Free flaps are the gold standard for reconstruction of the mandible, tongue and floor of the mouth. Free fibular flaps are the most preferable option for reconstruction of complex mandibular defects, ...as well as for tongue and mouth floor reconstruction, since they are harvested easily, present excellent sculptability and good functional outcomes. Alternative options for bone reconstruction include the fibular and iliac crest free flap, and for soft tissue reconstruction include the anterolateral thigh, the radial forearm free flap, and the nasolabial island flap. The principles of the surgical approach include resection of the mandibular segment, intraoperative evaluation of the defect, and various surgical manipulations of the flap on site to reconstruct the defect. Advances in computerized preoperative planning have allowed virtual simulation of the defect and fabrication of an individualized stereolithic mandibular model. This short review discusses the current trends of bone and soft tissue flaps for complex oromandibular reconstructions aiming to present a comprehensive review that the readers would find interesting and informative.
Hand macrodactyly is a very scarce deformity. It was first described over 200 years ago and was characterized as "local gigantism" of one or multiple digits. Benign bone overgrowth, massive increase ...of soft tissue volume, and nerve involvement are associated with hand macrodactyly have been consistently reported in the literature. Often, macrodactyly affects one or more digits and is further classified as static or progressive, depending on the growth pattern, and as sporadic or syndromic, according to its genetic predisposition. Surgical treatment for hand macrodactyly remains a complex issue even for expert hand surgeons. In most of the cases, macrodactyly is diagnosed during early childhood and can be appropriately managed with minimal and well affordable surgical approaches that stabilize its fast progression. However, adults with progressive hand macrodactyly develop advanced deformities leading to severe functional deterioration and aesthetic hand dysmorphia. The purpose of this report is to document the management and surgical approach of the oldest published case, a 60-year-old adult patient with neglected progressive hand macrodactyly despite previous surgical attempts for disease stabilization. A personalized preoperative planning was created, which included ray resection involving the fourth metacarpal and fourthfinger along with extensive debulking of the overgrown fatty soft tissue and carpal tunnel release. At six months' follow-up, the patient reported an excellent aesthetic and functional outcome.
•The combined free serratus anterior muscle-rib flap is a reliable surgical option for reconstruction of small and medium size bone and soft-tissue defects even if infected, provided adequate ...debridement and appropriate antibiotic administration.•Due to its multipennate anatomy, it permits the coverage of complex three-dimensional wounds and it can be used as a functional transplant.•It has a relative ease of dissection, increased vascular pedicle length and excellent diameter for anastomosis. Yet, a skilled microsurgical technique, as well as knowledge of the anatomy are prerequisites for a successful outcome.
We report the case of a 40 year-old male with Staphylococcus aureus osteomyelitis of the proximal humerus after open reduction and internal fixation of a fracture from motor vehicle accident. Removal of the osteosynthesis, extensive debridement and intravenous antibiotics administration was done followed by external fixation stabilization and reconstruction with a combined pedicled flap using the serratus anterior reversed flap and the 6th rib. At the last follow-up, healing of the bone flap was observed; the patient experienced useful motion of his upper extremity without any evidence of recurrent infection.
Pachydermodactyly: An Unknown Entity Tolis, Konstantinos, MD, MSc; Stavropoulos, Nikolaos, MD, PhD; Mavrogenis, Andreas, MD, PhD ...
The Journal of hand surgery (American ed.),
08/2016, Letnik:
41, Številka:
8
Journal Article
Recenzirano
Pachydermodactyly is a rare benign disease that usually affects the dorsal skin and subcutaneous tissue of the proximal interphalangeal joints of the index, middle, ring, and little fingers; the ...thumb is usually spared. Hyperkeratosis on the dorsal side of the affected areas is common. We present a case of a 19-year-old man who was diagnosed with pachydermodactyly after evaluation of a painless, progressive swelling and hyperkeratosis at the proximal interphalangeal and distal interphalangeal joints of all fingers, bilaterally, for 6 years before presentation. Conservative treatment was prescribed and the patient remains asymptomatic. Given the benign and nonprogressive course of the disease, symptomatic treatment alone is all that is usually required.
Prospective controlled study.
Previous studies evaluated the effectiveness of sensory reeducation (SR) after peripheral nerve injury and repair. However, evidence for long-term clinical usefulness of ...SR is inconclusive.
The purpose of this study is to compare the sensory results of patients with low-median nerve complete transection and microsurgical repair, with and without SR at long term.
We prospectively studied 52 consecutive patients (mean age, 36 years; range, 20-47 years) with low-median nerve complete transection and microsurgical repair. When reinnervation was considered complete with perception of vibration with a 256-cycles per second tuning fork (mean, 3.5 months after nerve injury and repair), the patients were sequentially allocated (into 2 groups group SR, 26 patients, SR; group R, 26 patients, reassured on recovery without SR). SR was conducted in a standardized fashion, in 2 stages, as an independent home-based program: the first stage was initiated when reinnervation was considered complete, and included instruction in home exercises to identify familiar objects and papers of different roughness, and localization of light touch (eyes open and closed); the second stage was initiated when the patients experienced normal static and moving 2-point discrimination (2PD) at the index fingertip of injured hand, and included instruction in home exercises for stereognosia, supplementary exercises for localization of light touch, and identification of small objects (eyes open and closed). Exercises were prescribed for 5-10 minutes, 4 times per day. At 1.5, 3, and 6 years after nerve injury and repair, we evaluated the static and moving 2PD, stereognosia with the Moberg's pick-up test, and locognosia with the modified Marsh test. Comparison between groups and time points was done with the nonparametric analysis of variance (Kruskal-Wallis analysis of variance).
Static and moving 2PD and stereognosia were not significantly different between groups at any study period. Locognosia was significantly better at 1.5 and 3 years in group SR; locognosia was excellent in 17 patients of group SR vs 5 patients of group R at 1.5-year follow-up and in 14 patients of group SR vs 5 patients of group R at 3-year follow-up. Locognosia was not different between the study groups at 6-year follow-up.
A 2-stage home program of SR improved locognosia at 1.5 and 3 years after low-median nerve complete transection and repair without significant differences in other modalities or the 6-year follow-up of a small subsample.
Isolated scaphoid dislocations are extremely rare injuries and are commonly associated with significant ligamentous disruptions. A dorsiflexion-supination force upon the hand is considered as the ...most common mechanism of injury. Different treatment options have been proposed for the management of this uncommon entity, ranging from conservative treatment with closed reduction and casting to a wide range of open or percutaneous surgical techniques. In this article, we reported ona case of this rare injury managed with open reduction and pinning along with ligamentous reconstruction.
Background
Operative management of scapular body fractures, when indicated, typically involves extensive exposure through a posterior approach. We present our experience with a deltoid preserving ...approach that allows excellent exposure of the fracture lines for reduction and fixation while minimizing muscle detachment and overall tissue trauma.
Technique
Exposure of the scapula was obtained through a posterior incision. The posterior deltoid was exposed and retracted superiorly while the arm was abducted in accordance with Brodsky et al. The scapula was exposed in the interval between infraspinatus and teres minor.
Patients and methods
Six patients were treated using this approach and were retrospectively reviewed. All were men with a mean age of 34 years (range 24–45 ± 6.7 years). The injuries involved two 14-A3.1 and four 14-A3.2 AO/OTA types of fractures. The mean follow-up after surgery was 28 months (range 21–36 ± 4.93 months).
Results
All fractures could be anatomically reduced and healed without compromise. The mean Constant score was 93.8 (range 91–97 ± 2.13), while range of motion and strength returned to levels equal to the uninjured shoulder. All patients returned to their previous level of activity. We did not observe atrophy of the posterior muscles or hardware complications, and none required hardware removal.
Conclusion
The deltoid and external rotators preserving posterior approach permitted good visualization of the fractures while allowing reduction and fixation without extensive muscular dissection and provided excellent functional outcomes. We consider that it offers obvious advantages over more aggressive muscle detaching approaches.
Level of evidence
Therapeutic study, IV.
Background
Four-corner fusion is a rational surgical option for the management of degenerative conditions of the wrist. Most related studies have compared four-corner fusion with scaphoid excision or ...proximal row carpectomy, with a variety of reported results. To enhance the literature, we performed this study to evaluate a series of patients with degenerative conditions of the wrist treated with four-corner fusion using 3 surgical techniques and to discuss the clinical and radiographic outcome of the patients.
Materials and methods
We retrospectively studied 31 patients (24 men, 7 women; mean age, 43 years; 9 heavy manual laborers) who underwent four-corner fusion of their wrists for degenerative conditions from 2005 to 2015. Internal fixation was done using multiple Kirschner wires (14 patients), headless compressive screws (8 patients), or a circular plate (9 patients). Mean follow-up was 4 years (1–11 years). We evaluated the clinical outcome with the Patient-Rated Wrist Evaluation (PRWE) score and fusion with radiographs.
Results
All patients experienced improvement of their pain, function, range of motion and grip strength (
p
< 0.05). Twenty-three patients (74 %) reported no pain, and eight patients reported mild, occasional pain. Twenty-one patients (68 %) were able to do usual and specific activities. Mean wrist motion improved to 70 % and mean grip strength improved to 85 % of opposite wrist. Two heavy manual labor patients requested a job modification because of wrist impairment. Radiographs of the wrist showed fusion of all fused joints in 28 (90.3 %) patients and partial fusion in three patients (9.7 %). No patient with partial fusion required a reoperation for symptomatic nonunion until the period of this study. Three patients experienced complications (10 %). Two patients treated with a circular plate experienced complex regional pain syndrome and painful implant impingement; another patient treated with Kirschner wires and headless compression screws experienced radiolunate arthritis from impingement of the lunate screw to the radius.
Conclusions
Four-corner fusion is a reliable limited wrist fusion technique that provides pain relief, grip strength and satisfactory range of motion in patients with degenerative conditions of the wrist. Partial union is more common with Kirschner wire fixation and complications are more common with circular plate fixation.
Purpose To compare the sensory results of patients with low median nerve complete transection and repair, with and without sensory re-education. Methods We studied 40 patients, aged 20 to 32 years, ...with low median nerve complete transection. Primary epineural repair using 8-0 single-strand sutures was done in all patients. Hands were immobilized in a splint for 4 weeks, followed by physical therapy for 1 month. At a mean of 3.5 months (range, 3–4 months) after surgery, when vibration sense (pallesthesia), using the 256-cycles-per-second tuning fork, was perceived at the fingertips of the 3.5 radial fingers innervated by the median nerve, the patients were randomly assigned to 2 equal groups: group A patients were rehabilitated with a sensory re-education program, and group B patients had no further treatment. Clinical evaluation at 18 months after surgery (range, 17.5–18.5 months) included locognosia (the ability to localize touch), the static and moving 2-point discrimination tests, and the Moberg pick-up test. Results All patients were included in the postoperative evaluation. Static and moving 2-point discrimination were not statistically significant between groups. Locognosia was significantly improved in group A, and a statistical trend was identified regarding the Moberg pick-up test in group A compared to group B. Conclusions Sensory re-education appeared to have significant value only in re-education of locognosia at 18 months after low median nerve complete transection and repair. Type of study/level of evidence Therapeutic II.
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