Weiyang Gao

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.

A comparative study of finger pulp reconstruction using arterialised venous sensate flap and insensate flap from forearm

OBJECTIVE The aim of this study was to investigate the feasibility of finger pulp reconstruction using arterialised venous flaps from forearm and compare the outcomes of arterialised venous sensate flap and insensate flap. METHODS Twenty-seven arterialised venous flaps were reviewed retrospectively in the reconstruction of finger pulp defects in 23 patients, including 15 sensate flaps (sensate group) and 12 insensate flaps (insensate group). Nine flaps in this series were harvested from the dorsal aspect of the forearm and the other 18 were harvested from the volar aspect. Standardised assessment of outcomes in terms of objective sensory recovery, pinch power of the reconstructed digits, cold intolerance and time of returning to work was completed. RESULTS All flaps survived completely. Twenty-six flaps were available for follow-up of more than 9 months (mean, 15.4 months). Almost all the flaps in the sensate group obtained normal sensation, while most cases of the insensate group only achieved protective sensation. Cold intolerance was present in most cases of the insensate group in comparison with the sensate group with only one case suffering from slight cold intolerance. There was no significant difference of pinch power between the two groups. All the patients were contented with the aesthetic outcomes of the surgery. CONCLUSION The arterialised venous sensate flap from forearm is a practical alternative for finger pulp reconstruction with satisfactory functional and aesthetic outcomes. The forearm region can be an acceptable donor site for arterialised venous sensate flap in the reconstruction of larger finger pulp defect.

The management of degloving injury of lower extremities: technical refinement and classification.

BACKGROUND Degloving injuries are severe and frequently underestimated lesions. Lower extremities are the most commonly affected limbs. This injury is associated with a high morbidity and mortality if mismanaged. The treatment of such patients still varies, clinical indicators for its prognosis are scarce, and some technical protocols are also controversial. METHODS Between August 2002 and July 2011, 102 patients with skin avulsion of 129 lower extremities were treated with immediate full-thickness skin graft following a protocol of radical debridement. The full-thickness skin grafts were processed with sharp scalpels in situ. They were further secured with multiple sutures after repositioning to improve skin graft take. Outcomes were evaluated based on different patterns and age groups. RESULTS Three patterns of injury, that is, a purely degloving injury (Pattern 1), a degloving injury with the involvement of deep soft tissues (Pattern 2), and a degloving injury with long-bone fractures (Pattern 3), were revealed. Among the three patterns, much higher primary healing rates were observed in Patterns 1 and 2. Younger patients in Pattern 3 achieved a higher primary healing rate than the old ones, whereas no differences of primary healing rate regarding different age groups were noted in Patterns 1 and 2. CONCLUSION The degloving injuries of the lower extremities can be generally divided into three patterns. The preparation of full-thickness skin graft with scalpels is very simple and prompt. The management of degloving injury of the lower extremity with immediate full-thickness skin grafting following the protocol of radical debridement is feasible. Age has little impact on the skin graft take except for severe cases (Pattern 3) in which old age is an indicator of unfavorable prognosis and special attention is required. LEVELS OF EVIDENCE Prognostic study, level IV; therapeutic study, level V.

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.

The expression of α-SMA in the painful traumatic neuroma: potential role in the pathobiology of neuropathic pain.

The exact mechanism of neuroma-associated pain is not yet fully understood, thus contributing to the substantial challenge faced in managing patients with painful neuromas. We aimed to observe the expression of alpha smooth muscle actin (α-SMA) in the painful traumatic neuroma and to investigate its possible roles in the cause of neuroma-associated pain. Its expression is considered to be a useful phenotypic marker for myofibroblast, and may contribute to its increased contractile activity. We collected peripheral neuroma specimens prospectively and subsequently divided them into two groups: painful (n=21) and non-painful (n=27) based on blinded preoperative visual analogue scale (VAS) pain scores. We also harvested normal nerve specimens from the discarded limbs as a control group (n=8). We performed immunohistological studies to observe the expression of α-SMA in each group, and calculated the expression level by a high-resolution pathological image analysis system. There was no positive staining of α-SMA observed in the control group, slight positive staining in the non-painful group, and obviously positive staining in the painful group. Pearson correlation analysis demonstrated that VAS scores were significantly associated with the expression intensity of α-SMA (R=0.831; p<0.001). Linear regression analysis indicated that the expression intensity of α-SMA was positively related to the scale of VAS (R(2)=0.691, p<0.001). These findings suggest that: 1) expression of α-SMA may play certain roles in painful traumatic neuroma, either as a direct cause of neuroma-associated pain or as an indirect marker of local mechanical stimuli, and 2) the presence of α-SMA in the painful group may provide rationale for transpositional procedures in the management of traumatic neuroma. The persistent existence of α-SMA in the painful group and the correlation with VAS scores may provide insight into the development of new therapeutic strategies.

Management of Degloving Injuries of the Foot with a Defatted Full-Thickness Skin Graft

BACKGROUND Degloving injuries of the foot with involvement of the heel and sole occur relatively rarely but pose an extreme challenge to the reconstructive surgeon due to the unique anatomy of the foot. Very limited studies are available regarding the outcomes of reattachment of the degloved skin as a full-thickness graft. METHODS Twenty-one patients, including eight children and thirteen adults, were treated for a degloving injury of the foot with an immediate defatted full-thickness skin graft from September 2002 to January 2010. After reattachment to its original anatomical site, the graft was further secured with multiple sutures and was fenestrated to improve skin graft incorporation. Traditional dressings were applied. At the time of follow-up, the clinical outcome was graded with use of the Maryland Foot Score. RESULTS Complete incorporation of the graft occurred in ten of the thirteen adults and seven of the eight children (p > 0.05). Follow-up at an average of 32.8 months (range, twenty-four to sixty months) revealed stable wounds in 81% (seventeen) of the twenty-one patients. All stated that they were satisfied with the cosmetic appearance of the affected foot. At the time of the last follow-up, seventeen of the twenty-one patients had a good to excellent score according to the Maryland Foot Score. Sensation restoration in the pediatric group started earlier and progressed faster than that in the adult group, but all patients obtained at least protective sensation eventually and none complained of cold intolerance in the foot. CONCLUSIONS Degloving injuries can be treated successfully with a defatted full-thickness skin graft followed by conventional dressings in both children and adults. This procedure is relatively simple, without the demands of microsurgical techniques, and can provide good functional and cosmetic results.

Role of the NO/cGMP pathway in postoperative vasodilation in perforator flaps.

BACKGROUND The nitric oxide (NO)/cyclic guanylyl monophosphate (cGMP) pathway is one of the most important regulators of tissue perfusion. Here, we sought to elucidate the protective effects of the NO/cGMP pathway on the microcirculation of axial pattern skin flaps. MATERIAL AND METHODS Overall 40 rats were divided into four groups (n = 10 each): group A, sildenafil was administered orally at 10 mg/kg daily; group B, sildenafil citrate (10 mg/kg, oral) and nitro-amino-methyl-L-arginine (L-NAME, intraperitoneal injection), a nitric oxide synthase inhibitor, were administered daily; group C, L-NAME was administered alone; and group D, no drugs were administered. After surgery, the surviving flap area was calculated as a percentage of total flap dimensions using the paper template technique. Angiography and imaging were performed to compare the macrovascular changes of the choke zones in the flaps. Histological examinations were performed to compare the differences in microvascular changes between the two choke zones. RESULTS A significant improvement of flap survival area and a significant dilation of vessels in both choke zones were found after administration of sildenafil. We also found that the postoperative vasodilation of choke vessels could be altered by inhibition of NO synthase (NOS). Moreover, the vasodilatory effect prolonged by the phosphodiesterase 5 inhibitor sildenafil was attenuated after administration of L-NAME. L-NAME significantly reversed the protection afforded by sildenafil. CONCLUSIONS Targeting the NO/cGMP pathway can dilate vessels along the axis of the flap, including the choke vessels, thus augmenting flap viability. Therefore, targeting of this pathway may have therapeutic applications.

Vasculature Characterization of a Multiterritory Perforator Flap: An Experimental Study

Background Tip necrosis in the perforator flap is a significant problem in clinical practice. This study aimed to characterize the vasculature of a multiterritory perforator flap using a rat model and to investigate the impact of the vasculature on flap survival. Methods In total, 105 Sprague Dawley rats were divided into seven groups, including the control, 3 hours postoperative (PO), 12 hours PO, 1 day PO, 3 days PO, 5 days PO, and 7 days PO. A perforator flap with three territories based on the deep iliac circumflex artery was performed. Flaps with only skin incisions and vessel exposure were performed in the control group. The first choke zone (FCZ) was located between the anatomical and dynamic territories, and the second choke zone (SCZ) was located between the dynamic and potential territories. Sodium fluorescein and lead oxide‐gelatin angiography and histological examination were performed in each group. Results Sodium fluorescein angiography revealed delayed staining in the perforator flap PO, particularly in the FCZ and SCZ. The delay phenomenon disappeared after 12 hours PO in the FCZ and after 1 day PO in the SCZ. Nonfluorescein‐stained areas were found distal to the potential territory. In the FCZ PO, the choke vessels were dilated, while the number of microvessels was increased in the SCZ without choke vessel dilation. Conclusions The remodeling of choke vessels and increase in microvessel number represent arteriogenesis and angiogenesis, respectively. This neovascularization was responsible for flap survival in the entire dynamic territory and part of the potential territory.

Significance of alpha smooth muscle actin expression in traumatic painful neuromas: a pilot study in rats.

Treatment of painful neuromas remains a challenge and the mechanism of neuroma-associated pain is not yet fully understood. In this study, we aimed to observe the expression of alpha smooth muscle actin (α-SMA) in traumatic neuromas and to investigate its possible roles in the cause of neuropathic pain in a rat model. The rat sciatic nerve was used and the experiment was divided into two parts. In part I, our results showed significantly higher levels of α-SMA and the pain marker c-fos in the autotomy group than in the no-autotomy group. In part II, the expression of α-SMA in neuromas was down- and up-regulated using SB-431542 and GW9662, respectively. A significant correlation between autotomy scores and the expression level of α-SMA was found (R = 0.957; p < 0.001) and the expression level of α-SMA was positively related to the autotomy scores (R2 = 0.915, p < 0.001). We concluded that the expression of α-SMA plays certain roles in the neuroma-associated pain, either as a direct cause of pain or as an indirect marker of existence of local mechanical stimuli. Our findings may provide new insights into the development of new treatment modalities for the management of intractable painful neuromas.

Experimental study of survival of pedicled perforator flap with flow-through and flow-end blood supply.

Flap viability after transfer depends on blood flow from the arterial blood supply below the fascia. This study evaluated survival of a pedicle flap with a perforator lateral branch and flow‐through blood supply, compared with that of a flap with a flow‐end blood supply and perforator terminal branch.