Reconstruction of the Base of Skull Defect-Lessons Learned over 25 Combined Years.

With an increased understanding of the pathological processes involved in perinerual spread, surgery has come to play a greater role in its management. As skull base techniques have been refined, the reconstructive surgeon has been presented with increasingly complex and voluminous defects requiring repair. To enable such surgery to have acceptable outcomes, attention to form and function is paramount. This article describes the methods of repair, which have evolved over the last 25 years of practice, and that we find to be both reliable and durable. Our accumulated experience is presented as a treatment algorithm, which will aid the skull base reconstructive surgeon to achieve success for the wide variety of defects encountered with these patients.

Soft tissue reconstruction after compound tibial fracture: 235 cases over 12 years.

BACKGROUND: Outcomes in management of compound tibial fractures are measured by the rate of infection and non-union. These are a function of many variables that interact in complex ways. Our aims are to describe changes in these injuries over the past decade, to determine which variables predict a poor outcome and to compare reconstructive options controlling for these variables. METHODS: All compound tibial fractures reconstructed at the Princess Alexandra Hospital from 1999 to early 2009 were reviewed retrospectively. The remainder of 2009 and 2010 were reviewed prospectively. Data were collected from departmental audits, medical records and imaging. RESULTS: 251 flaps were performed in 235 patients. Reconstructions within one week declined after 2000, which correlated with increasing Negative Pressure Dressings use (R = 0.77). Free flap use increased though the incidence of distal fractures did not (R = 0.29). Muscle flaps were consistently preferred. Injuries with a poor outcome had a greater delay or failed soft tissue reconstruction. A poor outcome was more likely in patients with a contaminated distal fracture (p = 0.0038). Outcomes in muscle and fasciocutaneous flaps were not significantly different. CONCLUSIONS: Compound tibial fracture management has evolved to temporary followed by definitive fixation. Free flap use has increased, particularly in diaphyseal injuries. Delays in reconstruction should prompt aggressive surgical management. Injuries at risk of a poor outcome can be further characterised as being distal and contaminated. Reconstructive surgeons should not be discouraged from using muscle flaps. A management algorithm based on the evidence provided is presented. LEVEL OF EVIDENCE: Therapeutic III.

History of lower limb reconstruction after trauma.

BACKGROUND: The principles guiding reconstruction of the lower limb after trauma have become established over 300 years through advances in technology and studies of epidemiology. This paper reviews how these principles came about and why they are important. METHODS: This is a structured review of historical and recent literature pertinent to lower limb reconstruction. The outcomes assessed in the pre-modern era were wound mortality, amputation mortality and amputation rate. In the modern era, infection and non-union emerged as measures of outcome, which are morbidity- rather than mortality-based. Indications for amputation published during the eras are taken to reflect the reconstructive practices of the time. RESULTS: Amputation and wound mortality fell throughout the pre-modern era, from 70% and 20% to 1.8% and 1.8%, respectively. Amputation rates peaked in the American Civil War (53%) but have remained less than 20% since then. Infection and non-union rates in the modern era have fluctuated between 5% and 45%. CONCLUSIONS: Priority areas for research include refinement of soft tissue reconstruction, injury classification, standardization of outcome measures and primary prevention. The impact of débridement and antisepsis on outcomes should not be forgotten as progress is made.