Outcome comparison between muscle and fasciocutaneous flaps after secondary orthopedic procedures.

Lower extremity wounds associated with fractures and bony defects often require secondary orthopedic procedures after flap coverage has been performed. In this study, we compare complications between muscle and fasciocutaneous flaps after secondary orthopedic procedures. A retrospective chart review study of all lower extremity soft tissue reconstructions by a single surgeon over seven years yielded a subgroup of patients who underwent secondary orthopedic procedures, including hardware removal, hardware revision, and bone grafting after flap reconstruction. Of 355 lower extremity, soft tissue reconstructions for orthopedic coverage performed in the time period studied, 102 patients underwent secondary orthopedic procedures after flap reconstruction. Of these, 54 received muscle flaps (52.94%), and 48 received fasciocutaneous flaps (47.06%). Using this subgroup of 102 patients, we compared muscle and fasciocutaneous flaps using three categories of wound complications following these secondary procedures: There were no superficial wounds requiring local wound care only in the muscle flap group (0%, n = 0) versus 4.17% (n = 2; p = 0.130) in the fasciocutaneous flap group. There were 2 lost flaps requiring surgical debridement and additional skin grafting in the muscle flaps group (3.70%) versus 2 (4.17%; p = 0.904) in the fasciocutaneous flap group. In the third category, flap loss requiring additional soft tissue reconstruction was 18.52% (n = 10) in the muscle group versus 2.08% (n = 1; p = 0.008) in the fasciocutaneous flap group. Our data support the existing literature indicating that fasciocutaneous flaps can tolerate secondary procedures better than muscle flaps and should initially be considered in patients with higher probability of needing additional orthopedic procedures after reconstruction.

Blast Injury to the Hand: Assessing the Injury Pattern and Functional Outcome of the Thumb.

BACKGROUND: In the United States, approximately 30% of about 10,000 annual blast injuries involve the hand, causing a broad spectrum of injury severity. The first web space is typically most severely affected. As the carpometacarpal (CMC) joint is critical to the unique function of the thumb, we evaluated typical patterns of injury to this joint, subsequent salvageability and functional outcomes of the thumb. METHODS: We conducted a retrospective chart review on patients with blast injuries to the hand from January 1995 through July 2019 and excluded penetrating trauma. We assessed hand function as reported in occupational therapy records. Injury severity was classified independently by structures. RESULTS: Twenty-one patients were included, two with bilateral injuries, for a total of 23 hands. Eighteen patients had injuries to one or both thumbs, for a total of 20 thumbs evaluated. Average follow-up was 1.58 years. Most injuries qualified as severe in at least one category: soft tissue, neurovascular, or bone/joint. All 10 CMC joint dislocations required surgical fixation and pinning. Eight patients had applicable occupational therapy notes available. Severely injured thumbs had statistically significant decreased range of motion (ROM) at the interphalangeal joint, metacarpophalangeal joint and with radial abduction compared to mildly injury thumbs (P value 0.02, 0.03, 0.04, respectively). CONCLUSIONS: Blast injury to the hand often results in severe deficits, frequently affecting thumb functionality and irreversibly altering occupational capabilities. Half the patients studied had severe damage to the thumb CMC joint. Objectively, severely injured thumbs had significantly worse ROM than mildly injured thumbs.

Revision Targeted Muscle Reinnervation Improves Secondary Pain Insult in an Upper Extremity Amputee: A Case Report.

Targeted muscle reinnervation (TMR) has been shown to improve phantom and neuropathic pain in both the acute and chronic amputee population. Through rerouting of major peripheral nerves into a newly denervated muscle, TMR harnesses the plasticity of the brain, helping to revert the sensory cortex back toward the preinsult state, effectively reducing pain. We highlight a unique case of an above-elbow amputee for sarcoma who was initially treated with successful transhumeral TMR. Following inadvertent nerve biopsy of a TMR coaptation site, his pain returned, and he was unable to don his prosthetic. Revision of his TMR to a more proximal level was performed, providing improved pain and function of the amputated arm. This is the first report to highlight the concept of secondary neuroplasticity and successful proximal TMR revision in the setting of multiple insults to the same extremity.

Vascularized Olecranon Bone Graft: An Anatomical Study and Novel Technique.

PURPOSE: Autologous bone grafting is commonly used in reconstructive hand surgery. Various sources of nonvascularized autologous bone grafts have been described in the literature. However, in some situations, a vascularized bone graft may be needed. Popular vascularized bone grafts are taken from the distal radius, iliac crest, and medial femoral condyle. The purpose of this study was to examine the feasibility of harvesting a free vascularized bone flap from the proximal ulna. METHODS: Latex was injected via the brachial artery to facilitate visualization of perforators in 10 cadaveric specimens. Dissections were performed of the olecranon; all periosteal perforators were noted, and their lengths and diameters recorded. Corticocancellous bone flaps with their supplying pedicles were harvested. Three additional fresh specimens were injected with india ink via the pedicles to demonstrate perfusion of the harvested bone flap. RESULTS: Consistent vascular anatomy supplied the olecranon. A perforator from the posterior ulnar recurrent artery supplied the proximal ulna and olecranon, from which a vascularized bone flap can be harvested. Branches to the flexor carpi ulnaris muscle may allow chimeric flaps to be harvested. Average pedicle length was 5.8 cm and average pedicle diameter was 2.4 mm. India ink injection of the pedicles showed perfusion of the periosteum as well as intraosseous cancellous bone. CONCLUSIONS: A vascularized olecranon free flap can be harvested based on the posterior ulnar recurrent artery. Vascular anatomy is consistent and flap harvest is simple and straightforward in all cadaveric specimens. CLINICAL RELEVANCE: A vascularized olecranon free flap represents a potential new surgical option when vascular bone flap reconstruction is considered.

Distally Based Pedicled Flexor Carpi Ulnaris Muscle Flap: An Anatomical Study and Clinical Application.

BACKGROUND: Proximally based, pedicled flexor carpi ulnaris (FCU) muscle flap has been described previously for soft tissue coverage of the proximal forearm and elbow. No studies have been done on the distal muscular perforators and its use as a distally based flap. METHODS: Ten fresh-frozen cadaveric dissections were done. Specimens were injected with latex to facilitate identification of the perforators. Distal muscular perforators were dissected and distances of the pedicles from the distal wrist crease and ulnar styloid were measured and recorded. A clinical case is also presented where a distally based FCU muscle flap was used for coverage in a patient with median nerve neuroma. RESULTS: A distal muscular perforator and a second more proximal perforator were identified in all specimens. The average distance from the most distal muscular perforator to the ulnar styloid was 3.0 cm. The average distance to the wrist crease was 4.6 cm. The more proximal perforators had an average distance to the ulnar styloid and wrist crease of 7.3 cm and 8.8 cm, respectively. At 7 months post-op, the patient who underwent median nerve neurolysis and coverage with pedicled FCU flap had much improved sensation, with complete resolution of pain and tingling, and without any functional deficits. CONCLUSIONS: The use of a distally based FCU muscle flap is a good option for soft tissue coverage of the distal forearm, wrist, and hand. The distal muscular perforators from the ulnar artery exhibit a relatively consistent anatomy.

Paravertebral block associated with decreased opioid use and less nausea and vomiting after reduction mammaplasty.

BACKGROUND: In light of data finding that postoperative pain, nausea, and vomiting worsen outcomes, a renewed emphasis has been placed on optimizing the perioperative period. Use of preoperative paravertebral block (PVB) has been shown to reduce opioid administration and postoperative nausea and vomiting (PONV) in many surgical populations, though its role in reduction mammaplasty remains undefined. Therefore, we seek to evaluate PVB as an adjunct to general anesthesia (GA) for reduction mammaplasty. MATERIALS AND METHODS: We reviewed records for patients who underwent reduction mammaplasty at our institution from 2010 to 2015. Patients were categorized into two groups: GA alone and GA + PVB (GA with PVB adjunct). Demographic information, opioid administration, phase I/II pain scores, presence of PONV, and anesthesia time were analyzed. Analysis was performed using t-tests and Fisher's exact test, with P-values less than 0.05 statistically significant. RESULTS: We identified 264 patients meeting criteria: 209 (79%) received GA alone and 55 (21%) received GA + PVB. Intraoperative opioid administration were lower for GA + PVB patients (morphine equivalent of 44 mg versus 35 mg, P = 0.019), though there was no difference in postoperative opioid administration (P = 0.915). Phase I and II pain scores were significantly lower for those receiving PVB (2.9 versus 3.9, P = 0.012, and 3.0 versus 4.2, P = 0.001, respectively). GA + PVB was associated with less PONV (14% versus 33%, P = 0.007) and longer anesthesia times (271 min versus 236 min; P = 0.001). CONCLUSIONS: By improving pain control and reducing PONV, factors known to be associated with poor patient satisfaction and inferior outcomes, PVB is an attractive anesthetic adjunct in elective breast surgery.

Seeing is Believing? Preoperative Magnetic Resonance Imaging for Pressure Ulcers: Implications for Surgical Management.

BACKGROUND: Pressure ulcers represent a particularly difficult disease process and remain a financially important entity. The underlying bone in advanced ulcers may harbor osteomyelitis. Radiologic diagnosis of osteomyelitis is confounded by chronic pressure and shear. We sought to determine the test characteristics of preoperative magnetic resonance imaging (MRI) in the diagnosis of osteomyelitis compared to intraoperative bone culture. METHODS: A retrospective review of patients undergoing flap reconstruction who had preoperative MRI and intraoperative bone cultures between 1995 and 2015 was included. Recorded variables included age, sex, level of spinal cord injury and duration, preoperative MRI interpretation, microbiologic bone culture, smoking history, comorbidities, colostomy or urostomy, healing time, complications, length of stay, and discharge facility. RESULTS: A total of 152 patients (175 flaps) were reconstructed, of which 41 patients (73 flaps) met inclusion criteria. Most patients were male (82.2%) with an average age of 50.4 years. Overall complication rate was 32.4% (n = 23) of which 34.7% (n = 8) were major. Positive and negative predictive MRI values were 84.6% and 16.7%, respectively. There were no significant differences in healing time or complication rate in those with or without osteomyelitis. Intraoperative growth was associated with decreased postoperative complications (hazard ratio = 0.361; P = 0.037). CONCLUSION: Test properties of MRI for diagnosis of osteomyelitis in patients with chronic pressure ulcers have limited ability to diagnose osteomyelitis and do not aid in surgical management, but do increase health-care expense. The diagnosis of osteomyelitis by intraoperative bone cultures does not predict inferior outcomes and paradoxically may be associated with fewer postoperative complications.

Genome-wide association study of Lp-PLA(2) activity and mass in the Framingham Heart Study.

Lipoprotein-associated phospholipase A(2) (Lp-PLA(2)) is an emerging risk factor and therapeutic target for cardiovascular disease. The activity and mass of this enzyme are heritable traits, but major genetic determinants have not been explored in a systematic, genome-wide fashion. We carried out a genome-wide association study of Lp-PLA(2) activity and mass in 6,668 Caucasian subjects from the population-based Framingham Heart Study. Clinical data and genotypes from the Affymetrix 550K SNP array were obtained from the open-access Framingham SHARe project. Each polymorphism that passed quality control was tested for associations with Lp-PLA(2) activity and mass using linear mixed models implemented in the R statistical package, accounting for familial correlations, and controlling for age, sex, smoking, lipid-lowering-medication use, and cohort. For Lp-PLA(2) activity, polymorphisms at four independent loci reached genome-wide significance, including the APOE/APOC1 region on chromosome 19 (p = 6 x 10(-24)); CELSR2/PSRC1 on chromosome 1 (p = 3 x 10(-15)); SCARB1 on chromosome 12 (p = 1x10(-8)) and ZNF259/BUD13 in the APOA5/APOA1 gene region on chromosome 11 (p = 4 x 10(-8)). All of these remained significant after accounting for associations with LDL cholesterol, HDL cholesterol, or triglycerides. For Lp-PLA(2) mass, 12 SNPs achieved genome-wide significance, all clustering in a region on chromosome 6p12.3 near the PLA2G7 gene. Our analyses demonstrate that genetic polymorphisms may contribute to inter-individual variation in Lp-PLA(2) activity and mass.