Revisiting the reconstructive ladder for soft tissue reconstruction in the lower extremity.

Soft tissue reconstruction of the lower limb has seen a paradigm shift over the past two decades. Typically, these defects arise from trauma, infection or tumor. It is no longer enough to simply achieve coverage. Factors like patient-reported outcomes and aesthetic considerations are essential in the decision-making process. This is especially in light of increasing technological advancement, availability of dermal substitutes, microsurgical expertise and development of the field of microsurgical reconstruction as a whole with more novel flaps and techniques. Advancements in reconstructive modalities have also been equally matched by better emergency medical mobilization, transportation and access, early initiation of subspecialty care, accessibility and types of imaging, as well as oncological advances in radiotherapy and chemotherapy regimens. Yet, this has also meant that our patient profile has expanded to include older patients with more co-morbidities and other considerations such as frailty or the irradiated field which could influence what reconstructive modality is suitable and the goals of reconstruction specific to the patient. Previously deemed unsalvageable limbs are now being successfully reconstructed with good function and aesthesis. In the lower limb, this implicates the ability for early mobilization, range of motion and weight bearing which allow the patient to successfully partake in early rehabilitation. Expedient and reliable healing is also important in the oncological population where a proportion of these patients would need to go on to receive post-operative chemotherapy or radiotherapy. The reconstructive ladder has been what many reconstructive surgeons have been taught upon with regard to the basic principles of pre-operative planning and choosing the appropriate reconstructive modality. In this article, we examine the relevance of the reconstructive ladder in modern practice and the additional considerations in the approach to a soft tissue defect in the lower extremity.

Histology of the volar plate of the thumb metacarpophalangeal joint.

BACKGROUND: The aim of the study was to describe the histology of the thumb MCPJ volar plate. METHODS: Five fresh-frozen thumbs were dissected. The volar plates were harvested from the thumb MCPJ. Histological analyses were performed using 0.04% Toluidine blue and counterstained with 0.005% Fast green. RESULTS: The thumb MCPJ volar plate comprised two sesamoids, dense fibrous tissue and loose connective tissue. The two sesamoids were connected by dense fibrous tissue, with collagen fibers oriented transversely (perpendicular to the long axis of the thumb). In contrast, the collagen fibers within the dense fibrous tissue on the lateral sides of the sesamoid were oriented longitudinally in line with long axis of the thumb. These fibers blended with the fibers of the radial and ulnar collateral ligaments. The collagen fibers in the dense fibrous tissue distal to the sesamoids ran transversely, perpendicular to the long axis of the thumb. The proximal aspect of the volar plate showed only loose connective tissue. The volar plate of the thumb MCPJ was largely uniform with no division of layers from the dorsum to the palmar surface. There was no fibrocartilaginous component in the thumb MCPJ volar plate. CONCLUSIONS: The histology of the volar plate of the thumb MCPJ differs significantly from the conventional understanding of the volar plate, based on the volar plate of finger proximal interphalangeal joints. The difference is likely due to the presence of the sesamoids, which confer additional stability, reducing the need for a specialized trilaminar fibrocartilaginous structure with the lateral check-rein ligaments found in the volar plate of finger proximal interphalangeal joints to confer additional stability.

Comparison of proximal and distal involvement of upper extremity metastatic lesions: an analysis of 55 cases.

We analysed the differences in clinical presentation between proximal (above elbow) and distal (below elbow) upper limb metastases in a retrospective review of patients presenting to our centre from 2011 to 2019. There were 55 cases, 64% involving the humerus and 62% occurring in men. The median age at the time of diagnosis was 64 years. Thirty-one per cent of the cases were proximal lesions. Distal upper limb metastases were more likely to be soft tissue lesions (71%) compared with proximal lesions (8%). The median age of patients with distal lesions was significantly lower at 58 years compared with 65 years for proximal lesions. Overall, non-small cell lung carcinoma was the most common primary malignancy (25%), however haematological cancers were most common in the distal group (29%). Distal upper limb metastases have distinct features that distinguish them from proximal lesions.Level of evidence: IV.

Sandblasting Injury: A Case Report and a Review of Literature.

Sandblasting injuries are uncommon with only four reports in literature. We report a patient with a sandblasting injury of the dorsum of the hand and wrist and summarise published literature on the management of such injuries. We recommend early (<24 hours) C-arm-guided debridement of embedded foreign bodies and repeated saline washouts with a soft surgical scrub brush. Level of Evidence: Level V (Therapeutic).

Management of a mutilated hand: the current trends.

Mutilated upper limbs suffer loss of substance of various tissues with loss of prehension. The most important factor in salvage of a mutilated hand is involvement of a senior surgeon at the time of initial assessment and debridement. A regional block given on arrival helps through assessment and investigations in a pain-free state. Infection still remains the important negative determinant to outcome and is prevented by emergent radical debridement and early soft tissue cover. Radical debridement and secure skeletal stabilization must be achieved on day one in all situations. Dermal substitutes and negative pressure wound therapy are increasingly used but have not substituted regular soft tissue cover techniques. Ability to perform secondary procedures and the increased use of the reconstructed hand with time keeps reconstruction a better option than prosthesis fitting. Toe transfers and free functioning muscle transfers are the two major secondary procedures that have influenced outcomes.

Pedicled Osteo-Onchyocutaneous Island Flap for Finger Macrodactyly: A Review of Literature.

We present a case of middle finger macrodactyly reconstructed in a single stage using multiple techniques. We elevated a pedicled osteo-onychocutaneous island flap, excised the remnant distal phalanx with a segment of 1 digital nerve and skin over the dorsum of the middle phalanx, performed epiphysiodesis and reduction of the middle phalanx as well as soft-tissue debulking, and inset the flap over the dorsum of the middle phalanx. Follow-up at 12 months revealed a satisfactory aesthetic and functional outcome.

A Pragmatic and Evidence-Based Approach to Mallet Finger.

A mallet finger is a common injury that results from a sudden flexion force on an extended distal phalanx or rarely, from hyperextension of the distal interphalangeal joint. Mallet finger can be purely tendinous or bony when associated with an avulsion fracture. The management of this injury is largely conservative with the use of a splint, although surgery may be indicated for select patients. There is little consensus on the indications for surgery or the suitable surgical technique. The aim of this review article is to provide a pragmatic and evidence-based approach to mallet finger that will guide the treating surgeon in providing best care for their patient.

Trigger Finger Associated with Fencing in an Adolescent: A Case Report.

Trigger digits in children are rare and the vast majority of cases are primary and involve the thumb. Although there are isolated reports of trigger digits in children after trauma, we were unable to find any report of a trigger digit in a child caused by repetitive forceful gripping. We report a 14-year-old fencer who developed a trigger of his middle finger to highlight this unusual association. This was initially managed with a splint and analgesics and eventually required two intrathecal steroid injections for resolution of symptoms.

Palmar Dislocations of the 5th Carpometacarpal Joint: Case Report of a Rare Injury and Review of Published Cases.

Isolated palmar dislocation of the 5th carpometacarpal joint (CMCJ) is a rare injury that can be easily missed and requires a high index of suspicion to detect. We report a case of an initially missed isolated ulnopalmar dislocation of the 5th CMCJ and a summary of other published case reports comparing methods of fixation and outcomes. We conclude that a delay in diagnosis will significantly reduce the chances of successfully managing this injury via closed reduction.

Time to Resolution of Triggering after Steroid Injection for First Presentation Trigger Digits.

Background: Steroid injection is a proven treatment for trigger digits. The time taken for resolution of triggering following an injection is a question often asked by patients and one that has not been adequately addressed in existing literature. The aim of this study was to determine the time taken for triggering to resolve after a single steroid injection in patients presenting for the first time with a trigger digit. Methods: A prospective study was conducted in patients with first presentation of a grade II or grade III trigger digit(s) that received a steroid injection. Data with regards to age, gender, digit(s) involved, duration of symptoms, trigger grade, and presence of diabetes were collected. They were given a stamped addressed postcard with instructions to fill in the date that the triggering resolved and mail the postcard back to us. If the postcard was not received at three weeks, we contacted the patient by telephone to ask for the date of resolution of trigger. Results: 56 patients with 66 trigger digits were included in the study. 52 out of 66 digits (79%) had resolution of the trigger at one month. The mean duration for resolution of trigger was 8.8 days (range 1-30 days). Conclusions: Patients can be counselled that a steroid injection is effective in resolving the trigger in 79% of trigger digits presenting for the first time and that the mean time taken for resolution of triggering is 8.8 days. It is recommended to wait for at least one month before considering another injection or alternative treatments.

Maximal advancement of homodigital neurovascular island flaps.

We investigated the maximal advancement of the homodigital neurovascular island flap with the digit in full extension and its correlation to the digital length. In 32 adult cadaveric digits, flaps measuring 1 × 1 cm were sequentially elevated to different dissection points. Dissection of the flap to the proximal interphalangeal joint crease, palmo-digital crease, division of adjacent digital artery and the superficial arch resulted in flap advancement of 8, 12, 15 and 18 mm, respectively. The degree of advancement correlated to the length of the finger and was approximately 19% of the finger length. We conclude that dissection of a homodigital antegrade neurovascular island flap to the proximal interphalangeal joint, palmo-digital crease, after ligation of adjacent digital artery and the superficial arch allows progressively more advancement. The advancement obtained by flap dissection to the palmo-digital crease was about 19% of the finger length.

Considerations in Flap Selection for Soft Tissue Defects of the Hand.

Soft tissue defects of the hand commonly arise as a consequence of trauma or infection and after resection of tumors. Restoring a thin and pliable soft tissue envelope is critical to restoring mobility and optimizing functional outcomes. The appearance, color, and texture match as well as donor site issues are increasingly important aspects of hand reconstruction. This article discusses the principles of soft tissue reconstruction in the hand and presents a rational approach to clinical decision making to ensure optimal outcomes.

MnSOD is implicated in accelerated wound healing upon Negative Pressure Wound Therapy (NPWT): A case in point for MnSOD mimetics as adjuvants for wound management.

Negative Pressure Wound Therapy (NPWT), a widely used modality in the management of surgical and trauma wounds, offers clear benefits over conventional wound healing strategies. Despite the wide-ranging effects ascribed to NPWT, the precise molecular mechanisms underlying the accelerated healing supported by NPWT remains poorly understood. Notably, cellular redox status-a product of the balance between cellular reactive oxygen species (ROS) production and anti-oxidant defense systems-plays an important role in wound healing and dysregulation of redox homeostasis has a profound effect on wound healing. Here we investigated potential links between the use of NPWT and the regulation of antioxidant mechanisms. Using patient samples and a rodent model of acute injury, we observed a significant accumulation of MnSOD protein as well as higher enzymatic activity in tissues upon NPWT. As a proof of concept and to outline the important role of SOD activity in wound healing, we replaced NPWT by the topical application of a MnSOD mimetic, Mn(III) meso-tetrakis(N-ethylpyridinium-2-yl)porphyrin (MnTE-2-PyP5+, MnE, BMX-010, AEOl10113) in the rodent model. We observed that MnE is a potent wound healing enhancer as it appears to facilitate the formation of new tissue within the wound bed and consequently advances wound closure by two days, compared to the non-treated animals. Taken together, these results show for the first time a link between NPWT and regulation of antioxidant mechanism through the maintenance of MnSOD activity. Additionally this discovery outlined the potential role of MnSOD mimetics as topical agents enhancing wound healing.

Computer Aided Assessment in Microsurgical Training.

BACKGROUND: Acquiring competence in microsurgical suturing is a basic requirement for any trainee aspiring to perform clinical microsurgery. New methods and simulation platform continue to evolve, but the assessment of the quality of microsurgical suturing is largely subjective. We present the concept of computer aided assessment of standardised microsurgical task, using a novel training platform. The platform comprises of a simulator (hardware) that provides the trainee standardised microsurgical tasks, which are then evaluated using a customised software. METHODS: A cohort of trainees attending a five day microsurgery training course was selected. The trainees performed three standardised exercises on the platform, on the first third and the fifth day of the course. All the exercises were subjected to computer aided assessment. RESULTS: Trainees demonstrated a learning curve over the five day period through the evaluation system, with initial increase in performance followed by a plateau. Eighty four percent of the trainees were able to achieve acceptable scores. Sixteen percent of the trainees were unable to perform a suturing of acceptable quality at the end of the training (fifth day). CONCLUSIONS: The mean scores correlated with the level of difficulty of the exercise. We conclude that computer aided assessment can provide an objective view of the quality of suturing as well as skill maintenance in for trainees.

Factors associated with failure of free gracilis flap in reconstruction of acute traumatic leg defects.

BACKGROUND: Possible factors associated with failure of free gracilis flaps were studied. MATERIALS AND METHODS: All gracilis free flaps used to reconstruct acute traumatic leg defects in a 5 year period were collected. This included open fractures of the tibia and/or fibula in which a gracilis free flap was used for reconstruction. Pre-op factors included age, ethnicity, gender, presence of diabetes, ischaemic heart disease, peripheral vascular disease, or coagulation disorders; days from trauma to flap surgery, Gustilo class, presence of a concurrent ipsilateral femur fracture, and use of CT angiogram to determine adequacy of blood supply. Intra-op factors included type of arterial anastomosis (end to side or end to end), presence of arterial transection, initial arterial anastomotic failure, initial venous anastomotic failure, use of systemic vasoconstrictors by anaesthetists for correction of hypotension, and use of modulators of the coagulation mechanism (dextran/heparin). Post-op factors included post-op day when flap was removed and use of modulators of the coagulation mechanism. RESULTS: Patients with a concurrent ipsilateral femur fracture had a 9.67 (95% CI of OR = 1.32-70.96) times increased risk of flap failure compared to patients without an associated femur fracture. CONCLUSION: The finding of increased risk of free gracilis flap failure for coverage of leg defects in patients with ipsilateral femur fractures has implications on flap selection and pre-operative counselling. In such a situation, a non-microvascular option could be safer if it is available as an alternative.

Direct Radiological Visualization of Loading on Four Flexor Tendon Repair Suture Configurations.

PURPOSE: To study the deformation of 4 suture configurations used in flexor tendon repair using fluoroscopy. METHODS: All flexor tendon repair techniques have a longitudinal component, a link component, and/or a transverse component. We had previously described 4 types of link components, namely an arc (grasping loop), a simple loop (locking loop), a complex loop, and a knot. The effect of loading on suture configurations using each of these link components was tested in flexor tendon from the first ray of porcine feet. Forty flexor tendons were divided into 4 groups of 10 each, and one-half of a tendon repair was simulated on each group using 0.5 mm stainless steel wire. The tendons were mounted on a materials testing machine, and tensile force was applied until failure. The deformation of the suture within the tendon substance was observed using an image intensifier, and the maximal load to failure was measured. RESULTS: The loading of the suture led to unraveling of the suture in an arc, constriction and unraveling in a simple loop, and initial constriction with no further change of the construct in the complex loop with no change in the knot design. The mean pullout strength of the complex loop was statistically greater than all the other 3 designs. CONCLUSIONS: Each of the link component designs demonstrated unique deformation characteristics. The complex loop design had the strongest grasping ability. CLINICAL RELEVANCE: This study identified the differences in the deformation characteristics of the 4 types of link components used in flexor tendon repair. This knowledge may allow for the development of better flexor tendon repair techniques and the adoption of a more precise classification of flexor tendon repair techniques.

Post Traumatic Avascular Necrosis of the Proximal Carpal Row--A Case Report.

We report a case of avascular necrosis of the scaphoid, lunate and triquetrum in a young 21-year-old patient, after a purely ligamentous peri-lunate dislocation of the wrist. He presented with a Mayfield III peri-lunate dislocation after a road traffic accident and underwent an open reduction and internal fixation. Post-operatively, the scapho-lunate gap widened after removal of the temporary K-wires, and he gradually developed avascular necrosis of the scaphoid, lunate and triquetrum, and osteoarthritis of his wrist. We present this unusual case of simultaneous avascular necrosis of multiple carpal bones and discuss the possible risk factors and subsequent management plans for this complex injury. Our patient has no identifiable contributing factors to developing avascular necrosis. We suspect that the violence of the injury and surgery may have compromised the circulation, and advise caution when treating and counseling these patients pre-operatively.