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Therapeutic, III.

Background Whether to perform an end-to-end (ETE) versus end-to-side (ETS) arterial anastomosis is an integral part of preoperative planning and intraoperative decision making in free flap-based reconstructions. This study evaluated the impact of microsurgical anastomotic technique on outcomes of lower extremity reconstructions, with a focus on patients with peripheral arterial disease (PAD). Methods Over a 6-year period, 425 patients underwent 437 microvascular lower extremity free flap reconstructions with fasciocutaneous anterolateral thigh- or gracilis muscle flaps at a single surgical center. The cases were divided into an ETE (n = 297 patients) versus ETS (n = 128 patients) group according to the anastomotic technique. A retrospective analysis of patients' demographics, perioperative details, surgical complications, free flap types, recipient sites, flap survival, and the potential impact of PAD on outcomes was performed. Patient groups were comparable regarding comorbidities, American Society of Anesthesiologists scores, types of performed free flaps and recipient sites. Results We found no significant differences between the ETE versus ETS groups regarding the rate of major or minor complications (p > 0.05). Specifically, in patients suffering from PAD (n = 64) the type of arterial anastomosis had no effect on the outcome. Conclusion Overall, no significant differences in outcomes were observed when comparing the types of performed arterial anastomosis. This observation also held true for the subgroup of patients with PAD. Given that an ETS anastomosis did not increase the risk to encounter complications while preserving distal perfusion, we believe that this technique is the method of choice, especially in patients with impaired vascular status.

Background: This study aims to present a new therapeutic option for the treatment of thumb carpometacarpal joint osteoarthritis. Knowing that autologous fat may be beneficial for osteoarthritis through antiinflammatory and chondroprotective effects, the authors transplanted autologous adipose fat into the thumb carpometacarpal joint with the objective of postponing definite resection arthroplasty surgery. Methods: In this pilot study, the authors performed surgery on 99 joints. The study population consisted of patients with symptomatic and radiologically confirmed osteoarthritis of the thumb carpometacarpal joint. After harvesting abdominal adipose tissue, 1 to 2 ml of fat without physical or enzymatic manipulation were transplanted into the thumb carpometacarpal joint. Surgical outcome was quantified by use of the Michigan Hand Outcomes Questionnaire in addition to strength and pain measurements during a 12-month follow-up consultation. We conducted Friedman’s analysis of variance to gauge the differences over time regarding Michigan Hand Outcomes Questionnaire and pain under stress. Results: From 2 weeks on, there was pain relief, both under stress and at rest. Friedman’s analysis of variance revealed a significant change in pain under stress [chi-square (5) = 68.52; p < 0.001]. Postoperative Michigan Hand Outcomes Questionnaire Scores improved significantly over 12 months [chi-square (5) = 90.56; p < 0.001]. Conclusion: The authors’ preliminary findings suggest that intraarticular autologous fat transplantation is a promising alternative treatment of carpometacarpal joint osteoarthritis of the thumb. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Background Several patient-related factors have been identified with regard to the safety and efficacy of breast reconstructions. Using the largest database available in Europe, the presented study investigated the impact of cigarette smoking on deep inferior epigastric artery perforator (DIEP) free-flap breast reconstructions. Methods In total, 3,926 female patients underwent 4,577 free DIEP-flap breast reconstructions after malignancies in 22 different German breast cancer centers. The cases were divided into two groups: nonsmokers (NS) and smokers (S). Impact of smoking on surgical complications, controlled for covariates, and cluster effects within the cancer centers were analyzed by using generalized linear mixed models. Results Overall, there was no significant difference between the groups of patients regarding the rate of total flap loss. However, the rate of partial flap loss (0.9 vs. 3.2%, p < 0.001) and wound-healing disturbances requiring revision surgery (donor site: 1.5 vs. 4.0; recipient site: 1.3 vs. 3.6%, both p < 0.001) was significantly higher in smokers. Multivariable analysis identified smoking to be an independent risk factor for revision surgery (p = 0.001) and partial flap loss (p < 0.0001). Conclusion Our findings suggest that successful free tissue transfer can be achieved in smokers despite higher rates of partial flap losses and wound-healing disturbances. However, patients with a history of smoking requiring DIEP flap reconstruction should be critically evaluated preoperatively, informed in detail about the higher risk of complications and encouraged to quit smoking prior to surgery.

Background:There exist various operative approaches for the treatment of trapeziometacarpal joint osteoarthritis. The aim of this study was to compare the results of Lundsborg’s resection arthroplasty (RA) with implantation of a total endoprosthesis.Patients and Methods:In this 2-center study, we retrospectively analyzed 71 patients with symptomatic osteoarthritis of the carpometacarpal I joint stage III according to the Eaton-Littler classification. Thirty-two patients underwent a Lundsborg’s RA group, and 39 patients received a total endoprosthesis of the carpometacarpal I joint (TEP group). We evaluated operative time, DASH score, postoperative time until resolution of symptoms, pain level, pinch force, and satisfaction with the treatment.Results:Both groups had a similar mean length of follow-up of 42 months (TEP group) and 36 months (RA group). The final DASH score was significantly better in the TEP-group (10.1 versus 21.5 in the RA group; P ≤ 0.05). Also, the time interval from surgery till absence of any pain (1.5 versus 5.9 months) and the time of inability to work (6 versus 21 weeks) were significantly shorter for the TEP group compared with the RA group (P ≤ 0.05). The pinch force, pain intensity, and the satisfaction with the treatment were comparable (P > 0.05). The duration of the operation was significantly shorter in the RA group (31 min versus 65 min in the TEP group; P ≤ 0.05).Conclusion:Both techniques resulted in improved function of the operated hand and a clear reduction of symptoms. However, the implantation of a total endoprosthesis seems to have advantages, given a significantly better DASH score and a significantly shorter time until resolution of symptoms.

Background: Following Achilles tendon rupture and repair, reruptures or infections are not infrequent. Consequently, several surgical techniques have been described to decrease complication rates. This study aimed to evaluate the outcomes of the free composite fasciocutaneous anterolateral thigh flap including fascia lata for reconstruction of combined complex soft-tissue and Achilles tendon defects. Methods: Within an 8-year period, 34 patients having undergone microvascular Achilles tendon reconstruction fulfilled inclusion criteria for this study: 25 of these patients (73.5 percent) returned for follow-up examination, seven of whom (28.0 percent) underwent additional bilateral contact pressure and power measurements. The data were screened for patients’ demographics, intraoperative and perioperative details, flap survival, surgical complications, and overall long-term outcomes. Results: Mean follow-up time was 40.8 months. The Thompson test was negative in all patients. The pain score assessed by the Numerical Rating Scale at the reconstructed site was low overall, but showed significant differences between rest and activity (p < 0.05). The assessment of the Vancouver Scar Scale showed very good results with both techniques. The measurements of the peak pressures, power while walking, and foot contact area did not show differences between the operated and nonoperated sides (p > 0.05), whereas range of motion revealed significant differences (p < 0.05). Conclusions: In patients who suffer complex Achilles tendon injury requiring free flap coverage, the composite anterolateral thigh flap including fascia lata provides a reliable and safe approach with very good functional and aesthetic outcomes. It should be considered one of the first reconstructive options. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.