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Marra C, Pentangelo P, Losco L, Ceccaroni A, Barbato A, Alfano C. Lower Extremity Trauma: A Multidimensional Reconstructive Approach with Hyperbaric Oxygen Therapy. J Clin Med 2024; 13:1407. [PMID: 38592225 PMCID: PMC10931990 DOI: 10.3390/jcm13051407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 02/10/2024] [Accepted: 02/27/2024] [Indexed: 04/10/2024] Open
Abstract
Background: Distal lower extremity reconstruction is challenging. This study aims to propose a protocol for the treatment of traumatic soft tissue defects. The key concept is to combine the surgical armamentarium of the reconstructive surgeon with the advantages provided by hyperbaric oxygen therapy. Methods: This retrospective study analyzed data of 57 patients affected with unilateral or bilateral lower extremity trauma distal to the knee and involving soft tissues with no indication of immediate reconstruction between 2010 and 2021. Before the reconstructive procedure, all the patients underwent a stick swab procedure for the collection of microbiological samples and debridement. Patients were divided into two treatment groups and only one group underwent a combined therapeutic procedure with hyperbaric oxygen therapy. Negative pressure wound therapy (NPWT) was employed only if deemed necessary according to the defect's depth and wound exudate. Surgical techniques, outcomes, and complications were discussed. Results: All patients achieved a complete recovery with no major complications and only minor complications observed. The study group treated with HBOT had a lower complication rate and lower percentages of minimal and partial graft loss compared with the same complications observed in the control group. No patients experienced HBOT-related complications. Significant reductions in the time to complete healing and the time from reconstruction to healing were found (p = 0.002 and p < 0.00001, respectively). Conclusions: A lower complication rate was observed in the group treated with HBOT. The administration of HBOT prior to soft tissue reconstruction significantly reduced the time to complete healing and the time interval from skin grafting to healing. However, prospective studies and randomized trials with larger cohorts should be designed to investigate the efficacy of HBOT for the treatment of lower extremity injuries with extensive soft tissue defects.
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Affiliation(s)
- Caterina Marra
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA, Italy; (C.M.); (P.P.)
| | - Paola Pentangelo
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA, Italy; (C.M.); (P.P.)
| | - Luigi Losco
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA, Italy; (C.M.); (P.P.)
| | - Alessandra Ceccaroni
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA, Italy; (C.M.); (P.P.)
| | - Alfonso Barbato
- Plastic Surgery Unit, Azienda Ospedaliera Universitaria OO.RR. San Giovanni di Dio e Ruggi d’Aragona, 84131 Salerno, SA, Italy
| | - Carmine Alfano
- Plastic Surgery Unit, Department of Medicine, Surgery and Dentistry, University of Salerno, 84081 Baronissi, SA, Italy; (C.M.); (P.P.)
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Singh S, Toci GR, Kapadia K, Colon A, Greenberg P, Iyer H, Katt B, Shah A. Vascularized Bone Grafting Versus the 2-Stage Masquelet Technique for Upper-Extremity Bone Reconstruction: A Meta-Analysis. J Hand Surg Am 2023; 48:984-992. [PMID: 37542493 DOI: 10.1016/j.jhsa.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2022] [Revised: 05/15/2023] [Accepted: 06/23/2023] [Indexed: 08/07/2023]
Abstract
PURPOSE Vascularized bone grafting (VBG) has been described as the technique of choice for larger bone defects in bone reconstruction, yielding excellent results at the traditional threshold of 6 cm as described in the literature. However, we hypothesize that the 2-stage Masquelet technique provides equivalent union rates for upper-extremity bone defects regardless of size, while having no increase in the rate of patient complications. METHODS A systematic literature review was conducted using PubMed and Scopus for outcomes after VBG and the Masquelet technique for upper-extremity bone defects of the humerus, radius, ulna, metacarpal, or phalanx (carpal defects were excluded). A meta-analysis was performed to compare outcomes following VBG and the Masquelet technique at varying defect sizes. RESULTS There were 77 VBG (295 patients) and 25 Masquelet (119 patients) studies that met inclusion criteria. Patients undergoing the Masquelet technique had defect sizes ranging from 0-15 cm (average 4.5 cm), while patients undergoing VBG had defect sizes ranging from 0-24 cm (average 5.9 cm). The union rate for Masquelet patients was 94.1% with an average time to union of 5.8 months, compared to 94.9% and 4.4 months, respectively, for VBG patients. We did not identify a defect size threshold at which VBG demonstrated a significantly higher union rate. No statistically significant difference was found in union rates between techniques when using multivariable logistic regression analysis. CONCLUSION There was no statistically significant difference in union rates between VBG and the Masquelet technique in upper-extremity bone defects regardless of defect size. Surgeons may consider the Masquelet technique as an alternative to VBG in large bone defects of the upper extremity. TYPE OF STUDY/LEVEL OF EVIDENCE Therapeutic IV.
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Affiliation(s)
| | - Gregory R Toci
- Rothman Orthopaedics at Thomas Jefferson University Hospital, Philadelphia, PA
| | | | | | | | - Hari Iyer
- The Center for Hand and Upper Extremity Surgery, Hackensack, NJ
| | - Brian Katt
- Rutgers Robert Wood Johnson University Hospital, New Brunswick, NJ
| | - Ajul Shah
- The Center for Hand and Upper Extremity Surgery, Hackensack, NJ
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Outcomes of free vascularised fibular graft reconstruction in upper limb trauma-a systematic review. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:207-223. [PMID: 35083566 DOI: 10.1007/s00590-021-03185-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 12/09/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE To evaluate existing literature describing the use of free fibular flaps in upper extremity trauma and summarise flap outcomes. Secondary objectives are to evaluate patient demographics and flap characteristics. METHODS EMBASE, PubMed, MEDLINE and the Cochrane Database were searched for eligible studies published from 1975 to January 2019. Primary outcome measures collected were rate of union, graft survival rate, and complication rates. Patient demographics and flap characteristics were also collected. Statistical analysis was performed using SPSS software (SPSS version 25; IBM, Chicago, USA). Pooled data were presented as mean and standard deviation or median and range. Categorical variables were assessed by chi-squared test. Quality of studies were assessed using the National Institutes of Health (NIH) Quality Assessment Tool for case series studies. RESULTS Initial search yielded 1070 articles. A total of 25 studies (151 cases) met the inclusion criteria. Flap survival was 97% (147/151) at time of follow-up, with first union rate of 95% (142/151) and second union rate of 97% (147/151) following bone graft or further procedure. Overall complication rate was 33% (47/140). There was a statistically significant association between recipient flap site and rates of flap fracture (p = 0.049). There was no statistically significant association between flap type, evidence of infection at donor or defect site, or method of flap fixation on outcomes. CONCLUSIONS Vascularised fibular flaps are a safe and efficacious reconstructive option for upper limb trauma. Further research is required to enable better understanding of the impact of patient and clinical factors on flap outcome measures.
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Martin J, Taqatqeh F, Dragu A, Notov D, Fritzsche H, Grigorescu O, Bota O. Thumb reconstruction after radical tumor resection using free osteocutaneous lateral arm flap with secondary humerus fracture-a case report. Arch Orthop Trauma Surg 2023; 143:1725-1729. [PMID: 36151479 PMCID: PMC9957847 DOI: 10.1007/s00402-022-04623-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/11/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Malignant diseases with infiltration of bony structures in the area of the phalanges or metacarpals require either amputation or complex reconstruction. The decision for reconstruction means to restore length, mobility, sensibility, stability as well as aesthetics. METHODS We present a case of complex first ray reconstruction of the left hand using a free osteocutaneous lateral arm flap from the ipsilateral side. The reconstruction was performed after radical resection of an exulcerated squamous cell carcinoma, including the first metacarpal bone, trapezium, partial trapezoid and distal scaphoid as well as partial resection of the extensor pollicis longus, extensor pollicis brevis, abductor pollicis longus and flexor carpi radialis tendons. The osteosynthetic restoration was achieved distally by a double wire cerclage and a proximally by temporary K-wire suspension. Moreover, to reconstruct the extensor pollicis longus tendon the ipsilateral palmaris longus tendon was harvested and used. Postoperatively, a secondary humerus fracture occurred, which was initially attended by plate osteosynthesis. The fracture showed delayed healing, which was treated by re-plating and autologous cancellous bone. RESULTS 12 months postoperatively, the patient showed an excellent outcome with length preservation and good range of motion, sensibility, stability and aesthetic of the thumb. Furthermore, the quarterly tumor aftercare showed no evidence of recurrence. CONCLUSION This case report showed that the free osteocutaneous lateral arm flap is a reliable solution for the reconstruction of the first ray with a great functional and aesthetic outcome. To prevent a secondary humerus fracture, a preventive plate osteosynthesis simultaneous with the osteocutaneous flap elevation should be considered.
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Affiliation(s)
- Judy Martin
- Faculty of Medicine Carl Gustav Carus, University Center for Orthopedics, Trauma and Plastic Surgery, TU Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
| | - Feras Taqatqeh
- grid.4488.00000 0001 2111 7257Faculty of Medicine Carl Gustav Carus, University Center for Orthopedics, Trauma and Plastic Surgery, TU Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Adrian Dragu
- grid.4488.00000 0001 2111 7257Faculty of Medicine Carl Gustav Carus, University Center for Orthopedics, Trauma and Plastic Surgery, TU Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Dmitry Notov
- grid.4488.00000 0001 2111 7257Faculty of Medicine Carl Gustav Carus, University Center for Orthopedics, Trauma and Plastic Surgery, TU Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Hagen Fritzsche
- grid.4488.00000 0001 2111 7257Faculty of Medicine Carl Gustav Carus, University Center for Orthopedics, Trauma and Plastic Surgery, TU Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Oana Grigorescu
- grid.4488.00000 0001 2111 7257Faculty of Medicine Carl Gustav Carus, University Center for Orthopedics, Trauma and Plastic Surgery, TU Dresden, Fetscherstraße 74, 01307 Dresden, Germany
| | - Olimpiu Bota
- grid.4488.00000 0001 2111 7257Faculty of Medicine Carl Gustav Carus, University Center for Orthopedics, Trauma and Plastic Surgery, TU Dresden, Fetscherstraße 74, 01307 Dresden, Germany
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Ellabban MA, Gomaa AA, Moghazy AM, Elbadawy MA, Adly OA. Aesthetic and functional outcomes of thinned anterolateral thigh flap in reconstruction of complex wounds of the upper limb. J Hand Surg Eur Vol 2021; 46:857-864. [PMID: 33541223 DOI: 10.1177/1753193421989603] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
We studied outcomes of reconstruction of complex upper limb wounds using thinned anterolateral thigh flaps. There were 18 patients with a mean age of 27.5 years. The mean thickness of the flap before and after thinning was 23 mm and 5 mm, respectively. Two patients had partial tip necrosis that was treated conservatively. Aesthetic and functional evaluations were performed using a 5-point Likert scale, QuickDASH score, passive range of motion and power grip at 12 months after surgery. The study showed good results in the aesthetic evaluation by a panel of plastic surgeons (mean score: 19.7) and patient self-assessment (mean score: 18.1). There was a significant correlation between the total scores of the panel and the patients. The mean QuickDASH score was 21, with a high percentage in the middle category 'had a problem but working'. The thinned anterolateral thigh flap is versatile and safe in upper limb reconstruction with good aesthetic and functional results.Level of evidence: IV.
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Affiliation(s)
- Mohamed A Ellabban
- Plastic and Reconstructive Surgery Unit, Department of Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Amr A Gomaa
- Plastic and Reconstructive Surgery Unit, Department of Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Amr M Moghazy
- Plastic and Reconstructive Surgery Unit, Department of Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Mohamed A Elbadawy
- Plastic and Reconstructive Surgery Unit, Department of Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
| | - Osama A Adly
- Plastic and Reconstructive Surgery Unit, Department of Surgery, Faculty of Medicine, Suez Canal University, Ismailia, Egypt
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di Summa PG, Higgins G, Cotrufo S, Sapino G, Reekie T, Leonard D, Shaw-Dunn J, Hart A. Distal Brachial Artery Perforator flap: a new chimeric option for complex hand and digits defects. J Plast Reconstr Aesthet Surg 2021; 75:613-620. [PMID: 34728156 DOI: 10.1016/j.bjps.2021.08.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 06/11/2021] [Accepted: 08/26/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Reconstruction of fingers pose unique challenges, as a thin and flexible flap is needed in order to guarantee a good functional outcome. For the first time, in this report, we present the DBAp (distal brachial artery perforator) flap, based on the distal perforator closer to the medial epicondyle. The DBAp flap was used to reconstruct complex digit defects as free flap, and to cover an elbow defect while raised as a propeller. METHODS Four patients underwent finger reconstruction (free flaps): two patients presented an unstable finger scar following previous surgery, whereas the other two patients presented a terminalized finger at the level of the middle phalanx. A further patient presented a post-traumatic loss of substance at the elbow and was reconstructed using a perforator propeller DBAP flap. RESULTS Loss of tissues included skin and subcutaneous tissue in all patients and in one patient it included a bone component. Flap dimensions ranged from 48 to 18 cm2 (average: 32 cm2). Among complications, patient n.2 flap presented a marginal flap necrosis requiring a small skin graft after necrosis debridement. CONCLUSION The DBAp flap provides a slim, glabrous and pliable skin tissue with a well-hidden donor site scar and thanks to the anatomic location of the distal perforator can be designed to include a vascularized bone graft from the medial epicondyle. Despite the low number of cases, we believe that this flap should be considered as a dependable and effective source for complex reconstructions of both soft tissue and bone in fingers.
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Affiliation(s)
- P G di Summa
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G40SF, UK; Department of Plastic and Hand Surgery, University Hospital of Lausanne (CHUV), University of Lausanne, Lausanne, CH
| | - G Higgins
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G40SF, UK
| | - S Cotrufo
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G40SF, UK; Department of Plastic and Reconstructive Surgery, University of Messina, Messina, IT
| | - G Sapino
- Department of Plastic and Reconstructive Surgery, University of Modena, Modena, IT; Department of Plastic and Hand Surgery, University Hospital of Lausanne (CHUV), University of Lausanne, Lausanne, CH
| | - T Reekie
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G40SF, UK; College of Medical Veterinery & Life Sciences, The University of Glasgow, University Avenue, Glasgow, United Kingdom
| | - D Leonard
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G40SF, UK; College of Medical Veterinery & Life Sciences, The University of Glasgow, University Avenue, Glasgow, United Kingdom
| | - J Shaw-Dunn
- College of Medical Veterinery & Life Sciences, The University of Glasgow, University Avenue, Glasgow, United Kingdom
| | - A Hart
- Canniesburn Plastic Surgery Unit, Glasgow Royal Infirmary, 84 Castle Street, Glasgow G40SF, UK; College of Medical Veterinery & Life Sciences, The University of Glasgow, University Avenue, Glasgow, United Kingdom.
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75 Years of Hand and Peripheral Nerve Surgery in Plastic and Reconstructive Surgery: Standing on the Shoulders of Giants. Plast Reconstr Surg 2021; 147:1473-1479. [PMID: 34019521 DOI: 10.1097/prs.0000000000008003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Willemot L, Stewart D, Lawson R. Reconstruction of an infected midshaft radius and ulna nonunion using a free vascularized fibula and medial femoral condyle flap. Microsurgery 2021; 41:666-670. [PMID: 33932250 DOI: 10.1002/micr.30750] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/16/2021] [Accepted: 04/23/2021] [Indexed: 11/07/2022]
Abstract
Conventional grafts do not perform well in the treatment of large diaphyseal bone defects. Forearm nonunions are especially challenging due to complex biomechanical and kinematic demands. Free bone flaps may yield more predictable bony restoration in these cases, while keeping morbidity acceptable to the patient. We aim to illustrate one combination of flaps which can be used in these conditions. This article reports on a 23 year old patient with an 8 cm diaphyseal nonunion of the radius and a similar 7 cm defect of the ulna after infection of fracture fixation hardware. The radius was treated with a free fibular flap (FFF) and the ulna with a medial femoral condyle (MFC) flap in a staged procedure after initial debridement. The patient was followed up for 6 months without significant complications. Both flaps healed within 3 months, yet the MFC demonstrated faster bony incorporation. We attributed this to the spongious nature of the MFC flap compared to the thick cortical FFF. This case report hopes to illustrate one type of flap combination for extensive forearm bone defects. The selection and approach minimizes donor site morbidity to a single limb and possibly hastens bony union of the forearm.
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Affiliation(s)
- Laurent Willemot
- Department of Orthopedic Surgery, Ghent University Hospital, Ghent, Belgium.,Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, Australia
| | - David Stewart
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Richard Lawson
- Department of Hand Surgery and Peripheral Nerve Surgery, Royal North Shore Hospital, Sydney, Australia
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Kotsougiani-Fischer D, Fischer S, Platte J, Nagel SS, Kneser U, Harhaus L. [Evaluation of secondary refinement procedures following free microvascular tissue reconstruction of the upper extremity]. HANDCHIR MIKROCHIR P 2021; 53:356-363. [PMID: 33851377 DOI: 10.1055/a-1294-9593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND The primary cosmetic and functional outcome following successful upper limb salvage using free tissue transfer can often be unfavourable, which may motivate patients to undergo secondary procedures. In this study, we sought to identify predictors for secondary procedures and to analyse the type and number of these procedures. PATIENTS AND METHODS Patients who underwent free tissue transfer to the upper extremity between 2010 and 2017 were included in a retrospective cohort study: patients with secondary procedures to optimise the functional and aesthetic flap design (S cohort) vs. control cohort (C cohort). A multivariate regression analysis was used to identify predictors for secondary procedures. RESULTS One hundred and twenty-eight patients were included in the study (S cohort 36, C cohort 92). All in all, 56 secondary refinement procedures were performed in a mean of eight months after the initial free flap reconstruction. Most of the defects in the S cohort were localised at the hand (53 %), and upper limb salvage was mostly accomplished by fasciocutaneous and adipocutaneous free flaps (S cohort 89 %). The most frequently performed secondary refinement procedures were direct partial flap excision (61 %), followed by liposuction (16 %) and the combination of both (17 %). Furthermore, 64 % of the secondary refinement procedures from the S cohort were combined with further surgical interventions to improve hand function, e. g. tenolysis and arthrolysis. Patients with defects of the hand received secondary procedures 2.4 times more frequently (p = 0.05). Also, patients with a good general health condition (ASA 1 and 2) were six times more likely to undergo a secondary procedure (p = 0.03). CONCLUSION Secondary procedures are safe and frequently requested by patients following successful free flap upper limb salvage. In particular, this applies to patients who are in a good health condition and with free flaps to the hand. Therefore, we recommend the implementation of secondary refinement procedures in the reconstructive plan to increase patient compliance and satisfaction.
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Affiliation(s)
- Dimitra Kotsougiani-Fischer
- BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg
| | - Sebastian Fischer
- BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg
| | - Juliana Platte
- BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg
| | - Sarah Sophie Nagel
- BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg
| | - Ulrich Kneser
- BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg
| | - Leila Harhaus
- BG Klinik Ludwigshafen, Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Mikrochirurgie, Schwerbrandverletztenzentrum, Plastische Chirurgie und Handchirurgie der Universität Heidelberg
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Sauerbier M, Maldonado AA, Hoffmann R, Kuz N. [Possible applications of free microsurgical fibula transplantation in the reconstruction of complex bone defects in the extremities: review of the literature and case series]. HANDCHIR MIKROCHIR P 2020; 52:505-517. [PMID: 32820485 DOI: 10.1055/a-1183-4532] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Extensive osseous defects of the extremities following trauma and tumour resection represent a major challenge for plasticreconstructive surgical teams. Defect reconstruction by free microsurgical fibula transplantation has become a standard method but is associated with a considerable rate of complications. The aim of the present work is to provide an up-to-date overview of the various reconstruction methods and to report our personal experiences with free fibula transplantation in a case series. PATIENTS AND METHODS The literature search on the subject was performed on Pubmed and Web of Science, and a retrospective collection of data was conducted based on our own cases, including clinical and radiological data. RESULTS From 2007 to 2018, free fibula transplantation was performed in 11 patients under the guidance of the senior author (MS). The defects were a result of pseudarthrosis in four cases, osteitis in three, and a tumour in two cases. Two patientssustained a primary defect due to a high-energy trauma. In nine cases the upper limb was affected; only two had the defect in the lower limb. No graft failure was observed. In eight cases, an osteoseptocutaneous graft was taken; in two cases there was a post-operative loss of the skin island. Fibula length ranged between 5 and 22 cm. In all cases, bony integration of the graft was complete. The range of motion in the affected limb after physiotherapy was very good to satisfactory. CONCLUSION Extensive bone defect reconstruction using free fibula flaps is undoubtedly the gold standard method, but the high rate of complications described in the literature necessitates a strict indication in due consideration of possible alternatives. Close cooperation between the disciplines of plastic reconstructive surgery and trauma orthopaedics is indispensable.
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Affiliation(s)
- Michael Sauerbier
- PROFESSOR SAUERBIER, Privatärztliche Praxis für Hand- und Plastische Chirurgie, Bad Homburg v. d. Höhe
| | - Andres A Maldonado
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Abteilung für Plastische, Hand- und -Rekonstruktive Chirurgie
| | - Reinhard Hoffmann
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Unfallchirurgie und Orthopädische Chirurgie
| | - Nikolai Kuz
- Berufsgenossenschaftliche Unfallklinik Frankfurt am Main, Abteilung für Plastische, Hand- und -Rekonstruktive Chirurgie
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Matsumoto T, Tsumura T, Kishimoto K, Sano H, Doi K, Matsushita M, Murakami H. Sequential chimeric free deep circumflex iliac artery bone flap and superficial circumflex iliac artery perforator flap from the same site for one-stage reconstructions of severe hand injury: A report of two cases. JPRAS Open 2020; 26:49-53. [PMID: 33134470 PMCID: PMC7588655 DOI: 10.1016/j.jpra.2020.09.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 09/27/2020] [Indexed: 11/19/2022] Open
Abstract
Two flaps, namely the free vascularized iliac bone graft supplied by the deep circumflex iliac artery (DCIA) and the superficial circumflex iliac artery perforator flap supplied by the superficial circumflex iliac artery (SCIA), can be individually harvested from a single surgical field. We report two cases treated by these free flaps for severe hand injury with large skin defect and osteomyelitis. Sequential chimeric flaps were anastomosed between the ascending branch of the DCIA and the SCIA. The advantage of this method is more freedom in the flap insetting for complex tissue defects. For this reason, this method is also excellent for cosmetic appearance. Furthermore, donor site morbidity can be minimized because the flaps are harvested from the same site.
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Affiliation(s)
- Taiichi Matsumoto
- Department of Orthopaedic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan
| | - Takuya Tsumura
- Department of Orthopaedic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan
| | - Katsuma Kishimoto
- Department of Orthopaedic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan
| | - Hirokazu Sano
- Department of Orthopaedic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan
| | - Kohei Doi
- Department of Orthopaedic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan
| | - Mutsumi Matsushita
- Department of Orthopaedic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan
| | - Hiroshi Murakami
- Department of Orthopaedic Surgery, Kurashiki Central Hospital, 1-1-1 Miwa, Kurashiki, Okayama 710-8602, Japan
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Acharya AM, Ravikiran N, Jayakrishnan KN, Bhat AK. The role of pedicled abdominal flaps in hand and forearm composite tissue injuries: Results of technical refinements for safe harvest. J Orthop 2019; 16:369-376. [PMID: 31193279 DOI: 10.1016/j.jor.2019.04.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 04/15/2019] [Indexed: 10/26/2022] Open
Abstract
We evaluated the outcome of new technical refinements in abdominal flap coverage of major defects in upper limb for its reliability and safety. 68 patients were assessed for indications, additional procedures, complications and DASH questionnaire evaluation at the end of a year. The mean size of flap was 56 cm2 (range 6-250 cm2). Median DASH score was 11.5 (range: 0-63). Hand stiffness was observed in 39% of patients. However, this was absent in whom prophylactic pinning of metacarpophalangeal joints were done in James position. Abdominal flaps give satisfactory results in hand injuries. Competent hand therapy program is essential to get best results.
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Affiliation(s)
- A M Acharya
- Unit of Hand and Microsurgery, Department of Orthopaedics, Kasturba Medical College Hospital, Manipal, Manipal Academy of Higher Education, India
| | - N Ravikiran
- Department of Plastic Surgery, All India Institute of Medical Sciences, New Delhi, India
| | - K N Jayakrishnan
- Unit of Hand and Microsurgery, Department of Orthopaedics, Kasturba Medical College Hospital, Manipal, Manipal Academy of Higher Education, India
| | - Anil K Bhat
- Unit of Hand and Microsurgery, Department of Orthopaedics, Kasturba Medical College Hospital, Manipal, Manipal Academy of Higher Education, India
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Abstract
With the advent of the Industrial Revolution, traumatic injuries of the upper extremity increased exponentially. As a result, surgeons began to reevaluate amputation as the standard of care. Following the Second World War, local and regional pedicled flaps became common forms of traumatic upper extremity reconstruction. Today, microsurgery offers an alternative when options lower on the reconstructive ladder have been exhausted or will not produce a desirable result. In this article, the authors review the use of free tissue transfer for upper extremity reconstruction. Flaps are categorized as fasciocutaneous, muscle, and functional tissue transfers. The thin pliable nature of fasciocutaneous flaps makes them ideal for aesthetically sensitive areas, such as the hand. The radial forearm, lateral arm, scapula, parascapular, anterolateral thigh, and temporoparietal fascia flaps are highlighted in this article. Muscle flaps are utilized for their bulk and size; the latissimus dorsi flap serves as a "workhorse" free muscle flap for upper extremity reconstruction. Other muscle flaps include the rectus abdominis and serratus anterior. Lastly, functional tissue transfers are used to restore active range of motion or bony integrity to the upper extremity. The innervated gracilis can be utilized in the forearm to restore finger flexion or extension. Transfer of vascularized bone such as the fibula may be used to correct large defects of the radius or ulna. Finally, replacement of "like with like" is embodied in toe-to-thumb transfers for reconstruction of digital amputations.
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Affiliation(s)
- Rami Dibbs
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
| | - Luke Grome
- Division of Plastic Surgery, Baylor College of Medicine, Houston, Texas
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Demir B, Ozkul B, Lapcin O, Beng K, Arikan Y, Yalcinkaya M. A Modification of Internal Bone Transport Method for Reconstruction of Nonunion of Forearm. Indian J Orthop 2019; 53:196-203. [PMID: 30906002 PMCID: PMC6394197 DOI: 10.4103/ortho.ijortho_52_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Defects of bone and soft tissue occur frequently after high-energy trauma, infections, and tumor resection. Treatment options are limited and outcomes are controversial in nonunion. Classical reconstruction methods are challenging. We describe a method of internal bone transport for treatment of complicated nonunion of the forearm. This method permits axial and internal bone transport without harming the distorted and complex neurovascular anatomy or soft-tissue envelope. MATERIALS AND METHODS Five patients (mean age, 27 years) with defect nonunion (3 ulna, 2 radius) were treated. Mean preoperative defect size was 36 mm, mean shortening was 14 (0-30) mm, and the extent of surgical resection was 24 (20-40) mm. Total bone loss due to defect, resection, or shortening was 74 mm. According to Paley classification, two of the patients had B1, and three had B3 defect nonunion. This study treats defect nonunion of the forearm using an internal bone-transport method. Our method involved cannulated screws, a cerclage wire, and a circular fixator being used in combination. When transportation was completed, internal fixation of the docking site with a plate and screws was done, with bone grafting after fixator removal. Bone healing and functional outcomes were assessed with radiographs and disabilities of the arm, shoulder, and hand (DASH) scores, respectively. RESULTS Mean followup was 67.6 months. Solid osseous union and functional improvement were achieved in all cases. Mean bone loss was 66 mm, mean fixator time was 131.8 days, the lengthening index was 1.3 days/mm, and the fixator index was 2.1 days/mm. DASH score was 82.2 before treatment and 15.36 after treatment. CONCLUSIONS Using our method, internal bone transport and progressive axial docking of defects can be done with minimal effects on surrounding neurovascular arrangements and soft tissues. Size of fixators can be decreased and formation of painful scar tissue can be avoided.
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Affiliation(s)
- Bilal Demir
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Baris Ozkul
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey,Address for correspondence: Dr. Baris Ozkul, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital. Rumeli Hisari Street. No: 62, 34470, Baltalimani, Sariyer, Istanbul, Turkey.” E-mail:
| | - Osman Lapcin
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Kubilay Beng
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Yavuz Arikan
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
| | - Merter Yalcinkaya
- Department of Orthopaedic Surgery and Traumatology, Metin Sabanci Baltalimani Bone Diseases Training and Research Hospital, Istanbul, Turkey
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Gandolfi S, Auquit-Auckbur I, Poirot Y, Bonmarchand A, Mouton J, Carloni R, Nseir I, Duparc F. Focus on anatomical aspects of soft tissue coverage options in elbow reconstruction: an updating review. Surg Radiol Anat 2018; 40:943-954. [DOI: 10.1007/s00276-018-2066-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 07/05/2018] [Indexed: 11/30/2022]
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16
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Wang C, Xu J, Wen G, Chai Y. Reconstruction of complex tissue defect of forearm with a chimeric flap composed of a sural neurocutaneous flap and a vascularized fibular graft: A case report. Microsurgery 2018; 38:790-794. [PMID: 29736923 DOI: 10.1002/micr.30334] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2017] [Revised: 03/28/2018] [Accepted: 04/06/2018] [Indexed: 11/12/2022]
Affiliation(s)
- Chunyang Wang
- Department of Orthopedic Surgery; Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai China
| | - Jia Xu
- Department of Orthopedic Surgery; Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai China
| | - Gen Wen
- Department of Orthopedic Surgery; Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai China
| | - Yimin Chai
- Department of Orthopedic Surgery; Shanghai Jiao Tong University Affiliated Sixth People's Hospital; Shanghai China
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17
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Kitazawa T, Shiba M, Tsunekawa K. Free serratus anterior fascial flap combined with vascularized scapular bone for reconstruction of dorsal hand and finger defects. CASE REPORTS IN PLASTIC SURGERY AND HAND SURGERY 2018; 5:1-8. [PMID: 29296632 PMCID: PMC5738652 DOI: 10.1080/23320885.2017.1415760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/11/2017] [Accepted: 12/07/2017] [Indexed: 11/26/2022]
Abstract
We present two cases of serratus anterior free fascial flap combined with vascularized scapular bone graft for reconstruction of traumatized dorsal hand and phalangeal bone defects. Composite flaps with single vascular pedicles allowed conservation of severely injured fingers and provided good functional and cosmetic outcomes.
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Affiliation(s)
- Takeshi Kitazawa
- Department of Plastic and Reconstructive Surgery, Matsunami General HospitalGifuJapan
| | - Masato Shiba
- Department of Plastic and Reconstructive Surgery, Matsunami General HospitalGifuJapan
| | - Kazuhiro Tsunekawa
- Department of Plastic and Reconstructive Surgery, Iida Municipal HospitalNaganoJapan
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18
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Abstract
The elbow is particularly prone to trauma, and soft-tissue reconstruction can be challenging given the inherent motion, pressure, and lack of local tissue laxity. Small wounds and those without exposure of vital structures may be amenable to primary repair. Large wounds and those requiring more substantial structural or anatomic repair may require local, regional or free flap-based reconstruction. A comprehensive review of soft-tissue reconstruction of the elbow is provided to offer surgeons alternative options in complicated upper extremity wounds.
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Affiliation(s)
- Brian P. Kelley
- House Officer, Section of Plastic Surgery, The University of Michigan Health System
| | - Kevin C. Chung
- Professor of Surgery, Section of Plastic Surgery, Assistant Dean for Faculty Affairs, The University of Michigan Medical School
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Song D, Deng X, Chen Y, Xie S, Zhou X. Thinned chimeric radial collateral artery perforator flap in complex distal thumb reconstruction. Arch Orthop Trauma Surg 2015; 135:1623-31. [PMID: 26377731 DOI: 10.1007/s00402-015-2324-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2014] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Tissue loss accompanied by bone defects in the thumb is a challenging reconstruction problem. Traditional repair methods are unsatisfactory. METHODS Microsurgical thumb reconstruction was performed using 13 thinned chimeric radial collateral artery (RCA) perforator flaps. The flap was created with a thinned skin paddle and humeral bone segments using independent perforators. Primary defatting was completed when the thickness of the perforator entry was approximately similar to that in the periphery. The posterior cutaneous nerve of the arm was carried to make a sensory flap. Defects were 8.5 × 4.5 cm(2) on average (ranging in size from 4.5 × 1.5 to 15.0 × 6.0 cm(2)), and flap size was 9.0 × 5.5 cm(2) on average (ranging in size from 5.0 × 2.0 to 16.0 × 7.0 cm(2)), whereas the humeral fragments were 2.0 × 1.0 cm(2) on average (ranging in size from 1.5 × 0.5 to 4.0 × 1.5 cm(2)). All data were expressed as mean ± SD. The cosmetic appearance of the donor and recipient sites, Kapandji opposition score and static two-point discrimination of the operated thumb were evaluated during a follow-up visit. RESULTS Follow-up time was 16.6 months (ranging from 14 to 28 months). Flap thickness before defatting, measured immediately after flap elevation was 14.5 mm (ranging from 10.0 to 25.0 mm). Average flap thickness after defatting was 3.5 mm (ranging from 3.0 to 6.0 mm). Venous congestion occurred in two cases. Successful microsurgical revision was achieved in both cases. All flaps survived. Bone components achieved union in all cases at an average period of 4.8 months (ranging from 3 to 6 months). Based on Kapandji opposition score, the mean thumb opposition score was 6. The mean sensation of flap was 7.5 mm (ranging from 6 to 11 mm). No further flap revision or defatting procedures were required in all cases. Cosmetically acceptable results were achieved for all patients. CONCLUSIONS Findings proved that thinned chimeric RCA perforator flap is a beneficial microsurgical alternative for reconstructing complex bone and soft tissue defects in thumb.
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Affiliation(s)
- Dajiang Song
- Department of Head and Neck Surgery, Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China.,Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China
| | - Xiangwu Deng
- Hand Surgical Centre, Nanhua Hospital, Nanhua University, Henyang, China
| | - Yanmin Chen
- Hand Surgical Centre, Nanhua Hospital, Nanhua University, Henyang, China
| | - Songlin Xie
- Hand Surgical Centre, Nanhua Hospital, Nanhua University, Henyang, China. .,Department of Orthopaedics, Xiangya Hospital of Central South University, Changsha, China.
| | - Xiao Zhou
- Department of Head and Neck Surgery, Department of Oncology Plastic Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China.
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20
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Houdek MT, Wagner ER, Wyles CC, Nanos GP, Moran SL. New options for vascularized bone reconstruction in the upper extremity. Semin Plast Surg 2015; 29:20-9. [PMID: 25685100 DOI: 10.1055/s-0035-1544167] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Originally described in the 1970s, vascularized bone grafting has become a critical component in the treatment of bony defects and non-unions. Although well established in the lower extremity, recent years have seen many novel techniques described to treat a variety of challenging upper extremity pathologies. Here the authors review the use of different techniques of vascularized bone grafts for the upper extremity bone pathologies. The vascularized fibula remains the gold standard for the treatment of large bone defects of the humerus and forearm, while also playing a role in carpal reconstruction; however, two other important options for larger defects include the vascularized scapula graft and the Capanna technique. Smaller upper extremity bone defects and non-unions can be treated with the medial femoral condyle (MFC) free flap or a vascularized rib transfer. In carpal non-unions, both pedicled distal radius flaps and free MFC flaps are viable options. Finally, in skeletally immature patients, vascularized fibular head epiphyseal transfer can provide growth potential in addition to skeletal reconstruction.
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Affiliation(s)
- Matthew T Houdek
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Eric R Wagner
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Cody C Wyles
- School of Medicine, Mayo Clinic, Rochester, Minnesota
| | - George P Nanos
- Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Steven L Moran
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota ; Division of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, Minnesota
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21
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[Functional reconstruction of the forearm by composite free flap of fibula and soleus reinnervated. About a clinical case]. ANN CHIR PLAST ESTH 2014; 60:153-9. [PMID: 25168403 DOI: 10.1016/j.anplas.2014.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2014] [Accepted: 07/29/2014] [Indexed: 11/21/2022]
Abstract
SUBJECT We present the case of a forearm functional reconstruction of composite fibula free flap. This is a complex forearm trauma by crushing in a 24-year-old patient. The assessment of the lesions showed a bone defect of 15cm radial and ulnar diaphysis, a muscular defect of the posterior compartment of the forearm and a large skin defect next. The radial pedicle was also injured. METHODS At 48hours, we conducted a reconstruction by free fibular flap and soleus muscle. The fibula osteosynthesys was performed between the proximal ulna and radius distally. The nerve of the soleus muscle was anastomosed to a branch of the posterior interosseous nerve and tendons of the extensor muscles of the wrist and fingers were sutured to the distal portion of the transferred muscle. RESULTS At 6 months, bone healing is achieved. Soleus muscle contracts and the strength of the extensor muscles of the fingers and wrist has been listed 4. Joint amplitudes of -20°/75° for the wrist, complete for the long fingers and the elbow. The aftermath of the donor site is minimal. CONCLUSION Reconstruction by free fibular flap and reinnervated soleus muscle is often cited in the literature but few cases are described. It is for us, the best therapeutic solution for this type of injury. It restores muscle function satisfactorily all ensuring high quality coverage defect of the forearm.
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22
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Abstract
Traumatic lesions at the elbow involving great loss of substance are uncommon, but represent a significant problem when such cases are referred to a trauma department. Most of these injuries may cause severe final functional impairment, thereby jeopardising future activities, particularly in cases where treatment was delayed or inappropriate. The timing and method of treatment are critical. The trauma may involve soft tissues only, or bone and joint, or several structures at the same time, which results in combined complex tissue defects. Each type of tissue loss should be managed by choosing the most suitable technique from the armamentarium of reconstructive surgery, taking into account different priorities and the optimum timing (immediate or delayed, one- or two-stages). The authors describe a spectrum of indications and techniques that can be useful tools in managing these injuries.
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Wu X, Wang W, Meng C, Duan D, Xu W, Liu X, Wang H, Yang S. Functional outcome of limb-salvage surgery with shoulder abduction brace for bone tumors around the shoulders. J Surg Oncol 2014; 109:714-20. [PMID: 24395023 DOI: 10.1002/jso.23555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Accepted: 12/13/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND The current trend is toward salvage of the extremity after tumor excision without compromising the extent of resection for bone tumor around the shoulders. OBJECTIVES The aim of this study was to evaluate functional outcome of patients treated with limb-salvage surgeries combined with shoulder abduction braces. METHODS Thirty-six patients with bone tumors around the shoulders, who had limb-sparing resection and reconstruction performed with a shoulder abduction brace, were retrospectively reviewed. Allograft transplantation and rigid internal fixation was performed in 22 patients and artificial prosthetic replacement was performed in 14 patients. Functional evaluation was performed based on the Musculoskeletal Tumour Society (MSTS) scoring system. RESULTS The overall survival was 78.8% (26/33) at 2 years. The mean final functional score was (81.2 ± 19.6%). The MSTS of patients treated by allograft transplantation and prosthetic replacement were (79.4 ± 15.3%) and (81.9 ± 18.1%), respectively. The MSTS scores differed only slightly between these two groups (P > 0.05). All the patients regained good ROM of the shoulder joints. CONCLUSIONS Satisfactory functional outcomes can be obtained by limb-salvage surgery for bone tumor around the shoulder. Postoperatively shoulder crutches with shoulder abduction brace are encouraged as the aid of reconstruction of shoulder joint function.
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Affiliation(s)
- Xinghuo Wu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Abstract
INTRODUCTION The aim of this study was to investigate the intraoperative findings, postoperative complications, donor site morbidity and patients' Quality of Life in order to evaluate the usefulness of the free osteofasciocutaneous fibula flap in the reconstruction or construction of a mandibula, neophallus, lower leg or forearm. MATERIALS AND METHODS 104 patients were treated with free osteofasciocutaneous fibula flaps in our clinic. 23 for mandible reconstruction, 66 for neophallus reconstruction, 9 for lower leg reconstruction and 6 for forearm reconstruction. These patients were asked to answer a questionnaire and to be present for a clinical and a radiological examination in our department. In addition, their previous records were evaluated retrospectively. RESULTS The dimension of the surface of the skin island was 178.6 cm(2) (72-352 cm(2)) in average and the average length of the fibular bony part was 15.4 cm (10-23 cm). The most frequent and severe complication was skin island edge necrosis (n=7); no total flap necrosis was found. Donor-site morbidity was low, since no joint instability could be reported. Quality of Life was improved according to the standardised FLZ(M) questionnaire. CONCLUSION Advantages of free osteofasciocutaneous fibula flaps were the wide cortical bone and the relative constant anatomy, the long pedicle, flat, uniform and sufficient large and pliable skin island, as well as the good blood circulation also by massive modelling of the skin and bone part. The skin island could be harvested large enough in order to reconstruct extended soft-tissue defects in the face and the extremities as well as to construct neophallus in its normal size without any restrictions. The lower leg donor-site morbidity was moderate and can be readily covered with a sock in patients' everyday life common activities. Finally, in our hands, the utilisation of the free osteofasciocutaneous fibula flap is the best possible therapy for these difficult composite reconstructions.
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Abstract
BACKGROUND This retrospective study was performed to verify the advantages and disadvantages of the free lateral arm flap for defect reconstruction of the forearm and hand. PATIENTS AND METHODS Between 2001 and 2010, 21 patients underwent defect coverage of the forearm and hand with the free lateral arm flap. The mean patient age was 48 years (17-78). The results concerning defect origin, flap size, pedicle length, operative time, revisions of the anastomoses or other complications, donor site morbidity, and length of hospital stay were evaluated. RESULTS The majority of defects were caused by infections or chronic wounds. The defects were localized at the forearm in 6 cases and at the hand in 15 cases. The flap width ranged from 3 to 8 cm, and the length was from 5 to 20 cm. All flaps survived. Only in one case, a revision of the anastomosis was necessary. Primary closure of the donor site was possible in all patients. No complications occurred during the healing procedure. The majority of the patients were satisfied with the aesthetic result at the recipient site as well as at the donor site. CONCLUSION The free lateral arm flap is a very reliable option for defect coverage at the forearm and hand for small and medium size defects. A satisfactory aesthetic appearance, an excellent tissue quality, and frequent primary donor site closure are great advantages for selecting this flap.
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Kremer T, Giusti G, Friedrich PF, Willems W, Bishop AT, Giessler GA. Knee joint transplantation combined with surgical angiogenesis in rabbits--a new experimental model. Microsurgery 2011; 32:118-27. [PMID: 22113889 DOI: 10.1002/micr.20946] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 07/18/2011] [Indexed: 11/10/2022]
Abstract
PURPOSE We have previously described a means to maintain bone allotransplant viability, without long-term immune modulation, replacing allogenic bone vasculature with autogenous vessels. A rabbit model for whole knee joint transplantation was developed and tested using the same methodology, initially as an autotransplant. MATERIALS/METHODS Knee joints of eight New Zealand White rabbits were elevated on a popliteal vessel pedicle to evaluate limb viability in a nonsurvival study. Ten additional joints were elevated and replaced orthotopically in a fashion identical to allotransplantation, obviating only microsurgical repairs and immunosuppression. A superficial inferior epigastric facial (SIEF) flap and a saphenous arteriovenous (AV) bundle were introduced into the femur and tibia respectively, generating a neoangiogenic bone circulation. In allogenic transplantation, this step maintains viability after cessation of immunosuppression. Sixteen weeks later, X-rays, microangiography, histology, histomorphometry, and biomechanical analysis were performed. RESULTS Limb viability was preserved in the initial eight animals. Both soft tissue and bone healing occurred in 10 orthotopic transplants. Surgical angiogenesis from the SIEF flap and AV bundle was always present. Bone and joint viability was maintained, with demonstrable new bone formation. Bone strength was less than the opposite side. Arthrosis and joint contractures were frequent. CONCLUSION We have developed a rabbit knee joint model and evaluation methods suitable for subsequent studies of whole joint allotransplantation.
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Affiliation(s)
- Thomas Kremer
- Department of Orthopedic Surgery, Microsurgery Research Laboratory, Mayo Clinic, Rochester, MN 55905, USA
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Neumeister M, Hegge T, Amalfi A, Sauerbier M. The reconstruction of the mutilated hand. Semin Plast Surg 2011; 24:77-102. [PMID: 21286307 DOI: 10.1055/s-0030-1253245] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The challenging reconstructive treatment of defects in the upper extremity requires a sound working knowledge of a variety of flaps. As the hand surgeon weighs the pros and cons of each possible flap to obtain definitive closure, he or she must also integrate the priorities of function, contour, and stability as well as the anticipation of further reconstructive surgery in choosing the flap of choice. This review describes the various flaps available for closure of soft tissue defects of the upper extremity. The principles of management of wounds of the upper extremity is described to guide hand surgeons in the early treatment of massive wounds that will eventually need free tissue coverage. Currently used flaps include fasciocutaneous, fascial, musculocutaneous, muscle, and osteocutaneous flaps. Flap selection is based on the characteristics of the defect including size, shape, and location, the availability of donor sites, and the goals of reconstruction. Improved techniques of microsurgery and an ever increasing repertoire of flaps provide the framework for hand surgeons to offer the most appropriate flap based on donor site, thickness, amount of tissue needed, and composition. A discussion of the selection of ideal flaps for any given defect should enable the reconstructive hand surgeon to provide the most appropriate coverage of wounds to the hand and upper extremity.
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Affiliation(s)
- Michael Neumeister
- Division of Plastic Surgery, SIU School of Medicine, Springfield, Illinois
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Reconstructive treatment of soft tissue sarcoma of the upper extremity. J Hand Surg Am 2011; 36:1241-7. [PMID: 21664071 DOI: 10.1016/j.jhsa.2011.04.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2011] [Accepted: 04/27/2011] [Indexed: 02/02/2023]
Abstract
Limb-sparing surgery is currently the cornerstone of treatment for most patients with soft-tissue sarcoma of the upper extremity. To achieve the best outcome, the reconstructive surgeon must be part of a multidisciplinary team and is required to have a thorough understanding of the whole treatment concept. This article provides an update for the current surgical management of patients with soft tissue sarcoma of the upper extremity. Relevant nonsurgical aspects are also highlighted.
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Hollenbeck ST, Komatsu I, Woo S, Schoeman M, Yang J, Erdmann D, Levin LS. The current role of the vascularized-fibular osteocutaneous graft in the treatment of segmental defects of the upper extremity. Microsurgery 2011; 31:183-9. [DOI: 10.1002/micr.20703] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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30
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Sauerbier M, Giessler G, Germann G, Sedigh Salakdeh M, Döll M. Einsatzmöglichkeiten des freien lateralen Oberarmlappens zur Defektdeckung an Hand und Unterarm. Unfallchirurg 2010; 113:821-31. [DOI: 10.1007/s00113-010-1846-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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31
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Chai YM, Wang CY, Zeng BF, Chen ZG, Cai PH, Kang QL, Ruan HJ. Peroneal artery perforator chimeric flap for reconstruction of composite defects in extremities. Microsurgery 2010; 30:199-206. [PMID: 20146382 DOI: 10.1002/micr.20729] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Large bone defects of extremities, especially those associated with soft tissue defects, represent difficult reconstructive problems. Chimeric flap is a suitable option for reconstruction of complex bone and soft-tissue defects. In this report, we present the experience on use of the peroneal artery perforator chimeric flap for the reconstruction of complex bone and soft tissue defects in the extremities in 16 patients. The bone defects were located in the tibia in 8 patients, in both tibia and fibula in 1 patient, in the ulna in 2 patients, in both ulna and radius in 2 patients, and the metatarsal bone in 3 patients. The flap was created with skin paddle and fibula bone segments based on independent perforators. The sizes of flap ranged from 8 x 6 to 20 x 11 cm(2), and the length of fibular grafts ranged from 6 to 22 cm. All flaps survived completely. Bone union was ultimately obtained in all cases at 5 to 11 months, while two cases suffered from stress fractures in 12 month and 18 month after operation, respectively, which eventually healed with external fixation treatment. The follow-up time ranged from 12 to 37 months. The definite bone hypertrophy was observed from X-ray at 18 months after operation. In conclusion, our results show that the peroneal artery perforator chimeric flap is a good option for reconstruction of complex bone and soft-tissue defects of extremities, particularly for those with three-dimensional defects and bone defects exceeding 6 cm in length.
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Affiliation(s)
- Yi-Min Chai
- Department of Orthopedic Surgery, Shanghai Sixth People's Hospital, JiaoTong University, Shanghai, China
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Jupiter JB, Fernandez DL, Levin LS, Wysocki RW. Reconstruction of posttraumatic disorders of the forearm. J Bone Joint Surg Am 2009; 91:2730-9. [PMID: 19884450 DOI: 10.2106/00004623-200911000-00027] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Jesse B Jupiter
- Hand and Upper Limb Service, Massachusetts General Hospital, Yawkey Building, Suite 2100, 55 Parkman Street, Boston, MA 02114, USA.
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Roje Z, Roje Z, Eterović D, Druzijanić N, Petrićević A, Roje T, Capkun V. Influence of adjuvant hyperbaric oxygen therapy on short-term complications during surgical reconstruction of upper and lower extremity war injuries: retrospective cohort study. Croat Med J 2008; 49:224-32. [PMID: 18461678 DOI: 10.3325/cmj.2008.2.224] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIM To determine the effects of hyperbaric oxygen (HBO) therapy on short-term complications of complex war wounds to the upper and lower extremities in patients who were and those who were not treated according to North Atlantic Treaty Organization (NATO) emergency war surgery recommendations. METHOD We retrospectively analyzed data of 388 male patients undergoing reconstructive surgery for Gustilo type III A, B, and C war wounds to the extremities at the Department of Reconstructive Surgery, Split University Hospital Center, between 1991 and 1995. The occurrence of main wound complications (deep infection, osteomyelitis, skin grafts lyses, and flap necrosis) during hospitalization and time from wounding to granulation formation were analyzed with respect to the use of HBO therapy as a risk factor. Odds ratio (OR) with 95% confidence intervals (CI) was calculated for the occurrence of wound complications with respect to HBO therapy and adjusted for NATO surgical strategy by logistic regression. RESULTS Of 388 patients, 310 (80%) were initially treated according to the NATO surgical strategy and 99 (25%) received HBO therapy. Deep soft-tissue infection developed in 196 (68%) patients who did not receive HBO therapy and in 35 (35%) who received it (P<0.001, xi(2) test). Osteomyelitis developed in 214 (74%) patients who did not receive HBO therapy and in 62 (63%) who received it (P=0.030). Skin graft lysis occurred in 151 (52%) patients who did not receive HBO therapy and in 23 (23%) who received it (P<0.001). Flap necrosis occurred in 147 (51%) patients who did not receive HBO therapy and in 15 (15%) who received it (P<0.001). Median time to granulation formation was 9 (5-57) days in patients who received HBO therapy, and 12 (1-12) days in those who did not (P<0.001, Mann-Whitney test). These results were consistent over the groups of patients stratified according to the wound severity and remained unaltered after the adjustment for NATO surgical strategy. The effect of HBO therapy was greater in non-NATO than in NATO treated patients in case of deep soft-tissue infection (OR, 10.7 vs OR, 3.8; P=0.031 for interaction). CONCLUSION HBO therapy reduced the frequency of wound complications in patients with Gustilo type III wounds and shortened the time to granulation formation. HBO therapy was more effective in non-NATO than in NATO treated patients for the prevention of deep soft-tissue infection but not flap necrosis.
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Affiliation(s)
- Zdravko Roje
- Division of Plastic Surgery and Burns, Department of Surgery, Split University Hospital Center, Soltanska 1, 21000 Split, Croatia.
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Rashid M, Hafeez S, Zia ul Islam M, Taokeer Rizvi S, ur Rehman S, Sarmad Tamimy M, Aman S. Limb salvage in malignant tumours of the upper limb using vascularised fibula. J Plast Reconstr Aesthet Surg 2008; 61:648-61. [DOI: 10.1016/j.bjps.2007.11.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Revised: 05/17/2007] [Accepted: 11/09/2007] [Indexed: 11/16/2022]
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Plastisch-rekonstruktive Verfahren in der interdisziplinären Therapie chronischer Wunden. Chirurg 2008; 79:546-54. [DOI: 10.1007/s00104-008-1503-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Jensen M, Moran SL. Soft tissue coverage of the elbow: a reconstructive algorithm. Orthop Clin North Am 2008; 39:251-64, vii. [PMID: 18374815 DOI: 10.1016/j.ocl.2007.12.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Soft tissue defects can occur for various reasons, but they are primarily due to trauma, tumor, and infection. Coverage choices may include primary closure, skin grafting, local cutaneous flaps, fasciocutaneous transposition flaps, island fascial or fasciocutaneous flaps, muscle or myocutaneous pedicled flaps, and microvascular free-tissue transfer. Despite the multitude of options for coverage, the authors have found four flaps to provide reliable coverage for most elbow deficits within their practice; these flaps are the latissimus dorsi flap, the radial forearm flap, the anconeus flap, and the free anterior lateral thigh flap. This article provides an overview of treatment options for elbow coverage, with specific emphasis on the use of these four specific flaps.
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Affiliation(s)
- Mark Jensen
- Department of General Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Abstract
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.
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Affiliation(s)
- Karim Bakri
- Mayo Clinic, Division of Plastic Surgery, 200 First Street SW, West 12 Mayo, Rochester, MN 55905, USA
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Whitaker I, Josty IC, van-Aalst VC, Banis JC, Barker JH. Microvascular Reconstruction of the Upper Extremity. Eur J Trauma Emerg Surg 2007; 33:14-23. [PMID: 26815970 DOI: 10.1007/s00068-007-7022-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2007] [Accepted: 02/04/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Upper extremity composite tissue defects may result from trauma, tumor resection, infection, or congenital malformations. When reconstructing these defects the ultimate objectives are to provide adequate soft tissue protection of vital structures, and to provide optimal functional and esthetic outcomes. The development of clinical microsurgery has added a large number of treatment options to the trauma surgeon's armamentarium - primarily replantation of amputated tissues and transplantation of vascularized tissues from distant donor sites. Since the early 1970s, considerable refinement in microsurgical tools and techniques together with a better understanding of the anatomy and physiology of microcirculatory tissue perfusion led to the introduction of a variety of thin, pliable and versatile-free flap designs. METHODS Sources for this manuscript include a comprehensive literature search using the PUBMED and EMBASE databases along with relevant text books, Selected Readings in Plastic Surgery(®), and personal experiences of upper extremity reconstruction and microsurgery. RESULTS In this manuscript, we describe the primary microsurgical techniques used to reconstruct upper extremity tissue defects and discuss the basis for selecting one technique over another. CONCLUSION Where possible, the best results may be achieved by reattaching the amputated original tissues (microsurgical replantation). In noninfected, uncontaminated traumatic injuries resulting in composite soft tissue defects, Early free flap reconstruction of the upper extremities has important advantages over delayed (72 h-3 months) or late wound closure (3 months-2 years). In recent years, thin, pliable, and versatile fasciocutaneous flaps such as the anterolateral thigh (ALT) and lateral arm (LA) free flaps have been increasingly used with great success to reconstruct the upper extremity. The use of "spare parts" and functional reconstructions using osteomyocutaneous free flaps or toe to thumb transfers complete the armamentarium of the upper limb reconstructive microsurgeon.
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Affiliation(s)
- Iain Whitaker
- Plastic Surgery Research Laboratory, University of Louisville, Louisville, KY, USA.,Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK
| | - Ian C Josty
- Welsh Centre for Burns and Plastic Surgery, Morriston Hospital, Swansea, UK
| | - Vera C van-Aalst
- Plastic Surgery Research Laboratory, University of Louisville, Louisville, KY, USA
| | - Joseph C Banis
- Plastic Surgery Research Laboratory, University of Louisville, Louisville, KY, USA
| | - John H Barker
- Plastic Surgery Research Laboratory, University of Louisville, Louisville, KY, USA. .,Plastic Surgery Research Laboratory, University of Louisville, 511 South Floyd Street, 320 MDR Building, Louisville KY, 40202, USA.
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Gohla T, Kehrer A, Holle G, Megerle K, Germann G, Sauerbier M. Funktionelle und ästhetische Gesichtspunkte bei der Defektdeckung der Streckseite an Hand und distalem Unterarm mit freien Lappenplastiken. Unfallchirurg 2007; 110:5-13. [PMID: 17124616 DOI: 10.1007/s00113-006-1203-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Free coverage of exposed functional structures of the hand and distal forearm can be achieved using a variety of free flaps. However, there is a lack of data in the literature which tissue components are best used for defect coverage of this specific area regarding aspects such as tendon gliding and tissue elasticity. The purpose of this retrospective study was to compare and to evaluate the functional and aesthetical results using free cutaneous, fascial and muscle flaps. PATIENTS AND METHODS Between 1994 and 2002, a total of 56 patients underwent free flap coverage at the dorsal side of the hand and forearm at our institution. Of these patients, 20 with 21 free flaps met the study criteria and were available for follow-up examination. Depending on the tissue component used patients were allocated into three different groups. In group 1 eight patients received a fascial flap, in group 2 eight a cutaneous flap and in group 3 five a muscle flap. The mean follow-up was 50 months (range: 4-103 months). At follow-up examination the patients answered the Client Satisfaction Questionnaire (CSQ 8) and the DASH questionnaire. RESULTS Regarding range of motion of the wrist and fingers, fascial flaps clearly showed the best results. Concerning grip strength and pinch grip, fascial and cutaneous flaps demonstrated the same results. Patients with cutaneous flaps showed the best DASH score. Regarding the overall aesthetical outcome, fascial and cutaneous flaps were far better than muscle flaps. Donor site morbidity was lowest for fascial flaps followed by muscle flaps and was highest for cutaneous flaps. CONCLUSION Cutaneous and fascial flaps had the best functional and aesthetical results. Fascial flaps achieved the best aesthetical outcome of the donor site. We recommend free fascial flaps and cutaneous flaps as the first choice due to their advantages in the specific area of the dorsal site of the hand and distal forearm which requires pliable and thin tissue coverage.
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Affiliation(s)
- T Gohla
- Klinik für Hand-, Plastische und Rekonstruktive Chirurgie, Schwerbrandverletztenzentrum, Berufsgenossenschaftliche Unfallklinik Ludwigshafen, Klinik für Plastische und Handchirurgie der Universität Heidelberg, 67071 Ludwigshafen.
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