Superficial Circumflex Iliac Artery Perforator Flap Reconstruction of the Upper Extremity.

The superficial circumflex iliac artery perforator (SCIP) flap is thin, pliable tissue well suited for reconstruction of injuries of the hand and upper extremity. Based upon perforators from the superficial circumflex iliac artery, the SCIP flap has advantages over the traditional groin flap due to reduced need for secondary procedures and improved donor site morbidity This article offers a detailed exploration of the SCIP flap design and technique, its advantages over traditional methods, and its potential applications in reconstructive surgery. Post-operative care and critical points are also discussed, and case examples are provided to guide readers through the intricacies of the technique, emphasizing the surgical skill and precision required for successful implementation.

The Continued Impact of Godina's Principles: Outcomes of Flap Coverage as a Function of Time After Definitive Fixation of Open Lower Extremity Fractures.

BACKGROUND: Early soft tissue coverage of open lower extremity fractures within 72 hours of injury leads to improved outcomes. Little is known about outcomes when definitive fixation is completed first. The purpose of this study is to quantify postoperative outcomes when soft tissue reconstruction is delayed until after definitive open reduction and internal fixation (ORIF) is completed. METHODS: An insurance claims database was queried for all patients with open lower extremity fractures between 2010 and 2020 who underwent free or axial flap reconstruction after ORIF. This cohort was stratified into three groups: reconstruction performed 0 to 3, 3 to 7, and 7+ days after ORIF. The primary outcome was 90-day complication and reoperation rates. Bivariate and multivariable regression of all-cause complications and reoperations was evaluated for time to flap as a risk factor. RESULTS: A total of 863 patients with open lower extremity fractures underwent ORIF prior to flap soft tissue reconstruction. In total, 145 (16.8%), 162 (18.8%), and 556 (64.4%) patients underwent soft tissue reconstruction 0 to 3 days, 4 to 7 days, and 7+ days after ORIF, respectively. The 90-day complication rate of surgical site infections ( SSI; 16.6%, 16,7%, 28.8%; p = 0.001) and acute osteomyelitis (5.5%, 6.2%, 27.7%; p < 0.001) increased with delayed soft tissue reconstruction. Irrigation and debridement rates were directly related to time from ORIF to flap (33.8%, 51.9%, 61.9%; p < 0.001). Hardware removal rates were significantly higher with delayed treatment (10.3%, 9.3%, 39.3%; p < 0.001). The 0 to 3 day (odds ratio [OR] = 0.22; 95% confidence interval [CI]: 0.15, 0.32) and 4 to 7 day (OR = 0.26; 95% CI: 0.17, 0.40) groups showed protective factors against all-cause complications after bivariate and multivariate regression. CONCLUSION: Early soft tissue reconstruction of open lower extremity fractures performed within 7 days of ORIF reduces complication rates and reduces the variability of complication rates including SSIs, acute osteomyelitis, and hardware failure.

Targeted muscle reinnervation in upper extremity amputations.

PURPOSE: Targeted muscle reinnervation (TMR) is a relatively recent surgical innovation that involves the coaptation of major peripheral nerves to a recipient motor branch that innervates an expendable muscle target. The original indication for TMR was augmentation and optimization of myoelectric signals in the amputated limb for use of myoelectric prosthetics. Incidentally, surgeons and patients discovered that the technique also could treat and prevent phantom and residual limb pain. TMR is performed at the time of amputation or delayed any time after the amputation, and TMR can also be performed at any level of amputation. In the upper extremity, studies have detailed the various techniques and coaptations possible at each amputation level to create intuitive myoelectric signals and treat neurogenic pain. Treatment of peripheral nerves in the amputee with TMR should be a consideration for all patients with major upper extremity amputations, especially at large institutions able to support multidisciplinary limb salvage teams. This review article summarizes the current literature and authors' techniques and recommendations surrounding TMR in the upper extremity amputee including techniques relevant to each level of upper extremity amputation.

Technical Strategies for Harvest of the Subtotal Pedicled Fillet of Thigh Flap for Reconstruction of External Hemipelvectomy and Hemicorporectomy Defects.

External hemipelvectomy and hemicorporectomy have been described in the literature for a variety of indications. A commonly used reconstructive technique is the pedicled anterior subtotal fillet of thigh flap. However, there are few descriptions regarding the technical pearls of harvest and inset of this flap. Here, we describe our step-by-step technique, as performed in three patients. The flap is pedicled on the common femoral artery and extends longitudinally to the knee to achieve the length required to extend past the midline and resurface sacral pressure ulcers, which are commonly found in patients who undergo this procedure for refractory pelvic osteomyelitis. Additionally, we describe a potential salvage option with late division of the popliteal artery to preserve the option for free tissue transfer of a subtotal fillet of lower leg flap.

Analysis of a National Database Investigating Development of Trigger Finger after Treatment of Dupuytren Disease.

Dupuytren disease is associated with inflammation and myofibroblast overgrowth, as is stenosing tenosynovitis (trigger finger). Both are linked with fibroblast proliferation, but a potential associative link between the diseases is unknown. The purpose of this study was to evaluate the progression of trigger finger following treatment for Dupuytren contracture in a large database. Methods: A commercial database encompassing 53 million patients was utilized from January 1, 2010 to March 31, 2020. The study cohort included patients diagnosed with either Dupuytren disease or trigger finger utilizing International Classification Codes 9 and 10. Terminology codes were used to identify common Dupuytren procedures, as well as trigger finger release. Logistic regression analysis was used to define independent risk factors for developing trigger finger. Results: A total of 593,606 patients were diagnosed with trigger finger. Of these patients, 15,416 (2.6%) were diagnosed with trigger finger after diagnosis of Dupuytren disease, whereas 2603 (0.4%) patients were diagnosed with trigger finger after treatment of Dupuytren contracture. Independent risk factors for trigger finger included age 65 years or older (OR 1.00, P < 0.05), diabetes (OR 1.12, P < 0.05) and obesity (OR 1.20, P < 0.005). Patients who received collagenase clostridium histolyticum treatment (OR 0.34, P < 0.005) for Dupuytren contracture were significantly less likely to develop trigger finger. Conclusions: Dupuytren contracture is associated with inflammation and subsequent trigger finger development at a higher rate than the background population frequency. Collagenase clostridium histolyticum injection may lead to a decreased risk of trigger finger requiring surgical intervention in patients with risk factors.

Concepts in soft-tissue reconstruction of the contracted hand and upper extremity after burn injury.

Burns and their subsequent contracture result in devastating functional and aesthetic consequences which disproportionally affect the upper extremity. By focusing on reconstruction with analogous tissue and utilizing the reconstructive elevator, function can be restored concomitantly with form and aesthetic appearance. General concepts for soft-tissue reconstruction after burn contracture are presented for different sub-units and joints.

The Clinical Utility and Cost of Routine Staging Exam under Anesthesia for Oral Cavity Squamous Cell Carcinoma.

INTRODUCTION: The standard complete evaluation of patients with head and neck squamous cell carcinoma (HNSCC) has included a staging exam under anesthesia (EUA) since the 1970s. The EUA for all sites of HNSCC has historically consisted of panendoscopy for the purpose of diagnostic biopsy, accurate staging of primary disease, and identification of second primary tumors. However, due to the accessibility of the oral cavity, the sole purpose of EUA for tumors of this site is to identify second primary tumors. Since the EUA became the gold standard for evaluation of HNSCC, there have been significant advancements in less invasive technologies such as CT, PET-CT, MRI, and fiberoptic examination. In this study, we sought to determine the value to patient care and cost-effectiveness of EUA in patients with oral cavity squamous cell carcinoma (OCSCC). METHODS: A retrospective chart review identified 77 patients who underwent EUA for OCSCC. RESULTS: The most common subsites were the oral tongue and floor of mouth (59.7% and 24.7% respectively). All underwent direct laryngoscopy, 94.8% underwent esophagoscopy, and 20.8% underwent flexible transnasal examination in clinic prior to EUA. For 90.9% of patients, the EUA did not change initial T-staging based on clinical examination and imaging. The remaining 9.1% of patients were upstaged after EUA, however this change did not impact the treatment plan. Second primary tumors were identified in 3.9% of patients, all were found in either the oral cavity or oropharynx, and were also identified with clinical examination or imaging. Analysis of patient charges determined an average cost of $8,022.93 per patient under the current paradigm involving EUA, however with a new algorithm eliminating mandatory EUA average cost decreases to $1,448.44. CONCLUSION: Formal EUA has historically been the gold standard for all HNSCC tumors. However, when performed for cases of oral cavity carcinoma, it is safe and cost effective to limit its use to select clinical scenarios.

Digital ischemia after lidocaine with epinephrine injection in a patient with primary Raynaud's phenomena.

Lidocaine with epinephrine is ubiquitous in hand procedures. Although existing literature supports the overall safety of this, significant physiologic changes accompanying epinephrine can disproportionately affect vascularly compromised patients, such as in Raynaud's phenomenon. The literature is reviewed and a case presented regarding the dangers of epinephrine injection in this population.

Thumb reconstruction by "on-top-plasty" of the long finger.

A 61 year old man sustained electrical burns to hands requiring amputation of the right thumb and index finger at the metacarpophalangeal level. The thumb was reconstructed by means of on-top-plasty of the long finger. This is a reliable and safe technique in selected patients with severe, traumatic hand injuries.

Five Essential Principles for First Web Space Reconstruction in the Burned Hand.

BACKGROUND: Burn injuries commonly affect the hand, and the development of adduction contractures of the first web space is frequent and deleterious, both functionally and aesthetically. Many corrective techniques and algorithmic approaches have been described to treat this problem, but there is no consensus on the optimal management. METHODS: A retrospective review at a single high-volume pediatric burn center was undertaken to evaluate the clinical course of these patients. All pediatric patients undergoing initial release of burn scar contracture of the first web space from 2005 through 2015 were included in a retrospective cohort study. RESULTS: The authors identified 40 patients with 57 burned hands. The initial approach to management was variable. Z-plasty or other local flap was the first technique used in 28 hands (49 percent), split-thickness skin graft in 19 hands (33 percent), full-thickness skin graft in seven hands (12 percent), groin flaps in two hands (4 percent), and a reverse radial forearm flap in one hand (2 percent). The mean numbers of total reconstructive procedures per hand including the initial procedure were as follows: groin flap, 4.0; full-thickness skin graft, 3.1; split-thickness skin graft, 2.1; Z-plasty, 1.4; and reverse radial forearm flap, 1.0. CONCLUSIONS: Successful reconstruction of the first web space must be addressed in the context of the entire hand. It is the authors' preference to use split-thickness skin grafting whenever a skin deficiency is present-only then should leading edge contractures be addressed with Z-plasty. Based on their experience, the authors recommend five principles that are essential to successfully treat postburn contractures of the first web space. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Efficiency in Replantation/Revascularization Surgery.

Digital replantation and revascularization have evolved significantly since the first published reports in the 1960s. Advances in techniques and instruments have made these once formidable procedures a routine part of hand surgery training. Despite this, the frequency of successful outcomes for replantation may be on the decline in the United States. This review summarizes key mechanisms and innovations used to maximize efficiency when presented with a digital replantation, from the moment the patient arrives in the emergency department until the time of discharge.

Outcomes and indications for early hand therapy after multiple concomitant elective hand procedures.

STUDY DESIGN: Retrospective comparative study. INTRODUCTION: Trigger finger and carpal tunnel surgery are common, but not without complications including pain and edema, which are treated with hand therapy (HT). There are limited data for the outcomes of multiple trigger finger releases (MTFRs) or combined trigger finger and carpal tunnel surgery and the subsequent need for HT. PURPOSE OF THE STUDY: Based on our hypothesis that patients with more than 1 procedure may benefit from an early HT visit, we performed this study to compare the frequency of HT orders after single trigger finger releases (STFRs) and MTFRs and determine the reasoning for variation in the rate of HT orders after releases. METHODS: Subjects receiving either an STFR or an MTFR were identified. Patient-reported outcomes were recorded preoperatively and 2 weeks postoperatively. RESULTS: One hundred fifty-nine eligible subjects were identified; 33 MTFRs and 126 STFRs. MTFR subjects were prescribed postoperation HT at a higher rate compared with STFR subjects (66.7% vs 34.1%; P < .001). Of the HT subjects, MTFR subjects received prescriptions for edema management at a significantly higher rate compared with STFR subjects (P = .02). DISCUSSION: Patients with soft tissue dissection, edema, and stiffness would most likely benefit from HT services. It is important to identify these at-risk subpopulations to potentially alter their postoperative trajectories and improve outcomes. CONCLUSIONS: Higher rates of referral to HT occur when there are multiple concomitant hand procedures. This suggests surgeons triage HT services based on need. Policies that disallow postoperative therapy will have a greater impact on patients with these indications.

A new method for in vivo visualization of vessel remodeling using a near-infrared dye.

OBJECTIVES: Vascular obstructive events can be partially compensated for by remodeling processes that increase vessel diameter and collateral tortuosity. However, methods for visualizing remodeling events in vivo and with temporal comparisons from the same animal remain elusive. METHODS: Using a novel infrared conjugated polyethylene glycol dye, we investigated the possibility of intravital vascular imaging of the mouse ear before and after ligation of the primary feeder artery. For comparison, we used two different mouse models known to have impaired vascular remodeling after ligation (i.e., aged and PAI-1(-/-) mice). The results obtained with the infrared dye were confirmed using immunofluorescence labeling of the ear microvasculature with confocal microscopy. RESULTS: After ligation, increases in vessel diameter (between 10% and 60%) and tortuosity (approximately 15%) were observed in C57Bl/6 mice using both the infrared dye and the immunofluorescence technique. However, aged C57Bl/6 and PAI-1(-/-) mice did not show vascular remodeling following ligation. CONCLUSIONS: Vascular remodeling can be visualized and accurately quantified using a new infrared dye in vivo. This analysis technique could be generally employed for quantitative investigations of changes in vascular remodeling.

Plasminogen activator inhibitor-1 regulates myoendothelial junction formation.

RATIONALE: Plasminogen activator inhibitor-1 (PAI-1) is a biomarker for several vascular disease states; however, its target of action within the vessel wall is undefined. OBJECTIVE: Determine the ability of PAI-1 to regulate myoendothelial junction (MEJ) formation. METHODS AND RESULTS: MEJs are found throughout the vasculature linking endothelial cells (ECs) and vascular smooth muscle cells. Using a vascular cell coculture we isolated MEJ fractions and performed two-dimensional differential gel electrophoresis. Mass spectrometry identified PAI-1 as being enriched within MEJ fractions, which we confirmed in vivo. In the vascular cell coculture, recombinant PAI-1 added to the EC monolayer significantly increased MEJs. Conversely, addition of a PAI-1 monoclonal antibody to the EC monolayer reduced the number of MEJs. This was also observed in vivo where mice fed a high fat diet had increased PAI-1 and MEJs and the number of MEJs in coronary arterioles of PAI-1(-/-) mice was significantly reduced when compared to C57Bl/6 mice. The presence of MEJs in PAI-1(-/-) coronary arterioles was restored when their hearts were transplanted into and exposed to the circulation of C57Bl/6 mice. Application of biotin-conjugated PAI-1 to the EC monolayer in vitro confirmed the ability of luminal PAI-1 to translocate to the MEJ. Functionally, phenylephrine-induced heterocellular calcium communication in the vascular cell coculture was temporally enhanced when recombinant PAI-1 was present, and prolonged when PAI-1 was absent. CONCLUSION: Our data implicate circulating PAI-1 as a key regulator of MEJ formation and a potential target for pharmacological intervention in diseases with vascular abnormalities (eg, diabetes mellitus).