Preoperative Angiography for Free Fibula Flap Harvest: A Case Series.

Purpose: To assess if preoperative angiography of the lower extremity is necessary to detect abnormalities that alter operative planning of a free fibula flap (FFF). The secondary objective is to determine whether abnormalities are identified on physical examination. Methods: A retrospective case series of patients receiving preoperative lower extremity angiography for FFF was performed. Between November 2004 and July 2016, patients assessed for FFF reconstruction by a single surgeon were reviewed. Outcomes analyzed were preoperative physical examination, angiography findings, changes in operative plan, and perioperative complications including flap failure and limb ischemia. Level of agreement between physical examination and angiography findings was analyzed. Results: A total of 132 consecutive patients were assessed for FFF, of which 70 met the inclusion criteria. Mean age was 60.9 (range: 22-88) years old. All patients underwent aortic angiogram runoff, except for 2 who received computed tomography angiography. The surgical plan was altered based on angiography findings in 9 (12.9%) patients, and 7 (77.8%) of these cases had a normal physical examination. A further 6 (8.6%) patients had physical examination findings precluding the use of FFF, whereas imaging demonstrated the contrary. Physical examination demonstrated low predictability of aberrant vascular anatomy, with a sensitivity of 22.2%. There were no limb ischemia complications. Conclusions: Routine preoperative angiography of the lower extremity for all patients being evaluated for FFF is important to ensure safety and success of the procedure. Physical examination alone is insufficient to detect vascular abnormalities that may result in limb or flap compromise.

Objectif: Évaluer s'il faut procéder à une angiographie préopératoire de l'extrémité inférieure pour déceler des anomalies qui perturbent le plan opératoire en vue du prélèvement d'un lambeau libre de la fibula (ou péroné, LLF). L'objectif secondaire consiste à déterminer si des anomalies sont décelées à l'examen physique. Méthodologie: Les chercheurs ont examiné une série rétrospective de cas ayant subi une angiographie préopératoire de l'extrémité inférieure en vue du prélèvement d'un LLF. Ils ont examiné les patients évalués en vue d'une reconstruction par LLF effectuée par un même chirurgien entre novembre 2004 et juillet 2016. Ils ont analysé l'examen physique préopératoire, les résultats de l'angiographie, les modifications au plan opératoire et les complications périopératoires, y compris l'échec du lambeau et l'ischémie du membre. Enfin, ils ont analysé le degré de convergence entre l'examen physique et les résultats de l'angiographie. Résultats: Les chercheurs ont évalué 132 patients en vue du prélèvement d'un LLF, dont 70 respectaient les critères d'inclusion. Ils avaient un âge moyen de 60,9 ans (plage de 22 à 88 ans). Tous les patients ont subi une angiographie aortique détaillée, sauf deux qui ont subi une angiographie par tomodensitométrie. Le plan opératoire a été modifié en raison des observations angiographiques chez neuf patients (12,9 %), et l'examen physique était normal pour sept d'entre eux (77,8 %). Chez six autres patients (8,6 %), l'examen physique écartait le prélèvement du LLF, mais l'imagerie démontrait le contraire. L'examen physique a établi la faible prévisibilité des aberrations de l'anatomie vasculaire, selon une sensibilité de 22,2 %. Aucune complication ischémique des membres n'a été observée. Conclusions: Il est important de procéder à une angiographie préopératoire systématique de l'extrémité inférieure chez tous les patients évalués en vue du prélèvement d'un LLF pour garantir la sécurité et la réussite de l'intervention. L'examen physique seul ne suffit pas pour déceler les anomalies vasculaires susceptibles d'entraîner une atteinte du membre ou du lambeau.

A Retrospective Cohort and Systematic Review of Non-Operative Management of Exposed Calvaria Post-Radiotherapy.

Scalp defects with exposed calvaria that have previously been irradiated present a unique reconstructive challenge. Patients with previously radiated scalp defects often have few reconstructive options due to poor health or personal choice. The aim of this study was to evaluate the results of non-operative management for patients with prior radiotherapy to the scalp who developed exposed calvaria. The outcomes of interest were major and minor complications related to exposed calvaria with a time frame of follow-up of greater than one year or death from any cause. A retrospective chart review was performed to identify patients with prior radiotherapy and surgery for skin cancer to the scalp who subsequently developed exposed calvaria. Data from four surgeons from 2008 to 2019 was collected. Next, a systematic review of PubMed, EMBASE, Cochrane Library, and CINAHL was conducted to identify articles in which non-operative management was utilized for exposed calvaria post-radiotherapy. Nineteen patients were identified who received radiotherapy either before developing recurrent malignancy requiring operation or requiring radiation postoperatively because of close or involved margins and who subsequently developed exposed calvaria. Six of these patients had an additional attempt at local flap or skin grafting that failed. All patients had an American Society of Anesthesiologists score of three or four. All were managed with local wound care. Ten patients had near-complete healing with wound care alone. Eight patients are still alive from one to six years after the presentation. One patient, who remains alive, developed an intracranial abscess requiring long-term antibiotics but was medically compromised by concomitant myelodysplastic syndrome, mantle cell lymphoma on chemotherapy, atrial fibrillation on anticoagulation, and heart failure. Three patients developed new malignancies requiring re-operation with watchful waiting. Two of the three cases resulted in failure to control disease, but control of malignancy occurred in one case with resection of recurrent cancer and exposed bone.  The systematic review of the literature yielded three studies that met the inclusion criteria. None of the studies encountered cases of meningitis, encephalitis, or death due to the non-operative treatment of exposed calvaria post radiation. Coverage of the calvaria with well-vascularized tissue is the reconstructive goal in the majority of circumstances. This case series and systematic review found that non-operative management of exposed calvaria post-radiotherapy can be an option for patients who are either not candidates for aggressive surgical treatment or who refuse surgery.

Preoperative Angiography for Free Fibula Flap Harvest: A Meta-Analysis.

BACKGROUND: The necessity for routine preoperative imaging for free fibula harvest is controversial. The primary objective of this meta-analysis is to determine if lower extremity angiography is necessary to detect abnormalities that may alter flap selection. The secondary objective is to determine if physical examination alone is sufficient to predict these abnormalities. METHODS: A literature search was performed using Cochrane, CENTRAL, MEDLINE, CINAHL, and EMBASE. Studies were selected for inclusion if they included patients undergoing free fibula flap harvest with preoperative imaging, with or without physical examination findings. Data extraction was performed independently and in duplicate, including a change in flap selection and the level of agreement between physical examination and imaging. Pooled proportions were calculated using a random-effects model and 95% confidence intervals (CI). RESULTS: Sixteen studies were included for analysis. Mean sample size was 42 patients (range: 5-123). Included studies were of low methodologic quality. Pooled proportion of patients who had flap selection change secondary to abnormalities identified on preoperative angiography was 20.1% (95% CI: 9.6-33.2%). A pooled proportion of 71.5% (95% CI: 5-88.7%) of cases requiring change in flap selection was missed by physical examination findings alone. CONCLUSION: There is low-quality evidence suggesting a necessity for routine preoperative angiography for all patients undergoing free fibula flap harvest. Physical examination alone is insufficient in detecting vascular abnormalities that may result in limb compromise or an inability to successfully harvest a free fibula. Further investigation is warranted for cost-effectiveness of preoperative imaging protocols.

Partial Versus Total Trapeziectomy Thumb Arthroplasty: An Expertise-based Feasibility Study.

BACKGROUND: There are numerous surgical techniques for the treatment of first carpometacarpal joint osteoarthritis, however, controversy exists as to whether outcomes differ between techniques. This feasibility study aimed to determine if a large-scale, health-related quality of life and functional outcomes study comparing 2 surgical techniques, complete trapeziectomy with ligament reconstruction and tendon interposition (T + LRTI) versus partial trapeziectomy and tendon interposition (PT + TI) arthroplasty, is possible. METHODS: Patients with advanced stage arthritis (Eaton stages II-IV) of the thumb were invited to undergo either T + LRTI or PT + TI at 1 of the 2 hand surgery practices. Feasibility outcomes included: (1) Process: recruitment rate; (2) Resources: eligibility rate, eligibility criteria, retention, and compliance rates (completion of health-related quality of life questionnaires, Disabilities of the Arm, Shoulder, and Hand, EuroQol-5D-3L, and SF-36, and functional measurements, grip, key pinch, and tip pinch strength, at 1-week preoperatively and 1, 3, 6, and 12 months postoperatively); (3) Management: determining the practices' commitment to the study; and (4) Scientific: calculation of the variances and treatment effect sizes (ES) of differences between procedures. Data from baseline measurements and 6-month follow-up were used for analysis. RESULTS: Sixty patients were screened, of which 34 (57%) were eligible for surgery. Twenty-one (81%) of the 26 ineligible patients were excluded due to previous or additional planned surgical procedures on the same hand, particularly carpal tunnel release (n = 17). Twenty patients consented; 12 in the T + LRTI and 8 in the PT + TI group. The highest completion rate for the 3 questionnaires and the functional measurements, for both groups was at 6-month time point. Compliance rates for questionnaire completion at 6-months were calculated at 50% and 75% for the T + LRTI and PT + TI group, respectively. Functional measurement completion rate was 50% and 63% for T + LRTI and PT + TI groups, respectively. Treatment ES were group dependent, with Disabilities of the Arm, Shoulder, and Hand, EuroQol-5D-3L usual activities and anxiety/depression showing a large ES in the PT + TI group; the T + LRTI group showed large ES in EQ-5D state of health today. CONCLUSIONS: Authors conclude that a large-scale study is feasible and dependent on: (1) increasing sample size to account for the high attrition rate; (2) liberalizing inclusion criteria to include patients with carpal tunnel syndrome; (3) allotting more time at follow-up visits to ensure completion of all measurements; and (4) increasing staff involvement (ie, develop rapport with patients and maintain stability with research assistants).

Dupuytren's contracture and handwork: A case-control study.

OBJECTIVE: The objective of this study was to examine the association between Dupuytren's contracture (DC), repetitive handwork (RHW), heavy handwork (HHW), and/or vibration exposure. METHODS: Frequency and intensity of the three types of handwork were collected and compared between DC patients and controls. Hours of work were weighted by average "frequency," for RHW, and average "intensity," for HHW and use of vibrating tool. Logistic regression was used to evaluate risk of developing DC associated with the above-mentioned factors. RESULTS: Data from 129 cases (74 clinical, 106 controls) was analyzed. Family history, male gender and age (decades) were associated with increased risk of DC. Results indicate that the risk becomes substantial after about 30 years of steady RHW. Independent effects of intensity-weighted HHW and vibrating exposure were not established. CONCLUSIONS: Frequency-weighted RHW increases DC risk. Additionally, a strong association between DC, male gender and heredity was found.

Estimation of health-related-quality of life depends on which utility measure is selected for patients with carpal tunnel syndrome.

STUDY DESIGN: Cross-sectional. INTRODUCTION: Carpal tunnel syndrome (CTS) refers to the compression neuropathy of the median nerve at the wrist. PURPOSE OF THE STUDY: To establish the interinstrument reliability, convergent construct validity, and the levels of agreement of health utility indexes 2 and 3 (HUI-2 and HUI-3), EuroQol 5-dimensions (EQ-5D), EuroQol-visual analog scale (EQ-VAS) and to determine the difference of these utility measures based on age and gender in patients with carpal tunnel syndrome. METHODS: Seventy-four patients with a confirmed diagnosis of carpal tunnel syndrome completed the 3 questionnaires and EQ-VAS a month before surgery. Demographic characteristics were reported. Intraclass correlation coefficients were used to assess relative interinstrument reliability. Pearson correlation coefficients (r) were used to establish convergent construct validity. Bland-Altman plots and t tests were used to describe the levels of agreement between the 4 utility measures. A 2-way analysis of variance was performed to determine the effect of age and gender on the utility measures; HUI-2, HUI-3, and EQ-5D. RESULTS: The intraclass correlation coefficients were 0.85 for HUI-3 vs HUI-2 and 0.80 for HUI-2 vs EQ-VAS. Pearson correlation coefficients ranged from 0.60 to 0.89; HUI-3 vs HUI-2: 0.89, and HUI-3 vs EQ-5D: 0.60. One-sample t test demonstrated significant differences between HUI-3 vs HUI-2, HUI-3 vs EQ-5D, and HUI-3 vs EQ-VAS measures, with mean differences of -0.12, -0.15, and -0.14, respectively. A 2-way analysis of variance test controlling for age and gender indicated neither as predictors of outcome scores. CONCLUSIONS: The HUI-3 vs HUI-2 and HUI-2 vs EQ-VAS demonstrated excellent interinstrument relative reliability measures. The HUI-3 vs HUI-2 displayed very strong convergent construct validity measures, and strong validity measures were established between the remaining utility measures. In addition, the pair-wise utility comparisons demonstrated minimal bias between HUI-2 vs EQ-5D, HUI-2 vs EQ-VAS, and EQ-VAS vs EQ-5D measures. DISCUSSION: N/A. LEVEL OF EVIDENCE: N/A.

Users' guide to the surgical literature: how to assess an article about harm in surgery.

CLINICALSCENARIO: You are a new plastic surgeon in the community and you are referred a patient interested in breast reconstruction. The patient is a 35-year-old female school teacher who had a bilateral prophylactic mastectomy 2 years earlier, as she was a BRCA gene carrier. Since she is of a petite build with very little subcutaneous tissue or extra skin in the lower abdomen, you decide that she is not a suitable candidate for an abdomen-based autologous tissue reconstruction. You recommend the technique of tissue expansion and silicone gel implants. She is concerned, however, about the possibility of anaplastic large cell lymphoma (ALCL) developing in her breasts. She read in a magazine recently that ALCL, an unusual form of breast cancer, has been occurring in patients who have breast implants. She is very concerned that she might be at risk and asks for your opinion as to whether she should proceed with the procedure or not.

The use of the radial styloid in the extended osteocutaneous radial forearm free flap.

BACKGROUND: The osteocutaneous radial forearm free flap (OC-RFFF) remains a useful tool in head and neck reconstruction; however, it can be challenging to harvest sufficient bone for large reconstructions. The extended OC-RFFF is a modification that involves harvest of the distal border of the radius to the tip of the styloid. This increases the length of the bone flap by 2 cm to 3 cm, and the inherent contour of the styloid can be used to reconstruct the anterior curvature of the mandible or maxilla without additional osteotomies that may reduce blood supply. METHODS: The key steps in harvesting the extended OC-RFFF are described. Six patients with mandibular or maxillary defects underwent reconstruction with the extended OC-RFFF. Patient data including demographics, defect features, reconstruction details and outcomes were collected. RESULTS: Of the six patients who underwent the extended OC-RFFF, four had mandibular reconstruction and two had maxillary reconstruction. Two patients underwent reconstruction for osteoradionecrosis and the remainder for malignant disease. The average patient age at the time of surgery was 64.5 years. The length of radius harvested ranged from 8 cm to 14 cm (mean 9.7 cm). Two of six patients required a single osteotomy of their bone flap. Donor site complications included partial skin graft loss in 50% and a radius fracture in two patients. Recipient site complications included one patient with intraoral plate exposure. There have been no cases of nonunion. CONCLUSIONS: The extended OC-RFFF was a safe and reliable option for bony reconstruction in the head and neck.

HISTORIQUE: Le lambeau libre ostéocutané antébrachial radial (LL-OAR) étendu demeure utile pour la reconstruction de la tête et du cou. Cependant, il peut être difficile de prélever assez d'os pour effectuer des reconstructions importantes. Le LL-OAR étendu est une modification qui consiste à lever le bord distal du radius à la pointe de la styloïde. Cette technique accroît la longueur du lambeau osseux de 2 cm à 3 cm et permet d'utiliser le contour inhérent de la styloïde pour reconstruire la courbure antérieure de la mandibule ou de la maxillaire sans ostéotomies supplémentaires susceptibles de réduire l'apport sanguin. MÉTHODOLOGIE: Les auteurs ont décrit les principales étapes pour lever le LL-OAR étendu. Six patients présentant des anomalies mandibulaires ou maxillaires ont subi une reconstruction par LL-OAR étendu. Les auteurs ont décrit les données sur les patients, y compris les données démographiques, les caractéristiques des anomalies, les détails et les résultats de la reconstruction. RÉSULTATS: Des six patients qui ont reçu un LL-OAR étendu, quatre ont subi une reconstruction mandibulaire et deux, une reconstruction maxillaire. Dans deux cas, la reconstruction était causée par une ostéoradionécrose et dans les autres, par un cancer. Les patients avaient un âge moyen de 64,5 ans au moment de l'opération. Le radius prélevé était d'une longueur de 8 cm à 14 cm (moyenne de 9,7 cm). Deux des six patients ont dû subir une seule ostéotomie de lambeau osseux. Les complications au foyer du donneur incluaient une perte partielle de la greffe cutanée dans 50 % des cas et une fracture du radius chez deux patients. Les complications au foyer du receveur incluaient un patient dont la plaque intra-orale avait été exposée. Il n'y a eu aucun cas de non-union. CONCLUSIONS: Le LL-OAR étendu était sécuritaire et fiable pour procéder à la reconstruction osseuse de la tête et du cou.

Psychometric properties of health-related quality of life instruments in patients undergoing palmar fasciectomy for dupuytren's disease: a prospective study.

BACKGROUND: The traditional outcome measured following treatment of Dupuytren's Disease (DD) has been digital range of motion; specifically the gain in digital extension. The outcomes research movement in the last three decades however has been advocating the measurement of outcomes from the patient's perspective using Health-Related Quality of Life questionnaires (HRQOL). Although several generic and region-specific HRQOL questionnaires exist, there is no guidance as to which one is the most appropriate for this population. The objective of this study is to evaluate the psychometric properties of three self-reported HRQOL outcome measures in patients with DD. METHODS: Patients with DD were enrolled from the practices of three plastic surgeons. Test-retest reliability, concurrent validity and responsiveness of three HRQOL questionnaires were compared in a prospective study design. The HRQOL measures included Health Utilities Index Mark 3 (HUI3), Short Form-36 (SF-36), and the Michigan Hand Questionnaire (MHQ). RESULTS: All three measures demonstrated good test-retest reliability (ICC = 0.77-0.85). Concurrent validity was found between the HUI3 pain and dexterity attributes and SF-36 physical summary score. The sensitivity of the MHQ to detect changes in the status of the patient was found to be high (effect size = 1.14) whereas that of the SF-36 was trivial. CONCLUSIONS: The HUI3 and the MHQ seem to be reliable and valid tools to assess the HRQOL in patients with Dupuytren's Disease.

Health-related quality of life in patients undergoing palmar fasciectomy for Dupuytren's disease.

BACKGROUND: The present study was undertaken to assess the health-related quality of life in patients with Dupuytren's disease who undergo palmar fasciectomy. METHODS: A prospective cohort of patients with Dupuytren's disease undergoing palmar and/or digital fasciectomy was recruited from the practice of three plastic surgeons in Hamilton, Ontario, Canada. After written informed consent was obtained, participants were asked to complete three health-related quality-of-life questionnaires (i.e., Short Form-36, Michigan Hand Outcomes Questionnaire, and Health Utility Index Mark 3) at five time points: at 1 week and 1 day preoperatively, and at 1, 3, 6, and 12 months postoperatively. Ranges of motion and grip strength measurement were also recorded. RESULTS: For the 26 patients in the study, the multiattribute scores of the Health Utility Index Mark 3 improved from 0.80 before surgery to 0.83 at 12 months postoperatively (p > 0.05). There was no difference in the Short Form-36 scores, but the Michigan Hand Outcomes Questionnaire scores improved from 74 at 1 week preoperatively to 90 at the 12-month postoperative visit (p < 0.001). CONCLUSIONS: Patients who undergo palmar fasciectomy for Dupuytren's disease experience a substantial improvement in their health-related quality of life 12 months after surgery. In the authors' study population, a benefit of 0.85 quality-adjusted life-year within 12 months was observed. This can be translated as follows: the average patient who undergoes palmar fasciectomy gains the equivalent of approximately 14.4 days (0.48 months) in perfect health by undergoing palmar fasciectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Randomized controlled trial comparing health-related quality of life in patients undergoing vertical scar versus inverted T-shaped reduction mammaplasty.

BACKGROUND: There is controversy regarding the superiority of the vertical scar reduction technique versus the inverted T-shaped reduction technique for breast reduction surgery. METHODS: Two hundred fifty-five patients were randomized to either the vertical scar reduction or inverted T-shaped reduction technique immediately before surgery over a 5-year period. Patients completed the Health Utilities Index Mark 3, Short Form-36, Breast-Related Symptoms Questionnaire, and Multidimensional Body-Self Relations Questionnaire at 1 week preoperatively and 1, 6, and 12 months postoperatively. Data were treated according to intention-to-treat principles. The primary outcome was the difference in the change in Health Utilities Index Mark 3 score from baseline to 12 months postoperatively between the two techniques. RESULTS: Patients undergoing either technique gained a statistically significant and clinically important improvement from baseline to 1 year postoperatively in the Health Utilities Index Mark 3 (vertical scar reduction, 0.81, 0.16 to 0.87, 0.19; inverted T-shaped reduction, 0.79, 0.20 to 0.89, 0.15) and the Breast-Related Symptoms Questionnaire (vertical scar reduction, 50.26, 12.98 to 95.59, 9.36; inverted T-shaped reduction, 50.06, 12.50 to 94.09, 9.86). No difference in mean change in scores from baseline to 12 months postoperatively was seen in any of the quality of life questionnaires between the techniques. CONCLUSIONS: There was a clinically important improvement between baseline and 1 year postoperatively in both groups in the Health Utilities Index Mark 3 and the Breast-Related Symptoms Questionnaire. The authors conclude that the techniques are similar when quality of life is the outcome of interest. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Axon counts of potential nerve transfer donors for peroneal nerve reconstruction.

BACKGROUND: The common peroneal nerve is the most commonly injured nerve in the lower limb. Nerve transfer using expendable donor nerves is emerging in the literature as an alternative surgical procedure to traditional treatments. OBJECTIVE: To identify potential donors of motor axons from the tibial nerve that can be transferred to the common peroneal nerve branches. METHODS: Using 10 human cadaveric lower extremities, all motor nerve branches of the tibial nerve were identified and biopsied. These were compared with the motor branches to tibialis anterior and extensor hallucis longus (branches of the deep peroneal nerve). RESULTS: The most suitable donor nerves with respect to cross-sectional area to tibialis anterior (cross sectional area [mean ± SD] 0.255±0.111 mm) was the motor branch to lateral gastrocnemius (0.256±0.105 mm). When comparing the total number of axons, the branch to the tibialis anterior had a mean of 3363±1997 axons. The branch to the popliteus was most similar, with 3317±1467 axons. The most suitable donor nerves for the motor branch to extensor hallucis longus (cross sectional area 0.197±0.302 mm) with respect to cross-sectional area was the motor branch to flexor hallucis longus (0.234±0.147 mm). When comparing the total number of axons, the branch to the extensor hallucis longus had an average of 2062±2314 axons. The branch to the lateral gastrocnemius was most similar with 2352±1249 axons and was a suitable donor. CONCLUSION: Nerve transfers should be included in the armamentarium for lower extremity reinnervation, as it is in the upper limb.

HISTORIQUE: Le nerf péronier commun est le nerf des membres inférieurs qui subit le plus de blessures. Le transfert nerveux au moyen de nerfs sacrifiables de donneurs émerge dans les publications comme une intervention chirurgicale qui remplace les traitements classiques. OBJECTIF: Déterminer les donneurs potentiels d'axones moteurs du nerf tibial qui peuvent être transférés aux branches du nerf péronier commun. MÉTHODOLOGIE: Au moyen de dix membres inférieurs cadavériques humains, les chercheurs ont repéré toutes les branches nerveuses motrices du nerf tibial et en ont fait la biopsie. Ils les ont comparées avec les branches motrices du muscle tibial antérieur et du muscle long extenseur de l'hallux (branches du nerf péronier profond). RÉSULTATS: Les nerfs de donneurs qui convenaient le mieux à l'égard de la région transversale du muscle tibial antérieur (région transversale [moyenne±ÉT] de 0,255±0,111 mm) étaient la branche motrice du muscle gastrocnémien latéral (0,256±0,105 mm). Par rapport au nombre total d'axones, la branche du muscle tibial antérieur présentait une moyenne de 3 363±1 997 axones. La branche du muscle poplité était la plus similaire, avec 3 317±1 467 axones. Les nerfs de donneurs qui convenaient le mieux à la branche motrice du muscle long extenseur de l'hallux (région transversale de 0,197±0,302 mm) à l'égard de la région transversale étaient la branche motrice du muscle long fléchisseur de l'hallux (0,234±0,147 mm). Par rapport au nombre total d'axones, la branche du muscle long extenseur de l'hallux avait une moyenne de 2 062±2 314 axones. La branche du muscle gastrocnémien latéral était la plus similaire, avec 2 352±1 249 axones, et constituait un donneur convenable. CONCLUSION: Les transferts nerveux devraient faire partie de l'armada de réinnervation des membres inférieurs, comme ils le sont dans les membres supérieurs.

Clinical research in head and neck reconstruction.

Reconstructive head and neck surgery is not unlike other surgical fields in its paucity of clinical research. Difficulties exist in the design and execution of surgical studies, and there are many challenges and limitations that must be addressed. In this article, the types of studies that make up head and neck reconstructive literature are reviewed, as well as the evolution toward the use of quality-of-life scales, which measure patients' satisfaction with their state of health and function.

Through and through defects of the lower face.

This article considers the particular demands of reconstruction of this complex region of the head and neck in terms of its functional and aesthetic requirements. It presents a classification system that may assist in the selection of the appropriate reconstruction. Finally, the authors discuss some of the more common techniques and flaps that should be considered when planning microsurgical management, and they review the outcomes they have seen in terms of speech, diet tolerance, oral continence, and survival.

Oromandibular reconstruction after cancer resection.

The goals of this article are (1) to summarize the epidemiology of oromandibular cancer, (2) to describe the classification of defects after cancer extirpation, and (3) to discuss the principles of and state of the art in reconstruction of the oromandibular defect. The four commonly used flaps (fibula flap, radial forearm flap, scapula flap, and the iliac crest) and their key characteristics are summarized. Finally, some future speculations are entertained.

Compression neuropathies of the lower extremity.

Compression neuropathies of the lower extremity can be just as disabling as compression neuropathies in the upper extremity. The most common compression neuropathies encountered in the lower extremity affect the lateral femoral cutaneous nerve, the peroneal nerve, the saphenous nerve, the sural nerve, and the tibial nerve (including their branches). These are discussed in terms of anatomy, etiologies, manifestations, and surgical treatment.

Validation of the extensor carpi ulnaris groove as a predictor for the recognition of standard posteroanterior radiographs of the wrist.

This study was designed to establish the extensor carpi ulnaris groove (ECUG) as a reliable radiographic criterion for recognition of true neutral posteroanterior (PA) radiographs and to verify precise measurements of ulnar variance in a large cohort of patients. In 197 patients 197 wrists were evaluated with a series of radiographic views obtained during routine wrist arthrography. Posteroanterior views were taken in all patients at 90 degrees, 45 degrees, and 0 degrees arm abduction and in 171 patients at 90 degrees elbow flexion and 90 degrees arm abduction with full elbow extension. The ECUG position was classified according to its profile with the ulnar styloid as excellent, acceptable, or unacceptable. Ulnar variance was measured on all x-ray films. Statistical analysis included interobserver reliability with 100 x-ray films measured by 2 evaluators. The ECUG was excellent or acceptable in 100% of the x-rays on standard PA views (arm abducted 90 degrees ), 87% excellent or acceptable and 13% unacceptable on 45 degrees arm abduction views, and 23% excellent or acceptable and 77% unacceptable on 0 degrees arm abduction (adducted) views (all with the elbow flexed at 90 degrees ). With the arm at 90 degrees abduction and full elbow extension the ECUG was excellent or acceptable in 91% of cases. These results show that the ECUG is a reliable criterion to verify arm position during PA wrist radiography and therefore provides a standard for making treatment decisions. The need for repeat radiographs should be reduced.