Technical Variables in Lower Extremity Free Flap Reconstruction.

BACKGROUND: Lower extremity free flap failure rates are higher than in other areas of the body. While prior studies assessed the effect of intraoperative technical variables, these generally investigated individual variables and did not examine relationships between the many individual technical decisions made during free tissue reconstruction. Our purpose was to investigate the effect of variation in intraoperative microsurgical techniques on flap outcomes in a diverse cohort of patients requiring lower extremity free flap coverage. METHODS: Consecutive patients undergoing free flap reconstruction of the lower extremity at two level 1 trauma centers from January 2002 to January 2020 were identified using Current Procedural Terminology codes, followed by a review of medical records. Information regarding demographics and comorbidities, indications, intraoperative technical details, and complications was collected. Outcomes of interest included an unplanned return to the operating room, arterial thrombosis, venous thrombosis, partial flap failure, and total flap failure. Bivariate analysis was performed. RESULTS: In total, 410 patients underwent 420 free tissue transfers. The median follow-up time was 17 months (interquartile ranges: 8.0-37). Total flap failure occurred in 4.9% (n = 20), partial flap failure in 5.9% (n = 24), and unplanned reoperation in 9.0% (n = 37), with arterial thrombosis in 3.2% (n = 13) and venous thrombosis in 5.4% (n = 22). Overall complications were significantly associated with recipient artery choice, with arteries other than PT and AT/DP having a higher rate (p = 0.033), and with arterial revisions (p = 0.010). Total flap failure was also associated with revision of the arterial anastomosis (p = 0.035), and partial flap failure was associated with recipient artery choice (p = 0.032). CONCLUSION: Many interoperative options and techniques are available when performing microvascular lower extremity reconstruction that leads to equally high success rates. However, the use of arterial inflow outside of the posterior tibial and anterior tibial arteries leads to a higher overall complication rate and partial flap failure rate. Intraoperative revision of the arterial anastomosis portends poorly for ultimate flap survival.

Secondary Surgery after Lower Extremity Free Flap Reconstruction.

BACKGROUND: Microsurgical free tissue transfer may be the only reconstructive option for lower extremity limb salvage. However, the functional and aesthetic results following free tissue transfer after initial salvage may be suboptimal, thus requiring secondary operations to facilitate definitive wound healing and/or refinement. METHODS: A multi-institutional retrospective cohort study was performed including patients who underwent lower extremity free tissue transfer from January of 2002 to December of 2020. The authors' primary outcome variable was the presence of secondary surgery after free tissue transfer for lower extremity reconstruction. Independent variables (eg, wound cause, flap, donor type, recipient, comorbidities) were collected. Secondary surgery was categorized as (1) procedures for definitive wound closure and (2) refinement procedures. Multivariable logistic regression was performed to determine which variables were independently associated with the outcome. RESULTS: A total of 420 free tissue transfers for lower extremity reconstruction were identified. Secondary surgery was performed in over half (57%) of the patients. Presence of diabetes (OR, 2.0; P = 0.01; 95% CI, 1.2 to 3.5) and use of a latissimus dorsi donor (OR, 2.4; P = 0.037; 95% CI, 1.1 to 5.4) were predictors of wound closure procedures. Fasciocutaneous (OR, 3.6; P < 0.001; 95% CI, 1.8 to 7.2) and myocutaneous (OR, 3.0; P = 0.005; 95% CI, 1.5 to 9.9) flaps were predictors of refinement procedures when compared with muscle-only flaps with skin grafts. CONCLUSIONS: The majority of lower extremity free tissue reconstructions required secondary procedures to provide definitive wound closure and/or refinement. Overall, this study provides predictors of secondary surgery that will help formulate patients' expectations of lower extremity limb salvage. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Quantitative Analysis of the Volar Ulnar Corner of the Distal Radius: A Reference for Intraoperative Distal Radius Fracture Reduction.

PURPOSE: The reduction of distal radius fractures using volar locking plate fixation can be performed by securing the plate to the distal fragments and then levering the plate to the radial shaft. Oblique placement of the plate on the radial shaft may lead to malreduction. The aim of this study was to evaluate parameters that can be used for the assessment of intraoperative distal radius fracture reduction using "distal-first" volar plate fixation, especially the geometry of the ulnar corner. The prevalence of Tolat distal radioulnar joint (DRUJ) types was determined, and the angles of the volar corner were quantitatively described. METHODS: Three hundred seventy-five adult patients with a conventional wrist radiograph in their medical chart were identified. From this cohort, 50 radiographs of each Tolat DRUJ type were quantitatively analyzed using 4 angles. The probability density of each angle was described using Kernel density estimation graphs. A multivariable analysis was used to study the association between the 4 angles and Tolat DRUJ types and other patient factors. RESULTS: One hundred fifty-one patients (40%) had a wrist with type 1 DRUJ, 147 (39%) had a wrist with type 2 DRUJ, and 77 (21%) had a wrist with type 3 DRUJ. The measurements of the distal ulnar corner, volar ulnar corner, and DRUJ angulation were significantly different among each Tolat DRUJ type. The median lunate facet inclination, relative to the axis of the radial shaft, measured 14° (interquartile range, 12°-16°) across all the Tolat DRUJ types. CONCLUSIONS: The prevalence of Tolat type 1, 2, and 3 DRUJ was 40%, 39%, and 21%, respectively. The angles of the volar ulnar corner varied with each DRUJ type. CLINICAL RELEVANCE: Because the lunate facet inclination was relatively consistent among all the Tolat DRUJ types, this angle may be useful as a reference for "distal-first" distal radius volar plating.

Epidemiology and Fracture Patterns of Traumatic Phalangeal Fractures.

Background: Despite the relatively high incidence of phalangeal fractures, there is an imperfect understanding of the epidemiology and anatomical distribution of these fractures. This study describes the patient characteristics, anatomic distribution, and detailed fracture patterns of phalangeal fractures among a large adult cohort in the United States. Methods: A retrospective study was performed among patients with phalangeal fractures in the United States between January 2010 and January 2015. Included patients were 18 years old or older and had a diagnosis of a phalangeal fracture. A total of 2140 phalangeal fractures in 1747 patients were included, and a manual chart review was performed to collect epidemiological and radiographic information. Fractures were classified based on location and fracture pattern. Results: The median age at the time of injury was 45 years (interquartile range, 30-57), and 65% of patients were men. The small finger had the highest incidence of fractures (26%) followed by the ring finger (24%). Distal and proximal phalanges demonstrated the highest incidence of fractures at 39% each. The dominant hand was affected in 44% of cases. Eighteen percent of fractures were due to a work-related trauma mechanism, and the most common mechanism of injury was blunt trauma (46%). Conclusion: This study provides a detailed overview of the anatomic distribution and fracture patterns of phalangeal fractures in an adult US population and, thus, may aid hand surgeons treating these injuries.

Phalangeal Fractures Requiring Vascular Reconstruction: Epidemiology and Factors Predictive of Reoperation.

BACKGROUND: Demographic information related to phalangeal fractures that undergo simultaneous vascular repair, as well as their complication and reoperation profiles, remain incompletely understood. This study aimed to examine the patient and fracture characteristics influencing the outcomes after these injuries in a large Unites States adult patient cohort and to identify risk factors associated with unplanned reoperation of these fractures. METHODS: A retrospective study was performed, identifying 54 phalangeal fractures in 48 patients; all fractures were also associated with vascular injuries requiring repair. Patients with digital amputations were excluded. A manual chart review was performed to collect epidemiologic, radiographic, and surgical outcome information. RESULTS: The incidence of phalangeal fractures undergoing vascular repair was higher in the non-dominant hand, middle finger, proximal phalanx, and phalangeal shaft. Most (52.9%) fractures were due to occupational injury, with the most common mechanism being sharp injuries. More than half of the fractures had a nerve injury, and 13% required a vein graft for vascular repair. More than half of the fractures required at least one reoperation, most commonly due to "stiffness/tendon adhesion" (50%) and "nonunion or delayed union" (21.4%). In multivariable analysis, thumb (odds ratio [OR]: 35.1, P = .043) and index (OR: 14.0, P = .048) fingers' fractures were found to be independently associated with unplanned reoperation. CONCLUSIONS: Phalangeal fractures requiring vascular repair occurred most often in the occupational setting and more than 50% required at least one unplanned reoperation. Injuries sustained in the thumb and index finger were more likely to undergo unplanned reoperation, which may guide initial treatment decision-making and postoperative follow-up.