Morsy, Mohamed

Abstract The purpose of this study was to evaluate the incidence and outcomes of traumatic lunate fractures in a Level I trauma center over a 20-year period. Traumatic lunate fractures are rare, making it difficult to determine their frequency, outcomes, and patterns in clinical practice. A retrospective evaluation of 57 patients was conducted at a single institution from 2000 to 2022. Imaging studies, including radiographs, computed tomography, and magnetic resonance imaging, were reviewed to confirm traumatic etiology and fracture pattern. Fifty-seven lunate fractures met inclusion criteria: 11 were isolated and 46 had associated carpal fractures. Treatment included immobilization in 31 patients and surgery in 26. At a mean follow-up of 20.5 months (range, 2–186), average wrist flexion–extension range of motion was 90 degrees (range, 45–160), and grip strength averaged 26 kg (range, 6–48). Patient-reported outcomes were collected at a mean of 105 months (range, 12–226), with mean scores of 27 for the Disabilities of the Arm, Shoulder, and Hand, 19 for the Patient-Rated Wrist Evaluation, and 77 for the Mayo Wrist Score. Complications included 25 cases of posttraumatic arthritis, 2 cases each of avascular necrosis (AVN), nonunion, and complex regional pain syndrome, and 1 hardware infection. Posttraumatic arthritis was more frequently observed in patients with dorsal intercalated segment instability (DISI), age over 50 years, and displaced fractures. Lunate fractures occur in conjunction with greater arc injuries. Volar pole fractures were the most common fracture type observed. Predictors of long-term osteoarthritis included age over 50 years, DISI deformity, and displaced fractures at the time of diagnosis. Surgical fixation methods resulted in comparable outcomes. Two lunates progressed to AVN, both of which occurred following open operative fixation. Prognostic, Level IV

Introduction Tissue loss as a consequence of congenital anomalies, trauma, malignancy, or gangrene represents a major health care problem in the United States. Because younger individuals are disproportionately affected, the costs are magnified over time and the resultant individual and societal effects are tremendous. The currently available options to restore soft tissue defects are associated with donor site morbidities. Vascularized composite allotransplantation may provide form, function, and esthetics without a donor site; however, it comes with the significant risk associated with toxic immunosuppression (Biomaterials. 2015;61:246-256, Ann Plast Surg. 2015;75(1):112-116, Transplantation. 2009;88(2):203-210). Engineered tissues offer promise in finding viable alternatives to allograft and autologous tissues. In this study, we present our simple and quick method to decellularize a muscle without disrupting the vascular network integrity or the extracellular matrix. Optimizing the decellularization process is a crucial step toward creating an “off-the-shelf” flap that can be used for soft tissue reconstruction. Methods The superficial gracilis muscle of 20 rats were harvested on their circulation and decellularized using perfusion with Krebs-Henseleit buffer and sodium dodecyl sulfate for 6 hours. These flaps were evaluated by gross morphology, histology, DNA quantification, integrity of the vascular network, scanning electron microscopy, and transmission electron microscopy. Results All samples were decellularized successfully as determined by DNA content and histological analysis for cellular content. The vascular network was preserved in all samples. Conclusions We present a quick, simple, and affordable method to decellularize a muscle flap through the vascular network. Our proposed method is efficient and can be completed in a significantly shorter time when compared with other methods. It is also safe and does not affect integrity of tissue, and this is essential for a reliable recellularization.

Background: The superficial femoral artery and medial thigh region has been an underused donor site for perforator flaps. This study evaluated perforasomes of the superficial femoral artery and its principal branches to review the clinical applications for locoregional reconstruction. Methods: Twenty-six fresh cadaveric lower extremities were dissected. Perforator size and anatomical course from the superficial femoral artery, descending genicular artery, and saphenous artery branch were documented. Perforators were selectively injected with iodinated contrast to assess vascular territories using computed tomography. A retrospective chart review was conducted on consecutive patients (2014 to 2015). Results: One hundred thirty perforators were mapped in the medial thigh region. Eleven extended medial thigh perforator flaps and 15 hemicircumferential flaps were harvested. The mean distance from the joint line was 16.7 ± 7.3 cm. Perforators arose from the superficial femoral artery (62 percent), saphenous artery branch (23 percent), and descending genicular artery (15 percent). Superficial femoral artery perforators were located around the mid and proximal thigh region (p < 0.001). The median perforasome surface area was 244 cm2, representing 36 percent in hemithigh flaps with preferential filling in the anteromedial region. Proximal perforasomes were the smallest. Perforasome areas based on vessel origin were comparable; however, saphenous artery perforators had a broader perforasome compared with descending genicular (p = 0.01) and superficial femoral artery perforators (p = 0.04). Six clinical case examples were presented for knee, thigh, and lower leg reconstruction. Conclusions: The superficial femoral artery or its branches can provide nontraditional reconstructive perforator flap options in regional reconstruction. They can be simple to harvest using a free-style approach, do not require preoperative imaging, offer a one-stage reconstructive method with low morbidity, and obviate the need for microsurgery or muscle flaps.

Background: Various vascular pedicles have been used to supply the proximal fibula for vascularized epiphyseal transfer. The optimal pedicle has, however, not been agreed on. This study aimed to describe the detailed vascular anatomy of the proximal fibula to assist the surgeon in choosing the optimal pedicle. Methods: Twenty-eight lower extremities were injected with latex or a mixture of latex and barium sulfate. Vessels supplying the proximal fibula were identified and dissected, and the course, diameter, anatomical relations, length, and branches were documented. In the barium group, high-resolution computed tomographic scanning was conducted before dissection. In seven specimens, branches of the deep peroneal nerve to the tibialis anterior muscle were carefully preserved, and their relation to the proximal fibular vascularity was noted. Results: An anastomotic vascular network supplied the proximal fibula. This was formed superiorly by branches of the inferior lateral genicular artery, and inferiorly by branches of the anterior tibial artery, the most important of which were the first and second recurrent epiphyseal arteries. One or more deep peroneal nerve branches passed deep to the first recurrent epiphyseal artery in all specimens examined. In five specimens, all of the branches were superficial to the second recurrent epiphyseal artery, whereas two had branches deep to it. Conclusions: The proximal fibula can be transferred using the inferior lateral genicular or anterior tibial artery because of the existing anastomosis. Factors including length of pedicle, potential for nerve injury, and diaphyseal portion to be harvested should be considered in the pedicle choice.

Background: The medial femoral condyle free vascularized bone flap is a valuable alternative to other types of vascularized bone grafts. The donor-site morbidity and functional outcomes after flap harvest have not been fully appreciated. The authors report the postoperative outcomes and analyze the impact of increasing the size of the flap on knee donor-site morbidity. Methods: A retrospective chart review of patients who underwent medial femoral condyle flap surgery between 2001 and 2012 at their institution was performed. The size of the flap was stratified, based on the largest dimension, into three groups. Demographics, outcomes, and complications related to the flap donor site were recorded and analyzed. Subsequently, functional status was assessed by administering a validated condition-specific measure. A univariate logistic regression analysis was performed, and results were analyzed. Results: A total of 75 patients were identified. Average age was 29.5 ± 15.2 years. Average follow-up time was 13 months. The overall complication rate was 18.6 percent. Paresthesia in the saphenous nerve distribution was the most common complication. Increasing the size of the flap resulted in a significant elevation in complication risk (p < 0.05). A total of 47 patients completed the Lower Extremity Functional Scale questionnaire. The average Lower Extremity Functional Scale score was 72.12 ± 14.18. Fifty-one percent (n = 24) scored 80 points, indicating a normal level of function on average. Conclusions: The medial femoral condyle flap has overall acceptable donor-site morbidity, with a good level of function postoperatively. Larger flaps are associated with a greater number of complications. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Study Design. Systematic review and meta-analysis of observational studies. Objective. The aim of the study is to evaluate different treatment modalities in the management of sacrococcygeal chordoma. Summary of Background Data. Chordomas are primary malignant bone tumors associated with considerable morbidity and mortality. Methods. We searched MEDLINE, EMBASE, Cochrane Central-Register of Controlled Trials, and Scopus from inception to July 2015. Eligible studies included patients with sacrococcygeal chordoma treated exclusively with surgery, radiotherapy, or both. Two reviewers independently assessed the eligibility of potential studies, risk of bias, and extracted data. Outcomes of interest were all-cause mortality, progression-free survival, and metastases. We analyzed further surgical outcomes by resection margin. All outcomes were assessed at 60 months and more than 60 months following intervention. Results. We included 33 noncomparative studies reporting on 501 patients (mean age 57 years). Overall mortality rate was (16%) after surgical resection with adjuvant radiotherapy and (28%) after surgical resection, and (43%) after radiotherapy (P = 0.28). All-cause mortality following wide surgical resection was (32%) compared to (40%) after marginal resection (P = 0.51). Overall progression-free survival rate was (58%) after surgical resection with adjuvant radiotherapy and (55%) after surgery (P = 0.92). However, at more than 60 months follow-up, progression-free survival rates were significantly higher (P = 0.024) following surgical resection with adjuvant radiotherapy (74%) in comparison to surgery (55%) and radiotherapy (36%). Overall progression-free survival rates were nonsignificantly higher after wide surgical resection (66%) than marginal resection (33%) (P = 0.16). However, at 60 months follow-up, progression-free survival rates were significantly higher following wide surgical resection (73%) than marginal resection (33%) (P = 0.047). Conclusion. Sacrococcygeal chordoma is a difficult to treat disease entity. Until comparative studies become available, wide surgical resection and multidisciplinary management are the recommended approaches to improve patient outcomes. Level of Evidence: 3

Background: Multiple enchodromatosis of bone, termed Ollier’s disease, or Maffucci syndrome when associated with hemangiomas, is a rare disease that can affect the pediatric hand. This condition often causes a finger mass, deformity, pain and possible pathologic fractures, and has been associated with malignant transformation to chondrosarcoma. The aim of our study is to describe the long-term sequela of multiple enchondromatosis of the hand in the pediatric population, specifically the rates of malignant transformation, tumor recurrence, rates of pathologic fracture, and phalangeal growth arrest. Methods: We examined 15 pediatric patients who were treated in our institute with a total of 127 phalanges and metacarpals lesions. Only patients with follow-up of at least 4 years were included. We retrospectively reviewed patients’ chart and hand radiograph for symptoms including pathologic fractures, indications for surgery, and postoperative complications including tumor recurrence, and malignant transformation. We assessed phalangeal growth arrest with radiographs and normalized phalangeal growth charts. Results: Mean age of diagnosis was 5.8 years and mean follow-up time was 15.4 years. Pathologic fractures were common at 46% of pediatric patients, but ceased to occur once reaching adulthood. Outcomes of pathologic fractures were excellent, regardless of treatment. Malignant transformation occurred in 1 patient and did not occur during childhood. A total of 80% of patients and 29% of lesions underwent surgical treatment of curettage and bone graft for the lesion, yet recurrence was common and affected 33% of treated patients. Phalangeal growth arrest was the most common long-term sequela and affected 11% of phalanxes and metacarpals. This sequela was significantly more prevalent in patients who had surgical excision of the tumor. Conclusions: Our findings reassure that malignant transformation of enchodromatosis of the hand is unlikely in the pediatric population. Pathologic fracture is common, but has excellent outcomes. When considering surgery, parents should be counseled about the possibility of phalangeal growth arrest and recurrence of the lesion. Type of Study/Level of Evidence: Level IV—therapeutic.