Microsurgery is an indispensable tool of upper extremity reconstruction addressing defect coverage and the restoration of function. Perioperative anticoagulation and antiplatelet therapy are controversially discussed with impact on microsurgical outcome, but without clear evidence. This study aims to evaluate the impact of perioperative anticoagulation and antiplatelet therapy in microsurgical upper extremity reconstruction.

 All eligible patients treated with microsurgical upper extremity reconstruction between January 2000 and July 2014 were included in a comparative analysis to define a superior anticoagulation and antiplatelet regime in a retrospective study. Endpoints were all major complications (e.g., total flap loss, arterial and venous thrombosis) as well as minor complication.

 A total of 183 eligible free flaps to the upper extremity were transferred in 169 patients. Altogether, 11 arterial (6.0%) and 9 venous (4.9%) thromboses, 11 total flap losses (6.0%), and 16 cases with hematoma (8.7%) were detected. In the subgroup analysis, patients who did not receive any heparin intraoperatively (n = 21; 11.5%) had a higher rate of major complications (p = 0.001), with total flap loss being the most frequent event (p = 0.004). A trend was shown for intraoperative bolus administration of 501 to 1,000 units unfractionated heparin (UFH) intravenously to have the lowest rate of major complications (p = 0.058). Intraoperative administration of acetylsalicylic acid (n = 13; 8.1%) did not have any influence on the rate of major complications. Postoperative anticoagulation with continuous UFH intravenously (n = 68; 37.2%) resulted in more frequent complications (p = 0.012), for example, an increased rate of total flap loss (p = 0.02) and arterial thrombosis (p = 0.02).

 The results of the present study favor administration of 501 to 1,000 units UFH intravenously as an intraoperative bolus (e.g., 750 units UFH intravenously). Postoperative low molecular weight heparin subcutaneous application in a prophylactic dose given once or twice a day was associated with less complications compared with continuous infusion of UFH, although continuously applied UFH may reflect an increased risk profile.

The overall objective of this study was to determine the patient-level socioeconomic impact resulting from orthopaedic trauma in the available literature. The MEDLINE, Embase, and Scopus databases were searched in December 2019. Studies were eligible for inclusion if more than 75% of the study population sustained an appendicular fracture due to an acute trauma, the mean age was 18 through 65 years, and the study included a socioeconomic outcome, defined as a measure of income, employment status, or educational status. Two independent reviewers performed data extraction and quality assessment. Pooled estimates of the socioeconomic outcome measures were calculated using random-effects models with inverse variance weighting. Two-hundred-five studies met the eligibility criteria. These studies utilized five different socioeconomic outcomes, including return to work (n = 119), absenteeism days from work (n = 104), productivity loss (n = 11), income loss (n = 11), and new unemployment (n = 10). Pooled estimates for return to work remained relatively consistent across the 6-, 12-, and 24-month timepoint estimates of 58.7%, 67.7%, and 60.9%, respectively. The pooled estimate for mean days absent from work was 102.3 days (95% CI: 94.8-109.8). Thirteen-percent had lost employment at one-year post-injury (95% CI: 4.8-30.7). Tremendous heterogeneity (I2>89%) was observed for all pooled socioeconomic outcomes. These results suggest that orthopaedic injury can have a substantial impact on the patient's socioeconomic well-being, which may negatively affect a person's psychological wellbeing and happiness. However, socioeconomic recovery following injury can be very nuanced, and using only a single socioeconomic outcome yields inherent bias. Informative and accurate socioeconomic outcome assessment requires a multifaceted approach and further standardization.

Introduction Traditionally, the latissimus dorsi muscle with or without skin paddle has been the flap of choice for coverage of elbow defects. The ALT flap has found application in elective upper limb defects on account of it's ability to be tailor made for individual defects. Our series of 10 cases shows the advantages of using this flap for acute trauma defects. Materials and Methods Consecutive 10 cases of severe elbow injuries, involving varying amounts of the lower arm and proximal forearm underwent debridement followed by coverage using the free anterolateral thigh flap. Nine of 10 arterial anastomosis were done end to side to the brachial artery and venous anastomosis to the veins accompanying the artery. Seven of these patients had long bone fractures and elbow dislocations, stabilised using external fixator. Four patients needed primary muscle or tendon repair and nerve repair or graft. Results There was 1 total flap loss, intraoperatively where a TFL flap had been used in a 71 year-old patient. Nine of 10 had successful wound coverage. Using Jupiter criteria, 2 had excellent, 3 had good, 3 had fair, and 1 had poor outcome. Conclusion This consecutive series of moderate and severe elbow injuries demonstrates that the ALT flap should be considered as the flap of first choice, specifically when there is a need.

The authors aimed to characterize surgical and functional outcomes of open fractures of the distal radius in patients younger than 65 years. At their level I trauma center, the authors conducted a retrospective review of 92 patients (age range, 16-64 years) who had 94 open fractures of the distal radius (average follow-up, 30 months; range, 3-95 months). Sixty-four fractures received definitive treatment at the time of initial débridement; 30 received definitive fixation and soft tissue coverage after staged débridement. Primary surgical outcome was development of deep surgical site infection requiring repeat surgical débridement; secondary surgical outcome was surgical complications requiring reoperation. Functional outcome was assessed by wrist range of motion. Overall infection rate was 15% (14 of 94 fractures). Seven (11%) of 64 fractures in the immediate definitive fixation group developed infection compared with 7 (23%) of 30 fractures in the staged treatment group (P=.13). Twenty-one (33%) of 64 fractures in the immediate definitive fixation group required reoperation compared with 15 (50%) of 30 in the staged treatment group (P=.11). Deep surgical site infections and surgical complications associated with open fractures of the distal radius are driven by soft tissue injury. [Orthopedics. 2019; 42(4):219-225.].

Vascular injuries resulting in limb ischemia are traditionally treated acutely with autologous or prosthetic bypass grafts. Traumatic contaminated injuries with soft tissue and vascular segmental loss are challenging as prosthetic bypasses are at risk of erosion, infection, and occlusion; and autologous bypasses are at risk of desiccation, blow-out, infection, and clotting. We propose a novel approach to these injuries by using arterialized saphenous vein venous flow-through free flaps (S-VFTF) as an autologous bypass, and present the results of its application in a series of cases.

Spanning 2008 to 2015, four patients presenting with large contaminated crush/avulsion wounds with vascular injury underwent hand revascularization with S-VFTF, allowing the contaminated wounds to be serially debrided. Definitive soft tissue reconstruction was performed once the wound was considered clean. The S-VFTF skin paddle was de-epithelialized and the soft tissue defect covered with a free latissimus dorsi flap or a rectus abdominis myocutaneous flap.

All ischemic limbs were successfully reperfused and there were no take backs for perfusion issues. All S-VFTF remained patent at discharge and final follow-up. No partial or complete finger/hand amputations were required. All definitive coverage free flap survived with no complications.

The two-stage reconstruction presented may help reconstructive and vascular surgeons consider alternatives to traditional vascular reconstruction methods. This technique avoids an exposed vascular graft in an extensively contaminated open wound. It allows the surgeon to perform thorough and sufficient debridement of the wound, preventing definitive reconstruction in a not yet declared zone of injury.

To look into the management options of early debridement of the wound, followed by vascularized cover to bring in fresh blood supply to remaining tissue in electrical burns.

A total of 16 consecutive patients sustaining full thickness forearm burns over a period of one year were included in the study group. Debridement was undertaken within 48 h in 13 patients. Three patients were taken for debridement after 48 h. Debridement was repeated within 2-4 d after daily wound assessment and need for further debridement.

On an average two debridements (range 1-4) was required in our patients for the wound to be ready for definitive cover. Interval between each debridement ranged from 2-18 d. Fourteen patients were provided vascularized cover after final debridement (6 free flaps, 8 pedicled flaps). Functional assessment of gross hand function done at 6 wk, 2 mo, 3 mo and 6 mo follow-up.

High-tension electrical burns lead to significant morbidity. These injuries are best managed by early decompression followed by multiple serial debridements. The ideal timing of free flap coverage needs further investigation.

Toe-to-hand transfer is the last option for definitive reconstruction of the hand when digits have been lost as a result of traumatic amputations, congenital anomalies, or tumor ablation. Immediate toe-to-hand transfer for the treatment of acute hand injuries is defined as an emergency operation performed when replantation is impossible or failed. The aim of this article is to propose the indications, advantages and disadvantages of immediate toe to hand transfer as well as to compare the overall results with elective cases.

We describe the use of a composite flap composed of a sural neurofasciocutaneous flap and a vascularized peroneus longus tendon for the reconstruction of severe composite forearm tissue defects in a patient. A 43-year-old man had his left arm caught in a conveyor belt resulting in a large soft-tissue defect of 18 × 11 cm over the dorsum forearm. The extensor carpi radialis, superficial radial nerve, and radial artery were severely damaged. A free neurofasciocutaneous composite flap measuring 16 × 11 cm was outlined on the patient's left lower leg to allow simultaneous skin, tendon, nerve, and artery reconstruction. The flap, which included the peroneus longus tendon, was elevated on the subfascial plane. After the flap was transferred to the recipient site, the peroneal artery was anastomosed to the radial artery in a flow-through manner. The vascularized tendon graft with 15 cm in length was used to reconstruct the extensor carpi radialis longus tendon defect using an interlacing suture technique. As the skin paddle of the sural neurofasciocutaneous flap and the vascularized peroneus longus tendon graft were linked by the perforator and minimal fascial tissue, the skin paddle was able to rotate and slide with comparative ease. The flap survived completely without any complications. The length of follow-up was 12 months and was uneventful. Range of motion of his left wrist joint was slightly limited to 75 degrees. This novel composite flap may be useful for reconstructing long tendon defects associated with extensive forearm soft tissue defects.

Complex traumatic upper extremity injuries frequently possess compromised local vasculature or extensive defects that are not amenable to local flap reconstruction. Free tissue transfer is required to provide adequate soft tissue coverage. The present study aimed to evaluate risk factors that contribute to postoperative complications and flap loss in complex upper extremity reconstruction.

Retrospective chart review was performed for all patients undergoing free tissue transfer for upper extremity reconstruction from 1976 to 2001. Data collected included patient demographic characteristics, timing of reconstruction, location of injury, fracture characteristics, operative interventions, and postoperative complications. Statistical analysis was performed using χ(2) and Fisher exact tests.

In total, 238 patients underwent 285 free tissue transfers and met inclusion criteria, from which 3 were excluded because of inadequate information (n = 282). Extremities were repaired within 24 h (75 cases; 27%), in days 2-7 (32 cases; 12%), or after day 7 (172 cases; 62%). Timing of reconstruction did not significantly affect postoperative outcomes. Proximal location of injury was significantly associated with superficial (relative risk [RR], 6.5; P < .01) and deep infection (RR, 5.3; P < .01), and osteomyelitis (RR, 4.0; P < .01), although not with flap failure (P = .30). Presence of an open fracture was significantly associated with developing superficial (RR, 3.1; P = .01) and deep (RR, 1.9; P < .01) infection, as well as osteomyelitis (RR, 1.6; P < .01). Having a closed fracture did not negatively influence postoperative outcomes.

This study supports the safety of early free tissue transfer for reconstruction of traumatized upper extremities. Injuries proximal to the elbow and open fracture were associated with a significantly higher infection rate. Gustilo grade IIIC fractures, need for interpositional vein grafts, and anastomotic revision at index operation resulted in significantly higher risk of flap loss, whereas the presence of fracture, fracture fixation, and injury location were not predictors of flap failure.

Prehension is a complex function of the hand that gives it mechanical precision combined with a standard sensory pattern. The priority in soft tissue reconstruction for the upper extremity is to restore function. Significant injury to the upper extremity may result after trauma because of various etiologies. The timing and choice of soft tissue coverage for upper extremity defects warrant special consideration to avoid prolonged immobilization, which can result in joint stiffness, tendon adhesions, scar contractures, and ultimately, loss of function. This article reviews the various reconstructive options and considerations involved in providing coverage for upper extremity soft tissue defects.

Treatment of complex hand trauma includes adequate debridement of nonviable tissue, early reconstruction, and careful selection of various available surgical procedures tailored to patients' needs and requests. Debridement of all necrotic tissue is crucial before any attempt at reconstruction. Surgeons should also consider cosmetic outcomes of the reconstructed hand and donor-site morbidity. For best results reconstruction should be performed early, with proper early postoperative therapy. This article reviews the principles and surgical options in the management of complex hand injuries involving the dorsal and the palmar aspects of the hand, and the different types of tissue in the hand.

Restoration of structure, function, and sensation are critical after trauma or tumor resection of the hand. Thorough debridement, reconstruction of functional structures, and immediate soft tissue coverage are most effectively performed in a single stage within approximately 24 hours of the injury. Skin flaps provide robust, pliable, and cosmetically appropriate tissue that is not prone to contracture and that facilitates secondary reconstructive work. Muscle flaps retain indications for complex defects with substantial initial contamination or dead space, or for reanimation. In this article, the indications, options, and surgical techniques for free muscle flap reconstruction of upper limb defects are reviewed.

The recommendations on the timing of microsurgical extremity reconstruction are as variable and numerous as the flaps described for such reconstruction. Original articles suggested that reconstruction should take place within 72 hours of injury. However, significant changes in perioperative and intraoperative management have occurred in this field, which may allow for more flexibility in the timing of reconstruction. This article aims to review current literature on timing of upper extremity reconstruction to provide the microsurgeon with up-to-date recommendations.

A structured literature search including Spanish and English language articles published between January of 1995 and December of 2011 was performed using the MEDLINE and Scopus databases. The search strategy was conducted using groups of key words, and articles were subsequently reviewed for relevance. Bibliographies of selected articles were further reviewed for additional relevant publications. Rates of total flap loss, infection, hospital stay, and bony nonunion were recorded and analyzed according to emergent (<24 hours), early (<5 days), primary (6 to 21 days), or delayed (>21 days) reconstruction.

Fifteen articles met inclusion criteria. There was no significant association between timing of reconstruction and rates of flap loss, infection, or bony nonunion. Linear regression analysis displayed a significant association between length of hospital stay and timing of reconstruction.

No conclusive evidence exists to suggest that emergent, early, primary, or delayed reconstruction will eliminate or decrease complications associated with posttraumatic upper extremity reconstruction. Earlier reconstruction may decrease length of hospital stay and limit associated medical costs.

The evaluation, initial treatment, and definitive reconstruction of open fractures of the hand with associated soft tissue loss are reviewed. Specific attention is given to the literature on open fracture antibiotic prophylaxis in the hand; the timing of bone and soft tissue reconstruction; and options for soft tissue coverage, including local, regional, and distant tissue transfer. Factors that have shown association with outcomes in these injuries are also discussed, and the authors' preferred management is summarized.

The primary goal of limb salvage is to restore or maintain function. To achieve this goal, proper patient selection, timely reconstruction, and choosing the procedure best suited for the patient are paramount. The decision to salvage a limb should be individualized for each patient, taking into consideration not only the extremity wound but also the associated injuries, age, and socioeconomic status of the patient. Aggressive débridement and skeletal stabilization, followed by early reconstruction, are the current standard of practice and give better results than the more traditional approach of repeated débridements and delayed flap cover. Free tissue transfer remains the best choice for large defects, but local fasciocutaneous flaps are a reasonable alternative for smaller defects and cases in which free flaps are deemed not suitable.

Reconstruction of complex extremity trauma continues to be a challenging task for plastic surgeons. Characteristics of such injuries include destruction of functional structures, often due to high energy trauma that causes significant invalidity. Before the era of free flaps, pedicled fasciocutaneous and muscle flaps were the only option for reconstruction of the severely injured upper extremity. The management of complex injuries of the upper extremity has changed with the development of reconstructive microsurgery. Nowadays, we have a great variety of different free flaps to cover defects of the upper extremity and restore function by innervated free flaps. Sensibility, skin thickness, texture, colour, durability, binding of the flap to the underlying structures, donor site morbidity, possibility of secondary reconstructive procedures, the surgeon's experience and operative facilities must all be taken into consideration for choosing the optimal reconstructive procedure. Not only the reconstructive und functional requirements but the timing of reconstruction is extremely important for final result. The purpose of this paper is to define the principles of flap selection and timing of flap reconstruction, according to the assessment of trauma in the upper limb.

Complex trauma to the forearm often involves significant damage to or loss of bone, muscle, skin, tendons, and neurovascular structures. Treatment focuses on regaining long-term hand function, which is best achieved by combining plastic and orthopedic surgical expertise in a team that includes experienced upper arm rehabilitation therapists. The reconstruction goal is to restore a level of hand function that allows the patient to incorporate the injured hand back into daily activities. We define complex defects as those involving significant segmental loss of one or more tissue types. This article provides a framework by which these often formidable and overwhelming injuries can be approached, and discusses some of the surgical options used to reconstruct complex defects of the forearm.

This study presents the results of a meta-analysis based on the literature dealing with the clinical applications of vacuum-assisted closure (VAC) in the areas of chronic wounds, acute posttraumatic wounds, compartment syndromes, or injuries of the upper extremities. The studies were analysed for validity, significance of conclusion with respect to success rate, publications, and economic efficacy. The data show that with VAC a very valuable technique has been added to an integrated therapeutic concept of soft tissue reconstruction. However, clinical data from prospective randomised trials to support some of the positive aspects seen in the daily clinical application of the technique are still missing. These would create a sound basis demonstrating the economic efficacy of the technique.

After a severe digital or extremity injury, the replantation surgeon should always seek to make the best use out of what tissue is available for reconstruction. Exercising sound surgical judgment and being creative allow the surgeon to restore function to critical areas of the hand or extremity by the judicious use of available tissues that would otherwise be discarded. The use of "spare parts" should, therefore, always be considered to facilitate digital or extremity reconstruction when routine replantation is not possible or is likely to produce a poor functional result. The surgeon should always try to use available nonreplantable tissue to preserve length, obtain soft tissue coverage, or most importantly improve the function of remaining less injured digits. This article presents several case studies that illustrate the principals of spare parts reconstruction performed at the time of the initial debridement using nonreplantable tissue to provide coverage or improve function.

The advantages of free flap coverage of the upper extremity following trauma or tumor resection have been acknowledged by several authors. Most importantly, these benefits include the ability to provide early coverage with composite reconstruction of all damaged or missing tissues and early mobilization to restore function. The purpose of this article is to review the indications and options for selection of free flaps for soft tissue coverage of the upper extremity.

This article outlines current methods of toe transplantation as applied to posttraumatic finger reconstruction (excluding the thumb). Key points that are important during the initial assessment and surgical treatment of such injuries are addressed. Reconstructive options for distal and proximal finger injuries, single and multiple finger injuries, and metacarpal hand injuries are presented, and the timing of toe transplantation procedures is discussed. Finally, additional concepts and techniques that, with experience, have proved useful for optimizing functional and esthetic results are highlighted, along with schemes for motor and sensory rehabilitation.

Primary bone grafting and internal fixation is a reliable option for the treatment of segmental hand defects resulting from high-energy crush or avulsion injuries. Immediate reconstruction can be performed safely if radical debridement and adequate soft tissue coverage of bone can be achieved. When these two criteria cannot be met, staged reconstruction should be performed. The low infection rate (0%), the high union rate (92%), and the return to full, unrestricted, previous employment for all patients in the authors' series supports the use of primary bone grafting in an acute setting. This single-stage approach to fracture management also permits earlier and more aggressive hand therapy that, in turn, can lower the high functional morbidity so often associated with these injuries.

This article reviews the surgical options available for reconstruction of the upper extremity following tumor resection. In order to achieve maximum function and limb salvage a multidisciplinary approach to patient care is emphasized. With proper preoperative planning, salvage of limb form and function can be accomplished in over 95% of cases. Successful reconstruction is measured by preservation of patient health, limb function, limb sensation and cosmesis and stable wound coverage. Important adjuncts to reconstruction include adequate postoperative splinting and aggressive rehabilitation to maximize long-term upper extremity function.

Although primary toe-to-hand transplantation is performed with increasing frequency, its use is still controversial because of the lack of any comparative studies documenting its safety and efficacy. Between August of 1990 and December of 1993, 175 consecutive toe-to-hand transplantations for crush and avulsion injuries were performed in 122 patients. The average interval between injury and primary reconstruction was 7 days, and the average interval between injury and secondary reconstruction was 10.7 months. Follow-up ranged from 18 to 91 months, with an average follow-up of 58 months. There were 31 primary transplantations and 144 secondary transplantations. The survival rate was 96.8 percent (30 of 31) for primary reconstruction and 96.5 percent (139 of 144) for secondary reconstruction. Intraoperative anastomotic revision was necessary in 3.2 percent (one of 31) of primary transplantations and 7.6 percent (11 of 144) of secondary transplantations. Three primary toe-to-hand transplantations (9.7 percent) and 17 secondary toe-to-hand transplantations (11.8 percent) were re-explored in the postoperative period. Each group had one superficial infection. The infection rate was 6.5 percent and 0.7 percent in the primary and secondary groups, respectively. Other complications included partial skin loss, which occurred in one patient (3.2 percent) in the primary group and six patients (4.2 percent of 144 transplantations) in the secondary group. Secondary procedures to improve function were necessary in six secondary transplantations (4.2 percent) and in none of the primary transplantations. There was no statistical difference between the two groups in terms of survival, intraoperative anastomotic revision, re-exploration, future secondary procedure, infection, and complications. This series demonstrates that primary toe-to-hand transplantation can be performed in the suitable candidate safely with as much success as secondary reconstruction. Primary toe transplantation can potentially reduce the overall period of recovery and rehabilitation, allowing the patient to return to work sooner. Further study to evaluate and compare the final functional outcome and return to work time between primary and secondary toe-to-hand transplantation is needed.

In the past 5 years, 25 mutilated digits were reconstructed with immediate toe-to-hand transfers after acute hand injuries, for 21 patients. The overall results of the immediate toe-to-hand transfers were evaluated and compared with the results of 65 elective procedures performed during the same period by the same surgeon. There were 15 cases of great toe-to-hand transfer for thumb reconstruction, two cases of second toe transfer for index finger reconstruction, and four cases of simultaneous two-toe transfer for reconstruction of multiple-digit amputations. Two cases (two of 25 cases, 8 percent) were successfully salvaged with emergency reexploration. The incidences of emergency reexploration and postoperative infection were not significantly different from those for elective toe-to-hand transfer cases. The duration of industrial insurance coverage was much shorter than for elective cases, averaging 225 days (p < 0.001). Approximately 44 percent of the patients maintained their original jobs after immediate toe-to-hand transfer. The subjective satisfaction self-assessment scores of aesthetic appearance and function for the newly reconstructed thumb averaged 80 and 88 (of a total score of 100), respectively. Although satisfaction was lower than for elective reconstruction (p < 0.001), it was higher than for reconstruction of other digits. The donor-site appearance after great toe harvesting was mostly unsatisfactory. Immediate toe-to-hand transfer provides many advantages over the elective procedure in acute hand injuries, including single-stage reconstruction, shortened convalescence, early return to work, and socioeconomic efficiency. Because there were no significant differences in the success rates, frequencies of complications, or ultimate functional results, immediate toe-to-hand transfer is a safe and reliable procedure that is indicated for specific cases of acute digital amputation.

The gracilis muscle is one of the most extensively used muscles for free tissue transplantation. Its advantages are low donor-site morbidity with a concealed donor scar, a constant anatomy with large-diameter vessels, and the potential for a neurosensory flap as well as a large skin paddle. However, limitations comprise its limited size, and thus the muscle is limited to small-to-medium-sized defects. We present a novel technique by which the muscle can be enlarged 3-4 times over the regular muscle width. This can be achieved by microscopically aided intramuscular dissection of connective tissue with preservation of the intrinsic vessels of the muscle. With this technique, the field of application of the versatile gracilis muscle in reconstructive surgery can be further expanded.

Free tissue transfer has become the most important means of limb salvage treatment after severe trauma. This one-step procedure shortens healing and hospitalization time and minimizes the danger of infection. However, very few studies have considered the use of free tissue transfer for the reconstruction of traumatic limb injuries in children. This study reports 22 such cases treated in the authors' unit between 1993 and 2000 (17 boys and 5 girls; mean age, 8.9 years; age range, 18 months-15 years; 16 lower and 6 upper limbs). All flaps were indicated for repair of acute traumatic defects (20-500 cm2). Five different flaps were used: 12 scapular, 4 latissimus dorsi, 4 serratus anterior, 1 groin, and 1 temporalis fascia. All were successful, except for partial necrosis with the free groin flap. Three flaps requiring reexploration for venous insufficiency had a successful outcome. The microsurgical success rate in this pediatric population is very high, and the state and size of the donor site and recipient vessels have caused no problems. No long-term complications have been noted (mean follow-up, 3.8 years).

Antimicrobial drugs are commonly used in the treatment of mutilating hand injuries. Valid arguments for the use of systemic antibiotics can be made despite the lack of data clearly documenting their efficacy in this clinical scenario. There is no information to support the use of topical agents in open hand injuries. When choosing an appropriate systemic antibiotic, the physician should consider unique characteristics of these injuries, the various environments in which they occur, and the potential infecting organisms. The duration of antibiotic use is arbitrary but should be minimized to avoid complications and the development of bacterial resistance.

Plastic surgical therapy of mutilating hand injuries represents a multifaceted task to the hand surgeon, where considerations about indication, timing, and structure of the soft tissue coverage play a major role in reconstruction. The concept of early primary reconstruction (including emergency procedures) and fast rehabilitation not only demands thoughtful tissue preparation but also mastering of a bandwidth of plastic surgical techniques. Systematic algorithms based on the reconstructive ladder help in decision making in the complexity of soft tissue coverage but have to be adjusted to the individual case profile. General considerations and strategic planning are explained and illustrated by three clinical cases.

Two hundred eighty articles related to microvascular transplants and replants published in The Journal of Hand Surgery over the past 25 years were reviewed. Every facet of microsurgery was covered. One hundred seventy-one articles are referenced and discussed under the following major categories: microvascular transplants, replants, nerve grafts, vein grafts, cold intolerance, vasospasm, monitoring, immediate reconstruction, and historical. Contributions were received from 37 countries and 175 authors or groups of authors.

We present our therapeutic strategy for the treatment of type IIIB open tibial fractures. It involves emergency internal stabilisation of the bone by locked intra-medullary nailing when appropriate and skin cover using either a pedicled or free muscle flap. Where there is bone loss, a cancellous iliac graft is performed at the same time. Eighteen cases of type IIIB open tibial fractures treated between 1986 and 1995 were analysed. There were 17 men and 1 woman; the average age was 35 years. Each of the 18 patients underwent wound debridement as a primary emergency procedure with no secondary reoperation. Bone fixation was performed by locked intra-medullary nailing (AO nail, How Medica) 6-10 h after trauma. A primary cancellous iliac bone graft was performed in three cases. Cover was applied immediately after nailing (muscular pedicle flaps in 12 cases, muscular free flaps in 6 cases). Local flap cover led to two failures: both these fractures were followed by postoperative complications. The 6 free muscle flaps were successful. The average time to bone union was 6.5 months (range: 3-18.5 months) according to clinical criteria and 9 months (range: 4-27 months) according to radiological criteria. Out of the 18 fractures, 13 were primarily united (72.2% of cases); 3 involved osteitis and 2 nonunion. Sixteen patients were examined again with a mean follow-up of 4.8 years (range: 1-11 years). Six moderate malunions occurred; none needed surgical reoperation. Ankle motion was normal in 7 cases and reduced to below 50% in 9 cases when compared with the healthy ankle. Thirteen patients resumed their previous professional activities. This surgical strategy reduces bone union time, the number of operations and the time spent in hospital; it improves functional results.

A profusion of terms are currently used to describe free flap wound closure. It is important to broadly standardize nomenclature when embarking on a comparison of functional outcomes between institutions. Therefore, a series of 68 "emergency" (within 24 hours) free flaps performed by a single surgeon were reviewed with respect to a total experience of 188 free tissue transfers to formulate a consistent nomenclature applicable to free flap wound closure in general. The nomenclature presented divides free flap closure into three categories: "primary free flap closure" (12 to 24 hours), "delayed primary free flap closure" (2 to 7 days), and "secondary free flap closure" (after 7 days). This system is analogous to the standard terms "primary," "delayed primary," and "secondary wound closure." It is consistent with known biologic and microbiologic principles of wound closure in general and should provide a simple basis for classifying free flap wound closure. Illustrative examples are presented to highlight the classification scheme.

The reconstruction of large palmar defects of the hand remains a difficult problem due to the specific anatomical structures and highly sophisticated function of the palm. The glabrous skin and subcutaneous tissue in the palm are perfectly adapted to serve the prehensile function. The particular aim must be that repairs to this functional structure are similar in texture and colour and are aesthetically acceptable. Restoration of sensibility is desirable. For smaller defects a great variety of local pedicled or island flaps can be applied. However, for larger defects with exposed tendons, nerves or other essential structures, free flaps remain as a reliable alternative. This paper reviews our approach of soft tissue reconstruction in 16 patients with large palmar defects using various kinds of free flaps. The advantages, disadvantages and current indications for free flap resurfacing of the palm are discussed.