Free hemi-hamate arthroplasty: A review of donor site outcomes.

Introduction: The use of the dorsal hamate as a free osteochondral bone graft or vascularized bone flap has become the mainstay for large, comminuted middle phalanx volar lip fractures. To date, few studies have been conducted in the assessment of donor site morbidity for the hemi-hamate graft or flap, and none have discussed modes of repair or reconstruction of this donor site. Methods: A retrospective analysis of 14 hemi-hamate arthroplasty (HHA) procedures, including 6 vascularized and 8 non-vascularized grafts, from two surgeons was performed. Four hamate defect reconstruction techniques were utilized: no formal reconstruction, autologous bone grafting, gel foam, or synthetic bone substitute. The dorsal capsule was repaired with either extensor retinaculum grafting or by direct closure. Wrist range of motion, pain scores, and radiographic alignment were assessed. Results: At 6 months follow-up, all patients achieved full, pain-free wrist motion compared to the uninjured side, with visual analog scale pain scores of 0. Serial radiographs showed maintained carpal alignment without instability or subluxation. No differences based on the hamate defect reconstruction method or capsular repair technique was demonstrated. Conclusion: Safe return to pain free, unrestricted wrist function is achievable after HHA, regardless of hamate donor site management. Adequate dorsal capsular repair appears critical to prevent instability. Further study is needed to compare techniques, but choice may be guided by surgeon preference in the absence of clear evidence.

The Rectus Abdominis Perforator Turndown Flap for Preserving Rectus Continuity: A DIEP Alternative?

The deep inferior epigastric artery perforator (DIEP) flap for breast reconstruction has been popularized over the transverse rectus abdominis myocutaneous (TRAM) flap, as it spares rectus abdominis muscle and has low donor site morbidity. This progression to muscle preservation, however, has been associated with an increased difficulty in vascular dissection, perfusion-related complications, and lengthier surgical times. We pilot a technique that may achieve the benefits of the TRAM flap in terms of ease of dissection and vascularity, with the benefits of the DIEP flap in terms of maintaining rectus abdominis continuity. METHODS: A cohort of six consecutive patients underwent a free TRAM flap for reconstructive surgery. All patients underwent a segmental, periumbilical harvest of rectus abdominis muscle as part of flap design, and the segmental defect was reconstructed with an innervated rectus abdominis perforator turndown (RAPT) flap harvested supraumbilically. Postoperative assessment of rectus continuity was performed clinically, with muscle electromyography and ultrasound. RESULTS: In all six cases, there was successful TRAM flap transfer, with no flap-related complications. Rectus abdominis muscle reconstruction with the RAPT flap was achieved, with continuity and function of the rectus muscle confirmed. CONCLUSIONS: We describe the innervated RAPT flap for reconstitution of rectus continuity after TRAM flap harvest. This technique may achieve the benefits of the TRAM flap in terms of ease of dissection and flap vascularity, and the benefits of the DIEP flap in terms of maintaining rectus abdominis continuity.

The influence of skin tears following collagenase treatment of Dupuytren's disease on treatment outcomes.

This study investigated influence of skin tears on patient-reported outcomes of injection of collagenase clostridium histolyticum for Dupuytren's disease and association between extension deficit of digits before injection and skin tear after the injection. From 2016 to 2018, 391 Dupuytren's cords were treated in 184 patients in a prospective cohort study and the patients were evaluated before injection and six months after injection. Skin tears occurred in 50% of these patients. We found no significant differences in the patient-reported outcomes between patients with or without skin tears. A higher extension deficit before treatment was associated with significantly increased frequency of skin tears. We conclude that the incidence of skin tears after injection does not affect patient reported outcomes six months after collagenase injection, but the incidence of skin tears is significantly associated with the severity of pre-treatment finger extension deficits.Level of evidence: II.

Use of submental and submandibular free vascularized lymph node transfer for treatment of scrotal lymphedema: Report of two cases.

Genital lymphedema is a rare condition in males that can lead to difficulty in voiding, sexual function, hygiene, and mobility. Only several methods of treatment have been developed and studied, primarily focusing on restoring patency of diseased lymph channels or resection of affected tissue. We are the first to describe the surgical technique and our experience of using free submental and submandibular arterio-venous vascularized lymph node transfer specifically for the treatment of scrotal edema. We report on two patients who have undergone selective neck dissection of submental and submandibular lymph nodes based off the facial artery and vein. These vascularized lymph nodes were then transferred to the groin, with anastomosis to the deep inferior epigastric perforator artery and vein. The first patient, a 63 year old had initial pretreatment measurement of the anal verge to base of penis was 18 cm in length, and maximum circumference of scrotum 27 cm for the first patient, and 31-42 cm, respectively, for the second patient, a 66 year old. At 9-month review for the first patient and 6-month review for the second patient, both donor and recipient site wounds had healed. The anal verge to base of penis length had decreased to 16 cm, while maximum circumference of scrotum had decreased to 23 cm, and 25-38 cm, respectively, for the second patient. We have had good success with reducing the burden on patients using this novel technique, and hence it should be considered as a viable treatment methodology in appropriately selected patients.

Risk factors and timing of postoperative hematomas following microvascular breast reconstruction: A prospective cohort study.

BACKGROUND: Microvascular free tissue transfer has become the gold standard for breast reconstruction. While safe and reliable, there are operative complications, with hematomas developing under the free flap among the more common. These can compromise flap viability, lead to hemodynamic instability and infection. This study aims to identify predictors of hematomas following free-flap breast reconstruction. METHODS: A prospective study was undertaken of patients undergoing autologous free-flap breast reconstruction over a 4-year period. Precise times to hematoma formation, age, arterial and venous anastomosis time, and anastomosis length were recorded and analyzed for association with time to hematoma formation. RESULTS: One thousand two hundred twelve flaps were undertaken in 1,070 patients during the period of review. Seventy-one (5.8%) flaps were taken back to theater for hematomas. Immediate reconstruction had a significantly higher hematoma rate compared to delayed reconstruction 7.4% versus 5.2% (p < .001). It is noted that there were two main peaks for time to develop hematomas-less than 4 hr postsurgery and between 12 and 15 hr postsurgery. CONCLUSION: Hematomas are a complication, which must be managed with prompt return to theater to ensure flap salvage and patient stabilization. Predictors for hematoma are presented, with hematomas most likely encountered within the first 12 hr of surgery.

The use of Patient Reported Outcome Measures in assessing patient outcomes when comparing autologous to alloplastic breast reconstruction: a systematic review.

Breast reconstruction surgery after mastectomy has demonstrated positive psychological benefits, and is reflected in the number of patients undergoing the procedure, rising from 26.94% of patients after mastectomy in 2005, to 43.30% in 2014. Most of this is attributable to implant and expander-based reconstruction, with the rate of free flaps only increasing from 1.25% to 3.96% in this time period. Increasingly, breast cancer patients have higher survival rates. There is now an emphasis on Value Based Health Care (VBHC), which focusses on outcomes, and that can be measured by Patient Reported Outcome Measures (PROMs). To date, there has been no systematic review to analyse PROMs between those undergoing autologous or alloplastic reconstruction, using validated measurement tools, to determine if there is a preferred technique from the patient's perspective. We performed a systematic search on EMBASE, and together with bibliographic linkage, identified 146 articles. After screening and assessment of articles through abstract, and full article appraisal, 13 were identified suitable for inclusion in this systematic review. Using BREAST-Q, satisfaction of breast and psychosocial well-being were rated highly by the autologous group when compared to implant-based reconstruction. Physical well-being was less significant, with the least significant difference noted for sexual well-being. EORTC-QLQ-BR23/C30 PROMs noted similar trends. SF-36 however, noted virtually no difference between the two methods of reconstruction regarding similar PROM quality of life (QoL) domains. From the patient perspective, autologous reconstruction is either equal to or superior to implant-based reconstruction, and should be offered to all patients.

Incisional abdominal hernia repair with concomitant abdominoplasty: Maintaining umbilical viability.

INTRODUCTION: Abdominoplasty and abdominal hernia repair are often carried out in two-stage procedures, and those describing single-stage surgery require careful dissection to preserve often only partial blood supply to the umbilicus to maintain its viability. This paper aims to describe the surgical method of laparoscopic umbilical hernia repair in association with abdominoplasty. CASE PRESENTATION: A patient presents with an incisional hernia at a previous periumbilical port site of size 14 x 9 mm observed on ultrasound as well as a recurrent left inguinal hernia from previous bilateral laparoscopic inguinal hernia repair, oophorectomy, and laparoscopic cholecystectomy. A laparoscopic mesh repair of the hernia defect followed by abdominoplasty was performed. The patient made an uncomplicated recovery and was discharged home on day 5 post operation. There was complete healing of the umbilicus and remainder of the wounds. At 24-month follow-up, there was no recurrence of hernia. CONCLUSION: Previously documented methods of concomitant abdominoplasty and hernia repair use an open technique to repair the hernia. A laparoscopic approach is faster, but it poses a significant risk to the vascular supply to the umbilicus. This not only increases positive aesthetic outcomes and patient satisfaction but also reduces rates of postoperative complications and recovery time.

Cross-talk between MAP kinase pathways is involved in IGF-independent, IGFBP-6-induced Rh30 rhabdomyosarcoma cell migration.

Insulin-like growth factor binding protein-6 (IGFBP-6) inhibits the tumorigenic properties of IGF-II-dependent cancer cells by directly inhibiting IGF-II actions. However, in some cases, IGFBP-6 is associated with increased cancer cell tumorigenicity, which is unlikely to be due to IGF-II inhibition. The mechanisms underlying the contradictory actions of IGFBP-6 remain unclear. We recently generated an IGFBP-6 mutant that does not bind IGFs (mIGFBP-6) to address this issue. Although RD rhabdomyosarcoma cells express IGF-II, we previously showed that mIGFBP-6 promoted migration through an IGF-independent, p38-dependent pathway. We further studied the role of MAP kinases in IGFBP-6-induced migration of Rh30 rhabdomyosarcoma cells, which also express IGF-II. In these cells, mIGFBP-6 induced chemotaxis rather than chemokinesis. Both wild-type (wt) and mIGFBP-6 transiently induced phosphorylation of ERK1/2 and JNK1, but not p38. Inhibition of ERK1/2 phosphorylation completely prevented mIGFBP-6-induced ERK1/2 activation and cell migration, whereas a JNK inhibitor partially prevented migration. Interestingly, p38 pathway inhibition completely prevented mIGFBP-6-induced ERK1/2 and JNK1 activation and migration despite mIGFBP-6 not activating p38. Furthermore, blocking the ERK1/2 pathway also inhibited mIGFBP-6-induced JNK1 activation. In contrast, IGFBP-6 had no effect on Akt phosphorylation and an Akt inhibitor had no effect on migration. These results indicate that IGFBP-6 promotes Rh30 rhabdomyosarcoma chemotaxis in an IGF-independent manner, and that MAPK signaling pathways and their cross-talk play an important role in this process. Therefore, besides decreasing Rh30 cell proliferation by inhibiting IGF-II, IGFBP-6 promotes their migration via a distinct pathway. Understanding these disparate actions of IGFBP-6 may lead to the development of novel cancer therapeutics.