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Open distal radius fractures are rare injuries with few studies to guide treatment. Degree of soft tissue injury and contamination may be a primary consideration to dictate timing and operative intervention. Antibiotics should be started as early as possible and include a first-generation cephalosporin. Surgical fixation remains a matter of surgeon preference: although studies support the use of definitive internal fixation, many surgeons address contaminated injuries with external fixation. Although postoperative outcomes are similar to closed injuries for low-grade open distal radius fractures, high-grade injuries with more complex fracture patterns carry a high risk of complications, poor outcomes, and repeat surgical procedures., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Injury to the lunotriquetral ligament can result in midcarpal instability, with resultant alterations in normal wrist kinematics and subsequent arthrosis. We performed a previously undescribed technique of lunotriquetral ligament reconstruction in two patients utilizing a palmaris longus tendon autograft. Average age at presentation was 24 years old with a mean follow up of 10 months. Average range of motion was 62.5° of flexion and 57.5° of extension. Total arc of motion was 83% of the contralateral uninvolved extremity. Average grip strength was 31 kg which was 91% of the contralateral extremity. Average Quick Disability of Arm, Shoulder and Hand score was 12.5 and Modern Activity Subjective Survey of 2007 was 1.5. No complications were noted.

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Purpose: In the current study, we investigated the effects of existing education materials-either a Traumatic Brain Injury (TBI) factsheet or personal stories of people with TBI-on undergraduate students' misconceptions and attributions about the causes of TBI-related behavior., Method: Undergraduate students (N = 164) were recruited through the university participant pool. The participants were randomly assigned to receive either a factsheet about TBI, personal stories of people with TBI, or a control reading. Groups were compared on the number of TBI misconceptions endorsed, scores on an attribution measure, and their willingness to interact with people who have TBIs., Results: Both the TBI factsheet group and the personal stories group endorsed fewer misconceptions, on average, than the control group (p = .02). Additionally, those who read either the personal stories or the factsheet had significantly lower attribution scores, on average, than the control group (p = .001; p = .03). That is, those who read either of the educational materials were more likely to endorse a TBI explanation over an adolescent explanation, compared to those who read a control reading. The groups did not significantly differ on their willingness for social interaction., Implications: Results suggest that, on average, factsheets and personal stories are effective for increasing knowledge about moderate-to-severe TBI as compared to a control group. Personal stories and factsheets may also be useful, on average, for addressing tendencies to discount TBIs as explanations for behavioral change, as compared to a control group. (PsycINFO Database Record, ((c) 2017 APA, all rights reserved).)

Background  The anterolateral thigh (ALT) flap remains a workhorse for soft tissue reconstruction. However, the traditional ALT flap is often too bulky for resurfacing shallow, distal extremity defects, prohibiting adequate function, or well-fitted orthotics. This study evaluates extremity reconstruction using ALT flaps elevated in the suprafascial or super-thin plane. Methods  Retrospective review of ALT free flap reconstruction from October 2014 to July 2016 was performed. Suprafascial and super-thin flaps were those elevated just above the crural fascia and within the superficial scarpal plane, respectively. Adjunct operative procedures, demographics, and complications were recorded. Results  A total of 25 patients underwent suprafascial ( n  = 14) or super-thin ( n  = 11) ALT flap reconstruction for primarily lower extremity wounds ( n  = 19), with an average age and body mass index of 53.8 years and 26.3 kg/m 2 , respectively. Follow-up was 6.3 months. Comorbidities included smoking ( n  = 7), diabetes ( n  = 8), peripheral vascular disease ( n  = 6), and hypertension ( n  = 8). The presence of hardware ( n  = 9), trauma ( n  = 10), and chronic infection ( n  = 12) were common risk factors. Average flap size was 8.2 × 21.5 cm, with 64% ( n  = 16) taken on one perforator. Forty-eight percent ( n  = 12) were end-to-side anastomoses and 62% ( n  = 13) utilized one venous anastomosis. Mean hospital stay was 7.8 days with a 24% ( n  = 6) complication rate. There were no partial or complete flap losses. Conclusion  The ALT flap, elevated in a suprafascial or super-thin plane, is a safe, effective option for extremity soft tissue reconstruction. The decreased flap volume and bulk provides the improved contour and pliability necessary for appropriate distal extremity function. The potential versatility of super-thin flaps reinforces the importance of continued innovation by reconstructive microsurgeons., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background  Vascularized bone grafting (VBG) has the potential to yield reliable results in scaphoid nonunion; however, results across studies have been highly variable. This study critically evaluates surgical techniques, fracture location, and patient selection in relation to radiographic, clinical, and patient-centered outcomes after VBG for scaphoid nonunion. Methods  We conducted a systematic review of the literature for the use of VBG in scaphoid nonunion. Physical examination, radiographic, and patient-centered outcomes were assessed. Four substratifications were performed: the location of scaphoid nonunion, pedicled versus free technique, Kirschner wire (K-wire) versus screw fixation, and VBG done as a primary versus revision procedure. Results  A total of 41 publications were included in final analysis. VBG had an 84.7% union rate at 13 weeks after surgery. On an average, 89% of patients returned to preinjury activity levels by 18 weeks after surgery and 91% of patients reported satisfaction with the procedure. Proximal pole nonunions demonstrated similar union rates but lower functionality scores compared with nonunions across all regions of the scaphoid. Pedicled techniques demonstrated slightly improved range of motion compared with free technique. K-wire versus screw fixation demonstrated significantly higher union rates and faster union times. There were no differences in outcomes for VBG done as a primary versus revision procedure. Conclusion  VBG serves as a viable option for the treatment of scaphoid nonunion, with consistent union rates in addition to significantly improved postoperative patient functionality. The fixation of these vascularized bone grafts with K-wires versus screw fixation may result in superior radiologic outcomes. Level of Evidence  Therapeutic, Level III, systematic review.

Background  Three-dimensional (3D) printing has developed as a revolutionary technology with the capacity to design accurate physical models in preoperative planning. We present our experience in surgeon-based design of 3D models, using home 3D software and printing technology for use as an adjunct in vascularized bone transfer. Methods  Home 3D printing techniques were used in the design and execution of vascularized bone flap transfers to the upper extremity. Open source imaging software was used to convert preoperative computed tomography scans and create 3D models. These were printed in the surgeon's office as 3D models for the planned reconstruction. Vascularized bone flaps were designed intraoperatively based on the 3D printed models. Results  Three-dimensional models were created for intraoperative use in vascularized bone flaps, including (1) medial femoral trochlea (MFT) flap for scaphoid avascular necrosis and nonunion, (2) MFT flap for lunate avascular necrosis and nonunion, (3) medial femoral condyle (MFC) flap for wrist arthrodesis, and (4) free fibula osteocutaneous flap for distal radius septic nonunion. Templates based on the 3D models allowed for the precise and rapid contouring of well-vascularized bone flaps in situ, prior to ligating the donor pedicle. Conclusions  Surgeon-based 3D printing is a feasible, innovative technology that allows for the precise and rapid contouring of models that can be created in various configurations for pre- and intraoperative planning. The technology is easy to use, convenient, and highly economical as compared with traditional send-out manufacturing. Surgeon-based 3D printing is a useful adjunct in vascularized bone transfer. Level of Evidence  Level IV., Competing Interests: Disclosure The authors report no conflicts of interest in this work., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

It is essential to study whether physicians' perceptions align with their patients' views, as understanding patient perception leads to superior satisfaction and health outcomes. Previous studies have established differences in physician-patient perceptions, but no studies have been conducted in orthopedic clinics. The authors' primary goal was to evaluate differences in physician and patient perceptions of an orthopedic clinic visit. Their secondary objective was to determine the influence of visit length, demographics, and depression risk-level on patient satisfaction. The authors surveyed 143 new patients being seen by orthopedic surgeons at a level I trauma center. After their appointment, these patients completed surveys on satisfaction and likelihood of depression. The authors recorded wait times and visit lengths. Simultaneously, the physicians completed a self-evaluative satisfaction survey. Patients' and physicians' answers were compared using a Wilcoxon signed-rank test. Mann-Whitney and Spearman correlation analyses were used to assess factors that impact satisfaction. Physicians and patients showed no significant differences on most questions of the satisfaction survey, except that physicians reported feeling less satisfied with their own explanations (P<.001). Length of visit was positively correlated with patient satisfaction (R=0.276, P=.001), while waiting times had no effect. Patients at risk for depression were less satisfied with physicians' effort to include them in decision-making (P=.044). Age was a predictor of greater satisfaction with explanations (P=.032) and instructions (P=.009) from the physician. Thus, orthopedic clinics may not exhibit the same physician-patient perception patterns as primary care clinics, potentially because of differences in patient populations, conditions, or expectations. [Orthopedics. 2017; 40(4):242-246.]., (Copyright 2017, SLACK Incorporated.)

BACKGROUND AND OBJECTIVES Wide margin resection of a soft tissue sarcoma (STS) may require extensive removal of quadriceps muscle with or without the knee extensor mechanism. The objective of this study is to present present the use of a combined functional muscle transfer and soft tissue coverage through the use of chimeric anterolateral thigh flaps., Methods: Patients were retrospectively reviewed who underwent deep STS resection of the anterior compartment of the thigh with functional reconstruction of knee extension using a contralateral free anterolateral thigh (ALT) flap., Results: Three patients with an average age 53.6 years (range: 33-66) were included. Average follow-up was 82 weeks (76-92 months). Full active extension was regained in 66% of patients with all patients regaining active extensor capabilities beyond 100°. The mean Knee Society Score was 83.3 (range; 76-92) and Musculoskeletal Tumor Society Score 21.6 (range; 19-21). Isometric knee extensor strength exceeded 4+/5 in all patients., Conclusion: Following soft tissue sarcoma resections of the lower extremity, chimeric anterolateral thigh flaps for restoration of knee extension can provide significant improvements in the potential for ambulation and regaining quadriceps function., (© 2017 Wiley Periodicals, Inc.)

Purpose: Over 50,000 power saw-related injuries occur annually in the United States. Numerous safety measures have been implemented to protect the users of these tools. This study was designed to determine which interventions, if any, have had a positive impact on the safety of the consumer or laborer., Methods: We queried the National Electronic Injury Surveillance System database for hand and upper-extremity injuries attributed to power saws from 1997 to 2014. Demographic information including age, sex, date of injury, device, location, body part involved, diagnosis, and disposition was recorded. We performed statistical analysis using interrupted time series analysis to evaluate the incidence of injury with respect to specific safety guidelines as well as temporal trends including patients' age., Results: An 18% increase in power saw-related injuries was noted from 1997 (44,877) to 2005 (75,037). From 2006 to 2015 an annual decrease of 5.8% was observed. This was correlated with regulations for power saw use by the Consumer Safety Product Commission (CPSC) and Underwriters Laboratories. Mean age of injured patients increased from 48.8 to 52.9 years whereas the proportion of subjects aged less than 50 years decreased from 52.8% to 41.9%. These trends were most pronounced after the 2006 CPSC regulations., Conclusions: The incidence of power saw injuries increased from 1997 to 2005, with a subsequent decrease from 2006 to 2015. The guidelines for safer operation and improvements in equipment, mandated by the CPSC and Underwriters Laboratories, appeared to have been successful in precipitating a decrease in the incidence of power saw injuries to the upper extremity, particularly in the younger population., Clinical Relevance: The publication of safety regulations has been noted to have an association with a decreased incidence in power saw injuries. Based on this, clinicians should take an active role in their practice as well as in their professional societies to educate and counsel patients to prevent further injury., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

A case of volar forearm pain associated with ulnar nerve paresthesia caused by a reversed palmaris longus muscle is described. The patient, an otherwise healthy 46-year-old male laborer, presented after a previous unsuccessful forearm fasciotomy for complaints of exercise exacerbated pain affecting the volar forearm associated with paresthesia in the ulnar nerve distribution. A second decompressive fasciotomy was performed revealing an anomalous "reversed" palmaris longus, with the muscle belly located distally. Resection of the anomalous muscle was performed with full relief of pain and sensory symptoms., (Copyright © 2017 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

The 2 main routes of medical device approval through the U.S. Food and Drug Administration are the premarket approval (PMA) process, which requires clinical trials, and the 510(k) premarket notification, which exempts devices from clinical trials if they are substantially equivalent to an existing device. Recently, there has been growing concern regarding the safety of devices approved through the 510(k) premarket notification. The PMA process decreases the potential for device recall; however, it is substantially more costly and time-consuming. Investors and medical device companies are only willing to invest in devices if they can expect to recoup their investment within a timeline of roughly 7 years. Our study utilizes financial modeling to assess the financial feasibility of approving various orthopaedic medical devices through the 510(k) and PMA processes. The expected time to recoup investment through the 510(k) process ranged from 0.585 years to 7.715 years, with an average time of 2.4 years; the expected time to recoup investment through the PMA route ranged from 2.9 years to 24.5 years, with an average time of 8.5 years. Six of the 13 orthopaedic device systems that we analyzed would require longer than our 7-year benchmark to recoup the investment costs of the PMA process. With the 510(k) premarket notification, only 1 device system would take longer than 7 years to recoup its investment costs. Although the 510(k) premarket notification has demonstrated safety concerns, broad requirements for PMA authorization may limit device innovation for less-prevalent orthopaedic conditions. As a result, new approval frameworks may be beneficial. Our report demonstrates how current regulatory policies can potentially influence orthopaedic device innovation.

Background: The radiographic and clinical outcomes following vascularized bone grafting (VBG) for scaphoid nonunion have previously been reported in the literature; however, few studies report on patient-derived outcomes. The purpose of this study was to determine the effect of VBG for scaphoid nonunion on patient-derived outcomes. Methods: The MEDLINE and PubMed databases were queried for the use of VBG in scaphoid nonunion. We included studies that reported on patient-derived outcomes. We excluded studies with less than 10 patients or less than 6 months of follow-up. The primary outcomes assessed included functionality, percent and time to return to preinjury activity, postoperative pain, and patient satisfaction. Results: Twenty-six articles described the outcomes of 520 patients with an average of 19.3 patients per study. Functionality was most commonly assessed by the Mayo Modified Wrist Score and Disabilities of the Arm, Shoulder and Hand scores, which improved by 53.1% and 81.7% postoperatively, respectively. Within 16 weeks, 90.3% of patients returned to their previous occupation or sporting activity. Pain was most commonly reported using a 0 to 10 visual analog scale and improved 4-fold postoperatively. Complete satisfaction was reported by 92% of patients. The most common complications were superficial infections (1.56%), neuropathic pain (1.56%), and complex regional pain syndrome (1.25%). Conclusions: VBG for scaphoid nonunion results in the improvement of patient-derived outcomes, and high rates of return to preinjury activity levels and patient satisfaction. Multiple metrics of patient-derived outcomes were utilized by the studies in our review without a clear consensus as to which metric is most responsive and accurate., Competing Interests: Declaration of Conflicting Interests: The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: Venous thromboembolism encompasses a spectrum of disease, ranging from asymptomatic deep vein thrombosis to fatal pulmonary embolism. As microsurgical techniques increase in complexity, the overriding benefit from a microsurgical versus a venous thromboembolism prophylactic regimen remains unclear. This study evaluated the current recommendations and procedure-specific strategies for venous thromboembolism prophylaxis with a focus on the utility of prophylaxis in microsurgical procedures., Methods: A review was performed to identify all articles discussing the rates of venous thromboembolism in patients undergoing microsurgical procedures. Data were summarized based on body area, including hand, breast, lower extremity, and head and neck. Guidelines for venous thromboembolism prophylaxis in microsurgical cases were established., Results: The available studies demonstrate a reduction in postoperative venous thromboembolism. Unfortunately, chemoprophylaxis continues to be underused throughout plastic surgery, amid concern over the risk of bleeding complications. Based on the best available data, the use of mechanical and chemoprophylaxis should be strongly considered in all microsurgical cases. A preoperative screening algorithm based on a risk-assessment model should be used in all cases to preoperatively characterize and modify risk factors when possible, and plan for perioperative prophylaxis., Conclusions: Although not completely preventable, venous thromboembolism risks can be reduced with careful preoperative planning and medical history and the judicious use of chemoprophylaxis. Because there does not appear to be an increase in the rate of postoperative bleeding when prophylaxis is administered appropriately, the use of venous thromboembolism prophylaxis should be considered in all microsurgery patients except those at extremely high risk of bleeding.

Thumb web space contracture following hand trauma can be disabling with numerous reconstructive procedures existing to correct the resultant deformity. Following marked soft tissue injury to the hand we utilized the Stryker Hoffmann II Micro External Fixator System to link the first and second metacarpals by a multiplanar system using 1.6 or 2.0 mm self-drilling half-pins and 3 mm carbon fiber connecting rods. This facilitated placement of the thumb in maximal palmar abduction as well as allowed adjustment of thumb position throughout the postoperative period. This technique was performed on 5 patients. Two patients were treated with a first web space external fixator for table saw injuries to the radial aspect of the hand. An additional 2 patients were treated with a first web space external fixator following metacarpophalangeal joint capsular release in the setting of thermal burns. A fifth patient underwent second ray amputation, trapeziectomy and trapezoidectomy for squamous cell carcinoma with subsequent stabilization with the external fixator. The external fixator was left in place until soft tissues were healed (average 5.5 wk). The patients were allowed to mobilize their hand in as much as the external fixator allowed, and no device-associated complications were noted. Thumb web space was preserved with passive and supple thumb circumduction and web space abduction/adduction in all patients at an average follow-up of 5 months. The average Quick Dash Score was 35±5 and the average Modern Activity Subjective Survey of 2007 was 30±8.

Upper extremity malignancies have the potential to create significant functional impairment, and as such represent an opportunity for collaborative reconstruction to minimize potential morbidity. Given the increased complexity and array of potential reconstruction solutions, functional limb preservation is overwhelmingly and increasingly successful in appropriately selected patients. The purpose of this review is to familiarize the reader with the general functional considerations of the upper extremity, review major reconstructive options, and present a general algorithm for reconstruction and maintenance of function. J. Surg. Oncol. 2016;113:946-954. © 2016 Wiley Periodicals, Inc., (© 2016 Wiley Periodicals, Inc.)

Background: The purpose of this study was to conduct a systematic review and pooled analysis of vascularized toe-to-hand transfer to determine functional donor site morbidity among different techniques., Methods: Pubmed MEDLINE, EMBASE, and Cochrane databases search yielded 302 citations, with 56 meeting inclusion criteria. Pooled outcomes and analysis are reported based on donor site morbidity, specific toe transferred, technique used, and foot biomechanical changes., Results: A total of 802 digit transfers (418 isolated great toe transfers, 324 isolated second toe transfers, and 153 toes classified as "other") were included for analysis. Sex was reported in 510 patients (80.2 % men, 19.8% women). The mean patient age was 28.5 ± 8.4 years. Functional impairment analysis found 23.7% (97 digit transfers) experienced gait impairment. Great toe transfer versus second toe transfer versus the "other" group demonstrated morbidity rates of 21.8%, 14.5%, and 23% (P = 0.001), respectively. Donor site reoperative intervention occurred in 11.8% of cases (95 digits): 4.5%, 16.6%, and 16.0% (P < 0.001), respectively. Mean follow-up time was 62.6 months., Conclusions: Functional foot impairment can occur after various toe transfer procedures due to altered biomechanics of weight distribution and gait. Rigorous biomechanical foot evaluation of this subset of patients is lacking. Great toe transfer appears to have the highest morbidity rate, but lower reoperative intervention as compared to second toe transfer. Preserving ray projection does not prevent biomechanical changes to the foot, but may delay functional impairment leading to favorable functional interpretation by patients and surgeons.

Background: Efficient identification of dysvascular finger(s) following trauma is critical for triaging surgical care and optimizing patient outcomes. The authors designed a study evaluating an objective measure of digital hypoxia followed by surgical exploration and correlation with vascular injury., Methods: Patients with lacerating or penetrating trauma to the hand or digits were examined. A pulse oximeter was applied to the injured digit, and the oxygen saturation was recorded. The nonparametric Wilcoxon rank sum test was used to assess for differences in pulse oximetry for digits with and without an ischemic-type injury that required repair. Receiver operating characteristic curve analyses were used to determine cut-points., Results: Twenty patients with digital lacerations were enrolled, with a total of 49 digit measurements of pulse oximetry. Twelve dysvascular injuries requiring repair or amputation were confirmed in the operating room. There was a significant difference in pulse oximetry measurement in digits with (76 percent; 95 percent CI, 64 to 87 percent) and without (98 percent; 95 percent CI, 97 to 99 percent) ischemic injury (p < 0.001). Injured digits ranged in pulse oximetry values from 53 to 92 percent., Conclusions: Pulse oximetry is widely available and offers an objective measure of tissue oxygenation. No digit with a pulse oximetry value of at least 95 percent had an ischemic injury, and all digits with a pulse oximetry value of 84 percent or lower required operative vascular treatment. Based on these data, pulse oximetry should be adopted as a routine measure for the evaluation and communication of a potentially dysvascular digit.

Purpose: To evaluate the presence and degree of glenohumeral dysplasia (GHD) in infants undergoing surgical exploration for neonatal brachial plexus palsy (NBPP) and to identify potential predictive factors of early maladaptive shoulder morphology., Methods: We included all consecutive patients with NBPP who underwent surgical exploration of their brachial plexus and who had a preoperative magnetic resonance imaging scan at our institution over a 3-year period. Demographic, therapy, and surgical data were collected. Imaging was reviewed for glenoid morphology, glenoid version, percent humeral head anterior to the scapula, and alpha angle., Results: Of 116 infants who presented to our institution during this 3-year period, 19 (16%) underwent surgical exploration and were included in the study. Median age at the time of the scan was 16 weeks (interquartile range, 14-46 weeks). Fourteen of 19 (74%) had GHD of Waters class 2 or increased malformation. Babies who had more severe palsies underwent earlier surgery and had less severe GHD at the time of surgery than did those with less severe palsies who had surgery later. Less severe GHD was associated with more severe palsies, as indicated by Narakas classification and number of root avulsions. Active external rotation was almost universally absent whereas other shoulder movements were present to varying degrees. More severe GHD was associated with greater total shoulder active range of motion and greater pectoralis major muscle mass., Conclusions: Glenohumeral dysplasia occurs often and early in NBPP and may occur in the absence of restricted range of motion. Predictors include increasing age and factors related to muscular imbalance. As such, GHD likely affects the functional outcome that may be achieved with reinnervation, and early screening may improve outcomes., Type of Study/level of Evidence: Prognostic IV., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Purpose: To elucidate the vascular anatomy of the superolateral geniculate artery (SLGA) and its supply to the periosteum of the lateral femoral condyle (LFC) and to provide guidelines for flap design and describe an illustrative case., Methods: Thirty-one fresh cadaveric limbs were dissected. The vascular anatomy of the SLGA and its distal branches to skin, muscle, and periosteum were identified. Fluoroscopic images were taken during continuous perfusion of a radiopaque contrast dye into the SLGA. Intra-arterial injections of latex rubber were performed in 12 cadaver limbs. The vascular territory was traced from the SLGA to its distal branches, and surrounding soft tissues were dissected., Results: The SLGA originated from the popliteal artery 4.9 ± 1.2 cm (range, 2.8-7 cm) from the knee joint and its pedicle diameter was 1.8 ± 0.5 mm (range, 1-3 mm). SGLA pedicle-specific fluoroscopic angiography demonstrated a dense filigree of vessels over the lateral distal femur. Arterial latex injections confirmed that the SLGA supplied the periosteum of the LFC and distal femur shaft. The proximal-most extent of periosteal perfusion was 11.7 ± 2.1 cm (range, 9.3-14.1 cm) from the knee joint. The average pedicle length of LFC osteoperiosteal flaps was 4.8 ± 0.9 cm (range, 3.5-6.3 cm)., Conclusions: The LFC flap consistently demonstrated almost 12 cm of femur length perfusion based on the SLGA pedicle. The anatomy of this flap enables chimeric designs combining soft tissue, bone, and cartilage., Clinical Relevance: The vascularized LFC flap is an option for reconstruction of osseous defects of the upper extremity., (Copyright © 2015 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Hypoproteinemia and nutritional deficiencies are common after bariatric surgery, and although massive weight loss (MWL) patients experience increased wound complication rates, the association has not been causatively determined., Objectives: This study investigated preoperative nutritional parameters and wound complications in MWL patients (postbariatric and diet-controlled) undergoing panniculectomy at 2 academic institutions., Methods: One hundred sixty-one consecutive patients undergoing elective panniculectomy after bariatric surgery or diet-controlled weight loss were identified. Patient demographics and nutritional indices (serum protein, albumin, and micronutrient levels) were analyzed. Complications including wound separation, infection, and operative debridements were compared. Post hoc comparisons tested for correlation between complications and nutritional markers., Results: Postbariatric patients lost an average of 151 lb and presented at an average of 32 months after gastric bypass. Diet-controlled weight loss patients lost an average of 124 lb. Despite MWL, albumin levels were higher in the bariatric group (3.8 vs 3.4 g/dL, P < 0.05). Conversely, bariatric patients experienced increased wound complications (27% vs 14%; P < 0.05). Factors which were found to correlate to increased risk of wound dehiscence and infection were elevated body mass index at time of panniculectomy and amount of tissue removed. Multivariate analysis did not show serum albumin or percent weight loss to independently predict complications., Conclusions: Bariatric patients presenting for elective operations are at risk for protein and micronutrient deficiency. Despite aggressive replacement and normalization of nutritional markers, bariatric patients experience increased wound complications when compared to nonbariatric patients and traditional measures of nutritional evaluation for surgery may be insufficient in bariatric patients.

Background: With progressive lunate collapse, salvage procedures in advanced Kienbock disease attempt to provide pain relief and maintain motion. Scaphocapitate arthrodesis may provide a durable option with comparable outcomes to proximal row carpectomy in the well-selected patient., Methods: We performed a retrospective chart review of all consecutive patients with Lichtman stage IIIA or IIIB Kienbock's disease who underwent either scaphocapitate or scaphotrapeziotrapezoid-capitate arthrodesis from January 2004 to December 2013., Results: Twelve patients were included with a mean age of 41.6 years. Ten patients underwent scaphocapitate arthrodesis, while two patients underwent scaphotrapezio-trapezoid-capitate arthrodesis with an average clinical follow-up of 13.1 months. All patients achieved fusion. The average postoperative flexion-extension arc was 53° (range 20-110°). The average ulnar deviation was 9° (range 5-15°), and the average radial deviation was 13° (range 5-25°). Postoperative pain scores were significantly improved, having changed from an average of 6.6 preoperatively to 2.8 on a 10-point scale (W = 18, P < 0.05)., Conclusions: Despite a mean flexion-extension arc that is reduced from that of a normal individual, the postoperative range of motion following a midcarpal arthrodesis was not significantly different than that reported in a recent systematic review of proximal row carpectomy (73.5° compared with 53°, respectively) (P = 0.05). Additionally, given the significant postoperative reduction in associated pain symptoms at the time of follow-up, scaphocapitate arthrodesis should be considered as a treatment option for wrist salvage in the patient with advanced Kienbock's disease.

Background: Intraoperative vasospasm during reconstructive microsurgery is common, often unpredictable, and potentially devastating with regard to flap survival. Current methods of pharmacologic management vary, and may be shifting as a result of changes in the availability of individual medications. This review aims to provide a concise examination of the published literature regarding use, efficacy, and adverse effects of the agents described for local management of vascular spasm during microsurgery., Methods: A systematic review of the literature was performed to identify articles relevant to pharmacologic treatment of intraoperative vasospasm in vivo. An additional review of the literature was performed with regard to each agent identified in order to provide clinical background information., Results: Systematic review identified 20 articles, in which 14 vasodilator agents were evaluated. Drugs were classified into five pharmacologic categories: phosphodiesterase inhibitors (papaverine, pentoxifylline, and amrinone), local anesthetics (lidocaine), calcium channel blockers (nicardipine, verapamil, nifedipine, and magnesium sulfate), direct vasodilators (sodium nitroprusside, prostaglandin E1, nitroglycerin, and hydralazine), and alpha antagonists (phentolamine and chlorpromazine). Despite a variety of methods, these studies indicate some degree of experimental evidence of efficacy for each of these agents., Conclusions: Available literature regarding use of topical vasodilating agents for intraoperative management of vasospasm during microsurgery is limited and largely based on animal models, which may not reliably generalize to the reconstructive patient population. Well-controlled translational study in clinically applicable and reproducible models is needed to guide evidence-based clinical management of this important phenomenon.

Venous thromboembolism is a complication that results in a wide range of patient morbidity and potential mortality. Awareness of this risk has led to recent advances in both the perioperative planning of chemoprophylaxis and the stratification of risk factors. Together, these modifications have helped reduce the incidence and severity of venous thromboembolism. Major hospital-based initiatives to decrease the overall rate of venous thromboembolism and halt the progression of severe complications, including pulmonary embolism, are one such change. However, surgeon reluctance based on the potential for bleeding complications continues to decrease the use of these algorithms, despite several reports that fail to demonstrate an increase in postoperative bleeding or hematoma formation with chemoprophylaxis administered at appropriate dosages. This review summarizes the current recommendations and procedure-specific strategies for venous thromboembolism prophylaxis with a focus on elective or aesthetic surgery-based procedures. The authors will recommend which patients are appropriate, what doses are appropriate, and when the doses should be administered for aesthetic and elective surgery.

Background: Rupture of the Achilles tendon can be a debilitating event, affecting ankle stability and gait efficiency. When this rupture is combined with a large soft tissue defect, reconstruction of the tendon and free tissue transfer for wound resurfacing should be considered., Methods: A systematic review of the MEDLINE and Cochrane databases from January 1950 to August 2012 was completed. Search criteria identified all reports of vascularized, autograft, and allograft Achilles tendon reconstruction in combination with free tissue transfer. Inclusion criteria included strict objective outcomes of ankle range of motion and/or dynamometer testing. Correlated outcomes for the affected and normal extremities were accomplished using a subgroup comparison for the vascularized and avascular tendon reconstruction techniques with a 2-tailed z test for independent proportions., Results: Fifteen retrospective studies fit the inclusion criteria, representing 44 patients at an average age of 33 years. Twenty-two (50%) patients had a localized infection before reconstruction. Average skin defect was 85.3 (74.4) cm2, and average tendon gap was 7.8 (1.7) cm. Thirty (68%) patients underwent free tissue transfer with vascularized tendon reconstruction, 7 (16%) had either nonvascularized autograft or allograft, 5 (11%) had a muscle interposition, and 2 (5%) patients had combined vascularized and nonvascularized tendon repair. Overall average total range of motion was 54.6 (11.5) degrees. Repairs with vascularized tendon had an overall range of motion 80% of the unaffected side (55.4 vs 69.4 degrees) compared to avascular tendon repairs, at an average range of motion 82% of the unaffected side (51.2 vs 62.3 degrees) (P = 0.73). Dynamometric comparison with the unaffected extremity gave an average deficit for avascular reconstructions at 21.2% and 24.8% for 30 to 60 and 120 degrees/s, respectively, compared to an average deficit of 32.3% and 31.5% in the vascularized reconstructions (P = 0.55 and P = 0.78, respectively)., Conclusions: For combined free tissue transfer and Achilles tendon reconstruction, there seems to be no functional superiority in ankle range of motion or strength when vascularized tendon repairs were compared to avascular autograft and allograft methods.

The transconjunctival approach to lower lid blepharoplasty provides access for both fat resection and transposition to soften tear trough deformities and correct infraorbital fat herniation. Overall, there is a paradigm shift that has focused more on enhancing lower lid-cheek shape and contour and preserving orbital volume, (Copyright © 2015 Elsevier Inc. All rights reserved.)

Purpose: Injury to the extensor carpi ulnaris (ECU) fascial supports on the distal ulna can result in ulnar-sided wrist pain, particularly when the tendon subluxates medially out of the fibroosseous groove with forearm rotation. To better understand the potential risk factors for injury and the indications for modifying the ECU groove, we have evaluated and quantified the morphology of the ECU groove and tendon., Methods: Axial plane magnetic resonance imaging of the wrist obtained for triangular fibrocartilage complex and intercarpal pathology in 60 patients were reviewed. Mean and standard error of the mean were calculated and unpaired Student t tests performed to compare groove width and depth, radius of curvature of the groove, carrying angle, and tendon-to-groove ratio., Results: There were 23 females (38%), and the mean patient age was 40 years (range, 17-71 y). The average ECU groove depth and standard error of the mean was 1.4 mm ± 0.1 mm. The radius of curvature for the ulnar ECU groove was found to be 7.0 mm ± 0.4 mm with a carrying angle of 143° ± 2°. In neutral forearm rotation, the average ratio of the width of the ECU tendon to groove was 0.7 ± 0.02. The data approximated a normal distribution. There were no statistically significant differences in these measurements between the triangular fibrocartilage complex and the intercarpal pathology subgroups., Conclusions: Variability in the relationship of the ECU groove and tendon may combine to represent risk factors for tendinosis or tendon subluxation. There may be a more normal distribution of ECU groove morphology than previously recognized., Clinical Relevance: ECU injuries may require clinical imaging of the tendon and subsheath, in addition to potential surgical reconstruction and ulnar groove deepening. This report establishes the normative morphology and depth of the ECU groove and provides a comparative baseline when considering treatment modalities., (Copyright © 2014 American Society for Surgery of the Hand. Published by Elsevier Inc. All rights reserved.)

Background: Tibiofibular bone bridging (Ertl) during a below-knee amputation (BKA) is used to create a stable bony platform, granting the patient improved rotary stability, higher end bearing potential, and ultimately, more functional ambulatory ability. However, limited data are available in the literature on actual patient outcomes, despite numerous reports of the technique. The purpose of this study was to report our experience with distal tibiofibular bone bridging using a vascularized fibular bone graft in an elderly nontrauma population., Methods: We performed an institutional review board-approved, retrospective review of BKAs performed by the senior author between 2004 and 2011. Surgical indications, complications, and outcomes were recorded. A subgroup analysis and comparison was performed among patients that had received vascularized bone bridging and those that had not., Results: A total of 294 BKAs were performed on 270 nontrauma patients. Of these, 30 (11%) were done on 29 patients with tibiofibular bone bridging. The mean clinical follow-up among the Ertl subgroup was 11 months (range, 1-42 months), and 17 months (range, 23 days-78 months) in the non-Ertl subgroup. The ambulation rate was 100% (29/29) in the Ertl group, and 78% (161/207) in the control group (P = 0.004). The overall rate of operative revision due to any etiology among groups did not differ significantly (P = 0.255)., Conclusions: Tibiofibular bone bridging with vascularized fibula leads to a significantly higher rate of ambulation without a significantly higher rate of complications in a nontrauma population. Although this technique has been widely described in trauma patients, clinical data are lacking for the nontrauma population. This is the largest reported series of Ertl amputations in nontraumatic population to date and our results demonstrate a significant benefit of the Ertl technique in this population., Level of Evidence: Level IV.

Congenital insensitivity to pain is a rare sensory neuropathy that manifests with multiple and recurrent injuries secondary to a lack of negative pain stimuli. When present with compulsive onychophagia, prompt recognition and behavioral management to prevent chronic digital infection or amputation is imperative. We present the case of two 7 year-old monozygotic twins that presented with congenital insensitivity to pain and compulsive onychophagia without directed parental counseling or behavioral modification strategies. The presenting child was noted to have an acute digital felon and osteomyelitis of several distal phalanges, and the sister had a similar history with distal phalangeal amputations. The occurrence of these overlapping disorders in monozygotic twins has not been previously reported, however, patient and parental education with behavioral modifications of injurious and compulsive behavior is the cornerstone of management. In addition, we have provided a review of the diagnosis for clinical differentiation., (© The Author(s) 2013.)

Background:  Functional outcomes and quality-of-life measures following salvage reconstruction of composite Achilles/posterior leg defects are limited. We present our experience with combined Achilles defect reconstruction utilizing free tissue transfer with vascularized neotendon constructs., Methods:  Between 2011 and 2012, six patients underwent vascularized reconstruction of complex Achilles defects by a single surgeon. Demographic and functional data were collected for each patient. Subjective evaluation and quality-of-life measures were obtained preoperatively and postoperatively using American Orthopaedic Foot and Ankle Score (AOFAS) Ankle-Hindfoot and SF-36 scores. Early and late complications were noted for each case., Results:  All defects were reconstructed utilizing vascularized composite free tissue from the thigh. Average soft tissue defect was 76.7 cm(2) (range, 40-90 cm2) with a tendon gap of 7.8 cm (range, 5-10 cm). Mean follow-up was 17 months (range, 15-23 months). Flap survival was 100%. Overall range of motion of the reconstructed side was 82% of the unaffected side (48.2 degrees vs. 59 degrees, p = 0.004). Average percent increase in AOFAS and SF-36 scores were 71% (54 vs. 93, p = 0.0005) and 22% (86 vs. 104, p = 0.003), respectively. Operative revision was required for two patients with delayed-onset soft tissue infections and one donor site hematoma. Distal flap ischemia was managed with hyperbaric oxygen therapy in one patient. Functional and esthetic outcomes were judged good to excellent by all patients., Conclusions:  Free tissue transfer with vascularized tendon reconstruction is a viable option for combined Achilles tendon/posterior leg defects, as both functional and quality-of-life measures appeared to be significantly improved at 1-year follow-up., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Background: The goal of this review was to identify the safety and medical care issues that surround the management of patients who had previously undergone medical care through tourism medicine. Medical tourism in plastic surgery occurs via three main referral patterns: macrotourism, in which a patient receives treatments abroad; microtourism, in which a patient undergoes a procedure by a distant plastic surgeon but requires postoperative and/or long-term management by a local plastic surgeon; and specialty tourism, in which a patient receives plastic surgery from a non-plastic surgeon., Methods: The ethical practice guidelines of the American Medical Association, International Society of Aesthetic Plastic Surgery, American Society of Plastic Surgeons, and American Board of Plastic Surgeons were reviewed with respect to patient care and the practice of medical tourism., Conclusions: Safe and responsible care should start prior to surgery, with communication and postoperative planning between the treating physician and the accepting physician. Complications can arise at any time; however, it is the duty and ethical responsibility of plastic surgeons to prevent unnecessary complications following tourism medicine by adequately counseling patients, defining perioperative treatment protocols, and reporting complications to regional and specialty-specific governing bodies., Level of Evidence V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The transtibial amputation is a common operation for which there is little agreement regarding which technique provides the most reliable and resilient outcomes. We performed a retrospective chart review of all transtibial amputations performed by a single surgeon between 2004 and 2011 using the posterior myocutaneous flap with triceps surae myodesis technique. A stepwise logistic regression analysis was performed to evaluate the association between independent variables and dependent outcome variables. A total of 270 patients with 294 transtibial amputations were identified. Ambulation data were available for 192 patients with a mean follow-up 18.4 months. This cohort had an overall ambulation rate of 75%, a 12% incidence of stump wounds, 24% operative revision rate and only 2% required conversion to a transfemoral amputation. The posterior myocutaneous flap provides durable and reliable soft tissue coverage in the setting of a transtibial amputation.

Background: Great auricular nerve injuries are the most frequent nerve injuries following rhytidectomy, occurring at a rate of 6 percent. Short-scar techniques may decrease visualization and increase the risk of injury/compression of the great auricular nerve. Recent reviews have identified that great auricular nerve injury can contribute to long-term paresthesias and allodynia in a majority of patients. Identification of this injury, with subsequent exploration, wide release, and decompression, should be performed., Methods: Four patients with injury of the great auricular nerve were referred for persistent allodynia as a complication of short-scar rhytidectomy. Following confirmation of a Tinel sign over the great auricular nerve, each patient underwent subsequent exploration and neurolysis., Results: Diagnosis of compression and suture impingement was confirmed at exploration, and extensive decompression was performed with care taken to protect the nerve from postoperative scar formation. All patients noted postoperative improvement in symptoms, with nearly complete resolution at 6 months., Conclusions: Minimally invasive techniques may impart increased risk of nerve injury in exchange for reduced scar length. In instances of great auricular nerve injury, progressive metabolic changes and increased vascular permeability allow for inflammatory cellular influx and fibrin deposition, compounding nerve dysfunction and symptomatic complaints. Noninvasive modalities may not alleviate complaints of pain and hyperesthesia, particularly in the event of suture compression. Persistent injuries can affect quality of life, with intrusive thoughts about symptoms, or an inability to perform grooming activities. Exploration and decompression of the great auricular nerve may offer a long-term solution for the patient with postrhytidectomy allodynia., Clinical Question/level of Evidence: Therapeutic, V.

Learning Objectives: After studying this article, the participant should be able to: 1. Identify common precancerous and malignant cutaneous growths of the head and neck. 2. Recommend surgical treatment, including margins, based on consensus guidelines. 3. Counsel patients as to available evidence for expected recurrence, follow-up, and morbidity., Summary: Skin lesion excision is the most common procedure performed by plastic surgeons. Because of the cumulative risk factors of sun and carcinogen exposure, the head and neck are the most frequently affected regions of the body. Timely diagnosis and treatment are critical for preventing continued spread and metastasis, and it is incumbent on the treating physician to make the appropriate recommendations for surgical margin and the possibility of adjuvant therapy to prevent recurrence and optimize long-term survival. As clinical guidelines are developed from ongoing outcome studies, new generations of treatment recommendations are continuously in development. Therefore, a systematic review of the most relevant guidelines and clinically rigorous studies was performed with a summarization of treatment recommendations for the following: actinic keratosis, Bowen disease (squamous cell in situ), basal cell carcinoma, squamous cell carcinoma, malignant melanoma, and Merkel cell carcinoma of the head and neck.

Background : Acetaminophen is a widely used analgesic and antipyretic agent in the pediatric population. While the hepatotoxic effects of the drug have been well recognized in cases of acute overdose and chronic supratherapeutic doses, the toxic effects of acetaminophen are rarely documented in cases where therapeutic guidelines are followed. Case : An 8-month-old boy underwent cleft palate repair and placement of bilateral myringotomy tubes. His anesthetic course was uneventful, consisting of maintenance with desflurane and fentanyl. He received acetaminophen for routine postoperative pain management and was tolerating liquids and discharged home on postoperative day 1. On day 3, the child was profoundly lethargic with multiple episodes of emesis and was taken to the emergency department. He suffered a 45-second tonic-clonic seizure in transport to the regional children's medical center, and initial laboratory results demonstrated acute hepatitis with AST 24,424 U/L, ALT 12,885 U/L, total bilirubin 3.1 mg/dL, and a serum acetaminophen level of 83 μg/mL. Aggressive supportive measures including blood products and periprocedural fresh frozen plasma, piperacillin/tazobactam, and intravenous infusions of N-acetylcysteine, sodium phenylacetate and sodium benzoate, carnitine, and citrulline were administered. His metabolic acidosis and acute hepatitis began to correct by day 4, and he was discharged home without further surgical intervention on day 15. Conclusion : Although acetaminophen is an effective and commonly used analgesic in pediatric practice, hepatotoxicity is a potentially devastating complication. This report challenges the appropriateness of existing guidelines for acetaminophen administration and emphasizes the importance of close follow-up and hydration after even relatively minor surgery.

Background: Facial lipoatrophy is a common side effect of human immunodeficiency virus treatment with highly active antiretroviral therapy. To identify the most clinically durable and efficient way of addressing facial lipoatrophy, the authors reviewed all available evidence for the use of injectable dermal fillers and autologous fat transfers as treatment modalities, focusing on safety, outcomes, and long-term durability., Methods: A systematic review of the Cochrane and MEDLINE databases for autologous fat transfer and injectable dermal fillers for the treatment of human immunodeficiency virus-associated lipodystrophy was performed. Based on U.S. Food and Drug Administration approval in human immunodeficiency virus lipoatrophy, studies were limited to the use of hyaluronic acid and/or poly-L-lactic acid. Facial volume, subjective patient satisfaction, standardized outcome scales, reinjection rates, and complications were recorded., Results: Nineteen studies were included representing 724 patients, with 549 patients in the hyaluronic acid/poly-L-lactic acid cohort and 175 in the autologous fat transfer cohort. Improvements in facial volume and durability of treatment were similar between dermal fillers and fat transfer, as measured by both objective means and subjective patient outcomes. However, poly-L-lactic acid was reinjected at a rate three times that of autologous fat, and was associated with a relatively high rate of subcutaneous papule formation at 22 percent (range, 3 to 44 percent)., Conclusions: Dermal fillers and autologous fat transfer are effective treatment modalities for human immunodeficiency virus-associated facial lipoatrophy, with high rates of facial volume restoration and patient satisfaction. Autologous fat transfer may offer similar to superior long-term durability but with less of a financial burden compared with injectable fillers.

Distal tibiofibular bridging (Ertl modification) in a below-knee amputation can provide an improved transmission of torque from the distal femur to the prosthesis. Without this bridge, the distal tibia and fibula are left freely rotating and translating in the soft-tissue envelope. The distal fibular segment creates a bone bridge that allows for increased distal weight bearing and more versatile prosthetic design. The purpose of this article is to describe the authors' technique for performing the Ertl modification to the below-knee amputation using a segment of vascularized fibula and a headless compression screw.

Background: Our objective was to determine surgeon- and patient-based perceptions concerning proximal ulna fixation, including rates of implant removal and overall satisfaction., Methods: Orthopedic surgeons were surveyed about surgical experience managing proximal ulna fractures and their perception regarding implant removal/revision. A retrospective chart review identified all patients who underwent fixation for proximal ulna fractures and osteotomies between January 2004 and December 2008., Results: In total, 583 surgeons responded to the survey (80%). Of these, 67% believed that their implant removal rate was the same as other surgeons whereas 31% believed that their rate was lower. Seventy-one percent believed that patients required hardware removal less than 30% of the time. Ninety-eight percent believed that they were the same surgeons to remove the implant. In total, 138 consecutive patients were surveyed about their proximal ulna implant. Plating was performed in 80 (58%), and tension banding was performed in 55 (40%). The overall rate of implant removal was 64.5% (89 of 138) at 18.8 months. A second surgeon performed the removal in 68 patients (76%). Of the 49 patients without implant removal, 11 (22%) reported satisfaction with the implant and 19 (39%) reported a functional impairment because of the implant. If guaranteed a safe surgery, 36 (73%) would have the implant removed., Conclusion: Surgeons underestimate the rates of proximal ulna implant removal and patient dissatisfaction. Because 76% of the implant removals were performed by a second surgeon, in sharp contrast to the surgeon-perceived rate of 2%, we challenge surgeons to become more aware of this problem in their practices., (Copyright © 2012 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Mosby, Inc. All rights reserved.)

Background: Resident cosmetic surgery clinics, or "chief clinics," are arguably the most effective way to provide cosmetic surgery training. Approximately 70 % of plastic surgery training programs utilize a "chief resident clinic" to augment their cosmetic surgery experience, even though a quantitative outcome scale is lacking to guide education. We report the use of the FACE-Q, a novel patient outcome tool, to evaluate patients' satisfaction with nonsurgical facial rejuvenation performed by residents., Methods: The FACE-Q "Satisfaction with Facial Appearance Overall Scale" was administered to patients prior to and 1 week after undergoing nonsurgical facial rejuvenation performed by plastic surgery residents. All patients received nonsurgical facial rejuvenation with botulinum toxin A and hyaluronic acid as part of resident facial aesthetics training., Results: Eleven patients completed the pre- and postinjection FACE-Q survey. Average overall facial appearance satisfaction scores of 47.6 pre- and 51.1 postinjection were found (p < 0.037), with a total possible score of 68. Ten patients (91 %) reported feeling satisfied or very satisfied with the overall appearance of their face following injection., Conclusion: Despite resident inexperience and patient awareness that novices were performing the procedures, our experience supports use of the FACE-Q to optimize and endorse resident cosmetic surgery clinics. The learning curve for facial cosmetic procedures can be adversely affected by limited time available or exposure to improvement variables when initially performing the procedure. It is imperative to any technique that direct, and preferably quantitative, feedback is given so that an immediate modification can be generated and successive patient outcomes improved., Level of Evidence Iv: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Background: Use of biologically engineered acellular dermal matrices in the upper and lower extremities is increasingly recognized as a means of achieving definitive healing in the setting of both acute and chronic injuries but data and evidence supporting their use are limited. The authors performed this systematic review to identify all available evidence for the use of matrices in nonburn extremity reconstruction., Methods: A systematic review of the Cochrane and MEDLINE databases was performed to identify all reports of the application of matrices in wounds of the upper and lower extremities. Reports that included fewer than five patients and that involved cellular seeding, nonhuman studies, and burn injuries were excluded. Studies were evaluated for quality of statistical measures and outcomes, and a level of evidence was assigned in accordance with the American Society of Plastic Surgeons' Rating Levels of Evidence., Results: Of an initial 2422 reports, 13 primary reports were identified (10 case series and three randomized controlled trials) representing a total of 432 patients and 441 discrete wounds. After evidence review, 10 of these studies represented level IV evidence, two studies represented level II evidence, and one study achieved level I evidence., Conclusions: Extremity wound management continues to rely on adequate vascular supply, débridement with eradication of infection, off-loading, and/or immobilization. Current data, although limited, appear to support the use of acellular dermal matrices in chronic and acute injuries where there is exposed bone, tendon, and/or muscle. They may provide a simple technique to achieve timely and durable tissue coverage in extremity wounds.