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Microvascular Reconstructive Techniques in Orthopaedic Traumatology
Abstract
Great evolution has taken place in Orthopaedic Traumatology, regarding techniques, surgical means and equipment. However, we still encounter complicated cases of limb trauma that necessitate microvascular reconstruction. Through three different illustrative cases (one emergency foot revascularization by a free flap, covering an ankle arthrodesis and bridging the anterior tibial artery, one cure of a complex infected tibial non-union with extensive skeletal defect by double barrel fibular transfer and one osteo-chondral reconstruction of the scaphoid proximal pole using a vascularized graft harvested from the femoral medial condyle), the authors remind the Orthopaedic community about the benefits of microsurgery, especially if used in proper indication and timing. This article is a plea to preserve the knowledge and develop the technical abilities of microvascular techniques in the departments of Orthopaedics and Traumatology.
... The fibular proper artery at the base of the great toe is the main blood supply vessel for the toe flap. It is accompanied with nerves, which can minimise nerve dissociation and ischemia [28]. Therefore, all cases in this study recovered well in terms of personal sensation, and the clarity of fingerprints in the later stage was correlated with nerve recovery. ...
Background
This work aimed to investigate the change in fingerprint depth and the recovery rule of fingerprint biological recognition function after repairing finger abdominal defects and rebuilding fingerprint with a free flap.
Method
From April 2018 to March 2023, we collected a total of 43 cases of repairing finger pulp defects using the free flap of the fibular side of the great toe with the digital nerve. After surgery, irregular follow-up visits were conducted to observe fingerprint clarity, perform the ninhydrin test or detect visible sweating with the naked eye. We recorded fingerprint clarity, nail shape, two-point discrimination, cold perception, warm perception and fingerprint recognition using smartphones. The reconstruction process of the repaired finger was recorded to understand the changes in various observation indicators and their relationship with the depth of the fingerprint. The correlation between fingerprint depth and neural repair was determined, and the process of fingerprint biological recognition function repair was elucidated.
Result
All flaps survived, and we observed various manifestations in different stages of nerve recovery. The reconstructed fingerprint had a clear fuzzy process, and the depth changes of the fingerprint were consistent with the changes in the biological recognition function curve.
Conclusion
The free flap with the digital nerve is used to repair finger pulp defects. The reconstructed fingerprint has a biological recognition function, and the depth of the fingerprint is correlated with the process of nerve repair. The fingerprint morphology has a dynamic recovery process, and it can reach a stable state after 6–8 months.
Objective, With the help of network pharmacology and in vitro studies, this study aims to understand the mechanism by which Epimedium/ Icariin (EPI/ICA) promote angiogenesis through the HIF-1 signaling pathway, laying the groundwork for the treatment of bone discontinuity.
Methods, 1) The TCMSP database provided the gene targets for Epimedium's effect in this investigation. Search the GeneCards database for gene targets associated with "bone discontinuity". GO, KEGG, and Reactome enrichment analysis is performed after identifying possible gene targets for EPI/ICA treatment of bone discontinuity. Molecular docking to confirm the HIF-1 pathway's essential proteins' capacity to bind to ICA. 2) ①. Human umbilical vein vascular endothelial cells (HUVECs) were divided into blank control groups and ICA groups with different concentrations (0.01, 0.1, 1, 10 mol/L), and CCK8 measured the proliferative activity of HUVECs in each group after ICA intervention. These in vitro experiments sought to identify the optimal intervention concentration of ICA. ②. A test for angiogenesis to determine whether it can encourage angiogenesis. ③. After ICA intervention, Western blot and Elisa measured the level of HIF-1 pathway-related protein activity in each group.
Results, For the treatment of bone discontinuity, the bioinformatic analysis of EPI/ICA identified 164 potential therapeutic gene targets, including 45 important gene targets and 10 of these crucial gene targets (HIF1A, AKT1, TPT3, IL6, TNF, VEGFA, CASP3, MYC, EGFR, ESR1). The biological mechanisms examined in the GO of EPI/ICA for the treatment of osteonecrosis act primarily through the regulation of angiogenesis and the negative regulation of apoptotic processes, according to enrichment analysis of 45 important gene targets. The HIF-1 signaling pathway, TNF signaling pathway, IL-17 signaling pathway, and other signaling pathways were found to be primarily involved in the regulation of the EPI/ICA process in the therapy of bone discontinuity, according to KEGG analysis. Reactome enrichment analysis showed that the regulation of the EPI/ICA treatment of bone discontinuity mostly involves the regulation of inflammatory factors that are similar to interleukin and the body's autoimmune system. According to the results of molecular docking, ICA binds efficiently to the important target proteins of the HIF-1 signaling pathway, HIF-1A, VEGF, and IL-6. Further research revealed that ICA, the active ingredient in Epimedium, might increase the value-added differentiation of HUVECs, with the potential mechanism being angiogenesis via the HIF-1 signaling pathway.
Conclusion: This research revealed that EPI/ICA controls HIF-1A, VEGF, and IL-6, which are important HIF-1 signaling pathway target proteins, increases the value-added differentiation of HUVECs and angiogenesis, and offers a new approach for the treatment of bone discontinuity using EPI/ICA.
Today, microsurgery is an integral part of plastic surgery, maxillofacial surgery, hand surgery, and neurosurgery. More and more surgical procedures are accompanied by microsurgical intervention. Long training is required to develop the necessary skills for fine work with microsurgical instruments and delicate tissues under magnification. We suggest a methodology as to how to organize an inexpensive microsurgical training laboratory with minimal investment. Suggested guidelines provide information about cost-effective ways of arranging a comfortable training environment. An adapted stereoscopic microscope allows working with a wide range of magnification and focus distance. An ergonomic working position is set up by adjustable handmade table and chair. For performing basic microsurgical manipulations, a set of four instruments and inexpensive suture materials are used. A total amount of 323.5 USD was spent to purchase all of the necessary components for the microsurgical laboratory. The described components are available worldwide regardless of manufacturers. We suggest an inexpensive way to arrange a microsurgical laboratory. This approach is especially beneficial for students and residents from low-income countries.
The techniques of vascularized transfer of a bone segment, or of revascularization of a conventional bone autograft by a pedicle or a microsurgical muscular flap represent one of the most significant advances made during the last years for the treatment of large bone defects of the tibia with associated skin injury. The authors present their experience with 16 cases, including 5 microsurgical transfers.
The induced membrane technique for reconstruction of bone defects has proved its effectiveness and is now widely accepted. The 2 stages procedure, implying a cement spacer in the first stage and a huge bone graft in the second stage, responds to rigorous technical details involving each phase of the procedure. Prerequisites for the technique, cement spacer, bone fixation, time between the 2 stages, grafting, and postoperative course are reported and discussed.
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.
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.
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.
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.
Therapeutic III.
Crown Copyright © 2015. Published by Elsevier Ltd. All rights reserved.
Bone allografts were used in our department since twenty-five years to reconstruct segmental bone loss and our data were retrospectively reviewed to assess the complications related to the use of a bone allograft. A consecutive series of 128 patients who received a bone allograft was analyzed. The minimal follow-up was 18 months. Fracture, nonunion, infection and explantation were investigated using a multivariate analysis and logistical regression. Kaplan-Meier survival of the allograft was performed, using allograft removal as the end point. Tumour disease was excluded from this study. Patients were followed up for an average 103 months. Bone tumour occurred in 78% of the patients whereas revision arthroplasty was the cause of implantation in 15% of them. Nonunion was the most prevalent complication, occurring in 35% of the grafts. For nonunion occurrence, the type of reconstruction was found to be a significant variable, the intercalary allograft being the most exposed. Primary bone autografting at the anastomotic site was not significant to prevent nonunion. Fracture of the allograft was the second most frequent complication with a prevalence of 16.4%. The length of the allograft and an osteoarticular allograft were two significant variables in that occurrence. Infection of the allograft was present with a rate of 5.4% of patients. Explantation of failed allografts occurred in 30% of them. The duration of the frozen storage of the allograft and the donor age of the allograft were not significant on any local complication occurrence. Bone allografts are a reliable material but a high rate of local complications must be anticipated.
Background:
The treatment of highly comminuted tibial pilon fractures is controversial. The aim of this study was to determine the effectiveness and outcomes of primary arthrodesis following highly comminuted tibial plafond fractures.METHODS: A database search was performed to identify all patients who underwent blade plate arthrodesis at our institution over a sixteen-year period. Inclusion criteria included patients with an Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association type-C2 or type-C3 pilon fracture that was deemed to be non-reconstructable by the treating surgeon. Outcomes were measured using the Short-Form 36-Item Health Survey, time to independent walking, time to consolidation of the arthrodesis, and wound-healing complications.RESULTS: A total of twenty patients were included in this study, and seventeen patients (85%) were available for follow-up at a minimum of two years after their surgery. Wound infections or wound dehiscence did not occur in this series. All patients were walking without crutches or a walker at their latest follow-up. One patient developed an aseptic nonunion and healed successfully after revision surgery.CONCLUSIONS: Blade plate ankle fusion using a posterior approach is a reliable method for the treatment of a small subset of patients with severely comminuted, non-reconstructable pilon fractures.LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
Purpose:
The descending geniculate artery's branching pattern includes periosteal vessels supplying the cartilage-bearing trochlea of the medial patellofemoral joint. Previous cadaveric studies described anatomic similarities between the greater curvature of the proximal scaphoid and the convex surface of the medial femoral trochlea (MFT). We describe the technique and report our first 16 consecutive cases of vascularized osteocartilaginous arthroplasty for chronic scaphoid proximal pole nonunions using the MFT, with a minimum of 6 months of follow-up.
Methods:
Chart reviews of 16 consecutive cases of osteocartilaginous MFT flap transfers for scaphoid reconstruction were performed at 2 institutions. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months (range, 6-72 mo). Patient age and sex, duration of nonunion, number of previous surgical procedures, surgical technique, achievement of osseous union, preoperative and postoperative scapholunate angles, preoperative and postoperative range of motion, and pain relief were recorded.
Results:
Computed tomography imaging confirmed healing in 15 of 16 reconstructed scaphoids. Mean patient age was 30 years (range, 18-47 y). The average number of previous surgical procedures was 1 (range, 0-3). All patients experienced some wrist pain improvement (12/16 complete relief, 4/16 incomplete relief). Wrist range of motion at follow-up averaged 46° extension (range, 28° to 80°) and 44° flexion (range, 10° to 80°), which was similar to preoperative measurements (average 46° extension and 43° flexion). Scapholunate relationship remained unchanged with average scapholunate angles of 52° before surgery and 49° after surgery.
Conclusions:
Osteochondral vascularized MFT flaps provide a reliable means of achieving resolution of difficult proximal pole scaphoid nonunions. These flaps allow resection of the proximal portion of the unhealed scaphoid and reconstruction with an anatomically analogous convex segment of cartilage-bearing bone. This technique provides the advantages of vascularized bone and ease of fixation. Early follow-up demonstrates a high rate of union with acceptable motion and pain relief.
Clinical relevance:
Early follow-up suggests that the vascularized MFT osteocartilaginous flap is a valuable tool for treating challenging proximal pole scaphoid nonunions.
The metaphyses around the knee (distal femoral and proximal tibial) are junction areas subject to considerable stress. Double-barrel free vascular fibular graft (D-FVFG) provides good bone augmentation and restores the metaphyseal cone; the present study assessed its capacity to restore metaphyseal anatomy and axis and investigated its impact on the neighboring knee joint.
Eight D-FVFGs performed for metaphyseal segmental bone defect were followed up for a mean 6.5 years (range, 3-14 years). There were seven femoral nonunions, five of which were septic, and one chondrosarcoma of the tibia. Osteosynthesis used an external fixator (EF) in six cases (four of which bridged the knee), a double plate on the tibia in one case, and intramedullary nailing of the femur in two cases, including one to replace an EF. Adjuvant bone graft was associated in six cases. A protective leg brace was maintained for a mean 16.0±4.0 months. Three arthrolyses were required after final union.
Union was achieved in all cases, after a mean 6.4±2.1 months. Sixty-four percent of defect volume was reconstructed. The immediate postoperative mechanical femorotibial angle was 180.3±6.0° and 174.5±5.7° at FU. Mean knee flexion was 96.9±36.0° and extension -5.0±10.0°. Three patients showed symptomatic arthritis at follow-up.
D-FVFG satisfactorily restored the anatomy of the metaphyseal area. EF knee bridging seemed to impair varus correction, on top of the systematic problem of stiffness. When possible, internal fixation in first intention or as EF replacement appears to be preferable. Arthritic deterioration of the knee is worsened by initial joint lesions and femorotibial varus.
Level IV. Type of study: retrospective.
Composite tissue allograft (CTA) is defined as heterologous transplantation of a complex comprising skin and subcutaneous, neurovascular and mesenchymal tissue. Such techniques allow complex reconstruction using matched tissue, without donor site morbidity. The potential indications in orthopaedics-traumatology could in the future be more frequent than the present indications of heart, lung, liver, kidney and pancreas transplantation. International clinical experience clearly demonstrates the feasibility of CTA, both surgically and immunologically. However, immunosuppression remains indispensable, exposing the patient to risks that are not acceptable for purely functional surgery, except in very particular indications. The main hope for the future lies in induction of graft-specific tolerance.
The success of vascularized bone grafts from the medial femoral condyle in various clinical applications has sparked renewed interest in the microvascular anatomy of this region. This study describes the arterial supply of the distal medial femoral condyle and its implications in harvesting vascularized bone grafts. The location, branching pattern, internal diameter, and distribution of perforators of the descending genicular artery and superior medial genicular artery in 19 fresh cadaveric lower limbs were recorded. The descending genicular artery was present in 89% and the superior medial genicular artery was present in 100% of specimens with average distances proximal to the articular surface of 13.7 cm and 5.2 cm, respectively. The average number of perforating vessels was greatest in the posterior distal quadrant of the condyle. The blood supply of the medial femoral condyle is plentiful and consistent making it a useful source for free vascularized bone grafts.
Clinical, experimental, and fundamental studies have shown the interest of a foreign body-induced membrane to promote the consolidation of a conventional cancellous bone autograft for reconstruction of long bone defects. The main properties of the membrane are to prevent the resorption of the graft and to secrete growth factors. The induced membrane appears as a biological chamber, which allows the conception of numerous experimental models of bone reconstruction. This concept could probably be extended to other tissue repair.
This paper describes a new thin corticoperiosteal graft harvested from the medial condylar and supracondylar areas of the femur. It is based on the articular branch of the descending genicular artery and vein and consists of periosteum with a thin (0.5 to 1.0 mm) layer of outer cortical bone. By retaining the cortex, the cambium layer is preserved, and this is thought to have a better osteogenic capacity than vascularized periosteal grafts. This graft was used to treat six patients with fracture nonunion of the upper extremity in which conventional treatment had failed. Uneventful bony union was achieved in all patients within 10 weeks.
In selected patients with localized malignant bone tumors, radical en bloc resection with adjuvant chemotherapy is now performed. Vascularized bone autografts can be used for secondary reconstruction of the bone defect. These grafts have the advantages of the nonvascularized ones, as well as the advantages of preserved viability. The fibula is usually the most suitable donor bone. Our surgical technique and the advantages and limitations of vascularized bone grafts are discussed.
A further modification of the free vascularized fibular bone graft is described in which a transverse osteotomy is made from the anterolateral aspect of the fibular shaft just distal to the entry of the nutrient artery. This produces two vascularized bone struts that may be folded parallel to each other but that remain connected by the periosteum and muscle cuff surrounding the peroneal artery and vein. The proximal strut is vascularized by both a periosteal and an endosteal blood supply, whereas the distal strut is vascularized by a periosteal blood supply alone. This so-called "double barrel" free vascularized fibular graft has been employed in three patients with segmental bone defects of the distal femur and in one patient with adjacent bony defects of the radius and ulna.
Five hundred and thirty-two patients underwent microsurgical reconstruction following trauma to their extremities. They were divided into three groups for the purpose of review. Group 1 underwent free-flap transfer within 72 hours of the injury, group 2 between 72 hours and 3 months of the injury, and group 3 between 3 months and 12.6 years, with a mean of 3.4 years. The results were analyzed with respect to flap failure, infection, bone-healing time, length of hospital stay, and number of operative procedures. The flap failure rate was 0.75 percent in group 1, 12 percent in group 2, and 9.5 percent in group 3 (p less than 0.0005 early versus delayed; p less than 0.0025 early versus late). Postoperative infection occurred in 1.5 percent of group 1, 17.5 percent of group 2, and 6 percent of group 3. Bone-healing time was 6.8 months in group 1, 12.3 months in group 2, and 29 months in group 3. The average length of total hospital stay was 27 days for group 1, 130 days for group 2, and 256 days for group 3. The number of operations averaged 1.3 for group 1, 4.1 for group 2, and 7.8 for group 3.