This long-term study protocol aims to compare the clinical outcomes of patients with severe lower limb trauma undergoing orthoplastic and orthopedic surgeries, focusing on their physical and psychological status. Patients with lower limb injuries and open fractures have been recruited since October 2019 and will be followed up until October 2024. The patients will be divided into two groups: (1) Orthoplastic group, where single-stage debridement, fixation, and soft tissue repair will be performed, and (2) Orthopedic group, where soft tissue repair will be done in a delayed-stage. The follow-up period will be one year, during which clinical data, limb function recovery, psychological scores, and health-related quality of life (HRQOL) will be evaluated to assess postoperative recovery and clinical outcomes. Additional clinical data, such as socio-demographic information, baseline features, Enneking score, Visual Analogue Scale (VAS) score, two-point discrimination score, and blood test parameters will also be collected. The 36-Item Short Form Health Survey (SF-36) will be used to evaluate HRQOL, while the Post-traumatic Stress Disorder Checklist (PCL) will assess the severity of self-reported post-traumatic stress disorder. The results of this study will provide valuable insights into prognostically relevant targets and contribute to improving the management and outcomes of patients with lower limb injuries and open fractures, who often face challenges related to limb disability and potential amputation postoperatively, significantly impacting their psychological and physical well-being.

Secondary reconstruction in trauma surgery is crucial for restoring both functional and esthetic results in patients with complex defects. Established reconstructive techniques in plastic surgery offer a wide range of options for an effective treatment. This applies not only to covering large defects with free flaps but especially also for the functional reconstruction of bony, neural and musculotendinous impairments. Advances in the fields of microsurgery and 3D printing show innovative approaches to further improve the therapeutic options. A multidisciplinary approach, requiring close collaboration between trauma and plastic surgeons, is necessary to optimize treatment plans and outcomes. The effective management of complications and qualified postoperative care are essential for the success of reconstructive measures.
UNASSIGNED: Die sekundäre Rekonstruktion in der Unfallchirurgie ist entscheidend für die Wiederherstellung sowohl funktioneller als auch ästhetischer Ergebnisse bei Patienten mit komplexen Defekten. Etablierte rekonstruktive Techniken der plastischen Chirurgie bieten eine Vielzahl an Möglichkeiten für eine effektive Behandlung. Dies gilt nicht nur für die Deckung von großflächigen Defekten mithilfe freier Lappenplastiken, sondern insbesondere auch für die funktionelle Rekonstruktion knöcherner, nervaler und muskulotendinöser Einschränkungen. Fortschritte in Bereichen der Mikrochirurgie und des 3D-Drucks zeigen innovative Ansätze auf, die Therapieangebote weiter zu verbessern. Ein multidisziplinärer Ansatz, der eine enge Zusammenarbeit zwischen Unfall- und plastischen Chirurgen erfordert, ist notwendig, um Behandlungspläne und Ergebnisse zu optimieren. Das effektive Management von Komplikationen und eine qualifizierte Nachbehandlung sind entscheidend für den Erfolg der rekonstruktiven Maßnahmen.

UNASSIGNED: Periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) presents significant challenges, especially in elderly and comorbid patients, often necessitating revision surgeries. We report on a series of patients with confirmed PJI of the knee and concomitant soft-tissue/extensor apparatus defects, treated by using pedicled myocutaneous medial or lateral sural artery perforator (MSAP/LSAP) gastrocnemius flaps.
UNASSIGNED: Our retrospective study at the Center for Musculoskeletal Infections, included patients with knee PJI undergoing pedicled myocutaneous MSAP/LSAP gastrocnemius flap reconstruction for combined soft tissue and extensor apparatus defects. The tendinous back of the gastrocnemius muscle was used and, if required, the Achilles tendon for extensor apparatus reconstruction, with the skin island addressing the cutaneous defect. Perioperative complications and postoperative outcomes after 1 year were evaluated, including functional and clinical assessments with the American Knee Society Score (AKSS).
UNASSIGNED: Eight patients (mean age 73 years; five female) were included, predominantly with Staphylococcus aureus infections. Six patients involved isolated MSAP flaps, two were extended with the Achilles tendon. The median time for wound healing was 9 days. Short-term follow-up showed successful reconstruction in seven patients, with minor wound dehiscence in one patient. One patient required flap revision for a perigenicular haemato-seroma and two patients were diagnosed with new haematogenous PJI infection. Significant improvement in AKSS scores after surgery was observed (functional AKSS: median 33-85; clinical AKSS: median 64-91, p = 0.001).
UNASSIGNED: Pedicled myocutaneous MSAP/LSAP gastrocnemius flaps offer a safe, reliable and versatile option for reconstructing combined soft tissue and extensor apparatus defects in PJI after TKA. This approach yields excellent functional outcomes with minimal peri- and postoperative complications, which is particularly beneficial in elderly and comorbid patients and feasible in settings without microsurgical availability.
UNASSIGNED: Level IV.

UNASSIGNED: Popliteal artery entrapment syndrome (PAES) is a rare condition in which the popliteal artery becomes compressed by adjacent soft tissue structures causing progressive claudication. Due to its low incidence, this disorder and its surgical management is poorly described in the literature. This study presents our institutional data surrounding PAES management to further optimize care of this syndrome.
UNASSIGNED: This retrospective study gathered demographic, surgical, and outcome data of all patients with PAES who underwent surgical decompression at our institution from 2015 to 2022. Patients were identified using CPT and ICD-9/10 codes. Summary statistics were calculated, with Chi-squared and T-test used for subgroup analysis.
UNASSIGNED: 50 surgical patients with PAES were identified. On average, they were young (mean age: 20.7 years), mostly female (78 %), and predominately white (68 %). The vast majority were physically active, with 13 of the 50 patients being runners (26 %). Medically, the cohort was otherwise healthy, with 74 % reporting no comorbidities. Diagnosis was often delayed, with patients on average seeing 4.5 physicians over 2.0 years prior to arriving at our institution for care. In addition to popliteal artery release, the second most performed procedure was fasciotomy (82 %). Postoperatively, there was significant long-term subjective improvement, with 91 % of patients reporting they would repeat the operation and 65 % reporting improved activity.
UNASSIGNED: PAES is a rare condition affecting the lower limb that requires a nuanced surgical approach. From diagnosis to outcome, we hope to better inform surgeons of PAES so that these patients may receive the highest quality care.

Congenital clubfoot is addressed in infancy and rarely persists into adulthood. Ankle arthroplasty is an increasingly popular surgical intervention for patients with ankle arthritis since it allows a natural ankle range of motion and completely replaces a degenerative hindfoot. Here, we describe the first successful total ankle arthroplasty (TAA) for a patient with previously treated congenital clubfoot that reverted later in life. To address the patient\'s poor soft-tissue integument and reduce the likelihood of post-surgical complications, a perioperative latissimus muscle-free flap was performed. This two-staged, novel orthoplastic intervention addressed our patient\'s ankle issues and appears to be a viable option for clubfoot patients.

Negative pressure wound therapy (NPWT) is a wound-dressing system that applies sub-atmospheric pressure on the surface of a wound to promote healing. An evolution of this technology, NPWT with solution instillation and dwell time (NPWTi-d), is increasingly being used to maximise wound closure and reduce failure rates. However, there is still a lack of evidence concerning its use in orthoplastic surgery. Therefore, the aim of this study is to compare NPWTi-d with NPWT and standard of care for wound management in orthoplastic surgery. A comprehensive literature search using PubMed, Web of Science, and Cochrane databases up to 15 March 2022 was performed, including studies describing the outcomes of NPWTi-d for traumatic/orthopaedic injuries. A meta-analysis on the number of surgical debridements, as well as the rate of complete wound closure and complications was carried out, although for other outcomes, a descriptive statistic was applied. Risk of bias and quality of evidence were assessed using the Downs& Black\'s Checklist for Measuring Quality. Thirteen studies with a total number of 871 patients were included, in which NPWTi-d demonstrated significantly higher primary wound closure and lower complication rates (P < .05). No difference in the number of surgical procedures required for final wound healing was observed. Moreover, five out of six studies showed better results for NPWTi-d when the change of the bioburden and bacterial count of the wound were analysed. A singular study investigating the length of the hospital stay of patients treated with NPWTi-d showed a reduction in the latter. The present meta-analysis proves that NPWTi-d is superior to NPTW or conventional dressings in orthoplastic wound care management, in terms of complete wound closure rate and the reduced number of complications. Still, the limited quality of the studies analysed shows that future randomised studies are needed to confirm the benefits and to identify the most appropriate recommendations for using NPWTi-d in orthoplastic surgery, as well as to investigate the cost-effectiveness of this wound-dressing system.

Background: The principle of early flap reconstruction for high-grade traumatic lower-extremity injuries established in 1986 by Godina has been widely accepted. However, the lack of an orthoplastic center in China makes early reconstruction not accessible for all patients with a Gustilo IIIB fracture. This study aimed to analyze the impact of timing on outcomes in lower-extremity traumatic free-flap reconstruction. Methods: A retrospective review identified 394 free-flap reconstructions performed from January 2005 to January 2020 for Gustilo IIIB tibial fractures. Patients were stratified based on the number of debridements: two times or less (early) and more than two times (delayed). The interval between injury and reconstruction, surgery time, hemorrhage volume, length of hospitalization (LoS), wound and bone healing time, flap outcomes, and function restoration were examined based on times of debridement. Results: The mean interval between injury and flap reconstruction in the early-repair group with 6.15 ± 1.82 postoperative days (PODs) was significantly shorter than that of the delayed-repair group with 16.46 ± 4.09 PODs (p < 0.001). The flap harvest time, reconstructive time, and intraoperative blood loss were also significantly less in the early-repair group compared to the delayed-repair group. Interestingly, we observed an 8.20% enlargement of wound size due to multiple debridements in the delayed-repair group. Most importantly, the early-repair group had better outcomes with a decreased risk of total or partial flap necrosis, lower incidence of flap complications, and fewer overall late complications than the delayed-repair group. In addition, the LoS, as well as wound and bone healing time, were notably shorter in the early-repair group. Furthermore, 4.85% of cases in the delayed-repair group experienced additional operations on bone, while no additional operations were performed in the early-repair group. All cases in both groups obtained satisfying functional results, while the early-repair group showed better functional recovery. Conclusions: Early repair with free flaps performed within two instances of debridement had superior outcomes when compared with delayed reconstruction after multiple debridements, consistent with Godina’s findings. We recommended early referral to a higher-level hospital with orthoplastic capabilities after an aggressive and thorough initial debridement carried out by senior surgeons.

OBJECTIVE: Fracture-related infection (FRI) is one of the most serious complications in orthopedic trauma surgery. Despite its widespread use, the role of Negative Pressure Wound Therapy (NPWT) remains controversial in the management pathway of FRI. The aim of this study was to assess the relationship between the application of NPWT and its duration and recurrence of infection in operatively treated FRI patients.
METHODS: This is a retrospective cohort study based on the FRI database of three level 1 Trauma Centres. Included patients had to be at least 16 years of age and surgically treated for FRI between January 1st 2015 and September 1st 2020. Patients were subdivided in either the NPWT group, when NPWT was applied as part of the FRI treatment, or in the control group, when no NPWT had been applied. To limit confounding, patients were excluded if they (also) underwent NPWT prior to the diagnosis of FRI. The relation between the duration of NPWT during FRI treatment and the recurrence rate of infection was analyzed using a multivariable logistic regression model.
RESULTS: A total of 263 patients were included, 99 in the NPWT group and 164 in the control group. The median duration of NPWT was 18.0 (IQR 15.8) days. In the NPWT group, 28 patients (28.3%) developed a recurrent FRI. In the control group, 19 patients (11.6%) had a recurrent FRI (p = 0.001, 95% CI [0.174 - 0.635]). In the NPWT group there were no significant differences in baseline characteristics between the recurrence and non-recurrence group. The duration of NPWT was associated with a higher risk of recurrence of infection (p = 0.013, OR 1.036, 95% CI [1.008 - 1.066]).
CONCLUSIONS: Delayed wound closure with the application of NPWT increased the risk of recurrence of infection in patients with soft tissue defects after FRI treatment. Therefore, it is advised to consider NPWT only as a short-term (e.g. few days) necessity to bridge the period until definitive wound closure can be established.

BACKGROUND: This study investigates the outcomes of complex knee joint reconstructions performed by an orthoplastic surgery team at a tertiary referral hospital.
METHODS: Retrospective review of all the total knee arthroplasty (TKA)/revision TKA (rTKA) procedures with soft tissue flap reconstruction performed between 2008 and 2019 was conducted. Patients were stratified into two groups according to the urgency of surgery: scheduled non-complicated (SNC) and emergent complicated (EC). The whole study cohort was also categorized into non-infected and infected groups.
RESULTS: Of 20,184 TKAs operated, 58 patients required flap reconstruction (SNC group n = 27; EC group n = 31). The most common reconstruction was medial gastrocnemius flap (74%). Mean follow-up time was 31.9 months. Functional knee joint salvage was achieved in 96.3% the SNC group and in 80.6% the EC group patients (p = 0.07). Transfemoral amputation rates were 3.7% in the SNC group vs. 6.5% in the EC group (p = 0.36). Oxford Knee Score was 34.5 vs. 25.5 (p = 0.21), and range of motion was 100⁰ vs. 93⁰ (p = 0.37) in the SNC and EC groups, respectively. Superior functional knee joint salvage rates were achieved in the non-infected group compared to the infected group (97.1% vs. 75.0%, p = 0.004). However, the transfemoral amputation rate was nearly three-fold in the infected group (8.3% vs. 2.9%, p = 0.36). Estimated five-year survival with functional knee joint was higher in the non-infected group (p = 0.03).
CONCLUSIONS: Both the SNC and EC groups had similar acceptable limb salvage rates, and functional and PROM outcomes. Infection reduces the probability of a functional knee joint after TKA and flap reconstruction.

Major trauma care has improved in the UK since the evolution and acceptance of specialist centers . A mission statement for major trauma care is \"reduction in mortality and disability following trauma.\" The care for extremity trauma has benefited from this specialization. Traumatic loss of skin integument in the extremities, especially over mobile joints, may lead to a compromised functional outcome. Modern reconstructive plastic surgery aims to provide flaps with minimal donor site morbidity. In this case report, we present the use of two chimeric flaps undertaken sequentially (one acutely and the second delayed) around the knee joint to allow a greater range of motion and function after a severe traumatic event. In this clinical case, the original tissue defects had meant that a free flap was used to reconstruct an open fractured bone, and split skin grafting was undertaken on the anterior aspect of the knee. The latter was then replaced after some months of recovery.