Palmar Resurfacing of the Hand With Porcine Urinary Bladder Extracellular Matrix Following Traumatic Injury.

INTRODUCTION: Complex wounds of the hand often result in soft tissue defects that are not amenable to primary closure, vacuum-assisted closure, or tissue expansion. Injuries presenting with large defects involving multiple levels of tissue must be addressed by using techniques at higher rungs on the reconstructive ladder, such as split-thickness grafting, pedicled flaps, or free flaps. When repairing palmar tissue, these techniques fall short due to their failure to approximate structure and function of specialized skin. More recently, dermal substitutes containing a decellularized extracellular matrix (ECM) have been used in reconstruction of soft tissue defects, acting as a structural scaffold for the regrowth of native cells. Extracellular matrix products have been shown to improve functional and sensory outcomes in areas requiring highly specialized skin. Urinary bladder matrix (UBM), a porcine ECM scaffold, is unique in that it contains an intact epithelial basement membrane that promotes more organized regrowth through layered structure. CASE REPORT: This case presents a novel use of this product in resurfacing 80% of a palm after postoperative necrosis following a table saw injury to the right volar palm at the distal crease. The patient had intact sensation and near normal functional outcomes at most recent follow up. CONCLUSIONS: The UBM may be a valuable adjunct to achieve soft tissue coverage in large, complex hand wounds, particularly those involving the palmar surfaces.

A Novel Approach to Ray Resection of the Hand.

Ray resections have been a viable treatment option for patients with tumors, trauma, infection, vascular insufficiency, or other abnormalities of the hand since the procedure was described in the 1920s. The creation of a functional hand after central ray resection presents unique technical challenges: insufficient closure of the gap between the metacarpals bordering the resected ray can produce an enlarged space between remaining digits and potentially cause digital malrotation, both of which negatively affect hand function. The goal is to make the space between resulting fingers as close to normal as possible. A number of procedures were described to address this issue, but unfortunately, they can be technically onerous and may require prolonged immobilization, the use of internal hardware, or the use of temporary hardware requiring removal. We describe a technique for amputation of the affected ray at the proximal metacarpal metadiaphyseal flare and a concomitant closing wedge osteotomy to allow superior gap closure between the residual fingers while maintaining the structure of the carpus and alignment of the hand. This improves functional and aesthetic outcomes after central ray resection of the hand.

The Impact of Obesity on Orthopedic Upper Extremity Surgery.

Obese patients have increased rates of upper extremity injury, carpal tunnel syndrome, and upper extremity osteoarthritis. Preoperative considerations include cardiovascular disease, pulmonary disease, and diabetes mellitus. Intraoperative and anesthetic considerations include specialized equipment, patient positioning, and the physiology of obese patients. Postoperative considerations should include increased risk of cardiovascular complications as well as surgical site infections and malunion. Surgery of the hand and upper extremity may be less prone to the postoperative complications seen in other regions of the body. There are currently no direct contraindications for obese patients to undergo orthopedic procedures if the appropriate considerations have been made.