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1.  First results with the immediate reconstructive strategy for internal hardware exposure in non-united fractures of the distal third of the leg: case series and literature review 
Background
Fractures of the distal third of the leg are increasingly common and are often handled by open reduction and internal fixation. Exposure and infection of internal hardware could occur, especially after high energy traumas, requiring hardware removal and delayed soft tissue reconstruction. Nevertheless immediate soft tissue reconstruction without internal hardware removal is still possible in selected patients.
In this study the effectiveness and the complications of immediate soft tissue reconstruction without internal hardware removal is analyzed.
Methods
13 patients, affected by internal hardware exposure in the distal leg, treated with immediate soft tissue reconstruction with pedicled flaps and hardware retention, are retrospectively analyzed, with special regard to flap survival and wound infection.
Results
Wound infection was observed in 10 cases before surgery and in 5 cases surgical debridement was necessary before reconstruction which was performed in a separate operative session.
After reconstruction, wound dehiscence and infection occurred in 5 cases, and in 3 cases removal of internal hardware was necessary in order to achieve the complete healing of dehiscence. In one case the previous flap failed but prompt reconstruction with a sural fasciocutaneous flap was performed without hardware removal and without complications. Pre-operative infection and late reconstructive surgery are predictive for higher rates of post-operative complications (respectively p 0.018 and p 0.028).
Conclusion
Our approach achieved full recovery in 53.8% of the treated cases after one-step surgery, therefore reducing hospitalization and allowing early mobilization. Controlled trials are needed to confirm the effectiveness of this strategy, although the present case series shows encouraging results.
doi:10.1186/1749-799X-7-30
PMCID: PMC3489621  PMID: 22929129
Exposure; Flap; Internal fixator; Reconstruction; Leg; Fracture; Internal hardware exposure; Infection; Immediate reconstruction; Pedicled flaps; Lower limb
2.  Distally based sural fasciomusculocutaneous flap for treatment of wounds of the distal third of the leg and ankle with exposed internal hardware 
Soft tissue reconstruction of the distal third of the lower limb with exposure of the internal hardware is a challenging problem with several potential complications, such as exposure of the fracture line, fracture instability and bacterial contamination. The treatment of these lesions usually consists of substitution of the internal hardware with external fixation devices and further flap coverage. We propose a different reconstructive approach, characterized by harvesting a sural fasciomusculocutaneous flap on the exposed internal hardware once a sterile ground has been obtained. Four patients were retrospectively analyzed. Soft tissue reconstruction was achieved in all cases. In one case hardware removal was necessary for complete healing. The sural fasciomusculocutaneous flap is a safe alternative to other pedicled and free flaps. Moreover, it allows direct coverage of internal fixators, thus completing the reconstruction in less time. This flap fits best to the morphology of the wound and internal hardware, leaving the main vascular trunk of the leg intact and at the same time providing a reliable vascular supply.
doi:10.1007/s10195-011-0175-6
PMCID: PMC3284842  PMID: 22252286
Internal hardware; Exposure; Infection; Fasciomusculocutaneous sural flap; Lower limb
3.  Subcutaneous tissue flaps for hallux covering 
With the understanding of the extensive vascular supply of the subcutaneous tissue, of its efficacy in the protection of the anatomical structures and of its capability of promoting the adequate functioning of very stressed regions of the human body, the use of subcutaneous adipose flaps has become a valid and sometimes the only reasonable therapeutic weapon in the treatment of small and medium-sized tissue loss. Such a defect represents a common complication of great toe injuries and surgery. Here subcutaneous flap reconstruction is proposed for the treatment of dorsal and medial soft tissue losses of the hallux complicated with infection. Two case are reported. To the best of the authors’ knowledge, this application has not been reported in this anatomical site so far. The technique might be worth knowing both for orthopedic and plastic surgeons, as it may represent a safe, less invasive solution for most tegumentary problems of the dorso-medial side of the first ray.
doi:10.1007/s10195-009-0080-4
PMCID: PMC2837814  PMID: 20135337
Subcutaneous tissue flap; Turn-over flap; Hallux reconstruction; Tegument infection
4.  Subcutaneous tissue flaps for hallux covering 
With the understanding of the extensive vascular supply of the subcutaneous tissue, of its efficacy in the protection of the anatomical structures and of its capability of promoting the adequate functioning of very stressed regions of the human body, the use of subcutaneous adipose flaps has become a valid and sometimes the only reasonable therapeutic weapon in the treatment of small and medium-sized tissue loss. Such a defect represents a common complication of great toe injuries and surgery. Here subcutaneous flap reconstruction is proposed for the treatment of dorsal and medial soft tissue losses of the hallux complicated with infection. Two case are reported. To the best of the authors’ knowledge, this application has not been reported in this anatomical site so far. The technique might be worth knowing both for orthopedic and plastic surgeons, as it may represent a safe, less invasive solution for most tegumentary problems of the dorso-medial side of the first ray.
doi:10.1007/s10195-009-0080-4
PMCID: PMC2837814  PMID: 20135337
Subcutaneous tissue flap; Turn-over flap; Hallux reconstruction; Tegument infection

Results 1-4 (4)