Godina's Principles in the Twenty-First Century and the Evolution of Lower Extremity Trauma Reconstruction.

BACKGROUND: February of 2016 marked 30 years since the passing of Marko Godina, a pioneer and prodigy in the field of reconstructive microsurgery. Most noteworthy among his many contributions was his method of radical debridement of contaminated compound fractures followed by early free tissue transfer for wound closure. In the last three decades, the landscape of reconstructive surgery has undergone significant transformation owing to advances in reconstructive techniques and wound care technology, as well as new data. METHODS: Dr. Godina's work and legacy are reviewed, compared and contrasted with new and evolving data regarding lower extremity trauma reconstruction. RESULTS: Advancements in technique and technology have greatly molded lower extremtiy reconstruction over the past thirty years. Nonetheless, Dr. Godina's principles of timely care and early vascularized soft tissue coverage have withstood the test of time. CONCLUSION: Marko Godina's contribution to reconstructive microsurgery cannot be overstated and his groundbreaking work continues to serve as the foundation of lower extremity trauma reconstruction. Three decades after his seminal work, we honor Dr. Godina's legacy and explore how his principles have endured, evolved, or been replaced.

Anatomical Basis and Clinical Application of Synovial Flaps in the Wrist and Distal Forearm.

BACKGROUND: Neuropathic symptoms after median nerve repair at the wrist or secondary to refractory carpal tunnel syndrome may become debilitating. These symptoms develop because of perineural adhesions, intraneural fibrosis, and fixation of the nerve to the transverse carpal ligament after surgery, and often require neurolysis. Interposition of vascularized soft tissue over the median nerve at the time of neurolysis prevents recurrence of such adhesions. The synovial flap, fashioned from the synovial lining of the flexor tendon sheath, is an ideal tissue for this purpose. Previous authors have described the surgical technique of the synovial flap, but the anatomical basis and design of the flap have not been previously discussed. METHODS: Twenty fresh cadaver upper extremities were injected with Microfil to analyze the arterial anatomy, flap dimensions, and arc of rotation of the flexor tendon synovium mobilized as a flap suitable for coverage of the median nerve at the wrist. The authors determined that both radial and ulnar-based flaps are clinically useful for providing coverage in the wrist and distal forearm. This flap was used in 18 patients with complicated median nerve lesions in this region. RESULTS: All patients had an uncomplicated postoperative course. Of 13 patients treated for posttraumatic median nerve neuromas, all but two had significant resolution of symptoms. CONCLUSIONS: When used as a vascularized flap, the flexor tendon synovium provides adequate protection of the median nerve. Flap dimensions and vascularity of this tissue make it an ideal local flap option when performing reoperative surgery on the median nerve.

Achilles tendon lengthening: friend or foe in the diabetic foot?

BACKGROUND: Literature in the past decade has shown that Achilles tendon-lengthening surgery in addition to total contact casting decreases the rate of plantar ulcer recurrence in the forefoot and midfoot; however, the risk of heel ulceration or recurrent equinus deformity with new forefoot or midfoot wounds is not insignificant. The purpose of this study was to compare the rate of recurrent ulceration between the patient groups who have undergone soft-tissue repair of diabetic forefoot or midfoot wounds either with or without concomitant Achilles tendon-lengthening surgery. METHODS: All diabetic patients with plantar forefoot or midfoot ulceration who underwent soft-tissue reconstruction during two different time periods-from 1983 to 1991 or from 1996 to 2004-were reviewed. Multiple patient-related factors were compared. The "early group" consisted of 179 wounds in 149 patients who underwent wound closure surgery alone. The "later group" included 145 wounds in 138 patients who underwent similar wound closure procedures with the addition of Achilles tendon-lengthening surgery. RESULTS: Twenty-five percent in the early group and 2 percent of patients in the later group developed recurrent ulceration requiring reoperation, which resulted in 94 percent relative risk reduction (p < 0.001), whereas the risk factors and demographic data were similar in each group. In addition, 12 percent in the early group and 4 percent of the later group developed transfer lesions (p < 0.001). CONCLUSION: If one avoids excessive Achilles lengthening, the addition of an Achilles tendon-lengthening procedure can significantly reduce the risk of recurrent diabetic foot ulcerations. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

History of breast reconstruction.

The treatment of breast cancer has evolved significantly from the original surgical technique described by Halsted. The reconstruction of the breast has also been a large interest among surgeons and patients. The history of breast reconstruction dates back to the 1800s with an attempt to transplant a lipoma to a mastectomy site. Several techniques ranging from the "walking flap" of Gilles to the free perforator flap using autogenous tissue for recreation of a breast "mound" have been established and refined. The use of tissue expanders for breast reconstruction has also been perfected over the last three decades. Breast reconstruction, which was once admonished in the early part of the 20th century, has now become a routine choice for women undergoing breast cancer surgery.

Effects of University of Wisconsin and lactated Ringer's solutions to ischemia-reperfusion injury in isolated cremaster flap.

Ischemia-reperfusion (I/R) injury is a topic that has been much-discussed by various researchers during the last decade in plastic surgery. Though much progress has occurred, the problem is not totally solved yet. In particular, the pathophysiology of reperfusion injury in skeletal muscle has not been clearly elucidated. The aims of this study are to assess the effects of a variety of perfusants on the microcirculation after reperfusion injury and to better understand the pathophysiology of reperfusion injury. Isolated cremaster flaps were performed in 44 rats, preserving the femoral artery and vein in order to cannulate with microtubes. There were 2 control and 2 experiment groups. In one of the control groups and in both experimental groups, 2 h of ischemia were applied by clamping the iliac vessels. Immediately after this, the muscle was locally perfused and washed with lactated Ringer's (LR) and University of Wisconsin (UW) solutions, given from the femoral artery and drained by the femoral vein in the two respective experimental groups. The effects of these solutions to I/R injury were shown at the microcirculatory level via measuring and determining preischemic and postischemic diameters of arterioles and venules, tissue perfusion, capillary density, velocity of red blood cells, and leukocyte sticking. Both tested perfusion solutions were found to be harmful in all parameters. This study demonstrates that both LR and UW solutions aggravate I/R injury.