Orthoplastic Surgery最新文献

Scapulothoracic dissociation, particularly in combination with open fractures of the shoulder girdle, can be associated with significant soft tissue injury and present challenges with coverage and fixation. A single case of an open scapulothoracic dissociation was reviewed. Case presentation, clinical course and initial outcomes are discussed. A 22-year-old patient presented with an open left segmental clavicle fracture, sternoclavicular dislocation and scapulothoracic dissociation after being ejected in a motor vehicle collision. The shoulder girdle was initially stabilized with trans-clavicular trans-manubrial plating followed by staged pedicled rotational rectus abdominis flap. Follow-up at 1 month revealed well healed wounds and 90 degrees of forward flexion. Patients with open fractures and scapulothoracic dissociation can present multiple challenges when considering fixation and soft tissue coverage. A viable option in these patients is a pedicled rotational rectus abdominis flap when more typical coverage options are precluded from associated injuries.

Purpose

This study compares the anterior deltopectoral and posterior approaches described for shoulder function outcomes in upper brachial plexus injuries.

Methods

A prospective study divided the upper brachial plexus injuries into two groups based on the surgical approach (anterior deltopectoral and posterior) in 46 patients. The age at the time of injury, delay in surgery, operating time, and postoperative motor recovery time was noted. The functional outcome assessed by the Medical Research Council (MRC grade) and range of shoulder movements were compared and statistically analyzed between these two groups.

Results

The age at the time of injury, delay in surgery, surgical approach, motor recovery time had no significant impact on the functional outcome (p > 0.05). The double nerve transfer for the shoulder achieved M4 and M5 grade abduction and a good to an excellent range of motion in both groups. However, there were no differences in the postoperative MRC grading and shoulder range of movements between these two groups. But the operating time was significantly reduced in the anterior approach (P < 0.05) for C5,6 brachial plexus injuries.

Conclusions

The anterior deltopectoral and posterior approaches efficiently restore shoulder abduction and range of movements in upper brachial plexus injuries. Targeting the second segment of the axillary nerve (anterior and posterior branch), access to multiple donors, and reduced operating time are the advantages of the deltopectoral approach.

Level of evidence

IV

The gastrocnemius muscle flap remains a workhorse for lower extremity reconstruction. It provides ample vascularized tissue, is extremely reliable, and can be dissected with ease. However, conventional flap harvest requires additional incisions which increase morbidity. Endoscopic techniques have been described in the harvest of various muscle flaps but none have yet described an effective, minimally-invasive technique for medial gastrocnemius muscle harvest in a clinical case. We present a minimally invasive technique for the harvest of a medial gastrocnemius muscle flap without additional incision, thereby minimizing donor site morbidity and cosmetic deformity.

The free vascularized osteocutaneous flap from the medial femoral condyle is an attractive option for limb salvage given its low donor morbidity site and reliable vascular supply. Its use was originally described for the use of nonunions with small bony defects and has shown reliable results for a variety of reconstructive needs.

We present a case of a female patient who underwent two free vascularized corticoperiosteal medial femoral condyle grafts to her right ulna during two separate surgeries for treatment of consecutive ulnar shaft nonunions. The patient had a prior malignant soft tissue tumor resection of her forearm followed by chemotheraphy and radiation, which presented unique challenges during their course of limb salvage. Six months after the most recent procedure, the patient has a functional limb and no evidence of nonunion on imaging.

Introduction

Surgical site infection is low following endoscopic carpal tunnel release (ECTR), yet antibiotic prophylaxis is still common in these procedures. This study piloted a randomized, double-blind, placebo-controlled study design at a community hospital to generate discourse in support of discontinuing antibiotic prophylaxis in ECTR procedures.

Methods

Patients undergoing dual-incision endoscopic carpal tunnel release at a single community hospital between May 1, 2018 and December 31, 2020 were enrolled in a pilot study. Subjects were randomized to prophylactic antibiotics or placebo saline solution arms. Infection rates and complications were compared. Study workflow processes were streamlined to facilitate eventual study duplication at additional sites.

Results

One hundred twenty-four subjects (140 hands) were included in the final analysis. No subjects in either study arm sustained an infection. The race and ethnic distributions of the study sample closely resembled those of the census-reported community distributions. Implementing a randomized, double-blind, placebo-controlled study at a community hospital presented numerous challenges.

Discussion

Although statistical nor clinical significance could be established in the absence of infection, these results validate what is presently known regarding the low likelihood of infection in clean hand surgery and demonstrated the feasibility of designing and implementing methodologically sound research in a community setting.

Conclusion

Duplicating this study design at additional research sites can provide the level of evidence necessary to discourage unnecessary prophylactic antibiotic administration in clean hand surgery.

Introduction

Primary closure of large flap donor sites is a well-recognized challenge for reconstructive surgeons. At our institution, we have implemented a novel donor site closure strategy that enables single stage primary closure of large fasciocutaneous flaps while minimizing the morbidity, pain, and inconvenience associated with previously established donor site closure techniques. This strategy utilizes a continuous external tissue expansion (CETE) device to offload tension from a taut primary flap closure by generating progressive laxity in the surrounding soft tissues over the course of approximately one week.

Materials and methods

A retrospective review of fasciocutaneous flap reconstruction cases between October 2017 and July 2021 at a single institution in which donor site closure was performed through high-tension primary closure with CETE tension-offloading.

Results

Seventeen patients underwent high-tension primary closure offloaded with continuous external tissue expansion. Average flap width was 9.0 cm (range 7–11 cm). Average duration of the CETE device use was 6 days (range 1–9 days). Primary donor site wound closure was successfully achieved without complication using this strategy in 15 of 17 patients.

Conclusions

Continuous external tissue expansion tension-offloading of high-tension flap closures is a practical means for achieving single stage primary closure of large fasciocutaneous donor sites that can be applied across a wide range of flap harvest sites. The modified technique described here represents a simpler and less morbid strategy for large fasciocutaneous flap closures than the currently accepted alternatives.

The choice of which surgical dressing to use is an important step in the postoperative care of orthopaedic patients. This decision is influenced in part by the patient's level of activity prior to surgery, medical history, wound classification, and cost. As orthopaedic wounds are inherently complex, often overlying bony prominences, it is imperative that orthopaedic providers are aware of the dressings available and how best to deploy them.

Classified into three categories (passive, active, and interactive), orthopaedic surgical dressings can vary based upon their mechanism of action, absorptive capacity, and ability to provide wound protection. Through the activation or promotion of one of the four stages of wound healing, orthopaedic surgical dressings act to optimize postoperative wound care, leading to improved patient outcomes and a decrease in associated complications.

The combined use of multiple dressings, with varying attributes, provides the ultimate method for obtaining the ideal orthopaedic surgical dressing. Choosing the appropriate dressing and subsequent care regimen can prevent unnecessary hospitalizations and additional costs associated with complex wound care. Future prospective trials aimed at evaluating specific dressings and their utility in orthopaedics is warranted.

Introduction

Re-implantation of a severed body part is a demanding procedure that requires consolidated surgical efforts. Many factors influence the outcome, amongst them being availability of re-implantation team and necessary support structure. There is paucity of data on the management and outcome of the severed extremities in many resource constrained settings especially in Africa.

Objective

To determine clinical presentation and outcomes of patients offered re-implantation after cut extremities.

Patients and methods

We carried out a prospective cohort study of patients presenting with cut extremities managed by re-implantation in our center between January2018 and December 2019. Variables determined included anatomical locations, ischemic time, length of surgery, grafts utilized and outcome.

Results

A total of 11 patients with 12 cut extremities requiring re-implantation were managed at Kenyatta National Hospital during the period of our study. The age range was six to forty five years. Majority were male [11] with only one female. Most injuries involved the upper limb (11 patients) with one the lower limb. The mean ischemia time was 13.3 h. Ten patients required venous or arterial grafts during the surgery. The overall success rate was 71% for the re-implantations. The functional recovery varied from fair to good in all the patients whose limbs were saved.

Conclusion

Re-implantation surgery is a viable option in many countries with limited resources. Determinants of success rate include multidisciplinary team approach as well as motivation and necessary experience in microsurgery. Post-operative follow up is critical for functional outcome.

A knee dislocation associated with a popliteal artery injury often result in an amputation if there is a delay in diagnosis and treatment. The recommended protocol is early diagnosis with angiography followed by immediate revascularization. We report a patient who presented with a fracture dislocation of the knee with an ischemic limb 4 h after a road traffic accident. At presentation, he had a fixed equinovarus deformity of the foot. He underwent immediate revascularization and fasciotomy. The equinovarus deformity persisted after revascularization despite stretching, traction and partial excision of ischemic soleus and tibialis posterior muscles. The foot deformity gradually improved over the next 36 h, however he required multiple debridement due to extensive ischemia of deeper muscles and eventually underwent an above knee amputation. This presentation of limb ischaemia with a fixed equinovarus deformity followed by relaxation is similar to what is seen in ‘Rigor Mortis’, that is rigidity followed by relaxation. We were unable to find any similar reports in literature. We feel that this presentation suggests severe ischemia with irreversible muscle injury, and it is preferable to proceed with primary amputation instead of attempting revascularization.

The anatomy of gracilis muscle flap pedicle and its dissection technique are well described in the literature, although dissecting its most proximal portion is technically challenging, because of the deep location and the tension in the adductor muscles posed by the harvesting position. Some modifications have been described to facilitate proximal pedicle dissection, mainly combining approaches below and above the adductor longus muscle. Throughout his experience in several hundreds of gracilis free functioning muscle transfers, the senior author has found one maneuver particularly useful in deep pedicle dissection with minimal or no need for assistance.