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To Do or Not to Do? Neurorrhaphy in Great Toe Pulp Flap Fingertip Reconstruction. Plast Reconstr Surg Glob Open 2022; 10:e4539. [PMID: 36203734 PMCID: PMC9529029 DOI: 10.1097/gox.0000000000004539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Accepted: 07/29/2022] [Indexed: 11/26/2022]
Abstract
Since its inception, the great toe pulp (GTP) flap has represented a valid therapeutic choice in the reconstruction of defects of the hand. This study illustrates the clinical outcomes of GTP free flaps performed without nerve anastomosis' mainly for fingertip defect reconstruction. Methods We performed a retrospective, monocentric cohort study. All patients included in this study presented with fingertip traumatic injury, with tendon or bone exposure; reconstruction with GTP flap, without nerve reconstruction, was performed by the first author (L.T.) from May 2019 to October 2021. Results All 37 flaps survived completely. Due to COVID restrictions' we had to send the tests and PROMs to our patients; 28 of them replied. Cold intolerance was reported by 12 patients (moderate in two cases and mild in ten cases). No pain was complained about either in hand or donor site (Visual Analog Score 0, at rest and at movement). Complete range of motion was achieved in 22 of 28 patients. All flaps recovered protective sensitivity. In every section of the Michigan Hand Outcome Questionnaire, all patients expressed a high level of satisfaction based on the reconstruction's function and aesthetics. Regarding the donor site morbidity, no patient complained about gait disturbance. Conclusions This study showed that the GTP flap is the optimal choice for fingertip reconstruction, providing excellent functional and aesthetic results with durable and glabrous skin, satisfactory pulp contour, and sensory restoration. These results could be achieved with no need for nerve suture, especially in defects with no injuries proximal to the loss of substance.
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Mehmood Hashmi P, Musaddiq A, Hashmi A, Zahid M. Comparison of distally based sural artery and supramalleolar flap for coverage of dorsum of foot and ankle defects; a cross-sectional study of 53 patients. Ann Med Surg (Lond) 2021; 73:103109. [PMID: 34917350 PMCID: PMC8669369 DOI: 10.1016/j.amsu.2021.103109] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 11/20/2021] [Accepted: 11/21/2021] [Indexed: 11/18/2022] Open
Abstract
Background Soft tissue defects over the foot and ankle region are most challenging in reconstructive surgery. Sural artery and supramalleolar flaps have been commonly used for the reconstruction of non-weight-bearing surfaces of the foot. This article aimed to evaluate the long-term outcome comparisons between a sural artery and Supramalleolar flap in the reconstruction of extensive defects of foot and ankle only. Methods Between 1996 and 2020, a retrospective analysis of 53 fasciocutaneous flaps (27 sural and 26 Supramalleolar) used for reconstruction of soft tissue defects of foot and ankle were reviewed in this study. The parameters included were demographics data, causes, site and size of the defect, flap size, hospital stay, complications, and outcomes in a pre-structured proforma. The clinical outcome was assessed by a Self-Designed Tool based on flap survival, coverage of defect, weight-bearing status, functional activities of daily living, and cosmetic appearance. Data were analyzed through SPSS version 25. Results Among 53 flaps, the major cause of the defect was Trauma (60.4%). The maximum flap size harvested was 25*10 for sural and 20*8 cm for supramalleolar. Complications were seen in 8 (15%) cases in both flaps. Flap tip necrosis and venous congestion were seen in 4 cases. 2 each in Supramalleolar whereas 1 partial necrosis, 1 venous congestion, and 2 infections were seen in the sural artery flap. The flap survival rate in both flaps was 96.2%. Based on the self-designed Tool, flaps were graded Excellent in 43, Good in 8, and Fair in 2 cases. There was no case of Poor in both flaps. Conclusion Compared with the sural artery flap, the lateral supramalleolar flap demonstrated higher rates of functional outcomes although flap tip necrosis was higher in Supramalleolar. The comparative long-term clinical and functional outcomes of Sural and Supramalleolar flap is based on defect coverage, cosmetic appearance of surgical limb and activity of daily living. Compared with the sural artery flap, the lateral Supramalleolar flap is more reliable and exhibit higher rates of functional outcomes. Outcomes of Supramalleolar Flap was better than Sural artery flap as it was much more vascular and robust.
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Affiliation(s)
| | | | | | - Marij Zahid
- Aga Khan University Hospital, Karachi, Pakistan
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Hashmi DPM, Musaddiq A, Ali DM, Hashmi A, Zahid DM, Nawaz DZ. Long-Term Clinical and Functional Outcomes of Distally Based Sural Artery Flap: A Retrospective Case Series. JPRAS Open 2021; 30:61-73. [PMID: 34485662 PMCID: PMC8408557 DOI: 10.1016/j.jpra.2021.01.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/20/2021] [Indexed: 11/16/2022] Open
Abstract
Background Reconstruction of soft tissue defects around the lower leg, foot and ankle is a challenge for orthopedic surgeons. These defects commonly occur as a result of trauma, infection and tumor excision. Sural artery neurovascular island flap is a relatively thin, pliable and insensate flap with minimum donor-site morbidity and acceptable aesthetic outcome. Methods A retrospective analysis of a case series was conducted, all operated by a single surgeon over a period of 25 years from July 1996 to February 2020. Data were collected through a structured proforma; the variables included were as follows: demographic data, mechanism of injury, defect site and size, size of flap, hospital stay, complications, outcome of flap and functional status of limb. Data analysis was performed by using SPSS version 25.0. Results We included 89 patients out of 106, with 92 distally based sural artery flaps. The flap coverage was divided in two groups: group I for leg (n=41) and group II for foot (n=51). The mean flap dimension in leg was 9.98 ± 2.2 cm and 12.15 ± 3 cm in foot. Postoperatively functional outcomes were assessed using a self-designed tool and graded as excellent in 79 cases (leg=38; foot=41), good in 10 cases (leg=2; foot=8), fair in 3 cases (leg=1; foot=2) and poor in zero cases. All flaps survived uneventfully. Conclusion The reverse sural artery flap is versatile and reliable, and can be performed easily with good knowledge and using a microsurgical technique. It is useful for the reconstruction of soft tissue defects around the lower third of the leg, dorsum of the foot, malleoli and hind foot. The functional range of motion of the ankle is not compromised because of the flap's supple and pliable nature. The reverse sural artery flap is ideal for the coverage of the foot, ankle and lower one third of the leg. This flap is insensate and not suitable for the weight-bearing area of the heel.
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Affiliation(s)
- Dr Pervaiz Mehmood Hashmi
- Dr Pervaiz Mehmood Hashmi, Associate professor orthopedic, Hand & Reconstructive Microvascular surgeon, FCPS, Fellow in Hand, Member AAOS, Aga Khan University Hospital, Karachi, Pakistan
| | - Abeer Musaddiq
- Abeer Musaddiq, volunteer Research officer, Aga Khan University hospital, Karachi
| | - Dr Muhammad Ali
- Dr Muhammad Ali, Medical officer, Musculoskeletal service line, Aga Khan University hospital, Karachi
| | - Alizah Hashmi
- Alizah Hashmi, medical student, Aga Khan University hospital, Karachi
| | - Dr Marij Zahid
- Dr Marij Zahid, orthopedic resident, Aga Khan University hospital, Karachi
| | - Dr Zohaib Nawaz
- Dr Zohaib Nawaz, Senior medical Officer, Aga Khan University Hospital Karachi
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Fang F, Zhang Z, Wang K, Wang F, Zheng HP, Zhuang Y. The Skin Bridge Is More Important as an Additional Venous Draining Route in a Perforator-Plus Flap. J Surg Res 2019; 234:40-48. [DOI: 10.1016/j.jss.2018.09.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 08/06/2018] [Accepted: 09/07/2018] [Indexed: 12/27/2022]
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Patterns of sural nerve innervation of the sural artery with implication for reconstructive surgery. J Surg Res 2017; 220:261-267. [DOI: 10.1016/j.jss.2017.06.086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 05/28/2017] [Accepted: 06/29/2017] [Indexed: 11/19/2022]
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Neville RF, Kayssi A, Buescher T, Stempel MS. The diabetic foot. Curr Probl Surg 2016; 53:408-37. [PMID: 27687301 DOI: 10.1067/j.cpsurg.2016.07.003] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 07/25/2016] [Indexed: 01/22/2023]
Affiliation(s)
- Richard F Neville
- Vascular Services, INOVA Healthcare System, INOVA Heart and Vascular Institute, Falls Church, VA.
| | - Ahmed Kayssi
- Vascular Services, INOVA Healthcare System, INOVA Heart and Vascular Institute, Falls Church, VA
| | - Teresa Buescher
- Division of Plastic Surgery, George Washington University, Washington, DC
| | - Michael S Stempel
- Department of Medicine, George Washington University, Washington, DC; Department of Surgery, George Washington University, Washington, DC
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Anatomical basis and design of the distally based lateral dorsal cutaneous neuro-lateral plantar venofasciocutaneous flap pedicled with the lateral plantar artery perforator of the fifth metatarsal bone: a cadaveric dissection. Surg Radiol Anat 2016; 39:141-147. [PMID: 27294973 DOI: 10.1007/s00276-016-1712-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 06/09/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Detailed investigation of the vasculature of the lateral aspect of the foot has rarely been presented. However, harvesting the flap in this area to cover defects of the foot and hand is highly important. Repair of soft-tissue defects at the forefoot remains a challenge in reconstructive surgery. This study explores the characteristics of the distal-based lateral dorsal cutaneous neuro-lateral plantar venofasciocutaneous flap pedicled with the lateral plantar artery perforator of the fifth metatarsal bone to establish a repair procedure for ulcers or defects in the forefoot region. METHODS This study is divided into two parts: anatomical study and simulated operation. Thirty cadavers were utilized in the anatomical study after arterial injection. The tuberosity of the fifth metatarsal bone was used as the anatomical landmark. The lateral plantar artery perforator of the fifth metatarsal bone was identified through dissection. The perforators were dissected under a microscope. The details of the lateral plantar artery perforators, the distribution of the lateral dorsal cutaneous nerve and lateral plantar vein, the anastomosis in the lateral plantar artery perforator of the fifth metatarsal bone, the nutrient vessels of the lateral dorsal cutaneous nerve and lateral plantar vein, and other arteries of the lateral foot were recorded. The flap-raising procedure was performed on three fresh cadavers. RESULTS The lateral dorsal cutaneous nerve originated from sural nerve, traveled obliquely downward along the anterior lateral margin of the foot, and accompanied by the lateral plantar vein after bifurcation, and was eventually distributed on the lateral aspect of the foot. The nutrifying arteries to the lateral dorsal cutaneous nerve and lateral plantar vein were present segmentally and mainly originated from the lateral plantar artery perforator of the fifth metatarsal bone. These nitrifying arteries constantly originated from the lateral plantar artery in the area of tuberosity of the fifth metatarsal, ran along the medial side of the fifth metatarsal, traveled between the fifth metatarsal bone and the lateral muscle group (the flexor digitorum brevis and the abductor digiti minimi muscles), pierced the aponeurosis, vascularized the skin of the anterior lateral plantar region, and resulted in many minute branches, which anastomosed with the lateral tarsal artery and fourth dorsal metatarsal artery. The anatomical study showed that (1) the vasculature pattern can roughly be classified into three types and (2) constant anastomoses occurred between the above-mentioned arteries in the lateral-dorsum region of the foot. CONCLUSION A reliable large- or medium-sized neuro-venocutaneous flap with lateral dorsal cutaneous nerve, lateral plantar vein, and nutrient vessels can be raised using only the perforator of the lateral plantar artery of the fifth metatarsal bone, which is thin, is in the immediate vicinity of the forefoot, and has a reliable retrograde blood supply. This flap can be considered an alternative means to reconstruct soft-tissue defects of the forefoot.
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Song D, Yang X, Wu Z, Li L, Wang T, Zheng H, Hou C. Anatomic basis and clinical application of the distally based medialis pedis flaps. Surg Radiol Anat 2015; 38:213-21. [PMID: 26246341 DOI: 10.1007/s00276-015-1532-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2015] [Accepted: 07/31/2015] [Indexed: 11/29/2022]
Abstract
BACKGROUND Soft-tissue defects of the forefoot are difficult to cover adequately, particularly, although multiple options for reconstruction are available. This study especially focused on the vascularization of the medial side of the foot and the determination of the contribution of the nutrient vessels to medialis pedis flap viability. METHODS Thirty cadavers were available for this anatomical study. Microdissection was conducted under a microscope, and details of the course and distribution and the communication of the first plantar metatarsal artery with the fascial vascular network of the medial side of the foot were recorded. Clinically, six cases of soft-tissue defects at the forefoot region were reconstructed with distally based medialis pedis flap. RESULTS The perforator of the first plantar metatarsal artery pierces in the superficial fascia of the medial aspect of the foot 2.2 ± 0.7 cm proximal to the first metatarsophalangeal joint, vascularize the skin of the medial plantar region. The anatomical study showed that the vasculature pattern could roughly be classified into two types. In terms of clinical application, all flaps completely survived, and one patient had partial loss of skin graft. CONCLUSION The perforators of the medialis pedis flap are presented constant. The forefoot region can be repaired by the distally based medialis pedis flap on the perforator of the medial plantar artery of the hallux or the first plantar metatarsal artery perforator with medial plantar vein, medial plantar cutaneous nerve and nutrient vessels.
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Affiliation(s)
- Dajiang Song
- Department of Head and Neck Surgery, Hunan Province Cancer Hospital of Xiangya Medical School, Central South University, Changsha, China.,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
| | - Xiaodong Yang
- Department of Hand and Foot Surgery, Yiwu Central Hospital, Zhejiang, China
| | - Zedong Wu
- Department of Comparative Medicine, General Hospital of People's Liberation Army Nanjing District, Fujian Medical University, Fuzhou, 350108, China
| | - Lei Li
- Department of Comparative Medicine, General Hospital of People's Liberation Army Nanjing District, Fujian Medical University, Fuzhou, 350108, China
| | - Tianquan Wang
- Department of Comparative Medicine, General Hospital of People's Liberation Army Nanjing District, Fujian Medical University, Fuzhou, 350108, China
| | - Heping Zheng
- Department of Comparative Medicine, General Hospital of People's Liberation Army Nanjing District, Fujian Medical University, Fuzhou, 350108, China.
| | - Chunlin Hou
- Department of Orthopedics, Changzheng Hospital, The Second Military Medical University, Shanghai, China.
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Anatomic basis of the distally based venocutaneous flap on the medial plantar artery of the hallux with medial plantar vein and nutrient vessels: a cadaveric dissection. Surg Radiol Anat 2015; 37:975-81. [DOI: 10.1007/s00276-015-1464-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2015] [Accepted: 03/16/2015] [Indexed: 10/23/2022]
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Treatment of the Secondary Defect on the First Metatarsophalangeal Joint Using the Medial Plantar Hallucal Artery Dorsal Perforator Flap. Ann Plast Surg 2014; 76:536-40. [PMID: 25275474 DOI: 10.1097/sap.0000000000000344] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Injuries or burns to the dorsum of the first metatarsophalangeal (MTP) joint may develop scar formation, resulting in hyperextension contracture. Surgical correction of the deformity often produces a secondary defect. The purpose of this study is to report on the use of the medial plantar hallucal artery dorsal perforator flap for the treatment of such defect. From February 2010 to June 2011, 16 patients were treated. The mean preoperative hyperextension of the first MTP joint was 48 degrees. The mean size of the defects was 3.6 × 6 cm. The mean flap size was 4 × 6.5 cm. The mean pedicle length was 4 cm. All flaps survived completely. Patient follow-up lasted a mean of 14 months. At the final follow-up, the mean hyperextension of the first MTP joint was 9 degrees. After surgery, the mean Foot Function Index improved from 62 to 7. Almost all patients were satisfied with the results. Transferring the medial plantar hallucal artery dorsal perforator flap is a useful and reliable technique for the reconstruction of the secondary defect on the first MTP joint.
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Haenssgen K, Makanya AN, Djonov V. Casting materials and their application in research and teaching. MICROSCOPY AND MICROANALYSIS : THE OFFICIAL JOURNAL OF MICROSCOPY SOCIETY OF AMERICA, MICROBEAM ANALYSIS SOCIETY, MICROSCOPICAL SOCIETY OF CANADA 2014; 20:493-513. [PMID: 24564951 DOI: 10.1017/s1431927613014050] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
From a biological point of view, casting refers to filling of anatomical and/or pathological spaces with extraneous material that reproduces a three-dimensional replica of the space. Casting may be accompanied by additional procedures such as corrosion, in which the soft tissue is digested out, leaving a clean cast, or the material may be mixed with radiopaque substances to allow x-ray photography or micro computed topography (µCT) scanning. Alternatively, clearing of the surrounding soft tissue increases transparency and allows visualization of the casted cavities. Combination of casting with tissue fixation allows anatomical dissection and didactic surgical procedures on the tissue. Casting materials fall into three categories namely, aqueous substances (India ink, Prussian blue ink), pliable materials (gelatins, latex, and silicone rubber), or hard materials (methyl methacrylates, polyurethanes, polyesters, and epoxy resins). Casting has proved invaluable in both teaching and research and many phenomenal biological processes have been discovered through casting. The choice of a particular material depends inter alia on the targeted use and the intended subsequent investigative procedures, such as dissection, microscopy, or µCT. The casting material needs to be pliable where anatomical and surgical manipulations are intended, and capillary-passable for ultrastructural investigations.
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Affiliation(s)
- Kati Haenssgen
- 1 Institute of Anatomy, University of Bern, Baltzerstrasse 2, Ch-3000 Bern 9, Switzerland
| | - Andrew N Makanya
- 1 Institute of Anatomy, University of Bern, Baltzerstrasse 2, Ch-3000 Bern 9, Switzerland
| | - Valentin Djonov
- 1 Institute of Anatomy, University of Bern, Baltzerstrasse 2, Ch-3000 Bern 9, Switzerland
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