Comisuroplastia mediante colgajo de perforante digital en secuelas cicatriciales de quemaduras / Commissuroplasty using a digital perforator flap in the cicatricial sequelae of burns

Introducción y objetivo: Las bridas cicatriciales en mano como secuela de quemaduras pueden suponer impotencia funcional. El colgajo de perforante de la arteria digital tomado de la cara lateral de los dedos constituye una excelente opción terapéutica para el manejo de estas lesiones. Describimos nuestra experiencia con esta técnica quirúrgica y mostramos sus resultados morfológicos y funcionales. Material y método: Presentamos nuestra experiencia con 14 colgajos en 7 pacientes afectos de bridas comisurales en mano. Estos colgajos, basados en perforantes de la arteria digital, toman como zona donante la cara lateral de la falange proximal adyacente. Cubrimos la zona donante con injertos de piel de espesor total. Los pacientes fueron sometidos a rehabilitación precoz, presoterapia y férulas nocturnas. Resultados: La supervivencia de los colgajos fue completa en los 14 casos. En 1 caso se produjo necrosis del injerto en la zona donante del colgajo, solucionada con curas. Resolvimos la brida comisural en el 85.7 % de los casos (13 de 14 casos). El seguimiento medio fue de 27.3 meses (rango 12-45 meses). En 1 caso se produjo recidiva parcial a los 10 meses, solucionada mediante Z-plastias. Los pacientes experimentaron mejoría subjetiva de la funcionalidad y estética de la mano. La apertura del ángulo del espacio interdigital, medida en grados, mejoró desde una media de 22.5 grados preoperatorios (rango 150-350) a una media de 36.8 grados postoperatorios (rango 250-450). Conclusiones: En nuestra experiencia, el colgajo de perforante de arteria digital es una opción terapéutica rápida, sencilla y eficaz en el tratamiento de las contracturas tras quemaduras del segundo al cuarto espacio interdigital. Son fundamentales el adecuado cuidado postoperatorio, rehabilitación, presoterapia y ferulización para un resultado óptimo.(AU)

Background and objective: Scar contractures in the hand are a sequela of burns that can lead to functional impairment. The perforator flap from the digital artery, taken from the lateral aspect of the fingers, represents an excellent therapeutic option for managing these injuries. We present our experience with this surgical technique and our morphological and functional results. Methods: We present our experience with 14 flaps in 7 patients affected by web contractures in the hand. These flaps, based on perforators from the digital artery, use the adjacent lateral aspect of the proximal phalanx as the donor site. The donor area was covered with full-thickness skin grafts. Patients underwent early rehabilitation, pressure therapy, and nighttime splinting. Results: The survival of the flaps was successful in all 14 cases. One case experienced graft necrosis in the donor site of the flap, which resolved with conservative treatment. Commissural contractures were resolved in 85.7% of the cases (13 out of 14 cases). The mean follow-up period was 27.3 months (range 12-45 months). In 1 case, partial recurrence occurred at 10 months and it was successfully managed with Z-plasty. Patients reported subjective improvement in hand functionality and aesthetics. The interdigital space angle, measured in degrees, improved from a mean of 22.5 degrees preoperatively (range 15°-35°) to a mean of 36.8 degrees postoperatively (range 25°-45°). Conclusions: In our experience, the perforator flap from the digital artery represents a rapid, straightforward, and effective therapeutic option for treating contractures after burns in the second to fourth interdigital spaces. Adequate postoperative care, rehabilitation, pressure therapy and splinting are essential for optimal outcomes.(AU)

Protein Kinase C Inhibition Mediates Neuroblast Enrichment in Mechanical Brain Injuries.

Brain injuries of different etiologies lead to irreversible neuronal loss and persisting neuronal deficits. New therapeutic strategies are emerging to compensate neuronal damage upon brain injury. Some of these strategies focus on enhancing endogenous generation of neurons from neural stem cells (NSCs) to substitute the dying neurons. However, the capacity of the injured brain to produce new neurons is limited, especially in cases of extensive injury. This reduced neurogenesis is a consequence of the effect of signaling molecules released in response to inflammation, which act on intracellular pathways, favoring gliogenesis and preventing recruitment of neuroblasts from neurogenic regions. Protein kinase C (PKC) is a family of intracellular kinases involved in several of these gliogenic signaling pathways. The aim of this study was to analyze the role of PKC isozymes in the generation of neurons from neural progenitor cells (NPCs) in vitro and in vivo in brain injuries. PKC inhibition in vitro, in cultures of NPC isolated from the subventricular zone (SVZ) of postnatal mice, leads differentiation towards a neuronal fate. This effect is not mediated by classical or atypical PKC. On the contrary, this effect is mediated by novel PKCε, which is abundantly expressed in NPC cultures under differentiation conditions. PKCε inhibition by siRNA promotes neuronal differentiation and reduces glial cell differentiation. On the contrary, inhibition of PKCθ exerts a small anti-gliogenic effect and reverts the effect of PKCε inhibition on neuronal differentiation when both siRNAs are used in combination. Interestingly, in cortical brain injuries we have found expression of almost all PKC isozymes found in vitro. Inhibition of PKC activity in this type of injuries leads to neuronal production. In conclusion, these findings show an effect of PKCε in the generation of neurons from NPC in vitro, and they highlight the role of PKC isozymes as targets to produce neurons in brain lesions.

Nuestra experiencia en campaña humanitaria en Liberia / Our personal experience during an humanitarian project in Liberia

Las Organizaciones No Gubernamentales (ONG) intentan aportar bienes básicos y servicios sanitarios a aquellas personas afectadas ya sea por catástrofes humanas o naturales, o bien por situaciones de extrema pobreza. Con este planteamiento, surgió un acuerdo de colaboración entre la Sociedad Española de Cirugía Plástica Reparadora y Estética (SECPRE) y los Hermanos de San Juan de Dios, uno de cuyos frutos ha sido, por segundo año consecutivo, esta campaña en el Saint Joseph's Catholic Hospital de Monrovia (Liberia). En este artículo describimos nuestra estancia en dicho proyecto de ayuda humanitaria desarrollado en noviembre del 2017, tratando de transmitir no sólo las condiciones de trabajo a las que nos enfrentamos, sino también la experiencia personal de todos los componentes del equipo, con el objetivo de que sea útil para miembros de próximas campañas

Non-Governmental Organizations (NGO) aim to provide basic goods and health care to people affected by human and natural disasters or by situations of extreme poverty. With this objective, collaboration took place between the Spanish Society os Plastic, Reconstructive and Aesthetic Surgery (SECPRE) and the order of the Brothers of San Juan de Dios. One of its achievements has been that this campaign has taken place for the second consecutive year at Saint Joseph's Catholic Hospital in Monrovia (Liberia). In this article, we describe our personal experience during the humanitarian project carried out in November 2017. We intend to communicate not only the working conditions, but also the personal experience of all the team members involved, with the aim of supporting future campaigns

Tratamiento quirúrgico de la rizartrosis: evaluación de resultados de distintas técnicas / Surgical management of the thumb arthritis: asessment of outcomes of different techniques

Introducción y Objetivo. Larizartrosis o artrosis de la articulación trapeciometacarpiana (TMC) es uno de los principales motivos de consulta en una Unidad de Cirugía de Mano. Ante el fracaso del tratamiento conservador, recomendamos el tratamiento quirúrgico. Existen distintas opciones terapéuticas y la elección debe ser individualizada para cada paciente en función de varios factores: edad, grado de artrosis, demanda funcional, etc. En este trabajo analizamos los resultados obtenidos en nuestra práctica con las distintas técnicas. Material y Método. Entre abril de 2011 y febrero de 2015 intervinimos 97 casos de rizartrosis. La edad media de los pacientes fue de 54.01 años, con claro predominio del sexo femenino (85.5%). La técnica más frecuentemente empleada fue la artroplastia con reconstrucción ligamentaria y suspensión según técnica de Weilby, con 79 casos. En 9 casos realizamos una artroplastia artroscópica (ATK); en 4 una artrodesis TMC; y en 5 una ligamentoplastia. Resultados. De los 97 pacientes pudimos controlar postoperatoriamente a 49, con un seguimiento medio de 18,3 meses. Los pacientes experimentaron una mejoría de la fuerza de pinza del 24.28% con la técnica de Weilby; del 18.74% con la ATK; del 45.75% con la artrodesis TMC; y del 31.42% con la ligamentoplastia. Respecto al dolor, valorado según una escala visual analógica (0-10) la mejoría fue de 5.50, 5.1, 6.34 y 6.33 puntos respectivamente, en relación a la situación preoperatoria. Conclusiones. Los resultados obtenidos nos confirman la utilidad de la artroplastia de suspensión-interposición como técnica de elección para el paciente habitual de rizartrosis. En determinados casos, factores como la edad, la demanda funcional o el grado de degeneración articular nos encaminaran a elegir otras técnicas, buscando satisfacer las necesidades de cada paciente en concreto (AU)

Background and Objective. Osteoarthritis of the thumb carpometacarpal (CMC) joint remains one of the main reasons for visiting a Hand Centre. Whenever the conservative treatment fails, the surgical approach will be offered. This treatment should be indicated individually for each patient, depending on various factors as the age, the degeneration degree, the functional demand and so on. In this paper the author analyse the outcomes of different techniques, based on his own surgical experience. Methods. Between April 2011 and February 2015, 97 cases of thumb arthritis have been treated surgically. The average age of the patients was 54.01 years, with predominance of females (85.5 %). The most frequently used technique was the ligament reconstruction tendon interposition technique, as Weilby's recomends with 79 cases. In 9 cases an arthroscopic arthroplasty was performed (ATK); in 4 patients a CMC fusion; and in 5 a ligamentoplasty. Results. Out of the 97 patients, 49 have been controlled with an average follow up of 18.3 months. Patients referred an improvement in pinch strength of 24.28% in the Weilby's technique group; 18.74% in the ATK group; 45.75 % in the CMC fusion group; and 31.42 % in the ligamentoplasty group. Focus on the pain, assessed by the visual analog scale, the improvement was 5.50, 5.1, 6.34 and 6.33 points respectively, compared to the preoperative situation. Conclusions. These outcomes confirm the usefulness of the suspension - interposition arthroplasty as an ideal technique for the common patient of rizarthrosis. In some cases, some factors such as age, functional demand or the degree of joint degeneration, lead us to look for other techniques in order to satisfy needs patient's request (AU)

ELAC (3,12-di-O-acetyl-8-O-tigloilingol), a plant-derived lathyrane diterpene, induces subventricular zone neural progenitor cell proliferation through PKCß activation.

BACKGROUND AND PURPOSE: Pharmacological strategies aimed to facilitate neuronal renewal in the adult brain, by promoting endogenous neurogenesis, constitute promising therapeutic options for pathological or traumatic brain lesions. We have previously shown that non-tumour-promoting PKC-activating compounds (12-deoxyphorbols) promote adult neural progenitor cell (NPC) proliferation in vitro and in vivo, enhancing the endogenous neurogenic response of the brain to a traumatic injury. Here, we show for the first time that a diterpene with a lathyrane skeleton can also activate PKC and promote NPC proliferation. EXPERIMENTAL APPROACH: We isolated four lathyranes from the latex of Euphorbia plants and tested their effect on postnatal NPC proliferation, using neurosphere cultures. The bioactive lathyrane ELAC (3,12-di-O-acetyl-8-O-tigloilingol) was also injected into the ventricles of adult mice to analyse its effect on adult NPC proliferation in vivo. KEY RESULTS: The lathyrane ELAC activated PKC and significantly increased postnatal NPC proliferation in vitro, particularly in synergy with FGF2. In addition ELAC stimulated proliferation of NPC, specifically affecting undifferentiated transit amplifying cells. The proliferative effect of ELAC was reversed by either the classical/novel PKC inhibitor Gö6850 or the classical PKC inhibitor Gö6976, suggesting that NPC proliferation is promoted in response to activation of classical PKCs, particularly PKCß. ELAC slightly increased the proportion of NPC expressing Sox2. The effects of ELAC disappeared upon acetylation of its C7-hydroxyl group. CONCLUSIONS AND IMPLICATIONS: We propose lathyranes like ELAC as new drug candidates to modulate adult neurogenesis through PKC activation. Functional and structural comparisons between ELAC and phorboids are included.

12-Deoxyphorbols Promote Adult Neurogenesis by Inducing Neural Progenitor Cell Proliferation via PKC Activation.

BACKGROUND: Neuropsychiatric and neurological disorders frequently occur after brain insults associated with neuronal loss. Strategies aimed to facilitate neuronal renewal by promoting neurogenesis constitute a promising therapeutic option to treat neuronal death-associated disorders. In the adult brain, generation of new neurons occurs physiologically throughout the entire life controlled by extracellular molecules coupled to intracellular signaling cascades. Proteins participating in these cascades within neurogenic regions constitute potential pharmacological targets to promote neuronal regeneration of injured areas of the central nervous system. METHODOLOGY: We have performed in vitro and in vivo approaches to determine neural progenitor cell proliferation to understand whether activation of kinases of the protein kinase C family facilitates neurogenesis in the adult brain. RESULTS: We have demonstrated that protein kinase C activation by phorbol-12-myristate-13-acetate induces neural progenitor cell proliferation in vitro. We also show that the nontumorogenic protein kinase C activator prostratin exerts a proliferative effect on neural progenitor cells in vitro. This effect can be reverted by addition of the protein kinase C inhibitor G06850, demonstrating that the effect of prostratin is mediated by protein kinase C activation. Additionally, we show that prostratin treatment in vivo induces proliferation of neural progenitor cells within the dentate gyrus of the hippocampus and the subventricular zone. Finally, we describe a library of diterpenes with a 12-deoxyphorbol structure similar to that of prostratin that induces a stronger effect than prostratin on neural progenitor cell proliferation both in vitro and in vivo. CONCLUSIONS: This work suggests that protein kinase C activation is a promising strategy to expand the endogenous neural progenitor cell population to promote neurogenesis and highlights the potential of 12-deoxyphorbols as pharmaceutical agents to facilitate neuronal renewal.

Informe sobre el trasplante de 250 dedos del pie a la mano consecutivos. Indicaciones, resultados, fracasos y nuevas aplicaciones / Report on 250 consecutive toe to finger transplants. Indications, results, failures, and new applicactions

Propósito. Las transferencias de dedos del pie constituyen un arma fundamental en la rehabilitación de las lesiones de mano. Sin embargo, no gozan de mucha popularidad dada la posibilidad de fracaso y por las hipotéticas secuelas en la zona donante. Presentamos nuestra experiencia clínica, haciendo especial hincapié en las complicaciones y las nuevas aplicaciones. Material y métodos. En el periodo febrero de 1995 - enero de 2010 hemos realizado 250 transferencias de dedos del pie para amputaciones de todos o parte de los dedos. En las amputaciones de todos los dedos (23 casos) se trasplantaron el hallux de un pie y el 2.° y 3.er dedos del pie contralateral para lograr una pinza trípode. El resto de los casos corresponden a amputaciones multidigitales, simples o parciales de dedos, siendo 69 casos pulgares y el resto, dedos trifalángicos. Resultados. La tasa de reintervención por isquemia aguda fue del 16% (10% intraoperatoria), con una supervivencia final del 98,8% (3 fracasos) tras la revisión quirúrgica. No hubo ninguna necrosis parcial. Respecto a la zona donante, un paciente fue intervenido por presentar un neuroma; el resto no refirió ningún tipo de molestias a la marcha, en el seguimiento a largo plazo. Conclusiones. En nuestra experiencia, las transferencias de dedos del pie son un método seguro en la reconstrucción de lesiones graves de la mano. La secuela del pie es proporcional a la cantidad de dedos que se tomen, y es bien aceptada por el paciente, en especial en las graves lesiones (AU)

Purpose. Toe-to-hand transfers are an essential part of hand rehabilitation after loss of a finger. Despite this, the likelihood of failure and the hypothetical morbidity in the donor area, made this procedure not very popular among surgeons. The purpose of this paper is to present our clinical experience, highlighting the pitfalls and the new indications. Material and methods. Between February 1995-January 2010 we performed 250 toe-to-hand transfers for finger amputations. In metacarpal hands (23 cases) we transferred the hallux from one foot and the 2nd and 3rd from the other, to achieve a three-fingered (tripod) grasp. The rest of the patients had multi-digital, simple or partial amputations. In 69 the thumb was reconstructed and the rest of transfers were for finger reconstructions. Results. Re-operation rate due to acute ischaemia was 16% (10% intraoperative) and the overall success rate was 98.8% (3 failures). There was no partial necrosis in any case. Regarding the donor side, one patient was operated on due to a painful neuroma; the rest did not have complaints in the donor area. Conclusions. In our experience toe-to hand transfers are a safe and reliable method to rehabilitate severe hand injuries. Donor site morbidity is directly related to the number of toes harvested, and is well-tolerated by the patients, especially in severe injuries (AU)

Arthroscopically guided osteotomy for management of intra-articular distal radius malunions.

PURPOSE: A malunion with a step-off of 1 mm or more after an intra-articular distal radius fracture may cause pain and arthritic changes at midterm follow-up. We present our technique for treating intra-articular distal radius malunions by carrying out an osteotomy from inside the joint outward under arthroscopic guidance using the dry arthroscopy technique, with emphasis on the clinical and radiologic outcomes. METHODS: We performed surgery on 11 patients for intra-articular malunion of the distal radius 1 to 5 months after the injury. Preoperative step-offs ranged from 2 to 5 mm (average, 2.5 mm) on plain radiographs. Original fracture patterns involved 1 radial styloid fracture, 1 radiocarpal fracture-dislocation, and 9 comminuted intra-articular fractures. In 5 cases an anterior-ulnar or radial styloid fragment was repositioned. In the rest, more than 1 fragment (up to 3) was osteotomized. In 1 patient the articular osteotomy was combined with an ulnar shortening osteotomy. RESULTS: Follow-up ranged from 12 to 48 months. Step-offs were reduced in most cases to 0 mm; however, localized gaps (<2 mm) and cartilage defects were commonly seen intraoperatively because the fragments did not accurately fit. According to the Gartland and Werley score, there were 4 excellent and 7 good results (mean score of 2.8). The Modified Green and O'Brien system achieved a mean score of 83, with 3 excellent, 5 good, and 3 fair results. One patient showed radiolunate narrowing on follow-up radiographs. CONCLUSIONS: Arthroscopically assisted osteotomy permits direct visualization of the osteotomy site with good midterm clinical and radiologic outcomes. The technique can be used in irregularly defined fragments. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Late salvage of the ischemic finger after crush injury using flow-through flaps: case report.

The progressive evolution and late salvage of a posttraumatic digit with poor vascularization has not been discussed in the literature. We report the cases of 3 patients whose fingers were rescued at referral 5 to 16 days after the traumatic event by restoring the arterial inflow by means of flow-through free flaps. All 3 fingers were compromised vascularly with patchy necrosis and absence of Doppler signal distal to the injury. All were salvaged. In our experience, in the setting of a posttraumatic digit with poor vascularization, it is possible to reverse impending necrosis by late revascularization. Frank infection or mummification is considered an irreversible state and a contraindication to salvage.

Ischemic toe encountered during harvesting: report of 6 cases.

Local vessel disease causing lack of arterial inflow at the time of toe harvesting represents a surgical emergency. In a personal experience of 194 toe transfers to the hand, 6 cases (in 4 patients) were found to have diseased vessels at the first web to the point that acute ischemia of the toe occurred when the tourniquet was released at the lower limb. We report our experience in these 6 cases.

Super-thinned iliac flap for major defects on the elbow and wrist flexion creases.

Four free iliac flaps were used to treat or prevent flexion contracture at the elbow or wrist flexion crease. Flap size ranged from 13 x 6 cm to 18 x 8 cm. Two flaps were used for primary coverage, and the other 2 flaps were used to treat established flexion contractures. All flaps survived without vascular complications. Full range of motion was obtained at the elbow and 40 degrees of active extension was obtained at the wrist. The flap has a very thin dermis with minimal panniculus that can be thinned as required, making it ideal to cover flexion creases. Despite the fact that anatomic variations are common in the inguinal region, the flap can be expeditiously and safely elevated. If needed, pedicle length can be up to 8 to 10 cm. The donor site is comparable with that of a full-thickness skin graft harvested from the groin. The donor artery, however, can be very small.

A technique to improve foot appearance after trimmed toe or hallux harvesting.

We describe a technique to improve the appearance of the donor site after hallux harvesting. The surgery has been used in 6 consecutive patients having a trimmed-toe-type transfer. Instead of the classic stump closure advised by Wei, the following steps were performed on the donor site: (1) removal en bloc of the second metatarsal and transposition of the second toe on top of the proximal phalanx of the hallux, (2) interposition of a tibial (medial) glabrous flap from the tibial aspect of the hallux onto the tibial side of the second toe to increase its size, and (3) eponichial flap to increase the nail show on the second toe. Fixation of the toe was achieved with K-wires and cerclage wire. Crossed K-wires stabilized the first to the third metatarsals for 4 to 6 weeks. Ambulation with a stiff sole was allowed a few days after surgery. The main advantage of this technique is the improved donor site appearance. As a bonus, the amount of skin that can be harvested with the trimmed toe is slightly increased. The main drawback is that the number of toes is reduced to 4.

The tibial second toe vascularized neurocutaneous free flap for major digital nerve defects.

PURPOSE: Most digital nerve defects can be reconstructed by means of nonvascularized nerve grafts or artificial tubes, for example. When the bed is poor, the defect is long, or there is a concomitant soft-tissue loss; however, a vascularized nerve graft may be a better option. Our purpose is to introduce a method of 1-stage reconstruction of complex neurocutaneous defects in the fingers and to report the results and clinical effectiveness at a minimum 1-year follow-up period. METHODS: From 1997 to 2005 there were 6 consecutive patients who had a combined soft-tissue and digital nerve defect reconstructed by a vascularized neurocutaneous flap from the tibial (medial) side of the second toe. Three were acute and 3 were chronic cases. One flap was used for the ulnar side of the thumb, 2 for the radial aspect of the index finger, 1 for the radial of the small finger, and 2 for the ulnar side of the small finger. The nerve gap averaged 4.2 cm, and the flap size averaged 3.2 x 2.1 cm. The flaps were revascularized with standard microsurgical techniques to local vessels in the fingers. The nerves were sutured with epineural stitches. A split-thickness skin graft was used to close the donor site of the toe. RESULTS: All flaps survived without complications. At the latest follow-up evaluation static two-point discrimination (s2PD) averaged 8 mm on the pulp. Three patients had normal sensation when tested with Semmes-Weinstein filaments. Subjective feeling was 78% of that of the normal side. Five patients rated their feeling as excellent on a subjective scale. The Disabilities of the Arm, Shoulder, and Hand questionnaire score averaged 5. CONCLUSIONS: The tibial neurocutaneous second toe free flap is suitable for reconstructing a missing nerve and soft-tissue defect in the finger. We found good functional recovery and high satisfaction in this group of patients. The donor site morbidity has been minimal, although delayed healing is common. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

Dry arthroscopy of the wrist: surgical technique.

PURPOSE: To present a method to perform arthroscopic exploration and instrumentation without infusing any fluid. METHODS: The hand is suspended from a bow, with traction on all fingers. Portals are developed as in the classic (wet) wrist arthroscopic procedure except that no water is infused to distend the joint and create the optic cavity. For this procedure the joint must be dried; we use suction through the synoviotomes and neurosurgical patties to accomplish this. RESULTS: We have performed more than 100 wrist arthroscopies using the dry technique without any undue difficulty. CONCLUSIONS: The dry technique is as effective as the classic procedure, without the cumbersome leakage of water or the risk of compartment syndrome. It allows some sophisticated arthroscopic procedures to be performed that would be impracticable with water. In addition from these benefits, if open surgery is performed after the arthroscopic exploration then the tissue planes are dry, making surgery much easier. The technique is believed to be inappropriate if thermal probes are used. A learning curve exists.

Vascularized bone blocks from the toe phalanx to solve complex intercalated defects in the fingers.

PURPOSE: Vascularized bone transplants resist infection and allow rapid healing but keeping small bony segments vascularized, as needed for a finger defect, is a challenge. The purpose of this article is to present a cohort of patients with traumatic intercalated compound bony defects in the fingers that were reconstructed by a vascularized toe phalanx (or part of a phalanx) in a single stage. METHODS: Eight patients were treated with an intercalary vascularized bone graft that included a part of the proximal phalanx (3 patients), most of the middle phalanx (4 patients), or a portion of each phalanx (1 patient) of a second toe (totaling 9 bone blocks). There was an associated soft-tissue defect in each patient, an infection in 6 patients, and cartilage loss in 4 patients. The toes were pedicled on the proper digital artery (6 patients) or a segment of the first dorsal metatarsal artery (2 patients). A mean length of 12 mm of vascularized bone was transferred. The associated skin island varied from a minimum of 2 x 1 cm to a maximum of 5 x 3 cm. Bleeding from all of the bone surfaces was evidenced once the clamps were released. The homolateral digital nerve and the contralateral neurovascular pedicle of the toe were kept in place. The toe defect was treated by soft-tissue arthroplasty or arthrodesis. No toe was amputated. RESULTS: Radiologic bony union was evident at 4 to 6 weeks, except in 1 patient with an acute infection whose distal union failed to unite at 6 weeks because the infection recurred. Finger length loss averaged 3 mm. All patients returned to their preoperative occupation. CONCLUSIONS: In this group of patients the toe phalanx reliably maintained its vascularization, allowing us to solve compound osteocutaneous defects in the fingers in a single stage. Donor site morbidity was minimal.

Correction of malunited intra-articular distal radius fractures with an inside-out osteotomy technique.

PURPOSE: To present an inside-out osteotomy technique under arthroscopic guidance to correct an intra-articular malunion. METHODS: The joint is explored with a 2.7-mm arthroscope through the standard portals without infusing any water. To allow room to introduce the curettes and the osteotomes (4-mm wide), the instrumentation portals are made slightly larger than usual. Malunited fragments are cut with the osteotomes from inside the joint and advanced out. Fragments are mobilized, and granulating tissue and/or new bone is removed with curettes and synoviotomes. After disimpaction and reduction, fixation with plates or screws via the appropriate open approach is performed under arthroscopic control. No water is used throughout the procedure except at the end of the surgery to clear out debris. RESULTS: Steps were corrected to 0 mm in all patients. Gaps of less than 1 mm were common. CONCLUSIONS: This procedure allows us to define each cartilage-containing fragment and to re-create the original articular fracture line without the fear of creating new fracture lines on the articular surface. This technique can be used for patients with irregularly defined fragments that are not amenable to classic techniques. The key to the procedure is to perform the arthroscopic exploration without water infusion (dry technique).

Reconstruction of the distal radius facet by a free vascularized osteochondral autograft: anatomic study and report of a patient.

PURPOSE: Large chondral defects of the distal radius after fractures present a reconstructive challenge. The purpose of this study was to present the anatomic findings from a cadaver of a vascularized osteochondral autograft taken from the third metatarsal appropriate for reconstructing the distal radius articular facet. A patient is presented in whom 70% of the scaphoid fossa was reconstructed with this technique. METHODS: The base of the third metatarsal was studied in the feet of 20 cadavers. The size and shape of the cartilage were measured. Additionally vessel distribution was recorded and the diameters of vascular foramina were measured with Juch's method. RESULTS: The base of the third metatarsal is pear shaped and is wider dorsally than plantarly. It averages 19.2 mm long on its main axis. Its cartilaginous surface is minimally concave or flat and it is slanted slightly proximal-dorsal to distal-plantar and proximal-peroneal to distal-tibial. Nutrient foramina were found in every case in the dorsum and on both sides of the proximal shaft. At least 1 nutrient vessel could be tracked back to the dorsalis pedis in every dissected specimen. CONCLUSIONS: The anatomic features of the base of the third metatarsal make it a potential vascularized autograft to consider for osteochondral defects of the distal radius.

Results of osteotomy, open reduction, and internal fixation for late-presenting malunited intra-articular fractures of the base of the middle phalanx.

PURPOSE: To present our results in the treatment of late-presenting impaction fractures of the base of the middle phalanx treated by osteotomy with full exposure of the articular surface to restore the normal anatomy. METHODS: Eleven patients with a malunited (impacted) fracture of the base of the middle phalanx were treated by osteotomy more than 5 weeks after the injury. All fractures had varying degrees of impaction, comminution, and dorsal subluxation. The malunited joint surface was visualized by dislocating the joint by hyperextension (shotgun approach). The restoration of the cup-shape contour of the middle phalangeal base was accomplished by osteotomy and mobilization of small osteochondral fragments. Rigid fixation was performed by cerclage wire, screws, or a combination of these. A distal radius bone graft was placed beneath disimpacted fragments in 9 of the 11 procedures. RESULTS: Ten of 11 patients were followed-up for more than than 1 year. One patient with a volar lateral impaction fracture was lost to follow-up study 4 weeks after the surgery and was excluded from the results. All patients except 1 achieved a functional range of motion of the proximal interphalangeal joint. Moderate limitations of the distal interphalangeal joint motion were common. Grip and thumb-affected finger tip pinch strengths were 95% and 90%, respectively, of the healthy side. The average pain level (as rated on a visual analog scale of 0-10) improved from a preoperative score of 9.1 to a postoperative score of 0.8. One patient was somewhat dissatisfied; all other patients were satisfied or very satisfied. All returned to their previous work at an average of 13 weeks after surgery. CONCLUSIONS: Favorable results have been achieved in this challenging scenario in the short- and middle-term in 9 of 10 patients. Previous surgery and moderate to severe wearing of the cartilage of the proximal phalanx head negatively affected the results.