Complex reconstruction of the clavicle with a prefabricated medial femur condyle chimeric flap including a superficial circumflex iliac artery perforator flap: A case report.

The medial femur condyle (MFC) cortico-periosteal flap is a popular flap for bone reconstruction. The use of a chimeric version of this flap with a skin island has been described, but anatomical arterial variation can occur that prevent its harvest. Furthermore, the donor area of the skin paddle has been debated as poor because of the scarring in a visible area and because of the difficulty in obtaining pliable thin skin. We present a fabricated chimeric MFC cortico-periosteal flap joined with a superficial inferior epigastric perforator (SCIP) flap to reconstruct and augment a sclerotic and insufficient small clavicula with the skin paddle acting as a monitor and as a substitute for the overlying skin. A 52-year-old female patient had a history of multiple refractures of the right hypoplastic clavicle with a diameter of 7 mm, resulting in a sclerotic bone with a fibrotic scar. The reconstruction was done in one surgical session using a cortico-periosteal flap from the left medial condyle and a thin SCIP flap from the left groin. The area of the clavicle to be reconstructed was 3 cm, and the direct overlying skin (approximately 6 × 3 cm) was severely scarred and painful. The MFC flap was 5 × 4 cm, while the SCIP flap was 7 × 3.5 cm. The SCIP flap artery was anastomosed on the table end-to-side to the descending genicular (DG) artery of the MFC, and the vein was anastomosed end-to-end to a comitans vein of the DG artery. The flap fully survived after an initial congestion. At 12 months, we observed a satisfactory reconstruction of the clavicle with an enhanced diameter of 12 mm. The patient recovered full function of the shoulder with no pain. Using a fabricated chimeric flap composed of a medial femoral condyle and a superficial circumflex artery perforator flap may be an additional option for tailored reconstruction of complex osteo-cutaneous defect of clavicle.

[Joint Arthroplasty with a silastic Spacer in open defect Injuries of a Finger Joint during primary Surgery]. / Der Gelenkersatz mit einem Silikonimplantat bei der Primärversorgung offener Defektverletzungen eines Fingergelenkes.

Silastic spacer replacement for the treatment of destroyed finger joints due to degenerative, post-traumatic or rheumatoid osteoarthritis has been well established for years. In acute severely traumatized hands silastic spacer replacement is seldomly performed We report five consecutive patients in whom a defect injury of a finger joint was replaced by a silicone implant without complications during primary care. We reviewed all our patients with a follow up of at least 8 months. In all patients healing was uneventful, with no infections and a functional range of motion. No patient complained about instability. With the right patient selection, joint replacement with silastic spacers is a valuable alternative to arthrodesis in acute destroyed finger joints.

[An introduction into the use of fabricated chimeric flaps in replantation surgery of digits]. / Das Chimera-fabricata-Lappen-Konzept in der Replantationschirurgie von Fingern ­ eine Einführung.

Since microsurgical finger replantations started to be successfully performed at the beginning of the 1960 s, there has been an evolution in the techniques for restoring blood flow to the amputated fingers. Initially, end-to-end anastomoses were performed. Later on, vascular grafts - predominantly vein interpositional grafts - were successfully used for difficult avulsion injuries. These vascular grafts were extended by microvascular flaps in the form of flow-through flaps in cases with simultaneous soft tissue loss. A further development of these techniques has been achieved by the replantation of amputated fingers with the help of fabricated chimeric flaps. The amputated finger is anastomosed microsurgically with a flap "in tabula" before the actual replantation. Only then is the fabricated chimera replanted as a construct. The latest development so far is heterotopic replantation with secondary replantation in the form a fabricated chimeric flap. By way of introduction, we describe three cases in which we have successfully applied this concept of fabricated chimeric flap surgery for orthotopic thumb replantations.

Interosseous-lumbrical adhesions - a rare condition? A series of five cases.

Adhesions between the interosseous and lumbrical muscles involving the deep transverse metacarpal ligament (dTML) can be a cause of chronic pain and reduced range of motion. New reports on this condition are rare. We identified five patients experiencing pain, swelling and decreased range of motion in the metacarpophalangeal (MCP) joints during manual load. The condition was caused by a direct trauma. After not responding to conservative treatment, patients underwent surgery. Time between trauma and surgery was on average 16 months and the mean postoperative follow-up was 8 months. The lumbrical-interosseus junction was exposed by volar or dorsal incision, adhesions were widely released and the distal third of the dTML was resected. This resulted in normal passive excursion of the muscles and the tendon junction. At the mean follow-up time 8.2 months (3-18) after surgery, all patients were pain-free and had gained near normal range of motion in the MCP joints. Interosseous-lumbrical adhesions may be more common than reflected by the literature. Hand surgeons should keep this condition in mind in cases with chronic inter-metacarpal pain after trauma or infection. Surgical exploration is relatively straight forward and tends to lead to gratifying results. Level of Evidence: IV (therapeutic).

A New Proximal Dorsal Approach for DIP Arthroplasty.

Degenerative changes of the distal interphalangeal (DIP) joints can be painful, disabling, and disfiguring. Swanson spacers can be used for DIP arthroplasty. The standard approach for Swanson spacer implantation at the DIP joint involves transecting the extensor tendon close to its insertion, which necessitates a 6-week period of postoperative immobilization. Another DIP approach involves sparing the extensor tendons, as already published. Both techniques lead to a similar range of motion of the replaced DIP joints. We present a novel approach for DIP joint arthroplasty with division of the extensor tendon in zone 2 with only 2 weeks of postoperative immobilization. Optimizing the motion-preserving operative approaches is of value to our high-demand patients. Postoperative results do not differ from the postoperative range of motion published in the literature for both tendon-sparing and standard approaches. But our approach is technically easy and requires a significantly shorter time of immobilization.

Corticoperiosteal medial femoral condyle flap for recalcitrant nonunion in ankle and foot: Outcomes and radiological evaluation of donor site morbidity.

BACKGROUND: The aim of this study was to evaluate the effectiveness and safety of free corticoperiosteal medial femoral condyle (MFC) flap for ankle, hindfoot and midfoot reconstruction in patients with recalcitrant nonunion. METHODS: Patients who underwent ankle and foot reconstruction using the MFC flap at our clinic were recruited for assessment of the union rate, time to union and functional outcome. Furthermore, a clinical and radiological examination of the donor knee was performed using both computed tomography and magnetic resonance imaging. RESULTS: Thirteen patients with a mean follow-up time of 2.5 years were included; 10 of them had a previously failed ankle and foot arthrodesis. Union was achieved in 11 patients in an average time of 10 months after MFC flap surgery. Donor site morbidity was minor with no radiological evidence for soft tissue or bone complication. CONCLUSION: MFC flaps are a useful and safe reconstructive tool and may be considered after failed ankle and foot arthrodesis.

Hand and wrist joint procedures in patients with scleroderma: a systematic review.

We aimed to examine if joint procedures in hands and wrists of patients with scleroderma could be performed without major morbidity and conducted a systematic review of the literature to assess this hypothesis. Studies were identified in four different databases; soft tissue procedures in scleroderma patients were excluded, and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. Seven studies out of an initial total of 203 articles were included. One-hundred and twelve scleroderma patients with a total of 402 joint procedures in the hand and wrist were identified. A low complication incidence, comparable with that of non-sclerodermic population, in terms of infection, wound healing problems, and nonunion was reported in all studies. The application of joint procedures in scleroderma hands and wrists seems to be associated with low morbidity.

Percutaneous Intramedullary Headless Screw Fixation and Wide-Awake Anesthesia to Treat Metacarpal Fractures: Early Results in 25 Patients.

Metacarpal fractures constitute 7.8% of the upper extremity fractures. The common treatments remain nonsurgical procedure, but high-demanding patients or unstable fractures require fixation with Kirschner wire (K-wires), plate, and screws. However, these approaches may cause scarring and adhesion with poor functional results. From 2014 to 2015, the authors used an intramedullary headless screw to treat 25 patients (24 men, 1 woman) with metacarpal bones fractures (20 V, 3 IV, 1 III, and 1 II). The fractures patterns were 23 fractures of distal third of metacarpal bone (16 oblique, 5 comminute configurations, and 2 transverse), 1 fracture of the base of the II metacarpal bone. One case presented a multiple metacarpal and phalangeal facture associated. The authors used wide-awake anesthesia (bupivacaine-epinephrine 1:100,000) and intramedullary titanium headless screw fixation percutaneously inserted (CCS Medartis and HCS Synthes 3 mm of diameter). No open reduction was needed. Early active mobilization started with a buddy strapping soon after surgery (0-3 days). The authors followed all patients until satisfactory function was achieved (4-6 weeks) and recorded the time till return to work. All fracture healed with less than 5 degrees of rotational or axial deformities. All patients return to work within 2.38 weeks after surgery (0.5-6 weeks). No cases of complex regional pain syndrome (CRPS), tendon lesions, nerve injuries, infection, hardware protruding, or mobilization were reported. Intramedullary screw fixation with wide-awake anesthesia for transverse, oblique, and select comminuted fractures treatment metacarpal fractures represent a reliable option to early active mobilization recovery and a quick return to the work and ordinary activities.

Sonographic study of repair, gapping and tendon bowstringing after primary flexor digitorum profundus repair in zone 2.

We report sonographic findings with clinical outcomes after zone 2 flexor digitorum profundus tendon repairs in ten fingers. The tendons underwent a six-strand M-Tang core repair, no circumferential suture, and partial or complete division of the pulleys. Over 12 months after surgery and using ultrasound, we found no gapping at the repair site during finger motion. When the pulleys were divided, there was sonographic evidence of tendon bowstringing, but the bowstringing was minimal. Clinically, we did not find any fingers that displayed tendon bowstringing or had functional loss. With ultrasound examination, the repaired tendons remained enlarged over 12 months. Two patients developed heterotopic ossifications at the repair site without tendon gliding, and these required tenolysis. We conclude that the tendon repair site does not gap when a strong core suture is used in the repair without adding peripheral sutures. There is no notable tendon bowstringing clinically, though the repaired tendons have sonographic evidence of minor bowstringing. LEVEL OF EVIDENCE: III.

Flexor tendon repair in the hand with the M-Tang technique (without peripheral sutures), pulley division, and early active motion.

We report outcomes in 29 patients with flexor tendon repairs in 32 digits (five thumbs and 27 fingers) with our modified protocols. We repaired the lacerated flexor digitorum profundus tendons with core suture repairs using the 6-strand M-Tang method and without circumferential sutures. We divided the pulleys as much as needed to allow excursion of the repaired tendons, including complete division of the A4 or A2 pulleys when necessary. In nine fingers, we repaired one slip of the flexor digitorum superficialis tendon and resected the other half. When the flexor digitorum profundus tendon would not glide under the A2 pulley, we excised the remaining slip of the flexor digitorum superficialis tendon. The wrist was splinted in mild extension post-surgery with early commencement of tenodesis exercises. No tendon repair ruptured. By the Strickland criteria, out of 27 fingers, 18 had excellent, six had good, two had fair, and one had poor results. We conclude that a strong core suture (such as the M-Tang repair) without peripheral sutures, and with division of pulleys as necessary is safe for early active motion and yields good outcomes. LEVEL OF EVIDENCE: IV.

The novel treatment of SVF-enriched fat grafting for painful end-neuromas of superficial radial nerve.

INTRODUCTION: None of the existing treatments in the management of painful end-neuromas of the superficial branch of the radial nerve (SBRN) has been proven superior due to high levels of pain relapse. Fat grafts enriched with the stromal vascular fraction (SVF) could act as a mechanic barrier with biological effects decreasing the resorption rate and boosting the graft's regenerative potential. This study describes the novel surgical treatment technique of SVF-enriched fat grafting. PATIENTS AND METHODS: In this clinical study, five consecutive patients treated for painful end-neuromas of the SBRN between 2012 and 2013 were analyzed retrospectively. Microsurgical resection of end-neuromas followed by SVF-enriched fat grafting around the nerve stump was performed in all patients. Five different pain modalities and various predictors were compared pre- and up to 36 months postoperatively. RESULTS: Pain reduction observed at 2 months after surgery was constant over time, though not statistically significant compared to preoperative levels. Spontaneous pain could be reduced from 1.6 ± 0.55 to 1.2 ± 1.1 (p = 0.414), spikes from 2.2 ± 1.3 to 1.4 ± 1.34 (p = 0.180), hyperaesthesia from 1.6 ± 1.14 to 1.2 ± 1.64 (p = 0.713), tap pain from 2.8 ± 0.45 to 1.8 ± 1.3 (p = 0.197) and motion pain from 2.8 ± 0.45 to 1.4 ± 1.34 (p = 0.066). An improvement in overall pain reduction could be observed from 2.2 ± 0.97 to 1.4 ± 1.26 3 years after the surgery (p = 0.104). CONCLUSION: SVF-enriched fat grafting represents another alternative to numerous available treatments of painful end-neuromas of the SBRN. Our preliminary results could not show any significant difference in pain reduction following SVF-enriched fat grafting. Further larger trials are required in order to evaluate the therapeutic potential of SVF-enriched fat grafting.

Stromal Vascular Fraction-enriched Fat Grafting for the Treatment of Symptomatic End-neuromata.

The purpose of this study was to methodically illustrate and highlight the crucial steps of stromal vascular fraction (SVF)-enriched fat grafting as a novel treatment of symptomatic end-neuromata of peripheral sensory nerves, and in this study, specifically of the superficial branch of the radial nerve (SBRN). Despite a multitude of existing treatments, persistent postoperative pain and common pain relapse are still very common, independent of the procedure assessed. The neuroma is microsurgically excised accordingly to standardized protocol. Instead of the relocation of the regenerating nerve stump in neighboring anatomical structures, such as muscle or bone, a fat graft is applied perifocally and acts as a mechanical barrier. In order to reduce the fat resorption rate and boost the regenerative potential of the graft, the highly concentrated SVF is integrated in the grafting. The SVF is isolated from subcutaneous fat by enzymatic and mechanic separation of the lipoaspirate by a specific commercial isolation system. The SVF-enriched fat graft provides both a mechanical barrier and various biological effects at the cellular level, including improving angiogenesis, inflammation, and fibrosis. Both mechanical and biologic effects help to reduce the disorganized axonal outgrowth of the nerve stump during nerve regeneration and hence prevent the recurrence of painful end-neuromata.

Closed mallet thumb injury treated surgically: a case report.

In this report a case of closed mallet thumb injury is described, which was diagnosed clinically and indication for surgical treatment was confirmed with ultrasound examination. The EPL-tendon was successfully reconstructed with an excellent result. We propose a mandatory ultrasound examination of all closed mallet thumb injuries.

Evaluation of Cutaneous Spatial Resolution and Pressure Threshold Secondary to Digital Nerve Repair.

BACKGROUND: As the sophistication of functional reconstruction procedures continues to increase, so does the need for valid, precise, and reliable instruments to assess their clinical results. The authors compare two tests for spatial resolution and two for cutaneous pressure threshold in an adult patient cohort having undergone microsurgical digital nerve repair after traumatic transection. METHODS: Patients who underwent epineural coaptation after digital nerve transection at the authors' institution between June of 2006 and December of 2011 were asked to participate in a follow-up examination assessing spatial resolution (two-point discrimination and grating orientation test) and cutaneous pressure threshold (Semmes-Weinstein monofilament test and pressure-specifying sensory device). Interinstrument correlations were conducted and critically elucidated. RESULTS: Eighty-one patients (26 female and 55 male patients; median age, 42 years; interquartile range, 23 years) were examined with a mean follow-up period of 3.5 ± 1.4 years. Although all tests could differentiate between the healthy and operated fingers, poor to moderate correlations were found between two-point discrimination and grating orientation test (ρ(operated) = 0.483, p < 0.0001; ρ(healthy) = 0.350, p < 0.0001), and between Semmes-Weinstein monofilament test and Pressure-Specified Sensory Device testing (ρ(operated) = 0.287, p = 0.01; ρ(healthy) = 0.382, p < 0.001), indicating that they measure different properties. Altogether, the grating orientation test proved superior to two-point discrimination, whereas Pressure-Specified Sensory Device testing was superior to Semmes-Weinstein monofilament testing. CONCLUSIONS: Thoughtful use of test instruments is advisable when assessing sensibility of the hand. This study suggests including Pressure-Specified Sensory Device testing to assess cutaneous pressure threshold and the grating orientation test to assess spatial resolution in clinical, routine test batteries. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, III.

Gas-Phase Spectroscopic Detection and Structural Elucidation of Carbon-Rich Group 14 Binary Clusters: Linear GeC3Ge.

Guided by high-level quantum-chemical calculations at the CCSD(T) level of theory, the first polyatomic germanium-carbon cluster, linear Ge2C3, has been observed at high spectral resolution in the gas phase through its remarkably complex fundamental antisymmetric C-C stretching mode ν3 located at 1932 cm(-1). The observation of a total of six isotopic species permits the derivation of a highly accurate value for the equilibrium Ge-C bond length. The present study suggests that many more Ge-C species might be detectable in the future using a combination of laser-ablation techniques for production and high-resolution infrared and/or microwave techniques for spectroscopic detection.

Treatment of Painful Nonunion of the Distal Phalanx in the Finger With Bone Graft and Dorsal Reverse Adipofascial Flap Based on an Exteriorized Pedicle.

Reconstruction of the distal phalanx bone in cases with painful nonunion is a rare and challenging problem. To restore anatomy and to provide a good cover for the bone graft, an intact nailbed is often required due to the proximity of these 2 structures. We present 3 cases of distal phalanx reconstruction performed with a free corticocancellous bone graft from the distal radius and nailbed reconstruction with a homodigital dorsal reverse adipofascial flap based on an exteriorized pedicle that avoids the dissection of the germinal matrix of the nail. All bone grafts consolidated and all flaps survived. All nail plates grew back with no deformity. In this rare but challenging problem, our combined technique appears to be a valid option that enhances the possibility of good bone healing and maximizes the cosmetic result.

A systematic review of animal models for experimental neuroma.

Peripheral neuromas can result in an unbearable neuropathic pain and functional impairment. Their treatment is still challenging, and their optimal management is to be defined. Experimental research still plays a major role, but - although numerous neuroma models have been proposed on different animals - there is still no single model recognised as being the reference. Several models show advantages over the others in specific aspects of neuroma physiopathology, prevention or treatment, making it unlikely that a single model could be of reference. A reproducible and standardised model of peripheral neuroma would allow better comparison of results from different studies. We present a systematic review of the literature on experimental in vivo models, analysing advantages and disadvantages, specific features and indications, with the goal of providing suggestions to help their standardisation. Published models greatly differ in the animal and the nerve employed, the mechanisms of nerve injury and the evaluation methods. Specific experimental models exist for terminal neuromas and neuromas in continuity (NIC). The rat is the most widely employed animal, the rabbit being the second most popular model. NIC models are more actively researched, but it is more difficult to generate such studies in a reproducible manner. Nerve transection is considered the best method to cause terminal neuromas, whereas partial transection is the best method to cause NIC. Traditional histomorphology is the historical gold-standard evaluation method, but immunolabelling, reverse transcriptase-polymerase chain reaction (RT-PCR) and proteomics are gaining increasing popularity. Computerised gait analysis is the gold standard for motor-recovery evaluation, whereas mechanical testing of allodynia and hyperalgesia reproducibly assesses sensory recovery. This review summarises current knowledge on experimental neuroma models, and it provides a useful tool for defining experimental protocols. Furthermore, it could help future research to define standard experimental model(s) of peripheral neuromas, allowing better comparison of results and improvement of our understanding of such a complex disease.

Retrograde arterialized free venous flaps for the reconstruction of the hand: review of 14 cases.

PURPOSE: Although the literature is encouraging with regard to the survival rate of arterialized free venous flaps, previously reported difficulty in healing owing to early venous congestion and subsequent epidermolysis continues to prevent their widespread application. We report 14 arterialized free venous flaps for primary reconstruction of the hand, with inflow in the arterialized vein running against the valves. METHODS: Between February 2010 and May 2012, we performed 14 arterialized free venous flaps, each of which included at least 2 veins running in parallel. The arterialized vein was anastomosed in a retrograde manner, with the inflow running against the valves. All flaps were customized with regard to dimension, shape, quality of skin, pedicle length, vessel size, inclusion of additional anatomical structures, and donor site. The flaps were used to cover small, medium, and large defects; 2 flaps were larger than 100 cm(2). Three flaps were injected with indocyanine green on the table after harvesting, to visualize the vascular tree of the flap. These 3 flaps were then monitored with systemic indocyanine green injection and an infrared camera for 3 days postoperatively. RESULTS: All but 1 flap survived. Venous congestion and epidermolysis were observed in 2 small flaps. The flaps injected with indocyanine green displayed a ramified vascular tree with no arteriovenous flow-through phenomenon. CONCLUSIONS: Arterialized free venous flaps with retrograde arterial flow offer thin and pliable coverage that fits easily around the contours of the hand. They are easy to harvest, with little donor site morbidity. Tendons or nerves can be incorporated for reconstruction of composite defects. CLINICAL RELEVANCE: Our series suggests the possibility of routine use of a free venous flap with retrograde arterial flow for reconstruction of the hand. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.