Orthoplastic Surgery最新文献

Introduction

The presence of synthetic compounds like xylazine in the illicit opioid supply of the United States has led to presentations of unique upper extremity wounds in persons who inject drugs. As an alpha-2 adrenergic receptor agonist, xylazine causes local vasoconstriction of blood vessels as well as central nervous system depression. With increased vasoconstriction, patients experience more issues with adequate perfusion which is hypothesized to cause nerve deficiencies near injection sites.

Methods

Three patients presenting with a history of deep upper extremity forearm wounds secondary to injection with xylazine and fentanyl had clinically significant radial nerve palsies. Each patient's presentation and clinical course was observed and reported.

Results

In all three cases, patients presented with chronic necrotic forearm wounds that required repeated surgical debridement and wound care. There was evidence of weakness in the radial nerve distribution, with patients exhibiting dysfunction of the extrinsic digital and wrist extensors.

Conclusion

Providers should be aware of a common manifestation of radial nerve deficiency in upper extremity wounds in patients with a history of fentanyl-xylazine injections. While surgical management of nerve palsies such as tendon transfers are options for treatment, successful long-term treatment must also rely on multidisciplinary care for addiction and psychosocial support for ideal functional outcomes.

This comprehensive study explores the various aspects of metacarpal fractures, a prevalent condition in hand injuries. We delve into the anatomy of the metacarpals, elucidating how their structural characteristics influence fracture mechanics and treatment options. Special attention is given to the diverse types of fractures, particularly the differing tolerances for angular, shortening, and rotational deformities. The manuscript extensively reviews conservative treatment approaches, emphasizing the efficacy of non-surgical methods like modified braces and active mobilization techniques. Additionally, we provide a nuanced understanding of specific fracture types, such as neck fractures, highlighting their unique healing dynamics. This research offers valuable insights for orthopedic and plastic surgery practitioners, advancing the understanding and management of metacarpal fractures.

In hand and digital replantation, Kirschner wires (K-wires) osteosynthesis is regularly used for bone fixation. Percutaneous K-wire fixation (PKWF) has several disadvantages, such as restriction of range of motion (ROM)—as it often crosses the soft tissues of the joints—, need for early extraction before bone-union prolonging immobilization, potentially increasing pin tract infection, and the fact that it does not offer the strongest type of fixation construct compared to other methods.

All these factors limit early ROM rehabilitation protocols, therefore impacting functional outcomes. We present a case report of a near-total trans metacarpal (MCP) hand crush amputation by a hydraulic press injury that initially underwent PKWF. The K- wires were extracted at seven weeks post-operatively. The concern of impending non-union and the need for prolonged immobilization after K-wire extraction was addressed by intra-medullary nail fixation (IMNF).

In this case, we decided to utilize a less conventional method of osteo-synthesis IMNF to address the concern of impending non-union after initial fixation with K-wires in TMCHR. It provided a stronger fixation construct, no splint immobilization time, and early ROM rehabilitation protocol. All these factors facilitate bone union and improve functional outcomes.

This should stimulate further research for this type of situation between IMNF and other types of osteosynthesis by studying the incidence of non-union, infection rates, functional results, and other outcomes. This could also stimulate fabrication, in the laboratory, of intra-medullary nails for metacarpals with antibiotic impregnated hydroxyapatite/poly-L-lactide (HPLLA)—which are not only bioabsorbable, but also osteoconductive—for osteosynthesis in crushed amputations or comminuted fractures. There are several reports in the literature for digital replantation, but none found for amputations at the MCP level.

Background

Anterolateral thigh (ALT) flaps has served as a workhorse in lower extremity reconstruction. Flap design showcases both fasciocutaneous (ALT-FC) and myocutaneous variants; the latter includes variable amounts of vastus lateralis muscle (ALT-VL). This study aims to evaluate outcomes of ALT flaps for lower extremity reconstruction at a Level 1 trauma center between ALT-FC and ALT-VL variants and assess if there is any added benefit of muscle in flap design.

Methods

A retrospective review was conducted at Los Angeles General Medical Center (2007–2022). Demographics, medical comorbidities, injury characteristics, and outcomes were collected. Outcomes included flap necrosis, postoperative infection, and ambulatory function.

Results

Among 413 flaps placed, 63 were ALT flaps, of which 43 (68.3 %) were ALT-FC and 20 (31.7 %) were ALT-VL. Patient comorbidities, defect size, and wound severity were not significantly different across cohorts. Infectious and flap outcomes were comparable between cohorts, yet significantly more patients with hypertension and diabetes mellitus had osteomyelitis overall and in the ALT-FC cohort; patients with diabetes mellitus had significantly more flap complications. Flap survival was 96.8 % with 58.7 % of patients being fully ambulatory, without significance across degrees of ambulation or time to full ambulation.

Conclusions

Our findings demonstrated good outcomes with low rates of infection and flap loss that were comparable between both ALT-FC and ALT-VL cohorts. ALT-FC has recently been favored given decreased donor site morbidity without impaired function or infectious/flap complications. Accordingly, our findings may suggest that the addition of muscle to flap design may not be necessary for successful reconstruction.

The reconstructive surgeons are an important component in any multidisciplinary approach for the treatment of diabetic foot wounds. When technically feasible, the trend of management has shifted from major amputation to limb salvage. Furthermore, the reconstruction is not only providing adequate coverage but allowing the best possible function with minimum recurrence. By utilizing the orthoplastic approach, we can achieve these goals. The diabetic foot is one of the most difficult fields for reconstruction. With multidisciplinary and orthoplastic approach combined, the reconstructive surgeon can play a crucial part in avoiding amputation and providing an improved quality of life.

The lateral arm flap is a highly reliable and versatile fasciocutaneous flap for extremity reconstruction. The flap can be harvested in an extended fashion to include the thin skin of the proximal forearm. In the extended version, the maximum amount of skin that can be harvested from the forearm remains unknown. We performed a cohort fresh frozen cadaver dye injection study to investigate this question. A total of seventeen cadaver flap dissections were performed. Our primary goal was to capture the complete angiosome of the extended lateral arm flap, including length and width. Our secondary goal was to explore how much of the flap can be safely harvested distally, past the lateral epicondyle. The overall mean area of dye staining was 23.48±4.60 cm², which represents the angiosome of the flap. The dye traveled an average of 3.60±4.94 cm into the forearm, past the lateral epicondyle, which suggests a “safe” zone for distal flap harvest. In conclusion, the extended lateral arm flap is a versatile option for extremity reconstruction and can be safely harvested distal to the lateral epicondyle. There is likely a limit, however, to how far distally the skin paddle can extend, which can be explored in future research.

Introduction

The agonist-antagonist myoneural interface (AMI) is a surgical construct that, when incorporated into limb amputation, offers to potential to preserve or restore proprioception, augment functionality, reduce neuropathic pain and enhance overall limb stability. We here present our experience to date with AMI construction in the context of transfemoral amputation (TFA).

Methods

Patients were recruited for TFA with AMI construction at Brigham & Women’s and Brigham & Women’s Faulkner Hospital between June 2018 and June 2023. Data collection included demographic information, intraoperative parameters, clinical recovery metrics and complications. All data was then collated and analyzed.

Results

Seven TFA procedures were performed on seven patients during the study period. The operative technique employed evolved significantly over time, and included the development of both native and regenerative AMI models. Four patients were biological males (57%), and mean patient age was 42.0 ± 14.6 years. The etiology of conditions necessitating amputation included traumatic (43%), oncologic (29%), iatrogenic (14%) and congenital (14%). Mean operative time was 566 ± 97 min and average length of stay was 11.7 ± 8.4 days. Average postoperative follow-up was 2.19 ± 1.57 years (range 0.81–4.30 years). Postoperative imaging of AMI constructs demonstrated average muscle excursions of 6±3 mm, and total average limb volume preservation over time was 102 ± 14%. All patients demonstrated a complete wean from narcotic pain medications, with a mean time to wean of 86 ± 79 days. Minimal neuropathic pain was reported after the acute postoperative period. All seven (100%) of the subjects reported functional phantom limb sensation over the same time. Complications included significant soft tissue necrosis in two (29%) patients and minor wound healing issues in one (14%) patient.

Conclusions

TFA incorporating AMI construction appears to offer promising benefits similar to those previously reported in patients undergoing similar interventions at the transtibial level.

Soft tissue coverage of knee wounds can be challenging, in particular in the setting of peripheral arterial disease and knee arthroplasty complications. Options for soft-tissue coverage range from conservative wound care to invasive pedicled and free flaps. Unlike traditional wound coverage problems in plastic surgery patients, arthroplasty coverage decisions oblige surgeons to take into account the possibility of secondary orthopedic procedures. The two cases presented in this manuscript demonstrate the importance of vascular imaging, in particular angiography. In both cases, the workhorse medial gastrocnemius flap harvest could have resulted in critical limb ischemia. When secondary orthopedic revision is required at the site of the wound, angiography allows for planning of appropriate soft tissue coverage surgeries.

The role of plastic surgeons in the world of spine surgery is quickly evolving. The plastic surgeon now serves both a therapeutic and prophylactic role in addressing complications of complex and revision spine surgery. The field of Spino-plastic Surgery is characterized by the use of vascularized bone grafts (VBGs). VBGs are bone segments transferred on their corresponding muscular attachments without the inclusion of a named vessel. The bone graft is adequately vascularized through the connection of the tendon by Sharpey's fibers and their associated microvasculature. VBGs provide an autologous, pedicled tissue rearrangement option with osteoinductive properties and adequate structural support for complex spine reconstruction. VBGs are associated with a lower risk of adverse events and shorter times to fusion than allografts, and bypass the need for lengthy microsurgical anastomosis. Five types of VBGs for spine reconstruction are described in this article, including iliac crest, rib, occiput, scapula, and spinous process VBG. Virtually any vertebral level can be reached for arthrodesis using one or more of these VBGs.

Introduction

Open fractures with degloving injuries are commonly managed by serial debridements prior to definitive flap coverage in the United States (US). Some international institutions minimize the number of debridements prior to coverage. The purpose of this study was to compare clinical outcomes in patients with open tibia fractures requiring free flap coverage from institutions with differing debridement philosophies.

Methods

This was a multi-site retrospective cohort study of patients treated at two US tertiary care facilities (serial debridement cohort) and one in India (early total debridement cohort) with Type IIIB or IIIC open tibia fractures requiring free tissue transfer. The number of debridements prior to flap coverage were recorded and primary outcomes were rates of infection, non-union, and flap failure. Fischer's exact tests were used to compare outcomes between the cohorts.

Results

80 patients were included, 44 from India and 36 from the US. Patients in the serial debridement cohort underwent more debridements prior to flap coverage (mean 3.64 vs 1.84, p < 0.001) and had significantly higher rates of infection and non-union compared to patients in the early total debridement cohort (p < 0.05). There were no differences in rates of flap failure between the cohorts.

Conclusions

Patients with open tibia fractures treated at institutions favoring serial debridements underwent more debridements and had higher rates of infection and non-union compared to patients treated at a center favoring early total debridement. Serial debridements may not be necessary prior to flap coverage for open tibia fractures and the current practice should be further investigated.