Harvey W. Chim

Complications Related to Radial Artery Occlusion, Radial Artery Harvest, and Arterial Lines

Recent publications have suggested that there may be an important role for the radial artery regarding long-term perfusion of the hand. The increasing popularity of the radial artery as an access site for cardiac catheterization has also resulted in the recognition of acute and chronic radial artery occlusion, and cardiologists have placed renewed emphasis on preserving the patency of this artery for future interventional procedures. This article reviews the present literature on radial artery harvest and occlusion. Also discussed are the complications associated with radial artery occlusion and treatment options to prevent such complications.

Soft tissue coverage of the mangled upper extremity

Mangled upper extremity injuries usually involve high-impact trauma with crushing and tearing of the limb and its associated soft tissue structures. Such trauma is particularly mutilating because of the nature of the injury and the involvement of structures vital for proper function. Although advancements in flap technique and improvements in bone fixation methods have enabled good functional and clinical outcomes in limb salvage reconstruction, this remains a challenging area. Attempts at limb preservation should be fully exhausted before consideration is given for amputation, which results in significantly decreased function. Here the authors focus on the various modalities of soft tissue coverage available including allogenic substitutes, the adjunctive use of negative pressure wound therapy, and the design and utilization of flaps to address various defect configurations for the goals of wound healing, aesthetics, and functional restoration in the mangled upper extremity.

Soft Tissue Coverage of the Upper Extremity: An Overview

Prehension is a complex function of the hand that gives it mechanical precision combined with a standard sensory pattern. The priority in soft tissue reconstruction for the upper extremity is to restore function. Significant injury to the upper extremity may result after trauma because of various etiologies. The timing and choice of soft tissue coverage for upper extremity defects warrant special consideration to avoid prolonged immobilization, which can result in joint stiffness, tendon adhesions, scar contractures, and ultimately, loss of function. This article reviews the various reconstructive options and considerations involved in providing coverage for upper extremity soft tissue defects.

Approach to Complex Upper Extremity Injury: An Algorithm

Patients with complex upper extremity injuries represent a unique subset of the trauma population. In addition to extensive soft tissue defects affecting the skin, bone, muscles and tendons, or the neurovasculature in various combinations, there is usually concomitant involvement of other body areas and organ systems with the potential for systemic compromise due to the underlying mechanism of injury and resultant sequelae. In turn, this has a direct impact on the definitive reconstructive plan. Accurate assessment and expedient treatment is thus necessary to achieve optimal surgical outcomes with the primary goal of limb salvage and functional restoration. Nonetheless, the characteristics of these injuries places such patients at an increased risk of complications ranging from limb ischemia, recalcitrant infections, failure of bony union, intractable pain, and most devastatingly, limb amputation. In this article, the authors present an algorithmic approach toward complex injuries of the upper extremity with due consideration for the various reconstructive modalities and timing of definitive wound closure for the best possible clinical outcomes.

Heterotopic Intracranial Skin Presenting as Chronic Draining Sinus After Remote Craniotomy

BACKGROUND Craniotomies for trauma are associated with a significant risk of wound complications. We report a case in which a chronic nonhealing draining sinus was caused by an ectopic epidermal lining deep to the craniotomy bone flap, adherent to the underlying dura. CASE DESCRIPTION A 61-year-old man was examined for a 3-year-old, nonhealing scalp wound resulting after a traumatic brain injury. His initial surgery consisted of an intracranial hematoma evacuation through a temporoparietal craniotomy; this was complicated by wound dehiscence and a chronic sinus draining clear fluid that did not resolve with antimicrobial therapy. Intraoperatively, a layer of hair-bearing skin adherent to the dura was found deep to the entirety of the previous bone flap. There was no dura tear or overt cerebrospinal fluid leak. This necessitated removal of the skin over the dura as well as the overlying bone flap. The resultant defect was reconstructed with a titanium mesh and hydroxyapatite cranioplasty, with a scalp rotation flap for coverage of the cutaneous defect. Pathology confirmed skin with intact adnexal structures. CONCLUSION This case demonstrates that it is possible for hair-bearing skin to grow directly on dura, deep to an intact craniotomy bone flap. With a chronic draining sinus in the absence of computed tomography and magnetic resonance imaging findings, this should be part of the differential diagnosis.

Soft Tissue Reconstruction of Complete Circumferential Defects of the Upper Extremity

Background Upper extremity soft tissue defects with complete circumferential involvement are not common. Coupled with the unique anatomy of the upper extremity, the underlying etiology of such circumferential soft tissue defects represent additional reconstructive challenges that require treatment to be tailored to both the patient and the wound. The aim of this study is to review the various options for soft tissue reconstruction of complete circumferential defects in the upper extremity. Methods A literature review of PubMed and MEDLINE up to December 2016 was performed. The current study focuses on forearm and arm defects from the level at or proximal to the wrist and were assessed based on Tajimas classification (J Trauma 1974). Data reviewed for analysis included patient demographics, causality, defect size, reconstructive technique(s) employed, and postoperative follow-up and functional outcomes (when available). Results In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, 14 unique articles were identified for a total of 50 patients (mean=28.1 years). Underlying etiologies varied from extensive thermal or electrical burns to high impact trauma leading to degloving or avulsion, crush injuries, or even occur iatrogenically after tumor extirpation or extensive debridement. Treatment options ranged from the application of negative pressure wound dressings to the opposite end of the spectrum in hand transplantation. Conclusions With the evolution of reconstructive techniques over time, the extent of functional and aesthetic rehabilitation of these complex upper extremity injuries has also improved. The proposed management algorithm comprehensively addresses the inherent challenges associated with these complex cases.

Delayed treatment of unstable proximal interphalangeal joint fracture-dislocations with a dynamic external fixator

BACKGROUND Fracture-dislocations of the proximal interphalangeal joint (PIPJ) remain a challenging problem to treat. Although there are a number of papers describing the use of dynamic external fixators and force couples for treatment of unstable PIPJ fracture-dislocations acutely, the literature is scarce on delayed treatment of PIPJ fracture-dislocations, where malunion of the articular surface may theoretically compromise postoperative range of motion (ROM) at the PIPJ. The purpose of this study was to evaluate the effectiveness of dynamic distraction external fixation (DDEF) for the delayed treatment of PIPJ fracture-dislocations at least 3 weeks after the inciting injury. METHODS Ten consecutive patients were treated with delayed DDEF between 2010 and 2013. Postoperative ROM at the PIPJ was measured. Disabilities of the Arm, Shoulder and Hand (DASH) score and Michigan Hand Outcomes Questionnaire were administered to all patients postoperatively. RESULTS Mean time from injury to surgery was 27.5 days. The mean follow-up period was 23.7 months (range 10-36). The mean active ROM at the PIPJ on final postoperative follow-up was 83.9° (range 52-100). None of the patients experienced pin-tract infections. Mean DASH score was 3.7+3.4 and mean Michigan Hand Outcomes Questionnaire score was 97.3+3.0. All patients returned to work and resumed normal activities. CONCLUSIONS Delayed treatment of unstable PIPJ fracture-dislocations with a DDEF is effective in restoring function to the PIPJ. Nascent malunion of the PIPJ articular surface does not compromise postoperative outcomes and the joint surface undergoes remodelling over time to restore a smooth and functional articular surface.

Double-opposing Z-plasty for secondary surgical management of velopharyngeal insufficiency following primary furlow palatoplasty

Objective: The present study investigates the efficacy of performing a “palate rerepair” utilizing a double-opposing z-palatoplasty (DOZ) following primary Furlow palatoplasty. Design: Retrospective study. Setting: Tertiary referral academic center for craniofacial surgery. Patients: 15 consecutive patients who presented with velopharyngeal insufficiency (VPI) after primary Furlow palatoplasty. Main Outcome Measures: All subjects were evaluated using the perceptual speech assessment (PSA) scale. Criteria for inclusion in the study were (1) velopharyngeal gap size on phonation of 7 mm or less and (2) lateral wall motion at least 40% normal. Results: Mean PSA score was 7.13 + 3.31 (range 3-13) preoperatively, and decreased to 1.80 + 2.83 (range 0-11; P < .001 vs baseline) 3 months or more after surgery. A sphincter pharyngoplasty was performed as a tertiary procedure in 2 patients due to persistent nasal air emission. There was no symptomatic airway compromise following secondary or tertiary management in all patients. Presence of a cleft lip, lateral wall motion, and velopharyngeal gap size did not impact outcomes. Conclusions: We have demonstrated that a DOZ performed secondarily is anatomically possible following Furlow palatoplasty and can restore function of the levator muscle despite significant scarring following primary repair. This approach respects anatomic principles of palatoplasty without eliminating the possibility for extrapalatal procedures should velopharyngeal competence not be achieved.

Myoepithelial carcinoma or epithelioid sarcoma – A rare diagnosis with poor prognosis. A case report and review of literature

Highlights • Myoepithelial carcinoma of the vulva and epithelioid sarcoma has overlapping histological, immunohistochemical and genetic features.• Similarities between two diagnoses in aggressive vulvar cancer should be noted as a sarcoma-based chemotherapy regimen should be considered.• We recommend immediate surgical resection with bilateral superficial and deep inguinal lymph node dissections in these aggressive cancers.• Identification of SMARCB1-deficiency trials of targeted therapies such as EZH2 inhibitors which show promise in halting further progression.

Reconstruction of Flexor Tendon

This chapter describes in detail the surgical steps involved in the flexor tendon reconstruction. Details of the tendon debridement and epitenon suturing are discussed. Indications, preoperative markings, surgical steps, postoperative care, operative dictation, and suggested readings are included.