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BACKGROUND: Complex wounds of the distal third of the leg are challenging to treat. Despite free tissue transfer, local pedicled flaps such as the distally pedicled sural artery flap remain a valuable option. METHODS: The authors conducted a retrospective comparison of the classical harvesting technique of the sural artery flap with a simplified method without a skin island. RESULTS: We report on 148 patients who were treated with 104 adipofascial flaps and 44 fasciocutaneus flaps from 1997 to 2010. The adipofascial group showed a shorter operative time and a better aesthetic outcome. Complications did not differ in this multimorbid patient group. CONCLUSIONS: With a simple modification, the distally based sural artery flap is easier and faster to perform. The study shows that the adipofascial flap is as safe as the classic version, with the advantage of an improved donor-site appearance. Therefore, the described technique is a valuable tool in cases where free tissue transfer is not suitable. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Background Current surgical approaches to the distal radius include dorsal and palmar plate fixation. While palmar plates have gained widespread popularity, few reports have provided data on long term clinical outcomes in comparison. This paper reports the result of a randomised clinical study comparing dorsal Pi plates and palmar, angle-stable plates for treatment of comminuted, intraarticular fractures of the distal radius over the course of twelve months. Methods 42 patients with unilateral, intraarticular fractures of the distal radius were included and randomised to 2 groups, 22 were treated with a palmar plate, 20 received a dorsal Pi-plate. Results were evaluated after 6 weeks, 3, 6 and 12 months postoperatively focussing on functional recovery as well as radiological results. Results The palmar plate group demonstrated significantly better results regarding range of motion and grip strength over the course of 12 months. While a comparable increase in function was observed in both groups, the better results from the early postoperative period in the palmar plate group prevailed over the whole course. Radiological results showed a significantly increased palmar tilt and carpal sag in dorsal plates, with other radiological parameters being comparable. Pain levels were decreased in dorsal plates after hardware removal and failed to show significant differences after 12 months. However, complications such as tendon ruptures were more frequent in the dorsal plate group. Conclusions Functional advantage of palmar plates gained within the first 6 weeks prevails over the course of a year. Both groups demonstrate further gradual increase of function after 6 months, although dorsal plates did not catch up completely. Improved early postoperative function seems to be the cornerstone for the best possible results. Patients with dorsal plates benefit from hardware removal more than palmar plates in terms of reduction of pain levels. The advantage of palmar plates is a faster functional recovery with lower complication rates. This is especially important in the elderly population. Radiological results did not show a superiority of palmar plates over dorsal plates.

BACKGROUND The 180-degree propeller flaps allow closure of soft-tissue defects of the distal lower extremity. In addition to twist, the pedicle is often subject to additional kinking which increases proportionally to the angle at which the perforator pierces through the fascia. This study evaluates the directionality of the perforators at the fascial level to guide in the selection process of the best perforator. MATERIAL AND METHODS Perforators were identified in the lower extremities of 16 fresh cadavers. The angle of fascial perforation was measured. Perforators were grouped according to source vessel and location. Results were analyzed statistically regarding angle of fascial perforation along the source vessel and region. RESULTS A total of 324 perforators were identified. Distal perforators pierced the fascia at a significantly greater angle than in the proximal and middle segment of the peroneal and anterior tibial vessels (P < 0.005). Perforators originating from the posterior tibial artery pierced the fascia at less acute angles distally. When grouped according to the region of the perforators, no significant difference was found between perforators from all source vessels in the proximal region of the distal lower extremity. Even distally, perforators from the posterior tibial artery traveled almost perpendicular (P < 0.005). CONCLUSION Perforators traveling in a near perpendicular manner are ideal to serve as a pedicle for 180-degree propeller flaps as solely the twist has to be distributed along the vessel. The posterior tibial artery was the source to perforators with the most constant, near-perpendicular course, predisposing them for use in 180-degree propeller flaps.

Das Handgelenk (Carpus) beinhaltet mehr als 20 verschiedene Einzelgelenkabschnitte vom Unterarm bis zur Mittelhand und stellt somit ein hochst komplexes anatomisches Gebilde dar.

Soft tissue defects exposing the Achilles tendon are challenging. Local perforator flaps represent a valuable option gaining increasing popularity. Despite preoperative planning an adequate perforator cannot always be found intraoperatively. The free peroneal artery perforator flap can serve as a back-up option limiting the donor site morbidity to the same extremity without sacrificing major vessels or nerves.Nine patients with soft tissue defects exposing the Achilles tendon were treated with local perforator flaps, seven were scheduled for 180° propeller flap coverage after Doppler-ultrasound examination. However, in two patients (22%) no adequate perforators were found intraoperatively. As the perforators for the free peroneal artery perforator flap were routinely mapped out, this flap was harvested for microsurgical reconstruction.One patient with a 180° propeller flap developed a partial flap necrosis, another patient developed superficial epidermolysis, both requiring skingrafting. no complications were seen with free tissue transfer.Pedicled perforator flaps as propeller flaps add options to the armamentarium of microsurgeons. Despite thorough preoperative planning the surgeons must be prepared to perform a different method of reconstruction if inadequate vessels are encountered. To limit additional donor site morbidity, local options are preferred. The free peroneal artery perforator flap represents a good option as it matches the original tissue properties closely. The complication rate of propeller flaps in this series is tolerable. Propeller flaps should therefore be considered an alternative but not as a replacement of local fasciocutaneous flaps.

Congenital fusions of the carpal bones are rare anomalies, which occur in less than 1% of the population. This article describes a congenital pisiform hamate coalition which became symptomatic when caused by a trauma. The condition was successfully treated with the resection of the synchondrosis, autogenous bone graft, and screw stabilization.

Background: After massive upper extremity injuries, prosthetic use might be complicated by the formation of pressure ulcerations. Especially the coverage with insensate free flaps may predispose the patient for developing chronic ulcerations when using an upper extremity prosthesis. This complication may be reduced when sensate local flaps are used to cover bony prominences. Methods: A new operative technique is described. Results: Immediate sensate soft tissue coverage improves prosthetic fitting. Successful manipulation of the prosthesis can be quickly achieved with a decreased risk for pressure ulceration. Conclusion: This challenging procedure helps to achieve durable and sensate coverage of bony prominences. The use of local sensate tissue to cover bony prominences reduces the risk for pressure ulceration when wearing a prosthesis. Areas where prosthetic use causes only low pressure and shearing forces are adequately covered with free flaps. Immediate sensibility of local flaps allows prosthetic fitting and use as soon as wound healing has occurred. Return to work is thus expedited.

Traumatic and nontraumatic defects of the distal third of the tibia are challenging in regard to soft tissue coverage. While local, pedicled fasciocutaneous perforator flaps allow adequate coverage, the donor site often requires skin grafting. When a local perforator flap is designed as a 180-degree propeller flap, an excellent esthetic result and direct closure of the donor site can be achieved, with minimal morbidity.Eight patients with defects in the malleolar region were treated with 180-degree propeller flaps based on perforators from the tibial and peroneal vessels.One partial flap loss was encountered in an insulin-dependent diabetic. Partial superficial epidermolysis was encountered in 2 cases and healed without further interventions. No other complications were encountered. All patients returned to full ambulation within 8 weeks.The 180-degree propeller flap is an elegant and versatile method to achieve soft tissue coverage with local tissue in defects of the distal tibia. Contrary to other local perforator flaps, this specific design facilitates direct closure of the donor site. As only local, thin tissue is used, no interference with normal shoe wear occurs. Even in older patients, this flap has proven to be a reliable option.

Digital avulsions and amputations are not uncommon in outdoor activities. Rope entanglement is often the cause, though specific descriptions of the mechanism of injury have not been reported. We report a common scenario where entanglement during a fall resulted in an amputation injury. Although any roping activity may cause a loop formation leading to digital entrapment and subsequent amputation injury, activities involving soft and loose ropes may increase the chances of injury. Rope slack is to be avoided to minimize the likelihood of entanglement. This case report describes a digital amputation during an indoor climbing incident and also describes a possible mechanism for such injuries.

Hand aesthetics have been poorly described because function is the main reason why patients consult a surgeon about their hands. Ideal proportions are based on normal anatomy, which is a prerequisite for aesthetics. A literature review was performed. Anatomically correct proportions are, besides adequate soft tissue, the most important aspects of hands considered to be beautiful. The golden proportion may be used to identify suboptimal areas. Extrinsic and intrinsic aging must be distinguished, and therapy should be determined accordingly. Hand aesthetics are based on normal anatomy. Knowing this is essential for every surgeon treating hand patients.

Thoracic outlet syndrome (TOS), which is caused by osseous and soft tissue abnormalities and presents as tingling, paraesthesia, and weakness of the extremity, is a controversial subject. Surgical treatment for TOS is seen as the last resort and involves resection of the first rib and scalenotomy and leads to an overall improvement of 70% over a period of 5 years.1 The most common postoperative complications are pneumothorax, injury to the subclavian artery and vein, or brachial plexus and long thoracic nerve.2 Second rib fracture as a complication after surgery for TOS has not previously been described. A 54 year old woman had been symptomatic with bilateral constant numbness, tingling, paraesthesia, and weakness exacerbated by sports and exercises for well over 10 years. Numerous attempts at conservative treatment had failed. She also had bilateral omarthrosis which had been treated by previous acromioclavicular joint resection and subacromial decompression. Nevertheless, the symptoms persisted and increased in both ulnar innervated segments of the arm. The hyperabduction test (Wright) was positive on both sides. In conjunction with her other symptoms, a …

Background Intraarticular distal radius fractures can be treated with many methods. While internal fixation with angle stable implants has become increasingly popular, the use of bone graft substitutes has also been recommended to address comminution zones and thus increase stability. Whether a combination of both methods will improve clinical outcomes was the purpose of the study Methods The study was thus conducted as a prospective randomized clinical trial. 39 patients with unilateral, intraarticular fractures of the distal radius were included and randomized to 2 groups, one being treated with internal fixation only, while the second group received an additional bone graft substitute. Results There was no statistical significance between both groups in functional and radiological results. The occurrence of complications did also not show statistical significance. Conclusions No advantage of additional granular bone graft substitutes could be seen in this study. Granular bone graft substitutes do not seem to provide extra stability if dorsal angle stable implants are used. Dorsal plates have considerable complication rates such as extensor tendon ruptures and development of CRPS.