Treatment of volar defects of the finger using dorsal digital-metacarpal flap versus free medial plantar artery flap: a comparative study.

BACKGROUND: The treatment of defects on the volar surface of the finger has been scarcely reported, and its utility for digital resurfacing remains unclear. This study compared the outcomes of free medial plantar artery flap (MPAF) and dorsal digital-metacarpal flap (DDMF) in finger reconstruction. METHODS: This retrospective cohort study included 24 patients with soft-tissue defects on the volar surface of the finger from March 2014 to March 2017. The patients were divided into two groups: the MPAF group and the DDMF group. The operation time, complications, such as flap necrosis, graft loss, infection, paresthesia, and donor-site morbidity, as well as two-point discrimination (2-PD) were carefully recorded. The Michigan Hand Outcomes Questionnaire was used for conduct follow-up assessment. RESULTS: After more than 12 months of follow-up, the MPAF group had a longer operative time compared with DDMF group, but there was no significant difference between postoperative complications and 2-PD test result in patients without nerve injury. And in terms of overall function, Modified VSS score and 2-PD test (the patients with nerve injury), There were relatively obvious statistical differences, MPAF was superior to DDMF (p < 0.005). CONCLUSION: MPAF and DDMF are reliable for reconstruction of the volar surface of the finger; however, MPAF offers better functional outcomes and is associated with a lower incidence of postoperative complications.

Preserving the Knee in the Setting of High Segmental Tibial Bone and Massive Soft-Tissue Loss Using Vascularized Distal Tibial Bone Docking and a Foot Fillet Flap: A Case Report.

CASE: We discuss our reconstructive approach to avoid an above-knee amputation in a 33-year-old man presenting after lower extremity crush injury. We used a vascularized tibial bone flap and a foot fillet flap to restore length and joint functionality to the residual limb. The patient ambulates with good prosthetic fit on durable heel pad skin and 100° active knee motion. CONCLUSION: This pairing of intramedullary nail with vascularized bone flap and fillet flap to address soft-tissue coverage and retain limb length is a useful tool in traumatic lower extremity injury management, providing an alternative technique for tibial bone graft stabilization with robust, sensate tissue coverage.

Aspectos generales sobre el dolor osteomuscular en el baile flamenco / Overview of musculoskeletal pain in the flamenco dancer

Introducción. Los bailaores de baile flamenco son susceptibles de padecer dolor por su actividad, lo que les puede producir una gran limitación. Conocer cuáles son las localizaciones más frecuentes y con qué variables se relacionan es el objetivo de este trabajo, para desarrollar planes de atención más eficientes y medidas de medicina preventiva. Material y método. Hemos realizado un estudio descriptivo analítico, mediante una encuesta a bailaores, en donde se recogían datos personales, hábitos del bailaor y regiones donde habían presentado dolor. Los datos obtenidos han sido analizados con el programa informático SPSS utilizando como métodos estadísticos el ANOVA, la t de Student y la prueba de la X2. Resultados. Hemos obtenido 96 resultados, la mayoría mujeres, con un intervalo de edad muy amplio desde los 8 hasta los 53 años. La región más referida en cuanto a dolor es el pie, habiendo muchas localizaciones diferentes de dolor, seguidas en importancia por las rodillas, y espalda, cuello y región lumbar. Conclusiones. El calentamiento antes de bailar evita la aparición de molestias. Los tacones de más de 5cm predisponen a la aparición de dolor, así como un IMC mayor de 22,29, bailar más de 4 horas al día y más de 5 días a la semana. La mayoría de los bailaores recurren a las técnicas manuales para solucionar sus lesiones. Es necesario realizar estudios más específicos para poder profundizar más en el tema, ya que son muy pocos los estudios que hay en la literatura científica(AU)

Introduction. Flamenco dancers are susceptible to pain from their activity, which can be an important limitation. This study has aimed to discover what are the most common locations and what variables they are related to in order to develop more efficient care plans and preventive medicine measures. Material and methods. We have made a descriptive analysis study, conducting a survey to dancers that gathered personal data, habits of the dancer and regions where they had pain. The data obtained were analyzed with the SPSS statistical program using the ANOVA, T-Student and X2 statistical methods. Results. We obtained 96 results, mostly women, with a very wide age range from 8 to 53. The region referred to most in terms of pain is the foot, with many different locations of the pain, followed in importance by the knees, back, neck and lumbar region. Conclusions. Warming up before dancing prevents the onset of discomfort. Heels of more than 5cm predispose to pain, and a BMI greater than 22.29, dancing more than 4hours a day and more than 5days a week. Most of the dancers rely on manual techniques to address their injuries. More specific studies are needed to go deeper into the subject, since there are very few studies in the literature(AU)

Elective cross-over transfer of the foot: case report.

The case of a patient with sequels of a right Syme amputation and a left replanted upper tibial amputation was treated with elective cross-transfer of the left foot and ankle to the right distal tibial stump, and the left below-knee (BK) stump was resurfaced with a latissimus dorsi free flap. The patient regained independent walking capacity with a left BK prosthesis at 8 months postoperatively.

[Stump retention and extension on the lower extremity]. / Stumpferhalt und Stumpfverlängerung an der unteren Extremität.

Despite new techniques and better health programs in western industrialized nations, the numbers of amputations on the lower extremity remain constant. Approximately 100,000 amputations are performed annually in the U.S. and about 10,000 in Germany, more than 90% for gangrene resulting from ischemia and/or infection. Micro- and macroangiopathic changes in diabetes are the major cause of ischemia in the leg. The preservation of limb length and construction of an end bearing stump are important criteria for the functional outcome after amputation. Especially in trauma and tumor patients with "planned" amputations, all effort should be made to achieve an end bearing stump with sufficient length respectively an amputation level that is suitable for orthosis instead of prosthetic supplementation. After amputation, an interdisciplinary approach is mandatory to achieve sufficient soft tissue coverage or stump distalization. In case of insufficient bearing ability of the stump, various reconstructive possibilities must be considered to assure optimal outcome.

Investigation of risk acceptance in facial transplantation.

BACKGROUND: The surgical techniques necessary to transplant a human face are well established, and the early success of human hand transplants suggests that the immunological hurdles of transplanting human facial tissues have largely been overcome. Therefore, it is the ethical barriers that pose the greatest challenge to performing facial transplantation. At the center of the ethical debate is the question, "Do the risks posed by the life-long immunosuppression that a recipient would have to take justify the benefits of receiving a face transplant?" In this study, the authors answer this question by assessing the degree of risk individuals would be willing to accept to receive a face transplant. METHODS: To quantitatively assess risks versus benefits in facial transplantation, the authors developed the Louisville Instrument for Transplantation, or LIFT, which contains 237 standardized questions. Respondents in three study populations (healthy individuals, n = 150; organ transplant recipients, n = 42; and individuals with facial disfigurement, n = 34) were questioned about the extent to which they would trade off specific numbers of life-years, or sustain other costs, in exchange for receiving seven different transplant procedures. RESULTS: The authors found that the three populations would accept differing degrees of risk for the seven transplant procedures. Organ transplant recipients were the most risk-tolerant group, while facially disfigured individuals were the least risk tolerant. All groups questioned would accept the highest degree of risk to receive a face transplant compared with the six other procedures. CONCLUSIONS: This study presents an empirical basis for assessing risk versus benefit in facial transplantation. In doing so, it provides a more solid foundation upon which to introduce this exciting new reconstructive modality into the clinical arena.

Risk acceptance in composite-tissue allotransplantation reconstructive procedures.

Composite-tissue allotransplantation (CTA) is a new therapeutic modality to reconstruct major tissue defects of the face, larynx, and extremities. Unlike most life-saving organ-transplantation procedures, CTA is considered to improve quality of life. Therefore, the question arises, do the risks posed by the immunosuppression drugs that patients must take to prevent rejection justify the benefits of these procedures? The purpose of this study was to assess the relative risk that individuals are willing to accept in order to receive the benefits of CTA procedures. We used a psychometrically reliable and valid instrument to question two primary populations of individuals: those who live with the risks of immunosuppression, and healthy individuals. The level of risk acceptance for the seven transplant procedures tested (foot, single hand, double hand, larynx, kidney, hemiface, and full face) showed significant differences in research participants' risk acceptance for the different transplant procedures, but no significant differences between groups. Based on these findings, we conclude that certain CTA procedures convey benefits to recipients that are perceived by subjects, including individuals who live with the risks of immunosuppression, to warrant the risks of these procedures.

El pie en la Diabetes / The foot in diabetes

Proyecto becado por el Servicio Aragonés de Salud en el año 2000, de dos años de duración. Fue presentado en el XI Congreso de la FEAED (Federación Española de Asociaciones de Educadores en Diabetes) celebrado en Valencia en el 2004. Prepara y cualifica a Enfermería para la realización de una revisión de pie diabético de calidad con una intervención educativa complementada con un estudio transversal pre post intervención. Han participado 268 enfermeros de Atención Primaria que trabajan con diabéticos en las 34 zonas básicas de salud

Nursing was qualified to carry out an in depth study on the effects diabetes has on feet by means of an educational intervention complemented by a pre- and post-intervention transversal study. 268 primary care center nurses who deal with diabetics in 34 basic health areas participated in this study. This project was sponsored by SALUD, the Aragon Health service, in 2000 and it lasted two years. This study was presented at the XI FEAED (Spanish Federation of Association of Educators in Diabetes) Congress which took place in Valencia in 2004

Temporary ectopic implantation for salvage of amputated lower extremities: case reports.

Two cases of temporary ectopic implantation of a complex amputated foot, followed by replantation to its anatomic position, are reported. Both cases of amputated foot were complicated by devastating soft-tissue injuries in the proximal stump of the amputation, fracture of the femur, and hemorrhagic shock, which ruled out the possibility of primary foot replantation. Both feet were temporarily ectopically implanted onto the contralateral legs, with microvascular anastomoses of the vessels to the recipient posterior tibial artery and saphenous vein. When the patient's general condition allowed, and the soft-tissue defects were repaired, the ectopic implanted feet were replanted to their anatomic positions. Both feet survived the temporary ectopic implantation and second-stage replantation. The length of the injured legs was maintained, and the feet regained their function in 4- and 6-month follow-ups. We conclude that temporary ectopic implantation of amputated parts provides an innovative procedure for the salvage of amputated extremities under special circumstances. A contralateral healthy extremity is an ideal recipient site for temporary ectopic implantation. The temporary ectopic implantation and second-stage replantation of an amputated foot and distal leg with indications can obtain satisfactory results.

A unique case of total foot-to-hand transfer in an infant with monodactyly.

A unique case of total foot-to-hand transfer, including the calcaneus, in an 8 month-old infant with monodactyly is described. Several technical and psychological aspects of the case are also discussed.

Transtibial amputation with plantar flap for congenital deficiency of the tibia.

Disarticulation of the knee has been the preferred treatment for the severe type (Type Ia and Type Ib classification of Jones et al) of congenital deficiency of the tibia because of marked flexion contracture of the knee and loss of quadriceps function. In such cases, the disarticulated stump is often small and poorly covered by soft tissues because of dysplastic femoral condyles and calf muscles. Therefore, stump complications after disarticulation may prevent early aggressive walking exercises and delay independent ambulation. To overcome this problem, a greater weightbearing surface was created by a transtibial amputation with a short stump of the fibula using the flexed knee. By this method, the distal femoral condyle and the anterior surface of the fibula were used for weightbearing. In addition, coverage of the new weightbearing area by a neurovascular pedicled sensate plantar flap provided a more tolerable weightbearing site. The purpose of the current study was to report a 5-year-old boy with bilateral congenital total deficiency of both tibias, who was treated using this technique. The patient was ambulating independently 15 weeks after surgery. A transtibial amputation with a plantar flap is an alternative procedure to knee disarticulation for the severe type of congenital deficiency of the tibia.

Crossover replantation and fillet flap coverage of the stump after ectopic implantation: a case of bilateral leg amputation.

A successful case of crossover replantation of the left foot to the stump of the right leg and temporary ectopic implantation of the right amputated foot on the forearm is described. The ectopically implanted right foot was used as a free fillet flap for the late reconstruction of the left leg stump. At the latest follow-up examination, 18 months after the accident, the patient was able to walk independently with a prosthesis on the stump of the left leg. Both the cross-replanted foot and the free filleted foot flap, used for the reconstruction of the left leg stump, have maintained adequate protective sensation. The importance of utilization of amputated parts for functional reconstruction is stressed. Crossover replantations and ectopic implantations should be considered in bilateral amputations for the salvage of at least one extremity.

Gait analysis in patients after Van Nes rotationplasty.

Gait was analyzed through kinetic, kinematic, and temporal-distance parameters assessment to evaluate the functional performance of ten children treated by the classical Van Nes rotationplasty (VNR). Van Nes rotationplasty is a surgical procedure, which permits the conversion of the ankle joint into a "pseudo-knee" joint. The data were compared with measurements of a normal population of ten healthy subjects. Significant differences with respect to the normal were found in stride duration, stride length, cadence, velocity, and stance-swing ratio, and in ground-reaction forces parameters, which define the propulsive phase in the prosthetic side and the acceptance phase in the sound side. There were differences in some kinematic parameters as well. Van Nes rotationplasty is acceptable from a biomechanical-functional point of view, particularly with respect to the active control of the pseudo-knee, which allows a smooth and coordinate gait pattern.

Analysis of the role of basic fibroblast growth factor in growth and differentiation of transplanted fetal rat paws and intestines.

Paws and intestinal segments from 16-day-old rat fetuses were transplanted bilaterally under the kidney capsule of adult female hosts and grown there for different periods of time. The direct effects of an antiserum to bovine basic fibroblast growth factor (bFGF) and of recombinant bFGF on growth and tissue differentiation in the transplants were evaluated by infusing them into the right renal artery via a catheter attached to an osmotic minipump. Infusion of the antiserum into the right kidney of intact hosts for 6 or 10 days did not affect either growth of the paws or bone differentiation in them. By contrast, the anti-FGF serum significantly inhibited the growth of intestinal transplants and caused slight retardation of villus differentiation. We presume that this inhibition resulted from neutralization of the bFGF produced within the transplants, as infusion of nonimmune rabbit serum had no such effects on the intestinal segments. In hypophysectomized hosts growth of both types of transplants was greatly reduced, and tissue differentiation was retarded, presumably reflecting low serum insulin-like growth factor-I levels. Infusion of the recombinant bFGF (5 micrograms/rat.day) into the hypophysectomized hosts stimulated growth of the paws and promoted ossification of the phalanges, but not the carpals. Intestinal growth was not affected by bFGF, and villus development was not restored. These results indicate that fetal rat structures are differentially dependent on and responsive to bFGF for growth and differentiation. These findings, when considered in relation to our previous results with transplanted 10-day-old rat embryos, indicate that growth and tissue differentiation during the embryonic period of rat development are more dependent on bFGF than are these processes in the fetal period.

Insulin but not GH directly stimulates growth of transplanted fetal rat paws.

We have investigated whether insulin or growth hormone (GH) can affect growth of transplanted fetal rat paws by direct and/or indirect actions. Paws from 15-day rat fetuses were transplanted under the kidney capsule of adult female hosts, and grown for 7 days. In hypophysectomized (HX) or diabetic hosts their growth was reduced by 65% and 35%, respectively. The direct effects of insulin and GH were studied by inserting a catheter connected to an osmotic minipump into the left renal artery. Thus transplants on the left (infused) kidney were exposed directly to much higher concentrations of hormone than were those on the right (uninfused) side. In HX hosts, infusion of GH (0.1 microgram X g body wt-1 X day-1) had no effect on growth of paws on either kidney. At 0.3 or 1.0 microgram X g body wt-1 X day-1 GH caused a dose-related restoration of transplant growth that was equivalent on both sides. In diabetic hosts infusion of insulin (2 U X kg body wt-1 X day-1) partially restored growth of paws on the infused kidney without affecting those on the right. Insulin at 6 U X kg body wt-1 X day-1 caused full restoration of growth of the paws on the left and a partial increase in those on the right. At 9 U X kg body wt-1 X day-1 insulin caused full restoration of transplant growth on both kidneys. These results indicate that insulin promotes normal growth of transplanted fetal paws by direct and possibly indirect mechanisms, but the effects of GH are apparently only indirect.

The internal milieu of the pregnant rat is not growth promoting for maternal tissues and it reduces growth of fetal paw transplants.

We have investigated whether the internal milieu of the pregnant female rat is growth promoting to fetal or adult tissues. Adult female littermates were divided into two groups, one of which remained virginal while the other was bred repeatedly. Four successive pregnancies did not affect skeletal growth (i.e. tail length increase) or BW gain. Three-month-old females were hypophysectomized (HX) or sham HX on day 13 of pregnancy. Age-matched virgins were treated similarly. Eight days after surgery, the width of the tibial epiphysial plate of the HX virgins had decreased from 146.2 +/- 5.6 mu to 98.4 +/- 2.5 mu. In the pregnant rats, the width of the plate in the shams was reduced to 120.8 +/- 7.6 mu, and hypophysectomy tended to further reduce its width to 103.2 +/- 8.4 mu. Paws from 14- to 15-day fetal rats were transplanted under the kidney capsule of adult nonpregnant or pregnant hosts and grown there for 6 or 11 days. In the nonpregnant hosts the paws grew substantially during both periods, but in gravid females their growth was inhibited by about 35%. Paws were also transplanted to the kidney of HX pregnant and HX nonpregnant females to determine whether the internal milieu of the gravid female retains more growth-promoting/growth-supporting activity after pituitary removal than does that of HX virgin hosts. In both types of HX hosts, transplant growth was inhibited to the same degree (65-70%) relative to growth in intact hosts. The growth-inhibiting properties of the internal environment of the gravid hosts were not due to ovarian steroids because injections of estradiol plus progesterone had no effect on transplant growth. We also tested the effects of placental transplants and placental extracts on the growth of transplanted paws in juvenile female hosts. Both placental treatments caused inhibition of transplant growth by 25-30%. Overall, our results indicate that the internal milieu of the pregnant rat is not somatotrophic for her tissues, and it actually suppresses growth of fetal tissue transplants. The placenta may be responsible for this growth-inhibitory effect.