Darrell Brooks - Academia.edu (original) (raw)

Papers by Darrell Brooks

Research paper thumbnail of Evaluating Nerve Repair Outcomes in Complex Soft Tissue Reconstructions, a Multicenter Study Approach

Introduction: Severe trauma often results in complex peripheral nerve injuries that challenge eve... more Introduction: Severe trauma often results in complex peripheral nerve injuries that challenge even the most skilled reconstructive surgeon. As these injuries are highly variable, prospective clinical research on treatment algorithms are limited. In 2008, a multicenter, retrospective study was initiated to capture data on outcomes from the utilization of processed nerve allografts in today’s clinical practice. Analysis yielded a subgroup presenting with complex traumatic injuries requiring extensive soft tissue reconstructions. Here we report our findings on the outcomes of complex peripheral nerve injuries reconstructed using processed nerves allografts. Methods: The IRB approved study enrolled 12 sites with 25 contributing surgeons. Standardized data collection forms were completed for 132 individual nerve injuries. The aggregate data was reviewed to identify the subset of patients with multi-tissue, high energy, and extensive reconstructions. Quantitative assessment included: MRCC...

Research paper thumbnail of Determination of the Vascular Configuration in Autogenous Breast Reconstruction Using Abdominal Tissue: Simple but Not Necessarily Easy

Plastic and Reconstructive Surgery, 2006

Letters to the Editor and Viewpoints are welcome. Letters to the Editor discuss material recently... more Letters to the Editor and Viewpoints are welcome. Letters to the Editor discuss material recently published in the Journal. Letters will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters and Viewpoints are published at the discretion of the Editor. Viewpoints pertain to issues of general interest, even if they are not related to items previously published (such as unique techniques, brief technology updates, technical notes, and so on). Please note the following criteria for Letters and Viewpoints: • Text-maximum of 500 words (not including references) • References-maximum of five • Authors-no more than five • Figures/Tables-no more than two figures and/or one table Authors will be listed in the order in which they appear in the submission. Letters and Viewpoints should be submitted electronically via PRS' enkwell, at www.

Research paper thumbnail of Distraction Osteogenesis after Toe-to-Thumb Transplantation

Plastic and Reconstructive Surgery, 2002

Research paper thumbnail of The Free Partial Superior Latissimus Muscle Flap: Preservation of Donor-Site Form and Function

Plastic and Reconstructive Surgery, 2008

Research paper thumbnail of A Simple and Reliable Technique for Harvesting Skin from a “Spare Part” by a Single Operator

Plastic and Reconstructive Surgery, 2009

Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related t... more Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria: • Text-maximum of 500 words (not including references) • References-maximum of five • Authors-no more than five • Figures/Tables-no more than two figures and/or one table Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/ prs/. We strongly encourage authors to submit figures in color. We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

Research paper thumbnail of 7: The Free Partial Superior Latissimus (PSL) Muscle Flap: Preservation of Donor Site Form and Function

Plastic and Reconstructive Surgery, 2006

ObjeCTive: To assess current information regarding thread lifts, define the role they have in ope... more ObjeCTive: To assess current information regarding thread lifts, define the role they have in open and closed face lifting and explain the limits and possible pitfalls of the procedure.

Research paper thumbnail of 6: Outcome Analysis of Combined Ilizarov Bone Transport and Immediate Free Tissue Transfer for Lower Extremity Salvage

Plastic and Reconstructive Surgery, 2006

ObjeCTive: To assess current information regarding thread lifts, define the role they have in ope... more ObjeCTive: To assess current information regarding thread lifts, define the role they have in open and closed face lifting and explain the limits and possible pitfalls of the procedure.

Research paper thumbnail of Free Partial Medial Rectus Muscle Flap for Closure of Complex Extremity Wounds

Plastic and Reconstructive Surgery, 2005

Research paper thumbnail of Index finger salvage with replantation and revascularization: Revisiting conventional wisdom

Microsurgery, 2008

Replantation/revascularization of severely injured single digits is controversial, especially at ... more Replantation/revascularization of severely injured single digits is controversial, especially at the index position. Conventional wisdom is that these digits if salvaged will ultimately worsen residual hand function and they should be amputated. Twenty‐eight cases of such index salvages were reviewed to test this hypothesis. Five cases involved children and were excluded. Twenty‐three replants/revascularizations survived (100%). Total active motion was 170° in zone 1, and 133° for zone 2 injuries. Patient satisfaction was high in all cases. In selected cases, salvage of severely injured and amputated index fingers has the potential for satisfying survival and functional results and dogmatic treatment with completion amputation should be avoided. © 2008 Wiley‐Liss, Inc. Microsurgery, 2008.

Research paper thumbnail of Resurfacing of a complex upper extremity injury: An excellent indication for the dorsal thoracic fascial flap

Microsurgery, 2009

We report a case of a 24-year-old patient who sustained a mutilating crush injury to the left for... more We report a case of a 24-year-old patient who sustained a mutilating crush injury to the left forearm. After thorough debridement and stabilization of the skeletal injury, the dorsal thoracic fascial flap was used to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for the exposed tendons. The flap was safely transected during revision surgery, and at 6-months follow-up, excellent functional and cosmetic results were achieved. The dorsal thoracic fascia is a thin, durable, and pliable tissue that is based on a long vascular pedicle. We consider the dorsal thoracic fascial flap as a valuable option for coverage of complex upper extremity injuries and highly recommend its use.

Research paper thumbnail of Management of exposed total knee prostheses with microvascular tissue transfer

Microsurgery, 2008

Introduction: Exposure of a knee endoprosthesis represents a limb‐threatening condition, requirin... more Introduction: Exposure of a knee endoprosthesis represents a limb‐threatening condition, requiring long‐term antibiosis, irrigation, and serial debridement to avoid knee arthrodesis or amputation. Although traditional orthopedic surgical doctrine mandates removal of exposed hardware under a dehisced wound, salvage of exposed prostheses using local muscle flap coverage has been reported. However, the complex three‐dimensional geometry of the soft tissue surrounding the knee as well as the requirement for sustained local tissue levels of antibiotics to re‐sterilize the hardware suggest that microvascular tissue transfer may constitute an advantageous means of wound coverage, increasing both limb and prosthesis salvage rates. We report our experience with free tissue transfer reconstruction of these complex wounds. Methods: We treated 11 complex wounds with exposed total knee arthroplasty prostheses with free tissue transfer. Three of 11 patients had failed previous local muscular rota...

Research paper thumbnail of Use of circular external fixation to maintain foot position during free tissue transfer to the foot and ankle

Microsurgery, 2008

Limb salvage techniques of traumatized extremities using free‐tissue transfer and microsurgical t... more Limb salvage techniques of traumatized extremities using free‐tissue transfer and microsurgical techniques have become standard reconstructive methods. To our knowledge there is no published data on the incidence or likelihood of equinus following free tissue transfer about the ankle, although in our experience we have perceived an unacceptable incidence of equinus following free tissue transfers about the ankle and therefore initiated prophylactic ring fixation across the ankle. Fourteen patients were placed in circular external fixation spanning the ankle at the time of free tissue transfer for a mean of 12 weeks (Median 7 weeks, Range 6–28 weeks). The results were evaluated using the degree of active ankle dorsiflexion and return to independent ambulation. Six patients had excellent results with active ankle dorsiflexion beyond neutral, and four patients had good results with neutral ankle alignment that did not require further intervention. All patients saved their limb and retu...

Research paper thumbnail of Partial muscle harvest: Our first 100 cases attempting to preserve form and function at the donor site

Research paper thumbnail of Simultaneous Double Second Toe Transplantation for Reconstruction of Multiple Digit Loss in Traumatic Hand Injuries

Journal of Reconstructive Microsurgery, 2009

The objective of this study is to review a single institution&amp... more The objective of this study is to review a single institution's 10-year experience of simultaneous double second toe transplantations for reconstruction of traumatic hand injuries. Eleven cases of traumatic hand injuries treated with simultaneous double second toe transplantation for digital reconstruction were retrospectively reviewed. All patients sustained traumatic injury resulting in multiple digit loss not amenable to replantation. A simultaneous three-team approach was performed in all cases. The average operating time was 9 hours (range 7 to 15 hours). The mean time to reconstruction was 5.7 months following injury (range 2 to 15 months). Mean hospital stay was 8 days (range 6 to 11 days). Complications included microvascular thrombosis in two toes, loss of one transplanted toe, hematoma, and wound infection. Twenty-one toes survived; secondary surgery was performed in ten patients. Average moving 2-point discrimination was 8 mm in each digit at 7-month follow-up. Mean grip and pinch strength approached 67% of the contralateral hand. Mean time to return to work after finger reconstruction was 10 months. Simultaneous double second toe transplantation is a useful and efficient option for multidigit reconstruction. A three-team approach allows for single-stage reconstruction resulting in decreased operative time, decreased hospital stay, and good functional outcomes when compared with alternative techniques.

Research paper thumbnail of How often is the superficial inferior epigastric artery adequate? An observational correlation

Journal of Plastic, Reconstructive & Aesthetic Surgery, 2010

Adolescent Medicine Clinics, Volume 63, Issue 3, Pages e310-e311, March 2010, Authors:Fernando A.... more Adolescent Medicine Clinics, Volume 63, Issue 3, Pages e310-e311, March 2010, Authors:Fernando A. Herrera; Jesse C. Selber; Rudolf Buntic; Darrell Brooks; Gregory M. Buncke; Anuja K. Antony.

Research paper thumbnail of A Standardized Protocol for Management of Artery only Fingertip Replantations

The Journal of Hand Surgery, 2009

ABSTRACT HYPOTHESIS: Artery only fingertip replantation can be reliable if combined with a post-o... more ABSTRACT HYPOTHESIS: Artery only fingertip replantation can be reliable if combined with a post-operative protocol which promotes low-resistance flow through the replant until venous outflow is restored. METHODS: This is a retrospective study of patients with artery-only fingertip replantation. Artery-only fingertip replantation is defined as a complete amputation distal to the distal interphalangeal (DIP) joint replanted with repair of an inflow artery but without benefit of an outflow vein due to level or mechanism of amputation. All patients had the replant nail-plate removed and received intravenous Dextran and heparin to promote fingertip bleed and low-pressure flow across the repaired vessel. Anticoagulation was titrated to promote a controlled bleed until physiologic venous outflow was restored. Medicinal leeches and mechanical heparin scrubs were utilized for acute decongestion. By post-operative day 6 bleeding was no longer promoted. Fluoroscein studies were initiated to assess circulatory (arterial and venous) competence and direct further anticoagulant intervention. Lack of bleeding associated with a rise and fall in fluoroscein concentration would trigger a weaning of anticoagulation. Lack of bleeding associated with congestion or lack of a fall in fluoroscein concentration would result in reinstitution and maintenance of bleed from the fingertip. Length of hospitalization, complications, number of units of blood transfused, and patient satisfaction, were followed as well as characteristics of the injury including the finger amputated, mechanism of amputation, and zone of amputation as described by Ishikawa.

Research paper thumbnail of Functional Outcome Following Nerve Repair in the Upper Extremity Using Processed Nerve Allograft

The Journal of Hand Surgery, 2012

Purpose Reconstruction of peripheral nerve discontinuities with processed nerve allograft has bec... more Purpose Reconstruction of peripheral nerve discontinuities with processed nerve allograft has become increasingly relevant. The RANGER Study registry was initiated in 2007 to study the use of processed nerve allografts in contemporary clinical practice. We undertook this study to analyze outcomes for upper extremity nerve repairs contained in the registry database. Methods We identified an upper extremity-specific population within the RANGER Study registry database consisting of 71 nerves repaired with processed nerve allograft. This group was composed of 56 subjects with a mean age of 40 Ϯ 17 years (range, 18-86 y). We analyzed data to determine the safety and efficacy of processed nerve allograft. Quantitative data were available on 51 subjects with 35 sensory, 13 mixed, and 3 motor nerves. The mean gap length was 23 Ϯ 12 mm (range, 5-50 mm). We performed an analysis to evaluate response-to-treatment and to examine sensory and motor recovery according to the international standards for motor and sensory nerve recovery. Results There were no reported implant complications, tissue rejections, or adverse experiences related to the use of the processed nerve allografts. Overall recovery, S3 or M4 and above, was achieved in 86% of the procedures. Subgroup analysis demonstrated meaningful levels of recovery in sensory, mixed, and motor nerve repairs with graft lengths between 5 and 50 mm. The study also found meaningful levels of recovery in 89% of digital nerve repairs, 75% of median nerve repairs, and 67% of ulnar nerve repairs. Conclusions Our data suggest that processed nerve allografts offer a safe and effective method of reconstructing peripheral nerve gaps from 5 to 50 mm in length. These outcomes compare favorably with those reported in the literature for nerve autograft, and exceed those reported for tube conduits.

Research paper thumbnail of Detection of Perfusion Disturbances in Digit Replantation Using Near-Infrared Spectroscopy and Serial Quantitative Fluoroscopy

The Journal of Hand Surgery, 2006

The postoperative monitoring of digit replants continues to be a challenge. Current objective met... more The postoperative monitoring of digit replants continues to be a challenge. Current objective methods of digit monitoring have not been adopted widely because of their complexity or lack of sensitivity. Because tissue oxygen tension correlates directly with vascular inflow, a device that tracks changes in tissue oxygenation may be useful to monitor the perfusion and viability of digits after revascularization. A clinical study was undertaken to evaluate noninvasive monitoring of tissue oxygenation using near-infrared spectroscopy in postoperative digit replantation. Methods: Forty-eight patients were enrolled and 64 digits were monitored at 1 institute. There were 43 male and 5 female patients with an average age of 41 years (range, 13-79 y). Digits were monitored by clinical examination, fluorescein, and a tissue oximeter at 1-to 2-hour intervals for 24 to 48 hours. Results: Sixty-one digits survived and 3 digits failed. In the surviving digits the fluorescein and tissue oxygen saturation (StO 2) readings were similar to the control digit readings. There were no significant differences between fluorescein and StO 2 or between StO 2 readings for control and surviving digits. In the digits that failed to survive both fluorescein and StO 2 readings were significantly lower in the failed compared with control digits. The StO 2 values for failed digits were 30% to 70% lower and showed greater variation than the StO 2 values for the control digits. There were no complications associated with fluorescein or tissue oxygenation measurements. Conclusions: Near-infrared spectroscopy measurement of tissue oxygenation correlates with fluorescein monitoring and digit perfusion. This noninvasive monitoring is easy, reliable, safe, and useful in postoperative monitoring of digit replantation.

Research paper thumbnail of Selected Outcomes of Thumb Replantation After Isolated Thumb Amputation Injury

The Journal of Hand Surgery, 2010

The aim of this study was to assess thumb survival, pinch strength, grip strength, and need for s... more The aim of this study was to assess thumb survival, pinch strength, grip strength, and need for secondary surgery in patients undergoing thumb replantation after isolated thumb amputation injury. Methods We conducted a retrospective review of 52 consecutive isolated thumb replantations performed over a 4.5-year period. Charts were reviewed for mechanism of injury, level of amputation, and surgical technique. Primary outcomes of interest included survival and secondary surgery (eg, tenolysis, neurolysis) rates. Functional outcome was assessed by pinch and grip strengths after a mean follow-up period of 10 months from the initial injury. Results The overall thumb survival rate was 92% (48 of 52). One hundred percent of Zone I injuries (13 of 13), 94% of zone II injuries (29 of 31), and 75% of zone III injuries (6 of 8) survived; overall survival was 94% in sharp injuries (32 of 34), 89% in avulsion injuries (8 of 9), and 89% in crush injuries (8 of 9). Secondary surgery was performed in 18 patients with increasing need across the 3 zones (0%, 42%, and 63%, respectively; p for trend ϭ .002). Pinch and grip strengths of 17 patients after an average follow-up period of 10 months were significantly worse after crush/avulsion injuries (p ϭ .007 and .07, respectively) and injuries requiring joint intervention (p ϭ .004 and .02, respectively); grip strength was also found to be negatively associated with increasing zone of injury. Conclusions This retrospective study shows that a high rate of survival can be achieved after thumb replantation using current techniques. In addition, the need for secondary surgery is strongly related to zone of injury, with zone I injuries requiring the least amount of secondary surgery. Finally, pinch and grip strengths may be worse after crush or avulsion injuries and injuries requiring joint intervention.

Research paper thumbnail of An Aesthetic Perquisite of Rectus Muscle Transplantation in Extremity Reconstruction

Annals of Plastic Surgery, 2005

The authors combine a rectus abdominis muscle harvest with a mini-abdominoplasty in patients with... more The authors combine a rectus abdominis muscle harvest with a mini-abdominoplasty in patients with Matarasso type II and III body types admitted for extremity reconstruction. The dermolipectomy tissue was used as a source for split-thickness skin graft. Twenty-five patients underwent the combined procedure. All flaps survived. Average quantity of skin harvested from the dermolipectomy tissue was 150 cm 2 (range 100-250 cm 2). Twenty-three of 25 (92%) required no additional skin grafting. The remaining 2 cases required less than 50 cm 2 of additional split-thickness skin graft. There were no complications related to the mini-abdominoplasty. All patients were satisfied with their abdominal recontouring. The combined procedure results in an aesthetic improvement at the abdominal donor site and elimination or significant reduction of the morbidity related to a conventional skin graft donor site at the upper lateral thigh. This technique also allows thicker skin graft harvest without an associated increase in morbidity. The authors believe that this technique should be considered for patients with appropriate body habitus when a rectus abdominis muscle is the flap of choice or when multiple flaps including the rectus abdominis muscle are equal for the task.

Research paper thumbnail of Evaluating Nerve Repair Outcomes in Complex Soft Tissue Reconstructions, a Multicenter Study Approach

Introduction: Severe trauma often results in complex peripheral nerve injuries that challenge eve... more Introduction: Severe trauma often results in complex peripheral nerve injuries that challenge even the most skilled reconstructive surgeon. As these injuries are highly variable, prospective clinical research on treatment algorithms are limited. In 2008, a multicenter, retrospective study was initiated to capture data on outcomes from the utilization of processed nerve allografts in today’s clinical practice. Analysis yielded a subgroup presenting with complex traumatic injuries requiring extensive soft tissue reconstructions. Here we report our findings on the outcomes of complex peripheral nerve injuries reconstructed using processed nerves allografts. Methods: The IRB approved study enrolled 12 sites with 25 contributing surgeons. Standardized data collection forms were completed for 132 individual nerve injuries. The aggregate data was reviewed to identify the subset of patients with multi-tissue, high energy, and extensive reconstructions. Quantitative assessment included: MRCC...

Research paper thumbnail of Determination of the Vascular Configuration in Autogenous Breast Reconstruction Using Abdominal Tissue: Simple but Not Necessarily Easy

Plastic and Reconstructive Surgery, 2006

Letters to the Editor and Viewpoints are welcome. Letters to the Editor discuss material recently... more Letters to the Editor and Viewpoints are welcome. Letters to the Editor discuss material recently published in the Journal. Letters will have the best chance of acceptance if they are received within 8 weeks of an article's publication. Letters to the Editor may be published with a response from the authors of the article being discussed. Discussions beyond the initial letter and response will not be published. Letters submitted pertaining to published Discussions of articles will not be printed. Letters to the Editor are not usually peer reviewed, but the Journal may invite replies from the authors of the original publication. All Letters and Viewpoints are published at the discretion of the Editor. Viewpoints pertain to issues of general interest, even if they are not related to items previously published (such as unique techniques, brief technology updates, technical notes, and so on). Please note the following criteria for Letters and Viewpoints: • Text-maximum of 500 words (not including references) • References-maximum of five • Authors-no more than five • Figures/Tables-no more than two figures and/or one table Authors will be listed in the order in which they appear in the submission. Letters and Viewpoints should be submitted electronically via PRS' enkwell, at www.

Research paper thumbnail of Distraction Osteogenesis after Toe-to-Thumb Transplantation

Plastic and Reconstructive Surgery, 2002

Research paper thumbnail of The Free Partial Superior Latissimus Muscle Flap: Preservation of Donor-Site Form and Function

Plastic and Reconstructive Surgery, 2008

Research paper thumbnail of A Simple and Reliable Technique for Harvesting Skin from a “Spare Part” by a Single Operator

Plastic and Reconstructive Surgery, 2009

Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related t... more Viewpoints, pertaining to issues of general interest, are welcome, even if they are not related to items previously published. Viewpoints may present unique techniques, brief technology updates, technical notes, and so on. Viewpoints will be published on a space-available basis because they are typically less timesensitive than Letters and other types of articles. Please note the following criteria: • Text-maximum of 500 words (not including references) • References-maximum of five • Authors-no more than five • Figures/Tables-no more than two figures and/or one table Authors will be listed in the order in which they appear in the submission. Viewpoints should be submitted electronically via PRS' enkwell, at www.editorialmanager.com/ prs/. We strongly encourage authors to submit figures in color. We reserve the right to edit Viewpoints to meet requirements of space and format. Any financial interests relevant to the content must be disclosed. Submission of a Viewpoint constitutes permission for the American Society of Plastic Surgeons and its licensees and assignees to publish it in the Journal and in any other form or medium. The views, opinions, and conclusions expressed in the Viewpoints represent the personal opinions of the individual writers and not those of the publisher, the Editorial Board, or the sponsors of the Journal. Any stated views, opinions, and conclusions do not reflect the policy of any of the sponsoring organizations or of the institutions with which the writer is affiliated, and the publisher, the Editorial Board, and the sponsoring organizations assume no responsibility for the content of such correspondence.

Research paper thumbnail of 7: The Free Partial Superior Latissimus (PSL) Muscle Flap: Preservation of Donor Site Form and Function

Plastic and Reconstructive Surgery, 2006

ObjeCTive: To assess current information regarding thread lifts, define the role they have in ope... more ObjeCTive: To assess current information regarding thread lifts, define the role they have in open and closed face lifting and explain the limits and possible pitfalls of the procedure.

Research paper thumbnail of 6: Outcome Analysis of Combined Ilizarov Bone Transport and Immediate Free Tissue Transfer for Lower Extremity Salvage

Plastic and Reconstructive Surgery, 2006

ObjeCTive: To assess current information regarding thread lifts, define the role they have in ope... more ObjeCTive: To assess current information regarding thread lifts, define the role they have in open and closed face lifting and explain the limits and possible pitfalls of the procedure.

Research paper thumbnail of Free Partial Medial Rectus Muscle Flap for Closure of Complex Extremity Wounds

Plastic and Reconstructive Surgery, 2005

Research paper thumbnail of Index finger salvage with replantation and revascularization: Revisiting conventional wisdom

Microsurgery, 2008

Replantation/revascularization of severely injured single digits is controversial, especially at ... more Replantation/revascularization of severely injured single digits is controversial, especially at the index position. Conventional wisdom is that these digits if salvaged will ultimately worsen residual hand function and they should be amputated. Twenty‐eight cases of such index salvages were reviewed to test this hypothesis. Five cases involved children and were excluded. Twenty‐three replants/revascularizations survived (100%). Total active motion was 170° in zone 1, and 133° for zone 2 injuries. Patient satisfaction was high in all cases. In selected cases, salvage of severely injured and amputated index fingers has the potential for satisfying survival and functional results and dogmatic treatment with completion amputation should be avoided. © 2008 Wiley‐Liss, Inc. Microsurgery, 2008.

Research paper thumbnail of Resurfacing of a complex upper extremity injury: An excellent indication for the dorsal thoracic fascial flap

Microsurgery, 2009

We report a case of a 24-year-old patient who sustained a mutilating crush injury to the left for... more We report a case of a 24-year-old patient who sustained a mutilating crush injury to the left forearm. After thorough debridement and stabilization of the skeletal injury, the dorsal thoracic fascial flap was used to resurface the circumferential wound, protect the underlying structures, and provide a gliding surface for the exposed tendons. The flap was safely transected during revision surgery, and at 6-months follow-up, excellent functional and cosmetic results were achieved. The dorsal thoracic fascia is a thin, durable, and pliable tissue that is based on a long vascular pedicle. We consider the dorsal thoracic fascial flap as a valuable option for coverage of complex upper extremity injuries and highly recommend its use.

Research paper thumbnail of Management of exposed total knee prostheses with microvascular tissue transfer

Microsurgery, 2008

Introduction: Exposure of a knee endoprosthesis represents a limb‐threatening condition, requirin... more Introduction: Exposure of a knee endoprosthesis represents a limb‐threatening condition, requiring long‐term antibiosis, irrigation, and serial debridement to avoid knee arthrodesis or amputation. Although traditional orthopedic surgical doctrine mandates removal of exposed hardware under a dehisced wound, salvage of exposed prostheses using local muscle flap coverage has been reported. However, the complex three‐dimensional geometry of the soft tissue surrounding the knee as well as the requirement for sustained local tissue levels of antibiotics to re‐sterilize the hardware suggest that microvascular tissue transfer may constitute an advantageous means of wound coverage, increasing both limb and prosthesis salvage rates. We report our experience with free tissue transfer reconstruction of these complex wounds. Methods: We treated 11 complex wounds with exposed total knee arthroplasty prostheses with free tissue transfer. Three of 11 patients had failed previous local muscular rota...

Research paper thumbnail of Use of circular external fixation to maintain foot position during free tissue transfer to the foot and ankle

Microsurgery, 2008

Limb salvage techniques of traumatized extremities using free‐tissue transfer and microsurgical t... more Limb salvage techniques of traumatized extremities using free‐tissue transfer and microsurgical techniques have become standard reconstructive methods. To our knowledge there is no published data on the incidence or likelihood of equinus following free tissue transfer about the ankle, although in our experience we have perceived an unacceptable incidence of equinus following free tissue transfers about the ankle and therefore initiated prophylactic ring fixation across the ankle. Fourteen patients were placed in circular external fixation spanning the ankle at the time of free tissue transfer for a mean of 12 weeks (Median 7 weeks, Range 6–28 weeks). The results were evaluated using the degree of active ankle dorsiflexion and return to independent ambulation. Six patients had excellent results with active ankle dorsiflexion beyond neutral, and four patients had good results with neutral ankle alignment that did not require further intervention. All patients saved their limb and retu...

Research paper thumbnail of Partial muscle harvest: Our first 100 cases attempting to preserve form and function at the donor site

Research paper thumbnail of Simultaneous Double Second Toe Transplantation for Reconstruction of Multiple Digit Loss in Traumatic Hand Injuries

Journal of Reconstructive Microsurgery, 2009

The objective of this study is to review a single institution&amp... more The objective of this study is to review a single institution's 10-year experience of simultaneous double second toe transplantations for reconstruction of traumatic hand injuries. Eleven cases of traumatic hand injuries treated with simultaneous double second toe transplantation for digital reconstruction were retrospectively reviewed. All patients sustained traumatic injury resulting in multiple digit loss not amenable to replantation. A simultaneous three-team approach was performed in all cases. The average operating time was 9 hours (range 7 to 15 hours). The mean time to reconstruction was 5.7 months following injury (range 2 to 15 months). Mean hospital stay was 8 days (range 6 to 11 days). Complications included microvascular thrombosis in two toes, loss of one transplanted toe, hematoma, and wound infection. Twenty-one toes survived; secondary surgery was performed in ten patients. Average moving 2-point discrimination was 8 mm in each digit at 7-month follow-up. Mean grip and pinch strength approached 67% of the contralateral hand. Mean time to return to work after finger reconstruction was 10 months. Simultaneous double second toe transplantation is a useful and efficient option for multidigit reconstruction. A three-team approach allows for single-stage reconstruction resulting in decreased operative time, decreased hospital stay, and good functional outcomes when compared with alternative techniques.

Research paper thumbnail of How often is the superficial inferior epigastric artery adequate? An observational correlation

Journal of Plastic, Reconstructive & Aesthetic Surgery, 2010

Adolescent Medicine Clinics, Volume 63, Issue 3, Pages e310-e311, March 2010, Authors:Fernando A.... more Adolescent Medicine Clinics, Volume 63, Issue 3, Pages e310-e311, March 2010, Authors:Fernando A. Herrera; Jesse C. Selber; Rudolf Buntic; Darrell Brooks; Gregory M. Buncke; Anuja K. Antony.

Research paper thumbnail of A Standardized Protocol for Management of Artery only Fingertip Replantations

The Journal of Hand Surgery, 2009

ABSTRACT HYPOTHESIS: Artery only fingertip replantation can be reliable if combined with a post-o... more ABSTRACT HYPOTHESIS: Artery only fingertip replantation can be reliable if combined with a post-operative protocol which promotes low-resistance flow through the replant until venous outflow is restored. METHODS: This is a retrospective study of patients with artery-only fingertip replantation. Artery-only fingertip replantation is defined as a complete amputation distal to the distal interphalangeal (DIP) joint replanted with repair of an inflow artery but without benefit of an outflow vein due to level or mechanism of amputation. All patients had the replant nail-plate removed and received intravenous Dextran and heparin to promote fingertip bleed and low-pressure flow across the repaired vessel. Anticoagulation was titrated to promote a controlled bleed until physiologic venous outflow was restored. Medicinal leeches and mechanical heparin scrubs were utilized for acute decongestion. By post-operative day 6 bleeding was no longer promoted. Fluoroscein studies were initiated to assess circulatory (arterial and venous) competence and direct further anticoagulant intervention. Lack of bleeding associated with a rise and fall in fluoroscein concentration would trigger a weaning of anticoagulation. Lack of bleeding associated with congestion or lack of a fall in fluoroscein concentration would result in reinstitution and maintenance of bleed from the fingertip. Length of hospitalization, complications, number of units of blood transfused, and patient satisfaction, were followed as well as characteristics of the injury including the finger amputated, mechanism of amputation, and zone of amputation as described by Ishikawa.

Research paper thumbnail of Functional Outcome Following Nerve Repair in the Upper Extremity Using Processed Nerve Allograft

The Journal of Hand Surgery, 2012

Purpose Reconstruction of peripheral nerve discontinuities with processed nerve allograft has bec... more Purpose Reconstruction of peripheral nerve discontinuities with processed nerve allograft has become increasingly relevant. The RANGER Study registry was initiated in 2007 to study the use of processed nerve allografts in contemporary clinical practice. We undertook this study to analyze outcomes for upper extremity nerve repairs contained in the registry database. Methods We identified an upper extremity-specific population within the RANGER Study registry database consisting of 71 nerves repaired with processed nerve allograft. This group was composed of 56 subjects with a mean age of 40 Ϯ 17 years (range, 18-86 y). We analyzed data to determine the safety and efficacy of processed nerve allograft. Quantitative data were available on 51 subjects with 35 sensory, 13 mixed, and 3 motor nerves. The mean gap length was 23 Ϯ 12 mm (range, 5-50 mm). We performed an analysis to evaluate response-to-treatment and to examine sensory and motor recovery according to the international standards for motor and sensory nerve recovery. Results There were no reported implant complications, tissue rejections, or adverse experiences related to the use of the processed nerve allografts. Overall recovery, S3 or M4 and above, was achieved in 86% of the procedures. Subgroup analysis demonstrated meaningful levels of recovery in sensory, mixed, and motor nerve repairs with graft lengths between 5 and 50 mm. The study also found meaningful levels of recovery in 89% of digital nerve repairs, 75% of median nerve repairs, and 67% of ulnar nerve repairs. Conclusions Our data suggest that processed nerve allografts offer a safe and effective method of reconstructing peripheral nerve gaps from 5 to 50 mm in length. These outcomes compare favorably with those reported in the literature for nerve autograft, and exceed those reported for tube conduits.

Research paper thumbnail of Detection of Perfusion Disturbances in Digit Replantation Using Near-Infrared Spectroscopy and Serial Quantitative Fluoroscopy

The Journal of Hand Surgery, 2006

The postoperative monitoring of digit replants continues to be a challenge. Current objective met... more The postoperative monitoring of digit replants continues to be a challenge. Current objective methods of digit monitoring have not been adopted widely because of their complexity or lack of sensitivity. Because tissue oxygen tension correlates directly with vascular inflow, a device that tracks changes in tissue oxygenation may be useful to monitor the perfusion and viability of digits after revascularization. A clinical study was undertaken to evaluate noninvasive monitoring of tissue oxygenation using near-infrared spectroscopy in postoperative digit replantation. Methods: Forty-eight patients were enrolled and 64 digits were monitored at 1 institute. There were 43 male and 5 female patients with an average age of 41 years (range, 13-79 y). Digits were monitored by clinical examination, fluorescein, and a tissue oximeter at 1-to 2-hour intervals for 24 to 48 hours. Results: Sixty-one digits survived and 3 digits failed. In the surviving digits the fluorescein and tissue oxygen saturation (StO 2) readings were similar to the control digit readings. There were no significant differences between fluorescein and StO 2 or between StO 2 readings for control and surviving digits. In the digits that failed to survive both fluorescein and StO 2 readings were significantly lower in the failed compared with control digits. The StO 2 values for failed digits were 30% to 70% lower and showed greater variation than the StO 2 values for the control digits. There were no complications associated with fluorescein or tissue oxygenation measurements. Conclusions: Near-infrared spectroscopy measurement of tissue oxygenation correlates with fluorescein monitoring and digit perfusion. This noninvasive monitoring is easy, reliable, safe, and useful in postoperative monitoring of digit replantation.

Research paper thumbnail of Selected Outcomes of Thumb Replantation After Isolated Thumb Amputation Injury

The Journal of Hand Surgery, 2010

The aim of this study was to assess thumb survival, pinch strength, grip strength, and need for s... more The aim of this study was to assess thumb survival, pinch strength, grip strength, and need for secondary surgery in patients undergoing thumb replantation after isolated thumb amputation injury. Methods We conducted a retrospective review of 52 consecutive isolated thumb replantations performed over a 4.5-year period. Charts were reviewed for mechanism of injury, level of amputation, and surgical technique. Primary outcomes of interest included survival and secondary surgery (eg, tenolysis, neurolysis) rates. Functional outcome was assessed by pinch and grip strengths after a mean follow-up period of 10 months from the initial injury. Results The overall thumb survival rate was 92% (48 of 52). One hundred percent of Zone I injuries (13 of 13), 94% of zone II injuries (29 of 31), and 75% of zone III injuries (6 of 8) survived; overall survival was 94% in sharp injuries (32 of 34), 89% in avulsion injuries (8 of 9), and 89% in crush injuries (8 of 9). Secondary surgery was performed in 18 patients with increasing need across the 3 zones (0%, 42%, and 63%, respectively; p for trend ϭ .002). Pinch and grip strengths of 17 patients after an average follow-up period of 10 months were significantly worse after crush/avulsion injuries (p ϭ .007 and .07, respectively) and injuries requiring joint intervention (p ϭ .004 and .02, respectively); grip strength was also found to be negatively associated with increasing zone of injury. Conclusions This retrospective study shows that a high rate of survival can be achieved after thumb replantation using current techniques. In addition, the need for secondary surgery is strongly related to zone of injury, with zone I injuries requiring the least amount of secondary surgery. Finally, pinch and grip strengths may be worse after crush or avulsion injuries and injuries requiring joint intervention.

Research paper thumbnail of An Aesthetic Perquisite of Rectus Muscle Transplantation in Extremity Reconstruction

Annals of Plastic Surgery, 2005

The authors combine a rectus abdominis muscle harvest with a mini-abdominoplasty in patients with... more The authors combine a rectus abdominis muscle harvest with a mini-abdominoplasty in patients with Matarasso type II and III body types admitted for extremity reconstruction. The dermolipectomy tissue was used as a source for split-thickness skin graft. Twenty-five patients underwent the combined procedure. All flaps survived. Average quantity of skin harvested from the dermolipectomy tissue was 150 cm 2 (range 100-250 cm 2). Twenty-three of 25 (92%) required no additional skin grafting. The remaining 2 cases required less than 50 cm 2 of additional split-thickness skin graft. There were no complications related to the mini-abdominoplasty. All patients were satisfied with their abdominal recontouring. The combined procedure results in an aesthetic improvement at the abdominal donor site and elimination or significant reduction of the morbidity related to a conventional skin graft donor site at the upper lateral thigh. This technique also allows thicker skin graft harvest without an associated increase in morbidity. The authors believe that this technique should be considered for patients with appropriate body habitus when a rectus abdominis muscle is the flap of choice or when multiple flaps including the rectus abdominis muscle are equal for the task.