Extensor Indicis Proprius Opponensplasty – The Burkhalter Revisited

Introduction Biodegradable Polyurethane Matrix (BPM) are temporary, biocompatible scaffolds that support tissue regeneration in surgical defects while reducing the need for permanent solutions. Spiradenomas, benign skin tumors from sweat gland cells, often require surgical removal, which can lead to scarring, particularly around joints like the ankle. Preliminary studies show BPMs may be effective in managing defects from malignant resections in critical areas, but their role in resection margins is still an emerging area needing further investigation. Methods This case report presents the successful application of a BPM in the reconstruction of a soft tissue defect following wide local excision of a spiradenoma on the right ankle of a 64-year-old male patient, demonstrating the value of these matrices as an essential reconstructive tool in the management of soft tissue defects following malignant resections. Results Follow up evaluations showed good graft take of the split-thickness skin graft with good interval healing and smooth contour restoration. Importantly, the patient maintained full range of motion in the right ankle joint, thus highlighting the successful preservation of function in this critical area. Some minor hypergranulation tissue was observed and subsequently treated with silver nitrate. The use of BPM provided reliable and robust soft tissue coverage with optimal functional and aesthetic outcomes and minimal donor site morbidity when compared to skin grafting outcomes alone. Conclusions Overall, the use of BPM in this case of spiradenoma excision and subsequent wide local resection in a functional area of the ankle provided robust soft tissue coverage while enabling excellent functional recovery and cosmetic outcomes. The minimal donor site morbidity associated with this approach also further highlights its advantages over traditional skin grafting techniques. The successful application of BPMs in functional areas illustrates their value as an essential reconstructive in the management of soft tissue defects following potentially malignant/malignant resections. Applicability of Research to Practice BPMs provide an effective temporary solution for wound healing, as demonstrated in a case where they facilitated skin grafting after wide excision. This approach led to successful graft integration and excellent functional recovery, allowing the patient full ankle mobility. Their ability to preserve function during healing is crucial in joint areas, minimizing complications and enhancing quality of life. Additionally, BPMs reduce donor site morbidity, leading to less discomfort compared to larger graft sites while promoting better healing and mobility outcomes. Funding for the Study N/A

AlloDerm with Split‐Thickness Skin Graft for Coverage of the Forearm Free Flap Donor Site

The Osteochondral Autologous Transfer System (OATS) is a surgical technique initially developed for knee procedures to address focal articular cartilage defects. Although widely applied in the knee, elbow, shoulder, and ankle, its application in hand surgery is limited but growing. This review aims to compile evidence-based insights into OATS for hand surgery, focusing on indications, technical nuances, outcomes, and donor-site morbidity. Additionally, a demonstrative case is presented showcasing the reconstruction of a capitate using OATS. The systematic review followed PRISMA 2020 guidelines and was registered on PROSPERO. Electronic databases (PubMed, Google Scholar, Cochrane Library) and ClinicalTrials.gov were searched for studies up to August 1, 2024, using the keywords: OATS, osteochondral autologous transplantation system, hand, and wrist. Eligible studies included clinical applications of OATS in hand surgery with follow-up data. Case reports, series, and cohort studies were appraised for quality and risk of bias. Additionally, a narrative review addressed practical questions for hand surgeons. A demonstrative case involving capitate resurfacing during proximal row carpectomy was also included. Thirteen studies met the inclusion criteria, encompassing case reports and small series involving up to 11 patients. Indications for OATS in hand surgery included reconstruction of the lunate fossa, carpal bones, metacarpal heads, and interphalangeal joints. Favorable outcomes were reported, with donor sites including the lateral femoral condyle, medial femoral trochlea, and hemihamate bone. Donor-site morbidity was rare but included exertional knee pain and radiological degenerative changes. The demonstrative case highlighted capitate resurfacing with satisfactory functional and radiological outcomes. OATS shows promise in addressing osteochondral defects in the hand, with favorable outcomes across various applications. Although evidence remains limited to small case series and reports, the technique demonstrates potential as a motion-preserving option. Future research should address donor-site morbidity in healthy knees and explore the feasibility of allograft use.

Background and Objectives: Nail bed and germinal matrix loss due to wide excision for fingertip tumors or malignancy are occasionally encountered complications. These defects also result from severely comminuted fingertip crush injuries. Large-area dorsal finger or toenail bed defects, which usually present with phalangeal bone exposure, remain challenging regardless of the usage of different reconstruction strategies. This study aimed to evaluate the clinical outcome of a staged operation with an acellular dermal matrix coverage and subsequent skin graft as reconstruction for defects of total nail bed, germinal matrix loss, and bone exposure. Materials and Methods: From April 2018 to October 2019, four patients with total nail bed, germinal matrix, and bone exposure loss after surgery were enrolled in our series. A staged operation of the acellular dermal matrix coverage with subsequent skin graft was performed on these patients. Skin graft take rate, oncological prognosis, and cosmetic outcome were evaluated. Patients were followed up for 5–13 months. An excellent skin graft take rate with a satisfying aesthetic result without local malignancy recurrence was noted. Minimal functional deficit and donor site morbidity were reported. Results: A staged operation with acellular dermal matrix coverage and subsequent skin graft proves to serve as a feasible strategy for patients who experience total nail bed, germinal matrix loss, and bone exposure after surgery. Conclusions: This reconstruction method provides a reliable repair result, satisfying aesthetic outcomes, as well as having minimal functional deficits and donor site morbidity.

Paralysed upper extremity muscles of 24 tetraplegic patients were examined to determine whether their lower motor neuron was intact. Primary emphasis was placed on the forearm finger flexor muscles (Flexor Digitorum Superficialis and Flexor Digitorum Profundus) and finger extensor muscles (Extensor Digitorum Communis and Extensor Indicis). It was found that the vast majority of these muscles in C4, C5 and C6 subjects retained some or all of their lower motor neurons intact. In C5 subjects, examination was performed on additional muscles that were potentially most useful in an orthosis utilising functional stimulation. Similar to the results of the finger flexor and extensor muscles, the muscles of the wrist and thumb generally had the lower motor neuron at least partially intact. A muscle that often was an exception was M. Flexor Carpi Radialis. These studies indicate that most of the forearm muscles of the upper extremity in high level spinal cord injury patients which are paralysed have the lower motor neuron totally or partially intact. With electrically induced exercise, such muscles are strengthened to functional levels of contraction. Subsequent electrical activation enables the quadriplegic patients to use the muscle functionally.

Background One of the most common breast reconstruction techniques that uses autologous tissue is the free muscle-sparing transverse rectus abdominis myocutaneous (MS-TRAM) flap. However, patients hesitate to choose this method because of the long transverse scar between the anterior superior iliac spines. Furthermore, traditional reconstruction using a free MS-TRAM flap entails donor site morbidities such as pain, hematoma, or seroma. Here, we introduce a mini-abdominoplasty-designed free TRAM flap with flap beveling, which can be a good method for breast reconstruction in Asian patients who have small breasts. Methods Breast reconstruction with free MS-TRAM flaps using the mini-abdominoplasty design and flap beveling was performed in 10 patients following mastectomy. Patient age, presurgical brassiere cup size, tumor type, operation type, excised breast weight, elevated flap weight, flap weight used for the breast, recipient vessel, operation time, day that the abdominal drain was removed, and complications associated with both the flap and donor site were documented for all flaps and patients. Results For all 10 mini-abdominoplasty-designed free TRAM flap procedures, no flap loss or donor site morbidity was noted over a mean follow-up time of 16 months. Conclusions The mini-abdominoplasty-designed free TRAM flap can safely and satisfactorily be implanted for the reconstruction of mastectomy defects. It can transfer the lower abdominal skin and subcutaneous tissue for breast reconstruction with minimal donor site scarring and morbidity, especially in Asian patients, who generally have smaller breasts.

Extensor indicis proprius (EIP) opponensplasty is one of the commonly used techniques to restore thumb abduction and opposition in patients with thenar muscle dysfunction from various causes of median nerve palsy. However, its subcutaneous route around the distal ulna may not represent a straight line of pull, and part of the extensor hood sometimes has to be harvested along with the EIP tendon to gain adequate length to reach the insertion. The purpose of the study is to present the alternative method of EIP opponensplasty and report the clinical outcomes. The modified EIP opponensplasty was performed on 16 patients with severe carpal tunnel syndrome. At the final follow-up examination, all patients were able to regain their desired level of activities. The Kapandji score, abduction angle, and the disabilities of the arm, shoulder, and hand score improved in all patients. There were no complications related to harvesting the EIP tendon. Two patients developed finger stiffness, which improved after rehabilitation. This technique is safe and effective for restoring thumb function and can solve the insufficient tendon length problem of the original EIP opponensplasty.

BackgroundThe anterolateral thigh (ALT) free flap is a workhorse in head and neck reconstruction, offering versatility, long pedicle length, and low donor site morbidity. Nevertheless, anatomical variability of its perforators can occasionally result in absent or unusable vessels, jeopardizing intraoperative feasibility. In such cases, harvesting an additional donor site increases operative time, morbidity, and aesthetic results. Salvage solutions within the same vascular territory are therefore essential to ensure safe and efficient reconstruction.Case presentationWe report a 70-year-old female with oral squamous cell carcinoma of the right retromolar triangle requiring composite resection with flap reconstruction. A patient-specific reconstructive plate and ALT free flap were planned. Intraoperatively, no usable perforators of the descending branch of the lateral circumflex femoral artery were identified. Proximal dissection revealed reliable perforators supplying the tensor fascia lata (TFL) territory, allowing elevation of a TFL free flap through the same incision. Microvascular anastomosis was performed successfully. The postoperative course was uneventful, and the flap remained viable throughout follow-up.ConclusionThis case highlights the importance of intraoperative flexibility when encountering ALT perforator absence. The TFL free flap represents a dependable salvage solution, characterized by more consistent vascular anatomy and minimal additional donor site morbidity. By enabling conversion within the same surgical field, the TFL flap reduces operative time and avoids the drawbacks of a second donor site. Incorporating this strategy into a structured decision-making algorithm enhances reconstructive safety and broadens the armamentarium for complex head and neck reconstruction.

Upper lid reconstruction depends on the size of the defect, and a general consensus holds that partial-thickness defects can be reconstructed using simple or composite grafts. Full-thickness defects involving up to 30% of the upper lid are repaired easily by direct suturing with or without upper lid sliding flaps. When defects affect more than 50-70% of the upper lid, complex reconstruction is needed. Traditionally, this devolves upon lower lid flaps, as in the Cutler-Beard and Mustardé techniques. These methods share intrinsic disadvantages, such as donor site morbidity and the need for two surgical sessions to detach the flap pedicle. To our knowledge, upper lid reconstruction with a grafted forehead galeal-pericranial flap has not been previously reported. This proves to be an excellent reconstructive option for extensive upper lip defects. Moreover, it has many advantages over other reconstruction techniques, such as technical ease and very low donor site morbidity. Furthermore, it is a single-stage procedure. We present our experience with five extensive upper lid reconstructions using galeal-pericranial forehead grafted flaps. Five patients needed major upper lid reconstruction, which consisted of a galeal-pericranial forehead flap grafted with oral mucosa and retroauricular skin. Four of them had had the lid removed surgically for oncological reasons, while one patient suffered from orbital-periorbital fasciitis. All of the flaps and grafts survived. The functional and morphological results were satisfying, and no complications were noted. The forehead galeal-pericranial flap appears to be an excellent instrument for upper lid reconstruction. Compared to other techniques, it has the advantages of simplicity and very minimal donor site morbidity. Moreover, it does not necessitate a two-stage surgical procedure.

We evaluated the use of a lateral thigh free flap in pharyngoesophageal reconstruction, which is often overlooked and less widely used despite its distinct advantages. This study reviewed the patient's medical records, including the patient's age, gender, histopathologic diagnosis, surgical defects, flap size, flap survival, donor and recipient site complications, and swallowing function and voice rehabilitation. Twelve lateral thigh free flaps were used to primarily reconstruct the pharyngoesophagus in 11 patients after tumor resection from July 1997 to May 1999. Eleven of the 12 flaps (91.7%) were transferred successfully. In one patient, the flap failure occurred as a result of venous thrombosis, and therefore another lateral thigh free flap from the opposite thigh was used 3 days later. The swallowing function was restored in all patients. Prosthetic voice rehabilitation was successfully achieved in all five patients, who primarily underwent tracheoesophageal punctures. No frank fistula or stricture developed. Significant donor site morbidity was not noted. The lateral thigh free flap is useful and reliable in selected cases of pharyngoesophageal reconstruction and versatile in flap design with favorable functional outcomes of swallowing and voice rehabilitation with minimal donor site morbidity.

Purpose One of the pillars of successful anterior cruciate ligament (ACL) reconstruction is the choice of the ideal graft substitute. The central one-third of the quadriceps tendon is apparently a good autograft option, representing a modular reconstructive option with minimal donor site morbidity. The aim of this research is to compare the functional outcome of primary ACL reconstruction using quadriceps tendon autografts in comparison to the hamstring tendon autograft. Patients and methods This prospective, randomized clinical study included 60 patients with torn ACL randomly divided into group I (the control group), whereby ACL reconstruction was performed using the hamstring tendon autograft or group II (the study group), whereby ACL reconstruction was done using the central part of quadriceps tendon pure soft tissue autograft. The study was performed in our hospital between January 2016 and March 2018. The mean follow-up period was 2.2 ± 0.4 years. Assessment was done clinically using the IKDC 2000 subjective and objective scoring system. Objective laxity measurements were performed using the KT-1000 at the end of follow-up. Results Clinical assessment of the patients in the 6th month postoperatively and at the end of follow-up averaged 2.2 ± 0.4 years according to the IKDC 2000 Subjective and Objective Scoring System and revealed significantly better results for group II in early postoperative after 6 months, with comparable results at the end of follow-up. Objective laxity measurements at the end of follow-up revealed that the side-to-side difference is a little bit better in the quad group with no statistically significant results. Conclusion The central part of the quadriceps tendon is a viable autograft option for primary ACL reconstruction with good mid-term functional results, and minimal donor site morbidity as compared with the standard most commonly used hamstring tendon autograft; however, a longer term and multicenter studies are still needed to validate its routine use.

This article reviews the buccinator flap, its relevant surgical anatomy, surgical technique, and applications in head and neck reconstruction. Reconstruction of defects after extirpation of head and neck neoplasms can be challenging and complex. Various reconstructive techniques, including skin grafts, regional flaps, and free tissue transfer, can be employed in restoration of form and function after ablative surgery. Although a wide array of reconstructive options is available, the technique employed will largely depend on the surgeon preference and experience. Commonly used pedicled flaps and free tissue transfer techniques can share several disadvantages, including prolonged operative time, poor cosmesis, donor site morbidity, functional limitations, and excessive tissue bulk for intraoral reconstruction. The ideal reconstructive method would adhere to the plastic surgery principle of replacement of 'like with like'. The ease of dissection and useful application makes the buccinator flap an excellent additional reconstructive option for the head and neck surgeon. The buccinator myomucosal flap is a versatile and dependable flap for head and neck reconstruction. Its minimal donor site morbidity, pliability, ease of elevation, and flexible usage while offering optimal functional and cosmetic results make it a viable option for select defects.

Knee Donor Site Morbidity Following Harvest of Medial Femoral Trochlea Osteochondral Flaps for Carpal Reconstruction

Breast reconstruction with autologous tissue has been generally accepted as a reliable procedure, the preferred donor site being lower abdominal tissue. To sacrifice the minimal amount of muscle tissue and to reduce donor site morbidity, the concept of a perforator flap was applied to the fields of breast reconstruction, such as the deep inferior epigastric artery perforator (DIEAp) flap. The DIEAp flap provides essentially the same soft tissue components as the transverse rectus abdominis muscle (TRAM) flap while significantly reducing harvesting of the rectus muscle from the abdominal wall, thereby minimizing donor site morbidity; which includes abdominal weakness, hernia, and postoperative pain, with decreased recovery time. However, there are some concerns about the tedious and risky dissection of intramuscular perforators, and the variable vascularity of the flap supplied by tiny perforators. According to our novel flap harvesting techniques, using bipolar electrocauterization for intramuscular dissection is useful in preventing injury to the tiny perforators. Including some fibers of rectus muscle and soft tissue without full isolation and skeletonization around the pedicles is also useful for prevention of vascular injury and intraoperative vessel spasms. Moreover, the flap must include 2 to 3 reliable perforators, regardless of lateral or medial rows, for prevention of postoperative fat necrosis. The superficial inferior epigastric vein can provide additional venous drainage. These surgical tips can aid in overcoming the pitfalls of the DIEA perforator flap in breast reconstruction. The DIEAp flap is an excellent choice for breast reconstruction. According to our experience, it has been shown to be a safe and reliable method for providing good results and patient satisfaction with minimal donor morbidity in breast reconstruction.

Developments in the microsurgery have made perforator fasciocutaneous free flaps more popular in lower extremity reconstructions. They have acceptable donor site morbidities when compared to traditional methods. However; there are some possible limitations with these flaps such as anatomical variations and insufficiency to cover large and/or complex defects with a single flap. Anterolateral thigh flap (ALT), which has proven its advantages in the reconstruction of many regions of the body, is one of the versatile perforator fasciocutaneous flap options. We present our experience of using sequential double ALTs for complex lower extremity reconstruction. A 44-year-old patient, who had a history of multiple traumas as a result of a traffic accident, had interconnected anterior tibial (6 × 4 cm) and bimalleolar defects (4 × 4 cm, 4 × 5 cm) in his left lower extremity. Double ALT flaps (16 × 9 cm, 17 × 10 cm) were used to reconstruct three individual defects. The posterior tibial artery was the only uninjured artery perfusing the lower extremity, so the already occluded anterior tibial artery was chosen as the recipient to avoid disturbing the posterior tibial vessels. The dominant comitant vein of one of the flaps was leaving the pedicle too early and following an aberrant path with increased diameter. As it was understood that the other comitant vein had poor drainage, it was taken as an interposition vein graft to lengthen the dominant aberrant vein. The two flaps were customized as one by flow-through anastomoses on the operating table. The anterior tibial artery was washed and debrided distal to proximal until arterial spurting was seen. At the distance of 8 cm superior, the artery was found as feasible and anastomoses were performed. The proximal flap was inset vertically and the distal flap was inset on the horizontal axis to reach the bilateral malleolar defect. No complications were observed in both flaps. The patient was followed-up for 8 months. Despite the successful reconstruction, the patient is still unable to walk unaided due to multiple traumas and the rehabilitation process continues. We believe that the use of sequential double ALT may be a useful alternative to reconstruct large lower extremity defects with minimal donor site morbidity when a suitable single recipient vessel is available.