Orthoplastic Surgery最新文献

Background

Extremity amputation due to traumatic or oncologic etiology in the pediatric population confers reduced quality of life, psychosocial trauma, and chronic pain in the form of neuroma, and residual and/or phantom limb pain. Several techniques have been described with inconsistent efficacy, yet little is available prophylactically. The advent of targeted muscle reinnervation (TMR) has shown to have strong outcomes for this purpose in adults, affording aberrant nerves an adequate growth path. This study aims to describe our experiences with using TMR in a previously undescribed pediatric cohort.

Methods

TMR consisted of isolation of major residual nerves following surgical amputation. Residual nerves undergo microsurgical coaptation to motor nerves innervating remaining regional stump-muscles. Patients are followed post-operatively for development of pain and prosthetic usage.

Results

Two subjects were identified. The first was a 17-year-old female who suffered from fulminant liver failure and subsequent bilateral lower extremity necrosis necessitating bilateral below knee amputation (BKA). She concomitantly underwent TMR to both limbs. The second was a 12-year-old male with Ewing's sarcoma of the femur who previously underwent femoral resection and allograft/autograft reconstruction. On recurrence, above knee amputation (AKA) was conducted with concomitant TMR. On 16- and 12-month follow-up, respectively, both patients demonstrate use of prosthetic devices and report no pain, without the usage of pain medications.

Conclusion

TMR is feasible in the pediatric population. This intervention may warrant consideration in pediatric patients who are undergoing amputation for a variety of etiologies and can effectively serve to mitigate risk of neuroma formation and residual or phantom limb pain.

The authors report targeted muscle reinnervation (TMR) in an 11-year-old male who sustained a trans-radial amputation of the right upper extremity in an ATV accident. A combination of targeted muscle reinnervation, external tissue expansion, and free muscle transfer allowed us to preserve elbow function, prevent neuroma formation, and allow for the future use of a myoelectric prosthetic. The use of TMR in pediatrics leverages the enhanced cortical plasticity of younger patients to improve outcomes and quality of life following traumatic injury, limiting the otherwise significant financial and psychosocial impact of amputation. This report offers the first account of TMR performed on a pediatric patient with no neuroma formation or phantom limb pain.

Background

Effective treatment and rehabilitation of complex hand injuries are often challenging. Various corrective techniques and approaches have been proposed for the first web space contractures based on a classification system, however, consensus regarding optimal management does not exist.

Method

In this study, we evaluated twelve consecutive patients with the mean age of 46.72 years who underwent first web space dilatation using Ilizarov mini fixator from 2009 to 2020. The tip length during radial/palmar abduction and radial/palmar abduction angles were measured preoperatively, after instrumentation, and in the last follow-up.

Result

The average thumb-index finger distance during Passive Radial Abduction (PRA) increased from 4.3 to 9 cm, and the distance during Passive Palmar Abduction (PPA) decreased from 10.2 to 9.22 cm, the average passive radial abduction angle (PRAA) of the first web space increased from 21.6 to 58.3°, Active Radial Abduction Angle (ARAA) from 20.0 to 49.7°. The average Passive Palmar Abduction Angle (PPAA) increased from 32.5 to 59.1°, and Active Palmar Abduction Angle (APAA) from 30.9 to 47.7° after using Ilizarov mini fixator.

Conclusion

Ilizarov mini fixator provides promising outcomes with the optimal range of motion in severe first web space contractures.

Introduction

Revision amputation remains an important consideration in the management of severely crushed or contaminated finger injuries. The duration and type of antibiotic usage in revision amputations vary greatly among providers. This study sought to elucidate the role of antibiotics in revision amputations performed in the emergency department.

Methods

A retrospective review of all patients who underwent revision amputations by the plastic surgery division in the emergency department was performed.

Results

150 patients with 190 digit amputations met the inclusion criteria. 136 patients (91%) received antibiotics at the time of revision amputation. 61 (41%) received a single dose of IV antibiotics alone, 24 (16%) received a course of outpatient oral (PO) antibiotics, and 51 (34%) patients received a combination of a single dose IV and a course of outpatient PO antibiotics. There was an 12% complication rate and a 4% infection rate. There was no significant difference found in the rates of infection across antibiotic groups.

Conclusion

For performing revision amputation in the Emergency Room setting, the best treatment would be meticulous debridement, irrigation, and closure of the wound. We recommend a single dose of IV antibiotic for prophylaxis, except for cases involving mammalian bite wounds.

Introduction

Targeted Muscle Reinnervation (TMR) has been shown to prevent and treat neuropathic pain as well as enhance bioprosthetic function. A paucity of data and anatomical description exist regarding TMR in the setting of proximal amputations at the level of the brachial plexus region. In this work, the technique and anatomical description of TMR for proximal amputations at the shoulder level and above, with the corresponding brachial plexus nerve transfers and reconstruction, will be described as an anatomic reference and operative guide.

Methods

Cadaveric dissections of four shoulder and forequarter level amputations were performed. Major mixed motor and sensory nerve branches were identified, dissected, and tagged. Amputated peripheral nerves were then transferred to identified and labeled target motor nerves within the shoulder and chest levels via direct end-to-end coaptations per traditional TMR technique. A retrospective review was completed by our multi-institutional team including clinical case correlates for TMR performed at the described levels.

Results

A total of 8 TMR brachial plexus clinical cases were performed between 2016 and 2020 in a primary or secondary setting following oncologic resection or traumatic injuries. Follow-up ranged from 18 to 58 months, mean follow-up of 34.6 months. Six out of 8 patients require no narcotics, while 2 require supplemental narcotic use. One patient requires no pain medication. Four of the 7 patients utilize an EMG enhanced bioprosthetic. The eighth patient died from tumor recurrence.

Conclusions

Technical considerations for brachial plexus TMR surgery have been outlined with early follow-up data showing beneficial pain control and prosthetic outcomes.

High energy trauma injuries in the lower extremity represent unique challenges to surgeons and often involve complex, limb threatening wounds with extensive soft tissue and bone loss. In this case report, we present a case of a 20 year old male who was presented to us with a history of 8 months old high impetus road traffic trauma which resulted in multiple open fracture of the midfoot with ipsilateral closed tibial - fibular shaft and medial malleolar fracture. Open midfoot injury with severe bone loss included complete loss of navicular, all three cuneiforms, base of 1st and 2nd metatarsals. For reconstructing this severe midfoot defect, we have utilized a titanium mesh cage which is routinely used in spinal surgeries. This innovative technique and orthoplastic approach has given the patient a stable plantigrade foot with a near normal midfoot biomechanics and ultimately, restoration of this patient's quality of life.

Background

Low-grade central osteosarcoma usually exhibits a long course with nonspecific symptoms, while the imaging and histological findings may be easily confused with a variety of benign fibroosseous lesions.

Materials and methods

A 15-year-old boy was referred for a painless swelling of the proximal phalanx associated with shortening of the right hallux. A benign cystic bone lesion complicated by a pathological fracture had been diagnosed on the radiographs at 8 and 10 years of age after sport injuries. He was referred for evaluation and treatment of the bone lesion. Magnetic resonance imaging and computed tomography were performed. A referral centre was contacted, since there was a strong evidence of malignancy. An open biopsy was suggested, which indicated bone malignancy. The patient was then referred to the specialized tumor centre. A new biopsy was performed there, since the previous sampling was considered insufficient or inadequate to secure a differentiation from fibrous dysplasia. It ensured the diagnosis of low-grade central osteosarcoma. Radical excision of the proximal phalanx and reconstruction of the defect with an iliac graft associated with arthrodesis of both the hallux metatarsophalangeal and interphalangeal joints was the treatment of choice. Disturbed wound healing necessitated hardware removal 4 months postoperatively. No further interventions were required in the follow-up.

Results and conclusion

Clinical and radiographic evaluation at 12 years confirmed no evidence of local recurrence or distant metastasis. The patient was satisfied with the final outcome and reported unrestricted participation to physical activities and sports.

Introduction

Mohs micrographic surgery (MMS) can clear oncologic margins and minimize tissue resection to limit morbidity in difficult anatomic areas such as the hand. We evaluated clinical and patient-reported outcomes of patients undergoing MMS with reconstruction for squamous cell cancer (SCC) of the hand and wrist.

Methods

Patients undergoing MMS with reconstruction for hand or wrist SCC from 2006 to 2018 at the University of Pennsylvania were identified. Demographic, disease, and treatment data were analyzed. Post-intervention upper extremity function was measured with the PROMIS-UE survey.

Results

424 patients with 615 surgeries met inclusion criteria, with 173 completed surveys. Mean age was 73.9 ± 11.8 years. 97.4% of lesions were located dorsally, most commonly on the hand (65.4%). Mean defect size was 4.85 ± 7.8 cm². Most defects were reconstructed by complex closure (53.8%) and secondary intention (22.4%). Complications were seen in 8.0%, and most commonly included dehiscence (4.7%) and surgical site infection (2.0%). For 262 patients with at least 1-year of oncologic follow-up (mean 3.9 ± 2.7 years), cancer recurrence rate was 3.8%. Mean T-score for PROMIS-UE was 52.9 ± 7.9, indicating function within normal population limits.

Conclusions

Mohs surgery with subsequent reconstruction for hand and wrist SCC has low risk of complication and recurrence and good preservation of hand and upper extremity function.

Bone development is a sequence of coordinated events that eventually forms the skeleton. The regenerative capacity of bone is preserved through adulthood. After injury, bone can be restored to its functional and homeostatic state. Orthopaedic surgeons take advantage of this regenerative potential in procedures such as distraction osteogenesis where a low-energy fracture is created followed by distraction at a controlled rate to form new bone. This review uses the fundamental elements of distraction osteogenesis to understand the molecular pathways underlying skeletal development harnessed during injury and orthopaedic surgery to regenerate bone. We highlight the developmental origins of the axial skeleton with an emphasis on the molecular signals driving the bone development. Additionally, we discuss the role of major signaling pathways during bone regeneration and highlight how bone regeneration recapitulates skeletal development. Although other pathways exist for this phenomenon such as anoxia, these pathways function during distraction osteogenesis has not been delineated from a basic science perspective. Finally, we review the four components of distraction osteogenesis that facilitate bone regeneration specifically outlining the best practices for tibial distraction.