Faculty Bibliography

INTRODUCTION: Injuries to the ulnar collateral ligament (UCL) are relatively common and are best treated in the acute setting. The acute version of this injury can often be repaired primarily but in the chronic setting the ligamentous remnants are often retracted making this method of repair difficult. We present a novel alternative approach for UCL repair after chronic injuries or difficult acute injuries. METHODS: We describe the procedure and postoperative results. A standard S-shaped incision over the dorsal ulnar aspect of the thumb is used. The adductor aponeurosis is identified and separated from the joint capsule. A proximally based and distally based rectangular flap containing the UCL remnants is elevated exposing the metacarpophalangeal joint. A burr is used to shave the condyles on the ulnar aspect of the metacarpal and proximal phalanx. The joint is stabilized with a Kirschner wire. A suture anchor is used to secure the proximally based flap. The distal flap is secured on top of this using the same sutures from the anchor. The repaired ligament is secured to the volar plate on the palmar aspect using a 4-0 Ethibond. RESULTS: This surgical technique has been used extensively by the senior authors; we present a representative case. At 3 months the patient had a grip strength of 85 lbs, tripod pinch of 12 lbs, lateral pinch of 5 lbs, 2-point pinch of 6 lbs, active range of motion at metacarpophalangeal joint of 0 to 70 and passive range of motion at the metacarpophalangeal joint MP of 0 to 85. CONCLUSION: Despite a number of options for ligament reconstruction many of the described methods of repair are relatively complex and involve derangement of local tissues. We offer a novel adjunct to current methods of UCL reconstruction in which condylar shaving makes repair much more simple and avoids the use of a tendon graft. This approach provides a shorter course for the retracted UCL remnants allowing primary repair in the chronic setting and in the difficult acute repair

PURPOSE: The 2 most common methods of ulnar nerve anterior transposition are submuscular and subcutaneous. Controversy exists as to which technique yields superior results. The purpose of this study was to examine the histologic differences between the 2 methods in a rat model. METHODS: Twenty forelimbs in 10 adult Sprague-Dawley rats had bilateral ulnar nerve transpositions; one side with the submuscular method, and the other side with the subcutaneous method. Animals were killed 6 weeks after the index surgery and the forelimbs were examined for histologic evidence of the health of the axons and perineural scar formation. RESULTS: Nerve health was assessed using a 4-part classification in which 4 = normal nerve, 3 = abnormal axons in one-third cross-sectional area (CSA), 2 = abnormal axons in two-thirds CSA, and 1 = abnormal axons in 100% CSA. Perineural scar formation was assessed using a 3-part classification in which 3 = scar completely encasing nerve, 2 = scar formation partially surrounding nerve, and 1 = no scar. The submuscular method displayed healthier ulnar nerve axons. In addition, the submuscular method displayed less perineural scar tissue. CONCLUSIONS: On this basis of this rat model, the submuscular method of ulnar nerve anterior transposition displayed histologically healthier axons and less perineural scar tissue when compared to the subcutaneous method

SUMMARY: At present, the literature dedicated to closed mallet thumb injury offers conflicting evidence between conservative and operative approaches. Although conservative treatment is often successful, retraction of the extensor pollicis tendon may lead to improper reattachment and continued deformity. This discussion and case report serve to highlight the use of magnetic resonance imaging as an adjunct in selecting the proper treatment strategy for this injury at initial presentation

INTRODUCTION: Large-volume soft-tissue defects often leave exposed neurovascular and vital structures not amenable to immediate flap coverage. We describe the use of AlloDerm, an acellular dermis allograft, in providing temporary coverage of these structures in multistage reconstruction of the extremity. METHODS: A prospective study of 25 patients was performed using AlloDerm for temporary coverage of exposed vital structures secondary to trauma and oncologic ablation. A direct examination of neurovascular structures and the wound bed after allograft removal was performed as a monitor of outcome. RESULTS: All allografts successfully covered the neurovascular structures at the time of removal with complete viability of neurovascular structures. Granulation tissue was appreciated in the wound bed with no clinical evidence of infection. The allograft was easily removed without damage to underlying structures. CONCLUSION: AlloDerm offers a safe and reliable alternative to cover critical neurovascular structures temporarily, before the definitive reconstruction of soft-tissue defects

BACKGROUND: The recommended treatment for Blauth types IIIB and IV congenital thumb hypoplasia is index pollicization and amputation of the functionless, hypoplastic thumb. Instead of completely discarding the functionless part, the authors retain a portion of the soft tissue as an adipofascial vascular island flap. This flap is inset at the base of the new thumb to simulate a thenar eminence and to improve the appearance of these hands. METHODS: This flap was used to augment the thenar base in 14 hands in 14 children. Follow-up ranged from 1 to 26 years. RESULTS: All pollicizations were successful and there were no major complications. All of the adipofascial flaps improved the appearance of the thenar eminence and held up their shape in the long term. CONCLUSIONS: Use of an adipofascial island flap is recommended for thenar eminence augmentation in index pollicization of types IIIB and IV thumb hypoplasia. This tissue improves the appearance of the hand, is easy to harvest, and adds no morbidity

Breast reconstruction after mastectomy should aim at resulting in an aesthetic outcome that matches the patient's expectations and without interfering in the oncologic treatment. Whether the reconstruction is performed immediately or in a delayed fashion depends on various factors, which needs detailed attention. Autologous tissue, implants or both are used in the reconstruction. This article reviews the current concepts in these, with emphasis on non-microsurgical methods of using the autologous tissue for reconstruction. Breast conservation has become an accepted practice of treatment. Reconstruction in these situations as well as in an occasion when the surgery is done for failed breast conservation is discussed in detail. The article also reviews the various methods for nipple reconstruction available

BACKGROUND: Silicone, in the form of injectable liquid and prosthetic blocks, has been used to correct facial contour defects. However, silicone also has been associated with many complications including malposition, dyschromia, dysesthesia, contractures, infection, and fistula. Complications related to injectable-liquid and prosthetic-block silicone use in treatment of facial deformities pose a challenging surgical dilemma. METHODS: Over a 15-year period, microvascular free flap technique has been used successfully as a surgical tool to correct severe soft-tissue complications of the face resulting from silicone treatment of facial contour deformities. Surgical treatment guidelines, methods, and results for treating this difficult problem with free tissue transfer are presented. RESULTS: In 23 patients, 24 free tissue transfers (22 inframammary extended circumflex scapular free flaps and two superficial inferior epigastric free flaps) were performed. Flap survival was 100 percent. Both hematoma and skin necrosis were encountered in three of 24 cases (12.5 percent). Revisional surgery combined with aesthetic surgical procedures was required in 20 of 24 cases (83 percent). CONCLUSIONS: We recommend the following surgical treatment guidelines for this unique subset of patients: silicone excision with immediate microvascular free flap reconstructive procedure when the skin and soft tissue are mildly to moderately affected, or silicone excision with delayed reconstructive procedure when the skin and soft tissue are severely affected. Free tissue transfer is a useful surgical tool for salvaging severe facial skin and soft-tissue deformities caused by previous silicone treatment

The carpometacarpal (CM) joint of the thumb is commonly affected by osteoarthritis. The strength required for a first CM ligament reconstruction depends on the forces across the joint. If these forces are rebalanced to reduce the requirements necessary to prevent subluxation, reconstructive requirements are lowered and surgical dissections reduced. A method to achieve this goal based on Landsmeer's zig-zag compression concept is presented. Fifteen consecutive patients (11 women; mean age, 63 years) with pantrapezial osteoarthritis were selected over a 2-year period to undergo this novel procedure. After standard trapezial resection, trapezoidal hemiresection was performed, allowing for medial movement of the first metacarpal base. Following the zig-zag concept, the first metacarpophalangeal joint reciprocally fell into flexion, decreasing forces causing subluxation of the first metacarpal base. A saddle-like suspension under the metacarpal base was created using the trapezial capsule. All 15 patients had excellent outcomes with elimination of pain, early recovery of mobility and power, and no recurrent subluxations. The durability of the procedure was confirmed clinically and radiologically. The medial relocation of the first metacarpal base rebalances and attenuates the normal deforming forces thereby eliminating the need for a strong CM ligament reconstruction