Free flap reconstruction of elbow soft tissue defects: Lessons learned from 15 years of experience.

BACKGROUND: The elbow is a complex joint that is vital for proper function of the upper extremity. Reconstruction of soft tissue defects over the joint space remains challenging, and outcomes following free tissue transfer remain underreported in the literature. The purpose of this analysis was to evaluate the rate of limb salvage, joint function, and clinical complications following microvascular free flap coverage of the elbow. METHODS: This retrospective case series utilized surgical logs of the senior authors (Stephen J Kovach and L Scott Levin) to identify patients who underwent microvascular free flap elbow reconstruction between January 2007 and December 2021. Patient demographics and medical history were collected from the medical chart. Operative notes were reviewed to determine the type of flap procedure performed. The achievement of definitive soft tissue coverage, joint function, and limb salvage status at 1 year was determined from postoperative visit notes. RESULTS: Twenty-one patients (14 male, 7 female, median age 43) underwent free tissue transfer for coverage of soft tissue defects of the elbow. The most common indication for free tissue transfer was traumatic elbow fracture with soft tissue loss (n = 12, [57%]). Among the 21 free flaps performed, 71% (n = 15) were anterolateral thigh flaps, 14% (n = 3) were latissimus dorsi flaps, and 5% (n = 1) were transverse rectus abdominis flaps. The mean flap size was 107.5 cm2. Flap success was 100% (n = 21). The following postoperative wound complications were reported: surgical site infection (n = 1, [5%]); partial dehiscence (n = 5, [24%]); seroma (n = 2, [10%]); donor-site hematoma (n = 1, [5%]); and delayed wound healing (n = 5, [24%]). At 1 year, all 21 patients achieved limb salvage and definitive soft tissue coverage. Of the 17 patients with functional data available, 47% (n = 8) had regained at least 120 degrees of elbow flexion/extension. All patients had greater than 1 year of follow-up. CONCLUSION: Microvascular free flap reconstruction is a safe and effective method of providing definitive soft tissue coverage of elbow defects, as evidenced by high rates of limb salvage and functional recovery following reconstruction.

Benchmarking Accomplishments of Presidents Elected to Hand Surgery Societies in the United States.

Objective: Qualifications needed to achieve national leadership positions in hand surgery are poorly defined. This study compares the academic accomplishments, demographics, and training backgrounds of presidents elected to serve the American Society for Surgery of the Hand (ASSH) and the American Association for Hand Surgery (AAHS). Methods: The ASSH and AAHS provided names of elected Presidents (1990-2022, n = 64). Curriculum vitae and academic web sites were used to collect demographic, training, bibliometric, and National Institutes of Health (NIH) funding data of presidents. Results: Presidents were predominately male (95%), Caucasian (90%), and orthopaedic surgery residency-trained (66%). Only 9% were racial minorities (8% Asian, 2% Hispanic, and 0% African American). The average age at appointment was 59 ± 7 years old, which was an average of 23 years from completion of hand surgery fellowship. More presidents received plastic surgery residency training in AAHS than ASSH (50 vs. 19%). The most represented hand surgery fellowships were Mayo Clinic (14%), University of Louisville (11%), and Duke University (9%). Twenty-one presidents participated in a travel fellowship (33%). Thirty presidents served as Department Chair or Division Chief at time of election (47%). The average h-index was 34 ± 18 resulting from 164 ± 160 peer-reviewed manuscripts and was similar between the two organizations. Eleven presidents had NIH grant funding (18%) and there were no differences in procurement or funding totals between the two organizations. Conclusion: Presidents of American hand surgery societies obtain high levels of scholarly activity regardless of training specialty. Women and racial minorities remain underrepresented at the highest levels of leadership.

Impact of Orthopedic Hand Surgery Fellowship Training on Hand Surgery Cases Performed by Plastic Surgeons in the United States.

Objective: Multiple pathways exist for hand surgery training in the United States. Plastic surgeons often select Orthopedic Hand Surgery Fellowships to complement their skills and bridge perceived deficiencies in bone and joint cases. This study aims to quantify the impact of this approach on operative hand experience. Materials and methods: Case logs were analyzed for plastic surgery residents and orthopaedic hand surgery fellows (2016-2017 to 2019-2020). Reported hand surgery cases were compared between residency and fellowship using Student's t-tests. In total, 606 plastic surgery residents and 393 orthopaedic hand surgery fellows were included in this study. One year of Orthopedic Hand Surgery Fellowship training afforded more than twice the volume of hand surgery cases than Plastic Surgery Residency training (886.1 ± 234.7 vs. 428.1 ± 147.2, p < 0.001). Results: Case categories with the greatest positive fold difference in case volume encountered during Orthopedic Surgery Hand Fellowship were tumor (138.2 ± 63.2 vs. 22.1 ± 11.8, p < 0.001), joint reconstruction (108.7 ± 21.6 vs. 18.8 ± 11.5, p < 0.001), nerve decompression (158.4 ± 63.1 vs. 53.0 ± 32.6, p < 0.001), Dupuytren's (18.4 ± 10.5 vs. 7.6 ± 6.4, p < 0.001), and fracture management (132.8 ± 21.7 vs. 59.6 ± 24.1, p < 0.001). Conclusion: Orthopedic Hand Surgery Fellowship training doubles the operative hand case volume encountered during Plastic Surgery Residency. Significant increases are especially encountered for select case categories including bone and joint cases.

Improving Skin Paddle Reliability and Muscle Gliding in Free Functional Gracilis Transfers.

Free functional muscle transfer is an attractive option within reconstructive surgery when seeking to restore critical muscle function. The gracilis muscle has long been utilized for this purpose due to its expendability and consistent anatomy. Historically, survival of the skin overlying the distal one-third of the myocutaneous gracilis flap has been unpredictable. To address this, the myofasciocutaneous technique was developed, with prior studies demonstrating improved distal skin paddle viability with this approach; however, the mechanism is poorly defined. This study aimed to understand what factors contribute to survival benefit in myofasciocutaneous gracilis flaps. Using cadaveric dissections followed by latex dye injections, we discuss the creation of a deep fascial sheath that contains a rich vascular network and permits adhesion-free excursion at the recipient site. This study advances our understanding of the myofasciocutaneous gracilis flap and provides wider clinical applicability in free functional muscle transfer.