A Quantitative Evaluation of Functional Recovery after Traumatic Lower Extremity Salvage.

INTRODUCTION: Soft tissue reconstruction is a routine component of lower extremity trauma care and focus is increasingly being directed towards understanding functional outcomes. This study aims to quantify functional recovery and identify variables associated with functional outcomes of patients who undergo traumatic limb salvage. METHODS: A retrospective review was performed of patients with lower extremity traumatic injuries requiring vascularized soft tissue reconstruction at a Level 1 trauma center between July 2007-December 2015. Postoperatively, patients were administered the 36-Item Short Form Health Survey Version 2 (SF-36v2) and the Lower Extremity Functional Scale (LEFS) questionnaires by telephone. Demographics, perioperative variables, and postoperative outcomes were analyzed by univariate and bivariate analysis. RESULTS: Forty-two patients with 42 flaps and a mean of 12.7 months follow up were included in the study. Limb salvage was successful in 38 patients (90.5%). Patients ≥ 40 years old had significantly worse SF-36v2 scores in physical functioning (P ≤0.01) and mental health (P ≤0.05) than their younger counterparts. Patients who had pre-existing hypertension demonstrated significantly lower physical functioning (P ≤0.01). Role limitation due to emotional health was significantly lower in patients who were female (P ≤0.01) or required revision surgery (P ≤0.01). The mean LEFS score was 37.7 ± 18.5. CONCLUSIONS: Patients exhibited poor functional outcomes following major limb trauma with attempted limb salvage based on two validated patient reported outcomes measures (PROMs). Patient characteristics should be considered in evaluating candidates for reconstruction to optimize outcomes and to effectively counsel patients on their functional prognosis.

Functional Outcomes After Sauve-Kapandji Arthrodesis.

PURPOSE: The Sauve-Kapandji procedure (SK) combines a distal radioulnar joint (DRUJ) arthrodesis with the creation of an ulnar pseudarthrosis for the salvage of DRUJ instability or arthritis. Despite several published case series, there are limited data on postoperative functional outcomes. This study evaluates patient-reported outcomes of SK using a validated functional outcomes scale. METHODS: We performed a retrospective review of patients who underwent SK in 2 health care systems over 10 years (2008-2018). Preoperative and postoperative range of motion, Quick-Disabilities of the Arm, Shoulder, and Hand (QuickDASH) scores, and wrist plain film radiographic measurements were recorded. Preoperative and postoperative outcomes analyses and subgroup comparisons were performed. RESULTS: We included 57 patients in the study. Surgical indications included posttraumatic DRUJ arthritis (n = 35), rheumatoid arthritis (n = 10), degenerative DRUJ arthritis (n = 7), Madelung deformity (n = 3), psoriatic arthritis (n = 1), and giant cell tumor of bone (n = 1). During the first postoperative year, QuickDASH scores decreased from a mean of 52 before surgery to 28 at 12 months. The QuickDASH scores at final follow-up demonstrated significant improvement in patients with osteoarthritis and inflammatory arthritis. Supination significantly improved after surgery, from 48° to 74°, whereas wrist flexion, wrist extension, and pronation remained unchanged. Radiographically, significant postoperative decreases were seen in ulnar variance and McMurtry's translation index. The postoperative complication rate was 21%, including revision osteotomy in 4 patients (7.0%) and hardware removal in 4 patients (7.0%). No DRUJ nonunions were seen. CONCLUSIONS: The Sauve-Kapandji procedure for DRUJ salvage significantly improved patient-reported outcomes after 1 year and significantly improved supination. Similar functional improvements after SK were seen in both osteoarthritis and inflammatory arthritis. TYPE OF STUDY/LEVEL OF EVIDENCE: Therapeutic IV.

The Efficacy of Negative Pressure Wound Therapy and Antibiotic Beads in Lower Extremity Salvage.

BACKGROUND: Antibiotic beads and negative pressure wound therapy (NPWT) represent two methods of wound management used during staged debridement in the post-trauma limb salvage pathway. The efficacy of NPWT and antibiotic beads in preventing infection remains unclear. METHODS: This study is a retrospective review of patients with traumatic lower extremity open fractures who received NPWT and/or antibiotic beads before soft tissue reconstruction at an urban level 1 trauma center between August 2007 and December 2015. Patients with wound infections before application of NPWT and/or antibiotic beads were excluded. RESULTS: In 73 lower extremities requiring soft tissue coverage, 46 received antibiotic beads and 48 received NPWT. Overall infection rate was 15.1%. Use of antibiotic beads was associated with a decreased risk of infection (6.4% versus 30.7%; P = 0.01). Use of NPWT was associated with an increased risk of one or more complications (45.7% versus 4.2%; P = 0.001). The development of infection was associated with a greater period of time between application of antibiotic beads (22 ± 13 versus 12 ± 6 d, P = 0.01) or NPWT (23 ± 15 versus 10 ± 11 d, P = 0.004) and soft tissue coverage. Overall limb salvage rate was 95.9%; secondary amputation was associated with development of infection (P = 0.001) but not with use of NPWT or antibiotic beads. CONCLUSIONS: Antibiotic beads may prevent infections in patients awaiting soft tissue coverage of wounds. NPWT may contribute to a greater rate of complication. Limb salvage was successful in most cases regardless of method of wound management.

Carpal Translocation Following Dorsal Bridge Plate Fixation of Distal Radius Fractures: A Cadaveric Study.

Background Dorsal bridge plate fixation is an effective technique for stabilization of highly comminuted, complex distal radius fractures. However, it is unknown whether fixation to the second or third metacarpal is optimal. Given dorsal bridge plating spans the radiocarpal joint, it is unclear if the dorsal spanning plate affects carpal position. This study investigates differences in carpal translocation resulting from bridge plate distal fixation to either the second or third metacarpal. Methods Ten paired cadaveric upper extremities without evidence of gross deformity or prior surgery distal to the elbow were evaluated with three-view wrist fluoroscopic images for baseline radiographic measurements. An unstable distal radius fracture model was created via a volar approach using a 1-cm osteotomy. Following fracture creation, a dorsal bridge plate was applied with random to the second metacarpal on one limb, and the third metacarpal on the contralateral limb. Laterality for distal fixation was chosen randomly. Fluoroscopic images were repeated and radial inclination, radial height, radiocarpal angle, volar tilt, ulnar variance, radiolunate angle, radioscaphoid angle, radial rotation index, and carpal translocation were measured. Results Radial inclination, radial height, radiocarpal angle, volar tilt, ulnar variance, radiolunate angle, and radioscaphoid angle were not statistically different before and after fixation, or when comparing the second or third metacarpal fixation. Additionally, there was no difference in Taleisnik's ulnar translocation index, Chamay's ulnar translation index, or McMurtry's carpal translation index based on which metacarpal was used for distal fixation. Conclusions Dorsal bridge plate fixation of distal radius fractures restores preoperative physiologic measures of the radius, ulna, and carpus. Carpal translocation was similar when comparing distal fixation to the second or third metacarpal in distal radius fractures stabilized with a bridge plate. Level of Evidence This is a Level V, therapeutic study.

Effects of Perioperative Venous Thromboembolism on Outcomes in Soft Tissue Reconstruction of Traumatic Lower Extremity Injuries.

BACKGROUND: Venous thromboembolism (VTE), including deep vein thrombosis and pulmonary embolism, represents a significant perioperative complication. However, the outcomes of lower extremity salvage in the setting of perioperative VTE are not well reported. METHODS: A retrospective review of lower extremity trauma patients requiring soft tissue reconstruction between July 2007 and December 2015 at an urban trauma center was performed. Patients with clinically apparent VTE during inpatient stay were identified. Outcomes compared included success of limb salvage, flap survival, and flap complications. Comorbidities, injury characteristics and perioperative data were also compared between patients with and without VTE. RESULTS: One hundred ninety patients with lower extremity injuries underwent local and free flap procedures, with 12 (6.3%) patients developing clinically apparent VTE during hospitalization. Nine VTEs (75.0%) were diagnosed prior to soft tissue reconstruction, and 3 (25.0%) VTEs were diagnosed postreconstruction. The limb salvage rate in patients with VTE was 100%. There were no flap losses in patients with VTE, and the overall flap complication rate was similar between VTE and non-VTE groups (P = 0.26). However, there was an increased risk of postoperative hematoma in patients undergoing free flap transfer with diagnosed VTE compared with patients receiving free flaps without VTE (40.0% vs 2.6%, P = 0.02). Additionally, 1 patient died as a result of pulmonary embolism, and another patient experienced an ischemic stroke from a paradoxical embolism. CONCLUSIONS: These results suggest that successful limb salvage and flap survival may be achieved in the setting of perioperative VTE, although anticoagulation prophylaxis and treatment are critical in this population due to significant morbidity and mortality associated with VTE.

Functional outcomes of traumatic lower extremity reconstruction.

BACKGROUND: Lower extremity trauma accounts for over 300,000 injuries annually. While soft tissue transfer is a well-accepted practice for open fracture coverage, functional outcomes remain unclear. HYPOTHESIS: This study investigates functional outcomes following soft tissue reconstruction for open tibial fractures. MATERIALS AND METHODS: A retrospective review of a prospectively maintained database of open tibia fractures requiring soft tissue reconstruction was performed at an urban level 1 trauma center between October 2013 and March 2015. OUTCOMES: were evaluated using Pearson's chi square test with significant p value < 0.05. RESULTS: In 30 patients, fractures were graded Gustilo-Anderson type I (3.3%), 30% type II, 3.3% type IIIa, 53.3% type IIIb, and 10% type IIIc. Fixation was 56.7% plate and screw, 20% intramedullary nail, and 16.7% external fixator. Definitive closure was achieved in 43.3% through local rotational flap (38.5% gastrocnemius, 61.5% soleus), and in 56.7% by free tissue transfer (29.4% latissimus, 23.5% rectus, 17.6% ALT, 17.6% gracilis). In 10 patients, 70% returned to full ambulation, 30% required an assistance device, and 50% achieved union in 6 months. Local flap use was predictive of ambulation at discharge. DISCUSSION: Following lower extremity fracture, 70% of patients returned to pre-injury function. Use of a local tissue flap was associated with early ambulation.

Peripheral nerve injury with Nexplanon removal: case report and review of the literature.

BACKGROUND: Implantable devices offer convenient, long-acting, and reversible contraception. Injury to the peripheral nerves and blood vessels have been reported as rare complications of implantation and extraction. CASE PRESENTATION: We present a case of ulnar nerve injury in a 21-year-old woman from attempted in-office removal of a deeply implanted Nexplanon® device. The injury resulted in an ulnar nerve palsy requiring surgical exploration, neuroma excision, and sural nerve cable grafting. CONCLUSIONS: In-office attempts to remove contraceptive implants that are deep or have migrated can cause iatrogenic nerve injury. Devices that are non-palpable, deep, or migrated should be imaged before formal surgical exploration and removal. Any patient with neurologic symptoms after placement or after attempted removal requires prompt diagnosis and referral to a peripheral nerve surgeon.

A Systematic Review of Prognostic Factors for Sensory Recovery After Digital Nerve Reconstruction.

BACKGROUND: Successful digital nerve repair is crucial in preventing painful neuroma formation and restoring sensory function after traumatic hand injury. The purpose of this study is to identify prognostic factors affecting sensory recovery following digital nerve reconstruction. METHODS: A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines including studies reporting patients 18 years and older, greater than 10 reconstructed digital nerves, and greater than or equal to 3 months follow-up. Studies with proximal nerve injuries in the same distribution or inadequate sensory data were excluded. Included studies were evaluated by methodological index for nonrandomized studies score. Possible predictors were examined using the t test and 1-way analysis of variance with α ≤ 0.05. RESULTS: Twenty-five studies met the inclusion criteria, consisting of 818 surgically reconstructed digital nerves (mean age, 38 years; 78% male) with a mean ± SD defect length of 1.5 ± 0.5 cm. Mean follow-up time was 22 months. Fifty-six percent of patients presented with concomitant injuries to tendons (31%) and the digital artery (13%). Mean ± SD time to surgical repair was 36 ± 73.8 days. Reconstructive techniques included 35% end-to-end primary neurorrhaphy, 31% nerve grafts, and 11% synthetic conduits. Postoperatively, 81% of the patients demonstrated sensory recovery of S3+/S4, with 45% complaining of hyperesthesia. Nerve reconstructions performed within 15 days of injury had significantly better static 2-point discrimination than delayed procedures (P = 0.02). Static 2-point discrimination measurements were also significantly better for shorter defect lengths (<1.3 cm, P = 0.05). No significant functional differences were found across age, follow-up time, injured digit or side, nor reconstructive technique. CONCLUSIONS: Digital nerve reconstruction has good to excellent sensory recovery in up to 81% of patients with improved results in nerve gaps less than 1.3 cm. Performing the reconstruction within 15 days of injury is also correlated with improved sensory recovery.

Alternatives to Autologous Bone Graft in Alveolar Cleft Reconstruction: The State of Alveolar Tissue Engineering.

Alveolar cleft reconstruction has historically relied on autologous iliac crest bone grafting (ICBG), but donor site morbidity, pain, and prolonged hospitalization have prompted the search for bone graft substitutes. The authors evaluated bone graft substitutes with the highest levels of evidence, and highlight the products that show promise in alveolar cleft repair and in maxillary augmentation. This comprehensive review guides the craniofacial surgeon toward safe and informed utilization of biomaterials in the alveolar cleft.A literature search was performed to identify in vitro human studies that fulfilled the following criteria: Level I or Level II of evidence, ≥30 subjects, and a direct comparison between a autologous bone graft and a bone graft substitute. A second literature search was performed that captured all studies, regardless of level of evidence, which evaluated bone graft substitutes for alveolar cleft repair or alveolar augmentation for dental implants. Adverse events for each of these products were tabulated as well.Sixteen studies featuring 6 bone graft substitutes: hydroxyapatite, demineralized bone matrix (DBM), ß-tricalcium phosphate (TCP), calcium phosphate, recombinant human bone morphogenic protein-2 (rhBMP-2), and rhBMP7 fit the inclusion criteria for the first search. Through our second search, the authors found that DBM, TCP, rhBMP-2, and rhBMP7 have been studied most extensively in the alveolar cleft literature, though frequently in studies using less rigorous methodology (Level III evidence or below). rhBMP-2 was the best studied and showed comparable efficacy to ICBG in terms of volume of bone regeneration, bone density, and capacity to accommodate tooth eruption within the graft site. Pricing for products ranged from $290 to $3110 per 5 mL.The balance between innovation and safety is a complex process requiring constant vigilance and evaluation. Here, the authors profile several bone graft substitutes that demonstrate the most promise in alveolar cleft reconstruction.

Combined Direct and Indirect Cerebral Revascularization Using Local and Flow-Through Flaps.

BACKGROUND: Extracranial-intracranial bypass is indicated in ischemic disease such as moyamoya, certain intracranial aneurysms, and other complex neurovascular diseases. In this article, we present our series of local and flow-through flaps for cerebral revascularization as an additional tool to provide direct and indirect revascularization and/or soft tissue coverage. METHODS: A retrospective review of a prospectively maintained database was performed identifying nine patients. Ten direct arterial bypass procedures with nine indirect revascularization and/or soft tissue reconstruction were performed. RESULTS: Indications for arterial bypass included intracranial aneurysm (n = 2) and moyamoya disease (n = 8). Indications for soft tissue transfer included infected cranioplasty (one) and indirect cerebral revascularization (eight). Four flow-through flaps and five pedicled flaps were used including a flow-through radial forearm fasciocutaneous flap (one), flow-through radial forearm fascial flaps (three), and pedicled temporoparietal fascial (TPF) flaps with distal end anastomosis (five). The superficial temporal vessels (seven) and facial vessels (two) were used as the vascular inflow. Arterial bypass was established into the middle cerebral artery (six) and anterior communicating artery (three). There were no intraoperative complications. All flaps survived with no donor-site complications. In one case of flow-through TPF flap, the direct graft failed, but the indirect flap remained vascularized. CONCLUSION: Local and flow-through flaps can improve combined direct and indirect revascularization and provide soft tissue reconstruction. Minimal morbidity has been encountered in early outcomes though long-term results remain under investigation for these combined neurosurgery and plastic surgery procedures. LEVEL OF EVIDENCE: The level of evidence is IV.

Investigation Into the Optimal Number of Intercostal Nerve Transfers for Musculocutaneous Nerve Reinnervation: A Systematic Review.

BACKGROUND: The purpose of this study was to systematically review outcomes following intercostal nerve (ICN) transfer for restoration of elbow flexion, with a focus on identifying the optimal number of nerve transfers. METHODS: A systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines to identify studies describing ICN transfers to the musculocutaneous nerve (MCN) for traumatic brachial plexus injuries in patients 16 years or older. Demographics were recorded, including age, time to operation, and level of brachial plexus injury. Muscle strength was scored based upon the British Medical Research Council scale. RESULTS: Twelve studies met inclusion criteria for a total of 196 patients. Either 2 (n = 113), 3 (n = 69), or 4 (n = 11) ICNs were transferred to the MCN in each patient. The groups were similar with regard to patient demographics. Elbow flexion ≥M3 was achieved in 71.3% (95% confidence interval [CI], 61.1%-79.7%) of patients with 2 ICNs, 67.7% (95% CI, 55.3%-78.0%) of patients with 3 ICNs, and 77.0% (95% CI, 44.9%-93.2%) of patients with 4 ICNs ( P = .79). Elbow flexion ≥M4 was achieved in 51.1% (95% CI, 37.4%-64.6%) of patients with 2 ICNs, 42.1% (95% CI, 29.5%-55.9%) of patients with 3 ICNs, and 48.4% (95% CI, 19.2%-78.8%) of patients with 4 ICNs ( P = .66). CONCLUSIONS: Previous reports have described 2.5 times increased morbidity with each additional ICN harvest. Based on the equivalent strength of elbow flexion irrespective of the number of nerves transferred, 2 ICNs are recommended to the MCN to avoid further donor-site morbidity.

Soft tissue reconstruction and salvage of infected fixation hardware in lower extremity trauma.

BACKGROUND: Tibial fracture management may be complicated by infection of internal fixation hardware (iIFH) resulting in increased morbidity and amputation rate. When iIFH removal is not possible, salvage of the lower extremity is attempted through debridement, antibiotics, and vascularized soft tissue coverage. This study investigates lower extremity salvage with retention of iIFH. METHODS: Demographics, outcomes, and bacterial speciation in patients with tibial fractures at a level 1 trauma center from 2007 to 2014 were reviewed. The primary outcome was infection suppression, while secondary outcomes included limb salvage, amputation, and osseous union. RESULTS: Twenty-five patients underwent soft tissue reconstruction for salvage of iIFH. Average age was 41, 19 (76%) were male, average BMI 30.1 kg/m2 , 10 (40%) patients smoked. Tibial fractures were closed in 8 (32%), Gustilo-Anderson grade I in 1 (4%), II in 8 (32%), IIIb in 5 (20%), and IIIc in 1 (4%). Staphylococcus was most commonly cultured with 11 (44%) demonstrating methicillin-resistance. Soft tissue reconstruction was performed by local flap in 15 (60%) and free flap in 10 (40%). At an average of 16.1 months, 19 (76%) hardware salvage patients demonstrated clinical suppression of infection, 11 of 19 (57.9%) patients had bony union, and 24 (96%) maintained a salvaged limb. One patient was amputated for recurrent infection. CONCLUSIONS: Following complex, infected tibial fractures, salvage of the lower extremity may be attempted even when iIFH cannot be removed. Thorough debridement, antibiotics, and vascularized soft tissue may suppress infection long enough to facilitate osseous union and subsequent removal of iIFH.

Redefining the Anatomic Boundaries for Safe Dissection of the Skin Paddle in a Gracilis Myofasciocutaneous Free Flap: An Indocyanine Green Cadaveric Injection Study.

The gracilis free flap remains a versatile option in the reconstructive ladder. The flap itself can be harvested with or without a skin paddle. The gracilis myocutaneous free flap, however, is known for partial skin flap necrosis, especially in the distal one-third of the skin island. The gracilis myofasciocutaneous flap has been previously described as a technique to improve perfusion to the skin by harvesting surrounding deep fascia in a pedicled flap. However, limitations to this study required injection of multiple pedicles to demonstrate its perfusion. We demonstrate a novel technique using a cadaveric model that shows perfusion through injection via a single dominant pedicle (medial circumflex) with a large cutaneous paddle (average 770 cm2) with included deep fascia, using indocyanine green and near-infrared imaging. For comparison, we are also able to confirm the lack of perfusion to the distal cutaneous paddle when the fascia is not harvested, correlating with previous findings and ink injection studies. This novel technique is versatile, relatively inexpensive, and can demonstrate perfusion patterns via perforasomes that were otherwise not possible from previous techniques. Additionally, real-time imaging is possible, helping to elucidate the sequence of flow into the flap and potentially predict areas of flap necrosis.

Preoperative surgical rehearsal using cadaveric fresh tissue surgical simulation increases resident operative confidence.

BACKGROUND: Rehearsal is an essential part of mastering any technical skill. The efficacy of surgical rehearsal is currently limited by low fidelity simulation models. Fresh cadaver models, however, offer maximal surgical simulation. We hypothesize that preoperative surgical rehearsal using fresh tissue surgical simulation will improve resident confidence and serve as an important adjunct to current training methods. METHODS: Preoperative rehearsal of surgical procedures was performed by plastic surgery residents using fresh cadavers in a simulated operative environment. Rehearsal was designed to mimic the clinical operation, complete with a surgical technician to assist. A retrospective, web-based survey was used to assess resident perception of pre- and post-procedure confidence, preparation, technique, speed, safety, and anatomical knowledge on a 5-point scale (1= not confident, 5= very confident). RESULTS: Twenty-six rehearsals were performed by 9 residents (PGY 1-7) an average of 4.7±2.1 days prior to performance of the scheduled operation. Surveys demonstrated a median pre-simulation confidence score of 2 and a post-rehearsal score of 4 (P<0.01). The perceived improvement in confidence and performance was greatest when simulation was performed within 3 days of the scheduled case. All residents felt that cadaveric simulation was better than standard preparation methods of self-directed reading or discussion with other surgeons. All residents believed that their technique, speed, safety, and anatomical knowledge improved as a result of simulation. CONCLUSIONS: Fresh tissue-based preoperative surgical rehearsal was effectively implemented in the residency program. Resident confidence and perception of technique improved. Survey results suggest that cadaveric simulation is beneficial for all levels of residents. We believe that implementation of preoperative surgical rehearsal is an effective adjunct to surgical training at all skill levels in the current environment of decreased work hours.

A Critical Appraisal of Vascularized Bone Grafting for Scaphoid Nonunion.

Background Vascularized bone grafting (VBG) has the potential to yield reliable results in scaphoid nonunion; however, results across studies have been highly variable. This study critically evaluates surgical techniques, fracture location, and patient selection in relation to radiographic, clinical, and patient-centered outcomes after VBG for scaphoid nonunion. Methods We conducted a systematic review of the literature for the use of VBG in scaphoid nonunion. Physical examination, radiographic, and patient-centered outcomes were assessed. Four substratifications were performed: the location of scaphoid nonunion, pedicled versus free technique, Kirschner wire (K-wire) versus screw fixation, and VBG done as a primary versus revision procedure. Results A total of 41 publications were included in final analysis. VBG had an 84.7% union rate at 13 weeks after surgery. On an average, 89% of patients returned to preinjury activity levels by 18 weeks after surgery and 91% of patients reported satisfaction with the procedure. Proximal pole nonunions demonstrated similar union rates but lower functionality scores compared with nonunions across all regions of the scaphoid. Pedicled techniques demonstrated slightly improved range of motion compared with free technique. K-wire versus screw fixation demonstrated significantly higher union rates and faster union times. There were no differences in outcomes for VBG done as a primary versus revision procedure. Conclusion VBG serves as a viable option for the treatment of scaphoid nonunion, with consistent union rates in addition to significantly improved postoperative patient functionality. The fixation of these vascularized bone grafts with K-wires versus screw fixation may result in superior radiologic outcomes. Level of Evidence Therapeutic, Level III, systematic review.

Vascularized Bone Grafting in Scaphoid Nonunion: A Review of Patient-Centered Outcomes.

Background: The radiographic and clinical outcomes following vascularized bone grafting (VBG) for scaphoid nonunion have previously been reported in the literature; however, few studies report on patient-derived outcomes. The purpose of this study was to determine the effect of VBG for scaphoid nonunion on patient-derived outcomes. Methods: The MEDLINE and PubMed databases were queried for the use of VBG in scaphoid nonunion. We included studies that reported on patient-derived outcomes. We excluded studies with less than 10 patients or less than 6 months of follow-up. The primary outcomes assessed included functionality, percent and time to return to preinjury activity, postoperative pain, and patient satisfaction. Results: Twenty-six articles described the outcomes of 520 patients with an average of 19.3 patients per study. Functionality was most commonly assessed by the Mayo Modified Wrist Score and Disabilities of the Arm, Shoulder and Hand scores, which improved by 53.1% and 81.7% postoperatively, respectively. Within 16 weeks, 90.3% of patients returned to their previous occupation or sporting activity. Pain was most commonly reported using a 0 to 10 visual analog scale and improved 4-fold postoperatively. Complete satisfaction was reported by 92% of patients. The most common complications were superficial infections (1.56%), neuropathic pain (1.56%), and complex regional pain syndrome (1.25%). Conclusions: VBG for scaphoid nonunion results in the improvement of patient-derived outcomes, and high rates of return to preinjury activity levels and patient satisfaction. Multiple metrics of patient-derived outcomes were utilized by the studies in our review without a clear consensus as to which metric is most responsive and accurate.

Outcomes of Soft Tissue Reconstruction for Traumatic Lower Extremity Fractures with Compromised Vascularity.

Traumatic lower extremity fractures with compromised arterial flow are limb-threatening injuries. A retrospective review of 158 lower extremities with traumatic fractures, including 26 extremities with arterial injuries, was performed to determine the effects of vascular compromise on flap survival, successful limb salvage and complication rates. Patients with arterial injuries had a larger average flap surface area (255.1 vs 144.6 cm2, P = 0.02) and a greater number of operations (4.7 vs 3.8, P = 0.01) than patients without vascular compromise. Patients presenting with vascular injury were also more likely to require fasciotomy [odds ratio (OR): 6.5, confidence interval (CI): 2.3-18.2] and to have a nerve deficit (OR: 16.6, CI: 3.9-70.0), fracture of the distal third of the leg (OR: 2.9, CI: 1.15-7.1) and intracranial hemorrhage (OR: 3.84, CI: 1.1-12.9). After soft tissue reconstruction, patients with arterial injuries had a higher rate of amputation (OR: 8.5, CI: 1.3-53.6) and flap failure requiring a return to the operating room (OR: 4.5, CI: 1.5-13.2). Arterial injury did not correlate with infection or overall complication rate. In conclusion, arterial injuries resulted in significant complications for patients with lower extremity fractures requiring flap coverage, although limb salvage was still effective in most cases.

Optimizing Outcomes following Total and Subtotal Tongue Reconstruction: A Systematic Review of the Contemporary Literature.

Background More than 45,000 Americans are diagnosed with oropharyngeal cancer annually and multimodal treatment often requires wide excision, lymphadenectomy, chemotherapy, and radiation. Total and subtotal lingual resection severely impairs speech, swallow, and quality of life (QoL). This study investigates functional outcomes and QoL following subtotal and total tongue resection with free tissue transfer reconstruction. Materials and Methods A systematic review of the English language literature was performed using PubMed, Ovid, Embase, and Cochrane databases based on predetermined inclusion/exclusion criteria. Included studies were reviewed for surgical technique, adjuvant treatment, surgical and functional outcomes, and QoL. Results From an initial search yield of 1,467 articles, 22 studies were included for final analysis. Speech intelligibility was correlated with the volume and degree of protuberance of the neotongue. Adjuvant therapy (radiation) and large tumor size were associated with worse speech and swallow recovery. At 1 year follow-up, despite 14 to 20% rates of silent aspiration, 82 to 97% of patients resumed oral feeding. Neurotized flaps have been demonstrated to improve flap sensation but have not yet demonstrated any significant impact on speech or swallow recovery. Finally, many patients continue to experience pain after surgery, but patient motivation, family support with physician, and speech therapist follow-up are associated with improved QoL scores. Conclusion Tongue reconstruction is dictated by the amount of soft tissue resection. Taking into consideration the most common factors involved after tongue resection and reconstruction, further studies should focus on more objective measurements to offer solutions and maximize final outcomes.

Surgical research using national databases.

Recent changes in healthcare and advances in technology have increased the use of large-volume national databases in surgical research. These databases have been used to develop perioperative risk stratification tools, assess postoperative complications, calculate costs, and investigate numerous other topics across multiple surgical specialties. The results of these studies contain variable information but are subject to unique limitations. The use of large-volume national databases is increasing in popularity, and thorough understanding of these databases will allow for a more sophisticated and better educated interpretation of studies that utilize such databases. This review will highlight the composition, strengths, and weaknesses of commonly used national databases in surgical research.