Allan M. MacLeod

The late functional results of upper limb revascularization and replantation

The functional results in 25 of 30 patients after successful upper limb revascularization or replantation were evaluated by subjective-patient surveying and objective measurements. Young patients with complete, sharply amputated extremities at the wrist level or those with incomplete injuries and uninjured peripheral nerves had the best functional results. Multiple-level, diffuse crush, or avulsion injuries, even if the injuries were incomplete, and patients with high-level nerve injury had less return of function.

Microvascular free jejunum transfer

A series of 37 microvascular free jejunal transfers for reconstruction of the pharyngolaryngeal region using a conduit or oropharynx using a patch of jejunum is reported. The technique results in a high success rate with only two failures in the series. Post-operative recovery is rapid with low morbidity and many patients are able to go home after seven to ten days. Radiotherapy, either pre-operatively affecting the recipient vessels or post-operatively affecting the transferred jejunal segment, has not been found to affect adversely the outcome of the reconstructive procedure.

Functional evaluation of the hand and foot after one-stage toe-to-hand transfer

Twenty toe-to-hand transfers in 17 patients with an average follow-up of 54 months have been reviewed to quantify hand function and donor morbidity. Eleven toe-to-thumb and nine toe-to-finger procedures were performed. Surgical and follow-up data were available for all patients. Twelve patients (14 procedures) were reviewed in detail, with particular attention given to foot and hand function. Total active motion after toe-to-thumb transfer was 48 degrees and 106 degrees after toe-to-finger transfer. Two-point discrimination was less than or equal to 15 mm in 13 digits (65%). Grip and pinch power were related to the number of digits present on the reconstructed hand and to the presence or absence of functioning thenar muscles. Eleven of 12 patients can walk and run normally (mean of 5 years after surgery). Six (50%) cannot wear thongs or heavy boots, but all can wear normal shoes. The transferred great toe decreased in volume by an average of 10% over the years since the operation. Transferred toes became useful digits in the hand, and foot morbidity was minor and not progressive.

Microvascular osteocutaneous transfer using the groin flap and iliac crest and the dorsalis pedis flap and second metatarsal

Abstract It can be concluded that 1-stage free flap bone graft procedures enhance the armamentarium of the reconstructive surgeon. In the 7 cases presented, 5 were completely successful and 2 failed. These latter 2 cases reflect the hard core of unpredictability in the occasional microvascular case. But this should not deter reconstructive surgeons from proceeding. In our experience 80 per cent or more of microvascular reconstructive procedures achieve their aim.

The free radial forearm flap with and without bone for closure of large palatal fistulae.

Three cases of palatal fistulae closed by microvascular transfer of radial forearm flaps are presented. Vascularised bone was included in one flap and all operations were free of complications. Facial scarring is minimal and the secondary deformity in the arm has not been significant. It is suggested that this procedure presents fewer difficulties than other techniques for treating the large palatal fistula and may prevent the collapse of the alveolar arch which follows the scarring associated with closure by local tissue.

Free flap transfers with microvascular anastomoses

Abstract A series of 9 cases of free flap transfer with microvascular anastomoses in both elective and emergency situations in the limbs, and head and neck is presented. Seven free groin flaps were utilised and 2 lateral forehead flaps for nasal reconstruction following cancer surgery. One flap loss occurred and arterial thromboses in 2 other cases were overcome using vein grafts. Free flap transfer has advantages over tube pedicles and many direct flaps, and broadens the scope of reconstructive surgery.

Hallux-to-hand transfer.

Abstract A hallux-to-hand microvascular transplantation for thumb reconstruction is presented and variations in the technique discussed.

Simultaneous double toe transfer for severely disabled hands

Two cases are presented in which a severely damaged hand was reconstructed by the simultaneous transfer of two toes using microvascular techniques. A two year evaluation of the functional result is made in both cases. Conventional reconstructive methods have little place in the reconstruction of these severe disabilities.

Free vascularized small joint transfer to the hand

Free vascularized digital joint transfers should provide joint stability, painless functional range of motion (ROM), tolerance of normal stresses without degeneration, and growth potential in children. In our department since 1977, seven transfers have been carried out in seven patients, including four children aged 4 to 11 years and three adults aged 19 to 46 years. Donor sites were the metatarsophalangeal joint of the second toe (four cases), the proximal interphalangeal (PIP) joint of the second toe (two cases), and the PIP joint of a useless amputated small finger (one case). Recipient sites were digital PIP and metacarpophalangeal (MP) joints (three cases each) and the MP joint of a thumb (one case). Six of the seven procedures were successful. There was retention of normal joint space and stable, painless functional ROM, while epiphyseal centers in the children remained open and showed normal growth. Follow-up ranged from 2 to 4.7 years, averaging 3.5 years. Some adherence of an associated extensor tendon has been observed. The feet have been asymptomatic. When digital joint replacement is required because of local causes of destruction, free toe joint transfer should certainly be considered in children and in young adults.

Replantation and Revascularisation Surgery in Children

Salvage of any amputated, or devascularised, digit or extremity in a child should be seriously considered and carefully planned. Bone shortening should be minimised. Replanted and revascularised digits and extremities do grow and aften demonstrate minimal retardation when well revascularised and minimally traumatised. Even in more extensive injuries progressive growth is observed. Replanting of single digits is worth while in children. Vein grafting should be seriously considered when replanting any avulsed digit. The return of excellent sensation and good function in amputated parts in children makes these procedures rewarding and beneficial.