Surgical Management of Pachyonychia Congenita in a 3-Year-Old.

Pachyonychia congenita is a rare genetic disorder characterized by hypertrophic nail plates, hyperkeratotic nail beds, and thickened hyponychium of the fingers and toes, impairing manual dexterity and resulting in poor aesthetics. The current body of literature describes various treatment modalities, but no singular approach has been defined as the gold standard. In this case, the authors employed different surgical techniques for treating pachyonychia congenita to evaluate the most effective approach. A 3-year-old boy presented with hypertrophic nail growth involving all digits of both hands and feet. Three surgical procedures were performed on the patient's fingers and toes using germinal matrix excision (GME) alone, GME plus partial sterile matrix excision (pSME), or GME plus complete sterile matrix excision (cSME). The digits treated with GME + cSME exhibited no recurrence of nail growth. Those treated with GME alone exhibited recurrence of hypertrophic nail growth, although their growth slowed. Excision of GME + cSME prevented recurrence of hypertrophic nails, while GME alone or with pSME led to slower-growing hypertrophic nails. Complete excision of the germinal and sterile matrices with skin graft closure may be a definitive treatment for pachyonychia congenita, but further studies are needed to validate these findings.

Prevention of Venous Thromboembolism in Microvascular Surgery Patients Using Weight-Based Unfractionated Heparin Infusions.

BACKGROUND: Unfractionated heparin infusions are commonly used in microvascular surgery to prevent microvascular thrombosis. Previously, fixed-dose heparin infusions were believed to provide sufficient venous thromboembolism (VTE) prophylaxis; however, we now know that this practice is inadequate for the majority of patients. Anti-factor Xa (aFXa) level is a measure of unfractionated heparin efficacy and safety. This study evaluated the pharmacodynamics of weight-based dose heparin infusions and the impacts of real-time aFXa-guided heparin dose adjustments. METHODS: This prospective clinical trial enrolled adult microvascular surgery patients who received a weight-based heparin dose following a microsurgical procedure. Steady-state aFXa levels were monitored, and patients with out-of-range levels received dose adjustments. The study outcomes assessed were aFXa levels at a dose of heparin 10 units/kg/hour, time to adequate aFXa level, number of dose adjustments required to reach in-range aFXa levels, and clinically relevant bleeding and VTE at 90 days. RESULTS: Twenty-one patients were prospectively recruited, and usable data were available for twenty patients. Four of twenty patients (20%) had adequate prophylaxis at a heparin dose of 10 units/kg/hour. Among patients who received dose adjustments and achieved in-range aFXa levels, the median number of dose adjustments was 2 and the median weight-based dose was 11 units/kg/hour. The percentage of patients with in-range levels was significantly increased (65 vs. 15%, p = 0.0002) as a result of real-time dose adjustments. The rate of VTE at 90 days was 0%, and clinically relevant bleeding rate at 90 days was 15%. CONCLUSION: Weight-based heparin infusions at a rate of 10 units/kg/hour provide a detectable level of anticoagulation for some patients following microsurgical procedures, but most patients require dose adjustment to ensure adequate VTE prophylaxis.

Investigating the effects of flexor tendon shortening on active range of motion after finger tendon repair.

Evaluation of surgical effects is often done using simple cadaver experimentation. This study uses a robotic testbed to estimate the best-case clinical outcomes of flexor tendon shortening during repair surgery on cadaver hands. Nine fresh-frozen cadaver subjects were connected to an extrinsic index finger robotic muscle testbed and measurement system. The flexor digitorum profundus tendons were severed and surgically repaired at different shortening levels. The index finger's extrinsic tendons were robotically actuated using Hill-type muscle models to emulate the muscle force-length relationships. Extensor muscles were then activated to estimate the active range of motion (ROM) of the all-finger joints after surgery. The effects of metacarpophalangeal (MCP) joint extension limits and extensor muscle activation were also investigated. The resulting interphalangeal joint ROM was clinically graded. Active ROM of the finger decreases as tendon shortening increases ( ηp2=0.92 ), like passive ROM. This results in a clinical reduction of functionality grade from excellent to good at 10 mm of shortening. Blocking MCP joint ROM and extensor activation also showed significant effects on recovered ROM ( ηp2=0.72 and 0.86). Significant two-way interactions were also observed between shortening and MCP joint blocking ( ηp2=0.80 ) and between shortening and extensor activation ( ηp2=0.78 ). Results support clinical recommendations of limiting shortening to 10 mm. While this article provides additional experimental evidence for current surgical recommendations, it also validates a new robotic-cadaver methodology for predicting active hand recovery in terms of clinical measurements.

Optimal Dosing of Prophylactic Enoxaparin after Surgical Procedures: Results of the Double-Blind, Randomized, Controlled FIxed or Variable Enoxaparin (FIVE) Trial.

BACKGROUND: The accepted "one-size-fits-all" dose strategy for prophylactic enoxaparin may not optimize the medication's risks and benefits after surgical procedures. The authors hypothesized that weight-based administration might improve the pharmacokinetics of prophylactic enoxaparin when compared to fixed-dose administration. METHODS: The FIxed or Variable Enoxaparin (FIVE) trial was a randomized, double-blind trial that compared the pharmacokinetic and clinical outcomes of patients assigned randomly to postoperative venous thromboembolism prophylaxis using enoxaparin 40 mg twice daily or enoxaparin 0.5 mg/kg twice daily. Patients were randomized after surgery and received the first enoxaparin dose at 8 hours after surgery. Primary hypotheses were (1) weight-based administration is noninferior to a fixed dose for avoiding underanticoagulation (anti-factor Xa <0.2 IU/ml) and (2) weight-based administration is superior to fixed-dose administration for avoiding overanticoagulation (anti-factor Xa >0.4 IU/ml). Secondary endpoints were 90-day venous thromboembolism and bleeding. RESULTS: In total, 295 patients were randomized, with 151 assigned to fixed-dose and 144 to weight-based administration of enoxaparin. For avoidance of under anticoagulation, weight-based administration had a greater effectiveness (79.9 percent versus 76.6 percent); the 3.3 percent (95 percent CI, -7.5 to 12.5 percent) greater effectiveness achieved statistically significant noninferiority relative to the a priori specified -12 percent noninferiority margin (p = 0.004). For avoidance of overanticoagulation, weight-based enoxaparin administration was superior to fixed-dose administration (90.6 percent versus 82.2 percent); the 8.4 percent (95 percent CI, 0.1 to 16.6 percent) greater effectiveness showed significant safety superiority (p = 0.046). Ninety-day venous thromboembolism and major bleeding were not different between fixed-dose and weight-based cohorts (0.66 percent versus 0.69 percent, p = 0.98; 3.3 percent versus 4.2 percent, p = 0.72, respectively). CONCLUSION: Weight-based administration showed superior pharmacokinetics for avoidance of underanticoagulation and overanticoagulation in postoperative patients receiving prophylactic enoxaparin. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, I.

Creating an Outpatient, Local Anesthetic Hand Operating Room in a Resource-Constrained Ghanaian Hospital Builds Surgical Capacity and Financial Stability.

INTRODUCTION: Expanding surgical capacity is very difficult in resource-constrained countries. Financial input and additional physical operating room space are needed. The surgical patient volume exists, but the lack of operating room time causes postponement of cases. Hand surgery is particularly important as it improves patient function and allows for a timely return to the workforce after injury. Some hand surgery cases may be performed under local anesthesia with a very basic instrument set in a procedure room. This arrangement eliminates the need and financial burden of an equipped operating room and the need for an anesthesiologist. We hypothesized that performing hand surgery in a simple procedure room by a surgeon with knowledge of adequate local anesthesia could increase hand surgery capacity significantly in a low-income country. METHODS: This technique has been instituted at Komfo Anokye Teaching Hospital in Kumasi, Ghana, with the use of a single procedure room that was previously used for storage. A surgeon trained in performing wide-awake local anesthesia no tourniquet technique visited Komfo Anokye Teaching Hospital and provided lectures about hand surgery under local anesthesia and evidence-based sterility for 6 years. The number and type of cases performed in the procedure room were recorded for the first 11 months after it opened in 2017. RESULTS: For 11 months, use of this room had increased surgical capacity by 33 cases per month. Patient ages ranged from 2 months to 65 years. There have been 358 total cases performed, 240 of which were hand cases. This included washout of hand wounds (n = 87), tendon repair (n = 54) including a single tendon transfer, fracture pinning (n = 33), amputations (n = 24), trigger finger repair (n = 10), nerve repair (n = 6), congenital hand surgery (n = 4), and other (n = 22). Cost savings per case in the procedure room ranges from 500 cedis (US $100) to 2000 cedis (US $400). CONCLUSIONS: The simple procedure room runs more efficiently and is less costly compared with the main operating rooms. Although the case volume has increased surgical capacity significantly, costs to the hospital and patient have decreased. The hospital is reimbursed in a timely fashion for the procedures directly by the patient using this technique. The creation of a single procedure room for wide-awake local anesthesia no tourniquet hand surgery has helped address the issues of inadequate operating room space, time, and expense in resource-constrained Ghana.

Direct Comparison of Patient-completed and Physician-completed Caprini Scores for Plastic Surgery Patients.

We examined the ability of plastic surgery patients to perform their own venous thromboembolism (VTE) risk stratification using a previously validated patient-completed Caprini risk scoring sheet. METHODS: Patients' Caprini scores were obtained by an attending physician at an office visit through interview and chart review. Subsequently, patients independently completed a previously validated patient reported scoring sheet. We compared patient and physician reported Caprini scores by each Caprini subquestion and by the overall score. We described discordance of scores using frequencies and proportions, quantified the level of agreement using Cohen's Kappa coefficient, Spearman's correlation coefficient, and the Wilcoxon rank-sum test, and visualize scoring differences using Bland-Altman plots, where appropriate. RESULTS: We prospectively enrolled 50 patients. Only 24% (n = 12) of patients had exact matches in physician-completed and patient-completed Caprini scores. Among the 76% (n = 38) with discrepancies, 26 received a higher patient-reported score (median = 2 points, range 1-8 points) and 12 received a lower patient-reported score (median = -1.5 points, range -1 to -6 points). Existing venous thromboembolism prophylaxis guidelines support chemical prophylaxis for inpatients with Caprini scores ≥7. Among 38 patients with score discrepancies, 8 (21.1%) would have been incorrectly prescribed chemical prophylaxis and 4 (10.5%) would have been incorrectly denied chemical prophylaxis. CONCLUSIONS: Plastic surgery patients cannot reliably calculate their own 2005 Caprini scores. Reliance on patient completed scores alone would promote ~25% of patients receiving inappropriate prophylaxis strategies.

Adequacy of Fixed-Dose Heparin Infusions for Venous Thromboembolism Prevention after Microsurgical Procedures.

BACKGROUND: In microvascular surgery, patients often receive unfractionated heparin infusions to minimize risk for microvascular thrombosis. Patients who receive intravenous (IV) heparin are believed to have adequate prophylaxis against venous thromboembolism (VTE). Whether a fixed dose of IV heparin provides detectable levels of anticoagulation, or whether the "one size fits all" approach provides adequate prophylaxis against VTE remains unknown. This study examined the pharmacodynamics of fixed-dose heparin infusions and the effects of real-time, anti-factor Xa (aFXa) level driven heparin dose adjustments. METHODS: This prospective clinical trial recruited adult microvascular surgery patients placed on a fixed-dose (500 units/h) unfractionated heparin infusion during their initial microsurgical procedure. Steady-state aFXa levels, a marker of unfractionated heparin efficacy and safety, were monitored. Patients with out-of-range aFXa levels received protocol-driven real-time dose adjustments. Outcomes of interest included aFXa levels in response to heparin 500 units/h, number of dose adjustments required to achieve goal aFXa levels, time to reach goal aFXa level, and 90-day clinically relevant bleeding and VTE. RESULTS: Twenty patients were recruited prospectively. None of 20 patients had any detectable level of anticoagulation in response to heparin infusions at 500 units/h. The median number of dose adjustments required to reach goal level was five, and median weight-based dose to reach goal level was 11.8 units/kg/h. Real-time dose adjustments significantly increased the proportion of patients with in-range levels (60 vs. 0%, p = 0.0001). The 90-day VTE rate was 5% and 90-day clinically relevant bleeding rate was 5%. CONCLUSIONS: Fixed-dose heparin infusions at a rate of 500 units/h do not provide a detectable level of anticoagulation after microsurgical procedures and are insufficient for the majority of patients who require VTE prophylaxis. Weight-based heparin infusions at 10 to 12 units/kg/h deserve future study in patients undergoing microsurgical procedures to increase the proportion of patients receiving adequate VTE prophylaxis.

Salvage of Threatened Cardiovascular Implantable Electronic Devices: Case Series and Review of Literature.

BACKGROUND: The treatment of infected or exposed cardiac pacing and defibrillator devices is controversial. The conservative and widely accepted management calls for removal of the device and leads with immediate or delayed replacement of new components in a new site. Lead extraction carries a 2% major complication risk. In this article, we describe our experience with device salvage techniques and review the current literature. METHODS: This is a retrospective case series of consecutive patients with infected, exposed, or at-risk implanted cardiac devices that were treated with aggressive surgical debridement, local pocket irrigation, and revision. A comprehensive review of the literature regarding device infection management was performed. RESULTS: Ten patients with threatened devices were identified. Surgical revision with the aim to salvage the device was successful in 8 (80%) of 10 cases. Seventeen retrospective publications were reviewed. All indicate success with attempted salvage surgery, but heterogeneity of data limits formal meta-analysis and prevents management recommendations. CONCLUSIONS: Cardiac pacing and defibrillator devices with low-grade infection or threatened exposure may be salvaged without explantation. Despite the lack of clear management guidelines or data, plastic surgeons may be asked to assist in the management of threatened cardiac devices. Further prospective trials are required to evaluate the safety, efficacy, and cost-effectiveness of attempted implant salvage.

Combining Breast Reduction Techniques to Treat Gigantomastia in Ghana.

In this presentation of 2 consecutive cases of symptomatic juvenile breast hypertrophy in Ghana, we review the patient presentation, workup, and discuss outcomes following a combined technique of inferior pedicle stump with free nipple graft reduction mammoplasty. Surgical goals for treatment of gigantomastia were 2-fold: to resect adequate tissue to obtain symptomatic relief with improved quality of life, while avoiding a flat, boxy-appearing breast shape.

Twice-Daily Enoxaparin among Plastic Surgery Inpatients: An Examination of Pharmacodynamics, 90-Day Venous Thromboembolism, and 90-Day Bleeding.

BACKGROUND: Low anti-factor Xa level, indicative of inadequate enoxaparin dosing, has a significant association with 90-day venous thromboembolism events. The authors examined the pharmacodynamics of enoxaparin 40 mg twice daily and its correlation with anti-factor Xa level, postoperative venous thromboembolism, and bleeding. METHODS: Adult patients were admitted after plastic and reconstructive surgery and received enoxaparin 40 mg twice daily. Peak anti-factor Xa levels, which quantify enoxaparin's antithrombotic effect, were drawn, with a goal level of 0.2 to 0.4 IU/ml. Ninety-day symptomatic venous thromboembolism and clinically relevant bleeding were identified. RESULTS: The authors enrolled 118 patients who received enoxaparin 40 mg twice daily. Of these patients, 9.6 percent had low peak anti-factor Xa levels (<0.2 IU/ml), 62.6 percent had in-range peak anti-factor Xa levels (0.2 to 0.4 IU/ml), and 27.8 percent had high anti-factor Xa levels (>0.4 IU/ml). With enoxaparin 40 mg twice daily, 90.4 percent of patients received at least adequate prophylaxis. Patient weight predicted the rapidity of enoxaparin metabolism. Zero acute 90-day venous thromboembolism occurred. Eight patients (6.8 percent) had clinically relevant 90-day bleeding: clinical consequences ranged from cessation of enoxaparin prophylaxis to transfusion to operative hematoma evacuation. CONCLUSIONS: When enoxaparin 40 mg twice daily is provided, 90 percent of patients receive at least adequate venous thromboembolism prophylaxis (anti-factor Xa level >0.2 IU/ml). However, 27 percent of the overall population is overtreated (anti-factor Xa level >0.4 IU/ml). These pharmacodynamics data likely explain the low rate of 90-day acute venous thromboembolism (0 percent) and the high rate of clinically relevant bleeding (6.8 percent) observed. Future studies are needed to better optimize the risks and benefits of enoxaparin prophylaxis in plastic and reconstructive surgery patients. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The Impact of Once- versus Twice-Daily Enoxaparin Prophylaxis on Risk for Venous Thromboembolism and Clinically Relevant Bleeding.

BACKGROUND: Venous thromboembolism is a life- or limb-threatening complication that occurs in plastic surgery patients. At present, the optimal dose of enoxaparin that balances the risk of venous thromboembolism and the risk of medication-related adverse drug events-specifically, bleeding-remains unknown. METHODS: This study compared pharmacodynamic and clinical outcomes, including 90-day venous thromboembolism and 90-day clinically relevant bleeding, between two prospectively performed clinical trials whose sole difference was postoperative anticoagulation strategy. Patients in trial 1 received enoxaparin 40 mg once daily for the duration of inpatient stay, and patients in trial 2 received enoxaparin 40 mg twice daily for the duration of inpatient stay. The study also examined the potential impact of a weight-based twice-daily prophylaxis strategy to achieve in-range anti-factor Xa levels. RESULTS: The study compared 94 patients who received once-daily enoxaparin to 118 patients who received twice-daily enoxaparin. Twice-daily enoxaparin was associated with a significant decrease in 90-day acute venous thromboembolism (0 percent versus 5.3 percent; p = 0.012) and a nonsignificant increase in 90-day clinically relevant bleeding (6.8 percent versus 3.2 percent; p = 0.25). Twice-daily enoxaparin at 0.4 to 0.5 mg/kg may allow an increased proportion of patients to avoid both inadequate anticoagulation and overanticoagulation, based on anti-factor Xa levels. CONCLUSIONS: Twice-daily enoxaparin is superior to once-daily enoxaparin for 90-day acute venous thromboembolism risk reduction. Twice-daily enoxaparin may increase clinically relevant bleeding, although observed differences in this study were not significant. Weight-based twice-daily enoxaparin dosing may optimize the risks and benefits of prophylactic anticoagulation after plastic and reconstructive surgery. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Inadequate Enoxaparin Dosing Predicts 90-Day Venous Thromboembolism Risk among Plastic Surgery Inpatients: An Examination of Enoxaparin Pharmacodynamics.

BACKGROUND: Evidence-based plastic surgery guidelines support the effectiveness of once-daily enoxaparin prophylaxis. Despite prophylaxis, one in 25 highest risk patients has a venous thromboembolism event. The authors examined the pharmacodynamics of standard enoxaparin doses in plastic surgery patients to examine whether patient-level factors predict enoxaparin metabolism, whether inadequate enoxaparin dose predicts downstream venous thromboembolism events, and whether a pharmacist-driven dose-adjustment protocol was effective. METHODS: The authors recruited adult plastic surgery patients who received postoperative enoxaparin at 40 mg/day. Steady-state peak anti-factor Xa levels, a marker of enoxaparin effectiveness and safety, were determined. Patients with out-of-range anti-factor Xa levels had real-time dose adjustment based on a written protocol. Patients were followed for 90-day venous thromboembolism events. RESULTS: Ninety-four patients were recruited, and 44 percent had in-range peak anti-factor Xa levels in response to standard enoxaparin dosing. Patient-level factors including extent of surgical injury and gross weight were independent predictors of enoxaparin metabolism. Patients with low anti-factor Xa levels were significantly more likely to have 90-day venous thromboembolism (10.2 percent versus 0 percent; p = 0.041). Real-time dose adjustment allowed a significantly increased proportion of patients to have in-range levels (67.1 percent versus 44.3 percent; p = 0.002). CONCLUSIONS: Based on pharmacodynamic data, the majority of plastic surgery patients receive inadequate enoxaparin prophylaxis using fixed dosing. Patient-level factors can predict how patients will metabolize enoxaparin, and patients who receive inadequate enoxaparin prophylaxis are significantly more likely to have downstream venous thromboembolism events. Individualization of enoxaparin prophylaxis may minimize perioperative venous thromboembolism risk and further improve patient safety after plastic and reconstructive surgery procedures. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Importance of Postoperative Hydration and Lower Extremity Elevation in Preventing Deep Venous Thrombosis in Full Abdominoplasty: A Report on 450 Consecutive Cases Over a 37-Year Period.

BACKGROUND: Abdominoplasty is a common plastic surgery procedure and has a higher rate of postoperative deep venous thrombosis (DVT) than any other such surgery. DVT prevention remains an important topic in the plastic surgery community. Many surgeons avoid DVT chemoprophylaxis, because they are concerned about the risk of postoperative bleeding. OBJECTIVE: This study was performed in order to evaluate postoperative hydration and lower extremity elevation as two alternative methods of aiding DVT prevention after abdominoplasty. METHODS: Preoperative, intraoperative, and postoperative measures were taken to monitor patient hydration via urine output and to ensure adequate hydration by providing intravenous fluids. In addition, measures were taken throughout these three phases to ensure adequate lower extremity elevation. RESULTS: In a group of 450 consecutive full abdominoplasties from 1976 to 2013, the overall rate of patient DVT at 30 days following surgery was 0.22%. CONCLUSIONS: Hydration and lower extremity elevation are innocuous and risk-free adjuncts that improve venous return from the legs and lessen the chance of postoperative DVT.

Symptomatic elbow ganglion causing pronator syndrome.

SUMMARY: Descriptions of ganglion cysts date back to 400 BC. Ganglions causing peripheral nerve compression have been described most notably at the wrist. Ganglion compression of the median nerve at the elbow is rare. We report a case of a palmar elbow ganglion causing median nerve compression and the clinical presentation of pronator syndrome. After removal of the ganglion and median nerve decompression, the patient's symptoms fully resolved.

Surgical Excision of Non-Melanoma Skin Cancer in an Elderly Veteran's Affairs Population.

BACKGROUND: Non-melanoma skin cancer (NMSC) is the most common malignancy in the United States. Recommended treatment for NMSC remains surgical excision following a positive biopsy. Evidence of complete spontaneous regression of residual NMSC exists in the case of small lesions macroscopically removed by shave biopsy, but with a positive microscopic margin. The present study investigates the rate at which residual tumor is present at subsequent excisional biopsy, with the aim to assess if recommendation to forgo surgical excision can be made. METHODS: A total of 233 shave biopsies of basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) were performed during a 5-year period. All specimens included in the study were less than 2 cm in diameter, were macroscopically removed by shave biopsy, and had a positive initial microscopic margin. RESULTS: On subsequent surgical excisional biopsy, 42% of BCC specimens were negative for residual tumor, 38% had residual tumor, but the tumor was completely contained in the excised specimen, and 20% of the specimens had positive margin residual tumor. For SCC specimens, 73% were negative for residual tumor, 21% had residual tumor, but the tumor was completely contained in the excised specimen, and 6% of the specimens had positive margin residual tumor. CONCLUSIONS: Although reduction of residual tumor at reexcision is noted with both BCC and even more so with SCC, the rate at which this occurs is not sufficient that a general recommendation to forgo surgical excision can be made.

The impact of breast reduction surgery on low-back compressive forces and function in individuals with macromastia.

BACKGROUND: Macromastia can be a morbid condition causing affected women to endure shoulder pain, back pain, intertrigo, and shoulder grooving from the bra straps. Subjective symptoms are effectively relieved by reduction mammaplasty surgery. Reliable objective evidence is limited in evaluating benefits for this patient population. METHODS: Eleven women undergoing reduction mammaplasty were evaluated before surgery and 3 months after surgery. Evaluation modeled maximal compressive forces at the low back during an unconstrained lifting task using inverse dynamics and measured the subjective level of disability using the Functional Rating Index. RESULTS: The analysis of the kinematic and kinetic data demonstrated no significant difference in ankle, knee, and hip joint angles between pretests and posttests. In addition, the average maximum low-back compressive forces decreased 35 percent for the unconstrained lifting task, and the Functional Rating Index scores improved 76 percent following surgery. Greatest improvement was reported for the frequency of pain and travel. CONCLUSION: Reduction mammaplasty surgery produced objective improvement in low-back compressive forces and patients' reported level of functional disability.

Pelvic and abdominal wall reconstruction using human acellular dermis in the separation of ischiopagus tripus conjoined twins.

Separating ischiopagus conjoined twins presents the challenge of closing complex pelvic and abdominal wall defects. Traditionally, synthetic mesh has been used to reconstruct large body wall defects. Recent studies demonstrate increased complications while using synthetic mesh for complex musculofasciocutaneous defects. Acellular dermis is a bioprosthetic material that offers advantages over synthetic mesh. These include the ability to become revascularized and remodeled with host tissue, thereby increasing resistance to infection, providing tolerance to overlying skin breakdown, and augmenting strength. The authors describe the use of acellular dermis to reconstruct the pelvic and abdominal walls in the separation of 4-year-old female ischiopagus tripus conjoined twins. Acellular dermis has proven to be effective, as 18 months postoperatively there is no evidence of ventral herniation, wall weakness, or infection. Acellular dermis is a valuable and effective alternative to synthetic mesh for reconstructing large pelvic and abdominal wall defects.

Advances in extensor tendon diagnosis and therapy.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify clinical situations in which hand sonography can result in the detection of partial extensor tendon tears. 2. Identify the limitations of magnetic resonance imaging in diagnosing extensor tendon tears. 3. Understand the various postoperative therapeutic protocols for extensor tendon repair. 4. Choose the appropriate surgical repair and postoperative therapeutic protocol for a specific extensor tendon injury. 5. Identify the social and economic variables that may influence the availability and efficacy of the various postoperative therapeutic protocols. BACKGROUND: This article describes how the application of radiographic imaging facilitates the earlier detection and differentiation of extensor tendon injuries. Furthermore, it defines the best surgical procedure and postoperative therapy for a specific injury. METHODS: A literature review was performed of extensor tendon injury articles published since 1989. RESULTS: High-resolution sonography was more accurate than physical examination and magnetic resonance imaging in detecting extensor tendon injuries. Traditional postoperative static splinting was equivalent to early motion protocols for all uncomplicated thumb injuries and zone 1 to 3 injuries of the second through fifth digits. The only definable benefit of early motion therapy compared with static splinting was a quicker return to final function for proximal zones of injury in the second through fifth digits. The results of early active and passive motion, measured at 6 months, were comparable to those from static splinting. A higher rupture rate for early active motion and greater cost for early active and passive motion were noted compared with static splinting. CONCLUSIONS: High-resolution sonography allows identification of difficult to diagnose partial and complete extensor tendon injuries. Static splinting should remain the postoperative standard of care for extensor tendon injuries to the thumb and distal zones of injury for digits 2 through 5. The best therapy protocol for proximal zones of injury should be individualized based on social and economic variables.

Advances in extensor tendon diagnosis and therapy.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Identify clinical situations in which hand sonography can result in the detection of partial extensor tendon tears. 2. Identify the limitations of magnetic resonance imaging in diagnosing extensor tendon tears. 3. Understand the various postoperative therapeutic protocols for extensor tendon repair. 4. Choose the appropriate surgical repair and postoperative therapeutic protocol for a specific extensor tendon injury. 5. Identify the social and economic variables that may influence the availability and efficacy of the various postoperative therapeutic protocols. BACKGROUND: This article describes how the application of radiographic imaging facilitates the earlier detection and differentiation of extensor tendon injuries. Furthermore, it defines the best surgical procedure and postoperative therapy for a specific injury. METHODS: A literature review was performed of extensor tendon injury articles published since 1989. RESULTS: High-resolution sonography was more accurate than physical examination and magnetic resonance imaging in detecting extensor tendon injuries. Traditional postoperative static splinting was equivalent to early motion protocols for all uncomplicated thumb injuries and zone 1 to 3 injuries of the second through fifth digits. The only definable benefit of early motion therapy compared with static splinting was a quicker return to final function for proximal zones of injury in the second through fifth digits. The results of early active and passive motion, measured at 6 months, were comparable to those from static splinting. A higher rupture rate for early active motion and greater cost for early active and passive motion were noted compared with static splinting. CONCLUSIONS: High-resolution sonography allows identification of difficult to diagnose partial and complete extensor tendon injuries. Static splinting should remain the postoperative standard of care for extensor tendon injuries to the thumb and distal zones of injury for digits 2 through 5. The best therapy protocol for proximal zones of injury should be individualized based on social and economic variables.

Marjolin's ulcer: modern analysis of an ancient problem.

BACKGROUND: Marjolin's ulcer is a rare but highly aggressive squamous cell cancer that is most often associated with chronic burn wounds. Although many individual case reports exist, no thorough evaluation of Marjolin's ulcer patients has been conducted to date. METHODS: The authors present their experience with 10 patients encountered over a period of 15 years and analyze 25 previous publications, for a total of 443 patients diagnosed with Marjolin's ulcer. RESULTS: Although burn scar represents 76.5 percent of patients in the authors' review, venous stasis ulcers, traumatic wounds, osteomyelitis, and pressure sores are also represented as wound types that can undergo malignant degeneration. CONCLUSIONS: The authors' review suggests that there is much variability in the anatomical location of Marjolin's ulcers, with the majority occurring in wounds of the upper and lower extremities. Marjolin's ulcer appears to be preventable if early wound coverage is undertaken. Countries with limited access to medical treatment report a high number of Marjolin's ulcers compared with more developed regions.