A Systematic Review of Clinical Outcomes of Pedicled Flap Repairs of the Knee Extensor Mechanism.

BACKGROUND: Rupture of the extensor mechanism of the knee has severe functional morbidity, and repair can be complicated by infection, allograft degeneration, and recurrent rupture. Techniques of autologous tissue repair utilizing pedicled flaps such as the gastrocnemius offer vascularized methods of reconstruction, with potentially diminished complication rates. The goal of this study was to evaluate the functional outcomes and complications associated with pedicled flap repair of the knee extensor mechanism. METHODS: A systematic review was conducted following the Preferred Reporting Items for Systemic Reviews and Meta-Analyses guidelines. Publications that focused on local myocutaneous flaps as a means for reconstruction were included. Causes for knee extensor mechanism deficit, flap characteristics, ambulation rate, changes in range of motion pre- and postoperation, and postoperative complications were analyzed. Technique reports including primary suture repairs, synthetic mesh, and allograft use were excluded. RESULTS: An initial 119 studies were identified, with final review of 22 observational studies encompassing 128 cases of pedicled flap reconstructions. The gastrocnemius (88.2%, n = 113), quadriceps (6.3%, n = 8), and a combination of the vastus and gastrocnemius flaps (5.5%, n = 7), were the most frequently utilized flaps. Functional outcomes were favorable with 87.2% of patients achieving ambulation without external support. Variability in range of motion outcomes across different flap may be secondary to the patient characteristics as well as extent of initial injury. CONCLUSIONS: Autologous pedicle flap reconstruction of the knee extensor mechanism emerges as a viable option for cases characterized by extensive defects and insufficient soft tissue coverage, which are not amenable to direct suture repairs or allografts. Postoperative assessments revealed that the majority of patients experienced improved ambulation status, with no instances of deterioration noted among the patients.

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.

Risk factors associated with pressure ulcer recurrence after reconstruction: Analysis of a national database.

In this study, we sought to clarify the patient traits and comorbidities that are associated with pressure injury recurrence following pressure injury reconstruction. An insurance claims database, PearlDiver, was used to conduct a retrospective cohort study. The two cohorts included patients who underwent pressure injury reconstruction without recurrence and patients who experienced recurrence with subsequent reconstruction. Multiple logistic regression analysis was used to identify risk factors for recurrence after reconstruction. Recurrence was associated with hypoalbuminemia (p < 0.05), paraplegia (p < 0.05), and osteomyelitis (p < 0.05). In patients with osteomyelitis, primary closure was associated with recurrence (p < 0.05) while flap reconstruction was not (p > 0.05). Osteomyelitis was not associated with recurrence after flap reconstruction. Prior to reconstruction, patients with osteomyelitis and hypoalbuminemia should have their nutrition and infection optimised.

Venous Anastomoses in Anterolateral Thigh Flaps for the Lower Extremity: Vessel Selection In Lieu of Obligatory Number.

BACKGROUND: Dual venous drainage for anterolateral thigh flaps has been proposed to protect against flap-related complications in head and neck applications. Here we report our experience with single vs dual venous anastomosis during lower extremity free-tissue transfer. METHODS: All free anterolateral thigh flaps for lower extremity reconstruction from 2011 to 2017 were retrospectively reviewed. An algorithm was used to determine the type and number of venous anastomoses, emphasizing patient anatomy, venous quality, and size match. Patients were divided into single- and dual-venous-anastomosis groups. Univariate analysis determined differences between the groups. A multivariable analysis identified independent risk factors. RESULTS: Fifty patients met the inclusion criteria. Patient demographics, recipient sites, wound type, and flap characteristics were similar in 1 and 2 vein groups. Average follow-up was 9.6 months. Forty-two percent underwent single venous drainage anastomoses. Mean age was 52.7 years, 78.0% were male, and 60% had defects of the foot and ankle. Increased flap area and early dangling did not increase flap demise. Thirty-three percent of single-drainage patients and 31.0% of dual-drainage patients had a complication. A body mass index of greater than 30 kg/m 2 was a predictor for both flap complication ( P = 0.025) and partial flap loss ( P = 0.031) in univariate analysis. No independent predictors were found in multivariate analysis. CONCLUSIONS: The number of venous anastomoses, area, and dangling protocol did not influence outcomes while using our lower extremity vein method. Thoughtful evaluation of venous egress should outweigh the routine use of multiple veins in perforator flap reconstructions of the lower extremity.

Macromastia and Reduction Mammaplasty: Analysis of Outpatient Cost of Care and Opioid Consumption at 5 Years Postoperatively.

BACKGROUND: Macromastia is associated with increased opioid consumption, which could potentially be the initial exposure for patients with an opioid use disorder amid an escalating opioid crisis in the United States. OBJECTIVES: The purpose of this study was to evaluate outpatient cost of care and opioid consumption in patients with macromastia and compare those who underwent reduction mammaplasty vs those who did not have surgery. METHODS: PearlDiver, a database encompassing a national cohort of private payers with 153 million unique patients, was queried. The study cohort included patients diagnosed with macromastia who did or did not undergo reduction mammaplasty utilizing both ICD-9 and ICD-10 and CPT codes. Outpatient cost of care and morphine milligram equivalents (MME) were calculated up to 5 years postoperatively for both cohorts. RESULTS: At 1 to 3 years postoperatively, there was no statistically significant difference in outpatient cost of care between cohorts. At every follow-up thereafter, outpatient cost of care was higher among macromastia patients who did not undergo reduction mammaplasty, with cohort differences of US$240.68 and US$349.90 at 4 years and 5 years, respectively (P < .05). MME consumption was greater in patients who underwent reduction mammaplasty up to 30 days postoperatively (P < .01). Beyond that, there was no significant difference in MME consumption between cohorts. However, patients who did not undergo surgery had opioid consumption levels above 50 MME/day until 3 years after diagnosis of macromastia. CONCLUSIONS: Patients with macromastia who undergo reduction mammaplasty have lower outpatient care costs than patients who do not undergo reduction mammaplasty, with safer long-term opioid consumption in alignment with current Centers for Disease Control and Prevention guidelines.

Analysis of Complications in Patients With a History of Cannabis Use and Tobacco Use Undergoing Implant-Based Breast Reconstruction.

BACKGROUND: There is limited information regarding the perioperative effects of marijuana in breast reconstructive surgeries. OBJECTIVES: The objective of this study was to explore the association between a history of cannabis use and postoperative complications in the setting of implant-based breast reconstruction. METHODS: Two databases, TriNetX and PearlDiver, were queried for patients undergoing implant-based breast reconstruction. Patients were divided into 4 groups based on active ICD-10 diagnostic codes: (1) cannabis use only, (2) tobacco use only, (3) cannabis and tobacco use, and (4) neither cannabis nor tobacco use. Associations with postoperative complications were analyzed with a logistic regression test. RESULTS: TriNetX search revealed that 327 patients had an active diagnosis of cannabis use only and 1118 had an active diagnosis of tobacco use only. Patients in the cannabis only cohort had a significantly increased risk of developing surgical site infection. Patients in the tobacco only cohort had significantly increased risk of developing wound dehiscence, need for debridement, and surgical site infection. The PearlDiver search included 472 patients who had an active diagnosis of both cannabis and tobacco use and 17,361 patients with a diagnosis of tobacco use only. Patients with a diagnosis of cannabis and tobacco use had a significantly increased risk of developing postoperative complications including surgical site infection, wound dehiscence, need for incision and drainage, and debridement. CONCLUSIONS: Patients undergoing implant-based breast reconstruction with an active diagnosis of cannabis with or without tobacco use were at increased risk of developing postoperative complications, and the risk was even higher in patients using both tobacco and cannabis.

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.

Choosing between Muscle and Fasciocutaneous Free Flap Reconstruction in the Treatment of Lower Extremity Osteomyelitis: Available Evidence for a Function-Specific Approach.

BACKGROUND: Limb salvage in the setting of extremity osteomyelitis, though previously dependent on amputation, has been markedly improved through the application of free tissue flaps. Concern exists as to the utility of the fasciocutaneous flap to combat infection verses the traditional muscle flap. Prior studies have shown success with fasciocutaneous flaps in these patients, but given the small series, the choice remains controversial. The goal of this article was to determine if there is statistical evidence for flap choice in the setting of extremity osteomyelitis. METHODS: A systematic review utilizing Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was completed of the current literature pertaining to the treatment of extremity osteomyelitis and flap reconstruction within the MedLine and PubMed databases. Six hundred forty-six studies were reviewed and ultimately 31 were included in the final analysis. RESULTS: Eight hundred seventy-eight flap reconstructions were identified. Of the 588 muscle flaps, 7.8% (n = 46) had recurrence of osteomyelitis after an average of 36.1 (8.0-111.6) months follow-up. There were seven cases (4.3%) of osteomyelitis recurrence in the 163 fasciocutaneous flap group after an average of 29.8 (18.2-44.6) months follow-up (p = 0.165). Secondary outcomes such as flap loss, hematomas, and infection were analyzed without statistically significant differences between the muscle and fasciocutaneous flap groups. CONCLUSION: Selection of flap type is less important than adequate debridement, appropriate antibiotic selection, and sufficient duration of treatment. This study demonstrates that within the literature, fasciocutaneous flaps have a lower recurrence rate of osteomyelitis compared with muscle flaps. As such, fasciocutaneous flaps are appropriate for reconstruction and treatment of extremity osteomyelitis.

Targeted Muscle Reinnervation: Outcomes in Treating Chronic Pain Secondary to Extremity Amputation and Phantom Limb Syndrome.

BACKGROUND: Secondary to vascular disease, oncological resection, or devastating trauma, lower extremity amputations are performed globally at a yearly rate exceeding 1 million patients. Three-quarters of these patients will develop chronic pain or phantom pain, which presents a functional limitation for prosthetic use and contributes to deconditioning and increased mortality. Targeted muscle reinnervation (TMR) presents a surgical solution to this problem as either a primary or secondary intervention. METHODS: A review of the existing literature was conducted using a combination of the terms "phantom pain" "chronic pain," "neuroma," and "targeted muscle reinnervation" in Medline and PubMed. RESULTS: Five articles were found which addressed TMR for pain syndromes, four of which involved lower extremity amputation. Four of the articles were retrospective reviews, and one was a randomized control trial. A total of 149 patients were included, of which 82 underwent lower extremity amputation. Ninety-two of the patients underwent prophylactic TMR, of which 57 were secondary procedures.In patients who underwent TMR at the time of amputation, all studies reported a minimal development of symptomatic neuromas (27%). For secondary TMR, near-complete resolution of previous pain was found (90%). Phantom pain was noted to be similar to other studies in the literature but noted to improve over time with both primary (average drop of 3.5 out of 10 points on the numerical rating scale) and secondary (diminishing from 72% of patients to 13% over 6 months) operations. CONCLUSION: Although much of the current literature is limited to retrospective studies with few patients, these data point toward near-complete resolution of neuroma pain after treatment as well as complete prevention of chronic pain if TMR is used as a prophylactic measure during the index amputation. THIS STUDY WAS A LEVEL OF EVIDENCE IV: .

Identifying Complications and Optimizing Consultations following Transradial Arterial Access for Cardiac Procedures.

BACKGROUND: The radial approach to cardiac procedures has become increasingly common. Although previous studies have suggested a favorable risk profile, serious complications can occur. The purpose of this study is to examine the incidence, subsequent treatment, and outcome of all suspected significant neurovascular complications following transradial cardiac procedures at a large US hospital. METHODS: We reviewed all patients who underwent a left heart catheterization, coronary angiogram, or percutaneous coronary intervention via the transradial approach at a single large academic medical center in the United States between 2010 and 2016. Consultations to the vascular and hand surgery services were examined to assess demographic variables, risk factors, presenting symptoms, subsequent treatment, and outcome of all serious complications. RESULTS: A total of 9,681 radial access cardiac procedures were performed during the study period. Twenty-four cases (0.25%) were suspected to have major complications and subsequently received consults. A total of 18 complications were diagnosed, including 8 vascular injuries or perforations, 4 hematomas, 4 radial artery occlusions, 1 case of compartment syndrome, and 1 severe radial artery spasm. Of the complications noted, 3 (16.7%) required operative interventions, but all recovered neurovascular function. CONCLUSIONS: Radial artery access for cardiac procedures has become increasingly common and has been associated with a low rate of major peripheral neurovascular complications. The majority (83.3%) of complications were successfully treated with a nonoperative management algorithm.

Readability, Suitability, and Complexity of Online Resources for Lower Extremity Reconstruction.

BACKGROUND: Surgical options for lower extremity reconstruction frequently include a decision between autologous free flap reconstruction and amputation. Patients rely on health education materials for information before making treatment decisions. This study evaluates the quality of online health information for lower extremity reconstruction. METHODS: We identified the top 10 Web sites for "leg amputation" and "leg free flap reconstruction." Three validated tools were used to evaluate literacy demand of materials, including (1) the Simple Measure of Gobbledygook for readability; (2) the Peter Mosenthal and Irwin Kirsch readability formula for complexity of nonprose materials such as list, graphs, charts; and (3) the Centers for Disease Control and Prevention's Clear Communication Index (Index). Differences in mean between the 2 groups were compared using Student t test. RESULTS: Average Simple Measure of Gobbledygook reading grades approximated 12th-grade level and were similar between the 2 groups. This is above the recommended level of sixth-grade health literature. Complexity scores for nonprose materials of these groups were within recommended range and corresponded to very low complexity at a fourth- to seventh-grade level. The Centers for Disease Control and Prevention index was higher for amputation literature compared with free flap reconstruction (70% vs 54%), but the difference was not statistically significant. CONCLUSIONS: Overall, online health resources for lower extremity amputation and free flap reconstruction do not meet the standard for quality and accessible health information. Free flap reconstruction resources are scarce and complex. Patients facing decisions about extremity reconstruction may not have appropriate online health resources available to them to make informed decisions.

Coronary Artery Disease Association With Arterial Calcifications on Routine Hand Radiographs.

PURPOSE: Arterial calcifications in the lower extremity, chest, and cardiac vessels have been linked to coronary artery disease (CAD). However, the relation between arterial calcifications observed on routine hand and upper-extremity radiographs and atherosclerosis has not been determined. This study examined whether arterial calcifications found on hand radiographs are associated with CAD. METHODS: A record review from a single institution identified 345 patients with both hand radiographs and CAD screening with cardiac stress testing or coronary angiography. Patients with chronic kidney disease, end-stage renal disease, or incomplete hand films were excluded. We reviewed x-rays for findings of arterial calcifications. Cardiac testing results were used to establish a baseline diagnosis of CAD. We made group comparisons and employed multivariable logistic regression to evaluate the association between upper-extremity calcification and CAD. RESULTS: A total of 210 patients met inclusion criteria: 155 with CAD and 55 without it. Mean age was 72 years, body mass index was 28.8, and 54% were male. Patients had comorbidities of hypertension (91%), hyperlipidemia (87%), diabetes (39%), cerebrovascular accident (9%), and a history of tobacco use (53%). Of 155 CAD patients, 67 had arterial calcifications on hand radiographs (43%), compared with 6 of 55 without it (11%). In a multivariable model controlling for sex, hyperlipidemia, and diabetes, the presence of arterial calcifications on hand plain films indicated a 6.2-fold increased odds of CAD. CONCLUSIONS: The current data demonstrate that arterial calcifications on hand radiographs are independently associated with CAD. This may represent an opportunity to the treating physician as a point of referral or investigation for underlying or occult CAD. TYPE OF STUDY/LEVEL OF EVIDENCE: Prevalence III.

Wrist arthrodesis with the medial femoral condyle flap: Outcomes of vascularized bone grafting for osteomyelitis.

BACKGROUND: Osteomyelitis of the wrist is rare but destructive. Subsequent bone defects often require vascularized bone for successful healing. Recent literature has pointed to the successful use of the medial femoral condylar (MFC) flap for difficult non-unions, yet it has not been specifically described for wrist fusion. We present our experience with this technique for limited and complete wrist arthrodesis. PATIENTS AND METHODS: We reviewed 4 cases of radiocarpal bone loss from osteomyelitis. All cases utilized debridement of nonviable tissues, and at least 6 weeks of intravenous antibiotics, followed by vascularized bone grafting with a MFC flap. The flap was based on the horizontal periosteal branch of the descending geniculate artery, and utilized to directly bridge the bony defects following resection. RESULTS: Three patients healed primarily, and 1 patient required secondary cancellous bone grafting to reach union. One patient required revision of the donor site closure. None of the patients had a recurrence of infection or other complications. Average follow up was 8.5 months after reconstruction. Average time to union was 11.5 weeks. Three patients demonstrated full composite fist, and 1 patient had incomplete finger range of motion following several flexor and extensor tendon grafts. CONCLUSIONS: These cases illustrate the use of the MFC in wrist arthrodesis after osteomyelitis defects. In all cases, there was complete union in a short time, no recurrence of infection, and low donor-site morbidity.

Evaluating Venous Drainage in Reverse Flow Pedicles: Available Evidence and Mechanisms.

BACKGROUND: The anatomy and physiology of venous drainage in the reversed flow vascular pedicle is controversial and there have been few well-designed, controlled studies to effectively evaluate the physiology. We evaluated the available evidence for venous drainage to synthesize the conclusions of these studies, and to identify areas in need of further research. METHODS: Electronic databases were searched for articles published from January 1, 1950 to November 1, 2017. A total of 316 citations were screened for inclusion. Fifty articles met inclusion criteria and underwent review, yielding 12 articles for final data analysis. Three principal study types were found: human cadaveric (7), animal (3), human clinical (1), and mixed (1). RESULTS: We identified two main theories regarding the mechanism of venous drainage in reverse flow flaps. The "avalvular bypass" theory is based on the findings of intact valves of the venae comitantes, and venous outflow through the crossover pattern of the communicating branches and bypass pattern of the collateral branches. Alternatively, the "valvular incompetence" theory implies that pedicle dissection, proximal ligation, and insetting of the flap cause physiologic changes, such as increased venous pressure, denervation, and simultaneous proximal and distal filling, which together result in valvular insufficiency. CONCLUSION: The mechanism by which retrograde venous outflow occurs in reverse flow flaps remains controversial. Nonetheless, a few well-designed studies have contributed to the understanding of venous anatomy and outflow. Most likely, the true mechanism is based on venous outflow that occurs via the "avalvular bypass" route initially and the "valvular incompetence" route later.

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.

Assessing the Safety and Efficacy of Regional Anesthesia for Lower Extremity Microvascular Reconstruction: Enhancing Recovery.

BACKGROUND: Perioperative pain, increased sympathetic tone, and peripheral vasospasm may be safely managed with regional nerve blockade during microvascular reconstruction in the lower extremity. Limited reports exist in this setting; therefore, we evaluated our use of peripheral nerve catheters (PNCs) during microvascular limb salvage to determine safety and efficacy for both patient and flap. METHODS: A single-institution, retrospective review of a prospectively maintained database on all patients with lower extremity free tissue transfers between 2012 and 2017 was completed. Patients were matched into groups based on PNC utilization. The use of intravenous narcotics including patient-controlled analgesia (PCA), oral narcotics, antiemetics, length of stay (LOS), associated pain scores, flap-related performance, and patient morbidity was recorded. RESULTS: Of 48 patients who underwent lower extremity free tissue transfer, 35 satisfied criteria for comparison. Of these, PNC was utilized in 83%. The mean pain score in the immediate postoperative period was 3.84 ± 2.47 (10-point Likert scale). PCA and narcotic use were decreased in the PNC group, and no adverse effects of the catheter were identified. Microsurgical outcomes were not adversely affected in comparison. CONCLUSION: PNC utilization for lower extremity free flap transfer significantly reduced concurrent narcotic use and attained a shorter LOS. The technique provided for safe analgesia during lower extremity free flap reconstructions satisfying the microsurgeon and the anesthesiologist.

Reconstruction of quadriceps function with composite free tissue transfers following sarcoma resection.

BACKGROUND AND OBJECTIVES Wide margin resection of a soft tissue sarcoma (STS) may require extensive removal of quadriceps muscle with or without the knee extensor mechanism. The objective of this study is to present present the use of a combined functional muscle transfer and soft tissue coverage through the use of chimeric anterolateral thigh flaps. METHODS: Patients were retrospectively reviewed who underwent deep STS resection of the anterior compartment of the thigh with functional reconstruction of knee extension using a contralateral free anterolateral thigh (ALT) flap. RESULTS: Three patients with an average age 53.6 years (range: 33-66) were included. Average follow-up was 82 weeks (76-92 months). Full active extension was regained in 66% of patients with all patients regaining active extensor capabilities beyond 100°. The mean Knee Society Score was 83.3 (range; 76-92) and Musculoskeletal Tumor Society Score 21.6 (range; 19-21). Isometric knee extensor strength exceeded 4+/5 in all patients. CONCLUSION: Following soft tissue sarcoma resections of the lower extremity, chimeric anterolateral thigh flaps for restoration of knee extension can provide significant improvements in the potential for ambulation and regaining quadriceps function.

Reversed Palmaris Longus Muscle Causing Volar Forearm Pain and Ulnar Nerve Paresthesia.

A case of volar forearm pain associated with ulnar nerve paresthesia caused by a reversed palmaris longus muscle is described. The patient, an otherwise healthy 46-year-old male laborer, presented after a previous unsuccessful forearm fasciotomy for complaints of exercise exacerbated pain affecting the volar forearm associated with paresthesia in the ulnar nerve distribution. A second decompressive fasciotomy was performed revealing an anomalous "reversed" palmaris longus, with the muscle belly located distally. Resection of the anomalous muscle was performed with full relief of pain and sensory symptoms.

The Impact of Safety Regulations on the Incidence of Upper-Extremity Power Saw Injuries in the United States.

PURPOSE: Over 50,000 power saw-related injuries occur annually in the United States. Numerous safety measures have been implemented to protect the users of these tools. This study was designed to determine which interventions, if any, have had a positive impact on the safety of the consumer or laborer. METHODS: We queried the National Electronic Injury Surveillance System database for hand and upper-extremity injuries attributed to power saws from 1997 to 2014. Demographic information including age, sex, date of injury, device, location, body part involved, diagnosis, and disposition was recorded. We performed statistical analysis using interrupted time series analysis to evaluate the incidence of injury with respect to specific safety guidelines as well as temporal trends including patients' age. RESULTS: An 18% increase in power saw-related injuries was noted from 1997 (44,877) to 2005 (75,037). From 2006 to 2015 an annual decrease of 5.8% was observed. This was correlated with regulations for power saw use by the Consumer Safety Product Commission (CPSC) and Underwriters Laboratories. Mean age of injured patients increased from 48.8 to 52.9 years whereas the proportion of subjects aged less than 50 years decreased from 52.8% to 41.9%. These trends were most pronounced after the 2006 CPSC regulations. CONCLUSIONS: The incidence of power saw injuries increased from 1997 to 2005, with a subsequent decrease from 2006 to 2015. The guidelines for safer operation and improvements in equipment, mandated by the CPSC and Underwriters Laboratories, appeared to have been successful in precipitating a decrease in the incidence of power saw injuries to the upper extremity, particularly in the younger population. CLINICAL RELEVANCE: The publication of safety regulations has been noted to have an association with a decreased incidence in power saw injuries. Based on this, clinicians should take an active role in their practice as well as in their professional societies to educate and counsel patients to prevent further injury.

Surgeon-Based 3D Printing for Microvascular Bone Flaps.

Background Three-dimensional (3D) printing has developed as a revolutionary technology with the capacity to design accurate physical models in preoperative planning. We present our experience in surgeon-based design of 3D models, using home 3D software and printing technology for use as an adjunct in vascularized bone transfer. Methods Home 3D printing techniques were used in the design and execution of vascularized bone flap transfers to the upper extremity. Open source imaging software was used to convert preoperative computed tomography scans and create 3D models. These were printed in the surgeon's office as 3D models for the planned reconstruction. Vascularized bone flaps were designed intraoperatively based on the 3D printed models. Results Three-dimensional models were created for intraoperative use in vascularized bone flaps, including (1) medial femoral trochlea (MFT) flap for scaphoid avascular necrosis and nonunion, (2) MFT flap for lunate avascular necrosis and nonunion, (3) medial femoral condyle (MFC) flap for wrist arthrodesis, and (4) free fibula osteocutaneous flap for distal radius septic nonunion. Templates based on the 3D models allowed for the precise and rapid contouring of well-vascularized bone flaps in situ, prior to ligating the donor pedicle. Conclusions Surgeon-based 3D printing is a feasible, innovative technology that allows for the precise and rapid contouring of models that can be created in various configurations for pre- and intraoperative planning. The technology is easy to use, convenient, and highly economical as compared with traditional send-out manufacturing. Surgeon-based 3D printing is a useful adjunct in vascularized bone transfer. Level of Evidence Level IV.