Objective: Presentation of a case of isolated renal hydatid cyst with novel findings and unusual surgical scenario. Clinical Presentation and Intervention: A 54-year-old female patient presented with left loin pain and a palpable left renal mass. Imaging described a welldemarcated left renal cystic lesion with a two-layer wall. Radical nephrectomy was done due to the possibility of malignancy. On retrograde revision, the two-layer wall represented the detached germinative membrane of a hydatid cyst that was confirmed by histopathology. Conclusion: Isolated renal hydatid cyst could be misinterpreted as a renal tumor. It should be considered in the differential diagnosis of renal cystic lesions.

Vascularized composite allotransplant (VCA) offers functional, social, and quality of life improvements for patients who have exhausted traditional reconstructive options. Unlike solid organ transplant, VCA success is not only based upon the quality of perfusion and level of immunosuppression, but also on the success of nerve regeneration within the transplanted part. This paper will summarize the present state of peripheral nerve regeneration in the context of VCA and will explore the latest research advances that will affect the future of the field. These advances offer promising future strategies to improve patient outcomes in VCA.

Background: The purpose of this study was to use micro–computed tomography to demonstrate the intraosseous vascularity of the lunate within a three-dimensional orientation to identify areas of greatest perfusion and define vascular “safe zones” for surgical intervention. Methods: Fourteen upper extremities were injected with a lead-based contrast agent. The lunates were harvested and scanned using a micro–computed tomography scanner. The intraosseous vascularity was incorporated into a three-dimensional image. Vessel number, diameter, distribution, and pattern were evaluated and analyzed. Vascularity of all specimens was projected onto one representative lunate to identity areas of higher and lower vascularity. Results: Twelve specimens had nutrient vessels entering the bone from volar and dorsal; two specimens had no dorsal vessels. The intraosseous vascularity could be classified according to the Y, I, and X patterns described by Gelberman et al. Average number and diameter of vessels were 2.3 and 118.1 μm, respectively, for volar; and 1.4 and 135.8 μm, respectively, for dorsal. The long axis of the lunate showed the highest vascularity on both axial and lateral views. Lower vascularity was observed in the dorsoradial and volar-ulnar quadrants on the axial view, and in the proximal part on the lateral view. Lunate shape was not associated with an increase or decrease in nutrient vessels or vascular pattern. Conclusions: Vascular safe zones were identified, allowing for potentially safer surgical interventions to the lunate. Volar approaches to the lunate may result in localized ischemia in a subset of patients with absent dorsal nutrient vessels. This study may help to better define patients at risk for Kienböck disease.

HYPOTHESIS: The superior lateral genicular artery (SLGA) is the main blood supply to the lateral femoral condyle.1–3 This study addresses the detailed anatomy of this artery from the reconstructive surgeon’s point of view, for the harvest of a vascularized bone flap from the lateral femoral condyle. METHODS: 12 fresh frozen lower extremities were used. These were injected with ward’s red latex (Ward’s, Rochester, NY), then left to cool for 24–48 hours. Through a posterior incision at the popliteal fossa, blunt dissection was performed to the popliteal vessels. The SLGA was identified at its origin from the popliteal artery, and meticulously dissected distally along its course. The course, diameter, anatomical relations, length and branches were documented. Dissection was carried out under 3.5x loupe magnification and all measurements were done using an electronic digital caliper. RESULTS: The SLGA was consistent in all specimens. It originated from the popliteal artery at a mean distance of 40.07 mm proximal to the knee joint line. The mean diameter at origin was 1.73 mm. It ran laterally posterior to the femur, until the lateral intermuscular septum. Posterior to the septum, it divided into superficial and deep branches. At this point, a sizable skin perforator emerged and ran laterally posterior to the intermuscular septum to supply the lateral skin (Figure 1). The superficial branch travelled anteriorly giving off skin perforators and ended at the superolateral patella. The deep branch pierced the intermuscular septum to travel anteriorly on the lateral surface of the femur, giving branches to the vastus lateralis, periosteum of the femur and ending by terminal branches to the lateral femoral condyle (Figure 2). Mean length from origin of the SLGA to the termination point of the deep branch was 63.29 mm. CONCLUSION: The SLGA has very consistent anatomy, formidable length and suitable diameter at origin for microvascular anastomosis, which makes it a good pedicle for a vascularized bone flap from the lateral femoral condyle.

Introduction Although the perforating branches of the deep femoral artery have been introduced as recipient vessels for vascularized fibular grafts in the treatment of osteonecrosis of the femoral head, comprehensive knowledge of the related anatomy is deficient. The aims of this study were to provide detailed anatomical data for the perforating branches of the deep femoral artery and validate their usefulness as recipient vessels for vascularized fibular grafts. Materials and methods Anatomical dissection was performed on 11 fresh human cadaveric lower extremities. The number, locations, and diameters of the perforating branches were documented. The topographic relationships with the vastus ridge and the tendinous insertion of the gluteus maximus were clarified. The diameters of the perforating branches were compared with those of the ascending branch of the lateral circumflex femoral and the peroneal arteries. Results The mean number of perforating branches was 3.5. The mean distances from the vastus ridge to the first, second, and third perforating branches were 8.1, 13.7, and 20.4 cm, respectively. The first perforating branch was always located medial to the tendinous insertion of the gluteus maximus, whereas the second perforating branch was always located distal to the gluteus maximus. The mean diameters of the first, second, third, and fourth perforating branches were 3.1, 2.3, 1.6, and 1.2 mm, respectively. The mean diameters of the ascending branch of the lateral circumflex femoral and the peroneal arteries were 2.0 and 3.6 mm, respectively. Conclusion The first perforating branch of the deep femoral artery is an appropriate alternative recipient vessel for vascularized fibular grafts in the treatment of osteonecrosis of the femoral head. It has a very consistent anatomy with a suitable location and diameter for anastomosis of the peroneal artery.

Background: Multiple enchodromatosis of bone, termed Ollier’s disease, or Maffucci syndrome when associated with hemangiomas, is a rare disease that can affect the pediatric hand. This condition often causes a finger mass, deformity, pain and possible pathologic fractures, and has been associated with malignant transformation to chondrosarcoma. The aim of our study is to describe the long-term sequela of multiple enchondromatosis of the hand in the pediatric population, specifically the rates of malignant transformation, tumor recurrence, rates of pathologic fracture, and phalangeal growth arrest. Methods: We examined 15 pediatric patients who were treated in our institute with a total of 127 phalanges and metacarpals lesions. Only patients with follow-up of at least 4 years were included. We retrospectively reviewed patients’ chart and hand radiograph for symptoms including pathologic fractures, indications for surgery, and postoperative complications including tumor recurrence, and malignant transformation. We assessed phalangeal growth arrest with radiographs and normalized phalangeal growth charts. Results: Mean age of diagnosis was 5.8 years and mean follow-up time was 15.4 years. Pathologic fractures were common at 46% of pediatric patients, but ceased to occur once reaching adulthood. Outcomes of pathologic fractures were excellent, regardless of treatment. Malignant transformation occurred in 1 patient and did not occur during childhood. A total of 80% of patients and 29% of lesions underwent surgical treatment of curettage and bone graft for the lesion, yet recurrence was common and affected 33% of treated patients. Phalangeal growth arrest was the most common long-term sequela and affected 11% of phalanxes and metacarpals. This sequela was significantly more prevalent in patients who had surgical excision of the tumor. Conclusions: Our findings reassure that malignant transformation of enchodromatosis of the hand is unlikely in the pediatric population. Pathologic fracture is common, but has excellent outcomes. When considering surgery, parents should be counseled about the possibility of phalangeal growth arrest and recurrence of the lesion.

Background: The area perfused by a single perforator depends on its perforasome and its unique interperforator flow pattern. The purpose of this study was to clarify the interperforator flow patterns of the peroneal and posterior tibial artery perforators using three-dimensional computed tomographic angiography. Methods: Thirteen whole-leg skin flaps were harvested in the subfascial plane from fresh cadavers. Peroneal, posterior tibial, anterior tibial, and sural artery perforators with a diameter greater than 0.5 mm were documented. Three-dimensional computed tomographic angiography with an injection of iodinated contrast medium into the peroneal or posterior tibial artery perforator was used to investigate the percentages of the area and the perforators that were perfused. Results: The mean percentage of the total area perfused was as follows: peroneal artery perforator, 42.0 percent; posterior tibial artery perforator, 38.0 percent (p = 0.084). The mean percentage of the total perforators perfused was as follows: peroneal artery perforator, 55.0 percent; posterior tibial artery perforator, 44.2 percent (p = 0.004). Although the mean percentages of same-source artery perforators perfused by a peroneal artery perforator (73.6 percent) and by a posterior tibial artery perforator (77.2 percent) did not differ (p = 0.513), the mean percentages of other-source artery perforators perfused by a peroneal artery perforator (49.9 percent) and by a posterior tibial artery perforator (32.3 percent) were significantly different (p 0.001). Conclusions: This study demonstrated that a single peroneal or posterior tibial artery perforator perfused approximately 40 percent of the whole leg surface and that peroneal and posterior tibial artery perforators had different interperforator flow patterns. The results of this study may improve preoperative planning for pedicled perforator flap surgery.

Purpose To describe the demographics, diagnosis, management, and outcomes of capitate fractures in the adult and pediatric population treated in our institution. Methods We performed a retrospective chart and radiographic review of 53 patients with capitate fractures treated in our institution between 2002 and 2015. Patients’ demographic characteristics, mechanism of injury, management including surgery-related data, and outcomes, including complications, were recorded. A radiographic evaluation of the location and pattern of the fracture was performed. Results Capitate fractures were prevalent in young males and older females. Fracture location was variable with 9 different locations; in addition 80% of patients had an associated fracture in the wrist or hand. The most common fracture pattern was the transscaphoid, transcapitate perilunate dislocation. Most diagnoses were made with the aid of advanced imaging. Within this series, there was only 1 case (4%) of fracture nonunion and there were no cases of avascular necrosis of the proximal pole in limited follow-up. Isolated capitate fractures were significantly more common in children. In addition, children had better functional outcomes than adults. Conclusions This series provides updated information on this rare injury. Nonunion of the capitate, which was previously described as the most common complication, was rare in this cohort.

Summary: Extended knowledge of vascular anatomy has propagated the development of perforator flaps, which preserve muscle function and reduce morbidity. This has been achieved through the exemplary works of Manchot, Salmon, Milton, Taylor, and many others. With over 350 clinically relevant perforators in the body, this has created new flap options and a sense of creative freedom for reconstruction tailored toward a specific defect, without constraints of specific landmarks and using a “free-style” approach. Dominant perforators may be found in zones of high perforator density or “hot spots,” which can help to conceptualize local flap options and aid flap design. This article aims to outline the history, physiology, and principles of flap design and harvest, and highlight traditional and evolving concepts and modifications of contemporary and traditional flaps that are changing reconstructive practice. This is a broad overview focusing on clinical applications, highlighting key concepts in a selection of new or evolving flaps being used in clinical practice and providing source references to acquire detailed flap descriptions.

Background The pedicled latissimus dorsi (LD) flap serves an important function in breast reconstruction, but its utility is limited by its inability to provide sufficient breast volume. Objectives The purpose of this preliminary report was to review the techniques and outcomes of utilizing fat-grafted, volume-enhanced LD flap transfer with fat grafting recipient sites in autologous breast reconstruction. Methods A retrospective study was performed of 10 patients (14 breasts) who underwent autologous breast reconstruction utilizing the LD flap transfer technique and simultaneous fat grafting between August 2012 and September 2014. Multilayer, multisite fat grafting was performed to the LD muscle, LD skin paddle, mastectomy skin flaps, and the pectoralis major and serratus muscles simultaneously with the LD flap transfer. Results Three patients underwent an immediate breast reconstruction, four underwent a delayed breast reconstruction, and four underwent a tertiary breast reconstruction following previously failed breast reconstructions (one patient underwent each of the first two procedures, one on each breast). The average age of the patients was 55 years (range, 39-76 years), the average body mass index of the patients was 29.3 (range, 19.6-39.9), and the average fat grafting volume for the patients was 176 mL (range, 50-300 mL). There was 100% flap survival and complete wound healing. No seroma or fat grafting–related complications were clinically detected. Three patients required additional fat grafting. Conclusions The fat-grafted, volume-enhanced LD flap procedure with fat grafting recipient sites offers a simple and safe technique for autologous breast reconstruction, with low morbidity and fast recovery. It can be a useful alternative to utilizing abdomen-based flaps in autologous breast reconstruction or could be performed to salvage both implant-based and free-flap breast reconstructions.