The Effect of Preoperative Gender-Affirming Hormone Therapy Use on Perioperative Adverse Events in Transmasculine Individuals Undergoing Masculinizing Chest Surgery for Gender Affirmation.

BACKGROUND: Many providers require cessation of gender-affirming hormone therapy (GAHT) for transgender patients prior to undergoing masculinizing chest surgery (MCS) due to concerns about increased adverse events in the presence of exogenous hormones. Evidence has suggested that continuation of GAHT for certain patients may be safe for gender-affirming procedures. OBJECTIVES: The aim of this study was to compare adverse event rates for GAHT cessation vs GAHT continuation in patients undergoing MCS. METHODS: This multicenter, retrospective study included patients at the Cleveland Clinic and MetroHealth System who underwent MCS between 2016 and 2020. RESULTS: There were 236 patients who met the inclusion criteria. Of these, 172 (72.9%) discontinued testosterone GAHT prior to surgery and 64 (27.1%) continued the therapy. Mean [standard deviation] age at surgery was 25 [8] years, and mean BMI was 29.5 [6.6] kg/m.2 The median duration of testosterone therapy was 18 months (range, 0-300 months). There was no significant difference in tobacco use (P = 0.73), diabetes (P = 0.54), thrombophilia (P = 0.97), or history of thromboembolism (P = 0.39). Most patients underwent the double-incision free nipple graft technique (77.9%). There was no significant difference in surgical time (P = 0.12), intraoperative complications (P = 0.54), or postoperative complications (P = 0.34). The most common complication was postoperative bleeding/hematoma (7.2%). Other complications included seroma (2.1%), infection (1.3%), and nipple graft failure (0.4%). There were no thromboembolic complications. CONCLUSIONS: There is no significant difference in the incidence of perioperative adverse events for patients who continue GAHT preoperatively vs patients who stop GAHT prior to MCS.

The Muscle-Sparing Descending Branch Latissimus Dorsi Free Flap for Lower Extremity Reconstruction.

BACKGROUND: The muscle-sparing descending branch latissimus dorsi muscle (MSLD) flap is a versatile flap with numerous benefits. It is an often overlooked but useful option when considering free flap donors. In this article, the authors present the largest experience with the MSLD flap, with focus on its use in lower extremity reconstruction. METHODS: Patients undergoing lower extremity reconstruction with the MSLD flap at a single institution from 2012 to 2017 were identified. Patient and wound characteristics, surgical details, complications, and outcomes were examined. Outcomes were compared to a cohort who underwent lower extremity reconstruction with other free muscle flaps during the same period. RESULTS: Thirty-six consecutive patients who underwent MSLD flap surgery were identified. Mean follow-up was 18.8 months. Mean body mass index was 29.2 kg/m and 56 percent were smokers. The most common wound causes were motor vehicle collision (46 percent) and fall (22 percent). The most common anatomical location was the distal third of the tibia (33 percent). Mean operative time was 380 minutes. Complications included three total losses (8 percent) and one partial loss (3 percent). No donor-site seromas were reported. Four patients required subsequent amputation for orthopedic issues (nonunion/pain). Patients receiving MSLD and other flaps had similar rates of amputation, donor- and recipient-site complications, and ambulation status (p > 0.05). CONCLUSIONS: The MSLD flap is a useful and reliable option for free flap reconstruction of the lower extremity. Advantages include an easily contourable flap, low revision rate, low complication rate, and the ability to harvest in supine position. In addition, the MSLD flap preserves donor function useful for rehabilitation and minimizes seroma risk. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Hexapod Stacked Transport for Tibial Infected Nonunions With Bone Loss: Long-Term Functional Outcomes.

OBJECTIVES: To analyze long-term functional outcomes in patients with posttraumatic infected tibial nonunions having undergone bone transport with hexapod external fixator. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Thirty-eight patients with infected nonunions of the tibia. INTERVENTION: Resection of nonunion with application of stacked hexapod external fixator for bone transport. MAIN OUTCOME MEASUREMENTS: Functional outcome was measured using the short Musculoskeletal Functional Assessment (sMFA). Parameters measured included age, sex, presence of diabetes, smoking, use of a free flap, bone defect size, length in frame, external fixation index, and direction of lengthening. RESULTS: The mean sMFA score for the entire group was 27.1. Average patient age was 46.8 ± 12.7 years, 74% patients were male, 8% were diabetic, and 29% were smokers. Seventeen patients had soft-tissue defects that required a free flap. Smokers had higher degrees of disability compared with nonsmokers (39 ± 16 vs. 22 ± 14, P = 0.011). Patients requiring adjunctive stabilization had worse functional scores compared with those who did not receive adjunctive stabilization (33 ± 17 vs. 22 ± 15, P = 0.049). Sixteen patients returned 2 sMFA surveys at different time points after completion of bone transport. Initial average sMFA score was 26.5 at a mean of 25.3 months; subsequent sMFA scores averaged 19.4 at a mean of 98.8 months. CONCLUSIONS: Stacked hexapod external fixator bone transport is a reliable technique for infected nonunion of the tibia with bone loss. Improved sMFA scores can be expected from 2 to 8 years, suggesting full recovery takes longer than previously anticipated. Limb salvage with hexapod bone transport is justified over time. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Hexapod Frame Stacked Transport for Tibial Infected Nonunions With Bone Loss: Analysis of Use of Adjunctive Stability.

OBJECTIVES: The stacked hexapod bone transport technique is an effective treatment for infected tibial nonunions with bone loss. The purpose of this study was to evaluate the patients' risk factors and timing for requiring adjunctive stabilization. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Seventy-five patients with infected posttraumatic nonunions of the tibia. INTERVENTION: Resection of nonunion with application of stacked hexapod frame for bone transport. MAIN OUTCOME MEASUREMENTS: Parameters measured included age, sex, diabetes, smoking, use of a free flap, bone defect size, length in frame, external fixation index, and direction of lengthening. Outcomes recorded: removal of frame, below knee amputation, or adjunctive stability. Further analysis evaluated location of nonunion, timing of adjunctive stabilization, and type of fixation. RESULTS: The average patient age was 45.7 ± 12.5 years, 76% patients were men, 11% were diabetic, and 44% were smokers. Forty two percent had soft tissue defects that required a free flap. Thirty-eight patients had removal of frame, whereas 36 patients required adjunctive stability of the hexapod frame. Patient receiving adjunctive stabilization had a longer length of time in the hexapod frame (P = 0.026) and were more likely to require a free flap (P = 0.053). Ninety-three percent docking site nonunions occurred after the removal of the frame (P = 0.032); whereas 79% regenerate nonunions occurred before the hexapod frame was removed (P = 0.029). CONCLUSIONS: The use of a hexapod frame for the infected tibial nonunions with bone loss is an effective method for achieving union and eradicating infection in a difficult orthopaedic patient population. Use of adjunctive stabilization is a reasonable technique to address delayed regenerate and docking site nonunions. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Free tissue transfer with distraction osteogenesis is effective for limb salvage of the infected traumatized lower extremity.

BACKGROUND: Salvage of acute and chronic tibial osseocutaneous defects in the lower extremity poses a formidable problem. Although local, distant, and free tissue transfer or bone grafting alone may be adequate for repair of small wounds or osseous defects, large or complicated defects necessitate a different approach. The authors describe their experience with free tissue transfer in combination with distraction osteogenesis for complex composite osteocutaneous defects. METHODS: The authors reviewed a consecutive series of 28 patients who underwent treatment over an 8-year period, with follow-up ranging from 1 to 8.5 years. Mean time to flap after injury was 1082 days (range, 6 days to 30 years). Indications for treatment included infected nonunion of the tibia (n = 18), acute traumatic bone loss (n = 5), skin and soft-tissue breakdown that occurred during distraction osteogenesis (n = 4), and exposed bone following previous failed free flap (n = 1). RESULTS: Free flaps used included the rectus abdominis (n = 17), latissimus dorsi (n = 5), gracilis (n = 5), and radial forearm (n = 1). Mean length of bone gap was 63 mm (range, 30 to 140 mm), and mean area of wound requiring flap coverage was 219 cm (range, 35 to 400 cm). Twenty-five patients (89.3 percent) had successful flap coverage and went on to ambulate independently and return to work. The minor complication rate was 42.9 percent. CONCLUSIONS: Distraction osteogenesis in combination with free tissue transfer is a powerful technique that allows limb salvage, particularly when local and regional flaps are unavailable or inadequate. For infected nonunion of the tibia, it permits a staged approach that allows underlying osteomyelitis to declare itself and provides vascularized healthy soft-tissue coverage that facilitates repeated operations for the purpose of distraction.

Cleland's ligaments: an anatomic study.

The anatomy and function of Cleland's ligaments--thought by the authors to require clarification because of the conflicting anatomic descriptions in the literature--are reviewed. A statistical representation of the structure of these ligamentous bundles was derived from the study of 16 fixed human cadaveric digits and five fresh cadaveric digits, all from different patients. The results demonstrate a large variation in anatomy. However, this anatomic heterogeneity is not indicative of an equally varied function. In general, it was found that the majority of Cleland's ligaments traversed a great distance adherent to the skin before actually inserting in the dermis. Over one-third of the dorsal fibers demonstrated a multiplanar organization, fanning out before inserting into the skin. In contrast, the ventral fibers did not fan out before inserting into the skin. Excision of these ventral fibers revealed a separate "ledgelike" plane of fibers arising from the fibrous flexor sheath and running in a straight line perpendicular to the long axis of the digit. A branch of the digital nerve was found to pierce this ligamentous layer in the majority of digits studied. Unlike those of previous reports, the results of the present study suggest that the ligaments have a constant function of anchoring the skin of the digit on both the dorsal and ventral aspects, thereby preventing the displacement of skin during flexion of the digits. All previous studies failed to make this conclusion. The anatomic relationship to the digital neurovascular bundle also suggests that Cleland's ligaments may stabilize the digital vessels during flexion. In conclusion, Cleland's ligaments are highly functional structures and are essential for normal cutaneous stability during digital movements.