Chronic osteomyelitis is characterized by compromised blood supply and eventual osteonecrosis. Definitive treatment requires aggressive resection of affected bone. The resultant defect poses a unique challenge to reconstructive surgeons. Much of the literature on craniofacial osteomyelitis focuses on infection eradication, rather than subsequent reconstruction. This article reports representative cases from our experience with free flap reconstruction for defects secondary to chronic osteomyelitis of the craniofacial skeleton.The authors selected 5 of the most difficult reconstructive cases of craniofacial osteomyelitis from our experience in a single tertiary referral institution with a follow-up of at least 6 months. Three of the 5 cases arose in the setting of previous head and neck cancer treated with resection and radiation therapy. One case had a previous surgical craniotomy complicated by osteomyelitis and multiple failed alloplastic reconstructions. The final case was due to multiple gunshots to the head, with subsequent cerebral and cranial abscess (>1000cc). In each case, the defect was successfully treated with free tissue transfer. Two cases required creation of recipient vessels with an arteriovenous loop.Free tissue transfer provides a versatile and effective tool in the reconstruction of extensive craniofacial osteomyelitis defects. Furthermore, the addition of vascularized tissue can protect against further episodes of osteomyelitis. Finally, arteriovenous loops can be employed successfully when prior radiation and infection of the wound bed precludes the use of local recipient target vessels.
PURPOSE: Infections following total knee arthroplasty (TKA) often result in plastic surgery consultation in attempt to salvage the prosthesis. Muscle and fasciocutaneous flaps have become a mainstay of this salvage reconstruction.1,2 These flaps often lead to short-term success.3–5 However, does short-term success result in long-term knee salvage? Does flap reconstruction help eradicate infection when a large foreign body must be maintained in the wound? Or does the flap merely suppress the infection with later failure of the knee reconstruction? We have attempted to answer these questions by retrospectively analyzing a large number of TKA reconstructions requiring muscle or fasciocutaneous flap coverage. MATERIALS AND METHODS: A retrospective review of patients treated with flaps after failed TKA between 1998 and 2014 was conducted. Patients requiring flap coverage of soft-tissue defects were included into Group 1. Patients with no soft-tissue defects, but with extensive debridement during revision TKA requiring immediate flap reconstruction were included into Group 2. RESULTS: Fifty-eight patients in Group 1 were treated with 86 flaps, and 15 patients in Group 2 were treated with 17 flaps. Mean length of follow-up was 67.0 and 54.7 months, respectively (p=0.21). Flap related complications and number of subsequent flap revisions were comparable in both groups. Patients in Group 1 had a higher rate of implant reinfection (58% vs. 27%; p<0.05), amputations (25% vs. 0%; p<0.05), and number of subsequent prosthesis revisions (2.2 vs. 0.9; p<0.05). Functional joint was preserved in 54% and 80% of cases, respectively. Mean range of motion and quality of life were significantly better in Group 2 (p<0.05). CONCLUSION: Flap reconstruction allowed achieving stable coverage of the prosthesis, but the reinfection rate was surprisingly high, patients needed multiple additional revisions and only 54% an 80% of functional implants were retained after 5 years. This should be taken into consideration while discussing different treatment options for soft-tissue defects around the knee prosthesis.
Background: The muscle-sparing descending branch latissimus dorsi muscle (MSLD) flap is a versatile flap with numerous benefits. It is an often overlooked but useful option when considering free flap donors. In this article, the authors present the largest experience with the MSLD flap, with focus on its use in lower extremity reconstruction. Methods: Patients undergoing lower extremity reconstruction with the MSLD flap at a single institution from 2012 to 2017 were identified. Patient and wound characteristics, surgical details, complications, and outcomes were examined. Outcomes were compared to a cohort who underwent lower extremity reconstruction with other free muscle flaps during the same period. Results: Thirty-six consecutive patients who underwent MSLD flap surgery were identified. Mean follow-up was 18.8 months. Mean body mass index was 29.2 kg/m 2 and 56 percent were smokers. The most common wound causes were motor vehicle collision (46 percent) and fall (22 percent). The most common anatomical location was the distal third of the tibia (33 percent). Mean operative time was 380 minutes. Complications included three total losses (8 percent) and one partial loss (3 percent). No donor-site seromas were reported. Four patients required subsequent amputation for orthopedic issues (nonunion/pain). Patients receiving MSLD and other flaps had similar rates of amputation, donor- and recipient-site complications, and ambulation status ( p > 0.05). Conclusions: The MSLD flap is a useful and reliable option for free flap reconstruction of the lower extremity. Advantages include an easily contourable flap, low revision rate, low complication rate, and the ability to harvest in supine position. In addition, the MSLD flap preserves donor function useful for rehabilitation and minimizes seroma risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
Background Traumatic brain injury (TBI) associated with facial fractures is a major public health concern worldwide. The rate of TBI in patients with mandibular fractures ranges from 21.3% to 39.6%. However, the risk factors for TBI in patients with mandibular fractures remain unknown. Our study evaluates these risk factors. Methods We retrospectively reviewed patients who presented with traumatic mandibular fractures in 2018 and 2019. Excluded were patients with no documentation of Glasgow Coma Scale. Our primary outcomes were: (1) prevalence of concomitant TBI on presentation defined as having a positive head computed tomography scan (hemorrhage, parenchymal contusion, diffuse axonal injury), or a negative scan with Glasgow Coma Scale < 15 or any neurologic symptom/sign; (2) prevalence of posttraumatic neurologic symptoms assessed at ≥4 weeks after injury. The mandibular injury severity score (MISS) was calculated for all patients. Bivariate analysis and multivariable logistic regression were performed. Results Of 390 patients with mandibular fractures, 165 (42.3%) had concomitant TBI on presentation. Of those, 61% (n = 101) had mild TBI, 12% (n = 20) had moderate TBI, and 27% (n = 44) had severe TBI. Almost half of the mandibular fractures were due to assault (182 [47%]). Older age at injury and the presence of other facial fractures were associated with significantly greater odds of TBI on presentation (adjusted odds ratio 95% confidence interval [CI] 1.016 [1.001–1.032], P = 0.040; 2.457 [1.551–3.891], P < 0.001). Of 195 patients who were assessed at ≥4 weeks after injury, 99 (51%) had neurologic symptoms, most commonly facial numbness (74 [38%]). Mandibular body fracture and a high MISS were associated with significantly greater odds of having neurologic sequelae at ≥4 weeks after injury (adjusted odds ratio [95% CI] 3.12 [1.31–7.50], 1.12 [1.04–1.20]). Conclusions Older patients and those with mandibular body fractures and a high MISS may benefit from TBI screening and close longitudinal follow-up to identify and manage neurologic sequelae.
