Osteocutaneous Radial Forearm Flap: Harvest Technique and Prophylactic Volar Locked Plating.

Background: The osteocutaneous radial forearm (OCRF) flap is a variation of the traditional radial forearm flap with incorporation of an anterolateral segment of corticocancellous bone of the radius, periosteum, and overlying skin. The OCRF flap is indicated in traumatic injuries or extirpation defects with segmental bone loss and is well suited to foot and ankle reconstruction due to its thin pliable skin. Methods: In this single-center case series, a retrospective review was conducted to identify patients who underwent OCRF free flap for foot and ankle reconstruction that required harvest of more than 50% of the cross-sectional area of the radius with prophylactic volar locked plating of the donor site. Outcome measures included flap failure rates, postoperative fracture, thrombotic events, time to follow-up, and time to full weightbearing. Flap harvest technique is extensively discussed. Results: Six cases were included in this series. There were no flap failures or thrombotic events. Recipient site healing was confirmed in all patients, with partial distal skin paddle loss in one patient requiring operative debridement. No patients sustained donor site complications or functional impairment. Full lower extremity weightbearing was achieved at 12.4 ± 3.3 weeks after surgery. Conclusions: The OCRF free flap transfer provides a reliable means of obtaining thin, supple soft tissue coverage with a large, vascularized segment of bone for reconstruction in the foot and ankle. Here, we describe use of more than 50% of the cross-sectional area of the radius with volar locked prophylactic plating. These updates expand use of this reconstructive technique.

Femoral Neck Fracture in a Pediatric Patient with Primary Hyperparathyroidism.

Case: A previously healthy 11-year-old girl underwent expedited surgical fixation of a femoral neck fracture sustained while jump-roping. After further work up, she was diagnosed with primary hyperparathyroidism. Parathyroidectomy of a hypertrophic adenoma proved curative. Now, five months post left hip surgery, the patient is pain-free and walks without a limp. Conclusion: We describe the first published case of primary hyperparathyroidism presenting as a pathologic hip fracture in a child. Although presentation with a fracture is exceedingly rare, bone pain is a frequent complaint of pediatric hyperparathyroidism. Orthopedic surgeons may find themselves the front-line caregivers for the condition.

The Clinical Outcomes of Radiocapitellar Reconstruction With Radiocapitellar Arthroplasty: A Systematic Review and Meta-Analysis.

Background: Radiocapitellar arthroplasty fills a treatment void for young patients who experience isolated capitellar fractures or radiocapitellar osteoarthritis who are not candidates for total elbow arthroplasty. The outcomes of this procedure are sparsely reported. We designed a meta-analysis to determine the utility of radiocapitellar arthroplasty with respect to functional and patient reported outcomes. Methods: The PubMed database was searched for relevant studies. Only studies published in English language that assessed patient reported outcomes following radiocapitellar arthroplasty were included in this study. Reporting followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses for 2020. Results: The initial review yielded 562 studies that met the criteria. After excluding duplications and confounding factors, eight case series were identified for review. Of the eight studies, seven were eligible for inclusion in the meta-analysis for Mayo Elbow Performance Score, flexion-extension arc, and pronation-supination arc. The pooled standard mean difference was found to be statistically significant between pre-operative and post-operative outcomes for Mayo Elbow Performance Score (SMD = 3.04, 95% CI [2.40, 3.67]), flexion-extension arc (SMD = 1.28, 95% CI [0.73, 1.83]), and pronation-supination arc (SMD = 0.81, 95% CI [0.43, 1.18]). Cochran's Q-test and I2 statistics indicated statistically significant heterogeneity for Mayo Elbow Performance Score (p = .04, I2 = 54%) and flexion-extension arc (p < .01, I2 = 67%). Conclusions: Patients undergoing radiocapitellar arthroplasty showed statistically significant improvements in flexion-extension arc, pronation-supination arc, and Mayo Elbow Performance Scores compared to pre-operative measures.

The effect of operative time on surgical-site infection following total shoulder arthroplasty.

BACKGROUND: Many factors contribute to the risk of surgical-site infection (SSI) following total shoulder arthroplasty (TSA). Operative time is a modifiable factor that may contribute to SSI occurrence after TSA. This study aimed to determine the correlation between operative time and SSI following TSA. MATERIALS AND METHODS: By use of the American College of Surgeons National Surgical Quality Improvement Program database, a total of 33,987 patient records were queried from 2006 to 2020 and sorted by operative time and the development of an SSI in the 30-day postoperative period. Odds ratios for the development of an SSI were calculated based on operative time. RESULTS: An SSI developed in the 30-day postoperative period in 169 of the 33,470 patients in this study, resulting in an overall SSI rate of 0.50%. A positive correlation was identified between operative time and the SSI rate. An inflection point was identified at an operative time of 180 minutes, with a significant increase in the rate of SSI occurrence for operative times >180 minutes. DISCUSSION AND CONCLUSION: Increased operative time was shown to be strongly correlated with an increased risk of SSI within 30 days following surgery, with a significant inflection point at 180 minutes. The target operative time for TSA should be <180 minutes to reduce the risk of SSI.

Predictors of Mortality and Revision Following Digital Amputation for Infection and Necrosis.

PURPOSE: Digital amputation is a commonly performed procedure for infection and necrosis in patients with diabetes, peripheral vascular disease (PVD), and on dialysis. There is a lack of data regarding prognosis for revision amputation and mortality following digital amputation in these patients. METHODS: All digital amputations over 10-year period (2008-2018) at a single center were reviewed. There were 484 amputations in 360 patients, among which 358 were performed for trauma (reference sample) and 126 for infection or necrosis (sample of interest). Patient death and revision were determined from National Vital Statistics System and medical records. Propensity score matching was performed to compare groups. Data were then compared to the Social Security Administration Actuarial Life Table for 2015 to determine age-matched expected mortality. RESULTS: The 2-year revision rate was 34% for amputations performed for infection or necrosis, compared to 15% for amputations due to trauma. For amputations performed for infection or necrosis, the revision rate was 47.7% when diabetes, PVD, and dialysis were present. Among all patients with infection or necrosis (n = 104) undergoing a digital amputation, overall survival at 2, 5, and 10 years was 79.4%, 57.3%, and 17.5%, respectively, which represented a 3.2-fold increased risk of death compared to controls. (hazard ratio, 3.19; 95% confidence interval, 1.47-6.93). For amputations due to trauma, mortality was no different from that in the age-matched general population. CONCLUSIONS: Mortality and revision risk are high for patients requiring a digital amputation for infection or necrosis and are further increased with medical comorbidities. Hand surgeons should consider the prognostic implications of these data when counseling patients. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.