Volume 11, Issue 1 - Special issue: Orthoplastic surgery – regenerative concepts and reconstructive strategies; Guest Editors: Justus P. Beier and Frank Hildebrand

Objectives Combined bone and soft tissue injuries and defects pose a challenge for the interdisciplinary orthoplastic surgical team. These conditions are not only encountered in young, healthy patients, but, due to various causes ranging from trauma over chronic osteomyelitis to tumor resection, also in patients with pre-existing vascular disease and even many years after the initial trauma. Methods An efficient interdisciplinary treatment approach by orthopedic/trauma surgeons and plastic surgeons, and if necessary, vascular surgeons, who develop a joint strategy as early as possible is crucial for optimal functional restoration of form and function. Results The goal of this orthoplastic approach is early definitive fracture stabilization or bony 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. Conclusions The different steps of the orthoplastic surgical approach for interdisciplinary extremity reconstruction is described in the following manuscript and should encourage and provide a guideline for other orthoplastic teams, possibly leading to establishing specialized extremity reconstruction centers.

Objectives The application of 3D-based methods for deformity correction of the upper extremity, including patient-specific instruments (PSIs), is attracting increasing attention in clinical practice and requires the collaboration of orthopaedic surgeons and medical engineers. Methods The management of various elbow deformities using 3D-based surgical methods, including PSIs, is presented. A narrative literature review with a defined search strategy using PubMed as a database was conducted to identify further applications around the elbow that have been published to date. Results This case series presents with one case each the correction of the following deformities: cubitus varus, dorsal radial head subluxation, translational deformity of the distal humerus, cubitus valgus (CVL) and radial head dislocation in hereditary multiple exostoses (HME). The Supplementary literature with 28 studies presents further deformities that were corrected on a 3D basis: intra-articular fracture of the capitulum radii, extension deformity of the distal humerus and malunited radial neck fractures. These 3D-based procedures have been used most frequently to correct cubitus varus and are superior to conventional methods in terms of accuracy in comparative studies. Conclusions The application of 3D-based planning methods, including PSIs use, offers excellent opportunities and accuracy for corrective osteotomies around the elbow. In addition to the correction of cubitus varus, extension to the correction of chronic dislocation of the radial head after Monteggia fracture and HME appears promising. The future implementation of 3D-based planning based on magnetic resonance imaging (MRI) would be highly desirable.

Objectives This study examines the clinical application of interdisciplinary reconstructive strategies for complex forearm and hand defects. Emphasis is placed on principles guiding flap selection, anatomical localization, and the central role of plastic surgeons within coordinated surgical teams. The aim is to clarify how collaborative planning and technique adaptation influence reconstructive outcomes in upper extremity salvage. Methods A retrospective review was conducted of 79 patients who underwent upper extremity reconstruction between 2020 and 2024 at a tertiary care center. Inclusion required composite defects of the hand or forearm treated with local, regional, or free flaps. Demographics, etiology, defect location, reconstructive technique, interdisciplinary collaboration, and complications were analyzed descriptively. Results Most patients were male (n=62), with a mean age of 53.3 years. Defects most often involved the long fingers (n=32) and thumb (n=31). Trauma (68 %) was the main cause, followed by oncologic resection (22 %) and infection (10 %). Free flaps (n=15) were primarily used for larger or composite defects requiring microsurgical reconstruction, while local and regional flaps were employed zone-specifically for smaller soft tissue defects, especially in digits and thumb. Functional reconstruction addressed tendon, nerve, vessel, and bone injuries. The overall complication rate was 12.6 %, with no flap failures or limb loss. Conclusions Upper limb reconstruction benefits from individualized, anatomy-driven planning and interdisciplinary cooperation. Plastic surgeons play a key role in adapting techniques to anatomical zones, achieving favorable functional and aesthetic outcomes.

Objectives Soft tissue sarcomas are rare and heterogenous tumors, that often pose diagnostic and therapeutic challenges. Guideline-compliant therapy includes surgical resection with negative margins, supplementary radiotherapy and, if necessary, accompanied by systemic therapy. Diagnostic and therapeutic approaches should be discussed and planned in an interdisciplinary oncological conference. The aim of this article is to provide an overview of guideline-based interdisciplinary therapeutic options, limitations and prospects. An exemplary case is used to illustrate interdisciplinary concepts. Case Presentation A six-year-old girl with a locally advanced epithelioid sarcoma of the right hand was recommended to receive a hand amputation. Due to a request for limb-preservation, the patient presented at various sarcoma centers and initially received neoadjuvant radiotherapy. This resulted in a reduction of the tumor mass so that a tumor resection could subsequently be performed. Despite pronounced local findings, microscopically negative margins and a satisfactory postoperative result in hand function were achieved. Conclusions This case highlights the critical role of interdisciplinary collaboration and centralized care in the treatment of soft tissue sarcomas. Plastic reconstructive surgery enables radical oncological resection while preserving function, especially in anatomically complex cases. Early referral to a specialized sarcoma center and adherence to current guidelines (e.g., ESMO-EURACAN-GENTURIS) are essential to achieving optimal oncological and functional outcomes.

Objectives The orthoplastic approach has emerged as the gold standard in the reconstruction of complex extremity injuries. While robot-assisted microsurgery (RAMS) enhances precision and ergonomics, its role in the challenging orthoplastic setting remains largely unexplored. This study aimed to evaluate our initial institutional experience with robot-assisted free flap reconstruction for complex limb injuries within an orthoplastic approach. Methods From February 2023 to February 2025, we prospectively collected data on patients with combined traumatic bone and soft tissue injuries undergoing robot-assisted free flap transfer to the extremities. Data included patient demographics, surgical details (e.g., operating times, anastomosis/coaptation duration), and complications. Ethical approval was obtained. Results Our cohort of 18 patients (78 % male, mean age 50.3 years) received free flaps for traumatic soft tissue defects (78 % lower extremity). The ALT flap was most commonly used (67 %). Mean operating time was 353.0 min. 19 anastomoses and coaptations were performed, with no conversions to conventional techniques. A major complication (arterial thrombosis) occurred in one case, successfully salvaged with conventional re-anastomosis, resulting in no complete flap losses. There was one partial flap loss. Three minor complications (delayed wound healing, 17 %) were observed. Conclusions Our experience shows the feasibility of RAMS in orthoplastic limb reconstruction. Further studies are needed to validate these findings and define the optimal role and benefits of RAMS in orthoplastic surgery.

Objectives Extensive soft tissue defects of the lower leg can be effectively addressed by transplantation of various free microvascular flaps. A fundamental requirement for successful free microvascular flap coverage is the availability of adequate recipient arteries and veins. In cases where vascular conditions are compromised, such as in peripheral artery disease (PAD), achieving effective defect coverage through free microvascular flap transplantation poses significant challenges. One potential treatment option is the creation of an arteriovenous (AV) - loop to facilitate the attachment of a free flap. Methods Our study comprises patients receiving AV-loops with free latissimus dorsi flaps between 2019 and 2021. A retrospective review was performed of all patients who underwent this operative procedure with a minimum follow-up time of 3 years. We conducted pre- and intraoperative flow measurements with ultrasound. Flap survival, autonomisation and patient satisfaction was analyzed clinically, with thermography and the Freiburg Index of Patient Satisfaction (FIPS). We focus on identifying which patients benefit from this approach, as well as exploring limitations related to the severity of peripheral arterial occlusive disease (PAOD). Results Our study showed that this procedure can be used to cover defects safely and with a low flap loss rate, even in highly compromised vascular situations. It was also shown that even in PAOD, permanent patency of the pedicle vessel is not essential for the flap. In this study, with its associated limitations, we were unable to establish a reliable correlation between preoperative and intraoperative flow measurements and flap loss in the two-stage procedure we chose. Despite the high physical and psychological stress on the individual patients, the majority were satisfied with the procedure and the result. Conclusions Defect coverage of the lower extremity using a loop and free muscle flap is a safe, reliable procedure with a high patient satisfaction.

Objectives Polytrauma is characterized by high mortality and morbidity rates, partly due to the post-traumatic immune response. This follow-up study investigated the effect of combined inhibition of complement factor 5 (C5) and CD14 on systemic (plasma) and local (fracture hematoma) protein levels in a porcine polytrauma model. Methods 18 male pigs ( sus scrofa ) were used for this study: a control group (n=6), and two groups that were subjected to standardized polytrauma, followed by standard treatment (intramedullary nailing; n=8) or standard treatment with C5/CD14 inhibition therapy (n=4). Plasma and fracture hematoma samples were collected at specified time points and the expression levels of proteins related to the post-traumatic immune response and fracture healing were determined using enzyme-linked immunosorbent assays. Results Pro-inflammatory proteins such as IL-1β, IL-6, and IFN-α were significantly reduced in both plasma and fracture hematoma samples at 72 h after trauma in the treated vs. the non-treated group. Soluble TLR4, a possible inhibitor of cell membrane TLR4, was increased in both the plasma and the fracture hematoma following therapy, suggesting that TLR4 was released from the cell membrane to the fluid phase. Conclusions These findings show that systemic C5/CD14 inhibition effectively reduced the concentration of several pro-inflammatory proteins in the systemic circulation and locally, at the fracture site, in the fracture hematoma. The levels in the plasma were in line with those in the fracture hematoma, albeit that they were markedly lower in the plasma compared to the fracture hematoma.

Objectives Osteomyelitis (OM) represents a major clinical challenge in reconstructive surgery. It is characterized by chronic infection, impaired healing, and high treatment costs. Despite the high relevance, the local immune and regenerative microenvironment of infected human bone tissue remains insufficiently characterized. This study aimed to evaluate cytokine concentrations in osteomyelitic bone tissue. Methods Bone samples were collected intraoperatively from patients with sternal, vascular, and posttraumatic OM and compared to noninfected control tissue. Cytokine concentrations of IL-6, IL-8, MCP-1, osteopontin, and SPARC were quantified in tissue homogenates by enzyme-linked immunosorbent assays (ELISA). Bacterial pathogens were identified using routine clinical microbiological diagnostics, and cytokine profiles were compared across the OM subgroups. Results Pathogen identification revealed Staphylococcus epidermidis as the most common isolate in sternal OM, while vascular OM exhibited a broader spectrum including S. epidermidis , Corynebacterium striatum , Enterobacter cloacae , and Proteus mirabilis . Posttraumatic OM showed both monomicrobial and polymicrobial infections. The concentrations of the examined cytokines were significantly elevated in OM. No significant differences were observed between OM subtypes for most cytokines, except for MCP-1, which was higher in sternal compared to vascular OM. Spearman analysis revealed strong positive correlations between IL-6, IL-8, and MCP-1, indicating a coordinated inflammatory response. Osteopontin correlated significantly with inflammatory cytokines, while SPARC correlated primarily with osteopontin but not with inflammatory cytokines. Conclusions Cytokine profiling demonstrated simultaneous activation of inflammatory and regenerative processes in OM. The preserved regenerative marker profile across OM subtypes supports individualized surgical strategies even in chronic infections. Distinct correlation patterns between inflammatory and regenerative cytokines suggest differential regulation of immune and repair mechanisms within infected bone tissue.

Introduction Musculoskeletal tissues, including bone, tendon, cartilage, and muscle, are vital for movement and structural support, yet, their repair after injury remains a significant clinical challenge. Their regeneration relies on complex molecular signaling that regulates inflammation, repair, and remodeling. Understanding these cues, offers opportunities to design targeted therapeutic strategies. Content This review summarizes current evidence on molecular regulators of musculoskeletal tissue regeneration with emphasis on both shared and tissue-specific mechanisms across bone, tendon, cartilage and muscle. Key molecular cues include growth factors, cytokines, extracellular matrix-derived signals, and non-coding RNAs, particularly microRNAs. Critical pathways such as TGF-β, NF-κB, FGF, and YAP/TAZ can either promote healing or drive pathological fibrosis depending on their modulation. This review discusses therapeutic strategies targeting these molecular cues, including microRNA replacement therapies, small molecules, growth factor delivery, and pathway-specific inhibitors or activators. Summary and Outlook Understanding how these molecular cues and pathways function and interact to regulate healing and regeneration offers valuable insight into tissue-specific and cross-tissue repair strategies. These advances may support the development of targeted therapies to enhance musculoskeletal regeneration and functional recovery. Furthermore, future research should focus on integrating these molecular insights with biomaterial and mechanobiological approaches to develop next-generation regenerative interventions.