Moran, Steven L.

Background Small recalcitrant defects of the mandible and maxilla may be secondary to tumor, trauma, infection, and congenital origin. Vascularized bone grafting has been shown to effectively manage these defects; however, donor sites are limited. The vascularized medial femoral condyle (MFC) provides adequate cortical cancellous bone with the option of a skin island, consistent anatomy, and minimal donor site morbidity. This article outlines the use of the MFC flap for maxillomandibular reconstruction. Methods A retrospective chart review of patients who required segmental maxillomandibular reconstruction with the MFC flap was conducted. A total of 9 patients (5 men and 5 women) with an average age of 45.3 years were identified. The etiology of the defects, flap sizes, and postoperative outcomes were recorded. Results Three patients had osteoradionecrosis of the neomandible after irradiation of the free fibula reconstruction, 3 patients had defects after cancer extirpation (1 mandible, 2 maxillary), 1 patient had a maxillary defect from trauma, and 2 patients had a residual cleft palate defect. All defects failed initial treatment with nonvascularized bone grafts. The average dimensions of the MFC flaps were 1.2 × 2.5 × 4 cm. Two of 9 flaps included a skin island. Eight flaps survived completely, but 1 patient suffered from flap failure requiring debridement and resulted in an oroantral fistula. Four patients received endosseous dental implants. Average time to union was 6.7 months, and average time to implant was 6.75 months. The average follow-up time was 24.9 months. Conclusions The MFC flap is useful in the reconstruction of small segmental maxillomandibular defects and for the salvage of a neomandible after osteoradionecrosis. The MFC flap provides a reliable platform for endosseous dental implants and serves as an alternative source of vascularized bone reconstruction in the head and neck.

Background: There continues to be controversy regarding the treatment of early-stage arthritis of the wrist, particularly in young patients, because of the large number of techniques, the poor long-term results for many of these techniques, and the overall paucity of high-level scientific data. Proximal row carpectomy (PRC) and 4-corner arthrodesis (4CA) have been established as the mainstay motion-sparing surgical treatment options in cases of early scapholunate advanced collapse and scaphoid nonunion advanced collapse arthritis. However, there is marked controversy surrounding the best treatment option for younger patients with greater physical demands because of the questionable outcomes associated with these motion-sparing options in such patients 1–9 . Traditionally, many surgeons prefer 4CA over PRC for young, high-demand patients, in part because studies have suggested that young age and work status as a laborer are important risk factors for worse outcomes following PRC 1,8 . However, the concern for symptomatic nonunion and potential for radiolunate arthritis in 4CA, as well as the lack of medium to long-term comparative studies in this subset, make this recommendation controversial 10 . Description: The wrist is accessed via the dorsal approach, creating a retinacular flap and a radially based ligament-sparing capsulotomy. The scaphoid, lunate, and triquetrum are then excised en bloc. The radioscapholunate ligament is protected. The capsule and retinaculum and then repaired. Alternatives: Alternatives to PRC include nonoperative treatment, 4CA, capitolunate arthrodesis, posterior and anterior interosseous neurectomies, total wrist arthroplasty, and total wrist arthrodesis. Rationale: A recent study by Wagner et al. compared patients <45 years old who underwent either PRC or 4CA 11 . Overall, PRC and 4CA had similar complication rates, postoperative pain levels, wrist function, and long-term outcomes free of conversion to arthrodesis. Patients who underwent PRC had improved motion and fewer complications, whereas patients who underwent 4CA had slightly lower rates of radiocarpal arthritis. Therefore, in this technique article, we describe PRC for wrist arthritis in patients <45 years old.

AbstractTargeted muscle reinnervation enables native muscles to send electromyographic signals to myoelectric receptors, which drive movements in a prosthesis. This system requires voluntary contracture of muscles for sequential control of powered prosthetic joints. This report describes a surgical solution for cases where the chest wall is depleted of muscle targets. A 13‐year‐old boy with left forequarter amputation and pectoralis major resection as a result of extended necrotizing facilities 8 years prior received a neurotized free Vertical Rectus Abdominus Mycocutaneous (VRAM) flap (28 × 10 cm) designed to produce myoelectric signals, reduce pain, and provide stability for prosthetic fitting. Five intercostal nerves from the VRAM were coapted to portions of the brachial plexus to create a myoelectric interface for targeted muscle reinnervation. The postoperative course was uneventful. At 39 months of follow‐up, the patient gained control of the transferred VRAM and was able to operate a custom‐fitted myoelectric prosthesis together with contraction of the ipsilateral infraspinatus muscle. The neurotized VRAM transfer created a neural interface in an area with depleted neuromuscular targets while decreasing pain and adding tissue bulk for proper prosthesis fitting. Such a surgical strategy may have applications in other areas of the body.

Background: Foam-mediated external suction (FMES) has previously shown to improve tissue microcirculation. We hypothesized that preconditioning fasciocutaneous perforator flaps with FMES would augment perfusion and demonstrate greater capillary recruitment. Methods: Gluteal perforator flaps were designed on sixteen 400 g rats. Continuous FMES at −125 mm Hg was applied on one side (intervention) to precondition tissue for 5 days, with the contralateral side as a paired control. In group A, we assessed changes following pretreatment, after surgery, and 7 days postprocedure, and in group B, we evaluated changes during preconditioning alone. In group A (N = 8), control and intervention flaps were assessed using laser-assisted indocyanine green fluorescence angiography. In group B, flap regions were assessed using 4-dimensional computed tomographic angiography. All flaps were analyzed for microvessel density using micro–computed tomography and histological assessment using hematoxylin and eosin and CD3 immunohistochemistry. Results: Thirty-two flaps were included in this study (N = 16 intervention and matched controls). Four-dimensional computed tomographic angiography demonstrated 17% greater tissue perfusion in preconditioned flaps (mean, 78.7 HU; SD, 8.8) versus controls (mean, 67.3 HU; SD, 15.7; P < 0.01). Laser-assisted indocyanine green fluorescence angiography showed a 30% higher mean absolute intensity in preconditioned flaps versus controls (P < 0.01). Postsurgery mean absolute intensity in preconditioned flaps remained 21% higher than in controls (P = 0.03). Preconditioned flaps demonstrated a 2-fold increase in mean vessel volume of 9.1 mm3 (SD, 7) versus 4.5 mm3 (SD, 3) in controls (P = 0.04); there was a 33% higher mean area fraction of CD31 in preconditioned flaps, 3.9% (SD, 3) versus 2.9% (SD, 3) in controls (P = 0.03). Conclusion: FMES preconditioning has the potential to augment vascularity of tissue for flap harvest; however, further experimental studies are required to optimize strategies and evaluate long-term effects for clinical applications.

Introduction Dysfunction of the distal radioulnar joint (DRUJ) can be significantly debilitating. The Sauve-Kapandji (S-K) procedure can be indicated to address multiple etiologies of DRUJ dysfunction. The purpose of this study was to review our institution’s results performing the S-K procedure for DRUJ dysfunction in terms of clinical and radiographic outcomes, as well as complications and reoperations. Methods A retrospective review of S-K procedures performed at 2 institutions between 1998 and 2017 with a minimum of 1-year follow-up was performed. Preoperative and postoperative visual analog scale (VAS) pain, grip strength, and wrist range of motion were reviewed. Radiographs were reviewed for DRUJ healing, carpal translation, and radiocarpal degenerative changes. Results The cohort included 35 patients. The mean age was 51 years. The mean follow-up was 49.5 months. The postoperative range of motion was unchanged in regard to pronation, supination, and wrist extension. There was a decrease in wrist flexion from 43 degrees to 34 degrees. Successful union was noted in 100% of the wrists. There was 1 case (2.8%) of progressive ulnar translation and 4 major complications (11.3%). Conclusion The S-K procedure has several theoretical benefits compared to other procedures for DRUJ dysfunction with results of this study demonstrating excellent pain relief, improved postoperative grip strength, retained wrist pronation, supination, and extension, high rate of successful arthrodesis and low rate of major complications. Level of Evidence Level IV

Four corner arthrodesis and proximal row carpectomy are the most common techniques for the management of advanced radiocarpal arthritis due to longstanding scapholunate instability and scaphoid nonunion. The advantages and short comings of each technique have been well defined in the literature. Advancements in joint replacement and arthroscopic surgery have resulted in new operations to manage radiocarpal and midcarpal arthritis. Most of these new procedures are modifications of the two classical operations, but some use modern implants and newer materials. New individualized options, like osteochondral grafting in combination with proximal row carpectomy or (arthroscopic) distal resection of the scaphoid, allowed us to improve our treatment and offer patients less invasive but equally effective procedures. We consider that four corner arthrodesis and proximal row carpectomy should not always be standard management for advanced radiocarpal arthritis.

AbstractBackgroundThe non‐weight‐bearing (NWB) Achilles tendon and weight‐bearing (WB) heel pad regions are technically challenging to reconstruct with distinct functional and aesthetic considerations that have not been previously considered in the literature. This study is the first to characterize the long‐term clinical and patient‐reported outcomes of these components to better inform patients about the postreconstruction period.MethodsA retrospective review of medical records and phone‐based survey of adult patients who underwent free flap reconstruction of the heel/ankle with 6‐month minimum clinical follow‐up was performed.ResultsForty‐three patients, with 31 (72.1%) NWB and 12 (27.9%) WB defects, treated from January 1, 2000 to February 28, 2017 were included. Muscle flaps were more common than fasciocutaneous flaps (N = 36 [83.7%] vs. 7 [16.3%]). Flap survival rate was 95.3% and limb salvage rate was 93.0% at median follow‐up of 12.0 months (interquartile range [IQR] 6.2, 25.5). Flap ulceration occurred more frequently in the WB region (41.7 vs. 6.5%, p = .0123). The survey response rate was 63.6%. The majority of patients complete daily tasks with no/little impairment (76.2%), walk half a mile or more (85.7%), returned to work (86.6%), and fit shoes “fair” or “well” (71.4%). Most patients were “very satisfied” with heel/ankle function (71.4%) and would “very likely” undergo the same procedure if needed (76.2%).ConclusionsFree flap reconstruction in both the NWB Achilles tendon and WB heel pad has excellent limb salvage and flap survival rates. Patients were satisfied with heel/ankle function, but additional counseling is recommended for variance in appearance and higher ulceration rates in WB defects.

AbstractReducing tendon failure after repair remains a challenge due to its poor intrinsic healing ability. The purpose of this study is to investigate the effect of a novel tissue‐engineered purified exosome product (PEP) patch on tendon healing in a canine ex vivo model. Lacerated flexor digitorum profundus (FDP) tendons from three canines' paws underwent simulated repair with Tisseel patch alone or biopotentiated with PEP. For the ex vivo model, FDP tendons were randomly divided into three groups: FDP tendon repair alone group (Control), Tisseel patch alone group, and the Tisseel plus PEP (TEPEP) patch group. Following 4 weeks of tissue culture, the failure load, stiffness, histology, and gene expression of the healing tendon were evaluated. Transmission electron microscopy revealed that in exosomes of PEP the diameters ranged from 93.70 to 124.65 nm, and the patch release test showed this TEPEP patch could stably release the extracellular vesicle over 2 weeks. The failure strength of the tendon in the TEPEP patch group was significantly higher than that of the Control group and Tisseel alone group. The results of histology showed that the TEPEP patch group had the smallest healing gap and the largest number of fibroblasts on the surface of the injured tendon. Quantitative reverse transcription polymerase chain reaction showed that TEPEP patch increased the expression of collagen type III, matrix metallopeptidase 2 (MMP2), MMP3, MMP14, and reduced the expression of transforming growth factor β1, interleukin 6. This study shows that the TEPEP patch could promote tendon repair by reducing gap formation and inflammatory response, increasing the activity of endogenous cells, and formation of type III collagen.

Abstract Keloid scar formation arises from a disorganized fibroproliferative collagen response that extends beyond the original wound margins because of excessive production of extracellular matrix (ECM). Despite treatment options for keloid scars including medical and surgical therapies, such as intralesional steroid injection and surgical excision, the recurrence rate remains high. Herein we consolidate recently published narrative reviews, systematic reviews, and meta‐analyses to provide an overview of updated treatment recommendations for keloidal scar formation. PubMed search engine was used to access the MEDLINE database to investigate updates regarding keloid incidence and treatment. More than 100 articles were reviewed. Keloid management remains a multimodal approach. There continues to be no gold standard of treatment that provides a consistently low recurrence rate; however, the increasing number of available treatments and synergistic combinations of these treatments (i.e., laser‐based devices in combination with intralesional steroids, or 5‐fluorouracil (5‐FU) in combination with steroid therapy) is showing favorable results. Future studies could target the efficacy of novel treatment modalities (i.e., autologous fat grafting or stem cell‐based therapies) for keloid management. This review article provides updated treatment guidelines for keloids and discusses insight into management to assist patient‐focused, evidence‐based clinical decision making.