Bone and soft tissue reconstruction with tendon balance in severe foot trauma.

In severe foot trauma, it is difficult to determine the level of amputation when the crush injury is severe. We report a case of amputation near Lisfranc that achieved forefoot amputation-like results by using bone and soft tissue reconstruction while considering tendon balance. The patient was a 40-year-old male. The patient's left leg was caught in a garbage truck and sustained a crush injury. The second to fifth metatarsals were amputated at the diaphysis, and a high degree of instability of the Lisfranc joint was observed. A high degree of contamination was detected in the patient's wound, and the second to fifth toes were amputated at the Lisfranc joint during the initial treatment. The ends of the tibialis anterior, tibialis posterior and peroneus longus were preserved. On day 5 in the hospital, Lisfranc joint fixation of the hallux, amputation of the first metatarsal and reconstruction of the peroneus brevis were performed. On day 13, extensor hallucis longus tendon transfer and free anterolateral thigh flap were performed. On day 80, the patient was able to walk in regular shoes or non-orthopedic shoes. One year after reconstructive surgery, the patient had an average SAFE-Q score of 86.2 and mild varus deformity of the foot remained. In cases of severe foot trauma, the aim of reconstruction should be partial forefoot amputation whenever possible.

Trend of female first authorship in Journal of Orthopaedic Science, the official journal of the Japanese orthopaedic association from 2001 to 2021: An observational study.

BACKGROUND: Women are underrepresented in orthopaedic surgery, especially in Japan. Authorship is associated with representation and career advancement, but the academic representation of women in Japanese orthopaedic surgery has not been elucidated. This study aimed to elucidate the proportion of female first authorship and its associating factors, as well as trends in the Journal of Orthopaedic Science (JOS), the official journal of the Japanese Orthopaedic Association. METHODS: The study reviewed original articles published in JOS from 2002 to 2021 using data from PubMed on March 16, 2022. The gender of the first and last authors was determined using genderize. io, an online gender detection tool and manual search. The study used multivariable logistic regression to identify the factors associated with female first authorship and visualized the trend of predicted probability using restricted cubic spline curve. RESULTS: Among 2272 original articles, 148 (6.5%) and 79 (3.5%) had female first and last authors, respectively. Compared with 2002-2006, female first authorship significantly increased in 2012-2016 (adjusted odds ratio [aOR], 2.04; 95% confidence interval [CI], 1.09-4.05; p = 0.03) and 2017-2021 (aOR, 2.72; 95% CI, 1.46-5.276; p = 0.002). Affiliation with an institution in Japan (aOR, 0.51; 95% CI, 0.35-0.74; p < 0.001) and affiliation in orthopaedics (aOR, 0.16; 95% CI, 0.11-0.23; p < 0.001) were negatively associated with female first authorship. Around 2020, the trend showed a gradual then rapid increase in women with non-orthopaedic affiliations. Only a very small increase was observed in women with an orthopaedic affiliation. CONCLUSIONS: Female first authorship in JOS has been increasing. However, the proportion of female authors remains low. Authors outside of Japan and not affiliated with orthopaedics largely affect female authorship statistics. The results indicate the persistent gender gap in the academic representation of women in Japanese orthopaedic publications.

A novel technique for stabilising sacroiliac joint dislocation using spinal instrumentation: technical notes and clinical outcomes.

PURPOSE: Currently, sacroiliac joint dislocations, including crescent fracture-dislocations, are treated using several techniques that have certain issues. We present the technical details and clinical outcomes of a new technique, anterior sacroiliac stabilisation (ASIS), performed using spinal instrumentation. METHODS: ASIS is performed with the patient in a supine position via the ilioinguinal approach. The displacements are reduced and fixed by inserting cancellous screws from the sacral ala and iliac brim; the screw heads are bridged using a rod and locked. We performed a retrospective review of patients with iliosacral disruption who underwent ASIS between May 2012 and December 2020 at two medical facilities. The patients were assessed for age, sex, injury type, associated injuries, complications, functional outcome by evaluating the Majeed pelvic score after excluding the sexual intercourse score and fracture union. RESULTS: We enrolled 11 patients (median age: 63 years). The median operative time was 195 min, median blood loss was 570 g, and eight patients (72.3%) required blood transfusion. The sacral and iliac screws had a diameter of 6.0-8.0 mm and 6.2-8.0 mm, and a length of 50-70 mm and 40-80 mm, respectively. Bone union was achieved with no marked loss of reduction in the median follow-up period of 12 months in all cases. The median Majeed score at the final follow-up was 85/96. CONCLUSION: ASIS is a rigid internal fixation method that provides angular stability. Despite invasiveness issues compared to iliosacral screw fixation, this method is easy to confirm and achieves precise reduction.

Free tensor fascia lata true-perforator flap transfer for reconstruction of the calcaneal soft tissue defect complicated with osteomyelitis in a patient with alcohol-induced Charcot foot: A case report and literature review.

Charcot foot is can result in bone deformities and soft tissue defects. We report a case of alcohol-induced Charcot (AIC) foot with soft tissue defect including the weight-bearing zone of the heel and osteomyelitis, which was successfully reconstructed with free tensor fascia lata true-perforator flap (TFLtp). A 56-year-old male suffered from AIC foot with an 18 × 6 cm defect. Based on the preoperative ultrasound, we identified the overlying upper thigh area offering one of the thickest dermis. A TFLtp flap was raised sparing the TFL muscle based on one perforator without including the main trunk of the transverse/ascending branch of the lateral femoral circumflex vessel. The TFLtp flap was transferred to the heel and anastomosed to the posterior tibial artery in an end-to-side fashion. The patient complained no postoperative discomfort of the donor site and was able to walk on his foot after 5 weeks. This case report highlights that the TFLtp flap may offer thick dermis, faster surgery due to perforator level dissection and a concealed donor site.

Supermicrosurgery for oncologic reconstructions.

With advancement of microsurgical techniques, supermicrosurgery has been developed. Supermicrosurgery allows manipulation (dissection and anastomosis) of vessels and nerves with an external diameter of 0.5 mm or smaller. Because quality of life of cancer survivors is becoming a major issue, less invasive and functionally-better oncological reconstruction using supermicrosurgical techniques attracts attention. Conventional free flap reconstruction usually sacrifices major vessels and muscle functions, whereas supermicrosurgical free flaps can be transferred from anywhere using innominate vessels without sacrifice of major vessel/muscle. Since a 0.1-0.5 mm vessel can be anastomosed, patient-oriented least invasive reconstruction can be accomplished with supermicrosurgery. Another important technique is lymphatic anastomosis. Only with supermicrosurgery, lymph vessels can be securely anastomosed, because lymph vessel diameter is usually smaller than 0.5 mm. With clinical application of lymphatic supermicrosurgery, various least invasive lymphatic reconstruction has become possible. Lymphatic reconstruction plays an important role in prevention and treatment of lymphatic diseases following oncologic surgery such as lymphedema, lymphorrhea, and lymphocyst. With supermicrosurgery, various tissues such as skin/fat, fascia, bone, tendon, ligament, muscle, and nerves can be used in combination to reconstruct complicated defects; including 3-dimensional inset with multi-component tissue transfer.

Technical pearls in lymphatic supermicrosurgery.

Lymphedema is becoming a major public issue with improvement of cancer survival rate, as the disease is incurable and progressive in nature, and the number of cancer survivor with lymphedema is increasing over time. Surgical treatment is recommended for progressive lymphedema, especially when conservative therapies are ineffective. Among various lymphedema surgeries, supermicrosurgical lymphaticovenular anastomosis (LVA) is becoming popular with its effectiveness and least invasiveness. There are many technical knacks and pitfalls in LVA surgery. In preoperative evaluation, indocyanine green lymphography is recommended for considering indication and incision sites. Intraoperatively, intravascular stenting method, temporary lymphatic expansion maneuver, field-rotating retraction, and several navigation methods are useful. The most important postoperative care is immediate compression after LVA surgery. Compression is critical to keep lymphatic pressure higher than venous pressure, allowing continuous lymph-to-venous bypass flow. These technical pearls should be shared with lymphedema surgeons for better lymphedema management.

Fracture dislocation of the ankle with posterior tibial tendon entrapment within the tibiofibular interosseous space: A case report.

In rare cases of ankle fracture dislocation, the posterior tibial muscle tendon (TP tendon) is incarcerated between the tibia and fibula, thereby impeding reduction. Here we describe a case that presented with such a condition, in which ankle reduction was achieved and surgical repair of the incarcerated TP was delayed. The subject was a 30-year-old male who sustained a fracture dislocation of the left ankle (AO:44-C1.3) in a motorbike accident. After repairing the ankle dislocation, external fixation was performed and osteosynthesis was conducted 10 days after the injury. Plate fixation for the fibula fracture and tight rope fixation for the separation between the tibia and fibula were performed; however, internal fixation for the medial malleolus fracture was delayed because the skin on the medial side of the ankle was in poor condition. One month after the injury, osteosynthesis of the medial malleolus was performed, and the TP tendon was identified in the fracture site. After removing the incarcerated tendon, good reduction of the medial malleolus was achieved, and thus, internal fixation and wound closure could be performed. Re-examination revealed that the TP tendon had an abnormal course. After 3 months, upon re-exposing the entire length of the TP tendon, the TP tendon was incarcerated between the tibia and fibula. To date, although several cases have been reported regarding TP tendon incarceration caused by fracture dislocation of the ankle, no study has reported the anatomical repair of the ankle, regardless of tendon incarceration. In our case, rotational displacement of the medial malleolus fracture remained when the second surgery was completed; however, the presence of some type of incarcerated tissue was suspected. Because leaving the incarcerated TP tendon untreated can cause irreversible long-term complications, early anatomical repair is recommended.

Definition of perforator flap: what does a "perforator" perforate?

Perforator flap concept plays an important role in reconstructive surgery, because it allows less invasive and more complex reconstruction by preserving major vessels and muscles with intramuscular vessel dissection. Originally "perforator" represents vessel perforating the muscle, then vessel perforating the deep fascia regardless of muscle perforation. With technical progress in reconstructive microsurgery, the previous definition becomes inappropriate for least invasive flaps, only requiring intra-adiposal vessel dissection, such as superficial circumflex iliac artery perforator flap. Based on our experience of various least invasive flap reconstructive surgeries, a new concept for perforator flap has been developed. The new definition of perforator is a vessel perforating an envelope of a targeted tissue to be transferred; the superficial fascia for skin, the periosteum for bone, the perineurium for nerve, and the deep fascia for muscle. According to the new definition, all flaps can be precisely classified based on the corresponding "perforator".