Hemodynamics in Distally Based Sural Flaps for Lower Leg Reconstruction: A Literature Review.

Coverage of posttraumatic and chronic wounds at the distal leg is a difficult problem due to limited soft tissue available for local flaps. The sural flap is a versatile and effective method for reconstruction in this area since it does not need a significant amount of time or assistance to complete. Improving the survival of these flaps is critically dependent on understanding the basics of flap circulation and why recent modifications were introduced. This review will serve as a much-needed comprehensive analysis of these topics for surgeons looking to increase the reliability of their sural flaps.

Long Head of Triceps Tendon Transfer for Agenesis of Biceps and Brachialis: Two Cases.

Congenital lack of elbow flexion results in significant disability and may be seen in conjunction with syndromes, plexopathies, neuromuscular disorders, or as an isolated muscular agenesis of elbow flexors. There are many tendon transfer options to address this issue, but there is a lack of data on the functional results in the pediatric population. In this series, we present 1 patient with isolated muscular agenesis of the biceps and brachialis musculotendinous units and another with this same muscular agenesis in the setting of arthrogryposis. They were treated with anterior ulnar nerve transposition and transfer of the long head of triceps tendon around 2 years of age resulting in functional elbow flexion in both patients.

Delayed perfusion evaluation in extremity trauma.

After severe trauma to an extremity, it is essential to achieve a stable and non-infected wound in order to facilitate the best outcome following reconstruction. That said, timely, meticulous and adequate debridement is very important. To facilitate the best possible debridement of the wound, it is important to understand the tissue circulation. One available method to evaluate tissue circulation following extremity trauma is indocyanine green (ICG) angiography. Though playing an important role in flap surgeries, ICG may also provide information regarding the perfusion at the zone of injury while circulation quality diminishes. We present a case where ICG angiography initially showed good circulation in a mangled extremity, but later used in alternative way to display lack of flow in the same area of interest.

Management of Highly Comminuted Intra-articular Fracture Subluxations at the Proximal Interphalangeal Joint by Subchondral Buttress Fixation and Early Mobilization.

This article describes our technique of managing highly comminuted intra-articular fracture subluxations at the proximal interphalangeal joint by subchondral buttress fixation followed by early mobilization. This technique has proven to be reliable and all patients have been able to return to their preinjury level of activity.

Surgical Technique for Harvesting ECRL and ECRB Concurrently as Upper Extremity Tendon Autograft.

Upper extremity tendon autograft harvest has many indications and techniques. Many harvest sites provide only 1 single autograft and/or require surgical set up of more extremities than the primary one of interest. In this report, we describe an easily reproducible, quick, and low-morbidity technique using both the wrist extensors-extensor carpi radialis longus and extensor carpi radialis brevis, from near their distal attachments to their musculotendinous junctions proximally-as a source of tendon autograft for a variety of applications.

A Vascular Malformation in the Hand with Compromised Neurologic Status.

BACKGROUND: Vascular malformations of the hand are rare vascular malformations that are challenging to treat. METHODS: We present a case of a large vascular malformation with left hand pain and decreased sensation of the small and ring fingers. The lesion was treated operatively with surgical excision. RESULTS: The malformation was successfully removed surgically, and pain resolved and numbness recovered by 2 weeks after surgery. CONCLUSIONS: This is a rare case of large vascular malformation in the hand with compromised neurologic status. Surgical treatment provided complete relief of the disease, and the patient returned to normal daily activities.

The radial and ulnar collateral ligaments of the wrist are true ligaments.

PURPOSE: Our hypothesis in this study is that the radial and ulnar collateral ligaments of the wrist exist and are true ligaments which can be visualized by high-resolution ultrasonography (US). METHODS: High-resolution US examination of the radial and ulnar collateral ligaments of the wrist was performed on 56 fresh cadaveric wrists. The visibility of these ligaments was assessed by four observers who classified the ligaments in consensus as well seen, adequately seen, or not seen. Surgical dissections of 12 radial collateral ligaments and 12 ulnar collateral ligaments were then performed and the ligaments were classified as present or absent. The US and dissection results were then compared. To confirm that the dissected structures represent true ligaments a histologic examination of the ligaments was performed. RESULTS: All examined radial and ulnar collateral ligaments were seen on the US examination. The radial collateral ligament was seen between the radial styloid and radial aspect of the scaphoid. The ulnar collateral ligament was seen between ulnar styloid process and the triquetrum. On all surgical dissections, the radial collateral ligament was present at the floor of the first extensor compartment and the ulnar collateral ligament was at the floor of the sixth extensor compartment. Both ligaments were proven to be true capsular ligaments on both dissection and histologic examinations. CONCLUSION: The radial and ulnar collateral ligaments of the wrist are true ligaments and can be seen at the floor of the first and the sixth extensor compartments, respectively, using high-resolution US. Based on their anatomic location, they most likely provide static stability to the wrist joint.

Spontaneous Regeneration of Medial Cuneiform Following Gunshot Wound.

Level of Evidence: Level V, expert opinion.

Ulnar Nerve Injury as a Result of Galeazzi Fracture: A Case Report and Literature Review.

BACKGROUND: Sparse documentation of Galeazzi fracture with associated nerve injury exists in the medical literature. The purpose of this report is to review the available literature in regard to incidence, nerve injury type, treatment strategies, and expected outcomes. METHODS: We present a classic Galeazzi fracture dislocation with associated complete ulnar nerve transection injury at the level of the wrist. After rigid internal bony stabilization, allograft nerve repair was performed. The patient's presentation, operative management, recovery, and a thorough literature review are discussed. RESULTS: Fracture union was attained with near full wrist and elbow range of motion. Despite lack of ulnar nerve function return, the patient was able to resume manual labor occupation. CONCLUSIONS: Despite its close proximity to the dislocating distal radioulnar joint (DRUJ), thorough review reveals rare associated ulnar nerve palsy. If there is suspicion for nerve injury in the setting of open DRUJ dislocation, the nerve should be explored to identify possible entrapment or transection. Literature supports likely return of nerve function in cases of intact nerve; however, management of nerve transection remains debatable.

Disseminated sporotrichosis in an immunocompetent patient.

Sporothrix schenckii, the causative agent of sporotrichosis, is a relatively rare infection. Local infection usually occurs through direct inoculation of the organism through the skin; disseminated disease is rarely seen. This article describes a case of disseminated sporotrichosis in a middle-aged man without the commonly seen risk factors for dissemination.

Extensor tendon gap reconstruction: a review.

BACKGROUND: The extensor tendons of the hand are located in a superficial position on the dorsal aspect of the hand and are highly susceptible to injury. Laceration, crush and avulsion injuries are common extensor tendon injuries presenting for acute care. Such injuries that involve tendon loss or gaps in the extensor tendons require specialised attention and can be some of the most challenging to repair, as extensor tendons have less excursion than flexor tendons. Reconstructive techniques for such defects may differ according to the location of the defect, especially in Verdan's extensor zones 1-5. Adequate repair of extensor tendon defects in zones 1-5 is especially important because (a) even a 1 mm tendon gap in those zones may cause 20° extension loss, and (b) shortening of the extensor tendon by as little as 1 mm may cause decreased finger flexion. REVIEW: This article reviews and discusses the literature on the various approaches and techniques for extensor tendon reconstruction, delineated by zone of injury (zones 1-8). CONCLSIONS: Awareness of the various techniques available to repair defects in each zone of injury is important so that surgeons can choose the technique most in alignment with the type of injury, the surgeon's skills, and patient characteristics, and optimise the repair of such injuries.

A Methodology for Determining Standard of Care Status for a New Surgical Procedure: Hand Transplantation.

BACKGROUND: Hand allotransplantation was initially criticized as unethical and unlikely to succeed. The results proved to be better than anticipated, now raising the issue of whether hand transplantation is the standard of care. The purpose of this article is to outline a reasonable methodology for determining whether a surgical procedure is the standard of care, and then to apply that methodology to hand transplantation. METHODS: Publications on ethics and definitions of medical (not legal) standard of care were reviewed. All hand transplantations completed in the United States were evaluated regarding their status as experimental, standard of care, or both. Then, the stakeholders, physicians, public insurers, and regulators were examined to determine whether they accepted hand transplantation as the standard of care. Utility and incremental cost-utility ratio were determined. Hand transplantation was considered the standard of care when stakeholders were using, insuring, and regulating the procedure. RESULTS: The public expresses a desire for hand transplantation. A minority of surgeons consider the procedure the standard of care. Ethical committees, institutional review boards, and scholarly articles deem the procedure ethical. A series of institutions have carried out the procedure with a record of successes. Some institutions perform the surgical procedure as the standard of care. Scholarly work demonstrates beneficial outcomes. Some commercial and federal government insurers are willing to cover the cost of the procedure. Utility determination justifies the procedure. There are no incremental cost-utility ratio analysis studies that justify the procedure. CONCLUSION: Hand transplantation is moving from acceptance as an ethical surgical experiment to the standard of care.

A Statistical Comparative Assessment of Face and Hand Transplantation Outcomes to Determine Whether Either Meets the Standard of Care Threshold.

BACKGROUND: Hand and face transplantation has established itself as a clinical option for certain reconstructive problems. The purpose of this study was to carry out a rigorous statistical analysis of all hand and face transplantations to determine whether hand and/or face transplantation is the standard of care. METHODS: Data from September of 1998 until March of 2014 on all hand and face transplantations in the world were obtained through publications, news articles, personal communications, and presentations. Data on solid organ transplantation were obtained from the Scientific Registry of Transplant Recipients for comparison with the results of hand transplantation. Resampling and permutation statistical analysis was used to compare structured cohorts of hand, face, and solid organ transplantation. RESULTS: Routine immunosuppression can achieve intermediate- to long-term graft survival in hand transplantation that is empirically superior to solid organ transplantation. Chronic rejection in hand transplantation is statistically significantly less than in solid organ transplantation. Renal failure in hand and face transplantation is empirically less than in solid organ transplantation. Bone marrow transplant with hand transplantation produces both statistically superior and statistically inferior results compared with hand transplantation without bone marrow. In hand transplantation, acute rejection does not seem to increase late allograft loss. The function of hand transplantation is statistically significantly superior to prosthesis yet inferior to hand replantation. Not all hand and face transplants have good results, yet those hand transplants completed within certain parameters obtain excellent results. CONCLUSIONS: Certain hand transplants arguably can be considered the standard of care. Face transplantation requires more time and patient numbers and a clearer definition of inclusion and exclusion criteria before standard of care assessment can be made.

Deepithelized posterior interosseous artery flap for 3-dimensional defect coverage in the hand.

The posterior interosseous artery (PIA) flap is a pedicle flap that can be harvested at the posterior forearm based on blood supply from the PIA and its concomitant veins. The flap can be used for posttrauma coverage of exposed bones, tendons, and defects; for treatment of a surgical wound; or as a spacer in congenital or burn-related contracture releases. The surgical technique has been reported with limited donor morbidity and few complications to cover exposed structures. In this article, we present our methods and experience using a modification of the posterior interosseous flap that was deepithelized to fill a 3-dimensional cavity in the hand. This method has been successfully used, and the example of the patient shows good outcome, function, and range of motion with no significant complications. The deepithelized PIA flap is a technique that surgeons may add to their toolbox for 3-dimensional defect coverage in the hand. It offers the following advantages: (a) technically uncomplicated; (b) does not create significant donor site morbidity; (c) does not sacrifice any major vessels; and (d) provides good cosmetic appearance, especially in the dorsum of the hand.

Hand infections: a retrospective analysis.

Purpose. Hand infections are common, usually resulting from an untreated injury. In this retrospective study, we report on hand infection cases needing surgical drainage in order to assess patient demographics, causation of infection, clinical course, and clinical management. Methods. Medical records of patients presenting with hand infections, excluding post-surgical infections, treated with incision and debridement over a one-year period were reviewed. Patient demographics; past medical history; infection site(s) and causation; intervals between onset of infection, hospital admission, surgical intervention and days of hospitalization; gram stains and cultures; choice of antibiotics; complications; and outcomes were reviewed. Results. Most infections were caused by laceration and the most common site of infection was the palm or dorsum of the hand. Mean length of hospitalization was 6 days. Methicillin-resistant Staphylococcus aureus, beta-hemolytic Streptococcus and methicillin-susceptible Staphylococcus aureus were the most commonly cultured microorganisms. Cephalosporins, clindamycin, amoxicillin/clavulanate, penicillin, vancomycin, and trimethoprim/sulfamethoxazole were major antibiotic choices. Amputations and contracture were the primary complications. Conclusions. Surgery along with medical management were key to treatment and most soft tissue infections resolved without further complications. With prompt and appropriate care, most hand infection patients can achieve full resolution of their infection.

Zone I extensor reconstruction with tendon salvaged from another finger.

Laceration, crush, and avulsion injuries are common acute extensor tendon injuries. Simple lacerations may often be repaired in the emergency room, but crush or avulsion injuries may involve tendon loss and gaps in the extensor tendons. Reconstruction can be difficult. The purpose of this article is to present a salvage technique for reconstruction of large extensor tendon gaps in extensor zone I in patients with severe injuries to multiple fingers. This technique, in which a tendon is transplanted from an unsalvageable finger to another with a terminal tendon gap in the same patient, may be a reasonable remedy for reconstruction of tendon loss or gaps and may offer advantages over other traditional reconstructive techniques in certain cases.

Hypotheses for ongoing evolution of muscles of the upper extremity.

There are organs and muscles in the human body that may be considered rudimentary in that they have insignificant or undetermined function. Several such muscles are found in the upper extremity. In this review, four muscles that appear to be undergoing evolutionary changes are discussed: flexor digitorum superficialis to the fifth finger, anconeus, palmaris longus, and anconeus epitrochlearis. The present study synthesizes, advances and extends previously described work about these muscles and extends the hypotheses and concludes that: (a) the flexor digitorum superficialis to the fifth finger is currently under adaptive evolution, (b) the anconeus has currently stabilized its evolution and is serving as a transient stability augmenter during a short portion of the human lifespan, and (c) the entire distal upper extremity is currently in the process of undergoing evolutionary change. Understanding of these muscles and their evolutionary context is important for understanding of impact on function, dysfunction, treatment and future research.

Response of dupuytren fibroblasts to different oxygen environments.

PURPOSE: It is thought that local ischemia and oxygen radicals are responsible for fibroblast-to-myofibroblast cell transformation and proliferation. We hypothesized that hypoxia could differentially activate the contractility of fibroblasts from normal human palmar fascia and from fibroblasts-myofibroblasts of Dupuytren cords. METHODS: Normal palmar fascia from 5 patients with carpal tunnel syndrome and Dupuytren cords from 5 patients were harvested. Cells were cultured from all tissue samples, and collagen lattices were prepared containing these cells. Oxygen treatment subgroups were created and incubated under hypoxic (1% O(2), 5% CO(2), and 94% N(2)), normoxic (21% O(2), 5% CO(2), and 74% N(2)), and hyperoxic (100% oxygen using 2.4 atm pressure twice a day for 7 d) conditions. After 7 days, each subgroup was photographed, and lattices were released from dishes. Postrelease photographs were taken immediately, 5 minutes after release, and after 1 hour. Areas of the lattices at each time point were calculated using MetaMorph software. Actin staining and live/dead cell analysis was performed. Linear repeated measures analysis of variance was used for data analysis given that contraction levels were measured over 3 distinct time points. RESULTS: We found a statistically significant difference between normal samples and Dupuytren samples in mean contraction levels over time. There was no statistically significant difference between tissue groups over the 3 time periods based on the oxygen treatment received. CONCLUSIONS: Our results showed a greater degree of contractility in Dupuytren disease cells than normal fibroblasts. However, the contraction in either group was not affected by oxygen level. Future in vivo research is needed to better understand the nature of pathophysiology of Dupuytren disease.