Orthoplastic Surgery最新文献

Purpose

We report our technique, graft reposition flap for fingertip injuries with bone and nailbed loss.

Methods

We reconstructed Allen's IV fingertip amputations in 25 patients between 2015 and 2019. The graft reposition flap technique involves reattaching the amputated stump (distal phalanx, free nailbed graft) with Kirschner wire. In addition, we reconstructed the volar defect with cross finger flap, thenar flaps, first dorsal metacarpal artery-based flap, volar V–Y advancement flap, and antegrade homodigital flaps.

Results

The mean follow-up was 25 months. (Range, 12–36 months). We classified the results based on nail aesthetics, finger length, pulp pad, bone consolidation, cosmesis, sensation, pain, range of motion, grip strength, and return to work. Excellent or good results were achieved in 20 cases. Three cases had fair results, and 1 had poor results. We observed partial flap necrosis (n = 1), exposure of distal phalanx (n = 1), hook nail (n = 1) and absent nail (n = 1)

Conclusions

This method is simple, reliable, and effective for restoring Allen's type IV fingertip amputation. This technique can be performed efficiently by surgeons in rural and urban hospitals lacking microsurgical expertise. It is an excellent alternative option for replantation.

Combined upper extremity injuries involving both bone and soft tissue destruction are commonly referred to as “mangled hands”. These injuries often involve a twisting or crushing mechanism or are the result of a high energy trauma, and their reconstruction requires a knowledge of both advanced orthopedic and plastic surgery techniques – the epitome of an orthoplastic approach. In this review, we outline 10 decisions and technical steps to optimize the outcomes in these complex injuries. Specifically, we discuss why the integrity of the soft tissue envelope, or lack thereof, predicates our algorithm with regard to limb salvage and reconstruction.

Introduction

Thoracic outlet syndrome (TOS) has many controversies that include nomenclature, etiology, diagnosis, treatment and surgical approach. The aim of this article is to give a comprehensive review of our experience of treatment of TOS for more than 35 years.

Materials and methods

From 1985 to 2021, a total of 100 TOS patients were treated and 114 surgeries were performed. They all had decompression surgeries for their compression neuropathy in the thoracic outlet with at least one year postoperative follow-up. Fourteen patients were bilateral TOS, undergoing bilateral TOS surgeries. Preoperative evaluation covered “TOS Examination Sheet” and imaging studies MRI and CT. Diagnosis was confirmed by intraoperative findings. All had near-total resection of the anterior scalene muscle and the first rib. Additional structual abnormalities were treated at the same time. The operative time was typically 2–3 h.

Results

Major postoperative complications were rare. Nearly all patients (96%) experienced significant symptoms and signs relief after a period of clinical follow-up and rehabilitation.

Conclusion

TOS is a real clinical entity. Once the preoperative diagnosis is made, conservative treatment is followed but failed, decompression surgery with extensive resection of anterior scalene muscle and the 1^st rib, and any other structural abnormalities is recommended to resolve the problems. Long-term postoperative follow-up is crucial and important to resolve the residual problems. Our result carries a 96% success rate with a favorable benefit:risk ratio.

Background

Nonunions after complex upper extremity injury in young adults may result in diminished function, pain and decreased quality of life. The use of vascularized bone flaps is challenging. However, it offers the most bone healing stimulating properties in revision surgery.

Cases

First, we describe the case of a young man with complex open wrist injury. He developed an osteoarthritis of the wrist, with abundant bone loss of the distal radius, ulna and carpal bones. He underwent wrist arthrodesis with the use of a vascularized iliac crest bone flap. Secondly, the case of a young woman is presented following a 4-part luxation fracture of the proximal humerus. She developed a nonunion with concomitant avascular necrosis. A reconstruction with plate fixation and a vascularized fibula flap was performed.

Discussion

In our cases, the use of vascularized autologous bone flaps resulted in union and a good clinical outcome. In literature, scarce evidence is present on the indications, procedure specifics, complications, clinical outcome, and patient related outcome measurements of the use of vascularized bone flaps for posttraumatic bone defects of the upper limb. This is likely due to the heterogeneity and scarcity of the patient population.

Conclusion

The use of vascularized bone flaps is a viable treatment option for patients with complex nonunions of the upper extremity.

High-energy hand trauma damaging bone and soft tissue often leads to amputation. Thumb loss leads to significant disability and decreased quality of life. A variety of options exist to preserve or restore thumb function, but many are not viable when significant bone and overlying soft tissue are lost. In this case report, we present a case of a 30-year-old warehouse worker who suffered a gunshot blast injury to the hand, destroying his metacarpophalangeal joint and overlying soft tissue. Initially this was repaired at an outside hospital with a nonvascularized bone graft and no definitive soft tissue coverage that subsequently became infected. Free fibula osteocutaneous flap reconstruction prevented amputation and restored form and function to the thumb. Implementing an orthoplastic approach resulted in thumb salvage and restoration of this patient's quality of life.

Purpose

This study represents an effort to examine the national eligibility of patients who would benefit from lower extremity (LE) targeted muscle reinnervation (TMR) in the United States. The objective of this study is to quantify and characterize the patient population eligible for LE TMR.

Methods

Using the National Inpatient Sample database from 2008 to 2015, patients undergoing lower extremity amputations were identified by ICD-9 diagnosis code. Differences in patient-level demographic parameters and hospital-level factors were compared using descriptive statistics.

Results

Over the study period, a weighted total of 369,717 patients met inclusion criteria, representing an annual mean of 46,214 patients per year. 214,756 patients underwent below-knee amputation, and 150,634 underwent above-knee amputation. Patients were predominantly male (63%), from the south (47.4%), and of the lowest income quartile (38.8%). Younger patients were more likely to be privately insured (44.1%) or on Medicaid (44.1%), while older patients were predominantly on Medicare (89.4%). Peripheral vascular disease affected 45.5%, 51.3%, and 52.0% of patients in the sixth, seventh, and eighth decades of life respectively. Black patients also made up 26% of amputations despite only composing 13% of the overall population.

Conclusions

At least 46,214 patients per year present a population that would possibly benefit from TMR, with about half of those with peripheral vascular disease. In addition to the high prevalence of vascular disease, low-income, minority individuals are disproportionately affected by LE amputation.

Shoulder arthrodesis is generally considered a last resort procedure for patients with refractory shoulder pain or instability due to brachial plexus injuries, arthritis, trauma, or following resection of a neoplasm. Failure of a shoulder arthrodesis is thus a devastating and highly challenging complication with limited salvage options. Various factors may inhibit bone healing including inadequate fixation, poor bone stock, and poor bone surface preparation [1]. For effective bony fusion, vascularized bone stock is preferential to promote osseous regeneration [[2], [3], [4]]. Patients requiring shoulder arthrodesis have often undergone multiple procedures to the glenohumeral region rendering the area relatively devoid of normally perfused tissue. There are multiple adjuncts to encourage bone regeneration. Among the more effective options is transfer of vascularized tissue to the site. Here we present a patient with chronic pseudoarthrosis following shoulder arthrodesis and multiple attempts at revision. Given a lack of vascular recipient options, a pedicled osteofascial flap from the scapula was performed to introduce vascularized bone to the joint.

Introduction

Tibia fractures are a common fracture of the lower extremity that pose increased risk for vascular injury. The clinical relevance of vascular injury, including particular vessel and number of vessels injured, remains ambiguous. In this study, we evaluate the effect of arterial injury on orthopaedic outcomes for patients with tibia fractures, while identifying trends in fracture characteristics, fixation, and plastic surgery intervention.

Methods

This single-center retrospective cohort study performed at an academic level I trauma center included 61 patients with 62 tibia fractures undergoing computed tomography angiography (CTA) from 2010 to 2019. Patients were stratified by presence (n = 26) and absence of arterial injury (n = 36) with an average age of 43.6 years (74.2% male) and no differences in patient demographics or comorbidities. Primary outcome measures included delayed- or non-union, amputation, compartment syndrome, infection, revision fixation, and time to full weight bearing (FWB). Fracture characteristics, fixation methods, and plastics interventions were also recorded.

Results

Patients with arterial injury had higher rates of open fracture (73.1% vs 44.4%, p = 0.025), infection (46.2% vs 25%, p = 0.042), and delayed- or non-union (42.3% vs 13.9%, p = 0.012). No differences were identified for revision fixation (p = 0.233), compartment syndrome (p = 0.196), amputation (p = 0.093), time to FWB (143.4 vs 109.4 days, p = 0.911) or plastic surgery intervention (p = 0.05).

Conclusions

Arterial injury in patients with tibia fractures is associated with higher rates of open fractures and increased risk of infection and delayed- or non-union. Higher-powered studies are required to better characterize the association between arterial injury in tibial fracture and clinical outcomes.

Background

Chronic lateral epicondylitis can be a painful and functionally limiting condition of the elbow. Non-operative and standard surgical treatment results can vary. Moreover, outcomes for patients who have failed previous surgical treatment are limited. We report our experience using the anconeus muscle flap transfer in comparison to standard surgical treatment and report our clinical results.

Methods

We performed a retrospective case series of 19 patients with chronic lateral epicondylitis and failure of previous treatments that were managed with anconeus muscle flap transfer. There were 11 males and 8 females, with a mean age of 44 years (range 19–72); 13 were on the right side and 6 on the left. The average time from diagnosis to the surgical procedure was over 1 year (1–10 years) and the average follow-up period was 3.7 years (1–14 years).

Results

The average pain preoperatively was 6.61 and decreased postoperatively to 1.89 (range 0–10) (P < 0.0001). Complete flexion, extension and rotation of the elbow were present in all patients except one with a 5° extension lag. The average muscle strength was 4.5/5 and grip strength almost equivalent to the contralateral arm. No infection or other postoperative complications were observed. Patients were evaluated using the Roles and Maudsley score and demonstrated excellent results for 14 patients, good for 4, and poor for 1. The average time for return to work was 2.8 months (1–7 months). Ninety-five percent of patients were satisfied with the flap transfer and pain improvement.

Conclusion

The anconeus muscle flap transfer is a safe and acceptable procedure providing satisfactory results for chronic lateral epicondylitis of the elbow. This procedure can be useful for treating patients with continued pain after previous standard surgical release.

Purpose

We sought to identify preoperative wound characteristics associated with a higher risk of adverse outcomes in patients undergoing lower extremity (LE) reconstruction with microvascular free flaps.

Materials and methods

A retrospective review of patients undergoing free flap reconstruction of the LE at a single academic institution between 2010-2021 was conducted. Preoperative wound culture results were classified by Gram stain, aerobe status, multi-drug resistance (MDR), and presence of multiple bacteria. Outcomes studied included flap viability at 60, 120, and 180 days, as well as flap dehiscence, partial and full necrosis, sepsis, and amputation.

Results

A total of 218 LE free flap reconstructions were performed during the study period. 152 (69.7%) of patients were male. Rate of secondary amputation following attempted limb salvage was 4.6%. LE reconstructions utilized either fasciocutaneous (79.4%) or muscular flaps (20.6%). The type of free flap used for reconstruction had no effect on reconstructive outcomes or flap viability. Preoperative bacterial wound cultures were obtained in 102 (46.8%) patients; 80 cultures (78.4%) were positive for bacterial growth. Of these, 33 (41.2%) grew Gram-positive bacteria, 14 (17.5%) grew Gram-negative bacteria, and 33 (41.2%) grew multiple organisms. Positive preoperative wound culture was independently associated with flap failure at 120 days (p = 0.04) when compared to wounds with no infection. Among patients with positive cultures, polymicrobial infection was significantly associated with higher rates of amputation (p = 0.04) compared to single Gram-positive or Gram-negative infectious agents.

Conclusion

Identification and management of positive wound cultures may play an important role in outcomes of microvascular free flap reconstruction.