Radiocarpal Joint Reconstruction with a Double Free Metatarsophalangeal Joint Transfer.

Background: Destruction of the radiocarpal and midcarpal joints causes loss of wrist motion, pain, and reduced grip strength. A novel technique for radiocarpal reconstruction is presented. Methods: Two patients who had radiocarpal and midcarpal destruction and osteoarthritis underwent reconstruction using simultaneous bilateral microvascular second metatarsophalangeal joint transfer. The insetting was performed, inverting the distal-proximal orientation of both metatarsophalangeal joints and fixing them with two 2.0 screws in proximal and Kirschner wires in distal. Results: Radiocarpal extension and flexion without pain were preserved after a minimum of 4 years follow-up. Both patients could return to recreational activities. No secondary procedures were needed. Conclusions: This technique could be an alternative for radiocarpal reconstruction, although longer follow-up and more cases are needed.

Circumferential Radical Debridement and Omental Free Flap in the Treatment of Severe Chronic Venous Ulcers.

BACKGROUND: Chronic venous leg ulcers are a significant health care burden with a difficult and unreliable treatment. Free flaps may be needed for wound coverage in severe cases. Incomplete removal of dermatoliposclerosis (DLS) area and/or not addressing the underlying venous dysfunction may contribute to the reported modest long-term results. METHODS: A series of 5 patients with severe chronic venous ulcers of the leg, resistant to conservative treatment and superficial venous surgery, were treated with radical, circumferential, subfascial resection of the DLS skin and coverage with omental free flaps. Delayed arteriovenous (AV) loops were used as recipients. All patients had previous superficial venous surgery and multiple skin grafts. Mean follow-up was 8 years (4-15 years). RESULTS: One hundred percent of flaps survived completely. No major complications occurred. One patient developed ulceration of the flap at 2 years and healed with basic wound care. At a mean follow-up of 8 years, all patients were ulcer-free. One patient died 15 years after the surgery for unrelated causes. CONCLUSIONS: Radical circumferential resection of DLS area in severe chronic venous leg ulcers and coverage with a free omental flap using staged AV loop provided durable coverage in a series of 5 patients. Complete resection of DLS area, addressing the underlying venous pathology, and draining the flap to a healthy competent vein graft (AV loop) may contribute to these favorable results.

Reconstruction of the Flexor Pollicis Longus Tendon with Vascularized Tendon with Ulnar Artery Preservation.

Reconstruction of the flexor pollicis longus tendon using staged grafting yields modest results. A modification of the pedicled vascularized flexor digitorum superficialis transfer, without division of the ulnar artery, was used in five patients. Methods: The flexor digitorum superficialis and its gliding tissue were transferred in five patients, based on a branch of the ulnar artery without division of the ulnar vessels. Functional results were evaluated using a total active range of motion and Buck-Gramko score at 10 months by an independent hand therapist. Results: The mean total active motion of the interphalangeal joint was 49 degrees, with a Buck-Gramko score of excellent in three cases and good in two. No complications were recorded. Conclusion: Reconstruction of the flexor pollicis longus tendon with single-staged vascularized FDS transfer without ulnar artery division yielded good results in a small cohort of five cases.

Monitor selection according to the defect location in the medial femoral condyle flap.

BACKGROUND: Medial femoral condyle(MFC) flap is frequently used in hand reconstruction, but like other buried flaps, MFC is not easy to monitor and follow.In this study, we present our adipofascial and periosteal tissue technical modifications and results for MFC free flap monitoring and compare different monitoring methods. METHODS: Twenty one patients with wrist bone or metacarpal defect reconstructed with MFC flap were included in the study. Adipofascial tissue in wrist defect and periosteal tissue in metacarpal defect were selected as MFC flap's monitor. Patient characteristics, type of injury, flap size, early or late-period complications, flap elevation time,satisfaction scale, visual analogue scale (VAS) and postoperative X-ray view were noted. RESULTS: There were 3 female and 18 male patients in the study. The mean age of the patients was 50.8 (38-68). The elevation times of flaps with adipofascial and periosteal monitors were 48 and 53.3 min, respectively. The satisfaction scale averages for the adipofascial and periosteal monitor groups were 3.5 and 3.54, respectively. The VAS scores of the adipofascial and periosteal monitor groups were 2.9 and 3.9, respectively. The flap sizes with periosteal and adipofascial monitors were 10.48 cm3 and 1.36 cm3, respectively. There was no statistically significant difference between flap elevation, VAS, and satisfaction scale (>0.05). There was a statistically significant difference in flap sizes. (<0.05) CONCLUSION: MFC free flap is frequently used in wrist and metacarpal reconstruction. Monitor selection according to the defect area positively affects the prognosis of the flap in the postoperative period.

Vascularized Ribs in the Treatment of Posterior Instrumentation Infection after Thoracic Vertebrectomy. Case Report.

Isolated vertebral mestastases can be successfully treated by surgical removal of the affected vertebral body and stabilization with alloplastic material. The bone union between the upper and lower vertebra is expected, yet a relatively high rate of a non-union has been reported. In case of infection, bone consolidation is altered, and removal of alloplastic material is recommended, which decreases spinal stability and is a devastating complication. This case report of delayed infection and exposure of posterior hardware after thoracic vertebrectomy without an interbody osseous union, authors present a successful treatment with vascularized rib flaps through an anterior approach followed by hardware removal.

Salvage of Devascularized and Amputated Upper Extremity Digits with Temporary Ectopic Replantation: Our Clinical Series.

BACKGROUND: One of the reasons for unsuccessful replantation is recipient site problems. In cases where proximal stump status cannot be predicted exactly, reamputation may be required depending on the result of infection and tissue necrosis. The ectopic banking method has been defined for this type of injury. In this study, we presented the amputated or devascularized upper extremity digit ectopic banking application results in our clinical practice. METHODS: Nineteen digits (17 patients) banking ectopically were included in the study. All digits ectopically banked in the forearm volar of the non-injured upper limb. Transfers were made after waiting for the appropriate time. Ectopic banking periods, postoperative complications, and other descriptive data were recorded. In the postoperative 6th month, the range of motion (ROM) values of the digits were measured and compared with the ROM values of the same digit on the non-injured extremity.Also, in the postoperative 6th month, a questionnaire with a score of 1-5 was conducted for cosmetic results. RESULTS: The mean follow-up time was 13.6 months. The mean patient age was 39.5 years. The ectopic banking success rate is 94.1% (16/17). The orthotopic/heterotopic transfer success rate is 100% (17/17). Ectopic banking time is, on average, 19.2 days (min 5-max 55). Average cosmetic scale is 3.54. CONCLUSIONS: We think that the results of our study will shed light on surgeons who make ectopic banking applications.

Unusual Late Complication of Latissimus Dorsi Free Flap Donor Site: Elastofibroma Dorsi.

In existing literature about elastofibroma dorsi (ED), no cases reported ED arising after latissimus dorsi flap harvest. Concretely, we present a patient who developed an ED at latissimus dorsi free flap donor site 10 years after harvesting. After our research, we found the occurrence of ED after thoracotomy surgery, stressing the importance of previous local trauma. Latissimus dorsi flap harvest is also a local traumatic episode, although its association with ED has not been previously reported. Thus, ED should be considered in the differential diagnosis of deep soft tissue lumps after latissimus dorsi harvest.

Arteriovenous Vascular Loop Using a Bifurcated Greater Saphenous Vein.

High-energy lower limb trauma may result in complex defects with extensive vascular damage. Free flap reconstruction in these cases may require vein grafts to reach healthy proximal recipient vessels. Vascular loops are an increasingly popular technique in managing recipient vessels in reconstructive microsurgery, especially in the lower limb. The use of an entire omega segment of the greater saphenous vein had not been described before but offered two advantages: the caliber match for arterial repair was better using one of the limbs of the omega compared with the parent greater saphenous vein, and it allowed two venous anastomoses instead of one. A case report of a fully bifurcated segment of the greater saphenous vein as a vascular loop for microvascular reconstruction in the lower limb is presented. To the best of the authors' knowledge, no similar case has been reported previously.

Facial Nerve Reconstruction with Free Vascularized Composite Nerve Flap from Intrapetrous Portion to Terminal Branches-Case Report.

The case presented here is a delayed reconstruction of a facial nerve defect after radical parotidectomy without a useful nerve stump at the stylomastoid foramen. A composite free flap was used to reconnect the nerve's intrapetrous portion to the peripheral branches and reconstruct the soft-tissue deficit.

Unique Techniques or Approaches in Microvascular and Microlymphatic Surgery.

Several methods can be used for identifying tissues for transfer in donor-site-depleted patients. A fillet flap can be temporarily stored in other parts of the body and transferred back to the site of tissue defect, including covering the amputated stump of the lower extremity. Human arm transplant is rare and has some unique concerns for the surgery and postsurgical treatment. Cosmetics of the narrow neck of transferred second toes can be improved with insertion of a flap. Lymphedema of the breast after cancer treatment can be diagnosed with several currently available imaging techniques and treated surgically with lymphaticovenous anastomosis.

Abdominal Wall Reconstruction with a Free Fibula Flap after Internal Extended Hemipelvectomy.

Major pelvic resections for malignant tumors are infrequent and have significant morbidity and mortality, for instance, incisional hernias are postoperative complications uncommonly reported probably because most cases are overshadowed by more serious complications. Reconstruction depends on the extent of the resection and overall prognosis of the patient. A case of a late complex hypogastric and femoral incisional hernia after extended hemipelvectomy for recurrent osteosarcoma treated with distal abdominal wall fixation into a free fibula flap is reported.

Treatment of Neuroma of the Dorsal Branch of the Ulnar Nerve With Transfer to the Distal Anterior Interosseous Nerve.

Painful neuromas of the dorsal branch of the ulnar nerve may be difficult to treat. Proximal transposition is the standard treatment, but pain may recur. Sensory-to-motor nerve transfer as an evolution of targeted muscle reinnervation is a recently described technique to reduce neuroma formation in the treatment of painful neuromas. This report describes sensory-to-motor transfer of the dorsal branch of the ulnar nerve to the distal anterior interosseous nerve to treat a painful neuroma.

Total Nasal Reconstruction With Prefabricated and Prelaminated Free Flap.

Nasal reconstruction is a complex staged procedure. When optimal donor areas are unavailable, flap prefabrication and prelamination techniques can be used for total nasal reconstruction. A technique of total nasal reconstruction using neovascularization of the supraclavicular skin from a skin free flap used for internal lining, along with prelamination of the cartilage framework and surgical delays, is described in 2 patients with adverse anatomical conditions.

Clinical Significance of Alloantibodies in Hand Transplantation: A Multicenter Study.

BACKGROUND: Donor-specific antibodies (DSAs) have a strong negative correlation with long-term survival in solid organ transplantation. Although the clinical significance of DSA and antibody-mediated rejection (AMR) in upper extremity transplantation (UET) remains to be established, a growing number of single-center reports indicate their presence and potential clinical impact. METHODS: We present a multicenter study assessing the occurrence and significance of alloantibodies in UET in reference to immunological parameters and functional outcome. RESULTS: Our study revealed a high prevalence and early development of de novo DSA and non-DSA (43%, the majority detected within the first 3 postoperative y). HLA class II mismatch correlated with antibody development, which in turn significantly correlated with the incidence of acute cellular rejection. Cellular rejections preceded antibody development in almost all cases. A strong correlation between DSA and graft survival or function cannot be statistically established at this early stage but a correlation with a lesser outcome seems to emerge. CONCLUSIONS: While the phenotype and true clinical effect of AMR remain to be better defined, the high prevalence of DSA and the correlation with acute rejection highlight the need for optimizing immunosuppression, close monitoring, and the relevance of an HLA class II match in UET recipients.

Immediate Versus Overnight-Delayed Digital Replantation: Comparative Retrospective Cohort Study of Survival Outcomes.

PURPOSE: Ischemia time has been traditionally considered a critical factor in replantation survival rate. The objective of this study was to compare the survival rate between immediate and overnight-delayed digital replantation. METHODS: We performed a retrospective cohort study of all digital replantations performed at our clinic between 2005 and 2016. The survival rate was compared between the immediate digital replantation group (immediate replantation group) and those that were replanted the morning after they were admitted to the hospital (overnight-delayed replantation group). The decision to delay the replant was made in cases admitted in the evening with less than 12 hours of previous ischemia time and without farm-related contamination. RESULTS: Five hundred ninety-seven digital replantations (456 patients) were analyzed. One hundred eighty-five (31%) digital replantations were performed the following day (delayed replantation group) and 412 (69%) digital replantations were performed the same day that they were admitted to the hospital (immediate replantation group). The overall survival rate was 91.9% (549 of 597). In the immediate replantation group, the survival rate was 91.2% (376 of 412) and in the delayed replantation group, the survival rate was 93.4% (174 of 185). There were no statistically significant differences between the immediate and the delayed replantation groups with respect to age, zone of amputation, or presence of multiple amputations. CONCLUSIONS: Our study suggests that overnight delay is a safe approach for digital replantation when performed by experienced microsurgeons. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.

Treatment of Hand Macrodactyly With Resection and Toe Transfers.

Macrodactyly is an uncommon congenital hand condition that can be difficult to treat and that can have a profound negative impact on patients and their families. Although many treatments have been described, results tend to be inconsistent. The authors report a case in which a combination of ray resection, partial finger resection, and toe transfer resulted in a 4-digit hand with acceptable function and cosmesis.

Salvage of Infected Nasal Reconstruction with a Polymethyl Methacrylate Spacer.

Total nasal reconstruction is a challenging multistage procedure. Infections can destroy the cartilage framework and seriously compromise the result. The use of polymethyl methacrylate with antibiotics as a spacer has been described in the treatment of skeletal infections. Using this same principle, the use of a polymethyl methacrylate with antibiotics spacer for an infected nasal reconstruction is reported in a clinical case.

Interbrachial Pinch by Trapezius Transfer in Amyoplasia Congenita: A Case Report.

Amyoplasia congenita, or "classic distal arthrogryposis," is the most common disorder among the congenital, non-progressive, multiple joint contractural conditions named arthrogryposis. The cause remains unknown, and it occurs sporadically. Abnormal neurological examination indicates that movement in utero was diminished as a result of an abnormality of the central or peripheral nervous system, the motor end plate, or muscle. The absence of central neural pathology indicates the origin in akinetic fetal condition. Three weeks are enough to cause muscle weakness and joint fibrosis. Joint contractures in amyoplasia are often rigid and refractory to nonoperative treatment such as passive stretching. Surgery is focused on each patient's need respecting adaptive maneuvers to accomplish daily tasks. We present a case in which pectoral major muscle had no strength for pinching; a trapezius muscle transfer was planned to obtain an interbrachial pinch useful for grasping.

Ulnar Head Reconstruction with Microvascular Second Metatarsal.

BACKGROUND: The distal radioulnar joint along with the interosseous ligament of the forearm and the proximal radioulnar joint, form a functionally integrated system responsible for the pronation-supination of the hand. The distal ulna, the so-called ulnar head, is an integral part of this system. Apart from its well-known role in forearm rotation, the ulnar head is essential in transverse load transmission through the distal radioulnar joint upon resisted elbow flexion. Autologous reconstruction of ulnar head would theoretically be beneficial with respect to prostheses. METHODS: Three cases of ulnar head reconstruction with microvascular second metatarsal are reported herein including trauma, oncological, and congenital ethiologies. RESULTS: The clinical result was good without complaints of instability. CONCLUSIONS: The cases included in this series, although heterogeneous, indicate that this treatment may be feasible also in postoncological resections and in congenital cases.

Composite Arteriovenous Radial Conduit Flap for Lower Limb Reconstruction.

In complex lower limb trauma, the healthy recipient vessels can be far from the defect to be reconstructed due to the usually high-energy injury sustained. The use of vein grafts, either directly or in the form of arteriovenous loops, is the usual solution in these cases. In the vein graft donor-depleted patient, other options are required; the composite arteriovenous radial conduit flap may be a useful resort in these situations.