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.

Aim: Free tissue transfer is essential for extremity reconstruction following traumatic injuries, oncologic resection, and diabetic complications. However, given the circumferential shape of the arm and leg, a small amount of ongoing edema can prevent a tension-free closure. Additionally, intraoperative thrombosis, vascular disease can lead to proximal exposure of the pedicle or vein grafts. This study evaluates the outcomes of microvascular transfers that utilized a skin graft for closure over the pedicle, in comparison with a matched cohort with a tension-free primary closure.

Methods: A retrospective review was completed of all patients that underwent free flap reconstruction of an extremity defect from January 2014 to December 2017 at a single academic institution. Flaps that utilized skin grafting for closure were compared to those closed primarily. Adjunct operative procedures, demographics, and complications were evaluated.

Results: A total of 71 patients fulfilled the inclusion criteria. The 11 flaps in 10 patients underwent skin grafting over the pedicle. The two cohorts were comparable in age, gender, BMI, and co-morbidities, excluding renal disease which was present in 40% (n = 4) of skin grafted group compared to 6.5% (n = 4) in the primary closure group. Flap area, operative time, and anastomosis technique were comparable between the two groups. There was no significant difference in the rates of post-operative complications including partial flap loss, complete flap loss, infection. Mean follow up time in the skin grafting group was 14.2 months and 20.2 months for the primary closure group.

Conclusion: As per the principal, a tension-free closure is paramount to preventing tissue complications including direct compression of a microvascular pedicle. However, with ongoing tissue edema skin grafting should be considered as a reliable technique to ensure both protection of the pedicle as well as prevention of direct compression without additional complications and comparable post-operative outcomes.

Lower extremity injury and deformity can result from a number of etiologies. Regardless of the underlying cause, the decision to pursue amputation or reconstruction of a lower limb is challenging for both patients and practitioners. This decision is largely dependent on the patient’s premorbid health and function, functional goals and preferences, and characteristics and viability of the affected limb. The role of adaptive devices following surgery should never be underestimated. Advances in prostheses and orthoses have provided patients with a wider range of options to consider when deciding between limb reconstruction and amputation. The primary goals of any adaptive device are to improve function, prevent recurrence or ulceration of the defect, and allow for use of conventional footwear and/or clothing. When a lower extremity amputation is indicated, selection of the correct level is of critical importance in order to optimize healing potential and function. Each distinct level has certain inherent prosthetic and orthotic considerations. Likewise, the application of an adaptive device following reconstruction of the lower extremity also has demonstrable benefits and must be tailored to the specific defect and procedure performed. Knowledge of available prosthetic and orthotic options is of considerable importance for the reconstructive surgeon tasked with limb salvage or resurfacing an amputated extremity. This article reviews considerations of various types of lower extremity amputation and reconstruction, and provides a framework for the role of adaptive devices following surgery.

Aim: Mass casualty incidents (MCIs) are a devastating source of morbidity and mortality, testing the infrastructure of acute care management and challenging the ability to reconstruct limbs. Herein, we look to further a discussion on upper and lower limb reconstruction following MCIs.

Methods: Review of the literature, including our institute’s experience with the 2013 Boston Marathon Bombings, the 2015-2016 Terror Attacks in Ankara, and the 2010 earthquake in Haiti, pertaining to extremity reconstruction following MCIs.

Results: The three aforementioned case profiles highlight extremity wounds associated with MCIs and the subsequent reconstructive role of plastic surgeons. Surgical intervention or temporization of extremity wounds is a critical responsibility of plastic surgeons in this setting. Limb salvage is possible and often the preferred option following disasters.

Conclusion: Intentional or naturally occurring MCIs are a grim reality. Successful response to these events requires prompt mobilization of emergency medical staff and hospital activation. Plastic surgeons play a paramount role in multidisciplinary management of trauma with a particularly important involvement in limb reconstruction.