Donor Site Pain Research Articles

Prospective Randomized Controlled Trial

INTRODUCTION: Pain at split skin graft donor sites is common. Fibrin sealant has been demonstrated to reduce time to hemostasis at wound sites, and patients receiving this treatment were noted to report less pain, triggering this study, which aimed to evaluate pain and incapacity with and without fibrin sealant. METHODS: Fifty patients requiring split skin grafts were prospectively randomized to receive either Mefix only (Mölnlycke Health Care Ltd), or the fibrin sealant TISSEEL (Baxter Healthcare Ltd) plus Mefix, as primary donor site dressings. External secondary dressings were the same. Patients were blinded with regard to treatment group. Using visual analogue scales (scored 0-5), patients were asked to rate their donor site pain and incapacity for 14 days post-operatively. Secondary endpoints were length of hospital stay and duration of requirement for dressings. RESULTS: Fifty patients were recruited and 43 (86.0%) completed self-reported pain and incapacity scores. Twenty-two received TISSEEL plus Mefix and twenty-one received Mefix only (controls). Patients using TISSEEL plus Mefix reported significantly less pain (mean score 0.41 vs. 1.46, p<0.001), and significantly less incapacity (mean score 0.44 vs. 1.54, p<0.001). Patients allocated to the TISSEEL group recorded shorter lengths of stay and faster time to discontinuation of dressing, though statistical significance was not achieved. CONCLUSION: Patients whose split skin graft donor sites were dressed with TISSEEL plus Mefix experienced significantly less pain and incapacity than patients with Mefix dressings. This resulted in a shorter inpatient stay for patients treated with TISSEEL.Figure 1: Mean Daily Post Operative Pain Score, with 95% Confidence Intervals.Table 1: Table 1.

Buccal versus lingual mucosal graft urethroplasty for complex hypospadias repair

ObjectivesTo compare surgical outcomes and donor site complications of buccal and lingual mucosa used as ventral onlay graft for complex hypospadias cases. Patients & methodsForty four cases with complex hypospadias after failed previous surgery were prospectively included. All had severely scarred penile skin with reasonable residual urethral plate. Cases were categorized into two groups: Group I (23) where buccal mucosal graft [BMG] was used and group II (21) where lingual mucosal graft [LMG] was used. Donor site complications as well as functional and esthetic outcomes were recorded for each group. ResultsMean follow up was 20.8 months (range 12–24). Average graft harvesting time was 24 min for BMG and 19 min for LMG. Donor site pain was reported with both techniques but recovery was earlier with LMG. Slurred speech and difficult tongue protrusion were reported with lingual but not buccal grafts; however mouth tightness, peri-oral numbness and persistent oral discomfort were reported only with buccal grafts. Successful urethroplasty was obtained in 78.2% of BMG compared to 76.1% of LMG. ConclusionSurgical outcomes of LMG urethroplasty were comparable to those of BMG in complex hypospadias cases. Compared to buccal mucosa, LMG is easy to harvest, with minimal donor site complications.

Local distal radius bone graft versus iliac crest bone graft for scaphoid nonunion: a comparative study

The aim of the study is to find whether there is any superiority of the iliac crest bone graft over the distal radius bone graft, in surgery of nonunion of scaphoid fractures. This is a prospective randomized controlled trial comparing 50 patients treated with internal fixation and distal radius bone graft (group 1) and 50 patients in whom iliac crest bone graft was used instead (group 2). The patients donor site pain in the postoperative period was assessed using visual analogue scale. At each follow-up, each patient was evaluated using Quick DASH score and Mayo's scoring system. Minimum follow-up was 3 years. Mean value of visual analogue scale for pain was 7.1 for group 2 and 4.2 for group 1. There was no statistically significant difference between the two groups in terms of range of wrist joint motion, functional scores, union rate and fracture reduction. There is no advantage of the iliac crest over the distal radius graft to justify its greater morbidity.

A Microneurovascular TRAM Flap Does Not Compromise Abdominal Sensibility More Than a Conventional One

Classic abdominoplasty for a transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction impairs abdominal somatosensory function at the donor site. The aim of this study was to investigate whether the type of surgical procedure has an effect on somatosensory alterations of abdominal skin after TRAM flap breast reconstruction. Sixty patients (mean ± SD age, 50 ± 6.0 years) who underwent microvascular TRAM flap breast reconstruction and 20 healthy subjects (control group; mean age, 46 ± 6.7 years) participated in the study. Twenty patients had bilateral-nerve anastomosis, 20 had single-nerve anastomosis, and 20 underwent no nerve dissection for the TRAM flap. Clinical sensory examination and tactile and thermal quantitative sensory testing were performed and a patient questionnaire was administered at a mean of 2 to 4.5 years after surgery. All surgical techniques produced significant sensory impairment below the umbilicus, but there were no significant differences in total sensibility scores between the groups with single-nerve (mean sensibility score, 21.98 ± 2.7) and double-nerve (mean sensibility score, 20.71 ± 3.6) anastomosis of the TRAM flap. The best sensibility scores were found in the group with single-nerve dissection. Fifteen percent of patients complained of mild pain, and 13 percent felt occasional tactile hyperesthesia in their abdominal skin, mostly around the umbilicus and scars. In this study, unilateral or bilateral nerve dissection when preparing and lifting a TRAM flap did not seem to increase sensory alterations or postoperative pain in the abdominal donor site after breast reconstruction surgery. Cautious microneurovascular dissection techniques may even improve sensory recovery of the abdominal skin after TRAM flap breast reconstruction surgery.

Osteoconductive Bone Graft Extenders in Posterolateral Thoracolumbar Spinal Fusion

A systematic review. To evaluate the efficacy, safety, and outcomes of osteoconductive bone graft extenders (BGEs) compared with iliac crest bone graft (ICBG) in posterolateral thoracolumbar spinal fusion. ICBG is the current "gold standard" for achieving spinal arthrodesis. However, morbidity associated with its harvesting has led to the increased use of BGEs. An electronic literature search was conducted through April 2011 using MEDLINE, EMBASE, CENTRAL, and Cochrane Library. Risk of bias and methodological assessment was performed using the Cochrane Risk of Bias Tool. Higgins I(2) test was used to assess for heterogeneity. Pooled weighted relative risk (RR) ratios were calculated to compare fusion and adverse event rates. Weighted standardized mean differences were calculated to compare functional outcome and pain scores. Thirteen studies were included representing a total of 768 patients. Overall study quality was low (mean Cochrane Risk of Bias score, 4.8 out of 12; range, 3-6). Fusion rates were comparable between the BGE and ICBG groups (RR, 0.96; 95% confidence interval [CI], 0.89-1.03; P = 0.28). Higgins I(2) test (58%) suggested substantial heterogeneity in the pooling of studies. The pooled rate of donor site pain in the ICBG group was 11.2% (95% CI, 7.4%-15.1%). Reported adverse events, excluding donor site pain, were significantly lower in the BGE group (RR, 0.42; 95% CI, 0.28-0.64; P < 0.0001). Functional outcomes were not significantly different between the 2 groups. Osteoconductive BGEs combined with local spine autograft and/or bone marrow aspirate have comparable fusion rates, similar functional outcomes, lower complication rates, and a lower risk of donor site pain than ICBG. Caution should be taken in interpreting these findings, given the low quality of the studies and the heterogeneity in the results. Randomized controlled studies using blinded assessments are required to help elucidate more conclusive evidence.

The effects of bone marrow aspirate, bone graft, and collagen composites on fixation of titanium implants

Replacement of extensive local bone loss especially in revision joint arthroplasty and spine fusion is a significant clinical challenge. Allograft and autograft have been considered as gold standards for bone replacement. However, there are several disadvantages such as donor site pain, bacterial contamination, and non union as well as the potential risk of disease transmission. Hydroxyapatite and collagen composites (HA/Collagen) have the potential in mimicking and replacing skeletal bones. This study attempted to determine the effects of newly developed HA/Collagen-composites with and without bone marrow aspirate (BMA) on enhancement of bone implant fixation. Titanium alloy implants were inserted into bilateral femoral condyles of eight skeletally mature sheep, four implants per sheep. The implant had a circumferential gap of 2 mm. The gap was filled with: HA/Collagen; HA/Collagen-BMA; autograft or allograft. Allograft was served as the control group. The observation period was 5 weeks. The sheep were euthanized and both femurs were harvested. A push-out mechanical test and histological analysis were performed. No significant differences were seen in the mechanical properties and histomorphometry between autograft and allograft groups. The implants in both the HA/Collagen and HA/Collagen-BMA groups were mostly surrounded by fibrous tissue. Thus, mechanical testing of these samples was impossible. The histomorphometry results showed significantly more new bone and bone ongrowth in the allograft and autograft group compared with the HA/Collagen and HA/Collagen-BMA groups, but no significant difference between HA/Collagen and HA/Collagen-BMA. Autograft and allograft have similar effect on fixation of bone implants. HA/Collagen composite with or without BMA has no effect on the early fixation of bone implants in this sheep model.

A systematic review of anterolateral thigh flap donor site morbidity

The anterolateral thigh (ALT) flap is widely used in reconstruction. Its advantage over other flaps is its purported minimal donor site morbidity. The present systematic review summarizes the types of complications and their incidence with this flap. A secondary objective is to delineate factors that influence these complications and make recommendations to avoid them. Two independent assessors undertook a systematic review of the literature using multiple databases. All patients with ALT flap reconstruction for any defect were included. Donor site complications including lateral thigh paresthesia, musculoskeletal dysfunction, hypertrophic scarring, wound breakdown, infection, donor site pain, seroma, hematoma, compartment syndrome and muscle necrosis were extracted from identified articles and tabulated. Based on the number of pooled events and the number of cases performed, an incidence rate was calculated. Forty-two relevant articles were identified that included 2324 flaps. Of the 2324 flaps, the majority were fasciocutaneous (n=737), and 1303 of the flaps were used in head and neck reconstruction. The incidence of complications were: lateral thigh paresthesia (24.0%); musculoskeletal dysfunction (4.8%); hypertrophic scarring or wound dehiscence (4.8%); donor site pain (3.3%); seroma (2.4%); infection (2.2%); hematoma (0.7%); compartment syndrome (0.09%); and partial muscle necrosis (0.09%). Lateral thigh paresthesia is the most common complication. Severe complications such as compartment syndrome and muscle necrosis can occur, but are rare. Preservation of the lateral cutaneous nerve of the thigh, femoral motor nerve branches and deep fascia decreases the risk of complications. The degree of vastus lateralis disruption did not show a significant impact on musculoskeletal dysfunction.

397 Buccal versus lingual mucosal graft urethroplasty for complex hypospadias repair

Abstract Objectives: To compare surgical outcomes and donor site complications of buccaland lingual mucosa used as ventral onlay graft for complex hypospadias cases.Patients & methods: Forty four cases with complex hypospadias after failed previous surgerywere prospectively included. All had severelyscarred penile skin with reasonable residualurethral plate. Cases were categorized into two groups: Group I (23) where buccal mucosalgraft [BMG] was used and group II (21) where lingual mucosal graft [LMG] was used. Donor sitecomplications as well as functional and esthetic outcomes were recorded for each group.Results: Mean follow up was 20.8 months (range 12e24). Average graft harvesting time was24 min for BMG and 19 min for LMG. Donor site pain was reported with both techniques butrecovery was earlier with LMG. Slurred speech and difficult tongue protrusion were reportedwith lingual but not buccal grafts; however mouth tightness, peri-oral numbness and persistentoral discomfort were reported only with buccal grafts. Successful urethroplasty was obtainedin 78.2% of BMG compared to 76.1% of LMG.Conclusion: Surgical outcomes of LMG urethroplasty were comparable to those of BMG incomplex hypospadias cases. Compared to buccal mucosa, LMG is easy to harvest, with minimaldonor site complications.a 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.* Corresponding author. Department of Urology, Faculty of Medicine, Zagazig University, Zagazig, Egypt. Tel.: þ201008113355;fax: þ20552357478.E-mail address: arifmarof@yahoo.com (A.M. Maarouf).1477-5131/$36 a 2012 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.http://dx.doi.org/10.1016/j.jpurol.2012.08.013Journal of Pediatric Urology (2013) 9, 754e758

Role of Autologous Bone Graft in the Surgical Treatment of Atrophic Nonunion of Midshaft Clavicular Fractures

A retrospective study was conducted to evaluate the role of autologous bone graft in treating atrophic nonunion of midshaft clavicle fracture with a limited-contact dynamic compression plate (LC-DCP). Between 1995 and 2008, sixty cases of atrophic nonunion of midshaft clavicle fractures were managed with open reduction and internal fixation with an LC-DCP. The cases were separated into 2 groups to evaluate the effect of autologous bone graft in the enhancement of bone union. In group 1 (n=24), autologous bone graft was not used; in group 2 (n=36), autologous bone graft was used. Pre- and postoperative management were the same in both groups. Radiographic results and functional outcomes according to the Quick Disability of Arm, Shoulder, and Hand score were evaluated. Average follow-up was 25.2 months (range, 24-48 months).No statistically significant difference was found between the 2 groups regarding demography and preoperative functional scores (P>.05). Operative time and hospital stay were statistically significant longer in group 2 (P<.001), and donor site pain was apparent in group 2. All 60 patients had uneventful union. No statistically significant differences were found between the 2 groups regarding union time (average, 9.8 weeks in group 1 and 9.2 weeks in group 2) and postoperative functional scores (P>.05). Limited-contact dynamic compression plate fixation is an effective method for treating atrophic nonunion of midshaft clavicle fractures. Autologous bone graft was not needed.

The Availability of Autogenous Bicortical Iliac Bone Graft in Anterior Cervical Interbody Fusion

Study Design: Retrospective study. Objectives: To demonstrate the fusion rate, degree of subsidence and donor site morbidity of anterior cervical interbody fusion with autogenous bicortical iliac bone graft and anterior cervical locking plate. Summary of Literature Review: In anterior cervical discectomy and fusion with autogenous tricortical iliac bone graft, a large percentage of patients report chronic donor site pain. Materials and Methods: Retrospective research was done for 39 patients who underwent anterior cervical interbody fusion with autogenous bicortical iliac bone graft, from January 2006 to July 2011, with a follow up period of longer than 1 year. Fusion rates and subsidece of the graft is estimated with radiographs. Neck pain and donor site pain was estimated with visual analogue scale (VAS) and dysfunction was estimated with the neck disability index (NDI). Results: A 95% of patients who underwent anterior cervical interbody fusion with autogenous bicortical iliac bone graft revealed definitive fusion with little amount of subsidence. The mean VAS score was 0.7 on the donor site and the mean NDI score was 3.8 at the final visit. There was excellent clinical outcome without complication at the donor site or the recipient site. Conclusions: Anterior cervical interbody fusion with autogenous bicortical iliac bone graft showed high fusion rates and minimal subsidence with excellent clinical outcomes. Therefore, bicortical iliac bone graft is an effective operational procedure in anterior cervical interbody fusion.

Stem cell-mediated osteogenesis: therapeutic potential for bone tissue engineering

Intervertebral disc degeneration often requires bony spinal fusion for long-term relief. Current arthrodesis procedures use bone grafts from autogenous bone, allogenic backed bone, or synthetic materials. Autogenous bone grafts can result in donor site morbidity and pain at the donor site, while allogenic backed bone and synthetic materials have variable effectiveness. Given these limitations, researchers have focused on new treatments that will allow for safe and successful bone repair and regeneration. Mesenchymal stem cells have received attention for their ability to differentiate into osteoblasts, cells that synthesize new bone. With the recent advances in scaffold and biomaterial technology as well as stem cell manipulation and transplantation, stem cells and their scaffolds are uniquely positioned to bring about significant improvements in the treatment and outcomes of spinal fusion and other injuries.

Comparison of Operating Time between Stand-alone Cage and a Standard Method for a Single Level Cervical Disc Disease.

ObjectiveAutologous bone graft with anterior plating had been a standard method for anterior cervical discectomy and fusion (ACDF). Drawbacks of a standard method were donor site problem and problem associated with anterior plate. The stand-alone cage was introduced to reduce such problems. However, problems associated with subsidence and local kyphosis at the index level (segmental kyphosis) still persist with stand-alone cage and a standard method would be required in some cases. It seems that harvest of autologous bone and anterior plating procedure is time consuming, but this has not been verified. The aim of this study was to compare the operating time between patients operated on with stand-alone cage versus a standard method for single-level cervical disc disease.MethodsConsecutive 29 patients (M:F=18:11; mean age, 58.4±12.4 years), who had undergone ACDF for single-level disc disease by a single surgeon from incision to closure during 2009-2011, were selected for this retrospective study. Seventeen patients were operated with stand-alone cage (Group I), and twelve patients were with a standard method (Group II). Operating time (from incision to closure), estimated blood loss, clinical and radiological outcomes were compared. Follow-up period was 11.4±6.3 months.ResultsOperating time was not different between groups longer; Group I (96.1±28.7 minutes) and Group II (112.4±31.7 minutes) (p=0.13). There was no surgery related complication. Excellent or good outcome was achieved in 11 and 10 patients of group I and II, respectively. Bony fusion was achieved in 15 and 10 patients of group I and II respectively, while one subsidence occurred in each group. Postoperative segmental angle at the index level and cervical curvature was not different between groups. No patient complained donor site pain at the last follow-up.ConclusionsACDF with a standard method for single-level cervical disc disease was not a time-consuming procedure comparing stand-alone cage.

A Novel Technique for Split-Thickness Skin Donor Site Pain Control

Abstract : Pain after split-thickness skin grafting can be severe. The current management of donor site pain is limited to oral and parenteral narcotics and nonnarcotic adjuncts, topical analgesics, and regional and axial anesthesia.1 The ON-Q Postop Pain Relief System (I-Flow Corporation, Lake Forest, CA) consists of an ON-Q pump and Soaker catheter designed to deliver a continuous infusion of local anesthetic to a surgical site. The device is Food and Drug Administration approved for postoperative/postinjury pain control and has been described after laparotomy, thoracotomy, inguinal hernia repair, and rib fractures.2 4 We describe our experience at the U.S. Army Institute of Surgical Research (USAISR) with the use of subcutaneous catheter placement for continuous infusion of local anesthetic placed deep to lower extremity split-thickness skin graft donor sites. Standard excisional preparation of a skin or soft tissue wound is carried out. A split-thickness donor site is chosen, typically from the upper lateral thigh, and skin is harvested at a depth of 0.010 inches. Autografting is completed and the grafted wounds are dressed. The local anesthetic infusion catheters are then inserted in the subcutaneous space deep to the skin donor site via palpation as the included introducer and needle are advanced. Of note, when using the sharp (as opposed to the blunt tip) introducer, 2 to 3 cm of the distal end of the Soaker catheter must be trimmed to allow it to pass through the introducer and remain with its perforated portion entirely within the subcutaneous space deep to the donor site. The insertion site is placed 2 to 5 cm cephalad to the most proximal portion of the donor site. Two (optionally, only one) 10-cm catheters are passed in parallel, one medially and one laterally, to cover the entire field of a 200- cm2 donor site (Figure 1). The catheters are primed with 2 ml of 1 4% bupivacaine and attached to the ON-Q Pain Pump device, which infuses at a rate of 4 ml/hr.

Allograft Cellular Bone Matrix in Extreme Lateral Interbody Fusion: Preliminary Radiographic and Clinical Outcomes

Introduction. Extreme lateral interbody fusion (XLIF) is a minimally disruptive alternative for anterior lumbar interbody fusion. Recently, synthetic and allograft materials have been increasingly used to eliminate donor-site pain and complications secondary to autogenous bone graft harvesting. The clinical use of allograft cellular bone graft has potential advantages over autograft by eliminating the need to harvest autograft while mimicking autograft's biologic function. The objective of this study was to examine 12-month radiographic and clinical outcomes in patients who underwent XLIF with Osteocel Plus, one such allograft cellular bone matrix. Methods. Forty (40) patients were treated at 61 levels with XLIF and Osteocel Plus and included in the analysis. Results. No complications were observed. From preoperative to 12-month postoperative followup, ODI improved 41%, LBP improved 55%, leg pain improved 43.3%, and QOL (SF-36) improved 56%. At 12 months, 92% reported being “very” or “somewhat” satisfied with their outcome and 86% being either “very” or “somewhat likely” to choose to undergo the procedure again. Complete fusion was observed in 90.2% (55/61) of XLIF levels. Conclusions. Complete interbody fusion with Osteocel Plus was shown in 90.2% of XLIF levels, with the remaining 9.8% being partially consolidated and progressing towards fusion at 12 months.

The efficacy of porous hydroxyapatite bone chip as an extender of local bone graft in posterior lumbar interbody fusion

To evaluate whether a synthetic bone chip made of porous hydroxyapatite can effectively extend local decompressed bone graft in instrumented posterior lumbar interbody fusion (PLIF). 130 patients, 165 segments, who had undergone PLIF with cages and instrumentation for single or double level due to degenerative conditions, were investigated retrospectively by independent blinded observer. According to the material of graft, patients were divided into three groups. HA group (19 patients, 25 segments): with hydroxyapatite bone chip in addition to autologous local decompressed bone, IBG group (25 patients, 28 segments): with autologous iliac crest bone graft in addition to local decompressed bone and LB group (86 patients, 112 segments): with local decompressed bone only. Radiologic and clinical outcome were compared among groups and postoperative complications, transfusion, time and cost of operation and duration of hospitalization were also investigated. Radiologic fusion rate and clinical outcome were not different. Economic cost, transfusion and hospital stay were also similar. But operation time was significantly longer in IBG group than in other groups. There were no lasting complications associated with HA and LB group with contrast to five cases with persisting donor site pain in IBG group. Porous hydroxyapatite bone chip is a useful bone graft extender in PLIF when used in conjunction with local decompressed bone.

Anatomically safe and minimally invasive transcrestal technique for procurement of autogenous cancellous bone graft from the mid-iliac crest

Open iliac bone harvesting techniques can result in significant complications and residual morbidity. In reconstructive procedures where a small volume of autogenous cancellous bone graft is required, a minimally invasive technique for bone harvesting applied at the mid-iliac crest has been deemed satisfactory. We sought to assess the application of a well-established surgical technique to procure adequate volume of autogenous cancellous iliac bone graft with minimal trauma to adjacent structures. We retrospectively reviewed the cases of patients who underwent a minimally invasive transcrestal mid-iliac bone graft procurement technique between May 2003 and December 2007. The technique was performed using a 3.5-mm Steinmann pin as a trocar and a 4.5-mm AO drill sleeve as a trephine. We administered a questionnaire, either in the clinic or by mail, to assess a number of parameters, including postoperative pain, dysthesia, parasthesia, status of the donor site wound and patient satisfaction. Of the 37 consecutive patients who underwent the procedure, data from 26 patients were available for assessment. Donor site pain resolved within a few days of the surgery, and none of the patients experienced symptoms of chronic pain. At the final review, none of the patients reported any unpleasant signs and symptoms related to the residual scar. We recommend that the described minimally invasive trephine method be used when a small cancellous bone graft is needed. We found that patient morbidity was significantly lower with the trephine harvest technique than with open bone harvesting methods at the anterior iliac crest.

Continuous Bupivacaine Infusion Post-Iliac Crest Bone Graft Harvesting in Pediatric Cleft Surgery: Role and Comparison with Ketorolac

To investigate the use of intravenous ketorolac and iliac crest bupivacaine infusion in the management of iliac crest donor-site pain in the pediatric cleft population. The null hypothesis was there is no difference with respect to pain scores between ketorolac and iliac crest bupivacaine infusion as analgesic adjuncts to intravenous opioids. A total of 54 children and adolescents (27 boys, 27 girls) undergoing alveolar cleft repair or Le Fort I osteotomy were assigned randomly in a prospective, single-blinded fashion to one of three groups: intravenous ketorolac plus iliac crest normal saline infusion, intravenous ketorolac plus iliac crest bupivacaine infusion, or iliac crest bupivacaine infusion alone. Iliac crest infusions and ketorolac were administered for 48 hours or until discharge, whichever occurred first. All patients received morphine via a patient-controlled analgesia device. Primary outcome was pain score, and secondary outcomes were morphine consumption and satisfaction scores. Pain scores, morphine consumption, and satisfaction scores were not significantly different among groups. Estimated costs were significantly higher for bupivacaine infusion than intravenous ketorolac. Iliac crest donor-site pain is well managed in this patient population. Intravenous ketorolac and iliac crest bupivacaine infusion provide comparable analgesia for iliac crest bone graft donor-site pain in children and adolescents.

Deepithelialized reverse pedicled forearm flap: a technical modification useful in hand and wrist reconstruction

Reverse pedicled forearm flap is a reliable and easy option for hand and wrist reconstruction. Between 2000 and 2009, eight patients underwent elective reconstruction of an upper extremity using a pedicled reverse radial forearm flap with a modified technique; a retrospective chart review of the results is presented. The surgically modified procedure is described. The flap donor area is deepithelialized with a dermatome and the split-thickness skin graft obtained is left on the donor site pedicled proximally; the deepithelialized flap is then elevated and rotated with the standard technique and the forearm donor site is covered by repositioning and suturing the skin previously harvested with the dermatome. This useful and easy technical modification allows prevention of post-operative pain and long-term dyschromia in the split-thickness skin graft donor site, making the reverse pedicled forearm flap an even better option in hand and wrist reconstruction.

Single-level instrumented posterolateral fusion versus non-instrumented anterior interbody fusion for lumbar spondylolisthesis: a prospective study with a 2-year follow-up

BackgroundSurgery for lumbar spondylolisthesis is widely performed. However, there have been no reports comparing posterolateral and anterior interbody fusion prospectively. We compared instrumented posterolateral fusion with anterior interbody fusion for L4 spondylolisthesis in a prospective study. MethodsForty-six patients diagnosed with L4 degenerated spondylolisthesis were divided into two groups. Twenty-two consecutive patients underwent non-instrumented anterior interbody fusion using an iliac bone graft (ALIF; L4-L5 level), and 24 consecutive patients underwent instrumented posterolateral fusion with local bone (PLF; L4-L5 level). The rates of bone union, visual analog scale (VAS) score, Japanese Orthopedic Association (JOA) score, Oswestry Disability Index (ODI), surgical invasion, and complications were evaluated before and 2 years after surgery. ResultsAge, VAS score, JOA score, and ODI were not significantly different between the two groups before surgery (P > 0.05). Success of bone union between the two groups was not significantly different (P > 0.05). Blood loss during surgery was significantly less; however, periods of bed rest and hospital stay were significantly longer in the ALIF group (P < 0.05). Overall patient satisfaction, and low back and leg pain in both groups were significantly improved after surgery; however, low back pain showed greater improvement in the ALIF group compared with the PLF group (P < 0.05). Complications such as donor site pain (4 patients in the ALIF group) and dural tearing (3 patients in the PLF group) were observed. ConclusionsIf single level fusion for L4 spondylolisthesis is performed, both anterior and posterior methods reduce patients' low back and leg pain. Improvement of low back pain was significantly greater after ALIF; however, periods of hospital stay and of bed rest were significantly longer.

Complications following autologous bone graft harvesting from the iliac crest and using the RIA: A systematic review

Bone grafting is a commonly performed surgical procedure to augment bone regeneration in a variety of cases in orthopaedic and maxillofacial surgery. Autologous bone graft remains to be the ‘gold standard’ and the iliac crest to be the most common harvesting site. The intramedullary canal of long bones represents another potential site for large volume of autologous bone graft harvesting and is recently being used as an alternative donor site. However, harvesting of autologous bone graft is associated with morbidity and a number of complications. The aim of this systematic review was to collect and summarise the existing data on reported complications after harvesting autologous bone from the iliac crest (anterior and posterior) and the long bone intramedullary canal using the RIA device. We searched the PubMed Medline and Ovid Medline databases, from January 1990 to October 2010, to retrieve all relevant articles. A total of 92 articles (6682 patients) were included in the analysis. Overall, the complication rate following RIA was 6% (14 complications in 233 patients) and 19.37% after iliac crest bone graft harvesting (1249 complications in 6449 patients). The rate of each of the reported complications was assessed and, when the donor site was properly documented, comparison within the anterior and posterior iliac crest donor sites was performed. Although the difference of the overall morbidity rates between the two harvesting sites was not statistically significant (p=0.71); the rates of certain complications were found to significantly differ when anterior or posterior iliac crest was used. The rates of infection (p=0.016), haematoma formation (p=0.002), fracture (p=0.017), and hyperthrophic scar (p=0.017) were significantly higher when the donor site was the anterior iliac crest compared to the posterior iliac crest; whereas the rates of chronic donor site pain (p=0.004) and sensory disturbances (p=0.003) were significantly lower. The incidence of bone graft harvesting related complications can be reduced further if certain principles are followed depending on the performed harvesting methods; but overall the use of RIA device as harvesting method seems a promising alternative with a low complication rate.