James P. Higgins

Factors affecting outcome in free-tissue transfer in the elderly.

&NA; Free‐tissue transfers have become the preferred surgical technique to treat complex reconstructive defects. Because these procedures typically require longer operative times and recovery periods, the applicability of free‐flap reconstruction in the elderly continues to require ongoing review. The authors performed a retrospective analysis of 100 patients aged 65 years and older who underwent free‐tissue transfers to determine preoperative and intraoperative predictors of surgical complications, medical complications, and reconstructive failures. The parameters studied included patient demographics, past medical history, American Society of Anesthesiology (ASA) status, site and cause of the defect, the free tissue transferred, operative time, and postoperative complications, including free‐flap success or failure. The mean age of the patients was 72 years. A total of 46 patients underwent free‐tissue transfer after head and neck ablation, 27 underwent lower extremity reconstruction in the setting of peripheral vascular disease, 10 had lower extremity traumatic wounds, nine had breast reconstructions, four had infected wounds, two had chronic wounds, and two underwent transfer for lower extremity tumor ablation. Two patients had an ASA status of 1, 49 patients had a status of 2, 45 patients had a status of 3, and four had a status of 4. A total of 104 flaps were transferred in these 100 patients. There were 49 radial forearm flaps, 34 rectus abdominis flaps, seven latissimus dorsi flaps, seven fibular osteocutaneous flaps, three omental flaps, three jejunal flaps, and one lateral arm flap. Four patients had planned double free flaps for their reconstruction. Mean operative time was 7.8 hours (range, 3.5 to 16.5 hours). The overall flap success rate was 97 percent, and the overall reconstructive success rate was 92 percent. There were six additional reconstructive failures related to flap loss, all of which occurred more than 1 month after surgery. Patients with a higher ASA designation experienced more medical complications (p = 0.03) but not surgical complications. Increased operative time resulted in more surgical complications (p = 0.019). All eight cases of reconstructive failure occurred in patients undergoing limb salvage surgery in the setting of peripheral vascular disease. Free‐tissue transfer in the elderly population demonstrates similar success rates to those of the general population. Age alone should not be considered a contraindication or an independent risk factor for free‐tissue transfer. ASA status and length of operative time are significant predictors of postoperative medical and surgical morbidity. The higher rate of reconstructive failure in the elderly peripheral vascular disease population compares favorably with other treatment modalities for this disease process. (Plast. Reconstr. Surg. 106: 66, 2000.)

Vascularized Medial Femoral Trochlea Osteocartilaginous Flap Reconstruction of Proximal Pole Scaphoid Nonunions

PURPOSE The descending geniculate arterys branching pattern includes periosteal vessels supplying the cartilage-bearing trochlea of the medial patellofemoral joint. Previous cadaveric studies described anatomic similarities between the greater curvature of the proximal scaphoid and the convex surface of the medial femoral trochlea (MFT). We describe the technique and report our first 16 consecutive cases of vascularized osteocartilaginous arthroplasty for chronic scaphoid proximal pole nonunions using the MFT, with a minimum of 6 months of follow-up. METHODS Chart reviews of 16 consecutive cases of osteocartilaginous MFT flap transfers for scaphoid reconstruction were performed at 2 institutions. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months (range, 6-72 mo). Patient age and sex, duration of nonunion, number of previous surgical procedures, surgical technique, achievement of osseous union, preoperative and postoperative scapholunate angles, preoperative and postoperative range of motion, and pain relief were recorded. RESULTS Computed tomography imaging confirmed healing in 15 of 16 reconstructed scaphoids. Mean patient age was 30 years (range, 18-47 y). The average number of previous surgical procedures was 1 (range, 0-3). All patients experienced some wrist pain improvement (12/16 complete relief, 4/16 incomplete relief). Wrist range of motion at follow-up averaged 46° extension (range, 28° to 80°) and 44° flexion (range, 10° to 80°), which was similar to preoperative measurements (average 46° extension and 43° flexion). Scapholunate relationship remained unchanged with average scapholunate angles of 52° before surgery and 49° after surgery. CONCLUSIONS Osteochondral vascularized MFT flaps provide a reliable means of achieving resolution of difficult proximal pole scaphoid nonunions. These flaps allow resection of the proximal portion of the unhealed scaphoid and reconstruction with an anatomically analogous convex segment of cartilage-bearing bone. This technique provides the advantages of vascularized bone and ease of fixation. Early follow-up demonstrates a high rate of union with acceptable motion and pain relief. CLINICAL RELEVANCE Early follow-up suggests that the vascularized MFT osteocartilaginous flap is a valuable tool for treating challenging proximal pole scaphoid nonunions.

Barbed suture tenorrhaphy: an ex vivo biomechanical analysis.

Background: Using barbed suture for flexor tenorrhaphy could permit knotless repair with tendon-barb adherence along the sutures entire length. The purpose of this study was to evaluate the tensile strength and repair-site profile of a technique of barbed suture tenorrhaphy. Methods: Thirty-eight cadaveric flexor digitorum profundus tendons were randomized to polypropylene barbed suture repair in a knotless three-strand or six-strand configuration, or to unbarbed four-strand cruciate repair. For each repair, the authors recorded the repair site cross-sectional area before and after tenorrhaphy. Tendons were distracted to failure, and data regarding load at failure and mode of failure were recorded. Results: The mean cross-sectional area ratio of control repairs was 1.5 ± 0.3, whereas that of three-strand and six-strand barbed repairs was 1.2 ± 0.2 (p = 0.009) and 1.2 ± 0.1 (p = 0.005), respectively. Mean load to failure of control repairs was 29 ± 7 N, whereas that of three-strand and six-strand barbed repairs was 36 ± 7 N (p = 0.32) and 88 ± 4 N (p < 0.001), respectively. All cruciate repairs failed by knot rupture or suture pullout, whereas barbed repairs failed by suture breakage in 13 of 14 repairs (p < 0.001). Conclusions: In an ex vivo model of flexor tenorrhaphy, a three-strand barbed suture technique achieved tensile strength comparable to that of four-strand cruciate repairs and demonstrated significantly less repair-site bunching. A six-strand barbed suture technique demonstrated increased tensile strength compared with four-strand cruciate controls and significantly less repair-site bunching. Barbed suture repair may offer several advantages in flexor tenorrhaphy, and further in vivo testing is warranted.

Cutaneous Angiosome Territory of the Medial Femoral Condyle Osteocutaneous Flap

PURPOSE The medial femoral condyle flap is used for treatment of nonunions with or without intercalary bone loss. Most reported uses have been without a skin segment, but this flap can provide a skin component supplied by the saphenous artery branch (SAB) of the descending genicular artery (DGA) pedicle. Experience with this flap suggests that an additional distinct, reliable, more-distal, DGA-cutaneous branch can be found at condyle level, capable of supporting skin without using the SAB. This cadaver study evaluated SAB and DGA-cutaneous branch angiosome territories. A clinical case series assesses the DGA-cutaneous branchs clinical utility. METHODS The DGA and SAB were isolated in 12 cadaveric legs, divided, and separately cannulated. Red dye and methylene blue were selectively injected into each vessel manually. Skin perfusion was measured and photographed. RESULTS In all specimens, the DGA was present, originating 14.2 cm proximal to the joint line, and demonstrated a distinct cutaneous branch at condyle level. This vessel provided an average perfusion area of 70 cm(2), centered over the medial knee. The SAB was identified in 11 specimens (92%), with an average perfusion area of 361 cm(2) along the medial aspect of the distal thigh and proximal leg. The DGA communicating branch was present and used for perfusion of the skin paddle in 17 of 20 cases. The SAB was present in 18 of 20 cases, used with DGA-communicating branch in 4 cases, and the sole source of skin perfusion in 1 case. In 2 remaining cases, neither the SAB nor DGA communicating branch was adequate for perfusion of a skin segment. CONCLUSIONS The medial femoral condyle flap can be harvested with a large skin paddle based on the SAB. A smaller skin segment can be harvested using the more distal DGA-communicating branch at condyle level. CLINICAL RELEVANCE Improved understanding of the skin island associated with the DGAs saphenous and cutaneous branches can provide a rapid, reliable method of skin-segment harvest.

Prevention of anastomotic thrombosis by botulinum toxin a in an animal model

Background: Free tissue transfer is used widely for reconstruction of complex defects throughout the body. The most common cause for free flap failure remains vascular thrombosis. Currently, there exists no animal model for anastomotic vasospasm. Botulinum toxin type A has been successfully used to treat vasospasm in Raynaud’s phenomenon. A blinded, vasospasm animal model was designed to determine its ability to prevent anastomotic thrombosis. Methods: Ten Sprague-Dawley–derived rats were pretreated with botulinum toxin type A subcutaneously to a randomly determined femoral vessel. Animals acted as their own controls, receiving saline to the contralateral limb. Five days postoperatively, femoral vessels were measured to determine the effect of neuromuscular blockade on diameter. Vessels were then divided and reanastomosed. Animals were subjected to a systemic treatment with a peripheral vasoconstrictor, phenylephrine, and a lower extremity thermic challenge in an ice bath. Vessel patency was recorded before cold challenge and 1 hour after. Results: Vessel diameter was consistently larger in all neuromuscularly blocked vessels. The botulinum toxin type A–treated arterial average was significantly larger than the matched control average, and the venous average was significantly larger than the matched control average. Difficulty of anastomosis and time of suturing were significantly less in the pretreated botulinum toxin type A group. Patency was maintained in 100 percent of vessels treated with botulinum toxin type A and in 44 percent of saline-treated vessels at 1 hour after vasospastic challenge. Conclusions: Botulinum toxin type A was successful in preventing thrombosis within this model. Its ability to decrease vasospasm and thrombosis may have applications for improving free flap survival in select patients.

Osteochondral Flaps from the Distal Femur: Expanding Applications, Harvest Sites, and Indications

BACKGROUND The medial and lateral femur provide a source of convex osteochondral vascularized bone. The medial trochlea has been demonstrated to have similar contour to the proximal scaphoid, lunate, and capitate. Other sites of osteochondral harvest such as the posteromedial femur and the lateral trochlea are similar in morphology to the humeral capitellum and medial talus, respectively. These analogous structures offer potential solutions to difficult articular problems. PATIENTS AND METHODS Patients who underwent osteochondral reconstruction of the extremities were reviewed. These included 16 medial femoral trochlea (MFT) scaphoid nonunion reconstructions, 16 MFT Kienböck lunate reconstructions, 5 MFT capitate reconstructions, 2 lateral femoral trochlea osteochondral reconstructions of medial tarsal avascular necrosis, and 5 posteromedial femoral osteochondral reconstructions of the humeral capitellum for posttraumatic arthritis. RESULTS Computed tomography (CT) imaging demonstrated 15 of 16 reconstructed scaphoids achieving union. Follow-up wrist motion averaged 46.0 degrees extension and 43.8 degrees flexion, similar to preoperative measurements. CT imaging confirmed healing in 15 of 16 reconstructed lunates. Lichtman staging remained unchanged in 10 patients, improved in 4 patients (3A-2), and worsened in 2 patients (3A-3B). All but one patient experienced improvement in wrist pain. Wrist range of motion at follow-up averaged 50 degrees extension and 38 degrees flexion, similar to preoperative measurements. Capitate, talar, and capitellar reconstructions all resulted in achievement of osseous healing and restoration of joint alignment. CONCLUSIONS Vascularized osteochondral flaps provide a useful tool in the treatment of difficult articular problems in the extremities. Clinical experience thus far demonstrates a high rate of achieving union with acceptable range of motion and good pain relief.

The diminishing presence of plastic surgeons in hand surgery: a critical analysis.

Background: A growing trend of diminished presence of plastic surgery within the field of hand surgery has been observed in the membership of the American Society for Surgery of the Hand, applications for Certificate of Added Qualifications in Surgery of the Hand, and applications for hand surgery fellowships. Methods: The American Society for Surgery of the Hand resident education subcommittee has investigated this trend, collecting data from the Association of American Medical Colleges, the American Board of Orthopaedic Surgery, the American Board of Plastic Surgery, the National Residency Matching Program, the Accreditation Council for Graduate Medical Education, the American Society for Surgery of the Hand, the American Association of Hand Surgery, and the Certificate of Added Qualifications in Surgery of the Hand and from an online survey of plastic surgery–trained hand surgeons in the United States. Results: These data indicate that the subspecialty of hand surgery enjoys growing popularity with increasing fellowship applicants annually; uses an effective, fair, and multidisciplinary match; and demonstrates continued and healthy growth in its premier academic society. Despite these positive indicators, the percentage of new plastic surgery diplomates obtaining Certificate of Added Qualifications in Surgery of the Hand has decreased from 10 percent (20 applicants per year) to 4 percent (8 applicants per year), the percentage of examinees for the Certificate of Added Qualifications in Surgery of the Hand originating from plastic surgery training backgrounds has decreased from 30 percent to 15 percent, the percentage of the overall body of actively practicing plastic surgeons in the United States that hold Certificate of Added Qualifications in Surgery of the Hand qualifications is steadily decreasing (now to 10 percent), and the plastic surgery membership in the American Society for Surgery of the Hand is demonstrating negligible growth despite the overall expansion of the American Society for Surgery of the Hand. Conclusions: This report serves as a detailed and systematic account of these findings, a balanced interpretation, and a proposal of specific potential solutions. These include recommendations for changes in the structure and content of plastic surgery training programs and the National Residency Matching Program hand surgery fellowship designations.

Proximal Scaphoid Arthroplasty Using the Medial Femoral Trochlea Flap

Background The medial trochlea of the femur (medial femoral trochlea, MFT) provides a source of convex osteocartilaginous vascularized bone that has been demonstrated to have a similar contour to the proximal scaphoid. This provides a potential solution for difficult recalcitrant proximal pole scaphoid nonunions. Materials and Methods Sixteen consecutive patients who underwent MFT proximal scaphoid arthroplasty were reviewed. Follow-up data were recorded at a minimum of 6 months, with an average of 14 months. The results of this cohort were previously reported in detail but are summarized herein. Description of Technique The ability to reconstruct both bone and cartilage of the nonunion enables the surgeon to resect the nonunited proximal pole to prepare for scaphoid reconstruction. A segment of osteocartilaginous MFT is harvested in dimensions required by the scaphoid defect. The MFT segment is harvested on the transverse branch of the descending geniculate vessels. Fixation may be achieved with ease due to the size of the reconstructed segment. Results Computed tomography imaging demonstrated 15 of 16 reconstructed scaphoids achieving osseous union. Follow-up range of motion (ROM) of the wrist averaged 46.0° extension (range 28-80°) and 43.8° flexion (range 10-80°), which was similar to preoperative (average 45.7° extension and 43.0° flexion). Scapholunate angles remained unaffected (51.6° preoperatively and 48.6° postoperatively), indicating preservation of carpal relationships. Conclusions Vascularized MFT flaps provide a useful tool in the treatment of difficult proximal pole scaphoid nonunions. Early follow-up demonstrates high rate of achieving union with acceptable ROM and good pain relief.

Medial femoral condyle flap donor-site morbidity: a radiographic assessment.

Background: The medial femoral condyle has become a reliable source of vascularized bone with many advantages to the reconstructive microsurgeon. The authors examined the donor-site morbidity of medial femoral condyle flap harvest. Methods: A retrospective review of all patients who underwent medial femoral condyle free flap procedures between April of 2009 and December of 2010 was conducted. Study participants underwent computed tomographic scans of their bilateral distal femurs and knee joints to evaluate the donor site and examine differences between the operated and nonoperated sides. Results: Fifteen patients underwent medial femoral condyle free flap procedures. Ten of them agreed to participate in the study. The average time between surgery and computed tomographic scans was 18.0 months (range, 12.2 to 30.4 months). Average bone harvested per procedure was 16.1 cm3 (range, 2 to 34 cm3), representing an average condylar volume of 9 percent (range, 1 to 18 percent). Reparative bone formation was minimal, with an average thickness of 4.5 mm (range, 4 to 6 mm). There were no findings of new degenerative joint disease on computed tomographic scans resulting from medial femoral condyle harvest. The flap success rate was 100 percent (10 of 10) for patency and achieving osseous union. There were no major or flap-related complications. Two patients reported numbness of the donor site at long-term follow-up (average, 17.5 months; range, 12.2 to 30.4 months). Conclusions: Medial femoral condyle harvest creates minimal donor-site morbidity according to radiographic measures at more than 1-year follow-up. Surgeons can anticipate minimal unassisted bone regeneration at the donor site at this time interval. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Long-term results of surgical treatment for hypothenar hammer syndrome.

Background: Ulnar artery occlusion at the wrist and proximal palm can cause debilitating pain and tissue loss. There is disagreement in the literature as to whether the diseased ulnar artery needs to be reconstructed or merely resected. The authors report the long-term outcomes of patients treated surgically with reconstruction of the ulnar artery. Methods: The long-term outcomes of 14 patients treated for this condition were evaluated. Comparisons of late postoperative to preoperative and early postoperative measurements were performed for digital brachial index. Subjective symptoms and function impairment were compared for preoperative and postoperative states using validated questionnaires. Comparisons were also made based on ulnar artery patency versus occlusion at late postoperative measurement. Results: Two patients underwent excision of the thrombosed segment and direct ulnar artery repair. All reconstructions were performed using vein grafts. Eight reconstructions remained patent at a mean 52 months postoperatively. All patients had a mean improvement in digital brachial index (0.82 versus 0.70), decrease in pain and dysesthesia symptoms, and decrease in cold intolerance compared with preoperatively. Patients with ulnar artery occlusion at final measurement had more improvement in digital brachial index (0.19 versus 0.03) and tended to have better subjective improvement in symptoms and function than those whose ulnar artery remained patent. Conclusions: Ulnar artery reconstruction in the setting of hypothenar hammer syndrome results in immediate and long-term improvement of commonly used objective and subjective measurements of digital blood flow. Interestingly, long-term follow-up demonstrates superior endpoints in those reconstructions that occluded. A proposed mechanism to explain this phenomenon is presented.