Effects training in hypoxia on cardiometabolic parameters in obese people: A systematic review of randomized controlled trial / Efectos del entrenamiento en hipoxia sobre parámetros cardiometabólicos en personas obesas: una revisión sistemática de ensayos clínicos aleatorizados

Objective: The aim of the present review is to evaluate effects of intermittent hypoxia and exercise therapy in cardiometabolic parameters on adult obese people. Database: Three well-known databases were selected: EMBASE, MEDLINE and Web of Science. Studies selection: Inclusion criteria were: (a) human healthy overweight or obese adults, (b) study randomized controlled trial, (c) original experimental study, (d) English languages and (e) therapy with intermittent hypoxia and exercise. Design: The assessment of the methodological quality of each study was based upon the risk of bias (PEDro scale) and level of evidence (CBO Guidelines). Data extraction: five articles clearly met inclusion criteria and were reviewed to data extraction. Results: In the hypoxia groups, weight, body mass index, waist circumference, waist-hip ratio, fat mass and lean mass improved in at least two studies in comparison with the baseline. Systolic blood pressure improved in one study. The lipid profile and the aerobic capacity were not reduced significantly. Conclusions: Results suggest that combined hypoxia with exercise may help to improve cardiometabolic parameters in obese people

Objetivo: El objetivo de esta revisión es evaluar el efecto de la hipoxia intermitente y el ejercicio en parámetros cardiovasculares en adultos obesos. Fuentes de datos: Se utilizaron 3 bases de datos para seleccionar los artículos: EMBASE, MEDLINE and Web of Science. Selección de estudios: los criterios de inclusión fueron: a) muestra compuesta por humanos adultos con sobrepeso u obesidad, b) grupos organizados aleatoriamente, c) estudios experimentales, d) escritos en inglés y e) la intervención incluya hipoxia intermitente y ejercicio. Diseño: Para evaluar la calidad de los estudios se utilizó la escala PEDro y el nivel de evidencia con la guía CBO. Extracción de datos: 5 artículos cumplieron los criterios de inclusión y sus datos fueron extraídos y revisados. Resultados: El peso, el índice de masa corporal, la circunferencia de la cadera, la circunferencia de la cintura, el índice cintura-cadera, la masa grasa y la masa muscular mejoraron en al menos 2 estudios comparados con la línea base en los grupos hipoxia. La presión sistólica mejoró en uno de los estudios. El perfil lipídico y la capacidad aeróbica no mejoraron significativamente. Conclusiones: Los resultados sugieren que combinar ejercicio con hipoxia intermitente podría mejorar parámetros cardiovasculares en la población obesa

Sex differences in ACL loading and strain during typical athletic movements: a musculoskeletal simulation analysis.

PURPOSE: Female athletes experience anterior cruciate ligament (ACL) injuries at a much greater rate than males, yet the mechanisms responsible for this are not well-understood. The current investigation aimed using a musculoskeletal simulation-based approach, to examine sex differences in ACL loading parameters during cut and hop movements. METHODS: Fifteen male and fifteen female participants completed 45° cut and maximal one legged hop movements. Three-dimensional motion capture and ground reaction force data during the stance phase of the cut movement and landing phase of the one legged hop were obtained. Lower extremity muscle forces, ACL forces and ACL strains were extracted via a simulation-based approach using a musculoskeletal model, with an ACL insertion into the femur and tibia. RESULTS: During the hop movement, females were associated with significantly greater peak ACL forces (male = 15.01 N/kg and female = 15.70 N/kg) and strains (male = 6.87% and female = 10.74%). In addition, for both the cut (male = 4.45 and female = 1.45) and hop (male = 2.04 and female = 1.46) movements, the soleus/gastrocnemius ratio was significantly larger in males. CONCLUSIONS: The current investigation provides new information regarding sex differences during athletic movements that provide further insight regarding the increased incidence of ACL injuries in females.

Effects training in hypoxia on cardiometabolic parameters in obese people: A systematic review of randomized controlled trial.

OBJECTIVE: The aim of the present review is to evaluate effects of intermittent hypoxia and exercise therapy in cardiometabolic parameters on adult obese people. DATABASE: Three well-known databases were selected: EMBASE, MEDLINE and Web of Science. Studies selection: Inclusion criteria were: (a) human healthy overweight or obese adults, (b) study randomized controlled trial, (c) original experimental study, (d) English languages and (e) therapy with intermittent hypoxia and exercise. DESIGN: The assessment of the methodological quality of each study was based upon the risk of bias (PEDro scale) and level of evidence (CBO Guidelines). DATA EXTRACTION: five articles clearly met inclusion criteria and were reviewed to data extraction. RESULTS: In the hypoxia groups, weight, body mass index, waist circumference, waist-hip ratio, fat mass and lean mass improved in at least two studies in comparison with the baseline. Systolic blood pressure improved in one study. The lipid profile and the aerobic capacity were not reduced significantly. CONCLUSIONS: Results suggest that combined hypoxia with exercise may help to improve cardiometabolic parameters in obese people.

Urinary Steroid Profile in Ironman Triathletes.

The aim of this study was to determine variations in the urinary steroid profile of triathletes following an Ironman event. A total of 10 male participants (age = 36.0 ± 1.27 years; body height = 179.29 ± 10.77 cm; body mass = 74.50 ± 1.04 kg) completed an Ironman Championship. Urine samples were collected before, immediately after, and 24 hours following the race. Gas chromatography-mass spectrometry (GC/MS) was used to detect and quantify catabolic and anabolic hormones: Androsterone, Dehydroepiandrosteone (DHEA), Androstenedione and Testosterone (T), Betaestradiol, Estrone, Progesterone, Cortisol (C), Cortisone, Tetrahydrocortisol (THE) and Tetrahydrocortisone (THF). These were measured in their glucuroconjugated and free forms. Androsterone (3297.80 ± 756.83 vs. 2154.26 ± 1375.38), DHEA (47.80 ± 19.21 vs. 32.62 ± 15.96) and Beta-estradiol (59.36 ± 11.7 vs. 41.67 ± 10.59) levels decreased after the event. The significant decrease of DHEA (47.80 ± 19.21 vs. 32.11 ± 14.03) remained at 24 hours. Cortisol (200.38 ± 56.60 vs. 257.10 ± 74.00) and THE (238.65 ± 81.55 vs. 289.62 ± 77.13) increased after exercise and remained elevated 24 hours later (200.38 ± 56.60 vs. 252.48 ± 62.09; 238.65 ± 81.55 vs. 284.20 ± 66.66). The following anabolic/catabolic ratios fell after exercise: T/C (0.85 ± 0.54 vs. 0.54 ± 0.29), T/THE (0.66 ± 0.29 vs. 0.40 ± 0.08), T/THE+THF (0.38 ± 0.17 vs. 0.24 ± 0.06), DHEA/THE (0.22 ± 0.05 vs. 0.12 ± 0.05), DHEA/THF (0.34 ± 0.02 vs. 0.21 ± 0.01) and DHEA/THE+THF (0.12 ± 0.02 vs. 0.08 ± 0.03). The steroid profile showed that athletes were fatigued after finishing the competition and a catabolic state remained 24 hours later.

The lower body muscle activation of intermediate to experienced kayakers when navigating white water.

In white-water kayaking, the legs play a vital part in turning, stabilising and bracing actions. To date, there has been no reported information on neuromuscular activation of the legs in an authentic white-water environment. The aim of the current study was to identify lower body muscle activation, using 'in-boat' electromyography (EMG), whilst navigating a white-water run. Ten experienced male kayakers (age 31.5 ± 12.5 yr, intermediate to advanced experience) completed three successful runs of an international standard white-water course (grade 3 rapids), targeting right and left sides of the course, in a zigzag formation. Surface EMG (sEMG) outputs were generated, bilaterally, for the rectus femoris (RF), vastus lateralis, biceps femoris and gastrocnemius, expressed as a percentage of a dynamic maximal voluntary contraction (dMVC). Only RF showed significantly higher activation than any muscle on the left side of the body, and only on the left side of the course (P = .004; ETA(2) = 0.56). Other results showed no significant difference between muscle activation in the right and left legs during each run, nor when assessed at either the right or left side of the course (P > .05). These findings indicate that contralateral symmetry in lower limb muscle activation is evident during white-water kayaking. This symmetry may provide a stable base to allow more asymmetrical upper body and trunk movements to be fully optimised. Lower body symmetry development should be considered useful in targeted training programmes for white-water kayakers.

The Reliability of Electromyographic Normalization Methods for Cycling Analyses.

Electromyography (EMG) is normalized in relation to a reference maximum voluntary contraction (MVC) value. Different normalization techniques are available but the most reliable method for cycling movements is unknown. This study investigated the reliability of different normalization techniques for cycling analyses. Twenty-five male cyclists (age 24.13 ± 2.79 years, body height 176.22 ± 4.87 cm and body mass 67.23 ± 4.19 kg, BMI = 21.70 ± 2.60 kg·m-1) performed different normalization procedures on two occasions, within the same testing session. The rectus femoris, biceps femoris, gastrocnemius and tibialis anterior muscles were examined. Participants performed isometric normalizations (IMVC) using an isokinetic dynamometer. Five minutes of submaximal cycling (180 W) were also undertaken, allowing the mean (DMA) and peak (PDA) activation from each muscle to serve as reference values. Finally, a 10 s cycling sprint (MxDA) trial was undertaken and the highest activation from each muscle was used as the reference value. Differences between reference EMG amplitude, as a function of normalization technique and time, were examined using repeated measures ANOVAs. The test-retest reliability of each technique was also examined using linear regression, intraclass correlations and Cronbach's alpha. The results showed that EMG amplitude differed significantly between normalization techniques for all muscles, with the IMVC and MxDA methods demonstrating the highest amplitudes. The highest levels of reliability were observed for the PDA technique for all muscles; therefore, our results support the utilization of this method for cycling analyses.

Electromyographic response of global abdominal stabilizers in response to stable- and unstable-base isometric exercise.

Core stability training traditionally uses stable-base techniques. Less is known as to the use of unstable-base techniques, such as suspension training, to activate core musculature. This study sought to assess the neuromuscular activation of global core stabilizers when using suspension training techniques, compared with more traditional forms of isometric exercise. Eighteen elite level, male youth swimmers (age, 15.5 ± 2.3 years; stature, 163.3 ± 12.7 cm; body mass, 62.2 ± 11.9 kg) participated in this study. Surface electromyography (sEMG) was used to determine the rate of muscle contraction in postural musculature, associated with core stability and torso bracing (rectus abdominus [RA], external obliques [EO], erector spinae [ES]). A maximal voluntary contraction test was used to determine peak amplitude for all muscles. Static bracing of the core was achieved using a modified "plank" position, with and without a Swiss ball, and held for 30 seconds. A mechanically similar "plank" was then held using suspension straps. Analysis of sEMG revealed that suspension produced higher peak amplitude in the RA than using a prone or Swiss ball "plank" (p = 0.04). This difference was not replicated in either the EO or ES musculature. We conclude that suspension training noticeably improves engagement of anterior core musculature when compared with both lateral and posterior muscles. Further research is required to determine how best to activate both posterior and lateral musculature when using all forms of core stability training.

Perfusion Assessment with the SPY System after Arterial Venous Reversal for Upper Extremity Ischemia.

BACKGROUND: The timing and pattern of reperfusion following arterial- venous reversal (AVR) in patients with terminal ischemia of an upper extremity is not well understood. METHODS: The current case series describes the timing and pattern of reperfusion observed in patients with terminal upper extremity ischemia who underwent AVR and repeated postoperative indocyanine green (ICG) angiography between 2004 and 2009. For all included patients, the SPY Near-Infrared Perfusion Assessment System permitted visualization of ICG-labeled blood flow for 60-second sampling periods at scheduled postoperative time points; outflow and rate and amplitude of inflow were objectively quantified with SPY-Q Analysis Toolkit image analysis software. RESULTS: The series comprised 6 male patients (mean age, 46 years) who presented with upper extremity ischemia related to hypothenar hammer syndrome (n = 2), embolism with patent foramen ovale (n = 2), atherosclerosis (n = 1), and avulsion amputation of the thumb (n = 1); the patient with the avulsion amputation was diagnosed with thromboangiitis obliterans at the time of replantation. AVR was successful in all 6 patients. In 5 of 6 patients, ICG angiography and SPY-based visualization/quantification showed that venous outflow and arterial inflow gradually normalized (versus unaffected digits) between postoperative days (PODs) 0 and 3 and was maintained at long-term follow-up (≥3 months); for the patient who underwent thumb replantation, perfusion normalized between POD 3 and month 5 follow-up. CONCLUSIONS: AVR effectively reestablished blood flow in patients with terminal upper extremity ischemia. ICG angiography with SPY technology revealed that, in most cases, kinetic curves, timing, and patterns of perfusion gradually normalized over several PODs.

Three-dimensional kinematic comparison of treadmill and overground running.

The treadmill is an attractive device for the investigation of human locomotion, yet the extent to which lower limb kinematics differ from overground running remains a controversial topic. This study aimed to provide an extensive three-dimensional kinematic comparison of the lower extremities during overground and treadmill running. Twelve participants ran at 4.0 m/s (+/- 5%) in both treadmill and overground conditions. Angular kinematic parameters of the lower extremities during the stance phase were collected at 250 Hz using an eight-camera motion analysis system. Hip, knee, and ankle joint kinematics were quantified in the sagittal, coronal, and transverse planes, and contrasted using paired t-tests. Of the analysed parameters hip flexion at footstrike and ankle excursion to peak angle were found to be significantly reduced during treadmill running by 12 degrees (p = 0.001) and 6.6 degrees (p = 0.010), respectively. Treadmill running was found to be associated with significantly greater peak ankle eversion (by 6.3 degrees, p = 0.006). It was concluded that the mechanics of treadmill running cannot be generalized to overground running.

Functional outcome following nerve repair in the upper extremity using processed nerve allograft.

PURPOSE: Reconstruction of peripheral nerve discontinuities with processed nerve allograft has become increasingly relevant. The RANGER Study registry was initiated in 2007 to study the use of processed nerve allografts in contemporary clinical practice. We undertook this study to analyze outcomes for upper extremity nerve repairs contained in the registry database. METHODS: We identified an upper extremity-specific population within the RANGER Study registry database consisting of 71 nerves repaired with processed nerve allograft. This group was composed of 56 subjects with a mean age of 40 ± 17 years (range, 18-86 y). We analyzed data to determine the safety and efficacy of processed nerve allograft. Quantitative data were available on 51 subjects with 35 sensory, 13 mixed, and 3 motor nerves. The mean gap length was 23 ± 12 mm (range, 5-50 mm). We performed an analysis to evaluate response-to-treatment and to examine sensory and motor recovery according to the international standards for motor and sensory nerve recovery. RESULTS: There were no reported implant complications, tissue rejections, or adverse experiences related to the use of the processed nerve allografts. Overall recovery, S3 or M4 and above, was achieved in 86% of the procedures. Subgroup analysis demonstrated meaningful levels of recovery in sensory, mixed, and motor nerve repairs with graft lengths between 5 and 50 mm. The study also found meaningful levels of recovery in 89% of digital nerve repairs, 75% of median nerve repairs, and 67% of ulnar nerve repairs. CONCLUSIONS: Our data suggest that processed nerve allografts offer a safe and effective method of reconstructing peripheral nerve gaps from 5 to 50 mm in length. These outcomes compare favorably with those reported in the literature for nerve autograft, and exceed those reported for tube conduits.

Microvascular approach to scalp replantation and reconstruction: a thirty-six year experience.

BACKGROUND: Soft tissue defects of the scalp may result from multiple etiologies and can be challenging to reconstruct. We discuss our experience with scalp replantation and secondary microvascular reconstruction over 36 years, including techniques pioneered at our institution with twin-twin scalp allotransplant and innervated partial superior latissimus dorsi (LD) for scalp/frontalis loss. METHODS: A retrospective review of all patients presenting with scalp loss requiring microvascular reconstruction at a single center was performed from January 1971 to January 2007. Medical records were reviewed for age, gender, defect size/location, etiology, type of reconstruction, recipient vessels used, vein grafts, and complications. RESULTS: Thirty-three patients were identified; mean age was 33 years (range, 7-79). Mean scalp defect size was 442 cm(2) (range, 120-900 cm(2)). Thirty-six microvascular reconstructions were performed; of these, 10 scalp replants and 26 microvascular tissue transfers. Of these 26, 17 were LD based (partial superior LD with and without reinnervation, LD combined with serratus, LD combined with parascapular, LD combined with split rib, LD only) and 2 free scalp allotransplant among others. The superficial temporal artery and vein was used as recipient vessels in 70% of cases. Overall, microvascular success rate was 92%; complications occurred in 14 cases, nine major (tumor recurrence [n = 2], partial flap loss [n = 2], replant loss [n = 3, size <300 cm(2) ], hematoma [n = 2]) and five minor (donor site seroma /hematoma [n = 3], flap congestion [n = 1], superficial wound infection [n = 1]). CONCLUSIONS: Every attempt should be made at scalp replantation when the patient is stable and the parts salvageable. Larger avulsion defects had higher success rates after replantation than smaller defects (<300 cm(2) ), with the superficial temporal artery and vein most commonly used for recipient vessels (P = 0.0083). Microvascular tissue transfer remains a mainstay of treatment for scalp defects, with LD-based flaps, demonstrating excellent versatility for a range of defects.

The utility of multimedia in the diagnosis and management of acute and subacute problems in hand surgery.

A typical consultation is based on a phone conversation between the consulting service and the surgeon. If the description given to the surgeon misrepresents the severity of the condition, unnecessary transfer of the patient could follow. In an attempt to reduce the occurrence of unnecessary transfers, we started supplementing our consultation with video captured with a cell phone camera demonstrating specific points in clinical examination of the hand. These videos were sent to the surgeon to clarify the clinical picture. We found this method useful in some cases in ruling out the need for urgent transfer.

A multi-disciplinary approach to the management of fungal osteomyelitis: current concepts in post-traumatic lower extremity reconstruction: a case report.

Limb salvage in fungal osteomyelitis of the post-traumatic lower extremity represents a difficult clinical problem requiring aggressive management. We report lower extremity salvage by radical bony debridement, free tissue transfer, distraction osteogenesis with bone-docking, and a novel antifungal regimen in a clinical setting of infection with Scedosporium inflatum, historically requiring amputation in 100% of cases. We treated Scedosporium inflatum osteomyelitis of the tibia and calcaneus with radical debridement of infected bone, free partial medial rectus abdominis muscle flap coverage, transport distraction osteogenesis, and combination voriconazole/terbinafine chemotherapy, a novel antifungal regimen. We achieved successful control of the infection, limb salvage, and an excellent functional outcome through aggressive debridement of infected bone and soft tissue, elimination of dead space within the bony defect, the robust perfusion provided by the free flap, the hypervascular state induced by distraction osteogenesis, and the synergism of the novel antifungal regimen.

The test-retest reliability of anatomical co-ordinate axes definition for the quantification of lower extremity kinematics during running.

Three-dimensional (3-D) kinematic analyses are used widely in both sport and clinical examinations. However, this procedure depends on reliable palpation of anatomical landmarks and mal-positioning of markers between sessions may result in improperly defined segment co-ordinate system axes which will produce in-consistent joint rotations. This had led some to question the efficacy of this technique. The aim of the current investigation was to assess the reliability of the anatomical frame definition when quantifying 3-D kinematics of the lower extremities during running. Ten participants completed five successful running trials at 4.0 m·s(-1) ± 5%. 3-D angular joint kinematics parameters from the hip, knee and ankle were collected using an eight camera motion analysis system. Two static calibration trials were captured. The first (test) was conducted prior to the running trials following which anatomical landmarks were removed. The second was obtained following completion of the running trials where anatomical landmarks were re-positioned (retest). Paired samples t-tests were used to compare 3-D kinematic parameters quantified using the two static trials, and intraclass correlations were employed to examine the similarities between the sagittal, coronal and transverse plane waveforms. The results indicate that no significant (p>0.05) differences were found between test and retest 3-D kinematic parameters and strong (R(2)≥0.87) correlations were observed between test and retest waveforms. Based on the results obtained from this investigation, it appears that the anatomical co-ordinate axes of the lower extremities can be defined reliably thus confirming the efficacy of studies using this technique.

Processed nerve allografts for peripheral nerve reconstruction: a multicenter study of utilization and outcomes in sensory, mixed, and motor nerve reconstructions.

PURPOSE: As alternatives to autograft become more conventional, clinical outcomes data on their effectiveness in restoring meaningful function is essential. In this study we report on the outcomes from a multicenter study on processed nerve allografts (Avance® Nerve Graft, AxoGen, Inc). PATIENTS AND METHODS: Twelve sites with 25 surgeons contributed data from 132 individual nerve injuries. Data was analyzed to determine the safety and efficacy of the nerve allograft. Sufficient data for efficacy analysis were reported in 76 injuries (49 sensory, 18 mixed, and 9 motor nerves). The mean age was 41 ± 17 (18-86) years. The mean graft length was 22 ± 11 (5-50) mm. Subgroup analysis was performed to determine the relationship to factors known to influence outcomes of nerve repair such as nerve type, gap length, patient age, time to repair, age of injury, and mechanism of injury. RESULTS: Meaningful recovery was reported in 87% of the repairs reporting quantitative data. Subgroup analysis demonstrated consistency, showing no significant differences with regard to recovery outcomes between the groups (P > 0.05 Fisher's Exact Test). No graft related adverse experiences were reported and a 5% revision rate was observed. CONCLUSION: Processed nerve allografts performed well and were found to be safe and effective in sensory, mixed and motor nerve defects between 5 and 50 mm. The outcomes for safety and meaningful recovery observed in this study compare favorably to those reported in the literature for nerve autograft and are higher than those reported for nerve conduits.

Transverse upper gracilis flap as an alternative to abdominal tissue breast reconstruction: technique and modifications.

BACKGROUND: The inner thigh skin and fat based on the transverse upper gracilis musculocutaneous flap blood supply provide an autologous donor area with qualities favorable to microvascular breast reconstruction. The flap can be shaped to mimic a mastectomy specimen, providing excellent contour and projection, and has a consistent blood supply. The characteristics and skin color of the flap allow for immediate nipple-areola complex reconstruction in skin-sparing mastectomy. METHODS: From 2004 to 2007, the authors performed 32 free inner thigh flap microvascular breast reconstructions after mastectomy for breast cancer in 20 patients, in both delayed and immediate settings. RESULTS: All flaps survived without any soft-tissue loss or fat necrosis. Complications were a single take-back for venous thrombosis with salvage, donor-site skin breakdown in eight flaps, and five seromas. There was no functional loss at the donor site, and all patients resumed normal activity. CONCLUSIONS: Transverse upper gracilis musculocutaneous flap microvascular breast reconstruction is an excellent option for patients who desire autologous reconstruction and who do not have adequate abdominal donor tissue or who do not desire abdominal scarring. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Artery-vein-artery venous flap for simultaneous soft-tissue repair and radial artery reconstruction: case report.

We present a case of partial amputation of the forearm resulting in soft-tissue and radial artery defects that were simultaneously repaired using a large artery-vein-artery venous flap. The flap measured 4 × 11 cm, and we attribute its complete survival and long-term durability to the artery-vein-artery configuration.

Bridging the gap in hand replantation: use of the common digital artery for completion of the superficial palmar arch.

BACKGROUND: Traumatic hand amputations along a longitudinal axis are possible but, to the authors' knowledge, have not been described in the literature. To bridge the gap and repair the transected superficial palmar arch at its apex, a common digital artery can be sacrificed and turned toward the plane of the arch. An anatomical study was performed to investigate the possibility of using the common digital artery to the third web space for completion of the superficial palmar arch. METHODS: Fifteen fresh cadaveric hands were dissected to evaluate the caliber and origin of the common digital artery to the third web space for possible reconstitution of the arch. RESULTS: In all specimens, a complete superficial palmar arch was identified. In 10 specimens, the superficial palmar arch caliber tapered off from the ulnar to the radial aspect, indicating an anatomical ulnar dominance of the arch. The average diameter of the common digital artery to the third web space was 1.7±0.2 mm. The average superficial palmar arch diameter measured 1.6±0.7 mm on the radial side of the common digital artery. In two female cadaver specimens, a unique pattern in the origin of the common digital artery was identified. The common digital artery to the second and third web spaces originated from a common branch off of the superficial palmar arch. CONCLUSIONS: Replantation of a longitudinally amputated hand can be performed based solely on a common digital artery for reconstitution of palmar arch flow. However, because of known variability in the palmar arch configuration, intraoperative clamping must be used to ensure safe use of the donor vessels while avoiding distal ischemic risk.

Refining outcomes in dorsal hand coverage: consideration of aesthetics and donor-site morbidity.

BACKGROUND: With high success rates, flap survival should no longer be the sole criterion in judging success in dorsal hand and wrist reconstruction. The authors sought to determine the best flap for dorsal hand coverage in terms of aesthetic appearance, donor-site morbidity, and minimization of revision surgery. METHODS: A retrospective review of all free flaps for dorsal hand and wrist coverage from 2002 to 2008 was performed. Flaps were divided into four groups: muscle, fasciocutaneous, fascial, and venous flaps. Outcomes assessed included need for debulking, blinded grading of aesthetic outcomes, and flap and donor-site complications. RESULTS: A total of 125 flaps were performed with no flap losses. There was no difference in partial loss or infection among the different flap groups. There was a significant range in the need for future debulking procedures, with debulking required in 67 percent of fasciocutaneous, 32 percent of muscle, 5.8 percent of fascial, and 0 percent of venous flaps. There was a significant difference in aesthetic outcomes: venous flaps had the best overall aesthetic outcomes; fascia and muscle flaps scored equally in terms of overall aesthetics, color, and contour match; and fasciocutaneous flaps had significantly worse aesthetic, contour, and color match results compared with all other flap types. Fasciocutaneous flaps had greater donor-site morbidity in terms of need for skin grafting and wound breakdown. CONCLUSION: The aesthetic outcome of dorsal hand reconstruction is dependent on flap choice, with statistically significant differences in revision surgeries and aesthetics among flap types.

Standardized protocol for artery-only fingertip replantation.

PURPOSE: Artery-only fingertip replantation can be reliable if low-resistance flow through the replant is maintained until venous outflow is restored naturally. Injuring the tip of the replant to promote ongoing bleeding augmented with anticoagulation usually accomplishes this; however, such management results in prolonged hospitalization. In this study, we analyzed the outcomes of artery-only fingertip replantation using a standardized postoperative protocol consisting of dextran-40, heparin, and leech therapy. METHODS: Between 2001 and 2008, we performed 19 artery-only fingertip replants for 17 patients. All patients had the replanted nail plate removed and received intravenous dextran-40, heparin, and aspirin to promote fingertip bleeding and vascular outflow. Anticoagulation was titrated to promote a controlled bleed until physiologic venous outflow was restored by neovascularization. We used medicinal leeches and mechanical heparin scrubbing for acute decongestion. By postoperative day 6, bleeding was no longer promoted. We initiated fluorescent dye perfusion studies to assess circulatory competence and direct further anticoagulant intervention if necessary. The absence of bleeding associated with an initial rise followed by an appropriate fall in fluorescent dye concentration would trigger a weaning of anticoagulation. RESULTS: All of the 19 replants survived. The average length of hospital stay was 9 days (range, 7-17 d). Eleven patients received blood transfusions. The average transfusion was 1.8 units (range, 0-9 units). All patients were happy with the decision to replant, and the cosmetic result. CONCLUSIONS: A protocol that promotes temporary, controlled bleeding from the fingertip is protective of artery-only replants distal to the distal interphalangeal joint until physiologic venous outflow is restored. The protocol described is both safe and reliable. The patient should be informed that such replant attempts may result in the need for transfusions and extended hospital stays, factors that can help the physician and patient decide whether to proceed with replantation. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.