Karim Bakri

The vascularized medial femoral condyle periosteal bone flap for the treatment of recalcitrant bony nonunions.

The purpose of this study was to examine our experience with this flap for the treatment of recalcitrant nonunions of the extremities. A retrospective chart review was performed on 11 consecutive patients treated with the medial femoral periosteal bone flap from June 2003 to March 2005. Patient demographics, nonunion characteristics, complications, and long-term outcome based on radiographic and clinical parameters were analyzed. Nine free transfers and 3 pedicled flaps were used for a total of 12 nonunion sites in 11 patients. The average age of the patient population was 49 years (21–64 years). The location of the nonunion sites were femur (n = 4), tibia (n = 2), humerus (n = 3), clavicle (n = 2), and radius (n = 1). The nonunion sites were secondary to traumatic fractures complicated by osteomyelitis (n = 10) and tumor extirpation (n = 2). The time period of nonunion prior to the use of vascularized periosteal bone graft ranged from 10 months to 23 years (median = 23 months). All patients had previous attempts at debridement with or without antibiotic bead placement, and all underwent rigid fixation with or without nonvascularized bone grafts prior to vascularized grafting. Following flap placement, 9 (75%) of the nonunion sites healed primarily without complication at an average period of 3.8 months (2–7 months). Two nonunions healed secondarily following hardware modification. There was only 1 flap failure secondary to arterial thrombosis, resulting in a below-knee amputation. The rate of limb salvage was 91%. Donor-site morbidity was minimal, with postoperative seromas occurring in 3 patients.

Workhorse Flaps in Chest Wall Reconstruction: The Pectoralis Major, Latissimus Dorsi, and Rectus Abdominis Flaps

Large and life-threatening thoracic cage defects can result from the treatment of traumatic injuries, tumors, infection, congenital anomalies, and radiation injury and require prompt reconstruction to restore respiratory function and soft tissue closure. Important factors for consideration are coverage with healthy tissue to heal a wound, the potential alteration in respiratory mechanics created by large extirpations or nonhealing thoracic wounds, and the need for immediate coverage for vital structures. The choice of technique depends on the size and extent of the defect, its location, and donor site availability with consideration to previous thoracic or abdominal operations. The focus of this article is specifically to describe the use of the pectoralis major, latissimus dorsi, and rectus abdominis muscle flaps for reconstruction of thoracic defects, as these are the workhorse flaps commonly used for chest wall reconstruction.

The Vascularized Medial Femoral Corticoperiosteal Flap for Reconstruction of Bony Defects within the Upper and Lower Extremities

The periosteum of the medial femoral condyle and supracondylar region is supplied by branches of the descending genicular artery and can be harvested as a corticoperiosteal free flap with or without cancellous bone. This flap offers an alternative to other types of vascularized bone grafts providing a thin and pliable sheet of osteogenic tissue that can be transferred to sites of problematic fracture nonunions. The highly osteogenic nature of the periosteum combined with its excellent vascularity after microvascular or pedicled transfer achieves a high success rate in treating difficult nonunions where conventional bone grafts have either failed or are not suitable. Donor-site morbidity is minimal. This article provides an overview of the anatomic basis, indications, and operative technique for the use of this flap.

The effects of bone marrow stromal cell transplants on tendon healing in vitro

The purpose of this study was to investigate the effect of bone marrow stromal cells (BMSCs) on tendon healing in a canine ex vivo model. Bone marrow was harvested and BMSCs were isolated and cultured according to established protocols. Cells were seeded into 0.5mg/ml collagen gels and cultured for 24h to allow gel contraction, and then implanted between the lacerated ends of repaired flexor digitorum profundus tendons. Tendons repaired with a gel patch alone and without a gel patch served as control groups. After 2 and 4 weeks in culture, the repaired tendons were evaluated for breaking strength and stiffness. Cell viability was assessed by labeling the cells with PKH26 red fluorescent cell linker. The maximal strength and stiffness of repaired tendons with the BMSC-seeded patch were significantly higher than the repaired tendons without a patch or with a patch without cells, at both 2 and 4 weeks (p<0.05). Viable BMSC were present between the cut tendon ends at both 2 and 4 weeks. We conclude that BMSC-seeded gel patch transplantation has the potential to enhance flexor tendon healing, and we plan to investigate this effect in vivo.

Surgical management of subungual melanoma: mayo clinic experience of 124 cases.

BackgroundOptimal surgical management of subungual malignant melanoma (SMM) has been debated. MethodsOur tumor registry was reviewed for surgically treated cases of SMM from 1914 to 2010. Resection levels were compared with outcome. ResultsDuring a 96-year period, 124 cases of SMM were identified (65 men and 59 women). Mean age at diagnosis was 58 years. Mean length of symptoms before diagnosis was 2.2 years. Lesions occurred on the hand (n = 79) and foot (n = 45). The thumb (33.8%) and hallux (25.0%) were affected most. At diagnosis, most had local (83.9%) and regional nodal involvement (12.9%). Mean follow-up was 9.4 years.Mean Breslow depth was 3.1 mm. Amputations were most commonly performed on the thumb at the proximal phalanx or metacarpophalangeal joint (43.9%), and on the hallux at the proximal phalanx or metatarsophalangeal joint (69.0%).Disease progression occurred in 61 (49.2%) patients, and most commonly occurred as regional nodal (62.3%) and distant metastasis (42.6%). Disease progression–free survival rates at 5, 10, and 15 years were 57.1%, 49.9%, and 47.0%, respectively. Fifty-three patients died of melanoma-related causes. Disease-specific survival rates at 5, 10, and 15 years after surgery were 59.3%, 49.3%, and 45.2%. Overall survival rates at 5, 10, and 15 years were 60.5%, 43.8%, and 33.1%.In 116 patients who underwent amputation, resection level outcome analysis with univariate and multivariate analysis adjusting for tumor depth and clinical involvement demonstrated that level of resection was not significantly associated with progression-free, overall, or disease-specific survival. ConclusionsDiagnosis of subungual melanoma is often delayed and carries a poor prognosis. Conservative resections are warranted as resection level does not influence outcome when histologically free margins are obtained. Amputation through the proximal phalanx or the metatarsophalangeal joint is required in the hallux and toes. Fingers require resection through the distal interphalangeal joint. For the thumb, although resection through the interphalangeal joint proved adequate, secondary efforts should be directed toward maximizing function and quality of life. Function-preserving resections in the thumb with nail removal, partial distal phalanx resection, and volar flap reconstruction are easily performed and preserve length, maximize joint and sensory function, and improve cosmesis.

Combined massive allograft and intramedullary vascularized fibula transfer: the capanna technique for lower-limb reconstruction.

Limb salvage has now replaced amputation as the standard treatment for primary bone tumors and can usually be offered to more than 85% of patients. Recently, a novel approach to limb salvage has been described by Capanna and colleagues whereby a massive bone allograft and intramedullary vascularized fibula are combined to reconstruct large, segmental bone defects. This produces a structurally competent reconstruction with enhanced vascular and osteogenic capabilities and the potential to achieve lower rates of infection, fracture, and nonunion. The Capanna technique has become a well-established means of long bone reconstruction and limb salvage in cases of large bony resection. The operative technique and reported outcomes of the Capanna technique are reviewed, and cases are presented.

Functional Outcomes Following Bridge Plate Fixation for Distal Radius Fractures

PURPOSE To determine the functional outcomes of patients treated with dorsal spanning distraction bridge plate fixation for distal radius fractures. METHODS All adult patients at our institution who underwent treatment of a unilateral distal radius fracture using a dorsal bridge plate from 2008 to 2012 were identified retrospectively. Patients were enrolled in clinical follow-up to assess function. Wrist range of motion, grip strength, and extension torque were measured systematically and compared with the contralateral, uninjured wrist. Patients also completed Quick-Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation outcomes questionnaires. RESULTS Eighteen of 100 eligible patients, with a minimum of 1 year from the time of implant removal, were available for follow-up (mean, 2.7 y). All fracture patterns were comminuted and intra-articular (AO 23.C3). There were significant decreases in wrist flexion (43° vs 58°), extension (46° vs 56°), and ulnar deviation (23° vs 29°) compared with the contralateral uninjured wrist. Grip strength was 86% and extension torque was 78% of the contralateral wrist. Comparison of dominant and nondominant wrist injuries identified nearly complete recovery of grip (95%) and extension (96%) strength of dominant-sided wrist injuries, compared with grip (79%) and extension (65%) strength in those with an injured nondominant wrist. Mean Quick-Disabilities of the Arm, Shoulder, and Hand and Patient-Rated Wrist Evaluation scores were 16 and 14, respectively. There were 2 cases of postoperative surgical site pain and no cases of infection, tendonitis, or tendon rupture. CONCLUSIONS Distraction bridge plate fixation for distal radius fractures is safe with minimal complications. Functional outcomes are similar to those published for other treatment methods. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.

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.

Monitoring for Upper-Extremity Free Flaps and Replantations

I I m e 2 i t c t w f t In B ri ef REE TISSUE TRANSFER has a reported failure rate of 1% to 9% in the upper extremity. Despite this low failure rate, approximately 5% to 25% of free aps and replants require re-exploration for anastomotic hrombosis. Free flap salvage rates after re-exploraion range from 42% to 85%. Salvage rates in eplantations have been noted to be as high as 66% to 0%. Early recognition of vascular compromise has een shown to provide the best chance for flap salage; however, the best method for monitoring aps has yet to be established. Clinical observation of he nonburied free flap remains the gold standard with hich newer monitoring systems are compared. Here e review the current literature regarding monitoring ethods and protocols.

Thumb carpometacarpal arthritis

Summary: Osteoarthritis of the thumb carpometacarpal joint has a reported radiographic prevalence of 7 percent in men and 15 percent in women. Many patients remain minimally symptomatic; however, a subset of patients develop debilitating pain, weakness, and instability that severely limit hand function. Treatment options have focused on removal of the diseased trapezium and stabilization of the metacarpal base. Newer options, including carpometacarpal arthroplasty, may have a role in some patients for improving function. This article explores the anatomy and biomechanics of carpometacarpal arthritis and its present surgical treatment options.