Orthoplastic Surgery最新文献

The author reports a volar dislocation of the right-hand ring finger's proximal interphalangeal joint in 65-year-old women presented two days after the injury. Apparent shortening, rotation and ulnar deviation of the finger are the classical clinical findings. Radiographs are essential in differentiating between the variants of volar dislocation. Type 1 dislocation presents as irreducible dislocation because of the entangled proximal phalanx in the buttonhole and always associated with the same side collateral ligament injuries. Type 2 dislocation is reducible because of the central slip rupture and a resultant boutonniere deformity. The author reported a case with a complex spectrum of injury, causing the volar dislocation of the proximal interphalangeal joint with the proximal migration of the middle phalanx and radial displacement. This was because of the same side collateral ligament rupture and central slip avulsion. Central slip reconstruction and radial collateral ligament repair produced a stable, painless joint and a full range of movement at the final follow-up.

Level of evidence

V

Introduction

Percutaneous extension block pinning is one of the treatment modalities for displaced bony mallet injuries. Various technical modifications with one or more Kirschner wires have been described. The purpose of this study is to analyze the outcomes of fragment-specific dorsal Kirschner wire fixation for mallet fractures.

Methods

Twenty patients with mallet fractures were divided into dorso-radial, dorso-ulnar and central based on the displaced fragments in posteroanterior radiographs. A single dorsal Kirschner wire reduced the specific dorsoradial or dorsoulnar fragment along with an additional transarticular Kirschner wire. Two dorsal wires reduced the centrally displaced fragment. We analyzed the fracture size, pre- and postoperative articular gap and dorsal gap, union, postoperative range of movement, visual analogue score, and functional outcome according to the Crawford evaluation score.

Results

The mean age of the patients was 28 years (range, 19–41 years.). We saw dorso-radial displacement of the fracture fragment in eight patients, central in seven patients, and dorso-ulnar in five patients. The mean follow-up was 24 months (range, 18–29 months). Nineteen of the 20 patients achieved good radiological union. Fragment-specific fixation with 1 or 2 Kirschner wires significantly improved articular gap and dorsal gap (p < 0.05). Seventeen of 20 patients achieved a good or excellent Crawford score.

Conclusions

Fragment-specific fixation with one or two Kirschner wire is a rational approach for displaced mallet fractures. The technique is simple and reliable. This treatment modality achieves good radiological union and functional outcome.

Level of evidence

IV.

Open tibial fractures can be challenging to manage because of the paucity of soft tissue available locally to cover any wound post debridement. They commonly require both skeletal stabilisation and complex soft tissue reconstruction. This combined approach to manage open tibia fractures is the foundation upon which orthoplastic care is based. The optimal method of managing these patients is to perform a debridement on day one and then a combined “fix and flap” procedure no more than 7 days later.

We present three patients who underwent suprapatella tibial nailing in a lateral position purely to facilitate ease of access to the back so scapular and para-scapular flap could be harvested. These flaps are usually pliable, conformable and hair free with a reliable, long and large calibre pedicle which allows a relatively rapid flap harvest. To use scapular flaps the plastic surgery surgeons would have to wait for the orthopaedic surgeons to complete supine tibial nailing prior to commencing flap harvest. For a “fix and flap” procedure, this could mean performing microsurgical anastomosis late in the evening when surgeons may be tired. Therefore, other flaps with less reliable pedicles were used.

Stabilising open tibial fractures that require intramedullary tibial nailing and a free flap in a lateral position promotes orthoplastic teamwork. It facilitates the harvesting of a relatively straightforward flap in a time efficient manner as both surgical teams can operate simultaneously. This increases surgical efficiency, promotes orthoplastic teamwork and utilises a more reliable flap giving the best chance of recovery for these complex injuries.

Introduction

Free tissue transfer has added to the plastic surgeon's armamentarium and has afforded patients more chances towards limb salvage in recent decades following severe trauma. Venous congestion is a common occurrence, can be the result of several reasons and has devastating results in patients' outcomes. Recent studies have highlighted the importance of restrictive fluid administration. We hypothesized that a restrictive fluid administration in the intra – operative period would be associated with a lower incidence of venous congestion in patients undergoing free flap reconstruction of traumatic defects of the extremities.

Methods

All patients undergoing a perforator free flap soft tissue reconstruction of traumatic defects of the extremities, from 2005 to 2019 were retrospectively identified. Patient's demographics, comorbidities and technical aspects of the operation were extracted. The study population was divided in two groups based on the amount of fluids administered (restrictive: < 6 ml/kg/hr; liberal: ≥ 6 ml/kg/hr). Multivariate analyses were performed to identify the impact of fluid strategy on the development of clinically significant venous congestion.

Results

A total of 75 patients were identified. Out of these, 24 patients had clinically significant venous congestion. Fluid administration strategy [AOR (95% CI): 1.53 (1.22, 1.92)], use of the superficial venous system [0.03 (0.01, 0.26)], operative time [1.98 (1.97, 1.99)] and age>50 [5.60 (1.10, 28.52)]. A cut – off analysis identified 6 ml/kg/hr as the cut off point for fluid administration. Liberal fluid administration (≥6 ml/kg/hr) was independently associated with a higher incidence of venous congestion and return to the OR for flap debridement, both overall and after exclusion of anastomotic revisions.

Conclusions

Venous congestion in free flap reconstruction following traumatic defects of the extremities remains high. Several factors are associated with congestion. Liberal fluid administration ≥6 ml/kg/hr is independently associated with this complications and should be avoided when possible.

In the era of this pandemic, the use of free flaps for elective reconstruction should proceed with caution in the COVID-19 positive patient given the associated coagulopathy. In those who require free tissue transfer in an urgent or non-elective manner, it is advisable to consider systemic anticoagulation with an associated hematologic consultation given the theoretic higher risk of flap vascular complication.

We present a case report of a young healthy and otherwise asymptomatic COVID-19 positive patient whose associated coagulopathy resulted in free flap loss and need for further operations.

Background

Malignant peripheral nerve sheath tumors (MPNST) are aggressive and possibly morbid sarcomas because of their tissue of origin. However, postoperative functional status of MPNST patients has been understudied. Reconstructions may play a role in restoring lost function, but are still infrequently carried out. This study investigated how surgical considerations and the use of functional reconstructions differed among surgeons treating MPNST.

Methods

This survey was distributed among members of multiple surgical societies. Survey responses were analyzed overall and between surgical subspecialties (surgical oncology/neurosurgery/plastic surgery/other).

Results

A total of 30 surgical oncologists, 30 neurosurgeons, 85 plastic surgeons, and 29 ‘others’ filled out the survey. Surgical oncologists had the highest case load (p < 0.001). Functional status was usually considered preoperatively among all subspecialties (65.1%); 42.2% never considered performing less extensive resections to preserve function. Neuropathic pain and motor deficits are seen in 40.9 ± 22.9% and 36.7 ± 25.5% respectively. Functional reconstructions for motor and sensory deficits were more commonly considered by plastic surgeons and ‘others’. Relative contraindications for reconstructions did not differ between subspecialties (p > 0.05). Most surgeons would reconstruct directly or directly unless radiotherapy would be administered (62.7%). On average, surgeons would consider functional reconstructions when estimated survival is 3.0 ± 2.0 years.

Conclusions

Surgical treatment of MPNSTs differs slightly among subspecialties. Neuropathic pain, motor deficits, and sensory deficits are commonly acknowledged postoperative morbidities. Functional reconstructions are varyingly considered by surgeons. Surgical oncologists and neurosurgeons treat most patients, yet may be least likely to consider functional reconstructions. A multidisciplinary surgical and reconstructive approach may be beneficial in MPNSTs.

A 66-year-old male with chronic right distal tibial osteomyelitis presents with erythema and a draining sinus tract concerning for acute exacerbation. Previously stable on amoxicillin/clavulanate, worsening symptoms for 3–4 months prompted referral. Following evaluation, treatment consisted of debridement, insertion of an antibiotic cement spacer into the partial cortical tibial defect and free flap coverage. At five-year follow up, the antibiotic spacer remains in place without recurrence of osteomyelitis and with preserved function. Further investigation is needed to validate permanent retention of an antibiotic spacer as an alternative to vascularized or non-vascularized bone grafts for management of chronic tibial osteomyelitis in the comorbid diabetic limb salvage population.

Lower extremity fillet flaps are occasionally used for coverage of complex defects following external hemipelvectomy. When performed as a free flap, soft tissue from the lower leg is typically harvested with the popliteal or distal femoral vessels and transferred to the pelvis for anastomosis with the ipsilateral pelvic vessels. If the ipsilateral pelvic vessels are unavailable, the aorta, inferior vena cava (IVC), or contralateral pelvic vessels may be required. The use of a lower extremity free fillet flap when none of these vessels are available has not been previously described. In this case report, we describe a novel modification to a lower extremity free fillet flap when typical recipient vessels are unavailable. A patient with pelvic osteosarcoma with tumor thrombus extending into the pelvic vessels and IVC was treated with external hemipelvectomy, hemisacrectomy, and resection of involved vessels. A classic lower extremity free fillet flap was planned for reconstruction but required modification due to absence of suitable recipient vessels in the pelvis. The flap harvest included the full length of the femoral vessels, which were passed through a subcutaneous tunnel in the chest and anastomosed to the ipsilateral axillary vessels. The patient tolerated the procedure and the flap provided durable coverage. Further research is required to characterize the indications and limitations of this novel modification of lower extremity fillet flaps.

Purpose and background

Humeral shaft fractures associated with median nerve palsy in children are not commonly seen and reported in the literature. The purpose of this retrospective study is to discuss the injury pattern, treatment options, nerve recovery, and functional outcome in these injuries.

Methods

We treated twelve children with median nerve palsy between 2012 and 2015. We analyzed the clinical presentations, radiological features, fracture type, displacement, treatment modality, nerve recovery pattern, time to bone union, functional outcome, 2-point discrimination (PD), range of movements, DASH score, and complications interpreted.

Results

The mean follow-up was 67.3 (range 59–80 months). 7/12 patients with median nerve injury recovered with hanging U slab/Shoulder immobilizer/Functional brace. Three patients who had median nerve entrapped at the fracture site required microsurgical nerve repair, and two patients required neurolysis alone. 11/12 patients (92%) had an excellent motor and sensory recovery (M5/S4) with a full range of movement. All patients achieved an excellent radiological union. The mean time to bone union was 13.5 weeks (range 11–18 weeks). The mean time for complete median nerve motor recovery in 11 patients was 25.4 weeks (range 22–26 weeks), and sensory recovery was 30.4 weeks (24–42weeks). The mean 2PD was 5.4 mm (range 5–7 mm). THE mean DASH score was 5.2 (range 2.3–18.2). One patient had M2/S3 recovery because of a treatment delay of >180 days.

Conclusions

We can treat acute humeral shaft fractures associated with median nerve injuries with hanging U slab/Shoulder immobilizer/Functional brace to achieve a complete nerve recovery, good radiological union, and excellent functional results. In cases of delayed humeral shaft fractures with nerve entrapment and poor nerve recovery, neuroma excision and microsurgical nerve repair give excellent results.

Level of evidence

IV.