Direct comparison of postoperative monitoring of free flaps with microdialysis, implantable cook-swartz Doppler probe, and clinical monitoring in 20 consecutive patients.

BACKGROUND: There is an increasing demand for successful free tissue transfer, with postoperative monitoring of flaps a key to early salvage. Monitoring methods have ranged from clinical techniques to invasive options, of which two are particularly applicable to buried flaps (Cook-Swartz Doppler probe and microdialysis). The evidence for these options has been represented largely in separate cohort studies, with no single study comparing these three techniques. We aim to perform this comparison in a single cohort of patients. METHODS: A prospective, consecutive cohort study comparing clinical monitoring, microdialysis and the implantable Doppler probe was undertaken. In 20 patients receiving 22 flaps, 21 flaps were monitored with microdialysis, 18 flaps with clinical observation, and 21 flaps with the Cook-Swartz Implantable Doppler probe. Exclusion was based on applicability and availability intra-operatively. Efficacy was assessed through sensitivity, specificity, positive, and negative predictive values. RESULTS: Nineteen of 22 flaps had no suspected anastomotic problems; 3 of 22 flaps were explored for anastomotic problems, with two salvaged and one lost. The implantable Doppler and microdialysis were found to detect flap statistically earlier than clinical assessment, with microdialysis better at detecting flap compromise: 100% specificity (confidence interval 31-100%) when compared to the implantable probe and clinical assessment (67%: 13-98% and 33%: 2-87%, respectively). CONCLUSIONS: Each of the Cook-Swartz Doppler probe, microdialysis and clinical assessment was found suitable for monitoring in free tissue transfer. The implantable Doppler and microdialysis offer the potential for earlier detection of flap compromise.

Developments in image-guided deep circumflex iliac artery flap harvest: a step-by-step guide and literature review.

PURPOSE: The deep circumflex iliac artery (DCIA) flap has evolved significantly over time in the intricacies of flap design and breadth of surgical application. This has been facilitated by advances in preoperative imaging and planning, in particular, computed tomographic angiography. Studies have highlighted that advanced imaging modalities and other technologies such as image-guided stereolithographic biomodeling can substantially improve flap planning, flap harvest, and operative outcomes. PATIENTS AND METHODS: The present report comprises a combined literature review and clinical cohort study of 20 consecutive patients to assess the modern technologies applied to DCIA flap planning and harvest. We have also described a step-by-step guide for the implementation of these techniques into clinical practice. RESULTS: The protocol for a single, standardized technique of computed tomographic angiography scanning is presented and was applied to a range of techniques in the preoperative planning of DCIA flaps. These include 1) bony and vascular imaging analysis of both donor and recipient sites, 2) stereolithographic "biomodeling" of both donor and recipient bony and vascular anatomy, and 3) the use of preoperative "virtual surgery" with image-guided stereotactic navigation. The application and role of each technique was explored. CONCLUSIONS: Modern imaging and stereolithographic techniques are innovations that can substantially improve surgical outcomes in DCIA flap surgery, such as has been highlighted in our clinical experience and in published studies. Notably, few outcome studies have been reported, and the need for larger case series and comparative studies is apparent.

Digital neural loops: classification and implications of variation in hand surgery.

BACKGROUND: The "neural loop" describes a digital artery passing through a digital nerve, after which both the structures progress distally to supply the digit. While rare, past descriptions refer to neural loops located around the common palmar digital arteries, with no reports of more distal loops. METHODS: We describe a case in which a distal neural loop was identified, with the ulnar proper palmar digital nerve (PPDN) to the long finger split, and reconstituted around the radial proper palmar digital artery (PPDA) to the ring finger. This variation was explored within the previously reported classification systems for such neural loops in the literature. RESULTS: Previously reported neural loops have been localized to the palm, without report of formation of a neural loop by the penetration of a PPDA. A new classification of neural loops is presented in this context on the basis of anatomical location. CONCLUSION: This new model, of separating neural loop position into anatomical levels, provides more information to the hand surgeon when dissecting and raising vascular pedicles for flaps reconstruction.

The vascular basis of the hemi-hamate osteochondral free flap. Part 2: surgical anatomy and clinical application.

PURPOSE: The free vascularised hemi-hamate flap combines the utility of providing a small osteochondral portion of hamate for reconstruction, while providing a means of vascularisation to preserve articular cartilage after transfer. In Part 1 of this series, we highlighted the vascular approaches to such a technique. The current study investigates the bony architecture of the hamate, with particular emphasis on its utility for a range of osteochondral defects in the hand. METHODS: A morphometric assessment of the hamate as a potential osteochondral flap donor site for resurfacing digital phalangeal heads (either total or unicondylar) and/or bases was thus undertaken. This anatomic study was undertaken using in vivo imaging performed for a range of clinical indications, with computed tomographic angiography (CTA) and digital subtraction angiography (DSA) of the upper limb included. Bony and vascular measurements and relationships were recorded and assessed both quantitatively and qualitatively. A clinical case is presented, highlighting the application of these measurements. RESULTS: The mean digital artery diameter was 0.7 mm with a mean distance between digital artery and interphalangeal joint surface (i.e. pedicle length) of 1.18 mm. Mean hamate dimensions comprised a transverse width 16.62 mm, lateral width of 14.29 mm and ridge height of 1.43 mm. Measurements of the phalangeal bases, condyles and total phalangeal heads were recorded, and the optimal hamate harvest approaches demonstrated. Despite perceived differences, in all cases there was statistical similarity demonstrated between the fragments. CONCLUSION: The hemi-hamate osteochondral flap can be applied to a range of osteochondral defects in the hand and may offer new options to the hand surgeon.

The vascular basis of the hemi-hamate osteochondral free flap. Part 1: vascular anatomy and clinical correlation.

PURPOSE: The treatment of comminuted fractures of the proximal interphalangeal joint is highly challenging due to the complexities of joint bio-mechanics and stability. The hemi-hamate osteochondral auto-graft has been popularised in this role, able to replace articular loss and restore joint stability. Recent evaluation of their long-term follow-up however has shown the early development of osteoarthritis and potential early cartilage loss, which may be due to the non-vascularised nature of the graft. We offer a new technique that maintains vascularisation of the transferred hamate fragment, and investigate the anatomical vascular basis for the technique. METHODS: Dissection and angiographic studies of ten cadaveric specimens were undertaken, exploring the vascular anatomy of the dorsal hamate. A clinical case of hemi-hamate osteochondral free flap is presented, including preoperative, intraoperative and postoperative investigation of the relevant vasculature. RESULTS: Cadaveric studies demonstrated dorsal vascular supply to the hamate from the central of three dorsal carpal arches. The arch was supplied by the dorsal branch of the ulnar artery. Multiple supracapsular veins are present for use in flap venous drainage. This vascular pattern was found to be constant. A clinical case of hemi-hamate osteochondral free flap harvest demonstrated the same vascular anatomy intraoperatively. The digital artery was used as a recipient for microvascular anastomosis. Postoperative computed tomographic angiography and nuclear bone scan confirmed flap perfusion. CONCLUSIONS: The hemi-hamate osteochondral flap has a reliable anatomical vascular basis, and is clinically feasible as a technique for early vascularisation of the osteochondral fragment to sustain the transferred articular cartilage.

Quantification of level I neck lymph nodes for lymph node transfer in lymphedema treatment: an anatomical study and review of literature.

Background: Vascularized lymph node transfer (VLNT) is an effective microsurgical method for the treatment of lymphedema. Knowledge of lymph node quantity and regional anatomy of donor sites are essential for surgery optimization. The aim of the study was to quantify the level I lymph nodes of the neck (submental and submandibular lymph nodes), describe the regional anatomy and review the current literature. Methods: Level I lymph nodes were identified from pathology specimens of 73 patients in Melbourne, Australia who underwent radical, modified, and selective neck dissection were quantified. Level I was further subcategorized into levels IA (submental) and IB (submandibular), with data assessed qualitatively and quantitatively. PubMed, Google Scholar, Science Direct, Cochrane CENTRAL, and trial registries (http://clinicialtrials.gov/) were searched for relevant studies published from infinity to December 2021. Results: A mean of 5.2±2.9 lymph nodes were identified in the level I neck region. Subcategorization into level IA and level IB showed means of 3.7±1.6 and 4.7±3.0 lymph nodes, respectively. No statistical differences were detected regarding patients' gender (P=0.8) and age (P=0.5). Current literature shows level I neck VLNT is a suitable treatment for lymphedema. Conclusions: Level I of the neck offers a consistent quantity of lymph nodes and is suitable for free lymph node transfer. Current literature states VLNT is an effective technique for lymphedema treatment. This study details the regional anatomy of the level I neck lymph nodes, which will assist surgeons to optimize their surgeries and prevent donor-site morbidity.

Outcomes of contemporary management of gangrenous and non-gangrenous acute cholecystitis.

BACKGROUND: Gangrenous cholecystitis (GC) is considered a more severe form of acute cholecystitis. The risk factors associated with this condition and its impact on morbidity and mortality compared with those of non-gangrenous acute cholecystitis (NGAC) are poorly defined and based largely on findings from older studies. METHODS: Patients with histologically confirmed acute cholecystitis treated in specialized units in a tertiary hospital between 2005 and 2010 were identified from a prospectively maintained database. Data were reviewed retrospectively and patients with GC were compared with those with NGAC. RESULTS: A total of 184 patients with NGAC and 106 with GC were identified. The risk factors associated with GC included older age (69 years vs. 57 years; P= 0.001), diabetes (19% vs. 10%; P= 0.049), temperature of >38 °C (36% vs. 16%; P < 0.001), tachycardia (31% vs. 15%; P= 0.002), detection of muscle rigidity on examination (27% vs. 12%; P= 0.01) and greater elevations in white cell count (WCC) (13.4 × 109/l vs. 10.7 × 109/l; P < 0.001), C-reactive protein (CRP) (94 mg/l vs. 17 mg/l; P= 0.001), bilirubin (19 µmol/l vs. 17 µmol/l; P= 0.029), urea (5.3 mmol/l vs. 4.7 mmol/l; P= 0.016) and creatinine (82 µmol/l vs. 74 µmol/l; P= 0.001). The time from admission to operation in days was greater in the GC group (median = 1 day, range: 0-14 days vs. median = 1 day, range: 0-10 days; P= 0.029). There was no overall difference in complication rates between the GC and NGAC groups (22% vs. 14%; P= 0.102). There was a lower incidence of common bile duct stones in the GC group (5% vs. 13%; P= 0.017). Gangrenous cholecystitis was associated with increased mortality (4% vs. 0%; P= 0.017), but this was not an independent risk factor on multivariate analysis. CONCLUSIONS: Gangrenous cholecystitis has certain clinical features and associated laboratory findings that may help to differentiate it from NGAC. It is not associated with an overall increase in complications when treated in a specialized unit.

A Prognostic Dilemma of Basal Cell Carcinoma with Intravascular Invasion.

Basal cell carcinoma is the most common malignancy; however, it very rarely metastasizes. Despite the low mortality caused by this cancer, once it spreads, it has dim prognosis. We report a case of basal cell carcinoma with rare intravascular invasion and review the literature for risk factors and management of metastasis.

Median Nerve Trifurcation.

Median nerve trifurcation in the carpal tunnel has only rarely been described and never reported to be found at surgery. We present the first such case, highlighting a median nerve trifurcation found at carpal tunnel release. Consideration of amendment of the Lanz classification should be made to account for such cases, and surgeons should be aware of possible anatomical variations to avoid iatrogenic injury.

Clinical applications of dynamic infrared thermography in plastic surgery: a systematic review.

BACKGROUND: Infrared thermography (IRT) has become an increasingly utilized adjunct to more expensive and/or invasive investigations in a range of surgical fields, no more so than in plastic surgery. The combination of functional assessment, flow characteristics and anatomical localization has led to increasing applications of this technology. This article aims to perform a systematic review of the clinical applications of IRT in plastic surgery. METHODS: A systematic literature search using the keywords 'IRT' and 'dynamic infrared thermography (DIRT)' has been accomplished. A total of 147 papers were extracted from various medical databases, of which 34 articles were subjected to a full read by two independent reviewers, to ensure the papers satisfied the inclusion and exclusion criteria. Studies focusing on the use of IRT in breast cancer diagnosis were excluded. RESULTS: A systematic review of 29 publications demonstrated the clinical applications of IRT in plastic surgery today. They include preoperative planning of perforators for free flaps, post operative monitoring of free flaps, use of IRT as an adjunct in burns depth analysis, in assessment of response to treatment in hemangioma and as a diagnostic test for cutaneous melanoma and carpal tunnel syndrome (CTS). CONCLUSIONS: Modern infrared imaging technology with improved standardization protocols is now a credible, useful non-invasive tool in clinical practice.

Reducing radiation dose without compromising image quality in preoperative perforator flap imaging with CTA using ASIR technology.

Computed tomographic angiography (CTA) has become a mainstay in preoperative perforator flap planning in the modern era of reconstructive surgery. However, the increased use of CTA does raise the concern of radiation exposure to patients. Several techniques have been developed to decrease radiation dosage without compromising image quality, with varying results. The most recent advance is in the improvement of image reconstruction using an adaptive statistical iterative reconstruction (ASIR) algorithm. We sought to evaluate the image quality of ASIR in preoperative deep inferior epigastric perforator (DIEP) flap surgery, through a direct comparison with conventional filtered back projection (FBP) images. A prospective review of 60 consecutive ASIR and 60 consecutive FBP CTA images using similar protocol (except for radiation dosage) was undertaken, analyzed by 2 independent reviewers. In both groups, we were able to accurately identify axial arteries and their perforators. Subjective analysis of image quality demonstrated no statistically significant difference between techniques. ASIR can thus be used for preoperative imaging with similar image quality to FBP, but with a 60% reduction in radiation delivery to patients.

Free distal volar forearm perforator flap: clinical application in digital reconstruction.

INTRODUCTION: Soft tissue defects of the digits can be a challenging problem for the hand surgeon. For non-graftable defects, numerous local, regional and free flaps have been described for resurfacing, each with their own limitations - bulk, colour, texture mismatch, donor morbidity. Perforator flaps increasingly provide the optimal option for reconstruction of digital defects as they are thin, pliable and with low donor site morbidity. METHODS: A thin, pliable fasciocutaneous flap can be raised from the distal volar forearm based on a perforator of the radial artery. The pedicle is up to 2-3 cm in length with a diameter of at least 0.5 mm in diameter, suitable for anastomosis to the digital artery. Venous drainage is via the venae comitante of the radial artery and superficial volar veins. RESULTS: A patient presented to our emergency department following circular saw injuries. He suffered multi-digit trauma with subsequent soft tissue defects over the dorsum of the digit. Reconstructive requirements were met utilizing a free fasciocutaneous flap raised on a distal volar forearm perforator from the radial artery. The recovery was uneventful with no donor site morbidity. DISCUSSION: Dorsal digital soft tissue reconstruction requires thin, pliable, ideally hairless and sensate skin. Most locoregional options are limited by the need for multi-stage surgery, bulk, limited reach or donor site morbidity. In our patient, the reconstructive requirements were met with preservation of the radial artery. While it requires microsurgical skill and instruments, this flap provides another option for the reconstructive hand surgeon.

Trigger finger release with stepwise preservation of the A1 pulley: a functional pulley-preserving technique.

The first annular (A1) pulley is an important structure of the hand, providing a biomechanical support to the metacarpophalangeal joint and maintaining joint stability and flexor tendon alignment. Albeit uncommon, disruption of this pulley can result in dislocation or ulnar drift of the digit, particularly pronounced in patients with rheumatoid arthritis. Despite this, the A1 pulley is commonly divided without reconstruction in trigger finger. Several annular pulley reconstructive techniques have been developed to preserve its function. However, development of recurrent triggering has been observed due to fibrosis, largely due to inadequate release of the pulley. We have developed a technique to increase the volume within the flexor sheath while preserving the A1 pulley by way of stepwise lengthening. This has enabled an increase in the diameter of the pulley to 4 times its original size. A prospective study was performed comprising 10 trigger finger releases with stepwise lengthening of the A1 pulley. In all patients, there were no complications, and good hand function was achieved with no recurrence of triggering at 6 weeks of follow-up. This technique can thus safely achieve trigger release without sacrifice of the function of the A1 pulley.