RESUMEN
A male in his 70s presented with a chronic malunited comminuted Galeazzi fracture dislocation, including angular malunion, radial shortening (1.3 cm ulnar-plus variance) and distal radioulnar joint (DRUJ) instability secondary to chronic dislocation with mechanical rotation block. A modified, single-stage radius corrective osteotomy with bone grafting technique to overcorrect radius length was employed, restoring normal DRUJ motion and stability by engaging the secondary DRUJ stabilisers without triangular fibrocartilage complex repair. DRUJ stability was restored via radius lengthening, engaging the DRUJ's secondary stabilisers, bypassing the need for complex ligamentous reconstruction. The patient returned to full activity. We recommend our simple yet effective approach to treat chronic, malunited Galeazzi fractures with DRUJ instability.
Asunto(s)
Inestabilidad de la Articulación , Fracturas del Radio , Masculino , Humanos , Radio (Anatomía)/diagnóstico por imagen , Radio (Anatomía)/cirugía , Inestabilidad de la Articulación/diagnóstico por imagen , Inestabilidad de la Articulación/cirugía , Inestabilidad de la Articulación/complicaciones , Cúbito/diagnóstico por imagen , Cúbito/cirugía , Fracturas del Radio/complicaciones , Fracturas del Radio/diagnóstico por imagen , Fracturas del Radio/cirugía , Articulación de la Muñeca/diagnóstico por imagen , Articulación de la Muñeca/cirugíaRESUMEN
A 38-year-old right-hand dominant man sustained a severe, work-related left-hand crushing injury. A multi-staged approach to salvage was employed in conjunction with aggressive hand therapy involvement for a successful, functional outcome. Now at approximately 5 years postinjury, the patient can perform daily activities, coaches sports and has returned to and maintained his full-time work position. Mangled, severe hand crush injuries warrant immediate treatment to debride non-salvageable tissues, stabilise and revascularise the hand in an effort to maximise reconstructive potential and functional capacity. It is critical to recognise that these cases require multiple stages of operative reconstruction with direct and ongoing involvement of hand therapy and pending degree of injury, rehabilitation often lasting months to years.
Asunto(s)
Lesiones por Aplastamiento , Traumatismos de la Mano , Procedimientos de Cirugía Plástica , Adulto , Amputación Quirúrgica , Lesiones por Aplastamiento/cirugía , Traumatismos de la Mano/cirugía , Humanos , Recuperación del Miembro , Masculino , Resultado del Tratamiento , Extremidad Superior/cirugíaRESUMEN
A 22-year-old man presented with traumatic crush-avulsion injuries to the left index, ring and small fingers resulting in complex soft tissue loss and acute three-finger ischaemia. The patient underwent immediate revascularisation and soft tissue resurfacing of the three digits using three separate venous flow-through free flaps performed in a single-stage operation. Continued follow-up after 9 months confirmed successful salvage of these three digits. Multiple simultaneous venous flow-through free flaps can be considered as a viable alternative reconstructive modality for traumatic multi-digit ischaemia where both graft-based digital artery reconstruction and soft tissue coverage are required for multiple digits.
Asunto(s)
Traumatismos de los Dedos , Colgajos Tisulares Libres , Procedimientos de Cirugía Plástica , Traumatismos de los Tejidos Blandos , Adulto , Traumatismos de los Dedos/cirugía , Dedos/irrigación sanguínea , Colgajos Tisulares Libres/irrigación sanguínea , Humanos , Masculino , Procedimientos de Cirugía Plástica/métodos , Traumatismos de los Tejidos Blandos/cirugía , Resultado del Tratamiento , Adulto JovenRESUMEN
STUDY DESIGN: Technique Description with clinical presentation Correlates. PURPOSE: Revisit and discuss the advantages of the cervicodeltopectoral flap (CDP) as an alternative to microvascular reconstruction for head and neck cutaneous defects. METHODS: Retrospective chart review was performed on 2 patients with prior large cutaneous facial defects after tumor resection followed by cervicodeltopectoral flap reconstruction. These cases were performed at a single institution. The tumor resections, flap reconstructions, and postoperative management were led by the listed senior author (SPK). RESULTS: A 78-year-old (Clinical presentation 1) and 62-year-old (Clinical presentation 2) were evaluated for large nonmelanoma skin cancers of the face. Due to significant comorbidities, neither patient was an ideal candidate for microsurgical reconstruction. In both cases, lesion resection and CDP flap reconstruction was performed. The reconstruction allowed for successful coverage without significant donor site morbidity for each patient. CONCLUSIONS: The authors propose the addition of the CDP flap to the armamentarium of the head and neck reconstructive surgeon as a safe and reliable alternative to microvascular reconstruction.
Asunto(s)
Neoplasias de Cabeza y Cuello , Procedimientos de Cirugía Plástica , Anciano , Humanos , Neoplasias de Cabeza y Cuello/cirugía , Procedimientos de Cirugía Plástica/métodos , Estudios Retrospectivos , Colgajos Quirúrgicos/irrigación sanguíneaRESUMEN
Targeted muscle reinnervation (TMR) surgery has been shown to aid in prevention and treatment of neuropathic pain. Technical and anatomical descriptions of TMR surgery for upper extremity amputees (including transradial, transhumeral, and forequarter amputations) have been reported, yet such descriptions of TMR surgery for partial hand amputations are currently lacking. Herein we outline the technique of different types of partial hand amputation TMR surgeries to serve as a reference and guide. A retrospective review was performed by our multi-institutional team to identify clinical cases where partial hand TMR surgeries were performed. Patient demographics, characteristics, amputation subtype, nerve transfer, pain score, pain outcome, and functional outcome data were collected and analyzed. From January 2018 to September 2019, 13 patients underwent partial hand TMR procedures. Eight cases resulted from trauma, and 6 were secondary to oncologic procedures. The amputations consisted of 8 ray, 2 trans-metacarpal, 2 radial-sided hand, and 1 index finger amputation with recurrent painful neuromas. Twelve patients were weaned off narcotics completely and only 3 remained on a neuromodulator for ongoing pain control. Technical considerations for partial hand TMR surgery have been outlined, with early pilot data showing beneficial pain control outcomes.
RESUMEN
ABSTRACT: Management of head and neck defects in a radiated field can be quite challenging owing to the dearth of vasculature and significant degree of post-radiation fibrosis. In this setting, arteriovenous (AV) loop vascular grafts can bypass nonviable local vessels to provide viable and reliable inflow and outflow vessels for free tissue transfer in an otherwise hostile environment. Prior reports of the Corlett loop utilizing a cephalic vein transposition has been described however a common carotid-to-internal jugular AV loop has not been recently reported. Three patients underwent carotid artery to internal jugular vein AV loop creation to facilitate free-flap reconstruction secondary to radiation-induced vessel depletion. The specific technique described utilizes the saphenous vein as a donor and spares the cephalic vein for the possibility of flap complication. All three cases resulted in successful reconstruction, maintaining healthy tissue, vascular flow, and flap viability at all follow-up intervals. In our experience, vascular augmentation via AV loop formation provides reliable vascular inflow and outflow in the vessel-depleted neck to facilitate microvascular reconstruction. Sparing the cephalic vein yields an additional salvage mechanism in the event of venous congestion.
Asunto(s)
Colgajos Tisulares Libres , Procedimientos de Cirugía Plástica , Anastomosis Quirúrgica , Arteria Carótida Común , Humanos , Venas Yugulares/cirugía , Microcirugia , Cuello/cirugía , Colgajos QuirúrgicosRESUMEN
CASE: A 20-year-old woman presented with painful, snapping extensor pollicis longus (EPL) tendon subluxation and trapeziometacarpal (TMC) joint instability. Hemi-extensor carpi radialis longus (ECRL) tendon autograft stabilized the TMC joint, reconstructing the 1-2 intermetacarpal ligament. The subluxed EPL tendon was centralized over the dorsal first metacarpal by tightening the metacarpophalangeal radial sagittal band and creating a dorsal first metacarpal "neosheath" pulley using ECRL graft remnant. Postoperative rehabilitation included Spica bracing and immediate thumb interphalangeal joint exercises. CONCLUSION: The patient's pain due to EPL tendon subluxation and TMC joint instability completely resolved. Postoperative thumb range of motion and function were equivalent to the nonaffected side.
Asunto(s)
Luxaciones Articulares , Pulgar , Adulto , Femenino , Humanos , Luxaciones Articulares/complicaciones , Luxaciones Articulares/cirugía , Rango del Movimiento Articular , Tendones/cirugía , Pulgar/cirugía , Muñeca , Adulto JovenRESUMEN
ABSTRACT: Vessel depletion in the head and neck from radiation or previous surgical intervention adds to the operative complexity by limiting reconstructive options. Arteriovenous (AV) loop vascular grafts provide a conduit to bypass these nonviable local vessels to provide adequate blood flow. In certain situations, autologous donor vascular options are deficient or not readily available for creation of the AV loop. Cadaveric vein grafts provide an alternative option in these circumstances, but the efficacy and safety has not yet been delineated. In this study we discuss our experience utilizing cryopreserved cadaveric vein grafts for AV loop creation in head and neck reconstruction. In our initial cohort we aim to elucidate potential challenges and complications associated with the use of cadaveric vein grafts.
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Injerto Vascular , Venas , Cadáver , Cabeza/cirugía , Humanos , Cuello/cirugíaRESUMEN
Introduction We review the benefits of early motion protocols following replantation of a total right hand amputation at 1 and 2 years after replantation, and provide recommendations for postoperative management. Materials and Methods Replantation of the entire right hand in zone-4 was performed and supported by rigid external fixation spanning the forearm and hand. An early active "place-and-hold" motion protocol was initiated within the first 3 postoperative days. Metacarpophalangeal joint extensors were tethered by the pins, limiting full excursion. This resulted in stiffness and extensor adhesions that required a staged extensor tenolysis; however, all joints remained supple. The early motion protocol prevented the need for significant flexor tenolysis and joint releases. Results Early motion rehabilitation protocols can produce very successful results in complex replantation. The enhanced stability afforded by external fixation of the wrist allowed us to perform aggressive early rehabilitation. Conclusion This case highlights the benefits of early active motion (limiting the need for complex joint and flexor tendon releases) and demonstrates the degree of extensor adhesions caused by even minor extensor tendon tethering. This aggressive rehabilitation approach can produce excellent range of motion, and likely limit the need for secondary tenolysis and joint release procedures.
RESUMEN
BACKGROUND: Targeted muscle reinnervation (TMR) has been shown to decrease or prevent neuropathic pain, including phantom and residual limb pain, after extremity amputation. Currently, a paucity of data and lack of anatomical description exists regarding TMR in the setting of hemipelvectomy and/or hip disarticulations. We elaborate on the technique of TMR, illustrated through cadaveric and clinical correlates. METHODS: Cadaveric dissections of multiple transpelvic exposures were performed. The major mixed motor and sensory nerve branches were identified, dissected, and tagged. Amputated peripheral nerves were transferred to identified, labeled target motor nerves via direct end-to-end nerve coaptations per traditional TMR technique. A retrospective review was completed by our multi-institutional teams to include examples of clinical correlates for TMR performed in the setting of hemipelvectomies and hip disarticulations. RESULTS: A total of 12 TMR hemipelvectomy/hip disarticulation cases were performed over a 2 to 3-year period (2018-2020). Of these 12 cases, 9 were oncologic in nature, 2 were secondary to traumatic injury, and 1 was a failed limb salvage in the setting of chronic refractory osteomyelitis of the femoral shaft. CONCLUSIONS: This manuscript outlines the technical considerations for TMR in the setting of hemipelvectomy and hip disarticulation with supporting clinical case correlates.
Asunto(s)
Amputados/rehabilitación , Desarticulación/métodos , Hemipelvectomía/métodos , Músculos/inervación , Músculos/cirugía , Miembro Fantasma/prevención & control , Procedimientos de Cirugía Plástica/métodos , Femenino , Estudios de Seguimiento , Humanos , Masculino , Pronóstico , Estudios RetrospectivosRESUMEN
CASE: We discuss our reconstructive approach to avoid an above-knee amputation in a 33-year-old man presenting after lower extremity crush injury. We used a vascularized tibial bone flap and a foot fillet flap to restore length and joint functionality to the residual limb. The patient ambulates with good prosthetic fit on durable heel pad skin and 100° active knee motion. CONCLUSION: This pairing of intramedullary nail with vascularized bone flap and fillet flap to address soft-tissue coverage and retain limb length is a useful tool in traumatic lower extremity injury management, providing an alternative technique for tibial bone graft stabilization with robust, sensate tissue coverage.
Asunto(s)
Trasplante Óseo/métodos , Lesiones por Aplastamiento/cirugía , Pie/trasplante , Colgajos Quirúrgicos , Tibia/trasplante , Adulto , Miembros Artificiales , Humanos , Recuperación del Miembro , Masculino , ReoperaciónRESUMEN
BACKGROUND: Though cannabis is gaining broader acceptance among society and a noted increase in legalization, little is known regarding its impact on post-operative outcomes. We conducted this study to quantify the relationship between cannabis abuse or dependence (CbAD) on post-operative outcomes after cholecystectomy and appendectomy. METHODS: Using the 2013-2015 Nationwide Readmissions Database, we identified discharges associated with cholecystectomy or appendectomy from January 2013-August 2015. Patients were grouped by CbAD history. The primary outcomes were length of stay, serious adverse events, home discharge, and 30-day readmission. Propensity-score matching was used to account for differences between groups and all statistics accounted for the matched sample. RESULTS: The final sample included 3288 patients with a CbAD history matched 1:1 to patients without a CbAD history (total sample = 6576). After matching, acceptable balance was achieved in clinical characteristics between groups. In the cholecystectomy cohort (n = 1707 pairs), CbAD patients had longer hospitalizations (3.5 versus 3.2 d, P 0.003) and similar rates of serious adverse events (6.1 versus 4.8, P 0.092), home discharge (96.1 vs 96.2, P 0.855), and readmission (8.3 versus 6.9, P 0.137). In the appendectomy cohort (n = 1581 pairs), CbAD patients had longer hospital stays (2.7 versus 2.5 d, P 0.024); more frequent serious adverse events (5.0 versus 3.5, P 0.041); and similar home discharge (96.8 vs 97.3, P 0.404) and readmission (5.4 versus 5.1, P 0.639) rates. CONCLUSIONS: Patients with a history of CbAD in the cholecystectomy and appendectomy cohorts had slightly longer hospital stays, and patients with a history of CbAD in the appendectomy group displayed a slight increase in adverse events, but otherwise similar clinical outcomes without clinically significant increases in complications compared to patients without this history.
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Apendicectomía/estadística & datos numéricos , Colecistectomía/estadística & datos numéricos , Abuso de Marihuana/complicaciones , Complicaciones Posoperatorias/etiología , Adulto , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios RetrospectivosRESUMEN
CASE: A 61-year-old patient was referred 12 days postoperative with complex, infected, and dehisced paraspinal wound. After debridement and revision of hardware, deep dead space was eliminated through bilateral paraspinal muscle flap advancement. After hardware coverage, a large skin and tissue defect remained. The defect was reconstructed using a modified Keystone flap, eliminating the lateral cutaneous incision. Our patient healed without complication. CONCLUSION: The modified Keystone flap is an option for reconstructing spinal wound defects, yielding excellent tissue coverage and advancement, grants additional flap advancement if necessary because of elimination of the lateral cutaneous incision, and an overall pleasing aesthetic result.
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Fusión Vertebral/efectos adversos , Colgajos Quirúrgicos , Dehiscencia de la Herida Operatoria/cirugía , Infecciones por Acinetobacter/tratamiento farmacológico , Antibacterianos/uso terapéutico , Femenino , Humanos , Staphylococcus aureus Resistente a Meticilina , Persona de Mediana Edad , Reoperación/efectos adversos , Infecciones Estafilocócicas/tratamiento farmacológico , Dehiscencia de la Herida Operatoria/microbiologíaRESUMEN
Disruption to the flexor pulley system of the thumb is an infrequent but devastating injury that can lead to significant compromise in both strength and function. Acute rupture leads to pain, weakness, reduced range of motion (ROM), and potential bowstringing of the flexor tendons. Conservative treatment with a pulley ring should be considered in all patients. However, failure of conservative treatment and bowstringing of the thumb are indications for operative intervention. Reconstruction of the oblique pulley system can be performed either in situ or using a free palmaris longus graft. Care should be taken to identify the neurovascular bundles to avoid compression during the reconstruction. Conscious sedation protocols augmented by ultrasound-guided sheath blocks allow the patient to actively and strongly contract the flexor pollicis longus tendon intraoperatively to appropriately tension the construct for optimal results. Rehabilitation should be performed in a stepwise manner beginning with early passive ROM, active ROM, and finally strengthening at around 8 weeks postoperative.
Asunto(s)
Ligamentos/cirugía , Tendones/trasplante , Pulgar/cirugía , Autoinjertos , Humanos , Ligamentos/anatomía & histología , Ligamentos/lesiones , Pulgar/anatomía & histologíaRESUMEN
BACKGROUND: Historically, failed conservative treatment for irreparably damaged distal radioulnar joints (DRUJs) is treated via distal ulnar resection or DRUJ fusion; complications include disabling painful convergence of the radius and ulnar stump during lifting Various treatments for radioulnar impingement include distal radioulnar Achilles tendon allograft interpositional arthroplasty. This technique does not adequately prevent radioulnar impingement and we explore an alternative treatment. METHODS: We report 7 adult patients who failed Achilles tendon interposition, subsequently treated with Aptis total DRUJ prostheses (mean follow-up, 26 months; range, 7-40). RESULTS: Revision to Aptis prosthesis produced clinically stable DRUJ, improved grip strength and painless lifting capabilities, high patient satisfaction, and no major complications. All returned to daily activities and even recreational sports. CONCLUSIONS: Tendon lacks biomechanical features key to the shock-absorbing function of cartilage-features it cannot deliver when used to prevent radioulnar convergence. We report Aptis DRUJ prosthesis as an alternative to the tendon allograft technique.
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Artroplastia de Reemplazo , Inestabilidad de la Articulación/cirugía , Prótesis Articulares , Terapia Recuperativa , Cúbito/cirugía , Articulación de la Muñeca/cirugía , Tendón Calcáneo/trasplante , Adulto , Aloinjertos , Femenino , Estudios de Seguimiento , Fuerza de la Mano , Humanos , Masculino , Persona de Mediana Edad , Satisfacción del Paciente , Diseño de Prótesis , Recuperación de la Función , Reoperación , Insuficiencia del Tratamiento , Articulación de la Muñeca/diagnóstico por imagen , Adulto JovenRESUMEN
Adipose-derived stem cells (ASCs) have shown potential in the treatment of a myriad of diseases; however, infusion of cells alone is unlikely to provide the full range of potential therapeutic applications. Transient genetic manipulation of ASCs could increase their repair and regeneration characteristics in a disease-specific context, essentially transforming them into drug-eluting depots. The goal of this study was to determine the optimal parameters necessary to transduce ASCs with recombinant adeno-associated virus (rAAV), an approved gene therapy vector that has never been associated with disease. Transduction and duration of gene expression of the most common recombinant AAV vectors were tested in this study. Among all tested serotypes, rAAV5 resulted in both the highest and longest term expression. Furthermore, we determined the glycosylation profile of ASCs before and after neuraminidase treatment and demonstrate that rAAV5 transduction requires plasma membrane-associated sialic acid. Future studies will focus on the optimization of gene delivery to ASCs, using rAAV5 as the vector of choice, to drive biological drug delivery, engraftment, and disease correction.
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Dependovirus/genética , Terapia Genética , Células Madre , Transducción Genética , Tejido Adiposo/citología , Animales , Técnicas de Transferencia de Gen , Vectores Genéticos/genética , Humanos , SerogrupoRESUMEN
BACKGROUND: Mental health conditions, including psychiatric and substance abuse diagnoses, have been associated with poor postoperative outcomes, but no studies have quantified the relationship to date. OBJECTIVE: The authors examine the association between mental health conditions and immediate postoperative outcomes as defined by further hospital-based acute care within 30 days of surgery. METHODS: California State Ambulatory Surgery, Inpatient, and Emergency Department Databases were used to identify all adult patients undergoing outpatient cosmetic plastic surgery between January 2007 and October 2011. Patients were subgrouped by the presence of mental health or substance abuse conditions. Primary outcome was the need for hospital-based acute care (admission or emergency department visit) within 30 days after surgery. Multivariable logistic regression models compared outcomes between groups. RESULTS: Of 116,597 patients meeting inclusion criteria, 3.9% and 1.4% had either a psychiatric or substance abuse diagnosis, respectively. Adjusting for medical comorbidities, patients with psychiatric disorders more frequently required hospital-based acute care within 30 days postoperatively than those without mental illness diagnoses (11.1% vs 3.6%; adjusted odds ratio [AOR], 1.78 [95% confidence interval, 1.59-1.99]). This was true both for hospital admissions (3.5% vs 1.1%; AOR, 1.61 [1.32-1.95]) and emergency department visits (8.8% vs 2.7%; AOR, 1.88 [1.66-2.14]). The most common acute diagnoses were surgical in nature, including postoperative infection, hemorrhage, and hematoma; the median hospital admission charge was $35 637. Similar findings were noted among patients with a substance abuse diagnosis. CONCLUSIONS: Mental health conditions are independently associated with the need for more frequent hospital-based acute care following surgery, thus contributing to added costs of care. A patient's mental health should be preoperatively assessed and appropriately addressed before proceeding with any elective procedure. LEVEL OF EVIDENCE: 4.