Hede Yan

Safety and Efficacy of Operative Versus Nonsurgical Management of Distal Radius Fractures in Elderly Patients: A Systematic Review and Meta-analysis

PURPOSE To assess the safety and efficacy of operative versus nonsurgical treatment of distal radius fractures in elderly patients. METHODS We comprehensively searched the PubMed, Web of Science, and Cochrane Library databases for studies that satisfied predetermined inclusion and exclusion criteria. Outcomes of interest included pain level, grip strength, wrist range of motion, wrist functional assessment, radiographic parameters, and complications; we compared these using continuous measurements. We performed a systematic review and meta-analysis to assess operative versus nonsurgical procedures in patients aged 60 years and older. RESULTS Two randomized controlled trials and 6 retrospective studies were included. Meta-analysis did not detect statistically significant differences in pooled data for pain level, functional assessment, and wrist range of motion between the operative and nonsurgical groups. Grip strength was significantly greater in the operative group. The incidence of major complications requiring surgery and that of tendon injury were significantly higher in the operative group. Radiographic outcomes including volar tilt, radial inclination, and ulnar variance were significantly better in the operative group. Considerable heterogeneity was present in all studies and adversely affected the precision of the meta-analysis. CONCLUSIONS The current literature does not support the theory that operative management can provide better clinical outcomes for elderly patients with distal radius fractures. Although operative management can offer better radiographic outcomes and grip strength than can nonsurgical treatment, the risk of complications requiring surgical treatment is greater. Thus, indications for operative fixation should be considered carefully in the treatment of elderly patients. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic III.

The free dorsoradial forearm perforator flap: anatomical study and clinical application in finger reconstruction.

The perforator flaps are characterized by their thinness and the adjustable length of their vascular pedicle. The purpose of this investigation is to refine the anatomy of the perforators in the middorsoradial forearm and present our clinical experience using this free perforator flap in the reconstruction of finger defects. Anatomic study was conducted on 46 cadaver forearms. It was noted that a perforator was consistently observed in the midforearm exhibiting 4 patterns, in which a dorsoradial perforator was present with 37 cases (80.4%) originating from the interosseous artery system (patterns 1–3) and 9 cases (19.6%) from the descending branch of the radial recurrent artery (pattern 4). This perforator consistently emerged in the intermuscular septum between the extensor carpi radialis longus and extensor digitorum communis. Twenty free flaps based on this middorsoradial cutaneous perforator were elevated for the coverage of soft tissue defects of fingers (range: 3 cm × 2.0 cm to 5 cm × 2.5 cm) in 17 patients. All the flaps survived with satisfactory outcomes. Clinical findings on this perforator in terms of its origins and courses coincided with the anatomic results (&khgr;2 = 0.287, P = 0.962). The free flap based on this perforator is a reliable perforator flap in spite of varied origins.

Reconstruction of Totally Degloved Fingers With a Spiraled Parallelogram Medial Arm Free Flap

PURPOSE To investigate the results of resurfacing completely degloved digits using a parallelogram free flap from the medial arm in a spiral fashion. METHODS We reviewed the reconstruction of 26 digits in 21 patients with a parallelogram free flap from the medial arm in a spiral fashion following a non-replantable degloving injury. RESULTS The sizable perforator was observed consistently in the medial arm with 13 of 21 (62%) originating from the superior ulnar collateral artery, 6 of 21 (29%) directly from the brachial artery, and 2 of 21 (9%) from the superficial brachial artery. All the flaps but one, which sustained partial flap loss, survived uneventfully. Total active motion ranged from 93° to 145° and 112° to 154° in the cases with and without metacarpophalangeal joint involvement, respectively. The static 2-point discrimination test varied from 6 to 13 mm. No scar contracture was recorded in these patients. All the patients were satisfied with the overall results. CONCLUSIONS Resurfacing the defect in a spiral fashion is a valuable and reliable technique for the reconstruction of complete finger degloving injuries. The medial arm flap is a good candidate for this procedure, with satisfactory functional recovery and good aesthetic restoration. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

Reconstruction of large dorsal digital defects with arterialized venous flaps: our experience and comprehensive review of literature.

AbstractCoverage of the dorsal aspect of the fingers is difficult, especially when the defect is large and multiple digits are involved with composite tissue loss and very few conventional flaps are suitable in dealing with such situation. The purpose of this study was to present our experience of reconstruction of the large dorsal digital defects with the arterialized venous flap (AVF) and evaluate its merits and demerits in this clinical setting with a comprehensive review of literature. From August 2008 to December 2010, 7 composite palmaris longus venous flaps and 5 AVFs were used in the reconstruction of extensive dorsal digital injuries in 8 patients, and a comprehensive review of literature regarding the reconstruction of dorsal digital defects with AVFs was carried out. All the flaps survived completely. The outcomes were very satisfactory for functional recovery, aesthetic appearance, and sensation restoration at an average follow-up of 11.8 months; the literature review also revealed the similar results. On the basis of our experience and literature review, AVFs are reliable and good candidates for resurfacing large dorsal digital defects when local flaps are not available or insufficient for coverage. Composite AVF with palmaris longus tendon is an optimal choice for 1-stage reconstruction of dorsal composite finger injuries.

Improvement of Prearterialized Venous Flap Survival with Delay Procedure in Rats

The purpose of this experimental study is to investigate the improvement in flap survival of prearterialization with delay procedure in venous flaps in rats. The transverse superficial inferior epigastric flap was utilized. Forty-six rats were randomized into four groups: group 1 as arterialized venous flaps, group 2 as venous flaps of prearterialization with delay procedure, group 3 as arterial perfusion venous flap, and group 4 as venous perfusion venous flap. Direct observation, histological analysis, and vascular perfusion examination by Indian ink injection were performed for flap assessment. The percentage of flap survival was 41.6 +/- 2.4%, 98.0 +/- 1.8%, 89.5 +/- 1.0%, and 11.3 +/- 0.8% in these four groups, respectively. Significant differences were noted between groups ( P < 0.05) except for between group 2 and group 3 ( P > 0.05). Vascular perfusion studies revealed that the Indian ink filled the entire flaps of group 2 in comparison with partially filled flaps in other groups. Histological examination showed more small vessels were observed through all layers of the flaps as well as dilated superficial veins in group 2 than those in other groups. In conclusion, prearterialization with delay procedure can improve the viability of the flap, and this method may be a strategy for flap prefabrication based on the venous network.

Wound cultures as predictors of complications in reconstructive flap procedures.

Cultures were acquired from 125 cases of flap reconstruction. Specimens were collected from the wound beds at the time of wound closure. Fifty-one cases (41%) had negative cultures and 74 (59%) had positive cultures. The positive culture patients had a higher complication rate than the negative culture patients (49% vs. 7.8%, p <.004). Patients with positive cultures coincidentally receiving effective antibiotics relative to their wound cultures had a complication rate statistically comparable to negative culture patients. These findings suggest that wound bed cultures could be incorporated into operative sequence strategies, wound management outcome assessments, and surveillance analyses that could provide guidelines for perioperative antibiotics administration.

Repair of partial nerve injury by bypass nerve grafting with end-to-side neurorrhaphy.

The purpose of this study was to investigate the efficacy of bypass nerve grafting with end-to-side neurorrhaphy in repair of the partial nerve injury in a rabbit model. Thirty-six adult male New Zealand rabbits were divided into three groups. A partial nerve injury was created by removal of a segment of the lateral fascicle of the left peroneal nerve. In group one, the injured nerve was repaired with nerve graft bypassing the injury site in an end-to-side fashion 4 weeks after injury. In group two, the injured nerve was repaired with end-to-end interpositional nerve grafting 6 weeks after injury. The injured nerve without repair was used as the control. Sixteen weeks after nerve repair, in groups one and two, and 20 weeks after the initial nerve injury in the control group, the nerves were dissected for electrophysiological examination and biopsied for histology and molecular markers expression. The nerve repair with interpositional nerve grafting achieved maximal functional recovery. However, motor nerve conduction velocity and compound motor action potential in nerve repair with bypass nerve grafting were significantly higher than that in the nerve injury without repair. Histologically, the regenerated myelinated axons and unmyelinated axons were present in the distal peroneal nerves in the bypass nerve grafts. The axon counts in nerve repair with the bypass nerve grafting were also significantly higher than that in the nerve injury without repair. The comparisons of the ciliary neurotrophic factor and the calcitonin gene-related peptide gene expressions between nerves with and without repair were significantly different. End-to-side bypass nerve grafting can significantly improve functional recovery in the nerve with partial injury and may be a useful repair strategy in neuromas-in-continuity.

The role of an aligned nanofiber conduit in the management of painful neuromas in rat sciatic nerves.

BackgroundCapping techniques have been used as a treatment modality for the prevention of neuroma formation and the management of neuropathic pain. However, the results are inconsistent and unpredictable. We hypothesize that this situation may be attributable, in part, to the disparities in the type of materials used to manufacturing of the conduits. MethodsIn this study, a rat model was used and the sciatic nerve was selected for evaluation. In 1 capping group, a sciatic nerve stump was capped with a nonaligned nanofiber conduit (the nonaligned group), whereas in a second capping group, the conduit was made of aligned nanofibers (the aligned group). In another group, the sciatic nerve stump was not capped as a control (the control group). The results of autotomy behavior, extent of neuroma formation, histological changes in the neuroma, and the expression of c-fos as a pain marker in the fourth lumbar spinal cord were evaluated at 8 weeks postoperatively. ResultsThe control group presented more neuroma-like features in all the observed parameters in comparison with the 2 capping groups; of the 2 capping groups, the aligned group achieved even better outcomes than the nonaligned group. ConclusionsOur findings indicate that the aligned nanofiber conduit is a promising biomaterial for the nerve capping technique, and new treatment strategies using aligned nanofiber conduits may be developed for the management of painful amputated neuromas.

Flap reconstruction of distal lower extremity wounds in diabetic patients.

Lower extremity diabetic wounds have been a challenge to clinical surgeons because of the higher risk of limb ischemia, soft-tissue infection, and soft-tissue loss caused by the pathology of the disease. In the published data, the most commonly used reconstruction techniques include pedicled flaps, microsurgical muscle or musculocutaneous flaps, and microsurgical fasciocutaneous or perforator flaps. However, there is still no consensus about which type of flap should be preferred among various reconstructive options. It is therefore the aim of this study to review current articles describing distal lower extremity flap reconstruction in patients with diabetes to survey reported results from the literature.

Distally based sural neuro-fasciocutaneous perforator flap for foot and ankle reconstruction: Surgical modifications for flap pedicle and donor site closure without skin graft

BACKGROUND The conventional procedure of the sural neuro-fasciocutaneous flap enables the supply of blood and venous drainage by increasing the width of the adipofascial tissue and preserving tiny venous return routes. Moreover, skin graft is a common method for donor site closure, which may lead to some complications and influence the aesthetic appearance. We report modifications for a distally based sural neuro-fasciocutaneous perforator flap and a relaying flap for donor site closure without skin graft. METHODS Twelve patients undergoing the modified flap for foot and ankle reconstruction were included in this study between 2014 and 2016. A peroneal-based perforator, a superficial vein, and the vascular axis of the sural nerve were included in the pedicle. A Z-shape skin incision was performed to explore the perforator vessels and a relaying island perforator flap was used to close the donor site. RESULTS All flaps survived completely without necrosis. The area of the flaps ranged from 16 × 8 cm to 30 × 15 cm. The diameter width of the pedicle ranged from 1.0 to 2.0 cm. A relaying perforator island flap was used in 10 cases for donor site closure and no skin graft was performed. There were no serious donor site complications. All patients were satisfied with the aesthetic outcome postoperatively at the final follow-up. CONCLUSIONS The distally based sural neuro-fasciocutaneous perforator flap is considered a reliable method for foot and ankle reconstruction. The modification for flap pedicle and donor site closure method without skin graft should be recommended.