Primary Versus Staged Reconstruction and Risk of Surgical Failure in Patients With Ulcerative Colitis: a Nation-wide Cohort Study

Background Restorative surgery after colectomy due to ulcerative colitis (UC) may be performed simultaneously with colectomy (primary) or as a staged procedure. Risk factors for failure after restorative surgery are not fully explored. This study aimed to compare the risk of failure after primary and staged reconstruction. Methods This is a national register-based cohort study of all patients 15 to 69 years old in Sweden treated with colectomy due to UC and who received an ileorectal anastomosis (IRA) or ileal pouch-anal anastomosis (IPAA) between 1997 and 2017. Failure was defined as a reoperation with new ileostomy after restorative surgery or a remaining defunctioning ileostomy after 2 years. Risk of failure was calculated using the Kaplan-Meier method and Cox regression adjusted for sex, age, calendar period, primary sclerosing cholangitis, and duration of UC. Results Of 2172 included patients, 843 (38.8%) underwent primary reconstruction, and 1329 (61.2%) staged reconstruction. Staged reconstruction was associated with a decreased risk of failure compared with primary reconstruction (hazard ratio, 0.73; 95% CI, 0.58–0.91). The 10-year cumulative risk of failure was 15% vs 20% after staged and primary reconstruction, respectively. In all, 1141 patients (52.5%) received an IPAA and 1031 (47.5%) an IRA. In stratified multivariable models, staged reconstruction was more successful than primary reconstruction in both IRA (hazard ratio, 0.75; 95% CI, 0.54–1.04) and IPAA (hazard ratio, 0.73; 95% CI, 0.52–1.01), although risk estimates failed to attain statistical significance. Conclusions In UC patients undergoing colectomy, postponing restorative surgery may decrease the risk of failure.

1322 Two Staged Skin Pedicle Reconstruction of Superior Helical Rim

Introduction Skin grafting onto the ear has its challenges, loss of the skin results in inadequate vascular bed for the graft leading to decreased uptake 1,2. As a result, advancement flaps or sacrifice of the underlying cartilage allows primary closure with compromised aesthetics. A two staged procedure however leads to acceptable scarring, can be performed under local anaesthetic, is quick and easy enabling transfer of skin to acutely exposed cartilage. The authors demonstrate a two staged reconstruction technique of the superior helix after traumatic degloving of the dermal tissues. Method Under local anaesthetic an incision in line with the most inferior extent of the skin loss is made. A subdermal plane is expanded superiorly, and the exposed auricular cartilage inserted, healing of the adjacent margins occurs and enables later skin transfer. The patient was discharged on oral antibiotics and returns at two weeks to have the pedicle divided in an outpatient setting. A further skin incision superior to the extent of the tip of the helix is performed. This skin flap is then thinned and folded to reconstruct the posterior aspect of the ear. The skin is sutured in place and the patient is sent home on oral antibiotics. A further reviewed in two weeks to check healing is advised and the patient was subsequently discharged. Conclusions In conclusion, this is demonstrated to be a useful technique to add to the Oral and Maxillofacial Surgeons armament for reconstruction of the superior helix when iatrogenic or traumatic loss of skin coverage occurs.

Staged reconstruction of unilateral neglected hip dislocation through total hip arthroplasty and subsequent intramedullary femoral lengthening

Background and purpose Total hip arthroplasty (THA) is a successful approach to treat unilateral symptomatic neglected hip dislocation (NHD). However, the extensive leg length discrepancy (LLD) can hereby only be partially corrected. In case of residual LLD of more than 2 cm, subsequent femoral lengthening can be considered. Patients/material/methods Retrospective analysis of clinical data and radiographs of five patients (age 38.1 (28–51) years) with unilateral NHD who underwent THA with (n = 3) or without (n = 2) subtrochanteric shortening osteotomy (SSO) and secondary intramedullary femoral lengthening through a retrograde magnetically-driven lengthening nail (follow-up 18.4 (15–27) months). Results LLD was 51.0 (45–60) mm before and 37.0 (30–45) mm after THA. Delayed bone union at one SSO site healed after revision with autologous bone grafting and plate fixation. Subsequent lengthening led to leg length equalisation in all patients. Complete consolidation was documented in all lengthened segments. Conclusion Staged reconstruction via THA and secondary femoral lengthening can successfully be used to reconstruct the hip joint and equalise LLD. The specific anatomical conditions have to be taken into consideration when planning treatment, and patients ought to be closely monitored.

Breast Reconstruction and Post Mastectomy Radiotherapy: A Primer for Members of a Multidisciplinary Team

Background: Post-mastectomy radiation therapy (PMRT) is a key component in managing breast cancer with increased potential for locoregional recurrence. Breast reconstruction has evolved to include various techniques that can be categorized according to the type of reconstruction (implant-based versus autologous reconstruction), and the timing of reconstruction (one versus two-step techniques). Methods/Results: This review article aims to provide a digestible summary of PMRT in the context of breast reconstruction by summarizing salient existing literature with a focus on considerations of the plastic surgeon. The main findings summarized in this review include the technique and timing of breast reconstruction, how breast reconstruction can affect radiation delivery, and the type of reconstruction. Within implant-based reconstruction, existing data on the location of the implant in the context of PMRT and PMRT delivery to the tissue expander versus permanent implant are reviewed. Each consideration may alter the probability of successful reconstruction and patient satisfaction.Conclusion: It is essential for the multidisciplinary breast cancer team to have knowledge of the various reconstructive options, and to understand the safety and comparative effectiveness of staged reconstruction in the setting of PMRT. Additionally, one must consider that reconstructive procedures may have implications on the timely administration of PMRT. This review serves as a reference for members of the oncologic care team when discussing reconstructive options with patients who will receive PMRT as part of their treatment plan.

Distally Based Pedicled Fibula Flap for Reconstruction of Infected Charcot’s Midtarsal Collapse—Diabetic Rocker Bottom Foot

Introduction and Methods Diabetic rocker bottom foot with secondary infection exacts the expertise of a reconstructive surgeon to salvage the foot. The author selected 28 diabetic patients with secondarily infected Charcot’s degenerated rocker bottom feet and reconstructed their feet using distally based pedicled fibula flap. Reconstruction was done in a staged manner. Stage 1 surgery involved external fixation following debridement. In stage 2, struts were activated for distraction and arthroereisis. In stage 3, the distally based pedicled fibula was used for reconstruction and beaming of the arches. Results In this retrospective study, the author analyzed the outcome of all 28 patients using the Musculoskeletal Tumor Society Rating (MSTSR) score. The average MSTSR score was 27.536 in an average follow-up of 30.5 months. The limb salvage rate with the author’s procedure was 96.4% (p = 0.045). Conclusion Author’s protocol for the staged reconstruction and salvage of the infected diabetic rocker bottom foot, using the pedicled fibula flap, will be a new addendum in the reconstructive armamentarium of the orthoplastic approach.