This single-center retrospective study included patients who underwent free-flap transfer performed by the same surgeon; antithrombotic therapy was the only variable. The sample included 11 patients (group A) who received heparin and prostaglandin E1 (PGE1) postoperatively, 23 patients (group B) who did not receive heparin but received PGE1 postoperatively, and 24 patients (group C) who did not receive either heparin or PGE1 postoperatively. Patient background characteristics were not significantly different among the groups. The incidences of arterial occlusion, venous occlusion, postoperative bleeding, and partial necrosis were not significantly different among the groups (arterial occlusion: one patient in group A, none in group B, and one patient in group C, p = 0.5; venous occlusion: none in group A, two patients in group B, and one patient in group C, p = 0.79; postoperative bleeding: three patients in group A, two patients in group B, and two patients in group C, p = 0.29; partial necrosis: none in group A, three patients in group B, and three patients in group C, p = 0.63) . These results suggest that heparin and PGE1 administration do not improve impaired blood flow following free-flap transfer. Considering the potential complications, these drugs may be unnecessary.
A 70-year-old man with diabetes mellitus underwent total knee arthroplasty (TKA) for osteoarthritis secondary to infectious arthritis seven years ago. Revision TKA was followed by knee fixation because of latent infection two years ago. However, arthrodesis failed in nonunion because of the recurrence of infection. The knee was treated by thorough debridement, the placement of antibiotic-impregnated cement spacers (AICS) and negative pressure wound therapy with instillation (NPWTi) . After one month, a medial gastrocnemius flap and medial soleus flap with a mesh full thickness skin graft (FTSG) were transferred. Two months later, osteosynthesis with double plates and vascularized fibula graft (VFG) transfer with a peroneal flap were performed. The peroneal flap became necrotic and the plates were exposed. After NPWTi was repeated seven times over two months, the lateral gastrocnemius flap and tensor fasciae latae flap with the mesh FTSG were transferred. At the follow-up at one year and three months, the vascularity of the VFG and bone formation were confirmed without infection symptoms. Surgical vascularization with NPWTi is suggested to be effective for recalcitrant osteomyelitis.
An 82-year-old female diabetic patient had skin necrosis measuring 30 mm×30 mm with partial patellar tendon exposure after retrograde intramedullary nailing for repair of a distal femoral fracture. Although debridement of the knee lesion was performed and followed by negative pressure wound therapy (NPWT) for two weeks, which facilitated granulation formation, partial necrosis of the patellar tendon remained. Thus, the skin defect was reconstructed using a pedicle fascial flap based on the veno-neuro-accompanying artery fascio-cutaneous (V-NAF) flap procedure. The adipofascial flap, containing the small saphenous vein, sural nerve and accompanying arteries, was lifted from the posterior aspect of the leg and transferred to the skin defect through a subcutaneous tunnel. Subsequently, a skin graft from the lower abdomen was transplanted onto the grafted adipofascial flap, and NPWT was applied for 5 days. Both the grafted adipofascial flap and skin survived. The patient was discharged from the hospital at 14 days postoperatively. Our treatment method may be effective for skin defects on the leg, even in elderly patients.
Popliteal artery pseudoaneurysms are a rare vascular complication of osteochondroma. A 19-year-old male with osteochondroma had a painful pulsatile mass in the left thigh. Ultrasonography and CT angiography demonstrated a popliteal artery aneurysm and osteolytic change in the femur in the area contacting the aneurysm. The bottom of the pseudoaneurysm was missing the capsule and was continuous with the bone marrow of the femur through a cortical bone defect. The popliteal artery was partially resected, leaving 1 cm, and anastomosed end-to-end. After the operation, the pain improved rapidly, and lower limb blood supply was maintained. Three years after surgery, no recurrence of the pseudoaneurysm was noted. We report a rare case of a pseudoaneurysm that penetrated the femur in the left thigh of a patient with multiple osteochondromas.
There are fewer reports of lower extremity replantation than of upper extremity replantation because of the severity of the primary injury and its rarity. An amputated foot at the rearfoot was replanted in a 40-year-old man. Four months after surgery, he was able to walk more than one kilometer without crutches and returned to work. Three years after surgery, he is able to walk long distances without effort in normal shoes, and sensory recovery of the plantar area is good (Semmes-Weinstein monofilaments test: purple) . This is a superior result to that of amputation and prosthesis. Moreover, the potential psychological benefit to the patient should be considered. Replantation of the lower extremities has an increased risk of systemic complications, delayed return to work and plantar anesthesia. These problems make amputation and prosthesis a more realistic option. However, in some cases, replantation may produce results that are functionally and aesthetically superior to those of amputation and prosthesis.
We describe a rare pattern of thumb duplication consisting of an ulnar-side floating thumb and a radial-side distally hypoplastic thumb. The ulnar thumb was adhered in the first web and had a good nail shape, whereas the nail was absent from the radial thumb. In the presented case, ‘on-top plasty’ was considered the ideal method because combining the 2 thumbs would improve the appearance, position, and length. After the patient reached three years of age, surgery was performed using the ‘on-top plasty’ technique. During the operation, the ulnar-side segment was pedicled and transferred to the radial thumb, which was distally resected. The osteotomy site was then pinned with a 0.7-mm K-wire in the appropriate alignment. The total operative time was 206 minutes. The postoperative course was uneventful. At the 15-year follow-up, the patient had a well-aligned and widely mobile thumb, with a wide first web and excellent cosmetic appearance. The ‘on-top plasty’ technique may be useful for the reconstruction of certain atypical thumb duplications.
Although the usefulness of vascularized fibular grafts has been well documented, periarticular reconstruction remains challenging. We report a case in which a folded vascularized fibula was successfully used for reconstruction after resection of a locally aggressive bone tumor in the distal humerus. A 56-year-old man had polyostotic fibrous dysplasia in his right extremity, and underwent multiple surgeries on right elbow until the age of 44 years. After a 12-year asymptomatic period, he developed severe pain in his right elbow. Imaging studies revealed extensive osteolytic changes and pathological fracture in the distal humerus. Under the diagnosis of secondary aneurysmal bone cyst, two-stage surgery was performed. First, tumor resection combined with a cement spacer and external fixation was performed. Five weeks after the first surgery, reconstruction using the vascularized fibula was performed. After harvesting the graft, it was divided into two segments, which were then placed in parallel into the distal humerus. Bone union was observed 3 months after the second surgery. Although the range of motion was limited, the patient was satisfied with the functional outcome. Thus, folded vascularized fibula may be the procedure of choice for reconstruction of massive defects in the distal humerus.