Treatment of the soft tissues in combined injuries to the bone and soft tissue.
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Adolescent↗
Biomedical subjects
R Hierner
Publications and source records attributed to R Hierner.
Primary shortening with secondary limb lengthening in severe injuries of the lower leg: a six year experience.
Multiple secondary grafting procedures may be necessary in cases of complete or partial amputation of the lower limb if the aim is to preserve the initial limb length. The traditional concept of staged reconstruction often leads to a prolonged hospitalisation and a high complication rate, especially in cases with segmental nerve defects of more than one major nerve and severe skin loss. To minimize multiple secondary operations of soft tissue and bone, we have developed the concept of primary shortening with secondary limb lengthening. We perform a primary shortening of the amputation stump and the severed limb at the time of replantation, in order minimize the skin defect and to undertake a primary wound closure and/or primary nerve suture. Six to 12 months after replantation, secondary limb lengthening is started, using an external or internal distraction device. Since 1985, 7 patients presenting with complete or partial amputation of the lower leg had been treated using this concept. The indications, operative technique, complications and results are shown and discussed, comparing this new concept to the traditional concept with extensive free soft tissue transfer and secondary nerve grafting.
Adult↗
[The scapula flap--overview and personal experiences].
Since the first report in the literature by Dos Santos in 1980, the scapula flap has become one of the most commonly used fascio-cutaneous free flaps. This is due to its numerous advantages and its few inconvenients. Because of the constant anatomy, the minor donor site defect and its good aesthetic result, the scapula flap replaced other more traditional flaps such as the radial forearm or the latissimus dorsi flap. Being a flap of the "subscapular artery system", it offers the possibility to be harvested "en bloc" with the other flaps of this system for complex reconstruction procedures. In our opinion, the scapula flap is the treatment of choice to treat cutaneous defects of the lower extremity which could not be covered by local flaps. In head-neck reconstruction, the colour and texture of the skin offered by this flap is superior to other free flaps. A thick, well visible horizontal scar in the donor site is the only real inconvenience of the scapula flap. It seems that the parascapula-flap (Nassif et al. 1982) which offers the same properties as the scapula flap is on the way to replace the scapula flap in the future. After a six-year experience with this flap we will present a current concept review and our own experience based on 30 cases. Moreover, we would like to report on some technical refinements.
Adolescent↗
[Vascularized fibula transfer. A review].
The first vascularized fibula transfer was done by Ueba et al. (1983) in 1974 and has since become a standard technique for special indications in the English, French, Japanese and Chinese-world. Within the last 5 years this technique has received more and more attention in the German-speaking countries. The vascularized fibula transfer is successfully used to reconstruct segmental bone defects larger than 5 to 8 cm that are caused by trauma, tumor, pseudarthrosis or congenital defects. When used to treat osteomyelitis, the vascularized fibula transfer failed to fulfill expectations. Bone defects smaller than 10 cm can also be treated by vascularized iliac crest transfer. To achieve rapid healing, the following points must be followed carefully: when treating osteomyelitis, the infection must be healed--negative cultures and good granulation tissue--prior to bone transplantation. Application of systemic or local antibiotics and aggressive debridement of necrotic bone and soft tissue must be carried out until the cultures taken from the wound are negative. Soft tissue defects must be treated by soft tissue transfer in order to facilitate wound closure with well-vascularized tissue. Vascularized bone transfer should be the treatment of choice for the femur and upper extremities. Precise preoperative planning, especially in high-energy trauma cases, reduces the complication rate. Rigid internal fixation of the bone graft with the recipient site by a smaller proximal and distal plate or by a plate bridging the whole bone defect running parallel to the fibula graft leads to rapid healing without malalignment.(ABSTRACT TRUNCATED AT 250 WORDS)
Bone Neoplasms↗
The iliac crest region: donor site for vascularized bone periosteal and soft tissue flaps.
A review is presented of the classic vascularized iliac crest transfer and to show useful variations on this technique. A technical variation to reconstruct mandibular defects, the semisegmented iliac crest graft, is described. Another variation, the half iliac crest graft, is presented for use in the neovascularization of avascular necrosis of the femoral head. When such a flap is raised with a large periosteal flap and overlying muscle or skin, or both, as a composite flap, a primary osteoperiosteal tube can be created to reconstruct segmental defects in long bones. This primary osteoperiosteal tube is secondarily transformed into a completely osseous tube.
Bone Transplantation↗
[Plastic surgery measures in combined soft tissue defects of the lower leg].
Isolated or combined soft tissue defects of the lower leg are still a challenge as regard diagnostic and differential treatment. We distinguish acute and chronic isolated or combined soft tissue defect. Acute trauma within a multiple injury pattern is a special form of the acute soft tissue defect. For diagnostic purposes we use a preoperative and intraoperative standardized diagnostic programme. A new classification oriented towards the therapeutic procedure is presented, as is therapy algorithm which has been created.
Follow-Up Studies↗
[Vascularized periosteal transplant. A review of a new therapeutic possibility].
The idea of using vascularized periosteal flaps in reconstructing bone defects is more than one hundred years old. Up to now, experimental and clinical results regarding their osteogenic capacity have been a subject of debate. Experimental and clinical studies over the last ten years were able to demonstrate osteogenic capability of such vascularized periosteal flaps, provided the periosteum is well vascularized. To insure intact microcirculation, vascularized periosteal flaps must be freed up by sharp dissection. Small pieces of bone may be removed with the periosteum, whereas the periosteum must remain uninjured. There are many known donor sites in man: the iliac crest, the distal femur, the distal humerus and the tenth rib. There are no reports concerning donor site morbidity. Besides its osteogenic capacity, the periosteal flaps have "shape giving" and "space limiting" functions. The given volume within a periosteal flap rolled into a tube is the basis for the "Concept of the Given Space": the space within the tube defines where bone formation will occur, there being no loss of bone into the surrounding soft tissue. Because of the vascularized periosteal flap's fragility and the good results of other reconstructive procedures for segmental bone defects, there are few indications for extremity reconstruction using periosteal flaps: pseudarthrosis in the upper extremity is one example. In the lower extremity, a combination of vascularized periosteum with conventional and mainly vascularized bone grafts offers interesting possibilities for reconstruction.
Animals↗
[Tarsal tunnel syndrome. Nerve compression syndrome in the foot].
Pathological changes in sensation over the sole of the foot do not always correspond to the full area of distribution of the posterior tibial nerve. Some neurologists advise separate examination of the tibial nerve, the medial and lateral plantar nerves, in order to ascertain whether either or both might be affected. 60 preparations of cadaveric feet in the Department of Anatomy were examined. Using a measuring grid, the position and size of the nerves in the tarsal tunnel were assessed and the facial band which define and divide the osteofibrous canal delineated. The corners of the measuring grid were the tip of the medial malleolus (A), the tip of the calcaneal tubercle at its greatest distance from the medial malleolus (B) and the tuberosity of the navicular bone (C). These points can also be clearly identified clinically. They define a triangle whose sides A-B and B-C are of constant equal length and whose base A-C varies little. The operative approach includes a T-shaped incision of the retinaculum. The vertical line of the T lies underneath the skin incision. The horizontal line corresponds with the upper border of the abductor hallucis muscle. The upper border of the abductor hallucis is defined and the muscle retracted medially to expose the deep fascia. This layer is removed together with the connective tissue bridge which stretches between the fascia and the calcaneus. The plantar nerves are discovered and run to the sole of the foot without further obstruction.
Diagnosis, Differential↗