[Reconstruction with free vascularized or island flaps of soft tissue loss in the upper limb after tumor resection. 16 cases]

Improvement of the Rotation Arch of the Posterior Interosseous Pedicle Flap Preserving Both Reverse Posterior and Anterior Interosseous Vascular Sources

Purpose:

The reverse posterior interosseous artery flap has several advantages, not sacrificing any major blood vessel, but its relatively short pedicle limits the use to cover defects up to the metacarpophalangeal joint. Our purpose is to demonstrate that the ligature of the anterior interosseous artery (AIA), proximal to the communicating branch with the posterior interosseous artery, leads to an improved flap rotation arch, preserving both vascular sources.

Methods:

Sixteen fresh cadavers with latex perfusion were analyzed before and after our technique of elongation, and the so-obtained measures were standardized in “percentage of elongation of the pedicle.” Eight patient with the loss of substance at the dorsal aspect of the hand have been treated with this technique, and results were evaluated in terms of flap survival and complication rates.

Results:

The medium length of the pedicle in the normal flap was 10.8 cm, and after the section of the AIA, the medium length of the pedicle was 13.6 cm with a medium increase of 2.8 cm. It means a medium increase of 24% of the length of the pedicle. In all patients treated, full coverage of the defect was obtained, and we did not experience major complications.

Conclusions:

This anatomical study supported by our clinical experience demonstrates that the use of the variant described above permits to reach more distal part of the hand without being afraid to stretch the pedicle because of the connection with the anastomotic arcades of the AIA at the wrist reducing the risk of ischemia of the flap.

Fasciocutaneous cubital flap in soft tissue loss of the wrist

Surgical managment of soft tissue loss in the wrist consists of suitable coverage for the protection of vascular, nervous and tendinous structures. The fasciocutaneous cubital flap covers wrist defects, providing safe support over the nerves, tendons and vessels. Reported here is five cases of wrist defects by different etiology (extravasations, autolysis, trauma and neuritis). A fasciocutaneous cubital flap successfully covered the soft tissue loss in all cases. This flap is applied in an easy, one-stage procedure and it maintains the major arteries of the forearm.

Reconstruction after soft tissue sarcoma resection in the setting of brachytherapy: a 10-year experience

Management of recurrent soft tissue sarcomas often involves surgical resection and adjuvant brachytherapy. This study reviews our experience in the management of these patients and proposes a logical approach toward reconstruction. All patients who underwent soft tissue sarcoma resection, adjuvant brachytherapy, and soft tissue flap reconstruction (pedicled or free) during the 10-year period from 1991 to 2000 were included in this study. There were 17 patients (14 male, 3 female) with a mean age of 51 years (range, 16-80 years). Soft tissue sarcomas were distributed in the lower extremity (n = 9), upper extremity (n = 5), and trunk (n = 3). Reconstruction was accomplished by regional transposition flaps (n = 10) and free tissue transfer (n = 7). The average defect size was 143 cm. Patients received 5 to 12 (mean, 8) brachytherapy catheters. The brachytherapy dose delivered ranged from 1600 to 4500 cGy (mean, 3773 cGy). Brachytherapy catheters were loaded with radioactive sources between 5 and 7 days postoperatively. All flaps in this series survived. One patient required return to the operating room for revision of a venous thrombosis with flap salvage. Closed suction drainage tubes were left in place until after the brachytherapy catheters were removed to avoid dislodging the catheters. Two patients developed postradiation partial-thickness skin necrosis with delayed secondary wound healing. This study demonstrates that soft tissue reconstruction in the setting of sarcoma resection and brachytherapy catheter placement is safe and efficacious. Postoperative wound healing complications can be minimized through coordination among the ablative surgeon, reconstructive surgeon, and radiation oncologist. Specifically, placement of microvascular anastomoses well away from the radiation target area is indicated whenever possible. Finally, removal of closed suction drainage tubes should be deferred until after the brachytherapy catheters are removed to minimize complications resulting from catheter dislodgement.

Uncommon hand tumours

This paper presented clinical examples of some rare or uncommon presentations of tumours of the hand, including glomus tumour, intraosseous dermoid, fibrolipoma of the radial nerve, blastomycotic cyst and synovial sarcoma. Each lesion is illustrated by review of case histories, radiological and pathological features.