The Arterial System of the Fasciocutaneous Deltoid Flap Pedicle on 320-Detector Row Computed Tomography and Clinical Application in the Foot and Hand.

BACKGROUND: Fasciocutaneous free deltoid flaps are used to reconstruct hand, foot, and maxillofacial defects. Although anatomical studies of this flap pedicle have been performed on cadavers, there are no reports on the use of 320-detector row computed tomography angiography (CTA-320) to investigate the deltoid flap pedicle in living humans. This study aimed to investigate the arterial characteristics of the deltoid flap pedicle using the CTA-320 system in living humans. METHODS: Twenty-seven adult Vietnamese patients with 54 healthy deltoid regions underwent CTA-320 to investigate arterial blood supply before clinical free-flap transfer. Two- and three-dimensional reconstruction images of the arterial pedicle were visualized, and clinical reconstruction results were evaluated. RESULTS: The cutaneous vessel branches of the deltoid flap were separated from the posterior circumflex humeral artery (PCHA) and originated from the axillary (77.78%), subscapular (12.96%), and brachial (9.26%) arteries. The PCHA penetrated the quadrangular space in 90.74% of patients. The cutaneous arterial branch was present in the deltoid-triceps groove in 100% of patients. The average diameter and length of the PCHA were 3.38 ± 0.58 and 43.08 ± 6.60 mm, respectively. The average diameter and length of the flap cutaneous branch were 1.49 ± 0.28 and 44.57 ± 4.83 mm, respectively. The findings of CTA-320 were aligned with the intraoperative clinical findings well. All deltoid flaps were successfully free-transferred with good outcomes. CONCLUSION: The CTA-320 is a practical and effective method for investigating deltoid flap pedicles. It enables accurate flap design and harvesting of flaps, thereby enhancing the clinical success of free-flap transfer.

Quality of Life after Rhinoplasty: A Prospective Study.

As our previous studies have shown, cosmetic surgery has a positive correlation with postoperative well-being. The aim of this study was to prospectively examine the postoperative changes in quality of life (QoL) after a rhinoplasty. Thirty-four patients who underwent septorhinoplasty performed by a single surgeon from July 2015 to October 2018 reported in indication-specific self-developed and different validated questionnaires (FLZM or Fragen zur Lebenszufriedenheit Module, Freiburg Personality Inventor, Rosenberg self-esteem scale, Functional Rhinoplasty Outcome Inventory 17 [FROI-17], and Glasgow Benefit Inventory [GBI]) on the status of their QoL preoperatively (T0) and 6 months' follow-up (T1). Our goal was to assess the difference in psyche and self-esteem and to get objective insights into the effect of the operation. Significant improvements in QoL in terms of general module, health, and appearance were noted. The general part of the FLZM showed increasing T1 values in the sum scores (p = 0.005). With regard to the item "health," T1 was better than the norm data (p = 0.003). The statistically significant improvement for the item nose appearance (p < 0.0001) after operation and T1 versus reference data (p < 0.010) should be highlighted. The subjective patient ratings showed statistically significant T1 improvements for all items of the FROI-17: overall nose (p < 0.0001), nasal function (p = 0.001), general/further symptoms (p = 0.006), and confidence increased by aesthetic changes (p < 0.0001). Furthermore, the GBI score shows an improved QoL after rhinoplasty (p < 0.0001). Based on the assessment of a variety of disease- and nondisease-specific validated questionnaires, numerous improvements in the QoL of the patients were observed. Therefore, we support septorhinoplasty as a meaningful procedure regarding QoL improvement. The level of evidence is Level II prospective cohort study.

Management and prevention of acute bleedings in the head and neck area with interventional radiology.

BACKGROUND: The Interventional Neuroradiology is becoming more important in the interdisciplinary treatment of acute haemorrhages due to vascular erosion and vascular tumors in the head and neck area. The authors report on acute extracranial haemorrhage in emergency situations but also on preventive embolization of good vascularized tumors preoperatively and their outcome. METHODS: Retrospective analysis of 52 patients, who underwent an interdisciplinary approach of the ORL Department and the Interventional Neuroradiology over 5 ½ years at the Department of Otorhinolaryngology, Klinikum Rechts der Isar, Technical University of Munich, Germany. Their outcome was analysed in terms of success of the embolization, blood loss, survival rate and treatment failures. RESULTS: 39/52 patients were treated for acute haemorrhage. Twenty-five of them attributable to vascular erosion in case of malignant tumors. Affected vessels were the common carotid artery as well as its internal and external parts with branches like the ascending pharyngeal, the facial and the superior thyroid artery. Altogether 27/52 patients were treated for malignant tumors, 25/52 were attributable to acute haemorrhage due to epistaxis, after tonsillectomy, benign tumors and bleeding attributable to inflammations. Treatment of all patients consisted either of an unsuccessful approach via exposure, package of the bleeding, electrocoagulation or surgical ligature followed by embolization or the primary treatment via interventional embolization/stenting. CONCLUSIONS: The common monitoring of patients at the ORL and interventional neuroradiology is an important alternative especially in the treatment of severe acute haemorrhage, following vascular erosion in malignant tumors or benign diseases. But also the preoperative embolization of good vascularized tumors must be taken into account to prevent severe blood loss or acute intraoperative bleeding.

Development of volume-stable adipose tissue constructs using polycaprolactone-based polyurethane scaffolds and fibrin hydrogels.

Adipose tissue engineering aims at the restoration of soft tissue defects and the correction of contour deformities. It is therefore crucial to provide functional adipose tissue implants with appropriate volume stability. Here, we investigate two different fibrin formulations, alone or in combination with biodegradable polyurethane (PU) scaffolds as additional support structures, with regard to their suitability to generate volume-stable adipose tissue constructs. Human adipose-derived stem cells (ASCs) were incorporated in a commercially available fibrin sealant as well as a stable fibrin hydrogel previously developed by our group. The composite constructs made from the commercially available fibrin and porous poly(ε-caprolactone)-based polyurethane scaffolds exhibited increased volume stability as compared to fibrin gels alone; however, only constructs using the stable fibrin gels completely maintained their size and weight for 21 days. Adipogenesis of ASCs was not impaired by the additional PU scaffold. After induction with a common hormonal cocktail, for constructs with either fibrin formulation, strong adipogenic differentiation of ASCs was observed after 21 days in vitro. Furthermore, upregulation of adipogenic marker genes was demonstrated at mRNA (PPARγ, C/EBPα, GLUT4 and aP2; qRT-PCR) and protein (leptin; ELISA) levels. Stable fibrin/PU constructs were further evaluated in a pilot in vivo study, resulting in areas of well-vascularized adipose tissue within the implants after only 5 weeks. Copyright © 2013 John Wiley & Sons, Ltd.

The Psychologic and Psychosocial Impact of Otoplasty on Children and Adults.

BACKGROUND: In previous studies, our research group already evaluated the impact of aesthetic surgery on "quality of life" (QoL). This study evaluates QoL factors and perceptions of well-being after otoplasty as a single indication. METHODS: Eighty-one patients who underwent otoplasty were divided into three age groups: Youth 1 (Y1) = 8-12 years (n = 17), Youth 1 (Y2) = 13-17 years (n = 13), and Adult ≥18 years (n = 51). For competitive analysis, 2 groups of tests were used: a standardized self-assessment test on life satisfaction (FLZ(M)), the Glasgow Benefit Inventory (GBI), the standardized Rosenberg Self-Esteem Scale (RSES), the standardized Freiburg Personality Inventory (FPI-R), the Patient Health Questionnaire 4 (PHQ-4), and a self-developed and indication-specific questionnaire for "Adult" group. The tools for the groups Y1 and Y2 were: PHQ-4, KINDL(R), the Glasgow Child Benefit Inventory (GCBI), and a self-developed and indication-specific questionnaire either. RESULTS: Our data bared numerous significant improvements on patients' QoL. In the items "friends" (P = 0.036) and "freedom of anxiety" (P = 0.034) of the FLZ(M), important improvements were found. In section "satisfaction with appearance" (body image), the items "hair" (P = 0.003) and "ear" (P = 0.034) were to point out. The RSES (P = 0.001) and the FPI-R (P = 0.035) data indicated a well-balanced emotional stability. The results of the GBI/GCBI (P = 0.000/P = 0.000) showed a higher QoL of postsurgery patients. The data of the KINDL questionnaire provided increasing values in the modules "friends" (P = 0.033) and "total score" (P = 0.040) for boys of the ages 8 to 12. For all age groups, there was a less affinity to depression (PHQ-4) and a high satisfaction with the aesthetical result (indication-specific questionnaire). CONCLUSIONS: This study showed higher QoL in all age groups by using standardized tools in comparison with the norm data. The knowledge of postoperative psychologic benefits, such as "satisfaction with appearance" (body image) and "different areas of life," self-confidence, and self-esteem as well as lower level of depression support meaningfulness of otoplasty. LEVEL OF EVIDENCE: Therapeutic, III: Retrospective cohort or comparative study.

Vascularization of engineered cartilage constructs in a mouse model.

Tissue engineering of cartilage tissue offers a promising method for reconstructing ear, nose, larynx and trachea defects. However, a lack of sufficient nutrient supply to cartilage constructs limits this procedure. Only a few animal models exist to vascularize the seeded scaffolds. In this study, polycaprolactone (PCL)-based polyurethane scaffolds are seeded with 1 × 10(6) human cartilage cells and implanted in the right hind leg of a nude mouse using an arteriovenous flow-through vessel loop for angiogenesis for the first 3 weeks. Equally seeded scaffolds but without access to a vessel loop served as controls. After 3 weeks, a transposition of the vascularized scaffolds into the groin of the nude mouse was performed. Constructs (verum and controls) were explanted 1 and 6 weeks after transposition. Constructs with implanted vessels were well vascularized. The amount of cells increased in vascularized constructs compared to the controls but at the same time noticeably less extracellular matrix was produced. This mouse model provides critical answers to important questions concerning the vascularization of engineered tissue, which offers a viable option for repairing defects, especially when the desired amount of autologous cartilage or other tissues is not available and the nutritive situation at the implantation site is poor.

Prefabrication of 3D cartilage contructs: towards a tissue engineered auricle--a model tested in rabbits.

The reconstruction of an auricle for congenital deformity or following trauma remains one of the greatest challenges in reconstructive surgery. Tissue-engineered (TE) three-dimensional (3D) cartilage constructs have proven to be a promising option, but problems remain with regard to cell vitality in large cell constructs. The supply of nutrients and oxygen is limited because cultured cartilage is not vascular integrated due to missing perichondrium. The consequence is necrosis and thus a loss of form stability. The micro-surgical implantation of an arteriovenous loop represents a reliable technology for neovascularization, and thus vascular integration, of three-dimensional (3D) cultivated cell constructs. Auricular cartilage biopsies were obtained from 15 rabbits and seeded in 3D scaffolds made from polycaprolactone-based polyurethane in the shape and size of a human auricle. These cartilage cell constructs were implanted subcutaneously into a skin flap (15 × 8 cm) and neovascularized by means of vascular loops implanted micro-surgically. They were then totally enhanced as 3D tissue and freely re-implanted in-situ through microsurgery. Neovascularization in the prefabricated flap and cultured cartilage construct was analyzed by microangiography. After explantation, the specimens were examined by histological and immunohistochemical methods. Cultivated 3D cartilage cell constructs with implanted vascular pedicle promoted the formation of engineered cartilaginous tissue within the scaffold in vivo. The auricles contained cartilage-specific extracellular matrix (ECM) components, such as GAGs and collagen even in the center oft the constructs. In contrast, in cultivated 3D cartilage cell constructs without vascular pedicle, ECM distribution was only detectable on the surface compared to constructs with vascular pedicle. We demonstrated, that the 3D flaps could be freely transplanted. On a microangiographic level it was evident that all the skin flaps and the implanted cultivated constructs were well neovascularized. The presented method is suggested as a promising alternative towards clinical application of engineered cartilaginous tissue for plastic and reconstructive surgery.

Influence of different growth factors on chondrogenic differentiation of adipose-derived stem cells in polyurethane-fibrin composites.

INTRODUCTION: Chondrogenic differentiation of adipose-derived stem cells (ASCs) has proven to be feasible. To compensate for laryngeal palsy or cartilage defects after surgery or trauma using tissue engineering, a formable and stable scaffold material is mandatory. METHODS: ASCs were seeded in fibrin-polyurethane scaffolds and cultured in chondrogenic differentiation medium adding the growth factors TGF-b1, TGF-b3, and BMP-2 for up to 35 days. RESULTS: Histological examination showed acid glycosaminoglycans in the extracellular matrix in all groups. Immunofluorescence presented positive staining for collagen II, aggrecan, and SOX-9 in the TGF-b1-, TGF-b3-, and BMP-2-group. With Real-time PCR analyses, chondrogenic differentiation became apparent by the expression of the specific genes COL2A1 (collagen II), AGC 1 (aggrecan), and SOX-9, whereas collagen II expression was low in all groups compared to bone marrow-derived stem cells (BMSC) due to reduced chondrogenic ability. CONCLUSIONS: These findings demonstrate the general ability of ASCs to differentiate into matrix-producing chondrocytes in fibrin-polyurethane scaffolds. However, further experiments are necessary to enhance this chondrogenic potential of ASCs seeded in fibrin-polyurethane scaffolds in order to produce a suitable regeneration method for treating cartilage defects or an implantable medialization material for vocal cord palsy.

Engineering of vascularized adipose constructs.

Adipose tissue engineering offers a promising alternative to the current surgical techniques for the treatment of soft tissue defects. It is a challenge to find the appropriate scaffold that not only represents a suitable environment for cells but also allows fabrication of customized tissue constructs, particularly in breast surgery. We investigated two different scaffolds for their potential use in adipose tissue regeneration. Sponge-like polyurethane scaffolds were prepared by mold casting with methylal as foaming agent, whereas polycaprolactone scaffolds with highly regular stacked-fiber architecture were fabricated with fused deposition modeling. Both scaffold types were seeded with human adipose tissue-derived precursor cells, cultured and implanted in nude mice using a femoral arteriovenous flow-through vessel loop for angiogenesis. In vitro, cells attached to both scaffolds and differentiated into adipocytes. In vivo, angiogenesis and adipose tissue formation were observed throughout both constructs after 2 and 4 weeks, with angiogenesis being comparable in seeded and unseeded constructs. Fibrous tissue formation and adipogenesis were more pronounced on polyurethane foam scaffolds than on polycaprolactone prototyped scaffolds. In conclusion, both scaffold designs can be effectively used for adipose tissue engineering.

Chondrocytes suspended in modified fibrin glue for vocal fold augmentation: An in vitro study in a porcine larynx model.

BACKGROUND: Injection laryngoplasty is an option for treatment of dysphonia following vocal fold paralysis. Modified fibrin glue with suspended chondrocytes might be a favorable cell-based material for permanent vocal fold medialization. METHODS: We compared fibrin glue with suspended chondrocytes to collagen and hyaluronic acid gels concerning alteration of vocal fold vibration and correct intralaryngeal placement after intralaryngeal injection into porcine larynges. Viscoelastic properties of the materials were analyzed by means of a parallel plate rheometer. RESULTS: Fibrin glue with cells was comparable to collagen and hyaluronic acid with respect to amplitudes, symmetry, and periodicity of vocal fold vibration. Application and positioning of fibrin glue with suspended chondrocytes were technically undemanding and comparable with controls. Complex stress modulus of fibrin glue with suspended cells was comparable to that of collagen gel. CONCLUSIONS: Fibrin glue with suspended chondrocytes seems suitable for the indication of injection laryngoplasty and holds promise for permanent vocal fold medialization.

Combined aesthetic and functional reconstruction of ear malformations.

BACKGROUND: Surgery for major malformations of the outer and middle ear involves aesthetic as well as functional aspects. Whereas reconstruction of the auricle with autogenous rib cartilage is well established and has shown favorable results, functional repair using classic reconstructive techniques is possible only in a limited group of patients and the outcome is often unsatisfactory. Active middle ear implants (MEI) offer a promising alternative to reconstructive surgery. METHOD: Fifteen patients with ear malformations underwent implantation of an active middle ear implant (Soundbridge), with or without concomitant reconstruction of the auricle. The vibrating element, the floating mass transducer (FMT), was coupled either to the round window, stapes, oval window or incus, according to each individual's anatomical middle ear situation. Aesthetic as well as functional outcomes were evaluated. RESULTS: Implantation could be integrated into aesthetic reconstruction of the auricle without complications. In 14/15 patients, a satisfactory functional result could be achieved (< 30 dB pure-tone audiometry). Neither facial nerve palsy nor inner ear hearing loss was observed after implantation. CONCLUSION: The versatile form of the FMT of the Soundbridge allows for adaptation of the coupling procedure to the individual anatomical situations. Implantation of a Soundbridge MEI is a valuable option for functional reconstruction of the malformed ear, which may offer more consistent and reliable results than classic reconstructive surgery.

Customized tissue engineering for ear reconstruction.

Tissue engineering (TE) of cartilage for reconstructive surgery has proven to be a promising option for obtaining tissue for 3D structures that results in minimal donor site morbidity. Technological advances in this area are important since many defects can only be treated with customized implants. Most TE strategies rely on the use of resorbable 3D scaffolds to guide the growing tissue, with each tissue requiring a specific scaffold that has precisely defined properties depending on the physiological environment. Rapid prototyping (RP) technologies allow the fabrication of scaffolds of various geometric complexities from a variety of materials and as composites, while even allowing the inner architecture of the object to be varied in a defined manner at any given location. Scaffolds can be manufactured using RP techniques directly from computer aided design (CAD) data sources, e.g. via an STL file. The combination of TE and RP serves as the basis for the production of customized implants, for example the cartilage ear framework, and provides new perspectives for autologous ear reconstruction.

Cartilage tissue engineering for auricular reconstruction: in vitro evaluation of potential genotoxic and cytotoxic effects of scaffold materials.

Tissue engineering of autologous cartilage transplants is suggested as a new approach in reconstruction of external auricular deformities. 1.6-Hexanediol (HD), 1.8-diazabicyclo[5.4.0]undec-7-ene (DBU) and 6-hydroxyhexanoic acid (HHA) are matrices of the open-pored polyurethane three-dimensional scaffold. Since these bioresorbable materials may interact with the human organism, cytotoxic effects on human chondrocytes and lymphocytes and genotoxic effects on human lymphocytes were monitored. Staining with propidium iodide and fluorescence diacetate as well as the EZ4U proliferation assay served for the detection of cytotoxic effects of the materials on human chondrocytes. Trypan blue staining was used to monitor cytotoxicity on lymphocytes. Genotoxic effects on lymphocytes in terms of strand breaks, alkali labile sites and incomplete excision repair were determined by the alkaline single cell microgel electrophoresis (Comet) assay. Cytotoxic effects in chondrocytes and lymphocytes as well as genotoxic effects in lymphocytes were dose-dependent with threshold values of 5mg/mL HD, 0.5mg/mL DBU and 0.03 mg/mL HHA showing no effects. These data suggest that these matrices could be safely used for scaffolds made of polyurethane unless these compounds are not released at a rate giving higher concentrations at the site of implantation or in body fluids, respectively.

Optimization of platelet isolation and extraction of autogenous TGF-beta in cartilage tissue engineering.

Platelets are enriched with Transforming Growth Factor-beta (TGF-beta). However, information is limited concerning TGF-beta's effects at the molecular level. Nevertheless, it has been demonstrated that TGF-beta activates cell proliferation and its positive influence on cartilage formation has been proven within the field of Tissue Engineering (TE). As Platelet Rich Plasma (PRP) contains TGF-beta, it was the purpose of this study to optimize PRP-isolation for further TGF-beta extraction. Red blood cell count (RBC) was separated from whole blood by centrifugation. From the supernatant PRP and platelet poor plasma (PPP) layer, the latter supernatant was re-centrifuged to extract PRP. Various experimental series were run to investigate influences concerning anticoagulating alternatives, different amounts of buffer, various centrifugal forces, or substituting centrifugation for sedimentation. TGF-beta levels were determined using ELISA. The technique of platelet-/ TGF-beta-extraction described here proves to be more effective than other methods, is easily repeatable and not time-consuming, which predisposes it for TE requirements.

Cytotoxic and genotoxic effects of matrices for cartilage tissue engineering.

Customizing auricles with biodegradable polyurethane colonized with autologous chondrocytes as an approach for tissue engineering cartilage transplants has been suggested for the reconstruction of the external ear to repair auricular deformities. Dextrose, triethanolamine and poly(ethylene glycol)-block-poly(propylene glycol)-block-poly(ethylene glycol) (PEG-PPG-PEG) are matrices of an open-pored polyurethane three-dimensional scaffold. After release from the polymer, these compounds can be absorbed into the human organism. Therefore, cytotoxic effects on human chondrocytes and lymphocytes and genotoxic effects on human lymphocytes were determined. Propidium iodide and fluoresceine diacetate staining as well as quantitative proliferations testing with EZ4U served to detect cytotoxic effects on chondrocytes. In lymphocytes cytotoxicity was checked by trypan blue staining and the alkaline single cell microgel electrophoresis (Comet) assay was used to study genotoxic effects. Dose-dependent cytotoxicity and genotoxicity of the matrices could be shown. Concentrations up to 4.25mg/ml for dextrose, 0.15 mg/ml for PEG-PPG-PEG and 0.9 mg/ml for triethanolamine did not show cytotoxic effects in chondrocytes or genotoxic effects in lymphocytes. These data suggest that dextrose, triethanolamine and PEG-PPG-PEG could be safely used if scaffolds made of open-pored polyurethane do not release these compounds at a rate giving higher concentrations at the site of implantation or in body fluids, respectively.

Comparison of effective use of implanted vascular pedicles for skin flap prefabrication: an experimental study.

Thin, large, well-vascularized, and axial-pattern flaps are often desired in the clinical practice of defect reconstruction to maximize esthetic and functional results. Flap prefabrication based on the neovascularization development following vascular pedicle implantation allows surgeons to create such flaps as required. Using different types of implanted vascular pedicles, the aim of the study was to identify the most effective and suitable types of pedicles for clinical use. Five models of implanted vascular pedicles in Chinchilla Bastard rabbits were investigated as follows: model 1, arteriovenous (AV) pedicle with end ligation (minimal blood flow in the implanted vascular pedicle); model 2, AV pedicle with end anastomosis (new shunt formation between vein and artery stump for creating maximal blood flow in the implanted vascular pedicle); model 3, purely isolated arterialized venous loop; model 4, purely isolated arterial loop; model 5, AV pedicle with end anastomosis (similar to model 2) combined with flap expansion. These different types of vascular pedicles were implanted into a random-pattern abdominal skin flap as large as 8 x 15 cm. Neovascularization in the various prefabricated flaps was evaluated macroscopically, scintigraphically, microangiographically, and histologically. A total of 150 prefabricated flaps were investigated and randomly assigned to 5 models with 30 flaps each. Each model contained 5 groups of 6 flaps corresponding to the various retention times of 4, 8, 12, 16, and 20 days after vascular pedicle implantation. Six flaps were also designated to the control group. Neovascularization was best in model 5, followed by comparable results for models 2, 3, and 4, with the worst results found in model 1, especially for the time intervals of 8, 12, and 16 days. Twenty days remains the minimal length of time required for matured neovascularization in all models (P < 0.05). Models 2 and 3 both appear to be particularly promising for clinical application.

Complete middle forearm amputations after avulsion injuries--microsurgical replantation results in Vietnamese patients.

BACKGROUND: Replantation after complete avulsion amputations at the level of the middle forearm is rarely reported in the literature and remains one of the most difficult challenges for microsurgeons. Microsurgery and its clinical applications are new procedures in Vietnam. The purpose of this article is to evaluate our replantation results in Vietnamese patients relating to this type of injury using microsurgical techniques. METHODS: Ten replanted patients after complete avulsion amputations of the middle forearm, operated on at the Department of Trauma and Orthopedics in the Central University Hospital 108 in Hanoi, Vietnam during a 7-year period (between September 1999 and April 2006) were reviewed and subsequently evaluated. All patient information was reexamined and documented. RESULTS: All replants had survived. All cases of bone stabilization using plates and screws (3 of 10 cases) were postoperatively infected and required supplemental intervention with flap reconstructions, whereas this was not observed in seven other patients receiving Kirschner wires (KW) combined with cerclages. Replantation was performed in a patient associated with plexus brachialis paralysis of the affected limb, which was not detected before the procedure. The combined postoperative functional outcomes rated from "excellent" to "fair" in 70% of cases based on an average follow-up period of 20 months. CONCLUSION: With respect to social and psychologic effects, performance of the procedure is extremely worthwhile because it not only provides complete limb preservation, but also has excellent potential for a favorable functional outcome.

Effectiveness of free gracilis muscle flaps in the treatment of chronic osteomyelitis with purulent fistulas at the distal third of the tibia in children.

BACKGROUND: Chronic purulent infection at the distal third of the tibia resulting from of a previous hematogenous osteomyelitis in children is a severe infection which is seldom reported in the literature and remains a difficult challenge for orthopaedic surgeons. METHODS: A 6-year retrospective review from September 2001 to October 2006 (institutional review board-approved) was performed to evaluate postoperative surgical results of this type of infection using a free gracilis muscle flap. RESULTS: A total of 6 children with an average age of 9.8 years were included. The infective period of purulent fistulas ranged from 6 to 31 months (mean 17.7). Staphylococcus aureus were reported in all wounds (6/6) and were commonly combined with Escherichia coli (5/6). All of the free gracilis muscle transfers were successful (6/6 flaps). No postoperative recurrence of infection was observed with an average postoperative follow-up period of 3 years. All patients were also able to satisfactorily demonstrate walking and standing functions. CONCLUSIONS: Both the radical debridement of infected tissues and restoration of ample blood supply using free muscle flaps are the keys to success. Based on its favorable form, the free gracilis muscle flap can be considered a suitable muscle for use in reconstruction. LEVEL OF EVIDENCE: IV.

Successful re-construction of a large tissue defect using a free pre-fabricated flap with purely implanted arterialised venous loop.

Flap pre-fabrication represents an interesting technique in tissue-defect reconstruction. In this article we report the successful clinical application of a free pre-fabricated flap using an isolated arterialised venous loop as an implanted vascular pedicle for reconstruction of an extended soft-tissue defect on the leg, as well as clinical neo-vascularisation development following arterialised venous loop implantation. The procedure appears potentially useful in selected patients due to the easy harvest of an isolated vein loop as well as a favourable functional and aesthetic result at the donor site.