Measuring Functional Outcomes After Bilateral Vascularized Composite Hand Allotransplantation: A Report of 3 Cases.

PURPOSE: Currently, numerous assessment tools are available to measure functional outcomes after bilateral hand transplantation. The purpose of this article is to present our experience utilizing quantitative assessment tools for functional evaluation and to describe our results after bilateral hand transplantation. METHODS: A single surgeon's experience with bilateral hand transplantation from 2011 to 2016 was retrospectively reviewed. Three bilateral hand transplantations were performed in 2 adults and 1 child. A minimum 2-year follow-up evaluation was available. For the adult patients, postoperative outcome measures included patient-reported pain and disability scores, return of sensation, muscle strength, range of motion, and return to work/activities of daily living, the Hand Transplant Scoring System (HTSS), the Sollerman hand function test, and complications. For our pediatric patient, postoperative outcome measures included the Functional Independence Measure for children (WeeFIM) scale, a functional independence measure for children, the 9-Hole Peg Test, the Box and Block test, and complications. RESULTS: Our 2 adult patients were age 28 and our pediatric patient was age 8 at transplantation. Follow-up ranged from 2 to 7 years. The functional assessments were performed over a period from 11 to 48 months after transplantation. Both adult patients achieved functional independence and the HTSS, Short Form-36 Health Score (SF-36), DASH, and Sollerman tests demonstrated sequential improvement compared with pretransplantation scores assessed with the use of prostheses. Our pediatric patient demonstrated improvement in his Box and Block test score for each hand at sequential visits after transplantation. His 9-Hole Peg Test demonstrated improvement, and his WeeFIM assessment at 20 months indicated a greater level of independence. CONCLUSIONS: Patient-reported outcomes and the Sollerman test when used in addition to the HTSS appear to reflect functional improvement in adult patients after bilateral hand transplantation. Although children pose a unique challenge with functional assessment, we found the WeeFIM assessment, 9-Hole Peg Test, and the Box and Block test helpful in evaluating functional outcomes in our pediatric patient. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic V.

A Review on the Orthoplastic Approach to Lower Limb Reconstruction.

Just as in the craft of carpentry, a stable foundation and framework are absolutely essential to the final function of a building, but no more important than the drywall, trim, and paint that make the building functional, durable, and livable. Reconstruction of the lower extremity is similar; the orthopaedic surgeon must obtain stable fixation of the damaged or diseased bone once a thorough debridement of nonviable bone is performed, while the plastic or orthopaedic soft tissue surgeon must provide vascularized, stable coverage. These two components are complementary and both contribute to the success or failure of functional limb restoration. The stability of bone repair will predict the ultimate functional status, while the vascularized envelope will enhance the biology of bone and soft tissue healing. When both components are properly attended to, the result is often a functional limb with an acceptable appearance. While a single surgeon need not perform both of these tasks (although some may choose to do so), the orthopaedic and plastic surgeon involved in this care must have a clear understanding of each other's role and their importance for a good outcome. This is what we call the orthoplastic approach to reconstructive surgery of the extremities, that is, the application of principles and practice of both specialties applied simultaneously to optimize the outcomes in limb reconstruction. In this review article, we discuss the history of orthoplastic surgery, the key elements of orthoplastic surgery, and thoughts on factors that lead to good outcomes through select cases.

Free fibula reconstruction of distal tibial defects after sarcoma surgery.

Distal tibial tumor ablation results in combined soft tissue and bone defect that involves the ankle joint. This area is unique and problematic because it combines low caliber limb size, relatively soft tissue deficiency, suboptimal bone and soft tissue healing ability, and the need to sustain increased mechanical loads. The management is difficult, controversial, and traditionally was treated by primary amputation. We present our experience with a limb sparing surgery using biological reconstruction.Between 2004 and 2007, 5 patients with malignant bone tumors of the distal tibia underwent tumor resection and reconstruction with free vascularized osteoseptocutaneous fibula flap. The average age was 33.2 years (range, 11-62 years). In all cases, a skin island was harvested and used for wound closure. Arthrodesis of the ankle joint was preformed in all patients. Double fixation system was used to provide stability and avoid flap rotation.All flaps survived. There were no major complications. One patient had partial loss of the skin paddle that was treated conservatively. Callous formation was documented after an average time of 4 months, partial weight bearing after an average time of 4 months, and full weight bearing after an average time of 11.5 months. All patients regained almost normal ambulation within a year.

The effect of barbed suture tendon repair on work of flexion.

PURPOSE: To compare the work of flexion, ultimate strength, and gap resistance of a conventional 4-strand tendon repair to a knotless barbed-suture 4-strand tendon repair. METHODS: Tendon repairs were performed on 16 cadaver flexor digitorum profundus tendons using either a 4-strand double Kessler repair or a similar but knotless 4-strand repair with a unidirectional barbed suture. Work of flexion, gap resistance during cyclical loading, and ultimate strength of both techniques were determined and their means compared. RESULTS: There was no difference in mean maximum load and gap formation between the 2 techniques. Work of flexion was higher for the barbed-suture repair group compared with the traditional repair group (39 N·mm vs 31 N·mm). CONCLUSIONS: The higher work of flexion in the barbed-suture group suggests that barbed suture may negatively affect tendon gliding within the flexor tendon sheath. CLINICAL RELEVANCE: Knotless barbed-suture tendon repair leads to increased work of flexion compared with traditional flexor tendon repairs, which may result in an increased rupture incidence.

Complications related to harvest of the proximal end of the fibula: a systematic review.

BACKGROUND: The fibula is a common source of bone graft used in skeletal reconstruction. Although in most cases only the diaphysis of the fibula is used, there are clinical scenarios in which the proximal end of the fibula and fibular head are harvested for use in articular reconstruction. The purpose of this systematic review is to determine the incidence of knee instability and peroneal nerve motor dysfunction associated with removal of the proximal end of the fibula and fibular head. METHODS: A systematic search was performed using the PubMed, Ovid MEDLINE, and cochrane databases. Studies accepted for review included those that clearly reported donor site morbidity (instability or peroneal nerve motor dysfunction) after proximal fibula resection. All studies in which the proximal fibula was resected for bone graft or for marginal resection of tumor were included. RESULTS: Fifteen studies reporting a total of 337 patients were included. The rate of symptomatic knee instability after proximal fibula resection was 3.9%. The incidence of instability that was detectible on physical examination or stress radiographs was higher. Although transient motor dysfunction was not uncommon, the incidence of persistent peroneal nerve motor dysfunction was 2.6%. CONCLUSION: Although asymptomatic laxity is common, the incidence of symptomatic knee instability after resection of the proximal fibula is relatively low. The incidence of persistent peroneal nerve motor dysfunction is also low when the nerve is intentionally protected during surgery.

Building a Hand and Upper Extremity Transplantation Program: Lessons Learned From the First 20 Years of Vascularized Composite Allotransplantation.

Background: Upper extremity transplantation is a quality-of-life enhancing treatment for select patients with upper extremity loss. This article reviews the preoperative, intraoperative, and postoperative challenges in the upper extremity transplantation process and the lessons learned from the first 2 decades of hand transplantation. Methods: Key components of the author's hand transplantation protocol including patient selection, donor screening, surgical rehearsal, donor procurement, transplantation, immunosuppression, and patient outcome reporting/follow-up are reported to assist other teams who wish to establish a hand transplantation program. Results: There have been many advancements in the first 20 years of hand transplantation including better patient selection criteria, the recent addition of pediatric patients, improved surgical techniques such as the use of virtual surgical planning, and improved immunosuppression protocols. Improvement has also taken place in the tracking and reporting of hand transplant outcomes, but more work is clearly needed to fully define the benefits of transplantation, especially for pediatric patients. Conclusions: Over the past 20 years, significant progress has been made in upper extremity transplantation although a number of challenges remain including how to best document and share outcome measures, optimize immunosuppression, and diagnose/treat rejection. The authors encourage upper extremity transplant programs to report their experience and protocols to advance hand transplantation as standard of care for properly selected individuals.

Comparison of Fracture Location and Extent of Comminution in Isolated Scaphoid Fractures Versus Transscaphoid Fracture-Dislocations.

Background: Isolated scaphoid fractures (ISFs) are common, whereas transscaphoid fracture-dislocations (TSFDs) are not. Scaphoid fracture location and the extent of comminution are factors that affect treatment and outcome. The purpose of this study is to compare the radiographic characteristics of ISFs with TSFDs associated with greater arc injury. Methods: This study is a retrospective review of all ISFs and TSFDs that presented to our institution during a 5-year period. Fracture location (along the long axis of the scaphoid) was calculated by dividing the distance from the proximal pole to the fracture by the entire length of the scaphoid. The extent of comminution was measured in millimeters along the mid-axis of the scaphoid and divided by the entire length of the scaphoid. Results: One-hundred thirty-eight scaphoid fractures in 137 patients were identified. One-hundred twelve fractures (81%) were ISFs, and 26 (19%) were associated with a TSFD. The mean fracture location was more proximal in TSFDs than in ISFs. However, fractures occurred in the distal third of the scaphoid in 12% of ISFs compared with 0% of TSFDs. Nine percent of ISFs demonstrated comminution as compared with 12% of TSFDs. Extent of comminution was 16% and 28% for ISFs and TSFDs, respectively. Conclusion: Scaphoid fractures associated with greater arc injuries are located more proximally and are more comminuted than ISFs, and distal pole fractures rarely occur in the setting of TSFDs. The increased incidence and extent of comminution in TSFDs may be suggestive of a higher energy injury mechanism.

A Subperiosteal Proximal Phalanx Osteoid Osteoma: A Challenging Diagnosis.

A relatively rare tumor, osteoid osteoma most commonly affects the lower extremity. In 10% of the cases, it can affect the hand and wrist. We present a case of osteoid osteoma in the proximal phalanx of ring finger that was initially misdiagnosed as a soft tissue lesion. The soft tissue lesion was resected, but the symptoms recurred shortly thereafter, leading to repeat diagnostic workup. Despite X-rays, magnetic resonance imaging, and tissue biopsy, the diagnosis remained elusive until surgical re-exploration. Based on the lessons learned from this case and the experience reported in literature, we discuss the intricate nature of osteoid osteoma diagnosis in the hand, the obstacles often encountered, and how to approach these challenging patients in a stepwise and critical fashion.

The use of bidirectional barbed suture in the treatment of a complete common calcanean tendon rupture in a dog: Long-term clinical and ultrasonographic evaluation.

The canine common calcanean tendon can be repaired successfully using a modified Kessler knotless barbed technique. A long-term ultrasound follow-up showed improved and increased normal tendon fibrillar echotexture and homogeneity.

Medial Femoral Condyle Free Flap Reconstruction of Complex Foot and Ankle Pathology.

BACKGROUND: Complex hindfoot pathology may benefit from vascularized bone flap reconstruction rather than traditional bone grafting techniques. Medial femoral condyle (MFC) flaps provide vascularized periosteum, skin, and corticocancellous bone. METHODS: A retrospective, single-institution cohort study of consecutive MFC flaps performed for complicated hindfoot reconstruction between 2013 and 2019 was reviewed. Radiologic follow-up assessed osseous union and clinical outcomes were evaluated with the American Orthopaedic Foot & Ankle Society (AOFAS) hindfoot score. Thirty MFC flaps were performed in 28 patients for complex hindfoot pathology. Twenty-seven flaps had adequate clinical and radiographic follow-up (mean 15.8 months). RESULTS: The majority presented with avascular necrosis (83%) and failed prior operations (67%, mean 3.1). Most hindfoot procedures involved arthrodesis (n = 24, 80%); tibiotalocalcaneal (n = 11) and talonavicular (n = 7) most frequently. Mean osseous flap volume was 10.3 cm3 (range 1.7-18.4 cm3); one flap required takeback for venous congestion but no total flap losses occurred. Primary osseous union was initially achieved in 20 patients (74%, mean 217 days). Six flaps developed interface nonunion; 5 underwent revision arthrodesis and ultimately achieved union in 24/27 flaps (89%, mean 271 days). Risk factors for nonunion were body mass index (BMI) >30 (P = .017) and prior arthrodesis (P = .042). Mean AOFAS hindfoot scores increased significantly from 52.3 preoperatively to 70.7 postoperatively (P < .001). Subscore analysis demonstrated significant improvement in postoperative pain scores from 14.2 to 27.3 out of 40 (P < .001). CONCLUSION: The MFC free flap provided vascularized bone for complicated foot and ankle reconstruction with relatively low donor site morbidity, promising osseous union results, and improved functional outcomes. LEVEL OF EVIDENCE: Level IV, retrospective case series.

Surgical Treatment of Chronic Hand Ischemia: A Systematic Review and Case Series.

Background: Chronic hand ischemia refers to progressive, non-acute ischemic symptoms such as cold intolerance, rest pain, ulceration, tissue necrosis, and digit loss and poses a significant challenge in management. Conservative treatment begins with medical optimization and pharmacologic therapy, but when symptoms persist, surgical intervention may be required. Various operations exist to improve circulation including sympathectomy, arterial bypass, or venous arterialization. The purpose of this study is to systematically review published outcomes and present our experience with each surgical technique. Methods: A systematic review of literature regarding surgical treatment of chronic hand ischemia published between 1990 and 2016 was conducted using PRISMA guidelines. A retrospective-review of surgical interventions for chronic hand ischemia from 2010 to 2016 was then conducted. Primary outcomes included improvement in pain, wound-healing, and development of new ulcerations. Results: The review included 38 eight studies, showing all three techniques were effective in treating chronic hand ischemia. Sympathectomy had the lowest rate of new ulcerations (0.8%); bypass had the highest rate of healing existing ulcerations (89%). Arterialization was associated with consistent pain improvement pain (100%) but more complications (30.8%). Our series included 18 patients with 21 affected hands, 18 sympathectomies, 6 ulnar artery bypasses, and 1 arterialization. Most hands had improvement of wounds (89.5%) and pain (78.9%). No patients developed new ulcerations, but one required secondary amputation. Conclusions: When conservative measures fail to improve chronic hand ischemia, surgical intervention is an effective last line treatment. An algorithmic approach can determine the best operation for patients with chronic hand ischemia.

Arthroscopic Ganglionectomy in the Pediatric Population.

BACKGROUND: Arthroscopic dorsal wrist ganglionectomy is an established alternative to open excision in the adult population. The purpose of this study was to retrospectively compare outcomes of arthroscopic and open dorsal wrist ganglionectomy in the pediatric population. METHODS: All patients who underwent arthroscopic or open dorsal wrist ganglionectomy at a single pediatric institution between 2011 and 2014 were retrospectively evaluated by chart review and telephone interview. The primary outcome variable was whether or not the cyst had recurred. Other outcome measures included the incidence of complications, and patient-rated outcome measures such as satisfaction, pain, function, and aesthetics. RESULTS: There were eight cases of arthroscopic and 19 cases of open ganglionectomy, with a mean age of 14 years. At an average follow-up of 2 years, the recurrence rate was one of eight for the arthroscopic group and two of 19 for the open group. No patients in the arthroscopic group reported functional limitations, compared with three patients in the open group. On a 10-point scar appearance scale, with 1 being not satisfied at all and 10 being highly satisfied, the median score in the arthroscopic group was 9.5, compared with 8 in the open group. No patients in the arthroscopic group had residual pain at the surgical site, compared with nine patients in the open group, a finding that was statistically significant. All patients in the arthroscopic group reported that they would undergo surgery again, whereas two patients in the open group would not undergo surgery again. CONCLUSION: Arthroscopic dorsal wrist ganglionectomy compares favorably with open ganglionectomy in the pediatric population.

Pediatric burns in Israeli natives versus asylum seekers living in Israel: Lessons learned.

BACKGROUND: Burn injuries are one of the leading causes of morbidity and mortality in the pediatric population. In early childhood, burns have a wide range of adverse long-term consequences ranging from functional impairment to psychological implications. Children from low-income and middle-income countries are at a higher risk of suffering from burn injuries. In the last 10 years the population of asylum seekers from low-income countries in Israel has increased dramatically. About 25,000 or 60% of asylum seekers are living in the Tel Aviv area, making up roughly 6% of the city's total population (about 405,000). AIM: A retrospective study aimed to profile the pediatric burn injuries treated at the Tel Aviv Sourasky Medical Center over the last 9 years in an effort to examine the distinct characteristics of African asylum seekers who suffer burn injuries in comparison with Israeli nationals. PATIENTS & METHODS: Medical records of 876 patients under the age of 18 years presenting between 2007-2015 were retrospectively reviewed. The parameters collected included gender, causality, total body surface area (TBSA), burn depth and patient outcome. CONCLUSIONS: There was no significant difference regarding: age; male-female ratio; scald-types burns; limb involvement. However, hospitalization and length of hospital stay were significantly higher among asylum seekers, as was family burden. Questions may be raised regarding prevention, education & social support. Our research provides a small glimpse into the world of asylum seekers in Israel. We hope it will serve as a window into the much grander problems that this population faces on a daily basis.

The Chimeric Myo-Osseous Medial Femoral Condyle Flap for Tibial Nonunion: A Case Report.

Objective: The descending genicular artery provides the dominant pedicle for the medial femoral condyle and medial femoral trochlear free flaps. Variations of the flap include using a skin paddle for monitoring, a vastus medialis muscle component, and the medial superior geniculate artery for the pedicle. We present a case of a 49-year-old man with a distal tibial fracture from a motor vehicle accident complicated by chronic osteomyelitis, poor soft tissue envelope, and tibial nonunion. Methods: The composite lower extremity defect was reconstructed with a chimeric myo-osseous variant of the medial femoral condyle free flap since no perforator was available to the skin and there was a large amount of dead space. Results: At 9 months postoperatively, there was successful tibial union, adequate coverage of the defect, and a return to unassisted ambulation. Conclusions: The chimeric myo-osseous variant of the medial femoral condyle free flap adds to the versatility of this flap and has application in reconstructing defects of bone that also require soft tissue coverage.

Preparation is the Only Shortcut You Need in Surgery: A Guide to Surgical Rehearsals for Hand and Upper Extremity Transplantation.

As upper extremity transplantation is becoming more accepted worldwide, the demand for a fresh tissue cadaveric training model for this procedure is increasing and necessary to assure surgical success. Surgical rehearsals can decrease operative time, improve technique, and reduce errors made on the actual day of surgery. The purpose of this article is to describe a method for surgical rehearsal of upper extremity transplantation using cadaveric specimens based on the clinical experience of an academic institution with an active transplantation program. The logistics of rehearsal setup, equipment, and modified version of procedural checklists are described.

Ankle Arthrodesis with Free Vascularized Fibula Autograft Using Saphenous Vein Grafts: A Case Series.

BACKGROUND: In select high-risk cases of ankle arthrodesis, conventional techniques may lead to a high incidence of failure because of a combination of multiple operations; high risk of infection; avascular, often bulky allografts; and poor soft-tissue quality. In high-risk distal limb salvage, the authors have performed ankle arthrodesis using a free vascularized fibula graft from the ipsilateral limb with saphenous vein grafts. METHODS: The authors present data from six patients. The cause of the defect was avascular necrosis of the talus (n = 4), osteomyelitis (n = 1), and failed total ankle replacement (n = 1). The ipsilateral fibula was used in all cases as a free vascularized graft. Nonviable bone and soft tissue were débrided, and the fibula was shortened to size and impacted into the cavitary space spanning the distance between the tibia, talus, and calcaneus. The pedicle distally was anastomosed to saphenous vein grafts and proximally anastomosed to the divided peroneal vessels. RESULTS: The flap success rate was 83 percent (n = 5). The complication rate was 83 percent; complications included flap loss (intraoperative arterial thrombosis), loss of skin island, hematoma, and arterial thrombosis. Despite one flap failure and a high complication rate, successful union was obtained in all patients. All patients achieved full weight-bearing status by a mean of 4 months after surgery (range, 3 to 7 months). There were no amputations. CONCLUSIONS: Vascularized free fibula graft is a reliable option for ankle arthrodesis in complex salvage situations. Using a saphenous vein graft to perform the anastomosis with the divided peroneal vessels proximally should be considered.

Logistics in Coordinating the First Adult Transatlantic Bilateral Hand Transplant: Lessons Learned.

Hand transplantation requires precise preoperative planning and surgical execution. Coordinating a transplant team-including surgeons, anesthesiologists, nurses, and supporting staff-is a time-sensitive challenge when a donor-recipient match is confirmed. International human limb transplantation occurs when the recipient and donor are in separate countries. The authors describe the logistics behind the first transatlantic adult bilateral hand transplantation, which, to date, required the highest level of coordination and timing. The authors' experience serves as a proof of concept that international limb transplantation or salvage is possible when the complex logistics of such an endeavor are carefully anticipated.

Body Builder's Nightmare: Black Market Steroid Injection Gone Wrong: a Case Report.

In the pursuit of success in sports, some athletes are not deterred by health risks associated with the (mis)use of black market preparations of dubious origin as performance-enhancing agents. Several studies published in the recent years demonstrated that anabolic-androgenic steroids, but also stimulants and growth hormones, are misused by numerous recreational athletes from all over the world. Trenbolone is an anabolic steroid routinely used in the finishing phase of beef production to improve animal performance and feed efficiency. A 35-year-old male patient presented to our plastic surgery clinic after self-intramuscular administration of Trenbolone to the superior gluteal area bilaterally, which led to a full-thickness defect in a cone-like distribution. The wounds underwent surgical debridement and were treated locally with mafenide acetate irrigation and wound dressings. Closure was achieved by secondary intention healing. In this report, we discuss the first documented case of full-thickness skin and subcutaneous tissue necrosis after black market anabolic steroid injection. This illustrates a plastic complication and resolution of a widespread but seldom reported problem.

Practical Management of Metacarpal Fractures.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Understand the indications for metacarpal fixation. 2. Understand the rationale for various surgical treatment options, based on high-level evidence where available. 3. Describe selected operative techniques and their postoperative management. BACKGROUND: Metacarpal fractures are extremely common, constituting one in five fractures that present to the emergency department. Although many metacarpal fractures can be treated nonoperatively, some require surgery. The purpose of this CME article is to present a practical, up-to-date guide to the management of these common injuries. METHODS: A review of nonoperative management, surgical indications, and selected surgical techniques is provided. The authors reviewed the literature related to the treatment of metacarpal fractures, and the highest level evidence available to help guide decision-making is presented. CONCLUSIONS: Metacarpal fractures can often be treated nonoperatively, although some fractures will benefit from surgical treatment. Although there is some high-level evidence to guide decision-making, there are many clinical scenarios for which there is little high-quality applicable research. As a general principle, the treatment option that achieves the desired reduction and degree of fixation, allows early motion, and minimizes soft-tissue injury should be preferred.

Reconstruction of scaphoid non-union and total scaphoid avascular necrosis in a pediatric patient: a case report.

BACKGROUND: The medial femoral condyle vascularized bone graft has grown in popularity for treating recalcitrant fracture non-unions and has become particularly useful in treating scaphoid non-union with avascular necrosis of the proximal pole. The medial femoral condyle is an excellent source of dense, well-vascularized bone and results in minimal donor site morbidity. METHODS: We describe an unusual case of chronic scaphoid non-union and total scaphoid avascular necrosis in a skeletally immature patient. Scaphoid reconstruction was performed with a vascularized medial femoral condyle graft, with successful graft incorporation, and restoration of pain-free wrist motion. CONCLUSIONS: Technical considerations for harvest of the medial femoral condyle bone graft in the skeletally immature patient are discussed.