Use of the subscapular system by maintaining unilateral decubitus placement without repositioning in microvascular free tissue transplantation.

BACKGROUND: In microvascular free-tissue harvest and transfer, the need for repositioning from lateral decubitus position and the inability to use a two-team approach are major drawbacks of the subscapular system. We present our experience with the subscapular system for upper and lower extremity reconstruction using a two-team approach without need for repositioning. METHODS: We conducted a retrospective chart review for all patients undergoing free flap transplant based on the subscapular system to the upper or lower extremity at our microsurgical facility from January 1, 2007 to December 31, 2011. Only cases not requiring intraoperative repositioning were included. Sixty-four patients underwent the two-team approach (37 upper extremity and 27 lower extremity transplants). Flap types included latissimus dorsi musculocutaneous, partial superior latissimus, dorsal thoracic fascia, serratus, scapular bone, and thoracodorsal artery perforator, either alone or as chimeric flaps. All patients were placed in the lateral decubitus position for the duration of the surgery. RESULTS: The ipsilateral subscapular system was used in 16% of cases for lower extremity defects, where the anterior tibial vessels served as recipient vessels. The contralateral subscapular system was used in all remaining cases for upper extremity or the vast majority for lower extremity (84%) defects, where either the superficial femoral, genicular, popliteal, sural, or posterior tibial vessels served as recipient vessels. With the exception of one partial flap loss secondary to infection, all flaps survived. CONCLUSIONS: Proper lateral decubitus positioning allows for a two-team approach without compromising safety or outcomes.

Initial Management of Traumatic Digit Amputations: A Retrospective Study of Functional Outcomes.

BACKGROUND: Traumatic amputation of one or more digits can have a serious detrimental effect on social and economic standings which can be mitigated by successful replantation. Little has been recorded on preoperative management before replantation and how this affects the outcomes of the replanted digit. METHODS: A retrospective cohort study was conducted and data collected over an 18-month period. Three protocols for preoperative management were examined: minimal (basic wound management), complete Buncke (anticoagulation, dry dressing on amputate placed on indirect ice and absence of a digital block), and incomplete (any two or three criteria from complete Buncke in addition to the minimal) protocols. Data was collected on survival rate, secondary operations, and complication rate. Function was defined by sensation, range of movement, and strength. RESULTS: Seventy four of 177 digits were replanted with an overall survival rate of 86.5%. The rates for minimal, incomplete, and complete protocols were 95%, 87%, and 91%, respectively, and not significantly different. The complication rate was significantly different between the complete (20%) and minimal (60%) protocols (p = 0.0484). Differences in sensation and grip strength were statistically significant between protocols (p = 0.0465 and p = 0.0430, respectively). Anticoagulation, no digital block and dry gauze all showed reduced complication rates in comparison to their counterparts. CONCLUSIONS: The Buncke protocol, which includes anticoagulation, no digital block, and dry gauze, was found to significantly reduce the complication rate which suggests that it prevents compromise of tissue integrity. Significant differences were found between protocols for sensation and grip strength. A higher-powered study is needed to investigate the effects of preoperative management on complication rates and functional outcomes.

Great Toe Transplantation.

Despite being relatively uncommon in the general population, thumb amputations cause severe disability. More than 3,300 thumb amputations occurred in the United States. The thumb makes up around 40% of the function of the hand. Therefore, losing it would result in significant medical, hospital, and societal costs. Thumb reconstruction surgery's primary goal is to restore grip strength, including the range of motion, fine and tripod pinch, power grasp, strength, and sensibility, while secondary goals include restoring hand aesthetics. In cases of thumb replantation, like-for-like replacement is possible; however, when thumb replantation is not possible, great toe-to-hand transplantation is the best available reconstruction. When compared with other reconstructive options such as osteoplastic thumb reconstruction, pollicization, second toe transplantation, and the use of a thumb prosthesis, great toe transplantation provides superior function and aesthetics. For restoring pinch, sensitivity, strength, and aesthetics of the hand with well-tolerated donor site morbidity, toe to thumb transplantation is regarded as the gold standard.

Management of exposed total knee prostheses with microvascular tissue transfer.

INTRODUCTION: Exposure of a knee endoprosthesis represents a limb-threatening condition, requiring long-term antibiosis, irrigation, and serial debridement to avoid knee arthrodesis or amputation. Although traditional orthopedic surgical doctrine mandates removal of exposed hardware under a dehisced wound, salvage of exposed prostheses using local muscle flap coverage has been reported. However, the complex three-dimensional geometry of the soft tissue surrounding the knee as well as the requirement for sustained local tissue levels of antibiotics to re-sterilize the hardware suggest that microvascular tissue transfer may constitute an advantageous means of wound coverage, increasing both limb and prosthesis salvage rates. We report our experience with free tissue transfer reconstruction of these complex wounds. METHODS: We treated 11 complex wounds with exposed total knee arthroplasty prostheses with free tissue transfer. Three of 11 patients had failed previous local muscular rotation flap coverage. Five latissimus dorsi muscle flaps and 6 rectus abdominis muscle flaps were used in our series. Wounds were closed after aggressive surgical debridement, antibiotic irrigation, and intravenous antibiosis. RESULTS: Eleven of 11 free flaps were successful (100%), and we achieved limb salvage in 11/11 limbs (100%) and prosthesis salvage in 10/11 knees (91%), with one prosthesis removed at an outside facility followed by knee arthrodesis. CONCLUSION: The advantages of microvascular tissue transfer are well suited to the treatment of exposed knee endoprostheses. The reliable rectus and latissimus flaps provide robust local perfusion to the wound, fill complex three-dimensional contour defects around knee implants, and lead to a high rate of salvage of both limbs and prostheses.