Reconstruction Of Upper Extremity Research Articles

Characteristics of the Gantzer muscle and implications for its use as a tendon-graft source in upper extremity reconstruction

BackgroundThe Gantzer muscle is an anatomical variant muscle that functions in flexion of the volar forearm. The prevalence and laterality of this muscle has been studied more recently in the literature. This study aimed to determine the prevalence and size of this muscle and tendon. MethodsThis was an observational study done from September 2021 to January 2022 at the University of North Texas Health Science Center in Fort Worth, Texas. Cadaveric dissection was conducted in the Department of Physiology and Anatomy. 50 pairs for a total of 100 forearms were dissected bilaterally in cadavers comprising 17 females (34 %) and 33 males (66 %) to identify the Gantzer muscle. The mean age at death was 68.8 years of age (range 40–91 years). When present, the dimensions of each Gantzer tendon were measured in millimeters using digital calipers. As a study of cadaveric specimens, this study was exempt from Institutional Review Board (IRB) approval. ResultsThe Gantzer muscle was present in 62 of the 100 forearms (62 %). All 62 Gantzer muscles originated from flexor digitorum superficialis (FDS) (100 %). Of the 62 Gantzer muscles, 42 inserted distally into flexor pollicus longus (FPL) (72.5 %), while the remaining 17 muscles inserted distally into flexor digitorum profundus (FDP) (27.5 %). The tendons inserting into FDP had an average length of 65.495 mm, while those inserting into FPL had an average length of 16.353 mm (p = 0.002). The Gantzer muscle was present in 24 of the 33 male specimens (72.7 %) and 13 of the 17 female specimens (76.4 %). Of the 62 Gantzer muscles, 50 were present bilaterally (80.6 %), and there was no significant difference in bilateral occurrence between sexes (p = 0.189). ConclusionsOur results suggest that the Gantzer muscle may be of sufficient size and present commonly enough in the general population to be considered as an alternative graft source for certain upper extremity reconstruction procedures in place of, or in addition to, palmaris longus, extensor toe tendons, and other commonly used tendon grafts. In this study, when palmaris longus was absent in a specimen, a Gantzer muscle was likely present, and may provide surgeons an alternative tendon graft source in the upper extremity without requiring additional incisions in the lower extremity for alternative tendon graft sources. Further biomechanical testing of the Gantzer tendon with comparisons to other common tendon graft sources is warranted.

The Role of the Fascia-Only Anterolateral Thigh Flap in Extremity Reconstruction: The Fascia-Only Anterolateral Thigh Flap.

Free flap selection in extremity reconstruction can be challenging. The ideal flap has to be thin and pliable to achieve optimal contour and function. We explore the role of the fascia-only anterolateral thigh (fALT) flap in extremity reconstruction. We conducted a retrospective review of our experience using fALT-free flap for extremity reconstruction over a 2-year period. Patient demographics, mechanism of injury, flap characteristics, complications- and follow-up were recorded. Descriptive statistics were calculated. Twelve patients were included. The median (interquartile range [IQR]) age was 34 (28-52) years. One fALT flap was used for upper extremity reconstruction, while 11 flaps were used for lower extremity reconstruction (4 for lower third of the leg, 4 for dorsum of foot, and 3 for heel). The median (IQR) flap surface area was 90 (63-120) cm2 and time from injury to reconstruction was 10 (6-16) days. The postoperative course was uneventful for all flaps except for 1 flap failure and 1 delayed healing. The median (IQR) follow-up was 2 (1-4) months. In all cases, durable soft tissue reconstruction was achieved with no need for revisions. The fALT-free flap can be successfully used in extremity reconstruction. The ALT fascia has robust perfusion that allows for the harvest of a large flap that can be surfaced with a split thickness skin graft. Its thin pliable tissue provides excellent contour for the hand, distal leg, and foot that does not require future thinning, optimizing the cosmetic and functional result.

Сapabilities of Dynamic Infrared Thermography for Planning and Monitoring of Perforating Flaps

Background. Free perforating flaps are the most optimal for reconstruction of both upper and lower extremities. However, along with the obvious advantages of these flaps, there are also a number of difficulties associated with their more complex vascular anatomy and, as a consequence, more time-consuming dissection. This determines the need for a more thorough preoperative planning, including the mapping of perforating vessels and development of flap design. At the same time, the problems with intraoperative assessment of perfusion of perforating flaps and their monitoring in the postoperative period have not been solved. For these purposes, several instrumental methods of examination such as MRI and CT angiography, Doppler sonography, ICG and dynamic infrared thermography are used.
 Aim of the study — to evaluate the capabilities of dynamic infrared thermography (DIT) for mapping of perforating vessels when planning the design of perforating flaps, as well as for assessing their intra- and postoperative perfusion.
 Methods. We have analyzed the results of using DIT along with CT-angiography and Doppler sonography for preliminary mapping of perforating vessels in the design of 18 perforating flaps (ALT flap — 10, SCIP flap — 8) transplanted in 15 patients from 01.01.2022 to 30.07.2022. DIT was also used in all cases for intraoperative instrumental confirmation of flap perfusion and for its monitoring in the postoperative period.
 Results. A total of 39 perforating vessels were detected by CT angiography at the point of origin from the main arteries. DIT was used to detect the distal portions of 37 perforating vessels in 15 patients at the marking of 18 flaps. On average, 2.5 per ALT flap and 1.4 per SCIP flap. Thermographic examination time was approximately 10 minutes. Localization of all perforating vessels detected by DIT were first confirmed by Doppler sonography and then visualized intraoperatively during flap dissection. Intraoperatively, perfusion of all transplanted flaps was clearly confirmed by DIT. In the postoperative period, perfusion problems were clinically detected in 3 (16%) flaps and confirmed by DIT: venous stasis — 2 cases, arterial insufficiency — 1 case. In two patients (13%) with a body mass index of more than 35 (corresponding to class 2–3 obesity), the location of perforating vessels could not be determined by thermography and Doppler sonography. Also, in these patients DIT was ineffective for confirmation of flap perfusion intraoperatively and in the postoperative period.
 Conclusion. This study confirms that CT angiography, Doppler sonography and infrared thermography are complementary methods that allow to detect and visualize perforating arteries from their origin from a main artery to the site of their passage through the deep fascia (CT-angiography), as well as to determine their more accurate projection on the skin surface (DIT and Doppler sonography). DIT is also an auxiliary method for flap monitoring in the intraoperative and postoperative periods, which allows to engage nursing staff in postoperative monitoring.

Comparison of patient Satisfaction of Return to Work in Early Post-operative Periods in patients with High Radial Nerve Injury undergoing Primary Nerve Repair Plus Tendon Transfer Versus Primary Nerve Repair Alone

Background: High radial nerve injuries present complex challenges in upper extremity reconstruction, impacting both motor and sensory functions. The decision-making process for choosing the appropriate surgical intervention involves careful consideration of various factors, including the type of nerve repair and the potential need for adjunct procedures like tendon transfer. Aim: To compare patient satisfaction outcomes between these two surgical approaches, assessing grip strength, pinch strength, Disabilities of the Arm, Shoulder, and Hand (DASH) scores, and Quality of Life (QOL) scores. Methodology: This prospective, comparative, and observational study included 62 participants, equally divided into two groups: Group 1 undergoing Primary Nerve Repair plus Tendon Transfer (n=31) and Group 2 undergoing Primary Nerve Repair Alone (n=31). Data collection involved patient interviews, medical records review, and standardized questionnaires, covering variables such as age, gender, occupation, type of surgery, duration of injury, post-operative pain levels, and patient-reported satisfaction scores. Statistical analysis using SPSS vr 23.0 included descriptive statistics, independent samples t-tests, and chi-square tests. Results: Results indicated significant improvements in grip strength (Mean ± SD: 35.2 ± 4.2 pounds, p < 0.001), pinch strength (Mean ± SD: 7.9 ± 1.4 pounds, p = 1.081), DASH scores (Mean ± SD: 11.5 ± 2.9, p = 2.59), and QOL scores (Mean ± SD: 93.8 ± 7.3, p = 0.73) in both groups, emphasizing the positive impact of surgical interventions on functional outcomes and patient satisfaction. These findings contribute valuable insights into refining surgical strategies for high radial nerve injuries, emphasizing the enhancement of patient outcomes and satisfaction. Practical implication:The study's findings offer crucial guidance for surgeons in selecting optimal surgical strategies, ultimately leading to improved functional outcomes and higher patient satisfaction in individuals with high radial nerve injuries. Conclusion: Both surgical approaches demonstrated significant improvements in grip strength, pinch strength, disabilities of the arm, shoulder, and hand (DASH) scores, and Quality of Life (QOL) scores. Notably, grip strength showed a substantial increase (Mean ± SD: 35.2 ± 4.2 pounds, p < 0.001) in both groups, emphasizing the positive impact of surgical interventions on upper limb function. While pinch strength and QOL scores showed non-significant changes, the overall findings underscore the effectiveness of both surgical strategies in enhancing functional outcomes and patient satisfaction in the early post-operative periods for high radial nerve injuries. Keywords: High radial nerve injury, nerve repair, tendon transfer, patient satisfaction, early return to work, observational study.

Acute Free Fibula Reconstruction of a Ballistic Ulna Fracture

Long bone reconstruction is a complicated topic, especially in cases with a large bone deficit where traditional fixation methods would lead to a high rate of non-union requiring further surgical intervention. Our case is of a male with a gunshot wound to his ulna resulting in a 10cm bone defect and a 15x8cm soft tissue defect. Our goal was to maintain a both bone forearm by reconstructing his ulna to maintain forearm pronation and supination. A chimeric free fibula flap was transferred in the acute setting. Vascularized bone transfer in upper extremity reconstruction is typically considered as an operation after fracture non-union. We propose the use of a vascularized bone flap as a first line therapy in certain instances such as the case above. The use of the free fibula flap can provide vascularized bone and softs tissues and allow for optimal recovery while decreasing the need for further operations.

Comparing surgeries to restore upper extremity function in tetraplegia: Impact on function during the perioperative period

Context/Objective To assess short-term changes in health outcomes in people with cervical-level spinal cord injury (SCI) who underwent upper extremity (UE) reconstruction via either novel nerve transfer (NT) or traditional tendon transfer (TT) surgery with individuals who did not undergo UE surgical reconstruction. Design Prospective, comparative cohort pilot study. Participants 34 participants with cervical SCI met the following inclusion criteria: age 18 or older, greater than 6 months post-injury, and mid-cervical level SCI American Spinal Injury Association Impairment Scale (AIS) A, B or C. Setting Two tertiary academic hospitals and their affiliated veterans’ hospitals. Methods Health outcomes were assessed using two previously validated measures, the Spinal Cord Independence Measure (SCIM) and Short-Form Health Survey (SF-36). Demographic, surgical, and survey data were collected at the initial evaluation and one month postoperatively/post-baseline. Results 34 participants with cervical SCI were recruited across three cohorts: no surgery (n = 16), NT (n = 10), and TT (n = 8). The TT group had a decline in SCIM and SF-36 scores whereas the NT and no surgery groups experienced little change in independence or health status in the immediate perioperative period. Conclusions Surgeons and rehabilitation providers must recognize differences in the perioperative needs of people with cervical SCI who chose to have restorative UE surgery. Future work should focus on further investigation of health outcomes, change in function, and improving preoperative counseling and cross-disciplinary management.

Pre-expanded thin DIEP free flap in pediatric upper extremity reconstruction for burn sequelae: A case report

Deep burns sequelae involving the upper limb are challenging even for experienced surgeons, mainly because local reconstructive options and donor sites are often compromised. The use of free flaps for this type of reconstruction remains difficult due to the small recipient vessel diameter and tendency to vasospasm. Moreover, pediatric cases bring the challenge to another level. We present the case of a 13-year-old girl presenting major retractile sequelae of the upper left limb, including complete wrist immobilization combining wrist hyper-extension, ulnar deviation deformity, and a ulno-carpal dislocation. She was referred to our department where a two-stage reconstruction was performed using a pre-expanded free deep inferior epigastric artery perforator (DIEP) flap. The first surgery consisted of placing two kidney-shaped expanders in a subfascial plane in the hypogastric region. Four months later, after a bi-weekly expansion, an excision of the scar tissue, and the DIEP flap transfer were completed. At the 12-month follow-up evaluation, both aesthetic and functional results were satisfactory, with a good contour and regained mobility of the wrist.

Resurfacing of Sleeve-Like Circumferential Giant Congenital Melanocytic Nevi on the Upper Extremity With Pre-Expanded Pedicled Flap.

As the relative shortage of healthy tissue obviates the option of local soft tissue coverage, reconstruction of circumferential giant congenital melanocytic nevi (GCMN) on the upper extremity remains particularly challenging. Here the authors report a 3-stage procedure involving pre-expanded pedicled flap from the torso for the reconstruction of upper extremity after circumferential GCMN excision in pediatric patients. The giant nevus was completely removed and the size of the excised nevus was 31 × 14.5cm. The donor site was primarily closed. No major complication was encountered. Reconstruction with expanded pedicled flap achieved satisfactory results, both functionally and cosmetically.

Outcomes of Upper Extremity Reconstruction with a Modified Capanna Technique

Outcomes of Upper Extremity Reconstruction with a Modified Capanna Technique

Evolution of free flap reconstruction in the upper extremity: perspective from a tertiary plastic and reconstructive institution.

Soft tissue reconstruction of the upper extremity requires consideration of wound bed status, varied anatomic composition, future function and tissue match, whether in thickness, pliability or involvement of other tissue components. Of the options available, microvascular free tissue flaps allow maximal customizability with the avoidance of long-term donor site morbidity. Free tissue transfers have evolved, given increased surgical proficiency, from direct vessel-based flaps to septocutaneous vessel-based flaps, to musculocutaneous perforator flaps, and most recently to free-style free flaps. With increases in technical complexity come limitless alternatives. We documented the progression of free flap upper extremity reconstruction in recreating form and function of the upper extremity. The foundations laid should allow surgeons the freedom and versatility to choose the most faithful restoration of the defect and produce the best functional and aesthetic results.

Poster (Knowledge Generation) ID 2002621

Background Nerve transfer surgery for patients with spinal cord injury (SCI) is an emergent practice for upper extremity reconstruction currently being implemented in a few clinical settings around the world. In 2019, we implemented an interdisciplinary clinic for upper extremity care in tetraplegic patients. Since the beginning of this collaboration, thirteen patients underwent nerve transfer surgery and followed a specific two-year rehabilitation protocol. Presentation objectives: Methods Thirteen patients underwent a surgical reconstruction of their upper extremity. They followed a rehabilitation process with occupational therapists and physiotherapists. So far, eight patients have completed their two-year rehabilitation process. Routine outcome assessments were collected at 0, 6, 12, 24 months following the surgery. Results Twenty-four arms were operated, for a total of 51 nerve transfers. We will present our epidemiological data, details of the surgeries and results on hand opening, grip and pinch strength, functional testing, as well as satisfaction questionnaires. Conclusion Nerve transfer surgery is an exciting and innovative technique for our SCI patients. An interdisciplinary setting is the key to success. Our data shows that this surgery, well planned and accompanied by proper rehabilitation, is a promising avenue to improve upper extremity function in people with cervical spinal cord injury.

The Superficial Circumflex Iliac Artery Perforator Flap for Devastating Hand Injuries in the Obese.

Blast injuries to the hand, such as those from fireworks, are debilitating and life altering. Often, because of the nature of the injury, there is a need for soft tissue and skin coverage. However, in the increasingly obese American population, free flaps often are too bulky for functional hand coverage. In this study, we present a series of 7 patients who underwent the superficial circumflex iliac artery perforator (SCIP) flap for upper extremity reconstruction with improvement in cosmesis, including a primarily repaired donor site, as well as an overwhelmingly high return to work with minimal revision surgery necessary. All patients who underwent a SCIP for hand injuries from a blast were included. Flaps were harvested based on previously described methods. A single attending surgeon performed all surgeries. All patients were followed for at least 6 months. Preoperative and postoperative characteristics were described. A total of 7 patients were included in this study. Ages ranged from 16 to 58 years and body mass index from 19 to 48 kg/m2. More than half of the patients had a body mass index greater than 30 kg/m2. All donor sites were primarily closed. Five patients returned to their preinjury work. Three patients had neurotized flaps with return of protective sensation. Three patients required revision surgery; all 3 had liposuction, and 1 had additional flap advancement surgery. The SCIP flap is a versatile flap that can be used in hand reconstruction in blast injuries with good functional outcome and improved cosmesis compared with other perforator flaps for the upper extremity.

Reconstruction of oncologic upper extremity defects with fibula free flaps has high union rates and excellent functional outcomes.

Limb salvage has better functional outcomes than amputation in the upper extremity. This can however be challenging after bony tumor resections. This is a retrospective case series of patients who underwent humerus, ulna, or radius reconstruction with a fibula free flap. Data were collected on demographics, oncologic history, surgical details, and complications. Functional outcome measures included the patient's ability to perform activities of daily living (ADL), presence of pain, and musculoskeletal tumor society (MSTS) score. Over a 25-year period, 38 reconstructions were performed. The flap success rate was 97.5%. Bony union was obtained in 19 of 19 (100%) forearm reconstructions and in 15 of 19 (79%) humerus reconstructions (p = 0.10). All 19 forearm reconstruction patients and 18/19 humerus reconstruction patients were able to perform ADLs with no pain or only occasional pain. The MSTS scores were not significantly different between the humerus and forearm cohorts (27.1 vs. 27.3, p = 0.68). Functional outcomes were significantly better in limbs that achieved union (p < 0.001). Recipient and donor site complications occurred in 10 (26.3%) and 5 (13%) patients, respectively. Oncologic upper-extremity reconstruction with fibula free flaps has excellent functional outcomes. Bone union is a predictor of superior limb function.

Propeller Perforator Flaps Used for Hand and Digit Reconstruction: A Systematic Review

BackgroundPropeller perforator flaps (PPFs) have increased in popularity due to the freedom in design and ability to cover a variety of defects without sacrificing the major vessels. Present reports of PPFs for upper limb reconstruction have not provided guidance for hand reconstruction, specifically. This study aims to review the current literature and evaluate techniques for use of PPFs in hand reconstruction. MethodsA comprehensive literature review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for articles published from 1991 to 2021. The database search was queried for records using appropriate Medical Subject Headings (MeSH) terms. Studies reporting PPFs were limited to English language and excluded lower extremity or upper extremity reconstruction not specific to defects in the hand or digits. Study characteristics, patient demographics, indications, preoperative testing, flap characteristics, flap survival, and complication rates were collected. ResultsOut of the initial 1,348 citations yielded, 71 underwent full-text review. Ultimately, 25 unique citations were included encompassing 12 retrospective reviews (48%), 3 prospective cohort studies (10%), and 10 case series (40%). In review, 525 patients underwent reconstruction with a total of 613 propeller flaps performed to repair defects of the hand, digits, or both with use of 18 unique flap types. Overall flap survival was 97.8%. Acute wounds accounted for 72.9% of performed reconstructions. The mean flap coverage was 14.7 cm2. Complications occurred in 19.8% of cases, with venous congestion and partial flap necrosis occurring in 5.5 and 6.5% of cases, respectively, leading to a flap failure rate of 2.1%. ConclusionPPFs are a reliable option for hand or digital reconstruction, allowing surgeons to cover a variety of defects without sacrificing local vasculature. Despite nearly a 20% reported complication rate, nearly all flaps with venous congestion and partial flap necrosis included in these articles resolved without the need for secondary intervention, retaining an excellent overall flap survival.

Refinements in the Preexpanded Distant Flap for Giant Melanocytic Nevi of the Upper Extremity in Pediatric Patients.

Surgical treatment of large and giant congenital melanocytic nevi (GCMN) of the upper extremity is challenging because of limited options for reconstruction. A preexpanded distant flap is considered an important option in upper extremity reconstruction, where the soft tissue available for use is limited. The authors aimed to refine the preexpanded distant flap after excision of the GCMN in the upper extremity. Large (>10 cm) and giant (>20 cm) congenital melanocytic nevi of the upper extremities treated with tissue expansion and distant flaps over 10 years were retrospectively reviewed, and the authors describe in detail the surgical strategies for reconstruction of the upper extremity with a distant flap. From March of 2010 to February of 2020, 13 patients (mean age, 2.87 years) treated with 17 preextended distant flaps were included. The mean flap dimension was 154.87 cm 2 , ranging from 15 × 5 to 26.5 × 11 cm. All procedures were successfully completed except for one, in which partial flap necrosis occurred. Preconditioning was performed before flap transfer in 5 patients with larger rotation arcs and flap dimensions. The mean duration of postoperative follow-up was 51.85 months. A new reconstructive protocol was proposed that combined the 3 elements, including a distant flap, tissue expander, and preconditioning. In the treatment of GCMN in the upper extremities, careful planning and multiple stages are required. For pediatric patients, the preextended distant flap with preconditioning is useful and effective for reconstruction. Therapeutic, IV.

Shape-modified radial forearm flap: does it still have a role in upper extremity reconstruction?

ObjectivesTo carry out a radial forearm flap, the radial artery is usually harvested, incurring severe donor site morbidity. Advances in anatomical knowledge discovered constant radial artery perforating vessels, enabling the subdivision of the flap into smaller components suitable for a wide range of differently shaped recipient sites, with marked reduction of downsides. Material and methodsEight pedicled or free shape-modified radial forearm flaps were used to reconstruct upper extremity defects between 2014 and 2018. Surgical technique and prognosis were examined. Skin texture and scar quality were assessed on the Vancouver Scar Scale while function and symptoms on the Disabilities of the Arm, Shoulder and Hand score. ResultsAt a mean follow-up of 39 months, no cases of flap necrosis, impaired hand circulation or cold intolerance were found. ConclusionThe shape-modified radial forearm flap is not a new technique, but is poorly known by hand surgeons; in contrast, our experience showed it to be reliable, with acceptable functional and esthetic outcomes in selected cases.

Abstract No. 589 Reconstruction of Upper Extremity and Thoracic Central Veins Using Dedicated Venous Stents: Deployment of 75 Stents in 46 Patients

Dedicated bare-metal venous stents, including Abre (Medtronic; Dublin, Ireland), Venovo (Becton, Dickinson, and Company; Franklin Lakes, NJ), Vici (Boston Scientific; Marlborough, MA), and Zilver Vena (Cook Medical; Bloomington, IN), are approved for treatment of iliofemoral venous occlusive diseases. This study describes the use of these stents in the upper extremity and thoracic central veins. Forty-six patients (24 females and 22 males; mean age 52.8 ± 15.5 years) underwent reconstruction of the upper extremity and thoracic central veins using dedicated venous stents from 10/17/2019 to 08/15/2022. All patients presented with swelling, 21 with pain, three with dysphagia, and one with dyspnea. Stent placement parameters (type, location, diameter, length), technical success (stent deployment resulting in patent in-line flow), adverse events, clinical success (resolution of presenting symptoms), and revision parameters were recorded. Seventy-five stents were deployed during 52 procedures. Venous stents used included 43 Abre, 21 Venovo, seven Vici, and four Zilver Vena. Reconstructed veins included: superior vena cava (SVC)-to-bilateral brachiocephalic veins (BCVs) (n = 12), unilateral BCV (n = 12), SVC-to-unilateral BCV (n = 9), SVC only (n = 8), SVC-to-unilateral subclavian vein (SCV) (n = 6), and unilateral BCV-to-SCV (n = 5). Overall mean stent diameter was 13.7 ± 2.0-mm. Mean stent diameters of Abre, Venovo, Vici, and Zilver Vena were 13.2 ± 1.8-mm, 15.2 ± 1.8-mm, 12.3 ± 0.8-mm, and 14 ± 0-mm, respectively. Technical success was achieved in all procedures. One Venovo stent malexpansion occurred which responded to angioplasty. One patient experienced an access site hematoma at the left brachial vein which resolved without intervention. Clinical success was achieved in all patients. No stent fractures or migrations occurred. Six patients required stent revisions at mean of 124.3 ± 82.1 days after the initial procedures. The use of dedicated venous stents in the upper extremity and thoracic central veins yielded excellent technical and clinical success rates without immediate adverse events.

Perforator mapping and clinical experience with the superthin profunda artery perforator flap for reconstruction in the upper and lower extremities

Thin skin flaps have gained popularity for extremity reconstruction. However, the use of the profunda artery perforator (PAP) flap has not been explored as much. With its concealed donor site on the medial thigh and bulk, the PAP has become popular for reconstruction in the breast, head, and neck. The thickness of the subfascial PAP flap is decreased through elevation on the thin or superthin plane, making it more suitable for extremity reconstruction. A consecutive series of 28 patients with 29 flaps who received a thin or superthin single perforator PAP flap for upper or lower extremity reconstruction was reviewed. Our technique for preoperative localization of the dominant perforator using computed tomography angiography (CTA) and color duplex ultrasonography (CDU) is described. Flap success rate was 93.1%. Mean flap artery diameter, vein diameter, area, and thickness were 1.7+0.4mm, 2.2+0.4mm, 157.3+52.1cm2, and 0.7+0.2cm, respectively. Skin thickness at the suprafascial bifurcation point of a dominant "T" perforator measured on preoperative CTA correlated with actual intraoperative flap thickness. Patient body mass index did not correlate with flap thickness. The thin and superthin PAP flap has multiple favorable characteristics, making it suitable for extremity reconstruction, and it has become the workhorse skin flap in our institution. Conventional low-frequency CDU together with CTA can be used effectively to map the dominant perforator preoperatively, allowing accurate flap design and rapid flap harvest. Therapeutic Level IV.

Vascularized Bone Graft Reconstruction for Upper Extremity Defects: A Review.

Upper extremity reconstruction may pose clinical challenges for surgeons due to the often-critical, complex functional demands of the damaged and/or missing structures. The advent of vascularized bone grafts (VBGs) has aided in reconstruction of upper extremity (UE) defects due to their superior regenerative properties compared with nonvascularized bone grafts, ability to reconstruct large bony defects, and multiple donor site options. VBGs may be pedicled or free transfers and have the potential for composite tissue transfers when bone and soft tissue are needed. This article provides a comprehensive up-to-date review of VBGs, the commonly reported donor sites, and their indications for the treatment of specific UE defects.

Spare-parts free flap reconstruction in polytrauma with limb amputation: Pearls, pitfalls, and an illustrative case report

Spare-part free-flap reconstruction involves free tissue transfer from an unsalvageable extremity for reconstruction of a separate defect. In the setting of traumatic injury, spare-part surgery requires special attention to donor site zone of injury assessment and multidisciplinary coordination. Here we describe a case of upper extremity reconstruction using a free flap harvested from a lower extremity which was indicated for transfemoral amputation. Key pearls and pitfalls are reported in an effort to facilitate collaborative interdisciplinary reconstructive opportunities in cases where amputation is planned in the setting of multi-limb trauma. A 53-year-old male presented after a motorcycle collision with open fractures of the right elbow and tibia/fibula. After initial fracture stabilization and serial debridement, the upper extremity wound required flap coverage for the indication of exposed implants. Extensive bone and soft tissue loss of the lower limb indicated the patient for transfemoral amputation, and spare-part free flap reconstruction of the upper extremity defect was planned. Intra-operative venous pedicle thrombosis caused failure of an initial flap based on the posterior tibial artery. A second spare-part flap based on the anterior tibial artery was successfully transferred under the same anesthetic. When amputation is planned in the context of the multiply traumatized patient, coordinated orthopedic trauma and microsurgical care can facilitate spare-parts free-flap reconstruction. Though these cases require careful planning and intra-operative flexibility to accomplish flap harvest adjacent to a zone of injury, spare-part reconstruction worth pursuing as this strategy obviates the need for an additional donor site. • Spare-part free flaps are useful when amputation is planned in cases of polytrauma. • Collaboration and communication are critical to identify eligible patients. • Carefully assess the zone of injury adjacent to the donor site. • Harvest a large flap and assess with intraoperative fluorescence angiography. • Many unsalvageable limbs do not harbor an uninjured donor site.