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The management of complex upper extremity trauma can be overwhelming in its urgency and complexity. Having a systematic approach that maintains a clear set of priorities focused on hand and upper extremity function, operative efficiency, and long-term planning for future operations allows the reconstructive extremity surgeon to effectively treat these complex injuries. This article addressed these overall clinical considerations and details the approach taken at the Buncke Clinic including replantation and revascularization as well as osseous and soft tissue reconstruction.

Phalloplasty in the female to male transgender patient is a complex operation aimed at creating a functional and aesthetic phallus, external genitalia, and perineum. Functional goals include standing micturition and sexual function with erogenous and tactile sensation as well as the ability to participate in penetrative intercourse. Functional genital reconstruction relies on creating of a fully lengthened urethra from local tissues as well as the provision for additional length via tissue transplantation. This manuscript will review techniques for the creation of perineal urethral segment as well as primary flaps available for the creation of neophallus. Particular emphasis is given to our preferred method of reconstruction: single-stage urethral lengthening with radial forearm flap phalloplasty including a review of surgical techniques and complications.

Objective To describe the infrapubic approach to penile prosthesis insertion in transmen after phalloplasty. Materials and Methods After verifying phalloplasty vascular pedicle anatomy and reliable micturition, patients may be considered for implant surgery. Specific modifications of the infrapubic approach to penile prosthesis insertion as well as individualization of commercially available implants are performed intraoperatively to help reduce the risk of postoperative complications. Results In our single surgeon series (MLC) using the infrapubic approach with these specific implants after phalloplasty, 17/107 (16%) patients from October 2017 to November 2020 required revision surgery after mean follow-up of 79.8 weeks. Conclusion Our infrapubic prosthesis insertion after phalloplasty technique with modifications to commercially available implants may help reduce the risk of postoperative complications.

PURPOSE Labia majora, the embryologic homologs of the scrotum, are ideal donor tissue for transgender scrotoplasty. The technique is detailed, and surgical outcomes are assessed for scrotoplasty using labia majora rotational advancement flaps. METHODS We retrospectively reviewed the outcomes of phalloplasty patients who underwent either primary or secondary labia majora flap scrotoplasty and perineal reconstruction from October 1, 2017, to December 1, 2019. Bilateral elevation and rotational flap advancement from the posterior to anterior position formed a pouch-like scrotum. Perineal reconstruction involved multilayered closure with apposition of the inner thigh skin. RESULTS The mean follow-up was 12.5 months (0.5-26 months). One hundred forty-seven scrotoplasties were performed. Of the 147 total scrotoplasty patients, 133 had labia majora flap scrotoplasty and perineal reconstruction with single-stage phalloplasty. Distal flap necrosis occurred in 6 patients (4.1%); 5 were ipsilateral to the groin dissection required for phalloplasty. Large (>1 cm diameter) perineoscrotal junction dehiscence occurred in 7 patients (4.7%). All wounds were managed conservatively except for 3 patients who developed urethrocutaneous fistulas at the perineoscrotal junction. All 3 patients required fistula repair. Two (1.4%) scrotal hematomas and 3 (2.0%) perineal hematomas were seen; all required operative intervention. CONCLUSIONS Labia majora flap scrotoplasty via the bilateral rotational advancement technique and perineal reconstruction can be safely performed during phalloplasty. Minor wound complications are common and frequently heal with conservative management. Wounds that do not heal may be associated with urethral complications. Hematomas are rare but usually require operative intervention.

An abnormal clinical Allen's test is not a definitive exclusion criterion for free radial forearm flap use. A surgical Allen's test may be useful to determine whether flap harvest is feasible in patients with an abnormal clinical Allen's test.

Background In microvascular free-tissue harvest and transfer, the need for repositioning from lateral decubitus position and the inability to use a two-team approach are major drawbacks of the subscapular system. We present our experience with the subscapular system for upper and lower extremity reconstruction using a two-team approach without need for repositioning. Methods We conducted a retrospective chart review for all patients undergoing free flap transplant based on the subscapular system to the upper or lower extremity at our microsurgical facility from January 1, 2007 to December 31, 2011. Only cases not requiring intraoperative repositioning were included. Sixty-four patients underwent the two-team approach (37 upper extremity and 27 lower extremity transplants). Flap types included latissimus dorsi musculocutaneous, partial superior latissimus, dorsal thoracic fascia, serratus, scapular bone, and thoracodorsal artery perforator, either alone or as chimeric flaps. All patients were placed in the lateral decubitus position for the duration of the surgery. Results The ipsilateral subscapular system was used in 16% of cases for lower extremity defects, where the anterior tibial vessels served as recipient vessels. The contralateral subscapular system was used in all remaining cases for upper extremity or the vast majority for lower extremity (84%) defects, where either the superficial femoral, genicular, popliteal, sural, or posterior tibial vessels served as recipient vessels. With the exception of one partial flap loss secondary to infection, all flaps survived. Conclusions Proper lateral decubitus positioning allows for a two-team approach without compromising safety or outcomes.

INTRODUCTION AND OBJECTIVE:Urethral strictures and fistulas are common after gender affirming phalloplasty with urethral lengthening. We report our experience in urethroplasty and fistula repairs a...

Labia majora, the embryologic homologs of the scrotum, are ideal donor tissue for transgender scrotoplasty. The technique is detailed, and surgical outcomes are assessed for scrotoplasty using labia majora rotational advancement flaps.We retrospectively reviewed the outcomes of phalloplasty patients who underwent either primary or secondary labia majora flap scrotoplasty and perineal reconstruction from October 1, 2017, to December 1, 2019. Bilateral elevation and rotational flap advancement from the posterior to anterior position formed a pouch-like scrotum. Perineal reconstruction involved multilayered closure with apposition of the inner thigh skin.The mean follow-up was 12.5 months (0.5-26 months). One hundred forty-seven scrotoplasties were performed. Of the 147 total scrotoplasty patients, 133 had labia majora flap scrotoplasty and perineal reconstruction with single-stage phalloplasty. Distal flap necrosis occurred in 6 patients (4.1%); 5 were ipsilateral to the groin dissection required for phalloplasty. Large (1 cm diameter) perineoscrotal junction dehiscence occurred in 7 patients (4.7%). All wounds were managed conservatively except for 3 patients who developed urethrocutaneous fistulas at the perineoscrotal junction. All 3 patients required fistula repair. Two (1.4%) scrotal hematomas and 3 (2.0%) perineal hematomas were seen; all required operative intervention.Labia majora flap scrotoplasty via the bilateral rotational advancement technique and perineal reconstruction can be safely performed during phalloplasty. Minor wound complications are common and frequently heal with conservative management. Wounds that do not heal may be associated with urethral complications. Hematomas are rare but usually require operative intervention.

Background Full-thickness injuries to the hand require durable soft tissue coverage to preserve tendon gliding and hand motion. We aim to investigate the cost effectiveness of hand resurfacing comparing free fascial flap reconstruction versus bilaminate synthetic dermal matrices. Methods Cost effectiveness was modeled using decision tree analysis with the rollback method. Total active range of motion was modeled as the common outcome variable based on systematic literature review. Costing was performed from a payer perspective using national Medicare reimbursements. The willingness to pay threshold was determined by average worker's compensation for hand disability. Probabilistic sensitivity analysis was conducted for range of motion outcomes and the costs using 10,000 Monte Carlo simulations. Results The average cost of free fascial flap reconstruction was $14,201.24 compared with $13,674.20 for Integra, yielding an incremental cost difference of $527.04. Incremental range of motion improvement was 18.0 degrees with free fascial flaps, yielding an incremental cost effectiveness ratio of $29.30/degree of motion. Assuming willingness to pay thresholds of $557.00/degree of motion, free-fascial flaps were highly cost effective. On probabilistic sensitivity analysis, free fascial flaps were dominant in 25.5% of simulations and cost effective in 32.1% of simulations. Thus, microsurgical reconstruction was the economically sound technique in 57.5% of scenarios. Conclusion Free fascial flap reconstruction of complex hand wounds was marginally more expensive than synthetic dermal matrix and yielded incrementally better outcomes. Both dermal matrix and microsurgical techniques were cost effective in the base case and in sensitivity analysis. In choosing between dermal matrix and microsurgical reconstruction of complex hand wounds, neither technique has a clear economic advantage.

The anterolateral thigh (ALT) flap is a viable and reliable option for phalloplasty. The primary advantages of the ALT flap remain an inconspicuous donor site and flexibility in phallus length. The disadvantages of the ALT flap are a higher incidence of both flap and urethral complications compared with a radial forearm phalloplasty. Although the ALT phalloplasty can achieve the primary goals of standing micturition, penetrative intercourse, and an aesthetic phallus, multiple stages and revisions are often necessary. Careful patient selection is paramount in attaining acceptable results with the ALT phalloplasty technique.

Introduction: Osteomyelitis of a limb can lead to devastating functional consequences. Fungal osteomyelitis is rare in immunocompetent patients, and compared to bacterial osteomyelitis, fungal infections are more difficult to eradicate. Case Report: We present a case of a 59-year-old male who suffered traumatic left open radius and ulna fractures at the elbow with significant soft tissue loss. He underwent spanning fixation across the elbow, and soft tissue coverage was provided with a free latissimus flap. At the time of flap coverage, the patient was found to have fungal osteomyelitis with the organism Apophysomyces ossiformis. The patient achieved wound closure and functional use of the left upper extremity. Conclusion: The reported case demonstrates the pathogenicity of a microorganism not previously described in human disease. In this case, treatment was successful with local debridement, placement of antibiotic beads, and long-term antifungal therapy.

Despite advances in nutritional supplementation, sepsis management, percutaneous drainage and surgical technique, enterocutaneous fistulae remain a considerable source of morbidity and mortality. Use of adjunctive modalities including negative pressure wound therapy and fibrin glue have been shown to improve the rapidity of fistula closure; however, the overall rate of closure remains poor. The challenge of managing chronic, high-output proximal enterocutaneous fistulae can be successfully achieved with appropriate medical management and intra-abdominal placement of pedicled rectus abdominis muscle flaps. We report two cases of recalcitrant high output enterocutaneous fistulae that were treated successfully with pedicled intra-abdominal rectus muscle flaps. Indications for pedicled intra-abdominal rectus muscle flaps include persistent patency despite a reasonable trial of non-operative intervention, failure of traditional operative interventions (serosal patch, Graham patch), and persistent electrolyte and nutritional abnormalities in the setting of a high-output fistula.

The transverse tensor fascia lata (TTFL) flap is an important alternative flap for autologous breast reconstruction. It is a horizontal variant of the tensor fascia lata myocutaneous flap and contains fat from the prominence of the upper lateral thigh (saddle bag). We present the surgical management of a woman with trochanteric lipodystrophy, who underwent staged bilateral mastectomy and autologous breast reconstruction with TTFL flaps. We discuss technical points in TTFL flap design and harvest. Breast reconstruction was successful and the thigh donor sites had excellent aesthetic contour. There were no complications at either recipient or donor sites. The TTFL flap is an important alternative flap for autologous breast reconstruction when other options are less optimal, and has a secondary benefit of thigh donor site closure with lateral thigh lift techniques. The TTFL flap should be presented as an option for autologous breast reconstruction in women with prominent trochanteric lipodystrophy of the upper lateral thighs.

Surgeons and scientists have been developing alternative methods of hand reconstruction that may play an adjunctive role to, or completely supplant, more traditional reconstructive modalities. This article provides an overview of these emerging techniques, with an emphasis on skin substitutes and negative-pressure wound therapy as they apply to the treatment of soft tissue defects of the hand. The indications, contraindications, and relative advantages and disadvantages of these techniques are discussed in detail.

Dupuytren disease (DD) is a benign, generally painless connective tissue disorder affecting the palmar fascia that leads to progressive hand contractures. Mediated by myofibroblasts, the disease most commonly begins as a nodule in the palm or finger, and can progress where pathologic cords form leading to progressive flexion deformity of the involved fingers. The palmar skin overlying the cords may become excessively calloused and contracted and involved joints may develop periarticular fibrosis. Although there is no cure, the sequellae of this affliction can be corrected. This article focuses on the role of collagen in DD and the development of a collagen-specific enzymatic treatment for DD contractures.

In the elderly population with significant medical comorbidities, the safety of general anesthesia is often in question. In the head and neck, where regional and extradural anesthesia are not options, reconstruction of defects requiring free tissue transfer becomes a particular challenge for patients in whom general anesthesia is contraindicated. We present a case of a scalp reconstruction utilizing a latissimus dorsi free flap in a 91-year-old man performed entirely under local and regional anesthesia. General anesthesia was contraindicated secondary to the patient's multiple medical comorbidities. A paravertebral block was used for the harvest of the latissimus dorsi muscle and skin grafts. The microvascular portion of the procedure and the inset were performed under local anesthesia alone. The patient tolerated the procedure, and the operation was successful. This case is unique in that there are no published reports of head and neck free tissue transfer being performed entirely under local-regional anesthesia. We conclude that despite the medical challenges of performing complex reconstruction in elderly patients, expedient free tissue transfer can offer patients access to successful reconstruction.

Collagenase clostridium histolyticum has demonstrated safety and efficacy in the treatment of metacarpophalangeal and proximal interphalangeal joint contractures in Dupuytren’s disease as a 0.58-mg dose delivered via direct injection into the Dupuytren’s cord. Extension is achieved via manual manipulation 24 h following injection. Commercially available collagenase clostridium histolyticum is a combination of class I and class II collagenases that act in concert to degrade the type I and type III collagen content of pathologic Dupuytren’s cords and is available to practitioners who have completed focused training in injection technique. This article reviews collagenase clostridium histolyticum pharmacodynamics as well as the basic science and clinical studies resulting in US FDA and EMA approval for the treatment of Dupuytren’s disease. Clinical indications, technique and an analysis of future indications are reviewed.

The hand, by virtue of its position in space, complex anatomical composition, and characteristic biomechanical properties, is subject to a host of disease processes and traumatic injuries. This article reviews the presentation, evaluation, treatment, and outcomes of treatment in hand infections, high-pressure injection injuries, Dupuytren disease, and arthritis.

Given the complexity and diversity of congenital differences, a separate and broad category of generalized skeletal abnormalities was proposed to include all conditions that are unable to be neatly packaged into the other categories. Some of the conditions included in this category are obscure, whereas others are more common. Some conditions listed in this section may fit into other categories but may be considered as part of the overall classification scheme. This article presents congenital trigger finger, congenital clasped thumb, Madelung's deformity, and other skeletal hand deformities that are characteristic of generalized bone and connective tissue disorders, including achondroplasia and Marfan syndrome.

BACKGROUND: The best treatment for an inadequately reduced fracture of the distal part of the radius is not well established. We collected prospective outcomes data for patients undergoing open reduction and internal fixation of an inadequately reduced distal radial fracture with use of the volar locking plating system. METHODS: Over a two-year period, 161 patients underwent open reduction and internal fixation of an inadequately reduced distal radial fracture with use of the volar locking plating system. Patients were enrolled in the present study three months after the fracture on the basis of strict entry criteria and were evaluated three, six, and twelve months after surgery. Outcome measures included radiographic parameters, grip strength, lateral pinch strength, the Jebsen-Taylor test, wrist range of motion, and the Michigan Hand Outcomes Questionnaire. RESULTS: Eighty-seven patients with a distal radial fracture were enrolled. The mean age at the time of enrollment was 48.9 years. Forty percent (thirty-five) of the eighty-seven fractures were classified as AO type A, 9% (eight) were classified as type B, and 51% (forty-four) were classified as type C. Radiographic assessment showed that the plating system maintained anatomic reduction at the follow-up periods. At the time of the twelve-month follow-up, the mean grip strength on the injured side was worse than that on the contralateral side (18 compared with 21 kg; p < 0.01), the mean pinch strength on the injured side was not significantly different from that on the contralateral side (8.7 compared with 8.9 kg; p = 0.27), and the mean flexion of the wrist on the injured side was 86% of that on the contralateral side. All Michigan Hand Outcomes Questionnaire domains approached normal scores at six months, with small continued improvement to one year. CONCLUSIONS: The volar locking plating system appears to provide effective fixation when used for the treatment of initially inadequately reduced distal radial fractures. LEVEL OF EVIDENCE: Therapeutic Level IV. See Instructions to Authors for a complete description of levels of evidence. ORIGINAL ABSTRACT CITATION: “Treatment of Unstable Distal Radial Fractures with the Volar Locking Plating System” (2006;88:2687-94).

Background: Scapholunate advanced collapse wrist deformity is a common pattern of degenerative arthrosis of the wrist. This study prospectively evaluated a series of patients who underwent four-corner fusion using a circular plate internal fixation technique. Methods: Patients with symptomatic stage II scapholunate advanced collapse wrist deformity were treated with scaphoid excision and four-corner fusion using the Spider Limited Wrist Fusion Plate (KMI, San Diego, Calif.). Patients were prospectively evaluated at 6 months and 1 year using a standard study protocol with radiographs, functional tests, and an outcomes questionnaire. Outcomes were compared with those of historical series from the literature. Results: Eleven patients were enrolled and 10 patients completed their 1-year follow-up. Grip strength, lateral pinch strength, and Jebsen-Taylor test scores at 1 year were not significantly different from preoperative values. Mean active range of motion was 87 degrees preoperatively and 74 degrees at 1-year follow-up (p = 0.19). The Michigan Hand Outcomes Questionnaire showed no significant improvement in function, activities of daily living, work, pain, or patient satisfaction. The mean pain scores decreased from 54 preoperatively to 42 1–year postoperatively (p = 0.30), indicating persistent wrist discomfort. Three patients had broken screws: one was asymptomatic, one required 3 months of strict wrist immobilization, and one was reoperated for symptomatic nonunion. Conclusions: Four-corner fusion using the first-generation Spider plate technique has the advantage of earlier mobility and more patient comfort from absence of protruding Kirschner wires; however, patients continued to have disabling pain, functional limitations, work impairment, and low satisfaction scores postoperatively. Although limited by a small patient sample, this series presents outcomes data that may be useful in counseling patients who are contemplating four-corner fusion using this internal fixation device. Further investigation is necessary to evaluate the biomechanical properties of the Spider plate. The data suggest that better implants should be designed to avoid implant failure, which occurred in three of the 11 patients in this series.

Parathyroid hormone (PTH) regulation of matrix metalloproteinase-13 ( MMP-13) expression in osteoblasts contributes to normal bone turnover. The PTH response region of the rat MMP-13 gene spans nucleotides (nt) −148 to −38 and supports binding of numerous transcription factors, including Runx2, necessary for osteoblast differentiation, c-Fos/c-Jun, and Ets-1. These trans-acting proteins mediate hormone induction via incompletely defined combinatorial interactions. Within this region, adjacent to the distal Runx2 site, is a homopolymeric(dA:dT) element (−119/−110 nt) that conforms to the consensus site for the novel transcription factor nuclear matrix protein-4/cas interacting zinc finger protein (Nmp4/CIZ). This protein regulates bone cell expression of type I collagen and suppresses BMP2-enhanced osteoblast differentiation. The aim of this study was to determine whether Nmp4/CIZ contributes to MMP-13 basal transcription and PTH responsiveness in osteoblasts. Electrophoretic mobility shift analysis confirms Nmp4/CIZ binding within the MMP-13 PTH response region. Mutation of the Nmp4/CIZ element decreases basal activity of an MMP-13 promoter-reporter construct containing the first 1329 nt of the 5′-regulatory region, and overexpression of Nmp4/CIZ protein enhances the activity of the wild-type promoter. The same mutation of the homopolymeric(dA:dT) element enhances the MMP-13 response to PTH and PGE2. Overexpression of Nmp4/CIZ diminishes hormone induction. Mutation of both the homopolymeric(dA:dT) element and the adjacent Runx2 site further augments the PTH response. On the basis of these data and previous studies, we propose that Nmp4/CIZ is a component of a multiprotein assemblage or enhanceosome within the MMP-13 PTH response region and that, within this context, Nmp4/CIZ promotes both basal expression and hormonal synergy.

Large congenital melanocytic nevi are cutaneous lesions regarded by many as premalignant; estimates of malignancy incidence range from 0 to 42 percent. Given the often complex and extensive nature of large congenital melanocytic nevi resection and reconstruction, the risk of malignant transformation is a crucial factor that surgeons and families must weigh when deciding whether or not to excise the lesion. The authors conducted a systematic analysis of data from the existing literature to critically evaluate the published studies and to establish a crude incidence rate for the risk of malignant melanoma transformation in large congenital melanocytic nevi. After a comprehensive literature search, they analyzed data from eight studies (containing a total of 432 large congenital melanocytic nevi patients) of sufficient scientific quality. Twelve patients (2.8 percent) in this sample developed cutaneous malignant melanoma during the reported follow-up periods. Using a subset of this data and comparing the incidence rates to those of the Surveillance, Epidemiology, and End Results population-based database using a standardized morbidity ratio, the authors found that the large congenital melanocytic nevi patients had an increased risk of melanoma (standardized morbidity ratio, 2599; 95 percent confidence interval, 844 to 6064) compared with the general population. Regarding treatment before developing melanoma in the 12 patients, 50 percent were observed before diagnosis, 17 percent had partial excision, 8.3 percent had dermabrasion, 8.3 percent had a chemical peel, and 17 percent did not have any treatment information. These combined data are clinically useful when consulting with the parents of children with large congenital melanocytic nevi and in the management of older patients with existing lesions. This study shows that there is a significantly increased risk of melanoma in large congenital melanocytic nevi patients. The data also reveal the need for a standardized definition of large congenital melanocytic nevi and a long-term, prospective outcomes study to determine the true lifetime risk of melanoma in patients with and without surgical excision.

Surgical approaches to the hand are commonly executed in the treatment of fractures, ligament injuries, and less commonly in the resection of bony tumors. Careful design and execution of these surgical approaches translates into superior functional and aesthetic outcomes. We have provided a thorough review of commonly used approaches to the hand by evaluating each of these approaches in the context of core principles including safety, versatility, preservation of stability, and aesthetic outcomes.

Transcarpal and radiocarpal amputations present a distinct a set of challenges for the replant surgeon. While there are no motor units at the level of the wrist, skeletal fixation can be challenging. Radiocarpal amputations allow the surgeon the option to perform wrist arthrodesis, proximal row carpectomy (PRC), or shortening the radius or a Darrach procedure; shortening the bone allows for a tension-free closure and soft tissue repair while providing excellent postoperative function. This chapter will focus on transcarpal amputations. It will encompass the preoperative planning, surgical workup, technique, and postoperative care. It will address the goals of care and challenges of dealing with the wrist joint. We will address specifically different ways to approach the skeletal fixation to achieve primary repair of all structures.

Purpose To compare the efficacy, tolerance, and safety of manual manipulation at day 7 to day 1 following collagenase Clostridium histolyticum (CCH) injection for Dupuytren contracture. Methods Eligible patients were randomized to manipulation at day 1 versus day 7 following CCH injection. Preinjection, premanipulation, postmanipulation, and 30-day follow-up metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joint contractures were measured. Pain scores were recorded at each time point. Data were stratified per cohort based on primary joint treated (MCP vs PIP). Means were compared using paired and unpaired t -tests. Results Forty-three patients with 46 digits were eligible and were randomized to 1-day (22 digits) and 7-day (24 digits) manipulation. For MCP joints, there were no significant differences in flexion contractures between 1- and 7-day cohorts for initial (47° vs 46°), postmanipulation (0° vs 2°), or 30-day follow-up (1° vs 2°) measurements. Premanipulation, the residual contracture was significantly lower in the 7-day group (23° vs 40°). For PIP joints, there were no significant differences between 1- and 7-day cohorts for initial (63° vs 62°), premanipulation (56° vs 52°), postmanipulation (13° vs 15°), or 30-day (14° vs 16°) measurements. There were no significant differences in pain or skin tears between the 2 groups. No flexor tendon ruptures were observed. Conclusions The effectiveness of CCH in achieving correction of Dupuytren contractures was preserved when manipulation was performed on day 7, with no differences in correction, pain, or skin tears. These data suggest that manipulation can be scheduled at the convenience of the patient and surgeon within the first 7 days after injection. Type of study/level of evidence Therapeutic I.

Dupuytren disease (DD) is a benign, generally painless connective tissue disorder affecting the palmar fascia that leads to progressive hand contractures. Mediated by myofibroblasts, the disease most commonly begins as a nodule in the palm or finger, and can progress where pathologic cords form leading to progressive flexion deformity of the involved fingers. The palmar skin overlying the cords may become excessively calloused and contracted and involved joints may develop periarticular fibrosis. Although there is no cure, the sequellae of this affliction can be corrected. This article focuses on the role of collagen in DD and the development of a collagen-specific enzymatic treatment for DD contractures.

Treatment of Dupuytren disease with collagenase clostridium histolyticum is increasingly used among hand surgeons. Although it is generally safe and efficacious, complications related to enzymatic fasciotomy occur. Postapproval surveillance and communication among hand surgeons continues to refine the indications, contraindications, and complications recognized in the treatment of Dupuytren disease with enzymatic therapy. Major treatment-related adverse events previously reported include flexor tendon rupture and complex regional pain syndrome. We report a patient who experienced total loss of a well-established volar ring finger skin graft following collagenase injection and propose a potential mechanism of vulnerability. This case may illustrate the susceptibility of type I collagen, which is uniformly present in a healed skin graft bed, to degradation with collagenase. We propose a cautious approach when considering treatment of a Dupuytren cord with collagenase in the presence of an overlying skin graft, regardless of the age of the graft.

Proper hand function relies on a combination of strength and mobility. The intricate architecture that allows for hand mobility includes the articular surfaces of joints, periarticular ligamentous structures, tendon mechanisms, and the soft-tissue envelope. These structures are subject to injury and scarring. The net effect of a variety of etiologic factors is stiffness of the hand with diminution of hand function. This article reviews the biology of healing, pertinent anatomy of the hand, and operative and nonoperative treatment of the stiff hand.

Purpose Collagenase has been investigated in phase II and phase III clinical trials for the treatment of Dupuytren's disease. The purpose of this study is to report 8-year follow-up results in a subset of patients who had collagenase injection for the treatment of Dupuytren's contracture. Methods Twenty-three patients who participated in the phase II clinical trial of injectable collagenase were contacted by letter and phone. Eight patients were enrolled, completed a Dupuytren's disease questionnaire, and had independent examination of joint motion by a single examiner. Results Eight patients completed the 8-year follow-up study: 6 had been treated for isolated metacarpophalangeal (MCP) joint contracture, and 2 had been treated for isolated proximal interphalangeal (PIP) joint contracture. Average preinjection contracture was 57° in the MCP group. Average contracture was 9° at 1 week, 11° at 1 year, and 23° at 8-year follow-up. Four of 6 patients experienced recurrence, and 2 of 6 had no evidence of disease recurrence at 8-year follow-up. Average preinjection contracture was 45° in the PIP group. Average contracture was 8° at 1 weeks, 15° at 1 year, and 60° at 8-year follow-up. Both patients experienced recurrence at 8-year follow-up. No patients had had further intervention on the treated finger in either the MCP or the PIP group. Patients subjectively rated the overall clinical success at 60%, and 88% of patients stated that they would pursue further injection for the treatment of their recurrent or progressive Dupuytren's disease. Conclusions Enzymatic fasciotomy is safe and efficacious, with initial response to injection resulting in reduction of joint contracture to within 0°–5° of normal in 72 out of 80 patients. Initial evaluation of long-term recurrence rates suggests disease recurrence or progression in 4 out of 6 patients with MCP contractures and 2 patients with PIP contractures; however, recurrence was generally less severe than the initial contracture in the MCP group. In addition, patient satisfaction was high. Type of study/level of evidence Therapeutic IV.

Congenital limb duplications include pre- and post-axial polydactyly, central polydactyly, and the mirror-hand spectrum. Treatment of these duplications constitutes a significant functional and aesthetic challenge for the reconstructive hand surgeon. This article provides an inclusive review of the embryologic and molecular mechanisms underlying these deformities and focuses on their clinical treatment. The anatomic variation, classification, surgical treatment, and outcomes of surgical intervention are reviewed for each of the disorders of duplication.

In Triton X-100-skinned trachealis muscle, neither papaverine nor AH 21-132 modified responses to Ca 2+ . The (−)-enantiomer of AH 21-132 was more potent than the (+)-enantiomer both in relaxing intact trachealis muscle and in inhibiting tracheal cAMP phosphodiesterase (PDE). AH 21-132 (0.6 μM) potentiated forskolin in causing tracheal relaxation but did not potentiate isoprenaline, cromakalim or sodium nitrite. AH 21-132 (2 μm) potentiated all four agents in relaxing the trachea. AH 21-132 (1 μM) potentiated forskolin in increasing tissue cAMP content and, in higher concentration, itself increased tissue cAMP. Electrical effects of AH 21-132 included suppression of spontaneous slow waves and cellular hyperpolarisation. It is concluded that AH 21-132 lacks a direct depressant effect on the intracellular contractile machinery. The weight of evidence suggests that AH 21-132-induced relaxation results from inhibition of cAMP-PDE. However, in common with other PDE inhibitors, AH 21-132 increases tissue cAMP content only at concentration greater than that required to cause full relaxation.

Erb's palsy is well known to physicians across medical specialties, and its clinical manifestations present a formidable challenge to reconstructive surgeons. Although the condition is well established, knowledge pertaining to its namesake, Wilhelm Heinrich Erb, is rather obscure in the existing scientific literature. Erb was influential not only through his description of classic brachial plexus palsy involving the superior (or upper) roots, but also by his indelible contributions to our understanding of peripheral nerve physiology, deep tendon reflexes, and the muscular dystrophies. Erb's contributions to medicine transcend specialty boundaries. In this article, the authors seek to convey his scientific achievements and the character of the man through translation of his German manuscripts. These texts, complemented by the existing English literature, provide a unique perspective on Wilhelm Heinrich Erb's contribution to medicine. The authors will also emphasize his role in describing and clarifying the nature of Erb's palsy.

Localized gigantism poses a challenging surgical dilemma, and it may be treated with amputation. This case report documents the application of a reconstructive approach to a severe case of pedal macrodystrophia lipomatosa in a 1-year-old girl. A series of 3 surgeries were designed to reduce the length, width, height, and overall bulk of the congenitally enlarged foot. The 3 procedures debulked the foot for normal ambulation and same-size shoe wear for both feet. The resulting functional and aesthetic improvements achieved through reconstructive treatment provided a desirable alternative to amputation.

The functional role of the osteoblast nuclear matrix has been a matter of supposition. Its presumed function as an architectural agent of transcription derives primarily from the low solubility of nuclear matrix proteins and their typical localization into discrete subnuclear domains. In addressing how the nuclear matrix regulates skeletal genes, the authors compare Nmp4, Cbfal, and YY1 for the purpose of profiling osteoblast nuclear matrix transcription factors. All three proteins contribute to the transcription of ECM genes and partition into the osteoblast nuclear matrix via a nuclear matrix targeting domain. The authors propose that osteoblast nuclear matrix transcription factors involved in ECM regulation generally have the capacity to alter DNA geometry and reciprocally respond to DNA as an allosteric ligand. This may allow these proteins to adapt to the local nuclear architecture and generate the pattern of regulation specified by that architecture via unmasking of the appropriate transactivation domains. Osteoblast nuclear matrix transcription factors may also act as transcriptional adaptor molecules by supporting the formation of higher order protein complexes along target gene promoters. The genes encoding all three proteins considered here have trinucleotide repeat domains, although the significance of this is unclear. There is no canonical nuclear matrix binding motif, but finger-like structures may be suited for anchoring proteins to discrete subnuclear domains. Finally, the ability to leave the osteoblast nuclear matrix may be as important to the function of some nuclear matrix transcription factors as their association with this subcompartment.