Limb preservation in the multi-morbid patient remains a significant challenge. The combination of orthopedic and plastic reconstructive techniques (“Orthoplastics”) is well known to result in limb preservation (“limb salvage”) even in extremely high-risk patients. Despite advances, adjunctive healing techniques remain desirable.In this case series, we examined the use of hydrolyzed collagen powder in limb salvage in multi-morbid patients undergoing limb preservation surgery. The medical records of ten high-risk patients with multiple co-morbidities undergoing limb preservation reconstruction, who would otherwise have required a major level amputation, were reviewed retrospectively. Of these patients, there was an average of nine varying risk factors, including the presence of infection, diabetes mellitus, renal impairment, vascular disease, smoking, illicit drug or alcohol abuse, or nicotine use. The case review data included patient demographics, risk factors, specific pathophysiology, Orthoplastic procedure, and the volume of adjunctive hydrolyzed collagen during the reconstructive procedures.All patients achieved limb preservation or the prevention of an anticipated higher-level amputation. On average, two hydrolyzed collagen applications were used per patient with a mean volume of 1.8 g (range 2-4 g). Notably, the presence of an actively treated infection did not appear to diminish the efficacy of hydrolyzed collagen. Additionally, no adverse reactions were identified with the use of hydrolyzed collagen. These findings suggest that use of hydrolyzed collagen is a safe, valuable adjunct in Orthoplastic limb preservation surgery for patients at extreme risk for limb loss.

INTRODUCTION:The use of free tissue transfers has overshadowed the much simpler approach of using simpler local rotation flaps for soft tissue coverage, especially in the foot and ankle. In this study, the authors aimed to examine the results of a single surgeon experience (CB) of the distally based reverse peroneus brevis muscle flap as the first line flap coverage for soft tissue coverage of the foot and ankle in medically high-risk patients who would otherwise require a major amputation. METHODS:All patients underwent Doppler examination only, prior to and intraoperatively prior to elevation of the distally based (reverse) peroneus brevis muscle flap; formal angiography or CT angiogram was not performed. The number of muscular perforators was documented intraoperatively as well as the defect size and location of flap inset. Patient demographics, medical risk factors for limb loss, mechanism of injury, the presence of soft tissue or bone infection, and wound size were recorded. The number of flap muscular perforators, flap complications, and donor site morbidity were recorded. RESULTS:Complete flap survival was observed in 75% of patients, while 14% experienced partial flap necrosis. Minor donor site morbidity was seen in 11% of patients. Complete flap necrosis occurred in 11% of patients. Smoking demonstrated to a statistically significant influence for partial/full flap failure (P = 0.0383, Fisher's exact test). Additionally, among patients with diabetes, an abnormally elevated hemoglobin A1c, which was defined as ≥6.5, consistent with the standard for uncontrolled diabetes, demonstrated a statistical association for a flap-related complication (P = 0.0170, Fisher's exact test). Overall, at a mean follow-up of 6.9 years, an 83% limb salvage rate was achieved. Failed limb salvage resulting in amputation was not necessarily due solely to a flap complication. CONCLUSIONS:These data demonstrate that the distally-based reverse peroneus brevis muscle flap may be considered as a first line option for foot and ankle soft tissue coverage in the high-risk, multimorbid patient who is otherwise facing a major level amputation. The novelty lies in the patient population examined, specifically, high-risk, multimorbid patients with medium or large-sized soft tissue defects of the lower leg, foot and ankle.

Background Periprosthetic joint infections remain a serious complication following arthroplasty surgery, causing significant patient morbidity and economic burden to health-care systems. While surgical site infection (SSI) preventive measures have shown effectiveness, there remains a significant gap in literature regarding surgeon intraoperative practice, such as the use of intraoperative wound irrigation (IOWI). While studies highlight the potential in reducing SSIs, variability in clinical application and the lack of standardized, evidence-based guidelines necessitate a comprehensive understanding of current practices. Methods A 46-question survey was developed following literature review and validation with high-volume primary and revision arthroplasty surgeons. Deployed via online clinician engagement platform, the survey queried challenges of SSI in relation to IOWI, current IOWI practice, the role of biofilm in periprosthetic joint infections, and ideal properties of irrigation solutions. Results A total of 112 orthopaedic surgeons across the United States participated in the survey. Respondents indicated a high level of knowledge regarding the role of IOWI in SSI treatment and prevention. Key attributes of an ideal IOWI varied depending on procedural step (exposure, instrumentation, implantation, and closure) and procedure type (primary or revision). Variation in IOWI practice was evident in irrigant selection and decision rationale, with relatively lower alignment to contact time and residual antimicrobial activity. Conclusions This survey highlights the perception that IOWI is an important part of routine SSI reduction measures and suggests variation in practice interventions and solution preference. Our findings support the necessity for a rigorous, evidence-based consensus via expert guidance to address the key surgical challenges to improve consistency of IOWI solution utilization.

The medial plantar artery flap (MPAF) presents both unique value as well as significant challenges. As the plantar foot has specific anatomy, the use of the MPAF to recreate this highly specialized area may provide improvements in durability and rates of limb salvage. The purpose of this study is to establish the anatomic course of the branching patterns of the medial plantar artery (MPA) and provide a foundation for MPA flap nomenclature as it is related to design and elevation. Thirty-seven fresh frozen cadaver feet were used for dissection: 20 right and 17 left sided limbs. Anatomic measurements recorded included: branching pattern of the MPA, bifurcation distance of the superficial branch (SB) and deep branch (DB) from the origin of the MPA, distance from the MPA origin to the anterior colliculus of the medial malleolus, and the distance from the SB and the DB to the navicular tuberosity. The MPA was found to bifurcate into SB and DB in 30 (81%) specimens; 6 (16%) specimens had only a SB, whereas 1 (3%) specimen had only a DB, which had not been previously described. The distance from the anterior colliculus to the MPA was 3.0 cm, MPA to the distal bifurcation was 2.9 cm, and navicular tuberosity to the SB and DB was 2.2 cm and 1.3 cm, respectively. Minimizing the complexity of the dissection with the use of more reliable landmarks and a deeper understanding of the anatomy may reduce complications and allow for more reproducible outcomes when utilizing the MPAF.

IntroductionTotal hip arthroplasty (THA) has become a common intervention for Human Immunodeficiency Virus (HIV)-positive patients who have osteonecrosis of the femoral head. This paper provides a systematic review to assess survivorships, patient-reported outcomes (PROMs), infection rates, other complications, and immune competence for patients who had THAs who did and did not have HIV.MethodsA comprehensive and systematic review of published studies investigating the outcomes of THA in HIV-positive patients (osteonecrosis and non-osteonecrosis patients) was performed adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 10 studies with 9,534 HIV-positive patients fulfilled the inclusion and exclusion criteria. Manuscript quality was assessed on two scales: the Coleman Methodology Score and the level of evidence derived from Centre for Evidence-Based Medicine criteria. Data was extracted from studies in the five key areas of interest: survivorships; PROMs; infection rates; complications; as well as clusters of differention-4 (CD4+) counts and viral loads (VL).ResultsImplant survivorship was between 95 and 100%. Postoperative Harris Hip Scores were significantly improved from preoperative values in HIV-positive patients. Postoperative PROMs and infections did not appear to be different between HIV-positive and HIV-negative patients. Many of the cohort studies demonstrate comparable complication rates to matched controls. Where described (7 reports), mean CD4+ counts ranged from 425 to 646 cells/mm3, with low VL (3 reports) and variations not found to influence outcomes.ConclusionTotal hip arthroplasty (THA) is an effective treatment for HIV-positive patients, many of whom suffer from osteonecrosis of the femoral head. The results demonstrate excellent implant survivorship, improved quality of life, and a low risk of infections and complications.

Introduction: The typical circular external fixator possesses radiodense multi-level ring tibial blocks ad struts for stability, even in patients with intact osseous architecture. We analyzed the applications and outcomes of a fully radiolucent limited ring external fixation in the orthoplastic management of complex bone and soft tissue pathology. Methods: Consecutive patients were selected and followed, and data collected during the use of a fully radiolucent external fixation system in patients without large segment tibial bone loss. Basic patient demographics, risk factors, body mass index, the clinical indication, the use of external fixator, and time in external fixation were analyzed. All patients underwent early mobilization with full weight bearing with an assistive device. Any untoward external fixator complication and outcome was recorded. Institutional Review Board approval was obtained. Results: There were nine patients with a mean age of 44 (range = 22–73) with a mean follow-up of 17 months (range-6–26 months). Fifty-six percent were enrolled in the study who all received a two-ring radiolucent external fixation device. All patients had risks for external fixation complications with 89 % possessing multiple risk factors. Four patients (44 %) had neuropathy from the mid tibia to the foot. Bone stabilization was performed for 67 %, soft tissue offloading/limb stabilization for 55 %, a combination of bone and soft tissue stabilization for 33 % of patients. Conclusion: Lightweight radiolucent circular external fixation of the lower extremity in patients without intercalary bone loss can provide satisfactory stability and allow early mobilization with minimal component complications. The added advantage of having radiolucent rings and struts allows for better visualization of osseous structures such as fractures care and fusions. The ability to manipulate foot position required for a particular bone/soft tissue reconstruction is also possible.

Background Total knee arthroplasty (TKA) has become a common surgical intervention for human immunodeficiency virus (HIV)-positive patients who develop osteonecrosis of the knee. This paper summarized existing literature regarding the outcomes of HIV-positive patients undergoing TKA in 4 subsections: (1) complications; (2) survivorship analyses; (3) patient-reported outcomes; and (4) infections. Methods A review of PubMed was performed, searching for articles focused on HIV-positive patients undergoing TKA. There were 6 reports selected, containing 4765 HIV-positive patients, and data regarding the various domains was tabulated and analyzed. To ensure article quality, a methodology score and level of evidence were determined for selected studies. Results Complication rates for HIV-positive patients were low, with a larger study reporting that 7.8% of HIV-positive patients developed a complication in comparison to 8% of HIV-negative patients. Survivorship analyses showed similar results, with a study reporting implant survivorship of 98% for HIV-positive and 99% for HIV-negative patients. There were no differences in patient-reported outcomes; HIV-positive patients improved from baseline with respect to the mean Knee Society objective and mean Knee Society functional scores, and the University of California, Los Angeles self-reported activity levels. The infection rate for HIV-positive patients was low, with a larger database study reporting that 0.6% of HIV-positive patients developed a wound infection in comparison to 0.4% of HIV-negative patients. Conclusions A TKA is an effective treatment for HIV-positive patients who develop osteonecrosis of the knee. Results showed similar patient-reported outcomes, implant survivorships, revisions, and complication rates when compared to non-HIV patients.

Background: The first ray provides an important biomechanical function in ambulation. Loss of this region due to ulceration and pursuant amputation poses significant morbidity to patients. Utilizing the distally based (reverse) medial hemi-flexor hallucis brevis (rmFHB) muscle flap to cover defects of this region may decrease patient morbidity, as it may provide needed bulk and durability for rapid coverage and preservation of the first ray. Methods: In this case series, an uncontrolled, retrospective review of the medical records was performed, identifying patients with diabetes who underwent an rmFHB muscle flap performed by a single surgeon. Outcomes measured included the need for secondary soft-tissue procedures at the index surgery; complications; percentage and time to wound healing, defined as epithelialization of wound site; and short-term survival rate (12 months). Results: Healing was demonstrated at a mean of 12 weeks, and the preservation of the distal first ray was achieved in 94% of those patients (12/13). One patient went on to first ray amputation and two were deceased before healing. All patients ambulated in shoes with custom molded inserts without complication postoperatively. No recurrence of ulceration was encountered at 12 months follow-up. Conclusions: This study demonstrates that the rmFHB muscle flap may serve as an option for distal first ray soft-tissue defects when local flap coverage is needed due to exposed deep or avascular structures not amenable to skin grafting or conservative wound care techniques. No cases of recurrence of ulceration occurred during this study.

Reconstruction of the Achilles tendon for insertional disease, acute and chronic ruptures, severe mangling limb trauma, and tendon loss from necrotizing infections often results in a significant reconstructive challenge. Traditional issues that may be used to reconstruct the Achilles include a strip of the tensor fascia lata or tendon allograft. However, these tissues lack the inherent stability of autograft, are avascular and more subject to infection, and lack an intact functional muscle belly, providing no additional motor function to assist in plantar flexion. Functional muscle-tendon free flaps (such as the gracilis free flap) are complex, require microsurgical skills, and have a delayed and prolonged rehabilitation; they are a last resort to restore plantarflexion. Instead, tendon transfers are ideal to augment or substitute fully for the incompetent Achilles tendon. The most common tendon transfer to reconstruct the Achilles tendon is the flexor hallucis longus (FHL) tendon. The FHL tendon is vascularized, readily available, expendable, and provides in-phase plantar flexion function. Harvest of the FHL typically utilizes retrieval at the level of the subtalar joint, just deep to the posterior sulcus, or at the master knot of Henry in the midfoot. In the reconstruction of large Achilles defects, these harvest locations may produce an inadequate length of tendon for the reconstructive effort. The author provides an illustrative guide to harvest the full length of the FHL, which will provide enough tendon length for any Achilles reconstruction. Minimal donor morbidity can be expected by patients.

Charcot neuroarthropathy of the hindfoot and ankle poses substantial challenges due to deformity, segmental bone loss, chronic infection, and difficulty with bracing. Hindfoot or ankle arthrodesis is often employed at high rates of complications and nonunion. This study reports 15 consecutive patients with Charcot neuroarthropathy who underwent tibiotalocalcaneal or tibiocalcaneal fusion with simultaneous distal tibial distraction osteogenesis with a mean follow-up period of 20.2 ± 5.66 months. Arthrodesis rate was 93.3% (14 patients) with mean time to fusion of 4.75 ± 3.4 months. One hypertrophic nonunion occurred at the arthrodesis site. Complete consolidation of 4 cortices was achieved at the distraction site in 93.3% of patients (14 patients) with a mean duration to consolidation of 9.8 ± 3.3 months. One patient experienced hypertrophic nonunion at the regeneration site. The authors report a technique to enhance arthrodesis rates in Charcot neuroarthropathy by combining distal tibial distraction osteogenesis with simultaneous tibiotalocalcaneal or tibiocalcaneal arthrodesis for hindfoot fusion and salvage. Distraction osteogenesis supports enhanced vascularity to the arthrodesis site.Level of Clinical Evidence: Level 4.

In the diabetic and peripheral vascular disease population there is a high risk of further amputation following a primary amputation. Amputation surgery is often approached negating the biomechanics of the lower extremity leading to complications or additional surgery. Implementing appropriate tendon balancing of stump and applying orthoplastic techniques will improve outcomes. This article introduces the basic techniques to a wider audience of foot and ankle surgeons. Specifically, this article is intended to be a descriptive guide for the use of tendon balancing and intrinsic muscle advancements in the various levels of foot amputations.

Obtaining primary closure of the soft tissue envelope in complex wounds can pose significant challenges to the surgeon. Excess tension across the proposed line of closure and peri-incisional skin is common when closing complex defects. This may result in wound dehiscence or suture line and adjacent skin necrosis; potentially resulting in a soft tissue problem worse than the index defect. Soft tissue compromise can be followed by infection which places underlying vital structures and implants at risk. Techniques to reduce tension include skin meshing and the use of gradual mechanical assisted closure. Secondary wound closure techniques possess inherent risks and mechanical assisted techniques are prone to technical failure or are suited for only small wounds. This paper describes a perforator sparing deep fascia meshing technique (Bibbo Perforator Sparing Deep Fascial Meshing Technique) to assist with obtaining immediate primary closure of complex wounds. This technique allows for closure of wounds that would require a secondary closure procedure or skin grafting.

Non-weight bearing is mandatory after soft tissue reconstructions of the weight-bearing and the high-pressure areas in the lower extremity. The most common method of patient mobilization after surgical reconstruction of chronic foot and ankle wounds has been to place patients non-weight bearing with crutches, walkers, or a wheelchair. Often patients are older, have more complex medical comorbidities, are deconditioned, and simply cannot comply with the prescribed weight-bearing status with these methods, which leads to deconditioning, depression, or noncompliance. Noncompliance quickly leads to failure of the reconstructive effort and the serious threat of limb loss.

Reconstruction of critical size bone defects in the lower extremity poses a significant risk to not only limb malfunction but also amputation. The reconstructive goal of free bone flaps is to provide vascularized bone that restores length and stability. This applies to the native limb and also in amputations when a vascularized length of bone is required to maintain level of amputation. Multiple anatomic regions of the lower extremity may be successfully reconstructed with the fibula free flap.

Introduction. The COVID-19 virus is caused by the new coronavirus, SARS-CoV-2. COVID-19 has drastically changed the medical landscape. Although predominantly impacting the respiratory system, COVID-19 has several non-respiratory symptoms associated with its presentation and course. Among these are gastrointestinal symptoms and thromboembolic events with stroke. Increasingly recognized, but often overlooked, are the coagulopathy phenomena occurring with COVID-19. The severe respiratory symptoms are the primary focus of clinical management. However, close inspection of patients demonstrates that patients often exhibit both thromboembolic and bleeding events, ranging from simple skin lesions to overt emergencies. Case Report. The author presents a case of COVID-19-associated coagulopathy resulting in compartment syndrome of the arm with volar forearm necrosis, requiring flap reconstruction and tendon transfer to salvage the upper extremity. Conclusions. Massive rhabdomyolysis resulted in acute tubular necrosis with renal failure requiring hemodialysis. The timing of reconstruction of the sequelae of compartment syndrome in an acutely ill patient is challenging, but optimal timing can result in a successful outcome.

The gastrocnemius flap is a versatile flap when muscle, or, muscle and skin is desired for coverage of bone of the proximal one-third of the leg, and about the knee. Both the medial and lateral heads, or both combined, may be used as flaps. Typically, the reach of only the muscle will restrict reach to just below the knee. Release off the medial femoral condyle permits increased reach, and a bit more is obtained by scoring the deep fascia and gently slow expansion of the muscle.

Chronic wounds often are the result of bone deformities, compounded by musculotendinous and ligamentous imbalance. Sensory neuropathy places patients at greater risk for acute wounds to develop into chronic wounds. Etiologies of these deforming forces include Charcot neuroarthropathy, trauma, and congenital and acquired neuromuscular disorders. Management of these deformities ranges from simple relief of pressure with soft inserts to bracing for mechanical instability. Correction of more complex deformities requires resection of bone, osteotomies, fusions, and external fixation. Tendon and ligament imbalance must be addressed at all levels of deformity. Postoperatively, patients must be re-evaluated for continuation of orthoses and bracing.