Schedule Slot

Although the zone-of-injury concept is widely accepted, no histologic studies of vessel wall changes causing the phenomenon have been reported. In this prospective study, the vascular response to high-energy lower extremity trauma was investigated to evaluate the validity of the zone-of-injury concept.

The histologic appearance of arterial and venous walls in the zone of injury was studied in 19 patients (median age, 46 years; interquartile range, 29.5 to 62.5 years) who underwent osteosynthesis and free flap reconstruction after high-energy lower extremity open fracture. Vascular samples were harvested from the injured extremity, and control samples were harvested from the free flap donor site. Histologic and morphometric characteristics of the vessels were analyzed microscopically and using digital pathology QuPath software.

Vascular samples were harvested on postinjury days 1 through 11. Intimal thickness was more than 3 times greater in arteries harvested from the zone of injury than in control samples (P <= 0.01), and the intima/media ratio was 2-fold that in control samples (P = 0.01). Arterial intimal fibrosis was more evident in vessels harvested from the zone of injury (P <= 0.01), but medial fibrosis and medial thickness did not differ significantly between groups. Venous intimal thickening (P <= 0.01) and the intima/media ratio (P = 0.02) were greater in samples from the zone of injury. Fibrosis-related changes did not differ between groups (P = 0.45).

These findings support the validity of the zone-of-injury concept by providing a novel histologic basis for this phenomenon. Intimal thickening and arterial intimal fibrosis are prominent histologic features of vessels affected by major lower extremity trauma.

Foot and ankle soft-tissue defects are challenging due to limited local tissue, poor skin laxity, and the need for thin, contour-adapted coverage. Traditional reconstruction often requires bulky flaps, extensive incisions, patient repositioning, and secondary thinning procedures. Recent microsurgical advances, including SCIP, split ALT flaps, small innervated muscle flaps, and alternative recipient vessels such as the fibular artery or posterior tibial artery tunneled through the Achilles tendon, have expanded reconstructive options. Since 2023, our orthoplastic program has refined these strategies and established the St. Gallen Algorithm for structured, subunit-based foot and ankle reconstruction.

After program implementation, free-flap volume increased five-fold. We retrospectively reviewed patients treated using an algorithm based on defect size, location, depth, and exposure of critical structures or hardware. The strategy emphasized minimal flap bulk, short vessel access incisions, avoidance of pedicle crossing the ankle in foot defects, and reduction of secondary procedures. Representative cases included split (“kiss”) ALT for bilateral ankle defects, split latissimus with serratus segment for sensory heel reconstruction, PSC to fibular artery, ALT tunneled to posterior tibial artery, and SCIP to anterior tibial artery for dorsal foot defects. All cases used preoperative duplex ultrasonography, standardized flap monitoring, and follow-up.

All reconstructions were completed without flap loss or major revision. Mean operative time decreased with increasing team experience. Alternative vessels and tunneling reduced incision length, avoided ankle pedicle crossing, and lowered complication and debulking rates. Outcomes were favorable, with stable wound closure, early return to full weight-bearing, and minimal need for secondary procedures. PSC and SCIP avoided excessive bulk compared to ALT, particularly in female patients. Thus, the St. Gallen Algorithm (figure) was developed.

Foot and ankle reconstruction requires integration of advanced microsurgical techniques, imaging, and subunit-specific planning. The St. Gallen Algorithm provides a structured decision pathway prioritizing low bulk, minimal incisions, avoidance of flap–joint conflict, and fewer secondary procedures, enabling anatomically and aesthetically tailored reconstruction.

Free microvascular flap reconstruction is the gold standard for complex lower extremity defects. Postoperative “dangling” is routinely performed to gradually adapt the flap to hydrostatic stress. However, timing and duration vary widely between centers. In a systematic review conducted by our group, no uniform evidence-based protocol for flap training was identified, and monitoring remains largely subjective. Objective, continuous data on tissue perfusion and pressure during verticalization are lacking. We therefore developed a textile-based multisensor system for real-time, non-invasive monitoring of flap physiology during dangling, aiming to support an evidence-based approach to flap training.

In collaboration with biomedical textile engineers (EMPA St. Gallen), we designed a wearable textile sensor integrated into a compressive dressing. The system continuously records local tissue oxygen saturation, temperature, and external tissue pressure across the flap surface. It is flexible, skin-compatible, and suitable for bedside clinical use. Data are collected in real time during horizontal rest and vertical loading, allowing spatial and temporal analysis of perfusion dynamics. A pilot study in patients undergoing lower extremity free flap reconstruction is currently evaluating feasibility and data quality.

Our systematic review revealed substantial variability in the initiation, duration, session length, and escalation of dangling protocols. Most studies were retrospective, included small cohorts, and relied primarily on intermittent, subjective clinical assessment. Continuous objective perfusion monitoring was rare, and pressure-related parameters were not assessed. Overall, the level of evidence was low, and no standardized protocol could be identified. The ongoing pilot study aims to demonstrate feasibility and generate the first comprehensive dataset combining perfusion and pressure dynamics during postoperative dangling.

Dangling protocols after lower extremity free flap reconstruction remain heterogeneous and insufficiently evidence-based. The developed textile-based monitoring system seeks to provide objective physiological data during flap training. In a subsequent step, these data may enable individualized, evidence-based adaptation of dangling regimens, potentially improving patient safety and resource utilization.

Dangling (graduated limb dependency) remains widely practised after lower limb free flap reconstruction, though protocols vary, and its clinical benefit is uncertain. This systematic review and meta-analysis compared early, late, and no-dangling strategies. The primary outcomes were flap survival and secondary outcomes, including complications (wound dehiscence, infection, flap necrosis), return to the theatre, and length of hospital stay.

The authors systematically searched Medline, Embase, Cochrane Library, ClinicalTrials.gov, EU Clinical Trials Register, and ISRCTN (inception to March 2025) for clinical studies on lower extremity free tissue transfer with a defined dangling protocol or unrestricted mobilisation. Two reviewers independently screened the studies, extracted data (including patient/injury details, flap type, protocol, and outcomes), and assessed the risk of bias. Due to heterogeneity, single-arm meta-analyses of flap success and subgroup analyses by age and dangling strategy (early, late, or no-dangling) were performed using random-effects models.

Ten studies were included. Pooled flap survival was high (about 96–97%) with no significant differences between early, late, or no-dangling protocols. Subgroup analyses by age also revealed no meaningful differences. Early dangling or unrestricted mobilisation did not increase complications and often meant shorter hospital stays. Evidence quality was moderate, with some risk of bias.

Current evidence shows no clinical advantage to traditional dangling protocols. No-dangling or very early, brief dependency within structured monitoring or ERAS pathways appears safe, supports earlier discharge, and may reduce hospital-acquired risks and healthcare costs. Further multicentre trials embedded in standardised ERAS frameworks are warranted.

Free flap reconstructions of the lower extremity in patients requiring prior vascular intervention remains challenging. Restoration of adequate blood flow is essential for flap survival and limb salvage, yet compromised recipient vessels may increase perioperative risk. This study compares outcomes of microvascular lower limb salvage following recent vascular intervention with matched controls without prior revascularization.

A retrospective two-centre matched cohort study was conducted including all lower limb free flap reconstructions performed between 2006 and 2024. Patients who underwent significant vascular interventions in the same limb within 100 days prior to reconstruction were identified and matched 1:1 to controls using propensity score matching (sex, age, BMI, ASA, aetiology, smoking). Thirty-four matched pairs were analysed. Primary outcomes included flap survival, surgical complications, secondary amputation as well as long-term mortality.

Of the screened 821 reconstructions, 34 patients (4.1%) had undergone recent vascular intervention, predominantly percutaneous transluminal angioplasty (82.4%). Mean interval between intervention and reconstruction was 21.1 days. Operative time was significantly longer in vasculopathic patients (456 vs. 364min; p=0.003). Flap success was 88.2% in the intervention group versus 100% in controls (p=0.13). All flap losses (n=4) occurred when microvascular anastomoses were performed on the same vessel that previously underwent vascular intervention, corresponding to a 28.6% failure rate in this subgroup. No losses occurred when anastomoses were placed on independent or anatomically significantly more distal to the treated vessels. Overall secondary amputation rate was identical in both groups (5.9%). Limb salvage was ultimately achieved in 94.1% of vasculopathic patients. Rates of flap-related and orthopaedic complications as well as long-term mortality did not differ significantly between cohorts.

When managed within a specialised multidisciplinary setting, free flap reconstruction after recent vascular intervention is feasible and enables limb salvage in the vast majority of cases, despite increased operative complexity and a trend towards higher flap-related complications. Accordingly, these patients should not be denied gold standard treatment solely based on concerns about microvascular challenges.

To evaluate clinical and objective sensory outcomes of the MPS flap for heel reconstruction and to describe position-dependent technical differences encountered during flap harvest

A retrospective observational study was conducted from February 2024 to July2025. Eleven patients with weight-bearing and non-weight-bearing heel soft-tissue defects underwent reconstruction using the MPS flap. Flap harvest involved instep flap elevation and medial plantar neurovascular pedicle dissection for length. Six procedures were performed in the supine position and five in the prone position. Clinical outcomes, complications, donor-site morbidity, and intraoperative technical ease were assessed. Minimum clinical follow-up was 6 months. Two-point discrimination (2PD) testing was performed at a minimum of 1 year postoperatively in 8 neurologically intact patients and compared with corresponding normal plantar tissue using a paired t-test. Three paraplegic patients were excluded from objective sensory comparison due to pre-existing neurological impairment.

All flaps survived completely (100%) with no necrosis or venous congestion. Complications occurred in 3 of 11 patients (27.3%), including wound dehiscence (1),
surgical site infection (1), and transient facial edema with nonspecific parotiditis (1), the latter unrelated to flap viability. No recurrent ulceration was observed during follow-up. Sensory recovery followed a consistent chronological pattern: crude/deep tactile sensation returned within 2 weeks in all patients, and light touch sensation became appreciable between 4 and 6 weeks. At ≥1 year, mean 2PD in normal plantar tissue was 27 mm (SD 12.9) compared to 31 mm (SD 10.97) in flap tissue, with no statistically significant difference (two-tailed p = 0.2809). Instep elevation was easier in the prone position, whereas pedicle dissection to gain additional length was more straightforward in the supine position.

The medial plantar sensate flap provides reliable heel reconstruction with excellent survival, early return of protective sensibility, and objective long-term discriminatory function comparable to normal plantar tissue. Supine and prone positioning confer distinct stage-specific technical advantages during harvest. Recognition of these nuances allows tailored intraoperative positioning to optimize surgical ergonomics without compromising functional outcomes.

Unstable scarring of the heel represents a challenging reconstructive problem due to limited local soft tissue, high mechanical load, and the unique biomechanical function of the plantar fat pad. Chronic pain, recurrent ulceration, and impaired weight bearing are frequent consequences, particularly following trauma, infection, or prolonged pressure. Conventional reconstructive strategies often rely on bulky muscle flaps, which may compromise contour, sensation, and long-term function. Durable, well-padded, and anatomically adapted soft tissue reconstruction is therefore essential to restore function and quality of life.

We present a retrospective case series of four patients (two men, two women; mean age 47.5 years) with painful, unstable heel scars affecting partial or full weight-bearing zones. Etiologies included post-traumatic infection, pressure-related ulceration, and postinfectious fat pad loss. All patients underwent radical scar excision and direct reconstruction using free perforator flaps. Reconstructions included anterolateral thigh flaps (n=2), a superficial circumflex iliac artery perforator flap (n=1), and a parascapular flap (n=1). In all cases, microvascular end-to-side anastomosis was performed to the posterior tibial artery with venous anastomoses to its concomitant veins. Standard microsurgical technique, peri-operative antibiotic prophylaxis, antithrombotic protocols, and structured postoperative monitoring were applied.

All flaps demonstrated immediate and sustained perfusion without vascular complications. No revision of recipient vessels or conversion to alternative vascular axes was required. Stable soft tissue coverage was achieved in all patients, with marked pain reduction and improved weight-bearing capacity. No recurrent ulceration or breakdown occurred during follow-up. Harmonious contour and durable heel padding were obtained without bulky muscle flaps or secondary major contouring procedures. No donor site complications were observed.

Direct reconstruction using free perforator flaps anastomosed end-to-side to the posterior tibial artery represents a reliable approach for unstable heel scarring. This strategy enables tailored volume restoration, preserves regional vascular options, and avoids more invasive flap choices while achieving satisfactory functional and aesthetic outcomes.

To systematically review reconstructive strategies and clinical outcomes for extensor mechanism disruption (EMD) occurring in the setting of periprosthetic joint infection (PJI) after total knee arthroplasty (TKA), a rare but devastating complication associated with major functional loss and difficult limb salvage.

A systematic review was performed according to PRISMA 2020 guidelines. PubMed and Semantic Scholar were searched from inception using terms related to extensor mechanism reconstruction, TKA, and infection. Eligible studies included human clinical series, comparative studies, randomized trials, and systematic reviews reporting outcomes after reconstruction of infected post-TKA extensor mechanism deficiency. Data extracted included disruption type, reconstructive technique, functional outcomes, failure and reinfection rates, complications, and follow-up. 11 studies met inclusion criteria.

The review included 11 studies, comprising 2 primary clinical studies and 9 systematic reviews. Available evidence was dominated by small retrospective case series and heterogeneous cohorts. Across studies, allograft and synthetic mesh reconstruction showed comparable failure rates, generally ranging from 23% to 33%. Functional improvement was consistent, with postoperative Knee Society Scores frequently exceeding 70, mean extensor lag typically improving to less than 10°, and postoperative knee flexion usually ranging from 95° - 110°. Reinfection rates ranged from 13% to 15% and represented the main cause of late failure. Two-stage exchange with mesh achieved approximately 75% survivorship free of reinfection or mechanical failure at 2 years, while Achilles tendon allograft reconstruction after infection eradication demonstrated similar success. Reconstruction was favored over direct repair, particularly for patellar tendon disruption, which showed substantially higher complication rates after repair.

Extensor mechanism reconstruction after infected TKA is a demanding limb-salvage procedure with guarded prognosis. Allograft and synthetic mesh techniques appear to provide similar overall durability, while long-term success depends more on infection eradication, soft-tissue quality, and appropriate patient- and defect-specific technique selection than on graft material alone.

Soft tissue defects over the knee remain a reconstructive challenge, particularly in patients with trauma, infection, or prior surgical intervention. The pedicled medial sural artery perforator (MSAP) flap offers a versatile option, providing thin, pliable tissue with a reliable vascular supply and minimal donor site morbidity.

A case series of three patients undergoing reconstruction of complex knee defects using pedicled MSAP flaps is presented.

All cases involved patients with compromised wound conditions, including infection, prior surgery, or soft tissue injury. Reconstruction using pedicled MSAP flaps achieved stable wound coverage in all patients. No major complications were observed. The flaps provided adequate soft tissue coverage with satisfactory functional recovery and aesthetic outcomes.

The pedicled MSAP flap is a reliable and effective option for reconstruction of complex knee defects. It offers a less invasive alternative to free tissue transfer and may serve as a valuable option in selected patients with compromised local conditions.

A 27-year-old female patient was referred to our department four hours after accident due to a total amputation of the left lower extremity. The tibial nerve appeared compromised but intact. No distal perfusion of the left foot was detected.

The fractures were addressed by the orthopedic team. After revision of the avulsed vascular ends, they were deemed unsuitable for primary anastomosis. Therefore, an approximately 20 cm saphenous vein graft was used to reconstruct the posterior tibial artery and vein(ischemia 5h46mins).A chimeric flow-through ALT flap measuring approximately 15×35cm, including the vastus, was planned.Proximally, the LCFA was anastomosed to the anterior tibial artery. Distally, a flow-through anastomosis was performed to the dorsalis pedis artery. Despite confirmation of flow-through patency, venous insufficiency was detected. Peroneal vein was anastomosed as a supercharge .During postoperative monitoring, arterial insufficiency secondary to a steal phenomenon was observed. The patient was taken back. The distal flow-through segment was clamped but was deemed insufficient. At postoperative hour 48, a second chimeric flap measuring approximately 15×35cm, consisting of a latissimus and serratus flap, was planned. The flap was proximally anastomosed to the anterior tibial artery. The peroneal artery was connected distal part of anterior tibial artery. After confirming perfusion the operation was concluded.

In cases of vascular avulsion, it must be recognized that intimal injury frequently extends more proximally than anticipated. Therefore, confirmation of healthy intima under microscopic evaluation prior to anastomosis is essential. Surgeons should not hesitate to use long vein grafts following adequate debridement.Ischemia time should be minimized as much as possible, and cold and warm ischemia should be reduced through coordinated, simultaneous multidisciplinary intervention.

Despite successful design and anastomosis of flow-through myocutaneous flaps for large soft tissue defects, arterial steal phenomenon may compromise perfusion in extensive limb replantation cases. In such scenarios, consideration of alternative reconstructive strategies and salvage supercharging techniques, in addition to free tissue transfer, may represent a key factor in achieving success in major replantation surgery