Schedule Slot

Long-segment femoral bone loss with concomitant extensive soft-tissue injury in pediatric trauma is rare and presents significant reconstructive challenges. Reports describing single-stage orthoplastic reconstruction using concurrent vascularized bone and soft-tissue free flaps in adolescents remain limited. We present limb salvage of a traumatic femoral defect reconstructed with dual free flaps.

A 16-year-old male sustained a Gustilo-Anderson IIIB open femoral fracture with partial quadriceps and patellar tendon loss following a motorcycle collision. After serial debridements, the segmental femoral defect measured 165 mm, with a 300 cm² soft-tissue defect. Definitive reconstruction was performed in a single stage using retrograde intramedullary nailing with an interposition 240 mm free fibula osteocutaneous flap and concurrent free latissimus dorsi (LD) myocutaneous flap for coverage. Both flaps were anastomosed end-to-side to the superficial femoral artery. Postoperative complications included hematoma requiring evacuation and distal LD dehiscence with knee exposure, managed with pedicled lateral gastrocnemius flap coverage.

The patient was discharged to inpatient rehabilitation one month post-injury and home one month thereafter. At three months following reconstruction, all flaps remained viable with a stable, well-healed soft-tissue envelope and radiographic evidence of progressive femoral union. Knee range of motion improved to 40 degrees of flexion with full extension, and weight-bearing was advanced as tolerated.

Single-stage orthoplastic reconstruction using concurrent vascularized bone and muscle free flaps can achieve limb salvage in pediatric patients with massive composite femoral defects. Despite the need for staged secondary interventions, durable coverage and progressive osseous healing were achieved. Early multidisciplinary coordination may expand salvage options in complex pediatric extremity trauma.

At the 4th hour of accident, 27 y.o female patient due to total amputation (although n.tibialis was seen compromised, continuity was determined) on the lower extremity and 21 y.o male patient due to total amputation at the upper extremity were brought to emergency. In the 4th hour of the accident, the amputated upper limb was brought together with the patient.

Amputated arm was perfused with perfusion solution. It was determined that primary anastomosis of dissected vessel segments could not be achived . The avulsed brachial artery was anastomosed to the distal part by the roughly 25cm vein grafts (ischemia 6h53mins). Median and ulnar nerves were coaptated their avulsed corresponding parts after revising the nerve ends. The radial nerve was buried into the brachioradialis muscle due to interruption at the level of distal branching. On the simultaniously operated table, distal continuity of posterior tibial artery was obtained with using 20 cm vein graft (ischemia 5h46mins). For coating the circular defect, 15x30 cm VL muscle added chimeric ALT flap was harvested. Proximally, LCFA was anastomosed with anterior tibial artery. Distal part was anastomosed with the artery dorsalis pedis by using flow-throgh. Venous insufficiency was identified. Peroneal vein was anastomosed to the comitant superficial vein by flow-through. The leg patient underwent a second surgery due to arterial insufficiency caused by arterial steal phenomenon. At the 48th hour, chimeric latis and serratus flap were planned . It was anastomosed to the a.tibialis anterior proximally. Peroneal artery was anastomosed to the distal part of tibialis anterior.

Convenient design of chimeric flaps and correct choice of the savior flaps on time (optimise the cold ischemia by perfusion solution on the arm replantation and apply to the alternative circulation and tissue transfers on the leg) are important. Use of the perfusion solutions significantly reduces the need for post operative fasciotomy.

Simultaneous major limb amputations are rare cases but they can be handled with prompt and correct intervention by experienced team. There have been limited cases published about using perfusion solution for major limb replantations. This comprehensive study is presented as an elucidor work for applying perfusion solution and results of the early follow-ups for preparing of the amputates into the replantations.

Paediatric open tibial fractures (OTF) are uncommon but high-risk injuries; evidence for protocol-based orthoplastic care in children is limited. We evaluated whether introducing an open fracture treatment protocol reduced complications.

All paediatric patients (age under 18 years) with OTF from April 2007 to April 2025 were included in the study. We compared results before and after institutional open fracture protocol implementation in September 2016. The protocol emphasized senior joint orthoplastic planning, early administration of antibiotics, and definitive fixation with soft tissue coverage during the same operation, within seven days.
Primary outcome was non-union requiring reoperation. Secondary outcomes included deep infection requiring reoperation with positive deep cultures, secondary amputation, length of stay (LOS), and flap related complications.

Sixty children were operated for OTF (pre-protocol n=33; protocol n=27). Primary surgery within 24 h was achieved in 32/33 vs 27/27. Flap reconstruction was performed in 11 vs 10 children; combined definitive fixation plus cover within 7 days increased (6/11 to 9/10; p=0.149) and free-flap use increased (6/11 to 9/10). Patients requiring flap reconstruction all presented with high-grade Gustilo-Andersson (GA) 3b–3c fractures, whereas those managed without flaps had lower-grade GA 1–3a injuries.
Incidence of non-union decreased from 15,1% to 3,7% (p=0.215); in flap-reconstructed children (G-A 3b–3c fractures), the incidence of non-union decrease d from 45% (5/11) to 0% (0/9) (p=0.038), while remaining rare without flap (G-A 1–3a fractures) 0% (0/22) vs 5,8% (1/17); p=0.436). Deep infection was uncommon (1/33 vs 1/27; p=1.000). No secondary amputations occurred. No total flap losses were observed. LOS decreased in children managed without a flap (median 9.0 to 5.0 days; p=0.044), while flap cases, reflecting more severe injuries demonstrated trend for decreasing LOS (median 29.0 to 19.0 days; p=0.549)

Implementing an orthoplastic treatment protocol for paediatric open tibia fractures was associated with fewer non-union, with the largest apparent benefit in children with G-A 3b–3c fractures requiring vascularized soft-tissue reconstruction.

This study investigates the outcomes of complex knee joint reconstructions performed by an orthoplastic surgery team at a tertiary referral hospital.

Retrospective review of all the total knee arthroplasty (TKA)/revision TKA (rTKA) procedures with soft tissue flap reconstruction performed between 2008 and 2019 was conducted. Patients were stratified into two groups according to the urgency of surgery: scheduled non-complicated (SNC) and emergent complicated (EC). The whole study cohort was also categorized into non-infected and infected groups.

Of 20,184 TKAs operated, 58 patients required flap reconstruction (SNC group n = 27; EC group n = 31). The most common reconstruction was medial gastrocnemius flap (74%). Mean follow-up time was 31.9 months. Functional knee joint salvage was achieved in 96.3% the SNC group and in 80.6% the EC group patients (p = 0.07). Transfemoral amputation rates were 3.7% in the SNC group vs. 6.5% in the EC group (p = 0.36). Oxford Knee Score was 34.5 vs. 25.5 (p = 0.21), and range of motion was 100⁰ vs. 93⁰ (p = 0.37) in the SNC and EC groups, respectively. Superior functional knee joint salvage rates were achieved in the non-infected group compared to the infected group (97.1% vs. 75.0%, p = 0.004). However, the transfemoral amputation rate was nearly three-fold in the infected group (8.3% vs. 2.9%, p = 0.36). Estimated five-year survival with functional knee joint was higher in the non-infected group (p = 0.03).

Both the SNC and EC groups had similar acceptable limb salvage rates, and functional and PROM outcomes. Infection reduces the probability of a functional knee joint after TKA and flap reconstruction.

Open calcaneal fractures are a devastating type of injury that present with damage to the bone and its overlying soft tissue. Further information regarding the treatment strategies of these rare fractures is needed to update guidelines. This case series aims to delineate the orthoplastic management and associated outcomes of such patients in two university hospitals major trauma centres.

Data on all adolescent or adult patients (>=13) between January 2015 and November 2025 at Addenbrooke’s (UK) and Lausanne University Hospital (CH) were retrospectively reviewed. Patient demographic details including age, sex, BMI and comorbidities were collected. Injuries were assigned a post-debridement Gustilo-Anderson (GA) classification, and details of orthopaedic and plastic surgeries were also extracted. Follow-up data was also assessed to evaluate patients’ post-operative complication and recovery profiles.

60 fractures from 59 patients (12F 47M) with open calcaneal fractures were identified. GA grade III fractures were the most common, with 17, 19 and 7 fractures being assigned the subgrades IIIA, IIIB and IIIC respectively. In patients requiring plastic surgery input, methods of soft tissue coverage varied and included anterolateral thigh (n=6), sural (n=1), medial plantar (n=3), gracilis (n=5) and serratus (n=3) flaps. Grade III fractures displayed higher rates of post-operative complications, with amputation and infection arising in 20.9% and 23.2% of cases respectively, compared with 5.9% for both outcomes in combined Grade I-II fractures. Furthermore, although median time to full tissue coverage was higher in patients displaying infections, the results were not significant (136 vs 109 hours, p=0.56). Of note, logistic regression suggested a trend towards an increased risk of flap necrosis, with a 19% increase in odds, after each day without definitive soft tissue coverage (OR 1.19 every 24hrs, 95% CI 0.99–1.48, p=0.093).

Injury severity appears to be linked to patient complications and outcomes. Although timely definitive soft tissue coverage may ameliorate rates of flap necrosis, the presence of infection appears to be susceptible to other factors. Further investigation into how elements such as patient co-morbidities, timing/choice of antibiotics, or orthopaedic and plastic surgeon collaboration can affect rates of infection, may improve patient treatment.

Vascularized bone grafts (VBGs) are assumed to have advantages over non-VBGs, including preservation of cell viability, higher rates of graft survival and bone union, accelerated osteogenesis and better functional outcomes. However, to date no convincing clinical evidence exists to prove this superiority. Therefore, we present an overview of the current state of knowledge gained from experiments in animal models.

A systematic review was performed according to the PRISMA guidelines in February 2026, focusing on preclinical studies directly comparing VBGs to non-VBGs. Out of 520 initially identified publications, 17 studies were included.

VBGs versus non-VBGs were evaluated across a range of animal models, with a mean sample size of 30, a mean graft size of 40mm, and equal distribution of pedicled and free flaps harvested with intact periosteum in most cases. Graft survival, longitudinal growth, bone union, hypertrophy, biomechanical strength and histological integration were investigated over follow-up periods ranging from 2 to 52 weeks. VBGs achieved accelerated bone union or growth in all studies and showed more pronounced hypertrophy and longitudinal growth including prolonged epiphyseal opening. VBGs also proved highly viable with higher cellular survival. Finally, greater mechanical stability in VBGs was observed. On the other hand, anastomotic patency issues and loss of vascularity in up to 50% of VBGs were observed in studies with inadequate osseous stabilization. VBGs also presented technical difficulties and remained inferior as compared to normal bone controls in bone growth and union rates.

This evidence supports the biological and mechanical superiority of VBGs and their preferential use in large defects, compromised vascular beds, radiated tissue and situations requiring early structural stability. While some authors pointed out that VBGs do not prove superior in the long term and that non-VBGs successfully integrate later on, most studies used well-perfused recipient beds for all grafts. Future studies will need to evaluate the effects of prolonged intraoperative ischemia, causes of vascularization failures, effects of mechanical loading, overall functional outcomes and the effects of differences in graft size on outcomes in increased group sizes with longer follow-ups.

In ortho-plastic surgery, the provision of durable and well-padded soft tissue coverage is essential when prosthetic rehabilitation is anticipated. Microsurgical free tissue transfer offers reliable reconstruction options even in cases where amputation is required. In foot trauma, preservation of maximal foot length is crucial to maintain biomechanical stability, improve gait function, and optimize prosthetic fitting.

A 58-year-old patient sustained a severe blunt trauma to the left foot while working with heavy metal plates. Subsequently, he developed progressive necrosis of the toes. After clear demarcation of non-viable tissue, a Lisfranc amputation was performed, including resection of the toes and metatarsal bones at the tarsometatarsal joint level.

This resulted in a substantial soft tissue defect measuring approximately 15–20 cm. During the same operative session, reconstruction was performed using a contralateral free anterolateral thigh (ALT) flap. Microvascular anastomosis was carried out in an end-to-side fashion to the anterior tibial artery, accompanied by two venous hand-sewn anastomoses.

The ALT flap demonstrated uneventful integration with no postoperative wound healing complications. After three weeks, a customized orthotic foot cast was fitted in collaboration with the orthopedic team. The patient began full weight-bearing ambulation without assistive devices three weeks postoperatively. Preservation of foot length combined with stable soft tissue coverage resulted in excellent functional outcomes.

Even when amputation is unavoidable, microsurgical free tissue transfer represents a valuable option to enhance residual limb quality and functional outcome. Free flap reconstruction should not only be considered for limb salvage but also as an effective strategy to optimize prosthetic rehabilitation and restore extremity function following partial foot amputation.

Burn injuries are best managed in specialist units with dedicated multidisciplinary expertise. In Manchester, Wythenshawe Hospital is the designated regional burns centre, while Manchester Royal Infirmary (MRI) manages orthoplastic trauma. Recently, patients presenting to MRI with combined orthoplastic and friction burn injuries have frequently been managed locally rather than transferred to the specialist burns service. This audit aims to evaluate current practice at MRI, determine compliance with British Burn Association referral and transfer guidance, and identify gaps in the pathway to support the development of a standardized inter-site referral protocol.

A retrospective clinical audit has been conducted reviewing electronic medical records of all patients presenting to MRI with burn injuries over a 12 month period. Data collected includes patient demographics, mechanism of injury, burn size and depth documentation, initial management, timing of referral to the burns centre, transfer decisions, and multidisciplinary communication. Compliance has been measured against British Burn Association referral and transfer standards. Data is anonymized and analyzed to determine the proportion of eligible patients appropriately referred and managed according to national guidance.

Preliminary review suggests variability in referral practice and documentation of burn assessment parameters, particularly in patients admitted primarily under orthoplastic trauma pathways. Full data collection and analysis will be completed by March 2026. It is anticipated that the audit will quantify the proportion of patients meeting specialist referral criteria who were managed locally, identify delays in referral where present, and highlight areas requiring pathway clarification and staff education.

This audit addresses an important interface between trauma and burns services within a regional plastic surgery network. By benchmarking current practice against national standards, the project aims to improve patient safety, standardize referral processes, and ensure that patients with complex burn injuries receive care in the most appropriate specialist setting. The findings will inform the implementation of a formalized referral pathway and re-audit cycle, with potential applicability to other major trauma centres managing combined orthoplastic and burn injuries.

Reconstruction of complex lower leg defects with combined bone and soft-tissue loss remains a major challenge in reconstructive surgery. The combination of the Masquelet technique with free flap coverage represents a promising strategy to achieve reliable soft-tissue reconstruction, bone defect healing, and ultimately limb salvage. This study aims to evaluate clinical outcomes of this combined approach.

A retrospective single-center case series was conducted, including 15 patients with post-traumatic combined bone and soft-tissue defects of the lower leg treated between 2013 and 2025 at our university hospital in collaboration with the Department of Orthopedics and Traumatology in Innsbruck. All patients underwent reconstruction using the Masquelet technique combined with free flap coverage. The primary endpoint was limb salvage.

The mean patient age at the time of reconstruction was 45 years. 14 of the 15 patients were male. The mean bone defect length was 5.5 cm. Soft-tissue coverage was achieved using free gracilis flaps (n = 8), anterolateral thigh flaps (n = 4), and latissimus dorsi flaps (n = 3). The average interval between Masquelet stage I and stage II was approximately three months. Complications occurred in six patients, including two total flap losses. Nevertheless, stable bone consolidation was achieved in nearly all cases, while complete remodeling required approximately two years on average. One patient ultimately required amputation. At long-term follow-up, 93% of patients were able to ambulate without walking aids.

The combination of the Masquelet technique with free flap reconstruction represents an effective option for the treatment of complex lower leg defects, achieving high limb salvage rates and satisfactory functional outcomes despite considerable morbidity. Union and amputation rates in our series are comparable to those reported in the current literature.

Free vascularized tissue transfer is a well-established technique for the reconstruction of large or complex soft-tissue defects of the lower extremity. Although numerous variables influencing free flap outcomes have been investigated, the role of ischemia time remains scarcely investigated. Experimental studies have explored tissue tolerance to ischemia. However, the clinical relevance of these findings remains uncertain and such reports in lower extremity reconstruction are particularly limited.

A systematic review was conducted in accordance with PRISMA guidelines using a PICOS-based search strategy. Studies reporting ischemia time and partial or total flap loss after lower extremity free flap reconstruction were included. In addition, the findings will be compared to a retrospective analysis of all free flap reconstructions of the lower extremity conducted at our institution from 2021 to 2025 investigating ischemia time, complication rates, surgical techniques and flap types.

Eight studies with a total of 750 free flaps, met the inclusion criteria. Two studies linked prolonged ischemia to total flap loss, reporting cutoffs of 120 min and 105 vs. 90 min in failed versus successful cases. Conversely, six studies (mean ischemia time 39–132 min) reported no correlation between ischemia time and flap failure despite the absence of direct comparative analyses. At our institution, 98 free flaps in 93 patients were investigated, with a mean ischemia time of 68±27 min. Total flap failure occurred in 5.1% (n=5), with 80% in muscle flaps. Flap loss had a higher mean ischemia time (105±64 min), though not statistically significant (p=0.06).

The impact and threshold of ischemia time on microvascular flap outcomes in lower extremity reconstruction remains underexplored. Although prolonged ischemia has been associated with increased rates of partial or total flap failure and complications in some studies, inconsistent reporting and the lack of direct comparative analyses limit definitive conclusions. Similarly, contradictory findings across anatomical locations question the relevance of anatomical site. Differential ischemic tolerance among tissue types raises the question of whether flap type may be more influential than anatomical location for sequelae due to prolonged intraoperative ischemia, in addition to etiology of defect (trauma, oncological, malformation).

Combined bone and soft tissue injuries pose a challenge for treating surgeons. These injuries occur not only acutely in young, healthy patients, but also—due to various causes ranging from trauma to chronic osteomyelitis—in patients with pre-existing vascular conditions, even many years after the initial trauma. Crucial for optimal functional restoration of form and function is an efficient interdisciplinary treatment approach by trauma surgeons/orthopedic surgeons and plastic surgeons, who establish a joint strategy as early as possible. The goal of this orthoplastic procedure is early definitive fracture stabilization or bone reconstruction combined with adequate soft tissue coverage and reconstruction of other injured structures such as vessels, nerves, and tendons, in order to begin rehabilitation as early as possible.

Such a simultaneous—or, for some steps, sequential—orthoplastic approach and the associated need for early coordination of a joint interdisciplinary treatment plan will be illustrated in concrete terms using exemplary cases of limb reconstruction.

The wide variety of injury patterns necessitates highly variable approaches to the reconstruction of soft tissue defects and functional structures. This complicates standardized treatment and requires tailored solutions, which ideally involve an interdisciplinary approach with orthopedic surgeons/trauma surgeons, plastic surgeons, infectious disease specialists, and vascular surgeons, as well as other necessary specialties—such as internal medicine for patients with pre-existing cardiac and/or renal conditions—and psychiatric/psychological support. Following the interdisciplinary determination of the treatment plan, a coordinated, multi-step surgical procedure involving the various surgical specialties is typically performed.

Functional restoration often requires a combination of various reconstructive techniques, ranging from tissue grafts to free flap procedures and vascularized bone grafts. The expected course of treatment is analyzed by the interdisciplinary treatment team before the actual treatment begins. The orthoplastic diagnosis, which is sometimes additionally established intraoperatively, helps to plan the treatment and any necessary diagnostic measures in advance, coordinate surgery dates with other specialties, and avoid delays in the treatment process.