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Recent Advances in Trauma and Reconstructive Surgery of the Extremities

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A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Surgery".

Deadline for manuscript submissions: closed (31 October 2020) | Viewed by 34255

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Dr. Francesco De Francesco

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Department of Reconstructive Surgery and Hand Surgery, AOU Ospedali Riuniti, Ancona, Italy
Interests: plastic surgery; aesthetic surgery; reconstructive surgery; breast reconstruction; regenerative surgery; hand surgery
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Dr. Nicola Zingaretti

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Clinic of Plastic and Reconstructive Surgery, Academic Hospital of Udine, Department of Medicine (DMED), University of Udine, Udine, Italy
Interests: plastic surgery; reconstructive surgery; microsurgery; free flap; free tissue transfer
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Dr. Michele Riccio

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1. Department of Reconstructive Surgery and Hand Surgery, AOU Ospedali Riuniti, Ancona, Italy
2. Accademia del Lipofilling, Research and Training Center in Regenerative Surgery, Jesi, Ancona, Italy
Interests: plastic surgery; aesthetic surgery; reconstructive surgery; breast reconstruction; breast augmentation; oncoplastic surgery
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Prof. Pier Camillo Parodi

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Dear Colleagues,

Extremity injuries are common and can present a significant injury burden for patients, especially if an extremity is mangled. The frequency of injuries in these parts of the body has become more difficult to prevent with the rise in popularity of practices such as riding motorcycles, as well as extreme sports such as skiing, bungee jumping, and mountain-bike. Complex limb injuries due to high kinetic energy crushes are characterized by an extensive loss of soft tissue and bone substance and may be associated with vascular injury. These cases require coordination between the peripheral vascular and microsurgical team and the orthopedist to obtain a rapid and accurate diagnosis of vascularization and to plan adequate wound care and revascularization. Extremity injuries can represent a challenge for surgeons due to several factors, such as the extent of the trauma, wide loss of substance, and a close anatomic relation with vital structures. For these reasons, achieving an optimal outcome in patients with severe upper and lower extremity injury requires a multidisciplinary approach with oversight by the general or trauma surgeon and commitment from other specialists, including orthopedic, vascular, and plastic surgeons and rehabilitation specialists.

The aim of this Special Issue is to provide the readership with current information regarding diagnosis, pathophysiology, techniques, and strategies for the management for upper and lower extremity reconstruction.

This includes the orthopedic management of complex traumas of the extremities, presurgical assessment for the best reconstructive options, orthoplastic reconstruction of the arms and legs (e.g., locoregional flaps, perforator flaps, microsurgical techniques of extremity preservation), the available evidence for choosing individual reconstructive algorithms and practices, wound care treatment and management, the role of adjunctive therapy for wound healing (e.g., hyperbaric oxygen therapy, vacuum-assisted closure therapy), salvage in patients with devastating injuries or severe medical comorbidities, postsurgical complications and their clinical management, and rehabilitation solutions for extremities.

Furthermore, we encourage the publication of original and interesting case reports that contribute significantly to medical knowledge.

Dr. Francesco De Francesco
Dr. Nicola Zingaretti
Dr. Michele Riccio
Prof. Dr. Piercamillo Parodi
Guest Editors

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Keywords

Extremities trauma
Orthoplastic reconstruction
Regenerative medicine
Flaps
Extremity injuries
Rehabilitation

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Published Papers (8 papers)

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12 pages, 6894 KiB

Open AccessArticle

Anthropometric Factors on Safe Distances between Popliteal Vessels to the Femur for Cerclage Wiring of the Distal Femoral Fracture: A Magnetic Resonance Imaging Study

by Hao-Wei Chang, Chia-Yu Lin, Hui-Yi Chen, Yi-Wen Chen, Hsien-Te Chen, I-Hao Lin, Chin-Jung Hsu and Tsung-Li Lin

Medicina 2020, 56(12), 655; https://doi.org/10.3390/medicina56120655 - 28 Nov 2020

Cited by 1 | Viewed by 2212

Abstract

Background and Objectives: The proximity of the popliteal vessels in the distal femur may increase the risk of iatrogenic vascular injury during cerclage wiring. In this study, the closest location and distance of the popliteal vessels to the femur was examined using magnetic resonance imaging (MRI). The associations between anthropometric factors and the distance that would guide the placement of wires safely during surgery were also identified. Materials and Methods: We reviewed adult knee magnetic resonance images and recorded: (1) the relation and the shortest horizontal distance (d-H) from the femoral cortex to the popliteal vessels in axial images and (2) the vertical distance (d-V) from the adductor tubercle to the axial level of the d-H values in coronal images. The effects of anthropometric factors (sex, age, body height, body weight, body mass index, thigh circumference, femoral length and femoral width) on these distances were analysed. Results: Analysis of 206 knee magnetic resonance images revealed that the closet locations of popliteal vessels were at the posteromedial aspect of the femur. The d-H and d-V were 7.38 ± 3.22 mm and 57.01 ± 11.14 mm, respectively, and were both shorter in women than in men (p < 0.001). Multivariate analysis identified thigh circumference and femoral length as the most influential factors for the d-H and d-V, respectively (p < 0.001). Linear regression demonstrated a strong positive linear correlation between the thigh circumference and the d-H and between the femoral length and the d-V (Pearson’s r = 0.891 and 0.806, respectively (p < 0.001)). Conclusions: The closet location and distance of the popliteal vessels to the femur provide useful information for wire placement during distal femoral fracture surgery while minimising the risk of vascular injury. Given that patients with a smaller thigh circumference and a shorter femoral length are more likely to have a smaller d-H and a shorter d-V, respectively, cautious measures should be taken in such cases. Full article

(This article belongs to the Special Issue Recent Advances in Trauma and Reconstructive Surgery of the Extremities)

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12 pages, 5869 KiB

Open AccessArticle

Efficacy of the Arteriovenous Loop for Free Flap Reconstruction in Patients with Complex Limb Trauma: Case Series and Literature Review

by Andrea Marchesini, Letizia Senesi, Francesco De Francesco, Pier Paolo Pangrazi, Andrea Campodonico, Rocco Politano and Michele Riccio

Medicina 2020, 56(11), 632; https://doi.org/10.3390/medicina56110632 - 23 Nov 2020

Cited by 14 | Viewed by 3110

Abstract

Background and objectives: Complex limb traumas are commonly treated with microsurgical reconstruction and free flaps. However, complications are frequent in patients affected by a previous trauma or comorbidity, atheromasia and a single valid vessel. Free flap reconstruction is indeed a challenging procedure in complex injuries, which may increase the risk of limb ischemia. The Arteriovenous loop (AVL) technique may be considered an efficient alternative treatment. We herein report our procedure and previous research regarding the AVL method using a two-step reconstruction in cases of complex high-energy limb injuries. Materials and Methods: In this single center retrospective cohort study, all the patients from 2014 to 2018 who underwent to AVL reconstruction were assessed. A total of six patients were included in the study for traumatic limb trauma. The two-stage technique was performed each time. The age and sex of patient, the time between stage one and two, the length of AVL loop and rate of free flap success were evaluated. Results: A total of seven AVL reconstructions were performed. The mean age of patients was 36 years old. Eight free flaps were performed; six free flaps were transferred to the vascular loops. The average time between stage one and two was 13 days. The mean length of the pedicle was 25 cm for the upper limb and 33.7 cm for the lower limb. All the free flaps successfully take root. In one case, a surgical revision was required the second day post-operatory due to venous congestion. Conclusions: AVL is a useful and safe technique in microsurgical reconstruction which will prevent vascular complications. Our investigations suggest the efficacy and feasibility of a two-step intervention in acute post-traumatic events. A single-step procedure should be preferred in chronic situation and oncologic reconstruction. Full article

(This article belongs to the Special Issue Recent Advances in Trauma and Reconstructive Surgery of the Extremities)

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13 pages, 6354 KiB

Open AccessArticle

A Multistep Iter for Functional Reconstruction in Mangled Upper Limb: A Retrospective Analysis of Integrated Surgical and Medical Approach

by Francesco De Francesco, Andrea Marchesini, Andrea Campodonico, Alexander Dietrich Neuendorf, Pier Paolo Pangrazi and Michele Riccio

Medicina 2020, 56(8), 398; https://doi.org/10.3390/medicina56080398 - 7 Aug 2020

Cited by 7 | Viewed by 2879

Abstract

Background and objectives: Complex limb wounds with multiple tissue involvement are commonly due to high energy trauma. Tissue damage is a dynamic entity and the exact extent of the injury is rarely instantly perceptible. Hence, reconstruction frequently involves a multi-stage procedure concluding with tissue replacement. Materials and Methods: A retrospective study was conducted between 2006 and 2018 and included 179 patients with contaminated multi-tissue injuries treated with hyperbaric oxygen therapy, negative pressure therapy, physiotherapy and drug treatment associated with multiple surgical time in a multistep approach, focusing on pain levels and wound closure rates. Results: Despite the long-term response to traumatic events, a combined approach of delayed surgical reconstructive time in mangled upper limb yielded satisfactory functional outcomes. Conclusions: The complex upper limb wound with deep tissue exposure may be treated with a multi-stage procedure alternatively to immediate reconstruction. The integrated technique enables the preservation of existing healthy tissue and concurrent radical debridement, reducing the risk of infection, as well as avoiding the loss of free flaps and dehiscence due to incorrect wound estimation. Full article

(This article belongs to the Special Issue Recent Advances in Trauma and Reconstructive Surgery of the Extremities)

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9 pages, 1297 KiB

Open AccessArticle

The Effect of Muscle Exercise on Perforators Flow: A Prospective Cohort Study

by Francesco Amendola, Luca Vaienti, Giuseppe Cottone, Giovanna Zaccaria, Zvi Steinberger, Nicole Dereatti, Michele Riccio, Glenda Giorgia Caputo, Francesco De Francesco and Nicola Zingaretti

Medicina 2020, 56(7), 338; https://doi.org/10.3390/medicina56070338 - 8 Jul 2020

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Abstract

Background and objectives: The metabolic response after exercise causes a significant increase in the muscle blood flow. While these effects are demonstrated for intra-muscular vessels, there is no evidence about the inter-muscular vessels, such as the septocutaneous perforators supplying the skin after they branch out from the deep source artery. The aim of our prospective study was to quantify the changes in the anterior tibial artery perforators arterial blood flow after mild isotonic exercise in a young and healthy population. Material and Methods: We performed a prospective analysis of 34 patients who were admitted to the Plastic Surgery Department from December 2019 to April 2020. Flow velocities of two previously identified anterior tibial artery perforators were recorded both before and after 10 complete flexion-extensions of the foot. The time to revert to basal flow was measured. We further classified the overmentioned patients based on their level of physical activity. Results: We registered a significant increase in systolic, diastolic and mean blood flow velocities both in proximal and distal anterior tibial artery perforators after exercise. Fitter patients exhibited a higher increase in proximal leg perforators than those who did less than three aerobic workouts a week. The time to return to basal flow ranged from 60 to 90 s. Conclusions: This was the first study to describe the effect of muscular activity on perforators blood flow. Even mild exercise significantly increases the perforator flow. Waiting at least two minutes at rest before performing the Doppler study, thus avoiding involved muscle activation, can notably improve the reliability of the pre-operative planning. Full article

(This article belongs to the Special Issue Recent Advances in Trauma and Reconstructive Surgery of the Extremities)

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13 pages, 3518 KiB

Open AccessArticle

Acceleration of Skin Wound-Healing Reactions by Autologous Micrograft Tissue Suspension

by Shiro Jimi, Satoshi Takagi, Francesco De Francesco, Motoyasu Miyazaki and Arman Saparov

Medicina 2020, 56(7), 321; https://doi.org/10.3390/medicina56070321 - 29 Jun 2020

Cited by 19 | Viewed by 3407

Abstract

Background and objectives: Skin grafting is a method usually used in reconstructive surgery to accelerate skin regeneration. This method results frequently in unexpected scar formations. We previously showed that cutaneous wound-healing in normal mice is accelerated by a micrograft (MG) technique. Presently, clinical trials have been performed utilizing this technology; however, the driving mechanisms behind the beneficial effects of this approach remain unclear. In the present study, we focused on five major tissue reactions in wound-healing, namely, regeneration, migration, granulation, neovascularization and contraction. Methods: Morphometrical analysis was performed using tissue samples from the dorsal wounds of mice. Granulation tissue formation, neovascularization and epithelial healing were examined. Results: The wound area correlated well with granulation sizes and neovascularization densities in the granulation tissue. Vascular distribution analysis in the granulation tissue indicated that neovessels extended and reached the subepidermal area in the MG group but was only halfway developed in the control group. Moreover, epithelialization with regeneration and migration was augmented by MG. Myofibroblast is a known machinery for wound contraction that uses α-smooth muscle actin filaments. Their distribution in the granulation tissue was primarily found beneath the regenerated epithelium and was significantly progressed in the MG group. Conclusions: These findings indicated that MG accelerated a series of wound-healing reactions and could be useful for treating intractable wounds in clinical situations. Full article

(This article belongs to the Special Issue Recent Advances in Trauma and Reconstructive Surgery of the Extremities)

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7 pages, 2818 KiB

Open AccessArticle

Reconstruction for Defects of Total Nail Bed and Germinal Matrix Loss with Acellular Dermal Matrix Coverage and Subsequently Skin Graft

by Tsung-Hsien Liu, Meng-Chien Hsieh, Ping-Ruey Chou and Shu-Hung Huang

Medicina 2020, 56(1), 17; https://doi.org/10.3390/medicina56010017 - 3 Jan 2020

Cited by 10 | Viewed by 9743

Abstract

Background and Objectives: Nail bed and germinal matrix loss due to wide excision for fingertip tumors or malignancy are occasionally encountered complications. These defects also result from severely comminuted fingertip crush injuries. Large-area dorsal finger or toenail bed defects, which usually present with phalangeal bone exposure, remain challenging regardless of the usage of different reconstruction strategies. This study aimed to evaluate the clinical outcome of a staged operation with an acellular dermal matrix coverage and subsequent skin graft as reconstruction for defects of total nail bed, germinal matrix loss, and bone exposure. Materials and Methods: From April 2018 to October 2019, four patients with total nail bed, germinal matrix, and bone exposure loss after surgery were enrolled in our series. A staged operation of the acellular dermal matrix coverage with subsequent skin graft was performed on these patients. Skin graft take rate, oncological prognosis, and cosmetic outcome were evaluated. Patients were followed up for 5–13 months. An excellent skin graft take rate with a satisfying aesthetic result without local malignancy recurrence was noted. Minimal functional deficit and donor site morbidity were reported. Results: A staged operation with acellular dermal matrix coverage and subsequent skin graft proves to serve as a feasible strategy for patients who experience total nail bed, germinal matrix loss, and bone exposure after surgery. Conclusions: This reconstruction method provides a reliable repair result, satisfying aesthetic outcomes, as well as having minimal functional deficits and donor site morbidity. Full article

(This article belongs to the Special Issue Recent Advances in Trauma and Reconstructive Surgery of the Extremities)

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13 pages, 2413 KiB

Open AccessArticle

Retrospective Study on the Clinical Superiority of the Vacuum-Assisted Closure System with a Silicon-Based Dressing over the Conventional Tie-over Bolster Technique in Skin Graft Fixation

by Ping-Ruey Chou, Sheng-Hua Wu, Meng-Chien Hsieh and Shu-Hung Huang

Medicina 2019, 55(12), 781; https://doi.org/10.3390/medicina55120781 - 12 Dec 2019

Cited by 6 | Viewed by 6387

Abstract

Background and Objectives: The tie-over bolster technique has been conventionally used for skin graft fixation; however, long operative times and postoperative pain are the main disadvantages of this method. In this study, we introduce a new method using vacuum-assisted closure (VAC) with a silicon-based dressing as an alternative for skin graft fixation. This retrospective study aimed to evaluate the clinical effect of the VAC plus silicon-based dressing method and the conventional tie-over bolster technique for skin graft fixation in terms of pain, operative time, and skin graft take rate. Materials and Methods: Sixty patients who underwent skin graft surgery performed by a single surgeon from January 2017 to October 2018 were included in this clinical study. They were divided into two groups based on the type of treatment: tie-over bolster technique and vacuum-assisted closure (VAC), or silicon-based dressing groups. The operative times were recorded twice (during suturing or stapling of the graft and during removal of the dressing) in the two groups; similarly, pain was assessed using a numeric rating scale (NRS) after surgery and during dressing removal. Skin graft take rate was evaluated two weeks after dressing removal. Results: Twenty-six patients who met the eligibility criteria were enrolled into the study and assigned to one of the two groups (n = 13 each). No significant differences in age, gender, and graft area were noted between the two groups of patients. The VAC plus silicon-based dressing group demonstrated higher skin graft take rates (p < 0.05), shorter operation times (p < 0.05), and lower levels of pain (postoperative pain and pain during dressing removal) compared with the tie-over bolster technique group (p < 0.05). Conclusions: These findings indicate that VAC with silicon-based dressing can be used for skin graft fixation due to its superior properties when compared with the conventional method, and can improve the quality of life of patients undergoing skin graft fixation. Full article

(This article belongs to the Special Issue Recent Advances in Trauma and Reconstructive Surgery of the Extremities)

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7 pages, 3025 KiB

Open AccessCase Report

One-Step Lower Leg Reconstruction with Vascularized Functional Vastus Lateralis Muscle Flap in the Treatment of Embryonal Rhabdomyosarcoma for a Six-Month-Old Boy: A Case Report

by Dzintars Ozols, Marisa Maija Berezovska, Janis Krasts, Marika Grutupa and Aigars Petersons

Medicina 2020, 56(7), 362; https://doi.org/10.3390/medicina56070362 - 21 Jul 2020

Cited by 2 | Viewed by 2805

Abstract

Rhabdomyosarcoma (RMS) is a common soft tissue sarcoma in childhood, however, it is very rare in the neonatal period (0.4–2% of cases). This case depicts a boy, who presented with RMS at two weeks of age, but officially diagnosed at the age of three months. MRI and scintigraphy determined a soft tissue tumor in the soleus muscle, while biopsy confirmed embryonal RMS with high mitotic activity (Ki67 (monoclonal antibodies) ~80%). CWS (Cooperative Weichteilsarkom Studiengruppe)-2012 with I2VA (ifosfamide, vincristine, actinomycin) chemotherapy regimen was administered per protocol. Surgical treatment was performed at age of six months and 18 days. The operation consisted of radical tumor resection and total triceps surae with partial fibula resection. Immediate reconstruction of triceps muscle was accomplished using a vascularized functional musculocutaneous vastus lateralis flap. Functional outcome was measured using the Lower Extremity Functional Scale (LEFS) and the Foot and Ankle Outcome Score (FAOS) with the results of 92.5% and 99% respectively. Full article

(This article belongs to the Special Issue Recent Advances in Trauma and Reconstructive Surgery of the Extremities)

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