Soft-tissue defects and exposed hardware: a review of indications for soft-tissue reconstruction and hardware preservation.

BACKGROUND: Traditionally, management of exposed hardware has included irrigation and débridement, intravenous antibiotics, and likely removal of the hardware. Increasingly, the goal of wound closure without hardware removal using plastic surgical techniques of soft-tissue reconstruction has been emphasized. Identification of parameters for retaining exposed hardware may assist surgeons with management decisions and outcomes. METHODS: A current literature review was performed to identify parameters with prognostic relevance for management of exposed hardware before soft-tissue reconstruction. RESULTS: The following parameters were identified as important for the potential salvage of exposed hardware with soft-tissue coverage: hardware location, infection, duration of exposure, and presence of hardware loosening. CONCLUSIONS: Management of exposed hardware has included the removal of the hardware. However, if certain criteria are met--specifically, stable hardware, time of exposure less than 2 weeks, lack of infection, and location of hardware--salvage of the hardware with plastic surgical soft-tissue coverage may be a therapeutic option.

The distally based sural flap.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: (1) Describe the anatomy of the posterior lower leg as it is relevant to the distally based sural flap. (2) Describe the basic surgical technique of the distally based sural fasciocutaneous flap. (3) Understand the common complications associated with the sural flap and their approximate incidences in both a healthy and a multimorbid patient population. (4) Describe how skin, fascia, and muscle can be used to customize the sural flap for different purposes. (5) Understand the various modifications of the sural flap that have been described in the literature. SUMMARY: Over the past decade, the distally based sural flap has become increasingly used in reconstruction of the foot and lower leg. The rise in popularity of this flap has been paralleled by an increase in the number of cases, innovations, and technical refinements reported in the medical literature. This review summarizes the 79 publications in the English language literature on the subject of the distally based sural flap. The anatomical studies are summarized in a unified description of the relevant flap anatomy. The flap's indications and composition and a variety of modifications are described. Technical aspects are discussed and clinical insight to minimize complications is provided. In conclusion, the distally based sural flap offers an alternative to free tissue transfer for reconstruction of the lower extremity.

Technical and anatomical considerations of face harvest in face transplantation.

Total face transplantation may become a reconstructive option in the treatment of patients with acquired facial deformity. Here, 2 face-harvesting techniques are presented in a fresh human cadaver model. In technique 1, the skin and soft tissue of the face is harvested by dissecting in a subgaleal, sub-SMAS, subplatysmal plane. In technique 2, the entire soft tissue and the bony structures of the midface are harvested by dissecting in a subperiosteal plane and performing a Le Fort III osteotomy. Each face was harvested successfully as a bipedicled flap based on the external carotid arteries, the external jugular veins, and the facial veins. Each of these 2 techniques is a theoretically viable approach to face harvest for composite allograft transplantation. These techniques represent the 2 extremes of which tissues can be harvested while maintaining vascular integrity. Each will address different reconstructive needs.

Comparison of six methods for the assessment of ischemia-reperfusion injury in skeletal muscle following composite tissue allotransplantation.

Ischemia/reperfusion (I/R) injury is one of the factors determining tissue survival in replantation and transplantation surgery. However, more than 20 methods have been used to evaluate I/R injury in muscle. The aim of this study was to examine I/R injury in muscle tissue in a model of composite tissue allotransplantation (rat hindlimb transplantation), based on the analyses of six parameters: nitroblue tetrazolium staining (NBT); histology of the anterior tibial and extensor digitorum muscle; wet-to-dry weight ratio; serum potassium; and serum creatine kinase (CK)), in order to identify the most practicable and reliable outcome parameter. Results demonstrated that NBT staining and the wet/dry weight ratio are reliable tools for outcome measurement. The wet/dry weight ratio is the easiest to perform and the authors consider it to be useful for screening purposes. Histologic assessment shows areas of necrosis, but is not a reliable method for semi-quantitative evaluation. Serum potassium and CK levels were higher following transplantation, but they cannot be recommended for assessment purposes, as no significant correlation with other parameters was seen. These findings help further researchers in their selection of reliable outcome parameters to measure I/R injury in skeletal muscle.

A realistic complication analysis of 70 sural artery flaps in a multimorbid patient group.

The popularity of the sural artery flap has increased markedly throughout the years, and favorable results are reported almost uniformly. Previous publications have mainly presented results of small groups and of predominantly younger patients with posttraumatic defects, or they have reported technical modifications of the sural artery flap. The authors have increasingly used the reversed sural artery flap in a high-risk, critically multimorbid, and older patient population, and in contrast to the results of other authors, a considerable necrosis rate of 36 percent was seen. For the first time, a detailed, critical, retrospective complication analysis of 70 sural artery flaps is presented. The results reveal the following risk factors, which can potentially impair successful defect coverage and thus contribute to flap complications: concomitant diseases, particularly diabetes mellitus; peripheral arterial disease or venous insufficiency, which increase the risk of flap necrosis five-fold to six-fold; and patient age of over 40 years, because of an increased rate of comorbidity, underlying osteomyelitis, and the use of a tight subcutaneous tunnel. However, age alone did not seem to represent a risk factor by itself. Given the results of the analysis, the operative procedure was altered, as follows. In cases in which a lesser saphenous vein cannot be found, a delay procedure is recommended, or the flap is not utilized. In addition, an external fixation device seems to facilitate postoperative care markedly without adding specific complications; it is recommended in most patients. This analysis emphasizes specific risk factors that result in higher complication rates of the sural artery flap, and it leads to more realistic and appropriate expectations for this flap.