Open limb fractures are typically due to a high energy trauma. Several recent studied have showed treatment's superiority when a multidisciplinary approach is applied. World Health Organization reports that isolate limb traumas have an incidence rate of 11.5/100.000, causing high costs in terms of hospitalization and patient disability. A lack of experience in soft tissue management in orthopaedics and traumatology seems to be the determining factor in the clinical worsening of complex cases. The therapeutic possibilities offered by microsurgery currently permit simultaneous reconstruction of multiple tissues including vessels and nerves, reducing the rate of amputations, recovery time and preventing postoperative complications. Several scoring systems to assess complex limb traumas exist, among them: NISSSA, MESS, AO and Gustilo Anderson. In 2010, a further scoring system was introduced to focus open fractures of all locations: OTA-OFC. Rather than using a single composite score, the OTA-OFC comprises five components grades (skin, arterial, muscle, bone loss and contamination), each rated from mild to severe. The International Consensus Meeting of 2018 on musculoskeletal infections in orthopaedic surgery identified the OTA-OFC score as an efficient catalogue system with interobserver agreement that is comparable or superior to the Gustilo-Anderson classification. OTA-OFC predicts outcomes such as the need for adjuvant treatments or the likelihood of early amputation. An orthoplastic approach reconstruction must pay adequate attention to bone and soft tissue infections management. Concerning bone management: there is little to no difference in terms of infection rates for Gustilo-Anderson types I–II treated by reamed intramedullary nail, circular external fixator, or unreamed intramedullary nail. In Gustilo-Anderson IIIA-B fractures, circular external fixation appears to provide the lowest infection rates when compared to all other fixation methods. Different technique can be used for the reconstruction of bone and soft tissue defects based on each clinical scenario. Open fracture management with fasciocutaneous or muscle flaps shows comparable outcomes in terms of bone healing, soft tissue coverage, acute infection and chronic osteomyelitis prevention. The type of flap should be tailored based on the type of the defect, bone or soft tissue, location, extension and depth of the defect, size of the osseous gap, fracture type, and orthopaedic implantation. Local flaps should be considered in low energy trauma, when skin and soft tissue is not traumatized. In high energy fractures with bone exposure, muscle flaps may offer a more reliable reconstruction with fewer flap failures and lower reoperation rates. On exposed fractures several studies report precise timing for a proper reconstruction. Hence, timing of soft tissue coverage is a critical for length of in-hospital stay and most of the early postoperative complications and outcomes. Early coverage has been associated with higher union rates and lower complications and infection rates compared to those reconstructed after 5-7 days. Furthermore, early reconstruction improves flap survival and reduces surgical complexity, as microsurgical free flap procedures become more challenging with a delay due to an increased pro-thrombotic environment, tissue edema and the increasingly friable vessels. Only those patients presenting to facilities with an actual dedicated orthoplastic trauma service are likely to receive definitive treatment of a severe open fracture with tissue loss within the established parameters of good practice. We conclude that the surgeon's experience appears to be the decisive element in the orthoplastic approach, although reconstructive algorithms may assist in decisional and planification of surgery.
We designed a study to evaluate whether (1) there were differences in PROMs between different reasons for revision THA at baseline, (2) there was a different interaction effect for revision THA for all PROMs, and (3) complication and re-revision rates differ between reason for revision THA. Prospective cohort of 647 patients undergoing rTHA, with a minimum of 2 years FU. The reason for revision were classified as infection, aseptic loosening, dislocation, structural failure and painful THA with uncommon causes. PROMs (EQ-5D score, Oxford hip score (OHS), VAS pain, complication and failure rates were compared between different groups. Patients with different reason for revision had improvement of PROMs’ over time. Preoperatively, patients revised due to infection and aseptic loosening had poorer OHS and EQ-5D than patients with other reason for revision. Pain scores at baseline were highest in patients revised due to dislocation. Infection and aseptic loosening groups also showed a significant interaction effect over time in both OHS and EQ-5D. No PROMs significant differences between groups were observed 2 years postoperatively. Overall complications, and re-revision rates were 35.4 and 9.7% respectively. The reason for revision THA did not associate with clinical outcomes. Good outcomes were reached regardless of the reason for revision, as patients with the poorest pre-operative scores had the best improvement in PROMs over time. Complication and re-operation rates were relatively high, in line with previous reports, but did not differ between different reasons for revision THA.
Congenital infantile fibrosarcomas (CIFS) is a rare tumor of childhood that can be diagnosed from birth to 15 years. It has a ratio of 3.74/100 000 children and is well defined nosological entity with a well-defined pathogenetic patterns: translocation (12, 15) (p13, q25) with fusion of the gene ETV6-NTRK3. The differential diagnosis of upper CIFS in infants must be made with lymphatic malformations, and when associated with the Kasabach-Merritt phenomenon’s (disseminated intravascular coagulopathy), haemangiomas, emangioendotelioma kaposiforme. In 26% of cases is congenital, while in 63% is diagnosed in the first 5 years. Unlike fibrosarcomas of the adult is characterized by a low rate of metastasis and a high survival rate (90% at 5 years). 74% of cases is observed in the limbs (upper>
lower, distal>
proximal). The treatment of choice should to be, where possible, limb salvage and the recurrences are variable between 17% and 43%. The purpose of this paper is to present a case of CIFS, the clinical features, the oncological treatment, the reconstructive solutions and functional results obtained after reconstruction. Case report. The child (Z.A. female), was diagnosed with a neoplasia of soft tissues of the right forearm before birth. At birth the child underwent a needle biopsy with a diagnosis of CIFS. The patient received four cycles of chemotherapy with reduction tumor mass of more than 50% of volume. At month four she underwent an exeresi with wide margings and sacrifice of the radial nerve. The reconstruction required a free flap of re-innervated latissimus dorsi muscle. After 30 months from the surgical procedure the child is disease free and has recovered extesion of the muscles of the hand and fingers.
Sternal resection is commonly performed for primary and metastatic chest wall tumours involving the sternum or the ribs near the sternum and, in case of wide resections, it is necessary to restore the stability of the chest wall. We analyze our experience with emphasis on surgical management and survival. From 2001 to 2007, 16 patients underwent surgical resection of the sternum for malignant lesions: 10 (62.5%) primary lesions (chondorsarcoma n=8; osteosarcoma n=2) and 6 (37.5%) secondary lesions (4 local recurrence from breast cancer and 2 metastases). We performed 12 partial resections (resected area from 65 to 20 %), 2 subtotal resections (about 90% of total area) and 1 total resection. Chest wall stability was obtained by prosthetic material, rigid and non rigid, and muscolar flaps. As non rigid material we used a polytetrafluoroethylene patch (Gore-tex Dual Mesh Plus) while replacement after total sternectomy was performed using a new rigid system of mould-able titanium connecting bars and rib clips (Strasbourg Thoracic Osteosyntheses System, Medxpert, GMbH). Prosthetic material was combined in 3 cases with a latissimus dorsi muscolar flap, in 1 case with a vertical rectus abdominis muscolar flap, in 12 with a pectoralis major flap. There was no perioperative mortality or significant morbidity. All patients were extubated within 24 hours after operation. At a mean follow-up of 44.1 months (range 82–14), 5 years actuarial survival for primary tumours was 85%, while 3 years actuarial survival after resection of secondary tumours was 39% (median 20,5 months). In case of primary lesion wide resection with tumour-free margins is necessary to minimize local recurrence and to contribute to long-term survival; reconstruction with a rigid system composed of mould-able titanium bars and rib clips allows to plan extensive demolition minimizing the risk of chest wall instability. In metastatic disease surgery can provide good palliation, although survival is poor.
Allogeneic bone is one of the most commonly used tissue grafts, with a variety of applications in orthopaedic surgery. The aim of this work is to analyze the initial results obtained using allografts in reconstructive surgery of the hand. In the period between January 2000 and August 2003, eight patients between 16 and 52 years of age (average age: 36 years) were treated using an allograft to replace the metacarpal bone and/or phalangeal bone of the hand. In three cases the initial cause was a recurring neoplasm (aneurysm, cyst, osteoma, osteoid, and TGC); in the other patients the aetiology was traumatic. The site of reconstruction was a metacarpal bone in three patients; in two of these it was associated with reconstruction of MPj (in one patient there was double bone loss at the third and fourth metacarpal bone); in one patient the lesion affected only the MPj. In the other five patients the reconstruction was performed at the phalanx, transferring the proximal interphalangeal (PIP) joint as well (except in one case). Different synthesis procedures were performed to obtain a good stability: miniplates, micro-screw, K-wires, and staples. A bone allograft (two cases) was used with platelet gel and a compound of stem cells to promote better recovery of the bone. The patients were followed for a period of between 6 and 40 months after surgery. The time needed to obtain a good healing was on average 6 months (in one case without the proximal recovery of the bone). The total range of movement in fingers that were reconstructed was between 0° and 270°, with an average of 121°. No patient reported any persisting pain. In reconstructive surgery of the hand allografts have only been used occasionally up to now. We believe that this preliminary study provides some useful findings. The waiting time for perfect recovery of a bone before the start of rehabilitation treatment can cause severe stiffness to joints: the osteosynthesis must be as stable as possible to allow for early mobilisation of the joint, especially in post-traumatic cases. Some questions about the future of joint capsules, articular cartilage, and extensor tendons of allograft still remain unanswered. In conclusion, we believe that the results obtained in this preliminary report are encouraging and point towards obtaining a reconstruction of bone loss that is as “biological” as possible.
In order to investigate the efficacy of free vascularised fibular graft (VFG) after bone intercalary tumour resection in tibia, we present our results with a minimum follow-up of 2 years. From 1988 to 2001, 47 patients affected by high-grade tibial sarcoma in 31 cases (66%), and low-grade diesease in 16 cases (34%) were treated in our department. Average age was 19 years (range 5–60 years), with a male/female ratio of 1.35. The average length of tibial resection was 15 cm, while the average length of the fibular graft was 19 cm. In 11 cases (21%) VFG was assembled alone, while in 36 cases (79%) a massive bone allograft was associated to the fibula. Three patients developed a deep infection, treated by amputation in two cases and by graft removal and an Ilizarov device in one case. Minor complications occurred in 28 cases (55%) (stress fractures, wound slough, osteosynthesis breakage), all healed by minor surgery or conservative treatment. At an average follow-up of 108 months (range 24 to 185 months), four patients had died of disease and three were lost to follow-up. Regarding the overall results, the combined group of fibula plus massive allograft showed to be more effective than the group of fibula alone in terms of early weight bearing (6 versus 12 months), while VFG showed intrinsic efficacy in achieving early bony fusion at the osteotomy lines and hypertrophy of the graft in both groups. Furthermore, using the combined assembly the articular surface could be spared in all the trans-epiphyseal resections, while VFG alone appeared to be electively indicated for infected or irradiated fields. In conclusion, despite the demanding surgical technique, VFG appears to be a long-lasting and definitive biological reconstruction procedure after intercalary tibial resection.
Vascularised bone grafts have been most commonly applied in reconstructions of the lower extremities. However, the indications for vascularised bone grafts in the upper extremities have now been expanded, as this technique is becoming more widely appreciated. Between 1993 and 2000, 12 patients who had segmental bone defects following trauma of the forearm received vascularised fibular grafts, among them six men and six women. The average age was 39 years (range 16–65 years). The reconstructed sites were the radius in eight patients and the ulna in four. The length of the bone defect ranged from 6 to 13 cm. In four cases the fibular graft was raised as a vascular osteoseptocutaneous fibular graft. For fixation of the grafted fibula, plates were used in ten cases, screws and Kirschner wires in two. In these two cases an external skeletal fixator was used for immobilisation of the extremity. The follow-up period ranged from 93 to 10 months. In 11 patients grafting was successful. There were no instances of fractures of the grafted bone; however, non-union occurred at the proximal site in one case and only one patient required an additional bone graft. No patient showed evidence of resorption of the graft or symptoms related to the donor leg. No recurrence of local infection was encountered in the patients with previous osteomyelitis. The mean period to obtain radiographic bone union was 4.8 months (range 2.5–8 months). With the use of fibular grafts a segment of diaphyseal bone can be transferred that is structurally similar to the radius and ulna and that is of sufficient length for the reconstruction of most skeletal defects in the forearm. A vascularised fibular graft is indicated in patients with intractable non-unions, where conventional bone grafting has failed or for large bone defects (in excess of 6 cm) in the radius or ulna.
