[Plastic-surgical reconstruction of the lower extremity in senior patients]. / Plastisch-chirurgische Rekonstruktion der unteren Extremität bei alten Patienten.

The proportion of patients in the population beyond the 7th decade of life is increasing worldwide, especially in highly developed countries. Consequently, there is also an increasing need for complex lower extremity reconstructions after trauma, tumors, or infections in this age group. The reconstruction of soft tissue defects of the lower extremity should be performed according to the principle of the plastic-reconstructive ladder or elevator. The goal of reconstruction is to restore anatomy and function of the lower extremity to enable pain-free and stable standing and walking; however, for older patients in particular, a careful preoperative multidisciplinary planning, detailed preoperative assessment and optimization of comorbidities, such as diabetes, malnutrition or pathological vascular alterations, as well an age-adapted perioperative management are necessary. By implementing these principles, older and very old patients can maintain their mobility and autonomy, which are crucial for a high quality of life.

The Cleft Lip Education with Augmented Reality (CLEAR) VR Phase 2 Trial: A Pilot Randomized Crossover Trial of a Novel Patient Information Leaflet.

BACKGROUND: The Cleft Lip Education with Augmented Reality (CLEAR) project centers around the use of augmented reality (AR) in patient leaflets, as a visual means to overcome the "health literacy" gap. This trial followed Virtual Reality (VR CORE) guidelines for VR Phase 2 (Pilot) trials. METHODS: Participants included families of children treated for Cleft Lip and Palate at the Royal Hospital for Children, Glasgow. Interventions were AR leaflet or Traditional Leaflet. Objectives were to calculate sample sizes, assess outcome instruments, trial design, and acceptability to patients. Primary outcome measure was Mental Effort Rating Scale, and secondary outcomes were Patient Satisfaction (Visual Analogue Scale), Usefulness Scale for Patient Information Material (USE) scale, and Instructional Materials Motivation Survey (IMMS). Randomization was by block randomization. The trial was single blinded with assessors blinded to group assignment. RESULTS: 12 Participants were randomized, with crossover design permitting analysis of 12 per group. Primary outcome with Mental Effort Rating Scale indicated higher mental effort with Traditional compared to AR Leaflet (4.75 vs 2.00, P = .0003). Secondary outcomes for Satisfaction were Traditional 54.50 versus AR 93.50 (P = .0001); USE scale 49.42 versus 74.08 (P = .0011); and IMMS 112.50 versus 161.75 (P = .0003). Subjective interviews noted overwhelmingly positive patient comments regarding the AR leaflet. Outcome instruments and trial design were acceptable to participants. No harms were recorded. CONCLUSIONS: The CLEAR pilot trial provides early evidence of clinical efficacy of AR leaflets in patient education. It is hoped that this will provide a future paradigm shift in the way patient education is delivered.

Does muscle improve validated outcome measures in open tibial fractures? New insights from a cohort study of the anterolateral thigh flap (ALT) versus ALT-Vastus lateralis flaps.

The benefits of the muscle in open lower limb fractures remain to be determined. This study compared statistically equivalent groups of open tibial fractures treated by free anterolateral thigh (ALT) flaps or ALT flaps incorporating muscle (ALT-Vastus lateralis/ALT- VL). Method and Results: Chang Gung Memorial Hospital, Taiwan, 2004-2008, 49 free flaps in open lower limb fractures (38 open tibial) were specifically reconstructed with free ALT or ALT-VL flaps. Risk factors for non-union: equivalent between the two groups, with no differences in smoking, steroids, diabetes, time to flap and the AO classification of soft tissue and bone injury. Comparison of union rates: no difference was noted between groups in the Radiographic Union Score in Tibial Fractures (RUST) at 3, 6, 9 and 12 months. The only factor significantly associated with non-union was presence of a SPRINT trial defined 'critical' bone defect with odds ratio 14.4 (95% CI 1.36 - 131.5), with no association with AO bone classification, flap type, comorbidity or flap size. Patient-reported outcomes: the ALT-VL group showed improved patient satisfaction (p = 0.01, Cohen's d = 1.1). Functional outcomes (Enneking score) were not statistically significant, but the ALT-VL group trended towards significance in function and skin quality domains. Conclusions: Based on the results of this study, one can conclude that the degree of bone injury (specifically a 'critical' defect) is of greater relevance than flap choice with regard to fracture consolidation. Muscle does not result in improvements to union, the speed of union or deep infection. However, better PROMs may be related to the inclusion of the muscle around the fracture site.

Orthoplastics in Periprosthetic Joint Infection of the Knee: Treatment Concept for Composite Soft-tissue Defect with Extensor Apparatus Deficiency.

Introduction: 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. Methods and Results: One-hundred sixty patients had PJI after total knee arthroplasty. Plastic surgical reconstruction of a concomitant perigenicular soft-tissue defect was indicated in 47 patients. Of these, six presented with extensor apparatus deficiency. One patient underwent primary arthrodesis and five patients underwent reconstruction of the extensor apparatus. The principle to reconstruct missing tissue 'like with like' was thereby favoured: Two patients with a wide soft-tissue defect received a free anterolateral thigh flap with fascia lata; one patient with a smaller soft-tissue defect received a free sensate, extended lateral arm flap with triceps tendon; and two patients who did not qualify for free flap surgery received a pedicled medial sural artery perforator gastrocnemius flap. Despite good functional results 1 year later, long-term follow-up revealed that two patients had to undergo arthrodesis because of recurrent infection and one patient was lost to follow-up. Conclusion: These results show that PJI of the knee and extensor apparatus deficiency is a dreaded combination with a poor long-term outcome. Standardization of surgical techniques for a defined PJI problem and consensus on study variables may facilitate interinstitutional comparisons of outcome data, and hence, improvement of treatment concepts.

Free vascularised medial femoral condyle periosteal flaps in recalcitrant long bone non-union: a systematic review.

INTRODUCTION: In adults, treatment of recalcitrant long bone non-union is extremely challenging, with poorly vascularised and atrophic defects unresponsive to standard non-vascularised bone graft treatment. Recent studies have documented the use of free vascularised periosteal flaps to achieve union in refractory long bone fracture non-union, yet its use is not well established. This systematic review aims to assess the evidence for free vascularised periosteal flaps in recalcitrant long bone non-union. MATERIALS AND METHODS: The MEDLINE®/PubMed® and Embase databases were searched for the Medical Subject Heading (MeSH) terms periosteal flap/vascularised flap/long bone/non-union/non united fracture in accordance with the PRISMA guidelines. Bibliographies were scrutinised for additional articles. RESULTS: Pooled data from 14 studies met the inclusions criteria, comprising 137 cases of non-union, with 117 relating to long bone non-union. Pooled data indicated an overall 99% (116/117) successful union rate. All studies were of mid- to low-level evidence (Level III, IV and V). Only one study directly compared vascularised periosteal flaps to non-vascularised bone grafts, showing union rates of 100% versus 80% and faster time to union (2 versus 5.5 months). CONCLUSIONS: Free vascularised periosteal flaps are promising with pooled data showing a 99% success rate in achieving union in refractory long bone non-union. This compares favourably with standard orthopaedic care consisting of revision fixation and non-vascularised bone graft union rates of approximately 80%. However, study design flaws should be addressed by validated outcome measures plus adequate blinding, and further comparative studies with greater patient numbers are required.

Internally Fabricated Chimera Anterolateral Thigh-Amputate Flaps for Metachronous Reconstruction.

The chimera flap is a versatile and exciting tissue composition for the reconstruction of complex tissue defects. METHODS: Here, we present 2 cases of internally fabricated anterolateral thigh (ALT)-amputate chimera flaps for metachronous transfer. RESULTS: A 22-year-old man (case 1) developed extended soft tissue necrosis in both legs following meningococcal septicemia. Before unilateral amputation, a fasciocutaneous flap based on the posterior tibial artery perforators was saved and ectopically implanted onto the ipsilateral thigh, creating an ALT-amputate chimera flap. Three months later, it was shown that the islanded ALT-amputate chimera flap remained well vascularized on either pedicle alone. Thus, a "true chimera circulation" over the scar between the 2 flaps must have developed. Subsequent free tissue transfer to the remaining right lower leg was performed successfully with uneventful healing. A 57-year-old fisherman (case 2) suffered a traumatic avulsion of his left thumb, which was ectopically replanted onto the contralateral thigh, creating an ALT-amputate chimera flap. After 3 months, the flap was raised and orthotopically replanted successfully with arthrodesis through the metacarpophalangeal joint. The previously coapted radial digital lateral femoral cutaneous nerve was coapted in the palm, and an flexor digitorum superficialis (FDS) ring transfer was performed for flexor pollicis longus (FPL) reconstruction. CONCLUSIONS: To the best of our knowledge, these are the first case reports using the descending branch of the lateral circumflex femoral artery system for (1) temporary ectopic implantation of a thumb and (2) temporary implantation of fasciocutaneous tissue based on posterior tibial artery perforators just before below knee amputation to reconstruct the contralateral leg.

Management of intrathoracic defects.

Intrathoracic defects continue to provide one of the most challenging problems faced by the reconstructive surgeon, particularly in the presence of bronchopleural fistula. We review the principles of management of bronchopleural fistulae and empyema, with an emphasis on the Clagett principle, pedicled and free muscle flaps, and the concept of a "designed air fistula" in bronchopleural fistula management. Although the importance of muscle flap closure in intrathoracic defects is undisputed, the timing and relative superiority of muscle flap closure versus conventional thoracic-surgical techniques remains an unanswered question.