Total Joint Arthroplasties in Transgender Patients: Unique Considerations for an Emerging Patient Population.

Currently, no studies exist on transgender patients undergoing orthopaedic procedures within the orthopaedic literature at large. This echoes a trend within medicine in general, where despite their unique characteristics, transgender patients are largely ignored in medical research. As gender reassignment surgery becomes more commonplace and these patients' age into joint arthroplasties, orthopaedic surgeons will rapidly be faced with treating this patient group. Unique considerations include medical comorbidities commonly associated with the patient population, deep vein thrombosis risk while on cross-gender hormone therapy, surgical positioning considerations, and social support implications after surgery. In addition, risk reductions for possible future gender reassignment surgeries include consideration for extended perioperative antibiotics and diligent surveillance for implant ingrowth issues. An emphasis is placed on being comfortable with transgender patients to ensure equal access to health care while ensuring understanding and accuracy in describing the risks of surgery that are unique to this patient population.

Back to the Beginning: An Algorithmic Approach to Neonatal Myelomeningocele Repair.

INTRODUCTION: Myelomeningoceles are formed by prenatal failure of neural tube closure and can cause hydrocephalus, motor abnormalities, and developmental delay. Although small defects are amenable to primary closure, larger defects often require complex reconstruction. Our goal was to identify factors associated with postoperative soft tissue complications and develop a systematic approach for myelomeningocele closure. METHODS: A retrospective review was performed at the Children's Memorial Hermann Hospital from January 2013 to January 2019. Patients were identified using International Classification of Diseases, Ninth Revision/Tenth Revision , codes for myelomeningocele. Cohorts were stratified by reconstruction type and defect location. Primary outcomes were incidence of complications including cerebrospinal fluid leak, superficial and deep infection, and wound dehiscence. In addition, we developed an algorithm to standardize closure approach for patients with myelomeningoceles. RESULTS: A total of 172 patients with myelomeningocele were identified with 73 patients undergoing postnatal repair. Overall, 72% of defects were >5 cm. Defects were in the lumbar (9%), sacral (8%), and junctional (83%) regions. Overall, 30.1% patients underwent lumbar myofascial repair with 39.7% requiring fasciocutaneous flaps. Larger defects (>5 cm) were more likely to be closed with complex fasciocutaneous flaps (82.8% vs 66.0%, P = 0.11). No significant differences were observed in complication rates. CONCLUSIONS: In this series, patients with larger myelomeningoceles appear to benefit from complex flap closure. We propose a 5-layer closure for patients with myelomeningocele including the routine use of a myofascial layer. Cutaneous closure technique should be tailored based on specific defect characteristics as outlined in our algorithm. This approach streamlines myelomeningocele repair while optimizing outcomes and decreasing downstream complications.

Use of the Adductor Magnus Muscle Free Flap for Lower-Extremity Soft Tissue Coverage: An Alternative to the Gracilis Muscle Flap With Unfavorable Vascular Anatomy.

BACKGROUND: The gracilis muscle free flap has proven to be a dependable tool for the reconstructive microsurgeon for coverage of small- to medium-sized lower-extremity soft tissue defects because of its reliable anatomy, ease of elevation, and minimal donor site morbidity. We describe our experience with the adductor magnus muscle free flap which we have utilized in cases when confronted with the rare situation in which the dominant vascular pedicle to the gracilis muscle is insufficient or absent. METHODS: We conducted a retrospective chart review of a single surgeon's experience (EG Melissinos) over an 18-year period of all patients that underwent adductor magnus muscle free flap coverage for lower-extremity soft tissue injuries. RESULTS: Twenty-four adductor magnus free flaps in 24 patients were performed over an 18-year period (2000-2018). All of the adductor magnus muscle free flaps were performed with the initial intention of gracilis muscle harvest for lower-extremity soft tissue coverage. The most common wound etiology was motor vehicle collisions (8 patients, 33%). All of the adductor magnus free flaps were used for coverage of lower-extremity wounds in the following anatomic locations: distal third (10 patients, 41.7%), ankle (11 patients, 45.8%) and foot (3 patients, 12.5%). All flaps were successful. There were minimal donor site complications. Limb salvage rate was 100%. CONCLUSIONS: Use of the adductor magnus muscle free flap is a reasonable alternative to the gracilis muscle in cases when unfavorable gracilis vascular anatomy is encountered intraoperatively. It can be easily and safely harvested within the same donor incision and permits reliable coverage of small- to medium-sized lower-extremity soft tissue defects while avoiding the morbidity of a secondary donor site.

Self-amputation of the Upper Extremity: A Case Report and Review of the Literature.

Indications for upper-extremity replantation include wrist-level and wrist-proximal amputations, due to the devastating loss of function incurred from these severe injuries. Decisions regarding replantation must be made expeditiously at these proximal levels in an effort to minimize ischemia time. This decision-making process becomes more complicated when a patient presents following intentional self-amputation of an extremity, especially in the setting of an associated mood disorder, psychiatric illness, and/or frank psychosis. A case report is presented involving a 28-year-old right-hand dominant male with untreated depression and recent suicidal ideation who sustained a complete left forearm amputation (distal-third forearm-level) from a self-inflicted circular saw injury. We conducted a PubMed literature search of other reported cases of intentional self-amputations of the hand and upper extremity. The patient underwent replantation of the left upper extremity. At six years postoperatively, the patient was extremely satisfied with the appearance and function of the replanted extremity. Dash score was 5.8 with a Chen Grade 1 (excellent) functional recovery. A literature search identified 16 cases of self-inflicted upper extremity amputation. One patient died at the scene. 87% (13/15) of patients presenting to the hospital were diagnosed with a psychiatric disorder (depression n = 6, bipolar n = 2, and schizophrenia n = 5). 67% (10/15) of these patients were also diagnosed with psychosis. Ten patients underwent replantation (nine at hand/wrist level and one at forearm level), all of which were viable postoperatively. Detailed functional outcome data were not reported in any of the cases. Four patients (40%) were pleased or satisfied with the outcome, but subjective outcomes were not reported for the other six patients. Intentional self-amputation of the hand/upper extremity is an extreme and uncommon act, often presenting with complex psychiatric issues. Although replantation is technically feasible in this patient population, long-term subjective and objective functional outcomes are largely unknown. Future study of this unique group of patients is needed to better assess patient-reported outcomes and functional outcomes of replantation, which could help guide decision making at the time of initial injury.