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Vascularized bone grafts in spinal reconstruction: An updated comprehensive review

In the past two decades, plastic surgeons have advanced to the forefront of spinal surgery, joining orthopedic and neurosurgeons in the multidisciplinary field of spino-plastics. As the global disease burden grows with an increased incidence of spinal pathologies, vascularized bone grafts (VBGs) define the current frontier of spino-plastic surgery. Vascularized bone grafting involves lifting segments of bone with the muscular attachments but without the inclusion of a named vessel. When compared to traditional nonvascular bone grafts and allografts, VBGs have come forward as a favored technique for complex spinal reconstruction due to the unique opportunity to capitalize on the relationship between the tendons and Sharpey's fibers which maintain blood flow to both the bone and muscular segments. This technique ensures robust autologous tissue rearrangement and also takes advantage of the osteoinductive properties of the bone segments, promoting adequate structural support and the perfusion necessary for efficient direct healing and fusion in intricate spine reconstructions. Another one of the many favorable qualities of VBGs is the diversity of sources available to surgeons. The review explores the role of VBGs in enhancing spinal fusion rates and minimizing morbidity compared to traditional approaches. Additionally, a detailed examination of six common VBG sources-the iliac crest, ribs, medial scapula, occiput, spinous processes, and clavicle is included, highlighting each graft's specific techniques and emphasizing the range of options available to spino-plastic surgeons.

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Lower extremity degloving soft tissue injuries: Patterns, treatment, and short-term Outcome in Sudan: A Sub-Saharan African setting

BackgroundDegloving soft tissue injury is among the most devastating trauma types, especially when involving the lower extremities. This study aims to identify degloving soft tissue injury (DSTI) Patterns, Treatment, and Short-term Outcomes. MethodsThis is a prospective, cross-sectional, hospital-based study of patients with DSTIs over six months. ResultsFifty-six patients with lower extremity DSTIs were included. The mean age of the patients was. 29.2 years.Males were predominant (71.4 %). The common site for DSTIs is the dorsum of the foot. Fourteen patients with degloving injury to the foot dorsum had open fractures with type 3 A Gustilo classification. Participants with MESS 1 did not have underlying fractures. Patients with higher MESS scores experienced a more severe form of injury. Most of the patients presented late to plastic surgery services. Definitive management offered to the patients includes secondary intention, direct closure, SSG, and loco-regional flap. The loco-regional flaps used were random fascia-cutaneous, sural, saphenous, Lateral gastrocnemius, and medial gastrocnemius. Thirty-nine of the participants had no complications following management. The complications encountered include Surgical site infection, wound dehiscence, and partial graft or flap loss. These complications were managed by local wound care and a local flap. More extended hospital stay was observed in patients with low revised trauma scores. ConclusionLower extremity DSTIs are common injuries in Sudan, and it is management is challenging. DSTIs with underlying fractures are the most common pattern of injury, with the dorsum of the foot being the most commonly affected part. A multidisciplinary approach is essential for management.

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Evaluation of the cutaneous blood supply and vascular territories of the wrist

PurposeTo determine and evaluate the distal forearm and wrist's cutaneous blood supply and vascular territories. MethodsFour cadaveric upper extremities were injected with a radiopaque, lead-based contrast agent through the brachial artery. After the lead-based contrast agent set, the cadaveric limbs underwent computed tomographic (CT) scanning to assess the perforators to the cutaneous skin of the distal forearm and wrist. High-resolution axial CT and three-dimensional reconstructions were generated to highlight perforating vessels stemming from their parent arteries. Subsequently, anatomic microdissections were performed to identify and trace the perforating vessels identified on CT. ResultsCT analysis and anatomic microdissection demonstrated that the dorsal surface of the distal forearm and wrist are supplied by numerous perforators stemming predominantly from the anterior interosseous artery with some anastomotic contribution from the posterior interosseous, radial, and ulnar arteries. Perforators from the radial and ulnar arteries supply the volar surface. There are large anastomotic networks formed between the perforating vessels. ConclusionsThe distal forearm and wrist have a robust anastomotic blood supply that has contributions from the anterior interosseous, posterior interosseous, radial, and ulnar arteries. Clinical relevanceThe extensive perforator-derived blood supply to the skin likely accounts for the excellent soft tissue healing potential of the wrist following surgery utilizing multiple incisions.

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Exploring the success of fasciocutaneous flap techniques in treating distal leg injuries, a Sub-Saharan African experience from Sudan

BackgroundSoft tissue and bone injuries in the lower extremities associated with high-energy trauma remain a formidable challenge to treat. The timing of the operation, the most suitable type of tissue, and the decision between local or free flap coverage remain under discussion. MethodThis prospective, cohort, multi-center study was conducted in Khartoum, Sudan, from April 2021–September 2021. The study included 70 patients. Data was collected using a questionnaire filled with patients after getting informed consent. ResultsMales were 53(75.7 %) and females were 17(24.3 %). Male to female ratio was 3.1: 1. The mean age of the patients was 27.2 ± 3.4 years. The indications for the use of fascia-cutaneous flap in the management of traumatic soft tissue injuries of distal legs were distal substance loss areas of the leg 55(78.6 %), bone exposure 60(85.7 %), open fracture 29(41.4 %), and tendon exposure 31(44.3 %). The type of fasciocutaneous flap used for the patients in this study was perineal artery flap in 20(28.6 %), sural flap in 19(27.1 %), anterior tibial artery perforator flap in 18(25.7 %), and posterior tibial perforator flap in 13(18.6 %) of the patients in 42(60 %) of the patients, no complications were reported. The reported complications were infection 16(5.7 %), distal flap necrosis 8(11.4 %) and total loss 4(5.7 %). ConclusionDespite advances in microsurgery and free flap use, a fascia-cutaneous flap is still a valid option for distal leg soft tissue reconstruction in settings where this service is unavailable. fasciocutaneous flaps are an excellent option for distal leg defects to cover soft-tissue defects, exposed bones, and tendons.

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Radial nerve palsy in patients presenting with fentanyl/xylazine wounds of the dorsal forearm: A case series

IntroductionThe presence of synthetic compounds like xylazine in the illicit opioid supply of the United States has led to presentations of unique upper extremity wounds in persons who inject drugs. As an alpha-2 adrenergic receptor agonist, xylazine causes local vasoconstriction of blood vessels as well as central nervous system depression. With increased vasoconstriction, patients experience more issues with adequate perfusion which is hypothesized to cause nerve deficiencies near injection sites. MethodsThree patients presenting with a history of deep upper extremity forearm wounds secondary to injection with xylazine and fentanyl had clinically significant radial nerve palsies. Each patient's presentation and clinical course was observed and reported. ResultsIn all three cases, patients presented with chronic necrotic forearm wounds that required repeated surgical debridement and wound care. There was evidence of weakness in the radial nerve distribution, with patients exhibiting dysfunction of the extrinsic digital and wrist extensors. ConclusionProviders should be aware of a common manifestation of radial nerve deficiency in upper extremity wounds in patients with a history of fentanyl-xylazine injections. While surgical management of nerve palsies such as tendon transfers are options for treatment, successful long-term treatment must also rely on multidisciplinary care for addiction and psychosocial support for ideal functional outcomes.

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Intra- medullary nail fixation as a treatment method for impending fracture non-union of a near-total trans-metacarpal amputation initially treated with K-wire fixation – A case report

In hand and digital replantation, Kirschner wires (K-wires) osteosynthesis is regularly used for bone fixation. Percutaneous K-wire fixation (PKWF) has several disadvantages, such as restriction of range of motion (ROM)—as it often crosses the soft tissues of the joints—, need for early extraction before bone-union prolonging immobilization, potentially increasing pin tract infection, and the fact that it does not offer the strongest type of fixation construct compared to other methods.All these factors limit early ROM rehabilitation protocols, therefore impacting functional outcomes. We present a case report of a near-total trans metacarpal (MCP) hand crush amputation by a hydraulic press injury that initially underwent PKWF. The K- wires were extracted at seven weeks post-operatively. The concern of impending non-union and the need for prolonged immobilization after K-wire extraction was addressed by intra-medullary nail fixation (IMNF).In this case, we decided to utilize a less conventional method of osteo-synthesis IMNF to address the concern of impending non-union after initial fixation with K-wires in TMCHR. It provided a stronger fixation construct, no splint immobilization time, and early ROM rehabilitation protocol. All these factors facilitate bone union and improve functional outcomes.This should stimulate further research for this type of situation between IMNF and other types of osteosynthesis by studying the incidence of non-union, infection rates, functional results, and other outcomes. This could also stimulate fabrication, in the laboratory, of intra-medullary nails for metacarpals with antibiotic impregnated hydroxyapatite/poly-L-lactide (HPLLA)—which are not only bioabsorbable, but also osteoconductive—for osteosynthesis in crushed amputations or comminuted fractures. There are several reports in the literature for digital replantation, but none found for amputations at the MCP level.

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A Retrospective Cohort Study of the Anterolateral Thigh Flap in Lower Extremity Traumatic Reconstruction. Does the Muscle Matter?

BackgroundAnterolateral thigh (ALT) flaps has served as a workhorse in lower extremity reconstruction. Flap design showcases both fasciocutaneous (ALT-FC) and myocutaneous variants; the latter includes variable amounts of vastus lateralis muscle (ALT-VL). This study aims to evaluate outcomes of ALT flaps for lower extremity reconstruction at a Level 1 trauma center between ALT-FC and ALT-VL variants and assess if there is any added benefit of muscle in flap design. MethodsA retrospective review was conducted at Los Angeles General Medical Center (2007–2022). Demographics, medical comorbidities, injury characteristics, and outcomes were collected. Outcomes included flap necrosis, postoperative infection, and ambulatory function. ResultsAmong 413 flaps placed, 63 were ALT flaps, of which 43 (68.3 %) were ALT-FC and 20 (31.7 %) were ALT-VL. Patient comorbidities, defect size, and wound severity were not significantly different across cohorts. Infectious and flap outcomes were comparable between cohorts, yet significantly more patients with hypertension and diabetes mellitus had osteomyelitis overall and in the ALT-FC cohort; patients with diabetes mellitus had significantly more flap complications. Flap survival was 96.8 % with 58.7 % of patients being fully ambulatory, without significance across degrees of ambulation or time to full ambulation. ConclusionsOur findings demonstrated good outcomes with low rates of infection and flap loss that were comparable between both ALT-FC and ALT-VL cohorts. ALT-FC has recently been favored given decreased donor site morbidity without impaired function or infectious/flap complications. Accordingly, our findings may suggest that the addition of muscle to flap design may not be necessary for successful reconstruction.

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The keystone island perforator flap: An “ideal” local soft tissue flap for the lower extremity

BackgroundLower extremity reconstruction best requires co-operation between orthopedic and plastic surgeons to preserve the musculoskeletal integrity while establishing essential skin coverage. Traditional dogma suggests microvascular tissue transfers alone would be preferable, but today inherent risks can be avoided by instead using mainly local perforator flaps. MethodsOver a 5 year timeframe, 68 local flaps were used in 66 patients for non-specific lower extremity problems in all regions of the lower extremity in lieu of a free flap. These included both muscle and perforator flaps, the latter including peninsular, propeller, “true” island, and advancement variations. Particular emphasis on the choice of the keystone advancement flap alternative was here undertaken. ResultsAll chosen lower extremity local flaps were successful without resorting to a second flap or skin graft to treat complications. Muscle flaps were used only on 4 occasions, whereas the remaining flaps were perforator flaps. Of these, the keystone island perforator flap was by far the most common choice, [27 (42.2 %)], even exceeding the combined use of propeller and peninsular flaps [26 (40.6 %)]. Keystone flap complications were virtually nil. Keystone flaps were most often used within the flexible tissues of the thigh, but could be used throughout the lower extremity. ConclusionPerforator flaps may be the optimal local flap choice for the lower extremity. Since no discrete perforator need be dissected, the simplest variation is the keystone flap. Harvest and insetting is facile, reliable, aesthetically acceptable, and often sensate. The keystone island perforator flap indeed is an “ideal” lower extremity local soft tissue flap.

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