Analysis of the Radial Forearm Phalloplasty Donor Site: Do Dermal Matrices Improve Donor Site Morbidity?

Background: The radial forearm free flap is frequently chosen for phalloplasty; however, flap size required for phalloplasty is associated with a large scar burden and functional concerns. We sought to investigate donor site functionality, aesthetics, and volume deficits in a cohort of individuals who underwent radial forearm phalloplasty (RFP) with donor site skin grafting alone or dermal substitute and subsequent skin grafting. Methods: Donor site functionality was assessed using the quick Disabilities of Arm, Shoulder, and Hand (qDASH). Patient- and clinician-reported aesthetics were assessed using the Patient and Observer Scar Assessment Scale (POSAS). An Artec Leo three-dimensional scanner was used to measure volumetric differences from the donor site forearm and contralateral forearm. Results: Fifteen patients who underwent RFP agreed to participate. No statistically significant differences were identified between different donor site closure methods regarding qDASH, patient-reported POSAS, or total volumetric deficits. A blinded clinician reported that POSAS approached significance at 4.7 for biodegradable temporizing matrix (BTM), 4.2 for Integra, and 3.0 for split-thickness skin graft (P = 0.05). No statistically significant differences were identified regarding distal, middle, or proximal volume deficits; however, a trend was observed regarding total volumetric deficits with BTM experiencing the lowest deficit (10.3 cm3) and skin graft experiencing the highest deficit (21.5 cm3, P = 0.82). Conclusions: The addition of dermal matrix (BTM or Integra) to the treatment algorithm for RFP did not show statistically significant improvement in donor site volume deficits, patient-reported scar appearance (POSAS), or functionality (qDASH).

The importance of shoulder external rotation in activities of daily living: improving outcomes in traumatic brachial plexus palsy.

PURPOSE: To define the importance of shoulder external rotation in activities of daily living in normal individuals to better understand how restoration of shoulder external rotation in traumatic brachial plexus palsy could improve patient function. METHODS: Thirty-one normal individuals performed 12 common activities of daily living (ADLs) wearing a custom shoulder orthosis designed to selectively limit shoulder external rotation to 3 different settings, ranging from 0° (most restrictive) to 90° (least restrictive) of external rotation. Outcomes were measured with a visual analog scale of perceived difficulty in accomplishing the ADLs with each orthosis setting and the Disabilities of the Arm, Shoulder, and Hand questionnaire administered after each set of 12 ADLs was completed. RESULTS: Subjects perceived increasing difficulty during all ADLs tested and registered higher disability scores with increasing restriction of shoulder external rotation. The ADLs requiring motions predominantly above the waist exhibited more marked and earlier changes in visual analog scale scores with increasing shoulder external rotation restriction. CONCLUSIONS: Traditionally, surgeons have pursued restoration of shoulder abduction and forward elevation in secondary reconstruction of traumatic brachial plexus injuries. Recently, the concept of preferentially restoring shoulder external rotation has been proposed, without clear evidence in the literature of the role of shoulder external rotation in ADLs. CLINICAL RELEVANCE: Our results support the notion that restoring shoulder external rotation in the treatment of traumatic brachial plexus palsy patients might improve outcomes by decreasing patient disability and increasing the ability to perform ADLs.

Static-progressive splinting in under 25 minutes and 25 dollars.

Wrist stiffness can occur after injury to the wrist and surrounding structures. Frequently hand therapists treat this stiffness with static-progressive splinting techniques in an attempt to lengthen shortened tissues through tissue growth and collagen reorganization. The hand therapist's goal is to fabricate a splint that effectively increases range of motion in a timely and cost-effective manner. Through creative images, these authors illustrate their fabrication of a static-progressive wrist extension and/or flexion splint that is cost effective and can be fabricated in 22 minutes.

A Prospective, Randomized Trial of Mobilization Protocols Following Ligament Reconstruction and Tendon Interposition.

BACKGROUND: The purpose of this study was to evaluate the hypothesis that an increased duration of immobilization following trapeziectomy with ligament reconstruction and tendon interposition (LRTI) leads to improved patient-reported outcomes compared with an early mobilization protocol. METHODS: At 2 institutions, we prospectively randomized 223 patients (238 thumbs) undergoing LRTI to receive 1 of 2 postoperative rehabilitation protocols. The immobilization protocol consisted of use of a postoperative forearm-based thumb-spica splint for 7 days followed by a forearm-based thumb-spica cast for 5 weeks and then by a custom forearm-based thermoplastic thumb-spica splint for an additional 6 weeks. An active range of motion (ROM) was started 6 weeks postoperatively. The early mobilization protocol consisted of the same postoperative splint for 7 days followed by use of a forearm-based thermoplastic thumb-spica splint for 3 weeks and then by a hand-based thumb-spica splint for 4 weeks. An active ROM was started 4 weeks postoperatively. The outcome measures included the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire; pinch and grip strength; 9-hole peg test (NHP); visual analog scale (VAS) for pain; VAS for patient satisfaction; and wrist and thumb ROM. These were measured preoperatively and at 6, 12, 26, 52, and 104 weeks postoperatively. Differences in continuous and categorical variables were assessed with use of Tukey multiple comparisons following 1-way analysis of variance and Fisher exact tests, respectively. RESULTS: A minimum follow-up of 1 year (mean, 1.7 years) was achieved for 71% (169) of the 238 randomized thumbs (157 of the 223 patients): 74 patients (80 thumbs) treated with the immobilization protocol and 83 patients (89 thumbs) treated with the early mobilization protocol. DASH scores, VAS pain scores, VAS patient satisfaction scores, and strength all improved similarly with no significant differences between groups at any time point. Wrist and thumb ROM and NHP outcomes were significantly worse for the immobilization group at 6 weeks postoperatively, with no differences observed between groups at 12 weeks and beyond. CONCLUSIONS: A conservative immobilization protocol does not improve functional outcomes, satisfaction, strength, or ROM following LRTI compared with an early mobilization protocol. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Zone II flexor tendon rehabilitation: a proposed algorithm.

Many therapists in rural areas, or isolated in smaller hospitals, have to use their best professional judgment and experience when treating flexor tendon injuries. Protocols have been established over the years to aid in these treatments. However, realistically they are typically used more as a guideline versus exact treatment approaches. Instead of having to second guess our modifications, these authors have provided another indicator to help manage these patients. They have used tendon lag as an indicator and have nicely broken it down into a user friendly algorithmic chart.