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Orbital exenteration is a radical and disfiguring operation. It is still under debate the absence of correlation between the term describing the resulting orbital defect and the type of reconstruction. Authors' goal was to propose a consistent and uniform terminology for Orbital Exenteration surgery in anticipation of patients' tailored management. Twenty-five patients who underwent orbital exenteration between 2014 and 2020 were reviewed. A parallel comprehensive literature review was carried on. Five different types of orbital exenteration where outlined. Multiple reconstructive procedures were enclosed. An algorithm for orbital reconstruction was proposed based on anatomic boundaries restoration. Eyelid removal was first considered as an independent reconstructive factor, and both orbital roof and floor were indicated as independent reconstructive goals, which deserve different defect classification. In our opinion, this algorithm could be a useful tool for patient counseling and treatment selection, which might allow a more tailored patient care protocol.Level III.

Giant-cell tumor (GCT) is locally aggressive bone neoplasm, with an unpredictable pattern of biological aggressiveness. The optimal treatment had to achieve a negligible local recurrence rate while maximizing musculoskeletal function. Numerous options for reconstruction are available, but in the literature there is a lack of salvage surgery data. We present a case of a 67-year-old woman who underwent complete wrist arthrodesis with vascularized fibular graft as salvage procedure for allograft necrosis, after excision of a distal radius GCT. The patient did not complain of any impairment in daily use, and the functional score was 22 points (73%) at latest follow-up of 14 months. Despite joint salvage remains the most favorable treatment with regard to functional outcome for aggressive tumors of the distal radius, vascularized fibular grafts is a valuable alternative especially in salvage procedures, where the use of another allograft could lead to higher complications rate. Keywords: Vascularized fibular graft, Wrist arthrodesis, Giant-Cell Tumor, Fibula free flap.

Background Total wrist fusion (TWF) is indicated for longstanding degenerative, posttraumatic and/or post-oncological conditions to provide pain relief and wrist stability at partial expense of wrist motion. Patients and Methods A total of 11 consecutive patients who had completed TWF with Vascularized Fibula Graft (VFG) for massive distal radius defects were identified retrospectively from our centre using inpatient records. We evaluated bone fusion times and long term functional outcomes following the procedure. Post-operative grip strength (GS) and prono-supination were objectively measured. The new Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire was used to rate disability and symptoms; pre- and post- operative pain with the Visual Analog Scale (VAS) was assessed. A literature review of the present studies about TWF with VFG was performed, with the aim of comparing long-term functional results of the surgical techniques so far reported in the English literature. Results Our experience with TWF using VFG appeared slightly better than that found in the literature. The procedure was successful in all the cases, achieving bone union in 4,8 months on average. Complication rate was 27,2%, no flap loss was recorded. There were no wrist instability, deformation or dislocation; mean pronation/supination (P/S) was 57,5°/61,2°. Average grip strength resulted 59% of the contralateral side. Mean recorded levels of visual analog scale (VAS) for pain postoperatively were 2,32 ± 0,792, which improved significantly from the pre-operatively value of 7,90 ± 0,79. Mean overall satisfaction was good and all the patients comfortably returned to normal activities. Conclusions Wrist arthrodesis by means of VFG resulted to be an effective and reliable option in dealing with massive defects of distal radius with involvement of radio-carpal joint. Although the cohort analyzed is relatively small and definitive conclusions cannot be drawn, the long term radiographs and the overall functional outcomes encourage to use the described surgical option over other techniques, such as prosthetic replacement and non-vascularized bone grafts.

Quadriceps tendon re-rupture after surgical repair is an overall estimated 2% complication. We report a case of reconstruction in a large tendon and soft tissue defect using a reverse-flow anterolateral thigh (ALT) perforator flap including fascia lata in a 75-year-old man presented with septic necrosis of a reconstructed quadriceps tendon. A reverse-flow ALT flap was transferred to the knee defect; the fascia lata was sutured to the residual tendon. Post-operative flap congestion and infection were successfully treated with debridement and conservative treatment. One year after surgery, the patient was able to fully and actively extend the knee, with an acceptable aesthetic appearance. The reverse-flow anterolateral thigh flap including fascia lata may be a good option for coverage of soft-tissue defects around the knee and contemporary quadriceps tendon reconstruction, particularly in case of septic tendon necrosis, where the use of non-vascularised tissues is contraindicated.

Background Several options have been described for soft-tissue reconstruction in Achilles tendon region (ATR). The best procedure should be customized according to any single case taking into account the number of structures involved, the quality of the neighboring skin, and patient's general condition. The aim of this article is to describe a simplified reconstructive algorithm based on personal experience and reviewing literature. Methods Forty-four patients, who underwent ATR soft-tissue reconstruction between 1998 and 2016, have been retrospectively reviewed. Etiologies of the defect include the following: 18 posttraumatic, 10 postoncologic, 14 dehiscence/infection, and 2 chronic ulcers. Follow-up ranges between 12 and 96 months. Free flaps have been used in 30 cases (including two secondary surgeries due to propeller flap failure) and propeller flaps have been used in 16 cases. Results Thirty-six flaps survived uneventfully (78.3%). Total flap necrosis occurred in three cases (6.5%), namely, two propeller flaps and one free flap. Partial necrosis of the flap was observed in seven cases (15, 2%): three in the free flap group and four in the propeller group. The functional recovery was very good in all the patients without involvement of the tendon and also all the patients who underwent a simultaneous reconstruction of the tendon with different techniques recovered a full weight bearing and a satisfactory range of motion. Conclusion Propeller flaps are a valuable option for skin reconstruction in case of defects of small and medium size not involving the tendon. In case of larger defects and when a simultaneous ATR reconstruction is required, a free flap seems to be a better option.

Treatment of complex hand trauma includes adequate debridement of nonviable tissue, early reconstruction, and careful selection of various available surgical procedures tailored to patients' needs and requests. Debridement of all necrotic tissue is crucial before any attempt at reconstruction. Surgeons should also consider cosmetic outcomes of the reconstructed hand and donor-site morbidity. For best results reconstruction should be performed early, with proper early postoperative therapy. This article reviews the principles and surgical options in the management of complex hand injuries involving the dorsal and the palmar aspects of the hand, and the different types of tissue in the hand.

Reconstruction after excision of bone tumor of the proximal tibia is a challenging issue for the reconstructive surgeon. The combined use of a free fibular flap and allograft can provide a reliable reconstructive option in this location. This article describes the authors' long-term follow-up using this technique. Twenty-seven patients that had resection of proximal tibia bone tumors underwent reconstruction using this technique. Only 21 patients that had primary reconstruction were included in this study. All patients had their surgeries performed at least 24 months before the end of the study. The average age at time of operation was 18.1 years. The average follow-up time was 139.3 months. Limb salvage was 82.7%. The average length of the resected tibial segment was 15.3 cm and that of the residual proximal tibia remaining after resection was 2.7 cm. The average time of union of fibula was 5.4 months and for union of allograft was 19.1 months. Primary union of the allograft was achieved in 90.5% of cases. Full weight-bearing was achieved at an average of 21.6 months. Ten patients (47.6%) had 14 local complications. The (MTSRS) average score at final follow-up was 27.3. Local recurrences occurred in two patients (9.5%). Distant metastasis to the lung occurred in three patients (14.3%). One patient died of disease. This technique provides good long-term results in reconstruction of proximal tibia. The viability of the fibula is a cornerstone in both success of reconstruction as well as successful management of complications.

Introduction: The concept of limb salvage led to increased demand for more complex and sophisticated reconstructive options to achieve better functional and cosmetic outcome. Reconstruction of the total or partial loss of quadriceps muscle after soft tissue sarcomas excision with free functioning latissimus dorsi muscle transfer had become more popular in the last years. Patients and methods: Between November 1993 and October 2004, 11 patients with average age 45.5 years underwent excision of quadriceps muscle followed by simultaneous reconstruction with free functioning latissimus dorsi muscle. There were six men and five women. The tumors were high grade in 90.9% of patients and were >10 cm in 81.8% of patients. The tumor extension required the resection of the entire quadriceps in four cases, of three heads in six cases, of only two heads in one case. Results: The average follow up was 69 months. The average time of recovery of the contractile activity of the muscle was 8.3 months after operation. The musculoskeletal tumor society rating score (MTSRS) scored excellent or good in 73% of patients. Three patients (27.3%) died of metastatic disease. Local recurrence occurred in one patient (9.1%). Limb salvage was achieved in all the patients (100%). Conclusion: This method of reconstruction is a reliable technique not only to fill the defect resulting from oncological resection but also to provide better function. Microsurgical reconstruction of soft tissue sarcoma helps to expand the indications of limb salvage by allowing better local control and achieving adequate function and coverage. © 2008 Wiley-Liss, Inc. Microsurgery, 2009.

In the period between 1994 and 2004, 13 patients (10 male, 3 female) presenting with post-traumatic defects to the humerus were treated with vascularised fibula graft. Age ranged from 21 to 62 (mean 37) years. Length of the bony defect ranged from 6 to 16 cm. Graft fixation was performed with plates in 12 cases, and in one case only screws were used. All patients were clinically reviewed between 120 days and 14 months after surgery. In one patient the flap was lost and a second free fibula flap was performed to achieve the reconstructive goal. Mean time for segmental bony union was 6 months (range from 3 to 13 months). Vascularised fibula graft allows for a successful humerus reconstruction when traditional techniques provide unsatisfactory results.

Background Treatment of the loss of the distal part of the radius, including the physis and epiphysis, in a skeletally immature patient requires both replacement of the osseous defect and restoration of longitudinal growth. Autologous vascularized epiphyseal transfer is the only possible procedure that can meet both requirements. Methods Between 1993 and 2002, six patients with a mean age of 8.4 years (range, six to eleven years) who had a malignant bone tumor in the distal part of the radius underwent microsurgical reconstruction of the distal part of the radius with a vascularized proximal fibular transfer, including the physis and a variable length of the diaphysis. All of the grafts were supplied by the anterior tibial vascular network. The rate of survival and bone union of the graft, the growth rate per year, the ratio between the lengths of the ulna and the reconstructed radius, and the range of motion of the wrist were evaluated for five of the six patients who had been followed for three years or more. Results The mean duration of follow-up of the six patients was 4.4 years (range, eight months to nine years). All six transfers survived and united with the host bone within two months postoperatively. The five patients who were followed for three years or more had consistent and predictable longitudinal growth. Serial radiographs revealed remodeling of the articular surface. The functional result was rated as excellent for all but one patient, in whom the distal part of the ulna had also been resected because of neoplastic involvement. No major complication occurred at the recipient site, whereas a peroneal nerve palsy occurred at the donor site in three patients. The palsy was transient in two patients, but it persisted in one. No instability of the knee joint was observed. Conclusions After radical resection of the distal part of the radius because of a neoplasm in children, vascularized proximal fibular transfer, based on the anterior tibial artery, permits a one-stage skeletal and joint reconstruction, provides excellent function, and minimizes the discrepancy between the distal radial and ulnar lengths.

Vascularized bone graft is most commonly applied for reconstruction of the lower extremity; indications for its use in the reconstruction of the upper extremity have expanded in recent years. Between 1993-2000, 12 patients with segmental bone defects following forearm trauma were managed with vascularized fibular grafts: 6 males and 6 females, aged 39 years on average (range, 16-65 years). The reconstructed site was the radius in 8 patients and the ulna in 4. The length of bone defect ranged from 6-13 cm. In 4 cases, the fibular graft was harvested and used as a vascularized fibula osteoseptocutaneous flap. To achieve fixation of the grafted fibula, plates were used in 10 cases, and screws and Kirschner wires in 2. In the latter 2 cases, an external skeletal fixator was applied to ensure immobilization of the extremity. The follow-up period ranged from 10-93 months. Eleven grafts were successful. The mean period to obtain radiographic bone union was 4.8 months (range, 2.5-8 months). Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius and ulna and of sufficient length to reconstruct most skeletal defects of the forearm. The vascularized fibular graft is indicated in patients with intractable nonunions where conventional bone grafting has failed or large bone defects, exceeding 6 cm, are observed in the radius or ulna.

The aim of this study was to explore the tendinous vascularization of flexor carpi radialis (FCR) and investigate the anatomical basis for harvesting the compound radial forearm flap (free or pedicled) with the vascularized tendon for the reconstruction of cutaneotendinous defects. The area of the radial forearm flap was studied in seventeen forearms of fresh cadavers injected with red latex. A lozenge-shaped flap about 9 cm long and 4 cm wide was raised along the axis of the radial artery. Dissection of the flap was carried out subfascially. We searched perforators going into the flap and the nutritive branches for the tendon sheath of FCR were dissected up to their origin from the radial artery. Their distance from the scaphoid tubercle was recorded. We found nutritive branches for all the length of the tendon. The mean number of perforators going into the tendon sheath was 9.5 (range 8–12). Constant sizeable branches larger than 0.2 mm were identified from the scaphoid tubercle to the myotendinous junction; their distance from the scaphoid tubercle ranged between 0.5 and 12.5 cm. We found an average 0.8 perforators/cm of tendon (range 0.7–1). The donor sites were always closed primarily. Nutrient branches of the radial artery for the tendon of FCR were constantly found. Our anatomical findings confirm the possibility of raising a compound radial forearm flap including a sure vascularized tendon of FCR. Its clinical application provides a quick and straightforward single-stage option for the reconstruction of complex cutaneotendinous defects.

Over the last twenty years, progress in diagnosis and in adjuvant therapy in the field of malignant bone tumor treatment has allowed for development of limb-saving surgical techniques after oncological excision. In this context, the use of vascularized fibula for transplantation represents an important instrument in the reconstruction of bone, either with or without allografts.Moreover, in pediatric cases, the vascularized transplant of the proximal fibula with its open physis allows for an adequate reconstruction of the bone loss and the possibility of conserving the growth potential of the segment. The purpose of this article is to illustrate the various reconstructive possibilities that the use of the combined graft technique (VFT plus allograft) offers in the treatment of large-scale bone loss. In our department from 1988 to 2000, 142 vascularized fibula transplants were performed in oncological cases. Surgical reconstruction was carried out on the tibia in 70 cases, on the femur in 40, on the humerus in 26 and on the radius in 6. Combined graft intercalary reconstructions were 92. In 22 pediatric cases the fibula was transplanted, including the proximal growing epiphysis in the graft; in two of these cases massive allograft was associated to the VFG. Because of its biological properties, the grafted vascularized fibula allowed for fast bone fusion at the level of the osteotomy. It has also demonstrated a tendency of progressive hypertrophy and osteointegration with the allograft, when used. In 22 pediatric cases, the fibula graft with the proximal epiphysis maintained its ability to grow. Unsuccessful outcomes caused by vascular, mechanical, or septic failure were equal to 8.2 %. The fibula graft in the reconstruction of bone loss secondary to oncological excision is a trustworthy and versatile technique.

Conventional pedicled flaps for soft tissue reconstruction of lower extremities have shortcomings, including donor-site morbidity, restricted arc of rotation, and poor cosmetic results. Propeller flaps offer several potential advantages, including no need for microvascular anastomosis and low impact on donor sites, but their drawbacks have not been fully characterized. We assessed (1) frequency and types of complications after perforator-based propeller flap reconstruction in the lower extremity and (2) association of complications with arc of rotation, flap dimensions, and other potential risk factors. From 2007 to 2012, 74 patients (44 males, 30 females), 14 to 87 years old, underwent soft tissue reconstruction of the lower extremities with propeller flaps. General indications for this flap were wounds and small- and medium-sized defects located in distal areas of the lower extremity, not suitable for coverage with myocutaneous or muscle pedicled flaps. This group represented 26% (74 of 283) of patients treated with vascularized coverage procedures for soft tissue defects in the lower limb during the study period. Minimum followup was 1 year (mean, 3 years; range, 1–7 years); eight patients (11%) were lost to followup before 1 year. Complications and potential risk factors, including arc of rotation, flap dimensions, age, sex, defect etiology, smoking, diabetes, and peripheral vascular disease, were recorded based on chart review. Twenty-eight of 66 flaps (42%) had complications. Venous congestion (11 of 66, 17%) and superficial necrosis (seven of 66, 11%) occurred most frequently. Eighteen of the 28 complications (64%) healed with no further treatment; eight patients (29%) underwent skin grafting, and one patient each experienced total flap failure (2%) and partial flap failure (2%). In those patients, a free anterolateral thigh flap was used as the salvage procedure. No correlations were found between complications and any potential risk factor. We were not able to identify any specific risk factors related to complications, and future multicenter studies will be necessary to determine which patients or wounds are at risk of complications. Propeller flaps had a low failure rate and risk of secondary surgery. These flaps are particularly useful for covering small- and medium-sized defects in the distal leg and Achilles tendon region and are a reliable and effective alternative to free flaps. Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

PURPOSE: The aim of this study was to explore the cutaneous vascularization of the hypothenar region and investigate the anatomical basis for perforator propeller flaps for coverage of the flexor aspect of the little finger. METHODS: The area between the pisiform and the base of the little finger was studied in 14 hands of fresh cadavers injected with red latex. An oval flap 1.5 cm large was raised along the axis between these two points. Perforators going into the flap were dissected up to their origin from the ulnar palmar digital artery of the little finger, and their distance from the proximal edge of the A1 pulley was recorded. RESULTS: The mean number of perforator arteries entering the flap was 5.8 (range 4-8). A constant sizeable perforator was identified within 0.7 cm from the proximal margin of the A1 pulley in all 14 specimens. In the majority of cases (64 %), the most distal perforator was located at this level. Dissection of the flap was carried out suprafascially on the most distal perforator and 180° rotation allowed the flap to reach the flexor surface of the fifth finger. The donor site was closed primarily. CONCLUSION: Distal perforators of the ulnar palmar digital artery of the little finger are constantly found. Our anatomical findings support the possibility of raising a propeller perforator flap from the hypothenar region for coverage of the flexor aspect of the little finger. Its clinical application could provide a quick and straightforward single-stage option with a negligible donor-site morbidity for reconstruction of such defects.

Background Local flaps based on perforator vessels are raising interest in reconstructive surgery of the limbs. These flaps allow efficient coverage of large wounds without the need to sacrifice a major vascular axis. The operative technique does not require microvascular anastomosis and allows reconstruction of soft tissue defects using nearby similar tissues. The aim of this study was to evaluate the clinical results of local perforator flaps in the treatment of complex lower-limb defects. Materials and methods Twenty-two local perforator flaps were retrospectively studied. Loss of substance was due to postsurgical complications in seven cases, oncological resection in six, posttraumatic defect in five, pressure sores in three, and osteomyelitis in one. Results Postoperatively, two patients showed partial flap necrosis. In five patients, a superficial epidermolysis occurred. Minor complications were seen in three patients who showed transient venous congestion of the flap. Furthermore, transient leg edema was sometimes observed in patients with large propeller flaps. All but one patient healed without further major surgical procedures. In three cases, secondary skin grafts were performed. In most cases, the aesthetic result was optimal and patients were fully satisfied. Conclusions When characteristics of the defect are suitable for treatment with a propeller-based local flap, this technique should be considered as one of reasonable options for surgical reconstruction. Microsurgical techniques facilitate the management of complex trauma in emergency and may allow planning reconstructive procedures and limb salvage in elective orthopedic surgery.

The quality of reconstruction of soft tissue defects in the upper extremity, resulting either from traumatic injury or tumor excision, has relevant implications both from functional and aesthetic standpoints. Various local and free flaps with more or less consistent donor-site morbidity have been described in the past. The recent introduction of the perforator-based flap concept, has led to an evolution in upper extremity reconstruction, optimizing results at the recipient site whilst minimizing damage to the donor site and, performing this in the simplest way possible. In this study between 2001 and 2008, 31 patients having post-traumatic or post-tumor excision soft tissue defects of the upper limb, were treated using local perforator flaps raised according to two different modalities: "pedicled fasciocutaneous" and "transposition fasciocutaneous/cutaneous". Complete and stable coverage of the soft tissue losses was obtained in all cases with an inconspicuous, only aesthetic, donor-site defect. Superficial or partial necrosis of the tip of the flap, due to venous congestion, was observed in 2 cases of "pedicled fasciocutaneous flap". An additional surgical procedure was required in only one of these cases. In our series all 9 patients who had a transposition flap, underwent routinely a preoperative echo color Doppler investigation to identify the main perforators. In only one case did the Doppler investigation fail to accurately locate the perforator. Local perforator flaps allow the coverage of medium size defects in the upper extremity, can be raised with a relatively simple surgical technique, have a high success rate and good aesthetic results without functional impairment. In the light of this they can be considered among the surgical choices to resurface complex soft tissue defects of the upper extremity. Preoperative identification of the perforators in case of "transposition flaps" greatly facilitates the operation. In our experience echo color Doppler investigations provided reliable results.

The concept of limb salvage led to increased demand for more complex and sophisticated reconstructive options to achieve better functional and cosmetic outcome. Reconstruction of the total or partial loss of quadriceps muscle after soft tissue sarcomas excision with free functioning latissimus dorsi muscle transfer had become more popular in the last years.Between November 1993 and October 2004, 11 patients with average age 45.5 years underwent excision of quadriceps muscle followed by simultaneous reconstruction with free functioning latissimus dorsi muscle. There were six men and five women. The tumors were high grade in 90.9% of patients and were10 cm in 81.8% of patients. The tumor extension required the resection of the entire quadriceps in four cases, of three heads in six cases, of only two heads in one case.The average follow up was 69 months. The average time of recovery of the contractile activity of the muscle was 8.3 months after operation. The musculoskeletal tumor society rating score (MTSRS) scored excellent or good in 73% of patients. Three patients (27.3%) died of metastatic disease. Local recurrence occurred in one patient (9.1%). Limb salvage was achieved in all the patients (100%).This method of reconstruction is a reliable technique not only to fill the defect resulting from oncological resection but also to provide better function. Microsurgical reconstruction of soft tissue sarcoma helps to expand the indications of limb salvage by allowing better local control and achieving adequate function and coverage.

In skeletally immature patients, the transfer of vascularized epiphysis along with a variable amount of adjoining diaphysis may provide the potential for growth of such a graft, preventing future limb length discrepancy. This article describes the authors' experience with the vascularized transfer of the proximal fibular epiphysis in the reconstruction of large bone defects including the epiphysis in a series of 27 patients ranging in age from 2 to 11 years. The follow-up, ranging from 2 to 14 years, has been long enough to allow some evaluation of the validity, indications, and limits of this reconstructive option.

Humeral nonunions still present a challenge to the orthopedic surgeon. Many methods of treating recalcitrant, posttraumatic humeral shaft nonunions have been described, with varying degrees of success. The present report reviews our experience with the use of vascularized fibular grafting for the treatment of large humeral defects. We treated 13 patients, with an average length of the humeral defect of 10.5 cm. Nine patients healed primarily, 3 required additional bone grafting, and 1 had a second fibular transplant. The mean period to radiographic bone union was 6 months. Only 5 patients regained full range of motion of the shoulder and elbow. The vascularized fibular graft is a reliable reconstructive procedure for recalcitrant pseudoarthrosis of the humerus in which the bony gap is greater than 6 to 7 cm, especially when traditional procedures have not provided the expected result.

Epiphyseal transplants in children were introduced into clinical practice about 20 years ago. Among possible donor sites, the proximal fibula is definitely the most popular choice, and has been used mainly for reconstruction of the proximal humerus and distal radius. Provided that an adequate blood supply both to the physis and to the diaphysis must be restored in order to obtain acceptable axial growth of the transferred fibula and a bone fusion at the osteotomy site, the choice of feeding pedicle is still a controversial issue. Our contribution involves a homogeneous series of 24 patients under 11 years of age who had skeletal reconstruction in the upper limb by means of a vascularized transfer of the proximal fibula based on the anterior tibial artery. The aim of the present paper is to describe in detail the harvesting technique which has been partially modified and gradually refined in our 10-year experience.