Successful reconstruction of an ankle defect with free tissue transfer in a hemophilia A patient with repetitive hemoarthrosis:A case report

BACKGROUND Hemophilia, an uncommon yet consequential hereditary bleeding disorder, manifests as two clinically indistinguishable forms that hinder the normal functioning of the coagulation cascade. This impairment renders individuals more susceptible to excessive bleeding during significant surgical interventions. Moreover, individuals with severe hemophilia frequently encounter recurring hemarthrosis, resulting in progressive joint destruction and, subsequently, the need for hip and knee replacement surgeries.CASE SUMMARY The patient was a 53-year-old man with hemophilia A as the underlying disease and had self-injected factor Ⅷ twice weekly for several decades. He had undergone ankle fusion surgery for recurrent hemarthrosis at the Department of Orthopedic Surgery 1 mo prior and was referred to our department because of skin necrosis after a hematoma at the surgical site. An anterolateral thigh perforator free flap was created after three cycles of factor Ⅷ administration in addition to the concomitant administration of tranexamic acid(TXA)(Transamin 250 mg cap, 1 cap tid, q8h). After the operation, from postoperative days(PODs) 1-5, the factor Ⅷ dose and interval were maintained, and q12h administration was tapered to q24h administration after POD 6. Because the patient’s flap was stable 12 d after the operation, factor Ⅷ administration was tapered to twice a week. At 6 mo follow-up, the patient recovered well without any complications.CONCLUSION To the best of our knowledge, there are very few reports of successful free flaps in patients with hemophilia, and none have been reported in patients with hemophilia A. Moreover, there are several reports on the efficacy of TXA in free flaps in general patients;however, there are no case reports of combining factor Ⅷ and TXA in patients with hemophilia. Therefore, we report this case to contribute to future academic research.

Biothermomechanical behavior of skin tissue

Advances in laser, microwave and similar technologies have led to recent developments of thermal treatments involving skin tissue. The effectiveness of these treatments is governed by the coupled thermal, mechanical, biological and neural responses of the affected tissue： a favorable interaction results in a procedure with relatively little pain and no lasting side effects. Currently, even though each behavioral facet is to a certain extent established and understood, none exists to date in the interdisciplinary area. A highly interdisciplinary approach is required for studying the biothermomechanical behavior of skin, involving bioheat transfer, biomechanics and physiology. A comprehensive literature review pertinent to the subject is presented in this paper, covering four subject areas： （a） skin structure, （b） skin bioheat transfer and thermal damage, （c） skin biomechanics, and （d） skin biothermomechanics. The major problems, issues, and topics for further studies are also outlined. This review finds that significant advances in each of these aspects have been achieved in recent years. Although focus is placed upon the biothermomechanical behavior of skin tissue, the fundamental concepts and methodologies reviewed in this paper may also be applicable for studying other soft tissues.

Sensory reinnervation of free flaps in reconstruction of the breast and the upper and lower extremities

There is long-standing debate about sensate versus non-sensate free microvascular flaps among microsurgeons. The principle of connecting not only the vascular supply, but also sensitive nerves, in free tissue transfer is attractive. However, increased operating time and partial spontaneous innervation led to the common decision to restrict microsurgical tissue transfer to the vascular anastomosis and to leave the nerves ＂untreated＂. Nevertheless, in special cases such as breast reconstruction or extremity reconstruction, the question about sensory nerve coaptation of the flaps remains open. We present our experience with free microvascular tissue transfer for breast and extremity reconstruction and compare the data with previous literature and conclude that most free flap surgeries do not benefit from nerve coaptation.

Free tissue reconstruction of the anterior skull base:A review

Objective:There has been a significant shift from open craniofacial resection of the anterior skull base to endoscopic approaches that accomplish the same outcomes in tumor ablation.However,when open resection is required,free flap reconstruction is often necessary to provide sufficient well-vascularized tissue for optimal wound healing as well as providing adequate tissue bulk for cosmesis.This articleaims to providea focused review of free flaps most commonly used in anterior skull base reconstruction.Methods:This is a state-of-the-art review based on expert opinion and previously published reviews and journal articles,queried using PubMed and Google Scholar.Results&conclusion:Anterior skull base reconstruction via free tissue transfer is imperative in limiting complications and promoting healing,particularly with large defects,post-radiation,and in at-risk patients.The type of free flap utilized for a particular anterior skull base reconstruction should be tailored to the patient and nature of the disease.This review offers insight into the numerous reconstructive options for the free flap surgeon.

Soft tissue coverage of lower extremity defects:pearls and pitfalls in the chronic wound population

The incidence of chronic lower extremity(LE)wounds continues to increase.Lower limb amputations are associated with increased cardiovascular exertion,further decline in functional ability,and higher mortality rates.As such,there has been a shift towards limb salvage modalities.These include local debridement with advanced wound care,revascularization,bony reconstruction,and soft tissue reconstruction.Perioperative planning for soft tissue reconstruction requires careful consideration of several factors,including patient comorbidities,wound size and location,exposed underlying structures,and in the case of possible free flap,patency of donor and recipient vessels.This article reviews the perioperative factors that should be considered in preparation for successful soft tissue reconstruction of the LE.

Designing an evidence-based free-flap pathway in head and neck reconstruction

Background:The use of autologous free-tissue transfer is an increasingly utilized tool in the ladder of reconstructive options to preserve and restore function in patients with head and neck cancer.This article focuses on the evidence surrounding perioperative care that optimizes surgical outcomes and describes one tertiary center's approach to standardized free-flap care.Data Sources:This article examines English literature from PubMed and offers expert opinion on perioperative free-flap care for head and neck oncology.Conclusion:Free-flap reconstruction for head and neck cancer is a process that,while individualized for each patient,is best supported by a comprehensive and standardized care pathway.Surgical optimization begins in the preoperative phase and a thoughtful approach to intraprofessional communication and evidence-based practice is rewarded with improved outcomes.

Comparison of outcomes between early and delayed weight bearing following lower limb free flaps:an 18-month single-center study

Aim:Post-operative protocols following lower limb free flap surgery are not well defined,with a lack of consensus in the literature around limb dependency and weight bearing.The aim was to compare the complication rate for lower limb free flaps before and after the introduction of an enhanced lower limb free flap protocol with earlier dangling(day 3 vs.day 4)and weight bearing(day 5 vs.day 14)post lower limb free flap surgery.Methods:All lower limb free flaps between June 2020-January 2022 were identified from a departmental flap database.Patient data were collected from the comprehensive lower limb free flap database,medical notes,and electronic records.Patients prescribed an extended non-weight-bearing period due to the method of bone fixation were excluded.Results:A total of 37 patients,15 pre-and 22 post-enhanced protocol,were identified for comparison.The mean age was 43(17-72)with a M:F of 3:1.There was no difference in the type of flap reconstruction between groups,with the anterolateral thigh flap being the most common in both groups.No differences were identified in the number of complications related to dependency/weight bearing before and after the introduction of the enhanced protocol,with the mean length of stay reduced from 12.1 to 10.6 days(P=0.34).Conclusion:The new enhanced protocol remains the standard of care in our unit,as we demonstrated a reduction in length of stay with no difference in complication rates following early weight bearing after lower limb free flap surgery.

Dynamic infrared thermography and smartphone thermal imaging as an adjunct for preoperative, intraoperative, and postoperative perforator free flap monitoring

Aim:The versatile application of perforator free flaps for coverage of any extremity has been well proven.Often,a"freestyle"-like approach is used to design these flaps,as conventional imaging techniques for perforator identification may be too expensive or unavailable.As will be demonstrated,the recent application of a thermal imaging camera using a smartphone is a cheaper and therefore more universal means to better identify the requisite perforators upon which a free flap can be designed and then monitored.Methods:Smartphone thermography can be used on any patient preoperatively to identify preferable perforators or vascular network"hot spots"within the desired donor site territory.Intraoperative management of the choice of perforators and subsequent flap dissection can be similarly facilitated.Intermittent postoperative monitoring based on changes of the thermal image color palette will provide a comparison that can be used to determine if perfusion across the microanastomosis is sustained.Results:An overview of how to use a smartphone in concert with a thermal imaging camera is outlined.Dynamic infrared thermography represents a thermal stress necessary with a smartphone to better identify donor site"hot spots".Conclusion:Smartphone thermography is an inexpensive and expeditious means for identification of"hot spots"that correlate with perforators that would suffice to insure perfusion to a free perforator flap.However,since perforator caliber and course cannot be determined,this should be considered to be only a complementary adjunct for conventional methods.Nevertheless,its simplicity will overall improve the safer design,harvest,and subsequent monitoring of free flaps.

Reconstruction of extremity long bone defects with vascularized fibula bone grafts

Aim: Composite tissue defects encompassing bone and/or isolated bony defects can pose a surgical challenge;however, their reconstruction is critical for successful functional limb salvage. These cases become increasingly problematic as secondary defects, following multiple nonvascularized grafting attempts resulting in complex bony nonunion. Herein, our experience utilizing fibula vascularized bone grafts (VBGs) for bone restoration will be presented to demonstrate their utility in a variety of reconstructions for limb salvage. Methods: This is a case series describing a series of vascularized fibula grafts for extremity reconstruction performed by a single academic surgeon over multiple institutions in seven years. Results: Twenty-seven (27) total VBGs met inclusion criteria and underwent reconstruction for traumatic (16), oncologic (6) and chronic degenerative (5) etiologies. Bony union was achieved in 26 of 27 cases. Conclusion: The decision-making process for bony reconstruction in these scenarios is difficult and multivariable. Fibula VBGs can provide a single-stage solution for autologous bony and soft tissue replacement of large or complex bone defects and can often be superior options compared with non-vascularized bone grafts or non-bone internal fixation techniques. Their osteogenic potential is unmatched by allogenic or synthetic substitutions. These benefits are evident in a variety of clinical settings such as pediatrics, oncology and trauma.

The submental island pedicled flap and supraclavicular artery island flap in a free flap practice

Reconstruction of head and neck defects is a delicate endeavor that poses numerous intrinsic and extrinsic challenges,which are currently magnified by rising health care costs and limitations in system resources.Current trends in the United States heavily favor the use of free tissue transfer over locoregional pedicles flaps(LRPF);however,the latter group is often undervalued,offering high utility,practicality,and cost-efficiency whilst providing equivalent results.The submental island flap and supraclavicular artery island flap are two LRPF that should be in the arsenal of the modern reconstructive surgeon.