Successful Intraoperative Salvage of a Venous Congested Deep Inferior Epigastric Perforator Flap Using a Cross-thoracic Saphenous Vein Graft.

For autologous breast reconstruction using the deep inferior epigastric perforator flap, the internal mammary vessels are a common choice for recipient vessels. However, if these vessels are discovered to be inadequate, this may require the utilization of alternative vessels for successful salvage. Here, we demonstrate the use of a venous conduit for flap salvage in a patient undergoing bilateral deep inferior epigastric perforator flap breast reconstruction. Intraoperative venous congestion was identified on the left side. A contributing factor was an unresolvable size discrepancy between the deep inferior epigastric and the internal mammary venae comitantes. A saphenous vein graft can be used to drain the donor inferior epigastric vein to the contralateral internal mammary venae comitantes. In this discussion, adequate venous drainage was obtained with this approach, and the flap remained viable with good Doppler signals without further complications over a year postoperatively.

Use of a Multivector Mandibular Distractor for Treatment of Pediatric Proximal Interphalangeal Joint Pilon Fractures: A Case-Based Review.

BACKGROUND: The difficulties in surgical treatment of pilon fractures of the finger include fragment reconstitution and posthealing stiffness. In adults, external fixation with traction and early active range of motion (AROM)/passive range of motion (PROM) during healing is considered necessary for avoiding joint stiffness and attaining realignment. The authors present a unique approach to pediatric pilon fractures that uses open reduction and multivector external fixation with delayed AROM/PROM. Initial immobilization and significant traction allowed for joint realignment and prevented noncompliance with staged distraction. The authors believe this immobilization leads to a superior outcome because, unlike adults, children tend to avoid stiffness and a larger distraction force allowed for sufficient joint realignment to regain range of motion (ROM). METHODS: A right-handed 13-year-old boy sustained a right ring finger fracture and presented 12 days later. Radiographs revealed a comminuted Salter-Harris 4 fracture of the middle phalanx. The patient underwent open reduction and placement of multivector external fixation using a pediatric mandibular distractor/fixator. Significant traction was applied to distract the finger to length. RESULTS: Hardware was removed 6 weeks postoperatively and AROM was initiated after splinting. The patient started PROM 8 weeks postoperatively. Strengthening was initiated 2 weeks later. ROM improved and rehabilitation was continued. The patient exhibited nearly equal grip strength 12 weeks postoperatively. At 14 months follow-up, radiographs showed complete healing and joint realignment. There was no deformity or pain and finger length was restored. CONCLUSION: Management of pediatric pilon fractures is rarely described and presents unique considerations. Early-stage traction and immobilization using a multivector mandibular fixator/distractor is suitable in a child because noncompliance is avoided and there is a decreased risk for stiffness. Combining early immobilization with subsequent-staged AROM, PROM, and strengthening resulted in no loss of ROM and maintained articular symmetry.

Versatility of Free Cutaneous Flaps for Upper Extremity Soft Tissue Reconstruction.

The goals of upper extremity soft tissue reconstruction should go well beyond providing coverage and restoring function. As the field of reconstructive microsurgery has evolved, free cutaneous flaps (FCFs) are gaining wider application. The advantages of FCF include minimizing donor-site morbidity by preserving the muscle and fascia, improving versatility of flap design, and superior aesthetic results. This review highlights the application of anterolateral thigh, superficial circumflex iliac artery, deep inferior epigastric perforator, superficial inferior epigastric artery, and flow-through flaps for reconstruction of upper extremity defects. These flaps share several qualities in common: well-concealed donor sites, preservation of major arteries responsible of providing inflow to distal extremity, and potential for a two-team approach (donor and recipient sites). While the choice of flaps should be decided based on individual patient and defect characteristics, FCF should be considered as excellent options to achieve the goals of upper extremity reconstruction.

Treatment of a Recurrent Neuroma Within Nerve Allograft With Autologous Nerve Reconstruction.

BACKGROUND: The purpose of this case report is to describe the findings of a neuroma within an allograft, highlight the unique opportunity to evaluate the allograft (following human engraftment) ex vivo histologically, to reinforce an effective treatment strategy, and review outcomes in peripheral nerve surgery regarding gap defect distance. METHOD: A 55-year-old, right hand dominant man suffered a workplace injury 37 years ago resulting in lacerations and crush injury of the palm and lacerations of the left index finger requiring multiple neuroma excisions and eventual ray amputation. In an attempt to address stump neuroma pain and restore sensation of the radial digital nerve of the middle finger, which was lost after the ray amputation, a neuroma was resected and reconstructed with a 45-mm bioabsorbable allograft (AxoGen, Inc, Alachua, Florida). After the inciting injury in 1977, the patient initially presented to our clinic in 2013 with return of pain at the palm and numbness along the distribution of the common digital nerve and radial nerve of the middle finger prompting surgical exploration. A recurrent common digital nerve neuroma was identified at the proximal aspect of the allograft measuring 20 mm and was resected along with the remaining allograft. RESULTS: A 50-mm reversed superficial peroneal interpositional nerve graft was used for reconstruction resulting in progressive resolution of pain. On 6-month follow-up, the patient regained indiscriminate sensation with moving 2-point discrimination at the pulp of the middle finger with improved grasp function. CONCLUSION: In the setting of recalcitrant neuromas and intractable pain following multiple neuroma excisions, allografts may be suboptimal in reconstruction of larger gap defects. Autologous reconstruction with porcine submucosa extracellular matrix, as in this case, can avoid tethering, local ischemia, and nerve traction to optimize outcomes.

Modified rotational bowel vaginoplasty after total pelvic exenteration.

Vaginal reconstructive options commonly include the use of split-thickness skin grafts or intestinal conduits. When a colonic segment is chosen, the sigmoid colon is favored because of its location, size, and durability. When circumstances preclude the use of sigmoid colon and a colonic conduit is preferred, creative means of mobilization are required. This article describes a case and technique utilizing the descending colon in a tension-free vaginoplasty.

Prevention of ulceration, amputation, and reduction of hospitalization: outcomes of a prospective multicenter trial of tibial neurolysis in patients with diabetic neuropathy.

This is the first multicenter prospective study of outcomes of tibial neurolysis in diabetics with neuropathy and chronic compression of the tibial nerve in the tarsal tunnels. A total of 38 surgeons enrolled 628 patients using the same technique for diagnosis of compression, neurolysis of four medial ankle tunnels, and objective outcomes: ulceration, amputation, and hospitalization for foot infection. Contralateral limb tibial neurolysis occurred in 211 patients for a total of 839 operated limbs. Kaplan-Meier proportional hazards were used for analysis. New ulcerations occurred in 2 (0.2%) of 782 patients with no previous ulceration history, recurrent ulcerations in 2 (3.8%) of 57 patients with a previous ulcer history, and amputations in 1 (0.2%) of 839 at risk limbs. Admission to the hospital for foot infections was 0.6%. In patients with diabetic neuropathy and chronic tibial nerve compression, neurolysis can result in prevention of ulceration and amputation, and decrease in hospitalization for foot infection.

A positive Tinel sign as predictor of pain relief or sensory recovery after decompression of chronic tibial nerve compression in patients with diabetic neuropathy.

Predictive ability of a positive Tinel sign over the tibial nerve in the tarsal was evaluated as a prognostic sign in determining sensory outcomes after distal tibial neurolysis in diabetics with chronic nerve compression at this location. Outcomes were evaluated with a visual analog score (VAS) for pain and measurements of the cutaneous pressure threshold/two-point discrimination. A multicenter prospective study enrolled 628 patients who had a positive Tinel sign. Of these patients, 465 (74%) had VAS >5. Each patient had a release of the tarsal tunnel and a neurolysis of the medial and lateral plantar and calcaneal tunnels. Subsequent, contralateral, identical surgery was done in 211 of the patients (152 of which had a VAS >5). Mean VAS score decreased from 8.5 to 2.0 (p <0.001) at 6 months, and remained at this level for 3.5 years. Sensibility improved from a loss of protective sensation to recovery of some two-point discrimination during this same time period. It is concluded that a positive Tinel sign over the tibial nerve at the tarsal tunnel in a diabetic patient with chronic nerve compression at this location predicts significant relief of pain and improvement in plantar sensibility.

Venous flow-through flap reconstruction following severe finger wound infection: case report.

We report a case of a 22-year-old patient who sustained a box-cutter injury to the index finger on her right hand complicated by severe felon. Extensive tissue debridement left the patient with a defect exposing the underlying flexor tendon. A venous flow-through flap from the right forearm was used to provide coverage, which survived completely without venous congestion. Excellent functional and cosmetic result was achieved with this approach. Because of its similarity in color and non-hair-bearing nature, the venous flow-through flap serves as an excellent approach for volar digital defect coverage in which the underlying flexor tendon is exposed.