The presence of pluripotent mesenchymal cells in the periosteum along with the growth factors produced or released following injury provides this tissue with an important role in bone healing. Utilising this property, vascularised periosteal flaps may increase the union rates in recalcitrant atrophic long bone non-union. The novel chimeric fibula-periosteal flap utilises the periosteum raised on an independent periosteal vessel, thus allowing the periosteum to be inset freely around the osteotomy site, improving bone biology. Ten patients, with established non-union, underwent fibula-periosteal chimeric flaps (2016–2022) at the Canniesburn Plastic Surgery Unit, UK. Preoperative CT angiography was performed to identify the periosteal branches. A case-control approach was used. Patients acted as their own controls, which obviated patient specific risks for non-union. One osteotomy site was covered by the chimeric periosteal flap and one without. In two patients both the osteotomies were covered using a long periosteal flap.Introduction
Materials & Methods
Reconstruction of composite soft-tissue defects with extensor apparatus deficiency in patients with periprosthetic joint infection (PJI) of the knee is challenging. We present a single-centre multidisciplinary orthoplastic treatment concept based on a retrospective outcome analysis over 20 years. One-hundred sixty-seven patients had PJI after total knee arthroplasty. Plastic surgical reconstruction of a concomitant perigenicular soft-tissue defect was indicated in 49 patients. Of these, seven presented with extensor apparatus deficiency.Aim
Method
Traditional teaching, and indeed the impression from the BOA BAPS working party report on open tibial fractures, suggests that soft tissue cover of the distal third of the leg will often need a free flap. However, more recently with the introduction of propeller flaps by Quaba, and the reintroduction of the concept of Ponten's nerve oriented flaps with the reverse sural artery flap, the role of free tissue transfer comes into question. The attraction of local flaps for distal third fractures is the reduced operating time, reduced morbidity of donor site, versatility and reliability. However, detractors would argue that muscle enhances bone union and reduces local infection. Previous reviews of lower limb soft tissue cover look at all areas of the leg. This series of 30 (14 free and 16 local flaps) cases looks exclusively at the distal third fractures, compares the complication rate of free versus local flaps and looks at the change in approach to distal third fractures with the more recently described fascio-cutaneous flaps. Our results challenge the conventional teaching and indicate that fasciocutaneous flaps can play a more active role in distal third fractures. Our study shows that the local flaps are a valuable alternative to free flaps for managing soft tissue defects in distal third fractures of tibia especially in smaller wound size and low energy fractures. The advantages are lesser operating time, reliability, versatility, lesser wound complication and osteomyelitis incidence, earlier flap cover and lesser post op morbidity leading to shorter hospital stay. The free flaps on balance are probably better with larger soft tissue defects and with more severe limb injury. This supports the use of fascio-cutaneous flaps in distal third tibial fractures.
