Background Defects in the weight-bearing heel or forefoot are commonly derived from chronic wounds, acute trauma, or tumor excision. Reconstruction of such defects pose a significant challenge to provide a flap that is stable, durable, and sensate. Several flaps have been described for reconstruction of plantar defects, but recurrent ulcerations and/or the need of additional procedures are common. This article provides the approach and outcomes of innervated free medial plantar flap for weight-bearing plantar defects reconstruction. Methods Chart review was performed of 17 consecutive patients with defects in the weight-bearing heel and/or forefoot who were treated with innervated free medial plantar flaps between the years 1999 and 2016. Eleven patients were male, and 6 patients were female. The mean age was 29.5 years (range, 4–52 years). One case was combined heel/forefoot defect, 7 were heel defects, and 9 were forefoot defects. Indications were acute trauma, secondary reconstruction after trauma, and tumor excision. Results The mean defect size was 8.0 ± 5.4 cm × 5.1 ± 2.1 cm, and mean flap size was 9.7 ± 1.4 cm × 6.4 ± 0.9 cm. One flap suffered from arterial thrombosis, which necessitated reoperation, and was salvaged. For the remaining cases, the postoperative course was uneventful. The mean follow-up time was 59.3 (±51.3.6) months. Two patients received minor flap corrections due to hyperkeratosis and hypertrophic scar, and 2 patients required donor site correction owing to partial loss of skin graft. One patient succumbed within 1 year owing to metastatic disease. All patients that were followed more than 1 year (n = 15) could sense blunt touch of the flap. Ten patients underwent 2-point discrimination test. No patient had recurrence of ulceration. Conclusions The innervated medial plantar flap is an excellent solution for treatment of medium-to-large defects in the weight-bearing heel or forefoot. It provides glabrous skin that is stable, durable, and sensate. The long-term results are good, with no patient afflicted by recurrent ulceration during the follow-up time.

Introduction: Rupture of the extensor pollicis longus (EPL) tendon has been reported in the setting of distal radius fracture, chronic inflammatory arthritis, following steroid injection, and with excessive or repetitive activities. Truly, spontaneous EPL rupture, without an identifiable predisposing factor, has rarely been reported. Methods: We present a retrospective case series of eight patients with spontaneous EPL rupture who were treated in our institution. Results: The majority of the cases were female (75 %, n=6), and the nondominant (75 %, n=6) hand was most commonly involved. No identifiable predisposing factor could be identified in four patients. While four patients reported a history of a fall, radiographs failed to demonstrate skeletal abnormality in all four cases. No additional pathology could be identified at the time of surgery. Patients were treated using tendon transfer ( n=7) or interpositional graft ( n=1). There has been no case of clinical recurrence in the mean of 74.8 months (range 23–140 months) follow-up period. Conclusion: The EPL tendon is at risk for spontaneous rupture even in the absence of identifiable predisposing risk factor. Rather than pure mechanical irritation, vascular and metabolic factors may also play a substantial role in the etiology of this uncommon diagnosis.

Background Because of shearing forces, the forefoot is more prone to trophic ulcers than the heel. Reconstruction of trophic ulcers and other forefoot defects is a vexing challenge. We favor the innervated free medial plantar flap to replace like-with-like and confer protective sensation. We investigate the feasibility of this flap with the largest series to date and the first to describe ipsilateral flap transfer. Methods Between 2009 and 2013, 7 patients with forefoot defects were treated with innervated free medial plantar flaps. The average age of 4 men and 3 women was 35.1 years (range, 8–50 years). Indications were secondary reconstruction after trauma and coverage of oncologic defects. The mean defect was 5 × 7 cm (range, 4–6 cm × 6–10 cm). Four patients were treated with contralateral flaps and 3 with ipsilateral flaps using interposition vein graft. Results The mean flap size was 8.1 ± 1.6 cm × 5.9 ± 1.2 cm. There was no perioperative complication, venous congestion, or arterial insufficiency. Patients were followed clinically for 38.5 months (range, 6 months to 10 years). One patient died from complications of metastatic disease 7 months after plantar flap reconstruction. Two patients underwent sensory testing and gait analysis. The appearance was satisfactory, ambulation returned to normal, and there was protective sensation in every case. In 2 cases, hyperkeratotic tissue was excised in revision procedures. Conclusions The innervated free medial plantar flap is an attractive and feasible option for coverage of medium-to-large defects of the plantar forefoot in the hands of a skilled microsurgeon. It has a place in our algorithmic approach to forefoot reconstruction.

An innovative immunosuppressant with a minimally invasive delivery system has emerged in the biomedical field. The application of biodegradable and biocompatible polymer forms, such as hydrogels, scaffolds, microspheres, and nanoparticles, in transplant recipients to control the release of immunosuppressants can minimize the risk of developing unfavorable conditions. In this review, we summarized several studies that have used implantable immunosuppressant delivery to release therapeutic agents to prolong allograft survival. We also compared their applications, efficacy, efficiency, and safety/side effects with conventional therapeutic-agent administration. Finally, challenges and the future prospective were discussed. Collectively, this review will help relevant readers understand the different approaches to prevent transplant rejection in a new era of therapeutic agent delivery.

Despite the known advantages of virtual surgical planning and three-dimensional (3D) printing, translation of virtual planning to actual operation is a challenge, especially in secondary mandibular reconstruction. Patients who underwent secondary microvascular mandibular reconstruction were retrospectively reviewed and categorized into three categories as follows: (i) defect not crossing the midline (category I); (ii) defects crossing the midline with availability of previous imaging data (category II) and; (iii) defects crossing the midline with unavailability of previous imaging data (category III). The resulting 3D printed models were used as an effective guide for plate bending during secondary reconstruction surgery. Accuracy of the reconstruction was evaluated by superimposing post-operative images over virtual plan. Out of eleven patients, five were category I, three were category II, and three were category III. The mean linear discrepancy between the planned and post-operative position was measured. A Mann-Whitney U test was conducted to compare mean discrepancy among the groups showed no significant difference between group I and group II (p > 0.05) whereas comparison of groups I and II with group III showed a significant difference (p < 0.01). The proposed algorithm for the generation of defect template for manual plate bending during secondary reconstruction of mandibular defects is valid with acceptable accuracy in various defect configurations.