Jeffrey B. Friedrich

Repair of acute ulnar collateral ligament injuries of the thumb metacarpophalangeal joint: a retrospective comparison of pull-out sutures and bone anchor techniques.

Background: The use of intraosseous suture anchors in the treatment of ruptures of the ulnar collateral ligament of the thumb metacarpophalangeal joint has previously been described. However, no direct comparisons exist of ulnar collateral ligament repair with bone anchor versus repair with a pull-out button and immobilization. Methods: Two cohorts of patients with complete rupture of the ulnar collateral ligament of the thumb metacarpophalangeal joint were compared. Thirty patients in each cohort underwent repair of the ulnar collateral ligament with either an intraosseous suture anchor followed by early mobilization or a pull-out suture tied over a button with cast immobilization. Average follow-up was 29 months. Results: At follow-up, range of motion at the metacarpophalangeal and interphalangeal joints for the anchor group averaged 97 percent of that of the contralateral side compared with 86 percent and 87 percent, respectively, for the button group. For the anchor group, pinch strength averaged 101 percent that of the contralateral side compared with 95 percent for the button group. No significant difference was noted between the groups for grip strength. Average tourniquet time for the anchor group was 28 minutes compared with 43 minutes for the button group. Soft-tissue complications were present in 27 percent of patients (eight of 30) in the pull-out button group compared with 7 percent (two of 30) in the anchor group. Cost analysis demonstrates an approximately

Free Vascularized Fibular Graft Salvage of Complications of Long-Bone Allograft After Tumor Reconstruction

140-per-patient savings when using the suture anchor. Conclusions: Both repair methods are safe and effective for treating thumb ulnar collateral ligament injuries. Suture anchors allow for an accelerated rehabilitation protocol, which may account for the improved range of motion and pinch strength at follow-up.

Posttraumatic thumb reconstruction.

BACKGROUND Long-bone allograft reconstruction following tumor extirpation can be complicated by problems such as nonunion at the host-allograft junction, allograft fracture, or allograft infection. Free vascularized bone grafts can be used to address these complications. The purpose of the current study was to examine retrospectively the outcomes and complications following allograft reconstruction salvage with onlay vascularized fibular grafts. METHODS A tumor registry review was conducted to identify all patients who underwent a reconstruction with a vascularized fibular graft for allograft reconstruction complications following tumor resection (host-graft nonunion, allograft fracture, or allograft nonunion) in the last nineteen years. The records of these patients were analyzed for details regarding the neoplasms and the treatment thereof, details of the free vascularized fibular graft reconstruction, time to osseous union, functional outcome, and clinical outcome. RESULTS Thirty-three patients satisfied the criteria for this study. The involved bones were the femur (eighteen patients), tibia (eight), and humerus (seven). Osseous union was achieved in all patients at a mean of 7.7 months. The average duration of follow-up was seventy-three months. Twenty-three patients achieved a good or excellent functional outcome. Ultimately, seven patients had a failure of the allograft reconstruction, which resulted in limb loss in five of them. Postoperative complications were relatively common in this series. CONCLUSIONS Free vascularized fibular grafting is a useful adjunctive surgical treatment for nonunion, fracture, and infection of an intercalary allograft reconstruction in limb salvage surgery. It has, however, a high rate of associated complications often resulting in failure.

Soft Tissue Reconstruction of the Hand

Learning Objectives: After reading this article, the reader should be able to: 1. Discuss the critical anatomic features of the thumb as they affect on reconstructive decision making. 2. Define the goals of reconstruction. 3. Discuss an algorithm for thumb reconstruction according to the level of amputation. 4. Understand the role of prosthetics in thumb reconstruction. Background: The function of the thumb is critical to overall hand function. Uniquely endowed with anatomic features that allow circumduction and opposition, the thumb enables activities of pinch, grasp, and fine manipulation that are essential in daily life. Destruction of the thumb secondary to trauma represents a much more significant loss than would result from loss of any other digit. Therefore, significant effort has been focused on thumb reconstruction. Numerous techniques have been described, ranging from simple osteoplastic techniques to complex microsurgical procedures. With an appreciation of the unique anatomic properties of the thumb, the hand surgeon is better able to understand the goals of thumb reconstruction and to develop an algorithm for thumb reconstruction. With such an understanding, an individualized reconstructive plan can be developed for each patient. Methods: A great many options are available for posttraumatic thumb reconstruction. Optimal results are obtained by pursuing an organized and logical approach to reconstruction based upon the level of tissue loss. Reconstruction methods depend on the location of the amputation and range from homodigital and heterodigital flaps to partial-toe transfer or a great-toe wrap-around flap to first-web-space deepening using Z-plasties, a dorsal rotation flap, or a distant flap, to distraction osteogenesis, lengthening of the thumb ray, spare parts from another injured digit in the acute setting for pollicization or heterotopic replantation, and microvascular toe transfer. Results: Amputations in the distal third of the thumb are generally well-tolerated. The primary reconstructive issues are the restoration of a padded and sensate soft-tissue cover, as well as aesthetic considerations. First-web-space deepening will generally provide excellent results for amputations at the distal half of the middle third. In the proximal half of the middle third, lengthening of the thumb ray is generally required. Distraction lengthening of the first metacarpal is a useful and reliable technique that provides up to 3 cm of length without requiring complex microsurgical methods. Spare parts from another injured digit may be used in the acute setting for pollicization or heterotopic replantation. Microvascular toe transfer is an excellent option for elective reconstruction. However, other options also are available and may be more appropriate in some cases. Less ideal options include the various types of osteoplastic reconstruction. Conclusions: The reconstruction of posttraumatic thumb defects is a challenging and rewarding surgical endeavor. The value of a functioning thumb is immense, and its reconstruction is worthy of considerable effort. Despite the elegant reconstructive options available, the best results are obtained with replantation or revascularization whenever possible. Finally, the treatment plan always must be derived from a careful assessment of each patient’s posttraumatic function and specific reconstructive needs.

Infantile fibrosarcoma of the hand associated with coagulopathy.

There are a number of insults that can compromise the soft tissue envelope of the hand. Soft tissue reconstruction seeks to restore both the aesthetic appearance and the function of the hand. The purpose of this review is to describe recent advances in hand soft tissue reconstruction. Skin grafts and skin substitutes both are useful reconstructive options for certain defects. Digital coverage continues to be subject to refinements that lead to better reconstructions. Flaps based on donor sites from the dorsal metacarpal artery system are finding continually expanding uses in hand reconstruction. Traditional notions of forearm-based donor tissue are being challenged, leading to better hand reconstructions with less donor morbidity. Finally, improvements in free tissue transfer enable the expansion of reconstructive possibilities available for hand coverage.

Upper extremity replantation: current concepts.

Background: Large congenital neoplasms of the extremities may be associated with coagulopathies and significant hemorrhage in the neonatal period. At times, the differences between coagulation derangements can be very subtle, leading to errors in diagnosis. Infants with vascular lesions and coagulopathies are often found to have the Kasabach-Merritt phenomenon, which is a platelet-trapping coagulopathy. However, other neoplasms or vascular malformations can be accompanied by disseminated intravascular coagulation. It is important to obtain accurate diagnoses of the neoplasm and the coagulopathy because the treatments of similar-appearing tumors and coagulopathies can be markedly different. Methods: The authors report the case of a newborn with a congenital tumor of the left hand that was accompanied by a coagulopathy that caused significant bleeding. Results: A presumption was made by the neonatal critical care physicians and hematologists that the infant had a kaposiform hemangioendothelioma along with the Kasabach-Merritt phenomenon. However, steroid treatment did not reduce the size of the mass or correct the coagulopathy. Only after obtaining consultation with a hand surgeon and a tissue diagnosis was it learned that the patient had an infantile fibrosarcoma that was accompanied by disseminated intravascular coagulation. Limb-sparing resection of the lesion along with chemotherapy markedly improved the patient’s condition. Conclusions: Large congenital neoplasms presenting with attendant bleeding diatheses must be rapidly and accurately diagnosed with both a biopsy-proven tissue diagnosis and a hematologic characterization of the nature of the coagulopathy. The differential diagnosis of a vascular-appearing mass in the extremity can be subtle, and presumptive diagnosis, as occurred in this case, can lead to incorrect or delayed treatment. Specifically, kaposiform hemangioendothelioma must be differentiated from infantile fibrosarcoma. The principles of infantile fibrosarcoma treatment are limb-sparing resection and chemotherapy.

Community-Acquired Methicillin-Resistant Staphylococcus aureus in Surgically Treated Hand Infections

Background: Upper extremity replantation is a procedure that has revolutionized hand surgery. Since its introduction, a rapid evolution has occurred with a shifting focus from implant survival to optimization of functional outcomes and surgical efficiency. In this review, the current concepts surrounding the indications for replantation, variations in surgical technique, the factors affecting outcomes, and future directions of the specialty are analyzed. Methods: A literature review was performed of all recent articles pertaining to digit, hand, and upper extremity replantation surgery. Particular emphasis was placed on comparative studies and recent meta-analyses. Results: The indications and contraindications for replantation surgery are largely unchanged, with mechanism of injury remaining one of the most important determinants of implant survival. With advances in surgical technique, improved outcomes have been observed with avulsion injuries. Distal tip replantations appear to be more common with improved microsurgical techniques, and for these distal injuries, digital nerve and vein repair may not be necessary. Cold ischemia time for a digit amputation should not preclude transfer to a replantation facility or significantly affect the decision to perform a replantation. However, transferring physicians should thoroughly review the options with patients to prevent unnecessary transfers, which is an area where telemedicine may be useful. Conclusion: This review provides an update on the current concepts of the practice of replantation and the treatment and management of patients with upper extremity amputations.

New Workhorse Flaps in Hand Reconstruction

PURPOSE An increase in the incidence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) infections has been observed. The purpose of this study is to determine the change in proportion of surgically treated CA-MRSA hand infections over the last decade and to identify associated risk factors. METHODS A retrospective review was performed of all 159 hand infections treated in the operating room over an 11-year period (1997-2007). Mean age overall was 40 years, mean inpatient length of stay was 4.9 days, and 115 of the 159 patients were male. Examined data included known risk factors for MRSA, including human immunodeficiency virus infection, diabetes mellitus, intravenous drug use, incarceration, and homelessness. RESULTS Forty-eight patients had surgery for hand infections due to CA-MRSA. The yearly proportion of CA-MRSA increased over the study period, and the risk of having an MRSA infection was 41% higher with each progressive calendar year during the study period relative to the apparent incidence of non-MRSA hand infections. Other factors associated with CA-MRSA were intravenous drug use, felon-type infection, and prior hand infection. Multivariable logistic regression identified intravenous drug use as a significant, independent risk factor for CA-MRSA hand infection. CONCLUSIONS The proportion of surgically treated hand infections due to CA-MRSA has increased during the last decade. Intravenous drug use was the only independent risk factor for CA-MRSA infections treated in the operating room at our institution.

An evidence-based approach to metacarpal fractures.

With the passage of time, certain hand surgery procedures are anecdotally dubbed “workhorse” techniques. These are procedures that are extremely reliable and have repeatedly demonstrated good results. However, with time, paradigms undergo shifts, and this is as true for hand surgery as any other field. In this article, we will describe the use of three new “workhorse” flaps that we have found to have reliable results in complex hand reconstruction: the pedicled radial forearm fascia flap for dorsal hand reconstruction, the free anterolateral thigh flap for mangled hand reconstruction, and the medial femoral condyle vascularized bone graft for scaphoid fracture nonunion reconstruction.

Resection of panniculus morbidus: a salvage procedure with a steep learning curve.

Seattle, Wash. The Maintenance of Certification module series is designed to help the clinician structure his or her study in specific areas appropriate to his or her clinical practice. This article is prepared to accompany practice-based assessment of preoperative assessment, anesthesia, surgical treatment plan, perioperative management, and outcomes. In this format, the clinician is invited to compare his or her methods of patient assessment and treatment, outcomes, and complications, with authoritative, information-based references. This information base is then used for self-assessment and benchmarking in parts II and IV of the Maintenance of Certification process of the American Board of Plastic Surgery. This article is not intended to be an exhaustive treatise on the subject. Rather, it is designed to serve as a reference point for further in-depth study by review of the reference articles presented. (Plast. Reconstr. Surg. 126: 2205, 2010.)