Soft Tissue Reconstructive Procedures Research Articles

Description of sex difference as prescription for sex change: on the origins of facial feminization surgery.

This article explores the research project that led to the development of facial feminization surgery, a set of bone and soft tissue reconstructive surgical procedures intended to feminize the faces of male-to-female trans- women. Conducted by a pioneering surgeon in the mid-1980s, this research consisted of three steps: (1) assessments of sexual differences of the skull taken from early 20th-century physical anthropology, (2) the application of statistical analyses taken from late 20th-century orthodontic research, and (3) the vetting of this new morphological and metric knowledge in a dry skull collection. When the 'feminine type' of early 20th-century physical anthropology was made to articulate with the 'female mean' of 1970s' statistical analysis, these two very different epistemological artifacts worked together to produce something new: a singular model of a distinctively female skull. In this article, I show how the development of facial feminization surgery worked across epistemic styles, transforming historically racialized and gendered descriptions of sex difference into contemporary surgical prescriptions for sex change. Fundamental to this transformation was an explicit invocation of the scientific origins of facial sexual dimorphism, a claim that frames surgical sex change of the face as not only possible, but objectively certain.

A Bilobed Thoracoabdominal Myocutaneous Flap for Large Thoracic Defects

The author presents a surgical procedure for chest-wall soft tissue reconstruction due to large losses based on a modified thoracoabdominal myocutaneous flap. Designed in a bilobed shape, it rests on the superior epigastric vessels and may include the cranial one fourth of the rectus abdominis muscle and the premuscular fascia of external oblique muscle and constitutes one of the largest flaps based on a single minor artery. Local recurrent breast tumors and adjuvant therapy associated to obesity, high blood pressure, type II diabetes, and tobacco abuse on previously debilitated patients render the usual reconstructive procedure difficulties. These become indications for this flap, whose safety is improved by maintaining the deep fascia of the external oblique muscle attached to the flap to preserve the network of the arteries close to the fascia and a wide-ranging interarterial choke anastomosis alongside the lateral projection of the flap on the thorax. Thus, a wide range of angles allows us to reach even the opposite site of the thorax over the sterna area with an easy closure of the donor site facilitated by the vertical portion of the abdominal donor site. The flap was used in 55 patients, and no serious complications, including necrosis, notable dehiscence, hematoma, seroma, or abdominal wall weakness, were observed. The overall aspect is acceptable with the visible scars over the upper part of the abdomen.

Allografts in soft tissue reconstructive procedures: important considerations.

ContextAllografts offer several important advantages over autografts in musculoskeletal reconstructive procedures, such as anterior cruciate ligament reconstruction. Despite growing widespread use of allograft tissue, serious concerns regarding safety and functionality remain. We discuss the latest knowledge of the potential benefits and risks of allograft use and offer a critical review of allograft tissue regulation, management, and sterilization to enable the surgeon to better inform athletes considering reconstructive surgery options.Evidence AcquisitionA review of sources published in the past 10 years is the primary basis of this research.Study Design:Observational analysis (cohort study).Level of Evidence:Level 3.ResultsComparable outcome data for autografts and allografts do not support universal standards for anterior cruciate ligament reconstruction, and physician recommendation and bias appear to significantly influence patient preference and satisfaction. Sterilization by gamma and electron-beam irradiation diminishes the biomechanical integrity of allograft tissue, but radioprotective agents such as collagen cross-linking and free radical scavengers appear to have potential in mitigating the deleterious effects of irradiation and preserving tissue strength and stability.ConclusionAllografts offer greater graft availability and reduced morbidity in orthopaedic reconstructive procedures, but greater expansion of their use by surgeons is challenged by the need to maintain tissue sterility and biomechanical functionality. Advances in the radioprotection of irradiated tissue may lessen concerns regarding allograft safety and structural stability.

Application of Platelet-Rich Plasma and Platelet-Rich Fibrin in Fat Grafting: Basic Science and Literature Review

Due to the natural properties of fat, fat grafting remains a popular procedure for soft tissue volume augmentation and reconstruction. However, clinical outcome varies and is technique dependent. Platelet-rich plasma (PRP) contains α-granules, from which multiple growth factors such as platelet-derived growth factor, transforming growth factor-β, vascular endothelial growth factor, and epidermal growth factor can be released after activation. In recent years, the scope of PRP therapies has extended from bone regeneration, wound healing, and healing of musculoskeletal injuries, to enhancement of fat graft survival. In this review, we focus on the definition of PRP, the different PRP preparation and activation methods, and growth factor concentrations. In addition, we discuss possible mechanisms for the role of PRP in fat grafting by reviewing in vitro studies with adipose-derived stem cells, preadipocytes, and adipocytes, and preclinical and clinical research. We also review platelet-rich fibrin, a so-called second generation PRP, and its slow-releasing biology and effects on fat grafts compared to PRP in both animal and clinical research. Finally, we provide a general foundation on which to critically evaluate earlier studies, discuss the limitations of previous research, and direct plans for future experiments to improve the optimal effects of PRP in fat grafting.

The “Double-Barrel” Knot

The double-barrel knot is a new arthroscopic sliding knot for soft tissue reconstruction and repair procedures in arthroscopic and open shoulder surgery. The double-barrel knot is a modified sliding hitch, and is formed using 2 sutures from a single double-loaded anchor (single-pulley technique) or 2 sutures from 2 adjacent anchors (double-pulley technique). This paper describes the method of double-barrel knot formation, and its variations; in addition, single-pulley and double-pulley techniques for anterior glenoid labral repair are presented.

Avoiding Complications in Patellofemoral Surgery

The diagnosis and treatment of patellofemoral disorders can challenge even the experienced orthopedic surgeon. Differential diagnosis is broad and multiple anatomic abnormalities must be taken into account in order to manage care. The majority of patients with patellofemoral disorders can be treated successfully nonoperatively. When nonoperative management fails, and in the carefully selected patient, a variety of surgical options exist based on the anatomic pathology involved, but each brings its own potential for complication. We discuss several of the surgical treatment options that are available to the orthopedic surgeon for the treatment of patellofemoral disorders, including lateral retinacular release, medial soft-tissue reconstructive procedures, and bony procedures (including trochleoplasty and tibial tubercle osteotomy. We describe potential complications of each procedure and what the orthopedic surgeon can do to avoid them.

Conversion of open tibial IIIb to IIIa fractures using intentional temporary deformation and the Taylor Spatial Frame

The closure of small-to-moderate-sized soft tissue defects in open tibial fractures can be successfully achieved with acute bony shortening. In some instances, it may be possible to close soft tissue envelope defects by preserving length and intentionally creating a deformity of the limb. As the soft tissue is now able to close, this manoeuvre converts an open IIIb to IIIa fracture. This obviates the need for soft tissue reconstructive procedures such as flaps and grafts, which have the potential to cause donor-site morbidity and may fail. In this article, the authors demonstrate the technique for treating anterior medial soft tissue defects by deforming the bone at the fracture site, permitting temporary malalignment and closure of the wound. After healing of the envelope, the malalignment is gradually corrected with the use of the Taylor Spatial Frame. We present two such cases and discuss the technical indications and challenges of managing such cases.

Safety of Inpatient Reconstructive Surgery Care

INTRODUCTION: Improving quality of healthcare is a national priority. To establish quality benchmarks for plastic surgery, we must understand current rates of adverse events. This project assessed risk-adjusted rates of inpatient adverse events for soft-tissue reconstructive procedures. METHODS: Data from 2005-2009 were extracted from the Nationwide Inpatient Sample (NIS), an Agency for Healthcare Research and Quality database. Patients included had a soft tissue reconstructive procedure as their principal procedure. Adverse events were identified using established patient safety indicators (PSI). All procedure and diagnosis codes were identified using ICD9-CM codes. Our comparison group was all other surgical patients in NIS for 2009. Rates were risk-adjusted PSIs per 1,000 patients. RESULTS: We found 360,549 hospital stays with soft tissue reconstruction as principal procedure and 4.5% had an adverse event during their hospital stay. PSI were associated with increased risk-adjusted mortality (8.5 vs. 0.7, p<.01), and longer stays (29.4 vs. 10.0, p<.01). Overall, PSI rates in plastic surgery patients were lower than other surgical patients. However, PSI risk adjusted rates were significantly higher for death among surgical in-patients with serious treatable conditions (163.02 vs. 128.26), which was almost solely driven by patients with burns. Looking at specific procedures, size reduction (86.83) had significantly higher rates of hematoma/hemorrhage. Rates of hematoma were significantly increased in males compared to female (12.93 vs. 3.62) and were further accentuated when broken down by payer (male, Medicare: 6.02; male, Medicaid, 38.86, male, Private insurance: 12.56). CONCLUSION: Plastic surgery patients had lower PSI's than other surgical disciplines, but PSIs were not uncommon in plastic surgery. These data highlight areas in soft tissue reconstructive surgery where quality improvement efforts can be focused, certainly in males receiving size reduction procedures. With the establishment of the basal rate of PSI's, benchmarks can be devised and areas to target for improvement identified. DISCLOSURES: This study was supported in part VA RR&D Career Development Award (to Catherine Curtin, MD), and grant number K01HS018558 from the Agency for Healthcare Research and Quality. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Department of Veterans Affairs, Stanford University or the Agency for Healthcare Research and Quality.

Versatile Use of Submental Tissue for Reconstruction of Perioral Soft Tissue Defects

To obtain optimum aesthetic result, perioral soft tissue defects require reconstruction using similar tissue. The submental area has very similar characteristics to perioral soft tissue and consists of thin, pliable tissue with a perfect color match. Therefore, we have used submental tissues for reconstruction of perioral soft tissue defects and application of the techniques, and results are discussed in this article. Between February 2001 and April 2008, 14 perioral soft tissue reconstruction procedures using the submental tissues were performed. The defect was on the upper lip including nasal columella in 5 cases, mentum in 3 cases, and oral commissure including buccal cheek in 6 cases. The techniques that were used included composite graft in 3 cases, local advancement flap in 3 cases, pedicled flap in 5 cases, and free flap in 3 cases. Patients were followed up for 9 months to 5 years. During this period, no major complications were noted, and satisfactory aesthetic results were obtained. All transferred submental tissues survived. In all patients, donor defects were closed primarily except in cases of local advancement flap. The donor-site scar was inconspicuous and well hidden below the mandibular margin and did not restrict neck motion in all patients. In particular, hair restoration on the flap was excellent in male patients. We believe that the submental area can provide useful soft tissue for perioral soft tissue defects because it provides a good color and texture match with perioral skin and can be harvested with minimal donor-site morbidity.

Management strategies for shoulder reconstruction in obstetric brachial plexus injury with special reference to loss of internal rotation after surgery

We assessed the outcomes in 24 of 25 children (mean age 3 years) who had soft-tissue shoulder reconstruction procedures for obstetric brachial plexus injuries. All had latissimus dorsi and teres major transfers to strengthen external rotation combined with subscapularis lengthening, reduction of posterior dislocation or subluxation, and humeral osteotomy, if necessary. At a mean follow-up of 3.8 years, the mean Mallet score improved from 12.3 preoperatively to 17.4 postoperatively, active external rotation improved from 21° to 32°, and passive external rotation improved from 26° to 67°. The shoulder remained in joint in all patients. Active internal rotation deteriorated in nine shoulders, two requiring secondary internal rotation osteotomy. Combined soft tissue rebalancing and bony procedures gives reliable shoulder function improvement. Care is required regarding the effect on internal rotation.

Structural and functional analysis of the semitendinosus tendon after harvest for soft tissue reconstructive procedures: a dynamic ultrasonographic study

To assess the potential for regeneration of the hamstring tendons after harvesting for various soft tissue reconstructive procedures, this study uses dynamic, high-resolution ultrasound to evaluate the presence of any tissue in the harvest gap and to characterize tissue functionality. Patients who underwent ACL reconstruction using ipsilateral hamstring autograft were identified in the database of a single surgeon. Dynamic 12-MHz sonographic imaging was used to evaluate the ipsilateral and contralateral (control) semitendinosus tendons from their insertion sites to proximal muscle bellies. The presence or absence and echogenicity of tissue in the harvest defect, tissue appearance, degree of retraction of the proximal tendon stump, thickness of gap tissue, and motion of the proximal tendon stump were recorded. Data were analysed with Wilcoxon-Mann-Whitney, sign or binomial tests, with significance of P<0.05. Eighteen knees in 15 patients (aged 17-51years) were studied. The proximal amputated stump was retracted an average of 9.0±7.6cm (range, 0-18cm; P=0.0063). With dynamic testing, 9 of 15 knees demonstrated decreased excursion of the proximal tendon stump when compared to the native, contralateral muscle-tendon unit (P=0.0039). Tissue was detected in the harvest gap in nine knees, five of which had harvest gap tissue with a disorganized appearance compared to the native tendon (P<0.0001). Six of these nine knees had tissue in the gap demonstrating either less or no excursion with active knee flexion when compared to the native, contralateral side (P=0.0313). The presence of tissue in the harvest gap after ACL reconstruction is variable. When tissue is present, there is proximal retraction of the musculotendinous junction and disorganized appearance of the tissue that does not demonstrate normal excursion or physiological function similar to the native muscle-tendon unit. Case series, Level IV.

Chronic scapholunate instability treated by scaphocapitate fusion: A midterm outcome perspective

Chronic scapholunate instability can lead to functional deficits and radiocarpal osteoarthritis. A number of procedures, namely scapho-trapezio-trapezoid (STT) fusion, scaphocapitate (SC) fusion or soft tissue reconstruction procedures, aim to improve function while protecting the wrist from osteoarthritis. Define the role of scaphocapitate fusion in comparison to STT fusion and capsulodesis and ligament reconstruction. A clinical, radiographic and functional evaluation was performed on 31 SC fusion cases with an average follow-up of 5 years. Range of motion was 41° in flexion and 39° in extension. Radial-ulnar deviation was 43°. Strength was 32.5 kgf (Jamar). The DASH was 27% and the PRWE was 25%. Fifty percent of the wrists were pain-free at rest. Ninety-four percent of patients were satisfied with the procedure. Seventy-eight percent of patients had returned to their occupation. Radiographic analysis revealed that consolidation was obtained at 10.1weeks. The postoperative radioscaphoid angle was 55° with good radioscaphoid congruence. There was no osteoarthritis in the radioscaphoid joint in 84% of the cases. The non-union rate was 13%. These data are similar to the few series that exist. STT fusion leads the same clinical results, but it is technically more difficult and has a higher rate of complications. Capsulodesis and ligament reconstruction provide the same functional results as SC fusion, but with slightly less stiffening. However, these techniques do not seem to protect the wrist from arthritic degeneration at longer follow-up. SC fusion is superior to STT fusion for the treatment of chronic scapholunate instability. This is a pain-relieving intervention with good clinical results and preservation of scaphoid stability. As a component of the surgeon's armamentarium, it can be held in the same regard as capsulodesis and ligament reconstruction for cases of chronic scapholunate instability with a non-reducible scaphoid, or after failure of a soft tissue reconstruction procedure. Level 4, retrospective study.

Angiogenic Biomarkers and Healing of Living Cellular Constructs

The use of intra-oral soft-tissue-engineered devices has demonstrated potential for oral mucosa regeneration. The aim of this study was to investigate the temporal expression of angiogenic biomarkers during wound healing of soft tissue reconstructive procedures comparing living cellular constructs (LCC) with autogenous free gingival grafts. Forty-four human participants bilaterally lacking sufficient zones of attached keratinized gingiva were randomly assigned to soft tissue surgery plus either LCC or autograft. Wound fluid samples were collected at baseline and weeks 1, 2, 3, and 4 post-operatively and analyzed for a panel of angiogenic biomarkers: angiogenin (ANG), angiostatin (ANT), PDGF-BB, VEGF, FGF-2, IL-8, TIMP-1, TIMP-2, GM-CSF, and IP-10. Results demonstrated a significant increase in expression of ANT, PDGF-BB, VEGF, FGF-2, and IL-8 for the LCC group over the autograft group at the early stages of wound repair. Although angiogenic biomarkers were modestly elevated for the LCC group, no clinical correlation with wound healing was found. This human investigation demonstrates that, during early wound-healing events, expression of angiogenic-related biomarkers is up-regulated in sites treated with LCC compared with autogenous free gingival grafts, which may provide a safe and effective alternative for regenerating intra-oral soft tissues (ClinicalTrials.gov number, NCT01134081).

Effect of Early and Delayed Mechanical Loading on Tendon-to-Bone Healing After Anterior Cruciate Ligament Reconstruction

Modulation of the mechanical environment may profoundly affect the healing tendon graft-bone interface. The purpose of this study was to determine how controlled axial loading after anterior cruciate ligament reconstruction affects tendon-to-bone healing. Our hypothesis was that controlled cyclic axial loading after a period of immobilization would improve tendon-to-bone healing compared with that associated with immediate axial loading or prolonged immobilization. One hundred and fifty-six male Sprague-Dawley rats underwent anterior cruciate ligament reconstruction with use of a flexor digitorum longus autograft. A custom-designed fixture was used to apply an external fixator across the knee parallel to the anterior cruciate ligament graft. Animals were randomly assigned to be treated with immobilization (n = 36) or controlled knee distraction along the long axis of the graft to achieve approximately 2% axial strain beginning (1) immediately postoperatively (n = 36), (2) on postoperative day 4 ("early delayed loading," n = 42), or (3) on postoperative day 10 ("late delayed loading," n = 42). The animals were killed at fourteen or twenty-eight days postoperatively for biomechanical testing, micro-computed tomography, and histomorphometric analysis of the bone-tendon-bone complex. Data were analyzed with use of a two-way analysis of variance followed by a post hoc Tukey test with p < 0.05 defined as significant. Delayed initiation of cyclic axial loading on postoperative day 10 resulted in a load to failure of the femur-anterior cruciate ligament-tibia complex at two weeks that was significantly greater than that resulting from immediate loading or prolonged immobilization of the knee (mean and standard deviation, 9.6 ± 3.3 N versus 4.4 ± 2.3 N and 4.4 ± 1.5 N, respectively; p < 0.01). The new-bone formation observed in the tibial tunnels of the delayed-loading groups was significantly increased compared with that in the immediate-loading and immobilization groups at both two and four weeks postoperatively (1.47 ± 0.11 mm(3) [postoperative-day-10 group] versus 0.89 ± 0.30 mm(3) and 0.85 ± 0.19 mm(3), respectively, at two weeks; p < 0.003). There were significantly fewer ED1+ inflammatory macrophages and significantly more ED2+ resident macrophages at the healing tendon-bone interface in both delayed-loading groups compared with the counts in the immediate-loading and immobilization groups at two and four weeks (2.97 ± 0.7 [postoperative day 10] versus 1.14 ± 0.47 and 1.71 ± 1.5 ED2+ cells, respectively, per high-power field at two weeks; p < 0.02). The numbers of osteoclasts in the delayed-loading groups were significantly lower than those in the immediate-loading and immobilization groups at two and four weeks postoperatively (0.35 ± 0.15 [postoperative-day-10 group] versus 1.02 ± 0.08 and 1.44 ± 0.2 cells, respectively, per high-power field at two weeks; p < 0.01), and the delayed-loading groups also had significantly reduced interface tissue vascularity compared with the other groups (p < 0.003). Delayed application of cyclic axial load after anterior cruciate ligament reconstruction resulted in improved mechanical and biological parameters of tendon-to-bone healing compared with those associated with immediate loading or prolonged postoperative immobilization of the knee.

Diabetes mellitus impairs tendon-bone healing after rotator cuff repair

Studies have demonstrated a significant decrease in skeletal mass, bone mineral density, and impaired fracture healing in the diabetic population. However, the effect of sustained hyperglycemia on tendon-to-bone healing is unknown. Forty-eight male, Lewis rats underwent unilateral detachment of the supraspinatus tendon followed by immediate anatomic repair with transosseous fixation. In the experimental group (n = 24), diabetes was induced preoperatively via intraperitoneal injection of streptozotocin (STZ, 65 mg/kg) and confirmed with both pre- and post-STZ injection intraperitoneal glucose tolerance tests (IPGTT). Animals were sacrificed at 1 and 2 weeks postoperatively for biomechanical, histomorphometric, and immunohistochemical analysis. Serum hemoglobin A1c (HbA1c) levels were measured at 2 weeks postoperatively. Statistical comparisons were performed using Student t tests with significance set at P < .05. IPGTT analysis demonstrated a significant impairment of glycemic control in the diabetic compared to control animals (P < .05). Mean HbA1c level at 2 weeks postoperatively was 10.6 ± 2.7% and 6.0 ± 1.0% for the diabetic and control groups, respectively (P < .05). Diabetic animals demonstrated significantly less fibrocartilage and organized collagen, and increased AGE deposition at the tendon-bone interface (P < .05). The healing enthesis of diabetic animals demonstrated a significantly reduced ultimate load-to-failure (4.79 ± 1.33 N vs 1.60 ± 1.67 N and 13.63 ± 2.33 N vs 6.0 ± 3.24 N for control versus diabetic animals at 1 and 2 weeks, respectively) and stiffness compared to control animals (P < .05). Sustained hyperglycemia impairs tendon-bone healing after rotator cuff repair in this rodent model. These findings have significant clinical implications for the expected outcomes of soft tissue repair or reconstructive procedures in diabetic patients with poor glycemic control.

Tailoring the degradation kinetics of poly(ester carbonate urethane)urea thermoplastic elastomers for tissue engineering scaffolds

Biodegradable elastomeric scaffolds are of increasing interest for applications in soft tissue repair and regeneration, particularly in mechanically active settings. The rate at which such a scaffold should degrade for optimal outcomes, however, is not generally known and the ability to select from similar scaffolds that vary in degradation behavior to allow such optimization is limited. Our objective was to synthesize a family of biodegradable polyurethane elastomers where partial substitution of polyester segments with polycarbonate segments in the polymer backbone would lead to slower degradation behavior. Specifically, we synthesized poly(ester carbonate)urethane ureas (PECUUs) using a blended soft segment of poly(caprolactone) (PCL) and poly(1,6-hexamethylene carbonate) (PHC), a 1,4-diisocyanatobutane hard segment and chain extension with putrescine. Soft segment PCL/PHC molar ratios of 100/0, 75/25, 50/50, 25/75, and 0/100 were investigated. Polymer tensile strengths varied from 14 to 34 MPa with breaking strains of 660–875%, initial moduli of 8–24 MPa and 100% recovery after 10% strain. Increased PHC content was associated with softer, more distensible films. Scaffolds produced by salt leaching supported smooth muscle cell adhesion and growth in vitro. PECUU in aqueous buffer in vitro and subcutaneous implants in rats of PECUU scaffolds showed degradation slower than comparable poly(ester urethane)urea and faster than poly(carbonate urethane)urea. These slower degrading thermoplastic polyurethanes provide opportunities to investigate the role of relative degradation rates for mechanically supportive scaffolds in a variety of soft tissue repair and reconstructive procedures.

Angular Shortening and Delayed Gradual Distraction for the Treatment of Asymmetrical Bone and Soft Tissue Defects of Tibia: A Case Series

Acute shortening is reported to be an effective method for the treatment of open fractures with bone and soft tissue defects. Little is known about primary skin closure with angulation to the side of the defect and distraction at the fracture site. We present a series of three cases treated for defective fractures of tibia by angular shortening and delayed gradual distraction with hinged circular external fixator. Two cases were type IIIB open fractures and one case was an infected nonunion. Bone and soft tissue defects were managed by adaptation of edges and primary skin closure with angulation to the side of the defect. Axial alignment was restored by gradual distraction after a 2 to 3 weeks interval. Residual limb length discrepancy was lengthened through a separate corticotomy in two cases. Bone formation at both the fracture and corticotomy sites were sufficient to achieve union in all patients. Fixation time averaged 261 (182-392) days and average bone healing index was 42 days/cm. No further surgical intervention was necessary for soft tissue reconstruction after primary skin closure. Infection was eradicated in the case of infected nonunion. Angular compression to the side of the defect is a safe and reliable method of treatment for asymmetrical bone or soft tissue defects of tibia. It eliminates the need for complex soft tissue reconstruction procedures. Unnecessary debridement of bone is prevented by angular adaptation of edges. Definitive treatment of complex injuries is possible with a circular external fixator.

A Simplified Technique for Repair of Recurrent Peroneal Tendon Subluxation

Peroneal tendon subluxation or dislocation denotes intermittent or chronic anterior displacement of the peroneus longus and brevis tendons out of their fibro-osseous tunnel at the distal and posterior aspect of the fibula. Numerous surgical techniques have been described to address peroneal tendon subluxation, including isolated or combined soft tissue and osseous reconstructive procedures. The authors present an efficient and simplified approach for addressing this pathology using multiple, nonabsorbable retention sutures without the need for extensive dissection or osteotomy.

Combined Medial Patellofemoral Ligament and Medial Patellotibial Ligament Reconstruction in Skeletally Immature Patients –Surgical Technique

Patellar instability is a common knee disorder encountered in young athletes. Patients with normal osseous anatomy and mechanical alignment of the lower extremity are candidates for soft-tissue reconstructive procedures. In skeletally immature patients, surgical techniques that address patellar instability must avoid disruption of open physes and therefore must rely on soft-tissue techniques. Biomechanical research demonstrates that the medial patellofemoral ligament is the primary soft-tissue restraint to lateral subluxation of the patella, and the medial patellotibial ligament is an important secondary stabilizer. We present a novel physeal-sparing surgical technique that anatomically reconstructs both the medial patellofemoral and medial patellotibial ligaments using semitendinosus autograft.

Erfahrungen mit der distal gestielten, dorsalen Metakarpalarterien (DMCA)-Lappenplastik und ihren Varianten in 41 Fällen

Distally based DMCA flaps are an established procedure for soft tissue reconstruction in the hand. Since the introduction of the DMCA flaps, several variants have been developed to match specific defect requirements. The aim of this retrospective study is to give an overview of the experience with the DMCA flaps based on a single center's experience. 41 distally based DMCA flaps have been performed from 2000 to 2004. Twenty-nine times a distally based DMCA flap has been performed, nine times the extended distally based DMCA flap and three times a distally based DMCA fascial flap. In summary, 34 flaps showed no complications, five had a partial necrosis, but were successfully treated with split-thickness skin graft, and two flaps were lost due to infections. The distally based DMCA flaps II to IV have proven to be reliable flaps, but nevertheless require sufficient surgical experience. They are suitable for any kind of defects, including burn reconstruction. Defects of the entire finger can be covered by the various variants of the DMCA flaps.