orthopaedic and reconstructive plastic surgery approach, in our centre 38% of patients require some form of soft tissue reconstruction following tumour resection, with 13% of all patients requiring microvascular flap reconstruction. We have a 9% amputation rate, which is comparable with other published series. Reconstruction following soft tissue sarcoma is complex and highly demanding, the challenges being best met by a combined orthoplastic surgical team

Our experience using a skin stretching device applying KW and rib retractors for the approximation of extensive skin loss in the treatment of complex injuries involving massive loss of soft tissue is presented. Major soft tissue injury inflicted by the detonation of explosives in close proximity requires a unique approach for the closing of massive gaping wounds. This method has been applied in multiple situations at our medical center since 1995. The technique involved insertion of the KW into the deep dermal layer along the longitudinal edges on both sides of the wound, and the application of rib retractors to approximate the skin edges. Lately we have been combining this method with vacuum-assisted skin closure (VAC). This method enabled closure of massive soft tissue losses of limbs, trunks, and abdominal wall. Approximation of wound edges necessitated in some cases minor skin grafting of the residual gap. Application of the VAC system reduced edema, infection rate and skin necrosis, and also enabled early skin grafting. We will describe the novel use of VAC in extensive soft tissue trauma. The KW stretching device is inexpensive and is readily available in any OR setup. It enables setting of a vector traction on wound edges in a more homogenous manner. The VAC system may be combined for optimizing treatment

Purpose of the study: In sub-Sahara Africa, classical directed wound healing followed by a skin graft remains an important part of the treatment of open fractures with tissue loss. The purpose of his prospective cohort study was to assess a continuous series of muscle and fasciocutanous flaps, focusing on their contribution to the reduction of post-trauma focal infection. Material and method: From September 2007, patients with an open fracture of the leg were studied prospectively. After emergency debridement and stabilisation, open fracture foci were covered with a muscle or fasciocutaneous flap secondarily. Twenty-five patients received 29 flap covers of the lower limb (21 fasciocutaneous and 8 muscle) from October 26, 2007 to February 24, 2009. The Gustillo-Anderson and Catagni classification was noted. Evaluation criteria were successful cover of the bone and presence or not of focal osteitis at last follow-up. Results: Delay to admission was less than 4 hours in eight patients (30%). Time to primary surgery was greater than 4 h in 90% of patients. Time to flap cover was 29 days for the 18 first-intention flaps; 60 days for three repeat flaps; 217 days for seven second intention flaps. Inaugural colonisation of the fracture site was confirmed in 20 of the 25 patients. Complete necrosis of the flap occurred in four patients (16%) (two muscle flaps revised with fasciocutaneous flaps) and partial necrosis in two others. Successful primary cover was achieved with 12 flaps, and secondary cover in ten others after a new flap (n=3), directed healing, or complementary skin graft. At eight months, two patients had residual focal infection. Discussion: This series exhibited particularly long delay to primary surgical care and a high level of inaugural focal infections. Conclusion: Superficial tissue infection around the exposed fracture site should ideally be controlled within six weeks to prevent progression to osteitis. After complete excision of the irremediably damaged tissue, early cover with a flap closes the exogenous infection portal and prepares the wound for secondary bone reconstruction

Objective: 1997 Zwipp [. 1. ] proposed a 5-point scoring system for the classification of the complex trauma of the foot. However, outcome and quality of life after this injury have not been studied systematically. Therefore, the objective of this prospective cross-sectional study was to evaluate the functional outcome and quality of life after complex trauma of the foot. Patients and Methods: 74 patients with a complex trauma of the foot (≥5 points on the Zwipp-Scale) were treated between 2001 and 2007 in the authors’ institution. 50 patients met the inclusion criteria. Using standardized evaluation forms all relevant parameters concerning patients’ history and clinical data were recorded, including items to calculate the AOFAS-Score, the SF-12 and the VAS-Foot and Ankle Score. All patients were examined by an experienced orthopaedic surgeon and an experienced orthopedist. Finally, functional assessment was competed by dynamic baro-pedography and x-rays. Results: Primary amputation was necessary in 15 patients, 11 x on the level of the forefoot, 2x in the tarsal region and 1x at the level of the thigh. After initial preservation of the foot 4 secondary amputations were necessary. a compartment syndrome was diagnosed in 30 patients. Soft tissue coverage was achieved 12 x using a free vascular flap, 17 x using split skin grafts und 4 x using full skin grafts. On average 4 operations were necessary. The complication rate was 19%. Mean follow-up was 3.5 [1–5] years. At that time the AOFAS Score was 74 (60–100), the SF-12 Score 42.9 (physical health summary scale) and the VAS-Foot and Ankle Score was 76.4 (±12.3). The results showed a significant correlation the Zwipp-Scale (p=0,001). Pedographic evaluation demonstrated changes in gait (contact time, gait line, peak pressure) in 79% of the patients. These findings correlated with the radiologic changes of the foot. 46% of the patients did not wear their orthopaedic shoes. 31% of the orthopaedic shoes or orthotic appliances were regarded insufficient by the orthopaedic surgeon and the orthopedist. Conclusion: Quality of life after complex trauma of the foot is better than expected and comparable to complex monotrauma of the foot (e.g. calcaneus or talus). Long-term outcome is dictated by the trauma of the bones and joints and not the soft tissue trauma. Objective measurements like dynamic pedorgraphy show the limitations of the patients. Orthotic supply can be improved in a reasonable number of the patients

Purpose: To describe the technique and outcomes of patients requiring Lateral Gastrocnemius flaps for soft tissue coverage of the lateral side of the knee after sarcoma. Methods: Four patients with sarcomas on the lateral knee capsule were identified. 1 patient had an Osteosarcoma of the proximal tibia resected, requiring reconstruction. 2 patients had Malignant fibrous hystiocytoma proximal to the lateral knee joint and 1 patient had a leiomyosar-coma who presented after 6 failed local resections. The length of follow up is from 13 months to 5 years, average 3.25 years. There were no graft failures. The average surface area of the resection was 118 cm2. There were two sarcoma recurrences requiring excision and radiation. There was one death due to metastases. The technique involves the releasing the gastroc flap down to the aponeurosis and then the careful dissection of the peroneal nerve with delivery of the muscle up behind the peroneal nerve to the lateral aspect of the knee. The flap is rotated fibrous layer down and the muscle readily accepts a meshed skin graft taken locally, giving this technique the advantage of reconstructing a capsule and creating a superior bed for accepting skin grafts. Results: Average time to healing was 3.8 weeks. There have been no nerve injuries, no graft loss and all had a function range of motion. The functional results have been very reliable. Using the musculoskeletal tumour society score (MSTS) and the Toronto Extremity Salvage Scoring (TESS) system we had an average MSTS score of 21.5 with a percent of 71.5 and a TESS score of 44.5 for the living patients. These correlate to very good outcomes. Conclusions: The lateral gastrocs flap has a reputation of being technically complex. Meller et al.(1997) report peroneal nerve injuries in 8 of 27 cases. This institution has no complications with this flap and recommends it for soft tissue defects that extend to the midline on the lateral aspect of the knee joint

For decades the treatment of chronic post-traumatic osteomyelitis associated with bone exposure has been one of the most serious problems in the field of orthopaedic surgery. “Sterilisation” of the osteomyelitic site, that is radical débridement of all infected tissue, is the basic requirement of the treatment; in the past, the remaining defect of the débrided area was closed with skin grafts, which were removed in a further stage when the infection had cleared; then the defect was filled with muscle flap and bone graft of various types. Both soft tissue and osseous reconstruction took a relatively long period of time, requiring several-stage treatment. Over the years, introduction of microsurgery led to free muscle flaps and skin graft in one reconstruction setting in the 1970s and thin fascio-cutaneous flap reconstruction in the 1980s, allowing a shorter period of hospitalisation and an improvement in patients’ lifestyle. We performed a retrospective study of 22 patients treated for chronic osteomyelitis (middle or distal 1/3 of the leg, n=10; tarsus, n=6; forearm, n=6) by means of free vascularised bone graft or composite grafts between 1992 and 2003. In most of them a two-stage treatment was performed (resection and sterilisation in the first stage and bone transfer in the second one); in others a one-stage treatment was performed. In 78.5% of cases the infection was cured without requiring secondary procedures; revision of the flap was carried out in 12.3% of cases. In only one case leg amputation under the knee was necessary. In spite of advanced treatment protocols, persisting infection and residual functional deficit is not rare. Over the years the approach has changed. The application of microsurgical tissue transfers for reconstruction of the extremities allows repair of significant bone and soft-tissue defects. A wide variety of free flaps offers the potential to reconstruct nearly any defect of the limbs. The total array of flaps and their indications is beyond the scope of a single discussion, but this paper focuses on a few flaps that have found application for coverage and functional restoration of the limbs. Microsurgical transfers allow more radical débridement of the area affected by osteomyelitis with low peri-operative morbidity, reducing the number of procedures required to obtain bony union and subsequently effect a quick “return to work”. In management of chronic, post-traumatic osteomyelitis with soft-tissue loss, we prefer a well-vascularised muscle flap rather than a fascio-cutaneous flap (its important vascular supply helps reduce bacterial contamination)