Introduction: Gustilo-Anderson type III injury is a complex injury that usually results from high-energy trauma. Such injuries tend to be intractable due to the high frequency of infection.
Methods: A systematic review of the literature was performed using the MEDLINE database to investigate changes in infection rates in Gustilo-Anderson type III open fracture care over the past 20 years.
Results: The results indicated that the incidence of postoperative infection in Gustilo-Anderson type III has not improved for approximately 20 years, occurring at a frequency similar to that in the early 20th century.
Discussion and conclusion: The recommended treatment strategy for Gustilo-Anderson type III fractures is early initial debridement within 12 h and final bone coverage within 72 h. However, in reality, these ideal treatments are not always performed, which can lead to postoperative infection. Achieving early initial debridement and secondary bone coverage requires adequate resources in medical facilities, which is not viable as an immediate solution. Therefore, appropriate wound management should be performed to minimize the incidence of infection during the period awaiting surgery. Continuous irrigation therapy is considered a recommended treatment option.

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Lymphorrhea, which is a challenging disease to manage, can be treated using noninvasive or invasive procedures. We herein report a case of intractable lymphorrhea that did not respond to multimodal treatments, including direct suture after excision, lymphaticovenous anastomosis, and negative-pressure wound therapy; however, complete resolution was achieved by free flap transfer. A 47-year-old woman presented with severe lymphorrhea in her right upper arm due to repeated partial excision of a large lymphangioma extending from the upper arm to the cervicothoracic region. Despite multiple attempts to manage lymphorrhea using noninvasive procedures, she experienced persistent lymph leakage and recurrent cellulitis. Surgical interventions, including lymphaticovenous anastomosis, were tried but were ineffective, and negative-pressure wound therapy also did not show satisfactory outcomes. Free-flap transplantation was performed using an anterolateral thigh flap. Following anterolateral thigh flap transplantation, the patient experienced complete resolution of lymphatic leakage. There were no signs of lymphedema or cellulitis, indicating successful relief of these complex symptoms for six months postoperatively. This report highlights the successful treatment of intractable lymphorrhea with free anterolateral thigh flap transplantation. For refractory lymphatic leakage, a comprehensive approach that considers both lymphatic flow reduction and the promotion of wound healing around the fistula is crucial. In cases of uncontrolled lymphorrhea, an alternative option, such as free flap transfer, should be recommended as surgical intervention. (a) The lymph fistula together with the surround skin (15 × 5 cm) was resected using an ultrasonic energy device. (b) The left chimeric anterolateral thigh (ALT) flap, including a skin paddle (17 × 7 cm) and thin layer of vastus lateralis muscle (8 × 4 cm), was elevated with 2 perforators. (c) Vascular anastomoses were performed to the superior ulnar collateral artery, brachial vein, and brachial vein collateral vein. (d) After completely covering the wound surface using the vastus lateralis muscle, the skin defect was substituted with the skin island of the ALT flap.

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Splenic abscesses are rare and potentially fatal, and require an early diagnosis and intervention. However, few reports have described splenic abscesses with diabetic foot gangrene. Therefore, we report a case of splenic abscess associated with diabetic foot gangrene, along with a review of the relevant literature. The patient, a 47-year-old man on dialysis for type 2 diabetes mellitus, had a skin ulcer on the lateral right foot. The infection rapidly progressed, and the patient was emergently admitted to the hospital. Although antibiotics were administered intravenously and debridement were performed on the 1st and 12th day, the infection remained uncontrolled. Finally, below-knee amputation was performed on the 48th day and wound healing progressed favorably after surgery. However, the patient developed a fever again and blood tests revealed a prolonged inflammatory reaction. Since a computed tomography scan revealed a splenic abscess, some fistula catheters were placed through the abscess in the spleen under endoscopy on the 67th day. Genetic testing of the wound culture, splenic abscess, and blood culture revealed the same Staphylococcus aureus infection. After the implantation of the catheters, the splenic abscess demonstrated marked improvement. The possibility of a splenic abscess should be kept in mind in cases of prolonged inflammatory findings, since we do not think a splenic abscess is suspected in the early stages. The red arrow indicates a splenic abscess.

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We report a case of refractory ulcer after posterior neck vertebroplasty in which multiple debridement and intra-wound continuous negative pressure and irrigation treatment failed to improve the environment of the wound bed and healing was achieved with maggot debridement therapy. A 61-year-old man underwent cervical vertebroplasty in the orthopedic department. The patient was referred to our department due to delayed wound healing. Surgical debridement and intra-wound continuous negative pressure and irrigation treatment were performed, but wound healing was delayed. Further surgical debridement would have risked damaging the spinal cord. Therefore, two courses of maggot debridement therapy were performed to promote more selective debridement and the growth of benign granulation. After two courses of maggot debridement therapy, necrotic tissue decreased and the wound environment remarkably improved. A skin graft was performed and the wound healed.
In surgical debridement, the boundary between healthy areas is determined by bleeding from the wound surface. However, in practice, it is often difficult to clearly distinguish necrotic or infected areas from healthy areas. Additionally, proximity to blood vessels, nerves, and organs makes debridement even more difficult. Although maggot debridement therapy is not covered by insurance in Japan, it is considered an important treatment option for patients with delayed wound healing.

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A 46-year-old woman was admitted to the Plastic and Reconstructive Surgery Division of Ehime University Hospital for swelling and pain in both breasts. Approximately 10 years earlier, in June 2010, she had undergone bilateral breast augmentation surgery with hyaluronic acid. Computed tomography showed a shadow under the pectoralis major muscle and a breast abscess in the pectoralis major due to a foreign body was suspected. Puncture was performed under ultrasound guidance, but a bacteriological culture of the abscess was negative. Surgery was performed under general anesthesia and a white cystic lesion covered with a thin capsule was found in the pectoralis major. A histopathological examination revealed a foreign body reaction, and biochemical analysis showed that a small amount of hyaluronic acid remained. In breast reconstruction using a large amount of highly cross-linked hyaluronic acid, there is a high possibility that foreign substances containing hyaluronic acid will persist, so careful interviews and examinations are necessary. (a) CT image just before surgery. (b) Preoperative design. (c) A white cystic lesion covered with a thin capsule was found in the pectoralis major. (d) Specimens of removed bilateral cysts. (f) Cyst contents: White, muddy substance.

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Medical device-related pressure injuries result from the external pressure exerted by medical devices on the skin or subcutaneous floor. Although the concept of medical device-related pressure injuries was recently proposed, it has not gained widespread acceptance, frequently leading to the management of these injuries alongside common pressure ulcers without distinction. However, it is important to acknowledge that these injuries differ from common pressure ulcers and should be treated accordingly. We herein report a case of a stage 4 medical device-related pressure injury in the median back caused by a rigid dorsal brace. In addition, we describe the successful treatment of this issue through reconstructive surgery using a combination of flap formation and skin grafts. Medical device-related pressure injuries are iatrogenic and can lead to prolonged hospitalization and rehabilitation. Therefore, consulting a plastic surgeon specializing in wound care may facilitate early discharge of patients to their homes. (a) A rigid corset (b) Cervical collar (c) Noninvasive positive pressure ventilation mask (d) Splint (e) Antiembolism stocking

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Closed digital arterial injury is rare. A seven-year-old boy sustained a crush injury to his right middle finger, resulting in a proximal phalanx-neck fracture displaced to the dorsal side. On presentation, his finger was warm and normal in color. Initially, closed reduction and percutaneous pinning were performed. However, the middle finger vascularization diminished, and the finger became cyanosed three hours after the operation. At this point, the patient was transferred to our hospital. Color Doppler ultrasonography showed interruption of bilateral digital arterial flow. Bilateral digital arterial reconstruction with vein grafting was performed immediately to preserve the middle finger. Finger vascularization was then re-established. Six months postoperatively, the middle finger was functional, and its appearance was almost restored to its pre-injury state. Zigzag incision (A). The ulnar and radial digital arteries were crushed and ruptured. The black arrows indicate the distal and proximal ends of the ruptured arteries. Thrombosis was recognized on a digital artery (yellow dotted circle) (B and C). Vein grafting was performed (black double arrows) (D and E). The color of the middle finger improved at the end of surgery (F).

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Flap coverage is the preferred treatment for finger pulp injuries with bone exposure. We herein report a case of small finger pulp reconstruction using an ulnar parametacarpal flap. A 26-year-old man had accidentally caught his finger in a bar bender during work, resulting in soft tissue loss of the small finger pulp. On the day of the injury, reconstruction was performed with an ulnar parametacarpal flap nourished mainly by the perforating branch of the ulnar palmar digital artery of the small finger. The patient’s small finger was fixed in a flexed position. Twelve days after finger pulp reconstruction, the flap was amputated, and the small finger was immobilized in extension for six days. His hand was allowed to be washed, and he began joint range-of-motion exercises 18 days after the injury. Seven months after flap amputation, satisfactory aesthetic and functional outcomes had been achieved. (A) Photograph of the flap and the skin graft design. (B) Photograph of the donor site closure and flap fixation. The small finger was fixed in the flexed position (MCP joint in 30° flexion, PIP joint in 90° flexion, and DIP joint in 80° flexion). (C) The flap was elevated to the fascia layer. (D) Schematic illustration of the flap elevation. Two perforators from the ulnar palmar digital artery to the ulnar metacarpal region were ligated. One perforator from the ulnar palmar digital artery and another from the dorsal side flow into the flap.

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Managing infections of bony structures in the digit, especially in cases where the overlying soft tissue is damaged or the patient is immunocompromised, remains challenging. Although many reports have documented the efficacy of muscular and fascial flaps, few local flaps are available for affected hands. We herein report two complicated cases of purulent arthritis or osteomyelitis occurring in the interphalangeal joint of the hand. The patient underwent intrinsic adipofascial flap transfer to the actively affected joints, subsequently achieving prompt infection control and finally achieving functional and aesthetic healing of the hands. Clinical results suggest that intrinsic adipofascial flaps are extremely effective in controlling active infections of deep tissue in digits with few donor-site morbidities. (A) Meticulous sequestrectomy was performed. The flexor pollicis longus was taped (left). A design of two adipofascial flaps (right). (B) A cross-digital adipofascial flap and a reverse second metacarpal flap were elevated and transferred to the defect. (C) A schematic illustration of the surgery.

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Effective management of diabetic foot ulcers requires thorough evaluation and standardized treatment protocols. A well-defined framework is crucial for clinical quality, preventing the omission of critical aspects. While existing frameworks like the “TIME Concept” excel in chronic wound treatment, they lack specific elements vital for diabetic foot ulcers. The proposed “iTIME-DO” framework focuses on diabetic foot ulcers, incorporating “i” for ischemia before “TIME” and introducing “D” for deformity and “O” for off-loading after “TIME”, addressing crucial aspects for foot lesions. There are frameworks and scoring systems for chronic limb-threatening ischemia and diabetic foot ulcers, including ischemia and neuropathy as factors. However, in the real clinical setting of diabetic foot lesions, where recurrence is common, it is essential to evaluate not only ischemia and neuropathy, but also foot deformity and loading, always considering them as important treatment factors. Treating diabetic foot ulcers involves a complex combination of elements. A systematic examination of the framework’s elements and their treatment methods will ensure that nothing is overlooked, and treatment is provided at the optimal time. The iTIME-DO framework will contribute to preventing complications and shortening treatment time by focusing on ischemia and diabetic foot deformities at the onset of treatment. The essential elements of DFU (“i”schemia, “D”eformity, “O”ff-loading) are added to the TIME concept.

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